The approval of the first pill to combat LDL cholesterol in the United States marked a breakthrough, expanding the arsenal of available medications. However, this new development does not address a specific form of cholesterol that concerns cardiologists, and that most people are unaware of having.
This is lipoprotein(a), or Lp(a), a fraction of cholesterol that is almost entirely determined by genetic factors. High levels of this substance are associated with a risk of heart attack that can be up to three times higher.
The peculiarity of its name, with the lowercase “a” and the diminutive form “Lp(a)” used among doctors, hides a significant risk factor. Only now is Lp(a) beginning to receive due attention in clinics, driven by new health recommendations and the expectation of innovative treatments capable of reducing its levels.
Cholesterol that is inherited: the influence of genes and not diet
Unlike LDL cholesterol, whose levels can be influenced by eating habits, weight and medication use, lipoprotein(a) is predominantly dictated by family inheritance.
According to cardiologist Elzo Mattar, director of the Arterial Hypertension Department of the Brazilian Society of Cardiology (SBC) and professor at the São José do Rio Preto State School of Medicine (Famerp), around 90% of the individual Lp(a) value comes from genetics.
It is estimated that approximately one in five people has high levels of Lp(a), often without being aware of the condition.
“Lipoprotein(a) is mainly determined by genetics and is not corrected with diet. The person is born with a predisposition to have higher or lower levels”, explains the specialist.
This genetic origin makes Lp(a) a unique challenge: it is an important factor, but difficult to control, as diet, physical exercise and mainstay statins in cholesterol management have little or no effect on it.
The impact of high lipoprotein(a) levels on cardiovascular health
Interest in lipoprotein(a) has increased as observational studies have established a link between its high levels and serious outcomes. According to Mattar, concentrations above 50 mg/dL equivalent to the highest quartile of the population are related to a risk of heart attack approximately three times higher. Furthermore, this fraction also contributes to aortic valve calcification, a common condition in elderly individuals.
Functioning independently of LDL cholesterol, lipoprotein(a) acts as an additional risk marker. This means that two people with identical levels of “bad” cholesterol may have different cardiovascular risks, depending on their Lp(a) values.
The recent change in the recommendation for lipoprotein(a) dosage
For many years, measuring lipoprotein(a) did not have much practical impact, since there were no specific treatments and the result hardly changed medical management. However, this panorama began to change.
In March 2026, the guideline on dyslipidemia, published by the American College of Cardiology and the American Heart Association, together with other medical entities, started to recommend that all adults carry out lipoprotein(a) measurement at least once in their lives. This orientation is also endorsed by Mattar.
“The current recommendation is that each individual check their lipoprotein level at least once in their life to know their own cardiovascular risk”, says the cardiologist.
This is a simple blood test, generally performed once, as values tend to remain stable throughout life. Although discovering a high level of Lp(a) does not mean, for now, starting a specific medication to reduce it, the information serves as an essential warning to intensify the control of other modifiable risk factors.
“Those with high lipoproteins need to take extra care: keep LDL at low levels, triglycerides under control, blood pressure and blood glucose in order, in addition to practicing physical activity and following a balanced diet”, advises the specialist.
New therapies in development promise advances against genetic cholesterol
The lack of specific therapeutic options for Lp(a) may be coming to an end. Currently, several pharmaceutical companies are developing and testing substances aimed at reducing lipoprotein(a). Among them, pelacarsene, from Novartis, is the most promising, a monthly injection that, in initial studies, demonstrated a fraction reduction of around 80%.
This drug is the main focus of the Horizon study, the first large clinical trial designed to see whether lowering lipoprotein(a) actually results in a reduction in heart attacks and strokes. The study follows more than 8 thousand patients over several years.
The complete results of the study are expected by the end of 2026, with presentations scheduled for the Congress of the European Society of Cardiology (ESC), which will take place at the end of August, in Munich. Other therapeutic approaches, including a tablet version, are also in the testing phase.
Mattar, however, highlights a crucial distinction between the expectation of a new treatment and the proof of its benefits: the reduction of lipoprotein(a) is still not equivalent to the reduction of cardiovascular events.
“It is likely that the reduction in lipoprotein(a) will bring benefits, but we do not yet have studies that confirm this relationship. Research that demonstrates a significant reduction in heart attacks and strokes requires follow-up for more than five years”, he explains.
This is exactly the gap that the studies to be presented in the coming weeks are beginning to fill: they will seek not only to demonstrate how effective the new drugs are in reducing lipoprotein(a), but, more importantly, whether this decrease translates into a lower number of heart attacks.
For now, even without direct treatment to change it, the lipoprotein(a) level is a valuable piece of information to know, as it signals the importance of diligently protecting all other aspects of health.
And, in a few months, the medical community will be able to confirm that a risk, which for a long time could only be identified, can finally be mitigated, and, above all, that its reduction effectively saves lives.
