Long-term cardiovascular risk and mortality associated with uric acid to HDL-C ratio: a 20-year cohort study in adults over 40

Cardiovascular diseases (CVD) and mortality remain significant public health challenges, especially among middle-aged and older adults. However, their relationship with Uric Acid to High-Density Lipoprotein Cholesterol Ratio (UHR) has not been extensively studied in the US population. This study aimed to examine these associations in adults aged ≥ 40 based on the National Health and Nutrition Examination Survey (NHANES) 1999-2018. 29,742 participants' data in NHANES between 1999 and 2018 were retrospectively analyzed. Multivariable logistic regression, Cox proportional hazards models, restricted cubic spline (RCS) analyses, and subgroup analyses were used to assess the associations between UHR and various CVD outcomes. Among the participants, 4,505 (15.15%) reported a history of CVD. A positive association was observed between UHR and the risk of total CVD, including coronary heart disease, heart attack, heart failure, angina pectoris, and stroke (P _all < 0.05). UHR was associated with increased risks of all-cause mortality (HR = 1.02, 95% CI: 1.02-1.03) and CVD-specific mortality (HR = 1.03, 95% CI: 1.02-1.05). UHR had a linear dose-response relationship with CVD and a nonlinear relationship with all-cause mortality by RCS analyses. Subgroup analyses confirmed that these associations remained stable across different groups. The findings highlight UHR as a significant predictor of CVD risk and mortality in middle- and older-age adults. Given its strong association with adverse health outcomes, UHR can be a valuable indicator in facilitating the early identification of individuals at elevated cardiovascular risk.