Normal cholesterol but early heart attack risk? Doctors say Lipoprotein(a) test can reveal hidden danger

For years, heart health conversations have focused on familiar numbers: LDL, HDL, and triglycerides. These markers appear in almost every routine cholesterol report. Yet cardiologists say an important piece of the puzzle is often missing.
Across India, doctors are seeing a troubling pattern. People in their 30s and 40s are arriving at hospitals with heart attacks despite having “normal” cholesterol reports.
The explanation sometimes lies in a lesser-known marker called Lipoprotein(a), often written as Lp(a). Unlike many other cholesterol markers, this one is strongly influenced by genetics and can quietly increase heart risk long before symptoms appear.

Several global and Indian studies have highlighted this hidden risk. For example, a study from the Lancet has noted the unusually high burden of early cardiovascular disease among Indians in its national health reports.

Another major global assessment by the National Institutes of Health (NIH) also recognises elevated Lp(a) as a genetic risk factor for cardiovascular disease.

Understanding this overlooked marker could help many people detect risk earlier and protect their heart health.

Lipoprotein(a) is a type of cholesterol particle circulating in the blood. It looks similar to LDL cholesterol, often called “bad cholesterol,” but has an additional protein attached to it.

This extra protein changes the way the particle behaves inside the body.

Lp(a) can:

Increase plaque formation in arteries
Promote inflammation inside blood vessels
Make blood more likely to clot
All three factors raise the chances of heart attacks and strokes.

Unlike most cholesterol markers, Lp(a) levels are mostly determined by genes. Diet, exercise, and lifestyle changes have limited effect on it.

Cardiologists say this is why the test matters.

Dr Narasa Raju Kavalipati, Sr. Consultant Cardiology and Director, Interventional Cardiology at CARE Hospitals, Hyderabad, explains, “Most people who come for heart check-ups are familiar with cholesterol numbers like LDL, HDL, and triglycerides. However, an important marker that many people are not tested for is Lipoprotein(a), or Lp(a). It is a cholesterol particle largely determined by genetics and can raise the risk of early heart disease, even in people who seem otherwise healthy.”

India carries one of the world’s highest burdens of premature heart disease. According to data from a study published in NIH, cardiovascular disease accounts for more than 28% of all deaths in India.

More concerning is the age at which it appears.

Many heart attacks in India occur 10 to 15 years earlier than in Western populations.

Several factors contribute to this pattern:

Genetic predisposition
Diabetes and insulin resistance
High blood pressure
Sedentary lifestyle
Hidden lipid markers like Lp(a)

Doctors increasingly believe that genetic markers such as Lp(a) may partly explain why seemingly healthy individuals sometimes suffer sudden cardiac events.

Dr Narasa Raju Kavalipati says, “In many Indian patients, we see heart attacks occurring in their 30s or 40s despite normal routine cholesterol reports. In some of these cases, an elevated Lp(a) level is the underlying reason. Because it is largely inherited, lifestyle changes alone may not bring the level down, which makes early detection particularly important.”

Lp(a) behaves differently from other cholesterol particles. Once present in high levels, it accelerates the process known as atherosclerosis, the gradual buildup of plaque inside arteries.

Over time, this plaque narrows blood vessels that supply the heart and brain.

Two additional mechanisms make Lp(a) particularly dangerous.

First, it carries oxidised lipids that trigger inflammation inside artery walls.
Second, it interferes with the body’s natural system that dissolves blood clots.

This combination means plaques can grow faster and become unstable.

Dr N Dhananjaneya Reddy, Consultant, Interventional Cardiology at Arete Hospitals, explains, “One of the reasons early heart attacks occur in Indians is that traditional cholesterol tests do not always tell the full story. A person may have acceptable LDL cholesterol levels and still carry a higher cardiovascular risk. Lipoprotein(a), often written as Lp(a), is one such factor that many people have never heard about.”

He adds, “This particle behaves differently from regular cholesterol. Higher levels can promote plaque build-up in the arteries and increase the likelihood of blockages at a younger age.”

One of the most confusing aspects of Lp(a) is that routine lipid profiles usually do not measure it.

A standard cholesterol test typically includes:

Total cholesterol
LDL cholesterol
HDL cholesterol
Triglycerides
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Even if these numbers fall within normal ranges, Lp(a) may still be high.

This is why some people with otherwise healthy reports still develop heart disease early.

Cardiologists say the missing test can sometimes reveal a genetic risk that routine reports fail to capture.

Dr Reddy explains, “Since Lp(a) levels are mainly determined by genetics, the risk can run in families without people realizing it.”

Experts say the test is not required repeatedly like other cholesterol checks.

In most cases, one test in a lifetime is enough, because the level remains stable throughout life.

Dr Kavalipati explains, “The test itself is simple and needs to be done only once in a lifetime in most individuals. If the level is high, doctors can recommend closer monitoring and more aggressive control of other risk factors such as LDL cholesterol, blood pressure, diabetes, and smoking.”

A family history of early heart attack or stroke
Heart disease at a young age in relatives
Unexplained high cardiovascular risk
Normal cholesterol reports but strong family history

Dr Reddy adds, “People with a family history of early heart disease, stroke, or sudden heart problems at a young age should consider getting their Lp(a) level checked. In clinical practice, testing is particularly useful for individuals whose routine cholesterol reports look normal but who have a strong family history of premature heart disease.”

Learning about a high Lp(a) level can feel unsettling. But cardiologists say the information is powerful because it allows earlier prevention.

While the level itself may not drop significantly through lifestyle changes, doctors focus on reducing other cardiovascular risks aggressively.

That often includes:

Strict control of LDL cholesterol
Regular physical activity
Blood pressure management
Diabetes control
Avoiding smoking
Healthy diet and weight management

In other words, the test does not just reveal risk. It helps doctors act sooner.

The growing conversation around Lipoprotein(a) highlights an important truth about heart health.

Not all risks are obvious.
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Someone may exercise regularly, eat well, and maintain healthy cholesterol levels yet still carry a hidden genetic risk. The goal of modern medicine is to uncover these silent factors before they cause harm.

For many families in India, especially those with a history of early heart disease, a single blood test could provide valuable insight.

It does not predict destiny. But it can change the path toward prevention.


Medical experts consulted

This article includes expert inputs shared with TOI Health by:

Dr Narasa Raju Kavalipati, Sr. Consultant Cardiology and Director, Interventional Cardiology at CARE Hospitals, Hyderabad.
Dr N Dhananjaneya Reddy, Consultant, Interventional Cardiology at Arete Hospitals.

Inputs were used to explain why many Indians are not tested for Lipoprotein(a), an often-overlooked cholesterol marker, and how identifying it early can help detect hidden risk for premature heart attacks.