Association between monocyte-to-high-density lipoprotein cholesterol ratio and stroke: a propensity score matched cross-sectional study

Background Stroke is one of the leading causes of death and long-term disability worldwide, and chronic inflammation plays a central role in its pathogenesis. The monocyte-to-high-density lipoprotein cholesterol ratio (MHR) integrates pro-inflammatory activity and anti-atherosclerotic capacity, but its association with stroke risk in the general population remains unclear. This study aims to explore the relationship between MHR and stroke among U.S. adults. Methods In this cross-sectional study, we leveraged data from the 1999–2020 National Health and Nutrition Examination Survey (NHANES). Multivariable logistic regression models were employed to examine the relationship between the MHR and stroke risk. Restricted cubic spline (RCS) analysis assessed potential non-linear dose–response relationships, while subgroup analyses evaluated its robustness. Propensity score matching (PSM) was applied to minimize confounding bias through sample refinement. Results The analytical cohort encompassed 43,321 participants, including 1,583 individuals with physician-diagnosed stroke. Following PSM, the non-stroke comparator group was refined to 4,719 subjects. In the fully adjusted multivariable model, elevated MHR demonstrated a statistically significant association with stroke predisposition [Odds ratio (OR) = 1.517; 95% Confidence interval (CI):1.096–2.099]. RCS regression confirmed a linear dose–response gradient between MHR and stroke risk ( P -non-linear = 0.9517). Stratified subgroup analyses further validated the robustness of this relationship across demographic and clinical strata (all P for interaction >0.05), indicating consistent effect magnitudes. Conclusion In this nationally representative cross-sectional study, higher MHR levels were associated with an increased risk of stroke. Although these findings suggest that MHR may be a potential biomarker related to stroke risk, further prospective studies are required to validate its temporal relationship and clinical applicability.