Major Lipids, Apolipoproteins, and Risk of Vascular Disease

This massive analysis from the Emerging Risk Factors Collaboration weighed the major lipids and apolipoproteins against each other to find the most useful way to assess vascular risk — and delivered a pragmatic, slightly deflating answer for apolipoprotein enthusiasts.

Drawing on over 300,000 people, it found that the apoB-to-apoA1 ratio and the non-HDL-to-HDL cholesterol ratio predicted coronary disease almost identically (hazard ratios of about 1.49 and 1.50). In other words, the apolipoprotein measures did not add meaningful predictive value over the cholesterol ratios that are cheaper and already standard. It also confirmed that fasting status barely affected the associations — a practical point that helped justify non-fasting lipid panels.

The nuance worth holding: this analysis concerns population-level discrimination, where the cholesterol ratios suffice. It does not negate apoB’s value in individual patients with discordance — where the cholesterol number misleads and apoB does not.

We rate the evidence very strong. It is an enormous, rigorous meta-analysis whose careful, somewhat conservative conclusion shaped how guidelines weigh apolipoproteins against standard lipids.