What is the clinical evidence from this study?

Study design: Cohort. Population: Acute coronary syndrome (n=1317). Intervention: Platelet/high-density lipoprotein cholesterol ratio (PHR) vs. Quartile 3 (223.53-285.00). Primary outcome: One-year all-cause mortality (HR 2.420, 95% CI 1.411-4.151, p=0.001).

What does this research mean for the field?

The platelet/high-density lipoprotein cholesterol ratio (PHR) exhibits a U-shaped association with 1-year all-cause mortality and major adverse cardiovascular events in patients with acute coronary syndrome, with both the lowest and highest quartiles significantly increasing risk compared to the third quartile. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

March 24, 2026Open Access

The U-shape relationship between platelet/high-density lipoprotein cholesterol ratio and 1-year all-cause mortality in acute coronary syndrome patients: a retrospective cohort study

Key Result

Both the lowest and highest quartiles of platelet/HDL-C ratio significantly increased 1-year all-cause mortality risk (HR 2.077 and 2.420, respectively) compared to the third quartile in ACS patients.

Key Points

This research examines the relationship between the platelet/high-density lipoprotein cholesterol ratio and one-year all-cause mortality in acute coronary syndrome patients.
Retrospective cohort study design involving hospitalized ACS patients
Participants categorized into quartiles based on platelet/HDL cholesterol ratio
Primary outcome measured was one-year all-cause mortality
Multivariate Cox regression and two-piecewise linear regression analyses used to examine associations
10.17% of participants died within one year
Significantly higher mortality risks noted in the lowest and highest PHR quartiles compared to the third quartile
Nonlinear U-shaped association observed between PHR and all-cause mortality
Inflection point identified at a PHR level of 213.60

Study Design

Type

Cohort (n=1,317)

Multicenter

Structured PICO

Does the platelet/high-density lipoprotein cholesterol ratio (PHR) predict 1-year all-cause mortality in patients with acute coronary syndrome?

Population

Patients with acute coronary syndrome (ACS), median age 67 years, 75.6% male

Intervention

Lowest (Q1) and highest (Q4) quartiles of platelet/high-density lipoprotein cholesterol ratio (PHR)

Comparator

Third quartile (Q3) of platelet/high-density lipoprotein cholesterol ratio (PHR)

Outcome

1-year all-cause mortalityhard clinical

The platelet/high-density lipoprotein cholesterol ratio (PHR) exhibits a U-shaped association with 1-year all-cause mortality and MACCE in ACS patients, indicating that both very low and very high PHR levels are linked to worse clinical outcomes.

Main Result

Effect estimate: HR 2.420 (95% CI 1.411-4.151)

p-value: p=0.001

Limitations

Single-center retrospective design
High rate of missing data for body mass index (56.57% missing)

Abstract

The platelet/high-density lipoprotein cholesterol ratio (PHR) reflects the balance between platelet activity and lipid metabolism. This study aimed to investigate the association between PHR and 1-year all-cause mortality in patients with acute coronary syndrome (ACS) and to characterize the nature of this association. Patients with ACS who were hospitalized at the Affiliated Hospital of Guangdong Medical University between January 2022 and December 2023 were retrospectively enrolled. The patients were divided into four equal quartiles based on their PHR levels. The primary outcome was 1-year all-cause mortality, and the secondary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE). Multivariate Cox proportional hazards regression, two-piecewise linear regression, and restricted cubic spline (RCS) methods were used to analyze the associations of PHR with all-cause mortality and MACCE. Of the 1317 enrolled participants (median age 67 years), 134 (10.17%) died and 273 (20.73%) experienced MACCE within the 1-year follow-up. After full adjustment, participants in the lowest PHR quartile (Q1) (adjusted hazard ratio HR: 2.077, 95% confidence interval CI 1.230–3.507, P = 0.006) and the highest PHR quartile (Q4) (adjusted HR: 2.420, 95% CI 1.411–4.151, P = 0.001) exhibited significantly higher risks of 1-year all-cause mortality compared with those in the third quartile (Q3). RCS analysis revealed a nonlinear association between PHR and 1-year all-cause mortality. The two-piecewise linear regression model identified an inflection point at 213.60 (95% CI 130.61–244.96). A similar U-shaped association was observed for MACCE. The PHR shows a U-shaped association with 1-year all-cause mortality among ACS patients, with both low and high levels associated with an increased risk of mortality. A similar U-shaped association was also identified between PHR and MACCE. Trial registration The details of the design were registered on https://www.chictr.org.cn/ (registration number: ChiCTR2500110802; registration date: 21 October 2025).

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