Heart disease biomarkers your checkup probably skips

A cardiovascular surgeon spends his career fixing damaged hearts. Then, at 55 and seemingly in great shape, he had a heart attack himself. His story, shared in a recent conversation with Dr. Mark Hyman, is a warning: looking healthy tells you almost nothing about your cardiovascular risk, because the biomarkers that actually predict heart disease are rarely part of a standard checkup.

When "healthy" hides a hidden risk

The surgeon, Dr. Jeremy London, dismissed his first symptoms as reflux for an entire day, even walking through the woods with his teenage son while his chest tightened. It took a coronary stent to confirm what he had been avoiding: a blocked artery. What led there had been invisible for years. A continuous glucose monitor his son suggested revealed unacceptably high baseline glucose and a fasting insulin of 40, when it should sit under 5. His ApoB came back at 180. None of it had ever been tested, despite decades of clean diet and heavy exercise.

The biomarkers a standard panel skips

Traditional cholesterol panels check LDL, but LDL alone misses most of the picture. ApoB measures every atherogenic particle, including LDL, triglyceride-rich particles, and Lp(a), and is now considered the strongest predictor of cardiovascular risk, yet it is almost never ordered by primary care doctors. Lipoprotein(a), a genetic risk factor, is worth checking at least once in a lifetime.

Insulin resistance deserves equal attention. Elevated insulin and glucose damage the vessel wall years before cholesterol numbers shift, and a new insulin resistance score, calculated from C-peptide and insulin levels through mass spectrometry, is far more precise than the older HOMA-IR calculation. High-sensitivity CRP is useful too, not as a marker of arterial plaque itself, but as a signal of how resilient the artery wall is against damage.

Heart disease starts as inflammation, not plumbing

For decades, cardiovascular surgery treated arteries like clogged pipes: open them up, reroute the flow, move on. But a blockage starts earlier, when an ApoB-carrying particle penetrates the artery wall and triggers an inflammatory reaction that draws in immune cells and accumulates cholesterol as part of a healing response. What determines whether that process spirals into a blockage is the resilience of the artery wall itself, which insulin resistance, chronic high glucose, and belly fat all weaken over time. As Dr. London puts it, if a farmer sees all of his crops getting sick, he checks the soil first, not each individual plant.

Two numbers you can track without a lab

Blood pressure remains the most modifiable cardiovascular risk factor, yet a single reading at a doctor's visit is not enough. The recommended approach is the seven-two-two rule: measure twice a day for seven days and average the results. Waist-to-height ratio is just as simple. Measure your waist at the belly button and your height in the same units; a ratio above 0.5 signals visceral fat that behaves like an active endocrine organ, driving inflammation throughout the body.

Imaging that catches disease before symptoms

A coronary artery calcium score, a quick chest CT scan, shows how much calcified plaque has already built up and works well as a first screening step. For more detail, AI-enhanced CT angiograms can now distinguish soft plaque from calcified plaque, turning what used to be a subjective read into an objective measurement. Autopsy studies show fatty streaks in the arteries of children as young as three, which is why the guest describes atherosclerosis as something we are born with, not something we suddenly get: the goal is to extend the runway before it causes problems, not wait for a diagnosis.

The habits that move every number

No test replaces the basics, but the basics work best when guided by data instead of guesswork.

• Move daily. Cardio and strength training are each valuable alone and compound when combined. A ten-minute walk after meals is one of the most underrated tools, since contracting muscles pull glucose out of the bloodstream without needing extra insulin.
• Eat more fiber, less ultra-processed food. Fiber supports the microbiome, slows glucose spikes, and helps with satiety. Saturated fat's effect is highly individual, so it is worth tracking your own lipid panel rather than following a blanket rule.
• Protect sleep. A dark, cool bedroom, a consistent schedule, and morning sunlight were the changes that helped the guest the most, along with tracking heart rate variability as an early signal of recovery.
• Track trends, not single numbers. A biomarker checked once tells you little; checked yearly starting in your 20s or 30s, it shows the direction you are heading before symptoms appear.

The bottom line

Heart disease is largely preventable, but prevention depends on measuring what standard checkups tend to skip: ApoB, insulin resistance, blood pressure trends, waist-to-height ratio, and, starting at 45, a coronary calcium score. Waiting to feel unhealthy before checking is, as this cardiovascular surgeon learned firsthand, the most dangerous assumption of all.