New Cholesterol Guidelines for the Management of Atherosclerotic Cardiovascular Disease Risk: A Comparison of the 2013 American College of Cardiology/American Heart Association Cholesterol Guidelines with the 2014 National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia

Safety and efficacy of dyslipidemia treatment in NAFLD patients: a meta-analysis of randomized controlled trials

INTRODUCTION AND OBJECTIVES

Practicing physicians often hesitate to use statins and/or other lipid-lowering therapies in NAFLD due to concern for hepatotoxicity. The aim of this study is to examine the safety of lipid lowering therapies in NAFLD patients.

MATERIALS AND METHODS

Data from randomized control trials (RCT) among NAFLD patients were pooled to examine the effect of lipid-lowering therapies on liver chemistry, lipid profile, and liver histology. Results are reported as the mean difference of the change (pretreatment-posttreatment) between the treatment and control group.

RESULTS

A total of 21 placebo-controlled RCT on 1900 patients (304 receiving statins, 520 other lipid-lowering therapies, and 61 combinations) were treated for 26 weeks [Interquartile range (IQR): 17.5-52 weeks]. Pooled data showed an improved lipid profile without any worsening of ALT, AST, total bilirubin, or alkaline phosphatase at the end of the treatment period. NAFLD activity score improved with other lipid-lowering agents but not with statins. There was no change in individual components of NAFLD activity score or fibrosis stage.

CONCLUSION

This meta-analysis of randomized controlled trials examining statins and/or other lipid-lowering therapies in NAFLD patients showed no evidence of worsening liver chemistry. Studies with longer use of lipid-lowering therapies are suggested to examine the benefit of liver histology among patients with NAFLD.

Association of Low-Density Lipoprotein Cholesterol Levels During Statin Treatment With Cardiovascular and Renal Outcomes in Patients With Moderate Chronic Kidney Disease

Background The benefit of low-density lipoprotein cholesterol (LDL-C) levels in chronic kidney disease populations remains unclear. This study evaluated the cardiovascular and renal outcomes in patients with stage 3 chronic kidney disease with different LDL-C levels during statin treatment. Methods and Results There were 8500 patients newly diagnosed as having stage 3 chronic kidney disease under statin treatment who were identified from the Chang Gung Research Database and divided into 3 groups according to their first LDL-C level after the index date: <70 mg/dL, 70 to 100 mg/dL, and >100 mg/dL. Inverse probability of treatment weighting was performed to balance baseline characteristics. Compared with the LDL-C ≥100 mg/dL group, the 70≤LDL-C<100 mg/dL group exhibited significantly lower risks of major adverse cardiac and cerebrovascular events (6.8% versus 8.8%; subdistribution hazard ratio [SHR], 0.76 [95% CI, 0.64-0.91]), intracerebral hemorrhage (0.23% versus 0.51%; SHR, 0.44 [95% CI, 0.25-0.77]), and new-onset end-stage renal disease requiring chronic dialysis (7.6% versus 9.1%; SHR, 0.82 [95% CI, 0.73-0.91]). By contrast, the LDL-C <70 mg/dL group exhibited a marginally lower risk of major adverse cardiac and cerebrovascular events (7.3% versus 8.8%; SHR, 0.82 [95% CI, 0.65-1.02]) and a significantly lower risk of new-onset end-stage renal disease requiring chronic dialysis (7.1% versus 9.1%; SHR, 0.76 [95% CI, 0.67-0.85]). Conclusions Among patients with stage 3 chronic kidney disease, statin users with 70≤LDL-C<100 mg/dL and with LDL-C <70 mg/dL had similar beneficial effect in the reduction of risks of major adverse cardiac and cerebrovascular events and new-onset end-stage renal disease compared with those with LDL-C >100 mg/dL. Moreover, the 70≤LDL-C<100 mg/dL group seemed to have a lowest risk of intracerebral hemorrhage, although the incidence was low.

The Potential of the Marine Microalga Diacronema lutheri in the Prevention of Obesity and Metabolic Syndrome in High-Fat-Fed Wistar Rats

Long-chain polyunsaturated fatty acids n-3 series (n-3 LC-PUFAs), especially eicosapentaenoic and docosahexaenoic acids, are known to exert preventive effects on obesity and metabolic syndrome. Mainly consumed in the form of fish oil, LC-PUFAs n-3 are also found in significant quantities in other sources such as certain microalgae. The aim of this study was to evaluate the effects of Diacronema lutheri (Dia), a microalga rich in n-3 LC-PUFAs, on metabolic disorders associated with obesity. Three groups of male Wistar rats (n = 6 per group) were submitted for eight weeks to a standard diet or high-fat and high-fructose diet (HF), supplemented or not with 12% of Dia (HF-Dia). Compared to HF rats, HF-Dia rats showed a 41% decrease in plasma triacylglycerol (TAG) and an increase in plasma cholesterol (+35%) as well as in high-density lipoprotein cholesterol (+51%) without change to low-density lipoprotein cholesterol levels. Although fasting glycemia did not change, glucose and insulin tolerance tests highlighted an improvement in glucose and insulin homeostasis. Dia supplementation restored body weight and fat mass, and decreased levels of liver TAG (−75%) and cholesterol (−84%). In HF-Dia rats, leptin was decreased (−30%) below the control level corresponding to a reduction of 68% compared to HF rats. Similarly, the anti-inflammatory cytokines interleukin-4 (IL-4) and IL-10 were restored up to control levels, corresponding to a 74% and 58% increase in HF rats, respectively. In contrast, the level of IL-6 remained similar in the HF and HF-Dia groups and about twice that of the control. In conclusion, these results indicated that the D. lutheri microalga may be beneficial for the prevention of weight gain and improvement in lipid and glucose homeostasis.

The Marine Microalga, Tisochrysis lutea, Protects against Metabolic Disorders Associated with Metabolic Syndrome and Obesity

Long-chain polyunsaturated fatty acids n-3 series and especially docosahexaenoic acid are known to exert preventive effects on metabolic disturbances associated with obesity and decrease cardiovascular disease risk. n-3 LC-PUFAs are mainly consumed in the form of fish oil, while other sources, such as certain microalgae, may contain a high content of these fatty acids. The aim of this study was to evaluate the effects of Tisochrysis lutea (Tiso), a microalga rich in DHA, on metabolic disorders associated with obesity. Three male Wistar rat groups were submitted for eight weeks to a standard diet or high-fat and high fructose diet (HF), supplemented or not with 12% of T. lutea (HF-Tiso). The supplementation did not affect plasma alanine aminotransferase (ALAT). Bodyweight, glycemia and insulinemia decreased in HF-Tiso rats (ANOVA, p < 0.001), while total plasma cholesterol, high-density lipoprotein-cholesterol (HDL-C) increased (ANOVA, p < 0.001) without change of low-density lipoprotein-cholesterol (LDL-C) and triacylglycerol (TAG) levels. Tiso supplementation decreased fat mass and leptinemia as well as liver TAG, cholesterol and plasma tumor necrosis factor-alpha levels (ANOVA, p < 0.001) while it did not affect interleukin 6 (IL-6), IL-4 and lipopolysaccharides levels. HF-Tiso rats showed an increase of IL-10 level in abdominal adipose tissue (ANOVA, p < 0.001). In conclusion, these results indicated that DHA-rich T. lutea might be beneficial for the prevention of obesity and improvement of lipid and glucose metabolism.

Association between serum non-high-density lipoprotein cholesterol and cognitive dysfunction after acute ischemic stroke: a cross-sectional study

This study aimed to explore the association between serum non-high-density lipoprotein cholesterol (non-HDL-C) and cognitive dysfunction risk in patients with acute ischemic stroke (AIS). This cross-sectional study enrolled 583 AIS patients. Biochemical markers and lipid profile were collected after admission. AIS patients were classified into high group (non-HDL-C ≥3.4 mM) and normal group (non-HDL-C <3.4 mM). Mini-Mental State Examination scale (MMSE), Montreal Cognitive Assessment scale (MoCA), Activities of Daily Living (ADL) scale, Neuropsychiatric Inventory (NPI), and Hamilton Depression scale 21 version (HAMD-21) were applied on the third day after admission. Compared with the control group, patients of the high group had higher body mass index and higher frequency of intracranial artery stenosis, and exhibited higher levels of non-HDL-C, total cholesterol, triglycerides, low-density lipoprotein cholesterol, homocysteine, fasting blood glucose, and glycosylated hemoglobin (HbA1c), and lower levels of high-density lipoprotein cholesterol (all P<0.05). Compared with the control group, patients of the high group had significantly lower MMSE and MoCA scores (MMSE: 26.01±4.17 vs 23.12±4.73, P<0.001; MoCA: 22.28±5.28 vs 20.25±5.87, P<0.001) and higher scores on the NPI and HAMD-21 (both P<0.001). MMSE (r=-0.306, P<0.001) and MoCA scores (r=-0.251, P<0.001) were negatively associated with non-HDL-C level. Multivariate regression analysis revealed that non-HDL-C level (OR=1.361, 95%CI: 1.059-1.729, P=0.016) was independently associated with the presence of cognitive dysfunction after adjusting for confounding factors. High serum non-HDL-C level might significantly increase the risk of cognitive dysfunction after AIS.

Inflammatory bowel disease and the risk of cardiovascular diseases

Inflammatory bowel disease (IBD) includes both ulcerative colitis and Crohn's disease, which are well recognised as chronic systemic and immune-mediated conditions that frequently involve extraintestinal manifestations. Although comorbidities have long been the subject of research in other chronic inflammatory diseases, this concept is also emerging in IBD. Many pathologies have been linked to IBD, including cardiovascular disease, which is the main cause of death in developed countries. IBD patients are at increased risk of conditions such as early atherosclerosis and myocardial infarction or venous thrombosis and pulmonary thromboembolism. The aim of this review is to make an approximation of the physiopathology of the different manifestations of cardiovascular disease in patients with IBD and how to prevent them.

Prognostic Value of Lipoprotein(a) Levels in Patients Undergoing Coronary Angiography for Premature Acute Coronary Syndromes

Little is known about the association between lipoprotein(a) [Lp(a)] levels and future ischemic cardiovascular events in patients with premature acute coronary syndrome (ACS). A total of 1464 consecutive patients who underwent coronary angiography for premature ACS (males <45 years and females <55 years) were enrolled in this study. Patients were divided into quartiles according to serum Lp(a) levels (Q1: ≤11.1 nmol/L; Q2: 11.1-27.7 nmol/L; Q3: 27.7-79.3 nmol/L; and Q4: >79.3 nmol/L). Major adverse cardiovascular events (MACEs) increased with Lp(a) quartiles after 2-year follow-up (among quartiles, respectively; P = .001). Kaplan-Meier curves revealed significant differences in event-free survival rates among Lp(a) quartile groups ( P = .001). Multivariate Cox proportional hazards regression analysis indicated that serum Lp(a) level was an independent predictor of MACE either as a continuous variable (hazard ratio [HR]: 1.002, 95% confidence interval [CI]: 1.001-1.004; P = .009) or as a categorical variable (HR: 1.443, 95% CI: 1.074-1.937; P = .015). Furthermore, Lp(a) levels (as a variable) significantly improved the prognostic value for MACE. These findings suggest that Lp(a) measurement has value for cardiovascular risk stratification in patients with premature ACS.

Evidence for changing lipid management strategy to focus on non-high density lipoprotein cholesterol

Low-density lipoprotein cholesterol (LDL-C) has been recommended as the primary treatment target on lipid management in coronary heart disease (CHD) patients for past several decades. However, even by aggressive LDL-C lowering treatment, patients still present a significant residual risk of major adverse cardiovascular events (MACE). Non-high-density lipoprotein cholesterol (non-HDL-C) contained all the atherogenic lipoproteins, such as chylomicron, very-low density lipoprotein (VLDL), LDL, intermediate density lipoprotein (IDL). Many prospective observation studies have found that non-HDL-C was better than LDL-C in predicting risks of MACE. Since non-HDL-C appears to be superior for risk prediction beyond LDL-C, current guidelines have emphasize the importance of non-HDL-C for guiding cardiovascular prevention strategies and have flagged non-HDL-C as a co-primary therapeutic target. The goals of non-HDL-C were recommended as 30 mg/dl higher than the corresponding LDL-C goals, but the value seemed inappropriate. This review provide evidence for changing lipid management strategy to focus on non-HDL-C and appropriate values for adding to LDL-C goals would be proposed.

Preventive Effects of the Marine Microalga Phaeodactylum tricornutum, Used as a Food Supplement, on Risk Factors Associated with Metabolic Syndrome in Wistar Rats

Long-chain polyunsaturated fatty acids, n-3 series (n-3 LC-PUFA), are known for their preventive effects against cardiovascular disease. In an unfavourable economic and environmental context of fish oil production, marine microalgae could be an alternative source of n-3 LC-PUFA and are of interest for human nutrition. The aim of this study was to evaluate the effects of P. tricornutum, a microalga rich in eicosapentaenoic acid and used as a food supplement, on the metabolic disorders associated with metabolic syndrome and obesity development. Three male Wistar rat groups (n = 6) were submitted for eight weeks to a standard diet or high-fat diet (HF) with 10% fructose in drinking water, supplemented or not with 12% of P. tricornutum (HF-Phaeo). Supplementation led to n-3 LC-PUFA enrichment of lipids in the liver, plasma and erythrocytes. Plasma transaminases showed no difference between the HF and HF-Phaeo groups. Body weight, fat mass, inflammatory markers and insulinemia decreased in HF-Phaeo rats versus the HF group. Plasma total cholesterol, triacylglycerols and leptine diminished in HF-Phaeo rats, while HDL-cholesterol increased. In conclusion, this study highlights the beneficial effects of P. tricornutum in reducing the metabolic disorders associated with metabolic syndrome.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPROVE-IT: what have we learned?

PURPOSE OF REVIEW

Recent studies and dyslipidemia treatment guidelines indicate that combination lipid-lowering therapy is frequently needed and its use has increased in recent years. Ezetimibe and simvastatin as a fixed dose is an efficacious treatment choice based on positive results of the recent IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT). In this review, we discuss recent controversies surrounding ezetimibe and provide clinical perspective on the results of the IMPROVE-IT study.

RECENT FINDINGS

IMPROVE-IT is the first trial that demonstrates a significant clinical benefit of a nonstatin hypolipidemic agent (ezetimibe) used in combination with statin (simvastatin) therapy in patients who have experienced an acute coronary syndrome. For almost a decade, the use of ezetimibe was limited by a relative lack of definitive evidence. However, the most recent Plaque Regression With Cholesterol Absorption Inhibitor or Synthesis Inhibitor Evaluated by Intravascular Ultrasound study showed greater coronary plaque regression by statin/ezetimibe combination compared with statin monotherapy. The results of the IMPROVE-IT trial are fostering new debate about the value of adjunctive low-density lipoprotein cholesterol lowering over and above a statin.

SUMMARY

Ezetimibe/simvastatin combination, either as a single pill or as the combined use of the individual compounds, represents a well-tolerated and efficacious choice for dyslipidemia treatment in high-risk subjects, including patients with diabetes. Limited additional risk for adverse events compared with simvastatin monotherapy is observed, and an individualized, patient-centered approach to therapy is recommended.

Patterns of statin non-prescription in patients with established coronary artery disease: A report from a contemporary multicenter Japanese PCI registry

Statin therapy is regarded as an effective medication to reduce cardiovascular events in patients at higher risk for future incidence of coronary artery disease. However, very few studies have been conducted to examine its implementation in non-Western real-world practice. In this study, we sought to describe statin prescription patterns in relation to patient characteristics in a Japanese multicenter percutaneous coronary intervention (PCI) registry as a foundation for quality improvement. We studied 15,024 patients that were prospectively enrolled in the Japan Cardiovascular Database-Keio interhospital Cardiovascular Study Registry from January 2009 to August 2014. The overall discharge statin non-prescription rate was 15.2%, without significant interhospital (MOR = 1.01) or annual differences (MOR = 1.13) observed. Hierarchical multivariable logistic regression analysis accounting for regional differences revealed that the presence of chronic kidney disease was associated with higher rates of statin non-prescription (OR 1.87, 95% confidence interval, 1.69-2.08, p value <0.001), and higher age (per 1-year increase) showed a trend for prescription of low-intensity statin (OR 1.00, 95% confidence interval, 1.00-1.01, p value = 0.045) within the subset of PCI patients (N = 4,853) enrolled after the year 2011. Our study indicates that patients with chronic kidney disease and elderlies may be the primary targets for maximizing the beneficial effect of statin therapy in post PCI patients.

Novel Role for Matrix Metalloproteinase 9 in Modulation of Cholesterol Metabolism

Background

The development of atherosclerosis is strongly linked to disorders of cholesterol metabolism. Matrix metalloproteinases (MMPs) are dysregulated in patients and animal models with atherosclerosis. Whether systemic MMP activity influences cholesterol metabolism is unknown.

Methods and Results

We examined MMP‐9–deficient (Mmp9^−/−) mice and found them to have abnormal lipid gene transcriptional responses to dietary cholesterol supplementation. As opposed to Mmp9^+/+ (wild‐type) mice, Mmp9^−/− mice failed to decrease the hepatic expression of sterol regulatory element binding protein 2 pathway genes, which control hepatic cholesterol biosynthesis and uptake. Furthermore, Mmp9^−/− mice failed to increase the expression of genes encoding the rate‐limiting enzymes in biliary cholesterol excretion (eg, Cyp7a and Cyp27a). In contrast, MMP‐9 deficiency did not impair intestinal cholesterol absorption, as shown by the ¹⁴C‐cholesterol and ³H‐sitostanol absorption assay. Similar to our earlier study on Mmp2^−/− mice, we observed that Mmp9^−/− mice had elevated plasma secreted phospholipase A₂ activity. Pharmacological inhibition of systemic circulating secreted phospholipase A₂ activity (with varespladib) partially normalized the hepatic transcriptional responses to dietary cholesterol in Mmp9^−/− mice. Functional studies with mice deficient in other MMPs suggested an important role for the MMP system, as a whole, in modulation of cholesterol metabolism.

Conclusions

Our results show that MMP‐9 modulates cholesterol metabolism, at least in part, through a novel MMP‐9–plasma secreted phospholipase A₂ axis that affects the hepatic transcriptional responses to dietary cholesterol. Furthermore, the data suggest that dysregulation of the MMP system can result in metabolic disorder, which could lead to atherosclerosis and coronary heart disease.

Diabetic dyslipidaemia

PURPOSE OF REVIEW

The purpose is to discuss recent developments in the understanding of lipoprotein metabolism in diabetes, the cardiovascular risk associated with both type 1 and type 2 diabetes, recently published guidelines on the management of this risk, concerns over the use of statin treatment in diabetes, and other therapeutic options.

RECENT FINDINGS

Diabetic dyslipidaemia can be gross with massive hypertriglyceridemia, or subtle with a lipid profile which would be regarded as normal in a nondiabetic patient, but which hides underlying increases in atherogenic subfractions of LDL (e.g., small dense LDL, glycated LDL) and remnant lipoproteins. Statins can decrease these without the clinician being aware from routine biochemistry. In type 2 diabetes, HDL cholesterol levels are often reduced, whereas in type 1, insulin can raise HDL, but its antiatherogenic properties are compromised. Dyslipidaemia and hypertension predate the onset of glycaemia of diabetic proportions (metabolic syndrome). Obese people can thus die of diabetes before they develop it. Obesity should be prevented and treated. Statins decrease the risk of cardiovascular disease in diabetes or metabolic syndrome regardless of whether glycaemia worsens.

SUMMARY

One unassailable truth is that statin therapy is beneficial and should rarely, if ever, be withheld.