Background: Non-high density lipoprotein cholesterol (non-HDL-C) is increasingly incorporated into guidelines along with low density lipoprotein cholesterol (LDL-C) to guide lipid-lowering therapy decisions.
Objective: Examine patterns of LDL-C and non-HDL-C levels after statin initiation for primary prevention, and their association with incident cardiovascular events.
Methods: This was a population-based cohort study in Ontario, Canada among persons age ≥66 years starting a statin for primary prevention between January 1, 2012 and December 31, 2019. We identified those with a lipid panel in the 1-year after starting a statin and categorized individuals based on LDL-C and non-HDL-C thresholds for intensification in the 2021 Canadian Cardiovascular Society dyslipidemia guidelines. We stratified by diabetes/chronic kidney disease (CKD) status. The primary outcome was the composite of all-cause mortality or cardiovascular events, with follow-up to December 31, 2020. We used a Cox proportional hazards model for analysis.
Results: Our cohort comprised 125,013 people. Median follow-up was 2.5 years. Compared with those meeting both LDL-C and non-HDL-C thresholds, being above both thresholds was associated with an increased rate of the primary outcome for people without diabetes/CKD (HR 1.10, 95% CI 1.05 to 1.15) and for those with diabetes/CKD (HR 1.16, 95% CI 1.09 to 1.23). Being below the LDL-C threshold but above non-HDL-C threshold was associated with an increased rate of the primary outcome for people with diabetes/CKD (HR 1.16, 95% CI 1.03 to 1.30).
Conclusions: These findings support the residual risk associated with incompletely controlled LDL-C or non-HDL-C levels after statin initiation for primary prevention.
JACC: Advances Editor-in-Chief
Candice K. Silversides, MD, FACC
JACC: Advances CME Editor
Kenneth A. Ellenbogen, MD
Author
Barbara Wiggins, PharmD, FACC
Important Dates
Date of Release: July 23, 2025
Term of Approval/Date of CME/MOC Expiration: July 22, 2026