Elevated Remnant Cholesterol Improves the Prognosis of Patients With Ischemic Stroke and Malnutrition: A Cohort-Based Study.

Background: The mechanism of the lipid paradox remains uncertain, and malnutrition may be 1 explanation. In this prospective cohort study, we explored the associations between baseline remnant cholesterol (RC) concentrations and clinical outcomes in patients with ischemic stroke, stratified by nutritional status.

Methods: Patients with ischemic stroke in a single-center prospective cohort (Shanghai, China) from January 2018 to December 2022 were studied. Individuals were classified into 3 groups based on their Controlling Nutritional Status score. Poor outcome and all-cause mortality during up to 3 months of follow-up were compared among patients with varied nutritional status and RC levels utilizing multivariate logistic regression analyses, RC splines, and subgroup analyses.

Results: A total of 6892 patients with ischemic stroke were enrolled in the cohort, of which 5257 patients were included in the present study (without malnutrition: 2418 [46.0%]; mild malnutrition: 2516 [47.9%]; moderate-severe malnutrition: 323 [6.1%]). The median age was 69±12 years, and 3398 (64.6%) were male. Patients with moderate-severe malnutrition had the highest risks of poor outcome (198 [61.3%]; P<0.001) and all-cause mortality (106 [32.8%]; P<0.001) during the 3-month follow-up. A higher baseline RC level was an independent protective factor for adverse outcomes in patients with any degree of malnutrition (P<0.05), which was not observed in patients without malnutrition. In addition, compared with the moderate-severely malnourished with RC <0.471 mmol/L, the adjusted odds ratios for poor outcome and all-cause mortality were 0.805 (95% CI, 0.450-1.438) and 0.898 (0.502-1.607) for participants with 0.471 to 0.632 mmol/L, 0.259 (0.095-0.704) and 0.222 (0.061-0.810) for 0.633 to 0.868 mmol/L, and 0.160 (0.037-0.689) and 0.202 (0.042-0.967) for ≥0.869 mmol/L, respectively.

Conclusions: The lipid paradox was only observed in the malnourished patients with ischemic stroke. Strict lipid reduction therapy is still recommended for patients without malnutrition. However, when treating patients at any risk of malnutrition, the improvement of nutritional status may be more crucial.