When you think about your heart health, you probably think of your cholesterol numbers…and maybe whether your “good” cholesterol (the HDL kind) outweighs your “bad” cholesterol (the LDL kind). However, the trouble with just knowing the numbers from standard cholesterol tests is that they don’t tell enough about your risk for heart attack or stroke. To get a better picture, you need more.

What’s wrong with the cholesterol tests we’ve all come to know and trust? To better understand, it helps to know what cholesterol is and does. Cholesterol is a waxy, fatty substance produced in the liver (small amounts come from diet) and found in every cell. Among other functions, it is the prime material the body uses to make sex and adrenal hormones. Cholesterol circulates to and from cells via the bloodstream by combining with protein to form lipoproteins—hence, high-density lipoprotein (HDL) and low-density lipoprotein (LDL).

It might be helpful to picture this protein as a truck and the cholesterol as its load. With HDL, the load is light, so the “truck” can pick up (scavenge) more cholesterol from arteries on its way back to the liver—why it’s called “good.” With LDL, the load is heavy—so cholesterol tends to be dropped off along the way as plaque on artery walls, clogging arteries.

The problem: The numbers you get from traditional cholesterol tests tell only how much cholesterol is circulating in your blood. They don’t tell whether cholesterol is being deposited on your artery walls, which is the real danger. This is why some people with perfectly fine blood cholesterol numbers turn out to have serious heart disease (sometimes discovered too late)…and why some people with what look like alarming blood cholesterol numbers are not developing heart disease. The “enabler” of cholesterol-clogged arteries is inflammation. Inflammation roughs up the surface of artery walls, causing cholesterol to stick. Without inflammation, the surface of arteries remains smooth…and cholesterol has a better chance of flowing by without depositing plaque.

Because of these limitations of traditional cholesterol blood tests, many health-care professionals are turning to other tests that give a more comprehensive picture of heart health—including whether inflammation is a problem. These cardio tests are not part of a standard checkup, so you may need to ask your doctor for them specifically. While many labs do cardiovascular testing, the panel of tests that I find most useful are done by Boston Heart Diagnostics in Framingham, Massachusetts, who also provide an interpretation of the results and suggestions for treatment strategies based on overall results. Note: To order the tests from Boston Heart Diagnostics, your doctor will need to register with the lab first. The tests are also available from other labs, but the names of the tests may be different—your doctor will know which tests to order from the descriptions in this article. The tests may be covered by your insurance carrier, whether you have them done by Boston Heart Diagnostics or another lab, but check first whether you need preapproval.

The Boston Heart Diagnostics tests include…

  • Test for fatty-acid balance: The balance of fatty acids, such as omega-3 and omega-6, affects cholesterol and triglyceride (blood fat) levels and is important for heart health. The typical US diet tips toward too much omega-6 and not enough omega-3—an imbalance that contributes to inflammation and sets the stage for plaque depositing in arteries. This test shows whether dietary adjustments are needed to improve fatty-acid balance.
  • Statin-induced myopathy genotype test: Statin drugs, prescribed to reduce LDL cholesterol, sometimes cause statin-induced myopathy—muscle aches, cramps and in rare cases a life-threatening condition of severe muscle breakdown called rhabdomyolysis. This test looks for a gene that increases the risk of statin-induced myopathy by up to 17-fold.
  • Prediabetes Assessment: This assessment uses a patient’s blood glucose level along with height, weight and certain medical history information to predict the patient’s 10-year risk for developing type 2 diabetes. Since diabetes is a direct contributor to heart disease and inflammation, identifying a patient’s diabetes risk (and reducing it if necessary) is an important part of protecting heart health.
  • HDL Map Test: HDL is not all “good”—there’s a kind of HDL called apoA-1 that is associated with lower cardiovascular disease risk and a kind of HDL called prebeta-1 that is associated with higher cardiovascular risk. Knowing the balance of these HDL subgroups is one of the best predictors of whether plaque is depositing in arteries. This test helps estimate disease risk far better than knowing just the total HDL number…and helps doctor and patient determine a treatment strategy and track how well it’s working.
  • Test for cholesterol balance: This measures markers of LDL cholesterol that can determine whether cholesterol-lowering drugs are likely to be effective for the patient.

The results from these tests give you and your doctor a detailed picture of the current state of your cardiovascular health. The results also can help your doctor decide whether further testing, such as a coronary artery calcium scan or a test for C-reactive protein (CRP), might be appropriate…and if treatment is needed, what options, including medication and lifestyle changes, are most likely to work for your health profile and physiology.