Many of the patients I’ve performed surgery on didn’t know they were at risk for heart disease.
They didn’t have high cholesterol. They didn’t report any symptoms. And they didn’t have a family history of heart failure or cardiovascular disease.
So how did they wind up on my operating table?
The truth is that genetics and cholesterol levels are poor predictors of overall heart health. Sure, they play a role in your metabolic health, but they aren’t necessarily the most accurate measures of risk.
If you want a truly accurate number, you’re going to need to start with more modern measurements. I’m covering three of the most important ones below, including why they matter, how to order them, and how to interpret your results.
The three most precise measures of heart disease risk
As many as three in four people who are hospitalized for a heart attack have low to normal cholesterol readings. Plus, only around 10% to 15% of the US population has a strong family history of heart disease — the rest have far weaker links.
This means two things. First, that the vast majority of at-risk patients have no idea they’re at risk. Second, that lifestyle factors and hyperspecific metabolic blood tests are almost always a more accurate predictor of risk.
Fortunately, there are many other ways of gauging your risk for heart disease.
Below are the three of the most precise methods worth considering:
High-sensitivity C-reactive protein (hs-CRP)
Your CRP is typically a measure of inflammation, as it helps measure endothelial damage (aka, damage to blood vessel wells). It’s a substance created by your liver in response to cytokines, which indicates the presence of inflammation, trauma, or other internal damage.
High levels of C-reactive protein may indicate a high risk of heart failure or even death. Studies also show that your “C-reactive protein level is a stronger predictor of cardiovascular events than the LDL cholesterol level.” They’re also extremely accurate in predicting CVD for asymptomatic populations — very useful if you don’t know you’re at risk.
Some providers let you take a high-sensitivity CRP test at home, then ship your blood to a lab for testing. Normal levels typically run <1.0 mg/L, with anything between 1.0 and 3.0 mg/L indicating possible heart disease despite low LDL cholesterol. Anything at or above 10 mg/L may require immediate intervention.
You can learn more about getting at-home CRP testing kits through Rupa.
Coronary artery calcium (CAC) scan
I’m a big advocate of using preventative CAC scans to identify heart plaque early. This is a non-invasive X-ray of your heart and arteries that can help predict your likelihood of suffering from a heart attack.
Your CAC results will be on, from zero into the thousands, with lower numbers indicating lower risk, and higher numbers indicating greater risks. If you’re under the age of 40, this score should be very close to zero. But keep in mind it’s normal to see some amount of plaque buildup as we age — it’s the “too much too soon” that’s often an early indicator of heart disease.
The CAC scan is also highly accurate, with an 87% negative predictive value (NPV) in patient management. This is quite high compared to cholesterol readings alone.
You can have your doctor or a specialist order a CAC scan for you. Because it’s non-invasive, you can go home immediately afterwards. There’s a bit more to cover here than space allows, but I explain the details of getting a coronary artery calcium scan in its own guide.
Of course, it might be difficult to know just how ‘bad’ a CAC score is just by looking at it in isolation. I highly recommend ordering a full metabolic panel as well, either before or after, so you can check your risks for other health concerns (including metabolic syndrome).
Insulin resistance (A1C and C-peptides)
The level of insulin in your blood, plus your overall blood sugar levels, are a very accurate predictor of heart disease risk.
For context, each 1% increase in your A1C score leads to a 39% higher risk of heart failure, even adjusting for other covariates. Plus, measuring C-peptides, a protein released alongside insulin, is typically “a better predictor of [heart disease and overall mortality] than serum insulin and/or glucose derived measures.”
You can order an A1C test to take from home, although a C-peptide test will typically require more advanced equipment. That said, it may be possible to order a test online and then visit a local lab to complete the panel.
There’s a lot more regarding the interplay of insulin and heart disease here, so you can learn more about what it means to be insulin resistant here, including ways to get the most accurate blood test possible.
Sidenote: what about Apolipoprotein (ApoB)?
This is a question that comes up quite frequently with my patients, so I felt it was important to debunk the myth here.
Studies suggest that apoB is often a far more reliable metric than total cholesterol readings alone. But that doesn’t mean it’s the most accurate measure of heart disease, especially if you qualify as a lean mass hyperresponder.
First, some context. You can think of Apolipoprotein B as the transportation system for “bad” cholesterol — including low-density lipoprotein (LDL) and very low-density lipoprotein (VLDL). Getting a measure of the amount of apoB in your blood can help you better measure lipids compared to traditional cholesterol tests alone.
That said, having a high apoB score signals a need for more testing, not necessarily immediate statin treatments. Because while ApoB does correlate with increased risk of CVD, the size of the lipid particle matters quite a bit.
ApoB tests measure three types of particles: large fluffy LDL, small dense LDL, and very low-density lipoprotein. If you have a very high volume of very large, fluffy particles, you may not necessarily be at risk for heart disease. But if you have a large number of small dense LDL and VLDL, you might want to take action and schedule another test on this list.
This means even with a higher apoB score, you won’t necessarily develop heart disease. Of course, the likelihood is much higher if you are insulin resistant, suffering from inflammation, or have a high percentage of sdLDL in your blood. You can identify each of these with at-home tests and then determine whether or not it’s important to change fat sources and/or adjust your total carbohydrate intake to avoid further damage.
To summarize: the context of a high apoB score matters a lot. It might be more accurate than simply measuring LDL, but it shouldn’t be used to make decisions in a vacuum.
And if your PCP doesn’t understand this nuance, it might be time to fire your doctor.
What to do if you have a high risk for heart disease
We’ve known for years that these methods of predicting heart disease are flawed, and relying on them alone might prevent you from seeing the fuller picture of your metabolic health. Thankfully, we have many new methods of measuring risk and predicting the possibility of a heart attack.
Of course, if all you want is a preliminary look at your health, you can always start with my free metabolic health quiz.
But if you’re looking to go deeper (or have reason to suspect more imminent danger), one of the following resources may be more relevant to you:
- What it takes to reverse heart plaque
- How to recover from a heart attack
- Can chronic diseases be cured?
