Reduction in serum total cholesterol and risks of coronary events and cerebral infarction in Japanese men: the Kyushu Lipid Intervention Study

Features of Serum Fatty Acids at Acute Ischemic Stroke Onset in Statin-Treated Patients with Hypercholesterolemia

In addition to diet therapy, statins are used to prevent cardiovascular disease in patients with hypercholesterolemia (HC). However, acute ischemic stroke (AIS) still occurs in statin-treated patients. How strictly statin-treated patients follow diet therapy before they experience AIS and whether they increase seafood consumption remains unknown. We investigated the serum concentrations and proportions (weight percentages: wt %) of fatty acids (FAs) at AIS onset in statin-treated patients (statin group), compared to those in non-treated patients with HC (6.465 mmol/L or higher) as controls (non-treated group). We included patients with AIS admitted between 2016 and 2019 within 24 h of AIS onset who underwent analysis of serum FAs. During the study period, 188 patients met the inclusion criteria: 133 in the statin group and 55 in the non-treated group. Interestingly, serum FA concentrations in the statin group were lower than those in the non-treated group. However, serum FA wt % in the statin group was almost identical to that in the non-treated group. In conclusion, statin-treated AIS patients had low FA concentrations and identical FA wt %, compared to non-treated AIS patients with HC.

Effect of pravastatin on endothelial dysfunction in children with medium to giant coronary aneurysms due to Kawasaki disease

BACKGROUND

Ongoing low-grade inflammation and endothelial dysfunction persist in children with coronary lesions diagnosed with Kawasaki disease (KD). Statins, frequently used in the management of high cholesterol, have also shown to improve surrogate markers of inflammation and endothelial dysfunction. This study was undertaken to investigate the efficacy and safety of pravastatin in children with coronary artery aneurysms due to KD.

METHODS

The study enrolled 14 healthy children and 13 male children, aged 2-10 years, with medium-to-giant coronary aneurysms for at least 12 months after the onset of KD. Pravastatin was given orally to the KD group at a dose of 5 mg/day for children under 5 and 10 mg/day for children older than 5 years. To determine the effects of pravastatin on endothelial function, high-frequency ultrasound was performed before the start of the study and 6 months after pravastatin therapy. The parameters measured were brachial artery flow-mediated dilation (FMD), non-flow mediated dilation (NMD), and carotid artery stiffness index (SI). High sensitive C-reactive protein (hs-CRP) levels, the circulating endothelial progenitor cells (EPCs) number, and serum lipid profiles were also determined at baseline and after 6 months of pravastatin treatment.

RESULTS

Before treatment, the KD group had significantly decreased FMD (P<0.05) and increased SI and hs-CRP levels (P<0.05) compared with controls. After 6 months of pravastatin therapy, FMD improved significantly compared to the baseline KD group (3.16±6.49 to 10.05±7.74, P<0.05), but remained significantly less than that in the control group with no significant changes in NMD and SI. There were significant decreases in markers of inflammation after treatment. The hs-CRP levels decreased significantly from 2.93±0.81 mmol/L to 2.14±0.82 mmol/L (P<0.05) and the serum apo-B and apo-B/apo-A1 ratio were also reduced (P<0.05) in the KD group. However, the circulating EPC number was not significantly different between baseline and that following pravastatin treatment in the KD group and the control group (P>0.05). No significant complications were noted with paravastatin therapy.

CONCLUSIONS

Pravastatin improves endothelial function and reduces low-grade chronic inflammation in patients with coronary aneurysms due to KD. Children with coronary aneurysms due to KD may benefit from statin therapy.

Effect of pravastatin on endothelial dysfunction in children with medium to giant coronary aneurysms due to Kawasaki disease

BACKGROUND

Ongoing low-grade inflammation and endothelial dysfunction persist in children with coronary lesions diagnosed with Kawasaki disease (KD). Statins, frequently used in the management of high cholesterol, have also shown to improve surrogate markers of inflammation and endothelial dysfunction. This study was undertaken to investigate the efficacy and safety of pravastatin in children with coronary artery aneurysms due to KD.

METHODS

The study enrolled 14 healthy children and 13 male children, aged 2-10 years, with medium-to-giant coronary aneurysms for at least 12 months after the onset of KD. Pravastatin was given orally to the KD group at a dose of 5 mg/day for children under 5 and 10 mg/day for children older than 5 years. To determine the effects of pravastatin on endothelial function, high-frequency ultrasound was performed before the start of the study and 6 months after pravastatin therapy. The parameters measured were brachial artery flow-mediated dilation (FMD), non-flow mediated dilation (NMD), and carotid artery stiffness index (SI). High sensitive C-reactive protein (hs-CRP) levels, the circulating endothelial progenitor cells (EPCs) number, and serum lipid profiles were also determined at baseline and after 6 months of pravastatin treatment.

RESULTS

Before treatment, the KD group had significantly decreased FMD (P<0.05) and increased SI and hs-CRP levels (P<0.05) compared with controls. After 6 months of pravastatin therapy, FMD improved significantly compared to the baseline KD group (3.16±6.49 to 10.05±7.74, P<0.05), but remained significantly less than that in the control group with no significant changes in NMD and SI. There were significant decreases in markers of inflammation after treatment. The hs-CRP levels decreased significantly from 2.93±0.81 mmol/L to 2.14±0.82 mmol/L (P<0.05) and the serum apo-B and apo-B/apo-A1 ratio were also reduced (P<0.05) in the KD group. However, the circulating EPC number was not significantly different between baseline and that following pravastatin treatment in the KD group and the control group (P>0.05). No significant complications were noted with paravastatin therapy.

CONCLUSIONS

Pravastatin improves endothelial function and reduces low-grade chronic inflammation in patients with coronary aneurysms due to KD. Children with coronary aneurysms due to KD may benefit from statin therapy.

Statins and intracerebral hemorrhage: collaborative systematic review and meta-analysis

BACKGROUND

A recent large, randomized trial suggested that statins may increase the risk of intracerebral hemorrhage. Accordingly, we systematically reviewed the association of statins with intracerebral hemorrhage in randomized and observational data.

METHODS AND RESULTS

We screened 17 electronic bibliographic databases to identify eligible studies and consulted with experts in the field. We used DerSimonian-Laird random-effects models to compute summary risk ratios with 95% confidence intervals. Randomized trials, cohort studies, and case-control studies were analyzed separately. Only adjusted risk estimates were used for pooling observational data. We included published and unpublished data from 23 randomized trials and 19 observational studies. The complete data set comprised 248 391 patients and 14 784 intracerebral hemorrhages. Statins were not associated with an increased risk of intracerebral hemorrhage in randomized trials (risk ratio, 1.10; 95% confidence interval, 0.86-1.41), cohort studies (risk ratio, 0.94; 95% confidence interval, 0.81-1.10), or case-control studies (risk ratio, 0.60; 95% confidence interval, 0.41-0.88). Substantial statistical heterogeneity was evident for the case-control studies (I(2)=66%, P=0.01), but not for the cohort studies (I(2)=0%, P=0.48) or randomized trials (I(2)=30%, P=0.09). Sensitivity analyses by study design features, patient characteristics, or magnitude of cholesterol lowering did not materially alter the results.

CONCLUSIONS

We found no evidence that statins were associated with intracerebral hemorrhage; if such a risk is present, its absolute magnitude is likely to be small and outweighed by the other cardiovascular benefits of these drugs.

Statins for the primary prevention of cardiovascular events in older adults: a review of the evidence

BACKGROUND

Although statins have been demonstrated to be beneficial for secondary prevention in the elderly, their use for primary prevention has not been well described.

OBJECTIVE

In this review, we summarize data regarding the efficacy, safety, and current recommendations for statins for the primary prevention of cardiovascular events in older adults.

METHODS

This review is based on a computerized literature search of the PubMed database for articles published in the English language from January 1980 to June 2006. Key words searched individually and cross-referenced included: statins, HMG-CoA reductase inhibitors, cholesterol, elderly, aged, cardiovascular disease, primary prevention, risk stratification, and C-reactive protein. This search produced 445 citations; reference lists revealed an additional 12 citations, all of which were screened for relevance to the topic.

RESULTS

The existing evidence suggests, but does not confirm, benefit from the use of statins for primary prevention in the elderly subgroup (ie, those aged >65 years). Of the 6 published trials of statins for primary prevention, only 3 included subjects aged >75 years, and subgroup results in older adults are unavailable. Current guidelines recommend statins for individuals based on their assessed cardiovascular risk.

CONCLUSIONS

Extension of treatment guidelines should consider an individual's global risk of coronary heart disease. However, due to the prevalence of subclinical disease in older adults, risk may be higher or otherwise differ with age. In addition, tolerance for and barriers to adherence with long-term medical therapy are important treatment considerations in older adults. Prospective, randomized controlled trials that better define the tolerability, safety, and efficacy of statin therapy in older adults with elevated cholesterol levels and intermediate cardiovascular risk are needed.

Safety and efficacy of statins in Asians

Asian patients frequently have heightened responses to therapeutic drugs. As a consequence, the recommended drug doses are often lower in Asian countries than in Western countries. This practice extends to the use of cardiovascular drugs, including statins for the treatment of dyslipidemia. Pharmacokinetic investigations have noted higher plasma levels of statins in Asians compared with Caucasians, although postmarketing data for all statins have not identified any particular safety issues, even when statins are given at equivalent doses. The potential mechanisms of heightened response to statins in Asians are related to genetically based differences in the metabolism of statins at the level of hepatic enzymes and drug transporters. Studies indicate that lower statin doses achieve lipid improvements in Asian patients comparable with those observed with higher doses in Caucasians. In conclusion, prescribing lower starting doses of statins in Asians appears warranted while research on this subject continues.

Large-scale cohort study on the relationship between serum lipid concentrations and risk of cerebrovascular disease under low-dose simvastatin in Japanese patients with hypercholesterolemia: sub-analysis of the Japan Lipid Intervention Trial (J-LIT)

BACKGROUND

The Japan Lipid Intervention Trial was a nationwide cohort study of 52,421 hypercholesterolemic patients treated with open-labeled simvastatin for 6 years under standard clinical practices. Cerebrovascular disease (CVD) is one of the leading causes of death in Japan, but the effect of hypercholesterolemia on CVD has not been well established in Japanese patients. This study aimed to determine the relationship between the risk of CVD and serum lipid concentrations during treatment in Japan.

METHODS AND RESULTS

Patients were treated with 5-10 mg/day of simvastatin and all, including those who discontinued simvastatin for any reason, had their lipid concentrations and incidence of CVD monitored for 6 years. Data of 41,088 patients were analyzed in this study, excluding those who had a history of coronary heart disease or CVD. The risk of cerebral infarction was higher in patients whose mean total cholesterol concentrations during treatment were > or = 240 mg/dl, low-density lipoprotein cholesterol concentrations > or = 160 mg/dl, triglycerides > or = 150 mg/dl and high-density lipoprotein cholesterol concentrations <40 mg/dl. There was no obvious correlation between cerebral hemorrhage and serum lipid concentrations.

CONCLUSION

Improvement of serum lipid concentrations is important for reducing the incidence of cerebral infarction.

Morbidity of Myocardial Infarction Multicenter Study in Japan (3M Study): study design and event rates for myocardial infarction and coronary death by age category in Japanese workers

BACKGROUND

Although there have been regional studies, there has not been a detailed nationwide investigation of the morbidity from acute myocardial infarction (MI) in Japanese workers.

METHODS AND RESULTS

Registration of MI and sudden death was done by full-time occupational physicians in Japan. Among 133,099 workers (109,550 men, 23,549 women) from 41 workplaces (April 1994 to March 1997) and 257,440 workers (207,310 men, 50,130 women) from 76 workplaces (April 1997 to March 2000), 297 fatal and nonfatal cardiac events were registered. The definitions of MI and coronary death followed the criteria of the WHO MONICA Project. The event rate in men rose sharply around the age of 45 years. Using definition 1 (fatal definite + fatal possible + fatal unclassifiable + nonfatal definite), the age-standardized annual event rate and case fatality rate for men aged 35-64 years was 40.2 per 100,000 persons and 22.2%, respectively. These figures were significantly lower compared with those from Western reports and were also lower than previously reported for Japanese communities.

CONCLUSION

The Morbidity of Myocardial Infarction Multicenter Study in Japan revealed a surprisingly low incidence of coronary events, which may be attributable to prevention and early treatment of coronary risk factors among company workers in Japan.

Relation of serum total cholesterol and other factors to risk of cerebral infarction in Japanese men with hypercholesterolemia

BACKGROUND

Risk factors for cerebral infarction have not been well clarified, except for hypertension (HT), and few studies have examined the risk factors in the elderly.

METHODS AND RESULTS

Clinical and behavioral risk factors for cerebral infarction were examined in 4,349 Japanese men aged 45-74 years with a serum total cholesterol (TC) concentration of 220 mg/dl or greater who participated in the Kyushu Lipid Intervention Study. A total of 81 men developed definite cerebral infarction in a 5-year follow-up period. The Cox proportional hazards model was used with serum TC at baseline and during the follow-up, serum high-density lipoprotein-cholesterol (HDL-C), HT, diabetes mellitus (DM), and other factors as covariates. Serum TC during the follow-up, not at baseline, was positively associated with cerebral infarction, showing a stronger association in the elderly (>or=65 years old) than in the middle-aged (<65 years old). Statin use was related to a moderate decrease in the risk of cerebral infarction when follow-up TC was not considered, but the decrease was almost nullified after adjustment for follow-up TC. A low concentration of serum HDL-C, diabetes mellitus, hypertension, and angina pectoris were each related to an increased risk. No clear association was observed for body mass index, smoking or alcohol use.

CONCLUSIONS

Lowering cholesterol is important in the prevention of cerebral infarction in men with moderate hypercholesterolemia. A low concentration of HDL-C, DM, and HT are independent predictors of cerebral infarction.

The Risk of Cardiovascular Events in Japanese Hypertensive Patients with Hypercholesterolemia: Sub-Analysis of the Japan Lipid Intervention Trial (J-LIT) Study, a Large-Scale Observational Cohort Study

Coronary events and stroke are leading causes of death in Japan. However, the effects of hypertension on the risk of coronary events and stroke have not been well established in Japanese hypercholesterolemic patients. This study aimed to determine the relationship between the risk of coronary events or stroke and blood pressure and cholesterol levels during low-dose simvastatin treatment using data from the Japan Lipid Intervention Trial (J-LIT) study (a large scale nationwide cohort study). In the present study, 47,294 hypercholesterolemic patients were treated with open-labeled simvastatin (5 to 10 mg/day) for 6 years by a large number of physicians in a clinical setting. The adjusted incidence rates of coronary events in males and females were 8.9 and 2.3 and those of stroke were 17.6 and 11.3/1000 patients during the 6-year period, respectively. The incidence rate of stroke was higher than that of coronary events in both males and females. An obvious sex difference was observed in terms of the incidence of coronary events. The risk of coronary events, stroke, and total cardiovascular events were increased, with elevations in blood pressure observed in patients treated for hypercholesterolemia. The risk of total cardiovascular events in the groups exhibiting less lipid control increased, with lower blood pressure levels than those of the well-controlled group. For patients with hypercholesterolemia and hypertension, blood pressure should be strictly controlled in order to prevent both coronary events and stroke, and the serum total cholesterol levels should be maintained at low levels as well.

Effect of Pravastatin on Progression of Coronary Atherosclerosis in Patients After Coronary Artery Bypass Surgery Pravastatin Coronary Artery Bypass Graft Study

BACKGROUND

Although the anti-atherosclerotic effects of HMG-CoA reductase inhibitors are well known, their specific effect on saphenous vein grafts after coronary artery bypass graft (CABG) operation is not well documented and has not been studied in Japan, so the aim of the present prospective randomized controlled study involving 27 Japanese institutions was to investigate the effects of pravastatin on the progression of atherosclerosis in such grafts and native coronary arteries after CABG.

METHODS AND RESULTS

A total of 303 patients who had undergone CABG were randomly assigned to either the pravastatin group (n =168) or the control group (n = 167). Paired coronary angiograms were obtained at baseline and at the end of 5-year follow-up in 182 (60%) patients. The low-density lipoprotein cholesterol concentration significantly decreased in the pravastatin group from 141.4 mg/dl to 113.7 mg/dl (-19.6%), compared with 141.1 mg/dl to 133.7 mg/dl (-5.2%) in the control group (p < 0.001). Although there was no significant difference in the quantitative coronary angiography measurements between the 2 groups, the global change score indicated a significant pravastatin-mediated reduction in plaque progression (p < 0.01).

CONCLUSIONS

Pravastatin can potentially reduce atherosclerotic progression in both the bypass graft and native coronary arteries of patients after CABG.

Three-Year Follow-up Results of Angiographic Intervention Trial Using an HMG-CoA Reductase Inhibitor to Evaluate Retardation of Obstructive Multiple Atheroma (ATHEROMA) Study

BACKGROUND

The cardiovascular event rate in Japanese populations is strikingly lower than that in Caucasian populations and it has been postulated that this difference might be because of variations in atherosclerosis progression in patients with coronary artery disease (CAD). However, the rate of angiographically assessed progression and its response to statins has not been well described in Japanese patients.

METHODS AND RESULTS

The angiographic intervention trial using an HMG-CoA reductase inhibitor to evaluate the retardation of obstructive multiple atheroma (ATHEROMA) study was a multicenter, randomized, controlled clinical trial investigating the effects of pravastatin on coronary atherosclerosis in Japanese patients with CAD using quantitative coronary angiography. In total, 361 patients with mild to moderate elevated serum total cholesterol concentrations (195-265 mg/dl) received diet only (n = 179) or diet plus pravastatin 10-20 mg/dl (n = 182). Over 3 years, low-density lipoprotein-cholesterol in the pravastatin group decreased by 19.5% (p < 0.0001). A per-patient analysis showed that minimum lumen diameter increased by 0.034+/-0.17 mm in the pravastatin group, but decreased by 0.006+/-0.16 mm in the diet only group (p = 0.04). The mean difference between the treatment groups was 0.040 mm (95% confidence interval 0.020, 0.070 mm).

CONCLUSION

The ATHEROMA study indicates that pravastatin 10-20 mg/day for 3 years improves hyperlipidemia, then suppresses progression and induces regression of focal coronary atherosclerosis in Japanese CAD patients with elevated serum cholesterol.