Physicians' Academy for Cardiovascular Education

Non-fasting LDL-c levels have similar predictive value for mortality as fasting levels

Doran B et al. Circulation. 2014 - Circulation. 2014 Jul 11

Prognostic Value of Fasting vs. Non-Fasting Low Density Lipoprotein Cholesterol Levels on Long-term Mortality: Insight from the National Health and Nutrition Survey III (NHANES-III)

Doran B, Guo Y, Xu J et al.,
Circulation. 2014 Jul 11. pii: CIRCULATIONAHA.114.010001. [Epub ahead of print]


Current guidelines on cholesterol management recommend that lipid panel measurement should be performed after 8-12 hours of fasting [1-3], since certain lipid parameters can be variable depending on the timing and content of the last meal.
Levels of total cholesterol (TC), LDL-c and HDL-c vary little with respect to fasting time, while triglycerides may vary by up to 20-30% [4,5]. It has been suggested that non-fasting lipids may have equivalent predictive value for CV outcomes, since the non-fasting state may more accurately reflect the body’s exposure to circulating lipids [6-8]. No benefit or improved risk prediction has been demonstrated when using non-fasting as opposed to fasting triglycerides [9-12].
This study aimed to evaluate the prognostic value of fasting versus non-fasting LDL-c for prediction of all-cause mortality and CV mortality in men and women, by using the data of 16161 individuals in the National Health Examination and Nutrition Survey III (NHANES-III) database, linked to the National Death Index.

Main results

  • 10.023 (62.0%) participants were fasting (>8 hours), and 6238 (38.0%) were non-fasting at the time of phlebotomy.
  • In the unmatched cohort, there was an increased risk of all-cause mortality with increasing LDL-C tertile (HR 2nd vs 1st tertile: 1.57, 95%CI: 1.34-1.83, HR: 3rd vs. 1st: 2.00, 95%CI: 1.70-2.33).
  • The C-statistics for fasting vs. non-fasting LDL-c levels for prediction of all-cause mortality were similar (both 0.58), suggesting a similar prognostic value.
  • Results were similar when individuals with triglycerides >400 mg/dL were included, or when diabetic patients were considered separately from non-diabetics.
  • In a propensity score-matched cohort, a similarly increased risk of all-cause mortality was seen with increasing LDL-c tertile, and no difference in C-statistic was seen between the fasting and non-fasting groups.
  • CV mortality was also increased in higher LDL-c tertiles (HR 2nd vs. 1st tertile: 1.82, 95%CI: 1.38-2.39, and 3rd vs. 1st tertile: HR: 2.94, 95%CI: 2.20-3.93). C-statistics were similar in the fasting and non-fasting groups. Similar findings were seen in the propensity score-matched cohort.


This nationally representative cohort study of data of 16161 individuals, followed for 14.0 years, shows that non-fasting LDL-c have a similar prognostic value as fasting LDL-c levels, for prediction of both all-cause mortality and CV mortality.
These analyses excluded patients with triglycerides >400 mg/dL, but results did not change considerably after including these patients in a sensitivity analysis. Thus, it may not be necessary to use fasting lipid levels to risk stratify patients. The more convenient method of obtaining non-fasting LDL-c levels preserves the prognostic value of the test. These results suggest that the need for fasting LDL-c measurements should be reconsidered by guideline societies.
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1. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106:3143-3421.
2. De Backer G, Ambrosioni E, Borch-Johnsen K et al. European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force Of European and other societies on  cardiovascular disease prevention in clinical practice (constituted by representatives of eight societies and by invited experts). Arch Mal Coeur Vaiss. 2004;97:1019-1030.
3. Genest J, McPherson R, Frohlich J, et al. 2009 canadian cardiovascular society/canadian guidelines for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease in the adult–2009 recommendations. Can J Cardiol. 2009;25:567-579.
4. Sidhu D, Naugler C. Fasting time and lipid levels in a community-based population a crosssectional
Study fasting time and lipid levels. Arch Intern Med. 2012;172:1707-1710.
5. Langsted A, Nordestgaard BG. Nonfasting lipids, lipoproteins, and apolipoproteins in individuals with and without diabetes: 58 434 individuals from the Copenhagen General Population Study. Clin Chem. 2011;57:482-489.
6. Karpe F. Postprandial lipoprotein metabolism and atherosclerosis. J Intern Med. 1999;246:341-355.
7. Zilversmit DB. Atherogenesis: A postprandial phenomenon. Circulation. 1979;60:473-485.
8. Kolovou GD, Anagnostopoulou KK, Daskalopoulou SS, et al. Clinical relevance of postprandial lipaemia. Curr Med Chem. 2005;12:1931-1945.
9. Nordestgaard BG, Benn M, Schnohr P, et al. Nonfasting triglycerides and risk of myocardial infarction, ischemic heart disease, and death in men and women. JAMA. 2007;298:299-308.
10. Bansal S, Buring JE, Rifai N, et al. Fasting compared with nonfasting triglycerides and risk of cardiovascular events in women. JAMA. 2007;298:309-316.
11. Ridker PM. Fasting versus nonfasting triglycerides and the prediction of cardiovascular risk:
Do we need to revisit the oral triglyceride tolerance test? Clin Chem. 2008;54:11-13.
12. Langsted A, Freiberg J, Tybjærg Hansen A et al. Nonfasting cholesterol and triglycerides and association with risk of myocardial infarction and total mortality: The Copenhagen City Heart Study with 31 years of follow-up. J Intern Med. 2011;270:65-75.