Triglyceride-lowering therapy for the prevention of cardiovascular events, stroke, and mortality in patients with diabetes: A meta-analysis of randomized controlled trials

Assessing Omega-3 Therapy and Its Cardiovascular Benefits: What About Icosapent Ethyl? A Systematic Review and Meta-Analysis

Background: Lipid-lowering therapies are an option for stabilizing lipid levels. Icosapent ethyl (IPE) is a highly purified formulation of eicosapentaenoic acid, which can reduce lipid action, improve plaque stabilization, reduce platelet aggregation, lower TG, and prevent cardiovascular events. IPE is frequently used with statins to manage elevated TG levels. However, the evidence on IPE as a lipid-lowering agent is limited, and no updated systematic review and meta-analysis have been published considering the recent advancements in the field and newly published studies. Therefore, we aim to fill this gap. Methods: We used the PRISMA guidelines and the PICO (Population, Intervention, Comparison, and Outcome) framework to conduct this review, aiming to answer the question, "Can IPE benefit patients at cardiovascular risk?" GRADE was used to evaluate evidence levels to adhere to the highest criteria. Results: Predominantly, the evaluated population presented TG levels between ≥135 mg/dL and 500 mg/dL and LDL-C levels between >40 mg/dL and ≤100 mg/dL. The included studies showed a reduction in TG and LDL-C and a decrease in cardiovascular events. It means that, according to our systematic review evidence analysis, IPE has been effective in lowering blood lipid levels, including TG, and reducing cardiovascular death and events, such as non-fatal stroke or hospitalization for unstable angina. However, it is worth noting that these results were primarily from patients undergoing statin therapy. According to our meta-analysis, IPE may not be considered a lipid-lowering drug, as limited action associated with its use was evident in the quantitative results. However, caution is necessary, as only two studies were suitable for inclusion due to the differing outcomes in the analyzed samples. Conclusions: Despite the quantitative synthesis, IPE possesses anti-inflammatory, anti-thrombotic, and anti-atherogenic properties, highly related to cardiovascular protection. Based on our included studies, IPE was considered a promising therapy for atherosclerotic cardiovascular disease in conjunction with other lipid-lowering therapies, particularly statins, for patients with extremely high TG levels. The limitations of the reviewed studies may include small sample sizes, varying outcomes, and a small duration of interventions. Future clinical trials with similar outcomes, sample sizes, and intervention durations must be designed, and updated meta-analyses must be published in the following years to fully assess the effects of IPE as a lipid-lowering and cardiovascular protector drug.

Effects of seal oil supplementation on lipid profile biomarkers: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Seal oil (SO) supplementation has been purported to have cardiovascular health benefits due to its content of omega-3 fatty acids; however, the clinical evidence base for this intervention has yet to be comprehensively assessed.

OBJECTIVE

We aimed to evaluate the effects of oral SO supplementation on lipid profile biomarkers.

METHODS

A systematic search was performed on Pubmed, Embase, Web of Science and Cochrane Library, from inception to August 2024. Only randomized controlled trials (RCTs) assessing the effect of SO on lipid profile biomarkers were included. A random-effects meta-analysis was applied to determine the overall effect estimate. The certainty of evidence (CoE) was evaluated using the GRADE approach.

RESULTS

Nine RCTs were included in the review after the screening of 242 studies, comprising a total of 626 patients. Supplementation of SO resulted in no statistically significant effects on LDL-C (MD -0.07 mmol/L; 95 % CI [-0.19, 0.05]; CoE: Low) and total cholesterol (MD -0.12 mmol/L; 95 % CI [-0.30, 0.06]; CoE: Very low). There were statistically significant results of modest-to-trivial clinical importance on triglycerides (MD -0.19 mmol/L, 95 % CI [-0.30, -0.08]; CoE: Low) and trivial importance on HDL-C (MD 0.07 mmol/L, 95 % CI [0.003, 0.13]; CoE: Very low).

CONCLUSION

There is no sufficiently certain evidence to determine the effects of SO on cardiovascular lipid biomarkers. Our analyses may suggest a modest-to-trivial, clinically uncertain beneficial effect on triglyceride levels; and little to no effect on LDL-C. Effect estimates for HDL-C and total cholesterol levels were highly uncertain. Further evidence is required to conclusively determine the effects of oral SO on lipid biomarkers.

PROTOCOL REGISTRATION NUMBER

CRD42024583739.

Predictive value of uric acid to albumin ratio for carotid atherosclerosis in type 2 diabetes mellitus: A retrospective study

BACKGROUND

This study aims to evaluate the correlation between the uric acid (UA) to albumin (ALB) ratio (UAR) and carotid atherosclerosis (CAS) in patients with type 2 diabetes mellitus (T2DM), as well as to assess the predictive value of UAR for CAS.

METHODS

A cross-sectional, single-center study was conducted, retrospectively analyzing hematological parameters from 259 T2DM patients with CAS (T2DM-CAS) and 131 T2DM patients without CAS (T2DM-WCAS). Carotid intima-media thickness (IMT) and carotid plaques (CAP) were measured using Doppler ultrasound.

RESULTS

The UAR level in the T2DM-CAS group was significantly higher than that in the T2DM-WCAS group (P <  0.001). Multivariate logistic regression analysis revealed that UAR is an independent risk factor for T2DM-CAS (P <  0.001). The area under the ROC curve (AUC) for UAR in predicting T2DM-CAS was 0.712, with a Youden index of 0.278.

CONCLUSION

High levels of UAR are closely associated with the occurrence of T2DM-CAS and may serve as a useful biomarker for predicting T2DM-CAS.

Diabetes-Related Changes in Carotid Wall Properties: Role of Triglycerides

Background/Objectives: This study compares the power of the radiofrequency (RF) signal reflected from the media layer (media power) of the common carotid artery (CCA) and the CCA stiffness between individuals with and without type 2 diabetes mellitus (T2DM). It also evaluates the associations of CCA media power with plasma glucose and lipid levels, as well as carotid stiffness. Methods: A total of 540 individuals, 115 with and 425 without T2DM (273 males, mean age = 64 ± 8 years) were studied using RF-based tracking of the right CCA. The following parameters were measured: CCA media thickness, luminal diameter, wall tensile stress (WTS), local pulse wave velocity (PWV), and media power. Results: Compared to the non-diabetic individuals, the T2DM patients had significantly higher CCA media thickness (652 ± 122 vs. 721 ± 138 microns, p < 0.005), luminal diameter (6.12 ± 0.78 vs. 6.86 ± 0.96 mm, p < 0.0005), media power (36.1 ± 4.8 vs. 39.3 ± 4.6, p < 0.0001), and PWV (7.65 ± 1.32 vs. 8.40 ± 1.89 m/s; p < 0.01), but comparable WTS (32.7 ± 10.4 vs. 33.1 ± 10.7 kPa; p = 0.25). In the entire population, CCA media power was independently associated with male sex, pulse pressure, current smoking, and T2DM; when T2DM was not included in the model, triglycerides emerged as an independent determinant of media power. The CCA PWV was independently associated with age, pulse pressure, media power, and T2DM. Conclusions: Our findings suggest the presence of structural changes in the arterial media of T2DM patients, leading to carotid stiffening and remodeling, aiming to preserve WTS. T2DM-related changes in arterial wall composition may be driven by high plasma triglyceride levels, which have previously been associated with both arterial stiffening and the incidence of CV events.

Managing hypertriglyceridemia for cardiovascular disease prevention: Lessons from the PROMINENT trial

BACKGROUND

Numerous epidemiological studies have shown that hypertriglyceridemia is a significant risk factor for cardiovascular diseases (CVD). However, large clinical studies on triglyceride-lowering therapy have yielded inconsistent results. In the current review, we reassess the importance of triglyceride-lowering therapy in preventing CVD based on previous literature and the recently published findings of the PROMINENT trial.

METHODS

This narrative review is based on literature and public documents published up to November 2023.

RESULTS

Meta-analyses of trials on peroxisome proliferator-activated receptor α agonists and triglyceride-lowering therapy, including the PROMINENT trial, have indicated that triglyceride-lowering therapy can reduce CVD events. Mendelian randomization studies have also indicated that triglyceride is indeed a true risk factor for coronary artery disease, leaving no doubt about its relationship to CVD. Meanwhile, the negative results from the PROMINENT trial were likely due to the insufficient triglyceride-lowering effect, slight increases in low-density lipoprotein cholesterol and apolipoprotein B, and the inclusion of mostly high-intensity statin users as target patients. It is unlikely that adverse events counteracted the effectiveness of pemafibrate on outcomes. Additionally, pemafibrate has shown positive effects on non-alcoholic fatty liver disease and peripheral artery disease.

CONCLUSION

Although the PROMINENT trial did not demonstrate the significance of pemafibrate as a triglyceride-lowering therapy in a specific population, it does not necessarily negate the potential benefits of treating hypertriglyceridemia in reducing CVD events. It is necessary to explore appropriate populations that could benefit from this therapy, utilize data from the PROMINENT trial and other databases, and validate findings in real-world settings.

Fasting Triglycerides in the Upper Normal Range Are Independently Associated with an Increased Risk of Diabetes Mortality in a Large Representative US Population

The association between normal-range triglyceride levels and diabetes mortality remains unclear. This cohort study aimed to elucidate this relationship by examining 19,010 US adult participants with fasting serum triglycerides below 150 mg/dL. Cox proportional hazards models were employed to estimate mortality hazard ratios (HRs) and 95% confidence intervals (CIs). Participants were followed up for a mean of 15.3 years, during which 342 diabetes deaths were recorded. A 1 natural log unit increase in triglycerides was associated with a 57% higher risk of diabetes mortality (adjusted HR, 1.57; 95% CI, 1.04-2.38). Comparable results were obtained when triglycerides were analyzed in quartiles. Receiver operating characteristic curve analysis identified an optimal triglyceride cutoff of 94.5 mg/dL for diabetes mortality; individuals with triglyceride levels above this threshold faced a greater risk of diabetes mortality (adjusted HR, 1.43; 95% CI, 1.12-1.83). Further investigation revealed a positive association between normal triglyceride levels and all-cause mortality, though no association was observed between normal triglycerides and mortality from hypertension or cardiovascular disease. In conclusion, elevated triglyceride levels within the normal range were associated with an increased risk of diabetes mortality. Individuals with triglyceride levels of 95 mg/dL or higher may require vigilant monitoring for diabetes and its associated complications.