Dyslipidemia management in primary prevention of cardiovascular disease: Current guidelines and strategies

Frameshift variation in the HMG-CoA reductase gene and unresponsiveness to cholesterol-lowering drugs in type 2 diabetes mellitus patients

Dyslipidemia, an imbalance in blood lipid levels, is a frequent complication of type 2 diabetes mellitus (DM2) and heightens the risk of cardiovascular diseases (CVDs). Statins, which inhibit 3-hydroxy-3-methylglutaryl-CoA reductase, are potent competitive inhibitors that reduce plasma cholesterol levels. However, individual responses to statins can vary markedly, possibly due to genetic variations in the 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) gene. This study aimed to investigate the pharmacogenetic relationship between the HMGCR gene and hypercholesterolemia in type 2 diabetes mellitus patients who respond differently to atorvastatin, as well as in healthy individuals. Ninety participants were involved, including sixty with type 2 diabetes mellitus and hypercholesterolemia, and thirty healthy individuals. They were randomly assigned to three groups: responsive (received atorvastatin 40 mg), non-responsive (also received atorvastatin 40 mg), and control. Both responsive and non-responsive groups underwent fasting. Biochemical tests were conducted, followed by genetic analysis to identify mutations in the HMGCR gene. The effects of statins in each group were assessed using analysis of variance (ANOVA) and post hoc Tukey's Honestly Significant Difference (HSD) analysis. Atorvastatin 40 mg was administered to assess its efficacy in reducing cholesterol levels in patients with hypercholesterolemia and type 2 diabetes mellitus. The control group exhibited similar cholesterol levels to the responsive group (cholesterol < 200 mg/dl). However, both control and responsive groups significantly differed from the non-responsive group, which had markedly elevated cholesterol levels (> 240 mg/dl). Genetic analysis revealed a cytosine nucleotide insertion in the catalytic domain of the HMGCR gene in only two non-responsive participants to atorvastatin 40 mg therapy. These two patients showed non-responsiveness to atorvastatin 40 mg due to a genetic mutation in the HMGCR gene. This mutation altered the amino acid sequence in the flap domain, replacing isoleucine with a stop codon. As a result, translation was prematurely terminated, leading to the production of truncated proteins.

Effects of intermittent fasting combined with physical exercise on cardiometabolic outcomes: systematic review and meta-analysis of clinical studies

CONTEXT

Different intermittent fasting (IF) protocols have been proven to be efficient in improving cardiometabolic markers, but further research is needed to examine whether or not combining IF regimens plus physical exercise is superior to control diets (ie, nonfasting eating) plus physical exercise in this setting.

OBJECTIVE

The aim of this study was to determine whether or not combining IF plus exercise interventions is more favorable than a control diet plus exercise for improving cardiometabolic health outcomes.

DATA SOURCE

PubMed, Scopus, and Web of Science were comprehensively searched until April 2023.

DATA EXTRACTION

Electronic databases were searched for clinical trials that determined the effect of IF plus exercise vs a control diet plus exercise on body weight, lipid profile (high-density lipoprotein [HDL], low-density lipoprotein [LDL], triglycerides, and total cholesterol), and systolic and diastolic blood pressure (SBP and DBP, respectively). Analyses were conducted for IF plus exercise vs a nonfasting diet plus exercise to calculate weighted mean differences (WMDs).

DATA ANALYSIS

The meta-analysis included a total of 14 studies, with a total sample of 360 adults with or without obesity. The duration ranged from 4 to 52 weeks. IF plus exercise decreased body weight (WMD = -1.83 kg; P = 0.001), LDL (WMD = -5.35 mg/dL; P = 0.03), and SBP (WMD = -2.99 mm Hg; P = 0.003) significantly more than a control diet plus exercise. HDL (WMD = 1.57 mg/dL; P = 0.4) and total cholesterol (WMD = -2.24 mg/dL; P = 0.3) did not change significantly for IF plus exercise vs a control diet plus exercise, but there was a trend for reducing triglycerides (WMD = -13.13 mg/dL; P = 0.07) and DBP (WMD = 2.13 mm Hg; P = 0.05), which shows clinical magnitude.

CONCLUSION

IF plus exercise improved some cardiometabolic outcomes (body weight, blood pressure, and lipid profile) compared with a control diet plus exercise.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42023423878.

Healthcare dashboard technologies and data visualization for lipid management: A scoping review

BACKGROUND

Lipid disorders significantly increase cardiovascular disease (CVD) risk, the leading cause of mortality worldwide. Effective lipid management is critical for improving health outcomes. Traditional screening methods face challenges due to data complexity and the need for timely decision-making. Data visualization and dashboard technologies offer clear, actionable insights and supporting informed decision-making. This study investigates the use of these technologies in lipid management and their impacts on the quadruple aim of healthcare.

METHODS

This scoping review followed the Joanna Briggs Institute (JBI) approach, focusing on studies involving dashboard technologies or data visualization in lipid management. A comprehensive search across multiple databases (Embase, Web of Science, PubMed, Scopus, CINAHL) and gray literature was conducted, including English-language publications from 2014 to 2024. Data were analyzed using quantitative descriptive and qualitative content analysis to evaluate the key features, clinical applications, and outcomes.

RESULTS

Twenty-seven studies met the inclusion criteria, primarily focusing on dashboard utilization by physicians for managing diabetes and CVD, utilizing electronic medical records and clinical guidelines. Key analysis methods included comparing key performance indicators (KPIs) (85.2%) and trend analysis (74.1%). Lipid management workflows emphasized prevention (88.9%) and treatment planning (77.8%). Interventions included care packages (comprehensive sets of interventions for patient care), decision support systems, web-based tools, and mobile health solutions. Regarding Quadruple Aim outcomes: 12 studies focused on improving population health (8 positive, 4 no change), 9 on clinical outcomes (5 positive, 4 no change), 6 on provider work life (5 positive), 5 on patient experience (positive changes in education and time management), and 2 on cost reduction (1 positive, 1 negative).

CONCLUSIONS

Dashboards are important tools in managing lipid disorders in managing lipid disorders, integrating with educational tools, collaborative care models, and decision support systems. Although they are effective in enhancing population health and clinical experiences, their impact on patient outcomes and cost reduction requires further exploration. Future research should focus on detailed evaluations of dashboard impacts on patient outcomes and cost-effectiveness, emphasizing precision prevention of chronic diseases.

Multi-species synbiotic supplementation increased fecal short chain fatty acids and anti-inflammatory cytokine interleukin-10 in adult men with dyslipidemia; A randomized, double-blind, clinical trial

BACKGROUND

Mounting evidence revealed that an imbalance of Gut Microbiota (GM) leads to metabolic disorders. Synbiotics through regulation of GM composition can be an effective intervention in the management of metabolic diseases. This study aimed to investigate the effects of multi-species synbiotic supplementation on serum interleukin10 (IL-10) and fecal Short Chain Fatty Acids (SCFAs) in patients with dyslipidemia.

METHODS

In this double-blind, randomized, placebo-controlled clinical trial, fifty-six adult men with dyslipidemia were randomly allocated to intervention and control groups and received either synbiotic or placebo powder twice a day for 12 weeks. Each synbiotic sachet contained 6 species of probiotic microorganisms with a total dose of 3 × 1010 Colony Forming Unit (CFU) and 5 gr inulin and Fructooligosaccharide (FOS) as prebiotics. Blood and stool samples were collected at the baseline and end of the study. Dietary intake, physical activity, anthropometric measurements, serum IL-10, and fecal SCFAs were assessed before and after the intervention.

RESULT

There were no significant differences between the baseline characteristics of patients in the two groups. Serum IL-10 was increased in the synbiotic group (p < 0.0001). Moreover, synbiotic supplementation increased fecal concentration of acetate (p < 0.0001), butyrate (p = 0.043), propionate (p < 0.0001), and valerate (p < 0.026). A significant positive correlation was observed between the changes in fecal butyrate level and serum IL-10 concentration in the control group (r = 0.48, p = 0.01).

CONCLUSIONS

A Twelve-week synbiotic supplementation increased fecal SCFAs and improved inflammation in adult men with dyslipidemia.

Associations of urinary zinc exposure with blood lipid profiles and dyslipidemia: Mediating effect of serum uric acid

The relationship between zinc (Zn) exposure and abnormal blood lipids including dyslipidemia is contentious. Serum uric acid (SUA) has been reported to be correlated to both Zn exposure and dyslipidemia. The underlying mechanisms of Zn exposure associated with blood lipids and the mediating effects of SUA remain unclear. Therefore, this study analyzed the data from Chinese 2110 adults (mean age: 59.0 years old) in rural areas across China to explore the associations of Zn exposure with blood lipid profiles and dyslipidemia, and to further estimate the mediating effects of SUA in these relationships. The study data showed that urinary Zn was associated with increased levels of blood lipid components triglyceride (TG) and low-density lipoprotein cholesterol (LDL-C). Moreover, an increased risk of dyslipidemia was observed in the study participants who had higher urinary Zn levels. Compared with the first quartile, the fourth quartile of urinary Zn concentration corresponded to the increase of TG (β = 0.20, 95 % CI: 0.12, 0.28), LDL-C (β = 0.06, 95 % CI: 0.01, 0.10) and dyslipidemia risk (OR = 2.16, 95 % CI: 1.50, 3.10), respectively. Elevated urinary Zn was also associated with higher levels of SUA and hyperuricemia risk. The SUA levels were positively related to total cholesterol (TC), TG, LDL-C levels and dyslipidemia risk. Mediation analyses revealed that SUA mediated 31.75 %, 46.16 % and 19.25 % of the associations of urinary Zn with TG, LDL-C levels and dyslipidemia risk, respectively. The subgroup and sensitivity analyses confirmed the positive associations between urinary Zn and blood lipid profiles and the mediating effect of SUA. The national population-based study further enhanced our understanding of the associations between Zn exposure and blood lipid profiles and mediating effect of SUA among generally healthy, middle-aged, and elderly individuals.

Longitudinal Lipidomic Signature of Coronary Heart Disease in American Indian People

BACKGROUND

Dyslipidemia is an independent risk factor for coronary heart disease (CHD). Standard lipid panel cannot capture the complexity of the blood lipidome (ie, all molecular lipids in the blood). To date, very few large-scale epidemiological studies have assessed the full spectrum of the blood lipidome on risk of CHD, especially in a longitudinal setting.

METHODS AND RESULTS

Using an untargeted liquid chromatography-mass spectrometry, we repeatedly measured 1542 lipid species from 1835 unique American Indian participants who attended 2 clinical visits (≈5.5 years apart) and followed up to 17.8 years in the Strong Heart Family Study (SHFS). We first identified baseline lipid species associated with risk of CHD, followed by replication in a European population. The model adjusted for age, sex, body mass index, smoking, hypertension, diabetes, low-density lipoprotein cholesterol, estimated glomerular filtration rate, education, and physical activity at baseline. We then examined the longitudinal association between changes in lipid species and changes in cardiovascular risk factors during follow-up. Multiple testing was controlled by the false discovery rate. We found that baseline levels of multiple lipid species (eg, phosphatidylcholines, phosphatidylethanolamines, and ceramides) were associated with the risk of CHD and improved the prediction accuracy over conventional risk factors in American Indian people. Some identified lipids in American Indian people were replicated in European people. Longitudinal changes in multiple lipid species (eg, acylcarnitines, phosphatidylcholines, and triacylglycerols) were associated with changes in cardiovascular risk factors.

CONCLUSIONS

Baseline plasma lipids and their longitudinal changes over time are associated with risk of CHD. These findings provide novel insights into the role of dyslipidemia in CHD.

Exploration of Inflammatory Biomarkers and Psychological Cardiovascular Disease Risk Factors Among Community Dwelling Adults: A Gender Comparison Study

Patients with rheumatic disease (RD) are at high risk for cardiovascular disease (CVD), which is the leading non-communicable chronic disease cause of death worldwide. Inflammatory biomarkers and psychological health status are reliable predictors of CVD in patients with RD. The primary aim of this study was to compare the inflammatory biomarkers and psychological CVD risk factors (CRFs) between a group of community-dwelling adults with RD and CRFs and a group of their peers with CRFs only. The secondary aim of this study was to analyze and compare the collected data by gender in the RD group. Data were collected and analyzed from 355 participants, with the 135 participants with physician-diagnosed RD assigned to the RD group and the remainder (n = 220) assigned to the comparison group. The measures used included a demographic datasheet, medical information, serum homocysteine (Hcy) levels, high sensitive C-reactive protein (hs-CRP) levels, and depression and global sleep-quality scale scores. The RD group had higher ratios of hypertension and depression diagnoses than the comparison group. The gender analysis of the RD group found significantly more-severe sleep disturbances in women than men and a significantly higher mean value of Hcy in men than women. The women in the RD group were significantly older, less educated, and less employed than their male counterparts and thus may be presumed to at higher risk of health illiteracy. Gender-tailored interventions to modify the risk factors of CVD identified in this study for patients with RD are recommended.

Associations of metals and metals mixture with lipid profiles: A repeated-measures study of older adults in Beijing

Metals inevitably and easily enter into human bodies and can induce a series of pathophysiological changes, such as oxidative stress damage and lipid peroxidation, which then may further induce dyslipidemia. However, the effects of metals and metals mixture on the lipid profiles are still unclear, especially in older adults. A three-visits repeated measurement of 201 older adults in Beijing was conducted from November 2016 to January 2018. Linear Mixed Effects models and Bayesian kernel machine regression models were used to estimate associations of eight blood metals and metals mixture with lipid profiles, including total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), Castelli risk indexes I (CRI-1), Castelli risk indexes II (CRI-2), atherogenic coefficient (AC), and non-HDL cholesterol (NHC). Cesium (Cs) was positively associated with TG (β_Cs = 0.14; 95% CI: 0.02, 0.26) whereas copper (Cu) was inversely related to TG (β_Cu = -0.65; 95%CI: -1.14, -0.17) in adjusted models. Manganese (Mn) was mainly related to higher HDL-C (β_Mn = 0.14; 95% CI: 0.07, 0.21) whereas molybdenum showed opposite association. Metals mixture was marginally positive associated with HDL-C, among which Mn played a crucial role. Our findings suggest that the effects of single metal on lipid profiles may be counteracted in mixtures in the context of multiple metal exposures; however, future studies with large sample size are still needed to focus on the detrimental effects of single metals on lipid profiles as well as to identify key components.

Guidelines for dyslipidemia management in India: A review of the current scenario and gaps in research

Cardiovascular Diseases (CVD) have a high disease burden in India. Dyslipidemia, a major CVD risk factor, requires effective management. Our review describes the appropriateness of the international dyslipidemia guidelines in the Indian context. A systematic search was performed in PubMed, Google Scholar, Cochrane Library and Science Direct to obtain relevant articles. Dyslipidemia management guidelines by western medical associations are based on their studies, with ethnic minorities underrepresented and biological features of other racial groups inadequately incorporated. The Lipid Association of India (LAI) came up with a consensus statement guided by an expert panel to adapt the western guidelines to Indians. However, absence of Indian guidelines has led to physicians basing treatment on individual preference, contributing to heterogeneity. Our review underscores the need for formulating Indian dyslipidemia management guidelines and CV risk estimation algorithms, highlighting the scope for further research. This could supplement the clinical expertise of LAI and enhance patient experience.

Preformulation Studies of Ezetimibe-Simvastatin Solid Dispersions in the Development of Fixed-Dose Combinations

Two active pharmaceutical ingredients (APIs) with limited solubility, simvastatin and ezetimibe, prepared as a drug-drug solid dispersion (SD) was evaluated for physicochemical, microstructural, and aqueous dissolution properties. The simvastatin-ezetimibe SD was prepared using the co-grinding method in a wide range of weight fractions and differential scanning calorimetry (DSC) and X-ray powder diffraction (XRPD) were used to perform the phase composition analysis. DSC studies confirmed that simvastatin and ezetimibe form a simple eutectic phase equilibrium diagram. Analysis of Fourier transform infrared spectroscopy (FTIR) studies excluded strong interactions between the APIs. Our investigations have revealed that all studied dispersions are characterized by substantially improved ezetimibe dissolution regardless of simvastatin content, and are best when the composition oscillates near the eutectic point. Data obtained in our studies provide an opportunity for the development of well-formulated, ezetimibe-simvastatin fixed-dose combinations (for hypercholesterolemia treatment) with reduced ezetimibe dosages based on its dissolution improvement.

The dose-response relationship of serum uric acid with Dyslipidaemia and its components: a cross-sectional study of a Chinese multi-ethnic cohort

BACKGROUND

The association between serum uric acid (SUA) and the components of dyslipidaemia and their dose-response relationships have not been thoroughly explored. This study assessed the relationship between SUA and each dyslipidaemia component in Dong, Miao, and Bouyei populations in Guizhou by sex and ethnicities and investigated the dose-response relationship.

METHODS

In total, 16,092 participants aged 30-79 years from The China Multi-Ethnic Cohort (CMEC) Study were examined. Multivariable logistic regression models were applied to explore the relationship between SUA and each dyslipidaemia component by sex and three ethnicities. The dose-response associations between SUA and various dyslipidaemias were investigated using restricted cubic spline regression.

RESULTS

After controlling for confounding factors, the SUA level in total participants positively correlated with each dyslipidaemia component, and women had higher odds ratios (ORs) for each dyslipidaemia component than men (P for trend < 0.001). At the SUA level > 6.37 mg/dL, ORs (95% CI) for dyslipidaemia in the Dong, Miao and Bouyei were 2.89 (2.00-4.19), 2.43 (1.70-3.48), and 3.26 (2.23-4.78), respectively. When the SUA concentration increased by 1 mg/dL, the ORs (95% CI) for total dyslipidaemia was 1.31 (1.24-1.37). A positive dose-response but nonlinear association was found between SUA and total dyslipidaemia, high total cholesterol, and low HDL, whereas an inverse U-shaped association was found between SUA and high LDL-C ( P-nonlinear< 0.0001).

CONCLUSION

The SUA level was positively correlated with each dyslipidaemia component in Dong, Miao, and Bouyei adults, and sex and ethnic differences were also found. A nonlinear dose-response relationship was found between SUA levels and dyslipidaemia and its components. Further research is warranted to investigate the causal link between SUA levels and dyslipidaemia incidence.

Prevalence of and Factors Associated With the Prescription of Fibrates Among Patients Receiving Lipid-Lowering Drugs in Germany

ABSTRACT

Little recent data are available about the patterns of prescription for fibrates in patients followed in primary care practices. Therefore, the goal of this study was to analyze the prevalence of and the factors associated with the use of fibrates among patients receiving lipid-lowering drugs in Germany. The study included patients aged ≥18 years with at least 1 visit to 1 of 1070 general practices in Germany between January and December 2019. Lipid-lowering drugs included statins (without and with ezetimibe) and fibrates. The prevalence of the prescription of fibrates corresponded to the number of patients with at least 1 prescription for fibrates divided by the total number of patients receiving lipid-lowering drugs. A logistic regression model was used to assess the relationship between several demographic, clinical, and biological factors and the prescription of fibrates. A total of 111,329 patients were included in this study (mean [SD] age 68.8 [11.5] years; 56.0% of patients were men). The prevalence of the prescription of fibrates was 1.5%. Male sex, hypertension, diabetes mellitus, high low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol, and high triglyceride were positively associated with the use of fibrates. By contrast, there was a negative relationship between the odds of receiving fibrates and coronary heart disease, myocardial infarction, peripheral arterial disease, and stroke including transient ischemic attack. Overall, we found that fibrates were infrequently prescribed in general practices in Germany.

Maternal dyslipidemia and altered cholesterol metabolism in early pregnancy as a risk factor for small for gestational age neonates

We evaluated the relationship between maternal cholesterol levels and its biologically active precursors and metabolites in the first trimester and subsequent risk for small-for-gestational-age birthweight (SGA). This is a secondary analysis of a prospective cohort study which enrolled healthy singleton pregnancies (n = 1337). Maternal fasting blood was taken in the first trimester and followed up till delivery. The lipid parameters were compared between women who delivered SGA neonates (SGA-group, birthweight < 10th percentile, n = 107) and women who did not (non-SGA-group, n = 1230). In addition, metabolic signatures of cholesterol were evaluated in a subset consisting of propensity-score matched SGA (n = 56) and control group (n = 56). Among lipid parameters, maternal high-density lipoprotein cholesterol (HDL-C) levels were significantly lower in SGA-group than in non-SGA-group (p = 0.022). The risk for SGA was negatively correlated with maternal serum HDL-C quartiles (p = 0.003), and this association remained significant after adjustment for confounding variables. In metabolic signatures of cholesterol, the cholesterol/lathosterol ratio in SGA-group was significantly higher than non-SGA-group [(2.7 (1.6-3.7) vs. 2.1 (1.5-2.9), respectively; p = 0.034)], suggesting increased endogenous cholesterol biosynthesis. We demonstrated that dyslipidemia and increased cholesterol biosynthesis led to delivery of SGA neonates even in early pregnancy.

Regional and income disparities in treatment and drug adherence of patients with dyslipidemia: a retrospective cohort study in South Korea, 2003-2015

Backgrounds

Health disparities represent a major public health problem that needs to be addressed, and a variety of factors, including geographical location and income, can contribute to these disparities. Although previous studies have suggested that health differs by region and income, evidence on the difference in treatment rate is relatively insufficient. To identify differences in prescription rates by region and income in patients with dyslipidemia.

Methods

Using data from the National Health Insurance Service senior cohort, we included older adults who were diagnosed with dyslipidemia in Korea from 2003 to 2015. Overall prescription rate was determined for patients with dyslipidemia. In addition, medication possession ratio and a defined daily dose were analyzed in patients who were prescribed statins. A generalized estimating equation Poisson model was used to assess differences in prescription rates.

Results

Patients living in rural areas (Chungcheong-do, Jeolla-do, and Gyeongsang-do) had a significantly higher prescription rate than those in metropolitan cities. Unlike the prescription rate, the drug adherence was significantly higher in Seoul, Gyeonggi-do, and Gangwon-do but lower in Jeolla-do and Gyeongsang-do than in metropolitan cities. Patients with low income had lower prescription rates than those with high income, but this difference was not statistically significant.

Conclusion

Our findings demonstrate differences in the treatment rates of patients with dyslipidemia by region and income. Appropriate interventions are needed in vulnerable regions and groups to increase the treatment rate for patients with dyslipidemia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02510-5.

Recommendations and Associated Levels of Evidence for Statin Use in Primary Prevention of Cardiovascular Disease: A Comparison at Population Level of the American Heart Association/American College of Cardiology/Multisociety, US Preventive Services Task Force, Department of Veterans Affairs/Department of Defense, Canadian Cardiovascular Society, and European Society of Cardiology/European Atherosclerosis Society Clinical Practice Guidelines

BACKGROUND

Despite using identical evidence to support practice guidelines for lipid-lowering treatment in primary prevention of cardiovascular disease (CVD), it is unclear to what extent the 2018 American Heart Association/American College of Cardiology/Multisociety, 2016 US Preventive Services Task Force (USPSTF), 2020 Department of Veterans Affairs/Department of Defense, 2021 Canadian Cardiovascular Society, and 2019 European Society of Cardiology/European Atherosclerosis Society guidelines differ in grading and assigning levels of evidence and classes of recommendations (LOE/class) at a population level.

METHODS

We included 7262 participants, aged 45 to 75 years, without history of CVD from the prospective population-based Rotterdam Study. Per guideline, proportions of the population recommended statin therapy by LOE/class, sensitivity and specificity for CVD events, and numbers needed to treat at 10 years were calculated.

RESULTS

Mean age was 61.1 (SD 6.9) years; 58.2% were women. American Heart Association/American College of Cardiology/Multisociety, USPSTF, Department of Veterans Affairs/Department of Defense, Canadian Cardiovascular Society, and European Society of Cardiology/European Atherosclerosis Society strongly recommended statin initiation in respective 59.4%, 40.2%, 45.2%, 73.7%, and 42.1% of the eligible population based on high-quality evidence. Sensitivity for CVD events for treatment recommendations supported with strong LOE/class was 86.3% for American Heart Association/American College of Cardiology/Multisociety (IA or IB), 69.4% for USPSTF (USPSTF-B), 74.5% for Department of Veterans Affairs/Department of Defense (strong for), 93.3% for Canadian Cardiovascular Society (strong), and 66.6% for European Society of Cardiology/European Atherosclerosis Society (IA). Specificity was highest for the USPSTF at 45.3% and lowest for European Society of Cardiology/European Atherosclerosis Society at 10.0%. Estimated numbers needed to treat at 10 years for those with the strongest LOE/class were ranging from 20 to 26 for moderate-intensity and 12 to 16 for high-intensity statins.

CONCLUSIONS

Sensitivity, specificity, and numbers needed to treat at 10 years for assigned LOE/class varied greatly among 5 CVD prevention guidelines. The level of variability seems to be driven by differences in how the evidence is graded and translated into LOE/class underlying the treatment recommendations by different professional societies. Efforts towards harmonizing evidence grading systems for clinical guidelines in primary prevention of CVD may reduce ambiguity and reinforce updated evidence-based recommendations.

Admission LDL-C and long-term mortality in patients with acute aortic dissection: a survival analysis in China

BACKGROUND

The level of blood lipid is closely related to prognosis in cardiovascular diseases. This study aims to analyze the effect of serum low-density lipoprotein cholesterol (LDL-C) levels on the long-term mortality in acute aortic dissection (AAD). A lower admission LDL-C level is associated with an increased risk of long-term mortality in AAD.

METHODS

We analyzed the data of 284 patients with AAD admitted to the First Affiliated Hospital of Shantou University Medical College from February 2016 to September 2019. Patients were followed up post-discharge. All patients were divided into either an LDL-C low-level group or an LDL-C high-level group according to the optimal cut-off point obtained by the receiver operating characteristic (ROC) curve. The endpoint outcome was long-term mortality in AAD. A survival analysis and Cox proportional hazards model were used.

RESULTS

According to the Youden index, the optimal cut-off point for LDL-C was 2.755 mmol/L. The Kaplan-Meier survival analysis curves showed that the long-term mortality of the LDL-C low-level group (<2.755 mmol/L) was significantly higher than that of the LDL-C high-level group (≥2.755 mmol/L) (log-rank χ²=13.912, P<0.001). After multivariate Cox regression analysis, LDL-C <2.755 mmol/L was still significantly associated with long-term mortality in AAD (HR=3.287, 95% CI: 1.637-6.600, P=0.001). In addition, cystatin C was also an independent risk factor for the long-term prognosis of AAD (HR=1.253, 95% CI: 1.057-1.486, P=0.009).

CONCLUSIONS

A lower admission LDL-C level may be associated with an increased risk of long-term mortality in AAD.

Association between early treatment hospitals, serum cholesterol level and cardiovascular disease risk in dyslipidemia patients

BACKGROUND

Studies have shown the importance of managing chronic diseases, such as cardiovascular disease (CVD), at the primary treatment level. Here, we aimed to evaluate the association between medical treatment institutions and health outcomes in patients with dyslipidemia, a major risk of CVD, to provide evidence for increasing chronic disease management at the primary care level in Korea.

METHODS

We used National Health Insurance Sampling cohort data, of which 37 506 patients were newly diagnosed with dyslipidemia during 2009-14. CVD risk and changes in serum cholesterol level after dyslipidemia diagnosis were outcome variable examined. A generalized estimating equation model was used to identify associations between initial medical institution, CVD risk and changes in serum cholesterol levels. The Cox proportional-hazard ratio was used to assess the association between initial medical institutions and detailed CVD risk. Subgroup analyses were conducted to assess CVD risk following treatment with prescription medication.

RESULTS

Our analyses demonstrate that CVD risk was lower at primary care-level community health centers and clinics compared to tertiary hospitals, with a statistically significant difference observed in clinics. Ischemic heart disease was lower at community health centers and clinics. However, all medical institution types were associated with significantly lower serum cholesterol levels compared to the baseline.

CONCLUSIONS

Management of patients with dyslipidemia at primary care institutions was associated with reduced CVD risk and decreased serum cholesterol levels. Therefore, policymakers should strengthen the quality of healthcare at primary care institutions and educate patients that these institutions are appropriate for managing chronic disease.

Gemfibrozil-Induced Polyuria

Gemfibrozil is a lipid-regulating agent used mainly to treat patients with hypertriglyceridaemia, especially those at risk for acute pancreatitis. Like any other pharmacological agent, gemfibrozil has known adverse effects, mainly gastrointestinal, such as cholelithiasis, gallstones, elevated transaminase, and other non-specific symptoms including dyspepsia, nausea and vomiting. Other reported adverse reactions are dizziness and vertigo, myopathy and rhabdomyolysis, angioedema, urticaria and rash. As far as we knew, gemfibrozil does not have urinary tract adverse reactions. In this report, we present a case of polyuria secondary to gemfibrozil with a score of 9 on the Naranjo scale, and a literature review.

LEARNING POINTS

Gemfibrozil has known, mainly gastrointestinal, adverse effects.We aim to increase awareness of the urinary side effects of gemfibrozil so unnecessary investigations can be avoided.

Schinus terebinthifolius fruits intake ameliorates metabolic disorders, inflammation, oxidative stress, and related vascular dysfunction, in atherogenic diet-induced obese rats. Insight of their chemical characterization using HPLC-ESI-QTOF-MS/MS

ETHNOPHARMACOLOGY RELEVANCE

Schinus terebinthifolius is traditionally used for its anti inflammatory capacity, and indicated as a cardioprotective agent, whereas, its preventive effect against atherogenic diet fed (AD) induced metabolic disorders and the underlying mechanisms has not yet been explored.

AIM OF THE STUDY

This study was undertaken to investigate the ameliorative role of Schinus terebinthifolius fruits extract (STFE) against cardiovascular problem, oxidative and inflammatory status related to obesity in rats fed an atherogenic diet.

MATERIALS AND METHODS

The metabolites profile in STFE was evaluated using HPLC-DAD-ESI-QTOF-MS/MS analysis. In Wistar rats, atherogenic diet was added for 9 weeks to induce lipid accumulation simultaneously with STFE (50 mg/kg b. w) or saline treatment. Biochemical, oxidant, and inflammatory criteria together with hepatic and arterial integrity examination were assessed.

RESULTS

A total of thirty three metabolites were identified using HPLC-DAD-ESI-QTOF-MS, among them masazino-flavanone was the major compound (2645.50 μg/g DW). The results indicated that STFE supplementation during 9 weeks (50 mg/kg b. w.) significantly attenuated the altered lipid profile by decreasing the levels of TC, TG, LDL-C and increasing the HDL-C content both in plasma and liver, when compared with the AD-group. The histological analysis using ORO staining revealed a decrease in the lipid droplet deposit in the cytoplasm of hepatocytes of STFE + AD group. The addition of STFE could improve the glycemic status of AD-treated rats by decreasing the glucose and insulin secretion, and ameliorating the hepatic glycogen synthesis. The harmful effects of atherogenic diet on hepatic oxidative stress indicators (MDA, PC, GSH, SOD, CAT, and GPx), biochemical markers (AST, ALT, LDH and ALP), and liver function, were found to be decreased by the addition of STFE. Moreover, the reduction of inflammatory markers (CRP, IL-6 and TNF-α), associated to alleviating of aortic oxidative stress and integrity, highlighted the positive anti-atherogenic effect of STFE.

CONCLUSION

Overall, the pleiotropic protective effect observed with S. terebinthifolius fruits might be related to the presence of various bioactive compounds.

Influence of Omega-3 Fatty Acid-Rich Fish Oils on Hyperlipidemia: Effect of Eel, Sardine, Trout, and Cod Oils on Hyperlipidemic Mice

Dyslipidemia is one of the most important cardiovascular disease (CVD) risk factors. Polyunsaturated fatty acids (FAs), and especially omega-3 FAs, could significantly contribute to the management of dyslipidemia and the prevention of CVD. The anti-hyperlipidemic effect of selected fish oils (eel, sardine, trout, cod liver) was comparatively evaluated in a high fat diet (HFD)-fed mouse model. At the end of 30 days on the HFD, all animals were hyperlipidemic and were switched to a diet consisting of 90% standard rodent chow plus 10% of oil from eel, sardine, cod liver, or trout. At the end of 60 days on these diets, blood glucose, total blood cholesterol, triglycerides (TGs), and high density lipoprotein (HDL) were quantitated. All diets, except sardine and standard rodent chow, showed statistically significant decreases in blood glucose from day 30 to 90. Total blood cholesterol decreased in all diets except the HFD group, which was continued on this diet until the end of the study. Eel and cod liver oil diets showed significant decreases in TGs. All dietary groups showed a decrease in HDL, but only the trout and standard chow groups exhibited statistically significant decreases. The fish oils tested here for effects on hyperlipidemia vary in per cent of omega-3 FAs and omega-6/-3 FA ratios as determined by gas chromatography Overall, smoked eel was the best source of omega-3 FA, with a balance of omega-6 FA, that ameliorated HFD-induced mixed hyperlipidemia.

Develop and Evaluate a New and Effective Approach for Predicting Dyslipidemia in Steel Workers

The convolutional neural network (CNN) has made certain progress in image processing, language processing, medical information processing and other aspects, and there are few relevant researches on its application in disease risk prediction. Dyslipidemia is a major and modifiable risk factor for cardiovascular disease, early detection of dyslipidemia and early intervention can effectively reduce the occurrence of cardiovascular diseases. Risk prediction model can effectively identify high-risk groups and is widely used in public health and clinical medicine. Steel workers are a special occupational group. Their particular occupational hazards, such as high temperatures, noise and shift work, make them more susceptible to disease than the general population, which makes the risk prediction model for the general population no longer applicable to steel workers. Therefore, it is necessary to establish a new model dedicated to the prediction of dyslipidemia of steel workers. In this study, the physical examination information of thousands of steel workers was collected, and the risk factors of dyslipidemia in steel workers were screened out. Then, based on the data characteristics, the corresponding parameters were set for the convolutional neural network model, and the risk of dyslipidemia in steel workers was predicted by using convolutional neural network. Finally, the predictive performance of the convolutional neural network model is compared with the existing predictive models of dyslipidemia, logistics regression model and BP neural network model. The results show that the convolutional neural network has a good predictive performance in the risk prediction of dyslipidemia of steel workers, and is superior to the Logistic regression model and BP neural network model.

The efficacy and safety of statin in combination with ezetimibe compared with double-dose statin in patients with high cardiovascular risk: A meta-analysis

Currently, statins are the first-line therapies for dyslipidemia and atherosclerotic cardiovascular disease, however, their hypolipidemic effects have not been satisfactory. We performed a meta-analysis to compare lipid-lowering efficacy and safety of ezetimibe and statin combination therapy with double-dose statin monotherapy in patients with high cardiovascular risk. Fourteen studies involving 3105 participants were included in the final analysis; 1558 (50.18%) participants received ezetimibe and statin combination therapy and 1547 (49.82%) received double-dose statin monotherapy. Eight studies reported the percentages of changes in several lipid parameters from baseline to endpoint in both groups. Lipid parameters changed more significantly in patients coadministered with ezetimibe and statin (low-density lipoprotein cholesterol [LDL-C]: MD = -9.39, 95% CI -13.36 to -5.42; non-high-density lipoprotein cholesterol [non-HDL-C]: MD = -10.36, 95% CI -14.23 to -6.50; total cholesterol [TC]: MD = -8.11, 95% CI -10.95 to -5.26; and triglyceride [TG]: MD = -5.96, 95% CI -9.12 to -2.80), with moderate to high heterogeneity among the studies. Two out of fourteen studies investigated several different statins. Our subgroup analysis showed that, compared with double-dose atorvastatin monotherapy, ezetimibe and atorvastatin combination therapy significantly decreased LDL-C, non-HDL-C, TC, and TG levels by 14.16%, 14.01%, 11.06%, and 5.96%, respectively (p < 0.001). No significant difference was found in the incidence of laboratory-related adverse events (AEs) between statin combination therapy and monotherapy. Overall, ezetimibe and statin combination therapy significantly decreased LDL-C, non-HDL-C, and TC levels in patients with high cardiovascular risk, among which ezetimibe combined with atorvastatin had the best therapeutic effect. Compared with ezetimibe and statin combination therapy, double-dose statin monotherapy did not increase the risk of AEs.

Zygophyllum album saponins prevent atherogenic effect induced by deltamethrin via attenuating arterial accumulation of native and oxidized LDL in rats

The current study aimed to examine, for the first time, the relationship between exposure to deltamethrin (DLM) and atherogenic lipid profile disorders in adult Wistar rats, as well as, to verify the mechanism of the beneficial role of Zygophyllum album leaves extracts (ZALE). The experimental study was assessed using DLM (4 mg/kg b.w) either alone or co administered with ZALE (400 mg/kg b.w) orally for 90 days in rats. RP-HPLC-DAD-ESI-QTOF-MS was used to identify the bioactive metabolites present in ZALE. Plasmatic and aortic total cholesterol (TC), LDL-cholesterol (LDL-C), native LDL (LDL-apo B-100) and oxidized LDL (ox-LDL) were evaluated using auto-analyzer and a sandwich ELISA, respectively. The protein expressions of LDLR (native LDL receptor) and CD36 (Scavenger receptor class B) were evaluated in aorta or liver with a Western blot. The pathology has been confirmed with lipid stain (Oil Red O). Phytochemicals analysis revealed the presence of fifteen saponins in ZALE. Rats intoxicated with DLM revealed a significant increase in plasmatic and aortic lipid profile (TC, LDL-C, LDL-apo B-100 and ox-LDL), as well as, the concentration of the plasmatic cytokines include TNF-α, IL-2 and IL-6, compared to control. Hepatic native LDL and aortic CD36 receptor expression were increased in DLM treated group, however aortic LDL-R does not present any modification, when compared to control. The detected disturbances in lipid parameters were supported by Oil Red O applied. Due to their antioxidant activity, the bioactive compounds in ZALE as powerful agents able to prevent the pro-atherogenic effect observed in DLM-treated animals. These metabolites modulated most of inflammatory markers, prevented accumulation of lipid and lipoprotein biomarkers, regulated the major receptor regulators of hepatic cholesterol metabolism, as well as normalize lipid distribution in liver and aorta tissue.

Bifenthrin exerts proatherogenic effects via arterial accumulation of native and oxidized LDL in rats: the beneficial role of vitamin E and selenium

The purpose of this study was to investigate, for the first time, the effects of Bifenthrin (Bif) chronic exposure on plasmatic and aortic lipid parameters disturbance and their pro-atherogenic possibility in Wistar rats. The ameliorative role of vitamin E (Vit E) and selenium (Se) were also targeted. Thus, rats were treated by gastric gavage with combination of Vit E (100 mg/kg/bw) and Se (0.25 mg/kg/bw) in alone and co-treated groups for 90 days. Apart from control and Vit E-Se groups, all the groups were subjected to Bif (3 mg/kg, via gavage) toxicity. Results showed that Bif increased markedly plasmatic and aortic total cholesterol, LDL-cholesterol, native LDL-apoB-100, and oxidized-LDL, compared to the control. Moreover, Bif treatment significantly increased the plasmatic levels of the pro-inflammatory cytokines TNF-α, IL-2, and IL-6. In addition, the densitometric quantification of protein bands showed that the amount of hepatic native LDL-receptor protein decreased significantly in the intoxicated rats compared to the control group. The expression of arterial LDL receptors (LDLRs) and scavenger receptors (CD36) was amplified owing to Bif toxicity. This harmful effect was confirmed by histological study using Oil-Red-O staining. Owing to their antioxidant capacities, Vit E and Se have maintained all the changes in plasma and aorta lipids and prevented the pro-atherogenic effect observed in Bif-treated animals.

Risk Prediction of Dyslipidemia for Chinese Han Adults Using Random Forest Survival Model

OBJECTIVE

Dyslipidemia has been recognized as a major risk factor of several diseases, and early prevention and management of dyslipidemia is effective in the primary prevention of cardiovascular events. The present study aims to develop risk models for predicting dyslipidemia using Random Survival Forest (RSF), which take the complex relationship between the variables into account.

METHODS

We used data from 6328 participants aged between 19 and 90 years free of dyslipidemia at baseline with a maximum follow-up of 5 years. RSF was applied to develop gender-specific risk model for predicting dyslipidemia using variables from anthropometric and laboratory test in the cohort. Cox regression was also adopted in comparison with the RSF model, and Harrell's concordance statistic with 10-fold cross-validation was used to validate the models.

RESULTS

The incidence density of dyslipidemia was 101/1000 in total and subgroup incidence densities were 121/1000 for men and 69/1000 for women. Twenty-four predictors were identified in the prediction model of males and 23 in females. The C-statistics of the prediction models for males and females were 0.731 and 0.801, respectively. The RSF model shows better discriminative performance than CPH model (0.719 for males and 0.787 for females). Moreover, some predictors were observed to have a nonlinear effect on dyslipidemia.

CONCLUSION

The RSF model is a promising method in identifying high-risk individuals for the prevention of dyslipidemia and related diseases.

Efficacy of l-carnitine supplementation for management of blood lipids: A systematic review and dose-response meta-analysis of randomized controlled trials

BACKGROUND AND AIM

l-carnitine has an important role in fatty acid metabolism and could therefore act as an adjuvant agent in the improvement of dyslipidemia. The purpose of present systematic review and meta-analysis was to critically assess the efficacy of l-carnitine supplementation on lipid profiles.

METHODS AND RESULTS

We performed a systematic search of all available randomized controlled trials (RCTs) in the following databases: Scopus, PubMed, ISI Web of Science, The Cochrane Library. Mean difference (MD) of any effect was calculated using a random-effects model. In total, there were 55 eligible RCTs included with 58 arms, and meta-analysis revealed that l-carnitine supplementation significantly reduced total cholesterol (TC) (56 arms-MD: -8.53 mg/dl, 95% CI: -13.46, -3.6, I²: 93%), low-density lipoprotein-cholesterol (LDL-C) (47 arms-MD: -5.48 mg/dl, 95% CI: -8.49, -2.47, I²: 94.5) and triglyceride (TG) (56 arms-MD: -9.44 mg/dl, 95% CI: -16.02, -2.87, I²: 91.8). It also increased high density lipoprotein-cholesterol (HDL-C) (51 arms-MD:1.64 mg/dl, 95% CI:0.54, 2.75, I²: 92.2). l-carnitine supplementation reduced TC in non-linear fashion based on dosage (r = 21.11). Meta-regression analysis indicated a linear relationship between dose of l-carnitine and absolute change in TC (p = 0.029) and LDL-C (p = 0.013). Subgroup analyses showed that l-carnitine supplementation did not change TC, LDL-C and TG in patients under hemodialysis treatment. Intravenous l-carnitine and lower doses (>2 g/day) had no effect on TC, LDL-C and triglycerides.

CONCLUSION

l-carnitine supplementation at doses above 2 g/d has favorable effects on patients' lipid profiles, but is modulated on participant health and route of administration.

Trans-fatty acids aggravate anabolic steroid-induced metabolic disturbances and differential gene expression in muscle, pancreas and adipose tissue

AIMS

Although anabolic steroids (AS) and trans-fatty acids overload exerts systemic toxicity and are independent risk factors for metabolic and cardiovascular disorders, their interaction remains poorly understood. Thus, we investigated the impact of a diet rich in trans-fatty acids (HFD) combined with AS on glycemic control, lipid profile, adipose tissue, skeletal muscle and pancreas microstructure and expression of genes involved in energy metabolism.

MAIN METHODS

Forty-eight C57BL/6 mice were randomized into 6 groups treated for 12 weeks with a standard diet (SD) or a diet rich in C18:1 trans-fatty isomers (HFD), alone or combined with 10 or 20 mg/kg testosterone cypionate (AS).

KEY FINDINGS

Our results indicated that AS improved glycemic control, upregulated gene expression of Glut-4 and CPT-1 in skeletal muscle, FAS, ACC and UCP-1 in adipose tissue. AS also reduced total and LDL cholesterol in mice fed a SD. When combined with the HFD, AS was unable to induce microstructural adaptations in adipose tissue, pancreatic islets and β-cells, but potentiated GCK and Glut-2 (pancreas) and Glut-4 and CPT-1 (skeletal muscle) upregulation. HFD plus AS also downregulated FAS and ACC gene expression in adipose tissue. Combined with HFD, AS increased triacylglycerol circulating levels, improved insulin sensitivity and glycemic control in mice.

SIGNIFICANCE

Our findings indicated that HFD and AS can interact to modulates glycemic control and lipid profile by a mechanism potentially related with a reprogramming of genes expression in organs such as the pancreas, adipose tissue and skeletal muscle.

Identification of Novel Phospholipid Transfer Protein Inhibitors by High-Throughput Screening

Atherogenesis has been recognized as a risk factor for lethal cardiovascular diseases. Plasma low-density lipoprotein levels are correlated to the occurrence of atherosclerosis, and their control is critical for both the prevention and treatment of these diseases. Phospholipid transfer protein (PLTP) is one of the key regulators of lipoprotein metabolism; PLTP-deficient mice exhibit decreased apolipoprotein B (apoB)-containing lipoprotein secretion and atherosclerosis, indicating the validity of PLTP as a promising therapeutic target. Here, we demonstrate a high-throughput screening (HTS) method to identify a novel chemotype of PLTP inhibitors. Instead of using recombinant proteins, we used human plasma as a source of enzymes in the first screening, so as to efficiently exclude promiscuous inhibitors. The selected compounds were further confirmed to target PLTP both biochemically and biophysically and were shown to inhibit apoB secretion from hepatic cells with no apparent toxicity. We believe that our approach is suitable for filtering out nonspecific inhibitors at an earlier stage of screening campaigns and that these compounds should have potential to be developed into drugs to treat dyslipidemia.

Magnesium deficiency prevents high-fat-diet-induced obesity in mice

AIMS/HYPOTHESIS

Hypomagnesaemia (blood Mg²⁺ <0.7 mmol/l) is a common phenomenon in individuals with type 2 diabetes. However, it remains unknown how a low blood Mg²⁺ concentration affects lipid and energy metabolism. Therefore, the importance of Mg²⁺ in obesity and type 2 diabetes has been largely neglected to date. This study aims to determine the effects of hypomagnesaemia on energy homeostasis and lipid metabolism.

METHODS

Mice (n = 12/group) were fed either a low-fat diet (LFD) or a high-fat diet (HFD) (10% or 60% of total energy) in combination with a normal- or low-Mg²⁺ content (0.21% or 0.03% wt/wt) for 17 weeks. Metabolic cages were used to investigate food intake, energy expenditure and respiration. Blood and tissues were taken to study metabolic parameters and mRNA expression profiles, respectively.

RESULTS

We show that low dietary Mg²⁺ intake ameliorates HFD-induced obesity in mice (47.00 ± 1.53 g vs 38.62 ± 1.51 g in mice given a normal Mg²⁺-HFD and low Mg²⁺-HFD, respectively, p < 0.05). Consequently, fasting serum glucose levels decreased and insulin sensitivity improved in low Mg²⁺-HFD-fed mice. Moreover, HFD-induced liver steatosis was absent in the low Mg²⁺ group. In hypomagnesaemic HFD-fed mice, mRNA expression of key lipolysis genes was increased in epididymal white adipose tissue (eWAT), corresponding to reduced lipid storage and high blood lipid levels. Low Mg²⁺-HFD-fed mice had increased brown adipose tissue (BAT) Ucp1 mRNA expression and a higher body temperature. No difference was observed in energy expenditure between the two HFD groups.

CONCLUSIONS/INTERPRETATION

Mg²⁺-deficiency abrogates HFD-induced obesity in mice through enhanced eWAT lipolysis and BAT activity.

Expert opinion on the applicability of dyslipidemia guidelines in Asia and the Middle East

Cardiovascular disease (CVD) is a growing burden across the world. In Asia and the Middle East, in particular, CVD is among the most prevalent and debilitating diseases. Dyslipidemia is an important factor in the development of atherosclerosis and associated cardiovascular events, and so effective management strategies are critical to reducing overall cardiovascular risk. Multiple dyslipidemia guidelines have been developed by international bodies such as the European Society of Cardiology/European Atherosclerosis Society and the American College of Cardiology/American Heart Association, which all have similarities in practice recommendations for the optimal management of dyslipidemia. However, they differ in certain aspects including pharmacological treatment, lifestyle modification and the target levels used for low-density lipoprotein cholesterol. The evidence behind these guidelines is generally based on data from Western populations, and their applicability to people in Asia and the Middle East is largely untested. As a result, practitioners within Asia and the Middle East continue to rely on international evidence despite population differences in lipid phenotypes and CVD risk factors. An expert panel was convened to review the international guidelines commonly used in Asia and the Middle East and determine their applicability to clinical practice in the region, with specific recommendations, or considerations, provided where current guideline recommendations differ from local practice. Herein, we describe the heterogeneous approaches and application of current guidelines used to manage dyslipidemia in Asia and the Middle East. We provide consensus management recommendations to cover different patient scenarios, including primary prevention, elderly, chronic kidney disease, type 2 diabetes, documented CVD, acute coronary syndromes and family history of ischemic heart disease. Moreover, we advocate for countries within the Asian and Middle East regions to continue to develop guidelines that are appropriate for the local population.

Designing for Clinical Change: Creating an Intervention to Implement New Statin Guidelines in a Primary Care Clinic

Background

Recent clinical practice guidelines from major national organizations, including a joint United States Department of Veterans Affairs (VA) and Department of Defense (DoD) committee, have substantially changed recommendations for the use of the cholesterol-lowering statin medications after years of relative stability. Because statin medications are among the most commonly prescribed treatments in the United States, any change in their use may have significant implications for patients and providers alike. Prior research has shown that effective implementation interventions should be both user centered and specifically chosen to address identified barriers.

Objective

The objectives of this study were to identify potential determinants of provider uptake of the new statin guidelines and to use that information to tailor a coordinated and streamlined local quality improvement intervention focused on prescribing appropriate statins.

Methods

We employed user-centered design principles to guide the development and testing of a multicomponent guideline implementation intervention to improve statin prescribing. This paper describes the intervention development process whereby semistructured qualitative interviews with providers were conducted to (1) illuminate the knowledge, attitudes, and behaviors of providers and (2) elicit feedback on intervention prototypes developed to align with and support the use of the VA/DoD guidelines. Our aim was to use this information to design a local quality improvement intervention focused on statin prescribing that was tailored to the needs of primary care providers at our facility. Cabana’s Clinical Practice Guidelines Framework for Improvement and Nielsen’s Usability Heuristics were used to guide the analysis of data obtained in the intervention development process.

Results

Semistructured qualitative interviews were conducted with 15 primary care Patient Aligned Care Team professionals (13 physicians and 2 clinical pharmacists) at a single VA medical center. Findings highlight that providers were generally comfortable with the paradigm shift to risk-based guidelines but less clear on the need for the VA/DoD guidelines in specific. Providers preferred a clinical decision support tool that helped them calculate patient risk and guide their care without limiting autonomy. They were less comfortable with risk communication and performance measurement systems that do not account for shared decision making. When possible, we incorporated their recommendations into the intervention.

Conclusions

By combining qualitative methods and user-centered design principles, we could inform the design of a multicomponent guideline implementation intervention to better address the needs and preferences of providers, including clear and direct language, logical decision prompts with an option to dismiss a clinical decision support tool, and logical ordering of feedback information. Additionally, this process allowed us to identify future design considerations for quality improvement interventions.

Adipokine expression and endothelial function in subclinical hypothyroidism rats

The purpose of our study was to observe adipokine expression and endothelial function in subclinical hypothyroidism (sHT) rats and to determine whether levothyroxine (LT₄) treatment affects these changes. Sixty-five male Wistar rats were randomly divided into five groups: the control group; sHT A, B and C groups and the sHT + T₄ group. The sHT rats were induced by methimazole (MMI) and the sHT + T₄ rats were administered LT₄ treatment after 8 weeks of MMI administration. Thyroid function and lipid levels were measured using radioimmunoassays and enzymatic colorimetric methods, respectively. Serum adiponectin (APN), chemerin, TNF-α, endothelin (ET-1) and nitric oxide (NO) levels were measured using ELISA kits and a nitric-reductive assay. The expression of APN, chemerin and TNF-α in visceral adipose tissue (VAT) was measured in experimental rats using RT-PCR and Western blotting. Hematoxylin-eosin (HE) staining was used to observe changes in adipose tissue. The sHT rats had significantly higher levels of thyroid-stimulating hormone (TSH), TNF-α, chemerin, ET-1, total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) and lower levels of APN and NO than those in control and sHT + T₄ rats. Based on Pearson correlation analysis, the levels of chemerin, TNF-α, ET-1, LDL-C, TC and triglyceride (TG) were positively correlated with TSH, but APN and NO levels were negatively correlated with TSH. These findings demonstrated that high TSH levels contribute to the changes of adipokines and endothelial dysfunction in sHT, but LT₄ treatment ameliorates those changes.

Effects of a Combined Nutraceutical on Lipid Pattern, Glucose Metabolism and Inflammatory Parameters in Moderately Hypercholesterolemic Subjects: A Double-blind, Cross-over, Randomized Clinical Trial

BACKGROUND

There is an increasing interest for combined nutraceuticals that can act on several points of lipid and glucose metabolism with preventive purposes. However, the simple assemblage of nutraceuticals with potentially additive mechanism of action need to be clinically tested.

METHODS

To assess the effects of a combination of nutraceuticals based on artichoke, red yeast rice, banaba, and coenzyme Q10, we performed a double bind, cross-over designed trial versus placebo in 30 adults with LDL cholesterol suboptimal in primary prevention of cardiovascular disease. After a period of 3 weeks of dietary habits correction, patients began a period of 6 weeks of treatment with nutraceutical or placebo, followed by 2 weeks of washout and finally 6 weeks in cross-over. Data related to lipid pattern, insulin resistance, renal function, liver and CPK have been obtained at each visit.

RESULTS

In particular, the after the nutraceutical treatment the enrolled patients experienced a significant improvement in total cholesterol (-13.6 %), LDL-C (-18.2 %), non-HDL-C (-15 %), glutamic oxaloacetic transaminase (-10 %), glutamate-pyruvate transaminase (-30.9 %), and hs-CRP (-18.2 %) versus placebo. No changes have been observed in the other investigated parameters in both groups.

CONCLUSIONS

The tested combination of nutraceuticals has shown clinical efficacy in the reduction of total cholesterol, non-HDL, LDL and triglycerides, while improving the level of liver transaminases and high sensitivity C-reactive protein. Further confirmation are needed to verify these observations on the middle and long term with a larger number of subjects.

Astaxanthin in cardiovascular health and disease: mechanisms of action, therapeutic merits, and knowledge gaps

Cardiovascular disease is the main contributor to morbidity and mortality worldwide.

Porphyromonas gingivalis Differentially Modulates Cell Death Profile in Ox-LDL and TNF-α Pre-Treated Endothelial Cells

Objective

Clinical studies demonstrated a potential link between atherosclerosis and periodontitis. Porphyromonas gingivalis (Pg), one of the main periodontal pathogen, has been associated to atheromatous plaque worsening. However, synergism between infection and other endothelial stressors such as oxidized-LDL or TNF-α especially on endothelial cell (EC) death has not been investigated. This study aims to assess the role of Pg on EC death in an inflammatory context and to determine potential molecular pathways involved.

Methods

Human umbilical vein ECs (HUVECs) were infected with Pg (MOI 100) or stimulated by its lipopolysaccharide (Pg-LPS) (1μg/ml) for 24 to 48 hours. Cell viability was measured with AlamarBlue test, type of cell death induced was assessed using Annexin V/propidium iodide staining. mRNA expression regarding caspase-1, -3, -9, Bcl-2, Bax-1 and Apaf-1 has been evaluated with RT-qPCR. Caspases enzymatic activity and concentration of APAF-1 protein were evaluated to confirm mRNA results.

Results

Pg infection and Pg-LPS stimulation induced EC death. A cumulative effect has been observed in Ox-LDL pre-treated ECs infected or stimulated. This effect was not observed in TNF-α pre-treated cells. Pg infection promotes EC necrosis, however, in infected Ox-LDL pre-treated ECs, apoptosis was promoted. This effect was not observed in TNF-α pre-treated cells highlighting specificity of molecular pathways activated. Regarding mRNA expression, Pg increased expression of pro-apoptotic genes including caspases-1,-3,-9, Bax-1 and decreased expression of anti-apoptotic Bcl-2. In Ox-LDL pre-treated ECs, Pg increased significantly the expression of Apaf-1. These results were confirmed at the protein level.

Conclusion

This study contributes to demonstrate that Pg and its Pg-LPS could exacerbate Ox-LDL and TNF-α induced endothelial injury through increase of EC death. Interestingly, molecular pathways are differentially modulated by the infection in function of the pre-stimulation.