Heart disease is still the leading cause of death in many countries, including the United States. It often develops slowly over many years as fatty substances build up inside the arteries.
These substances form plaques that narrow the blood vessels and reduce blood flow. If a plaque breaks, it can block the artery completely, leading to a heart attack or stroke.
For many years, doctors have relied on a blood test that measures LDL cholesterol, often called “bad cholesterol,” to assess a person’s risk. Another related measure, non-HDL cholesterol, has also been used.
These tests are part of routine check-ups and are widely used to decide whether a person should take medications such as statins to lower their cholesterol.
However, a new study from Northwestern Medicine suggests that these traditional measures may not be the best way to guide treatment. The study, published in the journal JAMA, found that another marker in the blood, called apolipoprotein B, or apoB, may provide a more accurate way to assess risk and guide treatment decisions.
To understand this, it is important to know how cholesterol works in the body. Cholesterol does not travel freely in the blood. Instead, it is carried inside small particles. These particles can enter the walls of arteries and contribute to plaque formation.
LDL cholesterol measures the amount of cholesterol carried in these particles, but it does not directly measure how many particles are present.
ApoB, on the other hand, reflects the number of these harmful particles. Each particle contains one apoB molecule, so measuring apoB gives a clearer picture of how many particles are circulating in the blood. This may explain why apoB is a better indicator of risk.
In the study, researchers used a large computer model that simulated the health outcomes of 250,000 adults in the United States who were eligible for cholesterol-lowering treatment but did not yet have heart disease.
They compared three different strategies for guiding treatment: one based on LDL cholesterol, one based on non-HDL cholesterol, and one based on apoB levels.
If a person’s levels were above the target, treatment was intensified. This included using stronger statins or adding another medication called ezetimibe. The researchers then followed the simulated patients over their lifetimes, looking at outcomes such as heart attacks, strokes, life expectancy, and healthcare costs.
The results showed that using apoB to guide treatment led to better outcomes. It prevented more heart attacks and strokes and improved overall health in a cost-effective way. This means that even though apoB testing may require an additional test, the benefits may outweigh the costs.
The study also comes at an important time. New guidelines recommend starting cholesterol-lowering treatment earlier for many people. This makes it even more important to identify who is most at risk and who would benefit most from treatment.
In analysing the study, it is clear that apoB offers a more complete picture of cardiovascular risk than traditional cholesterol measures. However, there are still some limitations. The study was based on a simulation model rather than real-world clinical trials. While these models are useful, they rely on assumptions and may not capture all real-life factors.
In addition, apoB testing is not yet widely used in routine care. This may be due to cost, convenience, or lack of awareness among healthcare providers. More research and changes in clinical practice may be needed before apoB becomes a standard test.
Overall, the study provides strong evidence that measuring the number of harmful cholesterol particles may be more important than measuring the amount of cholesterol alone. This could lead to more accurate treatment decisions and better prevention of heart disease in the future.
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