Clinical Investigation
Acute Ischemic Heart Disease
The triglyceride/high-density lipoprotein cholesterol ratio predicts all-cause mortality in women with suspected myocardial ischemia: A Report From the Women's Ischemia Syndrome Evaluation (WISE)

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High triglycerides (TG) and low high-density lipoprotein cholesterol (HDL-C) are important cardiovascular risk factors in women. The prognostic utility of the TG/HDL-C ratio, a marker for insulin resistance and small dense low-density lipoprotein particles, is unknown among high-risk women.

Methods

We studied 544 women without prior myocardial infarction or coronary revascularization, referred for clinically indicated coronary angiography and enrolled in the Women's Ischemia Syndrome Evaluation (WISE). Fasting lipid profiles and detailed demographic and clinical data were obtained at baseline. Multivariate Cox-proportional hazards models for all-cause mortality and cardiovascular events (death, myocardial infarction, heart failure, stroke) over a median follow-up of 6 years were constructed using log TG/HDL-C ratio as a predictor variable and accounting for traditional cardiovascular risk factors.

Results

Mean age was 57 ± 11 years; 84% were white, 55% hypertensive, 20% diabetic, 50% current or prior smokers. Triglyceride/HDL-C ranged from 0.3 to 18.4 (median 2.2, first quartile 0.35 to <1.4, fourth quartile 3.66-18.4). Deaths (n = 33) and cardiovascular events (n = 83) increased across TG/HDL-C quartiles (both P < .05 for trend). Triglyceride/HDL-C was a strong independent predictor of mortality in models adjusted for age, race, smoking, hypertension, diabetes, and angiographic coronary disease severity (hazard ratio 1.95, 95% CI 1.05-3.64, P = .04). For cardiovascular events, the multivariate hazard ratio was 1.54 (95% CI 1.05-2.22, P = .03) when adjusted for demographic and clinical variables, but became nonsignificant when angiographic results were included.

Conclusion

Among women with suspected ischemia, the TG/HDL-C ratio is a powerful independent predictor of all-cause mortality and cardiovascular events.

Section snippets

Study population

The Women's Ischemia Syndrome Evaluation (WISE) study is a National Heart, Lung, and Blood Institute–sponsored 4-center prospective cohort study designed to improve the diagnostic reliability of cardiovascular testing in the evaluation of ischemic heart disease in women. Between 1996 and 2000, 936 women (out of 7,603 screened and 1,903 found eligible) ≥18 years presenting to study sites for clinically indicated coronary angiography to evaluate suspected myocardial ischemia were enrolled. Major

Baseline characteristics

The average age was 57 ± 11 years, 16% of women were African American, 55% had a history of hypertension, 20% were diabetic, and 50% had a history of smoking. The mean TG/HDL-C ratio with TG and HDL-C expressed in milligrams per deciliter (corresponding values expressed in millimoles per liter in parentheses) was 2.9 ± 2.2 (1.3 ± 0.96); median, 2.2 (0.96); range, 0.3 to 18.4 (0.13-8.0) (Figure 1).

Table I summarizes baseline characteristics by TG/HDL-C quartile. Age was similar across quartiles.

Discussion

To our knowledge, this is the first study among high-risk women to show that the TG/HDL-C ratio is a powerful predictor of total mortality independent of important prognostic variables including age, race, smoking, hypertension, diabetes, and severity of coronary artery disease. We also found a strong relationship between the TG/HDL-C ratio and severity of coronary artery disease as well as subsequent cardiovascular events among these women with suspected myocardial ischemia.

Correlates of high

Conclusion

Among high-risk women under evaluation for myocardial ischemia, the TG/HDL-C ratio is a powerful independent predictor of cardiovascular events and all-cause mortality. Clinical trials targeting the abnormal TG/HDL-C ratio in such women appear to be warranted.

Disclosures

Dr. Bairey-Merz has consulted for and/or received lecture fees from Novartis (East Hanover, NJ), CMP Media (Manhasset, NY), Rodale Press (New York, NY), Adventist Health (Roseville, CA), Bayer AG (Leverkusen, Germany), CV Therapeutics (Palo Alto, CA), Remillard and Associates (Honolulu, HI) Navigant Consulting (Chicago, IL), Hunt and Associates (Honolulu, HI), Pfizer (New York, NY). Dr. Bairey-Merz also has stock ownership in Boston Scientific (Natick, MA), Eli Lilly (Indianapolis, IN),

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    Funding sources: This work was supported by contracts from the National Heart, Lung and Blood Institutes, nos. N01-HV-68161, N01-HV-68162, N01-HV-68163, N01-HV-68164; grants U0164829, U01 HL649141, U01 HL649241, GCRC grant MO1-RR00425 from the National Center for Research Resources; and grants from the Gustavus and Louis Pfeiffer Research Foundation (Denville, NJ), The Women's Guild of Cedars-Sinai Medical Center (Los Angeles, CA), The Ladies Hospital Aid Society of Western Pennsylvania (Pittsburgh, PA), and The Edythe Broad Endowment for Women's Heart Research (Los Angeles, CA).

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