The Silent Risk: What Traditional Testing Misses in Heart Disease
Residents Anne Marie Lord and Michael Lord with his daughter, Dr. Adrienne Blessing, and her fiancé Tommy Zavesky
He exercised regularly. He saw his physician. He passed his stress test. And then, a few
months later, he had a heart attack. Stories like this are more common than most realize.
Not because medicine has failed, but because we have relied on tools that often detect
heart disease too late.
Heart disease remains the leading cause of death in the United States, yet up to half of
those aƯected report no warning signs. The underlying issue is this: traditional screening
(the one that insurance covers) does not always identify the patients most at risk.
Standard lipid panels oƯer a limited snapshot. LDL cholesterol alone does not tell us how
many atherogenic particles are present, how inflammatory the environment is, or whether
plaque is already forming within the arteries. Likewise, exercise stress testing evaluates
blood flow and identifies advanced blockages—but often misses earlier, non-obstructive
disease that can still rupture and cause a heart attack. To truly understand risk, we have to
look deeper.
Advanced lipid analysis provides a more complete picture. Apolipoprotein B (ApoB) reflects
the total number of atherogenic particles and is a stronger predictor of cardiovascular risk
than LDL alone. Lipoprotein(a), a genetically inherited marker, can significantly increase
the risk of premature heart disease—even in patients with otherwise excellent health.
High-sensitivity C-reactive protein (hs-CRP) identifies vascular inflammation, highlighting
risk that may not be apparent through cholesterol levels alone.
Genetics further refine this approach. Variations in ApoE influence how individuals process
fats and respond to diet. Certain genotypes, particularly ApoE4, are associated with
increased cardiovascular and neurodegenerative risk, allowing for more personalized
prevention strategies.
Importantly, many of these advanced tests are not out of reach. Insurance will often cover
components of advanced lipid testing, particularly when cholesterol is elevated, there is a
family history of heart disease, or overall risk is higher. What was once considered
specialized is increasingly becoming part of thoughtful, preventive care.
For patients in the gray zone (i.e. those with borderline cholesterol and who prefer to avoid
medication) and typically over 50 years old, the next step can often include imaging.
The coronary artery calcium (CAC) scan is one of the most powerful tools available. This
quick, non-invasive CT scan measures calcified plaque in the coronary arteries, oƯering
direct insight into whether disease is already present.
A CAC score of zero can be reassuring and may support continued conservative
management. However, an elevated score, particularly above 100 or high for age, confirms
atherosclerosis and often shifts the conversation toward more aggressive risk reduction,
including statin therapy. In this way, CAC scoring helps personalize decisions rather than
relying on generalized guidelines.
I saw this firsthand in my own family. A relative with only mildly to moderately elevated LDL
had been appropriately managed on a low-dose statin for years. He remained active,
maintaining a large property without limitation, and reported no symptoms. However, his
calcium score came back above 1400, an extraordinarily elevated result. Based on that
finding alone, despite his lack of symptoms and functional capacity, I recommended
proceeding directly to cardiac catheterization rather than relying on a stress test. The
cardiologist agreed and within two weeks, he underwent intervention which required three
coronary stents. Without that scan, his disease may have remained hidden until a life-
altering event occurred.
Beyond calcium scoring, newer technologies such as Cleerly coronary analysis provide
even deeper insight, identifying both calcified and non-calcified plaque. In contrast,
traditional cardiac stress testing remains useful for detecting flow-limiting disease, but
typically later in the disease process.
We are entering a new era of cardiovascular care: one that prioritizes early detection,
precision, and prevention. Because the question is no longer whether we can detect heart
disease. It is whether we are looking early enough to change its course.
- Dr. Blessing