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Apolipoprotein B and Non-HDL Cholesterol Better Reflect Residual Risk Than LDL Cholesterol in Statin-Treated Patients
Camilla Ditlev Lindhardt Johannesen1, Martin Bødtker Mortensen2, Anne Langsted1
1Department of Clinical Biochemistry and the Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark; The Copenhagen City Heart Study, Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Faculty of Health and Medical Science, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
Insights
Elevated apolipoprotein B (apoB) and non-high-density lipoprotein (non-HDL) cholesterol, not LDL cholesterol, predict residual risk for mortality and heart attack in statin-treated patients. ApoB is a superior risk marker compared to LDL and non-HDL cholesterol.
Area of Science:
- Cardiovascular Medicine
- Lipidology
- Preventive Cardiology
Background:
- Low-density lipoprotein (LDL) cholesterol is the primary target in current cholesterol guidelines.
- Apolipoprotein B (apoB) and non-high-density lipoprotein (non-HDL) cholesterol are considered secondary targets.
- Residual cardiovascular risk persists in some patients despite statin therapy.
Purpose of the Study:
- To evaluate if elevated apoB and/or non-HDL cholesterol are superior to elevated LDL cholesterol in identifying statin-treated patients at residual risk.
- To assess the association of apoB, non-HDL, and LDL cholesterol with all-cause mortality and myocardial infarction.
- To determine the predictive accuracy of discordant lipid values for adverse cardiovascular outcomes.
Main Methods:
- Analysis of 13,015 statin-treated patients from the Copenhagen General Population Study with a median 8-year follow-up.
- Utilized Cox regression models to examine associations between lipid parameters (apoB, non-HDL, LDL) and outcomes.
- Employed restricted cubic splines and median-based categories for concordant and discordant lipid values.
Main Results:
- High apoB and non-HDL cholesterol levels were associated with increased risk of all-cause mortality and myocardial infarction.
- Elevated LDL cholesterol alone was not associated with increased residual risk.
- Discordant high apoB or non-HDL cholesterol with low LDL cholesterol significantly predicted higher risks of mortality and myocardial infarction.
Conclusions:
- Elevated apoB and non-HDL cholesterol, not LDL cholesterol, are associated with residual risk of all-cause mortality and myocardial infarction in statin-treated patients.
- ApoB demonstrates superior accuracy in identifying patients at risk for all-cause mortality and myocardial infarction compared to LDL and non-HDL cholesterol.
- These findings suggest a potential role for apoB and non-HDL cholesterol as primary risk markers in statin-treated populations.
Background:
In cholesterol guidelines, low-density lipoprotein (LDL) cholesterol remains the primary target while apolipoprotein B (apoB) and non-high-density lipoprotein (non-HDL) cholesterol are secondary targets.
Objectives:
This study sought to determine if elevated apoB and/or non-HDL cholesterol are superior to elevated LDL cholesterol in identifying statin-treated patients at residual risk of all-cause mortality and myocardial infarction.
Methods:
In total, 13,015 statin-treated patients from the Copenhagen General Population Study were included with 8 years median follow-up. Cox regressions among apoB, non-HDL cholesterol, and LDL cholesterol, respectively, and all-cause mortality or myocardial infarction were examined on continuous scales by restricted cubic splines and by categories of concordant and discordant values defined by medians.
Results:
High apoB and non-HDL cholesterol were associated with increased risk of all-cause mortality and myocardial infarction, whereas no such associations were found for high LDL cholesterol. Compared with concordant values below medians, discordant apoB above the median with LDL cholesterol below yielded hazard ratios of 1.21 (95% confidence interval [CI]: 1.07 to 1.36) for all-cause mortality and 1.49 (95% CI: 1.15 to 1.92) for myocardial infarction. Corresponding values for high non-HDL cholesterol with low LDL cholesterol were 1.18 (95% CI: 1.02 to 1.36) and 1.78 (95% CI: 1.35 to 2.34). In contrast, discordant high LDL cholesterol with low apoB or non-HDL cholesterol was not associated with increased risk of all-cause mortality or myocardial infarction. Also, discordant high apoB with low non-HDL cholesterol yielded hazard ratios of 1.21 (95% CI: 1.03 to 1.41) for all-cause mortality and of 0.93 (95% CI: 0.62 to 1.40) for myocardial infarction. Furthermore, dual discordant apoB and non-HDL cholesterol above the medians with LDL cholesterol below presented hazard ratios of 1.23 (95% CI: 1.07 to 1.43) for all-cause mortality and 1.82 (95% CI: 1.37 to 2.42) for myocardial infarction.
Conclusions:
In statin-treated patients, elevated apoB and non-HDL cholesterol, but not LDL cholesterol, are associated with residual risk of all-cause mortality and myocardial infarction. Discordance analysis demonstrates that apoB is a more accurate marker of all-cause mortality risk in statin-treated patients than LDL cholesterol or non-HDL cholesterol, and apoB in addition is a more accurate marker of risk of myocardial infarction than LDL cholesterol.
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