Best Heart Health Tests Beyond Cholesterol
Heart tests beyond a cholesterol panel: ApoB, Lp(a), hs-CRP, calcium scoring, kidney markers and more, with what the 2026 guideline and USPSTF say.
ACT 2 Health Clinical Team · Updated September 23, 2026
A standard lipid panel gives you total cholesterol, HDL, triglycerides and an LDL cholesterol figure that is often calculated rather than measured. It is a good start and an incomplete picture. Two people with the same LDL cholesterol can carry very different numbers of particles, an inherited particle called Lp(a) is not reported on a standard panel at all, and plaque itself does not appear on any blood test. The tests below fill in parts of that gap. Several have strong guideline support; a few are widely sold but weakly supported, and we say which is which.
1. ApoB
What it is: a protein found on each LDL-type particle, so the ApoB level works as a particle count rather than a cholesterol estimate.
Why it matters after 45: the 2026 ACC/AHA dyslipidemia guideline says ApoB testing can improve risk assessment once LDL-C and non-HDL-C goals are met, especially with high triglycerides, diabetes or very low LDL-C. MedlinePlus notes a high ApoB can signal higher risk even when cholesterol is at target.
Practical note: it is most informative in the common midlife pattern of higher triglycerides, lower HDL and a normal-looking LDL. Our page on ApoB versus Lp(a) explains how the two differ.
2. Lipoprotein(a)
What it is: an LDL-like particle whose level is largely inherited.
Why it matters after 45: the 2026 US guideline and the European Atherosclerosis Society both say Lp(a) should be measured at least once in adults. The US guideline treats 125 nmol/L (about 50 mg/dL) or higher as a risk-enhancing factor, associated with about 1.4-fold higher risk, and 250 nmol/L or higher with about twice the risk. MedlinePlus explains why a normal LDL can hide it.
Practical note: one test is generally enough. A high result is worth telling first-degree relatives about, since the EAS consensus supports testing family members.
3. hs-CRP
What it is: high-sensitivity C-reactive protein, a blood marker of low-grade inflammation. See what hs-CRP measures.
Why it matters after 45: the AHA lists hs-CRP among the markers that can refine an individual's risk estimate. Support is mixed: the USPSTF found insufficient evidence (an I statement, 2018) to recommend adding it to routine risk assessment.
Practical note: infection, injury and smoking raise CRP, so a single high reading is usually repeated when you are well.
4. Coronary artery calcium (CAC) score
What it is: a non-contrast CT scan of the heart that measures calcified plaque in the coronary arteries. MedlinePlus notes a score of 0 is considered normal.
Why it matters after 45: it is the only item on this list that looks at plaque directly. The 2026 ACC/AHA guideline supports selective CAC scoring in men 40 and older and women 45 and older at borderline or intermediate risk, when the result would help decide on a statin. Evidence reviews differ: the USPSTF's 2018 I statement found insufficient evidence for adding CAC to routine risk assessment, and it lists an update in progress.
Practical note: the scan involves radiation and can find incidental lung nodules that lead to more testing. It is most useful when the answer would change a decision.
5. Blood pressure outside the office
What it is: home readings with a validated automated cuff, or 24-hour ambulatory monitoring.
Why it matters after 45: high blood pressure is a major, usually silent risk factor. The USPSTF gives screening an A grade and says readings outside the clinic should confirm a diagnosis before treatment starts, since office readings alone can mislead.
Practical note: bring a log of home readings to your next visit rather than a single number.
6. A1c or fasting glucose
What it is: A1c reflects average blood glucose over the past two to three months.
Why it matters after 45: diabetes and prediabetes raise cardiovascular risk. The USPSTF recommends screening adults 35 to 70 with overweight or obesity, and A1c is an optional input to the PREVENT risk equations.
Practical note: track the direction, not only whether you crossed a threshold.
7. Kidney markers: eGFR and UACR
What it is: eGFR estimates kidney filtration from a blood test; the urine albumin-to-creatinine ratio looks for protein leaking into urine.
Why it matters after 45: the heart and kidneys share risk. The PREVENT equations use eGFR as a core input and UACR as an optional one, and MedlinePlus notes that urine albumin can be an early sign of kidney disease.
Practical note: UACR is a separate urine test. Ask about it if you have high blood pressure, diabetes or heart disease.
8. A PREVENT risk estimate
What it is: not a test but a calculation, using your age, blood pressure, cholesterol, kidney function and other factors to estimate 10- and 30-year risk of heart attack, stroke and heart failure in adults 30 to 79.
Why it matters after 45: the 2026 guideline recommends PREVENT in place of the older Pooled Cohort Equations, which the AHA says overestimated 10-year risk by 40% to 50%.
Practical note: ask your clinician for your PREVENT estimate; it puts the individual markers above into one number you can track.
9. Resting or exercise ECG: know when it is screening
What it is: a recording of the heart's electrical activity, at rest or during a treadmill test.
Why it matters after 45: it is common in executive physicals, but for people without symptoms the evidence runs the other way. The USPSTF recommends against screening low-risk adults with a resting or exercise ECG (grade D) and found insufficient evidence for those at higher risk, because false positives lead to further testing.
Practical note: if you have chest pain, breathlessness or palpitations, an ECG is a diagnostic test and you should seek care promptly.
10. Ankle-brachial index (ABI)
What it is: the ratio of blood pressure at the ankle to blood pressure in the arm, used to look for narrowed leg arteries.
Why it matters after 45: peripheral artery disease shares risk factors with heart disease. The USPSTF's 2018 review found insufficient evidence to add ABI to routine risk assessment in people without symptoms.
Practical note: leg pain when walking that eases with rest is a reason to ask about it.
11. Homocysteine: weaker than it sounds
What it is: an amino acid that rises when vitamin B6, B12 or folate is low. More in our homocysteine explainer.
Why it matters after 45: high levels are linked with heart disease, but MedlinePlus notes that routine testing for heart risk is not recommended for everyone and that, in most cases, lowering homocysteine has not been shown to reduce heart attack or stroke risk.
Practical note: it is most useful as a clue to a B-vitamin problem, not as a heart score.
Putting the list in order
None of these tests is a verdict on its own, and more is not automatically better. A reasonable way to read the list is in layers: blood pressure and a lipid panel as the base, a one-time Lp(a), then ApoB, kidney markers and A1c as your risk profile suggests, all feeding a PREVENT estimate. A calcium scan sits on top, for when its answer would change a decision. The tests with I or D grades from the USPSTF are the ones to ask about before you accept them as part of a package.
Where this fits
ACT 2's page on heart risk when you look fit explains why a normal lipid panel is not the reassurance it reads as, and what a clinician can measure next.
If you want these markers measured and followed over time, our comparison of biomarker-guided longevity programs looks at who reviews results and how often each service retests.
For imaging such as a calcium score, the in-person programs in our executive health programs guide are the right place.
Sources
- https://professional.heart.org/en/science-news/2026-guideline-on-the-management-of-dyslipidemia/top-things-to-know
- https://newsroom.heart.org/news/accaha-issue-updated-guideline-for-managing-lipids-cholesterol
- https://medlineplus.gov/ency/article/003502.htm
- https://medlineplus.gov/lab-tests/lipoprotein-a-blood-test/
- https://eas-society.org/wp-content/uploads/2024/01/ehac361.pdf
- https://medlineplus.gov/lab-tests/c-reactive-protein-crp-test/
- https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cardiovascular-disease-screening-using-nontraditional-risk-assessment
- https://medlineplus.gov/ency/article/007344.htm
- https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hypertension-in-adults-screening
- https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-for-prediabetes-and-type-2-diabetes
- https://pubmed.ncbi.nlm.nih.gov/37947085/
- https://medlineplus.gov/lab-tests/microalbumin-creatinine-ratio/
- https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cardiovascular-disease-risk-screening-with-electrocardiography
- https://medlineplus.gov/lab-tests/homocysteine-test/
Frequently asked questions
The blood tests with the most guideline support are ApoB, which counts atherogenic particles, and a one-time Lp(a), which is largely inherited. hs-CRP adds information about inflammation. A coronary artery calcium scan can clarify risk for some adults in their 40s and older. Kidney markers and A1c feed into the newer PREVENT risk estimate. A clinician can tell you which fit your situation.
No. The 2026 ACC/AHA dyslipidemia guideline supports selective CAC scoring in men 40 and older and women 45 and older at borderline or intermediate risk, when the result would change a treatment decision. The USPSTF found insufficient evidence in 2018 to recommend it broadly, and it has an update in progress. The scan uses radiation and can turn up incidental findings.
It is a refinement rather than a replacement. The 2026 ACC/AHA guideline says ApoB testing can improve risk assessment once LDL-C and non-HDL-C goals are met, particularly for people with high triglycerides, diabetes or very low LDL-C. For many people, LDL-C and non-HDL-C remain the main numbers.
Not necessarily. A resting ECG records electrical activity; it does not measure plaque in the arteries. The USPSTF recommends against screening low-risk adults without symptoms with a resting or exercise ECG, and found insufficient evidence for people at higher risk. If you have symptoms such as chest pain or breathlessness, see a clinician promptly; that is diagnosis, not screening.
Routine homocysteine testing for heart risk is not recommended for everyone. MedlinePlus notes that in most cases, lowering homocysteine has not been shown to reduce the risk of heart attack or stroke. It is more useful when a clinician suspects low B12 or folate, or in specific higher-risk situations.
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