Remnant Cholesterol Concentration an Independent Predictor of Poor Cardiovascular Outcomes

red flags for high risk cholesterol – a detail of blood laboratory screening results with focus on lipids panel
Poor cardiovascular outcomes are more likely in patients with elevated remnant cholesterol or triglycerides.

Among patients with overweight or obesity, triglycerides and remnant cholesterol were identified as independent predictors of cardiovascular outcomes. These findings, from an observational cohort study, were published in the Journal of the American College of Cardiology.

Individuals (N=6901) with type 2 diabetes or who had 3 or more cardiovascular disease (CVD) risk factors (smoker, hypertension, high low-density lipoprotein cholesterol [LDL-C], low high-density lipoprotein cholesterol [HDL-C], high body mass index [BMI], family history of CVD) were recruited between 2003 and 2010 in Spain. Recruited men were aged 55 to 80 years, and women participants were aged 60 to 80 years. All were evaluated for health status through urine and blood samples.

At baseline, participants were 42.6% men, aged mean 67.0 plus or minus 6.17 years, with an average BMI of 30.3 plus or minus 3.85 kg/m2; 48.3% had diabetes, 72.7% had hypercholesterolemia, 83% had hypertension, and 13.9% were current smokers.

The lipid profile at baseline among the overall study population was an average total cholesterol of 206 plus or minus 36.0 mg/dl, HDL-C of 51.2 plus or minus 11.5 mg/dl, LDL-C of 129 plus or minus 32.2 mg/dl, triglycerides of 128 plus or minus 57.0 mg/dl, non-HDL-C of 155 plus or minus 34.1 mg/dl, and remnant cholesterol of 25.7 plus or minus 11.4 mg/dl.

Remnant cholesterol concentrations increased with BMI. People with low BMI (<25 kg/m2) had a mean remnant cholesterol of 22.4 plus or minus 11.2 mg/dl; those with intermediate BMI (25-30 kg/m2) had a remnant cholesterol of 24.1±11.1 mg/dl, and those with high BMI (>30 kg/m2) had concentrations of 27.2 plus or minus 11.5 mg/dl. Patients with diabetes had mean remnant cholesterol levels of 26.3 plus or minus 11.8 mg/dl while those without diabetes had lower remnant cholesterol concentrations (25.1±10.9 mg/dl; P <.001).

Major adverse cardiovascular events significantly increased with every 10 mg/dl increase of remnant cholesterol (hazard ratio [HR], 1.21; 95% CI, 1.03-1.33; P <.001), triglycerides (HR, 1.04; 95% CI, 1.02-1.06; P <.001), and non-HDL-C (HR, 1.05; 95% CI, 1.01-1.10; P =.026).

Study limitations include a potential lack of generalizability to a younger and healthier population. The observational design of this study did not allow for making causal relationships between cardiovascular events and lipid concentrations.

The study authors concluded that remnant cholesterol and not LDL-C or HDL-C concentrations were significantly associated with major adverse cardiovascular events among an older population of individuals who were at increased risk for CVD.

“Randomized controlled trials with hard CVD outcomes are warranted to compare the benefit of interventions directed at lowering [remnant cholesterol] against standard cholesterol-lowering therapy, particularly when LDL-C target levels have been achieved,” the researchers concluded.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of authors’ disclosures.


Castañer O, Pintó X, Subirana I, et al. Remnant cholesterol, not LDL cholesterol, is associated with incident cardiovascular disease. J Am Coll Cardiol. 2020;76(23):2712-2724. doi: 10.1016/j.jacc.2020.10.008