Recommendations for Lipoprotein (a)

1. Laboratory measurement of Lp(a)
   For the measurement of Lp(a), it is recommended that an immunochemical assay that is calibrated against the WHO/IFCCLM secondary reference material should be used and reported in nmol/L
   When using values of Lp(a) for clinical risk assessment and treatment decisions, the use of a factor to convert Lp(a) values from mg/dL to nmol/L is not recommended
   
   
2. Lipoprotein(a) testing in clinical practice
   1. Adults (aged ≥18 y): Measurement of Lp(a) in all adults is reasonable to refine risk assessment for ASCVD events
   2. Recommends selective screening of Lp(a) in high-risk children <18 years of age. This includes children with:
      1. clinically suspected or genetically confirmed FH;
      2. first-degree relatives with a history of premature ASCVD (age <55 years in men, <65 years in women);
      3. ischemic stroke of unknown cause; 
      4. first-degree relatives with elevated Lp(a)
   3. When Lp(a) levels are used for ASCVD risk assessment, it is reasonable to use measurements ≥125 nmol/L (≥50 mg/dL) as levels suggesting high risk, levels <75 nmol/L (<30 mg/dL) as low risk, and levels between as intermediate risky 
      
      
3. Treatment
   1. In adults aged 40–75 y with a 10-y ASCVD risk of 7.5 %–19.9 %, the finding of an Lp(a) ≥125 nmol/L or ≥50 mg/dL is reasonable to be used as a risk-enhancing factor to favor initiation of a moderate- or high-intensity statin in those with on-treatment LDL-C ≥ 70 mg/dL (or non-HDL-C ≥ 100 mg/dL)
   2. In high-risk or very-high-risk patients with Lp(a) ≥125 nmol/L or ≥50 mg/dL, it is reasonable to consider more intensive LDL-C lowering to achieve greater ASCVD risk reduction
   3. In high-risk or very-high-risk patients taking a maximally tolerated statin, with Lp(a) ≥125 nmol/L or ≥50 mg/dL, the addition of ezetimibe is reasonable in those with on-treatment LDL-C ≥ 70 mg/dL (or non-HDL-C ≥ 100 mg/dL)
   4. In high-risk or very-high-risk patients taking a maximally tolerated statin, with Lp(a) ≥125 nmol/L or ≥50 mg/dL, the addition of a PCSK9 inhibitor is reasonable in those with on-treatment LDL-C ≥ 70 mg/dL (or non-HDL-C ≥ 100 mg/dL)
   5. Lipoprotein apheresis is reasonable for high-risk patients with FH and ASCVD (coronary or peripheral arteries) whose Lp(a) level remains ≥60 mg/dL (∼150 nmol/L) and LDL-C ≥ 100 mg/dL on maximally tolerated lipid-lowering therapy
   6. Niacin or HRT with estrogen and progesterone, which lower Lp(a) concentration, is not recommended to reduce ASCVD
      
      

Definition:
High-risk patients: clinical ASCVD including myocardial infarction, acute coronary syndrome, stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral artery disease, including aortic aneurysm, all of atherosclerotic origin.

Very-high-risk patients: history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions.