For many years, cholesterol testing has often been explained in a simple way: LDL is “bad” cholesterol and HDL is “good” cholesterol. This is a useful starting point, but it is no longer the whole story. Modern cardiovascular screening looks at a wider picture, including the type and number of cholesterol-carrying particles, inflammation, blood pressure, diabetes risk, family history, lifestyle and an important inherited marker called lipoprotein(a), or Lp(a).
Why cholesterol is not just “good” and “bad”
Cholesterol itself is not harmful. The body needs cholesterol to make cell membranes, hormones and vitamin D. The issue is how cholesterol is carried in the blood and whether those cholesterol-carrying particles are contributing to plaque build-up in the arteries.
A standard lipid profile usually reports LDL cholesterol, HDL cholesterol, total cholesterol and triglycerides. These are helpful, but they do not always capture the whole risk picture.
LDL cholesterol
LDL carries cholesterol from the liver into the bloodstream. Higher LDL levels are strongly linked with atherosclerosis, which is the build-up of fatty plaque inside the arteries. Lowering LDL remains one of the most important ways to reduce the risk of heart attack and stroke.
HDL cholesterol
HDL helps move cholesterol away from the arteries and back to the liver. It has traditionally been called “good cholesterol”, but a high HDL number does not automatically mean someone is protected. HDL function, the overall risk profile and other blood markers all matter.
Triglycerides
Triglycerides are blood fats that often reflect diet, alcohol intake, weight, insulin resistance and metabolic health. High triglycerides can increase cardiovascular risk, particularly when combined with abdominal weight gain, low HDL, pre-diabetes or type 2 diabetes.
Non-HDL cholesterol and ApoB
Many clinicians now also consider non-HDL cholesterol and, in selected cases, apolipoprotein B, known as ApoB. ApoB gives an estimate of the number of artery-damaging cholesterol particles in the blood. This can sometimes give a clearer picture of cardiovascular risk than LDL cholesterol alone.
What is lipoprotein(a), or Lp(a)?
Lipoprotein(a), written as Lp(a), is a cholesterol-carrying particle that is similar to LDL but has an additional protein attached to it. This extra structure appears to make Lp(a) more likely to contribute to plaque formation, blood vessel inflammation and, in some people, clotting tendency.
Recent evidence describes Lp(a) as an important causal risk factor for atherosclerotic cardiovascular disease, including coronary artery disease, heart attack and stroke. It is also associated with calcific aortic valve stenosis, where the aortic valve becomes narrowed and stiff.
One of the key reasons Lp(a) matters is that it is mostly inherited. Around 70 to 90% of a person’s Lp(a) level is genetically determined, and levels usually remain fairly stable throughout adult life. Approximately one in five people globally may have an elevated Lp(a).
Why you may not know your Lp(a) level
Lp(a) is not usually included in a routine cholesterol test. This means a person can have a reassuring LDL cholesterol result but still have a raised Lp(a), which may mean their inherited cardiovascular risk has been underestimated.
Lp(a) testing can be particularly useful for people with a family history of early heart disease or stroke, a personal history of cardiovascular disease despite apparently normal cholesterol, familial hypercholesterolaemia, aortic valve disease, or unexplained high cardiovascular risk.
What recent research has shown
A major 2024 study in women showed that LDL cholesterol, Lp(a), and high-sensitivity C-reactive protein, a marker of inflammation, each independently predicted cardiovascular events over long-term follow-up. This supports a more modern approach to cardiovascular prevention: looking beyond a single cholesterol number and assessing the whole risk profile.
This wider risk profile includes cholesterol particles, inherited risk, inflammation, blood pressure, blood sugar, smoking, weight, activity, menopause status, sleep, stress and family history.
What does a raised Lp(a) mean?
A raised Lp(a) does not mean that someone will definitely have a heart attack or stroke. It means their baseline risk may be higher and should be taken seriously.
Because Lp(a) is largely genetic, it is not usually lowered significantly by diet, exercise or standard lifestyle measures. However, lifestyle remains very important. If Lp(a) is raised, it becomes even more important to reduce every other modifiable risk factor.
What can be done if Lp(a) is raised?
The current approach is to reduce overall cardiovascular risk as much as possible. This may include lowering LDL cholesterol more intensively, treating high blood pressure, optimising blood sugar and insulin resistance, stopping smoking, maintaining a healthy weight, exercising regularly, improving sleep and stress management, and considering medication where clinically appropriate.
Because Lp(a) is inherited, first-degree relatives may also benefit from testing if a significantly raised level is found. New treatments that specifically target Lp(a) are being studied, but they are not yet part of routine standard care.
Should everyone have Lp(a) tested?
Increasingly, expert groups recommend that Lp(a) should be measured at least once in adulthood. Because levels are genetically determined and usually stable, it often does not need to be repeated frequently unless there is a specific clinical reason.
Testing is especially valuable where there is a strong family history of cardiovascular disease, particularly if a parent or sibling had a heart attack, stroke, stent, bypass surgery or aortic valve disease at a relatively young age.
A more complete cardiovascular screen
A personalised cardiovascular assessment may include:
- Full lipid profile, including LDL, HDL, total cholesterol and triglycerides
- Non-HDL cholesterol and ApoB, where appropriate
- Lp(a), ideally at least once in adulthood
- HbA1c or fasting glucose to assess diabetes risk
- Blood pressure assessment
- Kidney, liver and thyroid function where relevant
- High-sensitivity CRP in selected cases
- Detailed family history, lifestyle review and cardiovascular risk calculation
- Further tests such as ECG or imaging where clinically indicated
The key message
Cholesterol testing is no longer just about “good” and “bad” cholesterol. LDL remains very important, but it is only part of the picture. Lp(a) can identify inherited cardiovascular risk that may otherwise be missed. Knowing your Lp(a) level can help you and your doctor make more personalised decisions about prevention, lifestyle, medication and family screening.
Dr Sera Shoukru offers a personalised approach to cardiovascular screening, helping patients understand not just their cholesterol numbers, but what those numbers mean for their long-term health.