Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel

Failure of LDL-C goals achievement and underuse of lipid-lowering therapies in patients at high and very high cardiovascular risk: Spanish subset from the European SANTORINI study

INTRODUCTION

There are very few studies evaluating lipid-lowering treatments (LLTs) and low-density lipoprotein-cholesterol (LDL-C) goal attainment after the release of the 2019 guidelines of the European Societies of Cardiology (ESC) and Atherosclerosis (EAS). This manuscript shows baseline data of the Spanish subset from SANTORINI study (namely SANTORINI Spain) on LDL-C goal attainment and use of LLTs in patients at high and very high cardiovascular risk.

METHODS

SANTORINI was a multinational, prospective, observational study involving patients at high and very high cardiovascular risk from 14 European countries in primary care and specialized healthcare settings. Sociodemographic data, blood lipid levels, and lipid treatments from the 1018 Spanish participants were separately analyzed and were put into perspective with the European cohort without Spanish participants.

RESULTS

According to physicians, 295 (29.0%) subjects were classified as high, and 723 (71.0%) as very high cardiovascular risk. Overall, 26.5% attained risk-based LDL-C targets recommended by 2019 European guidelines, with 23.1% of patients at high cardiovascular risk and 27.9% at very high cardiovascular risk. High-intensity statin therapy in monotherapy was used in 21.8%, LLT combination therapy in 41.2%, and 10.7% were not receiving any LLT.

CONCLUSIONS

Baseline data from SANTORINI Spain population show that only about one-fourth of patients attain LDL-C targets recommended by the 2019 ESC/EAS guidelines in patients at high and very high risk. Despite their cardiovascular risk, patients appear to be not adequately treated, and high-intensity and combination LLT seem to be underused for cardiovascular disease prevention in the real-world setting.

CLINICALTRIALS

gov Identifier: NCT04271280.

High low-density lipoprotein cholesterol levels in people with HIV by individual cardiovascular risk: A retrospective observational study

BACKGROUND

People with HIV (PWH) are at increased risk of atherosclerotic cardiovascular disease (ASCVD). Lowering low-density lipoprotein cholesterol (LDL-C) is central of cardiovascular disease prevention. The aim of this study was to assess the prevalence, treatment, and control of high LDL-C levels as assessed on the basis of the ASCVD risk profiles indicated by European Society of Cardiology (ESC) guidelines of a cohort of PWH in order to evaluate the state of LDL-C management in current clinical practice.

METHODS

We retrospectively assessed the prevalence, treatment, and control of high LDL-C levels in a cohort of PWH aged ≥40 years who accessed our HIV outpatient clinic between 1 March 2022 and 31 March 2023. Their 10-year ASCVD risk was calculated on the basis of their age and co-morbidities as recommended by guidelines. High LDL-C levels were defined as those above the "step two" target of their specific ASCVD risk category.

RESULTS

Among the 1404 assessed PWH, who were prevalently male (74.5 %) and Caucasian (85.6 %), and had a median age of 56 years (interquartile range [IQR] 49-61), 295 (21 %) were at very high risk (VHR), 634 (45.2 %) at high-risk (HR), and 348 (24.8 %) not at HR. The overall median LDL-C level was 116 mg/dL (IQR 96-141). Five hundred and sixteen (37 %) were undergoing lipid lowering treatment (LLT), and 650 (46.3 %) failed to achieve any step of their target LDL-C levels.

CONCLUSIONS

Despite the high prevalence of PWH at VHR/HR for ASCVD, LDL-C levels were poorly controlled and LLT was greatly under used.

Advances in the pharmacological management of hyperlipidemia through the use of combination therapies

INTRODUCTION

Lipid-lowering therapies are well established for the treatment of cardiovascular disease (CVD). Historically monotherapy studies have been performed, but the introduction of statins has led to these drugs being recognized as baseline therapies and to the investigation of combination therapy of both older and newer medications with them.

AREAS COVERED

Surrogate marker studies have shown additive effects on LDL-C, triglycerides and HDL-C of combination therapies with statins and these have extended to lipoprotein (a). Imaging studies have often shown benefits paralleling lipid studies. However, outcome studies have failed to show added benefits with niacin or fibrates while confirming the benefits of ezetimibe, bempedoic acid and proprotein convertase subtilisin kexin-9 (PCSK-9) inhibitors and icosapent ethyl.

EXPERT OPINION

Combination therapy for LDL-C in dual combinations is well validated. Data for intervention on triglycerides is limited to icosapent ethyl, but this may exert effects independent of lipids. New drugs targeting triglycerides through apolipoprotein C3 and angiopoietin-like peptides are in development. Studies on combination therapy raising HDL-C have generally disappointed, though cholesterol ester transfer protein (CETP) inhibition remains a target. Lipoprotein (a) is recognized as a CVD risk factor and effective therapies are in development but results on CVD events are lacking.

Guideline-directed Medical Therapy in Nonagenarians and Centenarians (≥ 90 Years Old) After First-onset Myocardial Infarction---a National Registry Study

BACKGROUND

Guideline-directed medical therapies (GDMTs), such as beta-blockers, antiplatelet drugs, lipid-lowering drugs, and renin-angiotensin system agents, have been associated with reduced risk of mortality after acute myocardial infarction (AMI). However, this survival benefit conferred by GDMTs in nonagenarians and centenarians (≥ 90 years old) is not well-defined.

METHODS

We investigated restricted mean survival times of patients ≥ 90 years of age with first-onset AMI treated with GDMTs from 2007 to 2020 in the Singapore Myocardial Infarction Registry. Primary analyses involved stratification by number of GDMTs prescribed at discharge, with derivation of pairwise restricted mean survival ratios free from all-cause mortality at 1, 3, and 5 years. Secondary analyses evaluated individual GDMTs within combinations of 1-3 GDMTs.

RESULTS

The analysis included 3264 patients: 0 GDMTs (561 patients, 17.2%), 1-2 GDMTs (1294 patients, 39.6%), 3 GDMTs (904 patients, 27.7%), and 4 GDMTs (505 patients, 15.5%), with a median follow-up duration of 5.71 years. Patients who received 4 GDMTs at discharge were younger, had more comorbidities, were more likely to be smokers, and were more likely to have undergone percutaneous coronary intervention than those prescribed fewer GDMTs. A greater number of GDMT classes at discharge was associated with longer survival free from all-cause mortality at 1, 3, and 5 years. Each drug class within combinations of 1-3 GDMTs was associated with significant survival benefit at all time points, except for beta-blockers.

CONCLUSIONS

Prescription of any number of GDMTs to nonagenarians and centenarians after first-onset AMI is associated with significant survival benefit.

Noncardiac chest computerized tomography scan as a predictor for plaque presence in coronary artery

BACKGROUND

Coronary artery calcium, a marker of coronary atherosclerosis, is often identified on noncoronary chest computed tomography (CT). We wanted to evaluate the correlation between the presence of coronary plaques in coronary artery catheterization and coronary calcifications as shown in noncardiac chest CT.

METHODS

A retrospective case-control study consisting of cases (N = 63) and controls (N = 29), aged 18-70 years old, residing in northern Israel and treated in the Intensive Cardiac Care Unit of Ziv Medical Center, between January 2020 and November 2022. All participants underwent coronary catheterization and noncoronary CT scans in the 5 years before the catheterization procedure. Data were taken from the participants' electronic files while considering the potential of cardiovascular risk factors.

RESULTS

The 92 participants had a mean age of 60.1 ± 10.3 years old. Multivariate logistic regression adjusted to age, sex, and hyperlipidemia showed that calcified coronary artery as shown on a previous noncardiac CT scan was positively and significantly associated with increasing risk of coronary plaque as presented in coronary catheterization: odds ratio = 5.93 (95% confidence interval: 1.85-19.07, P < 0.01) and was also associated with male sex who were more likely to have plaque on coronary catheterization than females: odds ratio = 3.77 (95% confidence interval: 1.29-11.32, P < 0.05).

CONCLUSION

Coronary calcifications on a previous noncoronary CT scan and sex are positively and significantly associated with coronary plaque risk as present in coronary catheterization. Coronary evaluation on CT scans is important for early detection of coronary disease. Early treatment can avoid coronary disease complications and increase patient survival.

Statin Use and Major Adverse Cardiovascular Events Among Patients with Ischemic Heart Diseases: A Multi-Center Retrospective Study

Objective: The objective of this study was to evaluate the effects of adherence to the ACC/AHA 2018 dyslipidemia guidelines on patient management of lipid-lowering therapy in patients with ischemic heart diseases (IHD) and its correlation with major adverse cardiovascular events (MACEs), including non-fatal MI, stroke, death, hospitalization for revascularization, and peripheral arterial disease. Methods: A multi-center retrospective observational study was conducted in patients with IHD between January 2019 and December 2020, who were followed for two years. The primary objective was to assess statin utilization and adherence to the 2018 ACC/AHA guidelines and the associated influence on MACE outcomes. Inferential statistical analyses, including chi-square tests and the Mann-Whitney test, were conducted to assess the associations between adherence to the guidelines, MACE rates, and LDL-C goal achievement. Results: The study included 1011 patients with ischemic heart disease (IHD), predominantly male (78.2%), with a mean age of 59 ± 10.9 years. Non-adherent patients had higher baseline LDL-C levels (3.0 ± 1.1 mmol/L vs. 2.7 ± 1.2 mmol/L; p = 0.0005), while adherent patients were more likely to be on cardiovascular medications, including statins (78.4% vs. 57.4%), aspirin (74.2% vs. 56.3%), and P2Y12 inhibitors (69.5% vs. 48.4%), compared to non-adherent patients. Adherence was associated with lower non-fatal MI rates (9.3% vs. 21.1%, p < 0.0001) and fewer revascularizations (9.3% vs. 16.8%; p = 0.0024). Additionally, 49.2% of adherent patients achieved target LDL-C goals, compared to 30.5% of the non-adherent patients (p < 0.0001). Notably, there were no significant differences in stroke, peripheral arterial disease, or mortality rates. Conclusions: The achievement of target LDL-C goals and reduced MACEs was observed with adherence to the 2018 ACC/AHA dyslipidemia guidelines. However, lipid management in IHD patients remains sub-optimal, highlighting opportunities for further enhancement.

Saturated fat in an evolutionary context

Evolutionary perspectives have yielded profound insights in health and medical sciences. A fundamental recognition is that modern diet and lifestyle practices are mismatched with the human physiological constitution, shaped over eons in response to environmental selective pressures. This Darwinian angle can help illuminate and resolve issues in nutrition, including the contentious issue of fat consumption. In the present paper, the intake of saturated fat in ancestral and contemporary dietary settings is discussed. It is shown that while saturated fatty acids have been consumed by human ancestors across time and space, they do not feature dominantly in the diets of hunter-gatherers or projected nutritional inputs of genetic accommodation. A higher intake of high-fat dairy and meat products produces a divergent fatty acid profile that can increase the risk of cardiovascular and inflammatory disease and decrease the overall satiating-, antioxidant-, and nutrient capacity of the diet. By prioritizing fiber-rich and micronutrient-dense foods, as well as items with a higher proportion of unsaturated fatty acids, and in particular the long-chain polyunsaturated omega-3 fatty acids, a nutritional profile that is better aligned with that of wild and natural diets is achieved. This would help prevent the burdening diseases of civilization, including heart disease, cancer, and neurodegenerative conditions. Saturated fat is a natural part of a balanced diet; however, caution is warranted in a food environment that differs markedly from the one to which we are adapted.

Multifunctional Nanomedicine for Targeted Atherosclerosis Therapy: Activating Plaque Clearance Cascade and Suppressing Inflammation

Atherosclerosis (AS) is a prevalent inflammatory vascular disease characterized by plaque formation, primarily composed of foam cells laden with lipids. Despite lipid-lowering therapies, effective plaque clearance remains challenging due to the overexpression of the CD47 molecule on apoptotic foam cells, inhibiting macrophage-mediated cellular efferocytosis and plaque resolution. Moreover, AS lesions are often associated with severe inflammation and oxidative stress, exacerbating disease progression. Herein, we introduce a multifunctional nanomedicine (CEZP) targeting AS pathogenesis via a "cell efferocytosis-lipid degradation-cholesterol efflux" paradigm, with additional anti-inflammatory properties. CEZP comprises poly(lactic-co-glycolic acid) nanoparticles encapsulated within a metal-organic framework shell coordinated with zinc ions (Zn2+) and epigallocatechin gallate (EGCG), enabling CpG encapsulation. Upon intravenous administration, CEZP accumulates at AS plaque sites, facilitating macrophage uptake and orchestrating AS treatment through synergistic mechanisms. CpG enhances cellular efferocytosis, Zn2+ promotes intracellular lipid degradation, and EGCG upregulates adenosine 5'-triphosphate-binding cassette transporters for cholesterol efflux while also exhibiting antioxidant and anti-inflammatory effects. In vivo validation confirms CEZP's ability to stabilize plaques, reduce lipid burden, and modulate the macrophage phenotype. Moreover, CEZP is excreted from the body without safety concerns, offering a low-toxicity nonsurgical strategy for AS plaque eradication.

Lipid Lowering Therapy Utilization and Lipid Goal Attainment in Women

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of the current status of lipid-lowering therapy utilization and lipid goal attainment in women. We focus on lipid-lowering therapy in individuals with and without established atherosclerotic cardiovascular disease, as well as familial hypercholesterolemia. Additionally, this review aims to explore the underlying mechanisms driving these sex differences and to identify existing knowledge gaps in this area.

RECENT FINDINGS

Despite the proven efficacy of lipid-lowering therapy in both sexes, real-world studies indicate that women with comparable risk profiles are less likely than men to receive these treatments. Furthermore, women who are prescribed statins typically receive lower-intensity regimens than men and are less likely to achieve guideline-recommended low-density lipoprotein cholesterol goals. Despite advancements in lipid-lowering therapies, women compared to men, are systematically undertreated. This difference is influenced by patient-related, physician-related, and societal factors.

Early-onset atherosclerotic cardiovascular disease

Recent trends indicate a concerning increase in early-onset atherosclerotic cardiovascular disease (ASCVD) among younger individuals (men aged <55 years women aged <65 years). These findings highlight the pathobiology of ASCVD as a disease process that begins early in life and underscores the need for more tailored screening methods and preventive strategies. Increasing attention has been placed on the growing burden of traditional cardiometabolic risk factors in young individuals while also recognizing unique factors that mediate risk of pre-mature atherosclerosis in this demographic such as substance use, socioeconomic disparities, adverse pregnancy outcomes, and chronic inflammatory states that contribute to the increasing incidence of early ASCVD. Additionally, mounting evidence has pointed out significant disparities in the diagnosis and management of early ASCVD and cardiovascular outcomes based on sex and race. Moving towards a more personalized approach, emerging data and technological developments using diverse tools such as polygenic risk scores and coronary artery calcium scans have shown potential in earlier detection of ASCVD risk. Thus, we review current evidence on causal risk factors that drive the increase in early ASCVD and highlight emerging tools to improve ASCVD risk assessment in young individuals.

Integrated Multivariate Predictive Model of Body Composition and Lipid Profile for Cardiovascular Risk Assessment

(1) Background/Objectives: Cardiovascular diseases (CVD) are the leading cause of morbidity and mortality globally, necessitating effective risk prediction strategies. This study was aimed at developing and validating a multivariate predictive model integrating body composition and lipid profile to assess cardiovascular risk in an adult population. (2) Methods: A cross-sectional analysis of 90 participants from the general Spanish population was conducted. Participants were classified into cardiovascular risk groups (low, medium, high) based on systolic blood pressure. (3) Results: Descriptive and multinomial logistic regression analyses revealed significant associations between cardiovascular risk and specific parameters, such as visceral fat, glucose levels, and waist-to-hip ratio. Visceral adiposity emerged as a strong predictor of high cardiovascular risk, highlighting its critical role in cardiovascular health. Glucose levels were also significantly associated with increased risk, underscoring the importance of metabolic health in cardiovascular outcomes. Contrary to expectations, lipid markers like cholesterol and triglycerides did not show significant variations across risk categories, suggesting that traditional lipid profiles may not fully capture cardiovascular risk in the study group. Waist-to-hip ratio showed significant associations with cardiovascular risk transitions, particularly between low and medium risk, emphasizing the importance of fat distribution patterns. (4) Conclusions: These findings suggest that body composition, particularly visceral fat, is a crucial determinant of cardiovascular risk, necessitating more personalized risk assessment approaches that move beyond traditional lipid markers.

Myricitrin Alleviates Hypercholesterolemia and Non-Alcoholic Fatty Liver Disease in High Cholesterol Diet-Fed Mice

BACKGROUND/OBJECTIVES

This research investigated the effects of myricitrin on hypercholesterolemia and non-alcoholic fatty liver disease (NAFLD) in mice given a high-cholesterol diet (HCD).

METHODS

C57BL/6J mice were maintained for 20 weeks on an HCD with or without myricitrin.

RESULTS

Myricitrin had no impact on the food consumption, body weight, or plasma triglyceride concentrations. However, myricitrin-supplemented mice had lower plasma total cholesterol (TC) concentrations and LDL + VLDL-cholesterol/TC proportion, and higher HDL-cholesterol/TC proportion than control mice, which resulted in a markedly decreased atherogenic index. Moreover, the levels of plasma C-reactive protein, oxidized LDL, lipoprotein(a), and plasminogen activator inhibitor-1, which are indicators for cardiovascular disease (CVD), were reduced, while levels of plasma paraoxonase, a cardioprotective enzyme, were greater in myricitrin-supplemented mice than in control mice. Myricitrin also meaningfully reduced liver weight and hepatic cholesterol content, and slightly alleviated fatty liver and fibrosis caused by an HCD. The plasma and hepatic cholesterol-lowering effects of myricitrin were partly associated with decreased activities of hepatic 3-hydroxy-3-methylglutaryl-CoA reductase and acyl-CoA:cholesterol acyltransferase, which are involved in cholesterol synthesis and esterification, respectively, as well as mRNA expression. Myricitrin also altered other hepatic genes implicated in cholesterol homeostasis, including the downregulation of SREBP2 and ABCA1 mRNA expression and the upregulation of LDLR mRNA expression. Moreover, myricitrin decreased TBARS levels in the liver and erythrocytes by activating antioxidant enzymes (SOD and catalase).

CONCLUSIONS

These results indicate that dietary myricitrin may offer therapeutic benefits for HCD-caused hypercholesterolemia and NAFLD, and may help reduce CVD risk.

Mutual mediation effects of homocysteine and PCSK9 on coronary lesion severity in patients with acute coronary syndrome: interplay with inflammatory and lipid markers

BACKGROUND

Homocysteine (Hcy) and the proprotein convertase subtilisin/kexin type 9 (PCSK9) significantly contribute to atherosclerosis (AS) as well as coronary lesion severity. Our previous work demonstrated that Hcy upregulates PCSK9, accelerating lipid accumulation and AS. A PCSK9 antagonist reduces plasma Hcy levels in ApoE-/- mice. These findings suggest complex roles for both Hcy and PCSK9 in AS. This study investigated the mutual mediating influence of Hcy together with PCSK9 on coronary lesion severity among individuals diagnosed with acute coronary syndrome (ACS), focusing on their interplay with inflammatory and lipid-related markers.

METHODS

This cross-sectional study encompassed 617 individuals diagnosed with ACS. Baseline characteristics, including inflammatory and lipid-related markers, were compared between individuals with non-severe (SYNTAX score ≤ 22) and severe (SYNTAX score > 22) coronary lesions. To evaluate both the impacts of Hcy and PCSK9 on coronary lesions severity, multivariate logistic regression along with mediation analyses were utilized. The robustness of the findings was validated by conducting subgroup analyses and sensitivity tests.

RESULTS

Patients with severe conditions showed higher levels of Hcy, PCSK9, and inflammatory markers compared to non-severe cases. Both Hcy and PCSK9 levels were independently linked to a heightened risk of severe coronary lesions(ORs: 1.03-1.04 and 1.01-1.02, respectively, all P < 0.001). PCSK9 mediated 34.04% of Hcy's effect on coronary lesion severity, whereas Hcy mediated 31.39% of PCSK9's effect, indicating significant mutual mediation between these biomarkers. Subgroup analyses revealed consistent associations, with notable interactions based on creatinine levels for Hcy and gender, smoking status, and diagnosis for PCSK9. Sensitivity analyses confirmed the robustness of the mediation effects.

CONCLUSIONS

These findings emphasize the mutual mediating effects of Hcy and PCSK9 on coronary lesion severity in patients suffering from ACS. These results highlight the complex interactions between lipid metabolism and inflammation in the pathophysiology of ACS, suggesting that targeting both Hcy and PCSK9 may offer novel therapeutic strategies to mitigate severe coronary lesions among high-risk patients.

Lipid-Lowering Therapy Use When Indicated and Subsequent Ischemic Stroke Severity

BACKGROUND

Elevated low-density lipoprotein cholesterol is a risk factor for atherosclerotic cardiovascular disease, including acute ischemic stroke (AIS), due to large- and small-vessel disease. Cholesterol management guidelines recommend lipid-lowering therapy (LLT) to prevent atherosclerotic cardiovascular disease events. This study assessed use of LLT at the time of AIS according to guideline recommendations and determined the association of prestroke LLT use with stroke severity.

METHODS AND RESULTS

We conducted a retrospective study of patients hospitalized with AIS from 2015 to 2020 at a large academic comprehensive stroke center. Patients with AIS secondary to either small-vessel disease or large-artery atherosclerosis recorded in the institutional Get With The Guidelines-Stroke registry and with a prestroke indication for LLT were included. Using propensity score subclassification, adjusted logistic regression models were built to explore the associations between LLT use before AIS when indicated and presenting National Institutes of Health Stroke Scale score >4. There were 384 patients with AIS who met guideline-recommended criteria for prestroke LLT (median age 70 years, 57% men), of whom only 207 patients (54%) were prescribed LLT before AIS. Not being prescribed LLT when indicated was associated with a significantly higher likelihood of a presenting with National Institutes of Health Stroke Scale score >4, even when adjusted for specific stroke cause (odds ratio, 1.13 [95% CI, 1.03-1.20]; P=0.006).

CONCLUSIONS

LLT is underused in patients who present with atherosclerosis-related AIS. Lack of prestroke LLT use was associated with more severe stroke symptoms upon presentation. These findings emphasize the need to prescribe LLT when indicated, because its use may mitigate poststroke disability.

Evaluation of Intensive Statins and Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors on Intracranial Artery Plaque Stability: A Prospective Single-Arm Study

BACKGROUND

Intracranial atherosclerotic stenosis is a leading cause of ischemic stroke and recurrent events due to plaque instability. High-resolution magnetic resonance imaging identifies plaque enhancement as a key marker of instability. This study evaluated the efficacy of combined high-intensity statins and proprotein convertase subtilisin/kexin type 9 inhibitors in plaque stabilization.

METHODS

In this prospective, single-arm study, patients with acute stroke and intracranial atherosclerotic stroke in the M1 segment of the middle cerebral artery or basilar artery were enrolled. After 24 weeks of intensive statin and evolocumab therapy, high-resolution magnetic resonance imaging assessments of intracranial vessels were conducted at baseline and follow-up. The primary end point was the change in stenosis degree; secondary end points included changes in plaque enhancement (contrast ratio) and plaque burden.

RESULTS

Thirty-six patients (median age, 58 years) participated. After therapy, stenosis decreased from 75.9% (interquartile range, 69.5%-84.8%) to 65.3% (interquartile range, 53.8%-75.0%; P<0.001). Contrast ratio grades and contrast volume decreased significantly (P<0.001), and lumen area increased (from 1.03 mm2 [interquartile range, 0.59-1.72 mm2] to 2.08 mm2 [interquartile range, 1.00-3.10 mm2]; P<0.001). No significant changes were observed in wall area, wall area index, or remodeling index. A notable correlation between the decrease in low-density lipoprotein cholesterol/apolipoprotein B ratio and reduction in contrast volume was observed.

CONCLUSIONS

Combining proprotein convertase subtilisin/kexin type 9 inhibitors with high-intensity statins may improve plaque stability and reduce lumen stenosis in patients with intracranial atherosclerotic stenosis. Larger randomized controlled trials are needed to confirm these findings.

REGISTRATION

URL: https://www.chictr.org.cn; Unique identifier: ChiCTR2200058029.

Inadequate awareness and attention to non-HDL cholesterol: undertreatment of high-risk patients in cardiology practice in Turkey

BACKGROUND

The relationship between low-density lipoprotein cholesterol (LDL-C) and atherosclerotic cardiovascular disease (ASCVD) is well-established. Recently, non-high-density lipoprotein cholesterol (non-HDL-C) has been validated as a superior predictor of ASCVD, especially in individuals with mild to moderate hypertriglyceridemia. The EPHESUS study evaluated real-life hypercholesterolemia management and awareness of non-HDL-C in cardiology outpatient practices.

METHODS

Data from 1868 patients with ASCVD or high-risk primary prevention were analyzed to assess cholesterol goal attainment, statin adherence, and physician perceptions. This analysis focused on awareness of non-HDL-C as an ASCVD predictor, adherence to lipid-lowering therapy, and clinicians' perceptions. Associations between patient demographics, clinical characteristics, and statin adherence were examined.

RESULTS

Among patients, 20.2% achieved non-HDL-C and 16.5% achieved LDL-C goals. In primary prevention, 18.1% reached non-HDL-C and 10.6% reached LDL-C goals, while in secondary prevention, 20.8% and 18.0% met these goals. High-intensity statin therapy was observed in 21.2% of patients, with 30.3% and 24.3% achieving non-HDL-C and LDL-C targets, respectively. Statin use was lower in women than men (54.0% vs 66.9%, P < 0.001). Women less frequently achieved non-HDL-C and LDL-C goals in both prevention groups.

CONCLUSIONS

Non-HDL-C goal attainment remains suboptimal in both primary and secondary prevention of hypercholesterolemia, particularly in women who had lower statin use and goal achievement. These findings highlight the need for improved awareness, education, and treatment strategies to reduce residual cardiovascular risk and improve outcomes.

CRISPR-Cas9 in Cardiovascular Medicine: Unlocking New Potential for Treatment

Cardiovascular diseases (CVDs) remain a significant global health challenge, with many current treatments addressing symptoms rather than the genetic roots of these conditions. The advent of CRISPR-Cas9 technology has revolutionized genome editing, offering a transformative approach to targeting disease-causing mutations directly. This article examines the potential of CRISPR-Cas9 in the treatment of various CVDs, including atherosclerosis, arrhythmias, cardiomyopathies, hypertension, and Duchenne muscular dystrophy (DMD). The technology's ability to correct single-gene mutations with high precision and efficiency positions it as a groundbreaking tool in cardiovascular therapy. Recent developments have extended the capabilities of CRISPR-Cas9 to include mitochondrial genome editing, a critical advancement for addressing mitochondrial dysfunctions often linked to cardiovascular disorders. Despite its promise, significant challenges remain, including off-target effects, ethical concerns, and limitations in delivery methods, which hinder its translation into clinical practice. This article also explores the ethical and regulatory considerations surrounding gene editing technologies, emphasizing the implications of somatic versus germline modifications. Future research efforts should aim to enhance the accuracy of CRISPR-Cas9, improve delivery systems for targeted tissues, and ensure the safety and efficacy of treatments in the long term. Overcoming these obstacles could enable CRISPR-Cas9 to not only treat but also potentially cure genetically driven cardiovascular diseases, heralding a new era in precision medicine for cardiovascular health.

The Safety Profile of Inclisiran in Patients with Dyslipidemia: A Systematic Review and Meta-Analysis

INTRODUCTION

Inclisiran is a novel drug that employs ribonucleic acid (RNA) interference to lower the levels of the proprotein convertase subtilisin/kexin type 9 (PCSK9) protein. It has demonstrated a significant reduction in LDL cholesterol levels compared to a placebo. We aim to comprehensively evaluate the safety of using Inclisiran in patients with dyslipidemia and ASCVD or an ASCVD risk equivalent.

METHODS

Four electronic databases, namely, Pubmed/MEDLINE, Web of Science, Embase, and ClinicalTrials.gov, were searched from inception to June 2024 to identify relevant randomized controlled trials (RCTs) comparing safety profiles of Inclisiran and the control group. The outcomes investigated were all-cause mortality, major adverse cardiovascular events (MACEs), injection-site adverse events, new-onset or worsening type 2 diabetes mellitus (T2DM), and nasopharyngitis. The effect estimates of outcomes were assessed using the risk ratio (RR) with a 95% confidence interval (CI). Random-effects meta-analysis was conducted using the restricted maximum likelihood method. Subgroup analysis was performed based on different dosing regimens.

RESULTS

The study included 7 RCTs, enrolling 4790 patients (age 63.8 ± 9.7 years, 33.2% females) who received Inclisiran. Compared to the control group, Inclisiran use did not yield a significant effect on all-cause mortality (RR, 0.92; 95% CI, 0.54 to 1.54; I2 = 0%), MACEs (RR, 0.98; 95% CI, 0.82 to 1.17; I2 = 0%), nasopharyngitis (RR, 1.10; 95% CI, 0.83 to 1.45; I2 = 0%), and T2DM (RR, 1.02; 95% CI, 0.85 to 1.21; I2 = 0%). However, Inclisiran use demonstrated a significant increase in injection-site adverse events (RR, 6.50; 95% CI, 3.20 to 13.20; I2 = 29%).

CONCLUSIONS

Inclisiran use significantly increased injection-site reactions, with no increase in mortality, T2DM, or nasopharyngitis. It demonstrates a generally favorable safety profile, making it a promising option for lipid management in individuals at high cardiovascular risk, such as those with ASCVD or equivalent conditions. While it effectively improves dyslipidemia, decision-makers should be aware of an increased incidence of injection-site reactions, which, though typically mild, warrant consideration in clinical practice. Further trials are required to assess the safety of Inclisiran, particularly the association of the severity of injection-site adverse events over longer treatment durations.

From Genetic Findings to new Intestinal Molecular Targets in Lipid Metabolism

PURPOSE OF REVIEW

While lipid-lowering therapies demonstrate efficacy, many patients still contend with significant residual risk of atherosclerotic cardiovascular diseases (ASCVD). The intestine plays a pivotal role in regulating circulating lipoproteins levels, thereby exerting influence on ASCVD pathogenesis. This review underscores recent genetic findings from the last six years that delineate new biological pathways and actors in the intestine which regulate lipid-related ASCVD risk.

RECENT FINDINGS

Specifically, we detail the role of LIMA1 in cholesterol absorption within enterocytes, the function of PLA2G12B in the expansion and lipidation of chylomicrons, the involvement of SURF4 in lipoprotein secretion, and the discovery of a gut-derived hormone named CHOLESIN that modulates cholesterol homeostasis through GPR146 via a gut-liver crosstalk. We further discuss the potential of these newly identified genes and pathways as novel targets for pharmaceutical intervention. Newly identified genetic and intestinal molecular mechanisms offer promising opportunities for preventing and treating ASCVD, but careful evaluation and further research are needed to optimize their clinical application.

Residual Traditional Risk in Non-Traditional Atherosclerotic Diseases

Individuals with chronic inflammatory and immune disorders are at an increased risk of atherosclerotic events and premature cardiovascular (CV) disease. Despite extensive literature exploring the relationship between "non-traditional" atherosclerotic conditions and CV risk, many aspects remain unresolved, including the underlying mechanisms promoting the "non-traditional CV risk", the development of an innovative and comprehensive CV risk assessment tool, and recommendations for tailored interventions. This review aims to evaluate the available evidence on key "non-traditional" CV risk-enhancer conditions, with a focus on assessing and managing CV risk factors. We conducted a comprehensive review of 412 original articles, narrative and systematic reviews, and meta-analyses addressing the CV risk associated with "non-traditional" atherosclerotic conditions. The analysis examined the underlying mechanisms of these relationships and identified strategies for assessing and mitigating elevated risk. A major challenge highlighted is the difficulty in quantifying the contribution of individual risk factors and disease-specific elements to CV risk. While evidence supports the cardiovascular benefits of statins beyond lipid lowering, such as pleiotropic and endothelial effects, current guidelines lack specific recommendations for the use of statins or other therapies targeting non-traditional CV risk factors. Additionally, the absence of validated cardiovascular risk scores that incorporate non-traditional risk factors hinders accurate CV risk evaluation and management. The growing prevalence of "non-traditional CV risk-enhancer conditions" underscores the need for improved awareness of CV risk assessment and management. A thorough understanding of all contributing factors, including disease-specific elements, is crucial for accurate prediction of cardiovascular disease (CVD) risk. This represents an essential foundation for informed decision-making in primary and secondary prevention. We advocate for future research to focus on developing innovative, disease-specific CV risk assessment tools that incorporate non-traditional risk factors, recognizing this as a promising avenue for translational and clinical outcome research.

Medical history predicts phenome-wide disease onset and enables the rapid response to emerging health threats

The COVID-19 pandemic exposed a global deficiency of systematic, data-driven guidance to identify high-risk individuals. Here, we illustrate the utility of routinely recorded medical history to predict the risk for 1741 diseases across clinical specialties and support the rapid response to emerging health threats such as COVID-19. We developed a neural network to learn from health records of 502,489 UK Biobank participants. Importantly, we observed discriminative improvements over basic demographic predictors for 1546 (88.8%) endpoints. After transferring the unmodified risk models to the All of US cohort, we replicated these improvements for 1115 (78.9%) of 1414 investigated endpoints, demonstrating generalizability across healthcare systems and historically underrepresented groups. Ultimately, we showed how this approach could have been used to identify individuals vulnerable to severe COVID-19. Our study demonstrates the potential of medical history to support guidance for emerging pandemics by systematically estimating risk for thousands of diseases at once at minimal cost.

Inclisiran, Reasons for a Novel Agent in a Crowded Therapeutic Field

PURPOSE OF THE REVIEW

A significant number of patients fail to achieve target LDL cholesterol (LDL-C) levels. This review aims to explore why inclisiran, a novel class of LLT, should be considered a valuable addition to the current treatment options.

RECENT FINDINGS

Inclisiran is a small interfering RNA (siRNA) that targets PCSK9 synthesis specifically in the hepatocytes. The drug remains in circulation for less than 48 h, but its effect lasts for over six months. Two subcutaneous injections per year consistently lowers LDL-C by approximately 55% with a favorable safety profile. In combination with other LLTs, it can achieve LDL-C reductions of over 80%, supporting its role in high-intensity LLT strategies. Inclisiran represents a novel class of LLT. Administered biannually, reduces baseline LDL-C levels by half. Additionally, it has a strong safety profile. Due to its pharmacokinetic properties, is likely to improve adherence to LLT and persistently maintain low LDL-C levels.

Pharmacotherapy, Lifestyle Modification, and Cardiac Rehabilitation after Myocardial Infarction or Percutaneous Intervention

Coronary artery disease is the leading cause of death in the US, and approximately 25% of MIs occurring each year are reinfarctions. Due to advances in percutaneous coronary intervention (PCI) and medical therapy, patients with prior MIs live longer but may be susceptible to additional cardiac events. Thus, secondary prevention after MI or PCI is key to improving mortality and quality of life. This review discusses pharmacotherapies and lifestyle interventions with a special focus on cardiac rehabilitation in the post-MI or PCI period to improve cardiovascular outcomes.

Learnings from Implementation Strategies to Improve Lipid Management

PURPOSE OF REVIEW

Lowering low-density lipoprotein (LDL)-cholesterol reduces cardiovascular risk. International lipid management guidelines recommend LDL-cholesterol goals or thresholds for initiating lipid-lowering therapy. However, contemporary real-world studies have shown that many high- and very high-risk patients are not attaining LDL-cholesterol goals and are not receiving intensive lipid-lowering therapies. In this review, recent examples of implementation strategies for optimising lipid management are discussed.

RECENT FINDINGS

Implementation studies are heterogenous in their strategies and design. At the clinician level, multidisciplinary team-based care (including multidisciplinary lipid clinics), pharmacist- or nurse-led interventions, decision-support algorithms or protocols, and educational initiatives have shown potential to improve lipid management. Various strategies to improve patient adherence to lipid-lowering therapies have demonstrated at least short-term efficacy, including education, shared decision-making, behavioural support and nudges. Electronic health records can be leveraged at low cost to identify patients requiring initiation or intensification of lipid-lowering therapies, but the optimal method of integrating automated alerts or nudges to influence decision-making requires further research. Moreover, telehealth and remote care delivery models can improve access to healthcare and facilitate lipid-lowering. Multifaceted strategies with a systematic approach to targeting clinician, patient and system related factors can be successful in improving lipid management. Future implementation research should evaluate longer-term outcomes and follow implementation science theories, models and/or frameworks at all stages. By doing so, ongoing implementation studies will help researchers better understand the impact, sustainability and scalability of strategies, and where barriers and facilitators to lipid management may exist in other contexts.

Intra-operative and post-operative management of conduits for coronary artery bypass grafting: a clinical consensus statement of the European Society of Cardiology Working Group on Cardiovascular Surgery and the European Association for Cardio-Thoracic Surgery Coronary Task Force

The structural and functional integrity of conduits used for coronary artery bypass grafting is critical for graft patency. Disruption of endothelial integrity and endothelial dysfunction are incurred during conduit harvesting subsequent to mechanical or thermal injury and during conduit storage prior to grafting, leading to acute thrombosis and early graft failure. Late graft failure, in particular that of vein grafts, is precipitated by progressive atherogenesis. Intra-operative management includes appropriate selection of conduit-specific harvesting techniques and storage solutions. Arterial grafts are prone to vasospasm subsequent to surgical manipulation, and application of intra-operative vasodilatory protocols is critical. Post-operative management includes continuation of oral vasodilator therapy and selection of antithrombotic and lipid-lowering agents to attenuate atherosclerotic disease progression in conduits. In this review, the scientific evidence underlying the key aspects of intra- and post-operative management of conduits for coronary artery bypass grafting is examined. Clinical consensus statements for best clinical practice are provided, and areas requiring further research are highlighted.

Association between Estimated Small Dense Low-Density Lipoprotein-cholesterol (sdLDL-C) and Atherosclerotic Cardiovascular Disease Risk

BACKGROUND

A new formula for estimating small, dense, low-density lipoprotein cholesterol (sdLDL-C) based on the results of the standard lipid panel is proposed.

OBJECTIVES

To assess the association between estimated sdLDL-C (EsdLDL-C) and atherosclerotic cardiovascular disease (ASCVD) risk.

METHODS

A total of 12,192 participants from the Korea National Health and Nutrition Examination Survey (KNHANES) database between 2010 and 2020 were included in this cross-sectional study. EsdLDL-C was calculated as EsdLDL-C= LDL-C - [1.43 × LDL-C - (0.14 × (ln (TG) × LDL-C)) - 8.99]. Logistic regression analyses were utilized to assess the association between EsdLDL-C and ASCVD risk. Subgroup analyses were performed based on age, body mass index (BMI), hypertension, and diabetes. An odds ratio (OR) with a 95% confidence interval (CI) was used for evaluation. P<0.05 was considered statistically significant.

RESULTS

Among 12,192 participants, 1,239 (10.16%) had ASCVD. The mean sdLDL-C of participants was estimated to be 42.43±14.75 mg/dL using the formula. Elevated EsdLDL-C levels (OR=1.33; 95%CI, 1.06-1.66) were associated with an increased risk of ASCVD. Subgroup analyses found that there may be an interaction between EsdLDL-C (Pinteraction= 0.001) or non-HDL-C (Pinteraction= 0.015) and hypertension on ASCVD risk.

CONCLUSIONS

Elevated estimated sdLDL-C levels were associated with the risk of ASCVD, and estimated sdLDL-C might be an alternative to sdLDL-C measurement for ASCVD risk assessment.

Prevalence, genetic variants, and clinical implications of hypocholesterolemia in children

BACKGROUND AND AIMS

In contrast to extensively studied hypercholesterolemia, knowledge of hypocholesterolemia is limited. This study aims to assess the prevalence, clinical characteristics, and genetics of children and adolescents with hypocholesterolemia.

METHODS

This national prospective cross-sectional cohort study was part of Slovenia's universal opt-out cholesterol screening program. The first part assessed hypocholesterolemia prevalence among 3538 children aged 5 years, randomly selected at the mandatory check-up. The second part included analysis of demographic and clinical data and genetic testing of 71 individuals with suspected hypocholesterolemia (total cholesterol [TC] < 3.0 mmol/L [116.0 mg/dL]) referred to the Lipid Clinic of University Children's Hospital Ljubljana.

RESULTS

The prevalence of hypocholesterolemia among 3538 children was 2.66 % (95 % CI: 2.13-3.19 %). Among the 71 genetically tested individuals with suspected hypocholesterolemia, those with pathogenic variants had lower TC (2.58 ± 0.44 mmol/L vs. 2.85 ± 0.42 mmol/L [99.77 ± 17.02 mg/dL vs. 110.20 ± 16.24 mg/dL]; p = 0.037) and low-density lipoprotein cholesterol (1.00 ± 0.40 mmol/L vs. 1.33 ± 0.40 mmol/L [38.67 ± 15.47 mg/dL vs. 51.43 ± 15.47 mg/dL]; p = 0.014) compared to those without such variants. Genetic testing identified pathogenic alterations in 15 subjects, including 4 novel loss-of-function variants in the APOB gene. All but one subject were asymptomatic.

CONCLUSIONS

This study provides new clinical and genetic insights into hypocholesterolemia. Asymptomatic patients with hypocholesterolemia may not require further evaluation, but additional research is needed to understand hypocholesterolemia better.

Clinical Impact of Lipoprotein (a) and Cumulative Low-Density Lipoprotein Cholesterol Exposure on Coronary Artery Disease in Patients with Heterozygous Familial Hypercholesterolemia

AIMS

Elevated lipoprotein (a) (Lp[a]), predominantly determined by genetic variability, causes atherosclerotic cardiovascular disease (ASCVD), particularly in patients with familial hypercholesterolemia (FH). We aimed to elucidate the clinical impact of Lp(a) and cumulative exposure to low-density lipoprotein cholesterol (LDL-C) on CAD in patients with FH.

METHODS

One hundred forty-seven patients clinically diagnosed with heterozygous familial hypercholesterolemia (HeFH) were retrospectively investigated. Patients were divided into 2 groups according to the presence of CAD. Their clinical characteristics and lipid profiles were evaluated.

RESULTS

There were no significant differences in untreated LDL-C levels between the 2 groups (p=0.4), whereas the cumulative exposure to LDL-C and Lp(a) concentration were significantly higher in patients with CAD (11956 vs. 8824 mg-year/dL, p＜0.01; 40 vs. 14 mg/dL, p＜0.001, respectively). A receiver operating characteristic (ROC) curve analysis demonstrated that the cutoff values of Lp(a) and cumulative LDL-C exposure to predict CAD in patients with FH were 28 mg/dL (AUC 0.71) and 10600 mg-year/dL (AUC 0.77), respectively. A multivariate analysis revealed that cumulative LDL-C exposure ≥ 10600 mg-year/dL (p＜0.0001) and Lp(a) level ≥ 28 mg/dL (p＜0.001) were independent predictors of CAD. Notably, the risk of CAD remarkably increased to 85.7% with smoking, Lp(a) ≥ 28 mg/dL, and cumulative LDL-C exposure ≥ 10600 mg-year/dL (odds ratio: 46.5, 95%CI: 5.3-411.4, p＜0.001).

CONCLUSIONS

This study demonstrated an additive effect of Lp(a) and cumulative LDL-C exposure on CAD in patients with HeFH. Interaction with traditional risk factors, particularly smoking and cumulative LDL-C exposure, enormously enhances the cardiovascular risk in this population.

Lipotoxicity-driven metabolic dysfunction-associated steatotic liver disease (MASLD)

Metabolic dysfunction-associated steatotic liver disease (MASLD) encompasses a spectrum of liver lesions, ranging from simple steatosis to metabolic dysfunction-associated steatohepatitis (MASH), that may further progress to cirrhosis. MASLD is estimated to affect more than one third of the general population and it represents a risk factor for end-stage liver failure and liver cancer, substantially contributing to liver-related morbidity and mortality. Although the pathogenesis of MASLD is incompletely understood, it is known to consist of a multifactorial process influenced by extrinsic and intrinsic factors such as metabolic, environmental and demographic features, gut microbiota and genetics. Dysregulation of both extracellular and intracellular lipid composition is known to promote the generation of toxic lipid species, thereby triggering lipotoxicity and cellular stress. These events ultimately lead to the activation of distinct cell death pathways, resulting in inflammation, fibrogenesis and, eventually, carcinogenesis. In this manuscript, we provide a comprehensive review of the role of lipotoxicity during MASLD pathogenesis, discussing the most relevant lipid species and related molecular mechanisms, summarizing the cell type-specific effects and highlighting the most promising putative therapeutic strategies for modulating lipotoxicity and lipid metabolism in MASLD.

Dietary fat quantity and composition influence hepatic lipid metabolism and metabolic disease risk in humans

The excessive accumulation of intrahepatic triglyceride (IHTG) in the liver is a risk factor for metabolic diseases, including type 2 diabetes and cardiovascular disease. IHTG can excessively accumulate owing to imbalances in the delivery, synthesis, storage and disposal of fat to, in and from the liver. Although obesity is strongly associated with IHTG accumulation, emerging evidence suggests that the composition of dietary fat, in addition to its quantity, plays a role in mediating IHTG accumulation. Evidence from human cross-sectional and interventional studies indicates that diets enriched with saturated fat compared to other fat types and carbohydrates produce divergent effects on IHTG content. However, the mechanistic reasons for these observations remain unknown. Given the challenges of investigating such mechanisms in humans, cellular models are needed that can recapitulate human hepatocyte fatty acid metabolism. Here, we review what is known from human studies about how dietary fat, its quantity and composition contribute to IHTG accumulation. We also explore the effects of fatty acid composition on hepatocellular fat metabolism from data generated in cellular models to help explain the divergences observed in in vivo studies.

Clinical and Genomic Prediction of Coronary Artery Disease Subtypes

BACKGROUND

Coronary artery disease (CAD) is a complex, heterogeneous disease with distinct etiological mechanisms. These different etiologies may give rise to multiple subtypes of CAD that could benefit from alternative preventions and treatments. However, so far, there have been no systematic efforts to predict CAD subtypes using clinical and genetic factors.

METHODS

Here, we trained and applied statistical models incorporating clinical and genetic factors to predict CAD subtypes in 26 036 patients with CAD in the UK Biobank. We performed external validation of the UK Biobank models in the US-based All of Us cohort (8598 patients with CAD). Subtypes were defined as high versus normal LDL (low-density lipoprotein) levels, high versus normal Lpa (lipoprotein A) levels, ST-segment-elevation myocardial infarction versus non-ST-segment-elevation myocardial infarction, occlusive versus nonocclusive CAD, and stable versus unstable CAD. Clinical predictors included levels of ApoA, ApoB, HDL (high-density lipoprotein), triglycerides, and CRP (C-reactive protein). Genetic predictors were genome-wide and pathway-based polygenic risk scores (PRSs).

RESULTS

Results showed that both clinical-only and genetic-only models can predict CAD subtypes, while combining clinical and genetic factors leads to greater predictive accuracy. Pathway-based PRSs had higher discriminatory power than genome-wide PRSs for the Lpa and LDL subtypes and provided insights into their etiologies. The 10-pathway PRS most predictive of the LDL subtype involved cholesterol metabolism. Pathway PRS models had poor generalizability to the All of Us cohort.

CONCLUSIONS

In summary, we present the first systematic demonstration that CAD subtypes can be distinguished by clinical and genomic risk factors, which could have important implications for stratified cardiovascular medicine.

ApoB100 remodeling and stiffened cholesteryl ester core raise LDL aggregation in familial hypercholesterolemia patients

Patients with familial hypercholesterolemia (FH) exhibit a significant residual cardiovascular risk. A new cardiovascular risk factor is the susceptibility of individual LDL particles to aggregation. This study examined LDL aggregation and its relationship with LDL lipid composition and biophysical properties in patients with FH compared to controls. LDL aggregation was measured as the change in particle size, assessed by dynamic light scattering, after exposure to sphingomyelinase, which breaks down sphingomyelin in the LDL phospholipid layer. Dynamic light scattering and transmission electron microscopy showed that LDL in FH patients exhibited smaller size and greater susceptibility to aggregation. Biochemical analyses revealed a higher cholesteryl ester (CE)/ApoB100 ratio in LDL from FH patients. Differential scanning calorimetry showed that LDL from FH patients had higher transition temperatures, indicating a more ordered CE core. Fourier transform infrared spectroscopy revealed fewer flexible α-helices (1658 cm⁻1) and more stable α-helices (1651 cm⁻1) in ApoB100 of LDL from FH patients. These structural changes correlated with higher CE content and increased LDL aggregation. In conclusion, a more ordered CE core in smaller LDL particles, combined with a higher proportion of stable α-helices in ApoB100, promotes LDL aggregation in FH patients. These findings suggest ApoB100 conformational structure as a new potential therapeutic targets within LDL to reduce cardiovascular risk in FH patients.

The relevance of remnant cholesterol as a guide for lipid management in Indian subjects undergoing coronary revascularization

BACKGROUND

The atherogenic potential of remnant cholesterol, which refers to the cholesterol content of triglyceride-rich, non-low-density lipoprotein (LDL) particles in circulation, has gained increasing attention recently. Unfortunately, very limited information is available regarding remnant cholesterol levels in Indian subjects.

METHODS

This was a retrospective study conducted at a premier, tertiary care center in North India. A total of 3064 consecutive subjects [mean age 61.3 ± 10.3 years, 2550 (83.2%) men] with newly diagnosed coronary artery disease (CAD) undergoing coronary revascularization were included. Enzymatic assays were used for measuring various lipid parameters. Remnant cholesterol was calculated by subtracting LDL cholesterol (LDL-C) and high-density lipoprotein cholesterol from total cholesterol. A value >30 mg/dL was considered elevated.

RESULTS

The mean LDL-C was 79.1 ± 33.1 mg/dL with 46.4% of all subjects having LDL-C <70 mg/dL and only 16.9% having LDL-C <50 mg/dL. The median remnant cholesterol level was 17.0 mg/dL (interquartile range 12.0-24.0 mg/dL) with only 11.9% of subjects having values >30 mg/dL. Only 4.5% of the patients with LDL-C <70 mg/dL and 2.9% of those with LDL-C <50 mg/dL had elevated remnant cholesterol. These proportions were significantly greater in patients with serum triglycerides >200 mg/dL.

CONCLUSION

Our study shows that in a North-Indian population with CAD, elevated remnant cholesterol was present in only a small proportion. The prevalence of elevated remnant cholesterol decreased further as the LDL-C control improved. These findings suggest that elevated remnant cholesterol may not be a clinically relevant therapeutic target in most patients with LDL-C below the currently recommended goals.

Bempedoic Acid: A Review in Cardiovascular Risk Reduction in Statin-Intolerant Patients

Oral bempedoic acid (NEXLETOL® in the USA; Nilemdo® in the EU) and the fixed dose combination (FDC) of bempedoic acid/ezetimibe (NEXLIZET® in the USA; Nustendi® in the EU) are approved to reduce cardiovascular (CV) risk in statin-intolerant patients who are at high risk for, or have, CV disease. A first-in-class therapy, bempedoic acid inhibits the adenosine triphosphate-citrate lyase enzyme in the cholesterol biosynthesis pathway. In the multinational phase III CLEAR Outcomes trial in statin-intolerant patients, once-daily bempedoic acid 180 mg significantly reduced the risk of the primary endpoint (a four-component major adverse CV event composite of CV death, nonfatal myocardial infarction, nonfatal stroke, or coronary revascularization) compared with placebo. Bempedoic acid was generally well tolerated and, unlike statins, was associated with a low incidence of musculoskeletal adverse events (AEs). In conclusion, bempedoic acid as a monotherapy or adjunctive to other lipid-lowering therapies expands the treatment options available for the pharmacological reduction of CV risk in statin-intolerant patients, supporting achievement of low-density lipoprotein cholesterol (LDL-C) targets required for CV risk reduction.

Relative increase in production ratio of small dense low-density lipoprotein in acute coronary syndrome with high coronary plaque burden: an ex-vivo analysis

The absolute value of small dense low-density lipoprotein (sd-LDL) including small LDL (s-LDL) and very small LDL (vs-LDL) has been shown to be associated with increased incidence of atherosclerosis. However, the impact of short-timeframe increases in sd-LDL on arteriosclerosis has not yet been elucidated. Therefore, we investigated the clinical roles of ex-vivo induced sd-LDL in acute coronary syndrome (ACS) using a novel method. This is a prospective, single-blind, and observational study that screened patients who underwent coronary angiography (CAG) for the treatment of ACS or investigation of heart-failure etiology between June 2020 and April 2022 (n = 247). After excluding patients with known diabetes mellitus and advanced renal disease, the patients were further divided into the ACS (n = 34) and control (non-obstructive coronary artery, n = 34) groups. The proportion of sd-LDL (s-LDL + vs-LDL) in total lipoproteins was observed before and after 2-h incubation at 37 ℃ (to approximate physiologic conditions) using 3% polyacrylamide gel electrophoresis. The coronary plaque burden was quantified upon CAG in the ACS group. There were no significant differences between the ACS and control groups in terms of clinical coronary risk factors. The baseline of large, medium, small, and very small LDL were comparable between the two groups. Following a 2-h incubation period, significant increases were observed in the ratios of s-LDL and vs-LDL in both the ACS and control groups (ACS, p = 0.01*; control, p = 0.01*). Notably, the magnitude of increase in sd-LDL was more pronounced in the ACS group compared to the control group, with s-LDL showing a significant difference (p = 0.03*) and vs-LDL showing a tread toward significance (p = 0.08). In addition, in both groups, there was a decrease in IDL and L-LDL, while M-LDL remained unchanged. The plaque burden index and rate of short-timeframe changes in both s-LDL (p = 0.01*) and vs-LDL (p = 0.04*) before and after incubation were significantly correlated in the ACS group. The enhanced production rate of sd-LDL induced under short-term physiologic culture in an ex-vivo model was greater in patients with ACS than in the control group. The increase in sd-LDL is positively correlated with coronary plaque burden. Short-timeframe changes in sd-LDL may serve as markers for the severity of coronary artery disease.

An up-to-date review of emerging biologic therapies for hypercholesterolemia

INTRODUCTION

Hypercholesterolemia and other lipid disorders are major causes of atherosclerotic cardiovascular disease (ASCVD). Statins have been the mainstay of lipid-lowering therapy for many years, but they may not be adequate to achieve the target low-density lipoprotein (LDL) cholesterol levels and there are other residual lipid risk factors.

AREAS COVERED

This article reviews the biologic therapies in development for hypercholesterolemia identified by a PubMed search. Inhibition of proprotein convertase subtilisin/kexin type 9 (PCSK9) is a major focus, but the drugs targeting apolipoprotein C3 (apoC3) and angiopoietin-like 3 (ANGPTL3) that were originally developed to reduce the levels of triglyceride-rich lipoproteins are now being explored to reduce cardiovascular events in a wider range of patients. A brief overview of biologic therapies targeting lipoprotein(a) [Lp(a)] is also proved.

EXPERT OPINION

Inhibition of PCSK9 remains an attractive target. In addition to the currently available monoclonal antibodies (mAbs) and small interfering RNA (siRNA), new mAbs and the adenectin lerodalcibep are promising therapies. The antisense oligonucleotide (ASO) and siRNA inhibitors of apoC3 and ANGPTL3 are effective in severe hypertriglyceridemia and homozygous familial hypercholesterolemia, respectively, and may prove to have wider applications. ASO and siRNA inhibitors of Lp(a) are currently in cardiovascular outcome studies.

Aortopathy: Effects of Lipid-Lowering Therapy

Aortopathies can be congenital or acquired. Aortic atherosclerosis, abdominal aortic aneurysm, and degenerative aortic stenosis are some of the major manifestations of acquired aortopathy. Dyslipidemia, an imbalance of plasma lipid levels, is strongly associated with common aortopathies. A relationship between abdominal aortic aneurysm, degenerative aortic stenosis, and dyslipidemia has been identified in the literature but finding effective preventive strategies has been challenging. Nevertheless, lipid-lowering therapy remains a mainstay of both treatment and prevention. In patients with aortic atheroma, statins were found to be protective through the review of this study. There is currently no place for statins in the treatment or prevention of disease progression in patients with calcific aortic stenosis. Their low cost, widespread availability, and strong safety profile tip the risk-to-benefit ratio toward statins for abdominal aortic aneurysms but more research is needed. A review of proprotein convertase subtilisin/kexin type 9 inhibitors may yield similar benefits for all aortopathy patients; however, those results are not yet available.

Independent Association of Individual Lipid Abnormalities with Cardiovascular All-cause Mortality: A Prospective Cohort Study

INTRODUCTION

Abnormalities in total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG) are each associated with increased cardiovascular risk, after adjusting for non-lipid risk factors. However, whether and to what extent the association for each lipid measure is confounded by other lipid measures is less understood.

AIM

This study aims to investigate the association of each lipid measure with cardiovascular and all-cause mortality while precluding the confounding caused by abnormalities in other lipid measures.

METHODS

The study utilized data from the third National Health and Nutrition Examination Survey (NHANES III, 1988-1994) and ten cycles of continuous NHANES (1999-2018). The study cohort included 23,761 participants who were 20 years or older, not pregnant, not receiving lipid-lowering treatment, and had complete data on all four lipid measures and mortality status. Participants were categorized into seven subgroups based on their lipid profiles. Kaplan-Meier survival curves and Cox proportional hazards models were used to examine the association between lipid abnormalities and mortality.

RESULTS

During a median follow-up of 140 months, 5,003 participants (14.1%) died, with 1,665 deaths (4.2%) attributable to cardiovascular causes. Compared with the reference group in which the four lipid measures were all normal, the subgroups with isolated high TC, two to three lipid abnormalities, and four lipid abnormalities were associated with increased risks for both cardiovascular and all-cause mortality in univariate analysis. However, only those with isolated high TC (for cardiovascular mortality, HR 1.52, 95% CI 1.13-2.06) and four lipid abnormalities (for all-cause mortality, HR 1.34, 95% CI 1.04-1.72) remained statistically significant after adjusting for non-lipid risk factors. Of note, compared with the reference group, the profile of non-lipid risk factors was apparently less favorable in the subgroup with two to three lipid abnormalities but similar (and some factors even more favorable) in the subgroup with isolated high TC. When the lipid measures were analyzed as continuous variables, a U-shaped relationship between HDL-C and mortality risk was observed for both cardiovascular and all-cause mortality, and very low LDL-C level was associated with increased mortality risk. No statistically significant association was found between TG levels and mortality risk.

CONCLUSION

Isolated high TC, very low LDL-C, and concurrent abnormalities in all four lipid measures were associated with increased mortality risk, whereas isolated high TG was not. A U-shaped relationship may exist between HDL-C level and mortality. Overall, these findings underscore the need for integrated management of dyslipidemia that takes all four lipid measures as well as non-lipid cardiovascular risk factors into account, particularly for those with concurrent abnormalities in two or more lipid measures.

Milk and dairy products - a scoping review for Nordic Nutrition Recommendations 2023

Milk and dairy products are major sources of protein, calcium, and other micronutrients. Milk and dairy products contribute with approximately half of the total intake of saturated fat in the Nordic and Baltic diets. Saturated fat is an important determinant of plasma total and low density lipoprotein (LDL)-cholesterol concentrations, and a causal relationship between high LDL-cholesterol and atherosclerotic cardiovascular disease has consistently been documented. The aim of this scoping review is to describe the evidence for the role of milk and dairy products for health-related outcomes as a basis for setting and updating food-based dietary guidelines. Two qualified systematic reviews were included (World Cancer Research Fund and a systematic review for the US Dietary Guidelines Advisory Committee 2020). In addition, systematic reviews published between January 2011 and January 2022 were considered, screened (555 records) and evaluated (159 records) for this review. The systematic reviews suggest that milk or dairy consumption is not associated with increased risk of cardiovascular disease and dyslipidaemia. Current evidence suggests an inverse association with some cardiometabolic risk factors, such as total and LDL-cholesterol, especially regarding fermented dairy products (i.e. yogurt and cheese). There was evidence of an association between intake of dairy products and reduced risk of colorectal cancer. Some studies reported an inverse association between intake of dairy and type 2 diabetes or markers of impaired glucose homeostasis, especially for low-fat dairy, yoghurt, and cheese. Most studies suggest that intake of milk or dairy is not associated with increased risk of cardiovascular risk and some suggestions of inverse association, especially with low-fat products and fermented dairy products, were found with respect to cardiovascular disease, type 2 diabetes, and colorectal cancer. Milk or dairy products are important dietary sources of calcium and iodine, and are fully compatible with a healthy dietary pattern.

Safety assessment of ezetimibe: real-world adverse event analysis from the FAERS database

BACKGROUND

Ezetimibe is known for its lipid-lowering safety and tolerability, but its real-world adverse effects have not been fully evaluated. In this study, adverse events associated with ezetimibe were investigated using the FAERS database for the period 2004 to 2023.

RESEARCH DESIGN AND METHODS

Adverse events data for ezetimibe, spanning from the first quarter of 2004 to the fourth quarter of 2023, were standardized and analyzed using signal quantification methods like Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Multi-item Gamma Poisson Shrinker (EBGM).

RESULTS

Among 11,550 adverse drug events reports with ezetimibe as the primary suspect drug, 211 preferred terms (PTs) were identified across 24 different system organ classes (SOCs).Notably, in addition to the adverse reactions already specified in the instruction manual, unstable angina (n = 120, ROR 30.53(25.47-36.58), PRR 30.41(25.49-36.28), IC 4.9(4.64), EBGM 29.85(25.66)), crush syndrome(n = 19,ROR 298.83(182.95-488.09), PRR 298.65(182.96-487.49), IC 7.97(7.29),EBGM 251.12(166.57)), and autoscopy (n = 7, ROR 28.81(13.64-60.85), PRR 28.80(13.68-60.65), IC 4.82(3.81), EBGM 28.30(15.14))were new adverse reactions that emerged as strong signals.

CONCLUSIONS

Ezetimibe is effective in lowering blood lipids, but there is a risk of adverse reactions such as unstable angina, rhabdomyolysis and autoscopy, which require careful monitoring by physicians.

E-cigarettes and arterial health: A review of the link between vaping and atherosclerosis progression

Recent studies have suggested an evolving understanding of the association between vaping, specifically electronic cigarette (e-cigarette) use, and the progression of atherosclerosis, a significant contributor to cardiovascular disease. Despite the prevailing perception of vaping as a safer alternative to traditional tobacco smoking, accumulating evidence suggests that the aerosols emitted by e-cigarettes contain harmful constituents that may promote endothelial dysfunction, oxidative stress, inflammation, and dyslipidemia-key mechanisms implicated in atherosclerosis pathogenesis. While past research, including experimental studies and clinical investigations, has shed light on the potential cardiovascular risks associated with vaping, gaps in knowledge persist. Future research endeavors should focus on interpreting the long-term effects of vaping on atherosclerosis development and progression, exploring the impact of different e-cigarette formulations and user demographics, and identifying effective strategies for mitigating the cardiovascular consequences of vaping. By identifying and addressing these research gaps, we can enhance our understanding of the cardiovascular implications of vaping and inform evidence-based interventions and policies to safeguard public health.

Valorizing Agro‐Food Waste for Nutraceutical Development: Sustainable Approaches for Managing Metabolic Dysfunction‐Associated Steatotic Liver Disease and Related Co‐Morbidities

This comprehensive investigation delves into the interconnectedness of different features of cardiometabolic syndrome, such as metabolic dysfunction‐associated steatotic liver disease (MASLD), atherosclerotic cardiovascular disease (ASCVD), and gut dysbiosis, highlighting the crucial role of nutraceuticals in their management and prevention. Given the significant overlap in the pathophysiology of these conditions, the treatment with nutraceuticals, especially those derived from agro‐food waste, offers a promising, sustainable, and innovative approach to healthcare. The 2030 Agenda for Sustainable Development and the One Health concept are key frameworks for selecting the most interesting supply chain for the production of nutraceuticals from agro‐food waste, ensuring environmental sustainability, and innovative agricultural practices. In this review, the therapeutic potential of kiwifruit and apples has been explored, detailing how their bioactive compounds, like polyphenols, fiber, pectin, kaempferol, phloretin, and phlorizin, may contribute to the management of MASLD, ASCVD, and gut dysbiosis. Various extraction methods for active ingredients, including chemical, water, and enzyme extractions, are analyzed for their respective benefits and drawbacks. By integrating scientific research, sustainable agricultural practices, and innovative extraction methods, we can develop effective strategies to combat these pervasive health issues. This holistic approach not only enhances individual health outcomes but also supports broader environmental and societal goals, promoting a healthier future for all.

The role of m6A modification in cardiovascular disease: A systematic review and integrative analysis

BACKGROUND AND AIMS

This study focused on the recent advancements in understanding the association between N6-methyladenosine (m6A) modification and cardiovascular disease (CVD).

METHODS

The potential mechanisms of m6A related to CVD were summarized by literature review. Associations between m6A levels and CVD were explored across 8 electronic databases: PubMed, Embase, Web of Science, Cochrane Library, Sinomed, Wan Fang, CNKI, and Vip. Standard mean difference (SMD) and 95 % confidence interval (95 % CI) were calculated to assess the total effect in integrated analysis.

RESULTS

The systematic review summarized previous studies on the association between m6A modification and CVD, highlighting the potential role of m6A in CVD progression. A total of 11 studies were included for integrative analysis. The mean m6A levels were significantly higher in CVD than those in normal controls (SMD = 1.86, 95 % CI: 0.16-3.56, P < 0.01).

CONCLUSIONS

This systematic review provided new targets for early detection and treatment for CVD. And the integrated analysis showed that increased level of m6A was associated with CVD.

Major adverse events associated with lipid reduction in inclisiran:a pharmacovigilance research of the FAERS database

OBJECTIVE

The effectiveness and safety of the short-interfering RNA drug inclisiran in lowering patients' lipoprotein cholesterol levels to lower their risk of cardiovascular disease are presently being investigated. Based on the real-world adverse event report record in the FDA Adverse Event Reporting System, this article explores the occurrence and risk of adverse events during inclisiran treatment.

RESEARCH DESIGN AND METHODS

We retrieved and screened all available data from the Food and Drug Administration website for the period from 2009 to the third quarter of 2023. In addition, we conducted a descriptive analysis of adverse event reports and calculated relevant pharmacovigilance measures, including reporting odds ratio, proportional reporting ratio, Bayesian confidence propagation neural network, and empirical Bayesian geometric mean.

RESULTS

4054 adverse reaction reports were filtered from 1151 patient reports of inclisiran. The top three incidence rates of adverse reaction signals for System Organ Class in adverse event reports are GENERAL DISORDERS AND ADMINITRATION SITE CONDITIONS (24.9% reported), MUSCOSKELETAL AND CONNECTIVE TISSUE DISORDERS (18.5% reported), and GASTROINTESTINAL DISORDERS (8.7% reported). The top five preferred terms screened for frequency of occurrence with the strongest risk signals for each of the top three system organ categories are INJECTION SITE PAIN，MYALGIA and DIARRHOEA.

CONCLUSIONS

Inclisiran has good long-term treatment outcomes and safety and can be used for a long time. However, attention should be paid to adverse events with high-risk signals, especially Injection Site Reactions.

Association between small dense low-density lipoprotein and carotid intima-media thickness

Cardiovascular disease (CVD) and atherosclerosis are major causes of mortality worldwide. Early and accurate diagnosis of vascular thickening by predictive markers can help reduce the death rate of these diseases. Low-density lipoprotein (LDL) particles, which are rich in cholesterol, are regarded as key biomarkers for CVD and atherosclerosis. Numerous studies have demonstrated that pattern B (small dense LDL, sdLDL) is more atherogenic than LDL and can serve as a superior quantitative marker for CVD than LDL. Furthermore, several studies have indicated that carotid intima-media thickness (cIMT) is a reliable marker for the early detection of CVD and atherosclerosis in various populations. This review examines the relationship between sdLDL concentration and cIMT. It is concluded that sdLDL concentration has a positive correlation with cIMT, and their combined use can facilitate a more precise assessment of the diseases, especially atherosclerosis.

Convergent relaxation of molecular constraint in herbivores reveals the changing role of liver and kidney functions across mammalian diets

Mammalia comprises a great diversity of diet types and associated adaptations. An understanding of the genomic mechanisms underlying these adaptations may offer insights for improving human health. Comparative genomic studies of diet that employ taxonomically restricted analyses or simplified diet classifications may suffer reduced power to detect molecular convergence associated with diet evolution. Here, we use a quantitative carnivory score-indicative of the amount of animal protein in the diet-for 80 mammalian species to detect significant correlations between the relative evolutionary rates of genes and changes in diet. We have identified six genes-ACADSB, CLDN16, CPB1, PNLIP, SLC13A2, and SLC14A2-that experienced significant changes in evolutionary constraint alongside changes in carnivory score, becoming less constrained in lineages evolving more herbivorous diets. We further consider the biological functions associated with diet evolution and observe that pathways related to amino acid and lipid metabolism, biological oxidation, and small molecule transport experienced reduced purifying selection as lineages became more herbivorous. Liver and kidney functions show similar patterns of constraint with dietary change. Our results indicate that these functions are important for the consumption of animal matter and become less important with the evolution of increasing herbivory. So, genes expressed in these tissues experience a relaxation of evolutionary constraint in more herbivorous lineages.

SYNTAX I score is associated with genetically confirmed familial hypercholesterolemia in chinese patients with coronary heart disease

BACKGROUND

Familial hypercholesterolemia (FH) is a genetically inherited disorder caused by monogenic mutations or polygenic deleterious variants. Patients with FH innate with significantly elevated risks for coronary heart disease (CHD). FH prevalence based on genetic testing in Chinese CHD patients is missing. Whether classical index of coronary atherosclerosis severity can be used as indicators of FH needs to be explored. To investigate the FH prevalence in Chinese CHD patients and the association of SYNTAX I score with FH genotype.

METHODS

The monogenic and polygenic FH related genes were genotyped in 400 consecutively enrolled CHD patients. The clinical characteristics and SYNTAX I scores were analyzed in a retrospective nested case-control study.

RESULTS

The prevalence of genetically confirmed FH in our CHD cohort was 8.75%. The cLDL-C level, SYNTAX I scores and incidences of triple vessel lesions in FH patients were significantly higher, while cLDL-C and SYNTAX I scores were independent risk factors for FH. Furthermore, cLDL-C levels of polygenic FH were significantly lower than monogenic FH, while their severity of coronary atherosclerosis was comparable.

CONCLUSIONS

Our study revealed that the SYNTAX I score was an independent risk factor for FH. Besides, polygenic origin of FH should be taken into consideration for CHD patients suspected of FH.

sJAM-C as a Potential Biomarker for Coronary Artery Stenosis: Insights from a Clinical Study in Coronary Heart Disease Patients

Purpose

Coronary artery stenosis caused by atherogenesis is a major pathological link in coronary heart disease (CHD), which is a leading cause of global morbidity and mortality. Junctional adhesion molecule C (JAM-C) presents more and more association with atherosclerosis. However, no studies have shown the relationship between soluble JAM-C (sJAM-C) and the degree of coronary artery stenosis. This study aimed to analyze the effect of sJAM-C on coronary artery stenosis and to verify whether sJAM-C could be a biomarker for coronary artery stenosis.

Patients and Methods

The participants registered at the Beijing Luhe Hospital, Capital Medical University in the cross-sectional study. A total of 121 patients without coronary stenosis and 408 patients with coronary artery stenosis were enrolled after matching age and sex. Demographic information, medication history, and laboratory data were collected. The level of serum sJAM-C was detected by enzyme-linked immunosorbent assay (ELISA) kits. We used the logistic regression model to evaluate the association between sJAM-C and coronary artery stenosis. Furthermore, the receiver operating characteristic (ROC) curve and area under curve (AUC) were used to evaluate the diagnostic value of sJAM-C on coronary artery stenosis.

Results

The serum level of sJAM-C was remarkably higher in patients with coronary artery stenosis than those without stenosis (p < 0.0001). Logistic regression models showed that there were positive association between serum sJAM-C level and coronary artery stenosis after adjustment, with corresponding ORs were 3.088 (95% CI 1.922-4.960, p < 0.0001). And the ROC curve revealed a sensitivity of 65.7% and specificity of 60.3% with AUC of 0.676 (95% CI 0.622-0.730) for the diagnosis of coronary artery stenosis with serum sJAM-C at a cut-off value of 18.1 pg/mL, indicating a certain diagnostic value.

Conclusion

In summary, higher serum sJAM-C level was possibly associated with the more severe coronary artery stenosis. Additionally, sJAM-C demonstrates a certain diagnostic value of coronary artery stenosis. These findings suggest sJAM-C may be a biomarker for coronary artery stenosis.