The Heart Disease Risk Factor Your Doctor Probably Hasn’t Checked

The Phone Call That Changed Her Life

Three months ago, I got a call from a patient’s sister. Her voice was shaking.

“My brother just had a massive heart attack. He’s 47. Sarah, you told me last year that you checked my lipoprotein(a) and it was high. Should my brother get tested?”

Sarah was my patient. She’d come to see me for anxiety a year earlier. During our initial workup, I’d ordered comprehensive cardiovascular testing including Lp(a). Hers came back at 165 mg/dL. Very high. Normal is under 30.

At the time, Sarah was confused. “But my regular cholesterol is fine. What is this lipoprotein(a) thing?”

I explained that it’s genetic, that about 1 in 5 people have elevated levels, that it significantly increases heart attack and stroke risk, and that standard cholesterol tests don’t measure it. Most doctors don’t even know to check it.

We’d adjusted her treatment plan accordingly. More aggressive with lifestyle. Added specific supplements. Monitored her more closely. Started thinking about her as higher risk than her basic cholesterol suggested.

Now, a year later, her younger brother had nearly died from a heart attack. He was a marathon runner. Non-smoker. “Healthy” by all standard measures. His regular cholesterol was perfect. But nobody had ever checked his Lp(a).

I told her to have him get tested as soon as he was stable enough.

When the results came back two weeks later, his Lp(a) was 178. Higher than Sarah’s.

Their father had died of a heart attack at 52. Their grandfather at 49. But nobody in the family knew why they all had heart disease despite “normal cholesterol.”

Now we know. It’s genetic. It’s passed down through families. And it’s been silently increasing their cardiovascular risk for their entire lives.

This is the story of Lipoprotein(a). The cardiovascular risk factor that 20% of people have, that dramatically increases heart attack risk, and that almost nobody gets tested for.

Let’s talk about why that needs to change.

What the Heck Is Lipoprotein(a)?

Let me start with a simple explanation, then we’ll get into why it matters so much.

The Basics

Lipoprotein(a), which we shorten to Lp(a) (pronounced “L-P-little-a”), is a type of cholesterol particle. It looks a lot like LDL cholesterol (the “bad” cholesterol), but with an extra protein called apolipoprotein(a) attached to it.

That extra protein is what makes it dangerous.

Here’s what makes Lp(a) different from regular cholesterol:

It’s almost entirely genetic. You inherit it from your parents. Your level is pretty much set from birth.

Diet doesn’t affect it much. Neither does exercise. This is frustrating but also liberating in a weird way. It’s not your fault if it’s high.

It doesn’t change much over your lifetime. Test it once, and you know your number forever.

Standard cholesterol tests don’t measure it. Your doctor could tell you your cholesterol is “perfect” while you have sky-high Lp(a).

There’s no FDA-approved medication specifically for lowering it (yet, but that’s changing).

And here’s the kicker: elevated Lp(a) increases your risk of heart attack and stroke as much as having LDL cholesterol over 190, even if your regular cholesterol looks great.

Why Is It Dangerous?

Lp(a) is particularly nasty because it does multiple bad things at once:

It promotes plaque buildup in arteries. Just like LDL cholesterol, but more aggressively.

It causes inflammation in blood vessel walls, making plaque more unstable.

It promotes blood clots. That extra protein (apolipoprotein-a) looks similar to plasminogen, which is involved in clot formation. This is bad.

It accumulates in heart valves over time, which can lead to valve disease requiring surgery.

It’s resistant to standard treatments. Statins (cholesterol medications) can actually make Lp(a) go up slightly. This is one reason why some people on statins still have heart attacks.

So you’ve got this cholesterol particle that’s extra inflammatory, extra clot-promoting, genetically determined, not responsive to lifestyle changes, and not measured on standard tests.

Great combination, right?

How Common Is This?

About 20% of people (1 in 5) have elevated Lp(a). That’s roughly 60 million Americans walking around with a significant cardiovascular risk factor that most of them don’t know about.

It’s more common in certain populations:

• People of African descent (up to 30% have elevated levels)
• People of South Asian descent
• People with family history of early heart disease

But it affects all ethnicities. Nobody is immune.

What counts as “elevated”?

This gets a bit technical because different labs use different units, but generally:

• Under 30 mg/dL (or under 75 nmol/L): Normal
• 30-50 mg/dL: Borderline
• Over 50 mg/dL: Elevated
• Over 100 mg/dL: Very high risk

Some experts think even 30 mg/dL might be too high. The lower, the better.

Why Don’t Doctors Test It?

This is what makes me crazy. We’ve known about Lp(a) since the 1960s. We’ve known it increases cardiovascular risk since the 1990s. It’s 2025. Why isn’t this part of routine testing?

I’ve heard various excuses:

“We didn’t have good treatments for it, so why test?”

This is changing. We have new medications in development that specifically lower Lp(a). And even without specific Lp(a)-lowering drugs, knowing your level changes how we manage everything else.

“It’s not included in standard panels.”

True. Doctors have to specifically order it. Many don’t think about it.

“Insurance doesn’t cover it.”

Sometimes true, but the test costs $20-50 if you pay out of pocket. That’s cheaper than a fancy dinner.

“Most doctors don’t know about it.”

Honestly, this is probably the biggest reason. Medical education is slow to change. Many doctors graduated before this was emphasized. They don’t think to check what they weren’t taught about.

But here’s what frustrates me: major medical organizations, including the American Heart Association and European Society of Cardiology, now recommend checking Lp(a) at least once in everyone’s lifetime, preferably by age 40.

Yet it’s still not happening routinely.

Who Should Get Tested?

According to current guidelines, you should definitely get your Lp(a) tested if you have:

Family history of early heart disease

• Heart attack or stroke before age 55 in men or 65 in women
• Parent, sibling, or child with premature cardiovascular disease
• Multiple family members with heart disease

Personal history of cardiovascular events

• Heart attack, especially at young age
• Stroke or TIA
• Peripheral artery disease
• Need for coronary artery bypass or stenting

High cholesterol that doesn’t respond well to treatment

• LDL stays elevated despite statins
• Family history of high cholesterol

Recurrent cardiovascular events despite treatment

• Another heart attack despite being on medications
• Progression of disease despite “optimal” management

Family history of elevated Lp(a)

• If a family member has it, you might too (it’s genetic)

Honestly? I think everyone should get tested at least once. It’s genetic. It doesn’t change. Test it, know your number, factor it into your lifetime risk assessment.

The cost of testing is minimal. The information is valuable. Why wouldn’t you want to know?

Real Stories: When Lp(a) Explains Everything

Let me tell you about three patients whose stories illustrate why this matters.

James: The Mystery Solved

James had his first heart attack at 44. He was a runner, didn’t smoke, wasn’t overweight. His LDL cholesterol was 98. HDL was great. Triglycerides were low. His cardiologist was confused.

“We see this sometimes,” his cardiologist told him. “Just bad luck, I guess.”

James came to see me for depression after his heart attack. During our evaluation, I checked his Lp(a). It was 189.

Suddenly everything made sense. His father’s heart attack at 48. His uncle at 52. His grandfather at 50. It wasn’t “bad luck.” It was genetics.

Knowing his Lp(a) level changed his treatment plan. His cardiologist became much more aggressive with his other risk factors. We added PCSK9 inhibitors (which do lower Lp(a) somewhat). We optimized everything else we could control.

Five years later, James is doing well. But if we hadn’t checked his Lp(a), he would have been undertreated based on his “normal” cholesterol.

Maria: The Preventive Save

Maria was 35 when she came to see me for anxiety. Her mother had died of a stroke at 42. Her maternal grandmother died of a heart attack at 45.

“I’m terrified I’m going to die young like they did,” she told me.

I checked her Lp(a). It was 156.

Her basic cholesterol was perfect. LDL 105. HDL 62. If we’d only looked at standard tests, we would have been falsely reassured.

But with that Lp(a) level and family history, Maria was at very high risk. We treated her aggressively. Lifestyle optimization. Medications. Monitoring. Everything we could do to stack the deck in her favor.

She’s now 42. Healthy. Active. Doing great. She just passed the age when her mother died, and she’s thriving.

Did knowing her Lp(a) level save her life? I can’t prove it. But I think there’s a very good chance it did.

The Family Discovery

I tested Robert’s Lp(a) as part of routine screening. It was 142. High.

When I told him, he immediately asked, “Should my kids get tested?”

His three children (ages 22, 25, and 28) all got tested. Two of them had elevated Lp(a). One had very high levels (over 180).

The 28-year-old was shocked. “But I’m healthy. I run. I eat well. This isn’t fair.”

“You’re right,” I told him. “It’s not fair. It’s genetics. But now you know. And knowledge is power. We can make sure you’re doing everything possible to offset this risk.”

All three kids are now being monitored and managed appropriately based on their Lp(a) levels. One simple test gave them information that will affect their healthcare for the rest of their lives.

What Can You Actually Do About High Lp(a)?

Okay, so here’s the frustrating part. Unlike regular cholesterol, we don’t have great ways to lower Lp(a) directly. Diet and exercise don’t do much. Standard statins can actually make it slightly worse.

But don’t despair. There’s still a lot we can do.

Optimize Everything Else

If you have high Lp(a), we need to be much more aggressive with your other risk factors:

LDL cholesterol: Target should be lower than standard guidelines suggest. Maybe aim for LDL under 70 or even under 55.

Blood pressure: Keep it well-controlled. Every point matters more when you have high Lp(a).

Blood sugar: No room for prediabetes or poorly controlled diabetes.

Weight: Maintain healthy weight, especially avoid belly fat.

Smoking: Absolutely not negotiable. Must quit.

Exercise: Regular physical activity, even though it doesn’t lower Lp(a) directly, it helps everything else.

Think of it like this: if one of your cardiovascular risk factors is stuck at high (Lp(a)), you need to be perfect with everything else you can control.

Medications That Help

PCSK9 inhibitors (like Repatha or Praluent) are injectable medications that lower both LDL cholesterol and Lp(a). They can reduce Lp(a) by about 20-30%. Not a cure, but significant.

These medications are expensive and usually reserved for people with very high cardiovascular risk. But if you have high Lp(a) plus other risk factors, you might qualify.

Aspirin may be beneficial if you have high Lp(a), though this should be discussed with your doctor based on your specific situation.

Statins should still be used if indicated for LDL cholesterol, even though they don’t lower Lp(a) (and might raise it slightly). The LDL-lowering benefit outweighs the small Lp(a) increase.

Supplements Worth Considering

Omega-3 fatty acids (fish oil) can modestly lower Lp(a) (maybe 5-10%) and also reduce inflammation and triglycerides. High-quality EPA/DHA, 2-4 grams daily.

Coenzyme Q10 may help, especially if you’re taking statins. 100-200mg daily.

L-carnitine shows some promise in research for lowering Lp(a), though evidence is limited. Worth discussing with your doctor.

Niacin (vitamin B3) can lower Lp(a) by up to 20-30%, but the side effects (flushing, itching) make it hard to tolerate, and outcome studies haven’t shown clear benefit despite the Lp(a) reduction.

Emerging Treatments (The Exciting Part)

Several new medications specifically targeting Lp(a) are in development:

Antisense oligonucleotides (like pelacarsen) can lower Lp(a) by 80-90%. Phase 3 trials are ongoing.

Small interfering RNA (siRNA) therapies are also in development and show similar dramatic reductions.

Within the next few years, we’ll likely have FDA-approved medications that can dramatically lower Lp(a). This is a game-changer.

If you have very high Lp(a), it might be worth asking your cardiologist about clinical trials for these new medications.

Lifestyle Strategies

Even though lifestyle doesn’t directly lower Lp(a), it still matters tremendously:

Anti-inflammatory diet: Mediterranean-style eating. Lots of vegetables, fish, olive oil, whole grains.

Regular exercise: Protects your cardiovascular system through multiple pathways even if it doesn’t lower Lp(a).

Stress management: Chronic stress accelerates cardiovascular disease. This matters even more with high Lp(a).

Good sleep: 7-9 hours. Poor sleep increases cardiovascular risk independently.

Don’t smoke: This should be obvious, but I’ll say it again.

The Family Connection

Here’s something important: if you have high Lp(a), your family members might too.

Lp(a) is inherited in an autosomal dominant pattern. That’s genetics-speak for: if one parent has the high-Lp(a) gene, each child has a 50% chance of inheriting it.

This means:

• If your Lp(a) is high, get your siblings and children tested
• If a parent had early heart disease, siblings should get tested
• Adult children (over 20) should get tested if a parent has elevated Lp(a)

Some of my patients feel guilty about this. “I gave this to my kids. It’s my fault.”

Stop. It’s not about blame. It’s about knowledge. You didn’t choose your genetics any more than your kids did. But by getting tested and having them tested, you’re giving everyone information they can use to protect their health.

That’s a gift, not a burden.

Common Questions I Get About Lp(a)

“My Lp(a) is high. Does that mean I’m definitely going to have a heart attack?”

No. It means your risk is higher than someone with low Lp(a), but it’s not a guarantee. Many people with high Lp(a) live long, healthy lives, especially if they manage their other risk factors aggressively.

“If I can’t lower it much, what’s the point of knowing?”

Because knowing changes how we manage everything else. It moves you from “average risk” to “high risk,” which means more aggressive treatment, closer monitoring, and access to preventive medications you might not otherwise qualify for.

“Should I test my kids?”

If they’re adults (over 18-20), yes. For younger children, talk to their pediatrician. There’s some debate about testing kids because we don’t treat them differently until they’re older anyway. But knowing the information can be valuable for long-term planning.

“Will insurance cover the test?”

Often yes, if you have appropriate indication (family history, personal cardiovascular history). Even if not, the test costs $20-50 out of pocket in most places.

“My doctor says testing Lp(a) isn’t necessary. What do I do?”

You could share the current guidelines from the American Heart Association recommending universal screening. Or you could find a doctor who stays current on cardiovascular risk assessment. Or you could order the test yourself through certain lab companies. You have options.

“I have high Lp(a) and I’m freaking out. What should I do right now?”

Take a breath. High Lp(a) is one risk factor among many. Focus on what you can control: your LDL cholesterol, blood pressure, blood sugar, weight, exercise, diet, stress, sleep. Get a good cardiologist who understands Lp(a). Consider seeing a preventive cardiologist or lipid specialist. You have more control than you think.

Frequently Asked Questions

Q: Can Lp(a) change over time?

A: Not much. Small variations can occur (maybe 10-20% variation), but your Lp(a) level is pretty stable over your lifetime. This is why testing once is usually enough. Some situations can temporarily affect it (pregnancy, illness, medications), but your baseline level is set by genetics.

Q: Does losing weight or eating healthy lower Lp(a)?

A: Unfortunately, no. Not significantly. Diet and exercise help cardiovascular health in many ways, but Lp(a) is one of the few things they don’t really affect. It’s frustrating, but that’s genetics for you.

Q: If my Lp(a) is normal, am I safe from heart disease?

A: Absolutely not. Normal Lp(a) is good, but you can still have other risk factors like high LDL cholesterol, high blood pressure, diabetes, smoking, family history, inflammation, etc. Lp(a) is just one piece of the puzzle.

Q: What number should I aim for with treatment?

A: We don’t have a specific treatment target yet because we haven’t had good treatments until recently. But lower is better. Any reduction is beneficial. When new medications become available, we’ll learn more about optimal targets.

Q: Can Lp(a) cause other problems besides heart disease?

A: Yes. High Lp(a) is also associated with aortic valve stenosis (valve disease requiring surgery), peripheral artery disease (circulation problems in legs), and possibly Alzheimer’s disease (though this is still being researched).

Q: If I have high Lp(a), should I take aspirin?

A: Maybe. This should be discussed with your doctor based on your overall risk profile. Aspirin has benefits but also risks (bleeding). The decision depends on your complete cardiovascular risk, not just Lp(a) alone.

Q: Are the new Lp(a)-lowering medications safe?

A: The early data looks promising, but they’re still in trials. We’ll know more in the next couple of years as these studies are completed and medications (hopefully) get FDA approval.

Q: Should I check my Lp(a) regularly once I know my number?

A: Usually not necessary. Once you know your number, that’s your number. Some doctors might recheck it if you start a medication that could affect it (like a PCSK9 inhibitor), but routine rechecking isn’t needed.

The Bottom Line

Lipoprotein(a) is a genetic cardiovascular risk factor that affects about 20% of people (1 in 5). Elevated Lp(a) increases your risk of heart attack and stroke as much as having very high LDL cholesterol, even if your regular cholesterol looks perfect.

Standard cholesterol tests don’t measure it. Most doctors don’t routinely check it. But major medical organizations now recommend testing it at least once in everyone’s lifetime.

If you have family history of early heart disease, you should definitely get tested. If you have high Lp(a), we can’t lower it much yet with current treatments, but we can be much more aggressive with your other risk factors, and new medications are coming soon that will dramatically lower Lp(a) levels.

Knowledge is power. One simple blood test can give you information that shapes your cardiovascular care for the rest of your life.

Don’t let this be the risk factor nobody tells you about.

Want Comprehensive Cardiovascular Assessment?

If you’re concerned about Lp(a) or other cardiovascular risk factors, especially if you have family history or mental health conditions that increase your risk, I can help.

In my practice, I routinely check Lp(a) as part of comprehensive cardiovascular assessment because I believe in knowing the full picture, not just basic cholesterol numbers.

Keep Reading

More about cardiovascular risk assessment:

• Your Cholesterol Is “Fine” But Your Heart Might Not Be (Advanced Testing)
• The Hidden Fire Inside You (Inflammation and heart disease)
• When Treating Depression Saves Your Heart
• Your Heart and Mind Are Connected: Complete Guide

References & Research

This article is based on current medical literature and guidelines:

1. Nordestgaard BG, Langsted A. (2024). Lipoprotein(a) and Cardiovascular Disease. Lancet. 404(10459):1255-1264. [Comprehensive recent review of Lp(a) as cardiovascular risk factor]
2. Wilson DP, et al. (2019). Use of Lipoprotein(a) in Clinical Practice: A Biomarker Whose Time Has Come. Journal of Clinical Lipidology. [Clinical practice guidelines on Lp(a) testing]
3. Vinci P, et al. (2023). Lipoprotein(a) as a Risk Factor for Cardiovascular Diseases: Pathophysiology and Treatment Perspectives. International Journal of Environmental Research and Public Health. 20(18):6721. [Mechanisms and treatment options]
4. Alhomoud IS, et al. (2023). Role of Lipoprotein(a) in Atherosclerotic Cardiovascular Disease: A Review of Current and Emerging Therapies. Pharmacotherapy. 43(10):1051-1063. [Emerging treatments for high Lp(a)]
5. Santos HO, et al. (2019). Lipoprotein(a): Current Evidence for a Physiologic Role and the Effects of Nutraceutical Strategies. Clinical Therapeutics. 41(9):1780-1797. [Supplements and natural approaches to Lp(a)]
6. Nordestgaard BG, et al. (2010). Lipoprotein(a) as a Cardiovascular Risk Factor: Current Status. European Heart Journal. 31(23):2844-53. [Establishing Lp(a) as independent risk factor]
7. Tsimikas S, et al. (2020). Statin Therapy Increases Lipoprotein(a) Levels. European Heart Journal. 41(24):2275-2284. [How statins affect Lp(a)]
8. Virani SS, et al. (2023). 2023 AHA/ACC Guidelines for Chronic Coronary Disease. Journal of the American College of Cardiology. 82(9):833-955. [Current guidelines including Lp(a) screening recommendations]
9. Emerging Risk Factors Collaboration. (2009). Lipoprotein(a) concentration and the risk of coronary heart disease, stroke, and nonvascular mortality. JAMA. 302(4):412-423. [Large epidemiological study establishing risk]
10. O’Donoghue ML, et al. (2019). Lipoprotein(a), PCSK9 Inhibition, and Cardiovascular Risk. Circulation. 139(12):1483-1492. [PCSK9 inhibitors and Lp(a) reduction]

For verification: Elevated Lp(a) (>50 mg/dL or >125 nmol/L) affects approximately 20% of the population. Lp(a) >50 mg/dL increases cardiovascular risk equivalent to LDL-C >190 mg/dL. PCSK9 inhibitors reduce Lp(a) by 20-30%. New antisense oligonucleotide therapies reduce Lp(a) by 80-90% in clinical trials. Current guidelines recommend screening Lp(a) at least once in all adults.

About Dr. Bliss Lewis

Dr. Bliss Lewis is a board-certified psychiatrist specializing in integrative medicine. She routinely checks Lp(a) in her patients because she believes comprehensive cardiovascular risk assessment should include this important genetic marker that most doctors overlook.

This article is for educational purposes. Decisions about testing and treatment should be made in consultation with healthcare providers familiar with your individual medical history.