Journal of Clinical Lipidology · Jul 14, 2026
Apolipoprotein B-low-density lipoprotein cholesterol discordance refines cardiovascular risk stratification across metabolic phenotypes
By Kim JA, Park MS, Cho EH et al.
BACKGROUND: The cardiovascular risk of metabolically healthy obesity (MHO) remains controversial. Discordance between apolipoprotein B (apoB) and low-density lipoprotein cholesterol (LDL-C) reflects residual atherogenic risk. OBJECTIVE: We aimed to evaluate whether apoB-LDL-C discordance improves cardiovascular risk stratification across metabolic phenotypes. METHODS: We analyzed 15,738 adults (median age 37 years; 86.3% men) who underwent repeated coronary artery calcium (CAC) assessments. MHO was defined as body mass index ≥25 kg/m² without metabolic syndrome components. ApoB-LDL-C discordance was assessed using a residual-based approach. Logistic regression was used to evaluate associations with CAC progression. RESULTS: Over a median follow-up of 6 (IQR, 4-9) years, 3072 participants (19.5%) experienced CAC progression. MHO was associated with higher CAC progression risk than metabolically healthy lean (MHL) (odds ratio [OR], 1.26; 95% CI, 1.03-1.53). Within metabolically healthy groups, apoB discordance further stratified risk: MHO with discordantly high apoB showed increased CAC progression risk (OR, 1.74; 95% CI, 1.13-2.66), comparable to metabolically unhealthy phenotypes, whereas discordantly low apoB showed no excess risk (OR, 1.03; 95% CI, 0.71-1.48). High discordance was also associated with increased risk in MHL (OR, 1.73; 95% CI, 1.02-2.92) and predicted transition to metabolically unhealthy status in MHO (OR, 1.62; 95% CI, 1.12-2.35). CONCLUSION: ApoB-LDL-C discordance refines cardiovascular risk stratification within metabolically healthy phenotypes. High discordance identifies individuals at increased risk of CAC progression and metabolic deterioration, supporting its role in early risk assessment beyond traditional metabolic criteria.