Alteration of relation of atherogenic lipoprotein cholesterol to apolipoprotein B by intensive statin therapy in patients with acute coronary syndrome (from the Limiting UNdertreatment of lipids in ACS With Rosuvastatin [LUNAR] Trial)

Beyond LDL-C: unravelling the residual atherosclerotic cardiovascular disease risk landscape-focus on hypertriglyceridaemia

Aims

Historically, atherosclerotic cardiovascular disease (ASCVD) risk profile mitigation has had a predominant focus on low density lipoprotein cholesterol (LDL-C). In this narrative review we explore the residual ASCVD risk profile beyond LDL-C with a focus on hypertriglyceridaemia, recent clinical trials of therapeutics targeting hypertriglyceridaemia and novel modalities addressing other residual ASCVD risk factors.

Findings

Hypertriglyceridaemia remains a significant ASCVD risk despite low LDL-C in statin or proprotein convertase subtilisin/kexin type 9 inhibitor-treated patients. Large population-based observational studies have consistently demonstrated an association between hypertriglyceridaemia with ASCVD. This relationship is complicated by the co-existence of low high-density lipoprotein cholesterol. Despite significantly improving atherogenic dyslipidaemia, the most recent clinical trial outcome has cast doubt on the utility of pharmacologically lowering triglyceride concentrations using fibrates. On the other hand, purified eicosapentaenoic acid (EPA), but not in combination with docosahexaenoic acid (DHA), has produced favourable ASCVD outcomes. The outcome of these trials suggests alternate pathways involved in ASCVD risk modulation. Several other pharmacotherapies have been proposed to address other ASCVD risk factors targeting inflammation, thrombotic and metabolic factors.

Implications

Hypertriglyceridaemia poses a significant residual ASCVD risk in patients already on LDL-C lowering therapy. Results from pharmacologically lowering triglyceride are conflicting. The role of fibrates and combination of EPA and DHA is under question but there is now convincing evidence of ASCVD risk reduction with pure EPA in a subgroup of patients with hypertriglyceridaemia. Clinical guidelines should be updated in line with recent clinical trials evidence. Novel agents targeting non-conventional ASCVD risks need further evaluation.

Higher Non-High-Density Lipoprotein Cholesterol Was Higher Associated With Cardiovascular Disease Comparing Higher LDL-C in Nine Years Follow Up: Cohort Study

Objective

Non-high-density lipoprotein cholesterol (non-HDL-C) may be equivalent to or superior to low-density lipoprotein cholesterol (LDL-C) for the prediction of cardiovascular disease (CVD). However, studies comparing the predictive values of LDL-C and non-HDL-C levels for CVD have yielded conflicting results. In this study, we evaluated the relationship between non-HDL-C, LDL-C, and CVD using a large-scale population dataset from the National Health Information Database (NHID).

Methods

We performed a retrospective observational cohort study of 3,866,366 individuals ≥ 20 years, from 2009 to 2018, using the NHID. The participants were divided into LDL-C and non-HDL-C quartiles. The outcome variables included stroke, myocardial infarction (MI), and both. All outcomes were analyzed using Cox proportional hazards regression analysis while controlling for baseline covariates (age, sex, smoking, drinking, regular exercise, body mass index, diabetes, hypertension, and statin use).

Results

During 9.1 years of mean follow-up, stroke was diagnosed in 60,081 (1.55%), MI in 31,234 (0.81%), and both stroke and MI in 88,513 (2.29%) participants. Multivariate-adjusted hazard ratios (HRs) for patients in the highest non-HDL-C quartile demonstrated that these patients had a higher risk of stroke (HR, 1.254; 95% confidence interval [CI], 1.224-1.285), MI (HR, 1.918; 95% CI, 1.853-1.986), and both (HR, 1.456; 95% CI, 1.427-1.486) compared with participants in the lowest quartile. These were higher than the HRs for patients in the highest LDL-C quartile for stroke (HR, 1.134; 95% CI, 1.108-1.160), MI (HR, 1.601; 95% CI, 1.551-1.653), and both (HR, 1.281; 95% CI, 1.257-1.306).

Conclusion

In our large population study, higher non-HDL-C levels were associated with CVD than LDL-C levels.

Non-HDL cholesterol is an independent predictor of long-term cardiovascular events in patients with dyslipidemia after renal transplantation

BACKGROUND

Posttransplant dyslipidemia is a common condition in renal transplantation recipients (RTR) and is related to poor cardiac outcomes. We aimed to demonstrate the value of non-high-density lipoprotein cholesterol (non-HDL-C) in predicting long-term major cardiovascular and cerebrovascular events (MACCE) in RTR with dyslipidemia.

METHODS

Patients who had undergone renal transplantation between 2011 and 2019 were retrospectively analysed and were classified as normal non-HDL-C and high non-HDL-C groups based on first year levels. Development of high non-HDL-C levels was used to predict the occurrence of MACCE (a combination of cardiac death, nonfatal myocardial infarction, unstable angina, and nonfatal stroke) and all-cause death during the long-term follow-up.

RESULTS

Overall, 674 patients were included, of whom 470 (69.7%) were male; the mean age was 43.6 ± 13.2 years. The mean follow-up duration was 5.5 ± 2.29 years 1 year after the transplant. MACCE occurred during the follow-up in 102 (61.8%) patients in the high non-HDL-C group and 13 (2.6%) patients in the normal non-HDL-C group (P < .001). High non-HDL-C was a predictor of MACCE in the multivariate analysis (hazard ratio [HR] 1.02, 95% confidence interval [CI] 1.01-1.02, P < .001). Smoking (HR: 1.92, 95% CI 1.16-3.20, P < .001), cadaver graft (HR: 2.55, 95% CI 1.52-4.26, P < .001), and left ventricular ejection fraction (HR: 0.96, 95% CI 0.94-0.98, P < .001) were also predictors of MACCE. Kaplan-Meier analysis revealed that all MACCE components and all-cause mortality were significantly higher in the high non-HDL-C group (P < .001).

CONCLUSION

Non-HDL-C was closely related to long-term cardiac outcomes in RTR with dyslipidemia. Non-HDL-C should be among the primary goals in lipid-lowering treatment in post-transplant dyslipidemia.

Lipid-lowering therapy: Guidelines to precision medicine

Dyslipidemia is correlated with a series of health problems, such as obesity, insulin resistance, and the development of cardiovascular disease (CVD). Currently, accumulating evidence sheds light on the fact that β-hydroxy β-methylglutaryl-CoA reductase inhibitors, named statins, could lower circulating lipid-density lipoprotein cholesterol (LDL-C) and represent a revolution for the prevention of metabolic disorder diseases. In addition, statins remain the cornerstone of LDL-C-lowering treatments, together with ezetimibe and bile acid sequestrants, which are used either in combination with statins or as monotherapies in the case of statin intolerance or side effects. On the other hand, other medicines that reduce circulating LDL-C have also been researched, including inhibitors of protein convertase subtilisin/kexin type 9 (PCSK9). More recently, PCSK9 inhibitors have been approved for the secondary prevention of CVD and for the atherogenic dyslipidemia therapy. Here, we summarize the latest guidelines for the management of dyslipidemia and its relation to CVD, focusing on LDL-C-lowering medicines that are either available in daily clinical practice or under investigation. In addition, we also discuss the "who, when, and how" with respect to treating patients with dyslipidemia according to LDL-C reduction as an individualized clinical precision medicine.

Bempedoic acid plus ezetimibe fixed-dose combination in patients with hypercholesterolemia and high CVD risk treated with maximally tolerated statin therapy

Aims

The aim of this study was to evaluate the low-density lipoprotein cholesterol lowering efficacy and safety of a bempedoic acid 180 mg and ezetimibe 10 mg fixed-dose combination in patients with hypercholesterolemia and a high risk of cardiovascular disease receiving maximally tolerated statin therapy.

Methods

This phase 3, double-blind clinical trial enrolled adult patients at high risk of cardiovascular disease due to atherosclerotic cardiovascular disease, heterozygous familial hypercholesterolemia, or multiple cardiovascular disease risk factors. Patients were randomly assigned (2:2:2:1) to treatment with the fixed-dose combination, bempedoic acid 180 mg, ezetimibe 10 mg or placebo added to stable background statin therapy for 12 weeks. The primary efficacy endpoint was the percentage change from baseline to week 12 in low-density lipoprotein cholesterol.

Results

Among the 301 patients included in the primary analysis, the mean baseline low-density lipoprotein cholesterol level was 3.87 mmol/L (149.8 mg/dL). At week 12, the fixed-dose combination lowered low-density lipoprotein cholesterol (–36.2%) significantly more than placebo (1.8% (placebo-corrected difference –38.0%); P < 0.001), ezetimibe alone (–23.2%; P < 0.001) or bempedoic acid alone (–17.2%; P < 0.001). The fixed-dose combination lowered low-density lipoprotein cholesterol levels similarly across subgroups, including patients receiving high-intensity, other-intensity or no statin therapy. Improvements with the fixed-dose combination were also observed in secondary efficacy endpoints, including high-sensitivity C-reactive protein. In this trial, fixed-dose combination treatment had a generally similar safety profile compared with bempedoic acid, ezetimibe or placebo.

Conclusion

The bempedoic acid and ezetimibe fixed-dose combination significantly lowered low-density lipoprotein cholesterol versus placebo or other oral monotherapies and had a favourable safety profile when added to maximally tolerated statin therapy in patients with hypercholesterolemia and high cardiovascular disease risk.

Trial Registration

ClinicalTrials.gov identifier: NCT03337308.

Goals of non-high density lipoprotein cholesterol need to be adjusted in Chinese acute coronary syndrome patients: Findings from the CCC-ACS project

BACKGROUND

Guidelines recommended non-high density lipoprotein cholesterol (non-HDL-C) as a co-primary target, and set non-HDL-C goals as 30 mg/dl higher than low-density lipoprotein cholesterol (LDL-C) goals. However, the value is largely uncertain in Chinese patients.

METHODS

We assigned non-HDL-C values at the same percentiles correspondent to LDL-C goals for patients from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) Project. We calculated the differences between non-HDL-C and LDL-C and proposed appropriate adding values according to LDL-C and TG concentrations.

RESULTS

Among 73,495 patients, 17.7% used lipid-lowering agents before admission. Of these, 27.2% achieved LDL-C <70 mg/dl while 39.4% achieved non-HDL-C <100 mg/dl. The mean difference between non-HDL-C and LDL-C was 23.2 mg/dl, which could be affected by LDL-C and TG concentrations. Importantly, of patients with LDL-C concentrations ≤100 mg/dl, the mean differences were 19.1 mg/dl in patients with TG ≤150 mg/dl and 24.6 mg/dl in patients with TG >150 mg/dl.

CONCLUSIONS

There are significant differences between LDL-C and non-HDL-C in Chinese ACS patients. For secondary prevention, on average, the adding values should be 20 mg/dl for patients with TG ≤150 mg/dl and 25 mg/dl for patients with TG >150 mg/dl when LDL-C goals of 70 mg/dl is achieved.

Evidence for changing lipid management strategy to focus on non-high density lipoprotein cholesterol

Low-density lipoprotein cholesterol (LDL-C) has been recommended as the primary treatment target on lipid management in coronary heart disease (CHD) patients for past several decades. However, even by aggressive LDL-C lowering treatment, patients still present a significant residual risk of major adverse cardiovascular events (MACE). Non-high-density lipoprotein cholesterol (non-HDL-C) contained all the atherogenic lipoproteins, such as chylomicron, very-low density lipoprotein (VLDL), LDL, intermediate density lipoprotein (IDL). Many prospective observation studies have found that non-HDL-C was better than LDL-C in predicting risks of MACE. Since non-HDL-C appears to be superior for risk prediction beyond LDL-C, current guidelines have emphasize the importance of non-HDL-C for guiding cardiovascular prevention strategies and have flagged non-HDL-C as a co-primary therapeutic target. The goals of non-HDL-C were recommended as 30 mg/dl higher than the corresponding LDL-C goals, but the value seemed inappropriate. This review provide evidence for changing lipid management strategy to focus on non-HDL-C and appropriate values for adding to LDL-C goals would be proposed.

Lipid Biomarkers for Risk Assessment in Acute Coronary Syndromes

PURPOSE OF REVIEW

The objective of this review was to summarize evidence gathered for the prognostic value of routine and novel blood lipids and lipoproteins measured in patients with acute coronary syndromes (ACS).

RECENT FINDINGS

Data supports clear association with risk and actionable value for non-high-density lipoprotein (Non-HDL) cholesterol and plasma ceramides in a setting of ACS. The prognostic value and clinical actionability of apolipoprotein B (apoB) and lipoprotein(a) [Lp(a)] in ACS have not been thoroughly tested, while the data for omega-3 fatty acids and oxidized low-density lipoprotein (Ox-LDL) are either untested or more varied. Measuring basic lipids, which should include Non-HDL cholesterol, at the time of presentation for ACS is guideline mandated. Plasma ceramides also provide useful information to guide both treatment decisions and follow-up. Additional studies targeting ACS patients are necessary for apoB, Lp(a), omega-3 fatty acids, and Ox-LDL.

Concerns About the Use of Non-High-Density Lipoprotein Cholesterol as a Lipid Predictor

Introduction: Non-high-density lipoprotein (non-HDL) cholesterol is the sum of low-density lipoprotein (LDL) cholesterol and very-low-density lipoprotein (VLDL) cholesterol, and is usually approximated by the total cholesterol minus HDL-cholesterol. The National Lipid Association (NLA) has advocated the use of non-HDL cholesterol as its favoured lipid predictor. Cut-off points are based on LDL cholesterol values, with a lower end at 100 mg/dL (2.50 mmol/L) and a higher end at 190 mg/dL (4.75 mmol/L), adding 30 mg/dL (0.75 mmol/L) to keep triglyceride (TG) levels <150 mg/dL (1.70 mmol/L). Objectives: The author will demonstrate that the use of non-HDL cholesterol has not been fully considered. Methods: The author will examine a general population lipid database to demonstrate the frequency of distribution of non-HDL cholesterol in the part of the population that was known to have developed a form of atherothrombotic disease (ATD) and in the part that was not known to have done so. The effect of stratifying each non-HDL cholesterol quintile in terms of another lipid predictor that does not involve VLDL-cholesterol or TG will be demonstrated. The other risk predictor is the cholesterol retention fraction (CRF) defined as (LDL-HDL)/LDL. Findings: All non-HDL cholesterol quintiles above the lowest quintile had higher frequencies in the ATD population than in the non-ATD population. The highest two quintiles had frequencies in the ATD population that are 2.5-times as high as those in the non-ATD population, whereas in the middle two quintiles, the frequency in the ATD population was minimally higher than in the non-ATD population. In the lowest quintile, the frequency is much higher in the non-ATD population than in the ATD population. At any non-HDL cholesterol quintile, the average age of ATD onset depends on cigarette smoking (not discussed here) and the CRF. Higher CRF levels equate to an earlier average age of ATD onset and lower levels of CRF equate to a later onset. A 75-year-old male who was a hypertensive diabetic and a former smoker was not on statins because of low lipid levels, had clean arteries on angiography, whereas a 45-year-old normotensive, non-smoking patient with severe dyslipidaemia (obtained at first encounter) had a massive stroke due to carotid stenosis. Both had non-HDL cholesterol levels in the intermediate ATD risk quintiles. Conclusions: Non-HDL cholesterol is not the optimal predictor of the population at risk of atherothrombotic disease and its use should be reconsidered.

Efficacy comparison of atorvastatin versus rosuvastatin on blood lipid and microinflammatory state in maintenance hemodialysis patients

Introduction: To investigate the effect of Atorvastatin (ATO) and Rosuvastatin (ROS) on blood lipid, high sensitivity CRP (hs-CRP), interleukin-6 (IL-6), albumin (ALB), prealbumin (PA), and transferring (TF) in maintenance hemodialysis (MHD) patients.

Methods: Eighty MHD patients were enrolled and divided into two groups: ROS and ATO. Patients in Group ROS (n = 38) received ROS (10 mg/day), and those in group ATO (n = 42) received ATO (20 mg/day) for 12 weeks, respectively.

Findings: Administration of ROS and ATO both significantly reduced the concentrations of TC, LDL-C, TG, hs-CRP, and IL-6, but increased high-density lipoproteincholesterol (HDL-C), ALB, PA, and TF levels. Furthermore, the level of LDL-C decreased more significantly with inhibited microinflammation and improved nutrition situation in ROS group compared with ATO group. ATO and ROS not only decreased blood lipid levels but also inhibited the microinflammatory state and improved nutrition situation in MHD patients.

Discussion: The results have shown that ROS is better than ATO in the treatment of MHD patients.

Non-HDL Cholesterol and Triglycerides

Objectives—

Non–high-density lipoprotein cholesterol (non-HDLC) levels reflect the full burden of cholesterol transported in atherogenic lipoproteins. Genetic studies suggest a causal association between elevated triglycerides (TGs)-rich lipoproteins and atherosclerosis. We evaluated associations between achieved non-HDLC and TG levels on changes in coronary atheroma volume.

Approach and Results—

Data were analyzed from 9 clinical trials involving 4957 patients with coronary disease undergoing serial intravascular ultrasonography to assess changes in percent atheroma volume (ΔPAV) and were evaluated against on-treatment non-HDLC and TG levels. The effects of lower (<100 mg/dL) versus higher (≥100 mg/dL) achieved non-HDLC levels and lower (<200 mg/dL) versus higher (≥200 mg/dL) achieved TG levels were evaluated in populations with variable on-treatment low-density lipoprotein cholesterol (LDLC) </≥70 mg/dL and C-reactive protein </≥2 mg/L and in patients with or without diabetes mellitus. On-treatment non-HDLC levels linearly associated with ΔPAV. Overt PAV progression (ΔPAV>0) was associated with achieved TG levels >200 mg/dL, respectively. Lower on-treatment non-HDLC and TG levels associated with significant PAV regression compared with higher non-HDLC and TG levels across all levels of LDLC and C-reactive protein and irrespective of diabetic status ( P <0.001 across all comparisons). ΔPAV were more strongly influenced by changes in non-HDLC (β=0.62; P <0.001) compared with changes in LDLC (β=0.51; P <0.001). Kaplan–Meier sensitivity analyses demonstrated significantly greater major adverse cardiovascular event rates in those with higher versus lower non-HDLC and TG levels, with an earlier separation of the non-HDLC compared with the LDLC curve.

Conclusions—

Achieved non-HDLC levels seem more closely associated with coronary atheroma progression than LDLC. Plaque progression associates with achieved TGs, but only above levels of 200 mg/dL. These observations support a more prominent role for non-HDLC (and possibly TG) lowering in combating residual cardiovascular risk.

Non-high-density lipoprotein cholesterol: current status as cardiovascular marker

PURPOSE OF REVIEW

In this review, we summarize the evidence with regard to the rationale of using nonhigh density lipoprotein cholesterol (non-HDL-C) as a cardiovascular disease (CVD) risk factor, in relation to low-density lipoprotein cholesterol (LDL-C) and apolipoprotein B (apoB).

RECENT FINDINGS

In the 2015 National Lipid Association Annual Summary non-HDL-C is considered a coprimary target, apart from LDL-C. The other data published in the last 18 months about non-HDL-C support all the previous published data. There are no recent findings, which we deem to cause a change of the current opinion about non-HDL-C as a predictor for CVD.

SUMMARY

The existing evidence supports the claim that non-HDL-C is superior to LDL-C in CVD risk estimation.

Oxidized high-density lipoprotein accelerates atherosclerosis progression by inducing the imbalance between treg and teff in LDLR knockout mice

High density lipoprotein (HDL) dysfunction has been widely reported in clinic, and oxidation of HDL (ox-HDL) was shown to be one of the most common modifications in vivo and participate in the progression of atherosclerosis. But the behind mechanisms are still elusive. In this study, we firstly analyzed and found strong relationship between serum ox-HDL levels and risk factors of coronary artery diseases in clinic, then the effects of ox-HDL in initiation and progression of atherosclerosis in LDLR knockout mice were investigated by infusion of ox-HDL dissolved in chitosan hydrogel before the formation of lesions in vivo. Several new evidence were shown: (i) the serum levels of ox-HDL peaked early before the formation of lesions in LDLR mice fed with high fat diet similar to oxidative low density lipoprotein, (ii) the formation of atherosclerotic lesions could be accelerated by infusion of ox-HDL, (iii) the pro-atherosclerotic effects of ox-HDL were accompanied by imbalanced levels of effector and regulatory T cells and relative gene expressions, which implied that imbalance of teff and treg might contribute to the pro-atherosclerosis effects of ox-HDL.

National lipid association recommendations for patient-centered management of dyslipidemia: part 1--full report

The leadership of the National Lipid Association convened an Expert Panel to develop a consensus set of recommendations for patient-centered management of dyslipidemia in clinical medicine. An Executive Summary of those recommendations was previously published. This document provides support for the recommendations outlined in the Executive Summary. The major conclusions include (1) an elevated level of cholesterol carried by circulating apolipoprotein B-containing lipoproteins (non-high-density lipoprotein cholesterol and low-density lipoprotein cholesterol [LDL-C], termed atherogenic cholesterol) is a root cause of atherosclerosis, the key underlying process contributing to most clinical atherosclerotic cardiovascular disease (ASCVD) events; (2) reducing elevated levels of atherogenic cholesterol will lower ASCVD risk in proportion to the extent that atherogenic cholesterol is reduced. This benefit is presumed to result from atherogenic cholesterol lowering through multiple modalities, including lifestyle and drug therapies; (3) the intensity of risk-reduction therapy should generally be adjusted to the patient's absolute risk for an ASCVD event; (4) atherosclerosis is a process that often begins early in life and progresses for decades before resulting a clinical ASCVD event. Therefore, both intermediate-term and long-term or lifetime risk should be considered when assessing the potential benefits and hazards of risk-reduction therapies; (5) for patients in whom lipid-lowering drug therapy is indicated, statin treatment is the primary modality for reducing ASCVD risk; (6) nonlipid ASCVD risk factors should also be managed appropriately, particularly high blood pressure, cigarette smoking, and diabetes mellitus; and (7) the measurement and monitoring of atherogenic cholesterol levels remain an important part of a comprehensive ASCVD prevention strategy.

Lipid-lowering efficacy of atorvastatin

BACKGROUND

This represents the first update of this review, which was published in 2012. Atorvastatin is one of the most widely prescribed drugs and the most widely prescribed statin in the world. It is therefore important to know the dose-related magnitude of effect of atorvastatin on blood lipids.

OBJECTIVES

Primary objective To quantify the effects of various doses of atorvastatin on serum total cholesterol, low-density lipoprotein (LDL)-cholesterol, high-density lipoprotein (HDL)-cholesterol and triglycerides in individuals with and without evidence of cardiovascular disease. The primary focus of this review was determination of the mean per cent change from baseline of LDL-cholesterol. Secondary objectives • To quantify the variability of effects of various doses of atorvastatin.• To quantify withdrawals due to adverse effects (WDAEs) in placebo-controlled randomised controlled trials (RCTs).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 11, 2013), MEDLINE (1966 to December Week 2 2013), EMBASE (1980 to December Week 2 2013), Web of Science (1899 to December Week 2 2013) and BIOSIS Previews (1969 to December Week 2 2013). We applied no language restrictions.

SELECTION CRITERIA

Randomised controlled and uncontrolled before-and-after trials evaluating the dose response of different fixed doses of atorvastatin on blood lipids over a duration of three to 12 weeks.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility criteria for studies to be included and extracted data. We collected information on withdrawals due to adverse effects from placebo-controlled trials.

MAIN RESULTS

In this update, we found an additional 42 trials and added them to the original 254 studies. The update consists of 296 trials that evaluated dose-related efficacy of atorvastatin in 38,817 participants. Included are 242 before-and-after trials and 54 placebo-controlled RCTs. Log dose-response data from both trial designs revealed linear dose-related effects on blood total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides. The Summary of findings table 1 documents the effect of atorvastatin on LDL-cholesterol over the dose range of 10 to 80 mg/d, which is the range for which this systematic review acquired the greatest quantity of data. Over this range, blood LDL-cholesterol is decreased by 37.1% to 51.7% (Summary of findings table 1). The slope of dose-related effects on cholesterol and LDL-cholesterol was similar for atorvastatin and rosuvastatin, but rosuvastatin is about three-fold more potent. Subgroup analyses suggested that the atorvastatin effect was greater in females than in males and was greater in non-familial than in familial hypercholesterolaemia. Risk of bias for the outcome of withdrawals due to adverse effects (WDAEs) was high, but the mostly unclear risk of bias was judged unlikely to affect lipid measurements. Withdrawals due to adverse effects were not statistically significantly different between atorvastatin and placebo groups in these short-term trials (risk ratio 0.98, 95% confidence interval 0.68 to 1.40).

AUTHORS' CONCLUSIONS

This update resulted in no change to the main conclusions of the review but significantly increases the strength of the evidence. Studies show that atorvastatin decreases blood total cholesterol and LDL-cholesterol in a linear dose-related manner over the commonly prescribed dose range. New findings include that atorvastatin is more than three-fold less potent than rosuvastatin, and that the cholesterol-lowering effects of atorvastatin are greater in females than in males and greater in non-familial than in familial hypercholesterolaemia. This review update does not provide a good estimate of the incidence of harms associated with atorvastatin because included trials were of short duration and adverse effects were not reported in 37% of placebo-controlled trials.

Proprotein convertase subtilisin/kexin type 9 expression is transiently up-regulated in the acute period of myocardial infarction in rat

BACKGROUND

The proprotein convertase subtilisin/kexin type 9 (PCSK9) has been confirmed as a major factor regulating cholesterol homeostasis and has low-density lipoprotein receptor (LDLR) independent effects. In addition, the pathogenesis of acute myocardial infarction (AMI) involves lipids alteration and other acute phase responses. It remains unknown whether the PCSK9 expression is influenced by the impact of AMI. The present study aimed to investigate the changes of PCSK9 concentration using AMI rat model.

METHODS

AMI (n = 6-8 at each time point) or sham operated (n = 6) adult male rats model were used. Whole blood and liver tissue were collected at 1, 3, 6, 9, 12, 24, 48, and 96 hour (h) post infarction. The plasma PCSK9 concentration was measured by ELISA and lipid profiles were measured by enzymatic assay. The liver mRNA levels of PCSK9, LDLR, sterol response element binding protein-2 (SREBP-2) and hepatocyte nuclear factor 1α (HNF1α) were measured by quantitative real-time PCR.

RESULTS

The plasma PCSK9 concentration was increased from 12 h to 96 h (P < 0.05 vs. control). Paralleled with the enhanced plasma PCSK9 concentration, the hepatic PCSK9 mRNA expression was up-regulated by 2.2-fold at 12 h and 4.1-fold at 24 h. Hepatic mRNA levels of LDLR, SREBP-2 and HNF1α were all increased and lipid profiles underwent great changes at this acute period.

CONCLUSIONS

We firstly demonstrated that PCSK9 was transiently up-regulated in the acute period of AMI, which is also driven by transcriptional factors, SREBP-2 and HNF1α, suggesting that the role of PCSK9 in myocardial injury may be needed further study.

Lipid-lowering efficacy of rosuvastatin

BACKGROUND

Rosuvastatin is one of the most potent statins and is currently widely prescribed. It is therefore important to know the dose-related magnitude of effect of rosuvastatin on blood lipids.

OBJECTIVES

Primary objective To quantify the effects of various doses of rosuvastatin on serum total cholesterol, low-density lipoprotein (LDL)-cholesterol, high-density lipoprotein (HDL)-cholesterol, non-HDL-cholesterol and triglycerides in participants with and without evidence of cardiovascular disease. Secondary objectives To quantify the variability of the effect of various doses of rosuvastatin.To quantify withdrawals due to adverse effects (WDAEs) in the randomized placebo-controlled trials.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 10 of 12, 2014 in The Cochrane Library, MEDLINE (1946 to October week 5 2014), EMBASE (1980 to 2014 week 44), Web of Science Core Collection (1970 to 5 November 2014) and BIOSIS Citation Index (1969 to 31 October 2014). No language restrictions were applied.

SELECTION CRITERIA

Randomized controlled and uncontrolled before-and-after trials evaluating the dose response of different fixed doses of rosuvastatin on blood lipids over a duration of three to 12 weeks.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility criteria for studies to be included and extracted data. WDAEs information was collected from the placebo-controlled trials.

MAIN RESULTS

One-hundred and eight trials (18 placebo-controlled and 90 before-and-after) evaluated the dose-related efficacy of rosuvastatin in 19,596 participants. Rosuvastatin 10 to 40 mg/day caused LDL-cholesterol decreases of 46% to 55%, when all the trials were combined using the generic inverse variance method. The quality of evidence for these effects is high. Log dose-response data over doses of 1 to 80 mg, revealed strong linear dose-related effects on blood total cholesterol, LDL-cholesterol and non-HDL-cholesterol. When compared to atorvastatin, rosuvastatin was about three-fold more potent at reducing LDL-cholesterol. There was no dose-related effect of rosuvastatin on blood HDL-cholesterol, but overall, rosuvastatin increased HDL by 7%. There is a high risk of bias for the trials in this review, which would affect WDAEs, but unlikely to affect the lipid measurements. WDAEs were not statistically different between rosuvastatin and placebo in 10 of 18 of these short-term trials (risk ratio 0.84; 95% confidence interval 0.48 to 1.47).

AUTHORS' CONCLUSIONS

The total blood total cholesterol, LDL-cholesterol and non-HDL-cholesterol-lowering effect of rosuvastatin was linearly dependent on dose. Rosuvastatin log dose-response data were linear over the commonly prescribed dose range. Based on an informal comparison with atorvastatin, this represents a three-fold greater potency. This review did not provide a good estimate of the incidence of harms associated with rosuvastatin because of the short duration of the trials and the lack of reporting of adverse effects in 44% of the placebo-controlled trials.

An International Atherosclerosis Society Position Paper: global recommendations for the management of dyslipidemia--full report

An international panel of the International Atherosclerosis Society has developed a new set of recommendations for the management of dyslipidemia. The panel identifies non--high-density lipoprotein cholesterol as the major atherogenic lipoprotein. Primary and secondary prevention are considered separately. Optimal levels for atherogenic lipoproteins are derived for the two forms of prevention. For primary prevention, the recommendations emphasize lifestyle therapies to reduce atherogenic lipoproteins; drug therapy is reserved for subjects at greater risk. Risk assessment is based on estimation of lifetime risk according to differences in baseline population risk in different nations or regions. Secondary prevention emphasizes use of cholesterol-lowering drugs to attain optimal levels of atherogenic lipoproteins.