Triglyceride-to-HDL Cholesterol Ratio as a Cardiovascular Risk Marker
Yes, the triglyceride-to-HDL cholesterol (TG/HDL) ratio serves as a valuable marker for cardiovascular risk assessment, though it should not be used as a treatment target. 1
Clinical Utility of the TG/HDL Ratio
The TG/HDL ratio reflects the relationship between triglyceride-rich lipoproteins and HDL cholesterol, providing insight into cardiovascular risk beyond traditional lipid measurements alone. 1 This ratio is particularly useful because:
The combination of elevated triglycerides and low HDL cholesterol is extremely common in high-risk patients with type 2 diabetes, abdominal obesity, insulin resistance, and physical inactivity, forming part of the atherogenic dyslipidemic triad. 2
A lower TG/HDL ratio (such as 0.49) suggests reduced risk of atherosclerotic cardiovascular disease (ASCVD). 1
The ratio serves as a marker of insulin resistance, with elevated ratios associated with odds ratios of 9.3 for overweight, 27.5 for obesity, and 4.41 for abdominal obesity in young adults. 3
Evidence Supporting Cardiovascular Risk Prediction
Elevated triglycerides are independently associated with cardiovascular disease risk, even after adjustment for HDL cholesterol. 2 The epidemiologic evidence demonstrates:
Nonfasting triglycerides >5 mmol/L (440 mg/dL) versus <1 mmol/L (88 mg/dL) were associated with 17-fold and 5-fold risk of myocardial infarction in women and men, respectively, during 27 years of follow-up. 2
Meta-analyses show that elevated triglycerides confer a relative risk of 1.14 in men and 1.37 in women for cardiovascular disease after adjustment for HDL cholesterol. 2
Genetic studies provide causal evidence: a 1-mmol/L genetic increase in remnant cholesterol (the cholesterol content of triglyceride-rich lipoproteins) was associated with a 2.8-fold causal risk increase for ischemic heart disease. 2
Critical Interpretation Guidelines
The TG/HDL ratio must be interpreted as part of a complete lipid profile, not in isolation. 1, 4 Key considerations include:
Fasting triglycerides >1.7 mmol/L (150 mg/dL) are considered a marker of increased cardiovascular risk, though this is not an evidence-based treatment target. 2
HDL cholesterol <1.0 mmol/L (40 mg/dL) in men and <1.2 mmol/L (45 mg/dL) in women indicates increased risk, but there is insufficient evidence to use HDL as a therapeutic goal. 2
Even with a favorable TG/HDL ratio, elevated absolute LDL cholesterol levels still warrant appropriate management according to the patient's overall cardiovascular risk category. 1, 4
Mortality and Outcome Data
The TG/HDL ratio predicts coronary heart disease, cardiovascular disease, and all-cause mortality after adjustment for established risk factors and non-HDL cholesterol. 5 Specifically:
Men with TG/HDL ratio >3.5 had significantly higher mortality rates from CHD, CVD, and all causes compared to those with lower ratios. 5
The combination of LDL/HDL ratio >5 and triglycerides >2.3 mmol/L identified a high-risk subgroup with a relative risk of 3.8 for cardiac events. 6
Annual incidence of type 2 diabetes was 2 times higher in men with high TG/HDL ratio compared to those with low ratios. 5
Common Pitfalls to Avoid
Do not use the TG/HDL ratio as a treatment target—European guidelines explicitly state there is insufficient evidence to establish HDL cholesterol values as therapeutic goals. 2, 4 Instead:
Focus on absolute LDL cholesterol targets based on overall cardiovascular risk: <1.8 mmol/L (70 mg/dL) for very high-risk patients. 2
Consider non-HDL cholesterol (total cholesterol minus HDL cholesterol), which equals LDL plus remnant cholesterol combined and has been emphasized in recent guidelines. 2, 1
Confirm fasting status when interpreting the ratio, as triglyceride levels vary significantly between fasting and non-fasting states. 1
Assess other cardiovascular risk factors including hypertension, diabetes, smoking, and family history as part of comprehensive risk stratification. 1, 4