Why You Should Ask For Advanced Lipid Testing

Controversies in Cardiovascular Medicine is the intriguing title of a 2009 article in the American Heart Association’s Circulation publication.

Stop laughing – cholesterol research can be intriguing!  I’d label the situation frustrating more than intriguing, but here’s what is going on.

The controversy is essentially that advanced lipid testing (explained in Cholesterol Tests Your Doctor Hasn’t Told You About) has been around for 50 years and is a better predictor of cardiovascular disease risk than standard cholesterol blood tests, and yet these ‘advanced’ tests are still not widely prescribed.

In fact, the ‘standard’ cholesterol blood panels (total cholesterol, LDL and HDL) often inaccurately portray risk for many people: those, for example, with normal cholesterol levels who heart attacks. And yet, standard lipid testing is still the norm.  It’s kind of crazy.

As explained in the Circulation article:

“Standard tests of low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) misidentify coronary heart disease (CHD) risk status in a substantial portion of the population. Tests of apolipoprotein concentrations are superior to standard LDL-C tests, and it can be argued that they should replace standard lipoprotein cholesterol testing.”

The Circulation article goes on to explain that the advanced testing used to be difficult and expensive – but this testing is now more widely available:

“Advanced lipoprotein tests that were previously available only from university research laboratories are now provided by several commercial laboratories.”

Indeed, since Berkeley Heart Lab (which was one of very few offering advanced lipid testing years ago) was bought first by Celera Corp in 2007 and then by Quest Diagnostics in 2011, it is now far easier — and inexpensive — to get advanced lipid testing!

And yet, it’s not widely prescribed.  Sigh.

I just had an advanced lipid panel done in December 2014. It wasn’t easy to get (my internist said not necessary; it wasn’t until I had to see cardiologist for sudden high blood pressure that he agreed it was a good idea). But I’m glad I did because I now have a much better understanding of my personal cardiac disease risk.

Here’s what I learned – and below these key points is some further info about test results that may be pertinent as you consider ASKING FOR advanced lipid testing:

  • My total cholesterol is ‘high’ at 266 and my LDL cholesterol is ‘high’ at 159
  • I have elevated ApoB (score of 123) which contributes to higher cardiac disease risk. But that is offset by other test results.
  • My LDL pattern is type A, which is optimal.  This is the fluffy kind that doesn’t stick to the arteries like the smaller, denser, more dangerous Type B LDL cholesterol.
  • My C-Reactive Protein score of 0.8 is also considered optimal / low risk.

Total and LDL Cholesterol: I find it frustrating that the lab reports still characterize my Total 266 and LDL cholesterol of 159 as ‘abnormal’ or ‘high’ (meaning, high ‘risk’) even though the November 2013 cholesterol guidelines say these scores are not, indeed, high or risky or need treatment. (The new guidelines indicate risk when  LDL>190, along with other factors).

Why do the lab reports not match the new guidelines?  This is inane.

ApoB: I am concerned about my elevated ApoB.  I wrote about apolipoprotein (ApoB) testing and explained why many believe it’s a better predictor of cardiac risk than LDL and total cholesterol testing in ApoB and Cardiovascular Risk.  So this is something I need to keep track of. Interestingly, the lab report says my score is ‘high’ risk and yet, when I dug further, I found a table that showed my personal target is probably <130 (see blog post for details).  Frustration #2 that there are not clear standards.

LDL Pattern Type: The type of LDL cholesesterol you have matters. As explained in the Physican’s Weekly article In The LDL World, Size Matters, roughly half of all people who have heart attacks have ‘normal’ cholesterol levels.  That’s because small sized LDL (Pattern B) can puncture the walls of the arteries and cause plaque buildup – so even ‘normal’ amounts can be dangerous.  If you have high LDL but it’s the Pattern A type which is big and fluffy, that cholesterol bounces off arterial walls so causes less plaque buildup and is thus less dangerous even if you have a ‘lot’ of it.

While I have the preferred / less dangerous Pattern A LDL cholesterol, I found in researching that Pattern B can be modified: if you have Pattern B, you can get it to change to pattern A with diet and exercise!  Which is great.  But that leads me to wonder whether just because I have pattern A now means it sticks (sorry, pun intended) or if it can change to pattern B.  I intend to stay with my lo-co diet and exercise plan, just wondering if I risk changing to Pattern B if I’m not careful. I need to check in with my cardiologist on this.

C Reactive Protein: I was relieved to find my C Reactive Protein score was low. As explained in a Circulation article from 2003 entitled C Reactive Protein: A Simple Test to Help Predict Risk of Heart Attack and Stroke, the C Reactive Protein test is an important measure in assessing cardiac risk. “When measured with new “high sensitivity” CRP assays, levels of CRP less than 1, 1 to 3, and greater than 3 mg/L (milligrams per liter) discriminate between individuals with low, moderate, and high risk of future heart attack and stroke…  Evidence also indicates that individuals with high CRP levels are at increased risk of developing diabetes.”

Now that the Advanced Lipid testing has provided a more in-depth look at my cardiac disease risk, I understand why my cardiologist feels that my 266 Total cholesterol is not terribly concerning. And doesn’t need treatment.

So if you, like me, want a far clearer understanding of your personal risk of cardiac disease, you should ask your doctor to order Advanced Lipid Testing, including scores for:

  • Advanced Lipid Panel Reflex Direct LDL (measures direct LDL and provides the info on particle pattern, number and size)
  • ApoB
  • C-Reactive Protein – the high sensitivity test

Sad to say you’ll probably have to ask your doctor to order Advanced Lipid Testing – he or she is NOT likely to order these tests unless you ask. Which is a shame.

Because as the Circulation article concludes, these tests have been around for 50+ years, are now easily and widely available, and they pick up risk that typical cholesterol panel testing might miss:

“One advantage of ALTs is the greater insight they provide clinicians into individual patient disorders often masked by standard lipid tests considered to be within “normal” ranges.”

It’s important to ask, because advanced lipid testing might reveal that although your cholesterol is not high, you are still at risk. This testing is easy, cheap and could save your life. It will provide you with a more in depth understanding of your cardiac disease risk.

It’s a simple, important question. Ask about advanced lipid panel testing the next time you see your doctor.


ApoB and Cardiovascular Risk

In Cholesterol Tests Your Doctor Hasn’t Told You About, I briefly describe a cholesterol blood test for Apolipoprotein B (ApoB).  This simple blood test measures the number and size of LDL (bad) cholesterol: it’s an important test if you have high LDL (bad) cholesterol or are at ‘high risk’ of cardiac disease, as it provides a more finely tuned assessment of cardiovascular risk.

In fact, it might be a critical test for those with low LDL (bad) cholesterol – because it can reveal hidden cardiac risk.

While studies show ApoB is a better predictor of cardiac risk, it is not yet a test that is widely prescribed. Indeed, the American Heart Association is waiting for more studies to determine if ApoB is a test doctors should recommend. Personally, I find this frustrating (of course this means nothing as I’m not a doctor, but…) To me, it’s frustrating because this is a simple blood test that provides a detailed risk assessment.

Scientific American’s Heart Health Special Report entitled ApoB – A Better Marker For Heart Attack Risk Than LDL-Cholesterol explains why it’s an effective and important test:

“A high level of low-density lipoprotein (LDL, or “bad”) cholesterol is an important risk factor for a heart attack. Yet about half of the people who develop coronary heart disease have normal or even low LDL cholesterol levels. Some research suggests that a component of LDL—called apolipoprotein B, or apo B—may be more accurate at predicting coronary heart disease.

A Limitation with LDL Cholesterol Testing
The problem with using LDL cholesterol levels to determine heart attack risk is that the test measures only the amount of cholesterol in the LDL cholesterol particles, not the number or size of these particles. Apo B measurements, on the other hand, provide information on the number of LDL cholesterol particles.

For example, people with a higher apo B value than LDL cholesterol value tend to have smaller, denser LDL cholesterol particles. Studies have shown that small, dense LDL cholesterol particles are more strongly associated with heart attack risk than large, “fluffy” LDL cholesterol particles.

The test itself is a simple blood test. It’s easy and cheap: easier, even than the standard cholesterol lipid panel as it does not require fasting.  In fact, the test can be done in conjunction with a standard lipid panel.

Finally, after I visited a cardiologist, I got the ApoB test and my results were, of course, mixed.

Ha! ha ha ha ha ha ha ha

Part of the problem is that since ApoB testing isn’t a standard test there is conflicting info on what the goal ApoB levels should be. My cardiologist was happy with my results because my ApoB is lower than my LDL level, my LDL Pattern is the far healthier Type A / Fluffy LDL, and because my C-Reactive Protein was low risk (more on C-Reactive Protein and LDL patterns in another post.).

But my actual lab report shows my ApoB level of 123 as ‘high risk’ and simply references a desired range of 49-103.  So at 123, I have ‘high’ ApoB.

Ruh Roh.

Who to believe?

Well, it’s simple.  My cardiologist. After a lot of online research (again, I’m no doctor so take all this with a grain of salt), I think the reason my cardiologist is OK with my ApoB score of 123 is because of all those elements I mention above AND ALSO because  I fall into the ‘low risk’ of cardiac disease segment. It turns out that there are different ApoB goals based on a person’s general cardiac disease risk, and the lab report seems not to take this into account.

ApoB goals by risk pool is well explained in Medscape’s emedicine article entitled Apoliprotein B article, in the chart here:

Screen Shot 2015-03-14 at 5.22.44 PM


Since my 10 year risk factor via the cardiac disease risk calculator is low (and I also have just 1 risk factor from the ‘old’ way of calculating risk), then it’s probably OK that my ApoB is 123 as it’s lower than 130.

I’m glad I got the ApoB test done – but it’s only because I asked two doctors for it.  If you want a more detailed risk assessment, ask your internist or cardiologist about ApoB testing.


Cholesterol Results 2014

So I finally bucked up and got my cholesterol tested in November and the results were surprising.  First of all, my cholesterol – after a year of reasonably careful eating and a lot more exercise, but no Metamucil or Fish Oil pills – actually moved in the right direction.

Details in a second.

Not only that, my new cardiologist (again, more in a sec on why I needed to finally see a cardiologist) actually called my cholesterol results “enviable.”

Enviable, people.

This shocked me. Especially because I gave up on the fish oil pills which apparently now, in a total turnaround from past belief, don’t help much with cholesterol. (It’s frustratingly difficult to keep up with what’s recommended –  and what is no long considered effective – for managing cholesterol without statins.)

That said, in the face of a genetic predisposition toward high cholesterol, I’ve managed through diet and exercise to avoid cholesterol medication.  Though truth be told, that’s more likely due to the American Heart Association’s 2013 revised Guidelines For Managing Blood Cholesterol than anything I’ve done… if the Guidelines hadn’t been revised, I’d probably still be having the statin conversation with my doctor.

In any case, here are my exciting (ha ha) cholesterol results.

My overall cholesterol is UP and now measures 246 – which used to be considered high but is apparently now not so big a deal.  Not a big deal, I guess, because my LDL (bad) cholesterol keeps falling (“goal” is less than 130 and mine is now 123) and my HDL (good) cholesterol keeps rising (“goal” is higher than 46 and mine shot up to 95).

NOTE: I put “goal” in quotes because these goals are no longer really in line with the new Guidelines; I find it fascinating that they are still reported as “goal” when the only goal according to the new guidelines is LDL (bad) cholesterol over 190 along with other heart disease risk factors that have nothing to do with cholesterol results.  Bizarre that this is still ‘outdated’ a year later.  Or maybe not bizarre, just sad.

In any case, I’m excited about the results.  Here’s a chart for those who prefer graphs.  If that’s not you, skip to cardiologist discussion 2 paragraphs below!

KLS Chol Trend Thru 2014

You’ll see the red line of total cholesterol is still high and rising – but no one seems worried about that, since the green line of LDL (bad) cholesterol is falling along with the purple triglyceride line … and because the blue line of HDL (good) cholesterol is rising.

Things certainly do change – I’m so glad I never started on a statin back in 2010-2011 when my numbers looked like a statin was in order.

Now, on to cardiologist.  My cholesterol results were surprising – and nicely so. But at same blood test I found I am positive for a blood clotting disorder, so that was a major bummer.  It’s not treated – and not dangerous unless you take hormones (which of course I was) so that had to stop immediately.

And then it turns out my blood pressure has risen quite dramatically.

Likely the stress of this past year – along with wondering and worrying about the blood clotting disorder.  Hence my doctor-referred trip to the cardiologist.

So my new cardiologist and primary care doctor are sorting out how to deal with my (hopefully short-lived) blood pressure issue … and on the plus side, I really liked the new cardiologist.  And when we discussed cardiac risk and my cholesterol trends and family history, he also thought that getting a handle on what my cardiac risk really looks like is a good idea.  So I had two more blood tests – and YAY – these are the very tests I’ve written about thinking made sense for me in Cholesterol Tests Your Doctor Hasn’t Told You About.  Finally!

So I had blood tests for both C Reactive Protein (CRP is a measure of inflammation in the body and high levels have been associated with heart disease) and also a full lipid analysis that will measure LDL density, ApoB and more.  I am really relieved to finally be getting a handle on cardiac risk.  Lastly, am debating about getting a Coronary Calcium test done – it’s a CT test so there’s radiation involved (and Aetna denied coverage) so I’ll likely wait until the blood test results come back to decide.

So on plus side, my cholesterol tests are now ‘enviable’ but am waiting for the blood test results to come back and really help hone in on cardiac disease risk. Oh, and trying to figure out how to get my blood pressure back to normal.

So I’ll end 2014 with a question for you: how’s your cholesterol? And, um, blood pressure? If you don’t know, please resolve in 2015 to have them checked.


Non-HDL Cholesterol and The New Cholesterol Guidelines

If non-HDL cholesterol was viewed as a key predictor of cardiac disease risk (on par with apoB or LDL particle testing), why was it abandoned in the new November 2013 cholesterol guidelines?

This is something I’ve been thinking about for a while.  Because for those with diabetes or high triglycerides, it was considered vital to know non-HDL cholesterol. (Do You Know Your Non-HDL Cholesterol? explains why, and how easy it is to calculate from just a standard cholesterol lipid blood test.)

Let me start with a brief, very non-technical definition (for more technical info click blog post link above).  Non-HDL cholesterol is a measure that estimates the level of ALL the bad types of cholesterol in the blood.  Think of it this way: subtracting HDL (good) from total cholesterol yield the non-HDL cholesterol number, which is a measure of all the ‘bad’ cholesterol in the blood. That means it’s a measure of all LDL: the ‘regular-old’ LDL (bad) cholesterol number, which is the number that appears on a report, plus all the other carriers of ‘bad’ cholesterol, such as VLDL (very low density lipoprotein) and IDL (intermediate density lipoprotein) – which are not included in the regular-old LDL cholesterol measurement listed on a cholesterol lipid panel report.

Though it was not as widely known/used by doctors as regular-old LDL cholesterol, it’s true that non-HDL-C was  proven to be a better indicator of cardiac disease risk than just LDL cholesterol.

Indeed, as explained in the Mayo Clinic’s Cardiovascular Risk Assessment Beyond LDL Cholesterol: Non-HDL Cholesterol, LDL Particle Number, and Apolipoprotein B, non-HDL-C  is a better measure of cardiac risk than LDL cholesterol:

“Several known limitations make LDL-C a less accurate marker of cardiovascular risk than either non-high-density lipoprotein cholesterol (non-HDL-C), LDL particle number, or apolipoprotein B (apoB).”

“Advocacy for non-HDL-C began following widespread recognition of its superiority over LDL-C as a measurement of vascular event risk and demonstrated equivalency to apoB or LDL particle number in some clinical trials.”

If it was widely accepted in the medical community that non-HDL-C was a better predictor than LDL alone – and indeed, a good proxy for apoB or LDL particle testing, why were BOTH the LDL and the non-HDL-C measures abandoned in the new guidelines?

The answer seems to be that there is no rationale for setting a specific number target for either LDL or non-HDL-C.

I get it for LDL cholesterol. LDL was used as a key measure to determine whether someone should take a statin, even though there was no real rationale for a specific LDL number as a goal (which is crazy but is basically what’s been the case for many years now). Thus, the committee recommended a new risk assessment measure that was based on research – and eliminated the ‘random’ LDL goal.

Makes sense.

And yet.

If it is/was widely accepted and studies have shown that apoB and LDL particle size are predictive of cardiac risk, and non-HDL-C is an easy, cost-effective way to approximately measure apoB and LDL particle size (because non-HDL is calculated from a typical cholesterol test – not a whole new test like apoB) then it seems to me that knowing your Non-HDL-C is a good idea.

But hey, I’m no doctor. (And I don’t even pretend to play one on TV). So I could be wrong.

That said, I’m concerned. The new guidelines say I’m (suddenly, now) very low risk for cardiac disease. But my non-HDL cholesterol is significantly higher than the old “goal” of 130 for those with high triglycerides.

And I get that the 130 figure is not, in and of itself, a meaningful target.

I do.  Truly.

But it seems clear since my non-HDL-C is “high” compared with ‘normal’ or a lot of other people, that this might indicate a potential problem. And thus warrant action.  Not treatment – I get that it doesn’t make sense to recommend a statin based on a goal number that’s not grounded in research.

But to me, it seems that if non-HDL-C is greater than 130 then further testing could be indicated.

Again, I’m no doctor.

But I think it’s important to ASK about this.  Perhaps the fact that my non-HDL is high indicates the need apoB and/or particle size testing – or one or several of the tests the AHA now indicates for those who might be at risk: see New Cholesterol Guidelines – An App For That.

Good thing I’m due for my annual checkup soon.  I will ask my doctor about these tests. AGAIN.


Cholesterol Tests Your Doctor Hasn’t Told You About

A standard cholesterol lipid panel  provides four measures: Total Cholesterol, LDL Cholesterol, HDL Cholesterol and Triglycerides.  But did you know that there are two other blood tests — and one ratio that’s easy to calculate — that can better predict your risk of heart disease?  Which means that even with high cholesterol, you might not need a statin medication if these tests show low cardiac disease risk.

Or you might think you don’t need a statin … and in fact do.

And yet, your doctor probably has not told you about these tests.  So let me.

Apolipoprotein B – or as it’s commonly referred to, ApoB, is a simple blood test that measures the number and size of LDL (bad) cholesterol. Why this test is useful is well explained by Johns Hopkins Health Alerts:

“The problem with using LDL cholesterol levels to determine heart attack risk is that the test measures only the amount of cholesterol in the LDL cholesterol particles, not the number or size of these particles. Apo B measurements, on the other hand, provide information on the number of LDL cholesterol particles.

For example, people with a higher apo B value than LDL cholesterol value tend to have smaller, denser LDL cholesterol particles. Studies have shown that small, dense LDL cholesterol particles are more strongly associated with heart attack risk than large, “fluffy” LDL cholesterol particles.”

So if you have high LDL cholesterol (goal is under 130), you might want to find out if you have the ‘fluffy’ kind of LDL (pattern A), or the more dangerous, small, dense type of LDL (pattern B). Indeed, the Johns Hopkins Health Alert goes on to explain, “Research published in The Lancet reviewed five studies of LDL cholesterol and ApoB in nearly 200,000 people. The researchers concluded that high levels of ApoB were more strongly linked with future heart attack risk than LDL cholesterol levels.”  Compelling, no?

Low Density Particle Number, or LDL-P, is a similar measure – and again, one that’s been shown to be a more accurate predictor of heart disease than the typical cholesterol measurements.  LDL-P measures the number of LDL particles in the blood, whereas LDL is just the total LDL cholesterol.

As explained in The Difference Between LDL-C and LDL-P on the Primal Docs website, two people with the same LDL numbers can have vastly different heart disease risk because one has low LDL-P (fewer LDL particles of the type A, big, fluffy kind) while the other has high LDL-P, or a lot of LDL particles, of the small, dense, type B kind:

“…one person (person A) may have large cholesterol rich LDL particles, while another (person B) may have smaller cholesterol depleted particles. These two persons may have the same LDL-C concentration. However, person B will have higher LDL particle number (LDL-P). Despite similar levels of LDL-C, person B is at higher risk four future cardiovascular events. Furthermore, person B will have more small LDL-particles.”

The doctor who wrote this explanation of LDL-C vs. LDL-P goes on to explain that both LDL-P and ApoB are stronger predictors of heart disease risk than typical cholesterol measures:

“Some studies have suggested that the size of LDL-particles may be of importance. People whose LDL particles are predominantly small and dense, have a threefold greater risk of coronary heart disease.

ApoB and LDL-P both reflect the number of atherogenic lipoprotein particles. Measurements of ApoB and LDL-P are better predictors of cardiovascular disease risk than LDL-C. Furthermore, ApoB and LDL-P may predict residual risk among individuals who have had their LDL-C levels lowered by statin therapy.”

Non-HDL Cholesterol is a third important measure — and you don’t even need to take a blood test. Non-HDL-C is simply your Total Cholesterol minus HDL Cholesterol.  The tricky part is figuring out goal: if your LDL cholesterol is “at goal” you can roughly estimate your non-HDL-C goal by simply adding 30 to your LDL goal (these goals are usually on the cholesterol report – they are also online or you can ask your doctor.) And if it’s not at goal, discuss this ratio with your doctor.  I wrote about non-HDL-C and how to calculate it in this blog post, Do You Know Your Non-HDL Cholesterol?

While researching these in-depth cholesterol tests, I came across this compelling medical case study. It socked me in the gut, as this woman’s lipid panel cholesterol results were similar to mine, and yet it turns out from the additional LDL-P and ApoB testing that she was at high risk for cardiac disease. And needed statins.


So how do you get these tests?

I asked my internist about them months ago, and she said I didn’t need them — that my cholesterol numbers are fine. But now that I’ve read this case study I feel I would love more information.  I’ll have to ask her again about additional testing – especially now that I have more info.

And just so you know, you don’t have to travel to the Cleveland Clinic or the Mayo Clinic or Berkeley, California to get these tests. The Johns Hopkins Health Report explains,

“One widely used test, called the NMR LipoProfile, analyzes the size of lipoprotein particles in the blood by measuring their magnetic properties. Several others, including the LipoPrint and the Berkeley (from Berkeley HeartLab) use electrical fields to distinguish the size and other attributes of lipoprotein particles. Still another, known as the VAP (for Vertical Auto Profile) test, separates lipoprotein particles using a highspeed centrifuge.”

Even though my cholesterol is at goal, I’ve got to put in a call to my internist to ask about getting both the LDL-P and ApoB testing done. Will keep you posted.