Low-density lipoprotein cholesterol and risk of intracerebral hemorrhage: A prospective study

Stroke Management and Analysis Risk Tool (SMART): An interpretable clinical application for diabetes-related stroke prediction

BACKGROUND AND AIMS

The growing global burden of diabetes and stroke poses a significant public health challenge. This study aims to analyze factors and create an interpretable stroke prediction model for diabetic patients.

METHODS AND RESULTS

Data from 20,014 patients were collected from the Affiliated Drum Tower Hospital, Medical School of Nanjing University, between 2021 and 2022. After handling the missing values, feature engineering included LASSO, SVM-RFE, and multi-factor regression techniques. The dataset was split 8:2 for training and testing, with the Synthetic Minority Oversampling Technique (SMOTE) to balance classes. Various machine learning and deep learning techniques, such as Random Forest (RF) and deep neural networks (DNN), have been utilized for model training. SHAP and a dedicated website showed the interpretability and practicality of the model. This study identified 11 factors influencing stroke incidence, with the RF and DNN algorithms achieving AUC values of 0.95 and 0.91, respectively. The Stroke Management and Analysis Risk Tool (SMART) was developed for clinical use.

PRIMARY ENDPOINT

The predictive performance of SMART in assessing stroke risk in diabetic patients was evaluated using AUC.

SECONDARY ENDPOINTS

Evaluated accuracy (precision, recall, F1-score), interpretability via SHAP values, and clinical utility, emphasizing user interface. Statistical analysis of EHR data using univariate and multivariate methods, with model validation on a separate test set.

CONCLUSIONS

An interpretable stroke-predictive model was created for patients with diabetes. This model proposes that standard clinical and laboratory parameters can predict the stroke risk in individuals with diabetes.

Cholesterol metabolism: physiological versus pathological aspects in intracerebral hemorrhage

Cholesterol is an important component of plasma membranes and participates in many basic life functions, such as the maintenance of cell membrane stability, the synthesis of steroid hormones, and myelination. Cholesterol plays a key role in the establishment and maintenance of the central nervous system. The brain contains 20% of the whole body's cholesterol, 80% of which is located within myelin. A huge number of processes (e.g., the sterol regulatory element-binding protein pathway and liver X receptor pathway) participate in the regulation of cholesterol metabolism in the brain via mechanisms that include cholesterol biosynthesis, intracellular transport, and efflux. Certain brain injuries or diseases involving crosstalk among the processes above can affect normal cholesterol metabolism to induce detrimental consequences. Therefore, we hypothesized that cholesterol-related molecules and pathways can serve as therapeutic targets for central nervous system diseases. Intracerebral hemorrhage is the most severe hemorrhagic stroke subtype, with high mortality and morbidity. Historical cholesterol levels are associated with the risk of intracerebral hemorrhage. Moreover, secondary pathological changes after intracerebral hemorrhage are associated with cholesterol metabolism dysregulation, such as neuroinflammation, demyelination, and multiple types of programmed cell death. Intracellular cholesterol accumulation in the brain has been found after intracerebral hemorrhage. In this paper, we review normal cholesterol metabolism in the central nervous system, the mechanisms known to participate in the disturbance of cholesterol metabolism after intracerebral hemorrhage, and the links between cholesterol metabolism and cell death. We also review several possible and constructive therapeutic targets identified based on cholesterol metabolism to provide cholesterol-based perspectives and a reference for those interested in the treatment of intracerebral hemorrhage.

Biological age construction for prediction of mortality in the Chinese population

Efforts to increase health span bring to light the necessity of constructing biological age (BA) for measuring aging. However, universally adaptive BA needs further investigation, especially among the Chinese population. Therefore, this study aimed to construct BA using routine clinical markers for the Chinese population. Included were two Chinese prospective cohorts, the Kailuan Study I (n = 83,571) for developing BA and the Kailuan Study II (n = 21,229) for validation. Leveraging baseline age-related clinical markers, we developed phenotypic BA (Pheno-Age) using Levine's methods and Klemera-Doubal BA (KDM-Age) using KDM methods and calculated the residuals of regressions of the two BA measured at baseline and during follow-up on chronological age, namely BA acceleration. The predictive performance of baseline, cumulative average, and updated BAs on mortality was evaluated using the area under the curve (AUC) and calibration plots. COX regressions were used to estimate hazard rations (HRs) and 95% confidence intervals (CIs) for the BA acceleration and risk of mortality. During 1,443,857 person-years of follow-up, 12,679 deaths were recorded in the two cohorts. Baseline Pheno-Age and KDM-Age produced desirable predictions for mortality in both the Kailuan Study I (AUC, 0.810 and 0.806, respectively) and the Kailuan Study II (AUC, 0.867 and 0.819, respectively). Calibration plots showed reasonable agreement between predicted and observed probabilities. The pooled multivariable-adjusted HRs (95% CIs) for per standard deviation increment of baseline Pheno-Age acceleration and mortality was 1.24 (1.18, 1.30), and for KDM-Age acceleration was 1.16 (1.10, 1.21). Similar predictive performance and association were observed when using cumulative average or updated BA. The associations were stronger in the adults aged ≤60 years, smokers, and drinkers, relative to their counterparts (P for interaction <0.05 for all). Pheno-Age and KDM-Age, developed and validated in the two large prospective cohorts, could predict mortality, independent of chronological age and other potential confounders, in Chinese populations.

Reducing LDL-Cholesterol to Very Low Levels: Sailing Between Established Benefits and Potential Risks

In view of the growing evidence supporting more marked reductions of low-density lipoprotein cholesterol (LDL-C), according to the concept of "the lower is better" and with the availability of powerful and well tolerated lipid-lowering drugs, physicians are facing today with the clinical management of patients with very low LDL-C levels. The fear of potential risks linked to extreme reductions of LDL-C down to very low levels may lead to the de-escalation of treatments with consequent paradoxical unfavorable consequences due to the exposure to a higher cardiovascular risk. The aim of this review is to point out evidence of very low LDL-C clinical impact, with a focus on potential adverse effects. Research on cholesterol homeostasis has identified complex mechanisms which guarantee cell functions even when circulating cholesterol levels are very low. The almost complete self-sufficiency of the human body in terms of cholesterol needs is confirmed by evidence derived from genetically determined models with very low LDL-C levels. Studies on the potential harm of lowering LDL-C to very low concentrations do not confirm an increased risk of cancer or neurodegenerative disease attributable to lipid-lowering treatments, whereas evidence suggests a potential benefit in these settings. A potential increased risk of hemorrhagic stroke has been reported, suggesting tight monitoring and control of blood pressure should be implemented in patients with very low LDL-C levels. With regard to statin treatment, a dose-dependent increased risk of newly diagnosed diabetes has been reported. This adverse effect has not been found with more recently approved lipid-lowering drugs.

Association between Life's Essential 8 and risk of heart failure: findings from the Kailuan study

AIMS

The impact of Life's Essential 8 (LE8) on heart failure (HF) remains poorly understood. We examined the associations between three forms of LE8 measurements and HF.

METHODS AND RESULTS

A total of 35 896 participants without a prior history of HF from the Kailuan community were included. The LE8 status was measured in 2014. A latent mixture model was employed to identify the trajectories of LE8 during 2006 to 2014. The LE8 annual change rate was defined as the slope of the linear regression equation fitted by five LE8 measurements. Cox proportional hazards models were used to assess the risk of HF associated with LE8, after adjusting for potential confounding variables. The predictive performance was quantified and compared using the C-index. Five distinct LE8 trajectories were identified. 461 HF events documented during follow-up. The LE8 trajectories presenting an upward trend in LE8 were associated with a reduced risk of HF, even when the initial LE8 level was low [HR (95% confidence interval) for moderate-increasing vs. moderate-decreasing trajectory was 0.43 (0.34, 0.55)]. The LE8 status was inversely associated with HF risk. A higher LE8 annual increase was associated with a lower risk of HF. The LE8 trajectory was more accurate in predicting the risk of HF compared with LE8 status.

CONCLUSION

LE8 was inversely associated with HF risk. Individuals with initially low LE8 levels experienced a reversal in HF risk upon improvement. Both LE8 trajectories and status are practicable in identifying individuals at high risk of HF, LE8 trajectories may provide added prognostic information.

Time course of remnant cholesterol and the risk of heart failure

BACKGROUND AND AIM

Previous studies have shown that remnant cholesterol (RC) was associated with heart failure (HF). However, lack of evidence regarding the long-term trend of RC with HF risk. We aimed to investigate the association between cumulative RC exposure with incident HF and to further explore the modulating effects of the time course of RC accumulation.

METHODS AND RESULTS

We enrolled 41,168 participants free of CVD from the Kailuan Study who completed the first three health examinations from 2006 to 2010. Cumulative RC exposure included cumulative RC and time-weighted cumulative RC. The combination of cumulative RC and RC slope over time was characterized as the time course of RC accumulation. Multivariable adjusted Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for HF risk. We also considered non-HF-related death as a competing event by performing competing risk models as a sensitivity analysis. During 8.84 years, 839 participants developed HF events. Cumulative RC exposure increased the HF risk, with HRs for cumulative RC of 1.72 (1.41-2.10) and for time-averaged cumulative RC of 1.54 (1.25-1.89). There was a nonlinear relationship between cumulative RC exposure and HF risk. Participants with higher cumulative RC and negative slope had the highest HF risk (HR, 1.46; 95% CI, 1.16-1.83).

CONCLUSIONS

Both cumulative long-term exposure and the time course of RC accumulation were associated with HF risk. Early RC accumulation resulted in a greater increase in risk compared to later accumulation. This finding suggests that long-term exposure to RC may be useful in identifying individuals at high risk of developing HF and highlights the need for early initiation of appropriate RC control to prevent or reduce incident HF.

Prediction of ischemic stroke in patients with H-type hypertension based on biomarker

Hypertension combined with hyperhomocysteinemia significantly raises the risk of ischemic stroke. Our study aimed to develop and validate a biomarker-based prediction model for ischemic stroke in Hyperhomocysteinemia-type (H-type) hypertension patients. We retrospectively included 3,305 patients in the development cohort, and externally validated in 103 patients from another cohort. Logistic regression, least absolute shrinkage and selection operator regression, and best subset selection analysis were used to assess the contribution of variables to ischemic stroke, and models were derived using four machine learning algorithms. Area Under Curve (AUC), calibration plot and decision-curve analysis respectively evaluated the discrimination and calibration of four models, then external validation and visualization of the best-performing model. There were 1,415 and 42 patients with ischemic stroke in the development and validation cohorts. The final model included 8 predictors: age, antihypertensive therapy, biomarkers (serum magnesium, serum potassium, proteinuria and hypersensitive C-reactive protein), and comorbidities (atrial fibrillation and hyperlipidemia). The optimal model, named A2BC ischemic stroke model, showed good discrimination and calibration ability for ischemic stroke with AUC of 0.91 and 0.87 in the internal and external validation cohorts. The A2BC ischemic stroke model had satisfactory predictive performances to assist clinicians in accurately identifying the risk of ischemic stroke for patients with H-type hypertension.

A global analysis of dairy consumption and incident cardiovascular disease

The role of dairy products in cardiovascular disease (CVD) prevention remains controversial. This study investigates the association between dairy consumption and CVD incidence using data from the China Kadoorie Biobank and the UK Biobank, complemented by an updated meta-analysis. Among Chinese participants, regular dairy consumption (primarily whole milk) is associated with a 9% increased risk of coronary heart disease (CHD) and a 6% reduced risk of stroke compared to non-consumers. Among British participants, total dairy consumption is linked to lower risks of CVD, CHD, and ischemic stroke, with cheese and semi-skimmed/skimmed milk contributing to reduced CVD risk. Meta-analysis reveals that total dairy consumption is associated with a 3.7% reduced risk of CVD and a 6% reduced risk of stroke. Notably, inverse associations with CVD incidence are observed for cheese and low-fat dairy products. Current evidence suggests that dairy consumption, particularly cheese, may have protective effects against CVD and stroke.

Time in target range for systolic blood pressure and glucose with cardiovascular disease and all-cause mortality risks

Evidence on the combined effect of time in the target range (TTR) for systolic blood pressure (SBP) and fasting blood glucose (FBG) in real-world settings was scarce. We aimed to evaluate the separate and combined effects of SBP TTR and FBG TTR on cardiovascular disease (CVD) and all-cause mortality risks among participants with comorbidity of hypertension and diabetes. The data was derived from the Kailuan study. The target ranges for SBP and FBG were set as 110-140 mmHg and 3.9-7.0 mmol/L, and linear interpolation to calculate TTR. Cox proportional hazard regression models were used to estimate the separate and combined effects of SBP TTR and FBG TTR on CVD and all-cause mortality risks. We included 11,899 participants with hypertension and diabetes comorbidity whose mean age was 54.52 ± 10.36 years, and 9,873 (83.00%) were male. After a follow-up of 6.67 years, 1,381 cases of CVD and 2,148 cases of all-cause mortality were documented. In the fully adjusted model, compared with the participants with both SBP TTR and FBG TTR lower than 25%, participants with both greater SBP TTR and FBG TTR had the lowest risks of CVD (HR: 0.53; 95%CI: 0.57-0.78) and mortality (HR: 0.59; 95%CI: 0.47-0.74). Per 1 SD increase in SBP TTR was associated with a 14% reduction in CVD risk (HR, 0.86; 95% CI, 0.80-0.92) and a 10% reduction in mortality risk (HR, 0.90; 95% CI, 0.85-0.95), all significant results were maintained in the FBG TTR analyses. Both higher SBP TTR and FBG TTR were associated with lower risks of CVD and all-cause mortality in participants with comorbidity of hypertension and diabetes. Simultaneous control of SBP and FBG within the target ranges is a beneficial strategy for CVD prevention.

Intracerebral haemorrhage - mechanisms, diagnosis and prospects for treatment and prevention

Intracerebral haemorrhage (ICH) is a devastating condition associated with high mortality and substantial residual disability among survivors. Effective treatments for the acute stages of ICH are limited. However, promising findings from randomized trials of therapeutic strategies, including acute care bundles that target anticoagulation therapies, blood pressure control and other physiological parameters, and trials of minimally invasive neurosurgical procedures have led to renewed optimism that patient outcomes can be improved. Currently ongoing areas of research for acute treatment include anti-inflammatory and haemostatic treatments. The implementation of effective secondary prevention strategies requires an understanding of the aetiology of ICH, which involves vascular and brain parenchymal imaging; the use of neuroimaging markers of cerebral small vessel disease improves classification with prognostic relevance. Other data underline the importance of preventing not only recurrent ICH but also ischaemic stroke and cardiovascular events in survivors of ICH. Ongoing and planned randomized controlled trials will assess the efficacy of prevention strategies, including antiplatelet agents, oral anticoagulants or left atrial appendage occlusion (in patients with concomitant atrial fibrillation), and optimal management of long-term blood pressure and statin use. Together, these advances herald a new era of improved understanding and effective interventions to reduce the burden of ICH.

Association of cumulative non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio with the risk of cardiometabolic disease

Background

One measurement of non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) is considered to be associated with insulin resistance and cardiovascular disease (CVD) risk. This study aimed to exploring the association between cumulative non-high-density lipoprotein cholesterol/high-density lipoprotein cholesterol (Cum NHHR) exposure levels and the risk of cardiometabolic disease (CMD).

Methods

This prospective cohort study included 43,735 participants, who participated in three consecutive health examinations in 2006, 2008, 2010 and had no history of CMD or cancer. The participants were divided into quartiles bases on their cum NHHR. Multivariate Cox proportional hazards model was used to assess the association between cum NHHR and the risk of CMD. Additionally, the direct method of standardized ratios was employed to calculate the absolute risk of CMD attributable to cum NHHR.

Results

Over a median follow-up period of 10.92 years (IQR: 10.22-11.26 years), 7,388 participants were newly diagnosed with CMD. In the multivariate-adjusted model, participants in quartiles Q2, Q3 and Q4 showed a progressively increased relative risk of CMD compared to those in Q1, The fully adjusted hazard ratios (95% confidence intervals) for the risk of CMD in the Q2, Q3, and Q4 groups were 1.11 (1.04-1.20), 1.23 (1.14-1.32), and 1.29 (1.20-1.38), respectively, compared with the Q1 group. This association remained significant even after further adjustment for single measurements of NHHR. Moreover, cum NHHR was positively correlated with the absolute risk of CMD, cardiovascular diseases (CVD), and type 2 diabetes (T2DM).

Conclusions

Higher cum NHHR is significantly associated with an increased risk of CMD, independent of single-point NHHR level. Additionally, there are significant different strengths of correlations between cum NHHR and different diseases.

Life's Essential 8 Trajectories and Risk of Stroke: A Prospective Cohort Study

BACKGROUND

Evidence is lacking regarding long-term patterns of change in Life's Essential 8 (LE8) and their association with the risk of stroke. We aim to evaluate LE8 trajectories and examine their association with the risk of stroke in China.

METHODS

This study, conducted in a workplace setting, recruited 26 719 participants (average age, 46.02±11.27 years and a male population of 73.73%) who had no history of stroke and consecutively participated in 6 surveys from 2006 to 2016. Repeated LE8 measurements were determined by taking the unweighted average of the 8 component scores ranging from 0 to 100. People with higher scores had better overall cardiovascular health. By examining the medical records of the participants, stroke cases were identified for the period from 2016 to 2020. A latent mixture model was applied to classify the trajectory clusters of LE8 from 2006 to 2016, and Cox proportional hazard models were used to analyze the data.

RESULTS

Five LE8 trajectories were detected between 2006 and 2016. Four hundred ninety-eight incident strokes including 55 (11.04%) hemorrhagic and 458 (91.97%) ischemic strokes were documented. After adjusting for covariates, the hazard ratios and 95% CIs for the association between stable-low, moderate-increasing, moderate-stable, and high-stable trajectories and incident stroke, compared with the moderate-decreasing trajectory, were 1.42 (1.11-1.84), 0.73 (0.56-0.96), 0.49 (0.39-0.62), and 0.19 (0.11-0.32), respectively. Individuals with high LE8 status (LE8≥80) exhibited a significantly reduced risk of stroke compared with those with low one (LE8≤49; P-trend <0.001). A faster annual growth in LE8 was related to a lower risk of stroke.

CONCLUSIONS

Maintaining high LE8 over an extended period and high baseline LE8 status were related to a decreased risk of stroke. Despite the initial low level of LE8, improvement in LE8 attenuates or even reverses the risk of stroke.

The correlation between mental health and arterial stiffness in Chinese population

This study aimed to evaluate the correlation between mental health status and arterial stiffness. A Symptom Checklist 90 (SCL-90) score was conducted for 10,688 employees of Kailuan Group Co., Ltd., of which 4936 participants received baPWV measurement. Of these, 4424 met the inclusion criteria. Based on the SCL-90 score, the study subjects were divided into normal mental health group (SCL-90 score < 160, 3993 cases) and abnormal mental health group (SCL-90 score ≥ 160, 431 cases). Statistical indicators include: General information, including levels of brachial-ankle pulse wave velocity (baPWV), age, gender, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), body mass index (BMI), smoking and alcohol consumption, daily activity levels, nature of work and educational qualifications. The proportion of males, baPWV value, and abnormal proportion of baPWV in normal mental health group were higher than those in abnormal mental health group (P < 0.05). The Hs-CRP in normal mental health group were lower than that in abnormal mental health group (P < 0.05). There were significant differences in activity level and educational attainment between the two groups (P < 0.05). After adjusting for confounders, the results of the multiple linear regression analysis showed that, Age, MAP, HR, FBG, TG were positively correlated with baPWV; SCL-90 score, gender, BMI, educational qualification were negatively correlated with baPWV. When the SCL-90 score of the general population increased by one point, baPWV decreased by 0.246 cm/s. Each such increase corresponded with a decrease in baPWV of 0.299 cm/s for male participants in general (β =  - 0.299, P = 0.007) and 0.412 cm/s for the male participants in the older-age group (β =  - 0.412, P = 0.017). Although adverse psychological factors have a certain impact on arterial stiffness, it does not constitute an independent risk factor.

Association of novel lipid indices with the white matter hyperintensities in cerebral small vessel disease: a cross-sectional study

BACKGROUND

Lipids are associated with atherosclerosis, and novel lipid indices have been recently identified to be closely linked to cardiovascular diseases. This study explored the association between four novel lipid indices and the white matter hyperintensities (WMHs) in patients diagnosed with cerebral small vessel disease (CSVD).

METHODS

Between January 2023 and February 2024, 219 patients were recruited, including 165 patients with CSVD WMHs and 54 healthy controls. Based on WMHs severity, patients with CSVD were categorised into mild and moderate-to-severe cohorts using the Fazekas rating scale. The plasma levels of four novel lipid indices (low-density lipoprotein cholesterol/high-density lipoprotein cholesterol ratio [LDL-C/HDL-C], triglyceride/high-density lipoprotein cholesterol ratio [TG/HDL-C], total cholesterol/high-density lipoprotein cholesterol ratio [TC/HDL-C], and non-high-density lipoprotein cholesterol [Non-HDL-C]), were rigorously monitored in the enrolled patients.

RESULTS

A total of 165 patients with CSVD WMHs were enrolled, including 94 with mild WMHs and 71 with moderate-to-severe WMHs. Multivariable logistic regression analysis revealed that LDL-C/HDL-C, TG/HDL-C, TC/HDL-C, and Non-HDL-C levels were significantly associated with WMHs (all P ≤ 0.001). Receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic performance of plasma lipid levels for WMHs in patients with CSVD. The novel lipid indicators outperformed traditional lipid indicators in assessing the diagnostic capability of WMHs. The combined index of the four blood lipid indices had an optimal cutoff point (OCP) of 0.489, with 88.3% sensitivity and 60.6% specificity. The area under the curve (AUC) is 0.800 (95% confidence interval [CI], 0.731-0.869; P < 0.001). Compared with males (OR = 1.126, 95% CI = 0.779-1.628), females (OR = 2.484, 95% CI = 1.398-4.414; P for interaction = 0.023) had a higher risk of developing WMHs.

CONCLUSION

This study demonstrates a significant association between four novel lipid indices and the cerebral WMHs in CSVD, highlighting the potential of these markers as novel plasma biomarkers and predictive indicators for assessing CSVD progression and guiding clinical management.

Association of socioeconomic status and life's essential 8 with cardiovascular diseases and all-cause mortality in north China: Kailuan study

BACKGROUND

We aimed to explore the association of socioeconomic status (SES) and life's essential 8 (LE8) with cardiovascular disease (CVD) and all-cause mortality in north China.

METHODS

A total of 91,365 adults from the Kailuan study were included in this study. Comprehensive individual SES, mainly including monthly household income, education, Occupation position, and community environment, was confirmed by latent class analysis. Furthermore, the mediation and combination effects of SES and LE8 on CVD and all-cause mortality were further assessed. The Cox regression model was conducted to estimate HRs and 95% CI.

RESULTS

During about 13 years of follow-up, 7,646 cardiovascular events and 11,749 deaths were recorded. Relative to the high SES, there were decreased risks of CVD [HR (95% CI): 1.57(1.43-1.72)] and high all-cause death [HR (95% CI): 1.43(1.31-1.53)] in the low SES. The associations between SES and CVD [Mediation % (95% CI): 22.3 (16.4-30.4)] and mortality [Mediation % (95% CI): 10.1 (7.1-14.0)] were partially mediated by LE8 when comparing medium SES to high SES. Meanwhile, relative to high LE8, the elevated risk of death [HR (95% CI): 1.72(1.56-1.89)], and incident CVD [HR (95% CI): 3.34(2.91-3.83)] were detected in low LE8. Compared to participants who had the high SES and LE8, participants who had both the low SES and LE8 further increased the risk of CVD [HR (95% CI): 7.76(5.21-11.55)] and all-cause mortality [HR (95% CI): 2.80(2.19-3.58)].

CONCLUSION

Low SES was related to a higher risk of CVD and mortality in low- and middle-income countries, which was partially mediated by LE8.

Intracerebral hemorrhage with massive milk-like serous fluid: a rare case report

Computed tomography (CT) scans of acute cerebral hemorrhage are often characterized by high-density imaging with occasional mixed density and low-density imaging features. Possible reasons for this are a lack of blood coagulation, extravasation of cerebrospinal fluid, and brain tissue edema. It is rarely due to the accumulation of lipid components associated with hyperlipidemia. In the present case, preoperative lipid tests and the intraoperative finding of a large amount of milky white fluid surrounding the hematoma confirmed that the low-density imaging surrounding the hematoma visible on the CT scan represented a rare case of lipid accumulation.

Association and its population heterogeneities between low-density lipoprotein cholesterol and all-cause and cardiovascular mortality: A population-based cohort study

BACKGROUND

The association and its population heterogeneities between low-density lipoprotein cholesterol (LDL-C) and all-cause and cardiovascular mortality remain unknown. We aimed to examine the dose-dependent associations of LDL-C levels with specific types of cardiovascular disease (CVD) mortality and heterogeneities in the associations among different population subgroups.

METHODS

A total of 2,968,462 participants aged 35-75 years from China Health Evaluation And risk Reduction through nationwide Teamwork (ChinaHEART) (2014-2019) were included. Cox proportional hazard models and Fine-Gray subdistribution hazard models were used to estimate associations between LDL-C categories (<70.0, 70.0-99.9, 100.0-129.9 [reference group], 130.0-159.9, 160.0-189.9, and ≥190.0 mg/dL) and all-cause and cause-specific mortality.

RESULTS

During a median follow-up of 3.7 years, 57,391 and 23,241 deaths from all-cause and overall CVD were documented. We observed J-shaped associations between LDL-C and death from all-cause, overall CVD, coronary heart disease (CHD), and ischemic stroke, and an L-shaped association between LDL-C and hemorrhagic stroke (HS) mortality ( P for non-linearity <0.001). Compared with the reference group (100.0-129.9 mg/dL), very low LDL-C levels (<70.0 mg/dL) were significantly associated with increased risk of overall CVD (hazard ratio [HR]: 1.10, 95% confidence interval [CI]: 1.06-1.14) and HS mortality (HR: 1.37, 95% CI: 1.29-1.45). Very high LDL-C levels (≥190.0 mg/dL) were associated with increased risk of overall CVD (HR: 1.51, 95% CI: 1.40-1.62) and CHD mortality (HR: 2.08, 95% CI: 1.92-2.24). The stronger associations of very low LDL-C with risk of CVD mortality were observed in individuals with older age, low or normal body mass index, low or moderate 10-year atherosclerotic CVD risk, and those without diagnosed CVD or taking statins. Stronger associations between very high LDL-C levels and all-cause and CVD mortality were observed in younger people.

CONCLUSIONS

People with very low LDL-C had a higher risk of all-cause, CVD, and HS mortality; those with very high LDL-C had a higher risk of all-cause, CVD, and CHD mortality. On the basis of our findings, comprehensive health assessment is needed to evaluate cardiovascular risk and implement appropriate lipid-lowering therapy for people with very low LDL-C.

10-year trajectory of Life's Essential 8 and incident hypertension: a community-based cohort study

BACKGROUND

The health effects of Life's Essential 8 (LE8) on chronic diseases have been disclosed, but its association with hypertension remains unknown. The current study aimed to explore the potential link between 10-year LE8 trajectory and the incidence of hypertension.

METHODS

LE8 was constructed from four behaviors and four metabolic factors, ranging from 0 to 100. Latent mixture models were used to identify trajectories of LE8 scores during 2006 to 2016. Incident hypertension was diagnosed based on self-reported clinical diagnoses and physical examinations from 2016 to 2020. Cox models were employed to assess the association of LE8 trajectories with hypertension. In addition to incorporating the mean hs-CRP levels from 2006 to 2016, age, sex, monthly income, educational level, and occupation at recruitment were adjusted for as confounding factors.

RESULTS

7500 participants aged 40.28 ± 10.35 years were included in the study, of whom 2907 (38.76%) were women. Five LE8 trajectory patterns were identified. After around four-year follow-up, 667 hypertension events were observed. Compared to the Low-Stable trajectory, the hazard ratios and 95% confidence intervals for the Moderate-Increasing, Moderate-Decreasing, Moderate-Stable, and High-Stable trajectories were 0.51 (0.40, 0.65), 0.81 (0.64, 1.02), 0.45 (0.36, 0.58), 0.23 (0.16, 0.33), respectively. The risk of incident hypertension decreased as participants improved their LE8 status. The robustness of the primary results was confirmed through several sensitivity analyses.

CONCLUSIONS

LE8 trajectories were associated with the incident hypertension. People who improved their LE8 scores over time experienced a decreased risk of hypertension, even if they started with lower LE8 scores initially.

U-shaped association between low-density lipoprotein cholesterol levels and risk of futile reperfusion mediated by stroke-associated pneumonia in acute ischemic stroke after endovascular thrombectomy

OBJECTIVE

Futile reperfusion (FR) is becoming a major challenge in the treatment of patients with acute ischaemic stroke (AIS) undergoing endovascular thrombectomy. This study aims to determine the dose-response relationship between low-density lipoprotein cholesterol (LDL-C) levels and the risk of FR in patients with AIS undergoing endovascular thrombectomy and to investigate potential mediators.

METHODS

A total of 614 patients with AIS undergoing endovascular thrombectomy were enrolled and divided into five groups according to quintiles of LDL-C levels: Q1(≤2.27 mmol/l), Q2 (2.27-2.5 mmol/l), Q3 (2.5-2.59 mmol/l), Q4 (2.59-2.97 mmol/l) and Q5 (≥2.97 mmol/l). Associations between LDL-C levels and the risk of FR and stroke-associated pneumonia (SAP) were estimated using multivariate logistic regression models. Restricted cubic spline curves were used to describe the dose-response relationship between LDL-C levels and the risk of FR and SAP. Mediation effect analysis was performed in R software with 100 bootstrap samples.

RESULTS

After adjustment for confounders, both low and high LDL-C levels were significantly associated with a higher risk of FR compared with the reference group (Q3). We observed a U-shaped association between LDL-C levels and the risk of FR (P for nonlinear =0.012). Mediation analysis showed that the association between LDL-C levels and the risk of FR was 29.7 % (95 % CI: 2.96 %-75.0 %, P=0.02) mediated by SAP.

CONCLUSIONS

We found a U-shaped association between LDL-C levels and the risk of FR that was mediated by SAP. Clinicians should note that in AIS patients undergoing endovascular thrombectomy, lower LDL-C levels are not always better.

The clinical value of nutritional and inflammatory indicators in predicting pneumonia among patients with intracerebral hemorrhage

Immunosuppression and malnutrition play pivotal roles in the complications of intracerebral hemorrhage (ICH) and are intricately linked to the development of stroke-associated pneumonia (SAP). Inflammatory markers, including NLR (neutrophil-to-lymphocyte ratio), SII (systemic immune inflammation index), SIRI (systemic inflammatory response index), and SIS (systemic inflammation score), along with nutritional indexes such as CONUT (controlling nutritional status) and PNI (prognostic nutritional index), are crucial indicators influencing the inflammatory state following ICH. In this study, our objective was to compare the predictive efficacy of inflammatory and nutritional indices for SAP in ICH patients, aiming to determine and explore their clinical utility in early pneumonia detection. Patients with severe ICH requiring ICU admission were screened from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The outcomes included the occurrence of SAP and in-hospital death. Receiver operating characteristic (ROC) analysis, multivariate logistic regression, smooth curve analysis, and stratified analysis were employed to investigate the relationship between the CONUT index and the clinical outcomes of patients with severe ICH. A total of 348 patients were enrolled in the study. The incidence of SAP was 21.3%, and the in-hospital mortality rate was 17.0%. Among these indicators, multiple regression analysis revealed that CONUT, PNI, and SIRI were independently associated with SAP. Further ROC curve analysis demonstrated that CONUT (AUC 0.6743, 95% CI 0.6079-0.7408) exhibited the most robust predictive ability for SAP in patients with ICH. Threshold analysis revealed that when CONUT < 6, an increase of 1 point in CONUT was associated with a 1.39 times higher risk of SAP. Similarly, our findings indicate that CONUT has the potential to predict the prognosis of patients with ICH. Among the inflammatory and nutritional markers, CONUT stands out as the most reliable predictor of SAP in patients with ICH. Additionally, it proves to be a valuable indicator for assessing the prognosis of patients with ICH.

Association of LDL-cholesterol <1.8 mmol/L and statin use with the recurrence of intracerebral hemorrhage

BACKGROUND

Recent intensive low-density lipoprotein cholesterol (LDL-C) lowering trials, including FOURIER, ODYSSEY OUTCOMES, and Treat Stroke to Target (TST) trials, have mostly refuted the concern surrounding statin use, LDL-C lowering, and intracerebral hemorrhage (ICH) risk. However, the results from these trials may not be fully applied to ICH survivors, as the populations studied were mainly patients without prior ICH, in whom the inherent ICH risk is more than 10 times lower than that of ICH survivors. Although available literature on statin use after ICH has demonstrated no excess risk of recurrent ICH, other potential factors that may modify ICH risk, especially hypertension control and ICH etiology, have not generally been considered. Notably, data on LDL-C levels following ICH are lacking.

AIMS

We aim to investigate the association between LDL-C levels and statin use with ICH risk among ICH survivors, and to determine whether the risk differed with patients' characteristics, especially ICH etiology.

METHODS

Follow-up data of consecutive spontaneous ICH survivors enrolled in the University of Hong Kong prospective stroke registry from 2011 to 2019 were retrospectively analyzed. ICH etiology was classified as cerebral amyloid angiopathy (CAA) using the modified Boston criteria or hypertensive arteriopathy, while the mean follow-up LDL-C value was categorized as <1.8 or ⩾1.8 mmol/L. The primary endpoint was recurrent ICH. The association of LDL-C level and statin use with recurrent ICH was determined using multivariable Cox regression. Pre-specified subgroup analyses were performed, including based on ICH etiology and statin prescription. Follow-up blood pressure was included in all the regression models.

RESULTS

In 502 ICH survivors (mean age = 64.2 ± 13.5 years, mean follow-up LDL-C = 2.2 ± 0.6 mmol/L, 28% with LDL-C <1.8 mmol/L), 44 had ICH recurrence during a mean follow-up of 5.9 ± 2.8 years. Statin use after ICH was not associated with recurrent ICH (adjusted hazard ratio (AHR) = 1.07, 95% confidence interval (CI) = 0.57-2.00). The risk of ICH recurrence was increased for follow-up LDL-C <1.8 mmol/L (AHR = 1.99, 95% CI = 1.06-3.73). This association was predominantly observed in ICH attributable to CAA (AHR = 2.52, 95% CI = 1.06-5.99) and non-statin users (AHR = 2.91, 95% CI = 1.08-7.86).

CONCLUSION

The association between post-ICH LDL-C <1.8 mmol/L and recurrent ICH was predominantly observed in CAA patients and those with intrinsically low LDL-C (non-statin users). While statins can be safely prescribed in ICH survivors, LDL-C targets should be individualized and caution must be exercised in CAA patients.

Risk of Hemorrhagic Stroke among Patients Treated with High-Intensity Statins versus Pitavastatin-Ezetimibe: A Population Based Study

High-intensity statin (HIS) is recommended for high-risk patients in current guidelines. However, the risk of hemorrhagic stroke (HS) with HIS is a concern for Asians. Pitavastatin carries pharmacological differences compared with other statins. We compared the risk of HS in patients treated with pitavastatin-ezetimibe vs. HIS. We conducted a population-based, propensity score-matched cohort study using data from the Taiwan National Health Insurance Research Database. From January 2013 to December 2018, adults (≥ 18 years) who received pitavastatin 2-4 mg/day plus ezetimibe 10 mg/day (combination group, N = 3,767) and those who received atorvastatin 40 mg/day or rosuvastatin 20 mg/day (HIS group, N = 37,670) were enrolled. The primary endpoint was HS. We also assessed the difference of a composite safety endpoint of hepatitis or myopathy requiring hospitalization and new-onset diabetes mellitus. Multivariable Cox proportional hazards model was used to evaluate the relationship between study endpoints and different treatment. After a mean follow-up of 3.05 ± 1.66 years, less HS occurred in combination group (0.74%) than in HIS group (1.35%) [adjusted hazard ratio (aHR) 0.65, 95% confidence interval (CI) 0.44-0.95]. In subgroup analysis, the lower risk of HS in combination group was consistent among all pre-specified subgroups. There was no significant difference of the composite safety endpoint between the 2 groups (aHR 0.91, 95% CI 0.81-1.02). In conclusion, pitavastatin-ezetimibe combination treatment had less HS compared with high-intensity atorvastatin and rosuvastatin. Pitavastatin-ezetimibe may be a favorable choice for Asians who need strict lipid control but with concern of HS.

The importance of LDL-C lowering in atherosclerotic cardiovascular disease prevention: Lower for longer is better

Cumulative exposure to low-density lipoprotein cholesterol (LDL-C) is a key driver of atherosclerotic cardiovascular disease (ASCVD) risk. An armamentarium of therapies to achieve robust and sustained reduction in LDL-C can reduce ASCVD risk. The gold standard for LDL-C assessment is ultracentrifugation but in routine clinical practice LDL-C is usually calculated and the most accurate calculation is the Martin/Hopkins equation. For primary prevention, consideration of estimated ASCVD risk frames decision making regarding use of statins and other therapies, and tools such as risk enhancing factors and coronary artery calcium enable tailoring of risk assessment and decision making. In patients with diabetes, lipid lowering therapy is recommended in most patients to reduce ASCVD risk with an opportunity to tailor therapy based on other risk factors. Patients with primary hypercholesterolemia and familial hypercholesterolemia (FH) with baseline LDL-C greater than or equal to 190 mg/dL are at elevated risk, and LDL-C lowering with high-intensity statin therapy is often combined with non-statin therapies to prevent ASCVD. Secondary prevention of ASCVD, including in patients with prior myocardial infarction or stroke, requires intensive lipid lowering therapy and lifestyle modification approaches. There is no established LDL-C level below which benefit ceases or safety concerns arise. When further LDL-C lowering is required beyond lifestyle modifications and statin therapy, additional medications include oral ezetimibe and bempedoic acid, or injectables such as PCSK9 monoclonal antibodies or siRNA therapy. A novel agent that acts independently of hepatic LDL receptors is evinacumab, which is approved for patients with homozygous FH. Other emerging agents are targeted at Lp(a) and CETP. In light of the expanding lipid treatment landscape, this manuscript reviews the importance of early, intensive, and sustained LDL-C-lowering for primary and secondary prevention of ASCVD.

Perceived Taste and Olfactory Dysfunctions and Subsequent Stroke Risk

Background

Taste and olfactory dysfunction are commonly associated with neurodegenerative diseases and cardiovascular risk factors, but their specific associations with stroke risk remain uncertain.

Objectives

The purpose of this paper was to explore whether perceived taste and olfactory dysfunctions were associated with stroke risk.

Methods

Included were 85,656 participants (mean age 51.0 ± 15.3 years) of the Kailuan study. Perceived olfactory and taste dysfunctions were assessed via a questionnaire at baseline (in 2014-2016). Incident stroke cases were confirmed by review of medical records. Cox proportional hazards models were used to investigate associations of perceived olfactory and taste dysfunctions with stroke risk, and mediation analysis was used to estimate the mediating effect of chronic disease statuses.

Results

We documented 2,198 incident stroke cases during a mean of 5.6 years of follow-up. Perceived taste dysfunction was associated with a doubled risk of developing total stroke (adjusted HR: 2.03; 95% CI: 1.36-3.04; P < 0.001) even with adjustment of lifestyle factors, biomarkers (ie, blood lipids, blood glucose, blood pressure, and uric acid), and other potential confounders. However, perceived olfactory dysfunction (adjusted HR: 1.22; 95% CI: 0.79-1.90; P = 0.34) was not significantly associated with a high risk of total stroke. Similar results of both perceived taste and olfactory dysfunctions were observed for ischemic stroke. Presence of chronic diseases, including hypertension, diabetes, chronic kidney disease, and overweight/obesity, mediated 4% to 5% of the association of perceived taste dysfunction with both total stroke and ischemic stroke.

Conclusions

In this large cohort study, perceived taste dysfunction was associated with a high risk of developing stroke.

Elevated atherogenic index of plasma associated with stroke risk in general Chinese

BACKGROUND AND AIMS

The atherogenic index of plasma (AIP) is supposed to be associated with cardiovascular disease (CVD), but there is limited evidence on its longitudinal effect. Our study aimed to explore the associations between baseline and long-term AIP with the risk of stroke and its subtypes.

METHODS AND RESULTS

A total of 97,959 participants free of stroke at baseline were included in the Kailuan study. The AIP was calculated as the logarithm of the ratio of triglyceride to high-density lipoprotein cholesterol. The updated mean AIP was calculated as the average of the AIP from baseline to the first occurrence of outcome or the end of follow-up. The outcome was the first occurrence of stroke, including ischemic stroke (IS) and intracerebral hemorrhage (ICH). We used univariable and multivariable Cox proportional hazard models to explore the association between AIP and the risk of stroke. During a median follow-up of 12.79 years, a total of 6307 participants developed stroke, including 5482 IS and 1024 ICH. Compared with the 1st quartile of baseline AIP, the multivariate-adjusted HR in the 4th quartile was 1.12 (95% CI, 1.03-1.22, p for trend <0.001) for stroke risk. Same results were found in IS, but no significant association was found for ICH. The associations between updated mean AIP and stroke and its subtypes showed similar results.

CONCLUSIONS

Elevated levels of both baseline and long-term updated mean AIP were associated with the risk of stroke and IS but not ICH in the general population.

Association of Life's Essential 8 with all-cause mortality and risk of cancer: a prospective cohort study

BACKGROUND

No study has concentrated on the association of LE8 with cancer risk and death. We aim to examine the association of LE8 with death and cancer.

METHODS

A total of 94733 adults aged 51.42 ± 12.46 years and 77551 participants aged 54.09±12.06 years were enrolled in longitudinal and trajectory analysis respectively. Baseline LE8 was divided into three groups based on the American Heart Association criteria and three trajectory patterns by latent mixture models. We reviewed medical records and clinical examinations to confirm incident cancer during the period from 2006 to 2020. Death information was collected from provincial vital statistics offices. Cox models were used.

RESULTS

12807 all-cause deaths and 5060 cancers were documented during a 14-year follow-up. Relative to participants with high LE8 at baseline, participants with lower levels of LE8 have a significantly increased risk of mortality and incident cancer. All these risks have an increasing trend with LE8 level decreasing. Meanwhile, the trajectory analysis recorded 7483 all-cause deaths and 3037 incident cancers after approximately 10 years. The associations of LE8 with death and cancer were identical to the longitudinal study. In the subtype cancer analysis, LE8 has a strong effect on colorectal cancer risk. Moreover, the cut point is 56.67 in the association between LE8 and death, while the cut point altered to 64.79 in the association between LE8 and incident cancers. These associations were enhanced among younger adults.

CONCLUSIONS

There was a significant association of LE8 with death and cancer risk, especially for the young population.

Evolving Concepts of the SCORE System: Subtracting Cholesterol from Risk Estimation: A Way for a Healthy Longevity?

The role of cholesterol, mainly low-density lipoproteins (LDL-C), as a causal risk factor for atherosclerotic cardiovascular disease (ASCVD) is now established and accepted by the international scientific community. Based on this evidence, the European and American guidelines recommend early risk stratification and "rapid" achievement of the suggested target according to the risk estimation to reduce the number of major cardiovascular events. Prolonged exposure over the years to high levels of LDL-C is one of the determining factors in the development and progression of atherosclerotic plaque, on which the action of conventional risk factors (cigarette smoking, excess weight, sedentary lifestyle, arterial hypertension, diabetes mellitus) as well as non-conventional risk factors (gut microbiota, hyperuricemia, inflammation), alone or in combination, favors the destabilization of the atherosclerotic lesion with rupture/fissuration/ulceration and consequent formation of intravascular thrombosis, which leads to the acute clinical manifestations of acute coronary syndromes. In the current clinical practice, there is a growing number of cases that, although extremely common, are emblematic of the concept of long-term exposure to the risk factor (LDL hypercholesterolemia), which, not adequately controlled and in combination with other risk factors, has favored the onset of major cardiovascular events. The triple concept of "go lower, start earlier and keep longer!" should be applied in current clinical practice at any level of prevention. In the present manuscript, we will review the current evidence and documents supporting the causal role of LDL-C in determining ASCVD and whether it is time to remove it from any score.

Risk and Population Attributable Fraction of Stroke Subtypes in Japan

BACKGROUND

Associations of major risk factors for stroke with total and each type of stroke, as well as subtypes of ischemic stroke, and their population attributable fractions had not been examined comprehensively.

METHODS

Participants of the Japan Public Health Center-based prospective (JPHC) Study Cohort II without histories of cardiovascular disease and cancer (n = 14,797) were followed from 1993 through 2012. Associations of current smoking, hypertension, diabetes, overweight (body mass index ≥25 kg/m2), non-high-density lipoprotein cholesterol (non-HDLC) categories, low HDLC (<40 mg/dL), urine protein, and history of arrhythmia were examined in a mutually-adjusted Cox regression model that included age and sex. Population attributable fractions (PAFs) were estimated using the hazard ratios and the prevalence of risk factors among cases.

RESULTS

Subjects with hypertension were 1.63 to 1.84 times more likely to develop any type of stroke. Diabetes, low HDLC, current smoking, overweight, urine protein, and arrhythmia were associated with risk of overall and ischemic stroke. Hypertension and urine protein were associated with risk of intracerebral hemorrhage, while current smoking, hypertension, and low non-HDLC were associated with subarachnoid hemorrhage. Hypertension alone accounted for more than a quarter of stroke incidence, followed by current smoking and diabetes. High non-HDLC, current smoking, low HDLC, and overweight contributed mostly to large-artery occlusive stroke. Arrhythmia explained 13.2% of embolic stroke. Combined PAFs of all the modifiable risk factors for total, ischemic, and large-artery occlusive strokes were 36.7%, 44.5%, and 61.5%, respectively.

CONCLUSION

Although there are differences according to subtypes, hypertension could be regarded as the most crucial target for preventing strokes in Japan.

Dyslipidemia Treatment and Cerebrovascular Disease: Evidence Regarding the Mechanism of Stroke

Dyslipidemia stands as a significant risk factor for stroke, on par with the impact of hypertension, diabetes, and smoking. While the role of dyslipidemia is firmly established in the context of coronary artery disease, its influence on strokes remains somewhat enigmatic. This complexity likely arises from the diverse mechanisms underpinning strokes, which encompass a heterogeneous spectrum (hemorrhagic and ischemic; large artery atherosclerosis, small vessel occlusion, cardioembolism, and etc.). The extent to which lipid-lowering treatments affect stroke outcomes may vary depending on the specific stroke subtype. For instance, in cases of large artery atherosclerosis (LAA), the optimal target level of low-density lipoprotein cholesterol (LDL-C) is relatively clear. However, when dealing with other stroke subtypes like small vessel occlusion or cardioembolism, the appropriate LDL-C target remains uncertain. Furthermore, reperfusion therapy has emerged as the foremost treatment for acute ischemic stroke. Nevertheless, the precise relationship between LDL-C levels and outcomes in patients undergoing reperfusion therapy remains shrouded in uncertainty. Consequently, we have undertaken an in-depth exploration of the existing evidence supporting the utilization of lipid-lowering medications such as statins, ezetimibe, and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. Our objective is to elucidate their role in secondary stroke prevention and the management of dyslipidemia across the various stroke subtypes.

The Impact of Anti-Amyloid Immunotherapies on Stroke Care

Anti-amyloid immunotherapies have recently emerged as treatments for Alzheimer's disease. While these therapies have demonstrated efficacy in clearing amyloid-β and slowing cognitive decline, they have also been associated with amyloid-related imaging abnormalities (ARIA) which include both edema (ARIA-E) and hemorrhage (ARIA-H). Given that ARIA have been associated with significant morbidity in cases of antithrombotic or thrombolytic therapy, an understanding of mechanisms of and risk factors for ARIA is of critical importance for stroke care. We discuss the latest data regarding mechanisms of ARIA, including the role of underlying cerebral amyloid angiopathy, and implications for ischemic stroke prevention and management.

QiShenYiQi pill inhibits atherosclerosis by promoting TTC39B-LXR mediated reverse cholesterol transport in liver

BACKGROUND

Tetranucleotide repeat domain protein 39B (TTC39B) was found to combine with ubiquitin ligase E3, and promote the ubiquitination modification of liver X receptor (LXR), which led to the inhibition of reverse cholesterol transport and development of atherosclerosis. QiShenYiQi pill (QSYQ) is a modern Chinese patent drug for treating ischemic cardiovascular diseases, the underlying mechanism is found to promote the expression of LXR-α/ ATP-binding cassette transporter G5 (ABCG5) in the liver of atherosclerotic mice.

PURPOSE

The aim of this study is to investigate the effect of QSYQ on TTC39B-LXR mediated reverse cholesterol transport in atherosclerotic mice.

STUDY DESIGN AND METHODS

Male apolipoprotein E gene knockout mice (7 weeks old) were fed with high-fat diet and treated with low dose of QSYQ (QSYQ-l, 0.3 g/kg·d), high dose of QSYQ (QSYQ-H, 1.2 g/kg·d) and LXR-α agonist (LXR-A, GW3965 10 mg/kg·d) for 8 weeks. C57BL/6 J mice were fed with normal diet and used as negative control. Oil red O staining, HE staining, ELISA, RNA sequencing, western blot, immunohistochemistry, RT-PCR, cell culture and RNA interference were performed to analyze the effect of QSYQ on atherosclerosis.

RESULTS

HE staining showed that QSYQ reduced the atherosclerotic lesion significantly when compared to the control group. ELISA measurement showed that QSYQ decreased serum VLDL and increased serum ApoA1. Oil Red O staining showed that QSYQ reduced the lipid content of liver and protect liver function. Comparative transcriptome RNA-sequence of liver showed that DEGs after QSYQ treatment enriched in high-density lipoprotein particle, ubiquitin ligase complex, bile secretion, etc. Immunohistochemical staining and western blot proved that QSYQ increased the protein expression of hepatic SR-B1, LXR-α, LXR-β, CYP7A1 and ABCG5. Targeted inhibiting Ttc39b gene in vitro further established that QSYQ inhibited the gene expression of Ttc39b, increased the protein expression of SR-B1, LXR-α/β, CYP7A1 and ABCG5 in rat hepatocyte.

CONCLUSION

Our results demonstrated the new anti-atherosclerotic mechanism of QSYQ by targeting TTC39B-LXR mediated reverse cholesterol transport in liver. QSYQ not only promoted reverse cholesterol transport, but also improved fatty liver and protected liver function.

Changing Patterns of Stroke and Subtypes Attributable to High Systolic Blood Pressure in China From 1990 to 2019

BACKGROUND

It is unknown whether high systolic blood pressure had a similar effect on the disease burden of stroke subtypes. The aim of our study is to compare the long-term trends of stroke subtypes and sex groups attributable to high systolic blood pressure in China from 1990 to 2019.

METHODS

Data about the age-standardized mortality rate and the age-standardized disability-adjusted life-year rate of stroke subtypes attributable to high systolic blood pressure in China were extracted in GBD (Global Burden of Disease) 2019. The trends in the age-standardized mortality rate and the age-standardized disability-adjusted life-year rate were calculated using the liner regression and age-period-cohort method, adjusted for age, period, and cohort.

RESULTS

The estimated annual percentage change for mortality of stroke attributable to high systolic blood pressure was different from subtypes, with an estimated annual percentage change and 95% CI of 0.56 (0.37-0.74) for ischemic stroke (IS), -1.52 (-1.97 to -1.07) for intracerebral hemorrhage, and -7.02 (-7.86 to -6.17) for subarachnoid hemorrhage (SAH). The curve of the net drifts showed a downward trend for intracerebral hemorrhage and SAH, but that showed a stable trend for IS. The curve of local drifts showed a slow upward trend with age for IS, a slow downward trend for intracerebral hemorrhage, and a sharp downward trend for SAH. The drift curves showed different trends for males and females. The proportion of stroke mortality in young males was gradually increasing. The cohort rate ratio varied by subtypes, with the greatest decline for SAH, a slight decrease for intracerebral hemorrhage, and a slight increase for IS. The period rate ratio had decreased over the past 3 decades, with the greatest decline for SAH and the weakest decrease for IS. Moreover, both the period and cohort rate ratios for IS mortality due to high systolic blood pressure in males have increased significantly over the past 3 decades.

CONCLUSIONS

Our results provided strong evidence that the disease burden of stroke attributable to high systolic blood pressure varied by subtypes and sex in China from 1990 to 2019. The age-standardized mortality rate and the age-standardized disability-adjusted life-year rate decreased for hemorrhagic stroke but increased for IS. Males had a higher mortality and exposure risk but a slighter decreasing trend than females. Our study suggested that greater attention should be given to the prevention of the burden of IS attributable to systolic blood pressure in China, especially for males.

Development and Validation of a Predictive Model for Intracranial Haemorrhage in Patients on Direct Oral Anticoagulants

BACKGROUND

Intracranial haemorrhage (ICH) poses a significant threat to patients on Direct Oral Anticoagulants (DOACs), with existing risk scores inadequately predicting ICH risk in these patients. We aim to develop and validate a predictive model for ICH risk in DOAC-treated patients.

METHODS

24,794 patients treated with a DOAC were identified in a province-wide electronic medical and health data platform in Tianjin, China. The cohort was randomly split into a 4:1 ratio for model development and validation. We utilized forward stepwise selection, Least Absolute Shrinkage and Selection Operator (LASSO), and eXtreme Gradient Boosting (XGBoost) to select predictors. Model performance was compared using the area under the curve (AUC) and net reclassification index (NRI). The optimal model was stratified and compared with the DOAC model.

RESULTS

The median age is 68.0 years, and 50.4% of participants are male. The XGBoost model, incorporating six independent factors (history of hemorrhagic stroke, peripheral artery disease, venous thromboembolism, hypertension, age, low-density lipoprotein cholesterol levels), demonstrated superior performance in the development dateset. It showed moderate discrimination (AUC: 0.68, 95% CI: 0.64-0.73), outperforming existing DOAC scores (ΔAUC = 0.063, P = 0.003; NRI = 0.374, P < 0.001). Risk categories significantly stratified ICH risk (low risk: 0.26%, moderate risk: 0.74%, high risk: 5.51%). Finally, the model demonstrated consistent predictive performance in the internal validation.

CONCLUSION

In a real-world Chinese population using DOAC therapy, this study presents a reliable predictive model for ICH risk. The XGBoost model, integrating six key risk factors, offers a valuable tool for individualized risk assessment in the context of oral anticoagulation therapy.

Relationship between the cumulative exposure to atherogenic index of plasma and ischemic stroke: a retrospective cohort study

BACKGROUND

Atherogenic index of plasma (AIP) has been demonstrated as a surrogate marker for ischemic stroke, but there is limited evidence for the effect of long-term elevation of AIP on ischemic stroke. Therefore, we aimed to characterize the relationship between cumulative exposure to AIP and the risk of ischemic stroke.

METHODS

A total of 54,123 participants in the Kailuan Study who attended consecutive health examinations in 2006, 2008, and 2010 and had no history of ischemic stroke or cancer were included. The time-weighted cumulative AIP (cumAIP) was calculated as a weighted sum of the mean AIP values for each time interval and then normalized to the total duration of exposure (2006-2010). Participants were divided into four groups according to quartile of cumAIP: the Q1 group, ≤-0.50; Q2 group, - 0.50 to - 0.12; Q3 group, - 0.12 to 0.28; and Q4 group, ≥ 0.28. Cox proportional hazard models were used to evaluate the relationship between cumAIP and ischemic stroke by calculating hazard ratios (HRs) and 95% confidence intervals (95% CIs).

RESULTS

After a median follow-up of 11.03 years, a total of 2,742 new ischemic stroke events occurred. The risk of ischemic stroke increased with increasing quartile of cumAIP. After adjustment for potential confounders, Cox regression models showed that participants in the Q2, Q3, and Q4 groups had significantly higher risks of ischemic stroke than those in the Q1 group. The HRs (95% CIs) for ischemic stroke in the Q2, Q3, and Q4 groups were 1.17 (1.03, 1.32), 1.33 (1.18, 1.50), and 1.45 (1.28, 1.64), respectively. The longer duration of high AIP exposure was significantly associated with increased ischemic stroke risk.

CONCLUSIONS

High cumulative AIP is associated with a higher risk of ischemic stroke, which implies that the long-term monitoring and maintenance of an appropriate AIP may help prevent such events.

Time-varying effect of postoperative cholesterol profile on long-term outcomes of isolated coronary artery bypass graft surgery

BACKGROUND

Controlling cholesterol levels is one of the primary goals of preventing atherosclerotic plaque progression in patients undergoing coronary artery bypass graft (CABG) surgery. This study aimed to investigate the impact of serum cholesterol profile at multiple time points following isolated CABG surgery on long-term patient outcomes.

METHOD

This retrospective cohort study was conducted on the admission and follow-up data of isolated CABG patients from the Tehran Heart Center registry between 2009 and 2016. The association of low-density lipoprotein (LDL), high-density lipoprotein (HDL), and their ratio as an atherogenic index with major adverse cardiac and cerebrovascular events (MACCE) and all-cause mortality were evaluated using time-varying survival analysis methods.

RESULT

A total of 18657 patients were included in this analysis. After adjusting for known confounding factors, no significant difference in all-cause mortality and MACCE was observed at different LDL levels. The incidence of acute coronary syndrome (ACS) in patients with LDL > 100 mg/dl and LDL < 50 mg/dl was significantly higher than in the control group (P-value = 0.004 and 0.04, respectively). The incidence of cerebrovascular accidents (CVA) at LDL > 100 mg/dl was also significantly higher compared to the control group (P -value = 0.033). Lower HDL levels were significantly associated with a higher MACCE (P -value < 0.001), all-cause mortality (P -value < 0.001), ACS (P -value = 0.00), and CVA (P -value = 0.014). The atherogenic index was also directly related to MACCE and all its components (all P-values < 0.001).

CONCLUSION

LDL/HDL ratio is suggested as a better marker for secondary prevention goals compared to LDL alone in patients undergoing CABG surgery.

Aggressive LDL-C Lowering and the Brain: Impact on Risk for Dementia and Hemorrhagic Stroke: A Scientific Statement From the American Heart Association

The objective of this scientific statement is to evaluate contemporary evidence that either supports or refutes the conclusion that aggressive low-density lipoprotein cholesterol lowering or lipid lowering exerts toxic effects on the brain, leading to cognitive impairment or dementia or hemorrhagic stroke. The writing group used literature reviews, references to published clinical and epidemiology studies, clinical and public health guidelines, authoritative statements, and expert opinion to summarize existing evidence and to identify gaps in current knowledge. Although some retrospective, case control, and prospective longitudinal studies suggest that statins and low-density lipoprotein cholesterol lowering are associated with cognitive impairment or dementia, the preponderance of observational studies and data from randomized trials do not support this conclusion. The risk of a hemorrhagic stroke associated with statin therapy in patients without a history of cerebrovascular disease is nonsignificant, and achieving very low levels of low-density lipoprotein cholesterol does not increase that risk. Data reflecting the risk of hemorrhagic stroke with lipid-lowering treatment among patients with a history of hemorrhagic stroke are not robust and require additional focused study.

Statin Treatment in Patients With Stroke With Low-Density Lipoprotein Cholesterol Levels Below 70 mg/dL

Background It is unclear whether statin treatment could reduce the risk of early vascular events when baseline low-density lipoprotein cholesterol (LDL-C) levels are already low, at <70 mg/dL, at the time of the index stroke. Methods and Results This study was an analysis of a prospective, multicenter, nationwide registry of consecutive patients with first-ever acute ischemic stroke with baseline low-density lipoprotein cholesterol levels <70 mg/dL and without statin pretreatment. An inverse probabilities of treatment weights method was applied to control for imbalances in baseline characteristics. The primary outcome was a composite of stroke (either hemorrhagic or ischemic), myocardial infarction, and all-cause death within 3 months. A total of 2850 patients (age, 69.5±13.4 years; men, 63.5%) were analyzed for this study. In-hospital statin treatment was used for 74.2% of patients. The primary composite outcome within 3 months occurred in 21.5% of patients in the nonstatin group and 6.7% of patients in the statin group (P<0.001), but the rates of stroke (2.65% versus 2.33%), hemorrhagic stroke (0.16% versus 0.10%), and myocardial infarction (0.73% versus 0.19%) were not significantly different between the 2 groups. After inverse probability of treatment weighting analysis, the primary composite outcome was significantly reduced in patients with statin therapy (weighted hazard ratio [HR], 0.54 [95% CI, 0.42-0.69]). However, statin treatment did not increase the risk of hemorrhagic stroke (weighted HR, 1.11 [95% CI, 0.10-12.28]). Conclusions Approximately three-quarters of the patients with first-ever ischemic stroke with baseline low-density lipoprotein cholesterol levels <70 mg/dL received in-hospital statin treatment. Statin treatment, compared with no statin treatment, was significantly associated with a reduced risk of the 3-month primary composite outcomes and all-cause death but did not alter the rate of stroke recurrence.

Association between intracerebral hemorrhage and cholesterol levels, and molecular mechanism underlying low cholesterol inhibiting autophagy in cerebral arterial smooth muscle cells leading to cell necrosis

BACKGROUND

An association between cholesterol and intracerebral hemorrhage (ICH) has been reported, but the mechanism is unclear.

METHODS

In this cross-sectional study, participants aged 50-75 years were selected using multistage stratified cluster sampling. All samples completed a questionnaire (age, gender, medication, etc.) and were examined (blood lipid, height, blood pressure, etc.) for risk factors. Multivariable logistic regression was used to analyze the association between cholesterol levels and ICH risk, after adjusting for age, smoking, hypertension, and other factors. We cultured rat cerebral artery smooth muscle cells at different cholesterol concentrations. The autophagy pathway was identified by transcriptome sequencing. The results were then validated using real-time polymerase chain reaction and western blot.

RESULTS

We included 39,595 patients, among whom 286 had ICH. The study showed that a low level of low-density lipoprotein cholesterol (LDL-C) was a risk factor of ICH (odds ratio 2.912, 95% confidence interval 1.460-5.806; P = 0.002). Cell experiments showed that lower cholesterol levels could significantly induce rat cerebral artery smooth muscle cell necrosis. In low-cholesterol groups, expression of the autophagy marker LC3 protein was significantly decreased and p62 protein was significantly increased. In western blot and comparison with the control group, the low cholesterol PI3K/Akt/mTOR signaling pathway was significantly activated in the autophagy pathway, resulting in its inhibition, which in turn led to smooth muscle cell death.

CONCLUSION

Low cholesterol levels may inhibit autophagy through PI3K/Akt/mTOR signaling and induce arterial smooth muscle cell necrosis, thereby increasing the risk of ICH.

Better Life's Essential 8 Is Associated With Lower Risk of Diabetic Kidney Disease: A Community-Based Study

Background Diabetic kidney disease (DKD) is a common diabetic complication and increases the complexity of diabetes management. No prospective study has focused on the association between DKD and Life's Essential 8 (LE8). Our study aims to examine the association between LE8 and DKD risk. Methods and Results A total of 7605 participants, aged 54.32±9.77 years, and 4688 participants, aged 56.11±10.38 years, were included in the longitudinal and trajectory analyses, respectively, from 2006 to 2020. The DKD was confirmed using data collected during each follow-up. LE8 was based on 4 health behaviors and 4 health factors. The range of each metric was 0 to 100, and the overall LE8 score was calculated as the unweighted average of all 8 component metric scores. The trajectories of LE8 during 2006 to 2010 were classified using latent mixture models. Cox models and restricted cubic splines were applied. After a median follow-up of 12.41 and 6.71 years in longitudinal and trajectory analyses, respectively, the DKD incidence decreased, with the LE8 level increasing (P-trend<0.05), and the linearity assumption for this relationship (P-nonlinear=0.685) had been satisfied. Adjusted hazard ratios (HRs) for the highest tertile were 0.77 (95% CI, 0.69-0.87) and 0.70 (95% CI, 0.62-0.78) in baseline and time-updated LE8 scores, respectively, compared with the lowest tertile. Adjusted HR was 0.53 (95% CI, 0.41-0.69) for the stable-high pattern compared with the stable-low pattern. Conclusions Although LE8 is an indicator of cardiovascular health, the beneficial impact of a high LE8 score is also evident in the protection of renal health among patients with diabetes.

Relationship between cumulative exposure to triglyceride-glucose index and heart failure: a prospective cohort study

BACKGROUND

High triglyceride-glucose index (TyG) is a major risk factor for heart failure, but the long-term effect of high TyG index on the risk of developing heart failure remains unclear. Therefore, we aimed to determine the relationship between the cumulative exposure to TyG index and the risk of heart failure.

METHODS

A total of 56,149 participants from the Kailuan Study, who participated in three consecutive health examinations in 2006, 2008, and 2010 and had no history of heart failure or cancer were recruited for this study. The cumulative TyG index was calculated as the weighted sum (value × time) of the mean TyG index for each time interval. The participants were placed into quartiles based on their cumulative TyG index. The study ended on December 31, 2020, and the primary outcome was new-onset heart failure during the follow-up period. In addition, a Cox proportional hazards regression model and a restricted cubic spline analysis were used to further evaluate the relationship between cumulative TyG index and the risk of heart failure.

RESULTS

During a median follow-up period of 10.04 years, a total of 1,312 new heart failure events occurred. After adjustment for potential confounding factors, the Cox regression analysis showed that the hazard ratios (95% confidence intervals) for the risk of heart failure in the Q2, Q3, and Q4 groups were 1.02 (0.83,1.25), 1.29 (1.07,1.56) and 1.40 (1.15,1.71), respectively, vs. the Q1 group. The subgroup analysis showed a significant interaction between cumulative TyG index and BMI or waist circumference, but there was no interaction between age, sex and cumulative TyG index. The restricted cubic spline analysis showed a dose-response relationship between cumulative TyG index and the risk of heart failure. In addition, the sensitivity analysis generated results that were consistent with the primary results.

CONCLUSIONS

High cumulative TyG index is associated with a higher risk of heart failure. Thus, the TyG index may be useful for the identification of individuals at high risk of heart failure. The present findings emphasize the importance of the long-term monitoring of the TyG index in clinical practice.

Admission LDL-cholesterol, statin pretreatment and early outcomes in acute ischemic stroke

BACKGROUND

Lipid paradox of low LDL-C may cause physicians to be reluctant to use statins in acute ischemic stroke (AIS) patients with low LDL-C levels at admission.

OBJECTIVE

This study investigated the association between LDL-C levels and early vascular outcomes and assessed the potential interaction effect between LDL-C and statin pretreatment on early outcomes.

PATIENTS AND METHODS

This was a study of a prospective, multicenter, registry of AIS patients with admission LDL-C. The subjects were divided into 3 groups according to LDL-C levels: low LDL-C (≤100 mg/dL); intermediate LDL-C (>100, <130 mg/dL); and high LDL-C (≥130 mg/dL). The primary early vascular outcome was a composite of stroke (ischemic or hemorrhagic), myocardial infarction and all-cause mortality within 3 months. The associations of LDL-C levels as a continuous variable and the risks of primary outcome using Cox proportional hazards models with restricted cubic splines were explored.

RESULTS

A total of 32,505 patients (age, 69 ± 12; male, 58.6%) were analyzed. The 3 groups showed significant differences in the 3-month primary outcome, with highest events in the low LDL-C group; after adjustment, no significant associations with the 3-month primary outcome remained. U-shaped nonlinear relationships of LDL-C levels with the 3-month primary outcome were observed (Pnon-linearity<0.001), with substantial relationships in the no pretreatment subgroup.

CONCLUSIONS

The relationships between admission LDL-C levels and early outcomes are complex but appear to be paradoxical in patients with low LDL-C and no statin pretreatment. The results suggest that statin pretreatment might offset the paradoxical response of low LDL-C on early vascular outcomes. Further study would be warranted.

Low-density lipoprotein cholesterol, statin therapy, and cerebral microbleeds: The CIRCLE study

BACKGROUND

Current evidence suggests a potential association between cerebral microbleeds (CMBs), low-density lipoprotein cholesterol (LDL-C) levels, and statin use, but the exact relationship remains unclear. This study aims to prospectively examine these relationships in a stroke-free population.

METHODS

From January 2010 to January 2020, we enrolled stroke-free individuals with at least one cerebral small vessel disease imaging marker from the CIRCLE study (ClinicalTrials.gov ID: NCT03542734). Participants underwent baseline and 1-year follow-up susceptibility-weighted imaging (SWI), and baseline LDL-C testing. New CMBs were categorized as strictly lobar and deep CMBs based on location.

RESULTS

A total of 209 individuals were included. Baseline serum LDL-C levels were divided into quartiles: Q1 (≤1.76 mmol/L), Q2 (1.77-2.36 mmol/L), Q3 (2.37-2.93 mmol/L), and Q4 (>2.93 mmol/L). The incidence of new deep CMBs was 30.0%, 11.1%, 10.9%, 8.2% in Q1, Q2, Q3, Q4, respectively. Multivariate logistic model revealed that only LDL-C in Q1 was associated with increased incidence of new deep CMBs (OR = 4.256; 95% CI: 1.156-15.666; p = 0.029). In a subset of 169 participants without prior statin use, the use of atorvastatin was associated with reduced occurrence of new deep CMBs (OR = 0.181; 95% CI: 0.035-0.928; p = 0.040), while it was not found with rosuvastatin (OR = 0.808; 95% CI: 0.174-3.741; p = 0.785).

CONCLUSIONS

While lower LDL-C levels were associated with higher CMB development, statin therapy did not increase the risk of new CMBs. Atorvastatin even demonstrated a protective effect.

Effect of lard plus soybean oil on blood pressure and other cardiometabolic risk factors in healthy subjects: a randomized controlled-feeding trial

Lard has been consumed by humans for thousands of years, but its consumption has declined substantially in the last few decades, because of negative publicity about the consumption of animal-derived saturated fats. Emerging evidence highlights that lard plus soybean oil (blend oil) could be more beneficial for body weight and liver function than the individual use of the two oils. This study aimed to evaluate the effects of blend oil on cardiometabolic risk factors in healthy subjects. This was a parallel, three-arm, randomized controlled-feeding trial. 334 healthy subjects (mean age: 33.1 years, 60% women) were randomized into three isoenergetic diet groups with three different edible oils (30 g day^-1) (soybean oil, lard, and blend oil [50% lard and 50% soybean oil]) for 12 weeks. 245 (73.4%) participants completed the study. After the 12-week intervention, reductions in both systolic blood pressure (SBP) and diastolic blood pressure (DBP) were greater in the blend oil group than in the other two groups (P = 0.023 and 0.008 for the interaction between the diet group and time, respectively). Reductions of SBP and DBP in the blend oil group were more significant than those in the soybean oil group with P = 0.008 and P = 0.026 and the lard group with P < 0.001 and P < 0.001. Changes in SBP/DBP at 12 weeks were -6.0 (95% CI: -8.6 to -3.4)/0.8 (95% CI: -1.7 to 3.2) mmHg in the blend oil group, -3.3 (95% CI: -5.7 to -0.9)/1.5 (95% CI: -1.0 to 4.0) mmHg in the soybean oil group and -1.2 (95% CI: -3.7 to 1.4)/3.3 (95% CI: 0.9 to 5.8) mmHg in the lard group. Subgroup analyses showed that blend oil significantly decreased SBP and DBP compared with the other two groups in participants with BP ≥ 130/80 mmHg and body mass index ≥25. There were no significant differences in the changes in body weight, waist circumference, serum lipids, or glucose between groups. In conclusion, our findings suggest that blend oil (lard plus soybean oil) reduces BP compared with soybean oil and lard in healthy subjects.

New-onset stroke on the risk of hip fracture: the Kailuan cohort study in China

PURPOSE

Stroke is a documented risk factor for hip fracture(HF). However, no data is currently available on this issue in mainland China, we therefore assessed the risk of hip fracture after new-onset stroke using a cohort study.

METHODS

This study included 165,670 participants without a history of stroke at baseline from the Kailuan study. All participants were followed biennially until December 31, 2021. During follow-up, a total of 8,496 new-onset stroke cases were identified. For each case subject, four control subjects was randomly selected, matched for age (± 1 years) and sex. The final analysis comprised 42,455 pair-matched cases and controls. A multivariate Cox proportional hazard regression model was used to estimate the effect of new-onset stroke on the risk of hip fracture.

RESULTS

During an average follow-up of 8.87 (3.94) years, a total of 231 hip fracture cases occurred, 78 cases in the stroke group and 153 cases in the control group, with incidence rates of 1.12 and 0.50 per 1000 person-years, respectively. The cumulative incidence of the stroke group was higher than that of the controls (P < 0.01). The adjusted hazard ratio (95% confidence interval) of hip fractures in the stroke group was 2.35 (1.77 to 3.12) (P < 0.001) to controls. After stratifying by gender, age, and body mass index, the higher risk was revealed in female (HR 3.10, 95 CI: 2.18 to 6.14, P < 0.001), age < 60 years old (HR 4.12, 95% CI: 2.18 to 7.78, P < 0.001), and non-obesity (BMI<28 kg/m²) (HR 1.74, 95% CI:1.31 to 2.31, P < 0.001) subgroup.

CONCLUSIONS

Stroke significantly increases the risk of hip fracture, strategy for protecting stroke patients from falls and hip fractures should be emphasized in poststroke long-term management, particularly the female, age < 60 years old, and non-obese patients.

Association of Multitrajectories of Lipid Indices With Premature Cardiovascular Disease: A Cohort Study

Background The multitrajectory model can identify joint longitudinal patterns of different lipids simultaneously, which might help better understand the heterogeneous risk of premature cardiovascular disease (CVD) and facilitate targeted prevention programs. This study aimed to investigate the associations between multitrajectories of lipids with premature CVD. Methods and Results The study enrolled 78 526 participants from the Kailuan study, a prospective cohort study in Tangshan, China. Five distinct multitrajectories of triglyceride, low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol over 6-year exposure were identified on the basis of Nagin's criteria, using group-based multitrajectory modeling. During a median follow-up of 6.75 years (507 645.94 person-years), 665 (0.85%) premature CVDs occurred. After adjustment for confounders, the highest risk of premature CVD was observed in group 4 (the highest and increasing triglyceride, optimal and decreasing LDL-C, low and decreasing high-density lipoprotein cholesterol) (hazard ratio [HR], 2.13 [95% CI, 1.36-3.32]), followed by group 5 (high and decreasing triglyceride, optimal and increasing LDL-C, low and decreasing high-density lipoprotein cholesterol) (HR, 2.07 [95% CI, 1.45-2.98]), and group 3 (optimal and increasing triglyceride, borderline high and increasing LDL-C, optimal and decreasing high-density lipoprotein cholesterol) (HR, 1.90 [95% CI, 1.32-2.73]). Conclusions Our results showed that the residual risk of premature CVD caused by increasing triglyceride levels remained high despite the fact that LDL-C levels were optimal or declining over time. These findings emphasized the importance of assessing the joint longitudinal patterns of lipids and undertaking potential interventions on triglyceride lowering to reduce the residual risk of premature CVD, even among individuals with optimal LDL-C levels.

Association of Low-Density Lipoprotein Cholesterol with Risk of Coronary Heart Disease and Stroke among Middle-Aged Japanese Workers: An Analysis using Inverse Probability Weighting

AIMS

The associations between low-density lipoprotein cholesterol (LDL-C) and the risk of cardiovascular disease (CVD) subtypes are not well established among the Japanese population. This study used longitudinal data from the Aichi Workers' Cohort Study to explore the association between LDL-C levels and the risk of coronary heart disease (CHD) and stroke subtypes.

METHODS

Pooled data of 8966 adults (7093men and 1903 women) who were recruited between (2002) and (2008) were used for the current analysis. Propensity scores for the LDL-C categories were generated using multinomial logistic regression. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated from the inverse probability weighted Cox proportional hazards model for LDL-C category associations with risks of CHD, stroke subtypes, and CVD.

RESULTS

During a median follow-up of 12 years, 122 strokes (57 ischemic strokes, 25 intracerebral hemorrhage, and 40 unknown subtypes) and 82 cases of CHD were observed. LDL-C 160- mg/dL compared to LDL-C 100-119 mg/dL was positively and significantly associated with the risk of CHD (HR: 4.56; 95% CI: 1.91-10.9) but not with ischemic stroke (HR: 0.99; 95% CI: 0.44-2.22). LDL-C was inversely associated with the risk of intracerebral hemorrhage (P for trend=0.009).

CONCLUSION

In middle-aged Japanese workers, LDL-C was significantly and positively associated with CHD, but not with ischemic stroke. LDL-C was inversely significantly associated with intracerebral hemorrhage.

Machine learning-based prediction of cerebral hemorrhage in patients with hemodialysis: A multicenter, retrospective study

Background

Intracerebral hemorrhage (ICH) is one of the most serious complications in patients with chronic kidney disease undergoing long-term hemodialysis. It has high mortality and disability rates and imposes a serious economic burden on the patient's family and society. An early prediction of ICH is essential for timely intervention and improving prognosis. This study aims to build an interpretable machine learning-based model to predict the risk of ICH in patients undergoing hemodialysis.

Methods

The clinical data of 393 patients with end-stage kidney disease undergoing hemodialysis at three different centers between August 2014 and August 2022 were retrospectively analyzed. A total of 70% of the samples were randomly selected as the training set, and the remaining 30% were used as the validation set. Five machine learning (ML) algorithms, namely, support vector machine (SVM), extreme gradient boosting (XGB), complement Naïve Bayes (CNB), K-nearest neighbor (KNN), and logistic regression (LR), were used to develop a model to predict the risk of ICH in patients with uremia undergoing long-term hemodialysis. In addition, the area under the curve (AUC) values were evaluated to compare the performance of each algorithmic model. Global and individual interpretive analyses of the model were performed using importance ranking and Shapley additive explanations (SHAP) in the training set.

Results

A total of 73 patients undergoing hemodialysis developed spontaneous ICH among the 393 patients included in the study. The AUC of SVM, CNB, KNN, LR, and XGB models in the validation dataset were 0.725 (95% CI: 0.610 ~ 0.841), 0.797 (95% CI: 0.690 ~ 0.905), 0.675 (95% CI: 0.560 ~ 0.789), 0.922 (95% CI: 0.862 ~ 0.981), and 0.979 (95% CI: 0.953 ~ 1.000), respectively. Therefore, the XGBoost model had the best performance among the five algorithms. SHAP analysis revealed that the levels of LDL, HDL, CRP, and HGB and pre-hemodialysis blood pressure were the most important factors.

Conclusion

The XGB model developed in this study can efficiently predict the risk of a cerebral hemorrhage in patients with uremia undergoing long-term hemodialysis and can help clinicians to make more individualized and rational clinical decisions. ICH events in patients undergoing maintenance hemodialysis (MHD) are associated with serum LDL, HDL, CRP, HGB, and pre-hemodialysis SBP levels.

Antithrombotic therapy and bleeding risk in the era of aggressive lipid-lowering: current evidence, clinical implications, and future perspectives

ABSTRACT

The clinical efficacy of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) in reducing major cardiovascular adverse events related to atherosclerotic cardiovascular disease (ASCVD) has been well established in recent large randomized outcome trials. Although the cardiovascular and all-cause mortality benefit of PCSK9i remains inconclusive, current cholesterol management guidelines have been modified toward more aggressive goals for lowering low-density lipoprotein cholesterol (LDL-C). Consequently, the emerging concept of "the lower the better" has become the paradigm of ASCVD prevention. However, there is evidence from observational studies of a U-shaped association between baseline LDL-C levels and all-cause mortality in population-based cohorts. Among East Asian populations, low LDL-C was associated with an increased risk for hemorrhagic stroke in patients not on antithrombotic therapy. Accumulating evidence showed that low LDL-C was associated with an enhanced bleeding risk in patients on dual antiplatelet therapy following percutaneous coronary intervention. Additionally, low LDL-C was associated with a higher risk for incident atrial fibrillation and thereby, a possible increase in the risk for intracranial hemorrhage after initiation of anticoagulation therapy. The mechanism of low-LDL-C-related bleeding risk has not been fully elucidated. This review summarizes recent evidence of low-LDL-C-related bleeding risk in patients on antithrombotic therapy and discusses potential measures for reducing this risk, underscoring the importance of carefully weighing the pros and cons of aggressive LDL-C lowering in patients on antithrombotic therapy.

Tissue Engineering and Targeted Drug Delivery in Cardiovascular Disease: The Role of Polymer Nanocarrier for Statin Therapy

Atherosclerosis-related coronary artery disease (CAD) is the leading cause of mortality and morbidity worldwide. This requires effective primary and secondary prevention in reducing the complications related to CAD; the regression or stabilization of the pathology remains the mainstay of treatment. Statins have proved to be the most effective treatment in reducing adverse effects, but there are limitations related to the administration and achievement of effective doses as well as side effects due to the lack of target-related molecular specificity. The implemented technological steps are polymers and nanoparticles for the administration of statins, as it has been seen how the conjugation of drug delivery systems (DDSs) with statins increases bioavailability by circumventing the hepatic-renal filter and increases the related target specificity, enhancing their action and decreasing side effects. Reduction of endothelial dysfunction, reduced intimal hyperplasia, reduced ischemia-reperfusion injury, cardiac regeneration, positive remodeling in the extracellular matrix, reduced neointimal growth, and increased reendothelialization are all drug-related effects of statins enhanced by binding with DDSs. Recent preclinical studies demonstrate how the effect of statins stimulates the differentiation of endogenous cardiac stem cells. Poly-lactic-co-glycolic acid (PLGA) seems to be the most promising DDS as it succeeds more than the others in enhancing the effect of the bound drug. This review intends to summarize the current evidence on polymers and nanoparticles for statin delivery in the field of cardiovascular disease, trying to shed light on this topic and identify new avenues for future studies.