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The Emerging Risk Factors Collaboration^*

JAMA. 2009;302(18):1993-2000.

Context  Associations of major lipids and apolipoproteins with the risk of vascular disease have not been reliably quantified.

Objective  To assess major lipids and apolipoproteins in vascular risk.

Design, Setting, and Participants  Individual records were supplied on 302 430 people without initial vascular disease from 68 long-term prospective studies, mostly in Europe and North America. During 2.79 million person-years of follow-up, there were 8857 nonfatal myocardial infarctions, 3928 coronary heart disease [CHD] deaths, 2534 ischemic strokes, 513 hemorrhagic strokes, and 2536 unclassified strokes.

Main Outcome Measures  Hazard ratios (HRs), adjusted for several conventional factors, were calculated for 1-SD higher values: 0.52 log_e triglyceride, 15 mg/dL high-density lipoprotein cholesterol (HDL-C), 43 mg/dL non–HDL-C, 29 mg/dL apolipoprotein AI, 29 mg/dL apolipoprotein B, and 33 mg/dL directly measured low-density lipoprotein cholesterol (LDL-C). Within-study regression analyses were adjusted for within-person variation and combined using meta-analysis.

Results  The rates of CHD per 1000 person-years in the bottom and top thirds of baseline lipid distributions, respectively, were 2.6 and 6.2 with triglyceride, 6.4 and 2.4 with HDL-C, and 2.3 and 6.7 with non–HDL-C. Adjusted HRs for CHD were 0.99 (95% CI, 0.94-1.05) with triglyceride, 0.78 (95% CI, 0.74-0.82) with HDL-C, and 1.50 (95% CI, 1.39-1.61) with non–HDL-C. Hazard ratios were at least as strong in participants who did not fast as in those who did. The HR for CHD was 0.35 (95% CI, 0.30-0.42) with a combination of 80 mg/dL lower non–HDL-C and 15 mg/dL higher HDL-C. For the subset with apolipoproteins or directly measured LDL-C, HRs were 1.50 (95% CI, 1.38-1.62) with the ratio non–HDL-C/HDL-C, 1.49 (95% CI, 1.39-1.60) with the ratio apo B/apo AI, 1.42 (95% CI, 1.06-1.91) with non–HDL-C, and 1.38 (95% CI, 1.09-1.73) with directly measured LDL-C. Hazard ratios for ischemic stroke were 1.02 (95% CI, 0.94-1.11) with triglyceride, 0.93 (95% CI, 0.84-1.02) with HDL-C, and 1.12 (95% CI, 1.04-1.20) with non–HDL-C.

Conclusion  Lipid assessment in vascular disease can be simplified by measurement of either total and HDL cholesterol levels or apolipoproteins without the need to fast and without regard to triglyceride.

*Authors/Emerging Risk Factors Collaboration (ERFC) Writing Committee: Emanuele Di Angelantonio, MD, University of Cambridge, Cambridge, United Kingdom; Nadeem Sarwar, PhD, University of Cambridge; Philip Perry, MBChB, University of Cambridge; Stephen Kaptoge, PhD, University of Cambridge; Kausik K. Ray, MD, University of Cambridge; Alexander Thompson, PhD, University of Cambridge; Angela M. Wood, PhD, University of Cambridge; Sarah Lewington, DPhil, University of Oxford, Oxford, United Kingdom; Naveed Sattar, FRCPath, University of Glasgow, Glasgow, United Kingdom; Chris J. Packard, DSc, University of Glasgow; Rory Collins, FMedSci, University of Oxford; Simon G. Thompson, DSc, Medical Research Council (MRC) Biostatistics Unit, Cambridge, United Kingdom; John Danesh, FRCP, University of Cambridge.

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