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 Table of Contents  
Year : 2022  |  Volume : 17  |  Issue : 4  |  Page : 931-938

Small dense low-density lipoprotein or low-density lipoprotein for cardiovascular disease in Indians: Meta-analysis addressing the diagnostic dilemma

Department of Public Health, Indian Institute of Public Health, Gandhinagar, Gujarat, India

Date of Submission30-Jan-2022
Date of Acceptance11-Apr-2022
Date of Web Publication10-Feb-2023

Correspondence Address:
Dr. Komal Shah
Indian Institute of Public Health, Gandhinagar, Opp. Air Force Head Quarters, Nr. Lekawada Bus Stop, Gandhinagar-Chiloda Road, Gandhinagar - 382 042, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_42_22

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Background: We aimed to assess the association of small dense low-density lipoprotein (sdLDL) – a novel lipid marker for cardiovascular disease (CVD) risk estimation in Indians with the meta-analysis approach. Methods: Various databases, namely PubMed, MEDLINE, and EMBASE, were used to identify the prospective studies showing an association between CVD risk and lipid profile in the Indian population. Heterogeneity was assessed using Q and I2 statistics, and data were expressed using the standardized mean difference (SMD) with 95% confidence interval (CI). Results: After database search, six eligible studies assessing levels of sdLDL and LDL in Indian patients with premature CVD were identified. Level of sdLDL was found to have positive relation with CVD risk in Indians (SMD = 1.352, 95% CI: 0.744–1.96 mg/dL, I2 94.04%, P < 0.001) along with LDL (SMD = 0.680, 95% CI: 0.180–1.180 mg/dL) levels. However, the degree of association was greater with sdLDL. Conclusions: The current meta-analysis clearly identifies sdLDL as the better marker of premature CVD in Indians, especially in case of normal values of classical markers such as LDL.

Keywords: Cardiovascular disease, Indians, meta-analysis, small dense low-density lipoprotein

How to cite this article:
Shah K, Varna V P, Thomas NE. Small dense low-density lipoprotein or low-density lipoprotein for cardiovascular disease in Indians: Meta-analysis addressing the diagnostic dilemma. J Datta Meghe Inst Med Sci Univ 2022;17:931-8

How to cite this URL:
Shah K, Varna V P, Thomas NE. Small dense low-density lipoprotein or low-density lipoprotein for cardiovascular disease in Indians: Meta-analysis addressing the diagnostic dilemma. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2023 Apr 1];17:931-8. Available from: http://www.journaldmims.com/text.asp?2022/17/4/931/369503

  Introduction Top

The process of epidemiological and demographic transition is happening at a remarkable pace all over the world. The changes in population size and distribution, the improvement in health care, and the transition of disease patterns from communicable to noncommunicable diseases have led to low mortality, high morbidity and a dual burden of disease in India. Noncommunicable diseases are the major cause of deaths, accounting for 68% (38 million) of all the deaths globally. Every year nearly 5.8 million (60%) people die from noncommunicable diseases, with cardiovascular diseases (CVD) being the leading cause of death in India.[1] CVDs contributed to 28·1% of total deaths and 14·1% of total disability-adjusted life years in Indians in 2016 compared with 15·2% and 6·9%, respectively, in 1990.[2]

“Atherogenic dyslipidemia” a condition characterized by a combination of hypertriglyceridemia, high levels of low-density lipoprotein (LDL), and low levels of high-density lipoprotein (HDL) cholesterol is typical of Asian Indians.[3] This condition is often associated with the interaction between environmental, lifestyle, dietary factors, and socioeconomic factors.[4],[5],[6] After more than 30 years of research, a causal relationship between LDL cholesterol levels and CVD outcomes was established.[7] However, substantial number of studies report the lack of association between LDL and risk of CVD in Indians.

LDLs are a group of lipoproteins consisting of discrete subsets possessing numerous atherogenic properties. LDL has three subclasses, namely large buoyant LDL, intermediate-density LDL, and small density LDL (sdLDL). Individuals with the lipoprotein Type A phenotype are characterized by the prevalence of large buoyant LDL (LDL >25.5 nm). The type B phenotype has a predominance of sdLDL (LDL ≤25.5 nm) levels along with high triglyceride (TG) levels, reduced HDL cholesterol and high hepatic lipase activity.[8] Many individuals with CVD manifestations have LDL levels within the normal range, thus demanding the need to identify the best biomarkers in predicting CVD risk. Recently, sdLDL has been suggested as a good biomarker of CVD risk. It is expressed in adulthood due to the interaction of genetic and environmental factors such as dyslipidemia, insulin resistance, and obesity. Due to their small size, biochemical and biophysical properties, sdLDL penetrates the arterial wall and serves as a source of cholesterol and lipid storage. The susceptibility of sdLDL to oxidation further enhances its atherogenic potential.[9],[10]

A subgroup analysis of the INTERHEART study performed on Asians suggested a need to identify the association between sdLDL and CVD, to further refine the risk prediction in this ethnic group. Although several studies gave promising results, the public health usage of sdLDL as lipid markers is not yet practised. Keeping in mind the economics of the conventional lipid tests and the test rates for detecting novel biomarkers, there is a need to clearly identify the better marker for the prediction of CVD risk in Indians. A cost-effectiveness analysis perspective will help in making better informed decisions. The critical components for the gap in translational research are as follows: (1) lack of systematic ethnicity-based assessment of prevalence and patterns of LDL sub-fraction abnormalities and (2) reported contradictory studies stating the lack of association between CVD and sdLDL after multivariate adjustment of confounding factors, mainly TG and HDL levels.[11]

The current study aims to compare the diagnostic efficacy of sdLDL with LDL for premature CVD in Indians through the meta-analysis approach.

  Methods Top


The current systematic review and meta-analysis was conducted in accordance with the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analyses[12] and is presented in [Figure 1].
Figure 1: Preferred reporting items for systematic reviews and meta-analyses chart

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Inclusion and exclusion criteria

The screening process to identify all the potentially relevant articles was performed by two independent reviewers. The articles selected for the review were limited to original papers in English with full text and abstract availability. Further only original articles from India and those that compared mean sdLDL levels in patients with coronary artery disease (CAD) and without CAD (≥18 years) were chosen for the review. Articles that used median as a measure for estimating sdLDL levels were excluded. Duplicated reports, studies on non-Indians, migrated population, and studies reporting association with other diseases were also excluded from the review.

Search strategy

Potentially relevant articles for the review were identified by searching various electronic databases-MEDLINE, EMBASE, and PubMed from inception to December 2021 using the following search terms: “small dense LDL” or “sdLDL,” and “cardiovascular disease” or “coronary artery disease” and “Indians” or “Indian population. Reference articles of the primary studies were also screened for identifying potential papers. Both the authors performed the literature search independently to avoid bias and any conflict was settled by discussion and mutual consent. Details collected from relevant publications were: first author, years of data collection, year of publication, number of cases and controls, and mean and standard deviations of various lipid parameters.

Risk of bias assessment

The Cochrane risk of bias tool was used to assess the quality of individual studies by two authors. The studies were categorized into low risk of bias, showing some concerns or high risk of bias domain based on the quality assessment.

Data analysis

The relationship between various lipid markers and CVD was extracted from each study in terms of standardized mean difference (SMD) with 95% confidence interval (CI) levels. I2 statistic (significant at P < 0.10) was used as a continuous measure of heterogeneity with various Grades of I2 indicating the level of heterogeneity (high– 75%–100%, medium– 50%–70%, low– 0%–50%). A two-tailed value of P < 0.05 was considered statistically significant where a fixed-effect model was used in cases with I2 below 50%, and in cases of I2 above 50%, a random-effect model was adopted. Statistical analyses were performed using MedCalc for Windows, version 20.013 (MedCalc Software, Ostend, Belgium). The association of lipid markers with CVD incidence is graphically presented as forest plots.

  Results Top

In the initial stage, we have identified 598 articles, of which 135 duplicate reports were removed. After first screening, remaining 463 articles were further evaluated based on abstract and titles, and finally, six articles were found suitable for the meta-analysis [Figure 1].[13],[14],[15],[16],[17],[18] The details of lipid parameters (both cases and control) of the included studies are presented in [Table 1] and [Table 2].
Table 1: Basic characteristics of the studies

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Table 2: The detailed lipid parameters of the studies included in the meta-analysis

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Relationship between cardiovascular disease and conventional lipid markers

The overall CVD risk prediction by conventional LDL lipid parameters is presented in [Figure 2]. Overall pooled effect showed that the CVD risk increases with increasing TG (SMD = 0.464, 95% CI: 0.250–0.678 mg/dL, I2 – 36.93%, P = 0.1905) and LDL (SMD = 0.680, 95% CI: 0.180–1.180 mg/dL, I2 – 87.85%, P < 0.0001) levels, whereas it was found to decrease with increasing HDL (SMD = ‒0.427, 95% CI: ‒0.751 to ‒0.104 mg/dL, I2 – 72.08%, P = 0.0132) levels as compared to placebo group.
Figure 2: Forest plot showing the association of low-density lipoprotein with premature cardiovascular disease in Indians

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Relationship between cardiovascular disease and small dense low density lipoprotein levels

[Figure 3] shows the pooled results from combining effect sizes for CVD risk with sdLDL levels using random and fixed effect models. Overall direct relation was observed between sdLDL levels and CVD (SMD = 1.352, 95% CI: 0.744–1.960 mg/dL, I2 – 94.04%, P < 0.0001). A study that contributed maximum to the heterogeneity showed inverse relationship between sdLDL levels and CVD risk, showing higher sdLDL values in control as compared to cases.[19] Elimination of this study resulted in reduction in the heterogeneity. The same study showed inverse association in case of LDL levels also. Two other studies by Bansal et al.[20],[21] showed discrepancies between the sdLDL values given in data table and its interpretation in the results section, hence it was removed. In summary findings of individual studies reporting association of LDL with CVD were inconsistent, pooled results (through meta-analysis) showed significant relationship between both. In case of sdLDL, all the individual studies observed significant association with CVD, irrespective of LDL status of the patients and this was clearly reflected in pooled analysis. The degree of association was almost double with sdLDL as compared to LDL with premature CVD in Indians.
Figure 3: Forest plot showing the association of small dense low-density lipoprotein with premature cardiovascular disease in Indians

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  Discussion Top

Lipoproteins have been considered as a risk factor for CVD since many years, and hence, screening for lipid profiles is critical for the early detection and treatment of CVDs. High levels of LDL play a key role in the development and progression of atherosclerosis and CVD. Based on the plasma lipid profile, individuals are categorized into Type A and Type B phenotype.[8] Phenotype B with predominance of sdLDL was found in individuals with metabolic disorders, obesity, and Type 2 diabetes mellitus. The National Cholesterol Education Program III considers predominance of sdLDL as a risk factor for CVD.[22] The graphical presentation of sdLDL effect and its association with premature CVD found in the current study is shown in [Figure 4].
Figure 4: The graphical presentation of small dense low density lipoprotein and its association with premature cardiovascular disease

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Atherosclerotic plaques formed by the accumulation of foam cells and lipids in the arterial wall are mainly due to LDL deposition. The native LDL particles do not exhibit the property of lipid accumulation in cultured cells, whereas sdLDL with its longer circulation time is prone to the formation of lipid complexes increasing its atherogenic potential. The atherogenicity of sdLDL can be attributed to the multiple atherogenic modifications such as deacylation, glycation, and oxidation in the blood plasma. Smaller and denser LDLs are more prone to uptake by arterial tissues as compared to larger dense LDL. sdLDL has greater affinity for proteoglycans, which can be attributed to the sialic acid content of the particle. This induces immunological changes leading to atherosclerosis.[23],[24] Thus, this review aims to identify if sdLDL levels can act as a better marker for predicting CVD risk in Indians.

To the best of our knowledge, this is the first and only available meta-analysis performed on the Indian population to measure the association between sdLDL and CVD and to compare it with the classical marker-LDL. The results presented here represent the most relevant information on efficacy/potency of sdLDL as CAD associate in this ethnic group. It is noteworthy to assess whether the inability of current lipid markers in estimating CVD risk in Indians, could be overcome by incorporating sdLDL levels with clinically relevant cut-offs.

Nine articles selected initially, assessed the role of LDL sub-fractions and conventional lipids in Asian Indian CAD patients. Although the cumulative results showed a positive association between CAD and sdLDL, three studies showed an inverse relationship between sdLDL levels and CVD. The discrepancy found between Todur and Ashavaid results and other reports could be attributed to the differences in the methods used for estimating sdLDL.[19] Subgrouping of the population according to genotype, caused significant reduction in the level of sdLDL in healthy control indicating the prime role of polymorphisms in influencing lipoprotein sub-fractions. Moreover, the heterogeneity in data collection can also be ascribed to the varying results. The other two studies by Bansal et al. showed discrepancies in the interpreted results and values in the table, hence it was removed.[20],[21]

Indians are genetically diverse populations with a unique risk factor profiling having great confounding effect of life style and environmental factors.[25],[26],[27],[28] The CURES-8 study investigated the levels of sdLDL in native Indian patients having diabetes with or without CAD and compared it with healthy individuals. CURES-8 study was a part of large epidemiological study and is of noteworthy importance as they have collected data from Indians residing in Chennai– South Indian state, representing true Indian lipid levels. One of the key findings of the study was the strong association of sdLDL with TGs/HDL ratio. A value of 3.0 had the optimum sensitivity and specificity to detect elevated sdLDL. In contrast to the popular belief, LDL was found to be within normal limits in more than 50% of the subjects and this paradox could be explained by different sizes of LDL, with sdLDL being more atherogenic in nature as compared to large buoyant LDL particles.[16] Similar to CURES-8, other two studies performed on North Indian population also showed a marked increase in sdLDL in cases as compared to controls and also are clinically significant in relation to severity of the CAD.[13],[16] Singh et al. in his study observed higher levels of sd-LDL levels in males, thus suggesting greater chances of developing acute coronary syndrome when compared to females.[18]

Another study by Sharma et al. examined the links between conventional and novel risk factors for CAD in parents and descendants. Metabolic syndrome was identified as a relatively greater risk factor for CAD. The multiple analysis of variance test performed in the study suggested that LDL cholesterol particle size had the strongest association in patients with CAD.[17] Although a majority of the studies suggested a significant association between sdLDL levels and risk of CVD, our findings generated through meta-analysis suggests that both LDL and sdLDL levels correlates well with premature CVD in Indians.

This meta-analysis has several limitations that must be considered: (1) Lack of representative Indian data for sdLDL on diseased and normal population (2) Lack of studies that explored the association by equation derived sdLDL levels, which led to difficulty in matching/calibrating/standardizing lab derived data with those of equation derived data. (3) The results of the study showed high heterogeneity.

  Conclusions Top

Current meta-analysis clearly identifies sdLDL as better marker of premature CVD in Indians, especially in case of normal values of classical markers such as LDL. These findings can have huge implication in screening guidelines for young Indians where the country is witnessing an increasing burden of disease. Although in order to make it clinically, more applicable and reliable larger prospective studies with longer follow-up in this ethnic group are highly recommended.


As this is a secondary data analysis based study using already published data, the study was exempted from ethical review.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Cardiovascular Diseases (CVDs). WHO. Available from: https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds). [Last accessed on 2022 Jan 27].  Back to cited text no. 1
Sreeniwas Kumar A, Sinha N. Cardiovascular disease in India: A 360 degree overview. Med J Armed Forces India 2020;76:1-3.  Back to cited text no. 2
Misra A, Luthra K, Vikram NK. Dyslipidemia in Asian Indians: Determinants and significance. J Assoc Physicians India 2004;52:137-42.  Back to cited text no. 3
Prasad DS, Kabir Z, Dash AK, Das BC. Abdominal obesity, an independent cardiovascular risk factor in Indian subcontinent: A clinico epidemiological evidence summary. J Cardiovasc Dis Res 2011;2:199-205.  Back to cited text no. 4
[PUBMED]  [Full text]  
Joshi SR, Anjana RM, Deepa M, Pradeepa R, Bhansali A, Dhandania VK, et al. Prevalence of dyslipidemia in urban and rural India: The ICMR-INDIAB study. PLoS One 2014;9:e96808.  Back to cited text no. 5
Manjunath CN, Rawal JR, Irani PM, Madhu K. Atherogenic dyslipidemia. Indian J Endocrinol Metab 2013;17:969-76.  Back to cited text no. 6
Weitgasser R, Ratzinger M, Hemetsberger M, Siostrzonek P. LDL-cholesterol and cardiovascular events: The lower the better? Wien Med Wochenschr 2018;168:108-20.  Back to cited text no. 7
Sancho-Rodríguez N, Avilés-Plaza FV, Granero-Fernández E, Hernández-Martínez AM, Albaladejo-Otón MD, Martínez-Mernández P, et al. Observational study of lipid profile and LDL particle size in patients with metabolic syndrome. Lipids Health Dis 2011;10:162.  Back to cited text no. 8
Taşcılar ME, Özgen T, Cihan M, Abacı A, Yeşilkaya E, Eker I, et al. The effect of insulin resistance and obesity on low-density lipoprotein particle size in children. J Clin Res Pediatr Endocrinol 2010;2:63-6.  Back to cited text no. 9
Mikhailidis DP, Elisaf M, Rizzo M, Berneis K, Griffin B, Zambon A, et al. “European panel on low density lipoprotein (LDL) subclasses”: A statement on the pathophysiology, atherogenicity and clinical significance of LDL subclasses. Curr Vasc Pharmacol 2011;9:533-71.  Back to cited text no. 10
Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2889-934.  Back to cited text no. 11
PRISMA 2020 Checklist. PRISMA-Statement. Available from: http://prisma-statement.org/PRISMAStatement/Checklist. [Last accessed on 2022 Jan 27].  Back to cited text no. 12
Bhattarai AM, Batra H, Bandyopadhyay S, Misra P, Sharma M, Agarwal D. Correlation of small dense LDL cholesterol and apolipoprotein B with LDL cholesterol and its clinical significance in overweight, type 2 diabetes mellitus and coronary artery disease. Med J Shree Birendra Hosp 2016;14:36-40.  Back to cited text no. 13
Goel PK, Ashfaq F, Khanna R, Ramesh V, Pandey CM. The association between small dense low density lipoprotein and coronary artery disease in North Indian patients. Indian J Clin Biochem 2017;32:186-92.  Back to cited text no. 14
Goswami B, Rajappa M, Chakraborty B, Patra SK, Kumar S, Mallika V. Comparison of the various lipid ratios and indices for risk assessment in patients of myocardial infarction. Clin Biochem 2012;45:445-9.  Back to cited text no. 15
Mohan V, Deepa R, Velmurugan K, Premalatha G. Association of C-reactive protein with body fat, diabetes and coronary artery disease in Asian Indians: The Chennai Urban Rural Epidemiology Study (CURES-6). Diabet Med 2005;22:863-70.  Back to cited text no. 16
Sharma P, Purohit P, Gupta R. Cardiac risk factors in descendants of parents with history of coronary artery disease (CAD): An evaluation focusing on small dense low density lipoprotein cholesterol (sdLDLc) and high density lipoprotein cholesterol (HDLc). Indian J Biochem Biophys 2013;50:453-61.  Back to cited text no. 17
Singh A, Puhan R, Pradhan A, Ali W, Sethi R. Small dense low-density lipoprotein for risk prediction of acute coronary syndrome. Cardiol Res 2021;12:251-7.  Back to cited text no. 18
Todur SP, Ashavaid TF. Association of CETP and LIPC gene polymorphisms with HDL and LDL Sub-fraction levels in a group of Indian subjects: A cross-sectional study. Indian J Clin Biochem 2013;28:116-23.  Back to cited text no. 19
Bansal SK, Agarwal S, Daga MK. Conventional and advanced lipid parameters in premature coronary artery disease patients in India. J Clin Diagn Res 2015;9:C07-11.  Back to cited text no. 20
Bansal SK, Agarwal S, Daga MK. Advanced atherogenic index for the assessment of consolidated lipid risk in premature coronary artery disease patients in India. J Lab Physicians 2016;8:77-84.  Back to cited text no. 21
[PUBMED]  [Full text]  
Norata GD, Raselli S, Grigore L, Garlaschelli K, Vianello D, Bertocco S, et al. Small dense LDL and VLDL predict common carotid artery IMT and elicit an inflammatory response in peripheral blood mononuclear and endothelial cells. Atherosclerosis 2009;206:556-62.  Back to cited text no. 22
Ivanova EA, Myasoedova VA, Melnichenko AA, Grechko AV, Orekhov AN. Small dense low-density lipoprotein as biomarker for atherosclerotic diseases. Oxid Med Cell Longev 2017;2017:1273042.  Back to cited text no. 23
Salman Khan M. Small Dense LDL: New marker for cardiovascular risk assessment and its therapeutic inflection. Biochem Anal Biochem 2012;1:118.  Back to cited text no. 24
Kondkar AA, Nair KG, Ashavaid TF. Genetic analysis of Indian subjects with clinical features of possible type IIa hypercholesterolemia. J Clin Lab Anal 2007;21:375-81.  Back to cited text no. 25
Eghlim FF, Ashavaid TF, Nair KG. Genetic determinants of hyperhomocysteinemia in atherosclerosis. Indian J Clin Biochem 2006;21:4-11.  Back to cited text no. 26
Ashavaid TF, Todur SP, Nair KG. Apolipoprotein E4 polymorphism as risk factor for coronary heart disease among Indian subjects. Indian J Clin Biochem 2002;17:83-93.  Back to cited text no. 27
Camejo G, López A, López F, Quiñones J. Interaction of low density lipoproteins with arterial proteoglycans. The role of charge and sialic acid content. Atherosclerosis 1985;55:93-105.  Back to cited text no. 28


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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