Focus on lipoprotein(a)

Abstract Lipoprotein(a) [Lp(a)] is a causal and independent cardiovascular risk factor for atherosclerotic cardiovascular disease and calcific aortic valve stenosis, with elevated levels observed in approximately 20% of the general population. Plasma Lp(a) concentrations are predominantly determined by genetic factors, particularly polymorphisms of the LPA gene, which modulate apolipoprotein(a) [apo(a)] size and influence its hepatic synthesis. Structurally, Lp(a) consists of an LDL-like particle containing apolipoprotein B100, covalently bound to apo(a), conferring markedly enhanced atherogenic, pro-inflammatory, and prothrombotic properties compared with an LDL particle. In the absence of therapies specifically approved for Lp(a) reduction, current clinical management relies on an intensive approach to global cardiovascular risk reduction. ESC/EAS guidelines recommend aggressive lowering of LDL cholesterol, particularly through high-intensity statin therapy and, in patients at high or very high risk, the addition of ezetimibe and PCSK9 inhibitors, in order to mitigate the residual risk associated with elevated Lp(a) levels. Lipoprotein apheresis represents the only intervention capable of producing a substantial and immediate reduction in Lp(a); however, its use is limited to selected patients due to its invasive nature and limited availability. In parallel, innovative therapies targeting LPA gene silencing—such as antisense oligonucleotides and small interfering RNA—as well as oral agents inhibiting Lp(a) assembly, are in advanced stages of development. These approaches have demonstrated Lp(a) reductions of up to 80–90%, offering concrete prospects for a causal therapeutic strategy, pending the results of cardiovascular outcome trials.