Use of Lipoprotein(a) in Clinical Practice
Recommendations
I. Laboratory measurement of lipoprotein(a)
1. For the measurement of Lp(a), it is recommended that an immunochemical assay that is calibrated against the WHO/IFCCLM secondary reference material should be used and reported in nmol/L.
(I, B-NR)2. When using values of Lp(a) for clinical risk assessment and treatment decisions, the use of a factor to convert Lp(a) values from mg/dL to nmol/L is not recommended.
(III - No Benefit, C-EO)3. When Lp(a) values are used for ASCVD risk assessment in Caucasian patients, it is reasonable to use measured values ≥50 mg/dL or ≥100 nmol/L as levels suggesting increased risk.
(IIa, B-R)II. Lipoprotein(a) testing in clinical practice
1. Adults (aged ≥20 y)
a. Measurement of Lp(a) is reasonable to refine risk assessment for ASCVD events in:
1) Individuals with a family history of first-degree relatives with premature ASCVD (<55 y of age in men; <65 y of age in women).
(IIa, C-LD)2) Individuals with premature ASCVD (males aged <55 y and females aged <65 y), particularly in the absence of traditional risk factors.
(IIa, B-NR)3) Individuals with primary severe hypercholesterolemia (LDL ≥190 mg/dL) or suspected FH.
(IIa, B-NR)4) Individuals at very high** risk of ASCVD to better define those who are more likely to benefit from PCSK9 inhibitor therapy.
(IIa, B-NR)b. Measurement of Lp(a) may be reasonable with:
1) Intermediate (7.5%–19.9%) 10-y ASCVD risk when the decision to use a statin is uncertain, to improve risk stratification in primary prevention.
(IIa, B-NR)2) Borderline (5%–7.4%) 10-y ASCVD risk when the decision to use a statin is uncertain, to improve risk stratification in primary prevention.
(IIb, B-NR)3) Less-than-anticipated LDL-C lowering, despite good adherence to therapy.
(IIb, C-LD)4) A family history of elevated Lp(a).
(IIb, C-LD)5) Calcific valvular aortic stenosis.
(IIb, C-LD)6) Recurrent or progressive ASCVD, despite optimal lipid-lowering therapy.
(IIb, C-LD)2. Youth (aged <20 y)
a. Measurement of Lp(a) may be reasonable with:
1) Clinically suspected or genetically confirmed FH.
(IIb, C-LD)2) A family history of first-degree relatives with premature ASCVD (<55 y of age in men, <65 y of age women).
(IIb, C-LD)3) An unknown cause of ischemic stroke.
(IIb, C-LD)4) A parent or sibling found to have an elevated Lp(a).
(IIb, C-LD)III. Treatment
1. In adults aged 40-75 y with a 10-y ASCVD risk of 7.5%–19.9%, the finding of an Lp(a) ≥50 mg/dL or ≥100 nmol/L is reasonable to be used as a risk-enhancing factor to favor initiation of a moderate- or high-intensity statin in those with on-treatment LDL-C ≥70 mg/dL (or non–HDL-C ≥100 mg/dL).
(IIa, B-NR)2. In high-risk* or very-high-risk** patients, with Lp(a) ≥50 mg/dL or ≥100 nmol/L, it is reasonable to consider more intensive LDL-C lowering to achieve greater ASCVD risk reduction.
(IIa, A)3. In very-high-risk** patients, taking a maximally tolerated statin with Lp(a) ≥50 mg/dL or ≥100 nmol/L, the addition of ezetimibe is reasonable in those with on-treatment LDL-C ≥70 mg/dL (or non–HDL-C ≥100 mg/dL).
(IIa, B-R)4. In high-risk* patients taking a maximally tolerated statin, with Lp(a) ≥50 mg/dL or ≥100 nmol/L, the addition of ezetimibe may be reasonable in those with on-treatment LDL-C ≥70 mg/dL (or non–HDL-C ≥100 mg/dL).
(IIb, B-R)5. In very-high-risk** patients taking a maximally tolerated statin and ezetimibe, with an LDL-C ≥70 mg/dL (or non–HDL-C ≥100 mg/dL) and an Lp(a) of ≥50 mg/dL or ≥100 nmol/L, the addition of a PCSK9 inhibitor is reasonable.
(IIa, B-R)6. Niacin, which lowers Lp(a) concentration, is not recommended to reduce ASCVD risk in patients receiving moderate- to high-intensity statins 1/2 ezetimibe and an on-treatment LDL-C <80 mg/dL.
(III - Harm, A)7. HRT with estrogen and progesterone, which lowers Lp(a) concentration, is not recommended in perimenopausal/postmenopausal women to reduce ASCVD risk.
(III - Harm, B-R)** Very high risk 5 Individuals with a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions.
† The NLA grading system adopted the methodology and classification system used in the 2015 ACC/AHA Clinical Practice Guideline Recommendation
Classification System.4 All recommendations were graded by the Class (or strength) of the Recommendation and by the Levels (or quality) of the Evidence
supporting the Recommendation.
Recommendation Grading
Disclaimer
Overview
Title
Use of Lipoprotein(a) in Clinical Practice
Authoring Organization
National Lipid Association
Publication Month/Year
May 1, 2019
Last Updated Month/Year
March 16, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
It reviewed an array of evidence-based considerations for testing of Lp(a) in clinical practice and the utilization of Lp(a) levels to inform treatment strategies in primary and secondary prevention.
Target Patient Population
Patients with risk of atherosclerotic cardiovascular disease
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Prevention, Management
Diseases/Conditions (MeSH)
D050171 - Dyslipidemias, D020521 - Stroke, D009203 - Myocardial Infarction, D008074 - Lipoproteins, D011322 - Primary Prevention, D055502 - Secondary Prevention, D017270 - Lipoprotein(a)
Keywords
dyslipidemia, lipoprotein(a), lipoprotein