The 42-year-old man was older than his father and brother were when they died of heart disease. But he wasn't worried. He'd had his cholesterol tested at a health fair, and it was 180, well within acceptable limits.

 `His wife sent him in anyway,' said Dr. Rick Gebhart. The family-practice physician in Vandalia is one of a few local doctors who orders complete lipoprotein profiles for patients with a family history of early-onset heart disease. They're more accurate and more thorough than the basic lipid numbers of good and bad cholesterol. `He had this tiny, tiny cholesterol,' Gebhart said, `so we started treating him right away.'

 `Small' cholesterol is turning out to be at least as bad as high cholesterol. We should be measuring the size as well as counting the numbers, medical scientists have learned in exploring what causes heart disease. Their research is explaining why more than half of Americans with heart disease have satisfactory amounts of both LDL (low-density lipoprotein, or bad) and HDL (high-density lipoprotein, or good) cholesterol. `We've missed a lot of patients using just plain lipids,' said Dr. Narinder K. Saini, a preventive cardiologist who practices in Springfield and offers consultations at the Ohio Academy of Holistic Health in Xenia.

 In a study of 750 bypass-surgery patients in the March 2000 issue of Atherosclerosis , University of Illinois researchers found only 20 percent had undesirable cholesterol numbers, and 45 percent were normal or better. LipoScience in Raleigh, N.C., the lab used by Gebhart, provides data for 15 subclasses of LDL, HDL and VLDL (triglycerides) by analyzing the radio signals emitted by lipoproteins. The quick blood test, which costs less than $150, earned Discover magazine's 1999 Columbus Foundation Award.

 `The smaller the cholesterol, the more likely it is to fit into nooks and crannies of the artery wall,' Gebhart said. Small LDL also is stickier, Saini said, so it attracts larger collections that eventually block the coronary arteries as plaque. The blockage leads to angioplasty or bypass surgery, or, if the plaque becomes dislodged, a heart attack.

 HDL is good cholesterol, Gebhart said, because `it's like a sticky popcorn ball that picks up the LDL and carries it back to the liver for destruction.' So it's the larger HDL that is desirable. `You can carry a lot more with a larger ball.'The LipoProfile isn't necessary for everyone, he said. Most of the patients he tests have had close relatives die young of heart disease. The others generally have already had angioplasty, surgery or a heart attack, but they can't figure out why because their cholesterol readings are normal.

 `It's amazing,' Gebhart said. `Their cardiologist told them, `Your cholesterol's 190. You're fine. Go home.' ' Basic cholesterol tests are still in common use, though `every medical education conference I go to, people are saying, `You should be doing more lipoprotein profiles,' ' he said.

 Saini suspected it was the same reason more people use drugs to lower their cholesterol than good nutrition and exercise. Drug manufacturers pay for much of the country's medical research and educational material for doctors, who are always pressed for time. Cholesterol testing is fast and familiar.

 When the LipoProfile indicates a patient needs treatment, Gebhart said, `We can't make the bad cholesterol bigger. That's heredity. It's probably the reason their father or brother died. But we can cut the LDL number in half. So we do that with a statin (drug) and work on adding more good cholesterol with exercise, niacin, Omega-3 fatty acids, that kind of thing.'

 Niacin, an inexpensive B-vitamin, can help reduce the amount of bad cholesterol as well as increasing the good cholesterol, Saini said. It also helps bring down LPa, another key lipoprotein. To decrease the amount of homocysteine, a heart-damaging amino acid, Saini prescribes B6, B12 and folic acid, a vitamin regimen corroborated again last month by research in the Journal of the American Medical Association.

 He calls stress management, diet, exercise and spirituality the best methods for correcting heart disease, and lipoprotein screens an essential tool for learning whom to treat.

 `You can catch disease before you need bypass surgery,' Saini said. `And with the more specific information, we can individualize the treatment plan rather than just giving everyone Lipitor.'