Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel

Impact of a personalized, strike early and strong approach on non-HDL-cholesterol levels and outcome in patients with acute myocardial infarction

AIMS

We retrospectively evaluated the impact on non-HDL-cholesterol (non-HDL-C) levels of the systematic introduction in our institution of an individualized, pre-defined, strike early and strong (SES) strategy for lipid-lowering therapy (LLT) in patients with acute myocardial infarction (MI).

METHODS

We analyzed data from 500 consecutive patients admitted across three periods: Period A (N = 198, January-June 2019), when the non-HDL-C goal was <100 mg/dL and a stepwise LLT approach was indicated; Period B (N = 180, January-June 2021), when the non-HDL-C goal was <85 mg/dL and a stepwise approach was recommended; Period C (N = 122, January-June 2023), when the SES protocol was introduced. Primary endpoints were the percentage of patients reaching the non- HDL-C goal during follow-up and the incidence of major adverse cardiovascular events (MACE) at one year.

RESULTS

Compared to the other periods, the prevalence of prescription at discharge of potent statins, alone or in combination with ezetimibe, and PCSK9 inhibitors was greater in Period C. The achievement of the non-HDL-C goal in Period C was higher (87 % vs 67 % and 58 % in Periods A and B, respectively; p < 0.001). This achievement was associated with a lower occurrence of MACE (7 % vs. 13 % in patients not at target; log-rank p = 0.027). MACE incidence was the lowest in patients with early and sustained non-HDL-C < 85 mg/dL during follow-up.

CONCLUSION

The systematic introduction of an individualized, SES approach for LLT in patients with acute MI led to higher achievement of the non-HDL-C goal and this translated into a lower risk of MACE.

Effect of xylitol on low‑density lipoprotein‑stimulated oxidative stress in THP‑1 cells

Atherosclerosis (AS) is a chronic inflammatory disease caused by oxidative stress and the oxidation of low‑density lipoprotein (LDL). Xylitol, a widely used sugar substitute, has antioxidant potential; however, its effects on LDL‑induced oxidative stress in AS remain unclear. Using western blot, reverse transcription‑quantitative PCR, flow cytometry and so on, the present study investigated the role of xylitol in mitigating oxidative stress induced by high levels of LDL in Tohoku Hospital Pediatrics‑1 (THP‑1) human monocytic cell line), a model for studying AS. Xylitol significantly alleviated high LDL‑induced oxidative stress in THP‑1 cells and decreased reactive oxygen species levels, malondialdehyde content and the expression of NADPH oxidase family enzymes. Concurrently, xylitol enhanced the activity and expression of superoxide dismutase and increased the glutathione levels. Mechanistically, xylitol activated the nuclear factor erythroid 2‑related factor 2 (Nrf2)/heme oxygenase‑1 (HO‑1) axis by increasing the NADPH/NADP+ ratio via the regulation of the pentose phosphate pathway via the Nrf2 transcription factor. This led to a decrease in LDL oxidative modification in THP‑1 cells (Figs. 6,7). Overall, xylitol attenuates high LDL level‑induced oxidative stress in THP‑1 cells by modulating the Nrf2‑mediated pentose phosphate pathway and activating the Nrf2/HO‑1 axis, highlighting its potential for the prevention and treatment of AS.

The interaction of human serum components with model membranes containing phospholipids and lipopolysaccharides

Lipoproteins, key mediators of lipid transport, facilitate the bidirectional transfer of lipids such as fatty acids, triglycerides, and cholesterol between soluble particles and cell membranes. High-density lipoproteins (HDL) primarily engage in reverse cholesterol transport, while low-density lipoproteins (LDL) predominantly deposit lipids, affecting cardiovascular health with a well-known role in the formation of the atherosclerotic plaque. In addition, lipoproteins play an important role in neutralizing bacterial lipopolysaccharides (LPS), the major component of Gram-negative bacterial outer membranes, which act as potent TLR4 agonists and can trigger severe immune responses. Lipoproteins bind LPS in plasma, with HDL showing strong binding affinity and LDL contributing to LPS clearance under specific conditions. Here, we explore the interaction of LDL and human serum albumin (HSA), another serum lipid-binding protein, with model lipid bilayers containing either phospholipids or LPS. Using neutron reflectometry and attenuated total reflection infrared spectroscopy, we characterize lipid transfer processes influenced by calcium levels and lipid composition. Calcium plays a key role in receptor-mediated LDL binding, but less is known on its effect on LDL-mediated lipid transfer in the absence of LDL receptors. Our results show that elevated calcium levels enhance stable LDL adsorption onto mammalian phospholipid-cholesterol membranes, promoting lipid cargo deposition despite the absence of specific LDL-receptors. Conversely, LDL showed no stable binding to LPS reconstituted in asymmetric outer membrane models but was able to deposit phospholipids in the membrane. In contrast, HSA removed lipids from mammalian membranes and exhibited minimal interaction with LPS-containing models. The findings elucidate the distinct lipid exchange mechanisms of LDL and HSA and their roles in modulating lipid transfer at membrane interfaces. Receptor-free enhanced LDL lipid deposition in calcium-enriched environments may have implications for cardiovascular disease progression. Conversely, the minimal interaction of LDL with bacterial LPS suggests a limited ability to extract LPS from membrane environments. This study provides structural insights into the interplay between lipoproteins, calcium, and membrane composition, with relevance to atherosclerosis and systemic endotoxemia.

LDL cholesterol burden in elderly patients with familial hypercholesterolemia: Insights from real-world data

Background and aims

Familial hypercholesterolemia (FH) is a genetic disorder characterized by elevated low-density lipoprotein cholesterol (LDL-C) and increased risk of premature coronary heart disease (CHD). While current LDL-C levels usually guides therapy, the cumulative exposure to LDL-C (the LDL-C burden) is suggested to offer a more precise estimate of cardiovascular risk in people with FH. Therefore, using real-world data, this study aimed to estimate the LDL-C burden at different ages in elderly FH patients with and without CHD, and to assess the LDL-C burden at CHD onset.

Methods

Data was retrospectively collected from the medical records of elderly (>60 years) FH patients at the Lipid Clinic in Oslo. The LDL-C burden (mM-years) was estimated based on repeated LDL-C measurements and information on lipid-lowering medication. Time-weighted average (TWA) LDL-C was calculated as LDL-C burden divided by years.

Results

We included 112 FH patients, of which 55 (49 %) had experienced at least one CHD-event, and 58 (52 %) were females. Median age at first and last visit were 50 years and 68 years, respectively, with a median of 9 (range; 2-14) available LDL-C measurements. Subjects with CHD had higher LDL-C burden at all ages tested (45, 50 and 60 years) compared with the non-CHD group (p < 0.01, also after adjusting for sex), and had higher TWA LDL-C before treatment at the Lipid Clinic (p = 0.004), but not during follow-up (p = 0.6). There were no sex differences in LDL-C burden at all ages tested, also after adjusting for CHD (p > 0.1). However, women had higher TWA LDL-C during follow-up at the Lipid Clinic (p = 0.01). Median LDL-C burden at CHD onset was 352 mM-years; numerically lower in women than in men (320 vs. 357 mM-years, respectively. p = 0.1).

Conclusion

Elderly FH patients with CHD had higher estimated LDL-C burden compared with FH patients without CHD, due to higher burden prior to treatment, highlighting the importance of earlydetection and treatment.

Implementation strategies for improving the care of familial hypercholesterolaemia from the International Atherosclerosis Society: next steps in implementation science and practice

Familial hypercholesterolaemia (FH) is the most common monogenic condition associated with premature atherosclerotic cardiovascular disease. Early detection and initiation of cholesterol lowering therapy combined with lifestyle changes improves the prognosis of patients with FH significantly. The International Atherosclerosis Society (IAS) published a new guidance for implementing best practice in the care of FH. Previous guidelines and position statements seldom provided implementation recommendations. To address this, an implementation science approach was used to generate implementation strategies for the clinical recommendations made. This process entailed the generation by consensus of strong implementation recommendations according to the Expert Recommendations for Implementing Change (ERIC) taxonomy. A total of 80 general and specific implementation recommendations were generated, addressing detection (screening, diagnosis, genetic testing and counselling) and management (risk stratification, treatment of adults or children with heterozygous or homozygous FH, therapy during pregnancy and use of apheresis) of patients with FH. We describe here the IAS guidance core implementation strategies to assist with the adoption of clinical recommendations into routine practice for at-risk patients and families worldwide. We summarise the IAS guidance core implementation strategies as operative statements.

Apolipoprotein B-containing lipoproteins in atherogenesis

Apolipoprotein B (apoB) is the main structural protein of LDLs, triglyceride-rich lipoproteins and lipoprotein(a), and is crucial for their formation, metabolism and atherogenic properties. In this Review, we present insights into the role of apoB-containing lipoproteins in atherogenesis, with an emphasis on the mechanisms leading to plaque initiation and growth. LDL, the most abundant cholesterol-rich lipoprotein in plasma, is causally linked to atherosclerosis. LDL enters the artery wall by transcytosis and, in vulnerable regions, is retained in the subendothelial space by binding to proteoglycans via specific sites on apoB. A maladaptive response ensues. This response involves modification of LDL particles, which promotes LDL retention and the release of bioactive lipid products that trigger inflammatory responses in vascular cells, as well as adaptive immune responses. Resident and recruited macrophages take up modified LDL, leading to foam cell formation and ultimately cell death due to inadequate cellular lipid handling. Accumulation of dead cells and cholesterol crystallization are hallmarks of the necrotic core of atherosclerotic plaques. Other apoB-containing lipoproteins, although less abundant, have substantially greater atherogenicity per particle than LDL. These lipoproteins probably contribute to atherogenesis in a similar way to LDL but might also induce additional pathogenic mechanisms. Several targets for intervention to reduce the rate of atherosclerotic lesion initiation and progression have now been identified, including lowering plasma lipoprotein levels and modulating the maladaptive responses in the artery wall.

Ellagic acid ameliorates atherosclerosis by inhibiting PCSK9 through the modulation of FoxO3 and HNF1α

INTRODUCTION

Proprotein convertase subtilisin/kexin type 9 (PCSK9) hinders the clearance of low-density lipoprotein cholesterol (LDL-C) by promoting the degradation of the low-density lipoprotein receptor (LDLR), leading to the accumulation of LDL-C and thus becoming an important cause of atherosclerosis. Ellagic acid, a naturally occurring polyphenol widely present in fruits, vegetables, and nuts, has attracted significant attention due to its potential role in the prevention and treatment of cardiovascular diseases. However, the molecular mechanisms by which ellagic acid alleviates atherosclerosis by inhibiting PCSK9 are not fully understood.

MATERIALS AND METHODS

This study further validated the mechanism of action of ellagic acid through in vitro HepG2 cell experiments and a high-fat diet-induced ApoE-/- mouse model.

RESULTS

The results showed that ellagic acid significantly reduced the expression and secretion of PCSK9 while upregulating LDLR protein levels; its mechanism is related to the inhibition of hepatocyte nuclear factor 1α (HNF1α) expression and the promotion of forkhead box O3 (FoxO3) expression increase. Additionally, ellagic acid reduced aortic plaque deposition in mice induced by a high-fat diet; consistent with the in vitro experimental results, ellagic acid lowered the expression and secretion of PCSK9 and elevated LDLR protein levels by inhibiting HNF1α and increased FoxO3 expression.

CONCLUSIONS

In summary, this study demonstrates that ellagic acid inhibits PCSK9 by regulating HNF1α and FoxO3, thereby increasing LDLR levels and alleviating atherosclerosis. This finding not only consolidates the scientific basis of plant-based diets for preventing cardiovascular diseases but also provides an important direction for developing functional foods and nutritional intervention strategies based on natural polyphenols.

Coagulation in familial hypercholesterolemic patients: effect of current hypolipidemic treatment and anticoagulants

Familial hypercholesterolemia (FH) is a relatively rare genetic disease associated with high serum cholesterol levels but also with abnormalities in blood coagulation. Novel pharmacotherapeutic approaches in FH including proprotein convertase subtilisin/kexin type 9 antibodies (PCSK9Ab) are very efficient in decreasing cholesterol levels but their impact on coagulation in FH is not yet established. Therefore, we hypothesized that these novel antidyslipidemic drugs can positively impact blood coagulation due to their more potent effect on cholesterol. A total of 15 healthy volunteers and all 15 available patients with severe FH treated at the University Hospital Hradec Králové were enrolled, coagulation was assessed by mechanic coagulometer, and the impact of four clinically used direct anticoagulants was analyzed ex vivo. FH patients were treated effectively as their total cholesterol was 4.11 ± 1.57 mM and LDL cholesterol was 2.44 ± 1.46 mM, which were even lower values than detected in our generally healthy controls. Twelve from the 15 FH patients were finally analyzed as 3 were treated with anticoagulants. Coagulation in FH patients was prolonged more extensively by dabigatran and rivaroxaban, when compared to healthy controls. Treatment with PCSK9Ab or lipid apheresis did not seem to have a significant effect on coagulation. The latter procedure however significantly decreased serum levels of one vitamin K form, MK4. Shorter coagulation time was associated with higher levels of LDL, non-HDL, and total cholesterol. Current treatment of FH seems to improve the effects of direct anticoagulants beyond known effects on LDL cholesterol levels.

Distinct Microbial Taxa Are Associated with LDL-Cholesterol Reduction after 12 Weeks of Lactobacillus plantarum Intake in Mild Hypercholesterolemia: Results of a Randomized Controlled Study

Probiotic microbes such as Lactobacillus may reduce serum total cholesterol (TC) and low-density lipoprotein (LDL) cholesterol. The objective of this study was to assess the effect of Lactobacillus plantarum strains CECT7527, CECT7528, and CECT7529 (LP) on the serum lipids, cardiovascular parameters, and fecal gut microbiota composition in patients with mild hypercholesterolemia. A randomized, double-blinded, placebo-controlled clinical trial with 86 healthy adult participants with untreated elevated LDL cholesterol ≥ 160 mg/dl was conducted. Participants were randomly allocated to either placebo or LP (1.2 × 109 CFU/d) for 12 weeks. LDL, HDL, TC, and triglycerides (TG), cardiovascular parameters (blood pressure, arterial stiffness), and fecal gut microbiota composition (16S rRNA gene sequencing) were assessed at baseline and after 12 weeks. Both groups were comparable regarding age, sex, and LDL-C at baseline. LDL-C decreased (mean decrease - 6.6 mg/dl ±  - 14.0 mg/dl, Ptime*group = 0.006) in the LP group but not in the placebo group. No effects were observed on HDL, TG, or cardiovascular parameters or overall gut microbiota composition. Responders to LP intervention (> 5% LDL-C reduction) were characterized by higher BMI, pronounced TC reduction, higher abundance of fecal Roseburia, and lower abundance of Oscillibacter. In conclusion, 12 weeks of L. plantarum intake moderately reduced LDL-C and TC as compared to placebo. LDL-C-lowering efficacy of L. plantarum strains may potentially be dependent on individual difference in the gut microbiota. Trial registration: DRKS00020384, dated 07/01/2020.

Small dense low-density lipoprotein as biomarker in the elderly

OBJECTIVES

Small dense low-density lipoprotein (sdLDL) is atherogenic and associated with atherosclerotic cardiovascular diseases (ASCVD). The aim of this study was to perform the prospective evaluation of sdLDL-c in new ASCVD over 18 years of follow up, and to compare the association of sdLDL-c and conventional lipids and apolipoproteins with ASCVD in the elderly.

METHODS

This prospective study included a total of 1770 subjects ≥ 64 years of age with an 18-year follow-up period. The determination of sdLDL-c was measured by a homogenous, selective enzymatic method. Levels of total cholesterol (TC), high-density lipoprotein cholesterol (HDL-c) and triglycerides (TG) were determined by enzymatic methods. Apolipoproteins, ApoA1 and ApoB, were analyzed by immunonephelometric methods. Low-density lipoprotein cholesterol (LDL-c) levels were calculated using the Friedewald formula.

RESULTS

According to Pearson's correlation coefficients, sdLDL-c concentration was positively correlated with LDL-c, nonHDL-c, TC and ApoB concentrations. During follow up, sdLDL-c was significantly associated with new ASCVD in men aged 64-76 years in both unadjusted and adjusted Cox regression models. The adjusted hazard ratio (95 % CI) for sdLDL-c was 1.61 (1.13-2.28). No significant associations between sdLDL-c and ASCVD were observed in men aged 77-97 years, nor in women aged 64-79 or 80-100 years.

CONCLUSIONS

Lipid and apolipoprotein concentrations of the elderly were high compared to the recommended target values. In addition, lipid and apolipoprotein baseline concentrations were not higher in the ASCVD group than in the control group. Our results indicated that sdLDL-c is as good a marker as ApoB and better than LDL-c.

Discordance between serum cholesterol concentration and atherogenic lipoprotein particle number in people with metabolic disease: A systematic review

This systematic review examines the discordance between low-density lipoprotein cholesterol (LDL-C), non-high-density lipoprotein cholesterol (non-HDL-C), and apolipoprotein B-100 (apoB) in individuals with metabolic diseases, such as metabolic syndrome and type 2 diabetes, and evaluates the implications for atherosclerotic cardiovascular disease (ASCVD) risk assessment. A systematic literature search was conducted using Academic Search Complete, CINAHL Complete, and MEDLINE databases from 10 January 2024 to 28 May 2024. Studies were selected based on pre-defined inclusion and exclusion criteria, focusing on observational studies that compared LDL-C, non-HDL-C, and apoB levels in individuals with metabolic disease. Studies were included if they assessed fasted blood samples and reported lipid measurements, excluding those involving drug therapies or dietary interventions. Nine studies met the inclusion criteria, revealing significant discordance between LDL-C and apoB levels in individuals with metabolic syndrome or type 2 diabetes. These individuals often achieve optimal LDL-C levels while exhibiting elevated apoB and non-HDL-C concentrations, highlighting the limitations of LDL-C as the sole marker for ASCVD risk. The discordance is largely attributed to differences in LDL particle size and density, with metabolic disease contributing to a higher proportion of small, dense, atherogenic LDL particles. Elevated triglyceride-rich lipoproteins (TRLs), such as very low-density lipoproteins (VLDL), were also identified as contributing to ASCVD risk underestimation by traditional LDL-C measurements. While LDL-C remains a central marker for ASCVD, apoB quantification provides a more accurate assessment of ASCVD risk, particularly in individuals with metabolic diseases. Incorporating apoB levels into therapeutic strategies for lipid reduction is recommended to improve cardiovascular risk management in this population.

Apolipoprotein C-III inhibitors for the treatment of hypertriglyceridemia: a meta-analysis of randomized controlled trials

INTRODUCTION

Hypertriglyceridemia is related to atherosclerotic cardiovascular risk and pancreatitis risk. The efficacy and safety of apolipoprotein C-III (APOC-III) inhibitors remains unclear.

AIM

To investigate the effects of APOC-III inhibitors on hypertriglyceridemia and its complications.

METHODS

We systematically searched PubMed, Embase, and Cochrane Central databases from inception to May 2024 for randomized controlled trials (RCTs) comparing APOC-III inhibitors to placebo in patients with hypertriglyceridemia. We pooled percentage standardized mean difference (SMD) changes and risk ratio (RR) for continuous and binary outcomes, respectively, with 95 % confidence interval (CI). Subgroup analyses were performed with APOC-III inhibitors drugs doses (Olezarsen, Volanesorsen and Plozasiran), and primary and secondary hypertriglyceridemia.

RESULTS

10 RCTs with 1204 participants were included, of which 46 % were men. APOC-III inhibitors significantly reduced triglycerides (TG) (SMD: -60.56 %; 95 % CI -68.94 to -52.18; p < 0.00001), APOC-III (SMD: -75.44 %; 95 % CI -80.81 to -70.07; p < 0.00001) and non-HDL-c (SMD: -27.49 %; 95 % CI -34.16 to -20.82; p < 0.00001) levels. Consistent results were found for all subgroup analyses. APOC-III inhibitors were capable to normalize TG levels in patients with severe hypertriglyceridemia (RR: 7.92; 95 % CI 4.12 to 15.23; p < 0.00001). There was a significant increase in HDL-c (SMD: 43.92 %; 95 % CI 37.27 to 50.57; p < 0.00001) and LDL-c (SMD: 33.05 %; 95 % CI 9.08 to 57.01; p = 0.007) levels. There was a significant relative risk reduction in acute pancreatitis in the APOC-III inhibitors group (RR 0.17; 95 % CI 0.05 to 0.53; p = 0.007). Adverse events were similar in both groups.

CONCLUSION

APOC-III inhibitors improve TG levels and other lipid panel parameters, as well as reduce episodes of acute pancreatitis in patients with primary and secondary hypertriglyceridemia.

Research Hotspots and Development Trends on Apolipoprotein B in the Field of Atherosclerosis: A Bibliometric Analysis

BACKGROUND

Cardiovascular diseases caused by atherosclerosis (AS) are the leading causes of disability and death worldwide. Apolipoprotein B (ApoB), the core protein of low-density lipoproteins, is a major contributor to cardiovascular disease-related morbidity and mortality, with apolipoprotein B (ApoB) playing a critical role in its pathogenesis. However, no bibliometric studies on the involvement of ApoB in AS have been published. This study aimed to conduct a comprehensive bibliometric analysis to explore the current and future trends regarding the role of ApoB in AS.

METHODS

Utilizing the Web of Science Core Collection, a thorough search was conducted for ApoB in AS-related papers related to research on ApoB in the field of AS during 1991-2023. The analysis focused on annual publication trends, leading countries/regions and institutions, influential authors, journal and key journals. CiteSpace and VOSviewer were employed to visualize reference co-citations, and keyword co-occurrences, offering insights into the research landscape and emerging trends.

RESULTS

This bibliometric analysis employed network diagrams for cluster analysis of a total of 2105 articles and reviews, evidencing a discernible upward trend in annual publication volume. This corpus of research emanates from 76 countries/regions and 2343 organizations, illustrating the widespread international engagement in ApoB-related AS studies. Notably, the United States and the University of California emerge as the most prolific contributors, which underscores their pivotal roles in advancing this research domain. The thematic investigation has increasingly focused on elucidating the mechanistic involvement of ApoB in atherosclerosis, its potential as a diagnostic biomarker, and its implications for therapeutic strategies.

CONCLUSION

This bibliometric analysis provides the first comprehensive perspective on the evolving promise of ApoB in AS-related research, emphasizing the importance of this molecule in opening up new diagnostic and therapeutic avenues. This study emphasizes the need for continued research and interdisciplinary efforts to strengthen the fight against AS. Furthermore, it emphasizes the critical role of international collaboration and interdisciplinary exploration in leveraging new insights to achieve clinical breakthroughs, thereby addressing the complexities of AS by focusing on ApoB.

The Monetary Value of a Statistical Life in the Context of Atherosclerotic Cardiovascular Disease

AIM

This study aims to estimate the value of a statistical life (VSL) in the context of atherosclerotic cardiovascular disease (ASCVD) in Spain using a contingent valuation/standard gamble (CV/SG) chained approach.

METHODS

The study employed a two-stage preference elicitation method that combined contingent valuation and a modified standard gamble technique. Specifically, willingness-to-pay and willingness-to-accept values were obtained for two health states depicting hypothetical outcomes following cardiovascular events. Subsequently, relative utility losses for the health states were derived using a modified standard gamble framing two risky choices. Chaining these elicited values allowed for VSL calculation without requiring direct valuation of small mortality risk reductions. The study was conducted through in-person interviews with a representative sample of 412 Spanish adults selected by stratified quotas.

RESULTS

The estimated VSL range is from 1.59 to 2.06 million euros. Minor differences emerge between VSL figures on the basis of each of the two health states. These VSL estimates for ASCVD are congruent with the recent update of the official VSL estimated for Spain in the context of road traffic accidents, though the upper limit of the range is slightly higher (almost 9%).

CONCLUSIONS

VSL estimates align with existing ranges in other European countries, particularly in the context of road safety, where a significant portion of existing studies is concentrated. Comparisons with other contexts, involving cardiovascular diseases, also lend support to the estimates presented here.

Lipid-lowering prescription patterns after a non-fatal acute coronary syndrome: A retrospective cohort study

Background

After an acute atherosclerotic cardiovascular event, high-intensity lipid-lowering therapy (LLT) is needed to reduce recurrence risk. This study aimed to describe LLT prescription patterns and LDL-C levels change after non-fatal acute coronary syndrome (ACS) events and to determine if the recommended goals for LDL-C levels were achieved.

Methods

Retrospective cohort study using electronic health records (EHR) of Unidade Local de Saúde de Matosinhos between 2015 and 2023. Participants were adults aged 40-80 years, with a non-fatal ACS hospitalization between 2016 and 2022 (index date); ≥1 general practice appointment in the three years before ACS; and one-year follow-up post-ACS. Sub-analyses focused on gender, age (

Results

Of 544 patients, 270 (49.6 %) were under 65 years, and 164 (30.1 %) were females. Before the ACS, 71.1 % of men and 56.7 % of women had no previous LLT prescription and younger patients showed poorer LDL-C control (132(IQR 64)mg/dL) than older patients (102(IQR 50)mg/dL). One-year post-ACS, only 11.3 % of males and 8.5 % of females met LDL-C target. The proportion of patients without LLT decreased from 66.7 % at baseline to 13.6 % post-ACS. High-intensity LLT prescriptions increased from 2.4 % to 16.5 %, while moderate-intensity LLT remained predominant (65.8 %). Still, 89.5 % of patients had uncontrolled LDL-C levels.

Conclusion

Despite initiating/intensifying LLT, one year after ACS most patients did not achieve LDL-C goals. This indicates a significant gap in guideline implementation in clinical practice.

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Key Words

• Atherosclerosis
• Electronic health records
• Hydroxymethylglutaryl-CoA reductase inhibitors
• Low-density lipoprotein cholesterol

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Affiliation(s)

Cristina Gavina Cardiology Department, Hospital Pedro Hispano–Unidade Local de Saúde Matosinhos, Matosinhos, Portugal Department of Medicine, Faculty of Medicine of University of Porto, Porto, Portugal UNIC, Faculty of Medicine of University of Porto, Porto, Portugal
Daniel Seabra Carvalho Cardiology Department, Hospital Pedro Hispano–Unidade Local de Saúde Matosinhos, Matosinhos, Portugal
Marta Afonso-Silva Real World Evidence Department, Novartis Farma–Produtos Farmacêuticos SA, Porto Salvo, Portugal
Inês Costa Real World Evidence Department, Novartis Farma–Produtos Farmacêuticos SA, Porto Salvo, Portugal
Ana Sofia Freitas Medical Department, Novartis Farma–Produtos Farmacêuticos S.A., Porto Salvo, Portugal
Mariana Canelas-Pais MTG Research and Development Lab, Porto, Portugal Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal
Nuno Lourenço-Silva MTG Research and Development Lab, Porto, Portugal Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal
Tiago Taveira-Gomes Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal Faculty of Health Sciences, Fernando Pessoa University (FCS-UFP), Portugal CINTESIS@RISE Center for Health Technology and Services Research, Porto, Portugal SIGIL Scientific Enterprises, Dubai, United Arab Emirates
Francisco Araújo Department of Internal Medicine, Hospital Lusíadas, Lisbon, Portugal

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Rationale, design and prerandomization data for a cluster randomized trial to assess the effect of a digitally enabled quality improvement intervention on LDL-C control in established atherosclerotic cardiovascular disease patients: The SAPPHIRE-LDL trial

BACKGROUND

Translating evidence into clinical practice in the management of established atherosclerotic cardiovascular disease patients is challenging. Few quality improvement interventions have successfully improved patient care.

OBJECTIVES

The main objectives are to evaluate the impact of a digitally enabled multifaceted quality improvement (QI) intervention on the control of LDL-cholesterol (LDL-C) in atherosclerotic cardiovascular disease (ASCVD).

DESIGN

We designed a pragmatic 2-arm cluster randomized trial involving 28 clusters (outpatient clinics from public or private hospitals or private practices). Clusters are randomized to receive a digitally enabled multifaceted QI intervention or to routine practice (control). The QI intervention includes reminders, electronic clinical decision support algorithms, audit and feedback reports, and distribution of educational materials to health care providers, as well as electronic educational materials and app-based tools for drug adherence control, lipid profile control, and communication to participants. The primary endpoint is the LDL-C at 06 months after the intervention period. All analyses are performed following the intention-to-treat principle and take the cluster design into consideration by using individual-level regression modeling (generalized estimating equations-GEE).

SUMMARY

If proven effective, this low-cost, digitally enabled multifaceted QI intervention would be highly useful in promoting optimal LDL-C control in ASCVD patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05622929.

Chronic statin-use before PCI in acute coronary syndromes and in-hospital outcomes: ACC-NCDR registry in India

Objective

To compare in-hospital major cardiovascular adverse outcomes among chronic statin-user and statin-naïve acute coronary syndrome(ACS) patients following percutaneous coronary intervention(PCI).

Methods

Successive patients with ACS who underwent PCI from Sep'17 to Dec'23 were enrolled in a prospective registry. Details of risk factors, presentation, angiography, interventions, and in-hospital outcomes were recorded. Chronic statin use was defined as > 1-month intake before presentation. Primary outcomes were in-hospital all-cause and cardiovascular deaths. Univariate and multivariate odds ratios(OR) and 95 % confidence intervals(CI) were calculated.

Results

8296 patients were enrolled, and ACS was in 7892(STEMI-ST elevation myocardial infarction 3222, non-STEMI/unstable angina 4670). Prior chronic statin use was in 2949(37.4 %), and 4943(62.6 %) were statin naïve. Statin-user vs. statin-naïve patients were older(62±10 vs. 60±11y), with more hypertension(61 vs. 48 %), diabetes(36 vs. 32 %), prior PCI(20 vs 8 %), CABG(5 vs 2 %), beta-blockers(61.7 vs 8.3 %), anti-platelets(92.8 vs 5.3 %), and lower mean total-, LDL-, and non-HDL-cholesterol(p < 0.001); chronic statin users had less STEMI(30 % vs 47 %) and better LVEF(46.5 ± 10 vs 44.5 ± 10 %) at presentation and median hospitalization was shorter(66.3 vs 68.6 h)(p < 0.001). In statin-user vs. statin-naïve groups, the incidence of all-cause deaths: 33(1.12 %) vs 85(1.72 %) (OR 0.65, CI 0.43-0.97) and CV deaths: in 29(0.98 %) vs 73(1.47 %) (OR 0.67, CI 0.43-1.02) were lower. The ORs attenuated following multivariate adjustments for risk factors, previous treatments, clinical features, angiographic findings and interventions.

Conclusions

Acute coronary syndrome patients taking pre-admission statins and other cardioprotective medicines have lower in-hospital all-cause deaths. This is associated with less STEMI, better LVEF, and shorter hospitalization in prior statin users.

Emerging roles of PCSK9 in kidney disease: lipid metabolism, megalin regulation and proteinuria

Chronic kidney disease (CKD) is a significant risk factor for cardiovascular disease (CVD). Key features of CKD include proteinuria and reduced glomerular filtration rate, both of which are linked to disease progression and adverse outcomes. Dyslipidemia, a major CVD risk factor, often correlates with CKD severity and is inadequately addressed by conventional therapies. Proprotein convertase subtilisin/kexin type 9 (PCSK9) plays a critical role in lipid metabolism by modulating low-density lipoprotein receptor (LDLR) levels and has emerged as a therapeutic target for managing dyslipidemia. PCSK9 inhibitors, including monoclonal antibodies and siRNA, effectively lower LDL cholesterol levels and have demonstrated safety in patients with mild to moderate CKD. Recent findings indicate that PCSK9 aggravates proteinuria by interacting with and downregulating megalin, a proximal tubule receptor essential for protein reabsorption in the kidney. Inhibition of PCSK9 has been shown to preserve megalin levels, reduce proteinuria, and improve the disease phenotype in experimental models. However, conflicting data from preclinical studies underscore the need for further research to clarify the mechanisms underlying PCSK9's role in kidney disease. This review highlights the potential of PCSK9 inhibition in addressing proteinuria and dyslipidemia in CKD, emphasizing its promise as a therapeutic strategy, while addressing current challenges and future directions for research.

Impact of remnant cholesterol to high-density lipoprotein cholesterol ratio on risk of incident ASCVD: the Kailuan prospective cohort study

BACKGROUND

The study utilized the remnant cholesterol (RC) to high-density lipoprotein cholesterol (HDL-C) ratio as a lipidemia indicator. Assessing its long-term impact on cardiovascular disease (ASCVD) is crucial for primary prevention.

METHODS

84,380 participants were enrolled in the prospective cohort. Participants were classified into low, medium, and high levels based on baseline RC/HDL-C levels at the 50th percentile and 90th percentile. Participants were followed until December 31, 2023. Calculate the incidence density of ASCVD for each group. The time-dependent Cox proportional hazards model was utilized to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) for ASCVD risk among different groups.

RESULTS

The study included 42,181, 33,739, and 8460 participants in the low, medium, and high levels respectively. A median follow-up of 16.92 years, 8397 ASCVD cases were identified. The 1000 person-years incidence density and 95% CIs for ASCVD were 5.86 (5.67, 6.05) in the low level, 6.92 (6.70, 7.15) in the medium level, and 8.85 (8.35, 9.39) in the high level. Compared to the low level, the Cox model showed that the HRs and 95% CIs for ASCVD were 1.09 (1.04, 1.14) and 1.23 (1.15, 1.32), respectively in medium and high levels.

CONCLUSION

Higher RC/HDL-C level was significantly associated with an increased risk of ASCVD. Including the RC/HDL-C in lipid evaluation can reduce the onset of ASCVD.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR2000029767.

Elevated remnant cholesterol and triglycerides are predictors of increased total mortality in a primary health care population of 327,347 patients

BACKGROUND

Hyperlipidemia is a well-established risk factor for cardiovascular disease and mortality. Recently, remnant cholesterol has been introduced as an important risk factor. This study explores the association between levels of remnant cholesterol, compared to the traditional lipid parameters (total cholesterol, low-density lipoprotein (LDL-C), high-density lipoprotein (HDL-C), non-high-density lipoprotein cholesterol (non-HDL-C) and triglycerides), and all-cause mortality in a population from general practice. Additionally, the impact of lipid-lowering treatment was evaluated.

METHODS

Observational cohort study based on the first lipid panel measurement from 327,347 patients from general practice in the Capital Region of Denmark between 2001 and 2018. LDL-C was calculated using the Friedewald equation. Patients with diagnoses or medical treatments that affected lipid levels were excluded. Cox proportional hazards models with restricted cubic splines were used to evaluate the association between all-cause mortality and lipid levels.

RESULTS

A total of 34,014 patients died during the study. In an analysis censoring individuals receiving lipid lowering treatment after the lipid measurement, remnant cholesterol increased all-cause mortality risk linearly, with a hazard ratio (HR) of 1.6 (95% CI: 1.4; 1.7) at 3 mmol/L compared to a reference level of 0.9 mmol/L. Total cholesterol showed a U-shaped relationship with all-cause mortality with a HR of 2.5 (95% CI: 2.3; 2.7) at 2.5 mmol/L and 1.7 (95% CI: 1.6; 1.9) at 9 mmol/L (reference level 5 mmol/L). LDL-C and non-HDL-C exhibited a very similar U-shaped pattern. HDL-C also showed a U-shaped curve with a HR of 1.7 (95% CI: 1.6; 1.9) at 0.5 mmol/L and 1.4 (95% CI: 1.3; 1.5) at 3.5 mmol/L (reference level 1 mmol/L). The mortality risk related to triglycerides increased with rising triglyceride level, with a HR of 1.5 (95% CI: 1.3; 1.6) at 4.5 mmol/L (reference level 2 mmol/L).

CONCLUSIONS

In this study, high levels of all the six lipids as well as low levels of total cholesterol, LDL-C, non-HDL-C and HDL-C were associated with higher all-cause mortality in a primary health care population. Further research is needed, to consider if the current lipid lowering guidelines are appropriate and if more focus on remnant cholesterol levels should be applied.

Changes in LDL-cholesterol levels following aromatase inhibitor treatment in early postmenopausal breast cancer

There is an unsettled concern that treatment with aromatase inhibitors (AIT) may adversely affect lipid-levels. In light of the improved survival of women with breast cancer and increased risk of atherosclerotic cardiovascular disease in older people, unfavorable effects on lipid-levels may represent a significant health concern for this group of patients. We used linked data from nationwide registries, including a clinical breast cancer database with information about allocated and dispensed AIT. Based on these, we investigated changes in plasma lipid-levels (primary outcome: low-density lipoprotein (LDL)-cholesterol, secondary outcomes: high-density lipoprotein (HDL)-cholesterol, total cholesterol, and triglycerides) following AIT in a nationwide cohort of postmenopausal women with early breast cancer, Denmark, 2009-2020. Included women had at least one LDL-cholesterol measurement before and after breast cancer diagnosis. Exposure was allocated and dispensed AIT as compared with not allocated to and no dispensed AIT. Outcome was the adjusted difference in lipid-level-change (from before to after breast cancer diagnosis) according to AIT. Among 10,461 women, there were 22,693 pre-breast cancer LDL-cholesterol measurements and 42,750 post-breast cancer LDL-cholesterol measurements. Overall, 7919 of the women were exposed to AIT and 2542 women were unexposed. For AIT exposed, the LDL-cholesterol-change was - 0.16 mmol/L (mM), and for unexposed, - 0.15 mM, respectively. The corresponding adjusted difference in LDL-cholesterol change for AIT exposed versus unexposed was - 0.03 mM (95% CI - 0.07 to 0.003). We found similar results in analysis of secondary outcomes. This study does not support the concern that AIT adversely affects lipid-levels.

Association Between Dietary Betaine Intake and Dyslipidemia in Chinese Children and Adolescents: A Cross-Sectional Study

Background: Evidence remains limited on the effects of dietary betaine intake and dyslipidemia. We aim to investigate the association between dietary betaine intake and dyslipidemia in Chinese children and adolescents and illustrate the differences in these associations stratified by different food sources. Methods: Based on a national cross-sectional study from the China National Nutrition and Health Surveillance of Children and Lactating Mothers, 11,452 individuals aged 6-17 years were enrolled between October 2016 and December 2018. Participants were divided into quartiles according to residual energy-adjusted dietary betaine intake. The associations of dietary betaine with dyslipidemia and lipid profiles were estimated using restricted cubic spline regression and logistic regression analysis. Results: Among the 11,452 participants, 2577 (22.5%) individuals were found to have dyslipidemia. The median (IQR) intake of dietary betaine was 56.35 (25.77, 207.66) mg/day. Negative dose-dependent associations were found between residual energy-adjusted dietary betaine intake and dyslipidemia. Compared with participants in the lowest quartile (Q1) of residual energy-adjusted betaine intake, participants in the fourth quartile (Q4) had lower odds of high total cholesterol (TC), high low-density lipoprotein cholesterol (LDL-C), high non-high-density lipoprotein cholesterol (non-HDL-C), high remnant cholesterol (RC), and dyslipidemia, with odds ratios (OR) and 95% confidence intervals (95% CI) of 0.56 (0.45, 0.70), 0.65 (0.48, 0.87), 0.53 (0.41, 0.68), 0.42 (0.28, 0.61), and 0.79 (0.69, 0.91), respectively. Furthermore, reduced odds of high TC, high LDL-C, high non-HDL-C, high RC, and dyslipidemia were observed in dietary betaine from plant-source foods but not in animal-source foods. Conclusions: High intake of dietary betaine (56.35-207.66 mg/day) was associated with reduced odds of dyslipidemia, including elevated TC, LDL-C, non-HDL-C, and RC, and dietary betaine from plant-source foods revealed significant benefits for dyslipidemia in Chinese children and adolescents.

The portfolio dietary pattern and risk of cardiovascular disease mortality during 1988-2019 in US adults: a prospective cohort study

BACKGROUND

The Portfolio Diet, a dietary pattern of cholesterol-lowering foods, has been shown to reduce cardiovascular disease (CVD) risk factors in clinical trials and lower CVD risk in observational cohorts of mainly white men and women. However, evidence on mortality outcomes in diverse populations is limited.

OBJECTIVE

To examine the association of the Portfolio dietary pattern with CVD mortality in a racially diverse cohort.

METHODS

A total of 14,835 US adults from the National Health and Nutrition Examination Survey, NHANES (1988-1994), were included. Diet was assessed by a 24-h dietary recall which was supplemented with a food frequency questionnaire at baseline using the Portfolio Diet Score (PDS), with positive points for nuts, plant protein, viscous fiber, phytosterols, and plant monounsaturated fatty acid sources, and negative points for foods high in saturated fat and cholesterol (range, 6-30 points). The primary outcome was CVD mortality. Other mortality outcomes included coronary heart disease (CHD), stroke, and all-cause mortality.

RESULTS

During 22 years of follow-up, 2300 CVD deaths, including 1887 CHD deaths, 413 stroke deaths, and 6238 all-cause deaths were documented. Greater adherence was inversely associated with risk factors including blood lipids, glycemia, and inflammation. Treated as a continuous variable, an increase in PDS by 8 points was associated with a 12% (hazard ratio 0.88 [95% confidence intervals:0.78, 0.99]), 14% (0.86 [0.78, 0.96]), and 12% (0.88 [0.82, 0.95]) lower risk of CVD, CHD, and all-cause mortality after adjustments for known CVD risk factors. Comparing the highest to lowest tertiles of the PDS, higher PDS was associated with 16% (0.84 [0.73, 0.98]), 18% (0.82 [0.72, 0.95]) and 14% (0.86 [0.78, 0.96]) lower risk of CVD, CHD, and all-cause mortality, respectively. As part of exploratory analyses, an interaction between PDS and race/ethnicity was observed, emphasizing the necessity of future research involving underserved groups.

CONCLUSIONS

Among a national cohort of racially diverse adults in the US, greater adherence to the Portfolio dietary pattern was inversely and prospectively associated with CVD, CHD, and all-cause mortality.

Relationship Between Timing of PCSK9 Inhibitor Monoclonal Antibody Initiation and Clinical Outcomes in Patients with Prior Cardiovascular Events

Purpose

Timing of initiation of proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) monoclonal antibody (mAb) therapy and its impact on cardiovascular outcomes is unknown. The aim was to identify any association between timing of PCSK9i mAb initiation after a major adverse cardiovascular event (MACE) and the rate of subsequent MACE.

Patient and Methods

A retrospective cohort study of adult patients in the United States with a MACE (myocardial infarction, stroke, unstable angina, or coronary revascularization) from January 1, 2017 to February 28, 2022 was conducted using administrative claims databases (index date = first observed MACE during this period). Patients were required to have ≥360 days of data visibility prior to (baseline period) and for ≥30 days after the index date (minimum, variable follow up period), and ≥1 prescription claim for PCSK9i mAb therapy on or after the index date. Subsequent MACE rates, time from index MACE to PCSK9i mAb initiation, and time to subsequent MACE were reported.

Results

A total of 58,997 patients with ≥1 MACE were identified (mean age = 64 years; 58% male; median follow up=1,241 days). Over half of the patients did not initiate a PCSK9i mAb in the first year after the index MACE. Overall, 35% (n = 20,465) had ≥1 subsequent MACE. Compared to the period between index MACE and prior to PCSK9i mAb initiation, rates of subsequent MACE after PCSK9i mAb initiation were reduced in a time-dependent manner by 70% among patients who initiated PCSK9i mAb therapy within 30 days, 78% (31-90 days), 76% (91-180 days), 65% (181-360 days), and 42% (>360 days) after the index MACE. Those who initiated PCSK9i mAb within 30 days of the index MACE had longer median time to the first subsequent MACE (111 days) compared to patients who initiated at later times.

Conclusion

This study provides evidence that earlier initiation of PCSK9i mAb therapy after a MACE appeared to be associated with longer time to a subsequent MACE. Patients without timely treatment are left at an unnecessarily elevated risk of further MACE.

Efficacy and Safety of Inclisiran in Adolescents With Genetically Confirmed Homozygous Familial Hypercholesterolemia: Results From the Double-Blind, Placebo-Controlled Part of the ORION-13 Randomized Trial

BACKGROUND

Homozygous familial hypercholesterolemia (HoFH) is a genetic disease characterized by high levels of low-density lipoprotein cholesterol (LDL-C) present from birth, leading to early-onset and progressive atherosclerotic cardiovascular disease. Early treatment initiation is crucial for cardiovascular risk reduction; however, many patients do not reach LDL-C treatment goals. Inclisiran, a small interfering RNA targeting hepatic PCSK9 (proprotein convertase subtilisin/kexin type 9), is effective and well tolerated in adult patients with hyperlipidemia; however, it has not yet been studied in pediatric patients.

METHODS

Herein we report results of the 1-year, double-blind, placebo-controlled part of the phase 3 study ORION-13 (Study to Evaluate Efficacy and Safety of Inclisiran in Adolescents With Homozygous Familial Hypercholesterolemia) in adolescents with HoFH. This 2-part multicenter study included 13 patients ≥12 to <18 years of age with a genetic diagnosis of HoFH (excluding LDL [low-density lipoprotein] receptor [LDLR] null/null genotypes) and elevated LDL-C levels (>130 mg/dL) on maximally tolerated statin treatment, with or without other lipid-lowering therapies. Eligible patients were randomized 2:1 to receive either 300 mg of inclisiran sodium or placebo, administered on days 1, 90, and 270. The primary end point was the mean percentage change in LDL-C from baseline to day 330.

RESULTS

The mean age of patients was 14.8 years, and mean baseline LDL-C was 272 mg/dL. The placebo-adjusted mean (95% CI) percentage change in LDL-C from baseline to day 330 was -33.3% (-59.2% to -7.3%). Six of 9 (66.7%) inclisiran-treated patients (versus 1 of 4 [25%] on placebo) achieved a >15% reduction in LDL-C, and 5 of 9 (55.6%) inclisiran-treated patients (versus none on placebo) achieved a >20% reduction. The placebo-adjusted mean (95% CI) percentage change in PCSK9 from baseline to day 330 was -60.2% (-79.8% to -40.7%); corresponding changes in apoB (apolipoprotein B), non-high-density lipoprotein cholesterol, and total cholesterol were -23.0%, -32.7%, and -27.8%, respectively. No serious adverse events, treatment discontinuations because of adverse events, or deaths occurred. No new safety findings were reported.

CONCLUSIONS

In a 1-year randomized controlled study (part 1 of ORION-13), inclisiran was effective in lowering LDL-C in adolescents with HoFH and was well tolerated. These results support inclisiran as a potentially useful addition for the treatment of adolescents with HoFH and a minimum of LDLR residual activity.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04659863.

Is Targeting LDL-C Levels Below 70 mg/dL Beneficial for Cardiovascular and Overall Health? A Critical Examination of the Evidence

Over the past two decades, cardiovascular disease (CVD) prevention guidelines have progressively lowered LDL-C targets to <70 mg/dL for high-risk individuals based on the assumption of a linear relationship between LDL-C levels and CVD risk. However, the available evidence challenges this premise. Multiple studies demonstrate a weak or inconsistent association between LDL-C levels and atherosclerosis progression at the individual patient-level. Systematic reviews supporting the linearity assumption have notable limitations, including extrapolation beyond observed LDL-C ranges and potential ecological fallacy, as meta-regression analyses rely on study-level data, while patient-level data within the same trials often show no association between LDL-C reduction and CVD outcomes. Moreover, randomized controlled trials explicitly designed to assess LDL-C targets have yielded inconclusive and biased results. LDL-C itself is a heterogeneous marker, with particle size and composition influencing its atherogenicity. The cardiovascular benefits of lipid-lowering therapies may arise in part from pleiotropic effects unrelated to LDL-C lowering. Additionally, several studies indicate that higher LDL-C levels are paradoxically associated with longevity in elderly populations that is equal to or even greater than that of the general population. Collectively, this body of evidence raises questions about the validity of current LDL-C targets < 70 mg/dL in high-risk patients.

Structural dynamics of LDL receptor interactions with E498A and R499G variants of PCSK9

CONTEXT

The low-density lipoprotein receptor (LDLR) regulates cholesterol uptake by mediating the hepatic clearance of plasma low-density lipoprotein cholesterol (LDL-C). Proprotein convertase subtilisin/kexin type-9 (PCSK9) attenuates LDLR function by binding to the LDLR, leading to its lysosomal degradation and preventing the total depletion of circulating LDL-C. However, pathogenic PCSK9 variants can reduce LDLR availability, significantly increase plasma LDL-C levels. Despite this understanding, the detailed molecular mechanism of LDLR-PCSK9 interaction remains unclear due to the incomplete LDLR structure. This study uses molecular dynamics (MD) simulations to predict LDLR structural dynamics upon binding to PCSK9. Furthermore, PCSK9 variants, E498A and R499G, that were identified in Malaysian FH patients were investigated for their mutational effects. Throughout the simulations, PCSK9 remained stable, while LDLR explored a larger conformational space. The LDLR-PCSK9 wild-type (WT) complex showed minimal changes, while the LDLR-PCSK9(R499G) complex exhibited pronounced conformational rearrangement. The MM/GBSA analysis revealed that the LDLR-PCSK9(E498A) complex had the highest binding affinity (- 63.81 kcal/mol), followed by the WT complex (- 33.07 kcal/mol), and LDLR-PCSK9(R499G) (- 24.21 kcal/mol). These findings offer novel insights into the dynamic interactions between LDLR and PCSK9, highlighting the role of structural flexibility in their relationship. Further MD simulation studies with the complete LDLR structure as well as experimental validation are needed to elucidate the molecular mechanisms underlying LDLR-PCSK9-mediated cholesterol homeostasis.

METHODS

The initial structure of the wild-type (WT) LDLR-PCSK9 complex was obtained from PDB ID 3P5C, and the PCSK9 mutant structures (E498A and R499G) were modeled using the SPDBV program. MD simulations for each complex-LDLR-PCSK9 WT, LDLR-PCSK9(E498A), and LDLR-PCSK9(R499G)-were conducted using the GROMACS package with the CHARMM36m force field. The simulations were performed at 310.15 K with 2-fs timesteps under the isothermal-isobaric (NPT) ensemble, with each run lasting 500 ns. Including triplicates, the total duration of MD simulation time for all complexes amounted to 3.5 μs.

Achievement of low-density lipoprotein cholesterol goals in patients with diabetes-related foot ulceration

Despite their elevated risk for cardiovascular complications, two-thirds of patients with diabetes-related foot ulceration in this contemporary real-world study were not achieving guideline-recommended goals for low-density lipoprotein cholesterol. Implementation research is needed to identify the barriers and facilitators to optimal lipid management in this high priority population.

HDLR-SR-BI Expression and Cholesterol Uptake are Regulated via Indoleamine-2,3-dioxygenase 1 in Macrophages under Inflammation

Macrophages play crucial roles in inflammation, and their dysfunction is a contributing factor to various human diseases. Maintaining the balance of cholesterol and lipid metabolism is central to macrophage function, and any disruption in this balance increases the risk of conditions such as cardiovascular disease, atherosclerosis, and others. HDLR-SR-BI (SR-BI) is pivotal for reverse cholesterol transport and cholesterol homeostasis. Our studies demonstrate that the expression of SR-BI is reduced along with a decrease in cholesterol uptake in macrophages, both of which are regulated by the activation of NF-κB. Furthermore, we have discovered that indoleamine-2,3-dioxygenase 1 (IDO1), which is a critical player in tryptophan (Trp) catabolism, is crucial to the regulation of SR-BI expression. Inflammation leads to elevated levels of IDO1 and the associated Trp catabolite kynurenine (KYN) in macrophages. Interestingly, knockdown or inhibition of IDO1 results in the downregulation of LPS-induced inflammation, decreased KYN levels, and the restoration of SR-BI expression as well as cholesterol uptake in macrophages. Beyond LPS, stimulation with pro-inflammatory cytokine IFNγ exhibits similar trends in inflammatory response, IDO1 regulation, and cholesterol uptake in macrophages. These observations suggest that IDO1 plays a critical role in SR-BI expression and cholesterol uptake in macrophages under inflammation.

Portfolio diet and LDL-C in a young, multiethnic cohort: cross-sectional analyses with cumulative exposure modeling

BACKGROUND

The Portfolio Diet is a plant-based dietary pattern of cholesterol-lowering foods that has demonstrated clinically meaningful reductions in low-density lipoprotein cholesterol (LDL-C) and other cardiovascular risk factors. However, the Portfolio Diet has not been assessed in an ethnoculturally diverse population of young adults.

OBJECTIVE

To examine the association of the Portfolio Diet Score (PDS) with LDL-C and other established cardiovascular risk factors in a young adult population.

METHODS

This cross-sectional analysis included 1,507 men and women (mean age, 23 ± 3 years) of diverse ethnocultural backgrounds from the Toronto Nutrigenomics and Health Study. Diet was assessed by a validated Toronto-modified Harvard 196-item food frequency questionnaire with adherence to the Portfolio Diet measured using the Portfolio Diet Score. Data were analyzed using multiple linear regressions with adjustment for potential confounders. Modeling analyses related LDL-C levels according to absolute adherence to the Portfolio Diet with cumulative LDL-C and onset of rising cardiovascular risk by age.

RESULTS

Participants were Caucasian (49%), East Asian (34%), South Asian (11%), or other (7%) with a mean LDL-C of 2.3 ± 0.7mmol/L. A 1-point higher PDS and higher PDS tertiles were associated with lower LDL-C (ß [95% CI] per 1-point: -0.009mmol/L [-0.016, -0.002], P = 0.013; Ptrend across tertiles =0.040), non-HDL-C (-0.010mmol/L [-0.018, -0.002], P = 0.014; Ptrend=0.028), total cholesterol (-0.011mmol/L [-0.019, -0.003], P = 0.011; Ptrend=0.038), systolic blood pressure (-0.150mmHg [-0.250, -0.050], P = 0.003; Ptrend<0.001) and diastolic blood pressure (-0.133mmHg [-0.219, -0.046], P = 0.003; Ptrend<0.001). Higher PDS tertiles were associated with lower triglycerides (Ptrend=0.039). A 1-point higher PDS was also associated with lower BMI (-0.038 kg/m2 [-0.071, -0.004], P = 0.026), waist circumference (-0.092cm [-0.171, -0.013], P = 0.022), body weight (-0.124 kg [-0.229, -0.019], P = 0.021) and FMI (-0.019 kg/m2 [-0.037, -0.001], P =0.039). There was no association with HDL-C, CRP, or fasting glucose. Modeling analyses suggest that compared to low adherence, 50% and 100% adherence to the Portfolio Diet may delay the onset of rising cardiovascular risk by an estimated 6 and 13 years, respectively.

CONCLUSIONS

Among young adults, the PDS was inversely associated with LDL-C and several other established cardiovascular risk factors. Early adherence to the Portfolio Diet may limit lifetime exposure to LDL-C and could delay the age at which cardiovascular events begin.

Therapeutic potential of fucoidan in atherosclerosis: a review

Atherosclerosis (AS) is a slowly progressive disease that significantly increases the risk of cardiovascular diseases. The development of AS is closely associated with various factors, including disturbances in lipid metabolism, endothelial damage, inflammation, and the formation of unstable plaques. AS is strongly linked to diseases with high incidence and mortality, such as ischemic heart disease and stroke, which pose significant economic burdens. Recent studies have focused on identifying effective treatments for preventing and reversing AS. New evidence indicates that fucoidan, a polysaccharide derived from rockweed, possesses lipid-lowering, antioxidant, anti-inflammatory, endothelial-protective and prebiotic properties that align with the pathophysiology of AS, making it a promising therapeutic candidate. This review systematically presents recent progress in understanding the anti-atherosclerotic effects of fucoidan, particularly its underlying mechanisms. These mechanisms involve the regulation of lipid levels, reduction of vascular inflammation, enhancement of antioxidant defenses, and protection of the vascular endothelium. These insights are essential for improving cardiovascular and cerebrovascular health.

A Real-World Retrospective Analysis of Secondary Prevention Patients Treated with Inclisiran over 27 Months

ASCVD is a global concern as it has become central to significant morbidity and mortality. LDL-C is the most important modifiable risk factor in developing ASCVD. Therefore, lowering LDL-C levels is paramount to tackling ASCVD; the lower the LDL-C, the better. Finding the right combination of medications patients are willing to adhere to is necessary for optimal lipid lowering. Inclisiran is a novel LDL-C lowering LLT that has demonstrated around 50% reduction in LDL-C with a low side effect profile. As long-term data is limited for Inclisiran, this retrospective analysis aims to observe whether Inclisiran's benefits are sustained as monotherapy and in combination with other LLTs. After 27 months, the clinic found sustained drops in LDL-C of 59% with good adherence. Only 4% of patients reported experiencing side effects, with 1 individual needing to discontinue the medication due to these effects. Our data indicates that incorporating Inclisiran into a patient's LDL-C treatment plan can provide long-term LDL-C reduction, thereby helping to decrease cardiovascular events.

Switching Therapy to the Second Brand of Generic Atorvastatin: A 6-Month Retrospective Cohort, Real-World Study

INTRODUCTION

High levels of low-density lipoprotein-cholesterol (LDL) is a major risk factor for cardiovascular diseases. While treatment with atorvastatin is beneficial, the original atorvastatin may be cost prohibitive to some patients. Currently, a second brand of generic atorvastatin is available on the market. This study aimed to evaluate the effectiveness of the second generic brand of atorvastatin.

METHODS

This was a retrospective cohort study conducted at Khon Kaen University Hospital, Thailand. The inclusion criteria were adult patients who received either Xarator® (original atorvastatin; Pfizer Pharmaceuticals, Puerto Rico) or Atorvastatin Sandoz® (Lek Pharmaceuticals, Slovenia) for at least 3 months prior to switching therapy to the second brand: Lipostat® (Siam Pharmaceutical, Thailand). The study period was between 1 April 2022 and 30 June 2023. The primary outcome of this study was a change in LDL 6 months after switching therapy from either the original (Xarator®) or generic atorvastatin (Atorvastatin Sandoz®).

RESULTS

There were 683 patients who switched therapy from the original atorvastatin (Xarator®), and 1044 patients who switched therapy from generic atorvastatin (Atorvastatin Sandoz®), for a total of 1727 patients. Regarding LDL levels, switching therapy from original atorvastatin (Xarator®) resulted in a slightly lower but not significant decrease in LDL at 6 months (- 0.96 mg/dL; 95% CI of - 3.20, 1.28), while switching therapy from generic atorvastatin (Atorvastatin Sandoz®) led to significantly lower LDL at - 3.30 mg/dL (95% CI of - 5.25, - 1.36). The original (Xarator®) and generic atorvastatin (Atorvastatin Sandoz®) group also resulted in a significantly lower estimated glomerular filtration rate at - 0.90 and - 1.21 mL/min/1.73 m2, respectively, from baseline.

CONCLUSIONS

The second generic atorvastatin (Lipostat®) resulted in comparable outcomes on LDL compared with the original (Xarator®), but significantly lower LDL levels than another generic atorvastatin (Atorvastatin Sandoz®) 6 months after switching therapy. However, renal function should be closely monitored.

Comparison of rosuvastatin 10 mg plus ezetimibe versus rosuvastatin 20 mg in atherosclerotic cardiovascular disease and type 2 diabetes

Studies comparing efficacy and safety of moderate-intensity statin plus ezetimibe versus high-intensity statin in patients with atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes (T2DM) are scarce. In this multicenter non-inferiority randomized trial, 223 ASCVD patients with T2DM were randomly assigned to receive either rosuvastatin 20 mg once daily or single-pill combination of rosuvastatin 10 mg plus ezetimibe 10 mg once daily for 24 weeks. Laboratory parameters and clinical events were evaluated at 12 and 24 weeks. Primary efficacy endpoint was the least square mean percent (LSM %) change of low-density lipoprotein cholesterol (LDL-C) level at 24 weeks from baseline. At 24 weeks, the LDL-C LSM % change from baseline was - 13.5 in the high-intensity rosuvastatin group and - 20.5 in the combination group, with the between-group difference remaining within the predefined non-inferiority margin (p = 0.06). Decrease in apolipoprotein B level at 24 weeks from baseline was significantly greater in the combination group than in the high-intensity rosuvastatin group (-15.6% vs. -9.9%, p-value = 0.008). Rates of achieving LDL-C < 55 mg/dL were higher in the combination group than in the high-intensity rosuvastatin group, with a significant difference at 12 weeks (p = 0.01), though the difference at 24 weeks was not statistically significant (p = 0.09). Incidence of total adverse events was lower in the combination groups than in the high-intensity rosuvastatin group (p = 0.048). Single-pill combination of moderate-intensity rosuvastatin plus ezetimibe was non-inferior to high-intensity rosuvastatin in LDL-C lowering efficacy with good safety profile in ASCVD patients with T2DM.

Increasing Statin-Prescribing and Low-Density Lipoprotein Cholesterol Control in Secondary Atherosclerotic Cardiovascular Disease Prevention: A Collaborative Approach

Despite ample evidence supporting their efficacy in atherosclerotic cardiovascular disease (ASCVD) management, statin-prescribing and low-density lipoprotein cholesterol (LDL-C) measurement are underused, especially for vulnerable populations. This study explores the impact of a Best Practices Learning Collaborative to improve the management of patients with ASCVD for secondary prevention. Conducted with the guidance of a subject-matter expert advisory committee, the ASCVD Collaborative convened a geographically diverse group of health care organizations (HCOs) over a 12-month implementation period to set goals, develop and implement interventions, collect and track quality performance measures, and share best practices. Interventions included provider/staff education, clinical decision support tools, care coordination, patient education and awareness, and the treatment of very high-risk patients. HCOs tracked three measures for patients with established ASCVD: any statin prescribed (stratified by sex and race/ethnicity), high-intensity statin prescribed, and LDL-C control (<70 mg/dL). After a 12-month implementation period, HCOs demonstrated improvement in one or more measures. The Collaborative model was shown to be an effective means for achieving improvement in the management of ASCVD, laying the groundwork for future more rigorous studies to identify the most impactful interventions.

Mechanisms and applications of apolipoproteins and apolipoprotein mimetic peptides: Common pathways in cardiovascular disease and cancer

Apolipoproteins are the defining functional component of lipoproteins and play critical roles in lipid transport and metabolism. High-density lipoprotein (HDL) and its primary functional constituent, apolipoprotein A-I, are of particular importance because of anti-inflammatory and antioxidant properties. Apolipoprotein mimetic peptides are short-chain amino acids designed to mimic the functions and alpha-helical structure of endogenous apolipoproteins and have demonstrated efficacy in ameliorating animal models of cardiovascular disease (CVD) and cancer. The mechanisms underlying the mimetics are yet to be fully elucidated, but a comprehensive review of the literature suggests that the peptides attack pathways shared in the pathophysiology of both diseases. This review also discusses the many pre-clinical studies on the mimetic peptides, highlighting possible mechanisms at work in each. Proposed mechanisms of protection against CVD and cancer include binding and removal of pro-inflammatory oxidized lipids, reduction in reactive oxygen species, and modulation of immune cell populations. Additionally, nanoparticles (NP) formulations incorporating apolipoprotein mimetic peptides or recombinant apolipoproteins have exhibited anti-atherogenic and anti-cancer activity. To date, clinical trials to assess the effect of reconstituted HDL NPs on CVD outcomes have not shown significant improvement. The large body of successful animal studies on apolipoproteins and apolipoprotein mimetic peptides presents a disconnect between pre-clinical and clinical efficacy, highlighting the need for a more complete understanding of the underlying pathways and mechanisms.

Safety and Efficacy of Obicetrapib in Patients at High Cardiovascular Risk

BACKGROUND

Obicetrapib is a highly selective cholesteryl ester transfer protein inhibitor that reduces low-density lipoprotein (LDL) cholesterol levels. The efficacy and safety of obicetrapib have not been fully characterized among patients at high risk for cardiovascular events.

METHODS

We conducted a multinational, randomized, placebo-controlled trial involving patients with heterozygous familial hypercholesterolemia or a history of atherosclerotic cardiovascular disease who were receiving maximum tolerated doses of lipid-lowering therapy. Patients with an LDL cholesterol level of 100 mg per deciliter or higher or a non-high-density lipoprotein (HDL) cholesterol level of 130 mg per deciliter or higher, as well as those with an LDL cholesterol level of 55 to 100 mg per deciliter or a non-HDL cholesterol level of 85 to 130 mg per deciliter and at least one additional cardiovascular risk factor, were eligible for inclusion. The patients were randomly assigned in a 2:1 ratio to receive either 10 mg of obicetrapib once daily or matching placebo for 365 days. The primary end point was the percent change in the LDL cholesterol level from baseline to day 84.

RESULTS

A total of 2530 patients underwent randomization; 1686 patients were assigned to receive obicetrapib and 844 to receive placebo. The mean age of the patients was 65 years, 34% were women, and the mean baseline LDL cholesterol level was 98 mg per deciliter. The least-squares mean percent change from baseline to day 84 in the LDL cholesterol level was -29.9% (95% confidence interval [CI], -32.1 to -27.8) in the obicetrapib group, as compared with 2.7% (95% CI, -0.4 to 5.8) in the placebo group, for a between-group difference of -32.6 percentage points (95% CI, -35.8 to -29.5; P<0.001). The incidence of adverse events appeared to be similar in the two groups.

CONCLUSIONS

Among patients with atherosclerotic cardiovascular disease or heterozygous familial hypercholesterolemia who were receiving maximum tolerated doses of lipid-lowering therapy and were at high risk for cardiovascular events, obicetrapib reduced LDL cholesterol levels by 29.9%. (Funded by NewAmsterdam Pharma; BROADWAY ClinicalTrials.gov number, NCT05142722.).

Causal cardiovascular risk factors for dementia: insights from observational and genetic studies

The escalating prevalence of dementia worldwide necessitates preventive strategies to mitigate its extensive health, psychological, and social impacts. As the prevalence of dementia continues to rise, gaining insights into its risk factors and causes becomes paramount, given the absence of a definitive cure. Cardiovascular disease has emerged as a prominent player in the complex landscape of dementia. Preventing dyslipidaemia, unhealthy western-type diets, hypertension, diabetes, being overweight, physical inactivity, smoking, and high alcohol intake have the potential to diminish not only cardiovascular disease but also dementia. The purpose of this review is to present our current understanding of cardiovascular risk factors for Alzheimer's disease and vascular dementia (VaD) by using clinical human data from observational, genetic studies and clinical trials, while elaborating on potential mechanisms. Hypertension and Type 2 diabetes surface as significant causal risk factors for both Alzheimer's disease and VaD, as consistently illustrated in observational and Mendelian randomization studies. Anti-hypertensive drugs and physical activity have been shown to improve cognitive function in clinical trials. Important to note is that robust genome-wide association studies are lacking for VaD, and indeed more and prolonged clinical trials are needed to establish these findings and investigate other risk factors. Trials should strategically target individuals at the highest dementia risk, identified using risk charts incorporating genetic markers, biomarkers, and cardiovascular risk factors. Understanding causal risk factors for dementia will optimize preventive measures, and the implementation of well-known therapeutics can halt or alleviate dementia symptoms if started early. Needless to mention is that future health policies should prioritize primordial prevention from early childhood to prevent risk factors from even occurring in the first place. Together, understanding the role of cardiovascular risk factors in dementia, improving genome-wide association studies for VaD, and advancing clinical trials are crucial steps in addressing this significant public health challenge.

Kratom leaf extracts exert hypolipidaemic effects via the modulation of PCSK9 and LDLR pathways in HepG2 cells

Kratom (Mitragyna speciosa (Korth.) Havil.) has been reported to reduce serum lipids. However, the molecular mechanism underlying hypolipidaemic effect of kratom is still unclear. This study aimed to investigate the effects of kratom leaf extracts on hypolipidaemia via the expression of LDLR and PCSK9 in HepG2 cells. Real-time RT-PCR, Western blotting, and flow cytometry analyses revealed that kratom leaf extracts from red-vein and white-vein strains increased LDLR protein expression but decreased that of PCSK9 via downregulation of SREBP-2 and HNF-1α. Furthermore, a confocal laser scanning microscope revealed that kratom leaf extracts from both strains increased LDL uptake into HepG2 cells. The bioactive compounds, e.g., mitragynine, quercetin, and rutin, in kratom leaf extracts from both strains were characterized by LC-MS/MS analysis. Mitragynine also significantly increased LDLR protein expression but decreased that of PCSK9. Molecular docking studies demonstrated that mitragynine had the strongest binding affinity for EGF-A domain of LDLR (- 7.57 kcal/mol), whereas quercetin had the strongest binding affinity for PCSK9 (- 8.45 kcal/mol). In conclusion, kratom leaf extracts from red-vein and white-vein strains possessed hypolipidaemic effects by decreased PCSK9 expression and increased LDLR expression through the modulation of SREBP2 and HNF-1α. Therefore, kratom could serve as a potential supplement for ameliorating hypercholesterolemia.

Evolving concepts of low-density lipoprotein: From structure to function

BACKGROUND

Low-density lipoprotein (LDL) is a central player in atherogenesis and has long been referred to as 'bad cholesterol.' However, emerging evidence indicates that LDL functions in multifaceted ways beyond cholesterol transport that include roles in inflammation, immunity, and cellular signaling. Understanding LDL's structure, metabolism and function is essential for advancing cardiovascular disease research and therapeutic strategies.

METHODS

This narrative review examines the history, structural properties, metabolism and functions of LDL in cardiovascular health and disease. We analyze key milestones in LDL research, from its early identification to recent advancements in molecular biology and omics-based investigations. Structural and functional insights are explored through imaging, proteomic analyses and lipidomic profiling, providing a deeper understanding of LDL heterogeneity.

RESULTS

Low-density lipoprotein metabolism, from biosynthesis to receptor-mediated clearance, plays a crucial role in lipid homeostasis and atherogenesis. Beyond cholesterol transport, LDL contributes to plaque inflammation, modulates adaptive immunity and regulates cellular signaling pathways. Structural studies reveal its heterogeneous composition, which influences its pathogenic potential. Evolving perspectives on LDL redefine its clinical significance, affecting cardiovascular risk assessment and therapeutic interventions.

CONCLUSIONS

A holistic understanding of LDL biology challenges traditional perspectives and underscores its complexity in cardiovascular health. Future research should focus on further elucidating LDL's structural and functional diversity to refine risk prediction models and therapeutic strategies, ultimately improving cardiovascular outcomes.

[Conservative Management of Chronic Coronary Syndrome]

CCS management, based on the 2024 ESC Guidelines, a cornerstone of contemporary cardiology, aims to prevent cardiovascular events, alleviate symptoms, and enhance quality of life through conservative and invasive strategies. Non-invasive approaches, encompassing patient education, lifestyle interventions, and optimized pharmacological treatments, have demonstrated significant benefits in prognosis and quality of life. The guidelines advocate for a patient-centered approach, tailoring therapies to pathophysiological mechanisms, comorbidities, and individual needs. Pharmacological strategies integrate antithrombotic, lipid-lowering, RAAS-blocking, anti-inflammatory, and antidiabetic agents for event prevention, alongside antianginal medications for symptom relief. Invasive interventions remain essential for high-risk patients with obstructive coronary artery disease (e.g., left main disease, three-vessel disease, or proximal LAD involvement) or refractory angina despite optimal medical therapy. However, the growing efficacy of medical management increasingly challenges the incremental benefits of early revascularization. The guidelines also highlight underdiagnosed conditions such as ANOCA (Angina with Non-Obstructive Coronary Arteries) and INOCA (Ischemia with Non-Obstructive Coronary Arteries). Recognizing diverse endotypes, including microvascular dysfunction and vasospastic angina, enables precise and individualized therapeutic approaches. Conservative therapy remains the foundation of CCS management, demanding a holistic, multidisciplinary, and patient-centered approach to optimize outcomes and improve quality of life.

Association between statin adherence and arterial stiffness in young adult patients with familial hypercholesterolemia: A cross-sectional study

BACKGROUND

Familial hypercholesterolemia (FH) causes elevated low-density lipoprotein cholesterol (LDL-C) levels, leading to an increased risk for premature atherosclerotic cardiovascular disease (ASCVD). To prevent ASCVD, lipid-lowering therapy (LLT), such as statins, is needed from childhood on, to lower LDL-C levels. Arterial stiffness can serve as a surrogate marker for atherosclerosis. The aim of this study is to determine the association between statin adherence and arterial stiffness in young adults with FH.

METHODS

The cohort for this cross-sectional study originally consisted of 214 children with heterozygous FH who participated in a placebo-controlled trial on the efficacy and safety of pravastatin, and all continued on LLT. After 20 years, these patients were invited for a follow-up visit, including a questionnaire where they reported the percentage of prescribed LLT they had taken over the past month, as well as a 4D flow MRI examination to assess carotid pulse wave velocity (PWV), in m/s.

RESULTS

We included 134 patients with FH (mean (SD) age: 31.7 (3.2) years; 67 (50.0 %) males). A higher adherence (%) to statin therapy was significantly associated with lower PWV (beta [β] -0.003 (95 % confidence interval [CI] -0.007 to -0.000); P = 0.039). After adjustment for potential confounders, this association remained similar (β -0.003 (95 % CI -0.007 to -0.000), P = 0.031).

CONCLUSIONS

The results of our study suggest that higher adherence to statin therapy is associated with less arterial stiffness, thereby reducing the risk for ASCVD compared to lower levels of adherence. These findings highlight the importance of adherence to LLT in patients with FH.

Pecan Intake Improves Lipoprotein Particle Concentrations Compared with Usual Intake in Adults at Increased Risk of Cardiometabolic Diseases: A Randomized Controlled Trial

BACKGROUND

Pecan consumption consistently improves lipoproteins, but less research has investigated the effect of pecans on lipoprotein subfractions.

OBJECTIVES

The aim was to investigate the effect of substitution of usual snack foods with 57 g/d of pecans on lipoprotein particle subfractions and apolipoproteins compared with continuing usual intake after 12 wk. Exploratory analyses evaluated effects on early markers of insulin resistance including the Lipoprotein Insulin Resistance Index (LP-IR), Diabetes Risk Index, and GlycA.

METHODS

A 12-wk, randomized, 2-armed parallel trial in adults at risk of cardiometabolic disease was conducted. Participants were instructed to either consume 57 g/d of pecans in place of usual snacks or to continue their usual intake. Plasma samples collected at baseline and 12 wk were analyzed for lipoproteins, apolipoproteins, and GlycA by proton nuclear magnetic resonance spectroscopy. Between-group differences in the change from baseline were evaluated with linear regression.

RESULTS

In total, 138 participants were randomly assigned (n = 69 per group) and 130 participants (pecan group n = 62; usual diet group n = 68) completed the trial. The pecan group had a greater reduction from baseline in the concentrations of apolipoprotein B (apoB) [-4.38 mg/dL; 95% confidence interval (CI): -8.02, -0.73], total low-density lipoprotein particles (-75.3 nmol/L; 95% CI: -144, -6.93), total triglyceride-rich lipoprotein particles (TRL-P) (-20.4 nmol/L; 95% CI: -33.8, -7.03), large (-1.47 nmol/L; 95% CI: -2.69, -0.26) and small (-11.3 nmol/L; 95% CI: -22.4, -0.27) TRL-P and the LP-IR (-4.42 points; 95% CI: -8.14, -0.69), and greater increases from baseline in the concentration of large high-density lipoprotein particles (0.35 μmol/L; 95% CI: 0.07, 0.63) compared with the usual diet group.

CONCLUSIONS

Incorporating 57 g/d of pecans into the diet in place of usual snacks for 12 wk improved apoB, atherogenic lipoprotein subfractions, and the LP-IR in adults at risk of cardiometabolic diseases. This trial was registered at clinicaltrials.gov as NCT05071807.

Persistent gaps in the implementation of lipid-lowering therapy in patients with established atherosclerotic cardiovascular disease: A French nationwide study

BACKGROUND

According to international guidelines, lowering LDL-cholesterol is the cornerstone of atherosclerotic cardiovascular disease (ASCVD) prevention. However, observational studies have identified current gaps in the implementation of lipid-lowering therapy (LLT). This whole-population study aimed to evaluate the prevalence and determinants of LLT use in ASCVD patients.

METHODS

Using the national health data system, all French adults with established ASCVD between 2012 and 2021 were identified using specific ICD-10 and/or procedure codes. LLT use was defined as ≥1 dispensing in the last quarter of 2021. Logistic regression was used to identify factors associated with the absence of LLT use.

FINDINGS

In 2021, 2,206,305 individuals (4.89 % among 45,082,270 adults) had established ASCVD (mean age: 72.2 years; 36.9 % women), including 56.1 % with coronary artery disease, 40.4 % with cerebrovascular disease, and 14.5 % with revascularized peripheral artery disease (PAD). Among the 2,056,354 patients alive on 31st December 2021, 32.5 % did not receive any LLT, while 64.8 % received a statin (27.0 % a high-intensity statin), 13.0 % a combination of statin and ezetimibe, and 0.25 % a PCSK9 inhibitor. The absence of LLT use was significantly associated with female sex (adjusted odds ratio [aOR]:1.42, 95 %CI, 1.41-1.43); lowest/highest ages: < 50 years (aOR (/65-74 years): 2.23, 95 %CI 2.20-2.27) and ≥ 85 years (aOR: 2.10, 95 %CI 2.08-2.13); and stroke and PAD, compared to myocardial infarction (aOR: 2.21, 95 %CI 2.19-2.23 and 1.88, 95 %CI 1.86-1.91, respectively).

INTERPRETATION

In real life, one-third of French ASCVD patients was not regularly treated with LLT, highlighting the urgent need to develop implementation strategies for lipid management.

How nutrigenomics impacts equine health - A case study of vitamin E

Nutrigenomics defines the interaction between the nutrients in our food and the genes in our body. Examples from human medicine of diseases and associated genes include lactose intolerance (genetic variants in LCT lactase), hypercholesteremia (low density lipoprotein receptor, LDLR) and caffeine sensitivity (adenosine A2A receptor, ADORA2A). In horses, examples include Hyperkalemic Periodic Paralysis (HYPP), where clinical signs of disease are managed through maintaining a diet low in potassium and Polysaccharide Storage Myopathy Type 1 (PSSM1), where low starch and high fat diets are recommended to prevent episodes of rhabdomyolysis. Personalized nutrition tailors nutrition advice for an individual based on their genetic makeup. In humans and in horses, there is a wide range of individual response to vitamin E supplementation. Some horses obtain very high serum vitamin E concentrations with minimal intake, whereas others require high doses of supplementation to remain in the normal range. In humans, the efficiency of vitamin E absorption is widely variable and is affected by dietary factors, such as food matrix, and genetic polymorphisms in genes related to vitamin E intake, distribution and metabolism. In horses, the efficiency of vitamin E absorption is also related to diet; however, genetic variation has not been yet evaluated. With over 200 genetic variants identified in and surrounding vitamin E candidate genes in horses, future genetic profiling of vitamin E response in horses should be performed.

Oral PCSK9 Inhibitors: Will They Work?

PURPOSE OF REVIEW

Lowering low-density lipoprotein cholesterol (LDL-C) is a crucial step in reducing the risk of atherosclerotic cardiovascular disease. Inhibitors of proprotein convertase subtilisin/kexin type 9 (PCSK9), an important regulator of circulating LDL-C levels, represent a modern approach for the treatment of hypercholesterolaemia. Approved approaches targeting PCSK9 to date include injectable biologics. Here, we provide an overview of the current state of research on the development of oral PCSK9 inhibitors.

RECENT FINDINGS

Several small molecules have been developed in recent years. Enlicitide decanoate (formerly known as MK-0616) has been shown to significantly reduce LDL-C levels by a maximum of 66% from baseline with a good safety and tolerability profile. Its formulation with sodium caprate enabled a higher bioavailability. Several clinical trials are currently underway to evaluate the efficacy and safety of this drug, including an outcome trial. AZD0780 is another oral small molecule that lowers LDL-C levels by 52% and can be administered on top of a statin. Several other small molecules with the potential to inhibit PCSK9 have been identified, some of which have stopped the development. Oral PCSK9 inhibitors are showing promising results in early studies. If the results of the outcome studies will be positive, we will have a safe, effective and easy-to-use oral therapy. Oral PCSK9 inhibitors could provide a convenient alternative to injectable PCSK9 inhibitors and result in a greater number of patients receiving an effective LDL-C-lowering therapy.

PCSK9 Inhibitors "Fast Track" Use Versus "Stepwise" Lipid-Lowering Therapy in Patients with Acute Coronary Syndrome: A Retrospective Single-Center Study in a "Real-World" Population

Background: The "fast track" addition (within 48 h) of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) to the optimized oral lipid-lowering therapy (LLT) during hospitalization for acute coronary syndrome (ACS) has been shown to rapidly achieve the low-density lipoprotein cholesterol (LDL-C) therapeutic targets. However, so far, its efficacy in real-world settings remains understudied. Methods: We retrospectively analyzed 128 ACS patients treated at our center, comparing "PCSK9i fast track" use within 48 h to standard "stepwise" LLT. Lipid levels and incidence of major adverse cardiovascular events (MACEs) were evaluated at 30 and 180 days. Results: The "PCSK9i fast track" group achieved significantly lower LDL-C levels at 30 days (41.5 ± 27.5 vs. 85.6 ± 35.9 mg/dL, p < 0.001) and 180 days (29.6 ± 21.0 vs. 59.0 ± 32.4 mg/dL, p < 0.001). Recommended LDL-C targets (<55 mg/dL) were met by 88.3% of the "PCSK9i fast track" group at 180 days, compared with 61.9% of controls (p < 0.001). No significant differences in MACEs were observed between groups. No adverse effects from PCSK9i use were noted. Conclusions: The "PCSK9i fast track" strategy was safe and effective in achieving LDL-C targets more rapidly than conventional approaches in real-world ACS patients.

Hypocaloric low-carbohydrate versus low-fat diets on flow-mediated dilation, blood pressure, cardiovascular biomarkers, and body composition in individuals with overweight or obesity: a systematic review and meta-analysis of randomized clinical trials

Obesity can impair cardiometabolism, but low-carbohydrate diets (LCDs) may be beneficial for mitigating risk. We aimed to investigate the effects of LCDs versus low-fat diets (LFDs), under hypocaloric conditions, on flow-mediated dilation (FMD) in individuals with overweight/obesity. Secondarily, we assessed other cardiovascular markers (systolic blood pressure, diastolic blood pressure, C-reactive protein [CRP], high-density lipoprotein [HDL], low-density lipoprotein [LDL], triglycerides [TG], total cholesterol [TC]), and anthropometric and body composition measurements. PubMed, Scopus, and Web of Science were searched through May 2023 for studies involving hypocaloric LCDs versus LFDs on FMD. Meta-analyses were conducted for LCDs vs. LFDs to calculate weighted mean differences (WMD), including 10 studies reporting FMD (n = 475). Overall, hypocaloric LCDs resulted in a non-significant decrease in FMD compared with hypocaloric LFDs [WMD = -1.04% (95% CI -2.28 to 0.20), p = 0.10], while very-low-carbohydrate diets (VLCDs) significantly reduced FMD when compared with LFDs [WMD = -2.12% (95% CI: -3.35 to -0.9) p = 0.001]. LCDs did not change anthropometric and body composition measurements, nor CRP, blood pressure, HDL, or TC when compared with LFDs. However, LCDs significantly decreased TG [WMD = -19.94 mg/dL (95% CI -31.83 to -8.06), p = 0.001] and increased LDL [WMD = 20.00 mg/dL (95% CI 14.09 to 25.90), p = 0.001] when compared with LFDs. In conclusion, LCDs did not exert superior effects on cardiovascular markers or body composition when compared with LFDs in individuals with overweight or obesity, but LCDs reduced TG and increased LDL levels more than LFDs. Yet, vascular function (FMD) was reduced primarily for VLCDs.