Everyone knows someone whose cholesterol was always fine. Reasonable diet, reasonable labs, and then at sixty-three, a heart attack.
This is not common, and it is not a reason to distrust your standard panel — we now have additional markers that can sharpen our prevention strategies. In March 2026, national guidelines added one of these markers as a recommendation for every adult. The other is worth a conversation with your physician to see if it could personalize your prevention plan.
A Look at the Lipid Panel
The standard panel, what most people already get
| Marker | What it is | Why it matters | Who should get it |
|---|---|---|---|
| Total Cholesterol | The total amount of cholesterol in your blood, from all sources combined. | A broad snapshot. On its own it does not tell you much, because it lumps the good and bad kinds together. | Included on every standard panel. |
| HDL | The "good" cholesterol. It helps clear other cholesterol out of your bloodstream. | Higher is generally better. Low HDL is linked to higher heart risk. | Included on every standard panel. |
| LDL | The "bad" cholesterol. This is the cholesterol carried by particles that can build up in artery walls. | Higher LDL means more cholesterol available to damage your arteries over time. | Included on every standard panel. |
| Triglycerides | A type of fat in your blood, mostly from the food you eat and how your body stores energy. | High triglycerides often go along with metabolic issues like insulin resistance or diabetes. | Included on every standard panel. |
The additional markers, not on the standard panel
| Marker | What it is | Why it matters | Who should get it |
|---|---|---|---|
| ApoB | A direct count of the harmful particles floating in your blood. Every particle that can damage an artery carries exactly one ApoB molecule. | LDL tells you how much cholesterol is inside those particles. ApoB tells you how many particles there are. When the two disagree, ApoB is the better predictor. | Most useful for people with diabetes, high triglycerides, or very low LDL, where standard numbers can be misleading. |
| Lp(a) | An inherited particle set by your genes. It barely moves with diet, exercise, or standard cholesterol medications. | About one in five people have an elevated level and do not know it. High Lp(a) meaningfully raises the risk of heart attack and stroke. | As of March 2026, guidelines recommend every adult have it measured once in their lifetime. |
What does LDL measure?
Your LDL number is the amount of cholesterol carried inside LDL particles, but what damages an artery is the particle itself lodging in the wall. Some particles carry a lot of cholesterol, some carry very little, so two people with the same LDL can be carrying very different numbers of particles.
ApoB solves that. Every particle capable of causing plaque carries exactly one ApoB molecule, so ApoB counts them directly. When the two disagree, ApoB is the better predictor.
That disagreement shows up in a specific place: your LDL looks good, but your particle count does not. It happens most often in people with diabetes, with high triglycerides, or with a very low LDL, where the standard math gets unreliable. Those are the people the guideline says to test, and they are the people I test. For most people with a well-controlled panel, ApoB simply confirms what we already knew. In others, it changes the plan.
What have the guidelines changed?
Lp(a) is an inherited particle, set by your genes, and it barely changes with diet, exercise, or statins. It has never been on a standard panel, which is why so many people who carry an elevated level do not know it.
That is what changed in March 2026. For the first time, the guidelines recommend every adult have Lp(a) measured once. Not yearly. Once. It is genetic, so the answer does not change much.
There is no medication that targets it yet, though several are close. What an elevated result changes is everything around it. We lower your LDL harder. We take your blood pressure more seriously. A borderline decision stops being borderline.
It is not only about you. Lp(a) is passed down directly, which means an elevated result in you is a coin flip for each of your children and each of your siblings. One test can tell you something about your whole family.
So should you get these checked?
Most people do not need every marker on an advanced panel. If your LDL is well controlled and you have no metabolic risk, ApoB will usually confirm what we already knew.
Lp(a) is worth doing once, for everyone. If you have diabetes, high triglycerides, or a family history that has always made you wonder, the rest of it is worth a conversation, because it may meaningfully change your prevention plan.
What to Do Next
- Ask whether Lp(a) testing makes sense for you — under the current guidelines, it's worth doing once for every adult, regardless of your other numbers.
- If you have diabetes, high triglycerides, or an LDL that runs low despite your other numbers, ask about ApoB testing — it can catch what the standard panel misses.
- If you have a family history of early heart disease and a cholesterol panel that's always looked normal, bring it up. Lp(a) is inherited, so one test can tell you something about your whole family.