Most notably in young adults, high levels of remnant cholesterol (remnant-C) confer an independent risk of major adverse cardiovascular events (MACE), even those with optimal levels of LDL-C, and identification of high remnant-C levels at a young age may enhance preventive strategies, according to a study presented at the 17th Asian Pacific Society of Atherosclerosis and Vascular Diseases Congress 2025 and simultaneously published Sept. 19 in JACC.

Ha Na Jung, MD, et al., used data from the National Health Insurance Service (NHIS) database, covering information for 50 million Koreans who participated in NHIS health screenings between 2002 and 2022 to conduct a study investigating the association between remnant-C and MACE across different age groups (20-39, 40-64 and ≥65 years).

A total of 4,308,405 participants without a history of myocardial infarction (MI) or ischemic stroke who underwent health examinations in 2012 were included and they were followed for a median of 9.3 years.

The primary endpoints was incident MACE, including ischemic stroke, MI and cardiovascular mortality. Remnant-C was calculated as non–HDL-C minus LDL-C in the fasting state. MACE risk was calculated across remnant-C quartiles among all participants.

Results showed that higher remnant-C quartiles were independently associated with a greater MACE risk across all age groups, but the strongest association was observed in young adults (20-39 years old).

During follow-up, 78,223 MIs, 84,832 ischemic strokes and 26,774 cardiovascular deaths occurred. Among young adults, adjusted hazard ratios (aHRs) comparing the highest and lowest remnant-C quartiles were 1.42 for MI, 1.30 for ischemic stroke and 2.19 for cardiovascular mortality, compared with 1.07, 1.12 and 1.08, respectively, in participants ≥65 years.

Of note, in participants in the younger cohort who had optimal LDL-C levels (<100 mg/dL) but high remnant-C level (≥30 mg/dL), the aHRs were 1.24 for MI, 1.29 for ischemic stroke and 1.83 for cardiovascular mortality.

The authors write, "Assessing remnant-C yields particularly important insights into residual cardiovascular risk among younger individuals." They add that their findings "underscore the importance of establishing surveillance strategies that incorporate remnant-C in cardiovascular risk assessments, with an emphasis on younger populations who are relatively overlooked in current [cardiovascular disease] prevention efforts."