Plasma lipoprotein(a) ILp(a)I, a low density lipoprotein particle with an attached apolipoprotein(a) Iapo(a)J, varies widely in concentration between individuals. These concentration differences are heritable and inversely related to the number of kringle 4 repeats in the apo(a) gene. To define the genetic determinants of plasma Lp(a) levels, plasma Lp(a) concentrations and apo(a) genotypes were examined in 48 nuclear Caucasian families. Apo(a) genotypes were determined using a newly developed pulsed-field gel electrophoresis method which distinguished 19 different genotypes at the apo(a) locus. The apo(a) gene itself was found to account for virtually all the genetic variability in plasma Lp(a) levels. This conclusion was reached by analyzing plasma Lp(a) levels in siblings who shared zero, one, or two apo(a) genes that were identical by descent (ibd). Siblings with both apo(a) alleles ibd (n = 72) have strikingly similar plasma Lp(a) levels (r = 0.95), whereas those who shared no apo(a) alleles (n = 52), had dissimilar concentrations (r = -0.23). The apo(a) gene was estimated to be responsible for 91% of the variance of plasma Lp(a) concentration. The number of kringle 4 repeats in the apo(a) gene accounted for 69% of the variation, and yet to be defined cis-acting sequences at the apo(a) locus accounted for the remaining 22% of the inter-individual variation in plasma Lp(a) Plasma concentrations of Lp(a) vary over a wide range among individuals, but are remarkably stable in any given individual (10). Many physiological, pharmacological, and environmental factors that affect the levels ofother plasma lipoproteins have no effect on the plasma concentration of Lp(a) (10). This lack of environmental and physiological influences suggests that plasma Lp(a) levels are largely genetically determined. Consistent with this formulation, early genetic studies suggested that the presence ofLp(a) in plasma was inherited as an autosomal dominant trait (1 1-13). When more sensitive immunoassays of plasma Lp(a) concentrations were used, it was found that plasma Lp(a) concentrations varied continuously among individuals ( 14), and the pattern of inheritance indicated that a major gene, as well as polygenic factors, contributed to plasma Lp(a) concentrations (15)(16)(17).Fless et al. ( 18) and Utermann et al. (19) found that the apo(a) glycoprotein varied in size among individuals. In an important series of studies, Utermann and his colleagues demonstrated that the size ofthe apo(a) protein is inversely related to the level of plasma Lp(a), thus implicating the apo(a) gene as a major determinant of plasma Lp(a) concentrations (20-23). However, the immunoblotting technique used to type the apo(a) isoforms was not sensitive enough to detect low levels of apo(a) protein, and not all of the apo(a) isoforms were detected. As a result, the frequency distribution of the apo(a) isoforms failed to fit the expectations ofHardy-Weinberg equilibrium (22). In addition, when immunoblotting was employed to examine the segregation o...