To (Measure Apo)B Or Not to (Measure Apo)B: A Critique of Modern Medical Decision-Making (Counterpoint‪)‬

In response to the above article by McNamara et al., who wrote in response to the editorial by Cianflone and myself, published in Clinical Chemistry last year [1], it appears that the word "standardization" means something different to them than it does to us. Words do matter, and they may be slippery creatures indeed. To illustrate this, let me first list various meanings that another important word, hypercholesterolemia, has taken on and then return to the word under discussion: standardization. In addition, I believe that a much more important question should be addressed; namely, if the measurement of apo B is as important as we have stated, why is it not in more widespread use? Trying to answer this question may shed light on some of the most important influences on decision-making in modern medicine, influences that have largely escaped common view and criticism, and it is on this issue I will particularly focus. I am a cardiologist, and coronary artery disease dominates my discipline. The initial clinical study by my colleagues and I involving apo B was published in 1980 [2]. We reported, as did Avogaro et al. before us [3], that many patients with coronary disease had apo B concentrations that were disproportionately increased compared with the serum concentrations of total or LDL-cholesterol. But attention then--and since--as McNamara et al. make clear, has centered almost exclusively on total and LDL-cholesterol, not on apo B. Unfortunately, the fact of the matter is that most patients with coronary disease do not have markedly high cholesterol concentrations. Indeed, for the most part, their concentrations of total and LDL-cholesterol are indistinguishable from those in individuals who do not have coronary disease [4-7]. In my opinion, that is the reason why the "normal" limits for cholesterol have decreased successively, first from the 95th to the 90th percentile [8], thence to the 75th [9], and after that all the way to the 50th percentile in my country, Canada [10]. Some very reputable people say that virtually everyone in Western Society is hypercholesterolemic in comparison with societies in which vascular disease is rare--and, of course, in an important way, they are right. But where does that leave those of us who try to diagnose and treat individuals from Western societies?