Baseline low-density lipoprotein cholesterol levels and outcome in patients with heart failure

Predictive value of remnant cholesterol level for all-cause mortality in heart failure patients

Background

Lower cholesterol levels are associated with increased mortality in heart failure (HF) patients. Remnant cholesterol corresponds to all cholesterol not found in high-density lipoprotein (HDL) and low-density lipoprotein (LDL). The prognostic role of remnant cholesterol in HF remains unknown.

Objective

To reveal the relationship between the baseline remnant cholesterol level and all-cause mortality in HF patients.

Methods

This study enrolled 2,823 patients hospitalized for HF. Kaplan-Meier analysis, Cox regression, C-statistic, net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were used to evaluate the prognostic value of remnant cholesterol for all-cause mortality in HF.

Results

The mortality rate was lowest in the fourth quartile of remnant cholesterol, which had an adjusted hazard ratio (HR) for death of 0.56 [HR: 0.39, 95% confidence interval (CI): 0.46-0.68, p < 0.001] relative to the first quartile. After adjustment, a one-unit increase in the level of remnant cholesterol was associated with a 41% decrease in the risk of all-cause mortality (HR: 0.59, 95% CI: 0.47-0.73, p < 0.001). A refinement in risk prediction was observed after adding remnant cholesterol quartile to the original model (ΔC-statistic = 0.010, 95% CI: 0.003-0.017; NRI = 0.036, 95% CI: 0.003-0.070; IDI = 0.025, 95% CI: 0.018-0.033; all p < 0.05).

Conclusion

Low remnant cholesterol levels are associated with increased all-cause mortality in HF patients. The addition of the remnant cholesterol quartile improved the predictive value over traditional risk factors.

Clinical Trial Registration

ClinicalTrials.gov, Unique Identifier: NCT02664818.

Cholesterol Content of Very-Low-Density Lipoproteins Is Associated with 1-Year Mortality in Acute Heart Failure Patients

Considering the relationship between the extent of metabolic derangement and the disease severity in heart failure, we hypothesized that the lipid content of very-low-density lipoprotein (VLDL) may have prognostic value for 1 year mortality in acute heart failure (AHF). Baseline serum levels of VLDL cholesterol (VLDL-C), VLDL triglycerides (VLDL-TG), VLDL phospholipids (VLDL-PL), and VLDL apolipoprotein B (VLDL-apoB) were measured using NMR spectroscopy. We calculated the ratios of the respective VLDL lipids and VLDL apoB (VLDL-C/VLDL-apoB, VLDL-TG/VLDL-apoB, and VLDL-PL/VLDL-apoB), as estimators of the cholesterol, triglyceride, and phospholipid content of VLDL particles and tested their association with mortality. Out of 315 AHF patients, 118 (37.5%) patients died within 1 year after hospitalization for AHF. Univariable Cox regression analyses revealed a significant inverse association of VLDL-C/VLDL-apoB (hazard ratio (HR) 0.43, 95% confidence interval (CI) 0.29−0.64, p < 0.001), VLDL-TG/VLDL-apoB (HR 0.79, 95% CI 0.71−0.88, p < 0.001), and VLDL-PL/VLDL-apoB (HR 0.37, 95% CI 0.25−0.56, p < 0.001) with 1 year mortality. Of the tested parameters, only VLDL-C/VLDL-apoB remained significant after adjustment for age and sex, as well as other clinical and laboratory parameters that showed a significant association with 1 year mortality in the univariable analyses. We conclude that cholesterol content of circulating VLDL (VLDL-C/VLDL-apoB) might be of prognostic value in AHF.

A Systematic Review with Meta-analysis of Biomarkers for detection of Pulmonary Arterial Hypertension

Rationale

The blood is a rich source of potential biomarkers for the diagnosis of idiopathic and hereditary pulmonary arterial hypertension (iPAH and hPAH, referred to as “PAH”). While a lot of biomarkers have been identified for PAH, the clinical utility of these biomarkers often remains unclear. Here, we performed an unbiased meta-analysis of published biomarkers to identify biomarkers with the highest performance for detection of PAH.

Methods

A literature search (in PubMed, Embase.com, Clarivate Analytics/Web of Science Core Collection and Wiley/Cochrane Library) was performed up to 28 January 2021. Primary end points were blood biomarker levels in PAH versus asymptomatic controls or patients suspected of pulmonary hypertension (PH) with proven normal haemodynamic profiles.

Results

149 articles were identified by the literature search. Meta-analysis of 26 biomarkers yielded 17 biomarkers that were differentially expressed in PAH and non-PH control subjects. Red cell distribution width, low density lipid-cholesterol, d-dimer, N-terminal prohormone of brain natriuretic protein (NT-proBNP), interleukin-6 (IL-6) and uric acid were biomarkers with the largest observed differences, largest sample sizes and a low risk of publication bias. Receiver operating characteristic curves and sensitivity/specificity analyses demonstrated that NT-proBNP had a high sensitivity, but low specificity for PAH. For the other biomarkers, insufficient data on diagnostic accuracy with receiver operating characteristic curves were available for meta-analysis.

Conclusion

This meta-analysis validates NT-proBNP as a biomarker with high sensitivity for PAH, albeit with low specificity. The majority of biomarkers evaluated in this meta-analysis lacked either external validation or data on diagnostic accuracy. Further validation studies are required as well as studies that test combinations of biomarkers to improve specificity.

Meta-analysis of 26 biomarkers yielded 17 differentially expressed biomarkers in PAH. NT-proBNP had the highest diagnostic accuracy but had a low specificity for PAH. Other markers, including IL-6, RDW, LDL-c, D-dimer and UA, lacked clinical validation.https://bit.ly/3J4YAyC

U-Shaped Association Between Serum Uric Acid Level and Hypertensive Heart Failure: A Genetic Matching Case-Control Study

Background: Heart failure (HF) is a global pandemic and lays an added burden on public healthcare. Previous studies indicated that high and low serum uric acid levels are associated with worse outcomes in many diseases. Reduced serum uric acid may not result in a better outcome.

Methods: A comparative, matched cross-sectional study design was implemented. The matching variables were age, sex, BMI, BP, and histories of CKD, CVD, diabetes mellitus, stroke, hyperlipidemia. We reviewed the electronic medical records to identify patients diagnosed with hypertension or hypertensive heart failure (HHF) admitted to Beijing Hospital's cardiology department.

Results: The median age of the two groups after matching are 71. There are 55.6% males in the hypertension group and 53.8% in the heart failure group. Univariate logistic regression analysis showed that UA's quadratic term is significant (OR = 1.00, 95% CI 1.00 to 1.00; P = 0.03), which indicated a u-shaped relationship between hypertension and HHF. FBS (OR = 0.22, 95% CI 0.05 to 0.95, p = 0.07) and HDL (OR = 1.23, 95% CI 1.00 to 1.54, P = 0.05) were not significant but close.

Conclusion: Our results supported that both low and high uric acid levels were predictive of hypertensive heart failure. Besides, high-density lipoprotein cholesterol and fasting blood sugar were also associated with hypertensive heart failure. Low-density lipoprotein cholesterol was not associated with hypertensive heart failure.

The Association between Nutritional Status and In-Hospital Mortality among Patients with Heart Failure-A Result of the Retrospective Nutritional Status Heart Study 2 (NSHS2)

BACKGROUND

A nutritional status is related to the prognosis and length of hospitalisation of patients with heart failure (HF). This study aims to assess the effect of nutritional status on in-hospital mortality in patients with heart failure.

METHODS

We conducted a retrospective study and analysis of medical records of 1056 patients admitted to the cardiology department of the University Clinical Hospital in Wroclaw (Poland).

RESULTS

A total of 1056 individuals were included in the analysis. A total of 5.5% of patients died during an in-hospital stay. It was found that in the sample group, 25% of patients who died had a BMI (body mass index) within the normal range, 6% were underweight, 47% were overweight, and 22% were obese. Our results show that non-survivors have a significantly higher nutrition risk screening (NRS) ≥3 (21% vs. 3%; p < 0.001); NYHA (New York Heart Association) grade 4 (70% vs. 24%; p < 0.001). The risk of death was lower in obese patients (HR = 0.51; p = 0.028) and those with LDL (low-density lipoprotein) levels from 116 to <190 mg/dL (HR = 0.10; p = 0.009, compared to those with LDL <55 mg/dL). The risk of death was higher in those with NRS (nutritional risk score) score ≥3 (HR = 2.31; p = 0.014), HFmrEF fraction (HR = 4.69; p < 0.001), and LDL levels > 190 mg/dL (HR = 3.20; p = 0.038).

CONCLUSION

The malnutrition status correlates with an increased risk of death during hospitalisation. Higher TC (total cholesterol) level were related to a lower risk of death, which may indicate the "lipid paradox". Higher BMI results were related to a lower risk of death, which may indicate the "obesity paradox".

The Association between Nutritional Status and In-Hospital Mortality among Patients with Acute Coronary Syndrome-A Result of the Retrospective Nutritional Status Heart Study (NSHS)

BACKGROUND

Nutritional status is related to the prognosis and the length of hospitalization of individuals with myocardial infarction. This study aimed to assess the effects of nutritional status on in-hospital mortality in patients with acute coronary syndrome.

METHODS

We performed a retrospective study of 1623 medical records of patients admitted to the cardiology department of the University Clinical Hospital in Wroclaw (Poland) between 2017 and 2019.

RESULTS

It was found that, of those who died in the sample, 50% had a BMI within the normal range, 29% were in the overweight range and 18% were in the obese range. Patients who died had significantly more frequent occurrences of the following: Nutrition Risk Screening (NRS) ≥ 3 (20% vs. 6%; p < 0.001); heart failure (53% vs. 25%; p < 0.001); or a history of stroke (22% vs. 9%; p < 0.001), arterial hypertension (66% vs. 19%; p < 0001) or diabetes (41% vs. 19%; p < 0.001). Statistically significant differences were found when considering the type of infarction, diabetes or people with low-density lipoprotein greater than or equal to 70 mg/dL.

CONCLUSIONS

This study shows that malnutrition correlates with an increased risk of death during hospitalization.

Low-density lipoprotein cholesterol and all-cause mortality: findings from the China health and retirement longitudinal study

OBJECTIVES

To investigate the relationship between low-density lipoprotein cholesterol (LDL-C) and all-cause mortality among middle-aged and elderly Chinese population.

DESIGN

Prospective cohort study.

SETTING

This study used data from the China Health and Retirement Longitudinal Study.

PARTICIPANTS

Middle-aged and elderly participants with complete data were enrolled for a 4-year follow-up of total mortality and plasma levels of LDL-C, including 4981 male respondents and 5529 female respondents.

RESULTS

During a 4-year follow-up, there were 305 and 219 deaths in men and women, respectively. Compared with the first quintile (Q1) of LDL-C, the adjusted HRs (95% CIs) were 0.818 (0.531 to 1.260) for Q2, 0.782 (0.507 to 1.208) for Q3, 0.605 (0.381 to 0.962) for Q4 and 0.803 (0.506 to 1.274) for Q5 in men. The results from restricted cubic spine (RCS) showed that when the 20th percentile of LDL-C levels (84 mg/dL) was used as the reference, a lower LDL-C concentration (<84 mg/dL) was associated with a higher 4-year all-cause mortality risk. By contrast, both quintile analysis and RCS analysis did not show a statistically significant association in women.

CONCLUSIONS

Compared with moderately elevated LDL-C (eg, 117-137 mg/dL), a lower plasma level of LDL-C (eg, ≤84 mg/dL) was associated with an increased risk of 4-year all-cause mortality in middle-aged and elderly Chinese men. The results suggest the potential harmful effect of a quite low level of LDL-C on total mortality.

Prognostic role of traditional cardiovascular risk factors in patients with idiopathic pulmonary arterial hypertension

INTRODUCTION

Metabolic alterations have been recently associated with onset and progression of idiopathic pulmonary arterial hypertension (IPAH). We aimed to determine the prevalence and prognostic role of cardiovascular risk factors in patients with IPAH.

MATERIAL AND METHODS

Between February 2009 and January 2015 we recruited consecutive IPAH patients. Clinical assessment included medical history, fasting glucose, lipid profile, N-terminal pro-brain natriuretic peptide concentration, 6-minute walk test distance, WHO functional class and hemodynamic evaluation. Patients' risk was estimated based on the Swedish PAH Register grading system.

RESULTS

The study group included 61 IPAH patients, and the control group included 2413 Polish residents. When compared to the general population, IPAH patients had lower low-density lipoprotein cholesterol (LDL-C) and a higher triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio. Female patients were characterized by elevated glucose level, higher prevalence of diabetes and lower HDL-C than controls. PAH severity grade correlated positively with age and TG/HDL-C ratio (R = 0.29, p = 0.02) and inversely with LDL-C (R = -0.28, p = 0.03) and HDL-C (R = -0.39, p = 0.02) concentrations. After a follow-up of 48 (23-79) months we recorded 28 deaths in the IPAH group. In the regression analysis lower LDL-C (p = 0.002) and HDL-C (p = 0.0002) levels, and higher TG/HDL-C ratio (p = 0.003) and glucose level (p = 0.003) were associated with all-cause mortality after adjustment for age, sex or PAH severity grade.

CONCLUSIONS

Patients with IPAH are characterized by an altered profile of lipid and glucose metabolism. Lowered levels of LDL-C and HDL-C and increased TG/HDL-C ratio correlate with disease severity and together with elevated plasma glucose level predict poor survival in IPAH.

CHOLESTEROL AND CHLORIDE IN ACUTE HEART FAILURE

Detecting predictors of poor outcome is crucial for understanding the underlying pathophysiology of heart failure (HF) and thus creating new therapeutic concepts. It is well established that low serum lipid levels are associated with unfavorable outcomes in HF patients. Several studies examined the association between serum lipids and established predictors of mortality in HF patients. The aim of the present study was to examine the association of serum lipid and chloride concentrations, as well as their impact on survival in acute heart failure (AHF). The present study was performed as a prospective, single-centre, observational research. The study included 152 patients with AHF. Spearman's correlation coefficient revealed a significant positive correlation of serum chloride levels with serum levels of total cholesterol (ρ 0.221, p=0.006), low-density lipoprotein cholesterol (LDL-c) (ρ 0.187, p=0.015) and high-density lipoprotein-cholesterol (HDL-c) (ρ 0.169, p=0.038). Binary logistic regression revealed a significant association of chloride, total cholesterol and LDL-c serum levels measured at admission with hospital survival (OR 1.077, CI 1.01-1.154, p=0.034), (OR 1.731, CI 1.090-2.748, p=0.020) and (OR 1.839, CI 1.033-3.274, p=0.038), respectively, as well as with 3-month survival (OR 1.065, CI 1.002-1.131, p=0.042), (OR 1.625, CI 1.147-2.303, p=0.006) and (OR 1.711, CI 1.117-2.622, p=0.014), respectively. In conclusion, positive statistical association between serum cholesterol (total cholesterol, LDL-c and HDL-c) and chloride levels may suggest their similar modulation by AHF pathophysiology. Serum levels of total cholesterol, LDL-c and chloride contribute to patient survival.

Prognostic Impact of Statin Intensity in Heart Failure Patients With Ischemic Heart Disease: A Report From the CHART-2 (Chronic Heart Failure Registry and Analysis in the Tohoku District 2) Study

Background

The beneficial prognostic impact of statins has been established in patients with ischemic heart disease but not in those with heart failure (HF). In addition, it is still unclear whether patients benefit from statins regardless of low‐density lipoprotein cholesterol levels.

Methods and Results

We examined 2444 consecutive stage C or D HF patients with ischemic heart disease registered in CHART‐2 (Chronic Heart Failure Registry and Analysis in the Tohoku District 2), a multicenter, prospective, observational cohort study in Japan. Patients were divided into 3 groups according to the Japanese standard doses of statins and statin‐intensity categories defined by the 2013 American College of Cardiology and American Heart Association guidelines: higher (moderate‐high)‐intensity (n=868), lower (low)‐intensity (n=526), and no statin (n=1050). The median follow‐up period was 6.4 years (13929 person‐years). Analysis with the inverse probability of treatment weighted using a propensity score for multiple treatment revealed that both the higher‐intesity group (hazard ratio [HR]: 0.68; P<0.001) and the lower‐intensity group (HR: 0.82; P<0.001) had significantly lower incidence of the primary end point—a composite of all‐cause death and HF admission—compared with the no statin group. The higher‐intensity statin group had significantly lower incidence of the primary end point (HR: 0.82; P<0.001), all‐cause death (HR: 0.83; P<0.001), and HF admission (HR: 0.78; P<0.001) than the lower‐intensity statin group. Moreover, the use of statins, either higher‐ or lower‐intensity, was associated with reduced incidence of the primary end point, regardless of low‐density lipoprotein cholesterol levels.

Conclusions

These results suggest that statin use, particularly the use of higher‐intensity statins, has a beneficial prognostic impact in HF patients with ischemic heart disease, regardless of low‐density lipoprotein cholesterol levels.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00418041.

Recovery of Serum Cholesterol Predicts Survival After Left Ventricular Assist Device Implantation

BACKGROUND

Advanced systolic heart failure is associated with myocardial and systemic metabolic abnormalities, including low levels of total cholesterol and low-density lipoprotein. Low cholesterol and low-density lipoprotein have been associated with greater mortality in heart failure. Implantation of a left ventricular assist device (LVAD) reverses some of the metabolic derangements of advanced heart failure.

METHODS AND RESULTS

A cohort was retrospectively assembled from 2 high-volume implantation centers, totaling 295 continuous-flow LVAD recipients with ≥2 cholesterol values available. The cohort was predominantly bridge-to-transplantation (67%), with median age of 59 years and 49% ischemic heart failure cause. Total cholesterol, low-density lipoprotein, high-density lipoprotein, and triglyceride levels all significantly increased after LVAD implantation (median values from implantation to 3 months post implantation 125-150 mg/dL, 67-85 mg/dL, 32-42 mg/dL, and 97-126 mg/dL, respectively). On Cox proportional hazards modeling, patients achieving recovery of total cholesterol levels, defined as a median or greater change from pre implantation to 3 months post-LVAD implantation, had significantly better unadjusted survival (hazard ratio, 0.445; 95% confidence interval, 0.212-0.932) and adjusted survival (hazard ratio, 0.241; 95% confidence interval, 0.092-0.628) than those without cholesterol recovery after LVAD implantation. The continuous variable of total cholesterol at 3 months post implantation and the cholesterol increase from pre implantation to 3 months were also both significantly associated with survival during LVAD support.

CONCLUSIONS

Initiation of continuous-flow LVAD support was associated with significant recovery of all 4 lipid variables. Patients with a greater increase in total cholesterol by 3 months post implantation had superior survival during LVAD support.

Statins attenuate but do not eliminate the reverse epidemiology of total serum cholesterol in patients with non-ischemic chronic heart failure

BACKGROUND

In patients with chronic heart failure (CHF) increasing levels of total serum cholesterol are associated with improved survival - while statin usage is not. The impact of statin treatment on the "reverse epidemiology" of cholesterol is unclear.

METHODS

2992 consecutive patients with non-ischemic CHF due to left ventricular systolic dysfunction from the Norwegian CHF Registry and the CHF Registries of the Universities of Hull, UK, and Heidelberg, Germany, were studied. 1736 patients were individually double-matched on both cholesterol levels and the individual propensity scores for statin treatment. All-cause mortality was analyzed as a function of baseline cholesterol and statin use in both the general and the matched sample.

RESULTS

1209 patients (40.4%) received a statin. During a follow-up of 13,740 patient-years, 360 statin users (29.8%) and 573 (32.1%) statin non-users died. When grouped according to total cholesterol levels as low (≤3.6mmol/L), moderate (3.7-4.9mmol/L), high (4.8-6.2mmol/L), and very high (>6.2mmol/L), we found improved survival with very high as compared with low cholesterol levels. This association was present in statin users and non-users in both the general and matched sample (p<0.05 for each group comparison). The negative association of total cholesterol and mortality persisted when cholesterol was treated as a continuous variable (HR 0.83, 95%CI 0.77-0.90, p<0.001 for matched patients), but it was less pronounced in statin users than in non-users (F-test p<0.001).

CONCLUSIONS

Statins attenuate but do not eliminate the reverse epidemiological association between increasing total serum cholesterol and improved survival in patients with non-ischemic CHF.

Low-density lipoprotein cholesterol and survival in pulmonary arterial hypertension

Low-density lipoprotein cholesterol(LDL-C) is a well established metabolic marker of cardiovascular risk, however, its role in pulmonary arterial hypertension (PAH) has not been determined. Therefore we assessed whether LDL-C levels are altered in PAH patients, if they are associated with survival in this group and whether pulmonary hypertension (PH) reversal can influence LDL-C levels. Consecutive 46 PAH males and 94 females were age matched with a representative sample of 1168 males and 1245 females, respectively. Cox regression models were used to assess the association between LDL-C and mortality. The effect of PH reversal on LDL-C levels was assessed in 34 patients with chronic thromboembolic pulmonary hypertension (CTEPH) undergoing invasive treatment. LDL-C was lower in both PAH (2.6 ± 0.8 mmol/l) and CTEPH (2.7 ± 0.7 mmol/l) patients when compared to controls (3.2 ± 1.1 mmol/l, p < 0.001). In PAH patients lower LDL-C significantly predicted death (HR:0.44/1 mmol/l, 95%CI:0.26-0.74, p = 0.002) after a median follow-up time of 33(21-36) months. In the CTEPH group, LDL-C increased (from 2.6[2.1-3.2] to 4.0[2.8-4.9]mmol/l, p = 0.01) in patients with PH reversal but remained unchanged in other patients (2.4[2.2-2.7] vs 2.3[2.1-2.5]mmol/l, p = 0.51). We concluded that LDL-C level is low in patients with PAH and is associated with an increased risk of death. Reversal of PH increases LDL-C levels.

Prevalence and characteristics of patients with low levels of low-density lipoprotein cholesterol in northern Denmark: a descriptive study

BACKGROUND

With the emergence of new lipid-lowering therapies, more patients are expected to achieve substantial lowering of low-density lipoprotein cholesterol (LDL-C). However, there are limited data examining the clinical experience of patients with low (<1.3 mmol/L) or very low (<0.65 mmol/L) levels of LDL-C. To provide information on patients with low LDL-C, we identified and characterized persons with low LDL-C using data from Danish medical databases.

METHODS

Using a population-based clinical laboratory database, we identified adults with at least one LDL-C measurement in northern Denmark between 1998 and 2011 (population approximately 1.5 million persons). Based on the lowest measurement during the study period, we divided patients into groups with low (<1.3 mmol/L), moderate (1.3-3.3 mmol/L), or high (>3.3 mmol/L) LDL-C. We described their demographic characteristics, entire comorbidity history, and 90-day prescription history prior to the lowest LDL-C value measured. Finally, we further restricted the analysis to individuals with very low LDL-C (<0.65 mmol/L).

RESULTS

Among 765,503 persons with an LDL-C measurement, 23% had high LDL-C, 73% had moderate LDL-C, and 4.8% had low LDL-C. In the latter group, 9.6% (0.46% of total) had very low LDL-C. Compared with the moderate and high LDL-C categories, the low LDL-C group included more males and older persons with a higher prevalence of cardiovascular disease, diabetes, chronic pulmonary disease, ulcer disease, and obesity, as measured by hospital diagnoses or relevant prescription drugs for these diseases. Cancer and use of psychotropic drugs were also more prevalent. These patterns of distribution became even more pronounced when restricting to individuals with very low LDL-C.

CONCLUSION

Using Danish medical databases, we identified a cohort of patients with low LDL-C and found that cohort members differed from patients with higher LDL-C levels. These differences may be explained by various factors, including prescribing patterns of lipid-lowering therapies.

Low levels of low-density lipoprotein cholesterol: a negative predictor of survival in elderly patients with advanced heart failure

OBJECTIVES

There are conflicting reports on the role of cholesterol as an adverse prognostic predictor in patients with heart failure (HF). This study aimed to examine the impact of low levels of low-density lipoprotein cholesterol (LDL-c) on cardiac mortality in a cohort of elderly patients with moderate and severe HF.

METHODS

Chronic HF patients from the HF Unit at the Tel-Aviv Medical Center (n = 212, 77% males) with an average NYHA classification of 2.8, a mean age of 76.9 ± 7.3 years (range 66-91) and a mean follow-up of 3.7 years were consecutively enrolled. The cohort was divided into tertiles according to LDL-c levels: LDL <90 mg/dl (group 1), LDL 90-115 mg/dl (group 2) and LDL >115 mg/dl (group 3).

RESULTS

The Cox regression analysis revealed that group 3 patients had the best outcome (p = 0.01 vs. groups 2 and 3), with 58% of them surviving longer than 50 months compared to 34% in group 1. The same trend was seen in the group of patients suffering from ischemic cardiomyopathy and in patients who were treated by statins (p = 0.04).

CONCLUSION

Low LDL-c levels are associated with a reduced survival in elderly patients with clinically controlled moderate and severe HF.

Anti-oxidized low-density lipoprotein antibodies in chronic heart failure

Oxidative stress may play a significant role in the pathogenesis of heart failure (HF). Antibodies to oxidized low-density lipoprotein (oxLDL Abs) reflect an immune response to LDL over a prolonged period and may represent long-term oxidative stress in HF. The oxLDL plasma level is a useful predictor of mortality in HF patients, and measurement of the oxLDL Abs level may allow better management of those patients. Antibodies to oxLDL also significantly correlate with the New York Heart Association score. Hypercholesterolemia, smoking, hypertension, and obesity are risk factors for atherosclerotic coronary heart disease (CHD) leading to HF, but these factors account for only one-half of all cases, and understanding of the pathologic process underlying HF remains incomplete. Nutrients with antioxidant properties can reduce the susceptibility of LDL to oxidation. Antioxidant therapy may be an adjunct to lipid-lowering, angiotensin converting enzyme inhibition and metformin (in diabetes) therapy for the greatest impact on CHD and HF. Observational data suggest a protective effect of antioxidant supplementation on the incidence of HD. This review summarizes the data on oxLDL Abs as a predictor of morbidity and mortality in HF patients.

TNFα in myocardial ischemia/reperfusion, remodeling and heart failure

TNFα is crucially involved in the pathogenesis and progression of myocardial ischemia/reperfusion injury and heart failure. The formation and release of TNFα and its downstream signal transduction cascade following activation of its two receptor subtypes are characterized. Myocardial TNFα and TNF receptor activation have an ambivalent role in myocardial ischemia/reperfusion injury and protection from it. Excessive TNFα expression and subsequent cardiomyocyte TNF receptor type 1 stimulation induce contractile dysfunction, hypertrophy, fibrosis and cell death, while a lower TNFα concentration and subsequent cardiomyocyte TNF receptor type 2 stimulation are protective. Apart from its concentration and receptor subtype, the myocardial action of TNFα depends on the duration of its exposure and its localization. While detrimental during sustained ischemia, TNFα contributes to ischemic preconditioning protection, no matter whether it is the first, second or third window of protection, and both TNF receptors are involved in the protective signal transduction cascade. Finally, the available clinical attempts to antagonize TNFα in cardiovascular disease, notably heart failure, are critically discussed.

Lipid paradox in rheumatoid arthritis: the impact of serum lipid measures and systemic inflammation on the risk of cardiovascular disease

OBJECTIVE

To examine the impact of systemic inflammation and serum lipids on cardiovascular disease (CVD) in rheumatoid arthritis (RA).

METHODS

In a population-based RA incident cohort (1987 American College of Rheumatology criteria first met between 1988 and 2007), details were collected of serum lipid measures, erythrocyte sedimentation rates (ESRs), C-reactive protein (CRP) measures and cardiovascular events, including ischaemic heart disease and heart failure. Cox models were used to examine the association of lipids and inflammation with the risk of CVD and mortality, adjusting for age, sex and year of RA incidence.

RESULTS

The study included 651 patients with RA (mean age 55.8 years, 69% female); 67% were rheumatoid factor positive. ESR was associated with the risk of CVD (HR=1.2 per 10 mm/h increase, 95% CI 1.1 to 1.3). Similar findings, although not statistically significant, were seen with CRP (p=0.07). A significant non-linear association for total cholesterol (TCh) with risk of CVD was found, with 3.3-fold increased risk for TCh <4 mmol/l (95% CI 1.5 to 7.2) and no increased risk of CVD for TCh ≥4 mmol/l (p=0.57). Low low-density lipoprotein cholesterol (LDL <2 mmol/l) was associated with marginally increased risk of CVD (p=0.10); there was no increased risk for LDL ≥2 mmol/l (p=0.76).

CONCLUSION

Inflammatory measures (particularly, ESR) are significantly associated with the risk of CVD in RA. Lipids may have paradoxical associations with the risk of CVD in RA, whereby lower TCh and LDL levels are associated with increased cardiovascular risk.