18 - Going Beyond Cholesterol in Cardiovascular Risk Assessment

It’s time we go beyond cholesterol when we look at cardiovascular risk. I have a strong interest in cardiometabolic health, and one of my ongoing bugbears is how cholesterol — particularly LDL cholesterol — tends to be honed in on as the only  risk factor we all need to focus on.

Cardiovascular disease is one of the biggest health risks in the Western world, so it’s important to be well-versed in it, understand our own health markers, and know what we can do to support them. This is really about understanding how cardiovascular risk is assessed.

Why Cholesterol Often Becomes the Trigger

One common scenario I see is people coming to me with raised cholesterol want to understand their options before starting medication. Cholesterol is often the first time cardiovascular risk has been brought to their attention, so understandably, they become quite concerned and want to do something about it.

What’s often the case, though, is that there may already be other cardiovascular risk factors present they are unaware of. For some reason, it’s cholesterol that tips people into seeking help.

There’s often not a clear understanding of why cholesterol is high or what other risk factors might be contributing.

Cholesterol as One Marker — Not the Whole Story

We’ll look at cholesterol as its own marker in more detail in the next post. For now, I want to place it alongside all the other cardiovascular risk factors and see how it fits into the bigger picture.

LDL cholesterol is important for  cardiovascular health, but it’s not necessarily the most important factor for everyone.

Despite the impression given in mainstream health media, we don’t actually want LDL cholesterol as low as possible. We want it in a sweet spot in the middle. The reason for this is that our body uses cholesterol to make hormones, vitamin D, and to support cell membranes. Cholesterol plays many essential roles, so suppressing it too much is not ideal. Balance is the goal.

LDL Cholesterol and Particle Size

LDL is often referred to as the “bad cholesterol,” but this oversimplifies the picture. What matters just as much is the particle size of LDL.

If we’re thinking about cardiovascular risk, we want to look much more broadly at multiple contributing markers so we can assess them all, address them where needed, and understand how they’re interacting.

When LDL cholesterol is raised, it’s extremely valuable to test LDL particle size. Larger particles don’t tend to get caught in the small cracks and crevices of blood vessels where they can trigger inflammation and blockages. It’s the very small, low-density particles that are more likely to cause issues.

This type of testing can often be ordered by naturopaths like myself or by functional or integrative doctors.

Triglycerides, HDL, and Key Ratios

Beyond LDL, I’m particularly interested in triglycerides. Elevated triglycerides often concern me more than mildly raised LDL.

Triglycerides need to be kept in balance with HDL, which is the more protective form of cholesterol. The ratio of triglycerides to HDL is especially important, so it’s worth ensuring this is being checked and discussed with your healthcare provider.

Blood Sugar, Insulin, and Cardiometabolic Risk

Beyond the lipid panel, I’m very interested in comparing fasting blood glucose with fasting insulin. Looking at blood sugar alone doesn’t tell the full story.

When we look at glucose and insulin together, we can assess whether insulin resistance may be present — a major driver of cardiometabolic risk.

Blood Thickness, Homocysteine, and Inflammation

Another important marker is fibrinogen, which reflects the thickness or stickiness of the blood. Like cholesterol, we want this in a healthy middle range.

Homocysteine is an independent cardiovascular risk marker and is also associated with unexplained weight gain, mood disorders, and other health issues. It’s a very valuable marker to assess.

Stress Hormones and Cortisol Patterns

Cortisol is our main stress hormone, which can drive cardiovascular problems.

Ideally, we want either morning and afternoon cortisol measurements or, even better, a saliva test measuring cortisol four times across the day. Cortisol follows a diurnal (circadian) rhythm — it naturally peaks and falls throughout the day.

If we only measure cortisol once, we don’t know whether we’re catching it at a peak or a trough. Multiple measurements give much more meaningful information, although even a single marker is better than not testing it at all.

Additional Cardiovascular Markers

Other markers I often consider include:

• Lipoprotein A versus Lipoprotein B, and which is predominant

• Blood pressure

Blood pressure is easy to check, even at a pharmacy, and becomes much more meaningful when tracked over time rather than relying on a single reading taken during stress or rushing.

If there’s a family history of cardiovascular disease, further testing such as a coronary calcium score can also be very valuable. This assesses how much calcium is contributing to arterial hardening and should ideally be considered alongside cholesterol when deciding on the best approach.

The Bigger Cardiovascular Picture

Ultimately, we want to look broadly at cardiovascular health:

• Blood sugar and insulin

• Stress hormones

• Cholesterol types and ratios

• Homocysteine

• Fibrinogen

• Blood pressure

• Arterial calcium

We also need to consider how other body systems are affecting cardiovascular health, along with family history, diet, and lifestyle.

Social connection, ability to relax, sleep quality, physical activity, and overall lifestyle all play a role in long-term cardiovascular risk.

When to Start Paying Attention

If you have concerns about your cardiovascular health, a family history, or symptoms that have raised questions, it’s worth exploring these markers.

Realistically, once we’re well into adulthood — 40 or beyond — it’s appropriate to start assessing these factors, monitoring trends over time, and addressing markers as they begin to move out of range.

Next Steps

If you’d like help with a thorough cardiovascular risk assessment, I would love to support you.

You’re welcome to book a discovery call so we can talk through your concerns and whether this approach is right for you, or you can book directly and we can move into referral and treatment as needed.