Unmet needs in the management of atherosclerotic cardiovascular disease: Is there a role for emerging anti-inflammatory interventions?

Associations between metabolic dysfunction-associated fatty liver disease and atherosclerotic cardiovascular disease

Non-alcoholic fatty liver disease (NAFLD) is closely related to metabolic syndrome and remains a major global health burden. The increased prevalence of obesity and type 2 diabetes mellitus (T2DM) worldwide has contributed to the rising incidence of NAFLD. It is widely believed that atherosclerotic cardiovascular disease (ASCVD) is associated with NAFLD. In the past decade, the clinical implications of NAFLD have gone beyond liver-related morbidity and mortality, with a majority of patient deaths attributed to malignancy, coronary heart disease (CHD), and other cardiovascular (CVD) complications. To better define fatty liver disease associated with metabolic disorders, experts proposed a new term in 2020 - metabolic dysfunction associated with fatty liver disease (MAFLD). Along with this new designation, updated diagnostic criteria were introduced, resulting in some differentiation between NAFLD and MAFLD patient populations, although there is overlap. The aim of this review is to explore the relationship between MAFLD and ASCVD based on the new definitions and diagnostic criteria, while briefly discussing potential mechanisms underlying cardiovascular disease in patients with MAFLD.

Methotrexate and cardiovascular prevention: an appraisal of the current evidence

New evidence continues to accumulate regarding a significant association between excessive inflammation and dysregulated immunity (local and systemic) and the risk of cardiovascular events in different patient cohorts. Whilst research has sought to identify novel atheroprotective therapies targeting inflammation and immunity, several marketed drugs for rheumatological conditions may serve a similar purpose. One such drug, methotrexate, has been used since 1948 for treating cancer and, more recently, for a wide range of dysimmune conditions. Over the last 30 years, epidemiological and experimental studies have shown that methotrexate is independently associated with a reduced risk of cardiovascular disease, particularly in rheumatological patients, and exerts several beneficial effects on vascular homeostasis and blood pressure control. This review article discusses the current challenges with managing cardiovascular risk and the new frontiers offered by drug discovery and drug repurposing targeting inflammation and immunity with a focus on methotrexate. Specifically, the article critically appraises the results of observational, cross-sectional and intervention studies investigating the effects of methotrexate on overall cardiovascular risk and individual risk factors. It also discusses the putative molecular mechanisms underpinning the atheroprotective effects of methotrexate and the practical advantages of using methotrexate in cardiovascular prevention, and highlights future research directions in this area.

Anti-inflammatory Treatment and Cardiovascular Outcomes: Results of Clinical Trials

Atherosclerosis is a chronic inflammatory disorder of the vasculature where cholesterol accumulates in the arterial wall stimulating infiltration of immune cells. This plays an important role in plaque formation, as well as complications caused by its build up. Pro-inflammatory cytokines and chemokines are implicated throughout the progression of the disease and different therapies that aim to resolve this chronic inflammation, reduce cardiovascular (CV) events and improve clinical outcomes have been tested. The results from the pivotal CANTOS trial show that targeting the pro-inflammatory cytokine IL-1β successfully reduces the incidence of secondary CV events. This review briefly assesses the role of inflammation in atherosclerosis, providing a picture of the multiple players involved in the process and offering a perspective on targeting inflammation to prevent atherosclerotic CV events, as well as focusing on the results of the latest Phase III clinical trials.

The Role of MicroRNAs in Regulating Cytokines and Growth Factors in Coronary Artery Disease: The Ins and Outs

Coronary artery diseases (CAD), as a leading cause of mortality around the world, has attracted the researchers' attention for years to find out its underlying mechanisms and causes. Among the various key players in the pathogenesis of CAD cytokines, microRNAs (miRNAs) are crucial. In this study, besides providing a comprehensive overview of the involvement of cytokines, growth factors, and miRNAs in CAD, the interplay between miRNA with cytokine or growth factors during the development of CAD is discussed.

Predictive value of three Inflammation-based Glasgow Prognostic Scores for major cardiovascular adverse events in patients with acute myocardial infarction during hospitalization: a retrospective study

Aim

Inflammation-based Glasgow Prognostic Scores (GPS) have been reported to predict the prognosis of patients with acute ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). The goal of this study was to investigate whether three kinds of GPSs can effectively predict major cardiovascular adverse events (MACEs) in STEMI or non-ST-segment elevation myocardial infarction (NSTEMI) patients undergoing PPCI, elective PCI (EPCI) or conservative drug therapy during hospitalization.

Methods

In this retrospective cohort study, patients with acute myocardial infarction (AMI) were divided into 0, 1 or 2 score according to the GPSs. Logistic regression and receiver operating characteristic (ROC) curve analysis were performed to assess the predictive value of GPSs for MACE and all-cause mortality during hospitalization. Three kinds of GPSs, Inflammation-based Glasgow Prognostic Score (GPS), modified GPS (MGPS) and high-sensitivity CRP-modified GPS (HS-MGPS) and Global Registry of Acute Coronary Events (GRACE) score were applied in this study.

Results

A total of 188 patients were enrolled. The ROC curve with MACE showed that the AUC of GPS (0.820 (95% confidence interval (CI) [0.754-0.885]), P < 0.001) was larger than that of MGPS (0.789 (95% CI [0.715-0.863]), P < 0.001), HS-MGPS (0.787 (95% CI [0.717-0.856]), P < 0.001) and GRACE score (0.743 (95% CI [0.672-0.814]), P < 0.001). The ROC curve with all-cause mortality showed that the AUC of GPS (0.696 (95% CI [0.561-0.831]), P = 0.005) was similar to the HS-MGPS (0.698 (95% CI [0.569-0.826]), P = 0.005) and higher than the MGPS (0.668 (95% CI [0.525-0.812]), P = 0.016), but lower than the GRACE score (0.812 (95% CI [0.734-0.889]), P < 0.001). Multivariate logistic regression analysis showed that the GPS was an independent risk factor for the incidence of MACE during hospitalization. Compared with the odds ratio (OR) value for a GPS of 0, the OR for a GPS of 1 was 7.173 (95% CI [2.425-21.216]), P < 0.001), and that for a GPS of 2 was 18.636 (95% CI [5.813-59.746]), P < 0.001), but not an independent risk factor for all-cause mortality (P = 0.302). GRACE score was an independent risk factor for MACE (1.019 (95% CI [1.004-1.035]), P = 0.015) and all-cause mortality (1.040 (95% CI [1.017-1.064]), P = 0.001). In the subgroups classified according to the type of AMI, the presence of disease interference GPSs and the type of PCI, the ability of GPS to predict the occurrence of MACE seemed to be greater than that of MGPS and HS-MGPS.

Conclusion

The GPS has a good predictive value for the occurrence of MACE during hospitalization in patients with AMI, regardless of STEMI or NSTEMI, the choice of PCI mode and the presence or absence of diseases that interfere with GPS. However, GPS is less predictive of all-cause mortality during hospitalization than GRACE score, which may be due to the interference of patients with other diseases.

New evidence on the role of inflammation in CVD risk

PURPOSE OF REVIEW

Based on compelling data from animal and human studies, over the past few decades, the viewpoint of atherosclerosis as an exclusively lipid-driven disease, has been gradually replaced by the concept of a chronic low-grade inflammatory process of the arterial wall. This review presents a brief description on the role of inflammation in atherosclerosis, and examines selected anti-inflammatory interventions that have been tested in clinical trials designed to prevent adverse cardiovascular disease (CVD) events and excess CVD risk.

RECENT FINDINGS

The Canakinumab Anti-inflammatory Thrombosis Outcomes Study trial has provided convincing evidence that neutralization of the interleukin (IL)-1β inflammatory pathway by the selective antibody canakinumab reduces major CVD events and significantly lowers IL-1β, IL-6 and high-sensitivity C-reactive protein, without affecting low-density lipoprotein cholesterol levels. In contrast, in the latest Cardiovascular Inflammation Reduction Trial, low-dose methotrexate compared with placebo did not reduce CVD events, probably because there was no reduction in IL-1β, or in downstream inflammatory biomarker levels either.

SUMMARY

Notwithstanding the utilization of effective medical treatments including statins and proprotein convertase subtilisin/kexin type 9 inhibitors or precise revascularizations, the recurrence of CVD events remains unacceptably high. Canakinumab is, at present, the only anti-inflammatory agent that has been proven to reduce cardiovascular events in patients with elevated markers of inflammation without modifying cholesterol levels. Nevertheless, clinical application related to this new evidence and associated knowledge has not yet been implemented in daily practice.

Repurposing existing drugs for cardiovascular risk management: a focus on methotrexate

About 20% of patients with a history of atherosclerotic cardiovascular disease will experience further cardiovascular events despite maximal pharmacological treatment with cardioprotective drugs. This highlights the presence of residual cardiovascular risk in a significant proportion of patients and the need for novel, more effective therapies. These therapies should ideally target different pathophysiological pathways involved in the onset and the progression of atherosclerosis, particularly the inflammatory and immune pathways. Methotrexate is a first-line disease-modifying antirheumatic drug that is widely used for the management of autoimmune and chronic inflammatory disorders. There is some in vitro and in vivo evidence that methotrexate might exert a unique combination of anti-inflammatory, blood pressure lowering, and vasculoprotective effects. Pending the results of large prospective studies investigating surrogate end-points as well as morbidity and mortality, repurposing methotrexate for cardiovascular risk management might represent a cost-effective strategy with immediate public health benefits. This review discusses the current challenges in the management of cardiovascular disease; the available evidence on the effects of methotrexate on inflammation, blood pressure, and surrogate markers of arterial function; suggestions for future research directions; and practical considerations with the use of methotrexate in this context.

Paeoniflorin prevents endoplasmic reticulum stress-associated inflammation in lipopolysaccharide-stimulated human umbilical vein endothelial cells via the IRE1α/NF-κB signaling pathway

Endoplasmic reticulum (ER) stress-associated inflammation is a critical molecular mechanism involved in the pathogenesis of endothelial dysfunction (ED). Hence, strategies for alleviating ER stress-induced inflammation may be essential for the prevention of cardiovascular diseases. Paeoniflorin (PF), a bioactive compound from Paeonia lactiflora Pallas is known for its functional properties against vascular inflammation. However, to date, PF-mediated protection against ER stress-dependent inflammation has not been identified. Herein, we investigate the protective effect of PF on lipopolysaccharide (LPS)-stimulated human umbilical vein endothelial cell (HUVEC) injury and explore its underlying mechanism. The result of the cell viability assay indicates that PF promotes the cell survival rate in LPS-stimulated HUVECs. In addition, the LPS-induced over-production of inflammatory cytokines (interleukin-6 (IL-6) and monocyte chemotactic protein 1 (MCP-1)) and ER stress markers (78 kDa glucose regulated protein (GRP78) and CCAAT/enhancer binding protein homologous protein (CHOP)) are significantly decreased by PF and the ER stress inhibitor 4-phenylbutric acid (4-PBA). The transmission electron microscopy (TEM) assay implies that the ultrastructural abnormalities in ER are reversed by PF treatment, which is similar to the protective effect of 4-PBA. Impressively, we find that the inositol-requiring enzyme 1α (IRE1α)/nuclear factor-kappa B (NF-κB) pathway is significantly activated and contributes to the progress of LPS-induced HUVEC injury by promoting inflammatory cytokine production. IRE1α siRNA, AEBSF (ATF6 inhibitor), GSK2656157 (PERK inhibitor), PDTC (NF-κB inhibitor) and thapsigargin (TG, IRE1 activator) are used to confirm the role of the IRE1α/NF-κB pathway in PF-mediated protection against LPS-induced HUVEC injury. Our findings indicate that PF has an inhibitory effect on endothelial injury. To summarize, PF might be a potential therapeutic agent to inhibit ER stress-associated vascular inflammation.

Role of Anti-inflammatory Interventions in Coronary Artery Disease: Understanding the Canakinumab Anti-inflammatory Thrombosis Outcomes Study (CANTOS)

Coronary artery disease (CAD) is the leading cause of death worldwide. Despite notable advances in understanding the nature of atherosclerotic processes and the use of effective medications such as statins, there remains a significant residual risk. Even after optimal medical treatments and precise revascularisations, the recurrence of MI remains at approximately one-third for 5 years after an acute coronary syndrome (ACS). Over the past two decades, compelling data from animal and human studies has clearly identified atherosclerosis as an inflammatory disease of the arterial wall, but clinical applications related to this accumulated knowledge are still scarce. Recently, the Canakinumab Anti-inflammatory Thrombosis Outcomes Study (CANTOS) has provided convincing evidence that an anti-inflammatory intervention with the monoclonal antibody canakinumab reduces cardiovascular events in well-treated CAD patients without affecting LDL cholesterol levels. This article presents a brief description of the role of inflammation in atherogenesis and examines selected anti-inflammatory interventions and their potential use in CAD-affected individuals.

Gut microbiota modulate host immune cells in cancer development and growth

Emerging evidence shows that microbe interactions with the host immune system impact diverse aspects of cancer development and treatment. As a result, exciting new opportunities exist for engineering diets and microbe cocktails to lower cancer risks with fewer adverse clinical effects than traditional strategies. Microbe-based therapies may ultimately be used to reinforce host immune balance and extinguish cancer for generations to come.

Microbial transformation of methyl cyperenoate by Cunninghamella elegans AS 3.2028 and the antithrombotic activities of its metabolites

Microbial transformation is a remarkable tool for the structural modification of bioactive natural compounds converting them into more valuable biologically active derivatives.