Atorvastatin lowers lipoprotein(a) but not apolipoprotein(a) fragment levels in hypercholesterolemic subjects at high cardiovascular risk

Lipoprotein(a): Its Association with Calcific Aortic Valve Stenosis, the Emerging RNA-Related Treatments and the Hope for a New Era in “Treating” Aortic Valve Calcification

The treatment of patients with aortic valve calcification (AVC) and calcific aortic valve stenosis (CAVS) remains challenging as, until today, all non-invasive interventions have proven fruitless in preventing the disease’s onset and progression. Despite the similarities in the pathogenesis of AVC and atherosclerosis, statins failed to show a favorable effect in preventing AVC progression. The recognition of lipoprotein(a) [Lp(a)] as a strong and potentially modifiable risk factor for the development and, perhaps, the progression of AVC and CAVS and the evolution of novel agents leading in a robust Lp(a) reduction, have rekindled hope for a promising future in the treatment of those patients. Lp(a) seems to promote AVC via a ‘three hit’ mechanism including lipid deposition, inflammation and autotaxin transportation. All of these lead to valve interstitial cells transition into osteoblast-like cells and, thus, to parenchymal calcification. Currently available lipid-lowering therapies have shown a neutral or mild effect on Lp(a), which was proven insufficient to contribute to clinical benefits. The short-term safety and the efficacy of the emerging agents in reducing Lp(a) have been proven; nevertheless, their effect on cardiovascular risk is currently under investigation in phase 3 clinical trials. A positive result of these trials will probably be the spark to test the hypothesis of the modification of AVC’s natural history with the novel Lp(a)-lowering agents.

Effect of different types and dosages of statins on plasma lipoprotein(a) levels: A network meta-analysis

BACKGROUND AND AIM

Studies differ with respect to the effects of statins and their on lipoprotein(a)[Lp(a)] levels. The aim of the present study was to resolve these differences by determining the effect of various types and dosages of statins on Lp(a) levels.

METHODS

We searched PubMed, Embase and the Cochrane library for randomized controlled trials (RCTs) investigating the efficacy of statins on plasma Lp(a) levels. Study selection, data extraction and risk of bias assessment were conducted independently by four authors. We conducted pairwise meta-analysis and network meta-analysis (NMA). Consistency models were applied to NMA and the ranking probabilities for each treatment's efficacy were calculated. Node-splitting analysis was used to test inconsistency. This study was registered with PROSPERO, number CRD42020167612.

RESULTS

Twenty RCTs with 23,605 participants were included, involving 11 interventions. Most of the included studies presented some risks of bias, especially risks of performance and detection bias. In the pairwise meta-analysis, pooled results showed a small but statistically significant difference between high-intensity rosuvastatin and placebo on Lp(a) levels (MD = 1.81, 95 % CI [0.43, 3.19], P = 0.01). In the NMA, different types and dosages of statins showed no significant effect on the level of Lp(a), and there was no obvious difference between them. Subgroup analysis based on different populations and treatment durations did not provide any statistically significant findings about different statins on Lp(a) levels. Node-splitting analysis showed that no significant inconsistency existed (P > 0.05).

CONCLUSIONS

Statins have no clinically significant effect on Lp(a) levels, and there is no significant difference in the effect on Lp(a) levels between different types and dosages of statins. Moderate-intensity pitavastatin tended to have the best effect on reducing Lp(a) levels; nevertheless, it was insignificant. Our findings highlight the necessity for further study of the effect of statins on Lp(a) levels in future studies.

The roles of apo(a) size, phenotype, and dominance pattern in PCSK9-inhibition-induced reduction in Lp(a) with alirocumab

An elevated level of lipoprotein (a) [Lp(a)] is a risk factor for CVD. Alirocumab, a monoclonal antibody to proprotein convertase subtilisin/kexin type 9, is reported to reduce Lp(a) levels. The relationship of Lp(a) reduction with apo(a) size polymorphism, phenotype, and dominance pattern and LDL cholesterol (LDL-C) reduction was evaluated in a pooled analysis of 155 hypercholesterolemic patients (75 with heterozygous familial hypercholesterolemia) from two clinical trials. Alirocumab significantly reduced total Lp(a) (pooled median: -21%, P = 0.0001) and allele-specific apo(a), an Lp(a) level carried by the smaller (median: -18%, P = 0.002) or the larger (median: -37%, P = 0.0005) apo(a) isoform, at week 8 versus baseline. The percent reduction in Lp(a) level with alirocumab was similar across apo(a) phenotypes (single vs. double bands) and carriers and noncarriers of a small size apo(a) (≤22 kringles). The percent reduction in LDL-C correlated significantly with the percent reduction in Lp(a) level (r = 0.407, P < 0.0001) and allele-specific apo(a) level associated with the smaller (r = 0.390, P < 0.0001) or larger (r = 0.270, P = 0.0183) apo(a) sizes. In conclusion, alirocumab-induced Lp(a) reduction was independent of apo(a) phenotypes and the presence or absence of a small size apo(a).

Lipoprotein(a)-activated immunity, insulin resistance and new-onset diabetes

OBJECTIVES

Some evidence suggests that serum lipoprotein[Lp](a) may be inversely linked to type-2 diabetes. We aimed to determine in nondiabetic people the relationship of serum [Lp](a) with insulin resistance and new-onset diabetes (NOD).

MATERIALS AND METHODS

Population-based middle-aged adults (n = 1685) were categorized by fasting glucose and stratified to gender, having excluded prevalent diabetic subjects. NOD (n = 90) occurred over a median 5 years' follow-up.

RESULTS

Subjects that subsequently developed NOD, derived both from the normoglycemia and impaired fasting glucose (IFG) groups,were distinguished, among others, primarily by significantly elevated serum gamma glutamyltransferase, reduced Lp(a) (by 31%) and, compared to IFG, by low total cholesterol levels. Partial correlation of Lp(a) with homeostatic model assessment (HOMA) was inverse in normoglycemic men; such correlation, neutral in normoglycemic women, proved inverse in IFG (r = -0.17). Circulating Lp(a) in individuals with paired measures increased significantly (1.55-fold) in the period from baseline up to NOD. Multivariable-adjusted logistic regression analysis for NOD in combined sexes indicated independent and additive prediction by serum Lp(a), albeit inverse in direction (RR 0.84, [95%CI 0.72; 0.97]).

CONCLUSION

Lp(a) is significantly reduced in the period preceding NOD and is inversely associated with HOMA index, observations consistent with underlying autoimmune activation.

Long-term statin therapy could be efficacious in reducing the lipoprotein (a) levels in patients with coronary artery disease modified by some traditional risk factors

BACKGROUND

Lipoprotein (a) [Lp (a)] is a well-established risk factor for coronary artery disease (CAD). However, up till now, treatment of patients with higher Lp (a) levels is challenging. This current study aimed to investigate the therapeutic effects of short-, medium and long-term statin use on the Lp (a) reduction and its modifying factors.

METHODS

The therapeutic duration was categorized into short-term (median, 39 days), medium term (median, 219 days) and long-term (median, 677 days). The lipid profiles before therapy served as baselines. Patients at short-, medium or long-term exactly matched with those at baseline. Every patient's lipid profiles during the follow-ups were compared to his own ones at baselines.

RESULTS

The current study demonstrated that long-term statin therapy significantly decreased the Lp (a) levels in CAD patients while short-term or medium term statin therapy didn't. When grouped by statin use, only long-term simvastatin use significantly decreased the Lp (a) levels while long-term atorvastatin use insignificantly decreased the Lp (a) levels. Primary hypertension (PH), DM, low density lipoprotein cholesterol (LDL-C) and high density lipoprotein cholesterol (HDL-C) could modify the therapeutic effects of statin use on the Lp (a) levels in CAD patients.

CONCLUSIONS

The long-term statin therapy could be efficacious in reducing the Lp (a) levels in CAD patients, which has been modified by some traditional risk factors. In the era of commercial unavailability of more reliable Lp (a) lowering drugs, our findings will bolster confidence in fighting higher Lp (a) abnormalities both for patients and for doctors.

Comparison of the effects of fibrates versus statins on plasma lipoprotein(a) concentrations: a systematic review and meta-analysis of head-to-head randomized controlled trials

BACKGROUND

Raised plasma lipoprotein(a) (Lp(a)) concentration is an independent and causal risk factor for atherosclerotic cardiovascular disease. Several types of pharmacological approaches are under evaluation for their potential to reduce plasma Lp(a) levels. There is suggestive evidence that statins and fibrates, two frequently employed lipid-lowering drugs, can lower plasma Lp(a). The present study aims to compare the efficacy of fibrates and statins in reducing plasma concentrations of Lp(a) using a meta-analysis of randomized head-to-head trials.

METHODS

Medline and Scopus databases were searched to identify randomized head-to-head comparative trials investigating the efficacy of fibrates versus statins in reducing plasma Lp(a) levels. Meta-analysis was performed using a random-effects model, with inverse variance weighted mean differences (WMDs) and 95% confidence intervals (CIs) as summary statistics. The impact of putative confounders on the estimated effect size was explored using random effects meta-regression.

RESULTS

Sixteen head-to-head comparative trials with a total of 1388 subjects met the eligibility criteria and were selected for this meta-analysis. Meta-analysis revealed a significantly greater effect of fibrates versus statins in reducing plasma Lp(a) concentrations (WMD, -2.70 mg/dL; 95% CI, -4.56 to -0.84; P = 0.004). Combination therapy with fibrates and statins had a significantly greater effect compared with statin monotherapy (WMD, -1.60 mg/dL; 95% CI, -2.93 to -0.26; P = 0.019) but not fibrate monotherapy (WMD, -1.76 mg/dL; 95% CI, -5.44 to +1.92; P = 0.349) in reducing plasma Lp(a) concentrations. The impact of fibrates versus statins in reducing plasma Lp(a) concentrations was not found to be significantly associated with treatment duration (P = 0.788).

CONCLUSIONS

Fibrates have a significantly greater effect in reducing plasma Lp(a) concentrations than statins. Addition of fibrates to statins can enhance the Lp(a)-lowering effect of statins.

Effects of Atorvastatin on Lp(a) and Lipoprotein Profiles in Hemodialysis Patients

Background:

Dialysis patients have many underlying traditional and nontraditional risk factors that may predispose them to a high prevalence of cardiovascular disease. The effects of statins (eg, atorvastatin) on altering nontraditional lipoprotein measures in dialysis patients have not been extensively investigated.

Objective:

To evaluate the efficacy of atorvastatin compared with a control group in inducing changes in lipoprotein(a) [Lp(a)], apolipoprotein (Apo) A-1, Apo-B, and fibrinogen levels, as well as the conventional lipoprotein profile, in hemodialysis patients over 36 weeks; secondary objectives were to assess changes in C-reactive protein, albumin, and safety measures.

Methods:

Forty-five hemodialysis patients with low-density lipoprotein cholesterol (LDL-C) levels greater than 100 mg/dL were randomized to parallel groups: atorvastatin (n = 19) or no treatment (n = 26). The atorvastatin dose was titrated from 10 mg to achieve an LDL-C goal of 100 mg/dL or less and therapy was continued for 36 weeks. Biochemical and lipoprotein laboratory tests for efficacy outcomes were obtained at baseline, 12 weeks, and 36 weeks.

Results:

The atorvastatin group exhibited clinically significant reductions (mean ± SD) compared with controls in total cholesterol (–21.7 ± 41.7 vs –3.2 ± 40.0 mg/dL, respectively; p = 0.017) and LDL-C (–13.1 ± 32.0 vs –1.1 ± 38.4 mg/dL. respectively; p = 0.056) levels, as well as Lp(a) (–10.6 ± 27 vs 3.5 ± 17.8 mg/dL, respectively; p = 0.046). Statistical analyses included analysis of variance on ranked measures for multivariable modeling and paired t-test to determine changes in efficacy measures between baseline and 36 weeks within groups.

Conclusions:

Atorvastatin was safe and effective in reducing Lp(a), total cholesterol, and LDL-C levels. Given the prevalence of atherosclerosis in hemodialysis patients, therapy aimed at reducing traditional and nontraditional risk factors may be beneficial.

Lipoprotein(a) in postmenopausal women: assessment of cardiovascular risk and therapeutic options

INTRODUCTION

Lipoprotein(a) [Lp(a)], a low-density lipoprotein (LDL)-like particle, has been independently associated with increased cardiovascular disease (CVD) risk in various populations, such as postmenopausal women. The purpose of this narrative review is to present current data on the role of Lp(a) in augmenting CVD risk in postmenopausal women and focus on the available therapeutic strategies.

METHODS

PubMed was searched for English language publications until November 2015 under the following terms: "therapy" OR "treatment" AND ["lipoprotein (a)" OR "Lp(a)"] AND ("postmenopausal women" OR "menopausal women" OR "menopause").

RESULTS

Only hormone replacement therapy (mainly oral estrogens) and tibolone have been specifically studied in postmenopausal women and can reduce Lp(a) concentrations by up to 44%, although evidence indicating a concomitant reduction in CVD risk associated with Lp(a) is lacking. As alternative treatments for women who cannot, or will not, take hormonal therapies, niacin and the upcoming proprotein convertase subtilisin / kexin type 9 (PCSK-9) inhibitors are effective in reducing Lp(a) concentrations by up to 30%. Statins have minimal or no effect on Lp(a). However, data for these and other promising Lp(a)-lowering therapies including mipomersen, lomitapide, cholesterol-ester-transfer protein inhibitors and eprotirome are derived from studies in the general, mainly high CVD risk, population, and include only subpopulations of postmenopausal women.

CONCLUSIONS

Past, present and emerging therapies can reduce Lp(a) concentrations to a varying extent. Overall, it remains to be proven whether the aforementioned reductions in Lp(a) by these therapeutic options are translated into CVD risk reduction in postmenopausal women.

Effects of Rosuvastatin Versus Atorvastatin, Alone or in Combination, on Lipoprotein (a)

Background: There are little evidences about the therapeutic efficacy of different lipid-lowering agents in the reduction of elevated lipoprotein(a) [Lp(a)]. Objective: testing the effect of different lipid-lowering agents on elevated Lp(a). Methods: prospective interventional study performed in patients with CAD, or high CAD risk, with Lp(a), >50 mg/dL. Lp(a), total cholesterol (C), HDL-C, LDL-C, triglycerides (TGs), apolipoprotein (Apo) A1, Apo B, enzymes of myocyte and hepatic injury were comparatively analyzed between 4 lipid-lowering strategies: rosuvastatin (R group) 40 mg, atorvastatin (A group) 80 mg, atorvastatin 40 mg add-on micronized fenofibrate (A+F group), and atorvastatin 40 mg add-on 1 g extended-release niacin (A+ERN group). Comparison was made for their therapeutic efficacy on Lp(a), and safety. Results: 87 patients with mean Lp(a) 94.6 ± 39.6 mg/dL were analyzed. Groups: 25 patients in the R, 22 in the A, 20 in the A+F and 20 in A+ERN group. Significant reduction in all lipid fractions in all treatment groups was reported after 6 months. The average reduction of Lp(a) was 15.9 ± 21.0 mg/dL, with: 18.2 ± 24.8 ( P = 0.001) in the R group, 17.3 ± 10.4 (P = 0.001) in A+F, 19.5 ± 10.9 (P = 0.001) in A+ERN and the lowest in the A group (11.24 ± 22.91, P = 0.032). No adverse effects were observed in any of the treatment groups. Conclusions: When compared with atorvastatin, it seems that rosuvastatin can achieve more significant decrease of Lp(a).The efficacy of the second one can be increased by adding fibrate or ERN.

PCSK9 inhibition-mediated reduction in Lp(a) with evolocumab: an analysis of 10 clinical trials and the LDL receptor's role

Lipoprotein (a) [Lp(a)] is independently associated with CVD risk. Evolocumab, a monoclonal antibody (mAb) to proprotein convertase subtilisin/kexin type 9 (PCSK9), decreases Lp(a). The potential mechanisms were assessed. A pooled analysis of Lp(a) and LDL cholesterol (LDL-C) in 3,278 patients from 10 clinical trials (eight phase 2/3; two extensions) was conducted. Within each parent study, biweekly and monthly doses of evolocumab statistically significantly reduced Lp(a) at week 12 versus control (P < 0.001 within each study); pooled median (quartile 1, quartile 3) percent reductions were 24.7% (40.0, 3.6) and 21.7% (39.9, 4.2), respectively. Reductions were maintained through week 52 of the open-label extension, and correlated with LDL-C reductions [with and without correction for Lp(a)-cholesterol] at both time points (P < 0.0001). The effect of LDL and LDL receptor (LDLR) availability on Lp(a) cell-association was measured in HepG2 cells: cell-associated LDL fluorescence was reversed by unlabeled LDL and Lp(a). Lp(a) cell-association was reduced by coincubation with LDL and PCSK9 and reversed by adding PCSK9 mAb. These studies support that reductions in Lp(a) with PCSK9 inhibition are partly due to increased LDLR-mediated uptake. In most situations, Lp(a) appears to compete poorly with LDL for LDLR binding and internalization, but when LDLR expression is increased with evolocumab, particularly in the setting of low circulating LDL, Lp(a) is reduced.

Lipoprotein(a) catabolism is regulated by proprotein convertase subtilisin/kexin type 9 through the low density lipoprotein receptor

Elevated levels of lipoprotein(a) (Lp(a)) have been identified as an independent risk factor for coronary heart disease. Plasma Lp(a) levels are reduced by monoclonal antibodies targeting proprotein convertase subtilisin/kexin type 9 (PCSK9). However, the mechanism of Lp(a) catabolism in vivo and the role of PCSK9 in this process are unknown. We report that Lp(a) internalization by hepatic HepG2 cells and primary human fibroblasts was effectively reduced by PCSK9. Overexpression of the low density lipoprotein (LDL) receptor (LDLR) in HepG2 cells dramatically increased the internalization of Lp(a). Internalization of Lp(a) was markedly reduced following treatment of HepG2 cells with a function-blocking monoclonal antibody against the LDLR or the use of primary human fibroblasts from an individual with familial hypercholesterolemia; in both cases, Lp(a) internalization was not affected by PCSK9. Optimal Lp(a) internalization in both hepatic and primary human fibroblasts was dependent on the LDL rather than the apolipoprotein(a) component of Lp(a). Lp(a) internalization was also dependent on clathrin-coated pits, and Lp(a) was targeted for lysosomal and not proteasomal degradation. Our data provide strong evidence that the LDLR plays a role in Lp(a) catabolism and that this process can be modulated by PCSK9. These results provide a direct mechanism underlying the therapeutic potential of PCSK9 in effectively lowering Lp(a) levels.

Lipoprotein (a): a Unique Independent Risk Factor for Coronary Artery Disease

The current epidemic affecting Indians is coronary artery disease (CAD), and is currently one of the most common causes of mortality and morbidity in developed and developing countries. The higher rate of CAD in Indians, as compared to people of other ethnic origin, may indicate a possible genetic susceptibility. Hence, Lp(a), an independent genetic risk marker for atherosclerosis and cardiovascular disease assumes great importance. Lp(a), an atherogenic lipoprotein, contains a cholesterol rich LDL particle, one molecule of apolipoprotein B-100 and a unique protein, apolipoprotein (a) which distinguishes it from LDL. Apo(a) is highly polymorphic and an inverse relationship between Lp(a) concentration and apo(a) isoform size has been observed. This is genetically controlled suggesting a functional diversity among the apo(a) isoforms. The LPA gene codes for apo(a) whose genetic heterogeneity is due to variations in its number of kringles. The exact pathogenic mechanism of Lp(a) is still not completely elucidated, but the structural homology of Lp(a) with LDL and plasmin is possibly responsible for its acting as a link between atherosclerosis and thrombosis. Upper limits of normal Lp(a) levels have not been defined for the Indian population. A cut off limit of 20 mg/dL has been suggested while for the Caucasian population it is 30 mg/dL. Though a variety of assays are available for its measurement, standardization of the analytical method is highly complicated as a majority of the methods are affected by the heterogeneity in apo(a) size. No therapeutic drug selectively targets Lp(a) but recently, new modifiers of apo(a) synthesis are being considered.

Type-2 diabetes and coronary heart disease: common physiopathology, viewed from autoimmunity

Two highly prevalent diseases, Type-2 diabetes mellitus and coronary heart disease (CHD), share risk factors. Excess levels of LDL-cholesterol have been overemphasized to uniformly encompass the development of CHD, and the origin of insulin resistance underlying Type-2 diabetes has not been fully elucidated. Autoimmune response has been recognized to be responsible only of a small minority of diabetes. The increasing trend in the worldwide prevalence of diabetes and the risk factors for both diseases are reviewed, the independent mediation for CHD of (central) adiposity in both diseases and the 'hypertriglyceridemic waist' phenotype are outlined. Evidence is described that serum lipoprotein (Lp)(a) concentrations, not only in excess, but also in apparently 'reduced' levels, as a result of autoimmune response, underlie both disorders and are closely related to insulin resistance.

Lipoprotein(a): an important cardiovascular risk factor and a clinical conundrum

Elevated plasma concentrations of lipoprotein(a) (Lp[a]) are an emerging risk factor for the development of coronary heart disease (CHD). Recent genetic and epidemiologic data have provided strong evidence for a causal role of Lp(a) in CHD. Despite these developments, which have attracted increasing interest from clinicians and basic scientists, many unanswered questions persist. The true pathogenic mechanism of Lp(a) remains a mystery. Significant uncertainty exists concerning the appropriate use of Lp(a) in the clinical setting. No therapeutic intervention remains that can specifically lower plasma Lp(a) concentrations, although the list of compounds that lower Lp(a) and LDL continues to expand.

Severe coronary disease in an adult considered at low cardiovascular disease risk with a healthy lifestyle

Lipoprotein(a) [Lp(a)] is a lipoprotein subclass well-known among the lipid community to accelerate atherosclerosis and promote thrombosis through incompletely understood mechanism. We report a case of a young man with a healthy lifestyle and no major coronary or vascular risk factors who presented to the emergency department with an acute coronary syndrome and was ultimately found to have severe coronary artery disease. A diagnostic workup revealed elevated Lp(a). He was treated with consequent reduction in Lp(a) concentration. This case highlights the need to better understand atypical lipoproteins, how they relate to cardiovascular disease, the implications for screening family members, and the need to standardize patient management guidelines for the purpose of mortality risk reduction.

Association between Low-Molecular Weight Apolipoprotein(a) Isoforms and Obesity in Italian Women

OBJECTIVE

Low-molecular weight (MW) apolipoprotein(a) [apo(a)] isoforms are closely associated with an increased incidence of atherothrombotic disease, prevalence of which is higher in obese individuals, particularly in women. The hypothesis of this study was to assess whether there are differences in the distribution of apo(a) phenotypes between obese patients and healthy controls.

RESEARCH METHODS AND PROCEDURES

One hundred three obese Italian women (BMI > or = 30.0 kg/m2) were enrolled in the study, and apo(a) phenotyping was performed in all subjects. The prevalence of low-MW apo(a) isoforms, detected in plasma samples of our obese women, was compared with that found in a control group of 84 normal-weight, never-obese (BMI < 25.0 kg/m(2)), age-matched women.

RESULTS

The distribution of apo(a) isoforms in the population of obese women was significantly different from that found in normal-weight female subjects. In particular, the percentage of subjects in the obese group with at least one apo(a) isoform of low MW was significantly higher than that in the control group (51.4% vs. 32.1%, p = 0.0079).

DISCUSSION

Our results seem to suggest the possibility that small-sized apo(a) isoforms may be used together with other traditional risk factors to better assess the overall predisposition to atherothrombotic disease in obese women.

Lipoprotein(a) and cardiovascular disease in diabetic patients

Lipoprotein(a) (Lp[a]) is a LDL-like particle consisting of an ApoA moiety linked to one molecule of ApoB(100). Recent data from large-scale prospective studies and genetic association studies provide highly suggestive evidence for a potentially causal role of Lp(a) in affecting risk of cardiovascular disease (CVD) in general populations. Patients with Type 2 diabetes display clustered metabolic abnormalities and elevated risk of CVD. Lower plasma Lp(a) levels were observed in diabetic patients in several recent studies. Epidemiology studies of Lp(a) and CVD risk in diabetic patients generated inconsistent results. We recently found that Lp(a)-related genetic markers did not predict CVD in two diabetic cohorts. The current data suggest that Lp(a) may differentially affect cardiovascular risk in diabetic patients and in the general population. More prospective studies, Mendelian randomization analysis and functional studies are needed to clarify the causal relationship of Lp(a) and CVD in diabetic patients.

Lipid and low-density-lipoprotein apheresis. Effects on plasma inflammatory profile and on cytokine pattern in patients with severe dyslipidemia

Available evidence on the effects of therapeutic plasmapheresis (TP) techniques and in particular lipid- and LDL-apheresis (LDL-a) on plasmatic inflammatory mediators including cytokines were reviewed. Studies on this issue are not numerous. However, the review of existing evidence clearly suggests an active role of apheresis on the profile of inflammatory molecules and on cytokine pattern in plasma. These non-lipid-lowering effects can be defined to some extent pleiotropic or pleiotropic-equivalent. Although further studies are desirable, the data reported in this review confirm that lipid- and LDL-a not only show acute lipid-lowering and cholesterol-lowering effects, but also efficacy in reducing several proinflammatory peptides, including cytokines. This effect was not related apparently to lipids and lipoproteins reduction. Thus, TP (lipid- and LDL-a), commonly utilized in the treatment of severe genetically determined lipid disorders, unresponsive to hypolipidemic drugs, offers new possibilities of interpretation of its role in the mechanisms leading to the blockade of atherosclerotic lesion development and progression. The ability of TP on short-term to induce such a profound change in the plasmatic metabolic and inflammatory profiles must be kept in mind in the treatment of acute coronary syndromes, before and after interventions of coronary revascularization, and in the acute phase of cerebrovascular ischemia, at least in patients with severe dyslipidemia. Further studies are needed, in particular aimed at assessing if circulating cytokines may be downregulated by TP not only by direct removal, but through indirect effects on both gene translation and transcription perhaps via the cytokine receptor function.

Lipoprotein(a) Is the Best Single Marker in Assessing Unstable Angina Pectoris

This study evaluated whether statin therapy changed a diagnostic validity of lipid and inflammatory markers in ischemic heart disease (IHD) patients. Levels of lipids, lipoproteins, apolipoproteins, inflammatory markers, and atherogenic indexes were determined in 49 apparently healthy men and women, 82 patients having stable angina pectoris (SAP), 80 patients with unstable angina (USAP), and 106 patients with acute ST-elevation myocardial infarction (STEMI) treated or not treated with statins. Diagnostic accuracy of markers was determined by ROC curve analysis. Significantly lower apoA-I in all statin-treated groups and significantly higher apoB in statin-treated STEMI group compared to non-statin-treated groups were observed. CRP showed the best ROC characteristics in the assessment of STEMI patients. Lp(a) is better in the evaluation of SAP and USAP patients, considering that Lp(a) showed the highest area under the curve (AUC). Regarding atherogenic indexes, the highest AUC in SAP group was obtained for TG/apoB and in USAP and STEMI patients for TG/HDL-c. Statins lowered total cholesterol, LDL-c, and TG but fail to normalize apoA-I in patients with IHD.

Lipoprotein(a) as a cardiovascular risk factor: current status

AIMS

The aims of the study were, first, to critically evaluate lipoprotein(a) [Lp(a)] as a cardiovascular risk factor and, second, to advise on screening for elevated plasma Lp(a), on desirable levels, and on therapeutic strategies.

METHODS AND RESULTS

The robust and specific association between elevated Lp(a) levels and increased cardiovascular disease (CVD)/coronary heart disease (CHD) risk, together with recent genetic findings, indicates that elevated Lp(a), like elevated LDL-cholesterol, is causally related to premature CVD/CHD. The association is continuous without a threshold or dependence on LDL- or non-HDL-cholesterol levels. Mechanistically, elevated Lp(a) levels may either induce a prothrombotic/anti-fibrinolytic effect as apolipoprotein(a) resembles both plasminogen and plasmin but has no fibrinolytic activity, or may accelerate atherosclerosis because, like LDL, the Lp(a) particle is cholesterol-rich, or both. We advise that Lp(a) be measured once, using an isoform-insensitive assay, in subjects at intermediate or high CVD/CHD risk with premature CVD, familial hypercholesterolaemia, a family history of premature CVD and/or elevated Lp(a), recurrent CVD despite statin treatment, ≥3% 10-year risk of fatal CVD according to European guidelines, and/or ≥10% 10-year risk of fatal + non-fatal CHD according to US guidelines. As a secondary priority after LDL-cholesterol reduction, we recommend a desirable level for Lp(a) <80th percentile (less than ∼50 mg/dL). Treatment should primarily be niacin 1-3 g/day, as a meta-analysis of randomized, controlled intervention trials demonstrates reduced CVD by niacin treatment. In extreme cases, LDL-apheresis is efficacious in removing Lp(a).

CONCLUSION

We recommend screening for elevated Lp(a) in those at intermediate or high CVD/CHD risk, a desirable level <50 mg/dL as a function of global cardiovascular risk, and use of niacin for Lp(a) and CVD/CHD risk reduction.

Lipoprotein a: where are we now?

PURPOSE OF REVIEW

To provide an update of the literature describing the link between lipoprotein a and vascular disease.

RECENT FINDINGS

There is evidence that elevated plasma lipoprotein a levels are associated with coronary heart disease, stroke and other manifestations of atherosclerosis. Several mechanisms may be implicated, including proinflammatory actions and impaired fibrinolysis.

SUMMARY

Lipoprotein a potentially represents a useful tool for risk stratification in the primary and secondary prevention setting. However, there are still unresolved methodological issues regarding the measurement of lipoprotein a levels. Targeting lipoprotein a in order to reduce vascular risk is hampered by the lack of well tolerated and effective pharmacological interventions. Moreover, it has not yet been established whether such a reduction will result in fewer vascular events. The risk attributed to lipoprotein a may be reduced by aggressively tackling other vascular risk factors, such as low-density lipoprotein cholesterol.

Case report. Hyperlipoproteinaemia(a): which is the optimal therapy? A case report

This case report presents the clinical history of a patient with elevated lipoprotein(a) and small size isoform, associated with mixed hyperlipaemia, which was probably familial combined hyperlipaemia. After premature myocardial infarction, the subject was treated with fibrates. Niacin was started after recurrence. One year ago, after another episode of acute coronary syndrome, rosuvastatin was added to niacin. The atherogenicity of this lipid disorder, along with the different options for therapy is discussed.

Relationship of heavy drinking, lipoprotein (a) and lipid profile to infrarenal aortic diameter

Abstract

The objective of this study was to examine the association of alcohol drinking and lipid profile with infrarenal aortic dimension. The diameter of the infrarenal aorta was measured using ultrasound in 395 individuals (mean 66.6 ± 10.3 years) with atherosclerotic diseases or risk factors. The associations between heavy drinking, serum lipoprotein (a) levels, lipid profile and infrarenal aorta diameters were examined. Heavy drinking and lipoprotein (a) were positively related with infrarenal aortic dimension, while low-density lipoprotein cholesterol (LDL-C)/high-density lipoprotein cholesterol (HDL-C), LDL-C and total cholesterol (TC)/HDL-C were negatively associated with infrarenal aortic diameter ( p < 0.05). In addition, there were negative associations of LDL-C/HDL-C, TC/HDL-C and positive associations of HDL-C and apolipoprotein AI (Apo AI) with heavy drinking ( p < 0.05). In conclusion, there was a positive association between infrarenal aortic diameters and heavy drinking, as well as lipoprotein (a) levels. Furthermore, the novel and unexpected inverse association between LDL-C/HDL-C, LDL-C, TC/HDL-C and abdominal aortic diameter may suggest a possible role for anti-atherogenic lipid profile (characterized by a higher level of HDL-C and lower level of LDL-C) in aortic dilatation processes, which need to be clarified by further studies.

Beneficial effects of raloxifene and atorvastatin on serum lipids and HDL phospholipids levels of postmenopausal women

Selective oestrogen receptor modulators (raloxifene) and statins (atorvastatin) have been shown to reduce the risk of cardiovascular disease associated with the postmenopausal status. Their beneficial effects may be mediated partly by favourable changes in serum lipids and particular on HDL phospholipid composition. In the present study, individual administration of either raloxifene (Group A) or atorvastatin (Group B) or both (Group C) was compared for a period of 3 months and their effects on total lipids and HDL phospholipids were evaluated. The combined treatment of raloxifene and atorvastatin resulted in profound changes in the majority of serum lipids, including a significant reduction in total cholesterol and triglycerides (P<0.001), a rise in total phospholipids (P<0.01) and a reduction in LDL-C and Apo B levels (P<0.001). Furthermore, Apo A-I was elevated (P<0.001) whereas total HDL phospholipids were significantly increased (P<0.05). Specifically, HDL phosphatidylcholine levels were markedly increased (P<0.001) and HDL lysophosphatidylcholine, sphingomyelin and phosphatidylinositol levels were reduced (P<0.05). A further attempt to evaluate each treatment group was performed and the significance of these results is discussed.

Evidence of improved serum fatty acid profile of postmenopausal women receiving atorvastatin and raloxifene

Raloxifene and atorvastatin have been shown to reduce the risk of cardiovascular disease associated with postmenopausal status and it has been postulated that their effects may be partly mediated by favourable changes in serum lipids and fatty acid composition. In the present study, individual administration of either raloxifene (Group A) or atorvastatin (Group B) or both (Group C) was compared for a period of 3 months and their effects on total lipids and fatty acids composition was evaluated. Postmenopausal women receiving both raloxifene and atorvastatin showed significant changes in the majority of serum lipids with important reductions in total cholesterol (p < 0.001), triglycerides (p < 0.001), LDL-C (p < 0.001) and Apo B levels (p < 0.001). Phospholipids concentrations (p < 0.01) as well as Apo A-I were also significantly raised (p < 0.001). Furthermore, oleic acid (18:1) and linoleic acid (18:2) levels were significantly increased (p < 0.01 and p < 0.001 respectively) followed by a marked reduction in palmitic acid (16:0) and arachidonic acid (20:4) concentrations (p < 0.01 and p < 0.001 respectively). The results of the study indicate that the serum lipid and fatty acid composition in postmenopausal women is influenced by the combined treatment of raloxifene and atorvastatin and a further attempt to evaluate the significance of these results is discussed.

Efficacy and tolerability of combined treatment with L-carnitine and simvastatin in lowering lipoprotein(a) serum levels in patients with type 2 diabetes mellitus

Lipoprotein(a) [Lp(a)] concentration is generally related to coronary artery disease (CAD) and cerebrovascular disease. However, at present, few interventions are available to lower Lp(a) concentrations. We investigated the effects of l-carnitine, co-administered with simvastatin, on hyper-Lp(a) in patients with type 2 diabetes mellitus. We conducted an open, randomised, parallel-group study, in one investigational center (University hospital). Fifty-two patients with type 2 diabetes mellitus, a triglyceride serum levels <400mg/dL (<4.5 mmol/L), and Lp(a) serum levels >20mg/dL (0.71 mmol/L) were randomised to receive simvastatin alone (n=26) or simvastatin plus l-carnitine (n=26) for 60 days. Simvastatin was administered, in both groups, at a dosage of 20 mg/day, while l-carnitine was administered at a dosage of 2g/day once daily. Both treatments were given orally. Serum levels of triglycerides, total cholesterol, LDL cholesterol, high-density lipoprotein (HDL) cholesterol, non-HDL cholesterol (total cholesterol minus HDL cholesterol), apolipoprotein B, and Lp(a) were measured at baseline and 60 days after starting treatment. No difference in time by groups (simvastatin and simvastatin plus l-carnitine) were observed in the reduction of LDL cholesterol, non-HDL cholesterol, and apoB serum levels. On the other hand, Lp(a) serum levels increase from baseline to 60 days in the simvastatin group alone versus a significant decrease in the combination group. Our findings provide support for a possible role of combined treatment with l-carnitine and simvastatin in lowering Lp(a) serum levels in patients with type 2 diabetes mellitus than with simvastatin alone. Our results strongly suggest that l-carnitine may have a role among lipid-lowering strategies.

Efficacy and safety of statins in hypercholesterolemia with emphasis on lipoproteins

Information of the effect of statin on lipoproteins such as apolipoprotein (apo) A-I, lipoprotein (a) [Lp (a)], or apolipoprotein B levels is limited. This investigation was a crossover study designed to evaluate the efficacy and safety of atorvastatin and simvastatin in patients with hyperlipidemia. Sixty-six patients were involved in the study. Group I consisted of 32 patients, who were first treated with atorvastatin (10 mg) then switched to simvastatin (10 mg). Group II consisted of 34 patients, who were first treated with simvastatin then switched to atorvastatin. Each regimen was used for 3 months (phase I), stopped for 2 months, and then restarted for another 3 months (phase II). Both statins effectively reduced total cholesterol, low-density lipoprotein cholesterol (LDL-C), apo B, and Lp (a) (P < 0.001 in all comparisons). A significant increase in the high-density lipoprotein cholesterol (HDL-C) was noted after both statin treatments (P < 0.05 in all comparisons). Both statins caused an increase in the apo A-I levels, and the extent of changes in apo A-I revealed no difference between the two drugs. Compared to the simvastatin group, there were more patients in the atorvastatin group achieving the National Cholesterol Education Program ATP-III LDL-C goal (P < 0.05) and European LDL-C goal (P < 0.001). Both treatments were well tolerated; no patient was withdrawn from the study. This study demonstrates that both statins can effectively improve lipid profiles in patients with hyperlipidemia. Atorvastatin is more effective in helping patients reach the ATP-III and European LDL-C goals than simvastatin at the same dosage.

A prospective study of lipoprotein(a) and risk of coronary heart disease among women with type 2 diabetes

AIMS

We examined the association between lipoprotein (Lp)(a) and CHD among women with type 2 diabetes.

METHODS

Of 32,826 women from the Nurses' Health Study who provided blood at baseline, we followed 921 who had a confirmed diagnosis of type 2 diabetes.

RESULTS

During 10 years of follow-up (6,835 person-years), we documented 122 incident cases of CHD. After adjustment for age, smoking, BMI, glycosylated HbA(1)c, triglycerides (TGs), high-density lipoprotein cholesterol, low-density lipoprotein cholesterol and other cardiovascular risk factors, the relative risk (RR) comparing extreme quintiles of Lp(a) was 1.95 (95% CI 1.07-3.56). The association was not appreciably altered after further adjustment for apolipoprotein B(100) or several inflammatory biomarkers. Increasing levels of Lp(a) were associated with lower levels of TGs. The probability of developing CHD over 10 years was higher among diabetic women with substantially higher levels of both Lp(a) (>1.07 micromol/l) and TGs (>2.26 mmol/l) than among diabetic women with lower levels (22 vs 10%, p log-rank test=0.049). Diabetic women with a higher level of only Lp(a) or TGs had a similar (14%) risk. In a multivariate model, diabetic women with higher levels of Lp(a) and TGs had an RR of 2.46 (95% CI 1.21-5.01) for developing CHD, as compared with those with lower levels of both biomarkers (p for interaction=0.413). The RRs for women with a higher level of either Lp(a) (RR=1.22, 95% CI 0.77-1.92) or TGs (RR=1.39, 95% CI 0.78-2.42) were comparable.

CONCLUSIONS/INTERPRETATION

Increased levels of Lp(a) were independently associated with risk of CHD among diabetic women.

Baseline levels of low-density lipoprotein cholesterol and lipoprotein (a) and the AvaII polymorphism of the low-density lipoprotein receptor gene influence the response of low-density lipoprotein cholesterol to pravastatin treatment

To investigate some individual and genetic factors that may influence the response of low-density lipoprotein cholesterol (LDL-C) to pravastatin treatment, we recruited 440 subjects with hypercholesterolemia (mean age, 57 years; 43% men) from 21 primary health care centers-outpatient clinics into a prospective, multicentered intervention trial. Pravastatin (20 mg/d) was prescribed for 16 weeks. The main outcome was the percentage variation in LDL-C concentration relative to baseline. Blood analyses and genotyping were performed centrally. The results indicated that LDL-C decreased by 20.5% (range, +21% to -66%) after pravastatin treatment. Baseline concentration of LDL-C (the higher the concentration, the greater the decrease), lipoprotein (a) levels (the lower the concentration, the greater the response), and Ava II polymorphism of the LDL-receptor gene significantly influenced the hypolipemic effect ( P < .001, P = .014, and P = .004, respectively). These 3 factors combined explained 10.6% of the variation in LDL-C response. Age, sex, smoking habit, alcohol consumption, body mass index, and apolipoprotein E genotype had no significant effect on response. We conclude that baseline levels of LDL-C and lipoprotein (a) together with the Ava II polymorphism of the LDL-receptor gene have a significant influence on the LDL-C response to pravastatin treatment in patients monitored in a standard primary health care outpatient clinic setting.

Lipoprotein (a) and coronary heart disease among women: beyond a cholesterol carrier?

AIMS

With its homology with plasminogen, lipoprotein(a) [Lp(a)] may be related to thrombosis and inflammation. We assessed the role of Lp(a) in coronary heart diseases (CHD) by a recently developed assay that is not affected by the plasminogen-like Kringle-type-2 repeats.

METHODS AND RESULTS

Of 32 826 women from the Nurses' Health Study, who provided blood at baseline, we documented 228 CHD events during 8 years of follow-up. Each case was compared with two matched controls. In a multivariable model adjusted for body mass index, family history, hypertension, diabetes, post-menopausal hormone use, physical activity, blood drawing characteristics, and alcohol intake, the odd ratio (OR) for Lp(a) levels > or =30 mg/dL was 1.9(95% CI: 1.3-3.0) when compared with those with Lp(a)<30 mg/dL. Women with high levels of both Lp(a) (> or =30 mg/dL) and fibrinogen (> or =400 mg/dL) had an OR of 3.2(95% CI: 1.6-6.5) for CHD, when compared with the combination of low levels (P interaction=0.05). Women with high levels of both Lp(a) and C-reactive protein (> or =3 mg/L) had an OR of 3.67(95% CI: 2.03-6.64) for CHD, when compared with the combination of low levels (P interaction=0.06).

CONCLUSION

Lp(a) levels >30 mg/dL are associated with twice the risk of CHD events among women and may be related to thrombosis and inflammation.

Lipid and non-lipid effects of statins

Long- and short-term trials with the 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) have demonstrated significant reductions in cardiovascular events in patients with and without history of coronary heart disease. Statins are well-established low-density lipoprotein (LDL)-lowering agents, but their clinical benefit is believed to result from a number of lipid and non-lipid effects beyond LDL lowering, including a rise in plasma high-density lipoprotein levels. Beyond improving the lipid profile, statins have additional non-lipid effects including benefit on endothelial function, inflammatory mediators, intima-media thickening, prothombotic factors that ultimately result in plaque stabilization. These effects arise through the inhibition of several mevalonate-derived metabolites other than cholesterol itself, which are involved in the control of different cellular functions. Although statins represent the gold standard in the prevention and treatment of coronary heart disease, combination therapy with other lipid-lowering drugs, as well as novel therapeutic indications, may increase their therapeutic potential.

Effect of atorvastatin on different fibrinolyis mechanisms in hypercholesterolemic subjects

BACKGROUND

Hydroxymethyl-glutaryl-CoA-reductase inhibitors (statins) reduce cardiovascular events by cholesterol lowering as well as non-lipid related actions. Among them, the modulation of fibrinolysis could play a relevant role in vascular protection. Atorvastatin is able of reducing platelet activity and thrombin generation before low-density lipoprotein cholesterol (LDL-C) decrease in hypercholesterolemic subjects in which coagulation and fibrinolysis are linked by the activation of thrombin activable fibrinolysis inhibitor (TAFI). The aim of our study was to evaluate whether atorvastatin could modulate fibrinolysis by interactions with endothelial mechanisms and thrombin generation.

METHODS

Forty-four pure hypercholesterolemic subjects (26 M, 18 F, mean age 52.7+/-13.7, LDL-C 194.8+/-9.3t mg/dl) were evaluated for plasmin-antiplasmin complexes (PAP), tissue-plasminogen acivator (t-PA) and its inhibitor (PAI-1) (ELISA), TAFI activity (HPLC), platelet P-selectin (P-sel) (cytofluorymetric detection), platelet-dependent thrombin generation (PDTG, coagulative-chromogenic method) and lipid profile at baseline and after 7, 14, 28 and 90 days of atorvastatin (10 mg/die) treatment.

RESULTS

PAP were significantly reduced at baseline in hypercholesterolemic versus control subjects (P<0.05) and were related to P-sel (P<0.01), PDTG (P<0.01) and its inhibitor (PAI-1) after venous occlusion (VO) (P<0.05). Atorvastatin induced a significant increase of PAP at T(2) related to modifications of P-sel (P<0.01) and PDTG (P<0.01) before significant LDL-C reduction (P=0.132). PAI-1 was significantly changed at T(3) with relation to LDL-C (P<0.01), Von Willebrand factor (VWF) (P<0.01) and sE-sel (P<0.05).

CONCLUSIONS

The profibrinolytic activity of atorvastatin in hypercholesterolemic subjects is related, initially, to the positive effects exerted on platelet function and thrombin generation which can modulate fibrinolysis by TAFI activity.

Effect of Nandrolone Decanoate on serum lipoprotein (a) and its isoforms in hemodialysis patients

Malnutrition, anemia and increased atherosclerosis are the main causes of mortality in hemodialysis patients. Therapies designed to improve the disorders might therefore be expected to improve outcome. The effects of Nandrolone Decanoate (ND), in 64 stable hemodialysis patients, were studied with respect to the following parameters: nutritional status, hematological indexes, lipid profiles including serum levels of lipoprotein(a) [Lp(a)] in terms of differences in apolipoprotein(a) [apo(a)]. The patients were treated with ND at dose of 100 mg/I.M./week for 4 months. After 2 and 4 months of treatment the elevations in the serum levels of albumin (p < 0.0001), creatinine (p < 0.009), hemoglobin (p < 0.03), hematocrit (p < 0.03), cholesterol (p = 0.007) and triglyceride (p < 0.04) were noticed. Marked decrease in the concentration of high-density lipoprotein cholesterol (p = 0.007) and Lp(a) (p < 0.0001) were also found. These effects after 2 months of treatment withdrawal were relatively constant. By dividing patients according to the baseline Lp(a) levels and molecular weight of apo(a) isoform, it was noticed that the decrease in serum Lp(a) was significant in patients with high Lp(a) (>30 mg/dl) than those of with low Lp(a) (<30 mg/dl), irrespective of apo(a) molecular weight. It may be suggested that, ND has beneficial effect on nutritional status and treatment of anemia in hemodialysis patients. In spite the adverse effect of ND on lipid profile, it decreases Lp(a) mostly in patients with high serum Lp(a) preferently by the effect on apo(a) gene transcriptional activity.

Electrophoretic measurement of lipoprotein(a) cholesterol in plasma with and without ultracentrifugation: comparison with an immunoturbidimetric lipoprotein(a) method

OBJECTIVES

Elevated plasma lipoprotein(a) [Lp(a)] is a significant risk factor for vascular disease. Standardization of Lp(a) mass measurement is complicated by the heterogeneity of apolipoprotein(a) [apo(a)]. We investigated whether Lp(a) cholesterol measurement, which is not influenced by apo(a) size, is a viable alternative to measuring Lp(a) mass.

DESIGN AND METHODS

Plasma Lp(a) cholesterol was measured electrophoretically, with and without ultracentrifugation, and results were compared to each other and to immunoturbidimetrically measured Lp(a) mass in 470 subjects.

RESULTS

Ultracentrifuged and whole plasma Lp(a) cholesterol levels demonstrated high correlation (R = 0.964). All samples with detectable (>/=2.0 mg/dl) Lp(a) cholesterol had Lp(a) mass >30 mg/dl (the clinically relevant cutpoint), while 59 samples with Lp(a) mass >30 mg/dl did not have detectable Lp(a) cholesterol.

CONCLUSIONS

Lp(a) cholesterol can be measured in whole plasma without interference from VLDL lipoproteins. The relative clinical merits of measuring Lp(a) cholesterol vs. Lp(a) mass or both in combination deserves investigation.

The Effects of Atorvastatin Treatment on the Fibrinolytic System in Dyslipidemic Patients

Statins have pleiotrophic effects related to the pathogenesis of atherosclerosis and thrombogenicity of the vessel wall beyond lipid lowering. The aim of the present study was to examine the effect of atorvastatin treatment on the fibrinolytic system in patients with dyslipidemia. The investigation was carried out on 41 dyslipidemic patients (21 males and 20 females) with a mean age of 53.8 years (range, 30-76). The patients were divided into subgroups according to their cholesterol and triglyceride levels as hypercholesterolemic (n = 26) and mixed-type hyperlipidemic (n = 15) and their risk factors for coronary heart disease including age, sex, hypertension, obesity, smoking, and family history. The patients were started on atorvastatin 10 mg/day, and evaluated within 6-12 weeks to assess the changes in fibrinolytic parameters including global fibrinolytic capacity, plasminogen activator inhibitor type-1 and tissue plasminogen activator, and lipids. After successful lipid-lowering therapy, global fibrinolytic capacity (P = 0.003) and tissue plasminogen activator levels (P = 0.04) were found to be increased and plasminogen activator inhibitor type-1 levels (P = 0.02) decreased in dyslipidemic patients. Global fibrinolytic capacity levels increased (P < 0.001) and plasminogen activator inhibitor type-1 levels decreased (P = 0.01) in patients with hypercholesterolemia (n = 26). However, no significant changes were observed in fibrinolytic parameters in patients with mixed-type hyperlipidemia (n = 15). When the patients were separately evaluated according to risk factors, significant beneficial effects on the fibrinolytic system were observed, especially in patients without obesity and hypertension as well as in older patients and males. These findings suggest that atorvastatin treatment has a beneficial effect on the fibrinolytic system in patients with hypercholesterolemia, but not in patients with mixed-type hyperlipidemia. Further studies are needed to show whether higher doses and longer periods of lipid lowering treatment have beneficial effects in patients with mixed type hyperlipidemia and some risk factors.

Report of the National Heart, Lung, and Blood Institute Workshop on Lipoprotein(a) and Cardiovascular Disease: Recent Advances and Future Directions

It has been estimated that ∼37% of the US population judged to be at high risk for developing coronary artery disease (CAD), based on the National Cholesterol Education Program guidelines, have increased plasma lipoprotein(a) [Lp(a)], whereas Lp(a) is increased in only 14% of those judged to be at low risk. Therefore, the importance of establishing a better understanding of the relative contribution of Lp(a) to the risk burden for CAD and other forms of vascular disease, as well as the underlying mechanisms, is clearly evident. However, the structural complexity and size heterogeneity of Lp(a) have hindered the development of immunoassays to accurately measure Lp(a) concentrations in plasma. The large intermethod variation in Lp(a) values has made it difficult to compare data from different clinical studies and to achieve a uniform interpretation of clinical data. A workshop was recently convened by the National Heart, Lung, and Blood Institute (NHLBI) to evaluate our current understanding of Lp(a) as a risk factor for atherosclerotic disorders; to determine how future studies could be designed to more clearly define the extent to which, and mechanisms by which, Lp(a) participates in these processes; and to present the results of the NHLBI-supported program for the evaluation and standardization of Lp(a) immunoassays. This report includes the most recent data presented by the workshop participants and the resulting practical and research recommendations.

Does Lipoprotein(a) Inhibit Elastolysis in Abdominal Aortic Aneurysms?

PURPOSE

to test the hypothesis that there is a negative association between serum levels of lipoprotein(a) (Lp(a)) and elastin-derived peptides (EDP) as well as matrix metalloproteinase (MMP)-9 activation in the aneurysm wall in patients with asymptomatic abdominal aortic aneurysms (AAA).

MATERIAL AND METHODS

from 30 patients operated for asymptomatic AAAs, preoperative serum samples and AAA biopsies were collected. Lp(a) (mg/L) and EDP (ng/ml) in serum were measured by enzyme linked immunosorbent assays. MMP-9 activity (arbitrary units) in the AAA wall was measured by gelatin zymography and the ratio: active MMP-9/total MMP-9 were calculated.

RESULTS

there was a significant negative correlation (Spearman's rho) between serum levels of Lp(a) and EDP (r= -0.707, p<0.001), as well as the share of activated MMP-9 (r= -0.461, p=0.01) in the AAA wall.

CONCLUSION

this preliminary study indicate that Lp(a) inhibit elastolysis in asymptomatic AAA.

Homocisteína y progresión de la aterosclerosis de la arteria carótida en pacientes con enfermedad coronaria

BACKGROUND AND OBJECTIVE

Carotid intima-media thickness (IMT) is a marker of generalized atherosclerosis. Sequential evaluation of carotid IMT has permitted to know the factors involved in its progression. However, there are few studies about the influence of homocysteine in such progression. The aim of this work was to know the effect of homocysteine values on the evolution of carotid IMT in patients with coronary disease.

PATIENTS AND METHOD

Carotid IMT (baseline and after 4 years of follow-up) was evaluated by a B-mode ultrasonography in 187 patients with coronary disease (166 males and 21 females; age: mean [standard deviation], 60 [7] years); 185 patients were treated with statins from the beginning of the study.

RESULTS

Carotid IMT progression was confirmed in 59 patients (31.6%; 95% confidence interval [CI], 25.0-38.7%). Cardiovascular risk factors, basal biochemical parameters and methylenetetrahydrofolate reductase-C677T polymorphism were similar in patients with and without progression except for homocysteine values which were higher in the former (13.3 [5.3]; 95% CI, 12.0-14.6 vs 11.1 [3.5]; 95% CI, 10.5-11.7 (mol/l; p = 0.001). Biochemical changes at the end of the study were similar in both groups. In the multivariate analysis, IMT progression was associated with basal values of homocysteine (odds ratio [OR] 1.19; 95% CI, 1.07-1.31; p = 0.0008), female gender (OR 3.50; 95% CI, 1.17-10.50; p = 0.02), hypertension (OR 2.52; 95% CI, 1.14-5.59; p = 0.02) and basal high-density lipoprotein (HDL)-cholesterol values (OR, 0.94; 95% CI, 0.90-0.98; p = 0.009).

CONCLUSIONS

The concentration of homocysteine is associated with the progression of carotid atherosclerosis in patients with coronary heart disease treated with statins.