What Is Lp(a)? The Inherited Cholesterol Risk Factor Most Singaporeans Have Never Heard Of
- Dr Chan Po Fun
- 3 days ago
- 7 min read
Dr Chan Po Fun [MBBS, MRCP, FRCP (UK), FAMS (Cardiology)] is a consultant cardiologist in Singapore with a focused practice in lipid management and cardiovascular risk reduction.
What Is Lp(a)?
Most people who have had a cholesterol test have seen their LDL, HDL and total cholesterol results. Far fewer have ever seen their Lp(a).
![Diagram of lipoprotein(a) [Lp(a)] particle structure showing apolipoprotein(a) attachment — inherited cardiovascular risk factor](https://static.wixstatic.com/media/faf328_f82f5b3e488845c7b50bd002cf2f2cf6~mv2.png/v1/fill/w_770,h_520,al_c,q_90,enc_avif,quality_auto/faf328_f82f5b3e488845c7b50bd002cf2f2cf6~mv2.png)
Lipoprotein(a), written as Lp(a) and pronounced "L-P-little-a", is a lipid particle in the blood that significantly raises the risk of heart attack, stroke, and coronary artery disease. It is separate from LDL cholesterol, behaves differently, and is not measured in a standard cholesterol panel.
Approximately 1 in 5 people globally has elevated Lp(a). In Singapore, with its large South Asian and Chinese populations, this is clinically highly relevant. Yet most patients have never been tested.
Lp(a) is a hidden cardiovascular risk factor that is genetically determined, unaffected by diet or statins, and not part of routine screening. This article explains what it is, why it matters, who should be tested, and what can be done about it.
Lp(a) is a genetically inherited cholesterol particle that raises heart attack and stroke risk but is not tested in a standard cholesterol panel.
Why Lp(a) Raises Cardiovascular Risk
Lp(a) is structurally similar to LDL cholesterol, but with an additional protein called apolipoprotein(a) attached to it. This additional component gives Lp(a) two properties that make it particularly harmful:
It promotes atherosclerosis, the build-up of plaque in artery walls, in a similar way to LDL cholesterol, contributing to the narrowing of coronary arteries over time.
It has prothrombotic effects, meaning it promotes blood clot formation. This is why elevated Lp(a) is associated not only with coronary artery disease but also with aortic valve disease and an increased risk of blood clots.
The result is that patients with elevated Lp(a) carry higher cardiovascular risk than their standard lipid panel suggests. A patient whose LDL looks controlled on a statin may still have significantly elevated total cardiovascular risk if their Lp(a) has never been measured.
What Makes Lp(a) Different From LDL Cholesterol
Understanding this distinction is important, because the two risk factors require different management approaches.
LDL cholesterol is determined by a combination of genetics, diet, weight, and lifestyle. It responds well to statins, dietary changes, and exercise.
Lp(a) is almost entirely genetically determined. It does not change meaningfully with diet, exercise, or weight loss. Statins do not lower Lp(a), and in some patients, statins may actually cause a modest rise in Lp(a) levels.
This means that a patient who is "well controlled" on a statin may still have a significant untreated risk factor if their Lp(a) has never been checked.
How Common Is Elevated Lp(a)?
Elevated Lp(a), defined as above 50 mg/dL or above 125 nmol/L depending on the assay used, affects approximately 20% of the general population.
It is more commonly elevated in:
Individuals of South Asian descent (a population well represented in Singapore)
Individuals of African descent
People with a strong family history of early cardiovascular disease People with familial hypercholesterolaemia (FH)
Importantly, elevated Lp(a) occurs across all body types and lifestyles. It is not related to being overweight, having a poor diet, or being sedentary. A lean, fit, non-smoking patient can have very high Lp(a) and be at substantially elevated risk without knowing it.
Who Should Be Tested for Lp(a)?
Current international guidelines, including the 2021 ESC/EAS dyslipidaemia guidelines and the 2025 ESC update, recommend that Lp(a) be measured at least once in every adult's lifetime.
Testing is particularly important if you have:
A strong family history of heart attack, stroke, or coronary artery disease, especially in first-degree relatives before age 60
Had a heart attack or stroke yourself at a younger-than-expected age LDL cholesterol that remains persistently high despite treatment
A diagnosis of familial hypercholesterolaemia
Aortic valve disease, particularly calcific aortic stenosis
Unexplained high cardiovascular risk despite apparently good cholesterol control
In Singapore's clinical context, I also test Lp(a) routinely in patients of South Asian origin given the elevated prevalence in this population, and in any patient presenting with cardiovascular disease whose standard risk factors do not fully explain their risk.
If you have never had your Lp(a) measured, it is worth asking your doctor for this test, particularly if any of the above apply.
What Do the Results Mean?
Lp(a) is measured in mg/dL or nmol/L, and different laboratories use different units. The key thresholds to be aware of are:
Below 30 mg/dL (75 nmol/L): considered low risk from Lp(a) 30 to 50 mg/dL (75 to 125 nmol/L): borderline, warrants attention in context of other risk factors
Above 50 mg/dL (125 nmol/L): elevated, associated with significantly increased cardiovascular risk
Above 180 mg/dL (430 nmol/L): very high, associated with a risk comparable to heterozygous familial hypercholesterolaemia
Because Lp(a) levels are largely stable throughout adult life, a single measurement is generally sufficient for risk stratification. It does not need to be repeated annually.
How Is Elevated Lp(a) Managed?
This is the area where Lp(a) management differs most significantly from standard LDL management, and where some patients feel frustrated, because the options have historically been limited.
The current approach centres on three strategies:
Aggressive management of all other cardiovascular risk factors
Because Lp(a) itself cannot be lowered by lifestyle measures, the response is to reduce every other modifiable risk factor as aggressively as possible. This means tighter LDL targets, often below 1.4 mmol/L or even lower in high-risk individuals, as well as optimal blood pressure control, glucose management in diabetic patients, smoking cessation, and regular physical activity.
In practice, identifying elevated Lp(a) often leads to a meaningful change in how aggressively a patient's other risk factors are managed. A patient who was previously considered moderate risk may be reclassified as high risk, with correspondingly lower LDL targets and earlier consideration of advanced lipid therapies.
Niacin and PCSK9 inhibitors
Niacin (nicotinic acid) can reduce Lp(a) by 20 to 30% but is rarely used today due to side effect concerns and the absence of clear cardiovascular outcome benefit in large trials.
PCSK9 inhibitors (evolocumab, alirocumab) lower Lp(a) modestly, by approximately 20 to 25%, in addition to their primary effect on LDL. For patients with both elevated LDL and elevated Lp(a), PCSK9 inhibitors therefore offer dual benefit. This is one reason why PCSK9 inhibitor therapy may be particularly appropriate for patients with both conditions.
Emerging Lp(a)-specific therapies
This is an area of significant development globally. Several novel therapies specifically targeting Lp(a) are in late-stage clinical trials, with some results expected in the next few years. These include RNA-based therapies that can reduce Lp(a) by 80% or more. None are yet approved for routine clinical use, but this is a rapidly evolving field.
For patients with significantly elevated Lp(a), staying informed about emerging options is relevant, and a cardiologist with a specific interest in lipid management can help navigate this as the evidence develops.
Want to understand what your Lp(a) result means for your management?
The Practical Takeaway
Lp(a) is a genuinely important risk factor that most patients have never had measured.
It does not respond to lifestyle changes or statins. It is not included in a standard cholesterol test. And for approximately 1 in 5 people, it is meaningfully elevated.
If you have a strong family history of early heart disease, unexplained cardiovascular risk, or LDL that has been difficult to control despite treatment, Lp(a) testing may materially change how your risk is understood and managed.
The test is simple. The result is stable. And knowing your Lp(a) level gives you and your cardiologist a more complete picture of your true cardiovascular risk.
About Dr Chan Po Fun
Dr Chan Po Fun is a consultant cardiologist in Singapore with a focused practice in lipid management, including Lp(a) assessment and risk counselling, familial hypercholesterolaemia, statin intolerance, and advanced lipid therapies.
She tests Lp(a) routinely as part of a complete cardiovascular risk assessment and provides personalised guidance on what the result means for each patient's management.
Consultations are available at Gleneagles Hospital and Mount Alvernia Hospital. No referral is required.
Frequently Asked Questions
Is Lp(a) included in a standard cholesterol test?
No. A standard lipid panel measures total cholesterol, LDL, HDL, and triglycerides. Lp(a) is a separate test that must be specifically requested. Most patients have never had it measured, even if they have been on statin therapy for years.
Does Lp(a) change with diet or exercise?
No. Lp(a) is almost entirely genetically determined. Diet, exercise, and weight management, which are important for LDL and overall cardiovascular health, have virtually no effect on Lp(a) levels. This is what makes it a distinct and sometimes overlooked risk factor.
Can statins lower Lp(a)?
Statins do not meaningfully lower Lp(a). In some patients, statins may cause a modest rise in Lp(a). This is one reason why Lp(a) testing is important even in patients who appear well controlled on statin therapy — their LDL may be at target while Lp(a) remains elevated.
How often does Lp(a) need to be tested?
Because Lp(a) levels are largely stable throughout adult life, a single measurement is generally sufficient for risk stratification. It does not need to be repeated annually unless there is a specific clinical reason.
My Lp(a) is high. Does that mean I will definitely have a heart attack?
No. Elevated Lp(a) is a risk factor, not a certainty. It means your cardiovascular risk is higher than your standard cholesterol panel suggests, and that more aggressive management of other modifiable risk factors is warranted. Many patients with elevated Lp(a) live long, healthy lives with appropriate cardiovascular risk management.
Are there treatments specifically for Lp(a)?
Currently, there are no approved therapies that specifically target Lp(a) with high efficacy. The management strategy is to reduce all other modifiable risk factors more aggressively, and in some cases PCSK9 inhibitors offer modest Lp(a) lowering alongside their primary LDL effect. Dedicated Lp(a)-lowering therapies are in late-stage clinical trials and are expected to become available in coming years.
I have South Asian heritage. Should I be tested?
Yes. Elevated Lp(a) is more prevalent in individuals of South Asian descent. Given Singapore's large South Asian population, Lp(a) testing is particularly relevant and is recommended as part of a complete cardiovascular risk assessment.
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