Optimizing lipoprotein(a) testing for immediate clinical impact in primary prevention

Guidelines recommend measuring lipoprotein(a) [Lp(a)] at least once in all adults, but testing remains limited in clinical practice. We evaluated pragmatic strategies to maximize the immediate clinical impact of Lp(a) testing on the need of lipid-lowering treatment (LLT) in a primary prevention setting.

In 24,994 individuals aged 50-65 years from the population-based Swedish Cardiopulmonary BioImage Study (SCAPIS), we assessed: (i) whether self-reported data can identify individuals likely to have elevated Lp(a) (≥50 mg/dL) and thus serve as a pre-screening tool, and (ii) how the clinical impact of Lp(a) testing-defined as eligibility for LLT according to ESC/EAS guidelines-varies by age and sex.

Self-reported data poorly predicted elevated Lp(a) (ROC-AUC 0.54). Overall, incorporating Lp(a) levels increased eligibility for LLT from 11.3% to 19.6%. However, the clinical impact varied by age and sex. The number needed to screen (NNS) to identify one additional individual eligible for LLT was lowest in men aged 50-60 years (≈10-15) and women ≥55 years (<20 at age 55 and < 10 at age 65), but substantially higher in younger women (NNS >50).

Elevated Lp(a) cannot be reliably identified using self-reported data. Incorporation of Lp(a) levels substantially increased eligibility for LLT. Targeting testing in men ≥50 years and women ≥55 years maximizes immediate clinical utility and may serve as a pragmatic interim strategy pending broader implementation of universal Lp(a) testing.