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Closure of a Patent Foramen Ovale (PFO): An Intervention Sequence
Published on: December 23, 2022
Incremental Predictive Value of the Non-HDL-C/HDL-C Ratio for Cryptogenic Stroke in Patients with Patent Foramen
Tarik Yildirim1, Mehmet Tolga Hekim1, Tuncay Kiris2
1Department of Cardiology, School of Medicine, Balikesir University, Balikesir 10145, Turkey.
Insights
The non-high-density lipoprotein cholesterol (non-HDL-C) to high-density lipoprotein cholesterol (HDL-C) ratio is linked to cryptogenic stroke in patent foramen ovale patients. This lipid ratio improves stroke risk prediction beyond the standard ROPE score.
Area of Science:
- Cardiology
- Neurology
- Lipid Metabolism
Background:
- Patent foramen ovale (PFO) is associated with cryptogenic stroke (CS).
- The non-high-density lipoprotein cholesterol (non-HDL-C) to high-density lipoprotein cholesterol (HDL-C) ratio is a marker of residual vascular risk.
- The predictive value of the non-HDL-C/HDL-C ratio in PFO-associated CS is not well understood.
Purpose of the Study:
- To investigate the association between the non-HDL-C/HDL-C ratio and CS in patients with PFO.
- To evaluate the incremental predictive value of the non-HDL-C/HDL-C ratio beyond the Risk of Paradoxical Embolism (ROPE) score.
Main Methods:
- Retrospective study of 316 patients with confirmed PFO (56 with CS).
- Utilized multivariable logistic regression, restricted cubic spline analysis, ROC analysis, NRI, IDI, and decision curve analysis.
- Internal validation was performed to ensure model stability.
Main Results:
- Patients with CS exhibited significantly higher non-HDL-C/HDL-C ratios (p < 0.001).
- The non-HDL-C/HDL-C ratio was independently associated with CS (OR: 1.881, p < 0.001).
- Adding the non-HDL-C/HDL-C ratio to the ROPE score improved stroke risk discrimination (AUC increased from 0.781 to 0.819, p = 0.010) and risk reclassification (NRI = 0.555, p = 0.002; IDI = 0.057, p = 0.002).
Conclusions:
- The non-HDL-C/HDL-C ratio is an independent predictor of CS in PFO patients.
- This lipid ratio offers incremental predictive value beyond the ROPE score for PFO-associated stroke.
- Metabolic lipid burden may contribute to thromboembolic risk and aid in individualized risk stratification for PFO-related stroke.
Abstract:
Background: The non-high-density lipoprotein cholesterol (non-HDL-C) / high-density lipoprotein cholesterol (HDL-C) ratio has emerged as a marker of residual vascular risk; however, its role in patent foramen ovale (PFO)-associated cryptogenic stroke (CS) remains unclear. We investigated the association between the non-HDL-C/HDL-C ratio and CS in patients with PFO and evaluated its incremental predictive value beyond the Risk of Paradoxical Embolism (ROPE) score. Methods: This retrospective study included 316 patients with confirmed PFO, including 56 patients with CS. Multivariable logistic regression, restricted cubic spline analysis, ROC analysis, net reclassification improvement (NRI), integrated discrimination improvement (IDI), decision curve analysis, and bootstrap internal validation were performed. Results: Patients with CS had significantly higher non-HDL-C/HDL-C ratio levels than those without CS (p < 0.001). In multivariable analysis, the non-HDL-C/HDL-C ratio remained independently associated with CS (OR: 1.881, 95% CI: 1.310-2.700, p < 0.001). Restricted cubic spline analysis demonstrated a significant nonlinear association between the non-HDL-C/HDL-C ratio and CS risk (overall p = 0.001; nonlinear p = 0.015). Addition of the non-HDL-C/HDL-C ratio to the ROPE score improved discrimination, increasing the AUC from 0.781 to 0.819 (DeLong p = 0.010), and significantly improved risk reclassification (continuous NRI: 0.555, p = 0.002; IDI: 0.057, p = 0.002). Internal validation demonstrated stable model performance with minimal optimism. Conclusions: The non-HDL-C/HDL-C ratio was independently associated with CS and demonstrated potential incremental predictive value beyond the ROPE score in patients with PFO. These findings suggest that metabolic lipid burden may contribute to thromboembolic susceptibility and may improve individualized risk stratification in PFO-related stroke.
