Beyond “Good and Bad Cholesterol’ - what Lipoprotein a), Apo B and Apo A1 tell you about heart risk?
Every week, we meet patients who are puzzled about their cholesterol results. They tell us they’re eating well and exercise regularly but then ask if their cholesterol numbers are good, bad or in between?
What most people do not realise is that HDL (good cholesterol) and LDL (bad cholesterol) only scratch the surface of what we know. To really understand there are a few deeper markers that tell us far more about your long-term cardiovascular risk than cholesterol ever could.
Here are the markers you should discuss with your private GP at One5Health:
Apo B: the marker that actually predicts risk
Not just another cholesterol marker!
The protein ApoB, is the actual count of particles that can cause artery plaque. Every LDL particle and all other lipoproteins carry this protein. The ApoB test tells us how many of these particles are circulating in the bloodstream.
Why is this important?
The higher the number of particles , the greater the chance that some enter the artery wall, leading to plaque, inflammation and eventually heart attacks and strokes.
The good news?
Apo B gives a more precise target and is very responsive to lifestyle changes.
If Apo B is high: tightening lifestyle changes around nutrition, weight and activity with concrete targets and intensifying cholesterol lowering therapy such as statins can improve these numbers and cardiovascular risk.
If Apo B is well controlled: it can reassure you and your GP that treatment is actually achieving the risk reduction you are aiming for.
“Medicine is moving beyond simple cholesterol tests. Markers like Apo B, Apo A1, and Lp(a) help us understand not just your cholesterol levels, but why your cardiovascular risk may be higher, and what we can do about it.”
-- Dr Amisha MehtaLp (a): the inherited risk you cannot ‘lifestyle away’
If Apo B shows us what’s happening right now, Lipoprotein (a) or Lp(a), tells us about your inherited risk and is almost entirely genetic. You’re born with this level and it barely changes throughout your life. Lifestyle can not meaningfully shift it.
Lp(a) levels vary widely - some people have very low amounts whilst others have levels of 50, 100 or even 200 times higher.
Why is it important?
High levels don’t guarantee you'll have heart disease, but it is linked with early heart attacks, stokes and aortic valve narrowing.
Who should consider Lp (a) testing?
Given it’s a once in a lifetime test, which gives additional information about your heart health, everyone should consider the blood test at some point. However, if heart disease runs in your family, especially if a parent, sibling or close relative had a heart attack or stroke at a young age, we would strongly recommend having this test.
What can be done if Lp (a) is high?
Emerging treatments are in development, however, knowing if this marker is high, changes how aggressively you and your GP tackle everything else. Together we can be far more proactive about reducing other risk factors: blood pressure control, Apo B, insulin resistance, weight, smoking and inflammation, which will then reduce your overall risk of heart disease.
Apo A1: how ‘protective’ is your good cholesterol?
ApoA1 (or ApoA) is the main protein found on the HDL particles - the ‘good’ cholesterol. HDL helps remove cholesterol from the artery wall and carry it back to the liver for disposal. ApoA gives us an extra layer of information beyond a simple HDL number. A high number generally indicates lower cardiovascular risk,
When is it useful?
ApoA is usually interpreted alongside ApoB, giving an APoPb/ApoA1 ratio. A higher ratio means more bad particles compared with protective ones. A lower ratio means a more favourable balance. Lifestyle, diet and nutrition tend to improve ApoA1 naturally.
Final thoughts
Lipoprotein (a): A genetically determined particle strongly linked with early heart disease stroke.
Apo B: Reflects the total number of atherogenic (artery-clogging) particles.
Apo A1: The main protein on HDL, indicating how protective your ‘good cholesterol’ really is.
Should you get tested?
If you have questions about your cholesterol, have a strong family history of heart disease, these tests are absolutely worth discussing with your doctor. Medicine is moving beyond simple cholesterol tests and these tests are helping us to understand the ‘why?’.
Bring these up at your next appointment, a little extra knowledge can really change the trajectory of your long term-health. You can also explore our Heart Health Programme here.
