Long-Term Risk of Major Cardiovascular Events by ApoB, ApoA-1, and the ApoB/ApoA-1 Ratio: The Swedish AMORIS Cohort

This updated AMORIS cohort analysis followed 137,100 Swedish subjects with baseline apolipoprotein measurements over a long follow-up period, examining the ApoB/ApoA-1 ratio as a predictor of MACE (major adverse cardiovascular events) and quantifying how far in advance risk is detectable.

The ApoB/ApoA-1 ratio was strongly and linearly associated with MACE risk across both sexes and all age groups. Subjects in the highest decile had a hazard ratio of 1.7 for MACE and 2.7 for non-fatal MI compared with the lowest decile. Crucially: elevated ApoB/ApoA-1 ratios were detectable up to 20 years before a cardiovascular event — demonstrating that this marker identifies risk decades before clinical disease manifests. The combination of high ApoB and low ApoA-1 conferred the highest absolute risk.

The 20-year lead time for risk detection is a finding of fundamental importance for primary prevention strategy. It means that ApoB/ApoA-1 measurement in midlife — or even early adulthood — could identify individuals who will develop coronary disease in their 50s and 60s in time to implement decades of preventive treatment. This is exactly the use case for which traditional 10-year risk scores are inadequate: they calculate near-term event probability but cannot capture the lifetime exposure to atherogenic particle burden that accumulates silently over decades.

We rate the evidence strong. A large long-term AMORIS cohort study in 137,100 subjects demonstrating that the ApoB/ApoA-1 ratio is detectable as a MACE predictor up to 20 years before events — foundational evidence for apolipoprotein-based early and lifetime cardiovascular risk stratification.