Is a Lipid Panel Worth It?
Half of heart attacks occur in people with "normal" cholesterol. Standard lipid panels miss critical risk markers—ApoB counts the particles that actually matter, not just the cholesterol they carry.
42%
of Australian adults have high cholesterol—yet standard testing misses 10-20% of people at elevated cardiovascular risk
Source: [1]
The Short Answer
Yes—but standard testing alone isn't enough. Lipid panels are foundational for cardiovascular risk assessment. The RACGP recommends testing every 5 years from age 45 (35 for Aboriginal and Torres Strait Islander peoples). But here's what matters: standard LDL cholesterol measures cargo, not vehicles. ApoB directly counts atherogenic particles—the actual drivers of plaque formation. For anyone serious about optimising cardiovascular health, ApoB isn't optional; it's the superior marker.[1][2]
The Australian Context
Cardiovascular disease kills one Australian every 12 minutes. With 42% of adults having high cholesterol and CVD claiming 1 in 4 Australian lives, lipid testing is fundamental to prevention.[1]
But here's the uncomfortable reality: roughly half of heart attacks occur in people with cholesterol in the "normal" range.[3] This isn't because cholesterol doesn't matter—it's because standard lipid testing measures the wrong thing.
The "Normal Cholesterol" Trap
Standard lipid panels measure cholesterol content. They don't count particles—and it's particles that penetrate artery walls and form plaque.
Two people with identical LDL-C can have wildly different particle counts. Person A might have 1,000 large particles. Person B might have 2,000 small particles. Same cholesterol, double the risk.
This is why ApoB—which directly counts atherogenic particles—outperforms LDL-C in 9 of 9 studies for predicting cardiovascular events.[2]
What's Measured in a Lipid Panel
A standard lipid panel measures several markers. Understanding what each represents—and what they miss—is critical.
| Risk Factor | Why It Matters |
|---|---|
| The sum of all cholesterol in your blood. A blunt instrument—tells you almost nothing about actual risk. Australian guidelines have moved away from using it as a treatment target. | |
| Low-density lipoprotein cholesterol. Called "bad" cholesterol because it's associated with plaque formation. But here's the catch: LDL-C measures cholesterol content, not particle number. It's usually calculated, not measured, using an equation that fails when triglycerides are elevated.[4] | |
The LDL Limitation Nobody Mentions
Here's what most people—and many GPs—don't realise: LDL cholesterol is rarely measured directly. It's calculated using the Friedewald equation from your total cholesterol, HDL, and triglycerides.
The equation assumes a fixed ratio that doesn't hold when triglycerides are elevated. And it measures cholesterol content, not the number of particles actually causing disease.
The Friedewald Problem
The Friedewald equation systematically underestimates LDL cholesterol when accuracy matters most:[4]
- Triglycerides 1.7-2.3 mmol/L: LDL underestimated by ~0.23 mmol/L
- Triglycerides 2.3-4.5 mmol/L: LDL underestimated by ~0.47 mmol/L
- Triglycerides >4.5 mmol/L: Calculation considered unreliable
"The Friedewald equation tends to underestimate LDL-C most when accuracy is most crucial," notes Johns Hopkins researcher Dr Seth Martin. Patients with metabolic syndrome—those at highest risk—get the least accurate results.[4]
Why ApoB Is Superior
Apolipoprotein B (ApoB) is a protein found on every atherogenic particle in your blood—LDL, VLDL, IDL, and Lp(a). There is exactly one ApoB molecule per particle.[2]
This means measuring ApoB gives you a direct particle count. Not an estimate. Not a calculation that fails when triglycerides are high. A direct measurement of the vehicles actually delivering cholesterol to your artery walls.
LDL-C: Measures Cargo
- Measures cholesterol content in LDL particles
- Usually calculated, not measured directly
- Inaccurate when triglycerides >1.7 mmol/L
- Misses VLDL and IDL particle contribution
- Standard of care for 40+ years
ApoB: Counts Vehicles
- Directly counts all atherogenic particles
- Directly measured—no calculation needed
- Accurate regardless of triglyceride levels
- Captures LDL + VLDL + IDL + Lp(a)
- Superior predictor in 9 of 9 studies[2]
The Discordance Problem
In 10-20% of people, LDL-C and ApoB tell radically different stories. This is called discordance—and it's where standard lipid testing fails most catastrophically.[5]
When LDL-C Lies
The mass of cholesterol per particle varies substantially. In discordant cases:[5]
- "Normal" LDL-C but elevated ApoB: Many small, cholesterol-depleted particles. Higher risk than LDL suggests. Common in metabolic syndrome.
- Elevated LDL-C but normal ApoB: Fewer, larger particles carrying more cholesterol each. Lower risk than LDL suggests.
A 2025 UK Biobank study of 41,099 participants found that even at just 2% discordance, cardiovascular risk was elevated. At 30% discordance, hazard ratios reached 2.5x for coronary artery disease.[6]
When discordant, ApoB is always the better predictor. Not sometimes. Always.
What the Guidelines Say
International guidelines have shifted decisively toward ApoB. Australian guidelines are lagging—but the evidence is unambiguous.
European Atherosclerosis Society (2025)
- "ApoB is recommended as the primary target for lipid-lowering therapy"
- Particularly in patients with elevated triglycerides, diabetes, or metabolic syndrome
- Recognises superior predictive accuracy vs LDL-C
National Lipid Association (2024)
- "ApoB has been shown to be superior to LDL-C in risk assessment"
- Recommends ApoB both before and during treatment
- Proposes stratified targets: <90 mg/dL intermediate risk, <70 high risk, <60 very high risk
Australian Guidelines
- RACGP and Heart Foundation guidelines still focus on LDL-C
- Updated guidance expected as international evidence accumulates
- Most Australian GPs unfamiliar with ApoB targets and management
Why Australian Guidelines Lag
Australian guideline updates follow a rigorous, slow process—rightly so for clinical care. But this means local recommendations can lag international evidence by years.
The European Atherosclerosis Society and National Lipid Association have reviewed the same evidence and reached clear conclusions: ApoB is superior. Australian guidelines will eventually follow—the question is whether you wait for them to catch up or act on the evidence now.[7][8]
When Triglycerides Make LDL Unreliable
If your triglycerides are elevated—and 30% of Australian adults have levels >1.7 mmol/L—your LDL-C result is unreliable. Not slightly off. Systematically underestimated.
Low Triglycerides (<1.2 mmol/L)
- Friedewald equation reasonably accurate
- LDL-C and ApoB usually concordant
- Standard lipid panel likely sufficient
- ApoB still superior but gap smaller
Elevated Triglycerides (>1.7 mmol/L)
- Friedewald equation systematically underestimates LDL
- LDL-C and ApoB frequently discordant
- Standard lipid panel inadequate
- ApoB testing essential for accurate risk assessment
Do You Need to Fast?
For most people, fasting is no longer required. Current Australian guidelines accept non-fasting lipid results for routine cardiovascular risk assessment.[1]
Non-Fasting Acceptable
- Routine cardiovascular risk assessment
- General lipid screening
- Most healthy adults
- When fasting would cause you to skip testing
Fasting Preferred
- Triglycerides previously very high (>4.5 mmol/L)
- Monitoring diabetes or metabolic syndrome
- When GP specifically requests it
- For most precise LDL calculation
Understanding Your Targets
Standard guidelines provide LDL-C targets. But if you're optimising based on ApoB—the superior marker—here are the evidence-based ranges:[7][8]
Target for those with recent cardiovascular event, multiple risk factors, or established atherosclerosis. Associated with lowest event rates. Requires medication; lifestyle alone cannot achieve this.
Target for existing cardiovascular disease, diabetes with complications, or very high calculated risk. National Lipid Association recommendation for high-risk individuals.
Appropriate for moderate-risk individuals. Many preventive cardiologists aim for this range proactively rather than waiting for disease.
Generally acceptable for those without cardiovascular risk factors. Still lower than population average but higher than optimal.
Associated with increased cardiovascular risk. Discuss management options with your health practitioner, particularly if other risk factors present.
Australian GPs and ApoB Targets
Most Australian GPs are unfamiliar with ApoB targets because RACGP guidelines don't specify them. The ranges above are based on European Atherosclerosis Society and National Lipid Association consensus—guidelines that reflect current evidence.
If you test ApoB, be prepared to educate your GP or work with a preventive cardiologist who routinely uses particle-based targets. This isn't a criticism of GPs—it's a lag in local guideline updates.[9]
How Often to Test
Testing frequency depends on your baseline results, risk factors, and whether you're monitoring treatment.
Baseline Screening
- Every 5 years from age 45[9]
- From age 35 for Aboriginal and Torres Strait Islander peoples
- Earlier if family history of premature heart disease
- Include ApoB for accurate particle assessment
With Risk Factors
- Every 1-2 years with high blood pressure or metabolic syndrome
- Annually with diabetes or prediabetes
- More frequently if borderline results
- ApoB essential—standard panel insufficient
Monitoring Treatment
- 6-8 weeks after starting lipid-lowering medication
- Then every 6-12 months once stable
- Sooner if side effects or dose changes
- ApoB superior to LDL-C for verifying treatment efficacy
After Lifestyle Changes
- Recheck 2-3 months after dietary changes
- After significant weight loss (5-10%)
- When starting regular exercise programme
- ApoB shows true impact on particle number
Is It Worth the Cost?
Standard lipid panels are Medicare-covered. ApoB testing costs $30-50 out-of-pocket. Here's when the additional cost delivers genuine value:
✗ Probably Skip If...
- You had a complete lipid panel with ApoB in the last 12 months with optimal results
- You're under 35 with no risk factors and low triglycerides (<1.2 mmol/L)
- Cost is a significant barrier and your risk factors are minimal
✓ Worth Considering If...
- You're 45+ and haven't had recent testing (35+ for Aboriginal and Torres Strait Islander peoples)[9]
- Metabolic syndrome, insulin resistance, or type 2 diabetes—LDL-C calculation unreliable[4]
- Elevated triglycerides (>1.7 mmol/L) making standard testing inaccurate
- Family history of early heart disease, particularly with 'normal' cholesterol
- You want the most accurate cardiovascular risk assessment available[2]
- You're on statin therapy and want to verify residual particle-level risk[7]
- You're serious about cardiovascular optimisation—not just disease prevention
Our Recommendation: Always Include ApoB
At Clarity Labs, we include ApoB in our Heart Health panel because standard lipid testing is insufficient for accurate risk assessment. The evidence is unambiguous: ApoB outperforms LDL-C for predicting cardiovascular events.
If you're testing lipids, you deserve accurate information. ApoB provides that. LDL-C alone does not.
The Bottom Line
Lipid testing is essential—but standard testing alone is insufficient.
With 42% of Australian adults having high cholesterol and CVD claiming one life every 12 minutes, knowing your lipid levels is fundamental. But standard LDL cholesterol measures cargo, not vehicles. It's calculated using an equation that fails when triglycerides are elevated—precisely when accuracy matters most.
ApoB directly counts atherogenic particles. It outperforms LDL-C in 9 of 9 studies. When LDL-C and ApoB disagree—which happens in 10-20% of people—ApoB is always the better predictor. The European Atherosclerosis Society and National Lipid Association have reviewed the evidence and reached clear conclusions: ApoB is superior.
Who needs ApoB testing?
- Anyone with metabolic syndrome, insulin resistance, or type 2 diabetes
- Anyone with elevated triglycerides (>1.7 mmol/L)
- Anyone with family history of early heart disease
- Anyone serious about accurate cardiovascular risk assessment
Set realistic expectations: Most Australian GPs aren't familiar with ApoB targets because local guidelines haven't updated yet. You may need to work with a preventive cardiologist or advocate for yourself. Medicare doesn't cover it ($30-50 out-of-pocket).
But if you're testing lipids, you deserve accurate information. ApoB provides that. Standard testing alone does not.
Frequently Asked Questions
Disclaimer:This information is educational only and not medical advice. Results should be interpreted by your health practitioner in the context of your symptoms and health history. Treatment decisions should be made with your doctor or specialist.