India faces a significant public health challenge due to the high incidence of cardiovascular diseases, which are responsible for nearly one-third of all fatalities in the nation. Alarmingly, there has been a rise in heart attacks among younger populations—individuals in their 30s and 40s—despite normal cholesterol test results. In light of this concerning trend, global cardiology authorities have stated that traditional lipid profiles may no longer suffice for accurately assessing heart attack risks. Recent updates in cholesterol management protocols by leading medical associations, including the American College of Cardiology and the American Heart Association, have introduced two crucial tests aimed at providing a more nuanced evaluation of heart health.

Importance of Apolipoprotein B and Lipoprotein(a) Measurements

The updated guidelines underscore the significance of assessing the novel biomarker apolipoprotein B (ApoB) as a more reliable indicator of cardiovascular risk. Additionally, it calls for every adult to be aware of their levels of lipoprotein(a) or Lp(a), a genetically influenced cholesterol variant correlated with heightened cardiovascular risk. Though these tests are not yet incorporated into India’s lipid management directives, an increasing number of healthcare professionals are advocating for their use, especially among high-risk individuals.

Dyslipidemia’s Role in Heart Disease

Dyslipidemia, characterized by aberrant lipid levels in the blood, remains a major contributor to heart diseases globally. This condition is often marked by elevated total cholesterol, high low-density lipoprotein cholesterol (LDL-C), increased triglycerides, and lowered high-density lipoprotein cholesterol (HDL-C). Such lipid imbalances can result in atherosclerotic cardiovascular disease (ASCVD), where fatty deposits build up inside the arteries, thus raising the likelihood of heart attacks and strokes. The new guidelines propose that measuring ApoB may facilitate better identification of individuals susceptible to such artery-clogging ailments.

Understanding ApoB Levels

The ApoB test quantifies the amount of ApoB protein circulating in the bloodstream, which is integral to various cholesterol-containing particles contributing to plaque formation in arterial walls. Essentially, ApoB acts as a carrier for lipids. Importantly, each LDL particle is associated with one ApoB molecule, which means that measuring ApoB reflects the total number of cholesterol particles capable of causing harm. Preliminary findings indicate that individuals in India may have elevated levels of these atherogenic particles compared to Western populations, with reference values of around 66–133 mg/dL for men and 60–117 mg/dL for women.

High Lp(a) Levels and Their Implications

The second biomarker highlighted in the guidelines is lipoprotein(a), or Lp(a). Unlike most cholesterol metrics, Lp(a) is predominantly influenced by genetic factors and remains relatively constant throughout a person’s lifetime. Experts suggest measuring Lp(a) at least once in adulthood, as elevated levels are linked to a significantly increased risk of cardiovascular diseases. Levels exceeding 125 nmol/L or 50 mg/dL are associated with approximately a 1.4-fold heightened risk of heart attacks or strokes.

Exploring New Therapeutics

Dr. Ashok Seth, a senior interventional cardiologist, highlights the connection between elevated Lp(a) and the high prevalence of premature heart disease in India. Notably, while traditional cholesterol-lowering medications such as statins do not effectively reduce Lp(a) levels, emerging therapies like PCSK9 inhibitors present new treatment avenues. These drugs enhance the liver’s capacity to eliminate harmful cholesterol from the bloodstream. Inclisiran, a recent gene-silencing drug, is among the new solutions available in India.

Importance of Early Detection

The guidelines also advocate for selective use of coronary artery calcium (CAC) scans, which can identify early calcium deposits and plaque in the coronary arteries. Such scans can be crucial for diagnosing atherosclerosis, complementing traditional testing methods. Screening for heart health risks is advised to start by age 30, particularly for those with risk factors like family history, smoking habits, hypertension, or diabetes. Moreover, abdominal obesity is a key risk indicator among Indians, highlighting the importance of waist circumference as a preventative measure.

Rethinking Traditional Cholesterol Tests

Cardiologists emphasize that relying solely on traditional cholesterol tests may overlook concealed cardiovascular risks. As more evidence accumulates, markers like ApoB and Lp(a) may become indispensable in identifying high-risk individuals earlier, potentially aiding in preventing severe cardiovascular events.

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