Limitations of using COX proportional hazards model in cardiovascular research

The article by Zhao et al. titled “Associations of Triglyceride-Glucose (TyG) Index with Chest Pain Incidence and Mortality among the U.S. Population” provides valuable insights into the positive correlation between the TyG index and chest pain incidence, as well as a nonlinear relationship with mortality. However, the use of the COX proportional hazards model in their analysis presents several limitations. The assumption of constant hazard ratios over time may not hold, potentially leading to biased estimates. The model’s struggle with time-dependent covariates and the possibility of residual confounding are notable concerns. Additionally, the study’s subgroup analyses might suffer from reduced statistical power, and potential interactions with other metabolic markers were not explored. Considering these limitations, future research should adopt alternative approaches, such as time-varying covariate models, to provide a more comprehensive understanding of the relationship between the TyG index and cardiovascular outcomes.