Lipids, Lipoproteins, and Apolipoproteins as Risk Markers of Myocardial Infarction in 52 Countries (INTERHEART)

The INTERHEART study enrolled 21,465 participants across 52 countries and compared the predictive power of conventional lipid measures against apolipoprotein ratios for acute myocardial infarction — in the most geographically and ethnically diverse cardiovascular risk dataset assembled to that point.

The ApoB/ApoA1 ratio was the strongest lipid predictor, with an odds ratio of 1.59 per standard deviation increase and a population attributable risk of 54 percent. This substantially outperformed the LDL/HDL ratio (PAR 37%) and total cholesterol/HDL ratio (PAR 32%). Critically, these results were consistent across all ethnic groups, age categories, and sexes — and the measurements worked equally well in nonfasting samples.

The global consistency of the apoB/ApoA1 advantage is the finding’s most important attribute. Many lipid risk markers perform differently across ethnic groups due to differences in lipid metabolism and body composition; the apolipoprotein ratio did not. This cross-cultural consistency suggests that atherogenic particle burden (apoB) relative to HDL-mediated reverse transport (ApoA1) is a universal cardiovascular risk signal.

We rate the evidence strong, with high clinical significance. A definitive global case-control study establishing the apoB/ApoA1 ratio as the superior lipid predictor across all populations studied — making the strongest cross-cultural case for apolipoprotein-based measurement in cardiovascular risk assessment.