Cholesterol confusion and statin controversy

Revisiting the Definition of 'Healthy' Participants in Substantiation of Structure/Function Claims for Dietary Supplements

Concepts and definitions of 'healthy' have been evolving within clinical treatment algorithms as well as reference standards such as Body Mass Index and Dietary Reference Intakes. Consumers' perception of the word 'healthy' is also changing to reflect longer life span, need to stay active and in a good state of mental well-being while managing multiple diseases. Guidelines from the US Food and Drug Administration indicate that substantiating evidence for support of Structure/Function (S/F) claims for dietary supplements is best derived from clinical research conducted in a 'healthy' population. S/F claims cannot be represented to diagnose, treat, cure or prevent any disease. However, in this context, the term 'healthy' is non-descriptive and largely interpreted as an absence of disease. Guidelines for treatment of disease have been broadened to include biomarkers of disease risk such that the pool of 'healthy' volunteers eligible to be enrolled in clinical trials for S/F claim substantiation is greatly diminished. This perspective presents the challenges faced by the food and dietary supplement industry and by researcher efforts designed to substantiate S/F claims and suggest the phrase 'physiologically stable' or 'apparently healthy' as descriptions better suited to replace the term 'healthy.'

Raman imaging and chemometric methods in human normal bronchial and cancer lung cells: Raman biomarkers of lipid reprogramming

This paper presents an approach to study biochemical changes in human normal bronchial cells (BEpiC) and human cancer lung cells (A549) by Raman spectroscopy and Raman imaging combined with chemometric methods. Based on Raman spectra and Raman imaging combined with chemometric methods we have proved that peaks at 845 cm-1, 2845 cm-1, 2936 cm-1, 1444 cm-1, 750 cm-1, 1126 cm-1, 1584 cm-1, can be treated as Raman biomarkers probing phosphorylation, lipid reprogramming, oxidative phosphorylation and changes in cholesterol and cytochrome in normal and cancer cells. Raman analysis of the bands at 845 cm-1, 2845 cm-1, 1444 cm-1, and 1126 cm-1 in human cancer lung cells and human normal bronchial cells demonstrate enhanced phosphorylation and triglycerides de novo synthesis, reduced levels of cholesterol and cytochrome c in cancer cells. The sensitivity is equal to 100% (nucleus), 87.5% (mitochondria), 100% (endoplasmic reticulum), 87.5% (lipid droplets), 87.5% (cytoplasm), 87.5% (cell membrane) for A549 cell line and 83.3% (nucleus), 100% (mitochondria), 83.3% (endoplasmic reticulum), 100% (lipid droplets), 100% (cytoplasm), 83.3% (cell membrane) for BEpiC. The values of specificity for cross-validation equal 93.4% (nucleus), 85.5% (mitochondria), 89.5% (endoplasmic reticulum), 90.8% (lipid droplets), 61.8% (cytoplasm), 94.7% (cell membrane) for A549 cell line and 88.5% (nucleus), 85.9% (mitochondria), 85.9% (endoplasmic reticulum), 97.4% (lipid droplets), 75.6% (cytoplasm), 92.3% (cell membrane) for BEpiC. We have confirmed that Raman spectroscopy methods combined with PLS-DA are useful tools to monitor changes in human cancer lung cells and human normal bronchial cells.

The Progress and Research Trends of Statin Medications: Advanced Epidemiological and Bibliometrical Assessment

Statin medications are considered as important lipid lowering agents to prevent subsequent cardiovascular events. However, there was limited evidence regarding the bibliometric analysis on preclinical and clinical studies. In January, 2021, the data was retrieved from Scopus and Dimensions database. For detail analysis, we focused on Scopus. Thirty-three thousand two hundred forty-seven research documents were found in the database which contained the word "Statin" either in titles, abstracts and/or keywords of the research documents. They mostly comprised of research articles (n = 22586/67.93%), reviews (n = 6366/19.15%). Scopus classified these documents in various subject categorized like medicine, biochemistry, genetics and molecular biology, pharmacology, toxicology and pharmaceutics, nursing, neuroscience, biological sciences, immunology, and microbiology to name a few. The highest documents are published in 2016 (n = 540/7.16%), followed by 2015 (n = 534/7.08%), 2017 (n = 527/6.99%), 2014 (n = 514/6.81%), and 2020 (n = 504/6.68%). The top sources as well as total number of authors, institutes, and countries involved in publications are described. For detail analysis, we designed the publication and citation clubs. Based on Vosviewer analysis we also provided details about co-authorship network for authors, institutes, and countries. In order to understanding the research focus of the publications, we performed the co-words analysis. The present study may provide details and research trends about statin publications.

The Benefits Outweigh the Risks of Treating Hypercholesterolemia: The Statin Dilemma

Cardiovascular diseases are one of the leading causes of death in the United States; therefore, primary and secondary prevention are of the utmost importance. In this regard, 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase (HMG-CoA) reductase inhibitors, also known as statins, have been anointed as the primary treatment method for lowering cholesterol to prevent cardiovascular diseases. Statins decrease the low-density lipoprotein (LDL) cholesterol and triglycerides in the body, thus lowering the total body cholesterol levels. Despite the benefits associated with statins, it is essential to understand the adverse effects of these drugs. Myotoxicity and statin-associated muscle symptoms are the most common adverse effects of statins. The impairment of mitochondrial function is another adverse effect that can lead to hepatic dysfunction, neurocognitive effects, and potentially the new onset of diabetes. The exact pathophysiology of these side effects is still not fully understood. However, several mechanisms have been proposed, although there is significant overlap among the hypothetical propositions. Understanding the overall outcomes of each of these adverse effects can allow a healthcare practitioner to carefully map out whether statin administration should be used to prevent hypercholesterolemia in the body. The adverse effect of statins is dependent on both the dose and the type of statin used. Lipophilic statins tend to possess a more remarkable ability to infiltrate membranes; they have been hypothesized to cause statin-induced myopathies as well as neurocognitive effects by significantly crossing the blood-brain barrier. In summary, this review has focused on the mechanistic and clinical aspects of this statin class of medication. Proposed mechanisms for different adverse effects associated with statins remain a focus of this communication.

An updated systematic review on the effects of aerobic exercise on human blood lipid profile

Sedentary lifestyle and dyslipidemia are well-recognized risk factors for cardiovascular diseases (CVD). Changes in blood lipid profile (total cholesterol (TC), triglycerides, high-density lipoprotein [HDL], and low-density lipoprotein [LDL]) due to the exercise may be beneficial for decreasing CVD-related events. In this review we aimed to investigate the effect of different types of exercise on lipid profile components in people with different health conditions and age ranges. A systematic search was performed covering PubMed, Web of Science, and Google Scholar for English articles from 2010 until November 2021. Finally, 31 studies were included in our study. Results showed that exercise in younger individuals sometimes resulted in no significant changes of any of the variables or some of them; however, efficient improvement was observed in all studies of older and middle-age groups. In terms of health condition and gender; healthy individuals, overweight people, subjects with type 2 diabetes and obesity, and male participants found to have benefited more from the exercise. In patients with chronic kidney diseases lipid profile improvement was not significant. The cardiac rehabilitation program, particularly comprehensive cardiac rehabilitation, proved to be more beneficial than exercise alone in the case of cardiovascular patients and those at elevated risk of CVD. In conclusion exercise is beneficial in terms of improving lipid profile but for younger population, and those with kidney problems and CVD patients, more further preparations are needed under the supervision of experts in the field of sports and medicine to achieve the desired result. Also, more studies are needed for these groups in order to provide a definite and reliable conclusion.

Biochemical risk factors of atherosclerotic cardiovascular disease: from a narrow and controversial approach to an integral approach and precision medicine

INTRODUCTION

Guidelines of management of dyslipidemias and prevention of cardiovascular disease (CVD) are based on firm scientific evidence obtained by randomized controlled trials (RCTs). However, the role of elevated low-density lipoprotein-cholesterol (LDL-C)as a risk factor of CVD and therapies to lower LDL-C are frequently disputed by colleagues who disagree with the conclusions of the RCTs published. This review focuses on this dispute, and evaluates the current approach of management of dyslipidemias and CVD prevention to find modern alternatives for more precise diagnosis and therapy of dyslipidemic patients.

AREAS COVERED

Recent interest in lipoprotein(a) (Lp(a)) and remnants lipoproteins and in therapies that do not influence LDL-C levels primarily, such as anti-inflammatory drugs and icosapent ethyl, has revitalized our concern to optimize the care for patients with increased CVD risk without focusing simply on reduction of LDL-C by therapy with statins, ezitemibe, and proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors.

EXPERT OPINION

The limited characterization of study populations by measurement of total cholesterol (TC), high-density lipoprotein-cholesterol (HDL-C) and triglycerides (TG) followed by measurement or calculation of LDL-C should be extended by a more integral approach in order to realize precision diagnostics and precision medicine, for the sake of personalized patient care.

Examining the Efficacy of a Very-Low-Carbohydrate Ketogenic Diet on Cardiovascular Health in Adults with Mildly Elevated Low-Density Lipoprotein Cholesterol in an Open-Label Pilot Study

Background:

The objective of this open-label pilot study was to investigate the efficacy of a very-low-carbohydrate ketogenic diet (VLCKD), known as Nic's Ketogenic Diet, for 140 days on cardiometabolic markers in healthy adults with mildly elevated low-density lipoprotein cholesterol (LDL-C).

Methods:

Study assessments were conducted at Day 0, 28, 56, 70, 84, 112, and 140, and weight and blood pressure (BP) were measured and fasting blood was collected for analysis of plasma lipids. A DEXA scan was performed and body mass index recorded on Day 0, 70, and 140. Blood glucose, inflammatory, and thyroid markers were measured on Day 0 and 140. Compliance was assessed using weekly 3-day food records and daily blood glucose and ketone monitoring.

Results:

The results showed that body fat percentage decreased by 2.25% and 4.41% at Day 70 and 140, respectively (P ≤ 0.012). Significant reductions in android, gynoid, and android/gynoid fat ratio and increases in muscle mass occurred by Day 70 and 140. Total cholesterol, LDL-C, and high-density lipoprotein cholesterol were increased and systolic BP and glycated hemoglobin (HbA1c) were decreased at Day 140 (P < 0.05). Following this VLCKD for 140 days was found to be safe and was well tolerated.

Conclusion:

The VLCKD showed beneficial changes in body composition and cardiometabolic markers in eutrophic and overweight participants in a 140-day study suggesting a future role for this diet in populations at cardiovascular disease risk. Future research with larger sample size in a randomized double blind clinical trial is warranted to confirm these results.

Clinical Trial Registration number: NCT04195594.

Atherosclerosis pathogenesis from the perspective of microvascular dysfunction

The article discusses different points of view on atherosclerosis development. The facts confirming the lipid hypothesis are presented. Attention is drawn to the possible participation of vasa vasorum in the development of atherosclerosis.

The Many Roles of Cholesterol in Sepsis: A Review

RATIONALE

The biological functions of cholesterol are diverse, ranging from cell membrane integrity and signalling, immunity, to the synthesis of steroid and sex hormones, Vitamin D, bile acids and oxysterols. Multiple studies have demonstrated hypocholesterolemia in sepsis, the degree of which is an excellent prognosticator of poor outcomes. However, the clinical significance of hypocholesterolemia has been largely unrecognized.

OBJECTIVES/METHODS

We undertook a detailed review of the biological roles of cholesterol, the impact of sepsis, its reliability as a prognosticator in sepsis, and the potential utility of cholesterol as a treatment.

MEASUREMENTS AND MAIN RESULTS

Sepsis affects cholesterol synthesis, transport and metabolism. This likely impacts upon its biological functions including immunity, hormone and vitamin production, and cell membrane receptor sensitivity. Early preclinical studies show promise for cholesterol as a pleiotropic therapeutic agent.

CONCLUSIONS

Hypocholesterolemia is a frequent condition in sepsis and an important early prognosticator. Low plasma levels are associated with wider changes in cholesterol metabolism and its functional roles, and these appear to play a significant role in sepsis pathophysiology. The therapeutic impact of cholesterol elevation warrants further investigation.

Genuine versus bogus scientific controversies: the case of statins

Science progresses through debate and disagreement, and scientific controversies play a crucial role in the growth of scientific knowledge. However, not all controversies and disagreements are progressive in science. Sometimes, controversies can be pseudoscientific; in fact, bogus controversies, and what seem like genuine scientific disagreements, can be a distortion of science set up by non-scientific actors (e.g., interest groups). Bogus controversies are detrimental to science because they can hinder scientific progress and eventually bias science-based decisions. The first goal of this paper is to elucidate the distinction between bogus and genuine scientific controversies and provide a qualitative methodology, based on the literature on expertise, for distinguishing between the two. We will illustrate six epistemic criteria for distinguishing bogus from genuine scientific debates in science and medicine. This heuristic strategy applies directly to scientific reports, and it relies mostly on the social structure of science. We will then apply the above criteria to a case study: the controversy over statins, which are widely prescribed drugs for reducing the level of cholesterol and preventing cardiovascular disease.

Combined LXR and RXR Agonist Therapy Increases ABCA1 Protein Expression and Enhances ApoAI-Mediated Cholesterol Efflux in Cultured Endothelial Cells

Endothelial ABCA1 expression protects against atherosclerosis and this atheroprotective effect is partially attributed to enhancing apoAI-mediated cholesterol efflux. ABCA1 is a target gene for LXR and RXR; therefore, treating endothelial cells with LXR and/or RXR agonists may increase ABCA1 expression. We tested whether treating cultured immortalized mouse aortic endothelial cells (iMAEC) with the endogenous LXR agonist 22(R)-hydroxycholesterol, synthetic LXR agonist GW3965, endogenous RXR agonist 9-cis-retinoic acid, or synthetic RXR agonist SR11237 increases ABCA1 protein expression. We observed a significant increase in ABCA1 protein expression in iMAEC treated with either GW3965 or SR11237 alone, but no significant increase in ABCA1 protein was observed in iMAEC treated with either 22(R)-hydroxycholesterol or 9-cis-retionic acid alone. However, we observed significant increases in both ABCA1 protein expression and apoAI-mediated cholesterol efflux when iMAEC were treated with a combination of either 22(R)-hydroxycholesterol and 9-cis-retinoic acid or GW3965 and SR11237. Furthermore, treating iMAEC with either 22(R)-hydroxycholesterol and 9-cis-retinoic acid or GW3965 and SR11237 did not trigger an inflammatory response, based on VCAM-1, ICAM-1, CCL2, and IL-6 mRNA expression. Based on our findings, delivering LXR and RXR agonists precisely to endothelial cells may be a promising atheroprotective approach.

Effect of Beetroot Consumption on Serum Lipid Profile: A Systematic Review and Meta-Analysis

Beetroot has recently become very popular among people as a medicinal superfood that decreases blood pressure and improves athletes' performance. The present meta-analysis aimed to investigate the effect of beetroot consumption on serum lipid profile. A literature search was conducted covering PubMed, ISI Web of Science, Scopus, and Google scholar of English human subject randomized clinical trials (RCT) up to December 2020. Pooled results showed that beetroot consumption had no significant effect on any of the variables. The mean difference (95% CI) between intervention and control groups for TC was 1.25 (-0.03, 2.53), for TG -0.47 (-1.16, 0.21), for HDL 0.54 (-0.13, 1.21) and for LDL was -0.48(-1.04, 0.09). Subgroup analysis by the health condition of subjects, the form of beetroot consumption, and type of intervention showed no significant differences. It can be concluded that beetroot cannot be categorized as an effective supplementation for adjustment of lipid profile.

Three Musketeers for Lowering Cholesterol: Statins, Ezetimibe and Evolocumab

Coronary heart disease (CHD) is closely related to hypercholesterolemia, and lowering serum cholesterol is currently the most important strategy in reducing CHD. In humans, the serum cholesterol level is determined mainly by three metabolic pathways, namely, dietary cholesterol intake, cholesterol synthesis, and cholesterol degradation in vivo. An intervention that targets the key molecules in the three pathways is an important strategy in lowering serum lipids. Statins inhibit 3-hydroxyl-3-methylglutaryl coenzyme A reductase (HMG-CoA reductase) to reduce low-density lipoprotein (LDL) by about 20% to 45%. However, up to 15% of patients cannot tolerate the potential side effects of high statin dosages, and several patients also still do not reach their optimal LDL goals after being treated with statins. Ezetimibe inhibits cholesterol absorption by targeting the Niemann-Pick C1-like 1 protein (NPC1L1), which is related to cholesterol absorption in the intestines. Ezetimibe lowers LDL by about 18% when used alone and by an additional 25% when combined with statin therapy. The proprotein convertase subtilisin/kexin type 9 (PCSK9) increases hepatic LDLR degradation, thereby reducing the liver's ability to remove LDL, which can lead to hypercholesterolemia. Evolocumab, which is a PCSK9 monoclonal antibody, can reduce LDL from baseline by 53% to 56%. The three drugs exert lipid-lowering effects by regulating the three key pathways in lipid metabolism. Combining any with the two other drugs on the basis of statin treatment has improved the lipid-lowering effect. Whether the combination of the three musketeers will reduce the side effects of monotherapy and achieve the lipid-lowering effect should be studied further in the future.

Role of Cholesterol and Lipid Rafts in Cancer Signaling: A Promising Therapeutic Opportunity?

Cholesterol is a lipid molecule that plays an essential role in a number of biological processes, both physiological and pathological. It is an essential structural constituent of cell membranes, and it is fundamental for biosynthesis, integrity, and functions of biological membranes, including membrane trafficking and signaling. Moreover, cholesterol is the major lipid component of lipid rafts, a sort of lipid-based structures that regulate the assembly and functioning of numerous cell signaling pathways, including those related to cancer, such as tumor cell growth, adhesion, migration, invasion, and apoptosis. Considering the importance of cholesterol metabolism, its homeostasis is strictly regulated at every stage: import, synthesis, export, metabolism, and storage. The alterations of this homeostatic balance are known to be associated with cardiovascular diseases and atherosclerosis, but mounting evidence also connects these behaviors to increased cancer risks. Although there is conflicting evidence on the role of cholesterol in cancer development, most of the studies consistently suggest that a dysregulation of cholesterol homeostasis could lead to cancer development. This review aims to discuss the current understanding of cholesterol homeostasis in normal and cancerous cells, summarizing key findings from recent preclinical and clinical studies that have investigated the role of major players in cholesterol regulation and the organization of lipid rafts, which could represent promising therapeutic targets.

Profilin 1 and Mitochondria-Partners in the Pathogenesis of Coronary Artery Disease?

Atherosclerosis remains a large health and economic burden. Even though it has been studied for more than a century, its complex pathophysiology has not been elucidated. The relatively well-established contributors include: chronic inflammation in response to oxidized cholesterol, reactive oxygen species-induced damage and apoptosis. Recently, profilin 1, a regulator of actin dynamics emerged as a potential new player in the field. Profilin is abundant in stable atherosclerotic plaques and in thrombi extracted from infarct-related arteries in patients with acute myocardial infarction. The exact role of profilin in atherosclerosis and its complications, as well as its mechanisms of action, remain unknown. Here, we summarize several pathways in which profilin may act through mitochondria in a number of processes implicated in atherosclerosis.

Pleiotropic effects of statins: A focus on cancer

The statin drugs ('statins') potently inhibit hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase by competitively blocking the active site of the enzyme. Statins decrease de novo cholesterol biosynthesis and thereby reduce plasma cholesterol levels. Statins exhibit "pleiotropic" properties that are independent of their lipid-lowering effects. For example, preclinical evidence suggests that statins inhibit tumor growth and induce apoptosis in specific cancer cell types. Furthermore, statins show chemo-sensitizing effects by impairing Ras family GTPase signaling. However, whether statins have clinically meaningful anti-cancer effects remains an area of active investigation. Both preclinical and clinical studies on the potential mechanisms of action of statins in several cancers have been reviewed in the literature. Considering the contradictory data on their efficacy, we present an up-to-date summary of the pleiotropic effects of statins in cancer therapy and review their impact on different malignancies. We also discuss the synergistic anti-cancer effects of statins when combined with other more conventional anti-cancer drugs to highlight areas of potential therapeutic development.

High-intensity statin therapy yields better outcomes in acute coronary syndrome patients: a meta-analysis involving 26,497 patients

Background

Whether high-intensity statin treatment provides more clinical benefits compared with standard statin regimens in acute coronary syndrome (ACS) patients remains controversial. This meta-analysis aimed to comparatively assess high-intensity and standard statin regimens for efficacy and safety in patients with ACS.

Methods

The PubMed, EMBASE, and Cochrane Library databases were searched for studies assessing high-intensity vs. standard statin regimens for ACS treatment from inception to April 2020. The publication language was limited to English, and 16 randomized controlled trials were finally included in this study, with a total of 26,497 patients.

Results

Compared to the standard statin regimens, the relative ratio (RR) of major adverse cardiovascular events (MACE) in ACS patients treated by high-intensity statin was 0.77 (95%CI, 0.68–0.86; P < 0.00001; prediction interval, 0.56–1.07). In subgroup analysis, high-intensity statin therapy resulted in more clinical benefits regarding MACE compared with standard statin treatment in both Asian (RR = 0.77; 95%CI, 0.61–0.98; P = 0.03) and non-Asian (RR = 0.79; 95%CI, 0.71–0.89; P < 0.0001) patients. Although adverse events were acceptable in patients with ACS administered high-intensity statin therapy, this treatment was associated with a higher rate of adverse events (4.99% vs. 2.98%), including myopathy/myalgia and elevated liver enzymes, as reflected by elevated serum aminotransferase or aminotransferase amounts.

Conclusion

The current findings indicated that high-intensity statin therapy might be beneficial in patients with ACS, and close monitoring for adverse effects should be performed.

The Pivotal Role of the Dysregulation of Cholesterol Homeostasis in Cancer: Implications for Therapeutic Targets

Cholesterol plays an important role in cellular homeostasis by maintaining the rigidity of cell membranes, providing a medium for signaling transduction, and being converted into other vital macromolecules, such as sterol hormones and bile acids. Epidemiological studies have shown the correlation between cholesterol content and cancer incidence worldwide. Accumulating evidence has shown the emerging roles of the dysregulation of cholesterol metabolism in cancer development. More specifically, recent reports have shown the distinct role of cholesterol in the suppression of immune cells, regulation of cell survival, and modulation of cancer stem cells in cancer. Here, we provide a comprehensive review of the epidemiological analysis, functional roles, and mechanistic action of cholesterol homeostasis in regard to its contribution to cancer development. Based on the existing data, cholesterol homeostasis is identified to be a new key player in cancer pathogenesis. Lastly, we also discuss the therapeutic implications of natural compounds and cholesterol-lowering drugs in cancer prevention and treatment. In conclusion, intervention in cholesterol metabolism may offer a new therapeutic avenue for cancer treatment.

Fluvastatin prevents the development of arthritis in env-pX rats via up-regulation of Rho GTPase-activating protein 12

The pleiotropic effects of statins, including an antiarthritic potential, have been noted. This study aimed to determine the efficacy of statins on rheumatoid arthritis (RA) and clarify how statins affect its pathogenesis. Fluvastatin (500 μg/kg/day) or vehicle was given per os to env-pX rats, which carry the human T-cell leukemia virus type I env-pX gene and spontaneously develop destructive arthritis mimicking RA, for 30 days. Blood sampling and ultrasonography (US) of the ankle joints were conducted on days 0, 10, 20, and 30. On day 30, all rats were euthanized, and the ankle joints were subjected to histological analysis. To clarify how fluvastatin affects the pathogenesis of RA, comprehensive serum exosomal microRNA (miRNA) analysis was performed. Gene expression in the primary culture of synovial fibroblasts derived from arthritic rat and human and non-arthritic rat periarticular tissues was determined quantitatively by real-time reverse transcription-polymerase chain reaction (RT-PCR). As a result, the development of arthritis in env-pX rats was significantly suppressed by fluvastatin, which was evident from the viewpoints of serology, US imaging, and histology. Comprehensive serum exosomal miRNA analysis suggested that the expression of Rho GTPase-activating protein 12 (Arhgap12) was decreased in arthritic env-pX rats but increased with the administration of fluvastatin. Corresponding results were obtained by quantitative RT- PCR using primary culture of synovial fibroblasts. The collective findings suggest that fluvastatin prevents the development of arthritis in env-pX rats via the up-regulation of ARHGAP12. This study suggests that ARHGAP12 can be a possible therapeutic target of RA.

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Application of nutrient essentiality criteria to dietary carbohydrates

The purpose of the present review is to describe how human physiology at very low carbohydrate intakes relates to the criteria for nutritional essentiality. Although we did not limit ourselves to one particular type or function of carbohydrates, we did primarily focus on glucose utilisation as that function was used to determine the recommended daily allowance. In the general population, the human body is able to endogenously synthesise carbohydrates, and does not show signs of deficiency in the absence of dietary carbohydrates. However, in certain genetic defects, such as glycogen storage disease type I, absence of dietary carbohydrates causes abnormalities that are resolved with dietary supplementation of carbohydrates. Therefore, dietary carbohydrates may be defined as conditionally essential nutrients because they are nutrients that are not required in the diet for the general population but are required for specific subpopulations. Ketosis may be considered a physiological normal state due to its occurrence in infants in addition to at very low carbohydrate intakes. Although sources of dietary carbohydrates can provide beneficial micronutrients, no signs of micronutrient deficiencies have been reported in clinical trials of low-carbohydrate ketogenic diets. Nonetheless, more research is needed on how micronutrient requirements can change depending on the dietary and metabolic context. More research is also needed on the role of dietary fibre during a low-carbohydrate ketogenic diet as the beneficial effects of dietary fibre were determined on a standard diet and several studies have shown beneficial effects of decreasing non-digestible carbohydrates.

Formal comment on "Systematic review of the predictors of statin adherence for the primary prevention of cardiovascular disease"

Statins have been prescribed for primary prevention of cardiovascular disease (CVD) for nearly 3 decades. Throughout this period key opinion leaders in the field have been dismayed by the high rate of non-adherence of patients to follow their statin regimen. Hope et al., [1] have addressed this issue by providing a systematic review of research on predictors of statin adherence for primary prevention of CVD. However, their review does not address the ongoing debate as to whether statin treatment is warranted for primary prevention of CVD, nor does it adequately address concerns regarding adverse effects of statins. We have therefore written a commentary which provides a broader perspective on the benefits versus harms of statin therapy. Our perspective of the literature is that non-adherence to statin treatment for primary prevention of CVD is justified because the meager benefits are more than offset by the extensive harms.

Situated Prevention: Framing the "New Dementia"

This article is about the recent and profound changes in the conceptualization of dementia, especially the turn towards prevention. The main argument is that more attention needs to be paid to "situated prevention" - the framing of internationally circulating data on the "new dementia" in different contexts. After introducing some of the more problematic issues related to the "new dementia," a first comparison of major preventive clinical trials in Europe and in North America will be provided. The major insight stemming from situating the global message of preventing dementia is recognition of the responsibility researchers and policy makers bear with respect to the implicit and potential moral narratives in emerging scientific landscapes.

Comparative Effectiveness of Inclisiran 100, 300, and 500 mg in a Population with Hyperlipidemia: A Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

To our knowledge, inclisiran was the first agent composed of small interfering RNAs (siRNAs) to be preliminarily used to reduce proatherogenic lipoprotein cholesterol levels. Inclisiran was evaluated in large clinical trials but did not receive government approval. The ability of inclisiran to reduce low-density lipoprotein cholesterol (LDL-C) greatly improved its chances of becoming a novel therapeutic option for patients with hyperlipidemia.

OBJECTIVE

Our goal was to summarize the preliminary effectiveness and safety data for inclisiran.

METHODS

We conducted a comprehensive search of PubMed, Scopus, Web of Science, the OVID EMB Reviews database, and Clinical Trials with the keyword "inclisiran" to find all related randomized controlled trials (RCTs). Five recently published RCTs involving 583 adults aged 18-65 years with hyperlipidemia were included in the analysis.

RESULTS

Subgroup analysis suggested that inclisiran 100 mg (standard mean difference [SMD] - 2.09; 95% confidence interval [CI] - 2.51 to - 1.66; p < 0.05), 300 mg (SMD - 2.74; 95% CI - 3.61 to - 1.87; p < 0.05), and 500 mg (SMD - 2.21; 95% CI - 2.62 to - 1.80; p < 0.05) significantly (p < 0.05) reduced LDL-C and total cholesterol even though pooled analysis showed no LDL-C-lowering effect (SMD 0.15; 95% CI - 0.34 to 0.04; p = 0.116). Compared with patients receiving placebo, pooled and subgroup analysis of patients receiving inclisiran showed no favorable changes in triglycerides or high-density lipoprotein cholesterol (p > 0.05). The most commonly reported adverse events were musculoskeletal pain, nasopharyngitis, headache, and elevated C-reactive protein (CRP), none of which were significant (p > 0.05).

CONCLUSIONS

To date, inclisiran has been effective in treating hyperlipidemia. Major adverse events were not identified, although other possible adverse events may be discovered with more RCTs and extensive long-term follow-up.

Physical Activity, Immune System, and the Microbiome in Cardiovascular Disease

Cardiovascular health is a primary research focus, as it is a leading contributor to mortality and morbidity worldwide, and is prohibitively costly for healthcare. Atherosclerosis, the main driver of cardiovascular disease, is now recognized as an inflammatory disorder. Physical activity (PA) may have a more important role in cardiovascular health than previously expected. This review overviews the contribution of PA to cardiovascular health, the inflammatory role of atherosclerosis, and the emerging evidence of the microbiome as a regulator of inflammation.

Statin wars: have we been misled about the evidence? A narrative review

Statins are the most widely prescribed, cholesterol-lowering drugs in the world. Despite the expiration of their patents, revenue for statins is expected to rise, with total sales on track to reach an estimated US$1 trillion by 2020. A bitter dispute has erupted among doctors over suggestions that statins should be prescribed to millions of healthy people at low risk of heart disease. There are concerns that the benefits have been exaggerated and the risks have been underplayed. Also, the raw data on the efficacy and safety of statins are being kept secret and have not been subjected to scrutiny by other scientists. This lack of transparency has led to an erosion of public confidence. Doctors and patients are being misled about the true benefits and harms of statins, and it is now a matter of urgency that the raw data from the clinical trials are released.

LDL Receptor Gene-ablated Hamsters: A Rodent Model of Familial Hypercholesterolemia With Dominant Inheritance and Diet-induced Coronary Atherosclerosis

Familial hypercholesterolemia (FH) is an autosomal dominant genetic disease caused mainly by LDL receptor (Ldlr) gene mutations. Unlike FH patients, heterozygous Ldlr knockout (KO) mice do not show a dominant FH trait. Hamsters, like humans, have the cholesteryl ester transfer protein, intestine-only ApoB editing and low hepatic cholesterol synthesis. Here, we generated Ldlr-ablated hamsters using CRISPR/Cas9 technology. Homozygous Ldlr KO hamsters on a chow diet developed hypercholesterolemia with LDL as the dominant lipoprotein and spontaneous atherosclerosis. On a high-cholesterol/high-fat (HCHF) diet, these animals exhibited severe hyperlipidemia and atherosclerotic lesions in the aorta and coronary arteries. Moreover, the heterozygous Ldlr KO hamsters on a short-term HCHF diet also had overt hypercholesterolemia, which could be effectively ameliorated with several lipid-lowering drugs. Importantly, heterozygotes on 3-month HCHF diets developed accelerated lesions in the aortas and coronary arteries. Our findings demonstrate that the Ldlr KO hamster is an animal model of choice for human FH and has great potential in translational research of hyperlipidemia and coronary heart disease.

Coronary artery calcium score plays an important role for cardiovascular risk stratification in the statin benefit groups of asymptomatic individuals

BACKGROUND

The purpose of this study was to describe and analyze the relationship between statin benefit groups based on statin-intensity class of drugs and coronary artery calcium score (CACS) using multidetector computed tomography (MDCT) in an asymptomatic Korean population.

METHODS

A total of 3914 asymptomatic individuals (mean age: 55 ± 10 years; male: female = 2649: 1265) who underwent MDCT for health examination between January 2009 and December 2012 were retrospectively enrolled. They were categorized into three groups based on statin-intensity class of drugs (high-intensity (n = 1284, 32.8%); moderate-intensity (n = 1602, 40.9%) and low-intensity (n = 931, 23.8%) statin therapy groups) according to the American College of Cardiology (ACC)/American heart Association (AHA) 2013 guideline and the relationship between CACS and statin benefit group was analyzed. The statin benefit group was defined as individuals who should be considered moderate- and high-intensity statin therapy.

RESULTS

Ten-year atherosclerotic cardiovascular disease (ASCVD; 12.6 ± 5.3% vs. 2.9 ± 1.9%, p < 0.001) and CACS (98 ± 270 vs. 3 ± 2, p < 0.001) were significantly higher in the high-intensity group compared to the moderate-intensity statin therapy group. In the high-intensity statin therapy group, age [odds ratio: 1.299 (1.137-1.483), p < 0.001], male gender [odds ratio: 44.252 (1.959-999.784), p = 0.001], and fasting blood glucose [odds ratio: 1.046 (1.007-1.087), p = 0.021] were independent risk factors associated with CACS ≥300 on multivariate logistic regression analysis.

CONCLUSIONS

CACS on MDCT might be an important complementary tool for cardiovascular disease risk stratification. This study indicates that individualization of statin therapy as well as lifestyle modification will be useful in asymptomatic individuals, especially those in whom high-intensity statin therapy is required.

Inference to the best explanation and mechanisms in medicine

This article considers the prospects of inference to the best explanation (IBE) as a method of confirming causal claims vis-à-vis the medical evidence of mechanisms. I show that IBE is actually descriptive of how scientists reason when choosing among hypotheses, that it is amenable to the balance/weight distinction, a pivotal pair of concepts in the philosophy of evidence, and that it can do justice to interesting features of the interplay between mechanistic and population level assessments.

Pleiotropic effects of statins: new therapeutic targets in drug design

The HMG Co-enzyme inhibitors and new lipid-modifying agents expand their new therapeutic target options in the field of medical profession. Statins have been described as the most effective class of drugs to reduce serum cholesterol levels. Since the discovery of the first statin nearly 30 years ago, these drugs have become the main therapeutic approach to lower cholesterol levels. The present scientific research demonstrates numerous non-lipid modifiable effects of statins termed as pleiotropic effects of statins, which could be beneficial for the treatment of various devastating disorders. The most important positive effects of statins are anti-inflammatory, anti-proliferative, antioxidant, immunomodulatory, neuroprotective, anti-diabetes, and antithrombotic, improving endothelial dysfunction and attenuating vascular remodeling besides many others which are discussed under the scope of this review. In particular, inhibition of Rho and its downstream target, Rho-associated coiled-coil-containing protein kinase (ROCK), and their agonistic action on peroxisome proliferator-activated receptors (PPARs) can be viewed as the principle mechanisms underlying the pleiotropic effects of statins. With gradually increasing knowledge of new therapeutic targets of statins, their use has also been advocated in chronic inflammatory disorders for example rheumatoid arthritis (RA) and in systemic lupus erythematosus (SLE). In the scope of review, we highlight statins and their pleiotropic effects with reference to their harmful and beneficial effects as a novel approach for their use in the treatment of devastating disorders. Graphical abstract Pleiotropic effect of statins.

Bioresorbable Scaffolds for Atheroregression: Understanding of Transient Scaffolding

This review focuses on the clinical and biological features of the bioresorbable scaffolds in interventional cardiology highlighting scientific achievements and challenges of the transient scaffolding with Absorb BVS. Special attention is granted to the vascular biology pathways which, involved in the resorption of scaffold, artery remodeling and mechanisms of Glagovian atheroregression setting the stage for subsequent clinical applications. Twenty five years ago Glagov described the phenomenon of limited external elastic membrane enlargement in response to an increase in plaque burden. We believe this threshold becomes the target for development of strategies that reverse atherosclerosis, and particularly transient scaffolding has a potential to be a tool to ultimately conquer atherosclerosis.

A call for the better utilization of physical activity and exercise training in the defense against cardiovascular disease

Statins, also known as 3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, effectively reduce elevated levels of serum LDL-C concentration and in turn lower cardiovascular morbidity and mortality. Regular exercise and physical activity also have significant preventive effects against cardiovascular diseases by simultaneously reducing multiple risk factors. However, statins also produce a number of adverse events, including muscle pain, which increases dramatically in statin users who also exercise, likely limiting the cardiovascular benefits. Most importantly, reduced physical activity participation due to statin-related side effects can cancel out the benefits of the pharmacological treatment. Although exercise training offers more modest benefits compared to pharmacological therapy against traditional risk factors, considering the total impact of exercise on cardiovascular health, it is now evident that this intervention may offer a greater reduction of risks compared to statin therapy alone. However, primary recommendations regarding cardiovascular therapy still center around pharmacological approaches. Thus a new outlook is called for in clinical practice that provides room for physical activity and exercise training, thus lipid targets can be reached by a combined intervention along with improvements in other cardiovascular parameters, such as endothelial function and low-grade inflammation. Databases such as Pubmed and Google Scholar as well as the reference list of the relevant articles were searched to collect information for this opinion article.