Your Cholesterol Is “Fine” But Your Heart Might Not Be: What Tests You’re Missing

The Test That Changed Everything

Last year, a patient named Rachel came to see me for anxiety and depression. She was 45, stressed about everything, not sleeping well. Pretty typical for my practice.

During our initial evaluation, I asked about family history. Her father died of a heart attack at 52. Her uncle at 49. Her grandfather at 54.

“Wow,” I said. “That’s really young. Has anyone checked your cardiovascular risk thoroughly?”

“Oh yeah,” she said, waving her hand. “My doctor checks my cholesterol every year. It’s always fine. Total cholesterol like 190. She says I’m good.”

I paused. “When you say cholesterol is fine, what exactly did they test?”

She pulled out her phone and showed me her patient portal. Sure enough: total cholesterol 192, LDL 118, HDL 58, triglycerides 95. By basic standards, these numbers look great.

“Can I run some additional tests?” I asked. “With that family history, I want to look deeper.”

She agreed. Two weeks later, we got the results.

Her lipoprotein(a) was 156 mg/dL. Normal is under 30. This single genetic marker put her at the same heart attack risk as someone with an LDL cholesterol of 190, even though her basic cholesterol looked perfect.

Her high-sensitivity CRP (an inflammation marker) was 4.8. Elevated. Another red flag.

Her ApoB (a marker of dangerous particle number) was high despite “normal” LDL cholesterol.

Rachel stared at the results. “But my cholesterol is fine. How is this possible?”

That’s exactly what I want to talk about today.

The Problem With Basic Cholesterol Tests

Here’s what most people get when they have their “cholesterol checked”:

Total cholesterol – basically meaningless on its own
LDL cholesterol – the “bad” cholesterol
HDL cholesterol – the “good” cholesterol
Triglycerides – a type of fat in your blood

This is called a basic lipid panel, and it’s been the standard for decades. Insurance companies love it because it’s cheap. Doctors order it because it’s what they’ve always ordered.

But here’s the problem: this basic panel misses a ton of critical information about your actual cardiovascular risk.

It’s like checking if your car has gas but ignoring the oil level, tire pressure, brake fluid, and whether the engine light is on. You might think everything’s fine when it’s really not.

Let me explain what you’re missing.

Lipoprotein(a): The Silent Killer Nobody Tests

This is the big one. The one that makes me angry when I think about how many people don’t know about it.

What Is Lipoprotein(a)?

Lipoprotein(a), or Lp(a) for short, is a type of cholesterol particle that’s almost entirely genetic. You inherit it from your parents. Diet and exercise barely affect it. For most of your life, it doesn’t change much.

About 20% of people (1 in 5) have elevated Lp(a). And elevated Lp(a) significantly increases your risk of heart attack, stroke, and valve disease.

How significant? High Lp(a) increases your cardiovascular risk about as much as having LDL cholesterol over 190, even if your regular LDL looks perfect.

Think about that. One in five people walking around with a major cardiovascular risk factor that almost never gets tested.

Why Don’t Doctors Test It?

Good question. I’ve asked myself this many times.

Part of it is that we didn’t have good treatments for high Lp(a) until recently, so the thinking was “why test for something we can’t treat?” (This is changing, by the way. We have new treatments in development.)

Part of it is that it’s not included in basic panels, so doctors have to specifically order it.

Part of it is that many doctors simply don’t know about it or don’t think about it.

But here’s the thing: knowing your Lp(a) level changes how aggressively we manage your other risk factors. If your Lp(a) is high, we need to be more careful about everything else. And there ARE things we can do to help, even if we can’t directly lower the Lp(a) much yet.

Who Needs Lp(a) Testing?

According to current guidelines, you should have your Lp(a) tested at least once in your lifetime if you have:

• Family history of early heart disease (before 55 in men, 65 in women)
• Personal history of heart attack or stroke, especially at a young age
• Family history of high cholesterol that doesn’t respond well to treatment
• Elevated cholesterol despite healthy lifestyle
• Family history of premature death from unclear causes

Honestly? I think everyone should have it tested once. It’s genetic. It doesn’t change. Test it once, know your number, and factor that into your lifetime risk assessment.

LDL Particle Number and Size: Not All Cholesterol Is Equal

Okay, stay with me here because this gets a little technical, but it’s important.

Your basic lipid panel measures LDL cholesterol by weight. But what actually matters for heart disease risk is the number of LDL particles and their size.

Think of it like this: imagine you’re moving rocks across a field. You could move 100 pounds of rocks using:

• Ten 10-pound rocks, or
• A hundred 1-pound rocks

The weight is the same, but the number of trips (particles) is very different. For heart disease, the number of particles matters more than the total weight.

Small Dense LDL: The Dangerous Kind

LDL particles come in different sizes. Some are large and fluffy. Some are small and dense.

Small, dense LDL particles are much more dangerous because they:

• Can more easily penetrate and damage artery walls
• Are more likely to become oxidized (which makes them even more dangerous)
• Stick around in your bloodstream longer
• Are more inflammatory

You can have “normal” LDL cholesterol on a basic panel but have tons of small, dense particles. Your basic test would say you’re fine. A more advanced test would show you’re at risk.

How We Test This

Advanced lipid testing measures:

• LDL particle number (LDL-P) – how many particles you have
• LDL particle size – whether they’re large and fluffy or small and dense
• ApoB – a protein marker that tells us particle number

These give us a much better sense of your actual risk than basic LDL cholesterol alone.

Inflammation Markers: The Other Half of the Story

Remember from my earlier posts that inflammation drives heart disease just as much as cholesterol does? We can measure that.

High-Sensitivity CRP (hs-CRP)

This measures inflammation in your blood vessels. It’s called “high-sensitivity” because it can detect low levels of chronic inflammation that regular CRP tests miss.

Why it matters: Research shows that inflammation predicts heart attack risk even when cholesterol is normal. People with high hs-CRP are at increased risk even with perfect LDL levels.

This is especially relevant if you have depression, anxiety, or chronic stress, because these conditions often cause elevated inflammation.

What the numbers mean:

• Under 1.0 mg/L: Low risk
• 1.0 to 3.0 mg/L: Average risk
• Over 3.0 mg/L: High risk

If your hs-CRP is elevated, we need to figure out why and address it. Sometimes it’s from depression or stress. Sometimes it’s from other sources of inflammation in your body.

Other Inflammation Markers

Depending on your situation, I might also check:

• Interleukin-6 (IL-6) – another inflammatory marker
• Fibrinogen – measures both inflammation and clotting tendency
• Myeloperoxidase (MPO) – indicates unstable plaque in arteries

These aren’t routine, but they can provide important information if your basic markers are concerning or if you have other risk factors.

Metabolic Markers: Catching Problems Early

Your cardiovascular risk isn’t just about cholesterol and inflammation. Your metabolism matters too.

Hemoglobin A1c: Blood Sugar Over Time

This test shows your average blood sugar over the past 3 months. It’s the standard way to diagnose diabetes and prediabetes.

Why it matters for heart disease: Diabetes is a major cardiovascular risk factor. But here’s the thing… by the time you’re diabetic, you’ve probably had elevated blood sugar for years, and that’s been damaging your blood vessels.

We want to catch this early, in the prediabetes stage, when we can still reverse it.

What the numbers mean:

• Under 5.7%: Normal
• 5.7% to 6.4%: Prediabetes
• 6.5% or higher: Diabetes

If you’re in the prediabetes range, this is your wake-up call. You can reverse this with lifestyle changes. Don’t wait until you’re diabetic.

Fasting Insulin: Even Earlier Detection

This is one of my favorite tests because it catches problems before they show up on hemoglobin A1c.

When your blood sugar starts creeping up, your pancreas pumps out more insulin to compensate. For a while, this works. Your blood sugar stays normal, but your insulin is sky-high. This is called insulin resistance.

Eventually, your pancreas can’t keep up, and your blood sugar rises. That’s when it shows up on standard tests.

Fasting insulin catches this earlier, while you still have time to prevent diabetes and protect your heart.

High insulin is also associated with:

• Inflammation
• High blood pressure
• Weight gain (especially belly fat)
• Increased cardiovascular risk

If your fasting insulin is elevated (over 10-12 μIU/mL), we need to work on insulin sensitivity through diet, exercise, stress management, and sometimes medication.

Homocysteine: The Forgotten Risk Factor

This is an amino acid that, when elevated, damages blood vessel walls and increases clotting risk.

Elevated homocysteine is associated with:

• Increased risk of heart attack and stroke
• Accelerated atherosclerosis
• Cognitive decline

What causes high homocysteine?

• B vitamin deficiencies (especially B12, B6, and folate)
• Genetic variants (like MTHFR mutations)
• Kidney disease
• Certain medications

The good news? High homocysteine is usually easy to treat with B vitamin supplementation.

Normal homocysteine is under 10-12 μmol/L. If yours is elevated, we can fix it.

Omega-3 Index: Your Cardiovascular Fuel

This test measures the amount of omega-3 fatty acids (EPA and DHA) in your red blood cell membranes. It’s expressed as a percentage.

Why it matters: Low omega-3 levels are associated with:

• Increased risk of heart attack and sudden cardiac death
• Higher overall mortality
• Increased inflammation
• Worse outcomes after heart attacks

Higher omega-3 levels are protective. Multiple large studies show this clearly.

What the numbers mean:

• Under 4%: High risk (deficient)
• 4% to 8%: Moderate risk
• Over 8%: Low risk (optimal)

Most Americans have omega-3 index under 4%. That’s a problem.

How to improve it: Eat more fatty fish (salmon, sardines, mackerel) or take high-quality fish oil supplements. We can retest in 3-4 months to see if your levels have improved.

This is one of the easiest cardiovascular risk factors to fix.

Putting It All Together: Who Needs Advanced Testing?

Not everyone needs all of these tests. But comprehensive cardiovascular assessment should be strongly considered if you have:

Strong family history of heart disease, especially if people in your family had heart attacks or strokes at young ages (before 55 in men, 65 in women)

Depression, anxiety, or chronic stress, because these conditions increase inflammation and cardiovascular risk through multiple pathways

“Normal” cholesterol but other concerning factors, like high blood pressure, prediabetes, obesity, or strong family history

Unexplained symptoms like fatigue, shortness of breath, or chest discomfort that isn’t clearly cardiac but makes you wonder

Multiple standard risk factors like smoking, high blood pressure, diabetes, or obesity

You’re on psychiatric medications that affect weight or metabolism

You just want to know your baseline cardiovascular health, especially if you’re over 35-40

In my practice, I tend to order comprehensive testing more liberally than standard guidelines suggest. Why? Because knowledge is power. If we find something, we can address it early. If we don’t find anything, you have peace of mind.

Real Stories: What We Find When We Look

Let me tell you about three patients whose advanced testing revealed problems that basic panels missed.

Tom: The Runner Who Wasn’t Fine

Tom was 50, ran marathons, ate healthy, wasn’t overweight. His basic cholesterol was perfect. LDL 95. HDL 62. Triglycerides 75. His doctor told him to keep doing what he was doing.

But Tom had significant family history. His father and two uncles all had heart attacks in their 50s.

I ordered advanced testing. His Lp(a) was 180 (very high). His CAC score (calcium in his arteries) showed he already had significant plaque despite perfect lifestyle and cholesterol.

We started him on a PCSK9 inhibitor (a medication that lowers both LDL and Lp(a)), added high-dose fish oil, and monitored him more carefully.

Two years later, his cardiologist told him: “Your advanced testing probably saved your life. We never would have found this otherwise until you had symptoms… or worse.”

Maria: The Inflammation Nobody Saw

Maria was 42, struggled with depression and anxiety for years. Slightly overweight but not obese. Her cholesterol was borderline high, so her doctor suggested she try diet changes first.

Her advanced testing showed:

• hs-CRP: 5.2 (high inflammation)
• Small dense LDL pattern (dangerous particles)
• Elevated insulin: 18 (insulin resistance)
• Low omega-3 index: 3.2% (deficient)

These weren’t just numbers. They told a story: chronic inflammation from her mental health struggles, early metabolic dysfunction, and nutritional deficiencies all conspiring to increase her cardiovascular risk.

We treated her depression more aggressively, started fish oil and specific supplements, worked on diet and movement. Six months later, her inflammation markers were much better, and her insulin had normalized.

James: The Wake-Up Call

James came to see me for what he thought was just work stress. He was 38, working crazy hours in finance, barely sleeping, living on coffee and takeout.

His basic cholesterol was 210 (slightly elevated) but his doctor said “let’s watch it and see if it comes down when you’re less stressed.”

His comprehensive testing showed:

• Lp(a): 142 (high)
• hs-CRP: 6.8 (very high inflammation)
• Hemoglobin A1c: 5.9% (prediabetes)
• Insulin: 22 (insulin resistance)
• CAC score: 45 (some plaque already, unusual at 38)

James stared at the results. “I’m 38. How do I already have plaque in my arteries?”

“Because this has been building for years,” I told him. “Your body’s been under chronic stress, your diet has been garbage, you haven’t been sleeping, and you’ve got genetic factors working against you. Your basic cholesterol test made everything look okay when it wasn’t.”

This was his wake-up call. We treated his anxiety and depression, completely overhauled his lifestyle, started appropriate medications. He’s a different person now. And he thanks me regularly for not just accepting that “his cholesterol was a little high but fine.”

What To Do With This Information

Maybe you’re reading this and thinking: “Great, now I’m worried about tests I’ve never even heard of.”

That’s not my goal. My goal is to empower you to ask better questions and advocate for yourself.

Questions To Ask Your Doctor

“Given my family history, should I have my lipoprotein(a) tested?”

“Can we do advanced lipid testing to check my LDL particle number and size?”

“Should we check inflammation markers like hs-CRP?”

“What about metabolic markers like fasting insulin?”

“Is my omega-3 index something we should look at?”

Most doctors will be receptive to these questions. If yours isn’t, that might tell you something about whether you’re with the right provider.

What If Your Doctor Says No?

Some doctors will say these tests aren’t necessary or aren’t covered by insurance. A few thoughts:

Many of these tests ARE covered by insurance when there’s appropriate indication (family history, other risk factors, etc.). It’s worth checking.

Some tests are inexpensive if you pay out of pocket. Lp(a) testing can be $20-50. hs-CRP is similar. Omega-3 index is around $50-100.

Your health is worth investing in. I’m not saying you need to spend thousands on testing. But if comprehensive testing costs $200-300 out of pocket and gives you critical information about your cardiovascular risk, that’s money well spent.

You can get testing done independently. There are labs that let you order your own tests. Results aren’t interpreted by a doctor, but you can bring them to your provider for discussion.

Working With Me

In my practice, I routinely order comprehensive cardiovascular testing for patients with mental health conditions, family history, or multiple risk factors.

Why? Because I can’t treat what I don’t know about. And I refuse to let patients walk around with significant cardiovascular risk that nobody’s identified because we only ran basic tests.

Does every test come back abnormal? No. Many patients have reassuring results. But when we do find something, we catch it early, when we have the most options to intervene.

Frequently Asked Questions

Q: Are these advanced tests covered by insurance?

A: It depends on your insurance and the indication for testing. Many are covered when you have family history, other risk factors, or prior abnormal results. Some tests (like Lp(a) and hs-CRP) are often covered. Others may require out-of-pocket payment, but many aren’t as expensive as you’d think.

Q: How often do I need these tests?

A: Lp(a) is genetic and doesn’t change, so you only need it once in your lifetime. Others depend on what we find. If everything’s normal and you have no risk factors, every few years is probably fine. If we find problems, we might retest every 3-12 months to monitor progress.

Q: Can I order these tests myself without a doctor?

A: In many states, yes. There are labs that allow direct-to-consumer testing. However, having a knowledgeable provider interpret results and help you create an action plan is really important. Tests without context and guidance aren’t as helpful.

Q: What if my tests come back abnormal? What happens then?

A: We create a plan. That might include lifestyle changes (always first-line), targeted supplementation, medications if needed, or referral to specialists. Finding something abnormal isn’t a disaster, it’s an opportunity to intervene early.

Q: My basic cholesterol is normal. Could I still have problems?

A: Absolutely. That’s the whole point of this article. Basic cholesterol panels miss a lot. Normal LDL cholesterol doesn’t rule out high Lp(a), small dense LDL particles, elevated inflammation, or metabolic problems. This is why comprehensive testing matters.

Q: Will eating better and exercising fix these markers?

A: Some of them, yes. hs-CRP often improves with weight loss, exercise, and stress management. Insulin resistance responds well to diet and movement. Omega-3 index improves with diet or supplements. But Lp(a) is genetic and doesn’t respond much to lifestyle. And some people need medication even with perfect lifestyle. That’s why testing helps, it tells us what we’re dealing with.

Q: I’m young and healthy. Do I really need to worry about this?

A: If you have strong family history, yes. Heart disease is often genetic, and the process starts decades before symptoms appear. Finding and addressing risk factors in your 30s and 40s prevents heart attacks in your 50s and 60s. Prevention is always better than treatment.

Q: What’s the single most important test I should push for?

A: If I had to pick one, it’s Lp(a). It’s genetic, affects 20% of people, significantly increases cardiovascular risk, is almost never included in basic panels, and knowing your level changes how we manage everything else. One test, done once, provides crucial information for your lifetime risk.

The Bottom Line

Basic cholesterol tests are better than nothing, but they’re not enough if you want to truly understand your cardiovascular risk.

Advanced testing that includes:

• Lipoprotein(a)
• Advanced lipid markers (particle number and size)
• Inflammation markers (hs-CRP)
• Metabolic markers (insulin, hemoglobin A1c)
• Omega-3 index

…provides a much more complete picture of your actual risk.

This is especially important if you have:

• Family history of heart disease
• Depression, anxiety, or chronic stress
• Multiple other risk factors
• “Normal” basic tests but lingering concerns

Knowledge is power. The earlier you know about cardiovascular risk factors, the more time you have to address them and prevent serious problems down the road.

Don’t settle for “your cholesterol is fine” if you have reasons to look deeper. Ask questions. Advocate for yourself. Get the information you need to protect your heart.

Want Comprehensive Assessment?

If you’re interested in comprehensive cardiovascular risk assessment along with mental health care, I can help.

In my practice, I look at the full picture of your health, including advanced testing when appropriate. We don’t just treat symptoms. We identify and address root causes to protect your long-term health.

Keep Reading

More about the heart-mind connection:

• Why Your Psychiatrist Should Care About Your Heart
• How Chronic Stress Is Damaging Your Heart
• When Treating Depression Saves Your Heart
• Your Heart and Mind Are Connected: Complete Guide

References & Research

This article is based on current medical guidelines and research:

1. Wilson DP, et al. (2019). Use of Lipoprotein(a) in clinical practice: A biomarker whose time has come. Journal of Clinical Lipidology. [Guidelines on Lp(a) testing and interpretation]
2. Nordestgaard BG, Langsted A. (2024). Lipoprotein(a) and Cardiovascular Disease. Lancet. 404(10459):1255-1264. [Comprehensive review of Lp(a) as cardiovascular risk factor]
3. Ridker PM, et al. (2023). Inflammation and Cholesterol as Predictors of Cardiovascular Events. Lancet. 401(10384):1293-1301. [Landmark study showing inflammation predicts cardiovascular events independent of cholesterol]
4. Kirkpatrick CF, et al. (2023). Nutrition Interventions for Adults With Dyslipidemia: A Clinical Perspective From the National Lipid Association. Journal of Clinical Lipidology. 17(4):428-451. [Current guidelines on lipid testing and management]
5. Mensah GA, et al. (2025). Inflammation and Cardiovascular Disease: ACC Scientific Statement. Journal of the American College of Cardiology. [New guidelines on inflammation assessment and management]
6. Harris WS, et al. (2021). The Omega-3 Index: Clinical Utility for Therapeutic Intervention. Pharmacological Research. [Review of omega-3 index as biomarker and therapeutic target]
7. Virani SS, et al. (2023). 2023 AHA/ACC Guidelines for Chronic Coronary Disease. Journal of the American College of Cardiology. 82(9):833-955. [Official guidelines including advanced testing recommendations]
8. Grundy SM, et al. (2019). 2018 AHA/ACC Guideline on the Management of Blood Cholesterol. Circulation. 139(25):e1082-e1143. [Comprehensive cholesterol management guidelines including advanced testing]
9. Hoogeveen RC, Ballantyne CM. (2021). Residual Cardiovascular Risk at Low LDL: Remnants, Lipoprotein(a), and Inflammation. Clinical Chemistry. 67(1):143-153. [Why standard lipid testing misses important risk factors]
10. Grant JK, et al. (2024). Historical, Evidence-Based, and Narrative Review on Commonly Used Dietary Supplements in Lipid-Lowering. Journal of Lipid Research. 65(2):100493. [Evidence on supplements for lipid and cardiovascular health]

For verification: Elevated Lp(a) (>50 mg/dL) affects approximately 20% of the population and increases cardiovascular risk equivalent to LDL-C >190 mg/dL. Small dense LDL particles are more atherogenic than large buoyant particles. hs-CRP >3.0 mg/L indicates high cardiovascular risk independent of cholesterol. Omega-3 index >8% is associated with significant cardiovascular protection.

About Dr. Bliss Lewis

Dr. Bliss Lewis is a board-certified psychiatrist specializing in integrative medicine. She believes in comprehensive assessment that goes beyond basic testing to truly understand your cardiovascular risk. Her practice combines evidence-based psychiatric care with thorough attention to physical health.

This article is for educational purposes. Decisions about testing should be made in consultation with healthcare providers familiar with your individual medical history and risk factors.