Decentralized Lipoprotein(a) Testing in Adults With Atherosclerotic Cardiovascular Disease: Initial Findings From the UNRAVEL Study

Background Lipoprotein(a) [Lp(a)] is an established cardiovascular risk factor, yet testing remains uncommon and often depends on clinician-initiated pathways. We evaluated the feasibility of decentralized Lp(a) testing among adults with atherosclerotic cardiovascular disease (ASCVD) in the United States. Methods The Understanding Racial and Ethnic Variations in Lipoprotein(a) (UNRAVEL) Study was a cross-sectional observational study integrating electronic health record (EHR)–enabled outreach, remote enrollment, participant-reported assessments, medical record verification, and decentralized laboratory testing. Results Among 2,463 individuals completing prescreening, 1,117 (45.3%) were eligible, 922 (82.5%) enrolled, and 917 (99.5% of enrolled participants) completed laboratory testing, yielding an analytical cohort of 921 adults with confirmed ASCVD. Recruitment involved multiple pathways, including EHR-enabled outreach, provider referrals, community engagement, and digital recruitment. The cohort included 606 White (65.8%), 141 Hispanic (15.3%), 135 Black (14.7%), and 39 South Asian (4.2%) participants. Overall, 61.5% had prior myocardial infarction or coronary revascularization, 33.4% had ischemic stroke, and 5.3% had symptomatic peripheral artery disease. Median Lp(a) was 40 nmol/L (IQR, 11–163), with 27.3% having levels ≥125 nmol/L. Despite efforts toward inclusive recruitment, enrollment remained geographically concentrated and uneven across racial and ethnic groups. Among 432 exit survey respondents (46.9%), overall study experience was rated highly (mean, 9.3/10). Conclusion UNRAVEL demonstrates the feasibility of EHR-enabled outreach, remote participation, and decentralized laboratory testing outside conventional testing pathways. High testing completion and favorable participant experiences notwithstanding, geographic concentration and potential digital selection bias highlight the need for inclusive recruitment and stronger linkage to clinical care.