There are few things as reassuring as hearing your doctor say that your cholesterol levels are “normal.” But don’t assume that these test results mean you have dodged the heart attack “bullet.”

Surprising fact: About half of all heart attacks occur in people with normal LDL “bad” cholesterol levels. Other important facts you should know about testing to increase your odds of being heart attack proof…


Most doctors rely heavily upon the results of their patients’ basic cholesterol tests to determine their heart attack risk. Total and LDL cholesterol—both measured by routine blood tests—are useful indicators of heart attack risk.

The problem is that the desirable levels recommended by the National Cholesterol Education Program are not the optimal levels that can protect you from having a heart attack.

For example, the optimal total cholesterol level is less than 150 mg/dL (rather than the standard recommendation of less than 200 mg/dL).

Dr. William Castelli of the landmark Framingham Heart Study noted that none of the participants with a total cholesterol level of less than 150 mg/dL had suffered a heart attack.

In addition, the desirable LDL cholesterol is listed as less than 100 mg/dL, yet clinical studies have demonstrated that the optimal level should be less than 70 mg/dL.

Why wait until you have already suffered a heart attack to strive for the optimal cholesterol levels?

My approach: All adults should aim for optimal levels of total cholesterol and LDL cholesterol by following a healthy lifestyle. If you are not able to achieve optimal levels with lifestyle changes alone, then your doctor should decide whether to add cholesterol-lowering medication based on your risk factors for heart disease. Remember, medications are never a substitute for a healthy lifestyle.


Newer, expanded tests can give clues beyond those provided by the basic cholesterol results discussed earlier. You may have to ask your doctor for these tests, but they are well worth it. Important blood tests for all adults to consider…

LDL-P. The “P” stands for “particle.” It measures the number of LDL particles that carry cholesterol. It’s a more effective indicator of cardiovascular risk than LDL cholesterol alone because it shows how likely you are to develop atherosclerosis. Elevated LDL-P means that you are at risk of having a heart attack even if your LDL cholesterol is normal. My approach: Patients should strive for an optimal LDL-P level of less than 700 nmol/L.

Apo-B. This test measures a protein known as Apolipoprotein-B (Apo-B). It appears on the surface of all cholesterol particles that can enter the artery walls and potentially lead to atherosclerosis. My approach: Patients should aim for an optimal level of less than 60 mg/dL. Depending upon the profiles offered by the laboratory that is being used, it’s appropriate to measure particle number with LDL-P and/or Apo-B to get an accurate assessment of heart attack risk.

CRP. Studies show that elevated C-reactive protein (CRP), which serves as a marker for inflammation, indicates an increased risk for heart disease and stroke. In some cases, a patient can have a normal cholesterol level but an elevated CRP reading. My approach: Ask for a high-sensitivity CRP (hs-CRP) test (it’s more accurate for vascular inflammation than standard CRP tests). Patients should strive for an hs-CRP level of less than 2 mg/L.

Vitamin D. Most people associate vitamin D with bone health—it plays a key role in promoting the absorption of bone-building calcium. But that’s not all vitamin D does. Preliminary research shows that correcting a vitamin D deficiency (through foods, such as salmon and vitamin D–fortified cereal, and/or supplements) can significantly lower heart disease risk. My approach: Ask your doctor to test your vitamin D level. An optimal level is greater than 30 ng/ml.

Omega-3 index. This blood test measures the percentage of healthful omega-3 fat in the membranes of your red blood cells. Low levels of omega-3 are linked to an increased risk for heart attack and sudden cardiac death. My approach: Patients should aim for an omega-3 level of greater than 8%.


If one or more results from these tests are not optimal, your doctor may choose from these treatments…*

Go Mediterranean. Better eating habits (including a Mediterranean diet that consists of plenty of seafood, a minimum of red meat and an abundance of fruits, vegetables, legumes) is the first step.

Although there are various diets that claim to reduce heart attack risk, the preponderance of evidence confirms that the Mediterranean approach does so most effectively. It improves cholesterol levels, reduces inflammation and lowers blood sugar levels.

Get off the couch! There is no way around it. Exercise is essential to becoming heart attack proof. It not only lowers blood pressure, heart rate and body weight, but it also helps control lipid levels, such as total and LDL cholesterol, and reduce inflammation and blood sugar levels. My approach: Walk 30 to 45 minutes daily. To make sure that you stay on track, buy a pedometer and strive for 10,000 steps each day. Believe it or not, most people walk less than 3,000 steps per day.

Consider taking a statin. These cholesterol-lowering drugs, which include atorvastatin (Lipitor), simvastatin (Zocor) and rosuvastatin (Crestor), can be used if lifestyle measures don’t sufficiently improve total and LDL cholesterol. It’s not well-known, but statins also can improve LDL-P, Apo-B and CRP levels.

Get more omega-3s. Foods that are rich in omega-3s (such as salmon and sardines) and supplements, including fish oil, boost omega-3 levels, reduce the inflammation marker CRP and lower triglyceride levels.


When determining one’s odds of having a heart attack, two factors often are overlooked…

Periodontal disease. Many doctors have been slow to recognize how poor dental hygiene can increase a person’s heart attack risk.

Here’s what happens: If you don’t brush and floss regularly, small particles of food get trapped between your teeth and gums, which promotes the buildup of plaque as well as inflammation and infection. Periodontal disease, in turn, causes a generalized inflammatory response that can increase heart attack risk.

In fact, a recent seven-year study of more than 100,000 people with no history of heart attack or stroke showed that those who had their teeth cleaned by a dentist or hygienist at least twice a year over a two-year period had a 24% lower risk for heart attack compared with people who did not go to the dentist or went only once in a two- year period. My approach: Brush and floss regularly…and see your dentist at least every six months.

Sleep apnea. Recent research shows that this nighttime breathing disorder increases a person’s risk for heart attack and stroke.

What’s the connection? With sleep apnea, the upper airway narrows or collapses during sleep, often disrupting sleep hundreds of times each night. This sleep disturbance decreases oxygen saturation in the bloodstream. Sleep apnea also raises adrenaline and inflammation—both of which increase risk for heart attack. My approach: Patients who have signs or symptoms of sleep apnea—such as snoring, periods of breathing cessation during sleep, daytime fatigue and/or morning headaches—should see a doctor. There is some evidence that treating sleep apnea can lower heart attack risk.

*Always discuss all heart disease prevention recommendations with your personal treating physician.