Most people know their cholesterol numbers matter. Far fewer have heard of lipoprotein (a), or Lp(a), a genetic risk factor that could be quietly raising their chances of heart disease. Waqas Malick, MD, Director of the Lipids and Cardiometabolic Disease Program at Valley Health System, wants to raise awareness about Lp(a) so that individuals can better understand that risk. Here, he breaks down what cholesterol really is, common misconceptions, and why this lesser-known number deserves attention.
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What cholesterol actually does in the body
Cholesterol is a waxy, fat-like molecule found in every cell of the body. About 80% of it is determined genetically, while the remaining 20% comes from diet. Because cholesterol cannot travel through the bloodstream on its own, lipoproteins carry it to where it needs to go. LDL, the “bad” cholesterol, carries cholesterol into artery walls. Over time, excess LDL can become trapped in those walls, contributing to plaque buildup, blockages, and elevated risk of heart attack and stroke.
The biggest misconception about cholesterol
Dr. Malick points to a common myth: that eating healthy and living well automatically means cholesterol does not need to be addressed. In reality, there are two types of risk. Genetic risk means being born with high cholesterol levels, regardless of lifestyle. Acquired risk builds over a lifetime through factors like weight gain, diabetes, and high blood pressure.
“Cholesterol should be individualized per person,” Dr. Malick reinforces, rather than assumed to be a non-issue based on lifestyle alone.
Understanding LDL, HDL, and triglycerides
LDL cholesterol remains the most important and most modifiable risk factor for heart disease. HDL, the “good” cholesterol, helps carry cholesterol away from arteries and back to the liver for clearance. So, low HDL means less protection against the damage LDL can cause. Triglycerides, meanwhile, serve as a marker of metabolic health, often rising alongside conditions like fatty liver disease and diabetes. “LDL matters the most,” Dr. Malick notes. “Even if you have good HDL, if you have very high LDL, you can still form plaque in your arteries.”
What counts as a good LDL number?
Ideal LDL targets depend heavily on individual risk. Patients with genetic familial hypercholesterolemia –LDL above 190 from a young age –generally aim for LDL under 100, or under 70 if plaque is already present. For the general population, risk calculators factoring in diabetes, kidney disease, smoking, and obesity help guide personalized targets. Genetic research suggests that a naturally occurring LDL of 70 to 90 offers strong long-term protection against coronary disease and stroke.
What is lipoprotein(a)?
Unlike LDL, Lp(a) is entirely determined by genetics and unaffected by lifestyle. “You are born with this concentration, and it runs in families,” Dr. Malick explains. Current guidelines recommend that everyone have it checked at least once, particularly those with a family history of coronary disease, stroke, peripheral artery disease, or valve replacement. Lp(a) is considered more atherogenic than LDL, meaning it is more likely to contribute to plaque formation, and elevated levels are linked to earlier cardiovascular disease, heart attacks, and strokes.
Why lipoprotein (a) is called a "hidden" risk factor
Despite its significance, Lp(a) remains widely unchecked. National screening rates have improved, but still only 1-3% of patients have ever had it tested. “That's why we call it the hidden risk factor,” Dr. Malick shares. Testing is simple. It can be added to a standard lipid panel during an annual physical.
What elevated Lp(a) means for treatment
A result above 125 is considered high, with 75 to 125 currently classified as a gray zone still under research. For those with elevated Lp(a), managing other risk factors becomes even more important: lowering LDL, exercising, eating well, and avoiding diabetes and obesity.
For patients who already have cardiovascular disease and elevated Lp(a), newer medications called PCSK9 inhibitors are now recommended. Dr. Malick also stresses screening first-degree relatives, since Lp(a) runs strongly in families.
Personalizing risk and treatment
Family history plays one of the largest roles in risk assessment, regardless of specific cholesterol numbers. Nutrition remains foundational. Dr. Malick recommends healthy fats like olive oil, nuts, avocados, chia and flax seeds, and fish, paired with a high-fiber diet rich in leafy greens and whole grains, while limiting saturated fat. When lifestyle changes are not enough, imaging tools like a coronary artery calcium score – a measure of hard calcium plaque in your heart’s blood vessels – or carotid artery Doppler – an imaging test that uses sound waves to check blood flow and detect blocked or narrowed arteries – can help determine whether medication is warranted.
A word on triglycerides and heart health
The connection between triglycerides and cardiovascular risk remains an evolving area of research. At more moderate levels, elevated triglycerides signal metabolic risk. At very high levels, typically above 880 to 1,000, the primary concern shifts to pancreatitis, a serious and potentially recurring condition. Newer medications are now available specifically for patients with severely elevated triglycerides.
Where to start with understanding your cholesterol levels
For anyone unsure of their numbers, Dr. Malick's advice is straightforward: Establish care with a primary care clinician and get an annual lipid panel, including Lp(a). Those with more advanced risk can be referred to a lipids and cardiometabolic disease program for specialized care.
A final word of caution
Dr. Malick urges patients to be wary of cholesterol misinformation circulating on social media. “What people preach or say online may not apply to you as an individual,” he cautions. Individualized guidance from a primary care doctor or cardiologist remains the safest path forward.
If you have questions about your cholesterol or want to know whether Lp(a) testing is right for you, talk to your doctor. For more information and resources, visit ValleyHealth.com/Heart.
About the Author
Dr. Malick serves as the Director of Lipids and Cardiometabolic Disease for Valley Medical Group.
