For isolated and very high lipoprotein (a) levels (LDL of > 140, has an Lp(a) > 100) in a patient with no cardiac symptoms or risk factors, would you start lipid lowering treatment, such as with a PCSK9i if they develop statin intolerance? 

There are a number of trials going on for reduction of Lp(a) with both IM and PO meds. We know that lifestyle modification does not help for reduction of this very atherogenic protein. If calc scores are high, I would look into entering one of the trials. If the score is low (unlikely), I would wait...