Head-to-head comparison of nine lipid-related composite indices for predicting clinical outcomes in patients with acute myocardial infarction

Background In the context of the newly defined cardiovascular-kidney-metabolic (CKM) syndrome, composite indices integrating inflammatory, lipid, and glycemic markers may offer improved risk stratification. However, a systematic head-to-head comparison of their predictive value in high-risk populations like acute myocardial infarction (AMI) patients is lacking. Purpose This study aimed to systematically compare the predictive value of nine different lipid-related composite indices for the 1-year composite endpoint of myocardial infarction and cardiac death in patients with AMI. Methods This prospective cohort study included 6,491 patients hospitalized with AMI who were not on prior lipid-lowering or glucose-lowering medications. We evaluated nine composite indices: 1) Neutrophil-to-HDL cholesterol ratio (NHR); 2) Non-HDL cholesterol-to-HDL cholesterol ratio (NHHR); 3) Triglyceride-glucose index (TyG); 4) High-sensitivity C-reactive protein-to-HDL cholesterol ratio (CHR); 5) LDL-C to Apolipoprotein B ratio (LDL-C/ApoB); 6) Triglyceride-to-HDL cholesterol ratio (TG/HDL-C); 7) LDL-C to HDL-C ratio (LDL-C/HDL-C); 8) Apolipoprotein B to Apolipoprotein A1 ratio (ApoB/ApoA1); and 9) C-reactive protein-triglyceride-glucose index (CTI). The primary outcome was a composite of myocardial infarction and cardiac death within one year. Multivariable Cox proportional hazards models were used to assess associations. Predictive performance was compared using the area under the receiver operating characteristic curve (AUC), Integrated Discrimination Improvement (IDI), and Decision Curve Analysis (DCA). Results During the 1-year follow-up, 386 patients (5.9%) experienced the primary composite endpoint. In the fully adjusted Cox model, NHR, CHR, CTI, and the ApoB/ApoA1 ratio were significantly and independently associated with the outcome. Among all indices, CHR demonstrated the strongest predictive ability (AUC = 0.601). A prediction model that incorporated CHR with demographic characteristics, medical history, and medication use showed significantly improved predictive performance, achieving an AUC of 0.675. This combined model also demonstrated a significant improvement in risk discrimination (IDI = 11.50%, P < 0.001) and provided the greatest net benefit in Decision Curve Analysis. Conclusion In this head-to-head comparison among AMI patients, the high-sensitivity C-reactive protein-to-HDL cholesterol ratio (CHR) emerged as the strongest single predictor for the one-year composite endpoint of myocardial infarction and cardiac death. Further analysis revealed that a predictive model integrating CHR with traditional risk factors, demonstrated superior performance compared to CHR alone, significantly enhancing patient risk stratification.