1
|
Sniderman AD, Dufresne L, Pencina KM, Bilgic S, Thanassoulis G, Pencina MJ. Discordance among apoB, non-high-density lipoprotein cholesterol, and triglycerides: implications for cardiovascular prevention. Eur Heart J 2024:ehae258. [PMID: 38700053 DOI: 10.1093/eurheartj/ehae258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 02/23/2024] [Accepted: 04/09/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND AND AIMS Despite growing evidence that apolipoprotein B (apoB) is the most accurate marker of atherosclerotic cardiovascular disease (ASCVD) risk, its adoption in clinical practice has been low. This investigation sought to determine whether low-density lipoprotein cholesterol (LDL-C), non-high-density lipoprotein cholesterol (HDL-C), and triglycerides are sufficient for routine cardiovascular care. METHODS A sample of 293 876 UK Biobank adults (age: 40-73 years, 42% men), free of cardiovascular disease, with a median follow-up for new-onset ASCVD of 11 years was included. Distribution of apoB at pre-specified levels of LDL-C, non-HDL-C, and triglycerides was examined graphically, and 10-year ASCVD event rates were compared for high vs. low apoB. Residuals of apoB were constructed after regressing apoB on LDL-C, non-HDL-C, and log-transformed triglycerides and used as predictors in a proportional hazards regression model for new-onset ASCVD adjusted for standard risk factors, including HDL-C. RESULTS ApoB was highly correlated with LDL-C and non-HDL-C (Pearson's r = .96, P < .001 for both) but less so with log triglycerides (r = .42, P < .001). However, apoB ranges necessary to capture 95% of all observations at pre-specified levels of LDL-C, non-HDL-C, or triglycerides were wide, spanning 85.8-108.8 md/dL when LDL-C 130 mg/dL, 88.3-112.4 mg/dL when non-HDL-C 160 mg/dL, and 67.8-147.4 md/dL when triglycerides 115 mg/dL. At these levels (±10 mg/dL), 10-year ASCVD rates for apoB above mean + 1 SD vs. below mean - 1 SD were 7.3 vs. 4.0 for LDL-C, 6.4 vs. 4.6 for non-HDL-C, and 7.0 vs. 4.6 for triglycerides (all P < .001). With 19 982 new-onset ASCVD events on follow-up, in the adjusted model, residual apoB remained statistically significant after accounting for LDL-C and HDL-C (hazard ratio 1.06, 95% confidence interval 1.0-1.07), after accounting for non-HDL-C and HDL-C (hazard ratio 1.04, 95% confidence interval 1.03-1.06), and after accounting for triglycerides and HDL-C (hazard ratio 1.13, 95% confidence interval 1.12-1.15). None of the residuals of LDL-C, non-HDL-C, or of log triglycerides remained significant when apoB was included in the model. CONCLUSIONS High variability of apoB at individual levels of LDL-C, non-HDL-C, and triglycerides coupled with meaningful differences in 10-year ASCVD rates and significant residual information contained in apoB for prediction of new-onset ASCVD events demonstrate that LDL-C, non-HDL-C, and triglycerides are not adequate proxies for apoB in clinical care.
Collapse
Affiliation(s)
- Allan D Sniderman
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre-Royal Victoria Hospital, 1001 Boulevard Décarie, Montreal, Québec H4A 3J1, Canada
| | - Line Dufresne
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre-Royal Victoria Hospital, 1001 Boulevard Décarie, Montreal, Québec H4A 3J1, Canada
| | - Karol M Pencina
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre-Royal Victoria Hospital, 1001 Boulevard Décarie, Montreal, Québec H4A 3J1, Canada
- Section on Men's Health, Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Selin Bilgic
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre-Royal Victoria Hospital, 1001 Boulevard Décarie, Montreal, Québec H4A 3J1, Canada
| | - George Thanassoulis
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre-Royal Victoria Hospital, 1001 Boulevard Décarie, Montreal, Québec H4A 3J1, Canada
| | - Michael J Pencina
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre-Royal Victoria Hospital, 1001 Boulevard Décarie, Montreal, Québec H4A 3J1, Canada
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, DCRI, Durham, NC, USA
| |
Collapse
|
2
|
Bilgic S, Sniderman AD. Low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol and apolipoprotein B for cardiovascular care. Curr Opin Cardiol 2024; 39:49-53. [PMID: 37934698 DOI: 10.1097/hco.0000000000001100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
PURPOSE OF REVIEW Some experts and consensus groups continue to argue that apolipoprotein B (apoB) should not be introduced broadly into clinical care. But, too often, the present approach to clinical care is not succeeding. An important reason for this failure, we believe, is that the conventional approach limits what the expert clinician can accomplish and is too complex, confusing, and contradictory for primary care physicians to apply effectively in their practise. RECENT FINDINGS There are four major reasons that apoB should be measured routinely in clinical care. First, apoB is a more accurate marker of cardiovascular risk than LDL-C or non-HDL-C. Second, the measurement of apoB is standardized whereas the measurements of LDL-C and non-HDL-C are not. Third, with apoB and a conventional lipid panel, all the lipid phenotypes can be simply and accurately distinguished. This will improve the care of the expert. Fourth, apoB, as the single measure to evaluate the success of therapy, would simplify the process of care for primary care physicians. SUMMARY By introducing apoB broadly into clinical care, the process of care will be improved for both the expert and the primary care physician, and this will improve the outcomes of care.
Collapse
Affiliation(s)
- Selin Bilgic
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | | |
Collapse
|
3
|
Ahmad M, Sniderman AD, Hegele RA. L’apolipoprotéine B dans l’évaluation du risque cardiovasculaire. CMAJ 2023; 195:E1644-E1645. [PMID: 38049165 DOI: 10.1503/cmaj.230048-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023] Open
Affiliation(s)
- Maud Ahmad
- École de médecine et de dentisterie Schulich (Ahmad, Hegele), Université Western, London, Ont.; Centre de prévention cardiovasculaire Mike et Valeria Rosenbloom, Département de médecine (Sniderman), Centre universitaire de santé McGill, Montréal, Qc
| | - Allan D Sniderman
- École de médecine et de dentisterie Schulich (Ahmad, Hegele), Université Western, London, Ont.; Centre de prévention cardiovasculaire Mike et Valeria Rosenbloom, Département de médecine (Sniderman), Centre universitaire de santé McGill, Montréal, Qc
| | - Robert A Hegele
- École de médecine et de dentisterie Schulich (Ahmad, Hegele), Université Western, London, Ont.; Centre de prévention cardiovasculaire Mike et Valeria Rosenbloom, Département de médecine (Sniderman), Centre universitaire de santé McGill, Montréal, Qc.
| |
Collapse
|
4
|
Bilgic S, Remaley AT, Sniderman AD. Triglyceride-rich lipoprotein cholesterol and cardiovascular risk. Curr Opin Lipidol 2023; 34:259-266. [PMID: 37773930 PMCID: PMC10872610 DOI: 10.1097/mol.0000000000000905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
PURPOSE OF REVIEW The triglyceride-rich apoB lipoprotein particles make up a minority of the apoB particles in plasma. They vary in size, in lipid, and in protein content. Most are small enough to enter the arterial wall and therefore most are atherogenic. But how important a contribution TRL particles make to the total risk created by the apoB lipoproteins remains controversial. A recent Mendelian randomization analysis determined that the cardiovascular risk related to the cholesterol within these apoB particles--the TRL cholesterol--was greater than--and independent of--the risk related to apoB. If correct, these observations have major clinical significance. RECENT FINDINGS Accordingly, we have analyzed these results in detail. In our view, the independent strength of the association between TRL cholesterol and apoB with cardiovascular risk seems inconsistent with the biological connections between apoB and cholesterol as integral and highly correlated constituents of apoB particles. These results are also inconsistent with other lines of evidence such as the results of the fibrate randomized clinical trials. Moreover, we are also concerned with other aspects of the analysis. SUMMARY We do not regard the issue as settled. However, this enquiry has led us to a fuller understanding of the determinants of the cholesterol content of the TRL apoB particles and the complex processing of cholesterol amongst the plasma lipoproteins.
Collapse
Affiliation(s)
- Selin Bilgic
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Alan T. Remaley
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Allan D. Sniderman
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
5
|
Solnica B, Sniderman AD, Wyszomirski A, Rutkowski M, Chlebus K, Bandosz P, Pencina MJ, Zdrojewski T. Concordance/discordance between serum apolipoprotein B, low density lipoprotein cholesterol and non-high density lipoprotein cholesterol in NATPOL 2011 participants - An epidemiological perspective. Int J Cardiol 2023; 390:131150. [PMID: 37429441 DOI: 10.1016/j.ijcard.2023.131150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/20/2023] [Accepted: 07/05/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND The study compared the distribution of serum LDL-C, non-HDL-C, and apolipoprotein B (apoB) among participants of the NATPOL 2011 survey and analysed concordance/discordance of results in the context of the risk for atherosclerotic cardiovascular disease (ASCVD). METHODS Serum levels of apoB, LDL-C, non-HDL-C and small dense LDL-C were measured/calculated in 2067-2098 survey participants. The results were compared between women and men, age groups and in relation to body mass index (BMI), fasting glucose and TG levels, and the presence of CVD. Percentile distribution of lipid levels and concordance/discordance analysis were based on medians and ESC/EAS 2019 target thresholds for ASCVD risk and on comparison of measured apoB levels and levels calculated from linear regression equations with serum LDL- C and non-HDL-C as independent variables. RESULTS Serum apoB, LDL-C and non-HDL-C were similarly related to sex, age, BMI, visceral obesity, cardiovascular disease, and fasting glucose and triglyceride levels. Serum apoB, LDL-C and non-HDL-C very high- and moderate- target thresholds were exceeded in 83%, 99% and 96.9% and in 41%, 75% and 63.7% of subjects, respectively. The incidence of the discordances between the results depended on the dividing values used and ranged from 0.2% to 45.2% of the respondents. Subjects with high apoB / low LDL-C/non-HDL-C discordance had features of metabolic syndrome. CONCLUSIONS Diagnostic discordances between apoB and LDL-C/non-HDL-C indicate limitations of serum LDL-C/non-HDL-C in ASCVD risk management. Due to the high apoB/low LDL-C/non-HDL-C discordance, obese/metabolic syndrome patients may benefit from replacing LDL-C/non-HDL-C by apoB in ASCVD risk assessment and lipid-lowering therapy.
Collapse
Affiliation(s)
- Bogdan Solnica
- Department of Clinical Biochemistry, Jagiellonian University Medical College, Kraków, Poland.
| | - Allan D Sniderman
- Mie and Valeria Centre for Cardiovascular Prevention, McGill University Health Centre, Montreal, Canada
| | - Adam Wyszomirski
- Department of Adult Neurology, Medical University of Gdańsk, Gdańsk, Poland
| | - Marcin Rutkowski
- Department of Preventive Medicine and Education, Medical University of Gdansk, Gdansk, Poland
| | - Krzysztof Chlebus
- I(st) Department of Cardiology, Medical University of Gdansk, Gdańsk, Poland
| | - Piotr Bandosz
- Department of Preventive Medicine and Education, Medical University of Gdansk, Gdansk, Poland
| | - Michael J Pencina
- Duke University, DCRI, Biostatistics and Bioinformatics, Durham, USA; Framingham Heart Study, USA
| | - Tomasz Zdrojewski
- Department of Preventive Medicine and Education, Medical University of Gdansk, Gdansk, Poland
| |
Collapse
|
6
|
Ahmad M, Sniderman AD, Hegele RA. Apolipoprotein B in cardiovascular risk assessment. CMAJ 2023; 195:E1124. [PMID: 37640407 PMCID: PMC10462411 DOI: 10.1503/cmaj.230048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Affiliation(s)
- Maud Ahmad
- Schulich School of Medicine and Dentistry (Ahmad, Hegele), Western University, London, Ont.; Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine (Sniderman), McGill University Health Centre, Montréal, Que
| | - Allan D Sniderman
- Schulich School of Medicine and Dentistry (Ahmad, Hegele), Western University, London, Ont.; Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine (Sniderman), McGill University Health Centre, Montréal, Que
| | - Robert A Hegele
- Schulich School of Medicine and Dentistry (Ahmad, Hegele), Western University, London, Ont.; Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine (Sniderman), McGill University Health Centre, Montréal, Que.
| |
Collapse
|
7
|
Abstract
Concern continues about whether the measurement of apolipoprotein B (apoB) is adequately standardized, and therefore, whether apoB should be applied widely in clinical care. This concern is misplaced. Our objective is to explain why and what the term "standardization" means. To produce clinically valid results, a test must accurately, precisely, and selectively measure the marker of interest. That is, it must be standardized. Accuracy refers to how closely the result obtained with 1 method corresponds to the result obtained with the standard method, precision to how reproducible the result is on repeated testing, and selectivity to how susceptible the method is to error by inclusion of other classes of lipoprotein particles. Multiple expert groups have determined that the measurement of apoB is adequately standardized for clinical care, and that apoB can be measured inexpensively, using widely available automated methods, more accurately, precisely, and selectively than low-density lipoprotein cholesterol or non-high-density lipoprotein cholesterol. ApoB is a standard superior to low-density lipoprotein cholesterol and high-density lipoprotein cholesterol because it is a defined molecule, whereas the cholesterol markers are the mass of cholesterol within lipoprotein particles defined by their density, not by their molecular structure. Nevertheless, the standardization of apoB is being further improved by the application of mass spectrophotometric methods, whereas the limitations in the standardization and, therefore, the accurate, precise, and selective measurement of low-density lipoprotein cholesterol and high-density lipoprotein cholesterol are unlikely to be overcome. We submit that greater accuracy, precision, and selectivity in measurement is a decisive advantage for apoB in the modern era of intensive lipid-lowering therapies.
Collapse
Affiliation(s)
| | - Michel R. Langlois
- Department of Laboratory Medicine, AZ St.‐Jan Hospital, Bruges, and Faculty of Medicine and Health SciencesUniversity of GhentGhentBelgium
| | - Christa Cobbaert
- Department of Clinical Chemistry and Laboratory MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - Allan D. Sniderman
- Department of MedicineMike and Valeria Rosenbloom Centre for Cardiovascular Prevention, McGill University Health CentreMontrealQuebecCanada
| |
Collapse
|
8
|
De Marco D, Pencina K, Pencina M, Dufresne L, Thanassoulis G, Sniderman AD. Is hypertriglyceridemia a reliable indicator of cholesterol-depleted Apo B particles? J Clin Lipidol 2023; 17:452-457. [PMID: 37225542 DOI: 10.1016/j.jacl.2023.05.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVES Because cholesterol-depleted Apo B particles are thought to be a hallmark of hypertriglyceridemia, American, Canadian and European Lipid Guidelines suggest screening for Apo B only in patients with hypertriglyceridemia. Accordingly, this study examines the relationship of triglycerides to the LDL-C/Apo B and non-HDL-C/Apo B ratios. METHODS The study cohort consisted of 6272 NHANES subjects adjusted for a weighted sample size of 150 million subjects without previously diagnosed cardiac disease. Data was reported by LDL-C/Apo B tertiles as weighted frequencies and percent. Sensitivity, specificity, negative predictive and positive predictive values were calculated for triglycerides thresholds of >150 mg/dL and >200 mg/dL. The range of values of Apo B for decisional levels of LDL-C and non-HDL-C were also determined RESULTS: Among patients with triglycerides >200 mg/dL, 75.9% were amongst the lowest LDL-C/Apo B tertile. However, this represents only 7.5% of the total population. Of patients with the lowest LDL-C/Apo B ratio, 59.8% had triglycerides <150 mg/dL. Moreover, there was an inverse relationship between non-HDL-C/Apo B such that elevated triglycerides were associated with the highest tertile of non-HDL-C/Apo B. Finally, the range of values of Apo B for decisional levels of LDL-C and non-HDL-C was determined and is so broad- 30.3-40.6 mg/dl Apo B for different levels of LDL-C and 19.5 to 27.6 mg/dl Apo B for different levels of non-HDL-C- that neither is an adequate clinical surrogate for Apo B. CONCLUSION Plasma triglycerides should not be used to restrict the measurement of Apo B since cholesterol-depleted Apo B particles may be present at any level of triglyceride.
Collapse
Affiliation(s)
- Davide De Marco
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Royal Victoria Hospital, Glen Site - C04.4180, 1001 Boulevard Décarie, Montreal, Quebec H4A 3J1, Canada
| | - Karol Pencina
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Michael Pencina
- Duke University School of Medicine, Biostatistics and Bioinformatics, DCRI, Durham, NC, United Kingdom
| | - Line Dufresne
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Royal Victoria Hospital, Glen Site - C04.4180, 1001 Boulevard Décarie, Montreal, Quebec H4A 3J1, Canada
| | - George Thanassoulis
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Royal Victoria Hospital, Glen Site - C04.4180, 1001 Boulevard Décarie, Montreal, Quebec H4A 3J1, Canada
| | - Allan D Sniderman
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Royal Victoria Hospital, Glen Site - C04.4180, 1001 Boulevard Décarie, Montreal, Quebec H4A 3J1, Canada.
| |
Collapse
|
9
|
Akl E, Sniderman AD. Cholesterol, Coronary Calcification, and Cardiovascular Prevention: Lessons We Can Learn From the Western Denmark Heart Registry. Circulation 2023; 147:1064-1066. [PMID: 37011071 DOI: 10.1161/circulationaha.123.063658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Affiliation(s)
- Elie Akl
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Allan D Sniderman
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| |
Collapse
|
10
|
Wilkins JT, Alruwaili W, Ning H, Sawicki KT, Sniderman AD, Otvos JD, Jacobs DR, Murthy VL, Shah RV, Rohatgi A, Allen NB. Abstract P594: High-Density Lipoprotein Particle Concentrations and Long-Term Atherosclerotic Disease Risk in Young Adults. Circulation 2023. [DOI: 10.1161/circ.147.suppl_1.p594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Introduction:
HDL particles vary in size and concentration. Indices of overall HDL particle concentration (HDL-P) and the concentrations of different HDL size subspecies (small: H1-H3, medium: H4, H5, and large: H6, H7) have differential associations with near-term CVD events in middle-aged adults. It is unclear if measures of HDL particle concentration predict long-term ASCVD risk in young adults.
Methods:
Among CARDIA participants (ppts), NMR was used to measure HDL-P and HDL particle size subgroup H1-H7 concentrations. HDL cholesterol (HDL-C) was measured using standard assays. We stratified the ppts into 2 age windows: 20-30y (n= 1645) and 30-40y (n=2922). We used adjusted Cox proportional hazards models to assess the associations between a 1SD higher HDL-C, HDL-P, and HDL1-7 subgroups with incident ASCVD events. We added HDL-P, HDL H1-H7, and HDL-C separately to a modified Pooled Cohort Equation (PCE) model; model performance (discrimination and reclassification) was evaluated.
Results:
81 and 163 ASCVD events occurred over (median (IQR)) 31.8y (31.1-32.0y) for the 20-30y age window and over 26.8y (19.1-27.1y) for the 30-40y age window, respectively. In ppts age 20-30y, a higher HDL-P and HDL-C were not associated with ASCVD events, however a higher HDL H6 subgroup level was associated with lower risk for ASCVD in demographic adjusted models. In the age 30-40y group, higher HDL-P, HDL-C, and H6 subgroup were significantly associated with lower ASCVD risks in all models. There were no significant differences in c-statistics across PCE models. However, there were improvements in reclassification for all HDL measures when added to the PCE model in the 20-30y age window, and significant improvements in reclassification when HDL H1-7 were added to the PCE for the 30-40y age window.
Conclusion:
At younger ages (<40y) differences in HDL particle abundance, in particular large particles, may help reclassify long-term risk for ASCVD in some.
Collapse
|
11
|
Wilkins JT, Ning H, Sawicki K, Sawicki KT, Sniderman AD, Otvos JD, Rana JS, Murthy V, Murthy VL, Shah RV, Allen NB, Lloyd-Jones D. Abstract P453: Apolipoprotein B, Low-Density Lipoprotein Particle Number, Non-High-Denisity Lipoprotein Cholesterol, Low-Density Lipoprotein Cholesterol, and Total Cholesterol for Atherosclerotic Cardiovascular Disease Risk Prediction in Young Adults. Circulation 2023. [DOI: 10.1161/circ.147.suppl_1.p453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Introduction:
Measures of atherogenic particle number (apoB and LDL particle number [LDL-P]) are stronger predictors of atherosclerotic cardiovascular disease (ASCVD) risk than measures of cholesterol concentration (LDL-C, non-HDL-C, total cholesterol [TC]) in middle-aged adults. It is unclear if this is true for younger adults.
Methods:
Among CARDIA participants (ppts), NMR was used to measure apoB and LDL-P. Non-HDL-C and TC were measured using standard assays; LDL-C was calculated using the Friedewald equation. We stratified the ppts into two age windows: age 20-30y (n=1645) and age 30-40y (n=2922). We used adjusted Cox proportional hazards models to assess the associations of 1SD higher apoB, LDL-P, non-HDL-C, LDL-C, or TC with incident ASCVD events. We substituted each measure of atherogenic lipid burden for TC in a modified Pooled Cohort Equation (PCE) model (with and without HDL-C); and model performance (discrimination and reclassification) was evaluated.
Results:
There were 81 and 163 ASCVD events over (median [IQR]) 31.8y (31.1-32.0y) for the age 20-30 age window and over 26.8y (19.1-27.1y) for the 30-40y age window, respectively. In ppts age 20-30y, a 1SD higher apoB, LDL-P, non-HDL-C, and LDL-C were significantly associated with incident ASCVD in demographic adjusted models. The strengths of associations with ASCVD were not significantly different across these measures. For the 30-40y age window, all measures of atherogenic lipoproteins were significantly associated with ASCVD; the strengths of association were not significantly different across atherogenic lipid measures in all models. There were no significant differences in the C-statistic and no improvement in reclassification when each measure was used to replace TC in the PCE model.
Conclusions:
ApoB, LDL-P, LDL-C or non-HDL-C may be slightly better markers of long-term ASCVD risk than TC in adults < 30y. However, in adults between 30-40y all measures of atherogenic lipid burden appeared to be equivalent predictors of long-term risk.
Collapse
|
12
|
Pencina KM, Pencina MJ, Lawler PR, Engert JC, Dufresne L, Ridker PM, Thanassoulis G, Mora S, Sniderman AD. Interplay of Atherogenic Particle Number and Particle Size and the Risk of Coronary Heart Disease. Clin Chem 2023; 69:48-55. [PMID: 36331823 PMCID: PMC10833272 DOI: 10.1093/clinchem/hvac172] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/09/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND We examined the interplay of apolipoprotein B (apoB) and LDL particle size, approximated by the LDL-cholesterol (LDL-C)/apoB ratio, on the risk of new-onset coronary heart disease (CHD). METHODS Participants without cardiovascular disease from the UK Biobank (UKB; n = 308 182), the Women's Health Study (WHS; n = 26 204), and the Framingham Heart Study (FHS; n = 2839) were included. Multivariable Cox models were used to assess the relationship between apoB and LDL-C/apoB ratio and incidence of CHD (14 994 events). Our analyses were adjusted for age, sex (except WHS), HDL-cholesterol (HDL-C), systolic blood pressure, antihypertensive treatment, diabetes, and smoking. RESULTS In all 3 studies, there was a strong positive correlation between apoB and LDL-C (correlation coefficients r = 0.80 or higher) and a weak inverse correlation of apoB with LDL-C/apoB ratio (-0.28 ≤ r ≤ -0.14). For all 3 cohorts, CHD risk was higher for higher levels of apoB. Upon multivariable adjustment, the association between apoB and new-onset CHD remained robust and statistically significant in all 3 cohorts with hazard ratios per 1 SD (95% CI): 1.24 (1.22-1.27), 1.33 (1.20-1.47), and 1.24 (1.09-1.42) for UKB, WHS, and FHS, respectively. However, the association between LDL-C/apoB and CHD was statistically significant only in the FHS cohort: 0.78 (0.64-0.94). CONCLUSIONS Our analysis confirms that apoB is a strong risk factor for CHD. However, given the null association in 2 of the 3 studies, we cannot confirm that cholesterol-depleted LDL particles are substantially more atherogenic than cholesterol-replete particles. These results lend further support to routine measurement of apoB in clinical care.
Collapse
Affiliation(s)
- Karol M. Pencina
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Michael J. Pencina
- North Carolina Department of Laboratory Medicine, Duke University School of Medicine, Biostatistics and Bioinformatics, DCRI, Durham, NC 27614, USA
| | - Patrick R. Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario M5G 2C4, Canada
| | - James C. Engert
- Research Institute of the McGill University Health Centre, Montreal, Quebec H4A 3J1, Canada
| | - Line Dufresne
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec H4A 3J1, Canada
| | - Paul M Ridker
- Department of Medicine, Center for Cardiovascular Disease Prevention, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - George Thanassoulis
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec H4A 3J1, Canada
| | - Samia Mora
- Center for Lipid Metabolomics, Division of Preventive Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Allan D. Sniderman
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec H4A 3J1, Canada
| |
Collapse
|
13
|
Sniderman AD. dal-GenE was negative-not positive except for COVID-19. Eur Heart J 2022; 43:5061. [PMID: 36378512 DOI: 10.1093/eurheartj/ehac637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Allan D Sniderman
- Department of Medicine, Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, McGill University Health Centre, Glen Site-C04.4180, 1001 Boulevard Décarie, Montreal, Quebec H4A 3J1, Canada
| |
Collapse
|
14
|
Sniderman AD. Apolipoprotein B versus non-high-density lipoprotein cholesterol: contradictory results in the same journal. Eur J Prev Cardiol 2022; 29:2347-2348. [PMID: 36402117 DOI: 10.1093/eurjpc/zwac253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Allan D Sniderman
- Department of Medicine, Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, McGill University Health Centre, Royal Victoria Hospital, Glen Site C04.4180, 1001 Boulevard Décarie, Montreal, QC, Canada H4A 3J1
| |
Collapse
|
15
|
Glavinovic T, Thanassoulis G, de Graaf J, Couture P, Hegele RA, Sniderman AD. Physiological Bases for the Superiority of Apolipoprotein B Over Low-Density Lipoprotein Cholesterol and Non-High-Density Lipoprotein Cholesterol as a Marker of Cardiovascular Risk. J Am Heart Assoc 2022; 11:e025858. [PMID: 36216435 DOI: 10.1161/jaha.122.025858] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In 2019, the European Society of Cardiology/European Atherosclerosis Society stated that apolipoprotein B (apoB) was a more accurate marker of cardiovascular risk than low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol. Since then, the evidence has continued to mount in favor of apoB. This review explicates the physiological mechanisms responsible for the superiority of apoB as a marker of the cardiovascular risk attributable to the atherogenic apoB lipoprotein particles chylomicron remnants, very low-density lipoprotein, and low-density lipoprotein particles. First, the nature and relative numbers of these different apoB particles will be outlined. This will make clear why low-density lipoprotein particles are almost always the major determinants of cardiovascular risk and why the concentrations of triglycerides and LDL-C may obscure this relation. Next, the mechanisms that govern the number of very low-density lipoprotein and low-density lipoprotein particles will be outlined because, except for dysbetalipoproteinemia, the total number of apoB particles determines cardiovascular risk, Then, the mechanisms that govern the cholesterol mass within very low-density lipoprotein and low-density lipoprotein particles will be reviewed because these are responsible for the discordance between the mass of cholesterol within apoB particles, measured either as LDL-C or non-high-density lipoprotein cholesterol, and the number of apoB particles measured as apoB, which creates the superior predictive power of apoB over LDL-C and non-high-density lipoprotein cholesterol. Finally, the major apoB dyslipoproteinemias will be briefly outlined. Our objective is to provide a physiological framework for health care givers to understand why apoB is a more accurate marker of cardiovascular risk than LDL-C or non-high-density lipoprotein cholesterol.
Collapse
Affiliation(s)
- Tamara Glavinovic
- Division of Nephrology, Department of Medicine McGill University Health Centre Montreal Quebec Canada
| | - George Thanassoulis
- Mike and Valeria Centre for Cardiovascular Prevention, Department of Medicine McGill University Health Centre Montreal Quebec Canada
| | - Jacqueline de Graaf
- University of Nijmegen Radboud University Medical Center Department of General Internal Medicine Nijmegen the Netherlands
| | - Patrick Couture
- Université Laval Centre Hospitalier Universitaire de Québec Quebec Canada
| | - Robert A Hegele
- Robarts Research Institute and Department of Medicine, Schulich School of Medicine and Dentistry Western University London Ontario Canada
| | - Allan D Sniderman
- Mike and Valeria Centre for Cardiovascular Prevention, Department of Medicine McGill University Health Centre Montreal Quebec Canada
| |
Collapse
|
16
|
Nelson AJ, Sniderman AD, Ditmarsch M, Dicklin MR, Nicholls SJ, Davidson MH, Kastelein JJP. Cholesteryl Ester Transfer Protein Inhibition Reduces Major Adverse Cardiovascular Events by Lowering Apolipoprotein B Levels. Int J Mol Sci 2022; 23:ijms23169417. [PMID: 36012684 PMCID: PMC9409323 DOI: 10.3390/ijms23169417] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/11/2022] [Accepted: 08/17/2022] [Indexed: 12/04/2022] Open
Abstract
Cholesteryl ester transfer protein (CETP) facilitates the exchange of cholesteryl esters and triglycerides (TG) between high-density lipoprotein (HDL) particles and TG-rich, apolipoprotein (apo) B-containing particles. Initially, these compounds were developed to raise plasma HDL cholesterol (HDL-C) levels, a mechanism that was previously thought to lower the risk of atherosclerotic cardiovascular disease (ASCVD). More recently, the focus changed and the use of pharmacologic CETP inhibitors to reduce low-density lipoprotein cholesterol (LDL-C), non-HDL-C and apoB concentrations became supported by several lines of evidence from animal models, observational investigations, randomized controlled trials and Mendelian randomization studies. Furthermore, a cardiovascular outcome trial of anacetrapib demonstrated that CETP inhibition significantly reduced the risk of major coronary events in patients with ASCVD in a manner directly proportional to the substantial reduction in LDL-C and apoB. These data have dramatically shifted the attention on CETP away from raising HDL-C instead to lowering apoB-containing lipoproteins, which is relevant since the newest CETP inhibitor, obicetrapib, reduces LDL-C by up to 51% and apoB by up to 30% when taken in combination with a high-intensity statin. An ongoing cardiovascular outcome trial of obicetrapib in patients with ASCVD is expected to provide further evidence of the ability of CETP inhibitors to reduce major adverse cardiovascular events by lowering apoB. The purpose of the present review is to provide an up-to-date understanding of CETP inhibition and its relationship to ASCVD risk reduction.
Collapse
Affiliation(s)
- Adam J. Nelson
- Victorian Heart Institute, Monash University, Clayton, VIC 3800, Australia
| | - Allan D. Sniderman
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | | | | | | | | | - John J. P. Kastelein
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Correspondence:
| |
Collapse
|
17
|
Guo W, Pencina KM, Furtado JD, Sacks FM, Vaisar T, Cheng M, Sniderman AD, Page ST, Bhasin S. Effect of Selective Androgen Receptor Modulator on Cholesterol Efflux Capacity, Size and Subspecies of HDL Particles. J Endocr Soc 2022; 6:bvac099. [PMID: 35822201 PMCID: PMC9271272 DOI: 10.1210/jendso/bvac099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Indexed: 11/28/2022] Open
Abstract
Context Selective androgen receptor modulators (SARMs), because of their preferential muscle vs prostate selectivity, are being developed for muscle-wasting conditions. Oral SARMs suppress high-density lipoprotein cholesterol (HDL-C) but their effects on functional capacity and atherogenic potential of HDL particles are unknown. Objective To determine the effects of an oral SARM (OPK-88004) on cholesterol efflux capacity, HDL particle number and size, apolipoprotein particle number and size and HDL subspecies Methods We measured cholesterol efflux capacity (CEC); HDL particle number and size; APOB; APOA1; and protein-defined HDL subspecies associated with coronary heart disease (CHD) risk in men, who had undergone prostatectomy for low-grade prostate cancer during 12-week treatment with placebo or 1, 5, or 15 mg of an oral SARM (OPK-88004). Results SARM significantly suppressed HDL-C (P < .001) but HDL particle size did not change significantly. SARM had minimal effect on CEC of HDL particles (change + 0.016, –0.036, +0.070, and –0.048%/µmol-HDL/L–1 at 0, 1, 5, and 15 mg SARM, P = .045). SARM treatment suppressed APOAI (P < .001) but not APOB (P = .077), and reduced APOA1 in HDL subspecies associated with increased (subspecies containing α2-macroglobulin, complement C3, or plasminogen) as well as decreased (subspecies containing APOC1 or APOE) CHD risk; relative proportions of APOA1 in these HDL subspecies did not change. SARM increased hepatic triacylglycerol lipase (HTGL) (P < .001). Conclusion SARM treatment suppressed HDL-C but had minimal effect on its size or cholesterol efflux function. SARM reduced APOA1 in HDL subspecies associated with increased as well as decreased CHD risk. SARM-induced increase in HTGL could contribute to HDL-C suppression. These data do not support the simplistic notion that SARM-associated suppression of HDL-C is necessarily proatherogenic; randomized trials are needed to determine SARM’s effects on cardiovascular events.
Collapse
Affiliation(s)
- Wen Guo
- Research Program in Men's Health: Aging and Metabolism; Claude D. Pepper Older Americans Independence Center, Brigham and Women's Hospital, Harvard Medical School , Boston, MA
| | - Karol M Pencina
- Research Program in Men's Health: Aging and Metabolism; Claude D. Pepper Older Americans Independence Center, Brigham and Women's Hospital, Harvard Medical School , Boston, MA
| | - Jeremy D Furtado
- Department of Nutrition, Harvard TH Chan School of Public Health , Boston, MA
| | - Frank M Sacks
- Department of Nutrition, Harvard TH Chan School of Public Health , Boston, MA
| | - Tomas Vaisar
- Division of Metabolism, Endocrinology, and Nutrition , University of Washington, Seattle, WA
| | - Ming Cheng
- Research Program in Men's Health: Aging and Metabolism; Claude D. Pepper Older Americans Independence Center, Brigham and Women's Hospital, Harvard Medical School , Boston, MA
| | - Allan D Sniderman
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre , Montreal, Quebec, Canada
| | - Stephanie T Page
- Division of Metabolism, Endocrinology, and Nutrition , University of Washington, Seattle, WA
| | - Shalender Bhasin
- Research Program in Men's Health: Aging and Metabolism; Claude D. Pepper Older Americans Independence Center, Brigham and Women's Hospital, Harvard Medical School , Boston, MA
| |
Collapse
|
18
|
Pencina KM, Pencina MJ, Dufresne L, Holmes M, Thanassoulis G, Sniderman AD. An adverse lipoprotein phenotype-hypertriglyceridaemic hyperapolipoprotein B-and the long-term risk of type 2 diabetes: a prospective, longitudinal, observational cohort study. Lancet Healthy Longev 2022; 3:e339-e346. [PMID: 36098309 DOI: 10.1016/s2666-7568(22)00079-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 03/14/2022] [Accepted: 03/22/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND This study examines the risk of new-onset diabetes in patients with hypertriglyceridaemic hyperapolipoprotein B (high triglycerides, high apolipoprotein B [apoB], low LDL cholesterol to apoB ratio, and low HDL cholesterol). The aim was to establish whether this lipoprotein phenotype identified a substantial group at high risk of developing diabetes over the next 20 years. METHODS In this prospective, longitudinal, observational cohort study, we used data from the Framingham Offspring cohort (recruited in Framingham, MA, USA). Participants were aged 40-69 years and free of diabetes and cardiovascular disease at a baseline examination done between April, 1987, and November, 1991, and were followed up until March, 2014. Cox proportional hazards regression with hierarchical adjustment for age and sex, waist circumference, and fasting blood glucose were used to model the relationship between each lipid marker and incident diabetes, as well as the relationship between hypertriglyceridaemic hyperapoB (defined as values greater than sample medians of triglycerides and apoB, and less than medians of HDL cholesterol and LDL cholesterol to apoB ratio) and incident diabetes. FINDINGS Of 3446 individuals aged 40-69 years who completed baseline examination, 2515 participants were eligible and included in all analyses. During median 21·1 years (IQR 11·1-23·1) of follow-up, 402 (16·0%) individuals developed diabetes. Age (p=0·032), waist circumference (p<0·0001), fasting blood glucose (p<0·0001), and natural logarithm-transformed triglycerides (p<0·0001) were associated with new-onset diabetes, as were apoB (p=0·0016), LDL cholesterol to apoB ratio (p=0·0018), and HDL cholesterol (p=0·0016) when added to this model. The age and sex-adjusted incidence of diabetes in the hypertriglyceridaemic hyperapoB group was 32·4% (95% CI 27·8-37·7) versus 5·5% (3·5-8·6) in the optimal lipid phenotype group and 15·5% (13·5-17·7) in the mixed lipid phenotype group. The fully adjusted hazard ratio, including glucose and waist circumference, for individuals with hypertriglyceridaemic hyperapoB was 3·30 (95% CI 2·06-5·30; p=0·0008) and for mixed lipid phenotype was 2·17 (1·38-3·40; p<0·0001) compared with those with the optimal lipid phenotype. INTERPRETATION Our findings suggest that individuals with hypertriglyceridaemic hyperapoB are at high risk of new-onset diabetes and might benefit from intensive measures to prevent diabetes. The association between this phenotype and incident diabetes is consistent with a pro-diabetic effect due to increased clearance of apoB particles from plasma, which could injure pancreatic islet cells. This mechanism might explain the increased risk of diabetes with statin therapy. FUNDING Doggone Foundation.
Collapse
Affiliation(s)
- Karol M Pencina
- Section on Men's Health, Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael J Pencina
- Duke University School of Medicine, Biostatistics and Bioinformatics, Duke Clinical Research Institute, Durham, NC, USA
| | - Line Dufresne
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Michael Holmes
- MRC Population Health Research Unit at the University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - George Thanassoulis
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Allan D Sniderman
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada.
| |
Collapse
|
19
|
Sniderman AD, Glavinovic T, Thanassoulis G. Key Questions About Familial Hypercholesterolemia: JACC Review Topic of the Week. J Am Coll Cardiol 2022; 79:1023-1031. [PMID: 35272797 DOI: 10.1016/j.jacc.2022.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/06/2022] [Accepted: 01/07/2022] [Indexed: 12/16/2022]
Abstract
Familial hypercholesterolemia (FH) is characterized as a monogenic, autosomal dominant disorder, producing severe hypercholesterolemia within families due to causal variants within genes regulating the low-density lipoprotein receptor pathway. Demonstration of a causal variant is widely accepted as evidence of substantially higher cardiovascular risk. However, recent large-scale population studies challenge this characterization of FH, which appears to account for only a minor portion of those with severe hypercholesterolemia. Moreover, a substantial portion of FH variant positive patients do not have marked hypercholesterolemia. These discordances raise doubt as to how FH should be defined and how the concentration of low-density lipoprotein in plasma is regulated in individuals with and without FH. Moreover, review of the evidence suggests the impact of an FH causal variant on cardiovascular risk may be less than previously accepted and that all patients with severe hypercholesterolemia should be prioritized for therapy and family screening.
Collapse
Affiliation(s)
- Allan D Sniderman
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada.
| | - Tamara Glavinovic
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
| | - George Thanassoulis
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada. https://twitter.com/thanassoulisMD
| |
Collapse
|
20
|
Sniderman AD, Navar AM, Thanassoulis G. Apolipoprotein B vs Low-Density Lipoprotein Cholesterol and Non-High-Density Lipoprotein Cholesterol as the Primary Measure of Apolipoprotein B Lipoprotein-Related Risk: The Debate Is Over. JAMA Cardiol 2021; 7:257-258. [PMID: 34773457 DOI: 10.1001/jamacardio.2021.5080] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Allan D Sniderman
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Ann Marie Navar
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada.,Associate Editor, JAMA Cardiology
| | - George Thanassoulis
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
21
|
Affiliation(s)
- Allan D Sniderman
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, QB, Canada
| |
Collapse
|
22
|
|
23
|
Abstract
PURPOSE OF REVIEW This review summarizes the evidence that apolipoprotein B (apoB) integrates the conventional lipid markers - total cholesterol, triglycerides, LDL-cholesterol, and non-HDL-cholesterol - into a single index that accurately and simply quantitates the atherogenic risk due to the apoB lipoprotein particles. RECENT FINDINGS Marked hypertriglyceridemia remains the essential signal for hyperchylomicronemia and potential pancreatitis. However, with the exception of Lp(a) and the abnormal cholesterol-enriched remnant particles that are the hallmark of type III hyperlipoproteinemia, recent evidence from discordance analyses and Mendelian randomization indicate that apoB integrates the risk due to the atherogenic lipoprotein particles because all LDL particles are, within the limits of our ability to measure any differences, equally atherogenic and all, except the largest VLDL particles are, within the limits of our ability to measure any differences, equally atherogenic. SUMMARY Measuring apoB as well as the conventional lipids is essential for accurate diagnosis. For almost all follow-up, however, apoB is all that need be measured. ApoB is the Rosetta Stone of lipidology because dyslipoproteinemia cannot be understood unless apoB is measured.
Collapse
Affiliation(s)
- Tamara Glavinovic
- Department of Medicine, Sunnybrook Health Sciences Centre, Division of Nephrology, Toronto, Ontario
| | - Allan D Sniderman
- Department of Medicine, Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
24
|
Affiliation(s)
- Allan D Sniderman
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - George Thanassoulis
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | | |
Collapse
|
25
|
Varghese B, Park J, Chew E, Sajja A, Brownstein A, Pallazola VA, Sathiyakumar V, Jones SR, Sniderman AD, Martin SS. Importance of the triglyceride level in identifying patients with a Type III Hyperlipoproteinemia phenotype using the ApoB algorithm. J Clin Lipidol 2020; 15:104-115.e9. [PMID: 33189625 DOI: 10.1016/j.jacl.2020.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hyperlipoproteinemia Type III (HLP3), also known as dysbetalipoproteinemia, is defined by cholesterol and triglyceride (TG) enriched remnant lipoprotein particles (RLP). The gold standard for diagnosis requires demonstration of high remnant lipoprotein particle cholesterol (RLP-C) by serum ultracentrifugation (UC), which is not readily available in daily practice. The apoB algorithm can identify HLP3 using total cholesterol (TC), plasma triglyceride (TG), and apoB. However, the optimal TG cutoff is unknown. OBJECTIVE We analyzed apoB algorithm defined HLP3 at different TG levels to optimize the TG cutoff for the algorithm. METHODS 128,485 UC lipid profiles in the Very Large Database of Lipids (VLDbL) were analyzed. RLP-C was assessed at TG ≥ 133 mg/dL, ≥175 mg/dL, ≥200 mg/dL, and ≥ 250 mg/dL. Sensitivity (Sn), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), and prevalence adjusted and bias-adjusted kappa (PABAK) were calculated against UC Criterion (VLDL-C/TG ≥ 0.25) for HLP3. RESULTS The median age (IQR) was 57 years (46-68). 45% were men, 20.1% had diabetes, and 25.5% had hypertension. The median RLP-C level for the TG cutoffs (mg/dL) of ≥ 133, ≥ 175, ≥ 200, and ≥ 250 were 34, 43, 50, and 62 mg/dL, respectively, compared to 67 mg/dL in UC defined HLP3. TG ≥ 133 mg/dL yielded optimal results (Sn 29.5%, Sp 98.5%, PABAK 0.96, PPV 13.6%, NPV 99.4%). CONCLUSION TG ≥ 133 mg/dL allows for high sensitivity in screening for HLP3. Higher TG cutoffs may identify more severe HLP3 phenotypes, but with a large loss in sensitivity for HLP3.
Collapse
Affiliation(s)
- Bibin Varghese
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jihwan Park
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Erin Chew
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aparna Sajja
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adam Brownstein
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vincent A Pallazola
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vasanth Sathiyakumar
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven R Jones
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allan D Sniderman
- Mike and Valeria Centre for Cardiovascular Prevention, McGill University Health Centre, Montreal, Quebec, Canada
| | - Seth S Martin
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| |
Collapse
|
26
|
Afshar M, Rong J, Zhan Y, Chen HY, Engert JC, Sniderman AD, Larson MG, Vasan RS, Thanassoulis G. Risks of Incident Cardiovascular Disease Associated With Concomitant Elevations in Lipoprotein(a) and Low-Density Lipoprotein Cholesterol-The Framingham Heart Study. J Am Heart Assoc 2020; 9:e014711. [PMID: 32892691 PMCID: PMC7726982 DOI: 10.1161/jaha.119.014711] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Elevated lipoprotein(a) is a well‐established risk factor for atherosclerotic vascular disease but is not measured in routine clinical care. Screening of high lipoprotein(a) in individuals with moderate elevations of low‐density lipoprotein cholesterol (LDL‐C) may identify individuals at high risk of cardiovascular disease. Methods and Results We examined 2606 Framingham Offspring participants (median age, 54 years; 45% men) prospectively with a median follow‐up of 15 years (n=392 incident cardiovascular events). Individuals with higher (≥100 nmol/L) versus lower lipoprotein(a) were divided into groups based on LDL‐C <135 mg/dL versus ≥135 mg/dL. In Cox models, after adjustment for known risk factors, high lipoprotein(a) (≥100 nmol/L) and LDL‐C ≥135 mg/dL were each significant predictors of cardiovascular disease (LDL‐C ≥135 mg/dL: hazard ratio [HR], 1.34; 95% CI, 1.09–1.64; P=0.006; high lipoprotein (a): HR, 1.31; 95% CI, 1.03–1.66; P=0.026). Across the groups of high/low lipoprotein (a) and LDL‐C ≥135 mg/dL or <135 mg/dL, the absolute cardiovascular disease risks at 15 years were 22.6% (high lipoprotein(a)/LDL‐C ≥135 mg/dL, n=248), 17.3% (low lipoprotein(a)/LDL‐C ≥135 mg/dL, n=758), 12.7% (high lipoprotein(a)/LDL‐C <135 mg/dL, n=275) and 11.5% (low lipoprotein(a)/LDL‐C <135 mg/dL, n=1328, reference group). Among individuals with LDL‐C ≥135 mg/dL, those with high lipoprotein(a) had a 43% higher risk (HR, 1.43; 95% CI, 1.05–1.97; P=0.02). Presence of high lipoprotein(a) with moderate LDL‐C levels (135–159 mg/dL) yielded absolute risks equivalent to those with LDL‐C ≥160 mg/dL (23.5%, 95% CI, 17.4%–31.3%; and 20.7%, 95% CI, 16.8%–25.3%, respectively). Conclusions Concomitant elevation of LDL‐C ≥135 mg/dL and lipoprotein(a) ≥100 nmol/L is associated with a high absolute risk of incident cardiovascular disease. lipoprotein(a) measurement in individuals with moderate elevations in LDL‐C, who do not otherwise meet criteria for statins, may identify individuals at high cardiovascular risk.
Collapse
Affiliation(s)
- Mehdi Afshar
- Division of Cardiology University of Toronto Toronto Canada
| | - Jian Rong
- Department of Neurology Boston University School of Medicine Boston MA
| | - Yang Zhan
- Department of Medicine McGill University Montreal Canada.,Preventive and Genomic Cardiology McGill University Health Centre and Research Institute Montreal Canada.,Division of Cardiology University of Saskatchewan Regina Canada
| | - Hao Yu Chen
- Department of Medicine McGill University Montreal Canada.,Preventive and Genomic Cardiology McGill University Health Centre and Research Institute Montreal Canada
| | - James C Engert
- Department of Medicine McGill University Montreal Canada.,Preventive and Genomic Cardiology McGill University Health Centre and Research Institute Montreal Canada
| | - Allan D Sniderman
- Department of Medicine McGill University Montreal Canada.,Preventive and Genomic Cardiology McGill University Health Centre and Research Institute Montreal Canada
| | - Martin G Larson
- NHLBI's and Boston University's Framingham Heart Study Boston MA.,Department of Biostatistics Boston University School of Public Health Boston MA
| | - Ramachandran S Vasan
- NHLBI's and Boston University's Framingham Heart Study Boston MA.,Department of Epidemiology Boston University School of Public Health Boston MA.,Preventive Medicine and Cardiology Boston University School of Medicine Boston MA
| | - George Thanassoulis
- Department of Medicine McGill University Montreal Canada.,Preventive and Genomic Cardiology McGill University Health Centre and Research Institute Montreal Canada.,Department of Clinical Epidemiology McGill University Health Centre Montreal Canada
| |
Collapse
|
27
|
Kohli-Lynch CN, Thanassoulis G, Moran AE, Sniderman AD. The clinical utility of apoB versus LDL-C/non-HDL-C. Clin Chim Acta 2020; 508:103-108. [DOI: 10.1016/j.cca.2020.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 12/25/2022]
|
28
|
Sniderman AD, Thanassoulis G, Glavinovic T, Navar AM, Pencina M, Catapano A, Ference BA. Apolipoprotein B Particles and Cardiovascular Disease: A Narrative Review. JAMA Cardiol 2020; 4:1287-1295. [PMID: 31642874 DOI: 10.1001/jamacardio.2019.3780] [Citation(s) in RCA: 256] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance The conventional model of atherosclerosis presumes that the mass of cholesterol within very low-density lipoprotein particles, low-density lipoprotein particles, chylomicron, and lipoprotein (a) particles in plasma is the principal determinant of the mass of cholesterol that will be deposited within the arterial wall and will drive atherogenesis. However, each of these particles contains one molecule of apolipoprotein B (apoB) and there is now substantial evidence that apoB more accurately measures the atherogenic risk owing to the apoB lipoproteins than does low-density lipoprotein cholesterol or non-high-density lipoprotein cholesterol. Observations Cholesterol can only enter the arterial wall within apoB particles. However, the mass of cholesterol per apoB particle is variable. Therefore, the mass of cholesterol that will be deposited within the arterial wall is determined by the number of apoB particles that are trapped within the arterial wall. The number of apoB particles that enter the arterial wall is determined primarily by the number of apoB particles within the arterial lumen. However, once within the arterial wall, smaller cholesterol-depleted apoB particles have a greater tendency to be trapped than larger cholesterol-enriched apoB particles because they bind more avidly to the glycosaminoglycans within the subintimal space of the arterial wall. Thus, a cholesterol-enriched particle would deposit more cholesterol than a cholesterol-depleted apoB particle whereas more, smaller apoB particles that enter the arterial wall will be trapped than larger apoB particles. The net result is, with the exceptions of the abnormal chylomicron remnants in type III hyperlipoproteinemia and lipoprotein (a), all apoB particles are equally atherogenic. Conclusions and Relevance Apolipoprotein B unifies, amplifies, and simplifies the information from the conventional lipid markers as to the atherogenic risk attributable to the apoB lipoproteins.
Collapse
Affiliation(s)
- Allan D Sniderman
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - George Thanassoulis
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Ann Marie Navar
- Duke Clinical Research Institute, Durham, North Carolina.,Associate Editor
| | - Michael Pencina
- Duke University School of Medicine, Durham, North Carolina.,Deputy Editor for Statistics
| | - Alberico Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Multimedica IRCCS, Milano, Italy
| | - Brian A Ference
- Centre for Naturally Randomized Trials, University of Cambridge, Cambridge, United Kingdom.,Institute for Advanced Studies, University of Bristol, Bristol, United Kingdom.,MRC/BHF Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
29
|
Kohli-Lynch CN, Bellows BK, Thanassoulis G, Zhang Y, Pletcher MJ, Vittinghoff E, Pencina MJ, Kazi D, Sniderman AD, Moran AE. Cost-effectiveness of Low-density Lipoprotein Cholesterol Level-Guided Statin Treatment in Patients With Borderline Cardiovascular Risk. JAMA Cardiol 2020; 4:969-977. [PMID: 31461121 DOI: 10.1001/jamacardio.2019.2851] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance American College of Cardiology/American Heart Association cholesterol guidelines prioritize primary prevention statin therapy based on 10-year absolute risk (AR10) of atherosclerotic cardiovascular disease (ASCVD). However, given the same AR10, patients with higher levels of low-density lipoprotein cholesterol (LDL-C) experience greater absolute risk reduction from statin therapy. Objectives To estimate the cost-effectiveness of expanding preventive statin treatment eligibility from standard care to patients at borderline risk (AR10, 5.0%-7.4%) for ASCVD and with high levels of LDL-C and to estimate cost-effectiveness of statin treatment across ranges of age, sex, AR10, and LDL-C levels. Design, Setting, and Participants This study evaluated 100 simulated cohorts, each including 1 million ASCVD-free survey respondents (50% men and 50% women) aged 40 years at baseline. Cohorts were created by probabilistic sampling of the 1999-2014 US National Health and Nutrition Examination Surveys from the perspective of the US health care sector. The CVD Policy Model microsimulation version projected lifetime health and cost outcomes. Probability of first-ever coronary heart disease or stroke event was estimated by analysis of 6 pooled US cohort studies and recalibrated to match contemporary event rates. Other model variables were derived from national surveys, meta-analyses, and published literature. Data were analyzed from May 15, 2018, through June 10, 2019. Exposures Four statin treatment strategies were compared: (1) treat all patients with AR10 of at least 7.5%, diabetes, or LDL-C of at least 190 mg/dL (standard care); (2) add treatment for borderline risk and LDL-C levels of 160 to 189 mg/dL; (3) add treatment for borderline risk and LDL-C levels of 130 to 159 mg/dL; and (4) add treatment for remainder of patients with AR10 of at least 5.0%. Statin treatment was also compared with no statin treatment in age, sex, AR10, and LDL-C strata. Main Outcomes and Measures Lifetime quality-adjusted life-years (QALYs) and costs (2019 US dollars) were projected and discounted 3.0% annually. The primary outcome was the incremental cost-effectiveness ratio. Results In these 100 simulated cohorts, each with 1 million patients aged 40 years at baseline (50% women and 50% men), adding preventive statins to individuals with borderline AR10 and LDL-C levels of 160 to 189 mg/dL would be cost-saving; further treating borderline AR10 and LDL-C levels of 130 to 159 mg/dL would also be cost-saving; and treating all individuals with AR10 of at least 5.0% would be highly cost-effective ($33 558/QALY) and would prevent the most ASCVD events. Within age, AR10, and sex categories, individuals with higher baseline LDL-C levels gained more QALYs from statin therapy. Cost-effectiveness increased with LDL-C level and AR10. Conclusions and Relevance In this study, lifetime statin treatment of patients in a hypothetical cohort with borderline ASCVD risk and LDL-C levels of 160 to 189 mg/dL was found to be cost-saving. Results suggest that treating all patients at borderline risk regardless of LDL-C level would likely be highly cost-effective.
Collapse
Affiliation(s)
- Ciaran N Kohli-Lynch
- Division of General Medicine, Columbia University Medical Center, New York, New York.,Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, United Kingdom
| | - Brandon K Bellows
- Division of General Medicine, Columbia University Medical Center, New York, New York
| | | | - Yiyi Zhang
- Division of General Medicine, Columbia University Medical Center, New York, New York
| | - Mark J Pletcher
- Department of Epidemiology & Biostatistics, University of California at San Francisco School of Medicine
| | - Eric Vittinghoff
- Department of Epidemiology & Biostatistics, University of California at San Francisco School of Medicine
| | | | - Dhruv Kazi
- Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Allan D Sniderman
- Division of Cardiology, McGill University, Quebec City, Quebec, Canada
| | - Andrew E Moran
- Division of General Medicine, Columbia University Medical Center, New York, New York
| |
Collapse
|
30
|
Abstract
PURPOSE OF REVIEW Guidelines propose using non-HDL cholesterol or apolipoprotein (apo) B as a secondary treatment target to reduce residual cardiovascular risk of LDL-targeted therapies. This review summarizes the strengths, weaknesses, opportunities, and threats (SWOT) of using apoB compared with non-HDL cholesterol. RECENT FINDINGS Non-HDL cholesterol, calculated as total-HDL cholesterol, includes the assessment of remnant lipoprotein cholesterol, an additional risk factor independent of LDL cholesterol. ApoB is a direct measure of circulating numbers of atherogenic lipoproteins, and its measurement can be standardized across laboratories worldwide. Discordance analysis of non-HDL cholesterol versus apoB demonstrates that apoB is the more accurate marker of cardiovascular risk. Baseline and on-treatment apoB can identify elevated numbers of small cholesterol-depleted LDL particles that are not reflected by LDL and non-HDL cholesterol. ApoB is superior to non-HDL cholesterol as a secondary target in patients with mild-to-moderate hypertriglyceridemia (175-880 mg/dL), diabetes, obesity or metabolic syndrome, or very low LDL cholesterol < 70 mg/dL. When apoB is not available, non-HDL cholesterol should be used to supplement LDLC.
Collapse
Affiliation(s)
- Michel R Langlois
- Department of Laboratory Medicine, AZ St-Jan Hospital, Ruddershove 10, B-8000, Bruges, Belgium. .,Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium. .,Working Group on Guidelines, European Federation of Clinical Chemistry and Laboratory Medicine (EFLM), Brussels, Belgium.
| | - Allan D Sniderman
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Division of Cardiology, Royal Victoria Hospital-McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
31
|
Pencina KM, Thanassoulis G, Wilkins JT, Vasan RS, Navar AM, Peterson ED, Pencina MJ, Sniderman AD. Trajectories of Non-HDL Cholesterol Across Midlife: Implications for Cardiovascular Prevention. J Am Coll Cardiol 2020; 74:70-79. [PMID: 31272554 DOI: 10.1016/j.jacc.2019.04.047] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/19/2019] [Accepted: 04/23/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Extended elevations of non-high-density lipoprotein cholesterol (non-HDL-C) across a lifespan are associated with increased risk of cardiovascular disease (CVD). However, optimal testing intervals to identify individuals with high lipid-related CVD risk are unknown. OBJECTIVES This study determined the extent to which lipid levels in young adulthood predict future lipid trajectories and associated long-term CVD risk. METHODS A sample of 2,516 Framingham Offspring study participants 25 to 40 years of age free of CVD and diabetes had their non-HDL-C progression modeled over 8 study examinations (mean follow-up 32.6 years) using group-based methods. CVD risk based on 25 to 30 years of follow-up was evaluated using Kaplan-Meier analyses for those with mean non-HDL-C ≥160 mg/dl ("high") and <130 mg/dl ("low") at the first 2 examinations. Levels of non-HDL-C for participants on lipid treatment were adjusted by nonparametric algorithm. RESULTS The trajectories of the lipid levels were generally stable over the 30-year life course; mean non-HDL-C measured in young adulthood were highly predictive of levels later in life. Individuals could be reliably assigned to high and low non-HDL-C groups based on 2 measurements collected between 25 to 40 years of age. Overall, 80% of those with non-HDL-C ≥160 mg/dl at the first 2 exams remained in the high group on subsequent 25-year testing, whereas 88% of those with non-HDL-C <130 mg/dl remained below 160 mg/dl. Those with high non-HDL-C in young adulthood had a 22.6% risk of CVD in the next 25 years as compared with a 6.4% risk in those with low non-HDL-C. CONCLUSIONS Most adults with elevated non-HDL-C early in life continue to have high non-HDL-C over their life course, leading to significantly increased risk of CVD. The results demonstrate that early lipid monitoring before 40 years of age would identify a majority of those with a high likelihood for lifetime elevated lipid levels who also have a high long-term risk for CVD. This information could facilitate informed patient-provider discussion about the potential benefits of preventive lipid-lowering efforts during the early midlife period.
Collapse
Affiliation(s)
- Karol M Pencina
- Section on Men's Health Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - George Thanassoulis
- Department of Medicine, Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada
| | - John T Wilkins
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ramachandran S Vasan
- Framingham Heart Study, Section of Preventive Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts; Section of Cardiology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts; Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | | | - Eric D Peterson
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Michael J Pencina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Allan D Sniderman
- Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
32
|
Affiliation(s)
- Allan D Sniderman
- From the Department of Medicine, McGill University, Montreal, Quebec, Canada (A.D.S., G.T.)
| | | | - George Thanassoulis
- From the Department of Medicine, McGill University, Montreal, Quebec, Canada (A.D.S., G.T.)
| |
Collapse
|
33
|
Pallazola VA, Sathiyakumar V, Park J, Vakil RM, Toth PP, Lazo-Elizondo M, Brown E, Quispe R, Guallar E, Banach M, Blumenthal RS, Jones SR, Marais D, Soffer D, Sniderman AD, Martin SS. Modern prevalence of dysbetalipoproteinemia (Fredrickson-Levy-Lees type III hyperlipoproteinemia). Arch Med Sci 2020; 16:993-1003. [PMID: 32863987 PMCID: PMC7444722 DOI: 10.5114/aoms.2019.86972] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Dysbetalipoproteinaemia (HLP3) is a disorder characterized by excess cholesterol-enriched, triglyceride-rich lipoprotein remnants in genetically predisposed individuals that powerfully promote premature cardiovascular disease if untreated. The current prevalence of HLP3 is largely unknown. MATERIAL AND METHODS We performed cross-sectional analysis of 128,485 U.S. adults from the Very Large Database of Lipids (VLDbL), using four algorithms to diagnose HLP3 employing three Vertical Auto Profile ultracentrifugation (UC) criteria and a previously described apolipoprotein B (apoB) method. We evaluated 4,926 participants from the 2011-2014 National Health and Nutrition Examination Survey (NHANES) with the apoB method. We examined demographic and lipid characteristics stratified by presence of HLP3 and evaluated lipid characteristics in those with HLP3 phenotype discordance and concordance as determined by apoB and originally defined UC criteria 1. RESULTS In U.S. adults in VLDbL and NHANES, a 1.7-2.0% prevalence is observed for HLP3 with the novel apoB method as compared to 0.2-0.8% prevalence in VLDbL via UC criteria 1-3. Participants who were both apoB and UC criteria HLP3 positive had higher remnant particles as well as more elevated triglyceride/apoB and total cholesterol/apoB ratios (all p < 0.001) than those who were apoB method positive and UC criteria 1 negative. CONCLUSIONS HLP3 may be more prevalent than historically and clinically appreciated. The apoB method increases HLP3 identification via inclusion of milder phenotypes. Further work should evaluate the clinical implications of HLP3 diagnosis at various lipid algorithm cut-points to evaluate the ideal standard in the modern era.
Collapse
Affiliation(s)
- Vincent A. Pallazola
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vasanth Sathiyakumar
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jihwan Park
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Rachit M. Vakil
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter P. Toth
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Medicine, Community Hospital General Medical Center, Sterling, IL, USA
| | - Mariana Lazo-Elizondo
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Emily Brown
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Renato Quispe
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Eliseo Guallar
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Maciej Banach
- Cardiovascular Research Centre, University of Zielona Gora, Zielona Gora, Poland
| | - Roger S. Blumenthal
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven R. Jones
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Marais
- Department of Internal Medicine, University of Cape Town Health Sciences, Cape Town, South Africa
| | - Daniel Soffer
- Department of Medicine and Institute for Translational Medicine and Therapeutics, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Allan D. Sniderman
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Seth S. Martin
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
34
|
Abstract
Supplemental Digital Content is available in the text. Background: To optimize preventive strategies for coronary heart disease (CHD), it is essential to understand and appropriately quantify the contribution of its key risk factors. Our objective was to compare the associations of key modifiable CHD risk factors—specifically lipids, systolic blood pressure (SBP), diabetes mellitus, and smoking—with incident CHD events based on their prognostic performance, attributable risk fractions, and treatment benefits, overall and by age. Methods: Pooled participant-level data from 4 observational cohort studies sponsored by the National Heart, Lung, and Blood Institute were used to create a cohort of 22 626 individuals aged 45 to 84 years who were initially free of cardiovascular disease. Individuals were followed for 10 years from baseline evaluation for incident CHD. Proportional hazards regression was used to estimate metrics of prognostic model performance (likelihood ratio, C index, net reclassification, discrimination slope), hazard ratios, and population attributable fractions for SBP, non–high-density lipoprotein cholesterol (non–HDL-C), diabetes mellitus, and smoking. Expected absolute risk reductions for antihypertensive and lipid-lowering treatment were assessed. Results: Age, sex, and race capture 63% to 80% of the prognostic performance of cardiovascular risk models. In contrast, adding either SBP, non–HDL-C, diabetes mellitus, or smoking to a model with other risk factors increases the C index by only 0.004 to 0.013. However, primordial prevention could have a substantial effect as demonstrated by population attributable fractions of 28% for SBP≥130 mm Hg and 17% for non–HDL-C≥130 mg/dL. Similarly, lowering the SBP of all individuals to <130 mm Hg or lowering low-density lipoprotein cholesterol by 30% would be expected to lower a baseline 10-year CHD risk of 10.7% to 7.0 and 8.0, respectively (absolute risk reductions: 3.7% and 2.7%, respectively). Prognostic performance decreases with age (C indices for age groups 45–54, 55–64, 65–74, 75–84 are 0.75, 0.72, 0.66, and 0.62, respectively), whereas absolute risk reductions increase (SBP: 1.1%, 2.3%, 5.4%, 10.3%, respectively; non–HDL-C: 1.1%, 2.0%, 3.7%, 5.9%, respectively). Conclusions: Although individual modifiable CHD risk factors contribute only modestly to prognostic performance, our models indicate that eliminating or controlling these individual factors would lead to substantial reductions in total population CHD events. Metrics used to judge importance of risk factors should be tailored to the research objectives.
Collapse
Affiliation(s)
- Michael J Pencina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.J.P., A.M.N., D.W., E.D.P.)
| | - Ann Marie Navar
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.J.P., A.M.N., D.W., E.D.P.)
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.J.P., A.M.N., D.W., E.D.P.)
| | | | - Irfan Khan
- Real-World Evidence and Clinical Outcomes, Sanofi, Bridgewater, NJ (I.K.)
| | - Joseph Elassal
- Regeneron Pharmaceuticals Inc, Tarrytown, NY (R.J.S., J.E.)
| | - Ralph B D'Agostino
- Department of Mathematics and Statistics, Boston University, MA (R.B.D.).,Baim Institute for Clinical Research, Boston, MA (R.B.D.)
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.J.P., A.M.N., D.W., E.D.P.)
| | - Allan D Sniderman
- Mike Rosenbloom Laboratory for Cardiovascular Research, McGill University Health Centre, Royal Victoria Hospital, Montreal, Quebec, Canada (A.D.S.)
| |
Collapse
|
35
|
Sniderman AD, Thanassoulis G, Pencina M. Letter by Sniderman et al Regarding Article, "Comparison of Conventional Lipoprotein Tests and Apolipoproteins in the Prediction of Cardiovascular Disease". Circulation 2019; 140:e822-e823. [PMID: 31815544 DOI: 10.1161/circulationaha.119.042776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Allan D Sniderman
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada (A.D.S., G.T.)
| | - George Thanassoulis
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada (A.D.S., G.T.)
| | | |
Collapse
|
36
|
Affiliation(s)
- Allan D Sniderman
- 1 Royal Victoria Hospital McGill University Health Centre Montreal Quebec Canada
| | - George Thanassoulis
- 1 Royal Victoria Hospital McGill University Health Centre Montreal Quebec Canada
| | - John T Wilkins
- 2 Department of Medicine (Cardiology) and Preventive Medicine Northwestern University Chicago IL
| | - Curt D Furberg
- 3 Public Health Sciences Wake Forest University Winston-Salem NC
| | - Michael Pencina
- 4 Duke Clinical Research Institute Duke University School of Medicine Durham NC
| |
Collapse
|
37
|
Abstract
Importance A 10-year benefit-based approach to statin therapy in primary prevention includes younger individuals with higher low-density lipoprotein cholesterol (LDL-C) and prevents more cardiovascular events than a risk-based approach. However, a 10-year treatment duration likely underestimates the expected benefits of statins. Objective To model the impact of a 30-year benefit approach to select individuals for statin therapy. Design, Setting, and Participants This cross-sectional analysis of the National Health and Nutrition Survey (NHANES) data set included samples of the US population from the 2009-2010, 2011-2012, and 2013-2014 data collection cycles. Individuals between 40 to 60 years old who did not have atherosclerotic cardiovascular disease, diabetes, or LDL-C levels greater than 190 mg/dL and who were not taking statins were included. Data analysis took place from November 2017 to August 2018. Exposures We calculated 10-year risk of atherosclerotic cardiovascular disease and 10-year and 30-year absolute risk reduction (10-year ARR and 30-year ARR) of atherosclerotic cardiovascular disease for each individual. Main Outcomes and Measures Number of individuals meeting eligibility for statins based on 10-year (atherosclerotic) cardiovascular disease risk, 10-year ARR, or 30-year ARR. Results A total of 1688 individuals were included, representing 56.6 million US individuals. Statin eligibility based on 7.5% CVR10 was 9.5%; based on 2.3% 10-year ARR, 13.0%, and based on 15% 30-year ARR, 17.5%. The 10-year risk, 10-year benefit, and 30-year benefit approaches all led to similar acceptable mean absolute risk reductions at 30 years, with the benefit-based approaches better able to avoid treatment of individuals with low expected benefit. Individuals who met statin eligibility based solely on the 30-year ARR threshold of 15% or greater were younger (mean age, 50 [95% CI, 48-52] years) and more likely to be women (43% [95% CI, 26%-59%]) than those recommended with a 10-year ARR threshold of 2.3% or greater (mean age, 56 [95% CI, 54-57] years; 22% [95% CI, 10%-34%] women). This group also had lower 10-year risk (mean risk, 4.7% [95% CI, 4.4%-5.1%]) and higher LDL-C levels (mean level, 149 mg/dL [95% CI, 142-155 mg/dL]) than those recommended with a 10-year ARR threshold of 2.3% or greater (mean risk, 9.3% [95% CI, 8.3%-10.2%]; mean LDL-C levels, 110 [103-118] mg/dL). Preventable atherosclerotic cardiovascular disease events in 10 and 30 years were highest using the 30-year benefit approach (296 000 at 10 years and 2.03 million at 30 years) and lowest based on 10-year risk (204 000 at 10 years and 1.18 million at 30 years). Conclusions and Relevance A long-term benefit approach to statin eligibility identifies nearly 1 in 6 individuals as having a high degree of expected long-term benefit of statins, with a number needed to treat of less than 7. This approach identifies younger individuals with higher LDL-C levels who would not be currently recommended for treatment and may provide a more optimal approach for determining statin eligibility in primary prevention.
Collapse
Affiliation(s)
- George Thanassoulis
- Preventive and Genomic Cardiology, McGill University Health Center, Montreal, Quebec, Canada.,Mike and Valeria Rosenbloom Center for Cardiovascular Prevention, McGill University Health Center, Montreal, Quebec, Canada
| | - Allan D Sniderman
- Preventive and Genomic Cardiology, McGill University Health Center, Montreal, Quebec, Canada.,Mike and Valeria Rosenbloom Center for Cardiovascular Prevention, McGill University Health Center, Montreal, Quebec, Canada
| | | |
Collapse
|
38
|
|
39
|
Sniderman AD. Type III Hyperlipoproteinemia: The Forgotten, Disregarded, Neglected, Overlooked, Ignored but Highly Atherogenic, and Highly Treatable Dyslipoproteinemia. Clin Chem 2018; 65:225-227. [PMID: 30538123 DOI: 10.1373/clinchem.2018.298026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 11/02/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Allan D Sniderman
- McGill University Health Centre, McGill University, Montreal, Quebec.
| |
Collapse
|
40
|
Abstract
Whether apoB adds significantly to the assessment of the risk and therapy of the atherogenic dyslipoproteinemias has been vigorously contested over many years. That trapping of apoB lipoprotein particles within the arterial wall is fundamental to the initiation and maturation of atherosclerotic lesions within the arterial wall is now widely accepted. At the same time, the concept that primary prevention should be based on the risk of a cardiovascular event, a measure that integrates the effects of age, sex, blood pressure, lipids and other factors, has also become widely accepted. Within the risk framework, the issue becomes whether apoB adds significantly to the assessment of risk. On the other hand, it can be argued that the risk model undervalues how important a role that LDL and blood pressure play as causes of atherosclerosis and that when considered as causes, the importance of apoB emerges. These are the two sides of the debate that will be presented in the article that follows: one will highlight the pros of measuring apoB, the second the cons. The reader can make up his or her mind which side of the issue they favour.
Collapse
Affiliation(s)
- Allan D Sniderman
- McGill University Health Centre, Royal Victoria Hospital, 1001 Decarie Boulevard, Montreal, Quebec, H4A 3J1, Canada.
| | - Jennifer G Robinson
- Departments of Epidemiology and Internal Medicine, Division of Cardiology, University of Iowa, 145 N Riverside Dr S455 CPHB, Iowa City, IA, 52242, United States
| |
Collapse
|
41
|
Affiliation(s)
- Allan D Sniderman
- Division of Cardiology, Royal Victoria Hospital-McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - George Thanassoulis
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Michael Pencina
- Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| |
Collapse
|
42
|
Sniderman AD, de Graaf J, Thanassoulis G, Tremblay AJ, Martin SS, Couture P. The spectrum of type III hyperlipoproteinemia. J Clin Lipidol 2018; 12:1383-1389. [PMID: 30318453 DOI: 10.1016/j.jacl.2018.09.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 09/04/2018] [Accepted: 09/11/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Type III hyperlipoproteinemia is a highly atherogenic dyslipoproteinemia characterized by hypercholesterolemia and hypertriglyceridemia due to markedly increased numbers of cholesterol-enriched chylomicron and very-low-density lipoprotein (VLDL) remnant lipoprotein particles. Type III can be distinguished from mixed hyperlipidemia based on a simple diagnostic algorithm, which involves total cholesterol, triglycerides, and apolipoprotein B (apoB). However, apoB is not measured routinely. OBJECTIVE The objective of the present study was to determine if patients with type III could be distinguished from mixed hyperlipidemia based on lipoprotein lipids. METHODS Classification was based first on total cholesterol and triglyceride and then on the apoB diagnostic algorithm using apoB plus total cholesterol plus triglycerides, and validated by sequential ultracentrifugation. Four hundred and forty normals, 637 patients with hypertriglyceridemia, and 714 with hypertriglyceridemia and hypercholesterolemia were studied. Plasma lipoproteins were separated by sequential ultracentrifugation and heparin-manganese precipitation. Cholesterol, triglyceride, and apoB were measured in plasma and isolated lipoprotein fractions. RESULTS Of the 1351 patients with hypertriglyceridemia, 49 had type III hyperlipoproteinemia, as diagnosed by the apoB algorithm and validated by ultracentrifugation. Plasma triglycerides were higher in the type III subjects: 4.16 mmol/L (3.35-6.08, 25th-75th percentile), but there was considerable overlap with the hypertriglyceridemic subjects 2.65 mmol/L (1.91-4.20, 25th-75th percentile) and the combined hyperlipidemic subjects 3.02 mmol/L (2.07-5.32, 25th-75th percentile). Similarly, total cholesterol was 4.79 mmol/L (4.31-5.58, 25th-75th percentile) for type III vs 5.5 mmol/L (4.64-5.78, 25th-75th percentile) and 7.02 mmol/L (6.39-7.96, 25th-75th percentile), respectively. By contrast, as identified by the apoB algorithm, the VLDL-C/TG, VLDL-C/VLDL-TG, VLDL-C/VLDL apoB, and VLDL apoB/LDL apoB ratios were all higher in type III than in the other hypertriglyceridemic dyslipoproteinemias with the exception of type V as diagnosed by the apoB algorithm. CONCLUSION Cholesterol and triglycerides cannot reliably distinguish type III hyperlipoproteinemia from mixed hyperlipidemia. Adding apoB and applying the apoB algorithm makes reliable diagnosis possible and easy. However, unless apoB is introduced into routine clinical care, type III hyperlipoproteinemia will often not be recognized. Given the cardiovascular risk associated with type III and its responsiveness to treatment, this should not be acceptable.
Collapse
Affiliation(s)
- Allan D Sniderman
- Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
| | - Jacqueline de Graaf
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - George Thanassoulis
- Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - André J Tremblay
- Centre Hospitalier de l'Universite Laval, Quebec, Quebec, Canada
| | - Seth S Martin
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Patrick Couture
- Centre Hospitalier de l'Universite Laval, Quebec, Quebec, Canada
| |
Collapse
|
43
|
Sniderman AD, McQueen MJ. A failure of standardization or a failure of the process of standardization. J Clin Lipidol 2018; 12:1325-1326. [DOI: 10.1016/j.jacl.2018.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 05/10/2018] [Indexed: 10/16/2022]
|
44
|
Mavrakanas TA, Sniderman AD, Barré PE, Alam A. Serial versus single troponin measurements for the prediction of cardiovascular events and mortality in stable chronic haemodialysis patients. Nephrology (Carlton) 2018; 23:69-74. [PMID: 27718506 DOI: 10.1111/nep.12945] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/04/2016] [Accepted: 10/06/2016] [Indexed: 11/30/2022]
Abstract
AIM This study aims to describe the variability of pre-dialysis troponin values in stable haemodialysis patients and compare the performance of single versus fluctuating or persistently elevated troponins in predicting a composite of mortality and cardiac arrest, myocardial infarction or stroke. METHODS A total of 128 stable ambulatory chronic haemodialysis patients were enrolled. Pre-dialysis troponin I was measured for three consecutive months. The patients were followed for 1 year. A troponin elevation (>0.06 μg/L) was considered high risk, and patients were classified into three risk groups: (i) patients who had normal troponin levels on all three measurements; (ii) patients with at least one elevated and one normal troponin value; and (iii) patients with elevated troponin values on all measurements. RESULTS A total of 81 patients had all three troponin values in the normal range; 29 had fluctuating values; 18 had all three values elevated. Twenty-seven deaths or composite events were observed: eight in the first risk group, 10 in the second and nine in the third. Persistently elevated and fluctuating troponin values were associated with higher mortality and cardiovascular event rate. Serial troponin measurement had a higher sensitivity for the composite outcome than single troponin measurement when either fluctuating or persistently elevated values were considered to confer high risk. CONCLUSION Most haemodialysis patients do not have elevated troponin levels at baseline. Troponin levels that remain elevated or fluctuate are associated with worse outcomes. A serial troponin measurement strategy is associated with better sensitivity and higher negative predictive value compared with single troponin measurement.
Collapse
Affiliation(s)
- Thomas A Mavrakanas
- Division of Nephrology, McGill University Health Center, Montreal, Canada.,Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Allan D Sniderman
- Division of Cardiology, McGill University Health Center, Montreal, Canada
| | - Paul E Barré
- Division of Nephrology, McGill University Health Center, Montreal, Canada
| | - Ahsan Alam
- Division of Nephrology, McGill University Health Center, Montreal, Canada
| |
Collapse
|
45
|
Sniderman AD, Couture P, Martin SS, DeGraaf J, Lawler PR, Cromwell WC, Wilkins JT, Thanassoulis G. Hypertriglyceridemia and cardiovascular risk: a cautionary note about metabolic confounding. J Lipid Res 2018; 59:1266-1275. [PMID: 29769239 DOI: 10.1194/jlr.r082271] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 05/14/2018] [Indexed: 12/22/2022] Open
Abstract
Triglycerides are the conventional tool to measure VLDLs, whereas LDL cholesterol (LDL-C) is the conventional tool to measure LDLs. Multiple epidemiological studies, including a series of genetically based analyses, have demonstrated that cardiovascular risk is related to triglycerides independently of LDL-C, and this has led to a series of new therapeutic agents designed specifically to reduce plasma triglycerides. The triglyceride hypothesis posits that increased levels of triglycerides increase cardiovascular risk and decreasing plasma triglycerides decreases cardiovascular risk. In this work, we will examine the validity of the triglyceride hypothesis by detailing the biological complexities associated with hypertriglyceridemia, the genetic epidemiological evidence in favor of hypertriglyceridemia, the evidence from the fibrate randomized clinical trials relating triglycerides and clinical outcomes, and the completeness of the evidence from the initial studies of novel mutations and the therapeutic agents based on these mutations that lower triglycerides. Because of the multiple metabolic links between VLDL and LDL, we will try to demonstrate that measuring triglycerides and LDL-C alone are inadequate to document the lipoprotein profile. We will try to demonstrate that apoB must be measured, as well as triglycerides and cholesterol, to have an accurate estimate of lipoprotein status.
Collapse
Affiliation(s)
| | - Patrick Couture
- Centre Hospitalier Universitaire de Québec, Quebec, Quebec, Canada
| | - Seth S Martin
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Heart Disease, John Hopkins University School of Medicine, Baltimore, MD
| | - Jacqueline DeGraaf
- Department of General Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, University Health Network, Heart and Stroke, Richard Lewar Centre of Excellence in Cardiovascular Research, University of Toronto, Toronto, Ontario, Canada
| | | | - John T Wilkins
- Departments of Medicine (Cardiology) and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | |
Collapse
|
46
|
Labos C, Brophy JM, Smith GD, Sniderman AD, Thanassoulis G. Response by Labos et al to Letter Regarding Article, “Evaluation of the Pleiotropic Effects of Statins: A Reanalysis of the Randomized Trial Evidence Using Egger Regression”. Arterioscler Thromb Vasc Biol 2018; 38:e87-e88. [DOI: 10.1161/atvbaha.118.310907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Christopher Labos
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - James M. Brophy
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - George Davey Smith
- MRC Integrative Epidemiology Unit, University of Bristol, United Kingdom
| | - Allan D. Sniderman
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - George Thanassoulis
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
47
|
Labos C, Brophy JM, Smith GD, Sniderman AD, Thanassoulis G. Evaluation of the Pleiotropic Effects of Statins: A Reanalysis of the Randomized Trial Evidence Using Egger Regression-Brief Report. Arterioscler Thromb Vasc Biol 2017; 38:262-265. [PMID: 29122815 DOI: 10.1161/atvbaha.117.310052] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 10/24/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To reanalyze data from recent randomized trials of statins to assess whether the benefits and risks of statins are mediated primarily via their LDL-C (low-density lipoprotein cholesterol) lowering effects or via other mechanisms. APPROACH AND RESULTS We adapted Egger regression, a technique frequently used in Mendelian randomization studies to detect genetic pleiotropy, to reanalyze the available randomized control trial data of statin therapy. For cardiovascular end points, each 1 mmol/L change in LDL-C with statin therapy was associated with a hazard ratio of 0.77 (95% confidence interval, 0.71-0.84) with an intercept that was indistinguishable from zero (intercept, -0.0032; [95% confidence interval, -0.090 to 0.084]; P=0.94), indicating no pleiotropy. For incident diabetes mellitus, a 1 mmol/L change in LDL-C with statin therapy was associated with a hazard ratio of 1.07 (95% confidence interval, 0.99-1.16) and an intercept nondistinguishable from zero (intercept, -0.015; [95% confidence interval, -0.30 to 0.27]; P=0.91), again indicating no pleiotropy. CONCLUSIONS Our reanalysis of the randomized control trial data using Egger regression adds to the existing evidence that the cardiovascular benefits of statins and their association with incident diabetes mellitus are mediated primarily, if not entirely, via their LDL-C lowering properties rather than by any pleiotropic effects.
Collapse
Affiliation(s)
- Christopher Labos
- From the Preventive and Genomic Cardiology, Division of Cardiology, McGill University Health Centre and Research Institute, Montreal, QC, Canada (C.L., J.M.B., A.D.S., G.T.); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada (J.M.B.); and MRC Integrative Epidemiology Unit, University of Bristol, United Kingdom (G.D.S.).
| | - James M Brophy
- From the Preventive and Genomic Cardiology, Division of Cardiology, McGill University Health Centre and Research Institute, Montreal, QC, Canada (C.L., J.M.B., A.D.S., G.T.); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada (J.M.B.); and MRC Integrative Epidemiology Unit, University of Bristol, United Kingdom (G.D.S.)
| | - George Davey Smith
- From the Preventive and Genomic Cardiology, Division of Cardiology, McGill University Health Centre and Research Institute, Montreal, QC, Canada (C.L., J.M.B., A.D.S., G.T.); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada (J.M.B.); and MRC Integrative Epidemiology Unit, University of Bristol, United Kingdom (G.D.S.)
| | - Allan D Sniderman
- From the Preventive and Genomic Cardiology, Division of Cardiology, McGill University Health Centre and Research Institute, Montreal, QC, Canada (C.L., J.M.B., A.D.S., G.T.); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada (J.M.B.); and MRC Integrative Epidemiology Unit, University of Bristol, United Kingdom (G.D.S.)
| | - George Thanassoulis
- From the Preventive and Genomic Cardiology, Division of Cardiology, McGill University Health Centre and Research Institute, Montreal, QC, Canada (C.L., J.M.B., A.D.S., G.T.); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada (J.M.B.); and MRC Integrative Epidemiology Unit, University of Bristol, United Kingdom (G.D.S.)
| |
Collapse
|
48
|
Burstein B, Altobelli KK, Williams K, Cannon CP, Pencina MJ, Sniderman AD, Thanassoulis G. Impact of Heart Outcomes Prevention Evaluation Trial on Statin Eligibility for the Primary Prevention of Cardiovascular Disease: Insights from the National Health and Nutrition Examination Survey. Circulation 2017; 136:1860-1862. [PMID: 29109198 DOI: 10.1161/circulationaha.117.029102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Barry Burstein
- From McGill University, Montreal, Canada (B.B.); KenAnCo Biostatistics, San Antonio, TX (K.K.A., K.W.); Baim Institute for Clinical Research, Boston, MA (C.P.C.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Canada (A.D.S., G.T.)
| | - Kathleen K Altobelli
- From McGill University, Montreal, Canada (B.B.); KenAnCo Biostatistics, San Antonio, TX (K.K.A., K.W.); Baim Institute for Clinical Research, Boston, MA (C.P.C.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Canada (A.D.S., G.T.)
| | - Ken Williams
- From McGill University, Montreal, Canada (B.B.); KenAnCo Biostatistics, San Antonio, TX (K.K.A., K.W.); Baim Institute for Clinical Research, Boston, MA (C.P.C.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Canada (A.D.S., G.T.)
| | - Christopher P Cannon
- From McGill University, Montreal, Canada (B.B.); KenAnCo Biostatistics, San Antonio, TX (K.K.A., K.W.); Baim Institute for Clinical Research, Boston, MA (C.P.C.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Canada (A.D.S., G.T.)
| | - Michael J Pencina
- From McGill University, Montreal, Canada (B.B.); KenAnCo Biostatistics, San Antonio, TX (K.K.A., K.W.); Baim Institute for Clinical Research, Boston, MA (C.P.C.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Canada (A.D.S., G.T.)
| | - Allan D Sniderman
- From McGill University, Montreal, Canada (B.B.); KenAnCo Biostatistics, San Antonio, TX (K.K.A., K.W.); Baim Institute for Clinical Research, Boston, MA (C.P.C.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Canada (A.D.S., G.T.)
| | - George Thanassoulis
- From McGill University, Montreal, Canada (B.B.); KenAnCo Biostatistics, San Antonio, TX (K.K.A., K.W.); Baim Institute for Clinical Research, Boston, MA (C.P.C.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Canada (A.D.S., G.T.).
| |
Collapse
|
49
|
Affiliation(s)
- George Thanassoulis
- Department of Medicine, McGill University Health Centre, Montreal, Québec, Canada
| | - Michael J. Pencina
- Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University, Durham, North Carolina4Deputy Editor for Statistics, JAMA Cardiology
| | - Allan D. Sniderman
- Royal Victoria Hospital–McGill University Health Centre, McGill University, Montreal, Québec, Canada
| |
Collapse
|
50
|
Affiliation(s)
| | - Eric D Peterson
- Duke University Medical Center, Durham, North Carolina
- Associate Editor
| |
Collapse
|