Black individuals have the highest Lp(a) levels of any ethnicity studied, followed by South Asians, complicating a single universal risk threshold, a review (Atherosclerosis 2022)

The initial studies focusing on lipoprotein(a) [Lp(a)] and its role in atherosclerotic cardiovascular disease were conducted exclusively in Whites. Subsequently, multiple large-scale, independent investigations have established clear race/ethnic differences in plasma Lp(a) concentration and population distribution over the last four decades. Blacks have the highest Lp(a) level of all race/ethnic groups studied followed by South Asians, Whites, Hispanics and East Asians. The mechanisms underlying these differences have been sought and genetics plays an important role in providing insights into the observed differences. The association of elevated Lp(a) level with cardiovascular disease risk in different race/ethnic groups has also been studied. These studies show that, in general, elevated Lp(a) level is associated with cardiovascular risk in all groups. However, given race/ethnic differences in Lp(a) level and distribution, finding an appropriate Lp(a) threshold that predicts risk, meaningfully categorizes risk among individuals, and guides preventive therapy use has been challenging. In this review, we discuss the available evidence regarding race/ethnic differences in Lp(a) and the underlying mechanisms. Additionally, the association of Lp(a) with cardiovascular risk in various race/ethnic groups and the nuances of identifying the appropriate Lp(a) threshold are discussed. The key points on Lp(a) and ethnicities are described in Box 1.