Normal cholesterol doesn’t always mean low heart attack risk, warns neurologist; here are markers your report may miss

Normal cholesterol doesn’t always mean low heart attack risk, warns neurologist; here are markers your report may miss

Many people take comfort in seeing ‘normal’ cholesterol numbers on their blood reports, assuming this automatically means their heart attack risk is low. However, this assumption can be misleading. In an Instagram post, Dr Priyanka Sehrawat, a general physician and neurologist, highlighted that cholesterol alone does not always tell the whole story of cardiovascular risk.

Addressing this common misconception, she explained, “Even if your cholesterol levels are normal, your risk of a heart attack can still be high.” She added, “When we look at a lipid profile, we usually focus on bad cholesterol, LDL levels and triglycerides, and assume these alone determine our risk. However, other predictors can give a more accurate picture.” These overlooked markers, she pointed out, can help identify hidden risks that routine tests may miss.

According to Dr Sehrawat, one such marker is ApoB. “The first is ApoB (Apolipoprotein B),” she said, explaining, “ApoB measures the number of cholesterol-carrying particles in the blood. All types of cholesterol, LDL, VLDL and others, contain these particles.” When these particles are present in high numbers, “they tend to stick to the walls of blood vessels, leading to plaque formation and increasing the risk of clotting.” She also noted that elevated ApoB levels are often associated with underlying metabolic dysfunction.

The second important marker she highlighted is Lipoprotein(a). “Lipoprotein(a) is considered a familial or genetic risk factor,” Dr Sehrawat said, adding, “People who have a family history of heart attacks at a young age should definitely get their Lipoprotein(a) levels checked.” Summing up her message, she cautioned against relying solely on standard lipid reports, stating, “Both ApoB and Lipoprotein(a) are extremely important in assessing heart attack risk, even when routine cholesterol values appear normal.”

ApoB and Lipoprotein(a) vs standard cholesterol tests

Dr CM Nagesh, honorary secretary at Indian College of Cardiology and Founder of Cardea Super Speciality Hospital, tells indianexopress.com, “Standard cholesterol tests mainly measure how much cholesterol is present in the blood, but they do not always reflect how many harmful particles are actually circulating. ApoB directly counts the number of atherogenic particles, such as LDL (Low-Density Lipoprotein), VLDL (Very-Low-Density Lipoprotein), and remnant lipoproteins, all of which can penetrate the arterial wall and trigger plaque formation. This makes ApoB a more accurate indicator of true cardiovascular risk, especially in people with normal LDL but high particle numbers.”

Lipoprotein(a), on the other hand, is a genetically determined particle that promotes both plaque buildup and abnormal clot formation. “Even when total cholesterol is normal, elevated Lipoprotein(a) can significantly increase heart attack and stroke risk. Together, these markers help identify hidden risk that conventional lipid profiles may miss,” notes Dr Nagesh.

Who should consider getting these additional markers tested?

Dr Nagesh mentions that testing for ApoB and Lipoprotein(a) is crucial for individuals with a family history of premature heart disease, unexplained heart attacks in relatives, or early cardiac events despite normal cholesterol levels. People with diabetes, metabolic syndrome, obesity, chronic inflammation, or autoimmune conditions may also benefit, as routine tests often underestimate their cardiovascular risk.

“In clinical practice, I also recommend these markers for patients who have already had a heart attack or angioplasty, as well as younger adults who appear healthy but have strong genetic risk factors. In such cases, these tests help guide more precise and preventive treatment strategies,” suggests the expert.

DISCLAIMER: This article is based on information from the public domain and/or the experts we spoke to. Always consult your health practitioner before starting any routine.