07/22/2026
Despite the New Guidelines, Why I Am Not Routinely Checking Lp(a) in My Patients. Just Yet.
The 2026 ACC/AHA Dyslipidemia Guidelines recommend measuring Lipoprotein(a), or Lp(a), at least once in an adult's lifetime. Lp(a) is a sticky form of cholesterol determined primarily by genetics that is thought to be an independent risk factor for arterial blockages, heart attacks, and strokes.
I attended 2026 American College of Cardiology (ACC) conference where the buzz surrounding Lp(a) was palpable. Furthermore, the internet is currently flooded with articles about it, prompting many of my patients to ask for the test.
Over my decades of practice as a cardiologist, I am always looking out for game-changers to combat cardiovascular disease—the number one killer across the globe. However, despite the new universal screening guidelines, I am still not routinely ordering Lp(a) tests for all of my patients for three specific reasons:
1. No Targeted Medications Are Currently Available
While there are at least six pharmaceutical companies currently developing promising compounds, none of them is yet available for standard clinical prescriptions.
2. Lowering Lp(a) May Not Necessarily Reduce Heart Disease
In medicine, we cannot assume that correcting a biological marker will automatically translate into fewer clinical events. History teaches us to be cautious:
• The HDL Trap: For decades, we believed increasing HDL ("good" cholesterol) would reduce heart attacks, yet multiple drugs designed to raise HDL failed in advanced clinical trials.
• The Homocysteine Misstep: Similarly, we once believed high homocysteine levels caused arterial blockages and aggressively lowered them with vitamins, only for subsequent research to show that lowering the number did not actually translate into reduced cardiovascular disease.
3. Fluctuations Challenge the "Once-in-a-Lifetime" Testing Rule
The foundational premise of the ACC recommendation is that Lp(a) levels remain stable across a lifespan, meaning a patient only needs to be tested once. However, many of us with busy practices have noted significant fluctuations in a patient’s Lp(a) levels when checked at different times. Until the medical community establishes better standardized laboratory testing procedures—or revises the "once-in-a-lifetime" protocol—the reliability of a single test remains a question mark.
