What labs do you order for cardiovascular screening?

Cardiovascular Screening Laboratory Tests

For general cardiovascular screening, order a lipid panel (total cholesterol, LDL-C, HDL-C, triglycerides), fasting glucose or HbA1c, and basic metabolic panel with creatinine; additional tests like BNP/NT-proBNP and high-sensitivity troponin should be reserved for specific clinical scenarios rather than routine screening. 1

Core Lipid Assessment

Standard lipid panel measurements are the foundation of cardiovascular screening:

• Total cholesterol, LDL-cholesterol, HDL-cholesterol, and triglycerides should be measured as the primary lipid assessment 1, 2
• Non-fasting lipids are acceptable for initial screening in most patients, though fasting samples may be needed if triglycerides are elevated (≥150 mg/dL) or for more accurate LDL-C calculation 2
• Calculate non-HDL cholesterol (total cholesterol minus HDL-C), which reliably guides cardiovascular disease prevention in both fasting and non-fasting states 2
• Lipoprotein(a) should be measured at least once in a lifetime as it is an independent risk factor for atherosclerotic disease 3, 4

LDL-C Calculation Considerations

• For patients with LDL-C >100 mg/dL and triglycerides ≤150 mg/dL, the Friedewald formula is reasonable 2
• For triglycerides 150-400 mg/dL, use the Martin/Hopkins method for more accurate LDL-C estimation rather than Friedewald 2
• When triglycerides ≥400 mg/dL, LDL-C estimating equations are not recommended; direct measurement or alternative methods should be considered 2

Glucose Metabolism Screening

Screening for diabetes is essential in cardiovascular risk assessment:

• Measure both HbA1c and fasting plasma glucose in all patients with suspected or known cardiovascular disease 1, 3
• If both HbA1c and fasting glucose are inconclusive, add an oral glucose tolerance test 1
• The U.S. Preventive Services Task Force recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40-70 years with overweight or obesity 1

Renal Function Assessment

Kidney function is critical for cardiovascular risk stratification:

• Measure serum creatinine and estimate glomerular filtration rate (creatinine clearance) in all patients 1
• Obtain urine albumin-to-creatinine ratio (UACR) to identify patients at risk of renal dysfunction or high cardiovascular risk 3
• UACR ≥30 mg/g indicates high cardiovascular risk; ≥300 mg/g indicates chronic kidney disease progression and very high cardiovascular and heart failure risk 3, 5

Cardiac Biomarkers: Context-Specific, Not Routine

Natriuretic peptides should NOT be ordered routinely but have specific indications:

• In patients with diabetes, measure BNP or NT-proBNP to identify those at risk for heart failure development, progression, and mortality 1
• BNP/NT-proBNP measurements should be considered in patients with suspected heart failure, not as routine screening in asymptomatic individuals 1
• Echocardiography is recommended for those with abnormal BNP levels 1
• High-sensitivity troponin should be reserved for patients with suspected acute coronary syndrome or clinical instability, not routine screening 1

Important Caveat on Troponin

Very low troponin levels can be detected in many stable patients with high-sensitivity assays, but troponin does not have sufficient independent prognostic value to recommend systematic measurement in asymptomatic outpatients 1

Additional Laboratory Tests

Complete the cardiovascular risk profile with these measurements:

• Full blood count including hemoglobin and white cell count provides prognostic information 1
• Thyroid function tests should be assessed at least once if there is clinical suspicion of thyroid disorder 1, 3
• Liver function tests are recommended in patients on or being considered for statin therapy 1
• High-sensitivity C-reactive protein (hs-CRP) can be used as an inflammatory marker associated with atherosclerosis, though not routinely required 3

Population-Specific Considerations

For Patients with Diabetes

• Annual control of lipids, glucose metabolism, and creatinine is recommended in all patients with known cardiovascular disease 1
• Screen for peripheral artery disease with ankle-brachial index in those aged ≥65 years, with microvascular disease, foot complications, or diabetes duration ≥10 years 1

For Patients with Suspected Peripheral Artery Disease

• Measure apolipoprotein B (ApoB), non-HDL-C, or LDL particle number to better assess atherosclerotic risk in select patients 3, 2
• Coagulation studies should be performed, as peripheral artery disease is associated with increased risk of venous thromboembolism 3

What NOT to Order Routinely

Avoid these common pitfalls:

• Do NOT order routine coronary artery calcium scoring or stress testing in asymptomatic patients, as screening does not improve outcomes when risk factors are treated 1, 5
• Do NOT measure HDL quotient (total cholesterol/HDL ratio) as it is an obsolete measure 2, 4
• Do NOT order advanced lipoprotein tests (LDL particle number, apoB) routinely; reserve these for select patients where standard lipid measurements are insufficient for therapeutic decisions 2

Laboratory Reporting Standards

Ensure your laboratory reports include:

• Identification of severe hypercholesterolemia (LDL-C ≥190 mg/dL at any age or ≥160 mg/dL in children) 2
• Flagging of fasting triglycerides ≥500 mg/dL as hypertriglyceridemia requiring immediate attention 2
• Desirable values clearly denoted to guide clinical decision-making 2