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Association between hypercholesterolemia and mortality risk among patients referred for cardiac imaging test:
Alan Rozanski1, Donghee Han2, Michael J Blaha3
1Division of Cardiology, Mount Sinai Morningside Hospital, NY, New York, United States of America.
Insights
High cholesterol (hypercholesterolemia) did not increase mortality risk in cardiac patients. Instead, it was associated with decreased mortality, suggesting other factors influence outcomes.
Area of Science:
- Cardiology
- Epidemiology
- Public Health
Background:
- Observational studies have yielded conflicting results regarding hypercholesterolemia and mortality post-cardiac procedures.
- A paradoxical association of lower mortality with hypercholesterolemia has been noted in some patient groups.
Purpose of the Study:
- To investigate the association between hypercholesterolemia and other cardiovascular disease (CAD) risk factors with mortality.
- To analyze these associations across diverse patient cohorts undergoing various cardiac diagnostic tests.
Main Methods:
- Four distinct cardiac cohorts were analyzed, including patients undergoing coronary artery calcium (CAC) scanning, coronary CT angiography (CCTA), and single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI).
- Risk-adjusted Cox models and a random-effects model were used to pool hazard ratios for all-cause mortality.
- Baseline characteristics and mortality rates varied significantly across the cohorts.
Main Results:
- Hypertension, diabetes, and smoking were consistently associated with increased mortality across all cohorts.
- Hypercholesterolemia was associated with a decreased risk of mortality (pooled hazard ratio: 0.71 [95% CI: 0.58-0.84]).
- An inverse relationship between LDL cholesterol and mortality was observed in patients undergoing CAC or CCTA.
Conclusions:
- In a broad spectrum of patients referred for cardiac testing, hypercholesterolemia was not linked to increased mortality.
- Findings suggest hypercholesterolemia's association with mortality may be confounded by clinical factors and treatment changes.
Aim:
Some observational studies have observed a lower, rather than higher, mortality rate in association with hypercholesterolemia during follow-up of patients after cardiac stress testing. We aim to assess the relationship of hypercholesterolemia and other CAD risk factors to mortality across a wide spectrum of patients referred for various cardiac tests.
Methods And Results:
We identified four cardiac cohorts: 64,357 patients undergoing coronary artery calcium (CAC) scanning, 10,814 patients undergoing coronary CT angiography (CCTA), 31,411 patients without known CAD undergoing stress/rest single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), and 5051 patients with known CAD undergoing stress/rest SPECT-MPI. Each cohort was followed for all-cause mortality using risk-adjusted Cox models. We pooled the hazard ratios between cohorts with a random effects model. Baseline risk varied markedly among cohorts, from an annualized mortality rate of 0.31%/year in CAC patients to 3.63%/year among SPECT-MPI patients with known CAD. Hypertension, diabetes, and smoking were each associated with increased mortality in each patient cohort (pooled hazard ratio[95% CI]: 1.38[1.33-1.44], 1.88[1.76-2.00], and 1.67[1.48-1.86], respectively). By contrast, hypercholesterolemia was associated with decreased rather than increased mortality (pooled hazard ratio[95% CI]: 0.71[0.58-0.84]). Analysis of serum lipids among 7744 patients undergoing CAC or CCTA scanning revealed an inverse relationship between LDL cholesterol and mortality.
Conclusions:
Among a broad spectrum of patients referred for a variety of cardiac tests and ranging from low to high clinical risk, hypercholesterolemia was not associated with increased mortality risk. Our findings suggest that hypercholesterolemia may be sensitive to confounding by other clinical factors and post-test treatment changes in patient populations.
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