Non-high-density lipoprotein cholesterol is a practical predictor of long-term cardiac death after coronary artery bypass grafting

The U-shaped association of non-high-density lipoprotein cholesterol with all-cause and cardiovascular mortality in general adult population

Background

Non-high-density lipoprotein cholesterol (non-HDL-C) has been associated with atherosclerosis. However, the association between non-HDL-C and mortality in adult population remains unclear. We intended to investigate the association of non-HDL-C with cardiovascular and all-cause mortality using national representative data.

Methods

The study included 32,405 participants from the National Health and Nutrition Examination Survey (1999-2014). Mortality outcomes were ascertained by linkage to National Death Index records through December 31, 2015. Multivariable-adjusted Cox regression models were used to evaluate hazard ratio (HR) and 95% confidence interval (CI) of non-HDL-C concentrations in quintiles. Two-piecewise linear regression and restricted cubic spline analyzes were performed to test dose-response associations.

Results

After a median follow-up of 98.40  months, 2,859 (8.82%) all-cause and 551 (1.70%) cardiovascular deaths occurred. Compared with the highest group, the multivariable-adjusted hazard ratio (HR) of the first quintile for all-cause mortality was 1.53 (95%CI, 1.35-1.74). Higher non-HDL-C above a cutoff value of 4.9 mmol/L was related with cardiovascular mortality (HR = 1.33, 95%CI, 1.13-1.57). A U-shaped relationship between non-HDL-C and all-cause mortality was found in spline analysis with a cutoff value around 4 mmol/L. Similar results in subgroups analyzes were found among male, non-white population, participants who were not taking lipid-lowering drugs, and with body mass index (BMI) <25 kg/m².

Conclusion

Our findings suggest a U-shaped association between non-HDL-C and mortality among adult population.

Nomograms Based on Non-High-Density Lipoprotein to Predict Outcomes in Patients with Prior Coronary Artery Bypass Grafting with Acute Coronary Syndrome: A Single-Center Retrospective Study

Introduction

Non-high-density-lipoprotein cholesterol (non-HDL-C) is a secondary therapeutic target in cardiovascular diseases and is used for residual risk assessment in patients with coronary artery syndrome (ACS). This study was designed to determine the association between non-HDL-C in patients with prior coronary artery bypass graft (CABG) with ACS and clinical outcomes.

Methods

We retrospectively analyzed 468 patients with prior CABG with ACS and categorized them into two groups based on the median non-HDL-C level. The primary endpoints were major adverse cardiovascular events (MACEs), including cardiovascular death and recurrent myocardial infarction. Kaplan-Meier curves, Cox proportional-hazard regressions, and restricted cubic splines were used to determine the association between non-HDL-C and MACEs. The discrimination and reclassification of the nomogram based on non-HDL-C were assessed using time-dependent receiver operating characteristic (ROC) curves and net reclassification improvement (NRI).

Results

During the average follow-up time of 744.5 days, non-HDL-C was independently associated with the occurrence of MACEs (hazard ratio [HR] = 5.01, 95% confidence interval [CI] = 1.65-15.24; p = 0.005) after adjusting for other lipid parameters. The spline curves indicated a linear relationship between non-HDL-C and MACEs (p-nonlinear: 0.863). The time-dependent areas under the ROC curves of prior-CABG-ACS nomograms containing non-HDL regarding MACEs in two consecutive years were 91.7 (95% CI: 85.5-97.9) and 91.5 (95% CI: 87.3-95.7), respectively. The NRI analysis indicated that the prior-CABG-ACS model improved the reclassification ability for 1- and 2-year MACEs (22.4% and 7%, p < 0.05, respectively).

Discussion

Non-HDL is independently associated with the risk of MACEs in patients with prior CABG with ACS. The prior-CABG-ACS nomogram based on non-HDL-C and five convenient variables generates valid and stable predictions of MACE occurrence.

The U-Shaped Association of Non-High-Density Lipoprotein Cholesterol Levels With All-Cause and Cardiovascular Mortality Among Patients With Hypertension

Background: Non-high-density lipoprotein cholesterol (non-HDL-C) is a valuable indicator in routine blood lipid tests, but the associations of non-HDL-C with mortality in hypertensive population still remain uncertain.

Methods: In the National Health and Nutrition Examination Surveys from 1999 to 2014, participants having hypertension were included and grouped by non-HDL-C levels (<130, 130–159, 160–189, 190–219, and ≥220 mg/dl). Multivariate Cox regression was conducted for calculation of hazard ratios (HR) and 95% confidence interval (CI). To reveal the relationship between non-HDL-C and mortality, Kaplan–Meier survival curves, restricted cubic spline, linear regression, and subgroup analysis were also applied.

Results: A total of 12,169 participants (47.52% males, mean age 57.27 ± 15.79 years) were included. During average follow-up of 92.5 months, 1,946 (15.99%) all-cause deaths and 422 (3.47%) cardiovascular deaths occurred. After adjusting for confounders, the association of non-HDL-C with mortality was detected as U-shaped. Threshold values were observed at 158 mg/dl for all-cause mortality and 190 mg/dl as to cardiovascular mortality. Below the threshold, every 10 mg/dl increment in non-HDL-C attributed to relatively low all-cause mortality significantly (HR = 0.94, 95% CI: 0.92–0.96). Above the threshold, non-HDL-C has significant positive associations with both all-cause (HR = 1.03, 95% CI: 1.01–1.05) and cardiovascular mortality (HR = 1.09, 95% CI: 1.05–1.14). For subgroups analysis, similar results were found among participants age <65 years old, non-white population, those were not taking lipid-lowering drugs, and subjects with body mass index (BMI) ≥25 kg/m².

Conclusion: The U-shaped association was detected between non-HDL-C and mortality among hypertensive population.

Non-High-Density Lipoprotein Cholesterol Predicts Adverse Outcomes in Acute Ischemic Stroke

[Figure: see text].

Clinical Characteristics and Outcomes in Young Patients With ST-Segment Elevation Myocardial Infarction After Primary Percutaneous Coronary Intervention

BACKGROUND

There are few published studies of ST-segment elevation myocardial infarction (STEMI) in younger individuals. The differences between these "younger" and "older" individuals may not be fully appreciated by clinicians. The aim of this study was to determine the reasons for the earlier presentation and help to identify strategies for prevention of recurrent myocardial infarction (MI) in younger patients.

METHODS

The study population was a cohort of 2,419 consecutive STEMI patients who were treated with primary percutaneous coronary intervention. The median follow-up time of this retrospective study was 2.2 years.

RESULTS

The all-cause mortality rates in patients ≤45 years of age at 30 days, 1 and 2 years were 1.7%, 2.0% and 2.2%, respectively. These rates were lower compared with their older matched counterparts whose all-cause mortality rates were 3.3%, 4.2% and 5.5%, respectively (P = 0.010). The incidence of recurrent MI was 4.0% for all age groups combined, 5.4% for younger patients and 3.8% for older patients. The number of stents showed association with recurrent MI in older patients with a first infarction, whereas only composition factor 1 with significantly higher non-high-density lipoprotein and low-density lipoprotein values was significantly associated with recurrent MI in the younger patients.

CONCLUSIONS

STEMI patients ≤45 years of age more often had lower rates of all-cause mortality, but the risk of recurrent MI was similar to that of older patients. Regardless of triglyceride level, neither non-high-density lipoprotein nor low-density lipoprotein were independent predictors for recurrent MI during the long-term follow-up in younger patients.

Non-high-density lipoprotein cholesterol predicts nonfatal recurrent myocardial infarction in patients with ST segment elevation myocardial infarction

Background

Lipids, which are associated with atherogenesis, clotting, and the fibrinolytic pathway, may be important prognostic indicators of recurrent myocardial infarction. The aim of this study was to determine the predictive value of baseline lipid fractions for nonfatal recurrent myocardial infarction in patients with ST segment elevation myocardial infarction 2 years after primary percutaneous coronary intervention in China.

Methods

Cox proportional-hazards models were used to evaluate the association between potential risk factors, including lipid fractions, and the occurrence of nonfatal recurrent myocardial infarction in 2402 consecutive patients who underwent primary percutaneous coronary intervention for ST segment elevation myocardial infarction.

Results

The cumulative incidence of recurrent myocardial infarction was 2.7% at 1 year, 3.8% at 2 years, and 5.8% at 3 years after percutaneous coronary intervention. The effects of collinearity of lipids were investigated. In concerning the principal components analysis, composing factor 1 (scoring factors were 0.689 for non-HDL, 0.702 for LDL, 0.182 for HDL) which had eigenvalues of 1.86 and explained 62% of the variability among lipid cholesterols was significantly associated with recurrent MI in the final adjusted analysis of the lipid cholesterols principal components. Non-high-density lipoprotein cholesterol was the strongest independent predictor of nonfatal recurrent myocardial infarction. The adjusted hazards ratios for nonfatal recurrent myocardial infarction were 1.26 (95% confidence interval (CI): 1.05–1.51) for non-high-density lipoprotein cholesterol, 1.17 (95% CI: 0.99–1.39) for low-density lipoprotein and 1.15 (95% CI: 0.95–1.40) for HDL. After adjusting for gender and age, the odds ratio for patients in the highest non-high-density lipoprotein cholesterol quartile was 2.10 (95% CI: 1.19–3.72).

Conclusions

Non-high-density lipoprotein cholesterol value is a stronger predictor of nonfatal recurrent myocardial infarction than other lipid risk factors in patients with ST segment elevation myocardial infarction. Moreover, the occurrence of reinfarction after percutaneous coronary intervention was highest for patients in the highest non-high-density lipoprotein cholesterol quartile.

Trial registration

http://www.chictr.org.cn/edit.aspx?pid=13583&htm=4, registration number: ChiCTR-EPC-16008199, date of registration:2013.01.01.

Electronic supplementary material

The online version of this article (doi:10.1186/s12944-017-0418-5) contains supplementary material, which is available to authorized users.

Prognostic value of non-high-density lipoprotein cholesterol for mortality in patients with coronary heart disease: A systematic review and meta-analysis

BACKGROUND AND AIMS

Recent studies have indicated the predictive value of non-high-density lipoprotein cholesterol (non-HDL-C) for mortality in patients without coronary heart disease (CHD). However, its independent prognostic value on patients with CHD has yet been explored. The purpose of this study was to investigate whether non-HDL-C could predict long-term mortality in patients with CHD.

METHODS

A comprehensive search for literature was performed in several database, including Medline, the Cochrane library, Embase and 3 Chinese databases. Studies were included if they reported risk estimation of mortality on CHD patients. Pooled risk ratios (RRs) and 95% confidence interval (CI) were calculated to assess the association. We performed sensitivity analyses to explore the potential sources of heterogeneity. Statistical analyses were carried out by Stata 12.0.

RESULTS

After screening 533 studies, 6 trials (follow up range from 18 to 148months) enrolling 11,057 CHD patients were included. CHD patients with high non-HDL-C level at baseline was associated with higher risk of mortality (RR: 1.24, 95%CI: 1.05-1.46, p: 0.011). Results from continuous analyze showed that each 10mg/dl increase in non-HDL-C was associated with an increased risk of mortality in CHD patients (RR: 1.13, 95%CI: 1.06-1.21, p<0.001).

CONCLUSION

The increased levels of non-HDL-C were significantly associated with an increased risk of mortality on CHD patients. Baseline non-HDL-C levels might be a practical predictor of long-term death in patients with CHD.

Optimal strategies for monitoring lipid levels in patients at risk or with cardiovascular disease: a systematic review with statistical and cost-effectiveness modelling

BACKGROUND

Various lipid measurements in monitoring/screening programmes can be used, alone or in cardiovascular risk scores, to guide treatment for prevention of cardiovascular disease (CVD). Because some changes in lipids are due to variability rather than true change, the value of lipid-monitoring strategies needs evaluation.

OBJECTIVE

To determine clinical value and cost-effectiveness of different monitoring intervals and different lipid measures for primary and secondary prevention of CVD.

DATA SOURCES

We searched databases and clinical trials registers from 2007 (including the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the Clinical Trials Register, the Current Controlled Trials register, and the Cumulative Index to Nursing and Allied Health Literature) to update and extend previous systematic reviews. Patient-level data from the Clinical Practice Research Datalink and St Luke's Hospital, Japan, were used in statistical modelling. Utilities and health-care costs were drawn from the literature.

METHODS

In two meta-analyses, we used prospective studies to examine associations of lipids with CVD and mortality, and randomised controlled trials to estimate lipid-lowering effects of atorvastatin doses. Patient-level data were used to estimate progression and variability of lipid measurements over time, and hence to model lipid-monitoring strategies. Results are expressed as rates of true-/false-positive and true-/false-negative tests for high lipid or high CVD risk. We estimated incremental costs per quality-adjusted life-year.

RESULTS

A total of 115 publications reported strength of association between different lipid measures and CVD events in 138 data sets. The summary adjusted hazard ratio per standard deviation of total cholesterol (TC) to high-density lipoprotein (HDL) cholesterol ratio was 1.25 (95% confidence interval 1.15 to 1.35) for CVD in a primary prevention population but heterogeneity was high (I(2) = 98%); similar results were observed for non-HDL cholesterol, apolipoprotein B and other ratio measures. Associations were smaller for other single lipid measures. Across 10 trials, low-dose atorvastatin (10 and 20 mg) effects ranged from a TC reduction of 0.92 mmol/l to 2.07 mmol/l, and low-density lipoprotein reduction of between 0.88 mmol/l and 1.86 mmol/l. Effects of 40 mg and 80 mg were reported by one trial each. For primary prevention, over a 3-year period, we estimate annual monitoring would unnecessarily treat 9 per 1000 more men (28 vs. 19 per 1000) and 5 per 1000 more women (17 vs. 12 per 1000) than monitoring every 3 years. However, annual monitoring would also undertreat 9 per 1000 fewer men (7 vs. 16 per 1000) and 4 per 1000 fewer women (7 vs. 11 per 1000) than monitoring at 3-year intervals. For secondary prevention, over a 3-year period, annual monitoring would increase unnecessary treatment changes by 66 per 1000 men and 31 per 1000 women, and decrease undertreatment by 29 per 1000 men and 28 per 1000 men, compared with monitoring every 3 years. In cost-effectiveness, strategies with increased screening/monitoring dominate. Exploratory analyses found that any unknown harms of statins would need utility decrements as large as 0.08 (men) to 0.11 (women) per statin user to reverse this finding in primary prevention.

LIMITATION

Heterogeneity in meta-analyses.

CONCLUSIONS

While acknowledging known and potential unknown harms of statins, we find that more frequent monitoring strategies are cost-effective compared with others. Regular lipid monitoring in those with and without CVD is likely to be beneficial to patients and to the health service. Future research should include trials of the benefits and harms of atorvastatin 40 and 80 mg, large-scale surveillance of statin safety, and investigation of the effect of monitoring on medication adherence.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003727.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Lipoprotein(a) level and apolipoprotein(a) phenotype as predictors of long-term cardiovascular outcomes after coronary artery bypass grafting

OBJECTIVE

To evaluate the relationships of lipoprotein(a) (Lp(a)) concentration and apolipoprotein(a) (apo(a)) phenotype to major adverse cardiovascular events after coronary artery bypass grafting (CABG) in long-term follow-up.

METHODS

This single-center study included 356 patients with stable coronary heart disease (CHD) who underwent successful CABG. At baseline, we assessed the patient's risk factor profile for atherosclerosis, Lp(a) concentration and apo(a) phenotype. The primary endpoint was the composite of cardiovascular death and non-fatal myocardial infarction (MI). The secondary endpoint also included hospitalization for recurrent or unstable angina and repeat revascularization.

RESULTS

Over a mean of 8.5 ± 3.5 years (range 0.9-15.0 years), the primary and secondary endpoints were registered in 46 (13%) and 107 (30%) patients, respectively. Patients with Lp(a) ≥30 mg/dL were at significantly greater risk for the primary endpoint (hazard ratio (HR) 2.98, 95% confidence interval (CI) 1.76-5.03, p < 0.001) and secondary endpoint (HR 3.47, 95% CI 2.48-4.85, p < 0.001) than patients with Lp(a) values <30 mg/dL. The low molecular-weight apo(a) phenotype was also associated with higher risk of both primary and secondary endpoints (3.57 (1.87-6.82) and 3.05 (2.00-4.62), respectively; p < 0.001 for both), regardless of conventional risk factors and statins use.

CONCLUSION

In stable CHD patients Lp(a) concentration and low molecular-weight apo(a) phenotype are independently associated with three-fold increase in risk of major adverse cardiovascular events within 15 years after CABG. Lp(a) levels may provide an additional information for postoperative cardiovascular risk assessment.