25 Essential Heart Health Tests: A Complete Guide to Cardiovascular Screening

Cardiovascular disease is the highest priority for most people. This post will not have a scintillating plot line or present an interesting case study. Instead, I’m providing a practical frame of reference you can use to hopefully prevent any heart attacks, strokes or other similar issues related to the development of arterial plaque.

CardioRisk scan: This carotid ultrasound test for about $200 out of pocket gives precise measurements for the amount of plaque in the arterial wall, the level of inflammation, an estimated risk of a cardiac event and the type of plaque–soft, unstable, heterogeneous transitional plaque or hard calcified plaque. It takes about 10 minutes. No radiation. Non-invasive. The degree of arterial plaque in the carotid arteries has over 95% correlation with the amount of plaque throughout the body. The one limitation is it can misrepresent the level of risk for the atypical individual who has single-vessel coronary artery disease as opposed to more uniform global arterial disease.

CT Angiogram: This is generally regarded as the gold standard for screening, but hard to get it covered by private insurances and would be expensive out of pocket, probably around $2,000. In February, 2026 I saw a 77-year-old female with a strong family history of coronary artery disease and moderately elevated cholesterol levels. Medicare covered her CT angiogram and of the four coronary arteries that supply the heart with blood, oxygen and nutrients, three showed minimal plaque but there was a 70-90% blockage in the left anterior descending artery (LAD). The LAD has the dark nickname “widow maker” because a heart attack involving this artery can be fatal. The CardioRisk scan would have missed this single-vessel disease. CT angiogram, in my opinion, is inferior to CardioRisk because it doesn’t give as precise or detailed information especially if the goal is reversing arterial plaque.

Nuclear Stress test: This combination test includes a treadmill stress test (below) and a nuclear imaging study after a contrast agent is added intravenously to visualize blood flow in the coronary arteries. This type of a stress test is typically denied by insurance companies.

Stress echocardiogram: This combines the echocardiogram (#11 below) and a treadmill stress test (#20 below). As a recurring theme, not typically covered by insurances.

Cardiac catheterization: In the past, this was the gold standard test for investigating the degree of plaque and disease of the coronary arteries, but has been replaced most of the time by CT angiogram. This is only done by an interventional cardiologist at his/her discretion.

Coronary Calcium CT scan: I was recommended this screening test for years with an out of pocket cost about $200 under the assumption that the measurement of the degree of calcification of the coronary arteries correlates adequately with total plaque and long-term risk. This only measures calcified plaque, however, and doesn’t pick up the more important soft lipid-rich plaque. I’ve moved away from using this test in clinical practice, but it still provides useful and precise information.

Treadmill stress test: The person walks or jogs on a treadmill with increasing levels of speed and incline to put a cardiovascular work load on the heart while being monitored with a continuous EKG. Primarily, the test is checking for signs of decreased blood flow (ischemia) to the heart muscle. It also provides information on cardiovascular fitness and whether the person has an abnormal blood pressure response. Potential for false negatives limiting its value to some degree.

Apolipoprotein B: This is the most important lipid marker as it correlates with the development of arterial plaque and cardiovascular risk. It does track with LDL for most people so doesn’t always change the management of risk factors relative to managing LDL alone.

Systolic blood pressure: The single most important predictor of stroke risk and also important as a risk factor for heart attack, peripheral arterial disease, dementia and chronic kidney disease.

Fasting Triglycerides: Particularly useful as a marker of lifestyle. If one of my patients levels go down, it is almost guaranteed they are making progress on diet, exercise and weight management. The converse is true also of course. For a minority, there is a genetic and hereditary explanation for elevated triglycerides and for that person, lifestyle is still the most important management, but it’s harder to reach the goal. Basic goal is to stay under 100 and potentially optimal is under 50.

LDL: This marker of “bad cholesterol” is an independent risk factor for cardiovascular disease. The goal for the general population is a level under 130 or sometimes under 100. For those with known cardiovascular disease or with significant risk factors especially diabetes, smoking and elevated Lipo (a), the is under 70 or sometimes under 55 based on clinical studies.

Echocardiogram: This provides useful information regarding the function of the heart described as the “Ejection Fraction” which measures the percentage of blood pumped forward by the left ventricle with each beat. Normal 55-65%. This

Lipoprotein (a): Twenty percent of the population has high Lipo (a) genetically. This level fluctuates, but is non-modifiable, i.e. a person can’t impact the level with improvements in lifestyle or by taking medications like statins. EVERYONE should have this test done once to determine if they have this as an independent risk factor.

VO2 Max: Many providers consider this the gold standard for cardiovascular fitness, but it has out of pocket cost and is cumbersome to perform in a specialized lab. The goal for VO2 Max varies depending on age, gender and other variables.

Resting heart rate: This is a free way to get an estimate of cardiovascular fitness. The goal for most would be a number in the 50s. Elite athletes like Tour de France cyclists are often in the 40s. For people over 80 years old, a low heart rate can be a sign of conduction problems within the heart rather than cardiovascular fitness.

hs-CRP: This is a marker of inflammation and some research has shown this correlates with cardiovascular risk more reliably than LDL levels. The CRP level, however, has to be put in context because there are sources of acute inflammation, like a viral illness, that can lead to a false level of concern. The goal is under 1.0 and needs to be followed over time.

Hemoglobin A1c: This provides a sense of average blood sugars over the 2-3 months prior to the blood level being drawn. It doesn’t give information regarding the degree of fluctuation of blood sugars. Normal is 5.0% to 5.5%. In the functional medicine world, some tell clients the goal is under 5.0% but this is a set up for failure because even those with optimal lifestyles don’t typically achieve this goal.

Fasting insulin level: A useful test in conjunction with A1c and fasting glucose to get a more complete picture regarding the degree of insulin resistance. Under 10 is good and the lower the better. [link to other Substack]

Fasting glucose level: Simple goal is under 100 and some say under 90 is optimal, but is hard to achieve. Primarily used to diagnose diabetes or prediabetes.

Fasting homocysteine level: Interpreting and managing this result requires clinical experience and often training within functional, integrative medicine. The basic goal under 8.0 and optimal potentially under 6.0 for some. This level reflects genetic anomalies that affect MTHFR and other enzymes within the methylation cycles [link to other SS] relative to a need for more B12, methylfolate and other B-vitamins.

Heart monitor: Most often ordered these days as a Zio patch for 3-30 days and measures every heart beat looking for irregularities. Incredibly valuable for a person with the symptom of heart palpitation, but not valuable as a screening measure for underlying cardiovascular disease in the general population.

Uric acid blood level: David Perlmutter, MD, had enough free time to write a book called Drop Acid that correlates uric acid level in the blood to sugar intake. It is more often used to check for gout vulnerability. Goal at least under 8.0 and optimal under 6.0.

Arterial doppler study of the legs: Some value in determining whether a person has a decrease in arterial blood flow, aka peripheral arterial disease. I’ve seen many patients over 65 years old who had global arterial disease and normal results reflecting a lack of precision and sensitivity.

Regular carotid ultrasound: As compared to the #1 option on this list, doing a standard carotid ultrasound has very limited value and only gives us vague information regarding whether the person has a significant obstruction.

EKG: Provides some useful information regarding cardiac rhythm and underlying cardiac valve problems, but limited utility and value for general screening. Much more helpful if the person is having active symptoms like chest pressure or shortness of breath while its being done. The EKG in that context is reliable to rule in o

Physical exam of the heart, carotid arteries and extremities: In listening to the heart, we can get a sense of the rate, the rhythm, the presence of murmurs that reflect valve problems and whether the person has active congestive heart failure. We sometimes listen to the carotid artery for something called a bruit that reflects abnormal blood flow, but a person with significant arterial disease of the carotids will only have an abnormal exam about 10% of the time. Checking pulses in the legs as a marker of circulation is also of some value, but limited.

In summary, everyone needs to have Lipoprotein (a) checked once to see if they have this independent risk factor for cardiovascular disease. Everyone should have their lipids and systolic blood pressure tracked over time. Everyone over 50 should have something like a CardioRisk scan that is then followed over time for monitoring. Those with a high Lipo (a) level, i.e. over 150 and especially if over 200, should potentially have a CardioRisk scan or similar screening in their 40s. Why wait? The goal for all of us is to minimize arterial plaque formation and reverse that plaque if possible.

Stay safe and be proactive with your health.

Andrew Lenhardt, MD