Why Normal Cholesterol Misses the Real Killers
Heart disease kills more than the next seven causes combined, yet 50-75% of heart attack victims have normal cholesterol. Traditional tests (EKG, stress tests, heart caths) miss early plaque because they detect only 70%+ blockages. Cardiac CT with AI can now visualize soft plaque and calcified plaque at 1/10th of a period's size, enabling early detection and reversal. The cure exists—we just don't look for it early enough.
The Detection Crisis
Heart disease is the number one killer, yet we miss it
Heart disease kills more people than the next seven causes of death combined. Despite this, 50-75% of people who suffer a heart attack have cholesterol levels that are normal or guideline-acceptable by traditional standards, meaning current screening methods fail to identify the highest-risk individuals.
We treat heart disease like we treat cancer after diagnosis
Modern medicine has the tools to prevent and reverse atherosclerosis, but we wait until catastrophic events (heart attack, stroke, sudden death) occur before intervening. We don't perform early screening like we do for cancer (colonoscopy, mammogram, CT lung scans), missing decades of preventable disease progression.
Why Old Tests Fail
EKGs are for electrical problems, not plumbing
EKGs detect heart rhythm issues and electrical disorders but are poor at identifying plumbing (blood vessel) problems. They are often normal even when a person is about to have a heart attack, and many people with abnormal-looking EKGs have perfectly healthy hearts.
Stress tests only detect 70%+ blockages and have high false-negative rates
Stress tests have a threshold detection of 70% blockage, meaning vessels that are 10-69% blocked appear normal. They carry a 25-40% false-negative rate (missing severe blockages) and 25-40% false-positive rate (false alarms). People can have a normal stress test one week and suffer a fatal heart attack the next.
Heart catheterization only sees the donut hole, not the plaque in the wall
Angiography during cardiac catheterization only visualizes the interior of the vessel (the donut hole). Plaque accumulates in the vessel wall (the donut itself) for years or decades before the vessel narrows inward. By the time plaque is visible on a cath, it's often too late. The procedure costs $20,000, carries risks (stroke, heart attack, bleeding, kidney damage), and 2.5 million are performed annually in the US despite limited diagnostic value.
How Plaque Really Forms and Ruptures
Plaque starts soft and lipid-rich, then hardens over decades
Cholesterol-rich soft plaque (the dangerous lava) accumulates in vessel walls for 20-30 years with no symptoms. The vessel expands outward to accommodate it (positive remodeling). Only after the vessel has doubled in size does plaque begin growing inward, causing blockage. Hard calcified plaque is stable and no longer active, but soft plaque ruptures, breaks off, and triggers blood clots that cause heart attacks or strokes.
The dangerous plaques are the small ones, not the big blockages
Plaques that cause sudden heart attacks or strokes are often only 20-30% blockages—too small to cause symptoms or fail a stress test. These soft, lipid-rich plaques are prone to rupture. In contrast, 70-90% blockages cause chest pain and are detectable but are usually stable calcified plaque that won't rupture. This explains why people can feel fine, pass a stress test, and have a fatal event days later.
The New Standard: Cardiac CT with AI
Cardiac CT with AI can see plaque at 1/10th the size of a period
Modern cardiac CT machines take 1,600 paper-thin slices through the heart with contrast, revealing hard plaque, soft plaque, lipid-rich plaque, blockages, and narrowings. AI layered on top can detect and quantify plaque down to 1/10th of a cubic millimeter (1/10th the size of a period at the end of a sentence), seeing details invisible to the human eye by distinguishing over 2,000 shades of gray in the image data.
One 20-second scan images the entire vascular system
A single cardiac CT protocol can image the heart, move up to the neck to visualize carotid arteries, and extend down to the belly button to assess all major vessels for plaque and aneurysms—all in 20 seconds with one bolus of contrast. The scan also incidentally captures bone density, lung pathology, liver fat, and other structural findings.
Calcium score (CAC) is cheap and accessible but limited
A coronary artery calcium (CAC) score is low-radiation, no-contrast, takes minutes, and costs little. However, there is only one normal score: zero. Any non-zero score means plaque is present. A CAC score only detects calcified (hard) plaque, missing the dangerous soft lipid-rich plaque and blockages. It's a good screening tool but incomplete without full cardiac CT.
Medicare reimburses cardiac CT at $378; heart cath at $20,000
Cardiac CT costs $378 under Medicare, while cardiac catheterization costs $20,000. Stress tests range from several hundred to several thousand dollars. Despite cardiac CT's superior diagnostic value, lower cost, and less labor intensity, many cardiologists continue ordering expensive, outdated tests due to reimbursement incentives and lack of training in modern imaging.
Blood Tests: Limited Without Imaging
Over 200 biomarkers exist but blood tests alone cannot diagnose plaque
More than 200 blood biomarkers correlate with heart attack and stroke risk, including various cholesterol metrics, particle sizes, and inflammatory markers. However, blood tests only tell you if risk factors are present (reds, greens, yellows), not whether plaque actually exists. You cannot determine if someone has plaque without imaging, making blood tests useful only after imaging establishes disease status.
Lipoprotein(a) is genetic, potent, and missed by standard tests
Lipoprotein(a) (Lp(a)) is a blood test that must be ordered separately—it does not appear on standard cholesterol panels. It is 100% genetic and present in 20% of the population. Lp(a) is six times more potent than regular cholesterol at forming plaque, highly sticky, promotes clotting, and causes inflammation. The National Lipid Association recommends everyone get Lp(a) checked once in their lifetime.
ApoB is a better marker than LDL for total bad cholesterol
Apolipoprotein B (ApoB) is a blood test that measures the protein coating all bad cholesterol particles, not just LDL. It is a sharper, more comprehensive marker than LDL alone because LDL is only one type of bad cholesterol. ApoB is cheap, simple, and more actionable than particle size or particle number testing.
Particle size and particle number are not actionable without imaging
In the past, cardiologists measured cholesterol particle size, particle number, and ApoA (HDL marker) to guess whether plaque was present. With modern cardiac CT and AI, these tests are no longer necessary—imaging provides definitive diagnosis. Once plaque status is known, treatment targets are personalized based on imaging findings, not guesswork from particle metrics.
When to Screen and What to Ask For
Start screening for plaque at age 40; earlier if risk factors present
Current guidelines from the Society of Cardiac CT recommend beginning plaque screening at age 40. While few people at 40 have plaque, those who do are at risk for events at 50-60. Plaque that causes symptoms decades later is already present and silent. For people with risk factors (smoking, diabetes, family history, high cholesterol), screening should start earlier.
Avoid the cardiology rubber stamp: EKG, Holter, echo, stress test
Many cardiologists order the same battery of tests (EKG, Holter monitor, echocardiogram, stress test) for every patient regardless of symptoms or risk—a practice Dr. Osborne calls the cardiology rubber stamp. These tests are 20th-century tools that provide little value for plaque detection. If a cardiologist recommends this workup without imaging, seek a second opinion.
Ask for cardiac CT with AI; consider carotid ultrasound or CT angiography
When seeing a cardiologist, specifically request cardiac CT with AI analysis for plaque imaging. For stroke risk assessment, carotid ultrasound is non-invasive and accessible, but high-resolution CT angiography of the carotid arteries with AI (newly FDA-approved) is more precise. A comprehensive protocol can image the heart, carotid arteries, and aorta in one 20-second scan.
Out-of-pocket cardiac CT typically costs $1,000-$1,500
While Medicare reimburses cardiac CT at $378, out-of-pocket costs for patients without insurance or seeking imaging outside traditional systems typically range from $1,000 to $1,500, depending on equipment and facility. Clear Cardio and other specialized centers offer this service; check clearcardio.com for access.
Cholesterol, Inflammation, and Sticky Vessels
Blood cholesterol levels are poorly correlated with plaque formation
Cholesterol in the bloodstream is the raw material for plaque, but blood cholesterol levels (whether low, average, or high) do not reliably predict whether cholesterol is being deposited in vessel walls. Some people with high LDL have no plaque; others with perfect cholesterol levels have extensive plaque. The paradox of cholesterol is that measured levels are relatively meaningless without imaging to confirm plaque presence.
Sticky vessels (Velcro) and slippery vessels (Teflon) determine plaque deposition
Whether cholesterol deposits in vessel walls depends on vessel stickiness (inflammation and endothelial dysfunction) and cholesterol levels working together. Sticky vessels (Velcro) from tobacco, high blood pressure, diabetes, or inflammatory conditions cause cholesterol to adhere even at low levels. Slippery vessels (Teflon) allow cholesterol to bounce off even at high levels. Both factors matter; ideally, you want low cholesterol and slippery vessels.
Tobacco, hypertension, diabetes, and inflammatory diseases make vessels sticky
Nicotine (from any form of tobacco—smoking, snorting, chewing, vaping) activates nicotine receptors in the endothelium, making vessels sticky. High blood pressure and diabetes have similar effects. Inflammatory and rheumatologic conditions (psoriasis, psoriatic arthritis, lupus, rheumatoid arthritis) cause systemic inflammation that extends to vessel walls, increasing atherosclerosis risk independent of cholesterol levels.
Age is the most powerful risk factor for heart disease
Age is by far the strongest predictor of atherosclerotic disease, yet it is rarely discussed because it cannot be modified. While other risk factors (cholesterol, blood pressure, smoking) are important and actionable, age alone carries more predictive power than any other single factor.
Treatment and Reversal of Plaque
Plaque can be reversed 20-30% in 1-3 years with aggressive treatment
Once plaque is detected by cardiac CT, aggressive personalized treatment targeting lipids, inflammation, blood pressure, and lifestyle can reliably reduce soft lipid-rich plaque by 20-30% within 1-3 years. This reversal is faster than the 20-30 year accumulation period, demonstrating that atherosclerosis is not a one-way street.
Colchicine reduces cardiovascular events by 31% via anti-inflammation
Colchicine, a drug used for gout and other conditions for decades, was FDA-approved in June 2023 for cardiovascular disease prevention based on trial data showing a 31% reduction in cardiovascular events (heart attacks, strokes, stents, bypass surgery, sudden death) without affecting cholesterol, blood pressure, or diabetes. It is cheap, safe, and targets inflammation independent of lipid levels.
Statins are the most studied drugs ever; side effects are usually manageable
Statins are the most exhaustively studied drug class in human history. They are proven, cheap, and well-tolerated in most people. Side effects are usually annoying (muscle aches) rather than harmful and can be managed by dose adjustment or switching to another drug. Claims that statins are mitochondrial poisons are not supported by scientific data.
New cholesterol-lowering tools: PCSK9 inhibitors, inclisiran, bempedoic acid
Beyond statins, multiple proven cholesterol-lowering drugs exist: PCSK9 inhibitors (injectables), inclisiran (injectable, lowers LDL 55% every 6 months), bempedoic acid, and others. These offer alternatives for statin-intolerant patients or those needing additional LDL reduction. Treatment should be personalized based on imaging findings and individual physiology.
Gene silencing and CRISPR gene editing are in clinical trials
Emerging therapies include antisense oligonucleotides and siRNA (gene silencing) that lower cholesterol via injectable drugs dosed monthly to every 6 months. CRISPR gene editing is in early human trials and can lower LDL by 70% with a single shot, though safety data is still being gathered. Epigenetic tools (turning genes on/off without editing) are also in development.
Diagnosis must precede treatment; imaging first, then blood tests
The principle is no diagnosis, no treat. Blood tests should be ordered after cardiac CT establishes whether plaque is present. If no plaque exists, cholesterol drugs may not be beneficial. If plaque is present, blood tests identify treatment targets. This reverses the traditional approach of starting drugs based on risk factors alone.
Emerging and Experimental Therapies
Stem cell therapy shows promise for heart failure, not yet proven for plaque
Stem cell research has focused on cardiomyopathy (weak heart squeeze) rather than atherosclerotic plaque. After 30 years of research, no large randomized trials have proven benefit. Anecdotal cases (e.g., a Costa Rican patient with severe heart failure who improved after stem cell therapy) are intriguing but not definitive. Dr. Osborne requires large, double-blind, placebo-controlled trials before endorsing stem cells.
Cardiac CT can definitively test whether stem cells work
If stem cell therapy is proven safe, cardiac CT with AI can objectively measure whether plaque improves or worsens over time. This allows rapid, definitive testing of stem cell efficacy without waiting decades for clinical events.
The Path Forward
We have cured atherosclerosis; we just don't look for it early
The tools, knowledge, and drugs to prevent, stop, and reverse atherosclerotic plaque exist today. The problem is not lack of cure but lack of early detection. Modern medicine waits for catastrophic events (heart attack, stroke, sudden death) before intervening, whereas early imaging and prevention could eliminate most cardiovascular disease.
Only 600 of 33,000 cardiologists are preventive; fewer trained in cardiac CT
Preventive cardiology is rare. Only about 600 of 33,000 cardiologists practice prevention, and even fewer are trained in cardiac CT imaging. Only about 100 cardiologists are board-certified in both cardiology and lipidology. This shortage of specialists trained in early detection and prevention is a major barrier to eliminating heart disease.
If referred to a cardiologist recommending EKG/stress test/echo, run
If a cardiologist recommends starting with EKG, stress test, and echocardiogram without cardiac CT imaging, this is 20th-century medicine. Seek a preventive cardiologist trained in cardiac CT. While such specialists are rare, they exist and are dedicated to early detection and disease elimination.
The goal: eliminate heart disease by putting cardiologists out of business
Dr. Osborne's ultimate goal is to eliminate atherosclerotic heart disease through early detection and prevention, making preventive cardiology obsolete. This requires widespread adoption of cardiac CT screening, public education, and a shift from reactive treatment to proactive prevention.
Notable quotes
We have cured the cancer of heart disease. Here's the problem. We don't look for the cancer. — Dr. John Osborne
If you have heart disease, we got to look at the heart. If you want to know if you have colon cancer, you actually look at the colon. — Dr. John Osborne
No diagnosis, no treat. You have to go through catastrophic fatal or near fatal event till we finally say, 'Oh, you have cancer of the coronaries.' — Dr. John Osborne
Action items
- Request cardiac CT with AI analysis at your next cardiology visit instead of EKG, stress test, or echocardiogram alone.
- Get a lipoprotein(a) blood test once in your lifetime to determine genetic cardiovascular risk.
- If you have risk factors (smoking, diabetes, family history, high cholesterol), ask about plaque screening via cardiac CT starting at age 40 or earlier.
- If a cardiologist recommends only EKG, stress test, and echo without imaging, seek a second opinion from a preventive cardiologist trained in cardiac CT.
- Ask your doctor about carotid ultrasound or CT angiography to assess stroke risk from plaque in the neck arteries.
- If plaque is detected, work with your cardiologist to personalize treatment targeting lipids, inflammation, blood pressure, and lifestyle.
- Avoid tobacco in all forms (smoking, vaping, chewing, snuff) to prevent vessel stickiness and plaque formation.
- Maintain healthy blood pressure and blood sugar to reduce vessel inflammation and plaque risk.
- Visit clearcardio.com to learn more about cardiac CT with AI or find preventive cardiology services in your area.