Uric acid-to-HDL-cholesterol ratio and incident carotid atherosclerosis: a retrospective cohort study

Background The uric acid-to-HDL-cholesterol ratio (UHR) has been proposed as a composite cardiometabolic biomarker, but prospective evidence linking UHR to incident carotid atherosclerosis remains limited. Methods In a retrospective cohort of 16,572 adults from a tertiary health examination center in Zhejiang, China, we examined the association between baseline UHR and incident carotid artery lesions using Cox proportional hazards regression. Incremental predictive performance was evaluated using C-statistic, integrated discrimination improvement, continuous net reclassification improvement, median improvement in individual predicted event probabilities, and decision curve analysis. Results Over a mean follow-up of 2.7 years, 4,454 incident events occurred. Each 1-SD increment in baseline UHR was independently associated with a 6% higher hazard of incident carotid artery lesions (HR 1.06, 95% CI 1.01–1.11; p = 0.015). In exploratory sex-stratified analyses, the association was statistically significant in males (HR 1.07, 95% CI 1.02–1.12; p = 0.010) but not in females (HR 0.98, 95% CI 0.93–1.04; p = 0.524), though the formal interaction test was not significant ( p = 0.261). UHR did not improve discrimination (ΔC = 0.0003) or net clinical benefit despite significant changes in individual predicted event probabilities in males ( p = 0.008). Conclusion Higher baseline UHR was independently associated with short-term carotid atherosclerotic progression. Exploratory analyses suggested a possible sex difference, but this requires confirmation in adequately powered studies. While UHR provides independent prognostic information, it does not meaningfully improve risk stratification beyond traditional cardiovascular risk factors in health examination populations.