This new test could veto cholesterol screenings as the best predictor of heart disease
Key Takeaways
Industry Buzz
“The main scenario that prompts me to use apoB is when a patient’s traditional lipid panel values are either normal, or even slightly abnormal, but have discrepancy with the quality/quantity of their other comorbid problems." — Austin Shuxiao, MD, internal medicine physician
Find more of your peers' perspectives and insights below.
For decades, LDL cholesterol (LDL-C) has been the standard for assessing cardiovascular risk. But new evidence suggests that apolipoprotein B (apoB) and lipoprotein(a) [Lp(a)] may be better predictors of atherosclerotic cardiovascular disease (ASCVD).
"Elevated Lp(a) is an independent marker of increased atherosclerotic cardiovascular risk and is an inherited condition."
— Ricky D. Grisson II, MD, MBA, MPH, FCAP
What’s the new evidence?
ApoB is found on all atherogenic lipoproteins (including LDL) and reflects the total number of plaque-forming particles. Lp(a) is a genetically inherited, more dangerous form of LDL that promotes clotting, inflammation, and plaque buildup.
A 2025 European Heart Journal review of over 200,000 adults followed for nearly 14 years found that apoB particle count and Lp(a) together gave the most accurate lipid-based prediction of coronary artery disease (CAD).[]
Similar signals emerged in a 2024 Danish cohort, which flagged “excess apoB” (higher apoB than expected for a given LDL-C) as an independent ASCVD driver.[] A CMAJ analysis likewise endorsed apoB as a practical alternative to LDL-C.[]
Here’s how some clinicians explain these new tests to their patients:
“For Lp(a), I explain that it is a type of LDL that has an extra protein on its surface, making it even more concerning for heart disease risk... it isn’t cleared by receptors as well, it is more likely to get oxidized, and it can promote blood clots.” — Bret Scher, MD, FACC
“I usually say that these are genetic markers of atherosclerosis and cardiac inflammation…. Measuring the apoB and Lp(a) will help to fully determine cardiac risk.” — Joyce Oen-Hsiao, MD, FACC, Associate Professor of Medicine, Yale School of Medicine
In the clinic: Status of apoB and Lp(a)
Some clinicians already include these markers in routine assessments. Mary Greene, MD, from Manhattan Cardiology in NYC, orders apoB and Lp(a) “on every patient at least once,” calling this her current practice standard. Dr. Oen-Hsiao at Yale adds the panel when strong family history, early coronary disease, or high lipids in younger patients raise suspicion of hidden risk.
Dr. Scher also tests routinely. He hypothesizes that uptake elsewhere lags mainly because explaining the results is labor-intensive and Lp(a) still lacks targeted therapy.
However, Ricky D. Grisson II, MD, MBA, MPH, FCAP, member of the CAP Clinical Chemistry Committee and Assistant Professor of Pathology and Laboratory Medicine at Brown University, reserves the test for the following patient groups: “This testing is offered to four populations of patients—those with a very low LDL-C and residual cardiovascular risk, a strong family history, mixed dyslipidemia, and a personal history of an early cardiovascular event,” he says.
According to Austin Shuxiao, MD, a board-certified internal medicine physician, “The main scenario that prompts me to use apoB is when a patient’s traditional lipid panel values are either normal, or even slightly abnormal, but have discrepancy with the quality/quantity of their other comorbid problems. If a patient has had 2-3 stents placed and peripheral vascular disease but only mildly elevated LDL, I will order an apoB measurement. If they have a normal lipid panel, but they have diabetes and high blood pressure, I will order an apoB on their next test.”
Impacts, access, and the bottom line
Dr. Grisson says, “Typically, patients with elevated Lp(a) have elevated LDL-C as well, and Lp(a) does not respond to statin therapy. Therefore, patients with elevated Lp(a) are treated with intense lifestyle medicine, in addition to cholesterol-lowering drugs to lower the overall risk of cardiovascular disease.”
ApoB testing is “widely available and inexpensive,” while Lp(a) is “more expensive, but still very easy to order,” reports Dr. Scher. Echoing the broad availability, Dr. Oen-Hsiao notes that most laboratories offer both assays, pricing apoB at roughly $20–$100 and Lp(a) at $40–$100—ranges comparable to a standard lipid panel ($39–$99). He adds that patients keen on fuller risk profiling seldom view these prices as prohibitive.
Particle-based metrics capture residual risk missed by LDL-C, and multiple guidelines already recognize apoB and Lp(a) in risk-stratification algorithms. As laboratory access widens and costs narrow toward standard lipid-panel prices, widespread adoption may be less a question of if than when.
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