Systematic review on the risk and benefit of different cholesterol-lowering interventions

Colesevelam - a bile acid sequestrant for treating hypercholesterolemia and improving hyperglycemia

INTRODUCTION

Low density Lipoprotein cholesterol)LDL-C) levels show a clear relationship with cardiovascular disease (CVD). Statins are first line agents to reduce LDL-C and CVD risk. However, combination lipid-lowering therapy is often required to achieve large reductions in LDL-C.

AREA COVERED

Colesevelam HCl is a bile acid sequestrant (BAS), which reduces LDL-C by 16-22% in monotherapy and adds a further 12-14% reduction in LDL-C when combined with other lipid-lowering drugs. Like statins, colesevelam reduces C-reactive protein levels by 16% in monotherapy and additional 6% when added to statins. Colesevelam also reduced HbA_1c by 4mmol/mol (0.5%) when used alone and added to other hypoglycaemic drugs in studies of patients with diabetes .

EXPERT OPINION

Bile acid sequestrants reduce LDL-C and HbA_1c and have some CVD outcome evidence. The uses of these agents are limited in patients with gastrointestinal disease or high triglycerides due to adverse effects on gut function and raising triglycerides and they interfere with the absorption of lipid-soluble drugs. Colesevelam has a higher bile acid binding capacity, and fewer adverse effects than other BAS. Colesevelam may be useful as a third line agent for treatment of hypercholesterolemia with some additional specific benefits on glycemic control.

Lipidomic Analysis to Assess Oxidative Stress in Acute Coronary Syndrome and Acute Stroke Patients

Alterations in lipid metabolism mediated by oxidative stress play a key role in the process of atherosclerosis and superimposed thrombosis; these can lead to acute coronary syndrome (ACS) and acute ischemic stroke (AIS). Multiple studies have shown that the formation of atheromatous lesions is initiated by oxidation of low-density lipoproteins incorporated into the intima of the vessel wall. Here, we studied lipids in plasma samples from three cohorts: 61 patients with ACS (group A), 49 patients with AIS (group D), and 82 controls (group K). Untargeted lipidomics based on high-performance liquid chromatography coupled to mass spectrometry (UHPLC-HRMS) was employed to obtain comprehensive information on whether relationships exist between these patient categories based on lipid patterns. In addition, malondialdehyde (MDA) as a standard marker of oxidative stress was monitored. The most characteristic lipids in group K were fatty acyls of hydroxyfatty acids (FAHFAs). As expected, MDA concentrations were the lowest in group K. Our findings can better explain ongoing pathologies, both acute and chronic, with the potential for future diagnosis and treatment.

Atherosclerosis: Conventional intake of cardiovascular drugs versus delivery using nanotechnology - A new chance for causative therapy?

Atherosclerosis is the leading cause of death in developed countries. The pathogenetic mechanism relies on a macrophage-based immune reaction to low density lipoprotein (LDL) deposition in blood vessels with dysfunctional endothelia. Thus, atherosclerosis is defined as a chronic inflammatory disease. A plethora of cardiovascular drugs have been developed and are on the market, but the major shortcoming of standard medications is that they do not address the root cause of the disease. Statins and thiazolidinediones that have recently been recognized to exert specific anti-atherosclerotic effects represent a potential breakthrough on the horizon. But their whole potential cannot be realized due to insufficient availability at the pathological site and severe off-target effects. The focus of this review will be to elaborate how both groups of drugs could immensely profit from nanoparticulate carriers. This delivery principle would allow for their accumulation in target macrophages and endothelial cells of the atherosclerotic plaque, increasing bioavailability where it is needed most. Based on the analyzed literature we conclude design criteria for the delivery of statins and thiazolidinediones with nanoparticles for anti-atherosclerotic therapy. Nanoparticles need to be below a diameter of 100 nm to accumulate in the atherosclerotic plaque and should be fabricated using biodegradable materials. Further, the thiazolidinediones or statins must be encapsulated into the particle core, because especially for thiazolidindiones the uptake into cells is prerequisite for their mechanism of action. For optimal uptake into targeted macrophages and endothelial cells, the ideal particle should present ligands on its surface which bind specifically to scavenger receptors. The impact of statins on the lectin-type oxidized LDL receptor 1 (LOX1) seems particularly promising because of its outstanding role in the inflammatory process. Using this pioneering concept, it will be possible to promote the impact of statins and thiazolidinediones on macrophages and endothelial cells and significantly enhance their anti-atherosclerotic therapeutic potential.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY GUIDELINES FOR MANAGEMENT OF DYSLIPIDEMIA AND PREVENTION OF CARDIOVASCULAR DISEASE

OBJECTIVE

The development of these guidelines is mandated by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs).

METHODS

Recommendations are based on diligent reviews of the clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols.

RESULTS

The Executive Summary of this document contains 87 recommendations of which 45 are Grade A (51.7%), 18 are Grade B (20.7%), 15 are Grade C (17.2%), and 9 (10.3%) are Grade D. These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world medical care. The evidence base presented in the subsequent Appendix provides relevant supporting information for Executive Summary Recommendations. This update contains 695 citations of which 203 (29.2 %) are EL 1 (strong), 137 (19.7%) are EL 2 (intermediate), 119 (17.1%) are EL 3 (weak), and 236 (34.0%) are EL 4 (no clinical evidence).

CONCLUSION

This CPG is a practical tool that endocrinologists, other health care professionals, health-related organizations, and regulatory bodies can use to reduce the risks and consequences of dyslipidemia. It provides guidance on screening, risk assessment, and treatment recommendations for a range of individuals with various lipid disorders. The recommendations emphasize the importance of treating low-density lipoprotein cholesterol (LDL-C) in some individuals to lower goals than previously endorsed and support the measurement of coronary artery calcium scores and inflammatory markers to help stratify risk. Special consideration is given to individuals with diabetes, familial hypercholesterolemia, women, and youth with dyslipidemia. Both clinical and cost-effectiveness data are provided to support treatment decisions.

ABBREVIATIONS

4S = Scandinavian Simvastatin Survival Study A1C = glycated hemoglobin AACE = American Association of Clinical Endocrinologists AAP = American Academy of Pediatrics ACC = American College of Cardiology ACE = American College of Endocrinology ACS = acute coronary syndrome ADMIT = Arterial Disease Multiple Intervention Trial ADVENT = Assessment of Diabetes Control and Evaluation of the Efficacy of Niaspan Trial AFCAPS/TexCAPS = Air Force/Texas Coronary Atherosclerosis Prevention Study AHA = American Heart Association AHRQ = Agency for Healthcare Research and Quality AIM-HIGH = Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides trial ASCVD = atherosclerotic cardiovascular disease ATP = Adult Treatment Panel apo = apolipoprotein BEL = best evidence level BIP = Bezafibrate Infarction Prevention trial BMI = body mass index CABG = coronary artery bypass graft CAC = coronary artery calcification CARDS = Collaborative Atorvastatin Diabetes Study CDP = Coronary Drug Project trial CI = confidence interval CIMT = carotid intimal media thickness CKD = chronic kidney disease CPG(s) = clinical practice guideline(s) CRP = C-reactive protein CTT = Cholesterol Treatment Trialists CV = cerebrovascular CVA = cerebrovascular accident EL = evidence level FH = familial hypercholesterolemia FIELD = Secondary Endpoints from the Fenofibrate Intervention and Event Lowering in Diabetes trial FOURIER = Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects With Elevated Risk trial HATS = HDL-Atherosclerosis Treatment Study HDL-C = high-density lipoprotein cholesterol HeFH = heterozygous familial hypercholesterolemia HHS = Helsinki Heart Study HIV = human immunodeficiency virus HoFH = homozygous familial hypercholesterolemia HPS = Heart Protection Study HPS2-THRIVE = Treatment of HDL to Reduce the Incidence of Vascular Events trial HR = hazard ratio HRT = hormone replacement therapy hsCRP = high-sensitivity CRP IMPROVE-IT = Improved Reduction of Outcomes: Vytorin Efficacy International Trial IRAS = Insulin Resistance Atherosclerosis Study JUPITER = Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin LDL-C = low-density lipoprotein cholesterol Lp-PLA2 = lipoprotein-associated phospholipase A2 MACE = major cardiovascular events MESA = Multi-Ethnic Study of Atherosclerosis MetS = metabolic syndrome MI = myocardial infarction MRFIT = Multiple Risk Factor Intervention Trial NCEP = National Cholesterol Education Program NHLBI = National Heart, Lung, and Blood Institute PCOS = polycystic ovary syndrome PCSK9 = proprotein convertase subtilisin/kexin type 9 Post CABG = Post Coronary Artery Bypass Graft trial PROSPER = Prospective Study of Pravastatin in the Elderly at Risk trial QALY = quality-adjusted life-year ROC = receiver-operator characteristic SOC = standard of care SHARP = Study of Heart and Renal Protection T1DM = type 1 diabetes mellitus T2DM = type 2 diabetes mellitus TG = triglycerides TNT = Treating to New Targets trial VA-HIT = Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial VLDL-C = very low-density lipoprotein cholesterol WHI = Women's Health Initiative.

Multicentric randomized clinical trial to evaluate the long-term effectiveness of a motivational intervention against smoking, based on the information obtained from spirometry in primary care: the RESET study protocol

Background

Spirometry is the recommended method of evaluating pulmonary function when respiratory disease is suspected in smokers. Nonetheless, no evidence exists of the usefulness of information obtained from this test as a motivational strategy for smoking cessation. The primary objective of this study is to evaluate the effectiveness of a motivational intervention based on spirometry results in achieving long-term smoking cessation.

Methods/Design

We propose a multicenter randomized clinical trial in the primary care setting. Study subjects: We will recruit active smokers of both sexes, aged 35-70 years, with a cumulated smoking habit exceeding 10 packs/year and who consult for any reason with their primary care physician in the 20 health centers in the province of Tarragona (Spain). Patients with a history of lung disease or who have undergone exploratory measures of pulmonary function in the preceding 12 months will be excluded. All patients who agree to participate will provide signed informed consent prior to their inclusion. A total of 1000 smokers will be consecutively randomized to a control or intervention group (1:1). Intervention: Participants in both groups will receive brief (5-minute) health counseling, in accordance with usual clinical practice. In a consultation lasting about 15 minutes, participants in the intervention group will also receive detailed, personalized information about the results of a spirometry test and about their lung age compared with their chronological age. Both groups will be followed up for 12 months. Main variables and analysis: The main variable will be sustained smoking abstinence at 12 months after the intervention, as confirmed by CO breath testing and urine cotinine test. Results will be analyzed based on intention to treat, using the chi-square test and logistical regression if necessary to adjust for confounding variables.

Discussion

We expect the rate of prolonged smoking abstinence in the intervention group will be at least 5 % higher than in the control group. If this strategy proves effective, it could easily be included in the health promotion activities offered in primary care settings.

Trial registration

ClinicalTrials.gov Identifier: NCT02153047. Registered on 28/05/2014

Function-impairing polymorphisms of the hepatic uptake transporter SLCO1B1 modify the therapeutic efficacy of statins in a population-based cohort

BACKGROUND

The efficacy of statins, which are used commonly in primary and secondary prevention of cardiovascular diseases, shows a wide range of interindividual variability. Genetic variants of OATP1B1, a hepatic uptake transporter, can modify access of statins to its therapeutic target, thereby potentially altering drug efficacy. We studied the impact of genetic variants of OATP1B1 on the lipid-lowering efficacy of statins in a population-based setting.

MATERIALS AND METHODS

The basis of the analysis was the Study of Health in Pomerania, a cohort of 2732 men and women aged 20-81 years. Included in the statistical analysis to evaluate the impact of OATP1B1 on therapeutic efficacy of statins were 214 individuals diagnosed with dyslipidaemia during initial recruitment and receiving statins during the 5-year follow-up.

RESULTS

Analysing the impact of the OATP1B1 genotype, we observed a trend for lower statin-induced total cholesterol reduction in carriers of the SLCO1B1 512C variant. Restricting the analysis to patients receiving simvastatin, pravastatin, lovastatin and fluvastatin indicated a statistically significant association of the OATP1B1 genotype on lipid parameters at the 5-year follow-up. No such effect was observed for atorvastatin. Calculation of achievement of treatment goals according to the NCEP-ATPIII guidelines showed a lower rate of successful treatment when harbouring the mutant allele for patients taking simvastatin (46.7 vs. 73.9%). A similar trend was observed for pravastatin (34.4 vs. 70.4%).

CONCLUSION

Genetic variants of OATP1B1 leading to impaired hepatic uptake of statins translated into reduced drug efficacy in a population-based cohort.

Improving the odds: ezetimibe and cardiovascular disease

The beauty of science is that well-conducted experiments provide answers to questions which were posed in times of greater ignorance. Cardiovascular disease (CVD) is the leading cause of death worldwide and will be for some time. Cholesterol is a critical player which drives the underlying pathophysiological process of atherosclerosis. Statins are the first line treatment for lipids in CVD given their ability to low-density lipoprotein cholesterol (LDL-C) by up to 50%, and their proven benefits in both primary and secondary intervention . Despite the unprecedented efficacy of statins, additional treatments are sought to potentially reduce the residual risk that remains despite statin treatment such as that associated with reduced high-density lipoprotein cholesterol levels (HDL-C) or triglycerides . In the last 5 years, several trials have reported on their potential additional benefit beyond statin therapy. These include omega-3 fatty acids in patients with prediabetes or diabetes , fibrates in diabetes , nicotinic acid/niacin in cardiovascular disease and cholesterol ester transfer protein inhibitors in cardiovascular disease . Despite their promise, none of these treatments were able to demonstrate benefit beyond baseline statin therapy when compared with placebo . The idea that benefit beyond statin treatment may be an unachievable goal has dogged the medical community working on CVD prevention. The phrase, 'Statins for atherosclerosis - as good as it gets?' was coined in 2005 and has rung true up until now .

Sugar-based amphiphilic nanoparticles arrest atherosclerosis in vivo

Atherosclerosis, the build-up of occlusive, lipid-rich plaques in arterial walls, is a focal trigger of chronic coronary, intracranial, and peripheral arterial diseases, which together account for the leading causes of death worldwide. Although the directed treatment of atherosclerotic plaques remains elusive, macrophages are a natural target for new interventions because they are recruited to lipid-rich lesions, actively internalize modified lipids, and convert to foam cells with diseased phenotypes. In this work, we present a nanomedicine platform to counteract plaque development based on two building blocks: first, at the single macrophage level, sugar-based amphiphilic macromolecules (AMs) were designed to competitively block oxidized lipid uptake via scavenger receptors on macrophages; second, for sustained lesion-level intervention, AMs were fabricated into serum-stable core/shell nanoparticles (NPs) to rapidly associate with plaques and inhibit disease progression in vivo. An AM library was designed and fabricated into NP compositions that showed high binding and down-regulation of both MSR1 and CD36 scavenger receptors, yielding minimal accumulation of oxidized lipids. When intravenously administered to a mouse model of cardiovascular disease, these AM NPs showed a pronounced increase in lesion association compared with the control nanoparticles, causing a significant reduction in neointimal hyperplasia, lipid burden, cholesterol clefts, and overall plaque occlusion. Thus, synthetic macromolecules configured as NPs are not only effectively mobilized to lipid-rich lesions but can also be deployed to counteract atheroinflammatory vascular diseases, highlighting the promise of nanomedicines for hyperlipidemic and metabolic syndromes.

Combination therapy with ezetimibe and simvastatin to achieve aggressive LDL reduction

A low-density lipoprotein (LDL) cholesterol goal of less than 100 mg/dl is recommended for patients at moderate to high risk of cardiovascular disease with an optional LDL goal of less than 70 mg/dl for patients at a very high risk of cardiovascular disease. Most patients will require reductions in LDL of more than 50% in order to achieve these more aggressive goals. Only a few agents will lower LDL by at least 50%. This review will focus on the efficacy and safety ezetimibe/simvastatin coadministered as a therapy with enhanced LDL-lowering efficacy, while minimizing the adverse effects of statins in a wide range of patients. Ezetimibe 10 mg/simvastatin 80 mg lowers LDL by approximately 60% and has been demonstrated to be superior to the highest doses of atorvastatin and rosuvastatin for lowering LDL and raising high-density lipoprotein.

Ginkgo suppresses atherosclerosis through downregulating the expression of connexin 43 in rabbits

INTRODUCTION

Ginkgo biloba extract (GBE) EGb761 is widely used for cardiovascular prevention. Here, we investigated the effects of GBE on atherosclerotic lesion development in rabbits with a high-fat diet.

MATERIAL AND METHODS

Forty New Zealand white male rabbits were randomly divided into four groups. The first two were the normal diet group (C) and the high-fat group (HF). The remaining two groups were those who received a high cholesterol diet supplemented with either the standard drug (simvastatin 2 mg/kg/day) or GBE (3 mg/kg/day). At 12 weeks, histopathological and chemical analyses were performed.

RESULTS

Plasma lipid measurement showed that GBE inhibited high-fat diet-induced increase of serum triglyceride (TG), total cholesterol (TC), and low density lipoprotein cholesterol (LDL-C) by 59.1% (0.9 ±0.2 4 mmol/l vs. 2.2 ±0.4 mmol/l), 18.2% (31.1 ±1.4 mmol/l vs. 38.0 ±0.4 mmol/l) and 15% (28.9 ±1.3 mmol/l vs. 34.0±1.0 mmol/l), respectively, at 12 weeks (p < 0.01). The en face Sudan IV-positive lesion area of the aorta in the GBE group (51.7 ±3.1%) was significantly lower compared with that in the HF group (88.2 ±2.2%; p < 0.01). The mean atherosclerotic lesion area of the GBE group was reduced by 53.2% compared with the HF group (p < 0.01). Immunohistochemistry and western blot analysis showed that GBE markedly suppressed high-fat diet-induced upregulation of connexin 43 (Cx43) in rabbits (p < 0.01).

CONCLUSIONS

Thus, our study revealed that GBE prevented atherosclerosis progress through modulating plasma lipid, suppressing atherosclerotic lesion development, and attenuating the expression of Cx43 protein.

Framingham risk-based survival of non-small-cell lung cancer

This study was undertaken to determine whether the Framingham cardiovascular risk prediction model can identify patients who will have reduced 5-year survival after resection for primary lung cancer. The Framingham risk model for predicting cardiovascular death rates in a 5-year period was calculated for 1,981 patients undergoing resection for non-small-cell lung cancer. Receiver operator curve analysis was performed to determine a cutoff with regard to Framingham risk, and this was utilized to construct Kaplan-Meier survival curves for stages I, II, and III. Cox regression analysis was used to determine factors significantly affecting long-term survival. The Framingham risk model predicted that 0.015% to 26.7 % (mean, 5.2%) of our patients would die over a 5-year period. Univariate analysis revealed the Framingham score as being significant for stages I and II, but not III. Cox regression analysis demonstrated age, body mass index, pneumonectomy, stage I, stage III, stage IV, and Framingham score were all significant determinants of 5-year survival. Framingham-based cardiovascular risk prediction in patients undergoing resection for non-small-cell lung cancer stages I and II defined a group with significantly worse 5-year survival.

Adverse events associated with individual statin treatments for cardiovascular disease: an indirect comparison meta-analysis

BACKGROUND

Statins are the most widely prescribed drug available. Due to this reason, it is important to understand the risks involved with the drug class and individual statins.

AIM

We conducted a meta-analysis and employed indirect comparisons to identify differing risk effects across statins.

DESIGN

We included any randomized clinical trial (RCT) of atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin and simvastatin used for cardiovascular disease event prevention. The main outcome was adverse events [all-cause mortality, cancers, rhabdomylosis, diabetes, aspartate and alanine aminotransferase (AST/ALT), and creatinine kinase (CK) increases beyond the upper limit of normal]. In order to evaluate the relative effects of each drug on adverse events, we calculated adjusted indirect comparisons of the adverse-event outcomes.

RESULTS

Seventy-two trials involving 159,458 patients met our inclusion criteria. Overall, statin treatments significantly increased the rate of diabetes when compared to controls (OR: 1.09; 95% CI: 1.02-1.16) and elevated AST (OR: 1.31; 95% CI: 1.04-1.66) and ALT (OR: 1.28; 95% CI: 1.11-1.48) levels when compared to controls. Using indirect comparisons, we also found that atorvastatin significantly elevated AST levels compared to pravastatin (OR: 2.21; 95% CI: 1.13-4.29) and simvastatin significantly increased CK levels when compared to rosuvastatin (OR: 4.39; 95% CI: 1.01-19.07). Higher dose studies had increased risk of AST elevations.

DISCUSSION

Although statins are generally well tolerated, there are risks associated with almost all drugs. With few exceptions, statins appear to exert a similar risk across individual drugs.

Salmon consumption by pregnant women reduces ex vivo umbilical cord endothelial cell activation

BACKGROUND

In vitro exposure of endothelial cells (ECs) to n-3 (omega-3) long-chain PUFAs (LCPUFAs) reduces cell adhesion molecule (CAM) expression. However, to our knowledge, no previous human studies have examined the influence of an altered diet on CAM expression.

OBJECTIVE

We assessed whether salmon (rich in n-3 LCPUFAs) consumption twice a week during pregnancy affected offspring umbilical vein EC CAM expression.

DESIGN

Women were randomly assigned to maintain their habitual diets or to consume 2 portions of salmon per week during pregnancy months 4-9. ECs were isolated from umbilical cord veins collected at birth and cultured. The cell surface expression of intercellular adhesion molecule 1 (ICAM-1) and vascular cell adhesion molecule 1 (VCAM-1) was assessed by flow cytometry after the culture of ECs in the presence and absence of bacterial LPS for 24 h. Cytokine and growth factor concentrations in culture supernatant fluid were measured by using a multiplex assay.

RESULTS

LPS increased the expression of VCAM-1 and the production of several cytokines and growth factors. The level of ICAM-1 expression per cell [ie, the median fluorescence intensity (MFI)] was increased by LPS stimulation in the control group (16.9 ± 2.4 compared with 135.3 ± 20.2; P < 0.001) and to a lesser extent in the salmon group (14.1 ± 3.8 compared with 65.8 ± 22.4; P = 0.037). The ICAM-1 MFI in the salmon group after LPS stimulation was lower than in the control group (P = 0.006).

CONCLUSION

Increased dietary salmon intake in pregnancy dampens offspring EC activation, which implicates a role for n-3 LCPUFAs in the suppression of inflammatory processes in humans. This trial was registered at clinicaltrials.gov as NCT00801502.

Stage-specific remodeling of atherosclerotic lesions upon cholesterol lowering in LDL receptor knockout mice

Reducing the concentration of circulating lipids leads to decreased cardiovascular morbidity and mortality, but the dynamic remodeling that established atherosclerotic lesions undergo upon lipid lowering is poorly understood. Early or advanced lesions in the aortic root were induced by feeding LDL receptor knockout mice a high-fat, high-cholesterol Western-type diet for 5 or 9 weeks, respectively. In the first week after switching to a chow diet, plasma total cholesterol levels dropped 70%, but both early and advanced lesions increased in size. Early lesions grew because of an increase in smooth muscle cells; advanced lesions had an enlargement of absolute macrophage area. From 1 to 3 weeks after the diet switch, plasma total cholesterol levels were completely normalized, but the size of early lesions remained stable; however, advanced lesions became smaller due to a reduction of the absolute macrophage area. From 3 to 6 weeks, both early and advanced lesions progressed further, as a result of expansion of the absolute collagen and necrotic core area. In contrast, early lesions became proinflammatory, as evidenced by the increased infiltration of neutrophils and increased oxidative stress, probably caused by the activation of mast cells in the adventitia. Thus, the severity of atherosclerotic lesions affects their dynamic response to lipid lowering, indicating the importance of establishing stage-specific therapeutic protocols for the treatment of atherosclerosis.

Polymer-based therapeutics: nanoassemblies and nanoparticles for management of atherosclerosis

Coronary arterial disease, one of the leading causes of adult mortality, is triggered by atherosclerosis. A disease with complex etiology, atherosclerosis results from the progressive long-term combination of atherogenesis, the accumulation of modified lipoproteins within blood vessel walls, along with vascular and systemic inflammatory processes. The management of atherosclerosis is challenged by the localized flare-up of several multipronged signaling interactions between activated monocytes, atherogenic macrophages and inflamed or dysfunctional endothelial cells. A new generation of approaches is now emerging founded on multifocal, targeted therapies that seek to reverse or ameliorate the atheroinflammatory cascade within the vascular intima. This article reviews the various classes and primary examples of bioactive configurations of nanoscale assemblies. Of specific interest are polymer-based or polymer-lipid micellar assemblies designed as multimodal receptor-targeted blockers or drug carriers whose activity can be tuned by variations in polymer hydrophobicity, charge, and architecture. Also reviewed are emerging reports on multifunctional nanoassemblies and nanoparticles for improved circulation and enhanced targeting to atheroinflammatory lesions and atherosclerotic plaques.

Intensive statin therapy compared with moderate dosing for prevention of cardiovascular events: a meta-analysis of >40 000 patients

AIMS

Statin therapy is associated with important benefits for patients at risk of, and with, established cardiovascular disease. There is widespread interest in whether intensive dosing of statins yields larger treatment effects. We aimed to determine if intensive dosing is clinically important using a meta-analysis of randomized clinical trials (RCTs).

METHODS

We conducted comprehensive searches of electronic databases from inception to December 2010. We included any RCT evaluating a larger dose with a clinically common dose. Two reviewers independently extracted data, in duplicate. We performed random-effects meta-analysis and a trial sequential analysis.

RESULTS

We identified 10 RCTs enrolling a total of 41 778 participants. Trials followed patients for a mean of 2.5 years. We did not find statistically significant effects on all-cause mortality [relative risk (RR) 0.92, 95% confidence interval (CI), 0.83-1.03, P = 0.14, I(2) = 38%] or cardiovascular disease (CVD) deaths (RR 0.89, 95% CI, 0.78-1.01, P = 0.07, I(2) = 34%). When we pooled the composite endpoint of coronary heart disease (CHD) death plus non-fatal myocardial infarction (MI), we found a significant protective effect of intensive statin dosing (RR 0.90, 95% CI, 0.84-0.96, P ≤ 0.0001, I(2) = 0%). We also found a significant effect on non-fatal MIs (RR 0.82, 95% CI, 0.76-0.89, P ≤ 0.0001, I(2) = 0%) and a significant reduction in the composite of fatal and non-fatal strokes (excluding transient ischaemic attacks) reported in 10 RCTs (RR 0.86, 95% CI, 0.77-0.96, P = 0.006, I(2) = 0%). A subgroup analysis of three trials examining acute coronary syndrome patients found significant effects on all-cause (RR 0.75, 95% CI, 0.61-0.91, P = 0.005, I(2) = 0%) and CVD mortality (RR 0.74, 95% CI, 0.59-0.94, P = 0.013, I(2) = 0%) with intensive dosing. Applying an analysis of optimal information size on the primary analysis, we found that the evidence for CHD death plus non-fatal MIs is conclusive. The evidence for CVD deaths alone is not yet conclusive.

CONCLUSIONS

Available evidence suggests that intensive statin therapy reduces the risk of non-fatal events and may have a role in reducing mortality.

Efficacy and safety of statin treatment for cardiovascular disease: a network meta-analysis of 170,255 patients from 76 randomized trials

BACKGROUND

Statins represent the largest selling class of cardiovascular drug in the world. Previous randomized trials (RCTs) have demonstrated important clinical benefits with statin therapy.

AIM

We combined evidence from all RCTs comparing a statin with placebo or usual care among patients with and without prior coronary heart disease (CHD) to determine clinical outcomes.

DESIGN

We searched independently, in duplicate, 12 electronic databases (from inception to August 2010), including full text journal content databases, to identify all statin versus inert control RCTs. We included RCTs of any statin versus any non-drug control in any populations. We abstracted data in duplicate on reported major clinical events and adverse events. We performed a random-effects meta-analysis and meta-regression. We performed a mixed treatment comparison using Bayesian methods.

RESULTS

We included a total of 76 RCTs involving 170,255 participants. There were a total of 14,878 deaths. Statin therapy reduced all-cause mortality, Relative Risk (RR) 0.90 [95% confidence interval (CI) 0.86-0.94, P ≤ 0.0001, I(2)=17%]; cardiovascular disease (CVD) mortality (RR 0.80, 95% CI 0.74-0.87, P<0.0001, I(2)=27%); fatal myocardial infarction (MI) (RR 0.82, 95% CI 0.75-0.91, P<0.0001, I(2)=21%); non-fatal MI (RR 0.74, 95% CI 0.67-0.81, P ≤ 0.001, I(2)=45%); revascularization (RR 0.76, 95% CI 0.70-0.81, P ≤ 0.0001); and a composite of fatal and non-fatal strokes (0.86, 95% CI 0.78-0.95, P=0.004, I(2)=41%). Adverse events were generally mild, but 17 RCTs reported on increased risk of development of incident diabetes [Odds Ratio (OR) 1.09; 95% CI 1.02-1.17, P=0.001, I(2)=11%]. Studies did not yield important differences across populations. We did not find any differing treatment effects between statins.

DISCUSSION

Statin therapies offer clear benefits across broad populations. As generic formulations become more available efforts to expand access should be a priority.

Development and results of a kidney disease knowledge survey given to patients with CKD

BACKGROUND

Little is known about disease-specific knowledge in patients with chronic kidney disease (CKD). We developed and examined the results of a survey to characterize kidney disease knowledge.

DESIGN

Survey about kidney disease knowledge, with questions developed by experts.

SETTING & PARTICIPANTS

401 adult patients with CKD (stages 1-5) attending a nephrology clinic from April-October 2009.

OUTCOMES & MEASUREMENTS

We calculated survey reliability using the Kuder-Richardson-20 coefficient and established construct validity by testing a priori hypotheses of associations between survey results and patient characteristics. We descriptively analyzed survey responses and applied linear regression analyses to evaluate associations with patient characteristics. Health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine.

RESULTS

Participants' median age was 58 (25th-75th percentile, 46-68) years, 83% were white, 18% had limited literacy, and 77% had CKD stages 3-5. The 28-question knowledge survey had good reliability (Kuder-Richardson-20 coefficient = 0.72), and mean knowledge score was 66% ± 15% (SD). In support of the construct validity of our knowledge survey, bivariate analysis shows that scores were associated with age (β = -0.01/10 years; 95% CI, -0.02 to -0.005; P = 0.003), formal education (β = 0.09; 95% CI, 0.03-0.15; P = 0.004), health literacy (β = 0.06; 95% CI, 0.03-0.10; P = 0.001), kidney education class participation (β = 0.05; 95% CI, 0.01-0.09; P = 0.009), knowing someone else with CKD (β = 0.05; 95% CI, 0.02-0.08; P = 0.001), and awareness of one's own CKD diagnosis (β = 0.07; 95% CI, 0.04-0.10; P < 0.001). Findings were similar in adjusted analyses.

LIMITATIONS

Recruitment from 1 clinic limits generalizability of findings.

CONCLUSIONS

For patients with CKD, this Kidney Knowledge Survey (KiKS) is reliable and valid and identifies areas of and risk factors for poor kidney knowledge. Further study is needed to determine the impact of CKD knowledge on self-care behaviors and clinical outcomes.

Colesevelam: an improved bile acid sequestrant for treating hypercholesterolemia and improving diabetes

There is a well-established association between serum cholesterol and coronary heart disease. Statins are the first-line agents for the treatment of hypercholesterolemia, yet combination therapy is required to achieve the desired reduction in low-density lipoprotein cholesterol (LDL-C). Niacin and bile acid sequestrants were among the first lipid-lowering drugs developed to lower LDL-C and have been established to be effective both in monotherapy and in combination therapy. However, tolerability and compliance issues have limited their use. Colesevelam HCl is the newest bile acid sequestrant and reduces LDL-C by 16-22% in monotherapy and adds 12-14% in combination dual therapy with statins, fibrates and ezetimibe or in triple therapy with statin and ezetimibe. It reduces C-reactive protein levels by 16-19% in monotherapy or by 23% in combination with statins and other lipid-lowering therapies. In addition, it consistently reduces hemoglobin A_1c by 0.5% in addition to other hypoglycemic drugs in studies of patients with diabetes. Compared with other bile acid sequestrants it has a higher bile acid-binding capacity, reduced adverse effects and, therefore, has better compliance. Colesevelam HCl is thus a useful addition to the lipid-lowering formulary as a second-line agent, particularly for patients with metabolic syndrome requiring extra reduction in LDL-C.

Smoking and atherosclerotic cardiovascular disease: Part I: atherosclerotic disease process

The normal endothelium inhibits platelet and leukocyte adhesion to the vascular surface maintaining a balance of profibrinolytic and prothrombotic activity. Endothelial function is assessed largely as endothelium-dependent vasomotion, partly based on the assumption that impaired endothelium-dependent vasodilation reflects the alteration of important endothelial functions. Atherosclerotic risk factors, such as hypercholesterolemia, hypertension, diabetes and smoking, are associated with endothelial dysfunction. In the diseased endothelium, the balance between pro- and antithrombotic, pro- and anti-inflammatory, pro- and antiadhesive or pro- and antioxidant effects shifts towards a proinflammatory, prothrombotic, pro-oxidative and proadhesive phenotype of the endothelium. A common mechanism underlying endothelial dysfunction is related to the increased vascular production of reactive oxygen species. Recent studies suggest that inflammation per se, and C-reactive protein in particular, may contribute directly to endothelial dysfunction. The loss of endothelial integrity is a hallmark of atherosclerosis and the causal possible link between each individual risk factor, the development of atherosclerosis and the subsequent clinical events, such as myocardial infarction or stroke.

[Advances in cholesterol-lowering interventions]

Numerous epidemiological and prospective studies have shown a direct relationship between total cholesterol and low-density lipoprotein cholesterol (LDL-C) and cardiovascular disease (cardiovascular morbidity and mortality). In many intervention studies with more than 100,000 subjects, statins have shown a powerful and significant reduction of cardiovascular events and a decrease in cardiovascular and overall mortality, far superior to those produced by any other lipid-lowering group. Consequently statins are considered to be safe and well tolerated and are the first choice in the treatment of hypercholesterolemia and in cardiovascular disease prevention. If targets are not reached, other pharmacological groups must be associated (resins, nicotinic acid, ezetimibe, fibrates, etc.). Moreover, when hypercholesterolemia is associated with low concentrations of high-density lipoprotein (HDL)-cholesterol and high triglyceride levels, the association of statins with nicotinic acid, fibrates or omega-3 should be considered. Some questions remain to be answered: what LDL-C levels are desirable in secondary prevention? Which individuals might benefit from treatment in primary prevention? Which lipid-lowering drug is the most suitable to combine with statins and diminish cardiovascular risk in each situation? The present article reviews these important points.

Synthesis of 4-(3-biaryl)quinoline sulfones as potent liver X receptor agonists

A series of 4-(3-biaryl)quinolines with sulfone substituents on the terminal aryl ring (8) was prepared as potential LXR agonists. High affinity LXRbeta ligands with generally modest binding selectivity over LXRalpha and excellent agonist potency in LXR functional assays were identified. Many compounds had LXRbeta binding IC(50) values <10 nM while the most potent had EC(50) values <1.0 nM in an ABCA1 mRNA induction assay in J774 mouse cells with efficacy comparable to T0901317. Sulfone 8a was further evaluated in LDL (-/-) mice and shown to reduce atherosclerotic lesion progression.

Meta-analysis of the effect of nicotinic acid alone or in combination on cardiovascular events and atherosclerosis

OBJECTIVE

High-density lipoprotein cholesterol (HDL-C) concentration is a strong predictor of cardiovascular events in both naïve and statin-treated patients. Nicotinic acid is an attractive option for decreasing residual risk in statin-treated or statin-intolerant patients since it increases HDL-C by up to 20% and decreases low-density lipoprotein cholesterol and lipoprotein(a) plasma concentrations.

METHODS

We performed a computerized PubMed literature search that focused on clinical trials evaluating niacin, alone or in combination with other lipid-lowering drugs, published between January 1966 and August 2008.

RESULTS

Among 587 citations, 29 full articles were read and 14 were eligible for inclusion. Overall 11 randomized controlled trials enrolled 2682 patients in the active group and 3934 in the control group. In primary analysis, niacin significantly reduced major coronary events (relative odds reduction=25%, 95% CI 13, 35), stroke (26%, 95% CI=8, 41) and any cardiovascular events (27%, 95% CI=15, 37). Except for stroke, the pooled between-group difference remained significant in sensitivity analysis excluding the largest trial. In comparison with the non-niacin group, more patients in the niacin group had regression of coronary atherosclerosis (relative increase=92%, 95% CI=39, 67) whereas the rate of patients with progression decreased by 41%, 95% CI=25, 53. Similar effects of niacin were found on carotid intima thickness with a weighted mean difference in annual change of -17 microm/year (95% CI=-22, -12).

CONCLUSIONS

Although the studies were conducted before statin therapy become standard care, and mostly in patients in secondary prevention, with various dosages of nicotinic acid 1-3g/day, this meta-analysis found positive effects of niacin alone or in combination on all cardiovascular events and on atherosclerosis evolution.

The cost-effectiveness of implementing a new guideline for cardiovascular risk management in primary care in the Netherlands

BACKGROUND

A new Dutch guideline for cardiovascular disease management substantially extends the number of individuals for whom treatment with statins and/or antihypertensive agents is recommended. We estimated the cost-effectiveness of implementing the new guideline at the national level.

METHODS

First, the number of currently untreated individuals who would become eligible for cholesterol-lowering or antihypertensive treatment under the new guideline was estimated using data from a recent population study. Cost-effectiveness of treating this group of patients was then assessed using a mathematical model.

RESULTS

Implementing the guideline in the age category 30-69 years would lead to an additional 465,000 individuals requiring treatment. Over a period of 20 years, the cumulative incidence of acute myocardial infarction in the whole population would drop by 3.0%, that of stroke by 3.9%, and all-cause mortality would drop by 0.9%. The lifetime cost-effectiveness ratio was calculated to be 15,000 Euro per quality-adjusted life year gained. In the age categories 70-79 years and 80 years or above, an additional 600,000 and 450,000 persons, respectively, would need to be treated, resulting in corresponding reductions in cumulative incidences of 14 and 18% (acute myocardial infarction), 17 and 22% (stroke), and 1.2 and 0.6% (all-cause mortality) with cost-effectiveness ratios of 20,800 and 32,300 Euro, respectively, per quality-adjusted life year.

CONCLUSION

Complete implementation of the new guideline would lead to a considerable increase in the number of individuals requiring treatment. This would be cost-effective up to the age of 70 years.

Efficacy of pharmacotherapies for short-term smoking abstinance: a systematic review and meta-analysis

BACKGROUND

Smoking cessation has important immediate health benefits. The comparative short-term effectiveness of smoking cessation interventions is not well known. We aimed to determine the relative effectiveness of nicotine replacement therapy (NRT), bupropion and varenicline at 4 weeks post-target quit date.

METHODS

We searched 10 electronic medical databases (inception to October 2008). We selected randomized clinical trials [RCTs] evaluating interventions for our primary outcome of abstinence from smoking at at-least 4 weeks post-target quit date, with biochemical confirmation. We conducted random-effects odds ratio (OR) meta-analysis and meta-regression. We compared treatment effects across interventions using head-to-head trials and calculated indirect comparisons.

RESULTS

We combined a total of 101 trials evaluating delivery of NRT versus inert controls at approximately 4 weeks post-target quit date (total n = 31,321). The pooled overall OR is OR 2.05 (95% Confidence Interval [CI], 1.89-2.23, P =< 0.0001). We pooled data from 31 bupropion trials contributing a total n of 11,118 participants and found a pooled OR of 2.25 (95% CI, 1.94-2.62, P =< 0.0001). We evaluated 9 varenicline trials compared to placebo. Our pooled estimate for cessation at 4 weeks post-target quit date found a pooled OR of 3.16 (95% CI, 2.55-3.91, P =< 0.0001). Two trials evaluated head to head comparisons of varenicline and bupropion and found a pooled estimate of OR 1.86 (95% CI, 1.49-2.33, P =< 0.0001 at 4 weeks post-target quit date. Indirect comparisons were: NRT and bupropion, OR, 1.09, 95% CI, 0.93-1.31, P = 0.28; varenicline and NRT, OR 1.56, 95% CI, 1.23-1.96, P = 0.0002; and, varenicline and bupropion, OR 1.40, 95% CI, 1.08-1.85, P = 0.01.

CONCLUSION

Pharmacotherapeutic interventions are effective for increasing smoking abstinence rates in the short-term.

Effect of shanzha, a Chinese herbal product, on obesity and dyslipidemia in hamsters receiving high-fat diet

AIM

The present study is designed to investigate the effect of shanzha (Crataegus pinnatifida) on obesity or dyslipidemia induced by high-fat diet in hamsters and characterize the role of PPARalpha in this action of shanzha.

MATERIALS AND METHODS

We induced dyslipidemia and obesity in hamsters using high-fat diet and treated hamsters with shanzha or vehicle for 7 days. We measured the body weight, adipose tissue weights, and food intake of hamsters. Plasma total cholesterol (TC), triglyceride (TG), LDL-cholesterol (LDL-C) and HDL-cholesterol (HDL-C) were determined at the beginning and end of this treatment. Effect of shanzha on adipogenesis was examined in vitro and change of PPARalpha was analyzed using Western blot.

RESULTS

The food intake, body weights, and weights of both brown and white adipose tissues were markedly reduced in hamsters receiving shanzha as compared with the vehicle-treated control. Plasma levels of TC, TG and LDL-C were decreased by this shanzha treatment while HDL-C was elevated. The effects of shanzha were reversed by the combined treatment with PPARalpha antagonist, MK886. Shanzha inhibited the fat droplet accumulation in 3T3-L1 adipocytes in a dose-dependent manner and this effect was abolished by MK886. Western blot results showed activation of PPARalpha by shanzha in hamster adipose tissue.

CONCLUSION

We suggest that shanzha could activate PPARalpha to improve dyslipidemia or obesity.

Lessons learned from statin trials

This article aims to review lessons learned about lipid lowering and statins in the past decade and to consider what developments the future may hold. Results from a series of landmark clinical trials confirm that statins significantly reduce cardiovascular morbidity and mortality in patients with and without previous coronary artery disease. The potential of this drug class has yet to be fully explored. Studies currently under way will answer many of the outstanding questions.

Primary prevention of cardiovascular mortality and events with statin treatments: a network meta-analysis involving more than 65,000 patients

OBJECTIVES

This study aimed to evaluate the effectiveness of 3-hydroxy-3-methyl-glutaryl-CoA reductase inhibitors (statins) in primary prevention of cardiovascular events.

BACKGROUND

The role of statins is well established for secondary prevention of cardiovascular disease (CVD) clinical events and mortality. Little is known of their role in primary cardiovascular event prevention.

METHODS

We conducted comprehensive searches of 10 electronic databases from inception to May 2008. We contacted study investigators and maintained a comprehensive bibliography of statin studies. We included randomized trials of at least 12-month duration in predominantly primary prevention populations. Two reviewers independently extracted data in duplicate. We performed random-effects meta-analysis and meta-regression, calculated optimal information size, and conducted a mixed-treatment comparison analysis.

RESULTS

We included 20 randomized clinical trials. We pooled 19 trials (n = 63,899) for all-cause mortality and found a relative risk (RR) of 0.93 (95% confidence interval [CI]: 0.87 to 0.99, p = 0.03 [I(2) = 5%, 95% CI: 0% to 51%]). Eighteen trials (n = 59,469) assessed cardiovascular deaths (RR: 0.89, 95% CI: 0.81 to 0.98, p = 0.01 [I(2) = 0%, 95% CI: 0% to 41%]). Seventeen trials (n = 53,371) found an RR of 0.85 (95% CI: 0.77 to 0.95, p = 0.004 [I(2) = 61%, 95% CI: 38% to 77%]) for major cardiovascular events, and 17 trials (n = 52,976) assessed myocardial infarctions (RR: 0.77, 95% CI: 0.63 to 0.95, p = 0.01 [I(2) = 59%, 95% CI: 24% to 74%]). Incidence of cancer was not elevated in 10 trials (n = 45,469) (RR: 1.02, 95% CI: 0.94 to 1.11, p = 0.59 [I(2) = 0%, 95% CI: 0% to 46%]), nor was rhabdomyolysis (RR: 0.97, 95% CI: 0.25 to 3.83, p = 0.96 [I(2) = 0%, 95% CI: 0% to 40%]). Our analysis included a sufficient sample to reliably answer our primary outcome of CVD mortality.

CONCLUSIONS

Statins have a clear role in primary prevention of CVD mortality and major events.

Targeted versus global approaches to the management of hypercholesterolaemia

AIMS

The role of statins in secondary prevention of cardiovascular disease is well established. However, there is debate about the most effective approach to primary prevention. This study simulated the effects of directed versus global approaches for intervention on coronary heart disease (CHD) event rates.

METHODS

A primary prevention population was generated by computer simulation derived from data from the National Health Survey for England. The efficacy of reductions in cholesterol, treatment to cardiovascular risk targets and effects of phytosterols or statins were assessed.

RESULTS

A 0.5 mmol/L reduction in population total cholesterol would result in a 10.4% reduction in CHD events, while 1.0 mmol/L, 1.5 mmol/L and 2.0 mmol/L reductions would achieve 21.0%, 30.6% and 41.9% reductions respectively. In statin-based cardiovascular risk targeted strategies, use of simvastatin 40 mg would result in 1.8% reduction by UK National Service Framework targets of 30%/decade CHD risk and 7.2% reduction in events for a 20%/decade target assuming perfect adherence. Similarly, aggressive primary prevention with 40 mg atorvastatin would result in a 2.5% or 10% reduction in events. Universal use of 10 mg simvastatin following an over-the-counter approach would result in a 25% reduction in CHD events. In contrast, whole population consumption of sitostanol/sitosterol products would result in 11.8% reduction.

CONCLUSION

Targeting and treating high-risk individuals may be beneficial for them and rewarding for medical practitioners. However, this approach has minimal effects on the population burden of atherosclerotic disease. This study suggests that universal therapy with phytosterols and/or wider availability of statins has the potential to dramatically decrease rates of CHD.

LDL-cholesterol differences predicted survival benefit in statin trials by the surrogate threshold effect (STE)

OBJECTIVE

We describe a new statistical method called the surrogate threshold effect (STE) that estimates the threshold level of a surrogate needed in a clinical trial to predict a benefit in the target clinical outcome. In this article, we apply this method to the LDL-cholesterol biomarker surrogate and survival benefit-target outcome in statin trials.

STUDY DESIGN AND SETTING

We identified randomized trials comparing statin treatment to placebo treatment or no treatment and reporting all-cause and cardiovascular mortality. Trials with fewer than five all-cause deaths in at least one arm were excluded. Multiple regression modeled the reduction in all-cause and cardiovascular mortality as a function of LDL-cholesterol difference. The 95% confidence and 95% prediction bands were calculated and graphed to determine the minimum LDL-cholesterol difference (the surrogate threshold) below which there would be no predicted survival benefit.

RESULTS

In 16 qualifying trials, regression analysis yielded an all-cause mortality model whose prediction bands demonstrated no overall survival gain with LDL-cholesterol difference values below 1.5 mmol/L. The cardiovascular mortality model yielded prediction bands that demonstrated no cardiovascular survival benefit with LDL-cholesterol difference values below 1.4 mmol/L.

CONCLUSIONS

In a multitrial setting, the STE approach is a promising yet straightforward statistical method for evaluating the surrogate validity of biomarkers.

The value of a specialist lipid clinic

AIMS

To establish the value of the first 3 years of a cardiovascular risk factor clinic in tackling the major risk factors for cardiovascular disease (CVD).

METHODS

A database review of all 339 patients referred to the clinic.

RESULTS

Blood pressure levels in the hypertensive patients were significantly reduced and 9% of the smokers managed to quit for 12 months, half of them subsequently relapsing. Ninety-eight oral glucose tolerance tests were performed and 40% were abnormal yielding 10 patients with hitherto unsuspected diabetes and 29 with impaired glucose tolerance. Sixty-four of the 97 referrals of patients in the primary prevention group (no evidence of CVD) were found to have calculated Framingham coronary heart disease risk estimates of < 15% per decade, the lowest being 0.3%. Lipid levels were significantly reduced in both the hypercholesterolaemic (n = 290) and hypertriglyceridaemic (n = 49) patient groups through the use of more potent statins, extensive use of combination therapy and appropriate use of fibrates and omega-3 fish oil supplements. The annual drug cost per patient treated only increased from 310.72 pounds sterling to 398.08 pounds sterling, yet there was a 3.5-fold increase in the number of patients achieving the General Medical Services 2 target of a total cholesterol < 5 mmol/l and a 4.5-fold increase in patients achieving the Joint British Societies 2 target of a low-density lipoprotein (LDL) cholesterol < 2 mmol/l.

CONCLUSION

The need for a specialist clinic was demonstrated by the 66% of primary prevention referrals who did not meet the current NICE treatment threshold. Additionally, the clinic was able to diagnose and treat 39 patients with undiagnosed diabetes mellitus/impaired glucose tolerance and 12 with hypothyroidism. LDL cholesterol was reduced overall by 36% implying a greater than one-third reduction in future cardiovascular events before the improvements in blood pressure control and smoking cessation are included and this was achieved at marginal extra cost to the mean drug bill at referral.

Circulating Markers Reflect Both Anti- and Pro-Atherogenic Drug Effects in ApoE-Deficient Mice

Background

Current drug therapy of atherosclerosis is focused on treatment of major risk factors, e.g. hypercholesterolemia while in the future direct disease modification might provide additional benefits. However, development of medicines targeting vascular wall disease is complicated by the lack of reliable biomarkers. In this study, we took a novel approach to identify circulating biomarkers indicative of drug efficacy by reducing the complexity of the in vivo system to the level where neither disease progression nor drug treatment was associated with the changes in plasma cholesterol.

Results

ApoE−/− mice were treated with an ACE inhibitor ramipril and HMG-CoA reductase inhibitor simvastatin. Ramipril significantly reduced the size of atherosclerotic plaques in brachiocephalic arteries, however simvastatin paradoxically stimulated atherogenesis. Both effects occurred without changes in plasma cholesterol. Blood and vascular samples were obtained from the same animals. In the whole blood RNA samples, expression of MMP9, CD14 and IL-1RN reflected pro-and anti-atherogenic drug effects. In the plasma, several proteins, e.g. IL-1β, IL-18 and MMP9 followed similar trends while protein readout was less sensitive than RNA analysis.

Conclusion

In this study, we have identified inflammation-related whole blood RNA and plasma protein markers reflecting anti-atherogenic effects of ramipril and pro-atherogenic effects of simwastatin in a mouse model of atherosclerosis. This opens an opportunity for early, non-invasive detection of direct drug effects on atherosclerotic plaques in complex in vivo systems.

Statin therapy in stroke prevention: a meta-analysis involving 121,000 patients

PURPOSE

More than 120,000 patients now have taken part in randomized trials evaluating statin therapy for stroke prevention. We aimed to conduct a comprehensive review of all randomized trials and determine the therapeutic potential of statins for all strokes.

METHODS

We searched 10 electronic databases (from inception to December 2006). We additionally contacted study authors and authors of previous reviews. We extracted data on study characteristics and outcomes related to all-cause mortality, all-stroke incidence, specific type of strokes, and cholesterol changes. We pooled data using a random-effects model and conducted meta-regression.

RESULTS

We included 42 trials assessing statin therapy for all-stroke prevention (n=121,285), resulting in a pooled relative risk (RR) of 0.84 (95% confidence interval [CI], 0.79-0.91). The pooled RR of statin therapy for all-cause mortality (n=116,080) was 0.88 (95% CI, 0.83-0.93). Each unit increase in low-density lipoprotein (LDL) resulted in a 0.3% increased RR of death (P=.02). Seventeen trials evaluated statins on cardiovascular death (n=57,599, RR 0.81, 95% CI, 0.74-0.90), and 11 evaluated nonhemorrhagic cerebrovascular events (n=58,604, RR 0.81, 95% CI, 0.69-0.94). Eleven trials reported hemorrhagic stroke incidence (total n=54,334, RR 0.94, 95% CI, 0.68-1.30) and 21 trials reported on fatal strokes (total n=82,278, RR 0.99, 95% CI, 0.80-1.21). Only one trial reported on statin therapy for secondary prevention.

CONCLUSIONS

Statin therapy provides high levels of protection for all-cause mortality and nonhemorrhagic strokes. This overview reinforces the need to consider prolonged statin treatment in patients at high risk of major vascular events, but caution remains for patients at risk of bleeds.

Cacao procyanidins reduce plasma cholesterol and increase fecal steroid excretion in rats fed a high-cholesterol diet

Cocoa powder is rich in polyphenols, such as catechins and oligomeric procyanidins, and has a hypocholesterolemic effect in humans. This study evaluated the principal active components and potential mechanism(s) for the hypocholesterolemic effect of polyphenolic substances from cocoa powder in rats. Male Wistar rats were fed a 1% high-cholesterol diet (HC) or a high-cholesterol diet containing 1% polyphenol extract from cocoa powder (PE) or a mixture of 0.024% catechin and 0.058% epicatechin (CE) for 4 weeks. We also examined the effects of these polyphenolic substances on micellar cholesterol solubility in vitro. The PE group had significantly lower plasma cholesterol concentrations, and had significantly greater fecal cholesterol and total bile acids excretion than the HC group. The CE group diet did not influence plasma cholesterol concentrations, or fecal cholesterol or total bile acids excretion. Micellar solubility of cholesterol in vitro was significantly lower for procyanidin B2 (dimer), B5 (dimer), C1 (trimer) and A2 (tetramer), which are the main components of polyphenol extract from cocoa powder, compared to catechin and epicatechin. These results suggest that oligomeric procyanidins from cocoa powder are the principal active components responsible for the hypocholesterolemic effect, and inhibit the intestinal absorption of cholesterol and bile acids through the decrease in micellar cholesterol solubility.

Development of a Nutrition Counselling Care Map For Dyslipidemia

Purpose: Care maps or clinical pathways for nutrition therapy of dyslipidemia could add to current practice guidelines, by providing templates for feasible and recommended diet counselling processes. A care map was therefore developed by engaging expert and generalist dietitians and external experts from across Canada in a multi-stage consensus process.

Methods: First, a qualitative study was undertaken with a convenience sample of 12 practitioners to identify possible diet care options, using hypothetical client scenarios and cognitive analysis. Second, these care options were rated for five case scenarios considered typical (overweight clients, with or without clinical cardiovascular disease and other comorbidities, potentially motivated to change, consuming high-fat diets, and facing various major barriers to eating behaviour change). The rating was conducted through a survey of participants. Highly appropriate, recommended, and feasible options for counselling were ranked through a two-round modified Delphi process, with teleconference discussions between rounds.

Results: Forty-nine professionals started the consensus process; 39 (80%) completed all aspects. Numerous care processes were appropriate for all clients, with additional focus on barriers for low-income clients, sodium intake for clients with hypertension, and smoking cessation in smokers.

Conclusions: The resulting care map, “Dietitians’ Quick Reference Guide for Clinical Nutrition Therapy for Overweight Clients with Dyslipidemia,” provides a basis for current practice and new effectiveness studies.

Non-cardiovascular mortality, low-density lipoprotein cholesterol and statins: a meta-regression analysis

BACKGROUND

As of today, the effect of statins on non-cardiovascular mortality is still being debated. Single studies have not been able to provide definite answers. We performed a meta-regression analysis on randomized statin trials in order to provide evidence that non-cardiovascular mortality is related to statin treatment and low-density lipoprotein (LDL) cholesterol plasma level.

METHODS

We selected 29 randomized controlled trials of statins versus placebo, a total of 90,480 patients, with a follow-up of >12 months. Baseline and follow-up LDL levels and all-cause, cardiovascular and non-cardiovascular mortality were recorded. Weighted linear regression analysis was carried out separately for placebo and treatment groups.

RESULTS

LDL level was inversely related to overall mortality (p = 0.0105) and non-cardiovascular mortality (p = 0.0171) in the treatment group. By contrast, in the placebo group only non-cardiovascular mortality was inversely correlated to LDL (p = 0.0032). The regression lines have similar slopes and run almost parallel to each other, with the treatment line lying below the placebo line. To identify the threshold of risk for starting statin therapy, we analysed the relationship between baseline cardiovascular risk and overall mortality in the two groups. Both correlations are highly significant and regression lines intersect at a risk of 0.29% per year. This implies that the effects of statins are favourable when the baseline cardiovascular risk exceeds approximately 3% in 10 years.

CONCLUSIONS

A trend of increased non-cardiovascular mortality with decreased LDL exists both in placebo and treatment groups. However, at each given LDL cholesterol level, non-cardiovascular mortality is lower in treated patients. Therefore, statin therapy may improve the biological impact of LDL on non-cardiovascular mortality.

Lipid-Altering Therapies and the Progression of Atherosclerotic Disease

Lipids play a key role in the progression of atherosclerosis, and lipid-lowering therapies have been studied for 30 years in coronary disease. Measurement of the progression of atherosclerosis through carotid intima-media thickness, coronary mean lumen diameter, and, mostly recently, intravascular ultrasound is generally accepted. This article reviews the role of lipid-lowering therapies in changing the rate of atherosclerosis progression in the coronary and carotid circulations. Statins are the primary therapy used to reduce atherosclerosis and cardiovascular events, including strokes and transient ischemic attacks, and have benefits in reducing events in patients undergoing carotid endarterectomy. In contrast, data for other agents, including fibrates and nicotinic acid, in reducing the progression of atherosclerosis are less extensive and not as well known. There is increasing interest in optimizing the whole lipid profile, as this might deliver extra benefits over and above statin therapy alone. Initial proof of this concept has recently come from studies that measured the progression of atherosclerosis and showed that adding nicotinic acid to statin therapy and, more directly, infusion of high-density lipoprotein-like particles reduced progression and indeed might induce regression of the disease. It is likely that the management of significant carotid stenosis will become ever more drug focused and will be customized to the lipid profile of each patient with intervention reserved only for late-stage symptomatic disease.

Dietetic guidelines on food and nutrition in the secondary prevention of cardiovascular disease ? evidence from systematic reviews of randomized controlled trials (second update, January 2006)

AIM

To update dietetic guidelines based on systematic review evidence on dietary advice to prevent further events in people with existing cardiovascular disease (CVD) (secondary prevention).

METHODS

The Cochrane Library, MEDLINE and EMBASE were comprehensively searched to January 2005 for systematic reviews on aspects of diet and heart health. Reviews were included if they searched systematically for randomized controlled trials relating to diet and secondary prevention of CVD. Each review was critically appraised by at least two members of the UK Heart Health and Thoracic Dietitians Group. The quality and results of each review were discussed and summarized at a group meeting.

RESULTS

Evidence-based strategies that reduce cardiovascular events in those with CVD include reduction in saturated fat and substitution with unsaturated fats. Individuals who have suffered a myocardial infarction may also benefit from adopting a Mediterranean type diet and increasing intake of omega 3 fats, but it is not clear whether they are beneficial for all patients with CVD. There is no systematic review evidence to support the use of antioxidant vitamins supplements, low glycaemic index diets, or homocysteine lowering therapies in this group.

CONCLUSION

There remains good evidence that reducing saturated fat reduces morbidity in patients with CVD. This advice is consistent for most manifestations of CVD, with the addition of Mediterranean dietary advice and increased omega 3 fats for those who have had a myocardial infarction.