Inflammation, pravastatin, and the risk of coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events (CARE) Investigators

Chronic inflammatory muscle diseases and risk of coronary artery disease

Despite recent advancements in the treatment of coronary artery disease (CAD), it remains the commonest cause of death in the world. Although traditional risk factors partially account for the development of CAD, other novel risk factors have recently been implicated. Specifically, chronic inflammation has been postulated to play a role in the development and propagation of this disease. The purpose of this review is to examine the available evidence to determine if patients with chronic inflammatory muscle diseases have higher rates of cardiovascular disease.

Microalbuminuria and C-reactive protein as a predictor of coronary artery disease in patients of acute chest pain

Microalbuminuria is a risk factor for cardiovascular disease. It is gaining importance as a marker of atherogenic milieu and indicates the target organ damage and can be a valuable tool in screening and identification of patients with cardiovascular disease. Markers of inflammation, such as C-reactive protein (CRP), were found to be related to cardiovascular disease (CVD) events in patients with chest pain. In addition, recent studies have shown that, in the case of atherosclerosis, increased levels of CRP, reflects inflammatory condition of vessel wall. In the present study, CRP and microalbuminuria were estimated in patients of acute chest pain. The patients were divided into two study groups (gp-1 patients of chest pain with CVD and gp-2 patients of chest pain of causes other than CVD) along with one healthy control group. It was found that microalbuminuria was higher in CVD patients (RR = 6.250,95% CI 2.346-16.45,P < 0.05) and also CRP was much higher in CVD patients (RR = 13.667,95% CI 4.528-41.253, P < 0.05) as compared to other two groups. Sensitivity, specificity and positive predictive value of CRP and microalbuminuria were also higher in gp-1 (CVD) patients as compared to other two groups. Therefore, CRP and microalbuminuria can be used as important biomarkers in screening CVD.

Metabolic biomarkers for predicting cardiovascular disease

Cardiac and peripheral vascular biomarkers are increasingly becoming targets of both research and clinical practice. As of 2008, cardiovascular-related medical care accounts for greater than 20% of all the economic costs of illness in the United States. In the age of burgeoning financial pressures on the entire health care system, never has it been more important to try to understand who is at risk for cardiovascular disease in order to prevent new events. In this paper, we will discuss the cost of cardiovascular disease to society, clarify the definition of and need for biomarkers, offer an example of a current biomarker, namely high-sensitivity C-reactive protein, and finally examine the approval process for utilizing these in clinical practice.

Obesity and inflammation: epidemiology, risk factors, and markers of inflammation

Obesity is a public health problem that has reached epidemic proportions with an increasing worldwide prevalence. The global emergence of obesity increases the risk of developing chronic metabolic disorders. Thus, it is an economic issue that increased the costs of the comorbidities associated. Moreover, in recent years, it has been demonstrated that obesity is associated with chronic systemic inflammation, this status is conditioned by the innate immune system activation in adipose tissue that promotes an increase in the production and release of pro-inflammatory cytokines that contribute to the triggering of the systemic acute-phase response which is characterized by elevation of acute-phase protein levels. On this regard, low-grade chronic inflammation is a characteristic of various chronic diseases such as metabolic syndrome, cardiovascular disease, diabetes, hypertension, non-alcoholic fatty liver disease, and some cancers, among others, which are also characterized by obesity condition. Thus, a growing body of evidence supports the important role that is played by the inflammatory response in obesity condition and the pathogenesis of chronic diseases related.

Pentraxins in nephrology: C-reactive protein, serum amyloid P and pentraxin-3

Every clinician uses C-reactive protein (CRP) levels as a biomarker for systemic inflammation in acute disorders. Nephrologists also consider CRP levels as a predictor for overall mortality in patients with chronic kidney disease or end-stage renal disease. But what is the biological function of CRP? CRP is a member of the family of pentraxins, which are small pentameric innate immunity effector proteins. Pentraxins are absent or weakly expressed during homeostasis. However, the pro-inflammatory cytokines interleukin (IL)-1, IL-6 and tumour necrosis factor induce CRP and serum amyloid P (SAP) in hepatocytes, whereas the long pentraxins, such as pentraxin (PTX)-3, are produced in peripheral tissues and monocytic phagocytes. Pentraxins opsonize pathogens or other particles such as dead cells, for their phagocytic clearance or induce pathogen killing in extracellular compartments. In this review, we discuss the immunoregulatory properties of the different members of the pentraxin family. We discuss the evolving evidence demonstrating their roles in acute and chronic forms of kidney disease and the significance of SAP and PTX3 as additional biomarkers of innate immune activation and systemic inflammation.

Fenofibrate reduces C-reactive protein levels in hypertriglyceridemic patients with high risks for cardiovascular diseases

Background and Objectives

The effects of fenofibrate on C-reactive protein (CRP) are under debate. We investigated the effect of fenofibrate on CRP levels and the variables determining changes.

Subjects and Methods

This case-control study enrolled 280 hypertriglyceridemic patients who were managed either with 200 mg of fenofibrate (Fenofibrate group, n=140) or with standard treatment (comparison group, n=140). CRP levels were measured before and after management for 2 months.

Results

CRP levels decreased in both the fenofibrate (p=0.003) and comparison (p=0.048) groups. Changes in CRP levels were not significantly different between the two groups (p=0.27) and were negatively associated with baseline CRP levels (r=-0.47, p<0.001). In patients with a baseline CRP level ≥1 mg/L, CRP levels also decreased in both groups (p=0.000 and p=0.001 respectively), however, more in the fenofibrate group than in the comparison group (p=0.025). The reduction of CRP was associated with higher baseline CRP levels (r=-0.29, p=0.001), lower body mass index (BMI, r=0.23, p=0.007), and fenofibrate therapy (r=0.19, p=0.025). CRP levels decreased more in the fenofibrate group than in the comparison group in patients with a BMI ≤26 kg/m² with borderline significance (-1.21±1.82 mg/L vs. -0.89±1.92 mg/L, p=0.097). In patients with a high density lipoprotein-cholesterol level <40 mg/dL, CRP levels were reduced only in the fenofibrate group (p=0.006).

Conclusion

Fenofibrate reduced CRP levels in hypertriglyceridemic patients with high CRP and/or low high density lipoprotein-cholesterol levels and without severe overweight. This finding suggests that fenofibrate may have an anti-inflammatory effect in selected patients.

Effects of atorvastatin on human C-reactive protein metabolism

OBJECTIVE

Statins are known to reduce plasma C-reactive protein (CRP) concentrations. Our goal was to define the mechanisms by which CRP was reduced by maximal dose atorvastatin.

METHODS

Eight subjects with combined hyperlipidemia (5 men and 3 postmenopausal women) were enrolled in a randomized, placebo-controlled double-blind, cross over study. Subjects underwent a 15-h primed-constant infusion with deuterated leucine after 8 weeks of placebo and 80 mg/day of atorvastatin. CRP was isolated from lipoprotein deficient plasma, (density > 1.21 g/ml) by affinity chromatography. Isotopic enrichment was determined by gas chromatography/mass spectrometry. Kinetic parameters were determined using compartmental modeling. Paired t test and Wilcoxon signed ranks test were used to compare differences between placebo and atorvastatin.

RESULTS

Compared with placebo, atorvastatin decreased median CRP pool size by 28.4% (13.31 ± 3.78 vs 10.26 ± 3.93 mg; p = 0.16), associated with a median CRP fractional catabolic rate increase of 39.9% (0.34 ± 0.06 vs 0.50 ± 0.11 pools/day; p = 0.09), with no significant effect on median CRP production rate (0.050 ± 0.01 vs 0.049 ± 0.01 mg/kg/day; p = 0.78).

CONCLUSION

Our data indicate that maximal doses of atorvastatin lower plasma CRP levels by substantially decreasing the median CRP plasma residence time from 2.94 days to 2.0 days, with no significant effect on the median CRP production rate.

Molecular pathways regulating macrophage polarization: implications for atherosclerosis

Recent years have seen a tremendous development of our insight into the biology of atherosclerosis and its acute thrombotic manifestations. Inflammation now takes center stage among traditional risk factors as a decisive factor in cardiovascular risk. Consequently, its assessment and modulation have become key to clinical care and fundamental research alike. Plaque macrophages orchestrate many of the inflammatory processes that occur throughout atherogenesis. These cells are characteristically heterogeneous and adopt diverse activation states in response to micro-environmental triggers. In this review, macrophage-mediated inflammation in atherosclerosis sets the scene for a discussion of the gene regulatory mechanisms that facilitate and shape polarized macrophage phenotypes. When applicable, we consider these factors within the context of atherosclerosis and reflect on opportunities for future application.

PPARα as a therapeutic target in inflammation-associated diseases

INTRODUCTION

The nuclear receptor peroxisome proliferator-activated receptor alpha (PPARα) plays a major regulatory function of genes involved in energy metabolism and is a therapeutic target for dyslipidemia. The last decade provided a constellation of findings demonstrating that PPARα behaves as a modulator of both acute and chronic inflammation. PPARα became a rational potential therapeutic target for the treatment of inflammatory disorders.

AERAS COVERED

The ability of PPARα to control inflammatory signaling pathways via a diversity of molecular mechanisms is discussed. This review is especially focused on the global action of PPARα on inflammation in several tissues from data obtained in numerous cell types and in vivo models exposed to inflammatory stimuli.

EXPERT OPINION

Available PPARα agonists currently used in clinic belong to the class of hypolipidemic drugs but were not expected and not designed to act as anti-inflammatory drugs. To date, accumulating preclinical suggest evidence promising benefits when considering PPARα as a drug target to treat inflammatory disorders. However, clinical studies are needed to validate this concept. Drug design should also be directed toward the elaboration of PPARα agonists more specifically active in the control inflammatory signaling.

Lipoprotein-Associated Phospholipase A2

The role of inflammation in atherosclerosis continues to emerge. Lipoprotein-associated phospholipase A(2) (Lp-PLA(2)), a novel plasma biomarker, circulates in the blood bound mainly to low-density lipoprotein (LDL) and promotes vascular inflammation. Several epidemiological studies have shown that circulating levels of Lp-PLA(2) are an independent risk factor for cardiovascular events. Recent studies demonstrate that Lp-PLA(2) is also associated with endothelial dysfunction and early atherosclerosis. This review provides an overview of these studies, suggests plausible mechanisms for the association between endothelial dysfunction and Lp-PLA(2), and highlights future potential therapies.

Assessment of serum leptin, pregnancy-associated plasma protein A and CRP levels as indicators of plaque vulnerability in patients with acute coronary syndrome

INTRODUCTION

A multifactorial aetiology of coronary artery disease (CAD) has been established in the recent past. Extensive research is now underway to understand the mechanisms responsible for plaque vulnerability. The identification of a novel biomarker that will help in the assessment of plaque status is urgently needed for the purpose of patient stratification and prognostication. The aim of the present study was to evaluate leptin, pregnancy-associated plasma protein A (PAPP-A) and C-reactive protein (CRP) levels in patients with acute coronary syndrome and to assess their diagnostic efficacy in the identification of vulnerable plaques.

METHODS

The study group comprised 105 patients who had chest pain along with ECG changes (ST elevation, ST depression, T inversion) and raised cardiac enzyme levels. Sixty-two patients with chest pain and ECG changes but with normal cardiac enzyme profiles were included in the control group. Lipid profiles, and leptin, PAPP-A and CRP levels were assessed in these two groups. Receiver operating characteristics (ROC) curves were plotted to determine the utility of the parameters under study as markers of plaque vulnerability.

RESULTS

Significantly higher levels of serum lipoprotein (a), leptin, PAPP-A and high-sensitivity CRP (hs-CRP) were observed in the cases than in the controls. A positive correlation was observed between CRP and PAPP-A levels as well as CRP and leptin concentrations. ROC curve analysis revealed similar efficacies of CRP and PAPP-A levels in their ability to detect unstable plaques with areas under the curve of 0.762 and 0.732, respectively. Multivariate analysis established the superiority of hs-CRP as a predictor of plaque instability.

CONCLUSIONS

Our study highlights the utility of both CRP and PAPP-A levels as determinants of plaque instability. Our findings necessitate population-based follow-up studies to establish the superiority of either of the two biomarkers in the field of preventive cardiology.

Red cell distribution width, inflammatory markers and cardiorespiratory fitness: results from the National Health and Nutrition Examination Survey

AIMS

Cardiorespiratory fitness is an important predictor of cardiovascular morbidity and mortality. Both red cell distribution width (RDW) and inflammatory markers like C-reactive protein (CRP) have been shown to predict adverse outcomes in patients with heart disease.

METHODS

We utilized pooled data from NHANES 1999-2004 to assess cardiorespiratory fitness in healthy adults 12-49 years old using submaximal exercise. The primary outcome was the estimated maximal oxygen uptake (VO2max). Low fitness was defined as VO2max < 20th percentile of age- and gender-based reference category.

RESULTS

In our study, we estimated 21.2% of individuals had low fitness. Elevated RDW (>13%) was encountered in 20.4% subjects with low fitness as compared to 14.0% subjects in the control group (p < 0.001). Similarly, elevated CRP (>0.5 mg/dL) was found among 17.4% subjects with low fitness as compared to 12.4% subjects in the control group (p < 0.001). Adjusted analysis demonstrated a dose-response relationship between low cardiorespiratory fitness and increasing RDW or CRP.

CONCLUSION

In a large representative database of general US population, we observed a significant association between elevated RDW and elevated CRP with low cardiorespiratory fitness.

Association between high-sensitivity C-reactive protein with arterial stiffness in healthy Korean adults

BACKGROUND

The detection of preclinical arterial dysfunction may improve the ability to predict the subsequent risk of its outcomes and lead to optimal strategies to prevent overt vascular damage. The aim of this study was to investigate whether high high-sensitivity C-reactive protein (hsCRP) is associated with increased arterial stiffness in Korean adults.

METHODS

The association between the hsCRP and cardiac-ankle vascular index (CAVI) was evaluated in 1347 healthy adults. Multivariate logistic analyses were done to identify the association of the hsCRP levels and high CAVI (≥ 8.0).

RESULTS

The age and gender adjusted mean values of the CAVI were significantly higher in the intermediate and high hsCRP groups than in the low hsCRP group. For all the study subjects, an intermediate and high hsCRP was associated with a high CAVI after adjusting for covariates. However, this association was observed only in female subjects in gender-specific analyses and did not change after further adjustment for other variables.

CONCLUSIONS

Even within the normal range, a high hsCRP level was a predictor of high CAVI in healthy adult females. This finding suggests that the risk of arteriosclerosis may be high in females whose hsCRP level is > 0.1mg/dl even in low-risk females.

Biomarkers of chronic inflammatory state in uremia and cardiovascular disease

Cardiovascular disease is the leading cause of death in the general population; traditional risk factors seem inadequate to explain completely the remarkable prevalence of cardiovascular mortality and morbidity observed in the uremic population. A role for chronic inflammation has been well established in the development of atherosclerotic disease, and, on the basis of these observations, atherosclerosis might be considered an inflammatory disease. Inflammation has been implicated in the etiology of coronary artery disease in the general population, and traditional inflammatory biomarkers such as C-reactive protein (CRP) and interleukin-6 (IL-6) have been shown to predict cardiovascular events in both symptomatic and asymptomatic individuals as well as those in the uremic population. Later on, new nontraditional markers were related to the risk of cardiovascular morbidity and mortality in general and in uremic population. As a consequence of the expanding research base and availability of assays, the number of inflammatory marker tests ordered by clinicians for cardiovascular disease (CVD) risk prediction has grown rapidly and several commercial assays have become available. So, up to now we can consider that several new nontraditional markers as CD40-CD40 ligand system and pentraxin-3 seem to be significant features of cardiovascular disease in general and in ESRD population.

Statin therapy to reduce stent thrombosis in acute myocardial infarction patients with elevated high-sensitivity C-reactive protein

OBJECTIVE

We investigated whether statin therapy and high-sensitivity C-reactive protein (hs-CRP) levels were associated with the risk of stent thrombosis (ST) in acute myocardial infarction (AMI) patients.

METHODS

A total of 9,162 AMI patients who underwent coronary stent implantation were analyzed in the Korean Acute Myocardial Infarction Registry. The study population was divided into four groups according to level of hs-CRP and peri-procedural statin treatment: low hs-CRP (≤ 2.0mg/L) and high hs-CRP (>2mg/L) with or without statin therapy. We compared the incidence of early ST among the groups.

RESULTS

Statin therapy did not significantly affect the development of early ST in the low hs-CRP group. In the high hs-CRP group, however, the incidence of early ST was significantly decreased with statin treatment. In a subgroup analysis of the high hs-CRP group, patients aged less than 65 years, without diabetes, with a high body mass index, and with a high Killip class seemed to benefit more from statin therapy. In a multivariable Cox regression analysis of the high hs-CRP group, lack of statin therapy was a significant predictor of ST incidence.

CONCLUSIONS

Peri-procedural statin treatment had an effect on reduced incidence of early ST in AMI patients with high levels of hs-CRP.

Developing and assessing cardiovascular biomarkers

Atherosclerosis is a slow process that over time can lead to fatal events. Early identification and prediction of future risk can allow for preventive strategies to be instituted. There is an increasing interest in utilizing novel biomarkers in cardiovascular disease screening and management. These novel biomarkers may help in cardiovascular disease risk assessment and treatment monitoring, and some may be treatment targets. To be useful for risk prediction, novel biomarkers need to show a significant association with cardiovascular disease events and bring additional value in risk stratification when added to known risk prediction models. Biomarkers used for treatment monitoring need to show that they can serve as good surrogates of cardiovascular disease status. In this article, we present 3 biomarkers that are currently approved by the U.S. Food and Drug Administration for use in cardiovascular disease management and risk assessment: C-reactive protein, lipoprotein-associated phospholipase A2, and myeloperoxidase. Other new biomarkers have also been shown recently to help in cardiovascular disease risk prediction and management. In this article, we will review 2 of these new biomarkers: cardiac troponin T measured by a highly sensitive assay and brain natriuretic peptide.

Biomarkers in cardiovascular clinical trials: past, present, future

BACKGROUND

Cardiovascular (CV) clinical trials are instrumental in understanding treatment effects and offer insights into the natural progression of CV disease. Biomarkers are a critical component of patient selection, end point definition, and safety monitoring, and clinical trials provide a platform for the discovery and validation of new biomarkers that may augment the understanding of disease mechanisms, risk stratification, and/or clinical decision-making.

CONTENT

We review the roles that biomarkers have played in CV clinical trials and roles that CV clinical trials have played and will continue to play in the discovery and validation of biomarkers and their implementation in clinical practice. Large biobanks containing multiple specimen types are increasingly being created from patients enrolled in clinical trials, and such biobanks, when coupled with advances in molecular techniques and bioinformatics, promise to accelerate our understanding of CV disease mechanisms and to help fuel the discovery and development of novel therapeutic targets and biomarkers of risk and treatment response.

SUMMARY

The past, present, and future of biomarkers and clinical trials have been and will remain intertwined. Biomarkers were once the workhorses of patient selection and end point definition in clinical trials; more recently, clinical trials have been the proving ground for individual biomarkers. Attention to biobanking and the application of modern informatics and molecular techniques to samples collected within clinical trials will usher in the era of stratified and personalized medicine.

Clinical utility of inflammatory markers and advanced lipoprotein testing: advice from an expert panel of lipid specialists

The National Cholesterol Education Program Adult Treatment Panel guidelines have established low-density lipoprotein cholesterol (LDL-C) treatment goals, and secondary non-high-density lipoprotein (HDL)-C treatment goals for persons with hypertriglyceridemia. The use of lipid-lowering therapies, particularly statins, to achieve these goals has reduced cardiovascular disease (CVD) morbidity and mortality; however, significant residual risk for events remains. This, combined with the rising prevalence of obesity, which has shifted the risk profile of the population toward patients in whom LDL-C is less predictive of CVD events (metabolic syndrome, low HDL-C, elevated triglycerides), has increased interest in the clinical use of inflammatory and lipid biomarker assessments. Furthermore, the cost effectiveness of pharmacological intervention for both the initiation of therapy and the intensification of therapy has been enhanced by the availability of a variety of generic statins. This report describes the consensus view of an expert panel convened by the National Lipid Association to evaluate the use of selected biomarkers [C-reactive protein, lipoprotein-associated phospholipase A(2), apolipoprotein B, LDL particle concentration, lipoprotein(a), and LDL and HDL subfractions] to improve risk assessment, or to adjust therapy. These panel recommendations are intended to provide practical advice to clinicians who wrestle with the challenges of identifying the patients who are most likely to benefit from therapy, or intensification of therapy, to provide the optimum protection from CV risk.

Value and level of plasma homocysteine in patients with angina pectoris undergoing coronary angiographic study

This study tested whether the plasma level of total homocysteine (tHcy) was predictive of obstructive coronary artery disease (CAD) and clinical outcome in patients undergoing coronary angiographic (CAG) study. From September 2002 to October 2004, 1,305 consecutive patients with angina pectoris undergoing CAG study were consecutively enrolled. Blood samples were prospectively collected to assess the plasma level of tHcy from each patient before catheterization. Of these 1305 patients, 676 (51.8%) had multivessel disease (group 1), 367 (28.1%) had single-vessel disease (group 2), and 262 (20.1%) had normal coronary artery or insignificant coronary artery disease (group 3). The plasma level of tHcy was notably higher in group 1 than in groups 2 and 3 (11.6 ± 4.4 versus 10.9 ± 4.0 versus 10.4 ± 3.8, P < 0.001). Univariate binary logistic regression analysis demonstrated that the plasma tHcy level was strongly associated with multiple-vessel disease (MVD) (defined as ≥ 2 vessel disease) (P < 0.001). Multivariate binary logistic regression analysis showed that tHcy level, fasting blood sugar, diabetes mellitus, and age were significantly and independently predictive of MVD (all P < 0.03). Univariate Cox regression analysis demonstrated that tHcy level was predictive of long-term mortality (P = 0.042). However, the tHcy level was not an independent predictor of long-term mortality on multivariate Cox regression analysis (P > 0.05). The results of our study support the hypothesis that tHcy level is an independent predictor of MVD in patients with chest pain undergoing CAG study. Conversely, our study did not support the tHcy level as an independent predictor of long-term mortality in this clinical setting.

Interleukin-1β inhibition and the prevention of recurrent cardiovascular events: rationale and design of the Canakinumab Anti-inflammatory Thrombosis Outcomes Study (CANTOS)

BACKGROUND

Inflammation contributes to all phases of the atherothrombotic process, and patients with elevated inflammatory biomarkers such as high-sensitivity C-reactive protein (hsCRP) have increased vascular risk. Yet, it remains unknown whether direct inhibition of inflammation will reduce cardiovascular event rates.

DESIGN

The CANTOS will evaluate whether interleukin-1β (IL-1β) inhibition as compared with placebo can reduce rates of recurrent myocardial infarction, stroke, and cardiovascular death among stable patients with coronary artery disease who remain at high vascular risk due to persistent elevations of hsCRP (>2 mg/L) despite contemporary secondary prevention strategies. Canakinumab is a human monoclonal antibody that selectively neutralizes IL-1β, a proinflammatory cytokine that plays multiple roles in the atherothrombotic process and that undergoes activation by the nucleotide-binding leucine-rich repeat-containing pyrin receptor 3 inflammasome, a process promoted by cholesterol crystals. Canakinumab significantly reduces systemic C-reactive protein and other inflammatory biomarker levels, is generally well tolerated, and is currently indicated for the treatment of inherited IL-1β driven inflammatory diseases such as the Muckle-Wells syndrome. In a multinational collaborative effort using an event-driven intention-to-treat protocol, CANTOS will randomly allocate 17,200 stable postmyocardial infarction patients with persistent elevation of hsCRP to either placebo or to canakinumab at doses of 50, 150, or 300 mg every 3 months, administered subcutaneously. All participants will be followed up over an estimated period of up to 4 years for the trial primary end point (nonfatal myocardial infarction, nonfatal stroke, cardiovascular death) as well as for other vascular events, total mortality, adverse events, and specific clinical end points associated with inflammation including new onset diabetes, venous thrombosis, and atrial fibrillation.

SUMMARY

If positive, CANTOS would confirm the inflammatory hypothesis of atherothrombosis and provide a novel cytokine-based therapy for the secondary prevention of cardiovascular disease and new-onset diabetes.

The vascular effects of infection in Pediatric Stroke (VIPS) Study

Understanding the vascular injury pathway is crucial to developing rational strategies for secondary stroke prevention in children. The multicenter Vascular Effects of Infection in Pediatric Stroke (VIPS) cohort study will test the hypotheses that (1) infection can lead to childhood arterial ischemic stroke by causing vascular injury and (2) resultant arteriopathy and inflammatory markers predict recurrent stroke. The authors are prospectively enrolling 480 children (aged 1 month through 18 years) with arterial ischemic stroke and collecting extensive infectious histories, blood and serum samples (and cerebrospinal fluid, when clinically obtained), and standardized brain and cerebrovascular imaging studies. Laboratory assays include serologies (acute and convalescent) and molecular assays for herpesviruses and levels of inflammatory markers. Participants are followed prospectively for recurrent ischemic events (minimum of 1 year). The analyses will measure association between markers of infection and cerebral arteriopathy and will assess whether cerebral arteriopathy and inflammatory markers predict recurrent stroke.

Inflammation as a marker for the prediction of internal carotid artery restenosis following eversion endarterectomy--evidence from clinical studies

The role of inflammation is well established in the pathogenesis of atherosclerosis and an increased level of circulating inflammatory markers may predict the future risk of atherosclerosis progression and plaque rupture. C-reactive protein (CRP) identification by hypersensitive methods (high-sensitivity CRP [hsCRP]) has become a clinical and laboratory inflammation marker. Carotid endarterectomy (CEA) is a well-established procedure for carotid stenosis treatment which can reduce stroke rate. Internal carotid artery (ICA) restenosis reduction may be prevented by the anti-inflammatory effect of statins. This review considers the recent findings on the presence of hsCRP and C3 complement concentration and inflammatory plaque composition as well as their effects on ICA restenosis rate, following eversion CEA with emphasis on human studies.

Vascular Dysfunction in Short-Term Hypercholesterolemia despite the Absence of Atherosclerotic Lesions

INTRODUCTION

The atherosclerotic effect of hypercholesterolemia on the vascular function is well-known. However, limited studies were done on the effect of hypercholesterolemia without atherosclerotic lesion on the vascular compliance. The aim of this study was to investigate the effects of hyperlipidemia induced by cholesterol rich diet on vessel function in isolated rat aorta in the absence of atherosclerotic lesion.

METHODS

Male wistar rats were randomly divided into 3 groups of 6 animals in each. The rats in normal control group were fed a standard laboratory diet and two other groups were fed a high fat diet for 36 days. A group of high fat fed rats was treated orally with Lovastatin started at day of 16 and continued for last 20 days of the experimental period. At the end of the experiment, inferior vena cava blood was collected to measure the lipid levels and the thoracic aorta was excised and used for isolated vessel preparation and histological study.

RESULTS

The results of this study indicated that high-cholesterol diet significantly increased total cholesterol and LDL levels in serum (p<0.001). The increase in the serum levels of cholesterol was associated with a profound reduction of endothelium dependent vasodilatation of the thoracic aorta. However, in histopathological study no atherosclerotic lesion was observed. Short-term treatment by Lovastatin (10 mg/kg/day) produced a significant reduction (p<0.05) in the level of total cholesterol and LDL. The endothelium-dependent vasodilatation was improved significantly (P<0.01) by Lovastatin as an anti-hyperlipidemic drug.

CONCLUSION

Hypercholesterolemia is associated with endothelial dysfunction in aorta, despite the absence of atherosclerotic lesions.

Inflammatory concepts of obesity

Obesity, long considered a condition characterized by the deposition of inert fat, is now recognized as a chronic and systemic inflammatory disease, where adipose tissue plays a crucial endocrine role through the production of numerous bioactive molecules, collectively known as adipokines. These molecules regulate carbohydrate and lipid metabolism, immune function and blood coagulability, and may serve as blood markers of cardiometabolic risk. Local inflammatory loops operate in adipose tissue as a consequence of nutrient overload, and crosstalk among its cellular constituents-adipocytes, endothelial and immune cells-results in the elaboration of inflammatory mediators. These mediators promote important systemic effects that can result in insulin resistance, dysmetabolism and cardiovascular disease. The understanding that inflammation plays a critical role in the pathogenesis of obesity-derived disorders has led to therapeutic approaches that target different points of the inflammatory network induced by obesity.

Effect of statins on cholesterol crystallization and atherosclerotic plaque stabilization

Pleiotropic effects of statins have not been fully elucidated. Recently we demonstrated that cholesterol expands when crystallizing and may trigger plaque rupture. The present study evaluated the potential direct effects of statins in altering cholesterol crystallization as a possible mechanism for plaque stabilization independent of cholesterol lowering. Cholesterol powder was dissolved in oil with and without pravastatin, simvastatin, or atorvastatin (10 to 90 mg) and then allowed to crystallize to measure peak volume expansion (ΔVE) in graduated cylinders. Effect of ΔVE on fibrous membrane damage was also evaluated. Human coronary, carotid, and peripheral arterial plaques (65 plaques from 55 patients) were incubated with statin or saline solution using matched plaque segments to evaluate direct effects of statins on preformed crystals. Also, the effect of in vivo use of oral statins on crystal structure was examined by scanning electron microscopy and crystal content in plaques scored from 0 to +3. For all statins, ΔVE decreased significantly in a dose-dependent fashion (0.76 ± 0.1 vs 0 ml at 60 mg, p <0.001). By scanning electron microscopy crystal structure with statins had loss of pointed tip geometries, averting fibrous membrane damage. Cholesterol crystal density was markedly decreased and appeared dissolved in human plaques incubated with statins (+2.1 ± 1.1 vs +1.3 ± 1.0, p = 0.0001). Also, plaques from patients taking oral statins compared to controls had significantly more dissolving crystals (p = 0.03). In conclusion, statins decreased ΔVE by altering cholesterol crystallization and blunting sharp-tipped crystal structure and dissolving cholesterol crystals in human arteries in vivo and in vitro, providing plaque stabilization.

Statins for acute coronary syndrome

BACKGROUND

The early period following the onset of acute coronary syndromes (ACS) represents a critical stage of coronary heart disease with a high risk for recurrent events and deaths. The short-term effects of early treatment with statins in patients suffering from ACS on patient-relevant outcomes are unclear.

OBJECTIVES

To assess the benefits and harms of early administered statins in patients with ACS from randomized controlled trials (RCTs).

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE, and CINAHL (to 1 February 2010). No language restrictions were applied. We supplemented the search by contacting experts in the field, by reviewing reference lists of reviews and editorials on the topic, and by searching trial registries.

SELECTION CRITERIA

RCTs comparing statins with placebo or usual care, initiation of statin therapy within 14 days following the onset of ACS, and follow-up of at least 30 days reporting at least one clinical outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. We pooled treatment effects and calculated risk ratios (RRs) for all outcomes in the treatment and control groups using a random effects model.

MAIN RESULTS

Eighteen studies (14,303 patients) compared early statin treatment versus placebo or usual care in patients with ACS. Compared to placebo or usual care, early statin therapy did not decrease the combined primary outcome of death, non-fatal myocardial infarction (MI), and stroke at one month (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.80 to 1.08) and four months (RR 0.93, 95% CI 0.81 to 1.06) of follow-up. There were no statistically significant risk reductions from statins for total death, total MI, total stroke, cardiovascular death, revascularization procedures, and acute heart failure at one month and at four months, although there were favorable trends related to statin use for each of these endpoints. The incidence of episodes of unstable angina was significantly reduced at four months following ACS (RR 0.76, 95% CI 0.59 to 0.96). There were nine individuals with myopathy (elevated creatinine kinase levels > 10 times the upper limit of normal) in statin treated patients (0.13%) versus one (0.015%) in the control groups. Serious muscle toxicity was mostly limited to patients treated with simvastatin 80 mg.

AUTHORS' CONCLUSIONS

Based on available evidence, initiation of statin therapy within 14 days following ACS does not reduce death, myocardial infarction, or stroke up to four months, but reduces the occurrence of unstable angina at four months following ACS.

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

BACKGROUND AND OBJECTIVES

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

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

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

RESULTS

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

CONCLUSIONS

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

Pleiotropic effects of statins: evidence for benefits beyond LDL-cholesterol lowering

Evidence is mounting that 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) have a number of pleiotropic effects over and above their lipid-lowering properties in patients with cardiovascular disease and heart failure. In addition to lowering low-density lipoprotein cholesterol and triglyceride levels, several studies have shown statins to improve survival and reduce the risk of major cardiovascular events in patients without established cardiovascular disease but with cardiovascular risk factors. Statins have also been shown to have beneficial effects, including a reduction in all-cause mortality, in patients with ischemic and non-ischemic congestive heart failure, and have been associated with a reduced incidence of atrial fibrillation. Furthermore, statins have been associated with improvements in renal function in patients with pre-existing renal disease or the prevention of new-onset renal dysfunction, as well as improvements in lung function in patients with chronic obstructive pulmonary disease or age-related decline in lung function. The pleiotropic effects of statins appear to result from improvements in endothelial function, a reduction in inflammatory mediators, a decline in the development of atheroma through the stabilization of atheromatous plaques, and the inhibition of cardiac hypertrophy through an antioxidant mechanism. Long-term statin use may reduce morbidity and mortality rates in a broad range of patients, and most patients at high risk of cardiovascular disease may benefit from statin treatment; however, further data are required to demonstrate conclusively whether these trends are truly independent of the lipid-lowering effects of statins.

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

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