"Ultimately the lipid story is about risk," says cardiologist Dr. Dennis Goodman. "If someone tells you your LDL is high and you need a statin, you should say, 'Hey, hang on – am I really at risk?'" Leading-edge cardiologists say the past decade of research has yielded diagnostic tools that can drill below that LDL reading to unearth more useful information about cardiac risk. These tests count the number of cholesterol particles, reveal the type that stick to artery walls to form plaques, and assess the health of the artery walls themselves.
They're readily available and relatively cheap, in the $50 to $100 range, on par with the annual-physical blood workup that gives you that LDL number. The catch: Despite all the research that proves these tests are far better predictors of heart-attack risk than LDL, they're not routine. You have to ask for them. If you're in a more vulnerable group – over 40 with high LDL and a red-flag risk factor like smoking or a family history of heart disease – Goodman recommends getting a CT scan of the heart. At the cost of about $500 (statins can cost more than $500 a month) and a not insignificant dose of radiation, Goodman says, "It will tell you if you've got plaque in your arteries, and if you do, you've got to be aggressive about cholesterol, and that usually includes going on a statin." Here are the top three tests that aren't on the primary-care doc's checklist. Ask for these before taking statins.
The standard LDL reading gives you the total amount of low-density cholesterol circulating in your bloodstream. What you really want to know is how many lipoprotein particles in your blood are capable of delivering this cholesterol inside the artery, where it can form heart-attack-causing plaques. That's your ApoB number: The higher the number (you want to be in the 60–90 range), the more particles have accumulated.
The Vertical Auto Profile test is one of several lipid tests that take the cholesterol in that vial of blood and break it down by type, from the good (HDL) to the not-so-good (big, fluffy LDL particles) to the truly vile (small, dense LDL particles). Again, for a relatively modest price (about $100), the extra info gives you a clearer sense of heart-attack risk. The more you've got of the small particles, the greater your risk and the more likely statins may be helpful.
Too much plaque is inherently bad, but what happens once it builds up inside the arteries depends on inflammation: The more inflammation, the more likely a plaque will rupture, blocking blood flow, triggering a heart attack. You can ask for a standard inflammation test, but Goodman and Dr. Michael Ozner recommend the PLAC blood test, which measures an enzyme produced by inflamed heart vessels, giving a more specific picture of heart attack risk.