VAP Test Is Back for Testing Your Cholesterol Particle Size!

By Stephen T. Sinatra, M.D., F.A.C.C., F.A.C.N., C.N.S., C.B.T.

In 2016, I learned that one of my top recommended heart tests—the VAP test for cholesterol particle size—was discontinued. The VAP was the first of a new generation of cholesterol tests that I began recommending nearly a decade ago.

I’m now happy to share that the VAP Test is back! You can learn more about it at Additionally, if you would like to find a lab that can perform the VAP test in your area, email [email protected] or call 877.901.8510.

In addition to VAP, I recommend these other cholesterol particle size tests:

Any of these tests are good options for getting a more detailed look at the various types of cholesterol particles in your blood, and a more accurate picture of your cardiovascular risk.

Why Measure Cholesterol Particle Size?

As I often note, and documented in my book The Great Cholesterol Myth, focusing on the total amount of cholesterol in your blood—particularly the amount of LDL cholesterol—has gone the way of dinosaurs. A more current and effective way to manage your heart health is to have a cholesterol fractionation test (also sometimes called a cholesterol particle size test).

Cholesterol “fractions” are the subtypes of LDL and HDL; some are benign, and some are inflammatory and can raise cardiovascular risk. For example, LDL comes in two different sized particles: large and small. The large particles are buoyant and mostly harmless. The small particles, however, are considerably more risky.

Knowing which size cholesterol particles make up the majority of your LDL can help you and your doctor better identify and manage your overall risk for cardiovascular disease. The old-school tests would have only shown how much LDL was circulating in your blood. Too much, and you probably would have been prescribed a statin drug. But with the additional information about particle size, medication can be prescribed to those who genuinely need it and avoided by those who don’t.

Triglyceride-HDL Ratio Is the New Benchmark for Assessing Health

While we’re talking cholesterol, I want to remind you that the old rules for determining cardiovascular risk by looking at ratios of LDL to HDL, or HDL to total cholesterol, are also outdated.

The new benchmark ratio is triglycerides to HDL cholesterol. A study published in the journal Circulation found that people who had the highest triglyceride-to-HDL cholesterol ratios were 16 times more likely to develop heart disease than those with the lowest ratios.

What Are Triglycerides?

The ideal triglyceride-to-HDL ratio, in my opinion, is 2:1 or less. So if your triglycerides are 100 mg/dL, for example, you want your HDL cholesterol to be at least 50 mg/dL.

The top-end limit for me is 5:1 (for example, triglycerides = 250 mg/dL, HDL = 50 mg/dL). I really don’t like to see numbers exceed this because the risk becomes too great. Fortunately, there are several effective ways to lower triglycerides and raise HDL without prescription medication.

5 More Rules for Cholesterol Management

Finally, when measuring and evaluating your blood lipid results, bear in mind these rules:

1. Total cholesterol is irrelevant unless it exceeds 400 mg/dL.

While I never recommend treating total cholesterol simply for the sake of keeping it low, I do take note of it when levels rise higher than 400. At that level, the wax-like consistency of cholesterol can begin to thicken the blood, raising the risk that a clot will form. You should certainly step up efforts to lower your cholesterol if you receive a result like this. Losing weight and adding more fiber to your diet are two good places to start. In extreme cases, pharmaceutical intervention may also be necessary.

2. Cholesterol can be too low.

You’d never know it from listening to many conventional physicians, but low cholesterol levels can be even more problematic than high ones—which is why you should be wary of doctors who constantly push their patients to reduce their LDL levels. Cholesterol plays a vital role in brain health, immune health, the production of vitamin D and various hormones, and the body’s ability to preserve and repair cellular membranes. Without enough of it, you may experience memory problems and be more likely to suffer a hemorrhagic stroke, more susceptible to gastrointestinal issues, and more prone to infectious disease.

3. Cholesterol is only dangerous when it’s oxidized.

Oxidation can occur when cholesterol molecules come into contact with free radicals, toxins, and other inflammatory particles in the blood. Once oxidized, cholesterol particles can then damage the delicate endothelial lining of arteries. This is one reason why it’s so important to consistently eat an anti-inflammatory diet, keep stress levels low, avoid known toxins, and supplement with additional antioxidant support.

Let’s Clear Up the Cholesterol Confusion

4. Small-pattern LDL particles are more inflammatory than large ones.

As I noted, cholesterol particle size is much important than how much LDL cholesterol you have. If your test results show the majority of your particles are the small undesirable kind, then healthy lifestyle choices are non-negotiable. You must do everything in your power to offset the inflammation they can cause! People who have predominantly small LDL cholesterol particles also need to be more diligent about getting regular blood tests to monitor their levels.

5. Lp(a) is the most dangerous cholesterol particle of the bunch.

A form of LDL cholesterol, Lp(a) is the most inflammatory of all cholesterol particles. If your cholesterol fractions show that your Lp(a) level is higher than normal, then your overall risk for heart disease is higher than normal, too. Unfortunately, Lp(a) levels are closely tied to heredity, and there aren’t any prescription medications that can effectively address them. The best option is to offset the inflammatory nature of Lp(a) with a healthy diet; grounding; and nutritional supplements such as niacin, omega-3 oils, and nattokinase or lumbrokinase (Bolouke).

Most of all, remember that cholesterol is not the cause of heart disease. You will always find cholesterol where arterial damage and blockages occur, because the body uses cholesterol to repair the harm. The true culprit is the inflammatory agent that caused the damage in the first place.


© 2016, 2019 HeartMD Institute. All rights reserved.

Leave a Reply


  1. Gail Boisvert Corso

    on August 25, 2016 at 1:23 pm

    What are your thoughts on the Boston Heart Lab test. I’ve had that done even though my cholesterol is fine, I have moderate blockage on one side of my carotid and my Dr. wanted to know why and where the plaque was forming. Seems my body doesn’t get rid of the normal amounts of cholesterol but rather shoots it back up to my arteries.

  2. Lolafel Ebarle

    on August 25, 2016 at 3:54 pm

    Hello, for some reason I am confused with all these tests, been with my doctor for 27 yrs with always High Cholesterol & Triglycerine all the time, however I was not inform of testing further with the 3 tests mentioned above. Been prescribed different statins but it has always no effect on me – either feeling dizzy & nauseous, headache & muscle/body aches, so I stopped taking any.
    Now my cholesterol and BP are still high, also taking last recourse for BP -, Amlopidine 10mg & Valsartan HCTZ160- 1205mg , still not working. Tried all types of pills, again no effect. Now am diagnose with mild aneurysm (40.9) with no medication, just told to watch my diet which I did and I am, hopefully the size will just stay to avoid surgery??
    Dr. Sinatra, what do you think I can do about this problems, any suggestions? Help!!!

    Thank You. Looking forward to hear from you and your advise.

  3. Dave

    on August 25, 2016 at 4:56 pm

    If you’re talking the Boston Heart Diagnostics I think that blows away any other tests, including the VAP. Atherotech went out of business back at the end of February 2016. I have a 37 page report from Boston Heart Diagnostics that is beyond great.

    Also, not sure if I read your post right but my doctor says I am an over absorber of cholesterol (Beta-Sitosterol) and I started on Vytorin recently. otherwise my cholesterol numbers are fairly good.

  4. Werner Randelzhofer

    on August 25, 2016 at 6:12 pm

    I had a heart attack 2 years ago and 2 stents put in. After taking Pravastatin my primary care doctor put me on Atorvastatin 20mg which I took for several months but stopped it completely because I got terrible leg and finger cramps. I found your articles and requested a particle test (Lipoprotein NMR with lipid panel) which showed only 3 tests over the standard range (LDL-P 1444nmol/L; LDL-C Calculated 138mg/dL and Cholesterol Total 218mg/dL) but my doctor did not comment on it. I assumed that my test was good but replaced a Wallgreen Krill Omega 3 pill with your Omega Q Plus 100 pills and are on my 2nd bottle now. I am 88 years old and have only been 2 nights in the hospital for the placements of the stents. I have no more cramps, feel fine and yesterdays blood pressure was 119/64 Puls 61 and feel fine. Am I doing right or wrong?

  5. Werner Randelzhofer

    on August 25, 2016 at 6:16 pm

    What should I cut out to moderate?

  6. Judi C.

    on November 7, 2016 at 1:20 pm

    My doctor is wanting to put me on Preluent as I do not tolerate statins, I do have stents, What is Dr. Sinatrs’s feeling on this drug? I don’t want to take it after reading all the info, plus it is very costly! Does he have any suggestions?

  7. John

    on January 5, 2017 at 12:54 pm

    So I take it that if my triglycerides are 51 and HDL is 62 then that is a good ratio .8:1, or can it be too low ? My total is 225. I will definitely speak with Dr. on my next physical regarding this new ratio.

  8. HeartMD Editor

    on January 27, 2017 at 10:09 am

    Hi Werner,

    I’m sorry but we can’t make any specific recommendations for you.

    However, you may benefit from connecting with an integrative doctor who would be able to guide you. Dr. Sinatra’s Top Docs List is a great place to start looking. Some doctors can do phone consultations if they are not close to you as well.

  9. Madar

    on March 7, 2017 at 12:51 pm

    Dr Sinatra, you mention taking magnesium …I understand it Is best to take with calcium……if you agree, what is the ratio? Also my tryglycerides are 66mg/dL
    and HDL 87mg/dL……seems way out of whack, Am trying to do everything correctly , what am I not doing?

  10. HeartMD Editor

    on April 25, 2017 at 10:51 am

    Hi Madar,

    Thank you for your question. We have posted Dr. Sinatra’s answer to it in our Vitamins & Supplements Q&A here.

  11. Jay S Anderson

    on August 24, 2017 at 8:27 am

    Do you do the tests online, with a finger jab? If not could you refer me to someone who does? I can not find any one who does, so please help me…

  12. Maya

    on October 26, 2017 at 4:12 pm

    Hi — I’m thrilled to see the VAP test return! I also just called VAP Diagnostics and the test is quite affordable. Everyone with “lipid issues” should definitely get a VAP test, in my opinion at least twice a year. I do have a question regarding the “triglyceride-to-HDL” ratio. Is it ever possible to be too low? My recent ratio was 0.68 (Triglycerides 52 mg/dL, HDL 75 mg/dL). I also notice on my reports a ratio for LDL/HDL, which shows a target (healthy) “reference range” of between 2.34 and 4.13. But mine’s consistently lower than that since I gave up sugar and started eating more saturated fats. My recent test showed an LDL/HDL ratio of 1.79, which got flagged as “out of range.” Should I be concerned about this? I so appreciate all the work you do!

  13. andrea allred

    on December 5, 2017 at 6:30 pm

    Can I pay and get this test myself? my clinic doesn’t even get what I’m talking about -much less will order. How can I do it myself??
    High runs in my family – mine is about 300, but HDL 61 and trig 109 — LDL 240.
    I am 69 female – XLNT health , no diabetes or high BP – overweight- 40lb – now on levothyroxine – could NOT lose weight.
    I bought Dr. Sinatra’s books and I get eating right and doing well.
    I am deathly afraid of the cholesterol lowering drugs – won’t do. saw too many friends get bad results with it.

    Can I pay and send in sample for it myself please??

  14. HeartMD Editor

    on December 6, 2017 at 11:01 am

    Hi Andrea,

    To my knowledge you would have to have the test ordered by a physician, however, you can contact [email protected] for more information. If your doctor is not familiar with the test, you may want to try connecting with a naturopath, doctor or osteopathy (DO) (they tend to be more holistic and integrative and may be knowledgeable about this test), or one of the doctors on Dr. Sinatra’s Top Docs List.

  15. Doris J. Dickson

    on February 28, 2018 at 9:53 am

    How’s triglycerides of 53 to HDL of 99? Age 53, T1D of >41 years – no cholesterol meds ever.

    I have had one VAP (and was light and fluffy) and I am trying to get another but man these doctors/hospitals in MA (including Brigham and Women’s) can’t seem to figure out how to do it with the EPIC software …

  16. Mary C.

    on July 11, 2018 at 10:52 pm

    My Lp(a) is 410 nmol/L. My total cholesterol is 170 mg/dL; LDL-C Direct is 90 mg/dL; HDL-C is 66 mg/dL; triglycerides are 77 mg/d;
    non HDL-C is 104mg/dL; LDL-P is 1272 nmol/L; small LDL-P is 661nmol/L. I am currently taking 40 mg per day of atorvastatin which is reflected in these lab readings. My doctor wants to reduce my Lp(a) and has prescribed Zetia 10mg/one per day to take along with same dosage of atorvastatin. I was also given the choice of taking niacin instead. After reading this research I am questioning the effectiveness of taking the Zetia. What form and dosage of niacin would be recommended? What would be the best supplement choice for my condition to reduce my Lp(a)? I am 72 y.o. female diagnosed with CAD (blockages not requiring stents-no cardiac events) and mitral valve regurgitation.

  17. Eric Zweigel

    on March 6, 2019 at 12:54 pm

    I just turned 65 and had my bloodwork done. Total cholesterol of 196 (up 8 from 20 mos ago). Triglycerides 96 (down from 108). HDl 57 (down from 62). LDL jacked up to 142 (from 108). Only diet change I made (~ 5 months ago) is no longer eating wheat/gluten. Is this the anomaly of LDL particle size shifting higher, when in reality I’m more healthy (fewer small LDL molecules)? My triglycerides/HDL ratio is less than 2. Am I really in good heart shape? If I wanted to measure LDL particle size, which of the many tests you listed, is the best one to use. Thx, Eric

  18. HMDI Editor

    on March 8, 2019 at 12:16 pm

    Hi Eric,
    Your triglyceride/HDL ratio is pretty good at 2. See Dr. Sinatra’s comments on this ratio here: With cholesterol, the important information is to know if the particles are inflammatory. The VAP test will evaluate the size and status of the cholesterol particles and should give you the information you’re looking for.

  19. Michelle

    on March 19, 2019 at 12:03 pm

    I recently received my lab results and my TGL is 8 ( yes, 8) and my HDL is 74. My total CHOL is 100. This seems way out of line with your suggested ratio levels. Can you help me understand if I should be concerned and what I should do? My doctor says this is just normal for me. Thank you

  20. mow

    on June 11, 2019 at 5:55 pm

    When I did my VAP Cholesterol test back on Nov 2014… my Lp(a) had a reading of 5 mg/l…. I was lower then the upper limit of 10 mg/l.
    I tried to repeat my VAP Cholesterol test on Nov 2016… however I could not because they discontinued it… instead they replaced it with the NMR Cholesterol Test… and this test gave me a reading Lp(a) of 62 mg/l…. higher then the upper limit of 30 mg/l.
    Consequently my cardiologist wanted to put me on statins… I refuse!
    I latter determined that the NMR Cholesterol Test included other parameters to calculate the Lp(a)… somehow the test included a fraction of my total cholesterol reading which was high between 250 mg/l to 300 mg/l.
    So now I believe that the Pharma industry had something to do with removing the VAP Cholesterol test and replace it with the NMR Cholesterol test so that doctors would prescribe more statins.
    I also became aware of a report that was issued in Nov 2016 by a European Medical Society that stated the medical profession had made a erroneous analysis about what the human liver produces… in years past the entire Pharma industry was creating statins which was supposed to suppress the liver “enzymes” that was responsible for production of cholesterol. BUT the report indicated that the liver didn’t produce the enzyme… INSTEAD the liver produces a “hormone” which is responsible for cholesterol. Futhermore, the Pharma statins is the wrong medication. Consequently 2 new self-injection drugs were design… initially at a $80,000 per year cost!!
    Now it’s around $20,000… still too expensive… but I have heard stories that it reduced LDL cholesterol from 150 mg/l to 10 mg/l within 6 months… but not without complications!

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