Effect of rosuvastatin on atherosclerotic plaque stability: An intravascular ultrasound elastography study

Alirocumab and Coronary Atherosclerosis in Asymptomatic Patients with Familial Hypercholesterolemia: The ARCHITECT Study

BACKGROUND

The effect of alirocumab, a PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitor, on coronary plaque burden in patients with familial hypercholesterolemia has not been addressed. Our aim was to assess changes in coronary plaque burden and its characteristics after treatment with alirocumab by quantification and characterization of atherosclerotic plaque throughout the coronary tree on the basis of a noninvasive analysis of coronary computed tomographic angiography in asymptomatic subjects with familial hypercholesterolemia receiving optimized and stable treatment with maximum tolerated statin dose with or without ezetimibe.

METHODS

This study is a phase IV, open-label, multicenter, single-arm clinical trial to assess changes in coronary plaque burden and its characteristics after 78 weeks of treatment with alirocumab in patients with familial hypercholesterolemia without clinical atherosclerotic cardiovascular disease. Participants underwent an initial coronary computed tomographic angiography at baseline and another at 78 weeks. Every patient received 150 mg of alirocumab subcutaneiously every 14 days in addition to high-intensity statin therapy. The main outcome was the change on coronary plaque burden and its characteristics by quantification and characterization of atherosclerotic plaque throughout the coronary tree on the basis of analysis of coronary computed tomographic angiography.

RESULTS

The study was completed by 104 patients. The median age was 53.3 (46.2-59.4) years. Of these patients, 54 were women (51.9%). Median low-density lipoprotein cholesterol was 138.9 (117.5-175.3) mg/dL at entry and 45.0 (36.0-65.0) mg/dL at follow-up (P<0.001). Coronary plaque burden changed from 34.6% (32.5%-36.8%) at entry to 30.4% (27.4%-33.4%) at follow-up (P<0.001). A significant change in the characteristics of the coronary atherosclerosis was also found: an increase in the proportion of calcified (+0.3%; P<0.001) and mainly fibrous (+6.2%; P<0.001) plaque, accompanied by a decrease in the percentage of fibro-fatty (-3.9%; P<0.001) and necrotic plaque (-0.6%; P<0.001).

CONCLUSIONS

Treatment with alirocumab in addition to high-intensity statin therapy resulted in significant regression of coronary plaque burden and plaque stabilization on coronary computed tomographic angiography over 78 weeks in these groups of patients with familial hypercholesterolemia without clinical atherosclerotic cardiovascular disease. ARCHITECT (Effect of Alirocumab on Atherosclerotic Plaque Volume, Architecture and Composition) could link and explain ODYSSEY OUTCOMES (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab) results.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT05465278.

Radial Wall Strain Assessment From AI-Assisted Angiography: Feasibility and Agreement With OCT as Reference Standard

Background

High-strain spots in coronary arteries are associated with plaque vulnerability and predict future events. Artificial intelligence currently enables the calculation of radial wall strain (RWS) from coronary angiography (RWSAngio). This study aimed to determine the agreement between novel RWSAngio and RWS derived from optical coherence tomography (OCT) followed by finite element analysis, as the established reference standard (RWSOCT).

Methods

All lesions from a previous OCT study were enrolled. OCT was automatically coregistered with angiography. RWSAngio was computed as the relative luminal deformation throughout the cardiac cycle, whereas RWSOCT was analyzed using finite element analysis on OCT cross-sections at 1-mm intervals. The luminal deformation in the direction of minimal lumen diameter was used to derive RWSOCT, using the same definition as RWSAngio. The maximal RWSOCT and RWSAngio at healthy segments adjacent to the interrogated lesion were also analyzed.

Results

Finite element analysis was performed in 578 OCT cross-sections from 45 lesions stemming from 36 patients. RWSAngio showed good correlation and agreement with RWSOCT (r = 0.91; P < .001; Lin coefficient = 0.85). RWSAngio in atherosclerotic segments was significantly higher than that in healthy segments (12.6% [11.0, 16.0] vs 4.5% [2.9, 5.5], P < .001). The intraclass correlation coefficients for intra- and interobserver variability in repeated RWSAngio analysis were 0.92 (95% CI, 0.87-0.95) and 0.88 (95% CI, 0.81-0.92), respectively. The mean analysis time of RWSOCT and RWSAngio for each lesion was 95.0 ± 41.1 and 0.9 ± 0.1 minutes, respectively.

Conclusions

Radial wall strain from coronary angiography can be rapidly and easily computed solely from angiography, showing excellent agreement with strain derived from coregistered OCT. This novel and simple method might provide a cost-effective biomechanical assessment in large populations.

Short-Term Risk Stratification of Non-Flow-Limiting Coronary Stenosis by Angiographically Derived Radial Wall Strain

BACKGROUND

Deferred revascularization of mildly stenotic coronary vessels based exclusively on physiological evaluation is associated with up to 5% residual incidence of future adverse events at 1 year.

OBJECTIVES

We aimed to evaluate the incremental value of angiography-derived radial wall strain (RWS) in risk stratification of non-flow-limiting mild coronary narrowings.

METHODS

This is a post hoc analysis of 824 non-flow-limiting vessels in 751 patients from the FAVOR III China (Comparison of Quantitative Flow Ratio Guided and Angiography Guided Percutaneous Intervention in Patients With Coronary Artery Disease) trial. Each individual vessel had ≥1 mildly stenotic lesion. The primary outcome was vessel-oriented composite endpoint (VOCE), defined as the composite of vessel-related cardiac death, vessel-related myocardial infarction (nonprocedural), and ischemia-driven target vessel revascularization at 1-year follow-up.

RESULTS

During 1-year follow-up, VOCE occurred in 46 of 824 vessels, with a cumulative incidence of 5.6%. Maximum RWS (RWSmax) was predictive of 1-year VOCE with an area under the curve of 0.68 (95% CI: 0.58-0.77; P < 0.001). The incidence of VOCE was 14.3% in vessels with RWSmax >12% vs 2.9% in those with RWSmax ≤12%. In the multivariable Cox regression model, RWSmax >12% was a strong independent predictor of 1-year VOCE in deferred non-flow-limiting vessels (adjusted HR: 4.44; 95% CI: 2.43-8.14; P < 0.001). The risk of deferred revascularization based on combined normal RWSmax and Murray-law-based quantitative flow ratio (μQFR) was significantly reduced compared with μQFR alone (adjusted HR: 0.52; 95% CI: 0.30-0.90; P = 0.019).

CONCLUSIONS

Among vessels with preserved coronary flow, angiography-derived RWS analysis has the potential to further discriminate vessels at risk of 1-year VOCE. (Comparison of Quantitative Flow Ratio Guided and Angiography Guided Percutaneous Intervention in Patients With Coronary Artery Disease [FAVOR III China Study]; NCT03656848).

Radial wall strain: a novel angiographic measure of plaque composition and vulnerability

BACKGROUND

The lipid-to-cap ratio (LCR) and thin-cap fibroatheroma (TCFA) derived from optical coherence tomography (OCT) are indicative of plaque vulnerability.

AIMS

We aimed to explore the association of a novel method to estimate radial wall strain (RWS) from angiography with plaque composition and features of vulnerability assessed by OCT.

METHODS

Anonymised data from patients with intermediate stenosis who underwent coronary angiography (CAG) and OCT were analysed in a core laboratory. Angiography-derived RWSmax was computed as the maximum deformation of lumen diameter throughout the cardiac cycle, expressed as a percentage of the largest lumen diameter. The LCR and TCFA were automatically determined on OCT images by a recently validated algorithm based on artificial intelligence.

RESULTS

OCT and CAG images from 114 patients (124 vessels) were analysed. The average time for the analysis of RWSmax was 57 (39-82) seconds. The RWSmax in the interrogated plaques was 12% (10-15%) and correlated positively with the LCR (r=0.584; p<0.001) and lipidic plaque burden (r=0.411; p<0.001), and negatively with fibrous cap thickness (r= -0.439; p<0.001). An RWSmax >12% was an angiographic predictor for an LCR >0.33 (area under the curve [AUC]=0.86, 95% confidence interval [CI]: 0.78-0.91; p<0.001) and TCFA (AUC=0.72, 95% CI: 0.63-0.80; p<0.001). Lesions with RWSmax >12% had a higher prevalence of TCFA (22.0% versus 1.5%; p<0.001), thinner fibrous cap thickness (71 μm versus 101 μm; p<0.001), larger lipidic plaque burden (23.3% versus 15.4%; p<0.001), and higher maximum LCR (0.41 versus 0.18; p<0.001) compared to lesions with RWSmax ≤12%.

CONCLUSIONS

Angiography-derived RWS was significantly correlated with plaque composition and known OCT features of plaque vulnerability in patients with intermediate coronary stenosis.

Anti-inflammatory effects of rosuvastatin treatment on coronary artery ectasia patients of different age groups

Background

Coronary artery ectasia (CAE) is an angiographic finding of abnormal coronary dilatation. Inflammation plays a major role in all phases of atherosclerosis. We investigated the relationship between CAE and serum high-sensitivity C-reactive protein (hs-CRP) and interleukin-6 (IL-6) levels to test our hypothesis that patient age is associated with the efficacy of anti-inflammatory therapy for CAE.

Methods

We conducted a prospective analysis of 217 patients with CAE treated at the Department of Cardiology, Shanghai East Hospital, Ji’an Campus and the Baoshan People’s Hospital, from January 1, 2015 to July 30, 2019. Baseline data of patients, including sex; age; and history of hypertension, hyperlipidemia, and diabetes, were collected from patient medical records. Study participants were grouped by age as follows: CAE-A (n = 60, age ≤ 50 years), CAE-B (n = 83, 50 years <age ≤ 70 years), and CAE-C (n = 74, age > 70). Additionally, there was a control (NC) group (n = 73) with normal coronary arteries.

Results

All patients received oral rosuvastatin therapy (10 mg, QN quaque nocte) when they were diagnosed with CAE and maintained good follow-up, with a loss rate of 0.0% at the end of the 6-month follow-up. The NC group received regular symptom-relieving treatments and rosuvastatin therapy. Of these four groups, the inflammatory markers, hs-CRP and IL-6, were significantly higher in patients with CAE than in the NCs (p < 0.05). Post-hoc tests showed that hs-CRP and Il-6 levels had significant differences between the CAE-A and CAE-C groups (P = 0.048, P = 0.025). Logistic regression analysis showed that hs-CRP (OR = 1.782, 95% CI: 1.124–2.014, P = 0.021) and IL-6 (OR = 1.584, 95% CI: 1.112–1.986, P = 0.030) were independent predictors of CAE. The inflammatory markers were higher in the CAE-A group than in the CAE-B group and higher in the CAE-B group than in the CAE-C group. Follow-up after 6 months of rosuvastatin therapy showed a significantly greater reduction in hs-CRP and IL-6 levels in the CAE-A group than in the CAE-B group, which again were greater in the CAE-B group than in the CAE-C group.

Conclusions

Anti-inflammatory therapy using rosuvastatin was more effective in younger CAE patients, indicating the need for early statin therapy in CAE.

Can atherosclerosis be cured?

PURPOSE OF REVIEW

Determine if evidence supports interventions to prevent development of atherosclerosis and atherosclerotic cardiovascular disease (ASCVD) events and death.

RECENT FINDINGS

An extensive body of evidence supports the fundamental causal role of apolipoprotein B lipoproteins in the development of atherosclerosis. Recent epidemiologic studies have shown that LDL-cholesterol (LDL-C) and non-HDL-cholesterol levels in early adults are associated with accelerated subclinical atherosclerosis and an excess of atherosclerotic cardiovascular events later in life. Animal and human data have shown that intensive LDL-C lowering can regress earlier stages of atherosclerosis.

SUMMARY

The next research priority is evaluating the impact of lowering LDL-C earlier in life to regress early atherosclerosis, followed by trials to demonstrate this approach will eradicate later-life ASCVD events and death. This approach of curing atherosclerosis will likely be the most effective strategy for reducing the huge global burden of atherosclerosis.

Plasma biomarkers and plaque strain predict long-term cardiovascular events in patients with acute coronary syndrome

To test whether circulating and intracoronary biomarkers and coronary plaque strain have additive values to Global Registry of Acute Coronary Events (GRACE) score for predicting long-term cardiovascular events in ACS patients. One hundred ACS patients were enrolled and the GRACE score and plasma levels and intracoronary gradients of a number of biomarkers were measured. Coronary plaque burden and morphology in non-critical stenotic plaques were determined by intravascular ultrasound (IVUS) technique, and the maximal shear strain (SS_max) and maximal area strain (AS_max) were determined by intravascular ultrasound elastography (IVUSE) technique. Patients were followed for cardiovascular events and the predictive values of clinical characteristics, plasma biomarkers and plaque parameters were compared with GRACE score, and the incremental values of these measurements to the GRACE score were assessed. GRACE score, plasma biomarkers and plaque strain were independent predictors of cardiovascular events. Combination of GRACE score, plasma biomarkers and plaque strains significantly improved the predictive value of the GRACE score alone with the receiver-operating characteristic area increased from 0.457 to 0.667 (P=0.014). The combination of circulating and intracoronary biomarkers, plaque strain and GRACE score provides a better predictive tool than GRACE score alone in patients with ACS.

Synergistic protective effects of a statin and an angiotensin receptor blocker for initiation and progression of atherosclerosis

Aim

Although the atheroprotective effects of statins and angiotensin II receptor blockers (ARBs) are well-established, little is known about their additive effects, especially during the early period of atherosclerosis. The aim of this study was to investigate whether combination of a statin and an ARB exerts synergistic anti-atherosclerotic effects, and to elucidate the mechanisms of combined effects.

Methods

Atherosclerotic plaques were developed in arteries of 23 rabbits using a high-cholesterol diet (HCD) and intra-arterial balloon inflation. Rabbits received one of five different treatment strategies for 4 weeks: positive control [n = 5, HCD]; negative control [n = 3, regular chow diet]; statin [n = 5, HCD and rosuvastatin 10 mg]; ARB [n = 5, HCD and olmesartan 20 mg]; and combination [n = 5, HCD and statin+ARB].

Results

Histological analysis demonstrated that development of atherosclerotic plaques was inhibited more in combination group than in statin group (P = 0.001). Although macrophage infiltration identified by RAM11 staining was not significantly different between combination and individual treatment groups (31.76±4.84% [combination] vs. 38.11±6.53% [statin; P = 0.35] or 35.14±2.87% [ARB; P = 0.62]), the relative proportion of pro-inflammatory M1-macrophages was significantly lower in combination group than in ARB group (3.20±0.47% vs. 5.20±0.78%, P = 0.02). Furthermore, M2-macrophage polarization was higher in combination group than in statin group (17.70±3.04% vs. 7.86±0.68%, P = 0.001).

Conclusion

Combination treatment with a statin and an ARB produced synergistic protective effects for atherosclerosis initiation and progression, which may be attributed to modulation of macrophage characteristics in the early period of atherosclerosis.

Oral administration of Zuccagnia punctata extract improves lipid profile, reduces oxidative stress and prevents vascular dysfunction in hypercholesterolemic rabbits

BACKGROUND

The consumption of flavonoids has been shown to prevent cardiovascular diseases including atherosclerosis. In this sense, in a recent in vitro study we demonstrated that a rich in flavonoids extract from Zuccagnia punctata has beneficial effects on vascular function in aorta from hypercholesterolemic rabbits.

PURPOSE

The aim of this study was to evaluate the ability of a hydroalcoholic extract from Z.puncata (ZpE) to prevent alterations induced by high cholesterol diet in rabbits.

METHODS

The major components of the ZpE, flavonoids, were analyzed by using a validated reversed phase HPLC method. Rabbits were separated in five groups: fed standard chow (CD); CD orally administrated 2.5 mg, 5 mg or 10 mg GAE/day ZpE (ZpE- CD); fed 1% cholesterol-enriched chow (HD); HD orally administrated 2.5 mg GAE/day ZpE (ZpE-HD); HD orally administrated 2.5 mg rosuvastatin/day (Ro-HD). All diets were administrated by 6 weeks. Body weights (BW), mean blood pressure (MAP), heart rate (HR), visceral abdominal fat (VAF), organ weight (heart, kidney, liver) and vascular morphology were determined. Total cholesterol (TC), triglycerides (TG), fasting glucose (FG), aspartate amino transferase (AST), alanine amino transferase (ALT), bilirubin, creatinine, thiobarbituric acids reactive substances (TBARS) and glutathione reduced/oxidized index were measured in serum. Abdominal aorta was excised and vascular function was assessed by acetylcholine and sodium nitroprusiate relaxation and contractile response to norepinephrine and angiotensin II.

RESULTS

The major compounds of ZpE identified were chalcones: 2',4'-dihydroxy-3'-methoxychalcone and 2',4'-dihydroxychalcone. Oral treatment with ZpE reduced MAP, TC, TG, TBARS, aortic intima/media ratio and increased glutathione reduced/oxidized index in HD rabbits. No differences were found in AST, ALT, bilirubin or creatinine. Acetylcholine relaxation was normalized and contractile response to norepinephrine and angiotensin II was reduced in ZpE-HD.

CONCLUSION

Oral administration of ZpE as natural product in the prevention of cardiovascular disease related with hypercholesterolemia and endothelial dysfunction is very promising.

Fluvastatin inhibits cardiomyocyte apoptosis after myocardial infarction through Toll pathway

The present study intended to investigate the effect of fluvastatin on cardiomyocyte apoptosis after myocardial infarction in rats. Eighty myocardial infarction rat models were established and randomly divided into 4 groups (n=20): experimental group (n=20) was given fluvastatin treatment; sham operation group (n=20) and normal control group (n=20) were given saline. The dose of fluvastatin was 20 mg/(kg·d), and irrigation gavage was given for 1 week. Western blot analysis and reverse transcription-quantitative PCR (RT-qPCR) were used to detect the expression of TLR4 mRNA and protein in cardiomyocytes. TUNEL method was used to detect the apoptosis of cardiomyocytes. After fluvastatin treatment for 1 week, RT-qPCR found that compared with myocardial infarction group, the TLR4 mRNA expression of fluvastatin treatment group and normal control group was significantly increased, and the differences between groups were a statistically significant difference (P<0.05). Western blot analysis showed that compared with the myocardial infarction group, the expression of TLR4 protein in normal control group, sham operation group and fluvastatin treatment group were significantly decreased, and they all were statistically significant (P<0.05). TUNEL method found that compared with the myocardial infarction group, the fluvastatin treatment group could significantly reduce the apoptosis of cardiomyocytes (19.2±3.8%), and the difference was statistically significant (P<0.05). Fluvastatin can inhibit myocardial infarction and decrease cardiomyocyte apoptosis by increasing the expression of TLR4-like receptor.

Intravascular ultrasound elastography analysis of the elastic mechanical properties of atherosclerotic plaque

To assess the elastic mechanical properties of atherosclerotic plaque with different morphological properties by intravascular ultrasound elastography (IVUSE). 30 purebred New Zealand rabbits were fed a high-cholesterol diet; the abdominal aorta endothelium was balloon-injured after 2 weeks; at week 12, 2 plaques with moderate echo from each rabbit were chosen for in situ imaging, and 2 consecutive frames near the end-diastole images in situ were used to construct an IVUS elastogram. Shear strain (SS) and area strain (AS) were greater for eccentric than centripetal plaque (SS: 2.65(2.45)% vs. 1.79 ± 0.97%, p < 0.05; AS: 4.81(4.99)% vs. 3.23 ± 1.75%, p < 0.05) but were lower with low than high plaque burden (SS: 2.14 ± 0.37% vs. 3.40 ± 0.34%, p < 0.05; AS: 3.88 ± 0.60% vs. 5.81 ± 0.54%, p < 0.05). SS and AS were significantly greater for plaque with negative than no remodeling (SS: 3.98 ± 1.53% vs. 1.82(1.40)%, p < 0.017; AS: 6.94 ± 2.24% vs. 2.59(2.87)%, p < 0.017) and were found correlated with eccentric index and plaque burden (R² = 0.365 and R² = 0.359, both p < 0.05). Plaques associated with eccentricity, high plaque burden and negative remodeling showed greater strain than those with centripetalism, low plaque burden and positive remodeling. Eccentric index and plaque burden may be useful to predict the elastic stability of plaque.

Overexpression of Toll-Like Receptors 2, 3, 4, and 8 Is Correlated to the Vascular Atherosclerotic Process in the Hyperlipidemic Rabbit Model: The Effect of Statin Treatment

BACKGROUND

Atherosclerosis is the major cause of cardiovascular disease; hypercholesterolemia is a major risk factor. We hypothesized that specific TLR members (TLR2, TLR3, TLR4, TLR8) may play a role in atherosclerosis progression and its accompanying inflammatory response. We determined the association of atherosclerotic lesions and TLR mRNA expression in different aortic sites. We also assessed the effects of fluvastatin (Flu) treatment on TLR expression and plaque characteristics.

METHODS

Male rabbits, fed with an atherogenic diet for a duration of 3 months, were screened for advanced atherosclerotic lesions in the aorta. Additional animals received normal diet or normal diet plus Flu for 1 additional month. TLR mRNA expression in various thoracic and abdominal aortic segments was assessed, together with atherosclerotic changes.

RESULTS

After high lipid diet, the atherosclerotic burden increased more in the abdominal than in the thoracic aorta; TLR2, 3, 4, and 8 also increased significantly. Flu decreased atherosclerotic plaque, calcium deposition, lipid cores, intraplaque hemorrhage, erythrocyte membranes, endothelial cells, and macrophage infiltration, while increasing smooth muscle cells in plaques of both aortic segments; it also lowered TLR2, 3, 4, and 8 expression in all aortic segments to a stronger degree than resumption of normal diet. There was a strong association between blood and tissue parameters during experimental period and finally a strong correlation found between these parameters with mRNA of TLR2, 3, 4, and 8 in various stages.

CONCLUSION

For the first time TLR2, 3, 4, and 8 mRNA expression is prospectively explored after hypercholesterolemic diet in the rabbit model. TLR2, 3, 4, and 8 mRNA expression is strongly upregulated and correlates with the progression of atherosclerosis in the aorta. Flu significantly inhibited this progress and reduced inflammation via TLR downregulation which was strongly associated with regression of plaque morphology and atherosclerosis promoting factors.