Uric acid-to-HDL-cholesterol ratio and risk of cardiovascular disease: a prospective cohort analysis of the Chinese middle-aged and older population

Uric acid-to-high-density lipoprotein cholesterol ratio (UHR) is an emerging biomarker reflecting the interplay between uric acid and HDL cholesterol. This study aimed to investigate the association between UHR and incident cardiovascular disease (CVD) risk in a community-based cohort of Chinese middle-aged and older adults using data from the China Health and Retirement Longitudinal Study (CHARLS). We included 7768 participants aged ≥ 45 years from the 2011 CHARLS baseline survey. UHR was calculated as serum uric acid (mg/dL) divided by HDL-C (mg/dL), multiplied by 100 and categorized into quartiles. The primary outcome was incident CVD, comprising self-reported physician diagnoses of myocardial infarction, stroke, or heart failure. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), with adjustment for age, sex, education, marital status, residence, body mass index, smoking, drinking, estimated glomerular filtration rate, hypertension, diabetes, and dyslipidemia. Subgroup and sensitivity analyses were performed. During a mean follow-up of 7.75 years, 1681 incident CVD events were documented. In the unadjusted model, the highest UHR quartile (Q4) was associated with an elevated CVD risk compared with the lowest quartile (Q1) (HR = 1.149, 95% CI: 1.004–1.315, P = 0.043). However, after full multivariable adjustment, this association was fully attenuated (Q4 vs. Q1: HR = 0.896, 95% CI: 0.770–1.042, P = 0.153). Continuous UHR (per SD) was not significantly associated with CVD risk (HR = 0.972, 95% CI: 0.920–1.027, P = 0.307). Penalized smoothing spline analysis showed no evidence of departure from linearity (P for nonlinearity = 0.178). Subgroup and sensitivity analyses were largely null overall; however, several subgroup and sensitivity estimates reached nominal significance ( P < 0.05) without correction for multiple testing. Among participants in this community-based cohort of Chinese adults, UHR was not independently associated with incident CVD after multivariable adjustment. These findings do not support an independent association with incident CVD beyond established risk factors in the analytic sample.