1
|
Volkova A, Shulgin B, Helmlinger G, Peskov K, Sokolov V. Optimization of the MACE endpoint composition to increase power in studies of lipid-lowering therapies-a model-based meta-analysis. Front Cardiovasc Med 2024; 10:1242845. [PMID: 38304061 PMCID: PMC10832431 DOI: 10.3389/fcvm.2023.1242845] [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: 07/02/2023] [Accepted: 12/12/2023] [Indexed: 02/03/2024] Open
Abstract
Aims To develop a model-informed methodology for the optimization of the Major Adverse Cardiac Events (MACE) composite endpoint, based on a model-based meta-analysis across anti-hypercholesterolemia trials of statin and anti-PCSK9 drugs. Methods and results Mixed-effects meta-regression modeling of stand-alone MACE outcomes was performed, with therapy type, population demographics, baseline and change over time in lipid biomarkers as predictors. Randomized clinical trials up to June 28, 2022, of either statins or anti-PCSK9 therapies were identified through a systematic review process in PubMed and ClinicalTrials.gov databases. In total, 54 studies (270,471 patients) were collected, reporting 15 different single cardiovascular events. Treatment-mediated decrease in low density lipoprotein cholesterol, baseline levels of remnant and high-density lipoprotein cholesterol as well as non-lipid population characteristics and type of therapy were identified as significant covariates for 10 of the 15 outcomes. The required sample size per composite 3- and 4-point MACE endpoint was calculated based on the estimated treatment effects in a population and frequencies of the incorporated events in the control group, trial duration, and uncertainty in model parameters. Conclusion A quantitative tool was developed and used to benchmark different compositions of 3- and 4-point MACE for statins and anti-PCSK9 therapies, based on the minimum population size required to achieve statistical significance in relative risk reduction, following meta-regression modeling of the single MACE components. The approach we developed may be applied towards the optimization of the design of future trials in dyslipidemia disorders as well as in other therapeutic areas.
Collapse
Affiliation(s)
- Alina Volkova
- Modeling and Simulation Decisions FZ—LLC, Dubai, United Arab Emirates
- Sirius University of Science and Technology, Sirius, Russia
| | - Boris Shulgin
- Research Center of Model-Informed Drug Development, Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Kirill Peskov
- Modeling and Simulation Decisions FZ—LLC, Dubai, United Arab Emirates
- Sirius University of Science and Technology, Sirius, Russia
- Research Center of Model-Informed Drug Development, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Victor Sokolov
- Modeling and Simulation Decisions FZ—LLC, Dubai, United Arab Emirates
- Sirius University of Science and Technology, Sirius, Russia
| |
Collapse
|
2
|
Gugliucci A. Sugar and Dyslipidemia: A Double-Hit, Perfect Storm. J Clin Med 2023; 12:5660. [PMID: 37685728 PMCID: PMC10488931 DOI: 10.3390/jcm12175660] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/10/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
The availability of sugar has expanded over the past 50 years, due to improved industrial processes and corn subsidies, particularly in the form of sweetened beverages. This correlates with a surge in the prevalence of cardiometabolic disorders, which has brought this issue back into the spotlight for public health. In this narrative review, we focus on the role of fructose in the genesis of cardiometabolic dyslipidemia (an increase in serum triglyceride-rich lipoproteins (TRL): VLDL, chylomicrons (CM), and their remnants) bringing together the most recent data on humans, which demonstrates the crucial interaction between glucose and fructose, increasing the synthesis while decreasing the catabolism of these particles in a synergistic downward spiral. After reviewing TRL metabolism, we discuss the fundamental principles governing the metabolism of fructose in the intestine and liver and the effects of dysregulated fructolysis, in conjunction with the activation of carbohydrate-responsive element-binding protein (ChREBP) by glucose and the resulting crosstalk. The first byproduct of fructose catabolism, fructose-1-P, is highlighted for its function as a signaling molecule that promotes fat synthesis. We emphasize the role of fructose/glucose interaction in the liver, which enhances de novo lipogenesis, triglyceride (TG) synthesis, and VLDL production. In addition, we draw attention to current research that demonstrates how fructose affects the activity of lipoprotein lipase by increasing the concentration of inhibitors such as apolipoprotein CIII (apoCIII) and angiopoietin-like protein 3 (ANGPTL3), which reduce the catabolism of VLDL and chylomicrons and cause the building up of their atherogenic remnants. The end outcome is a dual, synergistic, and harmful action that encourages atherogenesis. Thus, considering the growing concerns regarding the connection between sugar consumption and cardiometabolic disease, current research strongly supports the actions of public health organizations aimed at reducing sugar intake, including dietary guidance addressing "safe" limits for sugar consumption.
Collapse
Affiliation(s)
- Alejandro Gugliucci
- Glycation, Oxidation and Disease Laboratory, Touro University California, Vallejo, CA 94592, USA
| |
Collapse
|
3
|
Li J, Zhu P, Tang X, Jiang L, Li Y, Yan K, Yang W, Qiao S, Yang Y, Gao R, Xu B, Yuan J, Zhao X. Combined effect of D-dimer, hs-CRP, and Lp(a) on 5-year clinical outcomes after percutaneous coronary intervention: A large real-world study in China. iScience 2023; 26:107030. [PMID: 37485360 PMCID: PMC10362257 DOI: 10.1016/j.isci.2023.107030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/01/2023] [Accepted: 05/31/2023] [Indexed: 07/25/2023] Open
Abstract
To reduce cardiovascular risk in patients with established coronary heart disease, the present study investigated the combined effect of D-dimer, high-sensitivity C-reactive protein (hs-CRP), and lipoprotein(a) [Lp(a)] on long-term cardiovascular outcomes from the perspectives of thrombosis, inflammation, and lipid risk simultaneously. Consecutive 10,724 patients with percutaneous coronary intervention (PCI) were enrolled throughout 2013. Over a median follow-up of 5.1 years, each individual elevation of D-dimer, hs-CRP, and Lp(a) was associated with poor ischemic outcomes but not bleeding. Concurrent high D-dimer, hs-CRP, and Lp(a) had even greater risks of all-cause death (hazard ratio [HR] 2.714, 95% confidence interval [CI] 1.742-4.231) and cardiac death (HR 4.152, 95% CI 2.207-7.812) and had incremental value beyond the traditional risk factors model. Concurrent high D-dimer, hs-CRP, and Lp(a) levels had a synergistic effect on adverse 5-year ischemic outcomes, highlighting that the potential utility of simultaneous assessment of multiple cardiovascular risk biomarkers may help to identify high-risk patients after PCI.
Collapse
Affiliation(s)
- Jiawen Li
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Pei Zhu
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Xiaofang Tang
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Lin Jiang
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yulong Li
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Kailun Yan
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Weixian Yang
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Shubin Qiao
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yuejin Yang
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Runlin Gao
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Bo Xu
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Jinqing Yuan
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Xueyan Zhao
- Department of Cardiology, Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| |
Collapse
|
4
|
Bae JH, Lim H, Lim S. The Potential Cardiometabolic Effects of Long-Chain ω-3 Polyunsaturated Fatty Acids: Recent Updates and Controversies. Adv Nutr 2023; 14:612-628. [PMID: 37031750 PMCID: PMC10334139 DOI: 10.1016/j.advnut.2023.03.014] [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: 07/20/2022] [Revised: 03/09/2023] [Accepted: 03/30/2023] [Indexed: 04/11/2023] Open
Abstract
Various health-related effects of long-chain (LC) ω-3 PUFAs, EPA, and DHA have been suggested. LC ω-3 PUFAs reduce TG concentrations and have anti-inflammatory, immunomodulatory, antiplatelet, and vascular protective effects. Controversially, they might help in restoring glucose homeostasis via the gut microbiota. However, previous studies have not shown the clear benefits of LC ω-3 PUFAs for CVDs. REDUCE-IT and STRENGTH-representative randomized controlled trials (RCTs) that examined whether LC ω-3 PUFAs would prevent major adverse cardiovascular (CV) events (MACE)-showed conflicting results with differences in the types, doses, or comparators of LC ω-3 PUFAs and study populations. Therefore, we performed a meta-analysis using major RCTs to address this inconsistency and assess the clinical and biological effects of LC ω-3 PUFAs. We included RCTs that involved ≥500 participants with ≥1 y follow-up. Of 17 studies involving 143,410 people, LC ω-3 PUFA supplementation showed beneficial effects on CV death (RR: 0.94; 95% CI: 0.88, 0.99; P = 0.029) and fatal or nonfatal MI (RR: 0.83; 95% CI: 0.72, 0.95; P = 0.010). RCTs on EPA alone showed better results for 3-point MACE, CV death, and fatal or nonfatal MI. However, the benefits were not found for fatal or nonfatal stroke, all-cause mortality, and hospitalization for heart failure. Of note, studies of both the EPA/DHA combination and EPA alone showed a significant increase in risk of new-onset atrial fibrillation. Thus, well-designed studies are needed to investigate the underlying mechanisms involved in the distinct effects of EPA compared with DHA on cardiometabolic diseases. This review discusses the potential benefits and safety of LC ω-3 PUFAs from a cardiometabolic perspective focusing on recent updates and controversies.
Collapse
Affiliation(s)
- Jae Hyun Bae
- Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hyunjung Lim
- Department of Medical Nutrition, Research Institute of Medical Nutrition, Graduate School of East-West Medical Science, Kyung Hee University, Yongin, Republic of Korea
| | - Soo Lim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea.
| |
Collapse
|
5
|
Filatova AY, Afanasieva OI, Arefieva TI, Potekhina AV, Tyurina AV, Klesareva EA, Razova OA, Ezhov MV, Pokrovsky SN. The Concentration of PCSK9-Lp(a) Complexes and the Level of Blood Monocytes in Males with Coronary Atherosclerosis. J Pers Med 2023; 13:1077. [PMID: 37511689 PMCID: PMC10381556 DOI: 10.3390/jpm13071077] [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: 05/30/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/30/2023] Open
Abstract
In this study we analyzed the concentration of lipoprotein(a) (Lp(a)), PCSK9-Lp(a) complexes and the circulating monocyte subsets in coronary atherosclerosis. For this study, 257 patients with coronary atherosclerosis and 68 patients without stenotic atherosclerosis in the coronary, carotid and lower extremity arteries (control group) were enrolled. The monocyte subpopulations (classical CD14++CD16-, intermediate CD14++CD16+ and non-classical CD14+CD16++) were analyzed by direct immunofluorescence and flow cytometry. The Lp(a) and PCSK9-Lp(a) complexes in the serum were detected by ELISA. The concentration of Lp(a) was higher in the coronary atherosclerosis group compared with the controls (23.0 (9.1; 73.3) mg/dL versus 10.7 (4.7; 25.0) mg/dL, p < 0.05). No correlations between the level of Lp(a) and the concentration of the PCSK9-Lp(a) complexes, nor between the level of Lp(a) or PCSK9 and the total number of monocytes, were observed in either group. A slight positive correlation between the concentration of PCSK9-Lp(a) complexes and the absolute level of monocytes was obtained (r = 0.20, p = 0.002) in the patients with atherosclerosis due to the intermediate monocyte subsets (r = 0.33, p = 0.04). According to regression analysis, both the PCSK9-Lp(a) complexes concentration and BMI were related to the absolute number of blood monocytes in patients with atherosclerosis. Further studies are required to determine the pathogenetic contribution of PCSK9-Lp(a) complexes to the development of atherosclerosis.
Collapse
Affiliation(s)
- Anastasiia Yu Filatova
- Institute of Experimental Cardiology, National Medical Research Center of Cardiology Named after Academician E.I. Chazov, Ministry of Health of the Russian Federation, 121552 Moscow, Russia
| | - Olga I Afanasieva
- Institute of Experimental Cardiology, National Medical Research Center of Cardiology Named after Academician E.I. Chazov, Ministry of Health of the Russian Federation, 121552 Moscow, Russia
| | - Tatiana I Arefieva
- Institute of Experimental Cardiology, National Medical Research Center of Cardiology Named after Academician E.I. Chazov, Ministry of Health of the Russian Federation, 121552 Moscow, Russia
| | - Alexandra V Potekhina
- A.L. Myasnikov Institute of Clinical Cardiology, National Medical Research Center of Cardiology Named after Academician E.I. Chazov, Ministry of Health of the Russian Federation, 121552 Moscow, Russia
| | - Alexandra V Tyurina
- A.L. Myasnikov Institute of Clinical Cardiology, National Medical Research Center of Cardiology Named after Academician E.I. Chazov, Ministry of Health of the Russian Federation, 121552 Moscow, Russia
| | - Elena A Klesareva
- Institute of Experimental Cardiology, National Medical Research Center of Cardiology Named after Academician E.I. Chazov, Ministry of Health of the Russian Federation, 121552 Moscow, Russia
| | - Oksana A Razova
- Institute of Experimental Cardiology, National Medical Research Center of Cardiology Named after Academician E.I. Chazov, Ministry of Health of the Russian Federation, 121552 Moscow, Russia
| | - Marat V Ezhov
- A.L. Myasnikov Institute of Clinical Cardiology, National Medical Research Center of Cardiology Named after Academician E.I. Chazov, Ministry of Health of the Russian Federation, 121552 Moscow, Russia
| | - Sergey N Pokrovsky
- Institute of Experimental Cardiology, National Medical Research Center of Cardiology Named after Academician E.I. Chazov, Ministry of Health of the Russian Federation, 121552 Moscow, Russia
| |
Collapse
|
6
|
Gugliucci A. Triglyceride-Rich Lipoprotein Metabolism: Key Regulators of Their Flux. J Clin Med 2023; 12:4399. [PMID: 37445434 DOI: 10.3390/jcm12134399] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/15/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
The residual risk for arteriosclerotic cardiovascular disease after optimal statin treatment may amount to 50% and is the consequence of both immunological and lipid disturbances. Regarding the lipid disturbances, the role of triglyceride-rich lipoproteins (TRLs) and their remnants has come to the forefront in the past decade. Triglycerides (TGs) stand as markers of the remnants of the catabolism of TRLs that tend to contain twice as much cholesterol as compared to LDL. The accumulation of circulating TRLs and their partially lipolyzed derivatives, known as "remnants", is caused mainly by ineffective triglyceride catabolism. These cholesterol-enriched remnant particles are hypothesized to contribute to atherogenesis. The aim of the present narrative review is to briefly summarize the main pathways of TRL metabolism, bringing to the forefront the newly discovered role of apolipoproteins, the key physiological function of lipoprotein lipase and its main regulators, the importance of the fluxes of these particles in the post-prandial period, their catabolic rates and the role of apo CIII and angiopoietin-like proteins in the partition of TRLs during the fast-fed cycle. Finally, we provide a succinct summary of the new and old therapeutic armamentarium and the outcomes of key current trials with a final outlook on the different methodological approaches to measuring TRL remnants, still in search of the gold standard.
Collapse
Affiliation(s)
- Alejandro Gugliucci
- Glycation, Oxidation and Disease Laboratory, Department of Research, Touro University California, Vallejo, CA 94592, USA
| |
Collapse
|
7
|
There is urgent need to treat atherosclerotic cardiovascular disease risk earlier, more intensively, and with greater precision: A review of current practice and recommendations for improved effectiveness. Am J Prev Cardiol 2022; 12:100371. [PMID: 36124049 PMCID: PMC9482082 DOI: 10.1016/j.ajpc.2022.100371] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 07/10/2022] [Accepted: 08/05/2022] [Indexed: 12/12/2022] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) is epidemic throughout the world and is etiologic for such acute cardiovascular events as myocardial infarction, ischemic stroke, unstable angina, and death. ASCVD also impacts risk for dementia, chronic kidney disease peripheral arterial disease and mobility, impaired sexual response, and a host of other visceral impairments that adversely impact the quality and rate of progression of aging. The relationship between low-density lipoprotein cholesterol (LDL-C) and risk for ASCVD is one of the most highly established and investigated issues in the entirety of modern medicine. Elevated LDL-C is a necessary condition for atherogenesis induction. Basic scientific investigation, prospective longitudinal cohorts, and randomized clinical trials have all validated this association. Yet despite the enormous number of clinical trials which support the need for reducing the burden of atherogenic lipoprotein in blood, the percentage of high and very high-risk patients who achieve risk stratified LDL-C target reductions is low and has remained low for the last thirty years. Atherosclerosis is a preventable disease. As clinicians, the time has come for us to take primordial and primary prevention more serously. Despite a plethora of therapeutic approaches, the large majority of patients at risk for ASCVD are poorly or inadequately treated, leaving them vulnerable to disease progression, acute cardiovascular events, and poor aging due to loss of function in multiple visceral organs. Herein we discuss the need to greatly intensify efforts to reduce risk, decrease disease burden, and provide more comprehensive and earlier risk assessment to optimally prevent ASCVD and its complications. Evidence is presented to support that treatment should aim for far lower goals in cholesterol management, should take into account many more factors than commonly employed today and should begin significantly earlier in life.
Collapse
|
8
|
Zhu L, Fang Y, Gao B, Jin X, Zheng J, He Y, Huang J. Effect of an increase in Lp(a) following statin therapy on cardiovascular prognosis in secondary prevention population of coronary artery disease. BMC Cardiovasc Disord 2022; 22:474. [PMID: 36348286 PMCID: PMC9644478 DOI: 10.1186/s12872-022-02932-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Lipoprotein (a) [Lp(a)] is an independent risk factor for coronary artery disease (CAD). Recent studies have indicated that statins tend to increase Lp(a) levels by 10-20%. However, the association of statin-mediated increases in Lp(a) levels with CAD has not been determined. METHODS: This study included 488 patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI). Lp(a) levels were measured at baseline and 1 month after statin therapy. The study endpoints were major adverse cardiovascular events (MACE). Hazard ratios for the MACE were adjusted for potential confounder using Cox regression. RESULTS After statin therapy, the mean level of Lp(a) increased by 19.3% from baseline. Lp(a) levels increased in 307 patients (62.9%) with a median elevation of 4.1 mg/dL. Patients with an increase in Lp(a) were at higher risk for MACE than those without an increase in Lp(a) (p = 0.044). Subgroup analyses revealed that a mild-to-moderate increase in Lp(a) was not associated with MACE, whereas there was a strong correlation between the highest quartile increase in Lp(a) (≥ 10.1 mg/dL) and MACE (HR = 2.29, 95%CI = 1.36-3.84, p = 0.002). This correlation was independent of baseline Lp(a) levels but not independent of on-statin Lp(a) levels. CONCLUSIONS Severe increases in Lp(a) following statin therapy raise the risk of MACE, but a mild-to-moderate increase in Lp(a) may not affect the cardiovascular prognosis of CAD patients. Even if the baseline Lp(a) levels are low, it is necessary to continue testing for Lp(a) concentration at least once after statin.
Collapse
Affiliation(s)
- Lijun Zhu
- Department of Cardiology, Ningbo Municipal Medical Center LiHuili Hospital, Zhejiang, China
| | - Yangliang Fang
- Department of Cardiology, Ningbo Municipal Medical Center LiHuili Hospital, Zhejiang, China
| | - Beibei Gao
- grid.13402.340000 0004 1759 700XDepartment of Cardiology, The Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Xiangbo Jin
- grid.13402.340000 0004 1759 700XDepartment of Cardiology, The Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Jiamin Zheng
- grid.13402.340000 0004 1759 700XDepartment of Cardiology, The Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Ying He
- grid.13402.340000 0004 1759 700XDepartment of Cardiology, The Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Jinyu Huang
- grid.13402.340000 0004 1759 700XDepartment of Cardiology, The Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Zhejiang, China
| |
Collapse
|
9
|
Wakabayashi K, Suzuki H, Fukumoto Y, Obara H, Kakuma T, Sakuma I, Kimura T, Iimuro S, Daida H, Shimokawa H, Nagai R. Comorbidities Associated With Residual Cardiovascular Risk in Patients With Chronic Coronary Syndrome Receiving Statin Therapy ― Subanalysis of the REAL-CAD Trial ―. Circ Rep 2022; 4:422-428. [PMID: 36120482 PMCID: PMC9437477 DOI: 10.1253/circrep.cr-22-0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 11/10/2022] Open
Abstract
Background: Even with high-dose statin therapy, residual cardiovascular event risks remain in patients with chronic coronary syndrome (CCS). Thus, future treatment targets need to be elucidated. This study determined the factors associated with residual cardiovascular risk in patients with CCS treated with high-dose statins. Methods and Results: This study was a subanalysis of the REAL-CAD study. This study enrolled 5,540 patients with CCS receiving 4 mg/day pitavastatin and assessed the impacts of 3 representative risk factors (i.e., blood pressure, glucose level, and renal function), alone or in combination, on clinical outcomes. Each risk factor was classified according to its severity. The primary endpoint was a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal ischemic stroke, and unstable angina requiring emergency hospitalization. After adjusting for the effects of confounders, a significantly worse prognosis was observed in the group with an estimated glomerular filtration rate (eGFR) ≤60 mL/min/1.73 m2
(hazard ratio [HR] 1.36; 95% confidence interval 1.03–1.80; P=0.028). No other factors or combinations were associated with the primary endpoint. An eGFR ≤60 mL/min/1.73 m2
was also associated with cardiac (HR 2.38; P=0.004) and all-cause (HR 1.51; P=0.032) death. Conclusions: Insufficient renal function was associated with a worse prognosis in patients with CCS undergoing high-dose statin therapy, suggesting that renal function is the next target for reducing the risk of residual cardiovascular events.
Collapse
Affiliation(s)
| | - Hiroshi Suzuki
- Division of Cardiology, Showa University Fujigaoka Hospital
| | - Yoshihiro Fukumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine
| | | | | | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Satoshi Iimuro
- Innovation and Research Support Center, International University of Health and Welfare
| | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | | |
Collapse
|
10
|
Liu HH, Guo YL, Zhu CG, Wu NQ, Gao Y, Xu RX, Dong Q, Qian J, Dou KF, Li JJ. Synergistic effect of the commonest residual risk factors, remnant cholesterol, lipoprotein(a), and inflammation, on prognosis of statin-treated patients with chronic coronary syndrome. J Transl Med 2022; 20:243. [PMID: 35619146 PMCID: PMC9134647 DOI: 10.1186/s12967-022-03448-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 05/18/2022] [Indexed: 12/24/2022] Open
Abstract
Background Currently, remnant cholesterol (RC), lipoprotein(a) [Lp(a)], and inflammation are considered the principal residual cardiovascular risk (RCVR) factors. This study sought to evaluate the combined impact of RC, Lp(a), and inflammation on prognosis of statin-treated patients with chronic coronary syndrome (CCS), which has not been investigated. Methods A total of 6839 patients with CCS were consecutively enrolled. Baseline RC, Lp(a), and high-sensitivity C-reactive protein (hsCRP) concentrations were measured and their medians were used for categorizations. All patients were followed for the major adverse cardiovascular events (MACEs), including cardiovascular death, non-fatal myocardial infarction, and stroke. The individual and combined effects of RC, Lp(a), and hsCRP on MACEs were examined and stratification analysis according to low-density lipoprotein cholesterol (LDL-C) was performed. Results Over an average of 54.93 ± 18.59 months follow-up, 462 MACEs were recorded. Multivariate Cox analysis showed that elevated RC and Lp(a) levels were significantly associated with an increased risk of MACEs, while high hsCRP levels were related to a slightly but non-significantly increased MACEs risk. Moreover, when participants were subgrouped according to RC, Lp(a), and hsCRP levels together, only High RC-High Lp(a)-High hsCRP group had significantly higher risk of MACEs [hazard ratio (HR) 1.99, 95% confidence interval (CI) 1.15–3.47] compared with the reference group (Low RC-Low Lp(a)-Low hsCRP), especially in patients with LDL-C < 2.6 mmol/L. Conclusions The combination of elevated levels of RC, Lp(a), and hsCRP potentiated the adverse effect on MACEs among statin-treated patients with CCS, suggesting that multiple RCVR factors assessment may be a better strategy to improve stratification in very-high risk population. Supplementary Information The online version contains supplementary material available at 10.1186/s12967-022-03448-x.
Collapse
Affiliation(s)
- Hui-Hui Liu
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Yuan-Lin Guo
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Cheng-Gang Zhu
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Na-Qiong Wu
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Ying Gao
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Rui-Xia Xu
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Qian Dong
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Jie Qian
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Ke-Fei Dou
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Jian-Jun Li
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China.
| |
Collapse
|
11
|
Effect of PCSK9 Inhibitor on Blood Lipid Levels in Patients with High and Very-High CVD Risk: A Systematic Review and Meta-Analysis. Cardiol Res Pract 2022; 2022:8729003. [PMID: 35529059 PMCID: PMC9072011 DOI: 10.1155/2022/8729003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/30/2022] [Accepted: 04/07/2022] [Indexed: 11/24/2022] Open
Abstract
Objectives We aimed to investigate the effects of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor on blood lipid levels in patients with high and very-high cardiovascular risk. Design 14 trials (n = 52,586 patients) comparing treatment with or without PCSK9 inhibitors were retrieved from PubMed and Embase updated to 1st Jun 2021. The data quality of included studies was assessed by two independent researchers using the Cochrane systematic review method. All-cause mortality, cardiovascular mortality, and changes in serum low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), triglyceride (TG), apolipoprotein B (ApoB), lipoprotein (a) (LP (a)), non-high-density lipoprotein cholesterol (non-HDL-C), high-density lipoprotein cholesterol (HDL-C), and apolipoprotein A1 (ApoA1) from baseline were analyzed using Rev Man 5.1.0 software. Results Compared with treatments without PCSK9 inhibitor, addition of PCSK9 inhibitors (evolocumab and alirocumab) had obvious decreasing effects on the levels of LDL-C [MD = −46.86, 95% CI (−54.99 to −38.72), P < 0.00001], TC [MD = −31.92, 95% CI (−39.47 to −24.38), P < 0.00001], TG [MD = −8.13, 95% CI (−10.48 to −5.79), P < 0.00001], LP(a) [MD = −26.69, 95% CI (-27.93 to −25.44), P < 0.00001], non-HDL-C [MD = −42.86, 95% CI (−45.81 to −39.92), P < 0.00001], and ApoB [MD = −38.44, 95% CI (−42.23 to -34.65), P < 0.00001] in high CVD risk patients. Conversely, changes of HDL-C [MD = 6.27, CI (5.17 to 7.36), P < 0.00001] and ApoA1 [MD = 4.33, 95% CI (3.53 to 5.13), P < 0.00001] from baseline were significantly more in high cardiovascular disease risk patients who received PCSK9 inhibitors treatment. Conclusion Addition of PCSK9 inhibitors to standard therapy resulted in definite improvement in blood lipid levels compared with therapies that did not include them.
Collapse
|
12
|
Usefulness of Novel Atherogenic Lipid Indices for the Evaluation of Metabolic Status Leading to Coronary Heart Disease in a Real-World Survey of the Japanese Population. Healthcare (Basel) 2022; 10:healthcare10040747. [PMID: 35455924 PMCID: PMC9029713 DOI: 10.3390/healthcare10040747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/04/2022] [Accepted: 04/13/2022] [Indexed: 02/01/2023] Open
Abstract
We evaluated the usefulness of two novel cholesterol-triglyceride subgroup (CTS) indices, CTSqlt and CTSqnt, that potentially reflect the metabolic status regarding risk of coronary heart disease (CHD) using a retrospective longitudinal study of the Japanese general population. We recruited 12,373 individuals from the annual users of our healthcare center. Among them, the first onset of CHD was recorded in 131 individuals between April 2014 and March 2020. The multivariate Cox proportional hazards regression analyses for all normalized lipid indices revealed that the CTSqnt index showed a comparable hazard ratio for the CHD outcome to non-high-density lipoprotein cholesterol (nonHDL-c) and triglycerides. The HR of the CTSqlt index was significantly lower than for CTSqnt, but still comparable to that for low-density lipoprotein cholesterol (LDL-c). In comparison with the other indices, CTSqlt is more sensitive to risk increment while the index value increases. Linear regression analyses for the CTS indices and previously known lipid indices suggest that the CTSqnt and CTSqlt indices reflect the quantity of atherogenic lipoproteins and particle size (quality) of smaller and denser LDLs, respectively. Furthermore, the CTSqnt/HDL-c index can be used as a comprehensive risk indicator that may represent the status of lipid metabolism determined by the CTSqlt and CTSqnt indices and thus may be useful for screening. The CTS indices can be used to evaluate the metabolic status of individuals, which may increase the risk of future CHD.
Collapse
|
13
|
Lipoprotein(a), Immune Cells and Cardiovascular Outcomes in Patients with Premature Coronary Heart Disease. J Pers Med 2022; 12:jpm12020269. [PMID: 35207757 PMCID: PMC8876319 DOI: 10.3390/jpm12020269] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/08/2022] [Accepted: 02/10/2022] [Indexed: 11/16/2022] Open
Abstract
The detection of lipoprotein(a) [Lp(a)] in the artery wall at the stage of lipid-bands formation may indicate that it participates in the atherosclerosis local nonspecific inflammatory process. Innate immune cells are involved in atherogenesis, with monocytes playing a major role in the initiation of atherosclerosis, while neutrophils can contribute to plaque destabilization. This work studies the relationship between Lp(a), immune blood cells and major adverse cardiovascular events (MACE) in patients with the early manifestation of coronary heart disease (CHD). The study included 200 patients with chronic CHD, manifested up to the age of 55 in men and 60 in women. An increased Lp(a) concentration [hyperLp(a)] was shown to predict cardiovascular events in patients with premature CHD with long-term follow-up. According to the logistic regression analysis results, an increase in the monocyte count with OR = 4.58 (95% CI 1.04–20.06) or lymphocyte-to-monocyte ratio with OR = 0.82 (0.68–0.99), (p < 0.05 for both) was associated with MACE in patients with early CHD, regardless of gender, age, classical risk factors, atherogenic lipoproteins concentration and statin intake. The combination of an increased monocyte count and hyperLp(a) significantly increased the proportion of patients with early CHD with subsequent development of MACE (p = 0.02, ptrend = 0.003). The odds of cardiovascular events in patients with early CHD manifestation were highest in patients with an elevated lymphocyte-to-monocyte ratio and an elevated Lp(a) level. A higher neutrophil blood count and an elevated neutrophil-to-lymphocyte ratio determined the faster development of MACE in patients with a high Lp(a) concentration. The data obtained in this study suggest that the high atherothrombogenicity of Lp(a) is associated with the “inflammatory” component and the innate immune cells involvement in this process. Thus, the easily calculated immunological ratios of blood cells and Lp(a) concentrations can be considered simple predictors of future cardiovascular events.
Collapse
|
14
|
Berkowitz L, Cabrera-Reyes F, Salazar C, Ryff CD, Coe C, Rigotti A. Sphingolipid Profiling: A Promising Tool for Stratifying the Metabolic Syndrome-Associated Risk. Front Cardiovasc Med 2022; 8:785124. [PMID: 35097004 PMCID: PMC8795367 DOI: 10.3389/fcvm.2021.785124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/21/2021] [Indexed: 11/24/2022] Open
Abstract
Metabolic syndrome (MetS) is a multicomponent risk condition that reflects the clustering of individual cardiometabolic risk factors related to abdominal obesity and insulin resistance. MetS increases the risk for cardiovascular diseases (CVD) and type 2 diabetes mellitus (T2DM). However, there still is not total clinical consensus about the definition of MetS, and its pathophysiology seems to be heterogeneous. Moreover, it remains unclear whether MetS is a single syndrome or a set of diverse clinical conditions conferring different metabolic and cardiovascular risks. Indeed, traditional biomarkers alone do not explain well such heterogeneity or the risk of associated diseases. There is thus a need to identify additional biomarkers that may contribute to a better understanding of MetS, along with more accurate prognosis of its various chronic disease risks. To fulfill this need, omics technologies may offer new insights into associations between sphingolipids and cardiometabolic diseases. Particularly, ceramides –the most widely studied sphingolipid class– have been shown to play a causative role in both T2DM and CVD. However, the involvement of simple glycosphingolipids remains controversial. This review focuses on the current understanding of MetS heterogeneity and discuss recent findings to address how sphingolipid profiling can be applied to better characterize MetS-associated risks.
Collapse
Affiliation(s)
- Loni Berkowitz
- Department of Nutrition, Diabetes and Metabolism & Center of Molecular Nutrition and Chronic Diseases, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- *Correspondence: Loni Berkowitz
| | - Fernanda Cabrera-Reyes
- Department of Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Cristian Salazar
- Department of Nutrition, Diabetes and Metabolism & Center of Molecular Nutrition and Chronic Diseases, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carol D. Ryff
- Institute on Aging, University of Wisconsin-Madison, Madison, WI, United States
| | - Christopher Coe
- Institute on Aging, University of Wisconsin-Madison, Madison, WI, United States
| | - Attilio Rigotti
- Department of Nutrition, Diabetes and Metabolism & Center of Molecular Nutrition and Chronic Diseases, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| |
Collapse
|
15
|
Wang Y, Wang Y. Accelerated Ovarian Aging Among Type 2 Diabetes Patients and Its Association With Adverse Lipid Profile. Front Endocrinol (Lausanne) 2022; 13:780979. [PMID: 35432199 PMCID: PMC9005646 DOI: 10.3389/fendo.2022.780979] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 02/24/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The impact of diabetes on reproductive function is still not clearly defined. This study aimed to evaluate accelerated ovarian aging in women with type 2 diabetes mellitus (T2DM) and its association with adverse lipid profile. METHODS Female patients with T2DM (n=964) and non-T2DM controls (n=263) aging from 18-80 years were included. Levels of circulating sex hormones were measured at the follicular phase in menstruating women. We analyzed the age-specific trends in the levels of sex hormones between T2DM and controls. The correlations of sex hormones with the lipid profile, including low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), total cholesterol (TC) and triglycerides (TG) were also evaluated. RESULTS In the temporal trends analysis, LH and FSH both started to increase obviously approximately from the age of 45 years among patients with T2DM, and displayed peaks of LH and FSH among patients with T2DM aged between 61 and 65, both of which were obviously earlier than that in non-T2DM controls and proved the accelerated ovarian aging among patients with T2DM. E2 of patients with T2DM was continuous lower than that of non-T2DM controls from approximately 45 years old, and LH and FSH of patients with T2DM were higher than those of non-T2DM controls between the age of 55 to 65 years. Multiple linear regression analyses revealed that LH was positively correlated with LDL-C (Coefficient=0.156, P=0.001) and TC (Coefficient=0.134, P=0.025), and was negatively correlated with HDL-C (Coefficient =-0.065, P=0.001) in patients with T2DM aged between 51 and 60, which was independent of age, T2DM duration, body mass index (BMI), glycosylated hemoglobin (HbA1c), FSH, E2 and other potential confounders. Higher E2 level was significantly and independently correlated with lower LDL-C (Coefficient= -0.064, P=0.033) in patients with T2DM aged between 51 and 60. CONCLUSIONS This study suggests that patients with T2DM have accelerated ovarian aging, and it is correlated with the occurrence of disturbed lipid profile in patients with T2DM. With an ever increasing number of female patients with T2DM diagnosed at younger ages, the accelerated ovarian aging and its adverse impacts in T2DM need to be carefully managed.
Collapse
Affiliation(s)
- Yahao Wang
- Affiliated Hospital of Qingdao University, Qingdao, China
- Huashan Hospital, Fudan University, Shanghai, China
| | - Yangang Wang
- Affiliated Hospital of Qingdao University, Qingdao, China
- *Correspondence: Yangang Wang,
| |
Collapse
|
16
|
Grajek S, Michalak M, Urbanowicz T, Olasińska-Wiśniewska A. A Meta-Analysis Evaluating the Colchicine Therapy in Patients With Coronary Artery Disease. Front Cardiovasc Med 2021; 8:740896. [PMID: 34957237 PMCID: PMC8696075 DOI: 10.3389/fcvm.2021.740896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/31/2021] [Indexed: 11/28/2022] Open
Abstract
Background: Evidence from recent studies has shown the benefits of colchicine for patients with coronary artery disease. The aim was to assess the effect of colchicine treatment on cardiovascular events, with an estimation of the risk of discontinuation and net clinical benefit. Methods and Results: Fourteen trials with a total of 13,186 patients were selected through a systematic search. Colchicine therapy significantly reduced the relative risk of primary endpoint by about 30% [RR 0.70 (95%CI:0.56–0.88)]. Compared with placebo, colchicine significantly reduced the risk of ischemia-driven revascularization [RR 0.57 (95%CI 0.41–0.80)], ischemia-driven revascularization and resuscitation [RR 0.50 (95%CI 0.34–0.73)], myocardial infarction [RR 0.73 (95%CI 0.57–0.95)], and stroke [RR 0.49 (95%CI 0.30–0.7)]. Patients treated with colchicine in comparison with placebo have a significant increase in the risk of treatment cessation (RR 1.60 95%CI 1.06–2.42). However, in the analysis which excluded studies without placebo, the relative risk of discontinuation was smaller (RR 1.34 95%CI 0.97–1.84) and in the three largest studies, the risk of discontinuation was lower and insignificant [RR 1.26 (95%CI 0.87–1.83)]. The net clinical benefit was 17.8/1,000 patients (p < 0.001). Conclusion: In coronary artery disease, low-dose colchicine significantly reduces the risk of the primary composite endpoint by about 30%. The drug should be considered as part of the preventive treatment in patients with good tolerance.
Collapse
Affiliation(s)
- Stefan Grajek
- I Department of Cardiology, Poznan University of Medical Sciences, Poznań, Poland
| | - Michał Michalak
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, Poznań, Poland
| | - Tomasz Urbanowicz
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznań, Poland
| | - Anna Olasińska-Wiśniewska
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznań, Poland
| |
Collapse
|
17
|
Nagase C, Tanno M, Kouzu H, Miki T, Nishida J, Murakami N, Kokubu N, Nagano N, Nishikawa R, Yoshioka N, Hasegawa T, Kita H, Tsuchida A, Ohnishi H, Miura T. Reduction in GLP-1 secretory capacity may be a novel independent risk factor of coronary artery stenosis. Sci Rep 2021; 11:15578. [PMID: 34341424 PMCID: PMC8329155 DOI: 10.1038/s41598-021-95065-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 07/20/2021] [Indexed: 11/09/2022] Open
Abstract
Multiple factors regulate glucagon-like peptide-1 (GLP-1) secretion, but a group of apparently healthy subjects showed blunted responses of GLP-1 secretion in our previous study. In this study, we examined whether the reduction in GLP-1 secretory capacity is associated with increased extent of coronary artery stenosis in non-diabetic patients. Non-diabetic patients who were admitted for coronary angiography without a history of coronary interventions were enrolled. Coronary artery stenosis was quantified by Gensini score (GS), and GS ≥ 10 was used as an outcome variable based on its predictive value for cardiovascular events. The patients (mean age, 66.5 ± 8.8 years; 71% males, n = 173) underwent oral 75 g-glucose tolerant tests for determination of glucose, insulin and active GLP-1 levels. The area under the curve of plasma active GLP-1 (AUC-GLP-1) was determined as an index of GLP-1 secretory capacity. AUC-GLP-1 was not correlated with fasting glucose, AUC-glucose, serum lipids or indices of insulin sensitivity. In multivariate logistic regression analysis for GS ≥ 10, AUC-GLP-1 < median, age and hypertension were selected as explanatory variables, though fasting GLP-1 level was not selected. The findings suggest that reduction in GLP-1 secretory capacity is a novel independent risk factor of coronary stenosis.
Collapse
Affiliation(s)
- Chihiro Nagase
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University, Sapporo, Japan
| | - Masaya Tanno
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University, Sapporo, Japan
| | - Hidemichi Kouzu
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University, Sapporo, Japan
| | - Takayuki Miki
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University, Sapporo, Japan
| | - Junichi Nishida
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University, Sapporo, Japan
| | - Naoto Murakami
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University, Sapporo, Japan
| | - Nobuaki Kokubu
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University, Sapporo, Japan
| | - Nobutaka Nagano
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University, Sapporo, Japan
| | - Ryo Nishikawa
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University, Sapporo, Japan
| | | | - Tohru Hasegawa
- Department of Cardiology, JR Sapporo Hospital, Sapporo, Japan
| | - Hiroyuki Kita
- Department of Cardiology, JCHO Hokushin Hospital, Sapporo, Japan
| | | | - Hirofumi Ohnishi
- Department of Public Health, Sapporo Medical University, Sapporo, Japan
| | - Tetsuji Miura
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University, Sapporo, Japan. .,Department of Clinical Pharmacology, Faculty of Pharmaceutical Sciences, Hokkaido University of Science, 15-4-1, Maeda-7, Teine-ku, Sapporo, Japan.
| |
Collapse
|
18
|
Jang AY, Scherer PE, Kim JY, Lim S, Koh KK. Adiponectin and cardiometabolic trait and mortality: where do we go? Cardiovasc Res 2021; 118:2074-2084. [PMID: 34117867 DOI: 10.1093/cvr/cvab199] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 06/11/2021] [Indexed: 12/19/2022] Open
Abstract
Adiponectin is an adipocyte-derived cytokine known for its cardioprotective effects in preclinical studies. Early epidemiologic studies replicated these findings and drew great interest. Subsequent large-scale prospective cohorts, however, showed that adiponectin levels seemed not to relate to incident coronary artery disease (CAD). Even more surprisingly, a paradoxical increase of all-cause and cardiovascular (CV) mortality with increased adiponectin levels was reported. The adiponectin-mortality paradox has been explained by some groups asserting that adiponectin secretion is promoted by elevated natriuretic peptides (NP). Other groups have proposed that adiponectin is elevated due to adiponectin resistance in subjects with metabolic syndrome or heart failure (HF). However, there is no unifying theory that can clearly explain this paradox. In patients with HF with reduced ejection fraction (HFrEF), stretched cardiomyocytes secrete NPs, which further promote release of adiponectin from adipose tissue, leading to adiponectin resistance. On the other hand, adiponectin biology may differ in patients with heart failure with preserved ejection fraction (HFpEF), which constitutes 50% of all of HF. Most HFpEF patients are obese, which exerts inflammation and myocardial stiffness, that is likely to prevent myocardial stretch and subsequent NP release. This segment of the patient population may display a different adiponectin biology from its HFrEF counterpart. Dissecting the adiponectin-mortality relation in terms of different HF subtypes may help to comprehensively understand this paradox. Mendelian Randomization (MR) analyses claimed that adiponectin levels are not causally related to CAD or metabolic syndrome. Results from MR studies, however, should be interpreted with great caution because the underlying history of CAD or CHF were not taken into account in these analyses, an issue that may substantially confound the results. Here, we discuss many aspects of adiponectin; cardiometabolic traits, therapeutic interventions, and the ongoing debate about the adiponectin paradox, which were recently described in basic, epidemiologic, and clinical studies.
Collapse
Affiliation(s)
- Albert Youngwoo Jang
- Division of Cardiovascular Disease, Gachon University Gil Hospital, Incheon, Korea, Gachon Cardiovascular Research Institute, Incheon, Korea
| | - Philipp E Scherer
- Touchstone Diabetes Center, Departments of Internal Medicine and Cell Biology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, ., Dallas, TX, 75390-8549, USA
| | - Jang Young Kim
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Soo Lim
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kwang Kon Koh
- Division of Cardiovascular Disease, Gachon University Gil Hospital, Incheon, Korea, Gachon Cardiovascular Research Institute, Incheon, Korea
| |
Collapse
|
19
|
Affiliation(s)
- Albert Youngwoo Jang
- Division of Cardiovascular Disease, Gachon University Gil Hospital and Gachon Cardiovascular Research Institute
| | - Soo Lim
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital
| | - Sang-Ho Jo
- Cardiovascular Center, Hallym University Sacred Heart Hospital
| | - Seung Hwan Han
- Division of Cardiovascular Disease, Gachon University Gil Hospital and Gachon Cardiovascular Research Institute
| | - Kwang Kon Koh
- Division of Cardiovascular Disease, Gachon University Gil Hospital and Gachon Cardiovascular Research Institute
| |
Collapse
|
20
|
Cardiovascular effects of omega-3 fatty acids: Hope or hype? Atherosclerosis 2021; 322:15-23. [PMID: 33706079 DOI: 10.1016/j.atherosclerosis.2021.02.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 12/17/2022]
Abstract
Omega-3 fatty acids have emerged as a new option for controlling the residual risk for cardiovascular disease (CVD) in the statin era after a clinical trial (REDUCE-IT) reported positive results with icosapent ethyl (IPE) in patients receiving maximally tolerated statin therapy. However, another trial which used high dose eicosapentaenoic acid (EPA) + docosahexaenoic acid (DHA) combination (STRENGTH) has failed. Together, these results raise clinically important questions. Are effects of omega-3 fatty acids neutral or beneficial in patients on statin therapy, or perhaps even harmful? The current contradictory results could be attributed to different types of omega-3 fatty acids (only EPA or combination of EPA + DHA), doses (higher vs. lower dose) of omega-3 fatty acids or different comparators (corn oil or mineral oil), as well as the underlying severity of the CVD risk or use of statins. Together with these issues, we will discuss different biological and clinical effects of various types of omega-3 fatty acids and then interpret different results of past and current clinical studies and propose practical suggestions, which could be applied in patient management.
Collapse
|
21
|
Ezhov MV, Tmoyan NA, Afanasieva OI, Afanasieva MI, Pokrovsky SN. Lipoprotein(a) and Cardiovascular Outcomes after Revascularization of Carotid and Lower Limbs Arteries. Biomolecules 2021; 11:biom11020257. [PMID: 33578899 PMCID: PMC7916698 DOI: 10.3390/biom11020257] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/27/2021] [Accepted: 02/05/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Despite high-intensity lipid-lowering therapy, there is a residual risk of cardiovascular events that could be associated with lipoprotein(a) (Lp(a)). It has been shown that there is an association between elevated Lp(a) level and cardiovascular outcomes in patients with coronary heart disease. Data about the role of Lp(a) in the development of cardiovascular events after peripheral revascularization are scarce. Purpose: To evaluate the relationship of Lp(a) level with cardiovascular outcomes after revascularization of carotid and lower limbs arteries. Methods: The study included 258 patients (209 men, mean age 67 years) with severe carotid and/or lower extremity artery disease, who underwent successful elective peripheral revascularization. The primary endpoint was the composite of nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. The secondary endpoint was the composite of primary endpoint and repeated revascularization. Results: For 36-month follow-up, 29 (11%) primary and 128 (50%) secondary endpoints were registered. There was a greater risk of primary (21 (8%) vs. 8 (3%); hazard ratio (HR), 3.0; 95% confidence interval (CI) 1.5–6.3; p < 0.01) and secondary endpoints (83 (32%) vs. 45 (17%), HR, 2.8; 95% CI 2.0–4.0; p < 0.01) in patients with elevated Lp(a) level (≥30 mg/dL) compared to patients with Lp(a) < 30 mg/dL. Multivariable-adjusted Cox regression analysis revealed that Lp(a) was independently associated with the incidence of cardiovascular outcomes. Conclusions: Patients with peripheral artery diseases have a high risk of cardiovascular events. Lp(a) level above 30 mg/dL is significantly and independently associated with cardiovascular events during 3-year follow-up after revascularization of carotid and lower limbs arteries.
Collapse
Affiliation(s)
- Marat V. Ezhov
- Laboratory of Lipid Disorders, Department of Atherosclerosis, A.L. Myasnikov Institute of Clinical Cardiology, National Medical Research Center of Cardiology, Ministry of Health of the Russian Federation, 121552 Moscow, Russia
- Correspondence: (M.V.E.); (N.A.T.); Tel.: +7-4-954-146-067 (M.V.E.)
| | - Narek A. Tmoyan
- Laboratory of Lipid Disorders, Department of Atherosclerosis, A.L. Myasnikov Institute of Clinical Cardiology, National Medical Research Center of Cardiology, Ministry of Health of the Russian Federation, 121552 Moscow, Russia
- Correspondence: (M.V.E.); (N.A.T.); Tel.: +7-4-954-146-067 (M.V.E.)
| | - Olga I. Afanasieva
- Laboratory of Atherosclerosis, Institute of Experimental Cardiology, National Medical Research Center of Cardiology, Ministry of Health of the Russian Federation, 121552 Moscow, Russia; (O.I.A.); mi (M.I.A.); (S.N.P.)
| | - Marina I. Afanasieva
- Laboratory of Atherosclerosis, Institute of Experimental Cardiology, National Medical Research Center of Cardiology, Ministry of Health of the Russian Federation, 121552 Moscow, Russia; (O.I.A.); mi (M.I.A.); (S.N.P.)
| | - Sergei N. Pokrovsky
- Laboratory of Atherosclerosis, Institute of Experimental Cardiology, National Medical Research Center of Cardiology, Ministry of Health of the Russian Federation, 121552 Moscow, Russia; (O.I.A.); mi (M.I.A.); (S.N.P.)
| |
Collapse
|
22
|
Abstract
Two decades ago, it was recognized that lipoprotein(a) (Lp(a)) concentrations were elevated in patients with cardiovascular disease (CVD). However, the importance of Lp(a) was not strongly established due to a lack of both Lp(a)-lowering therapy and evidence that reducing Lp(a) levels improves CVD risk. Recent advances in clinical and genetic research have revealed the crucial role of Lp(a) in the pathogenesis of CVD. Mendelian randomization studies have shown that Lp(a) concentrations are causal for different CVDs, including coronary artery disease, calcified aortic valve disease, stroke, and heart failure, despite optimal low-density lipoprotein cholesterol (LDL-C) management. Lp(a) consists of apolipoprotein (apo) B100 covalently bound to apoA. Thus, Lp(a) has atherothrombotic traits of both apoB (from LDL) and apoA (thrombo-inflammatory aspects). Although conventional pharmacological therapies, such as statin, niacin, and cholesteryl ester transfer protein, have failed to significantly reduce Lp(a) levels, emerging new therapeutic strategies using proprotein convertase subtilisin-kexin type 9 inhibitors or antisesnse oligonucleotide technology have shown promising results in effectively lowering Lp(a). In this review we discuss the revisited important role of L(a) and strategies to overcome residual risk in the statin era.
Collapse
Affiliation(s)
- Albert Youngwoo Jang
- Division of Cardiology, Gachon University Gil Hospital.,Gachon Cardiovascular Research Institute
| | - Seung Hwan Han
- Division of Cardiology, Gachon University Gil Hospital.,Gachon Cardiovascular Research Institute
| | - Il Suk Sohn
- Department of Cardiology, Cardiovascular Center, Kyung Hee University Hospital at Gangdong
| | - Pyung Chun Oh
- Division of Cardiology, Gachon University Gil Hospital.,Gachon Cardiovascular Research Institute
| | - Kwang Kon Koh
- Division of Cardiology, Gachon University Gil Hospital.,Gachon Cardiovascular Research Institute
| |
Collapse
|
23
|
Zhang T, Tang X, Mao L, Chen J, Kuang J, Guo X, Xu D, Peng D, Yu B. HDL-associated apoCIII plays an independent role in predicting postprandial hypertriglyceridemia. Clin Biochem 2020; 79:14-22. [PMID: 32045574 DOI: 10.1016/j.clinbiochem.2020.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/21/2020] [Accepted: 02/07/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND The mechanism for an abnormal pattern of triglyceride (TG) metabolism in response to a meal still needs further investigation. Extensive pieces of evidence have shown that apolipoprotein CIII (apoCIII) is a critical modulator of plasma TG metabolism mostly by inhibiting the hydrolysis of TG. Little is known about the role of apoCIII contained in high density lipoprotein (HDL) in plasma TG metabolism after a meal. METHODS Fasting and 4-hour postprandial peripheral venous blood were collected in 91 subjects selected from our hospital. Serum lipid parameters, apoCIII levels and HDL subcomponents were tested by standard laboratory procedures, ELISA, and nuclear magnetic resonance (NMR), respectively. The t-test, and Non-parametric tests were performed to examine differences between groups, Pearson's correlation and multiple regression analysis were used to assess the correlations between apoCIII (HDL-associated or nonHDL-associated) and postprandial TG. RESULTS There was a significant increase in TG after a meal compared to fasting status [155.40(96.70-251.07) mg/dl.vs.118.53(83.38-173.29)mg/dl, p < 0.001]. However, the total apoCIII levels were unchanged before (11.56(7.89-16.22) mg/dl) and after a meal (11.66(7.75-16.02)mg/dl, p = 0.124), while a significant increase in HDL-associated apoCIII (HDL-apoCIII) was observed from fasting (5.25(3.92-7.83)mg/dl) to post-meal (6.46(4.57-8.76)mg/dl, p = 0.001). Unlike nonHDL-apoCIII, HDL-apoCIII was positively correlated with both fasting and postprandial plasma TG in subjects with baseline plasma TG > 118.53 mg/dl (R = 0.503, p < 0.001 for fasting, R = 0.584, p < 0.001 for postprandial). Besides, in the subjects who had an abnormal TG response to a meal, which was defined as postprandial plasma TG increase of>30% compared to baseline TG levels, postprandial HDL-apoCIII was also increased significantly [5.37(3.52-7.02)mg/dl.vs.6.64(4.61-8.86)mg/dl, p = 0.001]. The enrichment of apoCIII in HDL led to changes of TG, cholesterol, free cholesterol, phospholipid and apoAII contents in HDL particles defined by NMR. CONCLUSION Enrichment of apoCIII in HDL particles potentially plays an independent role in postprandial hypertriglyceridemia.
Collapse
Affiliation(s)
- Tianhua Zhang
- Department of Cardiovascular Medicine, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Xiaoyu Tang
- Department of Cardiovascular Medicine, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Ling Mao
- Department of Cardiovascular Medicine, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jin Chen
- Department of Cardiovascular Medicine, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jie Kuang
- Department of Cardiovascular Medicine, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Xin Guo
- Department of Cardiovascular Medicine, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Danyan Xu
- Department of Cardiovascular Medicine, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Daoquan Peng
- Department of Cardiovascular Medicine, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China.
| | - Bilian Yu
- Department of Cardiovascular Medicine, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China.
| |
Collapse
|
24
|
Tada H, Nomura A, Yoshimura K, Itoh H, Komuro I, Yamagishi M, Takamura M, Kawashiri MA. Fasting and Non-Fasting Triglycerides and Risk of Cardiovascular Events in Diabetic Patients Under Statin Therapy. Circ J 2020; 84:509-515. [PMID: 32023582 DOI: 10.1253/circj.cj-19-0981] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Few data specifically investigate associations between fasting/non-fasting triglycerides (TG) and cardiovascular (CV) events under statin therapy among Japanese diabetic patients.Methods and Results:We recruited 4,988 participants with diabetes from the EMPATHY study. Median follow-up was 3 years. We evaluated associations between serum fasting/non-fasting TG and first CV events in Cox-regression hazard models adjusted by classical risk factors. CV events were defined as (1) major adverse cardiac events (MACE) including myocardial infarction, stroke, or cardiac death; and (2) CV diseases (CVD) including myocardial infarction, unstable angina, ischemic stroke, or large artery disease or peripheral arterial disease. Fasting as well as non-fasting TG were associated with MACE (adjusted hazard ratio [HR]: 1.017 per 10 mg/dL; 95% confidence interval [CI]: 1.000-1.037; P=0.046, adjusted HR: 1.028 per 10 mg/dL; 95% CI: 1.006-1.050; P=0.0091) and CVD (adjusted HR: 1.024 per 10 mg/dL; 95% CI: 1.011-1.038; P=4.4×10-3, adjusted HR: 1.028 per 10 mg/dL; 95% CI: 1.010-1.046; P=4.9×10-3). Comparing the top quartile with the bottom quartile of non-fasting TG, adjusted HR significantly increased 5.18 (95% CI: 1.38-18.3, P=0.014) for MACE, and 2.40 (95% CI: 1.11-4.75, P=0.021) for CVD, while adjusted HR did not change when divided into quartile of fasting TG. CONCLUSIONS Non-fasting TG could be considered as a substitute for fasting TG as a risk stratification for future CV events among Japanese diabetic patients.
Collapse
Affiliation(s)
- Hayato Tada
- Department of Cardiology, Kanazawa University Graduate School of Medicine
| | - Akihiro Nomura
- Department of Cardiology, Kanazawa University Graduate School of Medicine.,Innovative Clinical Research Center, Kanazawa University
| | | | - Hiroshi Itoh
- Department of Endocrinology, Metabolism and Nephrology, Keio University School of Medicine
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo Graduate School of Medicine
| | | | - Masayuki Takamura
- Department of Cardiology, Kanazawa University Graduate School of Medicine
| | - Masa-Aki Kawashiri
- Department of Cardiology, Kanazawa University Graduate School of Medicine
| |
Collapse
|