Lipoprotein(a) at a "Tipping Point": case to move to universal screening.

Elevated lipoprotein(a) [Lp(a)] is well established as a common risk factor for atherosclerotic cardiovascular disease (ASCVD). Lp(a) levels are >90 % genetically determined. However, Lp(a) remains very underrecognized as a cardiovascular risk factor with low rates of testing. In this article, the case for universal Lp(a) screening is outlined including the high yield of a single test and the relative stability in levels and risk categories over time resulting in a need to test most people once. Additionally, Lp(a) testing impacts clinical management. At a minimum, elevated Lp(a) is associated with multiple cardiovascular diseases and Lp(a) measurement may be incorporated into more precise individual risk assessment. Elevated Lp(a) should prompt more aggressive risk factor modification, particularly low-density lipoprotein-cholesterol (LDL-C) lowering and a preference for Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i). There may also be a role for aspirin use in primary prevention based on currently available evidence. Identification of elevated Lp(a) also enables cascade screening to further identify affected individuals and helps to enable further research and individuals who may be candidates for novel therapies. While there are strategies to address increased cardiovascular risk in individuals with elevated Lp(a) today, it is clear that residual risk remains, and there are several novel, targeted therapies for lowering Lp(a) that are in advanced stages of development, which are also reviewed. Lp(a) remains underappreciated and undertested in clinical practice, and there are several arguments in favor of testing today with hope for potent targeted therapies for Lp(a)-lowering in the very near future.