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Lima do Vale MR, Buckner L, Mitrofan CG, Tramontt CR, Kargbo SK, Khalid A, Ashraf S, Mouti S, Dai X, Unwin D, Bohn J, Goldberg L, Golubic R, Ray S. A synthesis of pathways linking diet, metabolic risk and cardiovascular disease: a framework to guide further research and approaches to evidence-based practice. Nutr Res Rev 2023; 36:232-258. [PMID: 34839838 DOI: 10.1017/s0954422421000378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Cardiovascular disease (CVD) is the most common non-communicable disease occurring globally. Although previous literature has provided useful insights into the important role that diet plays in CVD prevention and treatment, understanding the causal role of diets is a difficult task considering inherent and introduced weaknesses of observational (e.g. not properly addressing confounders and mediators) and experimental research designs (e.g. not appropriate or well designed). In this narrative review, we organised current evidence linking diet, as well as conventional and emerging physiological risk factors, with CVD risk, incidence and mortality in a series of diagrams. The diagrams presented can aid causal inference studies as they provide a visual representation of the types of studies underlying the associations between potential risk markers/factors for CVD. This may facilitate the selection of variables to be considered and the creation of analytical models. Evidence depicted in the diagrams was systematically collected from studies included in the British Nutrition Task Force report on diet and CVD and database searches, including Medline and Embase. Although several markers and disorders linked to conventional and emerging risk factors for CVD were identified, the causal link between many remains unknown. There is a need to address the multifactorial nature of CVD and the complex interplay between conventional and emerging risk factors with natural and built environments, while bringing the life course into the spotlight.
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Affiliation(s)
| | - Luke Buckner
- NNEdPro Global Centre for Nutrition and Health, Cambridge, UK
| | | | | | | | - Ali Khalid
- NNEdPro Global Centre for Nutrition and Health, Cambridge, UK
| | - Sammyia Ashraf
- NNEdPro Global Centre for Nutrition and Health, Cambridge, UK
| | - Saad Mouti
- University of California Berkeley, Consortium for Data Analytics in Risk, Berkeley, CA, USA
| | - Xiaowu Dai
- University of California Berkeley, Consortium for Data Analytics in Risk, Berkeley, CA, USA
| | | | - Jeffrey Bohn
- University of California Berkeley, Consortium for Data Analytics in Risk, Berkeley, CA, USA
- Swiss Re Institute, Zürich, Switzerland
| | - Lisa Goldberg
- University of California Berkeley, Consortium for Data Analytics in Risk, Berkeley, CA, USA
| | - Rajna Golubic
- NNEdPro Global Centre for Nutrition and Health, Cambridge, UK
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Diabetes Trials Unit, University of Oxford, Oxford, UK
| | - Sumantra Ray
- NNEdPro Global Centre for Nutrition and Health, Cambridge, UK
- University of Ulster, School of Biomedical Sciences, Coleraine, UK
- University of Cambridge, School of the Humanities and Social Sciences, Cambridge, UK
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Panagiotakos D, Chrysohoou C, Pitsavos C, Tsioufis K. Prediction of 10-year cardiovascular disease risk by diabetes status and lipoprotein-a levels; the HellenicSCORE II. Hellenic J Cardiol 2023:S1109-9666(23)00192-6. [PMID: 37913991 DOI: 10.1016/j.hjc.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/22/2023] [Accepted: 10/02/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND The aim of this study was to develop an updated model to predict 10-year cardiovascular disease (CVD) risk for Greek adults, i.e., the HellenicSCORE II+, based on smoking, systolic blood pressure (SBP), total and high-density-lipoprotein (HDL) cholesterol levels, and stratified by age group, sex, history of diabetes, and lipoprotein (Lp)-a levels. METHODS Individual CVD risk scores were calculated through logit-function models using the beta coefficients derived from SCORE2. The Attica study data were used for the calibration (3,042 participants, aged 45 (14) years; 49.1% men). Discrimination ability of the HellenicSCORE II+ was assessed using C-index (range 0-1), adjusted for competing risks. RESULTS The mean HellenicSCORE II+ score was 6.3% (95% confidence interval (CI) 5.9% to 6.6%) for men and 3.7% (95% CI 3.5% to 4.0%) for women (p < 0.001), and were higher compared to the relevant SCORE2; 23.5% of men were classified as low risk, 40.2% as moderate, and 36.3% as high risk, whereas the corresponding percentages for women were 56.2%, 18.6%, and 25.2%. C-statistic index was 0.88 for women and 0.79 for men when the HellenicSCORE II+ was applied to the Attica study data, suggesting very good accuracy. Stratified analysis by Lp(a) levels led to a 4% improvement in correct classification among participants with high Lp(a). CONCLUSION HellenicSCORE II+ values were higher than SCORE2, confirming that the Greek population is at moderate-to-high CVD risk. Stratification by Lp(a) levels may assist in better identifying individuals at high CVD risk.
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Affiliation(s)
- Demosthenes Panagiotakos
- Department of Nutrition and Dietetics, School of Health Sciences and Education, Harokopio University, Athens, Greece.
| | - Christina Chrysohoou
- First Cardiology Clinic, Hippokration Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Christos Pitsavos
- First Cardiology Clinic, Hippokration Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Konstantinos Tsioufis
- First Cardiology Clinic, Hippokration Hospital, School of Medicine, University of Athens, Athens, Greece
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Feng T, Li Y, Xue X, Yang W, Li Q, Huang Y, Zhu T, Wang J, Xu L, Li X, Gao J, Sun S, Zhu B, Zhang S, Cao B, Xuan J, Zhao Z, Qian B. Association of statin use and increase in lipoprotein(a): a real-world database research. Eur J Med Res 2023; 28:212. [PMID: 37393291 DOI: 10.1186/s40001-023-01155-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 06/03/2023] [Indexed: 07/03/2023] Open
Abstract
BACKGROUND There is an increased concern that statins may have an unintended effect of elevated lipoprotein(a) [Lp(a)]. We conducted a large sample real-world study to test the association. METHODS This retrospective cohort study was conducted using data from an integrated SuValue database, which includes 221 hospitals across China covering more than 200,000 of population with longitudinal follow-up to 10 years. Propensity score matching was applied to identify two comparable cohorts with statin users and non-statin users. Detailed follow-up information such as Lp(a) levels were extracted. The hazard ratio was calculated on Lp(a) changes based on the statin usage cohorts. Detailed subgroup and different characteristic cohorts' analyses were also conducted. RESULTS After baseline propensity score matching, a total of 42,166 patients were included in a 1:1 matched ratio between statin users and non-statin users. In the case of no difference in low density lipoprotein (LDL-C), Lp(a) was increased significantly with the use of statins (adjusted HR 1.47; 95% confidence interval [CI] 1.43-1.50). Lp(a) increase was observed in various subgroup analyses and different cohorts. The dose intensity of statin was positively associated with the evaluated Lp(a) level. CONCLUSION The use of statins was associated with an increased risk of Lp(a) elevation compared with non-statin use counterparts. The clinical relevance of these increases needs to be addressed in surrogate marker trials and/or large, cardiovascular outcomes trials.
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Affiliation(s)
- Tienan Feng
- Hongqiao International Institute of Medicine, Shanghai Tongren Hospital and School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Second Affiliated Hospital of Chengdu Medical College, China National Nuclear Corporation 416 Hospital, Chengdu, Sichuan, China
| | - Yao Li
- Clinical Center for Intelligent Rehabilitation Research, Shanghai YangZhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), School of Medicine, Tongji University, Shanghai, China
| | | | - Wei Yang
- SuValue Health Ltd, Shanghai, China
| | - Qiang Li
- Hongqiao International Institute of Medicine, Shanghai Tongren Hospital and School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yushi Huang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Tengteng Zhu
- Hongqiao International Institute of Medicine, Shanghai Tongren Hospital and School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jue Wang
- Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Limin Xu
- Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xianchen Li
- Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Gao
- Hongqiao International Institute of Medicine, Shanghai Tongren Hospital and School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - Bin Zhu
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - ShuYu Zhang
- Second Affiliated Hospital of Chengdu Medical College, China National Nuclear Corporation 416 Hospital, Chengdu, Sichuan, China
| | - Beibei Cao
- Department of Printing Equipment Engineering, Shanghai Publishing and Printing College, Shanghai, China
| | - Jianwei Xuan
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA.
| | - Zhigang Zhao
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Biyun Qian
- Hongqiao International Institute of Medicine, Shanghai Tongren Hospital and School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Abstract
Importance Lipoprotein(a) (Lp[a]) is a low-density lipoprotein (LDL) cholesterol-like particle bound to apolipoprotein(a). This novel marker of cardiovascular disease acts through induction of vascular inflammation, atherogenesis, calcification, and thrombosis. While an absolute risk threshold remains to be universally accepted, an estimated 20% to 25% of the global population have Lp(a) levels of 50 mg/dL or higher, a level noted by the European Atherosclerosis Society to confer increased cardiovascular risk. Observations Compelling evidence from pathophysiological, observational, and genetic studies suggest a potentially causal association between high Lp(a) levels, atherosclerotic cardiovascular disease, and calcific aortic valve stenosis. Additional evidence has demonstrated that elevated Lp(a) levels are associated with a residual cardiovascular risk despite traditional risk factor optimization, including LDL cholesterol reduction. These findings have led to the formulation of the Lp(a) hypothesis, namely that Lp(a) lowering leads to cardiovascular risk reduction, intensifying the search for Lp(a)-reducing therapies. The ineffectiveness of lifestyle modification, statins, and ezetimibe to lower Lp(a); the modest Lp(a) reduction with proprotein convertase subtilisin/kexin type 9 inhibitors; the adverse effect profile and unclear cardiovascular benefit of pharmacotherapies such as niacin and mipomersen; and the impracticality of regular lipoprotein apheresis represent major challenges to currently available therapies. Nevertheless, emerging nucleic acid-based therapies, such as the antisense oligonucleotide pelacarsen and the small interfering RNA olpasiran, are generating interest because of their potent Lp(a)-lowering effects. Assessment of new-onset diabetes in patients achieving very low Lp(a) levels will be important in future trials. Conclusions and Relevance Epidemiologic and genetic studies suggest a potentially causal association between elevated Lp(a) levels, atherosclerotic cardiovascular disease, and aortic valve stenosis. Emerging nucleic acid-based therapies have potent Lp(a)-lowering effects and appear safe; phase 3 trials will establish whether they improve cardiovascular outcomes.
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Affiliation(s)
- Freddy Duarte Lau
- Department of Medicine, Yale New Haven Health, Bridgeport, Connecticut
| | - Robert P Giugliano
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Lippi G, Favaloro EJ, Sanchis-Gomar F. Antisense lipoprotein[a] therapy: State-of-the-art and future perspectives. Eur J Intern Med 2020; 76:8-13. [PMID: 32336611 DOI: 10.1016/j.ejim.2020.04.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 04/11/2020] [Accepted: 04/15/2020] [Indexed: 12/11/2022]
Abstract
Several lines of evidence now attest that lipoprotein[a] (Lp[a]) is a significant risk factor for many cardiovascular disorders. This enigmatic lipoprotein, composed of a single copy of apolipoprotein B (apoB) and apolipoprotein[a] (apo [a]), expresses peculiar metabolism, virtually independent from lifestyle interventions. Several therapeutic options have hence been proposed for lowering elevated Lp[a] values, with or without concomitant effect on low density lipoprotein (LDL) particles, mostly encompassing statins, ezetimibe, nicotinic acid, lipoprotein apheresis, and anti-PCSK9 monoclonal antibodies. Since all these medical treatments have some technical and clinical drawbacks, a novel strategy is currently being proposed, based on the use of antisense apo[a] and/or apoB inhibitors. Although the role of these agents in hypercholesterolemic patients is now nearby entering clinical practice, the collection of information on Lp[a] is still underway. Preliminary evidence would suggest that apo[a] antisense therapy seems more appropriate in patients with isolated Lp[a] elevations, while apoB antisense therapy is perhaps more advisable in patients with isolated LDL elevations. In patients with concomitant elevations of Lp[a] and LDL, either combining the two apo[a] and apoB antisense therapies (a strategy which has never been tested), or the combination of well-known and relatively inexpensive drugs such as statins with antisense apo[a] inhibitors can be theoretically suggested. The results of an upcoming phase 3 study with antisense apo[a] inhibitors will hopefully provide definitive clues as to whether this approach may become the standard of care in patients with increased Lp[a] concentrations.
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Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy.
| | - Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Fabian Sanchis-Gomar
- Department of Physiology, Faculty of Medicine, University of Valencia and INCLIVA Biomedical Research Institute, Valencia, Spain
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Achieving low-density lipoprotein cholesterol targets as assessed by different methods in patients with familial hypercholesterolemia: an analysis from the HELLAS-FH registry. Lipids Health Dis 2020; 19:114. [PMID: 32466791 PMCID: PMC7257219 DOI: 10.1186/s12944-020-01289-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 05/15/2020] [Indexed: 12/21/2022] Open
Abstract
Background Familial hypercholesterolemia (FH) is characterized by elevated low-density lipoprotein cholesterol (LDL-C) levels and increased cardiovascular disease (CVD) risk. FH patients often have increased lipoprotein(a) [Lp(a)] levels, which further increase CVD risk. Novel methods for accurately calculating LDL-C have been proposed. Methods Patients with FH were recruited by a network of Greek sites participating in the HELLAS-FH registry. LDL-C levels were calculated using the Friedewald (LDL-CF) and the Martin/Hopkins (LDL-CM/H) equations as well as after correcting LDL-CM/H for Lp(a) levels [LDL-CLp(a)corM/H]. The objective was to compare LDL-C levels and target achievement as estimated by different methods in FH patients. Results This analysis included 1620 patients (1423 adults and 197 children). In adults at diagnosis, LDL-CF and LDL-CM/H levels were similar [235 ± 70 mg/dL (6.1 ± 1.8 mmol/L) vs 235 ± 69 mg/dL (6.1 ± 1.8 mmol/L), respectively; P = NS], while LDL-CLp(a)corM/H levels were non-significantly lower than LDL-CF [211 ± 61 mg/dL (5.5 ± 1.6 mmol/L); P = 0.432]. In treated adults (n = 966) both LDL-CF [150 ± 71 mg/dL (3.9 ± 1.8 mmol/L)] and LDL-CM/H levels [151 ± 70 mg/dL (6.1 ± 1.8 mmol/L); P = 0.746] were similar, whereas LDL-CLp(a)corM/H levels were significantly lower than LDL-CF [121 ± 62 mg/dL (3.1 ± 1.6 mmol/L); P < 0.001]. Target achievement as per latest guidelines in treated patients using the LDL-CM/H (2.5%) and especially LDL-CLp(a)corM/H methods (10.7%) were significantly different than LDL-CF (2.9%; P < 0.001). In children, all 3 formulas resulted in similar LDL-C levels, both at diagnosis and in treated patients. However, target achievement by LDL-CF was lower compared with LDL-CM/H and LDL-CLp(a)corM/H methods (22.1 vs 24.8 vs 33.3%; P < 0.001 for both comparisons). Conclusion LDL-CLp(a)corM/H results in significantly lower values and higher target achievement rate in both treated adults and children. If validated in clinical trials, LDL-CLp(a)corM/H may become the method of choice to more accurately estimate ‘true’ LDL-C levels in FH patients.
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