Cholesterol and Lp(a): Why a standard lipid panel isn't enough

Dr. Charalampos Romanos · April 14, 2026 · 5 min read

Heart disease is the number one cause of death in Switzerland. And cholesterol is a risk factor. But here's the problem: most doctors only look at LDL cholesterol. That's too narrow. I regularly see patients who have a heart attack despite their LDL being "controlled". The reason is often Lp(a) — a genetic risk factor that is completely overlooked.

The standard lipid panel and its limitations

The standard lipid panel measures total cholesterol, LDL, HDL, and triglycerides. That's a start. But it's too simple. LDL cholesterol itself is not uniform — some LDL particles are large and fluffy (less dangerous), some are small and dense (very dangerous). A too high triglyceride-to-HDL ratio is also a warning sign.

Lp(a): The genetic risk factor nobody knows about

Lp(a) — lipoprotein(a) — is a genetically determined form of cholesterol. Some people have high Lp(a) because of their genes, not because of their diet. High Lp(a) doubles or triples the risk of heart attack and stroke. And here's the bad part: statins don't help against Lp(a). This is a genetic risk factor that you can't just make "go away" with drugs.

Who should be tested for Lp(a)?

Everyone should have Lp(a) measured at least once. This is a one-time test — the value doesn't change in life. If your family has early heart attacks, you should definitely have Lp(a) tested. Also if your LDL is "normal" but you still have cardiovascular events — that's often Lp(a).

The new therapeutic options

Lp(a) is not yet easy to treat like LDL. But there are new approaches. PCSK9 inhibitors can help when both LDL and Lp(a) are elevated. Lipoprotein apheresis is an option for very high Lp(a). But the best treatment is prevention — healthy diet, exercise, preventive medicine is essential here.

HDL and triglycerides — the underestimated partners

High HDL is protective. High triglycerides are dangerous. Some patients have "normal" total cholesterol and LDL, but high triglycerides and low HDL — this is the metabolic phenotype that is very dangerous. A low-carbohydrate diet with more fat can work wonders here.

Comprehensive cardiovascular risk assessment

It's not just cholesterol. I look at blood pressure, inflammation markers (CRP), homocysteine, lipoprotein particle number, apolipoprotein B. The Framingham Risk Score is a start, but not the end. It's a holistic health check-up approach to really understand what your heart risk is.