Association of remnant cholesterol with prognosis in atherosclerotic cardiovascular disease: A systematic review and meta-analysis

Abstract

BACKGROUND

Elevated remnant cholesterol (RC) is implicated in the pathogenesis of atherosclerosis.

OBJECTIVE

To assess the prognostic role of RC in atherosclerotic cardiovascular disease.

METHODS

We systematically searched PubMed, Embase, the Cochrane Library, and Web of Science from inception to January 18, 2026, for eligible studies. The primary outcome was a composite of major adverse cardiovascular events (MACE). Pooled hazard ratios (HRs) with 95% CIs were calculated using a random-effects model.

RESULTS

Twenty-one studies involving 114,592 participants were included. Higher RC levels were significantly associated with an increased risk of MACE (HR: 1.44, P < 0.001), all-cause mortality (HR: 1.40; P < 0.001), myocardial infarction (MI) (HR: 1.35; P < 0.001), stroke (HR: 1.21; P = 0.004), cardiac death (HR: 1.41; P < 0.001), and unplanned repeat revascularization (HR: 1.56; P < 0.001). Furthermore, each 1-SD increment in RC level was associated with an elevated risk of MACE (HR: 1.22; P < 0.001), all-cause mortality (HR: 1.16; P = 0.010), MI (HR: 1.11; P < 0.001), and unplanned repeat revascularization (HR: 1.31; P = 0.007). The association between RC levels and MACE risk was potentially modified by geographic region, body mass index, current smoking status, adjustment for traditional lipid parameters, and study quality.

CONCLUSION

Elevated RC is associated with a worse prognosis in patients with established coronary artery disease. This association persisted after adjustment for traditional cardiovascular risk factors in the included studies, although residual confounding cannot be excluded. These findings suggest that RC assessment may have potential value within secondary prevention strategies for coronary artery disease.