The RC/HDL-c Ratio: A Superior Predictor of Coronary Artery Calcification Severity Compared to Remnant Cholesterol Alone

Background We investigated the associations among remnant cholesterol (RC) and high-density lipoprotein cholesterol (HDL-c) with coronary artery calcification (CACS), quantified by noncontrast computed tomography, aiming to determine whether the RC/HDL-c ratio serves as a more effective indicator of CACS severity compared to RC alone. Methods This retrospective analysis included data from 11,526 participants, categorized into four groups based on their CACS Agatston scores. The relationships between RC levels and the RC/HDL-c ratio with CACS were assessed using cumulative logistic regression methods. Two statistical models were developed: Model 1 adjusted for age and sex, while Model 2 included additional adjustments for glucose, glycated hemoglobin, and triglyceride concentrations. Quartile analyses were performed for both RC and the RC/HDL-c ratio. Results Elevated RC/HDL-c ratios were associated with a significant increase in CACS in Model 1 (OR = 1.092; 95% CI, 1.048–1.137; p <  0.001), and this association persisted in the upper two quartiles in Model 2 ( p <  0.05). In contrast, while RC levels were significantly associated with CACS in Model 1, this association was attenuated and lost significance in Model 2 after further adjustments. Subgroup analyses revealed a particularly strong correlation between the RC/HDL-c ratio and CACS in participants with normal LDL-c levels. Conclusion Our findings suggest that the RC/HDL-c ratio is a superior marker for CACS compared to RC alone. This novel approach refines CACS evaluation by integrating the pro-atherogenic properties of RC with the protective attributes of HDL-c.