Lipid levels in the post-acute coronary syndrome setting: destabilizing another myth?

Exploratory analysis of predictors of ventricular aneurysm in a cohort of 291 patients with acute myocardial infarction

OBJECTIVE

In this study, we explored the determinants of ventricular aneurysm development following acute myocardial infarction (AMI), thereby prompting timely interventions to enhance patient prognosis.

METHODS

In this retrospective cohort analysis, we evaluated 297 AMI patients admitted to the First People's Hospital of Changzhou. The study was structured as follows. Comprehensive baseline data collection included hematological evaluations, ECG, echocardiography, and coronary angiography upon admission. Within 3 months post-AMI, cardiac ultrasounds were administered to detect ventricular aneurysm development. Univariate and multivariate logistic regression analysis were employed to pinpoint the determinants of ventricular aneurysm formation. Subsequently, a predictive model was formulated for ventricular aneurysm post-AMI. Moreover, the diagnostic efficacy of this model was appraised using the ROC curves.

RESULTS

In our analysis of 291 AMI patients, spanning an age range of 32-91 years, 247 were male (84.9%). At the conclusion of a 3-month observational period, the cohort bifurcated into two subsets: 278 patients without ventricular aneurysm and 13 with evident ventricular aneurysm. Distinguishing features of the ventricular aneurysm subgroup were markedly higher values for age, B-type natriuretic peptide(BNP), Left atrium(LA), Left ventricular end-diastolic dimension (LEVDD), left ventricular end systolic diameter (LVEWD), E-wave velocity (E), Left atrial volume (LAV), E/A ratio (E/A), E/e ratio (E/e), ECG with elevated adjacent four leads(4 ST-Elevation), and anterior wall myocardial infarction(AWMI) compared to their counterparts (p < 0.05). Among the singular predictive factors, total cholesterol (TC) emerged as the most significant predictor for ventricular aneurysm development, exhibiting an AUC of 0.704. However, upon crafting a multifactorial model that incorporated gender, TC, an elevated ST-segment in adjacent four leads, and anterior wall infarction, its diagnostic capability: notably surpassed that of the standalone TC, yielding an AUC of 0.883 (z = -9.405, p = 0.000) as opposed to 0.704. Multivariate predictive model included gender, total cholesterol, ST elevation in 4 adjacent leads, anterior myocardial infarction, the multivariate predictive model showed better diagnostic efficacy than single factor index TC (AUC: 0. 883 vs. 0.704,z =-9.405, p = 0.000), it also improved predictive power for correctly reclassifying ventricular aneurysm occurrence in patients with AMI, NRI = 28.42% (95% CI: 6.29-50.55%; p = 0.012). Decision curve analysis showed that the use of combination model had a positive net benefit.

CONCLUSION

Lipid combined with ECG model after myocardial infarction could be used to predict the formation of ventricular aneurysm and aimed to optimize and adjust treatment strategies.

Genetic Insights on the Relation of Vascular Risk Factors and Cervical Artery Dissection

BACKGROUND

The association between vascular risk factors and cervical artery dissections (CeADs), a leading cause of ischemic stroke (IS) in the young, remains controversial.

OBJECTIVES

This study aimed to explore the causal relation of vascular risk factors with CeAD risk and recurrence and compare it to their relation with non-CeAD IS.

METHODS

This study used 2-sample Mendelian randomization analyses to explore the association of blood pressure (BP), lipid levels, type 2 diabetes, waist-to-hip ratio, smoking, and body mass index with CeAD and non-CeAD IS. To simulate effects of the most frequently used BP-lowering drugs, this study constructed genetic proxies and tested their association with CeAD and non-CeAD IS. In analyses among patients with CeAD, the investigators studied the association between weighted genetic risk scores of vascular risk factors and the risk of multiple or early recurrent dissections.

RESULTS

Genetically determined higher systolic BP (OR: 1.51; 95% CI: 1.32-1.72) and diastolic BP (OR: 2.40; 95% CI: 1.92-3.00) increased the risk of CeAD (P < 0.0001). Genetically determined higher body mass index was inconsistently associated with a lower risk of CeAD. Genetic proxies for β-blocker effects were associated with a lower risk of CeAD (OR: 0.65; 95% CI: 0.50-0.85), whereas calcium-channel blockers were associated with a lower risk of non-CeAD IS (OR: 0.75; 95% CI: 0.63-0.90). Weighted genetic risk scores for systolic BP and diastolic BP were associated with an increased risk of multiple or early recurrent CeAD.

CONCLUSIONS

These results are supportive of a causal association between higher BP and increased CeAD risk and recurrence and provide genetic evidence for lower CeAD risk under β-blockers. This may inform secondary prevention strategies and trial design for CeAD.

A Modern Approach to Dyslipidemia

Lipid disorders involving derangements in serum cholesterol, triglycerides, or both are commonly encountered in clinical practice and often have implications for cardiovascular risk and overall health. Recent advances in knowledge, recommendations, and treatment options have necessitated an updated approach to these disorders. Older classification schemes have outlived their usefulness, yielding to an approach based on the primary lipid disturbance identified on a routine lipid panel as a practical starting point. Although monogenic dyslipidemias exist and are important to identify, most individuals with lipid disorders have polygenic predisposition, often in the context of secondary factors such as obesity and type 2 diabetes. With regard to cardiovascular disease, elevated low-density lipoprotein cholesterol is essentially causal, and clinical practice guidelines worldwide have recommended treatment thresholds and targets for this variable. Furthermore, recent studies have established elevated triglycerides as a cardiovascular risk factor, whereas depressed high-density lipoprotein cholesterol now appears less contributory than was previously believed. An updated approach to diagnosis and risk assessment may include measurement of secondary lipid variables such as apolipoprotein B and lipoprotein(a), together with selective use of genetic testing to diagnose rare monogenic dyslipidemias such as familial hypercholesterolemia or familial chylomicronemia syndrome. The ongoing development of new agents-especially antisense RNA and monoclonal antibodies-targeting dyslipidemias will provide additional management options, which in turn motivates discussion on how best to incorporate them into current treatment algorithms.

Treatment Outcomes of Patients with Acute Coronary Syndrome Admitted to Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia

BACKGROUND

Acute coronary syndrome (ACS) refers to a spectrum of conditions compatible with acute myocardial ischemia and/or infarction that are usually due to an abrupt reduction in coronary blood flow.

OBJECTIVE

The objective of the study was to assess the treatment outcome and associated factors for ACS.

METHODS

A retrospective cross-sectional study was conducted from January 1, 2012 to December 31, 2014.

RESULTS

Of 124 ACS patients who were admitted during the 3 years' period, 90 (72.6%) were diagnosed with ST segment elevation myocardial infarction (STEMI). The mean age was 56.3 ± 13.7 years. The average length of hospital stay was 9.77 ± 6.42 days. The average time from onset of ACS symptoms to presentation in the emergency department was 3.8 days (91.7 hours). In about 76 (61.3%) patients, hypertension was the leading risk factor for development of ACS, and 36.4% of ACS patients were either Killip class III or IV. Biomarkers were measured for 118 (95.2%) patients, and 79.2% of patients had ejection fraction of less than 40% and 29.2% had less than 30%. In-hospital medication use includes loading dose of aspirin (79%), anticoagulants (77.4%), beta blockers (88.1%), statins (85.5%), morphine (12.9%), and nitrates (35.5%). The in-hospital mortality was 27.4%. The predictors for in-hospital mortality were age (P = .042), time from symptom onset to presentation (P = .001), previous history of hypertension (P = .025), being Killip class III and IV (P = .001), and STEMI diagnosis (P = .005).

CONCLUSIONS

The medical management of ACS patients in Tikur Anbessa Specialized Hospital (TASH) was in line with the recommendations of international guidelines but in-hospital mortality was extremely high (27.4%).

Lipid Profile of Patients with Acute Myocardial Infarction (AMI)

Introduction  Irrespective of underlying hyperlipidemia, the serum lipid profile witnesses a phasic fluctuation immediately after a major cardiovascular event. This study aims to evaluate the change in serum lipid profile in patients with acute myocardial infarction (AMI). Methods It was a prospective, cross-sectional study conducted in the department of cardiology, Shalamar Hospital, and Punjab Institute of Cardiology, from October until December 2018, focusing on patients admitted with ST-elevation myocardial infarction (STEMI). The patient's demographics and lipid profile (in mg/dl) within the first 24 hours and after 48 hours of the event were recorded. Results The mean serum total cholesterol (TC) levels decreased from 207.5 ± 30.5 to 192.4 ± 49.3 after 48 hours (p-value <0.0001). Mean serum triglyceride (TGs) levels increased from 153.8 ± 10.2 to 183.8 ± 14.8 (p-value <0.0001). Mean serum low density lipid-cholesterol (LDL-C) decreased from 149.0 ± 41.2 to 133.4 ± 54.0 (p-value = 0.0003). Mean serum high density lipid-cholesterol (HDL-C) decreased from 46.6 ± 9.9 to 40.7 ± 11.8 (p-value <0.0001). Conclusion Phasic fluctuations in serum lipid profile are observed after acute myocardial infarction (AMI). The trend that follows include reduced TC, LDL-C, and HDL-C, and increased TGs. Periodic lipid profile must be evaluated in all patients admitted for AMI to understand the changing trend, initiate lifestyle measures to reach target lipid levels, and predict the choice of lipid-lowering therapy.

The effect of fasting status on lipids, lipoproteins, and inflammatory biomarkers assessed after hospitalization for an acute coronary syndrome: Insights from PROVE IT-TIMI 22

BACKGROUND

For decades, fasting for 8 to 12 hours has been recommended for measurement of lipid profiles. The effect of fasting on low-density lipoprotein cholesterol (LDL-C) and triglycerides (TG) has been described in healthy cohorts and those with stable disease states. Recently, guidelines suggested that fasting may not be necessary due to its small effect on lipid measures. Little is known, however, regarding whether the impact of fasting is altered in the setting of an acute coronary syndrome (ACS).

HYPOTHESIS

We hypothesized that the post-ACS period would minimally effect the impact of fasting status on lipid measurements.

METHODS

We evaluated the association of fasting on lipid and other biomarkers at the randomization visit, which occurred at a median of 7 days after the onset of an ACS, as well as during follow-up, in a cohort of 4177 subjects from the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis In Myocardial Infarction 22 (PROVE IT-TIMI 22) trial.

RESULTS

Fasting samples were independently associated with a higher LDL-C of 4.1 mg/dL and apolipoprotein-B 100 of 2.6 mg/dL as well as a lower TG of 21.0 mg/dL and high-sensitivity C-reactive protein of 0.48 mg/dL. The relative difference was 3.8% for LDL-C and -11.3% for TG. Fasting did not change total cholesterol, high-density lipoprotein cholesterol, apolipoprotein A-I, lipoprotein(a), or apolipoprotein C-III.

CONCLUSIONS

Although fasting does impact lipid measurements, the effect on LDL-C is small (about 4 mg/dL), both early after ACS and during follow-up. These data provide support for recent guidelines that no longer advocate for fasting lipid samples, including in the setting of ACS.

Secondary cvd prevention-Lipid modification strategies: A critical analysis

Lipid modification holds the key to effective secondary prevention of cardiovascular disease (CVD). However there is a controversy on whether it's all about targeting specific lipid sub fractions to a particular level or a direct effect of the agent(s) used or both. This review intends to look into these important issues from an evidence-based perspective. What is the appropriate timing of testing for lipid profile after a cardiovascular event? What is the rationale behind initiating with a high dose statin after an acute coronary event? What is the role of targeting lipid sub fractions beside LDL cholesterol? Is there any role for non-statin based therapy after an acute cardiovascular event? What constitutes a long-term lipid modification strategy in patients post CVD? These are very important questions, which needs to be addressed adequately as well as scientifically. The secondary CVD preventive strategies form a lipid perspective, which requires a thorough review.

A consensus statement on lipid management after acute coronary syndrome

In patients admitted for acute coronary syndrome (ACS), the guidelines of the European Society of Cardiology give a Class I, Level A recommendation for the prescription of high-intensity statins to be initiated as early as possible, regardless of the low-density lipoprotein cholesterol (LDL-C) level. Although statins are widely prescribed after ACS, the intensity of therapy and the proportion of patients achieving target LDL-C values are often not in line with recommendations due to a lack of compliance with guidelines by the physicians, a lack of compliance with treatment or poor tolerance by patients, and poor dose adaptation. In this context, a group of French physicians came together to define strategies to facilitate and improve the management of lipid-lowering therapy after ACS. This paper outlines the scientific rationale for the use of statins at the acute phase of ACS, the utility of ezetimibe, the measurement of LDL-C during the course of ACS, the opportunities for detecting familial hypercholesterolaemia and the results of the consensus for the management of lipid-lowering therapy, illustrated in two decision-making algorithms.

HIV and Hepatitis C-Coinfected Patients Have Lower Low-Density Lipoprotein Cholesterol Despite Higher Proprotein Convertase Subtilisin Kexin 9 (PCSK9): An Apparent "PCSK9-Lipid Paradox"

Background

Proprotein convertase subtilisin kexin 9 (PCSK9) inhibitors reduce low‐density lipoprotein cholesterol (LDL‐C) and improve outcomes in the general population. HIV‐infected individuals are at increased risk for cardiovascular events and have high rates of dyslipidemia and hepatitis C virus (HCV) coinfection, making PCSK9 inhibition a potentially attractive therapy.

Methods and Results

We studied 567 participants from a clinic‐based cohort to compare PCSK9 levels in patients with HIV/HCV coinfection (n=110) with those with HIV infection alone (n=385) and with uninfected controls (n=72). The mean age was 49 years, and the median LDL‐C level was 100 mg/dL (IQR 77–124 mg/dL); 21% were taking statins. The 3 groups had similar rates of traditional risk factors. Total cholesterol, LDL‐C, and high‐density lipoprotein cholesterol levels were lower in coinfected patients compared with controls (P<0.001). PCSK9 was 21% higher in HIV/HCV‐coinfected patients versus controls (95% CI 9–34%, P<0.001) and 11% higher in coinfected individuals versus those with HIV infection alone (95% CI 3–20%, P=0.008). After adjustment for cardiovascular risk factors, HIV/HCV coinfection remained significantly associated with 20% higher PCSK9 levels versus controls (95% CI 8–33%, P=0.001). Interleukin‐6 levels increased in a stepwise fashion from controls (lowest) to HIV‐infected to HIV/HCV‐coinfected individuals (highest) and correlated with PCSK9 (r=0.11, P=0.018).

Conclusions

Despite having lower LDL‐C, circulating PCSK9 levels were increased in patients coinfected with HIV and HCV in parallel with elevations in the inflammatory, proatherogenic cytokine interleukin‐6. Clinical trials should be conducted to determine the efficacy of targeted PCSK9 inhibition in the setting of HIV/HCV coinfection.

Serial measurement of lipid profile and inflammatory markers in patients with acute myocardial infarction

Serum concentration of lipids and lipoproteins changes during the course of acute coronary syndrome as a consequence of the inflammatory response. The objective of this study was to evaluate the effect of acute myocardial infarction (AMI) on the levels of lipid profile and inflammatory markers. We investigated 400 patients with AMI who were admitted within 24 h of onset of symptoms. Serum levels of total cholesterol (TC), triglyceride (TG), low density lipoprotein (LDL) and high density lipoprotein (HDL) were determined by standard enzymatic methods along with high sensitive C-reactive protein (hs-CRP) (latex enhanced immunoturbidimetric assay) and cytokines, interleukin (IL)-6 and IL-10 (quantitative ''sandwich'' enzyme-linked immunosorbent assay). The results indicate a trend of reduced TC, LDL, and HDL, and elevated TG levels, along with pro- and anti-inflammatory markers (p < 0.001), between day 1 and the day 2 serum samples of AMI patients. However, corrections in the serum levels have been observed at day 7. Our results demonstrate significant variations in the mean lipid levels and inflammatory markers between days 1, 2 and 7 after AMI. Therefore, it is recommended that the serum lipids should be assessed within 24 hours after infarction. Early treatment of hyperlipidemia provides potential benefits. Exact knowledge regarding baseline serum lipids and lipoprotein levels as well as their varying characteristics can provide a rational basis for clinical decisions about lipid lowering therapy.

The role of insulin-like growth factor-1 in development of coronary no-reflow and severity of coronary artery disease in patients with acute myocardial infarction

INTRODUCTION

Insulin-like growth factor-1 (IGF-1) has atheroprotective effects via reduction in oxidative stress, cellular apoptosis, pro-inflammatory signaling, and endothelial dysfunction.

AIM

We hypothesized that low levels of IGF-1 may be associated with the severity and extent of coronary artery disease and development of the coronary no-reflow phenomenon in patients with acute ST-elevation myocardial infarction (STEMI) and investigated the role of the IGF-1 molecule in the coronary no-reflow phenomenon and severity of coronary artery disease (CAD) in patients with acute STEMI in a tertiary hospital.

MATERIAL AND METHODS

The study was conducted among 113 patients undergoing primary percutaneous coronary intervention (PPCI) for STEMI, of whom 49 patients developed the no-reflow phenomenon. Coronary no-reflow was defined as Thrombolysis In Myocardial Infarction (TIMI) flow grade 2 or less after intervention. Insulin-like growth factor-1 levels were measured in both groups. The severity and extent of CAD were evaluated according to the Gensini and Syntax scores.

RESULTS

Although IGF-1 levels were lower in the no-reflow group, there was not a statistically significant difference between the no-reflow group and the control group (116.65 ±51.72 vs. 130.82 ±48.76, p = 0.130). Gensini and Syntax scores were higher in the no-reflow group. There was no association between Gensini and Syntax scores and IGF-1 levels (r = -0.071, r = 0.479, r = -0.158, p = 0.113).

CONCLUSIONS

In this study, IGF-1 levels were not statistically different between patients developing the no-reflow phenomenon and controls. There was no association between development of the no-reflow phenomenon and severity of CAD or IGF-1 levels. Nevertheless, large scale studies are needed to verify these results.

Plasma apolipoprotein O level increased in the patients with acute coronary syndrome

Apolipoprotein (apo) O is a novel apolipoprotein that is present predominantly in high density lipoprotein (HDL). However, overexpression of apoO does not impact on plasma HDL levels or functionality in human apoA-I transgenic mice. Thus, the physiological function of apoO is not yet known. In the present study, we investigated relationships between plasma apoO levels and high-sensitive C-reactive protein (hs-CRP) levels, as well as other lipid parameters in healthy subjects (n = 111) and patients with established acute coronary syndrome (ACS) (n = 50). ApoO was measured by the sandwich dot-blot technique with recombinant apoO as a protein standard. Mean apoO level in healthy subjects was 2.21 ± 0.83 µg/ml whereas it was 4.94 ± 1.59 µg/ml in ACS patients. There were significant differences in plasma level of apoO between two groups (P < 0.001). In univariate analysis, apoO correlated significantly with lg(hsCRP) (r = 0.48, P < 0.001) in ACS patients. Notably, no significant correlation between apoO and other lipid parameters was observed. Logistic regression analysis showed that plasma apoO level was an independent predictor of ACS (OR = 5.61, 95% CI 2.16–14.60, P < 0.001). In conclusion, apoO increased in ACS patients, and may be regarded as an independent inflammatory predictor of ACS patients.

The modification of serum lipids after acute coronary syndrome and importance in clinical practice

Atherosclerosis is a pathology characterized by low-grade vascular inflammation rather than a mere accumulation of lipids. Inflammation is central at all stages of atherosclerosis. Acute coronary syndrome significantly affects the concentration and composition of the lipids and lipoproteins in plasma. Plasma triglyceride and very low density lipoprotein levels increase, while high density lipoprotein, low density lipoprotein and total cholesterol levels decrease. Early treatment of hyperlipidemia provides potential benefits. However, post-event changes in lipid and lipoproteins lead to delays in the choice of the treatment. This review focuses on the mechanism and the clinical importance of the relevant changes.