Approach to the Patient with Elevated Lipoprotein(a)

Lipoprotein(a) [Lp(a)] is a common, genetically determined lipoprotein that is independently associated with myocardial infarction, stroke, peripheral artery disease, and calcific aortic stenosis. Because Lp(a) levels are stable over time and minimally influenced by lifestyle, the 2026 ACC/AHA/Multisociety Dyslipidemia Guideline now recommends one-time measurement in all adults and cascade screening in high-risk families; as a result, endocrinologists can expect to encounter and manage elevated Lp(a) frequently in routine clinical practice. Despite its clinical importance, no approved drug therapies specifically targeting Lp(a) yet exist, therefore management should currently focus on aggressive optimization of traditional risk factors, particularly LDL-C lowering with statins and selective use of adjunctive therapies such as PCSK9 inhibitors and lipid apheresis. Emerging evidence suggests potential benefit of selective aspirin use, while novel therapeutics – anti-sense oligonucleotides and small interfering RNAs – which robustly lower Lp(a) are currently being tested in phase 3 clinical trials. We present case-based examples to highlight practical approaches to risk assessment and management of elevated Lp(a).