An analysis of prescribing decisions for nearly 30,000 patients found most clinicians did not order preventive medications for patients with elevated lipoprotein(a) (Lp[a]) levels who were at low risk for atherosclerotic cardiovascular disease (ASCVD).

However, some clinicians did prescribe lipid-lowering therapy. In rare cases, patients received aspirin or a PCSK9 inhibitor, according to a multicenter retrospective cohort study of patients who were tested for Lp(a).

“There is still uncertainty about how to respond when we see an elevated Lp(a), especially in patients who otherwise do not meet traditional treatment thresholds,” Kevin Maymi Quintana, MD, co-author and an internal medicine resident at Boston University, Boston, told Medscape Medical News.

The research is set to be published in the American Journal of Preventive Cardiology and presented at the upcoming American College of Cardiology Scientific Session 2026.

While there has been growing interest in examining Lp(a) as a risk factor for ASCVD, current guidelines recommend measuring it once per lifetime as part of a first lipid profile because it is a genetic risk factor that generally remains the same over time.

The latest guidelines recommend reducing modifiable risk factors to lower the risk for ASCVD but do not provide explicit recommendations on pharmacotherapy for patients with elevated Lp(a).

Occasional Preventive Prescribing

The researchers used data from the TriNetX US Collaborative Network electronic health record platform to match 14,969 patients who had elevated Lp(a) with an equal number of patients who did not. The patients were seen at 70 US healthcare organizations between January 2021 and January 2026. Researchers considered patients to have an elevated Lp(a) if the value was ≥ 125 nmol/L.

The elevated and nonelevated Lp(a) groups were similar with regard to age (mean age, 49.1 vs 49.3 years), race (White individuals, 70.0% vs 70.7%), and sex (women, 61.8% vs 62.1%). The percentage of patients with hypertension (22.5% vs 21.9%) and hyperlipidemia (28.6% vs 28.2%) were also comparable.

Patients were excluded if they had a family history of ischemic heart disease, used nicotine, had developed ASCVD within 3 years of their Lp(a) measurement, or had used lipid-lowering therapies, PCSK9 inhibitors, aspirin, niacin, or bempedoic acid 3 years after their Lp(a) measurement.

The primary outcome was the proportion of patients who started lipid-lowering therapy in the 90 days after the Lp(a) measurement. Secondary outcomes included the proportion of patients who initiated a PCSK9 inhibitor or aspirin as secondary outcomes.

Overall, 21.4% of patients started lipid-lowering therapy in the 90 days following an Lp(a) measurement compared to 9.4% of patients without an elevated Lp(a) measurement (risk ratio [RR], 2.29; 95% CI, 2.16-2.43). Statins were the most commonly initiated therapy (20.8%).

Although less often prescribed, patients with elevated Lp(a) were also more likely to start aspirin (2.1% vs 1.2%; RR, 1.79; 95% CI, 1.49-2.16) or a PCSK9 inhibitor (0.53% vs 0.12%; RR, 4.39; 95% CI, 2.63-7.32) than patients with non-elevated Lp(a). The results for lipid-lowering therapy, aspirin, and PCSK9 inhibitor initiation persisted out to 180 days in a prespecified sensitivity analysis.

Lp(a) Increasingly Part of Patient Conversations

Researchers also conducted a time-to-event analysis and found patients with elevated Lp(a) were more likely to initiate lipid-lowering therapy, aspirin, or PCSK9 inhibitors than those who did not have elevated Lp(a).

The results suggest some clinicians may be unsure how to best proceed following an elevated Lp(a) result in discussions with patients, said Om Kothari, MD, who is also a co-author and an internal medicine resident at Boston University.

“Our findings are suggesting that clinicians are starting to incorporate Lp(a) in cardiovascular risk discussions, even for patients who don’t really reach traditional treatment thresholds, but the clinician responses to that elevated concentration of Lp(a) are heterogeneous,” he told Medscape Medical News.

Lp(a) levels are considered in the picture of the whole patient, but the picture is less clear when a patient doesn’t have a classic elevated ASCVD risk score, Rohan Ganti, MD, MPH, co-author and a cardiovascular disease fellow at Rutgers Robert Wood Johnson Medical School, told Medscape Medical News. Ultimately, future studies are needed to determine whether it is beneficial to treat low-risk patients with elevated Lp(a) levels, he said.

“While we don’t yet have an approved therapy that specifically lowers it, identifying Lp(a) can help clinicians potentially intensify management of other cardiovascular risk factors while we await results for ongoing trials of Lp(a)-targeted therapies,” he said.

Lowering Risk Factors After Elevated Lp(a)

The most notable finding was that prescribing of lipid-lowering therapy is low among clinicians, Eugenia Gianos, MD, director of Cardiovascular Prevention for Northwell Health, New York City, told Medscape Medical News. Gianos was not involved with the research.

“There is a misconception in the medical community and in the lay public that there is nothing we can do about risk related to Lp(a) until targeted therapies come to the market,” she said. “In fact, optimization of all modifiable risk factors in patients with elevated Lp(a) has been associated with a 67% lower risk among those with elevated Lp(a).”

The latest guidelines on dyslipidemia management “brings Lp(a) guided preventive care to the next level, clearly illustrating the graded increased risk noted at increased levels of Lp(a),” said Gianos, who is a co-author of the guidelines.

While preventive statin therapy does not lower Lp(a) levels, statins and PCSK9 inhibitors do reduce cardiovascular risk in patients with elevated Lp(a), Gianos noted.

“Lipoprotein(a) is a genetically determined causal risk factor for cardiovascular disease, and it needs to be recognized as game changing for preventive care,” she said.

No authors reported relevant financial relationships. Gianna reported being a site principal investigator for the HORIZON, OCEAN(a), and ACCLAIM-Lp(a)trials.

Jeff Craven is an independent journalist living in Wilmington, Delaware.