Outcomes of Patients with Normal LDL-Cholesterol at Admission for Acute Coronary Syndromes: Lower Is Not Always Better

BACKGROUND AND AIM

There are few prospective data on the prognostic value of normal admission low-density lipoprotein cholesterol (LDL-C) in statin-naïve patients with acute coronary syndromes (ACS) who are treated with a preemptive invasive strategy. We aimed to analyze the proportion of patients with normal LDL-C at admission for ACS in our practice, and their characteristics and clinical outcomes in comparison to patients with high admission LDL-C.

PATIENTS AND METHODS

Two institutions' prospective registries of patients with confirmed ACS from Jan 2017 to Jan 2023 were used to identify 1579 statin-naïve patients with no history of prior coronary artery disease (CAD), and with available LDL-C admission results, relevant clinical and procedural data, and short- and long-term follow-up data. Normal LDL-C at admission was defined as lower than 2.6 mmol/L. All demographic, clinical, procedural, and follow-up data were compared between patients with normal LDL-C and patients with a high LDL-C level (≥2.6 mmol/L) at admission.

RESULTS

There were 242 (15%) patients with normal LDL-C at admission. In comparison to patients with high LDL-cholesterol at admission, they were significantly older (median 67 vs. 62 years) with worse renal function, had significantly more cases of diabetes mellitus (DM) (26% vs. 17%), peripheral artery disease (PAD) (14% vs. 9%), chronic obstructive pulmonary disease (COPD) (8% vs. 2%), and psychological disorders requiring medical attention (19% vs. 10%). There were no significant differences in clinical type of ACS. Complexity of CAD estimated by coronary angiography was similar between the two groups (median Syntax score 12 for both groups). There were no significant differences in rates of complete revascularization (67% vs. 72%). Patients with normal LDL-C had significantly lower left ventricular ejection fraction (LVEF) at discharge (median LVEF 52% vs. 55%). Patients with normal LDL-C at admission had both significantly higher in-hospital mortality (5% vs. 2%, RR 2.07, 95% CI 1.08-3.96) and overall mortality during a median follow-up of 43 months (27% vs. 14%, RR 1.86, 95% CI 1.45-2.37). After adjusting for age, renal function, presence of diabetes mellitus, PAD, COPD, psychological disorders, BMI, and LVEF at discharge in a multivariate Cox regression analysis, normal LDL-C at admission remained significantly and independently associated with higher long-term mortality during follow-up (RR 1.48, 95% CI 1.05-2.09).

CONCLUSIONS

A spontaneously normal LDL-C level at admission for ACS in statin-naïve patients was not rare and it was an independent risk factor for both substantially higher in-hospital mortality and mortality during long-term follow-up. Patients with normal LDL-C and otherwise high total cardiovascular risk scores should be detected early and treated with optimal medical therapy. However, additional research is needed to reveal all the missing pieces in their survival puzzle after ACS-beyond coronary anatomy, PCI optimization, numerical LDL-C levels, and statin therapy.

Statins and Venous Thromboembolic Disease - Where are we Now?

Classical risk factors for atherosclerosis also play a role in the pathogenesis of venous thromboembolism (VTE). Low-density lipoprotein cholesterol has prothrombotic and endothelium- deteriorating effects which are not limited to the arterial system. The association between hypercholesterolemia and VTE has been established, but the benefits of statins in the prevention of VTE assessed by observation studies seemed equivocal. The large, randomized trial Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) recorded the occurrence of VTE as a protocol-specified endpoint and reported a reduced incidence of VTE among subjects taking 20 mg of rosuvastatin daily vs placebo (hazard ratio 0.57; 95% confidence interval 0.37-0.86; p=0.007). Similar results were confirmed by meta-analyses of observation studies and randomized trials. Recently, a Mendelian randomization study that took the presence of gene variants coding for less efficient hydroxymethyl-glutaryl coenzyme A reductase activity as a proxy for statin treatment, confirmed a small, but significant negative association between the score of selected genetic polymorphisms and the incidence of VTE. However, since the protective effects of statins are limited, they should not be substituted for guideline-recommended VTE prophylaxis or anticoagulation treatment.

Efficacy and Safety of Bempedoic Acid in Patients with High Cardiovascular Risk: An Update

Statins play a significant role in the prevention of cardiovascular (CV) diseases (CVDs); however, non-adherence with statin treatment or statin intolerance (mainly attributed to muscleassociated side effects) is not uncommon. New agents such as bempedoic acid (BA) can provide more treatment options. BA is administered orally, once daily, at a dose of 180 mg in current clinical practice. It can decrease circulating low-density lipoprotein cholesterol (LDL-C) levels by nearly 30% as monotherapy or by 20% as an add-on to statins. CV outcome studies have shown that BA decreases major adverse CV event risk in patients with established CVD or high CV risk by 13%. When patients with high CV risk were analyzed alone, the risk reduction was 30%. Its side effects include a rise in serum uric acid levels and liver enzyme activity, whereas it does not increase diabetes risk as statins do. BA can be used as adjunctive therapy to statins in patients at high CV risk in whom lipid targets cannot be achieved or as an alternative to statins in patients with statin intolerance.

High-Intensity Statin vs. Low-Density Lipoprotein Cholesterol Target for Patients Undergoing Percutaneous Coronary Intervention: Insights From a Territory-Wide Cohort Study in Hong Kong

Background: Different guidelines recommend different approaches to lipid management in patients with atherosclerotic cardiovascular disease. We aim to determine the best strategy for lipid management in Asian patients undergoing percutaneous coronary intervention (PCI).

Method: This was a retrospective cohort study conducted in patients who underwent first-ever PCI from 14 hospitals in Hong Kong. All participants either achieved low-density lipoprotein cholesterol (LDL-C) target of <55 mg/dl with ≥50% reduction from baseline (group 1), or received high-intensity statin (group 2), or both (group 3) within 1 yr after PCI. The primary endpoint was a composite outcome of all-cause mortality, myocardial infarction, stroke, and any unplanned coronary revascularization between 1 and 5 yr after PCI.

Results: A total of 8,650 patients were analyzed with a median follow-up period of 4.2 yr. After the adjustment of baseline characteristics, complexity of PCI and medications prescribed and the risks of the primary outcome were significantly lower in group 2 (hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.74–0.93, P = 0.003) and group 3 (HR, 0.75; 95% CI, 0.62–0.90; P = 0.002). The primary outcome occurred at similar rates between group 2 and group 3.

Conclusions: Use of high intensity statin, with or without the attainment of guidelines recommended LDL-C target, was associated with a lower adjusted risk of MACE at 5 yr, compared with patients who attained LDL-C target without high intensity statin.

Management of Dyslipidaemia for the Prevention of Stroke: Clinical Practice Recommendations from the Lipid Association of India

Stroke is the second most common cause of death worldwide. The rates of stroke are increasing in less affluent countries predominantly because of a high prevalence of modifiable risk factors. The Lipid Association of India (LAI) has provided a risk stratification algorithm for patients with ischaemic stroke and recommended low density lipoprotein cholesterol (LDL-C) goals for those in a very high risk group and extreme risk group (category A) of <50 mg/dl (1.3 mmol/l) while the LDL-C goal for extreme risk group (category B) is ≤30 mg/dl (0.8 mmol/l). High intensity statins are the first-line lipid lowering therapy. Non-statin therapy like ezetimibe and proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors may be added as an adjunct to statins in patients who do not achieve LDL-C goals statins alone. In acute ischaemic stroke, high intensity statin therapy improves neurological and functional outcomes regardless of thrombolytic therapy. Although conflicting data exist regarding increased risk of intracerebral haemorrhage (ICH) with statin use, the overall benefit risk ratio favors long-term statin therapy necessitating detailed discussion with the patient. Patients who have statins withdrawn while being on prior statin therapy at the time of acute ischaemic stroke have worse functional outcomes and increased mortality. LAI recommends that statins be continued in such patients. In patients presenting with ICH, statins should not be started in the acute phase but should be continued in patients who are already taking statins. ICH patients, once stable, need risk stratification for atherosclerotic cardiovascular disease (ASCVD).

Transition Patterns of Weight Status and Their Predictive Lipid Markers Among Chinese Adults: A Longitudinal Cohort Study Using the Multistate Markov Model

BACKGROUND

Obesity is well recognized as a risk factor for cardiometabolic diseases. The development of obesity is a dynamic process that can be described as a multistate process with an emphasis on transitions between weight states. However, it is still unclear what convenient biomarkers predict transitions between weight states. The aim of this study was to show the dynamic nature of weight status in adults stratified by age and sex and to explore blood markers of metabolic syndrome (MetS) that predict transitions between weight states.

METHODS

This study involved 9795 individuals aged 18 to 56 at study entry who underwent at least two health check-ups in the eight-year period of study in the health check-up centre of our institution. Weight, height and biochemical indices were measured at each check-up. The participants were divided into four groups based on age and sex (young male, middle-aged male, young female and middle-aged female groups). A multistate Markov model containing 3 states (healthy weight, overweight and obesity) was adopted to study the longitudinal weight data.

RESULTS

Young people were more likely to transit between weight states than middle-aged people, and middle-aged people were more resistant to recover from worse states. The mean sojourn time in obesity was greatest in the middle-aged male group (6.23 years), and the predicted rate of obesity beginning with healthy weight was greatest in the young male group (13.7%). In multivariate models, age group and triglyceride (TG) and high-density lipoprotein cholesterol (HDL) levels were significant for specific transitions in females, whereas age group and HDL levels were significant in males. In females, if HDL levels increased 1 mmol/L, the probability of progression from healthy weight to overweight decreased by 37.0% (HR= 0.63), and the probabilities of recovery (overweight to healthy weight and obesity to overweight) increased by 62.0% (HR= 1.62) and 1.23-fold (HR= 2.23), respectively. In males, if TG levels increased 1 mmol/L, the risk of progression from healthy weight to overweight increased by 24.0% (HR= 1.24). Each unit increase in HDL levels was associated with a 0.99-fold (HR= 1.99) increase in the chance of recovery from overweight to healthy weight and with a 0.37-fold (HR= 0.63) decrease in the risk of progression from healthy weight to overweight.

CONCLUSION

The weight status of young people was less stable than that of middle-aged people. Males were more likely to become overweight and more resistant to recover from worse states than females. Young males with healthy weight were more likely to develop obesity than other healthy weight groups. Blood lipid levels, especially HDL, were predictors of weight transitions in adults. Prevention and intervention measures should be applied early.

The effect of calcium supplement intake on lipid profile: a systematic review and meta-analysis of randomized controlled clinical trials

Despite the potential role of dietary calcium in fat excretion, the favorable effects of calcium supplements on lipid profile remains inconclusive. The current study aimed to review the effect of calcium supplement intake on lipid profile in randomized controlled clinical trials (RCTs). This systematic review and meta-analysis was conducted in PubMed, Scopus, Embase, and Central. RCTs which assessed the effects of calcium supplementation on lipid profile were included. All outcomes were recorded as continuous variables, and the effect size was measured. We classified studies according to dose of supplement, study duration, and dyslipidemia. Calcium supplement intake was associated with a significant reduction in low density lipoprotein cholesterol (LDL-C) level (WMD:-0.08; 95%CI:-0.16,-0.01)(mmol/l), especially with intakes of at least 1000 mg/day (WMD:-0.13; 95%CI:-0.23,-0.03)(mmol/l), with intakes of at least 12 weeks (WMD:-0.08; 95%CI: -0.16,-0.00)(mmol/l), and in individuals without dyslipidemia (WMD:-0.15; 95%CI:-0.26,-0.04)(mmol/l). Also, in another subgroup analysis, consumption of less than 1000 mg/day calcium supplement caused a significant increase in Total Cholesterol (TC) level (WMD: 0.24; 95%CI: 0.05,0.42) (mmol/l). In other blood lipids or study subgroups we observed no significant effect. We concluded that calcium supplements had a favorable effect on LDL-C level, especially in individuals without dyslipidemia, higher calcium intakes, and longer period of consumption.

Artificial Platelets for Efficient siRNA Delivery to Clear "Bad Cholesterol"

Low-density lipoprotein cholesterol (LDL-C) is usually considered as a "bad cholesterol" for it is one of the major risk factors for coronary heart disease. As a scavenger of LDL-C, the low density lipoprotein receptor (LDLR) binds with LDL-C in the liver. However, the protein levels and function of LDLR are regulated by Proprotein convertase subtilisin/kexin type 9 (PCSK9). Loss of PCSK9 induces the increase of LDLR levels and reduction of plasma LDL-C. Here, we developed a novel style of artificial platelets with biomimetic properties, high stability, and long circulation which enabled the efficient delivery of siRNA targeting Pcsk9. The bioinspired nanoparticles induced Pcsk9 mRNA reduction by 66% in vitro. For in vivo studies, the nanoparticles accumulated in the liver to reduce Pcsk9 transcription, which results in ∼28% reduction in plasma LDL-C concentrations with negligible effects on either high density lipoprotein cholesterol (HDL-C) or triglycerides (TGs). These results demonstrated the use of artificial platelets to deliver siRNA and induce effective RNAi therapeutics to specifically lower LDL-C which provides a potential strategy to lower PCSK9 and treat hypercholesterolemia.

The impact of the cumulative burden of LDL-c and hs-CRP on cardiovascular risk: a prospective, population-based study

Background: This study aims to demonstrate the impact of the cumulative burden of low density lipoprotein-cholesterol (cumLDL-c) and high sensitivity C-reactive protein (cumhs-CRP) on cardiovascular risk.

Results: During the 4.62 (±0.70) years of follow-up, 2,148 (5.92%) participants had MACE. Both of cumLDL-c and cumhs-CRP were independent risk factors for MACE. In participants without cumLDL-c during 2006-2013, the participants with cumhs-CRP had higher MACE risk during the subsequent 5 years, than those without cumhs-CRP (hazard ratio [HR]: 1.24, 95% confidence interval [CI]:1.04-1.47). In addition, cumhs-CRP correlated with MACE in a cumhs-CRP level-dependent pattern.

Conclusion: This study validated the effects of residual inflammation risk in patients with low LDL-c Level in a general population, using long-term burdens of hs-CRP or LDL-c other than a single time-point level.

Method: The Kailuan study is a prospective, population-based study began in 2006. These total 36,421 participants completed 4 measurements of hs-CRP and LDL-c biennially from 2006-2013. Cumhs-CRP or cumLDL-c levels were calculated as the number of interval years multiplied by the Δhs-CRP (more than 2.0 mg/L) or ΔLDL-c (more than 2.6 mmol/L). Outcomes measured during follow-up (2012-2017) were defined as major adverse cardiac events (MACE), including ischemic stroke, myocardial infarction, and all-cause mortality.

Low density lipoprotein cholesterol values and outcome of stroke patients: influence of previous aspirin therapy

Background: The link between low-density lipoprotein cholesterol (LDL-C) and stroke risk remains controversial and few studies have evaluated the effect of LDL-C after stroke survival.Aims: We assessed the hypothesis proposing the effect of LDL-C on the outcome of stroke patients under the influence of previous Aspirin Therapy.Methods: Associations between LDL-C and outcomes. The effect of LDL cholesterol on stoke outcome was evaluated using Kaplan-Meier methodology, log-rank test, Cox proportional hazard models and Bootstrap Analysis.Results: In a cohort of 342 cases, we observed that among stroke patients with no record of previous aspirin therapy LDL-C levels within recommended range (nLDL-C) are associated to a poor overall survival on (p < 0.001, log-rank test) leading to a 4-fold increased mortality risk in both timeframes of 12 (HR 4.45, 95% CI 1.55-12.71; p = 0.004) or 24 months (HR 4.13, 95%CI 1.62-10.50;p = 0.003) after the first event of stroke. Moreover, modelling the risk of a second event after the first stroke in the timeframe of 24 months demonstrated a predictive capacity for nLDL-C plasmatic levels (HR 3.94, 95%CI 1.55-10.05; p = 0.004) confirmed by Bootstrap analysis (p = 0.003; 1000 replications). In a further step, the inclusion of LDL-C in simulating models equations to predict the risk of a second event in the timeframe of 12 months increased nearly 20% the predictive ability (c-index from 0.763 to 0.956).Conclusion: A worse outcome was seen in stroke patients with normal levels of LDLC, but this finding was restricted to patients not under previous aspirin therapy.

High-Sensitivity C-Reactive Protein Discordance With Atherogenic Lipid Measures and Incidence of Atherosclerotic Cardiovascular Disease in Primary Prevention: The ARIC Study

Background Inflammation is an independent causal risk factor for atherosclerotic cardiovascular diseases (ASCVDs). However, whether hsCRP (high-sensitivity C-reactive protein) is prognostic across various levels of atherogenic lipid measures such as low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, apolipoprotein B and total cholesterol/high-density lipoprotein cholesterol in primary prevention is unknown. Methods and Results We studied 9748 ARIC (Atherosclerosis Risk in Communities) study participants who were free of ASCVD at baseline (visit 4, 1996-1998) and had measurements of lipids, apolipoprotein B, and hsCRP. We used multivariable adjusted Cox models to estimate the risk of incident ASCVD events associated with hsCRP levels (less than/greater than or equal to median) in individuals where triple lipid measures combined (low-density lipoprotein cholesterol + non-high-density lipoprotein cholesterol + apolipoprotein B) or quadruple measures combined [triple + total cholesterol/high-density lipoprotein cholesterol] were less than versus greater than or equal to median cut points. Mean age of participants was 62.6±5.6 years; 59% women, 22% black. There were 1574 ASCVD events over median (interquartile range) follow-up of 18.4 (12.8-19.5) years, and discordance between hsCRP and lipid measures was prevalent in 50% of the population. hsCRP greater than or equal to median (2.4 mg/L), compared with less than median, was associated with an increased risk of ASCVD in individuals with less than median levels of the triple (adjusted hazard ratio, 1.33; 95% CI, 1.09-1.60) and quadruple (adjusted hazard ratio,1.47; 95% CI, 1.18-1.85) lipid measures. Such increased risk was consistent among individuals with low (<7.5%) or high (≥7.5%) estimated risk by the pooled cohort equation. There were no interactions by sex, diabetes mellitus, or statin use. Conclusions Our findings suggest that inflammation is independently associated with ASCVD regardless of atherogenic lipid levels and pooled cohort equation risk score in individuals without known ASCVD.

PCSK9 E670G polymorphism increases risk of coronary artery disease in a Chinese Han population

OBJECTIVE

Coronary artery disease (CAD) is the leading cause of morbidity and mortality in the world. The proprotein convertase subtilisin/kexin type 9 (PCSK9) E670G polymorphism has been reported to be associated with variability in levels of low density lipoprotein cholesterol, a risk factor for CAD. However, the relationship between PCSK9 E670G and CAD is still not fully elucidated.

METHODS

A total of 225 patients and 189 control subjects were recruited in this study. DNA was extracted from peripheral blood samples and was genotyped by mass array method. In addition, we also conducted a meta-analysis of case-control studies to elucidate the relationship of CAD and polymorphism.

RESULTS

The GG genotype of PCSK9 E670G was associated with a higher risk of CAD [odds ratio (OR) 2.994, 95% confidence interval (CI): 1.174-7.631], even adjusting for risk factors (OR 2.794, 95% CI: 1.215-7.460). Logistic regression analysis showed that the dominant genetic model increased the CAD risk (OR 2.313, 95% CI: 1.070-6.983) after adjusting the confounding factors. Meta-analysis results of 13 studies revealed that PCSK9 E670G polymorphism was correlated with CAD risk under different genetic models.

CONCLUSION

Our results demonstrated that PCSK9 E670G genotype was associated with a high risk of CAD.

Lunasin Improves the LDL-C Lowering Efficacy of Simvastatin via Inhibiting PCSK9 Expression in Hepatocytes and ApoE-/- Mice

Statins are the most popular therapeutic drugs to lower plasma low density lipoprotein cholesterol (LDL-C) synthesis by competitively inhibiting hydroxyl-3-methyl-glutaryl-CoA (HMG-CoA) reductase and up-regulating the hepatic low density lipoprotein receptor (LDLR). However, the concomitant up-regulation of proprotein convertase subtilisin/kexin type 9 (PCSK9) by statin attenuates its cholesterol lowering efficacy. Lunasin, a soybean derived 43-amino acid polypeptide, has been previously shown to functionally enhance LDL uptake via down-regulating PCSK9 and up-regulating LDLR in hepatocytes and mice. Herein, we investigated the LDL-C lowering efficacy of simvastatin combined with lunasin. In HepG2 cells, after co-treatment with 1 μM simvastatin and 5 μM lunasin for 24 h, the up-regulation of PCSK9 by simvastatin was effectively counteracted by lunasin via down-regulating hepatocyte nuclear factor 1α (HNF-1α), and the functional LDL uptake was additively enhanced. Additionally, after combined therapy with simvastatin and lunasin for four weeks, ApoE^−/− mice had significantly lower PCSK9 and higher LDLR levels in hepatic tissues and remarkably reduced plasma concentrations of total cholesterol (TC) and LDL-C, as compared to each monotherapy. Conclusively, lunasin significantly improved the LDL-C lowering efficacy of simvastatin by counteracting simvastatin induced elevation of PCSK9 in hepatocytes and ApoE^−/− mice. Simvastatin combined with lunasin could be a novel regimen for hypercholesterolemia treatment.

Investigating the lowest threshold of vascular benefits from LDL cholesterol lowering with a PCSK9 mAb inhibitor (alirocumab) in healthy volunteers - a mechanistic physiological study (INTENSITY-LOW): protocol and study rationale

Objective: Whether reducing low density lipoprotein cholesterol (LDL-C) is associated with cardiovascular benefits in low risk normocholesterolaemic subjects is unknown. The INTENSITY LOW [Investigating the lowest threshold of vascular benefits from LDL-cholesterol lowering with a PCSK9 mAb inhibitor (alirocumab) in healthy volunteers] study aims to assess whether lowering LDL-C by alirocumab monotherapy can improve endothelial-dependent vascular function compared with placebo (primary objective) in low-risk normocholesterolaemic healthy individuals. Changes in endothelial-dependent or endothelial-independent vascular function, arterial stiffness and biomarkers of systemic inflammation by alirocumab, atorvastatin or their combination are secondary objectives.

Study design and methods: This is a single-center, randomized, two-period, single-blind, placebo-controlled clinical trial. The study was registered on clinicaltrials.gov (N03273972).

It will include 30 healthy low-risk subjects with LDL-C < 4.1 mmol/l. After passing the screening visit (Visit 1), eligible participants will be randomized 1:1 to either subcutaneous alirocumab 150 mg or placebo. These will be administered as single doses in 2 visits 14 days apart (Visits 2 and 3). Atorvastatin 20 mg once nightly will be prescribed for 14 days at Visit 3 in both groups through to Visit 4.

At baseline (Visit 2) and during all post-dose visits (Visits 3–4), endothelial function will be assessed using venous occlusion plethysmography. Specifically, changes in forearm blood flow responses to intra-arterial infusions of acetylcholine, sodium nitroprusside and L-N^G-monomethyl-arginine acetate will be assessed as surrogates of endothelial-dependent and -independent vasodilatation. Additionally, arterial stiffness and carotid intima-media thickness will be evaluated at the same timepoints. The above-mentioned changes will be correlated with changes in lipid and systemic inflammation biomarkers.

Low Levels of Low-Density Lipoprotein Cholesterol and Mortality Outcomes in Non-Statin Users

We aimed to test the association between low-density lipoprotein cholesterol (LDL-C) and cardiovascular disease (CVD), cancer, and all-cause mortality in non-statin users. A total of 347,971 subjects in Kangbuk Samsung Health Study (KSHS.57.4% men, mean follow up: 5.64 ± 3.27 years) were tested. To validate these associations, we analyzed data from another cohort (Korean genome and epidemiology study, KoGES, 182,943 subjects). All subjects treated with any lipid-lowering therapy and who died during the first 3 years of follow up were excluded. Five groups were defined according to baseline LDL-C concentration (<70, 70–99, 100–129, 130–159, ≥160 mg/dL). A total of 2028 deaths occurred during follow-up in KSHS. The lowest LDL-C group (LDL < 70 mg/dL) had a higher risk of all-cause mortality (HR 1.95, 1.55–2.47), CVD mortality (HR 2.02, 1.11–3.64), and cancer mortality (HR 2.06, 1.46–2.90) compared to the reference group (LDL 120–139 mg/dL). In the validation cohort, 2338 deaths occurred during follow-up. The lowest LDL-C group (LDL < 70 mg/dL) had a higher risk of all-cause mortality (HR 1.81, 1.44–2.28) compared to the reference group. Low levels of LDL-C concentration are strongly and independently associated with increased risk of cancer, CVD, and all-cause mortality. These findings suggest that more attention is needed for subjects with no statin-induced decrease in LDL-C concentrations.

Circulating vitamin E and cardiometabolic measures: a Mendelian randomization analysis

Although a large body of literature reported that high intake of vitamin E played a possible role in reducing risk of cardiometabolic diseases, conflicting results were also found in some observational studies due to confounding factors. Hence, we used a Mendelian randomization study as an alternative way to examine the causality between circulating vitamin E and cardiometabolic diseases. Summary-level data were extracted from consortia and three single nucleotide polymorphisms were used as instrumental variables. Our study showed that a one-SD increase in circulating vitamin E levels was causally associated with an increased risk of coronary artery disease [odds ratio (OR) 3.16 (95%CI 1.74, 5.73); p = 1.91 × 10^-3] at the Bonferroni-adjusted level of significance (p<0.005). Moreover, a one-SD increase in circulating vitamin E levels was associated with a 0.572-SD increase in low density lipoprotein cholesterol (mg/dl), a 0.693-SD increase in total cholesterol (mg/dl), and a 1.45-SD increase in triglyceride (mg/dl), but a 0.502-SD decrease in high density lipoprotein cholesterol (mg/dl) at the Bonferroni-adjusted level of significance (p<0.0028). Our findings indicated that genetically elevated vitamin E was associated with increased risk of coronary artery disease, suggesting an adverse causality between circulating vitamin E and coronary artery disease.

In search of a genetic explanation for LDLc variability in an FH family: common SNPs and a rare mutation in MTTP explain only part of LDL variability in an FH family

We previously identified a highly consanguineous familial hypercholesterolemia (FH) family demonstrating segregation of the JD Bari mutation in the LDL receptor as well as a putative cholesterol-lowering trait. We aimed to identify genes related to the latter effect. LDL cholesterol (LDLc) values were normalized for FH affectation status, age, and gender. Using genome-wide SNP data, we examined whether known SNPs gleaned from a genome-wide association study could explain the variation observed in LDLc. Four individuals with markedly reduced LDL levels underwent whole exome sequencing. After prioritizing all potential mutations, we identified the most promising candidate genes and tested them for segregation with the lowering trait. We transfected a plasmid carrying the top candidate mutation, microsomal triglyceride transfer protein (MTTP) R634C, into COS-7 cells to test enzymatic activity. The SNP score explained 3% of the observed variability. MTTP R634C showed reduced activity (49.1 nmol/ml) compared with the WT allele (185.8 nmol/ml) (P = 0.0012) and was marginally associated with reduced LDLc in FH patients (P = 0.05). Phenotypic variability in a FH pedigree can only partially be explained by a combination of common SNPs and a rare mutation and a rare variant in the MTTP gene. LDLc variability in FH patients may have nongenetic causes.

Elevated lipoprotein (a) levels are associated with the acute myocardial infarction in patients with normal low-density lipoprotein cholesterol levels

Elevated lipoprotein (a) [Lp(a)] and coronary artery disease (CAD) risk has been renewed interested in recent years. However, the association between Lp(a) and acute myocardial infarction (AMI) risk in patients with normal low-density lipoprotein cholesterol (LDL-C) levels has yet to been established. A hospital-based observational study including 558 AMI patients and 1959 controls was conducted. Lp(a) level was significantly higher in AMI patients with normal LDL-C levels than that in non-CAD group (median: 134.5 mg/l vs 108 mg/l, P<0.001). According to Lp(a) quartiles (Q1, <51 mg/l; Q2, 51–108 mg/l; Q3, 108–215 mg/l; Q4, ≥215 mg/l), the incidence of AMI increased with the elevated Lp(a) quartiles (P<0.001 and P for trend<0.001). Logistic regression analysis suggested that patients with Q3 and Q4 of Lp(a) values had 1.666 (95%CI = 1.230–2.257, P<0.001) and 1.769 (95%CI = 1.305–2.398, P< 0.001) folds of AMI risk compared with patients with Q1, after adjusting for traditional confounders. Subgroup analyses stratified by gender and age showed that the association only existed in male and late-onset subgroups. In addition, we analyzed the association of Lp(a) with AMI risk in different cut-off values (cut-off 1 = 170 mg/l, cut-off 2 = 300 mg/l). A total of 873 (34.68%) and 432 (17.16%) participants were measured to have higher Lp(a) levels according to cut-off 1 and cut-off 2, respectively. Participants with high Lp(a) levels had 1.418- (cut-off1, 95%CI = 1.150–1.748, P<0.001) and 1.521- (cut-off 2, 95%CI = 1.179–1.963, P< 0.001) folds of AMI risk compared with patients with low Lp(a) levels. The present large-scale study revealed that elevated Lp(a) levels were associated with increased AMI risk in Chinese population with normal LDL-C levels.

Defining apolipoprotein B treatment targets

Background

Apolipoprotein B (apo B) has been widely reported to be a better predictor of cardiovascular risk than low-density lipoprotein cholesterol (LDL-C). This is the reason apo B treatment target values based on the equivalence to LDL-C values in healthy population has been advocated using percentiles from population studies. The aim of this study was to determine the apo B values equivalent to currently used medical decision targets for LDL-C concentration in a population of healthy Nigerians and examine for any demographic influence.

Materials and Methods

A total of 252 apparently healthy individuals (89 males, 163 females), between the ages of 30 and 65 years were selected from core health workers (medical and nursing staffs) of University College Hospital Ibadan between December 2015 and May 2016. Serum lipids and apo B were measured using enzymatic and immunoturbidimetry method, respectively.

Results

The mean apo B of the study population were 94 and 98 mg/dL in men and women, respectively. Mean apo B concentration was significantly higher in the female participants in the age groups above 55 years. LDL-C concentrations of 100, 130, 160, and 190 mg/dL corresponded to the 15^th, 55^th, 87^th, and 95^th percentile, respectively. The corresponding apo B concentrations were 73 mg/dL (15^th percentile), 95 mg/dL (55^th percentile), 124 mg/dL (87^th percentile), and 145 mg/dL (95^th percentile). The group of participants with LDL-C of <130 mg/dL and the group with equivalent apo B of <95 mg/dL has the same clinical and biochemical characteristics in both men and women.

Conclusion

This study has defined apo B targets that may potentially be used to guide the initiation of therapy in persons with dyslipidemia. It has also demonstrated the population level relationship that exists between apo B and LDL-cholesterol and has shown the gender and age-related influence of apo B distribution in the population.

Major determinants of circulating myostatin in polycystic ovary syndrome

The present study was designed to investigate the possible impact of hormonal and demographic parameters of patients with polycystic ovary syndrome (PCOS) on the circulating levels of myostatin. The study cohort comprised 46 patients with PCOS and 42 healthy female controls, and all subjects were of normal weight. Multiple regression analysis was applied to investigate the possible associations between serum myostatin levels and other laboratory parameters. Evaluation of the levels of myostatin revealed no significant differences between the PCOS and control groups (P>0.05). In the control group, no significant correlations were identified between the myostatin levels and any other laboratory parameters. Only low-density-lipoprotein cholesterol (LDL-C) levels in the PCOS group were revealed to be significantly, although negatively, associated with myostatin levels (P=0.018). In the regression model of the PCOS group, an increase in LDL-C and prolactin (PRL) were associated with a decrease in myostatin (P=0.001 and P=0.013, respectively). Furthermore, a decrease in sex hormone-binding globulin (SHBG), fasting blood glucose (FBG) and monocytes were associated with an increase in myostatin (P=0.028, P<0.001 and P=0.026, respectively). An increase in triglycerides was also associated with an increase in myostatin (P=0.001). In the regression model of the control group, a decrease in LDL-C was associated with an increase in myostatin (P=0.003) and a decrease in thyroid-stimulating hormone was associated with a decrease in myostatin (P=0.028). These results indicated that the normal range of myostatin levels in patients with PCOS is regulated by changes in the circulating levels of PRL, LDL-C, SHBG, triglycerides, monocytes and FBG.

Trends in low-density lipoprotein-cholesterol blood values between 2012 and 2017 suggest sluggish adoption of the recent 2013 treatment guidelines

BACKGROUND

Over a 14-year period, age-adjusted high total cholesterol (≥240 mg/dL) in the United States declined from 18.3% in 1999 to 2000 to 11.0% in 2013 to 2014, coinciding with the 2001 National Cholesterol Education Program Adult Treatment Panel (ATP)-III guidelines that endorsed low-density lipoprotein (LDL)-cholesterol blood value goals. Statin treatment recommendations were revised by the American College of Cardiology and the American Heart Association (ACC/AHA) in November 2013 to a "risk-based prescription" approach that did not utilize blood cholesterol values. This increased dosage and expanded the statin-eligible population by an estimated 12.8 million US adults. These changes should further lower total and LDL cholesterol concentrations nationally.

METHODS

We examined data from 507 752 patients nationally aged ≥16 years whose fasting bloods were sent to Boston Heart Diagnostics for direct LDL-cholesterol measurements. Between 2012 and 2017, age-adjusted concentrations were examined by analysis of covariance and LDL-cholesterol ≥160 mg/dL by logistic regression.

RESULTS

Contrary to expectations, age-adjusted mean LDL-cholesterol concentrations (±SE, mg/dL) increased significantly (P < 10^-16 ) in men (2012:113.8 ± 0.3; 2013:115.3 ± 0.2; 2014:114.7 ± 0.2; 2015:116.0 ± 0.2; 2016:117.6 ± 0.2; and 2017:117.1 ± 0.2 mg/dL) and women (2012:119.5 ± 0.3; 2013:120.7 ± 0.2; 2014:119.8 ± 0.02; 2015:120.8 ± 0.2; 2016:122.7 ± 0.1; and 2017:123.8 ± 0.2 mg/dL). The percentage with LDL-cholesterol ≥160 mg/dL also increased significantly (P < 10^-9 ) in men and women. Similar results were obtained for ages 40 to 75 years olds (corresponding to ACC/AHA guidelines).

CONCLUSION

These results provide additional evidence that declining blood LDL-cholesterol levels observed following the ATP-III recommendations, did not further decline (actually increased) following the 2013 ACC/AHA recommendations.

High Low-Density Lipoprotein Cholesterol Inversely Relates to Dementia in Community-Dwelling Older Adults: The Shanghai Aging Study

Background: The relationship between cholesterol and cognitive function is unclear from the previous studies. This study was conducted to explore this association in older Chinese adults.

Methods: Data were from the Shanghai Aging Study, comprising 3,836 residents aged 50 years or over in an urban community. Diagnoses of dementia and mild cognitive impairment were established according to the fourth edition of diagnostic and statistical manual of mental disorders (DSM-IV) and Petersen criteria. Multivariate logistic regression models, non-matched and propensity score (PS) matched, were used to examine the association between cholesterol levels and cognitive function.

Results: There was a significantly higher proportion of participants with low levels of total cholesterol (TC) and low density lipoprotein cholesterol (LDL-C) in the dementia group than in groups without dementia (P < 0.05). High LDL-C level was inversely associated with dementia, with a negative trend in the PS matched model. TC and high density lipoprotein cholesterol (HDL-C) were not significantly related to dementia in either non-matched models or PS matched models.

Conclusion: Our result indicates that high level of LDL-C is inversely associated with dementia. High level of LDL-C may be considered as a potential protective factor against cognition decline.

Nutraceuticals as an Important Part of Combination Therapy in Dyslipidaemia

Several risk factors such as abnormality of lipid metabolism (e.g. high levels of low-density lipoprotein cholesterol (LDL-C), elevated triglycerides and low levels of high-density lipoprotein cholesterol (HDL-C)) play a central role in the aetiology of cardiovascular disease (CVD). Nutraceutical combination together with a cholesterol- lowering action, when associated with suitable lifestyle, should furnish an alternative to pharmacotherapy in patients reporting statin-intolerance and in subjects at low cardiovascular risk. The present review is focused on nutraceuticals and their synergetic combinations demonstrating a beneficial effect in the management of dyslipidaemia. Several nutraceuticals have been shown to positively modulate lipid metabolism having different functions. Plant sterols and soluble fibres can, for example, decrease the intestinal assimilation of lipids and increase their elimination. Furthermore, berberine and soybean proteins improve the cholesterol uptake in the liver. Policosanols, monacolins and bergamot inhibit hydroxy-methyl-glutaryl coenzyme A reductase (HMGCoA reductase) enzyme action determining the cholesterol hepatic synthesis. Moreover, pomegranate can decrease LDL oxidation and positively affect subclinical atherosclerosis; red yeast rice and berberine play, instead, an important role on endothelial dysfunction and psyllium, plant sterols and bergamot have positive effects on LDL subclasses. To the best of our knowledge, there are no long-term large-scale studies on the anti-atherogenic effect of the nutraceuticals that are available on the market. Thus, further clinical studies should investigate in order to achieve long term tolerability and safety and to provide a better nutraceutical combination tailored to the patient needs.

Impact of fish consumption by subjects with prediabetes on the metabolic risk factors: using data in the 2015 (6th) Korea National Health and Nutrition Examination Surveys

BACKGROUND/OBJECTIVES

The effects of fish consumption by subjects with prediabetes on the metabolic risk factors were examined based on the data from the 6^th Korea National Health and Nutrition Examination Surveys in 2015.

SUBJECTS/METHODS

A total of 1,520 subjects who agreed to participate in a blood test and dietary intake survey were divided into a prediabetes group and normal blood glucose group, and the level of the subjects' fish consumption was divided into ≤ 17.0 g/day, 18.0–93.0 g/day, and ≥ 94 g/day. The correlation between the level of fish intake and the metabolic risk factors was evaluated by multinomial logistic regression analysis.

RESULTS

A significant difference in the gender distribution was observed in the prediabetes group, which is a group with a high risk of non-communicable diseases, according to the fish intake, and there were significant differences in the total energy intake, protein intake, n-3 fatty acids intake, and the intakes of sodium and micro-nutrients according to the intake group (P < 0.05). In addition, the blood total cholesterol (TC) decreased 0.422 fold in model 1 (unadjusted) [95% confidence interval (CI): 0.211–0.845] and 0.422 fold in model 2 (adjusted for sex) (95% CI: 0.210–0.846) in those with a fish intake of 18.0–93.0 g/day (P < 0.05) compared to those with a fish intake of ≤ 17.0 g/day. The blood TC decreased 0.555 fold (95% CI: 0.311–0.989) in model 1 and 0.549 fold (95% CI: 0.302–0.997) in model 2 in those with a fish intake of ≥ 94 g/day compared to those with a fish intake of ≤ 17.0 g/day (P < 0.05).

CONCLUSIONS

Subjects with prediabetes or the metabolic risk factors can maintain their blood low density lipoprotein cholesterol (LDL-C) and blood TC concentrations at the optimal level by consuming fish (18.0–93.0 g/day).

[Long-Term Statin Adherence in Patients with Stable Angina after Coronary Stenting]

PURPOSE

To study adherence to therapy with statins and its relation to development of cardio-vascular complications (CVC) in patients with stable angina after elective percutaneous coronary intervention (PCI) at five-year observation.

MATERIALS AND METHODS

This study comprised 574 patients with stable angina (81 % men, mean age 60.3 years) hospitalized for elective PCI. All patients were prescribed therapy in accordance with recommendations on management of stable angina including statins. Adherence to statin therapy after PCI was assessed in 1 year at telephone interview and in 5 years at ambulatory examination and by filling of an adherence questionnaire. The following CVCs were registered during follow-up after hospital discharge: deaths from all causes, cardiovascular deaths, nonfatal myocardial infarctions and strokes, repetitive myocardial revascularizations. Associations of these events with adherence to hypolipidemic therapy were finally analyzed.

RESULTS

Mean duration of follow-up was 53.5 (from 3.4 to 67.6) months. In 1 year 490 patients (84.5 %) declared that they continued to take statins. In 5 years number of patients who continued taking statins was 380 (66.2 %). Doses of statins were low (mean for simvastatin 17.4, atorvastatin - 15.8, rosuvastatin - 12.1 mg). Only in 8.7 % of patients level of low density lipoprotein cholesterol (LDLC) was.

Meta-analysis of the Efficacy and Safety of Adjunctive Rosuvastatin for Dyslipidemia in Patients with Schizophrenia

Background

Metabolic syndrome in patients with schizophrenia is a major health concern. The efficacy and safety of adjunctive rosuvastatin in treating dyslipidemia were controversial.

Aims

To assess the efficacy and safety of adjunctive rosuvastatin for dyslipidemia in patients with schizophrenia.

Methods

We systematically searched for relevant controlled clinical trials from the following databases: PubMed, PsycINFO, Cochrane Library, China Knowledge Network, WanFang Database and Chinese Biomedical Database up to September 28, 2017. Standardized mean difference (SMD) and risk ratio (RR) along with their 95% confidence intervals (CIs) were calculated. The quality of the included studies was assessed using the Cochrane risk of bias assessment tool. The GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) system recommendation grading method was used as the reference standard.

Results

Four studies (n=274) comparing rosuvastatin (n=138) and control (n=136) groups were identified and analyzed. Adjunctive rosuvastatin showed greater efficacy than control group in low density lipoprotein cholesterol (LDL-C) [4 trials, n=272, SMD: -1.31 (95%CI: -1.93, -0.70), I²=81%], total cholesterol (2 trials, n=164, SMD: -2.00 (95%CI: -2.79, -1.21); I²=76%) and triglycerides (2 trials, n=164, SMD: -1.05 (95%CI: -1.38, -0.72); I²=0%), but not in high density lipoprotein cholesterol (2 trials, n=164, SMD: 0.14 (95%CI: -0.16, 0.45); I²=0%). After removing one study without randomization for LDL-C, significance remained [3 trials, n=172, SMD:-1.07 (95%CI: -1.60, -0.53); I²=63%]. No significant group differences regarding body weight (3 trials, n=208, SMD: -0.40 (95%CI:-1.29, 0.49); I²=89%), body mass index (2 trials, n=164, SMD: -0.34 (95%CI: -1.23, 0.56); I²=87%), waist circumference (3 trials, n=208, SMD): -0.43 (95%CI: -1.31, 0.46); I²=89%), and fasting glucose (4 trials, n=272, SMD: -0.25 (95%CI: -0.65, 0.15); I²=62%) were observed. The adverse reactions and any cause discontinuation rate were similar between the groups. According to the GRADE approach, the evidence levels of main outcomes were rated as “very low” (35.3%) to “low” (64.7%). Of them, the primary outcome (LDL-C) was rated as “very low “.

Conclusions

The data available on the effectiveness and safety of adjunctive rosuvastatin in treating dyslipidemia for patients with schizophrenia is insufficient to come to a definitive interpretation about its efficacy and safety. Further high quality RCTs with extended treatment duration are warranted to confirm the findings.

Review registration

PROSPERO: CRD42017078230

Hypercholesterolaemia - practical information for non-specialists

Hypercholesterolaemia is amongst the most common conditions encountered in the medical profession. It remains one of the key modifiable cardiovascular risk factors and there have been recent advances in the risk stratification methods and treatment options available. In this review, we provide a background into hypercholesterolaemia for non-specialists and consider the merits of the different risk assessment tools available. We also provide detailed considerations as to: i) when to start treatment, ii) what targets to aim for and iii) the role of low density lipoprotein cholesterol.

Lipid-lowering interventions targeting proprotein convertase subtilisin/kexin type 9 (PCSK9): an emerging chapter in lipid-lowering therapy

Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a serine protease that is mainly expressed in the liver but can also be found in the intestine and kidneys. PCSK9 promotes the degradation of low density lipoprotein receptors (LDLR) by reducing their recycling and targeting the receptors for lysosomal destruction, thereby decreasing the rate of removal of LDL-cholesterol from the circulation. Thus, interventions targeting PCSK9 by reducing its expression may lead to significant reductions of LDL-cholesterol and possibly decrease cardiovascular risk. The present review aims to present and discuss the current clinical and scientific data pertaining to lipid-lowering interventions targeting PCSK9.

Omega-3 Fatty Acids and Cardiovascular Disease: Summary of the 2016 Agency of Healthcare Research and Quality Evidence Review

We summarize the 2016 update of the 2004 Agency of Healthcare Research and Quality's evidence review of omega-3 fatty acids and cardiovascular disease (CVD). The overall findings for the effects of marine oil supplements on intermediate CVD outcomes remain largely unchanged. There is high strength of evidence, based on numerous trials, of no significant effects of marine oils on systolic or diastolic blood pressures, but there are small, yet statistically significant increases in high density lipoprotein and low density lipoprotein cholesterol concentrations. The clinical significance of these small changes, particularly in combination, is unclear. The strongest effect of marine oils is on triglyceride concentrations. Across studies, this effect was dose-dependent and related to studies' mean baseline triglyceride concentration. In observational studies, there is low strength of evidence that increased marine oil intake lowers ischemic stroke risk. Among randomized controlled trials and observational studies, there is evidence of variable strength of no association with increased marine oil intake and lower CVD event risk. Evidence regarding alpha-linolenic acid intake is sparser. There is moderate strength of evidence of no effect on blood pressure or lipoprotein concentrations and low strength of evidence of no association with coronary heart disease, atrial fibrillation and congestive heart failure.

Circulating proprotein convertase subtilisin-kexin type 9, all-cause mortality, and cardiovascular mortality: The Ludwigshafen Risk and Cardiovascular Health study

Background It is unclear whether proprotein convertase subtilisin-kexin type 9 (PCSK9) concentrations may be useful for cardiovascular risk stratification. Design The LUdwigshafen RIsk and Cardiovascular health (LURIC) study is a prospective observational registry of patients who were referred for coronary angiography. Methods Circulating PCSK9 was measured in 2139 participants of the LURIC study. There was a follow-up for all-cause and cardiovascular mortality with a median (interquartile range) duration of 10.1 (8.1-10.8) years. Results The mean (standard deviation) age of the participants (1470 males and 669 females) was 62.6 (10.8) years, body mass index 27.3 (4.0) kg/m², and low density lipoprotein cholesterol 114 (33) mg/dl. The mean (standard deviation) PCSK9 concentration was 220 (82) ng/ml. Of the participants, 1035 (48.4%) were on statins. Use of statins was associated with significantly lower low density lipoprotein cholesterol (106 vs 121 mg/dl, p < 0.001) but significantly higher circulating PCSK9 (244 vs 197 ng/ml, p < 0.001). A total of 674 (31.5%) study participants died from any cause and 431 (20.1%) from cardiovascular diseases. In the entire cohort, the third vs first tertile of PCSK9 was not associated with the risk of death from any cause (hazard ratio = 1.09, p = 0.367) and from cardiovascular diseases (hazard ratio = 1.09, p = 0.476). In participants without statins, the third vs first PCSK9 tertile was modestly associated with increased all cause mortality (hazard ratio = 1.34, p = 0.029) but not with cardiovascular mortality (hazard ratio = 1.25, p = 0.194). Conclusions Circulating PCSK9 may be upregulated by statin use and does not appear to be useful for cardiovascular risk stratification.

Associations between Serum 25-hydroxyvitamin D and Lipids, Lipoprotein Cholesterols, and Homocysteine

Background:

Serum 25(OH) vitamin D levels are inversely associated with cardiovascular disease (CVD) mortality, mediated in part by independent positive relationships with high-density lipoprotein cholesterol (HDLC) and inverse relationships with low-density lipoprotein cholesterol (LDLC), triglyceride, and homocysteine.

Aims:

In this study, we assessed relationships between fasting serum vitamin D and lipids, lipoprotein cholesterols, and homocysteine.

Materials and Methods:

We studied 1534 patients sequentially referred to our center from 2007 to 2016. Fasting serum total 25(OH) vitamin D, plasma cholesterol, triglyceride, HDLC, LDLC, and homocysteine were measured. Stepwise regression models were used with total cholesterol, triglyceride, HDLC, LDLC, and homocysteine as dependent variables and explanatory variables age, race, gender, body mass index (BMI), and serum vitamin D levels. Relationships between quintiles of serum vitamin D and triglycerides, HDLC, LDLC, and homocysteine were assessed after covariance adjusting for age, race, gender, and BMI.

Results:

Fasting serum vitamin D was positively correlated with age, HDLC, and White race, and was inversely correlated with BMI, total and LDL cholesterol, triglyceride, and fasting serum homocysteine (P ≤ 0.0001 for all). Serum vitamin D was a significant independent inverse explanatory variable for total cholesterol, triglyceride, and LDL cholesterol, and accounted for the largest amount of variance in serum total cholesterol (partial R² =3.6%), triglyceride (partial R² =3.1%), and LDLC (partial R² =2.9%) (P < 0.0001 for all). Serum vitamin D was a significant positive explanatory variable for HDLC (partial R² = 1.4%, P < 0.0001), and a significant inverse explanatory variable for homocysteine (partial R² = 6.0–12.6%).

Conclusions:

In hyperlipidemic patients, serum vitamin D was a significant independent inverse determinant of total cholesterol, LDLC, triglyceride, and homocysteine, and a significant independent positive determinant of HDLC. Thus, serum vitamin D might be protective against CVD.

[Effect of milk enriched with phytosterol ester on blood cholesterol of patients with hypercholesterolemia: a randomized controlled trial]

OBJECTIVE

To study the effect of milk enriched with phytosterol ester on blood cholesterol.

METHODS

Participants with hypercholesterolemia were recruited from community health center and randomly assigned to 3 groups: milk enriched with phytosterol ester group( PS group, n = 59), normal milk group( n = 58) and non-dairy group( n = 62). The intervention lasted for 2 months. At baseline, all subjects in the 3groups received health education on prevention and control of hypercholesterolemia. For PS and normal milk groups, subjects consumed 500 g milk per day, the intake ofphytosterol in PS group was 1. 58 g / d. For non-dairy group, subjects did not consume any dairy products during the trial. Subjects were assessed on their physical activity level and blood cholesterols were measured during monthly follow-up.

RESULTS

Finally 157 subjects completed the trial. By the end of the first month, the TC and LDL-C levels of PS group were significantly lower than that of normal milk group. After adjustment, there was no significant difference between baseline and 1-month TC levels in PS group. The levels of TG and HDL-C in PS group were significantly increased while the LDL-C level was significantly decreased after 1-month intervention. Compared with normal milk and nondairy groups, no differences were observed for these four indicators. After 2-month intervention, the TC and LDL-C levels of PS group were significantly lower than that of normal milk and non-dairy groups. The levels of TC and LDL-C in PS group were significantly reduced compared to baseline levels after adjustment. TG level was increased while HDL-C level was unchanged. Compared with normal milk and non-dairy groups, the levels of TC and LDL-C in PS group were significantly declined while no significant difference was observed for TG and HDL-C levels.

CONCLUSION

s Milk enriched with phytosterol ester has a notable effect on lowering TC and LDL-C levels in subjects with hypercholesterolemia.

From Lipids to Inflammation: New Approaches to Reducing Atherosclerotic Risk

The introduction of statins ≈ 30 years ago ushered in the era of lipid lowering as the most effective way to reduce risk of atherosclerotic cardiovascular disease. Nonetheless, residual risk remains high, and statin intolerance is frequently encountered in clinical practice. After a long dry period, the field of therapeutics targeted to lipids and atherosclerosis has entered a renaissance. Moreover, the demonstration of clinical benefits from the addition of ezetimibe to statin therapy in subjects with acute coronary syndromes has renewed the enthusiasm for the cholesterol hypothesis and the hope that additional agents that lower low-density lipoprotein will decrease risk of atherosclerotic cardiovascular disease. Drugs in the orphan disease category are now available for patients with the most extreme hypercholesterolemia. Furthermore, discovery and rapid translation of a novel biological pathway has given rise to a new class of cholesterol-lowering drugs, the proprotein convertase subtilisin kexin-9 inhibitors. Trials of niacin added to statin have failed to demonstrate cardiac benefits, and 3 cholesterol ester transfer protein inhibitors have also failed to reduce atherosclerotic cardiovascular disease risk, despite producing substantial increases in HDL levels. Although the utility of triglyceride-lowering therapies remains uncertain, 2 large clinical trials are testing the influence of omega-3 polyunsaturated fatty acids on atherosclerotic events in hypertriglyceridemia. Novel antisense therapies targeting apolipoprotein C-III (for triglyceride reduction) and apo(a) (for lipoprotein(a) reduction) are showing a promising trajectory. Finally, 2 large clinical trials are formally putting the inflammatory hypothesis of atherosclerosis to the test and may open a new avenue for cardiovascular disease risk reduction.

The blood lipid regulation of Monascus-produced monascin and ankaflavin via the suppression of low-density lipoprotein cholesterol assembly and stimulation of apolipoprotein A1 expression in the liver

BACKGROUND/PURPOSES

Monascin (MS) and ankaflavin (AK) produced by Monascus purpureus NTU 568 were proven to show excellent hypolipidemic effects in our previous studies; however, the mechanism is still unclear.

METHODS

This study used MS, AK, and monacolin K as test substances and performed tests on rats fed high-fat and high-cholesterol diet for 8 weeks. The lipid levels and the related protein levels of the rats were assessed to understand the effects of MS, AK, and monacolin K on lipid metabolism.

RESULTS

MS and AK lowered low-density lipoprotein cholesterol (LDL-C) and preserved high-density lipoprotein cholesterol contents. MS and AK inhibited acetyl-coenzyme A acetyltransferase, microsomal triglyceride transfer protein, and apolipoprotein (apo) B-100 expression, thereby preventing LDL assembly. In addition, enhanced LDL-receptor expression increased the transport of LDL-C to the liver for metabolism. MS and AK also significantly increase apo A1 expression, which facilitates high-density lipoprotein cholesterol formation.

CONCLUSION

Monascus-fermented MS and AK can perform blood lipid regulation via the suppression of LDL-C assembly and stimulation of apo A1 expression in liver.

PCSK9 inhibition-mediated reduction in Lp(a) with evolocumab: an analysis of 10 clinical trials and the LDL receptor's role

Lipoprotein (a) [Lp(a)] is independently associated with CVD risk. Evolocumab, a monoclonal antibody (mAb) to proprotein convertase subtilisin/kexin type 9 (PCSK9), decreases Lp(a). The potential mechanisms were assessed. A pooled analysis of Lp(a) and LDL cholesterol (LDL-C) in 3,278 patients from 10 clinical trials (eight phase 2/3; two extensions) was conducted. Within each parent study, biweekly and monthly doses of evolocumab statistically significantly reduced Lp(a) at week 12 versus control (P < 0.001 within each study); pooled median (quartile 1, quartile 3) percent reductions were 24.7% (40.0, 3.6) and 21.7% (39.9, 4.2), respectively. Reductions were maintained through week 52 of the open-label extension, and correlated with LDL-C reductions [with and without correction for Lp(a)-cholesterol] at both time points (P < 0.0001). The effect of LDL and LDL receptor (LDLR) availability on Lp(a) cell-association was measured in HepG2 cells: cell-associated LDL fluorescence was reversed by unlabeled LDL and Lp(a). Lp(a) cell-association was reduced by coincubation with LDL and PCSK9 and reversed by adding PCSK9 mAb. These studies support that reductions in Lp(a) with PCSK9 inhibition are partly due to increased LDLR-mediated uptake. In most situations, Lp(a) appears to compete poorly with LDL for LDLR binding and internalization, but when LDLR expression is increased with evolocumab, particularly in the setting of low circulating LDL, Lp(a) is reduced.

Controversies Regarding Lipid Management and Statin Use for Cardiovascular Risk Reduction in Patients With CKD

Adults with chronic kidney disease (CKD) are at heightened risk for dying of cardiovascular disease. Results from randomized clinical trials of statin drugs versus placebo demonstrate that statin drugs or statin plus ezetimibe reduce the absolute risk for coronary heart disease and mortality among adults with non-dialysis-dependent CKD. The Kidney Disease: Improving Global Outcomes 2013 clinical practice guideline for lipid management in CKD recommends that adults 50 years or older with non-dialysis-dependent CKD be treated with a statin or statin plus ezetimibe regardless of low-density lipoprotein cholesterol levels. However, at least 9 guidelines published during the last 5 years address lipid management for primary and secondary prevention of atherosclerotic cardiovascular disease, and not all guidelines address the utility of lipid-lowering therapy in adults with CKD. Because most patients with CKD receive most of their clinical care from non-nephrologists, differences in recommendations for lipid-lowering therapy for cardiovascular disease prevention may negatively affect the clinical care of adults with CKD and cause confusion for both patients and providers. This review addresses the identification and management of lipid levels in patients with CKD and discusses the existing controversies regarding testing and treatment of lipid levels in the CKD population.

Reduction of circulating PCSK9 and LDL-C levels by liver-specific knockdown of HNF1α in normolipidemic mice

The transcription factors hepatic nuclear factor (HNF)1α and HNF1β can bind to the HNF1 site on the proprotein convertase subtilisin/kexin type 9 (PCSK9) promoter to activate transcription in HepG2 cells. However, it is unknown whether one or both HNF1 factors are obligatory for transactivating hepatic PCSK9 gene expression in vivo. We developed shRNA adenoviral constructs (Ad-shHNF1α and Ad-shHNF1β) to examine the effects of knockdown of HNF1α or HNF1β on PCSK9 expression and its consequent impact on LDL receptor (LDLR) protein levels in cultured hepatic cells and liver tissue. We demonstrated that infection with Ad-shHNF1α, but not Ad-shHNF1β, markedly reduced PCSK9 mRNA expression in HepG2 cells with a concomitant increase in LDLR protein abundance. Injecting Ad-shHNF1α in mice fed a normal diet significantly (∼ 50%) reduced liver mRNA expression and serum concentration of PCSK9 with a concomitant increase (∼ 1.9-fold) in hepatic LDLR protein abundance. Furthermore, we observed a modest but significant reduction in circulating LDL cholesterol after knockdown of HNF1α in these normolipidemic mice. Consistent with the observation that knockdown of HNF1β did not affect PCSK9 mRNA or protein expression in cultured hepatic cells, Ad-shHNF1β infection in mice resulted in no change in the hepatic mRNA expression or serum content of PCSK9. Altogether, our study demonstrates that HNF1α, but not HNF1β, is the primary positive regulator of PCSK9 transcription in mouse liver.

Influence of physiological changes in endogenous estrogen on circulating PCSK9 and LDL cholesterol

Pharmacologically increased estrogen levels have been shown to lower hepatic and plasma proprotein convertase subtilisin/kexin type 9 (PCSK9) levels in animals and humans. We hypothesized that physiological changes in estrogen levels influence circulating PCSK9, thereby contributing to the known wide inter-individual variation in its plasma levels, as well as to the established increase in LDL cholesterol (LDL-C) with normal aging. Circulating PCSK9, estradiol, and other metabolic factors were determined in fasting samples from 206 female and 189 male healthy volunteers (age 20-85 years), The mean levels of PCSK9 were 10% higher in females than in males (P < 0.05). PCSK9 levels were 22% higher in postmenopausal than in premenopausal (P < 0.001) females. Within the group of premenopausal females, circulating PCSK9 correlated inversely to estrogen levels, and PCSK9 was higher (305 ng/ml) in the follicular phase than in the ovulatory (234 ng/ml) or the luteal (252 ng/ml) phases (P < 0.05). Changes in endogenous estrogen levels during the menstrual cycle likely contribute to the broad inter-individual variation in PCSK9 and LDL-C in normal females. PCSK9 levels increase in females after menopause but not in men during this phase in life. This likely contributes to why LDL-C in women increases in this period.

The serum lipid profile of Parkinson's disease patients: a study from China

BACKGROUND

The association between the fasting levels of serum lipids and Parkinson's disease (PD) in Chinese populations remains largely unknown.

METHODS

This study enrolled 555 sporadic PD patients and 555 age-, gender- and body mass index (BMI)-matched controls. The fasting serum lipid concentrations of all subjects, including total cholesterol, low-density lipoprotein (LDL-C), high-density lipoprotein (HDL-C) and triglycerides (TG), were measured.

RESULTS

Total cholesterol, LDL-C, HDL-C and TG were significantly lower in PD patients than in controls. The prevalence of PD is significantly lower in subjects with the second, third and fourth quartiles of total cholesterol than in those with the first quartile of total cholesterol, regardless of gender. The prevalence of PD is significantly lower in subjects with the third and fourth quartiles of LDL-C than in those with the first quartile of LDL-C, regardless of gender. Negative correlations were found between UPDRS part III score and level of total cholesterol/LDL-C.

CONCLUSIONS

PD patients are with lower levels of total cholesterol, LDL-C, HDL-C and TG than controls. Lipids may be a marker of PD severity.

Disruption of ldlr causes increased LDL-c and vascular lipid accumulation in a zebrafish model of hypercholesterolemia

Hyperlipidemia and arterial cholesterol accumulation are primary causes of cardiovascular events. Monogenic forms of hyperlipidemia and recent genome-wide association studies indicate that genetics plays an important role. Zebrafish are a useful model for studying the genetic susceptibility to hyperlipidemia owing to conservation of many components of lipoprotein metabolism, including those related to LDL, ease of genetic manipulation, and in vivo observation of lipid transport and vascular calcification. We sought to develop a genetic model for lipid metabolism in zebrafish, capitalizing on one well-understood player in LDL cholesterol (LDL-c) transport, the LDL receptor (ldlr), and an established in vivo model of hypercholesterolemia. We report that morpholinos targeted against the gene encoding ldlr effectively suppressed its expression in embryos during the first 8 days of development. The ldlr morphants exhibited increased LDL-c levels that were exacerbated by feeding a high cholesterol diet. Increased LDL-c was ameliorated in morphants upon treatment with atorvastatin. Furthermore, we observed significant vascular and liver lipid accumulation, vascular leakage, and plaque oxidation in ldlr-deficient embryos. Finally, upon transcript analysis of several cholesterol-regulating genes, we observed changes similar to those seen in mammalian systems, suggesting that cholesterol regulation may be conserved in zebrafish. Taken together, these observations indicate conservation of ldlr function in zebrafish and demonstrate the utility of transient gene knockdown in embryos as a genetic model for hyperlipidemia.

Lipoprotein apheresis and new therapies for severe familial hypercholesterolemia in adults and children

Familial hypercholesterolemia (FH), the most common and severe monogenic form of hypercholesterolemia, is an autosomal co-dominant disease characterized by an increased plasma low density lipoprotein (LDL)-cholesterol concentration and premature coronary heart disease (CHD). The clinical phenotype depends on the gene involved and severity of mutation (or mutations) present. Patients with homozygous or compound heterozygous FH have severe hypercholesterolemia (LDL-cholesterol >13 mmol/L) due to a gene dosing effect and without treatment have accelerated atherosclerotic CHD from birth, and frequently die of CHD before age 30. Cholesterol-lowering therapies have been shown to reduce both mortality and major adverse cardiovascular events in individuals with FH. Lipoprotein apheresis concomitant with lipid-lowering therapy is the treatment of choice for homozygous FH. This article describes the rationale and role of lipoprotein apheresis in the treatment of severe FH and outlines the recent advances in new pharmacotherapies for this condition.

Isolation and characterization of the circulating truncated form of PCSK9

Proprotein convertase subtilisin-kexin type 9 (PCSK9) is a secreted protein which regulates serum LDL cholesterol. It circulates in human and rodent serum in an intact form and a major truncated form. Previous in vitro studies involving the expression of human PCSK9 genetic variants and in vivo studies of furin knockout mice suggest that the truncated form is a furin cleavage product. However, the circulating truncated form of PCSK9 has not been isolated and characterized. Utilizing antibodies which bind to either the catalytic domain or the C-terminal domain of PCSK9, the truncated PCSK9 was isolated from serum. MS was used to determine that this form of PCSK9 is a product of in vivo cleavage at Arg218 resulting in pyroglutamic acid formation of the nascent N terminus corresponding to Gln219 of intact PCSK9. We also determined that the truncated PCSK9 in serum lacked the N-terminal segment which contains amino acids critical for LDL receptor binding. A truncated PCSK9, expressed and purified from HEK293 cells with identical composition as the circulating truncated protein, was not active in inhibition of LDL uptake by HepG2 cells. These studies provide a definitive characterization of the composition and activity of the truncated form of PCSK9 found in human serum.

Associations between serum perfluoroalkyl acids and LINE-1 DNA methylation

Perfluoroalkyl acids (PFAAs) are persistent, synthetic compounds that are used in a number of consumer products. Perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS) have been associated with cardiovascular risk factors, and changes in gene expression and DNA methylation in animals and cellular systems. However, whether PFAA exposure is associated with LINE-1 DNA methylation, a potential marker of cardiovascular risk, in humans remains unknown. We sought to evaluate the cross-sectional associations between serum PFAAs and LINE-1 DNA methylation in a population highly exposed to PFOA. We measured serum PFAAs twice four to five years apart in 685 adult participants (47% male, mean age±SD=42±11years). We measured percent LINE-1 DNA methylation in peripheral blood leukocytes at the second time point (follow-up), and estimated absolute differences in LINE-1 methylation associated with an interquartile (IQR) shift in mean PFAA serum levels. IQR increases in mean serum PFOA, PFOS, perfluorononanoic acid (PFNA), and perfluorohexane sulfonate (PFHxS) were associated with differences of -0.04 (p=0.16), 0.20 (p=0.001), 0.06 (p=0.19), and 0.02 (p=0.57), respectively, in % LINE-1 methylation at follow-up after adjustment for potential confounders. We observed a monotonic increase in LINE-1 DNA methylation across tertiles of PFOS and PFNA (ptrend=0.02 for both associations), but not across tertiles of PFOA or PFHxS (ptrend=0.71 and 0.44, respectively). In summary, serum PFOS was associated with LINE-1 methylation, while serum PFOA, PFHxS, and PFNA were not. Additional research is needed to more precisely determine whether these compounds are epigenetically active.

Relative contribution of obesity and serum adiponectin to the development of hypertension

AIMS

The aim of this study was to investigate the association between serum adiponectin level and new-onset hypertension, and the relative contribution of obesity and low serum adiponectin levels to the development of hypertension in normotensive men and women.

METHODS

We analyzed 1553 adults (584 men and 969 women) without hypertension, aged 40-70 years, who had participated in a cohort study in both time periods from 2005 to 2008 for baseline and 2008 to 2011 for follow-up. We divided participants into sex-specific tertiles according to serum adiponectin levels. We defined the highest tertile of serum adiponectin as 'high adiponectin'. Participants were then stratified into four groups: the non-obese with high adiponectin; the non-obese with low adiponectin; the obese with high adiponectin; and the obese with low adiponectin.

RESULTS

During an average of 2.6 years of follow-up, 79 men (13.5%) and 99 women (10.2%) developed hypertension. Low serum adiponectin level was an independent predictor of new-onset hypertension in men (Odds Ratio[OR]: 1.99; 95% CI: 1.03-3.86). The Obese men with low adiponectin had an increased risk of new-onset hypertension compared with the control group (OR: 2.80; 95% CI: 1.35-5.81). In postmenopausal women, the obese subjects with low adiponectin had an increased risk of new-onset hypertension compared with the control group (OR: 2.41; 95% CI 1.16-5.04).

CONCLUSION

Low serum adiponectin levels were associated with an increased risk of new-onset hypertension in men and postmenopausal women.

Activation of paraoxonase 1 is associated with HDL remodeling ex vivo

BACKGROUND

We hypothesize that during high density lipoprotein (HDL) remodeling PON1 reaches an optimal distribution in HDL subclasses by which it achieves maximum activity. We conducted this study to gain insight on PON1 fate and activation during short-term HDL remodeling ex vivo.

METHODS

Serum from 8 healthy volunteers was either frozen at -80°C (time 0) or incubated under sterile conditions for up to 48h at 37°C or at 4°C. Aliquots were taken at 3, 6, 9, 24 and 48 h and immediately frozen at -80°C. PON1 activities were measured, as well as PON1 and apolipoprotein distributions in HDL subclasses by gradient gel electrophoresis.

RESULTS

The first novel finding in our study is the evidence provided for a significant activation of both lactonase and arylesterase activities of PON1 that ensues in a very short time frame of incubation of serum ex vivo at 37°C. All subjects studied displayed these changes, the activation was apparent in <3h, peaked at 6h and amounted to >20%. This is associated with a temperature and time-dependent redistribution of PON1 activity in HDL subclasses, with an increase in activity in both very large HDL2 and small HDL3 in the first phase (3-9h), followed by a progressive transfer of PON1 to very large HDL2 as the particles mature. These changes are paralleled by the appearance of weak, but apparent PON1 activity at subspecies that correspond to sdLDL. During the first phase of PON1 activation and shifts, a parallel shift of apoE can be evidenced: at 3-9h, apoE increases in sdLDL, after that time it is lost from HDL and also from sdLDL and stays in VLDL at the origin of the run. ApoA-I shifts towards larger particles, which parallels the change in PON1. As HDL matures there is a progressive shift of apoA-II towards larger HDL. Low levels of apoA-IV at the initiation of the incubation are followed by time dependent quick disappearance of apoA-IV in HDL which parallels the changes in PON1, apoE and A-II.

CONCLUSION

Short, ex vivo incubation of serum leads to quick activation of PON1 associated with transfers to HDL3c, large HDL and sdLDL. The process is blocked by CETP and LCAT inhibitors. The data suggest that HDL maturation optimizes PON1 activity. These findings may be of interest for future studies aimed at modulating PON-1 activity for its cardioprotective effects and suggest a new mechanism whereby CETP inhibitors failed in clinical trials.

Evaluation of hypoglycemic activity of total lignans from Fructus Arctii in the spontaneously diabetic Goto-Kakizaki rats

ETHNOPHARMACOLOGICAL RELEVANCE

Fructus Arctii, called "Niubangzi" in China (Great burdock achene in English), is a well-known Chinese Materia Medica. It is the dried ripe fruit of Arctium lappa L. (family Asteraceae) and was included in the Chinese pharmacopoeia for its traditional therapeutic actions. Meanwhile it has been utilized extensively in a number of classical drug formulas as a major component for the treatment of noninsulin-dependent diabetes mellitus. It has also been reported recently that the clinical use of Fructus Arctii resulted in a satisfactory hypoglycemic effect in diabetic patients. The aim of this study was to investigate hypoglycemic activity of total lignans from Fructus Arctii (TLFA) in Goto-Kakizaki (GK) rats, a spontaneous type 2 diabetic animal model, and the mechanism of its hypoglycemic activity.

MATERIALS AND METHODS

Male GK rats and normal Wistar rats were used in this study, GK rats fed twice daily were given TLFA (300 mg/kg) or nateglinide (50mg/kg) orally before each meal for 12 weeks. Besides common evaluation indexes of hypoglycemic activity such as blood glucose level, oral glucose tolerance test (OGTT), glycated hemoglobin, as well as lipid metabolism parameters such as cholesterol (CHOL), triglycerides (TG), et al., in rat serum. The effects of TLFA on insulin secretion and pancreas tissue sections, the levels of serum glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), and the α-glucosidase inhibitory activity of TLFA in vitro were investigated.

RESULTS

TLFA demonstrated stable and long-lasting hypoglycemic activity in GK rats and showed significant improvement in glucose tolerance in glucose fed hyperglycemic GK rats. Both TLFA and nateglinide controlled the glycosylated hemoglobin levels of the experimental animals very well. Stimulation of insulin secretion was proved to be one of the hypoglycemic mechanism of TLFA, promoting the release of GLP-1 should be another one, and ɑ-glucosidase inhibitory activity of TLFA also contributes to its hypoglycemic activity. In this study, we didn't found that TLFA could effect the body weight of GK rats, which was also verified by the changes of biochemical parameters of blood in experimental rats.

CONCLUSION

The results of this study indicates that TLFA has significant hypoglycemic potential in GK rats, and it may be acting through stimulating insulin secretion, promoting the release of GLP-1, and decreasing intestinal absorption of glucose.

Eriosema laurentii De Wild (Leguminosae) methanol extract has estrogenic properties and prevents menopausal symptoms in ovariectomized Wistar rats

ETHNOPHARMACOLOGICAL RELEVANCE

Eriosema laurentii De Wild (Leguminosae) is a medicinal plant used in West and Central Africa for different diseases. In Cameroon, this plant is used as a treatment for infertility, and various gynecological and menopausal complaints. However, despite this use as a natural remedy, the biological activity of Eriosema laurentii has not been studied until now.

AIM OF STUDY

In order to determine the potential use of this plant in gynecological conditions/disorders, we evaluated the estrogenic properties of a methanol extract of its aerial parts and its ability to prevent different menopausal health problems induced by bilateral oophorectomy.

MATERIAL AND METHODS

Two approaches were used. In vitro, recombinant yeast systems were applied, featuring either the respective human receptors (ERα, AR, and PR) or into chromosome III integrated human aryl hydrocarbon receptor (AhR) and the respective reporter plasmid. In vivo, the investigation was carried out using the 3 days uterotrophic assay and 9 weeks oral treatment in ovariectomized rats.

RESULTS

The results showed that the methanol extract of the aerial parts of Eriosema laurentii transactivated the estrogen receptor-α and displayed AhR agonistic activity but was neither androgenic nor progesteronic. In rats, the extract did not induce endometrium proliferation either in the 3-day or the 9-week treatment regimens, but induced vaginal stratification and cornification, prevented loss of femur bone mass, increased high density lipoprotein cholesterol (HDL-C), and reduced total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), TC/HDL-C ratio, LDL-C/HDL-C ratio and the atherogenic index of plasma (AIP).

CONCLUSION

These results suggest that the methanol extract of the aerial parts of Eriosema laurentii does not seem to have an undesirable influence on the endometrium but might prevent vaginal dryness and bone mass loss and improve the lipid profile.

Modulation of liver function, antioxidant responses, insulin resistance and glucose transport by Oroxylum indicum stem bark in STZ induced diabetic rats

A decoction of stem bark of Oroxylum indicum Vent. (OI) is taken (2-3 times/day) by the tribal people of Sikkim, India to treat diabetes but scientific validation of its overall potential is lacking. Present study was aimed to assess in vitro antihyperglycemic activity of standardized OI extract using inhibition of α-glucosidase, BSA glycation and enhancement of insulin sensitivity. Antidiabetic and antioxidant modulatory effects of OI extract along with the blood biomarkers of toxic response were studied in streptozotocin (STZ) induced diabetic rats. In vitro analysis showed strong antioxidant capacity of OI -and potential to inhibit BSA glycation and α-glucosidase activity which was comparable to standard counterparts. Extract also improved insulin sensitivity in mature 3T3-L1 adipocytes. In vivo effects of OI extract (oral 250 mg/kg b.wt.) on STZ induced type II diabetic rats normalized the antioxidant status (p≤0.01). Analysis of blood biomarkers of toxic response indicated its safety. Lowering of total cholesterol and HDL levels (p≤0.05) and restoration of glycated Hb (p≤0.01) were also found in OI treated diabetic rats. HOMA-IR, QUICKI analysis along with area under the curve analysis showed the capacity of OI extract to enhance the insulin sensitivity significantly (p≤0.01) which was confirmed by increased GLUT-4 translocation in skeletal muscles.

Antidiabetic effect of total flavonoids from Sanguis draxonis in type 2 diabetic rats

ETHNOPHARMACOLOGICAL RELEVANCE

Sanguis draxonis (SD) is a kind of red resin obtained from the wood of Dracaena cochinchinensis (Lour.) S. C. Chen (Dracaena cochinchinensis). It is a Chinese traditional herb that is prescribed for the handling of diabetic disorders, which is also supported by an array of scientific studies published in recent years. Although chemical constituents of this plant material have also been previously evaluated (Tang et al., 1995; Wei et al., 1998), it still remains poorly understood which constituent is the major contributor to its antidiabetic activities. Moreover, very little is known about the molecular mechanisms underlying antidiabetic activities of SD. Flavonoids exist at a high level in SD. The aim of this study is to evaluate the antidiabetic effects of total flavonoids from SD (SDF) in type 2 Diabetes mellitus (T2DM) rats.

MATERIALS AND METHODS

T2DM rats were induced by 4 weeks high-fat diet and a singular injection of streptozotocin (STZ) (35mg/kg). Then T2DM rats were treated with SDF for 21 days, using normal saline as the negative control. For comparison, a standard antidiabetic drug, metformin (200mg/kg), was used as a positive control. Three weeks later, relative biochemical indexes were determined and histopathological examinations were performed to assess the antidiabetic activities of SDF.

RESULTS

SDF not only exhibited a significant hypoglycemic activity, but also alleviated dyslipidemia, tissue steatosis, and oxidative stress associated with T2DM. Moreover, considerable pancreatic islet protecting effects could be observed after SDF treatment. Further investigations revealed a potential anti-inflammation activity of SDF by determining serum levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α) and C-reactive protein (CRP).

CONCLUSIONS

This study demonstrates both hypoglycemic and hypolipidemic effects of SDF in T2DM rats, suggesting that flavonoids are the major active ingredients accounting for the antidiabetic activity of SD. Alleviating chronic inflammation responses and protecting pancreatic islets are possible mechanisms involved in the antidiabetic activity of SDF.

The diagnostic threshold of HbA1c and impact of its use on diabetes prevalence-a population-based survey of 6898 Han participants from southern China

OBJECTIVE

The objective of this study is to determine the diagnostic threshold of HbA1c for diabetes and the impact of using it on diabetes prevalence.

METHODS

A population-based stratified study was conducted in 2010 among community-dwelling adults aged ≥35years in southern China. Participants without previously-diagnosed diabetes (PDD) took oral glucose tolerance test (OGTT) and HbA1c assay. HbA1c diagnostic threshold was determined by receiver operating characteristic curve.

RESULTS

A total of 6989 participants with mean age of 52years were recruited. The area under curve of HbA1c was 0.903 (95% CI: 0.883-0.922), with optimal cut-off value at 6.25% (sensitivity 75.6% and specificity 91.9%). There were 449 (6.42%) patients with PDD and 422 (6.04%), 815 (11.66%) and 918 (13.13%) new cases diagnosed by OGTT, HbA1c ≥6.25% or either, respectively. When either HbA1c or OGTT was used, newly-diagnosed diabetes prevalence increased by 117.4%.

CONCLUSIONS

Diabetes is prevalent in southern China. Near half of the patients go undetected with current diagnostic criteria. HbA1c ≥6.25% may be the diagnostic threshold value but needs further verification. The introduction of HbA1c threshold into diabetes diagnosis in China will cause a substantial increase in diabetes prevalence and great challenge on the public healthcare system.