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ASCVD Risk Stratification Using Apolipoprotein B and the LDL-C to Total Cholesterol Ratio

Bin Wang1, Nick S Nurmohamed2,3, Jordan M Kraaijenhof2

  • 1Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua Medicine, Tsinghua University, Beijing, China.

European Journal of Preventive Cardiology
|May 9, 2026
PubMed

Insights

A dual-axis approach using Apolipoprotein B (ApoB) particle burden and LDL cholesterol/total cholesterol (LDL-C/TC) ratio better predicts atherosclerotic cardiovascular disease (ASCVD) risk than LDL-C alone. This method reveals hidden risks for improved ASCVD prevention.

Area of Science:

  • Cardiovascular Medicine
  • Lipidology
  • Preventive Cardiology

Background:

  • Low-density lipoprotein cholesterol (LDL-C) is a known cause of atherosclerotic cardiovascular disease (ASCVD).
  • Significant variation in ASCVD risk exists across the LDL-C spectrum.
  • Existing risk stratification may not fully capture individual susceptibility.

Purpose of the Study:

  • To evaluate a dual-axis model integrating Apolipoprotein B (ApoB) particle burden and LDL cholesterol/total cholesterol (LDL-C/TC) ratio for ASCVD risk.
  • To determine if this dual-axis structure offers superior risk prediction compared to traditional markers.
  • To identify distinct phenotypes based on ApoB and LDL-C/TC ratio for refined risk assessment.

Main Methods:

  • Analysis of six US adult cohorts without prior cardiovascular disease or lipid-lowering therapy.
  • Dichotomization of ApoB (90 mg/dL) and LDL-C/TC ratio (0.60) to define four risk phenotypes.
  • Incident ASCVD events assessed using multivariable Cox proportional hazards models.

Main Results:

  • ApoB and LDL-C/TC ratio showed stronger associations with ASCVD risk than LDL-C levels.
  • The dual-elevated phenotype exhibited the highest ASCVD incidence (HR 1.67).
  • Discordant phenotypes revealed varying risk levels, with high ApoB/low ratio showing borderline associations.

Conclusions:

  • A dual-axis framework of ApoB particle burden and LDL-C/TC ratio provides a more coherent explanation of LDL-related atherogenic risk.
  • This approach identifies composition-driven vulnerabilities missed by ApoB alone or standard risk scores.
  • Routine LDL-C/TC ratio interpretation combined with selective ApoB testing can enhance ASCVD risk stratification.
Abstract

Keywords:
ASCVD risk stratificationLDL-C/total cholesterol ratioapolipoprotein Bdual-axis lipid frameworkprimary prevention

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