Cardiovascular disease (CVD) remains the leading cause of death globally, and early identification of risk is essential to prevention. The Framingham Risk Score is a widely used tool that estimates an individual’s 10-year risk of developing heart disease. It includes standard measures such as HDL, total cholesterol, blood pressure, age, sex, smoking status, and diabetes status.

While valuable as a starting point, this tool has significant limitations. It does not account for many important biological, metabolic, and environmental contributors to cardiovascular disease. A more complete and individualized risk assessment is possible when including a wider range of biomarkers and diagnostic tests.

Framingham Risk Factors:

HDL (High-Density Lipoprotein): Often referred to as “good cholesterol,” HDL helps transport cholesterol away from the arteries to the liver for excretion. Higher HDL levels are protective and lower the risk of heart disease.

Total Cholesterol: Total cholesterol offers a general overview of lipid status, but it does not differentiate between harmful and beneficial lipoproteins. On its own, it does not provide accurate risk stratification.

Blood Pressure: Elevated blood pressure increases stress on artery walls, making them more vulnerable to plaque buildup and hardening. Over time, this accelerates atherosclerosis and raises cardiovascular risk.

Advanced and Complementary Cardiovascular Risk Markers:

To move beyond basic risk assessment and gain a more complete understanding of cardiovascular health, the following markers should also be considered:

-ApoB100 (Apolipoprotein B100): ApoB100 reflects the total number of atherogenic particles in the blood, including LDL, VLDL, remnant lipoproteins, and Lp(a). Research supports ApoB100 as a superior predictor of cardiovascular risk compared to LDL or total cholesterol alone.

-LDL to ApoB100 Ratio (LAR): This ratio estimates LDL particle size. A lower ratio indicates small, dense LDL particles — which are more likely to penetrate the arterial wall and initiate plaque formation.

-Lp(a) – Lipoprotein(a): Lp(a) is a genetically determined lipoprotein, found in 12-15% of the population, that significantly increases the risk for heart attack and stroke. It promotes clot formation and is highly atherogenic.

-Homocysteine: High levels of this amino acid are associated with risk for heart attack, stroke, and dementia. It accounts for about 10% of overall cardiovascular risk by promoting oxidative stress in the arteries.

-High-Sensitivity CRP (hs-CRP): This inflammatory marker provides insight into systemic inflammation. Chronic inflammation destabilizes plaque and makes arterial linings more susceptible to injury.

-Ferritin: While ferritin is often considered a marker of iron stores, elevated levels may reflect iron overload and contribute to oxidative damage, liver dysfunction, and cardiovascular risk.

-Uric Acid: High uric acid levels are linked to hypertension, kidney dysfunction, and gout. Its elevation may signal broader metabolic dysfunction and increased cardiovascular risk.

-Percent Body Fat: Excess body fat contributes to systemic inflammation, places additional strain on the cardiovascular system, and promotes insulin resistance — all of which exacerbate CVD risk.

-Visceral Fat: Fat accumulation around the internal organs is both a cause and consequence of insulin resistance. Called visceral fat, increases inflammatory signaling and drives the progression of metabolic syndrome.

-Insulin Resistance (HOMA-IR): Insulin resistance is arguably the most important modifiable risk factor for heart disease. The HOMA-IR reflects insulin sensitivity and can identify blood sugar problems long before diabetes develops.

-Triglyceride : HDL Ratio: This simple ratio offers a practical measure of insulin sensitivity. A high triglyceride-to-HDL ratio often reflects underlying insulin resistance and is a useful marker of cardiometabolic risk.

-Lead: Chronic lead exposure is associated with a 43% increased risk of heart disease and a 63% higher risk of stroke. Even low-level exposure can result in persistent hypertension and vascular dysfunction.

While the Framingham Risk Score remains a helpful tool for baseline risk estimation, it does not capture the full complexity of cardiovascular disease. By integrating advanced lipoprotein testing, inflammatory markers, metabolic indicators, toxic metal assessments, and body composition analysis, practitioners can uncover hidden risks and intervene earlier.

This more personalized and comprehensive approach empowers both patients and clinicians to take proactive steps toward preventing cardiovascular events and optimizing long-term heart health.