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Bellinge JW, Chan DC, Pang J, Francis RJ, Page MM, Watts GF, Schultz CJ. Plasma lipoprotein(a) is associated with calcification activity of the thoracic aorta and aortic valve in statin naïve individuals with diabetes mellitus. Eur J Clin Invest 2024; 54:e14167. [PMID: 38265272 DOI: 10.1111/eci.14167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/25/2024]
Affiliation(s)
- Jamie W Bellinge
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Nuclear Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Dick C Chan
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Jing Pang
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Roslyn J Francis
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Nuclear Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Michael M Page
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Clinical Biochemistry, Western Diagnostic Pathology, Perth, Australia
| | - Gerald F Watts
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Cardiometabolic Service, Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Carl J Schultz
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
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2
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Laffin LJ, Nissen SE. Lp(a) - an overlooked risk factor. Trends Cardiovasc Med 2024; 34:193-199. [PMID: 36681362 DOI: 10.1016/j.tcm.2023.01.003] [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: 10/05/2022] [Revised: 12/09/2022] [Accepted: 01/14/2023] [Indexed: 01/20/2023]
Abstract
Lipoprotein(a) (Lp(a)) is an increasingly discussed and studied risk factor for atherosclerotic cardiovascular disease and aortic valve stenosis. Many genetic and epidemiological studies support the important causal role that Lp(a) plays in the incidence of cardiovascular disease. Although dependent upon the threshold and unit of measurement of Lp(a), most estimates suggest between 20 and 30% of the world's population have elevated serum levels of Lp(a). Lp(a) levels are predominantly mediated by genetics and are not significantly modified by lifestyle interventions. Efforts are ongoing to develop effective pharmacotherapies to lower Lp(a) and to determine if lowering Lp(a) with these medications ultimately decreases the incidence of adverse cardiovascular events. In this review, the genetics and pathophysiological properties of Lp(a) will be discussed as well as the epidemiological data demonstrating its impact on the incidence of cardiovascular disease. Recommendations for screening and how to currently approach patients with elevated Lp(a) are also noted. Finally, the spectrum of pharmacotherapies under development for Lp(a) lowering is detailed.
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3
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Abstract
Prolonged or excessive exposure to oxidized phospholipids (OxPLs) generates chronic inflammation. OxPLs are present in atherosclerotic lesions and can be detected in plasma on apolipoprotein B (apoB)-containing lipoproteins. When initially conceptualized, OxPL-apoB measurement in plasma was expected to reflect the concentration of minimally oxidized LDL, but, surprisingly, it correlated more strongly with plasma lipoprotein(a) (Lp(a)) levels. Indeed, experimental and clinical studies show that Lp(a) particles carry the largest fraction of OxPLs among apoB-containing lipoproteins. Plasma OxPL-apoB levels provide diagnostic information on the presence and extent of atherosclerosis and improve the prognostication of peripheral artery disease and first and recurrent myocardial infarction and stroke. The addition of OxPL-apoB measurements to traditional cardiovascular risk factors improves risk reclassification, particularly in patients in intermediate risk categories, for whom improving decision-making is most impactful. Moreover, plasma OxPL-apoB levels predict cardiovascular events with similar or greater accuracy than plasma Lp(a) levels, probably because this measurement reflects both the genetics of elevated Lp(a) levels and the generalized or localized oxidation that modifies apoB-containing lipoproteins and leads to inflammation. Plasma OxPL-apoB levels are reduced by Lp(a)-lowering therapy with antisense oligonucleotides and by lipoprotein apheresis, niacin therapy and bariatric surgery. In this Review, we discuss the role of role OxPLs in the pathophysiology of atherosclerosis and Lp(a) atherogenicity, and the use of OxPL-apoB measurement for improving prognosis, risk reclassification and therapeutic interventions.
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Affiliation(s)
- Sotirios Tsimikas
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA.
| | - Joseph L Witztum
- Division of Endocrinology and Metabolism, University of California San Diego, La Jolla, CA, USA
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4
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Yuen T, Mancini GJ, Hegele RA, Pearson GJ. Consideration and Application of Lipoprotein(a) in the Risk Assessment of Atherosclerotic Cardiovascular Disease Risk in Adults. CJC Open 2024; 6:597-606. [PMID: 38559332 PMCID: PMC10980900 DOI: 10.1016/j.cjco.2023.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/13/2023] [Indexed: 04/04/2024] Open
Abstract
Lipoprotein(a) (Lp[a]) is an low-density lipoprotein (LDL)-like particle in which apolipoprotein (apo) B is covalently bound to a plasminogen-like molecule called apo(a). A High level of Lp(a) has been demonstrated to be an independent, causal, and prevalent risk factor for atherosclerotic cardiovascular disease (ASCVD), as well as aortic valve disease, through mechanisms that promote atherogenesis, inflammation, and thrombosis. With reliable and accessible assays, Lp(a) level has been established to be associated linearly with the risk for ASCVD. The 2021 Canadian Cardiovascular Society Dyslipidemia Guidelines recommend measuring an Lp(a) level once in a person's lifetime as part of the initial lipid screening. The aim of this review is to provide an update and overview of the utility and application of Lp(a) level in the assessment and treatment of adults at risk for ASCVD, consistent with this guideline recommendation.
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Affiliation(s)
- Tiffany Yuen
- Faculty of Medicine & Dentistry, University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - G.B. John Mancini
- University of British Columbia, Department of Medicine, Division of Cardiology, Vancouver, British Columbia, Canada
| | - Robert A. Hegele
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Glen J. Pearson
- Faculty of Medicine & Dentistry, University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
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5
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Sosnowska B, Stepinska J, Mitkowski P, Bielecka-Dabrowa A, Bobrowska B, Budzianowski J, Burchardt P, Chlebus K, Dobrowolski P, Gasior M, Jankowski P, Kubica J, Mickiewicz A, Mysliwiec M, Osadnik T, Prejbisz A, Rajtar-Salwa R, Wita K, Witkowski A, Gil R, Banach M. Recommendations of the Experts of the Polish Cardiac Society (PCS) and the Polish Lipid Association (PoLA) on the diagnosis and management of elevated lipoprotein(a) levels. Arch Med Sci 2024; 20:8-27. [PMID: 38414479 PMCID: PMC10895977 DOI: 10.5114/aoms/183522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 01/31/2024] [Indexed: 02/29/2024] Open
Abstract
Lipoprotein(a) [Lp(a)] is made up of a low-density lipoprotein (LDL) particle and a specific apolipoprotein(a). The blood concentration of Lp(a) is approximately 90% genetically determined, and the main genetic factor determining Lp(a) levels is the size of the apo(a) isoform, which is determined by the number of KIV2 domain repeats. The size of the apo(a) isoform is inversely proportional to the blood concentration of Lp(a). Lp(a) is a strong and independent cardiovascular risk factor. Elevated Lp(a) levels ≥ 50 mg/dl (≥ 125 nmol/l) are estimated to occur in more than 1.5 billion people worldwide. However, determination of Lp(a) levels is performed far too rarely, including Poland, where, in fact, it is only since the 2021 guidelines of the Polish Lipid Association (PoLA) and five other scientific societies that Lp(a) measurements have begun to be performed. Determination of Lp(a) concentrations is not easy due to, among other things, the different sizes of the apo(a) isoforms; however, the currently available certified tests make it possible to distinguish between people with low and high cardiovascular risk with a high degree of precision. In 2022, the first guidelines for the management of patients with elevated lipoprotein(a) levels were published by the European Atherosclerosis Society (EAS) and the American Heart Association (AHA). The first Polish guidelines are the result of the work of experts from the two scientific societies and their aim is to provide clear, practical recommendations for the determination and management of elevated Lp(a) levels.
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Affiliation(s)
- Bożena Sosnowska
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz (MUL), Lodz, Poland
| | | | - Przemyslaw Mitkowski
- 1 Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Agata Bielecka-Dabrowa
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz (MUL), Lodz, Poland
- Department of Cardiology and Adult Congenital Defects, Polish Mother's Memorial Hospital Research Institute (PMMHRI), Lodz, Poland
| | - Beata Bobrowska
- Department of Clinical Cardiology and Cardiovascular Interventions, University Hospital in Krakow, Krakow, Poland
| | - Jan Budzianowski
- Department of Interventional Cardiology and Cardiac Surgery, University of Zielona Gora, Collegium Medicum, Zielona Gora, Poland
- Multidisciplinary Hospital, Nowa Sol, Poland
| | - Pawel Burchardt
- Department of Cardiology, J. Strus Hospital, Poznan, Poland
- Department of Hypertension, Angiology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Krzysztof Chlebus
- National Center for Familial Hypercholesterolemia, 1 Chair and Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Piotr Dobrowolski
- Department of Epidemiology, Cardiovascular Disease Prevention and Health Promotion, National Institute of Cardiology, Warsaw, Poland
| | - Mariusz Gasior
- 3 Department of Cardiology, Silesian Centre for Heart Diseases, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Zabrze, Poland
| | - Piotr Jankowski
- Department of Internal Medicine and Geriatric Cardiology, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Agnieszka Mickiewicz
- Lipoprotein Apheresis Laboratory, 1 Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Malgorzata Mysliwiec
- Department of Paediatrics, Diabetology and Endocrinology, Medical University of Gdansk, Gdansk, Poland
| | - Tadeusz Osadnik
- Department of Pharmacology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Aleksander Prejbisz
- Department of Epidemiology, Cardiovascular Disease Prevention and Health Promotion, National Institute of Cardiology, Warsaw, Poland
| | - Renata Rajtar-Salwa
- Department of Clinical Cardiology and Cardiovascular Interventions, University Hospital in Krakow, Krakow, Poland
| | - Kristian Wita
- 1 Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Robert Gil
- Department of Cardiology, National Medical Institute of the Ministry of Internal Affairs and Administration, Warsaw, Poland
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz (MUL), Lodz, Poland
- Department of Cardiology and Adult Congenital Defects, Polish Mother's Memorial Hospital Research Institute (PMMHRI), Lodz, Poland
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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6
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Pantelidis P, Oikonomou E, Lampsas S, Zakynthinos GE, Lysandrou A, Kalogeras K, Katsianos E, Theofilis P, Siasos G, Vavuranakis MA, Antonopoulos AS, Tousoulis D, Vavouranakis M. Lipoprotein(a) and calcific aortic valve disease initiation and progression: a systematic review and meta-analysis. Cardiovasc Res 2023; 119:1641-1655. [PMID: 37078819 DOI: 10.1093/cvr/cvad062] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 02/18/2023] [Accepted: 03/01/2023] [Indexed: 04/21/2023] Open
Abstract
Although evidence indicates the association of lipoprotein(a) [Lp(a)] with atherosclerosis, the link with calcific aortic valve disease (CAVD) is unclear. This systematic review and meta-analysis explores the connection between Lp(a) and aortic valve calcification and stenosis (AVS). We included all relevant studies, indexed in eight databases, up to February 2023. A total of 44 studies (163 139 subjects) were included, with 16 of them being further meta-analysed. Despite considerable heterogeneity, most studies support the relationship between Lp(a) and CAVD, especially in younger populations, with evidence of early aortic valve micro-calcification in elevated-Lp(a) populations. The quantitative synthesis showed higher Lp(a) levels, by 22.63 nmol/L (95% CI: 9.98-35.27), for patients with AVS, while meta-regressing the data revealed smaller Lp(a) differences for older populations with a higher proportion of females. The meta-analysis of eight studies providing genetic data, revealed that the minor alleles of both rs10455872 and rs3798220 LPA gene loci were associated with higher risk for AVS (pooled odds ratio 1.42; 95% CI: 1.34-1.50 and 1.27; 95% CI: 1.09-1.48, respectively). Importantly, high-Lp(a) individuals displayed not only faster AVS progression, by a mean difference of 0.09 m/s/year (95% CI: 0.09-0.09), but also a higher risk of serious adverse outcomes, including death (pooled hazard ratio 1.39; 95% CI: 1.01-1.90). These summary findings highlight the effect of Lp(a) on CAVD initiation, progression and outcomes, and support the early onset of Lp(a)-related subclinical lesions before clinical evidence.
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Affiliation(s)
- Panteleimon Pantelidis
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, 152 Mesogeion St, Athens 11527, Greece
| | - Evangelos Oikonomou
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, 152 Mesogeion St, Athens 11527, Greece
| | - Stamatios Lampsas
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, 152 Mesogeion St, Athens 11527, Greece
| | - Georgios E Zakynthinos
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, 152 Mesogeion St, Athens 11527, Greece
| | - Antonios Lysandrou
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, 152 Mesogeion St, Athens 11527, Greece
| | - Konstantinos Kalogeras
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, 152 Mesogeion St, Athens 11527, Greece
| | - Efstratios Katsianos
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, 152 Mesogeion St, Athens 11527, Greece
| | - Panagiotis Theofilis
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, 152 Mesogeion St, Athens 11527, Greece
| | - Gerasimos Siasos
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, 152 Mesogeion St, Athens 11527, Greece
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Michael Andrew Vavuranakis
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, 152 Mesogeion St, Athens 11527, Greece
| | - Alexios S Antonopoulos
- Clinical, Experimental Surgery & Translational Research Center, Biomedical Research Foundation of the Academy of Athens, 4 Soranou Ephessiou St, Athens 11527, Greece
| | - Dimitris Tousoulis
- 1st Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Ippokrateio Hospital, 114 Vasilissis Sofias St, Athina 11527, Greece
| | - Manolis Vavouranakis
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, 152 Mesogeion St, Athens 11527, Greece
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7
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Botezatu SB, Tzolos E, Kaiser Y, Cartlidge TRG, Kwiecinski J, Barton AK, Yu X, Williams MC, van Beek EJR, White A, Kroon J, Slomka PJ, Popescu BA, Newby DE, Stroes ESG, Zheng KH, Dweck MR. Serum lipoprotein(a) and bioprosthetic aortic valve degeneration. Eur Heart J Cardiovasc Imaging 2023; 24:759-767. [PMID: 36662130 PMCID: PMC10229296 DOI: 10.1093/ehjci/jeac274] [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] [Received: 11/16/2022] [Accepted: 12/29/2022] [Indexed: 01/21/2023] Open
Abstract
AIMS Bioprosthetic aortic valve degeneration demonstrates pathological similarities to aortic stenosis. Lipoprotein(a) [Lp(a)] is a well-recognized risk factor for incident aortic stenosis and disease progression. The aim of this study is to investigate whether serum Lp(a) concentrations are associated with bioprosthetic aortic valve degeneration. METHODS AND RESULTS In a post hoc analysis of a prospective multimodality imaging study (NCT02304276), serum Lp(a) concentrations, echocardiography, contrast-enhanced computed tomography (CT) angiography, and 18F-sodium fluoride (18F-NaF) positron emission tomography (PET) were assessed in patients with bioprosthetic aortic valves. Patients were also followed up for 2 years with serial echocardiography. Serum Lp(a) concentrations [median 19.9 (8.4-76.4) mg/dL] were available in 97 participants (mean age 75 ± 7 years, 54% men). There were no baseline differences across the tertiles of serum Lp(a) concentrations for disease severity assessed by echocardiography [median peak aortic valve velocity: highest tertile 2.5 (2.3-2.9) m/s vs. lower tertiles 2.7 (2.4-3.0) m/s, P = 0.204], or valve degeneration on CT angiography (highest tertile n = 8 vs. lower tertiles n = 12, P = 0.552) and 18F-NaF PET (median tissue-to-background ratio: highest tertile 1.13 (1.05-1.41) vs. lower tertiles 1.17 (1.06-1.53), P = 0.889]. After 2 years of follow-up, there were no differences in annualized change in bioprosthetic hemodynamic progression [change in peak aortic valve velocity: highest tertile [0.0 (-0.1-0.2) m/s/year vs. lower tertiles 0.1 (0.0-0.2) m/s/year, P = 0.528] or the development of structural valve degeneration. CONCLUSION Serum lipoprotein(a) concentrations do not appear to be a major determinant or mediator of bioprosthetic aortic valve degeneration.
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Affiliation(s)
- Simona B Botezatu
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Chancellor's Building, Little France Crescent, EH16 4SB, Edinburgh, UK
- University of Medicine and Pharmacy “Carol Davila”, Cardiology Department, Euroecolab, 258 Fundeni Road, District 2, 022238, Bucharest, Romania
| | - Evangelos Tzolos
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Chancellor's Building, Little France Crescent, EH16 4SB, Edinburgh, UK
| | - Yannick Kaiser
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, the Netherlands
| | - Timothy R G Cartlidge
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Chancellor's Building, Little France Crescent, EH16 4SB, Edinburgh, UK
| | - Jacek Kwiecinski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Alpejska 42 04-628, Warsaw, Poland
| | - Anna K Barton
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Chancellor's Building, Little France Crescent, EH16 4SB, Edinburgh, UK
| | - Xinming Yu
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Chancellor's Building, Little France Crescent, EH16 4SB, Edinburgh, UK
| | - Michelle C Williams
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Chancellor's Building, Little France Crescent, EH16 4SB, Edinburgh, UK
| | - Edwin J R van Beek
- Edinburgh Imaging, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, EH16 4TJ, Edinburgh, UK
| | - Audrey White
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Chancellor's Building, Little France Crescent, EH16 4SB, Edinburgh, UK
| | - Jeffrey Kroon
- Department of Experimental Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, The Netherlands
| | - Piotr J Slomka
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd, CA 90048 Los Angeles, California, USA
| | - Bogdan A Popescu
- University of Medicine and Pharmacy “Carol Davila”, Cardiology Department, Euroecolab, 258 Fundeni Road, District 2, 022238, Bucharest, Romania
- Emergency Institute for Cardiovascular Diseases “Prof. Dr. C. C. Iliescu”, Cardiology Department, 258 Fundeni Road, District 2, 022238, Bucharest, Romania
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Chancellor's Building, Little France Crescent, EH16 4SB, Edinburgh, UK
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, the Netherlands
| | - Kang H Zheng
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, the Netherlands
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Chancellor's Building, Little France Crescent, EH16 4SB, Edinburgh, UK
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8
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Lauten P, Costello-Boerrigter LC, Goebel B, Gonzalez-Lopez D, Schreiber M, Kuntze T, Al Jassem M, Lapp H. Transcatheter Aortic Valve Implantation: Addressing the Subsequent Risk of Permanent Pacemaker Implantation. J Cardiovasc Dev Dis 2023; 10:230. [PMID: 37367395 PMCID: PMC10299451 DOI: 10.3390/jcdd10060230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/17/2023] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is now a commonly used therapy in patients with severe aortic stenosis, even in those patients at low surgical risk. The indications for TAVI have broadened as the therapy has proven to be safe and effective. Most challenges associated with TAVI after its initial introduction have been impressively reduced; however, the possible need for post-TAVI permanent pacemaker implantation (PPI) secondary to conduction disturbances continues to be on the radar. Conduction abnormalities post-TAVI are always of concern given that the aortic valve lies in close proximity to critical components of the cardiac conduction system. This review will present a summary of noteworthy pre-and post-procedural conduction blocks, the best use of telemetry and ambulatory device monitoring to avoid unnecessary PPI or to recognize the need for late PPI due to delayed high-grade conduction blocks, predictors to identify those patients at greatest risk of requiring PPI, important CT measurements and considerations to optimize TAVI planning, and the utility of the MInimizing Depth According to the membranous Septum (MIDAS) technique and the cusp-overlap technique. It is stressed that careful membranous septal (MS) length measurement by MDCT during pre-TAVI planning is necessary to establish the optimal implantation depth before the procedure to reduce the risk of compression of the MS and consequent damage to the cardiac conduction system.
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Affiliation(s)
- Philipp Lauten
- Department of Cardiology, Heart Center, Zentralklinik Bad Berka, Robert-Koch-Allee 9, 99437 Bad Berka, Germany (B.G.); (H.L.)
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9
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Motawea KR, Elhalag RH, Aboelenein M, Ibrahim N, Swed S, Fathy H, Awad DM, Mohamed Belal M, Talaat NE, Rozan SS, Aiash H, Mostafa MR. Association of aortic valve calcification and high levels of lipoprotein (a): Systematic review and Meta-analysis. Curr Probl Cardiol 2023; 48:101746. [PMID: 37100357 DOI: 10.1016/j.cpcardiol.2023.101746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 04/17/2023] [Indexed: 04/28/2023]
Abstract
AIM This study aimed to assess the association between aortic valve calcification and lipoprotein (a). METHODS We searched PUBMED, WOS, and SCOPUS databases. Inclusion criteria were any controlled clinical trials or observational studies that reported the level of Lipoprotein A in patients with aortic valve calcifications, excluding case reports, editorials and animal studies. RevMan software (5.4) was used to perform the meta-analysis. RESULTS After complete screening, 7 studies were included with a total number of 446179 patients included in the analysis. The pooled analysis showed a statistically significant association between the incidence of aortic valve calcium and increased levels of lipoprotein (a) compared with controls (SMD = 1.71, 95% CI = 1.04 to 2.38, p-value < 0.00001). CONCLUSION This meta-analysis showed a statistically significant association between the incidence of aortic valve calcium and increased levels of lipoprotein (a) compared with controls. Patients with high levels of lipoprotein (a) are at increased risk of developing aortic valve calcification. Medications targeting lipoprotein (a) in future clinical trials may be useful in primary prevention of aortic valve calcification in high risk patients.
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Affiliation(s)
| | | | | | | | - Sarya Swed
- Faculty of Medicine, Aleppo University, Aleppo, Syria
| | - Hager Fathy
- Faculty of Medicine, Minia University, Egypt
| | - Dina M Awad
- Faculty of Medicine, Alexandria University, Egypt
| | | | | | | | - Hani Aiash
- Upstate Medical University, NY, USA, Cardiovascular perfusion Department
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10
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Neels JG, Leftheriotis G, Chinetti G. Atherosclerosis Calcification: Focus on Lipoproteins. Metabolites 2023; 13:metabo13030457. [PMID: 36984897 PMCID: PMC10056669 DOI: 10.3390/metabo13030457] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
Atherosclerosis is a chronic inflammatory disease characterized by the accumulation of lipids in the vessel wall, leading to the formation of an atheroma and eventually to the development of vascular calcification (VC). Lipoproteins play a central role in the development of atherosclerosis and VC. Both low- and very low-density lipoproteins (LDL and VLDL) and lipoprotein (a) (Lp(a)) stimulate, while high-density lipoproteins (HDL) reduce VC. Apolipoproteins, the protein component of lipoproteins, influence the development of VC in multiple ways. Apolipoprotein AI (apoAI), the main protein component of HDL, has anti-calcific properties, while apoB and apoCIII, the main protein components of LDL and VLDL, respectively, promote VC. The role of lipoproteins in VC is also related to their metabolism and modifications. Oxidized LDL (OxLDL) are more pro-calcific than native LDL. Oxidation also converts HDL from anti- to pro-calcific. Additionally, enzymes such as autotaxin (ATX) and proprotein convertase subtilisin/kexin type 9 (PCSK9), involved in lipoprotein metabolism, have a stimulatory role in VC. In summary, a better understanding of the mechanisms by which lipoproteins and apolipoproteins contribute to VC will be crucial in the development of effective preventive and therapeutic strategies for VC and its associated cardiovascular disease.
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Affiliation(s)
- Jaap G Neels
- Université Côte d'Azur, INSERM, C3M, 06200 Nice, France
| | | | - Giulia Chinetti
- Université Côte d'Azur, CHU, INSERM, C3M, 06200 Nice, France
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11
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De Azevedo D, Geers J, Gheysens O, Dweck M, Vancraeynest D. 18F-Sodium Fluoride PET/CT in Assessing Valvular Heart and Atherosclerotic Diseases. Semin Nucl Med 2023; 53:241-257. [PMID: 36116988 DOI: 10.1053/j.semnuclmed.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022]
Abstract
Aortic valve stenosis is the most common valvular disease in Western countries, while atherosclerotic cardiovascular disease is the foremost cause of death and disability worldwide. Valve degeneration and atherosclerosis are mediated by inflammation and calcification and inevitably progress over time. Computed tomography can visualise the later stages of macroscopic calcification but fails to assess the early stages of microcalcification and cannot differentiate active from burnt out disease states. Molecular imaging has the ability to provide complementary information related to disease activity, which may allow us to detect disease early, to predict disease progression and to monitor preventive or therapeutic strategies for in both aortic stenosis and atherosclerosis. PET/CT is a non-invasive imaging technique that enables visualization of ongoing molecular processes within small structures, such as the coronary arteries or heart valves. 18F-sodium fluoride (18F-NaF) binds hydroxyapatite deposits in the extracellular matrix, with preferential binding to newly developing deposits of microcalcification, which provides an assessment of calcification activity. In recent years, 18F-NaF has attracted the attention of many research groups and has been evaluated in several pathological cardiovascular processes. Histologic validation of the 18F-NaF PET signal in valvular disease and atherosclerosis has been reported in multiple independent studies. The selective high-affinity binding of 18F-NaF to microscopic calcified deposits (beyond the resolution of μCT) has been demonstrated ex vivo, as well as its ability to distinguish between areas of macro- and active microcalcification. In addition, prospective clinical studies have shown that baseline 18F-NaF uptake in patients with aortic stenosis and mitral annular calcification is correlated with subsequent calcium deposition and valvular dysfunction after a follow-up period of 2 years. In patients with surgical bioprosthetic aortic valves but without morphological criteria for prosthetic degeneration, increased 18F-NaF uptake at baseline was associated with subsequent bioprosthetic degeneration over time. Similar data were obtained in a cohort of patients with transcatheter aortic valve implantation. Furthermore, several studies have confirmed the association of coronary 18F-NaF uptake with adverse atherosclerotic plaque features, active disease and future disease progression. 18F-NaF uptake is also associated with future fatal or nonfatal myocardial infarction in patients with established coronary artery disease. The link between 18F-NaF uptake and active atherosclerotic disease has not only been demonstrated in the coronary arteries, but also in peripheral arterial disease, abdominal aortic aneurysms and carotid atherosclerosis. It can be assumed that 18F-NaF PET/CT will strengthen the diagnostic toolbox of practitioners in the coming years. Indeed, there is a strong medical need to diagnose degenerative valvular disease and to detect active atherosclerotic disease states. Finally, the use of 18F-NaF as a biomarker to monitor the efficacy of drug therapies in preventing these pathological processes is attractive. In this review, we consider the role of 18F-NaF PET/CT imaging in cardiac valvular diseases and atherosclerosis.
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Affiliation(s)
- David De Azevedo
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium.
| | - Jolien Geers
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, The Chancellor's Building, Little France Crescent, Midlothian, Edinburgh, UK; Department of Cardiology, CHVZ (Centrum voor Hart en Vaatziekten), Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Olivier Gheysens
- Department of Nuclear Medicine, Cliniques Universitaires Saint-Luc and Institute of Clinical and Experimental Research (IREC), Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Marc Dweck
- Department of Cardiology, CHVZ (Centrum voor Hart en Vaatziekten), Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - David Vancraeynest
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
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12
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Girard A, Gaillard E, Puri R, Capoulade R, Chan KL, Paulin A, Manikpurage HD, Dumesnil J, Tam JW, Teo KK, Couture C, Wareham NJ, Clavel MA, Stroes ESG, Mathieu P, Thériault S, Tsimikas S, Pibarot P, Boekholdt SM, Arsenault BJ. Impact of C-reactive protein levels on lipoprotein(a)-associated aortic stenosis incidence and progression. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead032. [PMID: 37077580 PMCID: PMC10108885 DOI: 10.1093/ehjopen/oead032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/14/2023] [Accepted: 03/22/2023] [Indexed: 04/01/2023]
Abstract
Aims Elevated lipoprotein(a) [Lp(a)] levels are associated with the risk of coronary artery disease (CAD) and calcific aortic valve stenosis (CAVS). Observational studies revealed that Lp(a) and C-reactive protein (CRP) levels, a biomarker of systemic inflammation, may jointly predict CAD risk. Whether Lp(a) and CRP levels also jointly predict CAVS incidence and progression is unknown. Methods and results We investigated the association of Lp(a) with CAVS according to CRP levels in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Norfolk study (n = 18 226, 406 incident cases) and the UK Biobank (n = 438 260, 4582 incident cases), as well as in the ASTRONOMER study (n = 220), which assessed the haemodynamic progression rate of pre-existing mild-to-moderate aortic stenosis. In EPIC-Norfolk, in comparison to individuals with low Lp(a) levels (<50 mg/dL) and low CRP levels (<2.0 mg/L), those with elevated Lp(a) (>50 mg/dL) and low CRP levels (<2.0 mg/L) and those with elevated Lp(a) (>50 mg/dL) and elevated CRP levels (>2.0 mg/L) had a higher CAVS risk [hazard ratio (HR) = 1.86 (95% confidence intervals, 1.30-2.67) and 2.08 (1.44-2.99), respectively]. A comparable predictive value of Lp(a) in patients with vs. without elevated CRP levels was also noted in the UK Biobank. In ASTRONOMER, CAVS progression was comparable in patients with elevated Lp(a) levels with or without elevated CRP levels. Conclusion Lp(a) predicts the incidence and possibly progression of CAVS regardless of plasma CRP levels. Lowering Lp(a) levels may warrant further investigation in the prevention and treatment of CAVS, regardless of systemic inflammation.
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Affiliation(s)
- Arnaud Girard
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, G1V 4G5, Canada
| | - Emilie Gaillard
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, 1105 AZ, The Netherlands
| | - Rishi Puri
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Romain Capoulade
- Nantes Université, CNRS, INSERM, l’institut du thorax, F-44000 Nantes, 44007, France
| | - Kwan L Chan
- Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, K1Y 4W7, Canada
| | - Audrey Paulin
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, G1V 4G5, Canada
| | - Hasanga D Manikpurage
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, G1V 4G5, Canada
| | - Jean Dumesnil
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, G1V 4G5, Canada
| | - James W Tam
- Department of Medicine, St. Boniface General Hospital, Winnipeg, MB, R2H 2A6, Canada
| | - Koon K Teo
- Department of Medicine (Cardiology), McMaster University, Hamilton, ON, L8S 4L8, Canada
| | - Christian Couture
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, G1V 4G5, Canada
| | - Nicholas J Wareham
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB2 1TN, UK
| | - Marie-Annick Clavel
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, G1V 4G5, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC, G1V 0A6, Canada
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, 1105 AZ, The Netherlands
| | - Patrick Mathieu
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, G1V 4G5, Canada
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC, G1V 0A6, Canada
| | - Sébastien Thériault
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, G1V 4G5, Canada
- Department of Molecular Biology, Medical Biochemistry and Pathology, Faculty of Medicine, Université Laval, Québec, QC, G1V 0A6, Canada
| | - Sotirios Tsimikas
- Division of Cardiovascular Diseases, Department of Medicine, University of California San Diego, La Jolla, CA, 92093, USA
| | - Philippe Pibarot
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, G1V 4G5, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC, G1V 0A6, Canada
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, 1105 AZ, The Netherlands
| | - Benoit J Arsenault
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, G1V 4G5, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC, G1V 0A6, Canada
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13
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Wu J, Qiao H. Medical Imaging Technology and Imaging Agents. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1199:15-38. [PMID: 37460725 DOI: 10.1007/978-981-32-9902-3_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Medical imaging is a technology that studies the interaction between human body and irradiations of X-ray, ultrasound, magnetic field, etc. and represents anatomical structures of human organs/tissues with the implication of irradiation attenuation in the form of grayscales. With these medical images, detailed information on health status and disease diagnosis may be judged by clinical physicians to determine an appropriate therapy approach. This chapter will give a systematic introduction on the modalities, classifications, basic principles, and biomedical applications of traditional medical imaging along with the types, construction, and major features of the corresponding contrast agents or imaging probes.
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Affiliation(s)
- Jieting Wu
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
| | - Huanhuan Qiao
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China.
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14
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Bhatia HS, Wilkinson MJ. Lipoprotein(a): Evidence for Role as a Causal Risk Factor in Cardiovascular Disease and Emerging Therapies. J Clin Med 2022; 11:6040. [PMID: 36294361 PMCID: PMC9604626 DOI: 10.3390/jcm11206040] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/20/2022] [Accepted: 10/07/2022] [Indexed: 08/03/2023] Open
Abstract
Lipoprotein(a) (Lp(a)) is an established risk factor for multiple cardiovascular diseases. Several lines of evidence including mechanistic, epidemiologic, and genetic studies support the role of Lp(a) as a causal risk factor for atherosclerotic cardiovascular disease (ASCVD) and aortic stenosis/calcific aortic valve disease (AS/CAVD). Limited therapies currently exist for the management of risk associated with elevated Lp(a), but several targeted therapies are currently in various stages of clinical development. In this review, we detail evidence supporting Lp(a) as a causal risk factor for ASCVD and AS/CAVD, and discuss approaches to managing Lp(a)-associated risk.
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15
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Oostveen RF, Kaiser Y, Stroes ES, Verberne HJ. Molecular Imaging of Aortic Valve Stenosis with Positron Emission Tomography. Pharmaceuticals (Basel) 2022; 15:ph15070812. [PMID: 35890111 PMCID: PMC9319069 DOI: 10.3390/ph15070812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/16/2022] [Accepted: 06/21/2022] [Indexed: 11/16/2022] Open
Abstract
Aortic valve stenosis (AVS) is an increasingly prevalent disease in our aging population. Although multiple risk factors for AVS have been elucidated, medical therapies capable of slowing down disease progression remain unavailable. Molecular imaging technologies are opening up avenues for the non-invasive assessment of disease progression, allowing the assessment of (early) medical interventions. This review will focus on the role of positron emission tomography of the aortic valve with 18F-fluorodeoxyglucose and 18F-sodium fluoride but will also shed light on novel tracers which have potential in AVS, ranging from the healthy aortic valve to end-stage valvular disease.
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Affiliation(s)
- Reindert F. Oostveen
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (R.F.O.); (Y.K.); (E.S.G.S.)
| | - Yannick Kaiser
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (R.F.O.); (Y.K.); (E.S.G.S.)
| | - Erik S.G. Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (R.F.O.); (Y.K.); (E.S.G.S.)
| | - Hein J. Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Correspondence: ; Tel.: +31-20-562-8436
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16
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Arsenault BJ, Kamstrup PR. Lipoprotein(a) and cardiovascular and valvular diseases: A genetic epidemiological perspective. Atherosclerosis 2022; 349:7-16. [PMID: 35606078 DOI: 10.1016/j.atherosclerosis.2022.04.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/08/2022] [Accepted: 04/14/2022] [Indexed: 12/12/2022]
Abstract
Rates of atherosclerotic cardiovascular diseases (CVD) in the Western world have spectacularly decreased over the past 50 years. However, a substantial proportion of high-risk patients still develop heart attacks, strokes and valvular heart diseases despite benefiting from state-of-the-art treatments including lipid-lowering therapies. Over the past 10-15 years, it has become increasingly clear that Lipoprotein(a) (Lp[a]) is a critical component of this so-called residual risk. Genetic association studies revealed that Lp(a) is robustly, independently and causally associated with a broad range of cardiovascular and valvular heart diseases. Up to 1 billion people around the globe may have an Lp(a) level that places them in a high-risk category. Lp(a) is strongly associated with calcific aortic valve stenosis (CAVS), coronary artery disease (CAD), peripheral arterial disease (PAD) and to a lesser extent with ischemic stroke (IS) and heart failure (HF). Because of this strong association with cardiovascular and valvular heart diseases, Lp(a) even emerged as one of the most important genetic determinants of human lifespan and healthspan. Here, we review the evidence from the largest and most informative genetic association studies and prospective studies that have investigated the association between Lp(a) and human lifespan, healthspan, CVD, CAVS and non-cardiovascular diseases. We present Lp(a) threshold values that may be clinically relevant and identify other cardiovascular risk factors that may modulate the absolute risk of CVD in individuals with high Lp(a) levels. Finally, we identify key clinical and research questions that require further investigation to eventually and optimally reduce CVD risk in patients with high Lp(a) levels.
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Affiliation(s)
- Benoit J Arsenault
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec, Canada; Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada.
| | - Pia R Kamstrup
- Department of Clinical Biochemistry and, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 73, DK-2730, Herlev, Denmark; The Copenhagen General Population Study, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 73, DK-2730, Herlev, Denmark.
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17
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Kaiser Y, Nurmohamed NS, Stroes ESG, Boekholdt SM. Response to: Correspondence on "Lipoprotein(a) has no major impact on calcification activity in patients with mild to moderate aortic valve stenosis" by Pantelidis et al. BRITISH HEART JOURNAL 2022; 108:576-577. [PMID: 35086887 DOI: 10.1136/heartjnl-2021-320644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Yannick Kaiser
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nick S Nurmohamed
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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18
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Pantelidis P, Oikonomou E. Correspondence on "Lipoprotein(a) has no major impact on calcification activity in patients with mild to moderate aortic valve stenosis" by Kaiser et al. Heart 2022; 108:575-576. [PMID: 35086886 DOI: 10.1136/heartjnl-2021-320643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Panteleimon Pantelidis
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, "Sotiria" Chest Disease Hospital, Athens, Greece
| | - Evangelos Oikonomou
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, "Sotiria" Chest Disease Hospital, Athens, Greece
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19
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Trends in testing and prevalence of elevated Lp(a) among patients with aortic valve stenosis. Atherosclerosis 2022; 349:144-150. [PMID: 35144769 PMCID: PMC9674369 DOI: 10.1016/j.atherosclerosis.2022.01.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/10/2022] [Accepted: 01/27/2022] [Indexed: 11/25/2022]
Abstract
Background and aims: Lipoprotein(a) [Lp(a)] is causally associated with aortic valve stenosis (AS) but Lp(a) testing among AS patients is not broadly incorporated into clinical practice. We evaluated trends in Lp(a) testing in an academic medical center. Methods: Educational efforts and adding Lp(a) to the lipid panel on the electronic medical record (EMR) and preprocedure order sets were used to increase awareness of Lp(a) as a risk factor in AS. Medical records at University of California San Diego Health (UCSDH) were analyzed from 2010 to 2020 to define the yearly frequency of first time Lp(a) testing in patients with diagnosis codes for AS or undergoing transcatheter aortic valve replacement (TAVR). Results: Lp(a) testing for any indication increased over 5-fold from 2010 to 2020. A total of 3808 patients had a diagnosis of AS and 417 patients had TAVR. Lp(a) levels >30 mg/dL were present in 37% of AS and 35% of TAVR patients. The rates of Lp(a) testing in AS and TAVR were 14.0% and 65.7%, respectively. In AS, Lp(a) testing increased over time from 8.5% in 2010, peaking at 24.2% in 2017, and declining to 13.9% in 2020 (p < 0.001 for trend). Following implementation of EMR order-sets in 2016, Lp(a) testing in TAVR cases increased to a peak of 88.5% in 2018. Conclusions: Elevated Lp(a) is prevalent in AS and TAVR patients. Implementation of educational efforts and practice pathways resulted in increased Lp(a) testing in patients with AS. This study represents a paradigm that may allow increased global awareness of Lp(a) as a risk factor for AS.
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20
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Kaiser Y, Nurmohamed NS, Kroon J, Verberne HJ, Tzolos E, Dweck MR, Somsen AG, Arsenault BJ, Stroes ESG, Zheng KH, Boekholdt SM. Lipoprotein(a) has no major impact on calcification activity in patients with mild to moderate aortic valve stenosis. Heart 2022; 108:61-66. [PMID: 34593533 PMCID: PMC8666821 DOI: 10.1136/heartjnl-2021-319804] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/02/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE To assess whether patients with aortic valve stenosis (AS) with elevated lipoprotein(a) (Lp(a)) are characterised by increased valvular calcification activity compared with those with low Lp(a). METHODS We performed 18F-sodium fluoride (18F-NaF) positron emission tomography/CT in patients with mild to moderate AS (peak aortic jet velocity between 2 and 4 m/s) and high versus low Lp(a) (>50 mg/dL vs <50 mg/dL, respectively). Subjects were matched according to age, gender, peak aortic jet velocity and valve morphology. We used a target to background ratio with the most diseased segment approach to compare 18F-NaF uptake. RESULTS 52 individuals (26 matched pairs) were included in the analysis. The mean age was 66.4±5.5 years, 44 (84.6%) were men, and the mean aortic valve velocity was 2.80±0.49 m/s. The median Lp(a) was 79 (64-117) mg/dL and 7 (5-11) mg/dL in the high and low Lp(a) groups, respectively. Systolic blood pressure and low-density-lipoprotein cholesterol (corrected for Lp(a)) were significantly higher in the low Lp(a) group (141±12 mm Hg vs 128±12 mm Hg, 2.5±1.1 mmol/L vs 1.9±0.8 mmol/L). We found no difference in valvular 18F-NaF uptake between the high and low Lp(a) groups (3.02±1.26 vs 3.05±0.96, p=0.902). Linear regression analysis showed valvular calcium score to be the only significant determinant of valvular 18F-NaF uptake (β=0.63; 95% CI 0.38 to 0.88 per 1000 Agatston unit increase, p<0.001). Lp(a) was not associated with 18F-NaF uptake (β=0.17; 95% CI -0.44 to 0.88, p=0.305 for the high Lp(a) group). CONCLUSION Among patients with mild to moderate AS, calcification activity is predominantly determined by established calcium burden. The results do not support our hypothesis that Lp(a) is associated with valvular 18F-NaF uptake.
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Affiliation(s)
- Yannick Kaiser
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Nick S Nurmohamed
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Jeffrey Kroon
- Department of Experimental Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Evangelos Tzolos
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Aernout G Somsen
- Cardiology Centers of the Netherlands, Amsterdam, The Netherlands
| | - Benoit J Arsenault
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec Canada
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Kang H Zheng
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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21
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Evaluating Medical Therapy for Calcific Aortic Stenosis: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:2354-2376. [PMID: 34857095 DOI: 10.1016/j.jacc.2021.09.1367] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/08/2021] [Accepted: 09/27/2021] [Indexed: 12/23/2022]
Abstract
Despite numerous promising therapeutic targets, there are no proven medical treatments for calcific aortic stenosis (AS). Multiple stakeholders need to come together and several scientific, operational, and trial design challenges must be addressed to capitalize on the recent and emerging mechanistic insights into this prevalent heart valve disease. This review briefly discusses the pathobiology and most promising pharmacologic targets, screening, diagnosis and progression of AS, identification of subgroups that should be targeted in clinical trials, and the need to elicit the patient voice earlier rather than later in clinical trial design and implementation. Potential trial end points and tools for assessment and approaches to implementation and design of clinical trials are reviewed. The efficiencies and advantages offered by a clinical trial network and platform trial approach are highlighted. The objective is to provide practical guidance that will facilitate a series of trials to identify effective medical therapies for AS resulting in expansion of therapeutic options to complement mechanical solutions for late-stage disease.
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22
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Kraler S, Blaser MC, Aikawa E, Camici GG, Lüscher TF. Calcific aortic valve disease: from molecular and cellular mechanisms to medical therapy. Eur Heart J 2021; 43:683-697. [PMID: 34849696 DOI: 10.1093/eurheartj/ehab757] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 09/12/2021] [Accepted: 10/20/2021] [Indexed: 12/12/2022] Open
Abstract
Calcific aortic valve disease (CAVD) is a highly prevalent condition that comprises a disease continuum, ranging from microscopic changes to profound fibro-calcific leaflet remodelling, culminating in aortic stenosis, heart failure, and ultimately premature death. Traditional risk factors, such as hypercholesterolaemia and (systolic) hypertension, are shared among atherosclerotic cardiovascular disease and CAVD, yet the molecular and cellular mechanisms differ markedly. Statin-induced low-density lipoprotein cholesterol lowering, a remedy highly effective for secondary prevention of atherosclerotic cardiovascular disease, consistently failed to impact CAVD progression or to improve patient outcomes. However, recently completed phase II trials provide hope that pharmaceutical tactics directed at other targets implicated in CAVD pathogenesis offer an avenue to alter the course of the disease non-invasively. Herein, we delineate key players of CAVD pathobiology, outline mechanisms that entail compromised endothelial barrier function, and promote lipid homing, immune-cell infiltration, and deranged phospho-calcium metabolism that collectively perpetuate a pro-inflammatory/pro-osteogenic milieu in which valvular interstitial cells increasingly adopt myofibro-/osteoblast-like properties, thereby fostering fibro-calcific leaflet remodelling and eventually resulting in left ventricular outflow obstruction. We provide a glimpse into the most promising targets on the horizon, including lipoprotein(a), mineral-binding matrix Gla protein, soluble guanylate cyclase, dipeptidyl peptidase-4 as well as candidates involved in regulating phospho-calcium metabolism and valvular angiotensin II synthesis and ultimately discuss their potential for a future therapy of this insidious disease.
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Affiliation(s)
- Simon Kraler
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland.,University Heart Center, Department of Cardiology, University Hospital, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Mark C Blaser
- Center for Interdisciplinary Cardiovascular Sciences, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 3 Blackfan Street, Boston, MA 02115, USA
| | - Elena Aikawa
- Center for Interdisciplinary Cardiovascular Sciences, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 3 Blackfan Street, Boston, MA 02115, USA.,Center for Excellence in Vascular Biology, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 77 Ave Louis Pasteur, NRB7, Boston, MA 02115, USA
| | - Giovanni G Camici
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland.,University Heart Center, Department of Cardiology, University Hospital, Rämistrasse 100, 8091 Zurich, Switzerland.,Department of Research and Education, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952 Schlieren, Switzerland.,Heart Division, Royal Brompton & Harefield Hospitals, Sydney Street, London SW3 6NP, UK.,National Heart and Lung Institute, Imperial College, Guy Scadding Building, Dovehouse Street, London SW3 6LY, UK
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Lipoprotein (a) and Cardiovascular Disease: A Missing Link for Premature Atherosclerotic Heart Disease and/or Residual Risk. J Cardiovasc Pharmacol 2021; 79:e18-e35. [PMID: 34694242 DOI: 10.1097/fjc.0000000000001160] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/30/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Lipoprotein(a) or lipoprotein "little a" is an under-recognized causal risk factor for cardiovascular (CV) disease (CVD), including coronary atherosclerosis, aortic valvular stenosis, ischemic stroke, heart failure and peripheral arterial disease. Elevated plasma Lp(a) (≥50 mg/dL or ≥100 nmol/L) is commonly encountered in almost 1 in 5 individuals and confers a higher CV risk compared to those with normal Lp(a) levels, although such normal levels have not been generally agreed upon. Elevated Lp(a) is considered a cause of premature and accelerated atherosclerotic CVD. Thus, in patients with a positive family or personal history of premature coronary artery disease (CAD), Lp(a) should be measured. However, elevated Lp(a) may confer increased risk for incident CAD even in the absence of a family history of CAD, and even in those who have guideline-lowered LDL-cholesterol (<70 mg/dl) and continue to have a persisting CV residual risk. Thus, measurement of Lp(a) will have a significant clinical impact on the assessment of atherosclerotic CVD risk, and will assume a more important role in managing patients with CVD with the advent and clinical application of specific Lp(a)-lowering therapies. Conventional therapeutic approaches like lifestyle modification and statin therapy remain ineffective at lowering Lp(a). Newer treatment modalities, such as gene silencing via RNA interference with use of antisense oligonucleotide(s) or small interfering RNA molecules targeting Lp(a) seem very promising. These issues are herein reviewed, accumulated data are scrutinized, meta-analyses and current guidelines are tabulated and Lp(a)-related CVDs and newer therapeutic modalities are pictorially illustrated.
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Affiliation(s)
- Kwan-Leung Chan
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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25
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Martinez LO, Perret B, Genoux A. Update on proprotein convertase subtilisin/kexin type 9 inhibitors, lipoprotein(a) and cardiovascular risk. Curr Opin Lipidol 2021; 32:324-327. [PMID: 34472540 DOI: 10.1097/mol.0000000000000771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Laurent O Martinez
- I2MC, Université de Toulouse, Inserm, Université Toulouse III - Paul Sabatier (UPS)
| | - Bertrand Perret
- I2MC, Université de Toulouse, Inserm, Université Toulouse III - Paul Sabatier (UPS)
- Service de Biochimie, Pôle de biologie, Hôpital de Purpan, CHU de Toulouse, Toulouse, France
| | - Annelise Genoux
- I2MC, Université de Toulouse, Inserm, Université Toulouse III - Paul Sabatier (UPS)
- Service de Biochimie, Pôle de biologie, Hôpital de Purpan, CHU de Toulouse, Toulouse, France
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26
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Affiliation(s)
- Evangelos Tzolos
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Marc Richard Dweck
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
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Abstract
PURPOSE OF REVIEW Calcific aortic stenosis (CAVS) is the most common form of valvular heart disease in developed countries, increasing in prevalence with the aging population. Surgical or transcatheter aortic valve replacement is the only treatment available for CAVS. However, these interventions are typically reserved for severe symptomatic aortic stenosis (AS). The purpose of this review is to summarize the recent literature in uncovering the underlying pathophysiology of CAVS in the setting of lipoprotein (a) [Lp(a)] and emerging therapies targeting Lp(a) which may help halt disease progression in CAVS. RECENT FINDINGS Pathophysiologic, epidemiological, and genetic studies over the past two decades have provided strong evidence that Lp(a) is an important mediator of calcific aortic valvular disease (CAVD). Studies suggest that Lp(a) is a key carrier of pro-calcifying oxidized phospholipids (OxPL). The metabolism of OxPL results in a pro-inflammatory state and subsequent valvular thickening and mineralization through pro-osteogenic signaling. The identification of Lp(a) as a causal mediator of CAVD has allowed for opportunities for emerging therapeutic agents which may slow the progression of CAVD (Fig. 1JOURNAL/cocar/04.03/00001573-202109000-00007/figure1/v/2021-08-04T080204Z/r/image-jpeg). SUMMARY This review summarizes the current knowledge on the association of Lp(a) with CAVD and ongoing studies of potential Lp(a)-lowering therapies. Based on the rate-limiting and causal role of Lp(a) in progression of CAVS, these therapies may represent novel pharmacotherapies in AS and inform the developing role of Lp(a) in the clinical management of CAVD.
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Guertin J, Kaiser Y, Manikpurage H, Perrot N, Bourgeois R, Couture C, Wareham NJ, Bossé Y, Pibarot P, Stroes ESG, Mathieu P, Clavel MA, Thériault S, Boekholdt SM, Arsenault BJ. Sex-Specific Associations of Genetically Predicted Circulating Lp(a) (Lipoprotein(a)) and Hepatic LPA Gene Expression Levels With Cardiovascular Outcomes: Mendelian Randomization and Observational Analyses. CIRCULATION. GENOMIC AND PRECISION MEDICINE 2021; 14:e003271. [PMID: 34279996 DOI: 10.1161/circgen.120.003271] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Elevated Lp(a) (Lipoprotein(a)) levels are associated with coronary artery disease (CAD), ischemic stroke (IS), and calcific aortic valve stenosis (CAVS). Studies investigating the association between Lp(a) levels and these diseases in women have yielded inconsistent results. METHODS To investigate the association of Lp(a) with sex-specific cardiovascular outcomes, we determined the association between genetically predicted Lp(a) levels (using 27 single nucleotide polymorphisms at the LPA locus) and hepatic LPA expression (using 80 single nucleotide polymorphisms at the LPA locus associated with LPA mRNA expression in liver samples from the Genotype-Tissue Expression dataset) on CAD, IS, and CAVS using individual participant data from the UK Biobank: 408 403 participants of European ancestry (37 102, 4283, and 2574 with prevalent CAD, IS, and CAVS, respectively). The long-term association between Lp(a) levels and incident CAD, IS, and CAVS was also investigated in European Prospective Investigation into Cancer and Nutrition-Norfolk: 18 721 participants (3964, 846, and 424 with incident CAD, IS, and CAVS, respectively). RESULTS Genetically predicted plasma Lp(a) levels were positively and similarly associated with prevalent and incident CAD and CAVS in men and women. Genetically predicted plasma Lp(a) levels were associated with prevalent and incident IS when we studied men and women pooled together, and in men only. Genetically predicted LPA expression levels were associated with prevalent CAD and CAVS in men and women but not with IS. CONCLUSIONS Genetically predicted blood Lp(a) and hepatic LPA gene expression as well as serum Lp(a) levels predict the risk of CAD and CAVS in men and in women. Whether RNA interference therapies aiming at lowering Lp(a) levels could be useful in reducing cardiovascular disease risk in both men and women with high Lp(a) levels needs to be determined in large-scale cardiovascular outcomes trials.
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Affiliation(s)
- Jakie Guertin
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (J.G., H.M., N.P., R.B., C.C., Y.B., P.P., P.M., M.-A.C., S.T., B.J.A.).,Department of Medicine (J.G., R.B., P.P., M.-A.C., B.J.A.), Faculty of Medicine, Université Laval, Québec, Canada
| | - Yannick Kaiser
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, the Netherlands (Y.K., E.S.G.S., S.M.B.)
| | - Hasanga Manikpurage
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (J.G., H.M., N.P., R.B., C.C., Y.B., P.P., P.M., M.-A.C., S.T., B.J.A.)
| | - Nicolas Perrot
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (J.G., H.M., N.P., R.B., C.C., Y.B., P.P., P.M., M.-A.C., S.T., B.J.A.)
| | - Raphaëlle Bourgeois
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (J.G., H.M., N.P., R.B., C.C., Y.B., P.P., P.M., M.-A.C., S.T., B.J.A.).,Department of Medicine (J.G., R.B., P.P., M.-A.C., B.J.A.), Faculty of Medicine, Université Laval, Québec, Canada
| | - Christian Couture
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (J.G., H.M., N.P., R.B., C.C., Y.B., P.P., P.M., M.-A.C., S.T., B.J.A.)
| | - Nicholas J Wareham
- Department of Public Health and Primary Care, University of Cambridge, United Kingdom (N.J.W.)
| | - Yohan Bossé
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (J.G., H.M., N.P., R.B., C.C., Y.B., P.P., P.M., M.-A.C., S.T., B.J.A.).,Department of Molecular Medicine (Y.B.), Faculty of Medicine, Université Laval, Québec, Canada
| | - Philippe Pibarot
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (J.G., H.M., N.P., R.B., C.C., Y.B., P.P., P.M., M.-A.C., S.T., B.J.A.).,Department of Medicine (J.G., R.B., P.P., M.-A.C., B.J.A.), Faculty of Medicine, Université Laval, Québec, Canada
| | - Erik S G Stroes
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, the Netherlands (Y.K., E.S.G.S., S.M.B.)
| | - Patrick Mathieu
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (J.G., H.M., N.P., R.B., C.C., Y.B., P.P., P.M., M.-A.C., S.T., B.J.A.).,Department of Surgery (P.M.), Faculty of Medicine, Université Laval, Québec, Canada
| | - Marie-Annick Clavel
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (J.G., H.M., N.P., R.B., C.C., Y.B., P.P., P.M., M.-A.C., S.T., B.J.A.).,Department of Medicine (J.G., R.B., P.P., M.-A.C., B.J.A.), Faculty of Medicine, Université Laval, Québec, Canada
| | - Sébastien Thériault
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (J.G., H.M., N.P., R.B., C.C., Y.B., P.P., P.M., M.-A.C., S.T., B.J.A.).,Department of Molecular Biology, Medical Biochemistry and Pathology (S.T.), Faculty of Medicine, Université Laval, Québec, Canada
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, the Netherlands (Y.K., E.S.G.S., S.M.B.)
| | - Benoit J Arsenault
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (J.G., H.M., N.P., R.B., C.C., Y.B., P.P., P.M., M.-A.C., S.T., B.J.A.).,Department of Medicine (J.G., R.B., P.P., M.-A.C., B.J.A.), Faculty of Medicine, Université Laval, Québec, Canada
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29
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Bourgeois R, Bourgault J, Despres AA, Perrot N, Guertin J, Girard A, Mitchell PL, Gotti C, Bourassa S, Scipione CA, Gaudreault N, Boffa MB, Koschinsky ML, Pibarot P, Droit A, Thériault S, Mathieu P, Bossé Y, Arsenault BJ. Lipoprotein Proteomics and Aortic Valve Transcriptomics Identify Biological Pathways Linking Lipoprotein(a) Levels to Aortic Stenosis. Metabolites 2021; 11:metabo11070459. [PMID: 34357353 PMCID: PMC8307014 DOI: 10.3390/metabo11070459] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 12/17/2022] Open
Abstract
Lipoprotein(a) (Lp(a)) is one of the most important risk factors for the development of calcific aortic valve stenosis (CAVS). However, the mechanisms through which Lp(a) causes CAVS are currently unknown. Our objectives were to characterize the Lp(a) proteome and to identify proteins that may be differentially associated with Lp(a) in patients with versus without CAVS. Our second objective was to identify genes that may be differentially regulated by exposure to high versus low Lp(a) levels in explanted aortic valves from patients with CAVS. We isolated Lp(a) from the blood of 21 patients with CAVS and 22 volunteers and performed untargeted label-free analysis of the Lp(a) proteome. We also investigated the transcriptomic signature of calcified aortic valves from patients who underwent aortic valve replacement with high versus low Lp(a) levels (n = 118). Proteins involved in the protein activation cascade, platelet degranulation, leukocyte migration, and response to wounding may be associated with Lp(a) depending on CAVS status. The transcriptomic analysis identified genes involved in cardiac aging, chondrocyte development, and inflammation as potentially influenced by Lp(a). Our multi-omic analyses identified biological pathways through which Lp(a) may cause CAVS, as well as key molecular events that could be triggered by Lp(a) in CAVS development.
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Affiliation(s)
- Raphaëlle Bourgeois
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC G1V 4G5, Canada; (R.B.); (J.B.); (A.-A.D.); (N.P.); (J.G.); (A.G.); (P.L.M.); (N.G.); (P.P.); (S.T.); (P.M.); (Y.B.)
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
| | - Jérôme Bourgault
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC G1V 4G5, Canada; (R.B.); (J.B.); (A.-A.D.); (N.P.); (J.G.); (A.G.); (P.L.M.); (N.G.); (P.P.); (S.T.); (P.M.); (Y.B.)
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
| | - Audrey-Anne Despres
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC G1V 4G5, Canada; (R.B.); (J.B.); (A.-A.D.); (N.P.); (J.G.); (A.G.); (P.L.M.); (N.G.); (P.P.); (S.T.); (P.M.); (Y.B.)
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
| | - Nicolas Perrot
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC G1V 4G5, Canada; (R.B.); (J.B.); (A.-A.D.); (N.P.); (J.G.); (A.G.); (P.L.M.); (N.G.); (P.P.); (S.T.); (P.M.); (Y.B.)
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
| | - Jakie Guertin
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC G1V 4G5, Canada; (R.B.); (J.B.); (A.-A.D.); (N.P.); (J.G.); (A.G.); (P.L.M.); (N.G.); (P.P.); (S.T.); (P.M.); (Y.B.)
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
| | - Arnaud Girard
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC G1V 4G5, Canada; (R.B.); (J.B.); (A.-A.D.); (N.P.); (J.G.); (A.G.); (P.L.M.); (N.G.); (P.P.); (S.T.); (P.M.); (Y.B.)
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
| | - Patricia L. Mitchell
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC G1V 4G5, Canada; (R.B.); (J.B.); (A.-A.D.); (N.P.); (J.G.); (A.G.); (P.L.M.); (N.G.); (P.P.); (S.T.); (P.M.); (Y.B.)
| | - Clarisse Gotti
- Proteomics Platform of the CHU de Québec, QC G1V 4G2, Canada; (C.G.); (S.B.); (A.D.)
| | - Sylvie Bourassa
- Proteomics Platform of the CHU de Québec, QC G1V 4G2, Canada; (C.G.); (S.B.); (A.D.)
| | - Corey A. Scipione
- Toronto General Research Institute, University Health Network, Toronto, ON M5G 2C4, Canada;
| | - Nathalie Gaudreault
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC G1V 4G5, Canada; (R.B.); (J.B.); (A.-A.D.); (N.P.); (J.G.); (A.G.); (P.L.M.); (N.G.); (P.P.); (S.T.); (P.M.); (Y.B.)
| | - Michael B. Boffa
- Robarts Research Institute, London, ON N6A 5B7, Canada; (M.B.B.); (M.L.K.)
| | | | - Philippe Pibarot
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC G1V 4G5, Canada; (R.B.); (J.B.); (A.-A.D.); (N.P.); (J.G.); (A.G.); (P.L.M.); (N.G.); (P.P.); (S.T.); (P.M.); (Y.B.)
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
| | - Arnaud Droit
- Proteomics Platform of the CHU de Québec, QC G1V 4G2, Canada; (C.G.); (S.B.); (A.D.)
- Centre de Recherche du CHU de Québec, Québec, QC G1V 4G2, Canada
| | - Sébastien Thériault
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC G1V 4G5, Canada; (R.B.); (J.B.); (A.-A.D.); (N.P.); (J.G.); (A.G.); (P.L.M.); (N.G.); (P.P.); (S.T.); (P.M.); (Y.B.)
- Department of Molecular Biology, Medical Biochemistry and Pathology, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
| | - Patrick Mathieu
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC G1V 4G5, Canada; (R.B.); (J.B.); (A.-A.D.); (N.P.); (J.G.); (A.G.); (P.L.M.); (N.G.); (P.P.); (S.T.); (P.M.); (Y.B.)
- Department of Surgery, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
| | - Yohan Bossé
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC G1V 4G5, Canada; (R.B.); (J.B.); (A.-A.D.); (N.P.); (J.G.); (A.G.); (P.L.M.); (N.G.); (P.P.); (S.T.); (P.M.); (Y.B.)
- Department of Molecular Medicine, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
| | - Benoit J. Arsenault
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC G1V 4G5, Canada; (R.B.); (J.B.); (A.-A.D.); (N.P.); (J.G.); (A.G.); (P.L.M.); (N.G.); (P.P.); (S.T.); (P.M.); (Y.B.)
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
- Correspondence: ; Tel.: +1-418-656-8711 (ext. 3498)
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30
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Donato M, Ferri N, Lupo MG, Faggin E, Rattazzi M. Current Evidence and Future Perspectives on Pharmacological Treatment of Calcific Aortic Valve Stenosis. Int J Mol Sci 2020; 21:ijms21218263. [PMID: 33158204 PMCID: PMC7663524 DOI: 10.3390/ijms21218263] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 10/31/2020] [Accepted: 11/02/2020] [Indexed: 02/07/2023] Open
Abstract
Calcific aortic valve stenosis (CAVS), the most common heart valve disease, is characterized by the slow progressive fibro-calcific remodeling of the valve leaflets, leading to progressive obstruction to the blood flow. CAVS is an increasing health care burden and the development of an effective medical treatment is a major medical need. To date, no effective pharmacological therapies have proven to halt or delay its progression to the severe symptomatic stage and aortic valve replacement represents the only available option to improve clinical outcomes and to increase survival. In the present report, the current knowledge and latest advances in the medical management of patients with CAVS are summarized, placing emphasis on lipid-lowering agents, vasoactive drugs, and anti-calcific treatments. In addition, novel potential therapeutic targets recently identified and currently under investigation are reported.
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Affiliation(s)
- Maristella Donato
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, 35122 Padova, Italy; (M.D.); (N.F.); (M.G.L.)
| | - Nicola Ferri
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, 35122 Padova, Italy; (M.D.); (N.F.); (M.G.L.)
| | - Maria Giovanna Lupo
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, 35122 Padova, Italy; (M.D.); (N.F.); (M.G.L.)
| | - Elisabetta Faggin
- Department of Medicine—DIMED, University of Padova, 35122 Padova, Italy;
| | - Marcello Rattazzi
- Department of Medicine—DIMED, University of Padova, 35122 Padova, Italy;
- Correspondence: ; Tel.: +39-0498-211-867 or +39-0422-322-207
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31
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Pokrovsky SN, Afanasieva OI, Ezhov MV. Therapeutic Apheresis for Management of Lp(a) Hyperlipoproteinemia. Curr Atheroscler Rep 2020; 22:68. [DOI: 10.1007/s11883-020-00886-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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32
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Pedriali G, Morciano G, Patergnani S, Cimaglia P, Morelli C, Mikus E, Ferrari R, Gasbarro V, Giorgi C, Wieckowski MR, Pinton P. Aortic Valve Stenosis and Mitochondrial Dysfunctions: Clinical and Molecular Perspectives. Int J Mol Sci 2020; 21:ijms21144899. [PMID: 32664529 PMCID: PMC7402290 DOI: 10.3390/ijms21144899] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/08/2023] Open
Abstract
Calcific aortic stenosis is a disorder that impacts the physiology of heart valves. Fibrocalcific events progress in conjunction with thickening of the valve leaflets. Over the years, these events promote stenosis and obstruction of blood flow. Known and common risk factors are congenital defects, aging and metabolic syndromes linked to high plasma levels of lipoproteins. Inflammation and oxidative stress are the main molecular mediators of the evolution of aortic stenosis in patients and these mediators regulate both the degradation and remodeling processes. Mitochondrial dysfunction and dysregulation of autophagy also contribute to the disease. A better understanding of these cellular impairments might help to develop new ways to treat patients since, at the moment, there is no effective medical treatment to diminish neither the advancement of valve stenosis nor the left ventricular function impairments, and the current approaches are surgical treatment or transcatheter aortic valve replacement with prosthesis.
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Affiliation(s)
- Gaia Pedriali
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, 48033 Ravenna, Italy; (G.P.); (G.M.); (S.P.); (R.F.)
| | - Giampaolo Morciano
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, 48033 Ravenna, Italy; (G.P.); (G.M.); (S.P.); (R.F.)
- Department of Medical Sciences, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, 44121 Ferrara, Italy; (V.G.); (C.G.)
| | - Simone Patergnani
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, 48033 Ravenna, Italy; (G.P.); (G.M.); (S.P.); (R.F.)
- Department of Medical Sciences, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, 44121 Ferrara, Italy; (V.G.); (C.G.)
| | - Paolo Cimaglia
- Cardiovascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola, 48033 Ravenna, Italy; (P.C.); (E.M.)
| | - Cristina Morelli
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, 44121 Ferrara, Italy;
| | - Elisa Mikus
- Cardiovascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola, 48033 Ravenna, Italy; (P.C.); (E.M.)
| | - Roberto Ferrari
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, 48033 Ravenna, Italy; (G.P.); (G.M.); (S.P.); (R.F.)
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, 44121 Ferrara, Italy;
| | - Vincenzo Gasbarro
- Department of Medical Sciences, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, 44121 Ferrara, Italy; (V.G.); (C.G.)
| | - Carlotta Giorgi
- Department of Medical Sciences, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, 44121 Ferrara, Italy; (V.G.); (C.G.)
| | - Mariusz R. Wieckowski
- Laboratory of Mitochondrial Biology and Metabolism, Nencki Institute of Experimental Biology, Pasteur 3, 02-093 Warsaw, Poland;
| | - Paolo Pinton
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, 48033 Ravenna, Italy; (G.P.); (G.M.); (S.P.); (R.F.)
- Department of Medical Sciences, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, 44121 Ferrara, Italy; (V.G.); (C.G.)
- Correspondence: ; Tel.: +0532-455802
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Rajamannan NM, Moura LM, Best P. Bench to bedside defining calcific aortic valve disease: osteocardiology. Expert Rev Cardiovasc Ther 2020; 18:239-247. [PMID: 32319841 DOI: 10.1080/14779072.2020.1757431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION For years, calcific aortic valve disease (CAVD) was thought to be due to a degenerative process, but recent scientific discoveries have proven it to be an active process. Understanding the cellular mechanisms for the development of disease and translating the cellular changes critical in the development of calcific phenotypes. The use of multimodality imaging has been the gold standard to define the development of calcification to determine the timing of therapy. AREAS COVERED This review will discuss the scientific literature in a new and evolving field known as osteocardiology, which specifically defines the cellular mechanisms involved in the development of the osteogenic phenotype in the heart and vasculature. The work in this field has been highlighted by the calcific aortic valve disease working group at the NIH. This review will discuss the appropriate use criteria for multimodality imaging techniques to identify early cellular and hemodynamic disease progression in the aortic valve to help determine the timing of therapy, the osteocardiology theory. EXPERT OPINION The authors will provide their background in basic science and clinical medicine to support the opinions in this paper.
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Affiliation(s)
- Nalini M Rajamannan
- Division of Biochemistry and Molecular Biology, Visiting Scientist Mayo Clinic , Rochester, MN, USA.,Most Sacred Heart of Jesus Cardiology and Valvular Institute , Sheboygan, MN, USA
| | - Luis M Moura
- Faculty of Medicine and 3s Institute of Research and the Innovation in Health, University of Porto Hospital Lusiadas, Porto, Portugal
| | - Patricia Best
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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de Oliveira Sá MPB, Cavalcanti LRP, Perazzo ÁM, Gomes RAF, Clavel MA, Pibarot P, Biondi-Zoccai G, Zhigalov K, Weymann A, Ruhparwar A, Lima RC. Calcific Aortic Valve Stenosis and Atherosclerotic Calcification. Curr Atheroscler Rep 2020; 22:2. [PMID: 31912380 DOI: 10.1007/s11883-020-0821-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This review summarizes the pathophysiology of calcific aortic valve stenosis (CAVS) and surveys relevant clinical data and basic research that explain how CAVS arises. RECENT FINDINGS Lipoprotein(a) [Lp(a)], lipoprotein-associated phospholipase A2 (Lp-PLA2), oxidized phospholipids (OxPL), autotaxin, and genetic driving forces such as mutations in LPA gene and NOTCH gene seem to play a major role in the development of CAVS. These factors might well become targets of medical therapy in the coming years. CVAS seems to be a multifactorial disease that has much in common with coronary artery disease, mainly regarding lipidic accumulation and calcium deposition. No clinical trials conducted to date have managed to answer the key question of whether Lp(a) lowering and anti-calcific therapies confer a benefit in terms of reducing incidence or progression of CAVS, although additional outcome trials are ongoing.
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Affiliation(s)
- Michel Pompeu Barros de Oliveira Sá
- Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco, PROCAPE, Av. Eng. Domingos Ferreira n°4172. Edf. Paquetá, apt° 405, Recife, Pernambuco, 51021-040, Brazil. .,University of Pernambuco, UPE, Recife, Brazil. .,Nucleus of Postgraduate and Research in Health Sciences of Faculty of Medical Sciences and Biological Sciences Instituite, FCM/ICB, Recife, Brazil.
| | - Luiz Rafael P Cavalcanti
- Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco, PROCAPE, Av. Eng. Domingos Ferreira n°4172. Edf. Paquetá, apt° 405, Recife, Pernambuco, 51021-040, Brazil.,University of Pernambuco, UPE, Recife, Brazil
| | - Álvaro M Perazzo
- Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco, PROCAPE, Av. Eng. Domingos Ferreira n°4172. Edf. Paquetá, apt° 405, Recife, Pernambuco, 51021-040, Brazil.,University of Pernambuco, UPE, Recife, Brazil
| | - Rafael A F Gomes
- Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco, PROCAPE, Av. Eng. Domingos Ferreira n°4172. Edf. Paquetá, apt° 405, Recife, Pernambuco, 51021-040, Brazil.,University of Pernambuco, UPE, Recife, Brazil.,Nucleus of Postgraduate and Research in Health Sciences of Faculty of Medical Sciences and Biological Sciences Instituite, FCM/ICB, Recife, Brazil
| | - Marie-Annick Clavel
- Québec Heart and Lung Institute/Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, 2725 Chemin Sainte Foy, #A-2075, Quebec, QC, G1V4G5, Canada
| | - Philippe Pibarot
- Québec Heart and Lung Institute/Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, 2725 Chemin Sainte Foy, #A-2075, Quebec, QC, G1V4G5, Canada
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Mediterranea Cardiocentro, Naples, Italy
| | - Konstantin Zhigalov
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Ricardo Carvalho Lima
- Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco, PROCAPE, Av. Eng. Domingos Ferreira n°4172. Edf. Paquetá, apt° 405, Recife, Pernambuco, 51021-040, Brazil.,University of Pernambuco, UPE, Recife, Brazil.,Nucleus of Postgraduate and Research in Health Sciences of Faculty of Medical Sciences and Biological Sciences Instituite, FCM/ICB, Recife, Brazil
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