How can I improve my Apolipoprotein A1 (Apo A1) to Apolipoprotein B (Apo B) ratio to reduce cardiovascular risk?

From the Guidelines

To improve your Apolipoprotein A1 to Apolipoprotein B ratio and reduce cardiovascular risk, focus on both lifestyle changes and possibly medication, prioritizing interventions that raise Apo A1 and lower Apo B, as evidenced by the most recent guidelines 1.

Lifestyle Changes

• Adopt a Mediterranean diet rich in olive oil, nuts, fatty fish, fruits, vegetables, and whole grains while limiting processed foods, refined carbohydrates, and trans fats.
• Engage in regular exercise of at least 150 minutes of moderate activity weekly to help raise Apo A1 levels.
• Achieve weight loss if overweight, as this can significantly improve the Apo A1 to Apo B ratio.
• Limit alcohol to moderate amounts and quit smoking completely.

Medications

• Statins like atorvastatin (20-80mg daily) or rosuvastatin (10-40mg daily) effectively lower Apo B, as supported by studies 1.
• PCSK9 inhibitors such as evolocumab (140mg every 2 weeks) or alirocumab (75-150mg every 2 weeks) may be prescribed for those with high cardiovascular risk or familial hypercholesterolemia.
• Fibrates like fenofibrate (145mg daily) can raise Apo A1 while lowering Apo B, although the evidence for their use in improving the Apo A1 to Apo B ratio is less clear 1.
• Niacin (1-2g daily) may help but has more side effects and its use should be considered cautiously.

Targets for Therapy

• The European guidelines suggest that apo B levels can be used as a target for therapy, with targets of <80 mg/dL and <100 mg/dL for those at very high and high total CV risk, respectively 1.
• However, it's crucial to note that the measurement of apolipoproteins is not universally available and does not add more information than currently used lipid variables in all cases 1.

These interventions aim to create a more favorable cardiovascular risk profile by either increasing HDL production (raising Apo A1) or reducing LDL particles (lowering Apo B), based on the strongest and most recent evidence available 1.

From the FDA Drug Label

Fenofibrate therapy lowered LDL-C, Total-C, and the LDL-C/HDL-C ratio. Fenofibrate therapy also lowered triglycerides and raised HDL-C. In a subset of the subjects, measurements of apo B were conducted. Fenofibrate treatment significantly reduced apo B from baseline to endpoint as compared with placebo (-25.1% vs. 2.4%, p < 0.0001, n=213 and 143 respectively).

To improve your Apolipoprotein A1 (Apo A1) to Apolipoprotein B (Apo B) ratio, you can consider the following:

• Fenofibrate therapy may help by reducing Apo B levels and increasing HDL-C levels, which can contribute to a more favorable Apo A1/Apo B ratio.
• The exact effect of fenofibrate on Apo A1 levels is not directly stated in the provided drug label, but it does mention an increase in HDL-C, which is often associated with Apo A1.
• It is essential to consult with a healthcare professional to determine the best course of treatment for your specific situation, as the effect of fenofibrate on the Apo A1/Apo B ratio may vary depending on individual factors 2.

From the Research

Improving Apo A1/Apo B Ratio

To improve the Apolipoprotein A1 (Apo A1) to Apolipoprotein B (Apo B) ratio and reduce cardiovascular risk, consider the following:

• Dietary changes: A low-carbohydrate, high-saturated-fat diet, low fiber intake, low vitamin and mineral intake, and zinc and iron deficiency are associated with an elevated Apo B/Apo A1 ratio 3
• Increase consumption of:
  • Polyunsaturated fats
  • Vitamins
  • Minerals
  • Trace minerals
  • Lower excess sugars
• Healthy diet patterns:
  • Mediterranean diet
  • Vegan diet
  • Fermented dairy products
  • Omega-3-rich diet
• Micronutrients:
  • Vitamin D sufficiency
  • Increased serum vitamin C
  • Magnesium

Risk Assessment

The Apo B/Apo A1 ratio is a strong, new risk factor for cardiovascular disease and a target for lipid-lowering therapy 4

• Elevated Apo B and increased Apo B/Apo A1 ratio increase the risk of myocardial infarction (MI) and stroke, whereas high Apo A1 is protective 5
• An imbalance between Apo B and Apo A1 resulting in an increased Apo B/Apo A1 ratio is strongly associated with major adverse cardiovascular events (MACEs) 5

Monitoring and Prevention

• Measuring Apo B/A1 and Apo(a) in childhood identifies families at increased cardiovascular risk 6
• Simple evidence-based cut values should be considered in future cardiovascular guidelines 5
• Early recognition and primary prevention are crucial, as an increased Apo B/Apo A1 ratio can be detected decades before cardiovascular events develop 5