A routine blood test called apolipoprotein B outperforms traditional cholesterol panels in guiding treatment to prevent heart attacks and strokes, according to a Northwestern Medicine study published in JAMA. Meanwhile, new research shows coronary artery calcium testing may not provide much value for many people, though a separate study links calcium scores to broader health risks.
Heart disease remains the leading cause of death in the United States and a major driver of healthcare costs. For years, clinicians have relied on standard lipid panels measuring low-density lipoprotein—often called bad cholesterol—and non-HDL goals to decide when to start and intensify cholesterol-lowering medications such as statins and other medications. But a Northwestern University study suggests that a different blood test provides a much clearer picture of patient risk.
Apolipoprotein B Testing Outperforms Standard Cholesterol Panels
The study found that testing for apolipoprotein B, or apoB, is more effective at guiding cholesterol-lowering therapy than LDL or non-HDL cholesterol. When small, cholesterol-carrying particles become trapped in arterial walls, they form plaques that eventually restrict blood flow and trigger heart attacks and strokes.
“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.”
Ciaran Kohli-Lynch, assistant professor of preventive medicine in the division of epidemiology at Northwestern University Feinberg School of Medicine
Despite this clinical advantage, apoB is not widely integrated into routine medical care. The primary barriers are cost and convenience, as measuring apoB typically requires an additional blood draw beyond the standard lipid profile. To determine whether the added expense is justified, Northwestern scientists constructed a computer simulation model representing 250,000 U.S. adults who were eligible for statins but lacked existing cardiovascular disease.
- LDL cholesterol targeted to a goal below 100 mg/dL.
- Non-HDL cholesterol targeted to a goal below 118 mg/dL.
- ApoB targeted to a goal below 78.7 mg/dL.
When patients failed to reach their assigned threshold, their treatment was intensified by stepping up to stronger statins and subsequently adding ezetimibe. The model evaluated downstream health outcomes including heart attacks, strokes, overall life expectancy, quality of life, and economic costs. The analysis concluded that apoB-guided care outperformed the other two strategies, improving population health and saving lives cost-effectively for U.S. healthcare payers.
New Guidelines Emphasize Precision as Screening Evolves
The timing of the Northwestern findings coincides with a broader shift in cardiovascular care. Over the past decade, the pharmacological arsenal available to lower cholesterol has expanded significantly. Furthermore, the American Heart Association and 10 other medical associations issued updated guidelines recommending the initiation of cholesterol-lowering therapy at younger ages for eligible patients.
“This means it is increasingly important to accurately identify who would benefit most from intensive treatment.”
Ciaran Kohli-Lynch, assistant professor of preventive medicine in the division of epidemiology at Northwestern University Feinberg School of Medicine
While blood biomarkers like apoB gain traction for risk stratification, imaging approaches face a more complex evaluation. Recent research indicates that coronary artery calcium testing, which detects calcified plaque in the arteries supplying the heart, may not provide much value for many people despite its widespread popularity as a screening tool.
Intermountain Health Study Links Calcium Scores to All-Cause Mortality
Even as questions surround routine calcium screening for the general public, large-scale data highlights the broader prognostic significance of coronary artery calcium scores. In a study presented at the American Heart Association Scientific Sessions 2025 in New Orleans, researchers at Intermountain Health in Salt Lake City examined medical records for 40,018 patients who underwent PET/CT stress tests.
Of those patients, 7,967 recorded a calcium score of zero, while 32,051 exhibited varying levels of CAC. Over a five-year follow-up period, investigators tracked all-cause mortality across both cohorts. Patients who had any level of coronary artery calcium faced a two- to three-fold higher risk of dying from any medical condition compared to those with a score of zero.
“Someone’s coronary artery calcium score could be a more powerful predictor of a person’s overall health than we previously thought.”
Jeffrey L. Anderson, distinguished clinical and research physician at Intermountain Health and principal investigator
Strikingly, among the patients with detectable calcium who died during the study window, only about one-quarter succumbed to cardiovascular disease. The majority died from non-cardiovascular medical conditions. Researchers noted that while the exact biological mechanisms remain unproven, widespread arterial plaque may correlate with vascular disease elsewhere in the body or impair immune surveillance mechanisms that protect against other systemic illnesses.
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