From the Guidelines
Elevated apolipoprotein B (apoB) is a significant cardiovascular risk factor that requires immediate attention to reduce the risk of atherosclerotic cardiovascular disease (ASCVD) and improve quality of life, as evidenced by the 2019 American College of Cardiology/American Heart Association guideline 1. Elevated apoB levels indicate an increased number of atherogenic particles in the bloodstream, which can deposit in arterial walls and contribute to atherosclerosis. ApoB is a protein found on the surface of all atherogenic lipoproteins, including LDL, VLDL, and lipoprotein(a), with each particle containing exactly one apoB molecule.
Causes of Elevated ApoB
The elevation can occur due to:
- Genetic factors like familial hypercholesterolemia
- Poor diet high in saturated fats and refined carbohydrates
- Obesity
- Insulin resistance
- Diabetes
- Hypothyroidism
- Certain medications
Treatment and Management
Treatment typically involves:
- Lifestyle modifications, including a Mediterranean or DASH diet low in saturated fats and refined carbohydrates
- Regular exercise (150 minutes weekly of moderate activity)
- Weight loss if overweight
- Smoking cessation
- Medications, with statins being first-line therapy (such as atorvastatin 20-80mg daily or rosuvastatin 10-40mg daily) 1 For those not reaching targets with statins alone, ezetimibe 10mg daily may be added, followed by PCSK9 inhibitors in high-risk patients.
Monitoring and Targets
Regular monitoring of lipid profiles is important to assess treatment effectiveness, with target apoB levels generally below 80-90 mg/dL for high-risk patients. According to the 2019 guideline, an apoB level of $130 mg/dL or higher is considered a risk-enhancing factor for ASCVD, and statin therapy is recommended for individuals with elevated apoB levels, particularly those with persistently elevated triglycerides 1. While older studies, such as the 2006 introduction to apolipoproteins and guidelines for prevention of cardiovascular disease, provide some insight into the importance of apoB in cardiovascular risk assessment 1, the most recent and highest-quality evidence supports the use of apoB as a risk-enhancing factor and guides treatment decisions 1.
From the Research
Apolipoprotein B Elevated Explanation
Elevated apolipoprotein B (apoB) levels are associated with an increased risk of cardiovascular disease (CVD) and mortality 2, 3, 4, 5. ApoB is a key component of low-density lipoprotein (LDL) cholesterol and is considered a more accurate measure of cardiovascular risk than LDL-C or non-high-density lipoprotein cholesterol (non-HDL-C) 2.
Causes of Elevated ApoB
Several factors can contribute to elevated apoB levels, including:
- High levels of LDL-C 2
- Low levels of high-density lipoprotein (HDL) cholesterol 2
- High triglyceride levels 6
- Certain genetic mutations or polymorphisms in the APOB gene 5
Health Risks Associated with Elevated ApoB
Elevated apoB levels are associated with an increased risk of:
- Cardiovascular disease (CVD) 2, 3, 4, 5
- Ischemic heart disease 5
- Myocardial infarction 5
- Ischemic cerebrovascular disease 5
- Ischemic stroke 5
- All-cause mortality 3, 4
- Cardiovascular mortality 3, 4
Management of Elevated ApoB
Several lipid-lowering therapies can help reduce apoB levels, including:
- Statins 2, 3, 6
- Ezetimibe 2, 3
- Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors 2, 3
- Bile acid sequestrants 3
- Cholesteryl ester transfer protein inhibitors 3
- Fibrates 3
- Niacin 3
- Omega-3 fatty acids 3
Monitoring ApoB Levels
ApoB levels can be measured using nephelometry 4. The reference ranges for apoB concentrations are 55-140 and 55-125 mg/dL for men and women, respectively 4. Regular monitoring of apoB levels can help assess the effectiveness of lipid-lowering therapy and adjust treatment as needed 2, 6.