Managing Lipoprotein(a) and Cholesterol - Doctor Q&A

“What should I do if my blood levels of lipoprotein(a) are very high?”

“Is my family history of ischaemic heart disease linked to my own lipid levels?”

Lipoprotein(a), or Lp(a), is an often overlooked but significant genetic risk factor for cardiovascular disease.

Studies have shown that 1 in 5 people worldwide have elevated Lp(a), and locally, 1 in 6 individuals who experienced a heart attack were found to have elevated Lp(a). Despite this, awareness and testing for Lp(a) remain low.

Unlike common cholesterol markers, Lp(a) levels are largely inherited and remain relatively stable throughout life. As Lp(a) is genetically determined, lifestyle changes alone may not be sufficient to manage the risk.

Lp(a) is structurally like low-density lipoprotein (LDL), but with an added protein component that makes it more likely to stick to blood vessel walls, contributing to plaque build-up. This increases the risk of heart attacks, stroke, and other cardiovascular complications.

The good news: early detection of Lipoprotein(a) allows for better risk stratification and targeted management.

As cardiovascular disease remains a leading cause of death in Singapore and globally, individuals with a family history of heart disease, or those who have experienced unexplained cardiovascular events, are encouraged to undergo at least one Lp(a) test in their lifetime.

Individuals can take proactive steps to protect their heart health with the right combination of:

• Monitoring,
• Lifestyle optimisation, and
• Medical interventions

Have questions about Lipoprotein(a), genetic cardiovascular risks and management strategies, don't miss this chance to ask Dr Loh! This Q&A is for a limited time only.

Dr Loh Wann Jia is a Senior Consultant with the Department of Endocrinology at Changi General Hospital (CGH).

She is actively involved in research and teaching, with clinical and research interests in obesity, diabetes mellitus, lipid disorders, and broader metabolic conditions.

To deepen her sub-specialty expertise and foster international collaborations, Dr Loh completed fellowships at hospitals affiliated with Imperial College London in 2017, and at Royal Perth Hospital, Australia, in 2022.

Dr Loh is particularly passionate about advancing the understanding of genetic lipid disorders such as Lipoprotein(a), and works closely with multidisciplinary teams to improve early detection and long-term cardiovascular outcomes for patients.

1. Question by Janice

Hi Dr,

I have high lipoprotein(a) and cholesterol.

What lifestyle optimisation and medical interventions should I take? Thank you for your advice.

Answer by Dr Loh Wann Jia

Hi Janice, thank you for your question. Each patient requires individualised medical therapy and prescription. For individuals diagnosed with elevated Lp(a) levels, CGH adopts the LILAC approach, which underscores five key interventions:

L: Recognise Lp(a) as a cardiovascular risk factor. Learn about Lp(a) and your other lipid (cholesterol) profile for appropriate risk factors.

I: Improve all cardiovascular risk factors.

L: Lower LDL cholesterol level first, and in severe cases, consider lowering Lp(a) levels.

A: Assess for related conditions associated with elevated Lp(a), while considering aspirin.

C: Consider cascade testing to identify at-risk family members. “C” also stands for Care and Compassion.

Following the LILAC approach can help patients to reduce cardiovascular risks associated with elevated Lp(a) levels. Emphasis remains on the letter “I”- improving one’s lifestyle, including diet and exercise, controlling blood pressure and glucose levels, and avoiding obesity, as these are still the first steps.

On Saturday, 25^th April, we will be having a Lipid Disorders and Lipoprotein(a) Support and Awareness Day at CGH. You can sign up for this by registering via the QR code on the CGH website here.

We have also made a family-friendly informative cartoon video on LILAC for Lipoprotein(a), which you can view here.

2. Question by Effendy

Hi Dr,

If already have borderline high LDL, and following diet and medication to reduce the LDL, is it still necessary to test for Lp(a)?

And, if Lp(a) is genetic and high, is there anything else can be done to lower it? (especially if already trying to lower the LDL). Thank you.

Answer by Dr Loh Wann Jia

Hi Effendy,

Having high levels lipoprotein(a), otherwise called elevated lipoprotein(a) disorder, is quite common but underdiagnosed, with many people unaware they have it.  Depending on whether someone is already at high risk for cardiovascular disease or stroke, it may be more important to be tested earlier rather than later.

There are ways to lower cholesterol, whether its LDL cholesterol or lipoprotein(a) levels.

Learn about LILAC. It’s a simplified approach that we use to manage patients with genetic lipid conditions including lipoprotein(a). Emphasis remains on the letter “I”- improving one’s lifestyle, including diet and exercise, controlling blood pressure and glucose levels, and avoiding obesity, as these are still the first steps.

On Saturday, 25th April, we will be having a Lipid Disorders and Lipoprotein(a) Support and Awareness Day at CGH. You can sign up for this by registering via the QR code on the CGH website here.

We have also made a family-friendly informative cartoon video on LILAC for Lipoprotein(a), which you can view here.

3. Question by Tracy

Hi Dr,

My questions are:

a) Why does my body produce so much LDL cholesterol? Even with healthy lifestyle optimisation (healthy weight, regular exercise, plant-based diet, increased soluble fibre intake, no sugar/ultra-processed foods etc) levels are still elevated. Is there inflammation going on in my body that can/should be addressed vs taking a statin that brings LDL down but does not treat the cause?

b) Can HDL levels be too high and if so, how do you bring it down.

Thank you for taking the time to answer my questions. Look forward to hearing from you.

Answer by Dr Loh Wann Jia

Hi Tracy, thank you for your questions.

Our liver makes cholesterol, which is carried around via various cholesterol particles, the most well-known being LDL particle. Hence it is called LDL cholesterol. When LDL cholesterol level or any other cholesterol levels are extremely high (excessive), this is usually related to a genetic cause (e.g. familial hypercholesterolaemia); otherwise, it could be secondary to medical causes.

Yes, it is strongly recommended to lower LDL cholesterol to avoid build-up of cholesterol plaques in the artery walls.

Please discuss with your doctor on whether you need further investigations, including genetic testing, and what medication would be best for you. The most common initial treatment after diet control, is to add a statin therapy.

On Saturday, 25th April, we will be having a Lipid Disorders and Lipoprotein(a) Support and Awareness Day at CGH. You can sign up for this by registering via the QR code on the CGH website here.

4. Question by Esther

Dear Dr Loh,

Is Lp(a) level directly related to LDL level? In other words, if I have high LDL, is it likely that I will have high Lp(a)? Am I able to get Lp(a) test at government polyclinics? Thank you.

Answer by Dr Loh Wann Jia

Lp(a) blood particles are not at all related to LDL blood particles. However, when someone has extremely high levels of Lp(a) (e.g. 300 nmol/L, 400 nmol/L), this can cause the LDL cholesterol level to appear falsely higher than it is. While the test helps us estimate levels, it is not perfect yet, although this is expected to improve over time.

For now, government polyclinics have not made this test available. However, Lp(a) testing is offered in most hospitals and medical centres in Singapore now.

On Saturday, 25th April, we will be having a Lipid Disorders and Lipoprotein(a) Support and Awareness Day at CGH. You can sign up for this by registering via the QR code on the CGH website here.

We have also made a family-friendly informative cartoon video on LILAC for Lipoprotein(a), which you can view here.

5. Question by Robin

Hi Dr,

When is the recommended period for testing of LP(a)?

Can this be done in a Polyclinic or must go to a specialist? Thank you.

Answer by Dr Loh Wann Jia

For individuals suspected to be high or very high risk for cardiovascular disease, such as those with family history of heart attack in parents before the age of 55, or if the individual himself had a heart attack or stroke before, or those with familial hypercholesterolaemia (very high LDL cholesterol), it is recommended for them to get tested in early adulthood.

For individuals who are well and have no cardiovascular risk factors, the timing of testing is more flexible. Testing earlier allows for you to take necessary precautions such as eating healthy, exercising regularly, not smoking, and controlling blood pressure.

For now, government polyclinics have not made this test available. However, Lp(a) testing is offered in most hospitals and medical centres in Singapore now.

To learn more: 
On Saturday, 25th April, we will be having a Lipid Disorders and Lipoprotein(a) Support and Awareness Day at CGH. You can sign up for this by registering via the QR code on the CGH website here.

We have also made a family-friendly informative cartoon video on LILAC for Lipoprotein(a), which you can view here.

6. Question by Simon

Hi Dr,

I read with interest your article and found it intriguing because I had requested my Polyclinic doctor for a follow up LP (a) blood test, but was told there was no such protocol in place for him to do so.

For context, I turn 65 this year. I had a STEMI, PCI stents, in 1st Dec 2024, then a Midcab, LIMA LAD at NHCS on 5 March 2025; now just routine follow up.

Seem to have family history; older brother had bypass at 58, his son has had a stent in LAD at 39. Question: Even if I do the above test privately, what good is that I managing the disease, given diet and lifestyle do not alter the risk factor significantly?

Let me know your take. Thank you.

Answer by Dr Loh Wann Jia

Hi Simon,

For now, government polyclinics have not made this test available. However, Lp(a) testing is offered in most hospitals and medical centres in Singapore now.

Given your heart attack (STEMI) and strong family history of heart disease, I would strongly recommend you have your blood Lp(a) level checked.  You can go to Health Buddy to see if you have done this before. Otherwise, you can inform your doctor at your next appointment with NHC to request for this test. Most cardiologists are now aware of this condition. If the result is normal, you do not need to check this again.

For individuals diagnosed with elevated Lp(a) levels, CGH adopts the LILAC approach, which underscores five key interventions:

L: Recognise Lp(a) as a cardiovascular risk factor. Learn about Lp(a) and your other lipid (cholesterol) profile for appropriate risk factors.

I: Improve all cardiovascular risk factors.

L: Lower LDL cholesterol level first, and in severe cases, consider lowering Lp(a) levels.

A: Assess for related conditions associated with elevated Lp(a), while considering aspirin.

C: Consider cascade testing to identify at-risk family members. “C” also stands for Care and Compassion.

Following the LILAC approach can help patients to reduce cardiovascular risks associated with elevated Lp(a) levels. Emphasis remains on the letter “I”- improving one’s lifestyle, including diet and exercise, controlling blood pressure and glucose levels, and avoiding obesity, as these are still the first steps.

To learn more: 
On Saturday, 25th April, we will be having a Lipid Disorders and Lipoprotein(a) Support and Awareness Day at CGH. You can sign up for this by registering via the QR code on the CGH website here.

We have also made a family-friendly informative cartoon video on LILAC for Lipoprotein(a), which you can view here.

7. Question by Niru

Dear doctor,

I’m a 57-year-old woman of Indian origin. My father passed away at age 52 due to a heart attack.

I have high lipoprotein A-125mg/dL

I lead a relatively healthy lifestyle. Exercise 5 days a week. Walk more than 10,000 steps daily (mostly). Eat healthy most of the time- home cooked meals - less oil, salt, balanced.

Is there anything else i can do to lower my lipoproteinA levels.

Secondly is there any medication for this (had heard last year that there was a breakthrough in the U.S). Thank you.

Answer by Dr Loh Wann Jia

Hi Niru,

Thank you for your question and I’m sorry for your loss.

Yes, there are few things that may be specifically necessary for your case, because of your strong family history and severely elevated lipoprotein(a) level. Lp(a) blood level of more than ≥ 120 nmol/L (or 50 mg/dL) is considered high.

As far as we know, developing Lp(a)-lowering medications are currently undergoing further trials. The multidisciplinary team at the CGH Lipid Clinic is dedicated to uncovering insights and approaches to manage elevated Lp(a) levels. This includes the current use medications such as PCSK9 enzyme inhibitor which is prescribed to lower LDL by 50-70% primarily, which has an added benefit of lowering Lp(a) by 20-30% as a result. CGH is currently conducting research on the prevalence of elevated Lp(a) levels amongst the working-age population in Singapore.

In the meantime, for individuals diagnosed with elevated Lp(a) levels, CGH adopts the LILAC approach, which underscores five key interventions:

L: Recognise Lp(a) as a cardiovascular risk factor. Learn about Lp(a) and your other lipid (cholesterol) profile for appropriate risk factors.

I: Improve all cardiovascular risk factors.

L: Lower LDL cholesterol level first, and in severe cases, consider lowering Lp(a) levels.

A: Assess for related conditions associated with elevated Lp(a), while considering aspirin.

C: Consider cascade testing to identify at-risk family members. “C” also stands for Care and Compassion.

Following the LILAC approach can help patients to reduce cardiovascular risks associated with elevated Lp(a) levels. Emphasis remains on the letter “I”- improving one’s lifestyle, including diet and exercise, controlling blood pressure and glucose levels, and avoiding obesity, as these are still the first steps.

To learn more: 
On Saturday, 25th April, we will be having a Lipid Disorders and Lipoprotein(a) Support and Awareness Day at CGH. You can sign up for this by registering via the QR code on the CGH website here.

We have also made a family-friendly informative cartoon video on LILAC for Lipoprotein(a), which you can view here.

8. Question by Ms Kwek

Hi Dr,

I would like to know how I can check for lipoprotein a levels. The usual health screening tests only for LDL. Is this test available at Healthier SG clinics?

If my mother has high lp(a), does it mean that I am also at risk. If so, what should I look out for or do to mitigate my risks? Thank you.

Answer by Dr Loh Wann Jia

Hi Ms Kwek,

For now, the government polyclinics have not made this test available.

However, Lp(a) testing is offered in most hospitals and medical centres in Singapore now.

For individuals diagnosed with elevated Lp(a) levels, CGH adopts the LILAC approach, which underscores five key interventions:

L: Recognise Lp(a) as a cardiovascular risk factor. Learn about Lp(a) and your other lipid (cholesterol) profile for appropriate risk factors.

I: Improve all cardiovascular risk factors.

L: Lower LDL cholesterol level first, and in severe cases, consider lowering Lp(a) levels.

A: Assess for related conditions associated with elevated Lp(a), while considering aspirin.

C: Consider cascade testing to identify at-risk family members. “C” also stands for Care and Compassion.

Following the LILAC approach can help patients to reduce cardiovascular risks associated with elevated Lp(a) levels. Emphasis remains on the letter “I”- improving one’s lifestyle, including diet and exercise, controlling blood pressure and glucose levels, and avoiding obesity, as these are still the first steps.

To learn more: 
On Saturday, 25th April, we will be having a Lipid Disorders and Lipoprotein(a) Support and Awareness Day at CGH. You can sign up for this by registering via the QR code on the CGH website here.

We have also made a family-friendly informative cartoon video on LILAC for Lipoprotein(a), which you can view here.

9. Question by James

Hi Dr,

I'm on statin, and doing annual blood test to check Cholesterol level.

If Lp(a) is more likely to cause plaque build-up, why Polyclinic doctor does not prescribe this test?

Can the Polyclinic which do my Cholesterol test also check my Lp(a).

How much does it cost? Thank you.

Answer by Dr Loh Wann Jia

Hi James,

For now, government polyclinics have not made this test available. However, Lp(a) testing is offered in most hospitals and medical centres in Singapore now.

At CGH, the fee for Lp(a) testing varies depending on patient subsidy.

10. Question by WF

Dear Dr Loh, 

My husband is 54 years old and with family history increased CVD risk, on low dose Lipitor due to mildly elevated LDL and Lipo(a).

His doctor friend in Australia recommended Leqvio, so he is wondering if it is available in Singapore.

Also wondering how helpful is it in terms of lowering LDL or Lipo(a) and does lowering the number actually translates to a better clinical outcome? Thanks!

Answer by Dr Loh Wann Jia

Hi WF,

Leqvio (medical name: inclisiran) is a 6-monthly injectable that is very good at lowering LDL cholesterol by 50% and Lp(a) by about 25-30%.

In Singapore, we also have the 2-weekly injectable (self-injection) called Repatha (medical name: evolocumab), which works equally well for a much lower price.

Both medications are available in all hospitals, and evolocumab is now available at some polyclinics.

The aim to lowering severely elevated cholesterol levels early and consistently, is to reduce the cholesterol plaques that will eventually build in arteries wall if left untreated.

Every patient needs individualised therapy and discussions with their own doctor on the risk versus benefit of each treatment. Not everyone requires medications, but everyone should practice eating healthy, exercise regularly and control blood pressure and glucose.

11. Question by Mr Ying

Dear Doctor,

Is the total cholesterol count a good measure of the cardiovascular health of seniors if one has very high HDL, mildly elevated LDL, with a normal Triglyceride count, resulting in a high TC count?

Is full-cream dairy products (milk & cheeses) to be avoided/replaced by low-fat ones? What's the recent science behind this or has it remained inconclusive?

Thank you for your advice.

Answer by Dr Loh Wann Jia

Dear Mr Ping,

Total cholesterol level is only helpful when its very high (e.g. >8 mmol/L) or very low (<4mmol/L). The different types of cholesterol levels and triglyceride levels are more informative.

As with any food, it should be taken in moderation. High-fat foods make it easier for people to put on weight and have abnormal lipid levels.

For individuals who already have obesity, diabetes, high blood pressure and/or high cholesterol, dietary control should include reducing the intake of high-fat foods in both content and quantity.

12. Question by Alarice

Dear Dr,

The general guideline is always more exercise and a healthier diet. But just how much changes does one need to make to their exercise and diet regiment to not only lower their high lipoprotein levels, but also keep it under control? Thank you very much.

Answer by Dr Loh Wann Jia

Dear Alarice,

The minimum healthy amount of exercise is 150 minutes per week of moderate-intensity exercise, which is about 30 minutes, five times a day, or any combination you like.

Exercise has many advantages , including improving body metabolism. Exercise can potentially lower cholesterol by keeping your weight at a healthy level and help to reduce the risk of having diabetes.

However, exercise itself doesn’t immediately change any of our blood lipid levels, including lipoprotein(a) level. As lipoprotein(a) is mostly genetically determined (up to 90%), the variation in Lp(a) through any means, such as exercising and dieting, will only be about 10-20%.

Still, it is worth exercising regularly for the many benefits that it provides.

13. Question by CL

Dear Dr Loh,

I have been on high cholesterol medication (combination of Ezetimibe (10mg) and Simvastatin (10mg)) for about 30 years.

I have an acute family history of ischaemic heart disease.

Over the last one and a half year, my LDL have improved significantly (to 1.44 MMOL/L) and my HDL has remained stable (at 1.15 MMOL/L). This is largely due to improvements in lifestyle and diet since retiring. For example, I have been regularly taking soaked overnight oaks for breakfasts and healthier home cooked meals for dinner.

My questions are:

a) Assuming there lifestyle and dietary improvements are sustainable, are there significant benefits for me to reduce my high cholesterol medication (for example removing Ezetimibe and sticking only to Simvastatin)?

b) What are the potential long term effects or side effects if I continue with taking both Ezetimibe (10mg) and Simvastatin (10mg) for the rest of my life?

c) Should I structure a testing program to assess the effects of removing the Ezetimibe and/or even the Simvastatin medication altogether? How can such a program be structured and implemented?

Many thanks in advance for your kind advice.

Answer by Dr Loh Wann Jia

Dear CL,

From what you written, it sounds like you have a positive family history of cardiovascular disease, but you don’t have any personal history of cardiovascular disease before.

First, it is important to understand that it is the cumulative duration and the quantity of LDL cholesterol, or any other bad lipid forms, over years that increases the risk of cardiovascular disease. The lower the cholesterol levels of LDL, the lower the long-term risk of cardiovascular disease. So, an LDL level of 1.44 mmol/L is a good number to have, but I understand your concern.

If there were side effects from statin and ezetimibe, they would be obvious to you. If you feel well now and your blood test are fine, this suggests you are fine. You should not worry about ‘hidden’ side effects.

However, please know that every patient is slightly different in terms of preferences, side effect profiles and LDL cholesterol goal level.

Therefore, please discuss with your to determine your individualised LDL cholesterol goal. In addition, also talk to your doctor about your personal preference to reduce medication or change your medication regimen, if that’s what you want. 

I hope this helps you feel better.

14. Question by Glenise

Hi Dr Loh,

My questions are:

a) I read that food high in saturated fats affect LDL more than food high in cholesterol. Food such as squid is high in cholesterol but low in saturated fats. Putting frequency and a balanced diet in mind, would that mean squid is generally OK for people who is managing their cholesterol?

b) I deliberately incorporated tofu and mushrooms into my regular diet while I was trying to bring down my cholesterol from borderline high (4.07mmol/L) to the desirable range. I successfully brought it down to 3.31 within a year and further down to 3.1 in another 6 months. No medication.

I noticed my HDL also dropped from 1.92 to 1.78 and now 1.5mmol/L.

Does a healthier diet also lower the "good" cholesterol?

Meanwhile, my triglycerides went up from 0.88 to 0.92 to now 1.2mmol/L!

Why is that so?

Thanks in advance for answering my questions.

Answer by Dr Loh Wann Jia

Dear Glenise,

Generally, people can eat anything as long as it is in moderation.

Ultra-processed food and high saturated fats are less healthy, so try to reduce consumption as much as possible (e.g. once a week, during festivities, etc.).

However, there are some cases, that require an extremely strict, very low-fat diet, such as in familial chylomicronaemia. We do have cases like that in the Lipid Clinic, and for these patients, we advice certain types of diet.

For your case, you should continue the good job of eating more vegetables and fibre, which helps to reduce intestinal absorption of LDL cholesterol.

The HDL cholesterol change that you had is perfectly fine and does not need any concern. The HDL cholesterol of more than 1mmol/L is normal and a fasting triglyceride level <1.7 mmol/L is normal. 

Hope that helps to reassure you.

15. Question by FMY

Hello Dr Loh,

My brother tested & was found a have a high level of Lp(a) reading

Should I be unduly worried as my LDL/Triglycerides readings are very low as I have been taking Rosuvastatin for many years, with my high blood pressure under good control and I am non-diabetic?

What else can I do to lower my risk since I can't do anything about genetic issues? I have not gone for Lp(a) testing myself.

Answer by Dr Loh Wann Jia

Dear FMY,

For Lp(a), I have devised a management framework that patients, families, and healthcare professionals can adopt to manage this condition.

If Lp(a) is only mildly high, there is nothing much to worry about.

However, if Lp(a) is very high or you already have a high risk of heart attack (e.g smoking, diabetes, hypertension, family history), then practice LILAC:

L: Recognise Lp(a) as a cardiovascular risk factor. Learn about Lp(a) and your other lipid (cholesterol) profile for appropriate risk factors.
I: Improve all cardiovascular risk factors.
L: Lower LDL cholesterol level first, and in severe cases, consider lowering Lp(a) levels.
A: Assess for related conditions associated with elevated Lp(a), while considering aspirin.
C: Consider cascade testing to identify at-risk family members. “C” also stands for Care and Compassion.

Following the LILAC approach can help patients to reduce cardiovascular risks associated with elevated Lp(a) levels. Emphasis remains on the letter “I”- improving one’s lifestyle, including diet and exercise, controlling blood pressure and glucose levels, and avoiding obesity, as these are still the first steps.

To learn more: 
On Saturday, 25th April, we will be having a Lipid Disorders and Lipoprotein(a) Support and Awareness Day at CGH. You can sign up for this by registering via the QR code on the CGH website here.

We have also made a family-friendly informative cartoon video on LILAC for Lipoprotein(a), which you can view here.

16. Question by Carol

Dear Dr Loh,

May I know when should one consider taking cholesterol medication?

Can high HDL result of more than normal range of 1.5 points / ratio be Taken into consideration before decision in taking medication for  LDL that falls out of normal range  by 0.2 points & Total cholesterol by 1.3.

Thank you for your advice.

Answer by Dr Loh Wann Jia

Dear Carol,

Cholesterol medication usually refers to lowering LDL cholesterol.

We advise patients to take cholesterol lowering medication when they have very high levels (e.g. persistently >5 mmol/L), a family history of heart attack or stroke at an early age, diabetes, or other risk factors.

It is unnecessary and can be misleading to look at any cholesterol to HDL cholesterol ratios.

Doctors base treatment decisions on LDL cholesterol and triglyceride levels.

17. Question by Susie

Dear Dr,

I am 64-year-old and do my blood test every 6mth at a GP clinic. The report reading shows both HDL and LDL.

How can I include the reading for Lipoprotein(a), or Lp(a) to know if I am at risk. Does telling the doctor suffice or I need to take a separate test?

Thank you for your advice.

Answer by Dr Loh Wann Jia

Dear Susie,

Your GP clinic is most likely able to offer this test, but you would need to request for it specifically. If your lipoprotein(a) level is normal (i.e. <70 nmol/L or <30 mg/dL), it will remain low for life, so there is no need to check again usually.

For now, government polyclinics have not made this test available. However, Lp(a) testing is offered in most hospitals and medical centres in Singapore now.

We have also made a family-friendly informative cartoon video on LILAC for Lipoprotein(a), which you can view here.

18. Question by Irene

Dear Dr Loh,

I'm a patient diagnosed with high blood cholesterol and prescribed with Atorvastatin Tablet - 40mg, one tab at night.

How can I increase my HDL and lower my LDL significantly?

Currently I am exercising at least 3 times a week with Zumba and Aqua Tabata. I will also try to do a 30 min walk after lunch from Mon - Fri.

Thank you for your advice.

Answer by Dr Loh Wann Jia

Dear Irene,

The most effective way to lower LDL cholesterol is by medication.

However, the most important thing to do is to maintain a healthy diet and regular exercise, as you are already doing. So keep it up!

Statin is the most common medication used to lower LDL cholesterol, and to reduce your long-term risk of heart attack and stroke. Please discuss this with your doctor.

Don’t worry about the HDL level, unless it is critically low (<0.5mmol/L). We do not treat HDL cholesterol level unless it is critically low.

19. Question by KC

Dear Dr,

I recently went for a check-up and found that both my LDL and lipoprotein are high. 

I follow a reasonably healthy lifestyle and yet am unable to bring down the numbers.

What combination of the following will help me manage them better?

• Monitoring,
• Lifestyle optimisation, and
• Medical interventions

Can you provide with recommendations on what I can do?

Thank you for your advice.

Answer by Dr Loh Wann Jia

Dear KC,

I have created a framework for people to understand the five steps in managing high LDL and high Lp(a).

You msy eatch this family-friendly informative cartoon video on LILAC for Lipoprotein(a) here.

You’ll see that the answer to your question is all three. This includes monitoring, lifestyle optimisations and most likely medications.

20. Question by Simon

Dear Dr Loh,

Thank you for taking time to answer questions on lipoproteins.

I have two questions as follows:

a) The American Heart Association recommends every adult be tested for lipoprotein(a) at least once in their lifetime (see link), to measure the genetic marker which is strongly linked to higher risks of heart attacks and strokes. What is your take on such a test, and whether it would be introduced in Singapore?

b) Is there a too-high level for HDL, and what would the level be?

Thank you for your advice.

Answer by Dr Loh Wann Jia

Dear Simon,

Lp(a) blood level of more than ≥ 120 nmol/L (or 50 mg/dL) is considered high.

Yes, I strongly agree that all adults should be tested at least once in their life. As to when this should be tested, it is up to individual.

However, logically, it would make sense to test around one’s 20s or 30s, so that people can make positive lifestyle changes.

I have been working hard in the last five years to educate healthcare professionals and medical students on this topic. However, it takes years and many people to make a consistent change in clinical practice.

Testing itself is not difficult, but the focus should be on making sure healthcare providers and patients know how to manage this.

Hence, I created a management framework called LILAC to manage high Lp(a) and high LDL. Together with my team, other doctors, and medical societies, we are working to increase awareness, education and training, at both the national and international level. Do give us your support!

To learn more: 
On Saturday, 25th April, we will be having a Lipid Disorders and Lipoprotein(a) Support and Awareness Day at CGH. You can sign up for this by registering via the QR code on the CGH website here.

We have also made a family-friendly informative cartoon video on LILAC for Lipoprotein(a), which you can view here.

21. Question by Yeo

Dear Dr,

Where to test the Lipoprotein(a), or Lp(a) level? How much will it cost? Thanks.

Answer by Dr Loh Wann Jia

Hi Yeo,

Lp(a) testing is offered in most hospitals, medical centres and GP clinics in Singapore now. If your lipoprotein(a) level is normal (i.e. <70 nmol/L or <30 mg/dL), it will remain low for life, so there is no need to check again usually.

At CGH, the fee for Lp(a) testing varies depending on patient subsidy.

22. Question by Peter

Dear Dr,

I would like to know where can I go for a lipoprotein(a) test?

Answer by Dr Loh Wann Jia

Hi Peter,

Lp(a) testing is offered in most hospitals, medical centres, and GP clinics in Singapore now. If your lipoprotein(a) level is normal (i.e. <70 nmol/L or <30 mg/dL), it will remain low for life. Therefore, there is no need to check again usually.

23. Question by Adelene

Dear Dr,

What are the practical action to take if I have high levels of lipoprotein(a) eg more than 300nmol/L

Do exercise and special diets improve lipoprotein(a) levels?

Family members do not have early heart disease.

Answer by Dr Loh Wann Jia

Dear Adelene,

I would encourage you to learn about the LILAC method, as many patients have found it useful. It is true that exercise and healthy diet are important for overall cardiovascular risk control, but they do not specifically lower Lp(a) much, typically by no more than 5-10%.

An Lp(a) level of 300 nmol/L is quite high, but the management of each person needs to be individualised.

For Lp(a), I have devised a management framework that patients, families, and healthcare professionals can adopt to manage this condition.

If Lp(a) is only mildly high, there is nothing much to worry about.

However, if Lp(a) is very high or you already have a high risk of heart attack (e.g. smoking, diabetes, hypertension, family history), then practice LILAC:

L: Recognise Lp(a) as a cardiovascular risk factor. Learn about Lp(a) and your other lipid (cholesterol) profile for appropriate risk factors.
I: Improve all cardiovascular risk factors.
L: Lower LDL cholesterol level first, and in severe cases, consider lowering Lp(a) levels.
A: Assess for related conditions associated with elevated Lp(a), while considering aspirin.
C: Consider cascade testing to identify at-risk family members. “C” also stands for Care and Compassion.

Following the LILAC approach can help patients to reduce cardiovascular risks associated with elevated Lp(a) levels. Emphasis remains on the letter “I”- improving one’s lifestyle, including diet and exercise, controlling blood pressure and glucose levels, and avoiding obesity, as these are still the first steps.

We have also made a family-friendly informative cartoon video on LILAC for Lipoprotein(a), which you can view here.

24. Question by Evelyn

Dear Dr, I have the following questions :

a) Is Apolipoprotein A1 the same as Lipoprotein (a)?

b) If Apolipoprotein B is high, what is the impact of this? What needs to be done?

c) APO B/APO A1 Ratio is high, what is the meaning?

d) What and how to do the test for Familial Hypercholesterolemia, FH?

Thank you for your advice.

Answer by Dr Loh Wann Jia

Hi Evelyn,

Apolipoprotein A1 is not the same as Lipoprotein(a). The apolipoprotein A1 correlates with HDL cholesterol levels.

A very high ApoB concentration (e.g. more than 1 g/dL) suggests a lot of floating lipoproteins carrying cholesterol in your blood. Cumulatively over many years, this can cause an increase the risk of coronary plaques.

The ratio of ApoB/ApoA1 is more commonly used for an academic purpose and I don’t use that in clinical practice to manage patients.

Currently, the Ministry of Health has subsidised genetic testing of familial hypercholesterolemia, with a single criterion of LDL-C levels of more than or equal to 5.5mmol/L or 212 mg/dL.

There are other criteria that suggest this could be familial hypercholesterolemia, including having a strong family history of high LDL cholesterol from a young age.

25. Question by Louis

Hi Dr,

My cholesterol is normal w atorvastatin 10mg.

a) Do I still need to measure for Lp(a)?

b) Do I need to check apo B instead of LDL?

Thank you for your advice.

Answer by Dr Loh Wann Jia

Hi there,

For individuals suspected to be at high or very-high risk for cardiovascular disease, such as those with a family history of parents having a heart attack before 55 years of age, or if the individual himself has had heart/stroke disease before, or has familial hypercholesterolaemia (very high LDL cholesterol), it is strongly recommended for them to undergo an Lp(a) blood test in early adulthood.

For individuals who are very well, and have no cardiovascular risk factor, it is up to you when you want to be tested. Testing earlier allows for you to take necessary precautions such as eating healthy, exercising regularly, not smoking and taking control of blood pressure.

LDL cholesterol levels are a cheaper and more convenient method of monitoring of cholesterol levels compared to ApoB. However, some people prefer to do both.

26. Question by XH

Dear Dr Loh,

I am 33 years old this year and have been diagnosed with high cholesterol since primary school due to family history. I am currently on Atorvastatin to control my cholesterol. So far the results are quite stable and I do my 6 monthly follow up with SingHealth polyclinic.

However I came across your article about Lp(a) and wonder if I should also request for a test for that with my polyclinic doctor?

My mother is also diagnosed with high cholesterol since a young age and medication does not seem to be helping much to bring down her cholesterol levels. Should she also get this tested too?

What would be the recommendation to manage for individuals tested with elevated Lp(a)?

Looking forward to your reply! Thank you!

Answer by Dr Loh Wann Jia

Hi  there,

Whether cholesterol levels decrease with medication is not related to whether Lp(a) should be tested.

Lp(a) testing can be considered, as many guidelines recommend that all adults should be tested. If the result is normal, there is no need to check again.

It is up to you whether you would like to be tested. It is a simple test. Currently, Lp(a) testing is only offered in most hospitals, medical centres and GP clinics in Singapore.

Ref: F26