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

Z-Ligustilide: A Potential Therapeutic Agent for Atherosclerosis Complicating Cerebrovascular Disease

Atherosclerosis (AS) is one of the major catalysts of ischemic cerebrovascular disease, and the death and disease burden from AS and its cerebrovascular complications are increasing. Z-ligustilide (Z-LIG) is a key active ingredient in Angelica sinensis (Oliv.) Diels and Ligusticum chuanxiong Hort. In this paper, we first introduced LIG's physicochemical properties and pharmacokinetics. Then, we reviewed Z-LIG's intervention and therapeutic mechanisms on AS and its cerebrovascular complications. The mechanisms of Z-LIG intervention in AS include improving lipid metabolism, antioxidant and anti-inflammatory effects, protecting vascular endothelium, and inhibiting vascular endothelial fibrosis, pathological thickening, and plaque calcification. In ischemic cerebrovascular diseases complicated by AS, Z-LIG exerts practical neuroprotective effects in ischemic stroke (IS), transient ischemic attack (TIA), and vascular dementia (VaD) through anti-neuroinflammatory, anti-oxidation, anti-neuronal apoptosis, protection of the blood-brain barrier, promotion of mitochondrial division and angiogenesis, improvement of cholinergic activity, inhibition of astrocyte proliferation, and endoplasmic reticulum stress. This paper aims to provide a basis for subsequent studies of Z-LIG in the prevention and treatment of AS and its cerebrovascular complications and, thus, to promote the development of interventional drugs for AS.

High LDL Particle and APOB Concentrations in Patients With Adrenal Cortical Adenomas

CONTEXT

Patients with nonfunctioning adenomas (NFAs), adenomas with mild autonomous cortisol secretion (MACS) and Cushing syndrome (CS) demonstrate an increased cardiovascular risk.

OBJECTIVE

This work aimed to determine the extent of lipoprotein abnormalities in NFA, MACS, and CS.

METHODS

We conducted a single-center, cross-sectional study of patients with NFA (n = 167), MACS (n = 213), CS (n = 142), and referent individuals (n = 202) between January 2015 and July 2022. Triglyceride-rich lipoprotein particles (TRLP), low-density lipoprotein particles (LDLP), high-density lipoprotein particles (HDLP), their subclasses and sizes were measured using nuclear magnetic resonance spectroscopy. Multivariable logistic analyses were adjusted for age, sex, body mass index, smoking, hypertension, diabetes and lipid-lowering drug therapy.

RESULTS

In age- and sex-adjusted analysis, all patients categories demonstrated increased very large TRLP, large TRLP, and greater TRLP size (odds ratio [OR], 1.22-2.08) and total LDLP (OR, 1.22-1.75) and decreased LDL and HDL size compared to referent individuals. In fully adjusted analysis, LDLP concentrations remained elevated in all patient categories (OR, 1.31-1.84). Total cholesterol, LDL cholesterol, triglycerides, and apolipoprotein B (ApoB) were also higher in all patient categories in age- and sex-adjusted analysis, with ApoB remaining elevated in all patient categories in fully adjusted analysis. Similar LDLP and ApoB elevations were observed in all patient categories after excluding individuals on lipid-lowering therapy.

CONCLUSION

Patients with overt, mild, and even absent cortisol excess demonstrate lipoprotein profile abnormalities, in particular, high LDLP and ApoB concentrations, which conceivably contribute to high cardiometabolic risk.

Low-Density Lipoprotein Cholesterol Goal Achievement and Self-Reported Medication Adherence: Insights from the JET-LDL Registry

In patients with recent acute coronary syndromes (ACS), current guidelines recommend a low-density lipoprotein cholesterol (LDL-C) level <55 mg/100 ml. Despite the widespread use of different potent lipid-lowering therapies (LLT), this goal is not always achieved, often owing to less medication adherence. In this prespecified subanalysis of the JET-Low Density Lipoprotein (JET-LDL) registry, we sought to evaluate the relation between LDL-C targets achievement and LLT adherence in a cohort of patients hospitalized for ACS. The patients' self-reported medication adherence was assessed using the Morisky Medication Adherence Scale (MMAS) at 3-month follow-up. Depending on the score obtained, the population was divided into 2 groups: high adherence (HA, MMAS ≥6) versus low adherence (LA, MMAS <6). The occurrence of the primary end point (LDL-C reduction >50% from baseline or level <55 mg/100 ml at 1 month) was compared in the 2 groups. A total of 963 patients were included in the present analysis; in 277 cases (28.7%), an MMAS score <6 was reported (LA group), whereas in the remaining 686 (71.3%), the score obtained was ≥6 (HA group). No difference between the 2 groups was observed regarding LDL-C levels at admission and LLT prescribed at discharge. At 1 month, the primary end point occurred in 62.5% of cases, with a statistically significant difference between the 2 groups (LA 60% vs HA 65%, p = 0.034). At multivariate logistic regression analysis, LA was identified as an independent predictor of not achieving the primary end point (odds ratio 0.48, 0.39 to 0.85, p = 0.006). In conclusion, in a real-world cohort of patients with ACS, less medication adherence to LLT was a common event (28.7%), negatively affecting LDL-C goal achievement.

Drugs for dyslipidaemia: the legacy effect of the Scandinavian Simvastatin Survival Study (4S)

Since the discovery of statins and the Scandinavian Simvastatin Survival Study (4S) results three decades ago, remarkable advances have been made in the treatment of dyslipidaemia, a major risk factor for atherosclerotic cardiovascular disease. Safe and effective statins remain the cornerstone of therapeutic approach for this indication, including for children with genetic dyslipidaemia, and are one of the most widely prescribed drugs in the world. However, despite the affordability of generic statins, they remain underutilised worldwide. The use of ezetimibe to further decrease plasma LDL cholesterol and the targeting of other atherogenic lipoproteins, such as triglyceride-rich lipoproteins and lipoprotein(a), are likely to be required to further reduce atherosclerotic cardiovascular disease events. Drugs directed at these lipoproteins, including gene silencing and editing methods that durably suppress the production of proteins, such as PCSK9 and ANGPTL3, open novel therapeutic options to further reduce the development of atherosclerotic cardiovascular disease.

Subcellular Localization Guides eNOS Function

Nitric oxide synthases (NOS) are enzymes responsible for the cellular production of nitric oxide (NO), a highly reactive signaling molecule involved in important physiological and pathological processes. Given its remarkable capacity to diffuse across membranes, NO cannot be stored inside cells and thus requires multiple controlling mechanisms to regulate its biological functions. In particular, the regulation of endothelial nitric oxide synthase (eNOS) activity has been shown to be crucial in vascular homeostasis, primarily affecting cardiovascular disease and other pathophysiological processes of importance for human health. Among other factors, the subcellular localization of eNOS plays an important role in regulating its enzymatic activity and the bioavailability of NO. The aim of this review is to summarize pioneering studies and more recent publications, unveiling some of the factors that influence the subcellular compartmentalization of eNOS and discussing their functional implications in health and disease.

Lipid-lowering agent preferences among patients with hypercholesterolemia: a focus group study

Background

Non-adherence to lipid-lowering agents poses significant risks to patients and diminishes treatment effectiveness. Current understanding of patients' preferences regarding the characteristics of these agents is limited. This study aims to qualitatively identify the barriers to lipid-lowering medication adherence and the factors considered by patients with hypercholesterolemia when choosing lipid-lowering agents, and to inform the design of a medication preference study.

Methods

Face-to-face focus group interviews were conducted with Cantonese-speaking patients diagnosed with hypercholesterolemia in Hong Kong. Patients were recruited by cardiologists at a university-affiliated hospital using convenience sampling. The interviews consisted of three parts: gathering patients' perceptions of disease and medication, identifying important factors in selecting lipid-lowering agents, and completing the medication preference tasks designed using the Discrete Choice Experiment (DCE) method. Thematic analysis was used to categorise the codes derived from the transcripts into higher-order themes.

Results

Twenty patients completed the focus group interviews on the university campus between January and March 2023. Four main themes emerged: medication management issues, patients' medication preferences, structure, and comprehension of preference tasks. Barriers to medication adherence included lack of knowledge, a high pill burden, poor communication with healthcare providers, minimal treatment decision involvement, limited access to medication information, side effects, and forgetfulness. Factors influencing medication choice were treatment regimen (i.e. the route and frequency of administration), effectiveness, side effects, doctors' opinions, drug interactions, and out-of-pocket costs. Despite suggestions for modifying attributes and levels, the medication preference tasks effectively reflected patients' trade-offs.

Conclusions

The identified barriers to medication adherence and the factors influencing medication choice highlight the importance of considering patients' perspectives. These insights could assist decision-makers in selecting medications that align with patient preferences, thereby promoting medication adherence. A large-scale DCE preference study will be conducted in Hong Kong to quantify the relative importance of the attributes of lipid-lowering agents.

Statin Use in Children and Adolescents - Dos, Don'ts and Practical Tips

PURPOSE OF REVIEW

We review treatment criteria in the pediatric population, provide practical advice on how and when to prescribe statins, and share tips to improve compliance.

RECENT FINDINGS

Although long-term outcome studies of cardiovascular-related events, such as myocardial infarction (MI) and stroke, are lacking in this population, statin therapy initiated during adolescence has been shown to be safe and effective for up to 20 years of continuous use. HMG-CoA reductase inhibitors (statins) are the most effective class of drugs for lowering low-density lipoprotein cholesterol (LDL-C) in children and adolescents.

Management of Hypercholesterolemia in Patients with Coronary Artery Disease: A Glimpse into the Future

Cardio-cerebral vascular diseases due to atherosclerosis are still the leading cause of death worldwide. Low-density lipoprotein cholesterol (LDL-C) and apolipoprotein B have been identified as the primary factors responsible for the atherosclerotic process, with a causal effect. Many drugs aimed at reducing LDL-C levels are already on the market, acting in different ways in terms of mechanism of action, efficacy, and safety. Moreover, new lipid-lowering agents and new technologies in the fields of gene editing and immunotherapy are currently under investigation. A more recent biomarker associated with an increased risk of plaque generation, progression, and subsequent ASCVD is the lipoprotein (a) and, in the next few years, it will be the new target of pharmacological therapy. The aim of this review is to present the landscape of therapies already approved to reduce LDL-C levels, evaluating their efficacy, tolerability, and indications. Moreover, we take a glimpse into the future to evaluate experimental novel therapies to lower LDL-C levels that will be approved in the next few years or are under clinical evaluation.

Leveraging Mendelian randomization to inform drug discovery and development for ischemic stroke

Discovery and development of efficacious and safe pharmacological therapies is fraught with challenges. As proteins constitute the majority of drug targets and are encoded by genes, naturally occurring genetic variation within populations can provide valuable insights to inform drug discovery and development efforts. The drug target Mendelian randomization (MR) paradigm leverages these principles to investigate the causal effects of drug targets in humans. This review examines the application of drug target MR in informing the efficacy and development of therapeutics for ischemic stroke prevention and treatment. We consider applications of MR for existing and novel treatment strategies, including targeting blood pressure, lipid metabolism, coagulation, inflammation and glycemic control. Several of these genetically supported targets are under evaluation in late-stage clinical trials. Methodological limitations of drug target MR are addressed, followed by an outline of future research directions. We anticipate that careful application of drug target MR will enhance the efficiency of drug development for ischemic stroke, consequently accelerating the delivery of effective medications to patients.

Highlights of Cardiovascular Disease Prevention Studies Presented at the 2024 European Society of Cardiology Congress

PURPOSE OF REVIEW

To summarize selected late-breaking science on cardiovascular disease (CVD) prevention presented at the 2024 European Society of Cardiology (ESC) Congress.

RECENT FINDINGS

Key studies from the 2024 ESC Congress highlight advances in (CVD) management. Apolipoprotein A-1 infusions reduced risk in acute myocardial infarction patients with high LDL cholesterol. Plozasiran cut triglycerides and apolipoprotein C-III levels, lowering pancreatitis risk. A 14-year study linked smoking among youth to cardiac abnormalities. Baseline hsCRP, LDL-C, and Lp(a) were strong predictors of 30-year outcomes in women. Alternative LDL-lowering strategies matched high-intensity statins in effectiveness of LDL-C lowering and reduced diabetes risk. Early combination lipid lowering therapy improved outcomes post-myocardial infarction. Nordic and Mediterranean diets were linked to lower atherosclerotic CVD risk. The findings from the 2024 ESC Congress highlight significant advancements in CVD prevention, including novel lipid-lowering therapies, biomarker-based risk prediction, and lifestyle interventions. These studies underscore the importance of early and personalized treatment strategies to mitigate long-term cardiovascular risk.

Strict control of atherogenic cholesterol and cardiovascular disease prevention

The role of cholesterol associated to low density lipoproteins (LDL) as a causal agent of arteriosclerosis is scientifically consolidated. A number of seminal clinical trials of the highest scientific quality (randomized, controlled, double-blind versus placebo) in the last 40 years have confirmed that lipid lowering therapy with progressively ambitious therapeutic goals is associated with reductions in cardiovascular complications in the absence of major side effects at least up to the range of 30mg/dL of LDL cholesterol. Drugs that have demonstrated these effects act by reducing circulating LDL cholesterol by upregulating the LDL receptor, independently of their primary action: inhibition of synthesis (statins, bempedoic acid), or absorption of cholesterol (ezetimibe) and promoting recycling of the LDL receptor via proprotein conversin subtilisine kexin 9 blockade. The early reduction of LDL cholesterol and its maintenance over time reinforce the protective effect of these drugs. Additional efforts are needed to improve the LDL control of high-risk patients to reduce their cardiovascular complications.

PCSK9 Monoclonal Antibodies Have Come a Long Way

PURPOSE OF THE REVIEW

This review examines the pivotal role of monoclonal antibodies against PCSK9 in lipid-lowering therapy, emphasizing their biological and clinical impact.

RECENT FINDINGS

Randomized controlled trials have validated that PCSK9 monoclonal antibodies (Mabs) effectively reduce LDL-c levels by approximately 50%, even when added to maximal statin therapy. They moreover produce a notable 15-20% relative decrease in major cardiovascular events, with a greater reduction among high-risk patients and no evidence for serious adverse effects, assuaging previous concerns. This review highlights the benefits of PCSK9 Mabs in high cardiovascular risk patients. Despite their efficacy and safety, these therapies are hindered by limited access, and require broader integration into clinical practice to optimize therapeutic outcomes.

Role of metabolites in mediating the effect of triacylglycerol on aplastic anemia

BACKGROUND

Observational studies have found a link between lipid metabolism disorders and aplastic anemia (AA). However, due to confounding variables and reverse causation, it is difficult to conclude such a causal link. The precise mechanism and potential implications of lipid metabolism disorder in AA remain unclear, necessitating further studies in this area.

METHOD

This study aimed to examine the causal relationship between 38 different subtypes of triacylglycerols and AA using two-sample Mendelian randomization (MR). Additionally, two-step MR analyses were conducted to investigate the mediating effects of vitamin A to oleoyl-linoleoyl-glycerol (18:1-18:2) ratio.

RESULTS

MR analysis showed that triacylglycerol (53:3) levels were positively associated with the risk of AA [inverse variance weighting (IVW): odds ratio (OR) = 1.131,95% confidence interval (CI):1.029-1.243, P = 0.011; Bayesian weighted MR (BWMR): OR = 1.137,95% CI:1.031-1.254, P = 0.010]. Triacylglycerol (53:3) level showed no inverse causality with AA (IVW:P = 0.834; BWMR:P = 0.349). Mediation analyses showed that increasing the vitamin A to oleoyl-linoleoyl-glycerol (18:1-18:2) ratio can decrease the risk of AA.

CONCLUSION

This study revealed the association between vitamin A to oleoyl-linoleoyl-glycerol (18:1-18:2) ratio, triacylglycerol (53:3) levels and AA, and indicated that lowering triacylglycerol (53:3) levels can reduce the risk of AA.

New drugs for treating dyslipidemias. From small molecules to small interfering RNAs

Despite the various therapeutic tools available, many patients do not achieve therapeutic goals, and cardiovascular diseases remain a significant cause of death in our setting. Furthermore, even in patients who manage to reduce their LDL-C levels to the recommended targets, cardiovascular events continue to occur. The therapeutic challenge and the persistent risk have led to active research into new drugs targeting novel therapeutic pathways in the field of lipoprotein metabolism disorders. The therapeutic approach involves new pharmacological mechanisms, ranging from small molecules and monoclonal antibodies to RNA interference, with inclisiran being the first drug approved for clinical use in the cardiovascular domain. In this review, we aim to provide a comprehensive overview of the new therapeutic targets and pharmacological mechanisms under development, as well as their potential clinical impact.

Real-World Application of Evolocumab Among Patients with Hyperlipidemia in Korea: A Multicenter Prospective Study

INTRODUCTION

Elevated low-density lipoprotein cholesterol (LDL-C) is a major residual risk factor among patients with acute coronary syndrome (ACS). In the absence of sufficient real-world evidence, this observational (noninterventional) study investigated the effectiveness and safety of evolocumab in patients with hyperlipidemia treated with evolocumab for ACS in a real-world clinical setting in Korea.

METHODS

Between January 2022 and February 2023, patients from 10 hospitals in Korea who initiated evolocumab within 24 weeks of an ACS event were enrolled. Data collected at visit 1 (evolocumab initiation) included patients' characteristics, comorbidities, and lipid-lowering therapies. LDL-C reduction from visit 1 (week 0) to visit 2 (week 8) was assessed. The primary outcome was the proportion of patients who achieved LDL-C < 1.4 mmol/L (55 mg/dL) at follow-up; the secondary outcome was the proportion who achieved LDL-C < 1.8 mmol/L (70 mg/dL) at follow-up.

RESULTS

In this study, 89 out of 142 enrolled patients were included in the effectiveness analysis. The mean (SD) age of the included patients was 59.3 (12.3) years, with the majority being male (87.6%). Sixty-one patients received statin-ezetimibe combination therapy (68.5%). The median [Q1, Q3] LDL-C level at the start of the study was 2.5 [2.0, 3.0] mmol/L (98 [77, 115] mg/dL), which decreased to 1.3 [0.7, 1.7] mmol/L (49 [29, 67] mg/dL) after 8 weeks of evolocumab treatment, resulting in an mean (SD) 50.9 (28.6) % reduction and 1.4 (1.0) mmol/L (55.1 (37.9) mg/dL) absolute reduction. At follow-up, 55.1% and 78.7% of patients achieved LDL-C goals of < 1.4 mmol/L (55 mg/dL) and < 1.8 mmol/L (70 mg/dL), respectively. No adverse or serious adverse drug reactions were reported.

CONCLUSION

Evolocumab treatment was associated with significant LDL-C lowering and favorable safety and guideline-recommended LDL-C goal achievement rates among patients with ACS in the real-world clinical practice setting in South Korea.

Estimation of the proportion of cardiovascular disease cases in France attributable to high concentrations of low-density lipoprotein cholesterol

BACKGROUND

Elevated concentrations of low-density lipoprotein cholesterol (LDL-C) are highly prevalent and are associated with the development of cardiovascular diseases.

AIM

To estimate the proportion of cardiovascular disease cases attributable to high concentrations of LDL-C (population attributable fraction [PAF]) in France in 2017, based on the most recent individual data on LDL-C, and the attributable burden on hospitalizations and death.

METHODS

We estimated the PAF of high LDL-C concentrations for ischaemic heart disease (IHD), ischaemic stroke and aortic valve stenosis (AVS). Distributions of LDL-C concentrations were obtained from the most recent French health examination representative survey (ESTEBAN). The relative risks of each disease per 1-mmol/L increase in blood LDL-C were obtained either from the most appropriate meta-analyses or from Mendelian randomization.

RESULTS

The PAF of high LDL-C concentrations varied between 44.2% (95% CI 24.6%-60.5%) for IHD-related death and 49.4% (95% CI 35.6-60.8%) for IHD-related years-of-life lost (YLL), 22.5% (95% CI 0.0-43.3%) and 25.5% (95% CI 11.6-36.8%) for ischaemic stroke indicators, and 29.0% (95% CI 8.6-45.4%) and 29.3% (95% CI 8.4-45.6%) for AVS indicators. Overall, 230,000 hospitalizations, 1,303,000 prevalent cases and 23,000 deaths were estimated to be attributable to high LDL-C concentrations, with most cases related to IHD. PAFs were similar across sex and cardiovascular diseases, whereas PAF strongly varied with age for IHD and ischaemic stroke, with PAF reaching 80.6% (95% CI 55.3-92.7%) and 60.9% (95% CI 33.8-80.8%), respectively, in the group aged 35-44 years.

CONCLUSION

The high estimated PAF of elevated LDL-C concentrations for IHD, ischaemic stroke and AVS support the urgent need to reduce the prevalence of hypercholesterolaemia in this French population.

Lipoprotein Apheresis: Utility, Outcomes, and Implementation in Clinical Practice: A Scientific Statement From the American Heart Association

Despite the availability of multiple classes of lipoprotein-lowering medications, some high-risk patients have persistent hypercholesterolemia and may require nonpharmacologic therapy. Lipoprotein apheresis (LA) is a valuable but underused adjunctive therapeutic option for low-density lipoprotein cholesterol and lipoprotein(a) lowering, particularly in children and adults with familial hypercholesterolemia. In addition to lipid lowering, LA reduces serum levels of proinflammatory and prothrombotic factors, reduces blood viscosity, increases microvascular myocardial perfusion, and may provide beneficial effects on endothelial function. Multiple observational studies demonstrate strong evidence for improved cardiovascular outcomes with LA; however, use in the United States is limited to a fraction of its Food and Drug Administration-approved indications. In addition, there are limited data regarding LA benefit for refractory focal segmental glomerulosclerosis. In this scientific statement, we review the history of LA, mechanisms of action, cardiovascular and renal outcomes data, indications, and options for treatment.

A Causal Model for Primary Prevention of Cardiovascular Disease: The Health Economic Model for the Primary Prevention of Cardiovascular Disease

OBJECTIVES

Our objective was to design and develop an open-source model capable of simulating interventions for primary prevention of cardiovascular disease (CVD) that incorporated the cumulative effects of risk factors (eg, cholesterol years or blood-pressure years) to enhance health economic modeling in settings which clinical trials are not possible.

METHODS

We reviewed the literature to design the model structure by selecting the most important causal risk factors for CVD-low-density lipoprotein-cholesterol (LDL-C), systolic blood pressure (SBP), smoking, diabetes, and lipoprotein (a) (Lp(a))-and most common CVDs-myocardial infarction and stroke. The epidemiological basis of the model involves the simulation of risk factor trajectories, which are used to modify CVD risk via causal effect estimates derived from Mendelian randomization. LDL-C, SBP, Lp(a), and smoking all have cumulative impacts on CVD risk, which were incorporated into the health economic model. The data for the model were primarily sourced from the UK Biobank study. We calibrated the model using clinical trial data and validated the model against the observed UK Biobank data. Finally, we performed an example health economic analysis to demonstrate the utility of the model. The model is open source.

RESULTS

The model performed well in all validation tests. It was able to produce interpretable and plausible (consistent with expectations of the existing literature) results from an example health economic analysis.

CONCLUSIONS

We have constructed an open-source health economic model capable of incorporating the cumulative effect of LDL-C (ie, cholesterol years), SBP (SBP-years), Lp(a), and smoking on lifetime CVD risk.

Adherence to the Healthy Nordic Food Index is associated with reduced plasma levels of inflammatory markers in patients with heterozygous familial hypercholesterolemia

Background and aims

Familial hypercholesterolemia (FH) is an inherited disease associated with hypercholesterolemia, and dietary treatment is part of the treatment. We aimed to assess the dietary pattern in relation to the Healthy Nordic Food Index (HNFI) in adults with and without heterozygous FH (HeFH), and to examine the associations between dietary quality and biomarkers related to cardiovascular disease in adults with HeFH.

Methods

We included 205 adults (≥18 years) with HeFH who received follow-up at the Lipid Clinic in Oslo and compared them to controls (n = 228). Dietary intake was assessed using a food frequency questionnaire and dietary quality was assessed using the HNFI. Blood samples were analysed for levels of blood lipids, plasma fatty acids (FAs), and markers of inflammation and platelet activation.

Results

The HeFH patients (median 60 years; 50.2 % female; 25.9 % in secondary prevention) had lower intake of total and saturated fat compared to controls (32.6 energy percent (E%) vs. 34.9 E%, and 9.6 E% vs 12.0 E%, respectively; p < 0.001 for both). In the HeFH patients, increasing dietary quality was associated with increased plasma levels of the n-3 polyunsaturated FAs (PUFAs) eicosapentaenoic acid and docosahexaenoic acid, and the n-6 PUFA linoleic acid, and lower plasma levels of the inflammatory cytokines Tumor Necrosis Factor and interleukin-6, and of the platelet-derived inflammatory cytokines Platelet Factor 4 and Neutrophil-Activating Peptide-2.

Conclusion

Norwegian patients with HeFH followed up at a Lipid Clinic eat healthier than controls. Adherence to a healthy dietary pattern is associated with higher plasma levels of n-3 and n-6 PUFA, and lower levels of inflammatory markers, including platelet markers. This may suggest that adherence to an overall healthy dietary pattern might be beneficial for HeFH patients independent of the cholesterol-lowering effect of the diet.

Therapeutic and pharmacological applications of extracellular vesicles and lipoproteins

In recent years, various approaches have been undertaken to eliminate lipoproteins co-isolated with extracellular vesicles, as they were initially regarded as contaminating entities. However, novel discoveries are reshaping our perspective. In body fluids, these distinct particles not only co-exist, but also interactions between them are likely to occur. Extracellular vesicles and lipoproteins can associate with each other, share cargo, influence each other's functions, and jointly have a role in the pathomechanisms of diseases. Additionally, their association carries important implications for therapeutic and pharmacological aspects of lipid-lowering strategies. Extracellular vesicles and lipoprotein particles may have roles in the elimination of each other from the circulation. The objective of this minireview is to delve into these aspects. Here, we show that under certain physiological and pathological conditions, extracellular vesicles and lipoproteins are 'partners' rather than 'strangers' or 'rivals'.

Risk factors for cardiovascular diseases in patients with vitiligo: an analysis of current evidence

OBJECTIVE

The relationship between vitiligo and cardiovascular diseases remains controversial. This study aimed to systematically review the evidence comparing cardiovascular disease risk factors between patients with vitiligo and controls and to perform a meta-analysis of the results.

DATA SOURCES

A comprehensive database search was performed for all studies in PubMed, EMBASE, and Cochrane Central Register databases from inception to November, 2023. The main keywords used were vitiligo, hypertension, diabetes, hyperlipidemia, metabolic syndrome, obesity, smoking, alcohol consumption, C-reactive protein, and homocysteine.

STUDY SELECTION

Only observational studies and no randomized controlled trials were included. Of the 1269 studies initially selected, the full texts of 108 were assessed for eligibility, and 74 were ultimately included in the analysis.

DATA EXTRACTION AND SYNTHESIS

Three reviewers independently extracted the following data: study design, number and characteristics of participants, inclusion indicators, and disease duration. A meta-analysis of the single-group rates was performed for the diabetes, hypertension, hyperlipidemia, and obesity groups. Random-effects or fixed-effects models were used to calculate the sample-size weighted averages for the indicators included in the studies.

MAIN OUTCOMES AND MEASURES

The primary outcomes were co-morbidity analysis and co-morbidity rates of vitiligo with metabolic syndrome, obesity, hyperlipidemia, hypertension, and diabetes mellitus. Secondary outcomes were factors associated with vitiligo and cardiovascular disease.

RESULTS

This meta-analysis concluded that comorbidities in patients with vitiligo included metabolic syndrome, diabetes, obesity, hyperlipidemia, and hypertension, with comorbidity rates of 28.3%, 6.0%, 38.5%, 43.0%, and 15.8%, respectively. Simultaneously, we showed that the vitiligo group differed significantly from the control group in the following aspects: fasting blood glucose, insulin, systolic and diastolic blood pressure, total cholesterol, triglycerides, low-density lipoprotein, high-density lipoprotein, homocysteine, C-reactive protein, smoking, and alcohol consumption. However, no significant differences were observed between the vitiligo and control groups in terms of waist circumference, body mass index, or phospholipid levels.

LIMITATIONS

The vast majority of the studies were from Eastern countries; therefore, extrapolation of these results to Western populations is questionable. The significant heterogeneity may be due to different protocols, doses, durations, center settings, population registries, etc., which severely compromise the validity of the results.

CONCLUSION

This study summarized not only the factors associated with, but also those not associated with, cardiovascular disease in patients with vitiligo. This study provides a foundation for the prevention and treatment of cardiovascular disease in patients with vitiligo.

2024 Recommendations on the Optimal Use of Lipid-Lowering Therapy in Established Atherosclerotic Cardiovascular Disease and Following Acute Coronary Syndromes: A Position Paper of the International Lipid Expert Panel (ILEP)

Atherosclerotic cardiovascular disease (ASCVD) and consequent acute coronary syndromes (ACS) are substantial contributors to morbidity and mortality across Europe. Fortunately, as much as two thirds of this disease's burden is modifiable, in particular by lipid-lowering therapy (LLT). Current guidelines are based on the sound premise that, with respect to low-density lipoprotein cholesterol (LDL-C), "lower is better for longer", and recent data have strongly emphasised the need for also "the earlier the better". In addition to statins, which have been available for several decades, ezetimibe, bempedoic acid (also as fixed dose combinations), and modulators of proprotein convertase subtilisin/kexin type 9 (PCSK9 inhibitors and inclisiran) are additionally very effective approaches to LLT, especially for those at very high and extremely high cardiovascular risk. In real life, however, clinical practice goals are still not met in a substantial proportion of patients (even in 70%). However, with the options we have available, we should render lipid disorders a rare disease. In April 2021, the International Lipid Expert Panel (ILEP) published its first position paper on the optimal use of LLT in post-ACS patients, which complemented the existing guidelines on the management of lipids in patients following ACS, which defined a group of "extremely high-risk" individuals and outlined scenarios where upfront combination therapy should be considered to improve access and adherence to LLT and, consequently, the therapy's effectiveness. These updated recommendations build on the previous work, considering developments in the evidential underpinning of combination LLT, ongoing education on the role of lipid disorder therapy, and changes in the availability of lipid-lowering drugs. Our aim is to provide a guide to address this unmet clinical need, to provide clear practical advice, whilst acknowledging the need for patient-centred care, and accounting for often large differences in the availability of LLTs between countries.

2024 The Royal College of Physicians of Thailand (RCPT) clinical practice guidelines on management of dyslipidemia for atherosclerotic cardiovascular disease prevention

Background

The Royal College of Physicians of Thailand (RCPT) published a Clinical Practice Guideline on Pharmacologic Therapy of Dyslipidemia for Atherosclerotic Cardiovascular Disease (ASCVD) Prevention in 2016. The availability of newer classes of medications for dyslipidemia, supported by extensive clinical research findings, indicates a significant need for the updating of the existing clinical practice guideline.

Objectives

To serve as guidelines on the management of dyslipidemia for Thai adults.

Methods

The RCPT Dyslipidemia Guidelines Committee was established with representatives from selected professional societies to revise the 2016 Guideline by critically reviewing the latest evidence. Meetings were conducted from August to December 2023, culminating in a public hearing that engaged various stakeholders in January 2024. The final Thai version received approval in April 2024, while the English translation was completed in October 2024.

Results

Lifestyle modifications and statins remain the cornerstone of therapy for dyslipidemia in adults across various clinical settings. Emerging evidence regarding newer classes of lipid-lowering medications indicates that these treatments are effective in lowering LDL-cholesterol levels and reducing atherosclerotic cardiovascular events. This suggests that they may serve as an add-on therapy for individuals who cannot achieve target levels or who are at high risk for future cardiovascular events. The Thai CV Risk Score is recommended due to its specificity for the Thai population.

Conclusions

The 2024 updated clinical practice guidelines establish a framework, provide recommendations, and serve as a comprehensive resource for the contemporary management of dyslipidemia in adults, with the goal of preventing ASCVD in Thailand.

The OMNIVEG STUDY: Health outcomes of shifting from a traditional to a vegan Mediterranean diet in healthy men. A controlled crossover trial

BACKGROUND AND AIM

The Mediterranean diet is a plant-based dietary pattern with well-established health benefits such as the reduced risk of cardiovascular disease. Additionally, incorporating more plant-based foods into a Mediterranean diet may provide further health benefits. The study aimed to assess the effect of shifting from a traditional Mediterranean diet to a vegan Mediterranean diet on cardiorespiratory fitness and lipid profile in physically active and healthy men.

METHODS AND RESULTS

Participants underwent a baseline period with adhesion to the general patterns of the Mediterranean diet for three weeks and then they changed to an isocaloric vegan version of the Mediterranean diet for four weeks, with a 7-day washout period between diets. The shift from the traditional Mediterranean diet to the vegan Mediterranean diet required substituting animal-based foods with plant-based foods that contain comparable amounts of protein and fat. Fourteen participants with a mean age of 24.6 ± 7.0 years (range: 18-37 years), completed the study protocol. The change from the traditional to the vegan Mediterranean diet reduced blood concentration of total cholesterol (-22.6 mg/dl, p < 0.01, Effect size [ES] = 1.07) and low-density lipoprotein cholesterol (-12.8 mg/dl, p < 0.01, ES = 0.72). An inverse correlation was observed between the intake of dietary fibre and LDL-C (partial rho = -0.43, p = 0.040).

CONCLUSIONS

The adoption of a vegan Mediterranean diet with plant-based proteins and fats instead of the traditional Mediterranean diet improved several cardiometabolic health outcomes in physically active and healthy men.

CLINICAL TRIAL REGISTRY

NCT06008886.

The effects of saturated fat intake from dairy on CVD markers: the role of food matrices

CVD is the leading cause of death worldwide, and is commonly associated with modifiable risk factors. Most studies to date examining link between food intake and risk of CVD, have focused on modulation of plasma cholesterol concentrations (total cholesterol (TC), LDL-C). However, recent studies suggest LDL particle size is a more sensitive risk marker for CVD with smaller, dense LDL particles reported as more atherogenic than larger, more buoyant LDL. Although dietary guidelines recommend SFA intake of < 10 % of total energy, this does not consider food source, with recent evidence suggesting differing, sometimes beneficial, lipid responses following consumption of SFA from dairy compared to other food sources. This may be from differences in the physical food matrices, the nutrient content of the foods, and/or how these components interact with each other, described as a 'dairy matrix effect'. Dietary fat not only raises LDL-C, but also HDL cholesterol (HDL-C), associated with reduced CVD risk. HDL particles are complex emulsions of lipids, proteins and microRNAs that exhibit atheroprotective properties. In addition, HDL particles exhibit a very heterogeneous proteomic composition, dependent on a person's disease state - with a more pro-inflammatory proteome evident in patients with established CVD. This review will discuss the evidence to date on the importance of the food matrix in modulating response to dietary SFA and impact on CVD risk factors. A focus on potential biomarker properties of lipoprotein particles beyond cholesterol and current use of such biomarkers in human nutrition research will be considered.

Assessing long-term effectiveness and cost-effectiveness of statin therapy in the UK: a modelling study using individual participant data sets

Background

Cardiovascular disease has declined but remains a major disease burden across developed countries.

Objective

To assess the effectiveness and cost-effectiveness of statin therapy across United Kingdom population categories.

Design

The cardiovascular disease microsimulation model, developed using Cholesterol Treatment Trialists' Collaboration data and the United Kingdom Biobank cohort, projected cardiovascular events, mortality, quality of life and healthcare costs using participant characteristics.

Setting

United Kingdom primary health care.

Participants

A total of 117,896 participants in 16 statin trials in the Cholesterol Treatment Trialists' Collaboration; 501,854 United Kingdom Biobank participants by previous cardiovascular disease status, sex, age (40-49, 50-59 and 60-70 years), 10-year cardiovascular disease risk [QRISK®3 (%): < 5, 5-10, 10-15, 15-20 and ≥ 20] and low-density lipoprotein cholesterol level (< 3.4, 3.4-4.1 and ≥ 4.1 mmol/l); 20,122 United Kingdom Biobank and Whitehall II participants aged ≥ 70 years by previous cardiovascular disease status, sex and low-density lipoprotein cholesterol (< 3.4, 3.4-4.1 and ≥ 4.1 mmol/l).

Interventions

Lifetime standard (35-45% low-density lipoprotein cholesterol reduction) or higher-intensity (≥ 45% reduction) statin.

Main outcome measures

Quality-adjusted life-years and incremental cost per quality-adjusted life-year gained from the United Kingdom healthcare perspective.

Data sources

Cholesterol Treatment Trialists' Collaboration and United Kingdom Biobank data informed risk equations. United Kingdom primary and hospital care data informed healthcare costs (2020-1 Great British pounds); £1.10 standard or £1.68 higher-intensity generic statin therapy per 28 tablets; and Health Survey for England data informed health-related quality of life. Meta-analyses of trials and cohort studies informed the effects of statin therapies on cardiovascular events, incident diabetes, myopathy and rhabdomyolysis.

Results

Across categories of participants 40-70 years old, lifetime use of standard statin therapy resulted in undiscounted 0.20-1.09 quality-adjusted life-years gained per person, and higher-intensity statin therapy added a further 0.03-0.20 quality-adjusted life-years per person. Among participants aged ≥ 70 years, lifetime standard statin was estimated to increase quality-adjusted life-years by 0.24-0.70 and higher-intensity statin by a further 0.04-0.13 quality-adjusted life-years per person. Benefits were larger among participants at higher cardiovascular disease risk or with higher low-density lipoprotein cholesterol. Standard statin therapy was cost-effective across all categories of people 40-70 years old, with incremental costs per quality-adjusted life-year gained from £280 to £8530. Higher-intensity statin therapy was cost-effective at higher cardiovascular disease risk or higher low-density lipoprotein cholesterol. Both standard and higher-intensity statin therapies appeared to be cost-effective for people aged ≥ 70 years, with an incremental cost per quality-adjusted life-year gained of under £3500 for standard and under £11,780 for higher-intensity statin. Standard or higher-intensity statin therapy was certain to be cost effective in the base-case analysis at a threshold of £20,000 per quality-adjusted life-year. Statins remained cost-effective in sensitivity analyses.

Limitations

The randomised evidence for effects of statin therapy is for about 5 years of treatment. There is limited randomised evidence of the effects of statin therapy in older people without previous cardiovascular disease.

Conclusions

Based on the current evidence of the effects of statin therapy and modelled contemporary disease risks, low-cost statin therapy is cost-effective across all categories of men and women aged ≥ 40 years in the United Kingdom, with higher-intensity statin therapy cost-effective at higher cardiovascular disease risk or higher low-density lipoprotein cholesterol.

Future work

Cholesterol Treatment Trialists' Collaboration has ongoing studies of effects of statin therapy using individual participant data from randomised statin trials. Ongoing large randomised controlled trials are studying the effects of statin therapy in people ≥ 70 years old. Future economic analyses should integrate the emerging new evidence.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/140/02) and is published in full in Health Technology Assessment; Vol. 28, No. 79. See the NIHR Funding and Awards website for further award information.

Analysis of Inclisiran in the US FDA Adverse Event Reporting System (FAERS): a focus on overall patient population and sex-specific subgroups

BACKGROUND

Our study aimed to identify inclisiran-related adverse events(AEs) for primary hypercholesterolemia and arteriosclerotic cardiovascular disease(ASCVD) from the US FDA Adverse Event Reporting System (FAERS) database, analyzing its links to AEs in the overall patient population and sex-specific subgroups to improve medication safety.

METHODS

We analyzed inclisiran-related AEs signals by using statistical methods like Reporting Odds Ratio (ROR), Proportional Reporting Ratios (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Multi-item Gamma-Poisson Shrinker (MGPS).

RESULTS

Analyzing 2,400 AE reports with inclisiran as the primary suspected drug in the FAERS database, we identified 70 AE signals over 13 organ systems using the above four methods. Notable findings were strong signals for systemic diseases and various reactions at the site of administration (ROR 1.49, 95% CI 1.41-1.57), and various musculoskeletal and connective tissue diseases (ROR 4.07, 95% CI 3.83-4.03) in overall and gender-specific populations. Myalgia, a new ADE signal not in the drug insert, was a top signal by intensity and frequency (ROR 14.76, 95% CI 12.84-16.98).

CONCLUSION

Our study revealed the strongest AE signals associated with inclisiran in both the overall population and gender subgroups, highlighting potential risks in clinical medication use and guiding balanced clinical decision-making.

SGLT2 inhibition, blood lipids, and cardiovascular disease: A Mendelian randomization study

AIMS

We aim to investigate the causal effect of blood lipids mediating sodium-glucose cotransporter 2 (SGLT2) inhibition in cardiovascular disease (CVD) using Mendelian randomization (MR).

METHODS AND RESULTS

A two-sample two-step MR study was conducted to evaluate the association of SGLT2 inhibition with CVDs and the mediation effects of blood lipids linking SGLT2 inhibition with CVDs. Genetic instruments for SGLT2 inhibition were identified as genetic variants, which were associated with the expression of the SLC5A2 gene and glycated haemoglobin level (HbA1c). SGLT2 inhibition was associated with reduced risk of heart failure (HF) (OR 0.44 [95% CI 0.32-0.61]; P = 6.0 × 10-7), atrial fibrillation (AF) (0.47 [0.37-0.61]; P = 1.81 × 10-8), coronary artery disease (CAD) (0.47 [0.30-0.73]; P = 7.46 × 10-4), myocardial infarction (MI) (0.30 [0.15-0.61]; P = 7.44 × 10-4), any stroke (AS) (0.28 [0.18-0.42]; P = 1.14 × 10-9), and ischaemic stroke (IS) (0.27 [0.17-0.44]; P = 1.97 × 10-7). Our results indicated that the proportion mediated of the mediating effect of total cholesterol was 1.7% (OR 0.99 [95% CI 0.98, 0.99], P = 0.004), 4.7% (0.96 [0.95, 0.98], P = 0.002), and 2.7% (0.97 [0.95, 0.98], P = 0.002) in the association between SGLT2 inhibition and the risk of HF, CAD, and MI, respectively. For low-density lipoprotein cholesterol, the proportion mediated of the mediating effect was 2.2% for HF (OR 0.98 [95% CI 0.98, 0.99], P = 0.003), 8.6% for CAD (0.93 [0.91, 0.95], P = 5.74 × 10-4), and 5.0% for MI (0.95 [0.94, 0.96], P = 6.97 × 10-4). For non-high-density lipoprotein cholesterol, the proportion mediated of the mediating effect was 3.4% for HF (OR 0.98 [95% CI 0.97, 0.98], P = 4.42 × 10-6), 11.8% for CAD (0.92 [0.90, 0.93], P = 7.23 × 10-8), 5.7% for MI (0.94 [0.92, 0.95], P = 8.17 × 10-7), 1.5% for AS (0.98 [0.98, 0.99], P = 0.001), and 1.4% for IS (0.98 [0.98, 0.99], P = 0.004).

CONCLUSIONS

Our study showed the association of SGLT2 inhibition with the reduced risk of CVDs and blood lipids might mediate this association.

LDL cholesterol as a causal agent of atherosclerosis

Atherosclerosis is a chronic disease that begins in early childhood, and without intervention, progresses throughout life, and inevitably worsens over time, sometimes rapidly. LDL cholesterol, beyond being a cardiovascular risk factor, is a causal agent of atherosclerosis. Without LDL cholesterol there is no atherosclerosis, so the evolution of the disease is modifiable, and even reversible.

Impacts of Anabolic-androgenic steroid supplementation on female health and offspring: Mechanisms, side effects, and medical perspectives

The increasing prevalence of Anabolic-androgenic steroids (AAS) among women, driven by the pursuit of improved body aesthetics, characterized by higher lean mass and reduced adipose tissue, raises significant health concerns, particularly due to the limited knowledge regarding their effects on the female organism. Prolonged use and/or high doses of AAS are linked to various harmful side effects, including mood changes, psychiatric disorders, voice deepening, clitoromegaly, menstrual irregularities, and cardiovascular complications, prompting medical societies to discourage their widespread use due to insufficient evidence supporting their safety and efficacy. Studies in female rodents have shown that AAS can lead to increased aggression, inflammation, reduced neuronal density, and negative impacts on the myocardium and blood vessels. Additionally, maternal administration of androgens during pregnancy can adversely affect offspring's reproductive, neuronal, and metabolic health, resulting in long-term impairments. The complexity of the mechanisms underlying AAS effects, and their potential genotoxicity remains poorly understood. This review aims to elucidate the various ways in which AAS can impact female physiology and that of their offspring, highlight commonly used anabolic substances, and discuss the positions of medical societies regarding AAS use.

The identification and prediction of atrial fibrillation in coronary artery disease patients: a multicentre retrospective study based on Bayesian network

BACKGROUND

Atrial fibrillation (AF) coexisting with coronary artery disease (CAD) remains a prevailing issue that often results in poor short- and long-term patient outcomes. Screening has been proposed as a method to increase AF detection rates and reduce the incidence of poor prognosis through early intervention. Nevertheless, due to the cost implications and uncertainty over the benefits of a systematic screening programme, the International Task Force currently recommends against screening. This study is to employ Bayesian networks (BN) for assessing the pre-test probability (PTP) of AF in patients with CAD.

METHODS

A total of 12,552 patients with CAD were divided into the CAD patients with AF group (CHD-AF group) and the CAD patients without AF group (non-AF group). Univariate analysis and LASSO regression method were used to screen for potential risk factors. The maximum-minimum climb (MMHC) algorithm was used to construct the directed acyclic graph (DAG) of BN. Predictive power was tested using internal validation, external validation and 10-fold internal cross-validation. Finally, the generated BN model was compared with four machine learning algorithms.

RESULTS

Fourteen indicators were included in the BN, including age, gender, systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), serum uric acid (UA), gamma-glutamyltransferase (GGT), direct bilirubin (DBIL), lipoproteins [LP(a)], NYHA cardiac function grading, diabetes mellitus and hypertension, palpitation, dyspnoea and the left atrial diameter. The BN model performs well on both the test set (AUC = 0.90) and internal 10-fold cross-validation (AUC = 0.89 ± 0.01).

CONCLUSION

The prediction model of AF with CAD constructed based on BN has high prediction performance and may provide a new tool for large-scale AF screening.

Top 10 Tips for Using Statins in Clinical Practice

Statins are the mainstay of cholesterol treatment to prevent atherosclerotic cardiovascular disease. However, significant barriers, including physician and patient factors, prevent the optimal use of this drug class. In this article, we provide 10 clear and simple tips for clinicians when prescribing statins. The tips are based on the current guidelines, an extensive review of the literature, and decades of clinical practice of the senior author. Within the tips, we discuss key components of the guidelines, assessing cardiovascular risk profiles, evaluating drug-drug interactions, addressing adverse effects, and developing treatment plans that include statins and nonstatins. The tips will be useful for primary and specialty clinicians, such as cardiologists, endocrinologists, and nephrologists.

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.

Effect of synbiotic supplementation on obesity and gut microbiota in obese adults: a double-blind randomized controlled trial

BACKGROUND

Synbiotics, combining specific probiotics and selected prebiotics, may benefit health issues like obesity, but evidence remains inconsistent.

OBJECTIVE

This study aimed to verify the effect of a pre-screened synbiotics combination [containing Bifidobacterium animalis subsp. lactis MN-Gup (MN-Gup), galacto-oligosaccharides (GOS) and xylo-oligosaccharides (XOS)] on obesity in the population.

METHODS

In a randomized, double-blind, placebo-controlled trial, 80 individuals with obesity consumed daily synbiotics (containing MN-Gup 1 × 1011 CFU/day, GOS 0.7 g/day, and XOS 0.7 g/day) or placebo for 12 weeks. Body composition, blood lipids, serum hormone, bile acids, and gut microbiota were measured pre-and post-intervention.

RESULTS

Synbiotics supplementation significantly decreased body fat percentage, waist, and serum low-density lipoprotein cholesterol (LDL-C), increased peptide YY, cholecystokinin, oxyntomodulin, GSH (glutathione peroxidase) in individuals with obesity. Additionally, synbiotic supplementation led to an enrichment of beneficial bacteria and bile acids chenodeoxycholic acid (CDCA). Bifidobacterium and Romboutsia were significantly positively correlated with CDCA. A more favorable effect was observed in individuals with obesity and abnormal LDL-C compared to those without dyslipidemia.

CONCLUSION

Twelve-week synbiotics intervention reduced body fat percentage, waist, and serum LDL-C, especially in individuals with obesity and abnormal LDL-C. The possible mechanisms may be related to changes in gut microbiota, bile acids and gut hormones.

CLINICAL TRIAL REGISTRATION

Chictr.org.cn, identifier ChiCTR2200064156.

Is the Relationship Between Cardiovascular Disease and Alzheimer's Disease Genetic? A Scoping Review

BACKGROUND/OBJECTIVES

Cardiovascular disease (CVD) and Alzheimer's disease (AD) are two diseases highly prevalent in the aging population and often co-occur. The exact relationship between the two diseases is uncertain, though epidemiological studies have demonstrated that CVDs appear to increase the risk of AD and vice versa. This scoping review aims to examine the current identified overlapping genetics between CVDs and AD at the individual gene level and at the shared pathway level.

METHODS

Following PRISMA-ScR guidelines for a scoping review, we searched the PubMed and Scopus databases from 1990 to October 2024 for articles that involved (1) CVDs, (2) AD, and (3) used statistical methods to parse genetic relationships.

RESULTS

Our search yielded 2918 articles, of which 274 articles passed screening and were organized into two main sections: (1) evidence of shared genetic risk; and (2) shared mechanisms. The genes APOE, PSEN1, and PSEN2 reportedly have wide effects across the AD and CVD spectrum, affecting both cardiac and brain tissues. Mechanistically, changes in three main pathways (lipid metabolism, blood pressure regulation, and the breakdown of the blood-brain barrier (BBB)) contribute to subclinical and etiological changes that promote both AD and CVD progression. However, genetic studies continue to be limited by the availability of longitudinal data and lack of cohorts that are representative of diverse populations.

CONCLUSIONS

Highly penetrant familial genes simultaneously increase the risk of CVDs and AD. However, in most cases, sets of dysregulated genes within larger-scale mechanisms, like changes in lipid metabolism, blood pressure regulation, and BBB breakdown, increase the risk of both AD and CVDs and contribute to disease progression.

Association between low density lipoprotein cholesterol levels and prostate cancer risk in non-hypertensive middle-aged and older American men

Often linked with the risk of various diseases, blood low-density lipoprotein cholesterol (LDL-C) levels are typically deemed more favorable when lower. The objective of this investigation is to elucidate the link between blood LDL-C levels and the risk of prostate cancer (PCa) in middle-aged and older men without hypertension in the United States. Utilizing continuous data from the National Health and Nutrition Examination Survey (NHANES) database spanning 2003-2010, a selection of 1,223 non-hypertensive men aged ≥ 40 years was made from a pool of 41,156 participants, ensuring no missing information. Regression analyses were employed to investigate the correlation between blood LDL-C levels and the PCa risk, while identifying potential inflection points indicative of threshold effects. Additionally, we scrutinized the linkage between cholesterol-lowering prescription drug usage and PCa. In our study of 2,224 participants, we found no significant correlation between blood LDL-C levels and the PCa risk after adjusting for confounding variables (Odds Ratio = 0.99; P-value > 0.05). However, upon conducting a subgroup analysis, we discovered a meaningful correlation between lower blood LDL-C levels and an increased PCa risk in the non-hypertensive population (Odds Ratio = 0.99; P-value < 0.05). Meanwhile, we identified a threshold effect and a tipping point at an LDL-C levels of 67 mg/dl. Furthermore, a significant correlation was identified between cholesterol-lowering prescription drug usage and a heightened PCa risk in the non-hypertensive population (Odds Ratio = 18.87; P-value < 0.05; P for interaction < 0.05). Our results indicate that in non-hypertensive middle-aged and older men residing in the United States, lower blood LDL-C levels are not necessarily better and the PCa risk escalates when blood LDL-C levels drop below 67 mg/dl, which may guide early screening and prognosis of PCa in specific populations. This finding calls for further validation via larger sample sizes and a more in-depth analysis of PCa history.

Differential statin intensity and outcomes in patients following myocardial infarction with very low low-density lipoprotein cholesterol

BACKGROUND

Despite increasing evidence on the benefits of statin therapy for acute myocardial infarction (AMI), differential outcomes in accordance with statin intensity have not been evaluated in patients with AMI and low-density lipoprotein cholesterol (LDL-C) levels < 55 mg/dL. Therefore, this study aimed to compare the clinical outcomes of high- and moderate-intensity statin therapy in this population.

METHODS

A total of 752 participants with AMI and LDL-C levels < 55 mg/dL from a Korean nationwide multicenter observational cohort (2016-2020) were included and categorized into two groups: high-intensity statin group (n = 384) and moderate-intensity statin group (n = 368). The primary outcome was 1-year major adverse cardiac and cerebrovascular events (MACCEs). Propensity score matching (PSM) and Cox models were used to determine whether statin intensity independently influenced the primary outcome.

RESULTS

Compared to the moderate-intensity statin group, the high-intensity statin group had a comparable risk of MACCE in all Cox models and PSM-adjusted analyses. The cumulative incidence of MACCE was comparable between the two groups.

CONCLUSIONS

Statin intensity appeared to have no significant impact on clinical outcomes in AMI patients with LDL-C levels < 55 mg/dL. These results underscore the need for further investigations aimed at refining treatment strategies for this specific patient cohort, potentially reducing treatment-related burdens without compromising clinical effectiveness.

Portuguese Lipid Study (e_LIPID)

Background/Objectives: Incidence of cardiovascular disease (CVD) is increasing in low- and middle-income countries because of changing lifestyles. Since dyslipidaemia is a major independent cardiovascular risk factor, its correct identification is critical to implement specific interventions for CVD prevention. This study aimed to characterise the lipid profile of the Portuguese population. Methods: Overall, 1688 individuals from the general population (e_COR study, 2012-2014) were included. Population-specific percentiles for ten lipid biomarkers were estimated by bootstrapping methods to ensure national representativity. Statistical analyses were performed using RStudio. Results: The 50th percentile estimated for total cholesterol (TC), LDL-C, and non-HDL-C are similar to scientific societies recommended values for the general (low or moderate risk) population. National prevalence of having lipid parameters above recommended values was 64.6%, 66.9%, 51.3%, 68.9%, 17.8%, and 21.1% for TC, LDL-C, apoB, non-HDL-C, triglycerides, and Lp(a), respectively; these values are generally higher in men and increasing with age, except for Lp(a). A high prevalence of severe dyslipidaemia (>90th percentile) was identified, highest for small dense LDL-C (31.3%), apoB (30.4%), and LDL-C (30.3%). The national prevalence of CVD events was 5%. Three individuals were genetically identified with familial hypercholesterolemia, a high CVD risk condition. Conclusions: We provide for the first-time lipid biomarker percentiles for the general Portuguese population. Our results highlight that hypercholesterolemia is a neglected cardiovascular risk factor with over half of the population with TC, LDL-C, and apoB above recommended values. Since hypercholesterolemia is a modifiable risk factor, strategies to increase adherence to changes in lifestyle habits and medication need to be urgently discussed.

MiR-99a-5p up-regulates LDLR and functionally enhances LDL-C uptake via suppressing PCSK9 expression in human hepatocytes

Background

MicroRNAs (miRs/miRNAs) play pivotal roles in modulating cholesterol homeostasis. Proprotein convertase subtilisin/kexin type 9 (PCSK9) binds to low-density lipoprotein receptor (LDLR) at the surface of hepatocytes and accelerates its degradation in lysosomes, thereby impairing the clearance of circulating low-density lipoprotein cholesterol (LDL-C) from plasma. Thus, suppressing PCSK9 expression level has become an effective approach for treating hypercholesterolemia. Here, we sought to identify novel miRNAs that inhibit PCSK9 expression.

Methods

By in silico analyses, miR-99a-5p was predicted to bind to human PCSK9 mRNA. Following transfection of miR-99a-5p or anti-miR-99a-5p in human and mouse hepatocytes, qRT-PCR, Western blot, immunofluorescence, ELISA, flow cytometry, LDL-C uptake, and cellular cholesterol measurement were performed.

Results

miR-99a-5p overexpression potently inhibited PCSK9 expression, thereby up-regulating LDLR, functionally enhancing LDL-C uptake and increasing intracellular cholesterol levels in human, but not in mouse, cells. Conversely, anti-miR-99a-5p upregulates PCSK9, leading to a reduction in LDLR, attenuation of LDL-C uptake, and a decrease in the intracellular cholesterol levels of human hepatocytes. Furthermore, miR-99a-5p was shown to bind to the predicted target site "UACGGGU" in the 3'-UTR of human PCSK9 mRNA via a luciferase reporter assay in combination with site-directed mutagenesis.

Conclusion

MiR-99a-5p potently downregulates the expression of PCSK9 by directly interacting with a target site in the human PCSK9 3'-UTR, thereby up-regulating LDLR and functionally enhancing LDL-C uptake in human hepatocytes. MiR-99a-5p could serve as an inhibitor of PCSK9 for treating hypercholesterolemia to inhibit atherosclerosis.

Statin-Associated Muscle Symptoms: Identification and Recommendations for Management

PURPOSE OF REVIEW

Statins are first-line pharmacotherapy for the treatment of elevated low-density lipoprotein cholesterol and are generally well-tolerated. However, some patients may experience statin-associated muscle symptoms (SAMS). This paper reviews recommendations for identification and management of patients with SAMS.

RECENT FINDINGS

The National Lipid Association and other professional societies have issued guidance to assist clinicians in identifying and managing patients with partial or complete statin intolerance. The most common reason for intolerance is SAMS. This review discusses strategies to achieve therapeutic objectives for atherogenic lipoprotein management in patients with SAMS. Many patients who experience SAMS can tolerate some degree of statin therapy and non-statin medications are available as adjunctive or alternative treatments. With a thorough clinician-patient discussion and shared decision-making, a treatment plan can be identified to achieve therapeutic objectives and reduce the risk of atherosclerotic cardiovascular disease.

Effectiveness of treat-to-target cholesterol-lowering interventions on cardiovascular disease and all-cause mortality risk in the community-dwelling population: a target trial emulation

Little is known about the long-term effectiveness of risk-based treat-to-target cholesterol-lowering interventions on cardiovascular risk. Here, we show the emulated effectiveness of guideline-recommended low-density and non-high-density lipoprotein cholesterol-lowering interventions using the absolute risk reduction (ARR) and the restricted mean event-free time-based number needed to treat (NNT). With 5,375 participants, the 29-year risks for cardiovascular disease (CVD), all-cause mortality, and atherosclerotic CVD were 18.6%, 25.6%, and 17.7%, respectively. Long-term treat-to-target interventions showed significant reductions in CVD (ARR -2.3%, 95%CI -3.4% to -0.8%; NNT 115), all-cause mortality (-3.0%, -4.3% to -1.8%; 95), and atherosclerotic CVD (-2.6%, -3.5% to -1.2%; 104). Such effects appear more pronounced in women, smokers, and those with body mass index < 24 kg/m² or higher adherence rates.

The Emerging Potential of Apolipoprotein C-III Inhibition for ASCVD Prevention: A State-of-the-Art Review

PURPOSE OF REVIEW

Multiple agents are being developed that inhibit apolipoprotein (apo) C-III. This state-of-the-art review examines their potential for atherosclerotic cardiovascular disease (ASCVD) risk reduction.

RECENT FINDINGS

Apo C-III, an apolipoprotein on the surface of triglyceride-rich lipoproteins (TRLs), impairs clearance of TRLs through both lipoprotein lipase dependent and independent pathways, thereby resulting in increased concentrations of triglycerides. Apo C-III has also been shown to have pro-atherogenic effects when bound to high-density lipoprotein (HDL) particles. Classical and genetic epidemiology studies provide support for the concept that apo C-III is associated with an increased risk of ASCVD events. Drug efficacy of agents that silence APOC3 mRNA has been studied in populations with varying hypertriglyceridemia severity, including those with familial chylomicronemia syndrome, multifactorial chylomicronemia syndrome/severe hypertriglyceridemia, and mixed hyperlipidemia. Randomized controlled trials have reported significant reductions in TG and non-HDL cholesterol levels among these patients treated with APOC3 inhibitors. Upcoming clinical outcomes trials seek to establish a role for APOC3 inhibitors to reduce risk of ASCVD.

A review on the treatment of hyperlipidemia with Erchen Decoction

Hyperlipidemia, commonly referred to as dyslipidemia, is characterized by elevated serum cholesterol and/or triglyceride levels. This condition contributes significantly to the high mortality rates associated with cardiovascular diseases, posing a serious threat to global health. Although statins remain the predominant pharmacological treatment for hyperlipidemia, their associated side effects have led to a growing interest in alternative therapeutic approaches. Traditional Chinese Medicine (TCM) is exploring these alternatives, with the Erchen Decoction (ECD) emerging as a promising candidate. This review aims to summarize current clinical research, elucidate the mechanisms of action, and assess the compatibility of ECD in the management of hyperlipidemia. By doing so, we hope to provide valuable insights and references for clinical practice and future research.

Recaticimab as Add-On Therapy to Statins for Nonfamilial Hypercholesterolemia: The Randomized, Phase 3 REMAIN-2 Trial

BACKGROUND

Currently available antiproprotein convertase subtilisin/kexin type 9 monoclonal antibodies can effectively decrease low-density lipoprotein cholesterol (LDL-C) levels, but require frequent dosing. Recaticimab is a novel humanized monoclonal antibody against proprotein convertase subtilisin/kexin type 9. In a phase 1b/2 trial, recaticimab as add-on to stable statins showed robust LDL-C reduction with a dosing interval up to every 12 weeks (Q12W) in patients with hypercholesterolemia.

OBJECTIVES

REMAIN-2 (REcaticiMab Add-on therapy In patients with Nonfamilial hypercholesterolemia) aimed to assess the efficacy and safety of 48-week treatment with recaticimab as add-on therapy to statins in nonfamilial hypercholesterolemia.

METHODS

REMAIN-2 was a multicenter, randomized, double-blind, placebo-controlled, phase 3 trial. During the run-in period, patients received stable moderate or high-intensity statin, with or without cholesterol absorption inhibitors (ezetimibe) or fenofibrate, for ≥4 weeks. Patients with an LDL-C of ≥1.8 mmol/L (if with atherosclerotic cardiovascular disease [ASCVD]) or ≥2.6 mmol/L (if without ASCVD) were then randomized (2:2:2:1:1:1) to receive recaticimab 150 mg every 4 weeks (Q4W), 300 mg every 8 weeks (Q8W), or 450 mg Q12W, or matching placebo injections (Q4W, Q8W, or Q12W) for 48 weeks. The primary efficacy endpoint was percentage change from baseline to week 24 in LDL-C level.

RESULTS

A total of 689 randomly assigned patients received treatment (mean age, 55.8 years; male, 64.4%; ASCVD history, 69.5%; concomitant ezetimibe, 11.2%; mean baseline LDL-C, 2.8 mmol/L). Percentage change in LDL-C from baseline to week 24 was significantly more pronounced with recaticimab vs placebo (P < 0.0001), with least-squares mean differences of -62.2% (95% CI: -67.0% to -57.4%), -59.7% (95% CI: -65.0% to -54.4%), and -53.4% (95% CI: -58.7% to -48.2%) for the 150 mg Q4W, 300 mg Q8W, and 450 mg Q12W regimens, respectively. The decreases in LDL-C with recaticimab were maintained through week 48. Secondary lipid variables, including non-high-density lipoprotein cholesterol, apolipoprotein B, and lipoprotein(a) also favored the recaticimab groups. During the treatment period, the incidence of treatment-related adverse events (28.5% vs 26.6%) and serious treatment-related adverse events (0.4% vs 0.4%) was similarly low in both the recaticimab and placebo groups.

CONCLUSIONS

Recaticimab as add-on to stable statin therapy significantly decreased LDL-C levels at week 24 and sustained the decreases through week 48, providing a novel therapeutic alternative with a dosing interval of up to every 12 weeks in patients with nonfamilial hypercholesterolemia.

In-silico trial emulation to predict the cardiovascular protection of new lipid-lowering drugs: an illustration through the design of the SIRIUS programme

INTRODUCTION

Inclisiran, an siRNA targeting hepatic PCSK9 mRNA, administered twice-yearly (after initial and 3-month doses), substantially and sustainably reduced LDL-cholesterol (LDL-C) in Phase III trials. Whether lowering LDL-C with inclisiran translates into a reduced risk of major adverse cardiovascular events (MACE) is not yet established. In-silico trials applying a disease computational model to virtual patients receiving new treatments allow to emulate large scale long-term clinical trials. The SIRIUS in-silico trial programme aims to predict the efficacy of inclisiran on CV events in individuals with established atherosclerotic cardiovascular disease (ASCVD).

METHODS AND RESULTS

A knowledge-based mechanistic model of ASCVD was built, calibrated, and validated to conduct the SIRIUS programme (NCT05974345) aiming to predict the effect of inclisiran on CV outcomes. The SIRIUS Virtual Population included patients with established ASCVD (previous myocardial infarction (MI), previous ischemic stroke (IS), previous symptomatic lower limb peripheral arterial disease (PAD) defined as either intermittent claudication with ankle-brachial index <0.85, prior peripheral arterial revascularization procedure, or vascular amputation) and fasting LDL-C ≥ 70 mg/dL, despite stable (≥4 weeks) well-tolerated lipid-lowering therapies.SIRIUS is an in-silico multi-arm trial programme. It follows an idealized crossover design where each virtual patient is its own control, comparing inclisiran to (i) placebo as adjunct to high-intensity statin therapy with or without ezetimibe, (ii) ezetimibe as adjunct to high-intensity statin therapy, (iii) evolocumab as adjunct to high-intensity statin therapy and ezetimibe.The co-primary efficacy outcomes are based on the time to the first occurrence of any component of 3P-MACE (composite of CV death, nonfatal MI, or nonfatal IS) and time to occurrence of CV death over 5 years.

PERSPECTIVES/CONCLUSION

The SIRIUS in-silico trial programme will provide early insights regarding potential effect of inclisiran on MACE in ASCVD patients, several years before the availability of the results from ongoing CV outcomes trials (ORION-4 and VICTORION-2-P).

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT05974345.

Current treatments for the management of homozygous familial hypercholesterolaemia: a systematic review and commentary

AIMS

Homozygous familial hypercholesterolaemia (HoFH) is a rare disorder characterized by markedly elevated circulating low-density lipoprotein cholesterol (LDL-C) from birth. This review aimed to critically evaluate treatments for HoFH with respect to their efficacy, safety, accessibility, overall context and position within the treatment pathway.

METHODS AND RESULTS

A mixed-methods review was undertaken to systematically identify and characterize primary interventional studies on HoFH, with a focus on LDL-C reduction as the primary outcome. Interventions assessed were ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), lomitapide, evinacumab, with or without LDL apheresis. Twenty-six seminal studies reporting unique patient data were identified. Four studies were randomized controlled trials (RCTs) with the remainder being single-arm trials or observational registries. Data extracted were heterogeneous and not suitable for meta-analyses. Two RCTs, assessed at being low risk of bias, demonstrated PCSK9i were safe and moderately effective. A randomized controlled trial (RCT) demonstrated evinacumab was safe and effective in all HoFH subgroups. Lomitapide was reported to be efficacious in a single-arm trial, but issues with adverse events, tolerability, and adherence were identified. An RCT on ezetimibe showed it was moderately effective when combined with a statin. LDL apheresis was reported as effective, but its evidence base was at very high risk of bias. All interventions lowered LDL-C, but the magnitude of this, and certainty in the supporting evidence, varied.

CONCLUSION

In practice, multiple treatments are required to treat HoFH. The sequencing of these should be made on an individualized basis, with consideration made to the benefits of each intervention.

Use of combination therapy is associated with improved LDL cholesterol management: 1-year follow-up results from the European observational SANTORINI study

AIMS

To assess whether implementation of the 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) dyslipidaemia guidelines observed between 2020 and 2021 improved between 2021 and 2022 in the SANTORINI study.

METHODS AND RESULTS

Patients with high or very high cardiovascular (CV) risk were recruited across 14 European countries from March 2020 to February 2021, with 1-year prospective follow-up until May 2022. Lipid-lowering therapy (LLT) and 2019 ESC/EAS risk-based low-density lipoprotein (LDL) cholesterol (LDL-C) goal attainment (defined as <1.4 mmol/L for patients at very high CV risk and <1.8 mmol/L for patients at high CV risk) at 1-year follow-up were compared with baseline. Of 9559 patients enrolled, 9136 (2626 high risk and 6504 very high risk) had any available follow-up data, and 7210 (2033 high risk and 5173 very high risk) had baseline and follow-up LDL-C data. Lipid-lowering therapy was escalated in one-third of patients and unchanged in two-thirds. Monotherapy and combination therapy usage rose from 53.6 and 25.6% to 57.1 and 37.9%, respectively. Mean LDL-C levels decreased from 2.4 to 2.0 mmol/L. Goal attainment improved from 21.2 to 30.9%, largely driven by LLT use among those not on LLT at baseline. Goal attainment was greater with combination therapy compared with monotherapy at follow-up (39.4 vs. 25.5%).

CONCLUSION

Lipid-lowering therapy use and achievement of risk-based lipid goals increased over 1-year follow-up particularly when combination LLT was used. Nonetheless, most patients remained above goal; hence, strategies are needed to improve the implementation of combination LLT.

Lactobacillus johnsonii CCFM1376 improves hypercholesterolemia in mice by regulating the composition of bile acids

Aim: Strains with high bile salt hydrolase (BSH) activity have the potential to regulate cholesterol metabolism. This study aimed to assess the alleviating effect of Lactobacillus johnsonii (L. johnsonii) CCFM1376, a strain with high BSH activity, on mice with hypercholesterolemia and explore the mechanism of its effect through the modulation of bile acid metabolism. Methods: The BSH activity was measured using the ninhydrin method. C57BL/6J mice were given a high-cholesterol diet to induce hypercholesterolemia with simultaneous gavage of L. johnsonii CCFM1376 for 8 weeks. The biochemical parameters in the serum and liver of hypercholesterolemic mice were measured to assess the alleviating effect of L. johnsonii CCFM1376 on hypercholesterolemia. Bile acid content in the mouse liver, serum, distal ileum contents, and feces was determined using liquid chromatograph mass spectrometer (LC-MS). RNA was extracted from mouse ileum and liver, and the expression levels of relative genes implicated in bile acid metabolism were measured by quantitative real-time PCR (qPCR). Results: Compared to the model group, the group treated with L. johnsonii CCFM1376 exhibited significantly reduced levels of serum total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C), along with a significant increase in high density lipoproteins cholesterol (HDL-C) level. Moreover, hepatic levels of TC and LDL-C in the CCFM1376 group also decreased significantly. Furthermore, the content and amount of unconjugated bile acids in the hepatic-enteric circulation of the L. johnsonii CCFM1376 group significantly increased, and the total bile acid content in the feces also significantly increased. In the L. johnsonii CCFM1376 group, the relative expression levels of ileal farnesoid X receptor (FXR) and fibroblast growth factor 15 (FGF15) were downregulated, while the relative expression level of CYP7A1 was upregulated. Conclusion: These results indicated L. johnsonii CCFM1376 improves hypercholesterolemia in mice by regulating the composition of bile acids. This provides a reference for probiotic strategy to regulate cholesterol metabolism.