After more than a century of battling heart disease as the number one killer of Americans, you would think we’d know all about it. For a good part of the 20th century, cardiologists thought they had it nailed.

The culprit was high cholesterol, specifically high LDL cholesterol, and all their patients had to do to avoid a heart attack was take a statin every day.

That was after trying to alter the American diet didn’t result in a dramatic reduction of heart disease. Statins did make a difference: Heart disease mortality dropped from 1970 to 2022 (JAHA, June 25, 2025). But heart disease is still the leading cause of death in this country, as it has been since 1921.

Perhaps scientists need to scrutinize some risk factors besides cholesterol. One that is getting more attention lately is lipoprotein a, usually abbreviated Lp(a) and pronounced “ell-pee-little-ay” (rhymes with hay). Approximately one-fifth of the population has an elevated level of Lp(a), which is an independent risk factor for heart disease.

A study published in JAMA Cardiology followed more than 27,000 healthy women for three decades (Jan. 7, 2026). Investigators measured Lp(a) levels in these volunteers at the start of the study.

Those at the 75th percentile or above, with Lp(a) of 30 mg/dL or higher, were somewhat more likely to develop heart disease in the subsequent decades.

Women with very high Lp(a) levels of 120 mg/dL or above were at increased risk of stroke and death from heart disease.

The authors conclude: “Importantly, our data and those of others show that among healthy individuals, only a fraction will be at very high risk of cardiovascular disease due to elevated lipoprotein(a). That said, the cardiovascular risk among individuals with severely elevated lipoprotein(a) is comparable to that associated with familial hypercholesterolemia, emphasizing the importance of early identification of these individuals.”

Doctors have been reluctant until recently to test for Lp(a) because they have not had access to interventions that would reduce the risk. Some readers have taken action as they can. One physician wrote:

“I have been taking high-dose niacin (not slow-release or niacinamide) for about 30 years because of low HDL-C and high Lp(a). Although people have different tolerance levels to niacin, most do OK if the dose is raised slowly, beginning at 50 milligrams twice a day and increasing at intervals of a week or two and always taking the niacin after meals.

“If flushing is a problem at a given dose, it is then easy to either maintain the dose for a longer period or drop back slightly until symptoms are gone. I have never taken aspirin before my niacin and have taken a gram (1,000 milligrams) two or three times a day with only occasional mild flushing — perhaps once or twice a month.”

One of this country’s leading experts on Lp(a) reports, Dr. Sotirios Tsimikas, has suggested that people with elevated Lp(a) may benefit from taking aspirin on a regular basis (American Journal of Preventive Cardiology, April 27, 2024). For people with normal levels of this risk factor, aspirin does not offer an advantage. Of course, no one should undertake regular aspirin without medical supervision.

In their column, Joe and Teresa Graedon answer letters from readers. Write to them in care of King Features, 300 W. 57th Street, 41st Floor, New York, NY 10019, or email them via their website: www.PeoplesPharmacy.com. Their newest book is “Top Screwups Doctors Make and How to Avoid Them.”