ORIGINAL

PAPER

The Role of Plasma Triglyceride/High-Density Lipoprotein Cholesterol

Ratio to Predict New Cardiovascular Events in Essential Hypertensive
Patients
u
z, MD;1 Mehmet Ali Mendi, MD;1 C
Osman Turak, MD;1 Bars Afsar, MD;2 Frat Ozcan, MD;1 Fatih Oks
agr Yayla, MD;1
Adrian Covic, MD;3 Nathan Bertelsen, MD;4 Mehmet Kanbay, MD4
rkiyeYu
ksekIhtisas Education and Research Hospital Ankara, Ankara;1 Department of Nephrology, Konya
From the Department of Cardiology, Tu
Numune Hospital, Konya, Turkey;2 Nephrology Clinic, Dialysis and Renal Transplant Center, C.I. Parhon University Hospital, and Grigore T. Popa
University of Medicine, Iasi, Romania;3 and Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey4

Triglyceride (TG) to high-density lipoprotein cholesterol

(HDL-C) ratio (TG/HDL-C) has been suggested as a simple
method to identify unfavorable cardiovascular outcomes in
the general population. The effect of the TG/HDL-C ratio on
essential hypertensive patients is unclear. About 900 consecutive essential hypertensive patients (mean age
52.912.6 years, 54.2% male) who visited our outpatient
hypertension clinic were analyzed. Participants were divided
into quartiles based on baseline TG/HDL-C ratio and
medical records were obtained periodically for the occurrence of fatal events and composite major adverse cardiovascular events (MACEs) including transient ischemic
attack, stroke, aortic dissection, acute coronary syndrome,

and death. Participants were followed for a median of

40 months (interquartile range, 3544 months). Overall, a
higher quartile of TG/HDL-C ratio at baseline was significantly linked with higher incidence of fatal and nonfatal
cardiovascular events. Using multivariate Cox regression
analysis, plasma TG/HDL-C ratio was independently associated with increased risk of fatal events (hazard ratio [HR],
1.25; 95% confidence interval [CI], 1.131.37; P.001] and
MACEs (HR, 1.13; 95% CI, 1.061.21; P.001). Increased
plasma TG/HDL-C ratio was associated with more fatal
events and MACEs in essential hypertensive patients. J Clin
Hypertens (Greenwich). 2015:16. 2015 Wiley Periodicals,
Inc.

Despite advancements in technology, diagnosis, and

treatment, cardiovascular diseases including essential
hypertension remain the leading causes of death worldwide.1 Traditional risk factors such as increased age,
diabetes, and obesity are well-known risk factors for
adverse outcomes. However, recent evidence suggests
that nontraditional risk factors such as inflammation,
oxidative stress, insulin resistance, and endothelial
dysfunction also play a major role in adverse outcomes
associated with cardiovascular disorders.2 For better
risk stratification regarding cardiovascular outcomes, a
simple, accurate, reproducible, and easily measurable
marker is needed. Recently, a new parameter known as
triglyceride (TG) to high-density lipoprotein cholesterol
(HDL-C) ratio (TG/HDL-C) has been suggested as a
simple way to identify apparently healthy individuals
who are insulin resistant and at increased cardiometabolic risk.37 In addition, the joint occurrence
of high TG and low HDL-C in association with elevated
apolipoprotein B and small dense low-density lipoprotein (LDL) particles is strongly predictive of coronary
heart disease (CHD).8 Gaziano and colleagues9 were the
first to report in a case control study that this ratio

strongly predicts risk of myocardial infarction. Others

have linked a high TG/HDL-C ratio to coronary
atherosclerosis,10,11 impaired heart rate recovery after
exercise,12 CHD incidence,13 and CHD and cardiovascular and all-cause death.11 However, despite all these
data, the prognostic role of TG/HDL-C ratio is limited.
As a result, before using TG/HDL-C ratio as a
prognostic marker, more data are clearly needed to
support this hypothesis. For this reason we conducted
the current study with the aim of investigating whether
TG/HDL-C ratio has a prognostic impact with regard to
major adverse cardiovascular events (MACEs) in essential hypertensive patients as acknowledged in the
literature.

Address for correspondence: Osman Turak, MD, Department of

rkiye Yu
ksek Ihtisas Education and Research Hospital,
Cardiology, Tu
Kzlay sokak, 06100, Shhiye, Ankara, Turkey
E-mail: osmanturak@yahoo.com
Manuscript received: September 11, 2015; revised: November 5, 2015;
accepted: November 8, 2015
DOI: 10.1111/jch.12758

MATERIALS AND METHODS

Study Population
In this follow-up study, we included a total of 900
consecutive essential hypertensive patients who visited
our outpatient hypertension clinic between February
2008 and December 2011. Hypertension was defined as
a systolic BP (SBP) of >140 mm Hg and/or a diastolic
BP (DBP) of >90 mm Hg (mean of three measurements,
at least two visits). Patients with secondary hypertension, chronic liver disease, obvious active illness (eg,
malignancy or acute infection) at baseline, history of
cerebrovascular events, CHD, significant cardiac
arrhythmias, obstructive sleep apnea, or familial hyperlipidemias were excluded from the cohort. The study
complied with the Declaration of Helsinki, the study
The Journal of Clinical Hypertension

TG/HDL ratio and cardiovascular events | Turak et al.

protocol was approved by the Turkey Yuksek Ihtisas

Education and Research Hospital ethics committee, and
informed consent was obtained from all participants.
Patients Blood Tests and Clinical Data Collection
All blood samples were obtained from patients in the
morning after 12 hours of fasting for measurement
plasma glucose and lipids. Plasma triglyceride and highdensity lipoprotein levels were measured using a semiautomated enzymatic method with a Beckman Coulter
AU analyzer (AU 680; Beckman Coulter, Brea, CA).
Diabetes mellitus was defined according to international
guidelines. Smokers were defined as current smokers.
Body mass index was calculated as weight (kg)/height
(m2). Estimated GFR (eGFR) were calculated according
to the Chronic Kidney Disease Epidemiology Collaboration equation.
Follow-Up and Endpoints
Patients medical records were obtained periodically for
the occurrence of fatal and nonfatal cardiovascular
outcomes. All patients were followed up for time-toevent analysis until MACE occurrence, including transient ischemic attack, stroke, aortic dissection, acute
coronary syndrome, or death. MACEs were recorded by
reviewing outpatient clinic visits in the medical records
and telephone contact if such information was not
available. We also checked deaths from the national
death report system regularly.

Statistical Analysis
Statistical analyses were performed using SPSS software
version 19.0 (SPSS Inc; IBM, Armonk, NY). The
Kolmogorov-Smirnov method was used to test the
distribution of data. Analysis of variance test was used
to compare groups data displaying normal distribution
and Kruskal-Wallis test was applied to the data without
normal distribution. For correlation analysis, Spearmans correlation coefficient rho was used. Categorical
variables were compared with the chi-square test. Data
were summarized as meanstandard deviation, median
and interquartile range, or proportions. The effects of
different variables on fatal and nonfatal cardiovascular
endpoints were calculated in univariate Cox regression
analysis for each. The variables for which the unadjusted P value was <.10 in univariate analysis were
identified as potential risk markers and included in the
multivariable Cox regression model. The survival analysis for TG/HDL quartiles was performed by KaplanMeier method and statistical assessment was performed
using log-rank test. A P value <.05 was considered to be
statistically significant for all analyses.

RESULTS
A total 900 consecutive essential hypertensive patients
(mean age 52.912.6 years, 54.2% male) who visited
our outpatient hypertension clinic were included in our
study. Demographic characteristics including age, sex,
body mass index, presence of diabetes, use of antihy-

TABLE I. Baseline Characteristics of Patients According to Quartiles of Triglyceride/HDL Ratio

Triglyceride/HDL Ratio Quartiles
Variables
Age, y

Q1 (n=225)

Q2 (n=224)

Q3 (n=227)

Q4 (n=224)

P for Trend

58.012.6

57.712.6

58.513.6

57.411.7

.813

95 (42)
44 (20)

128 (57)
53 (24)

126 (56)
51 (23)

139 (62)
53 (24)

<.001
.692

Diabetes mellitus, No. (%)

Body mass index, kg/m2

28 (12)
27.11.5

30 (13)
26.91.6

47 (21)
27.01.5

47 (21)
26.81.5

.017
.122

Fasting glucose, mg/dL

eGFR, mL/min/1.73 m2

98 (90110)
102 (84131)

97 (89111)
100 (83119)

100 (91121)
97 (77118)

102 (93118)
94 (75114)

.001
.011

Hemoglobin, g/L
WBC count, 9109/L

14.21.4
7 (6.18)

14.31.4
6.7 (68)

14.51.4
7.1 (68.4)

14.71.4
7.6 (6.69)

.002
<.001

Male, No. (%)

Current smoker, No. (%)

HDL, mg/dL
LDL, mg/dL
Triglycerides, mg/dL

58.911.5

46.47.6

41.08.3

35.77.5

<.001

126.726.3
100.031.1

125.830.2
123.919.7

124.926.1
155.034.1

125.631.5
246.945.6

.944
<.001

Office SBP, mm Hg
Office DBP, mm Hg

155 (146174)
99 (91113)

Use of antihypertensive drugs, No. (%)

Use of antihyperlipidemic drugs, No. (%)

102 (45)

79 (35)

86 (38)

99 (44)

.952

Statins
Fibrats

83 (37)
2 (1)

84 (38)
12 (5)

96 (42)
27 (12)

103 (46)
56 (25)

.029
<.001

Others
Total

0
85 (38)

0
96 (43)

0
121 (53)

0
148 (66)

<.001

38.57.1

38.97.5

38.57.5

38.27.4

.782

Follow up time, mo

160 (149172)
101 (91115)

160 (150175)
101 (91115)

159 (149173)
98 (90114)

.303
.747

Abbreviations: DBP, diastolic blood pressure; eGFR, estimated glomerular filtration rate; HDL, high-density lipoprotein; LDL, low-density lipoprotein;
SBP, systolic blood pressure; WBC, white blood cell.

The Journal of Clinical Hypertension

TG/HDL ratio and cardiovascular events | Turak et al.

pertensive medication, follow-up time, and laboratory

parameters are given in Table I.
Patients with the highest TG/HDL-C were mostly
male and diabetic and had higher fasting blood glucose
and lower eGFR. TG/HDL-C ratio was correlated both
with eGFR (Spearmans rank correlation coefficient:
0.118; P<.001) and diabetes (Spearmans rank correlation coefficient, 0.099; P=.003).
Table II shows fatal and nonfatal cardiovascular
events according to TG/HDL-C during follow-up. As
seen in Table II, total mortality and MACEs are highest
in the highest TG/HDL-C quartile. Table III shows that
age, smoking, diabetes, eGFR, and TG/HDL-C were
independent predictors of mortality. Table IV shows
that age, smoking, diabetes, eGFR, and TG/HDL-C
were independent predictors of fatal and nonfatal
events. Lastly, the mortality and MACE curves according to TG/HDL-C quartiles are shown in the Figure.

TG/HDL ratio is a simple and reproducible parameter

that can easily be calculated during daily practice, and
this study adds to recent evidence suggesting that this
parameter has important prognostic value. TG/HDL
ratio is closely associated with insulin resistance.2,14
Apart from this, TG/HDL ratio has been shown to be a
powerful predictor of total mortality, incident CHD,
and cardiovascular death independent of important
prognostic variables including age, race, smoking,
hypertension, diabetes, and severity of coronary artery
disease.8,1113 This prognostic impact of TG/HDL has
also been valid in patients with diabetes.1517 Despite
these data, information on the role of TG/HDL in
hypertensive patients is scarce. A study by Onat and
colleagues18 demonstrated that atherogenic index of
plasma as determined by log10 triglyceride/highdensity lipoprotein cholesterol predicted diabetes and
high blood pressure after adjustments for covariates. In
a recent investigation, Salazar and colleagues19 investigated the prognostic impact of TG/HDL ratio with
regard to cardiovascular disease in hypertensive
patients. The study included 947 patients divided into
normotensive (n=574) and hypertensive (n=373)
groups.19 In this study, the authors demonstrated two
novel issues. First, they showed that prevalence of a

DISCUSSION
In the current study, we investigated the prognostic
impact of TG/HDL-C with respect to mortality and
MACEs prospectively. As a result, we showed that high
TG/HDL-C ratio was independently associated with
both mortality and MACEs.

TABLE II. Fatal and Nonfatal Cardiovascular Events During Follow-Up

Triglyceride/HDL Ratio Quartiles (%)
Q1 (n=225)

Q2 (n=224)

Q3 (n=227)

Q4 (n=224)

P Value

Transient ischemic attack

Stroke

3 (1)
3 (1)

2 (1)
5 (2)

2 (1)
6 (3)

2 (1)
4 (2)

1.00
.670

Acute coronary syndrome

Aortic dissection

6 (3)
1

9 (4)
4 (2)

14 (6)
0

19 (9)
2 (1)

.003
.865

3 (1)
15 (7)

9 (4)
24 (11)

13 (6)
30 (13)

21 (9)
39 (17)

Variables
Nonfatal cardiovascular events

Mortality
Total major cardiovascular events

<.001
<.001

Abbreviation: HDL, high-density lipoprotein. Bold values indicate significance.

TABLE III. Predictors of Mortality in Univariable and Multivariable Cox Regression Analyses
Univariable
Variables

Multivariable

HR (95% CI)

P Value

HR (95% CI)

Age, y

1.08 (1.051.10)

<.001

1.07 (1.041.10)

Male sex
Smoking

1.06 (0.591.90)
1.14 (1.031.26)

.832
.023

1.21 (0.612.42)

Diabetes mellitus
Use of antihyperlipidemic drug

6.14 (3.4410.96)
1.54 (1.241.87)

<.001
.001

3.33 (1.676.65)
0.61 (0.241.49)

eGFR, mL/min/1.73 m2

0.97 (0.960.98)

<.001

0.98 (0.970.99)

Hemoglobin, g/L
WBC count, 9109/L

0.88 (0.721.07)
1.08 (0.931.26)

.198
.289

LDL level
TG/HDL ratio

1.01 (1.001.02)
1.23 (1.131.34)

.043
<.001

P Value

1.01 (0.991.02)
1.25 (1.131.37)

<.001

.584
<.001
.283
.033

.091
<.001

Abbreviations: CI, confidence interval; eGFR, estimated glomerular filtration rate; HDL; high-density lipoprotein; HR, hazard ratio; LDL, low-density
lipoprotein; TG; triglyceride; WBC, white blood cell. Bold values indicate significance.

The Journal of Clinical Hypertension

TG/HDL ratio and cardiovascular events | Turak et al.

TABLE IV. Predictors of Fatal and Nonfatal Events in Univariable and Multivariable Cox Regression Analyses
Univariable

Multivariable

HR (95% CI)

P Value

HR (95% CI)

Age, y

1.06 (1.051.08)

<.001

1.05 (1.031.07)

Male sex
Smoking

1.03 (0.541.14)
1.55 (1.032.35)

.207
.036

1.66 (1.092.53)

Diabetes mellitus
Use of antihyperlipidemic drugs

4.18 (2.856.13)
1.62 (1.242.03)

<.001
<.001

2.80 (1.724.48)
1.08 (0.651.79)

eGFR, mL/min/1.73 m2
Hemoglobin, g/L

0.97 (0.960.98)
0.98 (0.911.08)

<.001
.574

0.99 (0.980.99)

WBC count, 9109/L

LDL level

1.10 (0.991.21)
1.01 (1.001.01)

.068
.025

1.00 (1.001.01)

TG/HDL ratio

1.15 (1.081.22)

<.001

1.13 (1.061.21)

Variables

P Value
<.001

.019
<.001
.762
.004

.040
<.001

Abbreviations: CI, confidence interval; eGFR, estimated glomerular filtration rate; HDL; high-density lipoprotein; HR, hazard ratio; LDL, low-density
lipoprotein; TG; triglyceride; WBC, white blood cell. Bold values indicate significance.

FIGURE. Kaplan-Meier survival curves of fatal and composite major adverse cardiovascular events in patients with essential hypertension
stratified by quartiles of triglyceride/high-density lipoprotein (HDL) cholesterol ratio.

high TG/HDL-C ratio was greater in those with

hypertension (38% vs 24%, P=.001) as compared with
the normotensive group. Second, CVD risk factors at
baseline were significantly worse in the high TG/HDL-C
group as compared with those in the low TG/HDL-C
group irrespective of BP status. Third, crude incidence
of combined CVD events increased across all four risk
groups: 1.9 in the normotensivelow TG/HDL-C ratio
group, 6.0 in the normotensivehigh TG/HDL-C ratio
group, 15.6 in the hypertensivelow TG/HDL-C ratio
group, and 19.9 in the hypertensivehigh TG/HDL-C
ratio group (P for trend <.001). The authors suggested
that TG/HDL-C can identify hypertensive patients who
develop CVD to a significant degree.19
As complimentary findings, we extend this present
study that clearly demonstrates the prognostic impact
of TG/HDL in essential hypertension. Why TG/HDL
4

The Journal of Clinical Hypertension

is associated with adverse outcomes? Currently

we dont know the answer, but speculations can be
made.
The major explanation is insulin resistance. Indeed,
various studies have shown that the TG/HDL ratio
might be a useful surrogate estimate of insulin
action.19,20 This relationship has been validated in
several chronic metabolic disorders such as diabetes
mellitus and hypertension.16,18,21 Insulin resistance
significantly contributes to accelerated atherosclerosis
and development of CVD as a cardiovascular risk
factor.22,23 Thus, TG/HDL and adverse outcomes may
be explained in the context of insulin resistance.
Unfortunately, we did not measure insulin resistance
in the current study.
A second explanation may be oxidative stress. In
contrast to larger LDL particles, small and dense LDL

TG/HDL ratio and cardiovascular events | Turak et al.

particles are more prone to oxidative damage. These

particles are avidly taken by arterial tissue and thus cause
oxidative damage.2426 The elevated TG/HDL-C ratio
reflects the presence of remnant lipoproteins and low
dense lipoprotein levels and increased atherogenic potential.2,4,27,28 Inflammation and body composition analysis
may be other explanations. Karelis and colleagues29
studied the relevance of elevated TG/HDL-C ratio in
postmenopausal women. Apart from insulin sensitivity
and insulin resistance they found that this ratio is closely
correlated with C-reactive protein levels and visceral fat.
Both inflammation30 and high levels of visceral fat have
been associated with metabolic disturbances including
insulin resistance, dyslipidemia, and hypertension.31,32
In addition, TGL/HDL ratio positively correlates with
adiposity, and the magnitude of weight loss is proportional with the decrease of TGL/HDL ratio.33,34 All these
mechanisms may link the relationship between high TG/
HDL-C ratios with worse outcomes.

STUDY LIMITATIONS
This study may have several potential limitations. First,
although the TG/HDL-C ratio is a well-established
correlate of insulin sensitivity, we did not measure
insulin sensitivity or insulin resistance in these patients.
Second, we did not measure visceral fat or inflammatory status. However, all patients with chronic conditions were excluded from the study. Third, these results
are from a single center and the applicability of our
findings to other geographical areas is limited. Lastly,
the follow-up time was relatively short and more
extended periods will be of value. In addition, TGL/
HDL ratio positively correlates with adiposity, and the
magnitude of weight loss is proportional with the
decrease of TGL/HDL ratio.

CONCLUSIONS
We have demonstrated that high TG/HDL-C ratio was
associated with MACEs and total mortality in essential
hypertensive patients. Further studies are needed to
identify underlying mechanisms.
Acknowledgments and disclosures: The authors have no conflicts of interest
to disclose. All authors approved the final version of the manuscript. No
financial support was provided.

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