New Cholesterol Guidelines Recommend 3 Tests That Can Better Predict Heart Disease Risk

The American Heart Association and the American College of Cardiology have updated their cholesterol management guidelines for the first time since 2018, aiming to improve how healthcare providers assess cardiovascular disease risk.

The new guidelines recommend three additional screening tests beyond standard LDL (“bad”) and HDL (“good”) cholesterol measurements: coronary artery calcium, lipoprotein (a), and apolipoprotein B.

When Standard Cholesterol Test Falls Short

LDL and HDL are lipoproteins that carry cholesterol through the bloodstream. About one in four U.S. adults has high LDL cholesterol, which causes plaque to build up in the arteries and increases the risk of heart attack and stroke. HDL cholesterol helps remove LDL cholesterol from the body.

Cholesterol levels are typically checked during routine blood work. If LDL levels are high, a healthcare provider may recommend cholesterol-lowering medications such as statins or lifestyle changes.

However, cholesterol numbers alone don’t always capture a person’s full risk for heart disease, and some people may benefit from additional screening tests.

“Studies have shown that cardiovascular events associated with the lipoprotein dysregulation characterizing [cardiometabolic] disorders are inadequately predicted by LDL-C,” Carl E. Orringer, MD, a writing committee member of the 2026 guidelines and director of preventive cardiology at Naples Comprehensive Health Care System in Florida, told Verywell in an email.

3 Tests That Can Better Predict Heart Disease Risk

The three recommended tests, which measure apolipoprotein B, lipoprotein (a), and coronary artery calcium, can offer “independent and important information about a patient’s risk,” Orringer said. They can help clinicians provide better and more targeted treatment.

1. ApoB: It Might Be More Accurate than LDL

Apolipoprotein B (apoB) is a protein attached to LDL that can cause plaque to build up in the arteries. ApoB does not attach to HDL, and each harmful LDL cholesterol particle can only have one apoB molecule. Measuring apoB gives healthcare providers a more precise count of the number of cholesterol particles that can lead to plaque buildup.

The apoB test may offer a more accurate measure of cardiovascular risk for certain people, including those with type 2 diabetes or cardiovascular-kidney-metabolic (CKM) syndrome.

“If the clinician wants to know if the patient is being treated in the most complete manner to reduce their atherogenic particle-related risk, apoB is the best test to order,” Orringer said.

2. Lp(a): A Common Genetic Risk Factor for Heart Disease

Lipoprotein(a), or Lp(a), is a type of LDL particle that is more likely to contribute to plaque buildup in the arteries than other forms of LDL. High Lp(a) levels affect one in five people in the world and are linked to a higher risk of heart disease.

Lp(a) levels are largely determined by genetics. That means you can have high Lp(a) even if you follow a heart-healthy lifestyle.

“We now know that 20% of the population has high levels of Lp(a), placing them at increased risk for both atherosclerotic cardiovascular disease and aortic valve stenosis,” Orringer said.

The new guidelines recommend having Lp(a) tested at least once, since lifestyle changes don’t lower Lp(a) levels.

3. CAC Scan: A Test That Can Estimate Future Risk

The guidelines now recommend a coronary artery calcium (CAC) scan for certain people who have unclear heart disease. The test may be particularly helpful for men over 40 and women over 45 who have an intermediate risk of having a heart attack or stroke within the next decade.

A CAC scan uses a specialized CT scan to detect calcium deposits in the arteries that supply blood to the heart. The results can reveal early plaque buildup and help estimate a person’s risk of future heart problems.

“CAC has been shown to be highly predictive of future cardiovascular disease events, and there is increasing evidence that those with severely elevated levels have a risk as high as that of very high-risk individuals with established cardiovascular disease,” Orringer said.

Healthcare providers can use CAC scores to help determine whether a patient may benefit from starting a statin medication or taking other steps to lower their cardiovascular risk.

Are These Tests Covered by Insurance?

Your healthcare provider may recommend one of the new screening tests during your next annual physical, but you can also ask if these tests are right for you.

Insurance does not always cover these tests. While Lp(a) is sometimes covered, the apoB test is usually no more than $100, and the CAC test can cost between $50 and $250 out-of-pocket.

Depending on your family history, age, and health status, you may benefit from one or all of these tests.

“Each of the above tests contributes different and additive information regarding risk,” Orringer said.