Low-serum, high-density lipoprotein cholesterol concentration is an important coronary risk factor in Chinese patients with low serum levels of total cholesterol and triglyceride

Relationship between Oxidative Stress and Left Ventricle Markers in Patients with Chronic Heart Failure

Oxidative stress is proposed in the literature as an important player in the development of CHF and correlates with left ventricle (LV) dysfunction and hypertrophy in the failing heart. In this study, we aimed to verify if the serum oxidative stress markers differ in chronic heart failure (CHF) patients' groups depending on the LV geometry and function. Patients were stratified into two groups according to left ventricular ejection fraction (LVEF) values: HFrEF (<40% (n = 27)) and HFpEF (≥40% (n = 33)). Additionally, patients were stratified into four groups according to LV geometry: NG-normal left ventricle geometry (n = 7), CR-concentric remodeling (n = 14), cLVH-concentric LV hypertrophy (n = 16), and eLVF-eccentric LV hypertrophy (n = 23). We measured protein (protein carbonyl (PC), nitrotyrosine (NT-Tyr), dityrosine), lipid (malondialdehyde (MDA), oxidizes (HDL) oxidation and antioxidant (catalase activity, total plasma antioxidant capacity (TAC) markers in serum. Transthoracic echocardiogram analysis and lipidogram were also performed. We found that oxidative (NT-Tyr, dityrosine, PC, MDA, oxHDL) and antioxidative (TAC, catalase) stress marker levels did not differ between the groups according to LVEF or LV geometry. NT-Tyr correlated with PC (r_s = 0.482, p = 0.000098), and oxHDL (r_s = 0.278, p = 0.0314). MDA correlated with total (r_s = 0.337, p = 0.008), LDL (r_s = 0.295, p = 0.022) and non-HDL (r_s = 0.301, p = 0.019) cholesterol. NT-Tyr negatively correlated with HDL cholesterol (r_s = -0.285, p = 0.027). LV parameters did not correlate with oxidative/antioxidative stress markers. Significant negative correlations were found between the end-diastolic volume of the LV and the end-systolic volume of the LV and HDL-cholesterol (r_s = -0.935, p < 0.0001; r_s = -0.906, p < 0.0001, respectively). Significant positive correlations between both the thickness of the interventricular septum and the thickness of the LV wall and the levels of triacylglycerol in serum (r_s = 0.346, p = 0.007; r_s = 0.329, p = 0.010, respectively) were found. In conclusions, we did not find a difference in serum concentrations of both oxidant (NT-Tyr, PC, MDA) and antioxidant (TAC and catalase) concentrations in CHF patients' groups according to LV function and geometry was found. The geometry of the LV could be related to lipid metabolism in CHF patients, and no correlation between oxidative/antioxidant and LV markers in CHF patients was found.

Synergistic Effects of Inflammation and Atherogenic Dyslipidemia on Subclinical Carotid Atherosclerosis Assessed by Ultrasound in Patients with Familial Hypercholesterolemia and Their Family Members

Low-density lipoprotein cholesterol (LDL-C) and total to high-density lipoprotein cholesterol (TC/HDL-C) ratio are both common risk factors for atherosclerotic cardiovascular diseases (ASCVDs). However, whether high-sensitivity C-reactive protein (hsCRP) has synergistic or attenuated effects on atherogenic dyslipidemia remains unclear. We investigated subclinical carotid atherosclerosis in patients with familial hypercholesterolemia (FH) and their family members. A total of 100 families with 761 participants were prospectively studied. Participants were categorized into four groups according to atherogenic dyslipidemia and inflammatory biomarkers. The group with LDL-C ≥ 160 mg/dL (or TC/HDL-C ratio ≥ 5) combined with hsCRP ≥ 2 mg/L have a thicker carotid intima-media thickness (CIMT) in different common carotid artery (CCA) areas and a higher percentage of high plaque scores compared with other subgroups. Multivariate logistic regression analysis revealed a significantly higher adjusted odds ratio (aOR) for thicker CIMT of 3.56 (95% CI: 1.56–8.16) was noted in those with concurrent LDL-C ≥ 160 mg/dL and hsCRP ≥ 2 mg/L compared with the group with concurrent LDL-C < 160 mg/dL and hsCRP < 2 mg/L. Our results demonstrated that systemic inflammation, in terms of higher hsCRP levels ≥ 2 mg/L, synergistically contributed to atherogenic dyslipidemia of higher LDL-C or a higher TC/HDL-C ratio on subclinical atherosclerosis.

Analysis of traditional and nontraditional risk factors for peripheral arterial disease in elderly type 2 diabetic patients in Taiwan

AIMS

Diagnosing peripheral arterial disease (PAD) and recognizing its associated risk factors in diabetes is important due to high cardiovascular disease and limb loss risk. However, both traditional and nontraditional risk factors have seldom been analyzed in the same diabetic cohort. The aim of this study was to examine the traditional and nontraditional risk factors for PAD in elderly type 2 diabetic patients.

METHODS

Five hundred and eighty type 2 diabetic subjects aged >or=60 years were cross-sectionally studied. Diagnosis of PAD was by ankle-brachial index (ABI) <0.90 on either leg. The association between traditional and nontraditional risk factors of PAD was analyzed.

RESULTS

Among the confounders, age, diabetes duration, HDL cholesterol, albuminuria, CKD (chronic kidney disease), hsCRP and insulin use differed between patients with and without PAD. Multiple logistic regression revealed that only CKD, insulin use, albuminuria, elevated hsCRP level (>3mg/l) and low HDL cholesterol were independent risk factors.

CONCLUSIONS

The findings of this study highlight the importance of monitoring nontraditional risk factors of PAD in diabetes. Implementing effective interventions to improve management of these risk factors may lower the risk for PAD.

Association among cigarette smoking, metabolic syndrome, and its individual components: the metabolic syndrome study in Taiwan

Insulin resistance is a common feature of metabolic syndrome. Smokers are at great risk of developing insulin resistance. Theoretically, smoking status should be associated with metabolic syndrome. This study aimed to explore the association among cigarette smoking, metabolic syndrome, and its individual components. Information of participants regarding previous and current diseases, family history of disease, smoking habits, alcohol consumption, betel nut chewing, and physical activity status were gathered from self-reported nutrition and lifestyle questionnaires. The fasting plasma glucose, triglyceride level, high-density lipoprotein cholesterol (HDL-C) level, blood pressure, and anthropometric indices in each patient were measured. Data of 1146 male subjects were analyzed. Individuals who currently smoked had a higher prevalence of metabolic syndrome than those who had never smoked and those who had quit smoking. The adjusted odds ratios of current smoking amount showed a statistically significant dose-dependent association with metabolic syndrome, high triglyceride level, and low HDL-C level. Current smokers who smoke > or =20 pack-years have a significantly increased risk of developing metabolic syndrome, high triglyceride level, and low HDL-C level. The higher risk of development of metabolic syndrome, high triglyceride level, and low HDL-C level was insignificant in former smokers. In conclusion, this community-based study supports the view that smoking is associated with metabolic syndrome and its individual components. Smoking cessation is beneficial to metabolic syndrome and its individual components.

Effect of conjugated equine estrogen in combination with two different progestogens on the risk factors of coronary heart disease in postmenopausal Chinese women in Taiwan: a randomized one-year study

BACKGROUND

To compare the effect of hormone replacement therapy (HRT) using estrogen plus dydrogesterone or estrogen plus medroxyprogesterone acetate (MPA) on the risk factors for coronary heart disease (CHD) in postmenopausal women.

METHODS

A randomized, prospective 1-year clinical trial was designed. All of the postmenopausal women (n = 279) received sequential conjugated equine estrogen (CEE) at a dose of 0.625 mg/day for 25 days (days 1-25) of each month. These women were also randomly assigned to receive either dydrogesterone 10 mg/day (E + D group, n = 140) or MPA 5 mg/day (E + P group, n = 139) for 14 days (days 12-25) of each month. Serum biochemical markers, lipoproteins, plasma prothrombin time (PT), partial prothrombin time (PPT) and antithrombin III-antigen (ATIII-Ag) were analyzed at baseline, and after 6 and 12 months of treatment.

RESULTS

Liver function, renal function, PT and PPT did not change significantly during the 12-month trial. The E + D group had a more pronounced increase in high density lipoprotein cholesterol (HDL-C) than the E + P group (10.6% vs. 2.7%) after 12 months of treatment (p < 0.05). Both groups showed reduced concentrations of total cholesterol (T-CHO), low density lipoprotein cholesterol (LDL-C) and ATIII, whereas triglyceride (TG) was increased at the end of the trial (without intergroup difference).

CONCLUSIONS

Our study demonstrated a favorable effect on lipoprotein profiles with both hormone replacement therapy regimens. Dydrogesterone appears to be superior to medroxyprogesterone acetate from the perspective of modification of coronary heart disease risk factors.

Left ventricular mass and correlated atherosclerotic risk factors in young adolescents: report from Chin-Shan community cardiovascular study in Taiwan

Various subclinical disease indicators can be used as an early stage marker of atherosclerosis. Left ventricular (LV) mass has been related to cardiovascular morbidity and mortality. The distribution of LV mass in Chinese is rarely studied and nothing is known about its relationships with various atherosclerotic risk factors in young teenagers, in particular, aspects of lipid profiles. We performed a community-based survey of 523 males and 555 females, aged 12-15, in Chin-Shan, a suburb area near Taipei, Taiwan. LV mass was calculated from the Penn convention. Normalized LV mass by height with power of 2.7 was defined. LV mass and normalized LV mass were significantly greater in males than in females. There were significant positive correlation coefficients between LV mass and age, blood pressure, body mass index, low density lipoprotein cholesterol (LDL-C), apolipoprotein (Apo) B, fasting insulin levels and significant negative correlation coefficients between LV mass and high density lipoprotein cholesterol (HDL-C) and Apo A1 level in both genders. Multiple linear regression models showed gender and body mass index (BMI) were important factors associated with LV mass or normalized values for adolescents. Age and systolic blood pressure were also significant predictors of LV mass, but not of normalized LV mass values. LV mass values were found to be negatively associated with HDL-C values at marginal statistically significant level. Age and BMI are the most significant factors of echocardiographic LV mass distributions in young adolescent in Taiwan. LV mass may also be associated with atherosclerotic risk factors.

Preventing, stopping, or reversing coronary artery disease--triglyceride-rich lipoproteins and associated lipoprotein and metabolic abnormalities: the need for recognition and treatment

A substantial number of treated patients with or at high risk for coronary artery disease continue to have fatal and nonfatal coronary artery events in spite of significant reduction of elevated levels of low-density lipoprotein cholesterol. Other lipoprotein abnormalities besides an elevated level of low-density lipoprotein cholesterol contribute to risk of coronary artery disease and coronary artery events, and the predominant abnormalities that appear to explain much of this continued risk are an elevated serum triglyceride level and a low level of high-density lipoprotein cholesterol. Most patients with coronary artery disease have a mixed dyslipidemia with hypertriglyceridemia, which is associated and metabolically intertwined with other atherogenic risk factors, including the presence of triglyceride-rich lipoprotein remnants, low levels of high-density lipoprotein cholesterol, small, dense, low-density lipoprotein particles, postprandial hyperlipidemia, and a prothrombotic state. Aggressive treatment of these patients needs to focus on these other lipoprotein abnormalities as much as on low-density lipoprotein cholesterol. Combination drug therapy will usually be required. Reliable assessment of risk of coronary artery disease from lipoprotein measurements and response to therapy requires inclusion of all atherogenic lipoproteins in laboratory measurements and treatment protocols. At present this may be best accomplished by use of non-high-density lipoprotein cholesterol (total cholesterol minus high-density lipoprotein cholesterol) calculated from standard laboratory lipoprotein values. Ultimately, a more comprehensive assessment of coronary artery disease risk and appropriate therapy may include measurement of lipoprotein subclass distribution including determination of low-density lipoprotein particle concentration and sizes of the various lipoprotein particles.

Protective effect of high density lipoprotein on endothelium-dependent vasodilatation

Low concentrations of high-density lipoprotein cholesterol (HDL-C) have been associated with increased risk of coronary heart disease (CHD) even when the total cholesterol (TC) and triglyceride (TG) levels are not elevated. The mechanism by which HDL confers protection against atherosclerosis remains speculative. Using high-resolution ultrasound, we measured the dilatation changes of brachial arteries during reactive hyperemia and after sublingual glyceryl trinitrate (GTN) in 63 patients with established (CHD) and 45 controls, in which the serum TC level was normal. The results showed that both flow-mediated dilatation (FMD) and GTN-induced dilatation of brachial arteries in patients with CHD were much reduced compared with control group (2.31+/-2.46% vs. 7.43+/-4.10% and 16.41+/-6.15% vs. 22.44+/-8.63%, respectively, P<0.001 for all). Univariate analysis indicated that FMD of brachial arteries was inversely related to age (r=-0.226, P<0.05), hypertension (r=-0.229, P<0.05), baseline diameter (r=-0.299, P<0.01) and LDL-C (r=-0.237, P<0.05) and positively related to HDL-C (r=0.491, P<0.01). GTN induced vasodilatation was inversely related to age (r=-0.216, P<0. 05) and baseline diameter (-0.476, P<0.01). Multiple stepwise regression analyses in two groups taken together showed that HDL-C and age were the independent predictors of the FMD of brachial arteries (beta=0.466, P=0.000 and beta=-0.184, P=0.020, respectively). Baseline diameter was significant predictor of GTN-induced vasodilatation (beta=-0.390, P=0.000). The analysis in the group of CHD patients showed that only HDL-C was significantly relate to the FMD of brachial arteries (beta=0.295, P=0.018 ) and in controls that hypertension and HDL-C were significantly relate to the FMD of brachial arteries (beta=-0.395, P=0.004 and beta=0.344, P=0.011, respectively). These finding suggest that endothelium-dependent and endothelium-independent vasodilatation are impaired in the patients with CHD. HDL exerts a protective effect on endothelium-dependent vasodilatation in TC being relatively normal population.

The effects of dyslipidemia on left ventricular systolic function in patients with stable angina pectoris

Large-scale clinical trials have shown that long-term treatment with lipid-lowering therapy results in a significant reduction in the occurrence of heart failure among patients with coronary artery disease without previous evidence of congestive heart failure, suggesting dyslipidemia may have an adverse effect on left ventricular performance. To examine whether dyslipidemia has a detrimental effect on left ventricular systolic function and whether this effect is dependent on the corresponding severity of coronary atherosclerosis, 114 consecutive patients with stable angina and a positive exercise thallium-201 myocardial perfusion single-photon emission computed tomography were studied. All patients underwent measurement of serum lipid profiles, right-sided heart catheterization, left ventriculography, and selective coronary arteriography. Mean serum levels of total cholesterol and triglycerides were 4.5 and 1.4 mmol/l, respectively. In univariate analysis, a significant positive correlation between serum high-density lipoprotein (HDL) cholesterol and left ventricular ejection fraction (LVEF) (r = 0.49, P<0.0001) was found. Patients in the lower tertile of serum HDL cholesterol had a significantly lower mean LVEF than those in the upper tertile (55.9+/-15.2 vs. 72.8+/-6.8%, P<0.0001). Stepwise multiple linear regression analysis revealed that LVEF significantly correlated with HDL cholesterol (P<0.0001), the Gensini score (P = 0.008), and diabetes mellitus (P = 0.08) (r = 0.55, P<0.0001). In subgroup analysis of patients with angiographically normal coronary arteries, serum HDL cholesterol was still significantly associated with LVEF. The present study demonstrated an independent association between low HDL cholesterol and subclinical left ventricular systolic dysfunction in Chinese patients with stable angina whose serum levels of total cholesterol and triglycerides were relatively low. Moreover, this correlation remained significant even in patients with normal coronary angiograms, suggesting HDL cholesterol might influence left ventricular systolic performance through extra-atherosclerotic mechanisms.

New concepts and paradigms in cardiovascular medicine: the noninvasive management of coronary artery disease

Coronary atherosclerosis is a diffuse heterogeneous process that occurs throughout the length of epicardial coronary arteries. Myocardial infarction and unstable coronary syndromes are caused most commonly by plaque rupture of lipid rich, less severe coronary artery stenoses. Vigorous cholesterol lowering by low fat food and lipid active drugs, control of hypertension, and smoking abstinence stabilize plaque and markedly reduce coronary events and angina pectoris with greater improvement in survival than reported for elective invasive revascularization procedures. The term "regression" or "reversal" of coronary artery disease (CAD) as used clinically incorporates the spectrum of beneficial changes in plaque composition and pathology, modest improvement in anatomic severity, endothelial healing, increased coronary flow and flow capacity, decreased symptoms, and improved survival. Standard coronary arteriography and standard noninvasive diagnostic tests (as commonly used) are inadequate for identifying or assessing severity of diffuse CAD. Newer technology or approaches using noninvasive positron emission tomography (PET), invasive intravascular ultrasound or pressure or flow velocity guide wires provide important new insights into the presence and severity of both segmental and diffuse CAD. Revascularization procedures may be beneficial in selected, restricted circumstances, primarily for 3-vessel disease and reduced left ventricular function and for "hibernating" or "stunned" myocardium. However, the benefits of revascularization procedures on survival in patients with good left ventricular function have not been convincingly documented, with substantive evidence that adverse outcomes outweigh the potential benefits. This collective new knowledge provides the basis for a shift in the management of CAD from an invasive, procedure-oriented viewpoint currently dominant in cardiology toward a noninvasive orientation that views the problem as a graded, continuous, heterogeneously diffuse disease process for which reversal treatment is optimal. Noninvasive management of CAD based on reversal treatment is a valid, safe, effective primary step, but it requires patient and physician knowledge. CAD should be treated immediately at the time of a firm diagnosis by simultaneous, vigorous risk factor management, low fat diet and a statin class drug. For control of high-density lipoprotein and triglycerides, other lipid active drugs should be added or substituted for statins if side effects prevent their use. Low fat food and weight control by appropriate caloric carbohydrate restriction are essential for reducing the highly atherogenic postprandial lipid surge that is not affected by statins. This vigorous reversal treatment, with aggressive anti-anginal and anti-platelet management as needed, should be used in every patient with diagnosed CAD before elective revascularization procedures are considered. In the author's experience, the majority of patients will pursue an effective reversal regimen when it is presented and managed appropriately with strong support by a knowledgeable participating physician providing sustained, intense guidance and pharmacologic control. For the minority of patients not responding to vigorous medical treatment or demonstrating progression, coronary arteriography and revascularization procedures are then appropriate.