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Apolipoprotein B-100: A Promising Marker for Predicting Cardiovascular Risk and Targeting Intensive Lowering

Tuesday, August 8th 2023 10:00am 5 min read
Dr. Jessica Peatross dr.jess.md @drjessmd

Hospitalist & top functional MD who gets to the root cause. Stealth infection & environmental toxicity keynote speaker.

Cardiovascular disease, including heart disease and stroke, remains a leading cause of mortality worldwide. Traditional risk factors such as cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and triglycerides have long been used to assess cardiovascular risk. However, emerging evidence suggests that
Apolipoprotein B-100 (ApoB) may offer a more reliable predictor of cardiovascular risk, potentially surpassing traditional lipid markers. Furthermore, ApoB has shown promise as a target for intensive lipid-lowering therapies. This article explores the importance of ApoB as a predictor of cardiovascular risk and discusses its potential as a therapeutic target, supported by findings from peer-reviewed studies.

ApoB as a Superior Predictor of Cardiovascular Risk:

  • ApoB and Atherogenic Lipoproteins: ApoB is the primary protein component of atherogenic lipoproteins, including LDL and very low-density lipoprotein (VLDL). Unlike LDL cholesterol, which measures the cholesterol content within LDL particles, ApoB quantifies the number of atherogenic lipoprotein particles. Several studies have highlighted that ApoB levels better reflect the overall burden of atherogenic particles than LDL cholesterol levels alone, providing a more accurate assessment of cardiovascular risk. (Refs: JAMA. 2007;297(12):1316-1319; Am J Cardiol. 2002;90(8A):22i-29i)
  • ApoB and Residual Risk: Residual risk refers to the continued risk of cardiovascular events despite achieving optimal LDL cholesterol levels. Studies have demonstrated that ApoB levels correlate more closely with residual risk compared to LDL cholesterol levels. This suggests that ApoB may help identify individuals who require more intensive lipid-lowering therapies beyond LDL cholesterol reduction alone. (Refs: Circulation. 2004;110(17):2678-2686; J Am Coll Cardiol. 2010;55(5):440-446)

ApoB as a Therapeutic Target for Intensive Lowering:

  • ApoB and Statin Therapy: Statins, commonly prescribed cholesterol-lowering medications, primarily target the inhibition of cholesterol synthesis, which indirectly affects ApoB production. Multiple clinical trials have shown that statins reduce ApoB levels, leading to significant cardiovascular risk reduction. However, some individuals may exhibit residual cardiovascular risk despite statin therapy, highlighting the need for additional approaches targeting ApoB. (Refs: JAMA. 2003;290(7):891-897; J Am Coll Cardiol. 2007;49(6):657-666)
  • Emerging Therapies: Recent developments in therapeutic strategies have focused on directly targeting ApoB-containing lipoproteins. Novel therapies such as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors and antisense oligonucleotides (ASOs) show promise in reducing ApoB levels and subsequently decreasing cardiovascular risk. Clinical trials investigating these interventions have demonstrated their efficacy in lowering ApoB and preventing cardiovascular events. (Refs: N Engl J Med. 2015;372(16):1489-1499; Lancet. 2017;390(10106):2180-2190)


Apolipoprotein B-100 represents a valuable advancement in cardiovascular risk assessment and management. By quantifying the number of atherogenic lipoprotein particles, ApoB surpasses traditional lipid markers in predicting cardiovascular risk. Moreover, ApoB has emerged as a promising target for intensive lipid-lowering therapies beyond the scope of LDL cholesterol reduction. The ability of ApoB to better capture residual risk and its association with atherogenic lipoproteins highlight its significance in clinical practice.

Therapeutic strategies that directly target ApoB, such as PCSK9 inhibitors and ASOs, have demonstrated efficacy in reducing ApoB levels and lowering cardiovascular risk. PCSK9 inhibitors block the degradation of LDL receptors, resulting in increased clearance of LDL particles from the bloodstream. Clinical trials have shown significant reductions in ApoB levels and cardiovascular events with PCSK9 inhibitors. ASOs, on the other hand, act by specifically inhibiting ApoB synthesis, leading to a decrease in atherogenic lipoproteins. These emerging therapies provide new avenues for intensive lipid-lowering approaches, particularly for individuals who exhibit residual risk despite statin therapy.

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