Abstract Body: Background
Cholesterol-based lipid measures are widely used to guide lipid-lowering therapy, yet they do not directly quantify atherogenic lipoprotein particle number. Low-density lipoprotein cholesterol (LDL-C) and non–high-density lipoprotein cholesterol (non–HDL-C) may therefore appear controlled despite persistently elevated atherogenic burden. Apolipoprotein B (apoB) directly reflects circulating atherogenic lipoprotein particle number and may identify residual vascular risk not captured by cholesterol-based measures.
Objectives
The objective of this study was to assess the prevalence of discordance between cholesterol-based lipid goals and elevated apoB levels in a nationally representative U.S. population.
Methods
We analyzed data from the National Health and Nutrition Examination Survey (NHANES) cycles spanning 2007–2008 through 2015–2016, the survey years in which apoB was measured. Adults with available fasting apoB, LDL-C, high-density lipoprotein cholesterol, triglycerides, and total cholesterol were included. Survey design variables and fasting weights were applied with multi-cycle weights calculated according to NHANES analytic guidance.
Primary outcomes included the proportion of adults meeting cholesterol-based lipid goals and the prevalence of discordance, defined as apoB ≥90 mg/dL among individuals meeting LDL-C <100 mg/dL or non–HDL-C <130 mg/dL.
Results
The analytic sample included 15,311 adults. Nationally, 40.0% met LDL-C <100 mg/dL and 49.2% met non–HDL-C <130 mg/dL. Despite appearing at goal, discordance was common. Elevated apoB levels were present in 5.7% of adults meeting LDL-C goals and 5.0% of those meeting non–HDL-C goals. These individuals would be reclassified as candidates for lipid therapy intensification under an apoB-informed strategy.
Conclusions
In a nationally representative U.S. population, approximately one in twenty adults who appear to meet cholesterol-based lipid goals have elevated apoB, indicating excess atherogenic lipoprotein particle burden despite apparently controlled cholesterol levels. Reflex apoB testing may improve identification of undertreated individuals and support more precise lipid management strategies at the population level.