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Cholesterol and Coronary Heart Disease: Predicting Risks by Levels and Ratios

Bruce Kinosian, MD; Henry Glick, MA; and Gonzalo Garland, MA
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From the University of Pennsylvania and the Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania. Requests for Reprints: Bruce Kinosian, MD, University of Pennsylvania, Division of General Internal Medicine, Ralston-Penn Center, Room 230, 3615 Chestnut Street, Philadelphia, PA 19104. Acknowledgments: The authors thank John Cook, PhD; Jose Escarce, MD; Keaven Anderson, PhD; and Joe Heyse, PhD, for statistical advice; Steven Grover, MD, for providing the subsample original data from the LRC Population Prevalence Study; and David Gordon, MD, PhD, for providing data from the LRC Coronary Primary Prevention Trial and analytical advice. Grant Support: By NIA grant R29-AG09837-03. No other financial support was received for this project.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1994;121(9):641-647. doi:10.7326/0003-4819-121-9-199411010-00002
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Objective: Comparison of four measures of cholesterol for predicting men and women who will develop coronary heart disease within 8 to 10 years.

Design: Cohort study.

Patients: 1898 men who received placebo (the placebo group of the Lipid Research Clinics [LRC] Coronary Primary Prevention Trial [CPPT]), 1025 men and 1442 women who participated in the 1970-1971 Framingham Heart Study biennial examination, and 1911 men and 1767 women without coronary heart disease who were from the LRC Population Prevalence Study.

Measurements: Total cholesterol, low-density lipoprotein (LDL) cholesterol, ratio of total cholesterol to high-density lipoprotein (HDL) cholesterol, and the ratio of LDL to HDL. Outcomes were coronary heart disease in the CPPT and Framingham studies and death from coronary heart disease in the Prevalence Study.

Results: Independent information in the total cholesterol/HDL ratio added risk-discriminating ability to total cholesterol and LDL cholesterol measures (P < 0.02), but the reverse was not true. Among women, a high-risk threshold of 5.6 for the total cholesterol/HDL ratio identified a 0% to 15% larger group at 25% to 45% greater risk in the Prevalence and Framingham studies, respectively, than did current guidelines. Among men in the same studies, a risk threshold of 6.4 for the total cholesterol/HDL ratio identified a 69% to 95% larger group at 2% to 14% greater risk than did LDL cholesterol levels alone. Eight-year likelihood ratios for coronary heart disease ranged from 0.32 to 3.11 in men and from 0.59 to 2.98 in women for total cholesterol/HDL ratios (grouped from < 3 to ≥ 9).

Conclusions: The total cholesterol/HDL ratio is a superior measure of risk for coronary heart disease compared with either total cholesterol or LDL cholesterol levels. Current practice guidelines could be more efficient if risk stratification was based on this ratio rather than primarily on the LDL cholesterol level.

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