In Part 1, we looked at an important principle: high cholesterol deserves attention but cardiovascular health involves much more than one number on a lipid panel.

So what other information might help us understand cardiovascular risk?

Some tests, such as ApoB, Lp(a), glucose markers and selected imaging are established tools for refining risk. Other areas, including gut-derived inflammatory signals, are still being investigated. Understanding that difference helps us choose testing that is useful rather than simply ordering more tests.

ApoB: How many atherogenic particles are circulating?
Apolipoprotein B, or ApoB, is a structural protein carried by atherogenic lipoproteins, including LDL, VLDL and their remnants, IDL and Lp(a). These particles can contribute to atherosclerotic plaque. Each particle contains one ApoB molecule, making ApoB a useful approximation of the total number of circulating atherogenic particles.

Think of LDL-C as telling us how much cholesterol is being carried, while ApoB helps tell us how many vehicles are carrying it.

Sometimes those measurements don’t tell exactly the same story. This can be particularly relevant in people with insulin resistance, diabetes or elevated triglycerides, where LDL-C may not fully reflect atherogenic particle burden.

Lp(a): The genetic risk factor many people have never tested
Lipoprotein(a), or Lp(a), is another atherogenic lipoprotein but its level is predominantly determined by genetics.

Elevated Lp(a) increases the risk of atherosclerotic cardiovascular disease and calcific aortic valve disease. Unlike many cardiovascular markers, lifestyle changes generally have relatively little influence on the Lp(a) level itself.

So why test it?

Because knowing that you carry an additional inherited risk can change how aggressively you and your medical team address the risk factors you can modify.

Current cardiovascular guidelines recommend measuring Lp(a) at least once in adulthood. If yours is elevated, first-degree relatives, including siblings and children may also benefit from discussing testing with their healthcare providers.

A recent research update: Preliminary results from the Lp(a)HORIZON trial, announced in September 2026, found that the investigational medication pelacarsen lowered Lp(a) but did not demonstrate a reduction in the trial’s main measure of major cardiovascular events. Full results are still pending at the time of this post; other Lp(a)-lowering medications remain under study, and researchers are separately investigating whether lowering Lp(a) can slow calcific aortic valve disease. Elevated Lp(a) therefore remains worth identifying, with continued attention to LDL/ApoB, blood pressure, metabolic health and other risks we can address.

Metabolic markers: How is your body managing glucose and fats?
Blood sugar and insulin regulation deserve a place in the cardiovascular conversation.

Depending on the individual, useful information may include:

  • Fasting glucose
  • HbA1c
  • Fasting insulin
  • Triglycerides
  • Blood pressure
  • Waist circumference and body composition

Together, these can help identify metabolic dysfunction that may be increasing cardiovascular risk. Insulin resistance can develop well before someone receives a diagnosis of diabetes.

In selected cases, an NMR lipoprotein test can also provide an LP-IR score, which summarizes particle patterns associated with insulin resistance. It can add information when the metabolic picture is unclear, but it does not replace glucose testing or diagnose diabetes.

Inflammation: What can hs-CRP tell us?
Atherosclerosis involves inflammatory processes as well as atherogenic lipoproteins, making inflammation another part of the cardiovascular picture.

High-sensitivity C-reactive protein, or hs-CRP, provides information about systemic inflammation and is used in cardiovascular risk assessment.

An elevated result tells us to investigate possible contributors such as infection, smoking, excess adiposity, periodontal disease or an inflammatory condition rather than identifying the cause by itself. Unexpected elevations may need to be repeated after an acute illness has resolved.

A low result is reassuring, but it does not exclude every inflammatory process or eliminate cardiovascular risk. Like other markers, hs-CRP is most useful when interpreted within the larger clinical picture.

One emerging area of research takes us somewhere that may seem surprising: the gut.

What does LPS have to do with cardiovascular health?
Certain Gram-negative bacteria contain lipopolysaccharide, or LPS, within their outer membrane. LPS is also commonly referred to as an endotoxin.

The presence of LPS within the intestinal environment is normal. Researchers are investigating what happens when greater amounts of bacterial products cross the intestinal barrier and enter circulation, a process sometimes described as metabolic endotoxemia.

Once in circulation, LPS can activate immune pathways that may affect blood vessels, inflammatory signaling and clotting processes.

Experimental research and human observational studies suggest that gut-derived bacterial products may contribute to vascular inflammation. However, we do not yet have established evidence that routine testing for these signals or treating them specifically reduces heart attacks or strokes. However, the line of thinking makes sense.

For someone with persistent digestive symptoms, metabolic dysfunction or other unexplained findings, gastrointestinal health may still deserve attention. That investigation should be guided by the individual’s symptoms and history while appropriate cardiovascular risk management continues.

What about looking directly at the arteries?
Blood tests tell us about risk factors. Imaging can help answer a different question:
Is atherosclerosis already present in the coronary arteries?

Two tests you may hear discussed are a coronary artery calcium scan, or CAC, and a coronary CT angiogram, or CCTA. Although both use CT imaging, they provide different information.

CAC: Is there calcified plaque?
A CAC scan is a quick, non-invasive CT scan that measures calcium contained within coronary plaque. It does not require IV contrast.

The calcium score helps quantify calcified plaque burden and can refine risk assessment when the potential benefit of preventive medication is uncertain.

Finding coronary calcium can support more intensive prevention. A score of zero can sometimes support deferring medication in appropriately selected people. However, CAC detects calcified plaque; it does not directly visualize noncalcified plaque. A zero score therefore does not guarantee that the arteries are free of atherosclerosis.

It also does not automatically remove the need for treatment, particularly with diabetes, very high LDL-C, smoking or a strong family history of premature cardiovascular disease.

CCTA: What do the coronary arteries look like?
CCTA uses CT imaging with intravenous contrast to visualize the coronary arteries. It can identify:

  • Calcified, noncalcified and mixed plaque
  • Where plaque is located
  • Whether plaque is narrowing an artery
  • The overall extent of coronary atherosclerosis

CAC primarily helps answer, “How much calcified coronary plaque is present?”
CCTA can help answer, “Is plaque present, where is it, and is it narrowing the artery?”

CCTA requires IV contrast, and radiation exposure varies with the equipment and scanning protocol. It is used when the additional anatomical information is expected to influence medical decisions.

Neither test is something everyone with high cholesterol needs. The choice depends on age, symptoms, family history, overall risk, previous testing and the question your physician is trying to answer.

Putting the pieces together
There isn’t one test that perfectly defines cardiovascular health. Different pieces of information answer different questions:

What we want to understand Information that may help
Standard lipid status LDL-C, HDL-C, triglycerides and non-HDL-C
Atherogenic particle burden ApoB
Additional inherited risk Lp(a)
Glucose and metabolic health Glucose, HbA1c, fasting insulin, triglycerides and sometimes LP-IR
Systemic inflammatory signal hs-CRP, interpreted within the clinical picture
Blood-pressure-related vascular stress Blood pressure
Possible secondary contributors to abnormal lipids Thyroid, liver and kidney assessment when appropriate
Calcified coronary plaque CAC in appropriately selected individuals
More detailed coronary anatomy and plaque assessment CCTA when medically indicated
Gastrointestinal issues affecting nutrition or inflammatory health Symptom-directed GI evaluation; gut-derived cardiovascular mechanisms remain an emerging research area

Not everyone needs all of these tests. The objective is to identify which unanswered questions matter for that individual and whether the answers would change the plan.

What can you do regardless of your test results?
The cardiovascular foundations still apply:

  • Eat a predominantly whole-food, plant-rich diet with abundant fiber. Consider both the amount and sources of saturated fat, and incorporate unsaturated fats from foods such as olive oil, nuts, seeds, avocado and fish.
  • Include regular aerobic movement and resistance training.
  • Address blood-sugar regulation and blood pressure.
  • Avoid smoking and tobacco exposure.
  • Prioritize adequate, consistent sleep.
  • Work toward a healthy body composition while preserving muscle.
  • Address chronic inflammatory contributors when identified.

From there, the plan becomes more individualized.

Someone with high ApoB and insulin resistance may need a different nutrition strategy from someone with high ApoB, excellent metabolic health and a strong genetic predisposition. Someone with elevated Lp(a) may benefit from more intensive management of other risks. Documented coronary plaque warrants medical assessment of the prevention strategy.

Personalization comes from understanding your pattern.

Where functional nutrition fits in
If you’ve received abnormal cholesterol results but aren’t sure what to do beyond being told to “eat better and exercise,” this is an area where I can help.

We can review your existing bloodwork, dietary patterns, health history and modifiable contributors, then turn that information into an actionable plan.

Depending on your situation, our work may include:

  • Identifying additional markers worth discussing with your healthcare provider
  • Assessing fiber intake, dietary fat sources, and protein and carbohydrate balance
  • Looking for patterns suggesting insulin resistance or impaired glucose regulation
  • Considering thyroid, menopausal and other factors that warrant medical evaluation
  • Addressing gastrointestinal imbalances when relevant
  • Developing practical movement, sleep and stress-support strategies
  • Selecting nutritional supplementation when appropriate
  • Planning follow-up testing to assess your response

Your physician or cardiovascular specialist can assess medical risk, determine whether imaging is appropriate, diagnose cardiovascular disease and recommend medication when indicated.

Cardiovascular health is about much more than achieving a target cholesterol number. Medication may help but it’s not the whole story. Understanding your individual risk factors, from metabolic health and inflammation to genetics and the condition of your arteries provides a more complete picture and creates opportunities for meaningful prevention. The goal isn’t simply better lab results; it’s protecting your heart, blood vessels, and long-term health for the years ahead.

This information is intended for educational purposes and is not a substitute for individualized medical care. Medication decisions, cardiovascular imaging and medical testing should be discussed with your physician or other qualified healthcare provider.