Low-density lipoprotein-dependent and -independent effects of cholesterol-lowering therapies on C-reactive protein: a meta-analysis

Anti-inflammatory effect of purified dietary anthocyanin in adults with hypercholesterolemia: a randomized controlled trial

BACKGROUND AND AIM

Atherosclerosis is a chronic inflammatory disease and previous studies have demonstrated that anthocyanin inhibits atherosclerosis. In the present study, we explored the effects of anthocyanins on inflammatory cytokines in hypercholesterolemic adults and cell lines.

METHODS AND RESULTS

A total of 150 subjects with hypercholesterolemia consumed a purified anthocyanin mixture (320 mg/d) or a placebo twice a day for 24 weeks in a randomized, double-blind trial. Anthocyanin consumption significantly decreased the levels of serum high sensitivity C-reactive protein (hsCRP) (-21.6% vs. -2.5%, P = 0.001), soluble vascular cell adhesion molecule-1 (sVCAM-1) (-12.3% vs. 0.4%, P = 0.005) and plasma IL-1β (-12.8% vs. -1.3%, P = 0.019) compared to the placebo. We also found a significant difference in the LDL-cholesterol (-10.4% vs. 0.3%, P = 0.030) and HDL-cholesterol level changes (14.0% vs. -0.9%, P = 0.036) between the two groups. In cell culture assays in vitro, purified anthocyanin mixture, delphinidin-3-Ο-β-glucoside (Dp-3g) and cyanidin-3-Ο-β-glucoside (Cy-3g) inhibited IL-6 and IL-1β-induced CRP production (P < 0.05) in HepG2 cell line and LPS-induced VCAM-1 secretion (P < 0.05) in porcine iliac artery endothelial cell line respectively in a dose-dependent manner. In addition, the reduction of inflammatory cytokines associated with anthocyanin mixture was stronger when compared with the effects of Dp-3g and Cy-3g separately (P < 0.05).

CONCLUSIONS

Anthocyanin mixture reduced the inflammatory response in hypercholesterolemic subjects. In addition, different anthocyanin compounds were found to have additive or synergistic effects in mediating anti-inflammatory responses in vitro cell culture assays.

High-sensitivity C-reactive protein and cardiovascular disease: a resolute belief or an elusive link?

The role of inflammation in the propagation of atherosclerosis and susceptibility to cardiovascular (CV) events is well established. Of the wide array of inflammatory biomarkers that have been studied, high-sensitivity C-reactive protein (hsCRP) has received the most attention for its use in screening and risk reclassification and as a predictor of clinical response to statin therapy. Although CRP is involved in the immunologic process that triggers vascular remodeling and plaque deposition and is associated with increased CV disease (CVD) risk, definitive randomized evidence for its role as a causative factor in atherothrombosis is lacking. Whether measurement of hsCRP levels provides consistent, clinically meaningful incremental predictive value in risk prediction and reclassification beyond conventional factors remains debated. Despite publication of guidelines on the use of hsCRP in CVD risk prediction by several leading professional organizations, there is a lack of clear consensus regarding the optimal clinical use of hsCRP. This article reviews 4 distinct points from the literature to better understand the current state and application of hsCRP in clinical practice: 1) the biology of hsCRP and its role in atherosclerosis; 2) the epidemiological association of hsCRP with CVD; 3) the quality of hsCRP as a biomarker of risk; and 4) the use of hsCRP as a tool to initiate or tailor statin therapy. Furthermore, we highlight recommendations from societies and important considerations when using hsCRP to guide treatment decisions in the primary prevention setting.

Statin use in giant cell arteritis: a retrospective study

OBJECTIVE

(1) To examine the association between statin use and giant cell arteritis (GCA); (2) to compare the clinical features and disease course of GCA among statin users and nonusers.

METHODS

For this retrospective study, we reviewed the medical records of all patients with biopsy-positive GCA diagnosed between 1998 and 2008. Using a case-control design, we compared the frequency of statin use in GCA patients to non-GCA population-based subjects who were randomly selected and individually matched by sex, age, and calendar year to the GCA cases. Statin use at diagnosis or index date and during followup was abstracted. In subjects with GCA, clinical information at diagnosis and followup was collected.

RESULTS

We included 594 patients, 297 with GCA (73% female), mean age at diagnosis 75 years. The rate of statin exposure at index date was 18.1% for GCA patients versus 33.3% for controls (p < 0.001). Patients using statins were less likely to develop GCA compared with patients not using statins (OR 0.31, 95% CI 0.15-0.6, p < 0.001), even after adjustment for cardiovascular risk factors. Among patients with GCA, the presenting clinical features and acute-phase reactants were similar in patients receiving statins compared to those not on statin therapy. These 2 groups were also similar with regard to relapse rate, prednisone tapering, and overall survival.

CONCLUSION

Patients using statins may be less likely to develop GCA compared to patients who are not using statins. Statin use does not appear to modify the clinical presentation or the course of the disease.

Comparison of anti-inflammatory effects and high-density lipoprotein cholesterol levels between therapy with quadruple-dose rosuvastatin and rosuvastatin combined with ezetimibe

BACKGROUND

Statins are frequently administered to reduce low-density lipoprotein cholesterol (LDL-C) and vascular inflammation, because LDL-C and high sensitive C-reactive protein (hs-CRP) are associated with high risk for cardiovascular events. When statins do not reduce LDL-C to desired levels in high-risk patients with coronary artery disease (CAD), ezetimibe can be added or the statin dose can be increased. However, which strategy is more effective for treating patients with CAD has not been established. The present study compares anti-inflammatory effects and lipid profiles in patients with CAD and similar LDL-C levels who were treated by increasing the statin dose or by adding ezetimibe to the original rosuvastatin dose to determine the optimal treatment for such patients.

METHODS

46 patients with high-risk CAD and LDL-C and hs-CRP levels of >70 mg/dL and >1.0 mg/L, respectively, that were not improved by 4 weeks of rosuvastatin (2.5 mg/day) were randomly assigned to receive 10 mg (R10, n = 24) of rosuvastatin or 2.5 mg/day of rosuvastatin combined with 10 mg/day of ezetimibe (R2.5/E10, n = 22) for 12 weeks. The primary endpoint was a change in hs-CRP.

RESULTS

Baseline characteristics did not significantly differ between the groups. At 12 weeks, LDL-C and inflammatory markers (hs-CRP, interleukin-6, tumour necrosis factor-alpha and pentraxin 3) also did not significantly differ between the two groups (LDL-C: R10 vs. R2.5/E10: -19.4 ± 14.2 vs. -22.4 ± 14.3 mg/dL). However, high-density lipoprotein cholesterol (HDL-C) was significantly improved in the R10, compared with R2.5/E10 group (4.6 ± 5.9 vs. 0.0 ± 6.7 mg/dL; p < 0.05).

CONCLUSION

Both enhanced therapies exerted similar anti-inflammatory effects under an equal LDL-C reduction in patients with high-risk CAD despite 2.5 mg/day of rosuvastatin. However, R10 elevated HDL-C more effectively than R2.5/E10.

TRIAL REGISTRATION

UMIN000003746.

Effects of pravastatin and atorvastatin on HDL cholesterol and glucose metabolism in patients with dyslipidemia and glucose intolerance: the PRAT study

AIMS

While statins have the property of increasing high-density lipoprotein cholesterol (HDL-C) in addition to lowering low-density lipoprotein cholesterol (LDL-C), a potential adverse effect on glucose metabolism has raised a concern over statin therapy. In a comparative trial, we investigated the effects of low-dose pravastatin and atorvastatin on HDL-C and glucose metabolism in patients with elevated LDL-C levels and glucose intolerance.

METHODS

Eligible patients were men aged ≥20 years or postmenopausal women who had LDL-C ≥140 mg/dL, HDL-C <80 mg/dL, and triglycerides <500 mg/dL and who had glucose intolerance. The patients were randomly allocated to either pravastatin (10 mg/day) or atorvastatin (10 mg/day) treatment for 12 months in an unblinded fashion. The percent changes from the baseline were compared between the treatments.

RESULTS

Of 202 patients who were randomized to either of the two treatments, 195 patients started the study medication, and 187 patients underwent the follow-up measurements at 6 or 12 months (pravastatin, n= 93; atorvastatin, n= 94). HDL-C increased by 4.3% (p= 0.03) in the pravastatin group and by 5.8% (p=0.0005) in the atorvastatin group and showed no between-group difference (p= 0.38). LDL-C decreased substantially in both groups (pravastatin, 21.5%; atorvastatin, 35.5%), and the decrease was much greater in the atorvastain group (p<0.0001). HbA1c slightly increased in both groups, but showed no measurable difference in the increase between the two treatments (p=0.30).

CONCLUSION

Pravastatin and atorvastatin of 10 mg per day each increased HDL-C by almost the same extent. These two statins did not show a differential effect on glucose metabolism.

Effect of High-Dose Statin Versus Low-Dose Statin Plus Ezetimibe on Endothelial Function

Background:

Combining low-dose statin and ezetimibe reduces the low-density lipoprotein cholesterol (LDL-C) similar to high-dose statin. However, whether there is a difference in the effect of these 2 lipid-lowering regimes on endothelial function is still controversial.

Methods:

We performed a systematic search of databases (MEDLINE [1950 to September 2011], EMBASE [1966 to September 2011]) and references of identified studies. Completely published randomized controlled trials comparing the effect of high-dose statin with low-dose stain plus ezetimibe on endothelial function (flow-mediated dilation [FMD] method) were included in this study.

Results:

Six trials with a total of 213 participants were included in the meta-analysis. The pooled weighted mean difference of FMD did not differ between the 2 lipid-lowering regimes (0.22%; 95% confidence interval [CI]: −0.85%-1.29%, P = .68). Furthermore, no significant reduction in LDL-C and C-reactive protein (CRP) occurred with high-dose statin versus low-dose statin plus ezetimibe (pooled weighted mean differences of LDL-C and CRP were −4.12 mg/dL, 95% CI: −9.54-1.12 mg/dL, P = .12, and −0.02 mg/L, 95% CI: −0.31-0.27 mg/L, P = .89, respectively).

Conclusions:

Based on the currently available evidence, combining a low-dose statin with ezetimibe may provide similar beneficial effects on endothelial function as high-dose statin.

Effect of soy isoflavones on circulating C-reactive protein in postmenopausal women: meta-analysis of randomized controlled trials

Strong evidence suggests that C-reactive protein (CRP) is a novel risk factor for cardiovascular disease. We aimed to examine the effect of soy isoflavones on circulating CRP concentrations in postmenopausal women by conducting a meta-analysis of randomized controlled trials. We performed a literature search using PubMed, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases in December 2010 for randomized controlled trials conducted in postmenopausal women, using soy foods with isoflavones or isoflavone extracts as treatment, and with a report of CRP change. A meta-analysis was performed using a fixed-effects model or a random-effects model to calculate the combined effect size. In addition, subgroup and metaregression analyses were carried out to examine the influences of study designs and participant characteristics on the effect estimates. A pooled analysis of 14 trials showed a slight, but not significant, reduction of 0.17 mg/L (95% CI, -0.38 to 0.04; P = 0.12) in CRP concentrations among postmenopausal women with soy isoflavone intervention compared with controls. No substantial heterogeneity was observed. Subgroup analyses showed that soy isoflavones significantly lowered CRP by 0.70 mg/L (95% CI, -1.17 to -0.23; P = 0.003) among women with baseline CRP concentrations greater than 2.2 mg/L. No significant changes in CRP were observed in the other subgroups. Metaregression analysis further revealed that baseline CRP was a potential effect modifier of isoflavone treatment in lowering CRP. The present meta-analysis found insufficient evidence that soy isoflavones significantly reduce CRP concentrations in postmenopausal women. However, soy isoflavones may produce a significant reduction in CRP among postmenopausal women with elevated CRP.

Relationship of antihypertensive treatment to plasma markers of vascular inflammation and remodeling in the Comparison of Amlodipine versus Enalapril to Limit Occurrences of Thrombosis study

BACKGROUND

Antihypertensive agents lower the risk of cardiovascular events, but whether they affect pathways important in inflammation and plaque remodeling in atherosclerosis is uncertain. We assessed whether 2 commonly used antihypertensive agents affected plasma biomarkers reflecting specific inflammatory and remodeling processes over 2 years in the Comparison of Amlodipine versus Enalapril to Limit Occurrences of Thrombosis (CAMELOT) study.

METHODS

The study was a randomized controlled trial of 2 antihypertensives (amlodipine and enalapril) compared with placebo in patients with coronary artery disease and diastolic blood pressure less than 100 mm Hg. In 196 subjects who had baseline and 2-year intravascular coronary ultrasound examinations, we measured plasma interleukin 18, interleukin 1 receptor antagonist, matrix metalloproteinase 9, neopterin, and C-reactive protein. Results for both treatment groups were pooled and compared with placebo.

RESULTS

Antihypertensive treatment with either agent significantly lowered diastolic blood pressure (-4.7 vs placebo 1.3 mm Hg, P = .002) and progression of coronary atheroma (Δ percent atheroma volume 0.6 vs placebo 2.1, P = .031). Antihypertensive therapy did not affect plasma biomarkers of inflammation or plaque remodeling in the 135 subjects with baseline and 2-year biomarker samples. Progression in percent atheroma volume was significantly less in subjects taking statins at baseline (-2.5%, P = .0008).

CONCLUSIONS

In patients with coronary artery disease and well-controlled risk factors, antihypertensive therapy lowered blood pressure and progression of coronary atherosclerosis but did not affect plasma biomarkers of inflammation and remodeling. Antihypertensives may decrease atheroma progression by mechanisms other than those reflected by these plasma biomarkers.

Double-dose pravastatin versus add-on ezetimibe with low-dose pravastatin - effects on LDL cholesterol, cholesterol absorption, and cholesterol synthesis in Japanese patients with hypercholesterolemia (PEAS study)

AIM

This study compared the effect of doubling the dose of pravastatin with that of adding ezetimibe to low-dose pravastatin on the LDL cholesterol (LDL-C) level and on cholesterol absorption and synthesis markers. The tolerability of the 2 regimens was also compared.

METHODS

This was a multicenter, open-label, parallel-group trial. Subjects were aged from 20 to 74 years and had an LDL-C ≥ 120 mg/dL despite pravastatin therapy at 5-10 mg/day. They were randomly allocated to receive either add-on ezetimibe (10 mg/day) or double-dose pravastatin, and follow-up was performed for 12 weeks. The primary endpoints were the changes of LDL-C and apolipoprotein (apo) B levels after 12 weeks of treatment. Cholesterol absorption and synthesis markers were also determined.

RESULTS

LDL-C and apo B decreased by 16% and 14% in the ezetimibe add-on group versus 5.9% and 4.4%, respectively, in the pravastatin double-dose group. The between-group differences of these decreases were highly significant. Cholesterol absorption markers (sitosterol, campesterol, and cholestanol) were reduced by 48%, 36%, and 10%, respectively, in the ezetimibe add-on group, and were increased by 17%, 14%, and 6%, respectively, in the pravastatin double-dose group. Lathosterol (a cholesterol synthesis marker) increased by 76% in the ezetimibe add-on group and by 24% in the pravastatin double-dose group. The difference was statistically significant. No serious adverse effect was observed in either group.

CONCLUSIONS

Adding ezetimibe to low-dose pravastatin achieves greater decreases in LDL-C, apo B, and cholesterol absorption markers than doubling the dose of pravastatin.

Evaluation of the effect of wheat aleurone-rich foods on markers of antioxidant status, inflammation and endothelial function in apparently healthy men and women

Observational data show an inverse association between the consumption of wholegrain foods, and inflammation and related diseases. Although the underlying mechanisms are unclear, wholegrains, and in particular the aleurone layer, contain a wide range of components with putative antioxidant and anti-inflammatory effects. We evaluated the effects of a diet high in wheat aleurone on plasma antioxidants status, markers of inflammation and endothelial function. In this parallel, participant-blinded intervention, seventy-nine healthy, older, overweight participants (45–65 years, BMI>25 kg/m2) incorporated either aleurone-rich cereal products (27 g aleurone/d), or control products balanced for fibre and macronutrients, into their habitual diets for 4 weeks. Fasting blood samples were taken at baseline and on day 29. Results showed that, compared to control, consumption of aleurone-rich products provided substantial amounts of micronutrients and phytochemicals which may function as antioxidants. Additionally, incorporating these products into a habitual diet resulted in significantly lower plasma concentrations of the inflammatory marker, C-reactive protein (P = 0·035), which is an independent risk factor for CVD. However, no changes were observed in other markers of inflammation, antioxidant status or endothelial function. These results provide a possible mechanism underlying the beneficial effects of longer-term wholegrain intake. However, it is unclear whether this effect is owing to a specific component, or a combination of components in wheat aleurone.

Effects of fibrates on C-reactive protein concentrations: a meta-analysis of randomized controlled trials

The effects of fibrates on C-reactive protein (CRP) are controversial. This meta-analysis was conducted to synthesize the available clinical trial evidence and summarize the effects of fibrates on CRP concentrations. In addition, this study assessed the relationship between changes in CRP and lipid measures.

A systematic search was conducted of randomized controlled trials on the effects of fibrates on CRP concentrations in the PubMed, Embase and Cochrane Library Database up to January 2011. A meta-analysis was performed using a random effect model. Meta-regression analysis was employed to assess the relationships between average change in CRP and lipid profiles.

Sixteen randomized controlled trials were included in the meta-analysis. Compared with placebo, treatment with fibrates significantly decreased CRP concentrations (weighted mean difference –0.47 mg/L, 95% confidence interval –0.93 to –0.01 mg/L, p=0.046). Fibrates significantly reduced CRP concentrations in trials with a higher baseline CRP concentrations (≥3 mg/L). There was a significant correlation between change in CRP and change in high-density lipoprotein cholesterol (regression coefficient or slope=–2.03, 95% CI –3.20 to –0.87, p=0.001).

Fibrates can reduce CRP concentrations and change in CRP was correlated with change in high-density lipoprotein cholesterol but not with triglyceride. These findings suggest that patients with dyslipidemia could benefit from fibrates treatment by CRP lowering and this benefit is associated with lipid profile improving.

Randomised study of ezetimibe, start doses of original statins, and their combination in patients with coronary heart disease and hyperlipidemia Part 2. Therapy effects on the levels of C-reactive protein and proinflammatory cytokines

Aim. To assess the effects of original statins as monotherapy or in combination with ezetimibe on the levels of proinflammatory cytokines and high-sensitive C-reactive protein (hsCRP) in patients with coronary heart disease (CHD) and hyperlipidemia (HLP). Material and methods. The study included 60 male and female patients with CHD, primary polygenic HLP, and the levels of low-density lipoprotein cholesterol (LDL-CH) of 2,9-4,9 mmol/l. Monotherapy with original statins or ezetimibe lasted for 6 months, while the combination therapy lasted for 3 months. In all randomised patients, the levels of hsCRP, interleukin 6 (IL-6), and monocyte chemotactic protein-1 (MCP-1) were measured at baseline, 12 and 24 weeks after the therapy started. Results. At baseline, median hsCRP levels in the groups of Ezetrol, Zocor, Liprimar, and Crestor monotherapy were 0,5-0,88 mg/l, with no significant dynamics after 3 months of the treatment. Baseline IL-6 levels across the monotherapy groups were 1,94-2,54 pg/ml; at 3 months, there was a non-significant reduction by 7-32 %. After 3 months of the therapy, the decrease in MCP-1 levels was not statistically significant (-1,3-7,7 %). The combined therapy did not result in a significant dynamics of hsCRP concentrations, with the exception of the group receiving Ezetrol and Liprimar. Although the combined therapy further reduced MCP-1 levels (by 30-78 pg/ml), these changes were not statistically significant. No significant difference was observed across statin and Ezetrol groups in terms of their effects on IL-6 and MCP-1 levels. Conclusion. The comparison of the three treatment schemes demonstrated similar, but not statistically significant reduction on the levels of hsCRP, IL-6, and MCP-1. No marked benefits were observed for either monotherapy or combination therapy over 12-24 weeks of the follow-up.

Inflammation and the development of atherosclerosis

Atherosclerosis is a progressive disease causally associated with multiple cardiovascular risk factors, including dyslipidemia. Without effective intervention, atherosclerosis becomes evidenced clinically as coronary artery and cerebrovascular disease, both of which remain the leading causes of death worldwide. Multiple lines of investigation indicate a central role for inflammation in atherosclerotic plaque progression, vulnerability and thrombogenicity. Randomized clinical trials have documented the benefit of lipid-lowering therapy for both primary and secondary prevention of cardiovascular events. Statins, a class of drugs that lower cholesterol levels by inhibiting 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, have been shown to slow the progression of the atheroma and the frequency of associated clinical events to an extent that cannot be attributed solely to LDL reduction. The non-LDL or pleiotropic effects of statins are attributed to anti-inflammatory activity, enhanced endothelial function, and inhibition of oxidative stress. In this review, we discuss the role of inflammation in atherogenesis along with the effects of statins in slowing this process through LDL-dependent and -independent mechanisms.

Statin or nonsteroidal anti-inflammatory drug use is associated with lower erythrocyte sedimentation rate in patients with giant cell arteritis

BACKGROUND

Previous studies have found that nonsteroidal anti-inflammatory drugs (NSAIDs) and statins may impact erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) levels in patients. The current study was performed to determine if NSAID or statin use is associated with lower ESR and CRP in patients with biopsy-proven giant cell arteritis (GCA).

METHODS

A retrospective cross-sectional study was conducted that included 161 patients via chart review. Charts of patients with GCA seen at the University of Iowa Hospitals and Clinics from 1960 to 2008 were reviewed. Inclusion criteria were adequate medication records, serum ESR and/or CRP on record, no prior corticosteroid use, and biopsy-positive GCA. Exclusion criteria were the presence of diseases known to elevate ESR or CRP. Main outcome measures included ESR and CRP values measured while evaluating patients for GCA but prior to receiving treatment.

RESULTS

Statin nonusers had an ESR of 85.0 mm per hour (interquartile range [IQR] = 60-110 mm per hour) and a CRP of 8.7 mg/dL (IQR = 2.7-16.2 mg/dL). Statin users had an ESR of 57.5 mm per hour (IQR = 35-85) and a CRP of 2.4 mg/dL (IQR = 0.8-15.9 mg/dL). Statin use was associated with a lower ESR (P = 0.005), while there was no significant association with a lower CRP (P = 0.127). NSAID nonusers had an ESR of 98.0 mm per hour (IQR = 64-116) and a CRP of 8.7 mg/dL (IQR = 2.1-16.2 mg/dL). NSAID users had an ESR of 75.0 mm per hour (IQR = 46-98.5 mm per hour) and CRP of 8.0 mg/dL (IQR. = 1.5-16.2 mg/dL). NSAID use was associated with a lower ESR (P = 0.004), but there was no significant association with a lower CRP (P = 0.522).

CONCLUSION

Statin use and NSAID use were associated with a lower ESR; however, they were not associated with lower CRP values. Clinicians should be aware that statin or NSAID use is associated with lower ESR in patients with GCA, and this test may therefore have lower sensitivity and specificity for recognizing patients with GCA, and CRP may be a superior test to evaluate patients for GCA.

Comparative efficacy of the addition of ezetimibe to statin vs statin titration in patients with hypercholesterolaemia: systematic review and meta-analysis

OBJECTIVE

To systematically review and analyse evidence for cholesterol-lowering efficacy of at least 4 weeks of add-on ezetimibe vs doubling statin dose, in adults with primary hypercholesterolaemia.

RESEARCH DESIGN AND METHODS

MEDLINE, EMBASE and Cochrane databases were searched to identify randomised controlled trials of ezetimibe-statin combination vs statin titration (January 1993 - March 2010). Studies were selected using predefined criteria. Two reviewers conducted screening of articles, critical appraisal and data extraction; a third reviewer resolved disagreements. The difference between treatments was analysed for four co-primary outcomes: mean percentage change from baseline in low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and total cholesterol (TC); and proportion of patients achieving LDL-C treatment goal. Data were combined by two sets of direct comparison fixed and random effects meta-analysis: (1) compared data in the same treatment period between groups; (2) compared the incremental change in lipid levels of add-on ezetimibe vs doubling statin dose. Heterogeneity was assessed using the I(2) statistic.

RESULTS

Thirteen studies including 5080 patients were included in the meta-analyses. Data on simvastatin, atorvastatin and rosuvastatin were analysed. Results for primary and secondary outcomes were in favour of the ezetimibe-statin combination. A significantly greater percentage reduction in LDL-C levels was achieved in patients treated with ezetimibe-statin vs statin monotherapy (weighted mean difference [WMD]: -14.1% [-16.1, -12.1], p < 0.001). Reduction in LDL-C levels attributed to add-on ezetimibe was significantly greater than that for statin dose doubling (WMD: -15.3% [-19.1, -11.4], p < 0.001). Achievement of LDL-C goal favoured add-on ezetimibe over statin titration and was statistically significant (odds ratio: LDL-C treatment goal 2.45 [1.95, 3.08], p = 0.007).

CONCLUSIONS

Meta-analyses were restricted by the limited number of studies with similar trial design and method of statin titration. Results indicate that add-on ezetimibe is significantly more effective in reducing LDL-C levels than doubling statin dose, enabling more patients to achieve LDL-C goal.

Atorvastatin and low-density lipoprotein cholesterol in type 2 diabetes mellitus patients on hemodialysis

BACKGROUND AND OBJECTIVES

Patients undergoing maintenance hemodialysis are at high cardiovascular risk. Lowering LDL-cholesterol with statins reduces the incidence rate of cardiovascular events in patients with chronic kidney disease. In contrast, two randomized, prospective, placebo-controlled trials have been completed in hemodialysis patients that showed no significant effects of statins on cardiovascular outcomes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A post hoc analysis was conducted of the 4D (Die Deutsche Diabetes Dialyze) study to investigate whether LDL-cholesterol at baseline is predictive of cardiovascular events and whether the effect of atorvastatin on clinical outcomes depends on LDL-cholesterol at baseline.

RESULTS

High concentrations of LDL-cholesterol by tendency increased the risks of cardiac endpoints and all-cause mortality. Concordantly, atorvastatin significantly reduced the rates of adverse outcomes in the highest quartile of LDL-cholesterol (≥145 mg/dl, 3.76 mmol/L). The hazard ratios and 95% confidence intervals were 0.69 (0.48 to 1.00) for the composite primary endpoint, 0.58 (0.34 to 0.99) for cardiac death, 0.48 (0.25 to 0.94) for sudden cardiac death, 0.62 (0.33 to 1.17) for nonfatal myocardial infarction, 0.68 (0.47 to 0.98) for all cardiac events combined, and 0.72 (0.52 to 0.99) for death from all causes, respectively. No such decrease was seen in any of the other quartiles of LDL-cholesterol at baseline.

CONCLUSIONS

In patients with type 2 diabetes mellitus undergoing hemodialysis, atorvastatin significantly reduces the risk of fatal and nonfatal cardiac events and death from any cause if pretreatment LDL-cholesterol is >145 mg/dl (3.76 mmol/L).

The risks of a new hypothesis: why did JUPITER patients have almost twice the predicted event rate of reduction?

High serum cholesterol levels are associated with death from coronary heart disease and statin therapy has been demonstrated to effectively lower low-density lipoprotein (LDL) cholesterol and reduce coronary events in broad sections of the population. Recently, the Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) randomized 17 802 apparently healthy individuals, with levels of LDL cholesterol below current treatment thresholds but with elevated levels of high-sensitivity C-reactive protein, to rosuvastatin 20 mg daily, or placebo. At a median follow-up of almost 2 years, compared to placebo, rosuvastatin treatment was associated with a significant reduction in the incidence of major cardiovascular or cerebrovascular events, that is, almost twice the magnitude found in previous statin trials. Such a noteworthy finding is discussed herein.

Pleiotropic effects of ezetimibe/simvastatin vs. high dose simvastatin

BACKGROUND

In the setting of stable coronary artery disease (CAD), it is not known if the pleiotropic effects of cholesterol reduction differ between combined ezetimibe/simvastatin and high-dose simvastatin alone.

OBJECTIVE

We sought to compare the anti-inflammatory and antiplatelet effects of ezetimibe 10mg/simvastatin 20mg (E10/S20) with simvastatin 80 mg (S80).

METHODS AND RESULTS

CAD patients (n=83, 63 ± 9 years, 57% men) receiving S20, were randomly allocated to receive E10/S20 or S80, for 6 weeks. Lipids, inflammatory markers (C-reactive protein, interleukin-6, monocyte chemoattractant protein-1, soluble CD40 ligand and oxidized LDL), and platelet aggregation (platelet function analyzer [PFA]-100) changes were determined. Baseline lipids, inflammatory markers and PFA-100 were similar between groups. After treatment, E10/S20 and S80 patients presented, respectively: (1) similar reduction in LDL-C (29 ± 13% vs. 28 ± 30%, p=0.46), apo-B (18 ± 17% vs. 22 ± 15%, p=0.22) and oxidized LDL (15 ± 33% vs. 18 ± 47%, p=0.30); (2) no changes in inflammatory markers; and, (3) a higher increase of the PFA-100 with E10/S20 than with S80 (27 ± 43% vs. 8 ± 33%, p=0.02).

CONCLUSIONS

These data suggest that among stable CAD patients treated with S20, (1) both E10/S20 and S80 were equally effective in further reducing LDL-C; (2) neither treatment had any further significant anti-inflammatory effects; and (3) E10/S20 was more effective than S80 in inhibiting platelet aggregation. Thus, despite similar lipid lowering and doses 4× less of simvastatin, E10/S20 induced a greater platelet inhibitory effect than S80.

C-reactive protein concentration and the vascular benefits of statin therapy: an analysis of 20,536 patients in the Heart Protection Study

BACKGROUND

It has been suggested that inflammation status, as assessed by C-reactive protein (CRP) concentration, modifies the vascular protective effects of statin therapy. In particular, there have been claims that statins might be more beneficial in people with raised CRP concentrations, and might even be ineffective in people with low concentrations of both CRP and LDL cholesterol. This study aimed to test this hypothesis.

METHODS

In 69 UK hospitals, 20,536 men and women aged 40-80 years at high risk of vascular events were randomly assigned to simvastatin 40 mg daily versus matching placebo for a mean of 5·0 years. Patients were categorised into six baseline CRP groups (<1·25, 1·25-1·99, 2·00-2·99, 3·00-4·99, 5·00-7·99, and ≥8·00 mg/L). The primary endpoint for subgroup analyses was major vascular events, defined as the composite of coronary death, myocardial infarction, stroke, or revascularisation. Analysis was by intention to treat. This study is registered, number ISRCTN48489393.

FINDINGS

Overall, allocation to simvastatin resulted in a significant 24% (95% CI 19-28) proportional reduction in the incidence of first major vascular event after randomisation (2033 [19·8%] allocated simvastatin vs 2585 [25·2%] allocated placebo). There was no evidence that the proportional reduction in this endpoint, or its components, varied with baseline CRP concentration (trend p=0·41). Even in participants with baseline CRP concentration less than 1·25 mg/L, major vascular events were significantly reduced by 29% (99% CI 12-43, p<0·0001; 239 [14·1%] vs 329 [19·4%]). No significant heterogeneity in the relative risk reduction was recorded between the four subgroups defined by the combination of low or high baseline concentrations of LDL cholesterol and CRP (p=0·72). In particular, there was clear evidence of benefit in those with both low LDL cholesterol and low CRP (27% reduction, 99% CI 11-40, p<0·0001; 295 [15·6%] vs 400 [20·9%]).

INTERPRETATION

Evidence from this large-scale randomised trial does not lend support to the hypothesis that baseline CRP concentration modifies the vascular benefits of statin therapy materially.

FUNDING

UK Medical Research Council, British Heart Foundation, Merck, Roche Vitamins, and GlaxoSmithKline.

Predictors of coronary intervention-related myocardial infarction in stable angina patients pre-treated with statins

INTRODUCTION

Peri-procedural myocardial infarction (PMI) is a frequent and prognostically important complication of percutaneous coronary intervention (PCI). This study was designed to determine the predictors of PMI in patients pre-treated with statins.

MATERIAL AND METHODS

A total of 418 stable angina pectoris patients taking statins and aspirin were included. All the patients underwent PCI. Serum concentrations of creatine kinase (CK-MB mass) and troponin I (TnI) were measured prior to and then within 16 to 24 hours after PCI. The incidence of PMI was assessed using the established criteria (≥ 3 times upper limit of normal).

RESULTS

Four hundred and eighteen stable patients (63 ±10 years, 68% males) were treated by PCI. The technical success rate of PCI was 99%. The incidence of PMI based on CK-MB mass or TnI release was 12% (PMI group). There were no significant differences in baseline clinical and procedural characteristics between PMI and non-PMI groups except for the balloon inflation time (40 ±44 s vs. 26 ±27 s; p = 0.02) and the proportion of treated type C lesions (42% vs. 28%; p = 0.03). In multivariate analysis, the independent predictors of PMI were balloon inflation time (OR = 1.01; 95% CI 1.001-1.020; p = 0.02) and pre-procedural level of C-reactive protein (OR = 1.38; 95% CI 1.059-1.808; p = 0.02).

CONCLUSIONS

These results suggest that C-reactive protein and balloon ischaemic time are independent predictors of PMI in stable angina patients pre-treated with statins.

Hypercholesterolemia and microvascular dysfunction: interventional strategies

Hypercholesterolemia is defined as excessively high plasma cholesterol levels, and is a strong risk factor for many negative cardiovascular events. Total cholesterol levels above 200 mg/dl have repeatedly been correlated as an independent risk factor for development of peripheral vascular (PVD) and coronary artery disease (CAD), and considerable attention has been directed toward evaluating mechanisms by which hypercholesterolemia may impact vascular outcomes; these include both results of direct cholesterol lowering therapies and alternative interventions for improving vascular function. With specific relevance to the microcirculation, it has been clearly demonstrated that evolution of hypercholesterolemia is associated with endothelial cell dysfunction, a near-complete abrogation in vascular nitric oxide bioavailability, elevated oxidant stress, and the creation of a strongly pro-inflammatory condition; symptoms which can culminate in profound impairments/alterations to vascular reactivity. Effective interventional treatments can be challenging as certain genetic risk factors simply cannot be ignored. However, some hypercholesterolemia treatment options that have become widely used, including pharmaceutical therapies which can decrease circulating cholesterol by preventing either its formation in the liver or its absorption in the intestine, also have pleiotropic effects with can directly improve peripheral vascular outcomes. While physical activity is known to decrease PVD/CAD risk factors, including obesity, psychological stress, impaired glycemic control, and hypertension, this will also increase circulating levels of high density lipoprotein and improving both cardiac and vascular function. This review will provide an overview of the mechanistic consequences of the predominant pharmaceutical interventions and chronic exercise to treat hypercholesterolemia through their impacts on chronic sub-acute inflammation, oxidative stress, and microvascular structure/function relationships.

Combination therapy of statin and ezetimibe for the treatment of familial hypercholesterolemia

High-dose potent statin therapy in combination with ezetimibe is now standard practice for the treatment of adult patients with heterozygous familial hypercholesterolemia (heFH), as the result of numerous studies in patients with primary hypercholesterolemia or heFH. These studies have shown the combination to be both effective and safe in the short to medium term. Recently, short-term ezetimibe therapy has also been shown to be effective and safe in combination with statin therapy for children and adolescents with heFH. Effective statin-ezetimibe combination therapy is capable of achieving near-normal lipid profiles in heFH patients, with expected improvement in risk for cardiovascular disease (CVD) and improved life expectancy resulting predominantly from reduction in levels of low-density lipoprotein cholesterol. There are few data to support a pleiotropic action of ezetimibe with regard to CVD benefit, unlike therapy with statins. No serious and unexpected clinical adverse effects of combination statin-ezetimibe therapy have emerged till date, although data are limited in children and adolescents, for whom longer-term studies are required. Recent data suggesting possible proatherogenic effects of ezetimibe require confirmation. One large long-term randomized controlled clinical outcomes trial is in progress in non-FH patients to determine the efficacy and safety of ezetimibe therapy; it is unlikely that such a trial will ever be performed in patients with FH.

C-reactive protein lowering with rosuvastatin in the METEOR study

OBJECTIVES

In addition to its LDL-C-lowering effects, statin treatment reduces the level of C-reactive protein (CRP). Long-term data on this effect in low-risk populations are limited. Furthermore, whether the CRP reduction is a consequence of LDL-C lowering or occurs independently remains unclear. We studied these aspects in the Measuring Effects on intima media Thickness: an Evaluation Of Rosuvastatin (METEOR) study, a randomized placebo-controlled trial amongst 984 low-risk subjects.

METHODS

METEOR is a randomized placebo-controlled trial that evaluated the effect of 40 mg of rosuvastatin on 2-year change in carotid intima media thickness (CIMT) amongst 984 low-risk patients (10-year Framingham risk < 10%) with modest CIMT (CIMT > or = 1.2 and < 3.5 mm) and elevated LDL-C. CRP levels were measured at baseline and after 2 years of treatment.

RESULTS

Median baseline CRP was 1.4 mg L(-1). Rosuvastatin lowered CRP significantly compared with placebo: -36% in the rosuvastatin group versus no change in the placebo group. There was no relation between change in CRP and change in LDL-C (Spearman correlation: 0.08; SE: 0.04). Stratified analyses showed that the CRP-lowering effect was present amongst all strata of baseline characteristics, including baseline lipids and CRP levels. However, the magnitude of CRP reduction was larger amongst women and participants older than 60 years.

CONCLUSIONS

Rosuvastatin (40 mg) lowers CRP independently from its effects on LDL-C in low-risk subjects with normal baseline CRP levels and modest CIMT.

C-reactive protein in gingival crevicular fluid may be indicative of systemic inflammation

BACKGROUND AND AIM

Periodontitis is associated with elevated C-reactive protein (CRP) in both serum and gingival crevicular fluid (GCF). Although the liver is the primary source of CRP, extra-hepatic production of CRP has been reported. This study aimed to determine whether CRP in GCF is produced locally in the gingivae.

MATERIALS AND METHODS

Gingivae and GCF were collected from non-periodontitis and periodontitis sites. Presence of CRP in gingivae was assessed by immunohistochemistry. CRP in GCF was measured using ELISA. Gene expression for CRP in gingivae was determined using real-time polymerase chain reaction.

RESULTS

CRP was found in both the gingivae and GCF. No gingivae had detectable amounts of CRP mRNA. Not all patients with periodontitis had detectable levels of CRP in the GCF. Some non-periodontitis patients had detectable levels of CRP in the GCF.

CONCLUSION

CRP in the GCF appears to be of systemic origin, and therefore may be indicative of systemic inflammation from either a periodontal infection or inflammatory disease elsewhere. The correlation between levels of CRP in GCF and serum requires validation in future studies.

Atorvastatin Reduces Macrophage Accumulation in Atherosclerotic Plaques

Background and Purpose— The object of our study was to compare the effect of high-dose vs low-dose atorvastatin vs nonstatin-based treatment (cholestyramine plus sitosterol) on cell composition of carotid plaque.

Methods— We recruited 60 hypercholesterolemic patients (total cholesterol, 5.83–7.64 mmol/L) eligible for carotid endarterectomy. Three months before surgery, patients were randomized into 3 groups (n=20) receiving atorvastatin 10 mg/day (AT-10) or atorvastatin 80 mg/day (AT-80) or cholestyramine 8 g/day plus sitosterol 2.5 g/day. Analysis of cell composition was performed on endarterectomy specimens.

Results— The 3 treatments resulted in a significant reduction of total cholesterol and low-density lipoprotein cholesterol (LDL-C), although the decrease in total cholesterol and LDL-C was of smaller magnitude in the cholestyramine plus sitosterol group. The 3 regimens did not influence the levels of inflammatory markers (including high-sensitivity C-reactive protein). Macrophage content was significantly lower in the AT-10 group plaques compared to the cholestyramine plus sitosterol group. It was further reduced in the AT-80 group plaques. These differences were no longer significant after adjustment for changes in LDL-C. No difference in lymphocyte number was observed among treatments, whereas the content of smooth muscle cells was higher in the AT- 80 group. An inverse association was observed between LDL-C changes in the 3 groups and macrophage content in the plaques.

Conclusions— Short-term treatment with high-dose statin is superior to a nonstatin lipid-lowering regimen in reducing the macrophage cell content within atherosclerotic lesions, but this effect was determined by the degree of LDL-C–lowering.

C-reactive protein concentration and risk of coronary heart disease, stroke, and mortality: an individual participant meta-analysis

BACKGROUND

Associations of C-reactive protein (CRP) concentration with risk of major diseases can best be assessed by long-term prospective follow-up of large numbers of people. We assessed the associations of CRP concentration with risk of vascular and non-vascular outcomes under different circumstances.

METHODS

We meta-analysed individual records of 160 309 people without a history of vascular disease (ie, 1.31 million person-years at risk, 27 769 fatal or non-fatal disease outcomes) from 54 long-term prospective studies. Within-study regression analyses were adjusted for within-person variation in risk factor levels.

RESULTS

Log(e) CRP concentration was linearly associated with several conventional risk factors and inflammatory markers, and nearly log-linearly with the risk of ischaemic vascular disease and non-vascular mortality. Risk ratios (RRs) for coronary heart disease per 1-SD higher log(e) CRP concentration (three-fold higher) were 1.63 (95% CI 1.51-1.76) when initially adjusted for age and sex only, and 1.37 (1.27-1.48) when adjusted further for conventional risk factors; 1.44 (1.32-1.57) and 1.27 (1.15-1.40) for ischaemic stroke; 1.71 (1.53-1.91) and 1.55 (1.37-1.76) for vascular mortality; and 1.55 (1.41-1.69) and 1.54 (1.40-1.68) for non-vascular mortality. RRs were largely unchanged after exclusion of smokers or initial follow-up. After further adjustment for fibrinogen, the corresponding RRs were 1.23 (1.07-1.42) for coronary heart disease; 1.32 (1.18-1.49) for ischaemic stroke; 1.34 (1.18-1.52) for vascular mortality; and 1.34 (1.20-1.50) for non-vascular mortality.

INTERPRETATION

CRP concentration has continuous associations with the risk of coronary heart disease, ischaemic stroke, vascular mortality, and death from several cancers and lung disease that are each of broadly similar size. The relevance of CRP to such a range of disorders is unclear. Associations with ischaemic vascular disease depend considerably on conventional risk factors and other markers of inflammation.

FUNDING

British Heart Foundation, UK Medical Research Council, BUPA Foundation, and GlaxoSmithKline.

Primary prevention of vascular events in patients with high levels of C-reactive protein: the JUPITER study

The Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) study was the first large-scale, prospective study to examine the benefits of statin therapy in subjects with elevated levels of high-sensitivity C-reactive protein but with low-to-normal LDL-cholesterol levels, who were not qualified for lipid-lowering treatment according to the current guidelines for primary prevention. The JUPITER study aimed to determine whether rosuvastatin 20 mg daily would reduce the rate of first major cardiovascular events, including cardiovascular death, nonfatal stroke, nonfatal myocardial infarction, hospitalization for unstable angina or arterial revascularization. Rosuvastatin reduced LDL-cholesterol levels by 50% and high-sensitivity C-reactive protein by 37%. Compared with placebo, the combined primary end point was reduced in 44% (p < 0.00001), and total mortality in 20% (p = 0.02). The trial confirmed the relationship between the rates of major cardiovascular events with both high-sensitivity C-reactive protein and LDL-cholesterol levels achieved after statin treatment. Interestingly, this was the first large, prospective statin trial to show benefit in the reduction of venous thromboembolism.

Lipid lowering versus pleiotropic effects of statins on skin microvascular function in patients with dysglycaemia and coronary artery disease

OBJECTIVES

To investigate the impact of lipid lowering therapy by different means on skin microvascular function in patients with dysglycaemia and coronary artery disease (CAD).

DESIGN AND SETTING

Thirty-six patients were randomized to simvastatin 80 mg daily (S80, n = 19) or ezetimibe 10 mg and simvastatin 10 mg daily (E10/S10, n = 17) for 6 weeks. Skin microvascular function was assessed by laser Doppler fluxmetry (LDF) at rest, following arterial occlusion (peak postocclusive LDF) and following local heating on the forearm (heat arm LDF) and foot (heat foot LDF). LDF parameters and serum lipids were evaluated at baseline and follow-up.

RESULTS

At follow-up, LDL cholesterol had decreased from 3.1 (2.7-3.5) to 1.6 (1.5-1.8) (mmol L(-1)) and 3.0 (2.4-3.9) to 1.3 (1.1-1.8) (mmol L(-1)) in the E10/S10 and S80 groups respectively. In the entire study group (n = 32), LDF parameters increased significantly; postocclusive LDF from 22 (17-27) to 26 (21-32) perfusion units (PU) (P < 0.001), heat foot LDF from 61 (44-82) to 66 (45-83) PU (P < 0.001) and heat arm LDF from 60 (48-121) to 75 (54-125) PU (P < 0.01). The changes in LDF parameters did not differ between the E10/S10 and S80 groups.

CONCLUSIONS

Lipid lowering improves microvascular function in patients with dysglycaemia and CAD. The data suggest that lipid lowering per se is more important than pleiotropic effects of statins for this effect.

Markers of inflammation, thrombosis and endothelial activation correlate with carotid IMT regression in stable coronary disease after atorvastatin treatment

BACKGROUND AND AIMS

MIAMI is a prospective multicenter clinical study designed to investigate the relationship between changes in carotid intima-media thickness (C-IMT) and changes in circulating markers of inflammation, thrombosis and endothelial activation in stable coronary patients treated for 20+/-3.7 months with 20mg/day atorvastatin.

METHODS AND RESULTS

Eighty-five subjects had their C-IMT, blood lipids and soluble markers measured at baseline, at the 12th month and at the end of the study. Almost all soluble markers decreased upon treatment except for high-sensitivity C-reactive protein (hs-CRP), interleukin-18 (IL-18), tissue factor pathway inhibitor-free (TFPI-free) and soluble vascular cell adhesion molecules-1 (sVCAM-1) which did not change significantly, and interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha) and soluble CD40 ligand (sCD40L) which increased. sCD40L, fibrinogen, tissue factor pathway inhibitor-total (TFPI-total), soluble intercellular adhesion molecules-1 (sICAM-1), sE-selectin, interleukin-8 (IL-8) and von Willebrand factor (vWF) changed significantly even after application of the Bonferroni correction for multiple comparisons. Changes in lipids did not correlate with C-IMT regression either when considered singly or when combined in a lipid score. Changes in soluble markers correlated poorly with C-IMT regression when analyzed singly, but strongly when combined in relevant composite scores (inflammation/coagulation score, endothelial activation score, soluble markers score and total score).

CONCLUSION

In patients with stable coronary artery disease treated with moderate doses of atorvastatin, carotid IMT regression correlated with changes of inflammation, thrombosis and endothelial activation profiles.