From the Guidelines
ApoB and Lp(a) should be measured in patients with triglyceride levels >200 mg/dL, family history of premature ASCVD, personal history of ASCVD not explained by major risk factors, and in women with hypercholesterolemia. These measurements are valuable in assessing cardiovascular risk, especially in patients with borderline LDL levels but multiple cardiovascular risk factors, and in cases where standard lipid panels provide unclear risk assessment.
- ApoB provides a more accurate count of atherogenic particles than LDL-C alone, especially in patients with metabolic syndrome, insulin resistance, or hypertriglyceridemia where LDL-C may underestimate cardiovascular risk 1.
- Lp(a) is genetically determined and represents an independent risk factor for cardiovascular disease that isn't reflected in standard lipid measurements, with elevated levels (>50 mg/dL or >125 nmol/L) indicating increased cardiovascular risk regardless of other lipid parameters 1. Key considerations for measuring apoB and Lp(a) include:
- Relative indications for apoB measurement: triglyceride >200 mg/dL, and a level >130 mg/dL corresponds to an LDL-C level >160 mg/dL and constitutes a risk-enhancing factor 1.
- Relative indications for Lp(a) measurement: family history of premature ASCVD or personal history of ASCVD not explained by major risk factors, and in women with hypercholesterolemia 1. These advanced lipid tests help clinicians better stratify risk and make more informed decisions about the intensity of lipid-lowering therapy and the potential need for additional treatments beyond statins.
From the Research
Patients Requiring apoB and lp(a) Measurement
- apoB should be measured in patients with mild-to-moderate hypertriglyceridemia (175-880 mg/dL), diabetes, obesity or metabolic syndrome, or very low LDL cholesterol < 70 mg/dL, as it is a more accurate marker of cardiovascular risk compared to non-HDL cholesterol 2
- Patients with a family history of cardiovascular disease may also benefit from apoB measurement, as family history is an independent predictor of cardiovascular disease and can help identify individuals at high risk 3, 4
- lp(a) measurement may be relevant in patients with high cardiovascular risk, although the provided evidence does not specifically address lp(a) measurement in these patients
- VLDL cholesterol is a significant contributor to the risk of myocardial infarction associated with apoB-containing lipoproteins, and its measurement may be useful in patients with elevated apoB levels 5
- High cardiovascular risk patients, including those with diabetes, peripheral artery disease, or other co-morbidities, may require more aggressive LDL-C-lowering approaches and potentially apoB measurement to assess their cardiovascular risk 6