A common genetic condition, affecting approximately one in five people, significantly increases the risk of heart attacks and strokes, yet it often goes undiagnosed. Lipoprotein(a), or Lp(a), is a type of "bad" cholesterol that carries no symptoms and is not detected by standard GP tests.
Many individuals with high Lp(a) levels are unaware of their condition until they experience a serious cardiovascular event, such as a heart attack or stroke. In some cases, individuals may die without ever knowing they had this hidden risk factor. Actor James Buckley recently revealed on his podcast that he is among those with dangerously high Lp(a) levels, which were discovered through a blood test.
Unlike LDL (low-density lipoprotein) cholesterol, which is influenced by diet and lifestyle, Lp(a) levels are primarily determined by genetics. When elevated, Lp(a) can contribute to inflammation and the buildup of fatty plaques in artery walls, narrowing blood vessels and increasing the likelihood of heart attacks and strokes. It may also make blood more prone to clotting.
Lp(a) vs. Standard Cholesterol
Standard cholesterol tests typically measure LDL, which is manageable through diet, exercise, and weight management. Lp(a), however, is less responsive to lifestyle changes. Each Lp(a) particle contains apolipoprotein(a) (Apo(a)), which allows it to more effectively burrow into artery walls, accelerate plaque formation, and cause inflammation. This cumulative damage over decades can lead to early-onset heart attacks and strokes, often before the age of 60.
Professor Kausik Ray, a cardiologist at Imperial College London, described Lp(a) as "more like a bazooka" compared to LDL's "100 bullets" due to its potent damage potential. Dr. Ravi Assomull, another cardiologist, noted that Lp(a) particles invade the vessel wall and cause inflammation, leading to plaque rupture and potential clots.
Diagnosis and Risk Factors
Because Lp(a) has no symptoms, a specific blood test is required for diagnosis. Standard cholesterol screenings do not assess Lp(a) levels. Regina Giblin, a senior cardiac nurse at the British Heart Foundation, emphasized that normal cholesterol levels do not rule out elevated Lp(a).
Family history can be an indicator; a high incidence of heart disease at a young age among relatives may warrant an Lp(a) test. A single blood test is generally sufficient as Lp(a) levels are largely fixed from birth. However, routine testing is not currently recommended by the National Institute for Health and Care Excellence (NICE) in the UK. Private tests are available, costing between £45 and £130.
Certain ethnic groups, including those of Afro Caribbean or South Asian heritage, may have higher Lp(a) levels, while individuals of Chinese and Japanese descent may be at lower risk. Conditions like chronic kidney disease and hyperthyroidism can also elevate Lp(a) levels. Some hormonal changes in women, such as during pregnancy or after menopause, may also affect levels, though more research is needed.
Managing and Treating Lp(a)
While statins do not lower Lp(a) levels and can even slightly increase them, they are effective in reducing LDL cholesterol and overall cardiovascular risk. Some studies suggest statins might shrink Lp(a) particles, but the clinical impact is unclear. PCSK9 inhibitors, such as Repatha and Praluent, can reduce Lp(a) by about 25% and are typically reserved for patients with persistently high LDL despite statin use or those who cannot tolerate statins.
A procedure called apheresis, a form of dialysis to filter cholesterol, is an option for very high-risk patients but carries risks like blood clots.
Several new drugs specifically designed to lower Lp(a) are in late-stage clinical trials and may become available within the next five years. Lepodisiran, a twice-yearly injection, has shown in trials to reduce Lp(a) levels by up to 94%. Pelacarsen is another promising treatment in trials that lowers Lp(a) by approximately 80%. Other emerging cholesterol drugs like enlicitide and obicetrapib also show potential in reducing Lp(a) levels.
Lifestyle Modifications
Despite the genetic component of Lp(a), experts stress that individuals can significantly reduce their overall cardiovascular risk by managing controllable factors. Quitting smoking, moderating alcohol intake, controlling blood pressure, and maintaining a healthy weight are crucial. A Mediterranean-style diet, rich in fruits, vegetables, whole grains, and fish, is recommended, along with regular exercise.
Professor Ray advises against excessive worry upon discovering high Lp(a), emphasizing that it is one factor among many influencing heart health. By addressing other risk factors, individuals can proactively protect their cardiovascular well-being.