Remnant cholesterol and the risk of cardiovascular disease in type 2 diabetes: a nationwide longitudinal cohort study

Joint association of remnant cholesterol and lipoprotein-associated phospholipase A2 with composite adverse events: A 12-year follow-up study from Asymptomatic Polyvascular Abnormalities Community study

AIMS

To explore the association of remnant cholesterol (RC) and lipoprotein-associated phospholipase A2 (Lp-PLA2) with composite adverse events in a large-scale prospective study.

METHODS

All data were collected from the Asymptomatic Polyvascular Abnormalities Community study between 2010 and 2022. Serum cholesterol levels and Lp-PLA2 were determined by enzyme-linked immunosorbent assay. The participants were categorized into four groups based on their RC and Lp-PLA2 levels: low-RC/Lp-PLA2-, high-RC/Lp-PLA2-, low-RC/Lp-PLA2+ and high-RC/Lp-PLA2+. The composite endpoint was a combination of first-ever stroke, myocardial infarction or all-cause mortality. Cox regression analyses were performed to evaluate associations of RC and Lp-PLA2 with composite adverse events.

RESULTS

Of the 1864 eligible participants, the average age was 60.6 years, and 74.3% were male. Over a follow-up of 12 years, we identified 500 composite adverse events, including 210 major adverse cardiovascular events and 342 all-cause deaths. When compared with the group of low-RC/Lp-PLA2-, the hazard ratios with 95% confidence intervals in the group of high-RC/Lp-PLA2+ for stroke, myocardial infarction, major adverse cardiovascular event, all-cause death and composite endpoints were 1.37 (0.87-2.16), 0.72 (0.28-1.82), 1.29 (0.85-1.95), 1.61 (1.10-2.38) and 1.43 (1.07-1.91), respectively. A significant interaction between RC and Lp-PLA2 status has been found for all-cause death and composite endpoint (p for interaction <0.05). In addition, joint association of RC and Lp-PLA2 with all-cause death was modified by sex and age of <60 versus ≥60 years (p for interaction: 0.035 and 0.01, respectively).

CONCLUSIONS

Elevated RC and Lp-PLA2 levels were associated with an increased risk of composite adverse events, with these associations significantly influenced by sex and age. Our study highlights the synergistic effect of RC and Lp-PLA2 on the composite adverse events.

Remnant Cholesterol Levels at Diagnosis May Predict Acute Coronary Syndrome Occurrence During Follow-Up in Patients with Antineutrophil Cytoplasmic Antibody-Associated Vasculitis

Background/Objectives: Previous studies have revealed the predictive potential of remnant cholesterol (RC) for acute coronary syndrome (ACS) occurrence in the general population. However, whether this association applies to patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV), in which a lipid paradox exists, remains unclear. We investigated whether RC levels at diagnosis could predict ACS occurrence during follow-up in patients with AAV. Methods: This study included 139 patients with AAV. ACS was defined as ST-elevation myocardial infarction (STEMI), non-STEMI, or unstable angina occurring after AAV diagnosis. RC levels were calculated as (total cholesterol)-(low-density lipoprotein cholesterol)-(high-density lipoprotein cholesterol). Patients were categorised into three groups by RC tertiles: highest (≥26.2 mg/dL), middle (19.1-26.1 mg/dL), and lowest (≤19.0 mg/dL) tertile groups. Results: The median age of the 139 patients (male, 31.7%) was 58.0 years. During follow-up, six, two, and one patients were diagnosed with ACS in the highest, middle, and lowest tertile groups, respectively. Patients in the highest tertile group exhibited a significantly lower ACS-free survival rate than those in the lowest tertile (p = 0.030). In the multivariable Cox hazards model, male sex (hazard ratio [HR] 9.054, 95% confidence interval [CI] 1.786-45.910), Birmingham vasculitis activity score (HR 1.147, 95% CI 1.033-1.274), and the highest tertile of RC levels (HR 10.818, 95% CI 1.867-62.689) were significantly and independently associated with ACS occurrence during follow-up in patients with AAV. Conclusions: Our findings indicate that RC levels at diagnosis may predict ACS occurrence during follow-up in patients with AAV, regardless of the traditional cardiovascular risk factors.

The relationship between remnant cholesterol and young-onset myocardial infarction in patients with type 2 diabetes: a retrospective study

Background

Remnant cholesterol (RC) has emerged as a novel therapeutic target beyond low-destiny-lipoproteins cholesterol (LDL-c). While elevated RC levels are strongly associated with cardiovascular disease risk in the general population, their specific role in young-onset acute myocardial infarction (AMI) among patients with type 2 diabetes mellitus (T2DM) remains insufficiently explored and warrants further investigation.

Methods

This retrospective study included AMI patients with T2DM admitted to the First Affiliated Hospital of Xi'an Jiaotong University from 2018 to 2022. Patients were stratified into tertiles according to RC levels and compared using thresholds derived the commanded values from the PREDIMED cohort study. The primary outcome was young-onset AMI. Group differences were analyzed using the chi-square test and the Kruskal-Wallis H test, while Spearman correlation analyses assessed relationships between variables. Univariate and multivariate logistic regression analyses were employed to evaluate the association between RC and young-onset AMI.

Results

Among the 2,514 participants (mean age 61.58 ± 11.15 years), 802 (31.9%) had young-onset AMI. The increase of young-onset AMI increased significantly with rising RC levels (27.0% vs 29.7% vs 39.1%, P < 0.001). RC showed significant positive correlation with total cholesterol (TC, r = 0.497, P < 0.001), triglycerides (TG, r = 0.411, P < 0.001), and LDL-c (r = 0.166, P < 0.001). RC was independently associated with a higher risk of young-onset AMI (OR: 1.579; 95% CI: 1.354-1.842; P < 0.001), even after adjusting for other traditional risk factors of cardiovascular disease (OR: 1.415; 95% CI 1.189-1.684; P < 0.001). Notably, RC levels remained strongly linked to young-onset AMI regardless of whether LDL-c levels were within the desired range.

Conclusion

RC is a significant and independent risk factor for young-onset AMI in T2DM patients, irrespective of LDL-c level. These findings underscore the importance of monitoring and managing RC levels in clinical practice to mitigate cardiovascular risk in this population.

The mediating role of remnant cholesterol in the associations of Angiopoietin-like 8 with all-cause, CVD, and cancer death: the China Cardiometabolic Disease and Cancer Cohort (4C) study

PURPOSE

To investigate the potential mediating effect of remnant cholesterol (RC) in the associations between angiopoietin-like 8 (ANGPTL8) and the risk of all-cause, cardiovascular disease (CVD), and cancer death.

METHODS

This prospective observational study included 3278 individuals from China. Binary logistic regression and mediation analyses were conducted to investigate the mediating effect of RC in the associations between ANGPTL8 and all-cause, CVD, and cancer death.

RESULTS

During up to 5-year follow-up, a total of 265 deaths (8.08%) were documented. Both increased levels of ANGPTL8 and RC were associated with a higher risk of death for all-cause, CVD, and cancer risk. The level of RC ≥ 33 mg/dL could identify individuals at a higher risk of death independent of low-density lipoprotein cholesterol (LDL-C) levels in Chinese general populations. Furthermore, RC significantly mediated the relationship between increased ANGPTL8 levels and higher risk of all-cause, CVD, and cancer death (proportion of mediation effect: 13.10%, 9.22%, and 6.07%, respectively, all p < 0.05).

CONCLUSION

Both increased circulating levels of ANGPTL8 and RC are the risk factors for all-cause, CVD, and cancer death and RC partially mediates the association between ANGPTL8 and death risk.

TSH is independently associated with remnant cholesterol in euthyroid adults: a cross-sectional study based on 29,708 individuals

PURPOSE

The study aims to investigate the relationship between thyroid-stimulating hormone (TSH) and remnant cholesterol (RC) in euthyroid adults.

METHODS

The adults who were recruited for the study had undergone physical examination at Beijing Chao-Yang Hospital. High RC levels were defined as the upper quartile of RC levels in males and females, respectively. The relationship between TSH and RC was assessed using the logistic and linear regression models.

RESULTS

A total of 29,708 adults (14,347 males and 15,361 females) were enrolled in this study. RC ≥ 0.77 mmol/L in males and RC ≥ 0.60 mmol/L in females were defined as high RC levels. With increasing serum TSH levels, the percentage of adults with high RC levels increased. The odds ratios (ORs (95% confidence intervals (CIs)) for high RC levels increased as TSH quartiles (Q) rose after full adjustments [males: Q2 1.11 (1.00-1.24), P < 0.05; Q3 1.03 (0.92-1.15), P > 0.05; Q4 1.25 (1.12-1.40), P < 0.001; and females: Q2 1.07 (0.96-1.20), P > 0.05; Q3 1.17 (1.05-1.31), P < 0.01, Q4 1.33 (1.20-1.48), P < 0.001, all P for trend < 0.001], using Q1 as the reference.

CONCLUSION

Higher TSH levels were independently associated with higher RC levels in euthyroid adults, this underscoring the significance of regulating TSH levels appropriately.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Remnant cholesterol and cardiovascular and all-cause mortality in Korean adults

BACKGROUND

Previous studies have investigated the relationship between remnant cholesterol (RC) and mortality outcomes in the general population, but the majority have focused on Western populations.

OBJECTIVE

This study aims to evaluate the association between RC and mortality-related outcomes in a relatively young and middle-aged Korean population.

METHODS

This cohort study included 268,219 participants (mean age, 38 years; 50.6% men) who were enrolled in the Kangbuk Samsung Health Study between 2003 and 2016. Fasting RC was calculated as total cholesterol minus low-density lipoprotein cholesterol minus high-density lipoprotein cholesterol.

RESULTS

The median RC was 0.47 mmol/L (18 mg/dL) and the prevalence of ≥1 mmol/L RC was 11.4%. During the median follow-up of 6.7 years, compared with the lowest quintile (RC <0.31 mmol/L), the hazard ratios (HRs) and 95% CIs for cardiovascular mortality were 1.95 [0.78, 4.84], 2.47 [1.03, 5.91], 2.39 [1.00, 5.72], and 2.84 [1.19, 6.78] in the second, third, fourth, and highest quintiles, respectively. The HRs for all-cause mortality in the third, fourth, and highest quintiles remained significant but were not significant for the risk of cancer mortality. Subgroup analyses showed that the high RC group with high-sensitivity C-reactive protein (hsCRP) or high lipoprotein(a) levels had more than 2-fold and 3-fold increased risks of cardiovascular mortality than the low RC group with low hsCRP or low lipoprotein(a) levels.

CONCLUSION

High RC levels were significantly associated with an increased risk of cardiovascular and all-cause mortality, but not with cancer mortality. Specifically, high hsCRP and lipoprotein(a) levels weighted the risk association between high RC and cardiovascular mortality.

The prognostic value of remnant cholesterol to adverse renal outcomes in patients with type 2 diabetes

BACKGROUND

Type 2 diabetes (T2DM) is known to have detrimental effects on renal health. Our study aimed to investigate the relationship between remnant cholesterol (remnant-C) and adverse renal outcomes in patients with T2DM.

METHODS

We utilized data from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, which included 10,196 participants with T2DM to investigate the relationship between remnant-C and adverse renal outcomes by performing Kaplan-Meier survival analysis, Cox proportional regression and Restricted cubic spline (RCS) analysis. Finally, several sensitivity analyses were conducted to assess the robustness of our findings.

RESULTS

Over a 7-year follow-up period, 2039 patients (23.2%) developed albuminuria, 5824 patients (57.1%) experienced worsening renal function, and 280 patients (2.7%) progressed to renal failure. After adjusting for multiple confounding factors, we found that remnant-C was significantly associated with the development of albuminuria (P = 0.007) and worsening renal function (P = 0.002). However, there was no discernible connection between remnant-C and renal faiure (P = 0.621). In sensitivity analyses, the association between remnant-C and the risk of adverse renal outcomes remained robust.

CONCLUSION

Our findings highlight the association between remnant-C and the risk of adverse renal outcomes in patients with T2DM. This easily calculable index can provide valuable information to physicians for predicting the risk of adverse renal outcomes in patients with T2DM.

Causal Associations Between Remnant Cholesterol Levels and Atherosclerosis-Related Cardiometabolic Risk Factors: A Bidirectional Mendelian Randomization Analysis

Background: Despite the widespread use of lipid-lowering agents, the risk of atherosclerotic cardiovascular disease (ASCVD) remains; this residual risk has been attributed to remnant cholesterol (RC) levels. However, the causal associations between RC levels and various atherosclerosis-related cardiometabolic and vascular risk factors for ASCVD remain unclear. Methods: Using genetic and biochemical data of 108,876 Taiwan Biobank study participants, follow-up data of 31,790 participants, and follow-up imaging data of 18,614 participants, we conducted a genome-wide association study, a Functional Mapping and Annotation analysis, and bidirectional Mendelian randomization analyses to identify the genetic determinants of RC levels and the causal associations between RC levels and various cardiometabolic and vascular risk factors. Results: We found that higher RC levels were associated with higher prevalence or incidence of the analyzed risk factors. The genome-wide association study unveiled 61 lead genetic variants determining RC levels. The Functional Mapping and Annotation analysis revealed 21 gene sets exhibiting strong enrichment signals associated with lipid metabolism. Standard Mendelian randomization models adjusted for nonlipid variables and low-density lipoprotein cholesterol levels unraveled forward causal associations of RC levels with the prevalence of diabetes mellitus, hypertension, microalbuminuria, and metabolic liver disease. Reverse Mendelian randomization analysis revealed the causal association of diabetes mellitus with RC levels. Conclusions: RC levels, mainly influenced by genes associated with lipid metabolism, exhibit causal associations with various cardiometabolic risk factors, including diabetes mellitus, hypertension, microalbuminuria, and metabolic liver disease. This study provides further insights into the role of RC levels in predicting the residual risk of ASCVD.

Impact of remnant cholesterol on short-term and long-term prognosis in patients with prediabetes or diabetes undergoing coronary artery bypass grafting: a large-scale cohort study

BACKGROUND

Remnant cholesterol (remnant-C) contributes to atherosclerotic cardiovascular disease (ASCVD), particularly in individuals with impaired glucose metabolism. Patients with impaired glucose metabolism and ASCVD remain at significant residual risk after coronary artery bypass grafting (CABG). However, the role of remnant-C in this population has not yet been investigated.

METHODS

Adult patients with prediabetes or diabetes undergoing isolated CABG were consecutively enrolled in a longitudinal cohort between 2013 and 2018. The impact of remnant-C on short-term and long-term outcomes after CABG was evaluated. The short-term outcomes included major perioperative complications. The long-term outcomes were major adverse cardiovascular and cerebrovascular events (MACCEs). Remnant-C was analyzed as both a categorical and continuous variable. Logistic regression, Cox regression, and restricted cubic spline analyses were performed with multivariate adjustments.

RESULTS

In terms of perioperative outcomes, patients with elevated remnant-C had a higher incidence of acute kidney injury (AKI) stage 2/3 (high vs. low remnant-C: 3.2% vs. 2.4%; OR: 1.404, 95% CI 1.080-1.824). Each 1-standard deviation (SD) increase in remnant-C was associated with a 16.6% higher risk of AKI stage 2/3 (OR: 1.160, 95% CI 1.067-1.260). Long-term outcomes were assessed after a median follow-up of 3.2 years, during which 1,251 patients (9.3%) experienced MACCEs. Each 1-SD increase in remnant-C was associated with a 6.6% higher risk of MACCEs (HR: 1.066, 95% CI 1.012-1.124), a 7.1% higher risk of all-cause death (HR: 1.071, 95% CI 1.008-1.209), and an 11.2% higher risk of myocardial infarction (HR: 1.112, 95% CI 1.011-1.222). These associations remained consistent when remnant-C was treated as a categorical variable. Importantly, the association between remnant-C and MACCEs was independent of LDL-C levels; higher remnant-C levels were associated with increased MACCE risk regardless of whether LDL-C was ≤ 2.6 mmol/L or > 2.6 mmol/L. Subgroup analysis indicated that this risk was more pronounced in insulin-treated patients.

CONCLUSIONS

Remnant-C is associated with AKI and MACCEs in patients with diabetes or prediabetes undergoing CABG. The MACCE risk associated with remnant-C is independent of LDL-C and is more pronounced in insulin-treated patients.

Reduction in Remnant Cholesterol in Obese Individuals After Bariatric Surgery with Gastric Bypass or Sleeve Gastrectomy

Background: The effectiveness of bariatric surgery in reducing remnant cholesterol (RC) levels, particularly when obesity is accompanied by elevated glycated hemoglobin (HbA1c), is insufficiently investigated. In this study, we aimed to examine the impacts of two common bariatric procedures, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), as regards their effects on RC and HbA1c levels. Methods: Adult morbidly obese subjects were included and assigned to receive either RYGB or SG. The levels of RC and HbA1c were determined 6 and 12 months after surgery and compared to preoperative levels to assess the efficacy of these surgical methods. In the statistical evaluation of covariations between RC and other biomarkers, previously determined C-reactive protein (CRP), triglycerides, apolipoprotein B, apolipoprotein A1, and low- and high-density lipoprotein cholesterol 6 and 12 months after surgery were included. A linear mixed regression model for repeated analyses was used. Results: The RC levels were markedly reduced both after RYGB and SG but without significant differences between the RYGB and the SG surgery. Furthermore, the RC values were strongly associated with the levels of CRP and HbA1c. Conclusions: A significant lowering of RC values after bariatric surgery appeared paralleled by concomitant reductions in HbA1c values and CRP levels. Together, these effects lead to a lower risk of cardiovascular disease.

The relevance of remnant cholesterol as a guide for lipid management in Indian subjects undergoing coronary revascularization

BACKGROUND

The atherogenic potential of remnant cholesterol, which refers to the cholesterol content of triglyceride-rich, non-low-density lipoprotein (LDL) particles in circulation, has gained increasing attention recently. Unfortunately, very limited information is available regarding remnant cholesterol levels in Indian subjects.

METHODS

This was a retrospective study conducted at a premier, tertiary care center in North India. A total of 3064 consecutive subjects [mean age 61.3 ± 10.3 years, 2550 (83.2%) men] with newly diagnosed coronary artery disease (CAD) undergoing coronary revascularization were included. Enzymatic assays were used for measuring various lipid parameters. Remnant cholesterol was calculated by subtracting LDL cholesterol (LDL-C) and high-density lipoprotein cholesterol from total cholesterol. A value >30 mg/dL was considered elevated.

RESULTS

The mean LDL-C was 79.1 ± 33.1 mg/dL with 46.4% of all subjects having LDL-C <70 mg/dL and only 16.9% having LDL-C <50 mg/dL. The median remnant cholesterol level was 17.0 mg/dL (interquartile range 12.0-24.0 mg/dL) with only 11.9% of subjects having values >30 mg/dL. Only 4.5% of the patients with LDL-C <70 mg/dL and 2.9% of those with LDL-C <50 mg/dL had elevated remnant cholesterol. These proportions were significantly greater in patients with serum triglycerides >200 mg/dL.

CONCLUSION

Our study shows that in a North-Indian population with CAD, elevated remnant cholesterol was present in only a small proportion. The prevalence of elevated remnant cholesterol decreased further as the LDL-C control improved. These findings suggest that elevated remnant cholesterol may not be a clinically relevant therapeutic target in most patients with LDL-C below the currently recommended goals.

A Synergistic Effect of Remnant Cholesterol and C-Reactive Protein on Predicting the Severity of Coronary Artery Disease

Background

Increased levels of remnant cholesterol (RC) and inflammation are linked to higher risks of atherosclerotic cardiovascular disease. Whether a combination of C-reactive protein (CRP) and RC improves the predictive ability for evaluating the severity of coronary artery lesions remains unknown.

Methods

A total of 1675 patients with coronary artery disease were stratified according to the Synergy Between Percutaneous Coronary Intervention (SYNTAX) score (SYNTAX score ≤22 versus SYNTAX score >22). Logistic regression and restricted cubic spline models were used to evaluate the relationship between RC, CRP and the severity of coronary artery lesions. Multivariate logistic regression was used to identify predictors of a mid/high SYNTAX score (SYNTAX score >22). The predictive value of RC combined with CRP was estimated by the ROC curve, continuous net reclassification improvement (NRI) and integrated discrimination improvement (IDI).

Results

The multivariable-adjusted odds ratios (95% CIs) for the highest versus lowest quartile of RC were 2.143 (1.450-3.166) for a mid/high SYNTAX score (SYNTAX score >22). The association of RC with severity of coronary artery lesions was maintained significant in the subsample of patients, regardless of traditional cardiovascular risk factors like LDL-C levels and glycemic metabolism status. Moreover, the addition of CRP and RC to the baseline risk model had an incremental effect on the predictive value for a mid/high SYNTAX score (increase in C‑statistic value from 0.650 to 0.698; IDI 0.03; NRI 0.306; all P < 0.01).

Conclusion

Elevated RC levels were significantly associated with the severity of coronary artery lesions even in patients with optimal low-density lipoprotein cholesterol levels. Adjustment of the RC by CRP further improved the predictive ability for the severity of coronary artery lesions. The combination of RC and CRP might serve as a noninvasive predictor of CAD complexity and could potentially influence the management and therapeutic approach.

Association of remnant cholesterol with insulin resistance and type 2 diabetes: mediation analyses from NHANES 1999-2020

BACKGROUND

Previous studies have established a correlation between elevated levels of remnant cholesterol (RC) and the occurrence of type 2 diabetes mellitus (T2D) as well as insulin resistance (IR); however, the precise nature of these associations remains incompletely elucidated. This study aimed to evaluate the relationships between RC and IR, as well as RC and T2D, and to determine the extent to which IR mediated the relationship between RC and T2D.

METHODS

This was an observational study that utilized cross-sectional methods to examine the general population in the National Health and Nutrition Examination Survey (NHANES) 1999-2020. The participants were divided into 4 groups according to the RC quartiles. The outcome was the prevalence of IR and T2D. Survey-weighted binary logistic regression analysis was used to analyze the associations, and the restricted cubic spline (RCS) curve was used to further analyze the nonlinear relationship. Receiver operating characteristic (ROC) curves were generated to evaluate the diagnostic performance, and the areas under the curves (AUC) of RC, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG) were compared using the DeLong test. The mediating effect of IR on the relationship between RC and T2D was evaluated through mediation analysis.

RESULTS

A total of 23,755 participants (46.02 ± 18.48 years, 48.8% male) were included in our study. Higher RC levels were significantly associated with increased prevalence of both IR and T2D. After adjusting for potential confounders, logistic regression analysis showed that higher RC quartiles were associated with the increased prevalence of IR [Quartile 4 vs. Quartile 1: odds ratio (OR) (95% confidence interval, CI): 1.65 (1.41-1.94), p < 0.001] and T2D [Quartile 4 vs. Quartile 1: OR (95% CI): 1.24 (1.03-1.50), p = 0.024]. RCS analysis revealed two distinct nonlinear relationships: one between RC levels and the prevalence of IR (nonlinear p < 0.001), and another between RC levels and the prevalence of T2D (nonlinear p < 0.001). ROC curve analysis demonstrated that RC had the highest discriminative ability, significantly outperforming LDL-C, HDL-C, and TG in predicting both IR and T2D risk (all P < 0.001 by DeLong test). Mediation analysis revealed that IR significantly mediated the relationship between RC and T2D, with approximately 54.1% of the effect of RC on T2D being indirect through IR.

CONCLUSIONS

Higher RC level was associated with increased prevalence of IR and T2D. IR mediated 54.1% of the association between RC and T2D, suggesting that managing IR could be crucial in reducing the risk of T2D in individuals with elevated RC levels.

Higher remnant cholesterol increases the risk of coronary heart disease and diabetes in postmenopausal women

Background

Postmenopausal women represent the demographic increasingly susceptible to cardiovascular and metabolic diseases. Elevated levels of remnant cholesterol (RC) have been implicated in atherosclerosis and insulin resistance.

Methods

This study aimed to investigate the relationship between RC and the prevalence of coronary heart disease (CHD), diabetes, and CHD combined with diabetes in a nationally representative sample of US postmenopausal women using data from the National Health and Nutrition Examination Survey (NHANES) 2007-2018. Multivariate logistic regression models were employed to evaluate the association between RC and the outcomes of interest. Nonlinear associations were assessed using restricted cubic splines (RCS), and subgroup analyses, along with interaction tests, were performed.

Results

A total of 1611 participants were included in the final analysis. Higher RC levels were significantly associated with increased risks of CHD [OR=1.67, 95%CI (1.02, 2.74)], diabetes [OR=1.77, 95%CI (1.22, 2.58)], and CHD combined with diabetes [OR=2.28, 95%CI (1.17, 4.42)] (all P<0.05). Compared to the lowest RC quartile (Q1), the highest quartile (Q4) demonstrated elevated incidences of CHD [OR=1.76, 95%CI (1.04, 2.98)], diabetes [OR=1.81, 95%CI (1.30, 2.53)], and CHD combined with diabetes [OR=3.08, 95%CI (1.29, 7.37)] (all P<0.05). RCS curves indicated a nearly linear relationship between RC and the risks of CHD, diabetes, and CHD combined with diabetes.

Conclusion

Our study reveals a significant positive correlation between RC levels and the prevalence of CHD, diabetes, and CHD combined with diabetes among postmenopausal women. Understanding these associations could potentially inform targeted prevention and management strategies tailored to this vulnerable population.

Triglyceride-glucose index mediates the association between residual cholesterol and stroke among middle-aged and older adults in China: a prospective, nationwide, population-based study

Background

Both triglyceride-glucose (TyG) index and residual cholesterol (RC) are predictors of stroke; however, to what extent the RC is associated with stroke through TyG index is unclear. This study examined whether the TyG index mediates the association of RC with incident stroke and the extent of interaction or joint relations of RC and TyG index with stroke in middle-aged and older Chinese adults.

Methods

This is an ongoing prospective cohort study initiated in 2011 that included 10,569 middle-aged and older Chinese adults without stroke at baseline. The exposure was RC, the mediator was TyG index, and the outcome was stroke which followed up from June, 2011, to June, 2018. Mediation analysis was used to explore whether the TyG index mediated the association between RC and stroke risk.

Results

Of the 10,569 participants, 4,978 (47.1%) were men; the mean (SD) age was 59.01 (9.43) years. During a median follow-up of 7.1 years, 734 (7.0%) participants experienced a stroke. In the adjusted Cox models, A one SD increase in RC was associated with an elevated risk of stroke (HR, 1.09; 95% CI, 1.02-1.16), as well as TyG index (HR, 1.14; 95% CI, 1.06-1.23). No significant multiplicative or additive interactions were found between the TyG index and RC on stroke risk (HR for multiplicative: 1.07, 95% CI, 0.67-1.70; Synergy index: 1.05, 95% CI, 0.16-6.88). TyG index mediated the association between RC and stroke (b, -0.16; 95% CI, -0.30 to -0.03). Subgroup analyses and sensitivity analyses showed consistent results.

Conclusions

This study evidence that the TyG index completely mediates the association between RC and stroke risk among middle-aged and older Chinese adults. These findings highlight the importance of considering RC and the TyG index in stroke risk assessment.

Impact of Remnant Cholesterol on Cardiovascular Risk in Diabetes

PURPOSE OF REVIEW

Individuals with diabetes face increased risk of atherosclerotic cardiovascular disease (ASCVD), in part due to hyperlipidemia. Even after LDL cholesterol-lowering, residual ASCVD risk persists, part of which may be attributed to elevated remnant cholesterol. We describe the impact of elevated remnant cholesterol on ASCVD risk in diabetes.

RECENT FINDINGS

Preclinical, observational, and Mendelian randomization studies robustly suggest that elevated remnant cholesterol causally increases risk of ASCVD, suggesting remnant cholesterol could be a treatment target. However, the results of recent clinical trials of omega-3 fatty acids and fibrates, which lower levels of remnant cholesterol in individuals with diabetes, are conflicting in terms of ASCVD prevention. This is likely partly due to neutral effects of these drugs on the total level of apolipoprotein B(apoB)-containing lipoproteins. Elevated remnant cholesterol remains a likely cause of ASCVD in diabetes. Remnant cholesterol-lowering therapies should also lower apoB levels to reduce risk of ASCVD.

Remnant cholesterol and the risk of diabetic nephropathy progression to end-stage kidney disease in patients with type 2 diabetes mellitus: a longitudinal cohort study

AIM

Diabetic nephropathy (DN) is the most common cause of end-stage kidney disease (ESKD). Remnant cholesterol has been investigated as a predictor for the progression of DN in type 1 diabetes mellitus patients, as well as the incidence of DN in type 2 diabetes mellitus (T2DM) patients. This study aimed to evaluate the longitudinal relationship between baseline remnant cholesterol and kidney outcomes using a Chinese T2DM with biopsy-confirmed DN cohort.

METHODS

We included 334 patients with T2DM and biopsy-confirmed DN during 2010-2019 West China Hospital T2DM-DN cohort. Remnant cholesterol was defined by Martin-Hopkins equation. Patients were divided into four groups based on the median (IQR) remnant cholesterol concentration at the time of renal biopsy. The kidney outcome was defined as ESKD, which was defined as the need for chronic kidney replacement therapy or estimated glomerular filtration rate (eGFR) < 15 mL/min/1.73 m2. The relationship between remnant cholesterol and kidney outcome was analyzed using the Kaplan‒Meier method and Cox regression analysis.

RESULTS

The mean age was 51.1 years, and 235 (70%) were men. During follow-up, a total of 121 (36.2%) patients reached ESKD. The Kaplan‒Meier analysis showed that patients in the highest quartile (quartile 4) group had lower cumulative renal survival (log-rank test, p = 0.033) and shorter median renal survival time [34.0 (26.4-41.6) vs. 55.0 (29.8-80.2) months] than patients in the lowest quartile (quartile 1) group. By univariate analysis, the high remnant cholesterol group was associated with a higher risk of progression to ESKD. Moreover, the risk of progression to ESKD in the highest quartile was still 2.857-fold (95% CI 1.305-6.257, p = 0.009) higher than that in the lowest quartile, and one-SD increase of remnant cholesterol was associated with a higher risk (HR = 1.424; 95% CI 1.075-1.886, p = 0.014) of progression to ESKD, after adjusted for confounding factors.

CONCLUSIONS

High remnant cholesterol is independently associated with a higher risk of ESKD in patients with T2DM-DN, and it may be a new noninvasive marker of ESKD.

CLINICAL RELEVANCE

Calculated remnant cholesterol has the advantages of being economical and clinically accessible. Moreover, to our knowledge, there are no longitudinal cohort studies for investigating the risk of progression of T2DM-DN to ESKD. In our study, higher remnant cholesterol was associated with a higher risk of ESKD in patients with T2DM-DN, and it may be a new noninvasive predictor of ESKD.

Temporal changes in lipid concentrations and the prevalence of dyslipidemia among individuals with diabetes, prediabetes, and normal blood glucose from 2011 to 2015

BACKGROUND

Dyslipidemia plays a pivotal role in the development of diabetes mellitus (DM) and other metabolic disorders. This study aimed to investigate the trends in lipid concentrations among Chinese participants with different blood glucose statuses-ranging from DM and prediabetes mellitus (pre-DM) to normal blood glucose levels-between 2011 and 2015. Additionally, this study sought to provide a comprehensive description of the potential temporal changes in the prevalence of dyslipidemia among these populations in China during this period.

METHODS

The data for this study were derived from the China Health and Retirement Longitudinal Study (CHARLS), encompassing two time points in 2011 and 2015. The 2011 data sample included 11,408 participants aged 45 years and above, whereas the 2015 data sample included 12,224 participants within the same age range.

RESULTS

In this study, a comparative analysis of data from 2011 to 2015 revealed that individuals diagnosed with DM and pre-DM experienced significant decreases in total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) and a significant increase in high-density lipoprotein cholesterol (HDL-C) (P < 0.05). For participants with pre-DM, the levels of residual cholesterol (RC) significantly increased, whereas the levels of the atherogenic index of plasma (AIP) significantly decreased (P < 0.05). Among participants with normal blood glucose, there was a significant decrease in the levels of TC and LDL-C and a significant increase in the levels of triglycerides (TGs), RCs, and the AIP (P < 0.05). Between 2011 and 2015, the concentrations of TC, TG, LDL-C, RC, and AIP, both unadjusted and adjusted, were significantly higher in individuals with DM than in those with pre-DM and normal blood glucose, with the opposite being true for HDL-C. In 2015, the prevalence of dyslipidemia among participants with DM, pre-DM, and normal blood glucose was 36.56% (95% CI: 34.49%, 38.66%), 15.78% (95% CI: 14.93%, 16.67%), and 11.23% (95% CI: 10.17%, 12.36%), respectively. The results of the present study revealed a significant decrease in the incidence of dyslipidemia in urban areas between 2011 and 2015 (P < 0.05).

CONCLUSION

This study revealed that the prevalence of dyslipidemia is greater among DM patients, particularly those in the 55-64 years age group. Notably, over the four-year observation period, lipid profiles improved among DM patients and pre-DM patients. However, TG levels remained elevated, especially in the 45-54 years age group.

Triglyceride-rich lipoproteins cholesterol, 10-years atherosclerotic cardiovascular disease risk, and risk of myocardial infarction and ischemic stroke

Triglyceride-rich lipoproteins cholesterol (TRLs-C) has been associated with atherosclerotic cardiovascular disease (ASCVD), even among individuals with low-density lipoprotein cholesterol in the targeted range. We assessed the associations of TRLs-C with myocardial infarction (MI) and ischemic stroke (IS) and compared the associations with those for other traditional lipids (i.e., triglycerides and non-high-density lipoprotein cholesterol [non-HDL-C]). Included were 327,899 participants from the UK Biobank who were free of MI or IS and did not receive lipid-lowering treatment at baseline. Ten-year risk for ASCVD was estimated by the Pooled Cohort Equations and was grouped as low (<7.5%), intermediate (7.5% to <20%), and high risk (≥20%). Multivariable Cox regression models were used to examine the associations of TRLs-C, triglycerides, and non-HDL-C with risk of MI and IS, overall and by the 10-years risk categories. During a median of 12.3 years of follow-up, 8,358 incident MI and 4,400 incident IS cases were identified. After multivariable adjustment, higher TRLs-C was associated with a higher risk of MI (p-trend <0.0001) but not IS (p-trend = 0.074), with similar associations for triglycerides and non-HDL-C. There were interactions between TRLs-C and 10-years ASCVD risk on risk of MI (p-interaction <0.0001) and IS (p-interaction = 0.0003). Hazard ratios (95% CIs) of MI comparing the highest with the lowest quartiles of TRLs-C were 2.10 (1.23-1.30) in the low-risk group, 1.52 (1.38-1.69) in the intermediate-risk group, and 1.22 (1.03-1.45) in the high-risk group. The corresponding estimates for IS were 1.24 (1.05-1.45), 0.94 (0.83-1.07), and 0.83 (0.67-1.04), respectively. Similar interactions with the 10-years ASCVD risk were observed for triglycerides and non-HDL-C on risk of MI and for triglycerides on risk of IS. Elevated levels of TRLs-C (or triglycerides or non-HDL-C) are associated with a higher risk of developing MI and IS (except non-HDL-C) predominantly among individuals who are typically classified as being low-risk. These findings may have implications for more detailed risk stratification and early intervention.

Elevated remnant cholesterol as a potential predictor for cardiovascular events in rheumatoid arthritis patients

Objective

The risk of cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA) remains inadequately defined. Consequently, this study aims to evaluate the predictive value of remnant cholesterol (RC) for assessing CVD risk in RA patients.

Methods

Plasma RC levels were measured in 114 RA patients and 41 healthy controls, calculated as total cholesterol minus HDL-C and LDL-C. These levels were further analyzed using 1H-NMR lipid/metabolomics. Meanwhile, the 28-joint Disease Activity Score (DAS28) assessed RA activity.

Results

RC levels were significantly elevated in RA patients (19.0 mg/dl, p < 0.001) compared to healthy controls (14.5 mg/dl). Furthermore, RC levels were significantly elevated at 37.4 mg/dl in patients who experienced cardiovascular event (CVE) compared to 17.4 mg/dl in those without CVE (p < 0.001). To enhance the precision and reliability of RC measurements, RC concentrations were further validated using 1H-NMR spectroscopy. Additionally, a positive correlation was observed between RC levels and DAS28. Multivariate analysis identified RC as a significant predictor of CVE (odds ratio = 1.82, p = 0.013). ROC curve analysis revealed superior predictive capability of RC for CVE (AUC = 0.919, p < 0.001) compared to LDL-C (AUC = 0.669, p = 0.018), with a high sensitivity of 94.7% and a specificity of 82.1%.

Conclusion

Elevated RC levels demonstrate greater accuracy in predicting CVE occurrence in RA patients compared to traditional measures such as LDL-C. These findings suggest that elevated RC levels may serve as a novel predictor for occurrence of CVE in RA patients, facilitating early intervention strategies based on the risk stratification.

Dietary isoflavone intake is inversely associated with remnant cholesterol in US adults: A cross-sectional study

BACKGROUND

Several studies have shown that dietary isoflavones are negatively correlated with total cholesterol and low-density lipoprotein cholesterol. However, few studies have investigated the link between dietary isoflavones and remnant cholesterol (RC).

OBJECTIVES

We used the National Health and Nutrition Examination Survey (NHANES) database to explore the association between dietary isoflavone intake and RC.

METHODS

A cross-sectional study was conducted with 4731 participants aged ≥ 20 years from the 2007-2008, 2009-2010, and 2017-2018 NHANES databases. We adopted univariate and multiple linear regression analysis and restricted cubic spline (RCS) to assess the relationship between dietary isoflavone intake and RC. Moreover, we conducted stratified and interaction analyses to ensure the stability of the results and identify specific populations.

RESULTS

The weighted multifactor linear regression model showed a negative correlation between dietary isoflavone intake and remnant cholesterol (Model 2, β = -0.049, 95% CI: (-0.096, -0.002), P = 0.040). The RCS analysis indicated that there was an L-shaped negative correlation between dietary isoflavone intake and RC (P-value for non-linearity was 0.0464). Stratified analyses showed the inverse relationship between dietary isoflavone intake and RC persisted in most subgroups and there was no interaction except for the recreational activity group.

CONCLUSIONS

Our study found a non-linear and negative association between dietary isoflavone intake and RC in US adults, so we hypothesized that consuming an isoflavone-rich diet may help reduce blood RC and further reduce the risk of cardiovascular disease.

Trajectories of Remnant Cholesterol are Associated with Diabetic Foot Ulcer in Adult Patients with Type 2 Diabetes: A Retrospective Cohort Study

Objective

This study aimed to investigate the potential association between long-term variations in remnant cholesterol (RC) levels and the development of diabetic foot ulcers (DFU) in participants with type 2 diabetes (T2D).

Methods

This was a retrospective cohort study. Variation in RC was assessed by the following metrics: mean, standard deviation (SD), coefficient of variation (CV) and trajectories pattern of RC. To identify RC trajectories, we employed the latent class mixture model. The primary endpoint was the development of DFU, and the time-to-event data were analyzed using Cox regression.

Results

A total of 1874 patients with T2D were included, with a median follow-up duration of 4.7 years. Among them, 129 individuals (6.9%) developed DFU. The proportion of DFU was significantly higher in the U-shaped group compared to the median group (P for trend < 0.001). Upon adjustment for confounding variables, the U-shaped trajectory correlated with a higher risk of DFU, demonstrating a hazard ratio (HR) of 2.57 (95% CI, 1.54-4.27). Subgroup analysis showed the U-shaped trajectory had a higher DFU risk regardless of gender (HR=2.40 and 2.81, respectively), glycemic control (HR=1.89 and 7.41, respectively), smoking (HR=2.36 and 2.93, respectively), or hypertension (HR=2.30 and 2.97, respectively). No association was found between mean, SD and CV of RC and DFU.

Conclusion

A U-shape trajectory of RC was independently associated with an elevated risk of DFU among patients with T2D.

The Risk of Coronary Artery Calcification according to Different Lipid Parameters and Average Lipid Parameters

AIM

We compared the association between the baseline and average lipid parameters over time and the coronary artery calcification (CAC) risk.

METHODS

Participants who underwent annual (biannual) health examinations and coronary artery computed tomography to measure CAC at least twice between March 2010 and December 2019, with a baseline CAC of 0, were included. The levels of apolipoprotein B (ApoB), Apolipoprotein A-I (ApoA1), ApoB/ApoA1, non-high-density lipoprotein cholesterol (non-HDL-C), low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), triglycerides (TG), TG/HDL-C, and TC/HDL-C were measured or calculated. The remnant cholesterol (RC) levels were calculated. The average lipid parameters before study entry were calculated using data from 2002 to 2010. The participants were divided into quartiles (Q) according to the parameter values. Cox proportional hazard modeling, adjusted for confounding factors, compared the CAC risk of the highest quartile to the lowest quartile.

RESULTS

Among 29,278 participants (mean age, 39.19±5.21; men, 88.27%), 2,779 developed CAC ＞0. The highest quartile of ApoB showed a numerically strong association with CAC risk, compared with the lowest quartile of ApoB (Q1: reference; Q2: HR,1.41, 95% CI,1.25-1.59; Q3: HR,1.97, 95% CI,1.75-2.21; Q4: HR,2.72, 95% CI,2.41-3.07). RC showed a modest association with CAC risk (Q1: reference; Q2: HR,1.13, 95% CI,0.99-1.28; Q3: HR,1.3, 95% CI,1.15-1.47; Q4: HR,1.7, 95% CI,1.51-1.91). The strength of the association was comparable between the parameters at baseline and the average lipid parameters over time.

CONCLUSIONS

A high ApoB level showed a strong association with CAC risk compared with the lowest ApoB quartile. The baseline lipid parameters can predict CAC development as effectively as the average of multiple measurements can.

Insulin resistance potentiates the effect of remnant cholesterol on cardiovascular mortality in individuals without diabetes

BACKGROUND AND AIMS

Remnant cholesterol (RC) and insulin resistance (IR) have been independently associated with cardiovascular risk. Here, we evaluated the role of IR and RC on cardiovascular disease (CVD) mortality.

METHODS

We conducted an analysis of 16,113 individuals ≥20 years without diabetes from the National Health and Nutrition Examination Survey (NHANES-III/IV). RC levels were calculated using total cholesterol, non-HDL-c, and LDL-c; IR was defined as HOMA2-IR≥2.5 and CVD mortality as a composite of cardiovascular and cerebrovascular mortality. Multiple linear regression was used to assess the relationship between HOMA2-IR and RC and Cox regression models to assess their joint role in CVD mortality. Causally ordered mediation models were used to explore the mediating role of IR in RC-associated CVD mortality.

RESULTS

We identified an association between higher HOMA2-IR and higher RC levels. The effect of IR on CVD mortality was predominant (HR 1.32, 95%CI 1.18-1.48) and decreased at older ages (HR 0.934, 95%CI 0.918-0.959) compared to RC (HR 0.983, 95%CI 0.952-1.014). Higher risk of CVD mortality was observed in individuals with IR but normal RC (HR 1.37, 95%CI 1.25-1.50) and subjects with IR and high RC (HR 1.24, 95%CI 1.13-1.37), but not in subjects without IR but high RC. In mediation models, HOMA2-IR accounted for 78.2% (95%CI 28.11-98.89) of the effect of RC levels on CVD mortality.

CONCLUSIONS

Our findings suggest that RC potentiates the risk of CVD mortality through its effect on whole-body insulin sensitivity, particularly among younger individuals.

Remnant cholesterol and risk of major adverse cardiovascular events: a systematic review and dose-response meta-analysis of cohort studies

Emerging evidence indicates a significant role of remnant cholesterol in contributing to the residual risk associated with major adverse cardiovascular events (MACE). This study aims to evaluate the dose-response relationship between remnant cholesterol and the risk of MACE. PubMed, Embase and Cochrane databases were reviewed to identify cohort studies published in English up to 1 August 2023. Twenty-eight articles were selected. Pooled hazard ratios (HR) and their 95% confidence intervals (CIs) were calculated using fixed or random-effects models to evaluate the association between remnant cholesterol and the risk of MACE. The dose-response relationship between remnant cholesterol levels and the risk of MACE was analyzed using the linear model and restricted cubic spline regression models. For calculated remnant cholesterol levels, the pooled HR (95% CI) of MACE for per 1-SD increase was 1.13 (1.08, 1.17); HR (95% CI) for the second quartile (Q2), the third quartile (Q3) and the highest quartile (Q4) of remnant cholesterol levels were 1.14 (1.03, 1.25), 1.43 (1.23, 1.68) and 1.68 (1.44, 1.97), respectively, compared with the lowest quartile (Q1). For measured remnant cholesterol levels, the pooled HR (95% CI) of MACE per 1-SD increase was 1.67 (1.39, 2.01). The dose-response meta-analysis showed a dose-response relationship between remnant cholesterol levels and the risk of MACE, both on a linear trend (P < 0.0001) and a nonlinear trend (P < 0.0001). The risk of MACE is associated with increased levels of remnant cholesterol, and the dose-response relationship between remnant cholesterol levels and the risk of MACE showed both linear and nonlinear trends.

Association of remnant cholesterol with risk of dementia: a nationwide population-based cohort study in South Korea

BACKGROUND

The association between remnant cholesterol (remnant-C) and cardiovascular disease risk is well established, but its association with dementia remains unclear. We aimed to examine this association using a large-scale population dataset.

METHODS

We did a nationwide, population-based cohort study in which we identified participants aged 40 years and older who underwent the national health examination in 2009 from South Korea's National Health Insurance Service. We excluded people who were younger than 40 years and those with a triglyceride concentration of 400 mg/dL or higher due to concerns regarding the accuracy of calculated low-density lipoprotein cholesterol concentration in individuals with extremely high triglyceride concentrations. People who were previously diagnosed with dementia before the index date, and those who had any missing variables were also excluded. To minimise the influence of possible reverse causation, we excluded individuals who had developed any type of dementia within 1 year of the baseline measurements. We calculated hazard ratios (HRs) for all-cause dementia, Alzheimer's disease, and vascular dementia in each quartile of remnant-C using the Cox proportional hazards model adjusted for age, sex, body-mass index, estimated glomerular filtration rate, income level, smoking status, alcohol consumption, regular exercise, diabetes, hypertension, statin and fibrate use, and total cholesterol concentrations. We also did subgroup analyses to investigate the association between remnant-C and the risk of dementia stratified by age, sex, obesity, glycaemic status (normoglycaemia, impaired fasting glucose, new-onset type 2 diabetes, type 2 diabetes with a duration of less than 5 years, and type 2 diabetes with a duration of 5 years or more), hypertension, chronic kidney disease, and dyslipidaemia, using likelihood ratio tests.

FINDINGS

4 234 415 individuals who underwent the national health examination in 2009 were deemed eligible for inclusion. We excluded 1 612 819 individuals on the basis of age, triglyceride concentration, missing variables, or having dementia at baseline. We identified 2 621 596 participants aged 40 years and older (1 305 556 men and 1 316 040 women) who underwent the national health examination and followed them up until the date of any incident of dementia or the end of the study period of Dec 31, 2020. During a median follow-up of 10·3 years (IQR 10·1-10·6), 146 991 (5·6%) participants developed all-cause dementia, 117 739 (4·5%) developed Alzheimer's disease, and 14 536 (0·6%) developed vascular dementia. The risk of dementia increased progressively with higher remnant-C concentrations. Compared with the lowest quartile of remnant-C (quartile 1), HRs in the highest quartile (quartile 4) were 1·11 (95% CI 1·09-1·13) for all-cause dementia, 1·11 (1·08-1·13) for Alzheimer's disease, and 1·15 (1·09-1·21) for vascular dementia. Subgroup analyses revealed that the risk of dementia associated with high remnant-C concentrations was higher in middle-aged people aged 40-59 years than in older people. The risk of dementia associated with high concentrations of remnant-C was notably more pronounced in individuals with diabetes compared with those without diabetes, and the risk increased steeply with a longer duration of diabetes.

INTERPRETATION

Results showed that higher remnant-C concentrations were independently associated with increased risks of all-cause dementia, Alzheimer's disease, and vascular dementia. More research is needed to determine the mechanisms underlying this finding. Monitoring and managing higher concentrations of remnant-C might have important implications for reducing the risk of dementia.

FUNDING

None.

A significant presence in atherosclerotic cardiovascular disease: Remnant cholesterol: A review

The current first-line treatment for atherosclerotic cardiovascular disease (ASCVD) involves the reduction of a patient's low-density lipoprotein cholesterol (LDL-C) levels through the use of lipid-lowering drugs. However, even when other risk factors such as hypertension and diabetes are effectively managed, there remains a residual cardiovascular risk in these patients despite achieving target LDL-C levels with statins and new lipid-lowering medications. This risk was previously believed to be associated with lipid components other than LDL, such as triglycerides. However, recent studies have unveiled the crucial role of remnant cholesterol (RC) in atherosclerosis, not just triglycerides. The metabolized product of triglyceride-rich lipoproteins is referred to as triglyceride-rich remnant lipoprotein particles, and its cholesterol component is known as RC. Numerous pieces of evidence from epidemiological investigations and genetic studies demonstrate that RC plays a significant role in predicting the incidence of ASCVD. As a novel marker for atherosclerosis prediction, when LDL-C is appropriately controlled, RC should be prioritized for attention and intervention among individuals at high risk of ASCVD. Therefore, reducing RC levels through the use of various lipid-lowering drugs may yield long-term benefits. Nevertheless, routine testing of RC in clinical practice remains controversial, necessitating further research on the treatment of elevated RC levels to evaluate the advantages of reducing RC in patients at high risk of ASCVD.

Predictive utility of remnant cholesterol in atherosclerotic cardiovascular disease

PURPOSE OF REVIEW

Remnant cholesterol (RC) is the cholesterol carried in lipoproteins derived from the catabolism of chylomicrons and very low-density lipoproteins. Evidence supporting the causal relationship of RC with atherosclerotic cardiovascular disease (ASVD) is accumulating rapidly. The number of impactful contributions to this field are increasing and provide a pathophysiological insight into the current residual cardiovascular risk beyond low-density cholesterol (LDL)-cholesterol (LDL-C). They also raise the question of whether RC should be used in prediction models and become the target of new therapeutic interventions. The intent of this review is to highlight the recent advances on the role of RC in atherogenesis and the validation of RC as a predictor of ASVD.

RECENT FINDINGS

Numerous prospective and retrospective cohorts helped validate a significant causal relationship of RC with various forms of ASVD, independent of LDL-C. A recent large Mendelian randomization study reinforced the existence of this relationship and showed that the risk of atherosclerotic events was driven nearly entirely by a direct effect of RC.

SUMMARY

Both available and accumulating evidence suggest that a lifelong reduction in RC could translate into a substantial reduction in ASVD risk. The data support a revision of current guidelines to incorporate RC as an independent risk factor for ASVD. We propose that early screening of RC should be implemented and that RC lowering should become the target of future drug developments.

Causal Associations of Environmental Pollution and Cardiovascular Disease: A Two-Sample Mendelian Randomization Study

Background

There is growing evidence that concentrations of environmental pollutants are previously associated with cardiovascular disease; however, it is unclear whether this association reflects a causal relationship.

Methods

We utilized a two-sample Mendelian randomization (MR) approach to investigate how environmental pollution affects the likelihood of developing cardiovascular disease. We primarily employed the inverse variance weighted (IVW) method. Additionally, to ensure the robustness of our findings, we conducted several sensitivity analyses using alternative methodologies. These included maximum likelihood, MR-Egger regression, weighted median method and weighted model methods.

Results

Inverse variance weighted estimates suggested that an SD increase in PM2.5 exposure increased the risk of heart failure (OR = 1.40, 95% CI 1.02-1.93, p = 0.0386). We found that an SD increase in PM10 exposure increased the risk of hypertension (OR = 1.45, 95% CI 1.02-2.05, p = 0.03598) and atrial fibrillation (OR = 1.41, 95% CI 1.03-1.94, p = 0.03461). Exposure to chemical or other fumes in a workplace was found to increase the risk of hypertension (OR = 3.08, 95% CI 1.40-6.78, p = 0.005218), coronary artery disease (OR = 1.81, 95% CI 1.00-3.26, p = 0.04861), coronary heart disease (OR = 3.15, 95% CI 1.21-8.16, p = 0.0183) and myocardial infarction (OR = 3.03, 95% CI 1.13-8.17, p = 0.02802).

Conclusion

This study reveals the causal relationship between air pollutants and cardiovascular diseases, providing new insights into the protection of cardiovascular diseases.

High remnant-cholesterol levels increase the risk for end-stage renal disease: a nationwide, population-based, cohort study

BACKGROUND

The effect of remnant-cholesterol (remnant-C) on incident end-stage renal disease (ESRD) has not been studied longitudinally. This retrospective cohort study evaluated the association between remnant-C and the development of ESRD in a nationwide Korean cohort.

METHODS

Participants in a National Health Insurance Service health examination (n = 3,856,985) were followed up until the onset of ESRD. The median duration of follow-up was 10.3 years. The Martin-Hopkins equation was used to determine low-density lipoprotein cholesterol (LDL-C) levels from directly measured triglyceride, high-density lipoprotein cholesterol (HDL-C), and total cholesterol levels. Remnant-C levels were determined by subtracting HDL-C and LDL-C from total cholesterol. The risk for incident ESRD was calculated for each quartile of remnant-C, adjusting for conventional risk factors such as baseline renal function, comorbidities, and total cholesterol levels.

RESULTS

ESRD developed in 11,073 (0.29%) participants. The risk for ESRD exhibited a gradual increase according to higher levels of remnant-C, with a 61% increased risk in the highest quartile than in the lowest (hazard ratio [HR] 1.61 [95% confidence interval (CI) 1.50-1.72]). The elevated risk for ESRD in the highest quartile versus the lowest quartile was more prominent in younger than in older subjects (20-29 years, HR 4.07 [95% CI 2.85-5.83]; 30-39 years, HR 2.39 [95% CI 1.83-3.13]; ≥ 70 years, HR 1.32 [95% CI 1.16-1.51]). In addition, the increased risk for ESRD related to higher remnant-C levels was greater in females than in males.

CONCLUSIONS

Independent of conventional risk factors, remnant-C levels were positively associated with incident ESRD, particularly in younger populations and adult females. Reducing remnant-C levels may be a novel preventive strategy against ESRD.

Remnant cholesterol as a new lipid-lowering target to reduce cardiovascular events

PURPOSE OF REVIEW

Remnant cholesterol has become increasingly recognized as a direct contributor to the development of atherosclerosis and as an additional marker of cardiovascular risk. This review aims to summarize the pathophysiological mechanisms, and the current evidence base from epidemiological investigations and genetic studies that support a causal link between remnant cholesterol and atherosclerotic cardiovascular disease. Current and novel therapeutic approaches to target remnant cholesterol are discussed.

RECENT FINDINGS

A recent Mendelian randomization study of over 12 000 000 single-nucleotide polymorphisms associated with high levels of remnant cholesterol, demonstrated a genetic association between remnant cholesterol and adverse cardiovascular events among 958 434 participants.

SUMMARY

In this light, the emerging role of remnant cholesterol as an independent lipid risk marker warrants a reevaluation of lipid management guidelines and underscores the potential for novel therapeutic targets in cardiovascular disease prevention.

Elevated remnant cholesterol is a risk factor for acute ischemic stroke

OBJECTIVES

Remnant cholesterol (RC) is thought to be an important pathogenic risk factor for atherosclerosis, however, the relationship between RC and acute ischemic stroke (AIS) is still unclear. This study aimed to determine whether fasting blood RC level is an independent risk factor for AIS.

MATERIALS AND METHODS

A retrospective analysis was performed on 650 patients with AIS and 598 healthy controls during the same time period. The association between RC and AIS was investigated using binary logistic regression, and the relationship between RC and AIS risk was demonstrated using Restricted Cubic Splines (RCS).

RESULTS

RC was significantly higher in the AIS group compared with control group, and was an independent risk factor for AIS when the covariates were not adjusted;After adjusting some covariates, RC was still an independent risk factor for AIS. The RCS analysis found the risk was non-linear: when RC concentration was less than 0.69 mol/L, the risk of AIS increased with the elevation of RC, and when RC concentration was more than or equal to 0.69 mol/L, the risk of AIS was insignificant with the elevation of RC. Correlation analysis revealed that RC was associated with diabetes and fasting glucose. Further analysis revealed that the incidence of AIS in diabetic patients increased significantly with the increase of RC, and RCS analysis revealed that the risk of AIS in diabetic patients increased with the increase of RC when RC was more than 1.15 mol/L.

CONCLUSIONS

This study confirms RC as an independent risk factor for AIS, which highlights a distinct non-linear association between RC levels and AIS risk. These findings suggest the need for targeted AIS risk assessment strategies, especially in diabetic patients, and underscore the relevance of RC as a biomarker in AIS risk stratification.

Relationship between remnant cholesterol and short-term prognosis in acute ischemic stroke patients

OBJECTIVE

Several studies have illustrated that elevated RC levels are related to a heightened risk of acute ischemic stroke (AIS). Our research aimed to explore the correlation between RC levels and poor prognosis after a 90-day interval in AIS patients.

METHODS

A total of 287 individuals were enrolled in the study, the primary outcome was defined as poor prognosis. RC was derived by the exclusion of low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) from total cholesterol (TC).

RESULTS

Following the screening process, 253 AIS patients were included in the study, presenting a median age of 66[57, 75] years. Upon stratifying RC levels into quartiles, those in the top quartile faced a greater likelihood of diabetes diagnosis (42.86%, p = .014) and experienced a higher rate of unfavorable outcomes after 90 days (36.51%, p = .001). After accounting for confounding factors, the correlation between the fourth quartile of RC levels and the amplified likelihood of poor prognosis remained significant (odds ratio (OR) 8.471, 95% confidence interval (CI) (1.841, 38.985); p = .006). Analysis of subgroups unveiled a notable correlation between higher RC levels and poor 90-day prognosis, particularly in individuals with elevated NIHSS scores (p = .044). A progressively increasing 90-day risk of poor prognosis after an RC greater than 0.38 mmol/L was visualized by restricted cubic spline plots (p-overall = .011).

CONCLUSIONS

Including RC as a contributing element may refine the prediction of poor 90-day prognosis for AIS patients. Integrating RC with traditional risk factors can potentially enhance the predictive value for cerebrovascular disease.

Associations between remnant cholesterol levels and mortality in patients with diabetes

BACKGROUND

Dyslipidemia is frequently present in patients with diabetes. The associations of remnant cholesterol and mortality remains unclear in patients with diabetes.

AIM

To explore the associations of remnant cholesterol with all-cause and cardiovascular mortality in patients with diabetes.

METHODS

This prospective cohort study included 4740 patients with diabetes who participated in the National Health and Nutrition Examination Survey from 1999 through 2018. Remnant cholesterol was used as the exposure variable, and all-cause and cardiovascular mortality were considered outcome events. Outcome data were obtained from the National Death Index, and all participants were followed from the interview date until death or December 31, 2019. Multivariate proportional Cox regression models were used to explore the associations between exposure and outcomes, in which remnant cholesterol was modeled as both a categorical and a continuous variable. Restricted cubic splines (RCSs) were calculated to assess the nonlinearity of associations. Subgroup (stratified by sex, age, body mass index, and duration of diabetes) and a series of sensitivity analyses were performed to evaluate the robustness of the associations.

RESULTS

During a median follow-up duration of 83 months, 1370 all-cause deaths and 389 cardiovascular deaths were documented. Patients with remnant cholesterol levels in the third quartile had a reduced risk of all-cause mortality [hazard ratio (HR) 95% confidence interval (CI): 0.66 (0.52-0.85)]; however, when remnant cholesterol was modeled as a continuous variable, it was associated with increased risks of all-cause [HR (95%CI): 1.12 (1.02-1.21) per SD] and cardiovascular [HR (95%CI): 1.16 (1.01-1.32), per SD] mortality. The RCS demonstrated nonlinear associations of remnant cholesterol with all-cause and cardiovascular mortality. Subgroup and sensitivity analyses did not reveal significant differences from the above results.

CONCLUSION

In patients with diabetes, higher remnant cholesterol was associated with increased risks of all-cause and cardiovascular mortality, and diabetes patients with slightly higher remnant cholesterol (0.68-1.04 mmol/L) had a lower risk of all-cause mortality.

Elevated blood remnant cholesterol and triglycerides are causally related to the risks of cardiometabolic multimorbidity

The connection between triglyceride-rich lipoproteins and cardiometabolic multimorbidity, characterized by the concurrence of at least two of type 2 diabetes, ischemic heart disease, and stroke, has not been definitively established. We aim to examine the prospective associations between serum remnant cholesterol, triglycerides, and the risks of progression from first cardiometabolic disease to multimorbidity via multistate modeling in the UK Biobank. We also evaluate the causality of these associations via Mendelian randomization using 13 biologically relevant SNPs as the genetic instruments. Here we show that elevated remnant cholesterol and triglycerides are significantly associated with gradually higher risks of cardiometabolic multimorbidity, particularly the progression of ischemic heart disease to the multimorbidity of ischemic heart disease and type 2 diabetes. These results advocate for effective management of remnant cholesterol and triglycerides as a potential strategy in mitigating the risks of cardiometabolic multimorbidity.

Remnant cholesterol is correlated with retinal vascular morphology and diabetic retinopathy in type 2 diabetes mellitus: a cross-sectional study

BACKGROUND

The association between remnant cholesterol (RC) and diabetic retinopathy (DR) in type 2 diabetes mellitus (T2DM) remains unclear. Morphological changes in retinal vessels have been reported to predict vascular complications of diabetes, including DR.

METHODS

This cross-sectional study included 6535 individuals with T2DM. The RC value was calculated using the recognized formula. The retinal vascular parameters were measured using fundus photography. The independent relationship between RC and DR was analyzed using binary logistic regression models. Multiple linear regression and subgroup analyses were employed to investigate the link between RC and vascular parameters, including the retinal arteriolar diameter (CRAE), venular diameter (CRVE), and fractal dimension (Df). Mediation analysis was performed to assess whether the vascular morphology could explain the association between RC and DR.

RESULTS

RC was independently associated with DR in patients with a longer duration of T2DM (> 7 years). Patients with the highest quartile RC levels had larger CRAE (5.559 [4.093, 7.025] μm), CRVE (7.620 [5.298, 9.941] μm) and Df (0.013 [0.009, 0.017]) compared with patients with the lowest quartile RC levels. Results were robust across different subgroups. The association between RC and DR was mediated by CRVE (0.020 ± 0.005; 95% confidence interval: 0.012-0.032).

CONCLUSIONS

RC may be a risk factor for DR among those who have had T2DM for a longer period of time. Higher RC levels were correlated with wider retinal arterioles and venules as well as higher Df, and it may contribute to DR through the dilation of retinal venules.

Remnant cholesterol and low-grade inflammation jointly in atherosclerotic cardiovascular disease: implications for clinical trials

PURPOSE OF REVIEW

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death despite the development of effective treatments. Recently, elevated remnant cholesterol and low-grade inflammation have emerged as factors explaining part of the residual ASCVD risk. Interestingly, the coexistence of both high remnant cholesterol and low-grade inflammation can further increase the risk of ASCVD. The aim of this review is to describe the role of elevated remnant cholesterol and low-grade inflammation, separately and combined, in ASCVD.

RECENT FINDINGS

Results from recently published studies, including observational and genetic Mendelian randomization studies, support a causal relationship between elevated remnant cholesterol and low-grade inflammation on risk of ASCVD in both primary and secondary prevention settings. In addition, current evidence from observational studies suggests that the coexistence of elevated remnant cholesterol and low-grade inflammation further increases the risk of ASCVD.

SUMMARY

Recent observational studies suggest that high remnant cholesterol combined with low-grade inflammation may confer a particular high risk for ASCVD. Attention on the dual threat from high remnant cholesterol and low-grade inflammation is necessary, and further research in this field is warranted. The effect of remnant cholesterol-lowering drugs and anti-inflammatory drugs on ASCVD risk alone and combined remains to be elucidated.

VIDEO ABSTRACT

http://links.lww.com/COCN/A20.

MX1 and UBE2L6 are potential metaflammation gene targets in both diabetes and atherosclerosis

Background

The coexistence of diabetes mellitus (DM) and atherosclerosis (AS) is widespread, although the explicit metabolism and metabolism-associated molecular patterns (MAMPs) responsible for the correlation are still unclear.

Methods

Twenty-four genetically wild-type male Ba-Ma mini pigs were randomly divided into five groups distinguished by different combinations of 90 mg/kg streptozotocin (STZ) intravenous injection and high-cholesterol/lipid (HC) or high-lipid (HL) diet feeding for 9 months in total. Pigs in the STZ+HC and STZ+HL groups were injected with STZ first and then fed the HC or HL diet for 9 months. In contrast, pigs in the HC+STZ and HL+STZ groups were fed the HC or HL diet for 9 months and injected with STZ at 3 months. The controls were only fed a regular diet for 9 months. The blood glucose and abdominal aortic plaque observed through oil red O staining were used as evaluation indicators for successful modelling of DM and AS. A microarray gene expression analysis of all subjects was performed.

Results

Atherosclerotic lesions were observed only in the HC+STZ and STZ+HC groups. A total of 103 differentially expressed genes (DEGs) were identified as common between them. The most significantly enriched pathways of 103 common DEGs were influenza A, hepatitis C, and measles. The global and internal protein-protein interaction (PPI) networks of the 103 common DEGs consisted of 648 and 14 nodes, respectively. The top 10 hub proteins, namely, ISG15, IRG6, IRF7, IFIT3, MX1, UBE2L6, DDX58, IFIT2, USP18, and IFI44L, drive aspects of DM and AS. MX1 and UBE2L6 were the intersection of internal and global PPI networks. The expression of MX1 and UBE2L6 was 507.22 ± 342.56 and 96.99 ± 49.92 in the HC+STZ group, respectively, which was significantly higher than others and may be linked to the severity of hyperglycaemia-related atherosclerosis. Further PPI network analysis of calcium/micronutrients, including MX1 and UBE2L6, consisted of 58 and 18 nodes, respectively. The most significantly enriched KEGG pathways were glutathione metabolism, pyrimidine metabolism, purine metabolism, and metabolic pathways.

Conclusions

The global and internal PPI network of the 103 common DEGs consisted of 648 and 14 nodes, respectively. The intersection of the nodes of internal and global PPI networks was MX1 and UBE2L6, suggesting their key role in the comorbidity mechanism of DM and AS. This inference was partly verified by the overexpression of MX1 and UBE2L6 in the HC+STZ group but not others. Further calcium- and micronutrient-related enriched KEGG pathway analysis supported that MX1 and UBE2L6 may affect the inflammatory response through micronutrient metabolic pathways, conceptually named metaflammation. Collectively, MX1 and UBE2L6 may be potential common biomarkers for DM and AS that may reveal metaflammatory aspects of the pathological process, although proper validation is still needed to determine their contribution to the detailed mechanism.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Association of remnant cholesterol and newly diagnosed early-onset type 2 diabetes mellitus in Chinese population: A retrospective cross-sectional study

BACKGROUND

With the increasing incidence of diabetes worldwide, patients diagnosed with diabetes has been getting younger. Previous studies have shown that high remnant cholesterol (RC) level leads to an increased risk of cardiovascular disease events. However, the relationship between RC levels and newly diagnosed early-onset type 2 diabetes mellitus (T2DM) is unknown. This study aimed to explore the association between RC and newly diagnosed early-onset T2DM.

METHODS

A total of 606 patients newly diagnosed with early-onset T2DM and 619 gender-matched subjects with normal blood glucose levels were retrospectively enrolled in this study. All T2DM patients showed onset age of 18-40 years. Binary logistic regression analysis was performed to analyze independent risk factors and receiver operating characteristic (ROC) analysis was used to explore the predictive value of RC and other unconventional lipids. Moreover, the correlation between RC and insulin resistance in patients with newly diagnosed early-onset T2DM was also examined with binary logistic regression analysis and Spearman correlation analysis.

RESULTS

Increased RC level was an independent risk factor for early-onset T2DM (p < .05). The area under the curve on ROC analysis of RC was 0.805, 95% confidence interval (CI) was 0.781 ~ 0.826, sensitivity was 82.18% and specificity was 66.24%, which showed higher predictive value than those of triglyceride/high-density lipoprotein cholesterol (TG/HDL-C) ratio and total cholesterol (TC)/HDL-C ratio. Cutoff value of RC was 0.32 mmol/L. Level of RC in early-onset T2DM patients with moderate or severe insulin resistance was significantly higher than that in patients with mild insulin resistance (p < .0001). No difference in RC levels was found between patients with moderate and severe insulin resistance (p > .05). RC was still correlated with insulin resistance after adjusting the conventional lipid parameters (TG, TC, HDL-C, and low-density lipoprotein cholesterol) using partial correlation analysis.

CONCLUSION

RC level was higher in patients with early-onset T2DM and was correlated to the degree of insulin resistance as well. Patients aged 18-40 years with RC >0.32 mmol/L showed an increased risk of developing T2DM.

Cumulative remnant cholesterol as a causal risk factor for ischemic heart disease: A prospective cohort study

BACKGROUND

While previous studies have established a significant correlation between baseline remnant cholesterol (RC) and ischemic heart disease (IHD), the enduring impact of RC on incident IHD remains to be elucidated. This study aimed to investigate the association between cumulative remnant cholesterol(cumRC) and IHD susceptibility.

METHODS

Participating from the Kailuan Study (2006-2010) were enrolled, excluding those with prior myocardial infarction, coronary artery revascularization and cancer across three consecutive examinations. The cumRC derived by multiplying the average RC with the interval between the two consecutive assessments. Participants were segmented into quartiles based on cumRC levels: Q1 (cumRC < 2.69 mmol/l); Q2 (2.69 ≤ cumRC < 4.04 mmol/l); Q3(4.04 ≤ cumRC < 5.65 mmol/l) and Q4 (cumRC ≥ 5.65 mmol/l). The correlation between cumRC and IHD risk was ascertained by using multivariable Cox proportional hazard models.

RESULT

The analysis encompassed 42,639 participants. Over an average tracking period of 9.97 years, 1,205 instances of IHD were identified. IHD susceptibility augmented with rising cumRC quartiles. After adjusting for potential confounders, the hazard ratios for IHD events were 1.06 (0.88-1.29) for Q2, 1.30 (1.08-1.56) for Q3 and 1.69 (1.42-2.01) for Q4, relative to Q1. Elevated cumRC was significantly associated with a heightened IHD risk, a trend consistent in both subgroup and sensitivity analyses.

CONCLUSION

Elevated cumRC significantly correlates with a higher risk of IHD, suggesting that consistent monitoring and regulation of RC might be instrumental in IHD prevention.

Association of remnant cholesterol with decreased kidney function or albuminuria: a population-based study in the U.S

BACKGROUND

Dyslipidemia is frequently exhibited in individuals with chronic kidney disease (CKD). Remnant cholesterol (RC), an emerging novel lipid marker, plays an elusive role in CKD progression. This study sought to investigate the association of RC with decreased kidney function or albuminuria in the general population of U.S.

METHOD

Data were retrieved from the continuous 2001 to 2018 cycle of the National Health and Nutrition Examination Survey (NHANES). Individuals aged between 18 and 70 years were included. RC was divided into quartiles. Albuminuria was defined by albumin-to-creatinine ratio (ACR) ≥30 mg/g, while reduced kidney function was described as an estimated glomerular filtration rate (eGFR) below 60 ml/min/1.73 m2. Using a multivariable regression model, the association of RC with decreased eGFR or albuminuria was examined. The dose‒response relationship between RC and eGFR or ACR was also investigated using a restricted cubic spline (RCS) model.

RESULTS

A total of 1551 (10.98%) participants with impaired renal function or albuminuria were identified. After multivariate adjustment, RC was not significantly associated with kidney function decline or albuminuria (odds ratio (OR) 1.24, 95% confidence interval (95% CI): 0.95, 1.61). However, a significantly inverse correlation was observed between RC and eGFR in a dose‒response manner (β -2.12, 95% CI: -3.04, -1.21). This association remained consistent when stratifying data by gender, age, race, hypertension, diabetes and body mass index (BMI).

CONCLUSION

A higher RC was significantly correlated with a lower eGFR in the general population. The role of RC in predicting kidney outcomes needed further investigation in prospective studies.

Correlation Between Glycolipid Metabolism Levels and Diabetic Retinopathy in Patients with Type 2 Diabetes Mellitus

Purpose

We investigate the correlation between glucose and lipid metabolism and diabetic retinopathy (DR) in patients with type 2 diabetes mellitus (T2DM) and its diagnostic and predictive value.

Patients and Methods

A retrospective analysis involved 620 patients diagnosed with T2DM, categorized into two groups based on fundus examination results: the non-diabetic retinopathy group (NDR, n=340) and the diabetic retinopathy group (DR, n=280). We collected baseline patient data, calculated the ratio of glycated hemoglobin (HbA1c) to high-density lipoprotein cholesterol (HDL-C), and analyzed its association with Type 2 Diabetic Retinopathy.

Results

HbA1c/HDL-C in DR group exhibited significantly higher than the NDR group (P<0.001). Mantel-Haenszel's chi-square trend analysis indicated a notable linear trend (P<0.001) between HbA1c/HDL-C and DR. HbA1c/HDL-C revealed moderate positive correlations with DR, r=0.342, P<0.001. Binary logistic regression analysis showed systolic blood pressure (SBP), diabetes course, fasting blood glucose (FBG) and HbA1c/HDL-C as independent risk factors for DR in T2DM patients. Restrictive cubic spline analysis demonstrated a significant nonlinear relationship between HbA1c/HDL-C and DR (P total trend <0.001, P nonlinear = 0.0196). ROC curve analysis identified that HbA1c/HDL-C had the highest diagnostic accuracy for DR, with an area under the ROC curve (AUC) of 0.711, 53.2% sensitivity, and 78.2% specificity.

Conclusion

Our study shows that HbA1c/HDL-C is an independent risk factor for DR in patients with type 2 diabetes. HbA1c/HDL-C has good diagnostic value for DR and can be used as a biological index for early screening of DR.

Elevated remnant cholesterol and atherosclerotic cardiovascular disease in diabetes: a population-based prospective cohort study

AIMS/HYPOTHESIS

Elevated remnant cholesterol is observationally and causally associated with increased risk of atherosclerotic cardiovascular disease (ASCVD) in the general population. This association is not well studied in individuals with diabetes, who are often included in clinical trials of remnant cholesterol-lowering therapy. We tested the hypothesis that elevated remnant cholesterol is associated with increased risk of ASCVD in individuals with diabetes. We also explored the fraction of excess risk conferred by diabetes which can be explained by elevated remnant cholesterol.

METHODS

We included 4569 white Danish individuals with diabetes (58% statin users) nested within the Copenhagen General Population Study (2003-2015). The ASCVDs peripheral artery disease, myocardial infarction and ischaemic stroke were extracted from national Danish health registries without losses to follow-up. Remnant cholesterol was calculated from a standard lipid profile.

RESULTS

During up to 15 years of follow-up, 236 individuals were diagnosed with peripheral artery disease, 234 with myocardial infarction, 226 with ischaemic stroke and 498 with any ASCVD. Multivariable adjusted HR (95% CI) per doubling of remnant cholesterol was 1.6 (1.1, 2.3; p=0.01) for peripheral artery disease, 1.8 (1.2, 2.5; p=0.002) for myocardial infarction, 1.5 (1.0, 2.1; p=0.04) for ischaemic stroke, and 1.6 (1.2, 2.0; p=0.0003) for any ASCVD. Excess risk conferred by diabetes was 2.5-fold for peripheral artery disease, 1.6-fold for myocardial infarction, 1.4-fold for ischaemic stroke and 1.6-fold for any ASCVD. Excess risk explained by elevated remnant cholesterol and low-grade inflammation was 14% and 8% for peripheral artery disease, 26% and 16% for myocardial infarction, 34% and 34% for ischaemic stroke, and 24% and 18% for any ASCVD, respectively. LDL-cholesterol did not explain excess risk, as it was not higher in individuals with diabetes. We also explored the fraction of excess risk conferred by diabetes which can be explained by elevated remnant cholesterol.

CONCLUSIONS/INTERPRETATION

Elevated remnant cholesterol was associated with increased risk of ASCVD in individuals with diabetes. Remnant cholesterol and low-grade inflammation explained substantial excess risk of ASCVD conferred by diabetes. Whether remnant cholesterol should be used as a treatment target remains to be determined in randomised controlled trials.

Lipoproteins, Cholesterol, and Atherosclerotic Cardiovascular Disease in East Asians and Europeans

One fifth of the world population live in East Asia comprising Japan, Korea, and China where ischemic heart disease, a major component of atherosclerotic cardiovascular disease (ASCVD), is the second most frequent cause of death. Each of low-density lipoproteins (LDL), remnant lipoproteins, and lipoprotein(a), summarized as non-high-density lipoproteins (non-HDL) or apolipoprotein B (apoB) containing lipoproteins, causes ASCVD. However, a significant proportion of the evidence on lipoproteins and lipoprotein cholesterol with risk of ASCVD came from White people mainly living in Europe and North America and not from people living in East Asia or of East Asian descent. With a unique biological, geohistorical, and social background in this world region, East Asians have distinctive characteristics that might have potential impact on the association of lipoproteins and lipoprotein cholesterol with risk of ASCVD. Considering the movement across national borders in the World, understanding of lipoprotein and lipoprotein cholesterol evidence on ASCVD in East Asia is important for both East Asian and non-East Asian populations wherever they live in the World.In this review, we introduce the biological features of lipoproteins and lipoprotein cholesterol and the evidence for their association with risk of ASCVD in East Asian and European populations. We also provide an overview of guideline recommendations for prevention of ASCVD in these two different world regions. Finally, specific preventive strategies and future perspectives are touched upon.

Nonlinear connection between remnant cholesterol and stroke risk: evidence from the China health and retirement longitudinal study

OBJECTIVE

The evidence on the relationship between remnant cholesterol (RC) and stroke remains controversial. Therefore, this study aimed to explore the relationship between RC and stroke risk in a Chinese population of middle-aged and elderly individuals.

METHODS

The present study included 10067 Chinese subjects of middle-aged and elderly individuals. The connection between RC and incident stroke was investigated using the multivariate Cox proportional hazards regression model, several sensitivity analyses, generalized additive models, and smoothed curve fitting.

RESULTS

A total of 1180 participants with stroke were recorded during the follow-up period. The multivariate Cox proportional hazards regression model identified a positive connection between RC and stroke risk (hazard ratio (HR) = 1.087, 95% confidence interval (CI): 1.001-1.180). In addition, the current study discovered a nonlinear connection between RC and incident stroke, and the point of inflection for RC was 1.78 mmol/L. The risk of stroke increased by 25.1% with each unit increase in RC level when RC was < 1.78 mmol/L (HR:1.251, 95%CI: 1.089-1.437, P = 0.0015). The results were not affected by sensitivity tests.

CONCLUSION

The current study showed a positive and nonlinear connection between RC and stroke risk in a middle-aged and elderly Chinese population. These findings provided new information to help researchers better understand the relationship between RC levels and incident stroke.

Remnant cholesterol associates with hypertension beyond low-density lipoprotein cholesterol among the general US adult population

Background

Previous findings have indicated that elevated low-density lipoprotein cholesterol (LDL-C) and remnant cholesterol (RC) are associated with hypertension. We aim to explore whether higher RC levels may be associated with hypertension beyond LDL-C in the general US adult population.

Methods

This study included 10,842 adults from the National Health and Nutrition Examination Survey (NHANES) 1999-2018. Weighted multivariable logistic regression models were used to estimate the odds ratios (ORs) of hypertension for LDL-C and RC. We also performed analyses examining the association between hypertension and LDL-C vs. RC concordant/discordant groups.

Results

A total of 4,963 (41.54%, weighted) individuals had hypertension. The weighted median levels were LDL-C: 118mg/dL, RC: 20mg/dL. At lower LDL-C clinical cut-point, the proportion of discordantly high RC dramatically increased. After multivariable adjustment, log RC was associated with higher prevalence of hypertension [OR 2.54, 95% confidence interval (CI) 2.17-2.99]. Participants with the highest tertile of RC were more likely to have hypertension (OR 2.18; 95% CI 1.89-2.52) compared with those with the lowest tertile of RC. This association remained marked after including body mass index (BMI), LDL-C, high-density lipoprotein cholesterol (HDL-C) or triglycerides. The association between LDL-C and hypertension was absent after adjusting for BMI, RC or triglycerides. Compared with low LDL-C/low RC group, the discordant low LDL-C/high RC group was associated with hypertension (OR 2.04; 95% CI 1.72-2.42), whereas the high LDL-C/low RC group was not, regardless of BMI, HDL-C or triglycerides. Similar results were observed when examining discordance among different clinical cut-points, except for the cut-point of LDL-C 70 mg/dL and RC 13 mg/dL. To better understand the association, we performed an additional analysis, which showed that among participants with apolipoprotein B < median (92mg/dL), those with discordant RC ≥ median (20mg/dL) had significantly higher odds of having hypertension (OR 1.73; 95% CI 1.38-2.17).

Conclusion

RC was associated with hypertension beyond LDL-C in the general US adult population. This association went beyond increased triglycerides levels, and lipoproteins other than apoB may be involved.

The Role of Triglyceride-rich Lipoproteins and Their Remnants in Atherosclerotic Cardiovascular Disease

Atherosclerotic cardiovascular disease (ASCVD) is the world's leading cause of death. ASCVD has multiple mediators that therapeutic interventions target, such as dyslipidaemia, hypertension, diabetes and heightened systemic inflammatory tone, among others. LDL cholesterol is one of the most well-studied and established mediators targeted for primary and secondary prevention of ASCVD. However, despite the strength of evidence supporting LDL cholesterol reduction by multiple management strategies, ASCVD events can still recur, even in patients whose LDL cholesterol has been very aggressively reduced. Hypertriglyceridaemia and elevated levels of triglyceride-rich lipoproteins (TRLs) may be key contributors to ASCVD residual risk. Several observational and genetic epidemiological studies have highlighted the causal role of triglycerides within the TRLs and/or their remnant cholesterol in the development and progression of ASCVD. TRLs consist of intestinally derived chylomicrons and hepatically synthesised very LDL. Lifestyle modification has been considered the first line intervention for managing hypertriglyceridaemia. Multiple novel targeted therapies are in development, and have shown efficacy in the preclinical and clinical phases of study in managing hypertriglyceridaemia and elevated TRLs. This comprehensive review provides an overview of the biology, pathogenicity, epidemiology, and genetics of triglycerides and TRLs, and how they impact the risk for ASCVD. In addition, we provide a summary of currently available and novel emerging triglyceride-lowering therapies in development.

Triglyceride-Rich Lipoproteins and Remnant Cholesterol in Cardiovascular Disease

Despite the well-established benefits of statin treatments in lowering low-density lipoprotein cholesterol (LDL-C), a significant residual risk for atherosclerotic cardiovascular disease (ASCVD) remains. Triglycerides (TGs) have long been recognized as potential residual risk factors in this context, but recent studies now disclose the substantial role of TG-rich lipoproteins (TRLs) and cholesterol components of metabolized TRLs (commonly referred to as remnant cholesterol) in atherogenesis, not just TGs alone. Evidence derived through diverse sources, including preclinical studies of pathogenic mechanisms, epidemiologic investigations, and genetic research, has consistently supported the considerable contribution of TRLs and remnant cholesterol in predicting occurrences of ASCVD. As emerging biomarkers for predicting atherosclerosis, they have thus become prioritized therapeutic targets, meant to augment LDL-C lowering efforts in individuals at high risk of ASCVD. However, routine clinical testing for remnant cholesterol and TRLs is still in question, necessitating further research into appropriate treatment plans if levels are elevated. New therapies targeting proteins in TG metabolic pathways, particularly angiopoietin-like protein 3 and apolipoprotein C-III, have shown potential advantages in patients with mild-to-moderate hypertriglyceridemia by reducing blood levels of TGs and remnant cholesterol. The aim of this review is to summarize existing evidence linking elevated TRLs and remnant cholesterol with development of ASCVD and to explore additional guidance for clinical therapy.