Beyond Total Cholesterol: How To Tell If You Really Need a Statin

You get your annual blood work back and you’re worried because your total cholesterol is high. Not only that, your LDL cholesterol (the so-called “bad cholesterol) is flagged in red. Your doctor highly suggests that you start taking a statin to lower your LDL cholesterol and reduce your risk of a heart attack or stroke.

But does high cholesterol and an elevated LDL level tell us enough to make that decision?

Think about stepping on a bathroom scale. If the number says 180 pounds, you know how much you weigh. But you don’t know how much of that weight is muscle, fat, bone or water.

Two people can weigh exactly the same amount and have very different body compositions.

Cholesterol testing can be similar.

A standard lipid panel provides baseline information. But when we’re trying to estimate your actual cardiovascular risk and decide whether cholesterol-lowering medication makes sense, sometimes we need to do more advanced testing. And if you go to a conventional primary care physician, you may be the one who has to request more comprehensive diagnostics, but more on that point later….

What Does a Standard Cholesterol Test Tell You?

Most routine lipid panels include:

• Total cholesterol
• LDL cholesterol (LDL-C)
• HDL cholesterol
• Triglycerides

Your lab report may also include calculated values based on these measurements, such as non-HDL cholesterol, which is simply your total cholesterol minus your HDL cholesterol. Because it includes LDL as well as other potentially atherogenic lipoproteins — particles that can contribute to plaque buildup in the arteries — it can provide a broader picture than LDL-C alone.

Some reports also show ratios, such as total cholesterol-to-HDL cholesterol or LDL-to-HDL cholesterol. These can provide additional context, although modern cardiovascular risk assessment generally relies more heavily on absolute cholesterol values and your overall risk profile than on cholesterol ratios alone.

In other words, a “good” cholesterol ratio doesn’t necessarily mean your cardiovascular risk is low. That’s because standard lipid panels don’t directly tell us how many potentially atherogenic particles are circulating in your bloodstream.

ApoB: Counting the Particles Instead of Just the Cholesterol

Apolipoprotein B, or ApoB, is a protein found on the major lipoprotein particles capable of contributing to atherosclerosis, the buildup of fatty plaque inside the arteries.

Each of these cholesterol- and fat-carrying particles has one ApoB molecule on its surface. That means measuring ApoB gives us a good estimate of the number of atherogenic particles circulating in your blood.

And to help you understand why this is important, let’s use a simple analogy.

Imagine two delivery trucks carrying cargo.

One truck is packed full. The other is carrying only a few boxes.

Measuring LDL cholesterol is somewhat like measuring how much cargo is being transported. ApoB helps us estimate how many trucks are on the road. Sometimes LDL cholesterol and ApoB tell essentially the same story but sometimes they don’t.

That difference is called “discordance.” Someone may have an LDL level that looks relatively normal while having a higher concentration of atherogenic particles than LDL-C alone suggests.

The National Lipid Association has concluded that ApoB testing can improve cardiovascular risk assessment and may correlate more closely with cardiovascular risk when ApoB and LDL-C disagree.

To put it simply, when your LDL cholesterol and ApoB tell different stories, ApoB may provide the better indication of your actual cardiovascular risk.

The newest cardiovascular guidelines also recognize ApoB testing as a useful additional tool in selected patients, particularly those with conditions such as high triglycerides, diabetes, cardiometabolic disease or established cardiovascular disease.

Elevated Lipoprotein(a): The Inherited CVD Risk Factor

There’s another blood test I believe more patients should know about: lipoprotein(a), or Lp(a).

Lp(a) is an LDL-like particle with an additional protein attached to it. Elevated levels are associated with greater risk of atherosclerotic cardiovascular disease.

Unlike many cardiovascular risk factors, Lp(a) is largely determined by your genetics. (So if yours is high, you can add it to the list of things to blame on Mom and Dad.)

Eating better, exercising more and losing weight are enormously beneficial for your overall cardiovascular health. But they generally don’t substantially lower a genetically elevated Lp(a).

That’s one reason knowing your Lp(a) number can be valuable.

In fact, current ACC/AHA guidelines recommend that every adult have Lp(a) measured at least once. Because it is largely genetically determined and tends to remain relatively stable, most people don’t need to continually repeat the test.

Yet there’s a good chance you’ve never seen Lp(a) on your routine blood work.

Summary: ApoB helps tell you how many atherogenic particles you’re dealing with overall; Lp(a) identifies a particular genetically influenced particle that carries additional cardiovascular risk.

These Tests May Not Be Included Unless You Ask

ApoB and Lp(a) aren’t necessarily part of the standard lipid panel ordered during an annual physical.

Depending on your health history and cardiovascular risk, you may need to specifically ask your healthcare provider whether additional testing makes sense.

Insurance coverage also varies. Some plans cover these tests under certain circumstances, while others may leave you responsible for some or all of the cost.

But if you’re facing a potentially long-term decision about cholesterol medication—or simply want a clearer understanding of your cardiovascular risk—it may be worth having that conversation.

Blood Tests Still Can’t Tell Us Everything

This is where cardiovascular testing requires some humility.

No blood test can tell you with certainty whether you’re going to have a heart attack or stroke. Not ApoB, not Lp(a), and not LDL cholesterol.

Even more advanced testing has limitations. A coronary artery calcium (CAC) scan, for example, is a noninvasive CT scan that detects calcified plaque in the coronary arteries. Current guidelines recommend selective use of CAC scoring when someone’s cardiovascular risk is uncertain and the result could help guide a decision about statin therapy.

A CAC score of zero can be reassuring in appropriately selected people. A higher score provides evidence that coronary atherosclerosis is already present.

But even a CAC scan isn’t a crystal ball.

It primarily identifies calcified plaque. It doesn’t tell us exactly which plaque—if any—will eventually become unstable, rupture and contribute to a clot.

Other imaging techniques, such as coronary CT angiography, can provide considerably more detail about coronary arteries and plaque. But they still cannot reliably predict that a particular plaque will rupture on a particular day.

Cardiovascular medicine is ultimately about estimating risk, not predicting the future.

How To Tell If You Need a Statin?

There’s no single laboratory value that can answer that question for everyone.

For some people, the evidence for cholesterol-lowering medication is strong. That includes many people who already have cardiovascular disease and people with certain high-risk conditions or very high LDL cholesterol.

For someone without known cardiovascular disease whose risk isn’t as obvious, however, the conversation can be more nuanced.

Your provider may consider your:

• LDL and non-HDL cholesterol
• ApoB
• Lp(a)
• Triglycerides
• Blood pressure
• Blood sugar and metabolic health
• Smoking history
• Age
• Kidney health
• Family history of premature cardiovascular disease
• Overall calculated cardiovascular risk
• CAC score, when appropriate

The goal is to collect enough meaningful information to make a better-informed decision about your individual risk.

Look Beyond the Red Flag on Your Lab Report

At Fundamental Wellness of Nebraska, I don’t believe your healthcare should begin and end with whether a number falls inside a laboratory’s reference range.

If your cholesterol results are concerning, or you’re trying to decide what those results actually mean, I can order additional testing such as ApoB and Lp(a) when appropriate and help you understand how those results fit into your larger health picture.

Sometimes that deeper look confirms that aggressive cardiovascular risk reduction is warranted. Other times it adds context that wasn’t apparent from a standard lipid panel alone.

Either way, you deserve more than a one-size-fits-all interpretation of your health.

Schedule a consultation with Jenna Witt, NP, founder of Fundamental Wellness of Nebraska, to discuss which cardiovascular and metabolic tests may be appropriate for you and what the results mean.