SO YOU FINALLY get to the doctor and it’s like being at a mechanic: You know they’re going to run some tests, and they’re going to find something wrong. But cardiologists don’t do it torture you. (At least I don’t.) Rather, we’re trying to make sure that problems like heart disease—which remains the leading killer of men—don’t catch you by surprise. Unfortunately, guys who seem to be in good health can still fall victim to sudden heart attacks. But with screening tests getting better and more widely available, it’s become less common to suddenly keel over. Here’s what you need to make sure your ticker isn’t running out of ticks.
Even if you think you’re healthy, the following tests tell you how proactive you need to be about changing your lifestyle or taking medications.
This blood test measures total cholesterol, triglycerides, LDL (“bad” cholesterol), and HDL (“good” cholesterol). Most doctors focus on LDL, which has been most closely tied to the risk of heart attack and stroke. Your specific LDL goal depends on how many risk factors you have for heart disease, but a level greater than 130 mg/dL is considered elevated. Start this check at age 20 at the latest, and get it every three years, at least.
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High pressure in your arteries wears them down and increases the buildup of heart-attack-causing plaque. Get your BP checked each year at the doctor’s office, or just grab your own cuff (ideally from the list of accurate ones at validatebp.org) and aim for less than 120/80.
Diabetes greatly increases the rate of plaque buildup in your arteries. The easiest way to screen for diabetes is the hemoglobin A1C test, which reflects your average blood sugar over several months. It can be done with a cholesterol panel. Normal is below 5.7; prediabetes is between 5.7 and 6.4. Above that indicates diabetes.
The ASCVD Risk Estimator Plus test
This one you do online. If you’re 40 or older, plug your blood pressure and cholesterol into the calculator at tools.acc.org/ASCVD-Risk-Estimator-Plus. This estimates your chances of a heart attack or stroke in the next ten years and determines how aggressive you need to be about getting your numbers down. For example, lower-risk people might try lifestyle changes, while people at higher risk may try medications. If you’re in the middle, the tests in the next section help clarify what you should do.
If Those Tests Bring Up Questions
WHEN the numbers from your initial tests don’t scream “lifestyle changes” or “medication,” these tests help determine your next steps.
Lipoprotein A, or Lp(a)
This type of cholesterol is associated with an elevated risk of heart disease but isn’t measured in the classic panel; there’s not enough data to support broad testing. And people at high risk are already getting treatment to reduce risk. But this number can be helpful in recalibrating your risk assessment if you have a strong family history of heart attacks—meaning your father, mother, or sibling had a heart attack before age 55. Lp(a) levels are stable over time, so you only ever have to get it checked once.
This number strongly predicts your future risk of a heart attack and is calculated based on a CT scan of your chest. The radiologist measures the amount of calcium, a sign of plaque, in the arteries supplying your heart with blood. So instead of just looking at risk factors for heart disease, you’re actually measuring if disease is present. (A score of 0 means no plaque/very low risk; >100 means a higher risk.) Why doesn’t everyone get it? There’s a radiation dose, so we avoid it when the chances of it changing anything are extremely low—meaning your risk is already clearly low or high. Be aware that this test is often not covered by insurance.
If You’re Already Having Heart Symptoms
Don’t blow off brief spasms of chest pain, mild shortness of breath, or occasional heart flutters. These tests, done at a doctor’s office or hospital, can reveal what’s going on and why.
The ECG’s electrodes measure the electrical signals from the heart; this test is widely done because it’s easy, harmless, and inexpensive. The image of your heart’s rate and rhythm can reveal arrhythmias (like atrial fibrillation), prior heart attacks, and more. Unfortunately, it has a high rate of false positives—abnormal findings that turn out to be nothing. As a result, an ECG is not recommended as a routine test (even though many docs still do it). Many smartwatches do ECGs as well; this function is most useful if you have palpitations. If the watch detects trouble, make an appointment with a doctor.
This just means an ultrasound of the heart, and it offers a look at your heart valves along with the size, function, and configuration of the four chambers. An echo is most helpful when you have symptoms of heart failure, like shortness of breath or swelling, and it can clearly show problems like a prior heart attack or cardiomyopathy. An echocardiogram isn’t used as a general screening test, since it’s time-consuming and rarely reveals anything useful when you feel fine and have no history of heart disease.
If you love to exercise, this is your chance to show off. You get wired up to an ECG and run on a treadmill that gets progressively faster and steeper; when you’re done, you may get an echocardiogram. As your heart pounds harder and faster, it needs more and more oxygen-rich blood. When the arteries nourishing your heart are clogged with plaque, they can’t meet that demand—resulting in chest discomfort, abnormal peaks or valleys on the ECG, and reduced muscle contraction in parts of the left ventricle, as seen on an ultrasound. Stress tests are best when you’re having symptoms of heart disease. Normal results do not prove your heart is plaque-free—only that there isn’t enough plaque to cause symptoms.
This invasive test for plaque is generally performed in the throes of a heart attack or as the follow-up to an abnormal stress test. A doctor threads a tube to the heart through an artery in your wrist or groin, then injects X-ray contrast into each of the arteries that supply the heart muscle with blood. It’s now possible to get similar info from a CT scan of the heart, though these aren’t widely available yet.
Two Tests You Probably Don’t Need
Carotid artery ultrasound
Although an ultrasound showing plaque in your carotid arteries can indicate a high risk of heart disease, it’s not as good as a calcium score. The carotid scan is more helpful if you’ve had a stroke or if your doc has some other reason to suspect plaque buildup in your carotids.
Genetic heart-risk test
Someday these may provide actionable intelligence for heart-disease prevention. But right now, the most common heart diseases come from the intersection of many different genes and lifestyle habits, not from the single-gene mutations these panels typically report.
This article originally appeared in the April 2023 issue of Men’s Health.
Christopher Rehbeck Kelly, M.D., M.S. is the chairman of cardiology at UNC Rex Hospital in Raleigh, NC. He serves on the board of the American Heart Association in North Carolina and is the founder of Exact Healthcare. He graduated from the Columbia University College of Physicians and Surgeons and served as an intern, resident, and chief resident at NewYork-Presbyterian Hospital/Columbia University Irving Medical Center. He is co-author of the book, Am I Dying?!: A Complete Guide To Your Symptoms, and What to Do Next.
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