JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
2, 2023
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VOL. 81, NO.
ª 2023 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
PUBLISHED BY ELSEVIER
Elevated LDL Triglycerides and
Atherosclerotic Risk
Mie Balling, MD,a,b,c Shoaib Afzal, MD, PHD, DMSC,a,b,c George Davey Smith, MD, DSC,d,e Anette Varbo, MD, PHD,a,b,c
Anne Langsted, MD, PHD,a,b,c Pia R. Kamstrup, MD, PHD,a,b Børge G. Nordestgaard, MD, DMSCa,b,c
ABSTRACT
BACKGROUND It is unclear whether elevated low-density lipoprotein (LDL) triglycerides are associated with an
increased risk of atherosclerotic cardiovascular disease (ASCVD).
OBJECTIVES This study tested the hypothesis that elevated LDL triglycerides are associated with an increased risk of
ASCVD and of each ASCVD component individually.
METHODS The study investigators used the Copenhagen General Population Study, which measured LDL triglycerides in
38,081 individuals with a direct automated assay (direct LDL triglycerides) and in another 30,208 individuals with nuclear
magnetic resonance (NMR) spectroscopy (NMR LDL triglycerides). Meta-analyses aggregated the present findings with
previously reported results.
RESULTS During a median follow-up of 3.0 and 9.2 years, respectively, 872 and 5,766 individuals in the 2 cohorts
received a diagnosis of ASCVD. Per 0.1 mmol/L (9 mg/dL) higher direct LDL triglycerides, HRs were 1.26 (95% CI: 1.17-
1.35) for ASCVD, 1.27 (95% CI: 1.16-1.39) for ischemic heart disease, 1.28 (95% CI: 1.11-1.48) for myocardial infarction,
1.22 (95% CI: 1.08-1.38) for ischemic stroke, and 1.38 (95% CI: 1.21-1.58) for peripheral artery disease. Corresponding
HRs for NMR LDL triglycerides were 1.26 (95% CI: 1.20-1.33), 1.33 (95% CI: 1.25-1.41), 1.41 (95% CI: 1.31-1.52), 1.13
(95% CI: 1.05-1.23), and 1.26 (95% CI: 1.10-1.43), respectively. The foregoing results were not entirely statistically
explained by apolipoprotein B levels. In meta-analyses for the highest quartile vs the lowest quartile of LDL triglycerides,
random-effects risk ratios were 1.50 (95% CI: 1.35-1.66) for ASCVD (4 studies; 71,526 individuals; 8,576 events), 1.62
(95% CI: 1.37-1.93) for ischemic heart disease (6 studies; 107,538 individuals; 9,734 events), 1.30 (95% CI: 1.13-1.49) for
ischemic stroke (4 studies; 78,026 individuals; 4,273 events), and 1.53 (95% CI: 1.29-1.81) for peripheral artery disease
(4 studies; 107,511 individuals; 1,848 events).
CONCLUSIONS Elevated LDL triglycerides were robustly associated with an increased risk of ASCVD and of each ASCVD
component individually in 2 prospective cohort studies and in meta-analyses of previous and present studies combined.
(J Am Coll Cardiol 2023;81:136–152) © 2023 by the American College of Cardiology Foundation.
E levated low-density lipoprotein (LDL) triglyc-
erides may be associated with an increased
risk of atherosclerotic cardiovascular disease
(ASCVD) and each ASCVD component individually.1-6
risk of ASCVD in both mendelian randomization
and conventional observational studies. 7-12 These 2
observations may be tied together, with elevated
LDL triglycerides as a marker of high concentrations
Related to this, elevated triglyceride-rich remnant li- of triglyceride-rich remnant lipoproteins, because
poproteins are robustly associated with an increased cholesteryl ester transfer protein during
From the aDepartment of Clinical Biochemistry, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev,
Denmark; bThe Copenhagen General Population Study, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev,
Denmark; cDepartment of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen,
Denmark; dMRC Integrative Epidemiology Unit, Bristol Medical School, University of Bristol, Bristol, United Kingdom; and the
e
Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’
institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more
information, visit the Author Center.
Manuscript received August 4, 2022; revised manuscript received October 6, 2022, accepted October 7, 2022.
ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2022.10.019
JACC VOL. 81, NO. 2, 2023 Balling et al 137
JANUARY 17, 2023:136–152 LDL Triglycerides and Atherosclerotic Risk

hypertriglyceridemia transfers cholesteryl esters from who were consecutively recruited in 2013 to ABBREVIATIONS

LDL in exchange for triglycerides from triglyceride- 2017. NMR LDL triglycerides using NMR AND ACRONYMS

rich remnant lipoproteins, thus leading to elevated spectroscopy were measured in another
ASCVD = atherosclerotic
levels of LDL triglycerides. 13,14 Alternatively, elevated 30,208 individuals consecutively recruited cardiovascular disease
LDL triglycerides themselves may directly cause (with case enrichment) in 2003 to 2015; 17,719
HDL = high-density lipoprotein
ASCVD, if triglycerides are degraded locally to tissue- individuals were consecutively recruited,
ICD = International
toxic free fatty acids after LDL particles enter the in- whereas in the remainder of the Copenhagen Classification of Diseases
tima, thereby leading to atherosclerosis with vulner- General Population Study, we measured NMR IDL = intermediate-density
able plaques ultimately causing ASCVD and its LDL triglycerides on individuals who, during lipoprotein

components of ischemic heart disease, myocardial follow-up, died or had common multifactorial LDL = low-density lipoprotein
infarction, ischemic stroke, and peripheral artery diseases, including ASCVD. The term “NMR NMR = nuclear magnetic
disease.2,4,11,15 It is, however, unclear whether LDL triglycerides” used in the present paper resonance

elevated LDL triglycerides are robustly associated includes triglycerides in both LDL and VLDL = very low-density

with an increased risk of ASCVD and of each ASCVD intermediate-density lipoprotein (IDL) lipoprotein

component individually. because NMR IDL þ LDL corresponds to LDL cali-

SEE PAGE 153
We tested the hypothesis that elevated LDL tri-
glycerides are associated with an increased risk of
ASCVD and each of its components individually, that
is, ischemic heart disease, myocardial infarction,
ischemic stroke, and peripheral artery disease. To do
so, we conducted 2 prospective studies within the
Copenhagen General Population Study. The first
study included 38,081 individuals with direct LDL
triglycerides measured on fresh samples using an
automated assay from Denka (direct
glycerides), whereas the second study included
another 30,208 individuals with nuclear magnetic
resonance (NMR) LDL triglycerides measured on
brated to standard clinical assays.18 Furthermore, 496
individuals who had NMR LDL triglycerides samples
collected in 2003 to 2004 had a repeated sample from
2014 to 2016.
The study complies with the Declaration of Hel-
sinki. All individuals gave written informed consent,
and the study was approved by the Danish Data
Protection Agency and by the Ethics Committee of the
Capital Region of Denmark (H-KF-01-144/01). The
Danish Data Protection Agency does not allow
open access to our data; however, on reasonable
LDL tri- request to the corresponding author, additional
analyses can be performed.
ATHEROSCLEROTIC CARDIOVASCULAR DISEASE.

samples that had been frozen (NMR LDL tri- ASCVD comprised fatal and nonfatal ischemic heart
glycerides). We included the 2 different studies to disease, myocardial infarction, ischemic stroke, and
document the association in 2 different settings with peripheral artery disease (World Health Organiza-
different assays, to strengthen inference. Moreover, tion International Classification of Diseases [ICD]:
the associations between elevated LDL triglycerides ischemic heart disease: ICD-8: 410-414, ICD-10:
and the risk of ASCVD and each ASCVD component I20-I25; myocardial infarction: ICD-8: 410, ICD-10:
individually were aggregated in meta-analyses add- I21-I22; ischemic stroke: ICD-8: 433-434, ICD-
ing 6 previous studies to our current data, totaling 10: I63; peripheral artery disease: ICD-8: 44020,
>110,000 individuals and >15,000 events. 44029, 44030, 44389, 44399, 44500, 44509, and
44590, ICD-10: I70.2, I70.2A, I73.9, and I73.9A-C),
METHODS ascertained from the national Danish Patient Reg-
istry in which all hospital contacts in Denmark are
THE COPENHAGEN GENERAL POPULATION STUDY. registered19 and the national Danish Causes of
The Copenhagen General Population Study was initi- Death Registry containing information from death
ated in 2003 and is ongoing.16,17 Adults aged between certificates.20 Hemorrhagic stroke (ICD-8: 430-431,
20 and 100 years of White Danish descent according ICD-10: I60-I61), which has an etiology different
to the Danish Civil Registration System were from that of ASCVD, was used as a “negative con-
randomly invited to participate in the study on the trol” endpoint. 21
basis of their Central Person Register number, a Information on emigration and death was
number given to every citizen at birth or immigration. acquired from the Danish Civil Registration System
Individuals filled in a questionnaire, underwent a where vital status on all Danes is recorded
medical examination, and had blood samples drawn continuously.22 Information on follow-up was avail-
at baseline (Figure 1). Direct LDL triglycerides using able on all individuals until death, emigration
the Denka assay were measured in 38,081 individuals (n ¼ 110 for those with direct LDL triglycerides and
138 Balling et al
LDL Triglycerides and Atherosclerotic Risk
F I G U R E 1 Flowchart of the Study Groups
Participated in the Copenhagen General Population Study
N = ~140,000 Year: 2003-2017
Baseline measurements
• Questionnaire
• Medical examination
• Blood samples
Direct LDL triglycerides NMR LDL triglycerides
N = 38,081 N = 30,208
Year: 2013-2017 Year: 2003-2015
Measured in all Measured in
consecutive individuals consecutive individuals
participating (with case-enrichment)
in the time-period
Flowchart of the 2 study groups, with directly measured low-density lipoprotein (LDL)
triglycerides and nuclear magnetic resonance (NMR) measured low-density lipoprotein
triglycerides, within the Copenhagen General Population Study. In both study groups,
individuals filled in a questionnaire, underwent a medical examination, and had blood
samples drawn.
n ¼ 84 for those with NMR LDL triglycerides), or end
of follow-up in December 2018, whichever came first.
LABORATORY ANALYSES. Direct LDL triglycerides
were measured with the Denka assay, described in
detail elsewhere.23 Briefly, in a first step, triglycerides
from chylomicrons, very low-density lipoprotein
(VLDL), and HDL are removed, and in the second
step, LDL triglycerides are quantified. Coefficients of
variation were within 4%.
NMR LDL triglycerides, NMR HDL triglycerides,
LDL particle number, LDL size, and VLDL tri-
glycerides were measured using the Nightingale
Health’s NMR spectroscopy platform, which was
previously described3,24-26 and has often been used in
epidemiologic studies (a publication list can be found
on the Nightingale Health Website 26 ). Coefficients of
variation have previously been reported to be 3.8%
for NMR LDL triglycerides. 3 Measurements of direct
LDL triglycerides were made on fresh samples,
whereas for NMR LDL triglycerides, the samples had
been stored at 80  C between 3 and 15 years before
batch measurement.
JACC VOL. 81, NO. 2, 2023
JANUARY 17, 2023:136–152
Using nonfasting plasma samples, we also
measured direct LDL cholesterol, direct small dense
LDL cholesterol, total plasma triglycerides, total
plasma cholesterol, plasma apolipoprotein B, direct
HDL cholesterol, and high-sensitivity C-reactive pro-
tein (Konelab and Roche). LDL cholesterol was also
calculated using the Friedewald equation when
plasma triglycerides were #4.0 mmol/L (354 mg/dL);
otherwise, a direct measurement of LDL cholesterol
was used. Finally, remnant cholesterol was calculated
by subtracting LDL cholesterol and HDL cholesterol
from plasma total cholesterol, as done previ-
ously.9,27,28 Nonfasting plasma remnant cholesterol
included cholesterol in both VLDL and chylomicron
remnants. Typically, results are similar for remnant
cholesterol whether it is calculated using LDL
cholesterol estimated by the Friedewald equation,
the Martin-Hopkins equation, or the Sampson-
National Institute of Health equation. 28
COVARIATES. Covariates were recorded at baseline.
Smoking and lipid-lowering therapy were self-
reported in the questionnaire. Blood pressure was
measured in millimeters of mercury. Diabetes melli-
tus was defined as a nonfasting glucose level
>11 mmol/L (198 mg/dL), a hemoglobin A1c value
>48 mmol/mol, self-reported diabetes mellitus, use
of antidiabetic medication, and/or hospital contact
for diabetes mellitus (ICD-8: 249 and 250; ICD-10: E10,
E11, E13, and E14). Atrial fibrillation was defined
according to the national Danish Patient Registry
(ICD-8: 427.93, 427,94; ICD-10: I48).
STATISTICAL ANALYSES. Stata software version S.E.
13 was used (StataCorp). Spearman’s correlation co-
efficients among direct LDL triglycerides, NMR LDL
triglycerides, and other lipids and lipoproteins
were calculated. The distributions of direct LDL
triglycerides and NMR LDL triglycerides were drawn
using kernel density plots.
In Cox regression analyses, multivariable chained
imputation was conducted for missing data on cova-
riates used for adjustment (data were >99% com-
plete); however, results were similar without
imputation. The imputation model included age, sex,
and missing covariates (smoking and systolic blood
pressure).
Direct LDL triglycerides and NMR LDL triglycerides
were examined according to the 1st to 50th, 51st to
95th, and 96th to 100th percentiles to focus on
extremely high levels and as continuous variables.
For direct LDL triglycerides, these percentiles corre-
sponded to <0.24 mmol/L (<21 mg/dL), 0.24 to
0.40 mmol/L (21-36 mg/dL), and 0.40 to 1.05 mmol/L
JACC VOL. 81, NO. 2, 2023
JANUARY 17, 2023:136–152
(36-93 mg/dL), and for NMR LDL triglycerides, they
corresponded to <0.29 mmol/L (< 26 mg/dL), 0.29 to
0.44 mmol/L (26-40 mg/dL), and 0.44 to 1.15 mmol/L
(40-102 mg/dL), respectively.
Cox regression analyses were used to examine
associations of levels of direct and NMR LDL tri-
glycerides with the risk of ASCVD, ischemic heart
disease, myocardial infarction, ischemic stroke, pe-
ripheral artery disease, and hemorrhagic stroke. In-
dividuals with an event before baseline were
excluded from relevant Cox regression analyses. The
analyses were multivariable adjusted for sex, smok-
ing, systolic blood pressure, lipid-lowering therapy,
and atrial fibrillation (for analyses including stroke),
with age as the underlying time scale (age adjusted)
and left truncation (delayed entry) at study entry; in
sensitivity analyses, we also used time on the study
as the underlying time scale, with adjustment for
baseline age.
Associations of levels of direct and NMR LDL tri-
glycerides with the risk of ASCVD were further
explored using a multivariable adjusted Cox regres-
sion restricted cubic spline model with 3 knots. The
number of knots was chosen according to Akaike’s
and Schwarz’s Bayesian information criteria and
placed at the default 10th, 50th, and 90th percentiles
with a reference value of 0.1 mmol/L (9 mg/dL).
Discordance on the risk of ASCVD between LDL
triglycerides and apolipoprotein B with a focus on
extremely high levels (top 20%) was examined by Cox
regression analyses, with individuals divided into
4 groups: 1) individuals with LDL triglycerides <80th
percentile and plasma apolipoprotein B <80th
percentile; 2) individuals with LDL triglycerides
<80th percentile and apolipoprotein B $80th percen-
tile; 3) individuals with LDL triglycerides $80th
percentile and apolipoprotein B <80th percentile; and
4) individuals with LDL triglycerides $80th percentile
and apolipoprotein B $80th percentile. The discor-
dance analysis was performed for both direct LDL tri-
glycerides and NMR LDL triglycerides.
For the Cox regression analyses on continuous
measurements of LDL triglycerides, linearity was
assumed, and the proportional hazards assumption
was tested using Schoenfeld residuals and graphically
evaluated using log-log plots of survival; no major
violations for our models were observed.
Regression dilution bias for NMR LDL triglycerides
was evaluated using replicated measurements on 496
individuals without lipid-lowering therapy roughly 10
years apart; HRs and 95% CIs were corrected using a
regression dilution ratio of 0.67 for NMR LDL
Balling et al 139
LDL Triglycerides and Atherosclerotic Risk
triglycerides.27 There were no repeated measure-
ments on direct LDL triglycerides to allow correction
for regression dilution bias.
META-ANALYSES. Studies on the association be-
tween LDL triglycerides and the risk of ASCVD and
each of its components were identified by an elec-
tronic search in PubMed up to March 29, 2022 (for
additional information on the meta-analyses, see
Supplemental Methods: Meta-Analyses). The full
search string was as follows: (“Cardiovascular Dis-
eases” [Medical Subject Headings {MeSH}] OR
“Myocardial Infarction” [MeSH] OR “Peripheral
Arterial Disease” [MeSH] OR “Stroke” [MeSH] or
“Cardiovascular Diseases” or “Myocardial Infarction”
or “Peripheral Arterial Disease” or “Stroke”) and
[“metabolomics” AND “triglyceride”] or “LDL-TG”).
No filters were used in the search. Inclusion criteria
were: 1) ASCVD, ischemic heart disease, ischemic
stroke, or peripheral artery disease as the endpoint;
2) an adult general population sample or subsample;
3) information on risk estimates of the association
between LDL triglycerides and ASCVD and/or its
subcomponents; and 4) study written in English. In
total 115 studies were identified; 11 studies were full-
text screened, and 4 of these were excluded for lack
of risk estimates or measurements of LDL tri-
glycerides (Supplemental Figure 1). There were no
other exclusion criteria. In total, 8 studies were
included in the meta-analyses, 6 from the search
strategy and the 2 studies from the present paper.
The extracted data included first author, publica-
tion year, number of participating individuals, num-
ber of events, method used to measure LDL
triglycerides, adjustment, and risk estimates
(Supplemental Table 1). Multivariable adjustment was
defined as adjustment for minimum sex, age, smok-
ing, systolic blood pressure, and lipid-lowering ther-
apy. Most risk estimates from the individual studies
were given as highest quartile vs lowest quartile, 1,2,6
including the 2 present studies. For März et al,4 an
OR was given between 2 consecutive quartiles. For
the remaining studies, estimates were converted to
quartiles,3,5 as done previously.29,30 Data from each
study were extracted by M.B. and confirmed by S.A.
The meta-analyses were performed with fixed-
effects models using the Mantel and Haenszel
method and with random-effects models using the
DerSimonian and Laird method. Heterogeneity was
quantified using I 2 (the percentage of variation among
the studies that is caused by heterogeneity and not by
sampling variation). Small study effects, including
publication bias, were assessed using funnel plots.
140 Balling et al JACC VOL. 81, NO. 2, 2023

LDL Triglycerides and Atherosclerotic Risk JANUARY 17, 2023:136–152

CORRELATIONS AMONG LIPID FRACTIONS. Coefficients

T A B L E 1 Baseline Characteristics of Subpopulations in the Copenhagen General
Population Study
of determination R 2 for direct LDL triglycerides were
11% with LDL cholesterol, 14% with plasma total tri-
Individuals With Direct Individuals With NMR
LDL Triglyceride Measurement LDL Triglyceride Measurement
glycerides, 11% with plasma total cholesterol, 14%
Number 38,081 30,208
with remnant cholesterol, 19% with apolipoprotein B,
Age, y 60 (51-70) 63 (52-73) and 4% with HDL cholesterol (Table 2). Correspond-
Women 21,217 (56) 15,416 (51) ing values for NMR LDL triglycerides were 31%, 38%,
Smokers 4,337 (11) 7,146 (24) 50%, 38%, 58%, and 0.6%, respectively. Levels of
Systolic blood pressure, mm Hg 138 (125-153) 140 (129-157) both direct and NMR LDL triglycerides were directly
Lipid-lowering therapy 5,796 (15) 4,274 (14)
proportional to levels of all lipids, lipoproteins, and
Atrial fibrillation 1,521 (4) 1,429 (5)
apolipoproteins, except HDL cholesterol, where the
Direct LDL triglycerides
correlation was inverse. Coefficients of determination
mmol/L 0.23 (0.19-0.29) N/A
mg/dL 21 (17-26) N/A R 2 for NMR LDL triglycerides were 39% with LDL
NMR LDL triglycerides particle number and 0.02% with LDL size
mmol/L N/A 0.29 (0.25-0.34) (Supplemental Table 2).
mg/dL N/A 26 (22-31)
LDL cholesterol
ATHEROSCLEROTIC CARDIOVASCULAR DISEASE.
mmol/L 2.9 (2.3-3.6) 3.2 (2.6-3.9) During a median follow-up of 3.0 years (range 2 days
mg/dL 113 (90-139) 124 (101-151) to 5.3 years) for those participants with direct LDL
Plasma total triglycerides triglycerides, 872 had ASCVD, 539 ischemic heart
mmol/L 1.4 (0.94-2.0) 1.5 (1.0-2.2) disease, 233 myocardial infarction, 295 ischemic
mg/dL 120 (83-179) 132 (91-194)
stroke, 210 peripheral artery disease, and 75 hemor-
Plasma total cholesterol
rhagic stroke. Corresponding values during a median
mmol/L 5.2 (4.5-5.9) 5.6 (4.9-6.4)
follow-up of 9.2 years (range 1 day to 15 years)
mg/dL 201 (174-228) 217 (190-248)
Remnant cholesterol for those participants with NMR LDL triglycerides
mmol/L 0.61 (0.43-0.89) 0.67 (0.47-0.99) were 5,766, 4,037, 2,313, 2,349, 894, and 535,
mg/dL 24 (16-34) 26 (18-38) respectively.
Apolipoprotein B With higher concentrations of both direct and NMR
g/L 0.97 (0.8-1.2) 1.1 (0.9-1.3) LDL triglycerides, we observed a higher risk of ASCVD
mg/dL 97 (80-117) 110 (90-134)
(Figure 3). In multivariable adjusted analyses per
HDL cholesterol
0.1 mmol/L (9 mg/dL) higher direct LDL triglycerides,
mmol/L 1.48 (1.15-1.86) 1.55 (1.22-1.92)
mg/dL 57 (45-72) 60 (47-74)
the HRs were 1.26 (95% CI: 1.17-1.35) for ASCVD,
1.27 (95% CI: 1.16-1.39) for ischemic heart disease, 1.28
Values are median (IQR) or n (%), unless otherwise indicated. Number of individuals in most parameters varies (95% CI: 1.11-1.48) for myocardial infarction, 1.22
slightly according to availability of data.
HDL ¼ high-density lipoprotein; LDL ¼ low-density lipoprotein; N/A ¼ not available; NMR ¼ nuclear magnetic
(95% CI: 1.08-1.38) for ischemic stroke, 1.38 (95% CI:
resonance. 1.21-1.58) for peripheral artery disease, and 1.03
(95% CI: 0.79-1.34) for hemorrhagic stroke (Figure 4,
top). Corresponding values for NMR LDL triglycerides
were 1.26 (95% CI: 1.20-1.33), 1.33 (95% CI: 1.25-1.41),
RESULTS
1.41 (95% CI: 1.31-1.52), 1.13 (95% CI: 1.05-1.23), 1.26
(95% CI: 1.10-1.43), and 0.87 (95% CI: 0.72-1.06),
Baseline characteristics of 38,081 individuals with
respectively (Figure 4, bottom).
measurements of direct LDL triglycerides and 30,208
Focusing on extremely high levels, we observed
individuals with measurements of NMR LDL tri-
stepwise higher risks of ASCVD, ischemic heart dis-
glycerides are shown in Table 1. In individuals with
ease, myocardial infarction, ischemic stroke, and pe-
directly measured vs NMR-measured LDL tri-
ripheral artery disease with higher direct and NMR
glycerides, age, systolic blood pressure, and most
LDL triglycerides in essentially all multivariable
lipid measures were slightly lower, more were
adjusted analyses; however, this was not the case for
women, and fewer were smokers, likely reflecting
hemorrhagic stroke (Figure 5).
that the direct LDL triglycerides cohort included
consecutively recruited individuals without case ADJUSTMENT FOR APOLIPOPROTEIN B. When main
enrichment. Distributions of direct and NMR LDL analyses were further adjusted for plasma apolipo-
triglycerides were both skewed with a tail toward protein B, most associations between higher LDL tri-
higher levels (Figure 2). glycerides and the risk of ASCVD and its individual
JACC VOL. 81, NO. 2, 2023 Balling et al 141
JANUARY 17, 2023:136–152 LDL Triglycerides and Atherosclerotic Risk

components were attenuated (compare Figure 6 with

F I G U R E 2 Distribution of LDL Triglycerides in Individuals in the General Population
Figure 4). This finding was most pronounced for
myocardial infarction. However, for the risk of
6
ischemic and hemorrhagic stroke, the HRs increased

Fraction of the Population

in the study with measured NMR LDL triglycerides,
which is the study with most statistical power.

DISCORDANCE BY APOLIPOPROTEIN B. With a focus 4

on extremely high levels and compared with in-
dividuals with both direct LDL triglycerides and
apolipoprotein B <80th percentiles, the HR for
ASCVD was 1.36 (95% CI: 1.09-1.69) for individuals
2
with apolipoprotein B $80th percentile (1.22 g/L;
122 mg/dL) only, 1.28 (95% CI: 1.06-1.54) for in-
dividuals with direct LDL triglycerides $80th
0
percentile (0.31 mmol/L; 27 mg/dL) only, and 1.80
(95% CI: 1.49-2.17) for individuals with both direct
mmol/L 0 0.5 1 1.5
LDL triglycerides and apolipoprotein B $80th mg/dL 0 44 89 133
percentile (Figure 7, top). Corresponding values using LDL Triglycerides
NMR LDL triglycerides with the $80th percentile of Direct LDL Triglycerides, n = 38,081
(0.36 mmol/L; 32 mg/dL) were 1.10 (95% CI: 1.00-1.21), NMR LDL Triglycerides, n = 30,208
1.18 (95% CI: 1.07-1.30), and 1.30 (95% CI: 1.21-1.39),
respectively (Figure 7, bottom). In the study using
The figure shows the distribution of directly measured low-density lipoprotein (LDL)
NMR LDL triglycerides apolipoprotein B $80th triglycerides and nuclear magnetic resonance (NMR) measured low-density lipoprotein
percentile corresponded to $1.4 g/L (140 mg/dL). triglycerides drawn using kernel density plots, on the basis of individuals from the
When we used the 50th percentiles rather than the Copenhagen General Population Study.

80th percentiles, results were similar but less pro-

nounced for apolipoprotein B (data not shown).
SENSITIVITY ANALYSES. Results were similar to
those reported if analyses used time on the study as
the underlying time scale with adjustment for base-
line age (Supplemental Figure 2). This was also the
case when Cox regression analyses included only
consecutive individuals with measurements of NMR
LDL triglycerides, albeit with reduced statistical po-
wer (compare Figure 4 with Supplemental Figure 3).
Moreover, the pattern of the results was similar when
the triglycerides in IDL were excluded from NMR LDL
triglycerides; however, HRs were nominally higher
(compare Figure 4 with Supplemental Figure 4). The
latter is likely explained by the fact that 0.1 mmol/L is
a larger fraction of LDL triglycerides when excluding
triglycerides from IDL. Furthermore, additional
adjustment for high-sensitivity C-reactive protein
(compare Figure 4 with Supplemental Figure 5) or LDL
particle number and LDL size, in NMR LDL tri-
glycerides analyses, yielded similar results (compare
Figure 4 with Supplemental Figure 6).

T A B LE 2 Correlation of LDL Triglycerides With Other Lipids, Lipoproteins, and Apolipoproteins

R
Direct LDL
NMR LDL LDL Plasma Total Plasma Total Remnant Apolipoprotein HDL
Coefficients of Triglycerides
Triglycerides Cholesterol Triglycerides Cholesterol Cholesterol B Cholesterol
Determination (R 2)
Direct LDL Triglycerides N/A 0.33 0.37 0.34 0.37 0.44 0.19
NMR LDL Triglycerides N/A 0.56 0.62 0.71 0.62 0.74 0.08
LDL Cholesterol 11% 31% 0.21 0.88 0.22 0.76 0.08
Plasma Total Triglycerides 14% 38% 4% 0.26 0.98 0.62 0.49
Plasma Total Cholesterol 11% 50% 78% 7% 0.27 0.73 0.23
Remnant Cholesterol 14% 38% 5% 96% 7% 0.62 0.50
Apolipoprotein B 19% 58% 58% 39% 53% 39% 0.29
HDL Cholesterol 4% 0.6% 0.6% 24% 5% 25% 8%

Number of individuals in most parameters varies slightly according to availability of data. All P values are <0.001.
Abbreviations as in Table 1.
142 Balling et al JACC VOL. 81, NO. 2, 2023

LDL Triglycerides and Atherosclerotic Risk JANUARY 17, 2023:136–152

triglycerides (Table 2) and ASCVD and each of

F I G U R E 3 Risk of ASCVD as a Function of Higher LDL Triglycerides
its components individually. When we instead
adjusted for VLDL triglycerides in the study on NMR
A LDL triglycerides, the results were attenuated even
20 further compared with when plasma triglycerides
were adjusted for (compare Supplemental Figure 9
Multivariable Adjusted HR

10 with Supplemental Figure 7, bottom). For the same

for ASCVD (95% CI)

n = 38,081 reason, the associations of 1 mmol/L (89 mg/dL)

higher plasma total triglycerides with ASCVD and
5
each of its components individually were attenuated
when further adjusted for either direct or NMR LDL
triglycerides (Supplemental Figures 10 and 11).
2
In multivariable adjusted analyses on NMR HDL
triglycerides, the pattern of the risk estimates was
1 similar to the NMR LDL triglyceride risk estimates
(compare Figure 4 with Supplemental Figure 12).
However, effect sizes are not directly comparable
mmol/L 0 0.2 0.4 0.6 0.8 1 because the median of NMR LDL triglycerides was
mg/dL 0 18 35 53 71 89 0.29 mmol/L (26 mg/dL) and of NMR HDL tri-
Direct LDL Triglycerides glycerides was 0.15 mmol/L (13 mg/dL). Thereby,
0.1 mmol is a larger fraction of NMR HDL triglycerides
B than of NMR LDL triglycerides.
META-ANALYSES. The meta-analyses on ASCVD
10
included 4 studies with a total of 71,526 individuals
Multivariable Adjusted HR

and 8,576 events, on ischemic heart disease 6 studies

with 107,538 individuals and 9,734 events, on
for ASCVD (95% CI)

5
n = 30,208 ischemic stroke 4 studies with 78,026 individuals and
4,273 events, and on peripheral artery disease 4
studies with 107,511 individuals and 1,848 events
2 (Figure 8). Supplemental Table 1 contains detailed
information on the studies.
In meta-analyses for the highest quartile vs the
1 lowest quartile of LDL triglycerides, random-effects
ORs were 1.50 (95% CI: 1.35-1.66) for ASCVD, 1.62
(95% CI: 1.37-1.93) for ischemic heart disease,
1.30 (95% CI: 1.13-1.49) for ischemic stroke, and 1.53
mmol/L 0 0.2 0.4 0.6 0.8 1
(95% CI: 1.29-1.81) for peripheral artery disease
mg/dL 0 18 35 53 71 89
(Figure 8). Corresponding fixed-effects HRs or ORs
NMR LDL Triglycerides
were 1.50 (95% CI: 1.37-1.64), 1.57 (95% CI: 1.46-
1.69), 1.30 (95% CI: 1.13-1.49), and 1.53 (95% CI: 1.29-
Multivariable adjusted Cox regression restricted cubic splines. When the 95% CI (dashed
1.81), respectively. There was an indication of
lines) does not overlap 1.0, the HR (red line) is statistically significant. The reference
moderate to strong heterogeneity with I 2 ¼ 77% for
low-density lipoprotein (LDL) triglyceride value was 0.1 mmol/L (9 mg/dL). Population
distributions are represented by the blue and red shaded areas. ASCVD ¼ atherosclerotic ischemic heart disease, whereas there was no such
cardiovascular disease; NMR ¼ nuclear magnetic resonance. evidence for ASCVD (I 2 ¼ 16%), ischemic stroke
(I 2 ¼ 0%), or peripheral artery disease (I2 ¼ 0%). For
meta-analysis on ischemic heart disease when
excluding the studies of Saeed et al2 and Tikkanen
When the multivariable adjusted Cox regression et al, 5 I 2 dropped to 14% with aggregated HRs or
models were further adjusted for plasma total tri- ORs of 1.82 (1.64-2.03, fixed effect) and 1.84 (1.63-
glycerides or for plasma total triglycerides, LDL 2.08, random effect). Using funnel plots there was
cholesterol, and HDL cholesterol, the associations no apparent evidence of publication bias for ASCVD,
were attenuated as expected (compare Figure 4 with ischemic stroke, or peripheral artery disease,
Supplemental Figures 7 and 8), because these addi- whereas this bias could not be excluded for studies
tional lipids and lipoproteins are correlated with LDL on ischemic heart disease with larger effect sizes in
JACC VOL. 81, NO. 2, 2023 Balling et al 143
JANUARY 17, 2023:136–152 LDL Triglycerides and Atherosclerotic Risk

F I G U R E 4 Risk of ASCVD on a Continuous Scale of Higher LDL Triglycerides

Direct LDL Triglycerides

N Total Events HR (95% CI)

ASCVD 34,580 872 1.26 (1.17-1.35)

Ischemic heart disease 35,412 539 1.27 (1.16-1.39)

Myocardial infarction 37,242 233 1.28 (1.11-1.48)

Ischemic stroke 37,316 295 1.22 (1.08-1.38)

Peripheral artery disease 37,758 210 1.38 (1.21-1.58)

Hemorrhagic stroke 37,542 75 1.03 (0.79-1.34)

0.8 1.0 1.1 1.2 1.3 1.5

NMR LDL Triglycerides

N Total Events HR (95% CI)

ASCVD 26,113 5,766 1.26 (1.20-1.33)

Ischemic heart disease 27,448 4,037 1.33 (1.25-1.41)

Myocardial infarction 29,099 2,313 1.41 (1.31-1.52)

Ischemic stroke 28,764 2,349 1.13 (1.05-1.23)

Peripheral artery disease 29,766 894 1.26 (1.10-1.43)

Hemorrhagic stroke 28,764 535 0.87 (0. 72-1.06)

0.8 1.0 1.1 1.2 1.3 1.5

Multivariable Adjusted HR (95% CI) Per 0.1 mmol/L
(0.9 mg/dL) Higher LDL Triglycerides

Cox proportional hazard regressions adjusted for age (underlying time scale), sex, smoking, systolic blood pressure, lipid-lowering therapy, and atrial fibrillation (for
atherosclerotic cardiovascular disease [ASCVD], ischemic stroke, and hemorrhagic stroke), on the basis of individuals from the Copenhagen General Population Study.
Abbreviations as in Figure 1.

smaller vs larger studies (Figure 8; funnel plots not infarction, ischemic stroke, and peripheral artery
shown). disease, in each of 2 prospective studies within the
Copenhagen General Population Study using 2
DISCUSSION different methods of measurement of LDL tri-
glycerides, as well as in meta-analyses of 8 previous
We found that elevated LDL triglycerides were and present studies with >110,000 individuals and
associated robustly with an increased risk of >15,000 events (Central Illustration). Overall, our
ASCVD, ischemic heart disease, myocardial study has with most statistical power so far,
144 Balling et al JACC VOL. 81, NO. 2, 2023

LDL Triglycerides and Atherosclerotic Risk JANUARY 17, 2023:136–152

F I G U R E 5 Risk of ASCVD According to Extremely High LDL Triglycerides

A Direct LDL Triglycerides

Percentiles N Total Events HR (95% CI) P for Trend

ASCVD
1st-50th 17,430 272 1.00 <0.001
51st-95th 15,425 514 1.37 (1.18-1.60)
96th-100th 1,725 86 2.00 (1.56-2.56)
Ischemic heart disease
1st-50th 17,821 174 1.00 <0.001
51st-95th 15,824 318 1.42 (1.18-1.71)
96th-100th 1,767 47 1.79 (1.28-2.51)
Myocardial infarction
1st-50th 18,682 73 1.00 0.01
51st-95th 16,710 143 1.46 (1.09-1.95)
96th-100th 1,850 17 1.62 (0.94-2.77)
Ischemic stroke
1st-50th 18,736 95 1.00 0.01
51st-95th 16,731 170 1.21 (0.94-1.56)
96th-100th 1,849 30 1.88 (1.24-2.85)
Peripheral artery disease
1st-50th 18,964 60 1.00 <0.001
51st-95th 16,926 124 1.42 (1.03-1.95)
96th-100th 1,868 26 2.78 (1.73-4.46)

Hemorrhagic stroke
1st-50th 18,878 29 1.00 0.84
51st-95th 16,807 45 1.37 (0.85-2.20)
96th-100th 1,857 1 0.28 (0.04-1.84)
0.5 1.0 1.5 2.0 2.5 3.0
Multivariable Adjusted HR (95% CI)

Cox proportional hazard regressions adjusted for age (underlying time scale), sex, smoking, systolic blood pressure, lipid-lowering therapy, and atrial fibrillation (for
atherosclerotic cardiovascular disease [ASCVD], ischemic stroke, and hemorrhagic stroke), on the basis of individuals from the Copenhagen General Population Study.
Abbreviations as in Figure 1.

Continued on the next page

whereas other novel aspects include: 1) direct
comparison of 3 individual components of ASCVD
within the same cohorts; 2) use of 2 independent
methods to measure LDL triglycerides in 2 different
cohorts; 3) adjustment of the association between
LDL triglycerides and ASCVD for plasma apolipo-
protein B; 4) discordance analysis by high levels of
LDL triglycerides and plasma apolipoprotein B on
the risk of ASCVD; and 5) meta-analyses summari-
zing previous and present results documenting the
JACC VOL. 81, NO. 2, 2023 Balling et al 145
JANUARY 17, 2023:136–152 LDL Triglycerides and Atherosclerotic Risk

F I G U R E 5 Continued

B NMR LDL Triglycerides

Percentiles N Total Events HR (95% CI) P for Trend

ASCVD
1st-50th 12,726 2,369 1.00 <0.001
51st-95th 12,054 3,007 1.29 (1.18-1.41)
96th-100th 1,333 390 1.60 (1.34-1.90)
Ischemic heart disease
1st-50th 13,478 1,696 1.00 <0.001
51st-95th 12,566 2,053 1.34 (1.20-1.48)
96th-100th 1,404 288 1.94 (1.59-2.36)
Myocardial infarction
1st-50th 14,368 953 1.00 <0.001
51st-95th 13,250 1,188 1.45 (1.26-1.66)
96th-100th 1,481 172 2.25 (1.74-2.91)
Ischemic stroke
1st-50th 14,266 1,008 1.00 0.047
51st-95th 13,060 1,216 1.21 (1.06-1.37)
96th-100th 1,438 125 1.02 (0.77-1.35)
Peripheral artery disease
1st-50th 14,862 401 1.00 0.022
51st-95th 13,430 430 1.16 (0.93-1.45)
96th-100th 1,474 63 1.67 (1.11-2.53)

Hemorrhagic stroke
1st-50th 14,266 262 1.00 0.46
51st-95th 13,060 244 0.84 (0.63-1.10)
96th-100th 1,438 29 1.05 (0.58-1.92)
0.5 1.0 1.5 2.0 2.5 3.0
Multivariable Adjusted HR (95% CI)

robustness of the association between elevated LDL
triglycerides and ASCVD.
Mechanistically, high concentrations of LDL tri-
glycerides occur during hypertriglyceridemia, where
cholesteryl ester transfer protein transfers cholesteryl
esters from LDL in exchange of triglycerides from
triglyceride-rich remnant lipoproteins.13,14 Normally,
lipoprotein lipase hydrolyzes triglycerides
triglyceride-rich remnant lipoproteins and converts
them to triglyceride-depleted LDL particles. Howev-
er, insufficient activity of lipoprotein lipase relative
to the amount of triglyceride-rich remnant lipopro-
teins in plasma, as seen in individuals with obesity,
untreated diabetes mellitus, chronic kidney disease,
thyroid disease, elevated inflammatory cytokines,
and/or with specific genetic variations, may lead
to elevated concentrations of LDL triglycerides
(together with elevated triglyceride-rich remnant li-
in poproteins) and subsequently to an increased risk of
ASCVD.4,13,14,31 Elevated LDL triglycerides could
therefore be a marker of elevated triglyceride-rich
remnant lipoproteins that, like LDL, are causally
146 Balling et al JACC VOL. 81, NO. 2, 2023

LDL Triglycerides and Atherosclerotic Risk JANUARY 17, 2023:136–152

F I G U R E 6 Risk of ASCVD According to LDL Triglycerides Adjusted for Apolipoprotein B

Direct LDL Triglycerides

N Total Events HR (95% CI)

ASCVD 34,425 864 1.18 (1.08-1.29)

Ischemic heart disease 35,255 537 1.16 (1.03-1.29)

Myocardial infarction 37,076 232 1.07 (0.90-1.28)

Ischemic stroke 37,151 291 1.18 (1.01-1.37)

Peripheral artery disease 37,591 208 1.33 (1.12-1.58)

Hemorrhagic stroke 37,378 74 0.97 (0.69-1.36)

0.8 1.0 1.1 1.2 1.3 1.5

NMR LDL Triglycerides

N Total Events HR (95% CI)

ASCVD 25,983 5,742 1.29 (1.19-1.39)

Ischemic heart disease 27,311 4,023 1.28 (1.17-1.40)

Myocardial infarction 28,957 2,304 1.29 (1.15-1.44)

Ischemic stroke 28,626 2,338 1.37 (1.22-1.55)

Peripheral artery disease 29,623 892 1.15 (0.93-1.41)

Hemorrhagic stroke 28,626 535 1.38 (1.04-1.84)

0.8 1.0 1.1 1.2 1.3 1.5

HR (95% CI) Per 0.1 mmol/L (0.9 mg/dL)
Higher LDL Triglycerides

Cox proportional hazard regressions adjusted for age (underlying time scale), sex, smoking, systolic blood pressure, lipid-lowering therapy, and atrial fibrillation
(for atherosclerotic cardiovascular disease [ASCVD], ischemic stroke, and hemorrhagic stroke), and apolipoprotein B, on the basis of individuals from the Copenhagen
General Population Study. Abbreviations as in Figure 1.

related to ASCVD. 7-12 In support of this idea, when associations remained strong, data on LDL tri-
further adjusting our analyses for plasma total tri- glycerides includes information beyond plasma total
glycerides, the association of elevated LDL tri- triglycerides with respect to the risk of ASCVD. In
glycerides with ASCVD and its components addition, when examining a multivariable adjusted
attenuated somewhat (compare Supplemental model of the association between plasma total
Figure 7 with Figure 4). However, given that most triglycerides and ASCVD and its components, the
JACC VOL. 81, NO. 2, 2023 Balling et al 147
JANUARY 17, 2023:136–152 LDL Triglycerides and Atherosclerotic Risk

F I G U R E 7 Discordance Between LDL Triglycerides and Apolipoprotein B on Risk of ASCVD

ASCVD

N Total Events HR (95% CI)

Direct LDL triglycerides and

23,321 470 1.00
apolipoprotein B <80th percentile

Only apolipoprotein B ≥80th percentile 3,986 99 1.36 (1.09-1.69)

Only direct LDL triglycerides ≥80th

percentile 3,891 149 1.28 (1.06, 1.54)

Direct LDL triglycerides and

3,227 146 1.80 (1.49, 2.17)
apolipoprotein B ≥80th percentile

0.9 1.0 1.1 1.2 1.5 2.0 2.5

ASCVD

N Total Events HR (95% CI)

NMR LDL triglycerides and

18,379 3,727 1.00
apolipoprotein B <80th percentile

Only apolipoprotein B ≥80th percentile 1,988 481 1.10 (1.00-1.21)

Only NMR LDL triglycerides ≥80th

percentile 1,925 483 1.18 (1.07-1.30)

NMR LDL triglycerides and

3,691 1,051 1.30 (1.21-1.39)
apolipoprotein B ≥80th percentile

0.9 1.0 1.1 1.2 1.5 2.0 2.5

HR (95% CI)

Cox proportional hazard regressions adjusted for age (underlying time scale), sex, smoking, systolic blood pressure, lipid-lowering therapy, and atrial fibrillation
(for atherosclerotic cardiovascular disease [ASCVD], ischemic stroke, and hemorrhagic stroke). Individuals were divided at the 80th percentile of apolipoprotein B and
low-density lipoprotein (LDL) triglyceride levels, on the basis of individuals from the Copenhagen General Population Study. NMR ¼ nuclear magnetic resonance.

associations were attenuated or abolished when
further adjusted for LDL triglycerides (Supplemental
Figures 10 and 11).
Alternatively, it can be speculated that elevated
LDL triglycerides may lead to low-grade chronic
inflammation in the intima, that is, when tri-
glycerides are degraded locally to tissue-toxic free
fatty acids after LDL particles enter the intima, thus
leading to atherosclerosis with vulnerable plaques
and ultimately causing ASCVD and its components of
148 Balling et al JACC VOL. 81, NO. 2, 2023

LDL Triglycerides and Atherosclerotic Risk JANUARY 17, 2023:136–152

F I G U R E 8 Meta-Analyses of Elevated Low-Density Lipoprotein Triglycerides on ASCVD and Its Components Individually

Number of Number of HR (95% CI)/ Weight (%)

Reference Year Participants Events OR (95% CI) Fixed Random

ASCVD
Ding X. 2017 1,499 153 1.67 (1.01-2.75) 3% 4%
Balling M. Direct 2022 34,508 872 1.62 (1.30-2.01) 16% 19%
Saeed A. 2018 9,334 1,785 1.31 (1.11-1.55) 28% 30%
Balling M. NMR 2022 26,113 5,766 1.56 (1.38-1.76) 53% 47%

Fixed effect estimate 1.50 (1.37-1.64)

Random effect estimate 1.50 (1.35-1.66)
I2 = 16%
Ischemic heart disease
Holmes M. 2018 2,378 912 1.73 (1.08-2.75) 3% 9%
Balling M. Direct 2022 35,412 539 1.89 (1.43-2.51) 7% 14%
März W. 2004 1,309 739 2.15 (1.74-2.65) 13% 17%
Saeed A. 2018 9,334 1,434 1.20 (1.00-1.45) 16% 19%
Balling M. NMR 2022 27,448 4,037 1.69 (1.47-1.95) 28% 20%
Tikkanen E. 2021 31,657 2,073 1.43 (1.25-1.63) 33% 21%

Fixed effect estimate 1.57 (1.46-1.69)

Random effect estimate 1.62 (1.37-1.93)

I2 = 77%

Ischemic stroke
Holmes M. 2018 2,612 1,146 0.97 (0.59-1.61) 8% 8%

Balling M. Direct 2022 37,316 295 1.20 (0.85-1.71) 16% 16%

Saeed A. 2018 9,334 483 1.57 (1.15-2.15) 20% 20%

Balling M. NMR 2022 28,764 2,349 1.29 (1.07-1.56) 56% 56%

Fixed effect estimate

1.30 (1.13-1.49)
Random effect estimate
1.30 (1.13-1.49)
I2 = 0%

Peripheral artery disease

Balling M. Direct 2022 37,758 210 1.66 (1.07-2.58) 15% 15%

Kou M. 2021 8,330 246 1.55 (1.06-2.27) 20% 20%

Tikkanen E. 2021 31,657 498 1.43 (1.05-1.93) 31% 31%

Balling M. NMR 2022 29,766 894 1.55 (1.16-2.06) 35% 35%

Fixed effect estimate

1.53 (1.29-1.81)
Random effect estimate
1.53 (1.29-1.81)
I2 = 0%

0.5 1 1.5 2 3
HR (95% CI) or OR (95% CI)

HRs or ORs are for highest vs lowest low-density lipoprotein triglyceride quartile. For individual studies, light blue box sizes are proportional to fixed-effect weights.
Red diamonds represent summary estimates, whereas diamond widths represent 95% CIs. The study by Balling et al (our study) is current; all other studies are
published.1-6 Abbreviations as in Figures 1 and 4.
JACC VOL. 81, NO. 2, 2023 Balling et al 149
JANUARY 17, 2023:136–152 LDL Triglycerides and Atherosclerotic Risk

C ENTR AL I LL U STRA T I O N Elevated Low-Density Lipoprotein Triglycerides on Risk of Atherosclerotic

Cardiovascular Disease in Cohorts and Meta-Analyses

Balling M, et al. J Am Coll Cardiol. 2023;81(2):136–152.

Percentages of increased risks of atherosclerotic cardiovascular disease are shown for its components of ischemic heart disease, ischemic stroke, and peripheral artery
disease. LDL ¼ low-density lipoprotein; NMR ¼ nuclear magnetic resonance; TG ¼ triglycerides.

ischemic heart disease, myocardial infarction, triglyceride-rich lipoproteins (here marked by

ischemic stroke, and peripheral artery disease.2,4,11,15
Future mechanistic studies should explore the exact
mechanism behind the higher risk of ASCVD and its
components in individuals with elevated
triglycerides.
Adjustment for plasma apolipoprotein B attenu-
ated the association of elevated LDL triglycerides
with the risk of particularly myocardial infarction, a
finding likely explained by the fact that elevated
apolipoprotein B is a marker of elevated LDL choles-
terol as well as LDL triglycerides (Table 2). The
opposite was observed for the risk of ischemic stroke
in the study using NMR LDL triglycerides, where the
risk increased after adjustment for apolipoprotein B,
thereby indirectly supporting the idea that elevated
elevated LDL triglycerides) are more strongly related
to the risk of ischemic stroke than is elevated LDL
cholesterol.32,33 That the risk of hemorrhagic stroke
LDL was similarly increased in the study using NMR LDL
triglycerides is more difficult to understand; howev-
er, some misclassification of ischemic stroke as
hemorrhagic stroke cannot be excluded. Finally,
discordance analysis demonstrated that the associa-
tion between elevated LDL triglycerides and the risk
of ASCVD did not depend on elevated apolipoprotein
B, whereas the highest risk was observed when both
LDL triglycerides and apolipoprotein B were high.
Although LDL triglycerides can be measured using
ultracentrifugation, chromatography, and electro-
phoresis, all of which are time-consuming manual
150 Balling et al
LDL Triglycerides and Atherosclerotic Risk
methods, 23 the automated assay developed by Denka
and NMR spectroscopy have made it feasible to
measure LDL triglycerides in high-throughput labo-
ratories and thereby to conduct the present 2 large-
scale prospective cohort studies.
In support of the results from our 2 prospective
cohort studies included in the present paper, our
meta-analyses, including an additional 6 previous
studies, 1-6 showed that individuals in the highest
quartile vs the lowest quartile of LDL triglycerides
had an increased risk of ASCVD and each of its com-
ponents individually (Figure 8). These are the first
meta-analyses on LDL triglycerides related to risk of
ASCVD and each of its components individually.
STUDY STRENGTHS. A strength of our study is that it
includes the largest studies on elevated LDL tri-
glycerides with complete information on ASCVD and
all of its components. It is also a strength that the
median triglyceride concentrations were relatively
low, at 1.4 mmol/L (120 mg/dL) and 1.5 mmol/L
(132 mg/dL), in the 2 cohorts, respectively, ensuring
that the study results are not overshadowed by severe
hypertriglyceridemia. Further, we included hemor-
rhagic stroke, typically not caused by atherosclerosis
and therefore a “negative control” compared with
ASCVD. Moreover, to our knowledge, our study is the
first prospective study on the general population to
examine ASCVD by using fresh samples to measure
direct LDL triglycerides with the Denka assay; this is
important because the use of frozen samples may
affect measurement values, as seen for other lipo-
proteins. 34,35
We corrected the HRs of NMR LDL tri-
glycerides for regression dilution bias, which as a
result of intraindividual variation and measurement
errors can lead to underestimation of risk. 36
We did
not have the data to correct for regression dilution
bias in the analyses on direct LDL triglycerides.
Finally, and most importantly, we conducted the first
meta-analyses on elevated LDL triglycerides related
to the risk of ASCVD and each of its components
individually, including 8 studies with >110,000 in-
dividuals and >15,000 events. In the meta-analyses,
we believe it is a strength that we summarized
results using different methods to measure LDL tri-
glycerides (direct, NMR spectroscopy, and ultracen-
trifugation); however, other investigators may see
this as a limitation.
STUDY LIMITATIONS. The present study, including
the meta-analyses, contains conventional observa-
tional data, and therefore we cannot draw inferences
about causality because residual confounding and
reverse causation cannot be excluded.37 Thus, future
studies should explore the possibility of testing a
JACC VOL. 81, NO. 2, 2023
JANUARY 17, 2023:136–152
potential causal relationship between elevated LDL
triglycerides and the risk of ASCVD and its compo-
nents, by using genetic variants in a mendelian
randomization design.37 Ideally, genetic variants that
are robustly associated with LDL triglycerides, but
not associated (or to a lesser extent) with LDL
cholesterol, apolipoprotein B, and plasma tri-
glycerides, should be used to assess whether the
observed association between LDL triglycerides and
ASCVD is causal. Because extensive DNA chip data are
not available in the entire Copenhagen General Pop-
ulation Study, such analyses are unfortunately not
possible to perform in the present study. A previous
genetic study showed that genetic variants associated
with decreased hepatic lipase activity were associated
with increased LDL triglycerides and the risk of car-
diovascular disease31 ; however, given that hepatic
lipase activity affects other lipids and lipoprotein
subfractions, final conclusions regarding the causal
role of LDL triglycerides could not be drawn.
In addition, our 2 cohort studies included only
White Danes and therefore may not be generalizable
to other countries and ethnicities. However, the 6
previous studies included in the meta-analyses
studied people in other countries and of other eth-
nicities, and they provided results similar to those of
the 2 Copenhagen studies. Further, we did not have
information on LDL triglycerides measured after li-
poprotein ultracentrifugation, and therefore we are
not able to compare our results directly with results
from the gold-standard of b -quantification. It is also a
limitation that we did not measure apolipoprotein C-
III in our cohorts. Finally, we did not have informa-
tion on changes in statin use over the follow-up
period, which likely may have attenuated the results
observed and in consequence is unlikely to explain
our findings.
CLINICAL USE. If the found association between
elevated LDL triglycerides and the risk of ASCVD
were to be used in clinical practice for risk assess-
ment, the measurement of direct LDL triglycerides
would be preferred over NMR LDL triglycerides.
This is because the direct assay for LDL triglycerides
can be used on most autoanalyzers already available
in clinical chemistry laboratories, thereby allowing
inexpensive and fast delivery of results through
electronic medical records, just like any other blood
test performed for routine use. Another argument in
favor of direct LDL triglycerides is that this mea-
surement is less closely correlated with other lipid
and lipoprotein fractions than NMR LDL tri-
glycerides (Table 2), thus illustrating that direct LDL
triglycerides measure a lipid biomarker largely
JACC VOL. 81, NO. 2, 2023 Balling et al 151
JANUARY 17, 2023:136–152 LDL Triglycerides and Atherosclerotic Risk

unrelated to the information derived from a stan-
dard lipid profile. Elevated LDL triglycerides could
be included as an additional marker estimating risk
of ASCVD, just like, for example, elevated plasma
triglycerides, apolipoprotein B, and high-sensitivity
38
C-reactive protein.
Novo Nordisk. Dr Kamstrup has received lecture honoraria from
Physicians’ Academy for Cardiovascular Education; and has served as
a consultant for Silence Therapeutics and Novartis. Dr Nordestgaard
has served as a consultant for Akcea, Amarin, Amgen, AstraZeneca,
Abbott, Denka, Kowa, Novartis, Novo Nordisk, Sanofi, Regeneron,
Esperion, and Silence Therapeutics. All other authors have reported
that they have no relationships relevant to the contents of this paper
to disclose.

CONCLUSIONS
ADDRESS FOR CORRESPONDENCE: Dr Børge G.

Elevated LDL triglycerides were robustly associated
with an increased risk of ASCVD and each of its
components individually in 2 prospective cohort
studies using 2 different measurement methods
and in meta-analyses of 8 previous and present
studies.
ACKNOWLEDGMENTS The authors thank the staff of
and participants in the Copenhagen General Popula-
tion Study for their contributions.
FUNDING SUPPORT AND AUTHOR DISCLOSURES
Nordestgaard, Department of Clinical Biochemistry,
Herlev and Gentofte Hospital, Copenhagen University
Hospital, Borgmester Ib Juuls vej 73, DK-2730 Herlev,
Denmark. E-mail: boerge.nordestgaard@regionh.dk.
PERSPECTIVES
COMPETENCY IN MEDICAL KNOWLEDGE: Elevated
triglyceride-rich remnant lipoproteins, including LDL triglycer-
ides, are associated with an increased risk of atherosclerosis,
myocardial infarction, stroke, and peripheral artery disease,

This study was funded by the Department of Clinical Biochemistry,

possibly resulting from degradation of triglycerides into toxic
Herlev and Gentofte Hospital, Copenhagen University Hospital; the free fatty acids after LDL particles enter the arterial intima.
Danish Heart Foundation (grant 18-R124-A8511-22089 MB); the Novo
Nordisk Foundation (grant NNF18OC0052893 MB); and the Medical TRANSLATIONAL OUTLOOK: Further research is needed to
Research Council Integrative Epidemiology Unit at the University of
validate the utility of LDL triglyceride concentrations as a marker
Bristol (grant MC_UU_00011/1 GDS). The funders did not participate in
the design or conduct of the study; in the collection, analysis, or of cardiovascular risk independent of LDL cholesterol levels
interpretation of data; and in preparation, review, or approval of the alone.
manuscript. Dr Davey Smith has served on the scientific advisory
boards of Relation Therapeutics and insitro. Dr Varbo is employed by

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KEY WORDS atherosclerosis,
cardiovascular disease, lipids, remnants,
triglyceride-rich lipoproteins, very low-
density lipoprotein
A PPE NDI X For supplemental tables and
figures and a supplemental Methods
section, please see the online version of this
paper.