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COMMENT

The results of this study indicate that LDL-C may not be the best lipid marker for identifying residual cardiovascular risk in statin-treated patients. Instead, the authors propose either the use of either apoB or non-HDL-C as preferred biomarkers for this risk. This approach is also supported by expert consensus, which considered non-LDL lipoproteins (non-HDL-C, apoB, remnant cholesterol and lipoprotein(a)) as potential biomarkers of residual cardiovascular risk (1). Based on findings from this appraisal, non-HDL-C was proposed to better reflect the residual risk associated with atherogenic dyslipidemia, characterized by elevated triglycerides with or without low HDL-C, common in high-risk patients at LDL-C goal. Moreover, lipid guidelines recommend either apoB or non-HDL-C as secondary lipid targets, especially among individuals with cardiometabolic disease who may not necessarily have elevated LDL-C levels, due in particular to small and dense LDL (2).
The current study suggested that apoB may be the preferred marker. Such an approach makes sense, given current understanding of the integral role of apoB-containing lipoproteins in atherosclerosis. Each of these lipoproteins contains one molecule of apoB. Thus, apoB is likely to provide a more accurate estimate of residual atherogenic risk than other guideline-recommended lipid targets (3).

There is a possible misconception from this study that LDL-C may no longer be relevant in the context of residual risk. This relates to the finding from discordance analysis that a high LDL-C value with either a low apoB or low non-HDL-C value was not associated with increased risk of either all-cause mortality or MI in statin-treated patients. It should be emphasized, however, that LDL-C remains the primary lipid target for intervention to prevent cardiovascular events. Individuals with high LDL-C levels should receive intensified therapy, preferably combination therapy, to manage their LDL-related risk (2,4).