Your lipid panel is probably missing the most important number

DAILY RHYTHM · 4 MIN READ

What a standard cholesterol test won't tell you about your heart risk

Total cholesterol and LDL are the numbers most people get. They might not be the most important numbers to focus on. Here's what we focus on instead, and why it matters.

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1. 01Ask for particle count, not just LDL cholesterol. A standard lipid panel gives you LDL-C, which is the total amount of cholesterol carried in LDL particles. What it does not tell you is how many particles are carrying it. Two people can have the same LDL-C reading and have very different cardiovascular risk, because more, smaller LDL particles can more easily embed in arterial walls. Ask for LDL-P (particle number) or ApoB. Most labs can do these tests, but they aren't usually ordered by default. Ask for them by name, or ask us to include them in your panel at Expand Health.
2. 02Small, dense LDL particles are the ones that cause damage. Not all LDL is the same. Large, buoyant LDL particles are relatively benign. Small, dense LDL particles are more likely to penetrate the arterial wall and oxidise. A standard panel does not distinguish between the two. An NMR lipoprotein profile or an ApoB test gives you a much cleaner picture of actual risk. If your LDL-C looks fine but your ApoB or particle count is elevated, that is information worth having. You might also have a higher LDL-C reading with low particle count and large particles, which some clinicians consider lower risk. Context matters, and one number often isn't enough.
3. 03Pair it with a Lp(a) test, at least once. Lipoprotein(a), or Lp(a), is genetically determined and largely unaffected by lifestyle. Elevated Lp(a) is an independent risk factor for cardiovascular disease, and there's strong evidence for its importance. Around 20% of people have levels high enough to meaningfully raise their risk. Most have never been tested. It is not included in a standard lipid panel. You only need to check it once in your life in most cases, because the number barely changes, but knowing it helps you decide how to manage other risk factors or consider medications.

OUR VIEW

A lipid panel should give you enough information to act on, and a basic one often does not. At Expand Health, we moved to ordering ApoB, LDL particle number, and Lp(a) as standard because the extra cost is small and the difference in what you learn is significant. Cardiovascular disease is still the leading cause of death in most of the countries we work in. It starts with ordering the right tests.

P.S. Have you ever had ApoB or Lp(a) measured? Hit reply and let me know. I am curious how many people reading this have already been tested, and how many found out about it only after something went wrong.

— Emilian