Looking Beyond Cholesterol: Advanced Cardiovascular Testing for Women

Heart disease remains the leading cause of death in the United States – claiming more lives each year than all forms of cancer, including breast cancer. Yet cardiovascular risk in women is often overlooked, especially during midlife. Before menopause, women tend to experience fewer cardiovascular events, a trend largely attributed to the protective effects of estrogen. As estrogen levels decline during perimenopause and menopause, that protection fades – and risk begins to climb.

This increase is often underestimated, contributing to underdiagnosis in midlife women. Risk calculations based on age or past history may not fully reflect the physiologic changes underway. Recognizing this shift – and testing accordingly – can play a critical role in prevention.

A standard lipid panel typically measures total cholesterol, LDL, HDL, and triglycerides. While essential, these values don’t always correlate with cardiovascular events. Even when LDL appears normal, risk may still be elevated. This is where advanced markers can offer additional insight.

Apolipoprotein B (ApoB) measures the number of potentially harmful lipoprotein particles in the blood. Since each atherogenic particle contains one ApoB molecule, this test offers a more precise reflection of risk than LDL cholesterol alone. When combined with a standard lipid panel, ApoB also allows for calculation of several lipid ratios that can help uncover cardiovascular risk not evident on basic panels alone.

Lipoprotein(a) is a genetically influenced form of LDL cholesterol that is especially atherogenic. Elevated levels are associated with increased risk of heart attack and stroke – even in those with otherwise healthy lipid levels. Because lipoprotein(a) is not significantly impacted by standard treatments, testing at least once for baseline risk can be highly informative.

Vascular inflammation is a key factor in heart disease, yet it’s often overlooked in standard testing, even though it contributes to the buildup and progression of plaque in the arteries. Tests like high-sensitivity C-reactive protein (CRP-hs) and lipoprotein-associated phospholipase A2 (Lp-PLA2) can offer additional insight into hidden inflammatory activity that may raise cardiovascular risk, even when cholesterol levels appear normal.

Blood sugar regulation also plays a key role in cardiovascular health. Even when blood sugar levels don’t meet the threshold for diabetes, dysregulation can promote inflammation, damage blood vessels, and accelerate plaque formation. Testing hemoglobin A1c and fasting insulin can help identify early metabolic dysfunction that contributes to risk.

When blood markers raise concerns – or when family history or symptoms suggest elevated risk – imaging can provide further clarity. A coronary artery calcium (CAC) score uses a low-radiation CT scan to detect calcified plaque in the arteries, offering a visual snapshot of early atherosclerosis. Coronary CT angiography (CCTA) also evaluates soft plaque and coronary blood flow.

For many people, a heart attack is the first noticeable sign of cardiovascular disease. In fact, more than half of those who experience a heart attack report no prior symptoms. This makes proactive screening especially important for individuals who may appear outwardly healthy but have silent risk factors. Cardiovascular disease often develops quietly over years, and its warning signs – particularly in women – can be subtle or easily misattributed. As hormone levels shift and metabolism changes, this transitional phase becomes a critical window for assessing risk. Advanced testing may reveal patterns that standard labs overlook, offering an opportunity for early, informed action to support long-term heart health. Because cardiovascular risk doesn’t always present the same way in women as it does in men, it’s worth talking with your healthcare provider about whether additional testing could offer a more complete picture.

This article was originally published in Tigard Life‘s March 2024 issue. Click here for a PDF of this article in it’s original format.