You get your bloodwork back and breathe a sigh of relief—your LDL cholesterol levels are “normal.” But here’s the truth: people suffer heart attacks every day with what doctors consider “healthy” LDL numbers.
If that seems confusing, you’re not alone. In this article, I’ll explain why the standard LDL test doesn’t tell the full story when it comes to heart disease—and the advanced tests you need to get a clearer picture of your true cardiovascular risk.
You can also watch the short video explaining these concepts in more detail HERE
What Is LDL, and Why Is It Called “Bad” Cholesterol?
LDL stands for low-density lipoprotein. It’s one of several types of cholesterol your body makes, along with HDL (high-density lipoprotein), which is often referred to as the “good” cholesterol.
LDL gets its bad reputation because it’s the form of cholesterol that most often contributes to plaque buildup inside your arteries—a process called atherosclerosis. Over time, this plaque builds up, increasing your risk of heart attacks, strokes and dementia.
The Big Flaw in Standard LDL Testing
When your doctor orders a standard cholesterol test (lipid panel), your LDL is usually listed as “LDL-C. or LDL-Calc” The “C” stands for “calculated.” That’s right—your LDL number isn’t measured directly.
Instead, it’s estimated based on a mathematical formula that takes into account your total cholesterol, HDL, and triglycerides. This calculation gives a rough idea of how much cholesterol is being carried by LDL particles by weight—but not how many particles are actually present.
Why does that matter?
Why Particle Count and Size Matter More Than Weight
Let’s use an analogy to make this clear.
Imagine you have 5 pounds of gold. In one case, it’s made up of three large gold bars. In another, it’s made up of 100 gold pellets. Same weight—very different number of particles.
Now apply that to your LDL cholesterol. If your LDL-C number is 115 mg/dL, that could mean:
- A few large LDL particles (lower risk)
- Or many small, dense LDL particles (higher risk)
Smaller LDL particles are more dangerous because:
- They slip through the arterial wall more easily, starting the process of plaque formation.
- They cause more damage due to increased “shear stress” against artery walls, triggering inflammation and injury.
Unfortunately, your basic lipid panel won’t tell you any of this.
The Tests That Actually Measure LDL Particle Number and Size
To get a clearer picture of your heart disease risk, you need more advanced testing. The two most powerful tests I recommend are:
1. NMR Lipoprotein Profile (LDL-P)
This test uses Nuclear Magnetic Resonance (NMR) technology—think of it like an MRI for your blood.
- It directly counts the number of LDL particles (called LDL-P).
- It tells you the size of your LDL particles—whether they’re small and dense or large and fluffy.
The NMR profile gives you far more information than a standard test and is available through major labs like Quest and Labcorp. In my clinic, most insurance plans cover this test.
2. ApoB Test (Apolipoprotein B)
This is a simple, inexpensive blood test—and it’s one of the most powerful predictors of heart disease risk.
Every single LDL particle contains exactly one ApoB protein. So, by measuring your ApoB level, you get an accurate count of all the LDL particles in your bloodstream—regardless of size.
Many lipid experts now agree that ApoB is more predictive of cardiovascular events than LDL-C and even LDL-P in some cases, due to its accuracy and simplicity.
Bottom line: If your ApoB is high, your heart disease risk is high—even if your standard LDL appears “normal.”
Inflammation: The Silent Driver of Heart Disease
Now here’s the next layer. Even with advanced cholesterol testing, you’re still missing a major piece of the heart disease puzzle if you’re not looking at inflammation.
Once LDL cholesterol gets into the artery wall, inflammation and oxidation determine whether it turns into dangerous plaque.
That means you could have great cholesterol numbers—but if inflammation is high, your risk of heart attack can still be significant.
Key Inflammatory Markers to Ask For
These tests are not typically included in standard bloodwork but are essential for assessing your true cardiovascular risk:
- HS-CRP (High-Sensitivity C-Reactive Protein): Measures low-grade inflammation associated with arterial damage.
- Myeloperoxidase (MPO): An enzyme linked to oxidative stress and unstable plaque.
- Lp-PLA2 (Lipoprotein-Associated Phospholipase A2): Indicates active inflammation inside the arterial wall.
Ask your doctor about ordering these alongside an NMR or ApoB test. Together, they give a more comprehensive view of your cholesterol profile and your level of inflammation.
Summary: The Tests You Should Consider
Here’s a quick reference you can bring to your doctor:
| Test | What It Measures | Why It Matters |
| LDL-C | Calculated LDL cholesterol (by weight) | Common, but outdated and incomplete |
| LDL-P (NMR test) | Number and size of LDL particles | Better risk assessment |
| ApoB | Count of LDL particles using apolipoprotein B | Simple, accurate, inexpensive |
| HS-CRP | Inflammation in blood vessels | Helps identify hidden risk |
| Myeloperoxidase | Arterial oxidative stress | Linked to unstable plaque |
| Lp-PLA2 | Inflammation inside artery walls | Predicts plaque rupture risk |
Want Help Understanding Your Results?
This is exactly why I created my Heart Health Blood Test Guide.
It’s a 17-page resource that walks you through each of the advanced cardiovascular tests I use in my functional medicine clinic. You’ll learn:
- What each test measures
- Why it matters for your heart health
- The optimal ranges for each marker—not just the lab’s “normal” range
- How to interpret your results and reduce your risk
My goal is to help you avoid being blindsided by a heart event that “shouldn’t have happened.”
Relying solely on LDL-C is not a comprehensive preventative strategy. With more accurate testing and an understanding of inflammation, you can make better decisions—and take action to protect your heart.
Please share this with a friend or loved one who thinks their “normal” cholesterol means they’re safe. It might save a life.
