Examining the paradox of high high-density lipoprotein and elevated cardiovascular risk

Mendelian randomization analyses clarify the effects of height on cardiovascular diseases

An inverse correlation between stature and risk of coronary artery disease (CAD) has been observed in several epidemiologic studies, and recent Mendelian randomization (MR) experiments have suggested causal association. However, the extent to which the effect estimated by MR can be explained by cardiovascular, anthropometric, lung function, and lifestyle-related risk factors is unclear, with a recent report suggesting that lung function traits could fully explain the height-CAD effect. To clarify this relationship, we utilized a well-powered set of genetic instruments for human stature, comprising >1,800 genetic variants for height and CAD. In univariable analysis, we confirmed that a one standard deviation decrease in height (~6.5 cm) was associated with a 12.0% increase in the risk of CAD, consistent with previous reports. In multivariable analysis accounting for effects from up to 12 established risk factors, we observed a >3-fold attenuation in the causal effect of height on CAD susceptibility (3.7%, p = 0.02). However, multivariable analyses demonstrated independent effects of height on other cardiovascular traits beyond CAD, consistent with epidemiologic associations and univariable MR experiments. In contrast with published reports, we observed minimal effects of lung function traits on CAD risk in our analyses, indicating that these traits are unlikely to explain the residual association between height and CAD risk. In sum, these results suggest the impact of height on CAD risk beyond previously established cardiovascular risk factors is minimal and not explained by lung function measures.

The Association Between Lipid Profile and Subfoveal Choroidal Thickness in Chinese Patients with Proliferative Diabetic Retinopathy Secondary to Type 2 Diabetes

Introduction

Extensive studies have studied the factors associated with subfoveal choroidal thickness (SFCT). However, studies of the association between lipid profile and SFCT in patients with proliferative diabetic retinopathy (PDR) in type 2 diabetes remain limited. Thus, we aimed to investigate the relationship between lipid profile and SFCT in patients with PDR.

Materials and Methods

This was a retrospective cross-sectional study. The included participants were inpatients who underwent vitrectomy for PDR with type 2 diabetes and contralateral eyes of PDR patients meeting the criteria. Multivariate linear regression analysis was used to determine the independent association between lipid profile and SFCT.

Results

A total of 131 participants with PDR were enrolled in the final analysis. The average age of the participants was 55.76 ± 9.88 years, and the average SFCT was 276.10 ± 92.92 μm. Multivariate linear regression model results showed that in the fully adjusted model, total cholesterol, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) had a negative association with SFCT (β = -16.51, 95% CI: -29.57, -3.46; P = 0.0148; β = -42.65, 95% CI: -82.60, -2.70; P = 0.0390; β = -17.89, 95% CI: -33.24, -2.54; P = 0.0245, respectively), while triglyceride was not significantly associated with SFCT (β = 5.23, 95% CI: -18.57, 29.02; P = 0.6678). Furthermore, the results of stratified analysis showed that except for triglyceride, the trends of total cholesterol, HDL-C, LDL-C, and SFCT were consistent among different stratifications in participants.

Conclusion

The cholesterol profile had a significant negative association with SFCT in Chinese PDR patients, but triglyceride was not significantly associated with SFCT. This suggests that these systemic imbalances contribute to choroidal changes, and often coexist in diabetic patients.

Mendelian randomization analyses clarify the effects of height on cardiovascular diseases

An inverse correlation between stature and risk of coronary artery disease (CAD) has been observed in several epidemiologic studies, and recent Mendelian randomization (MR) experiments have suggested causal association. However, the extent to which the effect estimated by MR can be explained by established cardiovascular risk factors is unclear, with a recent report suggesting that lung function traits could fully explain the height-CAD effect. To clarify this relationship, we utilized a well-powered set of genetic instruments for human stature, comprising >1,800 genetic variants for height and CAD. In univariable analysis, we confirmed that a one standard deviation decrease in height (~6.5 cm) was associated with a 12.0% increase in the risk of CAD, consistent with previous reports. In multivariable analysis accounting for effects from up to 12 established risk factors, we observed a >3-fold attenuation in the causal effect of height on CAD susceptibility (3.7%, p = 0.02). However, multivariable analyses demonstrated independent effects of height on other cardiovascular traits beyond CAD, consistent with epidemiologic associations and univariable MR experiments. In contrast with published reports, we observed minimal effects of lung function traits on CAD risk in our analyses, indicating that these traits are unlikely to explain the residual association between height and CAD risk. In sum, these results suggest the impact of height on CAD risk beyond previously established cardiovascular risk factors is minimal and not explained by lung function measures.

The association between HDL-C and stroke in the middle-aged and elderly: A cross-sectional study

BACKGROUND

Previous epidemiological studies have indicated that high-density lipoprotein cholesterol (HDL-C) is inversely associated with the risk of cardiovascular disease. However, this issue has aroused controversy in recent years. Besides, the relationship between HDL-C and the risk of total stroke in sex and race is less clear. Thus, we aimed to examine the association between different ranges of HDL-C and the risk of total stroke in adults over 40 years old.

METHODS

This cross-sectional study was conducted on a sample of 8643 participants (4222 men and 4421 women) aged ≥40 years old from the National Health and Nutrition Examination Survey 2007-2016. HDL-C was an independent variable and stroke was a dependent variable in this study, with the other variables as potential effect modifiers. To examine the associations between them, we used multivariate logistical regression models and smooth curve fittings, as well as subgroup analyses.

RESULTS

HDL-C was inversely associated with stroke when HDL-C was less than 1.55 mmol/L (odds ratio [OR] = 0.36, 95% confidence interval [CI] :0.21-0.62, p < .05). However, above 1.55 mmol/L, the incidence of stroke was not significant (OR = 1.29, 95% CI: 0.79-2.09, p>.05). Stratified by race/ethnicity and sex, the subgroup analyses demonstrated that HDL-C was inversely associated with stroke in men and Whites, but no significant differences among women, Mexicans, blacks, and other races.

CONCLUSION

We found a nonlinear relationship between HDL-C and total stroke. Our study reveals a range of inverse associations between HDL-C and stroke (HDL-C<1.55 mmol/L), especially among men and Whites. This finding suggested that maintaining an appropriate HDL-C range may be beneficial in reducing the incidence of stroke.

HDL Is Not Dead Yet

High-density lipoprotein cholesterol (HDL-C) levels are inversely correlated with coronary heart disease (CHD) in multiple epidemiological studies, but whether HDL is causal or merely associated with CHD is unclear. Recent trials for HDL-raising drugs were either not effective in reducing CHD events or, if beneficial in reducing CHD events, were not conclusive as the findings could be attributed to the drugs’ LDL-reducing activity. Furthermore, the first large Mendelian randomization study did not causally relate HDL-C levels to decreased CHD. Thus, the hypothesis that HDL is protective against CHD has been rightfully challenged. However, subsequent Mendelian randomization studies found HDL characteristics that are causally related to decreased CHD. Many aspects of HDL structure and function, especially in reverse cholesterol transport, may be better indicators of HDL’s protective activity than simply measuring HDL-C. Cholesterol efflux capacity is associated with lower levels of prevalent and incident CHD, even after adjustment for HDL-C and apolipoprotein A-1 levels. Also, subjects with very high levels of HDL-C, including those with rare mutations that disrupt hepatic HDL uptake and reverse cholesterol transport, may be at higher risk for CHD than those with moderate levels. We describe here several cell-based and cell-free in vitro assays of HDL structure and function that may be used in clinical studies to determine which of HDL’s functions are best associated with protection against CHD. We conclude that the HDL hypothesis may need revision based on studies of HDL structure and function, but that the HDL hypothesis is not dead yet.

Is a High HDL-Cholesterol Level Always Beneficial?

The specific interest concerning HDL cholesterol (HDL-C) is related to its ability to uptake and return surplus cholesterol from peripheral tissues back to the liver and, therefore, to its role in the prevention of cardiovascular diseases, such as atherosclerosis and myocardial infarction, but also transient ischemic attack and stroke. Previous epidemiological studies have indicated that HDL-C concentration is inversely associated with the risk of cardiovascular disease and that it can be used for risk prediction. Some genetic disorders are characterized by markedly elevated levels of HDL-C; however, they do not translate into diminished cardiovascular risk. The search of the potential causative relationship between HDL-C and adverse events has shifted the attention of researchers towards the composition and function of the HDL molecule/subfractions. HDL possesses various cardioprotective properties. However, currently, it appears that higher HDL-C is not necessarily protective against cardiovascular disease, but it can even be harmful in extremely high quantities.

HDL in Atherosclerotic Cardiovascular Disease: In Search of a Role

For a long time, high-density lipoprotein cholesterol (HDL-C) has been regarded as a cardiovascular disease (CVD) protective factor. Recently, several epidemiological studies, while confirming low plasma levels of HDL-C as an established predictive biomarker for atherosclerotic CVD, indicated that not only people at the lowest levels but also those with high HDL-C levels are at increased risk of cardiovascular (CV) mortality. This “U-shaped” association has further fueled the discussion on the pathophysiological role of HDL in CVD. In fact, genetic studies, Mendelian randomization approaches, and clinical trials have challenged the notion of HDL-C levels being causally linked to CVD protection, independent of the cholesterol content in low-density lipoproteins (LDL-C). These findings have prompted a reconsideration of the biological functions of HDL that can be summarized with the word “HDL functionality”, a term that embraces the many reported biological activities beyond the so-called reverse cholesterol transport, to explain this lack of correlation between HDL levels and CVD. All these aspects are summarized and critically discussed in this review, in an attempt to provide a background scenario for the “HDL story”, a lipoprotein still in search of a role.

The significances and clinical implications of cholesterol components in human breast cancer

Breast cancer is one the most common malignancies and leading cause of cancer-related mortality in women. Recent studies suggested that hypercholesterolemia may be the potential modifiable risk factors for breast cancer. Cholesterol was well-known for its strong association with cardiovascular disease for long. Moreover, solid evidence has been provided by different studies to illustrate the correlation between lipid and incidence in multiple cancers. Although the conclusion remains controversial or sometimes contrary, which may be due to the multifactorial nature of the disease and the disparity of ethnic population, it is critical to elucidate the relationship between specific cholesterol components in certain population and the exact underlying mechanism of the lipid-associated signaling pathway in breast cancer. The implications of dysregulated lipoproteins as therapeutic targets or options for breast cancer provide novel strategies for us in combating with this malignant disease, which may be achieved by manipulating lipid levels with pharmacological compounds.

Prevalence of High HDL Cholesterol and Its Associated Factors Among Tunisian Women of Childbearing Age: A Cross-Sectional Study

The protective role of high high-density lipoprotein cholesterol (HDL-C) against cardiovascular risk has been questioned recently. Due to the increasing trend of cardiovascular diseases (CVD) in Tunisia, this study aimed to determine the prevalence of high HDL-C and its associated factors in Tunisian women of childbearing age. A cross-sectional survey was conducted among a subsample of 1689 women, aged 20 to 49 years, in the Great Tunis region. Data on socio-demographic and lifestyle factors were collected by a questionnaire. Overall adiposity was assessed by body mass index (BMI). All biological variables were assayed in blood samples coated with anticoagulant ethylene diamine tetra acetic acid (EDTA) by enzymatic methods. Stata software (2015) was used for data management and statistical analysis. High HDL-C values were recorded in 26.6% of selected women. After adjustment for all socio-demographic and lifestyle factors, age, hypertension, and smoking were negatively associated with high HDL-C levels, while family history of cancer was positively associated with high HDL-C in women. An additional investigation on the relationship between high HDL-C and cancer risk should be performed due to controversial results.

Association between extremely high high-density lipoprotein-cholesterol and hypertensive retinopathy: results of a cross-sectional study from Kanagawa Investigation of Total Checkup Data from the National Database-6 (KITCHEN-6)

OBJECTIVES

Doubt has been cast on the atheroprotective effect of very high high-density lipoprotein cholesterol (HDL-C). Hypertensive retinopathy (HR) is caused by persistent systemic hypertension. Therefore, we aimed to investigate the association between extremely high HDL-C (EH-HDL) and HR.

DESIGN

A cross-sectional study.

PARTICIPANTS

A total of 4072 general Japanese population aged 40-74 years who underwent regular medical check-ups including fundus examinations.

OUTCOME MEASURES

HR and clinical parameters including serum HDL-C were investigated. HR was determined by the Keith-Wagener classification and the Scheie classifications for Hypertension and Atherosclerosis (n=4054 available). Serum HDL-C was divided into five categories: 30-49, 50-69, 70-89, 90-109 and ≥110 mg/dL.

RESULTS

Overall, 828 (20.3%) subjects had Keith-Wagener-HR, 578 (14.3%) had hypertension-HR, and 628 (15.5%) had atherosclerosis-HR. Blood pressure decreased as HDL-C level increased, whereas the prevalences of HRs showed U-shaped curves against HDL-C with minimum values for HDL-C 90-109 mg/dL. In logistic regression analyses, EH-HDL ≥110 mg/dL was significantly associated with Keith-Wagener-HR and atherosclerosis-HR, compared with HDL-C 90-109 mg/dL after adjustments for age, sex and systolic blood pressure (OR 3.01, 95% CI 1.45 to 6.27 and OR 2.23, 95% CI 1.03 to 4.86). The hypertension-HR was not significantly associated with EH-HDL regardless of adjustment for the confounding factors (p=0.05-0.08). Although serum HDL-C as a continuous variable was inversely associated with three HRs, which disappeared after adjustment for the confounding factors.

CONCLUSION

EH-HDL may be associated with HR independently of blood pressure, suggesting that EH-HDL reflects a special atherosclerotic condition.

Sex and Racial Differences in High-Density Lipoprotein Levels in Acute Coronary Syndromes

BACKGROUND

This study aimed to assess sex and racial differences related to high-density lipoprotein cholesterol (HDL-C) levels in those presenting with acute coronary syndromes (ACS).

METHODS

Records from patients with ACS presenting to the Emergency Department of University of Florida Hospital Jacksonville from 2009 to 2012, were reviewed. Detailed medical history was obtained. HDL-C levels were measured within 72 h of presentation. Pearson chi-square and Wilcoxon rank sum tests were used to compare groups in univariate analysis. Analysis of variance was performed to determine independent predictors of higher HDL-C levels using variable selection.

RESULTS

Of 2400 patients screened, 614 (382 men and 232 women) met inclusion criteria. Hypertension, chronic kidney disease or prior CAD history was similar between sexes and races. Women were more likely to be older (62.4 vs 58.4 years), diabetic (56.5 vs 36.5%) and have higher body mass index (31.2 vs 30.1 kg/m2). Blacks were more likely to be diabetic (50.3 vs 41.3%). After adjusting for all clinical markers, women and blacks along with absence of CAD or diabetes, were significantly associated with higher HDL-C levels.

CONCLUSIONS

High HDL-C levels (> 40 mg/dL), considered cardio-protective, were seen in women and blacks with ACS more often than in men and whites. Significant differences in HDL-C levels between sexes were seen in whites but not in blacks. Relevance and quality of HDL-C levels in racial groups need further study as this may have important implications in the interpretation of current guidelines.

High-Density Lipoprotein Modifications: A Pathological Consequence or Cause of Disease Progression?

High-density lipoprotein (HDL) is well-known for its cardioprotective effects, as it possesses anti-inflammatory, anti-oxidative, anti-thrombotic, and cytoprotective properties. Traditionally, studies and therapeutic approaches have focused on raising HDL cholesterol levels. Recently, it became evident that, not HDL cholesterol, but HDL composition and functionality, is probably a more fruitful target. In disorders, such as chronic kidney disease or cardiovascular diseases, it has been observed that HDL is modified and becomes dysfunctional. There are different modification that can occur, such as serum amyloid, an enrichment and oxidation, carbamylation, and glycation of key proteins. Additionally, the composition of HDL can be affected by changes to enzymes such as cholesterol ester transfer protein (CETP), lecithin-cholesterol acyltransferase (LCAT), and phospholipid transfer protein (PLTP) or by modification to other important components. This review will highlight some main modifications to HDL and discuss whether these modifications are purely a consequential result of pathology or are actually involved in the pathology itself and have a causal role. Therefore, HDL composition may present a molecular target for the amelioration of certain diseases, but more information is needed to determine to what extent HDL modifications play a causal role in disease development.

Treatment with PCSK9 inhibitors induces a more anti-atherogenic HDL lipid profile in patients at high cardiovascular risk

BACKGROUND

Proprotein Convertase Subtilisin/Kexin type 9 inhibitors (PCSK9-I) have been reported to cause a moderate increase in high-density lipoprotein (HDL) cholesterol in human studies. We thus evaluated the effect of two approved PCSK9-I on the concentration and lipid composition of HDL particle subclasses.

SUBJECTS AND METHODS

95 patients (62.8 ± 10.3 years old, 58% men), with or without statin and/or ezetimibe treatment and eligible for PCSK9-I therapy, received either evolocumab (140 mg) or alirocumab (75 or 150 mg). Their HDL particle profiles were measured by NMR spectroscopy at baseline and after 4 weeks of PCSK9-I treatment.

RESULTS

PCSK9-I treatment increased the level of HDL-C by 7%. The level of medium-sized HDL particles (M-HDL-P) increased (+8%) while the level of XL-HDL-P decreased (-19%). The lipid core composition was altered in the smaller S- and M-HDL-P, with a reduction in triglycerides (TG) and an enrichment in cholesterol esters (CE), whereas the for the larger XL- and L-HDL-P the relative CE content decreased and the TG content increased. Ezetimibe therapy differentially impacted the HDL particle distribution, independently of statin use, with an increase in S-HDL-P in patients not receiving ezetimibe.

CONCLUSIONS

As S- and M-HDL-P levels are inversely related to cardiovascular risk, PCSK9-I treatment may result in a more atheroprotective HDL particle profile, particularly in patients not concomitantly treated with ezetimibe.

Anti-Inflammatory HDL Function, Incident Cardiovascular Events, and Mortality: A Secondary Analysis of the JUPITER Randomized Clinical Trial

Background

High‐density lipoprotein (HDL) cholesterol has inverse association with cardiovascular disease. HDL possesses anti‐inflammatory properties in vitro, but it is unknown whether this may be protective in individuals with inflammation.

Methods and Results

The functional capacity of HDL to inhibit oxidation of oxidized low‐density lipoprotein (ie, the HDL inflammatory index; HII) was measured at baseline and 12 months after random allocation to rosuvastatin or placebo in a nested case‐control study of the JUPITER (Justification for the Use of Statins in Prevention: An Intervention Evaluating Rosuvastatin) trial. There were 517 incident cases of cardiovascular disease and all‐cause mortality compared to 517 age‐ and sex‐matched controls. Multivariable conditional logistic regression was used to examine associations of HII with events. Median baseline HII was 0.54 (interquartile range, 0.50–0.59). Twelve months of rosuvastatin decreased HII by a mean of 5.3% (95% CI, −8.9% to −1.7%; P=0.005) versus 1.3% (95% CI, −6.5% to 4.0%; P=0.63) with placebo (P=0.22 for between‐group difference). HII had a nonlinear relationship with incident events. Compared with the reference group (HII 0.5–1.0) with the lowest event rates, participants with baseline HII ≤0.5 had significantly increased risk of cardiovascular disease/mortality (adjusted hazard ratio, 1.53; 95% CI, 1.06–2.21; P=0.02). Furthermore, there was significant (P=0.002) interaction for HDL particle number with HII, such that having more HDL particles was associated with decreased risk only when HDL was anti‐inflammatory.

Conclusions

In JUPITER participants recruited on the basis of chronic inflammation, HII was associated with incident cardiovascular disease/mortality, with an optimal anti‐inflammatory HII range between 0.5 and 1.0. This nonlinear relationship of anti‐inflammatory HDL function with risk may account in part for the HDL paradox.

Registration

URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT00239681.

Lower or higher HDL-C levels are associated with cardiovascular events in the general population in rural China

BACKGROUND

The present study aims to estimate whether high-density lipoprotein cholesterol (HDL-C) is correlated with cardiovascular events (CVEs) and cardiovascular mortality (CVM) in a large sample of the general population in rural areas of China.

METHODS

Adult participants (n = 10,266, age = 53.79 ± 10.49 years; 46.5% men) were enrolled from the Northeast China Rural Cardiovascular Health Study (NCRCHS). Laboratory testing, blood pressure, weight, height, and questionnaires about socioeconomic status were collected.

RESULTS

In all, 585 nonfatal or fatal CVEs and 212 cardiovascular deaths were documented during a 4.66-year follow-up. Compared to the reference groups (HDL-C between 1.5 and 1.99 mmol/L), either lower or higher levels of HDL-C were correlated with an increased incidence of CVEs but not CVM [hazard ratio (HR) _{the lowest} = 1.369, 95% confidence interval, 1.007-1.861; HR _{the highest} = 1.044, 0.509-2.231]. Elevated CVM was seen in the lowest HDL-C category (1.840; 1.121-3.021).

CONCLUSIONS

Lower or higher HDL-C was associated with a higher incidence of CVEs but not CVM in the general population of rural China. Perhaps if an appropriate level of HDL-C is maintained, CVEs can be effectively prevented.

Skeletal muscle area and density are associated with lipid and lipoprotein cholesterol levels: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Loss of muscle mass with age may be a key player in metabolic dysregulation. We examined the associations between abdominal muscle area and density with lipids and lipoproteins.

METHODS

One thousand eight hundred and sixty eight adults completed health history and physical activity questionnaires, provided venous blood samples for lipids and inflammatory biomarkers, and underwent computed tomography to quantify body composition. Associations between muscle area and density with multiple lipid measures were assessed with multivariable linear and logistic regression.

RESULTS

The mean age and body mass index of participants was 65 years and 28 kg/m², respectively, and 50% were female. After adjustment for demographics, cardiovascular disease risk factors, lipid-lowering medications, physical activity, sedentary behavior, inflammatory biomarkers, and central obesity, a 1-standard deviation increase in total abdominal, stability, and locomotor muscle areas was associated with a 13%, 11%, and 8% lower high-density lipoprotein cholesterol level, respectively (P < .05). With similar adjustment, a 1-standard deviation increase in total abdominal and stability muscle area was associated with a 13% and 12% lower total cholesterol level, respectively (P < .01). Compared to the lowest quartiles of total, stability, and locomotor muscle area, those in the higher quartiles of muscle area had over a 40% reduction in the odds of triglyceride levels greater than 150 mg/dL (P < .05). Total abdominal muscle density was positively associated with total cholesterol (P < .05) but was not associated with the other lipid outcomes.

CONCLUSION

Maintaining adequate skeletal muscle mass with age may decrease specific lipid levels related to hyperlipidemia and development of cardiometabolic disease.

Impaired Glucose Metabolism in People with Extremely Elevated High-Density Lipoprotein Cholesterol and Low Alcohol Consumption: Results of the Kanagawa Investigation of Total Checkup Data from the National Database-3 (KITCHEN-3)

BACKGROUND

Recently, we have shown that extremely high high-density lipoprotein cholesterol (HDL-C), which was observed mostly in heavy drinkers, was associated with the incidence of diabetes. However, the observed association was influenced by the consumption of alcohol. Furthermore, it is unknown whether impaired glucose metabolism exists in people with extremely high HDL-C, regardless of their alcohol consumption. Therefore, we addressed this issue in people who did not have a habit of drinking alcohol.

METHODS

In this community-based cross-sectional study, we included 177,034 participants (40-74 years old) who reported being nondrinkers. We investigated levels of HbA1c, fasting plasma glucose (FPG), HDL-C, and clinical parameters according to 11 levels of HDL-C concentration from 20 to 120 mg/dL or over.

RESULTS

A total of 6112 participants with HDL-C ≥ 100 mg/dL (3.5%) showed a better lipid profile, higher prevalence amongst women, more habitual exercise, a lower prevalence of smoking, and lower body mass index (BMI). Compared with an HDL-C of 70-79 mg/dL, HDL-C ≤ 69 mg/dL (except an HDL-C of 20-29 mg/dL) and HDL-C ≥ 90 mg/dL were significantly associated with a high HbA1c of ≥6.0%, independently of confounding factors. This finding was distinctly demonstrated in women. Similar trends were observed when high HbA1c was replaced with high FPG (≥110 mg/dL).

CONCLUSIONS

Our study demonstrated that impaired glucose metabolism may exist in people with extremely high HDL-C and who hardly drink alcohol.

Heart Failure and a Plant-Based Diet. A Case-Report and Literature Review

A 54-year-old female with grade 3 obesity body mass index (BMI 45.2 kg/m2) and type II diabetes (hemoglobin A1c 8.1%) presented to her primary care physician in May 2017 with a chief complaint of left lower extremity edema. Work-up revealed heart failure with depressed left ventricular systolic function. Upon diagnosis, she substantially altered her lifestyle, changing her diet from a "healthy western" one to a whole food plant-based one. Guideline directed medical therapy for heart failure was also utilized. Over five and a half months, she lost 22.7 kg and reversed her diabetes without the use of diabetes medications. Her left ventricular systolic function normalized. Although causality cannot be determined, this case highlights the potential role of a plant-based diet in helping to reverse heart failure with reduced ejection fraction. This article will review how a minimally processed whole food plant-based dietary pattern and similar dietary patterns, such as the Dietary Approach to Stop Hypertension diet, may contribute to the reversal of left ventricular dysfunction.

High Incidence of Diabetes in People with Extremely High High-Density Lipoprotein Cholesterol: Results of the Kanagawa Investigation of Total Checkup Data from the National Database-1 (KITCHEN-1)

BACKGROUND

It is unknown whether extremely high high-density lipoprotein cholesterol (HDL-C) has a protective effect against diabetes, which plays a key role in cardiovascular disease.

METHODS

In a community-based cohort study of 387,642 subjects (40⁻68 years old) without diabetes, the incidence of diabetes 6 years later was determined according to baseline HDL-C (≤39, 40⁻49, 50⁻59, 60⁻69, 70⁻79, 80⁻89, 90⁻99, 100⁻109, or ≥110 mg/dL).

RESULTS

At baseline, HDL-C ≥100 mg/dL was present in 12,908 subjects (3.3%), who had a better lipid profile and a high prevalence of heavy alcohol consumption and habitual exercise. The incidences of diabetes according to baseline HDL-C were 14.7, 11.2, 7.7, 5.3, 3.8, 2.8, 2.7, 2.5, and 3.5 per 1000 person-years, respectively. The adjusted relative risks (ARRs) for diabetes showed concave relationships with HDL-C, with minima at 80⁻89 mg/dL. The ARR (95% CI) of the lowest HDL-C category was 1.56 (1.40⁻1.74) and of the highest HDL-C category was 1.46 (1.18⁻1.81) (both p < 0.001), regardless of alcohol consumption. The latter ARR was higher in men (n = 219,047) (2.45 (1.70⁻3.53), p < 0.0001) after adjustment for baseline glycemic index.

CONCLUSION

Both extremely high and low HDL-C represent risks for diabetes, which deserves further study.