LDL Cholesterol and Subclinical Coronary Atherosclerosis in Asymptomatic Adults

Coronary atherosclerosis showed substantial variation across LDL cholesterol levels.

Among participants with LDL cholesterol ≥190 mg/dL, 40% had no coronary plaque. At the other end of the spectrum, 33% of those with LDL cholesterol <70 mg/dL had coronary plaque. Non-calcified plaque was present in 22.4% of this lower-LDL group.

However, coronary plaque generally became more common as LDL cholesterol increased.

This relationship was also seen in people with no detectable coronary calcium. In this group, coronary plaque increased from 13.2% at LDL cholesterol <70 mg/dL to 28.2% at LDL cholesterol ≥190 mg/dL.

Non-calcified plaque increased from 13.2% to 25.6% across the same LDL categories.

Important findings were also seen among participants classified as having low cardiovascular risk.

Although 76.7% had no detectable coronary calcium, 31.5% had coronary plaque and 18.3% had non-calcified plaque.

Within this low-risk group, coronary plaque increased from 17.9% to 45.2% across increasing LDL cholesterol categories. Non-calcified plaque increased from 12.8% to 23.8%.

LDL cholesterol is an important factor in the development of atherosclerosis. However, a cholesterol measurement does not directly show whether coronary atherosclerosis is already present or how extensive it is.

This study demonstrates considerable variation between individuals.

Some people with very high LDL cholesterol had no detectable coronary plaque. At the same time, coronary atherosclerosis was present in some people with low LDL cholesterol.

The findings also show why cardiovascular risk cannot always be understood from a single measurement.

LDL cholesterol, estimated cardiovascular risk and imaging evidence of coronary atherosclerosis provide different but complementary information. Together, they can contribute to a more individualized approach to long-term cardiovascular prevention.

The study should not be interpreted as evidence that elevated LDL cholesterol is unimportant when coronary plaque is absent.

Instead, it demonstrates that LDL cholesterol alone does not determine the amount or characteristics of coronary atherosclerosis already present in an individual.

The findings are particularly relevant when standard risk assessment leaves uncertainty. A low estimated cardiovascular risk or the absence of detectable coronary calcium did not completely exclude coronary plaque.

In selected patients with cardiovascular risk factors or symptoms that raise clinical suspicion, coronary CT angiography can provide important information beyond calculated risk, LDL cholesterol and coronary calcium.

CCTA can directly identify coronary plaque, including non-calcified plaque. It can also assess the presence and severity of coronary artery narrowing.

These findings can change clinical management. They may identify patients who need more intensive preventive treatment. In selected cases, they may also indicate the need for further functional assessment or invasive coronary angiography and evaluation for coronary intervention.

The aim is not routine CCTA screening of asymptomatic adults, but earlier recognition of clinically important coronary disease in appropriately selected patients.

The study itself was cross-sectional. It cannot determine how coronary atherosclerosis will progress over time or demonstrate that CCTA screening improves cardiovascular outcomes. The authors conclude that the role of CCTA for further risk stratification in asymptomatic adults requires additional study.