Should lipoproteins be measured in all adults, regardless of their cardiovascular disease (CVD) risk factors or medical history?

Should Lipoproteins Be Measured in Everyone?

No, advanced lipoprotein testing beyond a standard fasting lipid profile is not recommended for cardiovascular risk assessment in asymptomatic adults. 1

What Should Be Measured Instead

The ACC/AHA guidelines explicitly state that measurement of lipid parameters including lipoproteins, apolipoproteins, particle size, and density beyond a standard fasting lipid profile is Class III: No Benefit for cardiovascular risk assessment in asymptomatic adults. 1 This is the strongest recommendation against a practice in guideline terminology.

Standard Lipid Profile Components

A standard fasting lipid profile should include: 1

• Total cholesterol
• HDL cholesterol
• Triglycerides
• LDL cholesterol (calculated by Friedewald equation if triglycerides <300 mg/dL, or measured directly)

Who Should Be Screened and When

Age-Based Screening Recommendations

Men: 1, 2

• Age ≥35 years: Strongly recommended for all men
• Age 20-35 years: Only if risk factors present (diabetes, smoking, hypertension, family history of premature CHD)
• Not recommended for men 20-35 years without risk factors

Women: 1, 2

• Age ≥45 years with ≥2 risk factors: Strongly recommended
• Age 20-45 years: Only if risk factors present
• Not recommended for women 20-45 years without risk factors

All adults 40-75 years: The American College of Cardiology strongly recommends lipid testing regardless of risk factors. 2

Risk Factors That Warrant Earlier Screening (Age 20+)

1, 2

• Diabetes
• Current cigarette smoking
• Hypertension (BP ≥140/90 mm Hg or on antihypertensive medication)
• Family history of premature CHD (male first-degree relative <55 years; female first-degree relative <65 years)
• Family history suggestive of familial hyperlipidemia
• Obesity

Screening Intervals

1, 2

• Every 5 years is reasonable for those requiring screening
• Shorter intervals for persons with lipid levels close to treatment thresholds
• Longer intervals for low-risk persons with repeatedly normal lipid levels
• More frequent measurements for those with multiple risk factors or LDL slightly below goal

Important Technical Considerations

1, 2

• Total cholesterol and HDL can be measured on non-fasting samples
• Abnormal results must be confirmed by a repeated sample on a separate occasion
• Use the average of both results for risk assessment
• In patients with elevated screening results, lipoprotein analysis including fasting triglycerides may provide useful information for treatment selection

The Lipoprotein(a) Exception

While advanced lipoprotein testing is not recommended routinely, there is emerging evidence for Lipoprotein(a) [Lp(a)] as a special case, though this is not yet reflected in the primary prevention guidelines cited above:

3, 4, 5

• Elevated Lp(a) (≥50 mg/dL or ≥100 nmol/L) affects approximately 1 in 5 individuals
• It is a genetically determined, causal risk factor for premature atherosclerotic cardiovascular disease
• One lifetime measurement may be reasonable in high-risk populations

When to Consider Lp(a) Testing (Based on Emerging Evidence)

3, 4, 5

• Premature ASCVD (personal or family history)
• Familial hypercholesterolemia
• Individuals of African or South Asian ancestry (higher prevalence)
• Residual cardiovascular risk despite guideline-lowered LDL cholesterol (<70 mg/dL)

However, note that Lp(a) testing is not part of routine screening per the formal ACC/AHA guidelines and should be considered selectively. 1

Common Pitfalls to Avoid

1, 2

• Do not rely on a single lipid measurement for diagnosis or treatment decisions—always confirm abnormal results
• Do not screen all young adults regardless of risk factors, as this leads to unnecessary testing and cost
• Do not order advanced lipoprotein panels (particle size, density, apolipoproteins) for routine risk assessment in asymptomatic adults—the evidence does not support their use beyond standard lipid profiles

Risk Assessment Integration

Once lipid screening is performed, results should be integrated into a global cardiovascular risk score (Framingham, SCORE, Reynolds, or PROCAM) that combines multiple risk factors into a single quantitative estimate to guide preventive interventions. 1 Treatment decisions should account for overall cardiovascular risk, not lipid levels in isolation. 1