Comparative Analysis of Apolipoprotein B and LDL Cholesterol for Estimating CHD Risk in Established Coronary Disease

Pooling two large statin trials (IDEAL and TNT), this analysis compared apolipoprotein B against LDL and non-HDL cholesterol as predictors of events in patients with established coronary disease.

ApoB came out ahead. While all three markers predicted risk, the models using apoB fit better — and decisively, when apoB and LDL cholesterol were placed in the same model, apoB retained its predictive power while LDL cholesterol did not. The implication is that it is the number of atherogenic particles (apoB), not the cholesterol mass they carry (LDL-C), that drives residual risk in statin-treated patients.

The authors went further than most, suggesting apoB may be a more appropriate treatment target than LDL cholesterol in this population — a position the field has gradually moved toward.

We rate the evidence strong. As a pre-specified analysis of large randomized trials it is high-quality, contributing solid trial-based support to the case that apoB outperforms LDL cholesterol for gauging residual risk.