When to Check Lipoprotein(a) Levels
Lipoprotein(a) should be measured once in adults with a family history of premature cardiovascular disease (CVD before age 55 in men, 65 in women), unexplained early cardiovascular events in first-degree relatives, known elevated Lp(a) in family members, familial hypercholesterolemia, recurrent CVD despite optimal statin therapy, or borderline-to-high cardiovascular risk. 1
Primary Indications for Lp(a) Testing in Adults
Strong Indications (Measure Once)
- Personal or family history of premature atherosclerotic CVD (men <55 years, women <65 years) 1, 2, 3
- Unexplained early cardiovascular events in first-degree relatives 1
- Known elevated Lp(a) in first-degree relatives (>200 nmol/L or >75 nmol/L depending on guideline) 1, 2
- Familial hypercholesterolemia diagnosis 1, 2, 3
- Recurrent CVD despite optimal lipid-lowering therapy (particularly statin treatment) 1, 4, 2, 3
- Calcific aortic valve stenosis 2
Reasonable Indications
- Borderline cardiovascular risk (5-15% 10-year risk) where Lp(a) may reclassify risk 1, 2, 3
- ≥3% 10-year risk of fatal CVD (European SCORE) or ≥10% 10-year risk of fatal/non-fatal CHD (US guidelines) 3
- Inadequate LDL-cholesterol response to statins 4
- Multiple cardiovascular risk factors where additional risk stratification is needed 5, 4
Pediatric Population
In children, measure Lp(a) as early as age 2 years if there is a family history of early CVD or significant hypercholesterolemia (LDL-C ≥190 mg/dL or total cholesterol ≥240 mg/dL). 1, 6, 7
- Repeat testing at puberty (≥12 years) even if previous values were normal, as levels may change 7
- Perform cascade screening of first-, second-, and third-degree biological relatives when elevated Lp(a) is identified 1, 7
Key Clinical Thresholds
The European Society of Cardiology recommends measuring Lp(a) at least once in every adult's lifetime to identify those at very high lifetime cardiovascular risk, as Lp(a) levels are genetically determined and remain stable throughout life 8. Traditional thresholds for elevated Lp(a) are:
- >30 mg/dL or >75 nmol/L (approximately 75th percentile in white populations) 1
- >50 mg/dL or >100-125 nmol/L (80th percentile, European populations) 1, 3
Markedly elevated Lp(a) (>75 nmol/L) combined with elevated LDL-C increases myocardial infarction risk 10-fold or higher. 6, 7
Important Caveats
Not Recommended for Universal Screening
Screening for Lp(a) is NOT recommended for primary prevention in the general population without specific risk factors. 1 The American Heart Association/American Stroke Association explicitly states that routine screening should be avoided unless the specific indications above are present.
One-Time Measurement
Unlike LDL-cholesterol, Lp(a) should only be measured once (or repeated at puberty in children) because levels are genetically determined and remain stable throughout adult life 8, 3. There is no need for serial monitoring unless specific Lp(a)-lowering therapy becomes available.
Assay Considerations
Use an isoform-insensitive assay when measuring Lp(a), as apolipoprotein(a) size varies considerably between individuals 3. The lack of standardized assays remains a limitation in clinical practice 1.
Clinical Context Matters
The European guidelines emphasize that Lp(a) measurement is most valuable in patients at intermediate or high cardiovascular risk where the result will influence management decisions 1, 3. In very low-risk individuals, elevated Lp(a) may not substantially change clinical management, making testing less useful.