Cited by 2,731Lipoproteins and Cardiovascular HealthDiabetes, Cardiovascular Risks, and LipoproteinsCardiovascular Health and Risk Factors

Major lipids, apolipoproteins, and risk of vascular disease

Open access
The Emerging Risk Factors Collaboration*·2009·JAMA

Abstract

CONTEXT: Associations of major lipids and apolipoproteins with the risk of vascular disease have not been reliably quantified. OBJECTIVE: To assess major lipids and apolipoproteins in vascular risk. DESIGN, SETTING, AND PARTICIPANTS: Individual records were supplied on 302,430 people without initial vascular disease from 68 long-term prospective studies, mostly in Europe and North America. During 2.79 million person-years of follow-up, there were 8857 nonfatal myocardial infarctions, 3928 coronary heart disease [CHD] deaths, 2534 ischemic strokes, 513 hemorrhagic strokes, and 2536 unclassified strokes. MAIN OUTCOME MEASURES: Hazard ratios (HRs), adjusted for several conventional factors, were calculated for 1-SD higher values: 0.52 log(e) triglyceride, 15 mg/dL high-density lipoprotein cholesterol (HDL-C), 43 mg/dL non-HDL-C, 29 mg/dL apolipoprotein AI, 29 mg/dL apolipoprotein B, and 33 mg/dL directly measured low-density lipoprotein cholesterol (LDL-C). Within-study regression analyses were adjusted for within-person variation and combined using meta-analysis. RESULTS: The rates of CHD per 1000 person-years in the bottom and top thirds of baseline lipid distributions, respectively, were 2.6 and 6.2 with triglyceride, 6.4 and 2.4 with HDL-C, and 2.3 and 6.7 with non-HDL-C. Adjusted HRs for CHD were 0.99 (95% CI, 0.94-1.05) with triglyceride, 0.78 (95% CI, 0.74-0.82) with HDL-C, and 1.50 (95% CI, 1.39-1.61) with non-HDL-C. Hazard ratios were at least as strong in participants who did not fast as in those who did. The HR for CHD was 0.35 (95% CI, 0.30-0.42) with a combination of 80 mg/dL lower non-HDL-C and 15 mg/dL higher HDL-C. For the subset with apolipoproteins or directly measured LDL-C, HRs were 1.50 (95% CI, 1.38-1.62) with the ratio non-HDL-C/HDL-C, 1.49 (95% CI, 1.39-1.60) with the ratio apo B/apo AI, 1.42 (95% CI, 1.06-1.91) with non-HDL-C, and 1.38 (95% CI, 1.09-1.73) with directly measured LDL-C. Hazard ratios for ischemic stroke were 1.02 (95% CI, 0.94-1.11) with triglyceride, 0.93 (95% CI, 0.84-1.02) with HDL-C, and 1.12 (95% CI, 1.04-1.20) with non-HDL-C. CONCLUSION: Lipid assessment in vascular disease can be simplified by measurement of either total and HDL cholesterol levels or apolipoproteins without the need to fast and without regard to triglyceride.

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Crossref · 10.1001/jama.2009.1619

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  • In the Emerging Risk Factors Collaboration analysis, fasting and nonfasting TG levels were associated with increased risk of coronary heart disease after adjustment for nonlipid risk factors.

    “fasting and nonfasting TG levels were associated with increased risk of coronary heart disease”

    From The Forgotten Lipids: Triglycerides, Remnant Cholesterol, and Atherosclerotic Cardiovascular Disease Risk (2019) · cites this paper as [72]

    The Results > Triglyceride section reports an increased CHD risk with triglycerides after adjustment for nonlipid risk factors (HR 1.37), supporting the overall association. It does not report separate fasting and nonfasting estimates for that adjustment alone; the fasting-status estimates it does report are essentially null after further adjustment for HDL-C and non-HDL-C. (LLM, conf=0.84)

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  • In the Emerging Risk Factors Collaboration analysis, the association between TG levels and coronary heart disease was attenuated after adjustment for HDL-C.

    “However, the association was attenuated after adjustment for HDL-C”

    From The Forgotten Lipids: Triglycerides, Remnant Cholesterol, and Atherosclerotic Cardiovascular Disease Risk (2019) · cites this paper as [72]

    The Results (Triglyceride; page not provided) report that the triglyceride–CHD association weakened after adjustment for both HDL-C and non-HDL-C. The passage does not establish that adjustment for HDL-C alone produced the attenuation described in the claim. (LLM, conf=0.86)

    Experimental — accuracy not yet measured
  • In the Emerging Risk Factors Collaboration analysis, the association between TG levels and coronary heart disease was nonsignificant after adjustment for non-HDL-C.

    “was nonsignificant after adjustment for non-HDL-C”

    From The Forgotten Lipids: Triglycerides, Remnant Cholesterol, and Atherosclerotic Cardiovascular Disease Risk (2019) · cites this paper as [72]

    The Results > Triglyceride section reports a null association between triglycerides and coronary heart disease after adjustment: HR 0.99 (95% CI, 0.94–1.05). However, that result followed adjustment for both HDL-C and non-HDL-C; the passage does not establish that adjustment for non-HDL-C alone made the association nonsignificant. (LLM, conf=0.86)

    Experimental — accuracy not yet measured
  • In the Emerging Risk Factors Collaboration, the hazard ratio for coronary heart disease with triglycerides was 1.37 (95% CI, 1.31-1.42) after adjustment for nonlipid factors, but was reduced to 0.99 (95% CI, 0.94-1.05) after adjustment for HDL cholesterol and non-HDL cholesterol.

    “The hazard ratio for coronary heart disease with triglycerides was 1.37 (95% CI, 1.31-1.42)after adjustment for nonlipid factors, but was reduced to 0.99 (95% CI, 0.94 -1.05) after adjustment for HDL cholesterol and non-HDL cholesterol (9).”
  • Risk associations are similar in nonfasting study populations than in those who did fast.

    “Risk associations are similar in nonfasting study populations than in those who did fast [72,74].”

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Authors
The Emerging Risk Factors Collaboration*
Venue
JAMA
Published
2009-11-11
Volume
302
Issue
18
Pages
1993
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
OpenAlex
W2127427274
Cited by
2,731
References
41
Citations by year
2026: 89 · 2025: 116 · 2024: 150 · 2023: 178 · 2022: 169 · 2021: 188 · 2020: 156 · 2019: 177 · 2018: 188 · 2017: 175 · 2016: 163 · 2015: 187 · 2014: 198 · 2013: 189 · 2012: 160
FWCI
136.20
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • PubMed (publishedVersion)
  • Pure Amsterdam UMC (publishedVersion)
  • Amsterdam UMC (VU Amsterdam) - Institutional Repository (publishedVersion)
  • VU Research Portal (publishedVersion, other-oa)
  • University of Southern Denmark Research Portal (University of Southern Denmark) (publishedVersion)
  • PubMed Central (acceptedVersion)
  • UCL Discovery (University College London) (submittedVersion)
  • ORCA Online Research @Cardiff (Cardiff University) (submittedVersion)
  • Research Portal (Queen's University Belfast) (submittedVersion)
  • Bristol Research (University of Bristol) (submittedVersion)
  • LSHTM Research Online (London School of Hygiene and Tropical Medicine) (submittedVersion)
  • Spiral (Imperial College London) (submittedVersion)
  • OPUS (Augsburg University) (submittedVersion)
  • Padua Research Archive (University of Padova) (submittedVersion)
  • Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
Funders
  • Wellcome Trust
  • British Heart Foundation (RG/08/013/25942, RG/08/014, RG/07/008/23674, RG/08/014/24067)
  • Economic and Social Research Council (ES/G007438/1)
Topics
  • Health Sciences › Medicine › Surgery › Lipoproteins and Cardiovascular Health
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
Keywords
apolipoproteins, vascular risk, coronary artery disease, myocardial infarction, ischemic stroke, hemorrhagic stroke, triglycerides, HDL cholesterol, non-HDL cholesterol, LDL cholesterol, apolipoprotein A-I, apolipoprotein B, fasting state, lipid-lowering therapy, cardiovascular risk factors, prospective cohort, meta-analysis
MeSH terms
Apolipoproteins, Coronary Disease, Female, Humans, Lipids, Cholesterol, HDL, Male, Middle Aged, Regression Analysis, Risk Factors, Triglycerides, Vascular Diseases, Proportional Hazards Models, Stroke

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