Can anyone explain how/why Apo B/A1 are better markers of CVD risk than HDL and LDL?

#1

I’ve always had high HDL and low trigs, both pre- and post-keto. Most recent bloods were 72 and 71, respectively. LDL went up about 100 points since keto and has been fairly consistently at 270 for the past 3 years.

I requested additional lipid markers last week out of curiosity. Not surprisingly, Apo B was high (184, “bad”) and so was A (171, good?). I also got a lipoprotein A, which was in normal range 44.5. The problem is, I have no idea how to interpret these numbers! Are they reassuring relative to my high LDL? Or just saying the same thing? TIA!

(Bob M) #2

The short answer: they are no better. I was following someone on Twitter who had a massive list of studies where ApoB was a terrible marker for heart disease.

If you really want to know risk, get a coronary calcification scan done. It measures calcified plaque in your arteries. (There are other measurements that are better, which also measure non-calcified plaque, but good luck getting that approved.)

(You've tried everything else; why not try bacon?) #3

I am old enough to remember the progression from total cholesterol being bad, to “no, it’s really the LDL,” to “no, it’s really the small, dense LDL,” and now to “no, it’s really the oxidised LDL.” I guess “no, it’s really the ApoB” is the next stage in the progression. At some point, we’re going to have to realise that it’s not about lipids at all, but I suspect that, as Planck observed, a lot of people in authority are going to have to die off, first, before any new idea can take hold.

At any rate, the ratio of triglycerides to HDL and the particle-size pattern (large, buoyant versus small, dense) have as strong an association with cardiovascular risk as anything else, and are better predictors of risk than other lipid values (they also associate so strongly that a low ratio of triglycerides to HDL is an absolute predictor of a healthy Pattern A of particle sizes).

Myself, I don’t believe that cholesterol or lipid particles have any kind of causal role in cardiovascular disease; at best they are markers for the disease, and the presence of cholesterol in arterial plaque seems to be part of the repair process. As Dr. Phinney likes to say, “Blaming atherosclerosis on cholesterol makes about as much sense as blaming fires on fire engines.”

(Michael) #4

Can you link the list to me by chance? Would be very curious, as I have not read any papers saying such a thing.

Not sure that tells anyone how they are doing at all. Sure, it tells you how you have been doing in the past, but not how it is going now. While I would agree it is a great predictor if you have not changed much in the recent years, but if you went low carb last year, imho it tells you nothing except how bad your diet USED to be. My doc is trying to get a CT-Angiogram for me, since his opinion matches mine, that a CAC score will only tell me that I used to be a dumbass eating too much sugar. Now, if your diet has not changed in 10 years, then it could be very useful.

(You've tried everything else; why not try bacon?) #5

You need a baseline to establish a trend in your Agatston score. So if it’s stable or declining, that means minimal risk; increasing is something to worry about. Although I’m not sure the reasoning is entirely accurate, at least in the case of someone who has embarked on a ketogenic or carnivore diet. We had at least one person whose CAC score continued to rise for a while after he started keto, before coming back down.

Other measures are CIMT (coronary intima media thickness) scan, and another scan, the name of which I am suddenly blocking on. But the scan I’m trying to remember and the CIMT measure soft plaque, whereas the CAC measures only hard plaque, which is a later stage in the process, I believe.

(KM) #6

I really must know how or why you managed to get a doctor fighting on your behalf for a CT-angio. !!!

(Michael) #7

Step 1, get an LDL-C value of over 325 mg/dL :slight_smile:

(KM) #8

Oh. :frowning:

#9

What was it pre-keto?

(Michael) #10

Around 150 or so

(You've tried everything else; why not try bacon?) #11

When I got my lipids done in 2018, 150 was still the upper limit of normal LDL. (Mine was 148, and I asked Dr. Berry at Ketofest that year if I should be worried. He said no.)

Nowadays, the statin manufacturers have lowered the upper limit to 90, because studies have shown a positive correlation between the number of people taking statins and the annual bonuses of pharmaceutical company executives.

(Alec) #12

Mine was measured at 450 6 weeks ago. You can imagine what the Dr said! :joy::joy::joy::joy::man_facepalming:

(Alec) #13

Some of us realise this Paul (I suspect you are one), but we are a rare breed. The key is to manage the medical interface well ie leave without a statin prescription (in all circumstances).

(Michael) #14

I admire your courage and conviction. I am not on a statin either, however, I am not so convinced that I have nothing to fear. I DO believe that a metabolically healthy individual need not fear high LDL, but I am not metabolically healthy. As such I have concerns about what MY high LDL means for me. As always I prefer to follow science over dogma, with the only problem being the science is weak but also sufficient to justify my concerns. I would take a statin tomorrow if I had any knowledge of CVD damage currently. Only a CT angiogram can give that information, well, or an event :worried:. Hopefully we will be fine.

(You've tried everything else; why not try bacon?) #15

I don’t think I would take a statin, even with heart trouble. The reasons are that (1) my family has a propensity to Type II diabetes (the main reason I went keto in the first place), (2) I need all the functionality I can retain for my brain, (3) I can’t afford the muscle pain, and (4) even though I’m not using the equipment with anyone else anymore, I still want it to be in working order.

Not only that, but Nick Mailer’s lecture at Ketofest a few years ago on the mevalonate pathway (the mechanism by which statins do their work) was really scary.

(Alec) #16

Well, I am “only” an n=1, but I have had sky high LDL my whole life: 250-450 range. I am 58, so high LDL has had a lot of time to do its damage.

I had a CAC scan done 6 weeks ago. Result: CAC score of 10, meaning very close to zero calcification. People get CAC scores of 600, 800, 1000, 1400: they have CVD. If high LDL causes CVD, why is my calcification so low given I have had high LDL for nearly 60 years?

There is now a lot of evidence that LDL is neither a cause of CVD nor even a good marker for it.

Statins do 2 things: they reduce your LDL (doesn’t help in any way), and they reduce inflammation. They may help marginally if you are inflamed, but of course this doesn’t remove the source of the inflammation, which is the real problem.

Statins only continue to be prescribed because the pharma industry is excellent at pulling the wool over the eyes of doctors. And doctors are not prepared to go against the defined “standards of care” that they are expected to perform.

Statins will go down as one of the most expensive scams in history. On both monetary and health outcomes.