High Lp(a)? New Research Says This Could Cancel Out the Risk
New data show Lp(a) may only raise heart risk if paired with belly fat or inflammation. A simple waist-to-hip ratio could help you assess—and reduce—your true cardiovascular risk.
Imagine my surprise when a past letter on Lp(a) turned out to be one of the most popular I’ve ever written. I hadn't expected that.
To me, Lp(a) seemed like a highly specialized, even esoteric topic—something for academic circles, not a general audience.
But I was clearly mistaken. In hindsight, I now understand why it struck a cardiac chord.
Lp(a) has entered the public health conversation as a genetically determined, causal risk factor for cardiovascular disease. It’s no longer just a lab curiosity.
Briefly, Lp(a) is a type of lipoprotein particle—similar to LDL particles. But unlike LDL particles, Lp(a) has an apolipoprotein(a) tail that makes it “sticky,” more likely to promote blood clotting, and more atherogenic than LDL on a per-particle basis.
In short: Lp(a) is more dangerous than LDL—and worse, we don’t yet have effective treatments that lower Lp(a) and are proven to reduce cardiovascular risk.
That combination—a potent, genetically determined atherogenic particle with few, if any, effective therapies—makes Lp(a) something of a cardiovascular boogeyman.
If you're new to Lp(a) and already lost, take the scenic route through the prior Lp(a) letter and then return to this data digest.
A Roadmap to Today’s Letter
Today, I want to share a new 2025 study that gave me real hope—and even some peace of mind—about my own elevated Lp(a). Here's the roadmap for this video:
First, we’ll explore new findings on the relationship between Lp(a) and waist circumference.
Then, we’ll discuss mechanisms and describe other factors that can modify the relationship between Lp(a) and cardiovascular risk.
Finally, we’ll draw from the broader literature to puzzle together a specific protocol to reduce visceral fat and, potentially, reduce cardiovascular risk associated with high Lp(a).
Let’s dig in…
The Study: Waist-to-Hip Ratio Modifies Lp(a) Risk
The goal of this new study was to determine whether a measure of adiposity—waist-to-hip ratio—modifies the relationship between Lp(a) and cardiovascular disease risk.
To explore this, researchers analyzed data from 4,652 participants in the Multi-Ethnic Study of Atherosclerosis (MESA), following them over a median of 17.4 years. During that time, 792 participants developed new cardiovascular disease-related events.
*Nuance note: Here ‘new cardiovascular disease-related events’ is technically defined as myocardial infarction (heart attack), fatal and nonfatal coronary heart disease, definite angina, and probable angina if followed by revascularization, resuscitated cardiac arrest, fatal and nonfatal stroke (not transient ischemic attack), and other atherosclerotic or CVD death.
The study stratified individuals based on Lp(a) levels—defined as >50 mg/dL—and investigated how this risk interacted with waist-to-hip ratio as a marker of central adiposity. The findings were striking…
*Nuance note: if you have your Lp(a) in units of nmol/L, the conversion is as follows: Lp(a) (nmol/L) = Lp(a) (mg/dL) x 2.15.
Elevated Lp(a) Does Not Confer Increased Risk in Those with Lower Waist-to-Hip Ratio
Among those with high Lp(a), individuals with a higher waist-to-hip ratio were three times more likely to experience a cardiovascular event compared to those with high Lp(a) but a lower waist-to-hip ratio. And, remarkably, in individuals with a lower waist-to-hip ratio, Lp(a) levels were not significantly associated with increased cardiovascular risk.
In other words: If your waist-to-hip ratio is low, even high Lp(a) levels may pose much less concern for cardiovascular disease risk.
To drive this point home, take a look at the following graph. It shows the cumulative incidence of cardiovascular disease over ~20 years. Each line represents a different combination of Lp(a) levels and waist-to-hip ratios:
Blue line: Lower waist-to-hip ratio + low Lp(a)
Black line: Higher waist-to-hip ratio + low Lp(a)
Red line: Higher waist-to-hip ratio + high Lp(a)
Orange line: Lower waist-to-hip ratio + high Lp(a)
What stands out is that the orange line closely tracks with the blue line, suggesting that in leaner individuals, even genetically elevated Lp(a) carries minimal or no additional risk for cardiovascular disease.
This is a striking—and encouraging—finding for those with high Lp(a) who maintain a leaner, more metabolically healthy profile.
The “Tertiles” Tell the Same Story
Here’s another quick way to look at the data: When researchers divided participants into “tertiles”—three equally sized groups based on waist-to-hip ratios sampled in this study—a clear pattern emerged.
In both the lowest (left) and middle tertiles of waist-to-hip ratio, high Lp(a) did not confer a higher incidence of cardiovascular events compared to those with low Lp(a).
The increase in cardiovascular disease risk appeared only in the highest waist-to-hip tertile (right), i.e. the top third of participants with the greatest central adiposity. In that group, elevated Lp(a) was clearly associated with increased risk of cardiovascular events.
The takeaway is simple: According to these data, Lp(a) appears to elevate cardiovascular risk only in individuals with a high waist-to-hip ratio.
In the rest of this letter, we discuss:
Specific waist-to-hip ratio goals to aim for based on your sex.
Mechanisms by which an elevated waist-to-hip ratio could increase cardiovascular risk associated with Lp(a).
Other variables and markers you can track that are relevant to Lp(a)-associated cardiovascular risk.
A specific protocol to reduce visceral fat.
A summary of key points and takeaways.
