Cholesterol variability and the risk of mortality, myocardial infarction, and stroke: a nationwide population-based study

Eur Heart J. 2017 Dec 21;38(48):3560-3566. doi: 10.1093/eurheartj/ehx585.


Aims: A high visit-to-visit variability in cholesterol levels has been suggested to be an independent predictor of major adverse cardiovascular events in patients with coronary artery disease (CAD). Because whether this notion applies to general population is not known, we aimed to investigate the associations between total cholesterol (TC) variability and the risk of all-cause mortality, myocardial infarction (MI), and stroke.

Methods and results: We identified 3 656 648 subjects without a history of MI and stroke who underwent ≥3 health examinations from 2002 to 2007 in the Korean National Health Insurance System cohort. Total cholesterol variability was measured using the coefficient of variation (CV), standard deviation (SD), and variability independent of the mean (VIM). There were 84 625 deaths (2.3%), 40 991 cases of MI (1.1%), and 42 861 cases of stroke (1.2%) during the median follow-up of 8.3 years. There was a linear association between higher TC variability and outcome measures. In the multivariable adjusted model, the hazard ratios and 95% confidence intervals comparing the highest vs. lowest quartiles of CV of TC were 1.26 (1.24-1.28) for all-cause mortality, 1.08 (1.05-1.11) for MI, and 1.11 (1.08-1.14) for stroke, which was independent of mean TC levels and the use of lipid-lowering agents. The results were consistent when modelling variability of TC using SD and VIM, and in various sensitivity analyses.

Conclusion: High variability in lipid levels is associated with adverse health-related outcomes. These findings suggest that lipid variability is an important risk factor in the general population.

Keywords: Cholesterol; Mortality; Myocardial infarction; Stroke; Variability.

Publication types

  • Multicenter Study

MeSH terms

  • Adult
  • Biomarkers / blood
  • Cause of Death / trends
  • Cholesterol / blood*
  • Female
  • Humans
  • Hypercholesterolemia / blood
  • Hypercholesterolemia / complications*
  • Hypercholesterolemia / epidemiology
  • Incidence
  • Male
  • Middle Aged
  • Myocardial Infarction / epidemiology*
  • Myocardial Infarction / etiology
  • Republic of Korea / epidemiology
  • Risk Assessment*
  • Risk Factors
  • Stroke / epidemiology*
  • Stroke / etiology
  • Survival Rate / trends


  • Biomarkers
  • Cholesterol