Peripheral arterial disease, type 2 diabetes and postprandial lipidaemia: Is there a link?

The effect of pulmonary rehabilitation on cardiovascular risk, oxidative stress and systemic inflammation in patients with COPD

PURPOSE

Chronic obstructive pulmonary disease (COPD) is a leading cause of death, and cardiovascular (CV) comorbidities play a role. Evidence of the pulmonary rehabilitation (PR) effect in reducing the CV risk (CVR) in COPD patients is limited. In this study, we aimed to determine the impact of an 8-week PR program (PRP) on the CVR of the overall population and to compare the impact on the exacerbator versus non-exacerbator patients.

PATIENTS AND METHODS

This was a prospective study that included adults who had post-bronchodilator forced expiratory volume in 1 s (FEV1) to forced vital capacity (FVC) (FEV1/FVC) ratio <70 % and FEV1 <80 % predicted, had quit smoking for at least 1 year and had a history of tobacco consumption greater than 10 packs/year, and were clinically stable in the last 8 weeks. Pre- and post-PRP assessments included respiratory function evaluation, laboratory tests, and exercise capacity assessment (6-min walking test [6MWT]). CVR was assessed using different risk prediction models.

RESULTS

A total of 50 patients (28 exacerbators and 22 non-exacerbators) completed the PRP (median age: 64.5 years, men: 72 %; arterial hypertension: 70 %, dyslipidemia: 30 %, diabetes: 20 %; CV disease (CVD): 24 %. After the PRP, exacerbator patients showed a significant decrease in the CVR calculated by the COPDCoRi model (p < 0.001); patients with ≥30-m increase on the 6MWT showed statistically significant lower levels of glucose (p = 0.004), HbA1c (p = 0.004) and BODE index score (p = 0.026) compared to patients with <30-m increase.

CONCLUSIONS

PR reduced certain modifiable CVR factors and CVD risk, especially in exacerbator patients.

SEA 2024 Standards for Global Control of Vascular Risk

One of the objectives of the Spanish Society of Arteriosclerosis is to contribute to the knowledge, prevention and treatment of vascular diseases, which are the leading cause of death in Spain and entail a high degree of disability and health expenditure. Atherosclerosis is a multifactorial disease and its prevention requires a global approach that takes into account the associated risk factors. This document summarises the current evidence and includes recommendations for patients with established vascular disease or at high vascular risk: it reviews the symptoms and signs to evaluate, the laboratory and imaging procedures to request routinely or in special situations, and includes the estimation of vascular risk, diagnostic criteria for entities that are vascular risk factors, and general and specific recommendations for their treatment. Finally, it presents aspects that are not usually referenced in the literature, such as the organisation of a vascular risk consultation.

Cardiovascular and lipid-lowering effects of a marine lipoprotein extract in a high-fat diet-induced obesity mouse model

Obesity is a major health challenge worldwide, with implications for diabetes, hypertension and cardiovascular disease (CVD). Regular consumption of dark-meat fish is linked to a lower incidence of CVD and associated metabolic disorders due to the presence of long-chain omega-3 fatty acid ethyl esters in fish oils. The aim of the present study was to determine whether a marine compound like a sardine lipoprotein extract (RCI-1502), regulates fat accumulation in the heart of a high-fat diet-induced (HFD) mouse model of obesity. To investigate its effects in the heart and liver, we conducted a randomized, 12-week placebo-controlled study in which we analyzed the expression of vascular inflammation markers, obesity biochemical patterns and related CVD pathologies. Male HFD-fed mice treated with a RCI-1502-supplemented diet showed reduced body weight, abdominal fat tissue and pericardial fat pad mass density without systemic toxicity. RCI-1502 significantly reduced triacylglyceride, low-density lipoprotein and total-cholesterol concentrations in serum, but increased HDL-cholesterol levels. Our data show that RCI-1502 is beneficial for reducing obesity associated with a long-term HFD, possibly by exerting a protective effect on lipidic homeostasis, indicated also by histopathological analysis. These results collectively indicate that RCI-1502 acts as a cardiovascular therapeutic nutraceutical agent, which modulates fat-induced inflammation and improves metabolic health.

SEA 2022 Standards for Global Control of Cardiovascular Risk

One of the objectives of the Spanish Society of Arteriosclerosis is to contribute to better knowledge of vascular disease, its prevention and treatment. It is well known that cardiovascular diseases are the leading cause of death in our country and entail a high degree of disability and health care costs. Arteriosclerosis is a multifactorial disease and therefore its prevention requires a global approach that takes into account the different risk factors with which it is associated. Therefore, this document summarizes the current level of knowledge and includes recommendations and procedures to be followed in patients with established cardiovascular disease or at high vascular risk. Specifically, this document reviews the main symptoms and signs to be evaluated during the clinical visit, the laboratory and imaging procedures to be routinely requested or requested for those in special situations. It also includes vascular risk estimation, the diagnostic criteria of the different entities that are cardiovascular risk factors, and makes general and specific recommendations for the treatment of the different cardiovascular risk factors and their final objectives. Finally, the document includes aspects that are not usually referenced in the literature, such as the organization of a vascular risk consultation.

Postprandial Hyperlipidemia: Association with Inflammation and Subclinical Atherosclerosis in Patients with Rheumatoid Arthritis

OBJECTIVE

To describe postprandial lipidemia in patients with rheumatoid arthritis (RA) and to analyze its association with subclinical atherosclerosis and inflammatory activity.

METHODS

Observational study of 80 cases of RA and 80 sex- and age-matched controls. We excluded individuals with dyslipidemia. Postprandial hyperlipidemia (PPHL) was defined as postprandial triglycerides >220 mg/dL and/or postprandial ApoB48 levels >75th percentile (>p75). Plasma lipids, cholesterol, triglycerides, ApoB48, and total ApoB were evaluated at baseline and after a meal. Other variables analyzed included subclinical atherosclerosis (defined as presence of carotid atheromatous plaque), inflammatory activity (disease activity score (DAS28-ESR)), cytokines, apolipoproteins, and physical activity. A multivariate analysis was performed to identify factors associated with PPHL in patients with RA.

RESULTS

A total of 75 patients with RA and 67 healthy controls fulfilled the inclusion criteria. PPHL was more frequent in patients with RA than controls (No. (%), 29 (38.70) vs. 15 (22.40); p = 0.036), as was subclinical atherosclerosis (No. (%), 22 (30.10) vs. 10 (14.90); p = 0.032). PPHL in patients with RA was associated with subclinical atherosclerosis (OR (95% CI) 4.69 (1.09-12.11); p = 0.037), TNF-α (OR (95% CI) 2.00 (1.00-3.98); p = 0.048), high-sensitivity C-reactive protein (OR (95% CI) 1.10 (1.01-1.19); p = 0.027), and baseline triglycerides (OR (95% CI) 1.02 (1.00-1.04); p = 0.049).

CONCLUSION

PPHL was more frequent in patients with RA than in controls. PPHL in patients with RA was associated with inflammation and subclinical atherosclerosis.

Statins and Peripheral Arterial Disease: A Narrative Review

Peripheral arterial disease (PAD) is a highly prevalent atherosclerotic condition. In patients with PAD, the presence of intermittent claudication leads to a deterioration in quality of life. In addition, even in asymptomatic cases, patients with PAD are at high risk of cardiac or cerebrovascular events. Treatment of PAD is based on lifestyle modifications; regular exercise; smoking cessation; and control of cardiovascular risk factors, including hypercholesterolemia. A growing number of studies have shown that statins reduce cardiovascular risk and improve symptoms associated with PAD. Current guidelines recommend the use of statins in all patients with PAD in order to decrease cardiovascular events and mortality. However, the prescribing of statins in patients with PAD is lower than in those with coronary heart disease. This review provides relevant information from the literature that supports the use of statins in patients with PAD and shows their potential benefit in decreasing lower limb complications as well as cardiovascular morbidity and mortality.

Pathogenesis and Clinical Significance of In-Stent Restenosis in Patients with Diabetes

Diabetes mellitus (DM) is a strong risk factor for the development of cardiovascular diseases such as coronary heart disease, cerebrovascular disease, and peripheral arterial disease (PAD). In the population of people living with DM, PAD is characterised by multi-level atherosclerotic lesions as well as greater involvement of the arteries below the knee. DM is also a factor that significantly increases the risk of lower limb amputation. Percutaneous balloon angioplasty with or without stent implantation is an important method of the treatment for atherosclerotic cardiovascular diseases, but restenosis is a factor limiting its long-term effectiveness. The pathogenesis of atherosclerosis in the course of DM differs slightly from that in the general population. In the population of people living with DM, more attention is drawn to such factors as inflammation, endothelial dysfunction, platelet dysfunction, blood rheological properties, hypercoagulability, and additional factors stimulating vascular smooth muscle cell proliferation. DM is a risk factor for restenosis. The purpose of this paper is to provide a review of the literature and to present the most important information on the current state of knowledge on mechanisms and the clinical significance of restenosis and in-stent restenosis in patients with DM, especially in association with the endovascular treatment of PAD. The role of such processes as inflammation, neointimal hyperplasia and neoatherosclerosis, allergy, resistance to antimitotic drugs used for coating stents and balloons, genetic factors, and technical and mechanical factors are discussed. The information on restenosis collected in this publication may be helpful in planning further research in this field, which may contribute to the formulation of more and more precise recommendations for the clinical practice.

Postprandial Apolipoprotein B48 is Associated with Subclinical Atherosclerosis in Patients with Rheumatoid Arthritis

OBJECTIVE

To describe postprandial lipemia in patients with rheumatoid arthritis (RA) and to analyze its association with subclinical atherosclerosis measured as carotid intima-media thickness (cIMT).

METHODS

We performed an observational study of 40 patients with RA and 40 sex and age-matched controls. Patients with dyslipidemia were excluded. Pathologically increased cIMT was defined as a carotid thickness greater than the 90th percentile (>p90) for age and sex. Fasting and postprandial plasma lipids, cholesterol, triglycerides, apolipoprotein B48 (ApoB48), and total ApoB were evaluated. The other variables included were clinical and laboratory values, Framingham score, and the 28-joint Disease Activity Score (DAS28). Two multivariate models were constructed to identify factors associated with pathologic cIMT in patients with RA.

RESULTS

Fasting lipid values were similar in patients with RA and controls, although those of postprandial ApoB48 were higher (median (IQR), 14.4 (10.8-12.1) vs. 12.1 (2.3-9,8); p = 0.042). Pathologic cIMT was recorded in 10 patients with RA (25%) and nine controls (22.5%). In patients with RA, pathologic cIMT was associated with postprandial ApoB48 (OR (95% CI), 1.15 (1.0-1.3)) and total ApoB (OR [95% CI], 1.12 [1.1-1.2]). The second model revealed a mean increase of 0.256 mm for cIMT in patients with elevated anticitrullinated protein antibodies (ACPAs).

CONCLUSION

Postprandial ApoB48 levels in patients with RA are higher than in controls. Postprandial ApoB48 and total ApoB levels and markers of severity, such as ACPAs, are associated with pathologic cIMT in patients with RA. Our findings could indicate that these atherogenic particles have a negative effect on the endothelium.

Correlation between lower extremity arterial disease and skeletal muscle mass in patients with type 2 diabetes mellitus

Objectives

To evaluate skeletal muscle mass in patients with both type 2 diabetes mellitus (T2DM) and concomitant lower extremity arterial disease (LEAD) and determine the contribution of skeletal muscle mass to macrovascular diseases.

Methods

In total, 112 patients with T2DM were divided into the T2DM and T2DM + LEAD groups. Hepatic function, renal function, uric acid, blood glucose, and glycated hemoglobin (HbA1C) were measured. Dual-energy X-ray absorptiometry was used to measure visceral fat area and skeletal muscle mass index (SMI).

Results

Waist-to-hip ratio, uric acid, and body fat percentage were significantly higher in the T2DM+LEAD group than in the T2DM group; SMI was significantly lower in the T2DM+LEAD group than in the T2DM group. There were no significant differences in albumin, creatinine, fasting blood glucose, HbA1C, or blood lipids. Uric acid, SMI, and body fat percentage were significantly positively correlated with T2DM and concomitant LEAD. Logistic regression analyses suggested that SMI is an independent risk factor for LEAD in T2DM (odds ratio = 1.517; 95% confidence interval: 1.082–2.126).

Conclusions

Skeletal muscle mass is lower in patients with T2DM and concomitant LEAD than in patients with T2DM who do not exhibit LEAD. SMI is an important risk factor for LEAD.

Hypertriglyceridemia is associated with an increased risk of peripheral arterial revascularization in high-risk statin-treated patients: A large administrative retrospective analysis

Background

Peripheral artery disease (PAD) is common, and although it is associated with cardiovascular (CV) morbidity, mortality, reduced quality of life, and increased health care burden, PAD data are relatively scarce. Elevated triglycerides (TG) are associated with and are a risk factor for PAD.

Hypothesis

Large administrative retrospective data may provide further insight into the relationship between hypertriglyceridemia and peripheral arterial revascularization in high‐risk statin‐treated patients.

Methods

This retrospective administrative claims analysis of the Optum Research Database included statin‐treated patients aged ≥45 years with diabetes and/or atherosclerotic CV disease enrolled in 2010 and followed for ≥6 months. Patients with TG ≥150 mg/dL were propensity score‐matched to a comparator cohort with TG <150 mg/dL and high‐density lipoprotein cholesterol >40 mg/dL (n = 23 181 in each cohort). A sub‐analysis was conducted in patients with TG 200‐499 mg/dL and a matched comparator cohort (n = 10 990). Clustered P‐values were calculated using a Cox proportional hazard model with cohort as the independent variable (α, 0.05).

Results

Multivariate analysis showed a 37% higher rate of peripheral arterial revascularization in the elevated‐TG cohort vs the comparator cohort (hazard ratio [HR] 1.370, 95% confidence interval [CI] 1.263‐1.486; P < .001). Results in the high‐TG sub‐cohort were similar, with a 49% higher rate of revascularization vs the comparator cohort (HR 1.489; 95% CI, 1.348‐1.644; P < .001).

Conclusions

This large administrative retrospective analysis of high‐risk statin‐treated patients showed that elevated TG (≥150 mg/dL) and high TG (200‐499 mg/dL) were significant predictors of peripheral arterial revascularization; this warrants further study.

Standards for global cardiovascular risk management arteriosclerosis

One of the main goals of the Spanish Society of Arteriosclerosis is to contribute to a wider and greater knowledge of vascular disease, its prevention and treatment. Cardiovascular diseases are the leading cause of death in our country and also lead to a high degree of disability and health expenditure. Arteriosclerosis is a multifactorial disease, this is why its prevention requires a global approach that takes into account the different risk factors with which it is associated. Thus, this document summarizes the current level of knowledge and integrates recommendations and procedures to be followed for patients with established cardiovascular disease or high vascular risk. Specifically, this document reviews the main symptoms and signs to be evaluated during the clinical visit, the laboratory and imaging procedures to be routinely requested or those in special situations. It also includes the estimation of vascular risk, the diagnostic criteria of the different entities that are cardiovascular risk factors, and presents general and specific recommendations for the treatment of the different cardiovascular risk factors and their final objectives. Finally, the document includes aspects that are not often mentioned in the literature, such as the organisation of a vascular risk consultation.

Increased Cardiovascular Risk in Hypertriglyceridemic Patients With Statin-Controlled LDL Cholesterol

CONTEXT

Real-world evidence of the relationship between high triglyceride (TG) levels and cardiovascular (CV) disease (CVD) risk among statin-treated patients with low-density lipoprotein cholesterol (LDL-C) control is lacking.

OBJECTIVE

We aimed to compare CVD and mortality risk between patients with high vs normal TGs.

DESIGN

Longitudinal observational cohort study.

SETTING

Integrated delivery system.

PATIENTS

Patients aged ≥45 years whose TG level was either <150 mg/dL (normal) or between 200 and 499 mg/dL (high) in 2010, were taking only statins, had LDL-C values 40 to 100 mg/dL, and had diagnosed CVD.

OUTCOME MEASURES

Patients were followed through December 2016. Our primary outcomes were a composite of nonfatal myocardial infarction (MI), nonfatal stroke, unstable angina, coronary revascularization, and all-cause mortality and a second composite adding peripheral revascularization and aneurysm repair. We compared multivariable-adjusted incidence rates and rate ratios (RRs) of the outcomes and their components.

RESULTS

A total of 14,481 patients comprised the normal TG group, and 2702 patients were in the high TG group. Multivariable-adjusted incidence of the second composite was 10% greater in the high TG group [50.9/1000 person-years, 95% CI 47.0 to 55.2 vs 46.5, 44.8 to 48.2, RR 1.10, 95% CI 1.00 to 1.20, P = 0.041]. The difference was driven by nonfatal MI (RR 1.20, 95% CI 1.00 to 1.45, P = 0.045), coronary revascularization (RR 1.18, 95% CI 1.00 to 1.40, P = 0.045), and peripheral revascularization (RR 1.56, 95% CI 1.14 to 2.13, P = 0.006).

CONCLUSIONS

CVD risk in high-risk statin-treated patients with atherosclerotic CVD was associated with high TG levels.

Fasting and nonfasting triglycerides in cardiovascular and other diseases

Moderately elevated plasma/serum triglycerides (2-10 mmol/l) signalize increased risk for cardiovascular disease or presence of non-alcoholic steatohepatitis. Extremely elevated triglycerides (more than 10 mmol/l) signalize increased risk for pancreatitis and lipemia retinalis. The concentration of triglycerides is regulated by many genetic and nongenetic factors. Extremely elevated triglycerides not provoked by nutritional factors, especially inappropriate alcohol intake are more likely to have a monogenic cause. On the contrary, mildly to moderately elevated triglycerides are often caused by polygenic disorders; these could be also associated with central obesity, insulin resistance, and diabetes mellitus. Concentration of triglycerides is also closely interconnected with presence of atherogenic remnant lipoproteins, impaired reverse cholesterol transport and more atherogenic small LDL particles. In general, there is tight association between triglycerides and many other metabolic factors including intermediate products of lipoprotein metabolism which are frequently atherogenic. Therefore, reliable evaluation of the independent role of triglycerides especially in atherosclerosis and cardiovascular disease is difficult. In individual cases values of HDL cholesterol, non-HDL cholesterol (total minus HDL cholesterol), non-HDL/nonLDL cholesterol (total minus HDL minus LDL cholesterol, especially in nonfasting status), atherogenic index of plasma and/or apolipoprotein B could help in decisions regarding aggressiveness of treatment.

Incidence and Predictors of In-stent Re-Stenosis in the Superficial Femoral Artery: Evaluation of Long-Term Outcomes by Color Duplex Ultrasound

This study aimed to investigate the incidence and predictors of in-stent re-stenosis (ISR) for nitinol stents in the superficial femoral artery (SFA) by color duplex ultrasound (CDU). In total, 235 patients undergoing SFA stenting were included in the present study. The cumulative ISR rates at 3, 6, 12, 24 and 36 mo post-procedure were 5.4%, 24.0%, 49.0%, 61.5% and 71.5%, respectively. The markedly low peak systolic velocity of the popliteal artery (PSV2) post-operation was inversely correlated with the ISR. The threshold for ≥50% re-stenosis was PSV2 ≤ 63 cm/s with 86.6% sensitivity and 90.5% specificity. With regard to re-occlusion, the PSV2 was ≤40 cm/s with 98.1% sensitivity and 93.4% specificity. Cox regression analysis indicated that the cumulative stent length, diabetes, and pre-stent stenosis level were independent risk factors of ISR. In conclusion, the ISR incidence after SFA stenting is relatively high and CDU follow-up is a feasible method for evaluating ISR.

Ghrelin Promotes Functional Angiogenesis in a Mouse Model of Critical Limb Ischemia Through Activation of Proangiogenic MicroRNAs

Current therapeutic strategies for the treatment of critical limb ischemia (CLI) have only limited success. Recent in vitro evidence in the literature, using cell lines, proposes that the peptide hormone ghrelin may have angiogenic properties. In this study, we aim to investigate if ghrelin could promote postischemic angiogenesis in a mouse model of CLI and, further, identify the mechanistic pathway(s) that underpin ghrelin's proangiogenic properties. CLI was induced in male CD1 mice by femoral artery ligation. Animals were then randomized to receive either vehicle or acylated ghrelin (150 μg/kg sc) for 14 consecutive days. Subsequently, synchrotron radiation microangiography was used to assess hindlimb perfusion. Subsequent tissue samples were collected for molecular and histological analysis. Ghrelin treatment markedly improved limb perfusion by promoting the generation of new capillaries and arterioles (internal diameter less than 50 μm) within the ischemic hindlimb that were both structurally and functionally normal; evident by robust endothelium-dependent vasodilatory responses to acetylcholine. Molecular analysis revealed that ghrelin's angiogenic properties were linked to activation of prosurvival Akt/vascular endothelial growth factor/Bcl-2 signaling cascade, thus reducing the apoptotic cell death and subsequent fibrosis. Further, ghrelin treatment activated proangiogenic (miR-126 and miR-132) and antifibrotic (miR-30a) microRNAs (miRs) while inhibiting antiangiogenic (miR-92a and miR-206) miRs. Importantly, in vitro knockdown of key proangiogenic miRs (miR-126 and miR-132) inhibited the angiogenic potential of ghrelin. These results therefore suggest that clinical use of ghrelin for the early treatment of CLI may be a promising and potent inducer of reparative vascularization through modulation of key molecular factors.

Factors Affecting Penetration of Ciprofloxacin in Lower Extremity Ischemic Tissues

The aims of this study were to evaluate factors influencing the distribution of ciprofloxacin in tissue of patients suffering from varying degrees of peripheral arterial disease (PAD). Blood and tissue samples were collected from patients undergoing debridement or amputation procedures and the amount of ciprofloxacin in them was determined using high-performance liquid chromatography. All patients were administered a 200-mg dose of intravenous ciprofloxacin prior to the debridement or amputation procedure. Data, including patient gender, age, type of diabetes, presence of neuropathy, medications taken, and severity of PAD were collected. These data were then analyzed to determine factors influencing the concentrations of ciprofloxacin in tissue of the lower limbs. The Kruskal-Wallis test, Spearman correlation, and chi-square test were used to relate covariates and fixed factors with the concentration of ciprofloxacin in tissue. Following bivariate analysis, a 3-predictor regression model was fitted to predict tissue concentrations of ciprofloxacin given information about these predictors. Blood and tissue samples were collected from 50 patients having an average age of 68 years. Thirty-three patients were males and 35 patients suffered from type 2 diabetes. The average number of medications that these patients were taking was 10. The majority of patients (n = 35) were suffering from severe PAD. Tissue concentrations of ciprofloxacin were mainly related to plasma concentrations of ciprofloxacin, number of medications that the patients were taking and severity of PAD.

In vivo evidence for chylomicrons as mediators of postprandial inflammation

BACKGROUND AND AIMS

The postprandial situation is a pro-inflammatory condition most likely linked to the development of atherosclerosis. We evaluated the relationship between apolipoprotein (apo) B48 and fasting and postprandial leukocyte activation markers.

METHODS

Leukocyte activation markers and apo B48 were determined in 80 subjects with and without coronary artery disease (CAD). Twelve healthy subjects underwent an oral fat loading test (up to 8 h).

RESULTS

Fasting apo B48 was significantly higher in patients with CAD (n = 47, 8.1 ± 5.2 mg/L) than in subjects without CAD (n = 33, 5.9 ± 3.9 mg/L, p = 0.022). Fasting apo B48 and triglycerides correlated positively with fasting monocyte CD11b and neutrophil CD66b expression. Plasma apo B48 and leukocyte activation markers increased after an oral fat load. No correlations were found between fasting or postprandial triglycerides and postprandial leukocyte activation markers. We observed no correlations between postprandial apo B48 and postprandial neutrophil CD11b or CD66b expression.

CONCLUSION

This study suggests that chylomicron remnants may be responsible for postprandial leukocyte activation in the circulation. The postprandial chylomicron response may be a stronger mediator of postprandial inflammation than postprandial triglyceridemia.