Triglyceride to HDL Ratio May Be Best Lipid Marker for Predicting Death in Type 2 Diabetes

blood test tube on the results
Patients with type 2 diabetes still have a high risk for cardiovascular disease—even after lowering LDL cholesterol.

Higher triglyceride and triglyceride to high-density lipoprotein (HDL) cholesterol ratio and lower HDL cholesterol were independently associated with all-cause mortality in people with type 2 diabetes, according to research published in Cardiovascular Diabetology. Research results also indicate a modifying effect of gender on triglycerides and HDL cholesterol.

“There was a stronger impact on mortality of triglycerides in [men] and HDL cholesterol in [women], suggesting that [the triglyceride to HDL ratio] may be the best lipid marker for predicting death from any cause in these individuals,” the researchers concluded.

In an observational, prospective, cohort study, Italian researchers set out to examine the independent association between abnormal lipid profile characteristic of atherogenic dyslipidemia and death from any cause, as well as the possible modifying effect of gender, in a large cohort of people with type 2 diabetes.

The total study population included 15,773 patients from the RIACE (Renal Insufficiency and Cardiovascular Events) study ( identifier NCT00715481). Baseline data for age, smoking status, diabetes duration, comorbidities, and current glucose, lipid, and blood pressure lowering treatments, as well as body mass index and numerous laboratory values, were collected.

The final study group included 15,656 patients who were stratified into quartiles based on triglyceride levels, HDL cholesterol levels, and triglyceride to HDL ratio. Patients in the highest quartile (quartile 4) of either triglyceride levels or triglyceride to HDL ratio and in the lowest quartile (quartile 1) of HDL cholesterol were younger, less likely to be smokers, and had a shorter diabetes duration but a worse cardiovascular disease risk profile.

Among triglyceride quartiles, crude mortality rates were similar. When adjustments were made for age and gender, mortality rates increased significantly in quartiles 3 and 4 compared with quartile 1.

Crude age- and gender-adjusted mortality rates were also higher for quartile 1 of HDL cholesterol compared with quartile 4; adjusted rates were only higher for quartile 2 vs quartile 4. Both Kaplan-Meier estimates and unadjusted and adjusted hazard ratios (HRs) were higher for quartile 1 compared with quartile 4, except after further adjustments were made for triglycerides (HR, 0.968; 95% CI, 0.786-1.191; P =.756).

Investigators found that gender interaction was significant for HDL cholesterol, but not for triglycerides and triglyceride to HDL ratio. When stratified by quartiles for each variable, clinical features of men and women did not differ considerably compared with the whole cohort.

Study limitations include the lack of available information on patient’s causes of death, which did not allow investigators to detect differences in the relationship of cardiovascular disease as compared to non-cardiovascular disease deaths with lipid levels, a lack of information on possible confounders, and no information on lipid profiles or lipid lowering treatments over time.

Disclosure: This clinical trial was supported by Eli Lillly, Sigma-Tau, Takeda, Chiesi Farmaceutici, and Boehringer-Ingelheim. Please see the original reference for a full list of authors’ disclosures.


Orsi E, Penno G, Solini A, et al; the Renal Insufficiency and Cardiovascular Events (RIACE) Study Group. Independent association of atherogenic dyslipidaemia with all-cause mortality in individuals with type 2 diabetes and modifying effect of gender: A prospective cohort study. Cardiovasc Diabetol. 2021;20(1):28.