Walldius G, de Faire U, Alfredsson L, et al. - In both men and women of all ages, an imbalance between apolipoprotein B (apoB) and apolipoprotein A-1 (apoA-1) causing an elevated apoB/apoA-1 ratio was strongly linked with the outcome major adverse cardiovascular events (MACE) and its sub-components. Consideration should be given to simple evidence-based cut values in future cardiovascular guidelines. Findings imply that early identification and management of dyslipidemia could avert severe cardiovascular disease and save lives.

• Given that increased apoB and elevated apoB/apoA-1 ratio raise the risk of myocardial infarction and stroke, whereas high apoA-1 is protective.

• In this long-term observational Swedish study, apoB and apoA-1 laboratory analyses were linked to clinical registers to determine links with risk of new MACE.

• Overall 137,100 men and women, aged 25–84 years, were followed an average 17.8 years, and 22,473 participants suffered a MACE.

• Low protective levels of apoA-1 were found to be linked with elevated levels of apoB and a higher risk of MACE.

• A strong association of a high apoB/apoA-1 ratio with the risk of having a MACE was also evident.

• Relative to apoB alone, the apoB/apoA-1 ratio covers a broader range of individuals with dyslipidaemia at risk.

• For each increasing quintile of the apoB/apoA-1 ratio, MACEs occurred earlier on average in both genders.

• Increased apoB/apoA-1 ratio was present already 2 decades before the event, in individuals who had a MACE.