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You cannot spot heart disease, but you can find it in your lab work!

Heart disease is the leading cause of death for both men and women in the United States, yet it is reversible and preventable!

Why do many people have their first heart attack, when their cholesterol is “normal?” Why do many people have a second heart attack within 5 years of their first one, despite doctor visits, tests, medications and even procedures?

Below, I have extrapolated information from Dr. Mark Hyman’s newsletter dated January 29, 2024. Most important to note is the fractionation of cholesterol.

Looking at cholesterol, just like looking at a person, is tricky. One can look at an athlete paying basketball. Thin, agile on the court. Off the court, sore and inflamed-if the diet is 3 Gatorades, a burger, fries, ice cream, and later, beer. You can see that this partial day’s food intake is an inflammatory nightmare, leading to diabetes, and heart disease. Yet the individual may look healthy!

basketball player

The first symptom of heart disease for 50 percent of people who have it is sudden death! Yet 99 percent of screening for heart disease risk uses an outdated cholesterol panel that should be in the dustbin of history. Newer methods of testing cholesterol that reveal the true risk are done by less than 1 percent of doctors.

These are sobering statistics. But the problem isn’t that heart disease is difficult to spot. It’s that most physicians aren’t looking in the right places. Modern biomarkers such as lipoprotein fractionation (which measures not just the amount but the quality of your cholesterol), ApoB, Lp(a), and the artificial-intelligence-driven Cleerly Heart Scan have proven to be far more predictive of heart disease than the standard cholesterol profile—yet, frustratingly, many primary doctors aren’t aware of them.

Case study: a 47-year-old patient, for example, comes in with a completely normal lipid profile according to the tests used by 99 percent of physicians. His total cholesterol, triglycerides, LDL, and HDL were all fine, and in fact, looked great. But his lipoprotein fractionation—the size, quantity, and

density of his cholesterol particles—told a different story. His LDL particle number (which should be less than 1,000 particles) was more than 1,800 particles, and his small LDL particles (ideally less than 200 particles) were more than 600. So his blood was carrying a normal amount of cholesterol, but rather than being packaged in large fluffy particles, it was highly concentrated in small, dense particles that have a greater tendency to become oxidized and caught in arterial walls, causing plaque formation. And without lipoprotein fractionation, his high-risk profile would have been

missed, and he would have been headed toward a heart attack.

The good news is that the modern tests we have to paint a complete picture of cardiovascular risk are for the most part inexpensive and widely available, and I’m going to tell you what you need to know about them including where and how you can get them.

lipid testing

Why everyone should test for lipoprotein fractionation

A study published in the American Heart Journal looked at the lipid levels of 136,905 patients who went to the hospital with heart attacks and found that 75 percent of them had “normal” levels of LDL cholesterol.

This is because what’s most important isn’t the amount of cholesterol in the blood (a misconception that’s remained rampant since the 1940s), but the size, density, and quantity of the particles.

In short, the larger and less dense the particles, the less dangerous they are because they’re less likely to get lodged in the walls of your arteries, which reduces the risk of plaque formation. Whereas smaller, denser particles can more easily penetrate the arterial wall, leading to inflammation and plaque formation. Think of particle size as the difference between tossing a beach

ball at an object versus a golf ball; the beach ball (the large, fluffy particle) is likely to bounce off, while the golf ball (the small, dense particle) is more likely to cause damage.

Standard cholesterol tests only tell us the weight of cholesterol in the blood, so a “normal” LDL of 100 mg/dL doesn’t tell us much because the same amount of cholesterol could consist of a few large, fluffy particles or hundreds of dense, dangerous particles. In contrast, lipoprotein fractionation

is the gold standard of lipid tests because it shows us how our cholesterol is packaged: breaking down the distribution of LDL, HDL, and triglycerides by size, particle number, and density.

Lipoprotein fractionation is inexpensive and available from many of the same labs doctors use to run standard cholesterol tests, but many primary care physicians and even cardiologists simply aren’t caught up on the technology or are stuck in old ways of practicing medicine.

Assessing Cardiovascular Risk with ApoB, Lp(a), and hs-CRP

While lipoprotein fractionation is an absolutely essential metric for determining your risk of cardiovascular disease, it still tells us only part of the story. So measuring other biomarkers in conjunction can give us a more accurate picture.

Apolipoprotein B (ApoB)

Measuring Apolipoprotein B, or ApoB, a protein found on the surface of atherogenic (plaque-promoting) lipoproteins can provide additional insight into what’s happening inside your arteries. Because each atherogenic particle in the bloodstream contains a single ApoB molecule, measuring ApoB can provide an accurate reflection of the number of atherogenic particles in the blood, which correlates to a risk of atherosclerosis and heart attacks.

Lipoprotein (a), or Lp(a)

Another biomarker for risk and early detection is Lipoprotein (a), or Lp(a), a type of cholesterol in your blood that’s largely determined by genetics and stickier than other forms, making it more likely to cause blockages in the arteries.

Specialists regularly test Lp(a) to evaluate the early risk of cardiovascular disease for those who have concerning family histories or are known to have other risk factors; however, it has yet to be widely adopted by primary care physicians for early screening and prevention.

High-sensitivity c-reactive protein (hs-CRP)

Hs-CRP, is a blood test that measures the level of CRP, a protein produced by the liver that increases when there’s inflammation in your body. This test is “high-sensitivity” because it can detect even very low levels of CRP, making it useful in assessing the risk of cardiovascular disease, as inflammation is a key factor in the development of plaque in arteries, leading to heart disease and


Like lipoprotein fractionation, ApoB, Lp(a), and hs-CRP testing are relatively inexpensive and widely available from medical labs, but are primarily used by specialists rather than primary care physicians, which is unfortunate given the level of insight they can provide. Everyone should get them.

For more information on hsCRP testing, please refer to my newsletter from July 2023 in this link:

Advanced testing with artificial intelligence

While cardiologists have traditionally used calcium scans and angiograms to look for plaque in the arteries, both have their limitations. For example, calcium scans only look for calcified plaque (hard plaque), not noncalcified plaque (soft plaque), which can pose a greater risk than hard plaque.

Meanwhile, angiograms are invasive procedures involving the insertion of a catheter, usually in the groin or arm, to inject contrast dye into the coronary arteries, and are primarily effective at showing blockages in the arteries, not information about the artery walls and the nature of the plaque.

However, a new technology the Cleerly Heart Scan combines artificial intelligence with advanced CT angiogram imagery to provide a more comprehensive analysis by identifying both calcified and noncalcified plaque as well as other important insights such as the level of inflammation and the

degree of narrowing of your arteries.

These scans are a huge step forward in risk assessment, particularly for identifying early risk, and are increasingly available nationwide. Compared to blood tests, they’re more expensive, generally costing upwards of $1,000. But considering the statistics of heart disease, it’s well worth the cost for

those who can afford it—and hopefully more insurance companies will start to cover it. If you have abnormal biomarkers for the cardiovascular risk assessment we have just covered, it is a good idea to get a Cleerly Heart scan.

Addressing abnormal test results

  • Most abnormal issues with elevated small dense particles, ApoB, Lp(a), and hs-CRP are caused by poor metabolic health, so diet is one of the most powerful tools at our disposal.

  • The majority of heart attacks are caused by poor metabolic health and insulin resistance, which can be improved by eliminating ultraprocessed foods, sugar, starches, and refined carbohydrates and increasing the intake of phytochemical rich vegetables, nuts, and seeds.

  • A combination of strength and cardiovascular exercise also improves insulin sensitivity, metabolic health, and cardiovascular fitness.

  • Healthy fats can improve lipid profiles and reduce the overall risk of heart attacks and can be found in oils such as extra virgin olive oil and avocado oil; nuts such as almonds, walnuts, pecans, hazelnuts, and macadamia nuts; seeds such as pumpkin, hemp, and chia seeds; and pasture-raised, regenerative meats. In severe cases that include type 2 diabetes, a ketogenic diet can also improve lipids.

  • Omega-3 fatty acids from wild-caught fish or supplements are cardioprotective and have been shown to improve HDL lipid profiles, lower inflammation, and improve the size and function of HDL lipoproteins that absorb cholesterol from the blood and deliver it back to the liver [3].

  • Not eating three hours before bed and fasting for twelve to fifteen hours overnight can also help improve metabolic health.

I strongly encourage you to make these tests a foundational part of your annual visit. However many doctors are not willing to do tests that they are not familiar with or feel may be unnecessary. This is where you have to advocate for yourself in your healthcare!

Want to know why people have their second heart attack, despite doctor visits and medications and test? Find out, in my Heart Health Accelerator Cardiac Wellness Program

Mary Yuter Heart to Soul Cardiac Wellness

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