What is the clinical evidence from this study?

Study design: Cohort. Population: Coronary heart disease (n=23901). Intervention: Plasma lipid levels (HDL-C) vs. Normal HDL-C. Primary outcome: Incident CHD (myocardial infarction or CHD death) (HR 1.22 (White) / HR 0.94 (Black), 95% CI 1.05-1.43 (White) / 0.78-1.14 (Black), p=0.08).

What question did this study set out to answer?

This study aims to investigate the race-specific relationships between plasma lipid levels and coronary heart disease risk.

May 15, 2026Open Access

Race-Dependent Association of High-Density Lipoprotein Cholesterol Levels With Incident Coronary Artery Disease

Key Result

Low HDL-C increased incident CHD risk in White adults (HR 1.22; 95% CI 1.05-1.43) but not Black adults (HR 0.94; 95% CI 0.78-1.14), and high HDL-C was not protective in either group.

Key Points

This study aims to investigate the race-specific relationships between plasma lipid levels and coronary heart disease risk.
Cohort recruited 30,239 Black and White individuals aged ≥45 from 2003 to 2007.
Used Cox regression models to estimate hazard ratios for lipids and incident coronary heart disease.
Followed 23,901 participants for a median of 10 years, tracking CHD events.
Low HDL-C increased CHD risk in White adults (HR: 1.22; 95% CI: 1.05-1.43) but not in Black adults (HR: 0.94; 95% CI: 0.78-1.14).
High HDL-C was not protective against CHD events in either race (HR: 0.96; 95% CI: 0.79-1.16 for White, HR: 0.91; 95% CI: 0.74-1.12 for Black).
Low-density lipoprotein cholesterol and triglycerides modestly predicted CHD risk in both races.

Study Design

Type

Cohort (n=23,901)

Multicenter

Yes

Structured PICO

Does the association of HDL-C levels with incident CHD differ between Black and White adults?

Population

23,901 CHD-free Black and White adults aged ≥45 years from the contiguous United States, mean age 64 ± 9 years, 58.4% women, 57.8% White.

Intervention

Plasma lipid levels (HDL-C, LDL-C, triglycerides)

Outcome

Incident CHD (myocardial infarction or CHD death)hard clinical

Low HDL-C is associated with increased CHD risk in White but not Black adults, suggesting current HDL-C-based risk calculators may be inaccurate for Black patients.

Main Result

Effect estimate: HR 1.22 (White) / HR 0.94 (Black) (95% CI 1.05-1.43 (White) / 0.78-1.14 (Black))

p-value: p=0.08

Abstract

BACKGROUND: Plasma lipids are risk factors for coronary heart disease (CHD) in part because of race-specific associations of lipids with CHD. OBJECTIVES: The purpose of this study was to understand why CHD risk equations underperform in Black adults. METHODS: Between 2003 and 2007, the REGARDS (REasons for Geographic and Racial Differences in Stroke) cohort recruited 30,239 Black and White individuals aged ≥45 years from the contiguous United States. We used Cox regression models adjusted for clinical and behavioral risk factors to estimate the race-specific hazard of plasma lipid levels with incident CHD (myocardial infarction or CHD death). RESULTS: Among 23,901 CHD-free participants (57.8% White and 58.4% women, mean age 64 ± 9 years) over a median 10 years of follow-up, 664 and 951 CHD events occurred among Black and White adults, respectively. Low-density lipoprotein cholesterol and triglycerides were associated with increased risk of CHD in both races (P interaction by race >0.10). For sex-specific clinical HDL-C categories: low HDL-C was associated with increased CHD risk in White (HR: 1.22; 95% CI: 1.05-1.43) but not in Black (HR: 0.94; 95% CI: 0.78-1.14) adults (P interaction by race = 0.08); high HDL-C was not associated with decreased CHD events in either race (HR: 0.96; 95% CI: 0.79-1.16 for White participants and HR: 0.91; 95% CI: 0.74-1.12 for Black adults). CONCLUSIONS: Low-density lipoprotein cholesterol and triglycerides modestly predicted CHD risk in Black and White adults. Low HDL-C was associated with increased CHD risk in White but not Black adults, and high HDL-C was not protective in either group. Current high-density lipoprotein cholesterol-based risk calculations could lead to inaccurate risk assessment in Black adults.