The prevalence and correlates of subclinical atherosclerosis among adults with low-density lipoprotein cholesterol <70 mg/dL: The Multi-Ethnic Study of Atherosclerosis (MESA) and Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

Atherosclerosis. 2018 Jul;274:61-66. doi: 10.1016/j.atherosclerosis.2018.04.021. Epub 2018 Apr 28.


Background and aims: The prevalence and correlates of subclinical atherosclerosis when low-density lipoprotein cholesterol (LDL-C) levels are low remain unclear. Therefore, we examined the association of cardiovascular risk factors and subclinical atherosclerosis among individuals with untreated LDL-C <70 mg/dL.

Methods: We included participants from the Multi-Ethnic Study of Atherosclerosis (MESA) and the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) cohorts. To optimize accuracy, LDL-C was calculated by the validated Martin/Hopkins equation that uses an adjustable factor for the ratio of triglycerides to very low-density lipoprotein cholesterol. We defined subclinical atherosclerosis as a coronary artery calcium (CAC) score >0 in the combined cohort or common carotid intima media thickness (cIMT) in the 4th quartile, using cohort-specific cIMT distributions at baseline. Logistic regression models examined the cross-sectional associations of cardiovascular risk factors and subclinical atherosclerosis.

Results: Among 9411 participants not on lipid lowering therapy, 263 (3%) had LDL-C <70 mg/dL (MESA: 206, ELSA: 57). Mean age in this population was 58 (SD 12) years, with 43% men, and 41% Black. The prevalence of CAC >0 in those with untreated LDL-C<70 mg/dL was 30%, and 18% were in 4th quartile of cIMT. In demographically adjusted models, only ever smoking was significantly associated with both CAC and cIMT. Similar results were obtained in risk factor-adjusted models (smoking: OR, 2.29; 95% CI, 1.10-4.80 and OR, 3.44; 95% CI, 1.41-8.37 for CAC and cIMT, respectively).

Conclusions: Among middle-aged to older individuals with untreated LDL-C <70 mg/dL, subclinical atherosclerosis remains moderately common and is associated with cigarette smoking.

Publication types

  • Multicenter Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Age Factors
  • Aged
  • Aged, 80 and over
  • Asymptomatic Diseases
  • Atherosclerosis / blood*
  • Atherosclerosis / diagnostic imaging
  • Atherosclerosis / ethnology
  • Biomarkers / blood
  • Brazil / epidemiology
  • Carotid Artery Diseases / blood*
  • Carotid Artery Diseases / diagnostic imaging
  • Carotid Artery Diseases / ethnology
  • Carotid Intima-Media Thickness
  • Cholesterol, LDL / blood*
  • Computed Tomography Angiography
  • Coronary Angiography / methods
  • Coronary Artery Disease / blood*
  • Coronary Artery Disease / diagnostic imaging
  • Coronary Artery Disease / ethnology
  • Cross-Sectional Studies
  • Dyslipidemias / blood*
  • Dyslipidemias / diagnosis
  • Dyslipidemias / ethnology
  • Female
  • Humans
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Prevalence
  • Risk Assessment
  • Risk Factors
  • Smoking / adverse effects
  • Smoking / ethnology
  • Time Factors
  • United States / epidemiology
  • Vascular Calcification / blood*
  • Vascular Calcification / diagnostic imaging
  • Vascular Calcification / ethnology


  • Biomarkers
  • Cholesterol, LDL