22. Many Cancer Survivors Die of Cardiovascular Disease: What’s Your Risk?

Did you know that 10% of cancer survivors will die of cardiovascular disease (ref)? As you can see from the following figure, the greatest risk of dying from cardiovascular disease (CVD) occurs in the first year after diagnosis and >5 years after diagnosis.

Dr. Brian Lawenda reviews the main risk factors in developing cardiovascular disease, one of the most common causes of death in cancer survivors. Don’t beat your cancer only to die of heart disease.

A population-based study of cardiovascular disease mortality risk in US cancer patients
Standardized mortality ratios (SMR) for cancer sites with both ≤30% risk of death from the index-cancer and ≥20% risk of mortality from heart disease were calculated and binned by follow-up time. Cancers sites with at least 1000 person years of risk for death from heart disease between 2000 and 2015 were displayed.

The main risk factors for CVD include:

  • Lab test: Elevated Lp(a); only needs to be done one time
  • Lab test: Elevated ApoB; track over time (the best measure of atherogenic lipoproteins)
  • Lab test: Elevated total cholesterol; track over time
  • Lab test: Low HDL cholesterol; track over time
  • High blood pressure; track over time
  • Diabetes; track your insulin resistance over time (see below)
  • Cigarette smoking; quit!
  • Being overweight or obese; track over time
  • Not being physically active; focus on both muscle mass building and aerobic fitness
  • Family history of early heart disease, heart attacks or stroke

Estimating your risk of developing CVD

Use this calculator to estimate your risk. As you can see in the figure (below), you will need to know your:

  • Total cholesterol
  • HDL cholesterol
  • Systolic blood pressure
  • Coronary artery calcification score (optional)
  • Gender, age, race, history of diabetes, smoking status, family history of heart attack, lipid and blood pressure lowering medications

What is a CAC Test?

You may want to get a coronary artery calcification (CAC) test to find out your CAC score (measures the amount of calcification in your coronary arteries). CAC scoring may also be called:

  • Calcium Scan of the Heart
  • Coronary Calcium Score
  • Cardiac Scoring
  • Cardiac CT for Calcium Scoring
  • Calcium Scan Test

The test result is given as a number, called a CAC score. It can range from 0 to over 400. The more evidence of calcium and thickening that is seen in the inside lining of the arteries, the higher the score. The higher your CAC score, the more likely you are to develop heart disease or have an event such as a heart attack or stroke.

A coronary calcium scan is often done in a hospital or other medical imaging facility.

The test:

  • Is fairly quick (it takes about 10-20 minutes  to complete)
  • Uses a low dose of radiation
  • Doesn’t require contrast — a special dye that is injected in your vein that is needed for some other imaging tests
  • Often includes an electrocardiogram (ECG), too

CAC testing is not recommended if you are already known to have a high risk for CHD or have heart disease already, or if you’ve already had a heart attack, stroke, stent or bypass surgery. Learn more about this test here.

Use this simple calculator to find out how your CAC score compares with others your age.

High blood pressure increase your risk for CVD

Measuring your blood pressure has to be done correctly or it won’t be accurate. Learn more about this here.


  • Normal: <120 mm Hg (systolic) and <80 mm Hg (diastolic)
  • Elevated: 120-129 mm Hg (systolic) and < 80 mm Hg (diastolic)
    • Lifestyle changes recommended
  • Stage 1 Hypertension: 130-139 mm Hg (systolic) or 80-89 mm Hg (diastolic)
    • Lifestyle changes recommended +/- blood pressure medications
  • Stage 2 Hypertension: >/= 140 mm Hg (systolic) or >/=90 mm Hg (diastolic)
    • Lifestyle changes recommended + blood pressure medications
  • Stage 3 Hypertension: >180 mm Hg (systolic) and/or >120 mm Hg (diastolic)
    • Call your health care provider immediately. Lifestyle changes recommended + blood pressure medications

Lab tests for CVD risk factors

These are the most important CVD risk factor lab tests(*)

*Total cholesterol

  • Optimal < 200 mg/dL
  • Borderline 200-240 mg/dL
  • Increased risk >240 mg/dL

*HDL cholesterol

  • Optimal > 50 mg/dL (male), > 60 (female)
  • Borderline 40-50 mg/dL (male), 50-60 (female)
  • Increased risk <40 mg/dL (male), <50 (female)


  • Optimal < 80 mg/dL
  • Borderline 80-120 mg/dL
  • Increased risk >120 mg/dL
  • https://bostonheartdiagnostics.com/test/apolipoprotein-b-apob/
  • In a 2109 review article in JAMA Cardiology, Allan Sniderman and his colleagues make the case that apolipoprotein B (apoB) level—rather than LDL, non-HDL-cholesterol, or even LDL particle count (LDL-P)—is the best measure of potentially atherogenic lipoproteins. A greater number of apoB-containing particles leads to a greater number of these particles that enter and get trapped within the wall of the artery, leading to a greater amount of injury to the arterial wall.



  • Optimal: < 370 mg/dL
  • Borderline: 370-470 mg/dL
  • Increased risk: >470 mg/dL

High sensitivity C-reactive protein (hsCRP)

  • Optimal: < 1 mg/L
  • Borderline: 1-3 mg/L
  • Increased risk: >3 mg/L


  • Optimal: < 10 umol/L
  • Borderline: 10-14 umol/L
  • Increased risk: >14 umol/L

Oral glucose tolerance test (OGTT) with insulin

  • Fasting glucose: <90 mg/dL
  • Fasting insulin: <6 mIU/L
  • Oral glucose tolerance test (OGTT) 1-hour glucose: < 130 mg/dL
  • OGTT with insulin: 1-hour insulin: <30 mIU/L
  • OGTT 2-hour glucose: <100 mg/dL
  • OGTT with insulin: 2-hour insulin: <20 mIU/L


  • Optimal: </= 5.1%

In the video, below, Dr. Brian Lawenda explains why many patients may not know they have insulin resistance unless they get a test called “oral glucose tolerance test (OGTT) with insulin” (also called: insulin response to glucose test). This test is rarely ordered by primary care providers, who typically check for insulin resistance by getting a fasting glucose and HbA1c. These tests can identify this condition, but only at more advanced levels. The OGTT with insulin can identify even subtle cases of insulin resistance.

Being overweight increases your risk of CVD

My preferred measure of assessing body fat is the waist-to-height ratio (WHtR). There are other commonly used measures of fat mass, such as body mass index (BMI), waist circumference (WC) and waist-to-hip ratio (WHR), but recent studies have indicated that the WHtR may be the most accurate of these.

Calculate Your WHtR

  • Measure you height.Simply use the measurement of your height in either inches or centimeters.
  • Measure your waist.Use a measuring tape to get a value for your waist (either in inches or centimeters). Use the same measurement units for both waist and height.
  • Start by wrapping a tape measure around your body. Have the end (the one starting with 0) near your belly button in the front.
  • Pull the measuring tape so it’s about 1 inch above your belly button. This will accurately place the tape measure at your waist and not at hip-level.
  • Try to stand next to a mirror so you can see the tape measure around your body. Try to keep it parallel to the floor and at equal level all the way around your body.
  • Pull the tape measure so it’s snug around your waist, but not digging into your body.
  • Also, take this measurement as you breathe out, not as you’re inhaling. Your waist is naturally at its relaxed state as you exhale.
  • Use this calculator to enter both measurements to calculate your WHtR

What should you do if you have any of these risk factors?

#1) Talk with you primary care provider (PCP)

#2) Ask your PCP to refer you to see a cardiologist if your 10-year risk of CVD is >/=5% (see calculator, above)

#3) Ask your PCP to refer you to see a cardiologist if your Lp(a) or Apo(B) are in the increased risk group

#4) If you are overweight or have insulin resistance, read

#5) Focus on optimizing your overall health

  • Get better sleep
  • Reduce stress
  • Minimize toxic exposures
  • Improve your gut health
  • Use functional medicine testing to assess your underlying physiological status and make targeted changes to improve any deficiencies and abnormalities

More Information on Cholesterol and Heart Disease Risk:

Measuring cardiovascular disease risk and the importance of apoB

Deep Dive: Lp(a) — what every doctor, and the 10-20% of the population at risk, needs to know

AMA #14: What lab tests can (and cannot) inform us about our overall objective of longevity

Why Cholesterol May Not Be the Cause Of Heart Disease

What is ApoB? Your Heart and the Apolipoprotein B Test