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Clinical value of apoB testing

Many patients with normal—even optimal—values on a standard lipid panel still experience cardiovascular disease (CVD) events or disease progression.1,2

Measuring only LDL-C in a standard lipid panel isn’t always enough, as it can lead to underestimated risk. But healthcare providers can uncover a more accurate level of risk for CVD by expanding testing to include apolipoprotein B (apoB). This test is well suited to the primary care setting to identify risk earlier, leading to improved outcomes.

In this article:

Clinical challenge | Why it matters | Ordering recommendations | Interpreting test results | Next steps | Supporting resources

 

Clinical challenge: When traditional lipid testing isn’t enough to determine CVD risk

In most primary care settings, LDL‑C remains the default metric for CVD risk assessment and lipid management. Yet many high-risk patients who later have a CVD event have normal LDL‑C test results. This underestimation of risk can occur when triglycerides are elevated.3

Meanwhile, elevated apoB (≥130 mg/dL) is the most common atherogenic dyslipidemia and is a known risk-enhancing factor for CVD.4  Lipid discordance, defined by excess apoB compared to LDL-C, is commonly found in patients with obesity, metabolic syndrome, and type 2 diabetes,4 making apoB testing a more accurate measure for CVD.

While lipid testing is essential to assess cholesterol concentration levels, measuring the number of apolipoproteins or lipoprotein particles has been shown to better predict CVD.1,2,5

Difference between standard lipid testing and apoB testing

Traditional lipid testing reflects the mass of cholesterol within LDL particles, such as LDL-C and non-HDL. It does not measure the number of atherogenic particles.

 

ApoB testing measures the total number of atherogenic particles, thus quantifying the number of particles delivering cholesterol and making apoB results a stronger indicator of atherogenicity than testing LDL-C alone.

 

Why it matters: Importance of CVD risk assessment

Cardiovascular disease, including heart disease and stroke, can be prevented. However, CVD remains the leading cause of death and the most expensive disease in the US, costing nearly $1 billion every day.6

Expanding the way primary care providers can identify CVD risk through apoB testing has the potential to improve patient outcomes. The use of apoB testing is recommended by several medical organizations, including

  • American College of Cardiology (ACC)7,8
  • American College of Endocrinology (ACE)9
  • American Heart Association (AHA)7,8
  • European Atherosclerosis Society (EAS)3
  • European Society of Cardiology (ESC)3
  • National Lipid Association (NLA)10,11
  • The American Association of Clinical Endocrinologists (AACE)9
  • World Heart Federation (WHF) Cholesterol Roadmap12

 

The burden of cardiovascular disease in America

49%

of American adults have CVD13

1T

in annual healthcare costs are due to CVD6

33%

of deaths in the US are attributed to CVD13

 

Ordering recommendations for apolipoprotein B in primary care

Consider apoB testing as a more comprehensive metric to assess patient risk than LDL-C testing alone. When ordered in the primary care setting, apoB testing can provide additional detail about a patient’s lipid risk and can indicate when treatment initiation or modification is needed.

People who may have increased atherogenic particles and are therefore well-suited for apoB testing include those

  • With 1 or more risk factors for the development of CVD
    • Established CVD
    • Diabetes
    • Hypertension
    • Metabolic syndrome
  • At borderline risk (5%–<7.5% 10-year atherosclerotic cardiovascular disease [ASCVD] risk) or intermediate risk (≥7.5%–<20% 10-year ASCVD risk)
  • Receiving lipid-lowering therapy

 

Recommended tests: Apolipoprotein B as a standalone test or within a panel

Quest Diagnostics offers Cardio IQ® Apolipoprotein B as an individual test or as a component of several different test panels.

Cardio IQ® Apolipoprotein B (stand-alone option)

  • Test code: 91726
  • CPT code: 82172*

Metabolic Risk Panel

  • Test code: 39447
  • CPT codes: 80061,* 82172,* 83036,* 83525, 84681

Components include Cardio IQ Apolipoprotein B [91726], Cardio IQ Hemoglobin A1c [91732], Cardio IQ Insulin Resistance Panel with Score [36509], Lipid Panel, Cardio IQ [91716]

Cardiometabolic Disease Assessment (CMDA) Panel

  • Test code: 14273
  • CPT codes: 80061,* 82172,* 83036,* 83525, 84681, 82570, 82043, 80053, 85049,* 84443*

Components include HbA1c [496], Insulin Resistance Panel with Score [36509], Lipid Panel [7600], ApoB [5224], TSH [899], Kidney Profile [39165], Comprehensive Metabolic Panel with Fibrosis-4 (FIB-4) Index [10372]

Advanced Lipid Panel with Inflammation, Cardio IQ

  • Test code: 94220
  • CPT codes: 80061,* 83704,* 82172,* 83695,* 86141,* 83698*

Components include Cardio IQ Cholesterol, Total [91717], Cardio IQ HDL Cholesterol [91719], Cardio IQ Triglycerides [91718], Cardio IQ Non-HDL and Calculated Components, Cardio IQ Lipoprotein Fractionation, Ion Mobility [91604], Cardio IQ Apolipoprotein B [91726], Cardio IQ Lipoprotein (a) [91729], Cardio IQ hs-CRP [91737], Cardio IQ Lp-PLA2 Activity [94218]

Advanced Lipid Panel, Cardio IQ

  • Test code: 92145
  • CPT codes: 80061,* 83704,* 82172,* 83695*

Components include Cardio IQ Cholesterol, Total [91717], Cardio IQ HDL Cholesterol [91719], Cardio IQ Triglycerides [91718], Cardio IQ Non-HDL and Calculated Components, Cardio IQ Lipoprotein Fractionation, Ion Mobility [91604], Cardio IQ Apolipoprotein B [91726], Cardio IQ Lipoprotein (a) [91729]

 

Related tests

Cardio IQ Insulin Resistance Panel with Score

  • Test code: 36509
  • CPT codes: 83525, 84681

Components include Insulin, Intact LC/MS/MS [93103], C-peptide [372], Calculated IR Score, and Interpretive Report

Comprehensive Metabolic Panel with Fibrosis-4 (FIB-4) Index

  • Test code: 10372
  • CPT codes: 80053, 85049*

Components include Liver Fibrosis, Fibrosis-4 (FIB-4) Index Panel [30555], Comprehensive Metabolic Panel [10231] [includes Glucose [483], Calcium [303], Sodium [836], Potassium [733], Carbon Dioxide (CO2) [310], Blood Urea Nitrogen (BUN) [294], Creatinine with eGFR [375], BUN/Creatinine Ratio [296], Protein, Total, Serum [754], Albumin [223], Globulin, Albumin/Globulin Ratio, Alkaline Phosphatase (ALP) [234], Aspartate Aminotransferase (AST) [822], Alanine Aminotransferase (ALT) [823], Bilirubin, Total [287], Platelet Count [723]

Lipid Panel, Cardio IQ

  • Test code: 91716
  • CPT code: 80061*

Components include Cholesterol Total [334], Triglycerides [896], HDL Cholesterol [608], Calculated LDL-C, Cholesterol/HDL Ratio, Non-HDL-C, and Cardio IQ Interpretative Report

Lipid Panel, Standard

  • Test code: 7600
  • CPT code: 80061*

Components include Cholesterol Total [334], Triglycerides [896], HDL Cholesterol [608]

Liver Fibrosis, Fibrosis-4 (FIB-4) Index Panel

  • Test code: 30555
  • CPT codes: 84450, 84460, 85049*

Components include Aspartate Aminotransferase (AST) [822], Alanine Aminotransferase (ALT) [823], Platelet Count [723], and FIB-4 Index

Kidney Profile

  • Test code: 39165
  • CPT codes: 82043, 82565, 82570

Components include Albumin, Random Urine with Creatinine [6517], Creatinine with eGFR [375]

 

Note: The CPT codes provided are based on American Medical Association guidelines and are for informational purposes only. CPT coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.

*CPT code is subject to a Medicare Limited Coverage Policy and may require a signed ABN when ordering.

 

Interpreting test results: Apolipoprotein B relative risk threshold

ApoB relative risk (mg/dL) ranges are expressed as

  • <90 optimal
  • 90–129 moderate
  • ≥130 high

 

Next steps in caring for patients with high CVD risk

For patients demonstrating increased risk of CVD events through high apoB test results, appropriate treatment plans may consist of a combination of lifestyle modifications and medication therapy.

A desirable treatment target may be <80 mg/dL or lower depending on the risk category of the patient, including those on lipid-lowering therapies, patients with ASCVD, diabetes with >1 risk factors, Stage 3 or greater CKD with albuminuria, or heterozygous familial hypercholesterolemia. ApoB relative risk category cut points are based on AACE/ACE and ACC/AHA recommendations.15,16

 

Lifestyle modifications

Encourage patients to improve their diet,17 exercise,18 and smoking cessation19 habits.

Lipid-lowering therapies

Refer to the recommendations in the AHA/ACC guidelines on the management of blood cholesterol.7

Insulin-sensitizing therapies

Refer to the recommendations in the American Diabetes Association guidelines for the management of prediabetes/diabetes.20

 

Supporting resources

Advanced lipid testing page
Cardiovascular disease web page
ApoB test-level brochure
Advanced Lipid Panel with Inflammation test-level brochure
Metabolic Risk Panel overview brochure
CMDA Panel overview brochure

Comprehensive solutions to identify cardiovascular risk sooner

We can help you take a proactive approach to identifying and managing your patient’s cardiovascular risk.

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Clinical Education Center resources

Health & Wellness
Audio Podcast
Instant Insights: Apolipoprotein B
Health & Wellness
On-Demand Webinar
Utilizing Apolipoprotein B in Cardiovascular Risk Assessment
Pathology & Laboratory Medicine
Audio Podcast
Instant Insight: Metabolic Risk Panel
View all articles

References

1. Sniderman AD, Williams K, Contois JH, et al. A meta-analysis of low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, and apolipoprotein B as markers of cardiovascular risk. Circ Cardiovasc Qual Outcomes. 2011;4(3):337-345. doi:10.1161/CIRCOUTCOMES.110.959247

2. Sachdeva A, Cannon CP, Deedwania PC, et al. Lipid levels in patients hospitalized with coronary artery disease: An analysis of 136,905 hospitalizations in Get With The Guidelines. Am Heart J. 2009;157:111-117. doi:10.1016/j.ahj.2008.08.010

3. Mach F, Windecker S, Nibouche D, et al. 2019 ESC/EAS guidelines for the management of dyslipidaemias: Lipid modification to reduce cardiovascular risk. Atherosclerosis. 2019;290:140-205. doi: 10.1016/j.atherosclerosis.2019.08.014

4. Sniderman A, Couture P, de Graaf J. Diagnosis and treatment of apolipoprotein B dyslipoproteinemias. Nat Rev Endocrinol. 2010;6(6):335-346. doi:10.1038/nrendo.2010.50

5. Carr SS, Hooper AJ, Sullivan DR, et al. Non-HDL-cholesterol and apolipoprotein B compared with LDL-cholesterol in atherosclerotic cardiovascular disease risk assessment. Pathology. 2019;51(2):148-154. doi:10.1016/j.pathol.2018.11.006

6. American Heart Association. CDC prevention programs. Updated June 5, 2023. Accessed December 17, 2025. https://www.heart.org/en/get-involved/advocate/federal-priorities/cdc-prevention-programs

7. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140(11):e596-e646. doi:10.1161/CIR.0000000000000678

8. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;139(25):e1082-e1143. doi:10.1161/CIR.0000000000000625

9. Jellinger PS, Handelsman Y, Rosenblit PD, et al. American Association of Clinical Endocrinologists and American College of Endocrinology guidelines for management of dyslipidemia and prevention of cardiovascular disease. Endocr Pract. 2017;23(suppl 2):1-87. doi:10.4158/EP171764.APPGL

10. Wilson PWF, Jacobson TA, Martin SS, et al. Lipid measurements in the management of cardiovascular diseases: Practical recommendations a scientific statement from the National Lipid Association writing group. J Clin Lipidol. 2021;15(5):629-648. doi:10.1016/j.jacl.2021.09.046

11. Jacobson TA, Ito MK, Maki KC, et al. National Lipid Association recommendations for patient-centered management of dyslipidemia: part 1—full report. J Clin Lipidol. 2015;9(2):129-169. doi:10.1016/j.jacl.2015.02.003

12. Ray KK, Ference BA, Séverin T, et al. World Heart Federation Cholesterol Roadmap 2022. Glob Heart. 2022;17(1):75. doi:10.5334/gh.1154

13. Martin S, Aday A, Almarzooq Z, et al. 2024 heart disease and stroke statistics: A report of US and global data from the American Heart Association. Circulation. 2024;149(8). doi:10.1161/CIR.0000000000001209

14. Johannesen CDL, Mortensen MB, Langsted A, et al. Apolipoprotein B and non-HDL cholesterol better reflect residual risk than LDL cholesterol in statin-treated patients. J Am Coll Cardiol. 2021;77(11):1439-1450. doi:10.1016/j.jacc.2021.01.027

15. Grundy SM, Stone NJ, Bailey AL, et al. 2018 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. JACC. 2018;73 (24). doi:10.1016/j.jacc.2018.11.002

16. Handelsman Y, Jellinger PS, Guerin, CK, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Management of Dyslipidemia and Prevention of Cardiovascular Disease Algorithm - 2020 Executive Summary. Endocr Pract. 2020 Oct;26(10):1196-1224. doi:10.4158/CS-2020-0490

17. Solá R, Fitó M, Estruch R, et al. Effect of a traditional Mediterranean diet on apolipoproteins B, A-I, and their ratio: A randomized, controlled trial. Atherosclerosis. 2011;218(1):174-180. doi:10.1016/j.atherosclerosis.2011.04.026

18. Holme I, Høstmark AT, Anderssen SA. ApoB but not LDL-cholesterol is reduced by exercise training in overweight healthy men. Results from the 1-year randomized Oslo Diet and Exercise Study. J Intern Med. 2007;262(2):235-243. doi:10.1111/j.1365-2796.2007.01806.x

19. Kauss AR, Antunes M, de La Bourdonnaye G, et al. Smoking and apolipoprotein levels: A meta-analysis of published data. Toxicology Reports. 2022;9:1150-1171. doi:10.1016/j.toxrep.2022.05.009

20. American Diabetes Association. Cardiovascular disease and risk management: Standards of Medicare care in diabetes—2018. Diabetes Care. 2018;41(Supplement 1):S86-S104. doi:10.2337/dc18-S009

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