Coronary heart disease, hypercholesterolemia, and atherosclerosis. I. False premises

The Lipid-Heart Hypothesis and the Keys Equation Defined the Dietary Guidelines but Ignored the Impact of Trans-Fat and High Linoleic Acid Consumption

In response to a perceived epidemic of coronary heart disease, Ancel Keys introduced the lipid-heart hypothesis in 1953 which asserted that high intakes of total fat, saturated fat, and cholesterol lead to atherosclerosis and that consuming less fat and cholesterol, and replacing saturated fat with polyunsaturated fat, would reduce serum cholesterol and consequently the risk of heart disease. Keys proposed an equation that would predict the concentration of serum cholesterol (ΔChol.) from the consumption of saturated fat (ΔS), polyunsaturated fat (ΔP), and cholesterol (ΔZ): ΔChol. = 1.2(2ΔS - ΔP) + 1.5ΔZ. However, the Keys equation conflated natural saturated fat and industrial trans-fat into a single parameter and considered only linoleic acid as the polyunsaturated fat. This ignored the widespread consumption of trans-fat and its effects on serum cholesterol and promoted an imbalance of omega-6 to omega-3 fatty acids in the diet. Numerous observational, epidemiological, interventional, and autopsy studies have failed to validate the Keys equation and the lipid-heart hypothesis. Nevertheless, these have been the cornerstone of national and international dietary guidelines which have focused disproportionately on heart disease and much less so on cancer and metabolic disorders, which have steadily increased since the adoption of this hypothesis.

Wearable Flexible Electronics Based Cardiac Electrode for Researcher Mental Stress Detection System Using Machine Learning Models on Single Lead Electrocardiogram Signal

In the modern world, wearable smart devices are continuously used to monitor people's health. This study aims to develop an automatic mental stress detection system for researchers based on Electrocardiogram (ECG) signals from smart T-shirts using machine learning classifiers. We used 20 subjects, including 10 from mental stress (after twelve hours of continuous work in the laboratory) and 10 from normal (after completing the sleep or without any work). We also applied three scoring techniques: Chalder Fatigue Scale (CFS), Specific Fatigue Scale (SFS), Depression, Anxiety, and Stress Scale (DASS), to confirm the mental stress. The total duration of ECG recording was 1800 min, including 1200 min during mental stress and 600 min during normal. We calculated two types of features, such as demographic and extracted by ECG signal. In addition, we used Decision Tree (DT), Naive Bayes (NB), Random Forest (RF), and Logistic Regression (LR) to classify the intra-subject (mental stress and normal) and inter-subject classification. The DT leave-one-out model has better performance in terms of recall (93.30%), specificity (96.70%), precision (94.40%), accuracy (93.30%), and F1 (93.50%) in the intra-subject classification. Additionally, The classification accuracy of the system in classifying inter-subjects is 94.10% when using a DT classifier. However, our findings suggest that the wearable smart T-shirt based on the DT classifier may be used in big data applications and health monitoring. Mental stress can lead to mitochondrial dysfunction, oxidative stress, blood pressure, cardiovascular disease, and various health problems. Therefore, real-time ECG signals help assess cardiovascular and related risk factors in the initial stage based on machine learning techniques.

Atherosclerosis pathogenesis from the perspective of microvascular dysfunction

The article discusses different points of view on atherosclerosis development. The facts confirming the lipid hypothesis are presented. Attention is drawn to the possible participation of vasa vasorum in the development of atherosclerosis.

Effects of oxidative stress on blood pressure and electrocardiogram findings in workers with occupational exposure to lead

OBJECTIVE

To observe the correlation between the oxidative stress index and cardiovascular system damage in a population with lead exposure.

METHODS

Two populations (144 manufacturing workers and 94 administrators) from a lead-acid battery manufacturer in Shandong Province in China were recruited. The blood lead level, oxidative stress index, blood pressure, electrocardiogram findings, and their correlations were analyzed in both groups.

RESULTS

The blood lead level was significantly higher in manufacturing workers than administrators (254.34 vs. 65.32 µg/L, respectively). The differences in the oxidative stress index, serum total superoxide dismutase (T-SOD) concentration, and malondialdehyde (MDA) concentration between the two populations were statistically significant. The rates of abnormal blood pressure and electrocardiogram findings were significantly higher in manufacturing workers than administrators. Workers with middle- and high-dose lead exposure had lower T-SOD and higher MDA concentrations than those with low-dose lead exposure. Significant correlations were found between the blood lead level and the MDA concentration, systolic pressure, diastolic pressure, and electrocardiogram findings. Linear multiple regression analysis showed that T-SOD was negatively associated with blood lead, electrocardiogram findings, and MDA.

CONCLUSION

Lead exposure can lead to oxidative stress, increased blood pressure, and abnormal electrocardiogram findings and may impact cardiovascular diseases through oxidative stress.

Interference effect of oral administration of mulberry branch bark powder on the incidence of type II diabetes in mice induced by streptozotocin

Background

Diabetes is a group of metabolic diseases that has become a global health problem worldwide. Many researchers have found that mulberry branches have a hypoglycemic effect, but there have been few studies or investigations regarding the use of mulberry branches to prevent the incidence of diabetes.

Objective

This study aimed to investigate the potential preventive effect of mulberry branch bark powder (MBBP) from Morus multicaulis L against type II diabetes in mice induced by streptozotocin (STZ).

Design

The normal mice were fed a diet containing 2.5, 5.0, and 10.0%, MBBP, respectively, for 2 weeks. After that, STZ (100 mg/kg) was injected into the caudal vein of these mice. These mice continued to be fed the same diet, and the fasting blood glucose (FBG) levels were monitored on the 17th and 21st days.

Results

Oral administration of MBBP could effectively inhibit weight loss and maintain the FBG level. The incidence of diabetes in mice was almost inhibited by treatment with 10% MBBP. MBBP could also maintain the original antioxidant capacity and regulate the lipid metabolism in mice. An immunohistochemical assay showed that MBBP could prevent the injury of the insulin-secreting islet beta cells induced by STZ. RT-PCR also confirmed that the mRNA expression of the genes PI3K, Pdk1, Akt, and FoxO1, which were involved in the PI3K/Akt signaling pathway, hardly suffered from STZ in the 10% MBBP-dose group.

Conclusions

Our results indicate that powdered mulberry branch bark has a powerful anti-diabetic effect. These results clearly illustrated that MBBP has a potential use as a health food additive in the prevention of diabetes.

Lipids and cardiovascular disease: where does dietary intervention sit alongside statin therapy?

The Seven Countries Study suggested an association between serum cholesterol and cardiovascular disease (CVD). However, the association was not consistent across the various cohorts of participants in different countries; while it was very clear in US and Northern European cohorts, it was weak in Southern European and Japanese cohorts. Nevertheless, the study triggered research into cholesterol-lowering drug strategies, ultimately leading to the development of statins amongst others. Clinical evidence in support of statins is strong and the vast majority of the medical community advocate these drugs as highly effective first-line therapeutics in primary and secondary prevention of CVD. However, growing evidence of side-effects associated with statins in a significant proportion of patients suggests that these drugs are not a universal solution to CVD. There is a need, therefore, to revisit the evidence and to re-appraise the relative importance of cholesterol amongst many other lipids as potential modulators of atherogenesis. In this review, we assess the relative merits of statin therapy in CVD versus dietary interventions that impact on lipids other than cholesterol, including omega-3 fatty acids and polar lipid fractions of various foods (e.g. fish and olive oil). We conclude that careful design around the lipid components of dietary interventions presents a credible alternative in patients who are intolerant to statins or averse to taking such drugs.

Might the beneficial effects of statin drugs be related to their action on iron metabolism?

Although the cholesterol-heart hypothesis is often regarded as a dogmatic belief, controversy continues to surround the aetiology and pathogenesis of atherosclerosis. In fact, lowering cholesterol with statin drugs has been shown to reduce cardiovascular risk. However, statins have pleiotropic effects independent of their capacity to lower cholesterol. We highlight that statin drugs exert an important action on iron metabolism, which in turn may prevent progression and destabilization of atherosclerotic plaque. If it is found that the effect of statins on iron metabolism is a mechanism of their beneficial action, this consequence of statin use can be clinically replicated by other methods, such as controlled reduction of body iron stores. This might allow the use of lower doses or even obviate the use of statins in primary cardiovascular prevention, and therefore avoid the side effects and expense of these drugs.

Neovascularization of coronary tunica intima (DIT) is the cause of coronary atherosclerosis. Lipoproteins invade coronary intima via neovascularization from adventitial vasa vasorum, but not from the arterial lumen: a hypothesis

BACKGROUND

An accepted hypothesis states that coronary atherosclerosis (CA) is initiated by endothelial dysfunction due to inflammation and high levels of LDL-C, followed by deposition of lipids and macrophages from the luminal blood into the arterial intima, resulting in plaque formation. The success of statins in preventing CA promised much for extended protection and effective therapeutics. However, stalled progress in pharmaceutical treatment gives a good reason to review logical properties of the hypothesis underlining our efforts, and to reconsider whether our perception of CA is consistent with facts about the normal and diseased coronary artery.

ANALYSIS

To begin with, it must be noted that the normal coronary intima is not a single-layer endothelium covering a thin acellular compartment, as claimed in most publications, but always appears as a multi-layer cellular compartment, or diffuse intimal thickening (DIT), in which cells are arranged in many layers. If low density lipoprotein cholesterol (LDL-C) invades the DIT from the coronary lumen, the initial depositions ought to be most proximal to blood, i.e. in the inner DIT. The facts show that the opposite is true, and lipids are initially deposited in the outer DIT. This contradiction is resolved by observing that the normal DIT is always avascular, receiving nutrients by diffusion from the lumen, whereas in CA the outer DIT is always neovascularized from adventitial vasa vasorum. The proteoglycan biglycan, confined to the outer DIT in both normal and diseased coronary arteries, has high binding capacity for LDL-C. However, the normal DIT is avascular and biglycan-LDL-C interactions are prevented by diffusion distance and LDL-C size (20 nm), whereas in CA, biglycan in the outer DIT can extract lipoproteins by direct contact with the blood. These facts lead to the single simplest explanation of all observations: (1) lipid deposition is initially localized in the outer DIT; (2) CA often develops at high blood LDL-C levels; (3) apparent CA can develop at lowered blood LDL-C levels. This mechanism is not unique to the coronary artery: for instance, the normally avascular cornea accumulates lipoproteins after neovascularization, resulting in lipid keratopathy.

HYPOTHESIS

Neovascularization of the normally avascular coronary DIT by permeable vasculature from the adventitial vasa vasorum is the cause of LDL deposition and CA. DIT enlargement, seen in early CA and aging, causes hypoxia of the outer DIT and induces neovascularization. According to this alternative proposal, coronary atherosclerosis is not related to inflammation and can occur in individuals with normal circulating levels of LDL, consistent with research findings.

Low-fat diets for acquired hypercholesterolaemia

BACKGROUND

Hypercholesterolaemia, characterised by raised blood cholesterol levels, is not a disease itself but a metabolic derangement that often contributes to many diseases, notably cardiovascular disease. In most cases, elevated cholesterol levels are associated with high-fat diet, especially saturated fat, coupled with an inactive lifestyle. Less commonly, raised cholesterol may be related to an inherited disorder, familial hypercholesterolaemia. This systematic review is only concerned with acquired hypercholesterolaemia.

OBJECTIVES

To assess the effects of low-fat diets for acquired hypercholesterolaemia and to investigate the incidence of adverse effects from low-fat dietary interventions. We planned to compare the relative effectiveness of low-fat diets with calorie-restricted diets for acquired hypercholesterolaemia. We also wanted to look into the relative effectiveness of low-fat diets and pharmacological interventions for acquired hypercholesterolaemia.

SEARCH STRATEGY

Studies were obtained from computerised searches of The Cochrane Library, MEDLINE, EMBASE and databases of ongoing trials. Date of last search was February 2010.

SELECTION CRITERIA

Otherwise healthy adults (equal to or greater than 18 years) with acquired (not familial) hypercholesterolaemia. We defined hypercholesterolaemia as either total cholesterol greater than 5.2 mmol/L, LDL-cholesterol greater than 3.0 mmol/L, HDL-cholesterol less than 1.0 mmol/L or a combination thereof, although investigators' definitions were also accepted. We wanted to include any low-fat dietary intervention, like low-fat and low-saturated fat diets, intended to lower serum total and LDL-cholesterol or to raise HDL-cholesterol. A low-fat diet was considered as a fat calorie intake less than 20% of the total calories. The minimum duration of the intervention had to be six months. We excluded studies in unhealthy people.

DATA COLLECTION AND ANALYSIS

Two authors were planned to independently assess risk of bias and extract data.

MAIN RESULTS

No study met our inclusion criteria.

AUTHORS' CONCLUSIONS

Well designed, adequately powered randomised controlled trials investigating patient-relevant outcomes of low-fat diets for otherwise healthy people with hypercholesterolaemia are required.

Analysis of arterial intimal hyperplasia: review and hypothesis

BACKGROUND

Despite a prodigious investment of funds, we cannot treat or prevent arteriosclerosis and restenosis, particularly its major pathology, arterial intimal hyperplasia. A cornerstone question lies behind all approaches to the disease: what causes the pathology?

HYPOTHESIS

I argue that the question itself is misplaced because it implies that intimal hyperplasia is a novel pathological phenomenon caused by new mechanisms. A simple inquiry into arterial morphology shows the opposite is true. The normal multi-layer cellular organization of the tunica intima is identical to that of diseased hyperplasia; it is the standard arterial system design in all placentals at least as large as rabbits, including humans. Formed initially as one-layer endothelium lining, this phenotype can either be maintained or differentiate into a normal multi-layer cellular lining, so striking in its resemblance to diseased hyperplasia that we have to name it "benign intimal hyperplasia". However, normal or "benign" intimal hyperplasia, although microscopically identical to pathology, is a controllable phenotype that rarely compromises blood supply. It is remarkable that each human heart has coronary arteries in which a single-layer endothelium differentiates early in life to form a multi-layer intimal hyperplasia and then continues to self-renew in a controlled manner throughout life, relatively rarely compromising the blood supply to the heart, causing complications requiring intervention only in a small fraction of the population, while all humans are carriers of benign hyperplasia. Unfortunately, this fundamental fact has not been widely appreciated in arteriosclerosis research and medical education, which continue to operate on the assumption that the normal arterial intima is always an "ideal" single-layer endothelium. As a result, the disease is perceived and studied as a new pathological event caused by new mechanisms. The discovery that normal coronary arteries are morphologically indistinguishable from deadly coronary arteriosclerosis continues to elicit surprise.

CONCLUSION

Two questions should inform the priorities of our research: (1) what controls switch the single cell-layer intimal phenotype into normal hyperplasia? (2) how is normal (benign) hyperplasia maintained? We would be hard-pressed to gain practical insights without scrutinizing our premises.

Chronic exposure to schistosome eggs reduces serum cholesterol but has no effect on atherosclerotic lesion development

Previous studies have shown that people infected with schistosomiasis have lower levels of serum cholesterol than uninfected controls. To better understand the impact of this parasitic infection on serum cholesterol levels and on atherosclerotic lesion development induced by hypercholesterolemia, apolipoprotein E (ApoE)-deficient mice were chronically exposed to the eggs of Schistosoma mansoni over a period of 16 weeks. Total serum cholesterol and low-density lipoprotein (LDL) were reduced in egg-exposed ApoE-deficient mice fed a diet high in cholesterol compared to unexposed controls. However, exposure to eggs had no effect on atherosclerotic lesion size or progression in ApoE-deficient mice. Macrophages isolated from egg-exposed mice had an enhanced ability to take up LDL but not acetylated LDL (acLDL). This study suggests that schistosome eggs alone may alter serum lipid profiles through enhancing LDL uptake by macrophages, but these changes do not ultimately affect atherosclerotic lesion development.

Hypothetical hypercholesterolaemia and atherosclerosis

Recent pathological advances in experimental and iatrogenic atherosclerosis and critical review of the epidemiology of coronary heart disease revealed fallacious data and methodological errors underlying the hypercholesterolaemia/lipid hypothesis. Misuse of risk factors, inappropriate use of surrogates and misinterpretation of data pertaining to cholesterol's role in atherogenesis necessitate greater precision in word usage and terminology, reinstitution of the statistical reference range for cholesterol and closer scientific surveillance of aetiological endeavours in medicine.

Old and new cardiovascular risk factors: from unresolved issues to new opportunities

With the aim of identifying areas that may deserve some further thinking the present review deliberately points out controversial issues in cardiovascular research and risk assessment. In the first part of the review general aspects are addressed regarding the evaluation of risk factors. A first point of concern is the frequent practice of combining different vascular events and effects in different vascular beds into a single endpoint. Furthermore, verification of vascular events in clinical reality may be surprisingly inaccurate. Problems in risk assessment also arise from overlapping properties (shared pathophysiological pathways) of traditional risk factors like hypertension, obesity and diabetes. In the second part of the review unresolved issues concerning selected established and emerging risk factors are discussed. The difficulty of establishing causality in cardiovascular disease is addressed, using modification of LDL cholesterol and accumulating evidence for pleiotropic effects of the LDL cholesterol-lowering statins as an example. As an alternative or supplement to the notion of LDL-related cardiovascular risk it is proposed to distinguish between statin-sensitive and statin-insensitive cardiovascular risk. Finally the future prospects of selected new and emerging risk factors like CRP, homocysteine, asymmetrical dimethylarginine (ADMA), oxLDL, and isoprostanes are evaluated. In summary, imprecise terminology and varying definitions of "cardiovascular risk" may lead to a considerable blurring of our current risk estimates, which may also explain some presently controversial issues. With several new risk factors and substantial changes in lifestyle and treatment patterns on the horizon major changes in the hierarchy of risk factors may be inevitable.

Predicting Cholesterol, Progesterone, and Days to Ovulation Using Postpartum Metabolic and Endocrine Measures

The objective of this study was to examine relationships among metabolic and endocrine factors that may influence ovarian activity during early lactation. Holstein cows (n = 19) were bled twice each week to determine plasma concentrations of insulin (INS), glucose, cholesterol, insulin-like growth factor-1 (IGF-I), and progesterone (P4). Feed intake and milk production were recorded daily while body weights and milk composition were recorded weekly. Relationships among plasma cholesterol and P4, and days to first and second postpartum ovulation were modeled with energy balance (EB), dry matter intake, milk yield and composition, plasma metabolites, and hormones using the backward elimination technique of multivariate regression analysis. Variables that contributed the most to predicting plasma cholesterol concentrations were dry matter intake x SNF using model 1 (production variables) and the square of glucose (i.e., glucose2) using model 3 (plasma hormones and metabolites). For plasma P4 concentrations, EB (model 2, production variables) and IGF-I (model 3, plasma hormones and metabolites) were the major predictors. The production variables EB and percentage of milk lactose were the greatest contributors to the models predicting days to first and second postpartum ovulations, respectively. Of the plasma hormones and metabolites evaluated, IGF-I2 was the most significant predictor of days to first postpartum ovulation, whereas glucose2 and INS were the significant predictors of days to second postpartum ovulation. Plasma IGF-I, glucose, and INS have been implicated in ovarian functions and their significant contributions to these models are consistent with possible important roles in postpartum return to ovarian competence.

Analysis of definitions and word misusage in vascular pathology

Science being the search for truth or factual knowledge pertaining to nature and human health, accurate and precise word usage is prerequisite to avoid unintentional misrepresentation in scientific communication. The increasing frequency of word misusage necessitates review of a number of definitions and frequently misused words in vascular pathology. Correction of such errors is essential to foster accurate, standardized definitions. Otherwise scientific progress is delayed, the unwary are misled and fallacious data and concepts are propagated. Adherence to correct word usage facilitates the development of logic and precision so essential in education and in scientific thinking and literature, whereas consistently misused words ultimately become meaningless and unusable.

Coronary heart disease, hypercholesterolemia, and atherosclerosis. II. Misrepresented data

Early development of the hypercholesterolemic/lipid hypothesis of atherosclerosis was based on false premises including fallacious national mortality rates and misrepresentation of the vascular lesions in cholesterol-overfed animals and monogenic hypercholesterolemias (MH). Nonspecific coronary heart disease (CHD) was inappropriately used as a surrogate of atherosclerosis, unmeasured and unseen. Causality was assumed and implied by classifying statistical correlates of CHD as atherogenic risk factors. These faults were compounded by methodological errors, pooling of all causes of CHD, a large clinical diagnostic error, biased age selection of cohorts leading to confounding by age and MH, and emphasis on population and cohort mean values which conceal heterogeneity within cohorts and are inapplicable to individuals. Overzealous investigators neglected to review the premises and relevant pathology on which the hypothesis was based or to reconcile valid criticisms, inconsistencies, and invalidation of CHD epidemiology by pathological, experimental, and iatrogenic evidence. Statistical data, pertaining to CHD but with no scientific applicability to atherosclerosis, progressively imparted to readers a misleading perception of the relationship of serum cholesterol to CHD. Concurrently the statistical serum cholesterol range was unjustifiably abandoned. The evidence establishes that the lipid hypothesis of atherosclerosis lacks scientific basis.