Heart disease remains the leading cause of death for both men and women in the United States. [1] Yet many people who experience a heart attack were previously told their numbers looked “normal” during routine care.
That disconnect highlights an important limitation in traditional cardiovascular screening. Standard approaches were designed to identify obvious risks across large populations. They are useful, but they often miss the earlier, subtler physiologic changes that influence cardiovascular risk long before symptoms appear.
A standard annual physical may include blood pressure, cholesterol, blood glucose measurements, and sometimes an ECG. These tests matter, but they provide only a limited snapshot of cardiovascular health and are often interpreted within broad population-based models built largely around age and gender.
In reality, cardiovascular risk is far more individualized. Genetics, chronic inflammation, metabolic health, body composition, cardiorespiratory fitness, hormonal changes, sleep quality, and early plaque development all influence long-term heart health, often years before traditional screening detects a problem.
What does a personalized heart screening include?
A personalized heart screening looks beyond a single lab value or isolated test result. Instead, it evaluates cardiovascular risk across multiple physiologic systems to better understand how heart disease develops in a specific individual.
At Biograph, cardiovascular disease is one of the five core pillars around which the diagnostic framework is built. The goal is not simply to identify existing disease, but to detect early risk patterns while there’s still ample time to intervene. That evaluation includes the following blood biomarkers:
ApoB (Apolipoprotein B)
A more precise measure of atherogenic particle burden than LDL cholesterol alone.
Lp(a) (Lipoprotein(a))
A genetically determined cholesterol particle strongly associated with premature heart disease.
hsCRP
A marker of systemic inflammation and cardiovascular inflammation.
Fasting glucose, insulin, and HbA1c
Metabolic markers closely linked to cardiovascular risk.
Homocysteine
An amino acid associated with vascular disease when elevated.
Note: ApoB and Lp(a) testing in particular can identify hidden risk factors often missed during routine screening.
What is Lp(a) and why does it matter for heart health?
Lp(a), or Lipoprotein(a), is a genetically determined cholesterol particle associated with significantly increased cardiovascular risk. [2]
Unlike many traditional cardiovascular risk factors, Lp(a) concentration is largely inherited and remains relatively stable throughout life. Approximately 20% of people worldwide have elevated concentrations, though it’s often not included in most standard lipid panels. [3]
Someone can have normal LDL cholesterol levels, but still carry elevated cardiovascular risk due to a high Lp(a) concentration. This is one reason personalized heart screening is becoming increasingly important, especially in people with a family history of early heart disease or unexplained cardiac events.
Why isn’t a standard ECG enough to assess heart health?
An ECG measures the electrical activity of the heart. It can detect rhythm abnormalities, conduction issues, or signs of prior injury.
But a normal ECG doesn’t rule out coronary artery disease. Many people with significant plaque buildup or early atherosclerosis can still have completely normal ECGs and bloodwork results.
At Biograph, cardiovascular imaging is integrated into the broader risk assessment rather than treated as a downstream test after symptoms appear.
What is a coronary artery calcium (CAC) score?
A coronary artery calcium (CAC) scan is a specialized CT scan that measures calcified plaque within the coronary arteries.
Plaque accumulation often begins decades before symptoms develop. CAC scoring provides direct evidence of calcified atherosclerosis before a heart attack or other cardiovascular event occurs.
For many adults, particularly those with borderline or intermediate cardiovascular risk, CAC scoring can provide important additional context beyond cholesterol and blood pressure alone. [4]
However, calcium scoring also has limitations. Soft, or noncalcified plaque, does not appear on a CAC scan. This is why more advanced imaging, such as Coronary CT Angiography (CCTA) provides a more complete picture of coronary artery health.
Factors that contribute to atherosclerosis include inflammation, insulin resistance, metabolic dysfunction, hypertension, blood vessel endothelial injury and dysfunction, and elevated lipoprotein levels.
Visceral fat accumulation, insulin resistance, elevated triglycerides, poor sleep, chronic stress, and low cardiovascular fitness can all accelerate plaque development years before overt disease is diagnosed.
Chronic inflammation and heart disease are deeply interconnected. Markers like hsCRP can help identify persistent, low-grade systemic inflammation contributing to vascular injury and plaque progression. Likewise, metabolic dysfunction often develops silently long before diabetes or overt cardiovascular disease appears.
At Biograph, cardiovascular risk is evaluated alongside metabolic health, body composition, and physiologic performance because these systems rarely operate independently.
Can you have a heart attack with normal cholesterol?
Yes. Having LDL cholesterol in the normal range doesn’t eliminate cardiovascular risk, despite being strongly associated with it. Some individuals with normal cholesterol still develop significant coronary artery disease because traditional lipid panels don’t fully capture total particle burden, genetic risk, inflammation, or plaque formation.
This is why markers such as ApoB, Lp(a), hsCRP, insulin resistance, and advanced imaging can add important clinical context.
How does family history affect heart attack risk?
Family history remains one of the strongest predictors of cardiovascular disease risk, particularly when close relatives experienced heart attacks or strokes at younger ages.
But genetic risk is more nuanced than many people may realize. Some cardiovascular risk is driven by rare inherited mutations involving genes like LDLR, APOB, or PCSK9. [5] More commonly, however, risk reflects the cumulative influence of multiple smaller genetic variations interacting with lifestyle, metabolic health, inflammation, and environment over time.
While family history plays a role, some people with strong family histories stave off cardiovascular disease due to positive lifestyle factors, such as eating a balanced diet and regular exercise. Others without obvious family history may still go on to develop significant cardiovascular disease.
All of this is to say, personalized heart screening matters. Risk assessment should reflect the individual, not simply demographic averages.
Do women need different heart screenings than men?
Heart disease risk in women is often underrecognized because traditional cardiovascular screening models were historically developed using predominantly male populations.
Cardiovascular risk factors differ in women, and symptoms can present differently as well. Hormonal transitions, pregnancy complications, menopause, inflammation, metabolic changes, and autoimmune disease all influence cardiovascular risk in ways that standard screening tools do not always capture effectively.
Pregnancy-related conditions such as preeclampsia and gestational hypertension are now recognized as independent cardiovascular risk factors later in life. Similarly, insulin resistance and metabolic dysfunction can remain undetected for years in women, particularly during pregnancy, perimenopause, and menopause.
What makes Biograph’s heart health approach different?
Traditional cardiovascular screening often evaluates isolated markers, but Biograph approaches heart disease differently. Our team views cardiovascular disease as a multidimensional process developing over years across interconnected physiologic systems.
That approach combines:
The goal? To detect abnormalities early, while intervention is still highly actionable. This matters because cardiovascular disease rarely appears suddenly. It develops gradually and often silently over decades.
At Biograph, approximately two-thirds of members with otherwise optimal lipid levels still showed hidden cardiovascular findings on advanced imaging, including arterial plaque or evidence of vascular injury.
Among members over age 40 undergoing Coronary CT Angiography, approximately 41% were ultimately recommended for some form of therapy adjustment based on findings not detected through routine screening alone.
That doesn’t mean everyone requires aggressive intervention. But it reinforces an important point: A normal annual physical doesn’t provide a comprehensive understanding of cardiovascular risk. That’s why it can be beneficial to go to a clinic like Biograph that offers more advanced diagnostic testing.
The future of heart screening is personalized
Standard screening tools still play an important role in cardiovascular care. But they were never designed to provide a fully individualized understanding of long-term heart disease risk.
While it’s true that age, gender, cholesterol, and blood pressure matter, cardiovascular risk is also shaped by genetics, inflammation, metabolic health, fitness, body composition, sleep, hormones, and early plaque formation long before symptoms appear.
The future of heart screening isn’t about performing more tests indiscriminately. It’s about integrating the right data in the right context to better understand potential cardiovascular risk before disease becomes clinically obvious.
Commonly asked questions about heart screenings
What is a heart screening?
A heart screening is an evaluation designed to assess cardiovascular health and identify risk factors for heart disease before symptoms appear. Depending on the approach, it may include blood tests, blood pressure measurement, ECG testing, fitness assessment, and advanced cardiovascular imaging.
What does a personalized heart screening include?
A personalized heart screening may include advanced biomarkers, like ApoB and Lp(a), inflammation markers, metabolic testing, body composition analysis, cardiovascular fitness testing, and imaging such as coronary artery calcium scoring or Coronary CT Angiography.
Is a standard ECG enough to assess heart health?
An ECG evaluates the heart’s electrical activity, but many people with significant coronary artery disease still have normal ECG results. Structural imaging and advanced biomarkers often provide additional insight.
Can you have heart disease with normal cholesterol?
Some individuals with normal LDL cholesterol still develop cardiovascular disease because of elevated ApoB, high Lp(a), inflammation, insulin resistance, or early plaque formation.
What is a coronary artery calcium score?
A coronary artery calcium (CAC) score is a CT scan that measures calcified plaque in the coronary arteries. It helps identify early atherosclerosis before symptoms develop.
Why does inflammation matter for heart disease?
Inflammation contributes to plaque formation, vascular injury, and plaque instability. Chronic low-grade inflammation is now recognized as a major driver of cardiovascular disease progression.
Do women need different heart screenings than men?
Women may benefit from more personalized cardiovascular screening because hormonal transitions, pregnancy complications, and metabolic factors influence cardiovascular risk differently than in men.
Dr. Michael Doney is Biograph’s Executive Medical Director, with over 20 years of experience leading clinical care and advancing a more proactive, data-driven approach to medicine.
Clinical references
Centers for Disease Control and Prevention. Heart Disease Facts. CDC. Published October 24, 2024. https://www.cdc.gov/heart-disease/data-research/facts-stats/index.html
Lipoprotein (a). www.heart.org. https://www.heart.org/en/health-topics/cholesterol/genetic-conditions/lipoprotein-a
Doherty S, Hernandez S, Rishi Rikhi, et al. Lipoprotein(a) as a Causal Risk Factor for Cardiovascular Disease. Current Cardiovascular Risk Reports. 2025;19(1). doi:10.1007/s12170-025-00760-1
Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease. Circulation. 2019;140(11):e596-e646. doi:10.1161/cir.0000000000000678
Blumenthal RS, Morris PB, Gaudino M, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. Published online March 13, 2026. doi:10.1161/cir.0000000000001423
