Stroke Mortality and the ApoB/ApoA-I Ratio: Results from the AMORIS Prospective Study

This AMORIS prospective cohort analysis — using the same 175,553-subject Swedish cohort as the 2001 fatal MI paper — examined the relationship between the ApoB/ApoA-I ratio and fatal stroke risk, comparing the apolipoprotein ratio against conventional cholesterol ratios for stroke prediction.

The ApoB/ApoA-I ratio was linearly and significantly associated with fatal stroke risk. Comparing the highest to lowest decile of the ratio, the adjusted odds ratio for all fatal strokes was 2.07 (95% CI 1.49–2.88). The association was strongest for ischemic stroke (OR 3.13). In multivariate analyses, the ApoB/ApoA-I ratio outperformed total cholesterol/HDL and LDL/HDL ratios as stroke predictors, with the magnitude of association somewhat less than for MI.

The atherosclerotic mechanism linking ApoB-containing lipoprotein particle burden to ischemic stroke parallels the coronary mechanism: atherogenic particles accumulate in carotid and intracranial arteries, forming plaques that rupture and thrombose, or serve as embolic sources. The same particle-based risk framework that applies to coronary disease extends to cerebrovascular disease.

The result that ApoB/ApoA-I predicts stroke better than conventional lipid ratios extends the apolipoproteins’ clinical utility beyond MI to the full spectrum of atherosclerotic vascular disease — coronary, peripheral, and cerebrovascular. This has implications for the comprehensiveness of the ApoB/ApoA-I ratio as a single cardiovascular risk metric.

We rate the evidence moderate. A large prospective AMORIS analysis in 175,553 subjects demonstrating that the ApoB/ApoA-I ratio outperforms conventional cholesterol ratios for fatal stroke prediction — extending the apolipoprotein risk framework beyond coronary to cerebrovascular disease.