Prevalence of atherogenic dyslipidemia: association with risk factors and cardiovascular risk in Spanish working population. "ICARIA" study

OBJECTIVE

The aim of this study was to assess the prevalence of atherogenic dyslipidemia (AD) and the lipid triad (LT) in the working population in Spain, their associated variables and how far they are linked to cardiovascular risk (CVR).

METHODS

Observational cross-sectional study of 70,609 workers (71.5% male (M), 28.5% female (F), mean age 39.2 ± 10), who attended medical checkups and agreed to participate. Plasma samples were analysed in a central laboratory. AD definition used was: triglycerides ≥150 mg/dl and HDL cholesterol <40 mg/dl (M)/<50 mg/dl (F) and LT when LDL cholesterol > 160 mg/dl is further added. Univariate comparisons in the absence and presence of AD and LT and the probability of AD according to different parameters and their possible association with CVR were assessed. CVR was stratified following the European SCORE model for low risk-population.

RESULTS

5.7% (95% CI 4.7-6.9) of the working population have AD and 1.1% (95% CI 1.0-1.2) LT. In univariate analysis, workers with AD and LT had a higher prevalence of obesity, hypertension, smoking and diabetes than those who had not (p < 0.001). In multivariate analysis, BMI, sex, age 40-49, diabetes, tobacco, uric acid, LDL or blood pressure significantly influenced the risk of AD. AD was significantly associated with CVR after adjusting for alcohol and obesity. However, most of the AD subjects (91.8%) were classified as low risk.

CONCLUSIONS

About 6% of the working population in Spain meets AD criteria. Assuming that these subjects have increased CVR, AD allows to identify additional 5% of subjects with increased CVR to that one the SCORE model detects, helping to improve cardiovascular risk stratification.

Clinical decisions in patients with diabetes and other cardiovascular risk factors. A statement of the Spanish Society of Internal Medicine

Although the mortality associated to cardiovascular diseases (CVD) has been reduced in the last decades, CVD remains the main cause of mortality in Spain and they are associated with an important morbidity and a huge economic burden. The increasing prevalence of obesity and diabetes could be slowing down the mortality reduction in Spain. Clinicians have often difficulty making clinical decisions due to the multiple clinical guidelines available. Moreover, in the current context of economic crisis it is critical to promote an efficient use of diagnostic and therapeutic proceedings to ensure the viability of public health care systems. The Spanish Society of Internal Medicine (SEMI) has coordinated a consensus document to answer questions of daily practice with the aim of facilitating physicians' decision-making in the management of diabetes and cardiovascular risk factors from a cost-efficiency point of view.

Familial hypobetalipoproteinemia: analysis of three Spanish cases with two new mutations in the APOB gene

Extremely low LDL-cholesterol concentrations are very unusual and generally related with comorbidities accompanying malnutrition. Less frequently low LDL-cholesterol levels result from mutations in the APOB, PCSK9, ANGPTL3, SAR1B and MTTP genes (primary hypobetalipoproteinemia). We investigated three patients with plasma LDL-cholesterol levels below the fifth percentile of the Spanish population. We recorded data on demographic and anthropometric characteristics, life style habits, physical examination, liver ultrasound and lipid and lipoprotein levels, in the probands and their first-degree relatives. Secondary causes of hypocholesterolemia were ruled out by clinical study, complementary tests and follow-up. The APOB, MTTP and SAR1B genes were sequenced. Patients were found to be heterozygotes for point mutations located in the exon 26 of the APOB gene. One patient, with fatty liver, carried a previously described mutation (c.7600C>T) (Arg2507X), causing the formation of truncated Apo B-55.25. The other two mutations producing truncations are new. One asymptomatic patient carried the Arg3672X (Apo B-80.93) and the other with fatty liver and steatorrhea carried the Ser2184fsVal2193X (Apo B-48.32). Our study reinforces the concept that in the heterozygous carriers of truncated Apo Bs, the clinical manifestations of FHBL are dependent on the size of the truncations.

Fasting apolipoprotein B48 is a marker for peripheral arterial disease in type 2 diabetes

An earlier study showed that fasting and postprandial concentrations of apolipoprotein B48 were raised in patients with type 2 diabetes (DM2) and peripheral arterial disease (PAD) as compared with persons without DM2 or persons with DM2 but not PAD. The aim of this study was to confirm the association of PAD and B48 in a larger group of patients with DM2 and the relation of B48 with the preheparin lipoprotein lipase (LPL) mass. We studied 456 patients with DM2. PAD was defined as an ankle-brachial index (ABI) <0.9. Apolipoprotein B48 was quantified by ELISA. Apo B48 was significantly higher in the group with an ABI <0.9 than the groups with ABI of 0.9-1.3 and >1.3 (10.7 ± 6.28 vs. 9.24 ± 5.5 vs. 9.17 ± 8.8 mg/L, ANOVA test, p < 0.05). B48 was independently associated with an ABI <0.9 (OR 1.053; 95 % CI, 1.013-1.094; p < 0.05), together with smoking and duration of diabetes. The preheparin LPL mass was similar in the patients with and without PAD. In conclusion, we confirmed that fasting B48 is an independent marker of PAD in patients with DM2, unrelated to the preheparin LPL mass, statin therapy or glucose lowering treatment.

Postprandial apolipoprotein B48 is associated with asymptomatic peripheral arterial disease: a study in patients with type 2 diabetes and controls

BACKGROUND

Postprandial hyperlipidemia is a common feature in type 2 diabetes; our aim was to investigate whether there is an association between subclinical peripheral arterial disease (PAD) and the levels of apolipoprotein B48, as a specific marker for postprandial lipidemia.

METHODS

We enrolled 101 patients with type 2 diabetes and 73 controls free from clinical cardiovascular disease. Main outcome measures were the presence of subclinical PAD, assessed by the ankle-brachial index, and the intestinal particles measured as the concentration of apolipoprotein B48 at fasting and 4h after a mixed breakfast.

RESULTS

No control had subclinical PAD. Of the 101 diabetic patients, 21 had subclinical PAD. The levels of apo B48, both fasting and postprandial, were only significantly raised in the diabetic patients who had PAD. The diabetic patients without vascular disease had similar concentrations of triglycerides and apo B48 to the controls. In binary logistic regression analyses, only smoking and postprandial B48 levels, in addition to diabetes, were independently associated with PAD. On the other hand, PAD but not diabetes was associated with the fasting and postprandial levels of apo B48.

CONCLUSION

Our study suggests that apolipoprotein B48 levels might be a marker of occult PAD in patients suffering from type 2 diabetes mellitus. Accordingly, subclinical PAD should be taken into account in studies on postprandial lipidemia involving patients with diabetes.

Lupus-associated endothelial dysfunction, disease activity and arteriosclerosis

OBJECTIVE

To analyze endothelial function in systemic lupus erythematosus (SLE), and its relationship with disease activity and subclinical arteriosclerosis.

METHODS

We studied a group of 26 patients with SLE and 21 age- and sex-matched controls. None of the patients or controls had had any ischemic event. Data were recorded on medical history, anthropometrics, prior treatment and the lupus activity index (LAI). Endothelial function was quantified by flow-mediated dilatation in the brachial artery. The presence of subclinical arteriosclerosis was assessed by the average intima-media thickness (IMT) on carotid ultrasound.

RESULTS

The patients and the controls had a similar degree of carotid IMT (0.58+/-0.08 mm vs. 0.57+/-0.07 mm, NS) and a similar prevalence of carotid plaque (27% vs. 24%, NS). However, the SLE patients had worse endothelial function than the controls (FMD 12.4+/-4.4% vs. 16.9+/-5.5%, p<0.05). This difference remained after adjusting for age, smoking, body mass index, waist circumference, total cholesterol, triglycerides, HDL cholesterol, apolipoproteins A-1 and B100 and postmenopausal status. A significant association was found in the SLE patients between FMD and LAI (Spearman Rho -0.462, p<0.05).

CONCLUSION

SLE-associated endothelial dysfunction is present in patients who have no prior ischemic events and with the same degree of subclinical arteriosclerosis as controls. The endothelial dysfunction is significantly associated with the degree of disease activity.

Systemic lupus erythematosus in Europe at the change of the millennium: lessons from the "Euro-Lupus Project"

The "Euro-Lupus Cohort" is composed by 1000 patients with systemic lupus erythematosus (SLE) that have been followed prospectively since 1991. These patients have been gathered by a European consortium--the "Euro-Lupus Project Group". This consortium was originated as part of the network promoted by the "European Working Party on SLE", a working group created in 1990 in order to promote research in Europe on the different problems related to this disease. The "Euro-Lupus Cohort" provides an updated information on the SLE morbidity and mortality characteristics in the present decade as well as defines several clinical and immunological prognostic factors.

[Hepatic amyloidosis as cause of severe intrahepatic cholestasis]

The liver is frequently involved by amyloidosis, but hyperbilirubinemia and liver failure are uncommon features. A mild elevation of the serum alkaline phosphatase value and, less frequently, hepatomegaly are the most common findings. Usually the patients have no symptoms related with the liver involvement; the clinical manifestation and the long term prognosis depends on the renal and cardiac disease. We report an unusual clinical presentation of primary amyloidosis in a previously asymptomatic 65 years old woman who was admitted to the hospital because of ictericia and ascitis mimicking a drug induced acute hepatic failure.

Lessons from the "Euro-Lupus Cohort"

The "Euro-Lupus Cohort" is composed by 1,000 patients with systemic lupus erythematosus (SLE) that have been followed prospectively since 1991. These patients have been gathered by a European consortium - the "Euro-Lupus Project Group". This consortium was originated as part of the network promoted by the "European Working Party on SLE", a working group created in 1990 in order to promote research in Europe on the different problems related to this disease. The "Euro-Lupus Cohort" provides an updated information on the SLE morbidity and mortality characteristics in the present decade as well as defines several clinical and immunological prognostic factors.

Effects of interferon-beta on plasma lipid and lipoprotein composition and post-heparin lipase activities in patients with chronic hepatitis C

BACKGROUND

Interferon therapy has been shown to induce lipid abnormalities.

AIM

We assessed the effects of interferon-beta on the lipoprotein profile and post-heparin lipase activities in 26 normolipaemic patients with chronic hepatitis C.

METHODS

Interferon-beta was administered subcutaneously at doses of 6 x 106 U (units) three times a week, over 6 months, and lipoproteins and post-heparin lipases were measured at baseline and at the end of therapy.

RESULTS

Plasma triglycerides increased by 21% due to preferential enrichment in those contained in the very low density lipoprotein (VLDL) and low density lipoprotein (LDL) fractions. The concentration of cholesterol decreased slightly in the high density lipoprotein (HDL) subfractions. Lipoprotein lipase, but not hepatic lipase activity decreased by a 36%, and this change showed a significant negative correlation with changes in plasma triglycerides. Five patients (19.5%) responded to interferon-beta therapy. The lipoprotein profile was no different between responders and non-responders to therapy.

CONCLUSIONS

Interferon-beta treatment in normolipaemic patients with chronic hepatitis C induced moderate disturbances in plasma lipoproteins, associated with inhibition of lipoprotein lipase activity.

Chronic or recurrent headache in patients with systemic lupus erythematosus: a case control study

Controversy exists concerning the prevalence of headache in systemic lupus erythematosus (SLE) and its importance as a neuropsychiatric manifestation, especially when it occurs independently of disease activity and with the typical characteristics of primary chronic headache. Most reports to date have either studied both types of headache, whether or not related to systemic lupus erythematosus, or have not used adequate controls. This study determines the prevalence and types of chronic primary headache in patients with systemic lupus erythematosus in a case-control study which we performed in a tertiary care hospital. We studied 71 consecutive patients with systemic lupus erythematosus and 71 healthy unrelated subjects matched for age and sex from the same geographical area. Clinical evaluation using a specific standard protocol for the presence and characteristics of headache according to the operative classification criteria of the International Headache Society. The overall prevalence of headache, tension-type headache, and migraine was similar among patients and controls [33 (46.5%), 17 (23.9%) and 16 (22.5%) vs 31 (43.7%), 17 (23.9%) and 13 (18.3%), respectively]. The mean age of onset of headache was higher in the patients (28.7 +/- 14.3 vs 18.5 +/- 5.6 y; P = 0.001) and the subjective response to analgesics was lower than in the controls [19 (63%) vs 28 (93.3%); P = 0.004]. There were no differences in the presence of precipitating factors or family history of headache. There were no relevant clinical or immunological differences among the patients regarding the presence or absence of tension-type headache or migraine. Patients with systemic lupus erythematosus do not differ from healthy controls for the presence and type of chronic or recurrent headache.

Central vein thrombosis in the antiphospholipid syndrome

We report the case of a 38 y old man with antiphospholipid syndrome and exceptionally extensive central vein thrombosis in the right internal jugular vein, superior vena cava, and both subclavian veins. In spite of intensive anticoagulation therapy there was only a partial response. We suggest the MR angiography be the reference standard for diagnosis in this type of patient.

[Pneumothorax in patients with AIDS]

METHODS

From January 1986 to 31 November 1993, 354 cases of AIDS (CDC criteria 1987) were diagnosed. The possible existence of spontaneous pneumothorax at any time during the evolution and its presumed cause were evaluated.

RESULTS

During the period studied, 7 (1.9%) of AIDS patients presented pneumothorax. The existence of a pulmonary infection was proven in 6: 3 pneumonia by Pneumocystis carinii, 2 bacterial pneumonia (Streptococcus pneumoniae and Pseudomonas sp.) and 1 tuberculosis. One patient presented a Pneumocystis carinii pneumonia 3 months prior to the pneumothorax. In the study period 88 (22.8%) of the AIDS patients presented pneumonia by Pneumocystis carinii and 181 (51.1%) presented tuberculosis. The rate of pneumothorax in patients with a history or presence of pneumonia by Pneumocystis carinii was of 4.5% and 0.5% in patients with tuberculosis.

CONCLUSIONS

The development of pneumothorax is relatively frequent in patients with AIDS in our area. As found in other series, its most frequent cause was Pneumocistis carinii pneumonia, despite the high incidence of tuberculosis.

[Modifications in the composition of plasma HDLs in non-insulin-dependent diabetics]

The levels of plasmatic lipids and the lipo and apoprotein composition of lipoprotein of high density were analysed in 18 patients, diagnosed as having non-insulin dependent diabetes, and compared to a control group of 18 healthy patients. 10 patients showed a moderate hypertriglyceridemia, this sub-group having the main HDL alteration. In this lipoprotein fraction an increase of triglycerides was observed, and a decrease in cholesterol and apoprotein III, probably as result of a lower activity of lipoprotein lipase in plasma.

Lipids and lipoprotein changes after heart and liver transplantation in a patient with homozygous familial hypercholesterolemia

Changes in lipids and lipoprotein fractions were studied 6 months after a combined heart and liver transplantation in a patient with terminal ischemic heart disease due to homozygous familial hypercholesterolemia. The double transplant was followed by striking decreases in total and low-density-lipoprotein cholesterol levels (-71% and -79%) and content of apolipoprotein B in the low-density-lipoprotein fraction (-74%). There was also an increase in high-density-lipoprotein cholesterol (+7.8%). These changes are greater than those reported with portacaval shunt or plasma exchange. Liver transplantation may be considered in selected patients with homozygous familial hypercholesterolemia.