What is the first lab I should order if I have a family history of heart attacks?

If you have a first-degree relative (parent, sibling) who had a heart attack before age 55 (men) or 65 (women), the most clinically informative initial panel includes: (1) fasting lipid panel with ApoB; (2) Lp(a), this is the most common explanation for premature familial coronary disease with normal LDL-C; (3) hs-CRP; (4) fasting glucose with insulin; (5) blood pressure measurement; and (6) a discussion with a cardiologist about whether a coronary artery calcium (CAC) score CT is indicated (Grundy et al., JACC, 2019).

The family history of premature heart disease is one of the strongest cardiovascular risk factors available, yet it is frequently underweighted in risk calculators that do not directly account for it. A man whose father died of a heart attack at 52 and whose LDL-C is 110 mg/dL has a very different cardiovascular risk profile than a man with the same LDL-C without that history, and the difference may be captured by Lp(a), ApoB discordance, or early atherosclerosis visible on a CAC scan.

Honesty Scale: Solid (1) for this initial panel as the evidence-based starting point.

What to do: Make this appointment this month. Do not wait for your next annual physical. A family history of premature coronary disease is a medical finding that warrants a dedicated cardiovascular evaluation, the kind of evaluation that takes 45–60 minutes with a cardiologist, not a 7-minute addendum to a routine physical.

For the full picture, read The ApoB/Lp(a)/Lipids Deep Dive