Doctors often use a routine lipid panel – a blood test that measures levels of fat in the blood – to assess cardiovascular risk. Cardiovascular disease remains the leading cause of death worldwide. Among the many numbers a lipid panel reports, one is often missing despite its strong ability to predict heart disease. That number is Lipoprotein(a) or Lp(a). Though elevated Lp(a) levels are found in around 1.6 billion people globally, it is almost never measured.
A recent review paper published in the European Journal of Preventive Cardiology, led by physician-scientists at the Centre for Heart Lung Innovation (HLI), argues that it is time to change how and when we test for this overlooked risk factor.
The review, written by by Drs. Iulia Iatan and Gordon Francis, with co-authors Drs. Liam Brunham and John Mancini, presents a comprehensive case for testing Lp(a). It draws on clinical guidelines, epidemiologic and genetic data, and public health principles.
As Dr. Gordon Francis notes, “It is now recommended that Lp(a) be measured at the same time as the first cholesterol profile.”
How Lp(a) is unique and why it matters
Lp(a) is not your typical cholesterol biomarker. Unlike low-density lipoprotein (LDL) cholesterol – the “bad” cholesterol that raises heart disease risk and can change with diet or lifestyle changes – Lp(a) levels are genetically determined and remain stable throughout life.
Years of large-scale and genetic studies have shown that Lp(a) is an independent, causal risk factor for atherosclerotic cardiovascular disease and aortic stenosis. In other words, Lp(a) is associated with the development of both blocked arteries and narrowing of the heart valves. The higher someone’s Lp(a) is, the greater their risk is. Importantly, this risk is present even in individuals with low LDL cholesterol levels.
“The risk of atherosclerotic cardiovascular disease with markedly elevated Lp(a) is equal to that of untreated familial hypercholesterolemia.” – Dr. Gordon Francis
The authors cite a major study of 5.5 million U.S patients, where less than 1% had their Lp(a) levels measured. Yet, it is estimated that 1 in 5 people worldwide have elevated levels (Lp(a) > 125 nmol/L), making it as common as high blood pressure or smoking in some populations.
The evidence is clear, but underused
When evaluating Lp(a) against classical and modern population-level screening principles, the authors’ conclusion was clear: Lp(a) screening checks nearly every box. It is common, easy to measure with a reliable and simple blood test, provides actionable information to guide patient care, and is cost-effective.
In British Columbia, a one-time Lp(a) test costs just $29.61. As the authors note, “the value of knowing the result of the test is likely to be higher than the cost of the test.” That value includes helping doctors better predict who is most at risk so that they can intervene earlier and potentially prevent cardiovascular events and reduce associated healthcare costs.
While there is not yet an approved treatment that directly lowers Lp(a), several therapies are in late-stage clinical trials and expected to report outcomes within the next year. Still, the authors emphasize that Lp(a) testing can already be useful in informing care. Knowing a patient’s Lp(a) level can help clinicians decide whether to lower other modifiable risk factors more intensively, such as lowering LDL cholesterol levels or prioritizing imaging.
Test results can also prompt screening of family members, especially when there is history of premature cardiovascular disease or inherited high cholesterol (familial hypercholesterolemia).
According to Dr. Iulia Iatan, “When we identify a patient with elevated Lp(a), it’s not just about that individual – it’s an opportunity to screen family members and intervene earlier.”
As Dr. Francis notes, “When elevated Lp(a) is found, it is recommended to review the family history for premature cardiovascular events, try to reduce all other risk factors like smoking or elevated blood pressure, possibly perform a blood vessel imaging study like a carotid ultrasound or coronary calcium score, and consider initiating statin therapy to mitigate the risk of the high Lp(a).”
Global guidelines already recommend Lp(a) screening
International guidelines are beginning to reflect the growing consensus on the importance of Lp(a). Canadian and European lipid guidelines, as well as the American National Lipid Association, now recommend one-time Lp(a) testing for all adults, preferably when they get their first lipid panel.
Yet, as the paper highlights, “this recommendation has not been incorporated into a formalized screening programme in any health jurisdiction to our knowledge.” The authors suggest that Lp(a) testing could serve as a catalyst to reevaluate how lipids are screened at the population level.
Awareness isn’t enough
The authors conclude with a clear call to action: “The time has come to qualify Lp(a) as a routine screening test for cardiovascular risk assessment based on these cornerstone criteria.”
This paper reflects the ongoing leadership of physician-scientists at HLI, who continue to shape the future of proactive preventive medicine. Their efforts are helping change how inherited cardiovascular risks are detected, managed, and ultimately prevented in routine care.
Take a look at the full open-access article here:
Iulia Iatan, Marlys L Koschinsky, Logan Trenaman, Wei Zhang, George Thanassoulis, Liam R Brunham, G B John Mancini, Gordon A Francis, Rationale for the routine screening of Lipoprotein(a) in cardiovascular risk assessment, European Journal of Preventive Cardiology, 2025;, zwaf342, https://doi.org/10.1093/eurjpc/zwaf342