This patient with T2DM had lipid panel values that are classically reflective of metabolic dyslipidemia and insulin resistance (low HDL-C and high TG levels). Although her LDL-C level appeared to be at goal (<70 mg/dL) for an individual with T2DM and several ASCVD risk factors, further risk stratification demonstrated a discordantly elevated apo B level of 99 mg/dL.
Individuals with metabolic dyslipidemia tend to have small, cholesterol-depleted LDL particles; thus, calculated LDL-C levels may not be fully reflective of atherogenic particle number. There is one apo B molecule per atherogenic lipoprotein (LDL, VLDL, intermediate-density lipoprotein, and Lp[a]). Discordantly elevated apo B levels relative to LDL-C levels is highest in those with T2DM, obesity, and hypertriglyceridemia. Additionally, discordance may be greater for those taking lipid-lowering therapy who have lower LDL-C levels, but this discordance has been substantially reduced with new equations for calculating LDL-C levels (Martin-Hopkins, Sampson, the National Institutes of Health [NIH] equation) compared with the older Friedewald equation.
Measurement of apo B levels in this patient led to an intensification of lipid-lowering therapy to atorvastatin 40 mg and addition of ezetimibe 10 mg, with a follow-up apo B level of 75 mg/dL.
The 2026 ACC/AHA/Multisociety Guideline on the Management of Dyslipidemia provides a Class 2a recommendation for measurement of apo B levels among individuals taking lipid-lowering therapy, particularly those with clinical ASCVD, cardiovascular-kidney-metabolic syndrome, T2DM, and/or elevated TG levels to guide decisions regarding further intensification once LDL-C goals are achieved. There is a weaker Class 2b recommendation for measurement of apo B levels for individuals not taking lipid-lowering therapy to enhance ASCVD risk stratification and/or guide treatment decisions.
This patient case quiz is part of the larger Implementing the 2026 Dyslipidemia Guidelines: From Risk Stratification to Personalized Treatment initiative, supported by Merck & Co. and Eli Lilly and Company. To visit the Learn Prevention grant page and access additional educational activities on this topic, click here.
References
- Blumenthal RS, Morris PB, Gaudino M, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of dyslipidemia: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2026;87(19):2624-2757. doi:10.1016/j.jacc.2025.11.016
- Sathiyakumar V, Park J, Quispe R, et al. Impact of novel low-density lipoprotein-cholesterol assessment on the utility of secondary non-high-density lipoprotein-C and apolipoprotein B targets in selected worldwide dyslipidemia guidelines. Circulation. 2018;138(3):244-254. doi:10.1161/CIRCULATIONAHA.117.032463
