Beyond Cholesterol: My Top Add-On tests for a Deeper View of Cardiometabolic Health

Cardiometabolic health is influenced by far more than total cholesterol and blood pressure alone. While standard screening tools remain important, they often miss key drivers of cardiometabolic risk—such as insulin resistance, inflammation, thrombosis, autonomic imbalance, and hormonal signaling.

To create a more complete and personalized picture of cardiometabolic health, I routinely recommend a set of targeted add-on assessments that help uncover the underlying mechanisms contributing to metabolic dysfunction and cardiovascular risk.

Below are the core tests I consider most valuable.

1. HOMA-IR: Detecting Insulin Resistance Early

The HOMA-IR (Homeostatic Model Assessment of Insulin Resistance) provides insight into how effectively the body is responding to insulin by integrating fasting glucose and fasting insulin levels.

Why it matters:

• Insulin resistance often precedes abnormal glucose or A1C by years

• It is a central driver of metabolic syndrome, type 2 diabetes, and cardiovascular disease

• Elevated insulin promotes inflammation, dyslipidemia, endothelial dysfunction, and visceral adiposity

This marker allows us to intervene earlier—before cardiometabolic disease becomes clinically apparent.

2. ApoB: A Better Measure of Atherogenic Risk

Apolipoprotein B (ApoB) reflects the number of atherogenic lipoprotein particles (including LDL, VLDL, IDL, and Lp(a)), not just the cholesterol they carry.

Why it matters:

• Cardiovascular risk correlates more strongly with particle number than LDL-C

• ApoB is especially helpful in patients with insulin resistance or “normal” LDL-C but elevated risk

• It provides clarity when traditional lipid panels appear deceptively reassuring

In many cases, ApoB is a more actionable risk marker than LDL cholesterol alone.

3. Lipoprotein(a): Genetic Cardiovascular Risk

Lipoprotein(a), or Lp(a), is a genetically determined lipoprotein associated with accelerated atherosclerosis and thrombosis.

Why it matters:

• Elevated Lp(a) significantly increases lifetime cardiovascular risk

• Levels are largely unaffected by diet or exercise

• Identifying elevated Lp(a) helps refine risk stratification and intensity of prevention strategies

Because it is rarely checked, Lp(a) often represents a hidden contributor to early or unexplained cardiovascular disease. While very few interventions have been reliably shown to influence Lipo A, measuring this can provide greater context to other risk factors and the need for more or less aggressive interventions.

4. Fibrinogen: Clotting, Inflammation, and Vascular Risk

Fibrinogen is both an acute-phase inflammatory marker and a key player in blood clot formation.

Why it matters:

• Elevated levels increase blood viscosity and thrombotic risk

• It reflects the intersection of inflammation and cardiovascular disease

• High fibrinogen is associated with stroke, coronary disease, and metabolic dysfunction

This marker adds insight into vascular risk beyond lipids and glucose alone.

5. hs-CRP: Low-Grade Inflammation and Cardiometabolic Risk

High-sensitivity C-reactive protein (hs-CRP) measures chronic, low-grade inflammation that contributes to atherosclerosis and plaque instability.

Why it matters:

• Even modest elevations are associated with increased cardiovascular events

• Inflammation is a key driver of insulin resistance and endothelial dysfunction

• hs-CRP helps guide both lifestyle and targeted therapeutic interventions

It serves as an important signal of biological stress affecting cardiometabolic health.

6. Sex Hormones: Metabolism, Vascular Function, and Risk

Sex hormones—including estrogen, progesterone, testosterone, and SHBG—play critical roles in metabolic regulation and cardiovascular health in both men and women.

Why they matter:

• Hormonal shifts influence insulin sensitivity, lipid metabolism, and body composition

• Imbalances can worsen inflammation and vascular dysfunction

• Hormone assessment is especially relevant in perimenopause, menopause, and androgen decline

Evaluating sex hormones adds context to cardiometabolic risk that is often overlooked in conventional screening.

7. Heart Rate Variability (HRV): Autonomic Balance and Resilience

Heart rate variability (HRV) reflects the balance between the sympathetic and parasympathetic nervous systems.

Why it matters:

• Low HRV is associated with higher cardiovascular risk and mortality

• It reflects chronic stress, poor sleep, overtraining, and autonomic dysregulation

• HRV connects lifestyle, stress physiology, and cardiometabolic outcomes

This assessment offers a dynamic, functional view of cardiovascular resilience rather than a static lab value.

Bringing It All Together: A Systems-Based View of Cardiometabolic Health

Each of these assessments provides a unique piece of the puzzle. When interpreted together, they help reveal:

• Insulin resistance and metabolic stress

• Lipoprotein particle burden and inherited risk

• Inflammatory and thrombotic drivers

• Hormonal influences on metabolism

• Autonomic nervous system balance and recovery capacity

The goal is not simply to identify risk—but to understand the root contributors driving cardiometabolic dysfunction so that prevention and treatment strategies can be more precise, proactive, and individualized.