Comparison of the efficacy and safety of Shanhuang Jiangzhi tablets and atorvastatin in the treatment of patients with hyperlipidaemia

OBJECTIVES

To compare the efficacy and safety of Shanhuang Jiangzhi tablets and atorvastatin in reducing blood lipid levels.

METHODS

Patients with hyperlipidaemia admitted to the cardiac centre between January 2019 and December 2020 were included in the study. A total of 1063 patients with hyperlipidaemia took either Shanhuang Jiangzhi tablets (n = 372) or atorvastatin (n = 691) and met the inclusion and exclusion criteria. Clinical data, including total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol, were retrospectively evaluated after propensity score matching (PSM) analysis. The adverse events were also recorded during the therapy process.

RESULTS

Following PSM analysis, both groups were well matched across all parameters. Compared with the baseline, Shanhuang Jiangzhi tablets had greater effects on TC, TG and LDL-C, and the difference was statistically significant (p < 0.001). Furthermore, the results showed that Shanhuang Jiangzhi tablets are similar to atorvastatin in reducing TC and LDL-C, and all p-values were > 0.05. However, the decrease of TG was greater in the Shanhuang Jiangzhi group (p < 0.001). Clinical adverse reactions of Shanhuang Jiangzhi tablets are rare and have no statistical significance compared with atorvastatin (p = 0.682).

CONCLUSIONS

Shanhuang Jiangzhi tablets have a higher hypotriglyceridaemic performance than atorvastatin and an equivalent ability to lower TC and LDL-C. In addition, Shanhuang Jiangzhi tablets are a low-risk option for lowering blood lipids.

Effect of Grape Seed Procyanidins Combined with Allicin on Lipid Levels in Hyperlipidemic Rats

OBJECTIVES

To study the effects of grape seed proanthocyanidins (GSP) combined with allicin on serum lipids level and vascular damage in a rat model of hyperlipidemia.

MATERIALS AND METHODS

SD rats(male, 170-220 gn= 40) were randomized into five groups (n = 8/group): modelhigh fat and cholesterol diet; controlnormal diet; model+low-dose (GSP+allicin )(GSP 45mg/kg, allicin 30mg/kg, orally); model+high-dose (GSP+allicin) (GSP180mg/kg, allicin 90mg/kg, orally) and positive control (model+simvastatin (4 mg/kg)). Normal control group was fed conventionally, and remaining four groups were fed high cholesterol and fat food to replicate the high fat model. After 9 weeks, the normal control group continued to receive regular feeding, while the other groups continued to receive high-fat feeding. At the same time, model and normal control groups were given equal volume of physiological saline by gavage, and the other treatment groups began to receive corresponding drugs by gavage once a day. After 4 weeks, serum levels of total cholesterol (TC), triglyceride (TG), low density lipoprotein cholesterol (LDL-C) as well as high-density lipoprotein cholesterol (HDL-C) in rats were determined. And the body weight of rat, total antioxidant capacity (T-AOC), superoxide dismutase (SOD) and malondialdehyde (MDA)in serum were identified. The level of endothelin-1(ET-1) was quantitative analysis by ELISA assay.

RESULTS

In comparison to normal controls, the model group displayed a marked rise in body weight, an increment in serum concentrations of LDL-C, TG and TC, as well as a decline in HDL (P<0.01), demonstrating successful model replication; All doses of GSP in combination with allicin resulted in a reduction in TG, LDL-C, and TC and an enhancement in HDL-C in contrast to the model control (all P<0.05). High-dose (GSP+allicin ) decreased MDA, and increased T-AOC and SOD activity(all P<0.01). All doses of GSP combined with allicin decreased ET-1 (all P<0.05). In addition, the protective effect of GSP combined with allicin was dose-dependent.

CONCLUSIONS

Studies have shown that GSP combined with allicin can significantly improve blood lipids in hyperlipidemic rats, and this mechanism may be related to antioxidants and reduced endothelial damage.

Effect Of Tamoxifen On Plasma Lipid Profile In Patients Of Breast Cancer

BACKGROUND

To evaluate the effect of Tamoxifen on plasma lipid profile in breast cancer patients presenting at tertiary care hospitals.

METHODS

It was a longitudinal study conducted at the Department of Oncology of Jinnah Postgraduate Medical Center from December 2018 to November 2019. Eighty-eight females aged 26-66 years diagnosed with breast cancer were included in the study using a non-probability consecutive sampling technique. Detailed gynaecological and clinical investigations and detailed history were taken. The blood samples of all the patients were collected and the plasma lipid profile was measured before initiation of Tamoxifen treatment and three- and six-months post-treatment at the clinical laboratory. The plasma lipid profile includes the measurement of Total cholesterol (mg/dl), Triglyceride(mg/dl), High-density Lipoprotein (mg/dl) & Low-density Lipoprotein (mg/dl). SPSS version 23 was used to analyse data.

RESULTS

After treatment, there was a significant reduction in serum cholesterol & Low-density Lipoprotein level by 20.54 mg/dl & 16.46 mg/dl at 3 months (p<0.05), moreover there was a significant increase in Triglyceride by 22.14 at 3 months (p<0.05). No significant difference was observed in High density lipoprotein level at 3 months after using Tamoxifen. At 6 months there was a significant reduction in serum cholesterol and low-density lipoprotein by 32.29mg/dl and 24.11 mg/dl at 6 months (p<0.05), moreover there was a significant increase in Triglyceride level by 42.19 mg/dl at 6 months (p<0.05). No significant difference was observed in High-density lipoprotein level at 6 months after using Tamoxifen.

CONCLUSIONS

Total cholesterol and Low-density Lipoprotein levels showed significant reduction over the period of six months from the baseline with the use of Tamoxifen. Hence Tamoxifen should be considered to have an added advantage on lipid metabolism and therefore, can reduce the risk of cardiovascular events.

Monocyte to high-density lipoprotein cholesterol ratio decreased in patients with psoriasis treated with ixekizumab

Background

Monocyte to high-density lipoprotein cholesterol ratio (MHR) is a novel inflammatory biomarker which has been associated with cardiovascular diseases.

Objective

To study MHR in patients with psoriasis treated with biological agents.

Methods

Between April 2019 and August 2022, MHR was retrospectively evaluated in patients with psoriasis before and 3 months after treatment with infliximab, adalimumab, etanercept, ixekizumab, secukinumab, and ustekinumab in a university hospital in Ankara, Turkey.

Results

This study included 128 patients, 53 females and 75 males. 39 (30.5%) patients were treated with infliximab, 26 (20.3%) with adalimumab, 8 (6.3%) with etanercept, 18 (14.1%) with ixekizumab, 12 (9.4%) with secukinumab, and 25 (19.5%) with ustekinumab. The median MHR was 0.0127 (0.0086-0.0165) in females and 0.0146 (0.0119-0.0200) in males (p = 0.011). The median MHR decreased after treatment with adalimumab, ixekizumab, secukinumab, and ustekinumab, whereas it increased after treatment with infliximab and etanercept (p = 0.790, p = 0.015, p = 0.754, p = 0.221, p = 0.276, p = 0.889, respectively).

Conclusion

MHR significantly decreased in patients with psoriasis after treatment with ixekizumab. Since high MHR levels have been associated with poor clinical outcomes in patients with cardiovascular diseases, ixekizumab might have a positive impact in the treatment of psoriasis patients who had cardiovascular diseases. We suggest that MHR may be useful both in establishing appropriate biological agent treatment and in the follow-up of patients with psoriasis treated with biological agents.

A Systematic Review of Randomized Clinical Trials on the Efficacy and Safety of Pitavastatin

BACKGROUND

A subpopulation of statin users such as subjects with chronic kidney disease (CKD), Human Immune virus (HIV), acute coronary syndrome (ACS), revascularization, metabolic syndrome, and/or diabetes may particularly benefit from pitavastatin pharmacotherapy.

AIM

The current systematic review aimed systematically to evaluate the effect of pitavastatin on primary cardiac events in subjects receiving pitavastatin in comparison to the other four statin members.

METHODS

We conducted a systematic review on phases III and IV of randomized controlled trials (RCT-s, 11 trials) for subjects with primary cardiac events who received pitavastatin. Subjects diagnosed with any type of dyslipidemia (population 4804) and received pitavastatin (interventions) versus comparator (comparison) with the primary efficacy endpoint of minimization of LDL-C and non- HDL-C, had an increase in HDL-C and/or reduction in major adverse cardiac events (MACE, cardiovascular death, myocardial infarction (fatal/nonfatal), and stroke (fatal/nonfatal) and/or their composite (outcomes). The secondary safety endpoint was the development of any adverse effects.

RESULTS

In the included trials (11), participants (4804) were randomized for pitavastatin or its comparators such as atorvastatin, pravastatin, rosuvastatin, simvastatin and followed up for 12 to 52 weeks. In terms of the primary outcome (reduction in LDL-C), pitavastatin 4 mg was superior to pravastatin 40 mg in three trials, while the 2 mg pitavastatin was comparable to atorvastatin 10 mg in four trials and simvastatin 20 and 40 mg in two 2 trials. However, rosuvastatin 2.5 mg was superior to pitavastatin 2 mg in two trials. Pitavastatin increased HDL-C and reduced non-HDL-C in eleven trials. Regarding the safety profile, pitavastatin has proved to be tolerated and safe.

CONCLUSION

The FDA-approved indications for pitavastatin included primary dyslipidemia and mixed dyslipidemia as a supplementary therapy to dietary changes to lower total cholesterol, LDL-C, apolipoprotein B (Apo B), triglycerides (TG), and enhance HDL-C. Pitavastatin might be suitable for subjects with diabetes, ACS (reduced revascularization), metabolic syndrome, CKD, HIV, and subjects with low levels of HDL-C. We highly recommend rational individualization for the selection of statin.

[Effects of moderate dose rosuvastatin on carotid plaque in patients with diabetes mellitus evaluated by magnetic resonance imaging]

Objective: To observe the effect of lipid regulating therapy on carotid atherosclerotic plaque in diabetic patients. Methods: The REACH study, conducted between March 2009 and February 2012, enrolled asymptomatic patients with magnetic resonance imaging (MRI) confirmed carotid atherosclerotic plaque, who had never taken lipid-lowering drugs. Patients were treated with a moderate dose of rosuvastatin for 24 months. Blood lipid levels were measured and carotid MRI was performed at baseline, 3 and 24 months after treatment. The volume of carotid wall and lipid-rich necrotic core (LRNC) were measured by image analysis software. This study retrospectively analyzed patients in the REACH study. Patients were divided into diabetes group and non-diabetic group. The changes of blood lipid level and MRI parameters of carotid atherosclerotic plaque were compared between the two groups and their correlation was analyzed. Results: A total of 38 patients with carotid atherosclerotic plaque were included in this study, including 13 patients (34.2%) in the diabetic group and 25 patients (65.8%) in the non-diabetic group. Baseline parameters were comparable between the two groups, except higher HbA1c level in diabetes group (P<0.05). Compared with baseline, the total cholesterol (TC), low density lipoprotein cholesterol (LDL-C) and triglyceride (TG) levels were significantly decreased at 3 and 24 months in both two groups (P<0.05). The change of high-density lipoprotein cholesterol (HDL-C) in diabetes group was not obvious, while it was significantly increased in non-diabetic group at 24 months ((1.38±0.33) mmol/l vs. (1.26±0.26) mmol/l, P<0.05). MRI results showed that the volume and percentage of LRNC remained unchanged at 3 months, slightly decreased at 24 months (64.86 (45.37, 134.56) mm³ vs. 75.76 (48.20, 115.64) mm³, P>0.05) and (15.84% (11.47%, 24.85%) vs. 16.95% (11.64%, 22.91%), P>0.05) in diabetic group. In non-diabetic group, the volume and percentage of LRNC were significantly decreased at 3 months (63.01 (44.25, 188.64) mm³ vs. 72.49 (51.91, 199.59) mm³, P<0.05) and (13.76% (8.81%, 27.64%) vs. 16.04% (11.18%, 27.05%), P<0.05) respectively. Both parameters further decreased to (55.63 (27.18, 179.40) mm³) and (12.71% (8.39%, 24.41%)) at 24 months (both P<0.05). Wall volume, lumen volume and percent wall volume (PWV) were not affected post therapy in both two groups(P>0.05). There were no correlations between the changes of plaque parameters including volume and percentage of LRNC, wall volume, lumen volume, PWV and the changes of blood lipid parameters (TC, LDL-C, HDL-C and TG) in 3 and 24 months (P>0.05). Conclusion: Lipid-lowering therapy possesses different effects on carotid atherosclerotic plaque in diabetic and non-diabetic patients, and the LRNC improvement is more significant in non-diabetic patients as compared to diabetic patients.

High-density lipoproteins: A promising tool against cancer

High-density lipoproteins (HDL) are well known for their protective role against the development and progression of atherosclerosis. Atheroprotection is mainly due to the key role of HDL within the reverse cholesterol transport, and to their ability to exert a series of antioxidant and anti-inflammatory activities. Through the same mechanisms HDL could also affect cancer cell proliferation and tumor progression. Many types of cancers share common alterations of cellular metabolism, including lipid metabolism. In this context, not only fatty acids but also cholesterol and its metabolites play a key role. HDL were shown to reduce cancer cell content of cholesterol, overall rewiring cholesterol homeostasis. In addition, HDL reduce oxidative stress and the levels of pro-inflammatory molecules in cancer cells and in the tumor microenvironment (TME). Here, HDL can also help in reverting tumor immune escape and in inhibiting angiogenesis. Interestingly, HDL are good candidates for drug delivery, targeting antineoplastic agents to the tumor mass mainly through their binding to the scavenger receptor BI. Since they could affect cancer development and progression per se, HDL-based drug delivery systems may render cancer cells more sensitive to antitumor agents and reduce the development of drug resistance.

Pharmacokinetic/Pharmacodynamic Modelling to Describe the Cholesterol Lowering Effect of Rosuvastatin in People Living with HIV

BACKGROUND

Rosuvastatin is a lipid-lowering agent widely prescribed in people living with HIV, which is actively transported into the liver, making it a potential victim of drug-drug interactions with antiretroviral agents.

OBJECTIVES

The aims of this study were to characterise the pharmacokinetic profile of rosuvastatin and to describe the relationship between rosuvastatin concentrations and non-high-density lipoprotein (HDL)-cholesterol levels in people living with HIV.

METHODS

A population pharmacokinetic model (NONMEM) was developed to quantify the influence of demographics, clinical characteristics and comedications on rosuvastatin pharmacokinetics. This model was combined with an indirect effect model to describe non-HDL-cholesterol measurements.

RESULTS

A two-compartment model with sequential zero- and first-order absorption best fitted the 154 rosuvastatin concentrations provided by 65 people living with HIV. None of the tested covariates significantly influenced rosuvastatin pharmacokinetics. A total of 403 non-HDL cholesterol values were available for pharmacokinetic-pharmacodynamic modelling. Baseline non-HDL cholesterol decreased by 14% and increased by 12% with etravirine and antiretroviral drugs with a known impact on the lipid profile (i.e. protease inhibitors, efavirenz, cobicistat), respectively. The baseline value was surprisingly 43% lower in people living with HIV aged 80 years compared with those aged 40 years. Simulations based on the covariate-free model predicted that, under standard rosuvastatin dosages of 5 mg and 20 mg once daily, 31% and 64% of people living with HIV would achieve non-HDL-cholesterol targets, respectively.

CONCLUSIONS

The high between-subject variability that characterises both rosuvastatin pharmacokinetic and pharmacodynamic profiles remained unexplained after the inclusion of usual covariates. Considering its limited potential for drug-drug interactions with antiretroviral agents and its potent lipid-lowering effect, rosuvastatin prescription appears safe and effective in people living with HIV with hypercholesterolaemia.

CLINICAL TRIAL REGISTRATION NO

NCT03515772.

Beneficial Effects of Reconstituted High-Density Lipoprotein (rHDL) on Circulating CD34+ Cells in Patients after an Acute Coronary Syndrome

Background

High-density lipoproteins (HDL) favorably affect endothelial progenitor cells (EPC). Circulating progenitor cell level and function are impaired in patients with acute coronary syndrome (ACS). This study investigates the short-term effects of reconstituted HDL (rHDL) on circulating progenitor cells in patients with ACS.

Methods and Findings

The study population consisted of 33 patients with recent ACS: 20 patients from the ERASE trial (randomized to receive 4 weekly intravenous infusions of CSL-111 40 mg/kg or placebo) and 13 additional patients recruited as controls using the same enrolment criteria. Blood was collected from 16 rHDL (CSL-111)-treated patients and 17 controls at baseline and at 6–7 weeks (i.e. 2–3 weeks after the fourth infusion of CSL-111 in ERASE). CD34⁺ and CD34⁺/kinase insert domain receptor (KDR⁺) progenitor cell counts were analyzed by flow cytometry. We found preserved CD34⁺ cell counts in CSL-111-treated subjects at follow-up (change of 1.6%), while the number of CD34⁺ cells was reduced (-32.9%) in controls (p = 0.017 between groups). The level of circulating SDF-1 (stromal cell-derived factor-1), a chemokine involved in progenitor cell recruitment, increased significantly (change of 21.5%) in controls, while it remained unchanged in CSL-111-treated patients (p = 0.031 between groups). In vitro exposure to CSL-111 of early EPC isolated from healthy volunteers significantly increased CD34⁺ cells, reduced early EPC apoptosis and enhanced their migration capacity towards SDF-1.

Conclusions

The relative increase in circulating CD34⁺ cells and the low SDF-1 levels observed following rHDL infusions in ACS patients point towards a role of rHDL in cardiovascular repair mechanisms.

HDL-C levels and cardiovascular disease: more is not always better!

HMG-CoA reductase inhibitors have consistently demonstrated a relative risk reduction of death and myocardial infarction ranging between 29 and 35%. Nevertheless, in spite of significant improvement in prevention, cardiovascular disease remains the main cause of morbidity and mortality in industrialized countries. This significant residual risk observed in approximately 70% of patients under optimal anti-atherosclerotic therapies, warrants the exploration and development of alternative cardiovascular drugs. Specifically, HDL-C levels have been inversely correlated with the incidence of cardiovascular disease and an estimated 1 mg/dl higher HDL-C is associated with a 2% lower risk for men and a 3% lower risk for women. However, HDL-C-C pharmacological induced increases presented contradicting results regarding atherosclerotic development and in some cases increased cardiovascular mortality. In this review, we will focus on the structure and metabolism of HDL-C and patents related to HDL-C levels and cardiovascular disease along with the possible role of HDL-C increasing therapies in the future primary and secondary prevention of cardiovascular disease.

Antiarrhythmogenic effect of reconstituted high-density lipoprotein against ischemia/reperfusion in rats

OBJECTIVES

This study analyzed the antiarrhythmogenic effect of reconstituted high-density lipoprotein (rHDL) against ischemia/reperfusion in vivo.

BACKGROUND

Recent studies have suggested that a reduction in the plasma HDL level may contribute to cardiac sudden death. Although there are currently only a few therapeutic strategies for increasing HDL, an exciting new therapeutic option, rHDL, has recently been developed to prevent coronary artery disease.

METHODS

To analyze the suppression of reperfusion arrhythmia by rHDL (apolipoprotein A-I with 1-palmitoyl-2-oleoyl-phosphatidyl-choline), 92 male Wistar rats were divided into 10 groups: rats that had been pre-treated with or without rHDL, apolipoprotein A-I, or 1-palmitoyl-2-oleoyl-phosphatidyl-choline in the presence or absence of inhibitors of Akt protein kinase, nitric oxide (NO), or extracellular-signal-regulated kinase (ERK) administered intravenously before left coronary artery occlusion. We also used human coronary artery endothelial cells and adenosine triphosphate-binding cassette transporter (ABC) A1-, ABCG1-, or scavenger receptor class B, type I-transfected ldlA7 cells systems.

RESULTS

The duration of ventricular tachycardia or ventricular fibrillation after reperfusion in rHDL-pre-treated rats was much shorter than that in untreated rats. Apolipoprotein A-I or 1-palmitoyl-2-oleoyl-phosphatidyl-choline alone had no effect. The effect of rHDL was blocked by inhibitors of Akt, NO, and ERK. Plasma NO concentration in the rHDL group was significantly higher. In addition, rHDL activated phospho(p)-Akt, p-ERK, and p-endothelial NO synthesis in endothelial cells. The rHDL activated p-ERK in ABCA1- or ABCG1-transfected but not scavenger receptor class B, type I-transfected ldlA7 cells.

CONCLUSIONS

The rHDL-induced NO production, probably mediated by ABCA1 or ABCG1 through an Akt/ERK/NO pathway in endothelial cells, may suppress reperfusion-induced arrhythmias. The HDL-based therapy may hold the promise of reducing the incidence of such arrhythmias after ischemia/reperfusion.

Synthetic HDL as a new treatment for atherosclerosis regression: has the time come?

Plasma high-density lipoprotein cholesterol (HDL-C) has received considerable attention as a potential therapeutic target to further reduce cardiovascular events in the statin era. One therapeutic approach to enhance HDL-mediated atheroprotection involves the use of small, synthetic and orally-active compounds that substantially raise plasma HDL-C levels. However, doubts on the clinical benefit achievable with such treatments have been raised by the premature termination of a large Phase III trial with torcetrapib, the most potent and furthest developed HDL-C raising compound, because of excess mortality in patients receiving the drug. The alternative is the direct administration of synthetic HDL (sHDL), discoidal lipoprotein particles which mimic most, if not all, of the atheroprotective properties of plasma HDL. Short-term treatments with sHDL of different composition caused consistent and remarkable reductions of atheroma volume in patients with acute coronary syndromes (ACS). Although at early stages of drug development, sHDL hold vast promise for plaque stabilization/regression, and cardiovascular event reduction.

Role of imaging end points in atherosclerosis trials: focus on intravascular ultrasound

Increasing attention has been focused on the appropriate role of surrogate markers in the development of novel anti-atherosclerotic therapies. Technological advances in imaging modalities allow for visualisation of the entire arterial wall. Intravascular ultrasound (IVUS) has been increasingly employed to precisely quantify the extent of coronary atherosclerosis. Use of IVUS has provided a number of important insights into the natural history of atherosclerosis and the remodelling changes of the arterial wall in response to plaque accumulation. More recently, clinical trials have employed serial evaluations of arterial segments by IVUS to assess the impact of medical therapies.

Prospects for atherosclerosis regression through increase in high-density lipoprotein and other emerging therapeutic targets

In a process often seen as progressive and irreversible, deposition and retention of lipoproteins and the consequent inflammatory reaction result in the accumulation of atherosclerotic plaques from an early age. However, striking effects observed in experimental models support the concept that atherosclerosis can regress. This is often accompanied by changes in plaque composition favouring stability and decreased likelihood of rupture. Large clinical trials have established the value of low-density lipoprotein cholesterol reduction with statin treatment, although this may prevent no more than 30% of all cardiovascular events, and the magnitude of effect on plaque regression seems relatively modest. High-density lipoprotein cholesterol (HDL-C) is well recognised as an important and independent protective factor, although treatment options to increase HDL-C have until now been limited. The recent emergence of new treatments will probably establish increased HDL-C as another important strategy in antiatherosclerosis treatment. Beyond HDL-C increases, further appreciation of mechanisms of cellular lipid homoeostasis and regulation of gene transcription have revealed new targets for atherosclerosis treatment. This review considers emerging approaches to plaque regression together with some of the parallel developments in imaging technology that will improve our appreciation of response to treatment.

Effects of reconstituted high-density lipoprotein infusions on coronary atherosclerosis: a randomized controlled trial

CONTEXT

High-density lipoprotein (HDL) cholesterol is an inverse predictor of coronary atherosclerotic disease. Preliminary data have suggested that HDL infusions can induce atherosclerosis regression.

OBJECTIVE

To investigate the effects of reconstituted HDL on plaque burden as assessed by intravascular ultrasound (IVUS).

DESIGN AND SETTING

A randomized placebo-controlled trial was conducted at 17 centers in Canada. Intravascular ultrasound was performed to assess coronary atheroma at baseline and 2 to 3 weeks after the last study infusion.

PATIENTS

Between July 2005 and October 2006, 183 patients had a baseline IVUS examination and of those, 145 had evaluable serial IVUS examinations after 6 weeks.

INTERVENTION

Sixty patients were randomly assigned to receive 4 weekly infusions of placebo (saline), 111 to receive 40 mg/kg of reconstituted HDL (CSL-111); and 12 to receive 80 mg/kg of CSL-111.

MAIN OUTCOME MEASURES

The primary efficacy parameter was the percentage change in atheroma volume. Nominal changes in plaque volume and plaque characterization index on IVUS and coronary score on quantitative coronary angiography were also prespecified end points.

RESULTS

The higher-dosage CSL-111 treatment group was discontinued early because of liver function test abnormalities. The percentage change in atheroma volume was -3.4% with CSL-111 and -1.6% for placebo (P = .48 between groups, P<.001 vs baseline for CSL-111). The nominal change in plaque volume was -5.3 mm3 with CSL-111 and -2.3 mm3 with placebo (P = .39 between groups, P<.001 vs baseline for CSL-111). The mean changes in plaque characterization index on IVUS (-0.0097 for CSL-111 and 0.0128 with placebo) and mean changes in coronary score (-0.039 mm for CSL-111 and -0.071 mm with placebo) on quantitative coronary angiography were significantly different between groups (P = .01 and P =.03, respectively). Administration of CSL-111 40 mg/kg was associated with mild, self-limiting transaminase elevation but was clinically well tolerated.

CONCLUSIONS

Short-term infusions of reconstituted HDL resulted in no significant reductions in percentage change in atheroma volume or nominal change in plaque volume compared with placebo but did result in statistically significant improvement in the plaque characterization index and coronary score on quantitative coronary angiography. Elevation of HDL remains a valid target in vascular disease and further studies of HDL infusions, including trials with clinical end points, appear warranted.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00225719

CETP inhibition in cardiovascular risk management: a critical appraisal

In view of the cardioprotective effect of high-density lipoproteins (HDL) and the limited effects of statin and fibrate therapy on HDL cholesterol, it is clinically relevant to test whether pharmacological treatment aimed at raising HDL lowers cardiovascular risk. Cholesteryl ester transfer protein (CETP) is a new therapeutic target, because the cholesteryl ester transfer process lowers HDL cholesterol and contributes to an atherogenic lipoprotein profile, particularly when plasma triglycerides are high. Clinical evidence suggests that coronary artery calcification as well as intima media thickness is positively related to plasma cholesteryl ester transfer, and that high plasma CETP concentration is associated with increased cardiovascular risk in hypertriglyceridaemia. However, CETP could also have anti-atherogenic potential, since it provides a potentially beneficial route for delivery of HDL-derived cholesteryl esters to the liver. In addition, CETP could also favourably stimulate peripheral cell cholesterol removal and enhance hepatic cholesterol uptake. Recent evidence suggests that a high CETP level may confer lower cardiovascular risk in the context of low triglycerides. At maximal doses, the CETP inhibitors JTT-705 and torcetrapib elicit a marked rise in HDL cholesterol of up to 34% and 91-106%, respectively. The effectiveness of these drugs on (intermediate) clinical outcome measures is currently being tested in large-scale phase III clinical trials, with torcetrapib being only evaluated in combination therapy with atorvastatin. When and how to use CETP inhibitors, e.g. in combination with a statin or a fibrate, is a major challenge. We propose that low HDL cholesterol in the context of high triglycerides, such as found in type 2 diabetes mellitus, could become an important indication area for this new class of drugs.

High-density lipoproteins as therapeutic targets

PURPOSE OF REVIEW

The concentration of cholesterol in HDL is an inverse predictor of future cardiovascular disease, with evidence mounting that therapies that increase HDL concentration are antiatherogenic. The best known antiatherogenic function of HDL particles relates to their ability to promote the efflux of cholesterol from cells. However, they also have antioxidant, antiinflammatory and antithrombotic properties.

RECENT FINDINGS

The past year has seen the publication of several papers that highlight a potential major protective role of HDL in states of acute inflammation. Papers showing extremely promising results using novel inhibitors of cholesteryl ester transfer protein as HDL-raising agents have also appeared. Finally, the discovery that ATP-binding cassette transporter G1 (ABCG1) transports cell cholesterol to large HDL particles in the extracellular space has largely reconciled apparent inconsistencies between basic research indicating that small, pre-beta-migrating HDL particles are the antiatherogenic components of HDL and epidemiological research that implicates larger HDL particles as the protective fraction.

SUMMARY

The finding that ABCG1 promotes the efflux of cholesterol from cells to large HDL particles also provides powerful circumstantial evidence that cholesteryl ester transfer protein inhibition (which increases HDL size) may enhance, rather than reduce, cholesterol efflux, and thus inhibit the development of atherosclerosis.

Pharmaceutical initiatives to combat atherosclerosis--what to do with the good, the bad, and the ugly lipoproteins

The patient with peripheral arterial disease (PAD) poses a special problem. Not only are vascular surgeons interested in preventing the limb complications of PAD, but also the associated cardiac and neurological events that contribute greatly to the overall morbidity and mortality of their patients. Therefore, the control of atherosclerotic risk factors must be considered as important a therapeutic goal as surgical and endovascular control of limb ischemia. To accomplish this, the "complete" vascular surgeon must understand the common lipid abnormalities, their diagnosis, and treatment. The scientific literature on this subject is truly overwhelming in volume and scope, yet an overly simple "cook book" approach is not adequate or appropriate. This report summarizes current knowledge on this topic, providing sufficient essential detail for the reader to understand why, when, and how to administer which lipid-controlling agents to patients with PAD.