High-Density Lipoprotein Cholesterol and the Risk of Myocardial Infarction, Stroke, and Cause-Specific Mortality: a Nationwide Cohort Study in Korea

Abstract

High-Density Lipoprotein Cholesterol and the Risk of Myocardial Infarction, Stroke, and Cause-Specific Mortality: a Nationwide Cohort Study in Korea Yeoree Yang,1,2 Kyungdo Han,3 Sang Hyun Park,4 Mee Kyoung Kim,5 Kun-Ho Yoon,1,6 and Seung-Hwan Lee1,6 1Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea. 2Catholic Smart Health Care Center, The Catholic University of Korea, Seoul, Korea. 3Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea. 4Department of Medical Statistics, College of Medicine, The Catholic University of Korea, Seoul, Korea. 5Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea. 6Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul, Korea.

Correspondence to Seung-Hwan Lee. Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea. Email: hwanx2@catholic.ac.kr Received September 05, 2020; Revised November 05, 2020; Accepted November 18, 2020.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

See the editorial "HDL-C and Cardiovascular Risk: You Don't Need to Worry about Extremely High HDL-C Levels" in volume 10 on page 57.

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Objective We aimed to investigate the relationship between high-density lipoprotein cholesterol (HDL-C) level and the risk of myocardial infarction (MI), stroke, and cause-specific mortality.

Methods Using the Korean National Health Insurance Service-National Sample Cohort, we identified 343,687 subjects (men, 176,243; women, 167,444) aged ≥20 years who underwent health examinations between 2009 and 2012. HDL-C levels were categorized based on the concentration with 10 mg/dL intervals, starting from levels <30 mg/dL, with levels ≥90 mg/dL considered the highest. The endpoints of the study were newly-diagnosed MI, stroke, or mortality. We used the Cox proportional hazards model with restricted cubic splines.

Results During a median follow-up of 6.0 years, the number of cases of death, MI, and stroke were 6,617, 4,064, and 3,435 in men and 3,677, 2,804, and 2,891 in women, respectively. The risk of all-cause mortality, cancer mortality, other mortality, and stroke was the lowest at HDL-C concentrations of 57–76 mg/dL in the spline curves; inverse associations with increased risk were observed at the lower HDL-C levels. In contrast, the lowest risk of cardiovascular mortality and MI was observed at the extreme high end. In men, there was a significant inverse and graded increase in hazard ratios of all outcomes in the lower HDL-C categories compared to the reference group (50–59 mg/dL). In the higher HDL-C categories, no significant increase in outcomes was observed. Women showed similar trends.

Conclusion The risk of mortality, MI, and stroke was high at low HDL-C levels in the Korean general population. However, extremely high HDL-C levels were not associated with an increased risk of mortality, MI, and stroke.