Highlights

• This document aims to provide practical guidance on testing and management of Lp(a) for primary and secondary ASCVD risk management
• There is a graded relationship between Lp(a) level and ASCVD risk
• The 2026 ACC/AHA Multisociety Guideline on the Management of Dyslipidemia joins recommendations from the NLA and others for universal Lp(a) screening in adults at least one time
• Lp(a) levels are mostly determined by genetic factors, but specific conditions may warrant repeat testing, especially for individuals with intermediate levels
• Cascade screening of first-degree relatives is also recommended, especially with a family history of premature ASCVD
• Strategies to reduce ASCVD risk, including lifestyle interventions and pharmacologic lipid-lowering therapies, may be intensified in adults who have high Lp(a)
• Phase III cardiovascular outcomes trials, in both primary and secondary prevention settings, are in progress and the first of its kind trial is expected to report in 2026

Abstract

Background: Lipoprotein(a) [Lp(a)] is a unique apolipoprotein B (ApoB)-containing lipoprotein, similar to low-density lipoproteins (LDL). Plasma concentrations of Lp(a) are largely genetically determined. High Lp(a) levels are recognized as a causal and independent risk factor for ASCVD and are an important contributor to residual ASCVD risk. International guidelines reflect the importance of measuring Lp(a) at least once in all adults as an important component of ASCVD risk assessment and management.

Objective: This document aims to summarize the guidelines recommending universal measurement of Lp(a), including the associated risk thresholds that can be used to identify individuals with higher ASCVD risk based on their plasma Lp(a) concentrations. Additionally, direction on managing patients with high Lp(a) is provided as well as information on therapies in development to lower Lp(a)

Methods: The most recent statements and updates from international societies were reviewed for guidance on Lp(a) measurement and management with particular attention to the 2026 ACC/AHA Multisociety Guideline on the Management of Dyslipidemia. Information on pharmaceutical agents that are in late stages of development for targeted lowering of Lp(a) is also summarized.

Results: The synthesis of existing information on how to manage patients with elevated Lp(a) reinforces the importance of measurement of Lp(a) in all adults at least once in their lifetime and provides direction on when repeated measurement may be warranted. In the absence of available drugs to specifically and effectively lower Lp(a), management of modifiable risk factors is encouraged. Furthermore, the large contribution of genetics to the determination of Lp(a) levels underscores the importance of cascade screening of family members to identify at-risk individuals.

Conclusions: There is broad recognition of the importance of measuring Lp(a) at least once in all adults, owing to the recognized role of elevated Lp(a) as an important ASCVD risk enhancer. At present, this information is useful in risk stratification and can guide optimal management of ASCVD risk in patients. However, the potential for new Lp(a) lowering therapies to specifically and substantially reduce Lp(a) levels underscores the importance of Lp(a) measurement in all adults.