Testing
A 44-year-old woman with low calculated ASCVD risk but severe, calcified coronary disease illustrates why Lp(a) testing shouldn't wait for guideline mandates, case-based review argues (Am Heart J Plus 2025)
Original title: Lipoprotein(a) and coronary artery disease: The need for universal screening - A case-based review
This case-based review presents a 44-year-old premenopausal White woman with controlled stage 2 hypertension and a low calculated 10-year ASCVD risk score who presented with exertional chest discomfort and was found to have a heavily calcified proximal left anterior descending artery stenosis requiring percutaneous coronary intervention; elevated Lp(a) was identified as a contributing risk factor missed by standard risk calculators. The authors note the global prevalence of Lp(a) above 50 mg/dL is roughly 1.43 billion people, and that despite growing recognition of Lp(a) as an independent ASCVD risk factor by multiple international scientific statements, the 2018 ACC/AHA cholesterol guideline still classifies it only as a risk enhancer, a stance the authors argue, together with the lack of approved Lp(a)-specific therapy, has kept US testing rates below 1% of the general population. They conclude this case exemplifies how inadequate Lp(a) assessment underestimates cardiovascular risk and argue for universal screening now, ahead of investigational Lp(a)-lowering therapies reaching approval.
Original abstract
Introduction: Atherosclerosis cardiovascular disease (ASCVD), especially coronary artery disease (CAD), remains the leading cause of death worldwide, with several well-identified risk factors. This case report presents a premenopausal female with low calculated ASCVD risk, hypertension, elevated lipoprotein(a) [Lp(a)], and clinically significant CAD.
Case Report: A 44-year-old premenopausal White female with controlled stage 2 hypertension, and overall low calculated 10-year ASCVD risk, was found to have severe CAD. She presented to the clinic with worsening chest discomfort during exertion and was diagnosed with a heavily calcified proximal left anterior descending artery stenosis, necessitating percutaneous coronary intervention.
Discussion: The global prevalence of elevated Lp(a) >50 mg/dL is around 1.43 billion. Elevated lipoprotein(a) is now recognized, based on the preponderance of the evidence, by several international scientific statements as an independent risk factor for ASCVD, including CAD. Nevertheless, the current 2018 American College of Cardiology (ACC) and American Heart Association (AHA) multi-society guideline on the Management of Blood Cholesterol only classifies Lp(a) as a risk enhancer. This recommendation, along with the lack of approved pharmacotherapy has contributed to limited testing in current United States clinical practice (<1 % for the general population). Furthermore, the inadequate assessment of Lp(a) may lead to an underestimation of ASCVD risk.
Conclusion: This case highlights the shortcomings of inadequate assessment of Lp(a) leading to the underestimation of cardiovascular risk. Accordingly, with multiple recent international scientific statements, clinicians should universally screen for elevated Lp(a). In the future, investigational therapies for lowering Lp(a) may be crucial for improving patient outcomes.
Summary written by lp-a.org from the published abstract; figures as published. Page updated 17 August 2026. Methods.