How is your heart?

By Brian Vonk, M.D.


How to Determine Your Cardiovascular Health

By Brian Vonk, M.D.

You may have gotten to a point in your life where you’re asking, “Where is my health going and why am I in this handbasket?” Or you may be saying, “I feel fine and want to make sure I stay that way.”

The fact is, the majority of Americans older than 40 years already have a major health problem. Another disconcerting fact is that the majority of illnesses are sub-clinical, meaning they smolder under the surface for many years before they are recognized. Whatever your condition, sickness or apparent health, accurately assessing your current health is the proper place to start on your journey to vibrant health.

Since cardiovascular health is key to health in general — and the lack of it is so common — it is where I’d like to begin a health review. Heart disease is the #1 killer of Americans, followed, in order of prevalence, by cancer, stroke, emphysema, and accidents.

But every 34 seconds an American dies of heart disease!

Consequently, we all know someone with heart disease, or we have it ourselves. If you’re interested in avoiding or ending personal experience with this disease, I have good news for you: the majority of the causes of cardiovascular disease are in our control.

The first and foundational step in gaining or maintaining cardiovascular health is accurately measuring your current condition. Once that is clearly understood, an effective treatment or preventative plan can be made. In this article, we’ll review the most important factors indicating cardiovascular health or disease. Collect the information and grade yourself.

Blood Analysis

Most of us have had our blood drawn to determine our cholesterol level. That number alone, however, is actually quite useless.

There is a huge amount of misinformation about cholesterol, leaving most people thinking it is the grinch who steals youthful vitality. The truth is cholesterol is vital for health and we’d all be dead without it.

We get disease if cholesterol is too high or too low. But in the broad range of cholesterol levels from 180 to 240 there is no correlation with heart disease. Below 180 there is increased risk of hemorrhagic stroke, depression, and suicide. Above 240 there is increased risk of cardiovascular disease and ischemic stroke. Over age 70, elevated cholesterol and cardiovascular events no longer correlate. All told, total serum cholesterol alone is a poor indicator of cardiovascular disease. Half of all heart attack patients have normal total cholesterol levels.

So why are doctors recommending statin drugs for cholesterol levels above 200?

Ask the pharmaceutical companies who sponsor the drug studies and also help determine what normal cholesterol levels are. The upper limit of normal total cholesterol recently went down from 220 to 200, creating “disease” in additional millions of Americans. How convenient that the drug companies just so happen to have the “cure” for that disease!

I want to help you avoid that treatment trap. In fairness, compared to many drugs, most of the statin drugs are some of the safer drugs you might take and actually have the beneficial effects of being powerful antioxidant and anti-inflammatory agents. These beneficial features are likely the reason studies show decreased cardiac deaths when they are used.

Nevertheless, the statin drugs’ potential side effects are significant. In some they deplete coenzyme Q 10 within the liver enough to cause liver enzyme elevations and within the muscles to cause myopathy. Also, and this is not published to my knowledge, but in my and several of my physician colleagues’ experiences, statins cause depression or loss of motivation in the majority of patients, probably due to alteration of cholesterol metabolism in the brain. As a result, many of these patients are also on SSRI (selective serotonin reuptake inhibitor) drugs (eg Zoloft, Paxil, Prosac).

What is it worth to you to avoid depression and loss of motivation?

There are far safer ways to decrease cardiac deaths and treat abnormal cholesterol levels without risking drug side effects. Depite this, you would be astounded how many patients would rather take a pill with potential severe side effects than consider changing anything else.

As noted above, total serum cholesterol doesn’t correlate with cardiovascular disease in the range of 180 to 240 but certain fractions of that total cholesterol do correlate. These fractions are HDL and LDL cholesterol. This is why you need a Lipid Profile (also called a Lipid Panel) and not just a total cholesterol when you get your blood drawn.

I have compiled two tables below listing the components of cholesterol (ie the Lipid Profile) as well as listing several other markers for cardiovascular health and disease. The first table has the usually quoted normal levels and the second table has ideal levels. Normal levels can change depending upon the levels found in the majority of the population as well as upon what health officials decide is normal. Ideal levels are those which reflect health. We want the ideal levels for optimal wellness not just normal.

All of the markers listed in the tables are important. For example, you can have normal HDL/Chol ratio, normal homocysteine, normal fasting glucose, but have ferritin outside the ideal range and have cardiovascular disease as a result. It only takes one rascal to spill the beans.

Cardiovascular Disease Markers:

These are the declared “normal” levels that your doctor will use to tell you whether your various serum/blood levels are “normal” (NOTE: These levels do NOT necessarily mean healthy levels, rather these will include healthy and many very unhealthy patients):

“Normal” levels

Total Cholesterol (mg/dL)

Normal range = It changes with age but quite accurate:
= Upper level is 230 + age, Max 300
= Lower level is 115 + age
Recommended cholesterol level is a moving target. Recently cardiologists are recommending everyones level should be below 200 at all ages.

HDL Cholesterol (mg/dL)

Normal range = Males 30-70, Females 35-80

LDL Cholesterol (mg/dL)

Normal range = 60-150 below age 20
= 70-180 age 30-50
= 80-210 above age 50

Triglycerides (mg/dL)

Normal range = It changes with age but quite accurate: = Males upper level is 130 + age, Max 200
= Females lowerlevel is 80 + age, Max 165
= Males/Females lower level is your age

C-Reactive Protein(CRP) Normal range = Below 10 mg/L (1 mg/dL)
Homocysteine Normal range = Below 17 micromoles/L
Lipoprotein a (Lp a)

Normal range = Below 25 mg/dL


Normal range = Males 20-300, Females 15-120 ng/ml
Iron overload = Above 400 ng/ml


Normal range = Males 180-340, Females 190-420 mg/dL

Blood glucose(8hr fast) Normal = <120 mg/dL Borderline DM = 120-140 mg/dL
Diabetic = Above 140 mg/dL (W.H.O. definition)
Insulin (8 hr fasting)

Normal = Below 20 microUnits/ml
Borderline DM = 21-25 microUnits/ml
Diabetic = Above 25 microUnits/ml

Hemoglobin A1C

Normal range = Below 7.5% of total hemoglobin

The following serum levels are the most IDEAL (ie. beneficial) levels for cardiovascular (CV) health. Having any ONE of these outside the ideal range can cause or indicate CV disease! These ideal or healthy levels are much tighter than the often quoted “normal” levels referred to by your doctor. Remember “normal” does NOT necessarily mean “healthy”. We want healthy, not just normal:

“Ideal” levels

Total Cholesterol*

Ideal Range = 180 to 200 mg/dL if less than age 70
Ideal Range = Up to 300 if older than age 70

HDL Cholesterol

Ideal level = Above 50 mg/dL

LDL Cholesterol

Ideal level = Below 100 mg/dL

HDL % or Ratios

Ideal levels = See table below


Ideal level = Below 100 mg/dL

C-Reactive Protein(CRP)

Ideal level = Below 1 mg/L (0.1 mg/dL)


Ideal level = Below 8.0 micromoles/L


Ideal level = Below 10 mg/dL


Ideal range = 20-50 ng/ml (Above 80 is trouble)


Ideal range = 150-300 mg/dL

Blood glucose(8hr fast)

Ideal range = 60-85 mg/dL
Pre-diabetic = 95-110 mg/dL
Diabetic = Above 110 mg/dL
Hypoglycemic = Below 60 mg/dL
Critical levels = Below 40 or Above 450 mg/dL

Insulin (8 hr fasting)

Good level = Below 5 microUnits/ml
Best level = 2-3 microUnits/ml
High risk Diabetes= Above 10 microUnits/ml

Hemoglobin A1C***

Ideal range = Below 6% of total hemoglobin

* Cholesterol: It is not advisable to have total cholesterol below 150 at any age due to increased risk for internal hemorrhage, depression, and suicide.

Note: A mneumonic to help you remember that LDL is the “BAD” cholesterol: LDL = Low Down Loathsome cholesterol.

** Lp(a): LDL + APO(a) = Lp(a). Artery blockage (plaque) is composed of 90-100% Lp(a) NOT of ordinary cholesterol. Lp(a) is a substitute for ascorbate (Vitamin C). If you are not getting enough Vitamin C to produce collagen for tissue repair, when your arteries become injured they cannot heal properly. If there is inadequate Vitamin C, the next best way to repair your arterial injuries is make a Lp(a) plaque to cover the injury. Unfortunately the plaques tend to continue to grow. Simply removing plaque without restoring the artery to health is like tearing a scab off a wound. You do not want to remove the scab until after the tissue underneath has started healing. Your body needs sufficient Vitamin C so your arteries can heal. Elevated homocysteine can also play a role here and is detrimental because it causes the binding of Lp(a) to fibrin in very low concentrations thereby encouraging plaque formation in the vessel walls.

*** HbA1C (also called glycosylated hemoglobin) correlates well with your average blood sugar over the last 3 months. Tight blood sugar control makes a HUGE difference in complications in diabetics and prediabetics. When A1C levels are elevated above 6.5, for every 1 percent reduction in A1C levels there is a 14 percent to 40 percent decrease in diabetes-related complications! Diabetics with A1C levels of 6.5 or lower only need to have the test repeated every six months. Those with higher levels should be tested every two to three months until levels drop to 6.5 or lower, while they make corrections with improved diet and additional diabetes medication. Most diabetics have the disease for 10 years before it is diagnosed, but it has silently been doing damage for all those years.

Cholesterol Cardiac Risk Factors

Cholesterol/HDL Ratio (ie Total Cholesterol divided by HDL):

Cardiac Risk

Ratio in Males

Ratio in Females

High risk (3X):

9.7 to 23.4

7.2 to 11.0

Above average risk (2X):

5.1 to 9.6

4.5 to 7.1

Average risk:

3.5 to 5.0

3.4 to 4.4

Below average risk (1/2):

1.0 to 3.4

1.0 to 3.3

HDL Percentage: HDL/Cholesterol X 100 (ie HDL divided by Total Chol X 100):

Cardiac Risk

HDL in Males

HDL in Females

High risk (3X):

Below 10%

Below 14%

Above average risk (2X):

10 to 19%

14 to 22%

Average risk:

24% (Range 20 to 29)

26% (Range 23 to 30)

Below average risk (1/2):

Above 29%

Above 30%

LDL/HDL Risk Ratio (ie LDL divided by HDL) Male or Female:

Cardiac Risk

Ratio in Males

Ratio in Females

High risk (3X):

6.4 to 8.0

5.1 to 6.1

Above average risk (2X):

3.7 to 6.3

3.3 to 5.0

Average risk:

1.1 to 3.6

1.6 to 3.2

Below average risk (1/2):

Below 1.1

Below 1.6

Besides obtaining blood work, your doctor has other tests he can order to determine your cardiovascular state including resting EKG, treadmill stress test, CT coronary calcium scoring, echocardiogram, nuclear medicine scans, and coronary angiography. These are useful if you have known or suspected disease; however, as you advance from non-invasive to invasive studies there are increased risks for the tests themselves. There is a one in one thousand chance of dying from a coronary angiogram. This is an average. In your doctor’s hands you may have a much lower risk but it also could be much higher. These tests must be used wisely.

You obviously need to go to a doctor if you want to get the appropriate blood work and the other procedures listed above. But there are “low tech” and yet very useful evaluations you can do on your own which also help determine your cardiovascular risk.

The “low-tech” cardiovascular evaluations

Smoking: The first evaluation is a simple question. Have you smoked in the past twenty years? The more you have smoked and the more recent the habit, the more detrimental its effect. Chewing tobacco is also injurious but not nearly as much as smoking.

Systolic blood pressure: This is the top number of your blood pressure reading. Above 140 mmHg the risk of cardiovascular disease rises as the blood pressure rises.

Ankle-Arm Index: This is also called Ankle-Brachial Index (ABI) and is the ratio of the ankle systolic blood pressure* divided by the arm systolic blood pressure. A normal index is 1.0 and below 0.9 indicates cardiovascular disease. I mention this test because you may have heard of it, but be aware that it has limited value. The potential weakness of the test is that it tends to be falsely normal in people with calcifications in their arteries, people with diabetes, pre-diabetes, or those with Vitamin K deficiency. Millions of Americans are pre-diabetic or diabetic and most of them don’t even know it. Also, recent studies indicate that significant Vitamin K deficiency is becoming common.

So, if the Ankle-Arm Index is normal you must exclude these causes of arterial calcification before you can assume the test is truly normal. If the test is abnormal, you have some degree of cardiovascular disease.

* Ankle pressure is taken with the cuff just above the ankle and the stethoscope listening just below the cuff on the inner side of the ankle immediately behind the ankle bone.

Resting Heart Rate: An elevated resting heart rate is a powerful indicator of cardiovascular disease in men (however studies have not shown the correlation in women). Healthy = Below 64 beats/min, Mild risk = 64 to 69 beats/min, Moderate risk = 70 to 75 beats/min, High risk = 76 to 80 beats/min, Above 80 beats/min the risk is three times normal.

Heart Rate Recovery: This test assesses how quickly your heart rate returns to normal after exercise and is quite useful in determining cardiovascular health. This requires that you can reach 85% of your maximum predicted heart rate (your maximum predicted heart rate is calculated as 220 minus your age). If you currently aren’t accustomed to that degree of exercise, you should get an exercise program from your doctor or a fitness coach and build up to that level slowly. Once you are able to reach that heart rate, you stop the exercise and measure your heart rate 1 minute later. If the rate drops by 12 or less during that minute the test is abnormal and there is significant risk of cardiovascular disease.

Basal Body Temperature: This is a test of your core body temperature and is a very useful test to determine if your thyroid hormonal system is underactive (ie hypothyroid). What does being hypothyroid have to do with cardiovascular disease?

Hypothyroidism causes abnormal lipid metabolism which results in accelerated cardiovascular disease. Cholesterol and other lipids can become elevated due to diminished function of lipid metabolism enzymes caused by the lower body temperatures. Many body enzymes are highly temperature dependent, malfunctioning at abnormally low or high temperatures. The more abnormal the temperature, the more malfunctional the enzyme. On a molecular basis, this is why we become listless as our body temperatures go out of the normal range and we die at temperature extremes.

Although the frequency of hypothyroidism has been hotly debated for many decades, I am convinced that hypothyroidism is common and often unrecognized. The official normal range of thyroid blood tests are virtually useless except for obvious hypothyroidism and hyperthyroidism. These blood tests are useful if much tighter normal ranges are used. Additionally, accurate assessments of thyroid function can be obtained with basal body temperatures.

Ideally body temperature is taken immediately upon awakening and while still in bed, but it can be taken during the day at least 15 minutes after eating or drinking and when you haven’t been exercising. Men and post-menopausal women can take their temperatures on any day but menstruating women have some restrictions. Their temperature fluctuates with their menstrual cycle, lowest at ovulation and highest just before menstrual flow. They can most accurately measure the temperature on the second and third day of the period after the flow begins. Normal temperatures are: Armpit 98.0 +/- 0.2, Oral 98.6 +/- 0.2, and Rectal 99.0 +/- 0.2 degrees Fahrenheit.

Another useful assessment is an exceedingly low-tech question, “Do you tend to be very hot or cold when most others are not”? Characteristically, hypothyroid patients are very “cold blooded” and are cold to their core even when wearing warm clothes. As a corollary, these patients rarely can create any significant sweat. As an aside, two other conditions that can cause low body temperature are adrenal exhaustion and profound hypoglycemia but these diagnoses are usually quite obvious.

Gum health: Do your gums bleed when you brush your teeth even though you don’t have a blood coagulation disorder? If they do, you likely have either have periodontal disease or Vitamin C deficiency or both. Either condition predisposes you to cardiovascular disease.

Waist size: There are many cardiovascular risk formulas and ratios that use your waist measurement, but one of the simplest is also one of the most accurate:Your waist size in inches should not be greater than one half your height in inches. The greater your abdominal girth relative to your height, the greater your risk of cardiovascular disease.

Insurance companies are good at making money because their actuaries are very knowledgeable in determining risks. Why do you think they insist on knowing your height and waist measurements as part of your insurance physical? Increased abdominal girth is a strong indicator of hyperinsulinemia, pre-diabetes, and diabetes and consequently a useful indicator of cardiovascular disease.

Summary: We have reviewed several of the most important indicators of cardiovascular health and disease. As Goethe aptly stated, what one knows, one sees. You now have a knowledge of cardiovascular health and disease that few others have. You are equipped to see what most will overlook.

If you passed most or all of these tests in flying colors, congratulations, your risk of cardiovascular disease is very low.

If you underperformed on many of these tests, now is the time to do something about it. As long as there is life, there is hope. You will find instructions on what to do about abnormal cardiovascular tests in past and future articles here on the website, but the most basic intervention always is maximizing our daily nutrition.

JAMA. 1998 May 13;279(18):1477-82.

Association of fibrinogen, C-reactive protein, albumin, or leukocyte count with coronary heart disease: meta-analyses of prospective studies.

Danesh J, Collins R, Appleby P, Peto R.

Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Clinical Medicine, University of Oxford, England.

CONTEXT: A large number of epidemiologic studies have reported on associations between various “inflammatory” factors and coronary heart disease (CHD). OBJECTIVE: To assess the associations of blood levels of fibrinogen, C-reactive protein (CRP), and albumin and leukocyte count with the subsequent risk of CHD. DATA SOURCES: Meta-analyses of any long-term prospective studies of CHD published before 1998 on any of these 4 factors. Studies were identified by MEDLINE searches, scanning of relevant reference lists, hand searching of cardiology, epidemiology, and other relevant journals, and discussions with authors of relevant reports. STUDY SELECTION: All relevant studies identified were included. DATA EXTRACTION: The following information was abstracted from published reports (supplemented, in several cases, by the authors): size and type of cohort, mean age, mean duration of follow-up, assay methods, degree of adjustment for confounders, and relationship of CHD risk to the baseline assay results. DATA SYNTHESIS: For fibrinogen, with 4018 CHD cases in 18 studies, comparison of individuals in the top third with those in the bottom third of the baseline measurements yielded a combined risk ratio of 1.8 (95% confidence interval [CI], 1.6-2.0) associated with a difference in long-term usual mean fibrinogen levels of 2.9 pmol/L (0.1 g/dL) between the top and bottom thirds (10.3 vs 7.4 pmol/L [0.35 vs 0.25 g/dL]). For CRP, with 1053 CHD cases in 7 studies, the combined risk ratio of 1.7 (95% CI, 1.4-2.1) was associated with a difference of 1.4 mg/L (2.4 vs 1.0 mg/L). For albumin, with 3770 CHD cases in 8 studies, the combined risk ratio of 1.5 (95% CI, 1.3-1.7) was associated with a difference of 4 g/L (38 vs 42 g/L, ie, an inverse association). For leukocyte count, with 5337 CHD cases in the 7 largest studies, the combined risk ratio of 1.4 (95% CI, 1.3-1.5) was associated with a difference of 2.8 x 10(9)/L (8.4 vs 5.6 x 10(9)/L). Each of these overall results was highly significant (P<.0001). CONCLUSIONS: The published results from these prospective studies are remarkably consistent for each factor, indicating moderate but highly statistically significant associations with CHD. Hence, even though mechanisms that might account for these associations are not clear, further study of the relevance of these factors to the causation of CHD is warranted.



With so many heart attacks going unnoticed doesn’t it make sense to concentrate and focus on prevention? Of course it does. So the most important blood tests would be two HDL ratios.

First of all, please understand that a total cholesterol level is very close to meaningless unless it is above 300. I have seen a number of people over 250 who actually were at low heart disease risk due to their HDL levels. Conversely, I have seen even more who had cholesterol levels under 200 that were at a very high risk of heart disease based on the following additional tests.

HDL percentage is a very potent heart disease risk factor. Just divide your HDL level by your cholesterol. That percentage should be above 24%. You can also do the same thing with your triglycerides and HDL ratio. That percentage should be below 2.

However, while cholesterol levels are typically related to insulin resistance, there are clearly a certain segment of individuals who have a strong overriding component to their cholesterol levels that is unrelated to insulin issues.


A fasting blood sugar level test is the simplest and least expensive. One used to have a blood sugar level greater than 140 to be diagnosed with diabetes. That has now been reduced to 126. Anyone with a level between 110 and 125 is considered pre-diabetic. Earlier this year, however, the Cleveland Clinic Foundation announced they use a fasting blood sugar of 90 mg/dl or higher as a biomarker of coronary heart disease risk.

Fasting Insulin level should be below 10 for certain, but an better level is below 5 and ideal level is below 2.

Iron can have a devastating effect on your body. It is a major contributing factor for disease and can easily be screened for with a ferritin level and total iron binding capacity.

Homocysteine levels should be below 8 (Am J Clin Nutr. 2003 Jan;77(1):63-70)

Lipoprotein a [Lp (a)]: Acceptable levels per dl of blood would be <10 mg. 11-24 md/dl are borderline high; >25 are very high. If your Lp (a) levels are over 10, you need to take action at once.

Nearly five years ago I posted information from a JAMA article that is relevant today. The following are four additional blood tests that have been reported to help determine your risk for a hear attack.

1. An elevated C-reactive Protein (CRP) was a risk. CRP is elevated when there is inflammation going on somewhere in the body.

2. An increased white blood cell count (WBC) was also a risk. A WBC count greater than 8.5 was found to be the cutoff.

3. Decreased albumin levels were also a factor that could indicate a relative protein deficiency and excess of carbohydrates.

4. Elevated fibrinogen levels, which indicates an increased tendency towards clotting.


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