LDL-c/ApoB ratio is a predictor of MACE in patients with atherosclerosis

The LDL-C/ApoB ratio predicts major cardiovascular events in patients with established atherosclerotic cardiovascular disease

Literature - Drexel H, Larcher B, Mader A, et al., - Atherosclerosis 2021, doi.org/10.1016/j.atherosclerosis.2021.05.010

Introduction and methods

LDL particles vary in size, density and atherogenicity and they can be divided into subclasses [1]. Small dense LDL (sdLDL) particles are more atherogenic than large LDL particles [2-4]. A high proportion of sdLDL was reported in individuals with insulin resistance, including those with obesity, metabolic syndrome, and T2DM [4]. Measuring LDL particle size is time-consuming and expensive. Determining the LDL-c/ApoB ratio overcomes this limitation and is an easy and valid proxy of LDL particle size [5,6,7].

In this prospective cohort study, it was examined whether LDL-c/ApoB is a predictor of MACE in a high-risk cohort of patients with established atherosclerotic CVD.

Patients with established or suspected CAD or PAD were recruited between 1999 and 2008 in a hospital in Austria. Those with previous MI or ACS 3 months prior were excluded. 1389 Patients with CAD and 298 with PAD were included. Follow-up was 9.9 years (SD: 4.6). Primary endpoint was MACE, a composite of CV death, non-fatal MI and non-fatal stroke. Patients were divided into tertiles based on LDL-c/ApoB ratio using cut-off points of 1.23 and 1.46. Low to normal LDL-c/ApoB was ≤1.46 and high LDL-c/ApoB ratio was considered >1.46.

Main results

  • Strongest predictors of LDL-c/ApoB ratio were T2DM and age, followed by gender, smoking and hypertension.
  • Patients in the highest tertile of LDL-c/ApoB ratio had significant better outcome than those in the lower tertiles (log rank p=0.005).
  • In a fully adjusted model, high LDL-c/ApoB ratio was associated with lower MACE (HR 0.87, 95%IC: 0.78-0.97, P=0.013).
  • High LDL-c/ApoB ratio was also associated with lower all-cause mortality and total CV events (HR 0.88, ,95%CI: 0.80-0.97, P=0.012 and HR 0.88, 95%CI: 0.80-0.95, P=0.0003, respectively).


In this prospective cohort study, high LDL-c/ApoB ratio predicted MACE. LDL-c/ApoB ratio may therefore be used as a parameter to optimize risk estimation in patients with manifest atherosclerosis.


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Find this article online at Atherosclerosis

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