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apoB and Cardiovascular Disease

Most patients in our practice show up with their lipid profile in hand, most concerned about their LDL and HDL numbers. In this article, we’ll share our viewpoint on apoB and cardiovascular disease risk.

Old, Discarded Viewpoints

Lipidologists and preventative cardiologists no longer rely on LDL-C as a way to risk stratify someone for heart disease.

In most laboratories, LDL-C is often calculated and rarely measured directly, making LDL-C an even less reliable marker for cardiovascular disease risk.

Once believed to be protective, HDL-C is no longer considered of much value in assessing a lipid profile.

Modern Lipid Profile Analysis

If you have one of your old lipid profiles lying around, you can calculate your non-HDL cholesterol, which, 97% of the time, corresponds to apoB levels.

(Total cholesterol) – (HDL cholesterol) = non-HDL cholesterol

You can also use an online calculator.

Triglyceride Levels

these days, we mostly use triglyceride levels to determine if somebody’s dietary intake of simple carbohydrates is excessive.

The higher triglycerides are, or the more insulin resistance somebody is, the more likely they will have excess cholesterol needing transportation by apoB lipoproteins.

apoB Targets

apoB can be cheaply measured ($20 – $60) in most laboratories. Insurance often covers it, but that’s hardly necessary for lab testing.

The way we determine apoB targets is to determine a person’s overall cardiovascular disease risk.

1. Very High Risk

Those at very high risk should have apoB levels below 60 mg/dl. Dr. Peter Attia does an excellent job conveying the various risk profiles.

If apoB isn’t available, their non-HDL-C should be < 90 mg/dl.

From the old LDL-C understanding, the goal would be an LDL-C below 70 mg/dl.

2. High Risk

Those at high risk should have the following numbers with a little more wiggle room compared to someone who is at very high risk:

  • apoB < 75 mg/dl
  • non-HDL-C < 120 mg/dl
  • LDL-C < 100 mg/dl

ApoB and Cardiovascular Disease

The biggest drivers of Atherosclerotic Cardiovascular disease (ASCVD), sometimes also referred to as cardiovascular disease (CVD), are the following:

  • tobacco use
  • hypertension
  • elevated apoB
  • elevated Lp(a)
  • elevated fasting insulin levels

How to Lower apoB

It’s hard to know who responds to what treatment. Some may not be able to tolerate statins even though their apoB drops drastically.

Others may see a massive drop in apoB by changing their diet, especially if they are hyperabsorbers of cholesterol.

Just as we have hyperabsorbers, those whose intestines squeeze every last bit of cholesterol from the food, we have hyperproducers.

The hyperproducers produce a lot of cholesterol from the liver, which finds its way into the circulation, causing elevation of apoB.

These changes partly explain why some will respond well to statins and even better when we add ezetimibe.

Repeat Testing of apoB Lipoproteins

In general, we advise our clients to check their apoB levels annually. As soon as it starts to get out of range, we discuss various interventions.

Regular monitoring is necessary for early intervention as there is a low chance of a sudden increase in this lipoprotein level.

apoB Lowering Through Exercise

When it comes to lowering certain risk factors, blood pressure is quite amenable to lifestyle changes.

It does not seem to be the same case with apoB levels. For those with a high elevation of this molecule, it is always advisable to start with lifestyle modifications first.

Certain dietary changes, such as a very low-fat diet, can greatly improve someone’s apoB levels. Unfortunately, many cannot sustain such diets long-term.

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