Non-high-density lipoprotein cholesterol versus apolipoprotein B in cardiovascular risk stratification: do the math

With the emergence of new lipid risk markers and a growing cardiometabolic risk burden in the United States, there is a need to better integrate residual risk into cardiovascular disease (CVD) risk stratification. In anticipation of the Adult Treatment Panel IV (ATP IV) guidelines from the National Cholesterol Education Program (NCEP), there exists controversy regarding the comparative performance of the 2 foremost markers, apolipoprotein B (apoB) and non-high-density lipoprotein cholesterol (non-HDL-C), as they relate to the current standard of risk assessment and treatment: low-density lipoprotein cholesterol (LDL-C). Although some emerging markers may demonstrate better performance compared with LDL-C, certain fundamental characteristics intrinsic to a beneficial biomarker must be met prior to routine use. Collectively, studies have found that non-HDL-C and apoB perform better than LDL-C in CVD risk prediction, both on- and off-treatment, as well as in subclinical CVD risk prediction. The performance of non-HDL-C compared with apoB, however, has been a point of ongoing debate. Although both offer the practical benefits of accuracy independent of triglyceride level and prandial state, non-HDL-C proves to be the better marker of choice at this time, given established cutpoints with safe and achievable goals, no additional cost, and quick time to result with an easy mathematical calculation. The purpose of this review is to assess the performance of these parameters in this context and to discuss the considerations of implementation into clinical practice.