New strategies for the development of lipid-lowering therapies to reduce cardiovascular risk

The very high occurrence of cardiovascular events presents a major public health issue, because treatment remains suboptimal. Lowering LDL cholesterol (LDL-C) with statins or ezetimibe in combination with a statin reduces major adverse cardiovascular events. The cardiovascular risk reduction in relation to the absolute LDL-C reduction is linear for most interventions without evidence of attenuation or increase in risk at low LDL-C levels. Opportunities for innovation in dyslipidaemia treatment should address the substantial risk of lipid-associated cardiovascular events among patients optimally treated per guidelines but who cannot achieve LDL-C goals and who could benefit from additional LDL-C-lowering therapy or experience side effects of statins. Fresh approaches are needed to identify promising drug targets early and develop them efficiently. The Cardiovascular Round Table of the European Society of Cardiology (ESC) convened a workshop to discuss new lipid-lowering strategies for cardiovascular risk reduction. Opportunities to improve treatment approaches and the efficient study of new therapies were explored. Circulating biomarkers may not be fully reliable proxy indicators of the relationship between treatment effect and clinical outcome. Mendelian randomization studies may better inform development strategies and refine treatment targets before Phase 3. Trials should match the drug to appropriate lipid and patient profile, and guidelines may move towards a precision-based approach to individual patient management. Stakeholder collaboration is needed to ensure continued innovation and better international coordination of both regulatory aspects and guidelines. It should be noted that risk may also be addressed through increased attention to other risk factors such as smoking, hypertension, overweight, and inactivity.

Vascular cell adhesion molecule-1 and intercellular adhesion molecule-1 serum level in patients with chest pain and normal coronary arteries (syndrome X)

BACKGROUND

Plasma levels of soluble vascular cell adhesion molecule-1 (VCAM-1) and intercellular adhesion molecule-1 (ICAM-1) mediators of leukocyte adhesion to vascular endothelium may implicate in the pathogenesis of the syndrome of chest pain with normal coronary arteries.

HYPOTHESIS

We attempted to determine whether markers of endothelial activation are raised in patients with chest pain and normal coronary arteries.

METHODS

We measured plasma VCAM-1, ICAM-1 (ng/ ml) in 36 patients (34 men, 2 women, aged 62 +/- 9 years) with stable angina, coronary artery disease (CAD), and a positive response to exercise test; in 21 patients (6 men, 15 women, aged 56 +/- 9 years) with chest pain and normal coronary arteriograms (syndrome X); and in 11 healthy control subjects (8 men, 3 women, aged 49 +/- 14 years).

RESULTS

Plasma ICAM-1 levels were significantly higher both in patients with CAD (mean +/- standard error of the mean) (328 +/- 26, p < 0.05), and in syndrome X (362 +/- 22, p < 0.01) than in controls (225 +/- 29). VCAM-1 levels were also higher in syndrome X (656 +/- 42 ng/ml) and in patients with CAD (626 +/- 42 ng/ml) than in controls (551 +/- 60, p = 0.09).

CONCLUSIONS

ICAM-1 and VCAM-1 levels are increased both in patients with CAD and with syndrome X compared with control individuals. These findings may suggest the presence of chronic inflammation with involvement of the endothelium in patients with anginal chest pain and normal coronary angiograms.

Markers of Inflammation and Rapid Coronary Artery Disease Progression in Patients With Stable Angina Pectoris

BACKGROUND

Both endothelial cell activation and macrophage activation play a significant role in atherogenesis and atheromatous plaque vulnerability and may determine rapid coronary artery disease (CAD) progression. We sought to assess the association between serum inflammatory markers and rapid CAD progression in patients with chronic stable angina pectoris.

METHODS AND RESULTS

We studied 124 chronic stable angina pectoris patients (84 men; mean age, 61+/-10 years) who were on a waiting list for coronary angioplasty for a mean time of 4.8+/-2.4 months. CAD progression was defined as > or =10% diameter reduction of a pre-existing stenosis > or =50%, > or =30% diameter reduction of a stenosis <50%, development of a new stenosis > or =30% in a previously normal segment, or progression of any stenosis to total occlusion. CAD progression occurred in 35 patients (28%). After adjustment with binary logistic regression, neopterin (P<0.001), high-sensitivity C-reactive protein (P=0.017), matrix metalloproteinase-9 (P=0.002), soluble intercellular adhesion molecule 1 (P<0.001), and previous history of unstable angina (P=0.01) were independent predictors of rapid CAD progression. The association between rapid disease progression and inflammatory markers remained significant even when presence of complex lesions was introduced into the multivariate model.

CONCLUSIONS

Rapid CAD progression in patients with stable angina pectoris is associated with increased C-reactive protein levels and raised concentrations of biochemical markers of endothelial and macrophage activation.

Multiple complex stenoses, high neutrophil count and C-reactive protein levels in patients with chronic stable angina

Inflammation plays an important role in atherosclerosis and the genesis of acute coronary syndromes, i.e., atheromatous plaque disruption. Neutrophil count and C-reactive protein (CRP) levels are markers of ongoing inflammation and predictors of cardiovascular risk. We sought to assess whether these inflammatory markers are associated with the presence of multiple complex stenoses in patients with chronic stable angina.

METHODS AND RESULTS

We assessed 150 patients with chronic stable angina, 121 with significant coronary artery stenosis (> or =50% diameter reduction) and 29 without. CRP levels and neutrophil count were assessed at study entry. Stenoses were classified as "complex" (irregular or scalloped borders, ulceration or filling defects) or "smooth" (absence of complex features). Eighty-eight percent of the complex lesions were of type C according to AHA/ACC classification whereas the rest were type B. Patients with > or =3 complex lesions were considered to have multiple complex stenoses. Extent of coronary artery disease was assessed using a validated score. Baseline neutrophil count (4.39 x 10(9) L (-1) +/- 28 versus 3.82 x 10(9) L (-1) +/- 0.77; P = 0.004) and CRP levels (2.15 mg/L (4.6-1) versus 0.39 mg/L (0.69-0.23); P < 0.0001) were higher in patients with significant stenoses compared to patients without. No association was found between disease extent and CRP levels or neutrophil count. Neutrophil count, however (but not CRP) correlated with stenosis complexity (r = 0.28; P = 0.002 ) and was also an independent predictor of the presence of multiple complex stenoses (OR: 4.05; CI 95% (1.9-10.4); P = 0.038).

CONCLUSIONS

CRP levels and neutrophil count are higher in angina patients with coronary stenoses compared to those without. Neutrophil count, but not CRP levels, correlates with angiographic stenosis complexity.

Prognostic value of neopterin levels in treated patients with hypertension and chest pain but without obstructive coronary artery disease

We sought to assess the relation between circulating levels of inflammation markers, such as neopterin and C-reactive protein, and the development of adverse cardiovascular events in patients with hypertension but without obstructive coronary artery disease. We observed that patients who developed adverse events during follow-up had significantly higher neopterin levels compared with patients without events.

Chronic inflammation and increased arterial stiffness in patients with cardiac syndrome X

AIMS

Endothelial dysfunction and subangiographic atheroma have been reported in patients with cardiac syndrome X (CSX) but little is known regarding chronic inflammation and reduced arterial distensibility as pathogenic mechanisms. We assessed whether markers of inflammation and arterial distensibility differ in CSX patients compared to control subjects.

METHODS AND RESULTS

We studied 30 consecutive CSX patients (mean age 57+/-6 years, 25 women) and 30 healthy controls (mean age 54+/-8 years, 25 women). High sensitivity C-reactive protein (hs-CRP) levels were significantly higher in patients with CSX compared to controls (2.6 [1.7-4.5] vs 1.5[0.7-2.7] mg/l, P=0.02). Hs-CRP levels correlated with carotid intima-media thickness (IMT) (Spearman's rho=0.51; P=0.013). CSX patients also had significantly increased mean IMT values than controls (P<0.0001). Arterial stiffness and elastic modulus were also significantly increased in CSX patients compared to control subjects (P=0.04 and P=0.04, respectively). Distensibility tended to be lower in CSX patients than controls although this difference did not reach statistical significance.

CONCLUSIONS

This study showed for the first time that compared to control subjects, patients with CSX have higher hs-CRP serum levels, increased mean common carotid artery IMT and increased arterial stiffness. The role of these abnormalities in the pathogenesis of CSX deserves investigation.

Increased plasma adhesion molecule levels in patients with heart failure who have ischemic heart disease and dilated cardiomyopathy

BACKGROUND

Inflammatory mechanisms, including leukocyte activation, appear to play a pathogenetic role in the development of heart failure. Vascular cell adhesion molecule-1 (VCAM-1) and intercellular adhesion molecule-1 (ICAM-1) are important mediators of leukocyte adhesion to vascular endothelium. The plasma levels of the soluble form of these molecules may be elevated in chronic inflammation.

METHODS AND RESULTS

We measured plasma VCAM-1 and ICAM-1 levels (in nanograms per milliliter) with the commercially available enzyme-linked immunosorbent assay method in 12 patients (9 male, 3 female, aged 64 +/- 8 years) with dilated cardiomyopathy and heart failure, in 23 patients (23 male, aged 65 +/- 9 years) with ischemic cardiomyopathy and heart failure, and in 11 healthy control subjects (8 male, 3 female, aged 49 +/- 14 years). Plasma ICAM-1 levels were higher both in patients with dilated cardiomyopathy (363 +/- 77 ng/mL, P <.05) (mean +/- SEM) and in those with ischemic heart disease (320 +/- 32 ng/mL, P <.05) than in control subjects (225 +/- 29 ng/mL). VCAM-1 levels were also higher in both groups with heart failure (664 +/- 73 ng/mL) than in control subjects (551 +/- 60 ng/mL). VCAM-1 levels were higher in patients with class IV compared with those with class II and III heart failure.

CONCLUSIONS

Plasma adhesion molecule levels are increased in patients with heart failure and are unrelated to the presence or absence of angiographically demonstrable atherosclerotic coronary artery disease. The plasma level of VCAM-1 correlates with the severity of heart failure.

C-reactive protein in patients with chronic stable angina: differences in baseline serum concentration between women and men

AIMS

Serum C-reactive protein has prognostic significance in apparently healthy men and women and in men with coronary artery disease. Little is known regarding the predictive role of C-reactive protein in women with coronary heart disease. We assessed whether differences exist in C-reactive protein levels and their prognostic value in men compared with women. We also assessed whether C-reactive protein concentrations differed in women receiving hormone replacement therapy vs those on no hormone replacement therapy.

METHODS AND RESULTS

We prospectively studied 911 consecutive patients (327 women) with typical exertional angina. All patients underwent clinical, biochemical and angiographic characterization at study entry. Serum C-reactive protein was measured using a highly sensitive assay and correlated with clinical events during follow-up (from 1.0 to 3.7 years). C-reactive protein was significantly higher in women than men (3.0 mg. l(-1)[range 1.3-5.8] vs 2.1 mg. l(-1)[range 1.0-4.2], P<0.001), even after multiple regression adjustment for other risk factors. C-reactive protein was also significantly higher in women receiving hormone replacement therapy than in women not using hormone replacement therapy (P=0.001). C-reactive protein was an independent predictor of cardiovascular risk (logistic regression P=0.033) in the whole group but, despite higher C-reactive protein concentration, women had a similar rate of cardiac events compared to men.

CONCLUSIONS

Baseline C-reactive protein levels were higher in women than men but the event rate was similar in men and women. Women on hormone replacement therapy had significantly higher C-reactive protein than women not using hormone replacement therapy. In the group as a whole, increased C-reactive protein was associated with a higher cardiovascular risk.

Increased serum neopterin: a marker of coronary artery disease activity in women

OBJECTIVE

To assess whether neopterin concentrations in women with unstable angina differ from those in women with chronic stable angina.

DESIGN

Prospective cohort study.

SETTING

University hospital in south west London.

PATIENTS

114 consecutive women with angina were studied: 82 had chronic stable angina (typical exertional chest pain, positive exercise ECG testing, and/or abnormal myocardial scintigraphy; symptoms stable for at least three months), and 32 had unstable angina (Braunwald class III). All patients with chronic stable angina (100%) and 18 with unstable angina (56.3%) underwent digital coronary angiography; neopterin concentrations were determined using a commercially available immunoassay.

MAIN OUTCOME MEASURES

Major clinical events during one year follow up were readmission with Braunwald's class IIIb unstable angina, non-fatal myocardial infarction, and cardiac death.

RESULTS

Major events occurred in 12 women with chronic stable angina (14.6%) and nine women with unstable angina (28.1%). Mean (range) neopterin concentrations were significantly higher in women with unstable angina than in those with chronic stable angina (7.6 (5.1-11.5) nmol/l v 5.9 (4.4-7.5) nmol/l; p = 0.003), even after adjustment for variables which were significantly different on univariate analysis. In women with chronic stable angina, baseline neopterin concentrations were higher in those with cardiac events than in those without events (7.1 (5.9-9.1) nmol/l v 5.7 (3.9-7.3 nmol/l); p = 0.010), even after adjustment for variables with significant differences between both groups on univariate analysis.

CONCLUSIONS

On average, women with unstable angina had significantly higher neopterin concentrations than women with chronic stable angina. Women with chronic stable angina with events during follow up had higher neopterin concentrations than those without events. Neopterin concentrations were similar in patients with unstable angina and women with chronic stable angina who developed events. Neopterin concentrations may therefore be a marker of risk in women with coronary artery disease.