Should lipid lowering therapy be started in patients with isolated elevation in lipoprotein (a) and minimal cardiovascular risk?

At the current time the answer would be "no" for someone with minimal CVD risk. There are not any currently available therapies for effectively lowering Lp(a) nor randomized trials demonstrating clinical efficacy, though this could change in the near future.

I agree with Professor @Dr. First Last (hi!) with two exceptions.

First, there IS in fact one currently available therapy, lipoprotein apheresis (LA) which dramatically lowers Lp(a) levels (by 65-85% acutely and by ~30-60% time-averaged) and even more dramatically reduces CVD risk (by 70-95%! NOT a typo). Granted, there is only one controlled trial of LA, but there are over a dozen published studies using scores and hundreds and even thousands of patients as their own historical controls. These studies consistently and convincingly show these unprecedented CV event benefits. Because of these studies and many other convincing clinical and mechanistic studies, in 2020 the FDA approved for Lp(a) > 60 mg/dL (or approximately 125 nM/L). However,...