DOI: 10.1161/jaha.123.030405 ISSN: 2047-9980

Standardization of Apolipoprotein B, LDL‐Cholesterol, and Non‐HDL‐Cholesterol

John H. Contois, Michel R. Langlois, Christa Cobbaert, Allan D. Sniderman
  • Cardiology and Cardiovascular Medicine


Concern continues about whether the measurement of apolipoprotein B (apoB) is adequately standardized, and therefore, whether apoB should be applied widely in clinical care. This concern is misplaced. Our objective is to explain why and what the term “standardization” means. To produce clinically valid results, a test must accurately, precisely, and selectively measure the marker of interest. That is, it must be standardized. Accuracy refers to how closely the result obtained with 1 method corresponds to the result obtained with the standard method, precision to how reproducible the result is on repeated testing, and selectivity to how susceptible the method is to error by inclusion of other classes of lipoprotein particles. Multiple expert groups have determined that the measurement of apoB is adequately standardized for clinical care, and that apoB can be measured inexpensively, using widely available automated methods, more accurately, precisely, and selectively than low‐density lipoprotein cholesterol or non‐high‐density lipoprotein cholesterol. ApoB is a standard superior to low‐density lipoprotein cholesterol and high‐density lipoprotein cholesterol because it is a defined molecule, whereas the cholesterol markers are the mass of cholesterol within lipoprotein particles defined by their density, not by their molecular structure. Nevertheless, the standardization of apoB is being further improved by the application of mass spectrophotometric methods, whereas the limitations in the standardization and, therefore, the accurate, precise, and selective measurement of low‐density lipoprotein cholesterol and high‐density lipoprotein cholesterol are unlikely to be overcome. We submit that greater accuracy, precision, and selectivity in measurement is a decisive advantage for apoB in the modern era of intensive lipid‐lowering therapies.

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