How Do I Really Know How Healthy My Heart Is?

When it comes to heart health, “feeling fine” isn’t enough. Heart disease remains the leading cause of death, and many heart attacks occur in people with no prior symptoms.

So how can you really assess your heart’s health so that you know for certain how aggressively you need to act to lower your risks?

Spoiler: It’s not about your total or LDL (“bad”) cholesterol. Today’s most predictive metrics go beyond the basic lipid panel. They include inflammatory markers, metabolic function, particle-based lipids, and even fitness capacity. Follow these simple steps to evaluate your true cardiovascular risk and take charge of your long-term heart health.

1. Beyond LDL: ApoB and Lp(a) Are Critical

Traditional LDL doesn’t reflect how many cholesterol particles are circulating—just how much cholesterol they carry. But it’s the number of particles (and their ability to damage the arterial wall) that determines risk.

• ApoB: This measures all atherogenic particles (including LDL, VLDL, IDL). High ApoB (>90 mg/dL) significantly increases heart attack and stroke risk—even when LDL appears "normal." Each standard deviation increase in ApoB raises coronary heart disease risk by up to 2-fold.

• Lp(a): A genetically inherited LDL-like particle that promotes clotting and inflammation. Elevated Lp(a) (>50 mg/dL) increases cardiovascular risk by 40–60%, independently of all other lipids.

Takeaway: LDL is not enough. Ask for ApoB and Lp(a) to assess your real particle burden and hereditary risk.

2. HDL and Triglycerides: The “Ignored” Lipids That Matter

While doctors often dismiss HDL and triglycerides (TGs), research shows they’re potent risk indicators—especially in combination.

• HDL: Low HDL (<40 mg/dL in men, <50 in women) is associated with a 2–3x higher risk of CVD. But high HDL (>90) may paradoxically increase risk due to dysfunctional particles.

• Triglycerides: Elevated TGs (>150 mg/dL) increase coronary risk by up to 60%, particularly when insulin resistance is present. TG:HDL ratio >2.5 strongly suggests metabolic dysfunction and predicts early plaque formation.

Targets:

• HDL: >60 mg/dL is ideal

• TGs: <80 mg/dL is optimal

• TG:HDL ratio: <2.0 is ideal (closer to 1.0 is best)

Takeaway: High triglycerides and low HDL often signal metabolic problems and insulin resistance—a key driver of atherosclerosis that goes undetected in standard panels (and a leading cause of weight gain).

3. The Inflammation Marker That Predicts Events

High-sensitivity CRP (hsCRP) is a powerful, independent predictor of heart attacks and strokes—even in people with normal cholesterol.

• hsCRP >2.0 mg/L = 2x higher risk

• hsCRP >3.0 mg/L = 3–4x higher risk

CRP reflects systemic and blood vessel inflammation. The lower the better! Keeping it <0.5 mg/L is ideal.

4. Insulin Sensitivity: The Metabolic Risk Multiplier

Even without diabetes, poor glucose regulation increases cardiovascular risk substantially.

• HOMA-IR >2.0 = up to 3x greater risk of heart attack. Has your doctor calculated this for you?

• Fasting insulin >8 = likely insulin resistance

• A1c >5.7% = increased average blood sugar, often called “prediabetes” (but this can be wrong because it overestimates risk in fit individuals)

Takeaway: Insulin resistance is a vascular disease that increases heart attack and stroke risk, not just a blood sugar issue.

5. VO2 Max: Your Cardio Fitness = Your Heart Lifespan

Cardiorespiratory fitness is a stronger predictor of mortality than smoking, cholesterol, or hypertension.

• Low VO2 max (bottom 25%) = up to 5x higher risk of death

• Each increase of 3.5 ml/kg/min in VO2 max = 10–15% reduction in all-cause and heart disease mortality
  

Takeaway: A VO₂ max of ~35 mL/kg/min might be typical for a sedentary adult. By doing targeted exercise 4 hours per week and raising it to ~42 mL/kg/min, this person moves into the "excellent" range for most age groups—and lowers their risk of death by any cause by over 30%! Even better, an excellent VO2 predicts you will live better, be capable of more, and NOT NEED ANY CARE as you age!

6. Calculate your Risks

Heart disease rarely stems from a single issue. It's usually the result of multiple common problems—mildly elevated lipids, borderline blood sugar, low-grade inflammation—that add up over time.

Rather than focusing on one lab result, research shows that composite risk profiles (like the RISE Metabolic Scorecard or PREVENT risk models) are far more predictive. These models evaluate patterns across key biomarkers such as:

• Blood pressure

• Waist-to-height ratio

• Glucose and insulin levels

• Inflammatory markers

• Lipid particle numbers (like ApoB)

• HDL and triglyceride ratios

Each deviation from optimal nudges your risk higher. But here’s the good news:

If you move most of these markers into the optimal range, you can reduce your 10–30 year relative risk of cardiovascular disease, stroke, and dementia by up to 50-70%, according to longitudinal data and AI-based modeling.

7. What About a Heart Scan? The Role of CCTA in Risk Clarity

While blood tests and fitness metrics give you indirect signals of heart disease risk, Coronary CT Angiography (CCTA) offers a direct look at the actual status of your arteries.

Unlike a coronary calcium score—which only detects hardened plaque—CCTA shows both calcified and soft, vulnerable plaque, which is more likely to rupture and cause heart attacks.

Why it matters:

• You can have “normal” labs and still have significant plaque.

• CCTA identifies non-obstructive plaque that’s invisible on stress tests—but still dangerous.

• A zero-plaque result virtually rules out heart attacks for 5–10 years.

• Knowing the exact extent - or absence - of heart disease you have helps you and your doctor determine what measures to take - diet, exercise, medications - and how aggressive to be!

Who should consider it?

• People with multiple borderline or abnormal markers (e.g., high ApoB, CRP, Lp(a), fasting insulin)

• Those with a family history of early heart disease

• Fit individuals with unexplained symptoms or intermediate risk

• Anyone seeking definitive peace of mind

Bottom line: If you want the clearest picture of your heart health, CCTA is the most powerful non-invasive tool we have. It’s what cardiologists use when they want to know for sure.

What Gets Measured Gets Managed

If you care about performance, longevity, or protecting your loved ones from preventable loss—don't wait. Get comprehensive lab testing, track your fitness, optimize your inflammation and insulin, and train your heart like it’s the engine of your life. Because it is. If you would like my help with this, I would love to work with you!