Cardiovascular Health: Beyond the Lipid Panel
Cardiovascular disease (CVD) is the leading killer worldwide, yet most people are flying blind when it comes to assessing their risk. The standard lipid panel—total cholesterol, LDL-C, HDL-C, triglycerides—is a starting point, but it’s like judging a car’s performance by only checking the fuel gauge. To get serious about preventing heart attacks and strokes, you need to go deeper: advanced lipoprotein testing, coronary artery testing, and, when warranted, stress testing.
​
​
Why the Lipid Panel Falls Short
The traditional lipid panel is a blunt tool. LDL-C, the so-called “bad cholesterol,” measures cholesterol content in LDL particles but ignores their number or size—key drivers of atherosclerosis. HDL-C, the “good” cholesterol, is even less reliable; high levels don’t guarantee safety, and low levels don’t pinpoint the problem. Triglycerides hint at metabolic health but fluctuate with diet and lifestyle. These are proxies, not truth. If you’re aiming to outrun CVD, you need metrics that cut through the noise.
​
​
Lipoprotein Testing: The Real Risk Drivers
Advanced lipoprotein testing gets to the root of atherogenic risk by measuring the particles themselves. Apolipoprotein B (apoB) and low-density lipoprotein particle number (LDL-P) are the heavy hitters here. Each atherogenic particle carries one apoB molecule, so apoB is a direct count of the particles that can lodge in your arteries. A 2010 JAMA meta-analysis showed apoB outperforms LDL-C in predicting CVD risk. Two people with the same LDL-C can have wildly different risks if one has high LDL-P—more particles, more trouble.
This is critical for those with insulin resistance or metabolic syndrome, where small, dense LDL particles dominate. Tests like NMR LipoProfile or direct apoB measurement reveal the truth. Target apoB below 60 mg/dL if you’re high-risk. If it’s elevated, you’ve got work to do—lifestyle, statins, or PCSK9 inhibitors might be on the table.
Then there’s lipoprotein(a), or Lp(a), a genetically determined particle that’s a silent CVD risk factor. High Lp(a) ramps up atherosclerosis and thrombosis risk, and it’s stubbornly resistant to lifestyle changes. A one-time Lp(a) test is non-negotiable—it shapes your strategy. If it’s high, you might double down on lowering apoB or explore therapies like niacin or PCSK9 inhibitors, though the data’s still evolving.
​
​
Coronary Artery Testing: Measuring the Disease
Lipoprotein tests assess risk factors; coronary artery testing shows the damage. Coronary artery calcium (CAC) scoring is a low-cost CT scan that quantifies calcified plaque in your coronary arteries. A zero CAC is a strong sign you’re in near-term events, while a score >100 (or worse, >400) means atherosclerosis is active. The MESA nailed this: CAC is one of the best tools for risk prediction.
Consider a 50-year-old with “normal” lipids but a CAC of 300—they’re at higher risk than someone with high LDL-C but a CAC of zero. If you’re over 40, especially with risk factors (family history, diabetes, smoking), a one-time CAC scan is a no-brainer. It misses soft plaque, but it’s the best non-invasive option. For high CAC or symptomatic cases, a coronary CT angiogram (CCTA) can visualize both calcified and soft plaque, though it’s pricier and requires contrast.
​
​
Stress Testing: Use It Wisely
Stress testing—treadmill, nuclear, or echocardiographic—has its place, but it’s not for everyone. It’s most useful when symptoms (chest pain, dyspnea) or high-risk profiles (CAC >200, diabetes, family history) suggest ischemia. It tests how your heart under stress, catching blockages or electrical issues that might hide at rest.
But it’s not perfect. False positives lead to unnecessary procedures, especially in low-risk groups. False negatives can miss non-obstructive disease. Pair it with other data: a high CAC plus an abnormal stress test might justify catheterization, while a zero CAC might make it redundant absent symptoms.
​
​
Tying It All Together
Preventing CVD isn’t about ticking boxes—it’s about building a high-resolution risk profile. At South Denver Concierge, we have the time to take a deep dive into each patient's individual risk profile, health history, lifestyle, and family history to develop an individualized preventative plan.
​
​