Low-density lipoproteins and risk for coronary artery disease

A Practical Approach to the Management of Residual Cardiovascular Risk: United Arab Emirates Expert Consensus Panel on the Evidence for Icosapent Ethyl and Omega-3 Fatty Acids

PURPOSE

Patients with hyperlipidemia treated with statins remain at a residual cardiovascular (CV) risk. Omega-3 polyunsaturated fatty acids hold the potential to mitigate the residual CV risk in statin-treated patients, with persistently elevated triglyceride (TG) levels.

METHOD

We reviewed the current evidence on the use of icosapent ethyl (IPE), an omega-3 fatty acid yielding a pure form of eicosapentaenoic acid.

RESULTS

REDUCE-IT reported a significant 25% reduction in CV events, including the need for coronary revascularization, the risk of fatal/nonfatal myocardial infarction, stroke, hospitalization for unstable angina, and CV death in patients on IPE, unseen with other omega-3 fatty acids treatments. IPE was effective in all patients regardless of baseline CV risk enhancers (TG levels, type-2 diabetes status, weight status, prior revascularization, or renal function). Adverse events (atrial fibrillation/flutter) related to IPE have occurred mostly in patients with prior atrial fibrillation. Yet, the net clinical benefit largely exceeded potential risks. The combination with other omega-3 polyunsaturated fatty acids, in particular DHA, eliminated the effect of EPA alone, as reported in the STRENGTH and OMEMI trials. Adding IPE to statin treatment seems to be cost-effective, especially in the context of secondary prevention of CVD, decreasing CV event frequency and subsequently the use of healthcare resources.

CONCLUSION

Importantly, IPE has been endorsed by 20 international medical societies as a statin add-on treatment in patients with dyslipidemia and high CV risk. Robust medical evidence supports IPE as a pillar in the management of dyslipidemia.

Anti-inflammatory potential of ulvan

Green seaweeds are a widespread group of marine macroalgae that could be regarded as biorenewable source of valuable compounds, in particular sulfated polysaccharides like ulvans with interesting biological properties. Among them, anti-inflammatory activity represents an interesting target, since ulvans could potentially avoid side effects of conventional therapies. However, a great variability in ulvan content, composition, structure and properties occurs depending on seaweed specie and growth and processing conditions. All these aspects should be carefully considered in order to have reproducible and well characterized products. This review presents some concise ideas on ulvan composition and general concepts on inflammation mechanisms. Then, the main focus is on the importance of adequate selection of extraction, depolymerization and purification technologies followed by an updated survey on anti-inflammatory properties of ulvans through modulation of different signaling pathways. The potential application in a number of diseases, with special emphasis on inflammaging, gut microbiota dysbiosis, wound repair, and metabolic diseases is also discussed. This multidisciplinary overview tries to present the potential of ulvans considering not only mechanistic, but also processing and applications aspects, trusting that it can aid in the development and application of this widely available and renewable resource as an efficient and versatile anti-inflammatory agent.

Promoting analysis of real-world data: Prospects for preventive cardiology in Japan

According to the statistics for 2018 in Japan, cardiovascular disease and cerebrovascular disease were the most common causes of death (cardiovascular disease with 208,210, cerebrovascular disease with 108,165), and these two diseases account for 23.2% of all deaths. Stroke, especially cerebral hemorrhage, was the main cause of death in Japan after World War II. Along with improved management of hypertension, the mortality rate from cerebral hemorrhage reached a high of 266.7 per 100,000 men in 1960 and 213.9 per 100,000 women in 1951, then decreased to 15.9 per 100,000 men and 6.9 per 100,000 women in 2013. However, mortality from lifestyle-related diseases such as metabolic syndrome and ischemic heart disease has been on the rise since 1990 due to the westernization of diet, urban lifestyles, and lack of exercise habits. Moreover, since aging is the greatest risk factor for heart failure, the number of patients with heart failure in Japan will inevitably increase in the future. A large amount of evidence has demonstrated that prevention and proper management of risk factors can reduce the future incidence of cardiovascular disease. Specific health checkups (metabolic syndrome checkups) have been carried out in Japan since 2008. Big data on physical examinations are valuable real-world data that can be utilized for clinical research. As the importance of preventive cardiology increases in the future, we should analyze the real-world data from health checkups in Japan in detail and disseminate these results to clinical practice, which will contribute to development of preventive cardiology and the promotion of public health.

Update on pediatric metabolic and bariatric surgery

The prevalence of childhood obesity has risen sharply over the last several decades and poses a significant threat to the health and well-being of today's youth. Childhood-onset obesity is associated with a number of cardiometabolic consequences, which contribute to diminished quality of life. Metabolic and bariatric surgery offers a powerful treatment paradigm with positive long-term health effects. A growing body of literature supports the notion that earlier intervention in younger patients results in long-term health benefits. The development of a multidisciplinary care model and best practice guidelines are central to providing optimal care for this vulnerable patient population. Although the outcomes of metabolic and bariatric surgery in pediatric patients are reassuring and support the ongoing utilization of this important treatment paradigm, a number of significant challenges remain regarding access to care. As the literature continues to support earlier intervention for youth with severe obesity, future efforts should address these challenges to ensure that eligible patients are referred in timely fashion.

Differences Between Morbid Obesity With Metabolic Syndrome and Overweight Turkish Adult Participants in Multiple Atherosclerotic Cardiovascular Disease Risk Factors

Obesity and metabolic syndrome (MetS) are public health problems and are increasing globally. We assessed the differences in lipid profiles through lipid testing, thrombotic and inflammatory parameters, and oxidative stress indexes between overweight and obese patients with MetS in a Turkish adult population. We included 100 obese (body mass index [BMI] >30 kg/m²) patients with MetS (66 women, 34 men, mean age 54.0 ± 10.1 years) and 15 overweight (BMI 25-30 kg/m²) individuals (11 women, 4 men, mean age 50.2 ± 14.5 years) as controls. The group with MetS had significantly higher levels of glycaemia, uric acid, high-sensitivity C-reactive protein, homocysteine, fibrinogen, total cholesterol, low-density lipoprotein cholesterol (LDL-C), triglycerides, small dense LDL, oxidized LDL, apolipoprotein B (Apo B), lipoprotein (a), small and intermediate high-density lipoprotein (HDL) particles, oxidative stress index, and significantly lower levels of HDL-cholesterol (HDL-C), Apo A, and large HDL particles. In conclusion, obesity with MetS increase atherogenic dyslipidemia and thrombotic, inflammatory and oxidative stress biomarkers. Furthermore, obesity with MetS decreases protective mechanisms of atherosclerosis. We should at least try to prevent overweight individuals from becoming obese with MetS.

Acetylator Genotype-Dependent Dyslipidemia in Rats Congenic for N-Acetyltransferase 2

Recent reports suggest that arylamine N-acetyltransferases (NAT1 and/or NAT2) serve important roles in regulation of energy utility and insulin sensitivity. We investigated the interaction between diet (control vs. high-fat diet) and acetylator phenotype (rapid vs. slow) using previously established congenic rat lines (in F344 background) that exhibit rapid or slow Nat2 (orthologous to human NAT1) acetylator genotypes. Male and female rats of each genotype were fed control or high-fat (Western-style) diet for 26 weeks. We then examined diet- and acetylator genotype-dependent changes in body and liver weights, systemic glucose tolerance, insulin sensitivity, and plasma lipid profile. Male and female rats on the high fat diet weighed approximately 10% more than rats on the control diet and the percentage liver to body weight was consistently higher in rapid than slow acetylator rats. Rapid acetylator rats were more prone to develop dyslipidemia overall (i.e., higher triglyceride; higher LDL; and lower HDL), compared to slow acetylator rats. Total cholesterol (TC)-to-HDL ratios were significantly higher and HDL-to-LDL ratios were significantly lower in rapid acetylator rats. Our data suggest that rats with rapid systemic Nat2 (NAT1 in humans) genotype exhibited higher dyslipidemia conferring risk for metabolic syndrome and cardiovascular dysfunction.

A prospective study of hepatic safety of statins used in very elderly patients

BACKGROUND

Statins play an important role in the care of patients with cardiovascular disease and have a good safety record in clinical practice. Hepatotoxicity is a barrier that limits the ability of primary care physicians to prescribe statins for patients with elevated liver transaminase values and/or underlying liver disease. However, limited population-based data are available on the use of statin therapy and on the hepatotoxicity of statins in very elderly patients. This prospective study evaluated the liver enzyme elevation during statin therapy in very elderly patients (≥80 years old).

METHODS

Patients with hypercholesterolemia (LDL-C levels ≥3.4 and < 5.7 mmol/L), atherosclerosis, coronary heart disease (CHD), or a CHD-risk equivalent were enrolled and received once-daily statin treatment. Multivariate logistic regression models were used to study the impact of age, gender, hepatitis B infection, fatty liver disease, biliary calculus, other chronic diseases, drug kinds, alcohol abuse, statin variety, and statin dose variables.

RESULTS

A total of 515 consecutive patients ranging from 80 to 98 years old were included in the analysis. These patients were treated with simvastatin, fluvastatin, pravastatin, rosuvastatin, or atorvastatin. Twenty-four patients (4.7, 95% CI 2.7-6.6) showed an increase in their hepatic aminotransferase levels. No significant difference of hepatic aminotransferase elevation rates was observed in different statin treatment groups. The incidence of mild, moderate, and severe elevation of aminotransferase levels was 62.5% (15/24), 29.2% (7/24), and 8.3% (2/24), respectively. None of the patients developed hepatic failure. Nine patients with moderate or severe aminotransferase elevations discontinued therapy. The time of onset of hepatic aminotransferase elevation ranged from 2 weeks to 6 months after statin treatment. The onset of hepatic aminotransferase elevation was within 1 month for 70.8% of patients. The patients took 2 weeks to 3 months to recover their liver function after statin therapy cessation. Multivariate analysis identified chronic hepatitis B infection and alcohol consumption as independent factors associated with the hepatic response to statins: OR, 12.83; 95% CI (4.36-37.759) and OR, 2.736; 95% CI (1.373-5.454), respectively.

CONCLUSION

The prevalence of elevated transaminases was higher than published data in very elderly patients. Overall, statin treatment is safe for patients ≥80 years old.

Diabetic dyslipidemia: evaluation and mechanism

Diabetes is one of the well-established independent risk factors for cardiovascular diseases. Diabetes induces dyslipidemia which is characterized by elevated fasting triglyceride (TG) and reduced high-density lipoprotein-cholesterol (HDL-C), and such diabetic dyslipidemia is a crucial determinant for atherogenesis and atherosclerotic progression in patients with diabetes. Previous measurement methods of lipoproteins have problems including time-consuming (ultracentrifugation) and inaccurate and impossible measurements of TG-rich lipoproteins such as chylomicron, intermediate-density lipoprotein (IDL) and very low-density lipoprotein (VLDL). Our developed anion-exchange high-performance liquid chromatography (AEX-HPLC) can measure all fractions of lipoproteins accurately. Our studies using AEX-HPLC showed that IDL and VLDL in type 2 diabetes were higher than non-diabetic subjects, and IDL and VLDL were higher in the order of type 2 diabetic patients with obesity, type 2 diabetic patients without obesity, and non-diabetic subjects. Here, we also describe the underlying mechanisms for development of diabetic dyslipidemia.

Evaluation of Martin's equation for LDL-C estimation in type 2 diabetes mellitus Egyptian patients

INTRODUCTION

Type 2 Diabetes Mellitus has characteristic dyslipidemia. Low-density lipoprotein cholesterol (LDL-C) measurement plays a role in cardiovascular risk assessment and management. Friedewald equation (FE) has several limitations. This study aims to evaluate the effectiveness of Martin equation (ME) in Egyptian patients, especially those with type 2 diabetes.

METHODS

A cross-sectional study was conducted on 454 diabetic and non-diabetic patients who were referred to the internal medicine outpatient clinic. Lipid profile was assessed by Cobas 8000 Modular Analyzer.

RESULTS

The LDL-C was estimated by both FE and ME. In diabetic patients, LDL-C estimated by FE was underestimated with a bias of -3.9 ± 5.3 mg/dL (p = .04). But LDL-C estimated by ME was not significantly different compared to directly measured LDL-C. FE underestimate LDL-C with a bias of -4.6 ± 6.4 mg/dL (p = .042) in uncontrolled diabetic patients. A non-significant difference in both uncontrolled patients and controlled ones was detected by ME. FE had lower sensitivity and specificity (80% and 88.9 respectively) compared to the ME (95.9% sensitivity, and 95.6% specificity). ME was not influenced by triglyceride levels (p = .34).

CONCLUSION

The ME improves concordance of calculated LDL-C with a direct LDL-C assay in Egyptian diabetic patients.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY GUIDELINES FOR MANAGEMENT OF DYSLIPIDEMIA AND PREVENTION OF CARDIOVASCULAR DISEASE

OBJECTIVE

The development of these guidelines is mandated by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs).

METHODS

Recommendations are based on diligent reviews of the clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols.

RESULTS

The Executive Summary of this document contains 87 recommendations of which 45 are Grade A (51.7%), 18 are Grade B (20.7%), 15 are Grade C (17.2%), and 9 (10.3%) are Grade D. These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world medical care. The evidence base presented in the subsequent Appendix provides relevant supporting information for Executive Summary Recommendations. This update contains 695 citations of which 203 (29.2 %) are EL 1 (strong), 137 (19.7%) are EL 2 (intermediate), 119 (17.1%) are EL 3 (weak), and 236 (34.0%) are EL 4 (no clinical evidence).

CONCLUSION

This CPG is a practical tool that endocrinologists, other health care professionals, health-related organizations, and regulatory bodies can use to reduce the risks and consequences of dyslipidemia. It provides guidance on screening, risk assessment, and treatment recommendations for a range of individuals with various lipid disorders. The recommendations emphasize the importance of treating low-density lipoprotein cholesterol (LDL-C) in some individuals to lower goals than previously endorsed and support the measurement of coronary artery calcium scores and inflammatory markers to help stratify risk. Special consideration is given to individuals with diabetes, familial hypercholesterolemia, women, and youth with dyslipidemia. Both clinical and cost-effectiveness data are provided to support treatment decisions.

ABBREVIATIONS

4S = Scandinavian Simvastatin Survival Study A1C = glycated hemoglobin AACE = American Association of Clinical Endocrinologists AAP = American Academy of Pediatrics ACC = American College of Cardiology ACE = American College of Endocrinology ACS = acute coronary syndrome ADMIT = Arterial Disease Multiple Intervention Trial ADVENT = Assessment of Diabetes Control and Evaluation of the Efficacy of Niaspan Trial AFCAPS/TexCAPS = Air Force/Texas Coronary Atherosclerosis Prevention Study AHA = American Heart Association AHRQ = Agency for Healthcare Research and Quality AIM-HIGH = Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides trial ASCVD = atherosclerotic cardiovascular disease ATP = Adult Treatment Panel apo = apolipoprotein BEL = best evidence level BIP = Bezafibrate Infarction Prevention trial BMI = body mass index CABG = coronary artery bypass graft CAC = coronary artery calcification CARDS = Collaborative Atorvastatin Diabetes Study CDP = Coronary Drug Project trial CI = confidence interval CIMT = carotid intimal media thickness CKD = chronic kidney disease CPG(s) = clinical practice guideline(s) CRP = C-reactive protein CTT = Cholesterol Treatment Trialists CV = cerebrovascular CVA = cerebrovascular accident EL = evidence level FH = familial hypercholesterolemia FIELD = Secondary Endpoints from the Fenofibrate Intervention and Event Lowering in Diabetes trial FOURIER = Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects With Elevated Risk trial HATS = HDL-Atherosclerosis Treatment Study HDL-C = high-density lipoprotein cholesterol HeFH = heterozygous familial hypercholesterolemia HHS = Helsinki Heart Study HIV = human immunodeficiency virus HoFH = homozygous familial hypercholesterolemia HPS = Heart Protection Study HPS2-THRIVE = Treatment of HDL to Reduce the Incidence of Vascular Events trial HR = hazard ratio HRT = hormone replacement therapy hsCRP = high-sensitivity CRP IMPROVE-IT = Improved Reduction of Outcomes: Vytorin Efficacy International Trial IRAS = Insulin Resistance Atherosclerosis Study JUPITER = Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin LDL-C = low-density lipoprotein cholesterol Lp-PLA2 = lipoprotein-associated phospholipase A2 MACE = major cardiovascular events MESA = Multi-Ethnic Study of Atherosclerosis MetS = metabolic syndrome MI = myocardial infarction MRFIT = Multiple Risk Factor Intervention Trial NCEP = National Cholesterol Education Program NHLBI = National Heart, Lung, and Blood Institute PCOS = polycystic ovary syndrome PCSK9 = proprotein convertase subtilisin/kexin type 9 Post CABG = Post Coronary Artery Bypass Graft trial PROSPER = Prospective Study of Pravastatin in the Elderly at Risk trial QALY = quality-adjusted life-year ROC = receiver-operator characteristic SOC = standard of care SHARP = Study of Heart and Renal Protection T1DM = type 1 diabetes mellitus T2DM = type 2 diabetes mellitus TG = triglycerides TNT = Treating to New Targets trial VA-HIT = Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial VLDL-C = very low-density lipoprotein cholesterol WHI = Women's Health Initiative.

PCSK9 Inhibitors: Clinical Relevance, Molecular Mechanisms, and Safety in Clinical Practice

Coronary artery disease (CAD) is one of the leading causes of mortality. High circulating levels of low-density lipoprotein (LDL) in the blood are associated with cardiovascular mortality, whether through an etiological role or through its association with the progression of CAD per se. Randomized clinical trials have shown that, when LDL levels are reduced, cardiovascular risk is also reduced, which reinforces this association. The first major trial involving a hypolipidemic agent of the statin family, the Scandinavian Simvastatin Survival Study (4S), was published in 1994 and found a significant reduction in mortality in patients at high cardiovascular risk. However, even in subsequent studies with different statins, a residual risk persisted, and this seems not to have changed over time; it is speculated that this risk may be due to statin intolerance. In this scenario, the potential exists for novel hypolipidemic agents to drive a true revolution in the therapy of dyslipidemia. The recent discovery of PCSK9 inhibitors (PCSK9i), a class of hypolipidemic monoclonal antibodies, is extremely promising. PCSK9 inhibition is capable of promoting a mean LDL reduction of up to 60%, with potential for very significant clinical repercussions, as every 38 mg/dL reduction in LDL appears to be associated with a 22% reduction in cardiovascular risk. This review addresses a brief history of PCSK9i, major trials of these drugs, cardiovascular outcomes, and aspects related to their efficacy and safety. Finally, the molecular mechanisms and possible pleiotropic effects of PCSK9i are also discussed.

The pharmacodynamic and clinical trial evidence for statin dose

Statin doses around estimated effective dose 50 (ED50) can reduce myocardial infarction by over 25% and mortality by around 10%. Being a competitive enzyme inhibitor, statin efficacy plateaus at doses that are multiples above the ED50, whilst on- and off-target adverse events increase in number and severity with increasing dose. For example, myopathy has been shown to increase by up to 29-fold and liver dysfunction by up to nine-fold as statin dose is increased. Doses of up to 40-fold ED50 have been promoted, but above five-fold ED50, for example 10 mg of atorvastatin, there is no randomized controlled clinical trial evidence that coronary mortality is lowered, or that survival is increased.

Impact of high-dose statins on vitamin D levels and platelet function in patients with coronary artery disease

BACKGROUND

Statins represent a pivotal treatment in coronary artery disease, offering a reduction in cardiovascular risk even beyond their lipid-lowering action. However, the mechanism of these "pleiotropic" benefits of statins is poorly understood. Vitamin D has been suggested as a potential mediator of the anti-inflammatory, anti-thrombotic and vascular protecting effects of statins. Aim of present study was to assess the impact of a high-intensity statin therapy on vitamin D levels and platelet function in patients with coronary artery disease.

METHODS

Patients discharged on dual antiplatelet therapy and high-intensity statins after an ACS or elective PCI were scheduled for main chemistry and vitamin D levels assessment at 30-90days post-discharge. Vitamin D (25-OHD) dosing was performed by chemiluminescence method through the LIAISON® Vitamin D assay (Diasorin Inc). Platelet function was assessed by Multiplate® (multiple platelet function analyser; Roche Diagnostics AG).

RESULTS

Among 246 patients included, 142 were discharged on a new statin therapy or with an increase in previous dose (Inc-S), while 104 were already receiving a high-dose statin at admission, that remained unchanged (Eq-S). Median follow-up was 75.5days. Patients in the Inc-S group were younger (p=0.01), smokers (p<0.001), with a less frequent history of hypercholesterolemia (p=0.05), diabetes (p=0.03), hypertension (p=0.02), or previous cardiovascular events (p<0.001). They were more often admitted for an acute coronary syndrome (p<0.001) and used less anti-hypertensive drugs or nitrates. Higher total circulating calcium was observed in the Inc-S group (p=0.004), while baseline vitamin D levels were similar in the 2 groups (p=0.30). A significant reduction in the circulating low-density lipoprotein (LDL) cholesterol was observed in the Inc-S group. Vitamin D levels increased in the Inc-S patients but not in the Eq-S group (delta-25OHD: 23.2±20.5% vs 3.1±4.7%, p=0.003), with a linear relationship between the magnitude of vitamin D elevation and the reduction of LDL cholesterol (r=-0.17, p=0.01). Platelet reactivity was significantly lower in the Inc-S patients, when evaluating aggregation with different platelet activating stimuli (arachidonic acid, p=0.02, collagen, p=0.004, thrombin-activating peptide, p=0.07, ADP, p=0.002).

CONCLUSIONS

In patients with coronary artery disease, the addition of a high-intensity statin treatment, besides the lipid-lowering effects, is associated to a significant increase in vitamin D levels and lower platelet reactivity, potentially providing explanation of the "pleiotropic" benefits of statins therapy in cardiovascular disease.

Cholesterol trials and mortality

An overview of clinical trials can reveal a class effect on mortality that is not apparent from individual trials. Most large trials of lipid pharmacotherapy are not powered to detect differences in mortality and instead assess efficacy with composite cardiovascular endpoints. We illustrate the importance of all-cause mortality data by comparing survival in three different sets of the larger controlled lipid trials that underpin meta-analyses. These trials are for fibrates and statins. Fibrate treatment in five of the six main trials was associated with a decrease in survival, one fibrate trial showed a non-significant reduction in mortality that can be explained by a different target population. In secondary prevention, statin treatment increased survival in all five of the main trials, absolute mean increase ranged from 0.43% to 3.33%, the median change was 1.75%, which occurred in the largest trial. In primary prevention, statin treatment increased survival in six of the seven main trials, absolute mean change in survival ranged from -0.09% to 0.89%, median 0.49%. Composite safety endpoints are rare in these trials. The failure to address composite safety endpoints in most lipid trials precludes a balanced summary of risk-benefit when a composite has been used for efficacy. Class effects on survival provide informative summaries of the risk-benefit of lipid pharmacotherapy. We consider that the presentation of key mortality/survival data adds to existing meta-analyses to aid personal treatment decisions.

Development and Testing of the Cholesterol-Lowering Diet Self-Efficacy Scale

A cornerstone of treatment for hypercholesterolemia is dietary therapy. However, maintaining adherence to the therapeutic diet has been difficult for patients. There is evidence that self-efficacy is a predictor of positive behavior change like that involved in or necessary for initiating or maintaining recommended diet therapy for cholesterol reduction. This paper reports on two studies guided by Bandura's self-efficacy theory. The first study focuses on development and initial psychometric evaluation of an instrument measuring self-efficacy for adhering to a cholesterol-lowering diet in a sample of 44 cardiac rehabilitation patients; the second establishes psychometric properties of the instrument in a sample of 228 subjects treated for hypercholesterolemia. In both studies, subgroups completed the instrument a second time to provide data on the instrument's temporal stability. The Cholesterol-Lowering Diet Self-Efficacy Scale consists of 33 statements, some with branches for a total of 56 items. The scale measures several components of the eating habits domain related to adhering to a cholesterol-lowering eating plan, and shows good reliability and validity. Reported self-efficacy is related to prior persistence and past success in modifying and maintaining dietary changes, and also to concurrent measures of dietary adherence behaviors. The scale is psychometrically sound thus far and seems adequate in identifying success in achieving and maintaining a cholesterol-lowering eating plan.

The antihyperlipidemic mechanism of high sulfate content ulvan in rats

Numerous studies have suggested that hyperlipidemia is closely linked to cardiovascular disease. The aim of this study was to investigate the possible antihyperlipidemia mechanism of HU (high sulfate content of ulvan) in high-cholesterol fed rats. Wistar rats were made hyperlipidemic by feeding with a high-cholesterol diet. HU was administered to these hyperlipidemia rats for 30 days. Lipid levels and the mRNA expressions of FXR, LXR and PPARγ in liver were measured after 30 days of treatment. In the HU-treated groups, the middle dosage group of male rats (total cholesterol (TC): p < 0.01) and the low-dosage group of female rats (TC, LDL-C: p < 0.01) showed stronger activity with respect to antihyperlipidemia. Moreover, some HU groups could upregulate the mRNA expression of FXR and PPARγ and downregulate the expression of LXR. For the male rats, compared with the hyperlipidemia group, the middle dosage HU had the most pronounced effect on increasing the mRNA levels of FXR (p < 0.01); low- and high-dosage HU showed a significant inhibition of the mRNA levels of LXR (p < 0.01). All HU female groups could upregulate the mRNA expression of PPARγ in a concentration-dependent manner. In summary, HU could improve lipid profiles through upregulation of FXR and PPARγ and downregulation of LXR.

Cholesterol-lowering therapy: Old evidence, new guidelines--Which one to follow? A critical appraisal

Current guidelines of the European Society of Cardiology and the European Atherosclerosis Society (ESC/EAS), of the American College of Cardiology and the American Heart Association (ACC/AHA), and of the International Atherosclerosis Society (IAS) are all based on the same body of evidence, but come to strikingly different conclusions with regard to lipid lowering therapy. While the ESC/EAS guidelines assign appropriate treatments to distinct lipid disorders, the ACC/AHA guidelines focus exclusively on evidence from randomized controlled trials for statins, but lack advice for those lipid disorders without evidence from randomized trials. Thus, evidence based medicine in its strict sense may leave a clinically significant gap. In striking contrast, the position paper of the IAS suggests the most advanced evidence-based innovative concept of a goal of one and the same healthy cholesterol level for anyone.

Gal-geun-dang-gwi-tang improves diabetic vascular complication in apolipoprotein E KO mice fed a western diet

BACKGROUND

Gal-geun-dang-gwi-tang (GGDGT), an herbal medicine, is used to treat hypertension, stroke, and other inflammatory disorders in the clinical setting. Recently, GGDGT was recognized by the Korea Institute of Oriental Medicine. This study aimed to evaluate the effects of GGDGT in a diabetic atherosclerosis model using apolipoprotein E knockout (ApoE-/-) mice fed a Western diet.

METHODS

The mice were divided into four groups: control group, C57BL6J mice receiving a regular diet (RD); ApoE-/- group, ApoE-/- mice receiving a Western diet (WD); rosiglitazone group, ApoE-/- mice receiving rosiglitazone (WD + 10 mg · kg(-1) · day(-1)); GGDGT group, ApoE-/- mice receiving GGDGT (WD + 200 mg · kg(-1) · day(-1)).

RESULTS

Treatment with GGDGT significantly improved glucose tolerance and plasma lipid levels. In addition, GGDGT ameliorated acetylcholine-induced vascular relaxation of the aortic rings. Immunohistochemical staining showed that GGDGT suppressed intercellular adhesion molecule (ICAM)-1 expression; however, expression of endothelial nitric oxide synthase (eNOS) and insulin receptor substrate (IRS)-1 were restored in the thoracic aorta and skeletal muscle, respectively.

CONCLUSIONS

These findings suggest that GGDGT attenuates endothelial dysfunction via improvement of the nitric oxide (NO)-cyclic guanosine monophosphate (cGMP) signalling pathway and improves insulin sensitivity in diabetic atherosclerosis.

The GALAXY Program: an update on studies investigating efficacy and tolerability of rosuvastatin for reducing cardiovascular risk

The GALAXY Program is a series of clinical studies investigating the efficacy and tolerability of rosuvastatin in line with the hypothesis that the statin with the greatest efficacy for improving the atherogenic lipid profile and beneficially modifying inflammatory markers will also slow progression of atherosclerosis and improve cardiovascular outcomes. Completed studies report that rosuvastatin is more effective than comparator statins in reducing low-density lipoprotein cholesterol, improving the lipid profile and enabling patients to achieve lipid goals, including revised, more stringent goals, even in high-risk patients. Studies have also reported that rosuvastatin can arrest and even regress atherosclerosis. Ongoing outcomes studies will determine whether these beneficial effects of rosuvastatin translate into reduced morbidity and mortality.

Low-density lipoprotein lowering in 2013 by nonstatin agents: the discovery and development of promising novel targeted therapies

Dyslipidemia is a major risk factor for the development of coronary artery disease, a leading cause of morbidity and mortality worldwide. Lowering low-density lipoprotein (LDL) has significantly reduced the risk of death and other major cardiovascular events, and statins remain the therapy of choice. However, as some patients are limited by the side effects of statins, cannot achieve their target LDL on statin therapy, or have other abnormalities in their lipid profile, alternative agents are being developed. In this review, we highlight the major classes of novel nonstatin LDL-lowering agents that are currently in various stages of development. Although many hold great promise, the results of large Phase III trials will be needed to definitely establish the efficacy, safety, and clinical utility of these agents in the general population.

Vinpocetine attenuates lipid accumulation and atherosclerosis formation

Atherosclerosis, the major cause of myocardial infarction and stroke, is a chronic arterial disease characterized by lipid deposition and inflammation in the vessel wall. Cholesterol, in low-density lipoprotein (LDL), plays a critical role in the pathogenesis of atherosclerosis. Vinpocetine, a derivative of the alkaloid vincamine, has long been used as a cerebral blood flow enhancer for treating cognitive impairment. Recent study indicated that vinpocetine is a potent anti-inflammatory agent. However, its role in the pathogenesis of atherosclerosis remains unexplored. In the present study, we show that vinpocetine significantly reduced atherosclerotic lesion formation in ApoE knockout mice fed with a high-fat diet. In cultured murine macrophage RAW264.7 cells, vinpocetine markedly attenuated oxidized LDL (ox-LDL) uptake and foam cell formation. Moreover, vinpocetine greatly blocked the induction of ox-LDL receptor 1 (LOX-1) in cultured macrophages as well as in the LOX-1 level in atherosclerotic lesions. Taken together, our data reveal a novel role of vinpocetine in reduction of pathogenesis of atherosclerosis, at least partially through suppressing LOX-1 signaling pathway. Given the excellent safety profile of vinpocetine, this study suggests vinpocetine may be a therapeutic candidate for treating atherosclerosis.

Design and rationale of the LAPLACE-TIMI 57 trial: a phase II, double-blind, placebo-controlled study of the efficacy and tolerability of a monoclonal antibody inhibitor of PCSK9 in subjects with hypercholesterolemia on background statin therapy

Lowering low-density lipoprotein cholesterol (LDL-C) is a cornerstone for the prevention of atherosclerotic heart disease, improving clinical outcomes and reducing vascular mortality in patients with hypercholesterolemia. The clinical benefits of LDL-C reduction appear to extend even to patients starting with LDL-C as low as 60-80 mg/dL prior to initiating therapy. Statins are the first-line agents for treating hypercholesterolemia and are effective in reducing LDL-C, but many patients are unable to achieve their optimal lipid targets despite intensive statin therapy. Therefore, there has been a strong impetus for the development of novel pharmacologic agents designed to lower LDL-C further in patients already on statin therapy. Genetic mutations resulting in altered cholesterol homeostasis provide valuable information regarding novel approaches for treating hypercholesterolemia. To that end, mutations in proprotein convertase subtilisin/kexin type 9 (PCSK9) were linked to altered levels of LDL-C, illustrating this protein's role in lipid metabolism. PCSK9 promotes degradation of the LDL receptor, preventing its transport back to the cell surface and thereby increasing circulating LDL-C. Conversely, inhibition of PCSK9 can profoundly decrease circulating LDL-C, and thus is an attractive new target for LDL-C-lowering therapy. AMG 145 is a fully human monoclonal immunoglobulin G2 antibody that binds specifically to human PCSK9 and inhibits its interaction with the low-density lipoprotein receptor. In this manuscript, we describe the rationale and design of LDL-C Assessment with PCSK9 Monoclonal Antibody Inhibition Combined With Statin Therapy-Thrombolysis In Myocardial Infarction 57 (LAPLACE-TIMI 57; NCT01380730), a 12-week, randomized, double-blind, dose-ranging, placebo-controlled study designed to assess the safety and efficacy of AMG 145 when added to statin therapy in patients with hypercholesterolemia.

Hypotensive, Hypolipidemic, and Vascular Protective Effects of Morus alba L. in Rats Fed an Atherogenic Diet

Morus alba L. has been used in traditional Chinese medicine and almost all parts of this plant are useful in cardiovascular, liver and spleen disorders. The present study was designed to investigate the inhibitory effect of a water extract from Morus alba L. (WMA) on vascular dysfunction in rat models fed a high fat and high cholesterol diet. Male rats were fed an atherogenic diet consisting of food with 7.5% cocoa butter and 1.25% cholesterol, with or without 100 or 200 mg/day/kg WMA, for 14 weeks. Chronic treatment with low (100 mg/kg/day) or high (200 mg/day/kg) doses of WMA markedly attenuated hypertension and the impairments of acetylcholine-induced relaxation of aortic rings in rats fed an atherogenic diet. WMA reduced intima/media thickness in rats fed an atherogenic diet. WMA improved plasma levels of triglyceride (TG) and augmented plasma levels of high-density lipoprotein (HDL) and plasma low-density lipoprotein (LDL), but did not affect blood glucose levels. Interestingly, WMA suppressed increased cell adhesion molecules such as E-selectin, vascular cell adhesion molecule-1 (VCAM-1), and intracellular adhesion molecule-1 (ICAM-1) expression in the aorta. Taken together, these results suggested that Morus alba L. could improve an atherogenic diet-induced hypertension, hyperlipidemia, and vascular dysfunction through inhibition of cell adhesion molecules expression and induction of vascular relaxation.

Essential oil of Pinus koraiensis leaves exerts antihyperlipidemic effects via up-regulation of low-density lipoprotein receptor and inhibition of acyl-coenzyme A: cholesterol acyltransferase

Hyperlipidemia is an important factor to induce metabolic syndrome such as obesity, diabetes and cardiovascular diseases. Recently, some antihyperlipidemic agents from herbal medicines have been in the spotlight in the medical science field. Thus, the present study evaluated the antihyperlipidemic activities of the essential oil from the leaves of Pinus koraiensis SIEB (EOPK) that has been used as a folk remedy for heart disease. The reverse transcription polymerase chain reaction (RT-PCR) revealed that EOPK up-regulated low density lipoprotein receptor (LDLR) at the mRNA level as well as negatively suppressed the expression of sterol regulatory element-binding protein (SREBP)-1c, SREBP-2, 3-hydroxy-3-methyl-glutaryl-CoA reductase (HMGCR), fatty acid synthase (FAS) and glycerol-3-phosphate acyltransferase (GPAT) involved in lipid metabolism in HepG2 cells. Also, western blotting showed that EOPK activated LDLR and attenuated the expression of FAS at the protein level in the cells. Consistently, EOPK significantly inhibited the level of human acylcoenzyme A: cholesterol acyltransferase (hACAT)1 and 2 and reduced the low-density lipoprotein (LDL) oxidation activity. Furthermore, chromatography-mass spectrometry (GC-MS) analysis showed that EOPK, an essential oil mixture, contained camphene (21.11%), d-limonene (21.01%), α-pinene (16.74%) and borneol (11.52%). Overall, the findings suggest that EOPK can be a potent pharmaceutical agent for the prevention and treatment of hyperlipidemia.

Effects of mulberry (Morus alba L.) extracts on lipid homeostasis in vitro and in vivo

The objective of this study was to investigate the lipid-lowering effects of mulberry water extracts (MWEs). To evaluate the hypolipidemic effect of MWEs, hamsters were fed with either high fat/cholesterol diets (HFCD) or HFCD supplemented with 1 and 2% MWEs for 12 weeks. Plasma total cholesterol (TC) and triglyceride (TG) levels of hamsters fed HFCD with MWEs were significantly reduced by about 30-37% and 16-35%, respectively, as compared to those without MWEs. Similar results were also measured in hepatic TC and TG of hamsters fed HFCD with MWEs. Low-density lipoprotein receptor (LDLR) gene expression and the uptake ability of low-density lipoprotein (LDL) in HepG2 cells were also upregulated by additions of MWEs. MWEs also decreased the gene expressions of enzymes involved in the TG and TC biosyntheses. Results suggest that hypolipidemic effects of MWEs are via an enhancement of LDLR gene expression and the clearance ability of LDL and a decrease in the lipid biosynthesis. Therefore, MWEs could be used as a natural agent against hyperlipidemia.

Impact of ezetimibe on atherosclerosis: is the jury still out?

Ezetimibe is a new lipid-lowering agent that inhibits intestinal absorption of dietary cholesterol. It substantially lowers low-density lipoprotein cholesterol levels when used alone or in combination with statins. However, its effect on cardiovascular mortality remains unknown. We reviewed peer-reviewed published literature on the effect of ezetimibe on different phases of atherosclerosis. MEDLINE, EMBASE, BIOSIS, and other Web of Knowledge databases were searched for relevant abstracts and articles published in the English language that compared ezetimibe and statins as modulators of atherosclerosis. On the basis of the available evidence, ezetimibe appears to reduce inflammation when used in combination with statins, but its effect on endothelial function is mixed and less clear. The effect of ezetimibe on coronary disease progression or prevention of cardiovascular events is currently unknown. Use of ezetimibe as a second- or third-line agent to achieve low-density lipoprotein cholesterol treatment goals seems appropriate on the basis of the available evidence.

Prevention of non-communicable disease in a population in nutrition transition: Tehran Lipid and Glucose Study phase II

BACKGROUND

The Tehran Lipid and Glucose Study (TLGS) is a long term integrated community-based program for prevention of non-communicable disorders (NCD) by development of a healthy lifestyle and reduction of NCD risk factors. The study begun in 1999, is ongoing, to be continued for at least 20 years. A primary survey was done to collect baseline data in 15005 individuals, over 3 years of age, selected from cohorts of three medical heath centers. A questionnaire for past medical history and data was completed during interviews; blood pressure, pulse rate, and anthropometrical measurements and a limited physical examination were performed and lipid profiles, fasting blood sugar and 2-hours-postload-glucose challenge were measured. A DNA bank was also collected. For those subjects aged over 30 years, Rose questionnaire was completed and an electrocardiogram was taken. Data collected were directly stored in computers as database software- computer assisted system. The aim of this study is to evaluate the feasibility and effectiveness of lifestyle modification in preventing or postponing the development of NCD risk factors and outcomes in the TLGS population.

DESIGN AND METHODS

In phase II of the TLGS, lifestyle interventions were implemented in 5630 people and 9375 individuals served as controls. Primary, secondary and tertiary interventions were designed based on specific target groups including schoolchildren, housewives, and high-risk persons. Officials of various sectors such as health, education, municipality, police, media, traders and community leaders were actively engaged as decision makers and collaborators. Interventional strategies were based on lifestyle modifications in diet, smoking and physical activity through face-to-face education, leaflets & brochures, school program alterations, training volunteers as health team and treating patients with NCD risk factors. Collection of demographic, clinical and laboratory data will be repeated every 3 years to assess the effects of different interventions in the intervention group as compared to control group.

CONCLUSION

This controlled community intervention will test the possibility of preventing or delaying the onset of non-communicable risk factors and disorders in a population in nutrition transition.

TRIAL REGISTRATION

ISRCTN52588395.

Impact of dyslipidemia on cardiovascular risk stratification of hypertensive patients and association of lipid profile with other cardiovascular risk factors: results from the ICEBERG study

BACKGROUND

Hypertension, dyslipidemia, and other cardiovascular risk factors are linked epidemiologically, clinically, and metabolically. Intensive/Initial Cardiovascular Examination regarding Blood Pressure levels, Evaluation of Risk Groups (ICEBERG) study focuses on the effect of dyslipidemia on cardiovascular risk evaluation and association of lipid profile with other risk factors.

PATIENTS AND METHODS

The ICEBERG study consisted of two sub-protocols: ICEBERG-1, conducted at 20 university hospitals (Referral Group) and ICEBERG-2, conducted at 197 primary healthcare centers (Primary Care Group). Sub-protocol had two patient profiles: patients previously diagnosed with essential hypertension and under medical treatment (Treated Group) and patients with systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥85 mmHg, with no antihypertensive treatment for at least 3 months before inclusion (Untreated Group). Dyslipidemia was evaluated and cardiovascular risk stratification was performed according to ESC/ESH guidelines.

RESULTS

More than half of the treated and untreated subjects were classified into high or very high cardiovascular risk groups. In a total of 1817 patients, the percentage of patients in "high" plus "very high" added risk groups increased to 55.2% in Treated Referral Group (p < 0.001), to 62.6% in Untreated Referral Group (p = 0.25) and to 60.7% in Untreated Primary Care Group (p < 0.001), by re-evaluation of patients' lipid values.

CONCLUSIONS

Serum lipid levels are useful in stratifying hypertensive patients into cardiovascular risk groups more accurately, for appropriate antihypertensive treatment.

Rationale and design of IMPROVE-IT (IMProved Reduction of Outcomes: Vytorin Efficacy International Trial): comparison of ezetimbe/simvastatin versus simvastatin monotherapy on cardiovascular outcomes in patients with acute coronary syndromes

BACKGROUND

Reduction in low-density lipoprotein cholesterol (LDL-C) improves clinical outcomes in patients with chronic coronary artery disease and acute coronary syndromes (ACSs). The combination of ezetimibe/simvastatin produces greater reductions in LDL-C compared to simvastatin monotherapy. The IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) is a multicenter, randomized, double-blind, active-control trial designed to test the hypothesis that the addition of ezetimibe to statin therapy, using ezetimibe/simvastatin, will translate into increased clinical benefit on cardiovascular outcomes relative to simvastatin monotherapy in patients with ACS.

STUDY DESIGN

The study will recruit up to 18,000 moderate- to high-risk patients stabilized after ACS. Patients are randomized in a 1:1 ratio to once-daily doses of either ezetimibe/simvastatin 10/40 mg or simvastatin monotherapy 40 mg. Follow-up visits are at 1 and 4 months, and every 4 months thereafter. If consecutive measures of LDL-C are >79 mg/dL at follow-up visits, the simvastatin dose will be increased to 80 mg in a double-blind manner. The primary end point is the first occurrence of cardiovascular death, nonfatal myocardial infarction, rehospitalization for unstable angina, coronary revascularization (occurring at least 30 days after randomization), or stroke. Patients will be followed for a minimum of 2.5 years and until at least 5,250 patients experience a primary end point.

SUMMARY

IMPROVE-IT will determine whether the addition of ezetimibe to statin therapy, using ezetimibe/simvastatin, improves cardiovascular outcomes compared with simvastatin monotherapy in patients after ACS. In addition, the difference in achieved LDL-C levels between the groups will provide data on whether the target for LDL-C lowering should be reduced further.

Hypocholesterolemic effect of stilbenes containing extract-fraction from Cajanus cajan L. on diet-induced hypercholesterolemia in mice

Cajanus cajan (L) is a natural plant which contains a lot of potential active components. In the present study, we identified the effects of the stilbenes containing extract-fraction from Cajanus cajan L (sECC) on diet-induced (for 4 weeks) hypercholesterolemia in Kunming mice. All experimental mice were divided into 5 groups: control group, model group, sECC-treated with 200 or 100 mg/kg/day, and simvastatin group. The effects of sECC were investigated by monitoring serum and liver lipid profile (cholesterol homeostasis and triglyceride) as well as serum superoxide dismutase activity in those mice. To further explore the mechanism of sECC, hepatic 3-hydroxy-3-methylglutaryl-CoA reductase (HMG-CoA reductase), cholesterol 7α-hydroxylase (CYP7A1), and low density lipoprotein receptor (LDL receptor) expressions in cholesterol homeostasis were analyzed by reverse transcription PCR. After 4 weeks pretreatment, compared with model group, the increased serum and hepatic total cholesterol were markedly attenuated by sECC (200 mg/kg) by 31.4% and 22.7% (p<0.01), respectively, the triglyceride levels of serum and liver were also lowered by 22.98% and 14.39%, respectively. At the same time, serum LDL cholesterol decreased by 52.8% (p<0.01) accompanied with the activities of serum superoxide dismutase increased by 20.98%. Atherogenic index and body weight were also reduced markedly. The mRNA expressions of HMG-CoA reductase, CYP7A1, and LDL-receptor were significantly enhanced in the mice administered with sECC (200 mg/kg/day), whereas those expressions were suppressed by the hypercholesterolemic diet. These data indicate that sECC reduces the atherogenic properties of dietary cholesterol in mice. Its hypocholesterolemic effect may involve enhancement of the hepatic LDL-receptor and cholesterol 7alpha-hydroxylase expression levels and bile acid synthesis.

Rosuvastatin prevents endothelial cell death and reduces atherosclerotic lesion formation in ApoE-deficient mice

Accumulating evidence suggests that statins have beneficial effects which are independent of their lipid-lowering actions, on vascular cells. Here, we investigated whether the HMG-CoA reductase inhibitor rosuvastatin can inhibit atherosclerotic lesion development with favorable effects on endothelial cells in ApoE-deficient mice. Rosuvastatin rapidly phosphorylated Akt and endothelial nitric oxide synthase (eNOS) in human endothelial cells. Endothelial cell death induced by serum starvation was significantly inhibited by rosuvastatin (percent cell death; 45.9+/-2.4% vs. 37.3+/-1.1%, p<0.05). Eight-week-old ApoE-deficient mice were orally administered vehicle or rosuvastatin at a dose of 20mg/kg/day for 24 weeks. There was no significant difference in cholesterol profile. Rosuvastatin preserved endothelial lining at the aortic root (CD31-positive luminal side; 63.8+/-2.8% vs. 81.7+/-3.9%, p<0.05). En face Sudan IV staining of aorta revealed that rosuvastatin significantly decreased the atherosclerotic area (21.9+/-2.9% vs. 11.9+/-1.9%, p<0.05). Lipid deposition at the atherosclerotic area was also suppressed by rosuvastatin with more stabilized morphologic features as determined by oil red O staining (3.4+/-0.4% vs. 1.7+/-0.4%, p<0.05). Our findings indicate that rosuvastatin protects endothelial cells from death with phosphorylation of Akt and eNOS. These effects may contribute, at least in part, to the anti-atherosclerotic effects of rosuvastatin.

Benefits of statin therapy in patients with special risks: coronary bypass surgery, stable coronary disease, and acute coronary syndromes

Several major clinical studies have examined the impact of lipid lowering in patients with and without coronary heart disease and have demonstrated that lowering lipid levels can successfully and significantly delay the onset of cardiovascular events. Although epidemiologic studies and small clinical trials have suggested that more aggressive and sustained lowering of low-density lipoprotein cholesterol (LDL-C) to < 100 mg/dl (2.6 mmol/l) can result in reductions in cardiovascular events in these populations, reducing LDL-C to these concentrations has only recently been shown in larger clinical trials. However, few clinical trials have been conducted in patients with certain special high risks, such as those who have had a recent revascularization procedure or have experienced an acute coronary event. Three trials examined the short- and long-term clinical benefits of aggressive lipid lowering in patients who underwent coronary artery bypass surgery (Post-CABG), were candidates for angioplasty (AVERT), or were hospitalized for acute coronary syndromes (MIRACL).

Cholesterol--when is lower better?

When recommending how to treat a patient's lipid profile with drugs, there are two common misinterpretations of the data that are often quoted to support the current enthusiasm for the lower the cholesterol, the better.