Each year more than 1.5 million Americans suffer a heart attack or stroke. Despite significant advancements in cardiovascular care, heart disease continues to remain the most common killer of both men and women. Contemporary procedures are available for the effective treatment of obstructive coronary artery disease and include both angioplasty and bypass surgery. These techniques continue to evolve and are effective at relieving severe obstruction to blood flow in the major coronary arteries. However, what most people don’t know is that heart attacks occur more commonly in blockages that are less than 50%. Obstructions of this magnitude would not be detected with standard stress testing. They often remain clinically silent until they become active and inflamed with subsequent rupture and clotting. While cholesterol is an important risk factor for coronary atherosclerosis what may be equally or even more important is the level of vascular inflammation. Indeed, measurement of vascular inflammation by determining how “hot” your arteries are with specific blood tests have been shown to be a strong predictor of future cardiovascular events.
Imagine plaque and small atherosclerotic lesions as mini “volcanoes”. Each year they lie dormant but have the potential to erupt suddenly and cause heart attack or stroke. Inflammation is key in this process and by creating instability of cholesterol plaques causing rupture and exposure of contents within the plaque to the bloodstream. These contents induce clotting and more inflammation at the site leading to temporary or permanent obstruction of the vessel.
Standard cardiovascular stress testing and lipid analysis will not detect small plaques or the level of inflammation in your arteries. Fortunately there are tests that can be performed to improve the estimation of your overall risk of heart attack. These tests include non-invasive imaging detection of coronary atherosclerosis, blood markers of vascular inflammation, determination of lipoprotein particle size, and gene tests that detect genetic variants associated with clotting and heart attack.
I recommend advanced lipid testing in anyone with documented heart disease as well as patients over 40 with conventional risk factors including family history, smoking, high blood pressure, diabetes mellitus, high cholesterol, and body mass index greater than 25. I also recommend the tests for those individuals without a history of cardiac disease who are interested in preventative cardiovascular care.
Critics of advanced lipid testing will say that the tests do not change our recommendations and treatment for most people. This may be true in regards to diet and exercise as those recommendations apply to the general population. However, knowledge about your cardiovascular risk can be very empowering. I find in my own practice that patients can use the information as extra motivation to practice heart healthy lifestyle habits. Moreover, the tests do provide the ability to individualize your treatment to your specific genetic risk factors and level of vascular information. This may include the use of specific medications and supplements. The era of more personalized medicine is in its infancy and will no doubt be a part of standard care for many conditions in the near future.