For decades, cholesterol has been a primary focus in the discussion of cardiovascular health. Conventional wisdom has held that high cholesterol levels directly correlate with an increased risk of arterial sclerosis and heart disease. However, recent research suggests that cholesterol alone may not be the most accurate indicator of these conditions. Instead, apolipoprotein B (ApoB) and the coronary artery calcium (CAC) score are emerging as more reliable predictors.

The Limitations of Cholesterol as an Indicator

Cholesterol is a fatty substance found in the blood, and it is essential for building cells and producing hormones. It travels through the bloodstream in lipoproteins, which are classified based on their density: low-density lipoprotein (LDL) and high-density lipoprotein (HDL). LDL is often labeled as “bad” cholesterol because it can lead to plaque buildup in arteries, while HDL is considered “good” cholesterol because it helps remove LDL from the bloodstream.

Despite this dichotomy, cholesterol levels can be misleading. Many people with normal cholesterol levels still experience heart attacks or strokes, while others with high cholesterol live long, healthy lives without cardiovascular issues. This discrepancy indicates that cholesterol alone does not provide a complete picture of cardiovascular risk.

Apolipoprotein B: A Better Indicator

Apolipoprotein B is a protein found in lipoproteins, including LDL, very low-density lipoprotein (VLDL), and intermediate-density lipoprotein (IDL). It plays a crucial role in the metabolism of lipids and is essential for the formation of atherogenic particles that can lead to plaque buildup in arteries.

Unlike total cholesterol or LDL cholesterol, ApoB provides a more accurate measure of the number of atherogenic particles. Each atherogenic particle contains one ApoB molecule, making ApoB a direct indicator of the number of particles that can contribute to arterial sclerosis. Studies have shown that high levels of ApoB are strongly associated with an increased risk of cardiovascular events, even in individuals with normal cholesterol levels.

Optimal ApoB Levels: According to Dr. Peter Attia, optimal ApoB levels should be below 80 mg/dL for those at low to moderate risk and below 60 mg/dL for those at high risk of cardiovascular disease.

What Causes High ApoB Levels?

Several factors can contribute to elevated ApoB levels:

  1. Diet: Diets high in saturated fats and trans fats can increase the production of LDL particles, thereby raising ApoB levels. Consuming excessive amounts of sugar and refined carbohydrates can also contribute to high ApoB.
  2. Genetics: Genetic predispositions, such as familial hypercholesterolemia, can lead to naturally higher ApoB levels due to increased production or decreased clearance of LDL particles.
  3. Obesity: Excess body fat, particularly visceral fat, is associated with higher ApoB levels. Obesity often correlates with insulin resistance, which can exacerbate lipid abnormalities.
  4. Insulin Resistance and Diabetes: Insulin resistance and type 2 diabetes can lead to dyslipidemia, characterized by elevated triglycerides, low HDL, and high ApoB levels.
  5. Lack of Physical Activity: Sedentary lifestyles can contribute to unfavorable lipid profiles, including higher ApoB levels.
  6. Chronic Inflammation: Conditions that cause chronic inflammation, such as metabolic syndrome, can lead to elevated ApoB levels.
  7. Smoking: Tobacco use is associated with higher levels of ApoB and other atherogenic lipoproteins.

The Coronary Artery Calcium (CAC) Score

Another powerful tool in assessing cardiovascular risk is the coronary artery calcium (CAC) score. The CAC score is determined through a specialized CT scan that detects the presence and extent of calcified plaque in the coronary arteries. Calcified plaque is a marker of atherosclerosis, the hardening, and narrowing of arteries due to plaque buildup.

The CAC score is a strong predictor of future cardiovascular events. Unlike cholesterol levels, which can fluctuate due to various factors, the CAC score provides a direct measure of the disease process within the arteries. A higher CAC score indicates a greater burden of atherosclerosis and a higher risk of heart attack or stroke.

Optimal CAC Score: Ideally, a CAC score of zero indicates no detectable plaque and a low risk of cardiovascular events. Scores between 1 and 100 suggest mild to moderate plaque burden, while scores above 100 indicate a higher risk, warranting more aggressive management and monitoring.

Integrating ApoB and CAC Score for Comprehensive Assessment

For a more comprehensive assessment of cardiovascular risk, it is beneficial to consider both ApoB levels and the CAC score alongside traditional cholesterol measurements. ApoB offers insight into the number of atherogenic particles, while the CAC score provides a direct measure of atherosclerosis. Together, these indicators can help identify individuals at high risk who may benefit from more aggressive interventions.

Expert Insights

Dr. Peter Attia, a renowned physician specializing in the science of longevity, emphasizes the importance of looking beyond traditional cholesterol measurements. According to Dr. Attia, focusing on ApoB and CAC scores provides a clearer understanding of cardiovascular risk and helps in tailoring more effective prevention strategies.

Dr. Mark Hyman, a leading functional medicine expert, also supports this approach. He advocates for a comprehensive assessment that includes advanced lipid testing and imaging techniques like the CAC score to accurately evaluate heart health. Dr. Hyman’s perspective aligns with the growing consensus that traditional cholesterol metrics are insufficient on their own.


While cholesterol has long been the focus of cardiovascular health assessments, it is not the most accurate indicator of arterial sclerosis. Apolipoprotein B and the coronary artery calcium score offer more reliable measures of cardiovascular risk. By incorporating these indicators into routine evaluations, healthcare providers can better identify and manage individuals at risk of cardiovascular events, leading to more effective prevention and treatment strategies.

By considering the insights of experts like Dr. Peter Attia and Dr. Mark Hyman, it becomes clear that a shift in focus toward ApoB and CAC scores can revolutionize our approach to cardiovascular health. Optimal levels for ApoB and CAC scores provide clear targets for managing cardiovascular risk, ultimately improving patient outcomes and longevity.



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