Executive summary of Japan Atherosclerosis Society (JAS) guideline for diagnosis and prevention of atherosclerotic cardiovascular diseases for Japanese

A crossover study of rosuvastatin and pitavastatin in patients with type 2 diabetes

INTRODUCTION

The effects of a low dose of rosuvastatin (ROS) and pitavastatin (PIT) on lipid profiles and inflammation markers were assessed in subjects with type 2 diabetes mellitus.

METHODS

A total of 90 Japanese type 2 diabetes patients with hyperlipidemia (low-density lipoprotein cholesterol [LDL-C] ≥140 mg/dL) were enrolled in this study. They were randomly assigned to four groups with open-label treatment with ROS (2.5 mg daily) or PIT (2 mg daily); two groups were sequentially treated with both drugs, with crossover of medication after 12 weeks, and the other two groups underwent treatment with either ROS or PIT for 24 weeks. The primary endpoints were the percentage changes in LDL-C, high-density lipoprotein cholesterol (HDL-C) and triglyceride, and the LDL-C/HDL-C ratio.

RESULTS

Both ROS and PIT lowered LDL-C and triglyceride, and increased HDL-C. In particular, significantly greater reduction in LDL-C was seen with ROS (-44.1%) than with PIT (-36.9%, P<0.01) in the crossover group from ROS to PIT, and the same result was detected in the crossover group from PIT (-34.8%) to ROS (-44.7%). The ratio of LDL-C/HDL-C was significantly reduced with ROS treatment (from 3.45 to 1.85) compared with that with PIT (from 3.45 to 2.22, P<0.01). Both ROS and PIT lowered plasma levels of high-sensitivity C-reactive protein (hsCRP), tumor necrosis factor (TNF)-alpha, and plasminogen activator inhibitor-1 (PAI-1). In addition, the hsCRP level with the administration of ROS was significantly improved compared with the administration of PIT. There was no significant correlation between changes in LDL-C and hsCRP, TNF-alpha, and PAI-1 levels. ROS and PIT did not have an adverse effect on glycemic control in type 2 diabetes patients.

CONCLUSION

Therapy with both statins improved lipid profiles and reduced proinflammatory responses; however, 2.5 mg of ROS have a potent LDL-C-lowering and hsCRP-lowering effect compared with 2 mg of PIT in patients with diabetes.

Event reduction: revisiting why we treat with statins and harnessing current evidence towards optimal therapy

IMPORTANCE OF THE FIELD

Statins are widely accepted as the drugs of choice for achieving increasingly stringent low-density lipoprotein cholesterol (LDL-C) goals for dyslipidemic patients. However, when making treatment decisions, outcomes data from clinical trials are of greater importance than LDL-C-lowering ability.

AREAS COVERED IN THIS REVIEW

This review will provide an update on current lipid treatment guidelines in the context of statin trial evidence, with particular focus on the incremental benefit of more potent statin therapy compared with lower doses. The discussion will also address combination therapy, statin safety, goal attainment and treatment adherence. MEDLINE searches (1966 to July 2010) were performed.

WHAT THE READER WILL GAIN

The reader will gain a comprehensive review of the evidence base for statin therapy and an appreciation of other issues that affect treatment choice.

TAKE HOME MESSAGE

It is important to remember why we need to partner with our patients: to ensure that they are established on, and continue to adhere to, their appropriate evidence-based statin dose with a goal of achieving lipid targets, but more importantly to prevent cardiovascular disease-related morbidity and mortality. We treat patients to reduce clinical cardiovascular events, not just to control lipids and other important risk factors.

Usefulness of lipoprotein ratios in assessing carotid atherosclerosis in Japanese type 2 diabetic patients

OBJECTIVE

It is indicated that total/HDL cholesterol and LDL/HDL cholesterol ratios have more predictive power for cardiovascular disease compared to classic lipid parameters. However, there have been few reports about the usefulness of these indices for the assessment of early stage atherosclerosis in Japanese type 2 diabetic subjects.

METHODS

We examined the relation between various lipid parameters and carotid atherosclerosis in 934 type 2 diabetic subjects without apparent atherosclerotic diseases (males, 71.7%; age, 59.6 ± 10.5 years (mean ± SD)). Serum concentrations of total cholesterol (TC), HDL cholesterol (HDL-C), and triglyceride were measured. LDL cholesterol (LDL-C) level was calculated using the Friedewald formula. The presence of carotid plaque and intima-media thickness (IMT) were evaluated by ultrasonography.

RESULTS

A stepwise multivariate regression analysis demonstrated that HDL-C (β = -0.110, p<0.001), TC/HDL-C (β = 0.132, p < 0.001) and LDL-C/HDL-C ratios (β = 0.132, p < 0.001) were independent determinants of IMT even after adjustment of other conventional risk factors. However, there was no significant correlation between IMT and TC, triglyceride, LDL-C, and non-HDL-C levels. TC/HDL-C and LDL-C/HDL-C ratios and non-HDL-C levels were significantly higher, but HDL-C levels were significantly lower in patients with carotid plaque than those without it (p < 0.05). There was no significant difference between the groups regarding TC, LDL-C, and triglyceride levels. Furthermore, TC/HDL-C (OR; 1.34, p < 0.001) and LDL-C/HDL-C (OR; 1.54, p < 0.001) ratios showed a positive and linear relationship with the prevalence of carotid plaque, whether covariates were adjusted or not.

CONCLUSIONS

TC/HDL-C and LDL-C/HDL-C ratios are useful as a tool to assess the risk of early stage atherosclerosis in Japanese type 2 diabetic patients.

Optimizing lipid-lowering therapy in the prevention of coronary heart disease

Optimized lipid-lowering therapy is laid out in guidelines from national and international bodies. Statins are first-line treatment and instituted early in secondary prevention. The challenge in primary prevention is identification of the person at risk. This can be achieved by using scoring systems that assess classical risk factors, and then by adding information from predictive panels of biomarkers related to atherogenic pathways and by noninvasive imaging of vascular beds. At present, outcome trials validate the widespread use of statins in the population but studies of other agents have not generated proof of efficacy. Levels of high-density lipoprotein are related inversely to coronary heart disease risk but, so far, it is unclear if increasing high-density lipoprotein leads to a reduction in risk. Clinical trials on the utility of high-density lipoprotein raising on a background of statin therapy are underway.

Pravastatin potentiates increases in serum adiponectin concentration in dyslipidemic patients receiving thiazolidinedione: the DOLPHIN study

AIM

A reduced risk of type 2 diabetes has been reported following treatment with pravastatin. Adiponectin is an adipocyte-derived protein that has an antidiabetic property. The objective of this study was to evaluate the effect of pravastatin on serum adiponectin concentration and other influencing factors.

METHODS

This study was a multicenter observational study: Dyslipidemia Open-labeled observational study by Lipid-lowering therapy with Pravastatin of the effect on High-molecular weight adiponectin in Nippon Yokohama (DOLPHIN). The protocol was registered in the UMIN Clinical Trial Registry as UMIN000000791. All patients received pravastatin 10 mg/day for 6 months and the change in concentration of total and high molecular weight adiponectin was assessed before and after follow-up. The difference in the change in total adiponectin concentration by patient characteristics was analyzed by an unpaired t-test. Influences of continuous variable factors on the change in total adiponectin concentration were estimated by simple linear regression analyses. Finally, in order to estimate the influences of factors that potentially affect the change in total adiponectin concentration induced by pravastatin, multiple linear regression analysis was conducted.

RESULTS

After 6 months, total adiponectin concentration was increased significantly by 23.2% from 11.7±6.4 to 13.7±8.6 µg/mL (p=0.002). The use of thiazolidinedione as a concomitant medication was the only significant influencing factor (β=0.580, p<0.001).

CONCLUSION

Pravastatin increased the serum adiponectin concentration in Japanese dyslipidemic patients without previous coronary artery disease. Interestingly, this effect was seen synergistically in combination with thiazolidinedione.

Platelet aggregates detected by a conventional hematology analyzer method is a risk factor for stroke or a predictive factor in patients with chronic-stage cerebral infarction

Assessment of platelet activation and/or function is important for primary and secondary prevention of vascular events. To test the hypothesis that determination of platelet aggregation in patients with chronic-stage cerebral infarction (CI) provides a simple measure of risk for ischemic stroke, we used a conventional hematology analyzer to detect aggregates and to assess the efficacy of antiplatelet agents in preventing spontaneous aggregate formation. Platelet aggregates were measured in citrated blood from 142 magnetic resonance imaging confirmed CI patients and 97 controls without CI (nonstroke). Aggregates were detected in 1 of 36 (2.8%) nonstroke subjects without risk factors, but in 24 of 52 (46.2%) nonstroke subjects with risk factors (odds ratio [OR], 3.32; 95% confidence interval [CI], 1.10-10.00), in 21 of 35 (60.0%) nonstroke subjects with a predictive factor (carotid artery intima-media thickness [IMT] >1.1 mm) (OR, 9.13; 95% CI, 2.70-30.48), and in 31 of 63 (49.2%) CI patients who had not received antiplatelet therapy (OR, 2.16; 95% CI, 1.12-4.17). After adjusting for other risk factors, the appearance of platelet aggregates was correlated only with IMT ≥1.1 mm. The rate of appearance of platelet aggregates was 0.33-fold lower in patients on antiplatelet therapy compared with those not on antiplatelet therapy (24.1%; 19 of 79 CI patients). Patients with platelet aggregates in the blood are considered at high risk for ischemic stroke, because the appearance of aggregates is associated with increased IMT. Our method is suitable for screening platelet function in high-risk patients and for examining the efficacy of antiplatelet agents.

Effect of a worksite-based intervention program on metabolic parameters in middle-aged male white-collar workers: a randomized controlled trial

OBJECTIVE

An effective program for preventing metabolic diseases through lifestyle modification is urgently needed. We investigated the effects of the Life Style Modification Program for Physical Activity and Nutrition program (LiSM10!) on metabolic parameters in middle-aged male Japanese white-collar workers.

METHODS

One hundred and one male office workers, 30 to 59 years of age, with metabolic syndrome risk factors, were randomly allocated into no-treatment control (n=49) and LiSM intervention (n=52) groups. The LiSM group attended individualized assessment and collaborative goal setting sessions based on food group intake and physical activity, followed by two individual counseling sessions with a registered dietitian and physical trainer, and received monthly website advice during the 4-month period from December 2006 to May 2007, in Tokyo, Japan. They were encouraged to enter current targeted food intakes and pedometer data on self-monitoring websites during the entire study period.

RESULTS

Habitual food group intakes changed significantly in the LiSM group, showing improvements in 14 anthropometric and biochemical parameters contributing to inter-group differences in body weight, body mass index, fasting plasma glucose, insulin and homeostasis model assessment of insulin resistance changes (p<0.01).

CONCLUSION

The LiSM10! program effectively improved insulin resistance-related metabolic parameters in middle-aged male white-collar workers.

New evidence on pitavastatin: efficacy and safety in clinical studies

IMPORTANCE OF THE FIELD

Many clinical trials of pitavastatin have been done since its launch. New insights on pitavastatin from these trials are summarized and evaluated.

AREAS COVERED IN THIS REVIEW

The results of clinical studies using pitavastatin, from 2008 to 2009, the LIVES study, the JAPAN-ACS study, the CHIBA study, the PIAT study and Phase III clinical trials in the West are reviewed.

WHAT THE READER WILL GAIN

In the LIVES study, pitavastatin showed significant and continuous elevation of high-density lipoprotein cholesterol (HDL-C), estimated glomerular filtration rate (eGFR), as well as potential decrease in low-density lipoprotein cholesterol (LDL-C), in addition to long-term safety. Non-inferiority of pitavastatin against atorvastatin in the percentage change in plaque volume was proved in the JAPAN-ACS study. Also, comparable effects on LDL-C reduction rate of pitavastatin versus atorvastatin were confirmed in the CHIBA study and Phase III clinical trials in the West, and a greater increase in HDL-C was observed than with atorvastatin in the PIAT study.

TAKE HOME MESSAGE

Pitavastatin is a useful potent stain in raising HDL-C as well as in lowering of LDL-C, though a large-scale, clinical trial to confirm prevention of cardiovascular events is needed in the future.

Association between lowering low-density lipoprotein cholesterol with pravastatin and primary prevention of cardiovascular disease in mild to moderate hypercholesterolemic Japanese

AIMS

To evaluate the relationship between low-density lipoprotein cholesterol (LDL-C) change and reduction of cardiovascular disease in the Management of Elevated cholesterol in the primary prevention Group of Adult Japanese (MEGA) study.

METHODS

Patients in the diet plus pravastatin group were divided into tertiles by their on-treatment LDL-C level, and the hazard ratios (HRs) in each tertile were compared with the diet group at 5 years using the Cox proportional hazards model. In addition, the treatment groups were combined and divided into quintiles according to the on-treatment LDL-C level during follow-up, and the incidence of cardiovascular events was compared among the 5 groups.

RESULTS

In the tertiles of the diet plus pravastatin group, HR was lowest in the second tertile against the diet group (HR 0.57, p=0.01) with on-treatment LDL-C range of 119.8-133.4 mg/dL. In the analysis of quintiles of the total population, a significant risk reduction of CVD was found in the fourth quintile (HR 0.48, p=0.0015) with an on-treatment LDL-C range of 120.9-133.3 mg/dL, and in the fifth quintile (HR 0.64, p=0.048) with an on-treatment LDL-C range of 56.7-120.8 mg/dL against tertile 1 with an on-treatment LDL-C range of 157.5-206.2 mg/dL.

CONCLUSIONS

The usual Japanese dose of pravastatin therapy is sufficient in this low-risk patient population to reduce cardiovascular risk, with an achieved LDL-C level <133.4 mg/dL. Further risk reduction was not found with an achieved LDL <120 mg/dL.

Arterial stiffness and declines in individuals with normal renal function/early chronic kidney disease

OBJECTIVE

We evaluated the temporal association between arterial stiffening and the early stage of renal functional decline.

METHODS

In 2053 Japanese employees with an estimated glomerular filtration rate (GFR) of > or = 60 ml/min/1.73 m(2) plus no proteinuria (40+/-8 years old) at the start, brachial-ankle pulse wave velocity (baPWV) and serum C-reactive protein (CRP) were measured before and after a 5-6-year follow-up period.

RESULTS

After adjusting for confounding variables including serum CRP levels, higher baseline baPWV was associated with lower follow-up GFR (value expressed as per doubling: -16; 95% confidence interval: -24 to -9; P<0.01) and with higher annual rate of decline in GFR (value expressed as per doubling: -3; 95% confidence interval: -4 to -2; P<0.01). Every m/s higher baPWV was associated with a 36% increased odds (95% CI 1.09-1.70; P<0.01) for a development of a GFR <60 ml/min/1.73 m(2) at follow-up. In contrast, baseline GFR was not associated with follow-up baPWV (P=0.08) or the annual rate of change in baPWV (P=0.11).

CONCLUSION

In a Japanese occupational cohort with normal renal function/early chronic kidney disease, elevated arterial stiffness was an independent risk factor for the decline in renal function. CRP did not appear to exert any significant influence on this association.

Continuous smoking and progression of arterial stiffening: a prospective study

OBJECTIVES

We prospectively and longitudinally determined the effects of smoking on the progression of arterial stiffening as well as the involvement of inflammation in this process.

BACKGROUND

Smoking is an important avoidable risk factor for cardiovascular disease, and arterial stiffness might be involved in the pathophysiology. No prospective study has examined the effect of continuous smoking on the age-associated progression of arterial stiffening.

METHODS

In 2,054 Japanese subjects (40 +/- 8 years of age), brachial-ankle pulse wave velocity (baPWV) and serum C-reactive protein (CRP) levels were measured at the baseline and the end of a 5- to 6-year follow-up period.

RESULTS

The annual rate of change of the baPWV during the study period was significantly greater in the continuous heavy smokers (11.0 +/- 1.9 cm/s/year, n = 181) than in the never-smokers (5.5 +/- 0.6 cm/s/year, n = 1,018). This difference remained significant even after adjustments for covariates, including age (p < 0.05). In continuous smokers (n = 493), the mean number of cigarettes smoked/day during the study period showed a significant relationship with the changes in baPWV. No significant relationship was found between the change in baPWV and serum CRP levels.

CONCLUSIONS

Continuous smoking might accelerate the age-associated progression of structural stiffening of the large- to middle-size arteries. We also found a dose-response relationship between cigarette consumption and accelerated arterial stiffening. However, we failed to confirm any significant association between the rate of arterial stiffening and the serum CRP levels in the smokers.

Effects of toremifene and tamoxifen on lipid profiles in post-menopausal patients with early breast cancer: interim results from a Japanese phase III trial

OBJECTIVE

Toremifene and tamoxifen have been used for adjuvant therapy in post-menopausal patients with breast cancer in Japan. Dyslipidemias are common in post-menopausal women. However, limited data are available on the effects of these agents on lipid profiles in Japanese patients. The Japan Toremifene Cooperative Study Group has been conducting a Phase III randomized trial of post-menopausal patients with breast cancer. One of its secondary endpoints is to confirm the effects of these agents on serum lipid profiles.

METHODS

The subjects were post-menopausal Japanese patients who had undergone surgery for early breast cancer. Toremifene or tamoxifen was administered for 2 years. Lipid levels were measured before and up to 24 months after initiation.

RESULTS

Compared with baseline, at 24 months, the toremifene group (n = 123) showed significantly decreased total cholesterol (P < 0.001) and low-density lipoprotein cholesterol levels (P < 0.001), and significantly increased high-density lipoprotein cholesterol levels (P < 0.001). Their triglyceride levels were not affected (P = 0.677). The tamoxifen group (n = 120) also showed significantly decreased total cholesterol (P < 0.001) and low-density lipoprotein cholesterol levels (P < 0.001); no significant changes occurred in high-density lipoprotein cholesterol (P = 0.297) or triglyceride levels (P = 0.120).

CONCLUSIONS

Distinct differences between two selective estrogen receptor modulators on lipids were observed. Toremifene improved lipid profiles, particularly as an enhancer of high-density lipoprotein cholesterol. To a large extent, tamoxifen improved low-density lipoprotein cholesterol levels. The impact of these improved lipid profiles on the risk of cardiovascular diseases needs further confirmation.

A Randomized Controlled Study to Compare the Effects of Rosuvastatin 5 mg and Atorvastatin 10 mg on the Plasma Lipid Profile in Japanese Patients with Hypercholesterolemia (ASTRO-2)

OBJECTIVE

For new evidence of aggressive lipid lowering treatment with statins in Japanese hypercholesterolemic patients, we performed an open-label, randomized, parallel-group comparative study to assess the effect of rosuvastatin 5 mg and atorvastatin 10 mg on plasma lipids.

METHODS

A total of 900 patients in whom the target control levels of LDL-cholesterol (LDL-C) set by the Japan Atherosclerosis Society Guidelines (JASGL2007) had not been achieved were randomly assigned to receive rosuvastatin 5 mg / day (n = 450) or atorvastatin 10 mg / day (n = 450) for 8 weeks. The primary endpoint was the percent change of LDL-C at week 8.

RESULTS

LDL-C was lowered by -44.5% (from 170.2 to 93.3 mg / dL) in the rosuvastatin group and -41.6% (from 169.5 to 97.9 mg / dL) in the atorvastatin group, at week 8 (P = 0.002 vs. atorvastatin). LDL-C / HDL-C ratio was lowered by -47.6% (from 3.01 to 1.56) and -43.5 % (from 2.96 to 1.66), respectively, at week 8 (P < 0.001 vs. atorvastatin). The changes in HDL-C, ApoB, ApoA-1, and ApoB / ApoA-1 ratio showed significant improvement in the rosuvastatin group than in the atorvastatin group. Adverse events were observed comparably between the rosuvastatin group (121 events) and the atorvastatin group (104 events). None of these events had adverse clinical consequence. Both drugs were well tolerated.

CONCLUSION

Rosuvastatin 5 mg produced significantly greater reduction in LDL-C and beneficial effect on other lipid parameters than atorvastatin 10 mg, and was also well tolerated.

Relation of Gamma-glutamyltransferase and alcohol drinking with incident diabetes: the HIPOP-OHP study

AIM

Gamma-glutamyltransferase (GGT) is known to correlate well with alcohol consumption; however, the relation between GGT and diabetes and that between alcohol consumption and diabetes mellitus (DM) is inconsistent. Thus, several questions, such as whether light to moderate drinkers can be considered as low risk for diabetes incidence irrespective of their GGT level, is unresolved. In this study, we investigated the relation of GGT or alcohol drinking with DM incidence considering the body mass index (BMI) in healthy Japanese workers.

METHODS

We followed 3095 men who did not have DM at baseline for 4 years. Incident diabetes was defined as a fasting (non-fasting) plasma glucose level of >or=7.0 (11.1) mmol/L, or treatment of diabetes. Multiple adjusted hazard ratios (HR) were calculated using Cox proportional models.

RESULTS

Participants with higher GGT (GGT >or=27 IU/L) showed an increased risk of diabetes incidence even when their BMI level was low. Although a U-shaped relation between alcohol drinking and incident diabetes was observed, the risk to light to moderate drinkers (alcohol <23 g/day) was not low if they were either overweight (BMI >or=25 kg/m(2)) or had higher GGT (HR=2.60, p=0.08) or both overweight and higher GGT (HR=3.16, p=0.07) compared with never drinkers without higher GGT and overweight.

CONCLUSIONS

Higher GGT was associated with a higher incidence of DM irrespective of drinking status or obesity. Although a U-shaped relation between alcohol drinking and incident diabetes was observed, the risk to light to moderate drinkers was not low if they were either overweight or had higher GGT.

Association of the functional variant in the 3-hydroxy-3-methylglutaryl-coenzyme a reductase gene with low-density lipoprotein-cholesterol in Japanese

BACKGROUND

The association between single nucleotide polymorphisms (SNPs) at 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) and low-density lipoprotein-cholesterol (LDL-C) levels has been well replicated in genome-wide association studies (GWAS) of white populations. Recently, the common intronic SNP of HMGCR (rs3846662) has been reported to be a functional variant, influencing the alternative splicing of exon 13. The aim of this study was to examine the association between rs3846662 of HMGCR and the level of LDL-C in Japanese.

METHODS AND RESULTS

Significant differences in LDL-C levels were observed among the genotypes of rs3846662 (P=0.0002 (n=2,686) and P=0.004 (n=2,110)) for the Suita and Ehime samples, respectively. The G allele of rs3846662 was associated with higher LDL-C levels (beta, 3.56; P=4.91x10(-5)). Consistent with this observation, the risk G allele at rs3846662 was more prevalent in subjects with myocardial infarction (MI) (n=701) than in subjects without MI (n=3,118); 0.559 and 0.511 in MI cases and controls, respectively (nominal P=0.0038). The odds ratio adjusted for age, sex, diabetes, hypertension, and drinking and smoking habits was 1.15 (95% confidence interval 1.04-1.28; P=0.0075).

CONCLUSIONS

The previously reported association of rs3846662 with LDL-C levels was replicated in the present Suita and Ehime samples. The LDL-associated SNP, rs3846662, appears to confer susceptibility to MI in Japanese.

Cardio-ankle vascular index is independently associated with the severity of coronary atherosclerosis and left ventricular function in patients with ischemic heart disease

AIM

The cardio-ankle vascular index (CAVI) has been proposed as a new noninvasive marker of arterial stiffness independent of blood pressure. We investigated the association of the CAVI with coronary atherosclerosis and left ventricular (LV) systolic and diastolic function in patients with ischemic heart disease (IHD).

METHODS

A total of 206 consecutive subjects undergoing coronary angiography were enrolled. CAVI measurement and echocardiography were performed simultaneously. Patients having significant coronary stenosis were classified into the IHD group.

RESULTS

CAVI in the IHD group (n=133) was significantly higher than in the non-IHD group(n=73)(9.1+/-1.3 vs. 8.7+/-1.2, p=0.02). In all IHD patients, CAVI was negatively correlated with LV ejection fraction (LVEF)(r=-0.31, p<0.01), LV mass index (r=0.24, p<0.01) and angiographic scores of coronary atherosclerosis. Stepwise regression analysis revealed that CAVI was independently associated with LVEF, along with a history of myocardial infarction, LV mass index, and left atrial diameter in all IHD patients (p<0.01). In the sub-analysis of IHD patients with preserved LVEF, CAVI was correlated with echocardiographic parameters regarding LV diastolic function. Multivariate analysis demonstrated that the increased CAVI was significantly associated with LV diastolic dysfunction in patients with preserved LVEF.

CONCLUSION

CAVI, a new parameter of aortic stiffness, was independently associated with LV systolic and diastolic function as well as coronary artery disease in IHD patients.

Lipid-lowering effects of ezetimibe for hypercholesterolemic patients with and without type 2 diabetes mellitus

To date, there are very few clinical reports that have compared the effects of ezetimibe on lipid parameters between hypercholesterolemic patients with and without type 2 diabetes mellitus (T2DM). In this study, we recruited patients for hypercholesterolemic groups with T2DM (n = 42; men/women = 24/18; HbA1c = 6.7 ± 5.4%) and without T2DM (n = 21; men/women = 7/14; HbA1c = 5.3 ± 0.4%). Patients were prescribed ezetimibe at a dose of 10 mg/daily for the course of the 12-week study. At baseline and after 12 weeks of treatment, several lipid parameters, including serum low-density-lipoprotein cholesterol (LDL-C), non-high-density-lipoprotein cholesterol (non-HDL-C), high-sensitivity C-reactive protein (hs-CRP), and cholesterol synthesis/absorption-related markers, were measured. Compared with those at the baseline, the levels of LDL-C, non-HDL-C, campesterol, and sitosterol were significantly reduced after 12 weeks of ezetimibe treatment in both groups. After adjusting for confounding factors, such as age, gender, smoking, and BMI, the levels of LDL-C and non-HDL-C displayed significantly greater reductions in the patients with T2DM (-25.1 ± 13.6% in LDL-C, -20.5 ± 11.2% in non-HDL-C) than those without T2DM (-20.5 ± 7.8% in LDL-C, P < 0.05; -17.4 ± 7.6% in non-HDL-C, P < 0.05). The reduction of the level of cholestanol was significantly and positively correlated with those of LDL-C and non-HDL-C in the patients with T2DM. Taken together, these findings indicate that ezetimibe could reduce the levels of atherogenic lipoproteins to a greater extent in hypercholesterolemic patients with T2DM than in those without T2DM.

Critical appraisal of the role of pitavastatin in treating dyslipidemias and achieving lipid goals

Pitavastatin is a potent HMG-CoA reductase inhibitor and efficient hepatocyte low-density lipoprotein cholesterol (LDL-C) receptor inducer, producing robust reduction of the serum LDL-C levels, even at a low dose. Pitavastatin and its lactone form are minimally metabolized by CYP enzymes, and are therefore associated with minimal drug-drug interactions (DDIs). Pitavastatin 2 to 4 mg has potent LDL-C-reducing activity, equivalent to that of atorvastatin 10 to 20 mg; several clinical trials have revealed consistently superior high-density lipoprotein cholesterol (HDL-C) elevating activity of pitavastatin than that of atorvastatin. Pitavastatin-induced HDL-C elevation has been shown to be sustained, even incremental, in long-term clinical trials. Pitavastatin was as well-tolerated as atorvastatin or simvastatin in double-blind randomized clinical trials. Two-year long-term safety and effectiveness of pitavastain has been confirmed in a large-scale, prospective post-marketing surveillance. The safety and efficacy profile of pitavastatin is favorable for the treatment of dyslipidemia, especially in metabolic syndrome patients. In addition to control of LDL-C, adequate control of triglyceride (TG) and HDL-C, hypertension and hyperglycemia is also necessary in metabolic syndrome patients. Pitavastatin produces adequate control of LDL-C and TG, along with potent and incremental HDL-C elevation, with a low frequency of DDIs.

Effects of ezetimibe add-on therapy for high-risk patients with dyslipidemia

Background

Ezetimibe (Zetia^®) is a potent inhibitor of cholesterol absorption that has been approved for the treatment of hypercholesterolemia. Statin, an inhibitor of cholesterol synthesis, is the first-choice drug to reduce low-density lipoprotein-cholesterol (LDL-C) for patients with hypercholesterolemia, due to its strong effect to lower the circulating LDL-C levels. Because a high dose of statins cause concern about rhabdomyolysis, it is sometimes difficult to achieve the guideline-recommended levels of LDL-C in high-risk patients with hypercholesterolemia treated with statin monotherapy. Ezetimibe has been reported to reduce LDL-C safely with both monotherapy and combination therapy with statins.

Results

To investigate the effect of ezetimibe as "add-on" therapy to statin on hypercholesterolemia, we examined biomarkers and vascular endothelial function in 14 patients with hypercholesterolemia before and after the 22-week ezetimibe add-on therapy. Ezetimibe add-on therapy reduced LDL-C by 24% compared with baseline (p < 0.005), with 13 patients (93%) reaching their LDL cholesterol goals. Of the Ezetimibe add-on therapy significantly improved not only LDL-C, high-density lipoprotein-cholesterol (HDL-C), and apolipoprotein (apo)B levels, but also reduced levels of triglyceride (TG), the ratio of LDL/HDL-C, the ratio of apoB/apoA-I, and a biomarker for oxidative stress (d-ROMs). Furthermore, ezetimibe add-on therapy improved vascular endothelial function in high-risk patients with hypercholesterolemia.

Conclusion

In conclusion, ezetimibe as add-on therapy to statin might be a therapeutic good option for high-risk patients with atherosclerosis.

Inadequate increase in the volume of major epicardial coronary arteries compared with that in left ventricular mass. Novel concept for characterization of coronary arteries using 64-slice computed tomography

BACKGROUND

Previous studies have shown a correlation between coronary artery cross-sectional diameter and left ventricular (LV) mass. However, no studies have examined the correlation between actual coronary artery volume (CAV) and LV mass. In the present study, measurements of CAV by 64-multislice computed tomography (MSCT) were validated and the relationship between CAV and LV mass was investigated.

METHODS AND RESULTS

First, coronary artery phantoms consisting of syringes filled with solutions of contrast medium moving at simulated heart rates were scanned by 64-MSCT. Display window settings permitting accurate calculation of small volumes were optimized by evaluating volume-rendered images of the segmented contrast medium at different window settings. Next, 61 patients without significant coronary artery stenosis were scanned by 64-MSCT with the same protocol as for the phantoms. Coronary arteries were segmented on a workstation and the same window settings were applied to the volume-rendered images to calculate total CAV. Significant correlations between total CAV and LV mass (r=0.660, P<0.0001) were found, whereas an inverse relation was present between total CAV per 100 g of LV mass and LV mass.

CONCLUSIONS

The novel concept of "CAV" for the characterization of coronary arteries may prove useful for future research, particularly on the causes of LV hypertrophy.

Association of new arterial stiffness parameter, the cardio-ankle vascular index, with left ventricular diastolic function

AIM

Pulse wave velocity has been used as an index of aortic stiffness. Recently, the cardio-ankle vascular index (CAVI), which reflects the stiffness of the aorta independently of blood pressure, has been developed. In this study, we analyzed the relationship between CAVI and left ventricular (LV) diastolic dysfunction.

METHODS

A total of 119 patients were referred for echocardiography to evaluate ventricular function. Patients with reduced systolic function were excluded. Patients were divided on the basis of normal or reduced LV diastolic function determined by echocardiography. CAVI was measured using an automatic waveform analyzer.

RESULTS

CAVI was significantly higher in patients with reduced LV diastolic function than those with normal LV diastolic function (9.0+/-1.1 and 8.5+/-1.1, p=0.009). Multiple linear regression analysis revealed that CAVI was independently associated with the ratio of peak early diastolic velocity to peak atrial diastolic velocity and left atrial diameter. When patients were classified on the basis of CAVI quartiles, multiple logistic regression analysis demonstrated that the highest quartile of CAVI showed an increased odds ratio for the presence of LV diastolic dysfunction.

CONCLUSION

The present study revealed that an increased CAVI was independently associated with LV diastolic dysfunction in patients with preserved systolic function.

Rationale and design of the carotid plaque in human for all evaluations with aggressive rosuvastatin therapy (CHALLENGER trial): evaluation by magnetic resonance imaging

BACKGROUND

Intensive lipid-lowering therapy with statins reduces levels of low-density lipoprotein (LDL)-cholesterol (C) and improves plaque volume and composition in patients with cardiovascular disease. Furthermore, rosuvastatin ameliorated carotid stenosis in the ASTEROID study, and altered the composition of plaques in a predominantly Caucasian study population in the ORION study. However, it is not known whether statin therapy achieves similar quantitative improvement in carotid artery plaque in other ethnic groups.

METHODS AND RESULTS

Fifty patients with hypercholesterolemia (LDL-C >or=120 mg/dl) and a maximum carotid intima-media thickness >or=1.8 mm will be enrolled and treated with rosuvastatin at a dose of 5 mg/day for 96 weeks. The primary endpoints will be the percent change of carotid plaque volume and the change in plaque composition after 96 weeks of treatment, as evaluated by magnetic resonance imaging.

CONCLUSIONS

The CHALLENGER study will provide a noninvasive assessment of the changes in carotid plaque volume and composition achieved by reduction of LDL levels in Japanese patients with carotid stenosis on long-term rosuvastatin therapy.

Small dense low-density lipoprotein cholesterol concentration and carotid atherosclerosis

Low-density lipoprotein cholesterol (LDL-C) and the small dense LDL (SdLDL) phenotype are both predictors for ischemic heart disease. We examined whether cholesterol of SdLDL (SdLDL-C) is more closely associated with carotid artery intima-media thickness (CA-IMT), a surrogate measure of atherosclerosis, than LDL-C and other lipid parameters. The subjects were 326 consecutive participants including those with dyslipidemia, diabetes mellitus, hypertension, chronic kidney disease, and smokers. SdLDL-C was quantified by a newly developed precipitation method, and CA-IMT by high-resolution B-mode ultrasound. In univariate analysis, CA-IMT was most strongly correlated with SdLDL-C (Spearman's r=0.441, P<0.001), followed by apolipoprotein (apo) B, LDL-C, non-high-density lipoprotein cholesterol (Non-HDL-C), and plasma triglycerides (TG). HDL-C and apo A-I correlated inversely with CA-IMT. Non-lipid variables that were associated with CA-IMT were age, sex, presence of diabetes mellitus, presence of hypertension, estimate glomerular filtration rate (eGFR), and C-reactive protein (CRP). Even after adjustment for age, sex, diabetes mellitus, hypertension, smoking, eGFR and CRP, the positive association of CA-IMT with SdLDL-C remained significant, and again stronger than the associations with others lipid parameters. Further analyses revealed that the level of SdLDL-C was elevated in subgroups of the subjects including men, older subjects, smokers, those with higher CRP levels, those with diabetes mellitus, and hypertensive patients. These results indicate that SdLDL-C was the best marker of carotid atherosclerosis among the lipid parameters tested, and suggest that quantitative measurement of SdLDL-C gives useful information in the risk assessment for atherosclerotic disease.

Visceral fat accumulation as a predictor of coronary artery calcium as assessed by multislice computed tomography in Japanese patients

The impact of visceral adiposity on subclinical coronary atherosclerosis is unclear in Japanese patients. We investigated the sex-specific relationship between the amount of visceral fat and coronary artery calcium (CAC) using multislice computed tomography (MSCT). This is a cross-sectional study of 321 consecutive Japanese patients (213 men and 108 women) who underwent MSCT scanning for the examination of coronary heart disease. CAC score, visceral fat area (VFA), subcutaneous fat area (SFA), and waist circumference (WC) were determined by MSCT for all patients. The prevalence of detectable CAC was 73% and 57% in men and women, respectively. Using a multivariable logistic and ordinal regression analyses adjusting for traditional cardiovascular risk factors and adiposity measurements, VFA represented an independent predictor of the presence and extent of CAC (odds ratio (95% confidence interval) per one-unit-standard deviation increase in VFA: 2.48 (1.23-6.05) in logistic regression analysis; 2.05 (1.18-3.98) in ordinal regression analysis). Similar relationships were observed across the gender. We further assessed the sex-specific cut-off levels of VFA and WC to predict the presence of CAC. The results of receiver operator characteristic analysis indicated that the VFA cut-off level in men was 116cm(2); and in women, it was 82cm(2), corresponding to WC values of 87.7cm in men and 82.6cm in women. In conclusion, we found that visceral adiposity measured by MSCT is significantly associated with the presence and extent of CAC as a marker of subclinical atherosclerosis in Japanese patients.

Independent determinants of second derivative of the finger photoplethysmogram among various cardiovascular risk factors in middle-aged men

The second derivative of the finger photoplethysmogram (SDPTG) has been used as a non-invasive examination for arterial stiffness. The present study sought to elucidate independent determinants of the SDPTG among various cardiovascular risk factors in middle-aged Japanese men. The SDPTG was obtained from the cuticle of the left-hand forefinger in 973 male workers (mean age: 44+/-6 years) during a medical checkup at a company. The SDPTG indices (b/a and d/a) were calculated from the height of the wave components. Multiple logistic regression analyses revealed that the independent determinants of an increased b/a (highest quartile of the b/a) were age (odds ratio [OR]: 1.12 per 1-year increase, 95% confidence interval [CI]: 1.09-1.15), hypertension (OR: 1.65, 95% CI: 1.03-2.65), dyslipidemia (OR: 1.51, 95% CI: 1.09-2.09), impaired fasting glucose/diabetes mellitus (OR: 2.43, 95% CI: 1.16-5.07), and a lack of regular exercise (OR: 2.00, 95% CI: 1.29-3.08). Similarly, independent determinants of a decreased d/a (lowest quartile of the d/a) were age (OR: 1.11 per 1-year increase, 95% CI: 1.08-1.14), hypertension (OR: 3.44, 95% CI: 2.20-5.38), and alcohol intake 6 or 7 days per week (OR: 2.70, 95% CI: 1.80-4.06). No independent association was observed between the SDPTG indices and blood leukocyte count or serum C-reactive protein levels. In conclusion, the SDPTG indices reflect arterial properties affected by several cardiovascular risk factors in middle-aged Japanese men. The association between inflammation and the SDPTG should be evaluated in further studies.