Diet in secondary prevention: the effect of dietary patterns on cardiovascular risk factors in patients with cardiovascular disease: a systematic review and network meta-analysis

BACKGROUND

Improving dietary habits is a first-line recommendation for patients with cardiovascular disease (CVD). It is unclear which dietary pattern most effectively lowers cardiovascular risk factors and what the short- and long-term effects are. Therefore, this network meta-analysis compared the effects of popular dietary patterns on cardiovascular risk factors in patients with established CVD.

METHODS

A systematic search of PubMed, Embase, the Cochrane library, SCOPUS and Web of Science was conducted up to 1 April 2023. Randomized controlled trials (RCTs) comparing the effect of popular dietary patterns (Mediterranean, moderate carbohydrate, low glycemic index, low-fat and minimal dietary intervention) on cardiovascular risk factors (body weight, systolic blood pressure, lipids) in CVD populations were selected. A random-effects network meta-analysis was performed.

RESULTS

Seventeen RCTs comprising 6,331 participants were included. The moderate carbohydrate diet had the most beneficial effect on body weight (-4.6 kg, 95%CrI -25.1; 15.8) and systolic blood pressure (-7.0 mmHg 95%CrI -16.8; 2.7) compared to minimal intervention. None of the included dietary patterns had a favorable effect on low-density lipoprotein cholesterol. After 12 months, the effects were attenuated compared to those at < 6 months.

CONCLUSIONS

In this network meta-analysis of 17 randomized trials, potentially clinically relevant effects of dietary interventions on CV risk factors were observed, but there was considerable uncertainty due to study heterogeneity, low adherence, or actual diminished effects in the medically treated CVD population. It was not possible to select optimal dietary patterns for secondary CVD prevention. Given recent clinical trials demonstrating the potential of dietary patterns to significantly reduce cardiovascular event risk, it is likely that these effects are effectuated through alternative physiological pathways.

LDL cholesterol targets rarely achieved in familial hypercholesterolemia patients: A sex and gender-specific analysis

BACKGROUND AND AIMS

Despite lipid lowering therapy (LLT), reaching LDL-C targets in patients with familial hypercholesterolemia (FH) remains challenging. Our aim was to determine attainment of LDL-C target levels and reasons for not reaching these in female and male FH patients.

METHODS

We performed a cross-sectional study of heterozygous FH patients in five hospitals in the Netherlands and Norway. Clinical characteristics and information about LLT, lipid levels and reasons for not being on LDL-C treatment target were retrospectively collected from electronic medical records.

RESULTS

We studied 3178 FH patients (53.9% women), median age 48.0 (IQR 34.0-59.9) years. Median LDL-C before treatment and on-treatment was higher in women compared to men (6.2 (IQR 5.1-7.3) and 6.0 (IQR 4.9-7.2) mmol/l (p=0.005) and 3.0 (IQR 2.4-3.8) and 2.8 (IQR 2.3-3.5) mmol/L (p<0.001)), respectively. A minority of women (26.9%) and men (28.9%) reached LDL-C target. In patients with CVD, 17.2% of women and 25.8% of men reached LDL-C target. Women received less often high-intensity statins and ezetimibe. Most common reported reasons for not achieving the LDL-C target were insufficient effect of maximum LLT (women 17.3%, men 24.3%) and side effects (women 15.2%, men 8.6%).

CONCLUSIONS

In routine practice, only a minority of women and men with FH achieved their LDL-C treatment target. Extra efforts have to be made to provide FH patients with reliable information on the safety of statins and their long-term effects on CVD risk reduction. If statin treatment is insufficient, alternative lipid lowering therapies such as ezetimibe or PCSK9-inhibitors should be considered.

Effect of dietary patterns on cardiovascular risk factors in people with type 2 diabetes. A systematic review and network meta-analysis

AIMS

To identify the most effective dietary pattern for improving cardiovascular risk factors in people with type 2 diabetes.

METHODS

PubMed, Embase, the Cochrane library, SCOPUS and Web of Science were systematically searched for randomized controlled trials comparing the effects of dietary patterns on body weight, blood pressure, HbA1c and lipids after 6 and 12 months. Treatment effects were synthesized using Bayesian network meta-analysis. Six-month changes in HbA1c, SBP and LDL-C were used to estimate relative risk reductions (RRR) for cardiovascular events.

RESULTS

Seventy-three RCTs on eight different dietary patterns were included. All reduced body weight and HbA1c after 6 months, with the largest effects from the low carbohydrate (body weight -4.8 kg, 95 %credibility interval (95 %CrI) -6.5;-3.2 kg) and Mediterranean diet (HbA1c -1.0 %, 95 %CrI -15;-0.4 % vs usual diet). There were no significant 6-month blood pressure or lipid effects. Dietary patterns had non-statistically significant 12-months effects. The Mediterranean diet resulted in the largest expected RRR for cardiovascular events: -16 % (95 %CI -31;3.0) vs usual diet.

CONCLUSIONS

In patients with type 2 diabetes, all dietary patterns outperformed usual diet in improving body weight and HbA1c after 6 months and clinically relevant cardiovascular risk reduction could be achieved. There was insufficient evidence to select one optimal dietary pattern.

Effect of diet and lifestyle on the relationship between body mass index and waist circumference and cardiovascular mortality in myocardial infarction patients from the Alpha Omega Cohort

Introduction

The associations between measures of body adiposity body mass index (BMI) and waist circumference (WC) and cardiovascular disease (CVD) mortality have been frequently studied and usually follow a J-shaped curve or show a positive relationship. However, less is known about the influence of diet and physical activity on these associations.

Purpose

We aimed to gain insight in potential lifestyle-related effect modifiers of the association of BMI and WC with CVD mortality in myocardial infarction (MI) patients.

Methods

We included 4,837 Dutch patients from the Alpha Omega Cohort with a MI &lt;10 y prior enrolment. BMI and WC were assessed at baseline (2002–2006). Patients were followed through December 2018 for vital status and cause-specific mortality. Continuous associations of BMI and WC with CVD mortality were estimated using Cox proportional hazards models with restricted cubic splines. A BMI of 25 kg/m2 and a WC of 100 cm were used as the references. Age and sex adjusted associations were stratified for diet quality and physical activity level and interaction terms were calculated.

Results

Of the study population (69.0±5.6 y), 17% smoked, 21% had diabetes, 22% were female and &gt;85% used any type of cardiovascular medication. During a median follow-up of 12.4 years [8.5–13.8], 1,010 deaths occurred due to CVD. A J-shaped continuous association was observed between BMI and CVD mortality with inverse associations for a BMI between 25–30 kg/m2, compared to 25 kg/m2. The nadir (HR, 95% CI) was 27.4 kg/m2 (HR: 0.94, 95% CI: 0.88, 1.00) (A). For WC, a non-linear association was observed with CVD mortality with higher mortality risks for a WC above 100 cm (A). Results were similar in patients with low versus high diet quality and in patients with low versus high physical activity (B), interaction terms were not significant (all p&gt;0.55).

Conclusion

In MI patients, a BMI between 25–30 kg/m2 was associated with the lowest risk of CVD mortality. A WC above 100 cm was associated with a higher CVD mortality risk. The observed associations manifested independently of diet quality and physical activity level. Therefore, body adiposity seems to determine CVD mortality risk independently of underlying lifestyle factors.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Regio Deal Foodvalley

Effect of evolocumab versus placebo added to standard lipid-lowering therapy on fasting and post fat load lipids and lipoproteins in familial dysbetalipoproteinemia

Background

Familial Dysbetalipoproteinemia (FD) is the second most common genetic lipid disorder (prevalence ranging from 1 in 1000–2500), characterized by impaired postprandial lipoprotein clearance and associated with increased cardiovascular (CVD) risk. The majority of FD patients do not achieve non-HDL-cholesterol treatment goals, indicating the medical need for additional lipid-lowering treatment options.

Purpose

To evaluate the effect of the PCSK9 monoclonal antibody evolocumab added to standard lipid-lowering therapy on fasting and post fat load lipids and lipoproteins in FD patients.

Methods

A randomized placebo-controlled double-blind crossover trial comparing evolocumab (140 mg subcutaneous every 2 weeks) with placebo during two 12 week treatment periods. At the start and end of each treatment period FD patients received an oral fat load. The primary endpoint was the 8 hour post fat load non-HDL-cholesterol level expressed as area under the curve (AUC). Levels of other fasting and post fat load lipids and (apo)lipoproteins were assessed with ultracentrifugation, polyacrylamide gels, retinyl palmitate and SDS-PAGE.

Results

In total, 28 patients completed the study. Mean age was 62±9 years and 93% had an ɛ2ɛ2 genotype. Compared with placebo, evolocumab reduced fasting non-HDL-cholesterol with 51% (95% CI 43–57) and the 8 hours post fat load non-HDL-cholesterol AUC with 49% (95% CI 42–55). Fasting triglyceride levels were reduced with 24% (95% CI 14–37) and the 8 hours post fat load triglyceride AUC was reduced with 22% (95% CI 11–29). Except for HDL-cholesterol, all fasting and 8 hour post fat load lipids and (apo)lipoproteins were significantly reduced by evolocumab, including apolipoprotein B (8 hour post fat load AUC reduction 47% (95% CI 41–53) and remnant cholesterol (8 hour post fat load AUC reduction 49% (95% CI −38 to 59)), compared with placebo. After treatment with evolocumab, 89% of patients achieved their non-HDL-cholesterol treatment goal compared with 36% after placebo.

Conclusion

Evolocumab added to standard lipid-lowering therapy significantly reduced fasting and post fat load non-HDL-cholesterol and other atherogenic lipids and lipoproteins in FD patients. This is the largest clinical trial in FD to date and the first to investigate evolocumab in this very high-risk group. The large decrease in fasting and post fat load lipids and lipoproteins will likely lower CVD risk in these patients.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AmgenThis project was funded by Amgen for an investigator-initiated research project. The University Medical Center Utrecht was the sponsor of the study. The financial funder had no role in the design, collection of the data, conduct of the analyses or reporting of the study results.

Risk factors for the presence and development of Familial Dysbetalipoproteinemia in subjects from the general population with an APOE2E2 genotype

Background

Subjects who carry one or two ɛ2 alleles of the APOE gene are protected from cardiovascular disease due to low LDL-cholesterol levels. However, 10–18% of ɛ2 homozygotes (ɛ2ɛ2) develop Familial Dysbetalipoproteinemia (FD), which is characterized by extensive remnant lipoprotein accumulation, making it a good model to study the effect of remnants on atherosclerosis and cardiovascular disease. Important causal factors for FD, or an “FD like phenotype” in ɛ2 heterozygotes (ɛ2ɛ3), are thought to be adiposity and insulin resistance. However, to date this relation was only evaluated in cross-sectional studies.

Purpose

To evaluate the cross-sectional and longitudinal association of adiposity and insulin resistance on the presence and development of FD in ɛ2ɛ2 or an “FD-like” phenotype in ɛ2ɛ3 subjects.

Methods

For this study we included 18042 subjects with an APOE measurement from two Dutch population-based cohorts; the PREVEND cohort (follow-up 4.1 (interquartile range (IQR) 4.0–4.4) years) and the Rotterdam Study (follow-up 10.1 (IQR 5.6–10.8) years). Subjects with an ɛ3ɛ3 genotype (n=10391) and ɛ4 carriers were excluded (n=5265). FD and “FD like” phenotype were defined as triglyceride levels &gt;3 mmol/l or use of lipid lowering medication. Logistic regression models were used to evaluate the effect of age, sex, BMI, waist circumference, type 2 diabetes mellitus (T2DM) and metabolic syndrome (MetS) on FD lipid phenotype. Changes in adiposity measures and insulin resistance between baseline and follow-up were compared in subjects with and without development of FD at follow-up.

Results

In total, 2386 subjects were included of whom 118 participants had ɛ2ɛ2 and 2268 had ɛ2ɛ3 of whom 68% completed a follow-up visit. Subjects mean age was 59±14 years and 44% were male. In ɛ2ɛ2 subjects, 19% (n=23) had FD at baseline and 16% (n=11) developed FD during follow-up. In ɛ2ɛ3 subjects 13% (n=305) had an “FD like” phenotype at baseline and 11% (n=146) at follow-up. Cross-sectional determinants for the presence of an FD or “FD like” phenotype at baseline were male sex, BMI, waist circumference and non-lipid MetS criteria.

In ɛ2ɛ2 subjects who developed FD during follow-up, markers of adiposity and insulin resistance did not change compared to baseline. However, these FD patients more often had adiposity (BMI, weight and waist circumference) and T2DM at baseline, compared to those and who did not developed FD.

Conclusions

These results show for the first time that adiposity and insulin resistance are important risk markers for future development of FD or “FD like” phenotype in ɛ2ɛ2- and ɛ2ɛ3 subjects. The increased susceptibility of ɛ2 carriers for development of an FD lipid phenotype by adiposity and insulin resistance might be due to impaired remnant clearance consequent to decreased binding affinity of APOɛ2 to the LDL-receptor in combination with degradation of the heparan sulfate receptor by insulin resistance (mediated by sulfatase 2 activation).

Odds Ratios for FD lipid phenotype

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): UMC Utrecht; Erasmus MC; UMC Groningen

4943Remnant cholesterol increases the risk for recurrent vascular events independent of LDL-cholesterol in patients with clinical manifest vascular disease

Background

For many years, low density lipoprotein cholesterol (LDL-C) is recognized as an important risk factor for the development of atherosclerosis and cardiovascular disease. However, even with normal LDL-C levels there is a residual risk for cardiovascular disease and mortality. Previous research in patients with ischemic heart disease, diabetes mellitus type 2 (T2DM) and in the general population has shown that this residual risk could be explained by elevated plasma levels of very low density lipoprotein- (VLDL) and chylomicron-remnant cholesterol.

Purpose

We evaluated the relation between plasma levels of VLDL- and chylomicron-remnant cholesterol and recurrent vascular disease and all-cause mortality in a cohort of patients with clinical manifest arterial disease.

Methods

Prospective cohort study in 8057 patients with manifest arterial disease from the UCC-SMART study. Patients with triglyceride levels >9 mmol/L or known homozygote Apo E2 genotype were excluded. Cox proportional hazard models were used to evaluate the effect of fasting VLDL- and chylomicron-remnant cholesterol (calculated by total cholesterol - high density lipoprotein cholesterol (HDL-C) - LDL-C) on occurence of myocardial infarction (MI), stroke, vascular death, a composite endpoint (i.e. MI, stroke, vascular death) and all-cause mortality. Models were adjusted for LDL-C, current smoking, waist circumference, creatinine and systolic blood pressure. Effect modification of HDL-C and T2DM on the relation between remnant cholesterol and vascular endpoints was evaluated.

Results

Patients mean age was 60.0±10.3 years, 74% were male, 4894 (61%) had a prior history of coronary artery disease (CAD), 2445 (30%) of stroke and 1990 (25%) patients had peripheral arterial disease (PAD) or aneurysm abdominal aorta (AAA). There were 1544 vascular events and 1792 deaths during a median follow up of 8.2 (interquartile range (IQR) 4.5–12.2) years and a total follow up of 68699 person-years. For every 1 mmol/L increase in remnant cholesterol, risk for recurrent vascular events was increased in patients with manifest vascular disease (HR 1.17; 95% CI 1.05–1.31 for the composite endpoint (figure 1)). There was no effect for all-cause mortality in this population. Furthermore, there was no significant effect modification of HDL-C and the presence of T2DM on the relation between remnant cholesterol and vascular endpoints.

Figure 1

Conclusion

In patients with clinically manifest arterial disease plasma remnant cholesterol confers an increased risk for recurrent vascular events, independent of traditional risk factors such as LDL-C levels.