What Is Your Lp(a) Level? The Overlooked Cholesterol Risk

Most people know their LDL cholesterol number, often called the “bad” cholesterol. But far fewer know their Lp(a) level, another cholesterol particle that may be even more dangerous for some individuals.

Recently, I was quoted in TODAY.com discussing the importance of this often overlooked cholesterol marker known as lipoprotein(a), or Lp(a) (pronounced L-P-little-a).

When we talk about cholesterol and heart disease, most of the focus is on LDL cholesterol. But LDL has a neglected cousin, Lp(a), that has been around just as long.

In fact, I first wrote about Lp(a) more than 35 years ago while training at Johns Hopkins Hospital (see above). At the time, it received relatively little attention. Over the years, however, research has shown that Lp(a) can be even more damaging than LDL in increasing the risk of heart disease and stroke.

“Many people focus on LDL cholesterol, but for some patients Lp(a) may be the most dangerous cholesterol particle they have never heard of.”

Key Takeaways

• Lp(a) is a genetically determined cholesterol particle linked to heart disease and stroke.
• High Lp(a) can increase cardiovascular risk even when LDL cholesterol is not extremely high.
• The combination of high Lp(a) and high LDL cholesterol is particularly concerning.
• Traditional cholesterol medications such as statins do not lower Lp(a).
• New therapies currently under investigation may reduce Lp(a) levels by 70–80%.

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Why High Lp(a) Is Concerning

The combination of high Lp(a) and high LDL cholesterol is particularly worrisome. A high Lp(a) is equal to or greater than 125 nmol/L (or 50 mg/dL) and a very high Lp(a) is equal to or greater than 250 nmol/L (or 100 mg/dL).

If you have high Lp(a) but no personal history of heart disease, the new target LDL varies between 70-100 mg/dL depending upon your overall level of risk as described in the 2026 Cholesterol Guidelines. However, if your Lp(a) is very high, many specialists are aiming for an LDL less than 70 mg/dL due to the increased risk of a first heart attack/stroke.

What about if you have already suffered a heart attack or stroke? In these cases, the target LDL is again based on your Lp(a) level. If Lp(a) is high, the target LDL is less than 40 mg/dL and if Lp(a) is very high, the target LDL is less than 30 mg/dL.

A Case That Highlights the Risk

Several years ago, my colleagues and I published a case report about a 27-year-old woman who had already undergone coronary bypass surgery.

She had seen multiple physicians who could not explain why she had developed advanced coronary artery disease at such a young age. She was not diabetic and her LDL cholesterol was not extremely high—two of the most common explanations for early heart attacks in young women.

When we finally checked her Lp(a) level, the answer became clear.

Her level was 569 nmol/L, dramatically elevated. In fact, she was told that her coronary arteries looked more like those of a woman in her 80s.

Cases like this illustrate how Lp(a) can quietly accelerate atherosclerosis, even in people who otherwise appear to have relatively few traditional risk factors.

Why Lp(a) Is Difficult to Treat

One challenge with Lp(a) is that most traditional cholesterol-lowering medications do not reduce it.

For example:

• Statins effectively lower LDL cholesterol but do not significantly reduce Lp(a).
• PCSK9 inhibitors may lower Lp(a) by about 20–30%, which can help but may not be enough for individuals with very high levels.

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Why Lp(a) Is Receiving More Attention Today

For many years, Lp(a) was considered an interesting but difficult-to-treat risk factor. That is beginning to change.

Large genetic studies have confirmed that elevated Lp(a) is a causal risk factor for cardiovascular disease, including heart attacks and strokes. At the same time, new therapies designed specifically to lower Lp(a) are now in advanced clinical trials.

These developments have renewed interest in a cholesterol particle that scientists have known about for decades—but are only now beginning to target effectively.

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New Treatments on the Horizon

Fortunately, new therapies are being developed that specifically target Lp(a).

Several investigational injectable medications have shown the ability to lower Lp(a) levels by 70–90% in clinical trials. One of the most important studies evaluating these therapies is the HORIZON trial (pelacarsen; monthly injection) due to report out later this year. Other ongoing studies include, Oceans(a)-Outcomes (olpasiran; injection every 3 months); ACCLAIM-LP(a) (lepodisiran; injection every 6-12 months) and a daily pill (muvalapin) in Phase 3 development.

These studies are designed to determine whether dramatically lowering Lp(a) will also reduce the risk of heart attacks, strokes, and other cardiovascular events.

Stay tuned—because if these therapies prove effective, they could represent a major breakthrough in cardiovascular prevention.

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Who Should Have Their Lp(a) Checked?

Many experts now recommend checking Lp(a) levels, especially for people who:

• Have premature heart disease in the family
• Develop heart disease despite normal cholesterol levels
• Have very high LDL cholesterol
• Have had a heart attack or stroke at a young age

Because Lp(a) levels are largely determined by genetics, the number usually remains stable throughout life (and until Lp(a) lowering medications become available)

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Bottom Line

Many people know their LDL cholesterol number, but far fewer know their Lp(a) level.

Yet for some individuals, Lp(a) may be the most important cholesterol number of all.

So the next time you have your cholesterol checked, consider asking your doctor a simple question:

“What is my Lp(a) level?”

Knowing your Lp(a) level may be just as important as knowing your LDL cholesterol—because for some people, it is the hidden driver of heart disease.

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Michael Miller, MD, MASPC, FACC, FAHA, FNLA is Cardiologist and Professor of Medicine, Hospital of the University of Pennsylvania. He is also Chief of Medicine, Corporal Michael J Crescenz VAMC (Philadelphia).

Prior to moving to Philadelphia in 2022, Dr. Miller served as Professor of Cardiovascular Medicine at the University of Maryland School of Medicine (Baltimore).

Learn more: www.drmichaelmiller.net