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New study suggests apoB/apoA-1 ratio as an accurate marker for cardiovascular disease

Patients with the highest apoB/apoA-1 levels had a 70% increased risk of severe cardiovascular disease. Overall, the findings suggest that the apoB/apoA-1 ratio is a superior marker for identifying more people at risk of cardiovascular disease in the future than the apoB technique alone. (Image: A tissue stain showing extracellular lipid accumulation.)

Cardiovascular disease is the leading cause of mortality worldwide, and it encompasses a wide variety of illnesses such as stroke and myocardial infarction, as well as atherosclerosis in many body organs. In many situations, the condition may be avoided or slowed down by making lifestyle changes and utilizing statins and other lipid-lowering medications.

Reference levels for “bad” LDL cholesterol are commonly used to identify increased cardiac risk.
Other forms of fat particles are evaluated with apolipoproteins, which carry cholesterol in the blood, in various medical disorders. For individuals with type 2 diabetes, a high BMI, and very high blood lipid levels, international guidelines for cardiovascular disease advocate utilizing the apolipoprotein apoB, which transports the “bad” cholesterol, as an alternative risk measure.

Recent studies have shown, however, that the apolipoprotein apoA-1, which transports the “good” protective and anti-inflammatory HDL cholesterol, is equally important to consider. The apoB/apoA-1 ratio is used to calculate a risk quotient that reflects the balance between “bad” fat particles that speed up atherosclerosis and “good” protective apoA-1 particles that slow it down.

“The results show that the higher the apoB/apoA-1 value, the greater the risk of myocardial infarction, stroke and need for coronary surgery,” says Göran Walldius, senior author and professor at the Institute of Environmental Medicine, Unit of Epidemiology, Karolinska Institutet. “The study also showed that the risk was amplified in the presence of low protective levels of apoA-1.”

When compared to individuals with the lowest apoB/apoA-1 levels, those with the highest apoB/apoA-1 values had a 70% higher risk of serious cardiovascular disease and a nearly tripled risk of non-fatal myocardial infarction. Individuals with the greatest risk quotient were also more likely to develop serious cardiovascular disease several years before those with the lowest apoB/apoA-1 levels.

The link was seen in both men and women, and increased levels might be recognized as early as 20 years before the beginning of heart disease.

“Early preventive treatment and information about cardiovascular risk is, of course, important in enabling individuals to manage their risk situation,” Walldius says. “Early treatment can also reduce the cost burden on the public health services.”

According to the researchers, the data show that the apoB/apoA-1 ratio is a superior marker for identifying more people at risk of future cardiovascular illness than the apoB approach alone.

“It should be possible to introduce cut-values for apoB, apoA-1 and the apoB/apoA-1 ratio into new guidelines as a complement to current guidance on the detection and treatment of dyslipidaemia,” Walldius says.



The study was published in PLOS Medicine, on December 1st, 2021.

Abstract. An imbalance between apoB and apoA-1 resulting in an increased apoB/apoA-1 ratio is strongly associated with the outcome MACE and its sub-components, in both men and women of all ages. An increased apoB/apoA-1 ratio already 2 decades before events calls for early recognition and primary prevention. Simple evidence-based cut values should be considered in future cardiovascular guidelines.

Walldius G, de Faire U, Alfredsson L, Leander K, Westerholm P, Malmström H, et al. (2021) Long-term risk of a major cardiovascular event by apoB, apoA-1, and the apoB/apoA-1 ratio—Experience from the Swedish AMORIS cohort: A cohort study. PLoS Med 18(12): e1003853. https://doi.org/10.1371/journal.pmed.1003853

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