Dear Self-Advocate, 

One week ago, our family was shaken by the tragic news. A faculty member, coach, and an all-around wonderful person from my daughter’s former high school passed away suddenly from a heart attack. He was only 62 years old. We are still saddened and processing this loss.

This isn’t just an isolated event. Many of my patients come to me concerned about prostate issues, yet in reality, their greatest health risk is a heart attack—even more so than prostate cancer in some cases.

This newsletter isn’t about giving you a step-by-step plan to avoid heart disease. Instead, I want to empower you with the right information so you can have a meaningful discussion with your cardiologist and make informed health decisions.

Standard Heart Tests Are Suboptimal

The typical cholesterol panel (total cholesterol, LDL, HDL) often fails to give a full picture of heart disease risk. If you want a more accurate assessment, focus on these three key markers:

 Apolipoprotein B (ApoB)
 Triglyceride-to-HDL Ratio (TG/HDL-C)
 Coronary Artery Calcium Score (CAC Score)

Let’s break them down.

1. Apolipoprotein B (ApoB) – The True Measure of “Bad” Cholesterol

ApoB is a protein found in all the lipoproteins that contribute to plaque buildup in arteries, including LDL (bad cholesterol). Unlike traditional LDL tests, ApoB tells you how many atherogenic particles are circulating in your blood, not just how much cholesterol is inside them.

 Why it matters: The more ApoB particles you have, the greater your risk of plaque formation and heart disease—even if your LDL levels appear “normal.”

 Target Levels:

• High risk (existing heart disease or equivalent risk):< 130 mg/dL 
• Moderate risk (2+ risk factors): < 110 mg/dL
• Low risk (0-1 risk factor): < 90 mg/dL

If you’ve never had an ApoB test, ask your doctor for one. It’s a game-changer in cardiovascular risk assessment.

 Supporting Evidence:

• ApoB unifies, amplifies, and simplifies the information from conventional lipid markers as to the atherogenic risk attributable to apoB lipoproteins (Sniderman et al., JAMA Cardiol., 2019).
• ApoB levels correlate more closely with cardiovascular disease risk than LDL-C levels alone (Talebi et al., Lipids Health Dis., 2020).

2. Triglyceride-to-HDL Ratio (TG/HDL-C) – The Hidden Heart Attack Risk

One of the strongest predictors of heart disease risk is the ratio of triglycerides to HDL (“good” cholesterol). Studies have shown that people with a high TG/HDL ratio have up to 16 times the risk of a heart attack compared to those with a low ratio (Circulation, 1997).

 Ideal TG/HDL Ratios:
 2 or less → Ideal
 ≤ 3.0 → Acceptable
 4 or higher → High risk
 6 or higher → Extremely high risk

Pro tip: This ratio is also a marker of insulin resistance, which is a major driver of metabolic disease (Ann Intern Med., 2003).

 Supporting Evidence:

• The TG/HDL ratio is a strong predictor of heart attack risk and metabolic dysfunction (Circulation, 1997).
• High TG/HDL is linked to insulin resistance and future heart disease in multiple ethnic groups (Cardiovasc Diabetol., 2008).

3. Coronary Artery Calcium (CAC) Score – A Window Into Your Arteries

A CAC score is a CT scan that detects calcified plaque in your coronary arteries. This is one of the best tools we have to determine if you’re actually developing heart disease—even if your cholesterol numbers seem fine.

 What CAC Score Means:

• 0 → No detectable plaque, very low risk
• 1-99 → Mild plaque, moderate risk
• 100-399 → Significant plaque, higher risk
• 400+ → Extensive plaque, high risk of heart attack

A high LDL doesn’t always mean high risk, and a low LDL doesn’t always mean low risk—your CAC score gives you the real answer.

 Supporting Evidence:

• Coronary plaque burden, not LDL levels alone, is the primary determinant of heart attack risk (JAMA Netw Open., 2022).
• 46% of patients with LDL-C levels ≥190 mg/dL had zero plaque, suggesting that aggressive lipid-lowering therapy may not be necessary in all cases.
• CAC scoring helps distinguish between high-risk and low-risk individuals regardless of LDL (JAMA Netw Open., 2022).

Want to dive deeper? Check out my past podcast episodes on cardiovascular health and metabolic disease. 

Relevant Podcasts

Dr. Joel Kahn on Lipoprotein (a) diet and tests for Cardiovascular disease

• Podcast on YouTube
• Episode 96 on  Apple Podcast, Spotify, Amazon

Crucial Heart Tests to Avoid a Heart Attack with Alon Gitig, MD

• Podcast on You Tube
• Episode 95 on  Apple Podcast, Spotify, Amazon

Dietary Approaches to Prevent a Heart Attack and a Stroke with Daniel Chong, MD

• Podcast on YouTube
• Episode 97 on Apple Podcast, Spotify, Amazon

Final Thoughts and Takeaway: Advocate for Better Testing

If you take away one thing from this newsletter, let it be this: don’t rely on standard cholesterol tests alone. If your doctor is not testing for ApoB, TG/HDL ratio, or CAC score, you’re missing key data about your heart health.

Action Steps:
 Ask your doctor for an ApoB test and a TG/HDL ratio calculation.
 Consider a CAC scan, especially if you’re over 40 or have risk factors.
 If your numbers are off, take proactive steps—diet, exercise, and the right lifestyle choices can make a huge difference.

Your health is in your hands. Don’t wait for a heart attack to be your first warning sign. The more you know, the better choices you can make!

 References & Studies for Further Reading:

1. Sniderman AD, Thanassoulis G, Glavinovic T, et al. Apolipoprotein B Particles and Cardiovascular Disease: A Narrative Review. JAMA Cardiol. 2019;4(12):1287–1295.
2. Talebi S, Bagherniya M, Atkin SL, et al. The beneficial effects of nutraceuticals and natural products on small dense LDL levels, LDL particle number and LDL particle size: a clinical review. Lipids Health Dis. 2020;19(1):66.
3. McLaughlin T, Reaven GM, Abbasi F, et al. Is there a simple way to identify insulin-resistant individuals at increased risk of cardiovascular disease? Am J Cardiol. 2005;96(3):399–404.
4. Vega GL, Barlow CE, Grundy SM, et al. Triglyceride-to-high-density-lipoprotein-cholesterol ratio is an index of heart disease mortality. J Investig Med. 2014 Feb;62(2):345-9.
5. Mortensen MB, Caínzos-Achirica M, Steffensen FH, et al. Association of Coronary Plaque With Low-Density Lipoprotein Cholesterol Levels and Rates of Cardiovascular Disease Events Among Symptomatic Adults. JAMA Netw Open. 2022;5(2):e2148139.

Much Love!

Dr. Geo