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Hidden Heart Risk Found in Adults With Normal Cholesterol Levels

A blood ratio comparing two particle types flagged artery-damaging risk in adults whose standard cholesterol numbers looked completely normal.

By Dr. Josh Axe · November 5, 2026 · 1 source · Watch

Photo: Pexels

A ratio comparing two apolipoprotein particles uncovered artery-damaging risk in people whose standard cholesterol numbers looked normal, according to the ApoB/ApoA-I Ratio study, published October 30, 2026 in the journal Lipids.

A study of 104 apparently healthy adults ages 23 to 68, all with normal lipid profiles, found that a ratio comparing two apolipoprotein particles flagged artery-damaging risk invisible to standard cholesterol tests. The cross-sectional study, published October 30, 2026 in Lipids, measured apolipoprotein B (ApoB) and apolipoprotein A-I (ApoA-I) using standard lab methods. Participants with an ApoB/ApoA-I ratio above 0.8 showed significantly higher total cholesterol, LDL cholesterol, non-HDL cholesterol, triglycerides and atherogenic index scores, along with lower HDL cholesterol, compared with those below that cutoff, despite every participant's lipid values falling within the normal range. Men in the study also had significantly higher triglycerides, lower HDL and higher ApoB/ApoA-I ratios than women. A multivariate regression analysis identified LDL cholesterol and the LDL/ApoB ratio as independent predictors of the ApoB/ApoA-I ratio.

ApoB is a protein tag found on every artery-clogging particle, including LDL, so counting ApoB counts the number of particles capable of lodging in an artery wall, regardless of how much cholesterol each one carries. ApoA-I is the main protein on HDL, the particle type that helps clear cholesterol back out. The authors state that the ratio between the two reflects the balance between artery-damaging and artery-protective particles, and that this balance can reveal hidden risk that standard cholesterol numbers miss in people whose lipid panels otherwise look normal.

ApoB/ApoA-I Risk Cutoff

Lipids, 2026, Suganthy et al.

The study is a single-timepoint snapshot of 104 adults, not a group followed over months or years, so it shows a link, not proof that a higher ratio causes heart attacks or strokes down the road. The authors say longitudinal studies are needed to establish the ratio's predictive value for real cardiovascular outcomes.

Dr. Axe’s Take

This lines up with what I'd expect: a clean-looking cholesterol panel does not mean a clean artery. Standard LDL testing counts how much cholesterol is riding around in the blood, but ApoB counts the actual particles capable of lodging in an artery wall, and this research shows people can have normal cholesterol numbers while that particle count is already elevated. I'd ask for an ApoB test alongside a standard panel, especially with a family history of heart disease. Day to day, I'd lean on fiber-rich vegetables, wild-caught fish, olive oil and a daily walk to support a healthier particle balance.

— Dr. Axe

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Study summary

Who: 104 apparently healthy adults, ages 23-68, with normal lipid profiles.
Design: Cross-sectional analytical study; correlation, group comparison and multivariate regression analysis.
Dose: Not applicable; observational blood measurement study.
Primary result: Ratio above 0.8 linked to higher total cholesterol, LDL, non-HDL cholesterol, triglycerides and atherogenic indices, and lower HDL, versus ratio of 0.8 or below.
Secondary: Men had higher triglycerides, lower HDL and higher ApoB/ApoA-I ratios than women. LDL cholesterol and LDL/ApoB ratio were independent predictors of the ApoB/ApoA-I ratio.
Funding / conflicts: Funding and conflicts not reported in the abstract.
Date: Oct 30, 2026