Efficacy of fenofibrate and simvastatin on endothelial function and inflammatory markers in patients with combined hyperlipidemia: relations with baseline lipid profiles

Impact of statin therapy on CD40:CD40L signaling: mechanistic insights and therapeutic opportunities

Statins are widely utilized to reduce cholesterol levels, particularly in cardiovascular diseases. They interface with cholesterol synthesis by inhibiting the 3-hydroxy-3-methylglutaryl coenzyme-A (HMG-CoA) reductase enzyme. Besides their primary effect, statins demonstrate anti-inflammatory and immune-modulating properties in various diseases, highlighting the pleiotropic effect of these drugs. The CD40:CD40L signaling pathway is considered a prominent inflammatory pathway in multiple diseases, including autoimmune, inflammatory, and cardiovascular diseases. The findings from clinical trials and in vitro and in vivo studies suggest the potential anti-inflammatory effect of statins in modulating the CD40 signaling pathway and downstream inflammatory mediator. Accordingly, as its classic ligand, statins can suppress immune responses in autoimmune diseases by inhibiting CD40 expression and blocking its interaction with CD40L. Additionally, statins affect intracellular signaling and inhibit inflammatory mediator secretion in chronic inflammatory diseases like asthma and autoimmune disorders such as myasthenia gravis, multiple sclerosis, systemic lupus erymanthus, and cardiovascular diseases like atherosclerosis. However, it is essential to note that the anti-inflammatory effect of statins may vary depending on the specific type of statin used. In this study, we aim to explore the potential anti-inflammatory effects of statins in treating inflammatory diseases by examining their role in regulating immune responses, particularly their impact on the CD40:CD40L signaling pathway, through a comprehensive review of existing literature.

Association of serum calprotectin (S100A8/A9) concentrations and idiopathic hyperlipidemia in Miniature Schnauzers

BACKGROUND

Idiopathic hyperlipidemia (IH) is a common condition in Miniature Schnauzers (MS). Studies in people have linked IH to low-grade inflammation, which plays an important role in the pathogenesis of IH complications. The role of inflammation in MS with IH is unknown.

OBJECTIVE

Evaluation of the inflammatory markers serum calprotectin and S100A12 in MS with IH and in response to dietary intervention for IH management.

ANIMALS

One-hundred fifty clinically healthy MS.

METHODS

Serum triglyceride, cholesterol, calprotectin, and S100A12 concentrations were measured before and after placing the dogs on an ultra-low fat diet.

RESULTS

Hypertriglyceridemia (HTGL, P < .001) and hypercholesterolemia (HCHOL, P = .01) were independently associated with increased serum calprotectin but not S100A12 concentrations. Compared to normolipidemic MS, serum calprotectin concentrations were significantly higher in MS with HTGL (P < .001) or combined hyperlipidemia (P = .02), but not those with isolated HCHOL (P = 1.0000). Presence (P = .005) and severity (P = .003) of HTGL and serum cholesterol concentrations (P = .04) decreased in MS with IH within 14-26 weeks after being placed on the ultra-low fat diet, but neither serum calprotectin nor S100A12 concentrations changed significantly with this dietary intervention.

CONCLUSIONS AND CLINICAL IMPORTANCE

Subclinical (low-grade) inflammation appears to be present in some MS with IH, and an ultra-low fat diet does not decrease serum concentrations of inflammatory proteins in those dogs. Whether this presumed inflammatory phenotype in MS with IH is associated with the development of IH complications (eg, insulin resistance) requires further research.

[Pharmacological targets for dislipidemies correction. Opportunities and prospects of therapeutic usage]

Literature data on influence of existing and new groups of drug preparations for dyslipidemias correction are systemized, and molecular mechanisms of their effects are reviewed. The results of experimental and clinical investigations aimed at revealing of new pharmacological targets of dyslipidemias correction were analyzed. The approaches for activation of high density lipoproteins functionality are described. The implementation of alternative preparations with new alternative mechanisms of action may be suggested to improve the effectiveness of traditional treatment in the future.

DNA methylation as a marker of response in rheumatoid arthritis

Rheumatoid arthritis (RA) is a complex disease affecting approximately 0.5-1% of the population. While there are effective biologic therapies, in up to 40% of patients, disease activity remains inadequately controlled. Therefore, identifying factors that predict, prior to the initiation of therapy, which patients are likely to respond best to which treatment is a research priority and DNA methylation is increasingly being explored as a potential theranostic biomarker. DNA methylation is thought to play a role in RA disease pathogenesis and in mediating the relationship between genetic variants and patient outcomes. The role of DNA methylation has been most extensively explored in cancer medicine, where it has been shown to be predictive of treatment response. Studies in RA, however, are in their infancy and, while showing promise, further investigation in well-powered studies is warranted.

An epigenome-wide association study of inflammatory response to fenofibrate in the Genetics of Lipid Lowering Drugs and Diet Network

AIM

Fenofibrate, a PPAR-α inhibitor used for treating dyslipidemia, has well-documented anti-inflammatory effects that vary between individuals. While DNA sequence variation explains some of the observed variability in response, epigenetic patterns present another promising avenue of inquiry due to the biological links between the PPAR-α pathway, homocysteine and S-adenosylmethionine - a source of methyl groups for the DNA methylation reaction.

HYPOTHESIS

DNA methylation variation at baseline is associated with the inflammatory response to a short-term fenofibrate treatment.

METHODS

We have conducted the first epigenome-wide study of inflammatory response to daily treatment with 160 mg of micronized fenofibrate over a 3-week period in the Genetics of Lipid Lowering Drugs and Diet Network (GOLDN, n = 750). Epigenome-wide DNA methylation was quantified on CD4⁺ T cells using the Illumina Infinium HumanMethylation450 array.

RESULTS

We identified multiple CpG sites significantly associated with the changes in plasma concentrations of inflammatory cytokines such as high sensitivity CRP (hsCRP, 7 CpG sites), IL-2 soluble receptor (IL-2sR, one CpG site), and IL-6 (4 CpG sites). Top CpG sites mapped to KIAA1324L (p = 2.63E-10), SMPD3 (p = 2.14E-08), SYNPO2 (p = 5.00E-08), ILF3 (p = 1.04E-07), PRR3, GNL1 (p = 6.80E-09), FAM50B (p = 3.19E-08), RPTOR (p = 9.79e-07) and several intergenic regions (p < 1.03E-07). We also derived two inflammatory patterns using principal component analysis and uncovered additional epigenetic hits for each pattern before and after fenofibrate treatment.

CONCLUSION

Our study provides preliminary evidence of a relationship between DNA methylation and inflammatory response to fenofibrate treatment.

Trauma and Autonomic Dysregulation: Episodic-Versus Systemic-Negative Affect Underlying Cardiovascular Risk in Posttraumatic Stress Disorder

OBJECTIVE

Posttraumatic stress disorder (PTSD) has been linked to elevated heart rate (HR) and reduced heart rate variability (HRV) in cross-sectional research. Recent evidence suggests that this link may be driven by individual differences in autonomic arousal associated with momentary negative affect (NA). Using ecological momentary assessment (EMA) of NA and minute-to-minute HR/HRV monitoring, we examined whether NA-related HR/HRV mediated the association of PTSD symptom severity with 24-hour HRV and endothelial functioning.

METHODS

One hundred ninety-seven young adults (18-39 years), 93 with PTSD, underwent 1 day of Holter monitoring while concurrently reporting NA levels via EMA. Two noninvasive measures of endothelial functioning-flow-mediated dilation and hyperemic flow-were also collected. Multilevel modeling was used to assess the associations of momentary NA with HR and low- and high-frequency HRV during the 5-minute intervals after each EMA reading. Latent variable modeling was then used to determine whether individual differences in these associations mediated the association of PTSD symptom severity with 24-hour HRV, flow-mediated dilation, and hyperemic flow.

RESULTS

PTSD symptom severity was positively associated with NA-related autonomic arousal (β = .21, p < .001), which significantly mediated the association of PTSD symptom severity with 24-hour HRV and hyperemic flow, accounting for 62% and 34% of their associations, respectively, while overshadowing the influence of smoking, lifetime alcohol dependence, sleep duration, mean NA, and episodes of acute NA.

CONCLUSIONS

Results suggest that NA-related autonomic arousal is both a primary factor driving cardiovascular risk in PTSD and a potential point of intervention.

Heat Shock Protein Antibody Titers Are Reduced by Statin Therapy in Dyslipidemic Subjects: A Pilot Study

Antibody titers to heat shock protein (Hsp)-60 and -65 are positively related to risk of vascular disease and cardiovascular endpoints. There are few data on the factors that regulate the levels of these antibodies. It is known that the statins have antiinflammatory and immunoregulatory properties. The authors examined the effects of 2 statins, simvastatin (Zocor®) and atorvastatin (Lipitor®) on antibody titers to Hsp-60, -65, and -70 in a group of dyslipidemic patients. Twenty patients attending a lipid clinic, and previously not receiving lipid-lowering treatment, were treated with 10 mg of simvastatin (n=11) or atorvastatin (n=9) for 4 months. An additional 14 patients were recruited from the same clinic at the same hospital as a control group. The medication of these latter patients was unaltered for 4 months and the same parameters were measured as for the statin group. Antibody titers to Hsp-60, -65, and -70 were measured by enzyme-linked immunosorbent assay and lipoprotein profile and highly sensitive serum C-reactive protein (CRP) were measured by routine methods before and after treatment. Pretreatment and posttreatment data were compared by paired t or Mann-Whitney tests. Overall statin treatment was associated with a significant reduction in median antibody titers to Hsp-60 (17.2%, p=0.03), Hsp-65 (15.9%, p=0.003) and Hsp-70 (8.3%, p=0.006), but not in control patients. Both statins caused a reduction in median serum CRP concentrations (45% overall, p<0.05), but significant changes were not observed in the control patients. The effects on Hsp antibody titers were not related to changes in serum CRP concentrations (p>0.05). However, there was a significant correlation between changes in antibody titers to Hsp-60 vs Hsp-65 (p<0.01), Hsp-60 vs Hsp-70 (p<0.05), and Hsp-65 vs Hsp-70 (p<0.001). Statin treatment was associated with a reduction in antibody titers to Hsp-60, -65, and -70. This reduction is not fully explained by the antiinflammatory effects of the statins but may be due to their other immunomodulatory properties.

Extended-Release Niacin Versus Fenofibrate in HIV-Infected Participants With Low High-Density Lipoprotein Cholesterol: Effects on Endothelial Function, Lipoproteins, and Inflammation

BACKGROUND

Low levels of high-density lipoprotein cholesterol (HDL-C) are common in individuals with human immunodeficiency virus (HIV) infection, persist during antiretroviral therapy (ART), and are associated with increased cardiovascular disease (CVD) risk.

METHODS

Virologically controlled participants without CVD on stable ART with low HDL-C (men <40 mg/dL, women <50 mg/dL) and triglycerides >150 mg/dL were randomized to receive open-label extended-release niacin 1500 mg/day with aspirin 325 mg/day or fenofibrate 200 mg/day for 24 weeks. The primary endpoint was the week 24 within-arm change in brachial artery flow-mediated dilation (FMD) in participants with complete follow-up scans.

RESULTS

Of 99 participants, 74 had complete data (35 niacin, 39 fenofibrate). Median age was 45 years, 77% were male, median CD4(+) count was 561 cells/µL, and brachial FMD was 4.2%. Median HDL-C was 32 mg/dL for men and 38 mg/dL for women, low-density lipoprotein cholesterol was 103 mg/dL, and triglycerides were 232 mg/dL. In men, HDL-C increased a median of 3 mg/dL with niacin and 6.5 mg/dL with fenofibrate (P < .001 for both). In women, HDL-C increased a median of 16 mg/dL with niacin and 8 mg/dL with fenofibrate (P = .08 for both). After 24 weeks, there was no significant change in FMD in either arm; the median (interquartile range) change was +0.6% (-1.6 to 2.3) with niacin (P = .28) and +0.5% (-1.0 to 3.0) with fenofibrate (P = .19). Neither treatment significantly affected C-reactive protein, interleukin 6, or D-dimer levels.

CONCLUSIONS

Despite improvements in lipids, niacin or fenofibrate treatment for 24 weeks did not improve endothelial function or inflammatory markers in participants with well-controlled HIV infection and low HDL-C.

CLINICAL TRIALS REGISTRATION

NCT01426438.

Effects of established hypolipidemic drugs on HDL concentration, subclass distribution, and function

The knowledge of an inverse relationship between plasma high-density lipoprotein cholesterol (HDL-C) concentrations and rates of cardiovascular disease has led to the concept that increasing plasma HDL-C levels would be protective against cardiovascular events. Therapeutic interventions presently available to correct the plasma lipid profile have not been designed to specifically act on HDL, but have modest to moderate effects on plasma HDL-C concentrations. Statins, the first-line lipid-lowering drug therapy in primary and secondary cardiovascular prevention, have quite modest effects on plasma HDL-C concentrations (2-10%). Fibrates, primarily used to reduce plasma triglyceride levels, also moderately increase HDL-C levels (5-15%). Niacin is the most potent available drug in increasing HDL-C levels (up to 30%), but its use is limited by side effects, especially flushing.The present chapter reviews the effects of established hypolipidemic drugs (statins, fibrates, and niacin) on plasma HDL-C levels and HDL subclass distribution, and on HDL functions, including cholesterol efflux capacity, endothelial protection, and antioxidant properties.

Combination of peroxisome proliferator-activated receptor α/γ agonists may benefit type 2 diabetes patients with coronary artery disease through inhibition of inflammatory cytokine secretion

Patients with type 2 diabetes mellitus (T2DM) have a higher risk of cardiovascular disease (CVD). Peroxisome proliferator-activated receptors (PPARs) play an important role in the regulation of energy homeostasis. Therefore, we aimed to observe the effects of combined PPARα/γ agonists on T2DM patients with coronary artery disease (CAD). Patients were randomly divided into a rosiglitazone (RSG) group (n=20), a bezafibrate (BEZ) group (n=20), a combination of RSG and BEZ group (n=20) and a control group (n=20). Plasma C-reactive protein (CRP) and monocyte chemoattractant protein-1 (MCP-1) were measured by enzyme-linked immunosorbent assay before and 12 weeks after treatment. Fasting blood glucose (FBG), fasting insulin, insulin resistance index (IRI), hemoglobin A1c (HbA1c), lipid levels and body mass index were also investigated. At the end of the treatment, FBG, insulin, IRI, HbA1c and triglyceride levels decreased and the level of high-density lipoprotein cholesterol increased in the RSG, BEZ and combination groups. A decrease in low-density lipoprotein cholesterol was only observed in the combination group. Although the total cholesterol levels in all groups decreased, no significant difference was noted. The levels of CRP and MCP-1 were reduced in patients in the RSG, BEZ and combination groups. In addition, RSG, BEZ and the combination of RSG and BEZ also inhibited MCP-1 secretion. The combination of RSG and BEZ was more efficient than RSG or BEZ alone in downregulating cytokines. In conclusion, our results suggest that a combination of RSG and BEZ may be more efficient than RSG or BEZ alone in the treatment of T2DM patients with CAD.

Fenofibrate reduces C-reactive protein levels in hypertriglyceridemic patients with high risks for cardiovascular diseases

Background and Objectives

The effects of fenofibrate on C-reactive protein (CRP) are under debate. We investigated the effect of fenofibrate on CRP levels and the variables determining changes.

Subjects and Methods

This case-control study enrolled 280 hypertriglyceridemic patients who were managed either with 200 mg of fenofibrate (Fenofibrate group, n=140) or with standard treatment (comparison group, n=140). CRP levels were measured before and after management for 2 months.

Results

CRP levels decreased in both the fenofibrate (p=0.003) and comparison (p=0.048) groups. Changes in CRP levels were not significantly different between the two groups (p=0.27) and were negatively associated with baseline CRP levels (r=-0.47, p<0.001). In patients with a baseline CRP level ≥1 mg/L, CRP levels also decreased in both groups (p=0.000 and p=0.001 respectively), however, more in the fenofibrate group than in the comparison group (p=0.025). The reduction of CRP was associated with higher baseline CRP levels (r=-0.29, p=0.001), lower body mass index (BMI, r=0.23, p=0.007), and fenofibrate therapy (r=0.19, p=0.025). CRP levels decreased more in the fenofibrate group than in the comparison group in patients with a BMI ≤26 kg/m² with borderline significance (-1.21±1.82 mg/L vs. -0.89±1.92 mg/L, p=0.097). In patients with a high density lipoprotein-cholesterol level <40 mg/dL, CRP levels were reduced only in the fenofibrate group (p=0.006).

Conclusion

Fenofibrate reduced CRP levels in hypertriglyceridemic patients with high CRP and/or low high density lipoprotein-cholesterol levels and without severe overweight. This finding suggests that fenofibrate may have an anti-inflammatory effect in selected patients.

Increased atherothrombotic markers and endothelial dysfunction in steroid users

BACKGROUND

The use of androgenic anabolic steroids (AAS) may be associated with changes in atherothrombotic markers and endothelial function. The purpose of this study was to compare atherothrombotic markers and endothelial function of AAS users and non-users.

DESIGN

Cross-sectional study.

METHODS

Ten athletes who were users of AAS (confirmed by urine analysis) and 12 non-user athletes were evaluated. Body weight, blood pressure, exercise load (hours/week), complete blood count (CBC), platelets, fibrinogen, lipids, high-sensitivity C-reactive protein (hs-CRP), follicle-stimulating hormone, testosterone and estradiol were measured. Endothelium-dependent and independent functions were assessed by brachial artery ultrasound.

RESULTS

AAS users had higher body mass and blood pressure (p < 0.05). Platelet count was higher whereas HDL-cholesterol was lower in AAS users compared with non-users (p < 0.05). Levels of hs-CRP were higher in AAS users (p < 0.001). Follicle-stimulating hormone was suppressed in all users and not suppressed in non-users (p < 0.001). Compared with non-users, flow-mediated dilation was significantly reduced in AAS users (p = 0.03), whereas endothelium-independent function was similar in both groups. Additionally, flow-mediated dilation was positively associated with levels of HDL- cholesterol (r = 0.49, p = 0.03).

CONCLUSIONS

AAS users present important changes in blood lipids as well as in inflammatory markers, which are compatible with increased cardiovascular risk. Furthermore, this profile is accompanied by a reduction in the endothelial function.

Fenofibrate: a review of its use in dyslipidaemia

Fenofibrate is a fibric acid derivative indicated for the treatment of severe hypertriglyceridaemia and mixed dyslipidaemia in patients who have not responded to nonpharmacological therapies. The lipid-modifying effects of fenofibrate are mediated by the activation of peroxisome proliferator-activated receptor-α. Fenofibrate also has nonlipid, pleiotropic effects (e.g. reducing levels of fibrinogen, C-reactive protein and various pro-inflammatory markers, and improving flow-mediated dilatation) that may contribute to its clinical efficacy, particularly in terms of improving microvascular outcomes. Fenofibrate improves the lipid profile (particularly triglyceride [TG] and high-density lipoprotein-cholesterol [HDL-C] levels) in patients with dyslipidaemia. Compared with statin monotherapy, fenofibrate monotherapy tends to improve TG and HDL-C levels to a significantly greater extent, whereas statins improve low-density lipoprotein-cholesterol (LDL-C) and total cholesterol levels to a significantly greater extent. Fenofibrate is also associated with promoting a shift from small, dense, atherogenic LDL particles to larger, less dense LDL particles. Combination therapy with a statin plus fenofibrate generally improves the lipid profile to a greater extent than monotherapy with either agent in patients with dyslipidaemia and/or type 2 diabetes mellitus or the metabolic syndrome. In the pivotal FIELD and ACCORD trials in patients with type 2 diabetes, fenofibrate did not significantly reduce the risk of coronary heart disease events to a greater extent than placebo, and simvastatin plus fenofibrate did not significantly reduce the risk of major cardiovascular (CV) events to a greater extent than simvastatin plus placebo. However, the risk of some nonfatal macrovascular events and the incidence of certain microvascular outcomes were reduced significantly more with fenofibrate than with placebo in the FIELD trial, and in the ACCORD trial, patients receiving simvastatin plus fenofibrate were less likely to experience progression of diabetic retinopathy than those receiving simvastatin plus placebo. Subgroup analyses in the FIELD and ACCORD Lipid trials indicate that fenofibrate is of the greatest benefit in decreasing CV events in patients with atherogenic dyslipidaemia. Fenofibrate is generally well tolerated when administered alone or in combination with a statin. Thus, in patients with dyslipidaemia, particularly atherogenic dyslipidaemia, fenofibrate is a useful treatment option either alone or in combination with a statin.

Short-term effect of fenofibrate on C-reactive protein: A meta-analysis of randomized controlled trials

BACKGROUND

C-reactive protein (CRP) is positively associated with risk for cardiovascular disease and all-cause mortality. Some but not all randomized and non-randomized clinical trials found significant associations between fenofibrate therapy and CRP but the direction and magnitude of the association varied across studies. The duration of treatment, patient populations and sample sizes varied greatly, and most short-term studies (i.e., ≤ 12 weeks) had fewer than 50 patients. In this study we meta-analyzed randomized clinical trials to determine the short-term effect of fenofibrate on CRP.

METHODS

Two reviewers independently searched PubMed and other online databases for short-term randomized clinical trials that reported CRP concentrations before and after fenofibrate treatment. Of the 81 studies examined, 14 studies with 540 patients were found eligible. Data for the change in CRP and corresponding measures of dispersion were extracted for use in the meta-analysis.

RESULTS

The weighted mean CRP concentrations before and after fenofibrate therapy were 2.15 mg/L and 1.53 mg/L (-28.8% change), respectively. Inverse-variance weighted random effects meta-analysis revealed that short-term fenofibrate treatment significantly lowers CRP by 0.58 mg/L (95% CI: 0.36-0.80). There was significant heterogeneity between studies (Q statistic = 64.5, P< 0.0001, I2 = 79.8%). There was no evidence of publication bias and sensitivity analysis revealed that omitting any of the 14 studies did not lead to a different conclusion from the overall meta-analysis result.

CONCLUSION

Short-term treatment with fenofibrate significantly lowers CRP concentration. Randomized trials that will recruit patients based with high baseline CRP concentrations and with change in CRP as a primary outcome are needed.

Synthesis and biological evaluation of orally active hypolipidemic agents

A series of novel fenofibric acid ester prodrugs 1c-1h were synthesized and evaluated with the aim of obtaining potent hypolipidemic agents. Prodrugs 1c and 1d exhibited potent hypochlolesterolemic activity, lowering the mice plasma triglyceride level up to 47% in Swiss albino mice after oral administration of 50 mg/kg/day for 8 days. Fenofibric acid ester prodrugs 1c-1h were found lipophilic like fenofibrate (1b), indicated by partition coefficients measured in octanol-buffer system at pH 7.4. On the basis of in vivo studies, prodrugs 1c and 1d emerged as potent hypolipidemic agents.

Fenofibrate: a review of its lipid-modifying effects in dyslipidemia and its vascular effects in type 2 diabetes mellitus

Fenofibrate is a fibric acid derivative with lipid-modifying effects that are mediated by the activation of peroxisome proliferator-activated receptor-α. Fenofibrate also has a number of nonlipid, pleiotropic effects (e.g. reducing levels of fibrinogen, C-reactive protein, and various pro-inflammatory markers, and improving flow-mediated dilatation) that may contribute to its clinical efficacy, particularly in terms of improving microvascular outcomes. The beneficial effects of fenofibrate on the lipid profile have been shown in a number of randomized controlled trials. In primary dyslipidemia, fenofibrate monotherapy consistently decreased triglyceride (TG) levels to a significantly greater extent than placebo; significantly greater increases in high-density lipoprotein cholesterol (HDL-C) levels and significantly greater reductions in low-density lipoprotein cholesterol (LDL-C) and total cholesterol (TC) levels were also seen in some trials. Monotherapy with fenofibrate or gemfibrozil had generally similar effects on TG and HDL-C levels, although in one trial, TC and LDL-C levels were reduced to a significantly greater extent with fenofibrate than with gemfibrozil. Fenofibrate monotherapy tended to improve TG and HDL-C levels to a significantly greater extent than statin monotherapy in primary dyslipidemia, whereas statin monotherapy decreased LDL-C and TC levels to a significantly greater extent than fenofibrate monotherapy. Fenofibrate also had a beneficial effect on atherogenic dyslipidemia in patients with the metabolic syndrome or type 2 diabetes mellitus, reducing TG levels, tending to increase HDL-C levels, and promoting a shift to larger low-density lipoprotein particles. In terms of cardiovascular outcomes, fenofibrate did not reduce the risk of coronary heart disease (CHD) events to a greater extent than placebo in patients with type 2 diabetes in the FIELD trial. However, the risk of some nonfatal macrovascular events (e.g. nonfatal myocardial infarction, revascularization) and certain microvascular outcomes (e.g. amputation, first laser therapy for diabetic retinopathy, progression of albuminuria) was reduced to a significantly greater extent with fenofibrate than with placebo. Subgroup analysis revealed a significant reduction in the cardiovascular disease (CVD) event rate among fenofibrate recipients in the subgroup of patients with marked hypertriglyceridemia or marked dyslipidemia at baseline. In the ACCORD Lipid trial, there were no significant differences between patients with type 2 diabetes and a high risk of CVD events who received fenofibrate plus simvastatin and those who received placebo plus simvastatin for any of the primary or secondary cardiovascular outcomes. However, fenofibrate plus simvastatin was of benefit in patients who had markedly high TG levels and markedly low HDL-C levels at baseline. In addition, fenofibrate plus simvastatin slowed the progression of diabetic retinopathy. Fenofibrate is generally well tolerated. Common adverse events included increases in transaminase levels that were usually transient, minor, and asymptomatic, and gastrointestinal signs and symptoms. In conclusion, monotherapy with fenofibrate remains a useful option in patients with dyslipidemia, particularly in atherogenic dyslipidemia characterized by high TG and low HDL-C levels.

Effect of statin and fibrate treatment on inflammation in type 2 diabetes. A randomized, cross-over study

A randomized, crossover study compared the effects of atorvastatin, gemfibrozil and their combination on inflammatory markers in type 2 diabetes. C-reactive protein (CRP), lipoprotein-associated phospholipase A2 (Lp-PLA2), secretory phospholipase A2 (sPLA2), interleukin 8 (IL8), monocyte chemotactic protein 1 (MCP1) and tumor necrosis factor α (TNFα) were measured. Both lipid-lowering drugs had positive, complementary and additive effects on inflammatory markers, which were closely related to baseline inflammatory status.

The peroxisome proliferator-activated receptor α agonist fenofibrate decreases airway reactivity to methacholine and increases endothelial nitric oxide synthase phosphorylation in mouse lung

In the present study, we have investigated the effect of the peroxisome proliferator-activated receptor α (PPARα) agonist fenofibrate on airway reactivity and the role of the endothelial nitric oxide synthase (eNOS)/NO pathway in this effect. Airway reactivity to methacholine was assessed in C57BL/6 mice treated or not with fenofibrate by whole-body plethysmography. In some experiments, animals were administered with the NOS inhibitor L-NAME, one hour before airway reactivity measurement. Expression and phosphorylation of eNOS were evaluated in lung homogenates from fenofibrate and control animals using Western blotting. Fenofibrate dose and time dependently decreased airway reactivity to methacholine in mice. A statistically significant (P < 0.05) reduction was observed after a treatment of 10 days with a dose of 3 or 15 mg/day fenofibrate. Mice treated with fenofibrate and administered with l-NAME exhibited similar reactivity to methacholine than vehicle-treated mice administered with the NOS inhibitor, suggesting that NO mediates fenofibrate-induced decrease in airway reactivity. eNOS levels remained unchanged in the lung from mice treated with fenofibrate, but phosphorylation of the enzyme at Ser-1177 was increased by 118% (P < 0.05). Taken together, our data demonstrate that fenofibrate downregulates airway reactivity to methacholine in the mouse and suggest that this effect could involve an increase in NO generation through an enhanced eNOS phosphorylation.

Effect of bezafibrate on monocyte cytokine release and systemic inflammation in patients with impaired fasting glucose

This study assessed the effect of bezafibrate on monocyte secretory function and systemic inflammation in patients with impaired fasting glucose (IFG), comparing this effect with that produced by bezafibrate in mixed dyslipidemic subjects. The study included 28 patients with IFG, 29 individuals with mixed dyslipidemia, and 24 age-, sex- and weight-matched control subjects without lipid and glucose metabolism abnormalities. Compared with the control group, in both IFG and mixed dyslipidemic subjects, monocyte release of monocyte chemoattractant protein-1 (MCP-1), interleukin-6, tumor necrosis factor-α (TNF-α), and interleukin-1β was increased, which was accompanied by higher plasma levels of high-sensitivity C-reactive protein (hsCRP). Despite affecting plasma lipids in both treatment groups, bezafibrate administration (200 mg twice daily for 90 days) reduced fasting plasma glucose levels, the homeostasis model assessment index, and glycated hemoglobin only in IFG subjects. Bezafibrate treatment normalized monocyte release of MCP-1, interleukin-6, TNF-α, and interleukin-1β and also normalized plasma hsCRP levels in mixed dyslipidemic subjects, whereas in IFG individuals the drug reduced only MCP-1 and interleukin-6 release. This study shows that IFG is associated with the presence of systemic inflammation and abnormal monocyte secretory function. Compared with patients with mixed dyslipidemia, IFG patients who are administered bezafibrate experience a stronger effect on glucose metabolism and weaker anti-inflammatory and monocyte-suppressing actions.

Clinical significance of high-sensitivity C-reactive protein in cardiovascular disease

Large-scale prospective cohort studies consistently demonstrate a strong, independent relationship between high-sensitivity (hs) C-reactive protein (CRP) and incident cardiovascular events, with a magnitude of effect similar to, or larger than, that of blood pressure and lipid levels. As a biomarker of inflammation, hsCRP levels also predict incident Type 2 diabetes and modify the risk associated with the metabolic syndrome. Recent work further demonstrates that the addition of hsCRP to information provided by traditional risk factors improves risk classification, particularly for individuals otherwise considered to be at intermediate risk. Although there remains no direct evidence that lowering hsCRP lowers vascular risk, optimal clinical outcomes have been observed in statin trials among patients who not only reduced low-density lipoprotein cholesterol below 1.8 mmol/l (70 mg/dl), but who also reduced hsCRP below 2 mg/l. In addition to statins, CRP levels are lowered by diet, exercise and smoking cessation, all of which are known to lower vascular event rates. Whether or not CRP represents a causal agent in atherosclerosis is controversial and an area in need of further research. However, this controversy does not diminish the clinical utility of hsCRP as a biomarker of risk that, if appropriately used in clinical practice, can substantially improve clinical care.

Enhanced levels of soluble CD40 ligand and C-reactive protein in a total of 312 patients with metabolic syndrome

The metabolic syndrome (MS) is associated with a systemic inflammatory response that plays an important pathogenetic role in atherothrombotic disease. Increasing evidence indicates that CD40-CD40 ligand interactions constitute an important mediator for vascular inflammation. The purpose of this study was to assess whether high-sensitivity C-reactive protein (hs-CRP) and soluble CD40 ligand (sCD40L) levels were increased in patients with MS. During the study period from January 2004 to August 2004, 312 patients with MS and 98 control subjects were included. Anthropometric measurements, blood pressure assessment, electrocardiography, and blood measurements including fasting blood glucose, postprandial blood glucose, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglyceride, glycated hemoglobin, white blood cell (WBC), platelets, hs-CRP, and sCD40L were performed. Patients with MS were divided into 3 groups based upon their glucose tolerance (group 1, normal glucose tolerance; group 2, prediabetic group; and group 3, diabetes mellitus). Patients with MS showed a significant increase of WBC, hs-CRP, and sCD40L levels compared with control subjects. The levels of both hs-CRP and sCD40L were positively correlated with body mass index (BMI). High-sensitivity CRP levels were also positively correlated with waist circumferences, fasting blood glucose, postprandial blood glucose, and glycated hemoglobin, and negatively correlated with high-density lipoprotein cholesterol. In patients with MS, both hs-CRP and sCD40L levels were positively correlated with WBC count. We found a positive correlation between sCD40L and platelets. Among the subgroups of patients with MS, the mean levels of WBC, hs-CRP, and sCD40L did not show any significant differences. In conclusion, elevated levels of WBC, hs-CRP, and sCD40L in MS patients provide further insight into the relationship between MS and inflammation. In our study, positive correlations between BMI and both hs-CRP and sCD40L levels suggest that BMI is an important determinant of a chronic inflammatory state in patients with MS. Moreover, this study reports significantly increased levels of WBC, hs-CRP, and sCD40L not only in diabetic subjects with MS but also in prediabetic subjects and nondiabetic subjects with MS compared with control subjects. Our data suggest that MS patients have proinflammatory state independent of their glucose tolerance status. In our study, the positive correlation between the levels of sCD40L and platelets in patients with MS supports previous reports indicating that sCD40L are derived predominantly from platelets.

Blood pressure-lowering effects of statins: who benefits?

OBJECTIVES

To evaluate if the effect of statins on blood pressure is similar in patients grouped by use of antihypertensive medication, level of blood pressure, and high-density lipoprotein cholesterol (HDL-C).

METHODS

Blood pressure was compared in statins users (n = 995) and nonusers (n = 9536) from the National Health and Nutrition Examination Surveys. The overall effect of statins and their interactions with antihypertensive medication, blood pressure, and HDL-C were estimated using multiple linear and quantile regression.

RESULTS

Adjusted systolic blood pressure was on average 1.8 mmHg lower in statins users than in nonusers (P = 0.05). Although statins had no significant effect among nonusers, it decreased systolic blood pressure by 3.3 mmHg among users of antihypertensive medication (interaction P = 0.02). The effect of statins on systolic blood pressure was similar in individuals with HDL-C levels above and below the median (49 mg/dl). Statins also lowered diastolic blood pressure by an average of 1.9 mmHg (P < 0.01), regardless of antihypertensive medication use. Among individuals with high HDL-C statins did not lower diastolic blood pressure, whereas in those with low HDL-C diastolic blood pressure was reduced by 3.4 mmHg. The effect of statins on systolic and diastolic blood pressure increased with higher blood pressure and changed little with adjustment for total cholesterol.

CONCLUSION

Statins lower blood pressure by cholesterol-independent mechanisms, and the reduction is larger in individuals with higher blood pressure and those with low HDL-C. Statins may be beneficial in preventing hypertension and may contribute to better blood pressure control in hypertensive patients.

The Effect of Ciprofibrate on Flow-Mediated Dilation and Inflammatory Markers in Patients with Combined Hyperlipidemia

Impairment of flow-mediated dilation (FMD) has been shown to be associated with hypercholesterolemia and hypertriglyceridemia and reduction of cholesterol and/or triglyceride levels can improve FMD. In hyperlipidemia the role of inflammatory substances on endothelial function requires further clarification. In patients with combined hyperlipidemia (n = 29), the capacity of FMD was weaker whereas the levels of interleukin (IL)-lalpha, tumor necrosis factor alpha (TNFalpha), soluble intercellular adhesion molecule (sICAM), and fibrinogen were higher compared to normolipemic controls with normal FMD adjusted for age and sex. Patients were randomized to a diet-only or to a ciprofibrate treatment group. After 8 weeks FMD levels rose significantly both in the diet-only (10.2%) and the ciprofibrate treatment (79.4%) groups. In the diet-only group improvement of FMD was significantly associated with the reduction of triglyceride (by 15.9%) and cholesterol (6.9%) levels. The much larger improvement of FMD due to ciprofibrate therapy was accompanied by significant reductions of cholesterol (by 14.4%), fibrinogen, IL-1alpha, and sICAM levels and by significant increase of high-density lipoprotein (HDL) cholesterol concentration, but the change in FMD correlated only with the reduction of the cholesterol level. In line with previous data the authors emphasize that improvement of FMD in patients with combined hyperlipidemia treated with diet and/or ciprofibrate is linked directly to the reduction of cholesterol and triglyceride concentrations rather than to changes in the level of the investigated inflammatory markers.

Plasma-soluble CD40 is related to cholesterol metabolism in patients with moderate hypercholesterolemia

OBJECTIVES

CD40 is a marker of immunological activation and is expressed in the atherosclerotic lesions. We studied whether CD40 and cholesterol synthesis pathways are associated with each other.

DESIGN

Forty-three subjects were randomly assigned to receive either simvastatin (n = 14), atorvastatin (n = 15), or placebo (n = 14) for eight weeks. Plasma samples were obtained before and at the end of the follow-up. sCD40 levels were measured in duplicate using an enzyme-linked immunosorbent assay. Cholesterol, its precursor lathosterol, the plant sterols campesterol and sitosterol as well as 27-hydroxycholesterol were quantified by gas-liquid chromatography-mass spectrometry.

RESULTS

sCD40 was inversely correlated with the lathosterol to cholesterol ratio (r = - 0.47, p = 0.002), an indicator of cholesterol synthesis rate, as well as apolipoprotein A-I (r = - 0.38, p = 0.01) in addition to being directly correlated with 27-hydroxycholesterol (r = 0.40, p = 0.008). In multivariate linear regression analysis these three predictors explained 37% of the total variability of sCD40 levels. Simvastatin or atorvastatin treatment had no significant effect on sCD40 levels.

CONCLUSION

These results indirectly suggest that sCD40 concentrations are related to cellular cholesterol levels. This may be a novel indication for the relationship between immunological processes and cholesterol metabolism.

Lipids, lipid modifying agents and cardiovascular risk: a review of the evidence

It is well-established that serum total-cholesterol, LDL-cholesterol, low HDL-cholesterol and calculated indices such as total cholesterol:HDL-cholesterol ratio or less commonly used indices such as non-HDL cholesterol are strongly predictive of cardiovascular events. Serum triglycerides, by contrast, are only modestly associated with coronary heart disease (CHD) in multivariate analysis and incorporation of triglycerides into prediction algorithms is therefore unlikely to improve their prediction capability. Meta-analysis of studies including > 90,000 subjects has provided robust evidence that statins reduce important clinical end-points. These included a 12% fall in all-cause mortality, 19% fall in CHD mortality and 23% fall in CHD mortality or myocardial infarction. Furthermore there are high quality data showing additional benefit of intensive statin therapy over standard statin therapy for secondary prevention of cardiovascular disease. However, meta-analysis of 10 fibrate trials has shown inconsistent evidence of vascular benefit and non-cardiovascular mortality has been slightly but consistently elevated in most fibrate trials and in meta-analysis. The general use of fibrates for cardiovascular risk reduction can therefore not be supported at present. Other second line agents such as bile acid sequestrants, nicotinic acid and omega-3 fatty acid supplements have been evaluated in a few randomized controlled studies in which cardiovascular benefit has been found but clearly further data are required to properly establish their use in clinical practice. Ongoing studies such as ACCORD, IMPROVE-IT, ASCEND, ORIGIN and HPS2-THRIVE should assist in answering outstanding questions over the next 5 years.

Flow-mediated vasodilatation: variation and interrelationships with plasma lipids and lipoproteins

OBJECTIVE

Endothelial dysfunction is a critical, prerequisite step in atherosclerosis, and may be evaluated by flow-mediated vasodilatation (FMD). The objective of this study was to examine interrelationships between FMD and plasma lipids and lipoproteins, and to determine the between-operator and within-subject variability associated with this technique.

MATERIAL AND METHODS

FMD, plasma lipids and lipoproteins, including small dense LDL (sdLDL), were measured twice in 40 healthy volunteers, 4 weeks apart. Interrelationships between mean FMD responses and plasma lipids and lipoproteins were examined by correlation analysis. FMD measurements were taken by two independent operators, allowing determination of between-operator variability. Within-subject variability was determined by obtaining two measurements, 4 weeks apart, in every subject, and carried out by the same operator.

RESULTS

FMD was inversely related to plasma triglycerides (r = -0.47, p = 0.002), total cholesterol/HDL cholesterol (r = -0.35, p = 0.03) and apolipoprotein B (r = -0.36, p = 0.02), but not to other plasma lipids and lipoproteins. When measuring variation in FMD, the following results were found: Between operators (SD = 4.0 FMD%) and within subjects (SD = 2.9 FMD%).

CONCLUSIONS

The associations between FMD, plasma triglycerides and apoB provide evidence supporting a role for triglyceride-rich lipoproteins in endothelial dysfunction.

Long-term effects of fenofibrate on carotid intima-media thickness and augmentation index in subjects with type 2 diabetes mellitus

OBJECTIVES

The aim of this substudy was to ascertain whether long-term treatment with fenofibrate reduces surrogate measures of atherosclerosis, biomarkers of inflammation, and endothelial activation in patients with type 2 diabetes.

BACKGROUND

Some fibrates may decrease cardiovascular events, improve endothelial function, and reduce levels of acute-phase proteins. In the FIELD (Fenofibrate Intervention and Event Lowering in Diabetes) study, fenofibrate failed to decrease the primary end point of coronary events in patients with type 2 diabetes.

METHODS

A total of 170 patients with type 2 diabetes of the FIELD Helsinki cohort were randomly assigned to micronized fenofibrate 200 mg/day or placebo in a double-blind design. Carotid intima-media thickness (IMT) and the augmentation index (a measure of large artery stiffness) were measured at baseline and at second- and fifth-year visits. Plasma levels of interleukin (IL)-6, C-reactive protein (CRP), serum amyloid A (SAA), secretory phospholipase A2 IIA (SPLA2), E-selectin, vascular cellular adhesion molecule (VCAM)-1, and intercellular adhesion molecule (CAM)-1 were determined by commercial enzyme-linked immunosorbent assay kits at the same visits.

RESULTS

IMT and the augmentation index increased similarly in both treatment groups during the study. Plasma levels of CRP, IL-6, SPLA2, SAA, VCAM-1, ICAM-1, and E-selectin remained unchanged in both groups.

CONCLUSIONS

Fenofibrate treatment was not associated with beneficial changes in IMT, augmentation index, or biomarkers of inflammation and endothelial function. (Fenofibrate Intervention and Event Lowering in Diabetes; NCT00132886).

Treatment of hyperlipidaemia with fenofibrate and related fibrates

BACKGROUND

Fenofibrate is the most widely used fibrate. Its efficacy and tolerability in the treatment of hypertriglyceridaemia and combined hyperlipidaemia have been demonstrated in several clinical trials.

OBJECTIVE

To review the pharmacology, lipid-lowering and extra-lipid effects of fenofibrate and to preview ABT-335, an investigational new fenofibric acid molecule.

RESULTS

The effects of fenofibrate are mediated through the active metabolite fenofibric acid, and are described in detail in the paper. ABT-335 is a salt of fenofibric acid and, unlike fenofibrate, does not require first pass metabolism to the active moiety. ABT-335 is being developed for combination use with statins, and has recently completed three large Phase III randomised controlled trials in which the efficacy and safety of ABT-335 in combination with the three most commonly prescribed statins, atorvastatin, simvastatin and rosuvastatin, was evaluated in patients with mixed dyslipidaemia.

CONCLUSION

ABT-335 in combination with statins may provide a safe and efficacious treatment modality that enables achievement of several therapeutic goals in patients with mixed dyslipidaemia who have high cardiovascular risk.

The Role of PPARs in the Endothelium: Implications for Cancer Therapy

The growth and metastasis of cancers intimately involve the vasculature and in particular the endothelial cell layer. Tumours require new blood vessel formation via angiogenesis to support growth. In addition, inflammation, coagulation, and platelet activation are common signals in the growth and metastasis of tumour cells. The endothelium plays a central role in the homeostatic control of inflammatory cell recruitment, regulating platelet activation and coagulation pathways. PPARalpha, -beta/delta, and -gamma are all expressed in endothelial cells. This review will discuss the roles of PPARs in endothelial cells in relation to angiogenesis, inflammation, coagulation, and platelet control pathways. In particular, we will discuss the recent evidence that supports the hypothesis that PPARalpha and PPARgamma are antiangiogenic receptors, while PPARbeta/delta is proangiogenic.

Activation of peroxisome proliferator-activated receptor-alpha in mice induces expression of the hepatic low-density lipoprotein receptor

Background and purpose:

Mutations in the low-density lipoprotein receptor (LDLR) gene cause familial hypercholesterolaemia in humans and deletion of the LDLR induces lesion development in mice fed a high-fat diet. LDLR expression is predominantly regulated by sterol regulatory element-binding protein 2 (SREBP2). Fenofibrate, a peroxisome proliferator-activated receptor α (PPARα) ligand, belongs to a drug class used to treat dyslipidaemic patients. We have investigated the effects of fenofibrate on hepatic LDLR expression.

Experimental approach:

The effects of fenofibrate on hepatic LDLR expression (mRNA and protein) and function were evaluated by both in vitro (with AML12 cells) and in vivo experiments in mice.

Key results:

Fenofibrate increased LDLR expression and LDL binding in a mouse hepatoma cell line, AML12 cells. Fenofibrate restored sterol-inhibited hepatocyte LDLR expression. Mechanistic studies demonstrated that induction of LDLR expression by fenofibrate was dependent on PPARα and sterol regulatory elements (SRE). Specifically, fenofibrate induced LDLR expression by increasing maturation of SREBP2 and phosphorylation of protein kinase B (Akt) but had no effect on SREBP cleavage-activating protein. In vivo, a high-fat diet suppressed LDLR expression in mouse liver while elevating total and LDL cholesterol levels in plasma. However, fenofibrate restored LDLR expression inhibited by high-fat diets in the liver and reduced LDL cholesterol levels in plasma.

Conclusions and implications:

Our data suggest that fenofibrate increased hepatic LDLR expression in mice by a mechanism involving Akt phosphorylation and LDLR gene transcription mediated by SREBP2.

Beyond high-density lipoprotein cholesterol levels evaluating high-density lipoprotein function as influenced by novel therapeutic approaches

A number of therapeutic strategies targeting high-density lipoprotein (HDL) cholesterol and reverse cholesterol transport are being developed to halt the progression of atherosclerosis or even induce regression. However, circulating HDL cholesterol levels alone represent an inadequate measure of therapeutic efficacy. Evaluation of the potential effects of HDL-targeted interventions on atherosclerosis requires reliable assays of HDL function and surrogate markers of efficacy. Promotion of macrophage cholesterol efflux and reverse cholesterol transport is thought to be one of the most important mechanisms by which HDL protects against atherosclerosis, and methods to assess this pathway in vivo are being developed. Indexes of monocyte chemotaxis, endothelial inflammation, oxidation, nitric oxide production, and thrombosis reveal other dimensions of HDL functionality. Robust, reproducible assays that can be performed widely are needed to move this field forward and permit effective assessment of the therapeutic potential of HDL-targeted therapies.

Effect of rosuvastatin on capillary filtration of albumin and blood pressure in rats with streptozotocin-induced diabetes

An increase in capillary filtration of albumin (CFA) is well demonstrated in diabetes. Statins may exert a protective effect against endothelial dysfunction. The aim of this study was to test whether rosuvastatin may prevent the increase in peripheral CFA in diabetic rats and the role of blood pressure lowering. Rats with streptozotocin-induced diabetes were randomized to receive either rosuvastatin 20mg/kg/d (group R) or both rosuvastatin 20mg/kg/d and mevalonate 20mg/kg/d (group RM) or no treatment (group U). CFA index was measured on a limb by a non-invasive isotopic test using technetium-labelled albumin, at three time points: at mean age of 3 months, before treatment; at 5 and 8 months, i.e. after 2 and 5 months of treatment. At 3 months, interstitial albumin retention (AR) was markedly increased in the 3 groups. From 3 to 5 months, AR increased significantly in group U, decreased in group R and in group RM. At 5 and 8 months, AR was significantly lower in groups R and RM than in group U. Systolic blood pressure (SBP) was measured at 8 months and was significantly lower in group R than in group U and RM. At 8 months, serum cholesterol levels were not different between the three groups whereas triglycerides were significantly lower in groups R and RM than in group U. In conclusion, in diabetic rats rosuvastatin prevents the increase in peripheral CFA and induces a decrease in blood pressure. The beneficial effect of rosuvastatin on endothelial function does not seem to result from blood pressure reduction nor lipid lowering effects.

Reduction in blood pressure with statins: results from the UCSD Statin Study, a randomized trial

BACKGROUND

Some studies have suggested reductions in blood pressure (BP)with statin treatment, particularly in persons with hypertension. Randomized trial evidence is limited.

METHODS

We performed a randomized, double-blind, placebo-controlled trial with equal allocation to simvastatin, 20 mg; pravastatin sodium,40 mg; or placebo for 6 months. Nine hundred seventy-three men and women without known cardiovascular disease or diabetes mellitus, with low-density lipoprotein cholesterol screening levels of 115 to 190 mg/dL, had assessment of systolic and diastolic BP (SBP and DBP, respectively). Blood pressure values were compared for placebo vs statins by intention-to-treat (ITT) analysis. Additional analyses were performed that (1) were confined to subjects with neither high baseline BP (SBP>140 mm Hg or DBP>90 mm Hg) nor receiving BP medications, to exclude groups in whom BP medications or medication changes may have influenced results, and (2) separately evaluated simvastatin and pravastatin (vs placebo). The time course of BP changes after statin initiation and the effect of stopping statins on BP were examined.

RESULTS

Statins modestly but significantly reduced BP relative to placebo,by 2.2 mm Hg for SBP (P=.02) and 2.4 mm Hg for DBP (P<.001) in ITT analysis. Blood pressure reductions ranged from 2.4 to 2.8 mm Hg for both SBP and DBP with both simvastatin and pravastatin, in those subjects with full follow-up, and without potential for influence by BP medications (ie, neither receiving nor meriting BP medications).

CONCLUSIONS

Reductions in SBP and DBP occurred with hydrophilic and lipophilic statins and extended to normotensive subjects. These modest effects may contribute to the reduced risk of stroke and cardiovascular events reported on statins. Trial Registration clinicaltrials.gov Identifier: NCT00330980.

Effects of antidiabetic and antihyperlipidemic agents on C-reactive protein

Type 2 diabetes mellitus (DM) increases the risk of cardiovascular disease, a major cause of morbidity and mortality. Central to type 2 DM is insulin resistance, a proinflammatory, hypercoagulable state that predisposes patients to develop cardiovascular disease and that is associated with risk factors for atherosclerosis including dyslipidemia, hypertension, inflammation, and altered hemostasis. Atherosclerosis is recognized as a chronic inflammatory disease of the arteries. C-reactive protein (CRP) is an acute-phase response protein that is considered both a marker of inflammation and a predictor of cardiovascular events including myocardial infarction, stroke, peripheral arterial disease, and sudden cardiac death. Evidence indicates that CRP has a direct proatherogenic effect through up-regulation of angiotensin II type 1 receptors and through the stimulation of other proinflammatory factors. Patients with type 2 DM tend to have higher CRP concentrations than do those without it, suggesting an increased role of inflammation in the accelerated atherosclerosis seen in these patients. Reducing CRP concentrations through lifestyle changes or pharmacotherapeutics could have clinical benefit; long-term studies are needed to determine whether reductions in CRP concentrations translate into improved cardiovascular outcomes. Because glucose and lipid levels as well as CRP concentrations are often elevated in patients with type 2 DM, an agent that positively affects multiple cardiovascular risk factors would be most beneficial. This article reviews available data on antidiabetic and antihyperlipidemic agents that reduce CRP concentrations in addition to their primary effect of lowering glucose or lipid levels.

Vascular and metabolic effects of treatment of combined hyperlipidemia: focus on statins and fibrates

Combined hyperlipidemia results from overproduction of hepatically synthesized apolipoprotein B in very low-density lipoproteins in association with reduced lipoprotein lipase activity. Thus, this condition is typically characterized by concurrent elevations in total cholesterol and triglycerides with decreased high-density lipoprotein cholesterol. High levels of apolipoprotein B-containing lipoproteins, most prominently carried by low-density lipoprotein (LDL) particles, are an important risk factor for coronary heart disease. Statin therapy is highly effective at lowering LDL cholesterol. Despite the benefits of statin treatment for lowering total and LDL cholesterol, many statin-treated patients still have initial or recurrent coronary heart disease events. In this regard, combined therapy with statins and fibrates is more effective in controlling atherogenic dyslipidemia in patients with combined hyperlipidemia than either drug alone. Furthermore, statins and fibrates activate PPARalpha in a synergistic manner providing a molecular rationale for combination treatment in coronary heart disease. Endothelial dysfunction associated with cardiovascular diseases may contribute to insulin resistance so that there may also be additional beneficial metabolic effects of combined statin/fibrates therapy. However, there has been little published evidence that combined therapy is synergistic or even better than monotherapy alone in clinical studies. Therefore, there is a great need to study the effects of combination therapy in patients. When statins are combined with gemfibrozil therapy, this is more likely to be accompanied by myopathy. However, this limitation is not observed when fenofibrate, bezafibrate, or ciprofibrate are used in combination therapy.

Fenofibrate reduces fasting and postprandial inflammatory responses among hypertriglyceridemia patients with the metabolic syndrome

OBJECTIVE

To examine the effects of fenofibrate (160mg/d) therapy on fasting and postprandial cytokine production in subjects with metabolic syndrome and hypertriglyceridemia.

RESEARCH DESIGN AND METHODS

Randomized, double-blind, controlled trial that compared the effects of 3-month therapy with placebo and fenofibrate on fasting and postprandial cytokine production in 55 subjects with metabolic syndrome and elevated fasting triglycerides (>or=1.7 and <6.78mmol/L).

RESULTS

Fenofibrate treatment reduced concentrations of monohydroxy fatty acids (OH-FA) by 15.5% (p=0.001), lipopolysaccharide activated monocyte chemotactic protein-1 (MCP-1/CCL2) production in fasting blood samples by 3.4% (p=0.01 vs. placebo), macrophage inflammatory protein-1alpha (MIP-1alpha/CCL3) by 3.5% (p=0.01), and interleukin-1beta (IL-1beta) by 2.5% (p=0.04). After a standardized fat load (50kg/m(2)), OH-FA were reduced by 31.0% (p<0.0001), MCP-1/CCL2 was reduced by 5.2% (p=0.002), MIP-1alpha/CCL3 by 3.9% (p=0.007), and IL-1beta by 3.4% (p=0.02). Reductions in MCP-1/CCL2, MIP-1alpha/CCL3, and IL-1beta production correlated with changes in fasting and postprandial large very low-density lipoprotein (VLDL) (all p<0.005) and small low-density lipoprotein (LDL) particles (all p<0.05). In stepwise regression models that included age, gender, weight change, and drug assignment, large VLDL particles were associated with reductions in postprandial MCP-1/CCL2 (p=0.042), MIP-1alpha/CCL3 (p=0.003), and IL-1beta (p=0.02).

CONCLUSIONS

This study reports that fenofibrate reduces whole blood production of inflammatory cytokines and hepatic-synthesized inflammatory proteins, and the anti-inflammatory effects of fenofibrate therapy involve VLDL- and LDL-mediated pathways.

Effect of fenofibrate therapy on paraoxonase1 status in patients with low HDL-C levels

OBJECTIVES

We evaluated the effect of micro-coated fenofibrate on lipid parameters, high sensitivity C-reactive protein and paraoxonase1 levels in dyslipidemic patients with low high-density lipoproteins levels. In addition, the effects of the paraoxonase1 polymorphisms on lipid and paraoxonase1 responses to fenofibrate therapy were examined.

METHODS

A total of 61 dyslipidemic patients with low high-density lipoproteins levels were recruited into this study to receive micro-coated fenofibrate (160 mg/day) for 12 weeks. Lipid parameters, C-reactive protein, paraoxonase1 concentration and activity were measured at baseline and after 6 and 12 weeks of fenofibrate treatment. Four polymorphisms in both the coding (L55M and Q192R) and regulatory regions (T-108C and G-909C) of human paraoxonase1 were also quantified.

RESULTS

Micro-coated fenofibrate significantly decreased total cholesterol, triglycerides, non-high-density lipoprotein cholesterol, oxidized low-density lipoprotein and apolipoprotein-B levels after 6 and 12 weeks (all p<0.001). While high-density lipoprotein and apolipoprotein AI levels were significantly increased by 14.7% and 6.9%, respectively, after 6 weeks and by 17.3% and 7.2%, respectively, after 12 weeks (all p<0.01). There were no significant differences in the mean of low-density lipoprotein and C-reactive protein after fenofibrate treatment. There were significant increases in paraoxonase1 concentration and activity by 7.7% and 5.7% after 6 weeks and by 14.6% and 10.1% after 12 weeks, respectively (all p<0.01). After micro-coated fenofibrate therapy, a significantly positive correlation between the change in high-density lipoprotein and the changes in paraoxonase1 concentration and activity was observed (p=0.001). On the other hand, the changes in paraoxonase1 activity were significantly and negatively correlated with the changes in triglycerides (p=0.007). The therapeutic response of lipid parameters to micro-coated fenofibrate was independent of paraoxonase1 polymorphisms. However, paraoxonase1 Q192R and T-108C polymorphisms significantly affected the increase in paraoxonase1 activity (the highest increase in 192QQ and -108TT) and paraoxonase1 concentration (the highest increase in -108TT).

CONCLUSION

Lipid-modifying therapy with micro-coated fenofibrate in patients with low high-density lipoprotein levels not only reduced atherogenic lipids (total cholesterol, triglycerides, oxidized low-density lipoprotein and apolipoprotein-B) and increased atheroprotective lipids but also increased paraoxonase1 concentration and activity. Increasing paraoxonase1 levels by fenofibrate may play an important role in decreasing low-density lipoprotein oxidation.

CD40/CD40L system and vascular disease

Several distinct lines of investigation in the context of atherosclerosis dealing with low-grade inflammation, oxidative stress and platelet activation are now emerging, with CD40/CD40L system as the missing link. CD40 ligand is a transmembrane glycoprotein structurally related to tumour necrosis factor-alpha and more than 95% of the circulating CD40L derives from platelets. CD40L appears as a multiplayer of several cell types in the inflammatory network. The peculiarity of CD40L as an inflammatory mediator derived from platelets expands the functional repertoire of platelets from players of haemostasis and thrombosis to powerful amplifiers of inflammation by promoting the release of cytokines and chemokines, cell activation and cell-cell interactions. The multifunctional role of CD40L, as a simultaneous activator of all these systems, further blurs the intricate relationship between such events both in the physiological systems and the pathological derangement occurring in atherothrombosis.

C-reactive protein, bezafibrate, and recurrent coronary events in patients with chronic coronary heart disease

BACKGROUND

Elevated C-reactive protein (CRP) levels are related to increased coronary risk in healthy subjects and in patients with acute coronary syndromes. The aims of the present study were to assess the following: (1) the association between CRP and subsequent coronary risk in patients with chronic coronary heart disease (CHD), (2) the effect of long-term bezafibrate treatment on CRP levels, and (3) to evaluate the consequences of change in CRP level over time on subsequent risk.

METHODS

Patients with chronic CHD (n = 3122) were recruited to a secondary prevention study that assessed the efficacy of bezafibrate versus placebo. C-reactive protein was measured in plasma samples collected at prerandomization and after 2 years of follow-up. Mean follow-up time was 6.2 years. Primary end point was fatal and nonfatal myocardial infarction and sudden cardiac death.

RESULTS

Increased baseline CRP levels were associated with increased risk (hazard ratios [HRs] per unit of log-transformed CRP level change) of myocardial infarction (HR 1.17, 95% CI 1.03-1.33), the primary end point (HR 1.19, 95% CI 1.06-1.34), total death (HR 1.19, 95% CI 1.02-1.40) and cardiac death (HR 1.28, 95% CI 1.04-1.59). After 2 years, CRP levels increased by 3.0% (from a mean level of 3.44 mg/L) in the bezafibrate group and by 3.7% (from 3.49 mg/L) in the placebo group. C-reactive protein levels after 2 years were associated with increased subsequent cardiovascular risk.

CONCLUSIONS

Baseline CRP and 2-year CRP levels were associated with subsequent risk of myocardial infarction and death in patients with chronic CHD. Bezafibrate did not reduce CRP levels as compared with placebo.

Endothelial function, arterial stiffness and lipid lowering drugs

The endothelium is a dynamic organ that plays a pivotal role in cardiovascular homeostasis. Alteration in endothelial function precedes the development of atherosclerosis and contributes to its initiation, perpetuation and clinical manifestations. It has been suggested that the assessment of endothelial function could represent a barometer of vascular health that could be used to gauge cardiovascular risk. This review summarises the various methods used to assess endothelium-dependent vasodilatation and their potential prognostic implications. In addition, the techniques used to evaluate arterial stiffness are discussed. The latter is to some extent controlled by the endothelium and has been the subject of considerable research in recent years. This paper also discusses the effects of lipid lowering treatment on both endothelial function and arterial stiffness.

Effect of cerivastatin on peripheral capillary permeability to albumin and peripheral nerve function in diabetic rats

OBJECTIVE

To examine the effect of cerivastatin on capillary permeability to albumin and peripheral nerve function in diabetic rats.

ANIMALS

Diabetes was induced in male Wistar rats by i.p. injection of streptozotocin (STZ) at the age of 5 days. Forty diabetic rats were randomized in two groups: one treated by cerivastatin (diabetic treated group, DT) and the other untreated (diabetic untreated group, DU). The data were compared to a group of normal rats.

MEASUREMENTS

The peripheral capillary filtration of albumin (CFA) was studied on a limb by a non-invasive isotopic method, and nerve electrophysiological measurements were performed. Rats were followed-up until 6 months. In group DU albumin retention (AR) increased by 3 months and lymphatic uptake of interstitial albumin was impaired at 6 months. None of these disorders was observed in group DT. Motor and sensory nerve conduction velocities (MNCV and SNCV) were significantly slower at 6 months in group DU but not in group DT as compared to control rats. The duration of the sensory nerve action potential (SNAP) was significantly longer in group DU than in control rats at 6 months whereas it did not differ in group DT and in control animals.

CONCLUSIONS

This study shows that cerivastatin may prevent the peripheral increase in CFA and lymphatic dysfunction induced by diabetes. These beneficial effects on microcirculation may be involved in the prevention of nerve function deterioration. The underlying mechanisms are likely to be independent of a lipid-lowering effect, but their clarification needs further investigations.

PON1, a new biomarker of cardiovascular disease, is low in patients with systemic vasculitis

OBJECTIVES

Because systemic vasculitis (SV) predisposes to atherosclerosis, and high-density lipoprotein (HDL) prevents atherosclerosis by "reverse cholesterol transport" and by inhibiting low-density lipoprotein (LDL) oxidation thanks to apolipoprotein A-I (Apo-AI) and paraoxonase 1 (PON1), we assessed whether LDL oxidation was increased in SV and associated with less PON1 activity.

METHODS

The sera of 33 patients with active SV (ASV), 32 in full remission of SV (RSV) and 20 healthy subjects (HS) were analyzed for C-reactive protein (CRP), high-sensitivity-CRP, lipids, lipoproteins, apolipoproteins, PON1 activity, LDL-immune complexes (LDL-IC), and auto-antibodies to oxidized-LDL (ox-LDL), and anticardiolipin antibodies.

RESULTS

CRP was higher in ASV than RSV and HS, and negatively correlated with HDL-cholesterol and Apo-AI. Autoantibodies to ox-LDL and highly oxidized malondialdehyde-LDL were higher in RSV than ASV and HS (P<0.05). LDL-IC titers were higher in ASV than RSV and HS (P<0.05). PON1 activity was lower in ASV and RSV than HS (P=0.02). A trend toward a negative correlation between basal PON1 activity and anti-MDA-LDL antibodies (P=0.06) was observed.

CONCLUSION

Inflammatory markers in SV were associated with a modified lipoprotein profile, which could lower PON1 activity and contribute to increased ox-LDL titers and accelerated atherosclerosis development.