Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): a randomised open-label, blinded endpoint analysis

Emerging agents targeting triglycerides

PURPOSE OF REVIEW

Hypertriglyceridemia (HTG), which arises from defects in triglyceride-rich lipoprotein (TRL) metabolism, is associated with increased morbidity and mortality from pancreatitis and atherosclerotic cardiovascular disease. Traditional therapies, including fibrates and omega-3 fatty acids, have shown limited efficacy in controlling triglyceride (TG) levels and cardiovascular risk. This review explores the role of emerging therapies that target TG and TRL metabolism via novel biochemical pathways.

RECENT FINDINGS

Apolipoprotein C-III inhibitors appear most effective for patients with variants of severe HTG, particularly multifactorial and familial chylomicronemia syndromes, by enhancing TRL metabolism through both lipoprotein lipase-dependent and independent mechanisms. Angiopoeitin-like proteins 3 and 4 inhibitors appear most useful for mixed hyperlipidemia, with favorable effects across the entire spectrum of apoB-containing atherogenic lipoproteins. For patients with HTG and concomitant complications of insulin resistance, including metabolic associated steatotic liver disease and type 2 diabetes mellitus, fibroblast growth factor-21 analogs may provide significant benefit.

SUMMARY

HTG is a diverse condition. Apolipoprotein C-III inhibitors, angiopoeitin-like proteins 3 and 4 inhibitors, and fibroblast growth factor-21 analogs represent significant advancements in the treatment of HTG, offering new hope for effectively managing this condition across its full spectrum of disease.

Pharmacological countermeasures for long-duration space missions: addressing cardiovascular challenges and advancing space-adapted healthcare

Future long-duration crewed space missions beyond Low Earth Orbit (LEO) will bring new healthcare challenges for astronauts for which pharmacological countermeasures (pharmacological countermeasures) are crucial. This paper highlights current pharmacological countermeasures challenges described in the ESA SciSpacE Roadmap, with a focus on the cardiovascular system as a model to demonstrate the potential implication of the challenges and recommendations. New pharmacological approaches and procedures need to be adapted to spaceflight (spaceflight) conditions, including ethical and reglementary considerations. Potential strategies include combining pharmacological biomarkers such as pharmacogenomics with therapeutic drug monitoring, advancing microsampling techniques, and implementing a pharmacovigilance system to gain deep insights into pharmacokinetics/pharmacodynamics (PK/PD) spaceflight alteration on drug exposure. Emerging therapeutic approaches (such as long-term regimens) or manufacturing drugs in the space environment, can address specific issues related to drug storage and stability. The integration of biobanks and innovative technologies like organoids and organ-on-a-chip, artificial intelligence (AI), including machine learning will further enhance PK modelling leading to personalized treatments. These innovative pharmaceutical tools will also enable reciprocal game-changing healthcare developments to be made on Earth as well as in space and are essential to ensure space explorers receive safe effective pharmaceutical care.

Omega-3 Fatty Acids and Risk of Ischemic Stroke in REGARDS

We examined associations between lipidomic profiles and incident ischemic stroke in the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. Plasma lipids (n = 195) were measured from baseline blood samples, and lipids were consolidated into underlying factors using exploratory factor analysis. Cox proportional hazards models were used to test associations between lipid factors and incident stroke, linear regressions to determine associations between dietary intake and lipid factors, and the inverse odds ratio weighting (IORW) approach to test mediation. The study followed participants over a median (IQR) of 7 (3.4-11) years, and the case-cohort substudy included 1075 incident ischemic stroke and 968 non-stroke participants. One lipid factor, enriched for docosahexaenoic acid (DHA, an omega-3 fatty acid), was inversely associated with stroke risk in a base model (HR = 0.84; 95%CI 0.79-0.90; P = 8.33 × 10-8) and fully adjusted model (HR = 0.88; 95%CI 0.83-0.94; P = 2.79 × 10-4). This factor was associated with a healthy diet pattern (β = 0.21; 95%CI 0.12-0.30; P = 2.06 × 10-6), specifically with fish intake (β = 1.96; 95%CI 0.95-2.96; P = 1.36 × 10-4). DHA was a mediator between fish intake and incident ischemic stroke (30% P = 5.78 × 10-3). Taken together, DHA-containing plasma lipids were inversely associated with incident ischemic stroke and mediated the relationship between fish intake and stroke risk.

Icosapent ethyl reduces arterial thrombosis by inhibition of cyclooxygenase-1-induced platelet reactivity

Large, randomized trials testing omega-3 polyunsaturated fatty acid (ω-3 PUFA) supplementation to reduce cardiovascular events have reported contradictory results. Interpretation of these trials is challenging, because different dosages and formulations of ω-3 PUFA were tested. Furthermore, the exact mechanisms for the reduction in cardiovascular events are unclear. In this study, we investigated the effects of ω-3 PUFA on platelet adhesion, degranulation, and aggregation in vitro and in patients with cardiovascular disease using different formulations of ω-3 PUFA. We also investigated the effects of ω-3 PUFA in rodent models of arterial thrombosis and in tail bleeding assays, including in cyclooxygenase-1 (COX-1)-deficient animals. The ω-3 PUFA eicosapentaenoic acid (EPA) dose-dependently reduced platelet adhesion, degranulation, and aggregation in vitro. Moreover, arterial thrombus formation in wild-type mice was inhibited by oral EPA administration before thrombus formation. Photoaffinity labeling and in silico docking analyses suggested a direct, competitive interaction of EPA and arachidonic acid at the level of COX-1. The COX-1 dependency of EPA's inhibitory effects was confirmed by platelet-specific COX-1-deficient animals that had no reduction of thrombus burden by EPA. In patients with cardiovascular disease, switching from 2 grams of EPA twice daily to 1 gram of docosahexaenoic acid (DHA) (460 milligrams of EPA and 380 milligrams of DHA) once daily completely blunted the platelet inhibition achieved by EPA. Our results may partially explain contradictory results with different ω-3 PUFA formulations in clinical trials.

Hydroxytyrosyl Eicosapentaenoate as a Potential Antioxidant for Omega-3 Fatty Acids: Improved Synthesis and Comparative Evaluation with Other Natural Antioxidants

Hydroxytyrosol (HT), the primary phenolic compound in virgin olive oil, has notable cardiovascular benefits, particularly in preventing low-density lipoprotein (LDL) oxidation. However, its hydrophilicity limits its solubility and integration into lipid-based formulations. This study aimed to enhance its lipophilicity by synthesizing hydroxytyrosyl eicosapentaenoate (HT-EPA), a derivative of HT and eicosapentaenoic acid (EPA), using a one-step enzymatic catalysis with lipase B from Candida antarctica (CALB). The reaction, performed as a suspension of HT in ethyl eicosapentaenoate (Et-EPA) (1:9 molar ratio) under vacuum, achieved higher yields and shorter reaction times than previously reported, with a purity exceeding 98%, confirmed by 1H-NMR. For the first time, the antioxidant capacity of HT-EPA in comparison with other natural antioxidants was assessed using the FRAP assay, while its oxidative stability in an omega-3-rich oil matrix was evaluated via the Rancimat method. HT-EPA and hydroxytyrosyl acetate (HT-Ac) displayed antioxidant activity comparable to HT but significantly higher than α-tocopherol, a common food antioxidant. Given the scarcity of effective lipid-soluble antioxidants, HT-EPA represents a promising candidate for omega-3 nutraceuticals, offering enhanced stability and potential health benefits. This study provides a simple, efficient, and scalable strategy for developing functional lipid-based formulations with cardioprotective potential by improving HT solubility while preserving its antioxidant properties.

The effectiveness of the current lipid-lowering therapy for refractory dyslipidaemia in patients with coronary artery disease: the price of 'the lower, the better' - results of a survey by Japanese cardiologists

BACKGROUND

Optimal medical therapy plays a critical role in improving the prognosis of patients with coronary artery disease (CAD), particularly through the management of dyslipidaemia. This study investigated treatment practices for patients with dyslipidaemia-complicated CAD (DL-CAD) in Japan, focusing on cases considered refractory to standard management.

RESEARCH DESIGN AND METHODS

A web-based survey was conducted from 10 November 2023 to 1 December 2023 among cardiologists. Responses from 202 participants were analysed and divided into two groups based on the proportion of patients with refractory DL-CAD: <10% (n = 102) and ≥ 10% (n = 100).

RESULTS

There was no significant difference in the use of maximally tolerated statins between groups. However, ezetimibe, EPA, and omega-3-acid ethyl esters were used more frequently in the group with a higher proportion of refractory patients. Logistic regression analysis revealed that the use of ezetimibe was the only factor affecting the proportion of patients with refractory DL-CAD (odds ratio: 1.26, p = 0.0499).

CONCLUSIONS

Japanese cardiologists tend to prescribe ezetimibe in addition to maximally tolerated statin for patients with refractory DL-CAD. Furthermore, they are increasingly targeting elevated triglycerides using polyunsaturated fatty acids as a strategy to reduce residual cardiovascular risk when LDL-C targets are unmet.

Combination therapy and drug co-delivery systems for atherosclerosis

Atherosclerosis is a chronic inflammatory disease characterized by the accumulation of plaque within the arteries. Despite advances in therapeutic strategies including anti-inflammatory, antioxidant, and lipid metabolism modulation treatments over the past two decades, the treatment of atherosclerosis remains challenging, as arterial damage is the result of interconnected pathological factors. Therefore, current monotherapies often fail to address the complex nature of this disease, leading to insufficient therapeutic outcomes. This review addressed this paucity of effective treatment options by comprehensively exploring the potential for combination therapies and advanced drug co-delivery systems for the treatment of atherosclerosis. We investigated the pathological features of and risk factors for atherosclerosis, underscoring the importance of drug combination therapies for the treatment of atherosclerotic diseases. We discuss herein mathematical models for quantifying the efficacy of the combination therapies and provide a systematic summary of drug combinations for the treatment of atherosclerosis. We also provide a detailed review of the latest advances in nanoparticle-based drug co-delivery systems for the treatment of atherosclerosis, focusing on the design of carriers with high biocompatibility and efficacy. By exploring the possibilities and challenges inherent to this approach, we aim to highlight cutting-edge technologies that can foster the development of innovative strategies, optimize drug co-administration, improve treatment outcomes, and reduce the burden of atherosclerosis-related morbidity and mortality on the healthcare system.

Concept and practice in the use of high-dose eicosapentaenoic acid for cardiovascular disease prevention in hypertriglyceridaemia

Genetic and epidemiological evidence indicates that triglyceride-rich lipoproteins are causal risk factors for atherosclerotic cardiovascular disease (ASCVD). Elevated levels of plasma triglyceride are common in patients who are diabetic or obese and contribute substantially to residual, ongoing risk of an ASCVD event in individuals on low-density lipoprotein (LDL)-lowering treatment. Hypertriglyceridaemia, therefore, presents a target for further intervention. Clinical trials have demonstrated that high-dose eicosapentaenoic acid (EPA) is effective in reducing ASCVD risk in patients on statin therapy, and it is now being incorporated into strategies using combination lipid-regulating treatment to manage aggressively those at highest risk. This review summarises the concepts underpinning the use of high-dose EPA alongside intensive LDL-lowering therapy, especially in the context of post-acute coronary syndrome. A practical implementation algorithm is presented setting out treatment options for combination therapy, and the place of high-dose EPA in ASCVD prevention in hypertriglyceridaemia.

Clinical staging to guide management of metabolic disorders and their sequelae: a European Atherosclerosis Society consensus statement

Obesity rates have surged since 1990 worldwide. This rise is paralleled by increases in pathological processes affecting organs such as the heart, liver, and kidneys, here termed systemic metabolic disorders (SMDs). For clinical management of SMD, the European Atherosclerosis Society proposes a pathophysiology-based system comprising three stages: Stage 1, where metabolic abnormalities such as dysfunctional adiposity and dyslipidaemia occur without detectable organ damage; Stage 2, which involves early organ damage manifested as Type 2 diabetes, asymptomatic diastolic dysfunction, metabolic-associated steatohepatitis (MASH), and chronic kidney disease (CKD); and Stage 3, characterized by more advanced organ damage affecting multiple organs. Various forms of high-risk obesity, driven by maintained positive energy balance, are the most common cause of SMD, leading to ectopic lipid accumulation and insulin resistance. This progression affects various organs, promoting comorbidities such as hypertension and atherogenic dyslipidaemia. Genetic factors influence SMD susceptibility, and ethnic disparities in SMD are attributable to genetic and socioeconomic factors. Key SMD features include insulin resistance, inflammation, pre-diabetes, Type 2 diabetes, MASH, hypertension, CKD, atherogenic dyslipidaemia, and heart failure. Management strategies involve lifestyle changes, pharmacotherapy, and metabolic surgery in severe cases, with emerging treatments focusing on genetic approaches. The staging system provides a structured approach to understanding and addressing the multi-faceted nature of SMD, which is crucial for improving health outcomes. Categorization of SMD abnormalities by presence and progression is aimed to improve awareness of a multi-system trait and encourage a tailored and global approach to treatment, ultimately aiming to reduce the burden of obesity-related comorbidities.

The EPA oxylipin, 12-HEPE, directly regulates human platelet activity

Arterial thrombosis, driven by platelet hyperactivity, is the underlying pathophysiology of most major cardiovascular events. Dietary fish oil supplementation containing ω-3 polyunsaturated fatty acids (PUFAs) elicits cardiovascular protection in at-risk patients. Studies have attributed the cardiovascular benefits of ω-3 PUFAs to eicosapentaenoic acid (EPA), the primary ω-3 PUFA present in fish oil supplements. However, the role of EPA in platelet activation remains unclear. This study aimed to evaluate whether the cardiovascular protection observed in individuals taking dietary supplements containing EPA is achieved by altering platelet function. Additionally, we investigated whether these effects are mediated through the 12-lipoxygenase (12-LOX)-derived oxidized lipid (oxylipin) metabolite of EPA, 12(S)-hydroxy-5Z,8Z,10E,14Z,17Z-eicosapentaenoic acid (12-HEPE). Human whole blood, platelet-rich plasma, and washed platelets were treated with EPA or 12-HEPE to assess their ability to regulate platelet activity. Both EPA and 12-HEPE inhibited agonist-stimulated platelet aggregation, and 12-HEPE was found to be the primary oxylipin produced by platelets in the presence of EPA. Furthermore, 12-HEPE more potently attenuated dense granule secretion, α-granule secretion, and integrin αIIbβ3 activation, in comparison to EPA. Interestingly, while EPA delayed thrombin-induced clot retraction and reduced platelet adhesion under flow, 12-HEPE did not affect these processes. Both EPA and 12-HEPE attenuated ex vivo thrombus formation; however, the same inhibitory concentrations did not alter coagulation parameters in thromboelastography. This study demonstrates that EPA and its 12-LOX metabolite, 12-HEPE, effectively inhibit platelet activation. These findings suggest the antiplatelet effects of EPA are regulated, in part, through 12-HEPE, advancing our understanding of the cardiovascular benefits of EPA.

Diabetes and Lipids: A Review and Update on Lipid Biomarkers and Cardiovascular Risk

OBJECTIVE

To review existing and new evidence regarding the relationship between diabetes and dyslipidemia and to provide an update of the lipid biomarkers used to assess cardiovascular risk and the current guidelines reflecting these changes.

METHODS

We conducted a literature review pertaining to diabetes and lipids using the MEDLINE/PubMed database. We reviewed articles in English and primarily published between 1994 and early 2025. Also included are guidelines published by professional organizations who are recognized nationally or internationally in the fields of diabetes, lipids, and cardiovascular disease.

RESULTS

Studies evaluating the relationship between diabetes and hypertriglyceridemia have provided practice-changing evidence. Lipid markers such as apolipoprotein B, non-high-density lipoprotein cholesterol, and lipoprotein (a), as well as the concept of lipid variability have emerged as treatment targets.

CONCLUSION

Over the past 30 years, non-low-density lipoprotein cholesterol lipid markers have been identified to further stratify individuals with diabetes who are at risk for future cardiovascular events. Treatment targets and pharmacological therapy have been studied and continue to be updated.

Strategies for the Secondary Prevention of Atherosclerotic Cardiovascular Disease

Patients with atherosclerotic cardiovascular disease (ASCVD), such as those with a history of MI or stroke, are at high risk for morbidity and mortality associated with future cardiovascular events. Ideal management of these patients requires a multifactorial strategy for risk factor mitigation and prevention of additional cardiovascular events. Traditional management of secondary prevention patients involves lipid-lowering with statins, blood pressure control, and anti-platelet treatment. Several additional targets have been identified to optimize the secondary prevention of ASCVD, such as further lipid control, inflammation management, lifestyle and weight optimization, strict diabetes control, use of β-blockers, use of renin-angiotensin-aldosterone system inhibitors, vaccinations, and additional considerations of anti-thrombotic therapies. This review will describe the interventions associated with these targets, as well as the relevant research and indications for these therapies.

Glycerophospholipid and Sphingosine- 1-phosphate Metabolism in Cardiovascular Disease: Mechanisms and Therapeutic Potential

Cardiovascular disease remains a leading cause of mortality worldwide, driven by factors such as dysregulated lipid metabolism, oxidative stress, and inflammation. Recent studies highlight the critical roles of both glycerophospholipid and sphingosine- 1-phosphate metabolism in the pathogenesis of cardiovascular disorders. However, the contributions of glycerophospholipid-derived metabolites remain underappreciated. Glycerophospholipid metabolism generates bioactive molecules that contribute to endothelial dysfunction, lipid accumulation, and cardiac cell injury while also modulating inflammatory and oxidative stress responses. Meanwhile, sphingosine- 1-phosphate is a bioactive lipid mediator that regulates vascular integrity, inflammation, and cardiac remodeling through its G-protein-coupled receptors. The convergence of these pathways presents novel therapeutic opportunities, where dietary interventions such as omega- 3 polyunsaturated fatty acids and pharmacological targeting of sphingosine- 1-phosphate receptors could synergistically mitigate cardiovascular risk. This review underscores the need for further investigation into the interplay between glycerophospholipid metabolism and sphingosine- 1-phosphate signaling to advance targeted therapies for the prevention and management of cardiovascular disease.

Polyunsaturated Fatty Acids Improved Long Term Prognosis by Reducing Oxidative Stress, Inflammation, and Endothelial Dysfunction in Acute Coronary Syndromes

BACKGROUND

Oxidative stress, inflammation, and endothelial dysfunction are important processes in the progression of atherosclerosis and the occurrence of acute coronary syndromes (ACSs). Omega-3 polyunsaturated fatty acids (Omega-3 PUFAs) are present in marine organisms and have the capacity to reduce all these processes and, at the same time, the progression of atherosclerosis and the emergence of ACSs.

AIM

To evaluate the role of Omega-3 PUFAs therapy on parameters of oxidative stress, inflammatory syndrome, endothelial dysfunction, and long-term prognosis in acute coronary syndromes.

METHODS

One thousand one hundred forty patients were admitted to Clinic County Emergency Hospital Brasov with ACS and were enrolled in a prospective study. The study was divided into four groups related to the type of ACS and treatment with Omega-3 PUFAs added to the optimal medical therapy (OMT). The effect of Omega-3 PUFAs therapy associated with the OMT was determined by measuring the dynamics of the following parameters: (a) oxidative stress-total antioxidant status (TAS), oxidated low density lipoprotein cholesterol antibodies (Ab anti-ox-LDL), IgG anti-Myeloperoxidase antibodies (IgG type Ab anti-MPO); (b) inflammatory syndrome-C-reactive protein and fibrinogen; (c) endothelial dysfunction-flow mediated dilation (FMD) and von Willebrand factor (vWf) activity, from baseline to 6 months of follow-up. Clinical events followed at 5 years were cardiovascular and sudden death, Non-ST and ST segment elevation ACS, in stent thrombosis and restenosis, stroke, readmission in hospital for ACS and for heart failure.

RESULTS

In ACS groups, treatment with Omega-3 PUFAs added to the OMT significantly decreased the parameters of oxidative stress, inflammatory syndrome, and endothelial dysfunction at 6 months of follow-up. Regarding the clinical events, a significant reduction in the risk of cardiovascular and sudden death and a decreased incidence of Non-ST and ST segment elevation ACS, in-stent restenosis, readmission for ACS and heart failure, was observed in Omega-3 PUFA-treated groups in comparison to control groups.

CONCLUSIONS

In acute coronary syndromes, therapy with Omega-3 PUFAs added to the OMT resulted in a significant decrease of parameters of oxidative stress, inflammation, and endothelial dysfunction at 6 months and also a significant improvement in the long-term prognosis.

Pre- and post-operative administration of omega-3 polyunsaturated fatty acids in cardiac surgery patients. A narrative review

Eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA) are two biologically active omega-3 polyunsaturated fatty acids (n-3 PUFA), acquired by nutrition and incorporated in cell membranes' phospholipids, thus playing a crucial role in human health and homeostasis. Due to their potential cardioprotective, anti-inflammatory, and anti-arrhythmic actions, n-3 PUFA emerge as an interesting therapeutic option for cardiac surgery (CS) patients. The aim of this review was to assess the effects of perioperative administration of n-3 PUFA in CS patients. A comprehensive literature search was conducted in order to identify prospective cohort studies and randomized controlled trials (RCT) reporting on the perioperative effects of n-3 PUFA among adult patients undergoing CS. A total of 31 articles, published between 1995 and 2022, including 10 543 patients, met the inclusion criteria. There seems to be a beneficial effect of n-3 PUFA supplementation for arrhythmias such as in Postoperative Atrial Fibrillation (POAF), reduction of Intensive Care Unit Length of Stay (ICULOS) & Hospital Length of Stay (HLOS), reduction in postoperative ventilation time, in inotropic demand, in postoperative fatigue, as well as in overall morbidity and mortality. Moreover, n-3 PUFA increase antioxidant potential, attenuate oxidative stress and inflammation with subsequent significant reduction in myocardial ischemia/reperfusion (I/R) injury, thus promoting early metabolic recovery of the heart after elective CS leading to improved myocardial protection. They represent a readily available and cost-effective strategy that could improve the outcome of patients undergoing CS, by reducing the risks of serious cardiovascular adverse events (AE), both peri- and post-operatively.

Triglyceride/high density lipoprotein cholesterol index and future cardiovascular events in diabetic patients without known cardiovascular disease

The triglyceride/high-density lipoprotein cholesterol (TG/HDL-C) index, calculated as TG divided by HDL-C, has been suggested as a predictor of cardiovascular disease (CVD). We investigated the association between the TG/HDL-C index and CVD events in type 2 diabetes mellitus (T2DM) patients with retinopathy and hyperlipidemia but no known CVD, enrolled in the EMPATHY study, which compared intensive and standard statin therapy (targeting LDL-C levels < 70 mg/dL and ≥ 100 to < 120 mg/dL, respectively). A total of 4665 patients were divided into high (TG/HDL-C ≥ 2.5, n = 2013) and low (TG/HDL-C < 2.5, n = 2652) TG/HDL-C index groups. During a median follow-up of 36.8 months, 260 CVD events occurred. The high TG/HDL-C index group had higher CVD risk than the low group (HR 1.89, 95% CI 1.45-2.47, p < 0.001). This association remained consistent across subgroups. A trend toward interaction between TG/HDL-C index and statin treatment allocation for CVD risk was observed (p for interaction = 0.062). Intensive statin treatment reduced CVD risk in the high TG/HDL-C group but not in the low group. In conclusion, a TG/HDL-C index ≥ 2.5 was associated with higher CVD risk in T2DM patients with retinopathy and hyperlipidemia without a history of CVD. The TG/HDL-C index may identify patients who benefit from intensive statin treatment.

Nannochloropsis Lipids and Polyunsaturated Fatty Acids: Potential Applications and Strain Improvement

The genus Nannochloropsis comprises a group of oleaginous microalgae that accumulate polyunsaturated fatty acids (PUFAs), especially eicosapentaenoic acid (EPA). These molecules are essential for the correct development and health of humans and animals. Thanks to their attractive lipid profile, Nannochloropsis is mainly marketed as a feed ingredient in aquaculture. In microalgae of this genus, contents and cellular location of PUFAs are affected by the growth conditions and gene expression. Strain improvement through non-recombinant approaches can generate more productive strains and efficient bioprocesses for PUFA production. Nevertheless, the lack of specific markers, detection methods, and selective pressure for isolating such mutants remains a bottleneck in classical mutagenesis approaches or lipid quality assessment during cultivation. This review encompasses the importance of PUFAs and lipid classes from Nannochloropsis species and their potential applications. Additionally, a revision of the different ways to increase PUFA content in Nannochloropsis sp. by using classical mutagenesis and adaptive laboratory evolution is also presented, as well as various methods to label and quantify lipids and PUFAs from Nannochloropsis microalgae.

Are there Effective Vegan-Friendly Supplements for Optimizing Health and Sports Performance? a Narrative Review

PURPOSE OF REVIEW

Veganism, characterized by the exclusion of all animal-derived products, has grown in popularity due to ethical, environmental, and health considerations. However, vegan athletes often face unique nutritional challenges related to dietary deficiencies of critical nutrients such as proteins, vitamin B12, iron, calcium, and omega-3 fatty acids, among others. This narrative review aims to explore the efficacy and benefits of vegan-friendly supplements specifically tailored to athletic performance, focusing on essential micronutrients, ergogenic aids, and nutrient bioavailability.

RECENT FINDINGS

Nineteen key supplements are discussed, including protein powders, creatine, beta-alanine, caffeine, vitamin B12, vitamin D, omega-3 fatty acids, zinc, calcium, iron, iodine, vitamin K2, selenium, probiotics, nitrates, electrolytes (including sodium and potassium), taurine, vitamin A, and magnesium. Evidence suggests that the integration of these supplements into personalized nutrition plans can bridge dietary gaps while addressing specific performance needs, potentially leveling the competitive field for vegan athletes. Recent studies also highlight research gaps in sex-specific needs, synergistic effects, and strategies to enhance the bioavailability of nutrients from whole foods. Vegan diets, while conferring various benefits, require careful consideration of nutrient intake for athletes seeking optimal performance. Personalized biochemical assessments should be considered when possible for tailoring specific nutritional guidelines for each case. This narrative review provides practical guidelines for clinicians, nutritionists, trainers, sports scientists, and athletes to design personalized supplementation strategies that address common nutritional shortfalls, enhance performance, and serve as a foundation for future research in vegan sports nutrition.

Cardiovascular Outcomes With Icosapent Ethyl by Baseline Low-Density Lipoprotein Cholesterol: A Secondary Analysis of the REDUCE-IT Randomized Trial

BACKGROUND

The efficacy of icosapent ethyl among patients with very well-controlled baseline low-density lipoprotein cholesterol (LDL-C) is unknown.

METHODS

In this post hoc analysis of the REDUCE-IT (Reduction of Cardiovascular Events With Icosapent Ethyl-Intervention Trial) randomized clinical trial, statin-treated patients with high cardiovascular risk, elevated triglycerides (135-499 mg/dL), and baseline LDL-C of 41 to 100 mg/dL were included. Patients were randomized to icosapent ethyl (2 g twice daily) or placebo and then post hoc stratified by baseline LDL-C (<55 mg/dL versus ≥55 mg/dL). The primary composite end point included cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, coronary revascularization, or unstable angina.

RESULTS

Among 8175 patients with baseline LDL-C data, 7117 (87.1%) had LDL-C ≥55 mg/dL and 1058 (12.9%) had LDL-C <55 mg/dL. In patients with LDL-C <55 mg/dL, the rate of the primary composite end point was lower in the icosapent ethyl group (16.2% versus 22.8%) than in the placebo group (hazard ratio [HR], 0.66 [95% CI, 0.50-0.87]; absolute risk reduction, 6.6%; P=0.003). Among patients with LDL-C ≥55 mg/dL, a primary composite end point event occurred in a lower proportion of patients in the icosapent ethyl group (17.4% versus 21.9%) than in the placebo group (HR, 0.76 [95% CI, 0.69-0.85]; absolute risk reduction, 4.5%; P<0.0001). No significant interaction was observed between baseline LDL-C and treatment group (P for interaction=0.40). Findings were consistent among secondary cardiovascular end points and in sensitivity analyses.

CONCLUSIONS

Among statin-treated patients with elevated triglycerides and high cardiovascular risk, icosapent ethyl reduced the rate of cardiovascular end points irrespective of baseline LDL-C, including among eligible patients with optimal LDL-C control.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01492361.

A scoping review and hypothetical framework about the interplay between oxytocin and eating disorders

INTRODUCTION

Despite emerging evidence on oxytocin's role in eating disorders,there is a need for a comprehensive review to integrate findings across neurobiological, genetic, hormonal, and therapeutic dimensions. This scoping review synthesizes existing literature on OXT's role in EDs and proposes a new theoretical perspective based on diverse research findings.

METHODS

In accordance with PRISMA guidelines, we systematically synthesized all peer-reviewed articles indexed on PubMed which focused on both OXT and EDs as of December 2023 (k = 32 studies, n = 1942 participants). After summarizing this literature in tables, we completed the narrative synthesis with a discussion of mechanisms informed by an unstructured literature review.

RESULTS

The existing studies propose a connection between OXT receptor Oxtr polymorphisms and ED diagnoses, severity of symptoms, macronutrient preferences, reward function, and early life stress. In addition, OXT plasma levels normalized with ED symptom reduction. Although some OXT studies have failed to show therapeutic changes in food intake and weight, few have reported ameliorations in brain function, food-related attentional bias, cognition, and emotional regulation. Some data have also suggested a contributory role of the transforming growth factor β (TGFβ) and sterol regulatory element binding proteins (SREBPs) to the etiology of EDs through Oxtr expression.

CONCLUSION

Although the current evidence does not support OXT as a standalone cause of or treatment for EDs, OXT research holds promise as a way of identifying future therapies, and OXT itself may serve as a valuable adjunct.

New Approaches to Lipoproteins for the Prevention of Cardiovascular Events

Atherosclerotic cardiovascular disease (ASCVD) is a leading global cause of mortality, and recent research has underscored the critical role of lipoproteins in modulating cardiovascular (CV) risk. Elevated low-density lipoprotein cholesterol (LDL-C) levels have been linked to increased CV events, and while numerous trials have confirmed the efficacy of lipid-lowering therapies (LLT), significant gaps remain between recommended LDL-C targets and real-world clinical practice. This review addresses care gaps in LLT, emphasizing the necessity for innovative approaches that extend beyond LDL-C management. It explores combination therapy approaches such as statins combined with ezetimibe or PCSK9 inhibitors, which have shown promise in enhancing LDL-C reduction and improving outcomes in high-risk patients. Additionally, this review discusses new approaches in lipid modification strategies, including bempedoic acid, inclisiran, and drugs that lower Lp(a), highlighting their potential for CV risk reduction. Furthermore, it emphasizes the potential of polygenic risk scores to guide LLT and lifestyle changes despite challenges in implementation and genetic testing ethics. This article discusses the current guidelines and proposes innovative approaches for optimizing lipoprotein management, ultimately contributing to improved patient outcomes in ASCVD prevention.

American Association of Clinical Endocrinology Clinical Practice Guideline on Pharmacologic Management of Adults With Dyslipidemia

OBJECTIVE

To review the evidence and provide updated and new recommendations for the pharmacologic management of adults with dyslipidemia to prevent adverse cardiovascular outcomes. These recommendations are intended for use by clinicians, health care team members, patients, caregivers, and other stakeholders.

METHODS

This guideline was developed by a multidisciplinary task force of content experts and guideline methodologists based on systematic reviews of randomized controlled trials or cohort studies from database inception to November 7, 2023. An updated literature search was completed for any additional articles published by May 31, 2024. Clinical questions addressing nonstatin medications and patient-important outcomes were prioritized. The task force assessed the certainty of the evidence and developed recommendations using the Grading of Recommendations Assessment, Development, and Evaluation framework. All recommendations were based on the consideration of the certainty of the evidence across patient-important outcomes, in addition to issues of feasibility, acceptability, equity, and patient preferences and values.

RESULTS

This guideline update includes 13 evidence-based recommendations for the pharmacologic management of adults with dyslipidemia focused on patient-important outcomes of atherosclerotic cardiovascular disease (ASCVD) risk reduction. The task force issued a good practice statement to assess the risk of ASCVD events for primary prevention in adults with dyslipidemia. The task force suggested the use of alirocumab, evolocumab, or bempedoic acid for adults who have ASCVD or who are at increased risk for ASCVD in addition to standard care. The task force suggested against the use of these medications in adults without ASCVD. There was insufficient evidence to recommend for or against the addition of inclisiran. For adults with hypertriglyceridemia and ASCVD or increased risk of ASCVD, the task force suggested the use of eicosapentaenoic acid but not eicosapentaenoic acid plus docosahexaenoic acid and strongly recommended against the use of niacin. There was insufficient evidence for recommendations regarding pharmacologic management in adults with severe hypertriglyceridemia (≥500 mg/dL). The task force suggested a low-density lipoprotein cholesterol treatment goal of <70 mg/dL in adults with dyslipidemia and ASCVD or at increased risk of ASCVD.

CONCLUSIONS

Pharmacotherapy is recommended in adults with dyslipidemia to reduce the risk of ASCVD events. There are several effective and safe treatment options for adults with dyslipidemia who have ASCVD or at increased risk of ASCVD who need additional lipid-lowering medications. Shared decision-making discussions are essential to determine the best option for each individual.

Exploring emerging pharmacotherapies for type 2 diabetes patients with hypertriglyceridemia

INTRODUCTION

Atherogenic dyslipidemia with increased triglycerides, low high-density lipoprotein cholesterol levels and increased small dense low-density lipoprotein (LDL) particles is a major risk factor contributing to the increased cardiovascular (CV) risk in patients with type 2 diabetes (T2D). This is regarded as a residual risk after achieving target levels of LDL cholesterol.

AREAS COVERED

This article reviews the novel therapies to reduce triglycerides in patients with T2D. These were identified by a PubMed search and mainly focus on pemafibrate and the drugs targeting apolipoprotein C3 (apoC3) and angiopoietin-like 3 (ANGPTL3).

EXPERT OPINION

Current therapies to reduce triglycerides in patients with T2D include fibrates and omega-3 fatty acids but these are often not sufficient and the evidence for CV benefits is limited. Pemafibrate was effective in reducing triglycerides in patients with T2D but did not reduce CV events in the PROMINENT study. Inhibitors of apoC3 are effective in reducing triglycerides even in familial chylomicronaemia syndrome and olezarsen and plozasiran in this group are being studied in patients with combined hyperlipidemia. The ANGPTL3 inhibitor evinacumab has been approved for homozygous familial hypercholesterolemia, and other ANGPTL3 inhibitors may prove to be useful to reduce triglycerides in T2D.

Lipid-lowering drug therapy for reducing cardiovascular risk in diabetes. A clinical view of the Cardiovascular Disease Working Group of the Spanish Diabetes Society

Patients with type 2 diabetes mellitus (T2DM) managed in both hospital and out-ofhospital settings usually have a high/very high cardiovascular risk, with a high burden of cardiovascular disease. All this justifies that the reduction of low-density lipoprotein cholesterol is the main therapeutic goal in T2DM. However, residual cardiovascular risk is very prevalent in T2DM, and is usually associated with atherogenic dyslipidemia and hyperlipoproteinemia(a); therefore, it is also necessary to reverse these lipoprotein abnormalities to achieve effective cardiovascular prevention. Given the considerable armamentarium of lipid-lowering drugs currently available, the Cardiovascular Disease Working Group of the Spanish Diabetes Society has considered it appropriate to carry out a narrative review and update of the effectiveness of these lipid-lowering drugs in the population with T2DM taking into account their effect on the lipoprotein profile and their potential impact on glycemic control.

Long chain n-3 polyunsaturated fatty acid intake across the life span for cardiovascular disease prevention in women

Cardiovascular diseases (CVDs) are a major health concern for women. Historically there has been a misconception that men are at greater risk because CVD tends to occur earlier in life compared to women. Clinical guidelines for prevention of heart disease are currently the same for both sexes, but accumulating evidence demonstrates that risk profiles diverge. In fact, several CVD risk factors confer an even greater risk in women relative to men, including high blood pressure, obesity, diabetes and raised triglycerides. Furthermore, many female-specific CVD risk factors exist, including early menarche, pregnancy complications, polycystic ovary syndrome, reproductive hormonal treatments and menopause. Little is known about how diet interacts with CVD risk factors at various stages of a woman’s life. Long chain (LC) n-3 polyunsaturated fatty acid (PUFA) intakes are a key dietary factor that may impact risk of CVD throughout the life course differentially in men and women. Oestrogen enhances conversion of the plant n-3 PUFA, alpha-linolenic acid, to LCn-3 PUFA. Increasing the frequency of oily fish consumption or LCn-3 PUFA supplementation may be important for reducing coronary risk during the menopausal transition, during which time oestrogen levels decline and the increase in CVD risk factors is accelerated. Women are under-represented in the evidence base for CVD prevention following LC n-3 PUFA supplementation. Therefore it is not clear whether there are sex differences in response to treatment. Furthermore, there is a lack of evidence on optimal intakes of LC n-3 PUFA across the lifespan for CVD prevention in women.

Advances in the pharmacological management of hyperlipidemia through the use of combination therapies

INTRODUCTION

Lipid-lowering therapies are well established for the treatment of cardiovascular disease (CVD). Historically monotherapy studies have been performed, but the introduction of statins has led to these drugs being recognized as baseline therapies and to the investigation of combination therapy of both older and newer medications with them.

AREAS COVERED

Surrogate marker studies have shown additive effects on LDL-C, triglycerides and HDL-C of combination therapies with statins and these have extended to lipoprotein (a). Imaging studies have often shown benefits paralleling lipid studies. However, outcome studies have failed to show added benefits with niacin or fibrates while confirming the benefits of ezetimibe, bempedoic acid and proprotein convertase subtilisin kexin-9 (PCSK-9) inhibitors and icosapent ethyl.

EXPERT OPINION

Combination therapy for LDL-C in dual combinations is well validated. Data for intervention on triglycerides is limited to icosapent ethyl, but this may exert effects independent of lipids. New drugs targeting triglycerides through apolipoprotein C3 and angiopoietin-like peptides are in development. Studies on combination therapy raising HDL-C have generally disappointed, though cholesterol ester transfer protein (CETP) inhibition remains a target. Lipoprotein (a) is recognized as a CVD risk factor and effective therapies are in development but results on CVD events are lacking.

Progression of aortic calcification among Japanese in Japan and white and Japanese Americans: a prospective cohort study

AIMS

Continued low mortality from coronary heart disease in Japan, despite deleterious changes in traditional risk factors, remains unexplained. Since aortic calcification (AC) was an early predictor of cardiovascular mortality, we compared the progression and incidence of AC between Japanese in Japan, white Americans, and third-generation Japanese Americans in the ERA JUMP cohort. We examined whether higher blood levels of marine-derived n-3 fatty acids (FAs) in Japanese than in Americans accounted for the difference.

METHODS AND RESULTS

Men (n = 700) aged 40-49 years (252 Japanese in Japan, 238 white, and 210 Japanese Americans) were examined at baseline and 4-7 years later. AC was evaluated from the aortic arch to the iliac bifurcation with computed tomography and quantified by the Agatston method. Robust linear regression and linear mixed models were used to compare the progression of AC. Multivariable logistic regression models were fitted to compare the incidence of AC (AC ≥ 50 at follow-up) among those with baseline AC < 50. Japanese in Japan had a significantly slower progression of AC than white and Japanese Americans after adjusting for age, baseline AC, follow-up time, and traditional risk factors. White Americans had a significantly higher incidence of AC than Japanese in Japan [OR = 4.61 (95% CI, 1.27-16.82)]. Additional adjustment for blood levels of n-3 FAs accounted for the difference in AC incidence but not progression.

CONCLUSION

Japanese in Japan had a significantly slower progression and lower incidence of AC than white Americans. High levels of marine-derived n-3 FAs in Japanese in Japan partly accounted for the difference in incidence.

Pharmacotherapy, Lifestyle Modification, and Cardiac Rehabilitation after Myocardial Infarction or Percutaneous Intervention

Coronary artery disease is the leading cause of death in the US, and approximately 25% of MIs occurring each year are reinfarctions. Due to advances in percutaneous coronary intervention (PCI) and medical therapy, patients with prior MIs live longer but may be susceptible to additional cardiac events. Thus, secondary prevention after MI or PCI is key to improving mortality and quality of life. This review discusses pharmacotherapies and lifestyle interventions with a special focus on cardiac rehabilitation in the post-MI or PCI period to improve cardiovascular outcomes.

Practical Approaches to Managing Dyslipidemia in Patients With Metabolic Dysfunction-Associated Steatotic Liver Disease

Dyslipidemia is a major risk factor for cardiovascular disease, and its impact may be exacerbated when accompanied by metabolic dysfunction-associated steatotic liver disease (MASLD). The simultaneous management of these conditions poses multiple challenges for healthcare providers. Insulin resistance has been implicated in the pathogenesis of both dyslipidemia and MASLD, necessitating a holistic approach to managing dyslipidemia, glucose levels, body weight, and MASLD. This review explores the intricate pathophysiological relationship between MASLD and dyslipidemia. It also examines current guidance regarding the use of lipid-lowering agents (including statins, ezetimibe, fibrates, omega-3 polyunsaturated fatty acids, and proprotein convertase subtilisin/kexin type 9 inhibitors) as well as glucose-lowering medications (such as pioglitazone, glucagon-like peptide-1 receptor agonists, and sodium-glucose cotransporter 2 inhibitors) in patients with MASLD, with or without metabolic dysfunction-associated steatohepatitis (MASH), and dyslipidemia. Additionally, the review addresses the potential of emerging drugs to concurrently target both MASLD/MASH and dyslipidemia. Our hope is that a deeper understanding of the mechanisms underlying MASLD and dyslipidemia may assist clinicians in the management of these complex cases.

Inflammation and resolution in obesity

Inflammation is an essential physiological defence mechanism, but prolonged or excessive inflammation can cause disease. Indeed, unresolved systemic and adipose tissue inflammation drives obesity-related cardiovascular disease and type 2 diabetes mellitus. Drugs targeting pro-inflammatory cytokine pathways or inflammasome activation have been approved for clinical use for the past two decades. However, potentially serious adverse effects, such as drug-induced weight gain and increased susceptibility to infections, prevented their wider clinical implementation. Furthermore, these drugs do not modulate the resolution phase of inflammation. This phase is an active process orchestrated by specialized pro-resolving mediators, such as lipoxins, and other endogenous resolution mechanisms. Pro-resolving mediators mitigate inflammation and development of obesity-related disease, for instance, alleviating insulin resistance and atherosclerosis in experimental disease models, so mechanisms to modulate their activity are, therefore, of great therapeutic interest. Here, we review current clinical attempts to either target pro-inflammatory mediators (IL-1β, NOD-, LRR- and pyrin domain-containing protein 3 (NLRP3) inflammasome, tumour necrosis factor (TNF) and IL-6) or utilize endogenous resolution pathways to reduce obesity-related inflammation and improve cardiometabolic outcomes. A remaining challenge in the field is to establish more precise biomarkers that can differentiate between acute and chronic inflammation and to assess the functionality of individual leukocyte populations. Such advancements would improve the monitoring of drug effects and support personalized treatment strategies that battle obesity-related inflammation and cardiometabolic disease.

Changes in fatty acid intake and subsequent risk of all-cause and cause-specific mortality in males and females: a prospective cohort study

BACKGROUND

The associations between changes in fatty acid intake over time and subsequent mortality are unclear.

OBJECTIVES

The objective of this study was to prospectively examine associations between changes in fatty acid intake (as percentage of total energy) and mortality.

METHODS

Among 65,179 adults from the Nurses' Health Study and Health Professionals Follow-up Study, free from cardiovascular disease, cancer, and diabetes at baseline in 1994, we documented 20,571 deaths through 2020 (1,334,603 person-years). Diets were assessed every 4 years using validated questionnaires. Hazard ratios (HRs) and 95% confidence intervals (CIs) for mortality risk were estimated from Cox proportional hazards models.

RESULTS

A 5% energy increment in total fat intake was associated with 5% lower all-cause mortality (HR: 0.95; 95% CI: 0.93, 0.96; isocaloric comparison was total carbohydrate). The HRs of all-cause mortality (95% CI) were 0.83 (0.78, 0.89) and 0.91 (0.87, 0.94) for a 5% increment in energy intake from polyunsaturated fatty acid (PUFA) and monounsaturated fatty acid (MUFA), respectively, and was 1.10 (1.04, 1.17) for a 1% increase in energy intake from trans fatty acid (TFA; all Ptrend ≤ 0.001). Changes in saturated fatty acid (SFA) were not associated with all-cause mortality. Increases in intakes of linoleic acid, marine n-3 PUFA, and MUFA from plant sources were each significantly associated with lower all-cause mortality. In substitution analyses, replacing 5% energy from SFA with PUFA was associated with 19% lower all-cause mortality (HR: 0.81; 95% CI: 0.75, 0.87), whereas replacing 0.3% of energy from SFA with marine n-3 PUFA was associated with 11% lower all-cause mortality (HR: 0.89; 95% CI: 0.84, 0.93). Isocaloric substitution of SFA by PUFA, particularly marine n-3 PUFA, was associated with lower mortality due to cardiovascular, neurodegenerative, and respiratory diseases.

CONCLUSIONS

These findings support replacing SFA with unsaturated fatty acids (especially from plant sources) and eliminating dietary TFA to reduce premature death.

Effects of age and diet on triglyceride metabolism in mice

Both age and diet can contribute to alterations in triglyceride metabolism and subsequent metabolic disease. In humans, plasma triglyceride levels increase with age. Diets high in saturated fats can increase triglyceride levels while diets high in omega-3 fatty acids decrease triglyceride levels. Here we asked how age and long-term diet altered triglyceride metabolism in mice. We fed male and female C57Bl/6 mice a low-fat diet, a western diet (WD), or a diet high in polyunsaturated and omega-3 fatty acids (n3D) for up to 2 years. We measured survival, body composition, plasma triglyceride levels, chylomicron clearance, and oral fat, glucose, and insulin tolerance. Triglyceride levels in mice did not increase with age, regardless of diet. Oral fat tolerance increased with age, while chylomicron clearance remained unchanged. Decreased survival was observed in WD-fed mice. Interestingly, n3D-fed mice gained more lean mass and had lower insulin levels than WD-fed or LFD-fed mice. Moreover, triglyceride uptake into the hearts of n3D-fed mice was strikingly higher than in other groups. Our data indicate that in C57Bl/6 mice, age-induced changes in triglyceride metabolism differ from those observed in humans. Mice, like humans, appeared to have decreased fat absorption with age, but in mice plasma triglyceride clearance did not decrease with age, resulting in lower plasma triglyceride levels and improved fat tolerance with age. Although a chronic diet high in omega-3 fatty acids increased insulin sensitivity and triglyceride uptake specifically into the heart, how these observations are connected is unclear.

Lipid-lowering therapies and long-term stroke prevention in East Asians: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Stroke prevention is a pressing global health priority, with reducing elevated lipids recognized as a key strategy. East Asians, constituting more than 1.6 billion individuals and the largest racial group worldwide, are a key demographic in this effort. Yet, the effectiveness of lipid-lowering therapies for stroke prevention in this population remains uncertain.

AIMS AND METHODS

We conducted a systematic review and meta-analysis of large-scale randomized controlled trials (RCTs) with at least 3 years of follow-up to evaluate the long-term impact of lipid-lowering therapies on stroke incidence in East Asians. We systematically searched four electronic databases up to 11 January 2024. The association was quantified using relative risk (RR) with a 95% confidence interval (CI), and between-study heterogeneity was evaluated using the I2 statistic. In addition, we utilized the Cochrane Risk of Bias Tool to assess the risk of bias in each included RCT and applied the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to evaluate the certainty of the evidence.

RESULTS

This study incorporated data from nine large-scale RCTs involving 54,354 participants. Our findings of overall analyses revealed that lipid-lowering therapies did not significantly affect the long-term incidence of all strokes (9 RCTs; 54,354 participants; RR = 0.98 (95% CI = 0.87-1.10); P = 0.75), ischemic stroke (7 RCTs; 52,059 participants; RR = 0.91 (95% CI, = 0.79-1.04); P = 0.16), or hemorrhage stroke (7 RCTs; 52,059 participants; RR = 1.24 (95% CI = 0.97-1.59); P = 0.09) in East Asians. Notably, there was no evidence of heterogeneity or publication bias, and the quality of evidence assessed using GRADE methodologies was rated as high. Sensitivity analyses confirmed the robustness of our results, with no single study significantly affecting the overall findings. Furthermore, subgroup analyses consistently supported the conclusions, further bolstering the reliability of our study.

CONCLUSIONS

Lipid-lowering therapies did not demonstrate any beneficial effects on long-term stroke prevention among East Asians.

Regulatory Compliance of Health Claims on Omega-3 Fatty Acid Food Supplements

Unlike the mandatory information that must be provided on a food supplement label, health claims are voluntary. This study assesses the regulatory compliance of omega-3 fatty acid (ω-3-FA) supplement label claims. Of the 97 supplements, 76 (78.4%) carried verbal claims referring to active substance, of which 68 (89.5%) were claims specific to ω-3-FA. According to the European Union Health Claims Registry, 107 claims listed on 59 supplements were authorized, as opposed to nine unauthorized claims on nine supplements. The degree to which claims aligned with regulatory standards, expressed in terms of scores scaled from 0 to 1, was the highest for supplements intended for pregnant women (1), while, in the case of adults, the mean score was 0.76 ± 0.35, and, in case of children, was 0.85 ± 0.27. Statistical analysis revealed a minor tendency for higher health claim scores to be associated with lower product prices. Furthermore, differences in compliance levels across groups of supplements formed according to the country of origin/sources of ω-3-FA/target populations were explored. The main differences were associated with products from Sweden and Italy/fish oil/supplements for pregnant women. A comparison of the daily intake of ω-3-FA provided by the supplement (based on labeled information) with the intake requirements for supplements with claims referring to ω-3-FA, supported 91 claims, five were unsubstantiated, and 11 were missing required data. Supplements also contained mineral- (19 approved) and vitamin-related claims (73, of which 9 were unauthorized). This study's findings reveal the extent of misuse of labelled information in markets that require pre-market supplement registration. Importantly, the non-compliance of health claims can significantly undermine consumer trust.

TRAP-Induced Platelet Reactivity Is Inhibited by Omega-3 Fatty Acid-Derived Prostaglandin E3 (PGE3)

Background: Prostaglandins are naturally occurring local mediators that can participate in the modulation of the cardiovascular system through their interaction with Gs/Gi-coupled receptors in different tissues and cells, including platelets. Thrombin is one of the most important factors that regulates platelet reactivity and coagulation. Clinical trials have consistently shown that omega-3 fatty acid supplementation lowers the risk for cardiovascular mortality and morbidity. Since omega-3 fatty acids are the main precursors of PGE3 in vivo, it would be relevant to investigate the effects of PGE3 on Thrombin Receptor Activating Peptide (TRAP-6)-induced platelet reactivity to determine the receptors and possible mechanisms of action of these compounds. Methods: We have measured platelet aggregation, P-selectin expression, and vasodilator-stimulated phosphoprotein (VASP) phosphorylation to evaluate platelet reactivity induced by TRAP-6 to determine the effects of PGE3 on platelet function. Results: We assessed the ability of DG-041, a selective prostanoid EP3 receptor antagonist, and of ONO-AE3-208, a selective prostanoid EP4 receptor antagonist, to modify the effects of PGE3. PGE3 inhibited TRAP-6-induced platelet aggregation and activation. This inhibition was enhanced in the presence of a Gi-coupled EP3 receptor antagonist and abolished in the presence of a Gs-coupled EP4 receptor antagonist. The effects of PGE3 were directly related to changes in cAMP, assessed by VASP phosphorylation. Conclusions: The general effects of PGE3 on human platelet reactivity are the consequence of a balance between activatory and inhibitory effects at receptors that have contrary effects on adenylate cyclase. These results indicate a potential mechanism by which omega-3 fatty acids underlie cardioprotective effects.

The role for ω-3 polyunsaturated and short chain fatty acids in hypertension: An updated view on the interaction with gut microbiota

As of 2024, arterial hypertension is still considered the leading modifiable cardiovascular risk factor and, due to high rates of undertreatment and poor blood pressure control, the major contributor to human morbidity and mortality. Development of new treatment options and better interventions in lifestyle correction have become a priority of experimental and clinical research. In the last decades, dietary supplementation of omega-3 polyunsaturated fatty acids (ω-3 PUFAs) and generation of gut microbiota-derived short chain fatty acids (SCFAs) have surged as potential and promising interventions for hypertension and cardiovascular prevention. ω-3 PUFAs are considered "essential" fatty acids that can be obtained only from dietary sources. Although previous intervention trials were not consistent in reporting a significant benefit of ω-3 PUFAs, the recent REDUCE-IT trial has provided robust evidence in support of their role in cardiovascular prevention. Recent studies have also identified the intestinal microbiota as a potential player in the pathophysiology and progression of hypertension. Although this might occur through many pathways, generation of SCFAs that is highly dependent on dietary fiber intake is primarily involved, providing an additional target for the development of novel therapeutic strategies. For these reasons, some scientific societies currently recommend dietary supplementation of ω-3 PUFAs and fiber-containing foods in patients with hypertension. In this narrative review, we summarize the results of studies that examined the effects of ω-3 PUFAs and SCFAs on blood pressure, highlighting the mechanisms of action on the vascular system and their possible impact on hypertension, hypertension-related organ damage and, ultimately, cardiovascular outcomes.

Drugs for dyslipidaemia: the legacy effect of the Scandinavian Simvastatin Survival Study (4S)

Since the discovery of statins and the Scandinavian Simvastatin Survival Study (4S) results three decades ago, remarkable advances have been made in the treatment of dyslipidaemia, a major risk factor for atherosclerotic cardiovascular disease. Safe and effective statins remain the cornerstone of therapeutic approach for this indication, including for children with genetic dyslipidaemia, and are one of the most widely prescribed drugs in the world. However, despite the affordability of generic statins, they remain underutilised worldwide. The use of ezetimibe to further decrease plasma LDL cholesterol and the targeting of other atherogenic lipoproteins, such as triglyceride-rich lipoproteins and lipoprotein(a), are likely to be required to further reduce atherosclerotic cardiovascular disease events. Drugs directed at these lipoproteins, including gene silencing and editing methods that durably suppress the production of proteins, such as PCSK9 and ANGPTL3, open novel therapeutic options to further reduce the development of atherosclerotic cardiovascular disease.

Triglycerides and the Risk of Atherosclerotic Cardiovascular Events Across Different Risk Categories

AIMS

To investigate the association between triglyceride levels and major adverse cardiovascular events (MACE) in primary and secondary prevention cohorts.

METHODS

This retrospective study was conducted with a nationwide health insurance claims database, which included approximately 3.8 million participants with medical checkups between January 2005 and August 2020 in Japan. The participants were classified into primary prevention (n=3,415,522) and secondary prevention (n=29,806) cohorts based on cardiovascular or cerebrovascular disease history. Each participant was categorized as having very low (triglyceride ＜50 mg/dL), low normal (50-99), high normal (100-149), or hypertriglyceridemia (≥ 150). The primary prevention cohort was further stratified into low-, intermediate-, and high-risk groups according to atherosclerotic cardiovascular diseases risk. Outcome was MACE, including acute myocardial infarction (AMI), unstable angina, ischemic stroke, and cardiac death.

RESULTS

Over a mean follow-up of 3.25 years, 0.3% and 2.6% MACE occurred in primary and secondary prevention, respectively. Hypertriglyceridemia was associated with high risk of MACE in the primary prevention, but not in the secondary prevention. A significant interaction was observed between prevention categories and the association of TG levels with MACE in those with TG ＜150 mg/dL and ischemic stroke in those with TG ≥ 150 mg/dL. The population-attributable fraction for hypertriglyceridemia in primary prevention was 4.1% for MACE. In primary prevention, lower risks of AMI were observed in the lower TG category compared to the current threshold.

CONCLUSIONS

This study suggests distinct triglyceride thresholds for MACE risk in primary and secondary prevention cohorts, requiring further prospective validation for clinical implementation.

Research progress on the relationship between free fatty acid profile and type 2 diabetes complicated by coronary heart disease

Patients with type 2 diabetes mellitus (T2DM) have a 2 to 3 times higher risk of cardiovascular disease compared to non-diabetic individuals, and cardiovascular disease has consistently been a leading cause of death among diabetic patients. Therefore, preventing cardiovascular disease in diabetic patients remains a significant challenge. In addition to classic indicators such as cholesterol and lipoproteins, previous studies have demonstrated that plasma level of free fatty acid (FFA) is closely related to the occurrence of atherosclerosis, particularly in T2DM patients. In recent years, with further research and advancements in testing technologies, the FFA profile has garnered widespread attention. The FFA profile includes many different types of FFAs, and changes in the plasma FFA profile and concentrations in T2DM patients may lead to the development of insulin resistance, causing damage to vascular endothelial cells and promoting the occurrence and progression of atherosclerosis. Furthermore, some FFAs have shown potential in predicting cardiovascular complications in T2DM and are associated with the severity of these complications. Here, we aim to review the changes in the FFA profile in T2DM and discuss the relationship between the FFA profile and the occurrence of vascular complications in T2DM.

The effect of omega-3 Polyunsaturated Fatty Acid (PUFA) prescription preparations on the prevention of clinical cardiovascular disease: a meta-analysis of RCTs

IMPORTANCE

Evidence from systematic reviews of the cardioprotective effect of omega-3 polyunsaturated fatty acid (PUFA) remains controversial, and interventions including PUFAs dietary supplements or prescription medications cannot accurately reflect the role of PUFA RX in cardiovascular disease (CVD) prevention.

OBJECTIVE

We conducted a meta-analysis of randomized clinical trials (RCTs) to evaluate the efficacy of PUFA prescription medication in preventing CVD.

METHODS

Two reviewers conducted a literature search of Embase, MEDLINE/PubMed, and the Cochrane Library from their inception to September 2023. The inclusion criteria were RCTs evaluating long-term supplementation (≥ 1 year) with PUFA prescriptions and reporting cardiovascular outcomes. Data were extracted independently by two authors, and the certainty of evidence for each outcome was assessed using the GRADE system. Random-effects models were used to estimate the risk ratios (RRs) and 95% confidence intervals (CIs). The primary outcomes were cardiovascular events. Secondary endpoints included major adverse cardiovascular events (MACEs), cardiac death, all-cause mortality, myocardial infarction, stroke, and revascularization. Subgroup analyses were performed based on PUFA components, dosage, follow-up duration, and risk status.

RESULTS

Twelve RCTs involving 99,830 participants were included. The mean age of participants ranged from 59.4 to 74.0 years, with a follow-up period varying from 1 to 6.2 years. Compared with placebo and statins, PUFA prescription medication was associated with a reduced risk of cardiovascular events (8 RCTs, n = 75,929, RR, 0.88 [95% CI, 0.81-0.95]; P = 0.0007; I2 = 45%), cardiac death (10 RCTs, n = 95,440, RR, 0.91 [95% CI, 0.84-0.99]; P = 0.02; I2 = 23%), myocardial infarction (9 RCTs, n = 94,877, RR, 0.84 [95% CI, 0.73-0.96]; P = 0.009; I2 = 62%), and revascularization (9 RCTs, n = 91,242, RR, 0.91 [95% CI, 0.84-0.99]; P = 0.02; I2 = 63%).

CONCLUSIONS AND RELEVANCE

PUFA prescription medication could lower the risks of cardiovascular events, cardiac death, myocardial infarction and revascularization. This research provides insight into the efficacy of PUFA prescription medications in CVD prevention and contributes to the ongoing debate on the role of PUFA products in cardiovascular outcomes.

Targeting Insulin Resistance, Reactive Oxygen Species, Inflammation, Programmed Cell Death, ER Stress, and Mitochondrial Dysfunction for the Therapeutic Prevention of Free Fatty Acid-Induced Vascular Endothelial Lipotoxicity

Excessive intake of free fatty acids (FFAs), especially saturated fatty acids, can lead to atherosclerosis and increase the incidence of cardiovascular diseases. FFAs also contribute to obesity, hyperlipidemia, and nonalcoholic fatty liver disease. Palmitic acid (PA) is human plasma's most abundant saturated fatty acid. It is often used to study the toxicity caused by free fatty acids in different organs, including vascular lipotoxicity. Fatty acid overload induces endothelial dysfunction through various molecular mechanisms. Endothelial dysfunction alters vascular homeostasis by reducing vasodilation and increasing proinflammatory and prothrombotic states. It is also linked to atherosclerosis, which leads to coronary artery disease, peripheral artery disease, and stroke. In this review, we summarize the latest studies, revealing the molecular mechanism of free fatty acid-induced vascular dysfunction, targeting insulin resistance, reactive oxygen species, inflammation, programmed cell death, ER stress, and mitochondrial dysfunction. Meanwhile, this review provides new strategies and perspectives for preventing and reducing the impact of cardiovascular diseases on human health through the relevant targeting molecular mechanism.

Enzymatic Interesterification of Cold-Pressed Maqui (Aristotelia chilensis (Mol.) Stuntz) Seed Oil and Belly Oil from Rainbow Trout (Oncorhynchus mykiss) Through Supercritical CO2

A new antioxidant lipid (AL) was synthesized from rainbow trout (Oncorhynchus mykiss) belly oil and cold-pressed maqui (CPM) (Aristotelia chilensis (Mol.) Stuntz) seed oil via enzymatic interesterification using Thermomyces lanuginosus in supercritical CO2 medium. A Box-Behnken design with 15 experiments was employed, with the independent variables being the following: belly oil/CPM oil ratio (10/90, 50/50, and 90/10, w/w), supercritical CO2 temperature (40.0, 50.0, and 60.0 °C), and supercritical CO2 pressure (100.0, 200.0, and 300.0 bar) for enzymatic interesterification. A multiple optimization was conducted based on the response variables yield and eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and tocopherol contents. The optimized conditions for the AL synthesis were: 81.4/18.6 (w/w), 40.0 °C and 299.99 bar, respectively. The corresponding responses variables were: 77.10% for yield, 5.12 and 4.95 g·100 g-1 total fatty acids for EPA and DHA, respectively, and 217.96, 4.28, 3.48, 64.48, and 6.39 mg·kg-1 oil for α-tocopherol, α-tocotrienol, β-tocopherol, γ-tocopherol, and δ-tocopherol, respectively. A novel AL was successfully synthesized starting from two abundant natural resources commonly considered as by-products during industrial processing. In agreement with the high EPA, DHA, and tocopherol presence, this AL can be recommended to be employed in nutritional and therapeutic supplements, according to its health benefits, particularly concerning antioxidant and anti-inflammatory properties.

Lipoprotection in cardiovascular diseases

Cardioprotection is a well-established term in the scientific world. It describes the protection of various mediators on the cardiovascular system. These protective effects can also be provided by certain lipids. Since lipids are a very specific and clearly definable class of substances, we define the term lipoprotection as lipid-mediated cardioprotection. In this review, we highlight high-density lipoprotein (HDL), sphingosine-1-phosphate (S1P) and omega-3 polyunsaturated fatty acids (n-3 PUFA) as the most important lipoprotective mediators and show their beneficial impact on coronary artery disease (CAD), acute myocardial infarction (AMI) and heart failure (HF).

Effect of fish-oil supplementation on the glycemic and lipidemic profiles of pregnant women: a systematic review and meta-analysis

CONTEXT

Pregnant women have physiological metabolic changes in glycemic and lipid profiles that are essential for fetal development.

OBJECTIVE

The aim of this systematic review was to analyze the effects of fish-oil-capsule supplementation on the glycemic and lipid profiles of pregnant women.

DATA SOURCES

A systematic search was conducted of the MEDLINE (by PubMed), Embase, Cochrane Library (CENTRAL) databases and gray literature, including preprints for all relevant studies published in English, with no date restrictions.

DATA EXTRACTION

The estimated pooled results were analyzed using a random-effects model and represented by mean differences (MDs) and corresponding 95% confidence intervals (CIs). The analyses were performed with R software, version 4.2.1, using the "Meta" packages, versions 6.0-0.

DATA ANALYSIS

Fifteen eligible studies were included after screening. In a pooled analysis, overall fish-oil supplementation had no effect on parameters compared with placebo. In the subgroup analysis, fish-oil supplementation may be beneficial in insulin (MD: -2.11 IU/mL; 95% CI: -3.86, -0.36) and homeostasis model assessment of insulin resistance (HOMA-IR) (MD: -0.71; 95% CI: -1.14, -0.29) indices, with heterogeneity (I2 =0%) among pregnant women with diabetes mellitus. In the subgroup with doses of eicosapentaenoic acid (EPA) below 200 mg, there was a reduction in HOMA-IR in the intervention group (MD: -0.60; 95% CI: -1.14, -0.06).

CONCLUSION

Pregnant women taking fish-oil capsules showed significant beneficial changes in the subgroups of type 2 diabetes and EPA dosages below 200 mg for insulin and HOMA-IR.

Oestrogens, adipose tissues and environmental exposures influence obesity and diabetes across the lifecycle

Endogenous oestrogens regulate essential functions to include menstrual cycles, energy balance, adipose tissue distribution, pancreatic β-cell function, insulin sensitivity and lipid homeostasis. Oestrogens are a family of hormones which include oestradiol (E2), oestrone (E1) and oestriol (E3). Oestrogens function by binding and activating oestrogen receptors (ERs). Phytoestrogens are plant-derived compounds which exhibit oestrogenic-like activity and can bind to ERs. Phytoestrogens exert potential oestrogenic-like benefits; however, their effects are context-dependent and require cautious consideration regarding generalised health benefits. Xenoestrogens are synthetic compounds which have been determined to disrupt endocrine function through binding to ERs. Xenoestrogens enter the body through various routes and given their chemical structure they can accumulate, posing long-term health risks. Xenoestrogens interfere with endogenous oestrogens and their functions contributing to conditions like cancer, infertility, and metabolic disorders. Understanding the interplay between endogenous and exogenous oestrogens is critical in order to determine their potential health consequences and requires further investigation. This manuscript provides a summary of the role endogenous oestrogens have in regulating metabolic functions. Additionally, we discuss the impact phytoestrogens and synthetic xenoestrogens have on biological systems across various life stages. We highlight their mechanisms of action, potential benefits, risks and discuss the need for further research to bridge gaps in understanding and mitigate exposure-related health risks.

Eicosapentaenoic acid induces macrophage Mox polarization to prevent diabetic cardiomyopathy

Diabetic cardiomyopathy (DC) leads to heart failure, with few effective approaches for its intervention. Eicosapentaenoic acid (EPA) is an essential nutrient that benefits the cardiovascular system, but its effect on DC remains unknown. Here, we report that EPA protects against DC in streptozotocin and high-fat diet-induced diabetic mice, with an emphasis on the reduction of cardiac M1-polarized macrophages. In vitro, EPA abrogates cardiomyocyte injury induced by M1-polarized macrophages, switching macrophage phenotype from M1 to Mox, but not M2, polarization. Moreover, macrophage Mox polarization combats M1-polarized macrophage-induced cardiomyocyte injury. Further, heme oxygenase 1 (HO-1) was identified to maintain the Mox phenotype, mediating EPA suppression of macrophage M1 polarization and the consequential cardiomyocyte injury. Mechanistic studies reveal that G-protein-coupled receptor 120 mediates the upregulation of HO-1 by EPA. Notably, EPA promotes Mox polarization in monocyte-derived macrophages from diabetic patients. The current study provides EPA and macrophage Mox polarization as novel strategies for DC intervention.

Secondary prevention therapies following percutaneous coronary intervention or acute coronary syndrome in patients with diabetes mellitus

Diabetes mellitus (DM) promotes atherosclerosis, leading to increased risk for cardiovascular morbidity and mortality. Diabetics represent a challenging subset of patients undergoing percutaneous coronary intervention (PCI) or who have experienced an acute coronary syndrome (ACS), a subset characterized by higher rates of recurrent ischemic events compared with non-diabetics. These events are caused by both patient-related accelerated atherosclerotic disease progression and worse stent-related adverse clinical outcomes translating into a higher risk for repeat revascularization. In addition, DM is paradoxically associated with an increased risk of major bleeding following PCI or an ACS. Secondary prevention therapies following PCI or an ACS in diabetic patients are therefore of paramount importance. This mini review focuses on the currently available evidence regarding short- and long-term secondary prevention treatments for diabetic patients undergoing PCI or who have experienced an ACS.

Effects of omega-3 fatty acids on coronary revascularization and cardiovascular events: a meta-analysis

AIMS

Benefits of pharmacologic omega-3 fatty acid administration in cardiovascular prevention are controversial. Particularly, effects on coronary revascularization are unclear; also debated are specific benefits of eicosapentaenoic acid (EPA). We investigated incident coronary revascularizations, myocardial infarction (MI), stroke, heart failure (HF), unstable angina, and cardiovascular death, in subjects randomized to receive EPA or EPA + docosahexaenoic acid (EPA + DHA) vs. control.

METHODS AND RESULTS

Meta-analysis of randomized controlled trials (RCTs) was conducted after MEDLINE, Embase, Scopus, Web of Science, and Cochrane Library search. Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were followed for abstracting data and assessing data quality and validity. Data were pooled using a random effects model. Eighteen RCTs with 134 144 participants (primary and secondary cardiovascular prevention) receiving DHA + EPA (n = 52 498), EPA alone (n = 14 640), or control/placebo (n = 67 006) were included. Follow-up ranged from 4.5 months to 7.4 years. Overall, compared with controls, omega-3 supplementation reduced the risk of revascularization [0.90, 95% confidence interval (CI) 0.84-0.98; P = 0.001; P-heterogeneity = 0.0002; I2 = 68%], MI (0.89, 95% CI 0.81-0.98; P = 0.02; P-heterogeneity = 0.06; I2 = 41%), and cardiovascular death (0.92, 95% CI 0.85-0.99; P = 0.02; P-heterogeneity = 0.13; I2 = 33%). Lower risk was still observed in trials where most participants (≥60%) were on statin therapy. Compared with DHA + EPA, EPA alone showed a further significant risk reduction of revascularizations (0.76, 95% CI 0.65-0.88; P = 0.0002; P-interaction = 0.005) and all outcomes except HF.

CONCLUSION

Omega-3 fatty acid supplementation reduced the risk of cardiovascular events and coronary revascularization, regardless of background statin use. Eicosapentaenoic acid alone produced greater benefits. The role of specific omega-3 molecules in primary vs. secondary prevention and the potential benefits of reduced revascularizations on overall health status and cost savings warrant further research.

Targeting immune cell recruitment in atherosclerosis

Atherosclerosis is the primary underlying cause of myocardial infarction and stroke. Atherosclerotic cardiovascular disease is characterized by a chronic inflammatory reaction in medium-to-large-sized arteries, with its onset and perpetuation driven by leukocytes infiltrating the subendothelial space. Activation of endothelial cells triggered by hyperlipidaemia and lipoprotein retention in the arterial intima initiates the accumulation of pro-inflammatory leukocytes in the arterial wall, fostering the progression of atherosclerosis. This inflammatory response is coordinated by an array of soluble mediators, namely cytokines and chemokines, that amplify inflammation both locally and systemically and are complemented by tissue-specific molecules that regulate the homing, adhesion and transmigration of leukocytes. Despite abundant evidence from mouse models, only a few therapies targeting leukocytes in atherosclerosis have been assessed in humans. The major challenges for the clinical translation of these therapies include the lack of tissue specificity and insufficient selectivity of inhibition strategies. In this Review, we discuss the latest research on receptor-ligand pairs and interactors that regulate leukocyte influx into the inflamed artery wall, primarily focusing on studies that used pharmacological interventions. We also discuss mechanisms that promote the resolution of inflammation and highlight how major findings from these research areas hold promise as potential therapeutic strategies for atherosclerotic cardiovascular disease.