Low-density lipoprotein cholesterol and all-cause mortality: findings from the China health and retirement longitudinal study

Call for a consensual definition of dyslipidemia in coronary angiography trials

Dyslipidemia is extensively analyzed in clinical trials investigating its role as a risk factor for coronary artery disease (CAD). However, its definition varies vastly among studies, leading to different attributions to the variable dyslipidemia. The objectives of this study are to verify the hypothesis of a lack of a consensual definition of dyslipidemia in coronary angiography studies and to propose a consensual definition of dyslipidemia, considering the influence of each serum lipid parameter on mortality. A systematic search of coronary angiography studies focusing on dyslipidemia was conducted. We listed definitions and their references in the 258 articles the research found. Out of the 258 articles retrieved in the search, 52 studies (20%) provided a definition of dyslipidemia, and 20 (8%) mentioned the source. We identified 39 different definitions. To mitigate misinterpretations of cardiovascular risk factors, we propose the use of the "lipid triad" components to define dyslipidemia: LDL-cholesterol >3.0 mmol/L for primary prevention and >2.6 mmol/L or >1.4 mmol/L for secondary prevention in patients over/under 75 years old, respectively; or HDL-cholesterol <1.3 mmol/L (women) and <1.0 mmol/L (men); or triglycerides >1.7 mmol/L.

Associations of Low-density Lipoprotein Cholesterol With All-cause and Cause-specific Mortality in Older Adults in China

CONTEXT

Limited information was available on detailed associations of low-density lipoprotein cholesterol (LDL-C) with all-cause and cause-specific mortality in older adults.

METHODS

This prospective cohort study included a representative sample of 211 290 adults aged 65 or older who participated in Shenzhen Healthy Aging Research 2018-2019. The vital status of the participants by December 31, 2021, was determined. We estimated the hazard ratios (HR) with 95% confidence intervals for all-cause or cause-specific mortality using multivariable Cox proportional hazards models and Cox models with restricted cubic spline (RCS).

RESULTS

The median follow-up time was 3.08 years. A total of 5333 participants were confirmed to have died. Among them, 2037 cardiovascular disease (CVD) deaths and 1881 cancer deaths occurred. Compared to those with LDL-C of 100 to 129 mg/dL, the all-cause mortality risk was significantly higher for individuals with LDL-C levels that were very low (<70 mg/dL) or low (70-99 mg/dL). Compared with individuals with the reference LDL-C level, the multivariable-adjusted HR for CVD-specific mortality was 1.338 for those with very low LDL-C levels (< 70 mg/dL), 1.437 for those with high LDL-C levels (160 mg/dL ≤ LDL-C < 190 mg/dL), and 1.489 for those with very high LDL-C levels (≥190 mg/dL). Low LDL-C levels (70-99 mg/dL) and very low LDL-C levels (<70 mg/dL) were also associated with increased cancer mortality and other-cause mortality, respectively. The results from an RCS curve showed similar results.

CONCLUSION

Considering the risk of all-cause mortality and cause-specific mortality, we recommended 100 to 159 mg/dL as the optimal range of LDL-C among older adults in China.

Association between serum lipid and all-cause mortality in asthmatic populations: a cohort study

BACKGROUND

Presently, the majority of investigations primarily evaluate the association between lipid profiles and asthma. However, few investigations explore the connection between lipids and mortality related to the disease. This study aims to explore the association of serum lipids with all-cause mortality within asthmatic adults.

METHODS

The investigation included 3233 eligible patients with asthma from the NHANES (2011-2018). The potential associations were explored using three Cox proportional hazards models, restricted cubic splines (RCS), threshold effect models, and CoxBoost models. In addition, subgroup analyses were conducted to investigate these associations within distinct populations.

RESULTS

After controlling all covariables, the Cox proportional hazards model proved a 17% decrease in the probability of death for each increased unit of low-density lipoprotein-cholesterol (LDL-C) (mmol/L). Yet, there was no association seen between blood high-density lipoprotein cholesterol (HDL-C), total cholesterol, or triglyceride and all-cause mortality in asthmatics. The application of RCS and threshold effect models verified an inverse and linear association of LDL-C with all-cause mortality. According to the results from the CoxBoost model, LDL-C exhibited the most substantial impact on the follow-up status of asthmatics among the serum lipids.

CONCLUSION

Our investigation concluded that in American asthmatic populations, LDL-C levels were inversely and linearly correlated with mortality. However, no independent relationship was found between triglycerides, total cholesterol, or HDL-C and mortality.

Sex-Specific Relationships between HDL-Cholesterol Levels and 10-Year Mortality in Individuals with Atherosclerotic Cardiovascular Disease: A Nationwide Cohort Study of South Koreans

Large epidemiological studies show U-shaped relationships between high-density lipoprotein cholesterol (HDL-C) levels and all-cause mortality in individuals without atherosclerotic cardiovascular diseases (ASCVD). Association in those with ASCVD by sex is unclear. We examined the association between HDL-C levels and 10-year all-cause mortality in subjects (≥40 years of age) with ASCVD using the 2010 National Health Insurance Service and the National Death Registry of Korea. We categorized HDL-C levels into three groups (low: <40 mg/dL for males, <50 mg/dL for females; high: 40-90 mg/dL for males, 50-90 mg/dL for females; extremely high: >90 mg/dL) and 10 mg/dL intervals. We conducted a sex-stratified and adjusted Cox proportional hazards analysis. Out of 1,711,548 individuals (54% female, mean age 61.4 years), 10-year mortality was observed in 218,252 (12.8%). Males had a higher mortality rate than females (16.2% vs. 9.8%; p < 0.001). When adjusting for age, body mass index, LDL-cholesterol, triglycerides, hypertension, diabetes, smoking, and alcohol consumption, the low and extremely high HDL-C groups had significantly higher hazard ratios for 10-year mortality compared to the high HDL-C group in males [1.183 (1.166-1.199), 1.359 (1.288-1.434)] and in females [1.153 (1.138-1.169), 1.095 (1.029-1.167)]. The frequency distribution bars for the 10-year mortality rate showed sex-specific nadirs of 50-59 mg/dL in males and 70-79 mg/dL in females. In this ASCVD cohort, the extremely high HDL-C (>90 mg/dL) group had 35.9% and 9.5% higher 10-year mortality risks than the high HDL-C group for males and females, respectively. There was a slightly U-shaped relationship between baseline HDL-C levels and a 10-year mortality rate, with earlier inflection in males than in females.

Dyslipidemia paradox: Analysis from the veterans exercise testing study

BACKGROUND

Dyslipidemia is a well-established cardiovascular disease (CVD) risk factor, although its association with mortality is less clear. This study aimed to assess the association between established dyslipidemia criteria [National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults [Adult Treatment Panel (ATP) III] and all-cause mortality in men.

METHODS

Prospective cohort study of 1,479 men aged 59.7±10.7 years was conducted between 1987 and 2012. At baseline, dyslipidemia markers of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) were assessed as an exposure. Cox proportional hazard models were analyzed adjusting for conventional health risk factors using all-cause mortality as an outcome.

RESULTS

Mean and standard deviations of TC, LDL-C and HDL-C were 199.5±45.2, 149.4±47.4 and 44.3±12.2 mg/dL, respectively. During 8.9±4.5 years follow-up, 284 participants died. Compared to TC <200 mg/dL, levels of 200-239 mg/dL and ≥240 mg/dL were associated with 13% [hazard ratio (HR) = 0.87, 95% confidence intervals (CI) (0.66-1.1)] and 37% [HR = 0.63, 95% CI (0.44-0.92)] lower risks of mortality (p trend = 0.048), respectively. Compared to LDL-C <130 mg/dL, levels of 130-189 mg/dL and ≥190 mg/dL were associated with 26% [HR = 0.74, 95% CI (0.57-0.97)] and 32% [HR = 0.68, 95% CI (0.48-0.98)] lower risks of mortality (p trend = 0.044), respectively. Mean survival time was 0.9 to 1.9 years longer with higher TC and LDL-C categories (both p = 0.001). HDL-C was not associated with mortality.

CONCLUSION

In reference to established dyslipidemia criteria, this study showed that higher TC and LDL-C were independently and paradoxically associated with lower risk of all-cause mortality and longer survival time in men. Along with previous reports, these novel findings support a rigorous reevaluation of evidence on dyslipidemia and health risks. Systematic review and meta-analysis are warranted for evidence-based recommendations on dyslipidemia for primary and secondary prevention of CVD.

Association Between Lipid Profile Measurements and Mortality Outcomes Among Older Adults in a Primary Care Setting: A Retrospective Cohort Study

Background Lipid profile components play a role in predicting the development of cardiovascular disease and hence mortality, but recent studies have shown mixed results in the older population. The aim of our study was to investigate the association between levels of lipid profile components with all-cause mortality and cardiovascular outcomes among older adults in a primary care setting in Riyadh, Saudi Arabia. Methods A retrospective cohort study was performed among 485 individuals aged 60 years and older who visited the family medicine clinics linked to a tertiary care hospital during the first six months of 2010. The electronic charts of the participants were reviewed up to April 2022 to gather relevant data. Each lipid profile component, including total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TGs), was categorized into four quartiles. LDL was calculated using the Friedewald formula. Cardiovascular outcomes included ischemic heart disease (IHD), heart failure (HF), and stroke. Results The mean follow-up period was 12 years. The elderly participants with the lowest HDL-C quartile (<1.1 mmol/L) were at higher risk of all-cause mortality (adjusted hazard ratio of 2.023 (95% CI 1.21-3.38)) and IHD (adjusted hazard ratio 3.2 (95% CI 1.6-6.2)). High TC (≥5.7 mmol/L) was associated with an increased risk of HF (adjusted hazard ratio 2.1 (95% CI 1.1-4.0)). Conclusion In patients aged 60 years and older, low HDL-C (<1.1 mmol/L) was associated with a higher risk for all-cause mortality and IHD, and high TC was associated with an increased risk of having HF. No significant association was found for LDL-C, TC, and TGs with all-cause mortality.

Association of low-density lipoprotein cholesterol levels with the risk of mortality and cardiovascular events: A meta-analysis of cohort studies with 1,232,694 participants

BACKGROUND

Lowering elevated low-density lipoprotein cholesterol (LDL-C) is an important strategy to prevent cardiovascular disease (CVD), while some studies report low LDL-C increases all-cause mortality. Our study aimed to explore the appropriate low LDL-C level with the lower CVD risk but with no excess risk for all-cause mortality.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science were searched until April 7, 2021. Twenty cohort studies with 1232,694 adults were obtained. Effect size index was evaluated using pooled relative risk (RR) with 95% confidence interval (CI). Heterogeneity was assessed using the Cochran's Q test and I2 statistic, and heterogeneity sources was investigated using meta-regression. Publication bias was assessed and sensitivity analysis was performed.

RESULTS

The risks of all-cause mortality (RR: 1.34, 95%CI: 1.00-1.80), CVD death (RR: 1.79, 95%CI: 1.26-2.54), CHD death (RR: 2.03, 95%CI: 1.36-3.03) were higher in LDL-C ≥ 160 mg/dL than LDL-C of 70-129 mg/dL. Both LDL-C of 130-159 mg/dL and ≥ 160 mg/dL were associated with higher CVD risk than LDL-C of 70-129 mg/dL, with RR of 1.26 (95%CI: 1.08-1.47) and 1.70 (95%CI: 1.35-2.14), respectively. Compared to LDL-C of 70-129 mg/dL, no association was found between LDL < 70 mg/dL and all-cause mortality and CVD events.

CONCLUSION

Our results found LDL-C ≥ 130 mg/dL was associated with the higher risk of all-cause mortality and CVD risk, indicating that adults with high LDL-C should take interventions to regulate the LDL-C level lower than 130 mg/dL.

Serum Lipid Profiles and All-Cause Mortality: A Retrospective Single Center Study on Chinese Inpatient Centenarians

Objectives

To analyze the serum lipid profiles and investigate the relationship between the lipoprotein cholesterol levels and all-cause mortality in Chinese inpatient centenarians.

Design

Retrospective study.

Methods

Centenarians aged 100 years and older were admitted from January 2010 to January 2021 in our hospital. All centenarians completed a follow up visit till April 2021 of all-cause mortality and serum lipid profiles, including total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) levels. Cox proportional hazard models were used to assess the association between lipid profiles and all-cause mortality.

Results

(1) These 121 centenarians on average were 100.85 ± 1.37 years old (100~107 years), including 114 males and 7 females. (2) The rate of treatment with lipid-lowering drugs was 69.4%, and the lipid-lowering drugs were mainly statins (63.6%). (3) The results of serum lipid profiles were as follows: TC 3.90 ± 0.69 mmol/L, TG 1.36 ± 0.55 mmol/L, HDL-C 1.14 ± 0.24 mmol/L, and LDL-C 2.05 ± 0.46 mmol/L. (4) The median follow-up time was 589 days (95% CI: 475, 703), and the all-cause mortality rate was 66.1%. (5) Multivariable analysis showed that higher TC level (HR = 1.968, 95% CI = 1.191-3.253, P = 0.008), lower LDL-C level (HR = 0.379, 95% CI = 0.212-0.677, P = 0.001) was independent factors contributed to all-cause mortality. Sensitivity analysis showed that the above results were stable. The therapy and complication morbidity did not present significant publication bias.

Conclusions

The serum lipid profiles of Chinese inpatient centenarians were lower than those of the previous studies. Low LDL-C level was associated with an increased risk of all-cause mortality, which may indicate that more intensive lowering of LDL-C had a potential adverse effect on all-cause mortality for centenarians.

Biochemical risk factors of atherosclerotic cardiovascular disease: from a narrow and controversial approach to an integral approach and precision medicine

INTRODUCTION

Guidelines of management of dyslipidemias and prevention of cardiovascular disease (CVD) are based on firm scientific evidence obtained by randomized controlled trials (RCTs). However, the role of elevated low-density lipoprotein-cholesterol (LDL-C)as a risk factor of CVD and therapies to lower LDL-C are frequently disputed by colleagues who disagree with the conclusions of the RCTs published. This review focuses on this dispute, and evaluates the current approach of management of dyslipidemias and CVD prevention to find modern alternatives for more precise diagnosis and therapy of dyslipidemic patients.

AREAS COVERED

Recent interest in lipoprotein(a) (Lp(a)) and remnants lipoproteins and in therapies that do not influence LDL-C levels primarily, such as anti-inflammatory drugs and icosapent ethyl, has revitalized our concern to optimize the care for patients with increased CVD risk without focusing simply on reduction of LDL-C by therapy with statins, ezitemibe, and proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors.

EXPERT OPINION

The limited characterization of study populations by measurement of total cholesterol (TC), high-density lipoprotein-cholesterol (HDL-C) and triglycerides (TG) followed by measurement or calculation of LDL-C should be extended by a more integral approach in order to realize precision diagnostics and precision medicine, for the sake of personalized patient care.

Association between low density lipoprotein cholesterol and all-cause mortality: results from the NHANES 1999-2014

The association between low density lipoprotein cholesterol (LDL-C) and all-cause mortality has been examined in many studies. However, inconsistent results and limitations still exist. We used the 1999–2014 National Health and Nutrition Examination Survey (NHANES) data with 19,034 people to assess the association between LDL-C level and all-cause mortality. All participants were followed up until 2015 except those younger than 18 years old, after excluding those who died within three years of follow-up, a total of 1619 deaths among 19,034 people were included in the analysis. In the age-adjusted model (model 1), it was found that the lowest LDL-C group had a higher risk of all-cause mortality (HR 1.708 [1.432–2.037]) than LDL-C 100–129 mg/dL as a reference group. The crude-adjusted model (model 2) suggests that people with the lowest level of LDL-C had 1.600 (95% CI [1.325–1.932]) times the odds compared with the reference group, after adjusting for age, sex, race, marital status, education level, smoking status, body mass index (BMI). In the fully-adjusted model (model 3), people with the lowest level of LDL-C had 1.373 (95% CI [1.130–1.668]) times the odds compared with the reference group, after additionally adjusting for hypertension, diabetes, cardiovascular disease, cancer based on model 2. The results from restricted cubic spine (RCS) curve showed that when the LDL-C concentration (130 mg/dL) was used as the reference, there is a U-shaped relationship between LDL-C level and all-cause mortality. In conclusion, we found that low level of LDL-C is associated with higher risk of all-cause mortality. The observed association persisted after adjusting for potential confounders. Further studies are warranted to determine the causal relationship between LDL-C level and all-cause mortality.

Low density lipoprotein cholesterol and all-cause mortality rate: findings from a study on Japanese community-dwelling persons

Background

Low-density lipoprotein cholesterol (LDL-C) independently impacts aging-related health outcomes and plays a critical role in cardiovascular diseases (CVDs). However, there are limited predictive data on all-cause mortality, especially for the Japanese community population. In this study, it was examined whether LDL-C is related to survival prognosis based on 7 or 10 years of follow-up.

Methods

Participants included 1610 men (63 ± 14 years old) and 2074 women (65 ± 12 years old) who participated in the Nomura cohort study conducted in 2002 (first cohort) and 2014 (second cohort) and who continued throughout the follow-up periods (follow-up rates: 94.8 and 98.0%). Adjusted relative risk estimates were obtained for all-cause mortality using a basic resident register. The data were analyzed by a Cox regression with the time variable defined as the length between the age at the time of recruitment and that at the end of the study (the age of death or censoring), and risk factors including gender, age, body mass index (BMI), presence of diabetes, lipid levels, renal function, serum uric acid levels, blood pressure, and history of smoking, drinking, and CVD.

Results

Of the 3684 participants, 326 (8.8%) were confirmed to be deceased. Of these, 180 were men (11.2% of all men) and 146 were women (7.0% of all women). Lower LDL-C levels, gender (male), older age, BMI under 18.5 kg/m², and the presence of diabetes were significant predictors for all-cause mortality. Compared with individuals with LDL-C levels of 144 mg/dL or higher, the multivariable-adjusted Hazard ratio (and 95% confidence interval) for all-cause mortality was 2.54 (1.58–4.07) for those with LDL-C levels below 70 mg/dL, 1.71 (1.15–2.54) for those with LDL-C levels between 70 mg/dL and 92 mg/dL, and 1.21 (0.87–1.68) for those with LDL-C levels between 93 mg/dL and 143 mg/dL. This association was particularly significant among participants who were male (P for interaction = 0.039) and had CKD (P for interaction = 0.015).

Conclusions

There is an inverse relationship between LDL-C levels and the risk of all-cause mortality, and this association is statistically significant.

Outcomes of Ischemic Stroke and Associated Factors Among Elderly Patients With Large-Artery Atherosclerosis: A Hospital-Based Follow-Up Study in China

Large-artery atherosclerotic (LAA) stroke is the most common subtype of ischemic stroke. However, risk factors for long-term outcomes of LAA stroke in the elderly Chinese population have not been well-described. Therefore, we aimed to assess outcomes and risk factors at 3, 12, and 36 months after LAA stroke onset among stroke patients aged 60 years and older. All consecutive LAA patients aged ≥ 60 years were prospectively recruited from Dongying People's Hospital between January 2016 and December 2018. The clinical features and outcome data at 3, 12, and 36 months after stroke were collected. Differences in outcomes and relationship between outcomes and risk factors were assessed. A total of 1,772 patients were included in our study (61.7% male, 38.3% female). The rates of mortality, recurrence, and dependency were 6.6, 12.6, and 12.6%, respectively, at 3 months after stroke onset. The corresponding rate rose rapidly at 36 months (23.2, 78.7, and 79.7%, respectively). We found the positive predictors associated outcomes at 3, 12, and 36 months after stroke onset. The relative risk (RR) with 95% confidential interval (CI) is 1.06 (1.02–1.10, P = 0.006) at 3 months, 1.06 (1.02–1.10, P = 0.003) at12 months, and 1.10 (1.05–1.15, P < 0.001) at 36 months after stroke onset for age; 1.09 (1.01–1.19, P = 0.029) at 12 months for fasting plasma glucose (FPG) level; 4.25 (2.14–8.43, P < 0.001) at 3 months, 4.95 (2.70–9.10, P < 0.001) at 12 months, and 4.82 (2.25–10.32, P < 0.001) at 36 months for moderate stroke; 7.56 (3.42–16.72, P < 0.001) at 3 months, 11.08 (5.26–23.34, P < 0.001) at 12 months, and 14.30 (4.85–42.11, P < 0.001) at 36 months for severe stroke, compared to mild stroke. Hypersensitive C-reactive protein (hs-CRP) level was an independent risk factor for mortality at different follow-up times, with the RR (95%) of 1.02 (1.01–1.02, P < 0.001) at 3 months, 1.01 (1.00–1.02, P = 0.002) at 12 months. White blood cell count (WBC) level was associated with both stroke recurrence (RR = 1.09, 95%CI: 1.01–1.18, P = 0.023) and dependency (RR = 1.10, 95%CI: 1.02–1.19, P = 0.018) at 3 months. In contrast, a higher level of low-density lipoprotein cholesterol (LDL-C) within the normal range was a protective factor for recurrence and dependency at shorter follow-up times, with the RR (95%) of 0.67 (0.51–0.89, P = 0.005) and 0.67 (0.50–0.88, P = 0.005), respectively. These findings suggest that it is necessary to control the risk factors of LAA to reduce the burden of LAA stroke. Especially, this study provides a new challenge to explore the possibility of lowering LDL-C level for improved stroke prognosis.

The new European guidelines for prevention of cardiovascular disease are misleading

Introduction: The European Society of Cardiology and European Atherosclerosis Society (ESC/EAS) have recently published three major revisions of their guidelines for the management of chronic heart disease, blood lipids, and diabetes. Areas covered: We have scrutinized these guidelines in detail and found that the authors have ignored many studies that are in conflict with their conclusions and recommendations. Expert commentary: The authors of the guidelines have ignored that LDL-cholesterol (LDL-C) of patients with acute myocardial infarction is lower than normal; that high cholesterol is not a risk factor for diabetics; that the degree of coronary artery calcification is not associated with LDL-C; and that 27 follow-up studies have shown that people with high total cholesterol or LDL-C live just as long or longer than people with low cholesterol. They have also ignored the lack of exposure-response in the statin trials; that several of these trials have been unable to lower CVD or total mortality; that no statin trial has succeeded with lowering mortality in women, elderly people, or diabetics; and that cholesterol-lowering with statins has been associated with many serious side effects.