Clinical impact of combined LDL cholesterol and remnant cholesterol phenotypes after coronary revascularization: insights from a nationwide cohort
H S Jeon, H Kim, S Y Kim, J W Lee, Y J Youn, S G Ahn, J H LeeAbstract
Background
Low-density lipoprotein cholesterol (LDL-C) is a primary therapeutic target in coronary artery disease (CAD); however, residual cardiovascular risk persists despite LDL-C control. Remnant cholesterol (remnant-C) has emerged as a potential contributor to this residual risk.
Purpose
To evaluate clinical outcomes according to combined LDL-C and remnant-C phenotypes in patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG).
Methods
Using the National Health Insurance Service (NHIS) database, we identified 63,119 patients who underwent underwent PCI or CABG between 2011 and 2020. Patients were stratified into four groups according to LDL-C (cut-off 70 mg/dL) and remnant-C (cut-off 22.5 mg/dL): Group 1 (both low), Group 2 (low LDL-C/High remnant-C), Group 3 (high LDL-C/low remnant-C), and group 4 (both high). The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE), defined as cardiovascular death, myocardial infarction, repeat revascularization, or non-fatal stroke. Multivariable Cox models sequentially adjusted for demographic factors, comorbidities, lipid-lowering therapy, and antithrombotic medications.
Results
During follow-up, group 4 demonstrated the highest risk of MACCE compared with group 1 (adjusted hazard ratio [HR] 1.15; 95% confidence interval [CI] 1.11–1.20; p<0.001). Notably, patients with controlled LDL-C but elevated remnant-C (group 2) remained at increased risk (HR 1.07; 95% CI 1.03-1.12; p<0.001), whereas those with elevated LDL-C but low remnant-C (group 3) showed only modest risk elevation (HR 1.05; 95% CI 1.01-1.09; p=0.024). Elevated remnant-C was consistently associated with myocardial infarction, stroke, and repeat revascularization.
Conclusions
Remnant-C provides incremental prognostic value beyond LDL-C in patients undergoing coronary revascularization. Even when LDL-C is well controlled, elevated remnant-C identifies patients at persistent residual cardiovascular risk.Cubic Spline CurvesMACCEs