This Simple Blood Test Could Outperform “Bad Cholesterol” in Preventing Heart Disease

ApoB testing outperforms traditional cholesterol measures in preventing heart attacks and strokes while remaining cost-effective. It more accurately identifies risk, leading to better treatment decisions.

A common blood test used by millions of people in the U.S. each year to measure “bad” cholesterol may not be the most reliable tool for guiding treatment or preventing heart attacks and strokes, according to a new Northwestern Medicine study published in JAMA.

Researchers found that a different test, apolipoprotein B (apoB), performed better than LDL and non-HDL cholesterol in directing cholesterol-lowering treatment, including the use of statins and other medications.

“We found that apoB testing to intensify cholesterol-lowering medication would prevent more heart attacks and strokes than current practice, and that these health benefits were achieved at a cost that represents good value for U.S. healthcare payers,” said study lead author Ciaran Kohli-Lynch, assistant professor of preventive medicine in the division of epidemiology at Northwestern University Feinberg School of Medicine.

ApoB Improves Treatment Outcomes

Kohli-Lynch noted that this is the first comprehensive analysis to demonstrate that using apoB to guide cholesterol treatment is cost-effective.

Heart disease remains the leading cause of death in the United States and contributes heavily to healthcare spending. Cholesterol-carrying particles can become trapped in arteries, forming plaques that may eventually block blood flow and trigger heart attacks or strokes.

For many years, doctors have relied on LDL, often referred to as “bad cholesterol,” along with non-HDL levels to determine when to begin or intensify treatment. While useful, these measures do not fully capture a patient’s cardiovascular risk.

Why ApoB Is More Accurate

“Research strongly shows that apolipoprotein B (apoB) is better at identifying who is at risk, because it counts the total number of harmful particles in the blood,” explained Kohli-Lynch.

Even with growing evidence, apoB testing is still uncommon in routine care. One reason is cost and convenience, since it usually requires an extra blood test beyond the standard cholesterol panel.

“Our study asked, is it worth spending extra money to use apoB instead of LDL to guide treatment intensification?” Kohli-Lynch said.

Study Design and Comparison Methods

To explore this question, researchers built a large computer simulation that represented 250,000 U.S. adults who were eligible for statins but did not yet have cardiovascular disease.

They evaluated three treatment strategies:

• LDL cholesterol (goal <100 mg/dL)
• Non-HDL cholesterol (goal <118 mg/dL)
• ApoB (goal <78.7 mg/dL)

If patients failed to reach their target, treatment was stepped up by prescribing stronger statins and then adding another drug, ezetimibe. The model followed patients over their lifetimes, tracking outcomes such as heart attacks, strokes, life expectancy, quality of life, and healthcare costs.

Results Show ApoB Advantage

Care guided by apoB performed better than the other approaches, leading to improved overall health outcomes and saving more lives in a cost-effective way.

In the past decade, the number of medications available to lower cholesterol has increased significantly. In addition, the American Heart Association and 10 other medical organizations released new guidelines earlier this year recommending that many patients begin cholesterol treatment at younger ages.

“This means it is increasingly important to accurately identify who would benefit most from intensive treatment,” Kohli-Lynch said.

Reference: “Cost-Effectiveness of ApoB, Non–HDL-C, and LDL-C Goals for Primary Prevention Lipid-Lowering Therapy” by Samuel Luebbe, Allan D. Sniderman, Andrew E. Moran, John T. Wilkins and Ciaran N. Kohli-Lynch, 8 April 2026, JAMA.
DOI: 10.1001/jama.2026.2986

The study was supported by the American Heart Association Career Development Award 24CDA1274989 (Dr. Kohli-Lynch).

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