Coronary Calcium Score Refines Risk Assessment in Patients With Elevated Lp(a): Study

A new study published in the Journal of the American College of Cardiology showed that elevated lipoprotein(a) [Lp(a)] was associated with a higher relative risk of cardiovascular events across all coronary artery calcium (CAC) score categories, including individuals with a CAC score of 0. However, among those with CAC of 0, the absolute risk of events remained low despite elevated Lp(a) levels. These findings highlight that CAC scoring remains a valuable tool for cardiovascular risk stratification and can help refine risk assessment in individuals with elevated Lp(a).

Given the tendency of Lp(a) toward noncalcified plaque, the usefulness of CAC scoring for atherosclerotic cardiovascular disease (ASCVD) risk assessment in people with increased Lp(a) is still unknown. Thus, this study assessed the relationship between increased Lp(a) (>50 mg/dL) and CAC score as well as the relationship between Lp(a) and ASCVD risk across CAC strata.

With the baseline Lp(a) and CAC values, a pooled cohort of individuals without known ASCVD from 4 prospective cohort studies conducted in the US was analyzed. Multivariable Cox regression models were used to assess the relationship between incident ASCVD (myocardial infarction, stroke, and coronary revascularization) and high Lp(a) across CAC strata.

Nearly, 11,319 patients (mean age 56 years, 54% female) with 1,569 incident ASCVD events over a mean follow-up of 14.8 years were included in the research. ASCVD risk was independently correlated with Lp(a) >50 mg/dL (HR: 1.24; 95% CI: 1.09-1.41) and CAC >0 (HR: 2.44; 95% CI: 2.14-2.77) (P interaction = 0.80).

ASCVD incidence rates were generally low among those with CAC = 0, although they were higher in those with Lp(a) >50 mg/dL vs. ≤50 mg/dL (4.9 vs. 3.8/1,000 person-years, HR: 1.28; 95% CI: 1.01-1.60). Elevated Lp(a) was once more associated with higher risk among individuals with CAC >0 (21.2 vs. 18.2/1,000 person-years, HR: 3.03; 95% CI: 2.52-3.64).

Examining other CAC strata revealed similar findings, with the highest risk associated with both CAC ≥300 and Lp(a) >50 mg/dL (HR: 6.12; 95% CI: 4.80-7.81). Age and sex showed consistent results, with males and those over 50 generally having higher absolute risk.

Over a 15-year follow-up period, Lp(a) and CAC are independently linked to the risk of ASCVD and CHD. Across all CAC strata, including CAC of 0, elevated Lp(a) is linked to a greater relative risk of ASCVD and CHD. These findings imply that CAC scoring is still an effective method for evaluating risk in those with increased Lp(a).

Source:

Bhatia, H. S., Fan, Y., Dharmavaram, G., Razavi, A. C., Tsai, M. Y., Ramsis, M., Mahmud, E., Wilkinson, M., Taub, P., Nasir, K., Blaha, M. J., & Wong, N. D. (2026). Use of coronary artery calcium scoring in individuals with elevated lipoprotein(a): A multicohort study. Journal of the American College of Cardiology, 87(20), 2864–2872. https://doi.org/10.1016/j.jacc.2026.02.5067