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Invited Commentary
November 13, 2021

Apolipoprotein B vs Low-Density Lipoprotein Cholesterol and Non–High-Density Lipoprotein Cholesterol as the Primary Measure of Apolipoprotein B Lipoprotein-Related Risk: The Debate Is Over

Author Affiliations
  • 1Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
  • 2Associate Editor, JAMA Cardiology
JAMA Cardiol. 2022;7(3):257-258. doi:10.1001/jamacardio.2021.5080

In 1979, Avogaro et al1 reported that apolipoprotein B (apoB) was a more accurate marker of the risk of a myocardial infarction than total cholesterol. In 1980, Sniderman et al2 reported that low-density lipoprotein (LDL) apoB was a more accurate marker of the risk of angiographic coronary lesions than LDL cholesterol (LDL-C). They inferred that the mass of cholesterol per apoB particle could vary and they speculated that the number of apoB particles mattered more than the cholesterol they contained because it was the particle that entered and was deposited within the arterial wall.2 Since then, there has been considerable debate whether apoB, LDL-C, or non–high-density lipoprotein cholesterol (non-HDL-C) should be the primary measure of apoB lipoprotein-related risk. The debate is over. In this issue, Marston and colleagues3 supply decisive evidence from a large, prospective observational study, UK Biobank, and 2 clinical trials, FOURIER (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk) and IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial), that apoB should be the primary marker to assess the cardiovascular risk due to the apoB lipoproteins.

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