Recent Update to the US Cholesterol Treatment Guidelines: A Comparison With International Guidelines

Cumulative Incidence of Mortality Associated with Cardiovascular-Kidney-Metabolic (CKM) Syndrome

Key Points

Background

It is imperative to critically evaluate the prognostic implications of cardiovascular–kidney–metabolic (CKM) syndrome staging to inform clinical practice. The primary aims of this study were to define the risk of mortality associated with each CKM syndrome stage and to determine the corresponding restricted mean survival time over a 15-year period.

Methods

This was a longitudinal study of 50,678 community-dwelling US adults aged 20 years and older with baseline data for CKM stage determination participating in the 1999–2018 National Health and Nutrition Examination Survey. CKM stages were defined according to the American Heart Association presidential advisory. Fifteen-year adjusted cumulative incidences of cardiovascular mortality were calculated for each stage from confounder-adjusted survival curves using the G-formula.

Results

Over a median 9.5-year follow-up, 2564 participants experienced cardiovascular death. The 15-year adjusted cumulative incidences of cardiovascular mortality were stage 0, 5.5% (95% confidence interval [CI], 1.8 to 9.3); stage 1, 5.7% (95% CI, 3.2 to 8.2); stage 2, 7.9% (95% CI, 6.8 to 9.1); stage 3, 8.7% (95% CI, 6.7 to 10.8); and stage 4, 15.2% (95% CI, 13.6 to 16.8). The absolute risk difference between CKM stage 4 and stage 0 at 15 years was 9.6% (95% CI, 5.6 to 13.6). The survival difference between CKM stage 0 and stage 4 at 15 years was 8.1 (95% CI, 8.0 to 8.2) months.

Conclusions

Our findings reveal a graded risk of cardiovascular mortality associated with higher CKM syndrome stage.

Effects of statins in patients with coronary artery spasm: A nationwide population-based study

Controversies regarding the benefits of statin treatment on clinical outcomes in coronary artery spasm (CAS) without obstructive coronary artery disease (CAD) persist due to limited data. In this retrospective nationwide population-based cohort study from the Taiwan National Health Insurance Research Database during the period 2000-2012, the matched cohorts consisted of 12,000 patients with CAS. After propensity score matching with 1:1 ratio, 2216 patients were eligible for outcome analysis in either statin or nonstatin group, with the mean follow-up duration of 4.8 and 4.6 years, respectively. Statin users versus nonusers had a significantly reduced risk of major adverse cardiovascular events (MACEs) (6.7% vs. 9.5%, hazard ratio [HR] 0.68; 95% confidence interval [CI] 0.55-0.84) and all-cause mortality (6.0% vs. 7.6%; HR 0.77; 95% CI 0.61-0.96). While the results of MACEs were mainly contributed by cardiovascular death (1.9% vs. 3.2%; HR 0.56; 95% CI 0.38-0.83) and ischemic stroke (3.8% vs. 5.4%; subdistribution HR 0.69; 95% CI 0.52-0.91), they were primarily driven by reductions in ischemic but not hemorrhagic stroke. The benefit of statins was significantly pronounced in patients with hypertension and diabetes. Nevertheless, the effect on MACEs was consistent irrespective of age, sex, dyslipidemia, and mental disorder. Statins significantly reduced the risk of MACEs and all-cause mortality in CAS patients. The benefit of statin therapy in reducing MACEs appeared to be linear, with greater risk reduction with higher doses and longer duration without upper threshold, reflecting the dose-dependent relationship of statins with MACEs in CAS patients.

Cost-effectiveness of applying high-sensitivity troponin I to a score for cardiovascular risk prediction in asymptomatic population

INTRODUCTION

Risk stratification scores such as the European Systematic COronary Risk Evaluation (SCORE) are used to guide individuals on cardiovascular disease (CVD) prevention. Adding high-sensitivity troponin I (hsTnI) to such risk scores has the potential to improve accuracy of CVD prediction. We investigated how applying hsTnI in addition to SCORE may impact management, outcome, and cost-effectiveness.

METHODS

Characteristics of 72,190 apparently healthy individuals from the Biomarker for Cardiovascular Risk Assessment in Europe (BiomarCaRE) project were included into a discrete-event simulation comparing two strategies for assessing CVD risk. The standard strategy reflecting current practice employed SCORE (SCORE); the alternative strategy involved adding hsTnI information for further stratifying SCORE risk categories (S-SCORE). Individuals were followed over ten years from baseline examination to CVD event, death or end of follow-up. The model tracked the occurrence of events and calculated direct costs of screening, prevention, and treatment from a European health system perspective. Cost-effectiveness was expressed as incremental cost-effectiveness ratio (ICER) in € per quality-adjusted life year (QALYs) gained during 10 years of follow-up. Outputs were validated against observed rates, and results were tested in deterministic and probabilistic sensitivity analyses.

RESULTS

S-SCORE yielded a change in management for 10.0% of individuals, and a reduction in CVD events (4.85% vs. 5.38%, p<0.001) and mortality (6.80% vs. 7.04%, p<0.001). S-SCORE led to 23 (95%CI: 20-26) additional event-free years and 7 (95%CI: 5-9) additional QALYs per 1,000 subjects screened, and resulted in a relative risk reduction for CVD of 9.9% (95%CI: 7.3-13.5%) with a number needed to screen to prevent one event of 183 (95%CI: 172 to 203). S-SCORE increased costs per subject by 187€ (95%CI: 177 € to 196 €), leading to an ICER of 27,440€/QALY gained. Sensitivity analysis was performed with eligibility for treatment being the most sensitive.

CONCLUSION

Adding a person's hsTnI value to SCORE can impact clinical decision making and eventually improves QALYs and is cost-effective compared to CVD prevention strategies using SCORE alone. Stratifying SCORE risk classes for hsTnI would likely offer cost-effective alternatives, particularly when targeting higher risk groups.

The association between lipid parameters and erectile dysfunction: a two-sample Mendelian randomization and case-control study

PURPOSE

Lipid parameters have been shown to have significant predictive value for cardiovascular disease, but few studies have evaluated their correlation with erectile dysfunction (ED) in young men.

METHODS

The case-control study encompassed 186 young ED patients (ages 20-40) and 186 healthy controls. Lipid parameters, including total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), TC/HDL ratio, TG/HDL ratio, and LDL-C/HDL-C ratio, were assessed in all participants. The International Index of Erectile Function (IIEF-5) scores were collected for all participants to evaluate erectile status. Multivariate logistic regression analysis was utilized to appraise the association of lipid-related parameters with ED. Single-nucleotide polymorphisms (SNPs) significantly correlated with lipid parameters (TC, TG, LDL-C, HDL-C) were selected from genome-wide association studies (GWAS) as instrumental variables (IV) (P < 5.0 × 10-8). Summary data for ED was gathered from a GWAS with a sample size of (n = 17,353 cases/28,210 controls). The inverse variance weighted (IVW) method was employed as the primary mendelian randomization (MR) analysis method to assess causal effects. Causal estimates were represented as odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Results from the case-control study revealed that, when compared with the control group, levels of LDL-C, TG, UA, LDL-C/HDL-C, TG/HDL-C, and TC/HDL-C in the ED group were significantly elevated (P < 0.01), while HDL-C was significantly decreased (P < 0.01) in the ED group. Multivariate logistic regression analysis indicated LDL-C/HDL-C as a risk factor for both the incidence and severity of ED (P < 0.001). Two-sample MR analysis demonstrated no significant causal correlation between lipid parameters-LDL-C (OR, 0.98, 95% CI, 0.88-1.08, P = 0.616), HDL-C (OR, 1.07, 95% CI: 0.96-1.19, P = 0.249), TC (OR, 1.07, 95% CI, 0.96-1.18, P = 0.208), TG (OR, 0.98, 95% CI, 0.80-1.13, P = 0.579) -and an increased risk of ED (all P > 0.05).

CONCLUSIONS

The case-control analysis ascertained a significant association between LDL-C, HDL-C, LDL-C/HDL-C, and ED and its severity. However, results from the MR study do not support a causal role of lipid parameters in ED.

Lipid Profiles and Atrial Fibrillation in Ischemic Stroke Patients Treated with Thrombectomy: Experience from a Tertiary Italian Stroke Hospital

OBJECTIVES

To assess acute lipid profiles, atrial fibrillation and other cardiovascular risk factors in patients undergoing treatments by thrombectomy (EVT) with acute ischemic stroke (AIS).

METHODS

We performed a retrospective analysis of the lipid profile and vascular risk factor in 1639 consecutive patients with acute ischemic stroke between January 2016 and December 2021. To assess lipid profiles, laboratory tests, including total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG), were obtained the day after admission. We also examined the association between lipid profile, AF and EVT in multivariate logistic regression analysis.

RESULTS

Median age of patients was 74 years, 54.9% were males (95% CI 52.5-57.4%), and 26.8% (95% CI, 24.7-29.0%) had AF. EVT patients (n = 370; 22.57 %; 95% CI, 20.6-24.7) showed no difference in age (median 73 years (IQR; 63-80) versus 74 years (IQR; 63-82)), HbA1c levels (median 5.8 (IQR; 5.4-6.2) versus 5.9 (IQR; 5.4-6.4)), TG/HDL ratio (median 2.40 (IQR; 1.65-3.48) versus 2.51 (IQR; 1.73-3.64)), diabetes (OR 0.82; 95% CI 0.61 to 1.08), hypertension (OR 0.87; 95% CI 0.68 to 1.12) and obesity (OR 1.06; 95% CI 0.78 to 1.42) compared to non-EVT patients. Conversely, EVT patients showed lower levels of TC (160 mg/dl (IQR; 139- 187) versus 173 mg/dl (IQR; 148-202); p <0.001), LDL-C (105 mg/dl (IQR; 80-133) versus 113 mg/dl (IQR; 88-142); p <0.01), TG (98 mg/dl (IQR; 76-126) versus 107 mg/dl (IQR; 85-139); p <0.001), non-HDL-C (117 mg/dl (IQR; 94-145) versus 127 mg/dl (IQR; 103-154); p <0.001), HC (8.3 mmol/l (IQR; 6-11) versus 10 mmol/l (IQR; 7.3-13.5); p <0.001) than non-EVT patients. Multivariate logistic regression analysis showed an independent association of EVT with TC (OR 0.99, 95% CI 0.98-0.99), AF (OR 1.79, 95% CI 1.34-2.38), age (OR 0.98, 95% CI 0.96-0.99), and NIHSS (OR 1.17, 95% CI 0.14-1.19).

CONCLUSION

Total cholesterol and all cholesterol-related measures were significantly lower in patients undergoing thrombectomy than in other stroke patients. Conversely, we found that AF was significantly high in patients with EVT, suggesting that hypercholesterolemia could be mainly linked to small-vessel occlusion stroke while large vessel occlusion (LVO) stroke could show different causes. AIS patients may have different pathogenesis and their understanding may improve the discovery of specific and tailored preventive treatments.

Angiographic severity of coronary artery disease and the influence of major cardiovascular risk factors

Objective

To determine the angiographic severity of coronary artery disease (CAD) and assess the influence of major cardiovascular risk factors (CVRF).

Study design

a cross-sectional, hospital-based study.

Setting

the catheterisation laboratory of the National Cardiothoracic Centre, Accra, Ghana.

Participants

for 12 months, consecutive patients admitted for coronary angiography were assessed for the presence of CVRFs. Those with significant CAD after angiography were recruited into the study.

Intervention

The patient's angiograms were analysed, and the CAD severity was obtained using the SYNTAX scoring criteria.

Main outcome measure

The lesion overall severity (SYNTAX) score and the relationship with CVRFs present.

Results

out of the 169 patients that had coronary angiography, 78 had significant CAD. The mean SYNTAX score was 20.18 (SD= 10.68), with a significantly higher value in dyslipidaemic patients (p < 0.001). Pearson's correlation between the score and BMI was weak (r= 0.256, p= 0.034). The occurrence of high SYNTAX score lesions in about 18% of the population was significantly associated with hypertension (OR= 1.304, 95% CI [1.13-1.50]; p= 0.017) dyslipidaemia (OR= 5.636, 95% CI [1.17-27.23]; p= 0.019), and obesity (OR= 3.960, 95% CI [1.18-13.34]; p= 0.021). However, after adjusting for confounding factors, only dyslipidaemia significantly influenced its occurrence (aOR= 5.256, 95% CI [1.03-26.96]; p= 0.047).

Conclusion

Even though the most severe form of CAD was found in about one-fifth of the study population, its occurrence was strongly influenced by the presence of dyslipidaemia.

Funding

None.

The association of Carbohydrate Quality Index with cardiovascular disease risk factors among women with overweight and obesity: A cross-sectional study

Purpose

Diet is one of the most important factors influencing cardiovascular disease (CVD). The negative relationship between carbohydrate intake with lipid profiles and body weight has been previously investigated. However, this is the first study seeking to assess the association of carbohydrate quality index (CQI) with CVD risk factors.

Methods

This cross-sectional study was conducted on 291 Iranian overweight and obese women, with a body mass index (BMI) ranging between 25 and 40 kg/m², and aged 18–48 years. CQI scores were calculated by using a validated 168-item semi-quantitative food frequency questionnaire (FFQ). Biochemical and anthropometric measures were assessed using standard methods, and bioelectrical impedance was used to measure body composition.

Results

We observed that fruits (P < 0.001), vegetables (P < 0.001), and protein (P = 0.002) intake were higher in participants with a higher score of the CQI. When we adjusted for potential confounders, we observed that the CQI was negatively related to systolic blood pressure (SBP) (β = −6.10; 95% CI = −10.11, −2.10; P = 0.003) and DBP (β = −3.11; 95% CI = −6.15, −0.08; P = 0.04). Also, greater adherence to a high CQI dietary pattern, compared to the reference group, was negatively related to HOMA-IR (β = −0.53; 95% CI = −0.94, −0.12) (P for trend = 0.01), WC (β = −3.18; 95% CI = −6.26, −0.10) (P for trend = 0.04), BMI (β = −1.21; 95% CI = −2.50, 0.07) (P for trend = 0.06), and BF (β = −2.06; 95% CI = −3.82, −0.30) (P for trend = 0.02).

Conclusion

In line with previous studies, the CQI was inversely associated with blood pressure, WC, BMI, and BF. Further prospective and clinical trial studies are suggested to confirm these data.

Coenzyme Q10 Supplementation in Statin Treated Patients: A Double-Blinded Randomized Placebo-Controlled Trial

Myalgia and new-onset of type 2 diabetes have been associated with statin treatment, which both could be linked to reduced coenzyme Q10 (CoQ10) in skeletal muscle and impaired mitochondrial function. Supplementation with CoQ10 focusing on levels of CoQ10 in skeletal muscle and mitochondrial function has not been investigated in patients treated with statins. To investigate whether concomitant administration of CoQ10 with statins increases the muscle CoQ10 levels and improves the mitochondrial function, and if changes in muscle CoQ10 levels correlate with changes in the intensity of myalgia. 37 men and women in simvastatin therapy with and without myalgia were randomized to receive 400 mg CoQ10 daily or matched placebo tablets for eight weeks. Muscle CoQ10 levels, mitochondrial respiratory capacity, mitochondrial content (using citrate synthase activity as a biomarker), and production of reactive oxygen species were measured before and after CoQ10 supplementation, and intensity of myalgia was determined using the 10 cm visual analogue scale. Muscle CoQ10 content and mitochondrial function were unaltered by CoQ10 supplementation. Individual changes in muscle CoQ10 levels were not correlated with changes in intensity of myalgia. CoQ10 supplementation had no effect on muscle CoQ10 levels or mitochondrial function and did not affect symptoms of myalgia.

The association between visceral adiposity with systemic inflammation, oxidative stress, and risk of post-surgical adhesion

Abdominal and pelvic adhesions are common post-operative complications. Despite new medical technologies, these adhesions are appearing to be unavoidable and little is known about their causation; for example, why certain patients/or tissues are more prone to adhesions. There have been no clinical studies about increasing the risk adhesions in obese patients, but there is some evidence about the molecular mechanisms involving visceral fat (VF) that may lead to profibrotic conditions. VF is an endocrine/inflammatory organ which produces many biologically active molecules such as adipokines and inflammatory cytokines. Inflammatory conditions, oxidative stress, and the expression some fibrotic molecules in the VF may induce pathological conditions in the abdominal cavity that predispose to the formation of fibrotic bands.

Should mutant TP53 be targeted for cancer therapy?

Mutations in the TP53 tumour suppressor gene are found in ~50% of human cancers [1-6]. TP53 functions as a transcription factor that directly regulates the expression of ~500 genes, some of them involved in cell cycle arrest/cell senescence, apoptotic cell death or DNA damage repair, i.e. the cellular responses that together prevent tumorigenesis [1-6]. Defects in TP53 function not only cause tumour development but also impair the response of malignant cells to anti-cancer drugs, particularly those that induce DNA damage [1-6]. Most mutations in TP53 in human cancers cause a single amino acid substitution, usually within the DNA binding domain of the TP53 protein. These mutant TP53 proteins are often expressed at high levels in the malignant cells. Three cancer causing attributes have been postulated for mutant TP53 proteins: the inability to activate target genes controlled by wt TP53 (loss-of-function, LOF) that are critical for tumour suppression, dominant negative effects (DNE), i.e. blocking the function of wt TP53 in cells during early stages of transformation when mutant and wt TP53 proteins are co-expressed, and gain-of-function (GOF) effects whereby mutant TP53 impacts diverse cellular pathways by interacting with proteins that are not normally engaged by wt TP53 [1-6]. The GOF effects of mutant TP53 were reported to be essential for the sustained proliferation and survival of malignant cells and it was therefore proposed that agents that can remove mutant TP53 protein would have substantial therapeutic impact [7-9]. In this review article we discuss evidence for and against the value of targeting mutant TP53 protein for cancer therapy.

Beyond Ten-Year Risk: A Cost-Effectiveness Analysis of Statins for the Primary Prevention of Cardiovascular Disease

Cholesterol guidelines typically prioritize primary prevention statin therapy on the basis of 10-year risk of cardiovascular disease. The advent of generic pricing may justify expansion of statin eligibility. Moreover, 10-year risk may not be the optimal approach for statin prioritization. We estimated the cost-effectiveness of expanding preventive statin eligibility and evaluated novel approaches to prioritization from a Scottish health sector perspective.

Contribution of obesity and cardiometabolic risk factors in developing cardiovascular disease: a population-based cohort study

This study aims to assess the effects of central and general adiposity on development of cardiovascular diseases (CVDs) mediated by cardiometabolic risk factors and to analyze their degree of dependency for mediating their effects. To this end, data from the the Tehran Lipid and Glucose Study cohort with 6280 participants were included in this study. The hazard ratios were calculated using a 2-stage regression model in the context of a survival model. Systolic blood pressure (BP), total serum cholesterol, and fasting plasma glucose were designated as mediators. Assessing the interactions revealed that BP was the most important mediator for general ( (HRNIE: 1.11, 95% CI 1.17-1.24) and central obesity (CO) (HRNIE: 1.11, 95% CI 1.07-1.15) with 60% and 36% proportion of the effects mediated in the total population, respectively. The proportion of mediated risk for all three metabolic risk factors was 46% (95% CI 31-75%) for overweight, 66% (45-100%) for general obesity and 52% (39-87%) for central obesity. BP was the most important mediator for overweight and central obesity in men, comprising 29% and 36% of the risk, respectively. The proportion of the risk mediated through all three metabolic risk factors in women was 23% (95% CI 13-50%) for overweight, 36% (21-64%) for general obesity and 52% (39-87%) for central obesity. Based on the results of this study, cardiometabolic mediators have conciliated more than 60% of the adverse effects of high BMI on CVDs in men. Controlling the metabolic risk factors in women does not efficiently contribute to decreasing CVDs as effectively.

Statins and the risks of decompensated liver cirrhosis and hepatocellular carcinoma determined in patients with alcohol use disorder

BACKGROUND

Alcohol-related liver disease (ALD) is the most common cause of liver disease. No medication can improve ALD and abstinence from alcohol is the sole effective strategy. Statin use has been demonstrated to have protective effects against liver cirrhosis and hepatocellular carcinoma (HCC) in patients with virus-related liver diseases. Whether statin use has a similar association among patients with alcohol use disorder (AUD) that can lead to ALD, is unknown.

METHOD

We conducted a population-based cohort study using Taiwan's National Health Insurance Research Database from 1997 to 2013 to compare risks of decompensated liver cirrhosis and hepatocellular carcinoma (HCC) between the statin exposed and unexposed groups in the patients with AUD. The incidence rates of decompensated liver cirrhosis and HCC were calculated between patients exposed and unexposed to statins with 1:4 propensity score matching. Cox proportional hazard regressions were performed to evaluate hazard ratios (HRs).

RESULTS

The incidence rates of decompensated liver cirrhosis and HCC in the statin-exposed group differed from those in the unexposed group (decompensated cirrhosis: 269.9 vs. 628.9 cases per 100,000 person-years; HCC: 116.7 vs. 318.3 cases per 100,000 person-years). The HRs for decompensated liver cirrhosis and HCC were 0.43 (95% CI, 0.37-0.51) and 0.40 (95% CI, 0.31-0.51), respectively, after adjustment.

CONCLUSIONS

Statin use was associated with reduced risk of decompensated liver cirrhosis and HCC among AUD patients in a cumulative dose effect manner. Statins might have some potential effects on mitigating ALD progression beside abstinence from alcohol. Further research is needed.

Roadmap for translating results from the micronucleus assay into clinical practice: From observational studies to randomized controlled trials

According to the definition delivred by the WHO, a biomarker, independently from its role that may be indicative of exposure, response or effect, is inevitably linked to a clinical outcome or to a disease. The presence of a continuum from early biological events to therapy, and prognosis is the unifying mechanism that justifies this conclusion. Traditionally, the technical and inter-individual variability of the assays, together with the long duration between early pathogenetic events and the disease, prevented clinical applications to these biomarkers. These limitations became less important with the emerging of personalized preventive medicine because of the focus on disease prediction and prevention, and the recommended use of all data concerning measurable patient's features. Several papers have been published on the best validation procedures for translating biomarkers to real life. The history of cholesterol concentration is extensively discussed as a reliable example of a biomarker that - after a long and controversial validation process - is currently used in clinical practice. The frequency of micronucleated cells is a reliable biomarker for the pathogenesis of cancer and other non-communicable diseases, and the link with clinical outcomes is substantiated by epidemiological evidence and strong mechanistic basis. Available literature concerning the use of the micronucleus assay in clinical studies is discussed, and a suitable three-levels road-map driving this biomarker towards clinical practice is presented. Under the perspective of personalized medicine, the use of the micronucleus assays can play a decisive role in addressing preventive and therapeutic strategies of chronic diseases. In many cases the MN assay is either currently used in clinical practice or classified as adequate to consider translation into practice. The roadmap to clinical validation of the micronucleus assay finds inspiration from the history of biomarkers such as cholesterol, which clearly showed that the evidence from prospective studies or RCTs is critical to achieve the required level of trust from the healthcare profession. (307 words).

The risk of ischemic stroke and hemorrhagic stroke in Chinese adults with low-density lipoprotein cholesterol concentrations < 70 mg/dL

BACKGROUND

The risk of stroke in individuals with very low low-density lipoprotein cholesterol (LDL-C) concentrations remains high. We sought to prioritize predictive risk factors for stroke in Chinese participants with LDL-C concentrations < 70 mg/dL using a survival conditional inference tree, a machine learning method.

METHODS

The training dataset included 9327 individuals with LDL-C concentrations < 70 mg/dL who were free of cardiovascular diseases and did not use lipid-modifying drugs from the Kailuan I study (N = 101,510). We examined the validity of this algorithm in a second Chinese cohort of 1753 participants with LDL-C concentrations < 70 mg/dL from the Kailuan II study (N = 35,856).

RESULTS

During a mean 8.5-9.0-year follow-up period, we identified 388 ischemic stroke cases and 145 hemorrhagic stroke cases in the training dataset and 20 ischemic stroke cases and 8 hemorrhagic stroke cases in the validation dataset. Of 15 examined predictors, poorly controlled blood pressure and very low LDL-C concentrations (≤ 40 mg/dL) were the top hierarchical predictors of both ischemic stroke risk and hemorrhagic stroke risk. The groups, characterized by the presence of 2-3 of aforementioned risk factors, were associated with a higher risk of ischemic stroke (hazard ratio (HR) 7.03; 95% confidence interval (CI) 5.01-9.85 in the training dataset; HR 4.68, 95%CI 1.58-13.9 in the validation dataset) and hemorrhagic stroke (HR 3.94, 95%CI 2.54-6.11 in the training dataset; HR 4.73, 95%CI 0.81-27.6 in the validation dataset), relative to the lowest risk groups (presence of 0-1 of these factors). There was a linear association between cumulative average LDL-C concentrations and stroke risk. LDL-C concentrations ≤ 40 mg/dL was significantly associated with increased risk of ischemic stroke (HR 2.07, 95%CI 1.53, 2.80) and hemorrhagic stroke (HR 2.70, 95%CI 1.70, 4.30) compared to LDL-C concentrations of 55-70 mg/dL, after adjustment for age, hypertension status, and other covariates.

CONCLUSION

Individuals with extremely low LDL-C concentrations without previous lipid-modifying treatment could still be at high stroke risk.

TRIAL REGISTRATION

Chinese Clinical Trial Register, ChiCTR-TNRC-11001489 . Registered on 24-08-2011.

Three Statistical Approaches for Assessment of Intervention Effects: A Primer for Practitioners

INTRODUCTION

Statistical methods to assess the impact of an intervention are increasingly used in clinical research settings. However, a comprehensive review of the methods geared toward practitioners is not yet available.

METHODS AND MATERIALS

We provide a comprehensive review of three methods to assess the impact of an intervention: difference-in-differences (DID), segmented regression of interrupted time series (ITS), and interventional autoregressive integrated moving average (ARIMA). We also compare the methods, and provide illustration of their use through three important healthcare-related applications.

RESULTS

In the first example, the DID estimate of the difference in health insurance coverage rates between expanded states and unexpanded states in the post-Medicaid expansion period compared to the pre-expansion period was 5.93 (95% CI, 3.99 to 7.89) percentage points. In the second example, a comparative segmented regression of ITS analysis showed that the mean imaging order appropriateness score in the emergency department at a tertiary care hospital exceeded that of the inpatient setting with a level change difference of 0.63 (95% CI, 0.53 to 0.73) and a trend change difference of 0.02 (95% CI, 0.01 to 0.03) after the introduction of a clinical decision support tool. In the third example, the results from an interventional ARIMA analysis show that numbers of creatinine clearance tests decreased significantly within months of the start of eGFR reporting, with a magnitude of drop equal to -0.93 (95% CI, -1.22 to -0.64) tests per 100,000 adults and a rate of drop equal to 0.97 (95% CI, 0.95 to 0.99) tests per 100,000 per adults per month.

DISCUSSION

When choosing the appropriate method to model the intervention effect, it is necessary to consider the structure of the data, the study design, availability of an appropriate comparison group, sample size requirements, whether other interventions occur during the study window, and patterns in the data.

Factors associated with high LDL-Cholesterol in the Brazilian adult population: National Health Survey

The study analyzed factors associated with high LDL-Cholesterol in Brazilian population. This is a cross-sectional study with laboratory data from 8,534 individuals collected in National Health Survey were analyzed. The prevalence levels of LDL-Cholesterol <130 and ≥ 130 mg/dL were calculated. The outcome variable was high LDL-Cholesterol (≥ 130 mg/dL) and explanatory variables were sociodemographic, anthropometric, lifestyle, chronic diseases and self-rated health. To Poisson regression was used and estimated prevalence ratios (PR) with 95% confidence levels (CI) to verify associations. The prevalence of high LDL-Cholesterol was 18.58%. In the final multivariate model were associated with the outcome: 30 to 44 years (PR 1.99; CI 1.58-2.54), 45 to 59 years (PR 2.89; CI 2.29-3.64), 60 years or more (PR 2.90; CI 2.29-3.68), living in the Northeast Region (PR 1.16; CI 1.02 - 1.32), overweight (PR 1.32; CI 1.15-1.51), obesity (PR 1.41; CI 1.19-1.65) or anemia (PR 0.66; CI 0.54-0.80). The LDL-Cholesterol was associated with aging, overweight, obesity, live in the Northeast and anemia. The monitoring of LDL levels is relevant, due to the increased risk with age, and can guide the adopting healthy lifestyles and diagnosis in places with lower access.

The Molecular Basis of Predicting Atherosclerotic Cardiovascular Disease Risk

Atherosclerotic cardiovascular disease (ASCVD) proceeds through a series of stages: initiation, progression (or regression), and complications. By integrating known biology regarding molecular signatures of each stage with recent advances in high-dimensional molecular data acquisition platforms (to assay the genome, epigenome, transcriptome, proteome, metabolome, and gut microbiome), snapshots of each phase of atherosclerotic cardiovascular disease development can be captured. In this review, we will summarize emerging approaches for assessment of atherosclerotic cardiovascular disease risk in humans using peripheral blood molecular signatures and molecular imaging approaches. We will then discuss the potential (and challenges) for these snapshots to be integrated into a personalized movie providing dynamic readouts of an individual's atherosclerotic cardiovascular disease risk status throughout the life course.

Co-Medication and Nutrition in Hepatocellular Carcinoma: Potentially Preventative Strategies in Hepatocellular Carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related death worldwide, with about 841,000 new cases and 782,000 deaths annually. Given the clearly defined population at risk, mostly patients with liver cirrhosis, prevention of HCC could be highly effective.

SUMMARY

Besides regular ultrasound surveillance, numerous publications have suggested protective effects of diverse drugs and nutrients. However, none of those preventive options has made it into clinical routine or practice guidelines. We therefore summarize the current status of preventive effects of drugs such as statins, acetylsalicylic acid (ASA), and metformin, but also dietary aspects and nutrients such as coffee, tea, and vitamin D supplementation. A successful implementation of some of these strategies may potentially lead to improved prevention of HCC development in patients with liver cirrhosis. Key Messages: Accumulating data suggest that particularly ASA, antidiabetic therapies, and statins may substantially decrease HCC incidence in patients at risk.

Statin Treatment in Specific Patient Groups: Role for Improved Cardiovascular Risk Markers

Ample evidence supports the use of statin therapy for secondary prevention in patients with a history of atherosclerotic cardiovascular disease (ASCVD), but evidence is wanting in the case of primary prevention, low-risk individuals, and elderly adults 65+. Statins are effective in lowering low-density lipoprotein (LDL), which has long been a target for treatment decisions. We discuss the weakening dependence between cholesterol levels and mortality as a function of age and highlight recent findings on lipoprotein subfractions and other superior markers of ASCVD risk. The efficacy of statins is compared for distinct subsets of patients based on age, diabetes, ASCVD, and coronary artery calcium (CAC) status. Most cardiovascular risk calculators heavily weight age and overestimate one's absolute risk of ASCVD, particularly in very old adults. Improvements in risk assessment enable the identification of specific patient populations that benefit most from statin treatment. Derisking is particularly important for adults over 75, in whom treatment benefits are reduced and adverse musculoskeletal effects are amplified. The CAC score stratifies the benefit effect size obtainable with statins, and forms of coenzyme Q are discussed for improving patient outcomes. Robust risk estimator tools and personalized, evidence-based approaches are needed to optimally reduce cardiovascular events and mortality rates through administration of cholesterol-lowering medications.

Statin Use in Primary Prevention of Atherosclerotic Cardiovascular Disease According to 5 Major Guidelines for Sensitivity, Specificity, and Number Needed to Treat

Importance

Five major guidelines on statin use for primary prevention of atherosclerotic cardiovascular disease (ASCVD) have been published since 2014: the National Institute for Health and Care Excellence (NICE; 2014), US Preventive Services Task Force (USPSTF; 2016), Canadian Cardiovascular Society (CCS; 2016), European Society of Cardiology/European Atherosclerosis Society (ESC/EAS; 2016), and American College of Cardiology/American Heart Association (ACC/AHA; 2018).

Objective

To compare the sensitivity, specificity, and estimated number needed to treat (NNT10) to prevent 1 ASCVD event in 10 years according to statin criteria from the 5 guidelines.

Design, Setting, and Participants

Population-based contemporary cohort study. Analyses were performed in the Copenhagen General Population Study, with a mean follow-up time of 10.9 years. We included 45 750 individuals aged 40 to 75 years. The participants were enrolled between 2003 and 2009 and were all free of ASCVD at baseline. Data were analyzed between January 1, 2019, and August 4, 2019.

Exposures

Statin treatment according to guideline criteria. We assumed a 25% relative reduction of ASCVD events per 38 mg/dL (to convert to millimoles per liter, multiply by 0.0259) reduction in low-density lipoprotein cholesterol.

Main Outcomes and Measures

Sensitivity and specificity for ASCVD events and the NNT10 to prevent 1 ASCVD event according to guideline criteria.

Results

Median age at baseline examination was 56 years, and 43% of participants were men (n = 19 870 of 45 750). During follow-up, we observed 4156 ASCVD events. Overall, 44% of individuals in Copenhagen General Population Study were statin eligible with CCS (n = 19 953 of 45 750), 42% with ACC/AHA (n = 19 400 of 45 750), 40% with NICE (n = 19 400 of 45 750), 31% with USPSTF (n = 13 966 of 45 750), and 15% with ESC/EAS (n = 6870 of 45 750). Sensitivity and specificity for ASCVD events were 68% (n = 2815 of 4156) and 59% (n = 24 456 of 41 594) for CCS, 70% (n = 2889 of 4156) and 60% (n = 25 083 of 41 594) for ACC/AHA, 68% (n = 2815 of 4156) and 63% (n = 26 213 of 41 594) for NICE, 57% (n = 2377 of 4156) and 72% (n = 30 005 of 41 594) for USPSTF, and 24% (n = 1001 of 4156) and 86% (n = 35 725 of 41 594) for ESC/EAS. The NNT10 to prevent 1 ASCVD using moderate-intensity and high-intensity statin therapy, respectively, was 32 and 21 for CCS criteria, 30 and 20 for ACC/AHA criteria, 30 and 20 for NICE criteria, 27 and 18 for USPSTF criteria, and 29 and 20 for ESC/EAS criteria.

Conclusions and Relevance

With similar NNT10 to prevent 1 event, the CCS, ACC/AHA, and NICE guidelines correctly assign statin therapy to many more of the individuals who later develop ASCVD compared with the USPSTF and ESC/EAS guidelines. Our results therefore suggest that the CCS, ACC/AHA, or NICE guidelines may be preferred for primary prevention.

Epidemiology, Risk Factors, and Predictors of Disability in a Cohort of Jordanian Patients with the First Ischemic Stroke

OBJECTIVE

To identify the risk factors, etiologies, length of stay, severity, and predictors of disability among patients with the first ischemic stroke in Jordan.

METHODS

A retrospective cohort study of 142 patients who were admitted to the Neurology Department at King Abdullah University Hospital between July/2017 and March/2018 with a first ischemic stroke. Etiology was classified according to the TOAST criteria. Severity was represented by NIHSS score, disability by mRS score, and prolonged length of stay as hospitalizations more than 75th percentile of the cohort's median length of stay. Analysis of the sample demographics and descriptive statistics were done, including frequencies of prevalence of independent variables (risk factors) and frequencies of stroke and etiology work-up. Chi-square and univariate analysis of variance "ANOVA" were used to investigate the relationship between risk factors and type of stroke. Finally, logistic regression analysis was used to measure the contribution of each of the independent variables. IRB approval was obtained as necessary.

RESULTS

The mean age for the cohort was 66.5 years. The most common risk factors were hypertension (78.8%), diabetes mellitus (60.5%), and ischemic heart disease (29.4%). The most common stroke etiology was small-vessel occlusion (54.2%). Median length of stay was 4 days. Prolonged length of stay was observed in 23.23% of patients, which was associated with several factors, the most common of which were persistent dysphagia (57.5%), nosocomial infection (39.3%), and combined dysphagia and nosocomial infection (21.2%). The mean admission NIHSS score was 7.94, and on discharge was 5.76. In-hospital mortality was 2.81%, while 50% of patients had a favorable outcome on discharge (mRS score between 0-2). The mean discharge mRS score for the cohort was 2.47 (SD ± 1.79). Large artery atherosclerosis was associated with the highest residual disability with a mean score of 3.67 (SD ± 1.88), while the stroke of undetermined etiology was associated with the lowest residual disability with a mean score of 1.60 (SD ± 1.78). Significant predictors of mRS score were smoking (t 3.24, P < 0.001), age (t 1.98, P < 0.049), and NIHSS score (t 9.979, P 0.000).

CONCLUSION

Ischemic strokes have different etiologies that are associated with different levels of impact on the patient's clinical status and prognosis. Large artery atherosclerosis was associated with the highest residual disability. Regarding predictors of prognosis, current smoking status, age above 50, gender, and NIHSS on admission appear to be the strongest predictors of prognosis. Finally, higher NIHSS score on admission resulted in a longer hospital stay.

Honokiol inhibits carotid artery atherosclerotic plaque formation by suppressing inflammation and oxidative stress

Honokiol is a natural active compound extracted from Chinese herbal medicine, Magnolia officinalis. In this study, the role of honokiol in the development of carotid artery atherosclerotic lesions was evaluated in an ApoE-/- mouse model fed with a normal diet (ND) or a Western-type diet (WD) for ten weeks. After first two weeks, a perivascular collar was surgically placed on the right common carotid arteries of the mice. Then, WD-fed mice were intraperitoneally injected with honokiol (10 or 20 mg/kg) or administrated with 10 mg/kg atorvastatin calcium by gavage once a day for eight weeks. After that, the right common carotid arteries were excised for further experiments. The result showed that honokiol substantially inhibited the development of atherosclerotic lesions. Furthermore, honokiol downregulated the expression of pro-inflammatory markers, like tumor necrosis factor-α, interleukin (IL)-6, and IL-1β. Additionally, honokiol treatment decreased reactive oxygen species level and enhanced superoxide dismutase activity. Nitric oxide level, inducible nitric oxide synthase (iNOS) expression, and aberrant activation of nuclear factor-κB pathway were also significantly inhibited by honokiol treatment. Together, these findings suggest that honokiol protects against atherosclerotic plaque formation in carotid artery, and may be an effective drug candidate for the treatment of carotid artery atherosclerotic stenosis.

Cost-effectiveness of statin therapy for secondary prevention among patients with coronary artery disease and baseline LDL-C 70-100 mg/dL in Taiwan

BACKGROUND

The recommended target low-density lipoprotein cholesterol (LDL-C) level for coronary artery disease (CAD) patients has been lowered from 100 to 70 mg/dL in several clinical guidelines for secondary prevention. We aimed to assess whether initiating statin treatment in CAD patients with baseline LDL-C 70-100 mg/dL in Taiwan could be cost-effective.

METHODS

A Markov model was developed to simulate a hypothetical cohort of CAD patients with a baseline LDL-C level of 90 mg/dL. The incidence and recurrence of MI and stroke related to specific LDL-C levels as well as the statin effect, mortality rate, and health state utilities were obtained from the literature. The direct medical costs and rate of fatal events were derived from the national claims database. The incremental cost-effectiveness ratio (ICER) per quality-adjusted life years (QALYs) was calculated, and sensitivity analyses were performed.

RESULTS

Moderate-intensity statin use, a treatment regimen expected to achieve LDL <70 mg/dL in the base case, resulted in a net gain of 562 QALYs but with an additional expenditure of $11.4 million per 10,000 patients over ten years. The ICER was $20,288 per QALY gained. The probabilities of being cost-effective at willingness-to-pay thresholds of one and three gross domestic product per capita ($24,329 in 2017) per QALY were 51.1% and 94.2%, respectively. Annual drug cost was the most influential factor on the ICER.

CONCLUSION

Lowering the target LDL-C level from 100 to 70 mg/dL among treatment-naïve CAD patients could be cost-effective given the health benefits of preventing cardiovascular events and deaths.

Development of a 3-Dimensional Prognostic Score for Patients With Symptomatic Peripheral Artery Disease: PAD3D Score

Peripheral artery disease (PAD) is a high-risk condition for cardiovascular (CV) events, but no specific prognosis assessment tool exists. We developed an individual risk score (PAD^3D) based on the combined predictive value for mortality, including (1) age, (2) severity of PAD, and (3) extent of atherosclerosis. Patients (n = 1310) with symptomatic PAD were followed up for a mean of 50 ± 26 months. The cohort was randomly subdivided into a test and validation cohort. All-cause and CV mortality were prospectively analyzed for PAD^3D score and in combination with classical risk factors. For the test and validation cohort (n = 655 each), all-cause and CV mortality were predicted (P < .001) by the PAD^3D score. Additional inclusion of classical risk factors did not increase discrimination compared with PAD^3D as "area under receiver-operating characteristic" curves were similar for both scores at any time point. Thus, the addition of the classical risk factors to PAD^3D did not further improve the prognostic value. The PAD^3D score provides a risk gradient of a 4.5-fold increase in all-cause and CV mortality. We developed a score for precise prediction of all-cause and CV mortality. The PAD^3D score promises to allow for personalized goals in risk intervention.

Burden of comorbidities is higher among elderly survivors of oropharyngeal cancer compared with controls

BACKGROUND

The prevalence of survivors of oropharyngeal cancer (OPC) is increasing due to improved survival for individuals with human papillomavirus (HPV)-related disease. Although elderly survivors of OPC are known to have a high burden of comorbidities, to the authors' knowledge it is unknown how this compares with a similar cohort without a history of cancer.

METHODS

The current retrospective, cross-sectional study included individuals with a first incident primary diagnosis of OPC from 2004 through 2011 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked databases and matched controls. The baseline prevalence and subsequent incidence of comorbid conditions were identified. The association between comorbidity and overall survival was evaluated.

RESULTS

A total of 2497 eligible patients with OPC were matched to 4994 noncancer controls. Baseline comorbidity was higher in cases (Charlson Comorbidity Index >0 for 48.5% of cases vs 35.8% of controls). At 5 years, cases were more likely than controls to develop comorbidities. Survivors of OPC were at high risk (≥20% cumulative prevalence by 5 years) of developing several comorbidities, including cardiovascular diseases, cerebrovascular disease, chronic obstructive pulmonary disease, and tobacco abuse, and were at moderately high risk (10%-19% cumulative prevalence) of developing other conditions including carotid artery occlusive stroke, alcohol abuse, depression, and anxiety. In both cases and controls, the presence of the majority of comorbidities either at the time of diagnosis or during the follow-up period was associated with worse survival.

CONCLUSIONS

Patients with OPC have a higher comorbidity burden compared with matched controls, both at baseline and during survivorship, the majority of which are associated with decreased survival. Oncologic surveillance of survivors of OPC should include screening for highly prevalent conditions.

The current state of heart disease: statins, cholesterol, fat and sugar

After decades of improvement in the outlook for cardiovascular disease (CVD), we are now seeing a plateau. Statins, once believed to be the most important advance in the fight against heart disease, have not mitigated the incidence or prevalence of CVD.

AIM

New research into lipid-lowering drugs is not only questioning their usefulness in primary care, but identifying them as harmful, resulting in the development of other diseases. When the original research is critically analyzed, the data do not reveal drugs that significantly reduce the incidence or prevalence for primary prevention of CVD in the United States.

METHODS

The current article sheds light on our current beliefs into lipid-lowering to treat potential CVD. Through a discussion of the difference between relative risk reduction and absolute risk reduction, the author suggests lifestyle modifications have been and always will be the best way to fight against this deadly chronic disease.

RESULTS

There is over 60 years-worth of scientific research that has been desperately trying to identify sugar as the culprit and driver of CVD disease; however, the medical system continues to fight against fat and cholesterol. This article makes the reader question what the US government, in association with the Medical Establishment (American Heart Association, American Diabetes Association and the American College of Cardiology) have been eschewing for the last 60-70 years as it has NOT been working.

CONCLUSION

The time for a culture-wide paradigm change has come. The author suggests this will only happen if Big Pharma and Big Food industries will change their marketing habits from 'purely taste' to 'best for your health'.

Hyperlipidemia: An Evidence-based Review of Current Guidelines

Cholesterol treatment guidelines have evolved in the United States from the 1988 Adult Treatment Panel (ATP) I, the ATP II guidelines, ATP III guidelines, the 2013 American College of Cardiology/American Heart Association guidelines, to the most recent 2016 recommendations from the United States Protective Services Task Force. The use of statins to treat hyperlipidemia has been widely accepted and recommended in adults aged 40-75 years old with at least one risk factor and a calculated 10-year cardiovascular disease risk of 10%. However, statin use is associated with myalgias, myopathy, musculoskeletal injury, liver injury, and increased diabetes risk. The evidence for non-statin treatments is mixed. Bile acid sequestrants and ezetimibe reduce cardiovascular events. There is no evidence that the addition of any fibric acid derivative to a statin improves cardiovascular outcomes. Available evidence suggests that the use of proprotein convertase subtilisin/kexin type 9 (PCSK9) enzyme inhibitors likely leads to little or no difference in mortality despite lowering lipid levels.

The impact of online self-management interventions on midlife adults with type 2 diabetes: a systematic review

Background:

Online self-management education programmes are now recommended for people with type 2 diabetes to improve self-management capacities. There is limited evidence to determine whether such programmes improve the health outcomes for midlife adults with diabetes.

Aims:

The purpose of this systematic review was to assess the impact of online self-management interventions with digital consulting on glycated haemoglobin (HbA1c), total cholesterol, blood pressure, diabetes distress, self-efficacy, and depression in midlife adults.

Methods:

A systematic review was undertaken searching Medline, Embase and CINAHL. Studies were appraised using the Cochrane Collaboration's tool.

Results:

Eight studies were included. Online interventions resulted in the improvement of HbA1c (pooled mean difference on HbA1c: -0.35%, 95% CI (-0.52, -0.18), P<0.001). A narrative synthesis was conducted for all secondary outcomes. No conclusions could be drawn on the impact of these outcomes.

Conclusion:

Online interventions improve HbA1c. Further research is needed for secondary outcomes.

Therapeutic effects of statins against lung adenocarcinoma via p53 mutant-mediated apoptosis

The p53 gene is an important tumour suppressor gene. Mutant p53 genes account for about half of all lung cancer cases. There is increasing evidence for the anti-tumour effects of statins via inhibition of the mevalonate pathway. We retrospectively investigated the correlation between statin use and lung cancer prognosis using the Taiwanese National Health Insurance Research Database, mainly focusing on early-stage lung cancer. This study reports the protective effects of statin use in early-stage lung cancer patients regardless of chemotherapy. Statin treatments reduced the 5-year mortality (odds ratio, 0.43; P < 0.001) in this population-based study. Significantly higher levels of cellular apoptosis, inhibited cell growth, and regulated lipid raft content were observed in mutant p53 lung cancer cells treated with simvastatin. Further, simvastatin increased the caspase-dependent apoptotic pathway, promotes mutant p53 protein degradation, and decreased motile activity in lung cancer cells with p53 missense mutations. These data suggest that statin use in selected lung cancer patients may have clinical benefits.

Prevalence of altered total cholesterol and fractions in the Brazilian adult population: National Health Survey

OBJECTIVE

To analyze the prevalence of altered total cholesterol and fractions levels in the Brazilian population, according to biochemical data from the National Health Survey.

METHODS

A descriptive study, using data from the National Health Survey, collected between 2014 and 2015. Total cholesterol and fractions were analyzed and population prevalences of altered values according to socio-demographic variables were calculated. The cutoff points considered were: total cholesterol ≥ 200mg/dl; low-density lipoprotein LDL ≥ 130mg/dL and high-density lipoprotein HDL < 40mg/dL.

RESULTS

The prevalence of total cholesterol ≥200mg/dL in the population was 32.7%, and higher in women (35.1%). The prevalence of altered HDL was 31.8%, 22.0% in females and 42.8% in males. LDL ≥ 130mg/dL was found in 18.6% and was higher in women (19.9%). The population aged 45 years old and older and those with low levels of education presented a higher prevalence of altered cholesterol.

CONCLUSION

Altered values of total cholesterol and fractions were frequent in the Brazilian population, especially among women, the elderly and people with low levels of education. These results may guide control and preventative actions such as healthy eating, physical activity and treatment, all of which aim to prevent coronary diseases.

Correlation of T Cell Subsets and Hypercholesterolemia of the Donor and Its Association with Acute Graft-versus-Host Disease

Background: Acute graft-versus-host disease (aGVHD) is an important cause of death following allogeneic hematopoietic stem cell transplantation (allo-HSCT). The association between cholesterol and aGVHD was previously described potentially, resulting from pro-inflammatory responses associated with hypercholesterolemia. The aim of this study was to correlate T cell subsets in donor bone marrow (BM) samples with their levels of cholesterol and associate these results with recipients who developed aGVHD and those who did not. Materials and Methods: A prospective study was performed in 39 donor samples. T cell subsets were analyzed by flow cytometry. Results: Eleven (28%) donors had hypercholesterolemia. Donor samples with hypercholesterolemia had less Tregs compared to donors with normal levels of cholesterol (22.69 (IQR=30.6) cells/µL vs 52.62 (IQR=44.68) cells/µL, p=0.04). Among all individuals in the cohort, aGVHD was observed in 21%: 36% from donors with hypercholesterolemia versus 14% from donors with normal levels of cholesterol. Conclusion: As we described the association between hypercholesterolemia and diminished Tregs, our results might suggest that normalizing the levels of total cholesterol in the donor, prior performing allo-HSCT, might be an effective approach to diminish the risk of the receptor to develop aGVHD.

Evaluation of the Cascade of Diabetes Care in the United States, 2005-2016

IMPORTANCE

Treatment advances in diabetes can meaningfully improve outcomes only if they effectively reach the populations at risk.

OBJECTIVES

To evaluate whether the cascade of US diabetes care, defined as diabetes diagnosis, linkage to care, and achievement of individual and combined treatment targets, improved from 2005 to 2016 and to investigate potential disparities in US diabetes care.

DESIGN, SETTING, AND PARTICIPANTS

Nationally representative, serial cross-sectional studies included in the 2005-2016 National Health and Nutrition Examination Survey were evaluated. Data on nonpregnant US adults (age ≥18 years) with diabetes who had reported fasting for 9 or more hours (n = 1742 diagnosed and 746 undiagnosed) were included. Data analysis was performed from August 1, 2018, to May 10, 2019.

EXPOSURES

Time period (2005-2008, 2009-2012, and 2013-2016), age, sex, race/ethnicity, health insurance, and educational level incorporated into logistic regression models predicting odds of target achievement.

MAIN OUTCOMES AND MEASURES

Proportion of participants overall and stratified by age, sex, and race/ethnicity who were linked to diabetes care and met glycemic (hemoglobin A1c <7.0%-8.5%, depending on age and complications), blood pressure (<140/90 mm Hg), cholesterol level (low-density lipoprotein cholesterol <100 mg/dL), and smoking abstinence targets and a composite of all targets.

RESULTS

In 2013-2016, of 1742 US adults with diagnosed diabetes, 94% (95% CI, 92%-96%) were linked to diabetes care; 64% (95% CI, 58%-69%) met hemoglobin A1c level, 70% (95% CI, 64%-75%) met blood pressure level, and 57% (95% CI, 51%-62%) met cholesterol level targets; 85% were nonsmokers (95% CI, 82%-88%); and 23% (95% CI, 17%-29%) achieved the composite goal. Results were similar in 2005-2008 (composite 23%) and in 2009-2012 (composite 25%). There was no significant improvement in diagnosis or target achievement during the study period. Compared with middle-aged adults (45-64 years) with diagnosed diabetes, older patients (≥65 years) had higher odds (adjusted odds ratio [aOR], 1.70; 95% CI, 1.17-2.48) and younger adults (18-44 years) had lower odds (aOR, 0.53; 95% CI, 0.29-0.97) of meeting the composite target. Women had lower odds of achieving the composite target than men (aOR, 0.60; 95% CI, 0.45-0.80). Non-Hispanic black individuals vs non-Hispanic white individuals had lower odds of achieving the composite target (aOR, 0.57; 95% CI, 0.39-0.83). Having health insurance was the strongest predictor of linkage to diabetes care (aOR, 3.96; 95% CI, 2.34-6.69).

CONCLUSIONS AND RELEVANCE

It appears that the diabetes care cascade in the United States has not significantly improved between 2005 and 2016. This study's findings suggest that gaps in diabetes care that were present in 2005, particularly among younger adults (18-44 years), women, and nonwhite individuals, persist.

Detailed Description of Change in Serum Cholesterol Profile with Incremental Weight Loss After Restrictive Bariatric Surgery

INTRODUCTION

Dyslipidemia affects up to 75% of morbidly obese individuals and is a key driver of cardiovascular disease. Weight loss is an established strategy to improve metabolic risk, including dyslipidemia. We aimed to determine weight loss goals for resolution of serum lipid abnormalities, by measuring improvements during progressive weight loss in obese individuals.

METHODS

We performed a prospective cohort study of obese individuals with the metabolic syndrome undergoing adjustable gastric banding. Lipid levels were monitored monthly for 9 months, then three monthly until 24 months.

RESULTS

There were 101 participants included, age 47.4 ± 10.9 years with body mass index 42.6 ± 5.9 kg/m². At 24 months, total body weight loss (TBWL) was 18.3 ± 7.9%. This was associated with significant improvements in high-density lipoprotein (HDL) (1.18 vs 1.47, p < 0.001), triglyceride (2.0 vs 1.4, p < 0.001), and total cholesterol to HDL ratio (TC:HDL) (4.6 vs 3.6, p < 0.001). Over this time, progressive and linear improvements in HDL, triglycerides, and TC:HDL were seen with incremental weight loss (observed at 2.5% TBWL intervals). Significant improvements occurred after a threshold weight loss of 7.5-12.5% TBWL was achieved, with odds ratio (OR) 1.48-2.50 for normalization. These odds improved significantly with increasing weight loss (OR 18.2-30.4 with > 25% TBWL). Despite significant weight loss, there was no significant change in low-density lipoprotein (LDL).

CONCLUSION

Significant improvements in triglycerides, HDL, and TC:HDL occur after 7.5-12.5% TBWL, with ongoing benefit after greater weight loss. LDL needs to be addressed independently, as this was not observed to respond to weight loss alone.

TRIAL REGISTRATION NUMBER

Australian Clinical Trials Registry (ACTRN12610000049077).

Community pharmacies offer a potential high-yield and convenient arena for total cholesterol and CVD risk screening

Background

Moderately elevated blood total cholesterol (TC), blood glucose (BG) and blood pressure (BP) are rarely symptomatic and as such many individuals remain untreated. We studied the yield of an in-pharmacy screening for identifying undetected high TC and strategies to reach those with absence of prior measurement of TC, BG and BP.

Methods

A cross-sectional TC screening study with complementary TC measurements and self-administered questionnaire was conducted for 1 week in each of 2012 and 2014 in 148 and 149 BootsTM Norge AS community pharmacies nationwide in Norway.

Results

Non-medicated adults (n = 21 090) with mean age 54.5 ± 16.0 were included. The study population resembled the Norwegian population in regards to body mass index, educational level, smokers and physical inactivity level, but with an overrepresentation of middle-aged women. Of 20 743 with available data, 11% (n = 2337) were unaware of their high TC ≥7.0 mmol/L, and an additional 8% were unaware of TC ≥6.2 mmol/L. More than 40% of the study sample had not measured TC or BG before. In order for future screenings to reach those who are less likely to have previously measured TC and BG, our results suggest that young, low-educated, overweight men and women should be targeted for TC measurement, whereas normal weigh men in all ages should be targeted for BG measurement.

Conclusions

In total 19% in an in-pharmacy screening were unaware of their elevated TC of ≥6.2 mmol/L. We also identified characteristics that could be used reach those who are less likely to have measured TC and BG.

Small Dense Low-Density Lipoprotein Cholesterol Predicts Cardiovascular Events in Liver Transplant Recipients

Cardiovascular disease (CVD) is an important cause of morbidity and mortality after liver transplantation (LT). Although LT is associated with dyslipidemia, particularly atherogenic lipoprotein subparticles, the impact of these subparticles on CVD-related events is unknown. Therefore, the aim of the current study was to evaluate the impact of small dense (sdLDL-C) low-density lipoprotein (LDL) cholesterol (LDL-C) on CVD events. Prospectively enrolled patients (N = 130) had detailed lipid profile consisting of traditional lipid parameters and sdLDL-C and were followed for CVD events. The primary endpoint was a CVD composite consisting of myocardial infarction (MI), angina, need for coronary revascularization, and cardiac death. Mean age of the cohort was 58 ± 11 years, and the most common etiology of liver disease (LD) was hepatitis C virus (N = 48) and nonalcoholic steatohepatitis (N = 23). A total of 20 CVD events were noted after median follow-up of 45 months. The baseline traditional profile was similar in patients with and without CVD events. A serum LDL-C cutoff of 100 mg/dL was unable to identify individuals at risk of a CVD event (P = 0.86). In contrast, serum concentration of atherogenic sdLDL-C >25 mg/dL was predictive of CVD events with a hazard ratio of 6.376 (95% confidence interval, 2.65, 15.34; P < 0.001). This relationship was independent of diabetes, hypertension, sex, ethnicity, LD, obesity, and statin use. Conclusion: sdLDL-C independently predicted CVD events whereas LDL-C did not. Thus, sdLDL-C may provide a useful clinical tool in risk stratifying and managing patients after LT.

The Influence of Meal Frequency and Timing on Health in Humans: The Role of Fasting

The influence of meal frequency and timing on health and disease has been a topic of interest for many years. While epidemiological evidence indicates an association between higher meal frequencies and lower disease risk, experimental trials have shown conflicting results. Furthermore, recent prospective research has demonstrated a significant increase in disease risk with a high meal frequency (≥6 meals/day) as compared to a low meal frequency (1⁻2 meals/day). Apart from meal frequency and timing we also have to consider breakfast consumption and the distribution of daily energy intake, caloric restriction, and night-time eating. A central role in this complex scenario is played by the fasting period length between two meals. The physiological underpinning of these interconnected variables may be through internal circadian clocks, and food consumption that is asynchronous with natural circadian rhythms may exert adverse health effects and increase disease risk. Additionally, alterations in meal frequency and meal timing have the potential to influence energy and macronutrient intake.A regular meal pattern including breakfast consumption, consuming a higher proportion of energy early in the day, reduced meal frequency (i.e., 2⁻3 meals/day), and regular fasting periods may provide physiological benefits such as reduced inflammation, improved circadian rhythmicity, increased autophagy and stress resistance, and modulation of the gut microbiota.

Emerging drugs for the treatment of hypercholesterolemia

INTRODUCTION

Despite the consolidated role of statins and ezetimibe to treat hypercholesterolemia, often the desirable low-density lipoprotein cholesterol (LDL-C) values are not achieved, with a consequent increase of the residual cardiovascular (CV) risk. Areas covered: In this review, we summarize the main pharmacological characteristics of new lipid-lowering drugs, such as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, cholesteryl ester transfer protein inhibitors, microsomal triglyceride transfer protein inhibitors, ATP citrate lyase inhibitors, antisense oligonucleotides, small interfering RNA, and peroxisome proliferator-activated receptors type α agonists. The available clinical evidence of efficacy and safety as well as the prospects of application, based on the different mechanisms and targets of action, is critically discussed. Expert opinion: Some of these emerging agents represent an excellent therapeutic strategy to treat patients with LDL largely out of target, resistant or intolerant to statins, trying to minimize the residual CV risk, modulating different classes of lipoproteins, not just LDL. The main challenge for the large use of emerging drugs is their cost. Thus, the correct identification of the adequate target population for treatment is a priority. This is particularly true for safe, powerful, and fully developed drugs such as the PCSK9 inhibitors, for which a relatively large use is potentially expected.

Association of eggs with dietary nutrient adequacy and cardiovascular risk factors in US adults

OBJECTIVE

Whole eggs are rich sources of several micronutrients. However, it is not well known how egg consumption contributes to overall nutrient adequacy and how it may relate to CVD risk factors. Therefore, the present study aimed to determine how whole egg consumption contributes to nutrient intakes and to assess its association with CVD risk factors in US adults.

DESIGN

Cross-sectional study.

SETTING

The study was conducted using data from the National Health and Nutrition Examination Survey (NHANES) 2003-2012, a nationally representative survey of the US civilian population.ParticipantsAdults who completed two dietary recalls and provided information on relevant sociodemographic factors were included in the study (n 21 845).

RESULTS

Approximately 73 % of adults were classified as whole egg consumers. Egg consumption was associated with greater intakes of protein, saturated fat, mono- and polyunsaturated fats, Fe, Zn, Ca, Se, choline, and several other vitamins and minerals. Egg consumption was associated with a higher likelihood of meeting or exceeding recommendations for several micronutrients. Egg intake was positively associated with dietary cholesterol consumption, but not with serum total cholesterol (TC) when adjusted for multiple potential confounders. In multiple linear regression analyses, TAG, TAG:HDL-cholesterol and TC:HDL-cholesterol were significantly lower with greater egg consumption. Egg consumption had no significant relationship with LDL-cholesterol or C-reactive protein, but was associated with higher BMI and waist circumference.

CONCLUSIONS

Whole eggs are important dietary contributors of many nutrients and had either beneficial or non-significant associations with most CVD risk biomarkers examined.

Evaluation of the optimal values of cholesterol of high density lipoproteins in a cohort of men aged 40-59 with myocardial infarction (according to 30-year monitoring of the status of life)

Aim. To establish connection between the functions of 30-year survival rate and concentration of cholesterol high density lipoproteins (C-HDL) in men aged 40-59 years with a past history of a myocardial infarction (MI) and relying on the obtained data to determine the optimal level of C-HDL for the specified cohort.

Material and methods. The study includes 141 patients who have had MI more than 6 months ago and observed in clinics of Metallurgical district of the city of Chelyabinsk within the third group of dispensary register. Specified MI cases refer to types 1, 2 of the Third universal definition of MI. The initial stage of study of the target group of men who have a past history of MI lasted from 03.06.1974 to 24.11.1975. Observation points were 0 and 30 years. The endpoint was death. Information about the dead established during the annual monitoring of the status of life. During the observation period 130 persons/92,2% died. Evaluation of survival was carried out according to the method of Kaplan-Meier, based on which a Cox regression model was built with the inclusion of successively higher minimum level of C-HDL, so that survival curves were significantly different. 95% confidence intervals were determined. The confidence bands of survival functions were built on the basis of on non-parametric Kolmogorov-Smirnov test.

Results. The analysis of the function of 30-year survival in men aged 40-59 with past history of MI, depending on the level of HDL-C showed: the presence of statistically significant relationships between survival and levels of HDL-C. Optimal concentrations of HDL cholesterol for survival were the values of HDL-C ≥2,0 mmol/l. Statistically significant periods of survival differences are shown on survival curves at different levels of HDL-C. The possibility of prediction of survival of each patient to a certain time depending on the level HDL-C is determined. Initial levels of HDL-C determine the beginning, duration, end of periods of statistically significant survival differences on survival curves.

Conclusion. The analysis of 30-year monitoring of the life status of cohort of men aged 40-59 with past history of MI showed a statistically significant dependence of survival on the initial level of HDL-C. The initial concentration of HDL-C are optimal for survival of indicated cohorts of men. HDL-C levels of 2,0-2,9 mmol/l can serve as a therapeutic target for men aged 40-59 with a past history of MI. The functions of 30-year survival in the cohort of middle-aged men who underwent MI, allow to determine the probability of survival of patients with this level of HDL-C to certain time.

Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities

Psoriasis is a chronic, inflammatory, multisystem disease that affects up to 3.2% of the US population. This guideline addresses important clinical questions that arise in psoriasis management and care, providing recommendations on the basis of available evidence.

New strategies for the development of lipid-lowering therapies to reduce cardiovascular risk

The very high occurrence of cardiovascular events presents a major public health issue, because treatment remains suboptimal. Lowering LDL cholesterol (LDL-C) with statins or ezetimibe in combination with a statin reduces major adverse cardiovascular events. The cardiovascular risk reduction in relation to the absolute LDL-C reduction is linear for most interventions without evidence of attenuation or increase in risk at low LDL-C levels. Opportunities for innovation in dyslipidaemia treatment should address the substantial risk of lipid-associated cardiovascular events among patients optimally treated per guidelines but who cannot achieve LDL-C goals and who could benefit from additional LDL-C-lowering therapy or experience side effects of statins. Fresh approaches are needed to identify promising drug targets early and develop them efficiently. The Cardiovascular Round Table of the European Society of Cardiology (ESC) convened a workshop to discuss new lipid-lowering strategies for cardiovascular risk reduction. Opportunities to improve treatment approaches and the efficient study of new therapies were explored. Circulating biomarkers may not be fully reliable proxy indicators of the relationship between treatment effect and clinical outcome. Mendelian randomization studies may better inform development strategies and refine treatment targets before Phase 3. Trials should match the drug to appropriate lipid and patient profile, and guidelines may move towards a precision-based approach to individual patient management. Stakeholder collaboration is needed to ensure continued innovation and better international coordination of both regulatory aspects and guidelines. It should be noted that risk may also be addressed through increased attention to other risk factors such as smoking, hypertension, overweight, and inactivity.

American Heart Association's Cholesterol CarePlan as a Smartphone-Delivered Web App for Patients Prescribed Cholesterol-Lowering Medication: Protocol for an Observational Feasibility Study

Background

Adoption of healthy lifestyle and compliance with cholesterol-lowering medication reduces the risk of cardiovascular disease (CVD). The use of digital tools and mobile technology may be important for sustaining positive behavioral change.

Objective

The primary objective of this study is to evaluate the feasibility and acceptability of administering the Cholesterol CarePlan Web app developed by the American Heart Association aimed at improving lifestyle and medication adherence among patients prescribed cholesterol-lowering medication. The secondary objective is to assess the Web app’s efficacy.

Methods

A prospective, observational feasibility study will be conducted to demonstrate whether the Web app may be successfully taken up by patients and will be associated with improved clinical and behavioral outcomes. The study will aim to recruit 180 study participants being prescribed cholesterol-lowering medication for at least 30 days across 14 general practices in London, England. Potentially eligible patients will be invited to use the Web app on a smartphone and visit general practice for three 20-minute clinical assessments of blood pressure, height, weight, smoking, and nonfasting cholesterol over 24 weeks. The feasibility of administering the Web app will be judged by recruitment and dropout statistics and the sociodemographic and comorbidity profile of consenting study participants, consenting nonparticipants, and all potentially eligible patients. Acceptability will be assessed using patients’ readiness to embrace new technologies, the usability of the Web app, and patient satisfaction. The efficacy of the Web app will be assessed by changes in medication adherence and clinical risk factors by levels of the Web app compliance.

Results

This study is currently funded by the American Heart Association. Initial study recruitment will take place between February and July 2018 followed by patient follow-up. Patient level data will be obtained in January 2019. Data analysis will be completed by February 2019. Results will be submitted for publication in March 2019.

Conclusions

The potential of an app to improve patients’ lifestyle and management of cholesterol may inform the design of a randomized controlled trial and the delivery of more effective CVD prevention programs.

International Registered Report Identifier (IRRID)

PRR1-10.2196/9017

Interpretation of CVD risk predictions in clinical practice: Mission impossible?

BACKGROUND

Cardiovascular disease (CVD) risk prediction models are often used to identify individuals at high risk of CVD events. Providing preventive treatment to these individuals may then reduce the CVD burden at population level. However, different prediction models may predict different (sets of) CVD outcomes which may lead to variation in selection of high risk individuals. Here, it is investigated if the use of different prediction models may actually lead to different treatment recommendations in clinical practice.

METHOD

The exact definition of and the event types included in the predicted outcomes of four widely used CVD risk prediction models (ATP-III, Framingham (FRS), Pooled Cohort Equations (PCE) and SCORE) was determined according to ICD-10 codes. The models were applied to a Dutch population cohort (n = 18,137) to predict the 10-year CVD risks. Finally, treatment recommendations, based on predicted risks and the treatment threshold associated with each model, were investigated and compared across models.

RESULTS

Due to the different definitions of predicted outcomes, the predicted risks varied widely, with an average 10-year CVD risk of 1.2% (ATP), 5.2% (FRS), 1.9% (PCE), and 0.7% (SCORE). Given the variation in predicted risks and recommended treatment thresholds, preventive drugs would be prescribed for 0.2%, 14.9%, 4.4%, and 2.0% of all individuals when using ATP, FRS, PCE and SCORE, respectively.

CONCLUSION

Widely used CVD prediction models vary substantially regarding their outcomes and associated absolute risk estimates. Consequently, absolute predicted 10-year risks from different prediction models cannot be compared directly. Furthermore, treatment decisions often depend on which prediction model is applied and its recommended risk threshold, introducing unwanted practice variation into risk-based preventive strategies for CVD.

Herpes zoster infection and statins: which implications in clinical practice?

Herpes zoster (HZ), which is caused by reactivation of latent varicella zoster virus (VZV), constitutes a major public health concern in both short- and long-term periods. Over the last years, several epidemiological studies have demonstrated that statin use is associated with increased risk of HZ at cerebral level. Because statins are among the most popular and best-selling drugs in western countries, this potential negative pleiotropic effect could have important implications in the daily clinical practice. In the present manuscript, we reviewed the available data on the statin use and the relative risk of HZ infection.