Impact of expanded FDA indication for icosapent ethyl on enhanced cardiovascular residual risk reduction

Hypertriglyceridemia is associated with increased cardiovascular disease (CVD) risk. The Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT) demonstrated that the purified, stable ethyl ester of eicosapentaenoic acid, icosapent ethyl (IPE), added to statins reduced CVD events by 25% (p < 0.001), leading to an expanded indication in the USA. IPE is now approved as an adjunct to maximally tolerated statins to reduce CVD event risk in adults with triglyceride (TG) levels ≥150 mg/dl and either established CVD or diabetes mellitus plus ≥2 additional CVD risk factors. The new indication allows co-administration of IPE for elevated TG levels with statin treatment, enabling effective residual risk reduction in a broader at-risk population beyond what can be achieved with intensive low-density lipoprotein cholesterol control alone.

Targeting hypertriglyceridemia to mitigate cardiovascular risk: A review

A causal relationship between elevated triglycerides and cardiovascular disease is controversial, as trials of triglyceride-lowering treatments have not shown significant impact on cardiovascular outcomes. However, hypertriglyceridemia is associated with atherogenesis and risk for acute cardiovascular events that persist despite optimal statin treatment. Although most trials of triglyceride-lowering treatments have been negative, in trials of niacin and fibrates, subgroup analyses in patients with higher baseline triglycerides and lower HDL-C levels suggest reduced incidence of cardiovascular endpoints. The REDUCE-IT trial demonstrated that addition of purified prescription eicosapentaenoic acid (icosapent ethyl) 4 ​g/day in high-risk patients with triglyceride levels 135–499 ​mg/dL and optimized statin treatment significantly reduced cardiovascular events versus placebo (hazard ratio 0.75; 95% confidence interval 0.68–0.83; P ​< ​0.001). Benefit was seen regardless of baseline and on-treatment triglyceride levels, suggesting that other effects of eicosapentaenoic acid besides triglyceride reduction may have played a role.

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Hypertriglyceridemia is associated with atherogenesis & cardiovascular event risk.

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Most triglyceride treatment cardiovascular outcomes trials have been negative.

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However, icosapent ethyl significantly reduced cardiovascular events in REDUCE-IT.

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Effects of icosapent ethyl beyond triglyceride reduction may play a role.

Estimated ASCVD risk according to statin use in US adults with borderline triglycerides: Results from National Health and Nutrition Examination Survey (NHANES) 2007-2014

Background

Elevated triglycerides (TGs) are associated with atherosclerotic cardiovascular disease (ASCVD). Despite statin therapy, many US adults have borderline or elevated TG levels. Not characterized is the ASCVD risk associated with borderline TG levels in statin users, including the estimated number of adults who will sustain ASCVD events.

Methods

We studied 4986 US adults (weighted to 113 million) aged 40–74 from the National Health and Nutrition Examination Surveys 2007–2014. The proportion of persons at low (<5%), borderline (5-<7.5%), intermediate (7.5-<20%), and high (≥20%) 10-year ASCVD risk among those on statins was quantified for low (<70 ​mg/dL, 70-<100 ​mg/dL), borderline (100-<135 ​mg/dL and 135-<150 ​mg/dL), borderline high (150-<200 ​mg/dL), and elevated (≥200 ​mg/dL) TGs. Multiple logistic regression examined these TG categories in relation to high risk status.

Results

Overall, 18.6% of participants had TG ​< ​70 ​mg/dL, 24.2% TG 70-<100 ​mg/dL, 22.0% TG 100-<135 ​mg/dL, 6.2% TG 135-<150 ​mg/dL, 15.0% TG 150-<200 ​mg/dL, and 14.0% TG ​≥ ​200 ​mg/dL. Mean 10-year ASCVD risk for these groups were 5.6%, 6.9%, 7.8%, 10.3%, 9.6% and 10.8%, respectively (p ​< ​0.0001). One-fifth or more of statin users with TGs over 135 ​mg/dL were at ≥ 20% 10-year ASCVD risk and ≥60% of persons in all TG groups were at borderline or higher ASCVD risk. Compared to those with TGs <70 ​mg/dL, multiple logistic regression showed odds ratios of 3.1 to 4.6 (p ​< ​0.05 to p ​< ​0.01) for those in TG groups ≥135 ​mg/dL in the overall sample, but 3.4 to 8.1 (p ​< ​0.05 to p < 0.01) for those in TG groups of ≥100 ​mg/dL in statin users, despite adjustment including HDL-C.

Conclusion

Many US adults with borderline levels of TGs are at elevated ASCVD risk despite statin therapy, suggesting the need first for greater lifestyle modification efforts, and when indicated, evidence-based therapies known to reduce this residual ASCVD risk.

Lipid-lowering treatment and low-density lipoprotein cholesterol target achievement in patients with type 2 diabetes and acute coronary syndrome

BACKGROUND

Patients with type 2 diabetes mellitus characteristically display an atherogenic lipid profile with high triglyceride concentrations, low high-density lipoprotein cholesterol (HDL-C) concentrations and low-density lipoprotein cholesterol (LDL-C) concentrations not always elevated. It is unclear if patients with diabetes who present with an acute coronary syndrome (ACS) receive different or more-potent lipid-lowering therapy (LLT).

AIMS

To investigate lipid abnormalities in patients with and without type 2 diabetes hospitalised for an ACS, and use of LLT before admission and 4 months after the event.

METHODS

Patients were included in the observational DYSIS II study if they were hospitalised for an ACS and had a full lipid profile.

RESULTS

Of 3803 patients, diabetes was documented in 1344 (54.7%). Compared to patients without diabetes, those with diabetes had a lower mean LDL-C (101.2 vs. 112.0mg/dL; 2.6 vs. 2.9mmol/L; P<0.0001), with a greater proportion attaining concentrations<70mg/dL (1.8mmol/L) (23.9% vs. 16.0%; P<0.0001) and<55mg/dL (1.4mmol/L) (11.3% vs. 7.3%; P<0.0001), a higher mean triglyceride concentration (139.0 vs. 121.0mg/dL; 1.6 vs. 1.4mmol/L; P<0.0001) and a lower HDL-C concentration. LLT was more commonly given to patients with diabetes (77.5% vs. 58.8%; P<0.0001); there were no differences in types of therapy prescribed. Four months after hospitalisation, most patients from both groups were being treated with LLT (predominantly statin monotherapy).

CONCLUSIONS

Despite the different lipid profiles, the type of LLT prescribed did not vary depending on the presence or absence of type 2 diabetes. There was no difference in LLT in patients with and without diabetes at 4-month follow-up, except for fibrates, which were used in 2% of patients with and 1% of patients without diabetes. Statin monotherapy of intermediate potency was the predominant treatment in both groups.

Relationship between TSH Levels and the Advanced Lipoprotein Profile in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

The relationship between thyroid-stimulating hormone (TSH) and lipoprotein subfractions by Vertical Auto Profile (VAP) is unclear. We aimed to evaluate lipoprotein profiles according to TSH levels in euthyroid individuals.Material and Methods: Cross-sectional analysis of 3,525 participants from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) with no previous thyroid disease and who were not on lipid-lowering medication. Total-cholesterol and its fractions, lipoprotein subfractions, triglycerides, and triglyceride-rich lipoprotein cholesterol [TRL-C (VLDL₁₊₂-C, VLDL₃-C, IDL-C)] were determined by VAP. Associations between TSH quintiles and lipoprotein subfractions were evaluated by crude and adjusted linear regression models.Results: For the total sample, significant beta-coefficients in full adjusted models for the 5^th quintile of TSH (compared to 1^st) were found for the following VAP lipids and lipoproteins: IDL-C (β: 0.90; 0.11 to 1.69); VLDL-C (β: 2.80; 1.51 to 4.08), triglycerides (β: 18.66; 8.07 to 29.25), non-HDL-C (β: 4.63; 0.50 to 8.75 mg/dl), TRL-C (β:1.93;0.70 to 3.17), VLDL₃-C (β: 1.04; 0.50 to 1.57), as well as, TC/HDL-C (β: 0.15; 0.03 to 0.26) and TG/HDL-C ratio (β: 0.49;0.21 to 0.77). In women, similar results were found for VLDL-C, triglycerides, non-HDL-C, TRL-C, VLDL₃-C, TC/HDL-C and TG/HDL-C-ratios. In men, we also found positive associations between the highest quintile of TSH with VLDL-C, triglycerides, VLDL₃-C and TG/HDL-C.Conclusions: In the ELSA-Brasil, the highest TSH levels were mostly positively associated with lipoprotein levels, particularly TG, TRL and their remnants. Notwithstanding, our findings suggest that TSH levels within the normal range have little impact on the atherogenic profile.

Prevalence of United States adults with triglycerides ≥ 135 mg/dL: NHANES 2007-2014

n/a - brief communication.

TO001EFFECTS OF THE BET-INHIBITOR APABETALONE ON CARDIOVASCULAR EVENTS IN PATIENTS WITH TYPE 2 DIABETES MELLITUS AND ACUTE CORONARY SYNDROME, ACCORDING TO PRESENCE OR ABSENCE OF CHRONIC KIDNEY DISEASE. A BETONMACE TRIAL REPORT

Background and Aims

Patients with type 2 diabetes (T2D) and acute coronary syndrome (ACS) are at high risk for recurrent cardiovascular (CV) events, particularly in the presence of chronic kidney disease (CKD). Apabetalone (APB) is a novel inhibitor of bromodomain and extraterminal (BET) proteins. Its cardiovascular efficacy and safety were evaluated in a phase 3 trial, BETonMACE.

Method

BETonMACE was a randomized, double-blind, comparison of effects of ABP or placebo (PBO) on major adverse CV events (MACE) defined as CV-death, non-fatal myocardial infarct or stroke, in 2425 pts with T2D and recent ACS. Here we report MACE plus CHF hospitalization in subjects with or without CKD Stage 3.

Results

Baseline characteristics: median age 62 years, 25.6% female, 87.6% white, 90% high intensity statin use, mean LDL-C 70.3 and HDL-C 33.3 mg/dl, median HbA1c 7.3%, and 11% with CKD Stage 3. Overall in the trial, MACE plus CHF hospitalization occurred in 139 (11.5%) patients with ABP and 173 (14.3%) with PBO (HR 0.78, 95% CI 0.63-0.98). In the subgroup with CKD, MACE plus CHF hospitalization occurred in 16 (12.9%) on APB and 41 (25%) on PBO (HR 0.48, 95% CI 0.26-0.89). In the subgroup without CKD, MACE plus CHF hospitalization occurred in 123 (11.3%) and 132 (12.7%) with APB or PBO, respectively (HR 0.89, 95% CI 0.70-1.

Conclusion

Patients with T2D, ACS, and Stage 3 CKD have a very high risk of subsequent MACE plus CHF hospitalization. The BET protein inhibitor ABP may reduce this risk.

Effect of Apabetalone Added to Standard Therapy on Major Adverse Cardiovascular Events in Patients With Recent Acute Coronary Syndrome and Type 2 Diabetes: A Randomized Clinical Trial

IMPORTANCE

Bromodomain and extraterminal proteins are epigenetic regulators of gene transcription. Apabetalone is a selective bromodomain and extraterminal protein inhibitor targeting bromodomain 2 and is hypothesized to have potentially favorable effects on pathways related to atherothrombosis. Pooled phase 2 data suggest favorable effects on clinical outcomes.

OBJECTIVE

To test whether apabetalone significantly reduces major adverse cardiovascular events.

DESIGN, SETTING, AND PARTICIPANTS

A randomized, double-blind, placebo-controlled trial, conducted at 190 sites in 13 countries. Patients with an acute coronary syndrome in the preceding 7 to 90 days, type 2 diabetes, and low high-density lipoprotein cholesterol levels were eligible for enrollment, which started November 11, 2015, and ended July 4, 2018, with end of follow-up on July 3, 2019.

INTERVENTIONS

Patients were randomized (1:1) to receive apabetalone, 100 mg orally twice daily (n = 1215), or matching placebo (n = 1210) in addition to standard care.

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite of time to the first occurrence of cardiovascular death, nonfatal myocardial infarction, or stroke.

RESULTS

Among 2425 patients who were randomized (mean age, 62 years; 618 women [25.6%]), 2320 (95.7%) had full ascertainment of the primary outcome. During a median follow-up of 26.5 months, 274 primary end points occurred: 125 (10.3%) in apabetalone-treated patients and 149 (12.4%) in placebo-treated patients (hazard ratio, 0.82 [95% CI, 0.65-1.04]; P = .11). More patients allocated to apabetalone than placebo discontinued study drug (114 [9.4%] vs 69 [5.7%]) for reasons including elevations of liver enzyme levels (35 [2.9%] vs 11 [0.9%]).

CONCLUSIONS AND RELEVANCE

Among patients with recent acute coronary syndrome, type 2 diabetes, and low high-density lipoprotein cholesterol levels, the selective bromodomain and extraterminal protein inhibitor apabetalone added to standard therapy did not significantly reduce the risk of major adverse cardiovascular events.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02586155.

Effect of Evolocumab on Non-High-Density Lipoprotein Cholesterol, Apolipoprotein B, and Lipoprotein(a): A Pooled Analysis of Phase 2 and Phase 3 Studies

Background

Dyslipidemia guidelines recommend non‐high‐density lipoprotein cholesterol (non‐HDL‐C) and apolipoprotein B (ApoB) as additional targets of therapy and consider lipoprotein(a) a significant cardiovascular risk marker. The current analysis evaluates the effects of evolocumab on these parameters in various patient populations over time.

Methods and Results

Data from 7690 patients, 4943 of whom received at least 1 dose of evolocumab, in 15 phase 2 and phase 3 studies with a duration ranging from 12 weeks to 5 years were pooled based on study length, patient population, and ezetimibe or placebo comparator groups. Patients could receive intensive statin therapy but not in the statin intolerance and monotherapy studies. The effects of evolocumab on percent change from baseline for non‐HDL‐C, ApoB, and lipoprotein(a) and achievement of treatment goals for non‐HDL‐C and ApoB were examined. Compared with placebo, evolocumab at both approved dosing regimens substantially reduced mean non‐HDL‐C (Q2W dose: −49% to −56%, monthly dose: −48% to −52%), mean ApoB (Q2W dose: −46% to −52%, monthly dose: −40% to −48%), and median lipoprotein(a) (Q2W dose: −22% to −38%, monthly dose: −20% to −33%) at 12 weeks. Effects on all 3 parameters persisted over 5 years. Lipid‐lowering effects were consistent among the patient populations examined (hypercholesterolemia/mixed dyslipidemia, statin intolerance, heterozygous familial hypercholesterolemia, and type 2 diabetes mellitus).

Conclusions

In this pooled analysis, evolocumab substantially reduced non‐HDL‐C, ApoB, and lipoprotein(a) compared with placebo. The effect was consistent and maintained in various patient populations over 5 years.

Risk of cardiovascular events in patients with hypertriglyceridaemia: A review of real-world evidence

AIMS

To describe the real-world prevalence and consequences of hypertriglyceridaemia.

MATERIALS AND METHODS

We searched two large patient databases, the National Health and Nutrition Examination Survey (NHANES) database (2007-2014) and the Optum Research Database, as well as electronic medical records from two Kaiser Permanente regions.

RESULTS

The NHANES data showed that ~26% of US adults, including nearly one-third of statin users, had at least borderline hypertriglyceridaemia (triglycerides [TGs] ≥1.69 mmol/L), and ~40% of adults with diabetes had levels of ≥150 mg/dL despite statin use. The Optum analyses demonstrated that those with TG levels ≥1.69 mmol/L who were on statins had a significantly increased risk of composite initial major cardiovascular (CV) events (hazard ratio [HR] 1.26, 95% confidence interval [CI] 1.19-1.34; P < 0.001 vs. patients with TGs <150 mg/dL). This was accompanied by increased healthcare utilization and direct healthcare costs (HR 1.12, 95% CI 1.08-1.16; P < 0.001). In the analyses of the Kaiser Permanente records, patients with diabetes and TG levels 2.26-5.64 mmol/L had significantly higher adjusted incidence rates of non-fatal myocardial infarction (rate ratio 1.30, 95% CI 1.08-1.58; P = 0.006), non-fatal stroke (rate ratio 1.23; 95% CI 1.01-1.49; P = 0.037) and coronary revascularization (rate ratio 1.21; 95% CI 1.02-1.43; P = 0.027), but not unstable angina (rate ratio 1.33; 95% CI 0.87-2.03; P = 0.185) compared with patients with TG levels <1.69 mmol/L.

CONCLUSIONS

Real-world analyses suggest that elevated TGs are prevalent and commonly associated with increased CV risk. CV outcomes trials in patients with established hypertriglyceridaemia will clarify whether strategies to reduce TG levels can ameliorate residual CV risk in patients taking statins.

Continuity of care and outpatient management for patients with and at high risk for cardiovascular disease during the COVID-19 pandemic: A scientific statement from the American Society for Preventive Cardiology

The coronavirus disease 2019 (COVID-19) pandemic has consumed our healthcare system, with immediate resource focus on the management of high numbers of critically ill patients. Those that fare poorly with COVID-19 infection more commonly have cardiovascular disease (CVD), hypertension and diabetes. There are also several other conditions that raise concern for the welfare of patients with and at high risk for CVD during this pandemic. Traditional ambulatory care is disrupted and many patients are delaying or deferring necessary care, including preventive care. New impediments to medication access and adherence have arisen. Social distancing measures can increase social isolation and alter physical activity and nutrition patterns. Virtually all facility based cardiac rehabilitation programs have temporarily closed. If not promptly addressed, these changes may result in delayed waves of vulnerable patients presenting for urgent and preventable CVD events. Here, we provide several recommendations to mitigate the adverse effects of these disruptions in outpatient care. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be continued in patients already taking these medications. Where possible, it is strongly preferred to continue visits via telehealth, and patients should be counselled about promptly reporting new symptoms. Barriers to medication access should be reviewed with patients at every contact, with implementation of strategies to ensure ongoing provision of medications. Team-based care should be leveraged to enhance the continuity of care and adherence to lifestyle recommendations. Patient encounters should include discussion of safe physical activity options and access to healthy food choices. Implementation of adaptive strategies for cardiac rehabilitation is recommended, including home based cardiac rehab, to ensure continuity of this essential service. While the practical implementation of these strategies will vary by local situation, there are a broad range of strategies available to ensure ongoing continuity of care and health preservation for those at higher risk of CVD during the COVID-19 pandemic.

New Perspectives on Atherogenic Dyslipidaemia and Cardiovascular Disease

Over the past few decades, atherogenic dyslipidaemia has become one of the most common phenotypic presentations of lipid abnormalities, being strongly and unequivocally associated with an increased risk of cardiovascular (CV) disease. Despite the excellent results achieved from statin and non-statin management of LDL cholesterol and CV events prevention, there still remains a significant residual risk, associated with the prevalence of non-LDL cholesterol lipid patterns characterised by elevated triglyceride levels, low HDL cholesterol, a preponderance of small and dense LDL particles, accumulation of remnant lipoproteins and postprandial hyperlipidaemia. These qualitative and quantitative lipid modifications are largely associated with insulin resistance, type 2 diabetes and obesity, the prevalence of which has grown to epidemic proportions throughout the world. In this review, we analyse the pathophysiology of this particular dyslipidaemia, its relationship with the development of atherosclerotic CV disease and, finally, briefly describe the therapeutic approaches, including changes in lifestyle and current pharmacological interventions to manage these lipid alterations aimed at preventing CV events.

Spotlight from the American Society for Preventive Cardiology on Key Features of the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guidelines on the Management of Blood Cholesterol

The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol retains focus on recommendations for statin treatment in the original four statin-eligible groups [those with atherosclerotic cardiovascular disease (ASCVD), diabetes, low-density lipoprotein cholesterol (LDL-C) ≥ 190 mg/dL, and higher risk primary prevention] without the use of treatment initiation or target LDL-C levels from the earlier 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline, but has several new features. First, patients with primary prevention are divided into those who are at low (< 5%), borderline (5% to < 7.5%), intermediate (7.5% to < 20%), and high (≥ 20%) risk based on the ASCVD risk estimator. Moreover, the new guideline goes further to consider a wider range of factors [now called "risk enhancers"-premature family history of ASCVD, persistently high LDL-C, chronic kidney disease (CKD), metabolic syndrome, conditions specific to women, inflammatory diseases, and high-risk ethnicities] that can be used to better inform the treatment decision. Moreover, more detailed recommendations on how the results of coronary calcium scanning can be used to inform the treatment decision are provided, including how it may be used to "de-risk" certain patients for delaying or avoiding the use of statin therapy. There are also specific sections for cholesterol management in other patient subgroups including women, children, certain ethnic groups, those with CKD, chronic inflammatory disorders and HIV, as well as discussion on the management of hypertriglyceridemia. Importantly, for persons with known ASCVD, a distinction is made for those who are at "very high risk" based on having had two major ASCVD events or one major event and two or more other high risk conditions, such as diabetes or other major risk factors, or bypass surgery or percutaneous intervention. Finally, the concept of a threshold LDL-C for initiating a non-statin therapy (after considering highest tolerated statin dosage) is provided, with ezetimibe recommended as the key non-statin to be added if the LDL-C still remains ≥ 70 mg/dL for all ASCVD patients, and in those who are at "very high risk", further consideration for using a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor. While the new guideline does have greater detail (and arguably, complexity), the refinements provide a strategy for guiding the clinician to target both statin and non-statin therapy to those most likely to derive benefit.

Abstract WP219: Lipoprotein Subfractions Are Associated With Stroke Among 9,795 Patients in the Field Trial

Background: In the FIELD trial, a 5-year randomized double-blind placebo-controlled trial of fenofibrate vs. placebo in 9,795 adults with type 2 diabetes (T2D), the only standard lipid parameter correlating with microvascular (renal) events was triglycerides. Given the high prevalence of stroke among diabetic patients, we explored associations between lipoprotein subfractions and risk for stroke in the FIELD trial.

Methods: We performed ultracentrifugation using the vertical auto profile (VAP, Atherotech) on plasma (baseline and after 6 weeks of fenofibrate). Analyses were performed using Cox proportional hazards and logistic regression for new on-study events. Results were adjusted for gender and fenofibrate or placebo allocation.

Results: HDL related analytes (HDL-C, HDL3-C, apo A1, apoA2) correlated with reduced risk for all stroke. LDL and its subfractions and Lp(a)-C did not. VLDL and its subfractions, non-HDL-C, triglycerides, apo B, apo En, various ratios incorporating apo C3, and the ratios of apoB/A1 and apoB/apoA2 all correlated with increased risk for stroke.

Conclusions: VAP identifies multiple lipoprotein subclasses, apoproteins, and VAP subclass/apoprotein ratios associated with stroke. Many of these measures improved with fenofibrate therapy.

High-Sensitivity C-Reactive Protein Discordance With Atherogenic Lipid Measures and Incidence of Atherosclerotic Cardiovascular Disease in Primary Prevention: The ARIC Study

Background Inflammation is an independent causal risk factor for atherosclerotic cardiovascular diseases (ASCVDs). However, whether hsCRP (high-sensitivity C-reactive protein) is prognostic across various levels of atherogenic lipid measures such as low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, apolipoprotein B and total cholesterol/high-density lipoprotein cholesterol in primary prevention is unknown. Methods and Results We studied 9748 ARIC (Atherosclerosis Risk in Communities) study participants who were free of ASCVD at baseline (visit 4, 1996-1998) and had measurements of lipids, apolipoprotein B, and hsCRP. We used multivariable adjusted Cox models to estimate the risk of incident ASCVD events associated with hsCRP levels (less than/greater than or equal to median) in individuals where triple lipid measures combined (low-density lipoprotein cholesterol + non-high-density lipoprotein cholesterol + apolipoprotein B) or quadruple measures combined [triple + total cholesterol/high-density lipoprotein cholesterol] were less than versus greater than or equal to median cut points. Mean age of participants was 62.6±5.6 years; 59% women, 22% black. There were 1574 ASCVD events over median (interquartile range) follow-up of 18.4 (12.8-19.5) years, and discordance between hsCRP and lipid measures was prevalent in 50% of the population. hsCRP greater than or equal to median (2.4 mg/L), compared with less than median, was associated with an increased risk of ASCVD in individuals with less than median levels of the triple (adjusted hazard ratio, 1.33; 95% CI, 1.09-1.60) and quadruple (adjusted hazard ratio,1.47; 95% CI, 1.18-1.85) lipid measures. Such increased risk was consistent among individuals with low (<7.5%) or high (≥7.5%) estimated risk by the pooled cohort equation. There were no interactions by sex, diabetes mellitus, or statin use. Conclusions Our findings suggest that inflammation is independently associated with ASCVD regardless of atherogenic lipid levels and pooled cohort equation risk score in individuals without known ASCVD.

Associations between cardiovascular disease, cancer, and very low high-density lipoprotein cholesterol in the REasons for Geographical and Racial Differences in Stroke (REGARDS) study

Aims

Relatively little is known about the health outcomes associated with very low plasma concentrations of high-density lipoprotein cholesterol (HDL-C) mainly because of the small numbers of individuals with such extreme values included in clinical trials. We, therefore, investigated the association between low and very low HDL-C concentration at baseline and incident all-cause-mortality, death from malignant disease (i.e. cancer), and with fatal or non-fatal incident coronary heart disease (CHD) in individuals from the Reasons for Geographical And Racial Differences in Stroke (REGARDS) study.

Methods and results

Analysis was based on 21 751 participants from the REGARDS study who were free of CHD, other cardiovascular disease, and cancer at baseline and were categorized by baseline HDL-C into <30 mg/dL (very low), 30-<40 mg/dL (low), and ≥40 mg/dL (reference). A series of incremental Cox proportional hazards models were employed to assess the association between the HDL-C categories and outcomes. Statistical analysis was performed using both complete case methods and multiple imputations with chained equations. After adjustment for age, race, and sex, the hazard ratios (HRs) comparing the lowest and highest HDL-C categories were 1.48 [95% confidence interval (CI) 1.28-1.73] for all-cause mortality, 1.35 (95% CI 1.03-1.77) for cancer-specific mortality and 1.39 (95% CI 0.99-1.96) for incident CHD. These associations became non-significant in models adjusting for demographics, cardiovascular risk factors, and treatment for dyslipidaemia. We found evidence for an HDL paradox, whereby low HDL (30-<40 mg/dL) was associated with reduced risk of incident CHD in black participants in a fully adjusted complete case model (HR 0.63; 95% CI 0.46-0.88) and after multiple imputation analyses (HR 0.76; 95% CI 0.58-0.98). HDL-C (<30 mg/dL) was significantly associated with poorer outcomes in women for all outcomes, especially with respect to cancer mortality (HR 2.31; 95% CI 1.28-4.16) in a fully adjusted complete case model, replicated using multiple imputation (HR 1.81; 95% CI 1.03-3.20).

Conclusion

Low HDL-C was associated with reduced risk of incident CHD in black participants suggesting a potential HDL paradox for incident CHD. Very low HDL-C in women was significantly associated with cancer mortality in a fully adjusted complete case model.

Modern prevalence of the Fredrickson-Levy-Lees dyslipidemias: findings from the Very Large Database of Lipids and National Health and Nutrition Examination Survey

INTRODUCTION

Five decades ago, Fredrickson, Levy, and Lees (FLL) qualitatively characterized clinical dyslipidemias with specific implications for cardiovascular and non-cardiovascular morbidity and mortality. They separated disorders of elevated cholesterol and triglycerides into five phenotypes (types I-V) based on their lipoprotein profile. Although clinicians generally consider them rare entities, modern FLL prevalence may be greater than previously reported.

MATERIAL AND METHODS

We performed a cross-sectional analysis in 5,272 participants from the 2011-2014 National Health and Nutrition Examination Survey and 128,506 participants from the Very Large Database of Lipids study with complete, fasting lipid profiles. We used a validated algorithm to define FLL phenotypes employing apolipoprotein B, total cholesterol, and triglycerides.

RESULTS

Overall prevalence of FLL phenotypes was 33.9%. FLL prevalence in the general population versus clinical lipid database was: type I (0.05 vs. 0.02%), type IIa (3.2 vs. 3.9%), type IIb (8.0 vs. 10.3%), type III (2.0 vs. 1.7%), type IV (20.5 vs. 24.1%), and type V (0.15 vs. 0.13%). Those aged 40-74 years had a higher overall prevalence compared to other age groups (p < 0.001) and men had overall higher prevalence than women (p < 0.001). Those with diabetes (51.6%) or obese BMI (49.0%) had higher prevalence of FLL phenotypes compared to those without diabetes (31.3%; p < 0.001) and normal BMI (18.3%; p < 0.001).

CONCLUSIONS

FLL phenotypes are likely far more prevalent than appreciated in clinical practice, in part due to diabetes and obesity epidemics. Given the prognostic and therapeutic importance of these phenotypes, their identification becomes increasingly important in the era of precision medicine.

Modern prevalence of dysbetalipoproteinemia (Fredrickson-Levy-Lees type III hyperlipoproteinemia)

INTRODUCTION

Dysbetalipoproteinaemia (HLP3) is a disorder characterized by excess cholesterol-enriched, triglyceride-rich lipoprotein remnants in genetically predisposed individuals that powerfully promote premature cardiovascular disease if untreated. The current prevalence of HLP3 is largely unknown.

MATERIAL AND METHODS

We performed cross-sectional analysis of 128,485 U.S. adults from the Very Large Database of Lipids (VLDbL), using four algorithms to diagnose HLP3 employing three Vertical Auto Profile ultracentrifugation (UC) criteria and a previously described apolipoprotein B (apoB) method. We evaluated 4,926 participants from the 2011-2014 National Health and Nutrition Examination Survey (NHANES) with the apoB method. We examined demographic and lipid characteristics stratified by presence of HLP3 and evaluated lipid characteristics in those with HLP3 phenotype discordance and concordance as determined by apoB and originally defined UC criteria 1.

RESULTS

In U.S. adults in VLDbL and NHANES, a 1.7-2.0% prevalence is observed for HLP3 with the novel apoB method as compared to 0.2-0.8% prevalence in VLDbL via UC criteria 1-3. Participants who were both apoB and UC criteria HLP3 positive had higher remnant particles as well as more elevated triglyceride/apoB and total cholesterol/apoB ratios (all p < 0.001) than those who were apoB method positive and UC criteria 1 negative.

CONCLUSIONS

HLP3 may be more prevalent than historically and clinically appreciated. The apoB method increases HLP3 identification via inclusion of milder phenotypes. Further work should evaluate the clinical implications of HLP3 diagnosis at various lipid algorithm cut-points to evaluate the ideal standard in the modern era.

Most important advances in preventive cardiology during this past decade: Viewpoint from the American Society for Preventive Cardiology

The rapidly expanding field of preventive cardiology has brought with it several major advances in the past decade. Changes in guidelines for cholesterol mangement focusing on the identification of "statin eligible groups" and removal of actual low-density lipoprotein cholesterol (LDL-C) targets, in particular, as well as lower targets for blood pressure in updated hypertension guidelines, have made a major impact on healthcare. The availability of the sodium glucose transport protein-2 (SGLT2) inhibitors and glucagon-like peptide -1 receptor antagonists (GLP1-RA) for managing diabetes have shifted our focus in diabetes care beyond glucose lowering to addressing cardiovascular risk reduction. While many prior trials of fish oil therapy have failed to show benefit, the recent Reduction of Cardiovascular Events With EPA - Intervention Trial (REDUCE-IT) testing the efficacy of icosapent ethyl has shown dramatic benefit in further addressing residual atherosclerotic cardiovascular disease (ASCVD) risk beyond statin therapy not only in those with known ASCVD, but also in diabetic patients with multiple risk factors. The past decade also ushered in confirmation of the inflammation hypothesis of atherosclerosis with the Canakinumab Anti-Inflammatory Thrombosis Outcomes Study (CANTOS) using canakinumab, despite the fact the therapy was not approved by the Food and Drug Administration (FDA) for cardiovascular risk reduction. Also, to improve our understanding of heart disease in women, the emergence of novel concepts of ischemia or myocardial infarction in those with normal or nonobstructive atherosclerotic disease has been a major advance. Moreover, the past decade brought the emergence of proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibody therapy and the cardiovascular risk reduction benefits seen in the Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) and Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab (ODYSSEY OUTCOMES) trials, providing further evidence-based therapy for additional reduction of ASCVD risk beyond statin therapy. The PCSK9 monoclonal antibodies have facilitated the attainment of LDL-C levels never previously thought possible. Finally with the mRNA interference therapy inclisiran in development, we may soon have a "vaccine-like" approach for addressing dyslipidemia and atherosclerosis.

Elevated Triglycerides (≥150 mg/dL) and High Triglycerides (200-499 mg/dL) Are Significant Predictors of New Heart Failure Diagnosis: A Real-World Analysis of High-Risk Statin-Treated Patients

Purpose

Real-world data may provide insight into relationships between high triglycerides (TG), a modifiable cardiovascular (CV) risk factor, and increased heart failure (HF) risk.

Patients and methods

This retrospective administrative claims analysis included statin-treated patients aged ≥45 years with diabetes and/or atherosclerotic CV disease enrolled in 2010 and followed for ≥6 months to March 2016. Patients with TG ≥150 mg/dL and a comparator cohort with TG <150 mg/dL and high-density lipoprotein cholesterol >40 mg/dL were included. A sub-analysis was conducted in patients with TG 200–499 mg/dL. Hazard ratios (HR) were calculated from multivariate analyses controlled for patient characteristics and comorbidities using Cox proportional hazard modeling. New diagnosis of HF required diagnosis in the follow-up period without prior evidence of HF.

Results

Multivariate analyses revealed a 19% higher rate of new HF diagnosis in the TG ≥150 mg/dL cohort (HR=1.192; 95% confidence interval [CI]=1.134–1.252; P<0.001; n=24,043) and a 24% higher rate in the TG 200–499 mg/dL sub-cohort (HR=1.235; 95% CI=1.160–1.315; P<0.001; n=11,657), each versus the comparator cohort (n=30,218).

Conclusion

In a real-world analysis of statin-treated patients with high CV risk, elevated and high TG were significant predictors of new HF diagnosis.

Residual Hypertriglyceridemia and Estimated Atherosclerotic Cardiovascular Disease Risk by Statin Use in U.S. Adults With Diabetes: National Health and Nutrition Examination Survey 2007-2014

OBJECTIVE

Hypertriglyceridemia (HTG) is common in patients with diabetes, and statins remain the first-line therapy. However, the proportion of patients with diabetes having elevated triglycerides (TGs) on statin treatment and their atherosclerotic cardiovascular disease (ASCVD) risk has not been described. We quantified the prevalence of HTG in U.S. adults with diabetes currently treated versus not treated with statins and the estimated 10-year ASCVD risk.

RESEARCH DESIGN AND METHODS

Among 1,448 U.S. adults aged 20 years and over with diabetes (projected to 24.4 million) in the 2007-2014 National Health and Nutrition Examination Survey (NHANES), we compared the prevalence of borderline HTG (TG 150-199 mg/dL) and HTG (TG ≥200 mg/dL) by statin use and LDL cholesterol (LDL-C) levels, and we used logistic regression to identify risk factors for HTG. We also estimated the 10-year ASCVD risk in those without prior ASCVD.

RESULTS

The prevalence of borderline HTG and HTG was 20.0% and 19.5%, respectively, in statin users and 20.1% and 25.3%, respectively, in nonstatin users (P < 0.0001). Even among statin users with LDL-C <70 mg/dL, borderline HTG prevalence was 16.8% and HTG prevalence was 16.7%. Approximately 77.5% of those with HTG had an estimated 10-year ASCVD risk of ≥7.5%, with almost 40% of statin users having ASCVD risk ≥20%.

CONCLUSIONS

Residual HTG occurs in over one-fifth (∼5.5 million) of U.S. adults with diabetes, including those on statin therapy and with well-controlled LDL-C. Over three-quarters of adults with diabetes with HTG are at moderate or high 10-year risk for ASCVD. Greater efforts are needed to promote lifestyle and pharmacologic means to address residual HTG.