Lipoprotein(a): The Genetic Heart Risk Marker Everyone Should Know

Most people are familiar with having their cholesterol checked. You go for your annual blood work, your doctor looks at your total cholesterol, LDL, HDL and triglycerides, and if those numbers fall within the normal range, you probably assume your cardiovascular health is in pretty good shape.

But what if I told you there is another important cardiovascular marker that isn't included in a standard cholesterol panel, and approximately 1 in 5 people has an elevated level without even knowing it?

It's called Lipoprotein(a), or Lp(a), and unlike many of the other cardiovascular markers we monitor, this one is largely determined by your genetics.

That means you can eat a healthy diet, exercise regularly, maintain a healthy weight and have seemingly normal cholesterol levels, yet still carry an inherited risk factor for cardiovascular disease.

This is one of the reasons I include Lp(a) in my comprehensive blood work. I want to understand the bigger picture of someone's cardiovascular health, not simply whether their cholesterol is considered high or normal.

What Exactly Is Lipoprotein(a)?

Lipoprotein(a) is a type of particle circulating in your bloodstream that carries cholesterol and other fats. It is structurally similar to LDL, often referred to as "bad cholesterol," but it has an additional protein attached to it called apolipoprotein(a).

That extra protein makes Lp(a) different from ordinary LDL particles and is part of what makes elevated levels particularly concerning.

Research has established that elevated Lp(a) is an independent risk factor for atherosclerotic cardiovascular disease, including coronary artery disease, heart attack and ischemic stroke. It is also associated with calcification of the aortic valve, which can eventually contribute to a condition called aortic stenosis.

What makes this important is that someone can have a relatively reassuring standard cholesterol panel and still have elevated Lp(a). Without specifically ordering this test, that additional risk factor may go undetected for years.

Why Genetics Play Such a Big Role

One of the most interesting things about Lp(a) is that its concentration is primarily inherited. Unlike triglycerides, insulin resistance or even LDL cholesterol, which can be significantly influenced by diet, exercise, body composition and other lifestyle factors, Lp(a) is largely determined by the genes you inherit from your parents.

In other words, having elevated Lp(a) doesn't necessarily mean you've been eating poorly, exercising too little or doing something wrong with your health. You could be doing many of the right things and still have an elevated result.

For most people, Lp(a) levels remain relatively stable throughout adulthood, although certain medical conditions and hormonal changes can influence them. This is why having Lp(a) measured at least once in adulthood is so valuable. One blood test can identify an inherited cardiovascular risk factor you may have carried for much of your life.

The National Lipid Association recommends that every adult have Lp(a) measured at least once, yet it still isn't routinely included in standard cholesterol testing.

Think about that for a moment. Approximately 20% of the population has elevated Lp(a), but many people have never even heard of it.

What Is Considered a High Lp(a) Level?

When I review blood work, I think it's important that clients understand what their actual numbers mean rather than simply being told a marker is high or low.

Lp(a) may be reported in either nmol/L or mg/dL, depending on the laboratory. According to the National Lipid Association, the following ranges can help us understand cardiovascular risk:

Lp(a) Level	Risk Category
Below 75 nmol/L or 30 mg/dL	Lower risk
75–124 nmol/L or 30–49 mg/dL	Intermediate risk
125 nmol/L or higher, or 50 mg/dL or higher	Higher risk

An Lp(a) of 125 nmol/L or higher, or 50 mg/dL or higher, is considered an important cardiovascular risk-enhancing factor.

One thing worth mentioning is that nmol/L and mg/dL cannot be converted using a simple mathematical formula because Lp(a) particles vary in size. Always interpret your result using the units provided by your laboratory.

And remember, cardiovascular risk doesn't suddenly appear when you cross a particular number. Risk generally increases as Lp(a) levels rise, so the result needs to be considered alongside your other blood markers, family history and overall health.

Family History: An Important Piece of the Puzzle

Because Lp(a) is strongly influenced by genetics, an elevated result may provide valuable information not only about your cardiovascular health but also about your family's.

I always pay attention when someone tells me that heart disease runs in their family, especially when a parent, sibling or grandparent experienced a heart attack or stroke at a relatively young age.

Maybe your father had a heart attack in his early 50s, or a sibling developed coronary artery disease despite being active and eating reasonably well. There may be several contributing factors, but elevated Lp(a) could be one of the inherited risks worth investigating.

When someone has elevated Lp(a), parents, siblings and children should be encouraged to discuss testing with their healthcare providers. This approach, called cascade screening, can help identify family members who may also have increased cardiovascular risk.

This is particularly valuable because it creates an opportunity to address other cardiovascular risk factors long before symptoms or disease develop.

Why I Look at Lp(a) Alongside ApoB

If you've read my recent blog post, ApoB: The Heart Health Marker You May Not Be Testing, you already know that I believe there is much more to cardiovascular health than simply looking at total cholesterol or LDL.

ApoB and Lp(a) are two markers I find particularly valuable because they provide different, but complementary, information.

ApoB helps us understand the number of potentially artery-damaging lipoprotein particles circulating in the bloodstream. Each atherogenic particle, including LDL, VLDL remnants and Lp(a), carries one ApoB molecule.

Lp(a), on the other hand, identifies a specific genetically influenced type of particle that carries additional cardiovascular risk.

ApoB includes Lp(a) particles in its overall count, but an ApoB result cannot tell us how much of that particle burden comes specifically from Lp(a). That is why measuring both can be useful.

When we combine these results with LDL, HDL, triglycerides, blood pressure, inflammation markers and metabolic blood work, we can begin to understand someone's cardiovascular risk in a much more meaningful way.

This is also why I don't like evaluating cholesterol in isolation. Two people may have similar LDL cholesterol levels but very different ApoB levels, Lp(a) concentrations, metabolic health and family histories.

If you're interested in learning more about how your lipid panel connects to metabolic health, I've also written about why triglycerides deserve more attention and what your triglyceride-to-HDL ratio can reveal.

Can You Lower Lp(a) Naturally?

This is usually one of the first questions people ask when they learn their Lp(a) is elevated, and the answer is a little different from what we're used to hearing about other cardiovascular markers.

Diet, exercise and weight loss generally do not substantially lower genetically elevated Lp(a). This doesn't mean those habits aren't important. In fact, I would argue that knowing you have elevated Lp(a) makes taking care of the cardiovascular risk factors you can influence even more important.

If you have an inherited risk factor that you cannot easily change, the goal becomes reducing the additional risk associated with elevated ApoB, LDL cholesterol, blood pressure, insulin resistance, smoking and other modifiable factors.

For example, someone with elevated Lp(a) who also has high ApoB, elevated blood pressure and insulin resistance has a very different cardiovascular risk profile than someone with elevated Lp(a) whose other risk factors are well controlled.

This is where a comprehensive approach to nutrition, lifestyle and appropriate medical care becomes so valuable.

What Can You Do If Your Lp(a) Is Elevated?

When I work with clients, my goal is never to focus on one isolated number. I want to understand what is happening throughout the body and identify areas where we can make meaningful improvements.

With elevated Lp(a), I would pay particularly close attention to ApoB, LDL cholesterol, triglycerides, fasting insulin, glucose, hemoglobin A1C, blood pressure and inflammation markers such as hs-CRP. I would also consider family history, body composition, activity level, sleep and dietary habits.

From a nutrition and lifestyle perspective, there are several areas worth focusing on.

Support healthy cholesterol and ApoB levels. Increasing soluble fiber through foods such as oats, beans, lentils, vegetables and other plant foods can help lower LDL cholesterol. Replacing excessive saturated fat with unsaturated fats from olive oil, nuts, seeds, avocado and fish may also be beneficial, depending on the individual.

Pay attention to blood sugar and insulin resistance. Even when fasting glucose appears normal, elevated insulin can indicate that the body is working harder to maintain blood sugar balance. Improving insulin sensitivity through nutrition, physical activity, strength training and appropriate body composition changes can support long-term metabolic and cardiovascular health.

Make movement a regular part of your routine. Both cardiovascular exercise and strength training are important. Walking, cycling, swimming and resistance training can support blood pressure, insulin sensitivity, body composition and overall cardiovascular fitness.

Include omega-3-rich foods. Fatty fish such as salmon, sardines and mackerel provide EPA and DHA, which support cardiovascular health and can help lower elevated triglycerides. Omega-3s are not an established treatment for lowering Lp(a), but they can be part of a heart-healthy eating pattern.

Don't overlook sleep, blood pressure and smoking. Poor sleep, untreated high blood pressure and smoking can add to cardiovascular risk. When an inherited risk factor is already present, addressing these areas becomes especially important.

Depending on age, family history and overall cardiovascular risk, a physician may also recommend additional evaluation, such as a coronary artery calcium (CAC) scan. This can sometimes help clarify risk, although a calcium score of zero does not eliminate the risk associated with elevated Lp(a).

What About Medication?

For some people, particularly those with established cardiovascular disease, significantly elevated Lp(a) or multiple additional risk factors, lifestyle changes alone may not be enough to adequately reduce cardiovascular risk.

Although conventional cholesterol-lowering medications such as statins do not meaningfully lower Lp(a) itself, they can reduce LDL cholesterol and the risk of cardiovascular events. Other medications, including PCSK9 inhibitors, can lower LDL substantially and also reduce Lp(a) to a modest degree.

Researchers are also studying therapies specifically designed to lower Lp(a), which makes this an exciting and evolving area of cardiovascular medicine. However, lowering the Lp(a) number and demonstrating a reduction in heart attacks or strokes are not necessarily the same thing, and cardiovascular outcome evidence remains important.

For now, the priority is to work with your physician or cardiologist to determine whether more intensive LDL and ApoB lowering or other treatment is appropriate based on your overall risk.

Why I Include Lp(a) in Comprehensive Blood Work

One of the things I emphasize in my practice is that blood work should help us understand what's happening in the body rather than simply identify whether individual markers fall inside a laboratory's reference range.

When I'm reviewing cardiovascular health, I want to understand not only cholesterol levels but also particle burden, metabolic health, inflammation and inherited risk.

That is why my comprehensive blood work may include markers such as ApoB, Lp(a), a full lipid panel, fasting insulin, glucose, hemoglobin A1C, hs-CRP and other markers based on the individual.

These results give us an opportunity to have a much more meaningful conversation about cardiovascular health, particularly when someone has a family history of heart disease or has been told their cholesterol looks normal but still has other concerning risk factors.

The goal isn't to create unnecessary worry. It's to identify what we may be missing and understand where we can take action.

The Bottom Line: Know Your Lp(a)

Cardiovascular disease often develops silently over many years, which is why I believe understanding your risk before symptoms appear is so important.

If you've never had your Lp(a) measured, I encourage you to ask about it, especially if heart disease runs in your family or someone close to you experienced a heart attack or stroke at a young age.

Approximately 1 in 5 people has elevated Lp(a), and most will never know unless the test is specifically ordered.

An elevated result doesn't mean you're destined to develop heart disease, but it does give you information that can help guide decisions about your health. And while we may not be able to significantly change a genetically elevated Lp(a) through lifestyle alone, there is still a great deal we can do to support cardiovascular health and reduce overall risk.

If you're interested in taking a deeper look at your cardiovascular and metabolic health, I offer comprehensive blood work with a personalized review to help you understand your results and identify areas worth addressing.

Book your free 15-minute consultation to learn more about working together. And if you know someone who could benefit from understanding this often-overlooked cardiovascular marker, please feel free to pass this article along.