Lipid panels lie: 'It’s time to rethink the way we evaluate CV risk—before it’s too late'

By MDLinx staff

Published March 12, 2025

Key Takeaways

Today’s doctors are leveraging their platforms to spark conversations, battle misinformation, and drive positive change in health and wellness. Their influential posts are making waves—don’t miss them!

If you’re still relying on a standard lipid panel to assess cardiovascular risk, you might not be seeing the full picture. Sure, LDL, HDL, and total cholesterol are easy numbers to plug into risk calculators, but they don’t always tell the truth. Some “low-risk” patients are still suffering from heart attacks, while others with so-called “high” LDL are perfectly fine. What gives?

That’s exactly what pediatric cardiologist Derek Weyhrauch, MD, breaks down in a recent Instagram post, where he warns that standard cholesterol testing is leading physicians and patients astray.

LDL-C is out. LDL-P and ApoB are in

Here’s the problem: LDL cholesterol (LDL-C) is just a crude estimate of a patient’s actual atherogenic burden. It doesn’t tell you anything about LDL particle number (LDL-P) or ApoB—two markers that better predict cardiovascular risk. You could have a patient with an LDL-C of 100 mg/dL and think they’re in the clear, but if their LDL-P is sky-high, they’re still at risk for plaque formation.

“I see it all the time—patients reassured by ‘normal’ cholesterol who later end up in my office with a cardiac event,” said Dr. Weyhrauch. “LDL-C alone just doesn’t cut it.”

The patients falling through the cracks

You know the type: Middle-aged, BMI in the normal range, cholesterol looks fine, maybe a slightly elevated A1c, but nothing alarming. They exercise, eat reasonably well, and don’t smoke. Then, out of nowhere—MI at 50.

What’s happening? These are the patients with discordance between LDL-C and LDL-P. Their cholesterol concentration looks fine, but the number of atherogenic particles tells a different story. And let’s not forget Lp(a)—one of the strongest genetic risk factors for atherosclerosis that isn’t part of standard lipid testing. ^[]

“If you’re only checking a standard lipid panel, you’re missing key information,” Dr. Weyhrauch warned. “ApoB gives you a much clearer picture of actual risk.”

So, what should you do?

Stop relying on LDL-C alone. If a patient has metabolic syndrome, a family history of early heart disease, or unexplained risk, consider ordering an apoB or LDL-P test.
Watch out for discordance. If LDL-C is low but apoB or LDL-P is high, that patient is still at risk.
Advocate for better screening. Advanced lipid testing isn’t mainstream yet, but that doesn’t mean you can’t push for it in the right patients.

Bottom line? The cholesterol test your patients are getting is outdated. As Dr. Weyhrauch put it, “It’s time to rethink the way we evaluate cardiovascular risk—before it’s too late.”