PCSK9 inhibition
One in four clinicians never checks Lp(a), narrative review finds, blaming cost, isoform variability and thin treatment options for its clinical neglect (J Cardiovasc Dev Dis 2025)
Original title: Lipoprotein(a): Assessing the Current Knowledge and Gaps in Screening and Treatment-A Narrative Review
This narrative review examines why lipoprotein(a) screening remains limited in clinical practice despite growing evidence of its independent atherosclerotic risk, noting that one in four clinicians does not routinely check Lp(a) levels, reflecting a lack of awareness compounded by high testing cost and scarce treatment options. The review attributes part of the clinical hesitancy to significant apo(a) isoform-size variability, driven by differing numbers of kringle domains, which complicates assay standardisation and comparability of results, keeping the traditional LDL/HDL/triglyceride lipid profile as the practical gold standard. It notes statins have minimal effect on Lp(a), PCSK9 inhibitors lower it by 20-25% despite not being prescribed for that purpose, and gene-silencing therapies achieve the largest reductions but remain in phase 3 trials with cardiovascular benefit still unconfirmed. The authors argue ASCVD's complexity, including new-onset events in patients with well-controlled LDL, demands future interventional studies specifically testing whether PCSK9-inhibitor-driven Lp(a) reduction yields cardiovascular benefit independent of LDL.
Original abstract
Atherosclerotic cardiovascular disease (ASCVD) has long been screened using the traditional lipid profile, mainly focusing on LDL cholesterol. However, despite growing evidence supporting lipoprotein(a) [Lp(a)] as an independent risk factor involved in atherosclerosis, its clinical use remains limited. This review examines the reasons behind the limited use of Lp(a) screening in clinical practice, assessing its role in cardiovascular risk, comparing it to traditional lipid markers and evaluating current assessment methods. It also explores existing and emerging treatments, including gene-silencing therapies, for managing elevated Lp(a) levels. One in four clinicians does not routinely check Lp(a) levels, which proves a lack of awareness amongst them. The reasons for that are implied to be that the cost is too high and that available treatments are scarce. The traditional lipid profile, including LDL, high-density lipoprotein (HDL) and triglycerides, continues to be the gold standard for CV risk assessment. One limitation of using Lp(a) in clinical practice is the significant variability in apo(a) sizes, which results from the presence of multiple isoforms determined by the number of kringle domains. This structural diversity poses challenges in standardizing measurement methods, affecting the accuracy and comparability of results. While statins have a minimal impact on Lp(a), PCSK9-i lowers its levels by 20-25%, although this class is not prescribed primarily for this reason. Lastly, gene-silencing therapies, which achieve the greatest reduction in Lp(a) levels, are still in phase III trials, and there is still a need to examine whether this reduction translates into CV benefits. These limitations should not discourage further research, because ASCVD's complexity requires a more tailored approach. Current lipid-lowering therapy still fails in a minority of cases, as evidenced by new-onset cardiovascular events in patients with well-controlled LDL levels. There is a need for future interventional studies to assess whether a reduction in Lp(a) by PCSK9-i really translates into CV benefits, independent of LDL.
Summary written by lp-a.org from the published abstract; figures as published. Page updated 17 August 2026. Methods.