Across 687,780 primary prevention patients in the PITT-LIPID real-world registry, only 6,340 (0.9%) ever received lipoprotein(a) testing — despite multi-society guidelines recommending at least one lifetime screen for all adults. Among those tested, Lp(a) levels exceeding 125 nmol/L were independently associated with a 67% higher hazard of percutaneous coronary intervention (HR 1.67, 95% CI 1.16–2.41), a finding that persisted after multivariable adjustment. Tested patients also underwent CABG at roughly 3.5× the rate of untested patients, though selection bias likely inflates that gap.
Lp(a) is a genetically determined, LDL-like particle that standard lipid panels miss entirely, yet it elevates cardiovascular risk in roughly 20% of the global population. The near-total absence of testing in this large tri-state network quantifies a care gap that clinicians have long suspected but rarely documented at scale. Crucially, the mortality paradox — tested patients dying less despite more interventions — almost certainly reflects healthy-user bias: physicians order Lp(a) in more engaged, better-managed patients. That confounding limits causal inference. Practical implications are clear nonetheless: adults with premature cardiovascular disease family history or residual risk despite statin therapy should proactively request Lp(a) measurement, particularly as targeted RNA-based therapies (pelacarsen, olpasiran) near regulatory approval. This is a preprint posted on medRxiv and has not yet been peer-reviewed; findings, especially effect sizes, should be interpreted cautiously until formal review. Incrementally confirmatory but valuably quantifying a documented guideline-practice chasm.
