Implications of Hyperuricemia in Severe Coronary Artery Disease

Association between hyperuricemia and chronic total coronary occlusion in non-chronic kidney disease populations: a cross-sectional study

BACKGROUND

Chronic total coronary occlusion (CTO) is an extremely hazardous condition that leads to various clinical phenomena and complications and results in social and economic burdens. Hyperuricemia (HU) is often associated with atherosclerosis. Few studies, however, have investigated the risk of CTO in individuals with HU and the role of traditional cardiovascular risk factors in this setting.

METHODS

A cohort of 1245 individuals without chronic kidney disease from southwest China who underwent coronary angiography between February 2018 and June 2021 were enrolled. CTO was defined as a total occlusion of any coronary artery or arteries for more than 3 months. HU was defined as a serum uric acid level of ≥420 µmol/L in men and ≥360 µmol/L in women. Univariate and multivariate logistic regression models and subgroup analyses were applied to assess the relationship between HU and CTO.

RESULTS

After adjustment, HU was noted to be associated with a 1.47-fold increase in the risk of CTO [odds ratio (OR), 1.47; 95% confidence interval (CI), 1.06-2.58; P = 0.026]. As a continuous variable, uric acid was an independent predictor of CTO (OR, 1.002; 95% CI, 1.001-1.004; P = 0.047). Subgroup analyses showed that the risk of CTO was higher among individuals under 65 years of age (OR, 2.77; 95% CI, 1.3-5.89), nonobese individuals (OR, 1.9; 95% CI, 1.16-3.1), and those with dyslipidemia (OR, 1.8; 95% CI, 1.04-3.11), while sex, smoking, hypertension, and diabetes did not show similar effects. Interaction analyses revealed no interaction among subgroups.

CONCLUSION

Among individuals residing in southwest China, HU was associated with an increased risk of CTO in non-CKD individuals, especially those under 65 years of age and nonobese and dyslipidemic individuals.

Hyperuricemia is associated with heart failure readmission in patients with heart failure and preserved ejection fraction-an observational study in Chinese

BACKGROUND AND AIMS

This study aimed to explore the association between hyperuricemia and heart failure (HF) readmission in HF patients with preserved ejection fraction (HFpEF) because the impact of hyperuricemia on the prognosis of these patients has not been fully understood.

METHODS AND RESULTS

This retrospective observational study included 538 hospitalized patients diagnosed with HFpEF. A total of 57.6 % of patients with HFpEF suffered from hyperuricemia (serum uric acid (SUA) was >7 mg/dL in men and >6 mg/dL in women). Compared to those without hyperuricemia, patients with hyperuricemia were more likely to be female (62.6 % vs. 53.9 %, p = 0.044) and older (78.0 ± 8.4 vs. 75.9 ± 9.0 years, p = 0.008). Our Cox analysis revealed that SUA level (hazard ratio (HR) = 1.158, 95 % confidence interval (CI): 1.087-1.234, p<0.001) and hyperuricemia (HR = 1.846, 95 % CI: 1.308-2.606, p<0.001) were associated with HF readmission in patients with HFpEF, respectively. Kaplan-Meier analysis showed that patients with hyperuricemia had a significantly worse prognosis (p<0.001). The receiver operating characteristic analysis revealed that the area under the ROC curve of SUA for predicting HF readmission was 0.6276 (95 % CI: 0.5763-0.6790) and a designated cut-off value of 7.53 mg/dL.

CONCLUSIONS

Hyperuricemia is a common comorbidity among patients with HFpEF. Moreover, SUA level and hyperuricemia have been shown to be associated with HF readmission. Therefore, it is meaningful to monitor SUA levels in patients with HFpEF during the whole treatment period of HF. Whereas, whether intervention of hyperuricemia could benefit patients with HFpEF needs further studies.

Bean and Nut Intake Were Protective Factors for Comorbid Hypertension and Hyperuricemia in Chinese Adults: Results from China Nutrition and Health Surveillance (2015-2017)

This study aimed to describe the prevalence of comorbid hypertension and hyperuricemia (HH) and detected the dietary factors for HH in Chinese adults aged 18 to 64 years. All of the data were collected from the China Nutrition and Health Surveillance 2015-2017, with a stratified, multistage, random sampling method on a national scale. A total of 52,627 adult participants aged 18~64 years from the CNHS 2015-2017 were included in this study. HH was identified as SUA level cut-offs for males and females of 420 μmol/L and 360 μmol/L, respectively, with mean systolic blood pressure ≥140 mmHg and/or mean diastolic blood pressure ≥ 90 mmHg and/or received antihypertensive treatment within two weeks. The differences in HH prevalence between or among the subgroups were compared by the Rao-Scott chi-square test. The correlations between HH and covariates or metabolic factors were detected by a weighted two-level multivariate survey logistic regression. The total weighted sufficient intake ratios of beans and nuts, vegetables, and red meat were 59.1%, 46.6%, and 64.8%, respectively. The weighted prevalence of HH in the total participants was 4.7% (95% CI: 4.3-5.0%). The positive effects of bean and nut on HH were observed. The participants who had sufficient bean and nut intake showed lower risk for HH (for the total participants: OR = 0.734, 95% CI = 0.611-0.881). The prevalence of HH might have been a public health problem, and bean and nut intake might be a protective factor for HH in the Chinese population.

Hyperuricemia predicts increased cardiovascular events in patients with chronic coronary syndrome after percutaneous coronary intervention: A nationwide cohort study from Japan

Background

The causal relationship between hyperuricemia and cardiovascular diseases is still unknown. We hypothesized that hyperuricemic patients after percutaneous coronary intervention (PCI) had a higher risk of major adverse cardiovascular events (MACE).

Methods

This was a large-scale multicenter cohort study. We enrolled patients with chronic coronary syndrome (CCS) after PCI between April 2013 and March 2019 using the database from the Clinical Deep Data Accumulation System (CLIDAS), and compared the incidence of MACE, defined as a composite of cardiovascular death, myocardial infarction, and hospitalization for heart failure, between hyperuricemia and non-hyperuricemia groups.

Results

In total, 9,936 patients underwent PCI during the study period. Of these, 5,138 patients with CCS after PCI were divided into two group (1,724 and 3,414 in the hyperuricemia and non-hyperuricemia groups, respectively). The hyperuricemia group had a higher prevalence of hypertension, atrial fibrillation, history of previous hospitalization for heart failure, and baseline creatinine, and a lower prevalence of diabetes than the non-hyperuricemia group, but the proportion of men and age were similar between the two groups. The incidence of MACE in the hyperuricemia group was significantly higher than that in the non-hyperuricemia group (13.1 vs. 6.4%, log-rank P < 0.001). Multivariable Cox regression analyses revealed that hyperuricemia was significantly associated with increased MACE [hazard ratio (HR), 1.52; 95% confidential interval (CI), 1.23-1.86] after multiple adjustments for age, sex, body mass index, estimated glomerular filtration rate, left main disease or three-vessel disease, hypertension, diabetes mellitus, dyslipidemia, history of myocardial infarction, and history of hospitalization for heart failure. Moreover, hyperuricemia was independently associated with increased hospitalization for heart failure (HR, 2.19; 95% CI, 1.69-2.83), but not cardiovascular death or myocardial infarction after multiple adjustments. Sensitive analyses by sex and diuretic use, B-type natriuretic peptide level, and left ventricular ejection fraction showed similar results.

Conclusion

CLIDAS revealed that hyperuricemia was associated with increased MACE in patients with CCS after PCI. Further clinical trials are needed whether treating hyperuricemia could reduce cardiovascular events or not.

The U-Shaped Relationship Between Serum Uric Acid and Long-Term All-Cause Mortality in Coronary Artery Disease Patients: A Cohort Study of 33,034 Patients

Background

Associations between high serum uric acid (SUA) and cardiovascular diseases have been reported. However, few studies have been conducted to explore the relationship between SUA and long-term all-cause mortality in coronary artery disease (CAD) patients. Our study aims to investigate the relationship between SUA and long-term all-cause mortality in patients with CAD.

Methods

From January 2007 to December 2018, we divided 33,034 patients with CAD admitted in the Guangdong Provincial People's Hospital into five groups (quintile 1: SUA <5.05 mg/dl, quintile 2: 5.05 mg/dl ≤ SUA <5.59 mg/dl, quintile 3:5.59 mg/dl ≤ SUA <6.8 mg/dl, quintile 4, 6.8 mg/dl ≤ SUA <7.93 mg/dl, and quintile 5, SUA ≥7.93 mg/d;). This study used Kaplan–Meier survival analysis to evaluate patient outcomes with different ranges of SUA. Cox proportional hazards regression models and restricted cubic spline were applied to determine the association between serum uric and long-term all-cause mortality.

Results

A total of 33,034 participants were recruited, including 24,780 (75.01%) men and 8,254 (24.99) women in this cohort study. Median follow-up was 4.91 years. We found that SUA is an independent risk factor of long-term all-cause mortality according to the result of Cox proportional hazards models. This study also illustrated an approximate U-shape association between SUA and all-cause mortality when compared with 5.95 mg/lL ≤ SUA <6.8 mg/dl, SUA <5.0 5mg/dl (adjusted hazard ratio (aHR) =1.13, 95% CI: 1.01–1.26, p = 0.03), and SUA ≥8 mg/dL (aHR = 1.18, 95% CI: 1.06-1.32, p = 0.003).

Conclusion

Our study indicated a U-shaped relationship between SUA and long-term all-cause mortality in patients with CAD. No matter whether SUA is too high or too low, it increased the all-cause mortality in the CAD population, which deserves to be closely monitored.

Using machine learning to aid treatment decision and risk assessment for severe three-vessel coronary artery disease

BACKGROUND

Three-vessel disease (TVD) with a SYNergy between PCI with TAXus and cardiac surgery (SYNTAX) score of ≥ 23 is one of the most severe types of coronary artery disease. We aimed to take advantage of machine learning to help in decision-making and prognostic evaluation in such patients.

METHODS

We analyzed 3786 patients who had TVD with a SYNTAX score of ≥ 23, had no history of previous revascularization, and underwent either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) after enrollment. The patients were randomly assigned to a training group and testing group. The C4.5 decision tree algorithm was applied in the training group, and all-cause death after a median follow-up of 6.6 years was regarded as the class label.

RESULTS

The decision tree algorithm selected age and left ventricular end-diastolic diameter (LVEDD) as splitting features and divided the patients into three subgroups: subgroup 1 (age of ≤ 67 years and LVEDD of ≤ 53 mm), subgroup 2 (age of ≤ 67 years and LVEDD of > 53 mm), and subgroup 3 (age of > 67 years). PCI conferred a patient survival benefit over CABG in subgroup 2. There was no significant difference in the risk of all-cause death between PCI and CABG in subgroup 1 and subgroup 3 in both the training data and testing data. Among the total study population, the multivariable analysis revealed significant differences in the risk of all-cause death among patients in three subgroups.

CONCLUSIONS

The combination of age and LVEDD identified by machine learning can contribute to decision-making and risk assessment of death in patients with severe TVD. The present results suggest that PCI is a better choice for young patients with severe TVD characterized by left ventricular dilation.

The Impact of an Elevated Uric Acid Level on the Prevalence of Coronary Artery Disease in Pancreas Transplant Candidates with Type 1 Diabetes: A Cross Sectional Study

Pancreas transplantation is considered a high-risk surgery with cardiovascular complications. Early detection of all potential cardiovascular risk factors can decrease the perioperative risk and improve the pancreas recipients' outcome. The present study aims to evaluate the association between serum uric acid (UA) levels and the prevalence of coronary artery disease (CAD) in patients eligible for pancreas transplantation. We prospectively enrolled 63 consecutive patients with type 1 diabetes (T1D) who underwent cardiological evaluation before pancreas transplantation in our center. Participants underwent clinical evaluation, laboratory assays, and coronary angiography. The median concentration of UA in patients with CAD was significantly higher than in participants without CAD (6.43 (4.93-7.26) vs. 4.41 (3.64-5.49) mg/dL, p = 0.0002). We showed the positive correlation between UA concentration and systolic blood pressure, pulse pressure (PP) and triglycerides (r = 0.271, p = 0.032; r = 0.327, p = 0.009; r = 0.354, p = 0.004, respectively). In a multivariate analysis, the concentration of UA (OR 2.044; 95% CI: 1.261-3.311, p = 0.004) was independently associated with the prevalence of CAD in pancreas transplant candidates with T1D. We demonstrated that elevated UA levels were strongly associated with the high prevalence of CAD in pancreas transplant candidates with T1D. To stratify cardiovascular risk, the measurement of the UA concentration should be considered in all T1D patients qualified for pancreas transplantation.

Prevalence and Risk Factors of QTc Prolongation During Pregnancy

Background

Prolonged QT intervals have been observed in pregnant women, which predispose them to a higher risk of potentially lethal ventricular arrhythmias. This study was designed to evaluate the prevalence of QTc prolongation in Chinese hospitalized parturient women with single and twin pregnancies, and to explore potential risk factors associated with QTc prolongation.

Methods

This retrospective study included 1,218 patients from a large Chinese population between January 2014 and October 2020. Data from parturient women with single and twin pregnancies without pre-pregnancy cardiac diseases were collected. QTc was corrected by the Fridericia formula [QTc = QT/RR(1/3)], and QTc ≥ 460 ms for females was defined as prolonged QTc, QTc ≥ 500 ms was defined as severely prolonged QTc. The prevalence and common risk factors of QTc prolongation during pregnancy were analyzed in this cohort. Uni- and multivariable logistic regression analysis were performed to identify clinical parameters associated with QTc prolongation in this population.

Results

The prevalence of QTc prolongation was 48.19% among this population, 10.56% in single pregnancy, 89.44% in twin pregnancies. The prevalence of severely prolonged QTc was 23.48% among the total cohort, 0.49% in single pregnancy, and 46.47% in twin pregnancies. The mean QTc interval was significantly longer in twin pregnancies than in single pregnancy (498.65 ± 38.24 vs. 424.96 ± 27.67 ms, P < 0.001). Systolic blood pressure, diastolic blood pressure, total cholesterol, serum uric acid, gestational hypertension and twin pregnancies were associated with QTc prolongation in parturient women.

Conclusion

This is the first study to assess the prevalence and risk factors of QTc prolongation between single and twin pregnancies. QTc prolongation is more prevalent, and QTc intervals are significantly longer in twin pregnancies as compared to single pregnancy.

Hyperuricemia as a prognostic marker for long-term outcomes in patients with myocardial infarction with nonobstructive coronary arteries

Background

Hyperuricemia (HUA) has been proved as a predictor of worse outcomes in patients with coronary artery disease. Here, we investigated the prognostic value of HUA in a distinct population with myocardial infarction with nonobstructive coronary arteries (MINOCA).

Methods

A total of 1179 MINOCA patients were enrolled and divided into HUA and non-HUA groups. HUA was defined as a serum uric acid level ≥ 420 μmol/L in men or ≥ 357 μmol/L in women. The primary study endpoint was a composite of major adverse cardiovascular events (MACE), including all-cause death, nonfatal MI, nonfatal stroke, revascularization, and hospitalization for unstable angina or heart failure. Kaplan–Meier, Cox regression, and receiver-operating characteristic analyses were performed.

Results

Patients with HUA (prevalence of 23.5%) had a significantly higher incidence of MACE (18.7% vs. 12.8%; p = 0.015) than patients without during the median follow-up of 41.7 months. HUA was closely associated with an increased risk of MACE even after multivariable adjustment (hazard ratio 1.498, 95% confidence interval: 1.080 to 2.077; p = 0.016). HUA remained a robust risk factor of MACE after propensity score matching analysis. Moreover, HUA showed an area under the curve (AUC) of 0.59 for predicting MACE. Incorporation of HUA to the thrombolysis in myocardial infarction (TIMI) score yielded a significant improvement in discrimination for MACE.

Conclusions

HUA was independently associated with poor prognosis after MINOCA. Routine assessment of HUA may facilitate risk stratification in this specific population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12986-021-00636-2.

Prognostic Significance of Uric Acid in Patients with Obstructive and Nonobstructive Coronary Artery Disease Undergoing D-SPECT

Purpose

The association of serum uric acid (SUA) levels with cardiovascular outcomes in patients with coronary artery disease (CAD) has been extensively studied and yielded conflicting results. We aimed to investigate whether the severity of coronary stenosis and ischemia influences the prognostic impact of SUA levels in patients with CAD undergoing D-SPECT.

Patients and Methods

This study consecutively included patients who were admitted for CAD in Shanghai Tenth People's Hospital between June 2014 and August 2018, had complete SUA data and underwent both coronary angiography and D-SPECT within 3 months. Hyperuricemia was defined as an SUA level of >7 mg/dL in men and >6 mg/dL in women. The primary outcome was major adverse cardiovascular events (MACE), defined as a composite of cardiac death, unplanned coronary revascularization, nonfatal myocardial infarction, ischemic stroke, heart failure, and angina-related hospitalization.

Results

A total of 695 patients were included, of whom 432 (62.2%) presented with obstructive CAD and 117 (16.8%) had hyperuricemia. During a median follow-up of 26 months, the incidence rates of MACE in patients with hyperuricemia and normouricemia were 15.2% and 21.1%, respectively. After a multivariable adjustment, hyperuricemia was significantly associated with an increased risk of MACE (HR: 1.39, 95% CI: 1.03-1.87, p = 0.033) when compared with normouricemia. When repeating the primary analysis in patients with and without obstructive CAD, we showed that hyperuricemia was independently associated with an 80% increased risk of MACE among patients with nonobstructive CAD (HR: 1.80, 95% CI: 1.04-3.11, p = 0.035), while such a significant association was not found among those with obstructive CAD (HR: 1.18, 95% CI: 0.82-1.72, p = 0.373). Moreover, we uncovered a U-shaped and linear trajectory of SUA levels with MACE in the obstructive and nonobstructive CAD, respectively. The sex-specific analysis showed that the adverse impact of hyperuricemia was only pronounced in males (HR: 1.73, 95% CI: 1.18-2.53, p = 0.005) but not in females (HR: 0.98, 95% CI: 0.57-1.66, p = 0.933).

Conclusion

Hyperuricemia is significantly associated with increased risk of MACE in the nonobstructive CAD rather than in the obstructive CAD.

Hyperuricemia in Patients With Coronary Artery Disease and Its Association With Disease Severity

The biochemical background of coronary artery disease (CAD) has been intensively explored in the past several decades. Previous clinical investigations have demonstrated the association of non-traditional risk factors, such as hyperuricemia, with CAD. Studies have shown that increased serum uric acid (SUA) was associated with an increased risk of adverse cardiovascular (CV) outcomes in patients with CAD. While the exact pathophysiological mechanisms leading to increased risk are still unknown, it has been postulated that hyperuricemia leads to endothelial dysfunction, oxidative metabolism, and platelet adhesiveness and aggregation, leading to CAD. Moreover, previous studies have shown that hyperuricemia is an independent risk factor for CAD. However, the correlation between high SUA levels and the severity of CAD remains unclear. The purpose of this review was to elucidate the association of hyperuricemia to CAD severity and to determine the effect of urate-lowering therapy (ULT) on CAD. A search of PubMed up to June 24, 2021, was carried out by the reviewers. From the findings, hyperuricemia stands as an independent risk factor for CAD, and CAD patients treated with ULT had improved CV outcomes and reduced mortality. Therefore, while SUA level is valuable in predicting an augmented risk of CAD and anticipating worse outcomes, ULT has promising cardioprotective effects.

rs10865710 polymorphism in PPARG promoter is associated with the severity of type 2 diabetes mellitus and coronary artery disease in a Chinese population

BACKGROUND

Relationship between polymorphisms in peroxisome proliferator-activated receptor gamma (PPARG) and progression of type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD) remains to be clarified.

METHODS

635 subjects were divided into T2DM, CAD, T2DM complicated with CAD (T2DM/CAD) and control groups according to diagnostic criteria. The rs10865710 and rs3856806 polymorphisms were genotyped, and the severity of T2DM and CAD was evaluated for all subjects.

RESULTS

In patients with T2DM, G allele carriers of rs10865710 polymorphism had significantly higher levels of glucose, triglycerides, apolipoprotein B (ApoB) and lipoprotein (a) (Lp(a)) than non-carriers, T allele carriers of rs3856806 polymorphism had significantly higher levels of glucose, low-density lipoprotein cholesterol (LDL-C), ApoB and Lp(a) than non-carriers. In patients with CAD, G allele carriers of rs10865710 polymorphism had significantly higher levels of total cholesterol (TC), ApoB and Lp(a) than non-carriers, T allele carriers of rs3856806 polymorphism had significantly higher levels of body mass index, blood pressure, TC, LDL-C and ApoB than non-carriers. Patients with one or two G alleles of rs10865710 polymorphism had significantly higher levels of Gensini scores and more diseased coronary branches than those patients without CAD. The rs3856806 polymorphism was not associated with CAD severity, but it was found to be significantly associated with T2DM/CAD, T allele frequency was significantly higher in T2DM/CAD group than that in T2DM/CAD-free group.

CONCLUSIONS

The rs10865710 and rs3856806 polymorphisms in PPARG are significantly associated with glucose levels in patients with T2DM. The rs10865710 polymorphism is significantly associated with the severity of CAD, which is possibly mediated by hyperlipidaemia and hyperglycaemia.

Serum amyloid A1 can be a novel biomarker for evaluating the presence and severity of acute coronary syndrome

BACKGROUND

Serum amyloid A (SAA) is an acute phase protein and a novel inflammatory biomarker of cardiovascular diseases. Of the four subtypes, SAA1 is the most representative biomarker. In this study, we aimed to assess the value of SAA1 as a novel biomarker for evaluating the presence and severity of acute coronary syndrome (ACS) in Chinese patients.

METHODS AND RESULTS

A total of 140 ACS patients and 88 non-ACS patients (including 36 stable coronary artery disease (SCAD) patients and 52 healthy controls) who underwent coronary angiography were enrolled. The SAA1 level was significantly higher in ACS patients compared with the SCAD and healthy control subgroups (P < 0.001, respectively), and was significantly higher in the high SYNTAX Score II (SS II) group compared with the medium SS II group and low SS II group (P < 0.001, respectively) in ACS patients. The cutoff level of SAA1 for indicating the presence of ACS was 324.65 ng/mL (sensitivity of 77.9%, specificity of 60.2% and an area under the curve of 0.717). The increased SAA1 levels were positively associated with the presence (OR = 1.013, P < 0.001) and severity (OR = 1.023, P < 0.001) of ACS. Furthermore, there was a positive correlation between SAA1 levels and SS II (r = 0.467, P < 0.001).

CONCLUSIONS

Our results suggest that elevated SAA1 levels may be a novel biomarker for evaluating the presence of ACS and the severity of CAD in ACS patients. Measuring SAA1 levels makes it possible to evaluate the presence of ACS and severity of CAD in ACS patients.

Very low-density lipoprotein cholesterol is associated with extent and severity of coronary artery disease in patients with type 2 diabetes mellitus

Objective:

Patients with type 2 diabetes mellitus usually have multiple cardiovascular disease risk factors. The objective of this study was to examine the severity and associated risk factors in coronary artery disease patients with type 2 diabetes mellitus.

Methods:

Two hundred and five coronary artery disease patients with type 2 diabetes mellitus and 205 age-, gender- and smoking-matched coronary artery disease patients without type 2 diabetes mellitus were recruited from the Department of Cardiology of our hospital. Demographic and clinical data were collected for all participants. Severity of coronary artery disease was assessed using Gensini scoring system, the number of diseased coronary arteries, and the extent of coronary stenosis.

Results:

Coronary artery disease patients with type 2 diabetes mellitus had higher Gensini scores (p < 0.01), more numbers of diseased coronary arteries (p < 0.001), and higher degrees of coronary stenosis (p = 0.05) than coronary artery disease patients without type 2 diabetes mellitus. The plasma levels of very low-density lipoprotein cholesterol (p < 0.001) and triglycerides (p < 0.001) were also higher in coronary artery disease patients with type 2 diabetes mellitus than in coronary artery disease patients without type 2 diabetes mellitus. In coronary artery disease patients with type 2 diabetes mellitus, very low-density lipoprotein cholesterol was positively correlated with Gensini scores (r = 0.15, p = 0.03), the number of diseased coronary arteries (r = 0.15, p = 0.04), and the extent of coronary stenosis (r = 0.14, p = 0.05) by partial correlation analysis after controlling for other lipid parameters, and independently associated with Gensini scores (beta = 0.18, p = 0.02) and the number of diseased coronary arteries (odds ratio = 2.09, p = 0.05) after adjusting for other cardiovascular risk factors in the following multiple regression analysis.

Conclusion:

Very low-density lipoprotein cholesterol may represent a marker for the severity of coronary artery disease and be a target for the treatment in diabetic patients. Further research is needed to determine whether very low-density lipoprotein cholesterol plays a causal role of coronary artery disease in diabetic patients.