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Beyond LDL Cholesterol: Apolipoprotein B Unveils Your True Heart Risk

Updated: Apr 4

Introduction

Heart disease or Atherosclerotic Cardiovascular Disease (ASCVD) is the leading global cause of illness and death, rich and poor countries alike.1 In order to minimize the risk factors that lead to ASCVD, maintaining a healthy heart and metabolic profile is vital. 

One way to assess our cardiovascular health is through lipid panel testing, which provides valuable insights into our cholesterol and triglyceride levels. While cholesterol and triglycerides are familiar terms to many, lipoprotein particles, the carriers of these fats in the blood, may not be as well-known. These particles play a crucial role in understanding your test results beyond the commonly known "good" and "bad" cholesterol. Getting to know how these lipoprotein particles function is essential for gaining a deeper understanding of your overall health.2

There are five main types of lipoproteins:
  • High-density lipoprotein (HDL) is known as "good cholesterol" because it helps remove cholesterol from the body, lowering the risk of heart disease.

  • Low-density lipoprotein (LDL) is referred to as "bad cholesterol" as it can lead to the buildup of plaque in blood vessels, increasing the risk of heart attacks and strokes.

  • Very low-density lipoproteins (VLDL) are another form of "bad cholesterol" that transport triglycerides to tissues.

  • Intermediate-density lipoproteins (IDL) are formed when VLDLs release fatty acids and are either removed by the liver or converted into LDL.

  • Chylomicrons are large particles that also carry triglycerides.3



Importance of Apolipoprotein B Testing:

Some of these lipoprotein particles may build up in and on the artery walls and lead to the formation of atherosclerotic plaque, which is one of the major factors that leads to the development of cardiovascular disease. These lipoprotein particles are also called atherogenic particles, and the higher the atherogenic particle number, the greater the risk for a cardiovascular event.4

While traditional lipid panels focus on total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides, they may not provide a complete picture of cardiovascular risk. In assessing the risk of heart disease, we often look at LDL-C. It helps set goals for treatment to lower cholesterol. However, relying solely on LDL-C can lead to an incomplete risk assessment. Some people with lower LDL-C levels still face heart disease events or progression. This is because LDL-C levels may not fully reflect the risk for individuals with high triglycerides and metabolic disorders. Their lipid profiles might have more small, cholesterol-poor LDL particles, which can be a factor in heart disease risk.

Apolipoprotein B (ApoB) is another essential molecule that can offer a better assessment of cardiovascular risk. It is a vital component of "bad" cholesterol, including LDL and VLDL. Each LDL and VLDL particle contains one ApoB molecule, making it a critical marker that reflects the number of atherogenic (harmful) particles in the blood.

This is why multiple epidemiological and clinical trials have consistently demonstrated the superiority of ApoB as a risk predictor. These studies have shown that ApoB exhibits higher sensitivity and specificity compared to LDL cholesterol as a predictive variable, regardless of age or gender.5

If you have diabetes or multiple cardiometabolic risk factors (obesity, insulin resistance, and hypertension), asking your healthcare provider to include ApoB in your assessment can be beneficial in determining your risk. 

The experts from the ADA/ACC report have recommended certain goals for Apolipoprotein B (ApoB) levels, which can help understand your cardiovascular risk. For individuals with established heart disease or diabetes and one risk factor, the ApoB goal is 80 mg/dL. If you have two cardiometabolic risk factors but no heart disease, the recommended ApoB goal is 90 mg/dL.

Some specialists suggest using ApoB goals based on population percentiles from databases like the Framingham Offspring study. For example, if you are considered high-risk and need an LDL-C level of 100 mg/dL (the 20th percentile), your ApoB goal would be 78 mg/dL. Similarly, if you are at very high risk for heart disease and need an LDL goal of 70 mg/dL (the second percentile), your ApoB level should be around 54 mg/dL. These recommended ApoB levels can help you and your healthcare provider understand your risk factors and work towards maintaining a healthy heart.6


When should you get tested?

Regular lipid panel testing is crucial for proactive cardiovascular health management. The American Heart Association (AHA) emphasizes the importance of early testing, suggesting that individuals start as early as age 20, especially if there are risk factors such as a family history of cardiovascular disease or related conditions. By initiating testing at a younger age, individuals can establish a baseline and monitor changes in their lipid profile over time.7

In addition to the AHA recommendations, the Centers for Disease Control and Prevention (CDC) provides general guidelines for cholesterol screening frequency in healthy adults. For most individuals, cholesterol checks every 4 to 6 years are sufficient. However, certain groups require more frequent testing, including those with existing heart disease, diabetes, or a family history of high cholesterol.2

Remember, these guidelines serve as a general framework, and it is important to consult with healthcare professionals to determine the most suitable lipid panel testing schedule based on individual risk factors and medical history. Together, we can proactively manage our cardiovascular health and strive for a healthier future.


The Responsiveness of Lipid Panel to Lifestyle Changes:

The beauty of lipid panel testing lies in its ability to reflect the impact of lifestyle choices on our cardiovascular health. Lifestyle changes remain the cornerstone of management of lipid and lipoprotein disorders and obesity, and are warranted in primary as well as secondary prevention settings.8 By adopting healthier habits, such as improving diet, increasing physical activity, and quitting smoking, individuals can positively influence their lipid profile. Case studies have reported that the impact of lifestyle modifications such as altering diet and incorporating exercise can lead to a reduction in total cholesterol and LDL cholesterol levels at both 6 weeks and 6 month time periods, without taking any cholesterol-lowering drugs.9 It is essential to note that the magnitude of change may vary based on genetics, age, and other individual factors. 




A study examining whether lifestyle and dietary factors (both macronutrients and groups of foods and beverages) are associated with serum Apo parameters (ApoA1 and ApoB) in a large population-based cohort of nearly 25,000 individuals indicated that smoking, obesity, low physical activity, low alcohol consumption and a diet high in sugar and low in fermented dairy products are correlated with an unfavorable Apo profile.10


Take Charge of Your Heart Health

Regular lipid panel testing is essential for assessing cardiovascular health, and starting early allows for proactive management. Lifestyle changes have a significant impact on lipid levels, empowering individuals to improve their cardiovascular profile through healthier choices. Additionally, the incorporation of ApoB testing enhances the accuracy of lipid panels, providing a more comprehensive evaluation of cardiovascular risk. By prioritizing lipid panel testing and recognizing the importance of ApoB, individuals and healthcare providers can work together towards better heart and metabolic health. 

Remember, taking care of our cardiovascular health is a lifelong journey, and understanding the optimal age for lipid panel testing, embracing lifestyle changes, and leveraging advanced markers like ApoB can contribute to a healthier future.


References

1.       Kreatsoulas C, Anand SS. The impact of social determinants on cardiovascular disease. Can J Cardiol. 2010;26 Suppl C(Suppl C):8C-13C. doi:10.1016/s0828-282x(10)71075-8

2.       Get a cholesterol test (2023) Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/cholesterol/cholesterol_screening.htm#:~:text=Cholesterol%20should%20be%20checked%20starting,every%204%20to%206%20years. (Accessed: 19 July 2023).

3.       Cox RA, García-Palmieri MR. Cholesterol, Triglycerides, and Associated Lipoproteins. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 31. Available from: https://www.ncbi.nlm.nih.gov/books/NBK351/

4.       Petri T Kovanen , Matti Jauhiainen, Coronary heart disease prediction: Apolipoprotein B shows its might again – but still in vain?, European Journal of Preventive Cardiology, Volume 22, Issue 10, 1 October 2015, Pages 1317–1320, https://doi.org/10.1177/2047487315580892

5.       Pencina, M. J., D’Agostino, R. B., Zdrojewski, T., Williams, K., Thanassoulis, G., Furberg, C. D., … Sniderman, A. D. (2015). Apolipoprotein B improves risk assessment of future coronary heart disease in the Framingham Heart Study beyond LDL-C and non-HDL-C. European Journal of Preventive Cardiology, 22(10), 1321–1327. doi:10.1177/2047487315569411

6.       Harper CR, Jacobson TA. Using apolipoprotein B to manage dyslipidemic patients: time for a change?. Mayo Clin Proc. 2010;85(5):440-445. doi:10.4065/mcp.2009.0517

7.       2018 guideline on the management of blood cholesterol (no date) American Heart Association. Available at: https://www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Guidelines/2018/Guidelines-Made-Simple-Tool-2018-Cholesterol.pdf (Accessed: 19 July 2023).

8.       Enkhmaa B, Surampudi P, Anuurad E, et al. Lifestyle Changes: Effect of Diet, Exercise, Functional Food, and Obesity Treatment on Lipids and Lipoproteins. [Updated 2018 Sep 11]. In: Feingold KR, Anawalt B, Blackman MR, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK326737/

9.       Janse Van Rensburg, Walter J. “Lifestyle Change Alone Sufficient to Lower Cholesterol in Male Patient With Moderately Elevated Cholesterol: A Case Report.” American journal of lifestyle medicine vol. 13,2 148-155. 19 Oct. 2018, doi:10.1177/1559827618806841

10.  Frondelius, K. et al. Lifestyle and dietary determinants of serum apolipoprotein A1 and Apolipoprotein B concentrations: Cross-sectional analyses within a Swedish cohort of 24,984 individuals. Nutrients 9, 211 (2017).

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