“THERE IS A BETTER PREDICTOR OF HEART DISEASE, but many doctors and patients aren’t talking about it.” That’s the headline I recently read in the Washington Post. Today, we explore cholesterol and you.

My primary care providers have focused on my low-density lipoproteins (LDL) or “bad” cholesterol. They also note my high-density lipoproteins or “good” cholesterol.

But is this the right approach? The article suggests it is time to move beyond the simple concept of “good” versus “bad” cholesterol.

There is a better blood test to assess heart attack risk. The measure goes by the unwieldy name apolipoprotein B. Many refer to it as “apoB.”

Cholesterol basics

Cholesterol is a buzzword in health discussions, but what exactly is it?

Think of cholesterol as a friendly helper and a potential troublemaker all rolled into one. It’s a waxy, fat-like substance that our bodies need to build cells and make hormones.

However, having too much of the wrong kind can spell trouble for our arteries and heart. There are two main types of cholesterol:

• LDL (low-density lipoprotein), often referred to as “bad” cholesterol
• HDL (high-density lipoprotein), or “good” cholesterol.

Finding the right balance is key to keeping our hearts happy and healthy.

Cholesterol: Why you should care

Maintaining healthy cholesterol levels is crucial for overall well-being.

An excess of LDL cholesterol in our bloodstream can build up on the arteries’ walls, forming plaque.

This buildup narrows the arteries, making blood flow more challenging and increasing the risk of heart disease.

On the flip side, HDL cholesterol acts like a superhero by helping to remove LDL cholesterol from the bloodstream, preventing the potential clogs that could lead to heart issues.

It’s like a delicate dance between these two types, and understanding this dynamic is fundamental to taking charge of your cardiovascular health.

What Is apolipoprotein B?

Cholesterol is carried in LDL, very-low-density lipoproteins (VLDL), intermediate-density lipoproteins (IDL), and lipoprotein(A) particles.

Each tiny particle has a special protein called ApoB (apoprotein B) attached to it. Think of ApoB as a transporter that helps move fat around your body.

However, these fats can sometimes stick to the walls of your arteries, forming a plaque. When this occurs, it raises the chances of developing heart disease and having a stroke.

Is apoB a more accurate measure of heart risk?

ApoB protein moves fat throughout the body and helps it get through the arteries’ walls, where it forms plaque.

The available research suggests this:

Apolipoprotein B (apoB) levels are a potentially more accurate measure of heart attack risk than the usual good cholesterol/bad cholesterol lipid panel.

ApoB protein moves fat throughout the body and helps it get through the arteries’ walls, where it forms plaque.

Still, current guidelines do not focus on apoB.

A better cholesterol test?

Current guidelines only offer apoB as an option for certain high-risk patients.

Healthy individuals have low blood levels of low-density cholesterol, but higher numbers can mean you are at risk for heart problems.

Since each cholesterol carries one apoB, the test is a good measure for the total lipoproteins or bad cholesterol in your blood.

WebMD explains that your doctor might order an apoB test for different reasons, including:

• A family history of heart disease
• Previously diagnosed heart problems
• To monitor treatment
• Existing high cholesterol or blood fats.

What do the test results mean?

What Do the Test Results Mean?

The normal range for apolipoprotein B is under 90 milligrams per deciliter (mg/dL) of blood.

If you have normal test results, you have appropriate amounts of lipoproteins in your blood, and your heart disease risk is low.

Your apolipoprotein B -100 test results can range from 20 to 400 milligrams per deciliter (mg/dL).

If your Apo B is higher than 130 mg/dL, you’re at a higher risk of heart and blood vessel disease.

Some cardiology guidelines recommend a target of less than 65 or 80 mg/dL of Apo B. They suggest these goals for people between ages 40 and 75 who take statins.

On the other hand, abnormally high apoB levels can also mean you have an underlying health condition:

• Hypothyroidism (an underactive thyroid)
• Kidney disease
• Diabetes
• Pregnancy
• Nephrotic syndrome, a kidney issue.

Low levels of apoB

Below-normal lipoprotein levels can reflect an underlying condition, too. Such problems may prevent your body from creating lipoproteins or apolipoprotein.

Here are some examples of conditions related to low apoB levels:

Your Apo B test results may be lower if you:

• Have a blood infection (sepsis).
• Have liver disease.
• Take estrogen.

Your healthcare provider might compare your apoB to apoA levels. ApoA is an apolipoprotein that attaches to “good cholesterol.”

If you have more apoB than apoA, you might have an elevated heart attack and stroke risk.

Recent study

In a new research investigation presented at the 2023 American College of Cardiology annual Scientific Sessions in New Orleans, Intermountain Health (USA) scientists reported this:

ApoB testing may help identify patients still at increased risk for a cardiovascular event despite having normal LDL cholesterol levels.

The investigators analyzed patients’ electronic health records from 2010 through 2022 for their retrospective study.

Apo B testing is more common.

In the Intermountain Health study, Apo B testing frequency more than quadrupled over time.

Moreover, while ApoB levels correlated with LDL cholesterol, the ApoB/LDL cholesterol ratio increased as LDL cholesterol decreased.

This finding suggests the presence of too many risk-increasing small, dense LDL particles — particles with smaller amounts of LDL cholesterol per particle.

Current approaches to cholesterol measurement

Regular cholesterol checks are essential for keeping tabs on your heart’s well-being.

A simple blood test at your doctor’s office can reveal your cholesterol levels and help you make informed decisions about your lifestyle and diet.

The new study indicated that ApoB may help identify individuals who may still be at increased risk of a cardiovascular event (such as a heart attack or stroke) despite having normal LDL cholesterol levels.

Who should consider Apo B testing?

Dr. Salim Virani, a cardiologist at The Texas Heart Institute and the Aga Khan University, offers his take:

“I think sometimes knowing ApoB is more important for clinicians who need information beyond just regular cholesterol that they measure with the lipid panel and there is a subset of patients where it might be more useful.”

For instance, he offers that patients who are obese, have high triglycerides, or have metabolic syndrome (high triglycerides and low HDL cholesterol) may benefit from ApoB testing.

ApoB should complement, not replace, HDL, LDL, and non-HDL cholesterol values.

My thoughts (as a non-cardiologist)

Opting for a heart-healthy diet, regular exercise, and, in some cases, medication as prescribed by your healthcare provider can all play a role in maintaining optimal cholesterol levels.

By demystifying cholesterol basics, we empower ourselves to make informed choices, ensuring our hearts continue to beat strong for years.

Into the future – cholesterol and you

For decades, primary physicians and cardiologists have focused on two numbers: LDL or low-density lipoproteins, known as “bad cholesterol,” and HDL or high-density lipoproteins, a.k.a. “good cholesterol.”

The two numbers are key determinants of a patient’s cardiovascular disease risk.

But many physicians and researchers say it’s time to move beyond this timeworn emphasis on “good” or “bad” cholesterol.

ApoB is a potentially more accurate marker of heart attack risk. However, the ApoB test is not necessary for everyone. Talk to your doctor about whether it makes sense for you.

Thank you for reading “Cholesterol and you.”