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Familial hypercholesterolemia in patients with hypertension: the China H-type Hypertension Registry Study

Lipids in Health and Disease volume 24, Article number: 116 (2025) Cite this article

Abstract

Background and aims

Familial hypercholesterolemia (FH) significantly amplifies the risk of developing atherosclerotic cardiovascular disease (ASCVD). This study investigated the prevalence and clinical characteristics of FH in a hypertensive rural population.

Methods

In the China H-type Hypertension Registry Study, a prospective observational cohort study with a 4-year follow-up, 14,234 hypertensive participants from rural areas were enrolled in 2018, with onsite exams conducted in 2022. FH was identified using the Chinese-modified Dutch Lipid Clinic Network criteria.

Results

Among the 10,900 patients with hypertension, 5,675 (52.1%) were women, the median age was 65 years, the median blood pressure was 146/89 mmHg, 629 (5.8%) had previous coronary heart disease (CHD), and 4,726 (43.4%) were smokers. Among the cohort, 78 (0.72%) met the C-DLCN criteria for probable or definite FH. The rate of lipid-lowering therapy (LLT) usage in patients with FH reached 35.9%. After a median follow-up period of 1,477 days, a total of 658 deaths, 535 strokes, and 309 cardiovascular disease (CVD) events were observed. At baseline and subsequent follow-up, all patients with FH were at high or ultra/very high risk for ASCVD. During follow-up, a greater decrease in LDL-C was shown in patients with FH (FH: − 31%, 95% CI − 44.6% to –14.6%; P < 0.001) than patients without FH (2%, 95% CI: − 12.1% to 17.4%); however, only 3.6% of them achieved the recommended LDL-C targets based on ASCVD risk assessment. The risks of stroke and CVD were not significantly different between patients with and without FH after 4 years of follow-up.

Conclusions

This study highlights a marked gap between the high prevalence and low treatment rates of FH in rural populations with hypertension. These findings suggest the need to improve knowledge regarding FH and the need to treat this condition, especially when associated risk factors are present.

Graphical Abstract

Introduction

Familial hypercholesterolemia (FH) is an inherited cholesterol metabolism disorder characterized primarily by extremely high levels of low-density lipoprotein cholesterol (LDL-C) and an increased risk of accelerated atherosclerosis and premature coronary heart disease (CHD) [1,2,3]. The prevalence of FH among the general Chinese population is estimated to be 0.13% (aged 35–75 years), with a higher prevalence recorded in urban areas (0.18%) than in rural areas (0.10%) [4]. FH is more prevalent in high-risk populations, such as those with ischemic heart disease (1/31), early-onset ischemic heart disease (1/15) or severe hypercholesterolemia (1/14), than in the general population (1/313) [5]. Given the high prevalence of this disease, various countries have issued corresponding diagnosis and treatment guidelines to enhance the global understanding, diagnosis and treatment capabilities of this disease [6,7,8]. Therefore, targeting specific high-risk groups for FH screening has become an urgent means to alleviate the significant disease burden.

Hypertension represents a significant global public health challenge and is responsible for 19% of all deaths worldwide [9]. The occurrence of hypertension has doubled over the last thirty years, with the global population affected increasing from 650 million in 1990 to 1.3 billion in 2019. In China, the prevalence of hypertension among adults is 31.6%. Among the FH population, hypertension is more common in rural areas (33.7%) than in urban areas (29.1%) [9, 10]. Hypertension is a contributing factor to cardiovascular disease, and a significant proportion of patients have both dyslipidemia and hypertension [11]. Studies have shown that hypertension is more common in patients with FH than in those without FH (57.9% vs. 46.0%) [12]. In addition, previous FH screening revealed that the most common comorbidity in patients with FH was hypertension [13]. Another study also revealed that the percentage of hypertension among 480 heterozygous patients with FH reached nearly 43% [14]. Hypertension and FH are critical contributors to ASCVD, and their coexistence poses an even greater cardiovascular risk. However, the prevalence and clinical characteristics of FH within hypertensive populations remain underexplored, as previous studies have focused primarily on FH in general populations or other specific high-risk groups. Identifying FH incidence and characteristics in this high-risk group could enable earlier diagnosis and targeted interventions, improving outcomes. Therefore, the objectives of this study were 1) to assess the proportion of patients who meet the clinical criteria for FH and to analyze their clinical characteristics within a hypertensive population; 2) to examine the utilization rate of lipid-lowering therapy (LLT) in this population and the LDL-C target achievement rate during follow-up; and 3) to evaluate the risk of stroke and cardiovascular events in these patients.

Methods

Study population

This study analyzed data from the China H-type Hypertension Registry Study (ChiCTR1800017274), with previously described details on the data collection and exclusion criteria [15]. This multicenter observational study was conducted in March 2018 in Wuyuan, Jiangxi Province, China, and included adults aged 18 years or older with hypertension. The exclusion criteria were as follows: (1) had nervous or psychological system impairment, which rendered the individual incapable of providing informed consent; (2) were unable to adhere to the study's prescribed follow-up schedule or had imminent plans for relocation; and (3) were considered inappropriate for inclusion or long-term follow-up, as determined by the study physicians.

Annual onsite physical examination or telephone follow-up data were recorded from 2018–2022. In this study, individuals who had complete LDL-C, family history and personal medical history data in 2018 and who had complete follow-up data in 2022 were included. Ultimately, 10,900 participants were included at baseline. During the follow-up, data from 10,899 individuals’ outcome events were collected, and the LDL-C values and drug usage rates in 2022 were recorded (Supplementary Figure S1). The protocol received approval from the Ethics Committee of the Institute of Biomedicine, Anhui Medical University (NO. CH1059), and all participants provided written informed consent.

Identification of patients with FH

The Chinese modified Dutch Lipid Clinic Network criteria (C-DLCN criteria), Chinese Expert Consensus criteria (CEC criteria) and Dutch Lipid Clinic Network criteria (DLCN criteria) were used in this analysis [6,7,8]. Patient LDL-C levels were adjusted by multiplying by 1.43 if the patient had used statins prior to LDL-C measurement [6].

The C-DLCN, CEC and DLCN criteria are available in the Supplementary methods and Supplementary Table S1.

Data collection and definition of variables

The collection of basic data included face‒to‒face personal questionnaire surveys, physical measurements and laboratory examinations (Table 1).

Table 1 Baseline characteristics of hypertensive patients stratified by Chinese-modified DLCN criteria
Full size table

The questionnaire included questions about demographic characteristics, living habits, familial history, personal history, and common drug use history. If the age at which first-degree relatives presented with ASCVD was not provided, any history of ASCVD was accepted. The physical parameters, fasting plasma glucose levels and fasting lipid profiles of all the study patients were measured. The approach for index measurement and definitions of variables are available in the Supplementary methods.

Follow-up and outcomes

The life statuses of the participants in this study were determined based on methods described in a previous study [15]. Details regarding the definitions of the follow-up outcome variables, including cardiovascular composite endpoints, stroke, CVD, and cardiovascular mortality, are available in the Supplementary methods. The prespecified outcomes of interest were as follows: 1) FH incidence in the hypertensive population at baseline (2018); 2) use of LLT and LDL-C target achievement rates at the 4-year follow-up (2022); 3) LDL-C reduction after 4 years (2018 and 2022); and 4) incidence rates of stroke, CVD, cardiovascular composite endpoints, and all-cause mortality at 4 years (2022). The patients' ASCVD risk and personal LDL-C targets were established in accordance with the ASCVD risk calculated based on the Chinese guidelines for lipid management (2023) (Supplementary Figure S2, Supplementary Table S2) [16].

Statistical analysis

Quantitative data following an approximately normal distribution are reported as χ ± s and were analyzed using ANOVA. For data with a skewed distribution, expressed as the M (IQR), the Mann‒Whitney U test was used for pairwise analysis, whereas the Kruskal‒Wallis H test was employed for multigroup comparisons. Categorical variables are summarized as frequencies and percentages, and differences between groups were evaluated using the chi-square test. P < 0.05 was considered indicative of statistical significance. The process of the Cox risk‒proportional regression model is available in the Supplementary Methods. All comparisons in this study were made between the FH and non-FH groups. All the statistical analyses and graphical representations were conducted in RStudio with R (4.2.2).

Results

Baseline characteristics

A total of 10,900 individuals with hypertension were included in this study. Within this cohort, 5,675 were women with a median age of 65 years (Table 1, based on the C-DLCN criteria). Compared with patients without FH, patients with FH (defined + probable) exhibited significant differences in the following parameters: female sex (69.2% vs. 51.9%, P = 0.003), age (61 vs. 65, P < 0.001), smoking status (28.2% vs. 43.5%, P = 0.009), BMI (24.42 vs. 23.40, P = 0.001), hip circumference (93.9 vs. 91.9 cm, P = 0.044), and ankle–brachial index (ABI: 1.08 vs. 1.11, P = 0.009).

In addition, patients with FH had notably greater percentages of personal history of CHD (34.6% vs. 6.7%, P < 0.001), stroke (33.3% vs. 6.7%; P < 0.001) and hypertension (67.6% vs. 51.5%, P = 0.008). Moreover, patients with FH presented significant increases in serum lipid levels and other blood parameters, including TC (7.72 vs. 5.03 mmol/L, P < 0.001), TG (2.24 vs. 1.46 mmol/L, P < 0.001), HDL-C (1.68 vs. 1.46 mmol/L, P < 0.001), LDL-C (5.14 vs. 2.87 mmol/L, P < 0.001), AST (28 vs. 24 U/L, P < 0.001), ALT (22.5 vs. 17.0 U/L, P < 0.001), GGT (30.5 vs. 21.0 U/L, P < 0.001) and ALB (47.15 vs. 46.30 g/L, P = 0.010).

Occurrence of FH in patients with hypertension

The prevalence of clinically defined FH in this cohort was as follows: 0.72% (0.57–0.89%) (probable + definite, n = 78) based on the C-DLCN criteria; 0.52% (n = 57) based on the CEC criteria; and 0.06% (probable + definite, n = 7) based on the DLCN criteria. In addition, 35 individuals were diagnosed with FH according to both the C-DLCN and CEC criteria. The prevalence rates of FH diagnosed by the C-DLCN, CEC and DLCN criteria in the age and sex subgroups are shown in Supplementary Table S3, and the results indicated that there was a greater prevalence of FH among females (0.96%) and those in the < 60 years age group (0.99%). Although the hypertensive cohort exhibited a relatively high FH incidence in this study, the prevalence of FH did not vary across the different stages of hypertension (Supplementary Figure S3).

Furthermore, among the 1,359 patients with a personal history of stroke or CHD, 35 (2.58%, 95% CI: 1.80–3.56%) met the C-DLCN criteria for probable/definite FH. Among 1,520 patients with LDL-C ≥ 3.8 mmol/L (based on CEC criteria), 72 (4.74%, 95% CI: 3.72–5.93%) met the criteria for probable/definite FH. In addition, among the 211 patients who met both personal stroke or CHD history criteria and had LDL-C levels ≥ 3.8 mmol/L, the screening rate for FH increased to 13.8% (95% CI: 9.40–19.14%) (n = 29) (Graphical abstract).

Lipid-lowering therapies and LDL-C targets achieved at baseline and at the 4-year follow-up

Baseline

At baseline, the overall LLT usage rate in the hypertension cohort was 3.5% (n = 382) (Supplementary Table S4). However, among 5,188 patients with dyslipidemia, 3.1% (n = 211) underwent LLT. Among patients requiring secondary prevention (those with ASCVD, n = 1,543), the LLT usage rate was 12.1% (n = 186). In contrast, for patients without ASCVD (primary prevention, n = 9,357), the LLT usage rate was significantly lower at 2.1% (n = 196, P < 0.001). Among patients with FH (n = 78), the LLT usage rate was 35.9% (n = 28). Notably, among patients with FH with ASCVD (secondary prevention, n = 38), the usage rate was 34.5% (n = 18), whereas among patients with FH without ASCVD (primary prevention, n = 40), the usage rate was slightly lower at 25% (n = 10).

At baseline, LDL-C achievement based on the ASCVD risk assessment or threshold was seriously inadequate (Table 2). In accordance with the Chinese guidelines for lipid management (2023) [16], all patients with FH were at high or ultra/very high risk for ASCVD. Among these patients, those with a history of ASCVD (n = 38) requiring secondary prevention were categorized as ultra/very high risk. However, even in this high-risk group (primary prevention, n = 40), LDL-C management was suboptimal, with only one patient with FH (1.3%) achieving the LDL-C target (LDL-C < 100 mg/dL). Moreover, only 29.5% of patients without FH achieved the LDL-C target based on the ASCVD risk assessment. Furthermore, 35.3% of patients without FH reached the 100 mg/dL LDL-C threshold, and 6.0% achieved the 70 mg/dL threshold (1.8 mmol/L).

Table 2 Medicine and LDL-C achieved at baseline and 4-year follow-up
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Four-year follow-up

In the follow-up period, the medication records of 6,214 patients were documented. The overall LLT usage rate in the total cohort increased to 4.3% (n = 269) (Supplementary Table S4). A significant increase in LLT utilization was observed among 3,085 patients with dyslipidemia (5.6% vs. 3.5%, P < 0.001). For patients requiring secondary prevention (ASCVD, n = 1,057), the LLT usage rate decreased marginally to 11.2% (n = 118, P = 0.527). Conversely, among patients without ASCVD (primary prevention, n = 5,157), the LLT usage rate increased to 2.9% (n = 151, P = 0.002). Among patients with FH (n = 53), the LLT usage rate decreased significantly from 35.9% to 18.9% (P = 0.056). For patients with FH requiring secondary prevention (FH + ASCVD, n = 29), the LLT usage rate decreased significantly from 34.5% to 17.2% (P = 0.021). Among patients with FH without ASCVD (primary prevention, FH + no ASCVD, n = 24), the LLT usage rate slightly decreased from 25% to 20.8% (P = 0.939). Furthermore, the percentages of LLT usage among patients who experienced stroke or CVD during the follow-up period were 20.3% (n = 44) and 21.7% (n = 20), respectively.

Compared with those at baseline, patients with FH presented significant reductions in LDL-C levels (3.82 vs. 5.14 mmol/L, P < 0.001) and LDL-C changes after 4 years of follow-up (absolute: − 1.68 mmol/L; percent: − 31.0%) (Table 2). However, despite significant LDL-C reductions, goal attainment remained inadequate for both primary and secondary prevention. No patients with FH requiring secondary prevention (ultra/very high risk) achieved LDL-C targets, and only 2 patients with FH requiring primary prevention met the goal. Overall, LDL-C < 100 mg/dL was achieved by 12.7% of patients with FH, which was significantly lower than the 31.7% reported in patients without FH (P < 0.001) (Fig. 1). Moreover, only 27.2% of patients without FH achieved the LDL-C target as determined by the ASCVD risk assessment.

Fig. 1
figure 1

Waterfall plot of percent LDL-C Reduction at 4 Year Among Hypertensive Patients Stratified by Presence or Absence of FH: The percent LDL-C reduction at 4-year follow-up among patients with FH (left) and patients without FH (right) diagnosed by C-DLCN criteria. FH: familial hypercholesterolemia, LDL-C: low density lipoprotein cholesterol

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Stroke and CVD incidence at the 4-year follow-up

Over a four-year follow-up period, 535 patients with stroke, 309 patients with CVD and 658 patients who died were identified. The incidence of stroke did not significantly differ between patients with and without FH (6.4% vs. 4.9%, P = 0.724). Neither stroke nor CVDs were significantly different among patients with or without FH according to Kaplan‒Meier analysis (stroke: log-rank P = 0.557; CVDs: log-rank P = 0.876) (Fig. 2). The results of Cox proportional hazards modeling were similar between the unadjusted model (95% confidence interval [CI] 0.54–3.14; P = 0.558) and the multivariable model (95% CI 0.56–3.30; P = 0.505) (Table 3). Similarly, CVD incidence did not significantly differ between those with and without FH (2.6% vs. 2.8%, P = 1). Cox proportional hazards modeling for CVD incidence revealed that the unadjusted HR for FH was 0.90 (95% CI 0.22–3.60; P = 0.876), which increased to 1.23 (95% CI 0.29–5.29; P = 0.780) in the multivariable model. Moreover, compared with FH, FH had a similar influence on cardiovascular composite endpoints and all-cause mortality (Supplementary Table S5). In addition, significant HRs were not observed in 78 patients with FH and 3,432 controls matched for age, sex, smoking status or drinking habits after propensity score matching (PSM) (Supplementary Table S6 and Supplementary Figure S4).

Fig. 2
figure 2

Stroke and CVDs Incidence Among Hypertensive Patients Stratified by Presence or Absence of FH: Kaplan-Meier failure curves for stroke (A) and CVDs (B) in FH diagnosed by C-DLCN criteria. FH: familial hypercholesterolemia, HR: hazard ratio. The unadjusted or adjusted HR in Cox proportional hazards modelling were presented in the upper left corner of the diagram

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Table 3 Long-term outcomes of patients with hypertension and familial hypercholesterolaemia
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Discussion

In this cohort study, patients with potential FH in the hypertensive population were screened using three clinical diagnostic criteria. The main results were as follows: (1). According to the C-DLCN criteria, the prevalence of FH among patients with hypertension was 1/139. A history of combined personal stroke or CHD and an LDL-C concentration ≥ 3.8 mmol/L can significantly increase the FH screening rate to 13.8% among individuals with hypertension (2). At baseline, although the use rate of LLT was greater among patients with FH, the overall usage rate was still less than 50%. The LLT usage rate decreased to 18.9% at the 4-year follow-up. (3). The LDL-C target achievement rate was only 1.3% at baseline (4). Although the risk of cardiovascular disease and stroke was elevated in the FH group during the 4-year follow-up, there was no statistically significant difference between the FH and non-FH groups.

The participants in this study were mainly from rural areas. The incidence of CHD events in this group of patients has increased in recent years. Like those reported in the United States and other regions [17, 18], cardiovascular mortality rates in China are much greater in rural areas than in urban areas (336.13/100,000 vs. 291.04/100,000) [19]. Recent data suggest that the prevalence of dyslipidemia is comparable between rural and urban populations (43.2% vs. 43.3%). However, rural areas have lower awareness (13.6% vs. 20.7%) and treatment rates (5.8% vs. 11.5%) for dyslipidemia, contributing to higher cardiovascular mortality [20, 21]. Similarly, the incidence of hypertension is higher in rural areas (46.1% vs. 42.5%), but with lower awareness and treatment rates [4]. Therefore, strengthening the management of chronic diseases in rural populations is essential for ASCVD prevention.

Among the 25 million people with FH worldwide, fewer than 5% are diagnosed, with an even lower rate in China [22, 23]. In this hypertensive population, the FHs according to the C-DLCN and CEC criteria were 0.72% (95% CI: 0.57–0.89%) and 0.52% (95% CI: 0.40–0.68%), respectively, which was almost double that reported in the general Chinese population (0.28%) [8]. In accordance with the CEC criteria of the Chinese Patient-centered Evaluative Assessment of Cardiac Events (PEACE) Million Persons Project (MPP) study, Teng et al. reported that the overall FH incidence was 0.13% (95% CI: 0.12–0.14%) in the Chinese population (n = 1,059,936, aged 35–75) [24]. Aihaiti et al., based on the China ASCVD Risk Prediction (China-PAR) project and the Make Early Diagnosis to Prevent Early Death (MEDPED) criteria, reported that the prevalence of FH was 0.19% (95% CI: 0.17–0.22%) in the Chinese population (n = 98,885) [25]. However, the prevalence of FH obtained by applying the DLCN criteria in this study was lower (0.06%, 95% CI: 0.03–0.13%). The differences in results were due to varying LDL-C thresholds in the diagnostic criteria. Given the lower baseline cholesterol levels in the Chinese population, the C-DLCN and CEC criteria are more appropriate than the DLCN criteria are [24, 26]. This study indicates that the prevalence of FH diagnosed using the C-DLCN criteria is significantly greater in the hypertensive population (0.72%) than in the general population (0.28%) (Graphical abstract). Overall, there are many potential patients with FH in the hypertensive population, a finding that requires more attention.

This study revealed an extremely suboptimal rate of LLT use among patients with FH with hypertension, both at baseline (35.9%) and at follow-up (18.9%), which is in line with the overall rate reported in the literature in China, which differs from those reported in the international literature for both drug use and adherence [6, 24, 27]. In high-income countries, such as the US, the reduced ASCVD burden is largely attributed to increased LLT use (54.1%) and LDL-C control rates (66.0%), with statin usage increasing from 8.4% from 2002–2003 to 27.8% from 2012‒2013 [27, 28]. In contrast, dyslipidemia treatment and control rates are much lower in East Asia, with the 2015 China National Stroke Screening and Prevention Program (CNSSPP) reporting rates of 18.9% and 7.2%, respectively, among adults ≥ 40 years [28]. Similarly, LDL-C target rates in very high-risk and high-risk patients with ASCVD in China were only 6.8% and 25.5%, respectively [29]. Among patients with FH, LLT use reached 86.5% in the Mediterranean population and 48% in Danish populations but only 18.1% in the PEACE MPP study in China, where no treated patients met LDL-C targets [6, 24, 27]. The findings of this study underscore significant gaps in LLT utilization, treatment rates, and LDL-C target achievement among patients with FH, with challenges being particularly pronounced in rural areas. Poor tolerance to high-dose statins and side effects, along with treatment discontinuation or de-escalation due to perceived health improvements or safety concerns, contribute to the decline in LLT usage during follow-up [30]. Improving adherence among patients with FH requires greater disease awareness, particularly among physicians. Telemedicine, as evidenced by the findings of the MIRACLE-AF trial, offers promising solutions by enhancing specialist collaboration, education, and remote consultations to improve adherence and clinical decision-making, especially in rural areas [31]. Additionally, efforts should focus on strengthening the knowledge of primary care physicians in rural areas regarding the identification of chronic diseases and their subsequent treatment. Collaboration with local community committees to organize free clinics and health education activities could further increase public awareness of diseases and underscore the significance of medication adherence.

This study revealed no association between FH and an elevated risk of stroke, which might be expected in a population of subjects with hypertension. However, hypertension is a major risk factor for stroke [32]. In previous studies, evidence has suggested that the connection between FH and stroke may vary by stroke subtype. For total stroke, no increased risk has been observed in patients with genetically confirmed FH [33, 34]. The relationship between FH and ischemic stroke remains controversial. Although some studies have indicated no substantial increase in ischemic stroke risk among patients with FH, [34, 35] a meta-analysis revealed a greater risk of ischemic stroke or transient ischemic attack (OR: 7.658) [36]. Conversely, another meta-analysis reported no association (OR: 0.76) but noted a modest increase in risk with LDL-C > 4.9 mmol/L (OR: 1.42) [37]. The association of FH with hemorrhagic stroke remains unclear, as it is not typically related to atherosclerosis [35,36,37]. In this study, the small number of stroke events in the FH group (n = 5) may have limited the ability to detect significant associations. Overall, the data appear consistent with the literature, although the relatively modest sample size and the comparatively brief follow-up duration may have contributed to the absence of significant findings.

In addition, the percentage of the population at ultra/very high ASCVD risk was significantly greater among individuals with FH than among those without FH (48.7% vs. 13.9%), but no increased risk of CVDs was observed during follow-up. Multiple studies have shown that patients with FH are at significantly increased risk of developing ASCVD, even when they receive high-intensity statin therapy [6]. Several factors may account for this difference in the results. First, the small number of patients with FH and ASCVD and the short follow-up period may have affected the results. Additionally, hypertension, a key risk factor for cardiovascular mortality, may have masked the association between FH and CVD. Notably, patients with hypertension and hypercholesterolemia face a significantly greater ASCVD risk. Future long-term follow-up studies should confirm these findings.

Strengths and limitations

This was a cohort study based on a rural hypertensive population with relatively fixed research subjects and a robust follow-up system in which onsite physical examination data and outcome events were collected. However, the follow-up period was limited to only 4 years, and the study has the following limitations: 1) the lack of genetic testing in this study may have reduced the accuracy of the diagnosis; 2) data on tendon xanthomas and corneal arcus were not collected at baseline and may have led to the omission of some patients with FH; 3). the types of LLT were not distinguished, which may have affected the assessment of LDL-C levels and caused bias; 4) the inclusion of only 10,900 individuals with hypertension may have caused bias; and 5) the 4-year follow-up period could not yield a sufficient number of ASCVD events.

Conclusion

The present study demonstrated that the prevalence of FH among rural hypertensive populations (0.72%) was notably higher than that in the general population. Nevertheless, the rates of lipid-lowering therapy usage (35.9%) and LDL-C target achievement (3.6%) among patients with FH remained alarmingly low. These findings underscore the critical need to enhance the recognition, diagnosis, and treatment of FH in hypertensive populations, particularly in rural areas. Furthermore, implementing policies to improve chronic disease management, increasing public awareness of FH, and providing specialized training for rural healthcare providers are vital steps toward reducing the treatment gap and mitigating cardiovascular risk in this high-risk population.

Data availability

The data used and/or analyzed during the current study is available from the corresponding author on reasonable request.

Abbreviations

ABI:

Ankle-brachial index

ALT:

Alanine aminotransferase

ALB:

Albumin

AST:

Aspartate aminotransferase

baPWV:

Brachia-ankle pulse wave velocity

eGFR:

Estimated glomerular filtration rate

GGT:

Gamma-glutamyl transpeptidase

HDL-C:

High-density lipoprotein cholesterol

HCY:

Homocysteine

APOB:

Apolipoprotein B

ASCVD:

Atherosclerotic cardiovascular disease

CVDs:

Cardiovascular diseases

CEC criteria:

Chinese Expert Consensus criteria

C-DLCN criteria:

Chinese-modified Dutch Lipid Clinic criteria

CHD:

Coronary heart disease

DBP:

Diastolic blood pressure

DLCN criteria:

Dutch Lipid Clinic Network criteria

FH:

Familial hypercholesterolemia

FPG:

Fasting plasma glucose

IHD:

Ischemic heart disease

LDLR:

LDL receptor

LLT:

Lipid-lowering therapy

LDL-C:

Low-density lipoprotein cholesterol

PCSK9:

Proprotein convertase subtilisin/kexin type 9

SBP:

Systolic blood pressure

TC:

Total cholesterol, TG: triglycerides

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Acknowledgements

We thank all the participants in the study.

Funding

This research was funded by the National Key R&D Program of China (No. 2022YFE0209900, 2021YFC2500600, 2021YFC2500602); National Natural Science Foundation of China (82360181); National Natural Science Foundation for Young Scientists of China (81700792); The Natural Science Foundation of Jiangxi Province for Distinguished Young Scholars of China (Grant No.2018ACB21035); the Natural Science Foundation of Jiangxi Province for Young Scientists of China (Grant No.20171BAB215004); Nanchang University youth teacher training fund (Grant No.PY201821); Project of Jiangxi Provincial Health and Family Planning Commission (Grant No.20185208); the Cultivation of backup projects for National Science and Technology Awards (20223AEI91007); Jiangxi Science and Technology Innovation Base Plan—Jiangxi Clinical Medical Research Center (20223BCG74012); Fund project of the Second Affiliated Hospital of Nanchang University (2021efyA01, 2021YNFY2024).

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Author notes

  1. Tianzhou Shen and Renfei Luo contributed equally to this work.

Authors and Affiliations

  1. Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China

    Tianzhou Shen, Renfei Luo, Huihui Bao, Long Jiang & Xiaoshu Cheng

  2. Jiangwan Public Health Center, Wuyuan, China

    Hongdong Jiang

  3. Center for Cardiovascular Disease Prevention and Treatment, the Second Affiliated Hospital of Nanchang University, Nanchang, China

    Huihui Bao & Xiaoshu Cheng

  4. Jiangxi Provincial Cardiovascular Disease Clinical Medical Research Center, Nanchang, China

    Huihui Bao & Xiaoshu Cheng

  5. Jiangxi Sub-Center of National Clinical Research Center for Cardiovascular Diseases, Nanchang, China

    Huihui Bao & Xiaoshu Cheng

Authors
  1. Tianzhou Shen
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Contributions

XC. conducted the study design and revised the manuscript. TS. conducted data analysis and wrote the manuscript. HB. verified the underlying data reported in the manuscript. RL. created images and tables. HJ revised the article for scientific and logical accuracy. LJ. edited the article and critically revised the final manuscript. All authors have approved the submitted version and agreed to publication.

Corresponding authors

Correspondence to Long Jiang or Xiaoshu Cheng.

Ethics declarations

Ethics approval and consent to participate

The protocol was approved by the Ethics Committee of the Institute of Biomedicine, Anhui Medical University (NO. CH1059). All participants provided written informed consent.

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The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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Shen, T., Luo, R., Jiang, H. et al. Familial hypercholesterolemia in patients with hypertension: the China H-type Hypertension Registry Study. Lipids Health Dis 24, 116 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12944-025-02514-9

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Keywords

Lipids in Health and Disease

ISSN: 1476-511X