From the Guidelines
Apolipoprotein B (ApoB) levels should be managed to reduce cardiovascular risk, with optimal levels considered to be below 80 mg/dL, as recommended by the European guidelines on cardiovascular disease prevention in clinical practice 1. Apolipoprotein B (ApoB) is a protein that plays a crucial role in the transport of cholesterol and triglycerides throughout the body. It is the main protein component of low-density lipoprotein (LDL) and very low-density lipoprotein (VLDL) particles, which are responsible for carrying cholesterol from the liver to peripheral tissues. Each LDL particle contains exactly one ApoB molecule, making ApoB levels a direct measure of the number of atherogenic particles in circulation.
Key Points
- Elevated ApoB levels are strongly associated with increased cardiovascular risk, often providing better predictive value than traditional lipid measurements like LDL cholesterol 1.
- ApoB levels can be measured through a simple blood test.
- Management of high ApoB typically involves lifestyle modifications (diet low in saturated fats, regular exercise, weight management) and may include medications such as statins, ezetimibe, PCSK9 inhibitors, or bempedoic acid.
- ApoB is increasingly recognized as an important biomarker for cardiovascular risk assessment and treatment decisions, particularly in patients with diabetes, metabolic syndrome, or those with normal LDL but elevated triglycerides.
Clinical Considerations
- The evidence to support the lowering of ApoB is very strong, as it is the primary mechanism by which statins reduce cardiovascular risk 1.
- Laboratories could easily and inexpensively provide standardized measurements of ApoB, which may be a more reliable marker than LDL cholesterol, particularly in patients with hypertriglyceridemia 1.
From the FDA Drug Label
Rosuvastatin reduces Total-C, LDL-C, ApoB, non-HDL-C, and TG, and increases HDL-C, in adult patients with hyperlipidemia and mixed dyslipidemia In a multicenter, double-blind, placebo-controlled study in patients with hyperlipidemia, rosuvastatin given as a single daily dose (5 to 40 mg) for 6 weeks significantly reduced Total-C, LDL-C, non-HDL-C, and ApoB, across the dose range (Table 10) Table 10: Lipid-modifying Effect of Rosuvastatin in Adult Patients with Hyperlipidemia (Adjusted Mean % Change from Baseline at Week 6) DoseNTotal-CLDL-CNon-HDL-CApoBTGHDL-C Placebo13-5-7-7-3-33 Rosuvastatin 5 mg17-33-45-44-38-3513 Rosuvastatin 10 mg17-36-52-48-42-1014 Rosuvastatin 20 mg17-40-55-51-46-238 Rosuvastatin 40 mg18-46-63-60-54-2810
Apolipoprotein B (ApoB) is reduced by rosuvastatin in adult patients with hyperlipidemia and mixed dyslipidemia.
- The reduction in ApoB is dose-dependent, with significant reductions seen across the dose range of 5 to 40 mg.
- The percentage reduction in ApoB ranges from 44% to 60% compared to placebo. 2
From the Research
Apolipoprotein B as a Measure of Cardiovascular Risk
- Apolipoprotein B (apoB) is considered a more accurate measure of cardiovascular risk than low-density lipoprotein cholesterol (LDL-C) or non-high-density lipoprotein cholesterol (HDL-C) 3
- The 2019 European Society of Cardiology/European Atherosclerosis Society Guidelines endorse apoB as a better guide to the adequacy of lipid lowering than LDL-C or non-HDL-C 3
- ApoB can be measured more accurately than LDL-C or non-HDL-C, making it a more reliable indicator of risk 3
Comparison with LDL-Cholesterol
- LDL-C has been the cornerstone measurement for assessing cardiovascular risk, but recent data demonstrate that apoB is a better measure of circulating LDL particle number (LDL-P) concentration and is a more reliable indicator of risk than LDL-C 4
- ApoB is a more contemporary and physiologically relevant measure of atherogenic lipoproteins than LDL-C 5
- Multiple recent reports have found that LDL-C methods perform poorly at low concentrations (<70 mg/dl), while apoB is more analytically robust and standardized biomarker than LDL-C 5
Clinical Implications
- Using LDL-C to guide the adequacy of lipid lowering therapy represents an interpretive error of the results of the statin/ezetimibe/PCSK9 inhibitor randomized clinical trials, and apoB should be the primary metric to guide statin/ezetimibe/PCSK9 therapy 3
- The use of apoB for monitoring the efficacy of lipid-altering therapy would likely lead to more stringent criteria for lipid lowering 6
- ApoB is at worst clinically equivalent to LDL-C and likely superior when disagreement exists, but many obstacles prevent the wide spread adoption of apoB 5