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There is robust evidence based on epidemiological, genome-wide association studies, Mendelian randomisation as well as randomised controlled trials (RCTs) implicating low-density lipoprotein cholesterol (LDL-C) as a causative factor in atherosclerotic cardiovascular disease (CVD).1 This is consistent with lipoprotein turnover modelling where, in terms of lipoproteins, low-density lipoprotein (LDL) particles are approximately seven times greater in number and remain in the circulation seven times longer than triglyceride (TG) containing particles in most individuals. So given its importance, what is the best way of assessing LDL-C? The short answer is to measure apolipoprotein B (ApoB), and the long answer has recently become more complicated given the increase in the number of LDL-C equations and improvements in direct LDL-C assays.
Evidence from a meta-analysis of epidemiological studies and RCTs on statins has shown that ApoB as a CVD risk predictor outperforms both LDL and non-high-density lipoprotein cholesterol (HDL-C).2 3 This discordance is magnified in those with hypertriglyceridaemia, where less cholesterol will be included in LDL and more in remnant particles. In a recent primary/secondary population study, LDL-C and non-HDL-C become non-significant CVD risk markers when ApoB is taken into account.4 This demonstrates that the CVD risk of LDL-C and non-HDL-C is more accurately predicted by particle number rather than the cholesterol content of the ApoB particles. This is reflected in recent guidelines where ApoB has been recommended for CVD risk assessment and a recognition that measurement can be adequately standardised to meet requirements for patient care.5 6
ApoB-100 is carried …
Handling editor Vikram Deshpande.
Contributors All authors contributed equally to the draft and editing of this article.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.