Significance of the percentage of cholesterol efflux capacity and total cholesterol efflux capacity in patients with or without coronary artery disease

Association between pre-treatment with statin and its inhibitory effect on the onset of coronary artery disease at the time of coronary computed tomography angiography: a new look at an old medication

Coronary artery stenosis is often advanced by the time coronary computed tomography angiography (CCTA). Statins are the most important anti-lipidemic medication for improving the prognosis of coronary artery disease (CAD) patients. Although lipid-lowering therapy using statins appears to have been established as a method for preventing CAD, there remains the problem that CAD cannot be completely suppressed. In this study, we investigated whether pre-treatment with statin could significantly inhibit the onset of CAD when patients received CCTA for screening of CAD. The subjects were 1164 patients who underwent CCTA as screening for CAD. CAD was diagnosed when 50% or more coronary stenosis was present in the coronary arteries. Patient backgrounds were investigated by age, gender, body mass index, coronary risk factors [family history of cardiovascular diseases, smoking history, hypertension (HTN), diabetes mellitus (DM), dyslipidemia, chronic kidney disease (CKD) or metabolic sydrome] and medications. Patients were classified into two groups according to the presence or absence of statin pre-administration during CCTA [statin (-) group (n = 804) and (+) group (n = 360)]. Compared with the statin (-) group, the statin (+) group was significantly older and had higher rates of family history, HTN, and DM. The statin (+) group had a significantly higher % CAD than the statin (-) group. Serum levels of low-density lipoprotein cholesterol (LDL-C) were significantly lower in the statin (+) group than in the statin (-) group. There was no significant difference in either high-density lipoprotein cholesterol levels or triglyceride levels between the two groups. Age, male gender, HTN, DM and pre-treatment with statin were all associated with CAD (+) in all patients. In addition, factors that contributed to CAD (+) in the statin (-) group were age, male gender, and DM, and factors that contributed to CAD (+) in the statin (+) group were age, smoking, HTN and % maximum dose of statin. At the time of CCTA, the statin (+) group had a high rate of CAD and coronary artery stenosis progressed despite a reduction of LDL-C levels. To prevent the onset of CAD, in addition to strict control of other coronary risk factors (HTN etc.), further LDL cholesterol-lowering therapy may be necessary.

Association Between Major Adverse Cardiovascular Events and Left Ventricular Mass Index in Patients Who Have Undergone Coronary Computed Tomography Angiography: From the FU-CCTA Registry

Background

Left ventricular mass (LVM) is a predictor of future cardiovascular risk. We determined the association between LVM measured by coronary computed tomography angiography (CCTA) and the prognosis in patients who have undergone CCTA for screening of coronary artery disease (CAD).

Methods

We performed a prospective cohort study. Five hundred twenty consecutive patients who underwent CCTA at Fukuoka University Hospital (FU-CCTA registry) were enrolled. They were clinically suspected of having CAD or had at least one cardiovascular risk factor, and were a follow-up of up to 5 years. Equal to more than 50% of coronary stenosis as assessed by CCTA was diagnosed as CAD. Using CCTA, LVM index (LVMI), LV ejection fraction (LVEF), LV end-diastolic volume (LVEDV) and LV end-systolic volume were measured. The primary endpoint was major adverse cardiovascular events (MACEs: including all causes of death, ischemic stroke, acute myocardial infarction and coronary revascularization). The patients were divided into non-MACEs and MACEs groups.

Results

The non-MACEs and MACEs groups consisted of 478 and 42 patients, respectively. Percent of CAD in the MACEs group was significantly higher than that in the non-MACEs group. The MACEs group showed significantly higher LVMI and tended to have a lower LVEF and LVEDV than the non-MACEs group. Although LVMI was not associated with MACEs in all patients, LVMI was independently associated with MACEs in males (odd ratio: 1.018, 95% confidence interval: 1.002 - 1.035, P = 0.030), but not females.

Conclusions

Evaluation of LVMI by CCTA may be useful for predicting MACEs in males.

Association Between the Presence of Coronary Artery Disease or Peripheral Artery Disease and Left Ventricular Mass in Patients Who Have Undergone Coronary Computed Tomography Angiography

Background

Left ventricular mass (LVM) is a critical marker of future cardiovascular risk. We determined the association between LVM measured by coronary computed tomography angiography (CCTA) and the presence of coronary artery disease (CAD) or peripheral artery disease (PAD) in patients who had undergone CCTA for screening of CAD.

Methods

We enrolled 1,307 consecutive patients (66 ± 12 years old, 49% males) who underwent CCTA for screening of CAD at the Fukuoka University Hospital (FU-CCTA registry), and either were clinically suspected of having CAD or had at least one cardiovascular risk factor. Patients with coronary stenosis of ≥ 50% by CCTA were diagnosed as CAD. Patients with an ankle brachial pressure index < 0.9 or who had already been diagnosed with PAD were considered to have PAD. Left ventricular mass index (LVMI), left ventricular ejection fraction (LVEF), end-diastolic volume (EDV) and end-systolic volume (ESV) were measured. The patients were divided into CAD (-) and CAD (+) or PAD (-) and PAD (+) groups.

Results

The prevalences of CAD and PAD in all patients were 50% and 4.8%, respectively. Age, %males, %hypertension (HTN), %dyslipidemia (DL), %diabetes mellitus (DM), %smoking and %chronic kidney disease in the CAD (+) group were significantly higher than those in the CAD (-) group. Age, %males, %HTN, %DM and %smoking in the PAD (+) group were significantly higher than those in the PAD (-) group. CAD was independently associated with LVMI (odds ratio (OR): 1.01, 95% confidence interval (CI): 1.01 - 1.02, P < 0.01) in addition to age, male, HTN, DL, DM, and smoking. PAD was also independently associated with LVMI (OR: 1.01, 95% CI: 1.0 - 1.02, P = 0.018) in addition to age, DM, and smoking.

Conclusions

LVMI determined by CCTA may be useful for predicting atherosclerotic cardiovascular diseases including both CAD and PAD, although there were considerable differences between %CAD and %PAD in all patients.

High-density lipoprotein cholesterol efflux capacity and incidence of coronary artery disease and cardiovascular mortality: a systematic review and meta-analysis

Background

The preventive effect of cholesterol efflux capacity (CEC) on the progression of atherosclerotic lesions has been confirmed in animal models, but findings in the population are inconsistent. Therefore, this meta-analysis aimed to systematically investigate the relationship of CEC with coronary artery disease (CAD) and cardiovascular mortality in a general population.

Methods

Four electronic databases (PubMed, Embase database, Cochrane Library, Web of Science) were searched from inception to February 1st, 2022 for relevant studies, without any language restriction. For continuous variables, the mean and standard deviation (SD), maximum adjusted odds ratios (ORs), relative risks (RRs), or hazard ratios (HRs) and 95% confidence intervals (CIs) were extracted. The random-effects model was adopted to calculate the pooled results, and dose-response analyses were conducted. All pooled results were expressed by standardized mean difference (SMD) and ORs.

Results

Finally, 18 observational studies were included. Compared with the non-CAD group, the CAD group (SMD -0.48, 95% CI − 0.66 to − 0.30; I² 88.9%) had significantly lower CEC. In the high-CEC population, the risks of CAD (OR 0.52, 95% CI 0.37 to 0.71; I² 81%) significantly decreased, and a linear negative dose-response was detected. However, an association between CEC and the risk of cardiovascular mortality was not found (OR 0.44, 95% CI 0.18 to 1.06; I² 83.2%).

Conclusions

This meta-analysis suggests that decreased CEC is strongly associated with the risk of CAD, independent of HDL-C level. However, a decreased CEC seems not to be related to cardiovascular mortality. Meanwhile, CEC is linearly negatively correlated with the risk of CAD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12944-022-01657-3.

HDL associates with insulin resistance and beta-cell dysfunction in South Asian families at risk of type 2 diabetes

OBJECTIVE

Dyslipidemia precedes type 2 diabetes (T2D) and worsens with increasing glucose intolerance. First degree relatives of T2D patients have an increased risk to develop dyslipidemia and glucose intolerance. The aim of the present study was to assess the relation between the development of dyslipidemia and glucose intolerance in first-degree relatives of T2D patients.

RESEARCH DESIGN AND METHODS

Fasting lipoprotein profiles were determined by density gradient ultracentrifugation in T2D patients and their first-degree relatives (42 Caucasians and 33 South Asians), and in 29 normoglycemic controls from non-T2D families. Glucose tolerance, insulin sensitivity index (ISI) and insulin disposition index (DI) were assessed by an extended, frequently sampled oral glucose tolerance test (OGTT), and fractional insulin synthesis rate (FSR) was measured by ¹³C-leucine enrichment in urinary C-peptide during the OGTT.

RESULTS

Of the first-degree relatives, 40, 16 and 19 had NGT, prediabetes and T2D, respectively. NGT family members had lower plasma HDL-cholesterol (HDLC) (1.34 ± 0.07 vs 1.58 ± 0.06 mmol/L; p = 0.015), HDL₂-C (0.41 ± 0.05 vs 0.57 ± 0.05 mmol/L; p = 0.021) and HDL₃-C (0.62 ± 0.03 vs 0.72 ± 0.02 mmol/L; p = 0.043) than controls. HDL₂-C levels tended to decrease with increasing glucose intolerance state. In South Asians, buoyant LDL-C levels decreased with increasing glucose intolerance state (p = 0.006). In South Asian families, HDL-C correlated with both ISI and DI (β 0.42; p = 0.04 and β 0.53; p = 0.01, respectively), whereas HDL₂-C and HDL₃-C levels correlated with DI (β 0.64; p = 0.002 and β 0.57; p = 0.005, respectively). HDL₂-C and plasma triglyceride correlated with FSR (β 0.48; p = 0.033 and β -0.50; p = 0.029, respectively).

CONCLUSIONS

Low HDL₂-C and HDL₃-C levels are present in NGT first-degree relatives of T2D patients, and HDL₂-C tend to decrease further with increasing glucose intolerance. In South Asian families HDL₂-C and HDL₃-C levels linked predominantly to deteriorating beta cell function.

Associations between High-Density Lipoprotein Functionality and Major Adverse Cardiovascular Events in Patients Who Have Undergone Coronary Computed Tomography Angiography

The present study aimed to investigate the associations between high-density lipoprotein (HDL) functionality and major adverse cardiovascular events (MACE) in patients who have undergone coronary computed tomography angiography (CCTA). We performed a prospective cohort study and enrolled 151 patients who underwent CCTA and had a follow-up of up to 5 years. We measured cholesterol efflux capacity (CEC), caspase-3/7 activity and monocyte chemoattractant protein-1 (MCP-1) secretion as bioassays of HDL functionality. The patients were divided into MACE(−) (n = 138) and MACE(+) (n = 13) groups. While there was no significant difference in %CEC, caspase-3/7 activity or MCP-1 secretion between the MACE(−) and MACE(+) groups, total CEC and HDL cholesterol (HDL-C) in the MACE(+) group were significantly lower than those in the MACE(−) group. Total CEC was correlated with HDL-C. A receiver-operating characteristic curve analysis showed that there was no significant difference between the areas under the curves for total CEC and HDL-C. In conclusion, total CEC in addition to HDL-C, but not %CEC, was associated with the presence of MACE. On the other hand, HDL functionality with regard to anti-inflammatory and anti-apoptosis effects was not associated with MACE.

Association between high-density lipoprotein cholesterol levels and major adverse cardiovascular events in patients who underwent coronary computed tomography angiography: FU-CCTA registry

It is unclear whether higher levels of serum high-density lipoprotein cholesterol (HDL-C) prevent major adverse cardiovascular events (MACE). We prospectively evaluated 501 patients who had undergone coronary computed tomography angiography at Fukuoka University Hospital and either were clinically suspected of having coronary artery disease (CAD) or had at least one cardiovascular risk factor with a follow-up of up to 5 years. The primary endpoint was MACE (cardiovascular death, ischemic stroke, acute myocardial infarction and coronary revascularization). The patients were divided into tertiles according to the HDL-C level: 47 mg/dl ≥ HDL-C level [n = 167, lower HDL-C level (L-HDL)], 58 mg/dl ≥ HDL-C level ≥ 48 mg/dl [n = 167, middle HDL-C level (M-HDL)] and HDL-C level ≥ 59 mg/dl [n = 167, higher HDL-C level (H-HDL)] groups. There were significant differences in %CAD among the L-HDL, M-HDL and H-HDL groups. Unexpectedly, there was no difference in %MACE between M-HDL and H-HDL, although %MACE in M-HDL was significantly lower than that in L-HDL (p < 0.05). By a multivariate logistic regression analysis, MACE in H-HDL-C was independently associated with diabetes mellitus (DM) (p = 0.03). A Kaplan-Meier curve according to the HDL subgroup indicated that M-HDL, not H-HDL, enjoyed the greatest freedom from MACE among the 3 groups (log-rank test p = 0.047). Finally, the results of a Cox regression model indicated that L-HDL and H-HDL had significantly higher risk of MACE than M-HDL. In conclusions, patients with middle HDL-C levels, not higher HDL-C levels, showed the greatest freedom from MACE. Patients with higher HDL-C levels need to be strictly managed for DM to prevent MACE.

Cholesterol Efflux and Collateral Circulation in Chronic Total Coronary Occlusion: Effect-Circ Study

Background

The mechanism through which high‐density lipoprotein (HDL) induces cardioprotection is not completely understood. We evaluated the correlation between cholesterol efflux capacity (CEC), a functional parameter of HDL, and coronary collateral circulation (CCC). We additionally investigated whether A1BP (apoA1‐binding protein) concentration correlates with CEC and CCC.

Methods and Results

In this case‐control study, clinical and angiographic data were collected from 226 patients (mean age, 58 years; male, 72%) with chronic total coronary occlusion. CEC was assessed using a radioisotope and J774 cells, and human A1BP concentration was measured using enzyme‐linked immunosorbent assay. Differences between the good and poor CCC groups were compared, and associations between CEC, A1BP, and other variables were evaluated. Predictors of CCC were identified by multivariable logistic regression analysis. The CEC was higher in the good than in the poor CCC group (22.0±4.6% versus 20.2±4.7%; P=0.009). In multivariable analyses including age, sex, HDL‐cholesterol levels, age (odds ratio [OR], 0.96; P=0.003), and CEC (OR, 1.10; P=0.004) were identified as the independent predictors of good CCC. These relationships remained significant after additional adjustment for diabetes mellitus, acute coronary syndrome, and Gensini score. The A1BP levels were not significantly correlated with CCC (300 pg/mL and 283 pg/mL in the good CCC and poor CCC groups, respectively, P=0.25) or CEC.

Conclusions

The relationship between higher CEC and good CCC indicates that well‐functioning HDL may contribute to CCC and may be cardioprotective; this suggests that a specific function of HDL can have biological and clinical consequences.

Association Between the Level of Low-Density Lipoprotein Cholesterol and Coronary Atherosclerosis in Patients Who Have Undergone Coronary Computed Tomography Angiography

Background

Although the Japan Atherosclerosis Society Guidelines 2017 recommend lower levels of low-density lipoprotein cholesterol (LDL-C, < 70 mg/dL or ≤ 100 mg/dL) to prevent secondary cardiovascular events, we cannot conclude that a low level of LDL-C prevents primary cardiovascular events in patients with suspected coronary artery disease (CAD).

Methods

We registered 1,016 patients who were clinically suspected to have CAD and who underwent coronary computed tomography angiography (CCTA) for screening of coronary atherosclerosis. We excluded 350 patients who were receiving anti-lipidemic therapies and finally analyzed 666 patients. The patients were divided into three groups according to the LDL-C level: < 70 mg/dL (n = 25, Low LDL-C), 70 - 99 mg/dL (n = 141, Middle LDL-C), and ≥ 100 mg/dL (n = 500, High LDL-C). A ≥ 50% coronary stenosis was initially diagnosed as CAD, and the number of significantly stenosed coronary vessels (VD), Gensini score and coronary artery calcification (CAC) score were quantified.

Results

There were no significant differences in age, high-density lipoprotein cholesterol, rates of hypertension, hemoglobin A1c, blood sugar or systolic blood pressure among the Low, Middle and High LDL-C groups. On the other hand, there were significant differences in rates of males, smoking, dyslipidemia and diabetes, diastolic blood pressure and triglyceride among the groups. The prevalence of CAD values in the Low, Middle and High LDL-C groups were similar, at 52%, 47%, and 46%, respectively. In addition, there were no significant differences in the number of VD, Gensini score or CAC score among the Low LDL-C, Middle LDL-C and High LDL-C groups.

Conclusions

We showed that the level of LDL-C was not associated with the presence or severity of CAD, which indicates that we need to screen by CCTA to prevent primary coronary events even if patients without anti-lipidemic therapies show low levels of LDL-C.

Associations Between High Levels of High-Density Lipoprotein Cholesterol and the Presence and Severity of Coronary Artery Disease in Patients Who Have Undergone Coronary Computed Tomography Angiography

Background

Although a recent study in a Japanese cohort indicated that extremely high-density lipoprotein cholesterol (HDL-C, ≥ 90 mg/dL) had an adverse effect on atherosclerotic cardiovascular disease mortality, we could not conclude that high levels of HDL-C were associated with the presence or severity of coronary artery disease (CAD).

Methods

We enrolled 1,016 patients who were clinically suspected to have CAD and who underwent coronary computed tomography angiography (CCTA). The number of significantly stenosed coronary vessels (vessel disease (VD), ≥ 50% coronary stenosis is diagnosed as CAD) and the Gensini score were quantified using CCTA, and the lipid profile was measured. The patients were divided into four groups according to the HDL-C level: < 40 mg/dL (n = 115, low), 40 - 59 mg/dL (n = 530, normal), 60 - 89 mg/dL (n = 335, high) and ≥ 90 mg/dL (n = 36, very-high).

Results

The percentage (%) of CAD in the low, normal, high and very-high groups was 69%, 55%, 42% and 25%, respectively (P for trend < 0.01). The Gensini score in the low, normal, high and very-high groups was 20 ± 25, 12 ± 16, 8 ± 12 and 4 ± 6, respectively (P for trend < 0.01). The very-high group showed the lowest triglyceride (TG) levels among the four groups. There were no significant differences in the level of low-density lipoprotein cholesterol or % use of statin among the four groups. Finally, the presence of CAD was independently associated with a low level of HDL-C, in addition to age, male, high systolic blood pressure and hemoglobin A1c, but not TG, by a multivariate logistic regression analysis.

Conclusions

High levels of HDL-C at the time of CCTA for screening were associated with a reduced presence and severity of CAD.

Cholesterol efflux capacity in coronary artery disease: a meta-analysis

OBJECTIVE

To quantitatively analyze the association between cholesterol efflux capacity (CEC) and the risk and prognosis of coronary artery disease (CAD).

METHODS

A systematic search of electronic databases for studies published until September 2019 was performed. Cohorts, case-control studies, and randomized controlled trials that examined the effect of CEC on the risk and prognosis of CAD were included.

RESULTS

Eighteen studies with 12 685 subjects met our inclusion criteria. Among them, 14 studies reported the CEC in non-CAD and CAD groups, and eight studies reported the association between CEC and risk of CAD. Four studies reported the prognosis of stable CAD or acute coronary syndrome (ACS). In the pooled analyses, significantly decreased CEC was found in patients with stable CAD as compared with those without CAD. Decreased CEC was also present in subgroup in patients with ACS. High CEC was significantly associated with decreased risk of CAD [odds ratio (OR) = 0.65, 95% confidence interval (CI): 0.55-0.75, P < 0.001]. High CEC predicted lower all-cause mortality (OR = 0.39, 95% CI: 0.20-0.77, P = 0.007) and cardiovascular mortality (OR = 0.34, 95% CI: 0.13-0.90, P = 0.03) in patients with CAD. However, CEC failed to predict the occurrence of stroke and myocardial infraction in patients with CAD.

CONCLUSIONS

Decreased CEC is an independent risk factor for CAD, and it predicts all-cause and cardiovascular mortality in patients with CAD.

Ezetimibe Monotherapy Reduces Serum Levels of Platelet-Activating Factor Acetylhydrolase in Patients With Dyslipidemia

Background

The combination of ezetimibe with statin therapy reduced cardiovascular events compared to statin monotherapy in IMPROVEIT study, and ezetimibe monotherapy attenuated atherosclerosis in basic study. We previously showed ezetimibe monotherapy was especially effective for metabolic syndrome (MetS) patients. We investigated the effects of ezetimibe monotherapy for high-density lipoprotein cholesterol (HDL-chol) function and platelet-activating factor acetylhydrolase (PAF-AH) activity.

Methods

Forty-two patients who initially received ezetimibe (10 mg/day) without statin treatment for 16 weeks from January 2009 to August 2011 were enrolled. Patients were divided into MetS and non-MetS groups, and serum levels of lipids, PAF-AH, and HDL-chol efflux capacity (HDL-CEC) at baseline and after 16 weeks of treatment were investigated. Serum PAF-AH, HDL-associated PAF-AH (HDL-PAF-AH), and LDL-associated PAF-AH (LDL-PAF-AH) were measured.

Results

In all patients, age, the percentages of males, and body mass index were 61.0 ± 8.8 years, 59.5% and 26.3 ± 3.4 kg/m², respectively. Total cholesterol and low-density lipoprotein cholesterol (LDL-chol) were significantly decreased by ezetimibe monotherapy. Serum PAF-AH and LDL-PAF-AH were significantly decreased by ezetimibe monotherapy, whereas HDL-PAF-AH and HDL-CEC were not. There was no difference in the results of PAF-AH and HDL-CEC between MetS and non-MetS groups.

Conclusions

Ezetimibe monotherapy might prevent coronary heart disease (CHD) regardless of the presence of MetS, because PAF-AH was independent risk factor for CHD.

Atherosclerotic Coronary Artery Disease in Patients With Cardiometabolic Syndrome

Major risk factors for cardiovascular disease (CVD) include aging, gender, smoking, family history and cardiometabolic syndrome. The relative residual risks for CVD after statin treatment for primary and secondary prevention have been reported by several large-scale randomized clinical trials. Statin treatment appears to prevent one-third of the onset and progression of CVD, but not the remaining two-thirds. There are three major problems regarding the residual risk of CVD: 1) Insufficient reduction of low-density lipoprotein cholesterol levels; 2) Low levels of high-density lipoprotein cholesterol and elevated triglyceride; and 3) Insufficient control of other risk factors (high blood pressure, obesity, metabolic syndrome, type 2 diabetes, etc.). Thus, a multifaceted preventive approach should be needed to prevent CVD after statin treatment.

The pleiotropic vasoprotective functions of high density lipoproteins (HDL)

The pleiotropic functions of circulating high density lipoprotein (HDL) on peripheral vascular health are well established. HDL plays a pivotal role in reverse cholesterol transport and is also known to suppress inflammation, endothelial activation and apoptosis in peripheral vessels. Although not expressed in the central nervous system, HDL has nevertheless emerged as a potential resilience factor for dementia in multiple epidemiological studies. Animal model data specifically support a role for HDL in attenuating the accumulation of β-amyloid within cerebral vessels concomitant with reduced neuroinflammation and improved cognitive performance. As the vascular contributions to dementia are increasingly appreciated, this review seeks to summarize recent literature focused on the vasoprotective properties of HDL that may extend to cerebral vessels, discuss potential roles of HDL in dementia relative to brain-derived lipoproteins, identify gaps in current knowledge, and highlight new opportunities for research and discovery.