Low-Density Lipoprotein Cholesterol Lowering for the Primary Prevention of Cardiovascular Disease Among Men With Primary Elevations of Low-Density Lipoprotein Cholesterol Levels of 190 mg/dL or Above: Analyses From the WOSCOPS (West of Scotland Coronary Prevention Study) 5-Year Randomized Trial and 20-Year Observational Follow-Up

Improving the detection of familial hypercholesterolaemia

Familial hypercholesterolaemia (FH) is a dominantly inherited disorder of low-density lipoprotein (LDL) catabolism, which if untreated causes lifelong elevated LDL-cholesterol (LDL-c), accelerated atherosclerosis and premature cardiovascular disease. Recent evidence suggests the prevalence of heterozygous FH is ∼1:220, making FH the most common autosomal dominant condition. Lowering LDL-c with statin and lifestyle therapy reduces the risk of cardiovascular events. Furthermore, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors significantly lower LDL-c in addition to statin therapy, and early outcome data suggest improved vascular outcomes with these agents in FH patients in addition to statins. However, the vast majority of people with FH still remain undiagnosed. The onus is on clinicians to identify kindreds with FH, as PCSK9 inhibitors, although expensive, are funded for patients with FH in Australia. Multiple strategies for detecting FH have been proposed. The detection of index cases can be achieved through applying electronic screening tools to general practice databases, universal screening of children during immunisation, and targeted screening of patients with premature cardiovascular disease. Advances in genomic technology have decreased costs of genetic testing, improved the understanding of the pathogenesis of FH and facilitated cascade screening. However, awareness of FH amongst clinicians and the general public still requires optimisation. This review outlines recent advances in FH detection, including emerging strategies and challenges for the next decade.

Cholesterol transport system: An integrated cholesterol transport model involved in atherosclerosis

Atherosclerosis, the pathological basis of most cardiovascular disease (CVD), is closely associated with cholesterol accumulation in the arterial intima. Excessive cholesterol is removed by the reverse cholesterol transport (RCT) pathway, representing a major antiatherogenic mechanism. In addition to the RCT, other pathways are required for maintaining the whole-body cholesterol homeostasis. Thus, we propose a working model of integrated cholesterol transport, termed the cholesterol transport system (CTS), to describe body cholesterol metabolism. The novel model not only involves the classical view of RCT but also contains other steps, such as cholesterol absorption in the small intestine, low-density lipoprotein uptake by the liver, and transintestinal cholesterol excretion. Extensive studies have shown that dysfunctional CTS is one of the major causes for hypercholesterolemia and atherosclerosis. Currently, several drugs are available to improve the CTS efficiently. There are also several therapeutic approaches that have entered into clinical trials and shown considerable promise for decreasing the risk of CVD. In recent years, a variety of novel findings reveal the molecular mechanisms for the CTS and its role in the development of atherosclerosis, thereby providing novel insights into the understanding of whole-body cholesterol transport and metabolism. In this review, we summarize the latest advances in this area with an emphasis on the therapeutic potential of targeting the CTS in CVD patients.

The prediction of therapy-benefit for individual cardiovascular disease prevention: rationale, implications, and implementation

PURPOSE OF REVIEW

We aim to outline the importance and the clinical implications of using predicted individual therapy-benefit in making patient-centered treatment decisions in cardiovascular disease (CVD) prevention. Therapy-benefit concepts will be illustrated with examples of patients undergoing lipid management.

RECENT FINDINGS

In both primary and secondary CVD prevention, the degree of variation in individual therapy-benefit is large. An individual's therapy-benefit can be estimated by combining prediction algorithms and clinical trial data. Measures of therapy-benefit can be easily integrated into clinical practice via a variety of online calculators. Lifetime estimates (e.g., gain in healthy life expectancy) look at therapy-benefit over the course of an individual's life, and are less influenced by age than short-term estimates (e.g., 10-year absolute risk reduction). Lifetime estimates can thus identify people who could substantially benefit from early initiation of CVD prevention. Compared with current guidelines, treatment based on predicted therapy-benefit would increase eligibility for therapy among young people with a moderate risk-factor burden and individuals with a high residual risk.

SUMMARY

The estimation of individual therapy-benefit is an important part of individualized medicine. Implementation tools allow for clinicians to readily estimate both short-term and lifetime therapy-benefit.

Familial Hypercholesterolemia and Risk of Peripheral Arterial Disease and Chronic Kidney Disease

CONTEXT

Individuals with familial hypercholesterolemia (FH) have a high risk of coronary artery disease, but their risk of peripheral arterial disease (PAD) and chronic kidney disease (CKD) is unknown.

OBJECTIVE

In individuals with clinical FH, we tested the hypotheses (1) that the risks of PAD and CKD are elevated and (2) that low ankle-brachial index (ABI) and estimated glomerular filtration rate (eGFR) are associated with a high risk of myocardial infarction.

DESIGN AND SETTING

Prospective cohort study of the general population.

PARTICIPANTS

A total of 106,172 individuals, of whom 7109 were diagnosed with FH.

MAIN OUTCOME MEASURES

PAD, CKD, and myocardial infarction.

RESULTS

Compared with individuals with unlikely FH, multivariable adjusted ORs (95% CIs) of PAD were 1.84 (1.70 to 2.00) in those with possible FH and 1.36 (1.00 to 1.84) in individuals with probable/definite FH. For CKD, the corresponding ORs (95% CIs) were 1.92 (1.78 to 2.07) and 2.42 (1.86 to 3.26). Compared with individuals with unlikely FH and ABI >0.9, the multivariable adjusted hazard ratio (95% CI) of myocardial infarction was 4.60 (2.36 to 8.97) in those with possible/probable/definite FH and ABI ≤0.9. Compared with individuals with unlikely FH and eGFR ≥60 mL/min/1.73 m2, the corresponding value was 2.19 (1.71 to 2.82) in those with possible/probable/definite FH and eGFR <60 mL/min/1.73 m2.

CONCLUSIONS

Individuals with clinical FH have increased risks of PAD and CKD, and low ABI and eGFR are associated with high risk of myocardial infarction. Consequently, individuals with FH should be screened for PAD and CKD, and ABI and eGFR may be used as prognostic tools in the management and treatment of FH to identify those at very high risk of myocardial infarction.

Cardiac Troponin - diagnostic problems and impact on cardiovascular disease

The definition of a high-sensitivity cardiac Troponin (cTn) assay describes the ability to quantify a cardiac biomarker level in at least 50% of healthy individuals. This advance in analytic sensitivity has come with a perceived loss of specificity in the most classic application - chest pain triage and the diagnosis of acute myocardial infarction (AMI). As cardiac Troponin can no longer be used as a dichotomous test, the medical field is increasingly moving towards a more granular interpretation. However, rapid rule-out/rule-in algorithms for AMI still rely on concrete thresholds for efficient triage, irrespective of the patient's comorbidities. Owing to a slightly elevated cTn value, evermore patients appear to fall into an indeterminate risk zone of diagnostic uncertainty. The reasons are manifold, spanning biological variation, analytical issues, increased plasma membrane permeability and the potential cytosolic release of cTn. This review provides a contemporary overview of the literature concerning the use of cardiac Troponin in chronic and acute cardiovascular care. Key messages High-sensitivity cardiac Troponin assays have transformed the assessment of cardiovascular disease. Rapid rule-out algorithms for chest pain triage have become increasingly complicated, but enable safe rule-out. Cardiac Troponin tracks mid- to long-term risk in patients with hyperlipidaemia, heart failure and renal dysfunction.

Registry report of the prevalence of ECG abnormalities and their relation to patient characteristics in an asymptomatic population

BACKGROUND

Cardiovascular disease is the leading cause of morbidity and mortality in developed countries. Many patients do not experience symptoms before a first major cardiovascular event. Resting electrocardiogram (ECG) may help identify asymptomatic individuals with a high risk of cardiovascular disease.

OBJECTIVE

We sought to determine the prevalence of ECG abnormalities in an apparently symptom-free adult population within a prospective registry.

METHODS

The registry consisted of 4739 consecutive apparently healthy individuals [age 62.8 ± 6.2 (SD) years; 54% female], referred by their General Practitioners between 2009 and 2013. Patient demographics, and clinical data were obtained, alongside blood tests and a resting ECG.

RESULTS

ECG abnormalities were present in 1509 (31.8%) subjects and were commoner with increasing age (F = 0.161, p = 0.01), systolic (F = 0.134, p = 0.01) and diastolic (F = 0.44, p = 0.01) blood pressure and waist circumference (F = 0.53, p = 0.01). Left ventricular hypertrophy (LVH) was the most common abnormality (n = 281) and was positively associated with systolic (F = 0.12, p = 0.01) and diastolic blood pressure (F = 0.99, p = 0.01) and male gender (X2 = 60.5, p < 0.01). All ECG abnormalities (except for LVH) were associated with an increasing age, while right bundle branch block (F = 0.041, p = 0.01) and atrial fibrillation (n = 29; F = 0.036, p = 0.05) were associated with the presence of diabetes mellitus (n = 211). Only left bundle branch block (n = 50) was associated with angina (F = 0.05, p = 0.01).

CONCLUSIONS

Unrecognized cardiac abnormalities are common in middle-aged men and women with no overt symptoms. ECG offers the potential to identify these abnormalities and provide earlier intervention and treatment, and possibly improve cardiovascular outcome.

LDL-C does not cause cardiovascular disease: a comprehensive review of the current literature

INTRODUCTION

For half a century, a high level of total cholesterol (TC) or low-density lipoprotein cholesterol (LDL-C) has been considered to be the major cause of atherosclerosis and cardiovascular disease (CVD), and statin treatment has been widely promoted for cardiovascular prevention. However, there is an increasing understanding that the mechanisms are more complicated and that statin treatment, in particular when used as primary prevention, is of doubtful benefit. Areas covered: The authors of three large reviews recently published by statin advocates have attempted to validate the current dogma. This article delineates the serious errors in these three reviews as well as other obvious falsifications of the cholesterol hypothesis. Expert commentary: Our search for falsifications of the cholesterol hypothesis confirms that it is unable to satisfy any of the Bradford Hill criteria for causality and that the conclusions of the authors of the three reviews are based on misleading statistics, exclusion of unsuccessful trials and by ignoring numerous contradictory observations.

The potential of chronopharmacology for treatment of atherosclerosis

PURPOSE OF REVIEW

Development of atherosclerosis contributes to cardiovascular diseases that still are the leading cause of mortality worldwide. Successful strategies for treating inflammatory aspects of atherosclerotic lesion development are rare. Here, we review new insights into the impact of circadian rhythmicity on atherogenesis and their potential for innovative time-optimized pharmacological treatment strategies.

RECENT FINDINGS

Studies on the circadian clock revealed an extensive influence on immune cell activity. Immune cell functionality and their recruitment to injured tissues exhibit circadian rhythmicity. Many indications that the circadian clock also modulates atherogenesis were given in the past. Transcriptome analysis of the aorta reveals a time-dependent expression profile. Furthermore, deficiency of the core clock proteins Bmal1 and Clock consistently accelerates atherosclerosis. Recent work provided new insights on time-dependent leukocyte recruitment to atherosclerotic lesions and its regulatory mechanisms through the CCR2-CCL2 axis. Based on timed CCR2-CCL2 signaling blockage, an effective chronopharmacological treatment strategy was established to reduce early lesion development with concomitant reduction of systemic side effects.

SUMMARY

Circadian rhythmicity impacts on the pathogenesis of atherosclerosis. Circadian oscillation in the expression of drug targets may license timed intervention strategies with improved efficacy and lower risk.

Success in Achieving the Targets of the 20-Year Infancy-Onset Dietary Intervention: Association With Insulin Sensitivity and Serum Lipids

OBJECTIVE

We examined whether success in achieving the key targets of an infancy-onset 20-year dietary intervention associated with insulin sensitivity and serum lipids from early childhood to young adulthood.

RESEARCH DESIGN AND METHODS

The sample comprised 941 children participating in the prospective, randomized Special Turku Coronary Risk Factor Intervention Project (STRIP). Dietary counseling was given biannually based on the Nordic Nutrition Recommendations with the main aim to improve the quality of dietary fat in children's diets and the secondary aim to promote intake of vegetables, fruits, and whole-grain products. Food records and serum lipid profile were studied annually from 1 to 20 years of age, and HOMA of insulin resistance (HOMA-IR) was assessed between 7 and 20 years of age. Meeting the intervention targets for quality of dietary fat was defined as the ratio of saturated fatty acids (SAFA) to monounsaturated and polyunsaturated fatty acids (MUFA + PUFA) <1:2 and intake of SAFA <10% of total energy intake (E%). Meeting the target for intake of whole-grain products, fruits, and vegetables was indicated by a fiber intake ≥3 g/MJ.

RESULTS

Participants in the intervention group had a higher probability of meeting the targets of SAFA/(PUFA + MUFA) <1:2 (risk ratio [RR] 3.91 [95% CI 3.33-4.61]), intake of SAFA <10 E% (RR 3.33 [95% CI 2.99-3.96]), and intake of fiber >3 g/MJ (RR 1.37 [95% CI 1.04-1.80]). Participants who achieved more targets had lower HOMA-IR, lower concentrations of fasting serum glucose, insulin, LDL cholesterol, and non-HDL cholesterol, and a lower ratio of apolipoprotein (Apo) B/ApoA1 (P values all ≤0.003).

CONCLUSIONS

Achieving the key targets of an infancy-onset 20-year dietary intervention was associated with better insulin sensitivity and serum lipid profile throughout the early life course.

Origination, change, and modulation of geriatric disease-related gut microbiota during life

The age-related changes in the diversity and composition of the gut microbiota are well described in recent studies. These changes have been suggested to be influenced by age-associated weakening of the immune system and low-grade chronic inflammation, resulting in numerous age-associated pathological conditions. Gut microbiota homeostasis is important throughout the life of the host by providing vital functions to regulate various immunological functions and homeostasis. Based on published results, we summarize the relationship between the gut microbiota and aging-related diseases, especially Parkinson's disease, immunosenescence, rheumatoid arthritis, bone loss, and metabolic syndrome. The change in composition of the gut microbiota and gut ecosystem during life and its influence on the host immunologic and metabolic phenotype are also analyzed to determine factors that affect aging-related diseases. Approaches to maintain host health and prevent or cure geriatric diseases are also discussed.

It Must be True … I Read it in the Tabloids

Background

Previous attempts to improve the quality of health journalism have not led to more responsible reporting of health news.

Method

We reviewed the front pages of three daily tabloid and three daily broadsheet UK newspapers during a 1 month period in 2017 for medical headlines in which claims were made for diets, lifestyle behaviours or drug therapies that influence health.

Results

Front page medical headlines were carried by the Daily Express (11), Daily Mail (two), Daily Mirror (one) and Daily Telegraph (one). Neither the Guardian nor the Independent carried medical stories on their front pages during the period of study. Eleven headlines suggested benefits and three suggested harm. One headline accurately reflected its source material, but in this instance the source material was of doubtful clinical relevance. The remaining 13 headlines either exaggerated benefit (seven), exaggerated harm (two) or made false claims (four).

Conclusions

The cumulative effect of everyday misreporting of medical stories in UK newspapers may not only serve to confuse the public but also have serious consequences for public health.

Validity of a Novel Method for Estimating Low-Density Lipoprotein Cholesterol Levels in Cardiovascular Disease Patients Treated with Statins

AIM

The Friedewald equation is the standard method for estimating low-density lipoprotein cholesterol (LDL-C) levels [LDL-C(F)] and fixes the ratio of triglyceride (TG) to very LDL-C at 5. However, this has been reported to underestimate LDL-C, particularly in patients with LDL-C ＜70 mg/dL. A novel method for LDL-C estimation [LDL-C(M)] using an adjustable factor instead of a fixed value of 5 has recently been proposed. The purpose of this study was to validate LDL-C(M) in Japanese patients with cardiovascular disease (CVD) treated with statins.

METHODS

In 385 consecutive CVD patients treated with statins, LDL-C(M) and LDL-C(F) levels were compared with directly measured LDL-C [LDL-C(D)].

RESULTS

Mean LDL-C(D), LDL-C(F), and LDL-C(M) were 81.7±25.5, 76.4±24.6, and 79.9±24.5 mg/dL, respectively. In all patients, both LDL-C(F) and LDL-C(M) were significantly correlated with LDL-C(D) [LDL-C(F) vs. LDL-C(D): R=0.974, p＜0.001; LDL-C(M) vs. LDL-C(D): R=0.987, p＜0.001]. In patients with LDL-C(D) ＜70 mg/dL, LDL-C(M) showed a better correlation with LDLC(D) compared with LDL-C(F) [LDL-C(M) vs. LDL-C(D): R=0.935, p＜0.001; LDL-C(F) vs. LDLC(D): R=0.868, p＜0.001]. In contrast, the correlation of LDL-C(D) with LDL-C(M) or LDL-C(F) was similar in patients with LDL-C(D) ≥70 mg/dL.

CONCLUSIONS

In Japanese patients with CVD treated with statins, LDL-C level estimated by this novel method might be more accurate than those estimated using the Friedewald equation for LDL-C levels ＜70 mg/dL.

Vasa Vasorum Angiogenesis: Key Player in the Initiation and Progression of Atherosclerosis and Potential Target for the Treatment of Cardiovascular Disease

Plaque microvascularization and increased endothelial permeability are key players in the development of atherosclerosis, from the initial stages of plaque formation to the occurrence of acute cardiovascular events. First, endothelial dysfunction and increased permeability facilitate the entry of diverse inflammation-triggering molecules and particles such as low-density lipoproteins into the artery wall from the arterial lumen and vasa vasorum (VV). Recognition of entering particles by resident phagocytes in the vessel wall triggers a maladaptive inflammatory response that initiates the process of local plaque formation. The recruitment and accumulation of inflammatory cells and the subsequent release of several cytokines, especially from resident macrophages, stimulate the expansion of existing VV and the formation of new highly permeable microvessels. This, in turn, exacerbates the deposition of pro-inflammatory particles and results in the recruitment of even more inflammatory cells. The progressive accumulation of leukocytes in the intima, which trigger proliferation of smooth muscle cells in the media, results in vessel wall thickening and hypoxia, which further stimulates neoangiogenesis of VV. Ultimately, this highly inflammatory environment damages the fragile plaque microvasculature leading to intraplaque hemorrhage, plaque instability, and eventually, acute cardiovascular events. This review will focus on the pivotal roles of endothelial permeability, neoangiogenesis, and plaque microvascularization by VV during plaque initiation, progression, and rupture. Special emphasis will be given to the underlying molecular mechanisms and potential therapeutic strategies to selectively target these processes.

Appropriateness of statin prescription in the elderly

Statins, the most widely used drugs in the Western world, have become a pivotal component in the primary and secondary prevention of vascular diseases. Although benefits have been well documented in younger-than-75-year-old individuals, the value of statins in people aged >75years and over is controversial. The CTT meta-analysis calculated an absolute risk reduction of 0.6%/year per 38.7mg/dl reduction in LDL-C levels in patients aged >75years, that would translate into a number needed to treat of 167. However, the absolute effect of a 38.7mg/dl cholesterol lowering on the rate of annual ischemic heart disease mortality is 10-fold larger in older vs younger patients. In order to advise physician prescription, three major Guidelines have been published over the last few years, i.e. the AHA/ACC and the NLA in the US, and the ESC/EAS in Europe. Moreover, statin prescription in the elderly should also consider the cardiovascular outcomes of elderly patients reported in classical statin preventive trials which give important clues on adherence and persistence of use, as well as on drug safety. The present review discusses benefits of intensive vs moderate statin therapy, justifications for the use of aggressive lipid management in the very old and the use of statins in frail elderlies. The final decision on the therapeutic strategy with statins in elderlies at higher risk to develop cardiovascular events should be always based on a careful analysis of the patient's general health and on the presence of metabolic abnormalities or drug interactions potentially leading to risk.

Patient adherence, compliance, and perspectives on evolocumab for the management of resistant hypercholesterolemia

Evolocumab is a PCSK9 inhibitor which is administered subcutaneously, and when added to statin therapy it has been shown to cause a significant incremental LDL-C reduction, leading to a reduction of cardiovascular risk. Evolocumab has a favorable side effect profile, and its self-administration at home appears to be safe and effective with the appropriate training and instructions from a health care provider. Current studies are showing encouraging results regarding adherence to evolocumab in real-life settings, and adherence rates to evolocumab appear to be better than those to statins. However, further larger studies are needed for a more definitive assessment of the short- and long-term patient adherence rates to evolocumab. In addition, reductions in the price of evolocumab may also be necessary to improve cost-effectiveness of the drug.