ApoB Goal Level for Very High Risk Individuals

For individuals at very high cardiovascular risk, the target Apolipoprotein B (ApoB) level should be <80 mg/dL. 1, 2

Definition of Very High Risk Individuals

Very high-risk individuals include those with:

Documented atherosclerotic cardiovascular disease (ASCVD), either clinical or unequivocal on imaging 1
Diabetes mellitus with target organ damage, or with ≥3 major risk factors, or type 1 diabetes with duration >20 years 1
Chronic kidney disease (CKD) with estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m² 1
Calculated SCORE ≥10% for 10-year risk of fatal cardiovascular disease 1
Familial hypercholesterolemia (FH) with ASCVD or with another major risk factor 1
History of multiple major ASCVD events or a major ASCVD event with multiple high-risk conditions 1

ApoB is the main apoprotein of atherogenic lipoproteins (VLDL, IDL, and LDL) and serves as a direct measure of the number of atherogenic particles 1, 2
ApoB appears to be a similar risk marker to LDL cholesterol but provides a better index of the adequacy of LDL-lowering therapy 1
There is less laboratory error in the determination of ApoB than LDL cholesterol, particularly in patients with hypertriglyceridemia 1

European guidelines recommend an ApoB target of <80 mg/dL for subjects with very high cardiovascular risk 1, 2
For high-risk (but not very high-risk) patients, the target ApoB level is <100 mg/dL 1, 2

While on statin therapy, to reach an ApoB target of <80 mg/dL, it is typically necessary to reduce LDL-C to <70 mg/dL or non-HDL-C to <100 mg/dL 3
The correlation between ApoB and non-HDL-C is stronger than that between ApoB and LDL-C, especially during statin therapy (R² = 0.92) 3
For patients with elevated triglycerides (≥200 mg/dL), achieving an ApoB target of <80 mg/dL may require reducing LDL-C to approximately 68 mg/dL 4

High-intensity statin therapy is the first-line treatment for very high-risk patients 2
If ApoB targets are not achieved with maximally tolerated statin therapy, adding ezetimibe 10 mg daily should be considered 2
For patients with persistently elevated ApoB despite statin and ezetimibe therapy, PCSK9 inhibitors may be considered 2

In patients with diabetes and elevated triglycerides, achieving the ApoB target of <80 mg/dL may require more aggressive LDL-C lowering 4
Non-HDL-C can serve as a surrogate marker when ApoB measurement is not available, with a target of <85 mg/dL for very high-risk patients 5
For patients with triglycerides between 200-399 mg/dL, a significant proportion may not achieve very high-risk ApoB targets despite reaching LDL-C goals, indicating the need for more aggressive therapy 5

Most high-risk patients meeting non-HDL-C goals (<130 mg/dL) still fail to achieve the more stringent ApoB target of <80 mg/dL, suggesting that current treatment may be insufficient 6
Using ApoB as a treatment target may lead to more aggressive lipid-lowering therapy in high-risk patients compared to using LDL-C or non-HDL-C targets alone 7, 6
The tight correlation between non-HDL-C and ApoB during statin therapy suggests that non-HDL-C may be an acceptable surrogate when ApoB measurement is not available 3