Research Blog

September 15, 2023

Lipoprotein Biomarkers: ApoB to Apo A-1 Ratio

Optimal Takeaways

Evaluating the ratio between Apo B and Apo A-1 reflects the risk of advanced atherosclerotic CVD, MI, stroke, metabolic syndrome, and diabetic complications. An increasing ratio increases the risk of these cardiometabolic disorders. Apo B is associated with LDL and atherogenic, while Apo A-1 is associated with HDL and is protective.

Standard Range:

Male: 0.00 - 0.77 Ratio  

Female: 0.00 – 0.63 Ratio

The ODX Range: 0.00 - 0.60 Ratio                          

Low ratio of Apo B to Apo A-1 is associated with a decreased risk of CVD due to a relative decrease in atherogenic Apo B and a relative increase in protective Apo A-1.

High ratio of Apo B to Apo A-1 is associated with an increased risk of atherosclerosis and cardiovascular dysfunction, including myocardial infarction and stroke, due to a relative increase in atherogenic Apo B (Yaseen 2021, Tian 2019, Liu 2022). An increasing Apo B:Apo A-1 ratio is associated with a significantly increased risk of metabolic syndrome (Jing 2014, Reynoso-Villalpando 2019), increasing the severity of diabetic retinopathy (Ankit 2017).


Research indicates that the ratio of Apo B to Apo A-1 is a better tool for assessing coronary artery disease than 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 Apo B to Apo A-1 represents increased cardiovascular risk due to a relative increase in atherogenic Apo B or a decrease in protective Apo A-1. The ratio is strongly related to the risk of myocardial infarction, stroke, and other cardiovascular disorders (Tamang 2014, Lima 2007, Tian 2019). An elevated Apo B/Apo A-1 ratio is associated with early, subclinical development of atherosclerosis and dangerous, unstable plaque (Panayiotou 2008).

An Apo B:Apo A-1 ratio of 0.865 or above is considered an independent risk factor for major cardiovascular events, increasing risk by over 3-fold. In diabetic subjects, a ratio above 0.72 was associated with newly diagnosed CAD. An increasing Apo B to Apo A-1 ratio is also highly significantly associated with an increasing Gensini score (GS), a score that reflects the severity of atherosclerosis. It is significantly elevated in myocardial infarction. One cross-sectional observational study of 90 subjects with acute coronary syndrome found that the highest Apo B:Apo A-1 ratio (mean 0.96) was associated with the highest GS scores (above 47). In contrast, the lowest Apo B:Apo A-1 ratio, with a mean of 0.59, was associated with the healthiest GS (below 24) (Yaseen 2021).                          

A 5-year follow-up of 1,639 CAD patients found that complications, including multi-branch lesions, angina, MI, heart failure, stroke, and death due to cardiac causes increased as Apo B:Apo A-1 ratio increased. The ratio was considered superior to the Framingham Risk Score and total cholesterol to HDL ratio for assessing the severity and outcome of established coronary heart disease (Tian 2019).

The ratio of Apo B to Apo A-1 is helpful 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 Apo B:Apo A-1 (0.98 or greater) were at a 4.24-fold greater risk of metabolic syndrome compared to the lowest quartile (0.61) (Jing 2014).

One study examining metabolic syndrome risk in 100 type 2 diabetes patients revealed an association between Apo B:Apo A-1 ratio and metabolic syndrome in men and women. In women, an association was also observed between elevated Apo B:Apo A-1 and ischemic cardiomyopathy (Reynoso-Villalpando 2019).

New call-to-action


Ankit, B S et al. “Stronger relationship of serum apolipoprotein A-1 and B with diabetic retinopathy than traditional lipids.” Indian journal of endocrinology and metabolism vol. 21,1 (2017): 102-15. doi:10.4103/2230-8210.196030

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. doi:10.1186/1476-511X-13-81    

Ivert, Torbjörn et al. “Elevated Apolipoprotein B/A-1 Ratio is Associated With an Increased Risk of Aortic Stenosis: Experience From the AMORIS Cohort.” Heart, lung & circulation vol. 30,7 (2021): 1050-1057. doi:10.1016/j.hlc.2020.12.005

Liu, Dong et al. “Association of the Apo B/ApoA-I ratio with stroke risk: Findings from the China Health and Nutrition Survey (CHNS).” Nutrition, metabolism, and cardiovascular diseases : NMCD vol. 32,1 (2022): 203-209. doi:10.1016/j.numecd.2021.09.033

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. doi:10.1590/s0066-782x2007000600014

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.  

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. doi:10.1016/j.endinu.2019.03.019      

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. doi:10.7860/JCDR/2014/7588.4000

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, doi:10.1186/s12944-019-1144-y      

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. doi:10.1515/CCLM.2004.254

Yaseen, Rehab Ibrahim et al. “The relation between ApoB/ApoA-1 ratio and the severity of coronary artery disease in patients with acute coronary syndrome.” The Egyptian heart journal : (EHJ) : official bulletin of the Egyptian Society of Cardiology vol. 73,1 24. 16 Mar. 2021, doi:10.1186/s43044-021-00150-z  

Tag(s): Biomarkers

Other posts you might be interested in