Sara Szal MD
I’ve held two cholesterol panels side by side that were nearly identical. One belonged to a woman with a coronary artery calcium score of zero. The other belonged to a woman whose arteries were already calcifying, plaque that had been building for years before either of them felt a single symptom. Nothing on either page would have told you which was which.
That’s the disclosure that every cardiologist should have to say out loud before writing a prescription, but almost none of them do.
Heart disease is the leading cause of death in women, not breast cancer and not any of the diagnoses women are trained from adolescence to fear. [1] One in three of us will die from a heart attack or stroke, seven to ten times the rate of breast cancer deaths.
Women who present with a genuine cardiac event are more likely than men to have it missed on first pass, and the standard panel that clears most women at their annual physical was never built to catch the risk that is most likely to kill them. Instead, it was built around a population, a male-derived pathophysiology, and a set of numbers that were never fully hers.
The woman whose arteries were clear on the coronary artery calcium score was me. Which one are you?
I ran the calcium score on myself. You can order it yourself. I now insist that every woman in my practice run it starting at 45, or a CT angiogram. More about that in a moment. (I run a calcium score earlier than 45 if there’s risk factor burden and family history, but pre-test yield is roughly 2- to 2.5-fold lower in women).
What I was taught in my medical training: a normal lipid panel means low cardiovascular risk.
What I now understand: a normal lipid panel only tells you that one number came back fine, not that the right number was ever checked.
Atherosclerosis is the slow buildup of fatty, cholesterol-rich deposits inside artery walls, which triggers inflammation and scar-tissue growth, forms a plaque that can narrow the artery, and can rupture to trigger a clot that blocks blood flow entirely.
Think of an artery like a pipe that carries water throughout your home. Over years, mineral deposits build up along the inside wall of the pipe, not just floating in the water. The pipe doesn’t get clogged from buildup. The deposit itself gets inflamed, swells, and can suddenly crack. When it cracks, debris and scale flake off and jam downstream, sometimes stopping flow completely. That final jam is the heart attack or stroke. The narrowing is the early warning, and the crack is the emergency.
More specifically, atherosclerosis is the retention of apoB-containing lipoprotein particles in the arterial wall and the chronic inflammatory plaque that retention provokes.
The core mechanism of atherosclerosis in men and women is the same, including the initiating step and lifetime burden. However, other aspects differ. The timing (women accelerate in perimenopause and menopause), plaque details, mechanism of acute events (women have more erosion, microvascular dysfunction, and coronary reactivity abnormalities; men have more plaque rupture of lipid-rich lesions), angiographic burden (women have smaller vessels and less obstructive disease at equivalent symptoms but equal or greater ischemia and mortality, largely via non-obstructive coronary artery disease), and progression composition (women progress faster in calcified plaque; men faster in non-calcified plaque).
I believe a normal-looking lipid panel in a woman over 40 is one of the most dangerous phrases in modern medicine, precisely because it sounds like the end of the conversation instead of the beginning of a better one.
Here is the complete panel that I run now, on every woman in my medical practice, regardless of what her prior labs said. The first three are available to all. The rest, along with what I do when a number comes back wrong, is for paid subscribers, because this is the version that I wish someone had given me, and it takes more than a free post to hand it to you properly.
LDL cholesterol measures the cholesterol carried inside a set of particles. Atherosclerosis begins when apoB-containing particles cross into the artery wall and are retained there, and the retention provokes chronic inflammation. Because each particle carries exactly one apoB, apoB measures how many such particles are in circulation, and that total count predicts risk better than the cholesterol level when the two disagree. [2] Two women can have an identical LDL and carry very different particle levels, especially when triglycerides or insulin resistance are in play.
Optimal range: under 90 mg/dL at moderate-to-high risk, <80 at very high risk (established atherosclerotic cardiovascular disease, diabetes with additional risk factors), and <70 mg/dL at extreme risk. Unfortunately there are no sex-specific apoB targets at this time.
Lipoprotein(a) is more than 90 percent genetically determined and doesn’t change much over a lifetime though it can go up in perimenopause and menopause. The American Heart Association and American College of Cardiology now recommend that every adult receive at least one lipoprotein(a) test. [3]
Optimal range: under 75 to 100 nmol/L, and risk is continuous. Above 125 nmol/L identifies meaningfully elevated lifetime risk regardless of LDL and other risk factors.
The ApoE gene has three common variants: e2, e3, and e4. In large data sets, e4 carriers show a measurably weaker lipid-lowering response to statin therapy and a higher risk of cardiovascular and all-cause mortality. [4] You only need to order this once because it doesn’t change with age, hormones, or intervention, and it changes how I counsel women about the other results on this panel.
The paid section below are labs four through twelve, the ones that very few primary care providers order, and the two-part risk history most doctors need to start asking women.
I give you what’s optimal for each lab test, not just what your lab report calls normal, because for a woman over 40, those are rarely the same range. I share with you exactly what I do next, not just what it means.
This is the panel I wish someone handed my patient with the calcified plaque instead of a normal LDL and a falsely reassuring smile. It’s the one I hand every women who sits across from me in my office.
