Remnant cholesterol is an additional risk factor for cardiovascular disease beyond LDL cholesterol; Nationwide cohort study

Abstract Background Although elevated remnant cholesterol (remnant-C) level is considered an independent predictor of cardiovascular disease (CVD), it was not established in relatively healthy individuals. We investigated whether elevated remnant-C is a risk factor for CVD in the general population. Methods In total 8,874,254 Korean adults with unknown history of CVD were recruited in 2009 and followed until the date of incident myocardial infarction (MI) or ischemic stroke or December 31, 2018. Multivariate Cox regression models were used to estimate the risk for incident CVD associated with remnant-C. Results There were 184,771 individuals with incident CVD consisting of MI and ischemic stroke during 8.3 years of follow-up. The adjusted hazard ratios in the highest quartile of remnant-C were 1.681 (95% confidence interval, 1.636–1.726) for MI and 1.433 (1.407–1.46) for stroke. This pattern persisted when patients were stratified by age, sex, statin or fibrate use, and other cholesterol levels. Increased risk of MI or stroke owing to high concentrations of remnant-C was profound in patients with fewer traditional CVD risks (e.g. young age, women, non-obese, and those without hypertension, metabolic syndrome, chronic kidney disease, and diabetes). A remnant-C level ≥ 30 mg/dL was associated with an increased risk of CVD regardless of low-density lipoprotein cholesterol (LDL-C) levels being on target (LDL-C < 100mg/dL). Conclusions Elevated remnant-C is associated with an increased risk of CVD independent of traditional risk factors, including LDL-C. This finding suggests that remnant-C is an important CVD risk factor even in individuals with relatively low risk of atherosclerotic cardiovascular disease.