CAC is great for detecting calcified plaque in your coronary arteries. But before you have calcified plaque, the above risk factors tell you about the buildup of soft plaque. And 4 out of 5 of them are modifiable through lifestyle, exercise, and medication.
Fascinating how these tests are something that is an option in America with people getting them.
In the UK we have the NHS and, although private healthcare is available, the NHS are gatekeepers with long waiting lists to see the doctor.
In UK culture you are just not going to 'waste NHS time' by asking for the tests that could inform you on what lifestyle choices you might need to make in order to head off chronic non-communicable diseases. You have to get a chronic disease, then the doctor will interpret the test results and not let you know what the numbers are, just what medication to take, optionally with lifestyle changes.
As a consequence, nobody in the UK knows what their cholesterol levels and whatnot are, yet, in the USA, plenty of people know these numbers.
Do healthcare providers actively upsell testing in the USA?
>Do healthcare providers actively upsell testing in the USA?
In my experience, normal doctors do not, but there are a lot of private businesses that make their living selling testing.
Also, consider that despite a lot of people knowing their levels in the US through testing availability, health outcomes are not better. So, we know more, but don't do anything about it. I don't know what's worse.
In the UK, a cholesterol test is offered free of charge to everyone over the age of 40 by their GP, as well as younger people if they have a BMI over 25 or have a family history of high cholesterol levels or heart problems.
They're also available from most community pharmacies (again free of charge for at-risk patients, but for everyone else it should be about £10 for a simple finger-prick test or £30-50 for a full lipid profile).
I know my cholesterol numbers going back almost twenty years, over something like 15 tests. This is because that first test around 2007 showed my HDL was ridiculously low. So I took steps to modify it, and tested again (and again...) to see how it was progressing.
CAC is the right test for people who already have identified that they have major risk factors such as metabolic syndrome/T2D, high cholesterol, etc. It identifies whether heart disease has already advanced enough that the risk factor has become a risk.
Some of the tests you list (like A1C) are baseline things everyone should get checked every year. Agreed that the others could provide value for those who want to know more about their risk level; however, it’s uncommon for those tests to turn up positives without one of the baselines having already raised at least a yellow flag.
None of the tests you listed will tell you whether you have any soft plaque buildup. They just tell you more about your risk factors. However, there are ultrasound tests that can detect increased blood pressure in major arteries, which IIRC does reflect soft plaque buildup.
I've had high-ish LDL for ages and diet alone couldn't knock it all the way down.
It's only the CAC score that provided me with peace of mind that I didn't need to reach for statins.
The way I view this is that, if you can get more information, why wouldn't you? Cost of course, and I understand why insurance might not cover the procedure, but anybody of a certain age with any risk factors who is in a position to afford it benefits from doing so.
No, CAC only tests for end stage calcified plaque which is how your body tries to transform soft plaque. It's soft plaque that first lines your arteries and is capable of rupturing. You might be infested with soft plaque, but if none of it has calcified yet (which can take decades) then you'll have a CAC score of zero.
Using CAC store to gauge risk is like waiting until you have end stage symptoms of any disease before you consider yourself at risk. The ship has already sailed and you should have instead focused on prevention for decades.
The sibling comment is a great example of the misinformation here. They have high cholesterol but a CAC score of zero gave them the peace of mind to not use statins.
Given the low side effect rate and limited overall impact, shouldn't the bar for deciding to take statins be near-zero? Like, the articles say if there's a 5% chance of a heart attack in the next 10 years there's no reason to take a statin, but if the statin changes that 5% to 4% (that's speculation on my part) then given the limited side effects it would likely be worth it, right?
Statins often have the side effect of raising blood sugar. So there’s a non-trivial tradeoff for a population that is usually on the edge of metabolic disease.
I know a number of people who report memory issues since starting statins. They also clearly exhibit memory issues but it's hard as an outsider to pinpoint when they started. Unfortunately, they really do need statins.
I used to work with a cardiologist who joked that "we should just add statins to the water," so you have a point.
The current guidelines for prescribing statins are based on your risk of a major cardiac event in the next 10 years (forecasted using a statistical model). But given that plaque builds up in your arteries over your lifetime, there's a strong argument for using a 30-year or lifelong time horizon.
My cardiologist did all of these except the eGFR. My calcium score was fairly high, but not high enough to be concerning since my cholesterol is controlled and my diet and exercise regime are good now. Until the CAC was done, I had no idea if I had any or not. It's better to deal with cholesterol earlier than I did.
> My cardiologist did all of these except the eGFR
eGFR is typically inferred from serum creatinine (not creatine!), which is part of both a comprehensive and basic metabolic panel (CMP/BMP), which your GP usually orders, along with a CBC, and perhaps an HbA1c.
Saw your link, did your test and here's my feedback.
No "share" or "download" button in the app? Sure, "apps are cool" and all that - but what about folks who want to archive or share their health data? AFAIK literally no provision to share all those nifty biomarkers with my doctor (except many, many screenshots)?
Nowhere in the "how to get blood test" email instructions does it bother to mention a urine sample will also be needed. Kinda useful to know if you should not pee right before heading to the lab.
Unfortunately there is no approved oral medicine to lower Lp(a) that I am aware of. (I mean given a normal LDL.) Statins don't lower it afaik. An oral medicine named muvalaplin is being tested for it.
There's a clinical trial for a new drug, lepodisiran, which lowered Lp(a) by 93.9%.
Outside of that, if your Lp(a) is high, then the first strategy would be to choose a lower ApoB target than you would otherwise. (Every Lp(a) particle is also an ApoB/cholesterol particle, but 6x more atherogenic. So by lowering ApoB, you are compensating for the effect of high Lp(a))
That panel costs $190 (and includes 85 biomarkers).
FWIW, similar bundles I've seen online are priced at $400-$500.
All 85 biomarkers, if purchased separately, would cost a total of $1,490. ApoB, for example, usually costs $60 if done in isolation, Lp(a) is $45, hs-CRP is $65 at Quest, etc. The bundles end up having lower pricing due to volume discounts and being able to amortize some of the cost across biomarkers.
The first sign of trouble was chest pains while playing tennis. The pain subsided after a couple of minutes and I was fine. EKG showed no sign of heart attack or major blockage. Prior to that I had no symptoms whatsoever, exercised regularly, never smoked, 57yo male, 6 ft, 175lbs. A CAC scan revealed a calcium score of 411 and a stress test indicated a major lack blood flow to the front of the heart. A cardiac catheterization revealed 95% blockage of the Left Anterior Descending artery, the widowmaker. After placing two stents in the LAD I’m back to normal. It’s a small miracle I didn’t die that day on the tennis court. The CAC definitively diagnosed the life threatening blockage when I had absolutely no symptoms. I recommend everyone get this simple scan to find out if you have this killer inside of you.
63, no history of heart disease, all my numbers in the "normal" range, fit, don't smoke, not overweight, good diet, etc. I was building a greenhouse in the back yard and went from feeling kind of "shitty" to classic left chest and back of arm pain.
It's amazing how fast you get into the ER when you come in like that. I got an angiogram within 45 minutes and also had 2 stents in the LAD with 90-95% blockage.
Glad you’re ok. Stories like this are good to rebase myself and remember how important it is to enjoy life now while I can. No matter how healthy I try to keep myself, luck can change things in an instant.
I'm sure your doc already told you this but chest pain while playing tennis that goes away quickly sounds more like angina than a heart attack. IOW your episode was not a heart attack but rather a strong indicator that a future heart attack was likely and that further tests were warranted.
A real heart attack (MI) -- the kind that can kill you quickly -- is usually not exercise related and the pain continues for many tens of minutes without going away.
PSA: If you experience either type of symptom above, call 911. Don't wait around and don't drive yourself to the hospital. Take an aspirin if you have one handy and you're not allergic to it. Real aspirin, not ibuprofen or tylenol.
Chest pain during excretion is a symptom in my book.
>Recommend everyone to get it
A calcium scan is a ECG gated CT scan(a heart CT). It takes time from the CT machine schedule and it requires radiologists to describe it, meaning it's not infinitely accessible.
I wish cardiovascular monitoring was better. It's not uncommon for cardiologist to discharge you saying 'all fine, EKG ok' even though reality says otherwise.
EKGs should be extremely easy for AI to identify every disease with a range of probabilities and even some humans can’t identify from EKGs. Do we have the labelled dataset for this?
What I was told in the ER is that troponin basically only shows up when there's been heart muscle damage so is a pretty clear sign. It doesn't show up immediately though - typically a rise within a few hours of the heart attack.
RE: EKGs. There are clear signs in the more detailed 12 lead EKG that can show irregularities in the electrical patterns and specifically help pinpoint the location of the active problem.
A cardiologist told me (after a calcium test showed 95th percentile for calcium) that what I was looking for was a rapid drop in ability. Not over a decade, but over a couple weeks or a month. Well, I play ultimate, and one day I realized "I didn't get this winded a month ago". So I got a stress test, and it showed "abnormal motion of the heart wall under stress" (that is, not enough oxygen getting to all the heart muscles). They did a catheterization, and I wound up with two stents.
I mean, look, if you get the chest pains, don't ignore that. But it doesn't have to be that way. If you lose athletic ability, or wind, or endurance, in a short amount of time, get a stress test.
Researchers have discovered that gut bacteria produce a molecule that not only induces but also causes atherosclerosis, the accumulation of fat and cholesterol in the arteries that can lead to heart attacks and strokes.
I'm not sure quip generalizations like that are useful. If it was as simple as cheese bad, we would see the dutch and the like as outliers in statistics, but that's not the case.
”we evaluated the full spectrum of nutrient intake and identified a significant positive correlation between ImP [imidazole propionate] and saturated fat intake (driven by high cheese intake)”
Perhaps this depends on the type of cheese consumed.
Of course, it’s a correlation; ImP could be modulating eating habits and making people prefer eating cheese.
My cardiologist pointed out that hard calcified plaques are unlikely to come loose, so unless there’s significant narrowing, they’re not a big problem. However, that situation correlates with a high calcium score. So the calcium score is not always correlated to risk.
A CT angiogram distinguishes soft vs. hard plaques (and shows narrowing), so that’s the ultimate way to clarify the situation. (Bearing in mind radiation exposure risk and cost, of course.)
Yeah. Dr. Ford Brewer(https://www.youtube.com/@PrevMedHealth) talks a lot about this. I find him to be pretty current and he translates things into an easily understood format.
Basically the calcium stabilizes the plaque. Unstabilized plaque is what can rupture, squirting out from the artery wall into the blood and forming a clot. High cholesterol can cause deposits in the artery wall simply due to chemical diffusion. Inflammation, often caused by metabolic syndrome/diabetes expands the plaques. Idk, I probably got that wrong, but anyway calcium scores aren't well correlated with risk.
Calcium score is mostly for trends over a period of time, to get a sense of progression of disease. A single reading is not very useful is what I was told
One thing I’ve wondered is why getting a diagnostic test done out of pocket in the US of your own volition (without a doc prescription) isn’t possible. Why does it need to be controlled by a doc and insurance?
In India this is common. They probably use the same expensive machines for x rays and MRIs but anyone can walk in, and pay for a diagnostic test and get numbers (well, not everyone can afford it, but generally middle class folks can). I’m not saying the healthcare system in India is great, but this distinction intrigues me. Maybe the volumes are much higher in India so the diagnostic center can recoup costs? Are there laws preventing this business model in the US?
Some of these imaging that are overdone in India involve radiation: the most problematic being (not low dose) CT. So there is a rationale for controlling these modalities.
A Doctors refferal for preventative tests are easy though. I've done this in the USA fwiw due to a family member having a heart attack at a very young age. Go to a doctor and state "I have risk factors for heart disease and would like a reference to https://stanfordhealthcare.org/medical-clinics/preventive-ca... ". Other hospitals (eg. Mayo clinic) have similar programs.
Any decent doctor should agree to this. Once you have a reference you'll be put through a battery of tests. Blood tests, ECG, ultrasound, etc. A lot of it was covered by insurance anyway but it was out of network for me. That didn't matter to getting the reference though. The tests they do are all non-invasive and not risky in the first phase so definitely worth doing.
I get a 6 monthly KUB ultrasound and xray for around 1k inr which is around us$10.
If I go to a government hospital and ask the emergency doctor for a test when there is a lean time for them, they prescribe the test and its done for a hundred bucks or $1.
My impression (might be wrong) is that one can get this for some subset of blood tests but not say an MRI or x ray, let alone more complex tests. Are these just insurance company rules? If I found a way to make it profitable can I open a diagnostic lab independent of insurance companies?
I recently requested this test from my doctor. The lab technician asked if I had requested it or my doctor, and gave a very judgmental "that's what I thought" type response. Ends up I was 95%-tile and put on an aggressive statin therapy, from a risk profile that otherwise didn't determine statin use. The test was easy and (relatively speaking) inexpensive. It helped me in risk stratification in a determinative way.
I got pitched (along with a bunch of other people at an investment conference) on an insanely expensive concierge medicine service and they trotted out some super impressive doctor who was fascinating. Anyway the thing that stuck was that he said it takes 10-20 years for meaningful advances in medicine to show up in general use, which was a little depressing
>he said it takes 10-20 years for meaningful advances in medicine to show up in general use
Could it be that it takes that long to determine whether those advances are actually worthwhile? I can’t count the number of HN posts I’ve seen touting breakthroughs in medical research that ultimately didn’t pan out.
No, this is the time it takes for the proven treatment advances to reach rank-and-file doctors (and insurance policies). I've read the numbers 17 to 22 years I think. There are studies on this, but I don't have references handy.
Readit News
* ApoB - about 20% of people with normal cholesterol results will have abnormal ApoB, and be at risk of heart disease.
* Lp(a) - the strongest hereditary risk factor for heart disease.
* hs-CRP - inflammation roughly doubles your risk of heart disease
* HbA1c - insulin resistance is a risk factor for just about everything.
* eGFR - estimates the volume of liquid your kidneys can filter, and is an input to the latest heart disease risk models (PREVENT).
Easy to order online: https://www.empirical.health/product/comprehensive-health-pa...
CAC is great for detecting calcified plaque in your coronary arteries. But before you have calcified plaque, the above risk factors tell you about the buildup of soft plaque. And 4 out of 5 of them are modifiable through lifestyle, exercise, and medication.
In the UK we have the NHS and, although private healthcare is available, the NHS are gatekeepers with long waiting lists to see the doctor.
In UK culture you are just not going to 'waste NHS time' by asking for the tests that could inform you on what lifestyle choices you might need to make in order to head off chronic non-communicable diseases. You have to get a chronic disease, then the doctor will interpret the test results and not let you know what the numbers are, just what medication to take, optionally with lifestyle changes.
As a consequence, nobody in the UK knows what their cholesterol levels and whatnot are, yet, in the USA, plenty of people know these numbers.
Do healthcare providers actively upsell testing in the USA?
In my experience, normal doctors do not, but there are a lot of private businesses that make their living selling testing.
Also, consider that despite a lot of people knowing their levels in the US through testing availability, health outcomes are not better. So, we know more, but don't do anything about it. I don't know what's worse.
They're also available from most community pharmacies (again free of charge for at-risk patients, but for everyone else it should be about £10 for a simple finger-prick test or £30-50 for a full lipid profile).
Some of the tests you list (like A1C) are baseline things everyone should get checked every year. Agreed that the others could provide value for those who want to know more about their risk level; however, it’s uncommon for those tests to turn up positives without one of the baselines having already raised at least a yellow flag.
None of the tests you listed will tell you whether you have any soft plaque buildup. They just tell you more about your risk factors. However, there are ultrasound tests that can detect increased blood pressure in major arteries, which IIRC does reflect soft plaque buildup.
It's only the CAC score that provided me with peace of mind that I didn't need to reach for statins.
The way I view this is that, if you can get more information, why wouldn't you? Cost of course, and I understand why insurance might not cover the procedure, but anybody of a certain age with any risk factors who is in a position to afford it benefits from doing so.
Using CAC store to gauge risk is like waiting until you have end stage symptoms of any disease before you consider yourself at risk. The ship has already sailed and you should have instead focused on prevention for decades.
The sibling comment is a great example of the misinformation here. They have high cholesterol but a CAC score of zero gave them the peace of mind to not use statins.
The current guidelines for prescribing statins are based on your risk of a major cardiac event in the next 10 years (forecasted using a statistical model). But given that plaque builds up in your arteries over your lifetime, there's a strong argument for using a 30-year or lifelong time horizon.
The rate of serious side effects is quite low (e.g. brain fog), but the reported rate for muscle weakness is non-trivial.
eGFR is typically inferred from serum creatinine (not creatine!), which is part of both a comprehensive and basic metabolic panel (CMP/BMP), which your GP usually orders, along with a CBC, and perhaps an HbA1c.
No "share" or "download" button in the app? Sure, "apps are cool" and all that - but what about folks who want to archive or share their health data? AFAIK literally no provision to share all those nifty biomarkers with my doctor (except many, many screenshots)?
Nowhere in the "how to get blood test" email instructions does it bother to mention a urine sample will also be needed. Kinda useful to know if you should not pee right before heading to the lab.
Outside of that, if your Lp(a) is high, then the first strategy would be to choose a lower ApoB target than you would otherwise. (Every Lp(a) particle is also an ApoB/cholesterol particle, but 6x more atherogenic. So by lowering ApoB, you are compensating for the effect of high Lp(a))
Summary of the current research/evidence is here: https://www.empirical.health/blog/lipoprotein-a-blood-test/#...
https://x.com/gregmushen/status/1917780163242385586
And another guy lowering his with Amla, lysine and vitamin C
https://x.com/gregmushen/status/1924660722786828584
https://my.clevelandclinic.org/health/drugs/22550-pcsk9-inhi...
FWIW, similar bundles I've seen online are priced at $400-$500.
All 85 biomarkers, if purchased separately, would cost a total of $1,490. ApoB, for example, usually costs $60 if done in isolation, Lp(a) is $45, hs-CRP is $65 at Quest, etc. The bundles end up having lower pricing due to volume discounts and being able to amortize some of the cost across biomarkers.
It's amazing how fast you get into the ER when you come in like that. I got an angiogram within 45 minutes and also had 2 stents in the LAD with 90-95% blockage.
A real heart attack (MI) -- the kind that can kill you quickly -- is usually not exercise related and the pain continues for many tens of minutes without going away.
PSA: If you experience either type of symptom above, call 911. Don't wait around and don't drive yourself to the hospital. Take an aspirin if you have one handy and you're not allergic to it. Real aspirin, not ibuprofen or tylenol.
Chest pain during excretion is a symptom in my book.
>Recommend everyone to get it
A calcium scan is a ECG gated CT scan(a heart CT). It takes time from the CT machine schedule and it requires radiologists to describe it, meaning it's not infinitely accessible.
Heh, I think you mean exertion
Happy you got stents at the right time.
What about troponin? I was told by a Dr that it's more accurate than an EKG.
Edit: I had the word tryptophan before.
RE: EKGs. There are clear signs in the more detailed 12 lead EKG that can show irregularities in the electrical patterns and specifically help pinpoint the location of the active problem.
A cardiologist told me (after a calcium test showed 95th percentile for calcium) that what I was looking for was a rapid drop in ability. Not over a decade, but over a couple weeks or a month. Well, I play ultimate, and one day I realized "I didn't get this winded a month ago". So I got a stress test, and it showed "abnormal motion of the heart wall under stress" (that is, not enough oxygen getting to all the heart muscles). They did a catheterization, and I wound up with two stents.
I mean, look, if you get the chest pains, don't ignore that. But it doesn't have to be that way. If you lose athletic ability, or wind, or endurance, in a short amount of time, get a stress test.
https://english.elpais.com/health/2025-07-17/revolution-in-m...
Apparently eating too much cheese is a large risk factor.
”we evaluated the full spectrum of nutrient intake and identified a significant positive correlation between ImP [imidazole propionate] and saturated fat intake (driven by high cheese intake)”
Perhaps this depends on the type of cheese consumed.
Of course, it’s a correlation; ImP could be modulating eating habits and making people prefer eating cheese.
A CT angiogram distinguishes soft vs. hard plaques (and shows narrowing), so that’s the ultimate way to clarify the situation. (Bearing in mind radiation exposure risk and cost, of course.)
Basically the calcium stabilizes the plaque. Unstabilized plaque is what can rupture, squirting out from the artery wall into the blood and forming a clot. High cholesterol can cause deposits in the artery wall simply due to chemical diffusion. Inflammation, often caused by metabolic syndrome/diabetes expands the plaques. Idk, I probably got that wrong, but anyway calcium scores aren't well correlated with risk.
In India this is common. They probably use the same expensive machines for x rays and MRIs but anyone can walk in, and pay for a diagnostic test and get numbers (well, not everyone can afford it, but generally middle class folks can). I’m not saying the healthcare system in India is great, but this distinction intrigues me. Maybe the volumes are much higher in India so the diagnostic center can recoup costs? Are there laws preventing this business model in the US?
Any decent doctor should agree to this. Once you have a reference you'll be put through a battery of tests. Blood tests, ECG, ultrasound, etc. A lot of it was covered by insurance anyway but it was out of network for me. That didn't matter to getting the reference though. The tests they do are all non-invasive and not risky in the first phase so definitely worth doing.
Could it be that it takes that long to determine whether those advances are actually worthwhile? I can’t count the number of HN posts I’ve seen touting breakthroughs in medical research that ultimately didn’t pan out.
(coronary artery calcium testing)