1
|
Zhou Y, Madsen JM, Özbek BT, Køber L, Bang LE, Lønborg JT, Engstrøm T. The role of remnant cholesterol in patients with ST-segment elevation myocardial infarction. Eur J Prev Cardiol 2024; 31:1227-1237. [PMID: 38447015 DOI: 10.1093/eurjpc/zwae102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/26/2024] [Accepted: 03/05/2024] [Indexed: 03/08/2024]
Abstract
AIMS Remnant cholesterol (RC) is the cholesterol content within triglyceride-rich lipoproteins. It promotes atherosclerotic cardiovascular disease beyond LDL cholesterol (LDL-C). The prognostic role of RC in patients with ST-segment elevation myocardial infarction (STEMI) is unknown. We aimed to estimate RC-related risk beyond LDL-C in patients with STEMI. METHODS AND RESULTS A total of 6602 consecutive patients with STEMI treated with primary percutaneous coronary intervention (PCI) from 1999 to 2016 were included. Remnant cholesterol was calculated as total cholesterol minus LDL-C minus HDL cholesterol. Adjusted Cox models were used to estimate the association between continuous RC levels and all-cause mortality, cardiovascular death, ischaemic stroke, and recurrent myocardial infarction (MI) at long-term (median follow-up of 6.0 years). Besides, discordance analyses were applied to examine the risk of the discordantly high RC (RC percentile rank minus LDL-C percentile rank > 10 units) compared with the discordantly low RC (LDL-C percentile rank minus RC percentile rank > 10 units). The concordance was defined as the percentile rank difference between RC and LDL-C ≤ 10 units. The median age of patients was 63 years [interquartile range (IQR) 54-72] and 74.8% were men. There were 2441, 1651, and 2510 patients in the discordantly low RC group, concordant group, and discordantly high RC group, respectively. All outcomes in the discordantly high RC group were higher than the other groups, and the event rate of all-cause mortality in this group was 31.87%. In the unadjusted analysis, the discordantly high RC was associated with increased all-cause mortality [hazard ratio (HR) 1.82, 95% confidence interval (CI) 1.63-2.04] and increased cardiovascular death (HR 1.79, 95% CI 1.55-2.06) compared with the discordantly low RC. In an adjusted model, RC was associated with higher all-cause mortality (HR 1.14, 95% CI 1.07-1.22). The discordantly high RC was associated with increased all-cause mortality (adjusted HR 1.55, 95% CI 1.37-1.75) and increased cardiovascular death (adjusted HR 1.47, 95% CI 1.25-1.72) compared with the discordantly low RC. There were no associations between RC and ischaemic stroke or recurrent MI. CONCLUSION In patients with STEMI treated with primary PCI, elevated RC levels beyond LDL-C and discordantly high RC were independently associated with increased all-cause mortality.
Collapse
Affiliation(s)
- Yan Zhou
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Graduate School of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Jasmine Melissa Madsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Burcu Tas Özbek
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Lia Evi Bang
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Jacob Thomsen Lønborg
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Thomas Engstrøm
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| |
Collapse
|
2
|
Li M, Wang M, Zhao Y, Zhong R, Chen W, Lei X, Wu X, Han J, Lei L, Wang Q, Luo G, Wei M. Effects of elevated remnant cholesterol on outcomes of acute ischemic stroke patients receiving mechanical thrombectomy. J Thromb Thrombolysis 2024; 57:390-401. [PMID: 38180591 DOI: 10.1007/s11239-023-02939-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE Large cohort studies provided evidence that elevated remnant cholesterol (RC) was an important risk factor for ischemic stroke. However, the association between high RC and clinical outcomes in acute ischemic stroke (AIS) individuals was still undetermined. METHODS This retrospective study enrolled 165 AIS patients undergoing mechanical thrombectomy in one tertiary stroke center. We divided patients into two groups based on the median of their RC levels (0.49 mmol/L). The modified Rankin Scale (mRS) was used to evaluate the primary outcome 90 days after the onset of symptoms. The mRS scores ≤ 2 and ≤ 1 at 90 days were deemed as favorable and excellent outcomes, respectively. RESULTS In the overall AIS patients undergoing mechanical thrombectomy, there was no obvious distinction between the high and low RC group at 90-day favorable outcome (41.0% vs. 47.1%, P = 0.431) or excellent outcome (23.1% vs. 31.0%, P = 0.252). In the subgroup analysis stratified by stroke etiology, non-large artery atherosclerosis (non-LAA) stroke patients yielded with less favorable or excellent prognosis in the high RC group (26.8% vs. 46.8%, adjusted OR = 0.31, 95%CI: 0.11-0.85, P = 0.023; or 12.2% vs. 29.0%, adjusted OR = 0.18, 95%CI: 0.04-0.80, P = 0.024, respectively.). Post hoc power analyses indicated that the power was sufficient for favorable outcome (80.38%) and excellent outcome (88.72%) in non-LAA stroke patients. Additionally, RC can enhance the risk prediction value of a poor outcome (mRS scores 3-6) based on traditional risk indicators (including age, initial NIHSS score, operative duration, and neutrophil-to-lymphocyte ratio) for non-LAA stroke patients (AUC = 0.86, 95%CI: 0.79-0.94, P < 0.001). CONCLUSION In AIS patients undergoing mechanical thrombectomy, elevated RC was independently related to poor outcome for non-LAA stroke patients, but not to short-term prognosis of LAA stroke patients.
Collapse
Affiliation(s)
- Mengmeng Li
- Stroke Centre, Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Meng Wang
- Department of Neurology, Xi'an Children's Hospital, Xi'an, China
| | - Yixin Zhao
- Stroke Centre, Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Rui Zhong
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Wanying Chen
- Stroke Centre, Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiangyu Lei
- Stroke Centre, Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiaoyu Wu
- Stroke Centre, Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jiaxin Han
- Stroke Centre, Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Lei Lei
- Stroke Centre, Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Qingfan Wang
- Stroke Centre, Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Guogang Luo
- Stroke Centre, Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
| | - Meng Wei
- Stroke Centre, Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
| |
Collapse
|
3
|
Delialis D, Georgiopoulos G, Aivalioti E, Konstantaki C, Oikonomou E, Bampatsias D, Mavraganis G, Vardavas C, Liberopoulos E, Stellos K, Stamatelopoulos K. Remnant cholesterol in atherosclerotic cardiovascular disease: A systematic review and meta-analysis. Hellenic J Cardiol 2023; 74:48-57. [PMID: 37116829 DOI: 10.1016/j.hjc.2023.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Accumulating evidence suggests a substantial contribution of remnant cholesterol (RC) to residual risk for the development or relapse of atherosclerotic cardiovascular disease (ASCVD). We aimed to evaluate the association of RC levels with ASCVD risk by different risk categories and methods of RC assessment. We also assessed available evidence of the effects of lipid-lowering therapies (LLTs) on RC levels. METHODS English-language searches of Medline, PubMed, and Embase (inception to 31 January 2023); ClinicalTrials.gov (October 2022); and reference lists of studies and reviews. Studies reporting on the risk of the composite endpoint [all-cause mortality, cardiovascular mortality, and major adverse cardiac events (MACE)] by RC levels were included. Moreover, we searched for studies reporting differences in RC levels after the administration of LLT(s). RESULTS Among n = 29 studies with 257,387 participants, we found a pooled linear (pooled HR: 1.27 per 1-SD increase, 95% CI: 1.12-1.43, P < 0.001, I2 = 95%, n = 15 studies) and non-linear association (pooled HR: 1.59 per quartile increase, 95% CI: 1.35-1.85, P < 0.001, I2 = 87.9%, n = 15 studies) of RC levels and the risk of M ACE both in patients with and without established ASCVD. Interestingly, the risk of MACE was higher in studies with directly measured vs. calculated RC levels. In a limited number of studies and participants, LLTs reduced RC levels. CONCLUSION RC levels are associated with ASCVD risk both in primary and secondary prevention. Directly measured RC levels are associated with ASCVD risk more evidently. Available LLTs tend to decrease RC levels, although the clinical relevance of RC decrease merits further investigation. PROSPERO REGISTRATION CRD42022371346.
Collapse
Affiliation(s)
- Dimitrios Delialis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Georgios Georgiopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens Medical School, Athens, Greece; School of Biomedical Engineering and Imaging Sciences, King's College, London, UK
| | - Evmorfia Aivalioti
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Christina Konstantaki
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ermioni Oikonomou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Dimitrios Bampatsias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Georgios Mavraganis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Constantine Vardavas
- Department of Social Medicine, Faculty of Medicine, University of Crete, University Campus of Voutes, 700 13, Heraklion, Crete, Greece; Center for Global Tobacco Control, Department of Society, Human Development and Health, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
| | - Evangelos Liberopoulos
- 1(st) Department of Propedeutic Medicine, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Konstantinos Stellos
- Department of Cardiovascular Research, European Center for Angioscience (ECAS), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Kimon Stamatelopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens Medical School, Athens, Greece; Biosciences Institute, Vascular Biology and Medicine Theme, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK.
| |
Collapse
|
4
|
Ruscica M, Sirtori CR, Carugo S, Calder PC, Corsini A. OMEGA-3 AND CARDIOVASCULAR PREVENTION – IS THIS STILL A CHOICE? Pharmacol Res 2022; 182:106342. [DOI: 10.1016/j.phrs.2022.106342] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/01/2022] [Accepted: 07/01/2022] [Indexed: 02/07/2023]
|
5
|
Li W, Huang Z, Fang W, Wang X, Cai Z, Chen G, Wu W, Chen Z, Wu S, Chen Y. Remnant Cholesterol Variability and Incident Ischemic Stroke in the General Population. Stroke 2022; 53:1934-1941. [PMID: 35543132 DOI: 10.1161/strokeaha.121.037756] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 04/15/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Studies have demonstrated that remnant cholesterol is correlated with the risk of ischemic stroke. However, it is unknown whether visit-to-visit variability in remnant cholesterol concentration affects ischemic stroke. We sought to examine the role of remnant cholesterol variability in the subsequent development of ischemic stroke in the general population. METHODS We performed a post hoc analysis including eligible participants from the Kailuan Study cohort who underwent 3 health examinations and were free of atrial fibrillation, myocardial infarction, stroke, cancer, or known lipid-medication use from 2006 to 2010. Participants were followed up until the end of 2017. Variability was quantified as variability independent of the mean, average real variability, and SD. Multivariate analysis was performed using the Fine and Gray competing risk model to estimate subhazard ratios assuming death as a competing risk. RESULTS The final study cohort comprised 38 556 participants. After a median follow-up of 7.0 years, 1058 individuals were newly diagnosed with ischemic stroke. After adjusting for age (time scale), sex, smoking status, alcohol consumption, physical activity, hypertension, diabetes, family history of cardiovascular disease, body mass index, estimated glomerular filtration rate, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, and mean remnant cholesterol, the highest quartile (quartile 4) of variability independent of the mean of remnant cholesterol was associated with an increased ischemic stroke risk compared with the lowest quartile (quartile 1), (subhazard ratio, 1.27 [95% CI, 1.06-1.53]). For each 1-SD increase in variability independent of the mean of remnant cholesterol, the risk increased by 9% (subhazard ratio, 1.09 [95% CI, 1.03-1.16]). The association was also significant using average real variability and SD as indices of variability. CONCLUSIONS Greater remnant cholesterol variability was associated with a higher risk of ischemic stroke in the general population.
Collapse
Affiliation(s)
- Weijian Li
- Shantou University Medical College, China
| | - Zegui Huang
- Shantou University Medical College, China (W.L., Z.H., W.F., X.W.)
| | - Wei Fang
- Shantou University Medical College, China (W.L., Z.H., W.F., X.W.)
| | - Xianxuan Wang
- Shantou University Medical College, China (W.L., Z.H., W.F., X.W.)
| | - Zefeng Cai
- Department of Cardiology, Second Affiliated Hospital of Shantou University Medical College, China (Z. Cai, W.W., Z. Chen, Y.C.)
| | - Guanzhi Chen
- China Medical University, Shenyang, China (G.C.)
| | - Weiqiang Wu
- Department of Cardiology, Second Affiliated Hospital of Shantou University Medical College, China (Z. Cai, W.W., Z. Chen, Y.C.)
| | - Zhichao Chen
- Department of Cardiology, Second Affiliated Hospital of Shantou University Medical College, China (Z. Cai, W.W., Z. Chen, Y.C.)
| | - Shouling Wu
- Department of Cardiology, Kailuan General Hospital, Tangshan, China
| | - Youren Chen
- Department of Cardiology, Second Affiliated Hospital of Shantou University Medical College, China
| |
Collapse
|
6
|
Toth PP, Chapman MJ, Parhofer KG, Nelson JR. Differentiating EPA from EPA/DHA in cardiovascular risk reduction. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 17:100148. [PMID: 38559888 PMCID: PMC10978325 DOI: 10.1016/j.ahjo.2022.100148] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/19/2022] [Accepted: 05/19/2022] [Indexed: 04/04/2024]
Abstract
None of the clinical trials of omega-3 fatty acids using combinations of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) were able to show any effect on cardiovascular outcomes, despite reductions in triglyceride levels. In contrast, the Reduction of Cardiovascular Events With Icosapent Ethyl-Intervention Trial (REDUCE-IT), which employed high-dose (4 g) purified EPA, demonstrated a 25% reduction in atherosclerotic cardiovascular disease-related events compared with placebo (hazard ratio 0.75; 95% confidence interval 0.68-0.83; P < 0.001). Moreover, REDUCE-IT is the first clinical trial using a lipid-lowering agent as adjuvant therapy to a statin to show a significant reduction in cardiovascular mortality. Significant reductions in stroke, need for revascularization, and myocardial infarction were also observed. The pharmacology of EPA is distinct from that of DHA, with a differential effect on membrane structure, lipoprotein oxidation, and the production of downstream metabolites that promote the resolution of inflammation. Attained plasma levels of EPA may be an important determinant of efficacy, with a substudy of REDUCE-IT suggesting that the threshold for clinical benefit of EPA is approximately 100 μg/mL, a level achieved in only a minority of patients in other studies. No similar clinical trials of DHA monotherapy have been conducted, so no such threshold has been established. The results of the REDUCE-IT and the Japan EPA Lipid Intervention Study (JELIS) together affirm the efficacy of EPA therapy for cardiovascular disease risk reduction in certain patient populations.
Collapse
Affiliation(s)
- Peter P. Toth
- CGH Medical Center, Sterling, IL, USA
- Cicarrone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Klaus G. Parhofer
- Medical Clinic IV – Grosshadern Hospital of the University of Munich, Munich, Germany
| | | |
Collapse
|
7
|
Chapman MJ, Zamorano JL, Parhofer KG. Reducing residual cardiovascular risk in Europe: Therapeutic implications of European medicines agency approval of icosapent ethyl/eicosapentaenoic acid. Pharmacol Ther 2022; 237:108172. [PMID: 35304222 DOI: 10.1016/j.pharmthera.2022.108172] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/19/2022] [Accepted: 03/10/2022] [Indexed: 12/18/2022]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) and its atherothrombotic complications impose a substantial disease burden in Europe, representing a cost of €210 billion per year for the European Union. Hypertriglyceridemia, a major risk factor for premature ASCVD, is present in more than 20% of the European population, and is a key feature of atherogenic dyslipidemia. Recent findings from the Progression of Early Subclinical Atherosclerosis (PESA) cohort in Spain showed that even in apparently healthy, middle-aged individuals without a history of cardiovascular (CV) risk, elevated triglyceride levels are associated with subclinical atherosclerosis and arterial inflammation. Emerging evidence from epidemiologic and genetic studies supports an independent causative role of triglycerides, triglyceride-rich lipoproteins, and their remnants in this pathology. Icosapent ethyl (IPE) is a highly purified, stable ethyl ester of eicosapentaenoic acid (EPA) that was initially approved by the United States Food and Drug Administration to treat severe hypertriglyceridemia, and subsequently received an expanded indication to reduce the risk of CV events in adult statin-treated patients. Approval was based on the pivotal, randomized, placebo-controlled, double-blind Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT), which showed that high-dose IPE (4 g/day) significantly reduced the risk of primary and secondary composite endpoints comprising major CV events and CV death relative to placebo. In 2021, the European Medicines Agency (EMA) approved IPE to reduce the risk of CV events in adult statin-treated patients at high CV risk with elevated triglyceride levels (≥1.7 mmol/L [≥150 mg/dL]) and established CV disease, or diabetes and at least one other CV risk factor. Clinical studies in Europe, which included patients with acute myocardial infarction, coronary artery disease, and those undergoing cardiac rehabilitation, established that 12.5% to 23.3% of these high-risk populations may benefit from treatment with IPE. Such clinical benefit may in part result from the moderate triglyceride-lowering properties of IPE/EPA; equally however, concentrations of atherogenic remnant particle-cholesterol are markedly reduced. Furthermore, IPE/EPA exerts pleiotropic actions beyond its lipid-lowering properties, which include modulation of endothelial function, attenuation of intra-plaque inflammation and oxidative stress, and reduction in macrophage accumulation. Plasma phospholipids, into which EPA is primarily incorporated and transported, appear to serve as precursors for a series of anti-inflammatory metabolites involving the resolvins RvE1 to RvE3, a pathway which may confer cardioprotective benefits. In addition, plaque imaging data from the Effect of Icosapent Ethyl on Progression of Coronary Atherosclerosis in Patients With Elevated Triglycerides on Statin Therapy (EVAPORATE) and the Combination Therapy of Eicosapentaenoic Acid and Pitavastatin for Coronary Plaque Regression Evaluated by Integrated Backscatter Intravascular Ultrasonography (CHERRY) trials show that plaque stabilization may be favorably affected. These factors may act synergistically to stabilize atherosclerotic plaques and reduce CV risk. In addition to robust efficacy data, multiple cost-utility studies across several countries indicate that IPE/EPA is a cost-effective treatment option that is favorably situated relative to some common willingness-to-pay thresholds. This review will evaluate the relevance of hypertriglyceridemia to residual ASCVD burden in statin-treated dyslipidemic patients, the potential of IPE/EPA to reduce the risk of ASCVD and cardiovascular mortality in high-risk patient populations, and the mechanisms which may underlie these effects. Finally, the clinical implications of the EMA label for IPE will be critically appraised in light of the updated 2019 European Society of Cardiology/European Atherosclerosis Society guidelines on the management of dyslipidemia and the recent European Atherosclerosis Society consensus statement on triglyceride-rich lipoproteins and their remnants, together with considerations of its cost-effectiveness across several countries.
Collapse
Affiliation(s)
- M John Chapman
- Sorbonne University, Endocrinology and Cardiovascular Disease Prevention, Pitié-Salpétrière University Hospital, and National Institute for Health and Medical Research (INSERM), Paris, France.
| | | | - Klaus G Parhofer
- Medical Clinic IV - Grosshadern Hospital of the University of Munich, Munich, Germany
| |
Collapse
|
8
|
Role of EPA in Inflammation: Mechanisms, Effects, and Clinical Relevance. Biomolecules 2022; 12:biom12020242. [PMID: 35204743 PMCID: PMC8961629 DOI: 10.3390/biom12020242] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/28/2022] [Accepted: 01/31/2022] [Indexed: 02/01/2023] Open
Abstract
Many chronic inflammatory processes are linked with the continuous release of inflammatory mediators and the activation of harmful signal-transduction pathways that are able to facilitate disease progression. In this context atherosclerosis represents the most common pathological substrate of coronary heart disease, and the characterization of the disease as a chronic low-grade inflammatory condition is now validated. The biomarkers of inflammation associated with clinical cardiovascular risk support the theory that targeted anti-inflammatory treatment appears to be a promising strategy in reducing residual cardiovascular risk. Several literature data highlight cardioprotective effects of the long-chain omega-3 polyunsaturated fatty acids (PUFAs), such as eicosapentaenoic acid (EPA). This PUFA lowers plasma triglyceride levels and has potential beneficial effects on atherosclerotic plaques. Preclinical studies reported that EPA reduces both pro-inflammatory cytokines and chemokines levels. Clinical studies in patients with coronary artery disease that receive pharmacological statin therapy suggest that EPA may decrease plaque vulnerability preventing plaque progression. This review aims to provide an overview of the links between inflammation and cardiovascular risk factors, importantly focusing on the role of diet, in particular examining the proposed role of EPA as well as the success or failure of standard pharmacological therapy for cardiovascular diseases.
Collapse
|
9
|
Lakshmanan S, Budoff MJ. The Evolving Role of Omega 3 Fatty Acids in Cardiovascular Disease: Is Icosapent Ethyl the Answer? Heart Int 2021; 15:7-13. [PMID: 36277323 PMCID: PMC9524612 DOI: 10.17925/hi.2021.15.1.7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 02/18/2021] [Indexed: 09/06/2024] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality globally. Despite significant advances in pharmacotherapies and the beneficial effects of statin therapy on ASCVD outcomes and progression of atherosclerosis, residual cardiovascular (CV) risk remains. Extensive evidence has identified the contribution of atherogenic dyslipidaemia, which is particularly characterised by elevated triglycerides (TGL) as a key driver of CV risk, even if low-density lipoprotein cholesterol levels are well controlled. Epidemiologic and genetic/Mendelian randomisation studies have demonstrated that elevated TGL levels serve as an independent marker for an increased risk of ischaemic events, highlighting TGLs as a suitable therapeutic target. Clinical studies have shown that omega 3 fatty acids (OM3FA) are effective in lowering TGLs; however, to date, trials and meta-analyses of combined OM3FA products have not demonstrated any clinical CV outcome benefit in patients receiving statins. However, icosapent ethyl (IPE) - a highly purified, stable ethyl ester of eicosapentaenoic acid (EPA) - has been rigorously demonstrated in multiple studies to be a useful adjunctive therapy to address residual CV risk. EPA is an omega-3 polyunsaturated fatty acid that is incorporated into membrane phospholipid bilayers and is reported to exert multiple beneficial effects along the pathway of coronary atherosclerosis. In this brief review, we will provide an overview of the mode of action of IPE in coronary atherosclerosis, the robust clinical evidence and trial data supporting its use, and expert consensus/recommendations on its use in specific populations, as an adjunct to existing anti-atherosclerotic therapies.
Collapse
Affiliation(s)
- Suvasini Lakshmanan
- The Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Los Angeles, CA, USA
| | - Matthew J Budoff
- The Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Los Angeles, CA, USA
| |
Collapse
|
10
|
A Fishy Topic: VITAL, REDUCE-IT, STRENGTH, and Beyond: Putting Omega-3 Fatty Acids into Practice in 2021. Curr Cardiol Rep 2021; 23:111. [PMID: 34247311 DOI: 10.1007/s11886-021-01527-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW To examine recently published data from clinical outcome and arteriographic studies that examined the addition of omega-3 fatty acids, eicosapentaenoic acid (EPA) + docosahexanoic acid (DHA), to standard of care therapy on cardiovascular disease (CVD) risk. RECENT FINDINGS Several trials that tested purified EPA (JELIS, REDUCE-IT, EVAPORATE) were associated with reduced CVD risk and regression of low attenuation coronary plaque volume, whereas studies that employed the combination EPA/DHA (VITAL, OMEMI, STRENGTH) failed to derive clinical benefit. Trials testing purified EPA consistently demonstrated reduction in atheromatous volume or CVD events beyond standard of care therapies, whereas the combination of EPA/DHA did not, despite producing similar reductions in triglycerides. Experimental and in vitro data suggest that compared to DHA, EPA exhibits antioxidant, anti-inflammatory, and membrane stabilizing properties that enhance vascular function and CVD risk. Consequently, purified EPA appears to be the treatment of choice for high-risk patients with hypertriglyceridemia.
Collapse
|
11
|
Nelson JR, Budoff MJ, Wani OR, Le V, Patel DK, Nelson A, Nemiroff RL. EPA's pleiotropic mechanisms of action: a narrative review. Postgrad Med 2021; 133:651-664. [PMID: 33900135 DOI: 10.1080/00325481.2021.1921491] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Treatment with icosapent ethyl 4 g/day, a highly purified and stable ethyl ester of eicosapentaenoic acid (EPA), demonstrated a significant reduction in atherosclerotic cardiovascular disease (ASCVD) events and death in REDUCE-IT. However, analyses of REDUCE-IT and meta-analyses have suggested that this clinical benefit is greater than can be achieved by triglyceride reduction alone. EPA therefore may have additional pleiotropic effects, including anti-inflammatory and anti-aggregatory mechanisms. EPA competes with arachidonic acid for cyclooxygenase and lipoxygenase, producing anti-inflammatory and anti-aggregatory metabolites rather than the more deleterious metabolites associated with arachidonic acid. Changing the EPA:arachidonic acid ratio may shift metabolic status from pro-inflammatory/pro-aggregatory to anti-inflammatory/anti-aggregatory. EPA also has antioxidant effects and increases synthesis of nitric oxide. Incorporation of EPA into phospholipid bilayers influences membrane structure and may help to prevent cardiac arrhythmias. Clinically, this may translate into improved vascular health, including regression of atherosclerotic plaque. Overall, EPA has a range of pleiotropic effects that contribute to a reduction in ASCVD.
Collapse
Affiliation(s)
- John R Nelson
- California Cardiovascular Institute, Fresno, California, USA
| | - Matthew J Budoff
- Department of Medicine, Lundquist Institute, Torrance, California, USA
| | - Omar R Wani
- Northern Arizona Healthcare Medical Group - Flagstaff, Flagstaff, AZ, USA
| | - Viet Le
- Cardiovascular Research, Intermountain Heart Institute/CV Research, Intermountain Healthcare, Murray, Utah, and Rocky Mountain University of Health Professions, Provo, USA
| | - Dhiren K Patel
- Department of Pharmacy Practice, MCPHS University, Boston, MA, USA
| | - Ashley Nelson
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, California, USA
| | - Richard L Nemiroff
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| |
Collapse
|
12
|
Qian S, You S, Sun Y, Wu Q, Wang X, Tang W, Dong X, Liu CF, Xu T, Cao Y, Zhong C. Remnant Cholesterol and Common Carotid Artery Intima-Media Thickness in Patients With Ischemic Stroke. Circ Cardiovasc Imaging 2021; 14:e010953. [PMID: 33832329 DOI: 10.1161/circimaging.120.010953] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Remnant cholesterol makes great contribution to residual risk of cardiovascular disease, but population-based evidence on the relationship between remnant cholesterol and atherosclerosis is rare. Common carotid artery intima-media thickness (cIMT) is an imaging marker of subclinical atherosclerosis. We aimed to explore the association between remnant cholesterol levels and cIMT in patients with ischemic stroke. METHODS One thousand four hundred ninety-six ischemic stroke patients with baseline serum lipids and carotid artery imaging data were included in this analysis. Fasting remnant cholesterol was calculated as total cholesterol minus HDL (high-density lipoprotein) cholesterol minus LDL (low-density lipoprotein) cholesterol. Abnormal cIMT was defined as mean cIMT and maximum cIMT value ≥1 mm. Logistic regression and restricted cubic spline models were used to assess the relationships between remnant cholesterol levels and abnormal cIMT. RESULTS The multivariable-adjusted odds ratios (95% CIs) for the highest versus lowest quartile of remnant cholesterol were 2.06 (1.46-2.91) for abnormal mean cIMT and 1.70 (1.23-2.35) for abnormal maximum cIMT. There were linear associations between remnant cholesterol levels and both abnormal mean cIMT (P for linearity, <0.001) and abnormal maximum cIMT (P for linearity, 0.003). Moreover, the remnant cholesterol-cIMT association remained significant in the subsample of patients with optimal LDL cholesterol levels (n=179). CONCLUSIONS Elevated fasting remnant cholesterol levels were positively associated with mean cIMT and maximum cIMT in patients with ischemic stroke, even in patients with optimal LDL cholesterol levels. Future prospective studies are needed to verify our findings and to assess the effect of remnant cholesterol-lowering interventions in patients with ischemic stroke.
Collapse
Affiliation(s)
- Sifan Qian
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China (S.Q., T.X., C.Z.)
| | - Shoujiang You
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China (S.Y., C.L., Y.C.)
| | - Yaming Sun
- Department of Neurology, Zhangjiagang Hospital of Traditional Chinese Medicine, Nanjing University of Chinese Medicine, Suzhou, China (Y.S.)
| | - Qiuyi Wu
- Department of Neurology, Zhangjiagang First People's Hospital, Suzhou, China (Q.W.)
| | - Xianhui Wang
- Department of Neurology, Taicang First People's Hospital, Suzhou, China (X.W.)
| | - Weiting Tang
- Department of Neurology, Changshu Second People's Hospital, Suzhou, China (W.T.)
| | - Xiaofeng Dong
- Department of Neurology, Suzhou Hospital Affiliated to Nanjing Medical University, China (X.D.)
| | - Chun-Feng Liu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China (S.Y., C.L., Y.C.)
| | - Tan Xu
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China (S.Q., T.X., C.Z.)
| | - Yongjun Cao
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China (S.Y., C.L., Y.C.)
| | - Chongke Zhong
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China (S.Q., T.X., C.Z.)
| |
Collapse
|
13
|
Hoogeveen RC, Ballantyne CM. Residual Cardiovascular Risk at Low LDL: Remnants, Lipoprotein(a), and Inflammation. Clin Chem 2021; 67:143-153. [PMID: 33257928 PMCID: PMC7793228 DOI: 10.1093/clinchem/hvaa252] [Citation(s) in RCA: 126] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 09/29/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Current guidelines target low-density lipoprotein cholesterol (LDL-C) concentrations to reduce atherosclerotic cardiovascular disease (ASCVD) risk, and yet clinical trials demonstrate persistent residual ASCVD risk despite aggressive LDL-C lowering. CONTENT Non-LDL-C lipid parameters, most notably triglycerides, triglyceride-rich lipoproteins (TGRLs), and lipoprotein(a), and C-reactive protein as a measure of inflammation are increasingly recognized as associated with residual risk after LDL-C lowering. Eicosapentaenoic acid in statin-treated patients with high triglycerides reduced both triglycerides and ASCVD events. Reducing TGRLs is believed to have beneficial effects on inflammation and atherosclerosis. High lipoprotein(a) concentrations increase ASCVD risk even in individuals with LDL-C < 70 mg/dL. Although statins do not generally lower lipoprotein(a), proprotein convertase subtilisin/kexin type 9 inhibitors reduce lipoprotein(a) and cardiovascular outcomes, and newer approaches are in development. Persistent increases in C-reactive protein after intensive lipid therapy have been consistently associated with increased risk for ASCVD events. SUMMARY We review the evidence that biochemical assays to measure TGRLs, lipoprotein(a), and C-reactive protein are associated with residual risk in patients treated to low concentrations of LDL-C. Growing evidence supports a causal role for TGRLs, lipoprotein(a), and inflammation in ASCVD; novel therapies that target TGRLs, lipoprotein(a), and inflammation are in development to reduce residual ASCVD risk.
Collapse
Affiliation(s)
- Ron C Hoogeveen
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Christie M Ballantyne
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| |
Collapse
|
14
|
Chatterjee S, Hajra A, Bandyopadhyay D, Ghosh RK, Deedwania PC. Defining the Role of Icosapent Ethyl in Clinical Practice. Am J Cardiovasc Drugs 2020; 20:517-524. [PMID: 32157567 DOI: 10.1007/s40256-020-00402-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The health benefit of fish oil, i.e. omega-3 fatty acids (ω-3 FA) has a long history of debate. While there are a number of medications to reduce serum triglyceride levels, none have shown unanimous cardiovascular (CV) benefits. The most recent Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT) assessing the CV outcome of one highly purified prescription ω-3 FA has certainly rejuvenated the debate. While this trial has been regarded as one of the most important landmark trials in preventive cardiology, the tolerability issue in a very high dose (4 g/day, as administered in the trial) is still a matter of concern. This article summarizes the current status and future perspective of icosapent ethyl in clinical practice in light of REDUCE-IT.
Collapse
|
15
|
White AMB, Mishcon HR, Redwanski JL, Hills RD. Statin Treatment in Specific Patient Groups: Role for Improved Cardiovascular Risk Markers. J Clin Med 2020; 9:E3748. [PMID: 33233352 PMCID: PMC7700563 DOI: 10.3390/jcm9113748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 01/17/2023] Open
Abstract
Ample evidence supports the use of statin therapy for secondary prevention in patients with a history of atherosclerotic cardiovascular disease (ASCVD), but evidence is wanting in the case of primary prevention, low-risk individuals, and elderly adults 65+. Statins are effective in lowering low-density lipoprotein (LDL), which has long been a target for treatment decisions. We discuss the weakening dependence between cholesterol levels and mortality as a function of age and highlight recent findings on lipoprotein subfractions and other superior markers of ASCVD risk. The efficacy of statins is compared for distinct subsets of patients based on age, diabetes, ASCVD, and coronary artery calcium (CAC) status. Most cardiovascular risk calculators heavily weight age and overestimate one's absolute risk of ASCVD, particularly in very old adults. Improvements in risk assessment enable the identification of specific patient populations that benefit most from statin treatment. Derisking is particularly important for adults over 75, in whom treatment benefits are reduced and adverse musculoskeletal effects are amplified. The CAC score stratifies the benefit effect size obtainable with statins, and forms of coenzyme Q are discussed for improving patient outcomes. Robust risk estimator tools and personalized, evidence-based approaches are needed to optimally reduce cardiovascular events and mortality rates through administration of cholesterol-lowering medications.
Collapse
Affiliation(s)
- Alyssa M. B. White
- Department of Pharmaceutical Sciences and Administration, University of New England, Portland, ME 04103, USA; (A.M.B.W.); (H.R.M.)
| | - Hillary R. Mishcon
- Department of Pharmaceutical Sciences and Administration, University of New England, Portland, ME 04103, USA; (A.M.B.W.); (H.R.M.)
| | - John L. Redwanski
- Department of Pharmacy Practice, School of Pharmacy, University of New England, Portland, ME 04103, USA;
| | - Ronald D. Hills
- Department of Pharmaceutical Sciences and Administration, University of New England, Portland, ME 04103, USA; (A.M.B.W.); (H.R.M.)
| |
Collapse
|
16
|
Discrepancy Between Fasting Flow-Mediated Dilation and Parameter of Lipids in Blood: A Randomized Exploratory Study of the Effect of Omega-3 Fatty Acid Ethyl Esters on Vascular Endothelial Function in Patients With Hyperlipidemia. Adv Ther 2020; 37:2169-2183. [PMID: 32200533 PMCID: PMC7467499 DOI: 10.1007/s12325-020-01286-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Indexed: 11/03/2022]
Abstract
Introduction Omega-3 fatty acid ethyl esters (omega-3), an eicosapentaenoic acid and docosahexaenoic acid preparation (Lotriga®, Takeda Pharmaceutical Company Limited), are approved in Japan to treat triglyceridemia. We investigated the effects of omega-3 on vascular endothelial function, measured by flow-mediated dilation (FMD). Methods Patients with dyslipidemia receiving 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase inhibitors were randomized 1:1 to receive omega-3 at 2 g (QD) or 4 g (2 g BID) for 8 weeks. The primary end point was the change from baseline of fasting %FMD in each treatment group. Secondary end points included the 4-h postprandial %FMD and 4-h postprandial triglyceride (TG) level. Results Thirty-seven patients were randomized to receive omega-3 at 2 g (n = 18) or 4 g (n = 19). Mean fasting %FMD did not increase from baseline to week 8 in the 2-g group (− 1.2%) or 4-g group (− 1.3%). Mean 4-h postprandial %FMD did not change from baseline to week 8 in the 2-g group (0.0%), but increased in the 4-g group (1.0%). Mean 4-h postprandial TG level decreased by 34.7 mg/dl from baseline over week 8 in the 2-g group, with a significantly larger decrease in the 4-g group of 75.9 mg/dl (p < 0.001). No new safety concerns were identified. Conclusions Fasting %FMD did not improve after 8 weeks of omega-3 treatment at 2 g or 4 g. After 8 weeks, 4-h postprandial TG levels showed improvement at both doses, with a greater reduction in the 4-g group. Trial Registration ClinicalTrials.gov, ID: NCT02824432. Electronic supplementary material The online version of this article (10.1007/s12325-020-01286-1) contains supplementary material, which is available to authorized users.
Collapse
|
17
|
Mason RP, Libby P, Bhatt DL. Emerging Mechanisms of Cardiovascular Protection for the Omega-3 Fatty Acid Eicosapentaenoic Acid. Arterioscler Thromb Vasc Biol 2020; 40:1135-1147. [PMID: 32212849 PMCID: PMC7176343 DOI: 10.1161/atvbaha.119.313286] [Citation(s) in RCA: 228] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 03/03/2020] [Indexed: 02/07/2023]
Abstract
Patients with well-controlled LDL (low-density lipoprotein) levels still have residual cardiovascular risk associated with elevated triglycerides. Epidemiological studies have shown that elevated fasting triglyceride levels associate independently with incident cardiovascular events, and abundant recent human genetic data support the causality of TGRLs (triglyceride-rich lipoproteins) in atherothrombosis. Omega-3 fatty acids, such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), lower blood triglyceride concentrations but likely exert additional atheroprotective properties at higher doses. Omega-3 fatty acids modulate T-cell differentiation and give rise to various prostaglandins and specialized proresolving lipid mediators that promote resolution of tissue injury and inflammation. The REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial) with an EPA-only formulation lowered a composite of cardiovascular events by 25% in patients with established cardiovascular disease or diabetes mellitus and other cardiovascular risk factors. This clinical benefit likely arises from multiple molecular mechanisms discussed in this review. Indeed, human plaques readily incorporate EPA, which may render them less likely to trigger clinical events. EPA and DHA differ in their effects on membrane structure, rates of lipid oxidation, inflammatory biomarkers, and endothelial function as well as tissue distributions. Trials that have evaluated DHA-containing high-dose omega-3 fatty acids have thus far not shown the benefits of EPA alone demonstrated in REDUCE-IT. This review will consider the mechanistic evidence that helps to understand the potential mechanisms of benefit of EPA.
Collapse
Affiliation(s)
- R. Preston Mason
- From the Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (R.P.M., P.L., D.L.B.)
- Elucida Research LLC, Beverly, MA (R.P.M.)
| | - Peter Libby
- From the Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (R.P.M., P.L., D.L.B.)
| | - Deepak L. Bhatt
- From the Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (R.P.M., P.L., D.L.B.)
| |
Collapse
|
18
|
Mosca L, Navar AM, Wenger NK. Reducing Cardiovascular Disease Risk in Women Beyond Statin Therapy: New Insights 2020. J Womens Health (Larchmt) 2020; 29:1091-1100. [PMID: 32297837 DOI: 10.1089/jwh.2019.8189] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Management of residual and persistent cardiovascular disease (CVD) risk among statin-treated individuals has emerged as an important preventive strategy. The purpose of this article is to review the unique landscape of CVD in women and relevant prior prevention trials, and to discuss how the recent results of the Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT) might apply to the contemporary management of CVD risk among statin-treated women. Women have unique risk factors that may impact CVD and its prevention. Historically, women have been underrepresented in CVD trials, posing a challenge to development of clinical recommendations for women. Low-density lipoprotein cholesterol-targeting treatments have demonstrated CVD risk reduction, with comparable effects in both sexes. In contrast, triglyceride-lowering treatments (niacin, fenofibrate, and omega-3 fatty acids) have reported mixed findings for CVD risk reduction. Recent clinical trials of combination omega-3 fatty acids (docosahexaenoic acid/eicosapentaenoic acid [EPA]) have not found significant CVD risk reduction. The recently published REDUCE-IT study found that icosapent ethyl, an EPA-only omega-3 fatty acid, in combination with statins, significantly reduced CVD events in high-risk patients. The icosapent ethyl group had a significantly lower occurrence of the primary composite CVD endpoint (17.2%) than the placebo group (22.0%; hazard ratio 0.75; 95% confidence interval 0.68-0.83; p < 0.001). CVD risk reduction with icosapent ethyl treatment was comparable between women and men (p for interaction, 0.33). Data from REDUCE-IT suggest women benefit similarly to men with respect to icosapent ethyl, a novel therapy for prevention of CVD.
Collapse
Affiliation(s)
- Lori Mosca
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Ann Marie Navar
- Department of Medicine, Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Nanette Kass Wenger
- Department of Cardiology, Emory University School of Medicine; Emory Heart and Vascular Center; Emory Women's Heart Center, Atlanta, Georgia, USA
| |
Collapse
|
19
|
Effects of Icosapent Ethyl (Eicosapentaenoic Acid Ethyl Ester) on Atherogenic Lipid/Lipoprotein, Apolipoprotein, and Inflammatory Parameters in Patients With Elevated High-Sensitivity C-Reactive Protein (from the ANCHOR Study). Am J Cardiol 2019; 124:696-701. [PMID: 31277790 DOI: 10.1016/j.amjcard.2019.05.057] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/21/2019] [Accepted: 05/21/2019] [Indexed: 11/21/2022]
Abstract
Icosapent ethyl is pure prescription eicosapentaenoic acid approved at 4 g/day as an adjunct to diet to reduce triglycerides (TG) in adults with TG ≥500 mg/dl. Elevated high-sensitivity C-reactive protein (hsCRP) is associated with increased cardiovascular risk. The 12-week ANCHOR study randomized 702 statin-treated patients at increased cardiovascular risk with TG 200 to 499 mg/dl despite low-density lipoprotein cholesterol (LDL-C) control (40 to 99 mg/dl). This post hoc analysis assessed 246 ANCHOR patients with baseline hsCRP ≥ 2.0 mg/L randomized to icosapent ethyl 4 g/day (n = 126; approved dose) or placebo (n = 120). Without increasing LDL-C, icosapent ethyl significantly reduced median TG (-20%; p < 0.0001), non-high-density lipoprotein cholesterol (-12.3%; p < 0.0001), total cholesterol (-11.1%; p < 0.0001), high-density lipoprotein cholesterol (-5.2%; p = 0.0042), very LDL-C (-21.0%; p < 0.0001), very low-density lipoprotein TG (-22.9%; p < 0.0001), remnant lipoprotein cholesterol (-23.0%; p = 0.0125), apolipoprotein B (-7.4%; p = 0.0021), apolipoprotein C-III (-16%; p < 0.0001), oxidized LDL (-13.7%; p = 0.0020), lipoprotein-associated phospholipase A2 (-19.6%; p < 0.0001), and hsCRP (-17.9%; p = 0.0213) versus placebo, while interleukin-6 and intercellular adhesion molecule-1 were not significantly changed. Eicosapentaenoic acid increased with icosapent ethyl 4 g/day +637% in plasma and +632% in red blood cells versus placebo (both p < 0.0001). Icosapent ethyl exhibited a safety profile similar to placebo. In conclusion, in statin-treated patients with hsCRP ≥ 2.0 mg/L and TG 200 to 499 mg/dl at baseline, icosapent ethyl 4 g/day significantly and safely reduced TG and other atherogenic and inflammatory parameters without increasing LDL-C versus placebo.
Collapse
|
20
|
Gao L, Moodie M, Li SC. The cost-effectiveness of omega-3 polyunsaturated fatty acids - The Australian healthcare perspective. Eur J Intern Med 2019; 67:70-76. [PMID: 31285124 DOI: 10.1016/j.ejim.2019.07.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To examine the cost-effectiveness of a triglyceride lowering medication-icosapent ethyl added on to statin from Australian healthcare system perspective. METHODS A Markov-model was developed using data from the pivotal trial of icosapent ethyl in a secondary prevention population. Probabilities of CVD events were derived and extrapolated from the published Kaplan-Meier curve using a valid algorithm. Management cost of CVD, health-related quality of life, and background non-CVD mortality were extracted from publicly available sources. Acquisition cost of icosapent ethyl from the United States was used in the current analysis. Australian patients with histories of CVD were modelled for a 25 year time horizon and costs and benefits were discounted. Sensitivity analyses (SA) were undertaken. Value of perfect information (VPI) was quantified. RESULTS Treatment with icosapent ethyl was associated with both higher costs and benefits (i.e. quality-adjusted life year [QALY] and life year [LY]), resulting in an incremental cost-effectiveness ratio (ICER) of AUD59,036/QALY or AUD54,358/LY. Using the often quoted willingness-to-pay (WTP)/QALY of AUD50,000/QALY, icosapent ethyl was not considered cost-effective. SA showed that time horizon, drug cost, and discount rate were the key drivers of the ICER. Total monetary VPI for icosapent ethyl was over AUD15 million over 5 years. CONCLUSIONS Patients with established CVD in whom level of triglycerides is high would benefit from the treatment using icosapent ethyl, however, it is not a cost-effective from an Australian healthcare system perspective. The government may consider subsidising this medication given the clinical need but at a discounted acquisition cost.
Collapse
Affiliation(s)
- Lan Gao
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia; Global Obesity Centre, Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia; School of Biomedical Sciences and Pharmacy, The University of Newcastle, Callaghan, NSW, Australia.
| | - Marj Moodie
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia; Global Obesity Centre, Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | - Shu-Chuen Li
- School of Biomedical Sciences and Pharmacy, The University of Newcastle, Callaghan, NSW, Australia
| |
Collapse
|
21
|
Vijayaraghavan K, Szerlip HM, Ballantyne CM, Bays HE, Philip S, Doyle RT, Juliano RA, Granowitz C. Icosapent ethyl reduces atherogenic markers in high-risk statin-treated patients with stage 3 chronic kidney disease and high triglycerides. Postgrad Med 2019; 131:390-396. [PMID: 31306043 DOI: 10.1080/00325481.2019.1643633] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Objective: Patients with chronic kidney disease (CKD) have increased cardiovascular disease (CVD) risk, likely driven by atherogenic and inflammatory markers beyond low-density lipoprotein cholesterol (LDL-C). The objective of this hypothesis-generating post hoc subgroup analysis was to explore the effects of icosapent ethyl at 2 or 4 g/day (prescription pure ethyl ester of the omega-3 fatty acid eicosapentaenoic acid [EPA]) on atherogenic lipid, apolipoprotein, inflammatory parameters (high-sensitivity C-reactive protein [hsCRP], lipoprotein-associated phospholipase A2 [Lp-PLA2]), and oxidative parameters (oxidized-LDL [ox-LDL]) in statin-treated patients from ANCHOR with stage 3 CKD.Methods: The 12-week ANCHOR study evaluated icosapent ethyl in 702 statin-treated patients at increased CVD risk with triglycerides (TG) 200-499 mg/dL despite controlled LDL-C (40-99 mg/dL). This post-hoc analysis included patients from ANCHOR with stage 3 CKD (estimated glomerular filtration rate [eGFR] ≤60 mL/min/1.73 m2 for ≥3 months) randomized to icosapent ethyl 4 g/day (n = 19), 2 g/day (n = 30), or placebo (n = 36).Results: At the prescription dose of 4 g/day, icosapent ethyl significantly reduced TG (-16.9%; P = 0.0074) and other potentially atherogenic lipids/lipoproteins, ox-LDL, hsCRP, and Lp-PLA2, and increased plasma and red blood cell EPA levels (+879% and +579%, respectively; both P < 0.0001) versus placebo. Icosapent ethyl did not significantly alter eGFR or serum creatinine. Safety and tolerability were similar to placebo.Conclusions: In patients with stage 3 CKD at high CVD risk with persistent high TG despite statins, icosapent ethyl 4 g/day reduced potentially atherogenic and other cardiovascular risk factors without raising LDL-C, with safety similar to placebo. These findings suggest prospective investigation may be warranted.
Collapse
Affiliation(s)
| | - Harold M Szerlip
- Nephrology Division and Nephrology Fellowship Program, Baylor University Medical Center, Dallas, TX, USA
| | - Christie M Ballantyne
- Department of Medicine, Baylor College of Medicine and the Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA
| | - Harold E Bays
- Louisville Metabolic and Atherosclerosis Research Center, Louisville, KY, USA
| | - Sephy Philip
- Medical Affairs, Amarin Pharma Inc., Bedminster, NJ, USA
| | - Ralph T Doyle
- Clinical Development, Amarin Pharma Inc., Bedminster, NJ, USA
| | | | | |
Collapse
|
22
|
Doggrell SA. Clinical trials of eicosapentaenoic acid (EPA) prescription products for the treatment of hypertriglyceridemia. Expert Opin Pharmacother 2019; 20:1221-1225. [DOI: 10.1080/14656566.2019.1609942] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Sheila A Doggrell
- Faculty of Health, Queensland University of Technology, Brisbane, Australia
| |
Collapse
|
23
|
Icosapent Ethyl Effects on Fatty Acid Profiles in Statin-Treated Patients With High Triglycerides: The Randomized, Placebo-controlled ANCHOR Study. Cardiol Ther 2019; 8:79-90. [PMID: 30788718 PMCID: PMC6525216 DOI: 10.1007/s40119-019-0131-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Fatty acid content in plasma and red blood cells (RBCs) may provide insight into potential physiologic benefits of omega-3 fatty acids. Icosapent ethyl is a pure prescription form of eicosapentaenoic acid (EPA) ethyl ester approved by the US Food and Drug Administration at a dose of 4 g/day as an adjunct to diet to reduce triglyceride levels in adults with severe (≥ 500 mg/dl) hypertriglyceridemia. Methods This was a prespecified exploratory subset analysis of the ANCHOR study, which randomized 702 statin-treated patients at increased cardiovascular risk with triglycerides 200–499 mg/dl and controlled low-density lipoprotein cholesterol (40–99 mg/dl). This analysis examined effects of icosapent ethyl 4 g/day versus placebo on fatty acid levels in plasma and RBCs using a gas chromatograph assay method with flame ionization detector. Results In plasma, treatment with icosapent ethyl 4 g/day resulted in significant increases versus placebo in the mean concentrations of EPA (+ 635%; P < 0.0001) and its metabolite, docosapentaenoic acid n-3 (+ 143%; P < 0.0001) with no significant change in docosahexaenoic acid. Treatment with icosapent ethyl 4 g/day versus placebo also resulted in significant decreases in the omega-6 fatty acids linoleic acid (− 25%) and arachidonic acid (AA; − 31%), as well as the AA/EPA ratio (− 91%). Icosapent ethyl 4 g/day also decreased the omega-9 fatty acid oleic acid (− 29%) and the saturated fatty acids palmitic acid (− 23%) and stearic acid (− 16%) (all P < 0.0001). Results were similar for RBCs. Conclusions Icosapent ethyl 4 g/day significantly increased EPA and produced other potentially beneficial shifts in fatty acids in plasma and RBCs versus placebo. Trial Registration ClinicalTrials.gov Identifier, NCT01047501 Funding Amarin Pharma Inc. Plain Language Summary Plain language summary available for this article.
Collapse
|
24
|
Chitre NM, Moniri NH, Murnane KS. Omega-3 Fatty Acids as Druggable Therapeutics for Neurodegenerative Disorders. CNS & NEUROLOGICAL DISORDERS DRUG TARGETS 2019; 18:735-749. [PMID: 31724519 PMCID: PMC7204890 DOI: 10.2174/1871527318666191114093749] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/07/2019] [Accepted: 10/22/2019] [Indexed: 12/19/2022]
Abstract
Neurodegenerative disorders are commonly associated with a complex pattern of pathophysiological hallmarks, including increased oxidative stress and neuroinflammation, which makes their treatment challenging. Omega-3 Fatty Acids (O3FA) are natural products with reported neuroprotective, anti-inflammatory, and antioxidant effects. These effects have been attributed to their incorporation into neuronal membranes or through the activation of intracellular or recently discovered cell-surface receptors (i.e., Free-Fatty Acid Receptors; FFAR). Molecular docking studies have investigated the roles of O3FA as agonists of FFAR and have led to the development of receptor-specific targeted agonists for therapeutic purposes. Moreover, novel formulation strategies for targeted delivery of O3FA to the brain have supported their development as therapeutics for neurodegenerative disorders. Despite the compelling evidence of the beneficial effects of O3FA for several neuroprotective functions, they are currently only available as unregulated dietary supplements, with only a single FDA-approved prescription product, indicated for triglyceride reduction. This review highlights the relative safety and efficacy of O3FA, their drug-like properties, and their capacity to be formulated in clinically viable drug delivery systems. Interestingly, the presence of cardiac conditions such as hypertriglyceridemia is associated with brain pathophysiological hallmarks of neurodegeneration, such as neuroinflammation, thereby further suggesting potential therapeutic roles of O3FA for neurodegenerative disorders. Taken together, this review article summarizes and integrates the compelling evidence regarding the feasibility of developing O3FA and their synthetic derivatives as potential drugs for neurodegenerative disorders.
Collapse
Affiliation(s)
- Neha M. Chitre
- Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University Health Sciences Center, Mercer University, Atlanta, GA USA
| | - Nader H. Moniri
- Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University Health Sciences Center, Mercer University, Atlanta, GA USA
| | - Kevin S. Murnane
- Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University Health Sciences Center, Mercer University, Atlanta, GA USA
| |
Collapse
|
25
|
Hermans MP, Valensi P. Elevated triglycerides and low high-density lipoprotein cholesterol level as marker of very high risk in type 2 diabetes. Curr Opin Endocrinol Diabetes Obes 2018; 25:118-129. [PMID: 29493554 DOI: 10.1097/med.0000000000000398] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to describe in diabetic patients the determinants underlying atherogenic dyslipidemia, a complex dyslipidemia defined as the coexistence of fasting hypertriglyceridemia and low high-density lipoprotein cholesterol level. Atherogenic dyslipidemia is often comorbid with hyperglycemia in patients with the common form of type 2 diabetes mellitus (T2DM), namely that associated with obesity, insulin resistance, hyperinsulinemia and the metabolic syndrome phenotype. RECENT FINDINGS The role of triglyceride-rich lipoproteins, both fasting and nonfasting, is increasingly considered as a direct driver of atherosclerosis in diabetic patients, even in those receiving best standards of care, including low-density lipoprotein cholesterol level adequately controlled by statins and/or ezetimibe. The residual cardiovascular risk related to atherogenic dyslipidemia in T2DM patients can be inferred from subgroup analysis of diabetic patients within landmark lipid-lowering trials, or from T2DM-only trials, such as Fenofibrate Intervention and Event Lowering in Diabetes study or Action to Control Cardiovascular Risk in Diabetes-Lipid trial. SUMMARY The presence of atherogenic dyslipidemia markedly increases cardiovascular risk, and there is evidence that part of the residual cardiovascular risk in T2DM can be safely and effectively reduced by fibrates. Ongoing trials will determine whether new classes of drugs or dietary intervention targeting hypertriglyceridemia (such as n-3 fatty acids or SPPARMα) will reduce macro and microvascular residual risk in T2DM patients with atherogenic dyslipidemia at inclusion.
Collapse
Affiliation(s)
- Michel P Hermans
- Division of Endocrinology & Nutrition, Cliniques universitaires St-Luc and Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain, Brussels, Belgium
| | - Paul Valensi
- Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, AP-HP, Jean Verdier Hospital, Paris 13 University, Bondy, France
| |
Collapse
|
26
|
Brinton EA, Ballantyne CM, Guyton JR, Philip S, Doyle RT, Juliano RA, Mosca L. Lipid Effects of Icosapent Ethyl in Women with Diabetes Mellitus and Persistent High Triglycerides on Statin Treatment: ANCHOR Trial Subanalysis. J Womens Health (Larchmt) 2018; 27:1170-1176. [PMID: 29583081 PMCID: PMC6148718 DOI: 10.1089/jwh.2017.6757] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: High triglycerides (TG) and diabetes mellitus type 2 (DM2) are stronger predictors of cardiovascular disease (CVD) in women than in men, but few randomized, controlled clinical trials have investigated lipid-lowering interventions in women and none have reported results specifically in women with high TG and DM2. Icosapent ethyl (Vascepa) is pure prescription eicosapentaenoic acid (EPA) ethyl ester approved at 4 g/day as an adjunct to diet to reduce TG ≥500 mg/dL. Methods: The 12-week ANCHOR trial randomized 702 statin-treated patients (73% with DM; 39% women) at increased CVD risk with TG 200–499 mg/dL despite controlled low-density lipoprotein cholesterol (LDL-C; 40–99 mg/dL) to receive icosapent ethyl 2 g/day, 4 g/day, or placebo. This post hoc analysis included 146 women with DM2 (97% white, mean age 62 years) randomized to icosapent ethyl 4 g/day (n = 74) or placebo (n = 72). Results: Icosapent ethyl significantly reduced TG (−21.5%; p < 0.0001) without increasing LDL-C and lowered other potentially atherogenic lipid/lipoprotein, apolipoprotein, and inflammatory parameters versus placebo. Icosapent ethyl increased EPA levels in plasma (+639%; p < 0.0001; n = 49) and red blood cells (+599%; p < 0.0001; n = 47) versus placebo. Safety and tolerability of icosapent ethyl were generally similar to placebo. Conclusion: In women with DM2 at high CVD risk with persistently high TG on statins, icosapent ethyl 4 g/day reduced potentially atherogenic parameters with safety and tolerability comparable to placebo. Potential CVD benefits of icosapent ethyl are being tested in ∼8000 men and women at high CVD risk with high TG on statins in the ongoing Reduction of Cardiovascular Events with Icosapent Ethyl - Intervention Trial (REDUCE-IT) cardiovascular (CV) outcome trial.
Collapse
Affiliation(s)
| | - Christie M Ballantyne
- 2 Department of Medicine, Baylor College of Medicine and the Houston Methodist DeBakey Heart and Vascular Center , Houston, Texas
| | - John R Guyton
- 3 Department of Endocrinology, Metabolism, and Nutrition, Duke University School of Medicine , Durham, North Carolina
| | - Sephy Philip
- 4 Medical Affairs, Amarin Pharma, Inc. , Bedminster, New Jersey
| | - Ralph T Doyle
- 5 Clinical Development, Amarin Pharma, Inc. , Bedminster, New Jersey
| | - Rebecca A Juliano
- 5 Clinical Development, Amarin Pharma, Inc. , Bedminster, New Jersey
| | - Lori Mosca
- 6 Department of Medicine, Columbia University Medical Center , New York, New York
| |
Collapse
|
27
|
Elagizi A, Lavie CJ, Marshall K, DiNicolantonio JJ, O'Keefe JH, Milani RV. Omega-3 Polyunsaturated Fatty Acids and Cardiovascular Health: A Comprehensive Review. Prog Cardiovasc Dis 2018; 61:76-85. [PMID: 29571892 DOI: 10.1016/j.pcad.2018.03.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 03/18/2018] [Indexed: 01/16/2023]
Abstract
The potential cardiovascular (CV) disease (CVD) benefits of Omega-3 Polyunsaturated Fatty Acids (OM3) have been intensely studied and debated for decades. Initial trials were performed in patients with low use of maximal medical therapy for CVD, and reported significant mortality benefits with the use of 1 g/day OM3 intervention following myocardial infarction (MI). More recent studies, including cohorts of patients receiving modern guideline directed medical therapy for CVD, have often not shown similar benefits with OM3 use. We conducted a literature review using PubMed, professional society guidelines, specific journal databases including New England Journal of Medicine and Journal of the American College of Cardiology from January 1, 2007 to December 31, 2017. References from selected articles were also reviewed, as well as key articles outside of the selected time-frame for their important findings or historical perspectives. Currently, there are no Class I recommendations from the American Heart Association (AHA) for the use of OM3, however, considering the safety of this therapy and beneficial findings of some modern studies (including patients with current maximal medical therapy for CVD), the AHA has recently expanded their list of Class II recommendations, in which treatment with OM3 for CVD benefit is reasonable. This review discusses the current state of the evidence, summarizes current professional recommendations, and provides recommendations for future research.
Collapse
Affiliation(s)
- Andrew Elagizi
- Department of Internal Medicine, Leonard J Chabert Medical Center, Houma, LA
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, the University of Queensland School of Medicine, New Orleans, LA.
| | - Keri Marshall
- Director Global Lipid Science and Advocacy for DSM Nutritional Products, Columbia, MD
| | | | - James H O'Keefe
- Mid America Heart Institute at Saint Luke's Hospital, Kansas City, MO
| | - Richard V Milani
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, the University of Queensland School of Medicine, New Orleans, LA
| |
Collapse
|
28
|
Budoff M, Brent Muhlestein J, Le VT, May HT, Roy S, Nelson JR. Effect of Vascepa (icosapent ethyl) on progression of coronary atherosclerosis in patients with elevated triglycerides (200-499 mg/dL) on statin therapy: Rationale and design of the EVAPORATE study. Clin Cardiol 2018; 41:13-19. [PMID: 29365351 PMCID: PMC5838559 DOI: 10.1002/clc.22856] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/17/2017] [Accepted: 11/21/2017] [Indexed: 02/02/2023] Open
Abstract
Despite reducing progression and promoting regression of coronary atherosclerosis, statin therapy does not fully address residual cardiovascular (CV) risk. High‐purity eicosapentaenoic acid (EPA) added to a statin has been shown to reduce CV events and induce regression of coronary atherosclerosis in imaging studies; however, data are from Japanese populations without high triglyceride (TG) levels and baseline EPA serum levels greater than those in North American populations. Icosapent ethyl is a high‐purity prescription EPA ethyl ester approved at 4 g/d as an adjunct to diet to reduce TG levels in adults with TG levels >499 mg/dL. The objective of the randomized, double‐blind, placebo‐controlled EVAPORATE study is to evaluate the effects of icosapent ethyl 4 g/d on atherosclerotic plaque in a North American population of statin‐treated patients with coronary atherosclerosis, TG levels of 200 to 499 mg/dL, and low‐density lipoprotein cholesterol levels of 40 to 115 mg/dL. The primary endpoint is change in low‐attenuation plaque volume measured by multidetector computed tomography angiography. Secondary endpoints include incident plaque rates; quantitative changes in different plaque types and morphology; changes in markers of inflammation, lipids, and lipoproteins; and the relationship between these changes and plaque burden and/or plaque vulnerability. Approximately 80 patients will be followed for 9 to 18 months. The clinical implications of icosapent ethyl 4 g/d treatment added to statin therapy on CV endpoints are being evaluated in the large CV outcomes study REDUCE‐IT. EVAPORATE will provide important imaging‐derived data that may add relevance to the clinically derived outcomes from REDUCE‐IT.
Collapse
Affiliation(s)
- Matthew Budoff
- Department of Internal Medicine, Los Angeles Biomedical Research Institute, Torrance, California
| | - J Brent Muhlestein
- Department of Internal Medicine, Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah.,Department of Internal Medicine, University of Utah, Salt Lake City
| | - Viet T Le
- Department of Internal Medicine, Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Heidi T May
- Department of Internal Medicine, Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Sion Roy
- Department of Internal Medicine, Los Angeles Biomedical Research Institute, Torrance, California
| | - John R Nelson
- Department of Cardiology, California Cardiovascular Institute, Fresno, California
| |
Collapse
|
29
|
Nelson JR, True WS, Le V, Mason RP. Can pleiotropic effects of eicosapentaenoic acid (EPA) impact residual cardiovascular risk? Postgrad Med 2017; 129:822-827. [DOI: 10.1080/00325481.2017.1385365] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
| | | | - Viet Le
- Intermountain Medical Center, Murray, UT, USA
| | - R. Preston Mason
- Department of Medicine, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Elucida Research, Beverly, MA, USA
| |
Collapse
|
30
|
Borow KM, Mason RP, Vijayaraghavan K. Eicosapentaenoic Acid as a Potential Therapeutic Approach to Reduce Cardiovascular Risk in Patients with End-Stage Renal Disease on Hemodialysis: A Review. Cardiorenal Med 2017; 8:18-30. [PMID: 29344023 DOI: 10.1159/000479391] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Patients with end-stage renal disease on hemodialysis have excess cardiovascular disease (CVD) burden with substantially increased CV event rates compared with the general population. Summary Traditional interventions that, according to standard clinical guidelines, reduce CV risk such as antihypertensive therapy, diet, exercise, and statins are not similarly effective in the hemodialysis population. This raises the question of whether additional risk factors, such as enhanced inflammation and oxidative stress, may drive the increased CVD burden in hemodialysis patients. Eicosapentaenoic acid (EPA), an omega-3 polyunsaturated fatty acid, is incorporated into the atherosclerotic plaque as well as membrane phospholipid bilayers and produces beneficial effects on inflammatory and oxidative mechanisms involved in atherosclerotic plaque formation and progression. EPA levels and the ratio of EPA to the omega-6 polyunsaturated fatty acid arachidonic acid (AA) are reduced in hemodialysis patients. Serum EPA levels have been inversely correlated with proinflammatory cytokines, and the EPA/AA ratio has been inversely associated with CV events in hemodialysis cohorts. Three recent studies involving over 800 hemodialysis patients and follow-up of 2-3 years suggest that EPA therapy may improve clinical outcomes in this patient population as evidenced by significant reductions in cardiovascular mortality, all-cause mortality, and/or CV events. Key Messages Further studies with high-purity EPA are warranted in patients on hemodialysis, especially given the fact that other interventions including antihypertensives, diet, exercise, and statins have not provided meaningful benefit.
Collapse
Affiliation(s)
- Kenneth M Borow
- MediMergent, LLC and The National Medication Safety, Outcomes and Adherence Program, Bryn Mawr, Pennsylvania, USA
| | - R Preston Mason
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Elucida Research LLC, Beverly, Massachusetts, USA
| | | |
Collapse
|
31
|
Abstract
PURPOSE OF REVIEW To review recent advances in the field of remnant lipoproteins and remnant cholesterol with a focus on cardiovascular disease risk. RECENT FINDINGS In line with previous years' research, current observational, genetic, and mechanistic studies find remnant lipoproteins (defined in different ways) to be involved in atherosclerosis development and cardiovascular disease risk. High concentrations of remnant cholesterol could explain some of the residual risk of cardiovascular disease seen after LDL cholesterol lowering. This will be increasingly important as populations worldwide become more obese and more have diabetes, both of which elevate remnant cholesterol concentrations. Many smaller scale studies and post hoc analyses show that remnant cholesterol can be lowered by different types of drugs; however, results from large scale studies with the primary aim of reducing cardiovascular disease risk through lowering of remnant cholesterol in individuals with elevated concentrations are still missing, although some are under way. SUMMARY Remnant cholesterol is a risk factor for cardiovascular disease, and can be lowered by different types of drugs; however, large scale studies of cardiovascular disease risk reduction through remnant lipoprotein lowering are under way.
Collapse
Affiliation(s)
- Anette Varbo
- aDepartment of Clinical Biochemistry bThe Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital cFaculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | |
Collapse
|
32
|
Nelson J, Wani O, May H, Budoff M. Potential benefits of eicosapentaenoic acid on atherosclerotic plaques. Vascul Pharmacol 2017; 91:1-9. [DOI: 10.1016/j.vph.2017.02.004] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 02/17/2017] [Accepted: 02/28/2017] [Indexed: 12/31/2022]
|
33
|
Bhatt DL, Steg PG, Brinton EA, Jacobson TA, Miller M, Tardif JC, Ketchum SB, Doyle RT, Murphy SA, Soni PN, Braeckman RA, Juliano RA, Ballantyne CM. Rationale and design of REDUCE-IT: Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial. Clin Cardiol 2017; 40:138-148. [PMID: 28294373 PMCID: PMC5396348 DOI: 10.1002/clc.22692] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 01/31/2017] [Indexed: 12/14/2022] Open
Abstract
Residual cardiovascular risk persists despite statins, yet outcome studies of lipid-targeted therapies beyond low-density lipoprotein cholesterol (LDL-C) have not demonstrated added benefit. Triglyceride elevation is an independent risk factor for cardiovascular events. High-dose eicosapentaenoic acid (EPA) reduces triglyceride-rich lipoproteins without raising LDL-C. Omega-3s have postulated pleiotropic cardioprotective benefits beyond triglyceride-lowering. To date, no large, multinational, randomized clinical trial has proved that lowering triglycerides on top of statin therapy improves cardiovascular outcomes. The Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT; NCT01492361) is a phase 3b randomized, double-blinded, placebo-controlled trial of icosapent ethyl, a highly purified ethyl ester of EPA, vs placebo. The main objective is to evaluate whether treatment with icosapent ethyl reduces ischemic events in statin-treated patients with high triglycerides at elevated cardiovascular risk. REDUCE-IT enrolled men or women age ≥45 years with established cardiovascular disease or age ≥50 years with diabetes mellitus and 1 additional risk factor. Randomization required fasting triglycerides ≥150 mg/dL and <500 mg/dL and LDL-C >40 mg/dL and ≤100 mg/dL with stable statin (± ezetimibe) ≥4 weeks prior to qualifying measurements. The primary endpoint is a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, coronary revascularization, or unstable angina. The key secondary endpoint is the composite of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke. Several secondary, tertiary, and exploratory endpoints will be assessed. Approximately 8000 patients have been randomized at approximately 470 centers worldwide. Follow-up will continue in this event-driven trial until approximately 1612 adjudicated primary-efficacy endpoint events have occurred.
Collapse
Affiliation(s)
- Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Ph Gabriel Steg
- FACT (French Alliance for Cardiovascular Trials), an F-CRIN network, Département Hospitalo-Universitaire FIRE, AP-HP, Hôpital Bichat, Université Paris-Diderot, INSERM U-1148, Paris, France.,NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom
| | - Eliot A Brinton
- Utah Foundation for Biomedical Research, and Utah Lipid Center, Salt Lake City
| | - Terry A Jacobson
- Office of Health Promotion and Disease Prevention, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Michael Miller
- Department of Medicine, University of Maryland School of Medicine, Baltimore
| | | | | | | | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Paresh N Soni
- Amarin Pharma Inc., Bedminster, New Jersey.,Albireo Pharma, Boston, Massachusetts
| | - Rene A Braeckman
- Amarin Pharma Inc., Bedminster, New Jersey.,KemPharm, Inc., Celebration, Florida
| | | | - Christie M Ballantyne
- Department of Medicine, Baylor College of Medicine, and Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | | |
Collapse
|
34
|
Mosca L, Ballantyne CM, Bays HE, Guyton JR, Philip S, Doyle RT, Juliano RA. Usefulness of Icosapent Ethyl (Eicosapentaenoic Acid Ethyl Ester) in Women to Lower Triglyceride Levels (Results from the MARINE and ANCHOR Trials). Am J Cardiol 2017; 119:397-403. [PMID: 27939227 DOI: 10.1016/j.amjcard.2016.10.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 10/11/2016] [Accepted: 10/11/2016] [Indexed: 11/29/2022]
Abstract
There are limited data on the efficacy and safety of triglyceride (TG)-lowering agents in women. We conducted subgroup analyses of the effects of icosapent ethyl (a high-purity prescription form of the ethyl ester of the omega-3 fatty acid, eicosapentaenoic acid) on TG levels (primary efficacy variable) and other atherogenic and inflammatory parameters in a total of 215 women with a broad range of TG levels (200-2000 mg/dl) enrolled in two 12-week placebo-controlled trials: MARINE (n = 18; placebo, n = 18) and ANCHOR (n = 91; placebo, n = 88). Icosapent ethyl 4 g/day significantly reduced TG levels from baseline to week 12 versus placebo in both MARINE (-22.7%; p = 0.0327) and ANCHOR (-21.5%; p <0.0001) without increasing low-density lipoprotein cholesterol levels. Significant improvements were also observed in non-high-density lipoprotein cholesterol levels in MARINE (-15.7%; p = 0.0082) and ANCHOR (-14.2%; p <0.0001) and total cholesterol levels in MARINE (-14.9%; p = 0.0023) and ANCHOR (-12.1%; p <0.0001), along with significant increases of >500% in eicosapentaenoic acid levels in plasma and red blood cells (all p <0.001). Icosapent ethyl was well tolerated, with adverse-event profiles comparable with findings in the overall studies. In conclusion, icosapent ethyl 4 g/day significantly reduced TG levels and other atherogenic parameters in women without increasing low-density lipoprotein cholesterol levels compared with placebo; the clinical implications of these findings are being evaluated in the REDUCtion of Cardiovascular Events With Eicosapentaenoic Acid [EPA]-Intervention Trial (REDUCE-IT) cardiovascular outcomes study.
Collapse
Affiliation(s)
- Lori Mosca
- Columbia University Medical Center, New York, New York.
| | - Christie M Ballantyne
- Baylor College of Medicine and the Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Harold E Bays
- Louisville Metabolic and Atherosclerosis Research Center, Louisville, Kentucky
| | - John R Guyton
- Duke University School of Medicine, Durham, North Carolina
| | | | | | | |
Collapse
|
35
|
Brinton EA, Mason RP. Prescription omega-3 fatty acid products containing highly purified eicosapentaenoic acid (EPA). Lipids Health Dis 2017; 16:23. [PMID: 28137294 PMCID: PMC5282870 DOI: 10.1186/s12944-017-0415-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 01/16/2017] [Indexed: 11/10/2022] Open
Abstract
The omega-3 fatty acid eicosapentaenoic acid (EPA) has multiple actions potentially conferring cardiovascular benefit, including lowering serum triglyceride (TG) and non-high-density lipoprotein cholesterol (non-HDL-C) levels and potentially reducing key steps in atherogenesis. Dietary supplements are a common source of omega-3 fatty acids in the US, but virtually all contain docosahexaenoic acid (DHA) in addition to EPA, and lipid effects differ between DHA and EPA. Contrary to popular belief, no over-the-counter omega-3 products are available in the US, only prescription products and dietary supplements. Among the US prescription omega-3 products, only one contains EPA exclusively (Vascepa); another closely related prescription omega-3 product also contains highly purified EPA, but is approved only in Japan and is provided in different capsule sizes. These high-purity EPA products do not raise low-density lipoprotein cholesterol (LDL-C) levels, even in patients with TG levels >500 mg/dL, in contrast to the increase in LDL-C levels with prescription omega-3 products that also contain DHA. The Japanese prescription EPA product was shown to significantly reduce major coronary events in hypercholesterolemic patients when added to statin therapy in the Japan EPA Lipid Intervention Study (JELIS). The effects of Vascepa on cardiovascular outcomes are being investigated in statin-treated patients with high TG levels in the Reduction of Cardiovascular Events With EPA-Intervention Trial (REDUCE-IT).
Collapse
Affiliation(s)
- Eliot A. Brinton
- Utah Foundation for Biomedical Research and the Utah Lipid Center, 419 Wakara Way, Suite 211, Salt Lake City, UT 84108 USA
| | - R. Preston Mason
- Department of Medicine, Cardiovascular Division, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA and Elucida Research LLC, PO Box 7100, Beverly, MA 01915-6127 USA
| |
Collapse
|