Bertsch Ruth Ann, Merchant Maqdooda A
Hospitalist at the Sacramento Medical Center in CA.
Senior Data Consultant in the Division of Research in Oakland, CA.
Perm J. 2015 Fall;19(4):4-10. doi: 10.7812/TPP/14-237.
When assessing the lipid panel, practical physicians tend to focus on the low-density lipoprotein cholesterol (LDL-c). However, an elevated triglyceride/high-density lipoprotein cholesterol (HDL-c) ratio, suggesting insulin resistance, also effectively predicts cardiovascular outcomes but requires different treatments than an elevated LDL-c. We tested whether high triglyceride/HDL-c ratios are associated with more risk than high LDL-c concentrations or other lipid markers of atherogenicity.
We followed 103,646 members aged 50 to 75 years without cardiovascular disease or diabetes in a community health plan. Subjects were categorized as insulin sensitive or insulin resistant on the basis of triglyceride and HDL-c in the index year. The primary outcome was ischemic heart disease. The percentage of subjects with a primary outcome after 8 years was stratified by insulin category, lipid measures, and blood pressure. Hazard ratios (HR) for insulin resistance, LDL-c, age, sex, and the presence of hypertension were determined in a multivariate analysis.
Subjects with insulin resistance but lipid measures healthier than the median had worse outcomes than those who were insulin sensitive but had unhealthier lipid measures such as non-HDL-c and the ratios of total cholesterol/HDL-c and LDL-c/HDL-c. The HR for a 60 mg/dL increase in LDL-c was 1.14 (95% confidence interval [CI], 1.10-1.18); the HR for an LDL-c greater than 160 mg/dL was 1.19 (95% CI, 1.12-1.28). In contrast, the hazard ratio for having an insulin-resistant triglyceride/HDL-c ratio was 1.68 (95% CI, 1.57-1.80), compared with an insulin-sensitive ratio. There was no difference in outcomes between insulin-resistant but normotensive patients and insulin-sensitive but hypertensive patients.
Insulin resistance, as manifested by a high triglyceride/HDL-c ratio, was associated with adverse cardiovascular outcomes more than other lipid metrics, including LDL-c, which had little concordance. Physicians and patients should not overlook the triglyceride/HDL-c ratio.
在评估血脂指标时，临床医生往往倾向于关注低密度脂蛋白胆固醇（LDL-c）。然而，甘油三酯/高密度脂蛋白胆固醇（HDL-c）比值升高提示胰岛素抵抗，这也能有效预测心血管疾病结局，但所需治疗方法与LDL-c升高不同。我们测试了高甘油三酯/HDL-c比值是否比高LDL-c浓度或其他致动脉粥样硬化的血脂标志物具有更高的风险。
我们在一个社区健康计划中对103646名年龄在50至75岁之间、无心血管疾病或糖尿病的成员进行了随访。根据索引年份的甘油三酯和HDL-c将受试者分为胰岛素敏感或胰岛素抵抗。主要结局是缺血性心脏病。8年后发生主要结局的受试者百分比按胰岛素类别、血脂指标和血压进行分层。在多变量分析中确定胰岛素抵抗、LDL-c、年龄、性别和高血压存在情况的风险比（HR）。
胰岛素抵抗但血脂指标比中位数更健康的受试者，其结局比胰岛素敏感但血脂指标如非HDL-c以及总胆固醇/HDL-c和LDL-c/HDL-c比值更不健康的受试者更差。LDL-c每升高60mg/dL的HR为1.14（95%置信区间[CI]，1.10 - 1.18）；LDL-c大于160mg/dL的HR为1.19（95%CI，1.12 - 1.28）。相比之下，与胰岛素敏感比值相比，胰岛素抵抗的甘油三酯/HDL-c比值的风险比为1.68（95%CI，1.57 - 1.80）。胰岛素抵抗但血压正常的患者与胰岛素敏感但患有高血压的患者在结局方面没有差异。
高甘油三酯/HDL-c比值所表现出的胰岛素抵抗与不良心血管结局的关联比其他血脂指标（包括几乎没有一致性的LDL-c）更强。医生和患者不应忽视甘油三酯/HDL-c比值。
