Early Detection of Atherosclerosis: Which Tests Work | YEARS

Detecting Atherosclerosis Early: Which Tests Actually Matter

A heart attack or stroke rarely comes completely out of nowhere. It is often the result of a process that began many years earlier: atherosclerosis. The disease can progress silently for a long time before symptoms first appear.

Modern diagnostics can identify risk factors and, in some cases, existing vascular changes. This article explains which investigations can be used: from traditional risk factors and biomarkers to vascular ultrasound, functional tests and dedicated CT imaging.

What is atherosclerosis – and why does early detection matter?

Atherosclerosis is more than simple "hardening of the arteries." One central mechanism is the entry and retention of ApoB-containing lipoproteins such as LDL within the arterial wall. These particles can subsequently undergo modification and trigger inflammatory processes. Immune cells enter the vessel wall, take up lipids and contribute to the development of atherosclerotic plaques.

Over time, plaques can grow and may become calcified. If a plaque ruptures or erodes, a blood clot can form and abruptly obstruct blood flow, potentially causing a heart attack or stroke.

Cardiovascular disease remains one of the most common causes of death in Germany. The atherosclerotic process can begin decades before a clinical event occurs. Prevention therefore aims to identify and manage modifiable risk factors early.

The problem: Atherosclerosis can remain silent for years

Atherosclerotic plaques often cause no symptoms for long periods. Symptoms such as chest tightness, exertional leg pain or neurological deficits typically occur only when blood vessels are significantly affected or when an acute event develops.

For some people, a heart attack or stroke is the first clinical manifestation of previously undetected atherosclerosis.

Routine preventive care assesses important risk factors such as blood pressure, glucose metabolism and blood lipids. Direct imaging for subclinical atherosclerosis is not part of general routine screening.

Risk is increased in people with factors such as:

• Smoking
• Hypertension
• Elevated atherogenic lipoproteins
• Diabetes mellitus
• Chronic kidney disease
• Family history of premature cardiovascular disease
• Increasing age
• Certain genetic risk factors such as markedly elevated lipoprotein(a)

Risk factors provide a statistical estimate. Imaging can, in selected people, provide additional information on whether structural vascular disease is already present.

Traditional blood lipids and blood pressure: Benefits and limitations

LDL cholesterol, other lipid markers, blood pressure, smoking status and glucose metabolism form the basis of cardiovascular risk assessment.

LDL-C measures the amount of cholesterol carried within LDL particles. Apolipoprotein B (ApoB), by contrast, reflects the number of atherogenic lipoprotein particles, since each relevant atherogenic particle generally carries one ApoB molecule.

For many people, LDL-C and ApoB move in the same direction. In certain metabolic situations, however, the two can diverge. In such cases, ApoB can provide additional information about the actual number of atherogenic particles.

LDL-C nevertheless remains a central treatment target in European lipid guidelines.

Blood pressure is another major modifiable risk factor. Persistently elevated blood pressure increases vascular stress and raises the long-term risk of myocardial infarction, stroke and other cardiovascular diseases.

Risk calculators such as SCORE2 and SCORE2-OP combine several factors to estimate 10-year cardiovascular risk. They describe the statistical probability of an event; they do not directly show whether plaques are already present in a specific artery.

Carotid ultrasound: Plaques and intima-media thickness

High-resolution ultrasound can be used to examine the carotid arteries non-invasively.

Two different findings can be assessed:

1. Atherosclerotic plaques
2. Intima-media thickness (IMT) of the arterial wall

The direct assessment of carotid plaques is particularly relevant. The presence of plaque demonstrates existing structural atherosclerosis and can provide additional information for risk stratification in selected patients.

Intima-media thickness requires more careful interpretation. Increased IMT is associated with higher cardiovascular risk in epidemiological studies. However, routine systematic IMT measurement is not recommended by ESC guidelines as a general method for improving individual cardiovascular risk prediction. Reasons include methodological variation and limited additional predictive value beyond established risk factors.

Diffuse intima-media thickening is also not the same as a focal atherosclerotic plaque.

At YEARS: As part of vascular ultrasound, we assess the carotid arteries structurally and specifically look for plaques; intima-media thickness can be recorded as an additional parameter and interpreted within the wider clinical context.

Ankle-Brachial Index (ABI): A simple test for peripheral artery disease

The ankle-brachial index, or ABI, is a rapid and non-invasive test used to assess blood flow to the legs.

Method: Systolic blood pressure is measured at the arms and ankles. A ratio is then calculated from these measurements.

An ABI below 0.9 indicates peripheral artery disease and therefore a clinically relevant reduction in arterial blood flow to the legs. People with peripheral artery disease also have a substantially increased risk of other cardiovascular events.

However, ABI cannot rule out atherosclerosis that is limited to the coronary arteries. In people with diabetes or chronic kidney disease, heavily calcified and poorly compressible leg arteries can also produce unusually high or misleading ABI values.

At YEARS: ABI measurement is combined with other assessments of vascular function and structure, including arterial stiffness and carotid ultrasound.

Coronary Calcium Score: Measuring calcified coronary plaque

The coronary artery calcium score, or CAC score, is one of the best-studied imaging-based risk markers for coronary atherosclerosis.

Method: A low-dose, non-contrast CT scan detects calcium within the coronary arteries. The result is usually reported as an Agatston score.

A score of 0 means that no coronary calcium is detected. In many adult populations, this is associated with a low short- to medium-term cardiovascular risk. However, CAC 0 does not completely rule out coronary atherosclerosis.

The higher the score and the greater the calcium burden relative to age and sex, the higher cardiovascular risk tends to be.

The CAC score measures calcified coronary plaque burden. It does not measure total plaque burden or determine the degree of narrowing within the coronary arteries. Particularly in younger people, non-calcified coronary plaque can be present even when CAC is 0.

The test involves a small amount of radiation and is therefore used selectively. Current European guidelines consider CAC particularly useful as a potential risk modifier in people whose estimated risk is close to a treatment decision threshold.

At YEARS: The coronary calcium score is not part of the standard YEARS diagnostic programme. If it is considered clinically appropriate after medical assessment, the test can be performed at a specialised cardiology or radiology centre.

Whole-body MRI: Additional structural information

Whole-body MRI provides a radiation-free assessment of numerous organ systems and larger anatomical structures.

Depending on the imaging protocol, it can assess:

• The aorta and other large vessels
• Abnormalities such as aneurysms or major vascular changes
• The brain and certain vascular-associated findings
• Organs such as the liver and kidneys

For direct assessment of the coronary arteries, however, standard whole-body MRI is considerably less suitable than dedicated cardiac CT techniques. It does not provide a CAC score and does not replace CCTA where there is a specific coronary indication.

Incidental findings are another important consideration. Broad imaging frequently detects abnormalities that require medical interpretation or additional work-up and may later prove to be clinically insignificant.

At YEARS: Whole-body MRI in the YEARS Evolve® programme provides additional structural information across multiple organ systems and larger blood vessels. It is interpreted as one component of a comprehensive assessment and is not used as a standalone test for coronary atherosclerosis.

Biomarkers: What Lp(a), ApoB and hs-CRP can tell us about vascular risk

In addition to traditional lipid markers, several additional biomarkers can provide useful information.

Lipoprotein(a) – Lp(a)

Lp(a) is largely genetically determined. Elevated concentrations are causally associated with an increased risk of atherosclerotic cardiovascular disease and aortic valve stenosis.

Current ESC/EAS recommendations support measuring Lp(a) at least once during adulthood. Values above approximately 50 mg/dL or 105 nmol/L are increasingly regarded as a clinically relevant risk modifier.

Because Lp(a) is predominantly genetically determined and usually remains relatively stable during adulthood, repeated measurement at every check-up is generally unnecessary.

Apolipoprotein B – ApoB

ApoB reflects the number of atherogenic lipoprotein particles. It can be particularly useful when LDL-C and particle number are discordant, for example in people with elevated triglycerides, diabetes or other metabolic conditions.

Large epidemiological studies such as INTERHEART have demonstrated a strong relationship between ApoB-containing lipoproteins and myocardial infarction risk.

High-sensitivity C-reactive protein – hs-CRP

hs-CRP is a marker of systemic inflammatory activity. Higher values are epidemiologically associated with increased cardiovascular risk.

The JUPITER trial showed that selected people with elevated hs-CRP and relatively low LDL-C benefited from statin therapy. This does not mean that hs-CRP alone can diagnose atherosclerosis or that lowering CRP in isolation automatically reduces risk.

The marker is also non-specific and can be influenced by infections and other inflammatory conditions.

Omega-3 Index

The omega-3 index measures the proportion of EPA and DHA in red blood cell membranes.

Observational studies have identified associations between omega-3 index values and cardiovascular outcomes. However, the marker is not an established component of ESC cardiovascular risk stratification, and a specific omega-3 index target is currently not an official European treatment goal for cardiovascular prevention.

At YEARS, we therefore use the omega-3 index as an additional nutritional and metabolic marker rather than as a standalone marker of atherosclerosis.

At YEARS: Lp(a), ApoB, hs-CRP and the omega-3 index are included in our laboratory panel and are interpreted together with traditional lipid markers and other findings.

Which test is right for whom?

No single test captures total cardiovascular risk.

A robust cardiovascular risk assessment starts with:

• Medical history and family history
• Blood pressure
• Smoking status
• Glucose metabolism
• Standard lipid profile
• Individual risk calculation

Markers such as Lp(a) and ApoB can meaningfully add to this profile.

Imaging and functional tests answer different questions:

• Carotid ultrasound: Can detect existing plaques in the carotid arteries.
• ABI: Primarily used to detect peripheral artery disease.
• CAC score: Quantifies calcified coronary plaques and can alter risk classification in selected people.
• Whole-body MRI: Provides additional structural information but does not replace dedicated tests for coronary artery disease.

The most appropriate investigation therefore depends on age, baseline risk, medical history and the specific clinical question.

Detecting atherosclerosis early at YEARS in Berlin

Atherosclerosis usually develops over many years. This is exactly why it makes sense to identify modifiable risk factors early.

A practical starting point is to:

• Monitor blood pressure
• Know your LDL-C and complete lipid profile
• Measure Lp(a) at least once
• Add ApoB when a more detailed lipid assessment is useful
• Consider family history

At YEARS, we combine these risk factors with additional non-invasive investigations such as carotid ultrasound, ABI and measurements of arterial function.

These tests provide different kinds of information: laboratory markers describe risk factors, vascular ultrasound can reveal existing plaques, and functional measurements provide additional information about the vascular system.

If these findings raise a specific cardiological question, targeted investigations such as a CAC score or CCTA may subsequently be appropriate.

At YEARS in Berlin, these diagnostic assessments are carried out within one day and then reviewed together by a physician. The aim is not to perform as many individual tests as possible, but to interpret the findings in a medically meaningful way.

→ Book a consultation at YEARS.

Frequently Asked Questions

Can atherosclerosis be detected before symptoms occur?

To some extent, yes. Risk factors such as LDL-C, ApoB, Lp(a), blood pressure and diabetes can be identified early. Carotid ultrasound can detect existing plaques, and a CAC score can identify calcified coronary plaque. The most appropriate method depends on individual risk and the specific clinical question.

Which blood markers are particularly relevant for vascular health?

Central parameters include LDL-C and other standard lipid values. Lp(a) provides important genetic risk information, while ApoB reflects the number of atherogenic lipoprotein particles. hs-CRP can provide additional information about systemic inflammatory activity but is non-specific.

Is whole-body MRI useful for the early detection of atherosclerosis?

Whole-body MRI can provide additional information about large blood vessels, the brain and other organ systems. However, it is not an established standalone screening test for coronary atherosclerosis and does not replace dedicated procedures such as CAC scoring or CCTA.

Does private health insurance cover extended vascular diagnostics?

YEARS bills medical services according to the German physician fee schedule, GOÄ. Whether and to what extent a private health insurance policy reimburses individual services depends on the specific tariff, medical indication and contractual conditions. We recommend clarifying reimbursement with the insurer in advance.

This article is intended for general information only and does not replace individual medical advice. Diagnostics at YEARS are a preventive service and do not constitute clinical treatment.

Sources

• Aboyans, V., et al. (2012). Measurement and Interpretation of the Ankle-Brachial Index: A Scientific Statement From the American Heart Association. Journal of the American College of Cardiology, 60(20), 2092–2105.
• ESC. (2021). ESC Guidelines on cardiovascular disease prevention in clinical practice. European Heart Journal, 42(34), 3227–3337.
• Mach, F., Koskinas, K. C., Roeters van Lennep, J. E., et al. (2025). Focused Update of the 2019 ESC/EAS Guidelines for the management of dyslipidaemias. European Heart Journal.
• McQueen, M. J., et al. (2008). Lipids, lipoproteins, and apolipoproteins as risk markers of myocardial infarction in 52 countries: the INTERHEART study. The Lancet, 372(9634), 224–233.
• Ridker, P. M., et al. (2008). Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein. New England Journal of Medicine, 359(21), 2195–2207.
• Harris, W. S., et al. (2017). The Omega-3 Index and relative risk for coronary heart disease and all-cause mortality: a meta-analysis of prospective cohort studies. Atherosclerosis, 262, 51–54.