A 46-year-old woman with no diabetes mellitus or hypertension presents for preventive cardiovascular (CV) assessment. Her mother had a myocardial infarction at 54 years of age.
Her lipid profile shows LDL-C level 108 mg/dL, HDL-C level 58 mg/dL, and triglyceride level 92 mg/dL. Her Lp(a) level, measured once in her adulthood, is 186 nmol/L.
The correct answer is: B. Her elevated Lp(a) level is a risk-enhancing factor that should influence the intensity of her preventive strategy.
Lp(a) levels should be measured at least once in every adult. A concentration of 186 nmol/L is elevated and identifies genetically mediated, lifelong ASCVD risk that is not captured fully by the standard lipid profile. Management should focus on earlier and more intensive control of modifiable risk factors—particularly LDL-C levels—and may include cascade testing of first-degree relatives. At present, treatment decisions should not assume that lowering Lp(a) levels with an available nonspecific agent improves outcomes; dedicated Lp(a)-lowering therapies remain an evolving field. Guidelines and consensus statements recognize elevated Lp(a) levels as a risk-enhancing factor that supports earlier and more intensive management of modifiable risk.
Lp(a) level contributes independently to ASCVD risk, so a near-goal LDL-C level does not neutralize the inherited risk associated with a markedly elevated Lp(a) level. Additionally, Lp(a) is predominantly genetically determined and usually stable. Routine annual testing is unnecessary unless a specific clinical circumstance would change interpretation. Although niacin can lower Lp(a) levels, findings from randomized outcomes trials have not demonstrated CV benefit sufficient to recommend niacin solely for this purpose.
This patient case quiz is part of the larger Implementing the 2026 Dyslipidemia Guidelines: From Risk Stratification to Personalized Treatment initiative, supported by Merck & Co. and Eli Lilly and Company. To visit the Learn Prevention grant page and access additional educational activities on this topic, click here.
References
- Blumenthal RS, Morris PB, Gaudino M, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of dyslipidemia: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2026;87(19):2624-2757. doi:10.1016/j.jacc.2025.11.016
- Koschinsky ML, Bajaj A, Boffa MB, et al. A focused update to the 2019 NLA scientific statement on use of lipoprotein(a) in clinical practice. J Clin Lipidol. 2024;18(3):e308-e319. doi:10.1016/j.jacl.2024.03.001
- Kronenberg F, Mora S, Stroes ESG, et al. Lipoprotein(a) in atherosclerotic cardiovascular disease and aortic stenosis: a European Atherosclerosis Society consensus statement. Eur Heart J. 2022;43(39):3925-3946. doi:10.1093/eurheartj/ehac361
