As obesity and heart disease continue to rise globally, researchers warn that millions may be getting the wrong cholesterol test to assess their risk of heart attack and stroke.
A new study suggests that a blood test called apolipoprotein B (apoB) may be more effective than the commonly used LDL, or "bad" cholesterol, test in identifying people who need stronger treatment to protect their hearts.
Published in JAMA, the study found that using the apoB test to guide treatment could prevent more heart attacks and strokes while remaining affordable for healthcare systems.
Heart disease is the world’s leading killer, causing nearly 18 million deaths annually, according to the World Health Organisation (WHO). Rising obesity, poor diets, lack of exercise, smoking, and diabetes have all contributed to the growing burden.
Doctors have long relied on the LDL cholesterol test to decide whether patients should take medicines such as statins.
Researchers say the findings showed that using the apoB test to guide cholesterol-lowering treatment could prevent more heart attacks and strokes than the current approach while still offering good value for healthcare systems.
"ApoB testing to guide cholesterol-lowering treatment would prevent more heart attacks and strokes than current practice, and these health benefits were achieved at a cost that represents good value for healthcare systems."
Over time, fatty deposits narrow blood vessels, restricting blood flow to the heart and brain. If a vessel becomes blocked, it can trigger a heart attack or stroke.
Researchers say the apoB test gives doctors a clearer picture of risk. Instead of measuring how much cholesterol is in the blood, it counts the number of harmful particles that can stick to vessel walls. The more particles present, the higher the chance of developing heart disease.
Research shows apoB is a better way of identifying risk because it counts the total number of harmful cholesterol particles rather than simply measuring the cholesterol they carry.
"Research strongly shows that apolipoprotein B is better at identifying who is at risk because it counts the total number of harmful particles in the blood," he said.
To conduct the study, researchers used a computer model representing 250,000 adults eligible for cholesterol-lowering medicine but without existing heart disease.
They compared three approaches: the LDL test, the non-HDL cholesterol test, and the apoB test. If cholesterol levels remained high, treatment was intensified with stronger statins or additional medicines.
The researchers then estimated how many heart attacks and strokes each approach could prevent over a lifetime and how much each strategy would cost.
Results showed that the apoB test produced better health outcomes than the other two methods. It prevented more heart attacks and strokes, helped people live healthier lives, and remained cost-effective despite requiring an extra blood test.
Although scientists have studied apoB for years, it is not yet widely used in routine healthcare because it typically requires an additional blood test. Researchers believe wider adoption could help doctors identify high-risk patients earlier and ensure they receive the right treatment before a heart attack or stroke occurs.
Previous studies have found apoB to be a stronger predictor of heart attacks and strokes than LDL cholesterol because it measures the number of harmful particles rather than just the cholesterol they carry.
Research suggests this provides a more accurate picture of cardiovascular risk, particularly in people with obesity, diabetes or metabolic syndrome.
As a result, several international guidelines, including those from the European Society of Cardiology and the European Atherosclerosis Society, recommend apoB testing for people at high risk of cardiovascular disease.
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