Efficacy of cholesterol levels and ratios in predicting future coronary heart disease in a Chinese population

doi:10.1016/S0002-9149(01)01843-4

The American Journal of Cardiology

Volume 88, Issue 7, 1 October 2001, Pages 737-743

https://doi.org/10.1016/S0002-9149(01)01843-4 Get rights and content

Abstract

In this study, we assessed the efficacy of various lipid and lipoprotein measurements at baseline for predicting the risk for coronary heart disease (CHD) and determined the associated risk of CHD in subgroups stratified by different lipid and lipoprotein screening strategies to evaluate the adequacy of current total and low-density lipoprotein (LDL) cholesterol-based approaches in lipid management. We analyzed data from the Chin-Shan Community Cardiovascular Cohort study, a Chinese population-based prospective cohort study that began in 1990. During an 8-year follow-up period, 213 of 3,159 participants (6.7%) without CHD (aged ≥35 years) developed CHD. The total cholesterol/high-density lipoprotein (HDL) cholesterol ratio was the most powerful lipoprotein predictor of future CHD (hazard ratio 1.21 for a 1.0 increment in ratio; p <0.001). Subjects with “high-risk” LDL cholesterol levels (>160 mg/dl) and low total cholesterol/HDL cholesterol ratios (≤5) had an incidence of CHD similar to those with low levels of both LDL cholesterol (≤130 mg/dl) and total cholesterol/HDL cholesterol ratios (4.9% vs 4.6%). In contrast, subjects with “low-risk” LDL cholesterol levels (≤130 mg/dl) and high total cholesterol/HDL cholesterol ratios (>5) had a 2.5-fold higher incidence of CHD than those with similar LDL cholesterol levels but low total cholesterol/HDL cholesterol ratios (p <0.001). Compared with using an LDL cholesterol level of 130 mg/dl as the cut-off point, using a total cholesterol/HDL cholesterol ratio of 5 was associated with superior specificity (73% vs 59%, p <0.001) and accuracy (72% vs 58%, p <0.001), and similar sensitivity (50% vs 53%). Our data indicate that current guidelines for lipid management may misclassify subjects with high levels of HDL and LDL cholesterol as well as those with low levels of HDL and LDL cholesterol. Using the ratio of total to HDL cholesterol as the initial screening tool can obviate this discrepancy.

Section snippets

Subjects

The present study was based on the original cohort of the CCCC study, which began in 1990 to 1991 as a Chinese population-based prospective cardiovascular study. The study population included 1,703 men and 1,899 women aged ≥35 years, with a participation rate of 82.8%. All participants were recruited from the 1990 residential registration files of the Chin-Shan community in northern Taiwan. Details of the study design have been previously described.7 This study was approved by the Ethics

Baseline characteristics

During the 8-year follow-up period, 213 of the 3,159 participants (6.7%) had a first CHD event, either fatal or nonfatal. As expected, subjects with a first coronary event were older and had a higher body mass index, higher blood pressure, and a higher prevalence of diabetes (Table 1). They also had significantly higher levels of total cholesterol, LDL cholesterol, triglycerides, and apolipoprotein B, higher ratios of total to HDL cholesterol and LDL to HDL cholesterol, and significantly lower

Discussion

The major findings in the present study are: (1) the total cholesterol/HDL cholesterol ratio was the most powerful lipoprotein discriminator of future coronary events, irrespective of age, sex, and various cardiovascular risk factors; (2) subjects with “high-risk” LDL cholesterol levels (>160 mg/dl) but low total cholesterol/HDL cholesterol ratios (≤5) had a low incidence of CHD, which was similar to that in subjects with low levels of both LDL cholesterol (≤130 mg/dl, the clinically desirable

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A similar result was observed for the ratio of total cholesterol-to-HDL-C (Castelli index I) (Figures 1 and 2). These results are consistent with previous studies.31-34 In our study, the use of DMPA resulted in somewhat higher levels of fasting glucose as compared to nonhormonal users, whereas the fasting blood sugar levels were found within reference range.
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The results showed statistically significant differences in all parameters of lipid profile, namely cholesterol (180.7 ± 38.8 versus 133.03 ± 14.8 mg/dL, and P = 0.000), LDL (120.04 ± 36.2 versus 94.27 ± 19.6 mg/dL, and P = 0.000), very low-density lipoprotein cholesterol (24.6 ± 10.0 versus 20.99 ± 8.66 mg/dL, and P = 0.000), high-density lipoprotein (39.67 ± 3.6 versus 44.13 ± 4.22 mg/dL, and P = 0.000), total cholesterol (713.05 ± 110.2 versus 569.19 ± 80.4 mg/dL, and P = 0.000), triglycerides (126.33 ± 48.8 versus 99.03 ± 30.6 mg/dL, and P = 0.000), Castelli index I (4.61 ± 1.2 versus 3.02 ± 0.31, and P = 0.000) and Castelli index II (3.08 ± 1.07 versus 2.13 ± 0.41, and P = 0.000) between treated and control groups, respectively. Serum glucose levels were significantly higher (P ≤ 0.001) among the cases of DMPA (84.6394 ± 7.425 mg/dL) compared with that in the control (77.822 ± 7.733 mg/dL).
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^☆: This study was supported in part by grants from the Department of Health (DOH82-TD-068) and National Science Council (NSC83-0412-B002-064), Taipei, Taiwan, Republic of China.

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Regular paperEfficacy of cholesterol levels and ratios in predicting future coronary heart disease in a Chinese population☆

Abstract

Section snippets

Subjects

Baseline characteristics

Discussion

Is relationship between serum cholesterol and risk of premature death from coronary heart disease continuous and graded?findings in 356,222 primary screenees of the Multiple Risk Factor Intervention Trial (MRFIT)

JAMA

Incidence of coronary heart disease and lipoprotein cholesterol levels

JAMA

Cholesterol and coronary heart diseasePredicting risks by levels and ratios

Ann Intern Med

A prospective study of cholesterol, apolipoproteins, and the risk of myocardial infarction

N Engl J Med

Chin-Shan Community Cardiovascular Cohort in Taiwan-baseline data and five-year follow-up morbidity and mortality

J Clin Epidemiol

Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge

Clin Chem

The effects of dyslipidemia on left ventricular systolic function in patients with stable angina pectoris

Atherosclerosis

Plasma lipid profiles and epidemiology of atherosclerotic diseases in Taiwan—a unique experience

Atherosclerosis

Declining serum total cholesterol levels among US adultsThe national health and nutrition examination surveys

JAMA

Regular paper
Efficacy of cholesterol levels and ratios in predicting future coronary heart disease in a Chinese population☆