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Vieira IH, Carvalho TS, Saraiva J, Gomes L, Paiva I. Diabetes and Stroke: Impact of Novel Therapies for the Treatment of Type 2 Diabetes Mellitus. Biomedicines 2024; 12:1102. [PMID: 38791064 PMCID: PMC11117787 DOI: 10.3390/biomedicines12051102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/05/2024] [Accepted: 05/09/2024] [Indexed: 05/26/2024] Open
Abstract
Type 2 diabetes mellitus (T2DM) is a significant risk factor for stroke. Nevertheless, the evidence supporting stringent glycemic control to reduce macrovascular complications, particularly stroke, is not as clear as for microvascular complications. Presently, risk reduction strategies are based on controlling multiple risk factors, including hypertension, dyslipidemia, glycemia, smoking, and weight. Since 2008, new pharmacological therapies for treating T2DM have been required to undergo trials to ensure their cardiovascular safety. Remarkably, several novel therapies have exhibited protective effects against the combined endpoint of major cardiovascular events. Evidence from these trials, with stroke as a secondary endpoint, along with real-world data, suggests potential benefits in stroke prevention, particularly with glucagon-like peptide 1 receptor agonists. Conversely, the data on sodium-glucose cotransporter type 2 inhibitors remains more controversial. Dipeptidyl peptidase 4 inhibitors appear neutral in stroke prevention. More recent pharmacological therapies still lack significant data on this particular outcome. This article provides a comprehensive review of the evidence on the most recent T2DM therapies for stroke prevention and their impact on clinical practice.
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Affiliation(s)
- Inês Henriques Vieira
- Department of Endocrinology Diabetes and Metabolism, Hospitais da Universidade de Coimbra—ULS Coimbra, 3004-561 Coimbra, Portugal; (T.S.C.)
| | - Tânia Santos Carvalho
- Department of Endocrinology Diabetes and Metabolism, Hospitais da Universidade de Coimbra—ULS Coimbra, 3004-561 Coimbra, Portugal; (T.S.C.)
| | - Joana Saraiva
- Department of Endocrinology Diabetes and Metabolism, Hospitais da Universidade de Coimbra—ULS Coimbra, 3004-561 Coimbra, Portugal; (T.S.C.)
- Faculty of Medicine, Universidade de Coimbra, 3004-531 Coimbra, Portugal
| | - Leonor Gomes
- Department of Endocrinology Diabetes and Metabolism, Hospitais da Universidade de Coimbra—ULS Coimbra, 3004-561 Coimbra, Portugal; (T.S.C.)
- Faculty of Medicine, Universidade de Coimbra, 3004-531 Coimbra, Portugal
| | - Isabel Paiva
- Department of Endocrinology Diabetes and Metabolism, Hospitais da Universidade de Coimbra—ULS Coimbra, 3004-561 Coimbra, Portugal; (T.S.C.)
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Bess C, Mehta A, Joshi PH. All we need to know about lipoprotein(a). Prog Cardiovasc Dis 2024; 84:27-33. [PMID: 38759878 DOI: 10.1016/j.pcad.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 05/14/2024] [Indexed: 05/19/2024]
Abstract
Lipoprotein(a) [Lp(a)], a genetically determined macromolecular complex, is independently and causally associated with atherosclerotic cardiovascular disease (ASCVD) and calcific aortic stenosis via proposed proinflammatory, prothrombotic, and proatherogenic mechanisms. While Lp(a) measurement standardization issues are being resolved, several guidelines now support testing Lp(a) at least once in each adult's lifetime for ASCVD risk prediction which can foster implementation of more aggressive primary or secondary prevention therapies. Currently, there are several emerging targeted Lp(a) lowering therapies in active clinical investigation for safety and cardiovascular benefit among both primary and secondary prevention populations. First degree relatives of patients with high Lp(a) should be encouraged to undergo cascade screening. Primary prevention patients with high Lp(a) should consider obtaining a coronary calcium score for further risk estimation and to guide further ASCVD risk factor management including consideration of low dose aspirin therapy. Secondary prevention patients with high Lp(a) levels should consider adding PCSK9 inhibition to statin therapy.
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Affiliation(s)
- Courtney Bess
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern, Dallas, TX, United States of America; Parkland Health and Hospital System, Dallas, TX, United States of America
| | - Anurag Mehta
- VCU Health Pauley Health Center, Richmond, VA, United States of America
| | - Parag H Joshi
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern, Dallas, TX, United States of America; Parkland Health and Hospital System, Dallas, TX, United States of America.
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Penesova A, Minarik P, Huckova M, Vlcek M, Szantova M, Krizanova O. 5-Fluorouracil Induced Hypertriglyceridemia During the Colorectal Cancer Treatment in a Patient With Multifactorial Chylomicronemia Syndrome: A Case Report. Clin Ther 2024; 46:429-432. [PMID: 38763818 DOI: 10.1016/j.clinthera.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 05/01/2024] [Accepted: 05/01/2024] [Indexed: 05/21/2024]
Abstract
PURPOSE The case of a 47-year-old female patient who underwent sigmoidectomy for metastatic colorectal cancer is reported. Treatment with capecitabine and 5-fluorouracil induced severe hypertriglyceridemia repeatedly. METHODS Based on laboratory tests and clinical evaluations, treatment was suggested by specialists. FINDINGS After treatment with capecitabine, the patient's triglycerides increased from 19.7 mmol/L to 42 mmol/L. It was proposed that the patient had multifactorial chylomicronemia syndrome triggered by secondary factors. Statins, fenofibrate, ezetimib, and metformin were added to the therapy. After metastases appeared, FOLFIRI (leucovorin calcium [folinic acid], 5-fluorouracil, and irinotecan hydrochloride) chemotherapy and biological treatment (cetuximab) followed and triglycerides increased to 55.3 mmol/L. IMPLICATIONS Monitoring triglyceride levels before and during therapy is suggested.
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Affiliation(s)
- Adela Penesova
- Institute of Clinical and Translational Research, Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia; Faculty of Physical Education and Sport, Comenius University, Bratislava, Slovakia.
| | - Peter Minarik
- Institute of Clinical and Translational Research, Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia; St. Elisabeth University of Health and Social Work in Bratislava n.o, Institute for Prevention and Intervention, Bratislava, Slovakia
| | - Miroslava Huckova
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Miroslav Vlcek
- Institute of Clinical and Translational Research, Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia; Faculty of Medicine, Slovak Medical University, Bratislava, Slovakia
| | - Maria Szantova
- 3(rd) Internal Clinic, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Olga Krizanova
- Institute of Clinical and Translational Research, Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
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Wool CR, Shaw K, Saxon DR. A quality improvement project to improve treatment of severe hypertriglyceridemia in veterans. J Am Assoc Nurse Pract 2024:01741002-990000000-00215. [PMID: 38652650 DOI: 10.1097/jxx.0000000000001017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/06/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Severe hypertriglyceridemia (sHTG) is associated with an increased risk of acute pancreatitis. Prompt recognition and treatment of sHTG is key for prevention of acute pancreatitis and its associated life-threatening complications. LOCAL PROBLEM Patients with sHTG at a primary care clinic within the Veterans Affairs Eastern Colorado Health Care System were receiving suboptimal treatment that did not align with evidence-based guidelines. METHODS We initiated a quality improvement (QI) project to improve the management of sHTG in an outpatient primary care clinic. Veterans with a triglyceride level between 500 and 1,500 mg/dl were included in the project. INTERVENTIONS Project interventions included provider education, patient education, and targeted electronic consultations (e-consults) with treatment recommendations. The primary outcome was to decrease the percentage of patients with triglycerides ≥500 mg/dl by 25%. The secondary outcome was to decrease the mean triglyceride level of the patient population by 15%. RESULTS Education on evaluation and treatment of sHTG was given to 100% (n = 21) of primary care clinicians. Overall, 72.8% (95% CI [62.6-81.6%]) of patients (n = 67) received appropriate written education materials, and 72.8% (95% CI [62.6-81.6%]) of patients (n = 67) received a targeted e-consult. The percentage of patients with sHTG decreased by 47%. Average triglyceride level decreased from 651 to 483 mg/dl (25.8% decrease). CONCLUSION A multipronged QI project consisting of provider education, patient education, and targeted e-consults resulted in decreased triglyceride levels and improved access to specialist expertise. Clinical implications include decreased prevalence of sHTG and risk of acute pancreatitis among patients in the project.
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Affiliation(s)
- Caroline R Wool
- Division of Endocrinology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Kathy Shaw
- University of Colorado College of Nursing, Aurora, Colorado
| | - David R Saxon
- Division of Endocrinology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
- Division of Endocrinology, Metabolism, and Diabetes, University of Colorado School of Medicine, Aurora, Colorado
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Galozzi P, Padoan A, Moretti C, Aita A, Basso D. Plasma lipids paediatric reference intervals: Indirect estimation using a large 14-year database. J Pediatr Gastroenterol Nutr 2024. [PMID: 38606530 DOI: 10.1002/jpn3.12210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/25/2024] [Accepted: 04/01/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVES Establishing direct reference intervals (RIs) for paediatric patients is a very challenging endeavour. Indirect RIs can address this problem, using existing clinical laboratory databases from real-world data research. Compared to the traditional direct method, the indirect approach is highly practical, widely applicable, and low-cost. Considering the relevance of dyslipidemia in the paediatric age, to provide better laboratory services to the local paediatric population, we established population-specific lipid RIs via data mining. METHODS Our laboratory information system was searched for cholesterol (TC), triglycerides (TG), low-density lipoprotein (LDL) and high-density lipoprotein (HDL) of patients aged less than 18 years, performed from January 2009 until December 2022. RIs were estimated using RefineR algorithm. RESULTS Values from 215,594 patients were initially collected. After refining data on the basis of specific exclusion criteria that left 17,933 patients, we determined the RIs for each analyte, including corresponding 95% confidence interval (95% CI). Age and sex partitions were required for proper stratification of the heterogenous subpopulations. Age-related variations in TC and TG values were observed mainly in children until 5 years. RIs were defined for children less than 3 years and for those of 3-18 years. In our population, the obtained RIs were comparable with those of the literature, but the upper TG limit in subjects under the age of 3 (2.03 mmol/L with 95% CI: 1.45-2.86) was lower than that previously reported. CONCLUSIONS Our RIs, necessary for paediatric lipid monitoring, are tailored to the serviced patient population as should be done whenever possible.
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Affiliation(s)
- Paola Galozzi
- Laboratory Medicine Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Andrea Padoan
- Laboratory Medicine Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Carlo Moretti
- Paediatric Diabetes Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Ada Aita
- Laboratory Medicine Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Daniela Basso
- Laboratory Medicine Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
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Fassi EMA, Citarella A, Albani M, Milano EG, Legnani L, Lammi C, Silvani A, Grazioso G. PCSK9 inhibitors: a patent review 2018-2023. Expert Opin Ther Pat 2024; 34:245-261. [PMID: 38588538 DOI: 10.1080/13543776.2024.2340569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/28/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Proprotein convertase subtilisin/kexin 9 (PCSK9) plays a crucial role in breaking down the hepatic low-density lipoprotein receptor (LDLR), thereby influencing the levels of circulating low-density lipoprotein cholesterol (LDL-C). Consequently, inhibiting PCSK9 through suitable ligands has been established as a validated therapeutic strategy for combating hypercholesterolemia and cardiovascular diseases. AREA COVERED Patent literature claiming novel compounds inhibiting PCSK9 disclosed from 2018 to June 2023 available in the espacenet database, which contains more than 150 million patent documents from over 100 patent-granting authorities worldwide. EXPERT OPINION The undisputable beneficial influence of PCSK9 as a pharmacological target has prompted numerous private and public institutions to patent chemical frameworks as inhibitors of PCSK9. While several compounds have advanced to clinical trials for treating hypercholesterolemia, they have not completed these trials yet. These compounds must contend in a complex market where new, costly, and advanced drugs, such as monoclonal antibodies and siRNA, are prescribed instead of inexpensive and less potent statins.
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Affiliation(s)
| | - Andrea Citarella
- Dipartimento di Chimica, Università degli Studi di Milano, Milano, Italy
| | - Marco Albani
- Dipartimento di Scienze Farmaceutiche, Università degli Studi di Milano, Milano, Italy
| | - Erica Ginevra Milano
- Dipartimento di Scienze Farmaceutiche, Università degli Studi di Milano, Milano, Italy
| | - Laura Legnani
- Dipartimento di Biotecnologie e Bioscienze, Università di Milano-Bicocca, Milano, Italy
| | - Carmen Lammi
- Dipartimento di Scienze Farmaceutiche, Università degli Studi di Milano, Milano, Italy
| | - Alessandra Silvani
- Dipartimento di Chimica, Università degli Studi di Milano, Milano, Italy
| | - Giovanni Grazioso
- Dipartimento di Scienze Farmaceutiche, Università degli Studi di Milano, Milano, Italy
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Hilleman DE, Vacek JL, Backes JM. Elevated Lp(a): Guidance for Identifying and Managing Patients. South Med J 2024; 117:208-213. [PMID: 38569611 DOI: 10.14423/smj.0000000000001675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
Lipoprotein(a) (Lp(a)) is a unique low-density lipoprotein-like lipoprotein that is considered an independent and causal risk factor for atherosclerotic cardiovascular disease (ASCVD) and calcific aortic valve stenosis. The Lp(a) molecule also contains apolipoprotein A and apolipoprotein B, which collectively promote atherosclerosis, thrombosis, and inflammation. Lp(a) is highly genetic and minimally responsive to nonpharmacological measures. Lp(a) serum levels ≥125 nmol/L are associated with increased ASCVD risk, but this threshold has not been accepted universally. Elevated Lp(a) is the most common genetic dyslipidemia affecting approximately 20% of the general population. Certain currently available lipid-lowering drugs, including the proprotein convertase subtilisin/kexin type 9 therapies, produce moderate reductions in Lp(a); however, none are indicated for the treatment of elevated Lp(a). There are currently four investigational RNA-based therapeutic agents that reduce Lp(a) by 70% to 100%. Two of these agents are being evaluated for ASCVD risk reduction in adequately powered outcomes trials, with results expected in 2 to 3 years. Until such therapies become available and demonstrate favorable clinical outcomes, strategies for elevated Lp(a) primarily involve early and intensive ASCVD risk factor management.
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Affiliation(s)
- Daniel E Hilleman
- From the Creighton University School of Pharmacy and Health Professions, Omaha, Nebraska
| | - James L Vacek
- Department of Cardiovascular Medicine, University of Kansas Health System, Kansas City
| | - James M Backes
- the Atherosclerosis and LDL-Apheresis Center, University of Kansas Medical Center, KU School of Pharmacy, Lawrence
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Sridharan K, Kalra S. Dyslipidaemia in endocrine disorders. Indian Heart J 2024; 76 Suppl 1:S83-S85. [PMID: 38160791 PMCID: PMC11019327 DOI: 10.1016/j.ihj.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/26/2023] [Accepted: 12/28/2023] [Indexed: 01/03/2024] Open
Abstract
Lipid disorders are common in several endocrine conditions. Diabetes mellitus, hypothyroidism and Cushing's syndrome are the common endocrine disorders with dyslipidemia. Dyslipidemia has a significant impact on endocrine and metabolic health and the risk of atherosclerotic cardiovascular disease. In most cases of dyslipidemia, the suspicion of endocrine diseases must be based on clinical symptoms and signs. Optimal management of the dyslipidemia requires treatment of the underlying endocrine condition. Lipid lowering therapy is a useful adjunct or a requirement in many cases. The Indian guidelines provide a pragmatic and practical approach to the management of lipid disorders in endocrine disease, as well as endocrine vigilance with lipid therapy.
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Affiliation(s)
- Kalyani Sridharan
- Department of Endocrinology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India.
| | - Sanjay Kalra
- Consultant Endocrinologist, Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India
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Loh WJ, Soh HS, Tun MH, Tan PT, Lau CS, Tavintharan S, Watts GF, Aw TC. Elevated remnant cholesterol and non-HDL cholesterol concentrations from real-world laboratory results: a cross-sectional study in Southeast Asians. Front Cardiovasc Med 2024; 11:1328618. [PMID: 38385128 PMCID: PMC10879277 DOI: 10.3389/fcvm.2024.1328618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/22/2024] [Indexed: 02/23/2024] Open
Abstract
Introduction Triglyceride-rich remnant lipoproteins (TRLs) are considered atherogenic due to the presence of remnant cholesterol, which is transported by apolipoprotein B. In clinical practice, the concentration of TRLs can be estimated by calculating remnant cholesterol or non-HDL cholesterol levels. Aim This study aims to investigate the proportion of patients who have low LDL cholesterol (LDL-C) concentration but elevated remnant cholesterol concentration, stratified by the presence of hypertriglyceridaemia and ethnicity, using real-world hospital data. Our secondary aim is to investigate the proportion of patients with elevated non-HDL cholesterol levels using guideline-recommended goals. Methods A 2-year retrospective study was conducted at a single centre, analyzing lipid blood tests of all patients, including directly measured LDL-C. Fasting for blood tests was not mandatory. Results The study included a total of 21,605 consecutive patients with plasma lipid profiles analyzed in our hospital laboratory. The median age was 61 years. In patients with ASCVD (n = 14,704), 23.7% had an LDL-C level of <1.8 mmol/L, 11.3% had elevated remnant cholesterol concentrations at ≥0.65 mmol/L, and 48.8% were at the non-high-density lipoprotein cholesterol (non-HDL-C) goal (<2.6 mmol/L). Among patients diagnosed with atherosclerotic cardiovascular disease (ASCVD) with LDL-C levels of <1.8 mmol/L (n = 3,484), only 11.9% had high levels of remnant cholesterol, but 96% of the ASCVD patients also achieved the recommended non-HDL-C target of <2.6 mmol/L. When the LDL-C level was <1.8 mmol/L, the mean concentration of remnant cholesterol was 0.214 mmol/L when the triglyceride level was <1.7 mmol/L (n = 3,380), vs. 0.70 mmol/L when the triglyceride level was elevated (n = 724), p < 0.001. Among patients with a triglyceride level of ≥1.7 mmol/L and an LDL-C level of <.8 mmol/L, there were 254 patients with elevated remnant cholesterol concentration and 71 patients with suboptimal non-HDL levels. Malays had a higher mean remnant cholesterol concentration compared with both Chinese and Indians across all LDL-C levels, particularly in the presence of hypertriglyceridaemia. Conclusions An elevated remnant cholesterol concentration of >0.65 mmol/L was present in 11% of all patients. The current guideline-recommended non-HDL-C goal, which uses a 0.8 mmol/L estimate of remnant cholesterol concentration, was achieved in >92% of patients, suggesting that it is unlikely to be clinically useful for the majority of our patient population except where there is concomitant hypertriglyceridaemia. Further studies are needed to establish the appropriate non-HDL-C goal or calculated remnant cholesterol concentration, paired with the LDL-C goal or otherwise, in a Southeast Asian population.
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Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Heng Samuel Soh
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Mon Hnin Tun
- Health Services Research Unit, Changi General Hospital, Singapore, Singapore
| | - Pei Ting Tan
- Clinical Trial and Research Unit, Changi General Hospital, Singapore, Singapore
| | - Chin Shern Lau
- Department of Laboratory Medicine, Changi General Hospital, Singapore, Singapore
| | | | - Gerald F. Watts
- Medical School, University of Western Australia, Perth, WA, Australia
- Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, WA, Australia
| | - Tar Choon Aw
- Duke-NUS Medical School, Singapore, Singapore
- Department of Laboratory Medicine, Changi General Hospital, Singapore, Singapore
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Tasdighi E, Adhikari R, Almaadawy O, Leucker TM, Blaha MJ. LP(a): Structure, Genetics, Associated Cardiovascular Risk, and Emerging Therapeutics. Annu Rev Pharmacol Toxicol 2024; 64:135-157. [PMID: 37506332 DOI: 10.1146/annurev-pharmtox-031023-100609] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
Lipoprotein(a) [Lp(a)] is a molecule bound to apolipoprotein(a) with some similarity to low-density lipoprotein cholesterol (LDL-C), which has been found to be a risk factor for cardiovascular disease (CVD). Lp(a) appears to induce inflammation, atherogenesis, and thrombosis. Approximately 20% of the world's population has increased Lp(a) levels, determined predominantly by genetics. Current clinical practices for the management of dyslipidemia are ineffective in lowering Lp(a) levels. Evolving RNA-based therapeutics, such as the antisense oligonucleotide pelacarsen and small interfering RNA olpasiran, have shown promising results in reducing Lp(a) levels. Phase III pivotal cardiovascular outcome trials [Lp(a)HORIZON and OCEAN(a)] are ongoing to evaluate their efficacy in secondary prevention of major cardiovascular events in patients with elevated Lp(a). The future of cardiovascular residual risk reduction may transition to a personalized approach where further lowering of either LDL-C, triglycerides, or Lp(a) is selected after high-intensity statin therapy based on the individual risk profile and preferences of each patient.
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Affiliation(s)
- Erfan Tasdighi
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA;
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rishav Adhikari
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Omar Almaadawy
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Thorsten M Leucker
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael J Blaha
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA;
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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11
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Majumdar SK. Triglyceride Clearance in Hypertriglyceridemic Pancreatitis: Time Course and Its Implications for Management. Endocr Pract 2023; 29:971-979. [PMID: 37714331 DOI: 10.1016/j.eprac.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/25/2023] [Accepted: 09/05/2023] [Indexed: 09/17/2023]
Abstract
OBJECTIVE To characterize the time course of triglyceride (Tg) lowering in hypertriglyceridemic (HTg) pancreatitis according to the initial Tg values, causes, and interventions. METHODS Patients hospitalized from October 2013 through December of 2018 with a diagnosis of pancreatitis associated with HTg (Tg level, ≥500 mg/dL), in the absence of other causes, were identified by medical record review. Tg lowering was retrospectively assessed for differences in relation to the initial Tg values, use of intravenous insulin, ethanol-associated versus nonethanol-associated causes, and time to Tg values of <500 versus <1000 mg/dL. RESULTS Sixty-six cases were identified, and 45 had multiple measurements for time-course evaluation. Those with initial Tg values of <4000 mg/dL achieved Tg levels of <1000 mg/dL in <3 days, whereas 18.8% with higher values took 5-9 days. Insulin therapy was associated with a longer duration of HTg, whereas ethanol was associated with a shorter duration. Tg clearance in ethanol-associated HTg appeared independent of insulin treatment. Time to Tg levels of <500 mg/dL versus <1000 mg/dL was significantly longer when the initial Tg levels were >2000 mg/dL. CONCLUSION A threshold of 4000 mg/dL for the initial Tg levels in HTg pancreatitis appears to separate patients who are likely to achieve Tg levels of <1000 mg/dL in <3 versus >3 days, independent of cause or treatment. Insulin therapy is appropriate for patients with hyperglycemia but appears unnecessary for those with isolated ethanol-associated HTg. A threshold Tg level of <1000 mg/dL appears more practical than that of <500 mg/dL for resuming nutritional intake.
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Affiliation(s)
- Sachin K Majumdar
- Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut; Departments of Endocrinology and Internal Medicine, Bridgeport Hospital, Yale New Haven Health System, Bridgeport, Connecticut.
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Ibarra F. Acute Management of Hypertriglyceridemia With a Disease-Specific Intravenous Insulin Infusion Order Set. Ann Pharmacother 2023; 57:1248-1254. [PMID: 36840326 DOI: 10.1177/10600280231155921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Hypertriglyceridemia-associated acute pancreatitis is a disease lacking a standardized management approach. OBJECTIVE The main objective of this study was to evaluate the safety and efficacy of a continuous intravenous insulin infusion order set specifically designed for managing hypertriglyceridemia. METHODS This study compared the safety and efficacy of a standardized (postintervention) approach to managing hypertriglyceridemia to a nonstandardized (preintervention) approach. The primary efficacy outcome was the percentage of patients who achieved a triglyceride level less than 500 mg/dL. Additional outcomes included the time to achieving a triglyceride level less than 500 mg/dL and the percent reduction in triglyceride levels. The primary safety outcome was the number of patients who experienced hypoglycemia (glucose less than 70 mg/dL). RESULTS Twenty patients were included in both the preintervention and postintervention groups. There was a significantly greater reduction in triglyceride levels observed in the postintervention group. The number of patients who achieved a triglyceride level less than 500 mg/dL in the preintervention and postintervention groups were 10 (50%) and 17 (85%), respectively, P = 0.018. Within the postintervention group, the time to achieving a triglyceride level less than 500 mg/dL in those with and without diabetes was 56.8 hours (38.2-64.0) versus 27.6 hours (19.7-45.0), respectively, P = 0.028. CONCLUSION AND RELEVANCE Our findings demonstrate that insulin infusions are safe and effective when therapy is standardized and accounts for nursing to patient ratios. Our results provide the medical community with a standardized approach to acutely managing hypertriglyceridemia.
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Affiliation(s)
- Francisco Ibarra
- Department of Pharmacy Services, Community Regional Medical Center, Fresno, CA, USA
- College of Osteopathic Medicine, California Health Sciences University, Clovis, CA, USA
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13
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Hansen SEJ, Varbo A, Nordestgaard BG, Langsted A. Hypertriglyceridemia-Associated Pancreatitis: New Concepts and Potential Mechanisms. Clin Chem 2023; 69:1132-1144. [PMID: 37530032 DOI: 10.1093/clinchem/hvad094] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/17/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND Triglycerides are a major source of energy, while high plasma triglycerides are a risk factor for various diseases and premature death. Severely elevated plasma triglycerides are a well-established cause of acute pancreatitis with high mortality, likely due to the presence of elevated levels of chylomicrons and large very low-density lipoproteins in plasma. As markedly elevated levels of these very large lipoproteins are not generally found in mild to moderate hypertriglyceridemia, this was previously not regarded as a cause or marker of increased risk of acute pancreatitis. However, mild to moderate hypertriglyceridemia may identify individuals who at a later timepoint develop severe hypertriglyceridemia and acute pancreatitis. CONTENT We describe measurement of plasma triglycerides and studies on plasma triglycerides and risk of acute pancreatitis. Further, we summarize current European and American guidelines for the prevention of acute pancreatitis and, finally, the potential for future prevention of acute pancreatitis through lowering of plasma triglycerides. SUMMARY Recent observational and genetic studies indicate that mild to moderate hypertriglyceridemia is causally related to increased risk of acute pancreatitis, most likely as a marker of future severe hypertriglyceridemia. Current guidelines do not mention individuals with mild to moderate hypertriglyceridemia, even though newer evidence suggests an unmet medical need. Treatment could include plasma triglyceride-lowering therapy targeting the pathway for lipoprotein lipase as the main triglyceride degrading enzyme in plasma. Angiopoietin-like 3 and apolipoproteinC-III are inhibitors of lipoprotein lipase, and blocking of these 2 inhibitors is showing promising results in relation to marked triglyceride-lowering and could perhaps be used to prevent acute pancreatitis in the future.
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Affiliation(s)
- Signe E J Hansen
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anette Varbo
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anne Langsted
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Raschi E, Casula M, Cicero AFG, Corsini A, Borghi C, Catapano A. Beyond statins: New pharmacological targets to decrease LDL-cholesterol and cardiovascular events. Pharmacol Ther 2023; 250:108507. [PMID: 37567512 DOI: 10.1016/j.pharmthera.2023.108507] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/13/2023]
Abstract
The pharmacological treatment of dyslipidemia, a major modifiable risk factor for developing atherosclerotic cardiovascular disease (ASCVD), remains a debated and controversial issue, not only in terms of the most appropriate therapeutic range for lipid levels, but also with regard to the optimal strategy and sequence approach (stepwise vs upstream therapy). Current treatment guidelines for the management of dyslipidemia focus on the intensity of low-density lipoprotein cholesterol (LDL-C) reduction, stratified according to risk for developing ASCVD. Beyond statins and ezetimibe, different medications targeting LDL-C have been recently approved by regulatory agencies with potential innovative mechanisms of action, including proprotein convertase subtilisin/kexin type 9 modulators (monoclonal antibodies such as evolocumab and alirocumab; small interfering RNA molecules such as inclisiran), ATP-citrate lyase inhibitors (bempedoic acid), angiopoietin-like 3 inhibitors (evinacumab), and microsomal triglyceride transfer protein inhibitors (lomitapide). An understanding of their pharmacological aspects, benefit-risk profile, including impact on hard cardiovascular endpoints beyond LDL-C reduction, and potential advantages from the patient perspective (e.g., adherence) - the focus of this evidence-based review - is crucial for practitioners across medical specialties to minimize therapeutic inertia and support clinical practice.
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Affiliation(s)
- Emanuel Raschi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy.
| | - Manuela Casula
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
| | - Arrigo F G Cicero
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy; IRCCS AOU S. Orsola-Malpighi, Bologna, Italy
| | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Claudio Borghi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy; IRCCS AOU S. Orsola-Malpighi, Bologna, Italy
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Singh A, Gainder S, Banerjee P, Goel A, Kumar P, Mondal B, Banik SP, Bagchi D. Efficacy of a Proprietary Fenugreek Seed Extract ( Trigonella foenum-graecum, Furocyst®) in Women with Polycystic Ovary Syndrome (PCOS): a Randomized, Double-Blind, Placebo-Controlled Study. JOURNAL OF THE AMERICAN NUTRITION ASSOCIATION 2023; 42:651-659. [PMID: 36219198 DOI: 10.1080/27697061.2022.2126410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/09/2022] [Accepted: 09/15/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Polycystic ovary syndrome (PCOS) is characterized by hyperandrogenemia, a quite common heterogenous endocrine/hormonal disorder, and accompanied by elevated androgen level, menstrual irregularity, and hirsutism. The consequences include infertility or miscarriage. It is a challenging problem to the physicians. In a one-arm, non-randomized preliminary investigation in fifty premenopausal women, we demonstrated the efficacy of Furocyst®, a patented, standardized Trigonella foenum-graecum extract, in ameliorating the symptoms of PCOS over a period of 90 consecutive days. OBJECTIVE In the present study, a double-blind, two-arm, single-center, randomized, comparative study was conducted to assess the efficacy of Furocyst® (2 capsules of 500 mg/day) in 208 pre-menopausal women diagnosed with PCOS. METHODS Ethical committee approval was obtained. A total of 208 subjects (placebo = 95; Furocyst® = 113; age:18-45 years, BMI < 42 kg/m2) completed the investigation. The comparative efficacy of placebo and Furocyst® was assessed on the number of cysts, ovarian volume, hirsutism, LH:FSH ratio, titer of TSH, SHBG, prolactin and free testosterone. Key clinical parameters such as fasting blood glucose levels, HOMA Index, cholesterol, LDL, and triglyceride levels, as well as total blood chemistry were also investigated. RESULTS Furocyst® supplementation significantly reduced the number of cysts, ovarian volume, and hirsutism levels, as well as normalized the menstrual cycle in Furocyst®-treated subjects as compared to placebo group. Furocyst® significantly reduced luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels, and thyroid stimulating hormone (TSH) levels, and reduced the prolactin and SHBG levels. Furocyst® significantly reduced the fasting blood glucose levels, HOMA Index, cholesterol, LDL, and triglyceride levels as compared to the placebo group, while the free testosterone levels were significantly decreased in the Furocyst® group. CONCLUSION The studies collectively demonstrated the efficacy of Furocyst® as a safe, natural phytochemical-based formulation to alleviate the symptoms of PCOS. No significant adverse events were observed.
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Affiliation(s)
- Amarjeet Singh
- Department of Community Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, Panjab, India
| | - Shalini Gainder
- Department of Obstetrics & Gynecology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, Panjab, India
| | - Pradipta Banerjee
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Apurva Goel
- Regulatory Department, Chemical Resources (CHERESO), Panchkula, Haryana, India
| | - Pawan Kumar
- Research and Development Department, Chemical Resources (CHERESO), Panchkula, Haryana, India
| | - Banashree Mondal
- Parkinson's Disease and Movement Disorder Program, Institute of Neurosciences, Kolkata, India
| | - Samudra P Banik
- Department of Microbiology, Maulana Azad College, Kolkata, India
| | - Debasis Bagchi
- Department of Biology, Adelphi University, Garden City, New York, USA
- Department of Pharmaceutical Sciences, Texas Southern University, Houston, Texas, USA
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16
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Liang S, Yang J, Ma M, Zhou M, Liu Z, Huang H, He Y. Restenosis after excimer laser coronary atherectomy and drug-coated balloon dilation in Takayasu's arteritis: a case report and review of the literature. Thromb J 2023; 21:87. [PMID: 37563604 PMCID: PMC10413599 DOI: 10.1186/s12959-023-00529-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023] Open
Abstract
Takayasu's arteritis (TAK) is a rare chronic granulomatous arteritis that mainly affects the aorta and its major branches. Coronary artery (CA) involvement can be observed in 10-25% of TAK patients. We report a 21-year-old young female who was previously diagnosed with TAK and severe left main coronary artery (LMCA) stenosis and underwent numerous percutaneous coronary interventions (PCIs) in our hospital due to in-stent restenosis (ISR). This time, an excimer laser coronary atherectomy (ELCA) and drug-coated balloon (DCB) dilation was taken at the LMCA for the ISR. The blood flow was smooth after the operation, and she was symptom-free after discharge. Unfortunately, 5 months later, severe intimal hyperplasia was still seen in the stent of LMCA and left anterior descending (LAD) coronary artery. A coronary artery bypass graft surgery (CABG) was performed, and she has been symptom-free ever since. ELCA plus DCB is one of the novel ways we first reported. However, ensuring long-term inflammation control is equally important to restore blood flow. The combination of revascularization and anti-inflammation/immunosuppression is recommended to improve the outcomes of TAK patients with CA involvements.
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Affiliation(s)
- Shichu Liang
- Department of Cardiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, China
| | - Jinming Yang
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Min Ma
- Department of Cardiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, China
| | - Minggang Zhou
- Department of Cardiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, China
| | - Zhiyue Liu
- Department of Cardiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, China
| | - He Huang
- Department of Cardiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, China.
| | - Yong He
- Department of Cardiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, China.
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Abstract
PURPOSE OF REVIEW The aim of this study was to highlight the current best practice for atherosclerotic cardiovascular disease (CVD) risk evaluation, including selective use of adjunctive tools for risk stratification [e.g. coronary artery calcium (CAC) scoring] and risk enhancement [e.g. lipoprotein(a) [Lp(a)], polygenic risk scoring (PRS)]. RECENT FINDINGS New studies have evaluated the efficacy of various risk assessment tools. These studies demonstrate the role of Lp(a) as a risk-enhancing factor ready for more widespread use. CAC is the gold standard method of assessing subclinical atherosclerosis, enabling true risk stratification of patients, and informing net benefit assessment for initiating or titrating lipid-lowering therapy (LLT). SUMMARY Lp(a) concentration and CAC scoring, apart from the traditional risk factors, add the most value to the current CVD risk assessment approaches of all available tools, especially in terms of guiding LLT. In addition to new integrative tools such as the MESA CHD Risk Score and Coronary Age calculator, the future of risk assessment may include PRS and more advanced imaging techniques for atherosclerosis burden. Soon, polygenic risk scoring may be used to identify the age at which to begin CAC scoring, with CAC scores guiding preventive strategies.
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Affiliation(s)
| | - Erfan Tasdighi
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael J Blaha
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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18
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Madar H, Lalanne-Mistrih ML, Lebbar M, Wu Z, Robitaille Y, Pelletier J, Grou C, Brazeau AS, Rabasa-Lhoret R. Cardiovascular Risk Factors and Adherence to Cardiovascular Protection Practice Guidelines in Adults With Type 1 Diabetes: A BETTER Registry Cross-sectional Analysis. Can J Diabetes 2023; 47:473-481.e1. [PMID: 37059389 DOI: 10.1016/j.jcjd.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 02/12/2023] [Accepted: 04/05/2023] [Indexed: 04/16/2023]
Abstract
OBJECTIVES Cardiovascular disease (CVD) is a major cause of morbidity and mortality in people with type 1 diabetes (PWT1D). We assessed cardiovascular risk factors and pharmacologic treatment in a large Canadian cohort of PWT1D. METHODS This cross-sectional study used data from adult PWT1D in the BETTER registry (n=974). CVD risk factor status, diabetes complications, and treatments (used as proxy for blood pressure and dyslipidemia) were self-reported through online questionnaires. Objective data were available for a subgroup of PWT1D (23%, n=224). RESULTS Participants were adults (43.9±14.8 years) with a diabetes duration of 23.3±15.2 years; 34.8% reported glycated hemoglobin (A1C) levels of ≤7%, 67.2% reported a very high cardiovascular risk, and 27.2% reported at least 3 CVD risk factors. Most participants received care for CVD in accordance with the Diabetes Canada Clinical Practice Guidelines (DC-CPG), with a median recommended pharmacologic treatment score of 75.0%. However, 3 subgroups of participants with lower adherence (<70%) to DC-CPG were identified: 1) those with microvascular complications and receiving a statin (60.8%, 208 of 342) or renin-angiotensin axis nephroprotective therapy (52.6%, 180 of 342); 2) those aged ≥40 years and receiving statin therapy (67.1%, 369 of 550); and 3) those aged ≥30 years with a diabetes duration of ≥15 years and receiving statin therapy (58.9%, 344 of 584). Among a subgroup of participants with recent laboratory results, only 24.5% of PWT1D (26 of 106) achieved both A1C and low-density lipoprotein cholesterol targets. CONCLUSIONS Most PWT1D received recommended pharmacologic cardiovascular protection, but specific subgroups required special attention. Target achievement for key risk factors remains suboptimal.
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Affiliation(s)
- Houssein Madar
- Montreal Clinical Research Institute, Montréal, Québec, Canada
| | - Marie-Laure Lalanne-Mistrih
- Montreal Clinical Research Institute, Montréal, Québec, Canada; Department of Nutrition, University Hospital, Abymes, Guadeloupe, France; UFR Medicine, French West Indies University, Abymes, Guadeloupe, France
| | - Maha Lebbar
- Montreal Clinical Research Institute, Montréal, Québec, Canada; Department of Nutrition, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Zekai Wu
- Montreal Clinical Research Institute, Montréal, Québec, Canada; Department of Medicine, Division of Experimental Medicine, McGill University, Montréal, Québec, Canada
| | - Yves Robitaille
- Centre de Médecine Métabolique de Lanaudière, Terrebone, Québec, Canada
| | | | - Caroline Grou
- Montreal Clinical Research Institute, Montréal, Québec, Canada
| | - Anne-Sophie Brazeau
- Montreal Clinical Research Institute, Montréal, Québec, Canada; School of Human Nutrition, McGill University, Sainte-Anne-de-Bellevue, Québec, Canada; Montréal Diabetes Research Center, Montréal, Québec, Canada
| | - Rémi Rabasa-Lhoret
- Montreal Clinical Research Institute, Montréal, Québec, Canada; Department of Nutrition, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada; Department of Medicine, Division of Experimental Medicine, McGill University, Montréal, Québec, Canada; Montréal Diabetes Research Center, Montréal, Québec, Canada; Centre Hospitalier de l'Université de Montréal Endocrinology Division and CHUM Research Center, Montréal, Québec, Canada.
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Gligorijevic N, Stefanovic-Racic M, Kershaw EE. Medical management of hypertriglyceridemia in pancreatitis. Curr Opin Gastroenterol 2023:00001574-990000000-00085. [PMID: 37421386 DOI: 10.1097/mog.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
PURPOSE OF REVIEW Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) should be considered in all cases of acute pancreatitis and triglyceride levels measured early, so that appropriate early and long-term treatment can be initiated. RECENT FINDINGS In most cases of HTG-AP, conservative management (nothing by mouth, intravenous fluid resuscitation and analgesia) is sufficient to achieve triglyceride levels less than 500 mg/dl. Intravenous insulin and plasmapheresis are sometimes used, although prospective studies showing clinical benefits are lacking. Pharmacological management of hypertriglyceridemia (HTG) should start early and target triglyceride levels of less than 500 mg/dl to reduce the risk or recurrent acute pancreatitis. In addition to currently used fenofibrate and omega-3 fatty acids, several novel agents are being studied for long-term treatment of HTG. These emerging therapies focus mainly on modifying the action of lipoprotein lipase (LPL) through inhibition of apolipoprotein CIII and angiopoietin-like protein 3. Dietary modifications and avoidance of secondary factors that worsen triglyceride levels should also be pursued. In some cases of HTG-AP, genetic testing may help personalize management and improve outcomes. SUMMARY Patients with HTG-AP require acute and long-term management of HTG with the goal of reducing and maintaining triglyceride levels to less than 500 mg/dl.
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Affiliation(s)
- Nikola Gligorijevic
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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20
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Matveyenko A, Pavlyha M, Reyes-Soffer G. Supporting evidence for lipoprotein(a) measurements in clinical practice. Best Pract Res Clin Endocrinol Metab 2023; 37:101746. [PMID: 36828715 PMCID: PMC11014458 DOI: 10.1016/j.beem.2023.101746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
High levels of lipoprotein(a) [Lp(a)] are causal for development of atherosclerotic cardiovascular disease and highly regulated by genetics. Levels are higher in Blacks compared to Whites, and in women compared to men. Lp(a)'s main protein components are apolipoprotein (apo) (a) and apoB100, the latter being the main component of Low-Density Lipoprotein (LDL) particles. Studies have identified Lp(a) to be associated with inflammatory, coagulation and wound healing pathways. Lack of validated and accepted assays to measure Lp(a), risk cutoff values, guidelines for diagnosis, and targeted therapies have added challenges to the field. Scientific efforts are ongoing to address these, including studies evaluating the cardiovascular benefits of decreasing Lp(a) levels with targeted apo(a) lowering treatments. This review will provide a synopsis of evidence-based effects of high Lp(a) on disease presentation, highlight available guidelines and discuss promising therapies in development. We will conclude with current clinical information and future research needs in the field.
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Affiliation(s)
- Anastasiya Matveyenko
- Columbia University College of Physicians and Surgeons, Columbia University Irving Medical Center, 622 West 168th Street, P&S 10-501, New York, NY 10032, USA.
| | - Marianna Pavlyha
- Columbia University College of Physicians and Surgeons, Columbia University Irving Medical Center, 622 West 168th Street, P&S 10-501, New York, NY 10032, USA.
| | - Gissette Reyes-Soffer
- Columbia University College of Physicians and Surgeons, Columbia University Irving Medical Center, 622 West 168th Street, P&S 10-501, New York, NY 10032, USA.
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Perez V, Faust AC, Taburyanskaya M, Patil RA, Ortegon A. Effectiveness of an Intravenous Insulin-Based Treatment Protocol for the Management of Hypertriglyceridemia-Associated Acute Pancreatitis. J Pharm Technol 2023; 39:55-61. [PMID: 37051280 PMCID: PMC10084412 DOI: 10.1177/87551225231151570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
Background There is burgeoning interest in intravenous insulin for hypertriglyceridemia-induced acute pancreatitis (HTG-AP) as a less invasive alternative to plasmapheresis; however, there are few published descriptions of disease-specific insulin protocols. Objective To compare the efficacy and safety of an insulin infusion-based protocol with nonstandardized medical therapy for HTG-AP. Methods This is a retrospective analysis before and after creation of an HTG-AP-specific insulin infusion treatment protocol. Inclusion criteria were age ≥18 years, an initial triglyceride level >1000 mg/dL, and a diagnosis of AP. The primary outcome of the study was time to a triglyceride level ≤1000 mg/dL. Results Sixty-seven patients were included in this study (26 pre-protocol and 41 in the HTG-AP insulin protocol group). Baseline characteristics between the groups were similar, with median initial triglyceride levels >3500 mg/dL. There was a trend toward patients treated with the HTG-AP-specific infusion reaching a triglyceride level ≤1000 mg/dL faster (43.3 [24.9-72.1] vs 26.9 [17.7-51.1] hours; P = 0.07). Those treated to ≤500 mg/dL achieved this faster with the disease-specific infusion (49.2 [29.4-67.8] vs 70.9 [36.3-107.2] hours, P = 0.04). Hypoglycemia was numerically lower in the HTG-AP-specific insulin infusion group despite higher insulin infusion rates (7.3% vs 19.2%). No patient in the HTG-AP-specific protocol group required plasmapheresis. Conclusions The use of an HTG-AP-specific insulin infusion protocol, compared with antecedent nonstandardized care, resulted in prompter achievement of a triglyceride level ≤500 mg/dL and a strong trend toward faster achievement of ≤1000 mg/dL without an increased risk of hypoglycemia. While intravenous insulin may be considered the initial medical therapy for HTG-AP, further studies are needed to determine the optimal dosing.
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Affiliation(s)
- Valeria Perez
- Department of Pharmacy, Texas Health
Presbyterian Hospital Dallas, Dallas, TX, USA
- School of Pharmacy, Texas Tech
University Health Sciences Center, Dallas, TX, USA
| | - Andrew C. Faust
- Department of Pharmacy, Texas Health
Presbyterian Hospital Dallas, Dallas, TX, USA
| | | | | | - Anthony Ortegon
- Sound Physicians Pulmonary Critical
Care/Southwest Pulmonary Associates, Dallas, TX, USA
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Liu Y, Ma M, Li L, Liu F, Li Z, Yu L, Yang T, Wang Y, Gao S, Gao S, Yang R, Yu C. Association between sensitivity to thyroid hormones and dyslipidemia in patients with coronary heart disease. Endocrine 2023; 79:459-468. [PMID: 36434323 DOI: 10.1007/s12020-022-03254-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/05/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Thyroid hormones affect lipid metabolism via central and peripheral regulation. However, there have been few studies on the association between thyroid hormone sensitivity and dyslipidemia. We aimed to investigate the association between thyroid hormone sensitivity and dyslipidemia in patients with coronary heart disease (CHD). METHODS A total of 31,678 patients with CHD were included in this large multicenter retrospective study. Central thyroid hormone sensitivity was evaluated using the thyroid feedback quantile-based index (TFQI), parametric thyroid feedback quantile-based index (PTFQI), thyroid-stimulating hormone index (TSHI), and thyrotropin thyroxine resistance index (TT4RI); peripheral thyroid hormone sensitivity was assessed by the ratio of free triiodothyronine (FT3)/free thyroxine (FT4). Logistic regression analysis was used to analyze the association between thyroid hormone sensitivity and dyslipidemia. RESULTS Among 31,678 participants, 21,648 (68.34%) had dyslipidemia. In the multi-adjusted models, the risk of dyslipidemia was positively correlated with TFQI (odds ratio [OR]: 1.04; 95% confidence interval [CI]: 1.03-1.05), PTFQI (OR: 1.09; 95% CI: 1.06-1.12), TSHI (OR: 1.08; 95% CI: 1.06-1.11), and TT4RI (OR: 1.08; 95% CI: 1.05-1.11). Conversely, the risk of dyslipidemia was negatively correlated with FT3/FT4 (OR: 0.94; 95% CI: 0.92-0.97). In stratified analyses, the association between thyroid hormone sensitivity and dyslipidemia was statistically significant for different sexes, glucose levels, and blood pressure states. CONCLUSION There is a significant association between sensitivity to thyroid hormones and dyslipidemia, regardless of sex, glucose level, or blood pressure. Graphical abstract.
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Affiliation(s)
- Yijia Liu
- Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Mei Ma
- Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Lin Li
- Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Fanfan Liu
- Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Zhu Li
- Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Lu Yu
- Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Tong Yang
- Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Yang Wang
- Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Shan Gao
- Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Sheng Gao
- Nankai Hospital: Tianjin Hospital of Integrated Traditional Chinese and Western Medicine, Tianjin, 300199, China.
| | - Rongrong Yang
- Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China.
| | - Chunquan Yu
- Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China.
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23
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Pregnancy-induced severe hypertriglyceridemia effectively treated with therapeutic plasmapheresis. Transfus Apher Sci 2023:103659. [PMID: 36804190 DOI: 10.1016/j.transci.2023.103659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/01/2023] [Accepted: 02/13/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION Hypertriglyceridemia is associated with significant morbidity during pregnancy. Hypertriglyceridemia-induced pancreatitis (HTGP) is associated with genetically determined dyslipidemia or a secondary condition such as diabetes, alcohol, pregnancy, or medication use. The lack of data on the safety of drugs to be used to decrease triglyceride levels during pregnancy dictates that other strategies must be chosen. PATIENT AND METHODS We describe a case of a pregnant woman with severe hypertriglyceridemia treated with two different techniques of plasmapheresis (Dual Filtration apheresis and Centrifugal Plasma Separation). RESULTS The patient could be treated throughout the pregnancy, with good control of the triglycerides, and a healthy baby was born. CONCLUSION Hypertriglyceridemia is a major issue during pregnancy. The use of plasmapheresis is a safe and efficient tool in that clinical scenario.
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Loh WJ, Watts GF. The Management of Hypercholesterolemia in Patients with Neuromuscular Disorder. Curr Atheroscler Rep 2023; 25:43-53. [PMID: 36609642 DOI: 10.1007/s11883-022-01077-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW We describe and discuss the safety of statins and non-statin drugs in neuromuscular disorders (NMDs). We also propose a pragmatic model of care for the management of such cases. RECENT FINDINGS Patients with both NMD and hypercholesterolemia may be particularly disadvantaged owing to the toxic effects of cholesterol-lowering therapy and the inability to take medication. Specifically, the management of hypercholesterolemia in patients with NMD is complicated by the increased risk of statin-related myotoxicity and concerns that statins may aggravate or possibly induce the onset of a specific NMD. The most severe form of statin-related myotoxicity is immune-mediated necrotizing myopathy. Management of hypercholesterolemia in patients with NMDs include treating modifiable factors, consideration of toxicity risk of statin, use of non-statin lipid lowering agents, noting possible drug interactions, and careful monitoring.
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Affiliation(s)
- Wann Jia Loh
- School of Medicine, University of Western Australia, Perth, WA, 6001, Australia.
- Cardiometabolic Service, Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia.
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, WA, 6001, Australia
- Cardiometabolic Service, Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia
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Li J, Lei X, Li Z, Yang X. Effectiveness and safety of Inclisiran in hyperlipidemia treatment: An overview of systematic reviews. Medicine (Baltimore) 2023; 102:e32728. [PMID: 36701738 PMCID: PMC9857372 DOI: 10.1097/md.0000000000032728] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND This paper aimed to comprehensively evaluate the effectiveness and safety of Inclisiran in treating hyperlipidemia through an overview of systematic reviews (SRs). METHODS The Cochrane Library, EMBASE, PubMed, CNKI, WANGFANG database, VIP database, ClinicalTrials.gov, and ICRT were searched electronically to collect SRs and meta-analysis of Inclisiran in hyperlipidemia treatment from the establishment of the database till May 2022. Two researchers independently screened the relevant literature, then the assessment of multiple systematic reviews tool was made into assess the methodological quality of the included studies. Data extracted were used to perform the study through RevMan5.3 software. The grading of recommendations assessment, development, and evaluation tool was used to grade the quality of the evidence of the outcomes included in the SRs. Prospero ID: CRD 42022326845. RESULTS A total of 10 relevant SRs were included, involving 7 randomized controlled trials. The assessment results of the assessment of multiple systematic reviews tool suggested that the quality of the SRs included needed to be improved. The reduced level of low-density lipoprotein cholesterol of the experimental group was lower than the control group, and the difference in the amount of effectiveness was statistically significant (MD = -50.13, 95%CI: -56.2 to -44.06, P < .00001). The grading of recommendations assessment, development, and evaluation results showed that out of 27 outcomes, 8 were high-quality, 3 were of medium quality, 6 were of low quality, and 10 were of the most inferior quality. CONCLUSION 300mg Inclisiran with 2 injections a year has the best therapeutic effect, which can significantly reduce low-density lipoprotein cholesterol and total cholesterol, and increase high-density lipoprotein cholesterol levels in patients with hyperlipidemia. Inclisiran has a favorable safety profile, with no significant difference in the incidence of adverse reactions compared to a placebo. Most of the adverse effects were associated with the reaction on the injection site.
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Affiliation(s)
- Jiayi Li
- Geriatrics Department of Endocrinology and Metabolism, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Guangxi Key Laboratory of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention, Nanning, Guangxi, China
- Guangxi Clinical Research Center for Cardiocerebrovascular Diseases, Nanning, Guangxi, China
| | - Xiangguo Lei
- Geriatrics Department of Endocrinology and Metabolism, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Guangxi Key Laboratory of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention, Nanning, Guangxi, China
- Guangxi Clinical Research Center for Cardiocerebrovascular Diseases, Nanning, Guangxi, China
| | - Zihao Li
- Department of Cardio-Thoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xi Yang
- Geriatrics Department of Endocrinology and Metabolism, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Guangxi Key Laboratory of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention, Nanning, Guangxi, China
- Guangxi Clinical Research Center for Cardiocerebrovascular Diseases, Nanning, Guangxi, China
- * Correspondence: Xi Yang, Geriatrics Department of Endocrinology and Metabolism, The First Affiliated Hospital of Guangxi Medical University, Nanning Guangxi 530021, China (e-mail: )
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Major Global Coronary Artery Calcium Guidelines. JACC. CARDIOVASCULAR IMAGING 2023; 16:98-117. [PMID: 36599573 DOI: 10.1016/j.jcmg.2022.06.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/14/2022] [Accepted: 06/22/2022] [Indexed: 01/07/2023]
Abstract
This review summarizes the framework behind global guidelines of coronary artery calcium (CAC) in atherosclerotic cardiovascular disease risk assessment, for applications in both the clinical setting and preventive therapy. By comparing similarities and differences in recommendations, this review identifies most notable common features for the application of CAC presented by different cardiovascular societies across the world. Guidelines included from North America are as follows: 1) the 2019 American College of Cardiology/American Heart Association Guideline on the Primary Prevention of Cardiovascular Disease; and 2) the 2021 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for Prevention of Adult Cardiovascular Disease. The authors also included European guidelines: 1) the 2019 European Society for Cardiology/European Atherosclerosis Society Guidelines for the Management of Dyslipidemias; and 2) the 2016 National Institute for Health and Care Excellence Clinical Guidelines. In this comparison, the authors also discuss: 1) the Cardiac Society of Australia and New Zealand Guidelines on CAC; 2) the Chinese Society of Cardiology Guidelines; and 3) the Japanese Atherosclerosis Society Guidelines for Prevention of Atherosclerotic Cardiovascular Diseases. Last, they include statements made by specialty societies including the National Lipid Association, Society of Cardiovascular Computed Tomography, and U.S. Preventive Services Task Force. Utilizing an in-depth review of clinical evidence, these guidelines emphasize the importance of CAC in the primary and secondary prevention of atherosclerotic cardiovascular disease. International guidelines all empower a dynamic clinician-patient relationship and advocate for individualized discussions regarding disease management and pharmacotherapy treatment. Some differences in precise coronary artery calcium score intervals, risk cut points, treatment thresholds, and stratifiers of specific patient subgroups do exist. However, international guidelines employ more similarities than differences from both a clinical and functional perspective. Understanding the parallels among international coronary artery calcium guidelines is essential for clinicians to correctly adjudicate personalized statin and aspirin therapy and further medical management.
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Affiliation(s)
- Joseph J Saseen
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Skaggs School of Pharmacy; Aurora, CO, USA; Department of Family Medicine, University of Colorado Anschutz Medical Campus, School of Medicine; Aurora, CO, USA.
| | - Salim S Virani
- Section of Cardiology and Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA; Health Policy, Quality & Informatics Program, Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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Abstract
This article reviews the safety of statins and non-statin medications for management of dyslipidemia. Statins have uncommon serious adverse effects: myopathy/ rhabdomyolysis, which resolve with statin discontinuation, and diabetes, usually in people with risk factors for diabetes. The CVD benefit of statins far exceeds the risk of diabetes. Statin myalgia, without CK elevation, is likely caused by muscle symptoms with another etiology, or the nocebo effect. Notable adverse effects of non-statin medicines include injection site reactions (alirocumab, evolocumab, inclisiran), increased uric acid and gout (bempedoic acid), atrial fibrillation/flutter (omega-3-fatty acids), and myopathy in combination with a statin (gemfibrozil).
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Affiliation(s)
- Connie B Newman
- Division of Endocrinology, Diabetes and Metabolism, New York University Grossman School of Medicine, 435 East 30th street, Sixth floor, New York, NY 10016, USA.
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Abstract
Mild to moderate hypertriglyceridemia usually results from multiple small-effect variants in genes that control triglyceride metabolism. Hypertriglyceridemia is a critical component of the metabolic syndrome but can also occur secondary to several other conditions or drugs. Hypertriglyceridemia frequently is associated with an increased risk of cardiovascular disease (CVD). Statins are the mainstay of CVD prevention in hypertriglyceridemia, but eicosapentaenoic ethyl esters should be added in very-high-risk individuals. Although fibrates lower triglyceride levels, their role in CVD prevention remains unclear. Familial partial lipodystrophy is another relatively rare cause, although its true incidence is unknown.
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Affiliation(s)
- Alan Chait
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, 850 Republican, Box 358062, Seattle, WA 98109, USA.
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Goldberg IJ, Gjini J, Fisher EA. Big Fish or No Fish; Eicosapentaenoic Acid and Cardiovascular Disease. Endocrinol Metab Clin North Am 2022; 51:625-633. [PMID: 35963632 DOI: 10.1016/j.ecl.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Benefits of omega 3 fatty acids for cardiovascular and other diseases have been touted for more than 50 years. The one clear clinical benefit of these lipids is the reduction of circulating levels of triglycerides, making them a useful approach for the prevention of pancreatitis in severely hypertriglyceridemic patients. After a series of spectacularly failed clinical trials that were criticized for the choice of subjects and doses of omega 3 fatty acids used, Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT) using a high dose of icosapent ethyl (IPE) reported a reduction in cardiovascular disease (CVD) events. However, this trial has generated controversy due to the use of mineral oil in the control group and the associated side effects of the IPA. This review will focus on the following topics: What are the epidemiologic data suggesting a benefit of omega 3 fatty acids? What might be the mechanisms for these benefits? Why have the clinical trials failed to resolve whether these fatty acids provide benefit? What choices should a clinician consider?
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Affiliation(s)
- Ira J Goldberg
- Division of Endocrinology, Diabetes and Metabolism, New York University Grossman School of Medicine, 435 First Avenue, SB 617, New York, NY 10016, USA.
| | - Jana Gjini
- Division of Endocrinology, Diabetes and Metabolism, New York University Grossman School of Medicine, 435 First Avenue, SB 617, New York, NY 10016, USA
| | - Edward A Fisher
- Division of Cardiology and Center for the Prevention of Cardiovascular Disease, New York University Grossman School of Medicine, 435 First Avenue, SB 704, New York, NY 10016, USA
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Tannock LR. Management of Dyslipidemia in Endocrine Diseases. Endocrinol Metab Clin North Am 2022; 51:589-602. [PMID: 35963630 PMCID: PMC9382690 DOI: 10.1016/j.ecl.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Most endocrine disorders are chronic in nature, and thus even a minor effect to increase risk for cardiovascular disease can lead to a significant impact over prolonged duration. Although robust therapies exist for many endocrine disorders (eg suppression of excess hormone amounts, or replacement of hormone deficiencies), the therapies do not perfectly restore normal physiology. Thus, individuals with endocrine disorders are at potential increased cardiovascular disease risk, and maximizing strategies to reduce that risk are needed. This article reviews various endocrine conditions that can impact lipid levels and/or cardiovascular disease risk.
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Affiliation(s)
- Lisa R Tannock
- Division of Endocrinology, Diabetes, and Metabolism, University of Kentucky, Department of Veterans Affairs, MN145, 780 Rose Street, Lexington, KY 40536, USA.
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Goldsborough E, Osuji N, Blaha MJ. Assessment of Cardiovascular Disease Risk: A 2022 Update. Endocrinol Metab Clin North Am 2022; 51:483-509. [PMID: 35963625 DOI: 10.1016/j.ecl.2022.02.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Assessment of atherosclerotic cardiovascular disease (ASCVD) risk is the cornerstone of primary ASCVD prevention, enabling targeted use of the most aggressive therapies in those most likely to benefit, while guiding a conservative approach in those who are low risk. ASCVD risk assessment begins with the use of a traditional 10-year risk calculator, with further refinement through the consideration of risk-enhancing factors (particularly lipoprotein(a)) and subclinical atherosclerosis testing (particularly coronary artery calcium (CAC) testing). In this review, we summarize the current field of ASCVD risk assessment in primary prevention and highlight new guidelines from the Endocrine Society.
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Affiliation(s)
- Earl Goldsborough
- Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Ngozi Osuji
- Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA; Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael J Blaha
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Neves JS, Newman C, Bostrom JA, Buysschaert M, Newman JD, Medina JL, Goldberg IJ, Bergman M. Management of dyslipidemia and atherosclerotic cardiovascular risk in prediabetes. Diabetes Res Clin Pract 2022; 190:109980. [PMID: 35787415 DOI: 10.1016/j.diabres.2022.109980] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/26/2022] [Accepted: 06/29/2022] [Indexed: 11/03/2022]
Abstract
Prediabetes affects at least 1 in 3 adults in the U.S. and 1 in 5 in Europe. Although guidelines advocate aggressive management of lipid parameters in diabetes, most guidelines do not address treatment of dyslipidemia in prediabetes despite the increased atherosclerotic cardiovascular disease (ASCVD) risk. Several criteria are used to diagnose prediabetes: impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and HbA1c of 5.7-6.4%. Individuals with prediabetes have a greater risk of diabetes, a higher prevalence of dyslipidemia with a more atherogenic lipid profile and an increased risk of ASCVD. In addition to calculating ASCVD risk using traditional methods, an OGTT may further stratify risk. Those with 1-hour plasma glucose ≥8.6 mmol/L (155 mg/dL) and/or 2-hour ≥7.8 mmol/L (140 mg/dL) (IGT) have a greater risk of ASCVD. Diet and lifestyle modification are fundamental in prediabetes. Statins, ezetimibe and PCSK9 inhibitors are recommended in people requiring pharmacotherapy. Although high-intensity statins may increase risk of diabetes, this is acceptable because of the greater reduction of ASCVD. The LDL-C goal in prediabetes should be individualized. In those with IGT and/or elevated 1-hour plasma glucose, the same intensive approach to dyslipidemia as recommended for diabetes should be considered, particularly if other ASCVD risk factors are present.
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Affiliation(s)
- João Sérgio Neves
- Department of Endocrinology, Diabetes and Metabolism, São João University Hospital Center, Porto, Portugal; Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Connie Newman
- Division of Endocrinology, Diabetes and Metabolism, New York University Grossman School of Medicine, New York, NY, USA
| | - John A Bostrom
- Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Martin Buysschaert
- Department of Endocrinology and Diabetology, Université Catholique de Louvain, University Clinic Saint-Luc, Brussels, Belgium
| | - Jonathan D Newman
- Division of Cardiology and the Center for the Prevention of Cardiovascular Disease, New York University Grossman School of Medicine, New York, NY, USA
| | | | - Ira J Goldberg
- Division of Endocrinology, Diabetes and Metabolism, New York University Grossman School of Medicine, New York, NY, USA
| | - Michael Bergman
- Division of Endocrinology, Diabetes and Metabolism, New York University Grossman School of Medicine, New York, NY, USA; Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
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Miller M, Tokgozoglu L, Parhofer KG, Handelsman Y, Leiter LA, Landmesser U, Brinton EA, Catapano AL. Icosapent ethyl for reduction of persistent cardiovascular risk: a critical review of major medical society guidelines and statements. Expert Rev Cardiovasc Ther 2022; 20:609-625. [DOI: 10.1080/14779072.2022.2103541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- Michael Miller
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Klaus G. Parhofer
- Medizinische Klinik IV – Grosshadern, Klinikum der Universität München, Munich, Germany
| | | | - Lawrence A. Leiter
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ulf Landmesser
- Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Abstract
Lipid disorders involving derangements in serum cholesterol, triglycerides, or both are commonly encountered in clinical practice and often have implications for cardiovascular risk and overall health. Recent advances in knowledge, recommendations, and treatment options have necessitated an updated approach to these disorders. Older classification schemes have outlived their usefulness, yielding to an approach based on the primary lipid disturbance identified on a routine lipid panel as a practical starting point. Although monogenic dyslipidemias exist and are important to identify, most individuals with lipid disorders have polygenic predisposition, often in the context of secondary factors such as obesity and type 2 diabetes. With regard to cardiovascular disease, elevated low-density lipoprotein cholesterol is essentially causal, and clinical practice guidelines worldwide have recommended treatment thresholds and targets for this variable. Furthermore, recent studies have established elevated triglycerides as a cardiovascular risk factor, whereas depressed high-density lipoprotein cholesterol now appears less contributory than was previously believed. An updated approach to diagnosis and risk assessment may include measurement of secondary lipid variables such as apolipoprotein B and lipoprotein(a), together with selective use of genetic testing to diagnose rare monogenic dyslipidemias such as familial hypercholesterolemia or familial chylomicronemia syndrome. The ongoing development of new agents-especially antisense RNA and monoclonal antibodies-targeting dyslipidemias will provide additional management options, which in turn motivates discussion on how best to incorporate them into current treatment algorithms.
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Affiliation(s)
- Amanda J Berberich
- Department of Medicine; Schulich School of Medicine and Dentistry, Western University, London, ON, Canada, N6A 5C1.,Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada, N6A 5B7
| | - Robert A Hegele
- Department of Medicine; Schulich School of Medicine and Dentistry, Western University, London, ON, Canada, N6A 5C1.,Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada, N6A 5B7
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de Sá JR, Rangel EB, Canani LH, Bauer AC, Escott GM, Zelmanovitz T, Bertoluci MC, Silveiro SP. The 2021-2022 position of Brazilian Diabetes Society on diabetic kidney disease (DKD) management: an evidence-based guideline to clinical practice. Screening and treatment of hyperglycemia, arterial hypertension, and dyslipidemia in the patient with DKD. Diabetol Metab Syndr 2022; 14:81. [PMID: 35690830 PMCID: PMC9188192 DOI: 10.1186/s13098-022-00843-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetic kidney disease is the leading cause of end-stage renal disease and is associated with increased morbidity and mortality. This review is an authorized literal translation of part of the Brazilian Diabetes Society (SBD) Guidelines 2021-2022. This evidence-based guideline provides guidance on the correct management of Diabetic Kidney Disease (DKD) in clinical practice. METHODS The methodology was published elsewhere in previous SBD guidelines and was approved by the internal institutional Steering Committee for publication. Briefly, the Brazilian Diabetes Society indicated 14 experts to constitute the Central Committee, designed to regulate methodology, review the manuscripts, and make judgments on degrees of recommendations and levels of evidence. SBD Renal Disease Department drafted the manuscript selecting key clinical questions to make a narrative review using MEDLINE via PubMed, with the best evidence available including high-quality clinical trials, metanalysis, and large observational studies related to DKD diagnosis and treatment, by using the MeSH terms [diabetes], [type 2 diabetes], [type 1 diabetes] and [chronic kidney disease]. RESULTS The extensive review of the literature made by the 14 members of the Central Committee defined 24 recommendations. Three levels of evidence were considered: A. Data from more than 1 randomized clinical trial or 1 metanalysis of randomized clinical trials with low heterogeneity (I2 < 40%). B. Data from metanalysis, including large observational studies, a single randomized clinical trial, or a pre-specified subgroup analysis. C: Data from small or non-randomized studies, exploratory analyses, or consensus of expert opinion. The degree of recommendation was obtained based on a poll sent to the panelists, using the following criteria: Grade I: when more than 90% of agreement; Grade IIa 75-89% of agreement; IIb 50-74% of agreement, and III, when most of the panelist recommends against a defined treatment. CONCLUSIONS To prevent or at least postpone the advanced stages of DKD with the associated cardiovascular complications, intensive glycemic and blood pressure control are required, as well as the use of renin-angiotensin-aldosterone system blocker agents such as ARB, ACEI, and MRA. Recently, SGLT2 inhibitors and GLP1 receptor agonists have been added to the therapeutic arsenal, with well-proven benefits regarding kidney protection and patients' survival.
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Affiliation(s)
- João Roberto de Sá
- Endocrinology Division, Escola Paulista de Medicina, UNIFESP, São Paulo, Brazil
| | - Erika Bevilaqua Rangel
- Nephrology Division, UNIFESP, São Paulo, Brazil
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Luis Henrique Canani
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Andrea Carla Bauer
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Gustavo Monteiro Escott
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Themis Zelmanovitz
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Marcello Casaccia Bertoluci
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil
| | - Sandra Pinho Silveiro
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.
- Endocrinology Division, Hospital de Clínicas de Porto Alegre (HCPA), Ramiro Barcelos, 2350-Prédio 12, 4º andar, Porto Alegre, RS, Brazil.
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Macrovascular Complications. Prim Care 2022; 49:255-273. [DOI: 10.1016/j.pop.2021.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Importance Lipoprotein(a) (Lp[a]) is a low-density lipoprotein (LDL) cholesterol-like particle bound to apolipoprotein(a). This novel marker of cardiovascular disease acts through induction of vascular inflammation, atherogenesis, calcification, and thrombosis. While an absolute risk threshold remains to be universally accepted, an estimated 20% to 25% of the global population have Lp(a) levels of 50 mg/dL or higher, a level noted by the European Atherosclerosis Society to confer increased cardiovascular risk. Observations Compelling evidence from pathophysiological, observational, and genetic studies suggest a potentially causal association between high Lp(a) levels, atherosclerotic cardiovascular disease, and calcific aortic valve stenosis. Additional evidence has demonstrated that elevated Lp(a) levels are associated with a residual cardiovascular risk despite traditional risk factor optimization, including LDL cholesterol reduction. These findings have led to the formulation of the Lp(a) hypothesis, namely that Lp(a) lowering leads to cardiovascular risk reduction, intensifying the search for Lp(a)-reducing therapies. The ineffectiveness of lifestyle modification, statins, and ezetimibe to lower Lp(a); the modest Lp(a) reduction with proprotein convertase subtilisin/kexin type 9 inhibitors; the adverse effect profile and unclear cardiovascular benefit of pharmacotherapies such as niacin and mipomersen; and the impracticality of regular lipoprotein apheresis represent major challenges to currently available therapies. Nevertheless, emerging nucleic acid-based therapies, such as the antisense oligonucleotide pelacarsen and the small interfering RNA olpasiran, are generating interest because of their potent Lp(a)-lowering effects. Assessment of new-onset diabetes in patients achieving very low Lp(a) levels will be important in future trials. Conclusions and Relevance Epidemiologic and genetic studies suggest a potentially causal association between elevated Lp(a) levels, atherosclerotic cardiovascular disease, and aortic valve stenosis. Emerging nucleic acid-based therapies have potent Lp(a)-lowering effects and appear safe; phase 3 trials will establish whether they improve cardiovascular outcomes.
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Affiliation(s)
- Freddy Duarte Lau
- Department of Medicine, Yale New Haven Health, Bridgeport, Connecticut
| | - Robert P Giugliano
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Abstract
Hypertriglyceridemia is a common lipid disorder encountered in clinical practice. Plasma triglycerides are a marker for the concentration of triglycerides carried in chylomicrons and very low-density lipoprotein particles. A fasting triglyceride level <150 mg/dL is accepted widely as the upper limit of normal range. Guidelines for hypertriglyceridemia are variable without a global consensus on classification and goals for triglyceride levels. A general classification of hypertriglyceridemia is mild < 200 mg/dL, moderate = 200 to 500 mg/dL, moderate to severe = 500 to 1000 mg/dL, and severe > 1000 mg/dL. Because moderate hypertriglyceridemia does increase atherosclerotic cardiovascular disease risk, it is important to determine the underlying etiology to guide appropriate and timely management. This article provides stepwise recommendations on the diagnosis and management of moderate hypertriglyceridemia, based on 3 common scenarios encountered in clinical practice. Initial steps in management include evaluating for secondary contributors, especially diabetes mellitus. Based on patient characteristics, appropriate management decisions include lifestyle adjustments aimed at weight loss and decreasing alcohol consumption and use of statin and nonstatin therapies.
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Affiliation(s)
- Savitha Subramanian
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle WA, USA
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40
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Abstract
Lipodystrophy constitutes a spectrum of diseases characterized by a generalized or partial absence of adipose tissue. Underscoring the role of healthy fat in maintenance of metabolic homeostasis, fat deficiency in lipodystrophy typically leads to profound metabolic disturbances including insulin resistance, hypertriglyceridemia, and ectopic fat accumulation. While rare, recent genetic studies indicate that lipodystrophy is more prevalent than has been previously thought, suggesting considerable underdiagnosis in clinical practice. In this article, we provide an overview of the etiology and management of generalized and partial lipodystrophy disorders. We bring together the latest scientific evidence and clinical guidelines and expose key gaps in knowledge. Through improved recognition of the lipodystrophy disorders, patients (and their affected family members) can be appropriately screened for cardiometabolic, noncardiometabolic, and syndromic abnormalities and undergo treatment with targeted interventions. Notably, insights gained through the study of this rare and extreme phenotype can inform our knowledge of more common disorders of adipose tissue overload, including generalized obesity.
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Affiliation(s)
- Lindsay T Fourman
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA
- Correspondence: Lindsay T. Fourman, MD, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, 5LON207, Boston, MA 02114, USA.
| | - Steven K Grinspoon
- Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA
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Abstract
Endocrine diseases may be associated with dyslipidaemia and may increase atherosclerotic cardiovascular disease (ASCVD) risk. This chapter describes changes in lipids and lipoproteins in diseases of the pituitary, thyroid, adrenal glands, ovaries, and testes, the mechanisms for these changes, ASCVD risk in these endocrine disorders, and whether treatment of the endocrine disorder improves the lipid profile and reduces ASCVD risk. Acromegaly, GH deficiency, Cushing syndrome, chronic glucocorticoid replacement, hypothyroidism, PCOS and male hypogonadism can increase LDL-C and/or TG. Marked reductions in LDL-C are associated with hyperthyroidism, and extremely low HDL-C levels with testosterone and/or other anabolic steroid abuse. Acromegaly, GH deficiency, Cushing syndrome, and chronic glucocorticoid replacement are associated with increased ASCVD risk. Treatment of acromegaly, GH deficiency, hypothyroidism, Cushing syndrome, and testosterone deficiency reduce LDL-C, although statin therapy may still be needed. Effects on ASCVD are not known.
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Affiliation(s)
- Connie B Newman
- Division of Endocrinology, Diabetes and Metabolism, New York University Grossman School of Medicine, New York, NY 10016, USA.
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42
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Aguilar-Salinas CA, Gómez-Díaz RA, Corral P. New Therapies for Primary Hyperlipidemia. J Clin Endocrinol Metab 2022; 107:1216-1224. [PMID: 34888679 DOI: 10.1210/clinem/dgab876] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Indexed: 11/19/2022]
Abstract
Primary hyperlipidemias include a heterogeneous set of monogenic and polygenic conditions characterized by a strong family aggregation, severe forms of hypercholesterolemia and/or hypertriglyceridemia, appearance early on life, and a high risk of cardiovascular events and/or recurrent pancreatitis. In real life, a small proportion of the primary hyperlipidemia cases is recognized and treated properly. Our goal is to present an update of current and upcoming therapies for patients with primary hyperlipidemia. Recently, new lipid-lowering medications have obtained authorization from the U.S. Food and Drug Administration and the European Medicines Agency. These drugs target metabolic pathways, including (adenosine 5'-triphosphates)-citrate lyase (bempedoic acid), proprotein convertase subtilisin/kexin 9 (inclisiran), apolipoprotein CIII (volanesorsen), and angiopoietin-like 3 (volanesorsen), that have additive effects with the actions of the currently available therapies (i.e., statins, ezetimibe or fibrates). We discuss the potential clinical indications for the novel medications. To conclude, the addition of these new medications to the therapeutic options for primary hyperlipidemia patients may increase the likelihood of achieving the treatment targets. Also, it could be a safer alternative for patients with side effects for the currently available drugs.
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Affiliation(s)
- Carlos A Aguilar-Salinas
- Direction of Nutrition Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, México
| | - Rita A Gómez-Díaz
- Unidad de Investigación Médica en Epidemiología Clínica, UMAE Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico
| | - Pablo Corral
- Pharmacology Department, School of Medicine, FASTA University, Mar del Plata, Buenos Aires, Argentina
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Ferraro RA, Leucker T, Martin SS, Banach M, Jones SR, Toth PP. Contemporary Management of Dyslipidemia. Drugs 2022; 82:559-576. [PMID: 35303294 PMCID: PMC8931779 DOI: 10.1007/s40265-022-01691-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 12/30/2022]
Abstract
The treatment of dyslipidemia continues to be a dynamic and controversial topic. Even the most appropriate therapeutic range for lipid levels-including that of triglycerides and low-density lipoprotein cholesterol-remain actively debated. Furthermore, with ever-increasing options and available treatment modalities, the management of dyslipidemia has progressed in both depth and complexity. An understanding of appropriate lipid-lowering therapy remains an essential topic of review for practitioners across medical specialties. The goal of this review is to provide an overview of recent research developments and recommendations for patients with dyslipidemia as a means of better informing the clinical practice of lipid management. By utilizing a guideline-directed approach, we provide a reference point on optimal lipid-lowering therapies across the spectrum of dyslipidemia. Special attention is paid to long-term adherence to lipid-lowering therapies, and the benefits derived from instituting appropriate medications in a structured manner alongside monitoring. Novel therapies and their impact on lipid lowering are discussed in detail, as well as potential avenues for research going forward. The prevention of cardiovascular disease remains paramount, and this review provides a roadmap for instituting appropriate therapies in cardiovascular disease prevention.
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Affiliation(s)
- Richard A Ferraro
- From the Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thorsten Leucker
- From the Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Seth S Martin
- From the Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz, Lodz, Poland
| | - Steven R Jones
- From the Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter P Toth
- From the Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- CGH Medical Center, 101 East Miller Road, Sterling, IL, 61081, USA.
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Bengtsson D, Ragnarsson O, Berinder K, Dahlqvist P, Edén Engström B, Ekman B, Höybye C, Järås J, Valdemarsson S, Burman P, Wahlberg J. Increased mortality persists after treatment of Cushing’s disease: A matched nationwide cohort study. J Endocr Soc 2022; 6:bvac045. [PMID: 35480633 PMCID: PMC9037134 DOI: 10.1210/jendso/bvac045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Context
Whether biochemical remission normalizes life expectancy in Cushing’s disease (CD) patients remains unclear. Previous studies evaluating mortality in CD are limited by using the expected number of deaths in the background population instead of the actual number in matched controls.
Objective and setting
To study mortality by time-to-event analysis in an unselected nationwide CD patient cohort.
Design and participants
Longitudinal data from the Swedish Pituitary Register of 371 patients diagnosed with CD from 1991-2018 and information from the Swedish Cause of Death Register were evaluated. Four controls per patient (n=1484) matched at the diagnosis date by age, sex and residential area were included.
Main outcome measures
Mortality and causes of death.
Results
The median diagnosis age was 44 years (interquartile range [IQR] 32-56), and the median follow-up was 10.6 years (5.7-18). At the 1-, 5-, 10-, 15- and 20-year follow-ups, the remission rates were 80%, 92%, 96%, 91% and 97%, respectively. Overall mortality was increased in CD patients compared with matched controls (hazard ratio [HR] 2.1 [95% confidence interval {CI} 1.5-2.8]). The HRs were 1.5 (1.02-2.2) for patients in remission at the last follow-up (n=303), 1.7 (1.03-2.8) for those in remission after a single pituitary surgery (n=177), and 5.6 (2.7-11.6) for those not in remission (n=31). Cardiovascular diseases (32/66) and infections (12/66) were overrepresented causes of death.
Conclusions
Mortality was increased in CD patients despite biochemical remission compared to matched controls. The study highlights the importance of careful comorbidity monitoring, regardless of remission status.
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Affiliation(s)
- Daniel Bengtsson
- Department of Internal Medicine, Kalmar, Region of Kalmar County, 39 185, Kalmar, Sweden and Department of Biomedical and Clinical Sciences, Linköping University, 581 85, Linköping, Sweden
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and Department of Endocrinology, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
| | - Katarina Berinder
- Department of Endocrinology, Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76, Stockholm, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, 901 85 Umeå, Sweden
| | - Britt Edén Engström
- Department of Medical Sciences, Endocrinology and Mineral Metabolism, Uppsala University and Department of Endocrinology and Diabetes, Uppsala University Hospital, 751 85, Uppsala, Sweden
| | - Bertil Ekman
- Department of Endocrinology in Linköping and Department of Health, Medicine and Caring Sciences, Linköping University, 581 85, Linköping, Sweden
| | - Charlotte Höybye
- Department of Endocrinology, Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76, Stockholm, Sweden
| | - Jacob Järås
- Regional Cancer Centre, Stockholm/Gotland, 102 39, Stockholm, Sweden
| | - Stig Valdemarsson
- Department of Clinical Sciences, Skåne University Hospital, University of Lund, 221 85 Lund, Sweden
| | - Pia Burman
- Department of Endocrinology, Skåne University Hospital, University of Lund, 205 02 Malmö, Sweden
| | - Jeanette Wahlberg
- Department of Endocrinology in Linköping and Department of Health, Medicine and Caring Sciences, Linköping University, 581 85, Linköping, Sweden
- Faculty of Medical Sciences, Örebro University, 589 41, Örebro, Sweden
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45
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Ibarra F, Loi K, Vu AW. Safety and Efficacy of Various Intravenous Insulin Infusion Rates in Patients With and Without Diabetes Presenting With Hypertriglyceridemia. Ann Pharmacother 2022; 56:1016-1022. [DOI: 10.1177/10600280211070102] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background The use of IV insulin infusions in the acute management of hypertriglyceridemia has only been evaluated in small observational studies and case reports. Objective To evaluate the safety and efficacy of IV insulin infusions in the acute management of hypertriglyceridemia. Methods This was a retrospective chart review of adult patients who received an IV insulin infusion for the acute management of hypertriglyceridemia. The primary efficacy and safety outcomes were the number of patients who achieved a triglyceride level <500 mg/dL and experienced hypoglycemia (<70 mg/dL), respectively. A subgroup analysis was performed to compare outcomes between patients with and without diabetes, in addition to the IV insulin infusion rate received. Results In the total population (n = 51), there were no statistically significant differences between the insulin intensity groups in the number of patients who achieved TG levels <500 mg/dL. Compared to patients with a past medical history of diabetes, more patients without a past medical history of diabetes achieved triglyceride levels <500 mg/dL (14% vs 53%, respectively, P < 0.001). The number of hypoglycemic events observed in patients with and without a past medical history of diabetes were 5 (14%) and 4 (27%), respectively ( P = 0.023). Conclusion and Relevance Our findings suggest that patients who present with lower initial TG levels are more likely to achieve TG levels <500 mg/dL. To minimize the risk of hypoglycemia providers should consider prescribing a concomitant dextrose infusion and limiting IV insulin infusion rates ≤ 0.075 units/kg/h.
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Affiliation(s)
- Francisco Ibarra
- Department of Pharmacy Services, Community Regional Medical Center, Fresno, CA, USA
| | - Kaitlyn Loi
- Department of Pharmacy Services, Community Regional Medical Center, Fresno, CA, USA
| | - Ann W. Vu
- Department of Pharmacy Services, Community Regional Medical Center, Fresno, CA, USA
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46
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Rationale and pathways forward in the implementation of coronary artery calcium-based enrichment of randomized trials. Am Heart J 2022; 243:54-65. [PMID: 34587511 DOI: 10.1016/j.ahj.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/15/2021] [Indexed: 11/24/2022]
Abstract
The Food and Drug Administration recommends prognostic enrichment of randomized controlled trials (RCTs), aimed at restricting the study population to participants most likely to have events and therefore derive benefit from a given intervention. The coronary artery calcium (CAC) score is powerful discriminator of cardiovascular risk, and in this review we discuss how CAC may be used to augment widely used prognostic enrichment paradigms of RCTs of add-on therapies in primary prevention. We describe recent studies in this space, with special attention to the ability of CAC to further stratify risk among guideline-recommended candidates for add-on risk-reduction therapies. Given the potential benefits in terms of sample size, cost reduction, and overall RCT feasibility of a CAC-based enrichment strategy, we discuss approaches that may help maximize its advantages while minimizing logistical barriers and other challenges. Specifically, use of already existing CAC data to avoid the need to re-scan participants with previously documented high CAC scores, use of increasingly available, large clinical CAC databases to facilitate the identification of potential RCT participants, and implementation of machine learning approaches to measure CAC in existing computed tomography images performed for other purposes, will most likely boost the implementation of a CAC-based enrichment paradigm in future RCTs.
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47
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Cainzos-Achirica M, Acquah I, Dardari Z, Mszar R, Greenland P, Blankstein R, Bittencourt M, Rajagopalan S, Al-Kindi SG, Polak JF, Blumenthal RS, Blaha MJ, Nasir K. Long-Term Prognostic Implications and Role of Further Testing in Adults Aged ≤55 Years With a Coronary Calcium Score of Zero (from the Multi-Ethnic Study of Atherosclerosis). Am J Cardiol 2021; 161:26-35. [PMID: 34794615 PMCID: PMC8607758 DOI: 10.1016/j.amjcard.2021.08.067] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 12/30/2022]
Abstract
The long-term prognostic significance of a coronary artery calcium (CAC) score of 0 is poorly defined in younger adults. We evaluated this among participants aged 45 to 55 years from the Multi-Ethnic Study of Atherosclerosis, and assessed whether additional biomarkers can identify subgroups at increased absolute risk. We included 1,407 participants (61% women) without diabetes or severe hypercholesterolemia, with estimated 10-year risk <20% and CAC = 0. We evaluated all and hard cardiovascular disease (CVD) events, overall and among subjects with each of the following: high-sensitivity C-reactive protein levels ≥2 mg/L, homocysteine ≥10 µmol/L, high-sensitivity cardiac troponin T ≥95th percentile, lipoprotein (a) >50 mg/dl, triglycerides ≥175 mg/dl, apolipoprotein B ≥130 mg/dl, albuminuria, thoracic aortic calcium, aortic valve calcium (AVC), mitral annular calcium, ankle-brachial index <0.9, any carotid plaque, and maximum internal carotid artery intima-media thickness (ICA-IMT) ≥1.5 mm. Median follow-up was 16 years, and overall CVD event rates were low (4% at 15 years). For most exposures evaluated, rates of all CVD events were <6 per 1,000 person-years, except for ICA-IMT ≥1.5 mm (6.43) and AVC (13.8). The number needed to screen to detect ICA-IMT ≥1.5 mm was 8, and 84 for AVC. Among participants with borderline/intermediate risk or premature family history, hard CVD event rates were <7 per 1,000 for most exposures, except for ICA-IMT ≥1.5 mm (8.25), albuminuria (8.30), and AVC (13.47). Nonsmokers and those with ICA-IMT <1.5 mm had very low rates. In conclusion, our results demonstrate a favorable long-term prognosis of CAC = 0 among adults aged ≤55 years, particularly among nonsmokers. ICA-IMT testing could be considered for further risk assessment in adults ≤55 years with CAC = 0 and uncertain management.
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Affiliation(s)
- Miguel Cainzos-Achirica
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas; Center for Outcomes Research, Houston Methodist, Houston, Texas.
| | - Isaac Acquah
- Center for Outcomes Research, Houston Methodist, Houston, Texas
| | - Zeina Dardari
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Reed Mszar
- Center for Outcomes Research, Yale University, New Haven, Connecticut Yale University, New Haven, Connecticut
| | - Philip Greenland
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ron Blankstein
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marcio Bittencourt
- Center for Clinical and Epidemiological Research, University Hospital, University of São Paulo, São Paulo, Brazil
| | - Sanjay Rajagopalan
- Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Sadeer G Al-Kindi
- Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Joseph F Polak
- Tufts University School of Medicine, Boston, Massachusetts; Department of Radiology, Lemuel Shattuck Hospital, Boston, Massachusetts
| | - Roger S Blumenthal
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael J Blaha
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology and Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas; Center for Outcomes Research, Houston Methodist, Houston, Texas
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Choe HJ, Park S, Han KD, Moon MK, Koo BK. Contribution of hypertriglyceridemia to ischemic cardiovascular disease in Korean Women: A nationwide population-based study. J Clin Lipidol 2021; 16:83-93. [PMID: 34896034 DOI: 10.1016/j.jacl.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 11/17/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The independent effect of serum triglyceride levels on the development of ischemic cardiovascular disease (CVD) remains inconclusive, which might be due to heterogeneity among study populations. OBJECTIVE To evaluate the effect of triglyceride levels on ischemic CVD and mortality in Korean women, with stratification according to the menopausal status, diabetes mellitus, or low-density lipoprotein cholesterol levels (LDL-C). METHODS We retrospectively investigated Korean women aged 40-69 years who underwent health examination in 2009 and were followed up until 2018 using nationwide claim data. The subjects were divided according to triglyceride quartiles (Q): Q1 <70 mg/dL, Q2 71-99 mg/dL, Q3 100-142 mg/dL, and Q4 ≥143 mg/dL. The primary outcome was the incidence of CVD defined as a composite of myocardial infarction and ischemic stroke. RESULTS Among 2,208,347 women, primary outcome occurred in 62,255 (2.8%) subjects. As triglyceride levels increased, the event rate of primary outcome increased in both premenopausal and postmenopausal women in the fully adjusted model (hazard ratio [HR] per 1 Q, 1.10 [95% confidence interval (CI), 1.08-1.12] and 1.08 [95% CI, 1.07-1.09], respectively), which was maintained on further stratification according to diabetes or LDL-C (P<0.05 in all). Higher triglyceride levels were more significantly associated with the primary outcome, MI, and stroke risk among women with optimal non-high-density lipoprotein cholesterol levels (non-HDL-C) <130 mg/dL, but only weakly with stroke for women with non-optimal non-HDL-C. CONCLUSION Triglyceride is an independent prognosticator in the development of ischemic CVD in Korean women aged 40-69 years.
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Affiliation(s)
- Hun Jee Choe
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea
| | - SangHyun Park
- Department of Medical Statistics, College of Medicine, Catholic University of Korea, Seoul 06591, Korea
| | - Kyung-Do Han
- Department of Medical Statistics, College of Medicine, Catholic University of Korea, Seoul 06591, Korea
| | - Min Kyong Moon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea; Department of Internal Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul 07061, Korea
| | - Bo Kyung Koo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea; Department of Internal Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul 07061, Korea.
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49
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Loh WJ, Chang X, Aw TC, Phua SK, Low AF, Chan MYY, Watts GF, Heng CK. Lipoprotein(a) as predictor of coronary artery disease and myocardial infarction in a multi-ethnic Asian population. Atherosclerosis 2021; 349:160-165. [PMID: 34887076 DOI: 10.1016/j.atherosclerosis.2021.11.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The role of Lp(a) in multi-ethnic Asian populations with coronary artery disease (CAD) has not been well established. The aims of this study were (i) to investigate whether Lp(a) is a predictor of CAD, and (ii) amongst patients with CAD, to ascertain whether Lp(a) is a predictor of acute myocardial infarction (AMI) and severity of CAD. METHODS We compared three cardiovascular phenotypes from patients recruited at coronary angiography. CAD was defined as ≥50% coronary artery stenosis and subdivided into a group with AMI history (CAD+AMI+) and a group without (CAD+AMI-). Minimal CAD group (CAD-) was defined as normal or <30% coronary artery stenosis and no AMI. The severity of CAD was defined using the modified Gensini score. RESULTS We studied 2025 patients comprising 94.5% men and 61.4% of Chinese ethnicity. The median Lp(a) level was highest in CAD+AMI+, followed by CAD+AMI- and CAD- (26.2, 20.1, and 15.8 nmol/L respectively). Similarly, the frequency of patients with Lp(a) ≥120 nmol/L were in the same order (11.8%, 9.1% and 2.4%). Lp(a) levels were highest among Asian Indians, followed by Malays and Chinese patients (p < 0.001). Lp(a) levels and Lp(a) ≥120 nmol/L were significant predictors of CAD (Odds ratio (OR) = 1.12 per 10 nmol/L increment, p < 0.001, and OR = 5.41 p = 0.004 respectively). Among patients with CAD, higher Lp(a) levels were associated with increased AMI risk (OR = 1.02 per 10 nmol/L increment, p = 0.024). Lp(a) ≥120 nmol/L was positively associated with CAD severity (p = 0.020). CONCLUSIONS Plasma Lp(a) concentration is a positive predictor of CAD and AMI in a mostly male South East Asian population.
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Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, 2 Simei Street 3, 529889, Singapore.
| | - Xuling Chang
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 12, 119228, Singapore; Khoo Teck Puat - National University Children's Medical Institute, National University Health System, 5 Lower Kent Ridge Road, 119074, Singapore
| | - Tar Choon Aw
- Department of Pathology, Changi General Hospital, 2 Simei Street 3, 529889, Singapore
| | - Soon Kieng Phua
- Department of Pathology, Changi General Hospital, 2 Simei Street 3, 529889, Singapore
| | - Adrian F Low
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 117597, Singapore; National University Heart Centre, National University Health System, 119074, Singapore
| | - Mark Yan-Yee Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 117597, Singapore; National University Heart Centre, National University Health System, 119074, Singapore
| | - Gerald F Watts
- School of Medicine, University of Western Australia, 35 Stirling Hwy, Crawley, WA, 6009, Australia; Department of Cardiology, Royal Perth Hospital, Western Australia, Victoria Square, Perth, WA, 6000, Australia
| | - Chew-Kiat Heng
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 12, 119228, Singapore; Khoo Teck Puat - National University Children's Medical Institute, National University Health System, 5 Lower Kent Ridge Road, 119074, Singapore
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50
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Blaha MJ, Dzaye O. Subthreshold coronary artery calcium - Redefining the coronary artery calcium score of zero? J Cardiovasc Comput Tomogr 2021; 16:155-157. [PMID: 34862148 DOI: 10.1016/j.jcct.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 11/12/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, USA.
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, USA
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