Low-density lipoproteins cause atherosclerotic cardiovascular disease: pathophysiological, genetic, and therapeutic insights: a consensus statement from the European Atherosclerosis Society Consensus Panel

Causal associations between premature ovarian insufficiency and cardiovascular diseases: a Mendelian randomization study

To date, there remains a paucity of prospective studies examining the association between premature ovarian insufficiency (POI) and cardiovascular diseases (CVD). The objective of this study was to investigate the potential association between POI and CVD utilizing the method of Mendelian randomization (MR). MR analyses utilized summary statistics from the most extensive genome-wide association studies (GWAS) on POI and CVD extracted from European ancestry cohorts and the FinnGen biobank. The inverse variance-weighted (IVW) method was the primary MR analysis technique. Supplementary analyses were performed using MR-Robust Adjusted Profile Score (MR-RAPS). Cochran's Q statistic, MR-Egger, and weighted median MR models were employed to further assess heterogeneity and horizontal pleiotropy. Causal effects of POI on coronary heart disease (odds ratio [OR] = 1.048, 95% confidence interval [CI]: 1.006-1.091; p = 0.023)] and ischemic stroke (OR = 1.010, 95% CI: 1.000-1.020; p = 0.0498) were found. However, we did not observe a significant correlation between POI and hypertension (OR = 0.999, 95% CI: 0.994-1.004, p = 0.691), heart failure (OR = 1.009, 95% CI: 0.999-1.020, p = 0.0725), atrial fibrillation (OR = 0.995, 95% CI: 0.986-1.004, p = 0.3035), and myocardial infarction (OR = 1.002, 95% CI: 0.991-1.013, p = 0.7061). POI was causally associated with coronary heart disease and ischemic stroke, with no apparent impact on hypertension, heart failure, atrial fibrillation, or myocardial infarction. The causal relationship between POI and CVD underscores the imperative for proactive cardiovascular risk management in individuals with POI.

Clinical relevance of midkine as a biomarker predicting atherosclerotic risk factors in individuals with type-2 diabetes mellitus: a cross-sectional study

Objective

Midkine (MK) is a member of a small protein family that includes pleiotrophin. MK levels are elevated in obese patients and have a pro-arthrogenic effect through various pathophysiological processes including vascular inflammation and atherogenesis. This study aimed to investigate the association between serum MK levels and several atherosclerotic risk factors in patients with type 2 diabetes mellitus (T2DM).

Methodology

Ninety subjects were enrolled in this study, comprising 60 T2DM patients and 30 age-matched healthy subjects (HS). The patients were categorized into two groups based on dyslipidemia: group 1 consisted of 30 patients with dyslipidemia, while group 2 included 30 patients without dyslipidemia. Laboratory tests were conducted using routine assays at the National Diabetes Center. MK levels were analyzed using enzyme-linked immunosorbent assay (ELISA).

Results

MK levels were significantly higher in patients with dyslipidemia compared to those without dyslipidemia and HS (P ≤ 0.0001). A significant negative correlation was observed between MK levels and the atherogenic index of plasma (AIP), Castelli's risk index-1 (CRI-I), and Castelli's risk index-2 (CRI-II) (r = - 0.489, p = 0.005; r = - 0.465, p = 0.008; r = - 0.421, p = 0.018, respectively) in patients with dyslipidemia. Furthermore, a significant positive correlation was found between MK levels and HDL-C (r = 0.524, p = 0.002) in patients without dyslipidemia. MK, AIP, and CRI-I were identified as predictors of atherosclerosis in DM patients, with MK indicating very good discriminate power (AUC = 0.805) in identifying T2DM patients with dyslipidemia at a cut-off value of ≤ 4.457 ng/ml.

Conclusion

These findings suggest that MK could be considered a predictive biomarker for dyslipidemia associated with DM. MK levels correlate significantly with atherogenic risk factors, indicating its potential as a sensitive risk predictor for atherosclerosis in patients with T2DM.

LDL cholesterol burden in elderly patients with familial hypercholesterolemia: Insights from real-world data

Background and aims

Familial hypercholesterolemia (FH) is a genetic disorder characterized by elevated low-density lipoprotein cholesterol (LDL-C) and increased risk of premature coronary heart disease (CHD). While current LDL-C levels usually guides therapy, the cumulative exposure to LDL-C (the LDL-C burden) is suggested to offer a more precise estimate of cardiovascular risk in people with FH. Therefore, using real-world data, this study aimed to estimate the LDL-C burden at different ages in elderly FH patients with and without CHD, and to assess the LDL-C burden at CHD onset.

Methods

Data was retrospectively collected from the medical records of elderly (>60 years) FH patients at the Lipid Clinic in Oslo. The LDL-C burden (mM-years) was estimated based on repeated LDL-C measurements and information on lipid-lowering medication. Time-weighted average (TWA) LDL-C was calculated as LDL-C burden divided by years.

Results

We included 112 FH patients, of which 55 (49 %) had experienced at least one CHD-event, and 58 (52 %) were females. Median age at first and last visit were 50 years and 68 years, respectively, with a median of 9 (range; 2-14) available LDL-C measurements. Subjects with CHD had higher LDL-C burden at all ages tested (45, 50 and 60 years) compared with the non-CHD group (p < 0.01, also after adjusting for sex), and had higher TWA LDL-C before treatment at the Lipid Clinic (p = 0.004), but not during follow-up (p = 0.6). There were no sex differences in LDL-C burden at all ages tested, also after adjusting for CHD (p > 0.1). However, women had higher TWA LDL-C during follow-up at the Lipid Clinic (p = 0.01). Median LDL-C burden at CHD onset was 352 mM-years; numerically lower in women than in men (320 vs. 357 mM-years, respectively. p = 0.1).

Conclusion

Elderly FH patients with CHD had higher estimated LDL-C burden compared with FH patients without CHD, due to higher burden prior to treatment, highlighting the importance of earlydetection and treatment.

Rationale, design and prerandomization data for a cluster randomized trial to assess the effect of a digitally enabled quality improvement intervention on LDL-C control in established atherosclerotic cardiovascular disease patients: The SAPPHIRE-LDL trial

BACKGROUND

Translating evidence into clinical practice in the management of established atherosclerotic cardiovascular disease patients is challenging. Few quality improvement interventions have successfully improved patient care.

OBJECTIVES

The main objectives are to evaluate the impact of a digitally enabled multifaceted quality improvement (QI) intervention on the control of LDL-cholesterol (LDL-C) in atherosclerotic cardiovascular disease (ASCVD).

DESIGN

We designed a pragmatic 2-arm cluster randomized trial involving 28 clusters (outpatient clinics from public or private hospitals or private practices). Clusters are randomized to receive a digitally enabled multifaceted QI intervention or to routine practice (control). The QI intervention includes reminders, electronic clinical decision support algorithms, audit and feedback reports, and distribution of educational materials to health care providers, as well as electronic educational materials and app-based tools for drug adherence control, lipid profile control, and communication to participants. The primary endpoint is the LDL-C at 06 months after the intervention period. All analyses are performed following the intention-to-treat principle and take the cluster design into consideration by using individual-level regression modeling (generalized estimating equations-GEE).

SUMMARY

If proven effective, this low-cost, digitally enabled multifaceted QI intervention would be highly useful in promoting optimal LDL-C control in ASCVD patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05622929.

Evolving concepts of low-density lipoprotein: From structure to function

BACKGROUND

Low-density lipoprotein (LDL) is a central player in atherogenesis and has long been referred to as 'bad cholesterol.' However, emerging evidence indicates that LDL functions in multifaceted ways beyond cholesterol transport that include roles in inflammation, immunity, and cellular signaling. Understanding LDL's structure, metabolism and function is essential for advancing cardiovascular disease research and therapeutic strategies.

METHODS

This narrative review examines the history, structural properties, metabolism and functions of LDL in cardiovascular health and disease. We analyze key milestones in LDL research, from its early identification to recent advancements in molecular biology and omics-based investigations. Structural and functional insights are explored through imaging, proteomic analyses and lipidomic profiling, providing a deeper understanding of LDL heterogeneity.

RESULTS

Low-density lipoprotein metabolism, from biosynthesis to receptor-mediated clearance, plays a crucial role in lipid homeostasis and atherogenesis. Beyond cholesterol transport, LDL contributes to plaque inflammation, modulates adaptive immunity and regulates cellular signaling pathways. Structural studies reveal its heterogeneous composition, which influences its pathogenic potential. Evolving perspectives on LDL redefine its clinical significance, affecting cardiovascular risk assessment and therapeutic interventions.

CONCLUSIONS

A holistic understanding of LDL biology challenges traditional perspectives and underscores its complexity in cardiovascular health. Future research should focus on further elucidating LDL's structural and functional diversity to refine risk prediction models and therapeutic strategies, ultimately improving cardiovascular outcomes.

Discovery of ASGR1 and HMGCR dual-target inhibitors based on supervised learning, molecular docking, molecular dynamics simulations, and biological evaluation

3-Hydroxy-3-Methylglutaryl-CoA Reductase (HMGCR) and Asialoglycoprotein Receptor 1 (ASGR1) are potential therapeutic targets for atherosclerotic cardiovascular disease (ASCVD). In this study, we employed an innovative approach that combined ligand-based supervised learning, molecular docking, molecular dynamics simulations, and various in-silico techniques. The objective was to effectively screen the Chemdiv and SPECS molecule databases to discover potential inhibitors targeting both HMGCR and ASGR1, resulting in a dual inhibition effect. Compound 8006-6092, K007-0721, and D011-1471 exhibited inhibition rates of 41.48 %, 61.48 %, and 49.63 %, respectively, at a concentration of 10 μM against HMGCR. In addition, they demonstrated significant binding to ASGR1, with dissociation constants (Kd) of 461.33 μM, 67.63 μM, and 695.50 μM, respectively. These findings suggest that these dual inhibitors, 8006-6092, K007-0721, and D011-1471, present promising outcomes, potentially warranting further optimization as lead compounds for the treatment of ASCVD.

Cholesterol crystals in the pathogenesis of atherosclerosis

The presence of cholesterol crystals (CCs) in tissues was first described more than 100 years ago. CCs have a pathogenic role in various cardiovascular diseases, including myocardial infarction, aortic aneurysm and, most prominently, atherosclerosis. Although the underlying mechanisms and signalling pathways involved in CC formation are incompletely understood, numerous studies have highlighted the existence of CCs at various stages of atheroma progression. In this Review, we summarize the mechanisms underlying CC formation and the role of CCs in cardiovascular disease. In particular, we explore the established links between lipid metabolism across various cell types and the formation of CCs, with a focus on CC occurrence in the vasculature. We also discuss CC-induced inflammation as one of the pathogenic features of CCs in the atheroma. Finally, we summarize the therapeutic strategies aimed at reducing CC-mediated atherosclerotic burden, including approaches to inhibit CC formation in the vasculature or to mitigate the inflammatory response triggered by CCs. Addressing CC formation might emerge as a crucial component in our broader efforts to combat cardiovascular disease.

A Phase I Study to Evaluate the Relative Bioavailability, Pharmacodynamics, and Safety of a Single Subcutaneous Injection of Recaticimab at Three Different Sites in Healthy Chinese Subjects

BACKGROUND AND OBJECTIVES

Recaticimab (SHR-1209) is a humanized monoclonal antibody that binds to the proprotein convertase subtilisin/kexin type 9 (PCSK9) with high affinity. This study was conducted to compare the relative bioavailability, pharmacokinetics (PK), pharmacodynamics (PD), and safety of recaticimab following subcutaneous injection at three different sites in healthy Chinese subjects.

METHODS

In this randomized, parallel, open-label, phase I study, 159 healthy Chinese subjects were randomized to receive a single dose of 450 mg recaticimab subcutaneously into the abdomen, upper-arm, or thigh and were followed up until 113 days postdose. Adverse events were monitored, and serum samples were collected for PK, PD, and immunogenicity evaluation during the study.

RESULTS

The PK profiles of recaticimab were similar among different injection site groups. The geometric mean ratios of maximum serum concentration (Cmax), area under the serum concentration versus time curve (AUC) from time zero to the time of last quantifiable concentration (AUC0-last), and AUC from time zero extrapolated to infinity (AUC0-inf) between groups were all close to 1, with two-sided 90% confidence intervals within 0.8-1.25. Recaticimab showed similar effects on low-density lipoprotein cholesterol levels in all groups, with mean maximum percentage decreases ranging from 56.88% to 59.04%. The percentage changes from baseline in free PCSK9 and other lipid variables were similar across the three groups as well. Treatment-emergent adverse events were reported in 41/53 (77.4%, abdomen), 29/53 (54.7%, upper-arm), and 42/53 (79.2%, thigh) subjects, most of which were mild and resolved without treatment. The incidence of antidrug antibodies among the three groups was comparable.

CONCLUSIONS

A single subcutaneous injection of 450 mg recaticimab into the abdomen, upper-arm, or thigh was well-tolerated and presented similar PK and PD profiles, which supported the interchangeable use of the three injection sites for patients.

CLINICAL TRIAL IDENTIFIER

( www.

CLINICALTRIALS

gov ) NCT05370950 2022-05-07.

Preclinical and mechanistic perspectives on adipose-derived stem cells for atherosclerotic cardiovascular disease treatment

Adipose-derived mesenchymal stem cells (AD-MSCs) are a promising therapeutic modality for cardiovascular diseases due to their immunomodulatory, anti-inflammatory, and pro-angiogenic properties. This manuscript explores the current status, challenges, and future directions of AD-MSC therapies, focusing on their application in atherosclerosis (AS), myocardial infarction (MI), and heart failure (HF). Preclinical studies highlight AD-MSC's ability to stabilise atherosclerotic plaques, reduce inflammation, and enhance myocardial repair through mechanisms such as macrophage polarisation, endothelial protection, and angiogenesis. Genetically and pharmacologically modified AD-MSCs, including those overexpressing SIRT1, IGF-1, and PD-L1 or primed with bioactive compounds, exhibit superior efficacy compared to unmodified cells. These modifications enhance cell survival, immunopotency, and reparative capacity, showcasing the potential for tailored therapies. However, clinical translation faces significant hurdles. While recent clinical trials have confirmed the safety of AD-MSC therapy, their efficacy remains inconsistent, necessitating further optimisation of patient selection, dosing strategies, and delivery methods. Donor variability, particularly in patients with co-morbidities like type 2 diabetes (T2D) or obesity, impairs AD-MSC efficacy. Emerging research on extracellular vesicles (EVs) derived from AD-MSC offers a promising cell-free alternative, retaining the therapeutic benefits while mitigating risks. Future perspectives emphasise the need for multidisciplinary approaches to overcome these limitations. Strategies include refining genetic modifications, exploring EV-based therapies, and integrating personalised medicine and advanced diagnostic tools. By addressing these challenges, AD-MSC therapies hold the potential to revolutionise the treatment of cardiovascular diseases, providing innovative solutions to improve patient outcomes.

Inflammatory and lipemic response to red meat intake in women with and without Rheumatoid Arthritis: a single meal study within a randomized controlled trial

BACKGROUND

The risk of atherosclerotic cardiovascular disease (ASCVD) is increased in Rheumatoid Arthritis (RA). Previous research has suggested that lipid metabolism is altered in RA, but research under postprandial conditions is scarce. The aim of this study was to investigate whether women with RA have a different lipemic and inflammatory response to a mixed meal containing red meat compared to women without RA.

METHODS

Twenty-two women with RA, with modest disease activity, and 22 women without RA matched for age and body mass index (BMI) at the group level consumed a hamburger meal containing ca. 700 kcal (53 E% from fat, 27 E% from carbohydrate). Venous blood was sampled in the fasted state and after 30 min, 1, 2, 3 and 5 h and analysed for lipid species using nuclear magnetic resonance spectroscopy. Postprandial inflammation was measured by interleukin- 6 (IL- 6). The postprandial lipid response was calculated as the incremental area under the curve minimal value, and serial measurements were analysed by repeated measures analysis of variance. Lipid and inflammatory responses were compared by linear regression analysis, adjusted for age, BMI, physical activity, and baseline plasma concentration.

RESULTS

Plasma concentrations of IL- 6, triglycerides (TGs) and very low-density lipoprotein (VLDL) particles increased significantly after the meal compared to baseline within both groups, but no differences were observed between groups. However, the women with RA had a less pronounced response in cholesterol carried in VLDL particles (p = 0.03) and in TGs in the subfraction of VLDL particles with highest density (p = 0.03). No association was found between the response in TGs and IL- 6.

CONCLUSION

This study does not provide compelling evidence for any difference in the lipemic or inflammatory response in women with RA compared with age- and BMI-matched women without RA following ingestion of a mixed, high-fat meal containing red meat. The modest disease activity in women with RA should be considered when interpreting these findings. Subtle group differences found in the lipids carried by VLDL particles warrant further investigation.

TRIAL REGISTRATION

The PIRA (Postprandial Inflammation in Rheumatoid Arthritis) trial was registered 2020-01 - 28 at Clinicaltrials.gov (NCT04247009).

Residual cholesterol and inflammatory risk in statin-treated patients undergoing percutaneous coronary intervention†

BACKGROUND AND AIMS

Elevated LDL-cholesterol levels and inflammation, as assessed by high-sensitivity C-reactive protein, correlate with cardiovascular risk. However, data on the relative impact of residual LDL-cholesterol and inflammatory risk among statin-treated patients undergoing percutaneous coronary intervention (PCI) is lacking. Hence, this study aimed to investigate the impact of residual cholesterol/inflammatory risk in patients on statin therapy undergoing PCI.

METHODS

From 2012 to 2022, patients at a tertiary centre undergoing PCI were analysed. Patients were stratified according to LDL-cholesterol (≥70 vs <70 mg/dL) and high-sensitivity C-reactive protein (≥2 vs <2 mg/L) levels: no residual cholesterol or inflammatory risk, residual cholesterol risk, residual inflammatory risk, and combined residual cholesterol and inflammatory risk. Patients presenting with acute myocardial infarction, cancer, no statin treatment at admission, or high-sensitivity C-reactive protein levels >10 mg/L were excluded. The primary endpoint was major adverse cardiovascular events (MACEs), defined as the composite of all-cause mortality, spontaneous myocardial infarction, and stroke 1 year after the index PCI.

RESULTS

A total of 15 494 patients were included. After 1-year follow-up, individuals with isolated residual inflammatory risk had the highest MACE rate (5.1%), followed by patients with combined cholesterol and inflammatory risk, no residual risk, and isolated residual cholesterol risk. After multivariable Cox regression analysis, patients with residual inflammatory risk had a 1.8-fold higher risk for MACE (adjusted hazard ratio: 1.78, 95% confidence interval 1.36-2.33, P < .001) compared with those with no residual cholesterol or inflammatory risk. This was similar in patients with combined residual cholesterol and inflammatory risk (adjusted hazard ratio: 1.56, 95% confidence interval 1.19-2.04, P = 0.001). Of note, no independent association of isolated residual cholesterol risk (adjusted hazard ratio: 1.01, 95% confidence interval .76-1.35, P-value = .920) with MACE was noted (P-trend across all groups <.001).

CONCLUSIONS

Among statin-treated patients undergoing PCI, residual inflammation but not cholesterol risk was associated with an increased risk of MACE during follow-up.

Modern therapy of patients with lupus erythematosus must include appropriate management of their heightened rates of atherosclerotic cardiovascular events: a literature update

Atherosclerotic cardiovascular disease (ASCVD) remains the biggest killer of patients with lupus erythematosus (LE) and the general non-autoimmune population. In this literature update on LE and ASCVD, we focused on published work since our earlier review article, meaning from 2021 to the present, with an emphasis on cutaneous LE. Several themes emerged. First, new work shows that patients with lupus still exhibit a high burden of conventional risk factors for ASCVD events. Second, recent studies continue to implicate possible effects of lupus disease activity to worsen rates of ASCVD events beyond predictions from conventional risk factors. Third, new work on estimating the risk of future ASCVD events in patients with lupus supports arterial-wall imaging, inclusion of lupus-specific factors, estimators of ASCVD event risk that take lupus status into account and considering lupus as a diabetes equivalent or even as a diabetes-plus-smoking equivalent in this context. Technologies for arterial-wall imaging continue to improve and will likely play an increasing role in ASCVD assessment and management. Fourth, purported cardiovascular benefits from certain disease-modifying antirheumatic drugs such as antimalarials have become less clear. Fifth, earlier treatment of atherosclerosis, which is a lifelong disease, can be accomplished with diet, exercise, smoking cessation and new classes of safe and effective medications for lipid-lowering and blood pressure control. Benefits on subclinical arterial disease by imaging and on ASCVD events have been reported, supporting the concept that ASCVD is eminently manageable in this autoimmune condition. Sixth, despite the heightened risk for ASCVD events in patients with lupus, available therapeutic approaches remain unused or underused and, accordingly, event rates remain high.Raising awareness among patients and healthcare providers about ASCVD assessment and management in patients with LE is essential. Greater vigilance is needed to prevent ASCVD events in patients with lupus by addressing dyslipidaemias, hypertension, smoking, obesity and physical inactivity.

Small Remnants versus Large Triglyceride-Rich Lipoproteins in Risk of Atherosclerotic Cardiovascular Disease

BACKGROUND

Small remnants may penetrate the arterial intima more efficiently compared to large triglyceride-rich lipoproteins (TGRL). We tested the hypothesis that the importance of remnant cholesterol for the risk of atherosclerotic cardiovascular disease (ASCVD) may depend on the size of the remnants and TGRL carrying cholesterol.

METHODS

The cholesterol content of small remnants and large TGRL were measured in 25 572 individuals from the Copenhagen General Population Study (2003-2015) and in 222 721 individuals from the UK Biobank (2006-2010) using nuclear magnetic resonance spectroscopy. In the Copenhagen cohort during up to 15 years of follow-up and in the UK Biobank cohort during up to 16 years of follow-up, the numbers of individuals diagnosed with ASCVD (=myocardial infarction, ischemic stroke, and peripheral artery disease) in national health registries were 3869 and 11 424, respectively.

RESULTS

Compared to individuals with low cholesterol content in both small remnants and large TGRL (cutpoints were median cholesterol content), multivariable-adjusted hazard ratios for risk of ASCVD were 1.21 (95% confidence interval: 1.07-1.37) for individuals with high cholesterol content in small remnants only and 0.94 (0.83-1.07) for individuals with high cholesterol content in large TGRL only; the multivariable-adjusted hazard ratio for risk of ASCVD per 10 percentile-units higher cholesterol content in small remnants vs that in large TGRL was 1.04 (1.01-1.07). In the UK Biobank cohort, corresponding hazard ratios were 1.11 (1.03-1.20), 1.01 (0.93-1.09), and 1.05 (1.04-1.07), respectively.

CONCLUSION

The importance of remnant cholesterol for the risk of ASCVD may depend on the size of the TGRL and remnants carrying cholesterol.

The Atherosclerotic Plaque Microenvironment as a Therapeutic Target

PURPOSE OF REVIEW

Atherosclerosis is traditionally viewed as a disease triggered by lipid accumulation, but growing evidence underscores the crucial role of the plaque microenvironment in disease progression. This review explores recent advances in understanding how cellular and extracellular components of the plaque milieu drive atherosclerosis, with a focus on leveraging these microenvironmental factors for therapeutic intervention. This review highlights recent advances in cell-cell crosstalk and matrix remodeling, offering insights into innovative therapeutic strategies for atherosclerotic cardiovascular disease.

RECENT FINDINGS

While atherosclerosis begins with the subendothelial retention of apolipoprotein B (ApoB)-containing lipoproteins​, its progression is increasingly recognized as a consequence of complex cellular and extracellular dynamics within the plaque microenvironment. Soluble factors and extracellular matrix proteins shape mechanical properties and the biochemical landscape, directly influencing cell behavior and inflammatory signaling. For instance, the deposition of transitional matrix proteins, such as fibronectin, in regions of disturbed flow primes endothelial cells for inflammation​. Likewise, impaired clearance of dead cells and chronic extracellular matrix remodeling contribute to lesion expansion and instability, further exacerbating disease severity. Targeting the plaque microenvironment presents a promising avenue for stabilizing atherosclerotic lesions. Approaches that enhance beneficial cellular interactions, such as boosting macrophage efferocytosis to resolve inflammation while mitigating proatherogenic signals like integrin-mediated endothelial activation, may promote fibrous cap formation and reduce plaque vulnerability. Harnessing these mechanisms may lead to novel therapeutic approaches aimed at modifying the plaque microenvironment to combat atherosclerotic cardiovascular disease.

Advancing atherosclerosis research: The Power of lipid imaging with MALDI-MSI

Atherosclerosis is a chronic inflammatory disease that is one of the leading causes of mortality globally. It is characterized by the formation of atheromatous plaques in the intima layer of larger arteries. The (fibro-)fatty plaques usually develop asymptomatically within the vessel until a serious event such as myocardial infarction or stroke occurs. Lipids play a pivotal role in disease progression, but while the causal role of cholesterol is beyond doubt, the distribution of numerous other lipids within the heterogeneous layers of atherosclerotic plaques, and their biological function remain unclear. A deeper understanding of the pathophysiological progression of the disease for prognostics, diagnostics, treatment, and prevention is of great need. Mass spectrometry imaging (MSI), in particular with matrix-assisted laser desorption/ionization (MALDI) offers an unprecedented untargeted characterization of the physiological microenvironment, unraveling the spatial distribution of numerous biochemical compounds. MALDI-MSI offers an advantageous balance of sample preparation, chemical sensitivity, and spatial resolution, and thus has been established as a key technology in modern biomedical analysis. This review focuses on the analysis of lipids in atherosclerotic lesions with MALDI-MSI, for which the past years showed major developments in the spatial characterization of lipids and their interaction within atherosclerotic plaques. We will cover main contributions with a focus on the recent decade, elaborate possibilities, limitations, main findings, and recent developments from sample handling to instrumentation, and estimate current challenges and potentials of MALDI-MSI with respect to a clinical application.

Therapeutic PCSK9 targeting: Inside versus outside the hepatocyte?

As a major regulator of LDL receptor (LDLR) activity and thus of LDL-cholesterol (LDL-C) levels, proprotein convertase subtilisin/kexin type 9 (PCSK9) represents an obvious therapeutic target for lipid lowering. The PCSK9 inhibitors, alirocumab and evolocumab, are human monoclonal antibodies (mAbs) that act outside the cell by complexing circulating PCSK9 and thus preventing its binding to the LDLR. In contrast, inclisiran, a small interfering RNA (siRNA), inhibits hepatic synthesis of PCSK9, thereby resulting in reduced amounts of the protein inside and outside the cell. Both approaches result in decreased plasma LDL-C concentrations and improved cardiovascular outcomes. Marginally superior LDL-C reduction (≈ 60 %) is achieved with mAbs as compared to the siRNA (≈ 50 %); head-to-head comparisons are required to confirm between-class differences in efficacy. Both drug classes have shown variability in LDL-C lowering response between individuals in waterfall analyses. Whereas mAb-mediated inhibition leads to a compensatory increase in plasma PCSK9 levels, siRNA treatment reduces them. These agents differ in their pharmacokinetic and pharmacodynamic features, which may translate into distinct clinical opportunities under acute (e.g. acute coronary syndromes) as compared to chronic conditions. Both drug classes provide additional reduction in LDL-C levels (up to 50 %) beyond those achieved with statin therapy, facilitating attainment of guideline-recommended LDL-C goals in high and very high-risk patients. Additional PCSK9 inhibitors, including an oral macrocyclic peptide, a small PCSK9 binding protein and a novel small molecule, plus hepatic gene editing of PCSK9, are under development. This review critically appraises pharmacological strategies to target PCSK9 either inside or outside the cell.

Discordance analyses comparing LDL cholesterol, Non-HDL cholesterol, and apolipoprotein B for cardiovascular risk estimation

For decades, studies have tried to identify the cholesterol marker that best reflects risk of atherosclerotic cardiovascular disease(ASCVD). Comparing low-density-lipoprotein(LDL) cholesterol, non-high-density-lipoprotein(non-HDL) cholesterol, and apolipoprotein B(apoB) as ASCVD risk markers has been challenged by high correlation between them. Thus, discordance analyses, directly addressing disagreements between the cholesterol markers, have emerged. Approaches adopted to define discordance originate in one of three methods: discordance by cut-points, discordance by percentiles, or discordance by residuals. Commonly, concordant lipid levels serve as reference examining the association between discordant lipid levels with risk of ASCVD. Importantly, concordant reference groups present heterogeneity of clinical relevance across different discordance methods as concordant low lipid levels associate with lowest ASCVD risk while concordant high lipid levels associate with highest risk. Thus, results from different discordance approaches cannot be directly compared. Moreover, discordance between cholesterol markers is more frequently seen in individuals treated with lipid-lowering medication than in individuals not treated with lipid-lowering medication. Accordingly, studies performing discordance analyses have reported inconsistent and even conflicting results. Discordance by cut-points appears the most intuitive and clinically applicable method; results from these analyses suggest that elevated LDL cholesterol, non-HDL cholesterol, or apoB levels in individuals not treated with lipid-lowering medication confer increased ASCVD risk while in individuals treated with lipid-lowering medication, elevated non-HDL cholesterol and apoB levels best indicate residual risk. Results from discordance analyses comparing LDL cholesterol, non-HDL cholesterol, and apoB in risk of ASCVD as well as complexities of discordance analyses and considerations regarding interpretations are discussed in this review.

(Apo)Lipoprotein Profiling with Multi-Omics Analysis Identified Medium-HDL-Targeting PSRC1 with Therapeutic Potential for Coronary Artery Disease

Identification of (apo)lipoprotein subclasses causally underpinning atherosclerosis may lead to identification of novel drug targets for treatment of atherosclerotic cardiovascular disease (ASCVD). In this study, observational and genetic associations between (apo)lipoprotein profile and carotid intima-media thickness-assessed atherosclerosis, and risks of coronary artery disease (CAD) and ischemic stroke (IS) are assessed, using data from the UK Biobank study, with further exploration of potential drug target for these two ASCVD subtypes through multi-omics analysis integrating genetic, transcriptomic, and proteomic data. Cholesteryl ester content in medium high-density lipoprotein causally protective of atherosclerosis is identified, plus a target gene, PSRC1, with therapeutic potential for CAD, but not IS, supported by consistent evidence from multi-omics layers of data, which also reveals that such therapeutic potential may be through downregulation of circulating proteins including TRP1, GRNs, and Pla2g12b, and upregulation of Neo1. The results provide strong evidence as well as mechanistic clues of PSRC1's therapeutic potential for CAD.

Inflammation in atherosclerosis: a Big Idea that has underperformed so far

PURPOSE OF REVIEW

For many years, inflammation has been a major concept in basic research on atherosclerosis and in the development of potential diagnostic tools and treatments. The purpose of this review is to assess the performance of this concept with an emphasis on recent clinical trials. In addition, contemporary literature may help identify new therapeutic targets, particularly in the context of the treatment of early, rather than end-stage, arterial disease.

RECENT FINDINGS

Newly reported clinical trials cast doubt on the efficacy of colchicine, the sole anti-inflammatory agent currently approved for use in patients with atherosclerotic cardiovascular disease (ASCVD). New analyses also challenge the hypothesis that residual ASCVD event risk after optimal management of lipids, blood pressure, and smoking arises primarily from residual inflammatory risk. Current clinical practice to initiate interventions so late in the course of atherosclerotic arterial disease may be a better explanation. Lipid-lowering therapy in early atherosclerosis, possibly combined with novel add-on agents to specifically accelerate resolution of maladaptive inflammation, may be more fruitful than the conventional approach of testing immunosuppressive strategies in end-stage arterial disease. Also discussed is the ongoing revolution in noninvasive technologies to image the arterial wall. These technologies are changing screening, diagnosis, and treatment of atherosclerosis, including early and possibly reversable disease.

SUMMARY

The burden of proof that the Big Idea of inflammation in atherosclerosis has clinical value remains the responsibility of its advocates. This responsibility requires convincing trial data but still seems largely unmet. Unfortunately, the focus on inflammation as the source of residual ASCVD event risk has distracted us from the need to screen and treat earlier.

HOMA-IR and TyG index differ for their relationship with dietary, anthropometric, inflammatory factors and capacity to predict cardiovascular risk

BACKGROUND

HOMA-IR and the triglyceride-glucose index (TyG index) are surrogate indexes of insulin resistance. However, it remains to elucidate how HOMA-IR and the TyG index compare for their relationship with cardiometabolic health.

AIM

This study aimed at comparing HOMA-IR and the TyG index with regard to their relationship with anthropometric, dietary and inflammatory factors as well as ability to predict cardiovascular risk.

METHODS

438 subjects aged 55-80 years, underwent anthropometric, metabolic and nutritional characterisation. Spearman's correlation coefficient was used to evaluate the association between the parameters of interest. Predictors of HOMA-IR, the TyG index and the 10-year risk of cardiovascular events were investigated using stepwise multivariable regression analysis.

RESULTS

HOMA-IR and TyG index correlated positively with body mass index, waist circumference, fat mass, systolic and diastolic blood pressure, interleukin-18 and C-reactive protein. However, only HOMA-IR correlated with dietary factors. After adjusting for age and sex, waist circumference and interleukin-18 were stronger predictors of HOMA-IR compared to the TyG index. Instead, the TyG index, but not HOMA-IR, emerged as a predictor of cardiovascular risk.

CONCLUSIONS

The TyG index represents a better predictor of cardiovascular risk compared to HOMA-IR which, instead, exhibits a stronger relationship with anthropometric, inflammatory and nutritional variables.

Coronary artery event-free or resilient familial hypercholesterolemia: what's in a name?

PURPOSE OF REVIEW

Familial hypercholesterolemia (FH) is an autosomal semi-dominant condition, characterized by excessive circulating low-density lipoprotein cholesterol (LDL-C) from birth that substantially accelerates the onset and progression of atherosclerotic cardiovascular disease (ASCVD), classically coronary artery disease (CAD). Elevated plasma LDL-C integrated over time is unequivocally the major determinant of ASCVD in heterozygous FH (HeFH); however, the wide variation in incidence and progression of ASCVD suggests a role for a wide spectrum of risk modifiers. We reviewed recent evidence describing the features of an ASCVD-free entity referred to as resilient FH among patients with HeFH.

RECENT FINDINGS

Compared with nonresilient FH patients, resilient patients are more likely to be female, and have a lower prevalence of ASCVD comorbidities, higher levels of HDL-C and larger HDL particles, as well as a lower level of lipoprotein(a). A lower SAFEHEART risk score is also an independent predictor of resilient FH. Gene expression studies also demonstrate that resilient FH patients are associated with a less atherogenic gene expression profile in relation to HDL metabolism and immune responses, as reflected by higher expression of ABCA1 and ABCG1, and lower expression of STAT2 and STAT3, respectively.

SUMMARY

A group of HeFH patients, referred as resilient FH, can survive to advance ages without experiencing any ASCVD events. Several key contributors to the event-fee CAD in HeFH patients have been identified. This could not only improve risk stratification and management for FH but also be of major importance for the general population in primary and secondary prevention. However, resilient FH remains an under-investigated area and requires further research.

Examining the link between 179 lipid species and 7 diseases using genetic predictors

BACKGROUND

Genome-wide association studies of lipid species have identified several loci shared with various diseases, however, the relationship between lipid species and disease risk remains poorly understood. Here we investigated whether the plasma levels of lipid species are causally linked to disease risk.

METHODS

We built genetic predictors of 179 lipid species, measured in 7174 Finnish individuals, by utilising either 11 high-impact genomic loci or genome-wide polygenic scores (PGS). We assessed the impact of the lipid species on seven diseases by performing disease association across FinnGen (n = 500,348), UK Biobank (n = 420,531), and Generation Scotland (n = 20,032). We performed univariable Mendelian randomisation (MR) and multivariable MR (MVMR) analyses to examine whether lipid species impact disease risk independently of standard lipids.

FINDINGS

PGS explained >4% of the variance for 34 lipid species but variants outside the high-impact loci had only a marginal contribution. Variants within the high-impact loci showed association with all seven diseases. MVMR supported a causal role of ApoB in ischaemic heart disease after accounting for lipid species. Phosphatidylethanolamine-increasing LIPC variants seemed to lower age-related macular degeneration risk independently of HDL-cholesterol. MVMR suggested a protective effect of four lipid species containing arachidonic acid on cholelithiasis risk independently of Total Cholesterol.

INTERPRETATION

Our study demonstrates how genetic predictors of lipid species can be utilised to gain insights into disease risk. We report potential links between lipid species and age-related macular degeneration and cholelithiasis risk, which can be explored for their utility in disease risk prediction and therapy.

FUNDING

The funders had no role in the study design, data analyses, interpretation, or writing of this article.

Effects of residual inflammatory and cholesterol risks on cardiovascular events with evolocumab in patients with acute coronary syndrome undergoing percutaneous coronary intervention

BACKGROUND

Evolocumab has shown significant reductions in low-density lipoprotein cholesterol (LDL-C) levels and incident cardiovascular events among acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). Nonetheless, the potential modification of evolocumab's effectiveness by baseline inflammatory risk remains unclear. We aimed to assess evolocumab's effectiveness based on baseline neutrophil-to-lymphocyte ratio (NLR) and evaluate residual inflammatory and cholesterol-related risks across varying on-treatment NLR and LDL-C levels.

METHODS

This multicentric, retrospective analysis enrolled consecutive patients with ACS undergoing PCI and exhibiting elevated LDL-C at the First Affiliated Hospital of Zhengzhou University and Zhongda Hospital Southeast University between March 2019 and August 2021. Patients were categorized into evolocumab and standard-of-care treatment groups based on evolocumab administration. Hazard ratios for the primary composite outcome-including myocardial infarction, ischemic stroke, cardiac death, unplanned coronary revascularization, and hospitalization due to unstable angina-comparing baseline NLR quartiles were computed using multivariable Cox regression. We assessed evolocumab's impact on the primary outcome across median-based NLR dichotomization and evaluated the outcome across 1-month NLR and LDL-C levels.

RESULTS

The median baseline NLR was 2.99 (IQR: 2.14-4.69), remaining stable following evolocumab therapy. Each NLR quartile increase heightened the risk of primary outcome by 29% (95% CI, 17-42%; P < 0.01). The relative risk reductions with evolocumab were consistent across NLR categories (P-interaction > 0.05), but absolute risk reductions were higher in high-NLR patients (2.9% vs. 6.2%). Residual inflammatory and cholesterol risks, indicated by on-treatment NLR and LDL-C, independently correlated with the primary outcome (P < 0.001).

CONCLUSIONS

Higher baseline NLR is associated with increased cardiovascular risk in ACS/PCI patients. Relative risk reductions with evolocumab were consistent across NLR categories, while absolute risk reductions were more significant in high-NLR patients. Minimized risk is observed in patients with the lowest on-treatment NLR and LDL-C levels.

Research Progress on Anti-Hyperlipidemia Peptides Derived from Foods

Hyperlipidemia is a metabolic disorder in which cholesterol (TC) and triglycerides (TGs) in the blood exceed the normal physiological levels. The incidence of the condition has continued to rise in recent years, posing a serious threat to public health. Its clinical treatment mainly relies on drug interventions, such as statins, fibrate, and niacin. Although these drugs have shown some efficacy in the treatment of hyperlipidemia, their adverse effects cannot be ignored. In contrast, naturally derived peptides have gradually become potential candidates for the prevention and treatment of hyperlipidemia due to their strong anti-hyperlipidemic activity and safety; examples of such peptides include those from dairy products, grains, legumes, and seafood. This review systematically summarizes peptides with anti-hyperlipidemic activity and analyzes their mechanisms of action, providing a theoretical basis for further research. In addition, we also outline some challenges facing the application of peptides, hoping to prevent hyperlipidemia and reduce its incidence by encouraging the consumption of foods rich in anti-hyperlipidemia peptides.

Assessing LDL-C Levels and Lipid-Modifying Therapies in a Real-World Cohort of Patients with Atherosclerotic Cardiovascular Disease: The REALITY Study

Background and Objectives: Patients with atherosclerotic cardiovascular disease (ASCVD) remain at high risk of recurrent events. REALITY aims to analyse the actual levels of low-density lipoprotein cholesterol (LDL-C), the modalities of lipid-lowering therapies (LLT) used, and ASCVD patient outcomes in a real-world setting in Spain. Methods: REALITY is a retrospective observational study conducted using a healthcare database of 1.8 million patients representative of the Spanish population. The study included 26,976 patients with new or recurrent ASCVD events recruited from 2017 to 2019 and followed up for two years. Results: Management of ASCVD involved the utilisation of high-intensity (53%) or very high-intensity (36%) LLT. After two years, a decrease in total cholesterol (from 228.7 to 176.7 mg/dL), LDL-C (from 126.4 to 99.0 mg/dL), and triglycerides (from 216.7 to 163.7 mg/dL), accompanied by a moderate increase in HDL-C levels was observed. However, LDL-C goals of ESC/EAS guidelines were only reached by a minority of patients. Less than 15% of ASCVD patients achieved their LDL-C goals of <70, as stated in contemporary guidelines (3% if the present <55 mg/dL threshold in the ESC/EAS guidelines is considered). During the follow-up period, 9% of ASCVD patients died and 25% experienced a new ASCVD event. Conclusions: In the REALITY study, most patients did not achieve their target LDL-C goals despite receiving high- or very high-intensity LLT. Increasing the utilisation of extreme LLT is crucial to reducing recurrent ASCVD events and mitigating these patients' high morbidity and mortality risk.

Distinct lipoprotein contributions to valvular heart disease: Insights from genetic analysis

BACKGROUND

The per-particle pathogenicity of very-low-density lipoprotein (VLDL) and lipoprotein(a) [Lp(a)] with risk of valvular heart diseases (VHD) other than aortic stenosis compared with low-density lipoprotein (LDL) remains unclear.

METHODS

Single-nucleotide polymorphism specific clusters associated with LDL cholesterol (LDL-C), VLDL cholesterol (VLDL-C) and Lp(a) were identified. The relationships of genetically predicted variation in apolipoprotein B (apoB) in these lipoproteins with risk of VHD and its major types (aortic stenosis, aortic regurgitation, and mitral regurgitation) were evaluated to determine the comparative pathogenicity by Mendelian randomization (MR) analyses.

RESULTS

The VHD odds ratio (OR) per 1 g/L higher apoB was 1.09 [95 % confidence interval (CI) 1.04-1.15] in LDL vs. 1.45 (95 % CI 1.25-1.69) in VLDL vs. 2.71 (95 % CI 1.92-3.82) in Lp(a) based on the cluster-based MR analyses. The polygenic scores for each lipoprotein weighted by apoB similarly showed a greater OR of VHD per 1 g/L apoB in VLDL [1.20 (95 % CI 1.06-1.37)] and in Lp(a) [2.54, (95 % CI 1.95-3.32)] compared with that in LDL [1.05 (95 % CI 1.01-1.08)]. Multivariable MR analyses further revealed the strong effects of VLDL-C and Lp(a) on VHD risk independent of LDL-C. In addition, significant associations between Lp(a) and all three major types of VHD were observed, while LDL and VLDL had no impact on aortic and mitral regurgitation.

CONCLUSIONS

VLDL and Lp(a) appear to have significantly greater per-particle pathogenicity in VHD compared to LDL. The distinct impacts of lipoproteins on different VHD subtypes suggest the inadequacy of just focusing on LDL-lowering treatment for valve disorders.

Combined predictive value of uric acid and serum lipid for stroke events in non-valvular atrial fibrillation patients

Background

Serum uric acid (SUA) and lipid metabolism disorders are closely associated with atrial fibrillation (AF) and its prognosis. In patients with non-valvular AF (NAF), we evaluated the combined predictive value of SUA, triglycerides (TG), and low-density lipoprotein (LDL) for stroke to enhance stroke risk prediction and management.

Methods and results

We included 3,176 NAF patients treated at the First Affiliated Hospital of Dalian Medical University from January 2020 to December 2023. We analyzed SUA concentration and lipid profile, along with relevant clinical data, to assess their impact on the occurrence of ischemic stroke (IS) in NAF patients. Due to gender differences in TG (1.39 mmol/L vs. 1.28 mmol/L for males, P = 0.031;1.57 mmol/L vs. 1.28 mmol/L for females, P = 0.001) and SUA levels (424 µmol/L vs. 397 µmol/L for males, P = 0.008; 361 µmol/L vs. 328 µmol/L for females, P = 0.004), we determined the thresholds for SUA (400 µmol/L in males and 330 µmol/L in females) and TG (1.28 mmol/L in males and 1.29 mmol/L in females) that predict stroke events in NAF patients by restricted cubic spline curves. Kaplan-Meier cumulative risk analysis indicates that a gender-based combined assessment of SUA and TG enhances stroke risk stratification in NAF patients. Compared to patients with low levels of SUA and TG, those with high levels of these biomarkers have a higher risk of IS (HR = 1.98). On multivariable Cox regression analysis with potential confounders, elevated SUA and low-density lipoprotein (LDL) levels were significantly associated with an increased risk of stroke. In summary, we developed the CHA2DS2-VASc+SUA+TG+LDL stroke risk prediction model. Its clinical predictive value was assessed using Harrell's C-statistic (C-index), integrated discrimination improvement (IDI) statistics, and net reclassification index (NRI) analysis.

Conclusions

SUA, TG and LDL were strongly associated with stroke for NAF. The combination of SUA, TG, and LDL effectively enhanced the predictive value of the CHA2DS2-VASc score for IS.

Genetic and pharmacological targeting of Snail inhibits atherosclerosis by relieving intraplaque endothelium dysfunction and associated inflammation

The intraplaque endothelium dysfunction and associated inflammation contribute to the progression of atherosclerosis. We previously show that zinc-finger transcription factor Snail is predominantly expressed in embryonic vascular endothelial cells (ECs), and deletion of Snail in ECs induces severe defects in vascular development and thus causes embryonic lethality. Snail is essentially absent at postnatal stage, and inducible deletion of Snail in ECs has no impact on physiological angiogenesis in postnatally developing or adult mice. In this study we investigated whether Snail was reactivated in vascular ECs during pathologically angiogenic process (e.g. the formation of atherosclerotic plaque) or could play a functional role in atherosclerosis progression. We showed that the expression levels of Snail were significantly elevated in ECs of human and mouse atherosclerotic plaques, and associated with the disease severity. In the accelerated and canonical mouse models of atherosclerosis, tamoxifen-inducible, EC-specific Snail deletion significantly reduced intraplaque endothelial dysfunction, inflammation and lipid uptake accompanied by enhanced plaque stability. By conducting scRNA-sequencing in ECs of ApoE-/-SnailiΔEC versus ApoE-/-Snailfl/fl arterial vessels, we demonstrated that Snail deletion significantly decreased histone acetylation on Ccl5 and Cxcl10 promoters, thereby decreased CCL5/CXCL10-driven vascular damage and inflammation. Administration with recombinant CXCL10 protein (2 μg/kg, i.v., once per week for three weeks) efficiently restored atherosclerosis in EC-specific Snail-deleted mice. Finally, we developed an orally bioavailable small-molecule Snail inhibitor LFW273 that displayed potent anti-atherosclerotic effects in mice. These results reveal Snail as a promising therapeutic target in atherosclerotic disease.

Lipid profiles and their association with incident carotid atherosclerosis: A community-based prospective study in Taiwan

BACKGROUND AND AIMS

Dyslipidemia, characterized by abnormal blood lipid levels, contributes to atherosclerosis, a condition involving arterial plaque buildup and cardiovascular events. While LDL-C and LDL-to-HDL-C ratios are established atherosclerosis predictors, the role of non-HDL-C is less explored.

METHODS AND RESULTS

A cohort of 1062 participants without carotid plaque at baseline was analyzed over a 4.0-year follow-up. Age-specific incidence rates were calculated, and baseline characteristics of those who developed plaques were compared using logistic regression and area under the ROC curve (AUROC) analysis to evaluate predictive models. Carotid plaques developed in 284 participants (87 males, 197 females). Incidence rates increased with age, reaching 41.2 % in females and 60.0 % in males aged 70-74 years. Participants with plaques were older (58.2 vs. 55.4 years, p < 0.0001), had higher BMI, blood pressure, and lipid markers, and were more likely to be male, hypertensive, or hyperlipidemic. Logistic regression identified age (OR 1.26 per 5 years), BMI (OR 1.23 per 5 kg/m2), LDL-C (OR 1.07 per 10 mg/dL), and LDL-to-HDL-C ratio (OR 1.41) as significant predictors, with HDL-C offering a protective effect. Models incorporating lipid ratios (non-HDL-to-HDL-C or LDL-to-HDL-C) showed similar predictive power (AUROC 0.636).

CONCLUSION

Carotid plaque progression correlates with age, male sex, elevated BMI, hypertension, and adverse lipid profiles. Lipid ratios and age are consistent predictors, with HDL-C demonstrating protective effects. Comparable AUROC values across models underscore the value of lipid ratios for assessing atherosclerosis risk.

A natural small molecule isoginkgetin alleviates hypercholesterolemia and atherosclerosis by targeting ACLY

Rationale: Atherosclerotic cardiovascular disease (ASCVD) represents the predominant cause of mortality and morbidity globally. Given the established role of hypercholesterolemia as a significant risk factor for ASCVD, the discovery of new lipid-lowering medications is of paramount importance. ATP citrate lyase (ACLY) is a crucial enzyme in cellular metabolism, providing acetyl-CoA as the building block for the biosynthesis of fatty acids and cholesterol. Consequently, it has emerged as a promising drug target for innovative treatments of lipid metabolic disorders. Methods: Virtual screening of a natural product library was performed to identify small-molecule ACLY inhibitors, leading to the discovery of isoginkgetin (ISOGK). The lipid-lowering and anti-atherosclerotic effects of ISOGK were validated in hypercholesterolemic diet-induced animal models (mice and hamsters). The inhibitory effects of ISOGK on ACLY enzymatic activity were measured using commercial assay kits. The direct interaction between ISOGK and ACLY was confirmed by surface plasmon resonance (SPR) and cellular thermal shift assays (CETSA). Liver-specific ACLY knockdown mice were generated using GalNAc-conjugated siRNA (GalNAc-siAcly). Results: ISOGK directly bind to ACLY and inhibit its enzymatic activity in vitro and in vivo. By inhibiting ACLY, ISOGK treatment thus alleviates hypercholesterolemia and atherosclerosis in mice and hamsters. However, ISOGK fails to attenuate lipid accumulation and the expression of lipid-metabolism related genes in Acly knockout or depleted hepatocytes. In vivo, the lipid-lowering and anti-atherosclerotic effects of ISOGK were reversed by hepatic knockdown of Acly via treatment with GalNAc-siAcly in mice. Conclusions: Taken together, the present study identifies ISOGK as an effective and naturally-occurring small-molecule inhibitor of ACLY that limits hypercholesterolemia and atherosclerosis. ISOGK thus serves as a promising drug lead in cardiovascular therapeutics.

Unraveling the metabolic‒epigenetic nexus: a new frontier in cardiovascular disease treatment

Cardiovascular diseases are the leading causes of death worldwide. However, there are still shortcomings in the currently employed treatment methods for these diseases. Therefore, exploring the molecular mechanisms underlying cardiovascular diseases is an important avenue for developing new treatment strategies. Previous studies have confirmed that metabolic and epigenetic alterations are often involved in cardiovascular diseases across patients. Moreover, metabolic and epigenetic factors interact with each other and affect the progression of cardiovascular diseases in a coordinated manner. Lactylation is a novel posttranslational modification (PTM) that links metabolism with epigenetics and affects disease progression. Therefore, analyzing the crosstalk between cellular metabolic and epigenetic factors in cardiovascular diseases is expected to provide insights for the development of new treatment strategies. The purpose of this review is to describe the relationship between metabolic and epigenetic factors in heart development and cardiovascular diseases such as heart failure, myocardial infarction, and atherosclerosis, with a focus on acylation and methylation, and to propose potential therapeutic measures.

Small dense low-density lipoprotein as biomarker in the elderly

OBJECTIVES

Small dense low-density lipoprotein (sdLDL) is atherogenic and associated with atherosclerotic cardiovascular diseases (ASCVD). The aim of this study was to perform the prospective evaluation of sdLDL-c in new ASCVD over 18 years of follow up, and to compare the association of sdLDL-c and conventional lipids and apolipoproteins with ASCVD in the elderly.

METHODS

This prospective study included a total of 1770 subjects ≥ 64 years of age with an 18-year follow-up period. The determination of sdLDL-c was measured by a homogenous, selective enzymatic method. Levels of total cholesterol (TC), high-density lipoprotein cholesterol (HDL-c) and triglycerides (TG) were determined by enzymatic methods. Apolipoproteins, ApoA1 and ApoB, were analyzed by immunonephelometric methods. Low-density lipoprotein cholesterol (LDL-c) levels were calculated using the Friedewald formula.

RESULTS

According to Pearson's correlation coefficients, sdLDL-c concentration was positively correlated with LDL-c, nonHDL-c, TC and ApoB concentrations. During follow up, sdLDL-c was significantly associated with new ASCVD in men aged 64-76 years in both unadjusted and adjusted Cox regression models. The adjusted hazard ratio (95 % CI) for sdLDL-c was 1.61 (1.13-2.28). No significant associations between sdLDL-c and ASCVD were observed in men aged 77-97 years, nor in women aged 64-79 or 80-100 years.

CONCLUSIONS

Lipid and apolipoprotein concentrations of the elderly were high compared to the recommended target values. In addition, lipid and apolipoprotein baseline concentrations were not higher in the ASCVD group than in the control group. Our results indicated that sdLDL-c is as good a marker as ApoB and better than LDL-c.

Proatherogenic changes in the quantity and quality of lipoproteins in adults with idiopathic nephrotic syndrome

OBJECTIVE

Lipoprotein subclasses and high-density lipoprotein (HDL) functions are associated with atherosclerotic cardiovascular disease (ASCVD), but researches on them in patients with nephrotic syndrome (NS) are limited. The aims of this study were (1) to analyze the changes in quantity and quality of lipoprotein in patients with idiopathic nephrotic syndrome (INS) and patients in remission from NS, and (2) to evaluate the lipid-related atherosclerotic risk in these patients.

METHODS

51 patients with idiopathic nephrotic syndrome (NS group), 72 NS patients with complete remission (NS remission group), and 80 healthy controls (control group) were recruited. The levels of conventional lipids, lipoprotein subclasses, including VLDL, IDL (C, B, A), LDL (LDL1-7), HDL (large, intermediate, small) and HDL cholesterol efflux capacity (CEC), were measured and compared across the three groups.

RESULTS

Conventional lipid parameters [TG, TC, LDL-C, apo-B and Lp(a)] and lipoprotein subclasses (VLDL, IDL-C, IDL-B, LDL-2 and sdLDL) were higher in NS group when compared to NS remission group and control group (P < 0.05). CEC in NS group was significantly lower than that in control group [21.0 (18.3-27.2) % vs 25.7 (23.3-28.9) %] (P < 0.001) and improved to 22.8 (20.6-23.7) % in NS remission group with the disease recovery.

CONCLUSION

Proatherogenic changes in conventional lipid parameters, lipoprotein subclasses and HDL-CEC were observed in patients with NS, suggesting that more rigorous lipid regulation strategies may help reduce cardiovascular disease risk in patients with NS.

Regular-fat and low-fat dairy foods and cardiovascular diseases: perspectives for future dietary recommendations

Most current dietary guidelines for the prevention of cardiovascular diseases (CVD) recommend the consumption of low-fat dairy in place of regular-fat dairy foods, one of the main sources of dietary saturated fatty acids (SFAs). Here, we summarize the data presented and discussions held-relating to the validity of such recommendations-between a panel of international nutrition research experts at a high-level closed workshop on "Saturated Fat in Dairy and Cardiovascular Diseases," which took place in Amsterdam on 15-16 April, 2024. The most recent evidence indicates that overall, consumption of milk, yogurt and cheese, irrespective of fat content, is neutrally associated with CVD risk. There is also no evidence yet from randomized controlled trials that consumption of regular-fat milk, yogurt, and cheese has different effects on a broad array of cardiometabolic risk factors when compared with consumption of low-fat milk, yogurt, and cheese. Thus, the body of evidence does not support differentiation between regular-fat and low-fat dairy foods in dietary guidelines for both adults and children. Strategies focusing primarily on reduction of energy-dense, nutrient-poor foods, the main source of SFAs in Western diets, rather than on the fat content of dairy foods, are more likely to benefit the population's cardiovascular health. Future research is needed to understand better the place of regular-fat and low-fat dairy foods within healthy eating patterns.

ROS-responsive simvastatin nano-prodrug based on tertiary amine-oxide zwitterionic polymer for atherosclerotic therapy

Atherosclerosis (AS) is a major cause of cardiovascular disease and is characterized by high levels of reactive oxygen species (ROS) and lipid deposition. This study utilized ROS-responsive oxalate bonds to conjugate simvastatin (SV) and tertiary amine-oxide zwitterionic polymer (OPDH), resulting in the design of a ROS-responsive simvastatin nano-prodrug (OPDH-SV). In vitro experiments have proved that OPDH-SV has excellent stability and low toxicity, can effectively reduce intracellular ROS and lipid levels, and inhibit foam cells formation. In addition, OPDH-SV is able to achieve cell-to-cell transmission through the cell's "endocytosis-efflux" mechanism and target mitochondria. In vivo experiments further confirmed the long-term circulation, targeted enrichment, and reduction of ROS and lipid levels of OPDH-SV in vivo. In summary, OPDH-SV has good biosafety and excellent in vivo therapeutic effect, and is expected to become a new type of anti-atherosclerotic nano-prodrug.

Lipid Dysregulation in Tangier Disease: A Case Series and Metabolic Characterization

CONTEXT

Tangier disease (TD) is a rare, autosomal recessive genetic disorder associated with a deficiency in cellular cholesterol export leading to cholesterol accumulation in peripheral tissues. With approximately 150 described cases, the disease is significantly understudied, and the clinical presentation appears to be heterogenous.

OBJECTIVE

To investigate the phenotype and lipid metabolism in TD.

DESIGN

Multicenter cohort study.

PATIENTS

Four patients with TD.

MAIN OUTCOME MEASURES

Nuclear magnetic resonance (NMR)-based lipidomic and metabolomic analyses were performed in patients with TD and healthy controls.

RESULTS

While showing similar laboratory patterns with respect to high-density lipoprotein depletion, the clinical phenotypes of four TD patients were heterogenous with two patients diagnosed at 47 and 72 years having predominantly gastrointestinal and neurological phenotypes. Two previously undescribed variants (c.2418G>A, c.5055.del) were reported.Apart from pathognomonic changes in HDL composition, NMR spectroscopy revealed an increased abundance of VLDL with higher total lipid and cholesterol concentrations, pointing towards an impaired clearance of triglyceride-rich lipoproteins. Increased triglyceride-rich IDL supports impaired hepatic lipase activity, together with a CETP-mediated increase in LDL-triglycerides at higher abundance of large LDL subtypes and decreased small dense LDL.The lipid composition of HDL particles and LDL-1/LDL-4 remained the strongest differentiating factors as compared to healthy controls.

CONCLUSIONS

Clinical phenotypes of TD can be heterogeneous including gastrointestinal and neurological manifestations. Impaired triglyceride-rich lipoprotein clearance and hepatic lipase activity could be a pathophysiological hallmark of TD.

Evaluation of the beneficial effects of pemafibrate in hypertriglyceridemia with or without alcohol drinking (PAR-CHAT: PARmodia-CHikushi Anti-dyslipidemia Trial)

Purpose

To examine the efficacy and safety of pemafibrate in outpatients with hypertriglyceridemia, including alcoholic hypertriglyceridemia.

Method

This multicenter, open-label, prospective observational study (C20-07-009) included outpatients with hypertriglyceridemia being treated with pemafibrate who were registered at Fukuoka University Chikushi Hospital or associated clinics. Endpoints were changes in serum triglyceride (TG) and high-density lipoprotein cholesterol (HDL-C), hepatic biomarkers, and other blood values from baseline to 24 weeks and safety. Patients were compared according to alcohol drinking.

Result

From October 2020 to March 2022, 203 patients were registered at 14 facilities. We analyzed 174 patients (mean age, 65.5 years) with baseline fasting TG values who continued pemafibrate for 24 weeks; 55 % drank alcohol, and 35 % were receiving statins. Median fasting TG was 284 mg/dL (IQR, 228-392 mg/dL) at baseline and decreased significantly to 141 mg/dL (IQR, 108-194 mg/dL) at 24 weeks (p < 0.01), independent of alcohol use (non-drinking group, 259 to 134 mg/dL; daily drinking group, 318 to 169 mg/dL; occasional drinking group, 298 to 158 mg/dL; all p < 0.01). Median HDL-C increased significantly from 46 mg/dL (IQR, 39-53 mg/dL) at baseline to 53 mg/dL (IQR, 45-60 mg/dL) at 24 weeks (p < 0.01). Hepatic biomarkers improved significantly at 24 weeks. Low-density lipoprotein cholesterol (LDL-C) increased significantly overall, but not in patients receiving statins. Side effects throughout the study period included dizziness and nausea (1 patient each).

Conclusion

Pemafibrate improves TG, HDL-C, hepatic biomarkers and hypertriglyceridemia regardless of alcohol consumption and is safe. Increase of LDL-C was suppressed in patients treated with statins.

Fasting plasma C-peptide correlates with body mass index, hsCRP, apolipoprotein B, and other atherogenic lipids in healthy individuals

C-peptide has a complex role in human physiology, but its effects are not fully understood. Studies have shown a protective impact against diabetic complications, but also that C-peptide levels associate with cardiovascular events. Among the many applications to assess cardiovascular risk, circulating lipids are widely used, and one of the strongest biomarkers is apolipoprotein B. The aim of this investigation was to study the association of C-peptide with markers of metabolic, inflammatory, or cardiovascular alterations in a limited group of healthy individuals. Body mass index (BMI), lipids, and other plasma markers were studied in 28 consecutive healthy individuals within the age of 30-50 years. The results showed significant positive correlations between C-peptide and BMI (r = 0.498; p = 0.007); hsCRP (r = 0.530; p = 0.004); triglycerides (r = 0.530; p = 0.005); cholesterol (r = 0.507; p = 0.006), LDL-cholesterol (r = 0.550; p = 0.002), LDL/HDL ratio (r = 0.460; p = 0.014); apoB (r = 0.622; p < 0.001), apoB/apoA1 ratio (r = 0.563; p = 0.002); and non-HDL cholesterol (r = 0.566; p = 0.002). According to BMI values, 16 of the 28 individuals were overweight (BMI >25.0 kg/m2). If overweight individuals were excluded, C-peptide did only correlate with apoB (r = 0.636; p = 0.026). To conclude, C-peptide within normal levels associate with BMI and atherogenic lipids in healthy individuals, and apoB associate with C-peptide even at normal weight. These results suggest that C-peptide can be an early additional cardiovascular risk marker.

Recent Advances in the Management of Dyslipidemia: A Systematic Review

Dyslipidemia refers to abnormal levels of lipids in the bloodstream, typically exhibiting an increased pattern. Total cholesterol, high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), and triglycerides (TGs) are all contributing factors to this disorder. This leads to an increased risk of atherosclerosis and cardiovascular diseases, such as coronary artery disease, which elevates the likelihood of morbidity. Dyslipidemia can be managed via the use of numerous classes of drugs and treatments. The conventional pharmacological agents comprising 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors, selective cholesterol absorption inhibitors, proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), bile acid sequestrants, monoclonal antibodies, and nutritional supplementation, such as inhibitors of cholesterol synthesis and absorption, and promoters of LDL-C excretion, are also discussed. Furthermore, conventional pharmacological treatment of dyslipidemia may elicit a variety of adverse side effects that are detrimental to the quality of life of the user. These side effects include muscle pain, weakness, liver enzyme elevations, and hyperglycemia. This systematic review further analyzes the pharmacological actions of novel lipid-lowering agents such as adenosine triphosphate-citrate lyase inhibitors (ACLi), selective peroxisome proliferator-activated receptor alpha (PPARα) modulators, cholesteryl ester transfer protein inhibitors (CETPi), antisense oligonucleotides (ASO), and angiopoietin-like protein 3 inhibitors (ANGPTL3i) as well as their efficacy in treating dyslipidemia while sparing the user of potentially severe side effects. Compared to existing treatments, novel therapies have shown significantly greater effectiveness in managing dyslipidemia-related lipid profiles and exhibit fewer systemic adverse effects. Some of the recent therapies discussed are alternative treatments that offer patients promising efficacy and improved tolerability. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to ensure a robust and transparent search process, aiming to minimize bias and maximize the retrieval of pertinent studies for review. Thus, this systematic review provides an overview of current and novel treatments for dyslipidemia, describing their efficacy, mechanism of action, safety, and side effects. As experimental investigations and clinical research progress, there is a possibility that a combination of newly tested medications and traditional ones may emerge as a promising treatment option for dyslipidemia in the future.

Genetic Evidence for Causal Effects of Circulating Remnant Lipid Profile on Cerebral Hemorrhage and Ischemic Stroke: A Mendelian Randomization Study

BACKGROUND

Mendelian randomization was employed to investigate the impact of circulating lipids, specifically residual lipids, on the risk of susceptibility to cerebral hemorrhage and ischemic stroke.

METHODS

According to the previous studies, we chose 19 circulating lipids, comprising 6 regular lipids and 13 residual lipids, to investigate their potential causal relationship with intracranial hemorrhage and ischemic stroke. The effect estimates were computed utilizing the random-effects inverse-variance-weighted methodology.

RESULTS

The findings revealed negative correlations between high-density lipoprotein cholesterol (HDL-C) and cerebral hemorrhage and large artery stroke. HDL-C, apolipoprotein A1 (Apo A1), TG in very small VLDL, and TG in IDL were found to be negatively correlated with any ischemic stroke. apolipoprotein B (Apo B), triglycerides (TG), low-density lipoprotein cholestrol (LDL-C), L.VLDL-TG, TG in medium VLDL, and TG in small VLDL exhibited positive correlations with large artery stroke. TG in very large HDL and TG in IDL were positively correlated with cardioembolic stroke. No significant causal relationship was observed between circulating lipids, with the exception of HDL-C and cerebral hemorrhage. No causal relationship was identified between any circulating lipids and small vessel stroke. Furthermore, the causal relationships were only found between residual lipids and ischemic stroke.

CONCLUSIONS

This study provides evidence for the beneficial impact of Apo A1 and HDL-C in reducing the risk of ischemic stroke, as well as the protective effect of HDL-C against cerebral hemorrhage. It highlights the detrimental effects of Apo B, TG, and LDL-C in increasing the risk of ischemic stroke, particularly in cases of large artery stroke. Furthermore, the study underscores the heterogeneity and 2-sided effects of the causal relationship between triglyceride-rich lipoproteins and ischemic stroke, offering a promising avenue for the treatment of ischemic stroke.

Exploring the Potential Health and Economic Benefits of Optimized Low-Density Lipoprotein Cholesterol Management in Malaysia's Atherosclerotic Cardiovascular Disease Population: A Model-Based Analysis

OBJECTIVES

This study quantified the health and economic benefits of improving low-density lipoprotein cholesterol (LDL-C) control in Malaysian patients with established atherosclerotic cardiovascular disease (ASCVD). It aimed to inform policy discussions and healthcare planning for effective ASCVD management.

METHODS

A deterministic, prevalence-based model was used to project the annual health burden and direct medical costs associated with recurrent ASCVD events over a 10-year horizon. The target population included adults (≥30 years) with established ASCVD and uncontrolled LDL-C levels (>1.8 mmol/L). The model comprised 3 modules: population size projection, recurrent ASCVD risk calculation (by means of the Secondary Manifestations of ARTerial disease [SMART] risk model), and direct medical and productivity cost estimation. The current status quo and a scenario with a 50% improvement in mean LDL-C were compared.

RESULTS

We projected over 800 000 adults with established ASCVD in 2023, increasing to approximately 1.4 million by 2032. Under the status quo, about 55 000 recurrent ASCVD events were expected within 10 years, with significant direct medical costs and productivity losses. Improved LDL-C control could potentially reduce recurrent events by 7000 cases (13% reduction), prevent 2100 premature deaths, and save approximately 32 400 years of life. Economically, this could lead to a reduction of approximately 72 million MYR in direct medical costs and a gain of approximately 132.4 million MYR in productivity over a decade.

CONCLUSIONS

Optimizing LDL-C control in high-risk patients with ASCVD presents a critical opportunity to reduce health and economic burdens in Malaysia.

Mycoplasma pneumoniae drives macrophage lipid uptake via GlpD-mediated oxidation, facilitating foam cell formation

Cardiovascular diseases, primarily caused by atherosclerosis, are a major public health concern worldwide. Atherosclerosis is characterized by chronic inflammation and lipid accumulation in the arterial wall, leading to plaque formation. In this process, macrophages play a crucial role by ingesting lipids and transforming into foam cells, which contribute to plaque instability and cardiovascular events. Recent studies have suggested that various pathogens are involved in the development of atherosclerosis, with Mycoplasma pneumoniae considered one of the potential candidates. Therefore, this study investigated whether this bacterium induces lipid accumulation in macrophages, which play a crucial role in the development of atherosclerosis, using the Raw264.7 model. Our findings revealed that M. pneumoniae infection promotes lipid droplet formation in macrophages. Glycerol 3-phosphate oxidase, GlpD, in the bacterium is involved in this process by producing reactive oxygen species, which in turn causes the oxidation of low-density lipoprotein. Furthermore, the significant increase in the expression of oxidized lipid receptors involved in the uptake of this oxidized lipid indicates that the bacteria promote lipid uptake in infected macrophages. These results suggest that M. pneumoniae has a direct pro-atherogenic effect, promoting the formation of atherosclerotic lesions through foam cell formation. Understanding the mechanisms by which M. pneumoniae influences atherosclerosis provides valuable insights for devising new therapeutic strategies for the prevention and management of cardiovascular diseases.

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.

The biogenesis and transport of triglyceride-rich lipoproteins

Triglyceride-rich lipoproteins (TRLs) play essential roles in human health and disease by transporting bulk lipids into the circulation. This review summarizes the fundamental mechanisms and diverse factors governing lipoprotein production, secretion, and regulation. Emphasizing the broader implications for human health, we outline the intricate landscape of lipoprotein research and highlight the potential coordination between the biogenesis and transport of TRLs in physiology, particularly the unexpected coupling of metabolic enzymes and transport machineries. Challenges and opportunities in lipoprotein biology with respect to inherited diseases and viral infections are also discussed. Further characterization of the biogenesis and transport of TRLs will advance both basic research in lipid biology and translational medicine for metabolic diseases.

Ceramide in Coronary Artery Disease: Troublesome or Helpful Future Tools in the Assessment of Risk Prediction and Therapy Effectiveness?

Lipids are a complex entity of different molecules, among which ceramides (Cers), ubiquitous sphingolipids with remarkable biological activity, can represent a potential additive biomarker that can be used to better understand the underlying mechanisms which drive the onset and development of atherosclerotic damage and plaque vulnerability and facilitate coronary disease management, as possible risk/prognostic biomarkers and targets for therapeutic intervention. Accordingly, this review aims to discuss the available results on the role Cersplay in contributing to atherosclerosis development and acute coronary event precipitation, their impact on complications and adverse prognosis, as well as the impact of treatment options in modulating Cerlevels.

Lipid-lowering therapy and LDL target attainment in type 2 diabetes: trends from the Italian Associations of Medical Diabetologists database

BACKGROUND

Hypercholesterolemia is a major cardiovascular risk factor, particularly in individuals with type 2 diabetes (T2DM), where cardiovascular events are more prevalent. Adherence to low-density lipoprotein cholesterol (LDL-c) targets remains suboptimal globally and in Italy. This study evaluates trends in LDL-c target achievement and lipid-lowering treatment with a stratification by cardiovascular risk among Italian patients with type 2 diabetes from 2019 to 2022.

METHODS

A cross-sectional analysis was conducted using the AMD Annals database, encompassing over 700,000 patients with T2DM. Patients were categorized by cardiovascular risk levels, LDL-c ranges and therapy types (statins, ezetimibe, PCSK9 inhibitors). Linear trends across the four years were evaluated.

RESULTS

The percentage of patients achieving LDL-c targets improved across all risk levels. In very high-risk patients, LDL-c < 55 mg/dL was achieved by 16.3% in 2019, increasing to 23.6% in 2022. High-risk patients achieving LDL-c < 70 mg/dL rose from 20.3 to 26.6% over the same period. Use of PCSK9 inhibitors, particularly in combination with statins, was associated with the highest target achievement rates, reaching 62% in very high-risk patients by 2022. We observed a reduction of moderate-intensity statins use in favor of combination therapies across the four years. Despite this, nearly one-third of patients still had LDL-c levels ≥ 100 mg/dL in 2022.

CONCLUSIONS

While LDL-c management in Italian patients with T2DM has improved, significant gaps remain, particularly for very high-risk individuals. Expanding the use of advanced therapies like PCSK9 inhibitors and adhering more closely to guideline-based recommendations are critical to improve cardiovascular risk in this population.

Adverse events associated with inclisiran: a real-world pharmacovigilance study of FDA adverse event reporting system (FAERS)

OBJECTIVE

To gain an improved comprehension of inclisiran safety in real-world settings by data mining from FAERS.

METHODS

Data were gathered between 1 December 2020 and 31 December 2023. The Medical Dictionary for Regulatory Activities (MedDRA) corresponding preferred term (PT) and system organ class (SOC) were used to categorize adverse medication reactions in AE reports (AERs). By using reported odds ratio (ROR) method, positive signals were identified.

RESULTS

There were 2,652 reports of inclisiran, and 150 of those AEs had significant disproportionality. Among the 44 PTs with moderate clinical priority, 35 PTs were discovered on the medicine label, including 12 IMEs and 2 DMEs. Of note, 9 PTs were unanticipated AEs that were not discovered in the medication label or reported clinical studies, such as movement disorder (ROR: 3.05; 95%CI: 1.73,5.37), aphonia (ROR: 3.77; 95%CI: 1.79,7.91), and pulmonary congestion (ROR: 3.47; 95%CI: 1.44,8.34). Inclisiran was found to be related to 12 serious AEs. The median TTO of 1896 cases was 13.5 (IQR 0-100) days.

CONCLUSION

We identified not only known AEs, but also new AE signals such as movement disorder. However, signals does not reveal actual risk, prospective clinical trials are still required to verify their causal connection.

Nutrition and Lifestyle Interventions in Managing Dyslipidemia and Cardiometabolic Risk

Dyslipidemia, characterized by abnormal blood lipid levels, is a major public health concern due to its association with atherosclerotic cardiovascular disease (ASCVD) and other cardiometabolic disorders. In this context, appropriate nutrition patterns are pivotal as they represent the basic approach for providing a wide range of substantial advantages. The best evidence for dyslipidemia management is offered by the Mediterranean Diet, the Plant-Based Diet, the High-Fiber Diet and the Anti-inflammatory Diet, while the DASH Diet and the Ketogenic Diet have also been shown to target additional pathological features like hypertension and other comorbidities. The bioactive compounds that are enriched in these nutrition patterns and able to manage dyslipidemia include monounsaturated fatty acids such as ω-3, polyphenols such as oleuropein, resveratrol, flavonoids, and catechins, carotenoids, phytosterols and soluble and unsoluble fibers. Diets rich in these compounds can improve lipid profile by mitigating oxidative stress, reducing low-grade chronic inflammation, modulating macronutrient absorption and other mechanisms, thereby supporting cardiovascular health. Additionally, lifestyle interventions such as regular physical activity, weight loss, reduced alcohol consumption and smoking cessation further ameliorate lipid metabolism and manage circulated lipid profile. Furthermore, emerging insights from nutrigenomics underscore the potential for proper diet to address genetic factors and optimize treatment outcomes. The pivotal role of nutrition interventions in the context of dyslipidemia and its cardiometabolic implications is discussed in this review, emphasizing evidence-based and personalized approaches.

Cardiovascular Manifestations of Patients with Non-Alcoholic Fatty Liver Disease

Background: Non-alcoholic fatty liver disease (NAFLD), more recently redefined as metabolic-associated fatty liver disease (MAFLD), is now recognized as the most prevalent cause of chronic liver disease. Its strong association with cardiovascular disease (CVD) underscores its emerging role in global morbidity and mortality. Objective: This review critically examines the pathophysiological mechanisms that link NAFLD/MAFLD with CVD. It focuses on shared metabolic disturbances, inflammatory pathways, and alterations in the gut microbiota that contribute to hepatic and cardiovascular pathology. Review and Gaps: Current evidence highlights insulin resistance, dyslipidemia, systemic inflammation, and gut dysbiosis as pivotal factors connecting NAFLD/MAFLD to CVD. Despite these insights, inconsistencies in diagnostic criteria and a lack of validated non-invasive biomarkers hinder a clear understanding of the causal relationship between liver and cardiovascular diseases. Conclusions: Addressing these knowledge gaps through standardized diagnostic protocols and large-scale longitudinal studies is essential. Improved biomarker validation and clearer delineation of the underlying mechanisms will improve cardiovascular risk stratification and enable more personalized therapeutic strategies for patients with NAFLD/MAFLD.