Residual Apolipoprotein B Elevation Despite PREVENT-Guided LDL-C Goal Attainment Among Adults Without Known ASCVD

Low-density lipoprotein cholesterol (LDL-C) goal attainment is central to primary atherosclerotic cardiovascular disease (ASCVD) prevention, but LDL-C may not fully reflect the burden of apolipoprotein B (ApoB)-containing atherogenic particles. The prevalence and clinical correlates of residual ApoB elevation among adults who have attained PREVENT risk-stratified LDL-C goals remain unclear.

This cross-sectional study used data from the National Health and Nutrition Examination Survey (NHANES) 2005-2016 from adults aged 30-79 years without known ASCVD. The primary analytic sample included participants with 10-year PREVENT-ASCVD risk ≥ 3% who attained risk-stratified LDL-C goals. Residual ApoB elevation was defined as ApoB ≥ 90 mg/dL for PREVENT-ASCVD risk 3% to < 10% and ≥ 70 mg/dL for risk ≥ 10%. Survey-weighted analyses were used to estimate prevalence and identify factors associated with residual ApoB elevation.

Among 3857 adults with PREVENT-ASCVD risk ≥ 3%, 908 (23.5%) attained risk-stratified LDL-C goals. Of these, 128 had residual ApoB elevation, corresponding to a weighted prevalence of 17.7% (95% CI, 14.5%-21.4%). The prevalence was substantially higher among participants with triglycerides 150-400 mg/dL than among those with triglycerides < 150 mg/dL (43.6% vs. 4.3%; p < 0.001). In multivariable logistic regression, triglycerides of 150-400 mg/dL were strongly associated with residual ApoB elevation (adjusted OR, 15.87; 95% CI, 8.28-30.41; p < 0.001). Higher odds were also observed for PREVENT-ASCVD risk ≥ 10%, obesity, metabolic syndrome and advanced cardiovascular-kidney-metabolic stages (CKM Stages 2-4). The association with triglycerides was consistent across exploratory subgroups and robust in sensitivity analyses.

Among U.S. adults without known ASCVD who attained PREVENT risk-stratified LDL-C goals, residual ApoB elevation was common and strongly associated with triglyceride elevation. The prognostic and clinical significance of this discordant phenotype remains to be established.