Abstract Background Initiation of lipid-lowering therapy may primarily be prompted by high low-density lipoprotein (LDL) cholesterol levels. If so, individuals with high risk of atherosclerotic cardiovascular disease (ASCVD) due to elevated remnant cholesterol may not be started on lipid-lowering therapy. Purpose We tested the hypothesis that elevated remnant cholesterol confers high risk of ASCVD but less initiation of lipid-lowering therapy compared to elevated LDL cholesterol. Methods From the General Population Study, 94 299 lipid-lowering therapy naïve adults without a history of ASCVD were included. Discordance groups were formed by median levels of remnant cholesterol, LDL cholesterol and apolipoprotein B (apoB). In the national Danish health registries, individuals were followed for a prescription of lipid-lowering therapy and for incident ASCVD or until December 2021. Results During a median follow-up of 12 years, 9 269 developed ASCVD. Compared to individuals with concordant low values of LDL and remnant cholesterol, those with high remnant cholesterol and apoB but low LDL cholesterol had a hazard ratio (HR) of 1.45 (95% confidence interval: 1.34-1.56) for ASCVD and an odds ratio (OR) of 3.0 (2.5-3.6) for starting lipid-lowering therapy within one year. Correspondingly, those with low remnant cholesterol but high apoB and high LDL cholesterol had a HR of 1.20 (1.11-1.30) for ASCVD and an OR of 5.1 (4.3-5.9) for starting lipid-lowering therapy. Conclusions In primary prevention elevated remnant cholesterol confers high risk of ASCVD but less initiation of lipid-lowering therapy compared to elevated LDL cholesterol, representing an unmet medical need.
Hvid et al. (Sat,) studied this question.