Summary

• Get your apoB tested. ApoB is a biomarker that has significant implications for your cardiovascular health. You measure it through a blood test you can ask your doctor for. We also include it in the Ray Wu MD system. Email us at [email protected] to apply for the beta.
• ApoB is the best measure for "bad cholesterol." It is way more accurate and predictive than LDL.
• If you have a high level of apoB, we highly recommend lowering it aggressively. Decreasing ApoB directly lowers your risk for getting a heart attack.
• If you have low apoB, you are unlikely to suffer from heart disease or stroke, so lets all have low apoB!
• There are very effective medications for lowering apoB. Following a good nutrition plan can also help.

I want to prevent heart disease.

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Ray's Take

Everyone should ask for their doctor for an apoB test, and not accept the traditional cholesterol test which includes only Total cholesterol, LDL, triglyercides, and HDL.

Why? ApoB is a direct measurement for the number "bad" particles you have as every LDL has exactly one apoB. Direct measurement means that the test is actually measuring the number of particles you have in your blood.

Contrast this with LDL, which is calculated i.e. the LDL is estimated based on total cholesterol, triglycerides, and HDL. This estimation is often wrong and inconsistent!

ApoB also captures the number of other "bad" cholesterol you have as VLDL, IDL, and Lp(a) also has exactly one apoB. Thus it is a more accurate and comprehensive test.

Your goal is to get apoB as low as possible, as soon as possible. A good target is under 90 mg/dl but under 60 mg/dl is even better. This is especially important if you have high Lp(a), a biomarker everyone needs to measure.

We are fortunate to have many medications that can lower apoB, which include statins, PCSK9 inhibitors, and more. Following a good nutrition plan with plenty of fiber, unsaturated fats (olive oil, avocados, fish) with low to moderate saturated fat (butter, red meat) can also be beneficial for optimizing apoB. Think mediterranean diet...

Stupid Ideas

Stupid: Regular cholesterol tests and LDL are good enough
RW response: Might be good enough for you, but it's not good enough for me and the people I care about. LDL is usually calculated meaning its not measured directly. It is calculated based on triglycerides, HDL, and total cholesterol and honestly isn't accurate. In any case, LDL calculations don't include the particle count from VLDL, IDL, and Lp(a) which apoB includes.

Stupid: If my LDL is good, I don't need to worry about getting apoB
RW response: I'd still check it. There are many times when people think their LDL is good, but then check their apoB and it is sky high.

Stupid: My apoB is high, I'm gonna die.
RW response: No, you're not. The way heart disease works is.....very slowly. To go through the full atherogenic process takes time. Usually a long time. Age is the most powerful factor for predicting heart disease. The factors that decrease the time until a bad event include having high apoB and high Lp(a). Thus, the right thing to do is test asap and get the apoB down if its high asap. See below section to learn more.

Cool knowledge for normal people

ApoB100 aka ApoB

Image from Dr. Thomas Dayspring

There is one apoB (same thing as apoB100) on each beta-lipoprotein particle (which includes VLDL, IDL, LDL, and Lp(a)). 90% of apoB containing particles are LDL.

These lipoproteins transport cholesterol in our bloodstream, because cholesterol alone is not soluble in water. Cholesterol is a waxy substance that is essential for life, but having high levels of beta-lipoproteins (and LDL makes up the majority) can cause heart disease and stroke.

How does this actually happen?

Step 1 - LDL delivers cholesterol to where it needs to go (cells need cholesterol for their cell membranes, and other essential functions)

Step 2 - If LDL is high, it can get into the subendothelial space, which is a space within the blood vessel, itself and gets stuck.
Note: your LDL is high when there is more LDL around than your liver can clear. If there is too much LDL around, there are miles of blood vessels for them to get stuck in.

Step 3 - Once the LDL gets stuck, it gets oxidized which means it gets combined with oxygen. But Oxidized LDL particles are toxic to the blood vessel, so inflammation starts to occur.

Step 4 - Lots of inflammatory processes occur which injures the blood vessel wall (see below section if you care about the details) .

Step 5 - A plaque forms to heal the injured wall.

Step 6 - The plaque gets bigger and bigger and starts to obstruct (aka block) the lumen (the inside of the blood vessel)

Step 7 - The plaque can become unstable and rupture, which causes a full clot, which results in heart attack or stroke.

Ok so who cares?
Well we care, because endless scientific studies have shown that if we reduce the number of LDL particles, we reduce the risk of heart attack and stroke! And as explained above, the best measure of LDL particles is apoB.

Thus if we reduce apoB early and aggressively, your blood vessels will not go through the steps above and you will not get a heart attack or stroke.

Best ways to reduce apoB
The best way to reduce cholesterol is through medications. Statins are cheap and effective (and yes they are proven to be worth it), and PCSK-9 inhibitors work wonders (only downside being they are usually not covered by insurance so they cost $500 a month). If your apoB is over 90, you should 100% talk to your doctor about cholesterol lowering medications, or contact us to solve this important problem.

Diet can also have an effect on apoB. Our recommendation is to limit refined carbs, have plenty of unsaturated fat (olive oil, avocados, nuts, fish) and vegetables, and have a low to moderate amount of saturated fat (butter, red meat). We call this a mediterranean low-carb diet.

I want to prevent heart disease.

Add this objective to your health program

More info for nerding out

From Mass Spectrometry Reviews
Proteomic studies on apoB-containing lipoprotein in cardiovascular research: A comprehensive review

From Jama Cardiology
Apolipoprotein B Particles and Cardiovascular Disease: A Narrative Review.

From Peter Attia
When does heart disease begin (and what this tells us about prevention)?

From Simon Hill
How Endothelial Dysfunction Causes Atherosclerosis with Dr Thomas Dayspring