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For decades, low-density lipoprotein cholesterol (LDL-C) — the notorious “bad” cholesterol — has been vilified as public enemy number one by the medical profession. Yet none of the hundreds of cholesterol studies performed to date has ever shown that LDL-C causes heart attacks. This unscientific belief has become so ingrained in medical thinking that it’s been termed “the great cholesterol hoax.” Indeed, a large body of research suggests that your level of LDL-C is the worst lipoprotein predictor of your heart attack risk.

Instead, the most predictive measurement is apolipoprotein B-100 (ApoB), which can be checked with a $20 blood test available through almost all medical labs. Widespread use of this test — and the potentially lifesaving information it can provide — could prevent 500,000 heart attacks and strokes over the next 10 years, according to a recent paper published in Journal of the American College of Cardiology. Here’s the scoop on this test, why the BaleDoneen Method recommends it, and what everybody should know about cholesterol testing.

What does the ApoB test measure?

Cholesterol, a waxy substance produced by the liver, is ferried through the bloodstream by molecular “submarines” known as lipoproteins. ApoB is a major component of the four lipoprotein particles that are most harmful to the arteries when found at elevated levels: LDL, intermediate density lipoprotein (IDL), very low density lipoprotein (VLDL), and lipoprotein (a), or Lp(a).

Since each of these particles contains one ApoB molecule, measurements of ApoB reveal the total burden of dangerous lipoprotein particles circulating in your blood. It is similar to counting the number of submarines in an enemy attack force to assess how great a threat they pose. Each of these particles, including LDL particles (LDL-P) can contribute to the development of atherosclerosis (plaque in the arteries that could lead to a heart attack or stroke).

How does the ApoB test differ from the standard cholesterol test?

Based on current guidelines, most medical providers use a cholesterol test that certainly sounds comprehensive. Known as a “lipid profile” or “coronary risk panel,” it checks your levels of total cholesterol, LDL-C, high-density lipoprotein (HDL) — also called “good” cholesterol — and blood fats called triglycerides. The American Heart Association recommends that cholesterol testing start at age 20.

A little-known drawback of the standard test is that it doesn’t directly measure LDL-C. Instead, it tallies total cholesterol, HDL and triglycerides (TG), then uses a mathematical formula to calculate LDL-C, a measurement of the total concentration of cholesterol within the LDL, IDL and Lp(a) particles in the blood sample. However, this formula can be unreliable, particularly if your TG is high, sometimes creating a false sense of security.

Moreover, unlike the ApoB test, the standard test does not measure the number of lipoprotein submarines, such as LDL-P. Instead the test only tells you how much cholesterol cargo the fleet is carrying. Why is this difference important? In a recent study called JUPITER, there was no correlation between the 11,186 participants’ initial levels of LDL-C and their subsequent rate of  heart attacks, strokes and other cardiovascular (CV) events over the next two to five years, while their baseline levels of LDL-P, ApoB, TG and non-HDL cholesterol all predicted future CV risk.

What is the best lipoprotein measurement to predict your risk for atherosclerosis?

Evidence from multiple peer-reviewed studies shows that the most predictive measurement is the ApoB gang of four lipoprotein villains, plus your triglyceride level. Although TG does not cause arterial disease (because these blood fats don’t penetrate the arterial wall and form plaque), for people who already have atherosclerosis, elevated triglycerides nearly triple heart attack risk, according to a Harvard-led study.

This finding dovetails with another study showing that VLDL and IDL both trigger arterial inflammation and more than triple heart attack risk. Since VLDL and IDL are the cholesterol content of the lipoprotein submarines that transport TG in the bloodstream, the study suggests that it’s not TG itself, but rather these two cholesterol thugs, that drive the increased heart attack risk.

We call another member of the ApoB gang, lipoprotein (a), “the mass murderer” because elevated levels of this cholesterol nearly triple risk for heart attacks, according to three studies that included nearly 45,000 people. Having high levels of Lp(a) — an inherited condition that affects about 20% of the population — also raises risk for heart attacks and strokes at a young age.

What about LDL? Of the four cholesterol thugs that comprise ApoB, LDL is arguably the wimp. While patients — and even many doctors — think high LDL is the leading risk factor for heart attacks, a recent study found that 75% of nearly 137,000 men and women hospitalized for heart attacks had “normal” levels of LDL and nearly half had “optimal” levels. As a result, most doctors would not have considered these patients candidates for therapies that might have prevented their heart attacks — a horrifying example of how the LDL-C hoax puts lives at risk by focusing on the least predictive cholesterol measurement.

Should you get the ApoB test instead of the standard cholesterol test?

The BaleDoneen Method recommends that you get the standard and the ApoB test, because both provide valuable information about your heart health. Along with measuring your TG level, the standard test also provides a cholesterol number that ranks as one of the top predictors of heart attack risk: your total-cholesterol-to-HDL ratio (TC/HDL).

If this number doesn’t appear on your cholesterol results, doing the math yourself is simple. For example, if your total cholesterol is 180 mg/dL and your HDL is 60 mg/dL, you’d divide 180 by 60 to get your TC/HDL ratio of three (good). Based on scientific evidence from multiple studies, we consider a ratio of 3.5 to be a desirable target and a number below three to be optimal.

The BaleDoneen Method also recommends having your levels of Lp(a) checked. This blood test, which costs about $20, can be performed at the same time as the conventional cholesterol and the ApoB test. Because the Lp(a) test checks for an inherited condition, if your level is normal, there is no need to be tested again since your genes don’t change. To learn more about Lp(a) testing, check out our blog post, “Most Doctors Don’t Know About this $20 Test for Hidden Heart Attack Risk.