Do You & Your Doctor Know All 10 Heart Disease Risk Factors?

| March 7, 2012
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Heart disease is the #1 cause of death. About 50 percent of all people who die suddenly from heart disease have low or normal cholesterol. To protect yourself from heart disease, ask your doctor for a complete lipid evaluation. Fast 10-12 hours before blood is drawn (you can drink water). Because Total Cholesterol (TC) and LDL cholesterol are not the most reliable predictors of heart disease, they are not posted in the following chart.


Focus on Fasting Glucose, HDL, Triglycerides (TG) and the all important TG:HDL ratio. Keep in mind that before the advent of cholesterol-lowering statin drugs, the normal range for Total Cholesterol (TC) was:  180 mg/dl to 340 mg/dl. Also, it’s important to note that LDL is actually a family of particles. A discussion about LDL subclasses and LDL subclass testing follows in the summary of this article.

1. C-reactive protein (CRP) is produced by the liver in response to inflammation in the body. If monitored early enough, elevated CRP can be an early warning of a heart attack several years in advance. Optimum levels are below 1 mg/l. (You will have to request this test with most doctors.)

2. Fasting Glucose (FG) measures fasting blood sugar. Lowest all-cause mortality is associated with fasting glucose in the range of 80-89 mg/dl. According to the clinical experience of Dr. Robert Atkins, the risk of heart disease increases in linear manner as your Fasting Glucose goes over 100 mg/dl. (Specifically ask for this inexpensive test.)

3. Fibrinogen is a protein that in excess promotes blood clots. Elevated fibrinogen = thicker blood. Thicker blood flows less easily through partially blocked arteries. Consistent elevated fibrinogen (over 350 mg/dl) conveys a 250 percent increased risk of heart disease compared to people with fibrinogen levels below 235. (People who have recently suffered a heart attack will have elevated fibrinogen levels.)

4. Homocysteine is normally rapidly cleared from the bloodstream. Elevated homocysteine is a result of B-vitamin deficiencies, particularly folic acid, B-6 and B-12. Elevated homocysteine is associated with increased risk of heart attack, stroke, and all cause mortality. Levels less than 8 mmol/L are associated with longevity. (Again, you may have to request this test.)

5. Lipoprotein(a) has been called the “heart attack cholesterol.” Lipoprotein(a) is a sticky protein that attaches to LDL and accumulates rapidly at the site of arterial lesions or ruptured plaque. Readings of 30 mg/dl or more indicate serious increased risk of heart disease, especially in the presence of elevated fibrinogen (>350). While the Lp(a) level is largely genetically determined, it can be influenced by nutritional factors, such as high blood sugar and trans fatty acid consumption. (This test may not be as important as the rest and is seldom done routinely.)

6. HDL is made in the liver and acts as a cholesterol mop, scavenging loose cholesterol and transporting it back to the liver for recycling. HDL is associated with protection from heart disease. You want as much HDL as possible. HDL of 60 or more is associated with protection for men—70 or more for women.

7. Triglycerides (TG) should be under 100 mg/dl. Triglycerides are blood fats made in the liver from excess energy – especially carbohydrates. Risk is linear—the higher the number, the greater the risk, especially for women. While doctors may insist that a reading up to 150 is okay, Dr. Atkins’ clinical experience suggested otherwise.

8. TG:HDL ratio is the most reliable predictor of heart disease. Calculate your ratio by dividing TG by HDL. As an example, if TG = 80 and HDL = 80, your ratio is 1:1 representing low risk of heart disease. If your TG = 200 and your HDL = 50, your ratio is 4:1 representing serious risk of heart disease.

9. VLDL – Increasingly, Very Low Density Lipoprotein is measured/calculated. VLDL is sent out from the liver to deliver those liver made fats (Triglycerides) – as opposed to a Chylomicron that delivers dietary fat from the gut.  Generally, VLDL is one fifth of your triglyceride level, although this is less accurate if your triglyceride level is greater than 400 mg/dl. (Beyond the scope of this article, LDL is the offspring of VLDL – they are closely-related.)

LDL particle sizeSmall dense Pattern B/Large fluffy Pattern A

LDL – low density lipoprotein – is a family of particles. A lot of people with elevated LDL do not develop coronary artery disease, while individuals with low or modest levels often develop serious disease.  This can be explained by the LDL particle number and size. Routine cholesterol testing only reveals the amount of LDL; not the quality of LDL.

We now know (my doctor didn’t) that there are different subclasses of LDL (and HDL). Under an electron microscope, some LDL particles appear large and fluffy; others small and dense. The big, fluffy particles are benign, while the small dense particles are strongly associated with increased risk of heart disease.

In excess, small dense LDL is toxic to the artery lining (the endothelium), and much more likely to enter the vessel wall – become oxidized – and trigger atherosclerosis. It’s becoming consensus medical opinion that only oxidized LDL can enter the macrophages in the lining of the arteries and contribute to plaque buildup.

HOW DO YOU KNOW WHAT LDL YOU HAVE?  Certain clinical factors predict the presence of small dense LDL. These markers include HDL below 40 in men; below 50 in women – and Triglycerides (TG) higher than 120 mg/dl. Diabetes or pre-diabetes also predicts small dense LDL (Pattern B).

To determine LDL particle size, ask your doctor for a VAP (Vertical Auto Profile) test, which separates lipoprotein particles using a high speed centrifuge. The VAP test measures the basic information provided by a routine cholesterol test, but also identifies lipoprotein subclasses, LDL and HDL. (Go to for more information.)

There are other tests as well. The NMR LipoProfile analyzes the number and size of lipoprotein particles by measuring their magnetic properties ( Also Berkeley HeartLab’s LDL Segmented Gradient Gel Electrophoresis test measures all seven subclasses of LDL.  (

If you don’t have insurance and can pay for just one test, get your fasting blood sugar checked. Any number over 100 – over 95 according to the late Dr. Atkins – is an early warning of diabetes, metabolic syndrome, and heart disease. If you have insurance or can afford a complete lipid panel, consider additional testing to determine the size and number of LDL particles.  “A stitch in time saves nine.”

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Category: Diabetes/Heart Disease

Comments (18)

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  1. Alan, thank you so much for this summary. I was actually in the process of producing something very similar to this as a quick reference for my clients; you have saved me some work here!

    I have read both of your books and they occupy a prominent place in my health/fitness/nutrition library. Thanks for your excellent work!

  2. Cheryl Peterson says:

    I learned that the single focus on total cholesterol is very misleading. Haven’t seen a chart this comprehensive anywhere. thanks.

  3. PaulaM says:

    See the work of Peter Attia MD. Just google the name. Talk about cholesterol; Peter is shining the light where there hasn’t been any, ever.

  4. bill says:

    Why just focus on surogate markers, which in their own right are quite imperfect at predicting much of anything? Just measure the plaque using a coronary artery calcium scan and know if you have CAD. I did. The plaque IS the disease.

  5. Bill Davis says:

    Thanks for a good article but I do believe bill above has a very important point in that risk factors are not the disease. Coronary artery plaque is the disease and to date the very best way to access this killer is to measure calcified plaque in the arteries using a CAC scan. If I have no plaque I have no disease yet those surogate markers may then be misleading.

  6. Alan Watson says:

    I agree Bill. Measuring calcified plaque should be a clinical priority. At the same time, however, people need to be prepared for the statin sales pitch they will likely get at their doctor’s office. (I would welcome a guest article about coronary calcification. Thank you.)

  7. Susan says:

    Would you please give us an idea of which foods/nutrients that will lower triglycerides and/or will raise HDL?

    Thank you!

  8. Alan Watson says:

    Natural dietary fat increases HDL and reduces triglycerides. As an example, eating eggs and bacon for breakfast will boost HDL and reduce triglycerides; eating box cereal with skim milk will promote triglycerides and reduce HDL. There’s plenty of evidence that high carbohydrate diets are associated with elevated blood sugar, high insulin, elevated triglycerides and depressed HDL. An Atkins-style diet does the opposite

  9. Susan says:

    Thank you. Do you know if an artery that is completely blocked can be reversed by changing your diet? If so, would following the recommendations from your 21 Days to a Healthy Heart book be enough to help with this, or at least get started? Any advice would be greatly appreciated.

  10. Alan Watson says:

    Dr. Robert Atkins reversed type II diabetes using a high natural fat whole foods diet. In 21 Days to a Healthy Heart, the case study Maria reversed type II diabetes using an Atkins-style diet (confirmed by the Mayo Clinic). Cleaning the blood – via diet – can reduce clotting factors which, in turn, stop and eventually reverse plaque buildup. The 21 Day plan is anchored in Atkins decades of clinical experience. It worked for Maria – it can work for others too who are overweight, pre-diabetic, and clot-prone.

  11. Susan says:

    Thanks again, I really appreciate your knowledge right now.

    My mom has several blockages, Her arteries are too small for having by-pass surgery. Since she hasn’t had any pain since her last doctor’s visit(thank God), her cardiologist put off having her have balloon surgery unless absolutely necessary.

    She was told that diet & exercise would not help with reversing the clogged arteries.

    He did say that the arteries could create collateral arteries and she might be completely fine in not having any procedure done.

    We also talked about EECP as another option. I know it’s not ideal (she has a pacemaker and hypertension) but I asked him about it as an option because of the risks of having balloon surgery.

    She has been taking magnesium, eating eggs instead of cereal, and is changing her fats/oils to healthier ones. The next big step will be with grains & carbs which I know will be more difficult for her, she has cut back some already, so there is hope.

    I was a little confused about potatoes, are they okay or is cooking them a certain way (boiled instead of baked?) a healthier way to cook them?

    I’m just glad that I found your website and will read your books to learn more!

  12. Alan Watson says:

    People with diet-related heart disease can eat potatoes (not restaurant French fries prepared in unstable vegetable fat that contains excess omega 6). Potatoes are decent source of Vitamin C and add variety to our daily fare. Because they are a relatively fast release of sugar in the gut (high glycemic), it makes sense to combine them with a source of natural fat. Frying them in lard or using sour cream and butter on baked potatoes slows the sugar-release and adds nutrition.

    In my own experience, I do not eat any carbs until the evening meal – my “Carbohydrate Hour.” I am restricting carbs below 60 grams per day – choosing to eat them in the evening in the form of vegetables, salads, or potatoes. I can eat potatoes because I haven’t been eating carbs throughout the day – and my blood sugar is in the optimum range.

    We are biochemically unique! People who are sensitive to carbs or are pre-diabetic or diabetic may need to avoid potatoes and stick with salad vegetables – eating potatoes only occasionally. But when you do eat potatoes, don’t be afraid of smothering them in butter!

    Excess refined carbohydrates and excess vegetable fats (containing excess omega 6 linoleic acid) are the twin culprits in plaquing up our bodies. Potatoes are only a problem in diets that already include excess carbs. Restrict your carbs to fewer than 60 grams per day and choose them wisely.

  13. Jon Grant says:

    On your chart I see a TG:HDL of 2 as being at risk. I’ve always seen 3.8 as being the cutoff for this ratio.

  14. Alan Watson says:

    TG:HDL ratio of 2 is beginning of risk according to Dr. Atkins, 3-4 increased risk

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