Residual Cardiovascular Risk at Low LDL: Remnants, Lipoprotein(a), and Inflammation

Persistent lipoprotein(a) exposure and its association with clinical outcomes after acute myocardial infarction: a longitudinal cohort study

AIMS

To assess the link between persistent lipoprotein(a) [Lp(a)] exposure levels and clinical outcomes in patients with acute myocardial infarction (AMI).

METHODS

This longitudinal cohort study included 1131 AMI patients, categorizing persistent Lp(a) exposure based on measurements at admission and after 1 year. Patients were segmented into four groups using a 300 mg/L Lp(a) threshold: (1) persistent low Lp(a) (lowon admission - lowat 1 year); (2) fortified Lp(a) (lowon admission - highat 1 year); (3) attenuated Lp(a) (highon admission - lowat 1 year); and (4) persistent high Lp(a) (highon admission - highat 1 year). Multivariate Cox regression, subgroup analysis and sensitivity analysis assessed the association between Lp(a) trajectories and major adverse cardiovascular and cerebrovascular events (MACCE), cardiovascular death, non-fatal MI, non-fatal stroke, unplanned revascularization, and all-cause death.

RESULTS

Over a median 50-month follow-up, 343 (35.70%) patients encountered MACCE, and 210 (18.70%) died, including 126 (11.20%) from cardiovascular causes. The group with persistent high Lp(a) faced increased risk of MACCE (HRadjusted, 1.871; 95% CI: 1.474-2.374), non-fatal stroke (HRadjusted, 1.647; 95% CI: 1.031-2.632), unplanned revascularization (HRadjusted, 1.571; 95% CI: 1.008-2.449), and both all-cause (HRadjusted, 1.546; 95% CI: 1.134-2.108) and cardiovascular death (HRadjusted, 2.163; 95% CI: 1.405-3.331), compared to the persistent low Lp(a) group.

CONCLUSIONS

In AMI patients, sustained high Lp(a) levels were significantly associated with increased risk of MACCE, non-fatal stroke, unplanned revascularization, and both all-cause and cardiovascular death.

Association of atherogenic indices and triglyceride-total cholesterol-body weight index (TCBI) with severity of stenosis in patients undergoing angiography: a case-control study

OBJECTIVES

Coronary artery disease, caused by atherosclerosis, necessitates assessing plaque formation risk using indices like the atherogenic index of plasma (AIP), Castelli's risk indexes (CRI-I and CRI-II), the atherogenic coefficient (AC), and the triglyceride-total cholesterol-body weight index (TCBI). Although TCBI primarily assesses mortality risk, its relationship with stenosis severity is unclear. Utilizing data from a prior study, a case-control analysis was conducted on 1,187 subjects, which included 781 patients who underwent coronary angiography and 406 healthy controls. The indices were compared across varying degrees of arterial blockages.

RESULTS

AIP significantly correlated with stenosis severity in women, increasing the risk of three-vessel stenosis by 2.5 times. AC raised the risk of single-vessel stenosis in men by 2.7 times. CRI-I and CRI-II showed a positive relationship with arterial stenosis in women, with CRI-I increasing the risk of two and three-vessel blockages by 21.9% and 22.4%, respectively. A one-unit increase in CRI-II raised the risk by 33.1% for two arteries and 25.3% for three. In conclusion, AIP, CRI-I, and CRI-II in women, along with AC in men, correlated with arterial stenosis severity, while TCBI did not. Further research is needed to determine which index is most effective in predicting CAD risk.

Association between non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio and cerebral atherosclerotic stenosis: a retrospective study

BACKGROUND

Ischemic stroke (IS) is one of the leading causes of death and disability worldwide. Early identification of dyslipidemia associated with cerebral atherosclerosis is of great importance for reducing the risk of IS. The non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) is a novel lipid biomarker to assess atherosclerosis. The aim of this study is to investigate the association between NHHR and cerebral atherosclerotic stenosis using DSA imaging data, including intracranial/extracranial stenosis, anterior/posterior circulation stenosis, severe stenosis, and symptomatic stenosis.

METHODS

Patients who underwent DSA examination from July 2022 to December 2024 were included. Participants were divided into four groups based on NHHR levels. Univariable and multivariable logistic regression were applied to assess the association between NHHR and cerebral atherosclerotic stenosis, including intracranial and extracranial stenosis, anterior and posterior circulation stenosis, severe stenosis, and symptomatic stenosis. Restricted cubic splines (RCS) were applied to analyze and visualize the association between NHHR and cerebral atherosclerotic stenosis.

RESULTS

A total of 853 patients were included in the final analysis. After adjusting for covariables, compared to patients in the lower NHHR groups, those in the higher NHHR groups had a significantly higher occurrence rate of extracranial stenosis, posterior circulation stenosis, severe stenosis, and symptomatic stenosis. Multivariable-adjusted RCS showed a nonlinear association between NHHR and posterior circulation stenosis, and a linear positive association between NHHR and symptomatic stenosis.

CONCLUSIONS

NHHR may serve as a lipid management indicator for patients with extracranial stenosis, posterior circulation stenosis, severe stenosis, or symptomatic stenosis. NHHR could be an independent risk factor for symptomatic stenosis, which can aid in risk stratification and treatment decision-making for cerebral atherosclerotic stenosis patients.

Predictive Value of Complete Blood Count Indicators for Short-Term Mortality in Patients with Combined Coronary Artery Disease and Chronic Kidney Disease

Objective

Patients with chronic kidney disease (CKD) and coronary artery disease (CAD) had a poor prognosis. Indicators derived from complete blood count (CBC), like neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), monocyte-lymphocyte ratio (MLR), Systematic Inflammation Response Index (SIRI), systemic immune-inflammation index (SII) and Pan-Immune-Inflammation Value (PIV) had prognostic significance. But which one performed best in patients with CKD and CAD was still unclear.

Methods

CKD Patients with CAD admitted to ICU were retrospectively included. Patients with sepsis, connective tissue disease, tumor and receiving glucocorticoids were excluded. The primary endpoints encompassed in-hospital mortality and 30-day mortality.

Results

The study comprised 694 participants, with 60 patients died during hospitalization, and another 15 died in 30-day follow-up period. Both the admission level and maximal level of CBC-derived indicators were higher in the deceased group. ROC curve analysis demonstrated that maximal NLR had the highest AUCs - 0.795 for in-hospital mortality and 0.754 for 30-day mortality prediction. Furthermore, Net Reclassification Improvement (NRI) and Integrated Discrimination Improvement (IDI) analyses further confirmed that adding maximal NLR to the base model, which included traditional risk factors, significantly improved both NRI and IDI (p < 0.05 for both).

Conclusion

The maximum of NLR was with the best predictive value for in-hospital mortality and 30-day mortality in ICU patients with CAD and CKD. Predicting prognosis based on dynamic changes of NLR is more worthy of attention.

Sex differences between atherogenic index of plasma and α-klotho levels in middle-aged and older adults: NHANES 2007-2016

Objective

Klotho is an anti-aging gene, and the α-klotho protein it encodes reportedly has cardiovascular protective effects. The atherogenic index of plasma (AIP) is a novel and comprehensive lipid index that correlates with atherosclerotic burden and is a critical risk factor for cardiovascular diseases. There are no studies examining the relationship between AIP and α-klotho; thus, we aimed to explore this potential association.

Methods

Data were extracted from the National Health and Nutrition Examination Survey 2007-2016 database, and the relationship between AIP and serum α-klotho levels was analyzed using weighted multivariate linear regression.

Results

After adjusting for risk factors, AIP showed a significant negative correlation with the logarithm of serum α-klotho levels in women. The trend analysis and smoothed curve fitting showed a nonlinear dose-response relationship. Threshold effect analysis showed a significant difference in the association between AIP and α-klotho before and after the AIP break point (0.434). Subgroup analyses demonstrated that the negative association of AIP with α-klotho was consistent across subgroups. However, the correlation between AIP and serum α-klotho in men was not significant.

Discussion

Our study provides new evidence for sex differences in the association between AIP and serum α-klotho levels.

Remnant Cholesterol: Quantification, Concentrations by Sex and Age, and Risk of Ischemic Heart Disease

BACKGROUND

Observational and genetic causal studies have shown an association between high concentrations of remnant cholesterol and increased risk of ischemic heart disease. However, findings from randomized intervention trials that reduced plasma triglycerides, a surrogate marker of remnant cholesterol, have been conflicting. The exact mechanisms by which remnant cholesterol contributes to atherosclerosis and, ultimately, ischemic heart disease remain incompletely understood. Additionally, insight on sex and age differences and the importance of measurement differences of remnant cholesterol in plasma concentrations and risk of ischemic heart disease are sparse.

CONTENT

This review covers current knowledge regarding remnant cholesterol and its role in ischemic heart disease, with particular attention to measurement and sex- and age-specific differences.

SUMMARY

Findings from observational, genetic, and mechanistic studies support the notion that higher remnant cholesterol may be an important cause of ischemic heart disease in both women and men. Concentrations of remnant cholesterol vary by age, with a sharp increase at early adulthood for men and around menopause for women. Remnant cholesterol can be calculated from a standard lipid profile and in addition measured directly using manual ultracentrifugation, automated assays, and nuclear magnetic resonance spectroscopy. Irrespective of the method used to assess plasma concentrations, high concentrations of remnant cholesterol are consistently associated with increased risk of myocardial infarction and ischemic heart disease in observational and genetic causal studies; cholesterol rather than triglycerides in remnants drive this risk. Importantly, results from ongoing randomized clinical trials aiming specifically at lowering remnant cholesterol and ischemic heart disease are eagerly awaited.

Inflammation, lipids and cardiovascular risk: The quest for improving risk stratification and prognosis in ischemic heart disease

Lp(a): Lipoprotein (a). Created in BioRender. Romiti, G. (2024) BioRender.com/g02a734.

Association between remnant cholesterol and arterial stiffness: Evidence from NHANES 1999-2018

BACKGROUND AND AIM

Remnant cholesterol (RC), an emerging cardiovascular risk factor, has garnered increasing attention in atherosclerotic cardiovascular disease (ASCVD) research, though its relationship with arterial stiffness remains incompletely understood. This study investigated the association between RC and estimated pulse wave velocity (ePWV), a reliable marker of arterial stiffness, with the goal of enhancing our understanding of RC's role in cardiovascular risk assessment.

METHODS AND RESULTS

This study utilized the National Health and Nutrition Examination Survey (NHANES) data from 1999 to 2018, including 12,505 participants aged 20 years and above. Weighted linear regression, restricted cubic splines (RCS), and subgroup analyses were used to explore the association between RC levels and ePWV. Analysis revealed a significant positive association between RC levels and ePWV, with participants in the highest RC quintile (Q5) exhibiting substantially elevated ePWV compared to those in the lowest quintile (Q1). Notably, RCS analysis demonstrated a non-linear relationship characterized by a saturation effect (p-nonlinear <0.05). Subgroup analyses indicated stronger associations among specific demographic groups, including individuals under 40 years, females, non-Hispanic whites, and those above the poverty level (all interaction p < 0.05). Furthermore, mediation analysis found that various inflammatory markers such as neutrophil count (NEU), neutrophil-to-lymphocyte ratio (NLR), and monocyte-to-lymphocyte ratio (MLR) played a mediating role in this association.

CONCLUSION

Increased arterial stiffness is associated with higher RC levels, demonstrating a saturation effect at elevated concentrations. This association is partially mediated by NLR, MLR, and NEU, and was stronger among younger, females, non-Hispanic whites, and non-impoverished individuals.

Prognostic impact of residual inflammatory and triglyceride risk in statin-treated patients with well-controlled LDL cholesterol and atherosclerotic cardiovascular disease

AIMS

Identifying alternative contributors to the residual risk of atherosclerotic cardiovascular disease (ASCVD) beyond LDL cholesterol (LDL-C) levels is crucial. We investigated the relative impact of triglycerides (TGs) and high-sensitivity C-reactive protein (hs-CRP) on outcomes in statin-treated patients with well-controlled LDL-C undergoing percutaneous coronary intervention (PCI) for established ASCVD.

METHODS AND RESULTS

We included 9446 statin-treated patients with LDL-C < 70 mg/dL undergoing PCI between 2012 and 2022, stratified into four groups: (i) no residual risk (TG <150 mg/dL + hs-CRP <2 mg/L); (ii) residual TG risk (TG ≥150 mg/dL + hs-CRP <2 mg/L); (iii) residual inflammatory risk (TG <150 mg/dL + hs-CRP ≥2 mg/L); and (iv) residual TG and inflammatory risk (TG ≥150 mg/dL + hs-CRP ≥2 mg/L). The primary endpoint was major adverse cardiovascular events (MACE) at 1 year, consisting of all-cause mortality, myocardial infarction, or stroke. Cox regression analysis was performed, using the no residual risk group as a reference. Of the total population, 5339 (56.5%) had no residual risk, 555 (5.9%) presented residual TG risk, 3009 (31.9%) had residual inflammatory risk, and 543 (5.7%) exhibited residual combined risk. After multivariable adjustment, patients with residual inflammatory or combined risk showed a significantly higher hazard of MACE, mainly driven by all-cause mortality. No significant difference was observed between patients with residual TG risk and those with no residual risk.

CONCLUSION

In statin-treated patients with well-controlled LDL-C undergoing PCI, residual inflammatory risk-alone or in combination with residual TG risk-was associated with a higher incidence of MACE, highlighting the need for targeted preventive strategies beyond LDL-C lowering.

The relationship between remnant cholesterol and young-onset myocardial infarction in patients with type 2 diabetes: a retrospective study

Background

Remnant cholesterol (RC) has emerged as a novel therapeutic target beyond low-destiny-lipoproteins cholesterol (LDL-c). While elevated RC levels are strongly associated with cardiovascular disease risk in the general population, their specific role in young-onset acute myocardial infarction (AMI) among patients with type 2 diabetes mellitus (T2DM) remains insufficiently explored and warrants further investigation.

Methods

This retrospective study included AMI patients with T2DM admitted to the First Affiliated Hospital of Xi'an Jiaotong University from 2018 to 2022. Patients were stratified into tertiles according to RC levels and compared using thresholds derived the commanded values from the PREDIMED cohort study. The primary outcome was young-onset AMI. Group differences were analyzed using the chi-square test and the Kruskal-Wallis H test, while Spearman correlation analyses assessed relationships between variables. Univariate and multivariate logistic regression analyses were employed to evaluate the association between RC and young-onset AMI.

Results

Among the 2,514 participants (mean age 61.58 ± 11.15 years), 802 (31.9%) had young-onset AMI. The increase of young-onset AMI increased significantly with rising RC levels (27.0% vs 29.7% vs 39.1%, P < 0.001). RC showed significant positive correlation with total cholesterol (TC, r = 0.497, P < 0.001), triglycerides (TG, r = 0.411, P < 0.001), and LDL-c (r = 0.166, P < 0.001). RC was independently associated with a higher risk of young-onset AMI (OR: 1.579; 95% CI: 1.354-1.842; P < 0.001), even after adjusting for other traditional risk factors of cardiovascular disease (OR: 1.415; 95% CI 1.189-1.684; P < 0.001). Notably, RC levels remained strongly linked to young-onset AMI regardless of whether LDL-c levels were within the desired range.

Conclusion

RC is a significant and independent risk factor for young-onset AMI in T2DM patients, irrespective of LDL-c level. These findings underscore the importance of monitoring and managing RC levels in clinical practice to mitigate cardiovascular risk in this population.

MAFLD as a predictor of adverse cardiovascular events among CHD patients with LDL-C<1.8 mmol/L

BACKGROUND AND AIMS

Patients receiving statin therapy still suffer from adverse cardiovascular events. Metabolic (dysfunction)-associated fatty liver disease (MAFLD) is a newly proposed concept that shares common metabolic risk factors with cardiovascular disease. This study aimed to investigate the association between MAFLD and adverse cardiovascular outcomes in coronary heart disease (CHD) patients with LDL-C<1.8 mmol/L.

METHODS AND RESULTS

CHD patients with LDL-C<1.8 mmol/L were divided into MAFLD and non-MAFLD groups. Propensity score matching (PSM) was used to control for baseline differences between the two groups. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCEs). All MAFLD patients were further stratified into two groups with and without advanced liver fibrosis, according to the Fibrosis-4 (FIB-4) index cutoffs, and the associations between advanced liver fibrosis status and cardiovascular outcomes were analyzed. After PSM, 800 MAFLD and 800 non-MAFLD patients with LDL-C<1.8 mmol/L were analyzed. MAFLD patients exhibited a significantly greater cumulative incidence and risk of MACCEs than non-MAFLD patients (9.6 % versus 6.6 %, p < 0.05; HR 1.48, 95 % CI 1.04-2.1, p < 0.05). Among MAFLD patients with LDL-C<1.8 mmol/L, advanced liver fibrosis staged by the FIB-4 index was associated with an elevated risk for MACCEs (HR 2.91, 95 % CI 1.17-7.19, p < 0.05), all-cause mortality, myocardial infarction (MI) and stent thrombosis.

CONCLUSION

MAFLD was an independent risk factor for adverse cardiovascular outcomes in CHD patients with LDL-C<1.8 mmol/L. Additionally, advanced liver fibrosis predicts increased risks for adverse cardiovascular events among MAFLD patients. These findings suggest that MAFLD and liver fibrosis screening and management contribute to the residual cardiovascular risk of CHD patients.

Novel lipid profiles and atherosclerotic cardiovascular disease risk: insights from a latent profile analysis

BACKGROUND

Dyslipidemia is a key contributor to atherosclerotic cardiovascular disease (ASCVD). Despite the well-established correlation between abnormal lipid metabolism and ASCVD, existing diagnostic and predictive models based on lipid indices alone or in combination often exhibit suboptimal sensitivity and specificity. There is an urgent need for improved lipid indicators or novel combinations thereof.

METHODS

The study included 898 cardiology inpatients who underwent coronary angiography (CAG). A latent profile analysis (LPA) was utilized to delineate lipid profiles on the basis of four routine lipid indices (total cholesterol (TC), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides (TG)) and the triglyceride‒glucose (TyG) index as a proxy for the TG. Logistic regression models were used to assess the correlations between lipid profiles and the occurrence and severity of coronary artery stenosis (CAS and severe CAS), as well as the occurrence of coronary heart disease (CHD). Predictive modeling subsequently validated the predictive power of the lipid profiles for cardiovascular outcomes.

RESULTS

The LPA delineated four distinct lipid profiles: Profile 1 (relatively high HDL with the lowest TC, LDL and TyG, 41.20%), Profile 2 (relatively high TC, LDL, and TyG with the lowest HDL, 36.42%), Profile 3 (relatively low TC, LDL and TyG with relatively high HDL, 18.93%), and Profile 4 (the highest TC, LDL, and TyG with the highest HDL, 3.45%). Profile 1 was associated with the lowest ASCVD risk, whereas Profile 2 posed the highest risk for all adverse outcomes. The risk associated with Profile 3 and Profile 4 varied depending on the outcome. Profile 4 presented a lower odds ratio (OR) for CAS than did Profile 3, whereas Profile 3 presented a lower OR for severe CAS and CHD. The lipid profile variable substantially outperformed individual lipid indices or their combinations in predicting cardiovascular outcomes.

CONCLUSIONS

Four distinct lipid profiles were identified among patients, with a particular profile characterized by lower levels of TC, LDL, and TyG, as well as a lower HDL, emerging as the most predictive of adverse cardiovascular outcomes. This underscores the critical need for a thorough lipid profile analysis to pinpoint individuals at heightened risk for adverse cardiovascular outcomes.

Remnant cholesterol is associated with unstable carotid plaque in a neurologically healthy population

BACKGROUND

Remnant cholesterol (RC) is considered to be one of the most significant and important risk factors for atherosclerotic cardiovascular disease (ASCVD). Nonetheless, the association between RC and unstable carotid plaque remains unclear. Our primary objective is to ascertain whether RC exhibits an independent and significant association with unstable carotid plaque in a neurologically healthy population.

METHODS

In the cross-sectional study, we enrolled neurologically healthy participants who visited our centre for health checkups between 2021 and 2022. All eligible participants underwent a standardised questionnaire, physical examinations and laboratory testing. The carotid plaque was evaluated with a standard carotid ultrasound and an advanced ultrasound imaging technique called superb microvascular imaging. The correlation between lipids and unstable carotid plaque was primarily assessed utilising univariate and multivariate logistic regression.

RESULTS

The study totally enrolled 1100 participants who had an average age of 57.00 years (IQR: 49.00-63.00), with 67.55% being men. Among the participants, 321 (29.18%) had unstable carotid plaque. In the multivariate logistic regression analysis, higher RC had an independent association with an elevated incidence of unstable carotid plaque compared with the lowest concentrations of RC (OR=1.673, 95% CI 1.113 to 2.515, p=0.0134), but not other lipids. In addition, apolipoprotein A1 was negatively related to unstable carotid plaque (OR=0.549, 95% CI 0.364 to 0.830, p=0.0045).

CONCLUSIONS

Elevated concentrations of RC are independently and excellently correlated with unstable carotid plaque within a neurologically healthy population.

Advanced serum lipoprotein and glycoprotein profiling for cardiovascular event prediction in type 2 diabetes mellitus: the LIPOCAT study

BACKGROUND

Traditional risk factors cannot accurately predict cardiovascular events (CVE) in type 2 diabetes (T2D). The LIPOCAT study aimed to prospectively evaluate the clinical utility of advanced lipoprotein characteristics and glycoproteins to predict future cardiovascular events (CVE) in a large cohort of subjects with type 2 diabetes mellitus (T2D).

METHODS

From four different Spanish prospective cohorts, a total of 933 T2D subjects were selected to form the LIPOCAT study. Advanced 1H-Nuclear Magnetic Resonance (1H-NMR) analysis included lipoprotein (Liposcale®) and glycoprotein (Glycoscale) profiling. Random forest classification models and Area Under the Receiver Operating Characteristics (AUROC) analysis were used to assess the differential contribution of advanced variables in predicting CVE. Validation was performed using an external cohort.

RESULTS

Out of 933 T2D subjects, 104 reported a CVE during follow-up. Analysis of Liposcale®/Glycoscale uncovered elevations in the circulating VLDL-cholesterol(C), remnant IDL-triglycerides (TG) and LDL-TG in subjects with CVE, along with glycoproteins (Glyc) A and B. Moreover, the incorporation of advanced Liposcale® variables to a base model constructed with traditional risk factors significantly improved the prediction of CVE, as evidenced by 1.5-fold increase in the C statistic (AUROC), reaching AUROC values of 0.756. In the independent validation cohort, similar improvements in AUROC values were observed by adding the advanced variables to the traditional models.

CONCLUSIONS

Advanced 1H-NMR analysis revealed previously hidden lipoprotein and glycoprotein characteristics associated with CVE in T2D subjects.

Estimation of Cardiovascular Risk Using SCORE2, REGICOR and Vascular Age Scales in Spanish Healthcare Workers: A Retrospective Longitudinal Study

Background/Objectives: Cardiovascular diseases (CVD) are one of the major public health concerns worldwide due to their high morbidity and mortality rates. This situation has necessitated the development of tools to assess cardiovascular risk (CVR) in order to prevent the onset of CVD. The aim of this study is to assess how sociodemographic variables and health habits are associated with the values of CVR scales, such as REGICOR, SCORE2, and vascular age. Methodology: This is a descriptive and cross-sectional study involving 44,939 Spanish healthcare workers, where the association between age, sex, type of work, smoking, physical activity, and Mediterranean diet with CVR scales such as REGICOR, SCORE2, and vascular age was evaluated. Results: All the variables analyzed showed an association with the occurrence of moderate-high values in all three CVR scales. Age was the variable that showed the highest odds ratio values: 13.446 (95% CI 11.16-14.77) for REGICOR, 13.90 (95% CI 12.01-15.81) for vascular age, and 14.12 (95% CI 12.01-16.23) for SCORE2. Conclusions: The profile of a healthcare worker with the highest risk of presenting moderate-high values on all three CVR scales would be a male over 60 years old, a nursing assistant or orderly, a smoker, sedentary, and with low adherence to the Mediterranean diet.

Efficacy and safety of PCSK9 inhibitors, potent statins, and their combinations for reducing low-density lipoprotein cholesterol in hyperlipidemia patients: a systematic network meta-analysis

Background

The objective of this study is to assess the relative efficacy of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, such as alirocumab, evolocumab, and inclisiran, in conjunction with potent statins like atorvastatin and rosuvastatin, in patients presenting with hyperlipidemia or heightened cardiovascular risk attributable to elevated low-density lipoprotein cholesterol (LDL-C).

Methods

A systematic search was conducted across databases including PubMed, Embase, and the Cochrane Library to explore lipid-lowering therapies in hyperlipidemia from their inception to 7 November 2023. A network meta-analysis (NMA) was conducted via Stata 17 software, with two authors independently conducting the search, screening, and data abstraction.

Results

A total of 68 clinical studies involving 21,288 patients with hyperlipidemia were incorporated into the NMA. PSCK9 inhibitors and potent statins significantly reduced LDL-C levels from baseline vs. placebo regardless of background therapy. Regarding the efficacy of lipid reduction, four principal medications were evaluated: evolocumab and atorvastatin [mean standard deviation (MD) -3.41, 95% CI -4.81 to -2.00] and evolocumab with rosuvastatin (MD -3.44, 95% CI -5.10 to -1.78) vs. placebo; alirocumab combined with rosuvastatin (MD -2.91, 95% CI -3.95 to -1.88) and alirocumab with atorvastatin (MD -2.90, 95% CI -3.97 to -1.84) vs. placebo. Meanwhile, compared with placebo, evolocumab (MD -1.89, 95% CI -2.27 to -1.50), alirocumab (MD -1.83, 95% CI -2.09 to -1.57), rosuvastatin (MD -1.93, 95% CI -2.30 to -1.56), inclisiran (MD -1.68, 95% CI -2.10 to -1.27), and atorvastatin (MD -1.68, 95% CI -2.04 to -1.31) could also play a role in the treatment of LDL-C reduction. Moreover, the incidence of adverse events (AEs) was similar to that observed in the control group, which included both placebo and potent statin groups, with no significant differences identified in our study (P > 0.05).

Conclusions

The combination of PCSK9 inhibitors with robust statins like rosuvastatin and atorvastatin markedly decreases LDL-C levels in patients with hyperlipidemia when compared to placebo or monotherapy. Notably, the pairing of evolocumab and atorvastatin exhibited exceptional efficacy in this investigation. In the interim, the combination of PCSK9 inhibitors and potent statins demonstrates a notable safety profile when contrasted with the control group.

Causal Association Between Multidimensional Plasma Lipid Composition and Pediatric Asthma: A Mendelian Randomization Study

BACKGROUND

Asthma is the most common chronic disease among children and poses a major threat to their health. Observational studies have shown lipid disorders in children with asthma. However, it was not possible to determine whether there is a causal link between the two. Therefore, the aim of this study was to assess the causal relationship between serum liposomes and asthma in children.

METHODS

We used large-scale publicly available genome-wide association study summary statistics to elucidate causal associations between plasma liposomes and children using a two-sample Mendelian randomization (MR) approach. The IVW method was used as the primary analysis method, and tests such as the Cochran Q test, MR-Egger intercept, and leave-one-out method were utilized to explore whether there was heterogeneity and pleiotropy in the MR results. In addition, Steiger's test and reverse MR analysis were performed to test the directionality of the MR results.

RESULTS

Our MR results identified a causal link between six plasma liposomes and childhood asthma. Among them, negative association between Diacylglycerol (16:0_18:2) (OR = 0.952, 95%CI = 0.913-0.992, p = 0.018), Triacylglycerol (52:4) (OR = 0.949, 95%CI = 0.905-0.994, p = 0.028), Phosphatidylcholine (18:2_20:3) (OR = 0.915, 95%CI = 0.843-0.993, p = 0.034), sterol ester (27:1/22:6) (OR = 0.929, 95% CI = 0.869-0.994, p = 0.031) and childhood asthma. There is a positive association between Phosphatidylcholine (16:0_22:5) (OR = 1.061, 95%CI = 1.006-1.120, p = 0.030), sterol ester (27:1/20:4) (OR = 1.046, 95% CI = 1.021-1.072, p = 0.0003) and pediatric asthma. A series of sensitivity tests also demonstrate the robustness of the results.

CONCLUSION

This MR study identified a causal link between some plasma liposomes and childhood asthma. This will provide new perspectives on the prevention and treatment of childhood asthma in the future.

Evaluations of metabolic and innate immunity profiles in subjects with familial hypercholesterolemia with or without subclinical atherosclerosis

BACKGROUND

Familial hypercholesterolemia (FH) is a genetic condition characterized by high low-density lipoprotein cholesterol (LDL-C). The presence of risk modifiers could promote the atherosclerotic injury beyond LDL-C. Our aim was to evaluate metabolic and innate immunity profiles in FH subjects with or without subclinical atherosclerosis.

METHODS

In this cross-sectional observational study, we evaluated 211 genetically confirmed FH subjects on LDL-C target and without cardiovascular diseases. Biochemical analyses, LDL-C burden (LCB) calculation and vascular profile evaluation were obtained from all subjects. Study population was divided into two groups according to subclinical atherosclerosis: the subclinical atherosclerosis (SA) group and non-subclinical atherosclerosis (NSA) group.

RESULTS

SA group had higher LDL-C at diagnosis (288.35 ± 24.52 vs 267.92 ± 23.86, p < 0.05) and LCB (13,465.84 ± 3617.46 vs 10,872.63 ± 3594.7, p < 0.001) than NSA group. SA group had higher white blood cell count (WBCC, 6.9 ± 1.66 vs 6.1 ± 1.16), neutrophil count (NC, 4.2 ± 1.3 vs 3.6 ± 1.11), monocyte count (MC, 0.8 ± 0.2 vs 0.4 ± 0.1), triglyceride to high-density lipoprotein ratio (TG/HDL, 1.73 ± 0.72 vs 1.45 ± 0.69), triglyceride-glucose index (TyG, 8.29 ± 0.35 vs 8.01 ± 0.33) than NSA group (p value for all < 0.01). Multivariate logistic regression analysis showed that LCB (p < 0.01), WBCC (p < 0.01), NC (p < 0.05), MC (p < 0.05) were associated with subclinical atherosclerosis. Simple linear regression analyses showed that LCB was associated with WBCC, NC, MC (p value for all < 0.01).

CONCLUSION

An increased LCB and an impaired innate immunity profile were found in FH subjects with subclinical atherosclerosis and they were independently associated with atherosclerotic injury. LCB could modulate the innate immunity profile.

Joint exposure to multiple air pollutants and residual cardiovascular risk in hypertension

BACKGROUND

Despite the widespread availability of antihypertensive medications, residual cardiovascular risk of hypertension remained high. Limited studies have investigated the link between air pollution, particularly joint exposure to multiple air pollutants, with residual cardiovascular risk of hypertension.

METHODS

1981 hypertensive patients (≥ 18 years) from an ongoing longitudinal cohort in China, were enrolled between 2013 and 2019. Using high-quality datasets from China, the ground-level air pollutants concentrations, including PM2.5, PM2.5-10, SO2, O3, CO and NO2, at each participant's residence were calculated. The relationships between individual and multiple air pollutants with the residual cardiovascular risk were assessed by Cox proportional hazards models, air pollution score analyses and Bayesian Kernel Machine Regression model.

RESULTS

Over an average follow-up period of 2.24 years (SD, 1.25), 706 hypertensive patients developed cardiovascular disease. In the single-pollutant analysis, higher concentrations of PM2.5, PM2.5-10, SO2 and CO were linked to increased residual cardiovascular risk. The air pollution score analyses and Bayesian kernel machine regression suggested that combined exposure to multiple air pollutants had a positive association with the residual cardiovascular risk, and NO2 played a dominant role. With higher NO2 concentrations, the hazard ratio of individual pollutants to residual cardiovascular risk increased.

CONCLUSIONS

Prolonged exposure to a mixture of various air pollutants is linked to elevated residual cardiovascular risk in individuals with hypertension. Apart from taking antihypertensive medication and adopting healthy lifestyle behaviors, hypertensive patients should lower air pollutant exposure to decrease residual cardiovascular risk.

Mendelian randomization analysis does not support a causal influence between lipoprotein(A) and immune-mediated inflammatory diseases

Observational studies have reported an association between lipoprotein(a) (Lp(a)) and immune-mediated inflammatory diseases (IMIDs). This study used Mendelian Randomization (MR) and multivariable MR (MVMR) to explore the causal relationship between lipoprotein(a) [Lp(a)] and immune-mediated inflammatory diseases (IMIDs). We performed a bidirectional two-sample mendelian randomization analyses based on genome-wide association study (GWAS) summary statistics of Lp(a) and nine IMIDs, specifically celiac disease (CeD), Crohn's disease (CD), ulcerative colitis (UC), inflammatory bowel disease (IBD), multiple sclerosis (MS), psoriasis (Pso), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), type 1 diabetes (T1D), and summary-level data for lipid traits. Furthermore, we performed MVMR to examine the independence of relationship between Lp(a) and IMIDs after controlling other lipid traits, namely high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglycerides (TG). We didn't observe a causal association between Lp(a) and the risk of IMIDs in univariable and multivariable MR analysis, challenging previous observational studies. However, genetically predicted lipid traits HDL-C was associated with increased risk of Type 1 diabetes (T1D). The identification of potential mechanisms underlying the observed associations in observational studies necessitates further investigation.

Nanotechnology and Artificial Intelligence in Dyslipidemia Management-Cardiovascular Disease: Advances, Challenges, and Future Perspectives

This narrative review explores emerging technologies in dyslipidemia management, focusing on nanotechnology and artificial intelligence (AI). It examines the current treatment recommendations and contrasts them with the future prospects enabled by these innovations. Nanotechnology shows significant potential in enhancing drug delivery systems, enabling more targeted and efficient lipid-lowering therapies. In parallel, AI offers advancements in diagnostics, cardiovascular risk prediction, and personalized treatment strategies. AI-based decision support systems and machine learning algorithms are particularly promising for analyzing large datasets and delivering evidence-based recommendations. Together, these technologies hold the potential to revolutionize dyslipidemia management, improving outcomes and optimizing patient care. In addition, this review covers key topics such as cardiovascular disease biomarkers and risk factors, providing insights into the current methods for assessing cardiovascular risk. It also discusses the current understanding of dyslipidemia, including pathophysiology and clinical management. Together, these insights and technologies hold the potential to revolutionize dyslipidemia management, improving outcomes and optimizing patient care.

Causal Associations Between Remnant Cholesterol Levels and Atherosclerosis-Related Cardiometabolic Risk Factors: A Bidirectional Mendelian Randomization Analysis

Background: Despite the widespread use of lipid-lowering agents, the risk of atherosclerotic cardiovascular disease (ASCVD) remains; this residual risk has been attributed to remnant cholesterol (RC) levels. However, the causal associations between RC levels and various atherosclerosis-related cardiometabolic and vascular risk factors for ASCVD remain unclear. Methods: Using genetic and biochemical data of 108,876 Taiwan Biobank study participants, follow-up data of 31,790 participants, and follow-up imaging data of 18,614 participants, we conducted a genome-wide association study, a Functional Mapping and Annotation analysis, and bidirectional Mendelian randomization analyses to identify the genetic determinants of RC levels and the causal associations between RC levels and various cardiometabolic and vascular risk factors. Results: We found that higher RC levels were associated with higher prevalence or incidence of the analyzed risk factors. The genome-wide association study unveiled 61 lead genetic variants determining RC levels. The Functional Mapping and Annotation analysis revealed 21 gene sets exhibiting strong enrichment signals associated with lipid metabolism. Standard Mendelian randomization models adjusted for nonlipid variables and low-density lipoprotein cholesterol levels unraveled forward causal associations of RC levels with the prevalence of diabetes mellitus, hypertension, microalbuminuria, and metabolic liver disease. Reverse Mendelian randomization analysis revealed the causal association of diabetes mellitus with RC levels. Conclusions: RC levels, mainly influenced by genes associated with lipid metabolism, exhibit causal associations with various cardiometabolic risk factors, including diabetes mellitus, hypertension, microalbuminuria, and metabolic liver disease. This study provides further insights into the role of RC levels in predicting the residual risk of ASCVD.

The nonlinear association between lipoprotein(a) and major adverse cardiovascular events in acute coronary syndrome patients with three-vessel disease

Lipoprotein(a) [Lp(a)] is a lipoprotein with potent atherogenic and thrombogenic potential. Its role in patients with acute coronary syndrome (ACS) combined with three-vessel disease (TVD) remains unclear. This study aimed to investigate the correlation between Lp(a) levels and the occurrence of major adverse cardiovascular events (MACE) in patients with ACS combined with TVD. Patients who underwent coronary angiography and were diagnosed with ACS combined with TVD were selected for the study. Patients were divided into three groups based on their Lp(a) levels. The correlation between Lp(a) and MACE was evaluated using univariate and multivariate Cox regression analysis, subgroup analysis, sensitivity analysis, Kaplan-Meier survival curve, receiver operating characteristic curve (ROC), and restricted cubic spline plot (RCS). A total of 1504 patients were included, with a median follow-up time of 38 months. Univariate Cox regression analysis showed that patients with higher Lp(a) levels had a significantly increased incidence of MACE (P < 0.001). After adjusting for confounding factors, multivariate Cox regression analysis indicated that high Lp(a) levels remained an independent predictor of MACE (P < 0.05). Subgroup analysis revealed that higher Lp(a) levels were significantly associated with a higher risk of MACE in subgroups including patients aged ≥ 60 years, males, those with hypertension, CKD, without diabetes, without hyperlipidemia, and without stroke (P < 0.05). Sensitivity analysis further confirmed the close correlation between Lp(a) and MACE (P < 0.05). Kaplan-Meier survival curve showed that the cumulative incidence of MACE in the high Lp(a) group was significantly higher than in the low-level group (P < 0.001). The ROC curve analysis indicated that Lp(a) had some predictive value for the occurrence of MACE (AUC: 0.623, 95% CI: 0.593-0.653, P < 0.001). The RCS plot demonstrated that after transforming Lp(a) to a normal distribution as Log10Lp(a), there was an approximately U-shaped nonlinear association between Log10Lp(a) and the risk of MACE (P nonlinear < 0.001). Lp(a) levels were significantly associated with the risk of MACE in patients with ACS combined with TVD.

Longitudinal changes in remnant cholesterol and the risk of cardiovascular disease

BACKGROUND AND AIM

The analyses of longitudinal changes in remnant cholesterol (RC) and cardiovascular disease (CVD) remains are limited. The objective of the study was to investigate the associations of longitudinal changes in RC with the risks of CVD and its subtypes (myocardial infarction [MI] and stroke).

METHODS AND RESULTS

The participants were enrolled in the Kailuan study. The RC short-term change pattern was defined by RC cutoff points according to equivalent percentiles for low-density lipoprotein cholesterol of 2.6 mmol/L at visits in 2006 and 2008. The RC long-term change pattern was defined as the RC trajectories from 2006 to 2010. Multivariate Cox proportion models were used to calculate hazard ratios (HRs) and their 95% confidence intervals (CIs). The cutoff values of RC were 0.52 mmol/L at the 2006 visit and 0.51 mmol/L at the 2008 visit. In the RC short-term change analysis, the participants in the high stable group had a 31% increased risk of CVD (HR 1.31; 95% CI 1.22-1.41), 73% increased risks of MI (HR 1.73; 95% CI 1.47-2.03), and 21% increased risks of stroke (HR 1.21; 95% CI 1.12-1.31) compared with participants in the low stable group. Three RC trajectories were employed in the RC long-term change analysis. Compared with the low stable group, the high stable group had a 1.34-fold risk of CVD (HR 1.34; 95% CI 1.17-1.53), 1.66-fold risk of MI (HR 1.66; 95% CI 1.24-2.21), and 1.22-fold risk of stroke (HR 1.22; 95% CI 1.05-1.42).

CONCLUSIONS

The stable high RC was associated with a higher risk of CVD. Maintaining optional RC levels could reduce the lifetime risk of CVD and prolong the year of life free from CVD.

Valorizing Agro‐Food Waste for Nutraceutical Development: Sustainable Approaches for Managing Metabolic Dysfunction‐Associated Steatotic Liver Disease and Related Co‐Morbidities

This comprehensive investigation delves into the interconnectedness of different features of cardiometabolic syndrome, such as metabolic dysfunction‐associated steatotic liver disease (MASLD), atherosclerotic cardiovascular disease (ASCVD), and gut dysbiosis, highlighting the crucial role of nutraceuticals in their management and prevention. Given the significant overlap in the pathophysiology of these conditions, the treatment with nutraceuticals, especially those derived from agro‐food waste, offers a promising, sustainable, and innovative approach to healthcare. The 2030 Agenda for Sustainable Development and the One Health concept are key frameworks for selecting the most interesting supply chain for the production of nutraceuticals from agro‐food waste, ensuring environmental sustainability, and innovative agricultural practices. In this review, the therapeutic potential of kiwifruit and apples has been explored, detailing how their bioactive compounds, like polyphenols, fiber, pectin, kaempferol, phloretin, and phlorizin, may contribute to the management of MASLD, ASCVD, and gut dysbiosis. Various extraction methods for active ingredients, including chemical, water, and enzyme extractions, are analyzed for their respective benefits and drawbacks. By integrating scientific research, sustainable agricultural practices, and innovative extraction methods, we can develop effective strategies to combat these pervasive health issues. This holistic approach not only enhances individual health outcomes but also supports broader environmental and societal goals, promoting a healthier future for all.

Unraveling the discrepancies between REDUCE-IT and STRENGTH trials with omega-3 fatty acids: new analytical approaches

Two large-scale, randomized, double-blind, placebo-controlled trials-REDUCE-IT and STRENGTH-have garnered significant attention in cardiovascular medicine. Both trials aimed to evaluate the effects of prolonged administration of nutritional lipids, specifically omega-3 fatty acids, on major adverse cardiovascular events (MACEs) in high-risk patients undergoing statin therapy. REDUCE-IT used eicosapentaenoic acid (EPA) ethyl ester with mineral oil as a control, while STRENGTH utilized a carboxylic acid formulation of both EPA and docosahexaenoic acid (DHA) with corn oil as a control. Notably, REDUCE-IT demonstrated a reduction in MACE risk with EPA, whereas STRENGTH showed no such benefit with the combination of EPA and DHA. Despite extensive and insightful discussions following the publication of these trials, the underlying reasons for this discrepancy remain elusive. We posit that further investigation into resting heart rate (RHR), heart rate variability (HRV), and ethnic subgroup data-collected but not fully explored-is critical to unraveling the divergent outcomes of the REDUCE-IT and STRENGTH trials. These additional analyses could provide pivotal insights into the mechanisms driving the differential effects of omega-3 fatty acids in high-risk cardiovascular patients. Given that previous discussions have not fully addressed these potential variables, exploring them may illuminate unexplored pathways and offer a deeper understanding of the mechanistic and clinical roles of omega-3 s in cardiovascular health. We hypothesize that by delving into these under-analyzed factors, we can not only clarify the discrepancies between the trials but also advance our broader understanding of cardiovascular nutrition and medicine.

Erythrocyte Membrane Fluidity and Omega-3 Fatty Acid Intake: Current Outlook and Perspectives for a Novel, Nutritionally Modifiable Cardiovascular Risk Factor

Omega-3 fatty acids reduce triglycerides and have several positive effects on different organs and systems. They are also found in the plasma membrane in variable amounts in relation to genetics and diet. However, it is still unclear whether omega-3 supplementation can reduce the occurrence of major cardiovascular events (MACEs). Two trials, REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial), with highly purified EPA, and STRENGTH (Effect of High-Dose Omega-3 Fatty Acids vs. Corn Oil on Major Adverse Cardiovascular Events in Patients at High Cardiovascular Risk), with a combination of EPA and DHA, have produced different outcomes, triggering a scientific debate on possible explanations for the discrepancies. Furthermore, doubts have arisen as to the anti-inflammatory and anti-aggregating activity of these compounds. Recent studies have, however, highlighted interesting effects of EPA and DHA on erythrocyte membrane fluidity (EMF). EMF is governed by a complex and dynamic biochemical framework, with fatty acids playing a central role. Furthermore, it can be easily measured in erythrocytes from a blood sample using fluorescent probes. Recent research has also shown that EMF could act as a possible cardiovascular risk factor biomarker. This review aims to synthetize the latest evidence on erythrocyte membrane fluidity, exploring its potential role as a biomarker of residual cardiovascular risk and discussing its clinical relevance. Further, we aim to dissect the possible biological mechanisms that link omega-3 modifiable membrane fluidity to cardiovascular health.

Predictive value of remnant cholesterol inflammatory index for stroke risk: Evidence from the China health and Retirement Longitudinal study

INTRODUCTION

Remnant cholesterol (RC) and high-sensitivity C-reactive protein (hs-CRP) are established stroke risk factors, but their joint impact remains unclear.

OBJECTIVES

This study aimed to evaluate the predictive value of the remnant cholesterol inflammatory index (RCII), a novel index integrating RC and hs-CRP, in assessing stroke risk.

METHODS

We analyzed 9,898 participants aged 45 years or older, with no history of stroke at baseline, from the China Health and Retirement Longitudinal Study (CHARLS). RCII was calculated using the formula: RCII = RC (mg/dL) × hs-CRP(mg/L)/10. A subset of 5,704 participants was studied to investigate the relationship between cumulative RCII exposure and stroke incidence. The associations of both baseline and cumulative RCII with stroke risk were assessed using Cox proportional hazards regression model.

RESULTS

During a median 7-year follow-up, 560 participants (5.7 %) experienced an incident stroke. Stroke incidence escalated with increasing RCII quartiles, from 3.5 % (Q1) to 7.6 % (Q4). In multivariable-adjusted analyses, each standard deviation increase in RCII was significantly associated with a 10.6 % increased risk of stroke (HR = 1.106, 95 % CI: 1.048-1.167). ROC analysis revealed that RCII had the highest AUC at 0.581, higher than RC (0.566) and hs-CRP (0.560), though the difference with RC was not statistically significant (P = 0.166). Mediation analysis indicated a reciprocal mediation between RC and hs-CRP on stroke risk. In a 3-year subset analysis, 288 participants suffered a stroke. Participants with cumulative RCII levels exceeding 36.14 had a significantly increased risk of incident stroke (HR = 1.462, 95 % CI: 1.102-1.939). Subgroup analyses showed a significant positive association between elevated RCII levels and stroke risk in males, but not in females.

CONCLUSIONS

Elevated levels of RCII, both at baseline and cumulative, are significantly associated with an increased risk of stroke. Early intervention in patients with high RCII may further help reduce stroke risk.

Roles of Nontraditional Lipid Parameters for Predicting Restenosis in Patients with Intracranial Atherosclerotic Stenosis After Endovascular Treatment

PURPOSE

Nontraditional lipid parameters are associated with intracranial atherosclerotic stenosis (ICAS) progression. This study aimed to investigate the association of nontraditional lipid parameters with the risk of restenosis in patients with ICAS after endovascular treatment (EVT).

METHODS

This study retrospectively enrolled consecutive patients with symptomatic ICAS after successful EVT followed by at least 3 months of angiography. Participants were divided into restenosis or non-restenosis groups based on the angiographic follow-up results. The nontraditional lipid parameters were calculated from conventional lipid parameters. The COX regression models and restricted cubic splines (RCS) were used to explore the association between nontraditional lipid parameters and restenosis.

RESULTS

This study recruited 222 cases with 224 lesions eligible for our study, of which 56 (25%) had restenosis. Compared with the non-restenosis group, patients in the restenosis group had higher levels of the atherogenic index of plasma (AIP) (0.211, interquartile range, IQR, 0.065-0.404 vs. 0.083, IQR, -0.052-0.265, P = 0.001), remnant cholesterol (RC) (0.55, IQR, 0.33-0.77 vs. 0.30, IQR, 0.18-0.49, P < 0.001) and Castelli's index‑I (CRI-I) (4.13, IQR, 3.39-5.34 vs. 3.74, IQR, 2.94-4.81, P = 0.030). In the multivariable COX regression analysis, a 0.1 unit increase of AIP was an independent risk factor for restenosis (hazard ratio, HR = 1.20, 95% confidence interval, CI 1.05-1.35, P = 0.005) whereas such an association was not observed for RC (HR = 1.01, 95% CI 0.90-1.15, P = 0.835). The restricted cubic spline (RCS) plot revealed a linear relationship between AIP and restenosis (P for nonlinear = 0.835) but a nonlinear relationship for RC (P for nonlinear = 0.012). Patients were stratified according to tertiles (T) of AIP and RC and the risk of restenosis increased in T3 compared to T1 (HR = 3.21, 95% CI 1.35-7.62, P = 0.008 and HR = 2.99, 95% CI 1.11-8.03, P = 0.030, respectively). Furthermore, this association remained stable within each LDL‑C level subgroup.

CONCLUSION

The AIP and RC were positively and independently associated with restenosis in patients with ICAS after EVT.

ABCA1-Super Enhancer RNA Promotes Cholesterol Efflux, Reduces Macrophage-Mediated Inflammation and Atherosclerosis

We describe a previously uncharacterized ATP-binding cassette A1 super enhancer RNA (ABCA1-seRNA)-mediated cholesterol efflux. In addition, it promoted macrophage inflammatory cytokine release, and was causally correlated with coronary artery disease severity. Mechanistically, ABCA1-seRNA upregulated cholesterol efflux by interacting with mediator complex subunit 23 and recruiting retinoid X receptor-alpha and liver X receptor-alpha to promote ABCA1 transcription in a cis manner. Meanwhile, ABCA1-seRNA induced P65 ubiquitination degradation, and thereby repressed the macrophage inflammatory response. Consistently, overexpression of ABCA1-seRNA in ApoE-/- mice decreased plasma lipids, cytokines, and atherosclerotic plaques. These findings indicate ABCA1-seRNA is a critical epigenetic regulator that maintains cholesterol homeostasis and modulates inflammation, thus promising a therapeutic target for atherosclerotic cardiovascular diseases.

Effect of high sensitivity C-reactive protein on uric acid-related cardiometabolic risk in patients with coronary artery disease-a large multicenter prospective study

Although serum uric acid (SUA) is a risk factor for cardiometabolic outcome, but it remains unclear which patients with coronary artery disease (CAD) benefit the most from SUA lowering therapy (ULT). The association of SUA level, systemic inflammation and cardiometabolic risk is still unclear. The current study is aimed to examine whether SUA-associated cardiometabolic risk is modulated by systemic inflammation in CAD patients. A total of 16,598 CAD patients with baseline high-sensitivity C-Reactive Protein (hsCRP) and SUA available were included. Baseline and follow-up data were collected. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE), including death, myocardial infarction and stroke. In patients with hsCRP ≥ 2 mg/L, increasing quintiles of SUA were significantly associated with increased rates of 2-year MACCE (adjusted p < 0.001 for trend, p = 0.037 for interaction). Each unit increase in SUA levels was associated with a 11.3% increased risk of MACCE (adjusted p < 0.001, p = 0.002 for interaction). However, in patients with hsCRP < 2 mg/L, increasing quintiles of SUA were not associated with increased MACCE (adjusted p = 0.120). Elevated SUA levels are related to MACCE when hsCRP levels are 2 mg/L or more but not less than 2 mg/L. This finding suggests a potential benefit of combined ULT and anti-inflammation therapy in patients with hyperuricemia and greater systemic inflammation.

Elevated serum lipoprotein(a) levels as a potential risk factor for diabetic retinopathy in type 2 diabetes: a meta-analysis

PURPOSE

This meta-analysis aimed to clarify the correlation between serum lipoprotein(a) [Lp(a)] levels and diabetic retinopathy (DR) in type 2 diabetes (T2D) individuals.

METHODS

We searched electronic databases, including PubMed, Web of Science, and Embase, for relevant observational studies evaluating the association between serum Lp(a) levels and the risk of DR. Odds ratios (ORs) with 95% confidence intervals (CIs) were summarized to indicate the association between a high Lp(a) and the risk of DR. Data were extracted and pooled using a random-effects model to account for variability among studies. Heterogeneity was assessed using the I2 statistic, and publication bias was evaluated through funnel plots and Egger's test.

RESULTS

Eleven observational studies were included. Compared to T2D patients of the lowest Lp(a) category, those of the highest Lp(a) category were associated with a higher risk of DR (OR: 2.05, 95% CI: 1.43-2.93, I2 = 83%, p < 0.001). Subgroup analyses suggested this association was predominantly observed in cross-sectional and case-control studies but not cohort studies (p for subgroup differences = 0.03). Additionally, the link between Lp(a) and DR was consistent across variables such as study country, Lp(a) cutoff values, analysis model (univariate or multivariate), and adjustment for concurrent medication use. A further meta-analysis suggested a significant relationship between elevated Lp(a) levels and proliferative DR (OR: 1.90, 95% CI: 1.03-3.48, I2 = 86%, p = 0.04).

CONCLUSION

Elevated serum Lp(a) levels are associated with an increased risk of DR in individuals with T2D.

The mediating role of inflammation in the association between cotinine levels and remnant cholesterol: a cross-sectional study

BACKGROUND

Remnant Cholesterol (RC) has emerged as a significant risk factor for cardiovascular disease. However, the factors influencing RC levels remain incompletely understood. This research investigates smoking-a major modifiable risk factor-to elucidate its impact on RC levels and examine the mediating role of inflammation in this relationship.

METHODS

Using NHANES data from 1999 to 2018, this study analyzed the association between serum cotinine levels (a biomarker of smoking intensity) and RC in 8,829 participants aged 20 years and older. Through complex sampling design and adjustment for multiple covariables, we examined both linear and nonlinear relationships using linear regression models, restricted cubic splines (RCS), and subgroup analyses. Additionally, mediation analyses evaluated the role of inflammatory markers-neutrophils (NEU), monocytes (MON), lymphocytes (LYM), and platelets (PLT)-in this association.

RESULTS

The high cotinine exposure group demonstrated significantly elevated RC levels (β = 2.256, 95% CI: 1.401-3.112, p < 0.001) compared to the no/minimal exposure group. This positive association was particularly pronounced in females (p for interaction < 0.05). Restricted cubic spline analysis demonstrated a nonlinear, N-shaped relationship (p for nonlinearity < 0.05), with RC levels reaching their peak at cotinine concentrations of approximately 172 ng/mL. In the mediation analysis, inflammatory markers showed significant mediating effects: NEU (28%), LYM (14.1%), PLT (9.5%), and MON (6.9%) of the total effect.

CONCLUSION

A significant positive association exists between cotinine and RC levels, moderated by sex. Inflammatory markers, particularly NEU, partially mediate this association.

High hsCRP Concentration Is Associated With Acute Pancreatitis in Multifactorial Chylomicronemia Syndrome

BACKGROUND

Multifactorial chylomicronemia syndrome (MCS) is a severe form of hypertriglyceridemia (hyperTG) associated with an increased risk of acute pancreatitis. However, the risk of acute pancreatitis is very heterogenous in MCS. Previous studies suggested that inflammation might promote disease progression in hyperTG-induced acute pancreatitis.

OBJECTIVE

To determine if low-grade inflammation is associated with acute pancreatitis in MCS.

METHODS

This study included 102 subjects with MCS for whom high-sensitivity C-reactive protein (hsCRP) concentration was measured at their first visit at the Montreal Clinical Research Institute.

RESULTS

Patients with MCS who had a previous history of acute pancreatitis had a significant higher hsCRP concentration (4.62 mg/L vs 2.61 mg/L; P = .003), and high hsCRP concentration (≥ 3 mg/L) was independently associated with acute pancreatitis prevalence (P < .05). Up to 64% of the variability in acute pancreatitis prevalence was explained by the maximal triglycerides (TG) concentration, hsCRP concentration, the presence of rare variants in TG-related genes, and fructose intake, based on a stepwise multivariate regression model (P < .0001).

CONCLUSION

This retrospective study showed for the first time that hsCRP concentration is strongly associated with acute pancreatitis prevalence in MCS. It also suggests that low-grade inflammation may be a driver of acute pancreatitis in severe hypertriglyceridemia. Prospective studies could help determine the causality of this association and assess whether medication known to reduce low-grade inflammation could help prevent acute pancreatitis in individuals with severe hypertriglyceridemia.

An equation for calculating small dense low-density lipoprotein cholesterol

OBJECTIVE

Small dense low-density lipoprotein cholesterol (sdLDL-C), as an emerging atherogenic factor of cardiovascular diseases, requires additional tests. We aimed to establish a sdLDL-C equation using standard lipid profile and evaluate its capacity of identifying the residual cardiovascular risk beyond LDL-C and apolipoprotein B (ApoB).

METHODS

This cross-sectional study included 25 435 participants from Health Management Cohort and 11 628 participants from China Health and Retirement Longitudinal Study (CHARLS) to construct and evaluate the sdLDL-C equation by least-squares regression model. The equation for sdLDL-C depended on low-density lipoprotein cholesterol (LDL-C) and an interaction term between LDL-C and the natural log of triglycerides (TG).

RESULTS

The modified equation (sdLDL-C = 0.14*ln(TG)*LDL-C - 0.45*LDL-C + 10.88) was more accurate than the original equation in validation set (slope = 0.783 vs. 0.776, MAD = 5.228 vs. 5.396). Using the 80th percentile (50 mg/dL) as a risk-enhancer rule for sdLDL-C, accuracy of the modified equation was higher than the original equation in validation set (90.47% vs. 89.73%). The estimated sdLDL-C identified an additional proportion of high-risk individuals in BHMC (4.93%) and CHARLS (1.84%).

CONCLUSION

The newly developed equation in our study provided an accurate tool for estimating sdLDL-C level among the Chinese population as a potential cardiovascular risk-enhancer.

Causal association between remnant cholesterol level and risk of cardiovascular diseases: a bidirectional two sample mendelian randomization study

Serum lipids have been associated with an increased risk of various cardiovascular diseases (CVDs) in several observational studies, but the causal inference between the remnant cholesterol (RC) levels and several CVDs risk has not been established. The purpose of this study was to investigate whether there is a causal relationship between RC levels and risk of developing CVDs by a bidirectional two-sample Mendelian randomization (TSMR) analysis. One TSMR analysis was performed using the publicly released large-scale genome-wide association study (GWAS) data. Inverse variance weighted (IVW) method was chosen as the main analysis method, and MR-Egger, weighted median, simple mode, and weighted mode were used as supplementary methods. We conducted a series of sensitivity analyses to assess the robustness of the main results, including the Cochran's Q test, MR-Egger intercept test, leave-one-out sensitivity analysis, and funnel plot. The main IVW method revealed that genetically predicted serum level of RC is significantly associated with an increased risk of developing ischemic heart disease (OR = 1.409, 95%CI = 1.284-1.546, P value = 4.753E-13), unstable angina pectoris (OR = 1.621, 95%CI = 1.398-1.880, P value = 1.672E-10), myocardial infarction (OR = 1.526, 95%CI = 1.337-1.741, P value = 3.771E-10), cardiac arrest (OR = 1.595, 95%CI = 1.322-1.924, P value = 1.076E-06), heart failure (OR = 1.086, 95%CI = 1.009-1.169, P value = 0.028), hypertension (OR = 1.089, 95%CI = 1.043-1.136, P value = 9.458E-05), major coronary heart disease (CHD) events (OR = 1.515, 95%CI = 1.376-1.669, P value = 3.217E-17), coronary atherosclerosis (OR = 1.388, 95%CI = 1.231-1.564, P value = 7.739E-08), cardiac arrhythmias (OR = 1.067, 95%CI = 1.008-1.130, P value = 0.025), and atrial fibrillation and flutter (OR = 1.122, 95%CI = 1.039-1.211, P value = 0.003). Additionally, the causal associations between the RC levels and these CVDs remained significant after correcting for the false discovery rate (all P value < 0.05). However, this study did not find any significant association of RC with cardiomyopathy and pericarditis (both P value > 0.05). Heterogeneity existed in the IVs of RC and ischemic heart disease, unstable angina pectoris, myocardial infarction, heart failure, hypertension, major CHD events, cardiomyopathy, coronary atherosclerosis, cardiac arrhythmias and atrial fibrillation and flutter using the Cochran's Q test (all P value < 0.05). Moreover, there was no horizontal pleiotropy in this study (all P value > 0.05). The leave-one-out sensitivity analyses showed that the causal effects between RC level and CVDs (except for heart failure, cardiomyopathy, pericarditis and cardiac arrhythmias) are not driven by a single SNP. The funnel plots showed that there is no obvious potential bias in our study. In the replication analysis, the genetically predicted RC levels were positively associated with a 43.12% higher risk of coronary artery disease. This present study supported the causal link between RC and heightened the risk of CVDs, indicating that RC-lowering treatment might be effective in preventing CVDs.

The Combined Effect of the Systemic Immune-Inflammation Index and Aortic Valve Calcification on Major Adverse Cardiovascular Events in Patients with Coronary Heart Disease

Background

The combined effect of systemic immune-inflammation index (SII) and aortic valve calcification (AVC) on the risk of major adverse cardiovascular events (MACE) in patients with coronary heart disease (CHD) remains unclear. This study aimed to investigate their combined association with MACE in CHD.

Methods

This retrospective cohort study included 846 CHD patients. SII was calculated as platelet count × neutrophil count / lymphocyte count, and AVC status was determined by echocardiography. Patients were divided into four groups based on median SII and AVC presence: Low SII + AVC (-), High SII + AVC (-), Low SII + AVC (+), and High SII + AVC (+). Cox regression, subgroup and sensitivity analyses assessed the association between SII + AVC and MACE.

Results

Multivariate Cox regression revealed that, compared to the Low SII + AVC (-), MACE risk increased 6.542-fold in the High SII + AVC (+) group and 1.605-fold in the High SII + AVC (-) group (P < 0.05). Subgroup analysis indicated that, compared to the Low SII + AVC (-), MACE risk was significantly elevated in the High SII + AVC (-) group for patients over 60, both genders, with hypertension, hyperlipidemia, or without diabetes (P < 0.05). In the Low SII + AVC (+) group, MACE risk was elevated only in males (P < 0.05). The High SII + AVC (+) group had increased MACE risk in all subgroups except those with diabetes (P < 0.05). After excluding patients with estimated glomerular filtration rate < 60 mL/min/1.73m², the high SII + AVC (+) group remained significantly associated with increased MACE risk (P = 0.001), as did the High SII + AVC (-) group (P = 0.031).

Conclusion

The combination of SII and AVC is significantly associated with MACE risk in patients with CHD.

Expression of Monocytes Subsets in Patients Diagnosed With Coronary Artery Atherosclerosis and Their Impact on Disease Severity

Introduction Many studies have supported inflammation as a mediator of lipoprotein (a) (Lp(a)) induced increase in cardiovascular disease risk, as it has pro-inflammatory effects on endothelial cells and monocytes. Aim This study aims to correlate Lp(a) level with different monocyte subsets in coronary atherosclerotic patients with different severity. Method The study included 60 patients with a mean age of 53.1 ± 10.5 diagnosed as coronary atherosclerotic patients by coronary angiography. Lp levels were measured using enzyme-linked immunosorbent assay (ELISA), while blood counts and monocyte subsets were analyzed by flow cytometry, and 30 apparently healthy individuals were included as the control group. Results Patients showed significantly higher median monocytic %, Lp(a), and higher C-reactive protein (CRP) values than the control group. Patients were subdivided into two groups: normal Lp(a) < 6.2 mg/dL (n = 24) and hyperlipoproteinemia(a) (hyper Lp(a)) ≥ 6.2 mg/dL (n = 36). Patients with hyper Lp(a) had higher non-classical monocytes (31.5% vs. 20%). Coronary atherosclerosis severity was associated with higher Lp(a) levels as well as non-classical monocytes; patients with mild atherosclerosis showed the highest classical and intermediate subset levels. While for a non-classical subset, patients with severe atherosclerosis showed the highest median level. A significant moderate positive correlation between Lp(a) and monocyte counts, as well as monocyte-lymphocyte (M/L) index and non-classical monocytes, was found. Conclusions Hyper Lp(a) and increased count of non-classical monocytes are significantly increased with disease progression (triple-vessel coronary disease risk). These results suggest that the expansion of non-classical monocytes is a cardiovascular disease (CVD) risk and predictor for disease severity. Strategies targeting inflammatory monocytes may slow CVD progression.

The functions of apolipoproteins and lipoproteins in health and disease

Lipoproteins and apolipoproteins are crucial in lipid metabolism, functioning as essential mediators in the transport of cholesterol and triglycerides and being closely related to the pathogenesis of multiple systems, including cardiovascular. Lipoproteins a (Lp(a)), as a unique subclass of lipoproteins, is a low-density lipoprotein(LDL)-like particle with pro-atherosclerotic and pro-inflammatory properties, displaying high heritability. More and more strong evidence points to a possible link between high amounts of Lp(a) and cardiac conditions like atherosclerotic cardiovascular disease (ASCVD) and aortic stenosis (AS), making it a risk factor for heart diseases. In recent years, Lp(a)'s role in other diseases, including neurological disorders and cancer, has been increasingly recognized. Although therapies aimed at low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) have achieved significant success, elevated Lp(a) levels remain a significant clinical management problem. Despite the limited efficacy of current lipid-lowering therapies, major clinical advances in new Lp(a)-lowering therapies have significantly advanced the field. This review, grounded in the pathophysiology of lipoproteins, seeks to summarize the wide-ranging connections between lipoproteins (such as LDL-C and HDL-C) and various diseases, alongside the latest clinical developments, special emphasis is placed on the pivotal role of Lp(a) in cardiovascular disease, while also examining its future potential and mechanisms in other conditions. Furthermore, this review discusses Lp(a)-lowering therapies and highlights significant recent advances in emerging treatments, advocates for further exploration into Lp(a)'s pathogenic mechanisms and its potential as a therapeutic target, proposing new secondary prevention strategies for high-risk individuals.

Association Between Pericoronary Fat Attenuation Index as Evaluated by Coronary Artery CT Angiography and Clinical Interventions in Lipid Management Among Patients with Coronary Artery Disease

Objective

This study aims to evaluate the relationship between the pericoronary fat attenuation index (FAI), derived from coronary artery computed tomography angiography, and post-lipid management levels of low-density lipoprotein cholesterol in patients with coronary artery disease (CAD). Additionally, the study investigates coronary inflammation across different lipid management strategies.

Methods

We selected a cohort comprising 521 CAD patients who met the inclusion criteria. Patients were categorized into well-managed (LDL-C<2.6 mmol/L) and poorly managed (LDL-C≥2.6 mmol/L) groups based on lipid management efficacy. We collected anthropometric measures (height, weight, body mass index, and body surface area) and clinical indicators, including Gensini score, and FAI-related parameters for coronary atherosclerotic lesions. We analyzed the interrelations along these parameters and lipid management using statistical methods and assessed diagnostic value via receiver operating characteristic (ROC) curve analysis of these parameters was assessed through.

Results

The poorly managed group exhibited significantly higher levels of total cholesterol, triglycerides, and lower levels of high-density lipoprotein compared to the well-managed group (P < 0.05). Significant differences were observed between the groups in terms of lesion length in the proximal segment of the left anterior descending artery, FAI value in the proximal segment of lesions in the right coronary artery (RCA), volume thickness in the middle segment of RCA lesions, and lesion length in the distal segment of RCA (P < 0.05). ROC curve analysis revealed areas under the curve ranging from 0.484 to 0.660 for the parameters, indicating limited diagnostic efficacy.

Conclusion

The FAI in the RCA varies with lipid management strategies, suggesting it as a valuable metric for monitoring both perivascular inflammation and lipid status in CAD patients. However, its current diagnostic efficacy is limited, indicating the need for further research to improve its clinical utility.

Intraindividual Discordance Between Remnant Cholesterol and Low-Density Lipoprotein Cholesterol Associated With Incident Stroke: Results From 2 National Cohorts

BACKGROUND

The atherogenic effect of remnant cholesterol is being increasingly acknowledged. This study aimed to explore the association of discordance between remnant cholesterol and low-density lipoprotein cholesterol with stroke onset using 2 Chinese national cohorts.

METHODS AND RESULTS

We studied 11 139 participants from CHARLS (China Health and Retirement Longitudinal Study) and 5993 participants from CHNS (China Health and Nutrition Survey) aged 45 years or older. The discordance between remnant cholesterol and low-density lipoprotein cholesterol was defined using the difference in percentile units (>15 units). There were 988 (8.9%) and 128 (2.1%) stroke events reported during follow-up in the 2 cohorts. Elevated remnant cholesterol was significantly associated with a higher risk of total stroke in 2 cohorts. After adjusting for remnant cholesterol level, the discordantly high remnant cholesterol group was significantly associated with an increased stroke risk (CHARLS: subdistribution hazard ratio [sHR], 1.31 [95 CI, 1.10-1.55]; CHNS: sHR, 1.84 [95 CI, 1.15-3.08]) compared with the discordantly low group. Consistent results were shown even among those with optimal low-density lipoprotein cholesterol level.

CONCLUSIONS

The discordance between remnant cholesterol and low-density lipoprotein cholesterol, representing the intraindividual discrepancy, is significantly associated with stroke onset among Chinese adults.

Elevated remnant cholesterol as a potential predictor for cardiovascular events in rheumatoid arthritis patients

Objective

The risk of cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA) remains inadequately defined. Consequently, this study aims to evaluate the predictive value of remnant cholesterol (RC) for assessing CVD risk in RA patients.

Methods

Plasma RC levels were measured in 114 RA patients and 41 healthy controls, calculated as total cholesterol minus HDL-C and LDL-C. These levels were further analyzed using 1H-NMR lipid/metabolomics. Meanwhile, the 28-joint Disease Activity Score (DAS28) assessed RA activity.

Results

RC levels were significantly elevated in RA patients (19.0 mg/dl, p < 0.001) compared to healthy controls (14.5 mg/dl). Furthermore, RC levels were significantly elevated at 37.4 mg/dl in patients who experienced cardiovascular event (CVE) compared to 17.4 mg/dl in those without CVE (p < 0.001). To enhance the precision and reliability of RC measurements, RC concentrations were further validated using 1H-NMR spectroscopy. Additionally, a positive correlation was observed between RC levels and DAS28. Multivariate analysis identified RC as a significant predictor of CVE (odds ratio = 1.82, p = 0.013). ROC curve analysis revealed superior predictive capability of RC for CVE (AUC = 0.919, p < 0.001) compared to LDL-C (AUC = 0.669, p = 0.018), with a high sensitivity of 94.7% and a specificity of 82.1%.

Conclusion

Elevated RC levels demonstrate greater accuracy in predicting CVE occurrence in RA patients compared to traditional measures such as LDL-C. These findings suggest that elevated RC levels may serve as a novel predictor for occurrence of CVE in RA patients, facilitating early intervention strategies based on the risk stratification.

Advances in targeting LDL cholesterol: PCSK9 inhibitors and beyond

There is a direct relationship between the duration and level of exposure to low density lipoprotein cholesterol (LDL-C) levels over one's lifespan and cardiovascular events. Early treatment to lower elevated LDL-C is crucial for better outcomes with multiple therapies currently available to reduce atherogenic lipoproteins. Statins remain the foundation of LDL-C lowering therapy as one of the most cost-effective drugs to reduce atherosclerotic events (ASCVD) and mortality. Nonetheless, LDL-driven goal attainment remains suboptimal globally, highlighting a considerable need for non-statin therapies to address residual risk related to statin intolerance, non-adherence, and inherited lipoprotein disorders. LDL-C lowering interventions beyond statins include ezetimibe, PCSK9 monoclonal antibodies, inclisiran and bempedoic acid with specific guideline recommendations as to when to consider each. For patients with homozygous familial hypercholesterolemia requiring more advanced therapy, lomitapide and evinacumab are available, providing mechanisms that are not LDL receptor dependent. Lipoprotein apheresis remains an effective option for clinical familial hypercholesterolemia as well as elevated lipoprotein (a). There are investigational therapies being explored to add to our current armamentarium including CETP inhibitors, a third-generation PCSK9 inhibitor (small recombinant fusion protein oral PCSK9 inhibitor) and gene editing which aims to directly restore or disrupt genes of interest at the DNA level. This article is a brief review of the pharmacotherapy options beyond statins for lowering LDL-C and their impact on ASCVD risk reduction. Our primary aim is to guide physicians on the role these therapies play in achieving appropriate LDL-C goals, with an algorithm of when to consider each based on efficacy, safety and outcomes.

Cardiovascular Risk Estimation and Stratification Among Individuals with Hypercholesterolemia

PURPOSE OF THE REVIEW

This review aims to assess the variability in considering hypercholesterolemia for cardiovascular risk stratification in the general population. Recent literature on the integration of hypercholesterolemia into clinical risk scores and its interaction with other risk factors will be explored.

RECENT FINDINGS

The impact of hypercholesterolemia on risk estimation varies among different cardiovascular risk calculators. Elevated lipid levels during early life stages contribute to atherosclerotic plaque development, influencing disease severity despite later treatment initiation. The interplay between low-density lipoprotein cholesterol (LDLc), inflammatory markers and non-LDL lipid parameters enhances cardiovascular risk stratification. Studies have also examined the role of coronary artery calcium (CAC) score as a negative risk marker in populations with severe hypercholesterolemia. Furthermore, polygenic risk scores (PRS) may aid in diagnosing non-monogenic hypercholesterolemia, refining cardiovascular risk stratification and guiding lipid-lowering therapy strategies. Understanding the heterogeneity in risk estimation and the role of emerging biomarkers and imaging techniques is crucial for optimizing cardiovascular risk prediction and guiding personalized treatment strategies in individuals with hypercholesterolemia.

Intra-individual variability in lipoprotein(a): the value of a repeat measure for reclassifying individuals at intermediate risk

Aims

Lipoprotein(a) [Lp(a)] levels are predominantly genetically determined and repeat measurements are generally considered unlikely to be clinically useful. However, the temporal variation of Lp(a) is not well characterized. Our aim was to determine the intra-individual variability of Lp(a) and whether a repeated measure reclassified Lp(a)-specific cardiovascular risk using the European Atherosclerosis Society (EAS) consensus statement risk categories.

Methods and results

This retrospective cohort study analysed initial and repeated serum Lp(a) levels measured using the same methodology from 609 individuals in the Nashville Biosciences database, a de-identified electronic medical records database. Baseline and follow-up paired values were significantly different (P < 0.05), with an absolute change of ≥10 mg/dL in 38.1% [95% CI 34.2-42%] and a >25% change in 40.5% [95% CI 36.6-44.3%] of individuals. Although the categories of those whose values were in the EAS low-risk and high-risk categories did not change, 53% of those in the intermediate 'grey-zone' category transitioned to either the low-risk (20%) or high-risk (33%) category. Black individuals exhibited greater variability than White individuals and women exhibited greater variability than men. There was a positive correlation between the baseline Lp(a) levels and the absolute changes in Lp(a), (r = 0.59, P < 0.01).

Conclusion

Temporal-related changes in Lp(a) variability were present in many individuals. A repeat Lp(a) measure may allow more precise Lp(a)-specific cardiovascular risk prediction for individuals whose initial value is in the EAS-defined intermediate 'grey-zone' category. Lp(a) variability should be included in calculating the expected effect sizes in future clinical research studies targeting Lp(a).

Identification of symptomatic carotid artery plaque: a predictive model combining angiography with optical coherence tomography

Objective

Symptomatic carotid artery disease is indicative of an elevated likelihood of experiencing a subsequent stroke, with the morphology of plaque and its specific features being closely linked to the risk of stroke occurrence. Our study based on the characteristics of carotid plaque assessed by optical coherence tomography (OCT), the plaque morphology evaluated by digital subtraction angiography (DSA) and clinical laboratory indicators were combined, develop a combined predictive model to identify symptomatic carotid plaque.

Methods

Patients diagnosed with carotid atherosclerotic stenosis who underwent whole-brain DSA and OCT examination at the Affiliated Hospital of Jining Medical University from January 2021 to November 2023 were evaluated. Clinical features, as well as DSA and OCT plaque characteristics, were analyzed for differences between symptomatic and asymptomatic cohorts. An analysis of logistic regression was carried out to identify factors associated with the presence of symptomatic carotid plaque. A multivariate binary logistic regression equation was established with the odds ratio (OR) serving as the risk assessment parameter. The receiver operating characteristic curve was utilized to assess the combined predictive model and independent influencing factors.

Results

A total of 52 patients were included in the study (symptomatic: 44.2%, asymptomatic: 55.8%). Symptomatic carotid stenosis was significantly linked to four main factors: low-density lipoprotein-cholesterol >3.36 mmol/L [OR, 6.400; 95% confidence interval (CI), 1.067-38.402; p = 0.042], irregular plaque (OR, 6.054; 95% CI, 1.016-36.083; p = 0.048), ruptured plaque (OR, 6.077; 95% CI, 1.046-35.298; p = 0.048), and thrombus (OR, 6.773; 95% CI, 1.194-38.433; p = 0.044). The combined predictive model generated using four indicators showed good discrimination (Area Under Curve, 0.924; 95% CI, 0.815-0. 979). The p value was <0.05 with 78.26% sensitivity and 93.10% specificity.

Conclusion

OCT is valuable in evaluating the plaque characteristics of carotid atherosclerotic stenosis. The combined predictive model comprising low-density lipoprotein-cholesterol >3.36 mmol/L, irregular plaque, ruptured plaque, and thrombus could help in the detection of symptomatic carotid plaque. Further research conducted on additional independent cohorts is necessary to confirm the clinical significance of the predictive model for symptomatic carotid plaque.

Trajectories of Remnant Cholesterol are Associated with Diabetic Foot Ulcer in Adult Patients with Type 2 Diabetes: A Retrospective Cohort Study

Objective

This study aimed to investigate the potential association between long-term variations in remnant cholesterol (RC) levels and the development of diabetic foot ulcers (DFU) in participants with type 2 diabetes (T2D).

Methods

This was a retrospective cohort study. Variation in RC was assessed by the following metrics: mean, standard deviation (SD), coefficient of variation (CV) and trajectories pattern of RC. To identify RC trajectories, we employed the latent class mixture model. The primary endpoint was the development of DFU, and the time-to-event data were analyzed using Cox regression.

Results

A total of 1874 patients with T2D were included, with a median follow-up duration of 4.7 years. Among them, 129 individuals (6.9%) developed DFU. The proportion of DFU was significantly higher in the U-shaped group compared to the median group (P for trend < 0.001). Upon adjustment for confounding variables, the U-shaped trajectory correlated with a higher risk of DFU, demonstrating a hazard ratio (HR) of 2.57 (95% CI, 1.54-4.27). Subgroup analysis showed the U-shaped trajectory had a higher DFU risk regardless of gender (HR=2.40 and 2.81, respectively), glycemic control (HR=1.89 and 7.41, respectively), smoking (HR=2.36 and 2.93, respectively), or hypertension (HR=2.30 and 2.97, respectively). No association was found between mean, SD and CV of RC and DFU.

Conclusion

A U-shape trajectory of RC was independently associated with an elevated risk of DFU among patients with T2D.

Insulin resistance potentiates the effect of remnant cholesterol on cardiovascular mortality in individuals without diabetes

BACKGROUND AND AIMS

Remnant cholesterol (RC) and insulin resistance (IR) have been independently associated with cardiovascular risk. Here, we evaluated the role of IR and RC on cardiovascular disease (CVD) mortality.

METHODS

We conducted an analysis of 16,113 individuals ≥20 years without diabetes from the National Health and Nutrition Examination Survey (NHANES-III/IV). RC levels were calculated using total cholesterol, non-HDL-c, and LDL-c; IR was defined as HOMA2-IR≥2.5 and CVD mortality as a composite of cardiovascular and cerebrovascular mortality. Multiple linear regression was used to assess the relationship between HOMA2-IR and RC and Cox regression models to assess their joint role in CVD mortality. Causally ordered mediation models were used to explore the mediating role of IR in RC-associated CVD mortality.

RESULTS

We identified an association between higher HOMA2-IR and higher RC levels. The effect of IR on CVD mortality was predominant (HR 1.32, 95%CI 1.18-1.48) and decreased at older ages (HR 0.934, 95%CI 0.918-0.959) compared to RC (HR 0.983, 95%CI 0.952-1.014). Higher risk of CVD mortality was observed in individuals with IR but normal RC (HR 1.37, 95%CI 1.25-1.50) and subjects with IR and high RC (HR 1.24, 95%CI 1.13-1.37), but not in subjects without IR but high RC. In mediation models, HOMA2-IR accounted for 78.2% (95%CI 28.11-98.89) of the effect of RC levels on CVD mortality.

CONCLUSIONS

Our findings suggest that RC potentiates the risk of CVD mortality through its effect on whole-body insulin sensitivity, particularly among younger individuals.