Association Between Paradoxical HDL Cholesterol Decrease and Risk of Major Adverse Cardiovascular Events in Patients Initiated on Statin Treatment in a Primary Care Setting

HDL abnormalities in type 2 diabetes: Clinical implications

Atherosclerotic cardiovascular disease (ASCVD) represents the primary cause of mortality among patients with Type 2 Diabetes Mellitus (T2DM). In this population, High-Density Lipoprotein (HDL) particles exhibit abnormalities in number, composition, and function, culminating in diminished anti-atherosclerotic capabilities despite normal HDL cholesterol (HDL-C) concentrations. Hyperglycemic conditions contribute to these alterations in HDL kinetics, composition, and function, causing T2DM patients' HDL particles to exhibit decreased concentrations of diverse lipid species and proteins. Treatment of hyperglycemia has the potential to correct abnormal HDL particle attributes in T2DM; however, pharmacological interventions, including metformin and thiazolidinediones, yield inconsistent outcomes with respect to HDL-C concentrations and functionality. Despite numerous attempts with diverse drugs, pharmacologically augmenting HDL-C levels has not resulted in clinical benefits in mitigating ASCVD risk. In contrast, reducing Low Density Lipoprotein cholesterol (LDL-C) via statins and ezetimibe has demonstrated significant efficacy in curtailing CVD risk among T2DM individuals. Promising results have been observed in animal models and early-phase trials utilizing recombinant HDL and Lecitin Cholesterol Acyl Transferase (LCAT) -enhancing agents, but the evaluation of their efficacy and safety in large-scale clinical trials is ongoing. While aberrant HDL metabolism constitutes a prevalent aspect of dyslipidemia in T2DM, HDL cholesterol concentrations and composition no longer offer valuable insights for informing therapeutic decisions. Nevertheless, HDL metabolism remains a critical research area in T2DM, necessitating further investigation to elucidate the role of HDL particles in the development of diabetes-associated complications.

Statin Use in Relation to COVID-19 and Other Respiratory Infections: Muscle and Other Considerations

Statins have been widely advocated for use in COVID-19 based on large favorable observational associations buttressed by theoretical expected benefits. However, past favorable associations of statins to pre-COVID-19 infection outcomes (also buttressed by theoretical benefits) were unsupported in meta-analysis of RCTs, RR = 1.00. Initial RCTs in COVID-19 appear to follow this trajectory. Healthy-user/tolerator effects and indication bias may explain these disparities. Moreover, cholesterol drops in proportion to infection severity, so less severely affected individuals may be selected for statin use, contributing to apparent favorable statin associations to outcomes. Cholesterol transports fat-soluble antioxidants and immune-protective vitamins. Statins impair mitochondrial function in those most reliant on coenzyme Q10 (a mevalonate pathway product also transported on cholesterol)-i.e., those with existing mitochondrial compromise, whom data suggest bear increased risks from both COVID-19 and from statins. Thus, statin risks of adverse outcomes are amplified in those patients at risk of poor COVID-19 outcomes-i.e., those in whom adjunctive statin therapy may most likely be given. High reported rates of rhabdomyolysis in hospitalized COVID-19 patients underscore the notion that statin-related risks as well as benefits must be considered. Advocacy for statins in COVID-19 should be suspended pending clear evidence of RCT benefits, with careful attention to risk modifiers.

Development of synthetic lipoxin-A4 mimetics (sLXms): New avenues in the treatment of cardio-metabolic diseases

Resolution of inflammation is a complex, dynamic process consisting of several distinct processes, including inhibition of endothelial activation and leukocyte trafficking; promotion of inflammatory cell apoptosis and subsequent non-phlogistic scavenging and degradation; augmentation of pathogen phagocytosis; modulation of stromal cell phenotype coupled to the promotion of tissue regeneration and repair. Among these tightly regulated processes, the clearance and degradation of apoptotic cells without eliciting an inflammatory response is a crucial allostatic mechanism vital to developmental processes, host defence, and the effective resolution of inflammation. These efferocytic and subsequent effero-metabolism processes can be carried out by professional and non-professional phagocytes. Defective removal or inadequate processing of apoptotic cells leads to persistent unresolved inflammation, which may promote insidious pathologies including scarring, fibrosis, and eventual organ failure. In this manuscript, the well-established role of endothelial activation and leukocyte extravasation, as classical vascular targets of the 'inflammation pharmacology', will be briefly reviewed. The main focus of this work is to bring attention to a less explored aspect of the 'resolution pharmacology', aimed at tackling defective efferocytosis and inefficient effero-metabolism, as key targeted mechanisms to prevent or pre-empt vascular complications in cardio-metabolic diseases. Despite the use of gold standard lipid-lowering drugs or glucose-lowering drugs, none of them are able to tackle the so called residual inflammatory risk and/or the metabolic memory. In this review, the development of synthetic mimetics of endogenous mediators of inflammation is highlighted. Such molecules finely tune key components across the whole inflammatory process, amongst various other novel therapeutic paradigms that have emerged over the past decade, including anti-inflammatory therapy. More specifically, FPR2-agonists in general, and Lipoxin analogues in particular, greatly enhance the reprogramming and cross-talk between classical and non-classical innate immune cells, thus inducing both termination of the pro-inflammatory state as well as promoting the subsequent resolving phase, which represent pivotal mechanisms in inflammatory cardio-metabolic diseases.

Association of fasting blood glucose to high-density lipoprotein cholesterol ratio with short-term outcomes in patients with acute coronary syndrome

Background

Biochemical markers are crucial for determining risk in coronary artery disease (CAD) patients; however, the relationship between fasting blood glucose to high-density lipoprotein cholesterol (FG/HDL-C) ratio and short-term outcomes in acute coronary syndrome (ACS) patients remains unknown. Therefore, we have investigated the relationship between the FG/HDL-C ratio and short-term outcomes in ACS patients.

Methods

We used data from a pragmatic, stepped-wedge, cluster-randomized clinical trial to perform a post hoc analysis. A total of 11,284 individuals with ACS were subdivided into quartiles according to their FG/HDL-C ratios. We used a multivariate logistic regression model, two-piecewise linear regression model, and generalized additive model (GAM) to evaluate the relationship between the FG/HDL-C ratio and short-term outcomes (major adverse cardiovascular events [MACEs] and cardiovascular [CV] death within 30 days).

Results

The FG/HDL-C ratio was remarkably linked to an enhanced risk of MACEs and CV death in individuals with ACS in the highest quartile (MACEs, odds ratio [OR]: 1.49; 95% confidence interval [CI], [1.11, 1.99]; P < 0.01; CV death, OR: 1.69; 95% CI, [1.01, 1.41]; P = 0.04). The GAM suggested that the relationship between the FG/HDL-C ratio and MACEs and CV death was non-linear. The two-piecewise linear regression model demonstrated that the threshold values were 3.02 and 3.00 for MACEs and CV death, respectively.

Conclusions

A higher FG/HDL-C ratio is associated with a higher risk of MACEs and CV death in patients with ACS.

An association of ABCG8: rs11887534 polymorphism and HDL-cholesterol response to statin treatment in the Polish population

Background

Variation in lipid changes in response to statin treatment is associated with genetic polymorphism. Sterolin-1, encoded by ABCG5, and sterolin-2, encoded by ABCG8, together form a sterol transporter. There are some reports indicating association of rs11887534 (ABCG8:c.55G > C) polymorphism with lipid concentrations, both prior to and after statin treatment. The aim of this study was to analyze both baseline plasma lipids and their concentrations in response to statin treatment with regard to ABCG8: rs11887534 polymorphism in Caucasian patients of Polish origin.

Methods

The study group consisted of 170 consecutive adult out-patients treated with atorvastatin or simvastatin for a minimum of 2 months. Concentrations of triglycerides (TG), total cholesterol (TC), LDL-cholesterol (LDL-C) and HDL-cholesterol (HDL-C) were measured before and after statin treatment. The ABCG8 polymorphism was identified by mini-sequencing genomic DNA extracted from peripheral blood leukocytes.

Results

There were no significant differences in regard to ABCG8 variants for baseline TG, TC, LDL-C and HDL-C as well as for TG, TC or LDL-C concentrations after statin treatment. However, patients carrying at least one C allele showed a decrease in post-statin HDL-C concentrations and the absolute and relative changes between post- and pre-statin HDL-C concentrations were negative in contrast to positive values in wild-type homozygotes.

Conclusions

Our results suggest that the c.55C allele of the ABCG8: rs11887534 polymorphism might be associated with decrease in HDL-cholesterol in response to statin treatment in Polish patients.

Association Between an Acute, Drug-Induced Decrease in High-Density Lipoprotein Cholesterol Levels and Risk of Cardiovascular Events

BACKGROUND AND OBJECTIVE: The literature describing the long-term effect of an acute, drug-induced decrease in high-density lipoprotein cholesterol (HDL-C) and cardiovascular (CV) risk is limited. We aimed to further explore this potential association.

METHODS

A retrospective cohort study was conducted using the Clinical Practice Research Datalink (CPRD) between 2006 and 2014. The study enrolled patients who initiated statin therapy for a short term, to identify patients with an acute, short-term decrease in HDL levels rather than to assess sustained treatment. HDL-C measurements were assessed within 9 months before and after statin initiation and patients were followed up for up to 5 years for CV events, comparing those with a decrease in HDL-C with those with constant HDL-C levels. The primary composite endpoint of major adverse cardiac events (MACE) was defined as CV death, myocardial infarction, revascularisation, and hospitalised ischaemic stroke. We estimated crude and propensity score weighted 5-year cumulative risk differences and hazard ratios (HR) comparing both groups.

RESULTS

A total of 17,543 patients (HDL-C decrease group, n = 6454; HDL-C constant group, n = 11,089) were included in the study. The 5-year cumulative incidence of MACE in the HDL-C constant cohort was 5.91%. The corresponding risk differences for HDL-C decrease versus the constant group was 1.23% (95% confidence interval [CI] 0.28-2.18) and the HR was 1.20 (95% CI 1.04-1.39). This was mainly driven by an increased risk in ischaemic stroke (HR 1.44, 95% CI 1.08-1.90) and CV death (HR 1.23, 95% CI 0.93-1.63).

CONCLUSION

Patients with a short-term, drug-induced decrease in HDL-C had a moderately increased long-term risk of CV events compared with those with constant HDL-C levels.

TRIAL REGISTRATION NUMBER

207595 (GlaxoSmithKline Trial registry; https://www.gsk-studyregister.com/ ).

Association Between Clinical Practice Group Adherence to Quality Measures and Adverse Outcomes Among Adult Patients With Diabetes

IMPORTANCE

Clinical practice group performance on quality measures associated with chronic disease management has become central to reimbursement. Therefore, it is important to determine whether commonly used process and disease control measures for chronic conditions correlate with utilization-based outcomes, as they do in acute disease.

OBJECTIVE

To examine the associations among clinical practice group performance on diabetes quality measures, including process measures, disease control measures, and utilization-based outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, cross-sectional analysis examined commercial claims data from a national health insurance plan. A cohort of eligible beneficiaries with diabetes aged 18 to 65 years who were enrolled for at least 12 months from January 1, 2010, through December 31, 2014, was defined. Eligible beneficiaries were attributed to a clinical practice group based on the plurality of their primary care or endocrinology office visits. Data were analyzed from October 1, 2018, through April 30, 2019.

MAIN OUTCOMES AND MEASURES

For each clinical practice group, performance on current diabetes quality measures included 3 process measures (2 testing measures [hemoglobin A1c {HbA1c} and low-density lipoprotein {LDL} testing] and 1 drug use measure [statin use]) and 2 disease control measures (HbA1c <8% and LDL level <100 mg/dL). The rates of utilization-based outcomes, including hospitalization for diabetes and major adverse cardiovascular events (MACEs), were also measured.

RESULTS

In this cohort of 652 258 beneficiaries with diabetes from 886 clinical practice groups, 42.9% were aged 51 to 60 years, and 52.6% were men. Beneficiaries lived in areas that were predominantly white (68.1%). At the clinical practice group level, except for high correlation between the 2 testing measures, correlations among different quality measures were weak (r range, 0.010-0.244). Rate of HbA1c of less than 8% had the strongest correlation with hospitalization for MACE (r = -0.046; P = .03) and diabetes (r = -0.109; P < .001). Rates of HbA1c control at the clinical practice group level were not significantly associated with likelihood of hospitalization at the individual level. Performance on the process and disease control measures together explained 3.9% of the variation in the likelihood of hospitalization for a MACE or diabetes at the individual level.

CONCLUSIONS AND RELEVANCE

In this study, performance on utilization-based measures-intended to reflect the quality of chronic disease management-was only weakly associated with direct measures of chronic disease management, namely, disease control measures. This correlation should be considered when determining the degree of financial emphasis to place on hospitalization rates as a measure of quality in treatment of chronic diseases.

Increasing HDL-C levels with medication: current perspectives

PURPOSE OF REVIEW

To date, observational studies have repeatedly demonstrated an inverse association between HDL cholesterol (HDL-C) levels and cardiovascular outcomes. Although the efficacy of established HDL-modifying treatment strategies have been examined in multiple large-scale phase III trials, findings from these experimental studies conflict with the hypothesis that HDL-C levels are atheroprotective. In this review, we describe the trial evidence to date, and attempt to place these results in the broader context of recent hypotheses for the association between HDL-C levels and clinical outcomes.

RECENT FINDINGS

Both translational and genetic studies are in line with the hypothesis that HDL-C levels do not hold causal importance for cardiovascular risk reduction. In addition to its possible role as a biomarker for other atherogenic lipoproteins, efforts should be made to elucidate HDLs' role in lipoprotein flux, which is increasingly being linked to surrogate outcomes of importance to cardiovascular epidemiology. In the future, it will be of great importance to link this measure of HDL functionality to clinical endpoints.

SUMMARY

Although trial evidence does not support an atheroprotective role of overall HDL-C plasma levels, HDL function/lipoprotein flux holds great promise for the development of novel therapeutic approaches.

Omega-3 carboxylic acids monotherapy and combination with statins in the management of dyslipidemia

The 2013 American College of Cardiology/American Heart Association guidelines on cholesterol management placed greater emphasis on statin therapy given the well-established benefits in primary and secondary prevention of cardiovascular disease. Residual risk may remain after statin initiation, in part because of triglyceride-rich lipoprotein cholesterol. Several large trials have failed to show benefit with non-statin cholesterol-lowering medications in the reduction of cardiovascular events. Yet, subgroup analyses showed a benefit in those with hypertriglyceridemia and lower high-density lipoprotein cholesterol level, a high-risk pattern of dyslipidemia. This review discusses the benefits of omega-3 carboxylic acids, a recently approved formulation of omega-3 fatty acid with enhanced bioavailability, in the treatment of dyslipidemia both as monotherapy and combination therapy with a statin.

L-Carnitine/Simvastatin Reduces Lipoprotein (a) Levels Compared with Simvastatin Monotherapy: A Randomized Double-Blind Placebo-Controlled Study

Lipoprotein (a) [Lp(a)] is an independent risk factor for cardiovascular disease. There are currently limited therapeutic options to lower Lp(a) levels. L-Carnitine has been reported to reduce Lp(a) levels. The aim of this study was to compare the effect of L-carnitine/simvastatin co-administration with that of simvastatin monotherapy on Lp(a) levels in subjects with mixed hyperlipidemia and elevated Lp(a) concentration. Subjects with levels of low-density lipoprotein cholesterol (LDL-C) >160 mg/dL, triacylglycerol (TAG) >150 mg/dL and Lp(a) >20 mg/dL were included in this study. Subjects were randomly allocated to receive L-carnitine 2 g/day plus simvastatin 20 mg/day (N = 29) or placebo plus simvastatin 20 mg/day (N = 29) for a total of 12 weeks. Lp(a) was significantly reduced in the L-carnitine/simvastatin group [-19.4%, from 52 (20-171) to 42 (15-102) mg/dL; p = 0.01], but not in the placebo/simvastatin group [-6.7%, from 56 (26-108) to 52 (27-93) mg/dL, p = NS versus baseline and p = 0.016 for the comparison between groups]. Similar significant reductions in total cholesterol, LDL-C, apolipoprotein (apo) B and TAG were observed in both groups. Co-administration of L-carnitine with simvastatin was associated with a significant, albeit modest, reduction in Lp(a) compared with simvastatin monotherapy in subjects with mixed hyperlipidemia and elevated baseline Lp(a) levels.