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Cited by 83Lipoproteins and Cardiovascular HealthDiabetes, Cardiovascular Risks, and LipoproteinsCardiovascular Health and Risk Factors

Low-Density Lipoprotein Cholesterol, Cardiovascular Disease Risk, and Mortality in China

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Chen, Liang, Chen, Shi, Bai, Xueke, Su, Mingming, He, Linkang, Li, Guangyu, He, Guangda, Yang, Yang +9 more·2024·JAMA Network Open
DOI 10.1001/jamanetworkopen.2024.22558PMC PMC11258592
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Abstract

Importance: Limited evidence supports the association between low-density lipoprotein cholesterol (LDL-C) and mortality across different atherosclerotic cardiovascular disease (ASCVD) risk stratifications. Objective: To explore the associations between LDL-C levels and mortality and to identify the optimal ranges of LDL-C with the lowest risk of mortality in populations with diverse ASCVD risk profiles. Design, Setting, and Participants: The ChinaHEART project is a prospective cohort study that recruited residents aged 35 to 75 years from 31 provinces in mainland China between November 2014 and December 2022. Participants were categorized into low-risk, primary prevention, and secondary prevention cohorts on the basis of their medical history and ASCVD risk. Data analysis was performed from December 2022 to October 2023. Main Outcomes and Measures: The primary end point was all-cause mortality, and secondary end points included cause-specific mortality. Mortality data were collected from the National Mortality Surveillance System and Vital Registration. The association between LDL-C levels and mortality was assessed by using Cox proportional hazard regression models with various adjusted variables. Results: A total of 4 379 252 individuals were recruited, and 3 789 025 (2 271 699 women [60.0%]; mean [SD] age, 56.1 [10.0] years) were included in the current study. The median (IQR) LDL-C concentration was 93.1 (70.9-117.3) mg/dL overall at baseline. During a median (IQR) follow-up of 4.6 (3.1-5.8) years, 92 888 deaths were recorded, including 38 627 cardiovascular deaths. The association between LDL-C concentration and all-cause or cardiovascular disease (CVD) mortality was U-shaped in both the low-risk cohort (2 838 354 participants) and the primary prevention cohort (829 567 participants), whereas it was J-shaped in the secondary prevention cohort (121 104 participants). The LDL-C levels corresponding to the lowest CVD mortality were 117.8 mg/dL in the low-risk group, 106.0 mg/dL in the primary prevention cohort, and 55.8 mg/dL in the secondary prevention cohort. The LDL-C concentration associated with the lowest all-cause mortality (90.9 mg/dL vs 117.0 mg/dL) and CVD mortality (87 mg/dL vs 114.6 mg/dL) were both lower in individuals with diabetes than in individuals without diabetes in the overall cohort. Conclusions and Relevance: This study found that the association between LDL-C and mortality varied among different ASCVD risk cohorts, suggesting that stricter lipid control targets may be needed for individuals with higher ASCVD risk and those with diabetes.

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  • Elevated LDL-C is an independent risk factor for CHD.

    “Studies have shown that dyslipidemia, particularly elevated low-density lipoprotein cholesterol (LDL-C), is an independent risk factor for CHD (3–5).”

    From Remnant cholesterol, lipid ratios, and the severity of coronary artery lesions: a retrospective cohort study in patients with coronary heart disease (2025) · cites this paper as [5]

    The Introduction (page unavailable) describes LDL-C as a leading risk factor with a causal relationship to atherosclerotic cardiovascular disease. The Methods describe adjusted analyses, and the Results associate higher LDL-C with cardiovascular mortality, but the paper does not report a CHD-specific risk estimate establishing the claim at that level of specificity. (LLM, conf=0.83)

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Authors
Chen, L., Chen, S., Bai, X., Su, M., He, L., Li, G., He, G., Yang, Y., Zhang, X., Cui, J., Xu, W., Song, L., Yang, H., He, W., Zhang, Y., Li, X., & Hu, S.
Affiliations
Chinese Academy of Medical Sciences & Peking Union Medical College (CN)
Corresponding author
  • Chen, Liang
  • Li, Xi
ORCID
Venue
JAMA Network Open
Publisher
American Medical Association (AMA)
Published
2024-07-18
Volume
7
Issue
7
Pages
e2422558
ISSN
2574-3805 (ISSN-L)
DOI
10.1001/jamanetworkopen.2024.22558
PMC
PMC11258592
OpenAlex
W4400774722
Cited by
83
References
47
Citations by year
2026: 20 · 2025: 59 · 2024: 4
FWCI
34.95
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • JAMA Network Open (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • PubMed Central (publishedVersion, cc-by)
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
LDL cholesterol, LDL-C, cardiovascular mortality, all-cause mortality, primary prevention, secondary prevention, J-shaped association, U-shaped relationship, China, cardiovascular risk management, cardiovascular hospitalization
MeSH terms
Heart Disease Risk Factors, Adult, Aged, Cardiovascular Diseases, China, Female, Humans, Cholesterol, LDL, Male, Middle Aged, Prospective Studies, Risk Factors, Proportional Hazards Models, Risk Assessment

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