THERE ARE MANY misconceptions about important cardiovascular metrics. Often people think their risk of heart disease and other cardiovascular diseases is tied up with their total cholesterol numbers. In fact, total cholesterol is barely more relevant to your cardiovascular risk than your eye color or your dog’s name. Even HDL cholesterol (what many erroneously call “good” cholesterol) doesn’t mean much to your overall risk profile.
When I look at a person’s blood panel for the first time, my eyes immediately dart to two numbers: apoB and Lp(a). Numerous people have never heard of them, but these two tell me the most when it comes to predicting risk of ASCVD (atherosclerotic cardiovascular disease, the overall name for heart and cardiovascular diseases). Here’s what to ask for the next time you get your blood tested.
An apoB Test
YOUR IDEAL apo B TEST RESULT: 30 to 40 mg/dL—approximately the level it would be for a child (60 is the ceiling).
ApoB is short for apolipoprotein B, and evidence strongly indicates that concentrations of it are far more predictive of cardiovascular-disease risk than the more widely known metric of low-density lipoprotein (LDL) cholesterol. ApoB is a kind of cellular wrapper for LDL and every lipoprotein that contributes to ASCVD, including very low-density lipoprotein, or VLDL. These lipoproteins carry cholesterol, and the more apoB particles you have in circulation, the greater the risk that some of them will penetrate the lining of your arteries and stick—starting the process of becoming fatty streaks that can turn into plaques that can rupture, causing a heart attack or stroke.
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To gauge the true extent of your risk for ASCVD, we must know how many apoB particles are circulating in your bloodstream. I have all my patients tested for apoB concentration regularly, and you should ask for this the next time you see your doctor. (Don’t be dismissed by nonsensical arguments about cost: It’s $15 to $20.)
While cholesterol is important to the human body, lowering apoB “too much” is essentially impossible. If we all maintained the apoB levels we had when we were babies, there wouldn’t be enough heart disease on the planet for people to know what it was. Having an apoB north of60 mg/dL simply isn’t biologically necessary. (To give you a sense of why, consider that all the cholesterol traveling around your circulation—that “total cholesterol” reading you get from the lab—amounts to roughly 10 percent of your entire body’s pool of cholesterol.)
Some people can lower apoB by shifting from eating large quantities of saturated fats to eating monounsaturated fats, which are plentiful in foods including extra-virgin olive oil, macadamia nuts, and avocados. Exercise and cutting back on excessive carbohydrate intake can also help a lot if your high apoB is accompanied by high triglycerides. But if apoB can’t be reduced with lifestyle modifications alone, lipid-lowering medications are very helpful. Thankfully, today there are many classes beyond the tried-and-true workhorse, statins, which are good for most but problematic for some. (The other classes of drugs to consider are PCSK9 inhibitors, ezetimibe, and bempedoic acid.)
An Lp(a) Number
YOUR IDEAL Lp(a) TEST RESULT: < 30 mg/dL (<75 nmol/L)
When a patient tells me their father or grandfather or aunt, or all three, died of “premature” heart disease, elevated Lp(a)—pronounced “L-P-little-A”—is the first thing I think of. It is the most prevalent hereditary risk factor for heart disease. Most people have relatively small concentrations of this particle, but some can have up to 100 times as much as others. An estimated 10 percent of the population, and possibly more, have levels high enough that they are at increased risk, and the prevalence of high Lp(a) among people of African descent is even greater. We test every single patient for Lp(a) during their first blood draw, and since levels are largely genetic, the test need only be done once.
There isn’t a quick fix for high Lp(a), and some doctors use that as a reason not to test for it. It doesn’t respond to behavioral interventions or even traditional drug therapy. One class of drugs, called PCSK9 inhibitors (mentioned above), does seem to reduce LP(a) by an average of roughly 30 percent, but this has not been shown to be effective in preventing cardiovascular events. So the only real “treatment” for it right now is aggressive management of your other risk factors, starting with keeping apoB as low as possible but also making sure your blood-pressure and insulin levels stay under control, managing your weight, and of course, if you smoke, quitting as soon as possible.
This article appears in the December 2023 issue of Men’s Health.
