Evidence for a complex risk profile in obese postmenopausal Turkish women with hypertriglyceridaemia and elevated apolipoprotein B

Practical recommendations for the management of cardiovascular risk associated with atherogenic dyslipidemia, with special attention to residual risk. Spanish adaptation of a European Consensus of Experts

This document has discussed clinical approaches to managing cardiovascular risk in clinical practice, with special focus on residual cardiovascular risk associated with lipid abnormalities, especially atherogenic dyslipidaemia (AD). A simplified definition of AD was proposed to enhance understanding of this condition, its prevalence and its impact on cardiovascular risk. AD can be defined by high fasting triglyceride levels (≥2.3mmol/L / ≥200mg/dL) and low high-density lipoprotein cholesterol (HDL-c) levels (≤1,0 / 40 and ≤1,3mmol/L / 50mg/dL in men and women, respectively) in statin-treated patients at high cardiovascular risk. The use of a single marker for the diagnosis and treatment of AD, such as non-HDL-c, was advocated. Interventions including lifestyle optimization and low density lipoprotein (LDL) lowering therapy with statins (±ezetimibe) are recommended by experts. Treatment of residual AD can be performed with the addition of fenofibrate, since it can improve the complete lipoprotein profile and reduce the risk of cardiovascular events in patients with AD. Others clinical condictions in which fenofibrate may be prescribed include patients with very high TGs (≥5.6mmol/L / 500mg/dL), patients who are intolerant or resistant to statins, and patients with AD and at high cardiovascular risk. The fenofibrate-statin combination was considered by the experts to benefit from a favorable benefit-risk profile. In conclusion, cardiovascular experts adopt a multifaceted approach to the prevention of atherosclerotic cardiovascular disease, with lifestyle optimization, LDL-lowering therapy and treatment of AD with fenofibrate routinely used to help reduce a patient's overall cardiovascular risk.

Correlation between hormonal and lipid status in women in menopause

It is widely accepted that menopause leads to changes in hormonal status, metabolism and lipid profile. The aim of this study was to analyze the influence of menopause on the concentrations of lipids, lipoproteins and, the influence of estradiol, progesterone, FSH, LH on lipid profile in menopausal women as well. The menopausal women had higher but non-significant (p>0,05) concentrations of total cholesterol, VLDL, LDL, and triglycerides than women with regular menstruation. The concentration of HDL was significantly lower in menopausal women than in women with regular menstruation (p<0,05). Also, the concentration of apolipoprotein B was significantly higher in menopausal women (p<0,05), but the concentrations of apolipoprotein and lipoprotein (a) were lower but without significance (p>0,05). Estrogen concentration has significant negative correlation with VLDL and triglycerides (p<0,05) and significant positive correlation with HDL (p<0,05) in menopausal women. Progesterone concentration has shown no correlation with concentrations of lipids and lipoproteins in menopause. We can conclude that menopause leads to changes in lipid profile by reducing HDL, and elevating apolipoprotein B levels, thus increasing the risk for cardiovascular disease. These changes were caused by reduction of estrogen concentrations in menopause.

Ethnic gap in coronary artery disease: comparison of the extent, severity, and risk factors in Arab and Jewish middle-aged women

The authors examined risk factors and extent of coronary artery disease (CAD) among Jewish and Arab women in Jerusalem, where Arab women were found to have worse outcome. All angiographically confirmed cases of CAD among women aged 45 to 65 years who were hospitalized during 1990 to 1995 consisted of 40 Arab and 179 Jewish patients. Arab women had more atypical clinical presentations (P<.0001) and more extensive CAD (P=.0016) despite younger age (53+/-3 vs 55+/-5 years; P<.0003) and lesser smoking (P<.0006). The Arab women, however, were more likely to be obese (80% vs 46%; P=.0002), be physically inactive (100% vs 89%; P=.0285), and have diabetes mellitus (73% vs 40%; P=.0004). Moreover, they were more likely to have 3 or more risk factors (45% vs 23%; P=.036). Thus, a combination of an atypical presentation and higher risk (ie, diabetes mellitus combined with hypertension and other risk factors) and much more extensive disease readily explains their worse outcome.

Serum sex hormone-binding globulin, a determinant of cardiometabolic disorders independent of abdominal obesity and insulin resistance in elderly men and women

Serum sex hormone-binding globulin (SHBG) is related to cardiometabolic disorders; but whether or not this relationship is purely secondary to hyperinsulinemia and/or obesity, which down-regulates SHBG, is unknown. The aim of the study was to investigate the association of SHBG and total testosterone with atherogenic dyslipidemias, metabolic syndrome (MS), and diabetes among predominantly elderly Turkish adults. After appropriate exclusions, 777 randomly selected male and female subjects with available measurements of both variables were eligible and were analyzed cross-sectionally, with diabetic subjects analyzed separately. Free testosterone was calculated. Metabolic syndrome was identified by the modified criteria of the Adult Treatment Panel III. Metabolic syndrome was identified in half the sample, which had a median age of 58 years. The odds of low SHBG concentrations (<45 nmol/L in men, <55 nmol/L in women) for the likelihood of 2 types of dyslipidemias, MS, and diabetes were examined by regression analyses in standard models including age, smoking status, presence of abdominal obesity, and insulin resistance (homeostasis model assessment of insulin resistance). In both sexes, low SHBG was associated independently with high triglyceride/low high-density lipoprotein dyslipidemia and with MS, at significant 2.2- to 4.5-fold odds ratios, independent of waist circumference or homeostasis model assessment of insulin resistance index. Low SHBG among women was additionally associated with the likelihood of hypertriglyceridemia with elevated apolipoprotein B and-at borderline significance-with that of diabetes, again when adjusted for the same confounders. In an elderly population with prevalent MS, low SHBG levels significantly associate with high triglyceride/low high-density lipoprotein dyslipidemia, MS, and, in women alone, diabetes and a dyslipidemia marking small dense low-density lipoprotein particles, all independent of abdominal obesity and insulin resistance. Low SHBG may be an important independent factor for cardiometabolic risk, particularly in women.

Body composition and the apoB/apoA-I ratio in migrant Asian Indians and white Caucasians in Canada

Migrant and native South Asians appear to be at increased risk of Type II diabetes mellitus and coronary disease. The aim of the present study was to determine the relationship between the most accurate summary index of the lipoprotein-related risk of vascular disease, the apoB (apolipoprotein B-100)/apoA-I (apolipoprotein A-I) ratio, and body composition in established migrant South Asians and white Caucasians living in Canada. Men and women living in Montreal, Canada between the ages of 20–60 years were recruited for participation in the study. Subjects were excluded if they had a history of cardiovascular disease or were taking lipid-lowering medication. Individuals identified themselves as Asian Indian or Caucasian. Anthropometric measurements were collected, including weight, height, waist circumference, hip circumference and body fat percentage. Plasma samples were analysed for total cholesterol, HDL-C (high-density lipoprotein-cholesterol), apoA-I and apoB. Indian subjects had a substantially higher WHR (waist-to-hip ratio) than Caucasian subjects [men, 0.93±0.01 compared with 0.86±0.01 respectively (P<0.001); women, 0.88±0.01 compared with 0.77±0.01 respectively (P<0.0001)]. WHR correlated strongly with body fat percentage in Caucasians (men, r=0.63, P=0.0002; women, r=0.74, P<0.0001). By contrast, there was no correlation in Indians (men, r=0.22, P value not significant; women, r=0.23, P value not significant). In addition, Indian men and women had a higher apoB/A-I ratio than Caucasians [men, 0.85±0.04 compared with 0.66±0.04 respectively (P=0.001); women, 0.73±0.04 compared with 0.56±0.03 respectively (P=0.0003)]. Of interest, there were also significant correlations between the apoB/apoA-I ratio and WHR in all of the groups, except the Indian women, which were stronger than the correlation of the apoB/apoA-I ratio with BMI. On the other hand, there was no significant relationship between the apoB/apoA-I ratio and the body fat percentage in any of the groups. In conclusion, the present study confirms that, as body fat percentage increases, the distribution of body fat differs between migrant Indians and Caucasians living in Canada. It also relates differences in body fat distribution to differences in the apoB/apoA-I ratio, providing at least part of the answer as to why South Asians may be at increased risk of vascular disease.

Sex difference in development of diabetes and cardiovascular disease on the way from obesity and metabolic syndrome

AIM

The objective of this study was to investigate sex-specific differences existing on the way from (abdominal) obesity and metabolic syndrome (MS) to type 2 diabetes mellitus (DM) and cardiovascular disease (CVD).

METHODS

A population sample of 1974 men and women, representative of Turkish adults (mean age, 48 years), with normal glucose metabolism (GM) and free of CVD at baseline, was prospectively evaluated at a mean 4.1 years of follow-up. The term abnormal GM designated both DM and impaired fasting glucose (IFG). Metabolic syndrome was identified in 29% of men and 40% of women by the criteria of the National Cholesterol Education Program guidelines. Fatal and nonfatal CVD, diagnosed by clinical findings and Minnesota coding of resting electrocardiograms, developed in 121 subjects.

RESULTS

The cohort was dichotomized by the presence or absence of MS and of obesity defined by a body mass index of 30 kg/m 2 or greater. Compared with the major female group with no obesity or MS, women with MS, regardless of the presence of obesity, predicted highly significantly the development of abnormal GM with relative risks exceeding 2, whereas no independent significant association was noted in men with MS. Similar divergence of sexes pertained to the prediction of diabetes. When age, smoking status, grade of physical activity, IFG, DM, and the 4 groups with obesity and MS were analyzed for the prediction of CVD by logistic regression, men with MS, regardless of the presence of obesity, predicted highly significantly CVD (with relative risks ranging from 2 to 4), but neither DM nor IFG contributed independently. Conversely, in women, abnormal GM predicted CVD independent of age, smoking status, and grade of physical activity, but the groups with obesity and MS failed to significantly contribute independently.

CONCLUSIONS

In populations with prevalent MS, whereas women with normal GM are prone to DM within the context of MS and are exposed to CVD risk primarily by way of DM, men are prone to visceral adiposity, less susceptible to DM, and run CVD risk primarily by the intermediary of MS, largely independent of the DM component.