ESC/EAS Guidelines for the management of dyslipidaemias

Acute Pancreatitis as an Unusual Culprit of Diabetic Ketoacidosis in a Nondiabetic: A Case-Based Review

Acute pancreatitis has been associated with a multitude of complications including pancreatic necrosis, pseudocysts, abscesses, acute respiratory distress syndrome, disseminated intravascular coagulation, and hyperglycemia. To date, only rare case reports have demonstrated diabetic ketoacidosis (DKA) as a rare sequela of acute pancreatitis. We report a case of a 34-year-old female with no prior history of diabetes who was subsequently diagnosed with DKA after presenting with severe acute pancreatitis. This case serves as a framework to not only highlight DKA as a rare complication of acute pancreatitis but also to explore the potential pathophysiology that underlies this phenomenon including stress hyperglycemia and post-pancreatitis diabetes mellitus.

The TELE-DD Randomised Controlled Trial on Treatment Adherence in Patients with Type 2 Diabetes and Comorbid Depression: Clinical Outcomes after 18-Month Follow-Up

Clinical depression is associated with poorer adherence to hypoglycaemic medication in patients with diabetes mellitus, leading to poorer glycaemic control, diabetes management, and increased complications. The main aim of the TELE-DD trial was to demonstrate the efficacy of a proactive and psychoeducational telephonic intervention based on motivational interviewing and collaborative care to reduce nonadherence and improve prognosis in individuals with diabetes mellitus and concurrent depression.

DESIGN

The TELE-DD project is a three-phased prospective study including a nested randomised controlled trial.

METHODS

The baseline cohort included the entire population of adult patients diagnosed with type 2 diabetes and concurrent depression. A randomised controlled trial was conducted in a selection of patients from the baseline cohort, distributed into a control group (n = 192) and an intervention group (n = 192). Monthly telephonic interventions delivered by specifically trained research nurses were centred on a psychoeducational individualised monitoring protocol including motivational interviewing and collaborative care strategies. Clinical and patient-centred data were systematically collected during an 18-month follow-up including HbA1c, Patient Health Questionnaire, and the Diabetes Distress Scale.

RESULTS

During the trial, 18-month follow-up HbA1C levels significantly (p < 0.001) decreased in the intervention group at every follow-up from an average of 8.72 (SD:1.49) to 7.03 (SD:1.09), but slightly increased in the control group from 8.65 (SD:1.40) to 8.84 (SD:1.38). Similar positive results were obtained in depression severity and diabetes distress, LDL-cholesterol, and systolic and diastolic blood pressure, but only at the 18-month follow-up in body mass index reduction.

CONCLUSIONS

This is the first trial to concurrently decrease biological and psychological outcomes with a monthly brief telephonic intervention, pointing out that a combined biopsychosocial intervention and collaborative care strategy is essential for current world health challenges.

CLINICALTRIALS

gov Identifier: NCT04097483. Patient or Public Contribution: Diabetic patients not belonging to the TELE-DD population or trial sample were consulted during the study design to review and guarantee the clarity and understanding of the trial psychoeducational materials.

Artificial neuronal network analysis in investigating the relationship between oxidative stress and endoplasmic reticulum stress to address blocked vessels in cardiovascular disease

BACKGROUND

Cardiovascular disease is the leading cause of death in the world and is associated with significant morbidity. Atherosclerosis is the main cause of cardiovascular disease (CVD), including myocardial infarction (MI), heart failure, and stroke. The mechanism of atherosclerosis has not been well investigated in different aspects, such as the relationship between oxidative stress and endothelial function. This project aims to investigate whether an oxidative enzyme vascular peroxidase 1 (VPO1) and activating transcription factor 4 (ATF4) can be used as biomarkers in highlighting the pathogenesis of the disease and in evaluating the prognosis of the relationship with endoplasmic reticulum and oxidative stress. This paper used artificial neural network analysis to predict cardiovascular disease risk based on new generation biochemical markers that combine vascular inflammation, oxidative and endoplasmic reticulum stress.

METHODS

For this purpose, 80 patients were evaluated according to the coronary angiography results. hs-CRP, lipid parameters and demographic characteristics, VPO1, ATF4 and Glutathione peroxidase 1(GPx1) levels were measured.

RESULTS

We found an increase in VPO1 and hs-CRP levels in single-vessel disease as compared to controls. On the contrary, ATF4 and GPx1 levels were decreased in the same group, which was not significant. Our results showed a significant positive correlation between ATF4 and lipid parameters. A statistically significant positive correlation was also observed for VPO1 and ATF4 (r=0.367, P<0.05), and a negative correlation was found for ATF4 and GPx1 (r=-0.467, P<0.01). A significant negative relationship was noted for GPx1 and hs-CRP in two/three-vessel disease (r=-0.366, P<0.05). Artificial neural network analysis stated that body mass index (BMI) and smoking history information give us an important clue as compared to age, gender and alcohol consumption parameters when predicting the number of blocked vessels.

CONCLUSIONS

VPO1 and ATF4 might be potential biomarkers associated with coronary artery disease, especially in the follow-up and monitoring of treatment protocols, in addition to traditional risk factors.

TG/HDL-C Ratio Is a Risk Factor Associated with CKD: Use in Assessing the Risk of Progression of CKD

Background: Dyslipidemia is highly prevalent in patients with chronic kidney disease (CKD), and the relationship between dyslipidemia and renal function in these patients remains controversial. Our objectives were to determine the triglycerides/HDL-cholesterol ratio (TG/HDL-C), evaluate the correlation between TG/HDL-C and the urine albumin/creatinine ratio (ACR), and estimate the glomerular filtration rate (eGFR) according to MDRD in CKD patients. Methods: A descriptive cross-sectional study was conducted on 152 patients with CKD at the Endocrine Clinic, the University of Medicine and Pharmacy Hospital, Ho Chi Minh City, Vietnam. Study subjects were medically examined and recorded information on the data collection form. Subjects were tested for total cholesterol, triglycerides, HDL-C, LDL-C, urea, creatinine and albumin, urine creatinine, and eGFR according to the MDRD formula. Data were analyzed using SPSS Statistics version 20.0. Results: The average age was 58.08 ± 15.69 years, and the overweight and obesity rate was 54%. Most patients had comorbidities, among which the most common diseases were hypertension and diabetes mellitus. Among the subjects, 57.3% were CKD stage 3 patients, and ACR was in the range of 30−300 mg/g. According to the classification of CKD using GFR and ACR categories, 40.8% of patients were at very high risk. The average TG/HDL-C ratio was 5.09 ± 4.26. There was a medium negative correlation between TG/HDL-C and eGFR (R = 0.44, p < 0.01) and a weak positive correlation between TG/HDL-C and ACR (R = 0.34, p < 0.01). Conclusions: The TG/HDL-C ratio was a risk factor associated with CKD and was noticeable in monitoring and assessing the risk of progression of CKD.

Phyto-Enrichment of Yogurt to Control Hypercholesterolemia: A Functional Approach

Cholesterol is essential for normal human health, but elevations in its serum levels have led to the development of various complications, including hypercholesterolemia (HC). Cholesterol accumulation in blood circulation formsplaques on artery walls and worsens the individuals’ health. To overcome this complication, different pharmacological and non-pharmacological approaches are employed to reduce elevated blood cholesterol levels. Atorvastatin and rosuvastatin are the most commonly used drugs, but their prolonged use leads to several acute side effects. In recent decades, the potential benefit of ingesting yogurt on lipid profile has attracted the interest of researchers and medical professionals worldwide. This review aims to give an overview of the current knowledge about HC and the different therapeutic approaches. It also discusses the health benefits of yogurt consumption and highlights the overlooked phyto-enrichment option to enhance the yogurt’s quality. Finally, clinical studies using different phyto-enriched yogurts for HC management are also reviewed. Yogurt has a rich nutritional value, but its processing degrades the content of minerals, vitamins, and other vital constituents with beneficial health effects. The option of enriching yogurt with phytoconstituents has drawn a lot of attention. Different pre-clinical and clinical studies have provided new insights on their benefits on gut microbiota and human health. Thus, the yogurtphyto-enrichment with stanol and β-glucan have opened new paths in functional food industries and found healthy andeffective alternatives for HC all along with conventional treatment approaches.

Effectiveness and Safety of Lipid-Lowering Drug Treatments in Japanese Patients with Familial Hypercholesterolemia: Familial Hypercholesterolemia Expert Forum (FAME) Study

AIMS

Familial hypercholesterolemia (FH) is a genetic disorder characterized by high serum levels of low-density lipoprotein (LDL)-cholesterol (LDL-C), tendon and skin xanthomas, and premature coronary artery disease (CAD). In Japan, detailed information on the current status of drug therapies for patients with FH has not been reported so far, and their efficacy and safety have not been clarified. After the introduction of ezetimibe, which can further reduce serum LDL-C levels on top of statins, the changes of management for FH patients with these drugs are of particular interest. The current study aimed to evaluate the clinical status of FH heterozygotes and homozygotes, especially focusing on the real-world lipid-lowering drug therapy, attained serum LDL-C levels, and cardiovascular events at registration and during the follow-up.

METHODS

The FAME Study enrolled 762 heterozygous (including 17 newly diagnosed cases) and 7 homozygous FH patients from hospitals and clinics nationwide. Diagnosis of FH was based upon the criteria defined in the Study Report in 2008 of the Research Committee on Primary Hyperlipidemia supported by Grants-in-Aid for Scientific Research from the Japanese Ministry of Health, Labor and Welfare. Data analysis was primarily carried on heterozygous FH patients.

RESULTS

Xanthoma or thickening of the Achilles tendon was observed in more than 80% of the patients. CAD was recorded in 23% of patients. Patients with parental and sibling CAD accounted for 47% and 24%, respectively. At baseline, patients without CAD who had LDL-C ＜100 mg/dL accounted for 12.3% and those with CAD who had attained the target (LDL-C ＜70 mg/dL) in the secondary prevention accounted for only 1.8%. In the multiple logistic analysis, male sex, age ＞40, heterozygous FH score ＞20, hypertension, and sibling CAD were significantly and positively associated with prevalent CAD, whereas serum HDL-cholesterol levels showed a significant inverse association with CAD. Patients treated with statin alone, statin＋ezetimibe, statin＋resin, or statin＋probucol accounted for 31.1%, 26.3%, 4.0%, and 3.7%, respectively. Patients treated with three-drug combination (statin＋ezetimibe＋resin or statin＋ezetimibe＋probucol) accounted for 7.5%. Statins and ezetimibe were used in 88.0% and 48.0% at the baseline, respectively. Although high-intensity statins were mainly prescribed, statin doses were much lower than those reported in Western countries. The addition of ezetimibe resulted in ~20% reduction in serum LDL-C. CAD was diagnosed in 17 patients with 21 episodes during follow-up. The Cox hazard model analysis demonstrated that male sex, CAD at the baseline, and parental CAD were related to the development of atherosclerotic cardiovascular disease (ASCVD) events. Furthermore, an increase in serum HDL-C was associated with a significant reduction of ASCVD events, while serum LDL-C and triglyceride levels were not related to ASCVD events.

CONCLUSION

The prevalence of CAD in Japanese patients with heterozygous FH is still very high. In most of the cases, the target level of serum LDL-C was not achieved for primary and secondary prevention of CAD, suggesting that a more aggressive LDL-C lowering and appropriate management of residual risks are necessary.

Efficacy of Plant Sterol-Enriched Food for Primary Prevention and Treatment of Hypercholesterolemia: A Systematic Literature Review

Plant sterols/phytosterols (PSs) are molecules with a similar structure to cholesterol that have a recognized effect on elevated LDL concentrations (LDL-c). PSs are used as a natural therapy against elevated LDL-c in combination with a healthy diet and exercise. A systematic review was performed to evaluate the efficacy of PS-enriched foods in the treatment of hypercholesterolemia. Randomized controlled clinical studies reporting the use of PS-enriched foods to reduce LDL-c among adult individuals were retrieved and assessed for risk of bias. Meta-analyses were performed to assess changes in LDL-c by treatment, food matrix, LDL-c range, sterols dosage and risk of bias (RoB). In the 13 studies analyzed, LDL-c in PS-treated participants decreased by an average of 12.14 (8.98; 15.29) mg/dL. PS administration was statistically more effective in patients with LDL-c ≥ 140 mg/dL and for PS dosages > 2 g/day. It can be concluded that PSs can be used as an important primary prevention measure for hypercholesterolemia and as tertiary prevention for cardiovascular events in patients who already have mild to moderate LDL-c. However, in severe hypercholesterolemia and in cases of familial hypercholesterolemia, it is necessary to combine dietary treatment with the use of statins.

[Proper Perioperative Handling of Continuous Medication in Patients with Cardiac Comorbidities]

Cardiac comorbidities place a significant burden on the German population. Every third adult is diagnosed with arterial hypertension (AHT). In 2017 congestive heart failure (CHF) pertained approximately 2,5 million of mandatory health-insured patients. Coronary artery disease (CAD) is diagnosed in 28,3% of men and 19,1% of women older than 65 years.For optimal perioperative care it is important to have a sound knowledge of current treatment strategies of cardiac comorbidities. This helps in gaining an optimal risk stratification of the individual patient. It also ensures an optimal anesthesiological perioperative care for the patient at hand. Recommendations for the perioperative discontinuation or continuation of cardiac active drugs vary between countries and responsible medical societies.This article provides an in-depth review of the current medical therapies for cardiac conditions like AHT, CHF or CAD. The varying recommendations for the perioperative discontinuation/continuation of these therapies are also reviewed.

Pathogenetic rationale for using an inhibitor of 3-hydroxy-3-methylglutaryl-coenzyme A reductase and an antioxidant coenzyme Q₁₀ in the treatment and prevention of cardiovascular disease

The review discusses atherosclerosis-related mechanisms of car-diovascular disease development, as well as the optimization of their prevention and treatment methods. Recent experimental and clinical studies have shown the important role of vascular endothelium in the development and progression of atherosclerosis. Myocardial ischemia, activation of free-radical processes and impaired bioenergetics initiate a decrease in production of nitric oxide, which plays major vasodilator role. In this regard, the scientists is interested in the search for new drugs that can affect the main pathogenetic links of coronary artery disease. Statins are currently the drugs of choice. However, they are not always effective and have an ambiguous effect on oxidative potential of myocardial cells and endothelial function. Moreover, inhibition of mevalonic pathway for cholesterol synthesis is accompanied by a deficiency of coenzyme Q10, which is the central cellular antioxidant that protects phospholipids of cell membranes from free radicals. Rationale of using coenzyme Q10 in the complex treatment and secondary prev ention of cardiovascular diseases, including coronary artery di sease, is discussed.

A Cross-Sectional Study of the Effects of Physical Activity and Nutrient Intakes on Blood Glucose Control Rates in Middle-Aged and Elderly Diabetes Patients: Korean National Health and Nutrition Examination Survey 2015-2017

This study aimed to investigate factors affecting blood glucose control among middle-aged and older diabetic patients taking medications or receiving insulin therapy. In 2015–2017 data obtained from the Korean National Health and Nutrition Examination Survey (KNHANES), 1257 patients with diabetes were divided into a controlled group and an uncontrolled group based on blood glucose levels (cutoff ≥126 mg/dL). After adjusting for confounding factors, the BMI, total cholesterol level, and triglycerides level of the uncontrolled group were significantly higher than the controlled group. The total amount of moderate-intensity activity in controlled patients was significantly higher than that of the controlled group. Total energy, fat, saturated fatty acids, and cholesterol intakes were found to be significantly higher in the uncontrolled than controlled group. Intakes of calcium, phosphorus, potassium, riboflavin, niacin, and vitamin C were significantly lower in the uncontrolled than controlled group. Adequate nutrition intake and physical activity of patients undergoing diabetes therapy are required for effective blood glucose management for both diabetic drug and insulin therapies.

The Novelty of Icosapent Ethyl in the Management of Hypertriglyceridemia and Alleviating Cardiovascular Risk

Hypertriglyceridemia is believed to be independently associated with an elevated risk of cardiovascular disease (CVD) events. Lifestyle changes and dietary modifications are recommended for individuals with high serum triglyceride (TG) levels (150-499 mg/dl), and pharmacological therapy in addition to lifestyle modification is recommended when serum TG levels ≥ 500 mg/dl. A residual cardiovascular risk remains even in statin appropriate treated patients with CVD risk factors, and in this patient population, hypertriglyceridemia poses an independent and increased risk of ischemic events. In December 2019, the US FDA approved icosapent ethyl (IPE) as an adjunct to a maximally tolerated statin to reduce the risk of CVD events in adults with serum triglycerides > 150 mg/dl and have either established cardiovascular disease or diabetes and two or more additional CVD risk factors. Since IPE significantly decreases total ischemic events in the aforementioned patient population, it would be intriguing to know whether IPE alone added an advantage to lifestyle modification in the low-risk population, who has serum triglyceride between 150 mg/dl and 499 mg/dl.

Effects of Two Community-Based Exercise Programs on Adherence, Cardiometabolic Markers, and Body Composition in Older People with Cardiovascular Risk Factors: A Prospective Observational Cohort Study

Cardiovascular disease is one of the leading causes of death globally, and cardiovascular risk factors (CRFs) are major behavioral risk factors. Therefore, community-based programs are being designed based on the prescription of physical exercise from primary care centers to improve people’s health through changes in lifestyle. The objective was to compare the effects of two types of community exercise on adherence, lipid profile, body composition and blood pressure. A prospective observational cohort study was designed with two cohorts of study depending on the duration and type of physical exercise program performed. Fifty-one participants (82.4% women) with CRF completed the observation period in which they carried out a short-term, non-individualized exercise program (3 months), and 42 participants (71.4% women) with CRF completed the observation period in which they conducted a long-term, individualized exercise program (6 months). The results suggest that participants who carried out the longer program with an individualized progression produced greater adherence to physical exercise and a decrease in diastolic blood pressure. In addition, LDL and insulin levels decreased in both groups. Therefore, our results suggest that a longer duration and individualized evolution of the loads of a community exercise program lead to higher levels of physical activity (PA) and improvements diastolic blood pressure.

Bariatric surgery and cardiovascular outcome

BACKGROUND

Obesity is recognized as a classic risk factor for atherosclerosis and subsequent cardiovascular disease (CVD). Weight loss after bariatric surgery has been associated with reduced CV mortality and total mortality in obese patients. Our aim was to study the impact of bariatric surgery on CV risk profile, cardiac structure, and function postoperatively.

RESULTS

This prospective longitudinal study included 100 morbidly obese patients at final analysis. All patients were subjected to full clinical, laboratory, and echocardiographic examination at baseline and 6 months after bariatric surgery. The mean age of study population was 37.2 ± 10.49 with BMI of 47 ± 6.82. Females represented 84%. Sleeve gastrectomy and Roux-en-Y gastric bypass were performed in 79% and 21%, respectively. Surgery-related mortality and morbidity were 0.94% and 4.7%, respectively. After 6 months, there were significant decreases in BMI, heart rate, SBP, DBP, and Framingham risk score (P < 0.0001). The prevalence of risk factors decreased as follows: hypertension 24% vs. 12%, P = 0.0005; DM 21% vs. 11%, P = 0.002; dyslipidemia 32% vs. 7%, P < 0.0001; and metabolic syndrome 54% vs. 26%, P < 0.0001. Highly significant (P < 0.0001) decrease in fasting PG and 2 h PP-PG, HbA1c, ASL, ALT, fasting total cholesterol, LDL, TG, and increase in HDL were observed after bariatric surgery. There were significant shortening in QTc interval (P = 0.009), decrease in LV dimensions and LV mass index (P < 0.0001), and increase in LV EF% (P = 0.0003). BMI at follow-up showed significant positive correlation with age, Framingham risk score, and preoperative BMI (r = 0.289, P = 0.0036; r = 0.37, P = 0.0054; and r = 0.31, P = 0.0081, respectively).

CONCLUSION

In addition to enabling patients to achieve a substantial weight loss, bariatric surgery provides a myriad of health benefits. Weight reduction was associated with a favorable improvement in cardiovascular risk profile, cardiac structure, and function.

Pathophysiological mechanisms of statin-associated myopathies: possible role of the ubiquitin-proteasome system

BACKGROUND

Statins are the cornerstone of pharmacotherapy for atherosclerotic cardiovascular disease. While these drugs are generally safe, treatment adherence is not optimal in a considerable proportion of patients because of the adverse effects on skeletal muscles in the forms of myopathy, myalgia, muscular pain, nocturnal muscle cramping, weakness, and rare rhabdomyolysis.

METHODS

For the purpose of this narrative review, we searched for the literature suggesting the involvement of the ubiquitin-proteasome system in the development of statin-induced myopathy.

RESULTS

Statins have been shown to up-regulate the expression of the muscle-specific ubiquitin-proteasome system as the major non-lysosomal intracellular protein degradation system. It has been postulated that statins may provoke instability in the myocyte cell membrane when subjected to eccentric exercise stress, triggering activation of intracellular proteolytic cascades and changes in protein degradation machinery. This is accompanied by the up-regulation of a series of genes implicated in protein catabolism, in addition to those of the ubiquitin-proteasome system.

CONCLUSIONS

Based on the available literature, it seems that the involvement of ubiquitin-proteasome system is potentially implicated in the pathophysiology of statin-induced myopathy.

Transport, metabolism and remedial potential of functional food extracts (FFEs) in Caco-2 cells monolayer: A review

Caco-2, a human intestinal carcinoma cell line, has been used to test the absorption and transport mechanism of functional foods and drugs across the intestinal epithelium in order to study their antioxidant, anticancer and anti-inflammatory activities. Caco-2 cells represent the morphological and functional characteristics of small intestinal cells and capable of expressing brush borders, tight junctions, intestinal efflux and uptake transporters which regulate permeation of drugs and functional food extracts from intestinal lumen to systemic circulation. The integrity of the Caco-2 monolayer is controlled by establishing the TEER between 200 and 1000 O per cm². FFEs affect intestinal permeability by adjusting the tight junction proteins between the cells in order to maintain the epithelial barrier function. Because of the side effects of medicines, there is an increased interest in functional food extracts (FFEs) as drug substitutes. Functional foods undergo intricate transport processes and biotransformation after oral administration. Metabolism and transport studies of FFEs in Caco-2 cells are very important for determining their bioavailability. Functional foods and their constituents produce anti-proliferative and anti-cancer effects through apoptosis, cell cycle arrest and inhibition of various signal transduction pathways across Caco-2 cell lines. The current review has summarized the anti-inflammation, anticancer, antioxidant and cholesterol lowering potential of FFEs using Caco-2 cells through reducing local inflammatory signals, production of ROS and lipid accumulation. The transport, bioavailability, metabolism, mechanisms of actions, cellular pathways adopted by FFEs across Caco-2 cell lines are predominantly affected by their molecular weight, structures and physicochemical properties. These studies are beneficial for investigating the different mechanisms of action of FFEs in the human body.

Primary Hypertriglyceridemia: A Look Back on the Clinical Classification and Genetics of the Disease

INTRODUCTION

Hypertriglyceridemia (HTG) is one of the most common metabolic disorders leading to pancreatitis and cardiovascular disease. HTG develops mostly due to impaired metabolism of triglyceride-rich lipoproteins. Although monogenic types of HTG exist, most reported cases are polygenic in nature.

AIM

This review article is focused on the classification of Primary HTG and the genetic factors behind its development with the aim of providing clinicians a useful tool for early detection of the disease in order to administer proper and effective treatment.

DISCUSSION

HTG is often characterized by a complex phenotype resulting from interactions between genetic and environmental factors. In many instances, the complexity, perplexing causes, and classification of HTG make it difficult for clinicians to properly diagnose and manage the disorder. Better availability of information on its pathophysiology, genetic factors involved, environmental causes, and their interactions could help in understanding such complex disorders and could support its effective diagnosis and treatment.

CONCLUSION

The current review has summarized the case definition, epidemiology, pathophysiology, clinical presentation, classification, associated genetic factors, and scope of genetic screening in the diagnosis of primary HTG.

Sequence analysis and variant identification at the APOC3 gene locus indicates association of rs5218 with BMI in a sample of Kuwaiti's

Background

APOC3 is important in lipid transport and metabolism with limited studies reporting genetic sequence variations in specific ethnic groups. The present study aimed to analyze the full APOC3 sequence among Kuwaiti Arabs and test the association of selected variants with lipid levels and BMI.

Methods

Variants were identified by Sanger sequencing the entire APOC3 gene in 100 Kuwaiti Arabs. Variants and their genotypes were fully characterized and used to construct haplotype blocks. Four variants (rs5128, rs2854117, rs2070668, KUAPOC3N3 g.5196 A > G) were selected for testing association with serum lipid levels and BMI in a cohort (n = 733).

Results

APOC3 sequence (4.3 kb) of a Kuwaiti Arab was deposited in Genbank (accession number KJ437193). Forty-two variants including 3 novels were identified including an “A” insertion at genomic positions 116,700,599–116,700,600 (promoter region) and two substitutions in intron 1 at genomic positions 116,700,819 and 116,701,159. Only three variants, (rs5128, rs2854117, and rs2070668) were analyzed for association of which rs5128 showed a trend for association with increased BMI, TG and VLDL levels that was further investigated using multivariate analysis. A significant association of rs5128 with BMI (p <  0.05) was observed following a dominant genetic model with increased risk by an OR of 4.022 (CI: 1.13–14.30).

Conclusion

The present study is the first to report sequence analysis of APOC3 in an Arab ethnic group. This study supports the inclusion of rs5128 as a marker for assessing genetic risk to dyslipidemia and obesity and the inclusion of the novel variant g.5196 A > G for population stratification of Arabs.

The curative treatment of familial hypercholesterolemia: Liver transplantation

BACKGROUND

Familial hypercholesterolemia (FH) is an autosomal dominant genetic disorder characterized by premature mortal cardiovascular complications. Liver transplantation (LT) is the only curative treatment option. In this study, the long-term clinical follow-up data of 8 patients who underwent LT with a diagnosis of FH in our center are presented.

MATERIALS AND METHODS

A total of 638 LT were performed between December 1985 and June 2019 at Baskent University, of which 8 patients underwent LT with a diagnosis of FH and were evaluated retrospectively.

RESULTS

Of the 8 patients, 4 underwent deceased donor and 4 living donor transplantation. Five patients had preoperative cardiovascular disease and consequent interventional operations. There was significant reduction in postoperative LDL-C and TC levels starting from the first week, and stabilizing at the first month and first year. The median survival time of patients was 5 years (2-12 years). All patients are still alive. None of the complications of patients with preoperative cardiovascular complications had progressed.

CONCLUSION

Liver transplantation is the preferred curative treatment for the pathophysiology of FH. In our study, LDL-C levels were brought under control with LT performed on patients with FH. Median 5-year follow-up of patients showed that the progression of cardiac complications was abated.

Superior Role of Waist Circumference to Body-Mass Index in the Prediction of Cardiometabolic Risk in Dyslipidemic Patients

Coronary risk evaluation by conventional factors (age, gender, smoking, blood pressure and cholesterol) may further be specified by facets of the metabolic syndrome, namely insulin resistance, hypertriglyceridemia and obesity. Although obesity is usually defined as elevated body mass index (BMI), recent data indicate a superior role of waist circumference or hypertri-glyceridemic waist (HTGW) over BMI in the assessment of cardiometabolic risk. In dyslipidemic patients, the specific contributions of risky waist, HTGW or BMI have not been evaluated as yet. 686 dyslipidemic subjects (322 males and 364 females) were enrolled into a cross-sectional study. In each subject basic antropometry (i.e. waist circumference, HTGW, BMI) and laboratory parameters of lipid profile and insulin resistance were determined. Cardiometabolic risk was given by fulfilling the criteria (harmonized definition) of metabolic syndrome. The significance of risky waist, HTGW and BMI were assessed by comparing the respective predictive values for the presence of metabolic syndrome. Dyslipidemic patients with risky waist, HTGW or high BMI have a more atherogenic lipid profile and higher insulin resistance compared to those without risky waist, HTGW or high BMI. Risky waist is stronger predictor of metabolic syndrome (PPV 66 %, NPV 90 %) and thus posesa greater cardiometabolic risk than higher BMI per se does (PPV 42 %, NPV 97 %). The contribution of triglycerides (i.e. HTGW) to these predictive values is marginal (PPV 66 %, NPV 92 %). The present results highlight the superior role of waist circumference as a screening tool over BMI for the evaluation of cardiometabolic risk in dyslipidemic subjects. HTGW brings little additional benefit in risk stratification. Lower BMI proved to be optimal for identifying the subjects with inferior risk.

Metabolic Syndrome and Male Fertility

Metabolic syndrome (MetS) represents a cluster of conditions that have a negative impact on human health overall. Its prevalence has been rapidly increasing worldwide and has coincided with a global decrease in birth rates and fertility potential. This review aims to address this observation through studying the relationship between MetS and male reproductive health. The effects of obesity, dyslipidemia, hypertension, and insulin resistance on male fertility were examined and supporting evidence explaining the pathophysiology of sperm dysfunction with each MetS component were described. Adopting a healthy lifestyle appears to be the single most important intervention to prevent the unwanted effects of MetS on men's health and fertility. Further studies addressing the components of MetS and their impact on male reproduction are required to enhance our understanding of the underlying pathophysiology and to propose new methods for therapeutic intervention.

Real-World Data to Identify Hypercholesterolemia Patients on Suboptimal Statin Therapy

AIM

Statins are generally well-tolerated but some patients develop adverse events and down-titrate or discontinue statins. It is important to understand the frequency of dyslipidemia patients with the inability to continue statins. The aim of the present study was to identify the frequency of high-risk dyslipidemia patients who are unable to take or not taking statins for any reason using Japanese hospital claims database.

METHODS

2,527,405 dyslipidemia patients with atherosclerotic cardiovascular disease were investigated between April 2008 and September 2017. Definition 1 included statin discontinuation or down-titration with non-statin lipid modifying therapy (LMT) prescription, rhabdomyolysis or muscle-related symptoms with statin down-titration or discontinuation, or prescription for ≥3 statin types. Definition 2 included all components of Definition 1 in addition to statin down-titration or discontinuation for any reason. Patients never given statins but who started non-statin LMT were considered as Definition 3. The achievement rate of the target LDL-C level was investigated.

RESULTS

Among 54,296 patients with statin prescription, 2.32% and 48.38% patients were identified as Definition 1 and 2, respectively. Of eligible patients, 13.16% patients were identified as Definition 3. The achievement rate of target LDL-C level was lower in patients meeting each definition than not satisfying each definition.

CONCLUSIONS

There is a proportion of high-risk dyslipidemia patients unable to take or not taking statins for any reason, and it is associated with lower achievement rates of target LDL-C levels. Suboptimal management of LDL-C is directly associated with residual cardiovascular risk and implementation of alternative therapeutic options in addition to existing LMT is warranted.

Association between awareness of nutrition labeling and high-density lipoprotein cholesterol concentration in cancer survivors and the general population: The Korean National Health and Nutrition Examination Survey (KNHANES) 2010-2016

Background

Nutrition labeling has been found to affect the amount and type of food intake, with certain groups in the population, such as cancer survivors, being more aware of this information. A higher awareness of nutrition labeling is inversely related to the risk of dyslipidemia. This study therefore assessed the association between awareness of nutrition labeling and high-density lipoprotein cholesterol (HDL-C) concentration among cancer survivors in South Korea and in the general population of subjects without a history of cancer.

Methods

This cross-sectional analysis evaluated 25,156 adults who participated in the Korean National Health and Nutrition Examination Surveys (KNHANES) from 2010 to 2016. Factors influencing the association between awareness of nutrition labeling and HDL-C concentration in cancer survivors and the general population were determined by multiple regression analysis.

Results

Of the 25,156 participants, 2.88% were cancer survivors and 97.12% had no history of cancer. HDL-C concentrations were higher in subjects who were aware of nutrition labeling than in subjects who were not. Checking or using nutrition labeling had a greater effect on the management of HDL-C concentration for cancer survivors than for the general population.

Conclusion

Awareness of nutrition labeling was associated with better outcomes, including higher controlled HDL-C levels, and reductions in factors increasing the risk of coronary artery disease and cancer, especially in cancer survivors. Health policymakers or medical professionals should develop programs to promote the use of nutrition labeling among cancer survivors in South Korea.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5196-6) contains supplementary material, which is available to authorized users.

Ezetimibe in high-risk, previously treated statin patients: a systematic review and network meta-analysis of lipid efficacy

PURPOSE

While statins are used as first-line treatments for high-risk patients with hypercholesterolemia, statin monotherapy is often insufficient to achieve target low-density lipoprotein cholesterol (LDL-C) levels. Second-line treatment options include up-titration of statin dose, switching to a more potent statin, or combination therapy, e.g., with ezetimibe. The aim of this study was to evaluate the efficacy of adding ezetimibe to simvastatin, atorvastatin, or rosuvastatin monotherapy versus doubling the dosage or switching to a higher-potency statin in a population of patients with hypocholesterolemia at high risk of cardiovascular disease (CVD) and who had been previously treated with a statin.

METHODS

A systematic literature search was performed and evidence bases were established for populations of atorvastatin-, simvastatin-, and rosuvastatin-experienced patients using eligible randomized controlled trials (RCTs). Based on the available data, we constructed networks of evidence and conducted a Bayesian network meta-analysis (NMA) within each statin population. The primary outcome of interest was percent change from baseline in LDL-C. Changes in total cholesterol were explored as a secondary outcome.

FINDINGS

Across all patient populations, 35 RCTs were identified and included in the evidence base. Among patients on simvastatin therapy, the addition of ezetimibe resulted in a mean difference (MD) in LDL-C of - 13.62% (95% CrI - 19.99, - 6.91; see table below) compared to doubling the starting dose of simvastatin. In the population of patients on atorvastatin therapy, the addition of ezetimibe resulted in an MD in LDL-C of - 14.71% (95% CrI - 16.46, - 12.95) compared to doubling the starting dose of atorvastatin. The addition of ezetimibe to rosuvastatin resulted in an MD in LDL-C of - 14.96% (95% CrI - 17.79, - 12.11), compared to doubling the starting rosuvastatin dose. Similar trends were observed for changes in total cholesterol.

IMPLICATIONS

Given the available data, the addition of ezetimibe to ongoing simvastatin, atorvastatin, or rosuvastatin monotherapy offers greater reduction in LDL-C among patients at high risk of CVD compared to doubling the initial statin dose.

Association of macronutrient consumption with arterial aging in adults without clinically overt cardiovascular disease: a 5-year prospective cohort study

PURPOSE

There is limited and inconsistent evidence regarding longitudinal effects of macronutrients on blood pressure (BP) haemodynamics and arterial aging in populations without cardiovascular disease (CVD). We aimed to prospectively investigate potential association of dietary macronutrients with long-term changes in peripheral and central haemodynamics and arterial stiffness.

METHODS

One hundred and fifteen subjects (46.7 ± 8.73 years, 70 women), free of clinically overt CVD were consecutively recruited. Dietary macronutrient intake was evaluated using 3-day food records at baseline. Aortic stiffness and arterial wave reflections were assessed at baseline and in one follow-up visit 5 years later by pulse wave velocity (PWV) and augmentation index (AI), respectively.

RESULTS

Individuals with the highest consumption of saturated fatty acids (SFA) presented the highest rate of progression in PWV, AI and aortic diastolic BP (p < 0.05 for all) after adjustment for age, gender, smoking, body mass index, hyperlipidemia, insulin resistance, changes in systolic BP and treatment with antihypertensive and hypolipidemic drugs. After similar multivariable adjustments, high consumption of carbohydrates was associated with higher progression of AI, whereas high consumption of monounsaturated fatty acids (MUFA) and fibre with lower progression in aortic and peripheral systolic and diastolic BP (p < 0.05 for all).

CONCLUSIONS

In subjects without CVD, high consumption of SFA is related to accelerated arterial stiffening, while high consumption of MUFA and fibre and low intake of carbohydrates is associated with attenuated progression in blood pressure and arterial wave reflections, respectively. These findings expand current knowledge on the association of macronutrient consumption with arterial aging in the general population.

What to say and how to say it: effective communication for cardiovascular disease prevention

PURPOSE OF REVIEW

Current guidelines for cholesterol treatment emphasize the importance of engaging patients in a risk-benefit discussion prior to initiating statin therapy.

RECENT FINDINGS

Although current risk prediction algorithms are well defined, there is less data on how to communicate with patients about cardiovascular disease risk, benefits of treatment, and possible adverse effects.

SUMMARY

We propose a four-part model for effective shared decision-making: 1) Assessing patient priorities, perceived risk, and prior experience with cardiovascular risk reduction; 2) Arriving at a recommendation for therapy based on the patient's risk of disease, guideline recommendations, new clinical trial data, and patient preferences; 3) Communicating this recommendation along with risks, benefits, and alternatives to therapy following best practices for discussing numeric risk; and 4) Arriving at a shared decision with the patient with ongoing reassessment as risk factors and patient priorities change.

Genetic predisposition and induced pro-inflammatory/pro-oxidative status may play a role in increased atherothrombotic events in nilotinib treated chronic myeloid leukemia patients

Several reports described an increased risk of cardiovascular (CV) events, mainly atherothrombotic, in Chronic Myeloid Leukemia (CML) patients receiving nilotinib. However, the underlying mechanism remains elusive. The objective of the current cross-sectional retrospective study is to address a potential correlation between Tyrosine Kinase Inhibitors (TKIs) treatment and CV events. One hundred and 10 chronic phase CML patients in complete cytogenetic response during nilotinib or imatinib, were screened for CV events and evaluated for: traditional CV risk factors, pro/anti-inflammatory biochemical parameters and detrimental ORL1 gene polymorphisms (encoding for altered oxidized LDL receptor-1). Multivariate analysis of the whole cohort showed that the cluster of co-existing nilotinib treatment, dyslipidaemia and G allele of LOX-1 polymorphism was the only significant finding associated with CV events. Furthermore, multivariate analysis according to TKI treatment confirmed IVS4-14 G/G LOX-1 polymorphism as the strongest predictive factor for a higher incidence of CV events in nilotinib patients. Biochemical assessment showed an unbalanced pro-inflammatory cytokines network in nilotinib vs imatinib patients. Surprisingly, pre-existing traditional CV risk factors were not always predictive of CV events. We believe that in nilotinib patients an induced “inflammatory/oxidative status”, together with a genetic pro-atherothrombotic predisposition, may favour the increased incidence of CV events. Prospective studies focused on this issue are ongoing.

Antioxidant and hypolipidemic effects of soymilk fermented via Lactococcus acidophilus MF204

Previous studies have shown that fermentations can enhance the bioactivity and absorption rate of soybean products. Fermented soybean products can alleviate hyperlipidemia and decrease risks of atherosclerosis and cardiovascular diseases. This study aimed to investigate the effects and mechanisms of soymilk fermented by Lactococcus acidophilus on blood lipids and antioxidant enzyme activities of rats fed with a high fat diet. Sixty rats were randomly assigned to six groups: normal control group (NC), high-fat control group (HFC), positive control group (cholestyramine, PC), Lactococcus acidophilus group (LA), soymilk group (SM), and fermented soymilk group (FSM), respectively. The NC group was fed with a basic diet, while the other groups were fed with a high-fat diet. After the experimental period (6 W), rats were sacrificed by decapitation. Blood and liver were collected to measure the concentrations of lipids and antioxidant enzyme activities. Results demonstrated that fermented soymilk could regulate lipid levels, restore HDL-c and TG to normal levels, and lower the concentrations of LDL-c than hypolipidemic drugs in hyperlipidemia rats. More importantly, fermented soymilk caused significant reduction in arteriosclerosis index and coronary risk index. Fermented soymilk also improved antioxidant capacities of hyperlipidemia rats. The increase of aglycone isoflavones in fermented soymilk could explain the above phenomena. In conclusion, soymilk fermented by Lactococcus acidophilus reduced risks of arteriosclerosis and coronary heart disease by regulating lipid levels and improving the antioxidant capacities of hyperlipidemia rats.

Double product reflects the association of heart rate with MACEs in acute coronary syndrome patients treated with percutaneous coronary intervention

BACKGROUND

There is little information about the prognostic value of double product (DP) for acute coronary syndrome (ACS) patients treated with percutaneous coronary intervention (PCI). The aim of this study was to investigate whether DP reflects the predictive power of heart rate (HR) or systolic blood pressure (SBP) in ACS patients treated with PCI.

METHODS

A total of 7590 ACS patients who had undergone PCI, free from cardiac shock, were included. The follow-up duration was two years. The main adverse cardiovascular events (MACEs) included all-cause death, recurrent myocardial infarction and stroke.

RESULTS

In the unadjusted model, significantly higher rates of MACEs were recorded in the high DP group (relative risk 1.41, 95%CI 1.08 to 1.83, p = 0.012). However, in the full adjusted models, after including HR and SBP, the predictive value of DP was not significant (relative risk 0.86, 95%CI 0.55 to1.33, p = 0.499). The predictive value of HR for MACEs was statistically significant (relative risk 1.74, 95% CI 1.33-2.28, p < 0.001). It was worth noting that the history of hypertension was strongly associated with MACEs (relative risk 1.53, 95% CI 1.11-2.11, p = 0.009).

CONCLUSION

High DP is associated with MACEs for ACS patients treated with PCI. However, the predictive value of DP weakened when adjusted for HR. Therefore, we have shown that DP may reflect the predictive power of HR for ACS patients treated with PCI.

Statin-associated muscle symptoms (SAMS) in primary prevention for cardiovascular disease in older adults: a protocol for a systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

Although statins are commonly used for prevention of cardiovascular disease, there is limited evidence about statin-related adverse effects in older people. Statin-related adverse events (AEs), especially the statin-associated muscle symptoms (SAMS), are the most common reasons for their discontinuation. Therefore, it is important to determine the risk of SAMS in the older population. We will undertake a systematic review and meta-analysis primarily focusing on the risk of SAMS and secondarily targeting myopathy, rhabdomyolysis, AEs and serious AEs, dropouts due to SAMS in run-in period, related permanent discontinuation rate of statins and creatine kinase level, among older people who received statins for primary prevention.

METHODS AND ANALYSIS

This study has been developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols statement. We will include randomised controlled trials in which statin was compared with placebo with at least 1 year follow-up among older adults aged ≥65. This review is an update of a Cochrane systematic review that included the articles published before 2012. Cochrane Central Register of Controlled Trials, Medline OvidSP and Embase electronic database searches will be performed to identify relevant articles, limiting the publication date from 1 January 2012 to 13 February 2017. There will be no language limitation. Two independent reviewers will screen titles and abstracts and full text in duplicate. Risk of bias and evidence quality will be assessed using the Cochrane Collaboration's tool and the Grading of Recommendations Assessment, Development and Evaluation approach, respectively. A meta-analysis using pooled data will be undertaken, if appropriate. We will also perform metaregression and subgroup analyses to identify sources of heterogeneity.

ETHICS AND DISSEMINATION

This study is exempt from ethics approval due to the anonymous and aggregated data used. The outcomes will be disseminated by conference presentations and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

CRD42017058436.

Lipid levels and new-onset diabetes in a hypertensive population: the China Stroke Primary Prevention Trial

This study aimed to provide insights into the relationship between lipid levels and new-onset diabetes (NOD) in 14,864 Chinese hypertensive patients without diabetes (6056 men and 8808 women) aged 45-75 years from the China Stroke Primary Prevention Trial (CSPPT, led by Nanfang Hospital, Guangzhou, China). NOD (defined as fasting plasma glucose (FPG) ≥ 7.0 mmol/L at the end of study or self-reported physician diagnosis of diabetes or self-reported use of hypoglycemic agents during follow-up) was analyzed using multivariate analysis. Follow-up was censored on August 24, 2014. Among the 14,864 subjects, 1615 developed NOD (10.9%, men = 10.8% and women = 10.9%). Increased triglycerides (TG) [odds ratio (OR) = 1.18; 95% confidence interval (CI): 1.13-1.25, P < 0.001], TG/HDL (OR = 1.12; 95%CI: 1.08-1.17, P < 0.001), and decreased high density lipoprotein (HDL) (OR = 0.79; 95%CI: 0.67-0.93, P = 0.005) were associated with NOD, independently from age, gender, body mass index, clinical center, systolic blood pressure, diastolic blood pressure, FPG, smoking, and drinking. Compared to subjects with the methylenetetrahydrofolate reductase (MTHFR) 677 CC and TT genotypes, those with the CT genotype had a higher risk of NOD (OR = 1.54; 95%CI: 1.30-1.81, P for interaction = 0.044) in subjects with high TG. These results suggested that TG and TG/HDL were independent risk factors for NOD in this Chinese hypertensive population. HDL was a protective factor for NOD.

Influence of cognitive function on cerebrovascular disease among the elderly

OBJECTIVES

To determine the interrelationships between baseline Mini-Mental State Examination (MMSE) score and overall long-term risk of cerebrovascular disease (CBVD).

MATERIALS & METHODS

This was a prospective cohort study of subjects aged 55 years or more who were enrolled in the Beijing Longitudinal Study of Aging (BLSA) and had a baseline MMSE score available. Baseline MMSE score was divided into four categories: ≥28, 26-27, 23-25, and ≤22. Participants were followed for 23 years. Cox regression models were used to examine the association between MMSE score and CBVD.

RESULTS

A total of 2101 participants were included in this analysis, 335 (15.9%) with an MMSE score ≥28, 365 (17.4%) with a score of 26-27, 579 (27.6%) with a score of 23-25, and 822 (7.4%) with a score ≤22. There were 576 cases of CBVD. The overall risk of CBVD increased with decreasing MMSE score. The impact of MMSE score on the risk of CBVD was much stronger in women than in men. The hazard ratio for CBVD risk was 1.76 (95% confidence interval [CI], 1.29-2.39, P < 0.05) for subjects with an MMSE score ≤22, and 1.21 (95% CI, 0.91-1.61, P < 0.05) for those with an MMSE score of 23-25. Higher MMSE scores were less strongly associated with the risk of CBVD.

CONCLUSIONS

Elderly people with lower MMSE scores, especially women, are at higher long-term risk of CBVD.

A Review of Clinical Practice Guidelines for the Management of Hypertriglyceridemia: A Focus on High Dose Omega-3 Fatty Acids

Cardiovascular (CV) disease remains the leading cause of preventable death in the US. Hyperlipidemia is a major modifiable risk factor for CV disease, and after numerous clinical trials have demonstrated that reductions in low-density lipoprotein (LDL) cholesterol with statin therapy can prevent major adverse CV events, statins have emerged as the drug of choice to lower LDL cholesterol and reduce CV risk. However, some statin-treated patients remain at high residual risk of CV events despite achieving low LDL cholesterol levels, especially if their triglyceride (TG) levels are elevated or their high-density lipoprotein (HDL) cholesterol levels low. Evidence from genetic and observational studies has linked elevated TG levels to an increased risk of CV events. Furthermore, very high TG levels are associated with acute pancreatitis. Consequently, several clinical practice guidelines provide recommendations for the management and treatment of high and very high TG levels. This review focuses on the clinical practice guidelines for the management of hypertriglyceridemia and the role of prescription omega-3 fatty acids in preventing pancreatitis and CV disease in individuals with high and very high TG levels.

Management standards for stable coronary artery disease in India

Coronary artery disease (CAD) is one of the important causes of cardiovascular morbidity and mortality globally, giving rise to more than 7 million deaths annually. An increasing burden of CAD in India is a major cause of concern with angina being the leading manifestation. Stable coronary artery disease (SCAD) is characterised by episodes of transient central chest pain (angina pectoris), often triggered by exercise, emotion or other forms of stress, generally triggered by a reversible mismatch between myocardial oxygen demand and supply resulting in myocardial ischemia or hypoxia. A stabilised, frequently asymptomatic phase following an acute coronary syndrome (ACS) is also classified as SCAD. This definition of SCAD also encompasses vasospastic and microvascular angina under the common umbrella.

Hypolipidemic drugs in elderly subjects: Indications and limits

AIMS

Cardiovascular disease is a major cause of death worldwide. Safety and efficacy of lipid lowering therapy have been clearly established for either primary and secondary prevention of cardiovascular events in adults. Nevertheless, the use of hypolipidemic drugs in elderly individuals, especially in the oldest ones, still raises some concerns. Aim of this paper is to review indications and limits of lipid lowering in advanced age, furnishing a practical medical attitude tempered by clinical and geriatric competences.

DATA SYNTHESIS

While figures from randomized controlled trials and from observational studies seem to support the use of lipid lowering drugs for secondary prevention in the elderly, drawing inferences from primary prevention in old populations is far more challenging. Although these pharmacological agents seem to reduce the incidence of cardiovascular events, they do not prolong survival. In addition, there is some doubt about the cost-effectiveness of treatment because of a more delicate balance between benefit and potential adverse reactions. However, lipid-lowering drugs seem largely underutilized in older age, mainly due to safety concerns that must be reconsidered, at least in part, given the somewhat reassuring results deriving from specific cohort surveys.

CONCLUSIONS

Data on the use and on the effects of lipid lowering drugs in elderly populations are incomplete, especially those concerning very old subjects without established cardiovascular disease. Comprehensive guidelines for the management of dyslipidemias in this rapidly-growing population is a urgent need, and treatment should be based, besides the aforementioned considerations, on patient preferences, cognitive function and life expectancy.

Non-High-Density Lipoprotein Cholesterol Levels on the Risk of Asymptomatic Intracranial Arterial Stenosis: A Result from the APAC Study

Intracranial arterial stenosis (ICAS) is an important cause of ischemic stroke and transient ischemic attack (TIA), and the correlation between the plasma non-high density cholesterol (non-HDLC) levels and ICAS, especially asymptomatic ICAS (AICAS) is not clear. The Asymptomatic Polyvascular Abnormalities Community(APAC) study is a community-based, prospective, long-term follow-up observational study. 3387 participants were enrolled in this study. The diagnosis of AICAS was made by transcranial Doppler ultrasonography. The participants were then divided into 3 groups based on their non-HDLC levels. The cox regression was used to analyze the correlation between the non-HDLC level and the incidence of AICAS.9.98% of the participants were diagnosed with AICAS during 2 years following up. Multivariate analysis showed that non-HDL-C is an independent indicator for the incidence of AICAS (HR = 1.22, 95%CI: 1.06–1.40), The incidence of AICAS gradually increase with the increasing non-HDLC level. Compared with subgroup(non-HDLC < 3.4 mmol/l), incidence of AICAS was significantly higher in the subgroups(non-HDLC 3.4–4.1 mmol/l and non-HDLC ≥ 4.1 mmol/l) after adjustment for the confounding factors (HR = 1.32, 95%CI:1.02–1.73; HR = 1.46, 95%CI: 1.10–1.94, respectively). In conclusions, our findings suggest that elevated non-HDLC levels a significant risk factor for the development of AICAS in the APAC study.

Risk burdens of modifiable risk factors incorporating lipoprotein (a) and low serum albumin concentrations for first incident acute myocardial infarction

Risk burdens of modifiable risk factors incorporating lipoprotein (a) (Lp(a)) and low serum albumin (LSA) concentrations for first incident acute myocardial infarction (AMI) haven’t been studied previously. Cross-sectional study of 1552 cases and 6125 controls was performed for identifying the association of risk factors with first incident AMI and their corresponding population attributable risks (PARs). Modifiable risk factors incorporating LSA and Lp(a) accounted for up to 92% of PAR for first incident AMI. Effects of these risk factors were different in different sexes across different age categories. Overall, smoking and LSA were the 2 strongest risk factors, together accounting for 64% of PAR for first incident AMI. After multivariable adjustment, Lp(a) and LSA accounted for 19% and 41%, respectively, and together for more than a half (54%) of PAR for first incident AMI. Modifiable risk factors incorporating LSA and Lp(a) have accounted for an overwhelmingly large proportion of the risk of first incident AMI, indicating most first incident AMI is preventable. The knowledge of risk burdens for first incident AMI incorporating Lp (a) and LSA may be beneficial for further reducing first incident AMI from a new angle.

Lipoprotein apheresis in the management of severe hypercholesterolemia and of elevation of lipoprotein(a): current perspectives and patient selection

This review reports the current situation with respect to therapeutic options (lifestyle and drugs) reducing the concentrations of atherogenic low-density lipoprotein cholesterol (LDL-C) and lipoprotein(a) (Lp[a]). Three lipoprotein apheresis (LA) principles have been realized: precipitation, filtration, and adsorption. Available LA methods are herein described in detail - major components, pumps, extracorporeal volume, treated volume, and anticoagulation. General features of all LA methods as well as pleotropic effects are elaborated. Indications for LA therapy are quoted: homozygous familial hypercholesterolemia (HCH), severe HCH, and isolated elevation of Lp(a) and progress of atherosclerotic disease. A major focus is on the evidence of the effect of LA on cardiovascular outcome data, and the most important publications are cited in this context. The best studies have been performed in patients with elevated Lp(a) in whom cardiovascular events were reduced by more than 80%. Major adverse effects and contraindications are listed. The impact of an LA therapy on patient quality of life and the requirements they have to fulfill are also highlighted. Finally, the future role of LA in treating high-risk patients with high LDL-C and/or high Lp(a) is discussed. It is probable that the significance of LA for treating patients with elevated LDL-C will decrease (with the exception of homozygous familial HCH) due to the application of PCSK9 inhibitors. The antisense oligonucleotide against apolipoprotein(a) could replace LA in patients with high Lp(a), provided positive outcome data are generated.

Higher prevalence of elevated LDL-C than non-HDL-C and low statin treatment rate in elderly community-dwelling Chinese with high cardiovascular risk

Lipid levels are increasing in all age groups in the Chinese population, but the use of statin treatment in the elderly is not well documented. We examined serum lipids, statin usage and achievement of lipid goals in 3950 subjects aged ≥65 years. Established CVD was present in 7.77% of participants and increased CVD risk was common. Elevated LDL-C according to CVD risk level was present in 46.70% of all subjects and was more frequent (p < 0.01) than elevated non-HDL-C at 32.58%. With increasing age, LDL-C was unchanged but triglycerides and non-HDL-C decreased and HDL-C increased. Individuals at moderate risk for CVD had higher TC, LDL-C, and non-HDL-C than low-risk subjects, but the values were lower in high- and very-high-risk individuals, probably because of the use of statin which was 28.57% in high-risk subjects with established CVD and 37.60% in very-high-risk individuals, but only 2.62% in those with estimated high-risk and 3.75% in those with high-risk from diabetes. More subjects in each risk group reached the non-HDL-C goal than the LDL-C goal because of the relatively low triglycerides and VLDL-C levels. These findings demonstrate a high prevalence of elevated LDL-C but low rate of statin treatment in elderly community-dwelling Chinese.

Combined Treatment with Amlodipine and Atorvastatin Calcium Reduces Circulating Levels of Intercellular Adhesion Molecule-1 and Tumor Necrosis Factor-α in Hypertensive Patients with Prediabetes

Objective: To assess the effect of amlodipine and atorvastatin on intercellular adhesion molecule (ICAM)-1 and tumor necrosis factor (TNF)-α expression, as endothelial function and inflammation indicators, respectively, in hypertensive patients with and without prediabetes.

Methods: Forty-five consecutive patients with hypertension, diagnosed according to JNC7, were divided into two groups based on the presence (HD group, n = 23) or absence (H group, n = 22) of prediabetes, diagnosed according to 2010 ADA criteria, including impaired glucose tolerance (IGT) and fasting glucose tests. All patients simultaneously underwent 12-week treatment with daily single-pill amlodipine besylate/atorvastatin calcium combination (5/10 mg; Hisun-Pfizer Pharmaceuticals Co. Ltd). Serum isolated before and after treatment from overnight fasting blood samples was analyzed by ELISA.

Results: In the HD and H groups after vs. before 12-week amlodipine/atorvastatin treatment, there were significantly (all P < 0.01) lower levels of ICAM-1 (3.06 ± 0.34 vs. 4.07 ± 0.70 pg/ml; 3.26 ± 0.32 vs. 3.81 ± 0.60 pg/ml, respectively) and TNF-α (78.71 ± 9.19 vs. 110.94 ± 10.71 pg/ml; 80.95 ± 9.33 vs. 101.79 ± 11.72 pg/ml, respectively), with more pronounced reductions in HD vs. H group (ICAM-1Δ: 1.01 ± 0.80 vs. 0.55 ± 0.64 pg/ml, respectively, P = 0.037; TNF-αΔ: 32.23 ± 14.33 vs. 20.84 ± 14.89 pg/ml, respectively, P = 0.011), independent of the blood pressure (BP) and cholesterol level reduction.

Conclusions: Amlodipine/atorvastatin improved endothelial function and inflammation, as reflected by lower circulating levels of ICAM-1 and TNF-α, more prominently in hypertensives with than without prediabetes. Starting statin treatment before overt diabetes in hypertensives might thus improve cardiovascular outcomes.

Effects of extended-release niacin/laropiprant on correlations between apolipoprotein B, LDL-cholesterol and non-HDL-cholesterol in patients with type 2 diabetes

BACKGROUND

LDL-C, non-HDL-C and ApoB levels are inter-correlated and all predict risk of atherosclerotic cardiovascular disease (ASCVD) in patients with type 2 diabetes mellitus (T2DM) and/or high TG. These levels are lowered by extended-release niacin (ERN), and changes in the ratios of these levels may affect ASCVD risk. This analysis examined the effects of extended-release niacin/laropiprant (ERN/LRPT) on the relationships between apoB:LDL-C and apoB:non-HDL-C in patients with T2DM.

METHODS

T2DM patients (n = 796) had LDL-C ≥1.55 and <2.97 mmol/L and TG <5.65 mmol/L following a 4-week, lipid-modifying run-in (~78 % taking statins). ApoB:LDL-C and apoB:non-HDL-C correlations were assessed after randomized (4:3), double-blind ERN/LRPT or placebo for 12 weeks. Pearson correlation coefficients between apoB:LDL-C and apoB:non-HDL-C were computed and simple linear regression models were fitted for apoB:LDL-C and apoB:non-HDL-C at baseline and Week 12, and the correlations between measured apoB and measured vs predicted values of LDL-C and non-HDL-C were studied.

RESULTS

LDL-C and especially non-HDL-C were well correlated with apoB at baseline, and treatment with ERN/LRPT increased these correlations, especially between LDL-C and apoB. Despite the tighter correlations, many patients who achieved non-HDL-C goal, and especially LDL-C goal, remained above apoB goal. There was a trend towards greater increases in these correlations in the higher TG subgroup, non-significant possibly due to the small number of subjects.

CONCLUSIONS

ERN/LRPT treatment increased association of apoB with LDL-C and non-HDL-C in patients with T2DM. Lowering LDL-C, non-HDL-C and apoB with niacin has the potential to reduce coronary risk in patients with T2DM.

Cardiovascular risk factor control is insufficient in young patients with coronary artery disease

Background

Control of cardiovascular risk factor is important in secondary prevention of coronary artery disease (CAD) but it is unknown whether treatment targets are achieved in young patients. We aimed to examine the prevalence and control of risk factors in this subset of patients.

Methods

We performed a cross-sectional, single-center study on patients with documented CAD before age 40. All patients treated between 2002 and 2014 were invited to participate at least 6 months after the last coronary intervention. We included 143 patients and recorded the family history of cardiovascular disease, physical activity level, smoking status, body mass index, waist circumference, blood pressure, cholesterol levels, metabolic status, and current medical therapy. Risk factor control and treatment targets were evaluated according to the shared guidelines from the European Society of Cardiology.

Results

The most common insufficiently controlled risk factors were overweight (113 [79.0%]), low-density lipoprotein cholesterol above target (77 [57.9%]), low physical activity level (78 [54.6%]), hypertriglyceridemia (67 [46.9%]), and current smoking (53 [37.1%]). Almost one-half of the patients fulfilled the criteria of metabolic syndrome. The median (interquartile range) number of uncontrolled modifiable risk factors was 2 (2;4) and only seven (4.9%) patients fulfilled all modifiable health measure targets.

Conclusion

Among the youngest patients with CAD, there remains a potential to improve the cardiovascular risk profile.

Lipid-modifying effects of nutraceuticals: An evidence-based approach

The present review provides an up-to-date summary of the findings on the lipid-lowering effects of the most important nutraceuticals and functional foods. Based on current knowledge, nutraceuticals might exert significant lipid-lowering, and their use has several advantages: A number of important questions remain to be addressed, including whether longer durations of therapy would result in a better response and the exact safety profile of nutraceuticals, especially at doses higher than those consumed in an average diet. Additionally, data regarding the effects of nutraceutical supplementation on the incidence of cardiovascular outcomes are lacking, and it is not clear whether additional lipid lowering by nutraceuticals can modify the residual cardiovascular risk that remains after statin therapy.

Dietary cholesterol and egg yolk should be avoided by patients at risk of vascular disease

Recent recommendations that limits to dietary cholesterol be dropped were probably heavily influenced by propaganda from the egg industry. After conviction for false advertising, the industry has spent hundreds of millions of dollars to convince the public, physicians, and policy makers that dietary cholesterol and egg yolk are harmless. However, there are good reasons for longstanding recommendations that dietary cholesterol be limited to <200 mg/ day in persons at risk of vascular disease. It is seldom understood that this essentially means all people in developed countries who expect to attain an advanced age. There is abundant evidence that dietary cholesterol increases cardiovascular risk. The misdirection of the egg industry focuses on fasting levels of LDL cholesterol, which are only raised by ~ 10% by consumption of egg yolks. However, the main effect of diet is on the post-prandial state: for ~ 4 hours after a high fat/high cholesterol meal, there is oxidative stress, endothelial dysfunction, and arterial inflammation. One large (65 g) egg yolk contains 237 mg of cholesterol, well above the recommended limit-nearly as much as a 12-ounce hamburger. Besides the very high cholesterol content of egg yolk, the phosphatidylcholine in egg yolk leads, via action of the intestinal microbiome, to production of trimethylamine n-oxide (TMAO), which causes atherosclerosis in animal models. Levels of TMAO in the top quartile after a test dose of two egg yolks were associated with a 2.5-fold increase in the 3-year risk of stroke, death, or myocardial infarction among patients referred for coronary angiography. Persons at risk of cardiovascular disease should limit their intake of cholesterol and egg yolk.