What’s My Risk?
WakeMed recently introduced an online Heart Health Assessment tool. It’s free, fast and easy to use. Just answer a few questions and we’ll provide you with a preliminary assessment of your risk for heart disease.
From cholesterol particle size and count to lipoprotein levels and familial genetic considerations, the world of understanding your risk for heart disease is changing rapidly. For more than a decade, doctors have largely relied on basic factors, such as demographics, blood pressure, cholesterol levels and family history to determine an individual’s risk of heart disease. Yet, personalized medicine has come a long way in the past 10 years – giving physicians and patients access to more information than ever regarding cardiovascular risk. It can be overwhelming to understand it all, and to know when, where, and how to test – and what your results mean. We’ve connected with our experts to get the scoop on all the latest options available and how these new tools can help patients and clinicians better understand their individual risk for heart disease.
Standard Risk Calculation
In 2013, the American College of Cardiology released the ASCVD Risk Estimator Plus, a simple calculator that determines a patient’s risk for atherosclerotic cardiovascular disease (ASCVD), also known as heart disease. By plugging in a series of data points, including age, sex, race, blood pressure, cholesterol, smoking and family history, among others – physicians are able to estimate a patient’s 10-year risk of developing heart disease. In 2023, the American Heart Association introduced a new calculator called PREVENT, which removes race, but includes BMI and variables such as zip code, kidney function and A1c to get a more personalized look at an individual’s risk. These tools are used by primary care and cardiology physicians across the world to assess risk and make decisions regarding whether to perform advanced diagnostic testing, suggest lifestyle modifications, initiate medication management and more.
Emerging Tests & Screenings
While these standard calculators offer a sound baseline of information, we know that many people who suffer from cardiovascular events (such as heart attack or stroke) have no known risk factors – meaning the above-mentioned calculators did not identify these patients as ‘at risk’ for a cardiovascular event. With this in mind, researchers have examined other biomarkers and data points that may be associated with an increased risk for cardiovascular disease.
Advanced Lipid Testing
Cholesterol testing continues to evolve as we learn more about heart disease risk factors. While most doctors still use a standard lipid profile, which evaluates total cholesterol, HDL, LDL and triglycerides, there are new tests that look at additional indicators that are proving valuable in determining risk.
- LDL particle size and count: LDL is the cholesterol that’s been described as ‘bad’ because it builds up on arterial walls. And, while most experts agree that keeping LDL levels below 100 mg/dL is optimal, there are now additional tests that can measure the number and size of LDL particles – providing even more information about risk. Studies have shown that smaller LDL particles have been linked to a higher risk of heart disease, as well as a higher risk of stroke and death from stroke, according to a 2020 article in PLOS ONE, and a 2021 article in Lipids in Health and Disease, respectively. Smaller particles can find their way into smaller arteries and create blockages more easily than larger, fluffier particles. Having more of these smaller particles further increases risk, even for patients with seemingly ‘normal’ LDL levels.
- Lipoprotein (a): Lp(a) is a type of lipoprotein that transports cholesterol in the blood. Having high Lp(a) is an independent risk factor for heart disease that affects about 1 in 5 people. Most people with high Lp(a) have no symptoms and many live a healthy lifestyle with no other cardiovascular risk factors. When Lp(a) levels are too high, these proteins can stick to the walls of your blood vessels, which can cause plaque buildup, narrowed arteries and a reduction in blood flow. It also increases inflammation and blood clotting that can lead to plaque rupture, which can increase the risk for heart attack, stroke or pulmonary embolism.
Who should be tested?
Generally, most physicians are not recommending advanced lipid testing for everyone – largely because this area of lipid research is new and we don’t have enough data, yet, and therefore, the standard guidelines for care haven’t evolved. Through the years, Lp(a) has become more prominent in most guidelines around the world, but there are no standard recommendations yet.
“If patients come in with a strong family history or other significant risk factors and ask for these tests, I’ll order them with the caveat that the results may or may not change our treatment recommendations,” explains John Holly, MD, WakeMed Primary Care. “The real value of this testing is for patients who want to understand their risk and are highly motivated to make lifestyle changes.”
Is it covered?
Not all insurance plans cover these tests, so it’s important to check with your insurance company. If paying out-of-pocket, fees generally range from $50-$100, depending on the lab used.
Cardiac Calcium CT Scoring
Identifying calcified (hardened) plaque in your coronary arteries can help reveal your risk of heart disease, often before other warning signs appear. Cardiac calcium scoring is a quick and non-invasive screening that uses a computerized tomography (CT) scan that is synced with your heartbeat to look for these calcium deposits. While the test isn’t an absolute predictor, it’s an excellent prognostic tool. After a 10-minute scan, your doctor will get a risk score that identifies your level of risk for
developing heart disease.
Who should be screened?
Screening is recommended for adults age 40 to 70 who have an increased risk of heart disease but have no symptoms. This includes people with a family history of heart disease, those who use tobacco products or vape, are overweight, physically inactive or have a history of high cholesterol, blood pressure or diabetes.
Is it covered?
Insurance does not cover this elective screening, but WakeMed and its imaging partner, Raleigh Radiology, offer the test for a flat fee of $150. This testing is offered at two imaging centers in Raleigh (Oberlin and Midtown), Clayton and Wake Forest.
“As a cardiologist, calcium CT scoring is very useful in determining whether or not a patient is a good candidate for statin therapy,” explains Tapan Godiwala, MD, WakeMed Heart & Vascular - Cardiology. “If a patient has a high calcium CT score, I’m much more likely to be aggressive with my treatment plan. This information provides a better picture of overall risk so we can make a more informed clinical decision.”
Familial Hypercholesterolemia (FH)
This inherited genetic disorder affects how the body recycles LDL. Individuals with FH are born with higherthan-normal levels of LDL cholesterol, which can lead to plaque build-up and an increased risk for heart disease. It affects about 1 in 200 adults, although only 10 percent are aware they have it. According to the American Heart Association, if left untreated, people with FH have 20 times the risk of developing heart disease.
Who should be tested?
Since the screening is relatively new, guidance varies. The National Heart, Lung & Blood Institute and American Academy of Pediatrics recommend universal screening for children 9 to 11 years of age. For adults, opinions vary, but individuals with high cholesterol levels, family history of early heart disease or attacks, or physical signs of FH may want to consider testing. According to the CDC, genetic testing for FH can confirm your diagnosis, help you better understand your risks and inform your treatment team.
“Understanding genetic markers can help us personalize how we treat our patients,” explains Raj Fofaria, MD, WakeMed Heart & Vascular - Cardiology. “For those with familial hypercholesterolemia, I’m likely to be far more aggressive with treatment because when genetics are at play, it often requires more medication to reduce risk. Having access to this information can help motivate patients to maintain a healthy lifestyle, and can alert physicians to keep a close watch on risk factors – even for younger patients. It’s another great tool to have in our toolbox.”
Is it covered?
Insurance typically does not cover genetic testing; however, you may be eligible to receive it at no cost through a community research program.
Questions?
If you have questions about any of these advanced tests or screenings, talk to your physician. They can help you better understand the pros and cons, how the information will be used to guide your care or treatment, and they can place an order or referral, if needed.
This blog is adapted from Heart to Heart Magazine. Subscribe today.