TG/HDL-c Ratio as a Predictor of Cardiovascular Risk

Keywords
Cardiovascular Disease; Risk Fators; Dyslipidemias; Hypertension; Diabetes Mellitus

Cardiovascular diseases (CVD) continue to be an important public health problem and one of the main causes of morbidity and mortality worldwide, generating economic and social impacts.¹,² In Brazil, CVD costs have been increasing significantly and are the highest when compared to other causes of hospitalization. Moreover, as the population ages, and with the increase in CVD prevalence, these expenses tend to be even higher.³ Therefore, early detection and possible changes in cardiovascular risk factors can be important in order to reduce hospitalization and negative outcomes, as well as to improve the population's quality of life.

In an attempt to identify asymptomatic individuals with a greater predisposition for the disease and define therapeutic goals, many evaluation tools have been developed to estimate risks for CVD, such as Framingham's Global Risk Score (GRS), adopted by the Department of Atherosclerosis of the Brazilian Society of Cardiology (SBC-DA, in Portuguese) and which evaluates the risk of cardiovascular events over a 10-year period through the variables of age, sex, high-density lipoprotein cholesterol (HDL-c), total cholesterol, systolic blood pressure, smoking, and diabetes.⁴

Based in this premise, other indexes have been proposed to predict the cardiovascular risk, among which, what stands out are the ratio between triglycerides (TG) and HDL-c (TG/HDL-c), which reflects small and dense particles of low-density lipoprotein (LDL), which are more atherogenic than the larger floating LDL particles.⁵,⁶ The TG/HDL ratio has proven to be a good predictor for myocardial infarction⁷,⁸, and was associated with the incidence of cardiovascular diseases, type 2 diabetes mellitus, and metabolic syndrome.⁹ In addition, it was reported that a high TG/HDL-c relationship is significantly associated with an increase in the resistance to insulin in apparently healthy individuals, thus suggesting that this measure can serve as a simple and clinically useful method to identify apparently healthy young individuals who are resistant to insulin and who present an increased cardiometabolic risk.¹⁰

In the current edition of the International Journal of Cardiovascular Sciences, Silva et al.,¹¹ evaluated 833 individuals, of whom 62.8% were women, with an average age of 62 years, with high blood pressure and/or diabetes, who received medical care at the Family Health Unit in the city of Viçosa, Minas Gerais, Brazil. Exams showed that the cut-off values of the TG/HDL-c ratio that reflect a cardiovascular risk were ≥ 3.26 for men and ≥ 2.72 for women. Moreover, for women with multiple risks, the chance of an alteration in the TG/HDL-c ratio increased by 90%.

The cut-off values considered by Silva et al.,¹¹ were different from those observed in other populations, such as in Argentina (>3.5 in men; >2.5 in women)¹², Iran (>4.42 for men; 3.76 for women, and 3.68 for both sexes)¹³, and Spain (>2.75 for men and > 1.65 for women).¹⁴ Wakabayashi e Daimon⁵ compared the discrimination for cardiovascular risk for different cut-off values of the TG/HDL-c relationship and observed that the optimum cut-off value was of 2.967 in men and 2.237 in women. As observed, the values are diverse among the population, which can possibly be explained by genetic factors, the geographic region, race/ethnicity, and the age of the individuals.

In Brazil, studies that evaluate the cut-off values of the TG/HDL-c ratio are scarce, which hinders the comparison with the results obtained by Silva et al.,¹¹ and show the importance of this investigation for scientific literature. However, the results cannot be extrapolated to the Brazilian population in general, since the results were obtained in a specific population in the state of Minas Gerais. Brazil has a high degree of miscegenation and the TG/HDL-c ratio can be influenced by ethnicity; therefore, representative samples of each region should be used so that the results can be more broadly generalized.

In conclusion, the TG/HDL-c ratio is an easy, accessible, and economical measure that can be useful in predicting the cardiovascular risk in routine exams and triage in Primary Health Care. Nevertheless, more studies are warranted in order to establish the optimum cut-off point. Studies should also include confounding factors, such as socioeconomic status, food consumption, and physical activity.

• Referent to the article: Optimal Cutoff of the TG/HDL-c ratio for Cardiovascular Risk in Hypertensive and Diabetic Patients Monitored by Primary Health Care in a city in Minas Gerais

References

• ¹
  Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, et al. Global Burden of Cardiovascular Diseases and Risk Factors, 1990-2019: Update From the GBD 2019 Study. J Am Coll Cardiol. 2020 Dec 22;76(25):2982-3021. Doi:10.1016/j.acc.220.11.010.
  » https://doi.org/10.1016/j.acc.220.11.010
• ²
  Oliveira GMM, Brant LCC, Polanczyk CA, Biolo A, Nascimento BR, Malta DC, et al. Cardiovascular Statistics - Brazil 2020. Arq Bras Cardiol. 2020 Sep;115(3):308-439. Doi: 10.36660/abc20200812.
  » https://doi.org/10.36660/abc20200812
• ³
  Siqueira ADE, de Siqueira-Filho AG, Land MGP. Análise do Impacto Econômico das Doenças Cardiovasculares nos últimos Cinco anoso no Brasil. Arq Bras Cardiol. 2017;109(1):39-46.doi:10.5935/abc.20170068.
  » https://doi.org/10.5935/abc.20170068
• ⁴
  Précoma DB, Oliveira GMM, Simão AF, Dutra OP, Coelho OR, Izar MCO, et al. Atualização da Diretriz de Prevenção Cardiovascular da Sociedade Brasileira de Cardiologia – 2019. Arq Bras Cardiol. 2019; 113(4):787-891. Doi:10.5935/abc.20190204.
  » https://doi.org/10.5935/abc.20190204
• ⁵
  Wakabayashi I, Daimon T. Comparison of discrimination for cardio-metabolic risk by different cut-off values of the ratio of triglycerides to HDL cholesterol. Lipids Health Dis. 2019 Jul 27;18(1):156. Doi:10.1186/s2944-019-1098-0.
  » https://doi.org/10.1186/s2944-019-1098-0
• ⁶
  Moriyama K. The Association between the Triglyceride to High-density Lipoprotein Cholesterol Ratio and Low-density Lipoprotein Subclasses. Intern Med. 2020 Nov 1;59(21):2661-9. Dói:10.2169/internalmedicine.4954.
  » https://doi.org/10.2169/internalmedicine.4954
• ⁷
  Gaziano JM, Hennekens CH, O'Donnell CJ, Breslow JL, Buring JE. Fasting triglycerides, high-density lipoprotein, and risk of myocardial infarction. Circulation. 1997 Oct 21;96(8):2520-5. Doi:10.1161/01.cir.96.8.2520.
  » https://doi.org/10.1161/01.cir.96.8.2520
• ⁸
  Yang M, Rigdon J, Tsai SA. Association of triglyceride to HDL cholesterol ratio with cardiometabolic outcomes. J Investig Med. 2019 Mar;67(3):663-8.doi: 10.1136/jim-2018-000869.
  » https://doi.org/10.1136/jim-2018-000869
• ⁹
  Nie G, Hou S, Zhang M, Peng W. High TG/HDL ratio suggests a higher risk of metabolic syndrome among an elderly Chinese population: a cross-sectional study. BMJ Open. 2021 Mar 22;11(3):e041519. doi: 10.1136/bmjopen-2020-041519.
  » https://doi.org/10.1136/bmjopen-2020-041519
• ¹⁰
  Murguía-Romero M, Jiménez-Flores JR, Sigrist-Flores SC, Espinoza-Camacho MA, Jiménez-Morales M, Piña E, Méndez-Cruz AR, Villalobos-Molina R, Reaven GM. Plasma triglyceride/HDL-cholesterol ratio, insulin resistance, and cardiometabolic risk in young adults. J Lipid Res. 2013 Oct;54(10):2795-9.
• ¹¹
  da Silva EF, Cotta RMM, Mendonça ET, de Oliveira DM, Cardoso SA, Colodette RM, et al. Optimal Cutoff of the TG/HDL-c ratio for Cardiovascular Risk in Hypertensive and Diabetic Patients Monitored by Primary Health Care in a city in Minas Gerais. Int J Cardiovasc Sci. 2021; 34(5Supl.1):55-65.
• ¹²
  Salazar MR, Carbajal HA, Espeche WG, Leiva Sisnieguez CE, Balbín E, Dulbecco CA, Aizpurúa M, Marillet AG, Reaven GM. Relation among the plasma triglyceride/high-density lipoprotein cholesterol concentration ratio, insulin resistance, and associated cardio-metabolic risk factors in men and women. Am J Cardiol. 2012 Jun 15;109(12):1749-53. Doi:10.11136/bmjopen-2020-041519.
  » https://doi.org/10.11136/bmjopen-2020-041519
• ¹³
  Gharipour M, Sadeghi M, Dianatkhah M, Nezafati P, Talaie M, Oveisgharan S, Golshahi J. Comparison between European and Iranian cutoff points of triglyceride/high-density lipoprotein cholesterol concentrations in predicting cardiovascular disease outcomes. J Clin Lipidol. 2016 Jan-Feb;10(1):143-9. Doi:10.1016/j.jacl.2015.10.008.
  » https://doi.org/10.1016/j.jacl.2015.10.008
• ¹⁴
  Cordero A, Laclaustra M, León M, Casasnovas JA, Grima A, Luengo E,et al. MESYAS Registry Investigators. Comparison of serum lipid values in subjects with and without the metabolic syndrome. Am J Cardiol. 2008 Aug 15;102(4):424-8. Doi:10.1016/j.amjcard.2008.03.079.
  » https://doi.org/10.1016/j.amjcard.2008.03.079

Publication Dates

• Publication in this collection
  01 Nov 2021
• Date of issue
  2021