Comparison of calculated remnant lipoprotein cholesterol levels with levels directly measured by nuclear magnetic resonance

Remnant cholesterol and risk of premature mortality: an analysis from a nationwide prospective cohort study

AIMS

To explore the relationship between remnant cholesterol (RC) and the risk of premature mortality as well as life expectancy in the general population.

METHODS

We included a total of 428 804 participants from the UK Biobank for analyses. Equivalent population percentiles approach based on the low-density lipoprotein cholesterol cut-off points was performed to categorize participants into three RC groups: low (with a mean RC of 0.34 mmol/L), moderate (0.53 mmol/L), and high (1.02 mmol/L). We used multivariable Cox proportional hazards models to evaluate the relationship between RC groups and the risk of premature mortality (defined as death before age 75 years). Life table methods were used to estimate life expectancy by RC groups.

RESULTS

During a median follow-up of 12.1 years (Q1-Q3 11.0-13.0), there were 23 693 all-cause premature deaths documented, with an incidence of 4.83 events per 1000 person-years [95% confidence interval (CI): 4.77-4.89]. Compared with the low RC group, the moderate RC group was associated with a 9% increased risk of all-cause premature mortality [hazard ratio (HR) = 1.09, 95% CI: 1.05-1.14], while the high RC group had an 11% higher risk (HR = 1.11, 95% CI: 1.07-1.16). At the age of 50 years, high RC group was associated with an average 2.2 lower years of life expectancy for females, and an average 0.1 lower years of life expectancy for males when compared with their counterparts in the low RC group.

CONCLUSIONS

Elevated RC was significantly related to an increased risk of premature mortality and a reduced life expectancy. Premature death in the general population would benefit from measurement to aid risk stratification and proactive management of RC to improve cardiovascular risk prevention efforts.

The Risk of Coronary Artery Calcification according to Different Lipid Parameters and Average Lipid Parameters

AIM

We compared the association between the baseline and average lipid parameters over time and the coronary artery calcification (CAC) risk.

METHODS

Participants who underwent annual (biannual) health examinations and coronary artery computed tomography to measure CAC at least twice between March 2010 and December 2019, with a baseline CAC of 0, were included. The levels of apolipoprotein B (ApoB), Apolipoprotein A-I (ApoA1), ApoB/ApoA1, non-high-density lipoprotein cholesterol (non-HDL-C), low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), triglycerides (TG), TG/HDL-C, and TC/HDL-C were measured or calculated. The remnant cholesterol (RC) levels were calculated. The average lipid parameters before study entry were calculated using data from 2002 to 2010. The participants were divided into quartiles (Q) according to the parameter values. Cox proportional hazard modeling, adjusted for confounding factors, compared the CAC risk of the highest quartile to the lowest quartile.

RESULTS

Among 29,278 participants (mean age, 39.19±5.21; men, 88.27%), 2,779 developed CAC ＞0. The highest quartile of ApoB showed a numerically strong association with CAC risk, compared with the lowest quartile of ApoB (Q1: reference; Q2: HR,1.41, 95% CI,1.25-1.59; Q3: HR,1.97, 95% CI,1.75-2.21; Q4: HR,2.72, 95% CI,2.41-3.07). RC showed a modest association with CAC risk (Q1: reference; Q2: HR,1.13, 95% CI,0.99-1.28; Q3: HR,1.3, 95% CI,1.15-1.47; Q4: HR,1.7, 95% CI,1.51-1.91). The strength of the association was comparable between the parameters at baseline and the average lipid parameters over time.

CONCLUSIONS

A high ApoB level showed a strong association with CAC risk compared with the lowest ApoB quartile. The baseline lipid parameters can predict CAC development as effectively as the average of multiple measurements can.

Metformin-Induced Proprotein Convertase Subtilisin/Kexin Type 9 Inhibition Further Decreases Low-Density Lipoprotein Cholesterol Following Statin Treatment in Patients With Coronary Artery Disease and Without Diabetes

ABSTRACT

In vitro investigations have established metformin's capacity to downregulate proprotein convertase subtilisin/kexin type 9 (PCSK9) expression, suggesting a potential beneficial effect on atherogenic lipoprotein particles when combined with metformin therapy. Our objective was to assess whether metformin could mitigate statin-induced adverse effects on PCSK9, thereby improving lipid profiles in patients with coronary artery disease (CAD) but without diabetes. Employing an open-label, placebo-controlled, randomized trial, we randomized patients with CAD but without diabetes into CLA (cholesterol-lowering agents alone: atorvastatin ± ezetimibe, n = 38) and Met + CLA groups (metformin plus CLA, n = 33) in a 1:1 ratio. The primary end point was the therapeutic impact of 1-month metformin combination treatment on low-density lipoprotein cholesterol (LDL-C) and PCSK9 levels. Baseline LDL-C and PCSK9 levels were 76.18 mg·dL -1 and 80.54 ng·mL -1 , respectively. After 1 month, metformin significantly reduced LDL-C (-20.81%, P < 0.001), enabling 72% of patients to attain guideline-recommended LDL-C goals. Noteworthy reductions in PCSK9 levels (-15.03%, P < 0.001) were observed. Moreover, Met + CLA markedly reduced LDL particle number more than CLA alone (-10.65% vs. 1.45%, P = 0.009), primarily due to diminished small-dense LDL particle count. Mechanistically, our study demonstrated metformin's inhibition of statin-induced PCSK9 expression in human hepatocellular cells. In summary, a 1-month metformin combination regimen reduced LDL-C levels in patients with CAD but without diabetes by inhibiting PCSK9 expression.

TRIAL REGISTRATION

Chinese Clinical Trial Registry identifier: ChiCTR1900026925 (26/10/2019).

Association Between Remnant Cholesterol and Risk of Incident Atrial Fibrillation: Population-Based Evidence From a Large-Scale Prospective Cohort Study

BACKGROUND

Evidence for the relationship between remnant cholesterol (RC) and incident atrial fibrillation (AF) risk remains sparse and limited.

METHODS AND RESULTS

Participants were enrolled between 2006 and 2010 and followed up to 2021. The multivariable Cox proportional hazards model was used to examine the relationship between RC quartiles and risk of incident AF. Subgroup analyses and sensitivity analyses were performed to explore the potential modification of the association and the robustness of the main findings. A total of 422 316 participants (mean age, 56 years; 54% women) were included for analyses. During a median follow-up of 11.9 years (first quartile-third quartile, 11.6-13.2 years), there were 24 774 AF events documented with an incidence of 4.92 events per 1000 person-years (95% CI, 4.86-4.98). Participants in higher RC quartiles had a lower risk of incident AF than those in the lowest quartile (first quartile): hazard ratio (HR)=0.96 (95% CI, 0.91-1.00) for second quartile; HR=0.92 (95% CI, 0.88-0.96) for third quartile; and HR=0.85 (95% CI, 0.81-0.89) for fourth quartile (P for trend <0.001). The association between RC quartiles and risk of incident AF was stronger in participants aged ≥65 years, in men, and in participants without history of diabetes when compared with control groups (P<0.001 for interaction).

CONCLUSIONS

On the basis of data from this large-scale prospective cohort study, elevated RC was associated with a lower risk of incident AF.

Hypertension combined with limitations in activities of daily living and the risk for cardiovascular disease

OBJECTIVE

The aim of present study was to evaluate the combined effect of hypertension and activities of daily living (ADL)/instrumental activities of daily living (IADL) with the risk of CVD, stroke and cardiac events.

METHODS

A total of 14,083 participants aged 45 years or older from the China Health and Retirement longitudinal study were included in current study. Participants were divided into 4 groups according to hypertension and ADL/IADL status. Cox proportional hazards regression model was used to explore the associations between hypertension, ADL/IADL and new-onset CVD, stroke and cardiac events.

RESULTS

During the 7-year follow-up, a total of 2,324 respondents experienced CVD (including 783 stroke and 1,740 cardiac events). Individuals with limitations in ADL alone, or with hypertension alone, or with both limitations in ADL and hypertension were associated with increased risk of CVD, with the adjusted hazard ratios (95% confidence intervals) were 1.17(1.00-1.35), 1.36(1.24-1.49) and 1.44(1.23-1.68), respectively. Those with limitations in ADL and hypertension also had higher risk of stroke (hazard ratios = 1.64; 1.26-2.14) and cardiac events (hazard ratios = 1.37; 1.14-1.64). Similarly, individuals with both limitations in IADL and hypertension were associated with increased risk of CVD (hazard ratios = 1.34; 1.15-1.57), stroke (hazard ratios = 1.50; 1.17-1.95) and cardiac events (hazard ratios = 1.27; 1.06-1.53).

CONCLUSION

Hypertension and limitations in ADL/IADL jointly increased the risk of CVD, stroke and cardiac events.

Association of remnant cholesterol with decreased kidney function or albuminuria: a population-based study in the U.S

BACKGROUND

Dyslipidemia is frequently exhibited in individuals with chronic kidney disease (CKD). Remnant cholesterol (RC), an emerging novel lipid marker, plays an elusive role in CKD progression. This study sought to investigate the association of RC with decreased kidney function or albuminuria in the general population of U.S.

METHOD

Data were retrieved from the continuous 2001 to 2018 cycle of the National Health and Nutrition Examination Survey (NHANES). Individuals aged between 18 and 70 years were included. RC was divided into quartiles. Albuminuria was defined by albumin-to-creatinine ratio (ACR) ≥30 mg/g, while reduced kidney function was described as an estimated glomerular filtration rate (eGFR) below 60 ml/min/1.73 m2. Using a multivariable regression model, the association of RC with decreased eGFR or albuminuria was examined. The dose‒response relationship between RC and eGFR or ACR was also investigated using a restricted cubic spline (RCS) model.

RESULTS

A total of 1551 (10.98%) participants with impaired renal function or albuminuria were identified. After multivariate adjustment, RC was not significantly associated with kidney function decline or albuminuria (odds ratio (OR) 1.24, 95% confidence interval (95% CI): 0.95, 1.61). However, a significantly inverse correlation was observed between RC and eGFR in a dose‒response manner (β -2.12, 95% CI: -3.04, -1.21). This association remained consistent when stratifying data by gender, age, race, hypertension, diabetes and body mass index (BMI).

CONCLUSION

A higher RC was significantly correlated with a lower eGFR in the general population. The role of RC in predicting kidney outcomes needed further investigation in prospective studies.

Non-fasting lipids and cardiovascular disease in those with and without diabetes in Alberta's Tomorrow Project: A prospective cohort study

AIMS

Non-fasting remnant cholesterol (RC) is a novel marker of cardiovascular disease (CVD) risk, however, data on this relationship in Canadians with diabetes (at high risk of CVD) is lacking. The objective of this analysis was to determine the relationship of RC with CVD in individuals with and without diabetes in the Alberta's Tomorrow Project (ATP) cohort.

METHODS

Non-fasting lipid data collected as part of the ATP was linked to administrative health records (October 2000-March 2015) to ascertain incident CVD and prevalent diabetes. Participants without prevalent CVD or incident diabetes and who had complete, non-negative non-fasting lipid data collected with triglycerides <4.5 mmol/L were included (n = 13,631). The relationship between non-fasting RC and incident CVD diagnoses was assessed by Cox proportional hazards regression, after stratification by diabetes status.

RESULTS

Participants were 69.8% women with a mean age of 61.6 ± 9.7 years, and 6.5% had prevalent diabetes. Non-fasting RC was higher in participants with diabetes compared to those without (mean 0.94 ± 0.41 mmol/L vs. 0.77 ± 0.38 mmol/L, p < 0.0001) and was associated with increased risk of incident CVD among those without diabetes (adjusted hazard ratio (aHR) 1.22, 95% CI 1.03-1.43, p = 0.02). Although a similar trend was observed in participants with diabetes it did not reach statistical significance (aHR 1.31, 95% CI 0.84-2.05, p = 0.23).

CONCLUSIONS

Elevated non-fasting RC predicted increased CVD risk in middle and older-aged adults without diabetes; similar trends were observed in participants with diabetes and require further testing in a larger sample.

Association between remnant cholesterol level and severity of chronic kidney disease in patients with type 2 diabetes

BACKGROUND

Studies on whether remnant cholesterol (RC) affects the progression of chronic kidney disease (CKD) remain insufficient. This study aimed to determine whether RC level was associated with the severity of CKD in patients with type 2 diabetes mellitus (T2DM).

METHODS

In total, 3383 individuals diagnosed with T2DM were enrolled in this cross-sectional study from China. The severity of CKD was defined as no, moderate, severe, and very severe CKD based on the urinary albumin-to-creatinine ratio and estimated glomerular filtration rate. Because RC was non-normally distributed, it was log-transformed and categorized into quantiles. Multivariate logistic regression and multivariate ordinal logistic regression analysis were performed to investigate whether RC was independently associated with CKD and its severity.

RESULTS

The median RC level was 25.9 mg/dL. The number of patients with no, moderate, severe, and very severe CKD was 2587 (76.5 %), 520 (15.4 %), 189 (5.6 %), and 87 (2.5 %), respectively. After adjusting for confounding factors, the prevalence of CKD increased 1.67-fold when the log-transformed RC level was elevated by one unit (OR [95 % CI], 1.67 [1.43-1.95]). The likelihood of CKD severity increasing by one degree was 1.76-fold for each one-unit increase in log-transformed RC level (OR [95 % CI], 1.76 [1.52-2.05]). When RC was incorporated as a categorical variable, it still correlated with CKD severity compared with quantile 1 (Q1) (Q2, 1.30 [1.01-1.68]; Q3, 1.60 [1.23-2.07]; Q4, 2.39 [1.86-3.09]). The association remained regardless of whether the patient's traditional lipid profiles achieved the target range.

CONCLUSION

RC level was associated with CKD severity even when traditional lipid profiles were within the target range in patients with T2DM.

Remnant cholesterol, low-density lipoprotein cholesterol, and incident cardiovascular disease among Koreans: a national population-based study

AIMS

The synergistic association of remnant cholesterol (remnant-C) and low-density lipoprotein cholesterol (LDL-C) levels with incident cardiovascular disease (CVD) in various subgroups of Koreans was investigated.

METHODS AND RESULTS

Using the national health insurance data, we included subjects aged between 40 and 70 years without a history of CVD and at least two health screenings between 2009 and 2011. The subjects were divided into four groups by LDL-C and remnant-C levels. The primary outcome was CVD, which occurred between 2014 and 2017. Among 3 686 034 (45.6% women) subjects, 144 004 cardiovascular events occurred. Individuals in both high LDL-C and high remnant-C [hazard ratio (HR) 1.266, 95% confidence interval (CI) 1.243-1.289; 7.9%], high LDL-C only (HR 1.098, 95% CI 1.083-1.113; 21.2%), and high remnant-C only groups (HR 1.102, 95% CI 1.087-1.118; 19.1%) had higher risks of CVD than those in the reference group (LDL-C < 3.4 mmol/L and remnant-C < 0.8 mmol/L; 51.8%). A continuous and linear increase in CVD risk was found in those with higher remnant-C levels after adjustment for several confounders, including LDL-C levels. The association of remnant-C ≥ 0.8 mmol/L with an increased CVD risk was consistent across various strata.

CONCLUSIONS

Combined high remnant-C and LDL-C levels confer a higher CVD risk than that individually. Elevated remnant-C values independent of LDL-C levels were associated with a risk of incident CVD. Remnant cholesterol levels in addition to LDL-C levels are important considerations in risk stratification for the primary prevention of CVD.

Nonfasting remnant cholesterol and cardiovascular disease risk prediction in Albertans: a prospective cohort study

BACKGROUND

European studies have shown that nonfasting remnant cholesterol can be a strong predictor of cardiovascular disease risk and may contribute to identifying residual risk; however, Canadian data are lacking on nonfasting remnant cholesterol. In this study, we aimed to determine the relation between nonfasting remnant cholesterol, low-density lipoprotein (LDL) cholesterol and cardiovascular disease among people in Alberta.

METHODS

In this retrospective analysis, we used data from Alberta's Tomorrow Project, a large prospective cohort that enrolled Albertans aged 35-69 years (2000-2015). Participants with consent to data linkage, with complete nonfasting lipid data and without existing cardiovascular disease were included. The nonfasting remnant cholesterol and LDL cholesterol relation with a composite cardiovascular disease outcome of major incident cardiovascular diagnoses, ascertained by linking to Alberta Health databases, was determined by multivariable logistic regression, adjusting for age, sex, statin use, comorbidities, and LDL cholesterol or remnant cholesterol.

RESULTS

The final sample of 13 988 participants was 69.4% female, and the mean age was 61.8 (standard deviation [SD] 9.7) years. Follow-up time was approximately 15 years. Mean remnant cholesterol was significantly higher among individuals with versus without cardiovascular disease (0.87 [SD 0.40] mmol/L v. 0.78 [SD 0.38] mmol/L, standardized mean difference [SMD] -0.24), and mean LDL cholesterol was significantly lower (2.69 [SD 0.93] mmol/L v. 2.88 [SD 0.84] mmol/L, SMD 0.21). The odds of incident composite cardiovascular disease were significantly increased per mmol/L increase in remnant cholesterol (adjusted odds ratio [OR] 1.48, 95% confidence interval [CI] 1.27-1.73) but significantly decreased per mmol/L increase in LDL cholesterol (adjusted OR 0.73, 95% CI 0.68-0.79).

INTERPRETATION

In this large Albertan cohort of predominantly older females, nonfasting remnant cholesterol had a positive relation with cardiovascular disease incidence, whereas LDL cholesterol did not. These findings support the clinical utility of measuring non-fasting remnant cholesterol to detect cardiovascular disease risk.

The role of atherogenic lipoproteins in diabetes: Molecular aspects and clinical significance

Dyslipidaemia plays a prominent role in the genesis of atherosclerotic plaque and the increased cardiovascular risk in diabetes. Macrophages readily take up atherogenic lipoproteins, transforming into foam cells and amplifying vascular damage in the presence of endothelial dysfunction. We discuss the importance of distinct lipoprotein subclasses in atherogenic diabetic dyslipidaemia as well as the effects of novel anti-diabetic agents on lipoprotein fractions and ultimately on cardiovascular risk prevention. In patients with diabetes, lipid abnormalities should be aggressively identified and treated in conjunction with therapeutical agents used to prevent cardiovascular disease. The use of drugs that improve diabetic dyslipidaemia plays a prominent role in conferring cardiovascular benefit in individuals with diabetes.

Remnant cholesterol as a risk factor for all-cause and cardiovascular mortality in incident peritoneal dialysis patients

BACKGROUND AND AIMS

Remnant cholesterol (RC) adversely contributes to cardiovascular disease (CVD) and overall survival in various diseases. However, its role in CVD outcomes and all-cause mortality in patients undergoing peritoneal dialysis (PD) is limited. Therefore, we aimed to investigate the association between RC and all-cause and CVD mortality in patients undergoing PD.

METHODS AND RESULTS

Based on lipid profiles recorded using standard laboratory procedures, fasting RC levels were calculated in 2710 incident patients undergoing PD who were enrolled between January 2006 and December 2017 and followed up until December 2018. Patients were divided into four groups according to the quartile distribution of baseline RC levels (Q1: <0.40 mmol/L, Q2: 0.40 to <0.64 mmol/L, Q3: 0.64 to <1.03 mmol/L, and Q4: ≥1.03 mmol/L). Associations between RC and CVD and all-cause mortality were evaluated using multivariable Cox models. During the median follow-up period of 35.4 months (interquartile range, 20.9-57.2 months), 820 deaths were recorded, of which 438 were CVD-related. Smoothing plots showed non-linear relationships between RC and adverse outcomes. The risks of all-cause and CVD mortality increased progressively through the quartiles (log-rank, p < 0.001). Using adjusted proportional hazard models, a comparison of the highest (Q4) to lowest (Q1) quartiles revealed significant increases in the hazard ratio (HR) for all-cause mortality (HR 1.95 [95% confidence interval (CI), 1.51-2.51]) and CVD mortality risk (HR 2.60 [95% CI, 1.80-3.75]).

CONCLUSION

An increased RC level was independently associated with all-cause and CVD mortality in patients undergoing PD, suggesting that RC was important clinically and required further research.

Association of remnant cholesterol with depression among US adults

BACKGROUND

Remnant cholesterol is receiving increasing attention because of its association with various diseases. However, there have been no studies on remnant cholesterol levels and depression.

METHODS

A cross-sectional analysis was performed based on the National Health and Nutrition Examination Survey (NHANES) 2005-2016. Depression was assessed using a Patient Health Questionnaire (PHQ-9). Fasting remnant cholesterol was calculated as the total cholesterol minus high-density lipoprotein cholesterol (HDL-C) minus low-density lipoprotein cholesterol (LDL-C). Logistic regression analysis with sampling weights was used to examine the association between remnant cholesterol concentration and depression.

RESULTS

Among 8,263 adults enrolled in this study (weighted mean age, 45.65 years), 5.88% (weighted percentage) had depression. Compared to the participants without depression, those with depression had higher concentration of remnant cholesterol (weighted mean, 26.13 vs. 23.05, P < 0.001). There was a significant positive relationship between remnant cholesterol concentration and depression and multivariable-adjusted OR with 95% CI was 1.49 (1.02-2.17). Among the subgroup analyses, remnant cholesterol concentration was positively associated with depression among participants less than 60 years (OR, 1.62; 95% CI, 1.09-2.42), male (OR, 2.02; 95% CI, 1.01-4.05), BMI under 30 (OR, 1.83; 95% CI, 1.14-2.96), and those with diabetes (OR, 3.88; 95% CI, 1.43-10.49).

CONCLUSIONS

Remnant cholesterol concentration positively correlated with depression, suggesting that a focus on remnant cholesterol may be useful in the study of depression.

Remnant cholesterol can identify individuals at higher risk of metabolic syndrome in the general population

Remnant cholesterol (RC) is a highly atherogenic lipid. Previous studies have shown that RC was closely associated with many metabolism-related diseases. However, the relationship of RC with metabolic syndrome (MetS) remains unclear. This study's objective is to investigate the relationship of RC with MetS. A total of 60,799 adults who received health assessments were included in this study. RC was calculated by subtracting the directly measured values for low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) from total cholesterol (TC) and divided into 5 groups according to its quintile. MetS diagnosis according to National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) definitions. Application of receiver operating characteristic (ROC) curve analysis and multivariate logistic regression to assess the association of RC with MetS. In RC quintile groups, the prevalence of MetS was 0.84, 1.10, 1.92, 3.87 and 37.71%, respectively. Multivariate logical regression analysis showed that RC and MetS maintained a stable independent positive correlation between both sexes. An interaction test further showed that the MetS risk associated with RC was significantly higher in women than in men. Moreover, ROC analysis results showed that RC had high accuracy in identifying MetS, especially among young and middle-aged men [(area under the curve: AUC) < 30 years: 0.9572, 30-39 years: 0.9306, 40-49 years: 0.9067]. The current study provided the first evidence of a positive association between RC and MetS, and that this correlation was stronger in women than in man, which may be due to the relative deficiency of estrogen in women.

Association of remnant cholesterol with risk of cardiovascular disease events, stroke, and mortality: A systemic review and meta-analysis

BACKGROUND AND AIMS

Lipid disorders are associated with the risk of cardiovascular diseases (CVDs). Remnant cholesterol (RC), a non-traditional previously neglected risk factor for CVD, has received much attention in recent years. The aim of this study is to evaluate the association of RC with the risks of CVD, stroke, and mortality.

METHODS

MEDLINE, Web of Science, EMBASE, ClinicalTrials.gov, and Cochrane Central Register for Controlled Trials were searched. We included randomized controlled trials (RCTs), non-RCTs, and observational cohort studies assessing the association of RC with the risks of cardiovascular (CV) events, coronary heart disease (CHD), stroke, and mortality.

RESULTS

Overall, 31 studies were included in this meta-analysis. Compared with low RC, elevated RC was associated with an increased risk of CVD, CHD, stroke, CVD mortality, and all-cause mortality (RR = 1.53, 95% CI 1.41-1.66; RR = 1.41, 95% CI 1.19-1.67; RR = 1.43, 95% CI 1.24-1.66; RR = 1.83, 95% CI 1.53-2.19; and RR = 1.39, 95% CI 1.27-1.50; respectively). A subgroup analysis demonstrated that each 1.0 mmol/L increase in RC was associated with an increased risk of CVD events and CHD. The association of RC with an increased CVD risk was not dependent on the presence or absence of diabetes, a fasted or non-fasted state, total cholesterol, or triglyceride or ApoB stratification.

CONCLUSIONS

Elevated RC is associated with an increased risk of CVD, stroke, and mortality. In addition to the traditional cardiovascular risk factors, such as total cholesterol and LDL-C, clinicians should also pay attention to RC in clinics.

Effect of acute ketosis on lipid profile in prediabetes: findings from a cross-over randomized controlled trial

Background

Ketone monoester β-hydroxybutyrate (KEβHB) ingestion has emerged as an effective method of inducing acute ketosis. Although evidence suggests that KEβHB can offer several therapeutic benefits, whether KEβHB affects lipid profile is still unknown.

Aims

The primary aim was to study the effect of KEβHB on plasma lipid profile in individuals with prediabetes. The secondary aim was to investigate the role of saturated fat intake in that effect.

Methods

This study was a randomized controlled trial with cross-over design. Following an overnight fast, 18 adults (six women and 12 men) with prediabetes (diagnosed based on the American Diabetes Association criteria) ingested a single dose of KEβHB drink or placebo drink. Blood samples were collected every 30 min, from baseline to 150 min. Outcome variables included changes in total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, remnant cholesterol, triglycerides, and the triglycerides to HDL cholesterol ratio. The area under the curve (AUC) over 150 min was calculated for each outcome following ingestion of the drinks. Habitual saturated fat intake was ascertained using the EPIC-Norfolk food frequency questionnaire.

Results

Significant elevation of blood β-hydroxybutyrate from 0.2 mmol/L to 3.5 mmol/L (p < 0.001) was achieved within 30 min. Acute ketosis resulted in significantly lower AUCs for remnant cholesterol (p = 0.022) and triglycerides (p = 0.022). No statistically significant differences in the AUCs for total cholesterol, HDL cholesterol, LDL cholesterol, and the triglycerides to HDL cholesterol ratio were found. The changes in remnant cholesterol and triglycerides were statistically significant in individuals with high, but not low, habitual saturated fat intake.

Conclusion

Acute ketosis had no untoward effect on plasma lipid profile. Moreover, it led to significantly reduced circulating levels of remnant cholesterol and triglycerides. This paves the way for investigating whether exogenous ketone supplementation reduces cardiovascular disease risk (via its actions on triglyceride-rich lipoproteins) in at-risk populations.

 Trial registration: ClinicalTrials.gov, NCT03889210.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01571-z.

Hypertension, remnant cholesterol and cardiovascular disease: evidence from the China health and retirement longitudinal study

OBJECTIVE

Previous studies had reported the significant association between hypertension, remnant cholesterol (RC) and risk of cardiovascular disease (CVD). The aim of present study was to evaluate the combined effect of hypertension and RC on the risk of CVD.

METHODS

A total of 9456 participants from the China Health and Retirement Longitudinal Study were included. Multivariate Cox proportional hazards regression model was used to explore the associations between hypertension, RC and new-onset CVD, stroke and cardiac events.

RESULTS

During the follow-up period, 1702 CVD events (including 563 stroke and 1282 cardiac events) were recorded. Compared to those without hypertension and low RC level, the adjusted hazard ratios (95% confidence intervals) were 1.09 (0.95-1.24) for individuals with high RC alone, 1.27 (1.10-1.46) for individuals with hypertension alone and 1.32 (1.15-1.51) for individuals with comorbid hypertension and high RC. Individuals with co-existence of hypertension and high RC also had the highest risks of stroke and cardiac events.

CONCLUSION

Our study indicated that there was a combined effect of hypertension and RC on the risk of CVD, stroke and cardiac events. Larger-sample prospective cohort studies are still required to test the potential application of combination of hypertension and RC as a screening method to identify individuals at risk of CVD.

Association between remnant lipoprotein cholesterol, high-sensitivity C-reactive protein, and risk of atherosclerotic cardiovascular disease events in the Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND

Elevated remnant-lipoprotein (RLP)-cholesterol (RLP-C) and high-sensitivity C-reactive protein (hsCRP) are each individually associated with atherosclerotic cardiovascular disease (ASCVD).

OBJECTIVE

To evaluate the interplay of nuclear magnetic resonance (NMR)-derived RLP-C and hsCRP and their association with ASCVD in the Multi-Ethnic Study of Atherosclerosis (MESA).

METHODS

Lipoprotein particles were measured using NMR spectroscopic analysis at baseline. RLP-C includes very-low-density lipoprotein cholesterol and intermediate-density lipoprotein cholesterol. Four groups were created as follows: Group 1: RLP-C ≤ median (≤29.14 mg/dL) and hsCRP < 2 mg/L; Group 2: RLP-C ≤ median and hsCRP≥ 2 mg/L; Group 3: RLP-C > median and hsCRP level < 2 mg/L; and Group 4: RLP-C > median and hsCRP level ≥ 2 mg/L. Kaplan-Meier survival curves and multivariable-adjusted Cox proportional hazard models were used to examine the relationship between RLP-C and hsCRP with incident ASCVD.

RESULTS

A total of 6,720 MESA participants (mean age 62.2 y, 53% female) with a median follow-up of 15.6 years were included. In the fully adjusted model, compared to those in the reference group (Group 1), participants in Group 2, Group 3, and Group 4 demonstrated a 20% (95% CI, -2%-48%), 18% (-4%-44%), and 43% (18%-76%) increased risk of incident ASCVD events, respectively (p < 0.01). An additive and multiplicative interaction between RLP-C and hsCRP was not statistically significant.

CONCLUSION

NMR-derived RLP-C and hsCRP showed a similar independent association with incident ASCVD. Notably, the combination of increased RLP-C and hsCRP was associated with an increased risk of future ASCVD events.

Association of remnant cholesterol and lipid parameters with new-onset carotid plaque in Chinese population

Background

Remnant lipoprotein cholesterol (RC) is an independent risk factor for cardiovascular disease (CVD). However, the relationships of remnant cholesterol and other conventional lipid parameters with new-onset carotid plaque are not fully understood in the Chinese community-based population.

Materials and methods

A total of 872 plaque-free participants (51.39 ± 4.96 years old) with no history of CVD were included in this study. The plasma concentrations of RC were calculated by subtracting low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) from total cholesterol (TC). Multivariate regression models were used to evaluate and compare the associations between RC and other lipid parameters and new-onset carotid plaque.

Results

After a mean 6.77-year follow-up, the incidence of new-onset carotid plaque was 188 (21.56%). RC was significantly associated with new-onset carotid plaque [Odd ratio (OR) = 1.57 per 1 mmol/L increase, 95% confidence interval (CI): 1.03–2.41, p = 0.038]. The highest tertile of RC (T3 group) had the highest risk of new-onset carotid plaque (OR = 2.53, 95% CI: 1.63–3.95). Similar results were seen for increased other lipid parameters, but decreased HDL-C levels. When adding another lipid parameter into the adjusted model with RC simultaneously, only RC remained significantly associated with new-onset carotid plaque after adjusting for other lipid parameters (all p value < 0.005). Furthermore, RC was strongly associated with new-onset carotid plaque in participants with lower baseline LDL-C levels.

Conclusion

Increased RC levels were superior to other conventional lipid parameters to be associated with new-onset carotid plaque in the Chinese community-based population. Furthermore, RC should be considered in participants with lower LDL-C levels for the purpose of early atherosclerosis prevention.

The relationship of remnant cholesterol and abdominal obesity in children: A cross-sectional study

Background

Previous studies found that remnant cholesterol (RC) is a risk factor for cardiovascular diseases and childhood obesity is associated with cardiometabolic diseases. This study aimed to explore the relationship between RC and abdominal obesity in children.

Methods

A total of 5,959 children, aged 6−12 years old, were selected from a cross-sectional study in urban-rural areas of Chongqing, China. RC was calculated by total cholesterol (TC)—high-density lipoprotein (HDL-C) cholesterol—low-density lipoprotein (LDL-C) cholesterol and was divided into four groups by quartiles (Q1–Q4).

Results

Compared to children with the lowest RC (Q1), children with higher RC had significantly higher odds of abdominal obesity (Q2: OR = 1.450, 95% CI: 1.131−1.859, p < 0.05; Q3: OR = 2.127, 95% CI: 1.632−2.772, p < 0.001; Q4: OR = 2.386, 95% CI: 1.819−3.130, p < 0.001). In the stratified analyses by urban-rural areas, the odds ratios were greater in rural areas (Q2: OR = 2.228, 95% CI: 1.572−3.160, p < 0.001; Q3: OR = 3.668, 95% CI: 2.191−6.140, p < 0.001; Q4: OR = 6.490, 95% CI: 2.271−18.551, p < 0.001) than in urban areas (Q2: OR = 1.644, 95% CI: 1.192−2.266, p < 0.05; Q3: OR = 2.266, 95% CI: 1.667−3.082, p < 0.001; Q4: OR = 2.711, 95% CI: 2.005−3.665, p < 0.001).

Conclusions

Our study found that RC was positively correlated with abdominal obesity in children, and this association was higher for children living in rural areas.

Hypertriglyceridemia, a causal risk factor for atherosclerosis, and its laboratory assessment

Epidemiological and clinical studies show a causal association between serum triglyceride (TG) level, the number of triglyceride-rich lipoproteins (TRLs) and their remnants, and the increased risk of atherosclerosis and cardiovascular disease (CVD) development. In light of current guidelines for dyslipidemia management, the laboratory parameters reflecting TRL content are recommended as part of the routine lipid analysis process and used for CVD risk assessment, especially in people with hypertriglyceridemia (HTG), diabetes mellitus, obesity and low levels of low-density lipoprotein cholesterol (LDL-C), in which high residual CVD risk is observed. The basic routinely available laboratory parameters related with TRL are serum TG and non-high-density lipoprotein cholesterol (non-HDL-C) levels, but there are also other biomarkers related to TRL metabolism, the determination of which can be helpful in identifying the basis of HTG development or assessing CVD risk or can be the target of pharmacological intervention. In this review, we present the currently available laboratory parameters related to HTG. We summarise their link with TRL metabolism and HTG development, the determination methods as well as their clinical significance, the target values and interpretation of the results in relation to the current dyslipidemia guidelines.

Palmar striated xanthomas in clinical practice

Introduction

The aim of this study was to assess the occurrence of palmar striated xanthomas (PSX) in a wide spectrum of lipid disorders ranging from very severe hypercholesterolemia (homozygous familial hypercholesterolemia) to very severe hypertriglyceridemia (chylomicronemia).

Methods

This study involved 3,382 dyslipidemic Caucasian adult patients (1,856 men and 1,526 women) seen at the Chicoutimi Hospital Lipid Clinic (Quebec, Canada), covering a wide range of lipid disorders, from severe hypertriglyceridemia to severe hypercholesterolemia. Categorical variables were compared using the Pearson χ2 statistic, whereas univariate analysis of variance (ANOVA) or nonparametric Kruskal-Wallis were used for continuous variables.

Results

A total of 5.1% (173/3382) of the studied patients presented PSX, a majority of them (67.1%) being women. PSX were observed in 18.8% of patients with dysbetalipoproteinemia and also among 14.1% of hypertriglyceridemic patients with partial lipoprotein lipase deficiency, 3.7% of patients with chylomicronemia and in all of those with homozygous familial hypercholesterolemia. Overall, 10.7% of patients with PSX did not meet dysbetalipoproteinemia diagnosis criteria.

Conclusion

According to our study, the PSX prevalence estimate among patients without dysbetalipoproteinemia would be around 10% and they could be observed in a wide spectrum of lipid disorders associated with recurrent or sustained remnant lipoprotein accumulation.

ANGPTL3 Is Involved in the Post-prandial Response in Triglyceride-Rich Lipoproteins and HDL Components in Patients With Coronary Artery Disease

It is well-established that there exists an inverse relationship between high-density lipoprotein (HDL) cholesterol and triglyceride (TG) levels in the plasma. However, information is lacking on the impact of post-prandial triglyceride-rich lipoproteins (TRLs) on the structure of HDL subclasses in patients with coronary artery disease (CAD). In this study, the data of 49 patients with CAD were analyzed to evaluate dynamic alterations in post-prandial lipid profiles using nuclear magnetic resonance-based methods. An enzyme-linked immunosorbent assay was used to quantify the serum angiopoietin-like protein 3 (ANGPTL3). After glucose supplementation, the expression of hepatic ANGPTL3 was evaluated both in vitro and in vivo. Compared to fasting levels, the post-prandial serum TG level of all participants was considerably increased. Although post-prandial total cholesterol in HDL (HDL-C) remained unchanged, free cholesterol in HDL particles (HDL-FC) was significantly reduced after a meal. Furthermore, the post-prandial decrease in the HDL-FC level corresponded to the increase in remnant cholesterol (RC), indicating the possible exchange of free cholesterol between HDL and TRLs after a meal. Moreover, CAD patients with exaggerated TG response to diet, defined as TG increase >30%, tend to have a greater post-prandial increase of RC and decrease of HDL-FC compared to those with TG increase ≤30%. Mechanistically, the fasting and post-prandial serum ANGPTL3 levels were significantly lower in those with TG increase ≤30% than those with TG increase >30%, suggesting that ANGPTL3, the key lipolysis regulator, may be responsible for the different post-prandial responses of TG, RC, and HDL-FC.

A New Look at Novel Cardiovascular Risk Biomarkers: The Role of Atherogenic Lipoproteins and Innovative Antidiabetic Therapies

The presence of residual cardiovascular disease (CVD) risk is a current dilemma in clinical practice; indeed, despite optimal management and treatment, a considerable proportion of patients still undergo major CV events. Novel lipoprotein biomarkers are suggested as possible targets for improving the outcomes of patients at higher risk for CVD, and their impact on major CV events and mortality have previously been investigated. Innovative antidiabetic therapies have recently shown a significant reduction in atherogenic lipoproteins, beyond their effects on glucose parameters; it has also been suggested that such anti-atherogenic effect may represent a valuable mechanistic explanation for the cardiovascular benefit of, at least, some of the novel antidiabetic agents, such as glucagon-like peptide-1 receptor agonists. This emphasizes the need for further research in the field in order to clearly assess the effects of innovative treatments on different novel biomarkers, including atherogenic lipoproteins, such as small dense low-density lipoprotein (LDL), lipoprotein(a) (Lp(a)) and dysfunctional high-density lipoprotein (HDL). The current article discusses the clinical importance of novel lipid biomarkers for better management of patients in order to overcome residual cardiovascular risk.

Association of remnant cholesterol with chronic kidney disease in middle-aged and elderly Chinese: a population-based study

AIMS

Limited data regarding the association between remnant cholesterol (RC) and chronic kidney disease (CKD), largely based on an estimated glomerular filtration rate (eGFR) of < 60 mL/min/1.73 m² (low eGFR), have yielded inconsistent results, and no report has demonstrated the relationship of RC with CKD [defined as low eGFR and/or albuminuria (defined as urinary albumin-to-creatinine ratio (ACR) ≥ 30 mg/g)] in Chinese general middle-aged and elderly population. Hence, we aimed to investigate the association between RC and CKD in such population.

METHODS

In total, 7356 Chinese participants aged ≥ 40 years were recruited from five regional communities in Luzhou city between May 2011 and December 2011. Fasting RC was calculated from the lipid profile measured by standard laboratory procedures. Multivariate logistic regression models were used to evaluate the possible association between RC and CKD.

RESULTS

Participants in the highest quartile of RC had higher body mass index, systolic and diastolic blood pressure, total cholesterol, triglyceride, low-density lipoprotein cholesterol (LDL-C), fasting and 2-h postload blood glucose, glycated hemoglobin A1C, prevalence of prediabetes, type 2 diabetes mellitus (T2DM), hypertension, CKD, albuminuria, low eGFR, and lower high-density lipoprotein cholesterol (HDL-C) and eGFR compared with those in the lowest quartile (all P for trend < 0.01). Multivariate logistic regression analysis demonstrated that the risk of CKD gradually increased across RC quartiles (P for trend < 0.01), and participants in the highest quartile of RC were at a significantly increased risk of prevalent CKD compared to those in the lowest quartile in total subjects (odds rate: 1.344, 95% confidence intervals 1.097-1.648, P < 0.01). In subgroup analysis, significant relation between RC level and increased risk of prevalent CKD was detected in women, subjects with overweight/obesity, non-prediabetes, hypertension, normal HDL-C, appropriate and high LDL-C, and without cardiovascular disease (CVD) events after multiple adjustments.

CONCLUSIONS

Higher RC is independently associated with increased risk of prevalent CKD, and RC might serve as a new risk biomarker for CKD in a general middle-aged and elderly Chinese population, especially in women, subjects with overweight/obesity, non-prediabetes, hypertension, normal HDL-C, appropriate and high LDL-C, and without CVD events.

High-sensitivity CRP may be a marker of HDL dysfunction and remodeling in patients with acute coronary syndrome

In patients with coronary artery disease (CAD), further increasing the level of high-density lipoprotein (HDL) cholesterol (HDL-C) as an add-on to statins cannot reduce cardiovascular risk. And it has been reported that HDL functional metric—cholesterol efflux capacity (CEC) may be a better predictor of CAD risk than HDL-C. CEC measurement is time-consuming and not applicable in clinical settings. Thus, it is meaningful to explore an easily acquired index for evaluating CEC. Thirty-six CAD patients and sixty-one non-CAD controls were enrolled in this cross-sectional study. All CAD patients had acute coronary syndrome (ACS). CEC was measured using a [³H] cholesterol loading Raw 264.7 cell model with apolipoprotein B-depleted plasma (a surrogate for HDL). Proton nuclear magnetic resonance (NMR) spectroscopy was used to assess HDL components and subclass distribution. CEC was significantly impaired in CAD patients (11.9 ± 2.3%) compared to controls (13.0 ± 2.2%, p = 0.022). In control group, CEC was positively correlated with enzymatically measured HDL-C levels (r = 0.358, p = 0.006) or with NMR-determined HDL-C levels (NMR-HDL-C, r = 0.416, p = 0.001). However, in CAD group, there was no significant correlation between CEC and HDL-C (r = 0.216, p = 0.206) or NMR-HDL-C (r = 0.065, p = 0.708). Instead, we found that the level of high-sensitivity C-reactive protein (hsCRP) was inversely associated with CEC (r = − 0.351, p = 0.036). Multiple regression analysis showed that the hsCRP level was associated with CEC after adjusting other cardiovascular risk factors and HDL-C, although the association would not reach significance if adjusting for multiple testing. NMR spectroscopy showed that HDL particles shifted to larger ones in patients with high hsCRP levels, and this phenomenon was accompanied by decreased CEC. In patients with CAD, the level of HDL-C cannot reflect HDL function. The impaired correlation between HDL-C and CEC is possibly due to an inflammation-induced HDL subclass remodeling. These hypothesis-generating data suggest that hsCRP levels, a marker of acute inflammation, may associate with HDL dysfunction in ACS subjects. Due to the design limited to be correlative in nature, not permitting causal inference and a larger, strictly designed study is still needed.

Apolipoprotein E and Atherosclerosis

PURPOSE OF REVIEW

The functions, genetic variations and impact of apolipoprotein E on lipoprotein metabolism in general are placed in the context of clinical practice dealing with moderate dyslipidaemia as well as dysbetalipoproteinemia, a highly atherogenic disorder and lipoprotein glomerulopathy.

RECENT FINDINGS

Additional variants of apolipoprotein E and participation of apolipoprotein E in inflammation are of interest. The mostly favourable effects of apolipoprotein E2 as well as the atherogenic nature of apolipoproteinE4, which has an association with cognitive impairment, are confirmed. The contribution of remnant lipoproteins of triglyceride-rich lipoproteins, of which dysbetalipoproteinemia represents an extreme, is explored in atherosclerosis. Mimetic peptides may present new therapeutic approaches. Apolipoprotein E is an important determinant of the lipid profile and cardiovascular health in the population at large and can precipitate dysbetalipoproteinemia and glomerulopathy. Awareness of apolipoprotein E polymorphisms should improve medical care.

Prognostic impact of estimated remnant-like particle cholesterol in patients with differing glycometabolic status: an observational cohort study from China

Background

It is uncertain whether estimated remnant-like particle cholesterol (RLP-C) could predict residual risk in patients with different glycometabolic status. This study aimed to evaluate the relationship between estimated RLP-C and adverse prognosis in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) treated with percutaneous coronary intervention (PCI) and to identify the potential impact of glycometabolism on the predictive value of estimated RLP-C.

Methods

The study assessed 2419 participants with NSTE-ACS undergoing PCI at Beijing Anzhen Hospital from January to December 2015. Estimated RLP-C was calculated as follows: total cholesterol (TC) minus low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C). The adverse events included all-cause death, non-fatal myocardial infarction (MI), and ischemia-driven revascularization.

Results

Estimated RLP-C was prominently associated with adverse prognosis in the total population [hazard ratio (HR) 1.291 per 1-SD increase, 95% confidence interval (CI) 1.119–1.490, P <  0.001], independent of confounding risk factors. However, subgroup analysis showed that increasing estimated RLP-C was related to a higher risk of adverse events in the diabetic population only [HR 1.385 per 1-SD increase, 95% CI 1.183–1.620, P <  0.001]. Estimated RLP-C failed to be a significant determinant of adverse prognosis in non-diabetic and pre-diabetic subgroups. The addition of estimated RLP-C to a baseline model including traditional risk factors enhanced the predictive performance both in total and diabetic populations.

Conclusions

High estimated RLP-C level is a significant predictor for recurrent adverse events in patients with diabetes and NSTE-ACS treated with PCI.