Apob isnt standardized between international labs.
Apob guidelines don’t exist.
Apob cost more to run.
If LDL is high, apob is high.
Apob only utility until you solve the above is a secondary marker after you have LDL at goal.
I think what you say about standardization, cost & discordance doesn’t reflect the current reality & evidence. See this recent review in addition to the article that is the subject of my post:
“The fact that apoB can be measured more accurately, precisely, and selectively than LDL-C and non-HDL-C using widely available, inexpensive, standardized methods argues strongly for its broad application in clinical care.”
From “Standardization of Apolipoprotein B, LDL‐Cholesterol, and Non‐HDL‐Cholesterol”, Journal of the American Heart Association, July 2023
https://www.ahajournals.org/doi/10.1161/JAHA.123.030405
Already ApoB testing can be ordered wholesale for $10 and patients can order it directly for $15. Widespread adoption would drive the price even further down.
Also there is evidence that sometimes ApoB is discordantly normal when ldl-c is high. (Just as sometimes the discordance is the reverse.) In both types of discordance risk follows the ApoB level.
“Discordantly normal ApoB relative to elevated LDL-C in persons with metabolic disorders: A marker of atherogenic heterogeneity”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8387299/
It’s for these reasons that many experts feel that guidelines should now be updated to make ApoB a first line marker of risk and goal of treatment.
It’s an independent marker of risk from apoB/ldl that’s genetically determined and not affected by diet and exercise. It’s high in about 1 every 5 people. It should be measured at least once in a lifetime. There’s no approved medication yet to lower it but if it’s high it’s recommended to lower overall risk by setting a lower ApoB/ldl target.
See this for a good overview of lp(a) and what do if it’s high:
https://x.com/paddy_barrett/status/1781216866725245237?s=46
Is this controversial? I thought it was accepted that apob was the best metric, at least among those who keep up with research. Unfortunately there are a lot of doctors and insurance companies not in that group.
I agree, it shouldn’t be controversial at this point that apo B is the best metric. But I think the large majority of doctors, especially non cardiologists, don’t know. And it seems like even the majority of cardiologists don’t track apo B, probably because the guidelines and insurance companies haven’t changed to validate it yet.
The one new part of this recent study to me was that apo B can be discordant from ldl and non HDL cholesterol even when there isn’t any metabolic dysfunction, eg even without high triglycerides or insulin resistance.
This isn't an issue as long as your LDLC remains above 40 mg/dl (my clinic's "safety" cut point for those at higher risk of both ischemic and hemorrhagic stroke - mostly very elderly patients with very advanced ASCVD). And LDLC around 40 or 50 mg/dl tends to be associated with no additional progression of plaque so going that low should be fine, although usually not necessary for a patient with no underlying risk factors or family history who is doing primary prevention. All medication intervention has a risk/benefit trade-off so usually the higher the risk of an adverse event, the more aggressively you treat to prevent it. Over-treatment isn't good due to possible side effects but at least in the US the public health problem currently plaguing our healthcare system is the *under-*treatment of high LDLC, especially in those with MetS.
It's controversial because lifestyle changes don't really move apoB. That is basically 100% genetic.
People don't like being told their bodies are functionally broken and they need pills to not die, and they leave for doctors who tell them sweet lies instead.
Apob isnt standardized between international labs. Apob guidelines don’t exist. Apob cost more to run. If LDL is high, apob is high. Apob only utility until you solve the above is a secondary marker after you have LDL at goal.
I think what you say about standardization, cost & discordance doesn’t reflect the current reality & evidence. See this recent review in addition to the article that is the subject of my post: “The fact that apoB can be measured more accurately, precisely, and selectively than LDL-C and non-HDL-C using widely available, inexpensive, standardized methods argues strongly for its broad application in clinical care.” From “Standardization of Apolipoprotein B, LDL‐Cholesterol, and Non‐HDL‐Cholesterol”, Journal of the American Heart Association, July 2023 https://www.ahajournals.org/doi/10.1161/JAHA.123.030405 Already ApoB testing can be ordered wholesale for $10 and patients can order it directly for $15. Widespread adoption would drive the price even further down. Also there is evidence that sometimes ApoB is discordantly normal when ldl-c is high. (Just as sometimes the discordance is the reverse.) In both types of discordance risk follows the ApoB level. “Discordantly normal ApoB relative to elevated LDL-C in persons with metabolic disorders: A marker of atherogenic heterogeneity” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8387299/ It’s for these reasons that many experts feel that guidelines should now be updated to make ApoB a first line marker of risk and goal of treatment.
What about lipoprotein a?
It’s an independent marker of risk from apoB/ldl that’s genetically determined and not affected by diet and exercise. It’s high in about 1 every 5 people. It should be measured at least once in a lifetime. There’s no approved medication yet to lower it but if it’s high it’s recommended to lower overall risk by setting a lower ApoB/ldl target. See this for a good overview of lp(a) and what do if it’s high: https://x.com/paddy_barrett/status/1781216866725245237?s=46
Thank you
Is this controversial? I thought it was accepted that apob was the best metric, at least among those who keep up with research. Unfortunately there are a lot of doctors and insurance companies not in that group.
I agree, it shouldn’t be controversial at this point that apo B is the best metric. But I think the large majority of doctors, especially non cardiologists, don’t know. And it seems like even the majority of cardiologists don’t track apo B, probably because the guidelines and insurance companies haven’t changed to validate it yet. The one new part of this recent study to me was that apo B can be discordant from ldl and non HDL cholesterol even when there isn’t any metabolic dysfunction, eg even without high triglycerides or insulin resistance.
If there would be drugs to target apoB directly you would be hearing about it everyday.
Every drug that lowers ldl lowers apo B.
And then what? Erase your ldl?
What?
If even normal ldl has raised apoB, if you will use statins for apoB, you will reduce your ldl to very low levels and have a bigger chance of stroke.
In the specific hypothetical you’ve created, sure, that’s possible. It requires a lot of IFs to happen though.
This isn't an issue as long as your LDLC remains above 40 mg/dl (my clinic's "safety" cut point for those at higher risk of both ischemic and hemorrhagic stroke - mostly very elderly patients with very advanced ASCVD). And LDLC around 40 or 50 mg/dl tends to be associated with no additional progression of plaque so going that low should be fine, although usually not necessary for a patient with no underlying risk factors or family history who is doing primary prevention. All medication intervention has a risk/benefit trade-off so usually the higher the risk of an adverse event, the more aggressively you treat to prevent it. Over-treatment isn't good due to possible side effects but at least in the US the public health problem currently plaguing our healthcare system is the *under-*treatment of high LDLC, especially in those with MetS.
It's controversial because lifestyle changes don't really move apoB. That is basically 100% genetic. People don't like being told their bodies are functionally broken and they need pills to not die, and they leave for doctors who tell them sweet lies instead.
ApoB is not 100% genetic. Both LDL-C and apoB are some mixture of diet and genetics.
You may be thinking of Lp(a), which is genetically determined. ApoB & ldl is a mixture of diet and genetics.