The TL;DR
If you measure only one lipid marker, make it ApoB. Unlike LDL-Cholesterol (which measures the concentration of cholesterol), ApoB measures the number of particles that carry it. Since atherosclerosis is driven by particles crashing into arterial walls (not the cargo they carry), ApoB is the superior predictor of heart disease. It captures all atherogenic particles: LDL, VLDL, IDL, and Lp(a).
Accessibility Level
Level 2 (Optimization): Not standard in annual physicals (Level 1), but easily added. Doctors may resist, but guidelines (Europe) now recommend it. Cost is ~$20 out of pocket.
The Science of ApoB
The “Car vs. Passenger” Analogy
Imagine cholesterol is the passenger and the lipoprotein particle is the car.
- LDL-C measures the total weight of passengers.
- ApoB counts the number of cars on the road.
Traffic causes accidents (plaques), not passengers. You can have “normal” LDL-C but a high number of small, dense particles (high ApoB). This is common in insulin resistance and is a high-risk state missed by standard panels.
The Discordance
When LDL-C and ApoB disagree, risk follows ApoB.
- High LDL-C / Low ApoB: Lower risk (large, fluffy particles).
- Low LDL-C / High ApoB: High risk (small, dense particles). This is the “silent killer” phenotype often seen in metabolic syndrome.
Evidence Matrix
| Source | Verdict | Notes |
|---|---|---|
| Allan Sniderman | Pioneer | The cardiologist who established ApoB as the causal driver of atherosclerosis. |
| Peter Attia | Critical Priority | ”ApoB is the single best predictor of cardiovascular events.” Targets < 60 mg/dL. |
| European Society of Cardiology | Guideline | Recommends ApoB analysis for risk assessment, especially in high triglycerides/diabetes. |
Optimal Ranges
| Population | Target (mg/dL) | Notes |
|---|---|---|
| Standard Prevention | < 80 | Better than average, but not optimal. |
| High Risk / Prevention | < 60 | The “physiologic” level of a newborn. Hard to achieve without statins/PCSK9i for many. |
| Reversal / Secondary | < 40-50 | Aggressive target for those with established plaque. |
How to Optimize
- Pharmaceuticals: Statins, Ezetimibe, and PCSK9 Inhibitors are the most potent tools. (Consult a lipidologist).
- Diet (Saturated Fat): For many (but not all), reducing saturated fat lowers ApoB. Replace butter/beef with olive oil/fish/avocado.
- Diet (Fiber): Soluble fiber binds bile acids, forcing the liver to pull ApoB particles from the blood.
- Metabolic Health: Fixing insulin resistance often converts small, dense particles into larger ones, improving the profile.
References
Sniderman, A. D., et al. (2011). A meta-analysis of low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, and apolipoprotein B as markers of cardiovascular risk. Circulation: Cardiovascular Quality and Outcomes, 4(3), 337-345.
Ference, B. A., et al. (2017). Low-density lipoproteins cause atherosclerotic cardiovascular disease. European Heart Journal, 38(32), 2459-2472.
Marston, N. A., et al. (2022). Association of Apolipoprotein B-Containing Lipoproteins and Risk of Myocardial Infarction and Stroke. JAMA Cardiology.