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J-shaped association between non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio

Ping Lv1, Chenze Zhao1, Yu Shan2

  • 1Heart Center, Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China.

European Journal of Medical Research
|January 6, 2026
PubMed

Insights

The non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) shows a J-shaped link with heart failure (HF) risk. Both very low and very high NHHR levels are associated with increased HF risk in US adults.

Area of Science:

  • Cardiology
  • Lipid Metabolism
  • Public Health

Background:

  • The non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) is a key lipid indicator for cardiovascular and metabolic diseases.
  • The association between NHHR and heart failure (HF) risk remains incompletely understood.

Purpose of the Study:

  • To investigate the relationship between NHHR and the prevalence of HF in a representative US adult population.
  • To explore the nature of this association, including potential non-linear effects and threshold points.

Main Methods:

  • Analysis of data from 11,639 adults in the National Health and Nutrition Examination Survey (2011-2018).
  • Multivariate logistic regression, restricted cubic splines (RCS), and piecewise logistic regression were used to assess NHHR-HF associations.
  • Subgroup and sensitivity analyses were performed to confirm the robustness of the findings.

Main Results:

  • A J-shaped relationship was identified between NHHR and HF risk, with an inflection point at NHHR = 2.58.
  • Both low (NHHR < 2.0) and high (NHHR ≥ 5.0) NHHR levels were significantly associated with increased HF risk compared to NHHR 2.0–3.0.
  • The association remained significant on both sides of the inflection point (OR < 2.58 = 0.545; OR ≥ 2.58 = 1.132).

Conclusions:

  • Both extremely low and high NHHR levels are independently associated with a higher risk of heart failure in US adults.
  • The relationship between NHHR and HF risk is non-linear, exhibiting a J-shaped curve with a critical inflection point at 2.58.
Abstract

Keywords:
Heart failureInflection pointNHANESNHHRNon-linear association

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