2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk

Causal relationship between apolipoprotein B and risk of atherosclerotic cardiovascular disease: a mendelian randomization analysis

Background

Atherosclerotic cardiovascular disease (ASCVD) is a major threat to human life and health, and dyslipidemia with elevated low-density lipoprotein cholesterol (LDL-C) is an important risk factor, and in the optimal LDL-C scenario, apolipoprotein B (ApoB) has a more predictive value of ASCVD risk.

Methods

The study is a genome-wide association study (GWAS) based on a European population. A large GWAS dataset for atherosclerotic cardiovascular diseases was targeted, including coronary heart disease (CHD), ischemic stroke (IS), large-artery atherosclerotic stroke (ISL), small-vessel stroke (ISS), and myocardial infarction (MI). Univariate two-sample mendelian randomization (MR) analyses of ApoB and the above cardiovascular diseases were performed separately, and the association was assessed mainly using the inverse variance weighted (IVW) method, with confidence intervals for the superiority ratios set at 95%. In addition, the experiment was supplemented using MR-Egger, weighted model and weighted median (WM).

Results

Based on the results of univariate two-sample mendelian randomisation analysis, it was shown that there was a causal relationship between ApoB and CHD (OR = 1.710, 95% CI 1.529-1.912, P = 0.010), ISL (OR = 1.430, 95% CI 1.231-1.661, P = 2.714E-06), ISS (OR = 1.221, 95% CI 1.062-1.405, P = 0.005) were causally related to each other and the disease prevalence ratio was positively correlated with ApoB concentration.

Conclusion

This MR analysis demonstrated a causal relationship between ApoB and CHD, ISL, ISS, but not with the risk of developing IS and MI, which further validated the relationship between ApoB and the risk of ASCVD, and contributed to a better understanding of the genetic impact of ApoB on ASCVD, and to a certain extent, could improve the management of ApoB and reduce the prevalence of ASCVD.

Sudoscan® reclassifies cardiovascular risk in patients with type 2 diabetes mellitus according to the ESC 2023

Objectives

The objective of this study is to determine if the detection of DAN through Sudoscan® can reclassify cardiovascular risk in patients with T2DM according to the European Society of Cardiology guidelines 2023 (ESC 2023) compared to other risk scales.

Methods

A retrospective cross-sectional analytical study was conducted on 161 patients with T2DM who had undergone Sudoscan® in a Northern Mexico Hospital between December 2022 and July 2023. We compared the cardiovascular risk with SCORE-2, SMART, ADVANCE, ASCVD plus, and Globo Risk scales.

Results

Estimated cardiovascular risk according to the ESC 2023 without consideration of DAN was low for 91 (57%), moderate for 53 (33%), high for 11 (7%) and very high for 22 (3%) of patients. While inclusion of DAN resulted in low risk in 81 (51%), moderate in 46 (28%9, high in 9(5%) and very high risk for 25 ((16%), p = 0.004). The majority of patients were classified as low or moderate risk using other scales such as ASCVD plus, SCORE-2, Globo Risk, ADVANCE, and SMART.

Conclusions

Sudoscan® enhances cardiovascular risk assessment in T2DM by accurately diagnosing microvascular complications, ensuring comprehensive patient evaluation.

Abnormal blood pressure response to exercise and ventricular arrhythmias: a suspicious association in athletes

INTRODUCTION

Abnormal blood pressure response to exercise (ABPR) in athletes is considered a risk for incident hypertension, conferring a higher cardiovascular risk profile. We sought to describe the clinical cardiovascular features of athletes with ABPR and, moreover, the relationship of ABPR with occurrence of exercise-induced ventricular ectopic beats (VEBs).

METHODS AND RESULTS

We enrolled 1460 elite athletes (56.1% male; mean age 25.8 ± 5.1 years old), engaged in skills, power, mixed and endurance sport, who underwent clinical examination, transthoracic echocardiogram (TTE) and exercise stress testing. ABPR was defined as >220/85 mmHg in males and >200/80 mmHg in females. ABPR was found in 8% ( n  = 117) of athletes, being older ( P  = 0.049) and presenting higher cardiovascular risk profile (obesity, P  = 0.007; glucose intolerance, P  = 0.043 and familiarity for cardiovascular disease, P  = 0.026). Athletes with ABPR had higher prevalence of exercise-induced VEBs (19.6% vs. 11.9% in normotensive athletes, P  = 0.015). Uncommon VEBs morphology was more frequent in athletes with ABPR (64.7% vs. 19% in the normotensive, P  = 0.0002). Finally, in those with ABPR and VEBs, TTE revealed greater left ventricular end-diastolic diameter indexed ( P  = 0-006), LVEDVi ( P  = 0.017) and LVMi ( P  = 0.04) compared to those without VEBs.

CONCLUSION

A not small group of elite athletes (8%) presented an exaggerated blood pressure response to exercise and exhibited higher cardiovascular risk profile compared to their normotensive counterparts. Moreover, athletes with ABPR showed higher prevalence of ventricular arrhythmias on effort and the combination of ABPR and ventricular arrhythmias was associated with more pronounced cardiac remodelling.

Increasing provider awareness of Lp(a) testing for patients at risk for cardiovascular disease: A comparative study

Background

Lipoprotein(a) [Lp(a)] is a low-density lipoprotein variant with atherogenic, thrombogenic, and pro-inflammatory properties that may have numerous pathologic effects, including dyslipidemia. Screening for Lp(a) is clinically significant, due to its causal role in atherosclerotic cardiovascular disease (ASCVD). Among clinicians, however, there remains a general lack of both clinical awareness of Lp(a) and adequate tools to track Lp(a) testing in patients.

Objective

To study factors affecting Lp(a) screening by: i) determining the effectiveness of messaging providers at a large community health system about Lp(a) screening and measuring the subsequent percentage of Lp(a) tests requested; and ii) by determining the percentage of patients who obtained Lp(a) testing after being advised by the provider.

Methods

From December 2022 through March 2023, messages detailing the need for Lp(a) screening were sent via the Epic EHR™ to providers of patients meeting criteria for Lp(a) testing in advance of scheduled patient appointments. In this prospective study, providers were randomized into 2 groups: those receiving the pre-appointment message (Group 1) and those not receiving the pre-appointment message (Group 2).

Results

Sending pre-appointment messages correlated with more Lp(a) orders (16.6 % v. 4.7 %, P < 0.001) and consequently with more tests performed (10.2 % v. 3.7 %, p < 0.001). Among provider types, nurse practitioners and physician assistants had the highest number of Lp(a) results per order (Z = 16.40, P < 0.001), achieving 30.8-39.1 % more test results, even if they did not receive the pre-appointment message. Distribution of Lp(a) values in patients was 59.7 % ≤ 29 mg/dL; 9.7 % > 29 and < 50mg/dL; and 30.6 % ≥ 50 mg/dL.

Conclusion

Providers who received pre-appointment messages via an EHR were associated with requesting more tests and consequently receiving more Lp(a) results, compared with providers who did not receive messages.

Goal attainment, medication adherence and guideline adherence in the treatment of hypertension and dyslipidemia in Irish populations: A systematic review and meta-analysis

Background

The appropriate treatment high blood pressure (BP) and low-density lipoprotein cholesterol.(LDL-C), according to clinical guidelines, reduces a patient's risk of a cardiovascular event.

Aim

This systematic review aims to evaluate the attainment of BP and LDL-C goals among the Irish population in both primary and secondary prevention of cardiovascular diseases, the level of adherence to prescribing guidelines by doctors and the level of medication adherence among patients.

Methods

Five databases were searched in March 2024. Quantitative articles reporting levels of goals attainment, medication adherence or guideline adherence for LDL-C and BP among Irish adults aged ≥18 years were included. The proportion of patients attaining their LDL-Cor BP goals were statistically combined using the random effect model.

Results

Following screening, 23 eligible articles were identified. The achievement of LDL-C <1.8 mmol/L was 41 % (95 % CI 31,52), compared to 69 % of people (95 % CI 62,76) reported to have achieved the less stringent goal of LDL-C < 3 mmol/L. The achievement of BP < 140/90 mmHg was 56 % (95 % CI 46,65). Medication adherence levels ranged between 27 % and 92 %. Guideline adherence findings demonstrated that not all patients who should be on lipid-lowering therapy are and that choice of antihypertensive is not always in line with the guidelines.

Conclusion

Approximately one-third of deaths in Ireland annually are caused by cardiovascular disease, despite being preventable. There is room for improvement in goal attainments in people at risk of CVDs and optimization of medication adherence and guideline adherence may be beneficial in this population.

Emerging oral therapeutic strategies for inhibiting PCSK9

Pharmacological inhibition of Proprotein Convertase Subtilisin/Kexin 9 (PCSK9) have been firmly established to be an effective approach to reduce low-density lipoprotein (LDL) cholesterol levels and cardiovascular events. Subcutaneous administration of monoclonal antibodies (evolocumab and alirocumab) every 2 or 4 weeks determined a 60 % reduction of LDL cholesterol levels, while the GalNac-siRNA anti PCSK9 (inclisiran) provided an effective lipid lowering activity (-50 %) after an initial subcutaneous dose, repeated after 3 months and followed by a maintenance dose every 6 months. Although these two approaches have the potentiality to bring the majority of patients at high and very-high cardiovascular risk to the appropriate LDL cholesterol targets, their cost and subcutaneous administration represent a strong limitation for their large-scale use. These problems could be overcome by the development of small chemical molecules anti PCSK9 as oral therapy for controlling hypercholesterolemia. In the present review, we summarized the pharmacological properties of oral anti PCSK9 molecules that are currently under clinical development (DC371739, CVI-LM001, and AZD0780), including the mimetic peptides enlicitide decanoate (MK-0616) and NNC0385-0434.

Effectiveness of acupuncture on glycolipid metabolism in patients with coronary heart disease: A systematic review and meta-analysis

OBJECTIVE

Disorders of glycolipid metabolism are important pathogenic factors leading to coronary artery disease, and there is no safe and effective comprehensive treatment, while acupuncture has a certain efficacy in heart disease and disorders of glycolipid metabolism. To assess the effects of acupuncture on glycolipid metabolism in patients with coronary heart disease, we conducted a systematic review and meta-analysis.

METHODS

From the time of library construction to August 18, 2023, Searches were conducted in eight databases, with no language restriction. Only RCTs that included acupuncture as a sole or secondary effect on glucose-lipid metabolism in coronary heart disease were included.Our primary outcome indicators were Low-density lipoprotein cholesterol(LDL-C), Hemoglobin A1c(HbA1c). Our analyses were conducted in strict accordance with the PRISMA statement, and the researchers used the Cochrane Handbook for literature screening and data extraction, the "Risk of Bias" tool (ROB.2) for assessing risk of bias, and RevMan (version 5.3) for meta-analysis of outcome metrics, and the GRADE criteria for assessing quality of evidence. Assessing the quality of acupuncture literature using the Standards for reporting interventions in clinical trials of acupuncture.

RESULTS

Our analysis included 18 eligible RCTs (N = 1346 participants). For the primary outcome metrics, acupuncture combined with standard treatment was effective in reducing LDL-C (SMD =-0.56; 95 % CI, -0.75 to -0.38; P < 0.00001), and HbA1c (MD = -1.15; 95 % CI, -1.73 to -0.58; P < 0.0001). For secondary outcome measures, combination therapy improved TC (SMD = -0.97; 95 % CI, -1.44 to -0.51; P < 0.0001), TG (MD = -0.39; 95 % CI, -0.58 to -0.20; P < 0.0001), hs-CRP (MD = -0.98; 95 % CI, -1.43 to -0.52; P <0.0001), 2hPG (MD = -1.45; 95 % CI, -1.74 to -1.16; P < 0.00001), and ORR (RR, 1.27; 95 % CI, 1.19-1.36; P < 0.00001) levels more than standard therapy alone.However, the combination therapy did not prevail in lowering HDL-C (MD = 0.11; 95 % CI, 0.07-0.14; P < 0.00001) compared with standard therapy alone. Meanwhile heterogeneity analysis showed that After coronary heart disease intervention, acupuncture was able to reduce TC (SMD = -0.85; 95 % CI, -1.37 to -0.33; P = 0.001), TG (MD = -0.14; 95 % CI, -0.24 to -0.04; P = 0.004) levels, but did not dominate in lowering LDL-C.

CONCLUSIONS

Acupuncture effectively regulates glycolipid metabolism in coronary artery disease, serving as an adjuvant treatment. It may aid post-PCI healing via lipid metabolism regulation, but rigorous, large-scale, long-term RCTs are needed for validation.

Anti-atherosclerotic effects of natural compounds targeting lipid metabolism and inflammation: Focus on PPARs, LXRs, and PCSK9

A large body of evidence has shown that modulation of the nuclear receptors peroxisome proliferator-activated receptors (PPARs), the liver X receptors (LXRs), the proprotein convertase subtilisin/kexin type 9 (PCSK9) and inflammatory processes by natural compounds has hypolipidemic and anti-atherosclerotic effects. These beneficial outcomes are certainly related to the crucial function of these targets in maintaining cholesterol homeostasis and regulating systemic inflammation. Currently, the therapeutic scenario for cardiovascular diseases (CVD) offers a plethora of widely validated and functional pharmacological treatments to improve the health status of patients. However, patients are increasingly sceptical of pharmacological treatments which are often associated with moderate to severe side effects. The aim of our review is to provide a collection of the most recent scientific evidence on the most common phytochemicals, used for centuries in the Mediterranean diet and traditional chinese medicine that act on these key regulators of cholesterol homeostasis and systemic inflammation, which could constitute important tools for CVD management.

Progress of Angiographic Cardiac Allograft Vasculopathy in Patients With Long-Term Transplantation: Longitudinal Evaluation of Its Association With Dyslipidemia Patterns

Cardiac allograft vasculopathy (CAV) is a progressive disease with limited options for secondary prevention. Ways to manage lipid parameters and dyslipidemia patterns in care after transplantation remain unclear. In this longitudinal study, we included 32 patients with long-term heart transplantations (median interval after transplant 13.8 years) with angiographic manifest CAV. In 299 matched nonstented segments at 3 distinct time points ([TPs] 0 to 2, with median intervals of 2 years, respectively), progress of diameter stenosis (Δ%DS) defined CAV progress. Values above the median of maximal Δ%DS defined substantial CAV progress. Category of left ventricular ejection fraction was evaluated at TP0 and TP3 (2 years after TP2). Findings were correlated with dyslipidemia patterns at TP0, and lipid variations at follow-up (TP1 to TP3). Analyses included routine lipid assessment, and triglycerides/high-density lipoprotein-cholesterol ratio (TG/HDL-c) and atherogenic index of plasma (AIP). At TP1 and TP2, patients with increase of TG/HDL-c ≥0.1 (p = 0.02, respectively) and with increase of AIP (p = 0.01 and p = 0.049, respectively) presented a greater maximal Δ%DS. Dyslipidemia patterns at TP0 did not show a relevant association with CAV progress. At TP2, increase of TGs, TG/HDL-c, and AIP were associated with substantial CAV progress (odds ratio [OR] 5.0, p = 0.046, and OR 9.2, p = 0.01, OR 6.6, p = 0.02, respectively). At TP3, patients with CAV-related worsening of left ventricular ejection fraction category presented with a greater increase of TG/HDL-c (p = 0.03). Although findings at TP0 did not affect CAV progress, an increase of TG/HDL-c could define patients at greater risk of CAV progress and CAV-related deterioration of graft function.

Inadequate Intensification of LDL-cholesterol lowering therapy after coronary revascularization: Insights from the GOULD registry

BACKGROUND

Patients with a history of coronary revascularization are at a higher risk for subsequent cardiovascular events and all-cause mortality. Lowering LDL-cholesterol (LDL-C) levels post-revascularization significantly reduces these risks.

METHODS

This analysis compared LDL-C-lowering therapies at baseline and over time among patients with and without prior coronary revascularization in the GOULD registry (a prospective multicenter cohort study). Baseline- and 24-month follow-up characteristics-including LDL-C levels and strategies for lipid-lowering therapy (LLT)-were evaluated.

RESULTS

Out of 5006 patients, 2195 (43.8%) had prior coronary revascularization. At baseline, these patients had lower LDL-C (99.2 mg/dL vs. 102.5 mg/dL; p < 0.001) and were more likely to be on intensive LLT (52.8% vs. 42.7%; p < 0.001). At 24 months, they had small reductions in LDL-C (-15.6% vs. -13.7%; p = 0.145) and were more likely to be on intensive LLT (61.9% vs. 51.5%; p < 0.001). Similar LDL-C reductions were observed in the PCSK9i group regardless of revascularization status.

CONCLUSIONS

Despite slightly better baseline LLT among patients with prior revascularization, few patients met the <70 mg/dL goal and LLT was rarely escalated during 24 months of follow-up. Improved systems-based strategies and personalized treatment approaches are urgently needed to enhance LDL-C lowering and reduce cardiovascular events, especially in patients with a history of coronary revascularization.

The gut microbiota and its role in the development of cardiovascular disease

INTRODUCTION

The pathophysiology of cardiovascular diseases encompasses a complex interplay of genetic and environmental risk factors. Even if traditional risk factors are treated to target, there remains a residual risk.

AREAS COVERED

This manuscript reviews the potential role of gut microbiota in the development of cardiovascular disease, and as potential target. A systematic search was conducted until 30 October 2024 on PubMed (MEDLINE), using the MeSH terms [Gut microbiota] + [Dysbiosis] + [Cardiovascular] + [TMAO] + [bile acids] + [short-chain fatty acids].

EXPERT OPINION

The term dysbiosis implies changes in equilibrium, with modifications in the composition and functionality of microbiota and a series of additional factors: reduced diversity and uniformity of microorganisms; reduced short-chain fatty acid-producing bacteria; increased gut permeability; release of metabolites, such as trimethylamine N-oxide, betaine, phenylalanine, tryptophan-kynurenine, phenylacetylglutamine, and lipopolysaccharides; and reduced secondary bile acid excretion, leading to inflammation, oxidative stress, and endothelial dysfunction and facilitating the onset of pathological conditions, including obesity, hypertension, diabetes, atherosclerosis, and heart failure. Attempts to restore gut microbiota balance through different interventions, mainly changes in diet, have been shown to positively affect individual components and metabolites and reduce the risk of cardiovascular disease. In addition, probiotics and prebiotics are potentially useful. Fecal microbiota transplantation is a promising therapy.

Novel pharmacological approaches to lowering blood pressure and managing hypertension

Hypertension is the leading cause of death globally, primarily due to its strong association with cardiovascular disease. The global prevalence of hypertension has surged over the past three decades, driven by rising rates of diabetes mellitus and obesity. Despite current antihypertensive therapies, only a small proportion of patients with hypertension achieve adequate blood pressure control, necessitating novel therapeutic strategies. In this Review we explore the challenges and emerging opportunities in hypertension management. Aprocitentan, a dual endothelin receptor antagonist, is the first agent from a novel class of antihypertensive drug to be licensed since 2007 and exemplifies innovative treatments on the horizon. Here we also address the complex factors contributing to poor hypertension control, including genetic influences, lifestyle factors, therapeutic inertia and poor patient adherence. We discuss the limitations of existing therapies and highlight promising new pharmacological approaches to hypertension management. Integrating these novel treatments alongside current pharmaceuticals combined with improved diagnostic and management strategies could substantially reduce the global burden of hypertension and associated cardiovascular disease.

[Lp(a): What we know, what we don't know and what we hope for]

There is no doubt that lipoprotein(a) [Lp(a)] is a structurally complex molecule with unique biological functions. It plays an important role in the inflammatory process through multiple mechanisms, contributes to endothelial dysfunction, activation of monocytes, macrophages and proliferation of smooth muscle cells, and promotes the development of atherosclerotic cardiovascular disease (ASCVD). It is important to point out the complex bidirectional relationship between Lp(a) and inflammation, influencing one another and even exerting anti-inflammatory effects in certain situations. Likewise, Lp(a) can favor the development of heart valve disease, especially of the aortic valve. Numerous publications emphasize the need to determine Lp(a) levels in the population at least once in life and possible strategies to mitigate the risk of ASCVD generated by high Lp(a) levels. However, doubts or lack of knowledge persist about the need to measure this parameter, either due to the uncertainty of how to manage patients with high levels of Lp(a), due to insufficient knowledge about its physiological function or because its levels persist unchanged, to a large extent, throughout life as the genetic character of this molecule takes precedence. On the other hand, there are still no specific approved therapies that reduce its levels and arouse sufficient interest for its management. However, many societies, such as the European Society of Cardiology (SEC) or the Spanish Society of Atherosclerosis (SEA), raise the need to determine Lp(a) and intensive management of cardiovascular risk factors in patients with high Lp(a) levels along with therapies that mitigate the associated ASCVD risk. Likewise, the identification of high levels of Lp(a) offers the opportunity to screen family members, better control of cardiovascular risk and the possibility of developing clinical trials that profile individual and population risk that allow for more personalized actions.

Development of an atherosclerosis rabbit model to evaluate the hemodynamic impact of extracorporeal circulation

BACKGROUND

Aortic atherosclerosis increases the risk of embolic events under extracorporeal circulation (ECC). To evaluate the hemodynamic impact of ECC on atheromatous plaques, an atherosclerosis animal model, which is also eligible for ECC, is required.

METHODS

Twenty-nine New Zealand White rabbits received a pro-atherosclerotic diet (group diet, n = 10), a pro-atherosclerotic diet and additional intraaortic balloon insufflation injury (group BI, n = 9), or served as controls (n = 10). After 3 or 6 months, aortic explants were analyzed by (immuno-)histology and RT-PCR.

RESULTS

Blood serum analyses revealed increased cholesterol-levels in groups diet and BI compared to controls (3 months: p = 0.03 each, 6 months: p < 0.0001 each). Aortic inflammatory infiltration was significantly enhanced in groups diet (CD3 at 3 months: p < 0.0001, 6 months: p = 0.02; CD68 at 3 months: p = 0.01) and BI (CD3 at 3 months: p < 0.0001, 6 months: p = 0.03; CD68 at 3 months: p = 0.04, 6 months: p = 0.02). Increased intima hyperplasia occurred in both groups (p < 0.0001 each). Macroscopic analyses after 3 and 6 months showed ubiquitous lumen-narrowing aortic plaques. Calcification of the intima and media was increased in groups diet (intima: p < 0.0001 at 3 and 6 months; media at 3 months: p < 0.0001, 6 months: p = 0.01) and BI (intima: p < 0.0001 at 3 and 6 months; media at 3 months: p < 0.0001, 6 months: p = 0.02). Extensive lipid accumulation was found in the intima in both treatment groups (p < 0.0001 each).

CONCLUSIONS

A rabbit model with high aortic calcific plaque burden-diet-induced with no implicit need of an additional intimal injury by an intraaortic balloon insufflation due to comparable outcome-exhibiting multiple pathophysiological aspects of human atherosclerosis has been designed and thoroughly characterized. It is suitable for use in future studies on the interaction between atherosclerotic plaques and the arterial blood flow under ECC.

Clinical utility and implementation of polygenic risk scores for predicting cardiovascular disease

Genome-wide association studies have revealed hundreds of genetic variants associated with cardiovascular diseases (CVD). Polygenic risk scores (PRS) can capture this information in a single metric and hold promise for use in CVD risk prediction. Importantly, PRS information can reflect the causally mediated risk to which the individual is exposed throughout life. Although European Society of Cardiology guidelines do not currently advocate their use in routine clinical practice, PRS are commercially available and increasingly sought by clinicians, health systems, and members of the public to inform personalized health care decision-making. This clinical consensus statement provides an overview of the scientific basis of PRS and evidence to date on their role in CVD risk prediction for the purposes of disease prevention. It provides the reader with a summary of the opportunities and challenges for implementation and identifies current gaps in supporting evidence. The document also lays out a potential roadmap by which the scientific and clinical community can navigate any future transition of PRS into routine clinical care. Finally, clinical scenarios are presented where information from PRS may hold most value and discuss organizational frameworks to enable responsible use of PRS testing while more evidence is being generated by clinical studies.

Insights Into Causal Effects of Genetically Proxied Lipids and Lipid-Modifying Drug Targets on Cardiometabolic Diseases

BACKGROUND

The differential impact of serum lipids and their targets for lipid modification on cardiometabolic disease risk is debated. This study used Mendelian randomization to investigate the causal relationships and underlying mechanisms.

METHODS

Genetic variants related to lipid profiles and targets for lipid modification were sourced from the Global Lipids Genetics Consortium. Summary data for 10 cardiometabolic diseases were compiled from both discovery and replication data sets. Expression quantitative trait loci data from relevant tissues were employed to evaluate significant lipid-modifying drug targets. Comprehensive analyses including colocalization, mediation, and bioinformatics were conducted to validate the results and investigate potential mediators and mechanisms.

RESULTS

Significant causal associations were identified between lipids, lipid-modifying drug targets, and various cardiometabolic diseases. Notably, genetic enhancement of LPL (lipoprotein lipase) was linked to reduced risks of myocardial infarction (odds ratio [OR]1, 0.65 [95% CI, 0.57-0.75], P1=2.60×10-9; OR2, 0.59 [95% CI, 0.49-0.72], P2=1.52×10-7), ischemic heart disease (OR1, 0.968 [95% CI, 0.962-0.975], P1=5.50×10-23; OR2, 0.64 [95% CI, 0.55-0.73], P2=1.72×10-10), and coronary heart disease (OR1, 0.980 [95% CI, 0.975-0.985], P1=3.63×10-14; OR2, 0.64 [95% CI, 0.54-0.75], P2=6.62×10-8) across 2 data sets. Moreover, significant Mendelian randomization and strong colocalization associations for the expression of LPL in blood and subcutaneous adipose tissue were linked with myocardial infarction (OR, 0.918 [95% CI, 0.872-0.967], P=1.24×10-3; PP.H4, 0.99) and coronary heart disease (OR, 0.991 [95% CI, 0.983-0.999], P=0.041; PP.H4=0.92). Glucose levels and blood pressure were identified as mediators in the total effect of LPL on cardiometabolic outcomes.

CONCLUSIONS

The study substantiates the causal role of lipids in specific cardiometabolic diseases, highlighting LPL as a potent drug target. The effects of LPL are suggested to be influenced by changes in glucose and blood pressure, providing insights into its mechanism of action.

Comparative Effectiveness of Rosuvastatin Versus Atorvastatin in Acute Ischemic Stroke Treatment

BACKGROUND

Research specifically addressing the efficacy of rosuvastatin versus atorvastatin in patients with ischemic stroke is insufficient. Using a large stroke registry, we investigated whether 2 commonly used statins, rosuvastatin and atorvastatin, differ in their effectiveness in reducing the risk of vascular events in patients with acute ischemic stroke.

METHODS

We analyzed data from a nationwide stroke registry in South Korea between January 2011 and April 2022. Patients with acute ischemic stroke within 7 days of onset who were prescribed either atorvastatin or rosuvastatin at discharge were included. The primary outcome was a composite of recurrent stroke (either hemorrhagic or ischemic), myocardial infarction, and all-cause mortality within 1 year.

RESULTS

A total of 43 512 patients (age, 69.2±12.5 years; male, 59.8%) were analyzed in this study. Atorvastatin was used in 84.8% (n=36 903), and rosuvastatin was used in 15.2% (n=6609). The 1-year cumulative event rate of the composite of recurrent stroke, myocardial infarction, and all-cause mortality was significantly lower in the rosuvastatin group than in the atorvastatin group (9.7% [95% CI, 9.0-10.5] versus 10.7% [95% CI, 10.4-11.0]; P=0.049). Cox proportional hazards analysis revealed that rosuvastatin, compared with atorvastatin, was significantly associated with less risk of 1-year composite of recurrent stroke, myocardial infarction, and all-cause mortality, with an absolute risk reduction of 1% [95% CI, -1.8 to -0.2] and a relative risk reduction of 11% (hazard ratio, 0.89 [95% CI, 0.82-0.97]). However, there were discrepancies in the statistical significance of the results between the propensity score matching and stabilized inverse probability of treatment weighting analysis.

CONCLUSIONS

The results of this analysis of a large cohort of patients with ischemic stroke suggested that, compared with atorvastatin, rosuvastatin was significantly associated with a reduced risk of a 1-year composite of recurrent stroke, myocardial infarction, and all-cause mortality in patients with acute ischemic stroke. However, in real clinical practice, rosuvastatin is used less than one-fifth as frequently as atorvastatin in patients with acute ischemic stroke. This study serves as a hypothesis-generating function.

Temporal trends of characteristics and management of patients with suspected MINOCA

BACKGROUND

Myocardial infarction without obstructive coronary artery disease (MINOCA) is a challenging condition which requires appropriate management and therapy. Although specific guidelines and recommendations for this condition have been introduced, there are few data about management implementation over time. The aim of this study is to compare two cohorts of patients affected by suspected MINOCA to assess the temporal trends change in the clinical characteristics and management.

METHODS

Two patient cohorts were retrospectively selected from a single centre (Cardiology Department of Perugia University Hospital) and compared to investigate the differences in characteristics and management before and after the release of 2018 MINOCA guidelines. The Group included patients enrolled from January 2006 to December 2014, and the Group 2 from July 1st, 2020, to July 31st, 2023.

RESULTS

Group 1 included 150 patients and Group 2 83 patients. Compared to group 1, group 2 showed higher prevalence of hypercholesterolemia (57 % vs 27 % p < 0,001), prior acute myocardial infarction (23 % vs 5 %, p <0,001), preserved left ventricular ejection fraction (90 % vs 67 %, p = 0,03), use of cardiovascular magnetic resonance (27 % vs 0 %,p < 0.001), prescription of beta-blockers (69 % vs 31 %,p < 0.001), calcium channel blockers (46 % vs 16 %, p < 0.001), statins (81 % vs 59 %, p = 0.03) and a less frequent occurrence of ST-elevation on admission ECG (9 % vs 24 %, p = 0.005), prescription of dual antiplatelet therapy (20 % vs 58 %, p < 0.001) and nitrates (12 % vs 54 %, p < 0.001).

CONCLUSIONS

In the present study, characteristics and management of patients with suspected MINOCA has significantly changed over time. However, discrepancies with guidelines recommendation still exist and implementation strategies are needed to fill this gap and improve clinical practice.

Dose-response relationship between lipids and all-cause mortality in the dialysis population: a meta-analysis

BACKGROUND

The use of lipid-lowering drugs in the dialysis population has been controversial and there is no target for the dialysis population.

OBJECTIVES

To elucidate the dose-response relationship between lipids and all-cause mortality in the dialysis population.

METHODS

Computer searches of PubMed, Embase, Web of Science, CNKI, and Wanfang. Data were conducted to collect published cohort studies on lipids and all-cause mortality in the dialysis population from home and abroad up to February 2023. Meta-analysis was applied to calculate the combined effect size (Hazard ratio) and its 95% confidence interval and dose-response relationship by applying Stata17.0.

RESULTS

A total of 11 publications with a cumulative total of 106,808 individuals were included. All-cause mortality was statistically different between the highest dose total cholesterol (TC) group and the low TC group (HR = 0.82, 95% CI = 0.75-0.90, P < 0.05). The TC range for lower all-cause mortality is > 140.5 mg/dL, and on this basis, TC in the range of 180-220 mg/dL may have a better prognosis for dialysis population. There was a nonlinear relationship between Non-high-density lipoprotein cholesterol (NHDL-C) cholesterol and all-cause mortality, with no statistical difference between the high and low dose group. In contrast, Low-density lipoprotein cholesterol (LDL-C) masked its association with all-cause mortality due to changes in death spectrum, differences in relative time risks, and other factors. In the 50-450 mg/dL range, all-cause mortality in the dialysis population was positively associated with triglycerides (TG), with a 2.5% increase in all-cause mortality per 50 mg/dL increase in TG (HR = 1.025, 95% CI = 1.003-1.048, P = 0.01).

CONCLUSION

TC is a target for monitoring the dialysis population, which has the lowest all-cause mortality in the range of 180-220 mg/dL. However, NHDL-C and LDL-C monitoring is not clinically meaningful. Increased TG can contribute to the risk of higher all-cause mortality in dialysis patients.

Metabolic control and its associated factors in type 1 diabetic people: longitudinal trajectory modeling

BACKGROUND

Diabetes is a chronic disease, and hyperglycemia can increase the risk of diabetic complications and the need for more inpatient services. Therefore, the prevention and control of diabetes are important. This study aimed to identify the trajectories of metabolic control and its correlates in people with type 1 diabetes.

METHOD

This is a longitudinal study with 2020 type 1 diabetic individuals aged 18 to 59 years. The participants' glycosylated hemoglobin (HbA1c) was measured three times with a six-month interval between each measurement. The data were analyzed using group-based trajectory modeling. Multinomial logistic regression was used to determine the factors related to these groups.

RESULTS

The results showed four trajectories of safe controlled (46.2%), moderate stable risk (28.7%), moderate increasing risk (12.5%), and high decreasing risk trajectory (12.6%) (entropy = 0.70). The results of multinomial logistic regression showed dyslipidemia could increase the odds of being in the three risk trajectories. Education, physical inactivity, and poor psychological status could also increase the odds of being in the moderate stable and high decreasing trajectories. Moreover, sex, job, and BMI could increase the odds of being in the high decreasing risk group (p < 0.05).

CONCLUSION

Since there are different trajectories of metabolic control of diabetes, it is necessary for healthcare providers and health experts to plan behavioral interventions based on the location of individuals in different trajectories and the related significant risk factors. In this way, appropriate prevention, care, and treatment programs can be provided for the people in each group.

Ezetimibe Eligibility and Prescribing in Patients With Acute Coronary Syndrome

BACKGROUND

Ezetimibe is a safe and effective medication for achieving secondary prevention low-density lipoprotein-cholesterol (LDL-C) targets after acute coronary syndrome (ACS). We sought to examine ezetimibe prescribing after ACS and the effects of expanding the Australian Pharmaceutical Benefits Scheme eligibility criteria.

METHOD

A retrospective analysis was performed for the rates and factors of ezetimibe eligibility and prescribing in ezetimibe-naive patients with ACS admitted to a single quaternary centre between May 2020 and September 2022. Eligibility rates were also assessed with tighter LDL-C targets and with modelling to identify patients unlikely to achieve targets with first-line care.

RESULTS

Of 757 patients with ACS with LDL-C >1.8 mmol/L, 94 were eligible for ezetimibe. This subgroup was highly comorbid but only 16 patients were prescribed ezetimibe. The univariate logistic regression identified statin contraindication (odds ratio 19.4; 95% confidence interval 4.58-103.9; p<0.001) and higher LDL-C (odds ratio 2.43 per 1 mmol/L; 95% confidence interval 1.44-4.67; p=0.03) as key predictors of prescribing. Of 956 patients with ACS with an LDL-C >1.4 mmol/L, tightening LDL-C targets from 1.8 to 1.4 mmol/L increased eligibility from 94 (9.8%) to 152 (16.0%) patients, whereas predictive modelling substantially expanded eligibility to 309 (32.3%) and 620 (64.9%) with the 1.8 mmol/L and 1.4 mmol/L targets, respectively.

CONCLUSIONS

In the acute setting after ACS, Australian Pharmaceutical Benefits Scheme restrictions limit ezetimibe to highly comorbid patients with a high risk of recurrent disease. Despite this, the prescribing rates were poor. Furthermore, a larger group of patients are discharged on treatments that are unlikely to achieve guideline-directed LDL-C targets. Rationalising eligibility criteria for ezetimibe would likely improve access to early and effective secondary prevention.

Achievement of guideline targets among people with type 2 diabetes with eASCVD and high risk of ASCVD in the UAE: Results of the PACT-MEA-UAE cohort

AIM

The Prevalence of Atherosclerotic Cardiovascular Disease in Patients with Type 2 Diabetes across the Middle East and Africa (PACT-MEA) study compared cardiovascular disease (CVD) risk and 2021 ESC guidelines adherence between UAE and broader MEA region participants for enhanced type 2 diabetes mellitus (T2D) and atherosclerotic cardiovascular disease (ASCVD).

METHODS

A survey of 385 physicians explored clinical decision-making factors. Chart reviews of 3726 participants classified ASCVD risk as per 2021 ESC guidelines and compared T2D target achievement in primary and secondary care centers.

RESULTS

The survey highlighted factors influencing T2D management decisions, with most adhering to international guidelines. Among 542 UAE participants, 62.7 % were at high and 37.1 % at very high risk for ASCVD. Target HbA1c was achieved 45 % UAE vs. 37 % in regionally, BP by 41 % vs. 30 %, LDL by 36 % vs. 30 %, BMI <25 kg/m2 by 20 % vs. 15 %, SGLT2is use by 63 % vs. 37 % and GLP-1RAs use by 22 % vs. 13 %, respectively. No participants met all ESC-recommended targets for T2D.

CONCLUSION

Physicians followed international guidelines, considering patient history, drug efficacy, and HbA1c levels for diabetes and ASCVD risks. In UAE, <50 % of at-risk individuals with T2D met ESC targets. Cardioprotective medication use was higher in UAE.

Evaluating lipid-lowering drug targets for full-course diabetic retinopathy

BACKGROUND

Implementing lipid control in patients with diabetes is regarded as a potential strategy for halting the advancement of diabetic retinopathy (DR). This study seeks to use Mendelian randomisation (MR) to assess the causal relationship between lipid traits and lipid-lowering drug targets and full-course DR (background DR, severe non-proliferative DR (NPDR) and proliferative DR (PDR)).

METHODS

A two-sample MR and drug target MR to decipher the causal effects of lipid traits and lipid-lowering drug targets on full-course DR, including background DR, severe NPDR and PDR, was conducted in the study. Genetic variants associated with lipid traits and genes encoding the protein targets of lipid-lowering drugs were extracted from the Global Lipids Genetics Consortium and UK Biobank. Summary-level data of full-course DR are obtained from FinnGen.

RESULTS

No significant causal relationship was found between lipid traits and full-course DR. However, in drug target MR analysis, peroxisome proliferator-activated receptor gamma (PPARG) enhancement was associated with lower risks of background DR (OR=0.12, p=0.005) and PDR (OR=0.25, p=0.006). Additionally, mediation MR analysis showed that lowering fasting insulin (p=0.015) and HbA1c (p=0.005) levels mediated most of the association between PPARG and full-course DR.

CONCLUSIONS

This study reveals PPARG may be a promising drug target for full-course DR. The activation of PPARG could reduce the risk of full-course DR, especially background DR and PDR. The mechanism of the PPARG agonists' protection of full-course DR may be dependent on the glucose-lowering effect.

Efficacy of a novel PCSK9 inhibitory peptide alone and with evinacumab in a mouse model of atherosclerosis

Atherosclerosis is the major cause of cardiovascular disease. This study evaluated the effect of lipid lowering using a novel peptide inhibiting proprotein convertase subtilisin/kexin type 9 (PCSK9) and a monoclonal antibody against angiopoietin-like 3 (evinacumab), either alone or in combination in APOE*3-Leiden.CETP mice fed a Western diet. Effects on body weight, plasma lipids, atherosclerotic lesion size, severity, composition and morphology were assessed. Treatment with PCSK9 inhibitory peptide significantly decreased both cholesterol and triglycerides (-69% and -68%, respectively). Similar reductions were seen in evinacumab-treated mice (-44% and -55%, respectively). The combination of evinacumab and PCSK9 inhibitory peptide lowered these levels to a larger extent than evinacumab alone (cholesterol: -74%; triglycerides: -81%). Reductions occurred in non-HDL-C without changes in HDL-C. Atherosclerotic lesion size was significantly reduced in all treatment groups compared to vehicle controls (evinacumab: -72%; PCSK9 inhibitory peptide: -97%; combination: -98%). Similarly, all interventions improved atherosclerotic lesion severity, with more undiseased segments and fewer severe lesions. Evaluation of the composition of severe atherosclerotic plaques revealed significant improvement in lesion stability in mice treated with both evinacumab and PCSK9 inhibitory peptide, attributable to decreased macrophage content and increased collagen content. Additionally, evaluation of lipid concentrations in cynomolgus monkeys revealed the beneficial effects of the PCSK9 inhibitory peptide on total cholesterol and LDL-C levels. Together these data demonstrate that treatment with evinacumab and PCSK9 inhibitory peptide alone and in combination reduces lipids, development of atherosclerosis and improves lesion composition, making it a promising approach for treatment of atherosclerosis.

Rationale, design and pre-randomization 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 two-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.

Do genetically determined very high and very low LDL levels contribute to Lp(a) plasma concentration?

BACKGROUND AND AIMS

Lipoprotein(a) [Lp(a)] is a well-recognized risk factor for atherosclerotic cardiovascular disease (ASCVD). Few data are available on the distribution of Lp(a) levels among subjects at different cardiovascular risk and in subjects with monogenic and polygenic dyslipidemias (familial hypercholesterolemia, FH and familial hypobetalipoproteinemia type 1, FHBL1). The aim of this study was to investigate the distribution of Lp(a) plasma levels in subjects with high and low LDL-C levels (FH and FHBL1) and in the general population.

METHODS AND RESULTS

The study cohorts included 356 hypercholesterolemic patients, 212 carrying a FH causative mutation, 144 with clinical FH (mutation negative - FHneg), 52 FHBL1 and 797 free-living subjects. Lp(a) levels were significantly higher in FH subjects (both FH and FHneg) (median 12.46 mg/dl and 14.0 mg/dl, respectively) compared with FHBL1 and free-living subjects (7.68 mg/dl and 7.18 mg/dl, respectively). More, Lp(a) levels were similar in FH subjects carrying LDLR defective and null mutations and FHneg. Subjects at high and very high CV risk exhibited significant higher Lp(a) levels (median 10.68 mg/dl and 9.20 mg/dl, respectively) compared with low and moderate CV risk (median 5.72 mg/dl and 7.80 mg/dl, respectively) (p < 0.0008).

CONCLUSIONS

FH subjects exhibit higher Lp(a) levels than FHBL1 and general population. Lp(a) slightly contribute to hypercholesterolemia in FH patients. Subjects at high and very high CV risk exhibited significant higher Lp(a) levels compared with low and moderate CV risk. Combined evaluation of Lp(a) levels in FH subjects with other traditional risk factors could identify very high-risk individuals who may benefit from early aggressive treatments to avoid premature CV events.

Efficacy and safety of statins, ezetimibe and statins-ezetimibe therapies for children and adolescents with heterozygous familial hypercholesterolaemia: Systematic review, pairwise and network meta-analyses of randomised controlled trials

BACKGROUND AND AIMS

Statins, ezetimibe and statins-ezetimibe combination therapy are recommended lipid-lowering therapies (LLTs) in children with heterozygous familial hypercholesterolaemia (HeFH). However, their relative effectiveness is not well understood. We aimed to compare the safety and efficacy of these therapies using direct and indirect comparisons.

METHODS

We conducted systematic review, pairwise and network meta-analyses (NMAs) of randomised-controlled trials (RCTs) of statins, ezetimibe and statins-ezetimibe combination therapy in people <18 years with HeFH. Comprehensive bibliographic searches were conducted in December 2022, and a Medline update in January 2024. NMA models accounted for drug class, statin type and dosage.

RESULTS

Thirteen RCTs were included (n = 1649, median age 13 years, follow-up 6 weeks-2 years). All LLTs reduced low-density lipoprotein cholesterol (LDL-C) and total cholesterol; statins led to increases in high-density lipoprotein cholesterol and reductions in triglycerides. Statins reduced LDL-C by 33.61 % against placebo (95 % CI 27.58 to 39.63, I2 = 83 %). Adding ezetimibe to statins reduced LDL-C by an additional 15.85 % (95 % CI 11.91 to 19.79). NMAs showed intermediate-dose statins reduced LDL-C by an additional 4.77 % compared with lower-doses statins (95 % CrI -11.22 to 1.05); higher-dose statins and intermediate-dose statins + ezetimibe may be similarly effective and are probably superior to ezetimibe, intermediate-and lower-dose statins. There was no evidence of differences in maturation, safety or tolerability between LLTs and placebo.

CONCLUSIONS

Statins, ezetimibe and statins-ezetimibe are all effective treatments for children with HeFH, but the magnitude of LDL-C reductions varies and may depend on treatment dosage and combination. No safety or tolerability issues were found. Longer-term safety and effectiveness are uncertain.

Cardiovascular diseases health literacy among Italian navy personnel: A cross-sectional survey

Objectives

This study assesses cardiovascular disease (CVD) awareness among Italian Navy personnel, emphasizing the understanding of risk factors. It aims to provide insights that could enhance health education initiatives tailored to military settings.

Study Design

Cross-sectional survey.

Methods

From February 2021 to March 2022, participants were enrolled through opportunistic sampling among Italian Navy personnel. They were surveyed using a structured questionnaire divided into two parts. It was designed to elicit open-ended and closed-ended responses on their knowledge of CVD, its risk factors, and associated diagnostic thresholds. Statistical analyses included logistic regression conducted with R software.

Results

A total of 785 participants were enrolled. The findings indicate a higher recognition of acute myocardial infarction and hypertension compared to other diseases like atherosclerosis and cardiomyopathy. For risk factors, smoking was recognized by 57 % of respondents, while only 60 % correctly identified the diagnostic threshold for total cholesterol. Logistic regression analysis showed significant differences in awareness levels based on sex and rank (p < 000000.1); officers had higher awareness than enlisted personnel (p < 000000.1).

Conclusions

The results demonstrate significant disparities in CVD risk awareness among different ranks and sexes within the Italian Navy, highlighting the need for tailored educational programs. Through specific interventions, Addressing these knowledge gaps could enhance the health outcomes of military personnel and the overall efficacy of Navy health strategies. Furthermore, the work and life environment of the Navy could allow for more in-depth health education initiatives, leading to the adoption of healthier lifestyles by the personnel.

Selective peroxisome proliferator-activated receptor-α modulator improves hypertriglyceridemia and muscle quality in patients with chronic kidney disease: A retrospective observational study

BACKGROUND & AIMS

Patients with chronic kidney disease (CKD) often have additional health problems, including sarcopenia and sarcopenic obesity. These conditions involve ectopic fat accumulation within muscles. This ectopic fat deposition reduces muscle quality, leading to weaker muscle strength and poorer physical performance. Persistent hypertriglyceridemia contributes to ectopic fat accumulation. Metabolic abnormalities, including dyslipidemia, are major factors in CKD development. Triglycerides (TG) and muscle quality are thus important factors in CKD management. Recently developed selective peroxisome proliferator-activated receptor α modulator (SPPARMα) hold promises for improving hypertriglyceridemia. However, their effectiveness and impact on muscle quality in CKD patients remain unclear. This study aimed to evaluate the effect of SPPARMα on muscle quality and its efficacy in CKD patients.

METHODS

This retrospective observational study involved CKD patients with dyslipidemia. We included patients who initiated medications for hypertriglyceridemia. We compared changes in lipid profiles, renal function, and muscle quality, assessed by phase angle, over six months between two groups: those receiving this type of medication and those receiving conventional treatment.

RESULTS

Among 245 patients diagnosed with CKD and hypertriglyceridemia, 52 started medications for hypertriglyceridemia. Of these, 26 received SPPARMα, and 26 received conventional lipid-lowering medications (statins, ezetimibe, eicosapentaenoic acid, and fibrates). SPPARMα significantly reduced TG (from 296.8 ± 106.1 to 153.0 ± 86.1, p < 0.001) without affecting glomerular filtration rate or urinary protein levels. Conventional treatment also improved TG (from 261.6 ± 89.5 to 173.6 ± 81.3, p < 0.001). Only patients treated with SPPARMα showed significant improvement in muscle quality. Their phase angle increased from 5.41 ± 0.6 to 5.55 ± 0.6 after six months of treatment (p < 0.05).

CONCLUSIONS

Our study demonstrates that the newly developed SPPARMα significantly lowers TG levels in CKD patients without harming their kidneys. Additionally, only patients treated with SPPARMα showed improvement in muscle quality. These findings suggest that SPPARMα may be a valuable treatment option for CKD patients with dyslipidemia, particularly those with low muscle quality.

Treat the patient, not the disease: The embolic stroke of undetermined source as an opportunity to optimize cardiovascular prevention in a holistic approach

For any physician treating a patient with a medical condition of unclear etiology, the differential diagnosis aims to identify the actual most probable cause among various potential etiologies, in order to tailor treatment options. In patients with embolic stroke of undetermined source (ESUS), this can be challenging due to the frequent presence of multiple potential embolic sources, raising difficulties to identify the most likely cause. Additionally, despite targeted preventive measures for the presumed embolic source, patients may remain at risk for stroke and cardiovascular events due to other unrecognized or underestimated pathologies. The multi-level complexity and multimorbidity typically associated with ESUS, represents a challenge that requires broad knowledge of the cardiovascular pathophysiology, deep expertise of the available diagnostic and therapeutic options, and interdisciplinary approach. At the same time, it is an ideal opportunity to assess thoroughly the overall cardiovascular status of the patient, which in turn can allow us to optimize therapeutic and preventive strategies in a holistic approach, and prevent future strokes, cardiovascular events and disability through different parallel pathways. In this context, rather than narrowing our perspective on identifying the specific embolic source presumed to be the most likely cause of ESUS, it is crucial to shift our focus from the disease to the patient, and evaluate the overall cardiovascular profile by assessing the risk of all cardiovascular comorbidities present, no matter if causally associated with ESUS or not. In order to bring across these points and more, this article is centred around a clinical case that serves as a starting point to illustrate the holistic approach to the management of patients with ESUS. After all, this is the beauty, the magic and the art of Internal Medicine: to treat the patient, not the disease, the system or the organ.

Evaluations of metabolic and innate immunity profiles in subjects with familial hypercholesterolemia with or without subclinical atherosclerosis

BACKGROUND

Familial hypercholesterolemia (FH) is a genetic condition characterized by high low-density lipoprotein cholesterol (LDL-C). The presence of risk modifiers could promote the atherosclerotic injury beyond LDL-C. Our aim was to evaluate metabolic and innate immunity profiles in FH subjects with or without subclinical atherosclerosis.

METHODS

In this cross-sectional observational study, we evaluated 211 genetically confirmed FH subjects on LDL-C target and without cardiovascular diseases. Biochemical analyses, LDL-C burden (LCB) calculation and vascular profile evaluation were obtained from all subjects. Study population was divided into two groups according to subclinical atherosclerosis: the subclinical atherosclerosis (SA) group and non-subclinical atherosclerosis (NSA) group.

RESULTS

SA group had higher LDL-C at diagnosis (288.35 ± 24.52 vs 267.92 ± 23.86, p < 0.05) and LCB (13,465.84 ± 3617.46 vs 10,872.63 ± 3594.7, p < 0.001) than NSA group. SA group had higher white blood cell count (WBCC, 6.9 ± 1.66 vs 6.1 ± 1.16), neutrophil count (NC, 4.2 ± 1.3 vs 3.6 ± 1.11), monocyte count (MC, 0.8 ± 0.2 vs 0.4 ± 0.1), triglyceride to high-density lipoprotein ratio (TG/HDL, 1.73 ± 0.72 vs 1.45 ± 0.69), triglyceride-glucose index (TyG, 8.29 ± 0.35 vs 8.01 ± 0.33) than NSA group (p value for all < 0.01). Multivariate logistic regression analysis showed that LCB (p < 0.01), WBCC (p < 0.01), NC (p < 0.05), MC (p < 0.05) were associated with subclinical atherosclerosis. Simple linear regression analyses showed that LCB was associated with WBCC, NC, MC (p value for all < 0.01).

CONCLUSION

An increased LCB and an impaired innate immunity profile were found in FH subjects with subclinical atherosclerosis and they were independently associated with atherosclerotic injury. LCB could modulate the innate immunity profile.

[What is new in the management of peripheral arterial occlusive disease and diseases of the aorta? : Highlights of the ESC guidelines 2024]

The European Society of Cardiology (ESC) guidelines on peripheral arterial disease (PAD) and diseases of the aorta published in September 2024 for the first time combine recommendations for both diseases in a joint guideline document. The consolidation of PAD and aorta guidelines follows a holistic approach, which underlines the entirety of the arterial vascular system. This aim is underlined by a specifically introduced recommendation to take the entirety of the circulatory system into account in patients with vascular diseases. The focus in the current ESC guideline document is on a multidisciplinary, patient-centered management of PAD and diseases of the aorta, whereby the prevention and follow-up of patients after therapeutic interventions are emphasized. In PAD the document highlights exercise training and the procedure for patients with chronic wounds as well as risk stratification and hereditary diseases of the aorta.

Remnant cholesterol and long-term incidence of death in coronary artery disease patients

BACKGROUND

Remnant cholesterol (RC), defined as non-HDL-non-LDL cholesterol, has attracted recent scientific interest as a candidate lipid factor for residual cardiovascular risk. Despite a rising amount of epidemiologic information, there are imprecisions because most available data arise from non-fasting, frozen and calculated values.

METHODS

We enrolled 1474 consecutive patients with angiographically proven CAD, and measured RC in strictly fasting, non-frozen samples with a direct assay for LDL-C. Prospectively, all-cause mortality, cardiovascular mortality, and major adverse cardiovascular events (MACE) were recorded over a mean follow-up period of 11.6 ± 5.0 years, covering 17098 patient years.

RESULTS

During follow-up, CAD patients had a rate of all-cause mortality of 52.2 % (n = 769), of cardiovascular mortality of 20.6 % (n = 303), and an incidence of major adverse cardiovascular events (MACE) of 39.1 % (n = 576). Prospectively, RC was associated with all-cause mortality (HR 1.12 [1.03-1.23], p = 0.009), cardiovascular mortality (HR 1.20 [1.06-1.36], p = 0.005), and MACE (HR 1.10 [1.01-1.21], p = 0.033) in Cox regression analyses across various levels of adjustment (age, sex, smoking, LDL-C, HDL-C, hypertension, T2DM, and BMI). Findings did not differ between women and men. Furthermore, there was no discernible influence of statin treatment.

CONCLUSIONS

From our data we conclude that RC is associated with future all-cause mortality, cardiovascular mortality and MACE in patients with established coronary artery disease. Proper pre-analytic and analytic methods provided, RC represents a reliable indicator of residual risk.

Association Between Coronary Artery Spasm and Atherosclerotic Disease

In at least one-half of the patients with angina or ischemia and nonobstructive coronary arteries undergoing coronary function testing, coronary artery spasm (CAS) is detected. CAS is associated with an adverse prognosis regarding recurrent complaints and ischemic events. Current treatment options are mainly focused on the complaints, not on the underlying pathophysiological process. In this review we discuss available evidence regarding the presence, amount, and morphology of atherosclerosis in CAS patients. The reviewed evidence confirmed that atherosclerosis and vulnerable plaque characteristics are often detected in patients with CAS. The amount of atherosclerosis is higher in patients with focal CAS compared with patients with diffuse CAS. Severity of atherosclerosis is associated with the presence of CAS and the prognosis in CAS patients with atherosclerotic stenosis is worse. Therefore, CAS patients with atherosclerosis might benefit from targeted atherosclerotic treatment. Longitudinal studies are needed to elucidate the exact relation between atherosclerosis and CAS.

Efficacy of Low-Density Lipoprotein Cholesterol Apheresis in the Treatment of Familial Hypercholesterolemia: Single Center Experience

PURPOSE

  Familial hypercholesterolemia (FH) is a genetic disorder associated with extremely high levels of low-density lipoprotein cholesterol (LDL-C) and increased incidence of cardiovascular disease. We aimed to evaluate the efficacy and long-term outcomes of lipoprotein apheresis (LA) in the treatment of FH.

METHODS

  Cardiovascular events that occurred before and after LA treatment were evaluated by reviewing previous medical records of patients with FH.

RESULTS

  Thirteen patients (female/male: 8/5) were included in this study. The mean Dutch score was 20±4. All patients were treated with a combination of statin and ezetimibe. Before the onset of LA, 8 patients had a history of coronary artery disease, and the median age at onset of cardiovascular disease (CVD) in these patients was 24 years. At the initiation of LA, the median age was 22 years and the mean LDL-C level was 410±130 mg/dL. The mean duration of LA treatment was 13.9±6.9 years. The mean LDL-C levels before and after the latest three LA treatments were 267±63.4 and 71.5±23.4 mg/dL, respectively. The mean reduction in LDL-C levels after LA was 73±8.2%. De novo cardiovascular events occurred in 10 patients during LA treatment; six of these patients had a known history of CVD before LA. Eight of these patients underwent invasive procedures for therapeutic purposes and the total number of procedures was 12.

CONCLUSION

  LA is an effective method of reducing LDL-C levels and an additional treatment option that may slow disease progression in patients with FH who are at high risk of cardiovascular events.

Coronary computed tomography angiography improves assessment of patients with acute chest pain and inconclusively elevated high-sensitivity troponins

OBJECTIVES

To determine whether coronary computed tomography angiography (CCTA) can improve the diagnostic work-up of patients with acute chest pain and inconclusively high-sensitivity troponins (hs-troponin).

METHODS

We conducted a prospective, blinded, observational, multicentre study. Patients aged 30-80 years presenting to the emergency department with acute chest pain and inconclusively elevated hs-troponins were included and underwent CCTA. The primary outcome was the diagnostic accuracy of ≥ 50% stenosis on CCTA to identify patients with type-1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS).

RESULTS

A total of 106 patients (mean age 65 ± 10, 29% women) were enrolled of whom 20 patients (19%) had an adjudicated diagnosis of type-1 NSTE-ACS. In 45 patients, CCTA revealed non-obstructive coronary artery disease (CAD) or no CAD. Sensitivity, specificity, negative predictive value (NPV), positive predictive value and area-under-the-curve (AUC) of ≥ 50% stenosis on CCTA to identify patients with type 1 NSTE-ACS, was 95% (95% confidence interval: 74-100), 56% (45-68), 98% (87-100), 35% (29-41) and 0.83 (0.73-0.94), respectively. When only coronary segments with a diameter ≥ 2 mm were considered for the adjudication of type 1 NSTE-ACS, the sensitivity and NPV increased to 100%. In 8 patients, CCTA enabled the detection of clinically relevant non-coronary findings.

CONCLUSION

The absence of ≥ 50% coronary artery stenosis on CCTA can be used to rule out type 1 NSTE-ACS in acute chest pain patients with inconclusively elevated hs-troponins. Additionally, CCTA can help improve the diagnostic work-up by detecting other relevant conditions that cause acute chest pain and inconclusively elevated hs-troponins.

CLINICAL RELEVANCE STATEMENT

Coronary CTA (CCTA) can safely rule out type 1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in patients presenting to the ED with acute chest pain and inconclusively elevated hs-troponins, while also detecting other relevant non-coronary conditions.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT03129659). Registered on 26 April 2017 KEY POINTS: Acute chest discomfort is a common presenting complaint in the emergency department. CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population. CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.

Exploring emerging pharmacotherapies for type 2 diabetes patients with hypertriglyceridemia

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Atherogenic low-density lipoprotein and cardiovascular risk

PURPOSE OF REVIEW

Despite reductions in low-density lipoprotein (LDL) cholesterol (LDLc), residual cardiovascular risk remains due to factors beyond lipoprotein levels, such as LDL particle count, size, electronegativity and modifications. Technological advances allow detailed profiling of LDL particles, offering potential biomarkers for diagnosis, prognosis, and treatment of cardiovascular disease (CVD). The aim of this review is to provide an updated overview of the state of knowledge in the field of LDL atherosclerotic role, which is evolving rapidly due to technological advances in biomarker measurement and applications.

RECENT FINDINGS

While small dense LDL has been linked to increased CVD risk, current approaches favor a comprehensive evaluation of all lipoprotein subtypes, as this is a more feasible and standardized method. The atherogenic potential of circulating oxidized LDL (oxLDL) may be the key factor in the onset and progression of atherosclerosis. Thus, elevated oxLDL levels are recognized as a marker of increased CVD risk in both general and high-risk populations, although further research is needed to clarify some conflicting findings. The oxidized LDL receptor 1 (LOX-1) has emerged as a promising target for immunotherapy and innovative drug delivery strategies to modulate atherosclerosis.

SUMMARY

A panel of biomarkers related to LDL atherogenicity may help predict future ischemic events. An atheroprotective diet and increased physical activity could improve LDL oxidation. OxLDL has become a target for immunomodulatory antiatherosclerosis therapy and delivering LDL-based nanocarriers holds promise for both imaging and therapeutics.

The incremental predictive value of arterial stiffness over SCORE2 in the setting of primary cardiovascular prevention: a 6-year follow-up study

AIM

Arterial stiffness hallmarks age-related cardiovascular diseases, precedes their onset and strongly links to accelerated disease progression. However, whether carotid-to-femoral pulse wave velocity (PWV), a proxy of arterial stiffness, predicts cardiovascular risk over and above SCORE2, a newly introduced risk score remains to be investigated.

METHODS

We measured PWV among 747 individuals without established atheromatosis. Study participants were followed up over a 6-year period for the incidence of cardiovascular events [[MACE)-cardiovascular mortality, stroke and myocardial infarction].

RESULTS

PWV emerged as an independent and additive predictor of first cardiovascular events when added in a model encompassing SCORE2 (hazard ratio = 1.10; 95% confidence interval (95% CI) = 1.07-1.14; P  < 0.001, Brier score changed from 0.073 (0.060-0.086) to 0.067 (0.055-0.081); P  < 0.001, c-statistic increased from 0.71 to 0.75; P  = 0.017; likelihood ratio: 20.22; P  < 0.001; the overall net reclassification improvement (NRI): 0.577; P  < 0.001, AICc changed from 697.81 to 679.60; BIC changed from 702.42 to 688.82]. An increase in PWV predicted a greater risk of future MACEs additively to conventional risk factors ( P  < 0.05). We performed Kaplan-Meier survival analysis for the tertiles of PWV [first tertile < 8.04 m/s; the second tertile: (8.04-10 m/s); the third tertile: (10-17.10 m/s); ( P  < 0.05 for all comparisons between the tertiles). PWV tertiles also predicted MACE when added to SCORE2 [for the second tertile: hazard ratio: 5.87 (95% CI: 1.73-19.92); P  = 0.004 and for the third tertile: hazard ratio: 9.69 (95% CI: 2.97-31.55); P  < 0.001 with the respective change of c-statistic from 0.739 to 0.772; P  = 0.012 and continuous NRI = 0.598].

CONCLUSION

PWV confers additive prognostic value to the newly introduced SCORE2 for adverse outcome in primary prevention.

Dislocation and Snaring of an Aortic Bifurcation Stent During Transfemoral Aortic Valve Replacement-a Case Report

Transfemoral aortic valve replacement (TAVR) is an effective way to treat severe aortic valve stenosis, especially in patients who are high-risk for surgery. Dislocation of an endoluminal aortic bifurcation stent graft during TAVR is an extremely rare complication. We present a case on how management of this complication was successfully done. An 86-year-old man presented at the ER after syncope. He was admitted to the cardiology department for further examinations. Transthoracic echocardiography (TTE) revealed severe aortic stenosis. Other comorbidities included endovascular stent graft repair due to an infrarenal abdominal penetrating aortic ulcer. During the following TAVR procedure dislocation of the endoluminal stent graft was observed. Using a snare loop this foreign material was fixated in the right common iliac artery. The patient was hemodynamically stable and endoluminal aortic valve replacement could successfully commence. After implantation of aortic valve bioprothesis, the foreign material was retrieved from the right femoral artery. The patient remained asymptomatic and stable postprocedural. Dislocation of an endoluminal stent graft during TAVR remains a rare complication. This complication can arise due to several factors, including patient-specific anatomical challenges and procedural complexities. Decisions are based on the individual patient but are also made in consensus with the interventional cardiologist' team.

Secondary prevention and extreme cardiovascular risk evaluation (SEVERE-0): Prevalence of extreme cardiovascular risk in cardiological rehabilitation patients and its impact on functional improvement

BACKGROUND AND AIMS

Patients with recent Acute Coronary Syndrome (ACS) or Chronic Coronary Syndrome (CCS) are all at very high CardioVascular (CV) risk. However, some of them are more likely to experience recurrent cardiovascular events (i.e extreme CV risk). A definition of which patients should be included in this category has been recently proposed by the European Society of Cardiology but data on its prevalence are still lacking, especially in the context of Cardiac Rehabilitation (CR). Furthermore, if this condition had an impact on the CR related functional improvement is not known. Our study has been designed to answer to both these questions.

METHODS AND RESULTS

The study included 938 ACS/CCS patients who attended the CR program at the Niguarda Hospital (Milan). Extreme CV patients were defined as the presence of a previous CV events within 2 years or the presence of peripheral arteriopathy or the presence of a multivessel coronary involvement. Functional improvement was evaluated through 6-Minute Walking Test (6-MWT). As many as 26.9% of the patients had an extreme CV risk. They were older (67.8 ± 10.4 vs 64.1 ± 11.1 years; p ≤ 0.001), had a higher prevalence of CV risk factors and comorbidities and had a lower functional improvement during CR (102.9 ± 68.6 vs 138.1 ± 86.5 m; p ≤ 0.001). Extreme CV risk present a significant association with the 6-MWT results at multivariate analysis.

CONCLUSION

Extreme CV risk is a very frequent condition among patients with ACS/CCS reaching the prevalence of 26.9%. Furthermore, being at extreme CV risk adversely affects the patient's functional improvement obtained during CR.

[Management of acute coronary syndrome]

Coronary artery disease (CAD) is the leading cause of death worldwide. Acute coronary syndrome (ACS) encompasses a spectrum of diagnoses ranging from unstable angina pectoris to myocardial infarction with and without ST-segment elevation and frequently presents as the first clinical manifestation. It is crucial in this scenario to perform a timely and comprehensive assessment of patients by evaluating the clinical presentation, electrocardiogram and laboratory diagnostics using highly sensitivity cardiac troponin in order to initiate a timely and risk-adapted continuing treatment with immediate or early invasive coronary angiography. In addition to revascularization, the subsequent antithrombotic and lipid-lowering treatment plays a major role in the further secondary prevention of CAD. The choice and duration of medication over time should be tailored to the individual risk profile of the patient. Furthermore, appropriate patient education regarding risk factor management is of paramount importance.

Failure of LDL-C goals achievement and underuse of lipid-lowering therapies in patients at high and very high cardiovascular risk: Spanish subset from the European SANTORINI study

INTRODUCTION

There are very few studies evaluating lipid-lowering treatments (LLTs) and low-density lipoprotein-cholesterol (LDL-C) goal attainment after the release of the 2019 guidelines of the European Societies of Cardiology (ESC) and Atherosclerosis (EAS). This manuscript shows baseline data of the Spanish subset from SANTORINI study (namely SANTORINI Spain) on LDL-C goal attainment and use of LLTs in patients at high and very high cardiovascular risk.

METHODS

SANTORINI was a multinational, prospective, observational study involving patients at high and very high cardiovascular risk from 14 European countries in primary care and specialized healthcare settings. Sociodemographic data, blood lipid levels, and lipid treatments from the 1018 Spanish participants were separately analyzed and were put into perspective with the European cohort without Spanish participants.

RESULTS

According to physicians, 295 (29.0%) subjects were classified as high, and 723 (71.0%) as very high cardiovascular risk. Overall, 26.5% attained risk-based LDL-C targets recommended by 2019 European guidelines, with 23.1% of patients at high cardiovascular risk and 27.9% at very high cardiovascular risk. High-intensity statin therapy in monotherapy was used in 21.8%, LLT combination therapy in 41.2%, and 10.7% were not receiving any LLT.

CONCLUSIONS

Baseline data from SANTORINI Spain population show that only about one-fourth of patients attain LDL-C targets recommended by the 2019 ESC/EAS guidelines in patients at high and very high risk. Despite their cardiovascular risk, patients appear to be not adequately treated, and high-intensity and combination LLT seem to be underused for cardiovascular disease prevention in the real-world setting.

CLINICALTRIALS

gov Identifier: NCT04271280.

High low-density lipoprotein cholesterol levels in people with HIV by individual cardiovascular risk: A retrospective observational study

BACKGROUND

People with HIV (PWH) are at increased risk of atherosclerotic cardiovascular disease (ASCVD). Lowering low-density lipoprotein cholesterol (LDL-C) is central of cardiovascular disease prevention. The aim of this study was to assess the prevalence, treatment, and control of high LDL-C levels as assessed on the basis of the ASCVD risk profiles indicated by European Society of Cardiology (ESC) guidelines of a cohort of PWH in order to evaluate the state of LDL-C management in current clinical practice.

METHODS

We retrospectively assessed the prevalence, treatment, and control of high LDL-C levels in a cohort of PWH aged ≥40 years who accessed our HIV outpatient clinic between 1 March 2022 and 31 March 2023. Their 10-year ASCVD risk was calculated on the basis of their age and co-morbidities as recommended by guidelines. High LDL-C levels were defined as those above the "step two" target of their specific ASCVD risk category.

RESULTS

Among the 1404 assessed PWH, who were prevalently male (74.5 %) and Caucasian (85.6 %), and had a median age of 56 years (interquartile range [IQR] 49-61), 295 (21 %) were at very high risk (VHR), 634 (45.2 %) at high-risk (HR), and 348 (24.8 %) not at HR. The overall median LDL-C level was 116 mg/dL (IQR 96-141). Five hundred and sixteen (37 %) were undergoing lipid lowering treatment (LLT), and 650 (46.3 %) failed to achieve any step of their target LDL-C levels.

CONCLUSIONS

Despite the high prevalence of PWH at VHR/HR for ASCVD, LDL-C levels were poorly controlled and LLT was greatly under used.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

The Association Between Time of Lipid-Lowering Therapy Initiation and Acute Clinical Presentation Among Patients Admitted With Coronary Artery Disease, and Its Effect on Future Cardiovascular Events: An Australian Observational Study

BACKGROUND

Lipid-lowering therapy (LLT) is established as a key element in management of patients with coronary artery disease. However, the effect of time of initiation of LLT on outcomes is unclear.

METHOD

The study compared outcomes of 5,433 patients from Advara HeartCare's Percutaneous Coronary Intervention (PCI) Registry on the basis of timing of LLT initiation classified as pre- or post-PCI admission. The prevalence of acute coronary syndrome (ACS) as the indication for PCI was compared in groups. In patients who underwent PCI for ACS, the incidence of short- (≤30 days) and long-term (>30 days after admission) clinical events (composite of myocardial infarction, cerebrovascular disease, coronary revascularisation, all-cause readmission, and mortality) and first non-fatal cardiovascular events were compared in groups.

RESULTS

At the time of hospitalisation for PCI, 3,982 (73.7%) were on LLT (PRE-LLT), and 1,418 (26.2%) initiated LLT after admission (POST-LLT). Patients on PRE-LLT were significantly less likely to experience ACS before admission for PCI than were those commencing LLT after discharge (PRE-LLT 32.3% vs POST-LLT 56.9%; p<0.001), even after matching for baseline risk factors. Among these patients with ACS, patients on PRE-LLT were older than those on POST-LLT (mean 69.5±9.5 vs 65.0±10.0 years; p<0.001), and had a higher prevalence of cardiovascular risk factors including diabetes (31.5% vs 9.6%; p<0.001), hypertension (79.7% vs 51.7%; p<0.001), and renal failure (7.6% vs 2.0%; p<0.001). No difference was observed between groups in the risk of short- or long-term (median 2.0 years; interquartile range 1.0-3.0) post-PCI cardiovascular (hazard ratio [HR] 1.08; 0.83-1.40; p=0.55) or overall clinical events (HR 1.11; 0.93-1.32; p=0.26).

CONCLUSIONS

In patients with coronary artery disease, the risk of ACS is reduced by early initiation of LLT before revascularisation is required. Long-term outcomes of patients at high risk prescribed LLT before admission for ACS PCI may not differ from those of patients at lower risk commencing LLT after PCI for ACS.

Effect of Intensive Lipid-Lowering Therapy on Coronary Plaque Stabilization Derived from Optical Coherence Tomography: a Meta-analysis and Meta-regression

PURPOSE

The definitive impacts of intensive lipid-lowering therapy (LLT) on plaque stabilization and the relationship between the key markers during LLT and plaque stability remain unquestioned. Thus, these meta-analysis and meta-regression intend to holistically evaluate the influence exerted by rigorous LLT on the minimum fibrous cap thickness (FCT) and maximum lipid arc as discerned through optical coherence tomography (OCT). This study further scrutinizes the correlation of this impact with variations in high-sensitivity C-reactive protein (hs-CRP), low-density lipoprotein cholesterol (LDL-C), or additional parameters within patients diagnosed with coronary artery disease (CAD).

METHODS

Comprehensive searches were conducted on platforms including PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs) published until June 1, 2023. The search was language agnostic and targeted RCTs elaborating on the correlation between high-intensity statin therapy or statins used concomitantly with other lipid-lowering medications and the minimum FCT and maximum lipid arc as assessed by OCT. The meta-analyses were executed employing a standard mean difference (SMD) algorithm with random-effects on continuous variables. These methodologies align with the Preferred Reporting Items for Systematic and Meta-analysis (PRISMA) guidelines.

RESULTS

A spectrum of 12 RCTs engaging 972 patients were identified and mobilized for these analyses. Meta-analysis outcomes depicted a conspicuous correlation between intensive LLT and an enhanced minimum FCT (12 studies with 972 participants; SMD, 0.87; 95% CI, 0.54 to 1.21; P < 0.01), reduced maximum lipid arc (9 studies with 564 participants; SMD, -0.43; 95% CI, -0.58 to -0.29; P < 0.01). Meta-regression analysis has determined an association of elevated minimum FCT with decreased LDL-C (β, -0.0157; 95% CI, -0.0292 to -0.0023; P = 0.025), total cholesterol (TC) (β, -0.0154; 95% CI, -0.0303 to -0.0005; P = 0.044), and apolipoprotein B (ApoB) (β, -0.0209; 95% CI, -0.0361 to -0.0057; P = 0.022). However, no significant association was discerned relative to variations in hs-CRP/CRP (β, -0.1518; 95% CI, -1.3766 to -1.0730; P = 0.772), triglyceride (TG) (β, -0.0030; 95% CI, -0.0258 to -0.0318; P = 0.822), and high-density lipoprotein cholesterol (HDL-C) (β, 0.0313; 95% CI, -0.0965 to 0.1590; P = 0.608). Subsequent subgroup meta-analysis demonstrated that high-intensity statin therapy (5 studies with 204 participants; SMD, 1.03; 95% CI, 0.67 to 1.39; P < 0.01), as well as a combinative approach including PCSK9 antibodies and statins (3 studies with 522 participants; SMD, 1.17; 95% CI, 0.62 to 1.73; P < 0.01) contributed to an increase in minimum FCT. Parallelly, high-intensity statin therapy (4 studies with 183 participants; SMD, -0.42; 95% CI, -0.65 to -0.19; P < 0.01) or the combined application of PCSK9 antibodies and statins (2 studies with 222 participants; SMD, -0.98; 95% CI, -1.26 to -0.70; P < 0.01) was evidenced to decrease the maximum lipid arc.

CONCLUSIONS

Intensive LLT, mainly high-intensity statin therapy and combined PCSK9 antibody with statin, has a beneficial effect on coronary plaque stabilization derived from OCT in patients with CAD. Coronary plaque stabilization is primarily due to lipid-lowering effect, not anti-inflammatory effect. Moreover, the lipid-lowering effect has nothing to do with the changes in HDL-C and TG, but is mainly related to the reduction of LDL-C, TC, and ApoB.