Modifiable lifestyle risk factors and C-reactive protein in patients with coronary artery disease: Implications for an anti-inflammatory treatment target population

Association of life's essential 8 with risk of recurrent cardiovascular events among patients with coronary heart disease

AIMS

To examine the association of Life's Essential 8 (LE8) with the risk of recurrent cardiovascular events among patients with CHD.

METHODS

This prospective cohort study included 11,997 patients with CHD from the UK Biobank. The LE8 score was generated using five lifestyle factors (diet, body mass index, physical activity, smoking, and sleep) and three biological factors (blood lipids, blood glucose, and blood pressure). LE8 score ranged from 0 to 100 and was categorized into quartiles. Cox proportional hazards regression models were applied to estimate the hazard ratio (HR) and 95% CI (confidence interval).

RESULTS

During a median follow up of 12.5 years, we documented 3366 recurrent cardiovascular events, 1068 myocardial infarction, 1829 heart failure events, 703 strokes, and 934 cardiovascular deaths. The multivariable-adjusted HR (95% CI) for the highest versus the lowest quartile of LE8 score was 0.57 (0.50, 0.65) for recurrent cardiovascular events, 0.66 (0.52, 0.83) for myocardial infarction, 0.54 (0.45, 0.67) for heart failure, 0.50 (0.36, 0.68) for stroke, and 0.46 (0.37, 0.56) for cardiovascular death. Furthermore, the population attributable fraction of the lowest to the highest quartile of LE8 score were ranged from 16.2% to 32.5% for the various cardiovascular outcomes. In addition, biomarkers including renal function and inflammation collectively explained 47.6%-87.7% of the associations between the lifestyle factors and recurrent cardiovascular events.

CONCLUSIONS

Better cardiovascular health as measured by LE8 was associated with significantly lower risk of recurrent cardiovascular events among patients with CHD. Clinicians should prioritize educating patients with CHD on the importance of optimal cardiovascular health for secondary prevention. In addition, our findings indicated significant mediation effect of biomarkers involving of glycemic control, renal function, liver function, lipid profile, and systemic inflammation on the associations between overall lifestyle factors and recurrent cardiovascular events.

C-reactive protein, pharmacological treatments and diet: how to target your inflammatory burden

PURPOSE OF REVIEW

This article focuses on pharmacological agents as well as dietary changes aimed at the reduction of the inflammatory burden measured by circulating C-reactive protein concentrations.

RECENT FINDINGS

Over the last years, repurposed as well as new anti-inflammatory agents have been investigated in outcome trials in the cardiovascular field. Currently, a specific inhibition of the inflammatory cascade via the interleukin-6 ligand antibody ziltivekimab is being explored in large-scale outcome trials, after the efficacy of this agent with regard to the reduction of inflammatory biomarkers was proven recently. Next to the investigated pharmacological agents, specific dietary patterns possess the ability to improve the inflammatory burden. This enables patients themselves to unlock a potential health benefit ahead of the initiation of a specific medication targeting the inflammatory pathway.

SUMMARY

Both pharmacological agents as well as diet provide the opportunity to improve the inflammatory profile and thereby lower C-reactive protein concentrations. Whilst advances in the field of specific anti-inflammatory treatments have been made over the last years, their broad implementation is currently limited. Therefore, optimization of diet (and other lifestyle factors) could provide a cost effective and side-effect free intervention to target low-grade vascular inflammation.

Shifting perspectives in coronary involvement of polyarteritis nodosa: case of 3-vessel occlusion treated with 4-vessel CABG and review of literature

BACKGROUND

Polyarteritis Nodosa (PAN) is a systemic vasculitis (SV) historically thought to spare the coronary arteries. Coronary angiography and contemporary imaging reveal coronary stenosis and dilation, which are associated with significant morbidity and mortality. Coronary arteries in PAN are burdened with accelerated atherosclerosis from generalized inflammation adding to an inherent arteritic process. Traditional atherosclerotic risk factors fail to approximate risk. Few reports document coronary pathology and optimal therapy has been guarded.

METHODS

Database publication query of English literature from 1990-2022.

RESULTS

Severity of coronary involvement eludes laboratory monitoring, but coronary disease associates with several clinical symptoms. Framingham risk factors inadequately approximate disease burden. Separating atherosclerosis from arteritis requires advanced angiographic methods. Therapy includes anticoagulation, immunosuppression and revascularization. PCI has been the mainstay, though stenting is confounded by vagarious alteration in luminal diameter and reports of neointimization soon after placement.

CONCLUSIONS

When graft selection avoids the vascular territory of SV's, CABG offers definitive therapy. We have contributed report of a novel CABG configuration in addition to reviewing, updating and discussing the literature. Accumulating evidence suggests discrete clinical symptoms warrant suspicion for coronary involvement.

Mediterranean diet and a health behavior index in relation to cardiovascular biomarkers: Data from the Health and Retirement Study

BACKGROUND AND AIM

Although lifestyle factors have been repeatedly examined for their role on cardiovascular diseases, their composite effect has not been frequently explored. We aimed to investigate the relation of dietary patterns (DPs) and a health behavior index (HBI) with cardiovascular biomarkers.

METHODS AND RESULTS

A cross-sectional analysis with data from 3461 US residents, participants in the Health and Retirement Study (HRS), was performed. Nutritional data were obtained with a food frequency questionnaire, while adherence to Mediterranean Diet (MD) was determined by the Mediterranean Diet Score. A posteriori DPs were estimated using principal component analysis and the HBI was constructed combining adherence to MD, smoking status, physical activity levels, alcohol consumption and body mass index. Multiple linear regression models were performed to examine the relation between DPs or HBI and levels of C-reactive protein (CRP), glycosylated hemoglobin (HbA1C), cystatin C (Cys C), total cholesterol (TC), high density lipoprotein (HDL) and TC:HDL in blood. Multiple linear regression showed that the "healthy" DP and the MD had a significant negative association with CRP and Cys C (p < 0.05), while the "Western-type" DP had a significant positive association with TC:HDL ratio, CRP and Cys C. Moreover, the HBI was positively associated with HDL (p < 0.05) and negatively associated with TC:HDL ratio, CRP and Cys C (p < 0.05).

CONCLUSIONS

Adherence to MD and to a healthy dietary pattern was negatively associated with biomarkers of inflammation, while the HBI was associated with a better cardiometabolic profile, assessed with blood biomarkers.

Procedural and one-year outcomes of robotic-assisted versus manual percutaneous coronary intervention

BACKGROUND

Robotic-assisted percutaneous coronary intervention (rPCI) has proven to be feasible and safe. Comparative analyses of rPCI versus manual PCI (mPCI) are scarce.

AIMS

We aimed to investigate procedural aspects and outcomes of rPCI using the second-generation CorPath GRX Vascular Robotic System compared with mPCI in patients with chronic coronary syndrome and non-ST-segment elevation myocardial infarction acute coronary syndrome.

METHODS

From January to April 2021, 70 patients underwent rPCI at the University Heart & Vascular Center Hamburg-Eppendorf and were recruited into the INTERCATH study. By propensity score matching, a control cohort of 210 patients who underwent mPCI from 2015-2021 was identified. Co-primary endpoints were one-year all-cause mortality and major adverse cardiovascular events (MACE) as a composite of cardiovascular death, unplanned target lesion revascularisation, myocardial infarction, and stroke.

RESULTS

The median age of the patients (n=280) was 70.7 (25th percentile-75th percentile: 62.0-78.0) years, and 24.6% were female. The Gensini score (28.5 [16.2-48.1] vs 28.0 [15.5-47.0]; p=0.78) was comparable between rPCI versus mPCI. During the PCI procedure, total contrast fluid volume did not differ, whilst longer fluoroscopy times (20.4 min [13.8-27.2] vs 14.4 min [10.4-24.3]; p=0.001) were documented in the rPCI versus mPCI cohort. After 12 months of follow-up, neither all-cause mortality (p=0.22) nor MACE (p=0.25) differed between the groups.

CONCLUSIONS

rPCI was associated with longer fluoroscopy times compared with mPCI, though without increased use of contrast medium. One-year follow-up revealed no differences in all-cause mortality or MACE, supporting the safety of a robotic-assisted approach.

Inflammatory burden, lifestyle and atherosclerotic cardiovascular disease: insights from a population based cohort study

The inflammatory burden as measured by high-sensitivity C-reactive Protein (hsCRP) is recognized as a cardiovascular risk factor, which can however be affected by lifestyle-related risk factors (LRF). Up-to-date the interplay between hsCRP, LRF and presence and extent of atherosclerotic disease is still largely unknown, which we therefore sought to investigate in a contemporary population-based cohort. We included participants from the cross-sectional population-based Hamburg City Health Study. Affected vascular beds were defined as coronary, peripheral, and cerebrovascular arteries. LRF considered were lack of physical activity, overweight, active smoking and poor adherence to a Mediterranean diet. We computed multivariable analyses with hsCRP as the dependent variable and LRF as covariates according to the number of vascular beds affected. In the 6765 individuals available for analysis, we found a stepwise increase of hsCRP concentration both according to the number of LRF present as well as the number of vascular beds affected. Adjusted regression analyses showed an independent association between increasing numbers of LRF with hsCRP levels across the extent of atherosclerosis. We demonstrate increasing hsCRP concentrations according to both the number of LRF as well as the extent of atherosclerosis, emphasizing the necessity of lifestyle-related risk factor optimization.

Progression of C-reactive protein from birth through preadolescence varies by mode of delivery

Introduction

Delivery via caesarean section (C-section) has been associated with an increased risk of childhood chronic diseases such as obesity and asthma, which may be due to underlying systemic inflammation. However, the impact of specific C-section types may be differential, as emergency C-sections typically involve partial labor and/or membrane rupture. Our objectives were to determine if mode of delivery associates with longitudinal profiles of high sensitivity CRP (hs-CRP) -a marker of systemic inflammation-from birth through preadolescence, and to examine if CRP mediates the association between mode of delivery and preadolescent body mass index (BMI).

Methods

Data from the WHEALS birth cohort (N = 1,258) were analyzed; 564 of the 1,258 children in the cohort had data available for analysis. Longitudinal plasma samples (birth through 10-years of age) from 564 children from were assayed for hs-CRP levels. Maternal medical records were abstracted to obtain mode of delivery. Growth mixture models (GMMs) were used to determine classes of hs-CRP trajectories. Poisson regression with robust error variance was used to calculate risk ratios (RRs).

Results

Two hs-CRP trajectory classes were identified: class 1 (76% of children) was characterized by low hs-CRP, while class 2 (24% of children) was characterized by high and steadily increasing hs-CRP. In multivariable models, children delivered via planned C-section had 1.15 times higher risk of being in hs-CRP class 2, compared to vaginal deliveries (p = 0.028), while no association was found for unplanned C-section deliveries [RR (95% CI) = 0.96 (0.84, 1.09); p = 0.49]. Further, the effect of planned C-section on BMI z-score at age 10 was significantly mediated by hs-CRP class (percent mediated = 43.4%).

Conclusions

These findings suggest potentially beneficial effects of experiencing partial or full labor, leading to a lower trajectory of systemic inflammation throughout childhood and decreased BMI during preadolescence. These findings may have implications for chronic disease development later in life.

Weight variability and diabetes complications

Body weight is a recognized risk factor for cardiovascular diseases (CVD). More recently, weight variability, i.e. the oscillation of body weight over time, has also been suggested to be independently associated with development of CVD and mortality in subjects without diabetes and in people with both type 1 and type 2 diabetes (T2D). In T2D, weight variability emerged as one of the most relevant risk factors for CVD and it was suggested to interact with the variability of other risk factors to identify people at high cardiovascular risk. In addition, weight variability seems also to confer a higher risk for microvascular complications in people with T2D. While the exact mechanism linking weight variability to CVD is unknown, evidence from experimental models suggests that weight cycling promote an enduring pro-inflammatory program in the adipose tissue. Here we review the clinical evidence relative to the association of weight variability with CVD and microvascular complications of diabetes. We then briefly summarize the alterations proposed to explain this association. Finally, we synthesize the possible strategies, e.g. specific dietetic regimens and available glucose-lowering drugs, to minimize weight fluctuations.

Association of clinical, laboratory and imaging biomarkers with the occurrence of acute myocardial infarction in patients without standard modifiable risk factors - rationale and design of the "Beyond-SMuRFs Study"

BACKGROUND

Acute myocardial infarction (AMI) remains the leading cause of mortality worldwide. The majority of patients who suffer an AMI have a history of at least one of the standard modifiable risk factors (SMuRFs): smoking, hypertension, dyslipidemia, and diabetes mellitus. However, emerging scientific evidence recognizes a clinically significant and increasing proportion of patients presenting with AMI without any SMuRF (SMuRF-less patients). To date, there are no adequate data to define specific risk factors or biomarkers associated with the development of AMIs in these patients.

METHODS

The ''Beyond-SMuRFs Study'' is a prospective, non-interventional cohort trial designed to enroll patients with AMI and no previous coronary intervention history, who undergo coronary angiography in two academic hospitals in Thessaloniki, Greece. The rationale of the study is to investigate potential relations between SMuRF-less AMIs and the clinical, laboratory and imaging profile of patients, by comparing parameters between patients with and without SMuRFs. Complete demographic and comprehensive clinical data will be recorded, Venous blood samples will be collected before coronary angiography and the following parameters will be measured: total blood count, standard biochemistry parameters, coagulation tests, hormone levels, glycosylated hemoglobin, N- terminal pro-B-type natriuretic peptide and high-sensitivity troponin T levels- as well as serum levels of novel atherosclerosis indicators and pro-inflammatory biomarkers. Furthermore, all participants will undergo a complete and comprehensive transthoracic echocardiographic assessment according to a pre-specified protocol within 24 h from admission. Among others, 2D-speckle-tracking echocardiographic analysis of cardiac chambers and non-invasive calculation of myocardial work indices for the left ventricle will be performed. Moreover, all patients will be assessed for angiographic parameters and the complexity of coronary artery disease using the SYNTAX score. Multivariable linear and logistic regression models will be used to phenotypically characterize SMuRF-less patients and investigate independent clinical, laboratory, echocardiographic and angiographic biomarkers-predictors of SMuRF-less status in AMI.The first patient was enrolled in March 2022 and completion of enrollment is expected until December 2023.

DISCUSSION

The ''Beyond-SmuRFs'' study is an ongoing prospective trial aiming to investigate potential clinical, laboratory and imaging biomarkers associated with the occurrence of AMIs in SMuRF-less patients. The configuration of these patients' profiles could lead to the development of personalized risk-stratification models predicting the occurrence of cardiovascular events in SΜuRF-less individuals.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05535582 / September 10, 2022.

Smoking and alcohol consumption are associated with peripheral musculoskeletal involvement in patients with spondyloarthritis (including psoriatic arthritis). Results from the ASAS-PerSpA study

BACKGROUND

An inverse association between alcohol consumption and disease activity and functional impairment has been observed in patients with spondyloarthritis (SpA). However, neither this association nor the influence of smoking has been investigated in peripheral manifestations of SpA.

OBJECTIVES

The objective of this study was to analyze the association between smoking and alcohol consumption and the presence of peripheral musculoskeletal manifestations (arthritis, enthesitis or dactylitis) and to determine the specific location of these manifestations.

METHODS

Patients from the worldwide cross-sectional ASAS-PerSpA study with a diagnosis of axial SpA (axSpA), peripheral SpA (pSpA) or psoriatic arthritis (PsA) according to their rheumatologist were included. Generalised linear mixed models used peripheral manifestation (or location) as a dependent variable, smoking status and alcohol consumption as fixed effects and country as a random effect. The interaction between smoking and alcohol was tested. Analyses were performed for each diagnosis (axSpA, pSpA and PsA).

RESULTS

A total of 4181 patients were included. In axSpA patients, smoking was associated with a lower prevalence of any peripheral manifestation, and current alcohol consumption was associated with a lower prevalence of both current arthritis and current enthesitis. In pSpA patients, current alcohol consumption was associated with a lower prevalence of current arthritis or enthesitis. In PsA patients, a significant association was found for arthritis with smoking and for enthesitis with alcohol consumption, and current alcohol consumption was associated with a lower prevalence of current arthritis or enthesitis.

CONCLUSION

Taking into account the country, smoking and alcohol are associated with a lower prevalence of peripheral manifestations.

The Association between High-Sensitivity C-Reactive Protein and Metabolic Syndrome in an Elderly Population Aged 50 and Older in a Community Receiving Primary Health Care in Taiwan

Metabolic syndrome (MetS) has become the most important issue in family medicine and primary care because it is a cluster of metabolic abnormalities that are a burden on health care in many countries. Highly sensitive C-reactive protein (hsCRP), which is elevated in inflammatory situations, can be produced by monocyte-derived macrophages in adipose tissue. People with MetS tend to have more adipose tissue. Therefore, we aimed to investigate the association between hsCRP and MetS among elderly individuals aged 50 years and older in northern Taiwan. This study was a cross-sectional community-based study that included 400 middle-aged and elderly Taiwanese adults, and 400 participants were eligible for analysis. We divided the participants into a MetS group and a non-MetS group. Pearson's correlations were calculated between hsCRP and other related risk factors. Furthermore, the relationship between hsCRP and MetS was analyzed with logistic regression. People in the MetS group were more likely to have higher hsCRP levels. The Pearson's correlation analysis showed a positive correlation with hsCRP. In the logistic regression, hsCRP was significantly associated with MetS, even with the adjustment for BMI, uric acid, age, sex, smoking status, drinking status, hypertension, diabetes mellitus, and dyslipidemia. In summary, our research indicated that hsCRP could be an independent risk factor for MetS.

Dietary Inflammatory Index and Cardiometabolic Risk in Ecuadorian School-Age Children

BACKGROUND

Cardiometabolic diseases and metabolic syndrome (MetS) are becoming increasingly prevalent in low- and middle-income countries (LMICs). Cardiometabolic diseases and MetS are closely associated with low-grade systemic inflammation, which may be modified by diet. Previous studies have focused on the association of dietary inflammation with MetS and cardiometabolic risk in adult populations, but few studies have examined this issue in children, especially in LMICs.

METHODS

We conducted a cross-sectional study to explore the association of dietary inflammation with cardiometabolic risk components and MetS in urban Ecuadorian children aged 6-12 years old (n = 276). A semi-quantitative food frequency questionnaire (FFQ) was used to collect data on child dietary intake. Dietary inflammation was evaluated using an energy-adjusted Dietary Inflammatory Index (DII), divided into quartiles. Data were also collected on cardiometabolic risk indicators including blood lipids, blood pressure (BP), blood glucose, body mass index, and waist circumference. Data were analyzed using multivariable linear and logistic regression.

RESULTS

Child DII scores ranged from -4.87 (most anti-inflammatory) to 4.75 (most pro-inflammatory). We transformed the continuous scores into quartiles (Q): Q1 was the most anti-inflammatory (-4.87 to -3.35), Q2 was anti-inflammatory (-3.34 to -1.45), Q3 was pro-inflammatory (-1.44 to 1.08), and Q4 was the most pro-inflammatory (1.09 to 4.75). In the covariate-adjusted model, DII scores were positively associated with total blood cholesterol (p = 0.027), triglycerides (p = 0.034), and diastolic BP (p = 0.013). In addition, for every one-unit increase in DII score, MetS increased by 1.20 in the covariate-adjusted model (95% CI = 1.01,1.43).

CONCLUSIONS

The findings suggest that more pro-inflammatory diets may contribute to poorer cardiometabolic health in school-age children. This is important because even small increases in child blood pressure, blood cholesterol, and glucose levels over time can damage health and lead to earlier progression to conditions such as hypertension and atherosclerosis.

Subclinical Atherosclerosis Measure by Carotid Ultrasound and Inflammatory Activity in Patients with Rheumatoid Arthritis and Spondylarthritis

Objective: To compare the effect of inflammation on subclinical atherosclerosis using carotid ultrasound in patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA). Methods: Cross-sectional study including 347 participants (148 RA, 159 SpA, and 40 controls). We measured the carotid intima media thickness (cIMT) and detection of atheromatous plaques using carotid ultrasound. We recorded disease activity (DAS28-CRP/ASDAS-CRP) and traditional cardiovascular risk factors. We performed descriptive, bivariate, and linear multivariate analyses (dependent variable: cIMT) to evaluate the influence of diagnosis on cIMT in all patients. Two additional multivariate analyses were performed by stratifying patients according to their inflammatory activity. Results: cIMT correlated with the mean CRP during the previous 5 years in RA, but not with CRP at the cut-off date. We did not find such differences in patients with SpA. The first multivariate model revealed that increased cIMT was more common in patients with RA than in those with SpA (β coefficient, 0.045; 95% confidence interval (95% CI), 0.0002–0.09; p = 0.048) after adjusting for age, sex, disease course, and differential cardiovascular risk factors (arterial hypertension, smoking, statins, and corticosteroids). The second model revealed no differences in cIMT between the 2 groups of patients classified as remission–low activity (β coefficient, 0.020; 95% CI, −0.03 to 0.080; p = 0.500). However, when only patients with moderate–high disease activity were analysed, the cIMT was 0.112 mm greater in those with RA (95% CI, 0.013–0.212; p = 0.026) than in those with SpA after adjusting for the same variables. Conclusions: Subclinical atherosclerosis measured by carotid ultrasound in patients with RA and SpA is comparable when the disease is well controlled. However, when patients have moderate–high disease activity, cIMT is greater in patients with RA than in those with SpA after adjusting for age, sex, disease course, and cardiovascular risk factors. Our results point to greater involvement of disease activity in subclinical atherosclerosis in patients with RA than in those with SpA.

Lycopene: A Natural Arsenal in the War against Oxidative Stress and Cardiovascular Diseases

Lycopene is a bioactive red pigment found in plants, especially in red fruits and vegetables, including tomato, pink guava, papaya, pink grapefruit, and watermelon. Several research reports have advocated its positive impact on human health and physiology. For humans, lycopene is an essential substance obtained from dietary sources to fulfil the body requirements. The production of reactive oxygen species (ROS) causing oxidative stress and downstream complications include one of the major health concerns worldwide. In recent years, oxidative stress and its counter strategies have attracted biomedical research in order to manage the emerging health issues. Lycopene has been reported to directly interact with ROS, which can help to prevent chronic diseases, including diabetes and neurodegenerative and cardiovascular diseases. In this context, the present review article was written to provide an accumulative account of protective and ameliorative effects of lycopene on coronary artery disease (CAD) and hypertension, which are the leading causes of death worldwide. Lycopene is a potent antioxidant that fights ROS and, subsequently, complications. It reduces blood pressure via inhibiting the angiotensin-converting enzyme and regulating nitrous oxide bioavailability. It plays an important role in lowering of LDL (low-density lipoproteins) and improving HDL (high-density lipoproteins) levels to minimize atherosclerosis, which protects the onset of coronary artery disease and hypertension. Various studies have advocated that lycopene exhibited a combating competence in the treatment of these diseases. Owing to all the antioxidant, anti-diabetic, and anti-hypertensive properties, lycopene provides a potential nutraceutical with a protective and curing ability against coronary artery disease and hypertension.

Target Populations and Treatment Cost for Bempedoic Acid and PCSK9 Inhibitors: A Simulation Study in a Contemporary CAD Cohort

PURPOSE

The lowered LDL-C treatment goal of the 2019 European Society of Cardiology dyslipidemia guidelines results in a significant increase in the projected need for cost-intensive proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. Addition of bempedoic acid (BA) to established oral lipid-lowering medication (LLM) has the potential to enable affordable LDL-C goal attainment, particularly in patients with statin intolerance (SI). The goal of this study was to quantify the target populations for BA and PCSK9 inhibitors as well as the related treatment costs to achieve the LDL-C goal of <55 mg/dL and a ≥50% reduction assuming the addition of BA to LLM.

METHODS

This study included 1922 patients with coronary artery disease (CAD) from the contemporary observational cohort study INTERCATH. A Monte Carlo simulation incorporating an algorithm adding sequentially a statin, ezetimibe, optionally BA, and a PCSK9 inhibitor was applied to achieve the LDL-C treatment goal, with consideration of both partial and total SI. Two scenarios were simulated for both a moderate (2% full and 10% partial) and a high (12% full) rate of SI: (1) without BA; and (2) with BA.

FINDINGS

Patients' mean age was 69.3 years, and the median baseline LDL-C level was 86.0 mg/dL. The need for a PCSK9 inhibitor would be 41.4% for a moderate rate of SI and 46.1% for a high rate of SI. Addition of BA would: (1) reduce the need for a PCSK9 inhibitor to 25.3% and 29.4%, thus lowering the annual overall treatment cost incurred through PCSK9 inhibitor ± BA per 1 million patients with CAD by 13.3% and 10.5%; (2) lower the cost per prevented event in the entire cohort (-5.0% and -6.3%), although at the price of fewer prevented events (-8.7% and -4.5%); and (3) reduce the cost per prevented event (-6.8% for both rates of SI) while preventing more events (7.6% and 6.9%) in the subpopulation of patients with full SI.

IMPLICATIONS

Use of BA is projected to reduce the need for PCSK9 inhibitors as well as the treatment cost for add-on LLM. The subpopulation of patients with full SI might profit particularly.

Dietary Inflammatory Index and Cardiometabolic Risk in Ecuadorian Women

Low-grade systemic inflammation is implicated in metabolic syndrome (MetS) and cardiometabolic diseases. Diet is hypothesized to be an important low-grade inflammation modifier. However, few studies have examined the association of dietary inflammation with MetS and cardiometabolic risk in Latin American populations and their findings are inconsistent. Our cross-sectional study examined the association of dietary inflammatory potential with MetS and cardiometabolic risk components in 276 urban Ecuadorian women. Dietary inflammation was evaluated using an energy-adjusted Dietary Inflammatory Index (E-DII), divided into quartiles (Q). E-DII scores ranged from −4.89 (most anti-inflammatory) to 4.45 (most pro-inflammatory). Participants in the most pro-inflammatory (Q4) compared to the least inflammatory E-DII quartile (Q1) had a 4.4 increased adjusted odds for MetS (95% C.I. = 2.0, 9.63; p < 0.001). Every one-unit increase in E-DII was associated with a 1.4 increase in MetS (95% CI = 1.22, 1.52; p < 0.001). In other adjusted models, the most pro-inflammatory E-DII quartile (Q4) was positively associated with total blood cholesterol and triglycerides (p < 0.001), LDL-c (p = 0.007), diastolic blood pressure (p< 0.002), mean arterial pressure (p < 0.006), waist circumference (p < 0.008), and Framingham risk score (p < 0.001). However, the previously identified associations with pulse wave velocity and BMI were no longer evident in the models. These findings suggest that more pro-inflammatory diets may contribute to poorer cardiometabolic health. Promoting healthier diets with a lower inflammatory potential may help to prevent or slow development of cardiometabolic disorders.

Inflammation and Cardiovascular Disease: The Future

Despite considerable advances in reducing the global burden of atherosclerotic cardiovascular disease by targeting conventional risk factors, significant residual risk remains, with low-grade inflammation being one of the strongest risk modifiers. Inflammatory processes within the arterial wall or systemic circulation, which are driven in a large part by modified lipoproteins but subsequently trigger a hypercoagulable state, are a hallmark of atherosclerotic cardiovascular disease and, in particular, its clinical complications. Extending conventional guideline-based clinical risk stratification algorithms by adding biomarkers of inflammation may refine phenotypic screening, improve risk stratification and guide treatment eligibility in cardiovascular disease prevention. The integration of interventions aimed at lowering the inflammatory burden, alone or in combination with aggressive lipid-modifying or even antithrombotic agents, for those at high cardiovascular risk may hold the potential to reduce the still substantial burden of cardiometabolic disease. This review provides perspectives on future clinical research in atherosclerosis addressing the tight interplay between inflammation, lipid metabolism and thrombosis, and its translation into clinical practice.

Descriptive modification of inflammatory markers in HIV patients after cART initiation according to gender, smoking habit, CMV infection, BMI and serum lipids

Persistent inflammation, despite anti-retroviral therapy (ART), is an independent predictor of mortality and comorbidities in HIV infection. Multiple factors, including lifestyle and chronic viral coinfections, may contribute. Several of these factors are also associated with a chronic inflammation in the general population. Little is known about the degree to which these factors influence inflammation in HIV infection, particularly within the first year of ART. The purpose of this study was to distinguish the effects of factors (gender, body mass index, cholesterol and triglyceride levels, smoke habit and cytomegalovirus seropositivity), known to contribute to inflammation, on inflammation biomarkers over the first year of ART in HIV-infected patients. Linear mixed model analysis revealed significant biomarker decreases [soluble CD14 (s-CD14), soluble CD163 (s-CD163) and D-dimer (DD)], or increases [C Reactive Protein (CRP) and interleukin-6 (IL-6)] over time in the whole cohort, differences in most categories (genders for IL-6, smoke habit for s-CD14, cytomegalovirus infection for s-CD163 and IL-6) and in some category × time interactions [gender for interleukin-7 (IL-7)], cytomegalovirus infection for s-CD14 and cholesterol levels for s-CD14 and Tumor Necrosis Factor α (TNF-α)]. This explorative longitudinal study suggests further investigations on targeting inflammation pathophysiology in HIV-infected patients on ART.

Automatic text-mining as an unbiased approach to uncover molecular associations between periodontitis and coronary artery disease

The increasing prevalence of periodontal and cardiovascular diseases is the result of a sedentary lifestyle associated with poor diet, obesity, hypercholesterolaemia, smoking habits, alcohol consumption and stress. The present study aims to uncover molecular associations between periodontitis and coronary heart disease using an unbiased strategy of automatic text mining traditionally applied to bibliometric studies. A total of 1590 articles on these diseases were retrieved from the Web of knowledge database and searched using the VOS viewer to create a network of keywords associated with both diseases. These data were supplemented with data from DisGeNET, which stores known associations to either periodontitis or coronary heart disease. Overall, the automated text mining approach presented here highlighted inflammatory molecules as common associations between periodontitis and coronary heart disease. Specifically, this study showed that molecules such as C-reactive protein, interleukins 6 and 1-β, myeloperoxidase, and matrix metalloproteinase 9 are simultaneously associated with periodontitis and coronary artery disease by both text mining and DisGeNET analyses. This association validates the multiplex assessment of salivary inflammatory markers as a tool to assess cardiovascular disease risk and could become an important tool to identify common molecular targets to monitor both diseases simultaneously. In addition, the text mining protocol and subsequent data processing and methods using bioinformatics tools could be useful to uncover links between other diseases.

Assessment of the relationship between estimated cardiovascular risk and structural damage in patients with axial spondyloarthritis

Aims

To evaluate the association of estimated cardiovascular (CV) risk and subclinical atherosclerosis with radiographic structural damage in patients with axial spondyloarthritis (axSpA).

Methods

Cross-sectional study including 114 patients axSpA from the SpA registry of Córdoba (CASTRO) and 132 age- and sex-matched healthy controls (HCs). Disease activity and the presence of traditional CV risk factors were recorded. The presence of atherosclerotic plaques and carotid intima media thickness (cIMT) were evaluated through carotid ultrasound and the SCORE index was calculated. Radiographic damage was measured though modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS). The association between mSASSS and SCORE was tested using generalized linear models (GLM), and an age-adjusted cluster analysis was performed to identify different phenotypes dependent on the subclinical CV risk.

Results

Increased traditional CV risk factors, SCORE, and the presence of carotid plaques were found in axSpA patients compared with HCs. The presence of atherosclerotic plaques and SCORE were associated with radiographic structural damage. The GLM showed that the total mSASSS was associated independently with the SCORE [β coefficient 0.24; 95% confidence interval (CI) 0.10-0.38] adjusted for disease duration, age, tobacco, C-reactive protein, and non-steroidal anti-inflammatory drugs (NSAID) intake. Hard cluster analysis identified two phenotypes of patients. Patients from cluster 1, characterized by the presence of plaques and increased cIMT, had a higher prevalence of CV risk factors and SCORE, and more structural damage than cluster two patients.

Conclusion

Radiographic structural damage is associated closely with increased estimated CV risk: higher SCORE levels in axSpA patients were found to be associated independently with mSASSS after adjusting for age, disease duration, CRP, tobacco and NSAID intake.

The need for PCSK9 inhibitors and associated treatment costs according to the 2019 ESC dyslipidaemia guidelines vs. the risk-based allocation algorithm of the 2017 ESC consensus statement: a simulation study in a contemporary CAD cohort

BACKGROUND

The recently updated European Society of Cardiology (ESC) dyslipidaemia guidelines recommend a lower low-density lipoprotein cholesterol (LDL-C) goal of <55 mg/dL for patients with atherosclerotic cardiovascular disease (ASCVD), with a concomitant Class IA upgrade for proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) for patients not reaching their LDL-C goal under conventional lipid-lowering therapy.

AIMS

We aim to quantify the need for PCSK9i and the related costs to achieve the revised LDL-C goal in ASCVD patients compared to former ESC recommendations, in particular the risk-based 2017 ESC consensus update.

METHODS AND RESULTS

We included patients with ASCVD from an observational cohort study ongoing since 2015. A Monte Carlo simulation incorporating a treatment algorithm adding sequentially a statin, ezetimibe, and a PCSK9i was applied with consideration of partial and total statin intolerance. The need for PCSK9i was calculated for three different ESC recommendations (2019 guidelines, 2016 guidelines, 2017 consensus update). Preventable events and treatment costs due to PCSK9i were calculated for a range of annual event rates from 2% to 8% and annual treatment costs of ca. 6050 €. We included 1780 patients (mean age 69.5 years). Median LDL-C at baseline was 85.0 mg/dL, with 61% of patients taking lipid-lowering medication. The need for PCSK9i was simulated to be 42.0% (ESC 2019), 31.9% (ESC 2016), and 5.0% (ESC 2017). The LDL-C goals were achieved in 97.9%, 99.1%, and 60.9% of patients, respectively. Annual treatment cost for PCSK9i per 1 000 000 ASCVD patients would be 2.54 billion € (ESC 2019) compared to 0.30 billion € (ESC 2017). Costs per prevented event due to PCSK9i initiation differed widely, e.g. 887 000 € for an event rate of 3% and a treatment goal of <55 mg/dL compared to 205 000 € for an event rate of 7% and risk-based use of PCSK9i.

CONCLUSION

The revised LDL-C treatment goals increase the projected need for PCSK9i with a substantial increase in associated treatment cost. An allocation strategy based on residual LDL-C and clinical or angiographic risk factors leads to a more tailored target population for PCSK9i with a reasonable benefit/cost ratio.

Association between α1-antitrypsin and acute coronary syndrome

α1-antitrypsin (AAT) is a protein released as part of the anti-inflammatory response. It regulates the activity of serine proteinases and has a crucial role in the pathogenesis of acute coronary syndrome (ACS). The present study aimed to examine its role in patients with ACS. The plasma samples of 117 patients were collected at the Cardiology Department of the Affiliated Hospital of Youjiang Medical University (Baise, China). These included 46 cases of ACS (who met the diagnostic criteria for ACS and had ≥50% luminal stenosis of any coronary vessel), 35 cases of stable angina (SA; with ≥50% luminal stenosis of any coronary vessel but in a stable condition) and 36 normal healthy controls (subjects with no luminal stenosis in their coronary arteries). Plasma AAT protein concentrations were measured by ELISA and clinical data were collected. The plasma levels of AAT protein in patients with ACS were lower than those in controls and cases of SA (P<0.05), and the levels tended to decrease with the number of coronary artery lesions involved. There were no significant associations of the expression of plasma AAT protein and the number of diseased vessels in patients or the degree of stenosis. There was no correlation between the plasma protein levels of AAT and Gensini scores of patients with ACS. In conclusion, the plasma AAT protein levels in patients with ACS may contribute to the occurrence and development of coronary artery disease.

South Indian Cuisine with Low Glycemic Index Ingredients Reduces Cardiovascular Risk Factors in Subjects with Type 2 Diabetes

Background: Inflammation is considered as a predictor of cardiovascular diseases in type 2 diabetes mellitus. No previous studies have investigated the effect of low glycemic index (LGI) recipes of South Indian cuisine on the risk factors of cardiovascular disease in patients with diabetes. Aim: The aim of this randomized controlled trial was to evaluate the improvement in cardiovascular risk factors and blood glucose control, in patients with type 2 diabetes, after intervention with recipes of Kerala cuisine, from locally available whole grain cereals, low in glycemic index. Method: This was a prospective and randomized controlled study that was conducted over a period of 24 weeks. A total of 80 participants were recruited from the Department of Endocrinology and Diabetes Outpatient in Kerala, South India. All 80 patients had type 2 diabetes, and were aged between 35 and 65 years. Participants were randomly assigned and advised to follow either a LGI diet plan (n = 40) or their usual diet, which served as a control group (n = 40). The advice was reinforced throughout the study period. Anthropometric, biochemical parameters which included glycemic and cardio-metabolic parameters were measured according to standard procedures. T-tests were conducted to compare the differences between intervention and control groups, and the Pearson correlation coefficient was used to evaluate associations between the variables. Results: There were significant differences (p < 0.05) between the intervention and control groups with respect to weight, HbA1c, insulin, triglycerides, Homeostatic Model Assessment of Insulin Resistance (HOMA-IR), high sensitivity C-reactive protein (hs-CRP) and apolipoprotein B (ApoB). There was also a positive correlation between weight and blood glucose variables. ApoB was positively correlated with lipid profile and insulin levels. Conclusions: The long-term implementation of LGI diet of Kerala cuisine has been found to promote weight loss, enhance insulin sensitivity and reduce the cardiovascular risk.

The Beneficial Role of Exercise Training for Myocardial Infarction Treatment in Elderly

Worldwide, elderly people have a higher prevalence of myocardial infarction (MI), which is associated with body function aging and a sedentary lifestyle. In addition to medication, exercise training is a well-established supplementary method to prevent and treat cardiovascular diseases (CVDs). Substantial evidence has shown the value of different intensity exercise programs in the prevention and treatment of MI, and exercise rehabilitation programs are also applicable to elderly patients with MI. Although exercise rehabilitation programs could significantly improve function, quality of life (QoL), and lower mortality and morbidity for people with MI, such programs are underused because their mechanisms are not accurately elucidated. To promote the application of exercise therapy for MI, this review summarizes the benefits and mechanisms of exercise rehabilitation for post-MI patients and provides rationalized proposals for outpatient cardiac rehabilitation.