Lancet Reg Health West Pac. 2026;69:101844.

Age- and sex-specific attributable impact of modifiable risk factors on atherosclerotic cardiovascular disease in Korea: a nationwide population-based cohort study.

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제1저자 이희선, 강응재 · 교신저자 최수연

PMID 42004582 PMC13085072 DOI 10.1016/j.lanwpc.2026.101844 IF 9.4 순환기내과

소속 (6)

Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
Division of Cardiology, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Republic of Korea.
Integrated Major in Innovative Medical Science, Seoul National University Graduate School, Seoul, Republic of Korea.
Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
Cancer Research Institute, Seoul National University, Seoul, Republic of Korea.
Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.

Abstract

BACKGROUND While modifiable risk factors are central to the development of atherosclerotic cardiovascular disease (ASCVD), their relative contributions differ by age, sex, region, and period. However, contemporary evidence on these patterns in the large-scale Korean population remains scarce. We aimed to quantify the age- and sex-specific burden of major modifiable risk factors for ASCVD in a large nationwide cohort.

METHODS This retrospective cohort study included 6,249,852 Korean adults without prior ASCVD who underwent the National Health Screening between 2009 and 2010. The primary outcome was incident ASCVD, defined as cardiovascular death, myocardial infarction, or ischemic stroke. Participants were followed for these outcomes through linkage to the Korean National Health Insurance Service claims database and Statistics Korea mortality data. Population-attributable fractions (PAFs) for risk factors-body mass index, systolic blood pressure (SBP), smoking, diabetes, and non-HDL-cholesterol-were estimated from multivariable-adjusted Cox proportional hazards models and stratified by age and sex.

FINDINGS In this cohort (mean age 46.9 ± 13.7 years; 52.2% men), 279,093 ASCVD events occurred (incidence rate, 3.58/1000 person-years) during a median follow-up of 13.0 years. The five risk factors collectively explained 46.2% of the ASCVD burden, with the greatest contribution from SBP, followed by smoking, non-HDL-cholesterol, diabetes, and obesity. PAFs were higher in men (52.8%) than women (30.4%), and highest in men aged <50 years (71.5%), where SBP (48.6%) and smoking (29.4%) predominated. In women, SBP remained the leading contributor with less variation by age, whereas diabetes and atherogenic lipids contributed more prominently at older ages.

INTERPRETATION These findings reveal distinct age- and sex-specific patterns in the burden of modifiable risk factors in contemporary Koreans. Tailored prevention strategies that reflect national epidemiological profiles and demographic risk patterns are needed to effectively reduce the ASCVD burden.

FUNDING None.

Keywords

Atherosclerotic cardiovascular diseasesModifiable risk factorsPopulation-attributable fractionPrimary prevention

Figures

**Fig. 1** **Flowchart of the study design**. Approximately 6.3 million adults without prior ASCVD history who underwent the National Health Screening Examinations were enrolled in this cohort. They were followed up till the occurrence of incident ASCVD, defined as a composite of cardiovascular death, MI, and ischemic stroke, or 31 December 2022, whichever came first. ASCVD, atherosclerotic cardiovascular disease; MI, myocardial infarction.

**Fig. 2** **Associations of individual cardiovascular risk factors with ASCVD risk, stratified by age and sex**. Adjusted HRs for incident ASCVD according to modifiable risk factors were presented for the total population (green), men (blue), and women (red): (A) BMI, (B) abdominal obesity, (C) smoking, (D) hypertension, (E) SBP, (F) DBP, (G) glucose levels, and (H) non-HDL-c levels. The contribution of each risk factor was further compared across different age groups. BMI, body mass index; DBP, diastolic blood pressure; HDL-c, high-density lipoprotein cholesterol; HR, hazard ratio; SBP, systolic blood pressure.

**Fig. 3** **Aggregated PAFs for ASCVD according to age and sex**. The overall PAF for ASCVD attributable to five major modifiable risk factors was 46.2% in the Korean population. Notably, the attributable burden varied significantly by age and sex groups, with the highest PAF observed in men younger than 50 years. PAF, population-attributable fraction, other abbreviations as Fig. 1.

그림 출처: PubMed Central 공개 논문 (PMC13085072)

Conflict of interest statement

The authors have declared no conflict of interest.

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