9 Heart Tests Better Than Cholesterol Count

These top-of-the-line diagnostic tools can slash your heart disease risk.

Clean living may earn you a spot in heaven, but it won't necessarily prevent a premature heart attack. About half of all people hospitalized with heart attacks have normal cholesterol levels, and more than 14 percent of those who die of a first heart attack have no traditional risk factors at all.

If you are north of 40, chances are you know someone a little older or even your own age who has suffered a heart attack — maybe a fatal one. The shock of one of your peers having a chest-clutching moment may send you to your doctor for a checkup — or, more likely, inspire your wife to ask you to go. The doctor will test your blood cholesterol and set you up for a baseline electrocardiogram (ECG) to measure your heart's rate and rhythm, and may order an exercise stress test on a treadmill "to be safe," even if you aren't complaining of chest pain. And chances are you'll ace the test the way Eli Manning aces fourth and long.

But is your family doctor's thumbs-up and slap on the back enough to give you peace of mind?

"All a stress test tells your cardiologist is whether or not you have heart disease so bad that you need to be rushed into the cath lab tomorrow for an angioplasty procedure," says cardiologist H. Robert Superko, M.D., author of Before the Heart Attacks and a clinical professor at Mercer University's school of pharmaceutical sciences in Atlanta. Even if your arteries are half blocked, you can still have a perfectly normal treadmill test. It takes a blockage of more than 70 percent to show up positive, he says.

But new advanced imaging and blood procedures, as well as new genetic screenings, can now detect cardiovascular diseases many years before they become severe enough to be revealed by traditional ticker tests, says cardiologist Arthur Agatston, M.D., author of the South Beach Diet books and a pioneer in preventive medicine.

Let's say you're a 45-year-old man with normal blood pressure and cholesterol, but your dad had a first heart attack at 56 and your mom has diabetes. What more can you do to be proactive?

Sharing your clan's health secrets with your doctor is step one. "Family history is a critical predictor of heart-disease potential," says Florence Comite, M.D., an endocrinologist specializing in age-management medicine in New York City. "You might even consider it a 'free' genetic profile, and it could convince your doctor that further tests are prudent."

On the next page is a menu of the latest technically advanced cardio diagnostic tests to consider beyond the usual blood pressure and basic cholesterol screenings for HDL, LDL, and triglycerides. Note that not all cardiologists are fans of these procedures. (See "A Second Opinion.") Depending on your family history, age, and lifestyle, and certain known biomarkers, your doctor can coordinate the tests that are most appropriate for you.



It's an ultrasound of the heart that helps a doctor view your heart's structure, detect heart-valve problems, and measure pumping function. It's usually done in a doctor's office.

Why is it important?

A key measure of heart health is ejection fraction, the percentage of blood expelled by the left ventricle during each heartbeat. A left ventricle that's functioning well pumps about 60 percent with each beat.

Who is it best for?

Anyone with a heart valve problem, murmur, or history of heart attack. Lower percentages of blood pumped by the left ventricle may indicate dysfunction and increased risk of congestive heart failure.


A blood test measures levels of this abrasive amino acid, which irritates the lining of arteries, opening them up to infiltration by LDL and leading to plaque and blood clotting.

Why is it important?

One study showed that high homocysteine levels lead to an increase in stroke risk comparable to the risk of a pack-a-day smoker. The test can inform a doctor to prescribe folate, B6 and B12 supplements.

Who is it best for?

Patients who have symptoms of atherosclerosis but who may not have any of the traditional risk factors of heart disease, such as smoking, family history, high blood pressure, blood clots, or a poor diet.

3D Rendition of Hemoglobin

Hemoglobin A1C

Why is it important?

Also called glycated hemoglobin, HbA1C is a blood test that measures your average blood sugar over 2 to 3 months; it's more accurate than the standard fasting glucose test. "It's one of the best tests for healthy longevity," says Dr. Comite. It measures the percentage of your hemoglobin (a protein in your red blood cells) that is glycated, or coated with sugar.

Who is it best for?

Anyone 45 or older — and younger people who are overweight and also have one or more diabetes or heart disease risk factors, such as a family history of diabetes, high triglycerides, or low HDL cholesterol.


Also known as "Lp Little a," this blood test looks to measure a protein, attached to LDL particles, that encourages LDL to infiltrate coronary artery walls. This protein is inherited.

Why is it important?

"It's a very powerful predictor of heart disease in younger people," says Dr. Superko. In fact, it's nicknamed "the widow maker" because it's so closely linked to heart attack and stroke.

Who is it best for?

People with a family history of heart disease who may have normal cholesterol numbers. Diet, exercise, and statins have no effect on Lp(a); only high doses of niacin have been shown to decrease Lp(a) levels.

Heart CT Scan

CT scan for calcium score

The CT (computerized tomography) scan is a series of x-ray views taken from different angles to create a cross-sectional view of certain soft tissues, such as your heart.

Why is it important?

The scanner can detect calcified plaque in your coronary arteries. "The calcium score is the single best predictor of who is destined for a heart attack," says Dr. Agatston, who developed the scoring.

Who is it best for?

Men over 50 with risk factors, or younger men who have a family history of heart disease and several risk factors. Caveat: Calcium scanning delivers a radiation dose equivalent to 20 to 40 chest x-rays.

Endothelial Function test

A noninvasive test, such as the EndoPAT, analyzes the health of the thin lining of your blood vessels (called the endothelium) and the ability of your blood vessels to dilate.

Why is it important?

Endothelial dysfunction may be the first observable manifestation of vascular disease, when you still have an opportunity to protect the lining of blood vessels through diet, exercise and certain drugs.

Who is it best for?

Anyone who wants concrete evidence of a greater risk for heart disease and the knowledge that they need to make changes in their lifestyle. It's one of the best and easiest tests available.

Small, Dense LDL

Why is it important?

LDL cholesterol comes in different sizes. "If you have a lot of small LDL running around, you're at greater risk for heart disease," says Dr. Superko. Small, densely packed LDLs penetrate the endothelial walls more easily than large particles do. Losing weight and taking certain medications can increase the size of cholesterol particles, reducing your risk.

Who is it best for?

People who have a family history of heart disease and may have normal cholesterol numbers. These tests are extremely useful for monitoring individuals who are taking statins, according to Dr. Comite.


Genetic testing

Why is it important?

In 2007, the first common gene for coronary artery disease, called 9p21, was identified. Since then, scientists have identified more than 30 genes associated with increased risk.

Who is it best for?

"Heart disease is essentially a genetic disease," says Dr. Superko. "A gene test done once in your lifetime can provide the information your doctor needs to design a very specific treatment therapy." Anyone who wants predictive knowledge of the likelihood of developing heart disease. It's also a good prescreening method for someone considering a CT calcium scan.

hsCRP [high sensitivity CRP]

A blood test that measures the amount of this protein in your bloodstream.

Why is it important?

C-reactive protein is a telltale sign of inflammation (irritation) in the lining of your arteries. The hsCRP test is twice as effective as a LDL test in predicting heart attacks. "You can have normal cholesterol numbers and still be at high risk for cardiovascular disease if you have elevated hsCRP," says Dr. Comite.

Who is it best for?

Those individuals whose LDL and other risk factors identify them as borderline candidates for statins and lifestyle modification. Poor diet can increase the amount of inflammation in the body.


Some cardiologists, including those at the nation's premier cardiology clinic, do not advocate advanced cardio tests. "Even a stress test is a bad idea for the 'worried well,'" says Steven Nissen, M.D., who is chairman of the cardiology department at the Cleveland Clinic and coauthor of Heart 411: The Only Guide to Heart Health You'll Ever Need. The new tests, including advanced lipid profiles, CT scans, and genetic tests, are expensive; some can deliver false results, and some are inherently dangerous, he says. "They are not good medical practice. We know how to prevent heart disease. Stick to the basics: Don't smoke, follow a Mediterranean-style diet, and exercise."

Dr. Nissen also believes that monitoring blood pressure and LDL cholesterol are all most people need to do to protect themselves as long as they also keep their weight down. "Frankly, you can't be too thin," he says. "Midlife bulge, that fat accumulation in the abdomen that men develop, is more dangerous than elsewhere. Use portion control to keep a trim waist. That'll make a huge difference in lowering your risk."

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Jeff Csatari
Jeff Csatari, a contributing writer for Eat This, Not That!, is responsible for editing Galvanized Media books and magazines and for advising journalism students through the Zinczenko New Media Center at Moravian University in Bethlehem, PA. Read more
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