Apolipoprotein B/A-I ratio: from coronary heart disease risk prediction to the evolution of precision medicine management and its challenges

Globally, coronary heart disease (CHD) continues to rank as the foremost contributor to mortality and illness. Although the adoption of LDL-cholesterol-centric therapeutic approaches has markedly curbed cardiovascular incidents, a noteworthy residual hazard remains, highlighting the critical need for more sophisticated evaluative metrics. Two decades of empirical investigation have robustly corroborated the apolipoprotein B (ApoB)/apolipoprotein A-I (ApoA-I) quotient—a direct indicator of the pro-versus anti-atherogenic lipoprotein balance—as a cardinal biomarker for coronary heart disease susceptibility. The present review synthesizes the pathophysiological and analytical underpinnings of this ratio, offers a critical appraisal of its diagnostic performance, its role in primary stratification, and its correlation with disease burden and phenotypic complexity, alongside its applicability in steering acute episode care and revascularization tactics. The variability of this ratio across cohorts delineated by gender, age, and co‑existing pathologies — comprising diabetes, nephropathy, cardiac failure, and metabolic disturbance — is additionally dissected, thereby illuminating its capability for refined, individualized risk allocation. Through a juxtaposition of this biomarker with conventional lipid profiles and nascent markers, its distinct merits and additive prognostic worth are elucidated. To conclude, the principal obstacles hampering its broad clinical integration are encapsulated, with a particular focus on the absence of large-scale randomized controlled trials designating the ratio as a direct interventional goal, and strategic directions for its assimilation into bespoke cardiovascular therapeutics are cast forward, which is imperative for curtailing untimely deaths and augmenting community-wide cardiac wellness.