Beyond Low-Density Lipoprotein Cholesterol. Defining the Role of Low-Density Lipoprotein Heterogeneity in Coronary Artery Disease

James O. Mudd, Barry A. Borlaug, Peter V. Johnston, Brian G. Kral, Rosanne Rouf, Roger S. Blumenthal, Peter O. Kwiterovich

Research output: Contribution to journalReview articlepeer-review

110 Scopus citations


Recent clinical trials in patients with coronary artery disease (CAD) provide evidence that low-density lipoprotein cholesterol (LDL-C) levels should be lowered even further to prevent recurrent CAD. However, despite more aggressive interventions for lowering LDL-C levels, the majority of CAD events go undeterred, perhaps related to the fact that intervention was not started earlier in life or that LDL-C levels represent an incomplete picture of atherogenic potential. Nevertheless, LDL-C remains the contemporary standard as the primary goal for aggressive LDL reduction. If triglycerides are >200 mg/dl, the measurement of non-high-density lipoprotein cholesterol (HDL-C) is recommended. Measurement of apolipoprotein (apo)B has been shown in nearly all studies to outperform LDL-C and non-HDL-C as a predictor of CAD events and as an index of residual CAD risk. This is because apoB reflects the total number of atherogenic apoB-containing lipoproteins and is a superior predictor of the number of low-density lipoprotein particles (LDL-P). Estimates of LDL-P and size can also be made by nuclear magnetic resonance spectroscopy, density gradient ultracentrifugation, and gradient gel electrophoresis. Although a number of studies show that such estimates predict CAD, LDL-P, and size often accompany low HDL-C and high triglyceride levels, and therefore such additional lipoprotein testing has not been recommended for routine screening and follow-up. Because apoB is a superior predictor of LDL-P, we recommend that apoB and the apoB/apoA-I ratio be determined after measurement of LDL-C, non-HDL-C, and the ratio of total cholesterol/HDL-C to better predict CAD and assess efficacy of treatment.

Original languageEnglish (US)
Pages (from-to)1735-1741
Number of pages7
JournalJournal of the American College of Cardiology
Issue number18
StatePublished - Oct 30 2007
Externally publishedYes

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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