ApoB/ApoA-I Ratio is Associated With Faster Hemodynamic Progression of Aortic Stenosis: Results From the PROGRESSA (Metabolic Determinants of the Progression of Aortic Stenosis) Study

The influence of lipoprotein(a) on aortic valve calcification in patients undergoing transcatheter aortic valve replacement

BACKGROUND

Elevated levels of lipoprotein(a) (Lp[a]) have been recognized as substantial risk factors for cardiovascular disease and aortic stenosis (AS). However, the specific role of Lp(a) in promoting aortic valve calcification (AVC) and influencing mortality in elderly, multimorbid patients undergoing transcatheter aortic valve replacement (TAVR) remains unclear and warrants further investigation.

METHODS

A retrospective analysis was conducted on all consecutive patients who underwent TAVR between August 2019 and June 2020 at our clinic. Patients with missing data or prior aortic valve replacement were excluded. The study cohort was stratified based on an Lp(a) threshold of 60 mg/dl according to guidelines for lipoprotein apheresis in UK and Germany.1,2 RESULTS: In total, 454 patients were included into the analysis. Mean age was 81 ± 6 years and patients presented with a notable cardiovascular risk profile. Lp(a) values ≥ 60 mg/dl were detected in 102 (22.5%) patients, while 352 (77.5%) had Lp(a) values < 60 mg/dl. The median calcium volume of the total cohort was 894.5 [570.8; 1,382.8] mm2. No significant difference was observed between the groups (p = 0.83). Furthermore, Lp(a) did not emerge as a statistically significant predictor of calcium levels before TAVR. Notably, male gender (B = 404.11, p < 0.001) and mean trans-valvular pressure gradient (B = 15.64, p < 0.001) were identified as the strongest coefficients within the robust regression analysis. Log-rank tests indicated no prognostic utility of Lp(a) for 30-day all-cause mortality (p = 0.30) or 40 months long-term all-cause mortality (p = 0.60).

CONCLUSION

Lp(a) might not exert a significant effect on calcification levels or all-cause mortality in patients undergoing TAVR. Despite the study's highly selected population, these results align with current research, supporting the assumption that the influence of Lp(a) may be confined to the early stages of AS and its progression.

Predicting rotator cuff retear after arthroscopic repair: a lipoprotein-based model

BACKGROUND

Rotator cuff tear is the most common tendon injury. Currently, arthroscopic rotator cuff repair (ARCR) is the primary method for diagnosing and treating rotator cuff tear. One of the major complications following ARCR is retear. This study aims to evaluate the correlation between systemic lipid metabolism and retear occurrence after ARCR through a retrospective analysis of postoperative patients.

METHODS

This retrospective study reviewed consecutive patients of a single surgeon who underwent ARCR from January 2021 to January 2022. Eligibility for inclusion required complete sequential follow-up data, encompassing preoperative laboratory tests and a series of postoperative magnetic resonance imaging (MRI) evaluations at 1, 2, 3, and 6 months. Exclusion criteria included patients with incomplete laboratory tests, a history of tumors, prior shoulder surgeries, isolated subscapularis tendon tears, the rotator cuff related muscles are not clearly or completely displayed in MRI, absence of follow-up MRI, or those under treatment with lipid-lowering medications. Logistic regression analysis was employed to identify preoperative factors associated with retear, with statistical significance adjudged at P < .05.

RESULTS

From the initial cohort of 400 patients who underwent ARCR during the study period, 202 met both inclusion and exclusion criteria. These patients were subsequently divided into a training group (n = 122) and a test group (n = 80), maintaining a ratio of 6:4. Statistical analysis revealed significant risk factors for post-ARCR retear including high body mass index (>27.1; odds ratio (OR): 5.994, 95% confidential interval (CI): 1.762-13.980; P = .042), subscapularis muscle fatty infiltration of Grades 3 and 4 (OR: 8.509, 95%CI: 3.811-17.702; P = .009), serum apolipoprotein B (ApoB) levels exceeding 1.4 g/L (OR: 9.658, 95%CI: 3.520-21.753; P = .028), and an ApoB/A1 ratio greater than 1.8 (OR: 5.098, 95%CI: 1.787-10.496; P = .016). Conversely, the serum high-density lipoprotein level above 1.2 mmol/L (OR: -3.342, 95%CI: -7.466 to 0.659; P = .039) served as a protective factor. The model incorporating these 5 factors predicted retear with a sensitivity of 78.3% and specificity of 98.0% (area under the curve = 0.924, accuracy = 90.3%). Moreover, a new model comprising 3 lipid metabolism-related factors including high-density lipoprotein, ApoB and the ApoB/A1 ratio showed a sensitivity of 80.5% and specificity of 83.2% (area under the curve = 0.866, accuracy = 85.8%) for predicting retear after ARCR.

CONCLUSIONS

A predictive model utilizing key systemic lipid metabolism markers including HDL, ApoB, and the ApoB/A1 ratio, demonstrates effective forecasting of retear incidence following ARCR.

Association between triglyceride-glucose-body mass index and risk of aortic stenosis progression in patients with non-severe aortic stenosis: a retrospective cohort study

BACKGROUND

Triglyceride-glucose-BMI (TyG-BMI) index is a surrogate marker of insulin resistance and an important predictor of cardiovascular disease. However, the predictive value of TyG-BMI index in the progression of non-severe aortic stenosis (AS) is still unclear.

METHODS

The present retrospective observational study was conducted using patient data from Aortic valve diseases RISk facTOr assessmenT andprognosis modeL construction (ARISTOTLE). A total of 190 patients were recruited from one-center. Patients were divided into two groups according to the cut-off value of TyG-BMI index (Ln[triglycerides (mg/dL)* glucose (mg/dL)/2]*BMI). Cox regression and restricted subgroup analysis were used to evaluate the association of TyG-BMI index and progression of non-severe AS.

RESULTS

A total of 190 patients (mean age 72.52 ± 11.97 years, 51.58% male) were included in the study. During a median follow-up period of 27.48 months, 44 participants experienced disease progression. The cut-off of the TyG-BMI index is 239. After fully adjusting for confounding factors, high TyG-BMI index group was associated with a 2.219-fold higher risk of aortic stenosis progression (HR 2.219, 95%CI 1.086-4.537, p = 0.029).

CONCLUSION

TyG-BMI index was significantly associated with a higher risk of progression to non-severe AS. TyG-BMI index, as an effective alternative indicator of IR, can identify people at high risk of AS progression at an early stage of the disease, thereby improving the prognosis and reducing the socio-economic burden.

AI-Enhanced Prediction of Aortic Stenosis Progression: Insights From the PROGRESSA Study

Background

Aortic valve stenosis (AS) is a progressive chronic disease with progression rates that vary in patients and therefore difficult to predict.

Objectives

The aim of this study was to predict the progression of AS using comprehensive and longitudinal patient data.

Methods

Machine and deep learning algorithms were trained on a data set of 303 patients enrolled in the PROGRESSA (Metabolic Determinants of the Progression of Aortic Stenosis) study who underwent clinical and echocardiographic follow-up on an annual basis. Performance of the models was measured to predict disease progression over long (next 5 years) and short (next 2 years) terms and was compared to a standard clinical model with usually used features in clinical settings based on logistic regression.

Results

For each annual follow-up visit including baseline, we trained various supervised learning algorithms in predicting disease progression at 2- and 5-year terms. At both terms, LightGBM consistently outperformed other models with the highest average area under curves across patient visits (0.85 at 2 years, 0.83 at 5 years). Recurrent neural network-based models (Gated Recurrent Unit and Long Short-Term Memory) and XGBoost also demonstrated strong predictive capabilities, while the clinical model showed the lowest performance.

Conclusions

This study demonstrates how an artificial intelligence-guided approach in clinical routine could help enhance risk stratification of AS. It presents models based on multisource comprehensive data to predict disease progression and clinical outcomes in patients with mild-to-moderate AS at baseline.

Lipoprotein(a) and Calcific Aortic Valve Stenosis Progression: A Systematic Review and Meta-Analysis

Importance

There are currently no pharmacological treatments available to slow hemodynamic progression of aortic stenosis. Plasma lipoprotein(a) concentrations predict incident aortic stenosis but its association with hemodynamic progression is controversial.

Objective

To determine the association between plasma lipoprotein(a) concentrations and hemodynamic progression in patients with aortic stenosis.

Design, Settings and Participants

The study included patients with aortic stenosis from 5 longitudinal clinical studies conducted from March 2001 to March 2023 in Canada and the UK. Of 757 total patients, data on plasma lipoprotein(a) concentrations and rates of hemodynamic progression assessed by echocardiography were available for 710, who were included in this analysis. Data were analyzed from March 2023 to April 2024.

Exposure

Cohort-specific plasma lipoprotein(a) concentration tertiles.

Main Outcomes and Measures

Hemodynamic aortic stenosis progression on echocardiography as assessed by annualized change in peak aortic jet velocity, mean transvalvular gradient, and aortic valve area.

Results

Among the included patients, 497 (70%) were male and 213 (30%) were female. The mean (SD) age was 65.2 (13.1) years. Patients in the top lipoprotein(a) tertile demonstrated 41% (estimate, 1.41; 95% CI, 1.13-1.75) faster progression of peak aortic jet velocity and 57% (estimate, 1.57; 95% CI, 1.18-2.10) faster progression of mean transvalvular gradient than patients in the bottom tertile. There was no evidence of heterogeneity across the individual cohorts. Progression of aortic valve area was comparable between groups (estimate, 1.23; 95% CI, 0.71-2.12). Similar results were observed when plasma lipoprotein(a) concentrations were treated as a continuous variable.

Conclusions and Relevance

In this study, higher plasma lipoprotein(a) concentrations were associated with faster rates of hemodynamic progression in patients with aortic stenosis. Lowering plasma lipoprotein(a) concentrations warrants further investigation in the prevention and treatment of aortic stenosis.

The Risk of Coronary Artery Calcification according to Different Lipid Parameters and Average Lipid Parameters

AIM

We compared the association between the baseline and average lipid parameters over time and the coronary artery calcification (CAC) risk.

METHODS

Participants who underwent annual (biannual) health examinations and coronary artery computed tomography to measure CAC at least twice between March 2010 and December 2019, with a baseline CAC of 0, were included. The levels of apolipoprotein B (ApoB), Apolipoprotein A-I (ApoA1), ApoB/ApoA1, non-high-density lipoprotein cholesterol (non-HDL-C), low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), triglycerides (TG), TG/HDL-C, and TC/HDL-C were measured or calculated. The remnant cholesterol (RC) levels were calculated. The average lipid parameters before study entry were calculated using data from 2002 to 2010. The participants were divided into quartiles (Q) according to the parameter values. Cox proportional hazard modeling, adjusted for confounding factors, compared the CAC risk of the highest quartile to the lowest quartile.

RESULTS

Among 29,278 participants (mean age, 39.19±5.21; men, 88.27%), 2,779 developed CAC ＞0. The highest quartile of ApoB showed a numerically strong association with CAC risk, compared with the lowest quartile of ApoB (Q1: reference; Q2: HR,1.41, 95% CI,1.25-1.59; Q3: HR,1.97, 95% CI,1.75-2.21; Q4: HR,2.72, 95% CI,2.41-3.07). RC showed a modest association with CAC risk (Q1: reference; Q2: HR,1.13, 95% CI,0.99-1.28; Q3: HR,1.3, 95% CI,1.15-1.47; Q4: HR,1.7, 95% CI,1.51-1.91). The strength of the association was comparable between the parameters at baseline and the average lipid parameters over time.

CONCLUSIONS

A high ApoB level showed a strong association with CAC risk compared with the lowest ApoB quartile. The baseline lipid parameters can predict CAC development as effectively as the average of multiple measurements can.

Low-Density Lipoprotein Cholesterol, Type 2 Diabetes and Progression of Aortic Stenosis: The RED-CARPET Heart Valve Subgroup Cohort Study

Background

Low-density lipoprotein cholesterol (LDL-C) and type 2 diabetes (T2DM) are both independent risk factors for aortic stenosis (AS). In AS patients, whether LDL-C or T2DM is associated with fast AS progression (FASP) and their interaction is unknown. This study aims to test the hypothesis that there is a heightened risk of FASP when elevated LDL-C coexists with T2DM.

Methods

The Real-world Data of Cardiometabolic Protections (RED-CARPET) study enrolled participants with mild (peak aortic velocity = 2-3 m/s), moderate (3-4 m/s) and severe ( ≥ 4 m/s) AS between January 2015 and December 2020 at a single center. Participants were further stratified by baseline LDL-C joint T2DM, follow-up echocardiography was performed after 6 months, and the primary outcome was FASP, defined as the annual change in aortic peak velocity ( ≥ 0.3 m/s/year).

Results

Among the 170 participants included, 45.3% had mild AS, 41.2% had moderate AS, and 13.5% had severe AS. The mean age was 66.84 ± 12.64 years, and 64.1% were women. During the follow-up period of 2.60 ± 1.43 years, 35 (20.6%) cases of FASP were identified. Using non-T2DM with LDL-C < 2.15 mmol/L as reference, FASP risk was 1.30 [odds ratio (OR), 95% CI (0.99-7.78, p = 0.167)] for non-T2DM with LDL-C 2.15-3.14 mmol/L, 1.60 [OR, 95% CI (1.17-3.29, p = 0.040)] for non-T2DM with LDL-C ≥ 3.14 mmol/L, 2.21 [OR, 95% CI (0.49-4.32, p = 0.527)] for T2DM with LDL-C < 2.15 mmol/L, 2.67 [OR, 95% CI (1.65-7.10, p = 0.004)] for T2DM with LDL-C 2.15-3.14 mmol/L, and 3.20 [OR, 95% CI (1.07-5.34, p = 0.022)] for T2DM with LDL-C ≥ 3.14 mmol/L.

Conclusions

LDL-C joint T2DM was associated with FASP. This investigation suggests that fast progression of AS may develop if LDL-C is poorly managed in T2DM. Additional research is needed to validate this finding and explore the possible biological mechanism to improve the cardiometabolic management of T2DM and seek possible prevention for AS progression for this population.

Clinical Trial Registration

ChiCTR2000039901 (https://www.chictr.org.cn).

Evaluating Medical Therapy for Calcific Aortic Stenosis: JACC State-of-the-Art Review

Despite numerous promising therapeutic targets, there are no proven medical treatments for calcific aortic stenosis (AS). Multiple stakeholders need to come together and several scientific, operational, and trial design challenges must be addressed to capitalize on the recent and emerging mechanistic insights into this prevalent heart valve disease. This review briefly discusses the pathobiology and most promising pharmacologic targets, screening, diagnosis and progression of AS, identification of subgroups that should be targeted in clinical trials, and the need to elicit the patient voice earlier rather than later in clinical trial design and implementation. Potential trial end points and tools for assessment and approaches to implementation and design of clinical trials are reviewed. The efficiencies and advantages offered by a clinical trial network and platform trial approach are highlighted. The objective is to provide practical guidance that will facilitate a series of trials to identify effective medical therapies for AS resulting in expansion of therapeutic options to complement mechanical solutions for late-stage disease.

Effect of bicuspid aortic valve phenotype on progression of aortic stenosis

AIMS

To compare the progression of aortic stenosis (AS) in patients with bicuspid aortic valve (BAV) or tricuspid aortic valve (TAV).

METHODS AND RESULTS

One hundred and forty-one patients with mild-to-moderate AS, recruited prospectively in the PROGRESSA study, were included in this sub-analysis. Baseline clinical, Doppler echocardiography and multidetector computed tomography characteristics were compared between BAV (n = 32) and TAV (n = 109) patients. The 2-year haemodynamic [i.e. peak aortic jet velocity (Vpeak) and mean transvalvular gradient (MG)] and anatomic [i.e. aortic valve calcification density (AVCd) and aortic valve calcification density ratio (AVCd ratio)] progression of AS were compared between the two valve phenotypes. The 2-year progression rate of Vpeak was: 16 (-0 to 40) vs. 17 (3-35) cm/s, P = 0.95; of MG was: 1.8 (-0.7 to 5.8) vs. 2.6 (0.4-4.8) mmHg, P = 0.56; of AVCd was 32 (2-109) vs. 52 (25-85) AU/cm2, P = 0.15; and of AVCd ratio was: 0.08 (0.01-0.23) vs. 0.12 (0.06-0.18), P = 0.16 in patients with BAV vs. TAV. In univariable analyses, BAV was not associated with AS progression (all, P ≥ 0.26). However, with further adjustment for age, AS baseline severity, and several risk factors (i.e. sex, history of hypertension, creatinine level, diabetes, metabolic syndrome), BAV was independently associated with faster haemodynamic (Vpeak: β = 0.31, P = 0.02) and anatomic (AVCd: β = 0.26, P = 0.03 and AVCd ratio: β = 0.26, P = 0.03) progression of AS.

CONCLUSION

In patients with mild-to-moderate AS, patients with BAV have faster haemodynamic and anatomic progression of AS when compared to TAV patients with similar age and risk profile. This study highlights the importance and necessity to closely monitor patients with BAV and to adequately control and treat their risk factors.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov Unique identifier: NCT01679431.

ApoC-III is a novel inducer of calcification in human aortic valves

Calcific aortic valve disease (CAVD) occurs when subpopulations of valve cells undergo specific differentiation pathways, promoting tissue fibrosis and calcification. Lipoprotein particles carry oxidized lipids that promote valvular disease, but low-density lipoprotein-lowering therapies have failed in clinical trials, and there are currently no pharmacological interventions available for this disease. Apolipoproteins are known promoters of atherosclerosis, but whether they possess pathogenic properties in CAVD is less clear. To search for a possible link, we assessed 12 apolipoproteins in nonfibrotic/noncalcific and fibrotic/calcific aortic valve tissues by proteomics and immunohistochemistry to understand if they were enriched in calcified areas. Eight apolipoproteins (apoA-I, apoA-II, apoA-IV, apoB, apoC-III, apoD, apoL-I, and apoM) were enriched in the calcific versus nonfibrotic/noncalcific tissues. Apo(a), apoB, apoC-III, apoE, and apoJ localized within the disease-prone fibrosa and colocalized with calcific regions as detected by immunohistochemistry. Circulating apoC-III on lipoprotein(a) is a potential biomarker of aortic stenosis incidence and progression, but whether apoC-III also induces aortic valve calcification is unknown. We found that apoC-III was increased in fibrotic and calcific tissues and observed within the calcification-prone fibrosa layer as well as around calcification. In addition, we showed that apoC-III induced calcification in primary human valvular cell cultures via a mitochondrial dysfunction/inflammation-mediated pathway. This study provides a first assessment of a broad array of apolipoproteins in CAVD tissues, demonstrates that specific apolipoproteins associate with valvular calcification, and implicates apoC-III as an active and modifiable driver of CAVD beyond its potential role as a biomarker.

Consumption of Interesterified Medium- and Long-Chain Triacylglycerols Improves Lipid Metabolism and Reduces Inflammation in High-Fat Diet-Induced Obese Rats

Medium- and long-chain triacylglycerols (MLCTs) were synthesized from rapeseed oil (RO), one kind of commonly used edible long-chain triacylglycerols (TGs), and then delivered to high-fat diet (HFD)-induced obese rats. Compared with RO, MLCT consumption exhibited more potent effects on reducing body and tissue weight gains, plasma TG, and total cholesterol (TC) levels and on improving hepatic TG, TC, fatty acid synthase, acetyl-CoA carboxylase, and lipoprteinlipase contents. Meanwhile, lower amounts of tumor necrosis factor-α (TNF-α), monocyte chemoattractant protein-1, and endotoxin in plasma, lower levels of interleukin-6 and TNF-α, and higher levels of interleukin-10 in both livers and white adipose tissues were detected in MLCT-fed rats. MLCT intake also remarkably suppressed the size of adipocytes and the number of macrophages. In conclusion, our study suggested that the interesterified MLCT was more efficacious in improving the lipid metabolism and inflammation in HFD-induced obese rats than RO.

apoB/apoA-I Ratio and Lp(a) Associations With Aortic Valve Stenosis Incidence: Insights From the EPIC-Norfolk Prospective Population Study

Background

Apolipoprotein B/apolipoprotein A‐I (apoB/apoA‐I) ratio and lipoprotein(a) (Lp[a]) are associated with aortic valve stenosis (AVS) disease progression. Clinical characteristics such as age, sex, and presence of concomitant coronary artery disease may strongly modify these associations; however, these effects have not been well defined in longitudinal studies. We set out to assess these associations between apoB/apoA‐I ratio, Lp(a), and AVS incidence in a large population study.

Methods and Results

We analyzed data from 17 745 participants (mean age, 59.2±9.1 years; men, 44.9%) in the EPIC‐Norfolk (European Prospective Investigation Into Cancer in Norfolk Prospective Population Study) population study in whom apoB/apoA‐I and Lp(a) levels were measured. Participants were identified as having incident AVS if they were hospitalized or died with AVS as an underlying cause. After a median follow‐up of 19.8 years (17.9–21.0 years) there were 403 (2.2%) incident cases of AVS. The hazard ratio for AVS risk was 1.30 (95% CI, 1.19–1.41; P<0.001) per SD increase in apoB/apoA‐I. Adjusting for age, sex, and coronary artery disease, there was no significant association between apoB/apoA‐I and AVS incidence (hazard ratio, 1.06; 95% CI, 0.97–1.17 [P=0.215]). Elevated Lp(a) (>50 mg/dL) remained an independent risk factor for AVS after adjustment for age, sex, low‐density lipoprotein cholesterol, and concomitant coronary artery disease (hazard ratio, 1.70; 95% CI, 1.33–2.19 [P<0.001]).

Conclusions

In this population study, apoB/apoA‐I ratio was associated with risk of AVS incidence, especially in younger and female participants and those without concomitant coronary artery disease. Lp(a) was an independent risk factor for AVS incidence. Interventional trials are needed to investigate whether modulating apoB/apoA‐I or lowering Lp(a) can prevent or slow down AVS.