Elevated non-HDL cholesterol with normal ApoB suggests high VLDL cholesterol and potentially remnant VLDL particles.

“so what is it given the relative lack of particles that makes that such a dangerous condition i'm not sure we know really okay uh there it it there compared to normal there are 40 or 50 times as many of these particles but i'm not sure i understand why it's so dangerous in terms of particle number i do know that it means you can't just use the apo b when you're trying to make a diagnosis it seems that an analog go ahead and sorry yeah no when i follow a patient i really just look at the apob for normal patients that i'm treating with statins i only have to get one number right it seems that those particles are more atherogenic sort of in the way that an lp little a is more atherogenic so if you did a thought experiment and you said you know you take three people who all have the same apo b concentration but they could have three very different predicted risks if one of them has a very very high lp little a concentration another one has a normal phenotype and another one has a type three as we've just described yeah the the the first and the third have a much higher risk suggesting that on a particle-per-particle basis they have more atherogenic particles or particles that contribute to clinical events yeah i agree yeah the for me and for my practice uh i measure a light lipid panel i measure an lp little a in everybody and i measure a pob i measure the lp little a once when lp little a is high but apob is normal lp little ape may not add that much to risk but when you got two of them it's a double whammy and that i use as an another piece of information in trying to frame for the patient the potential futures that they face and so alan what is the treatment for the patients that are type threes these patients with um many cholesterol-rich vldls despite a normal apob statins and or fibrates and the they usually respond very well and the and the the fibrates in that patients remind me their triglycerides are normal or elevated no their triglycerides are elevated they're quite elevated they're vldl particles so the triglycerides are elevated we made up a a algorithm that's um i think it's the w the apo b app apo b app where you could plug in the total cholesterol triglyceride napo b and you get the diagnosis of any of the atherogenic capable dystrophies yeah that was a fantastic app i can still use it on my desktop but for some reason it stopped working on the phone does that am i the only one that has that's right it stopped working on on google and app but it's on the web yeah and remind me everybody available from the yeah what's the what's the url www dot apo b app dot app right app i think no i think it's just apob app okay do it i i saved it in my browser because i remember it was a counter-intuitive play i just actually relied on it i looked i looked something up a month ago on it so it's a great little yeah and he walks you through all the diagnostics he walks you through all this diagnosis and and it look a lot of people the part of the argument against um apob people say it makes things too complicated if i explain to a patient that they've got a lot of bad particles cholesterol particles they get it when when i review the results of how well somebody's doing on statins if their triglycerides were high to begin with they're unlikely to normalize the hdl cholesterol is unlikely to normalize i i so their apob is good they're good that's my target of therapy and because it's the total number of um uh of atherogenic particles and nordisguard had a lovely paper recently in uh was it jammu cardiology uh on on a discordance analysis of non-hdl cholesterol and apob and showing that apob was a more accurate index on statin treatment than non-hdl cholesterol it's a lovely paper yeah i mean frankly i find it much easier to explain to patients what apob is than to explain what non-hdl cholesterol is i do too i mean a non-number is hard to explain and it's interesting to me that with all the emphasis that's so many of the lipid guidelines have put on non-hdl cholesterol they all still say ldl cholesterol and the american guidelines clearly state apob and non-hdl are better than ldl but the world is has remained and it's a phenomenon that i'm that i don't really understand how resistant the lipid world has been to change but i think it's important to understand because we'll understand things like afghanistan and the financial crisis in 2008 and a whole series of bad decisions by good people thinking as hard as they could but when everybody in the room has the same opinion going in it's a bad way to solve problems yeah i mean are you optimistic i mean is this just a question of time i mean in in 10 years will kids in med school be learning about apob instead of ldl i'm pessimistic uh europe the 2019 guidelines were very pro-apopey and the evidence from mendelian randomizing like the newer technologies mendelian randomization they've just been slam dunk for apob let's explain that to folks because i want to talk about the causality of this and this might be the perfect way to to to actually explain the causality of apob in the context of this tool so can you explain to folks what a mendelian randomization is the word people see this all the time in studies but i don't i don't think it's entirely clear for the average person what it means i'll try okay it's not my expertise but i'll try”

“that's a freebie on the lipid profile it's basically total cholesterol minus HDL cholesterol so that means it's the cholesterol that is in your vldls and ldls”

“if your LDL cholesterol apob B is looking good but your vldl cholesterol is still high that would drive non-hdl cholesterol to be higher than it should”