Testing for ‘Bad Cholesterol’ Doesn’t Tell the Whole Story
Testing for ‘Bad Cholesterol’ Doesn’t Tell the Whole Story
检测“坏胆固醇”并不能说明全部问题
For decades, assessing cholesterol risk has been built around a simple idea: Lower “bad” cholesterol, lower your chance of a heart attack. The test at the center of that approach measures how much low-density lipoprotein, or LDL cholesterol, is circulating in part of the blood. It has shaped everything from clinical guidelines to the widespread use of statins, medications that reduce LDL. 几十年来，评估胆固醇风险一直基于一个简单的理念：降低“坏”胆固醇，就能降低心脏病发作的几率。该方法的核心检测指标是测量血液中循环的低密度脂蛋白（LDL）胆固醇含量。这一理念影响了从临床指南到他汀类药物（一种降低 LDL 的药物）广泛使用的方方面面。
It works. Lowering LDL cholesterol reduces heart attacks, strokes, and early death. But it doesn’t tell the whole story. 这种方法确实有效。降低 LDL 胆固醇可以减少心脏病发作、中风和过早死亡。但它并不能说明全部问题。
The LDL cholesterol test measures the amount of cholesterol inside the low-density lipoprotein particles circulating in the bloodstream. Those LDL particles containing the cholesterol can get trapped in artery walls, forming plaques that can eventually block blood flow. As the test measures the amount of cholesterol being carried, not the number of LDL particles themselves, two people can have the same LDL cholesterol level but very different numbers of particles, and therefore different levels of risk. LDL 胆固醇检测测量的是血液中循环的低密度脂蛋白颗粒内部的胆固醇含量。这些含有胆固醇的 LDL 颗粒可能会滞留在动脉壁中，形成最终阻塞血流的斑块。由于该检测测量的是所携带的胆固醇总量，而非 LDL 颗粒本身的数量，因此两个人的 LDL 胆固醇水平可能相同，但颗粒数量却大相径庭，从而导致风险水平也不同。
That gap has pushed researchers toward a different way of measuring risk. Apolipoprotein B, or apoB, reflects the total number of cholesterol-carrying particles in the blood rather than how much cholesterol they contain. A growing body of research suggests it’s a more accurate way of identifying who is at risk and who’s not. 这一差距促使研究人员转向另一种风险评估方式。载脂蛋白 B（apoB）反映的是血液中携带胆固醇的颗粒总数，而不是它们所含的胆固醇量。越来越多的研究表明，这是一种识别高危人群更准确的方法。
In March 2026, the American Heart Association and American College of Cardiology recognized this. Their updated cholesterol guidelines acknowledged apoB as a potentially more precise marker, in line with earlier European recommendations. But they stopped short of recommending apoB as the primary method for testing. 2026 年 3 月，美国心脏协会和美国心脏病学会认可了这一点。他们更新后的胆固醇指南承认 apoB 是一种可能更精确的指标，这与早期的欧洲建议一致。但他们并未将 apoB 推荐为主要的检测方法。
“They review the evidence and rank apoB as superior, but the actual rules of the road continue to prioritize LDL,” says Allan Sniderman, a cardiologist at McGill University. 麦吉尔大学的心脏病专家 Allan Sniderman 表示：“他们审查了证据并将 apoB 评为更优，但实际的临床准则仍然优先考虑 LDL。”
Sniderman was an author on a 2026 JAMA modeling study that analyzed lifetime outcomes for around 250,000 US adults eligible for statin treatment. Comparing LDL cholesterol, non-HDL cholesterol, and apoB, the study found that using apoB to guide treatment decisions would prevent more heart attacks and strokes than current approaches, while remaining cost-effective. Sniderman 是 2026 年《美国医学会杂志》（JAMA）一项建模研究的作者，该研究分析了约 25 万名符合他汀类药物治疗条件的美国成年人的终身健康结果。通过比较 LDL 胆固醇、非 HDL 胆固醇和 apoB，研究发现，使用 apoB 来指导治疗决策比当前的方法能预防更多的心脏病发作和中风，同时保持了成本效益。
ApoB testing can be done through standard blood tests. So why has it not filtered into routine care? Not even in Europe, where the guidelines have reflected its usefulness for years. ApoB 检测可以通过常规血液检查完成。那么，为什么它没有进入常规护理呢？即使在指南多年来一直反映其有效性的欧洲，情况也是如此。
Part of the answer is inertia. For decades, LDL cholesterol has been both a scientific breakthrough and a public health success story. It is simple, widely understood, and directly linked to treatments that work. 部分原因是惯性。几十年来，LDL 胆固醇既是一项科学突破，也是公共卫生的成功案例。它简单、广为人知，并与有效的治疗方法直接相关。
“For 50 years, LDL cholesterol was an amazing discovery,” Sniderman says. “It’s not that it isn’t a good marker. It is a good marker.” “50 年来，LDL 胆固醇一直是一项了不起的发现，”Sniderman 说，“并不是说它不是一个好的指标。它确实是一个好的指标。”
Børge Nordestgaard, president of the European Atherosclerosis Society, agrees that LDL cholesterol remains central for a reason. “The evidence is immense; it’s beyond discussion,” he says. “Statins reduce heart attacks, strokes, and early death through LDL cholesterol lowering.” 欧洲动脉粥样硬化协会主席 Børge Nordestgaard 也认为 LDL 胆固醇保持核心地位是有原因的。“证据是巨大的，毋庸置疑，”他说，“他汀类药物通过降低 LDL 胆固醇来减少心脏病发作、中风和过早死亡。”
That success helped shape a powerful narrative: LDL is “bad cholesterol,” and lowering it saves lives. But that simplicity has also limited how risk is understood. 这种成功塑造了一个强有力的叙事：LDL 是“坏胆固醇”，降低它就能挽救生命。但这种简单化也限制了人们对风险的理解。
“The result is patients and physicians know little or nothing about apoB,” Sniderman says. “结果是患者和医生对 apoB 知之甚少，甚至一无所知，”Sniderman 说。
More recent research suggests that the cholesterol picture is more complex, especially in people already taking statins. Previous studies led by Nordestgaard have shown that in treated patients, high levels of apolipoprotein B and non-HDL cholesterol remain associated with increased risk of heart attacks and mortality, while LDL cholesterol does not. ApoB, in particular, emerged as the most accurate marker. 最近的研究表明，胆固醇的情况更为复杂，尤其是在已经服用他汀类药物的人群中。由 Nordestgaard 领导的先前研究表明，在接受治疗的患者中，高水平的载脂蛋白 B 和非 HDL 胆固醇仍然与心脏病发作和死亡风险增加相关，而 LDL 胆固醇则不然。特别是 apoB，被证明是最准确的指标。
For Kausik Ray, a cardiologist at Imperial College London, the challenge is not choosing one marker over another, but understanding what each one captures, and what it misses. 对于伦敦帝国理工学院的心脏病专家 Kausik Ray 来说，挑战不在于选择哪一个指标，而在于理解每个指标捕捉到了什么，又遗漏了什么。
“We’re not interested in cholesterol for its own sake,” Ray says. “We’re trying to prevent heart attacks and strokes.” “我们关注胆固醇并不是为了胆固醇本身，”Ray 说，“我们是为了预防心脏病发作和中风。”
Cholesterol enters artery walls through apoB-containing particles, but those particles are not all the same. LDL makes up most of them, but lipoprotein(a) and triglyceride-rich particles also play a role. ApoB captures the total number, but not their source. 胆固醇通过含有 apoB 的颗粒进入动脉壁，但这些颗粒并不完全相同。LDL 占了其中的大部分，但脂蛋白(a)和富含甘油三酯的颗粒也起着作用。ApoB 捕捉到了总数，但没有捕捉到它们的来源。
“Having a very high apoB will pick up more people than just LDL,” Ray says. “But then what you do about that is another matter.” “apoB 水平极高的人群比仅通过 LDL 筛查出的人群要多，”Ray 说，“但接下来如何处理则是另一回事。”
An elevated apoB could be driven by different underlying problems—high LDL, insulin resistance, obesity, or genetic factors—and each may require a different intervention. apoB 升高可能由不同的潜在问题引起——高 LDL、胰岛素抵抗、肥胖或遗传因素——每种情况可能都需要不同的干预措施。
“If you only had apoB, you don’t know whether to focus on LDL-lowering or weight loss or glucose control,” Ray says. “如果你只有 apoB 数据，你不知道是该专注于降低 LDL，还是减肥，亦或是控制血糖，”Ray 说。
That is where nuance comes in. ApoB may be a better overall signal of risk, but clinicians still need to understand what is driving it. “Because then you can personalize it,” Ray says. 这就是细微差别所在。ApoB 可能是更好的整体风险信号，但临床医生仍需了解其背后的驱动因素。“因为这样你才能进行个性化治疗，”Ray 说。
That need for a more detailed picture is already pushing cholesterol testing beyond a single number. Both Ray and Nordestgaard point to lipoprotein(a), a genetically determined form of cholesterol that is rarely measured but can significantly increase risk. 这种对更详细图景的需求已经推动胆固醇检测超越了单一数值。Ray 和 Nordestgaard 都指出了脂蛋白(a)的重要性，这是一种由基因决定的胆固醇，虽然很少被测量，但会显著增加风险。
“We’ve got a huge problem in the UK with less than 5 percent of the population being tested,” Ray says. “You only need to measure lipoprotein(a) once in your lifetime.” “我们在英国面临一个巨大的问题，即不到 5% 的人口接受过这种检测，”Ray 说，“你一生中只需要测量一次脂蛋白(a)。”
Nordestgaard argues that if lipid testing were designed from scratch today, it would not center on a single measure at all. Nordestgaard 认为，如果今天从零开始设计血脂检测，它根本不会以单一指标为中心。
“You would test your LDL cholesterol, your remnant cholesterol, and your lipoprotein(a),” he says. “You would make three parallel tests.” “你会检测 LDL 胆固醇、残余胆固醇和脂蛋白(a)，”他说，“你会进行三项并行测试。”
The shift is not just about better markers, but earlier detection. Cardiovascular risk builds silently over decades, yet testing often begins only once symptoms or clear risk factors appear, e.g. being male and over 60. 这种转变不仅关乎更好的指标，更关乎早期发现。心血管风险在几十年间悄然积累，但检测往往只在症状或明显的风险因素（例如男性且超过 60 岁）出现时才开始。
“If you don’t look, you don’t know,” Ray says. “Typically, people in their twenties, thirties, forties are often not going to have things checked, because they feel fine.” “如果你不检查，你就不会知道，”Ray 说，“通常，二三十岁或四十岁的人往往不会去检查，因为他们感觉良好。”
Instead, he says, care is often reactive, which has consequences for prevention. 相反，他说，医疗护理往往是反应性的，这对预防工作产生了后果。