This study aimed to explore the relationship between total cholesterol/high-density lipoprotein cholesterol (TC/HDL-C) ratio and carotid artery plaque (CAP) in patients with ischemic stroke (IS), while also examining the influence of different sex and age on CAP presence and quantity. We performed a cross-sectional analysis of 12 166 IS patients, dividing them into three groups based on TC/HDL-C tertiles (T1: TC/HDL-C < 3.55, T2: 3.55 ≤ TC/HDL-C ≤ 4.48, T3: TC/HDL-C > 4.48). Logistic regression was used to analyze the association between TC/HDL-C and CAP, as well as CAP count. A receiver operating characteristic (ROC) curve was constructed to assess the predictive performance of TC/HDL-C for CAP. TC/HDL-C (odds ratio [OR]: 1.227; 95% confidence interval [CI]: 1.210-1.348; P < .001) was significantly correlated with CAP risk. Subgroup analyses of sex and age revealed a stronger association between TC/HDL-C and CAP, as well as CAP count, in females and older patients compared with males and younger patients. The area under the curve (AUC) values of the ROC were 0.748 and 0.658 for the sex and age stratified groups, respectively. This study underscores the potential of TC/HDL-C to predict CAP risk and CAP count, particularly among female and elderly IS patients.
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