You may think that you are at low risk for a heart attack because the heart tests that your doctor has ordered had "negative" results. The standard blood test that you received may show that your cholesterol and triglyceride levels are fine. And you may have even received a clean bill of health after taking a cardiac stress test (exercising on a treadmill while heart rhythms are electronically monitored).

Surprising fact: Those two standard heart tests miss many high-risk individuals with early heart disease. For example, a study published in the Journal of the American College of Cardiology found that 95% of women who had heart attacks at age 65 or younger were considered low risk.

For the greatest protection: In addition to the standard heart tests, all adults should consider receiving the highly accurate heart tests described in this article, which are not regularly ordered by most physicians but serve as stronger predictors of cardiovascular disease.

Why don't more doctors have conversations with their patients about these important tests? Many physicians closely adhere to the guidelines of the government's Preventive Services Task Force, whose evidence-based recommendations tend to include tests that are less sophisticated and less expensive.

But if your primary care physician or cardiologist does not mention these tests, ask him/her which ones might be right for you. The results will provide the best possible information for your doctor to create a customized medical and lifestyle regimen that can help prevent heart attacks and strokes.

Coronary Calcium CT Scan

This radiological imaging test-also called a CT heart scan detects and quantifies calcified plaque, a marker for atherosclerosis (fatty buildup in the arteries). This test is up to 10 times more predictive of future heart problems than a cholesterol test and can detect early heart disease that often goes undetected by a stress test.

My advice: Men over age 35 and women over age 40 with one to two risk factors for cardiovascular disease are good candidates for screening with a heart scan. Risk factors include being overweight...having hypertension, diabetes (or prediabetes), high LDL "bad" cholesterol, low HDL "good" cholesterol, elevated triglycerides, a family history of heart disease.. and/or smoking.

Risks: Cardiac CT tests expose patients to ionizing radiation (the same type used in Xrays), which has been linked to an increased risk for cancer. Heart scans, such as electron beam CT scans and late-generation spiral CT scans, now are performed at lower radiation doses-the equivalent of 10 to 25 chest X-rays is typical. These CT scans use faster speeds than standard CT scans to produce the image, are accurate and expose you to less radiation.

Cost and coverage: $150 to $500 and may be covered by insurance.

Carotid Test

An ultrasound test of the carotid (neck) arteries leading to the brain does not involve radiation and measures two important conditions that help predict cardiovascular disease—the dangerous presence of plaque and the thickness of the two inner layers of each artery (the intima and media).

The carotid test is a stronger predictor of a future stroke than coronary calcium and a moderate predictor of heart attack risk.

My advice: I recommend this test for men over age 35 and women over age 40 with one to two risk factors such as hypertension and/or a family history of heart disease or stroke. People with such risk factors as high cholesterol and type 2 diabetes also may benefit from the test.

Results: If there is any noticeable plaque or the thickness of the intima/media is in the top 25% for people of your age, sex and ethnicity, you are at a higher than desirable cardiovascular risk and should pay close attention to all risk factors-especially hypertension.

Cost and coverage: $100 to $500 and often is covered by insurance.

Advanced Lipoprotein Analysis

Advanced lipoprotein analysis includes blood tests that measure hidden risk factors such as…

  • Lp(a), a dangerous particle that often is elevated in families with a history of premature heart attacks.
  • ApoB/ApoAI, a ratio of dangerous particles to protective particles.

My advice: This analysis is especially useful for people with heart disease that occurs in the absence of risk factors or who have a family history of premature heart disease (heart attack before age 55 in a father or brother and before age 65 in a mother or sister, for example). Those with type 2 diabetes (or prediabetes) or "metabolic syndrome"—often with a bulging waistline, hypertension, low HDL, elevated triglycerides and/or elevated blood sugar-also are good candidates.

Cost and coverage: Varies widely from as little as $40 to as much as $400—often covered by insurance.

However, not all labs perform these tests. Labs that perform advanced lipoprotein analysis: Atherotech ( Heart Lab ( Heart Diagnostics ( ...Health Diagnostic Laboratory (www.bdlabinc. com)...LipoScience( SpectraCell (

Other Biomarkers

  • Lp-PLA2 (PLAC test). This blood test, which measures inflammation in blood vessels themselves, is a powerful predictor of the most common type of stroke ischemic stroke). The test is more specific for vascular disease than the commonly ordered test for C-reactive protein (which is elevated with any type of inflammation in the body).

Cost and coverage: About $50 to $200 and may be covered by insurance,

  • BNP or NT-proBNP (B-type natriuretic peptide). This is an early indicator of a weakening heart muscle (even before overt heart failure) and an excellent test for managing patients with heart failure. The test can also be used to help predict risk for heart attack.

Cost and coverage: About $50 to $250 and may be covered by insurance.

Aspirin Resistance Testing

Aspirin helps stop blood components called platelets from sticking together, which reduces the risk for an artery-plugging blood clot. A daily "baby" aspirin (81 mg) or higher doses usually are prescribed for anyone who has had a heart attack or stroke...or for someone who is at risk for either condition.

However, 25% of people are aspirin resistant--the drug doesn't effectively prevent platelet "stickiness."

Aspirin resistance testing measures a urinary metabolite (11-dehydrothromboxane B2), which is high if you are aspirin resistant.

Who should be tested: Anyone taking aspirin to treat or prevent cardiovascular disease.

Cost and coverage: $30 to $150 and often covered by insurance.

Good news: Recent research published in the Journal of the American College of Cardiology shows that supplementing the diet with omega-3 fatty acids can overcome aspirin resistance.

Sobering Statistics

About 81 million American adults have cardiovascular disease. This may include narrowed, blocked arteries (coronary artery disease)...irregular heartbeats (arrhythmia).. and/or a weakened heart muscle (heart failure).

Every year, 15 million of those Americans have heart attacks and 500,000 of them die. Another 800,000 have strokes, 140,000 of whom die.

Urgent Test for Heart Disease

In a study in Circulation, researchers at Harvard Medical School tracked levels of Lp-PLA2 in more than 3,000 patients who had survived a heart attack or a serious episode of unstable angina, a type of heart pain caused by a lack of oxygen. After two years, people with the highest Lp-PLA2 levels were 33% more likely to suffer another heart attack, stroke or cardiovascular-related death.

My advice: Ask your doctor to measure your blood levels of Lp-PLA2 if you are at risk for cardiovascular disease...if your low-density lipoprotein (LDL) cholesterol or CRP levels are high...or if you have survived a heart attack or stroke. The FDA-approved Lp-PLA2 test is called the PLAC test. The lower your Lp-PLA2, the better. If your LP-PLA2 is 235 ng/mL or higher, you have an above-average risk for a heart attack or stroke.

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