LDLR gene's promoter region hypermethylation in patients with familial hypercholesterolemia

Familial hypercholesterolemia (FH) is characterized by high low-density lipoprotein cholesterol (LDL-C) levels and a high risk of early coronary heart disease. Structural alterations in the LDLR, APOB, and PCSK9 genes were not found in 20-40% of patients diagnosed using the Dutch Lipid Clinic Network (DCLN) criteria. We hypothesized that methylation in canonical genes could explain the origin of the phenotype in these patients. This study included 62 DNA samples from patients with a clinical diagnosis of FH according to the DCLN criteria, who previously tested negative for structural alterations in the canonical genes, and 47 DNA samples from patients with normal blood lipids (control group). All DNA samples were tested for methylation in the CpG islands of the three genes. The prevalence of FH relative to each gene was determined in both groups and the respective prevalence ratios (PRs) were calculated. The methylation analysis of APOB and PCSK9 was negative in both groups, showing no relationship between methylation in these genes and the FH phenotype. As the LDLR gene has two CpG islands, we analyzed each island separately. The analysis of LDLR-island1 showed PR = 0.982 (CI 0.33-2.95; χ² = 0.001; p = 0.973), also suggesting no relationship between methylation and the FH phenotype. Analysis of LDLR-island2 showed a PR of 4.12 (CI 1.43-11.88; χ² = 13,921; p = 0.00019), indicating a possible association between methylation on this island and the FH phenotype.

Screening criteria for interstitial lung disease associated to rheumatoid arthritis: Expert proposal based on Delphi methodology

OBJECTIVE

To develop a joint proposal for screening criteria of interstitial lung disease (ILD) in patients with rheumatoid arthritis (RA) and vice versa, which serves as a guidelines in patient referral between the Rheumatology and Pneumology departments to early detection of these patients.

METHODS

A systematic literature review was carried out on the risk factors for the development of ILD in RA patients, and for the referral criteria to Rheumatology for suspected early RA. Based on the available evidence, screening criteria were agreed using the Delphi method by a panel of pneumologists and rheumatologists with expertise in these pathologies.

RESULTS

Screening criteria for ILD in patients with RA and for the early detection of RA in cases with ILD of unknown etiology have been developed. In both cases, a detection strategy was based on clinical risk factors. Recommendations also included the complementary tests to be carried out in the different clinical scenarios and on the periodicity that screening should be repeated.

CONCLUSION

A selective screening strategy is recommended for the first time in the early diagnosis of patients with ILD-RA. This multidisciplinary proposal aims to solve some common clinical questions and help decision-making, although its usefulness to identify these patients with good sensitivity must be confirmed in a validation study.

Evolocumab treatment reduces carotid intima-media thickness in paediatric patients with heterozygous familial hypercholesterolaemia

Background

Familial hypercholesterolemia (FH) is characterised by high plasma levels of low-density lipoprotein cholesterol (LDL-C) and increased risk of premature atherosclerotic cardiovascular disease (ASCVD). Previous studies show that carotid intima-media thickness (cIMT) is increased in children with FH, an indicator of early ASCVD. Add-on treatment with the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, evolocumab, substantially reduced atherosclerotic lipid levels in children with heterozygous FH (HeFH) and was safe and well tolerated. The effect of evolocumab on cIMT in paediatric patients (pts) has not been investigated.

Purpose

To investigate the effect of evolocumab treatment on cIMT progression in paediatric pts with HeFH.

Methods

HAUSER-RCT was a multicenter, randomised, placebo-controlled study in which paediatric FH pts (ages 10–17 years) received monthly subcutaneous injections of evolocumab 420 mg or placebo. Of 157 pts, 150 continued to an open-label extension study (HAUSER-OLE) during which all received up to 80 weeks of monthly evolocumab 420 mg on top of stable background statin therapy. cIMT was measured by B-mode ultrasound scanning at baseline, week 24 of the RCT, and weeks 24, 48, and 80 of the OLE. cIMT was measured on anterior, lateral, and posterior imaging angles of the right and left common carotid artery. Mean thickness at each visit and mean changes from baseline were summarised by treatment received during the RCT and artery location. In addition, the largest measurements (anterior, lateral, or posterior) from a patient's left and right carotid artery were averaged to calculate a summary score.

Results

Mean baseline cIMT summary score was 0.568 mm (SD=0.06) for 46 placebo pts and 0.586 mm (SD=0.06) for 82 evolocumab pts. During the RCT, 37 placebo pts had a mean increase of 0.006 mm (SD=0.05) from baseline to week 24; in contrast, 76 evolocumab pts had a mean decrease of 0.003 mm (SD=0.05). Although this treatment group difference was not statistically significant (P=0.403), the pattern of increased cIMT for placebo and decreased cIMT for evolocumab was consistent across artery locations (Table). During the OLE, for pts who initially received placebo, mean cIMT summary score decreased by 0.019 mm (SD=0.04, n=34) from baseline to week 80 (P=0.007) (Figure). Pts who received evolocumab in both the RCT and OLE showed continued improvement during the OLE; at week 80, mean cIMT summary score decreased by 0.012 mm (SD=0.05, n=59) from baseline (P=0.067). For all pts at week 80 (n=128), the mean decrease in LDL-C from baseline was 35.3% (SD=28.0).

Conclusions

Open-label evolocumab treatment for up to 80 weeks led to reductions in mean cIMT. In this small sample of pts with FH, the data suggest that the addition of PCSK9 inhibition to background lipid-lowering therapy has the potential to reduce the risk of ASCVD progression and future cardiovascular events in this vulnerable paediatric population.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen, Inc.

The effect of bariatric surgery on circulating levels of lipoprotein(a): a systematic review and meta-analysis

Background

Obesity, and especially severe obesity, are strongly related to higher risk of atherosclerotic cardiovascular disease (ASCVD) morbidity and mortality. Bariatric surgery is an effective weight loss therapy for people with severe obesity and weight-related co-morbid conditions. Elevated plasma level of lipoprotein(a) [Lp(a)] is causally associated with ASCVD.

Purpose

The aim of the present meta-analysis was to analyze whether bariatric surgery could influence Lp(a) concentrations.

Methods

A systematic literature search in PubMed, Scopus, Embase, and Web of Science was performed from inception to May 1st, 2021. A random-effects model and the generic inverse variance weighting method were used to compensate for the heterogeneity of studies in terms of study design, treatment duration, and the characteristics of the studied populations. A random-effect meta-regression model was used to explore the association with an estimated effect size. Evaluation of funnel plot, Begg's rank correlation and Egger's weighted regression tests were used to assess the presence of publication bias in the meta-analysis.

Results

Meta-analysis of 13 studies including 1,551 patients showed a significant decrease of circulating Lp(a) after bariatric surgery (SMD: −0.438, 95% CI: −0.702, −0.174, p<0.001, I2: 94.05%). The results of meta-regression did not indicate any significant association between the changes in Lp(a) and duration of follow up from surgery, reduction in body mass index, or baseline Lp(a) concentration. The reduction in circulating Lp(a) was robust in the leave-one-out sensitivity analysis.

Conclusions

Based on the results of the Mata-analysis we showed that bariatric surgery significantly decreases circulating Lp(a) concentrations.

Funding Acknowledgement

Type of funding sources: None.

Adiponectin predicts the antioxidant capacity and size of high-density lipoprotein (HDL) in individuals with diabetes mellitus

AIMS

The relationship between adiponectin and type 2 diabetes mellitus (T2DM) is established; however the evidence on its role in high-density lipoprotein (HDL) functionality is still scant. The aim of this study was to assess the association of adiponectin with HDL functionality especially on the antioxidant capacity and HDL subfractions in individuals with T2DM.

METHODS

This case-control study enrolled 356 individuals who were divided into two groups: diabetics [T2DM (n = 188)] and non-diabetic [nT2DM (n = 168)]. The association of adiponectin level on HDL functionality parameters was done in function of the cut-off point for adiponectin [percentile p < 75 = 12.9 μg/mL versus p ≥ 75 = 12.9 μg/mL] and multiple adjustments applied in the logistic regression models.

RESULTS

Body mass index (BMI), waist circumference (WC) and body fat mass (FM) were higher in T2DM. The larger HDL particles (HDL_LARGE) were lower in T2DM group in comparison with nT2DM (28.20% versus 30.40%; p = 0.016). Individuals with T2DM and simultaneous highest adiponectin (p ≥ 75) had 2.25 OR (95% CI = 1.03-4.91) and 5.14 OR (95% CI = 2.37-11.15) to present higher HDL-C and HDL_LARGE concentrations. After adjustment for multiple confounders, high level of adiponectin was independently related with improvement of the HDL antioxidant capacity (OR = 2.78; 95% CI = 1.16-6.67).

CONCLUSIONS

High adiponectin level associates with a lesser negative impact of T2DM on HDL functionality by increase in APO AI, particles size, and cholesterol content. On the same token, higher adiponectin was associated with greater odds to have high antioxidant capacity.

Structural and magnetic properties of ultra-low density BiFeO3 nanoparticles produced by pulsed laser deposition

Ultra-low-density BiFeO₃ nanoparticles have been prepared by pulsed laser deposition and their structure and magnetic properties have been studied. Annealing increases crystallinity and the size of the particles leading to an alteration of magnetic properties, observed from magnetic studies and evaluated using high-resolution transmission electron microscopy , selected area electron diffraction and x-ray diffraction patterns analysis. Transmission electron microscopy results show that the BiFeO₃ as-deposited nanoparticles annealed up to 400 °C exhibit a orthorhombic distorted perovskite structure without secondary phase and with diameters varying from 9 nm (as-deposited) to 17 nm (annealed at 400 °C). Magnetic data exhibit exchange bias and magnetic blocking effects at low temperatures and typical superparamagnetic behavior at high temperatures. Meanwhile, the BiFeO₃ nanoparticles annealed at 500 °C exhibit a rhombohedrally distorted perovskite structure with typical antiferromagnetic properties and diameter of about 56 nm. The analysis of magnetic relaxation time using the Arrhenius equation suggests a superparamagnetic blocking process of ferromagnetic clusters on the surface of the nanoparticles at low temperature. The magnetic properties are discussed considering the interactions between nanoparticles and the co-existence of different magnetic phases within the nanoparticles: an ordered antiferromagnetic core and ferromagnetic clusters on the surface.

Magnetic Precipitation: A New Platform for Protein Purification

One of the trends in downstream processing comprises the use of "anything-but-chromatography" methods to overcome the current downfalls of standard packed-bed chromatography. Precipitation and magnetic separation are two techniques already proven to accomplish protein purification from complex media, yet never used in synergy. With the aim to capture antibodies directly from crude extracts, a new approach combining precipitation and magnetic separation is developed and named as affinity magnetic precipitation. A precipitation screening, based on the Hofmeister series, and a commercial precipitation kit are tested with affinity magnetic particles to assess the best condition for antibody capture from human serum plasma and clarified cell supernatant. The best conditions are obtained when using PEG3350 as precipitant at 4 °C for 1 h, reaching 80% purity and 50% recovery of polyclonal antibodies from plasma, and 99% purity with 97% recovery yield of anti-TNFα mAb from cell supernatants. These results show that the synergetic use of precipitation and magnetic separation can represent an alternative for the efficient capture of antibodies.

Tocilizumab in giant cell arteritis: differences between the GiACTA trial and a multicentre series of patients from the clinical practice

OBJECTIVES

A potential point of concern among clinicians is whether results derived from the clinical trials can be reasonably applied or generalised to a definable group of patients seen in real world. It can be the case of the GiACTA study that is a phase III randomised controlled trial of tocilizumab (TCZ) in giant cell arteritis (GCA). To address this question, we compared the clinical features and the responses to TCZ from the GiACTA trial patients with those from a series of GCA seen in the daily clinical practice.

METHODS

Comparative study of clinical features between patients from the GiACTA trial (overall n=251) and those from a multicentre series of real-world GCA patients undergoing TCZ therapy (n=134). The diagnosis of GCA in the GiACTA trial was established by the ACR modified criteria whereas in the series of real-world patients it was made by using the ACR criteria, a positive biopsy of temporal artery or the presence of imaging techniques consistent with large-vessel vasculitis in individuals who presented cranial symptoms of GCA. GiACTA trial patients received subcutaneous TCZ (162 mg every 1 or 2 weeks) whereas those from the clinical practice series were treated using standard IV dose (8 mg/kg/month) or subcutaneous (162 mg/week).

RESULTS

Real-life patients undergoing TCZ were older with longer disease duration and higher values of ESR and had received conventional immunosuppressive therapy (mainly methotrexate) more commonly than those included in the GiACTA trial. Despite clinical differences, TCZ was equally effective in both GiACTA trial and clinical practice patients. However, serious infections were more commonly observed in GCA patients recruited from the clinical practice.

CONCLUSIONS

Despite clinical differences with patients recruited in clinical trials, data from real-life patients confirm the efficacy of TCZ in GCA.

P4397Health related quality of life is not reduced in elder familial hypercholesterolemia patients

Background

Familial hypercholesterolemia (FH) is a genetic disorder associated with high risk of early major cardiovascular events (MACE) that can impact on elderly's self-appraisal of health-related quality of life (HRQoL), however, this association is unclear.

Purpose

This study evaluated HRQoL of elder individuals (from 60 to 88 years old), index cases (IC) and first-degree relatives (FDR) at high risk of FH.

Methods

From 1030 participants of FH genetic cascade screening, 250 were ≥60 and 205 were eligible for this study. Data collection was performed before awareness of molecular diagnosis results. Individuals were divided into 4 groups according to molecular diagnosis: IC with (IC+) and without (IC-) identified mutations (n=38 and n=54, respectively), and their affected (FDR+, n=74) and non-affected (FDR-, n=39) FDR. HRQoL measurements, mental (MCS) and physical component (PCS) scores, were carried out with the SF-12 questionnaire. Associations were tested by multivariate models.

Results

The mean age was 68±7 years, 32.2% were men, MACE had occurred in 47.8%. HRQoL dimensions measure (variance of physical, mental and health quality component scores) did not differ between FH and non-FH individuals. Lower PCS were associated with female sex (p=0.043), lower education (p=0.047), previous MACE occurrence (p<0.001), arterial hypertension (p=0.005), depression (p=0.004) and Alzheimer's disease (p=0.016). Lower MCS were associated with the previous diagnosis of depression (p<0.001) and Alzheimer's disease (p=0.011). Lower HQS were associated with lower education level (p=0.001), previous MACE (p<0.001), arterial hypertension (p<0.001), depression and Alzheimer (p=0.004 and p=0.006). MACE and hypertension were predictive of lower PCS (p=0.003 and p=0.035). Depression was predictive of lower MCS (p<0.001). Education, MACE and depression were predictive of health quality self-appraisal. No association was found with either molecular defect or lipid-lowering therapy.

Conclusion

HRQol in elder suspected FH individuals relates more to a consequence of elevated cholesterol levels i.e. MACE and co-morbidities rather than molecular defects or pharmacological treatment.

P650Lipopolysaccharide-nuclear factor-kappa B pathway and lipoprotein apheresis effects in patients with familial hypercholesterolemia and coronary artery disease

Background

Inflammation may play an important role in atherosclerosis in familial hypercholesterolemia (FH). Lipopolysaccharide (LPS)-nuclear factor-kappa B (NF-κB) pathway is a routine signal process activated in inflammatory status.

Purpose

This study aimed to examine the LPS-NF-κB axis status and the impact of lipoprotein apheresis (LA) on this pathway in patients with FH and coronary artery disease (CAD).

Methods

In this matched case-control study a genetically diagnosed FH cohort who presented stable CAD (n=63) was compared with 63 non-FH CAD and 63 non-FH non-CAD controls matched by sex and age. Plasma LPS levels and NF-κB activity were compared among the three groups. In addition, we studied in vitro LPS-induced interleukin-6 (IL-6) production by mononuclear cells from 16 FH cases without previous statin use and compared them with their respective matched control groups. Subsequently, these 16 FH patients underwent LA. Blood samples were taken immediately before and regularly after LA for measuring LPS and NF-κB.

Results

FH plus CAD had higher LPS levels and NF-κB activity than CAD and non-CAD controls (all p values <0.01). LPS-induced IL-6 production by mononuclear cells of FH plus CAD was also much higher compared with CAD and non-CAD controls (both p values <0.01). Moreover, plasma LPS levels (p<0.001) and NF-κB activity (p<0.01) were dramatically reduced after apheresis in FH patients.

Conclusion

Genetically confirmed FH patients with CAD had a marked activation of LPS-NF-κB axis, while LA significantly attenuated this key inflammatory pathway, suggesting that inflammation may be an important therapeutic target for FH patients.

A new dawn for managing dyslipidemias: The era of rna-based therapies

The high occurrence of atherosclerotic cardiovascular disease (ASCVD) events is still a major public health issue. Although a major determinant of ASCVD event reduction is the absolute change of low-density lipoprotein-cholesterol (LDL-C), considerable residual risk remains and new therapeutic options are required, in particular, to address triglyceride-rich lipoproteins and lipoprotein(a) [Lp(a)]. In the era of Genome Wide Association Studies and Mendelian Randomization analyses aimed at increasing the understanding of the pathophysiology of ASCVD, RNA-based therapies may offer more effective treatment options. The advantage of oligonucleotide-based treatments is that drug candidates are targeted at highly specific regions of RNA that code for proteins that in turn regulate lipid and lipoprotein metabolism. For LDL-C lowering, the use of inclisiran - a silencing RNA that inhibits proprotein convertase subtilisin/kexin type 9 (PCSK9) synthesis - has the advantage that a single s.c. injection lowers LDL-C for up to 6 months. In familial hypercholesterolemia, the use of the antisense oligonucleotide (ASO) mipomersen, targeting apolipoprotein (apoB) to reduce LDL-C, has been a valuable therapeutic approach, despite unquestionable safety concerns. The availability of specific ASOs lowering Lp(a) levels will allow rigorous testing of the Lp(a) hypothesis; by dramatically reducing plasma triglyceride levels, Volanesorsen (APOC3) and angiopoietin-like 3 (ANGPTL3)-LRx will further clarify the causality of triglyceride-rich lipoproteins in ASCVD. The rapid progress to date heralds a new dawn in therapeutic lipidology, but outcome, safety and cost-effectiveness studies are required to establish the role of these new agents in clinical practice.

Tocilizumab in giant cell arteritis. Observational, open-label multicenter study of 134 patients in clinical practice

OBJECTIVE

Tocilizumab (TCZ) has shown efficacy in clinical trials on giant cell arteritis (GCA). Real-world data are scarce. Our objective was to assess efficacy and safety of TCZ in unselected patients with GCA in clinical practice Methods: Observational, open-label multicenter study from 40 national referral centers of GCA patients treated with TCZ due to inefficacy or adverse events of previous therapy. Outcomes variables were improvement of clinical features, acute phase reactants, glucocorticoid-sparing effect, prolonged remission and relapses. A comparative study was performed: (a) TCZ route (SC vs. IV); (b) GCA duration (≤6 vs. >6 months); (c) serious infections (with or without); (d) ≤15 vs. >15 mg/day at TCZ onset.

RESULTS

134 patients; mean age, 73.0 ± 8.8 years. TCZ was started after a median [IQR] time from GCA diagnosis of 13.5 [5.0-33.5] months. Ninety-eight (73.1%) patients had received immunosuppressive agents. After 1 month of TCZ 93.9% experienced clinical improvement. Reduction of CRP from 1.7 [0.4-3.2] to 0.11 [0.05-0.5] mg/dL (p < 0.0001), ESR from 33 [14.5-61] to 6 [2-12] mm/1st hour (p < 0.0001) and decrease in patients with anemia from 16.4% to 3.8% (p < 0.0001) were observed. Regardless of administration route or disease duration, clinical improvement leading to remission at 6, 12, 18, 24 months was observed in 55.5%, 70.4%, 69.2% and 90% of patients. Most relevant adverse side-effect was serious infections (10.6/100 patients-year), associated with higher doses of prednisone during the first three months of therapy.

CONCLUSION

In clinical practice, TCZ yields a rapid and maintained improvement of refractory GCA. Serious infections appear to be higher than in clinical trials.

Self-initiated changes in physical activity levels improve cardiometabolic profiles: A longitudinal follow-up study

BACKGROUND AND AIMS

While studies have described the importance of higher physical activity levels (PAL) in weight loss, the impact of self-initiated PAL on health status warrants further study. We aimed to prospectively examine the effects of self-initiated longitudinal PAL changes on body mass index (BMI) and cardiometabolic parameters in normal weight, overweight and obese adults.

METHODS AND RESULTS

We included 4840 adults (mean age 41.6 ± 7.9 years, 79% male) undergoing routine health screening examinations. Self-reported PAL, height, weight, blood pressure and blood samples were collected at baseline and after a mean (95% confidence interval) follow up of 536 (531-541) days. Subjects were stratified according to BMI [39.8% normal weight (<25 kg/m²), 45.1% overweight (25.0-29.9 kg/m²), and 19.1% obese (≥30 kg/m²)]. In normal weight individuals, BMI increased from baseline to follow-up, irrespective of PAL changes. On the other hand, overweight and obese individuals that increased PAL experienced a decrease in BMI by -0.9% and -3.1%, respectively (p < 0.05). Overweight and obese individuals that increased PAL also experienced a decrease in -5.8% -4.6% in non-HDL concentrations from baseline to follow-up (p < 0.05). Finally, in overweight individuals, LDL cholesterol concentrations decreased from baseline to follow-up, irrespective of PAL changes whereas in obese individuals, a maintenance or increased PAL were associated with a decrease in -4.7% and -6.1% (p < 0.05), respectively.

CONCLUSIONS

In a large cohort of screening patients, longitudinal self-initiated PAL is associated with improved BMI and cardiometabolic profile in overweight and obese individuals.

Association between non-alcoholic hepatic steatosis and hyper reactive blood pressure response on the exercise treadmill test

AIMS

Non-alcoholic hepatic steatosis (HS) is associated with hypertension and increased cardiovascular risk. While Blood pressure hyper-reactive response (HRR) during peak exercise indicates an increased risk of incident hypertension and increased cardiovascular risk, no data on the association of non-alcoholic HS and HRR exists. In this study, we have evaluated the association of HS with HRR.

METHODS

We included 13 410 consecutive individuals with a mean age: 42.4  ±  8.9 years, 3561 (26.6%) female with normal resting blood pressure and without a previous diagnosis of hypertension, who underwent symptom limited exercise treadmill test, abdominal ultrasonography and clinical and laboratory evaluation. HS was detected by abdominal ultrasonography. HRR was defined by a peak exercise systolic blood pressure  >220 mmHg and/or elevation of 15 mmHg or more in diastolic blood pressure from rest to peak exercise.

RESULTS

The prevalence of HS was 29.5% (n  =  3956). Overall, 4.6% (n  =  619) of the study population presented a HRR. Subjects with HS had a higher prevalence of HRR (8.1 vs. 3.1%, odds ratio 2.8, 95% CI 2.4-3.3, P  <  0.001). After adjustment for body mass index, waist circumference, fasting plasma glucose and low density lipoprotein cholesterol, HS (odds ratio 1.4, 95% CI 1.1-1.6, P  =  0.002) remained independently associated with HRR. HS was additive to obesity markers in predicting exercise HRR.

CONCLUSIONS

Non-alcoholic HS is independently associated with hyper-reactive exercise blood pressure response.

EUCLIS--an information system for circadian systems biology

A major barrier to progress in systems biology is the absence of suitable infrastructure for data and software integration, which would enable working biologists to use and manipulate the techniques directly. We describe the incremental development of key components of such an infrastructure for a research community focused on a specific (but important) biological system. EUCLOCK combines the expertise of 34 chronobiology laboratories from 29 institutions in 11 European countries in a 5-year effort to understand how circadian clocks are synchronised to their specific cyclic environment (entrainment). We envision that the EUCLOCK Information System (EUCLIS) will subsequently evolve to support the worldwide chronobiology community. The architecture of EUCLIS integrates a database for circadian systems biology, containing modules for experimental data (Clock Experiments) and models (Clock Models) with a digital library (Clock KnowledgeBase) for the research community. The digital library paradigm is superior to the simple 'access' or 'mining' as well as the 'data warehouse' approaches currently used in other systems as it provides a flexible framework for community information needs and the potential to use emerging reference models and standards, which will enable easier integration with other systems in the future. The main Clock KnowledgeBase components for EUCLIS V1.0, Clock Genes and Clock Library, are described in detail. An important aspect this work will need to address in the future is the integration of the database and digital library management functions.

Association of white blood cell count with systolic blood pressure within the normotensive range

Hypertension and inflammation promote cardiovascular disease (CVD). Even high normal systolic blood pressure (SBP) is associated with increased CVD risk. We assessed the relationship of elevated SBP within the normotensive range and white blood cell (WBC) count. This is a cross-sectional study of 3484 white asymptomatic individuals (mean age: 43+/-8 years, 79% males) without hypertension with SBP<140 mm Hg. White blood cell count >or=75th percentile (8.35 x 10(9) cells/l) was considered cutoff for elevated WBC. Subjects were classified into three levels of SBP (first: <120 mm Hg, n=1,176, 34%; second: 120-129 mm Hg, n=1,654, 47%; third: 130-139 mm Hg, n=654, 19%). Mean WBC count increased linearly across SBP categories (first: 6.14+/-1.54, second: 6.20+/-1.52, third: 6.41+/-1.62, P=0.02 for trend). There was a linear increase in prevalence of elevated WBC across higher SBP categories (22, 24 and 28%, P=0.02). As compared to those with SBP<120 mm Hg, in multivariate linear regression analyses (adjusting for age, gender, smoking status, diabetes, body mass index, physical activity, cholesterol/high-density lipoprotein cholesterol ratio) WBC count was significantly higher among participants with SBP 130-139 mm Hg (regression coefficient: 2.64, 95% confidence interval: 1.04-4.24, P=0.001). Odds ratio for prevalence of elevated WBC with SBP<120 mm Hg as reference group was 1.14 (0.92-1.41) for SBP 120-129 mm Hg and 1.50 (1.15-1.92) for SBP 130-139 mm Hg. In conclusion, Higher SBP within the normotensive range is also associated with elevated WBC count. Further studies are needed to clarify the role of inflammation in high normal SBP and associated CVD risk.

Hyperlipidemia related to the use of HIV-protease inhibitors: natural history and results of treatment with fenofibrate

Hyperlipidemia has been frequently recorded as a side effect of treating HIV patients with protease inhibitors (PI). This study was initiated to analyze the modifications on blood lipids in HIV-patients receiving PI and the safety and efficacy of the treatment with fenofibrate. Total (TC) and HDL-cholesterol, triglycerides (TG), and CD(4)(+) T-cell counts were measured in 30 HAART-naive patients (Group I) before and after PI introduction. In a second phase of the study, the effects of fenofibrate on lipids, CPK, CD(4)(+), and viral load were determined in 13 patients (Group II) with elevated TC or TG. In Group I, 60% of the patients showed TC or TG elevations. Average increments of 31% and 146% in TC and TG respectively (p<0.0006 and p<0.0001) were observed. In Group II, fenofibrate treatment was associated with decrements of 6.6% (TC) and 45.7% (TG) (p=0.07 and 0.0002) and no modifications on CPK, CD(4)(+), and viral load. In conclusion, hyperlipidemia is common during the treatment of HIV with protease inhibitors, and fenofibrate appears to be an effective and safe choice for its treatment.

Trends in the risk of mortality due to cardiovascular diseases in five Brazilian geographic regions from 1979 to 1996

OBJECTIVE - To analyze the trends in risk of death due to cardiovascular diseases in the northern, northeastern, southern, southeastern, and central western Brazilian geographic regions from 1979 to 1996. METHODS - Data on mortality due to cardiovascular, cardiac ischemic, and cerebrovascular diseases in 5 Brazilian geographic regions were obtained from the Ministry of Health. Population estimates for the time period from 1978 to 1996 in the 5 Brazilian geographic regions were calculated by interpolation with the Lagrange method, based on the census data from 1970, 1980, 1991, and the population count of 1996, for each age bracket and sex. Trends were analyzed with the multiple linear regression model. RESULTS - Cardiovascular diseases showed a declining trend in the southern, southeastern, and northern Brazilian geographic regions in all age brackets and for both sexes. In the northeastern and central western regions, an increasing trend in the risk of death due to cardiovascular diseases occurred, except for the age bracket from 30 to 39 years, which showed a slight reduction. This resulted from the trends of cardiac ischemic and cerebrovascular diseases. The analysis of the trend in the northeastern and northern regions was impaired by the great proportion of poorly defined causes of death. CONCLUSION - The risk of death due to cardiovascular, cerebrovascular, and cardiac ischemic diseases decreased in the southern and southeastern regions, which are the most developed regions in the country, and increased in the least developed regions, mainly in the central western region.

The effects of gemfibrozil upon the metabolism of chylomicron-like emulsions in patients with endogenous hypertriglyceridemia

OBJECTIVE

To evaluate the effects of gemfibrozil upon the intravascular metabolism of chylomicron-like emulsions in endogenous hypertriglyceridemia.

METHODS

We evaluated the plasma kinetics of a chylomicron-like emulsion in 39 subjects: 27 hypertriglyceridemics, total cholesterol (TC) expressed as median (%25; %75) 7.47 (6.1; 8.19) mmol/l and plasma triglycerides (TG) 4.28 (3.6; 18.5) mmol/l and in 12 normolipidemics, TC 4.7 (3.85; 5.37) mmol/l and TG 0.91 (0.64; 1.75) mmol/l. Hypertriglyceridemics were evaluated at baseline and after a 30-day 1200-mg/day gemfibrozil (n=8) or placebo treatment (n=7). The emulsion labelled with 14C-cholesteryl oleate (14C-CO) and 3H-triolein (3H-TO) was injected intravenously after a 12-h fast. The plasma kinetics of 3H-TO and 14C-CO were determined to assess, respectively, lipolysis and clearance of chylomicron and remnants by compartmental analysis.

RESULTS

The residence times (in minutes) of 3H-TO and 14C-CO of hypertriglyceridemics were roughly twice the values of normolipidemics, i.e. 8.0 (5.5; 12.0) versus 15.0 (11.0; 24.0) and 21.5 (14.0; 33.0) versus 44.0 (32.0; 72.0), P=0.001. Gemfibrozil treatment of hypertriglyceridemic patients reduced the residence times of 3H-TO and 14C-CO, respectively, by 46% (P=0.003) and 53% (P=0.008). Effects were noted on the slow phase of emulsion plasma removal, which was reduced in hypertriglyceridemics. After treatment, the emulsion residence times determined in hypertriglyceridemics attained the values of the normolipidemic group.

CONCLUSIONS

Gemfibrozil treatment normalised the defects in chylomicron-like emulsion catabolism observed in endogenous hypertriglyceridemia patients.

Effects of etofibrate upon the metabolism of chylomicron-like emulsions in patients with coronary artery disease

Slow chylomicron intravascular catabolism has been associated with coronary artery disease and screening for drugs that can speed-up this process can be important. In this study, the effects of etofibrate upon chylomicron metabolism was tested by determination of the plasma kinetics of a chylomicron-like emulsion model in 12 patients with coronary artery disease, aged 59+/-11 years, (total cholesterol: 240+/-41 mg/dl; triglycerides: 188+/-42 mg/dl) submitted to a randomized, crossover, double-blind, placebo-controlled study with administration of 1 g per day etofibrate or placebo for 1-month. A 1-month washout period was inserted between the treatment periods. Patients were intravenously injected a chylomicron-like emulsion doubly labeled with 14C-cholesteryl oleate and 3H-triolein at baseline and after treatments. After etofibrate treatment, there was decrease of total cholesterol and triglyceride plasma levels and a trend to increase high-density lipoprotein cholesterol plasma levels. Etofibrate elicited 62% enhancement of post-heparin lipolytic activity and 100% increase of 3H-triglyceride fractional clearance rate compared with placebo treatment. 14C-cholesterol ester fractional clearance rate was 260% greater after etofibrate than after placebo. Therefore, a potent effect of etofibrate on both chylomicron lipolysis and remnant removal was achieved, indicating that this drug can be used to improve this metabolism in future prospective studies.

Levels of lipoprotein (a) in pulmonary arterial hypertension

We compared the levels of lipoprotein (a) in 48 Caucasian patients with pulmonary arterial hypertension, comprising 32 females and 16 males, aged 28.0 +/- 12.0 years, with a range from 4 through 52 years, with 48 normal Caucasian subjects matched for age and sex. Pulmonary hypertension was secondary in 41 patients with Eisenmenger's syndrome, these comprising 27 females and 14 males aged 27.0 +/- 12.0 years, with a range from 4 through 51 years, and primary in the other 7 patients, 5 females and 2 males, whose age was 30.0 +/- 14.0 years, with a range from 9 through 52 years. Lipoprotein (a) was measured using an immunoprecipitation and turbidimetric assay after a 12 hour fast. Levels of the protein, expressed as the median (% 25; % 75), were higher in those with Eisenmenger's syndrome than in normal controls (p=0.003). In addition, there was a greater prevalence of levels of lipoprotein greater than 30.0 mg/dl in those with secondary pulmonary arterial hypertension patients than in our normal population (p = 0.03). We have found no differences, however, in the levels of lipoprotein(a) in those who had primary pulmonary arterial hypertension when compared with their matched controls, albeit that the number of patients studied was small. We conclude that increased levels of lipoprotein (a) may be secondary to pulmonary arterial hypertension as a marker of tissue damage or may be genetically determined. In either way, the increase in lipoprotein (a) could be an additional factor predisposing to the vascular alterations known to occur in this disease.

PANDORA - Survey of Brazilian cardiologists about cholesterol reduction

OBJECTIVE

To report about a group of physicians' understanding of the recommendations of the II Brazilian Guidelines Conference on Dyslipidemias, and about the state of the art of primary and secondary prevention of atherosclerosis.

METHODS

Through the use of a questionnaire on dyslipidemia, atherosclerosis prevention, and recommendations for lipid targets established by the II Brazilian Guidelines Conference on Dyslipidemias, 746 physicians, 98% cardiologists, were evaluated.

RESULTS

Eighty-seven percent of the respondents stated that the treatment of dyslipidemia changes the natural history of coronary disease. Although most of the participants followed the total cholesterol recommendations (<200mg/dL for atherosclerosis prevention), only 55.8% would adopt the target of LDL-C <100 mg/dL for secondary prevention. Between 30.5 and 36.7% answered, in different questions, that the recommended level for HDL-C should be <35mg/dL. Only 32.7% would treat their patients indefinitely with lipid- lowering drugs. If the drug treatment did not reach the proposed target, only 35.5% would increase the dosage, and 29.4% would change the medication. Participants did not know the targets proposed for diabetics.

CONCLUSION

Although the participating physicians valued the role played by lipids in the prevention of atherosclerosis, serious deficiencies exist in their knowledge of the recommendations given during the II Brazilian Guidelines Conference on Dyslipidemias.

Effect of pravastatin on plasma removal of a chylomicron-like emulsion in men with coronary artery disease

The speed of the plasma removal of chylomicrons, the lipoproteins that carry dietary lipids absorbed in the intestine, may influence atherogenesis. Thus, the effects of a 30-day pravastatin or placebo treatment on the plasma kinetics of chylomicron-like emulsions were evaluated in 25 patients with coronary artery disease who were not hypertriglyceridemic in a randomized, single-blinded study. Eleven patients (53 +/- 4 years, 10 men) received pravastatin 40 mg/day and 14 received placebo (52 +/- 3 years, 13 men). Emulsions labeled with triolein ((3)H-TO) and cholesteryl oleate ((14)C-CO) to assess lipolysis and clearance of chylomicron and remnants, respectively, were injected intravenously in a bolus after a 12-hour fast. Blood samples were collected during 60 minutes to determine radio isotope decaying curves and fractional catabolic rates. Subjects were studied at baseline and after the treatment period. Compared with placebo (data expressed as mean +/- SEM), pravastatin treatment increased the (14)C-CO fractional catabolic rates (70 +/- 45% vs 18 +/- 10%, p = 0.01), reduced total cholesterol (-21 +/- 3% vs -3 +/- 2% p = 0.0001), low-density lipoprotein (LDL) cholesterol (-25 +/- 5% vs 4 +/- 6%, p = 0.0001), and apolipoprotein B levels (-22 +/- 3% vs -7 +/- 3% p = 0.01). (3)H-TO fractional catabolic rates, plasma triglycerides, very-low-density lipoprotein (VLDL) cholesterol and high-density lipoprotein (HDL) cholesterol variations did not differ between the groups. The fractional catabolic rate of (14)C-CO was inversely correlated with plasma apolipoprotein B levels (r = -0.7, p = 0.04). This suggests that besides reducing LDL cholesterol, pravastatin also increases chylomicron remnant clearance, with possible antiatherogenic implications.

[Comparison of hypercholesterolemic men and women at high risk for atherosclerosis. Study of risk factors and response to pravastatin treatment]

PURPOSE

To compare the prevalence of risk factors, and the response to pravastatin treatment between men and women.

METHODS

We evaluated 486 men and 386 women, of these 230 men and 187 women received 10 mg of pravastatin for three months.

RESULTS

There were differences between women and men in respectively: arterial hypertension (45.5% vs 40.8%; p = 0.0012), left ventricular hypertrophy (33.0% vs 22.0%; p = 0.0041), sedentarism (94.8% vs 87.8%; p = 0.0005), smoking (43.0% vs 61.8%; p < 0.0001), Framingham scores (20.0 +/- 7.1 vs 16.0 +/- 7.6 p < 0.0001), HDL-C (43.0 +/- 11.0 vs 38.0 +/- 9.0 mg/dL; p 0.001), triglycerides-TG (216.0 +/- 115.0 vs 271.0 +/- 172.0 mg/dL; p < 0.001) and Castelli's indexes (CI) I and II (7.7 +/- 2.6 vs 8.6 +/- 3.2; p = 0.002 and 5.0 +/- 1.5 vs 5.5 +/- 2.0; p = 0.015). In men under pravastatin treatment there was a greater reduction in TG (32.0 vs 21.0% p < 0.05) and CI I (-41.0% vs -37.0%; p < 0.05) and II (-40.0% vs -38.0%; p < 0.05).

CONCLUSION

Men and women differed in risk factors prevalence and response to treatment with pravastatin.

[Assessment of short-term effects of awareness programs and pravastatin therapy on subjects from private clinics at high risk for cardiovascular disease]

PURPOSE

To evaluate short-term efficacy of awareness programs (AP) in reducing coronary heart disease risk factors (CHDRF).

METHODS

High risk hypercholesterolemic patients were divided in 2 groups during 16 weeks. Group A (n = 417, 54.3 +/- 10.0 years, 55% males) received verbal and written orientation on CHDRF control, and group B (n = 180, 54.4 +/- 10.9 years, 45% males) received only verbal orientation. All participants received pravastatin 10 mg q.d. for 12 weeks. The evolution of body weight, arterial pressure, lipid profile, Castelli's I and II indexes (TC/HDL and LDL/HDL), and Framingham scores were evaluated.

RESULTS

At baseline, A had a lower HDL-C (40.0 +/- 11.0 vs 43.0 +/- 11.0 mg/dl, p = 0.013) and a higher index I (8.2 +/- 3.0 vs 7.6 +/- 2.3, p = 0.008) than B. After 16 weeks, A had greater change than B in TC (-28.0 vs -25.0, p < 0.05), LDL-C (-29.0 vs -27.6, p < 0.05), HDL-C levels (+13.7 vs +10.8, p < 0.05) and in the Castelli's Index (-39.0 vs -33.0; p < 0.05). In both groups pravastatin use potentialized the effects of diet on the lipid profile.

CONCLUSION

The AP seemed to be more effective than verbal orientation alone in CHDRF reduction at short-term.

[Comparative study of gemfibrozil versus pravastatin in the treatment of patients with coronary artery disease and low HDL cholesterol levels]

PURPOSE

To evaluate the effects of gemfibrozil and pravastatin in coronary artery disease patients with HDL-cholesterol (HDL-C) < 35 mg/dl).

METHODS

Twenty-nine patients (20 males, 60 +/- 9) were divided in a gemfibrozil group (G) (1200 mg/day n = 15) and a pravastatin group (P) (10 or 20 mg n = 10 and 4, respectively). The plasma lipid profile (LP) e.g. total cholesterol (TC), fractions and triglycerides (TG) was determined at 4 and 12 weeks of treatment.

RESULTS

HDL-C was not affected in P, TC and LDL-cholesterol (LDL-C) reductions were superior to those in G (31.3% vs 13.4% and 38.7 and 11.5%, p < 0.05 and < 0.01 respectively). In G HDL-C raised by 50% (12th week p < 0.01). Gemfibrozil reduced TG levels in 44.7% while in P it varied -32.2% (12th week p < 0.01 and < 0.05 respectively).

CONCLUSION

Gemfibrozil is more effective in reducing TG and raising HDL-C than pravastatin. On the other hand, pravastatin was more potent in reducing LDL-C levels.

[Lipoprotein (a), apolipoproteins and the lipid profile late after heart transplantation]

PURPOSE--To evaluate if the levels of lipoprotein (a) [Lp(a)], apolipoproteins (apo) A1, B and the lipid profile (LP) differ among heart transplantation (HT) patients, with coronary artery disease (CAD) and patients without CAD (NL) and if LP discriminates patients with graft vascular disease (GVD). METHODS--A hundred and seventy patients separated in 3 groups: I) HT [n = 43 46 +/- 15 years, 24 months (median) after transplantation], of these 28 were submitted to serial angiography after the first year of transplantation subgroups with GVD (n = 9) and without GVD (NGVD) (n = 19); II) CAD (n = 72, 48 +/- 6 years); III) NL (n = 45, 50 +/- 6 years). RESULTS--HT presented higher apo A1 levels than CAD and NL (1.5 +/- 0.5 vs 1.2 +/- 0.05 vs 1.1 +/- 0.06 g/l p < 0.05 respectively). Apo B was higher on CAD than in HT and NL (1.5 +/- 0.05 vs 1.2 +/- 0.07 vs 1.3 +/- 0.09 g/l p < 0.05). Lp (a) presented a trend to higher levels in HT and CAD than in NL [25(2-97), 24(1-130) and 15 (1-100) mg/dl, p = 0.05)]. However, when individually evaluated against NL Lp(a) levels were higher in HT and CAD (p = 0.019 and 0.03 respectively). LP did not differ between GVD and NGVD. CONCLUSION--Increased Lp(a) levels after transplantation might be related to the high prevalence of GVD. The LP did not discriminate GVD.

Lipoprotein(a) levels in systemic lupus erythematosus

OBJECTIVE

To determine lipoprotein(a) [Lp(a)] levels in systemic lupus erythematosus (SLE) and its possible correlation with thrombosis, disease activity, anticardiolipin antibodies (aCL) and steroid therapy.

METHODS

Serum Lp(a) levels were determined by radioimmunoassay (RIA) in 34 Caucasian patients with SLE and compared to 66 healthy subjects.

RESULTS

In patients with SLE Lp(a) levels were higher than in controls (42 +/- 35 vs 26 +/- 25 mg/dl, p = 0.01). Lp(a) levels were high (> or = 30 mg/dl) in 56% of the patients with SLE and in 30% of controls (p = 0.02) but were not correlated with the clinical and laboratory findings.

CONCLUSIONS

Lp(a) levels are significantly higher in patients with SLE and are not influenced by disease activity, thrombosis, aCL and steroid therapy.

Early administration of captopril and nitroglycerin in combination after acute myocardial infarction: an invasive haemodynamic study

The combination of captopril and nitroglycerin early after acute myocardial infarction (AMI) could lead to a dangerous decrease in blood pressure coronary perfusion. To evaluate the safety aspects and haemodynamic effects of this combination, we studied 36 first 'Q wave' thrombolysed anterior wall AMI patients during the 24 h following the onset of symptoms. Afterwards, thrombolysis patients received a continuous infusion of nitroglycerin and were submitted to pulmonary artery catheterization. Those patients with mean arterial pressure (MAP) > or = 70 mmHg, cardiac index > or = 2.2 l.min-1.m-2, and wedge pressure > or = 10 mmHg were included and randomized to receive 6.25 mg of captopril every 6 h on the first day and 12.5 mg qid on the second if MAP > or = 70 mmHg (group 1). A second group (group 2) received a placebo. Haemodynamic parameters were determined after 1, 6 and then every 6 h up to 48 h after basal measurements. Significant differences were observed only for the MAP and the rate-pressure product (reduction in group 1 values, P < 0.05). However, MAP was maintained within acceptable limits. Our data support the fact that the combination of captopril and nitroglycerin in the early hours of a non-complicated anterior wall AMI is safe, and could guarantee its use in large clinical trials to determine the effects on left ventricle remodelling and survival after AMI.