An evidence-based analysis of the National Lipid Association recommendations concerning non-HDL-C and apoB.

Background: The National Lipid Association (NLA) selected non-HDL-C as its prime index of the cardiovascular risk associated with the apoB lipoproteins. ApoB was recommended only as an optional secondary target after low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (HDL-C) targets were achieved.

Objective: The aims of this analysis were to determine whether (1) all relevant uses of apoB were considered by the NLA; (2) all the relevant evidence was considered by the NLA panel; and (3) all the evidence that was considered was interpreted correctly.

Results: (1) The utility of apoB in the diagnosis of the atherogenic dyslipoproteinemias was not considered. (2) All the relevant observational studies were not identified, and some that were cited were incorrectly interpreted. In particular, an equal hazard ratio for two markers in a group does not mean they will predict risk equally in individuals within the group in whom they are discordant. This matters because discordance analysis consistently demonstrates apoB and LDL particle number are more accurate measures of cardiovascular risk than LDL-C/non-HDL-C. (3) The target levels of apoB selected by the NLA are too high relative to the levels selected for LDL-C and non-HDL-C.

Conclusions: The review of the evidence by the NLA was incomplete. More complete examination of the evidence indicates that apoB is a more accurate marker of cardiovascular risk than non-HDL-C and that the practice of lipidology would be improved by inclusion of apoB along with lipoprotein lipids in routine clinical care.