Key Takeaways

Fitness lowers cardiovascular risk. It does not erase inherited lipoproteins, blood pressure, plaque or family history.

Elevated lipoprotein(a) can be an important inherited cardiovascular risk factor. Public information about one cardiac arrest cannot establish a single root cause or prove that a particular test panel at age 40 would have predicted or prevented the event. [1]
MASTER@HEART was a cross-sectional observational study of 558 low-risk White men, not a randomized trial. Lifelong endurance athletes had more coronary plaque than active controls, but the design cannot prove that exercise caused plaque or worsened clinical outcomes. [2]
The 2026 ACC/AHA guideline recommends measuring Lp(a) at least once in adulthood. ApoB can refine risk in selected people, especially when residual risk or discordance remains. Neither result should be turned into one universal target or treatment plan without the rest of the cardiovascular context. [1]
Fasting insulin, HOMA-IR, and hsCRP can be informative in selected contexts. There is no single HOMA-IR cutoff that diagnoses insulin resistance across assays and populations, and hsCRP below 2 mg/L is not a universal treatment target for every asymptomatic adult. [1]
The 2026 guideline supports selective coronary calcium testing in men aged 40 or older and women aged 45 or older with borderline or intermediate estimated risk. The result should be able to change a lipid-treatment decision. The guideline does not recommend a scan for every adult before or immediately after a birthday. [1]

Common questions

Can a very fit middle-aged athlete still have hidden heart disease?

Yes. Fitness cannot rule out inherited Lp(a), high blood pressure or coronary plaque. A public account of 1 athlete's cardiac arrest still cannot prove the cause or show that a test at 40 would have prevented it. [1]

Does endurance exercise eliminate cardiovascular risk?

No. MASTER@HEART examined 558 low-risk White men at 1 point in time. Lifelong endurance athletes had more coronary plaque than active controls, but the study could not show that exercise caused the plaque or worsened outcomes. [2]

Should healthy adults test ApoB and Lp(a)?

The 2026 ACC/AHA guideline recommends at least 1 adult Lp(a) measurement. ApoB can clarify risk when standard cholesterol and particle number disagree. The result matters only with the rest of the risk assessment. [1]

Are fasting insulin and hs-CRP useful screening tests for healthy executives?

They can help in selected cases. HOMA-IR has no single diagnostic cutoff across assays and populations. An hs-CRP below 2 mg/L is also not a universal treatment target for an asymptomatic adult. [1]

When should I get a coronary artery calcium scan?

A calcium scan is most useful when the result could change a treatment decision. The 2026 guideline supports selective testing from age 40 in men and 45 in women with borderline or intermediate risk. It does not call for a scan on every birthday. [1]

Cardiovascular Screening in Midlife: ApoB, Lp(a), and Coronary Calcium