Using Apolipoprotein B to Manage Dyslipidemia

To the Editor: In their commentary on using apolipoprotein (apo) B to manage dyslipidemia, Harper and Jacobson¹ advocate supplanting low-density lipoprotein cholesterol (LDL-C) and non–high-density lipoprotein cholesterol (non–HDL-C) with apo B for risk assessment and as targets of therapy. Unfortunately, their enthusiasm for apo B is not supported by currently available evidence. In a recent meta-analysis of more than 90,000 individuals in 22 prospective cohort studies performed by the Emerging Risk Factor Collaboration, apo B was not superior to non–HDL-C.² Nor has apo B been shown to be superior to non–HDL-C for predicting risk in statin-treated individuals.^3,4 As Lavie et al⁵ correctly observe in their commentary, we currently lack clinical trial evidence that treatment intensification based on apo B levels in patients with LDL-C and non–HDL-C at goal results in improved clinical outcomes. Such trials are needed to support more aggressive lipid treatment strategies than are currently recommended.