The Apo B to Apo A1 Ratio
Dr. Dicken Weatherby & Beth Ellen DiLuglio, MS, RDN, LDN
There is so much more to cholesterol than meets the eye!
Apolipoproteins are structural, functional components of lipoproteins that facilitate cholesterol transport in the blood.
- ApoB is a constituent of VLDL and LDL.
- ApoA1 is a constituent of HDL.
Research indicates that evaluating the ratio of ApoB to ApoA1 is a better tool for assessing coronary artery disease than evaluating traditional biomarkers such as total cholesterol, LDL, HDL, triglycerides, or lipid ratios including total cholesterol/HDL-c, LDL-c/HDL-c, and TG/HDL-c.
- An increasing ratio of ApoB to ApoA1 represents increased cardiovascular risk due to a relative increase in atherogenic ApoB or a decrease in protective ApoA1.
- The ratio is strongly related to risk of myocardial infarction and stroke, as well as other cardiovascular disorders.
- Researchers suggest the use of ApoB:ApoA1 ratio as an integral component of cardiovascular risk assessment, especially in those with blood lipids within the normal range.[i]
A 5-year follow up of 1,639 coronary heart disease patients found that those with a higher ApoB:ApoA1 ratio had
- significantly increased risk of complications including multi-branch lesions, angina, MI, hear failure, stroke, and death due to cardiac causes.
- When adjusted for age, gender, BMI, smoking, alcohol, diabetes, and hypertension, the highest quartile for ApoB:ApoA1 ratio was 1.93 (1.1-3.13) while the lowest quartile ratio was
- The ratio was considered superior to the Framingham Risk Score and total cholesterol to HDL ratio for assessing severity and outcome of established coronary heart disease.[ii]
The ratio of ApoB to ApoA1 is useful in the assessment of metabolic syndrome risk as well. A 2009 health nutrition survey of 8,120 subjects in China revealed that both males and females in the highest quartile of ApoB:ApoA1 (0.98 or greater) were at a significant 4.24-fold greater risk of metabolic syndrome compared to the lowest quartile (0.61).[iii]
One study looked at metabolic syndrome risk in 100 patients with type 2 diabetes and revealed an association between ApoB:ApoA1 ratio and metabolic syndrome in men and women. In women an association was also observed between elevated ApoB:ApoA1 and ischemic cardiomyopathy.[iv]
|Clinical Implications High||Clinical Implications Low|
|Atherosclerotic plaque [v]
Cardiovascular disease risk increase [vi]
Rheumatoid arthritis [vii]
Statin therapy monitoring [viii]
|A low/desirable ApoB/Apo A-1 ratio represents decreased atherogenic ApoB and a relative increase in protective Apo A-1|
[i] Lima, Luciana Moreira et al. “Apo B/apo A-I ratio and cardiovascular risk prediction.” Arquivos brasileiros de cardiologia vol. 88,6 (2007): e187-90. [R]
[ii] Tian, Min et al. “Comparison of Apolipoprotein B/A1 ratio, Framingham risk score and TC/HDL-c for predicting clinical outcomes in patients undergoing percutaneous coronary intervention.” Lipids in health and disease vol. 18,1 202. 19 Nov. 2019, [R]
[iii] Jing F, Mao Y, Guo J, et al. The value of Apolipoprotein B/Apolipoprotein A1 ratio for metabolic syndrome diagnosis in a Chinese population: a cross-sectional study. Lipids Health Dis. 2014;13:81. Published 2014 May 14. [R]
[iv] Reynoso-Villalpando, Gabriela Lizet et al. “ApoB/ApoA1 ratio and non-HDL-cholesterol/HDL-cholesterol ratio are associated to metabolic syndrome in patients with type 2 diabetes mellitus subjects and to ischemic cardiomyopathy in diabetic women.” Endocrinologia, diabetes y nutricion vol. 66,8 (2019): 502-511. [R]
[v] Panayiotou, A et al. “ApoB/ApoA1 ratio and subclinical atherosclerosis.” International angiology : a journal of the International Union of Angiology vol. 27,1 (2008): 74-80. [R]
[vi] Walldius, Göran et al. “The apoB/apoA-I ratio is better than the cholesterol ratios to estimate the balance between plasma proatherogenic and antiatherogenic lipoproteins and to predict coronary risk.” Clinical chemistry and laboratory medicine vol. 42,12 (2004): 1355-63. [R]
[vii] Öhman, M et al. “The apoB/apoA1 ratio predicts future cardiovascular events in patients with rheumatoid arthritis.” Scandinavian journal of rheumatology vol. 43,4 (2014): 259-64. [R]
[viii] Walldius, Göran et al. “The apoB/apoA-I ratio is better than the cholesterol ratios to estimate the balance between plasma proatherogenic and antiatherogenic lipoproteins and to predict coronary risk.” Clinical chemistry and laboratory medicine vol. 42,12 (2004): 1355-63. [R]
[ix] Tamang, Hem Kumar et al. “Apo B/Apo A-I Ratio is Statistically A Better Predictor of Cardiovascular Disease (CVD) than Conventional Lipid Profile: A Study from Kathmandu Valley, Nepal.” Journal of clinical and diagnostic research : JCDR vol. 8,2 (2014): 34-6. [R]