Heart disease develops when blood vessels become blocked by fatty deposits over time. These deposits are made up of cholesterol and other materials.
When they build up inside the arteries, they can reduce blood flow and eventually lead to serious events such as heart attacks and strokes.
Doctors have long used LDL cholesterol, often called “bad cholesterol,” to measure this risk. Another measure, non-HDL cholesterol, has also been used.
These tests are simple and widely available, which is why they have become standard practice.
However, a new study from Northwestern Medicine, published in JAMA, suggests that these traditional measures may not be the most accurate way to assess risk. The researchers found that a different marker, called apolipoprotein B or apoB, may be a better guide for treatment.
The key difference lies in what these tests measure. LDL cholesterol measures the amount of cholesterol in the blood, but it does not show how many particles are carrying that cholesterol. These particles are important because they are the ones that enter the artery walls and cause damage.
ApoB measures the number of these particles. Each particle contains one apoB molecule, so counting apoB gives a direct estimate of how many harmful particles are present. This makes it a more precise indicator of risk.
To test this idea, researchers created a computer model that followed 250,000 adults over their lifetime. These individuals were eligible for cholesterol-lowering treatment but had not yet developed heart disease. The model compared three approaches to guiding treatment: using LDL cholesterol, using non-HDL cholesterol, and using apoB.
If patients did not meet the target level, their treatment was increased. This could involve stronger statins or adding other medications. The model then estimated how many heart attacks and strokes would occur under each approach, as well as the costs and quality of life.
The findings showed that the apoB-based approach performed the best. It led to fewer heart attacks and strokes and improved overall health outcomes. Importantly, it was also cost-effective, meaning the additional cost of testing was justified by the health benefits.
This is especially important because new medical guidelines are encouraging earlier treatment for people at risk of heart disease. As more people become eligible for treatment, it becomes crucial to identify those who will benefit the most.
In analysing the results, the study suggests that focusing on particle number rather than cholesterol amount may improve how doctors assess risk. However, it is important to note that the study used a simulation model rather than direct patient data. While the model is based on strong evidence, real-world studies are still needed to confirm the findings.
Another limitation is that apoB testing is not yet part of routine care in many places. It may require additional testing and changes in clinical practice. Education for both doctors and patients will be important if this approach is adopted more widely.
Despite these challenges, the study provides a strong argument for rethinking how cholesterol is measured. It highlights that a more detailed understanding of blood particles could lead to better prevention and treatment of heart disease.
Overall, this research represents an important step forward. It suggests that a simple change in testing could help save lives and improve healthcare outcomes.
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