ApoB/apoA-I ratio is better than LDL-C in detecting cardiovascular risk
Introduction
The concentration of low density lipoprotein cholesterol (LDL-C) is generally accepted as being one of the strongest risk factors for atherosclerotic cardiovascular (CV) disease and mortality [1]. Although LDL-C is widely recognized as the major atherogenic lipoprotein, other lipoproteins are involved in atherogenesis, including very low-density (VLDL), intermediate-density (IDL), and high-density lipoproteins (HDL). Each class of lipoprotein particles is associated with distinctive apolipoproteins which, in addition to stabilizing lipoprotein structure, play an essential role in regulating lipid metabolism. ApoB, being present in VLDL, IDL and LDL, represents the total number of atherogenic lipoproteins [2], [3]. ApoA-I is the major apolipoprotein associated with HDL and it is crucial in transferring excess cholesterol from tissues to the liver [3], [4]. ApoB and apoA-I appear then to exert opposing effects on atherogenic risk, to the extent that the apoB/apoA-I ratio seems very effective in characterizing the CV risk [3], [4], [5], [6], [7]. Furthermore, this ratio has a stronger relationship with CV risk than any other lipid ratio [7], [8].
Actually, based on data from large-scale intervention trials using statins [9], [10], the National Cholesterol Education Program (NCPE) has proposed guidelines for lipid management that are continually being updated [11], [12]. The current major treatment guidelines focus on LDL-C targets, taking into account individual patient's history and calculated risk profile [11], [12]. The NCPE update suggests to reach LDL-C target of 100 mg/dL in “high-risk individuals” and recommends the use of non-HDL-cholesterol (non-HDL-C) as target for individuals with high triglycerides (≥200 mg/dL).
Aggressive targeting of LDL-C with statins has been shown to reduce the incidence of CV disease by about one third. However a considerable proportion of patients with active atherosclerotic disease have levels of LDL-C within the recommended range, and some patients who achieve significant LDL-C reduction with lipid-lowering therapy still develop CV events [2], [13], [14]. Therefore, there is need for improving the cardiovascular risk assessment.
The analysis of epidemiological studies [3], [5] indicates that the higher the apoB/apoA-I ratio, the higher is the CV risk, such that cut-off values ≥0.9 and ≥0.8 have been proposed to define a high CV risk for males and females, respectively [4], [8]. Elevated levels of apoB are a component of the metabolic syndrome (MetS), a clinical condition where the presence of an atherogenic lipid profile, characterized by high triglycerides (TG) and low HDL-cholesterol (HDL-C) levels, is common [15]. Thus, the apoB/apoA-I ratio could be helpful in the clinical management of a very high CV risk syndrome where insulin resistance is widely believed to constitute a crucial pathogenetic factor [15].
In this study we investigate, in subjects with normal glucose tolerance (NGT), whether the apoB/apoA-I ratio could improve the detection of the CV risk profile with respect to the conventional cut-off LDL-C levels in relation to some clinical features of MetS, like insulin resistance and atherogenic lipid profile, each of them independently considered as a CV risk factor.
Section snippets
Methods
This study, conceived to verify the contribution of the apoB/apoA-I ratio, compared to the LDL-C levels, in defining the CV risk profile, was performed in a General Internal Medicine ward, affiliated with a Medical School, with an outpatients' facility for referrals targeted to arterial hypertension and/or metabolic abnormalities. After at least 5 days of a weight-maintaining diet (55% of calories from carbohydrates, 25% from fats, 20% from proteins) and avoidance of strenuous exercise, each
Results
Table 1 shows the clinical characteristics, OGTT and HOMA2%S data of subjects enrolled in the study. The 28.9% of this cohort were smokers, 23.05% were obese (BMI ≥ 30), 62.7% were affected by essential arterial hypertension; all subjects were NGT.
Table 2 shows the stratification of the 616 subjects according to the conventional LDL-C cut-off values, (100–130–160 mg/dL) [11], and the apoB/apoA-I ratio values proposed to define a higher CV risk (≥0.9 for males, ≥0.8 for females) [8]. Considering
Discussion
Vascular disease is the most common cause of death in the developed world and will become the leading cause of death in the developing world as well [18]. The identification of individuals at increased CV risk represents a priority. Actually, LDL-C, strictly related to CV disease and mortality [1], remains the cornerstone of lipid management. However, many reports attribute more weight to apoB/apoA-I ratio as an index of CV risk [3], [4], [5], [6], [7], [8], [19]. As to the determination of
Conflict of interest
None declared.
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