Lipoprotein(a) Screening Is Not Necessary for All Individuals During Routine Lipid Profiles
Routine screening for lipoprotein(a) is not recommended for all individuals, but should be selectively measured in specific high-risk populations based on established cardiovascular risk factors and clinical scenarios. 1
Standard Lipid Screening Components
The established lipid screening panel should include:
- Total cholesterol and HDL cholesterol are the recommended components of routine lipid screening, not lipoprotein(a). 2
- LDL cholesterol and triglycerides provide additional information but require fasting samples and are more expensive; triglyceride measurement has insufficient evidence for routine screening. 2
- These standard lipid measurements effectively identify most individuals at increased cardiovascular risk without universal Lp(a) testing. 2
Specific Indications for Lipoprotein(a) Testing
Lp(a) should be measured at least once in the following high-risk populations:
Primary Clinical Scenarios
- Patients with premature cardiovascular disease or stroke, especially when traditional risk factors don't fully explain the disease. 1
- Family history of premature CAD (before age 50 in male relatives or age 60 in female relatives), particularly first-degree relatives with premature atherosclerotic CVD or Lp(a) levels >200 nmol/L. 1
- All patients with familial hypercholesterolemia or other genetic dyslipidemia should have Lp(a) measured, as elevated Lp(a) and LDL cholesterol together confer a 10-fold or higher risk of myocardial infarction. 1, 3
Additional High-Risk Groups
- Intermediate cardiovascular risk by standard calculators (Framingham, PROCAM, ESC Heart Score), as Lp(a) levels >50 mg/dL may justify reclassification into a higher risk category. 1
- Recurrent or rapidly progressive vascular disease, especially in patients already on lipid-lowering medication. 1, 4
- Inadequate LDL cholesterol responses to statins, as Lp(a) testing may identify patients potentially less likely to respond to statin therapy. 5, 4
Clinical Rationale for Selective Screening
The selective approach is justified by several key considerations:
- Lp(a) is a genetically inherited, independent risk factor affecting approximately 20-25% of the global population, with levels remaining stable over time, requiring only one-time testing in most individuals. 5, 6
- Elevated Lp(a) is associated with a 2-3-fold increased risk of myocardial infarction, comparable to the risk seen in familial hypercholesterolemia. 6
- The American College of Cardiology Foundation/American Heart Association guidelines found continuous, independent associations of Lp(a) with increased risk for CHD and stroke based on 36 prospective studies involving >125,000 participants. 1
Management Implications When Elevated Lp(a) Is Identified
- Intensive treatment of traditional modifiable risk factors, especially LDL cholesterol, is justified by the additional risk conferred by elevated Lp(a), with lower LDL-C goals. 1
- Concomitant elevation of LDL-C ≥135 mg/dL and Lp(a) ≥100 nmol/L is associated with a 43% higher cardiovascular risk compared to elevated LDL-C alone. 7
- Cascade screening can help identify elevated Lp(a) in relatives of individuals with a personal or family history of premature ASCVD, with systematic screening identifying 1 new case of elevated Lp(a) for every 2.4 screened when the index case has both FH and elevated Lp(a). 3
Common Pitfalls to Avoid
- Do not order Lp(a) testing universally for all patients undergoing routine lipid screening, as this is not supported by current guidelines and is not cost-effective. 2, 1
- Do not rely on a single Lp(a) measurement for major treatment decisions without confirming the result, though Lp(a) levels generally remain stable over time. 8, 5
- Do not screen for Lp(a) without a clear plan for risk factor modification, as the primary management strategy involves intensive LDL-C lowering rather than specific Lp(a)-targeted therapies in current practice. 1, 4