Decrease in low-density lipoprotein cholesterol is associated with an increased risk of mortality in patients with diabetes mellitus.

Introduction: Research on the effect of low-density lipoprotein (LDL)-cholesterol levels and its serial change on all-cause mortality is limited. This study investigated serial change in LDL-cholesterol and its association with all-cause mortality or sudden cardiac arrest (SCA) in patients with diabetes mellitus.

Methods: Data was obtained from the nationwide health insurance database of South Korea. Patients with diabetes mellitus who underwent health screening between 2009 and 2012 and those with 4-year follow-up health screening data were included. Patients were further stratified by statin use and change in LDL-cholesterol levels during this 4-year interval. The primary and secondary outcomes were all-cause mortality and SCA, respectively. Outcomes were followed up from the day of health screening till December 2018. Kaplan-Meier analysis and the Cox-proportional hazards model were used to evaluate associations between LDL-cholesterol changes, all-cause mortality, and SCA.

Results And Discussion: A total of 1,329,982 patients were included, including 532,260 patients who did not receive statin therapy (non-statin users). Compared to statin users, non-statin users had a higher incidence of all-cause mortality (incidence rate 13.9-16.4 per 1,000 person-years) and SCA (1.6-1.9). Among non-statin users, patients with decreased LDL-cholesterol had the highest risk of all-cause mortality (adjusted hazard ratio 1.26, 95% confidence interval 1.21-1.31,  < 0.001) and SCA (1.21, 1.10-1.34,  < 0.001). Thus, in patients with diabetes mellitus not receiving statin therapy, a decrease in LDL-cholesterol may be a surrogate marker for all-cause mortality and SCA.