Do non-traditional lipid indices predict coronary heart disease in diabetes?

For people with diabetes, standard cholesterol tests (total cholesterol, LDL, HDL) may not fully capture their risk of coronary heart disease (CHD). Non-traditional lipid indices are calculated from routine blood tests and may provide additional insight. Research shows that several of these indices are strongly linked to CHD risk in people with diabetes, and some can help predict the severity of coronary artery blockages and long-term outcomes.

What the research says

A 2025 multicenter study of 1,823 patients with both metabolic dysfunction-associated steatotic liver disease (MASLD) and type 2 diabetes found that all eight non-traditional lipid indices tested were significantly associated with CHD risk. The strongest link was for Castelli risk index-II (CRI-II), which more than doubled the odds of having CHD (odds ratio 2.39) ⁵. This suggests that these indices can identify residual risk not captured by standard lipids.

Another 2025 study focused on elderly patients with coronary artery disease (many of whom likely had diabetes) found that triglyceride-rich lipoprotein cholesterol (TRL-C) strongly predicted both the severity of coronary lesions and long-term all-cause mortality. Models including TRL-C achieved high accuracy (AUC 0.94 for mortality prediction) ⁹. This indicates TRL-C may be a valuable biomarker for risk stratification.

Earlier research in Korean men showed that insulin resistance (common in diabetes) was the most important determinant of triglycerides, low HDL cholesterol, and the total cholesterol-to-HDL ratio, while obesity was more important for total and LDL cholesterol ¹⁰. This highlights that diabetes-related metabolic changes affect different lipid measures, and non-traditional indices may capture these diabetes-specific risks better than standard panels.

While these findings are promising, the evidence comes from specific populations (MASLD with diabetes, elderly patients, Korean men). More research in broader diabetes populations is needed to confirm the best indices and their added value over traditional risk factors.

What to ask your doctor

• Could non-traditional lipid indices like CRI-II or TRL-C be useful for assessing my heart disease risk?
• Are there any additional blood tests I should have beyond the standard lipid panel to better understand my risk?
• How do my diabetes and other conditions affect which lipid measures are most relevant for me?
• Would calculating non-traditional indices change my treatment plan or monitoring frequency?
• What is my current estimated risk of coronary heart disease, and how might these newer markers refine that estimate?