Reducing residual cardiovascular risk in Europe: Therapeutic implications of European medicines agency approval of icosapent ethyl/eicosapentaenoic acid

Influence of multiple risk factor control level on cardiovascular outcomes in hypertensive patients

AIMS

The relationship between the level of baseline risk factor control and cardiovascular outcomes in hypertensive patients with blood pressure interventions is not well understood. It is also unclear whether the level of baseline risk factor control is persuasively associated with cardiovascular outcomes in hypertensive patients with a blood pressure lowering strategy.

METHOD AND RESULTS

We performed an analysis of the Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP) trial. Participants without complete baseline risk factor data were excluded. The primary outcome was a composite of cardiovascular events and all-cause mortality. Cox proportional hazard models were used to calculate the hazard ratio (HR) and estimate the association between risk factor control levels (≥6, 5, 4, and ≤3) and cardiovascular outcomes. A total of 8337 participants were involved in the analysis, and the median follow-up period was 3.19 years. Each additional risk factor uncontrolled was associated with a 24% higher cardiovascular risk (HR 1.24, 95% CI 1.11-1.37). Compared with participants with optimal risk factor control, those with ≤3 factors control exhibited 95% higher cardiovascular risk (HR 1.95, 95% CI 1.37-2.77). The corresponding protective effects of multiple risk factor modification were not influenced by intensive or standard antihypertensive treatment (P for interaction = 0.71).

CONCLUSION

A stepwise association was observed between cardiovascular risk and the number of risk factor control in hypertensive patients. The more risk factors were modified, the less cardiovascular risk was observed, irrespective of different blood pressure lowering strategies. Comprehensive risk factor control strategies are warranted to reduce cardiovascular disease risk in hypertensive patients.

Recent Advances in Micro/Nanomotor for the Therapy and Diagnosis of Atherosclerosis

Atherosclerotic cardiovascular disease poses a significant global public health threat with a high incidence that can result in severe mortality and disability. The lack of targeted effects from traditional therapeutic drugs on atherosclerosis may cause damage to other organs and tissues, necessitating the need for a more focused approach to address this dilemma. Micro/nanomotors are self-propelled micro/nanoscale devices capable of converting external energy into autonomous movement, which offers advantages in enhancing penetration depth and retention while increasing contact area with abnormal sites, such as atherosclerotic plaque, inflammation, and thrombosis, within blood vessel walls. Recent studies have demonstrated the crucial role micro/nanomotors play in treating atherosclerotic cardiovascular disease. Hence, this review highlights the recent progress of micro/nanomotor technology in atherosclerotic cardiovascular disease, including the effective promotion of micro/nanomotors in the circulatory system, overcoming hemorheological barriers, targeting the atherosclerotic plaque microenvironment, and targeting intracellular drug delivery, to facilitate atherosclerotic plaque localization and therapy. Furthermore, we also describe the potential application of micro/nanomotors in the imaging of vulnerable plaque. Finally, we discuss key challenges and prospects for treating atherosclerotic cardiovascular disease while emphasizing the importance of designing individualized management strategies specific to its causes and microenvironmental factors.

Regular use of fish oil supplements, Life's Essential 8 score, and cardiovascular mortality in people with type 2 diabetes: a longitudinal cohort study

BACKGROUND

Till date, no studies have investigated the effects of cardiovascular health on the cardioprotective benefits of fish oil supplementation in people with type 2 diabetes (T2D). The utility of fish oil in reducing the risk of cardiovascular disease (CVD) mortality in people with diabetes remains unclear and inconsistent.

OBJECTIVE

To investigate the potential modifying effect of cardiovascular health (CVH) level, as assessed using the Life's Essential 8 (LE8) score, on the association between regular fish oil supplement use and CVD mortality in middle-aged and older people with T2D.

METHODS

Participants with T2D in the UK Biobank were included. CVH level was categorized by the mean LE8 score (55 points). Multivariable-adjusted Cox models were used to evaluate the longitudinal association between regular use of fish oil supplements and CVD mortality. We performed stratified analysis across different CVH levels, and tested for potential interaction between fish oil supplement use and CVH level.

RESULTS

The analysis included 19,003 participants (mean age 59.9±6.9 years, 36.1% women), of whom 39.6% were regular users of fish oil supplements. During a median follow-up of 13.7 years, regular use of fish oil supplements was significantly associated with a lower risk of CVD mortality among participants with better CVH (i.e., LE8 score ≥55 points; hazard ratio [HR]=0.65, 95% confidence interval [CI] 0.51-0.84, P = 0.001), but not among those with poorer CVH (i.e., LE8 score <55 points; HR=1.02, 95% CI 0.83-1.25, P=0.867). The interaction between the use of fish oil supplements and CVH level on CVD mortality was significant (P=0.018).

CONCLUSIONS

Middle-aged and older T2D individuals with a relatively low baseline CVH level may not obtain cardiovascular benefits from fish oil supplements. Our findings highlight the importance of promoting multimodal lifestyle interventions to improve survival outcomes of people with T2D.

Oxidative stress-mediated neuroinflammation in Alzheimer's disease

Reactive oxygen species (ROS) are metabolic by-products that constitute an indispensable component of physiological processes, albeit their heightened presence may proffer substantial perils to biological entities. Such a proliferation gives rise to a gradual escalation of oxidative stress within the organism, thereby compromising mitochondrial functionality and inflicting harm upon various bodily systems, with a particular predilection for the central nervous system. In its nascent stages, it is plausible that inflammation has been a facilitator in the progression of the malady. The precise role of inflammation in Alzheimer's disease (AD) remains somewhat enigmatic, although it is conceivable that activated microglia and astrocytes might be implicated in the removal of amyloid-β (Aβ) deposits. Nonetheless, prolonged microglial activation is associated with Tau phosphorylation and Aβ aggregation. Research studies have indicated that AD brains upregulate complementary molecules, inflammatory cytokines, acute phase reacting agents, and other inflammatory mediators that may cause neurodegeneration. In this review, oxidative damage products will be discussed as potential peripheral biomarkers for AD and its early stages. The disordered excretion of pro-inflammatory cytokines, chemokines, oxygen, and nitrogen-reactive species, along with the stimulation of the complement system by glial cells, has the potential to disrupt the functionality of neuronal termini. This perturbation, in turn, culminates in compromised synaptic function, a phenomenon empirically linked to the manifestation of cognitive impairments. The management of neurodegenerative conditions in the context of dementia necessitates therapeutic interventions that specifically target the excessive production of inflammatory and oxidative agents. Furthermore, we shall deliberate upon the function of microglia and oxidative injury in the etiology of AD and the ensuing neurodegenerative processes.

Macrophage membrane-functionalized manganese dioxide nanomedicine for synergistic treatment of atherosclerosis by mitigating inflammatory storms and promoting cholesterol efflux

Atherosclerosis (AS) poses a significant threat to human life and health. However, conventional antiatherogenic medications exhibit insufficient targeting precision and restricted therapeutic effectiveness. Moreover, during the progression of AS, macrophages undergo polarization toward the proinflammatory M1 phenotype and generate reactive oxygen species (ROS) to accelerate the occurrence of inflammatory storms, and ingest excess lipids to form foam cells by inhibiting cholesterol efflux. In our study, we developed a macrophage membrane-functionalized hollow mesoporous manganese dioxide nanomedicine (Col@HMnO2-MM). This nanomedicine has the ability to evade immune cell phagocytosis, enables prolonged circulation within the body, targets the inflammatory site of AS for effective drug release, and alleviates the inflammatory storm at the AS site by eliminating ROS. Furthermore, Col@HMnO2-MM has the ability to generate oxygen autonomously by breaking down surplus hydrogen peroxide generated at the inflammatory AS site, thereby reducing the hypoxic microenvironment of the plaque by downregulating hypoxia-inducible factor (HIF-1α), which in turn enhances cholesterol efflux to inhibit foam cell formation. In an APOE-/- mouse model, Col@HMnO2-MM significantly reduced inflammatory factor levels, lipid storage, and plaque formation without significant long-term toxicity. In summary, this synergistic treatment significantly improved the effectiveness of nanomedicine and may offer a novel strategy for precise AS therapy.

Effects of saline-alkaline stress on metabolomics profiles, biochemical parameters, and liver histopathology in large yellow croaker (Larimichthys crocea)

China has several saline-alkaline bodies. Studies on the adaptation of fish in saline-alkaline conditions are important for the efficient utilization of such areas. In this study, we employed a comprehensive approach combining histopathological analysis, biochemical markers, and metabolomic profiling to examine the impact of saline-alkaline stress on the liver of the large yellow croaker (Larimichthys crocea). It was found that the survival rate of L. crocea in the saline-alkaline treated group (EX) was significantly higher than that of the control group (CK). Saline-alkaline stress could not influence the structure of the liver of L. crocea, and not change the levels of superoxide dismutase (SOD), catalase (CAT), alkaline phosphatase (ALP), acid phosphatase (ACP). In addition, we identified 5953 metabolites, and 312 differentially expressed metabolites (DEMs) showed significant differential expression between the CK and EX groups. In the positive ion mode, 216 DEMs were identified, including 120 up-regulated and 96 down-regulated DEMs, and in the negative ion mode, 178 DEMs were identified, including 131 up-regulated and 47 down-regulated DEMs. Pathway enrichment analysis revealed significant involvement in 58 metabolic pathways, primarily linked to energy metabolism. These included the metabolism of amino acid, carbohydrate, and lipid pathways, including cysteine and methionine metabolism, biosynthesis of valine, leucine, isoleucine, and ascorbate; aldarate metabolism; galactose metabolism; glycerophospholipid metabolism; and the biosynthesis of unsaturated fatty acids. Metabolomics revealed that increased synthesis of compounds, such as succinic acid, arachidonic acid, and L-gulonic acid in the liver of L.crocea, is associated with adaptation to saline-alkaline aquaculture conditions. The findings of this study indicated that the fish mitigate reactive oxygen species induced by hyperosmotic environments and improve cellular membrane fluidity and intercellular signal transduction through the metabolism of unsaturated fatty acids and carbohydrates, facilitating adaptation to saline-alkaline conditions.

Risk factors for cerebral infarction and cerebrovascular stenosis in antiphospholipid antibody-positive patients: A retrospective single-center study with propensity score matching analysis

Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by the presence of antiphospholipid antibodies (aPLA), such as anticardiolipin (aCL), anti-β2-glycoprotein I (aβ2GPI), or lupus anticoagulant (LA). Although cerebrovascular events are commonly associated with APS, comprehensive studies on risk factors for cerebral infarction in aPLA-positive patients remain sparse. In this retrospective single-center study, data from 9844 patients tested for aPLA between January 2017 and March 2023 were analyzed. A total of 647 aPLA-positive patients were included, with assessments of various factors including age, gender, hypertension, diabetes, dyslipidemia, smoking history, and cardiac disease. Propensity score matching was employed to create 2 matched groups of 202 patients each, comparing those with and without cerebral infarction. Logistic regression analyses were conducted to identify risk factors for cerebral infarction and progression of cerebrovascular stenosis. The mean age of the study cohort was 65.8 years, with 60% being male. LA was positive in 95.2% of the cases, aCL in 8.8%, and aβ2GPI in 5.3%. High-risk aPLA profiles were identified in 7.1% of the cases. In the cerebral infarction group, both smoking history and aCL positivity were significantly associated with an increased risk (OR = 1.543; 95% CI: 1.020-2.334; P = .040 and OR = 3.043; 95% CI: 1.426-6.491; P = .040, respectively). Male gender and posterior circulation involvement were significant risk factors for exacerbation of cerebrovascular stenosis (OR = 3.73; 95% CI: 1.16-16.69; P = .046 and OR = 5.41; 95% CI: 1.80-16.05; P = .002, respectively). Smoking history and aCL positivity are prominent risk factors for cerebral infarction in aPLA-positive patients, while male gender and involvement of the posterior circulation emerge as significant risk factors for the progression of cerebrovascular stenosis. Further comprehensive prospective studies are necessary to deepen understanding of aPLA-related cerebrovascular diseases.

Eicosapentaenoic acid versus placebo as adjunctive therapy in chronic migraine: A randomized controlled trial

OBJECTIVE

This study was conducted to assess the efficacy of daily 2000 mg eicosapentaenoic acid (EPA) supplementation in individuals with chronic migraine.

BACKGROUND

Chronic migraine is characterized by a minimum of 15 headache days/month, necessitating a focus on preventive treatment strategies. EPA, a polyunsaturated fatty acid recognized for its anti-inflammatory properties, is examined for its potential effectiveness in chronic migraine management.

METHODS

A randomized, blinded, placebo-controlled trial of eligible participants with a confirmed diagnosis of chronic migraine were enrolled. The intervention group received 1000 mg of EPA twice daily for 8 weeks, while the control group received two placebo softgels. Symptoms were recorded at 4 and 8 weeks. The primary outcome was assessed using the Headache Impact Test-6 to evaluate changes in patients. Secondary outcomes encompassed migraine headache days, headache severity measured via a visual analog scale, and the number of consumed painkillers. Descriptive analyses were reported in mean (± standard deviation [SD]).

RESULTS

A total of 60 patients were included in the study and finally, 56 patients completed the study according to the protocol, including 47 (84%) females. The data comparison at baseline did not show any significant difference between the two groups except in the number of patients using valproic acid as prophylaxis (21 patients in the EPA group, and 13 in the placebo group; p = 0.037). The results showed after 8 weeks, a mean (SD) difference of Headache Impact Test-6 in the EPA and placebo groups was -6.96 (3.34) and -4.43 (5.24), respectively (p = 0.084). Regarding migraine headache days, participants reported a mean (SD) -9.76 (4.15) and -4.60 (4.87) decline in days with headache, respectively (p < 0.001). The number of attacks per month after 8 weeks was 3.0 (95% confidence interval [CI] 2.0-4.0) and 4.0 (95% CI 3.0-6.0), respectively (p < 0.001). Regarding severity, there was no significant difference between the two groups (mean [SD] difference: -0.76 [1.13] and -0.73 [1.04], respectively; p = 0.906). In terms of adverse events, two patients in the EPA group reported intolerable nausea and vomiting, and one patient in the placebo group reported dizziness.

CONCLUSIONS

This study's findings support the potential of a daily 2000 mg EPA as a prophylactic pharmacotherapy in chronic migraine management, specifically in mitigating migraine attacks, migraine headache days, and overall quality of life.

Addressing residual risk beyond statin therapy: New targets in the management of dyslipidaemias-A report from the European Society of Cardiology Cardiovascular Round Table

Cardiovascular (CV) disease is the most common cause of death in Europe. Despite proven benefits, use of lipid-lowering therapy remains suboptimal. Treatment goals are often not achieved, even in patients at high risk with atherosclerotic CV disease (ASCVD). The occurrence of CV events in patients on lipid-lowering drugs is defined as "residual risk", and can result from inadequate control of plasma lipids or blood pressure, inflammation, diabetes, and environmental hazards. Assessment of CV risk factors and vascular imaging can aid in the evaluation and management decisions for individual patients. Lifestyle measures remain the primary intervention for lowering CV risk. Where drug therapies are required to reach lipid treatment targets, their effectiveness increases when they are combined with lifestyle measures delivered through formal programs. However, lipid drug dosage and poor adherence to treatment remain major obstacles to event-free survival. This article discusses guideline-supported treatment algorithms beyond statin therapy that can help reduce residual risk in specific patient profiles while also likely resulting in substantial healthcare savings through better patient management and treatment adherence.

Young hearts at risk: Unveiling novel factors in myocardial infarction susceptibility and prevention

The increasing incidence of acute myocardial infarction (AMI) among the young population represents a significant and emerging health concern, contributing substantially to both mortality and morbidity. Unlike myocardial infarctions occurring in older individuals, traditional risk factors such as diabetes and hypertension exhibit a weaker association in the younger demographic. Consequently, there is a pressing need for a deeper understanding of novel risk factors that contribute to AMI in young patients. In this review, we explore distinct risk factor profiles associated with young-onset AMI in comparison to older patients. Special attention is given to novel risk factors, examining their susceptibility factors and exploring preventive measures. The comprehensive risk profile of extremely young South Asians who develop early coronary arterial disease is not yet fully understood. There are many novel evolving risk factors associated with young AMI which need intervention to reduce morbidity and mortality. It has been seen that established inflammatory markers like lipoprotein (a), dyslipidaemia, long COVID, and new emerging risk factors like air pollution (micro- and nanoplastics), periodontitis, acute stress, energy drinks, misuse of recreational drugs may increase risk and influence treatment, and outcomes of AMI in this young population. Screening of emerging novel risk markers and their optimization is important in preventing young patients with AMI. The role of conventional risk factors should not be overlooked and should be treated aggressively. Sex and geographic-specific base approaches are required to reduce risk factors and prevent AMI in young. More prospective studies are needed to evaluate the increasing incidence of young AMI and its associated novel risk factors.

Advances in secondary prevention mechanisms of macrovascular complications in type 2 diabetes mellitus patients: a comprehensive review

Type 2 diabetes mellitus (T2DM) poses a significant global health burden. This is particularly due to its macrovascular complications, such as coronary artery disease, peripheral vascular disease, and cerebrovascular disease, which have emerged as leading contributors to morbidity and mortality. This review comprehensively explores the pathophysiological mechanisms underlying these complications, protective strategies, and both existing and emerging secondary preventive measures. Furthermore, we delve into the applications of experimental models and methodologies in foundational research while also highlighting current research limitations and future directions. Specifically, we focus on the literature published post-2020 concerning the secondary prevention of macrovascular complications in patients with T2DM by conducting a targeted review of studies supported by robust evidence to offer a holistic perspective.

Real-world safety of icosapent ethyl: analysis based on spontaneous reports in FAERS database

BACKGROUND

The triglyceride-lowering drug, icosapent ethyl (IPE), was granted a new indication for the reduction of atherosclerotic cardiovascular disease risk in 2019. This study aimed to investigate the safety profile of IPE by mining the FDA Adverse Event Reporting System (FAERS) database.

METHODS

The reporting odds ratio was used to analyze IPE's adverse events (AEs) based on the FAERS data from July 2012 to December 2022. We described the characteristics of AE reports and evaluated the clinical prioritization of AEs. Then we defined and analyzed nine interested adverse drug reactions (ADRs) in both overall and subgroups, and investigated the times to onset.

RESULTS

The findings of our study strengthen the evidence for an increased risk of atrial fibrillation using IPE. IPE alone may not increase the risk of bleeding unless combined with antithrombotic drugs. Similar to statins, IPE alone can increase the risk of musculoskeletal pain, drug-related hepatic disorders, and hyperglycemia, but the risk could not double when IPE was combined with statins. Most ADRs occur in the early stage of treatment.

CONCLUSIONS

This study provides a comprehensive real-world safety profile of IPE, which indicates that IPE is well-tolerated.

Effect of omega-3 fatty acids supplementation on the prognosis of coronary artery disease: A meta-analysis of randomized controlled trials

AIMS

To evaluate whether omega-3 fatty acids (ɷ-3 FAs) supplementation can improve cardiovascular outcomes in patients with established coronary artery disease (CAD).

DATA SYNTHESIS

Five electronic databases were searched for randomized controlled trials that evaluated the effect of ɷ-3 FAs on cardiovascular outcomes in patients with CAD. The language was restricted to English. The risk ratio was pooled. Subgroup analyses were conducted to evaluate whether study-level variables might act as effect modifiers. A total of 12 studies involving 29913 patients were included. ɷ-3 FAs had no effects on major adverse cardiovascular events (MACEs) (RR, 0.93; 95 % CI: 0.85 to 1.01, P = 0.09). While ɷ-3 FAs reduced the incidences of all-cause death (RR, 0.90; 95 % CI: 0.83 to 0.97, P = 0.005), cardiovascular death (RR, 0.82; 95 % CI: 0.75 to 0.90, P < 0.0001), myocardial infarction (RR, 0.77; 95 % CI: 0.68 to 0.86, P < 0.0001), revascularization (RR, 0.80; 95 % CI: 0.69 to 0.93, P = 0.003), sudden cardiac death (RR, 0.67; 95 % CI: 0.52 to 0.86, P = 0.002) and hospitalization for heart failure or unstable angina pectoris (RR, 0.75; 95 % CI: 0.58 to 0.97, P = 0.03) in CAD. It did not statistically reduce the risk of stroke (RR, 0.96; 95 % CI: 0.77 to 1.21, P = 0.76). The favorable effects of ɷ-3 FAs on MACEs were significant in subgroups of intervention with EPA and baseline triglyceride ≥1.7 mmol/L.

CONCLUSION

ɷ-3 FAs supplementation, especially EPA, appears to be an effective adjunct therapy for improving the prognosis of CAD.

REGISTRATION NUMBER

PROSPERO CRD42022311237.

Associations of remnant cholesterol with cardiovascular and cancer mortality in a nationwide cohort

The health significance of triglyceride-rich lipoproteins, also known as remnant cholesterol, has been increasingly recognized. However, evidence of their associations with cause-specific mortality in the general population was previously insufficient. To explore these associations and their heterogeneities across subgroups, a prospective cohort study was conducted including 3,403,414 community-based participants from ChinaHEART, an ongoing government-funded public health program throughout China, from November 2014 through December 2022. The study assessed mortality risk of all-cause mortality, cardiovascular disease (CVD) mortality (including mortality from ischemic heart diseases (IHD), ischemic stroke (IS), and hemorrhagic stroke (HS), separately), and cancer mortality (including lung cancer, stomach cancer, and liver cancer, separately). During the 4-year follow-up, 23,646 individuals died from CVD (including 8807 from IHD, 3067 from IS, and 5190 from HS), and 20,318 from cancer (including 6208 from lung cancer, 3013 from liver cancer, and 2174 from stomach cancer). Compared with individuals with remnant cholesterol <17.9 mg/dL, multivariable-adjusted mortality hazard ratios (HRs) for individuals with remnant cholesterol ≥27.7 mg/dL were 1.03 (1.00-1.05) for all-cause mortality, 1.17 (1.12-1.21) for CVD (1.19 (1.12-1.27) for IHD mortality, and 1.22 (1.09-1.36) for IS mortality), and 0.90 (0.87-0.94) for all-cancer mortality (0.94 (0.87-1.02) for lung cancer, 0.59 (0.53-0.66) for liver cancer, and 0.73 (0.64-0.83) for stomach cancer). In summary, this study revealed a correlation between increased remnant cholesterol levels and an elevated risk of cardiovascular disease mortality, as well as a reduced risk of mortality for certain types of cancer.

Contribution of intestinal triglyceride-rich lipoproteins to residual atherosclerotic cardiovascular disease risk in individuals with type 2 diabetes on statin therapy

AIMS/HYPOTHESIS

This study explored the hypothesis that significant abnormalities in the metabolism of intestinally derived lipoproteins are present in individuals with type 2 diabetes on statin therapy. These abnormalities may contribute to residual CVD risk.

METHODS

To investigate the kinetics of ApoB-48- and ApoB-100-containing lipoproteins, we performed a secondary analysis of 11 overweight/obese individuals with type 2 diabetes who were treated with lifestyle counselling and on a stable dose of metformin who were from an earlier clinical study, and compared these with 11 control participants frequency-matched for age, BMI and sex. Participants in both groups were on a similar statin regimen during the study. Stable isotope tracers were used to determine the kinetics of the following in response to a standard fat-rich meal: (1) apolipoprotein (Apo)B-48 in chylomicrons and VLDL; (2) ApoB-100 in VLDL, intermediate-density lipoprotein (IDL) and LDL; and (3) triglyceride (TG) in VLDL.

RESULTS

The fasting lipid profile did not differ significantly between the two groups. Compared with control participants, in individuals with type 2 diabetes, chylomicron TG and ApoB-48 levels exhibited an approximately twofold higher response to the fat-rich meal, and a twofold higher increment was observed in ApoB-48 particles in the VLDL1 and VLDL2 density ranges (all p < 0.05). Again comparing control participants with individuals with type 2 diabetes, in the latter, total ApoB-48 production was 25% higher (556 ± 57 vs 446 ± 57 mg/day; p < 0.001), conversion (fractional transfer rate) of chylomicrons to VLDL was around 40% lower (35 ± 25 vs 82 ± 58 pools/day; p=0.034) and direct clearance of chylomicrons was 5.6-fold higher (5.6 ± 2.2 vs 1.0 ± 1.8 pools/day; p < 0.001). During the postprandial period, ApoB-48 particles accounted for a higher proportion of total VLDL in individuals with type 2 diabetes (44%) compared with control participants (25%), and these ApoB-48 VLDL particles exhibited a fivefold longer residence time in the circulation (p < 0.01). No between-group differences were seen in the kinetics of ApoB-100 and TG in VLDL, or in LDL ApoB-100 production, pool size and clearance rate. As compared with control participants, the IDL ApoB-100 pool in individuals with type 2 diabetes was higher due to increased conversion from VLDL2.

CONCLUSIONS/INTERPRETATION

Abnormalities in the metabolism of intestinally derived ApoB-48-containing lipoproteins in individuals with type 2 diabetes on statins may help to explain the residual risk of CVD and may be suitable targets for interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02948777.

New Insights into Cardiovascular Diseases Treatment Based on Molecular Targets

Cardiovascular diseases (CVDs) which consist of ischemic heart disease, stroke, heart failure, peripheral arterial disease, and several other cardiac and vascular conditions are one of the most common causes of death worldwide and often co-occur with diabetes mellitus and lipid disorders which worsens the prognosis and becomes a therapeutic challenge. Due to the increasing number of patients with CVDs, we need to search for new risk factors and pathophysiological changes to create new strategies for preventing, diagnosing, and treating not only CVDs but also comorbidities like diabetes mellitus and lipid disorders. As increasing amount of patients suffering from CVDs, there are many therapies which focus on new molecular targets like proprotein convertase subtilisin/kexin type 9 (PCSK9), angiopoietin-like protein 3, ATP-citrate lyase, or new technologies such as siRNA in treatment of dyslipidemia or sodium-glucose co-transporter-2 and glucagon-like peptide-1 in treatment of diabetes mellitus. Both SGLT-2 inhibitors and GLP-1 receptor agonists are used in the treatment of diabetes, however, they proved to have a beneficial effect in CVDs as well. Moreover, a significant amount of evidence has shown that exosomes seem to be associated with myocardial ischaemia and that exosome levels correlate with the severity of myocardial injury. In our work, we would like to focus on the above mechanisms. The knowledge of them allows for the appearance of new strategies of treatment among patients with CVDs.

Efficacy and safety of Qixue Tongzhi Granule in improving the exercise capacity of stable coronary artery disease: study protocol for a multicenter, randomized, double-blind, placebo-controlled trial

Background

Despite optimal medical therapy, patients with stable coronary artery disease (SCAD) still have a high risk of recurrent cardiovascular events. Exercise capacity measured by cardiopulmonary exercise testing (CPET) is a good surrogate marker for the long-term prognosis of SCAD. Qixue Tongzhi Granule (QTG) is created by academician Chen Keji and has the function of tonifying qi, promoting blood circulation, and regulating qi-flowing. This trial aims to investigate the efficacy and safety of QTG in improving exercise tolerance, alleviating angina pectoris and anxiety/depression symptoms, promoting health-related quality of life, and reducing the risk of adverse cardiovascular events in subjects with SCAD.

Methods

This is a randomized, double-blind, placebo-controlled trial. 150 SCAD patients with qi deficiency, blood stasis, and liver qi stagnation syndrome are enrolled. Patients will be randomly allocated to the QTG or placebo groups at a 1:1 ratio. QTG and placebo will be added to the modern guideline-directed medical therapy for 12 weeks and patients will be followed up for another 24 weeks. The primary outcome is the improvement of metabolic equivalents measured by CPET. The secondary outcomes are cumulative incidence of composite endpoint events, other indicators in CPET, changes in the Seattle Angina Questionnaire, traditional Chinese medicine syndrome scale, 12 items of Short Form Health Survey Questionnaire, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7, changes of ST-T segment in the electrocardiogram, improvement of left ventricular ejection fraction and left ventricular end-diastolic diameter in echocardiography. In addition, metabolomics analysis will be performed based on blood samples. Adverse events and safety evaluations will also be documented. A full analysis set, per protocol set, and safety analysis set will be conducted.

Discussion

This clinical trial can enrich treatment options for CHD patients with low cardiorespiratory fitness and psychological imbalance, and it may also create a new situation for promoting the application of traditional Chinese medicine in cardiac rehabilitation.Clinical Trial Registration: [http://www.chictr.org.cn], identifier: [ChiCTR2200058988].

Separate and Joint Associations of Remnant Cholesterol Accumulation and Variability With Carotid Atherosclerosis: A Prospective Cohort Study

Background We aimed to examine separate and joint associations of remnant cholesterol (RC) accumulation and variability with the risk of carotid atherosclerosis (CAS) in the general population. Methods and Results A total of 6213 participants who underwent 3 sequential health examinations during 2010 to 2015 were enrolled and were followed up until December 31, 2021. Cumulative RC (cumRC) and RC variability among the 3 visits were the exposure of interest in our study. Adjusted Cox models were performed to calculate the hazard ratio (HR) and 95% CI. C-statistics, integrated discrimination improvement, and the net reclassification index were used to estimate the incremental predictive ability. During a median follow-up of 4.00 years, 2613 participants developed CAS. Higher cumRC (HR, 1.33 [95% CI, 1.17-1.52]) and greater RC variability (HR, 1.22 [95% CI, 1.08-1.39]) were significantly associated with elevated risk of CAS, independent of traditional cardiovascular risk factors and low-density lipoprotein cholesterol. Participants were divided into 4 groups according to the median of cumRC and RC variability to assess their joint associations. Compared with "low cumRC and low variability," "high cumRC and high variability" had the highest risk of CAS, followed by "high cumRC and low variability" and "low cumRC and high variability." Finally, joint assessment of RC accumulation and variability had the significantly highest incremental effect on the predictive value of CAS versus single-time-point measures of RC. Conclusions Excessive cumRC levels and greater RC variability were each independently associated with higher incidence of CAS, and their coexistence could further yield significantly higher risks.

Icosapent ethyl in cardiovascular prevention: Resolution of inflammation through the eicosapentaenoic acid - resolvin E1 - ChemR23 axis

Cardiovascular outcome trials on omega-3 fatty acids have generated contradictory results but indicate a dose-dependent beneficial effect of eicosapentaenoic acid (EPA). Beneficial cardiovascular effects of EPA may in addition to triglyceride lowering be mediated through alternative mechanisms of action. In this review, the link between EPA and a resolution of atherosclerotic inflammation is addressed. EPA is a substrate for the enzymatic metabolism into the lipid mediator resolvin E1 (RvE1), which activates the receptor ChemR23 to transduce an active resolution of inflammation. This has been shown to dampen the immune response and provide atheroprotective responses in different models. The intermediate EPA metabolite 18-HEPE emerges as a biomarker of EPA metabolism towards proresolving mediators in observational studies. Genetic variations within the EPA-RvE1-ChemR23 axis affecting the response to EPA may open up for precision medicine to identify responders and non-responders to EPA and fish oil supplementation. In conclusion, activation of the EPA-RvE1-ChemR23 axis towards a resolution of inflammation may contribute to beneficial effects in cardiovascular prevention.

Clinical results and mechanism of action of icosapent ethyl

Serum triglyceride concentration is considered as an additional component that often contributes to residual cardiovascular risk in patients already at high risk; these considerations have led to several clinical studies aimed at evaluating the efficacy of supplements based on omega-3 fatty acids in reducing serum triglyceride levels and consequently cardiovascular risk. Although partially inconclusive and contradictory, these clinical trials laid the foundations for the implementation of the REDUCE-IT and EVAPORATE studies, in which the use of a purified derivative of eicosapentaenoic acid, icosapent ethyl, resulted in a significant reduction both of the composite for cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke and of the reduction in the volumetric progression up to the induction of a real regression of the coronary atheromatous plaques detected by computerized coronary angiography tomography. Surprisingly, these brilliant results seem to be, at least in part, not related to the reduction of triglyceride concentration. The purpose of this article is to examine the latest evidence regarding icosapent ethyl therapy, describing the results of the main clinical trials performed to date and formulating hypotheses on the potential mechanisms of action of this fascinating molecule.

Possibility of averting cytokine storm in SARS-COV 2 patients using specialized pro-resolving lipid mediators

Fatal "cytokine storms (CS)" observed in critically ill COVID-19 patients are consequences of dysregulated host immune system and over-exuberant inflammatory response. Acute respiratory distress syndrome (ARDS), multi-system organ failure, and eventual death are distinctive symptoms, attributed to higher morbidity and mortality rates among these patients. Consequent efforts to save critical COVID-19 patients via the usage of several novel therapeutic options are put in force. Strategically, drugs being used in such patients are dexamethasone, remdesivir, hydroxychloroquine, etc. along with the approved vaccines. Moreover, it is certain that activation of the resolution process is important for the prevention of chronic diseases. Until recently Inflammation resolution was considered a passive process, rather it's an active biochemical process that can be achieved by the use of specialized pro-resolving mediators (SPMs). These endogenous mediators are an array of atypical lipid metabolites that include Resolvins, lipoxins, maresins, protectins, considered as immunoresolvents, but their role in COVID-19 is ambiguous. Recent evidence from studies such as the randomized clinical trial, in which omega 3 fatty acid was used as supplement to resolve inflammation in COVID-19, suggests that direct supplementation of SPMs or the use of synthetic SPM mimetics (which are still being explored) could enhance the process of resolution by regulating the aberrant inflammatory process and can be useful in pain relief and tissue remodeling. Here we discussed the biosynthesis of SPMs, & their mechanistic pathways contributing to inflammation resolution along with sequence of events leading to CS in COVID-19, with a focus on therapeutic potential of SPMs.

A case control study on the relationship between occupational stress and genetic polymorphism and dyslipidemia in coal miners

Dyslipidemia is one of the known risk factors for cardiovascular disease, and its prevalence is increasing worldwide. At present, the study of dyslipidemia has gradually shifted from simple environmental or genetic factors to environment-gene interactions. In order to further explore the etiology and mechanism of dyslipidemia, we used occupational stress(OS) and LYPLAL1, APOC3 and SOD2 gene as research variables to explore their association with dyslipidemia.Here we used a case-control study to include Han workers from a coal mining enterprise in China to determine the association between study variables and dyslipidemia. Monofactor analysis showed that smoking, drinking, physical activity level, DASH diet score, sleep quality, BMI, hypertension, hyperuricemia, shift work, OS were significantly different between the two groups (P < 0.05). In the APOC3 rs2854116 dominant model, patients with CT/CC genotype had a higher risk of dyslipidemia than those with TT genotype. In SOD2 rs4880 recessive model, patients with GG genotype had a lower risk of dyslipidemia than those with AA/AG genotype, and the difference was statistically significant. We found that rs12137855 and OS, rs2854116 and OS, rs4880 and OS had joint effects, but no interaction based on the multiplication and addition model was found (P_interaction > 0.05). GMDR model showed that the rs12137855-rs2854116-rs4880-OS four-factor model had the highest cross-validation consistency and training-validation accuracy (P < 0.05), suggesting that there was a high-order interaction between them associated with dyslipidemia. We found that dyslipidemia in coal miners was related to OS and genetic factors. Through this study, we revealed the dual regulation of environmental factors and genetic factors on dyslipidemia. At the same time, this study provides clues for understanding the etiology and mechanism of dyslipidemia.

Longitudinal association of remnant cholesterol with joint arteriosclerosis and atherosclerosis progression beyond LDL cholesterol

BACKGROUND

Arteriosclerosis and atherosclerosis are closely related with cardiovascular disease (CVD) risk. Remnant cholesterol (RC) could predict CVD. However, its effect on joint arteriosclerosis and atherosclerosis progression remains unclear. This study aims to evaluate the association of RC with joint arteriosclerosis and atherosclerosis progression trajectories in the general population.

METHODS

This study collected data across five biennial surveys of the Beijing Health Management Cohort from 2010 to 2019. Multi-trajectory model was used to determine the joint arteriosclerosis and atherosclerosis progression patterns by brachial-ankle pulse wave velocity (baPWV) and ankle brachial index (ABI). We also performed discordance analyses for RC vs. low density lipoprotein cholesterol (LDL-C) using ordinal logistics model.

RESULTS

A total of 3186 participants were included, with three clusters following distinct arteriosclerosis and atherosclerosis progression patterns identified using a multi-trajectory model. In the multivariable-adjusted ordinal logistics analyses, RC was significantly associated with baPWV and ABI progression (OR: 1.20; 95% CI: 1.13-1.28, per 10 mg/dL). For the discordance analyses, the discordant low RC group was associated with decreased risk compared to the concordant group (OR: 0.73; 95% CI: 0.60-0.89). People with a high RC level were at an increased risk of joint arteriosclerosis and atherosclerosis progression, even with optimal LDL-C.

CONCLUSIONS

RC is independently associated with joint arteriosclerosis and atherosclerosis progression beyond LDL-C. RC could be an earlier risk factor than LDL-C of arteriosclerosis and atherosclerosis in the general population.

Proliferative Vasculopathy Associated With Antiphospholipid Antibodies in Patients With Neurological Symptoms

Background

Proliferative vasculopathy (PV) associated antiphospholipid syndrome (APS) in the central nervous system is a rare un(der)recognized form of extra-criteria manifestations of APS. This study investigated the angiographic characteristics of cerebral and cervical arteries in patients with PV associated with antiphospholipid antibodies (aPLs).

Methods

Patients with aPLs, neurologic symptoms and diffuse luminal narrowing on brain or neck magnetic resonance angiography were selected from electronic medical records. Vascular wall and intraluminal pathology were examined by high-resolution vessel wall MR imaging (VW-MRI).

Results

A total of 11 patients (six men and five women) with PV-aPL, of median (interquartile range) age 42 (34–61) years, were included. Median anticardiolipin antibodies IgG titer was 78.9 (28.2–134.0) units and anti-beta 2 glycoprotein I antibodies (aB2GPIs) IgG titer was 227.2 (0.0–1012.1) units. All patients had diffuse luminal narrowing in the carotid basilar and/or cerebral arteries, five in the internal carotid artery (ICA); two each in the middle cerebral artery (MCA) and vertebral artery; and one each in the basilar artery (BA) and posterior cerebral artery. On VW-MRI, four patients showed concentric thickening of the vascular walls of the ICA and/or MCA and two showed mild eccentric wall thickening of the ICA or BA. All patients received antithrombotic treatment. In two patients with extremely high aB2GPIs titer, diffuse narrowing progressed despite treatment with antithrombotic agents on follow-up imaging.

Conclusions

This study suggests that PV-aPL might be a distinct extra-criteria manifestation of APS that can manifest as long-segmental diffuse stenosis of cerebral and cervical arteries. It should be considered in relatively young patients with neurologic symptoms and aPLs.

Differentiating EPA from EPA/DHA in cardiovascular risk reduction

None of the clinical trials of omega-3 fatty acids using combinations of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) were able to show any effect on cardiovascular outcomes, despite reductions in triglyceride levels. In contrast, the Reduction of Cardiovascular Events With Icosapent Ethyl-Intervention Trial (REDUCE-IT), which employed high-dose (4 g) purified EPA, demonstrated a 25% reduction in atherosclerotic cardiovascular disease-related events compared with placebo (hazard ratio 0.75; 95% confidence interval 0.68-0.83; P < 0.001). Moreover, REDUCE-IT is the first clinical trial using a lipid-lowering agent as adjuvant therapy to a statin to show a significant reduction in cardiovascular mortality. Significant reductions in stroke, need for revascularization, and myocardial infarction were also observed. The pharmacology of EPA is distinct from that of DHA, with a differential effect on membrane structure, lipoprotein oxidation, and the production of downstream metabolites that promote the resolution of inflammation. Attained plasma levels of EPA may be an important determinant of efficacy, with a substudy of REDUCE-IT suggesting that the threshold for clinical benefit of EPA is approximately 100 μg/mL, a level achieved in only a minority of patients in other studies. No similar clinical trials of DHA monotherapy have been conducted, so no such threshold has been established. The results of the REDUCE-IT and the Japan EPA Lipid Intervention Study (JELIS) together affirm the efficacy of EPA therapy for cardiovascular disease risk reduction in certain patient populations.