To investigate the relationship between the ratio of non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol (NHHR) and new-onset stroke in different glucose metabolism states, and to provide new perspectives on stroke prevention and treatment.

Based on data from the China Health and Retirement Longitudinal Study (CHARLS), a total of 8 567 participants were selected to participate in five surveys in 2011, 2013, 2015, 2018, and 2020. First, the cumulative risk of stroke onset was estimated using the Kaplan-Meier method based on NHHR quartile groupings, and the Log-rank test was used to compare differences between groups. Second, the association between NHHR and new-onset stroke in the total population and in individuals with different glucose metabolic status was analyzed using Cox proportional risk regression models, and interaction analyses were performed.

A total of 745 (8.4%) participants had a new stroke during the 9-year follow-up period. The incidence of stroke in the NHHR quartiles from Q1 to Q4 groups was 6.1%, 8.2%, 9.4%, and 11.1%, respectively. Kaplan-Meier analysis showed a significant difference in cumulative incidence risk of stroke among the different NHHR groups (P<0.05). Cox regression modeling showed that the risk of stroke was increased by 34%, 56%, and 75% in Q2, Q3, and Q4 groups, respectively, compared with Q1 group, with HR and 95% CI of 1.34 (1.07-1.68), 1.56 (1.25-1.95), and 1.75 (1.41-2.18). In prediabetic and diabetic patients, elevated NHHR increased the risk of stroke onset, whereas the association was not observed in the normoglycemic group, and there was a significant interaction between NHHR and glucose metabolic status (P=0.020).

NHHR is positively associated with the risk of new stroke and shows different characteristics in different glycaemic states.