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Why do we need a broader view of cholesterol?
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Why do we need a broader view of cholesterol?

Cardiovascular disease remains one of the leading causes of death in the developed world. Almost everyone knows someone in their environment who has been affected by this type of disease. When we think of the risks that contribute to cardiovascular disease, we often think of LDL cholesterol, also known as the ‘bad’ cholesterol. According to current guidelines, it is a key factor in the excessive accumulation of fat in the arteries and the development of atherosclerosis, but the research presented below points out that LDL cholesterol alone is not the best indicator of the risk of developing cardiovascular disease and increased mortality. An important finding of the researchers is that Apolipoprotein B (ApoB) and non-HDL cholesterol are better predictors of heart disease risk than LDL cholesterol, especially in patients taking drugs such as statins.

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What are ApoB and non-HDL cholesterol?

ApoB is a protein found in certain types of fats in the blood, such as LDL (bad cholesterol) and VLDL. These fats can cause plaque buildup in the arteries, which increases the risk of heart disease. Higher levels of ApoB often mean a higher risk of cardiovascular problems.

Non-HDL cholesterol is obtained by subtracting HDL (the good cholesterol) from total cholesterol. This then represents all the types of fats in the blood that can be harmful to heart health. Therefore, non-HDL cholesterol may be a better indicator of heart disease risk than LDL cholesterol alone.

LDL, VLDL, IDL and other atherogenic lipoproteins contribute to plaque formation in arteries

Non-HDL cholesterol is calculated by subtracting HDL ("good" cholesterol) from total cholesterol. This includes all types of cholesterol that are associated with a higher risk of heart disease.

Key findings of the study

In a study involving more than 13,000 patients taking statins, researchers found the following:

  • Elevated ApoB and non-HDL cholesterol were associated with an increased risk of death and heart attack, while elevated LDL cholesterol showed no statistically significant association with risk.
  • Patients with high ApoB and low LDL had a 21% higher risk of death and a 49% higher risk of heart attack compared to patients with lower ApoB.
  • Those with high non-HDL cholesterol and low LDL cholesterol had an 18% higher risk of death and a 78% higher risk of heart attack.
  • Patients with high ApoB and non-HDL cholesterol and low LDL had a 23% higher risk of death and an 82% higher risk of heart attack.

Why is LDL not enough?

  • Traditionally, we have focused on LDL cholesterol when assessing heart disease risk, as it has long been the main target for cholesterol-lowering therapy. However, this approach does not take into account the risk posed by other lipoproteins, such as VLDL, IDL and other atherogenic lipoproteins, which also contribute to the formation of plaques in the arteries.

  • For this reason, researchers recommend measuring ApoB and non-HDL cholesterol in addition to LDL cholesterol levels to better assess the risk of cardiovascular disease. This assessment is important because elevated cholesterol does not usually cause obvious symptoms, but over time it can lead to serious cardiovascular problems such as heart attack or stroke.

Determining ApoB and non-HDL cholesterol would help to better assess the risk of cardiovascular disease.

Why is LDL not enough?

Although LDL cholesterol remains an important risk indicator, new research shows that ApoB and non-HDL cholesterol, together with LDL cholesterol, offer better information in predicting cardiovascular disease risk. In disease prevention, the identification of additional indicators would offer a more comprehensive view of cardiovascular health. For those who want to take care of their health and strive for a healthy lifestyle, it is advisable to consult a doctor, and you can also have a check-up with us.

SOURCES:

  1. Johannesen, C. D. L., Mortensen, M. B., Langsted, A., & Nordestgaard, B. G. (2021). Apolipoprotein B and non-HDL cholesterol better reflect residual risk than LDL cholesterol in statin-treated patients. Journal of the American College of Cardiology, 77(6), 766-776. https://doi.org/10.1016/j.jacc.2020.12.027
  1. Gorenjske pharmacie. (n.d.). Cholesterol and statins. Gorenjske pharmacies. Retrieved March 3, 2025, from https://www.gorenjske-lekarne.si/svetovanje-clanek/holesterol-in-statini
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