Pleiotropic beneficial cardiometabolic actions of a high-purity eicosapentaenoic acid product in high cardiovascular risk individuals

The ideal approach to the secondary dyslipidemia goal of lowering triglycerides (TG) is not well established. The available ω-3 fatty acid products differ from each other in composition and content. The purpose of the present study was to investigate the effect of a highly purified eicosapentaenoic acid (EPA) formulation on cardiometabolic biomarkers in high cardiovascular (CV) risk patients. The study included 226 subjects with high TG and ≥1 of the following CV risk factors: arterial hypertension, diabetes mellitus, ultrasound-documented atheromatosis, peripheral artery disease, previous myocardial infarction, or ischemic stroke. Participants received 2 g EPA twice daily for 3 months, along with typical nutritional counseling. Cardiometabolic hematological parameters (TG, low-density lipoprotein [LDL], high-density lipoprotein [HDL], non-HDL, total cholesterol [TChol], apolipoprotein A1 [Apo A1], apolipoprotein B [Apo B], glucose, glycated hemoglobin [HbA1c], and C-reactive protein [CRP]) were measured at baseline and at 3 months. The mean patients' age was 61.1 ± 1.4 years and the mean baseline TG was 2.97 ± 0.15 mmol/L. Apart from Apo A1, all other biomarkers significantly (p < 0.05) improved at 3 months, regardless of sex (except Apo B) and age: TG 1.75 ± 0.09 versus 2.97 ± 0.15 mmol/L, LDL 2.46 ± 0.08 versus 3.05 ± 0.13 mmol/L, HDL 1.22 ± 0.03 versus 1.11 ± 0.03 mmol/L, non-HDL 3.29 ± 0.10 versus 4.14 ± 0.16 mmol/L, TChol 4.55 ± 0.10 versus 5.15 ± 0.13 mmol/L, Apo A1 26.8 ± 9.3 versus 22.5 ± 8.6 μmol/L, Apo B 1.25 ± 0.23 versus 1.29 ± 0.23 μmol/L, glucose 5.66 ± 0.11 versus 5.99 ± 0.17 mmol/L, HbA1c 5.83 ± 0.1 versus 5.97 ± 0.1% and CRP 1.92 ± 0.2 versus 5.26 ± 2.8 mg/L. In conclusion, adding highly purified EPA product (4 g daily) on nutritional counseling leads to a significant TG reduction. In addition, this treatment appears to have pleiotropic beneficial cardiometabolic actions.

High-Intensity Exercise Promotes Deleterious Cardiovascular Remodeling in a High-Cardiovascular-Risk Model: A Role for Oxidative Stress

Although the benefits of moderate exercise in patients at high cardiovascular risk are well established, the effects of strenuous exercise remain unknown. We aimed to study the impact of strenuous exercise in a very high cardiovascular risk model. Nephrectomized aged Zucker obese rats were trained at a moderate (MOD) or high (INT) intensity or were kept sedentary (SED) for 10 weeks. Subsequently, echocardiography and ex vivo vascular reactivity assays were performed, and blood, aortas, perivascular adipose tissue (PVAT), and left ventricles (LVs) were harvested. An improved risk profile consisting of decreased body weight and improved response to a glucose tolerance test was noted in the trained groups. Vascular reactivity experiments in the descending thoracic aorta demonstrated increased endothelial NO release in the MOD group but not in the INT group, compared with SED; the free radical scavenger TEMPOL improved endothelial function in INT rats to a similar level as MOD. An imbalance in the expression of oxidative stress-related genes toward a pro-oxidant environment was observed in the PVAT of INT rats. In the heart, INT training promoted eccentric hypertrophy and a mild reduction in ejection fraction. Obesity was associated with LV fibrosis and a transition toward β-myosin heavy chain and the N2Ba titin isoform. Exercise reverted the myosin imbalance, but only MOD reduced the predominance of the N2Ba titin isoform. In conclusion, moderate exercise yields the most intense cardiovascular benefits in a high-cardiovascular-risk animal model, while intense training partially reverts them.

Higher Adherence to Plant-Based Diet Lowers Type 2 Diabetes Risk among High and Non-High Cardiovascular Risk Populations: A Cross-Sectional Study in Shanxi, China

This study aimed to investigate the association between the plant-based diet index (PDI) score and T2D risk among residents of Shanxi Province, China, and explore whether the association was influenced by different levels of cardiovascular risk. A total of 50,694 participants aged 35-75 years were recruited between 2017 and 2019, and they were further divided into the high cardiovascular risk population (HCRP; n = 17,255) and the non-high cardiovascular risk population (non-HCRP; n = 33,439). The PDI was calculated based on food frequency from a food frequency questionnaire (FFQ). Incident T2D was defined based on elevated plasma glucose (≥7 mmol/L) or hypoglycemic medicine use. We investigated the association of the PDI andT2D risk using a two-level generalized estimating equation and restricted cubic splines model. The results showed that quartile 4 of the PDI indicated significantly reduced T2D risk in the total population (OR: 0.83; 95% CI: 0.75-0.92), HCRP (OR: 0.80; 95% CI: 0.71-0.91), and non-HCRP (OR: 0.80; 95% CI: 0.74-0.87) compared with corresponding quartile 1 (OR = 1). In stratified analysis, the negative associations between PDI and T2D risk were stronger in the total population with the elderly (age > 60 years), BMI < 24, and men, and in the non-HCRP with men and BMI 24-28, and in the HCRP with the elderly and BMI < 24 than those with corresponding subgroups (p_interaction < 0.05). Linear curves were observed for the total population and non-HCRP, but an L-shaped association was observed for the HCRP. Therefore, our results suggest that higher PDI scores may effectively attenuate the T2D risk in the Chinese population and non-HCRP, and a beneficial association of PDI with T2D risk was observed in the HCRP at a certain threshold level. Longitudinal studies and intervention trials are required to validate our study findings.

Treatment and low-density lipoprotein cholesterol levels in patients with hypercholesterolaemia or mixed dyslipidaemia at high or very high cardiovascular risk: a population-based cross-sectional study in the Netherlands

OBJECTIVE

To describe treatment patterns, low-density lipoprotein cholesterol (LDL-C) levels and healthcare resource utilization (HCRU) in the Netherlands in 2018 of patients with hypercholesterolaemia or mixed dyslipidaemia at high or very high cardiovascular (CV) risk.

METHODS

From the PHARMO Database Network adult patients with a diagnosis or receiving lipid lowering therapy (LLT) between 2009 and 2018 were selected. Patients at high or very high CV risk according to 2016 ESC/EAS guidelines with recorded LDL-C levels who were treated with LLT or were characterized as statin intolerant in 2018 were included. LLT treatment patterns, LDL-C levels and HCRU (General Practitioner [GP] consultations and hospitalizations) were assessed.

RESULTS

The study population included 54,346 patients, of which 70% were at very high CV risk and 30% at high CV risk. The majority (93%) received statin monotherapy, mostly of moderate (73%) or high (15%) intensity. Only 3% received a combination of statin and ezetimibe. Statin intolerance, based on a treatment algorithm, was estimated at 3%. Average LDL-C decreased with LLT intensity. Overall, 74% reached LDL-C < 2.5 mmol/l and 34% <1.8 mmol/l with their current treatment, and 46% reached their LDL-C goal according to 2016 ESC/EAS guidelines. The highest rates of hospitalizations and GP consultations, including home visits, were recorded in patients with peripheral artery disease or polyvascular disease.

CONCLUSION

The treatment of hypercholesterolaemia and mixed dyslipidaemia in patients at high or very high CV risk in the Netherlands was suboptimal in 2018. To further lower CV risk alternative treatment strategies using add-on therapies are needed.

Association of body mass index with kidney function and mortality in high cardiovascular risk population: A nationwide prospective cohort study

BACKGROUND

There is increasing awareness of the impact of obesity and underweight on cardiovascular (CV) disease, chronic kidney disease (CKD) and mortality. Abnormal body mass index (BMI) might be associated with worse clinical outcomes, including CKD progression, but limited evidence exists among Asian patients with high CV risk.

OBJECTIVE

To investigate the association of BMI with progressive loss of kidney function and all-cause mortality in Thai patients with high CV risk.

METHODS

In a national cohort of 5887 high CV risk subjects, we assessed the association of high BMI with the composite renal outcome (estimated glomerular filtration rate [eGFR] decline over 40%, eGFR less than 15 mL/min/1.73 m² , doubling of serum creatinine, initiation of dialysis and death related to renal causes) and with all-cause mortality in Cox proportional hazards models.

RESULTS

A total of 5887 participants (3217 male and 2670 female) with high CV risk were enrolled. Participants were classified into five groups by their baseline BMI; <20 kg/m² (n = 482), 20-24.9 kg/m² (n = 2437), 25-29.9 kg/m² (n = 2140), 30-34.9 kg/m² (n = 665) and 35 kg/m² (n = 163), respectively. On multivariate analysis of Cox proportional hazards models, adjusted for other covariates, baseline BMI ≥35 kg/m² was an independent predictor of loss of kidney function (HR 1.60, 95% CI 1.04-2.40) and all-cause mortality (HR 2.68, 95% CI 1.50-4.80). Baseline BMI <20 kg/m² was an independent predictor of all-cause mortality as well (adjusted HR 2.26, 95% CI 1.50-3.42).

CONCLUSION

In the high CV risk Thai population, a BMI of 35 kg/m² or more is associated with loss of kidney function and mortality. On the other hand, a BMI less than 20 kg/m² is also associated with all-cause mortality.

Telemedicine Intervention to Improve Long-Term Risk Factor Control and Body Composition in Persons with High Cardiovascular Risk: Results from a Randomized Trial: Telehealth strategies may offer an advantage over standard institutional based interventions for improvement of cardiovascular risk in high-risk patients long-term

Background

Telehealth strategies are increasingly used to support people at high cardiovascular risk long-term, but is it unclear if these interventions are effective at improving cardiovascular risk.

Objective

To evaluate the effects of a telemedicine technology-based program on risk factor control and body composition in patients at high cardiovascular risk.

Methods

This is a population based randomized controlled trial. 100 patients at high and very high cardiovascular risk were randomly assigned to a telemedicine technology-based program consisting of: Comprehensive counseling on risk factors delivered by a physician; biweekly remote support via phone delivered by a trained nurse during the first three months after enrollment; and a control group receiving routine care with individual single-session counseling on patients' current risk factors without further support. The follow-up period was 1 year.

Results

Mean age of participants was 59.9 ± 4.5 years, 80% were women. Weight (-0.582; p < 0.001), waist circumference (-0.429; p = 0.01), body mass index (-0.216; p < 0.001) diastolic blood pressure (-0.881; p = 0.04), total cholesterol (-0.149; p = 0.01) and LDL cholesterol (-0.123; p = 0.003) were lower in the intervention group compared to the control group after 12-month. Body fat mass was also lower (-0.352; p = 0.01) and lean mass was higher (0.92; p = 0.03) in the intervention group. Anxiety scores (-2.5; p < 0.002) and depression scores (-2.6; p < 0.001) were also lower in the intervention group.

Conclusions

Among older people at high cardiovascular risk, the addition of telehealth strategies using remote support by phone calls over a period of 3 month resulted in small but significant improvements of cardiovascular risk factors, body composition, anxiety, and depression which are maintained long-term. Such telehealth strategies may offer an advantage over standard institution-based interventions.

Treatment of Hypertension to Prevent Atrial Fibrillation

Atrial fibrillation (AF) and hypertension (HT) are expected to rapidly rise worldwide in the next few years. Important improvements in AF therapy are hampered by pro-arrhythmic and bleeding risks of current medications. Prevention of AF is an important matter as it will not only prevent the disease but also medications side effects, and it is likely to be cost effective. HT is a major contributor to AF. As a modifiable risk factor, its treatment might reduce new-onset AF, and recurrent AF after cardioversion or ablation as well. We review here the effect of HT treatment to prevent AF. Renin-angiotensin system (RAS) blockers prevent new-onset AF in patients at high cardiovascular risk, and especially so in heart failure patients. The evidence is less strong among hypertensive patients, except in the presence of left ventricular hypertrophy or if at high cardiovascular risk. In such circumstances, losartan or valsartan were more effective than atenolol or amlodipine. After medical or electrical cardioversion, RAS blockers favourably affect AF recurrence and this class of drug should figure among the prescribed antihypertensive medications. Last, the addition of renal denervation to pulmonary vein isolation may provide even further therapeutic opportunities in patients with refractory HT and AF.

ANICHKOV study: the effect of combined hypotensive and lipid-lowering therapy on cardiovascular complications in patients of high and very high risk

AIM

The aim of the study was to assess cardiovascular risk in patients with elevated levels of total cholesterol and LDL-C and concomitant AH, a comparative analysis of adherence, efficacy and safety of various forms of combined therapy in outpatient practice, including promising lisinopril/amlodipine/rosuvastatin FC (Ekvamer®).

MATERIALS AND METHODS

The ANICHKOV study included 702 patients in Moscow and the Moscow region over 18 years old with a -chole-sterol level ≥7.5 mmol/l and/or LDL-C ≥4.9 mmol/l from March 2017 to December 2018 based on 2 federal centers. According to the results of visit I, patients were prescribed with one of three therapy schemes. In the absence of AH, patients received scheme I -(Mertenil® at initial dosage of 10 mg/day). When history of AH existed or AH detected at visit I, patients were randomized to scheme II (Ekvamer® 5/10/10 mg/day) or III (Mertenil® 10 mg/day + Ekvator® 5/10 mg/day). During the observation, the treatment scheme remained unchanged, however, if the target levels of LDL-C and/or BP were not reached, the doses could be increased. The analysis of the main effects of the prescribed therapy were carried out for 12 months, and the frequency of MACE (CVD, ACS, stroke, or hospitalization to perform PCI) was also evaluated.

RESULTS

Following the visit I, scheme I was assigned to 390 patients (55.6%), scheme II - 190 (27.1%), scheme III - 122 (17.4%). In 147 patients (20.9%), TG level was &gt;2.3 mmol/l, which required additional fenofibrate intake in a dose of 145 mg/day. Adherence level was 89.5%, including scheme I - 91.7%, scheme II - 90.5%, scheme III - only 81.8%. In general, among compliant patients (n = 590), the decrease in TCh level was 41.0%, LDL-C - 47.4%. 16.6% of patients reached target levels of LDL-C &lt;2.5 mmol/l, 5.6% - &lt;1.8 mmol/l. In the fenofibrate subgroup, TG level decrease was 34.6%. During the follow-up period, 47 cases of side effects were observed in 27 patients (4.6%), that did not require modification of therapy. Systolic BP reduction in compliant patients of schemes II and III was 20 mm. Hg (13.1%), diastolic BP - 12 mm. Hg (13.6%), target BP levels (&lt;140/90 mm. Hg) reached 83.7% and 80.8% of patients, respectively, target levels of BP and LDL-C &lt;2.5 mmol/l reached 14.5% and 13.1% of patients, respectively, &lt;1.8 mmol/l - 5.8% and 5.1%, respectively. During the observation period no deaths were recorded, other components of MACE were observed in 38 patients (5.8%), including 27 among compliant patients (4.6%) and 11 among non-compliant (15.9%, p&lt;0.01). In 19 out of 38 patients (50%), hospitalization for routine PCI was the end point, ACS - in 12 (31.6%), and stroke - in 7 (18.4%).

CONCLUSION

The results of the study demonstrated a sufficient hypolipidemic effect and high safety of Mertenil® and Ekvamer®. A higher adherence to the combined preparation than to two monodrugs was noted. Achieving target levels of BP and LDL-C is problematic, which dictates the expediency of using fixed combinations of drugs, especially in primary prevention.

Profile of evolocumab and its cost-effectiveness in patients with high cardiovascular risk: literature review

INTRODUCTION

Evolocumab is fully human monoclonal antibody which binds to proprotein convertase subtilisin/kexin type 9 (PCSK9), and prevents its blocking effect on recycling of liver low-density lipoprotein (LDL) receptors. Areas covered: The aim of this review is to assess efficacy, safety, and cost-effectiveness of evolocumab in adult patients with high cardiovascular risk. Major research databases MEDLINE, EBSCO, and CENTRAL were systematically searched for relevant study reports. Expert commentary: Even when given in full doses, statins augmented with ezetimibe and cholesterol-binding resins could not reduce cholesterol baseline level for more than 66%, while evolocumab reduces cholesterol level for 75% or even more. Up to now, evolocumab showed good safety profile, and patents tolerate it very well. The abovementioned advantages of evolocumab made it almost ideal drug for hypercholesterolemia, and probably in the future the best drug for secondary prevention of major cardiovascular events. Evolocumab is borderline cost-effective for the treatment of patients with high cardiovascular risk in European countries, while in the U.S.A. it is under debate where the underlying assumption (risk of cardiovascular disease events) determine the true value.

Standardised tomato extract as an alternative to acetylsalicylic acid in patients with primary hypertension and high cardiovascular risk - a randomised, controlled trial

INTRODUCTION

Cardiovascular (CV) diseases remain a leading global cause of death. It has been proven that the use of acetylsalicylic acid (ASA) in secondary prevention reduces the CV risk, while the benefits of ASA in primary prevention have recently been debated. The aim of the study was to compare the antiplatelet effect of standardised tomato extract (STE) and ASA in hypertensive patients with high CV risk.

MATERIAL AND METHODS

The study involved high-risk patients with arterial hypertension (AH) randomly assigned to one of two groups: group 1 included 33 patients receiving ASA and group 2 included 32 patients receiving STE. The platelet aggregation was determined using the VerifyNow analyser.

RESULTS

After 4 weeks of ASA treatment in group 1, a statistically significant reduction in aspirin reaction units (ARU) was observed (p < 0.001). However, the obese subgroup using ASA (n = 18) did not reveal a significant decrease in ARU (p > 0.05). After 4 weeks of STE treatment in the obese subgroup (n = 14), significant declines in ARU by 8.6% (95% CI: -19.5 to -1.7%; p < 0.05) and in P2Y12 reaction units (PRU) by 7.5% (95% CI: -17.6 to 1.8%; p < 0.05) were observed.

CONCLUSIONS

The antiplatelet effect of STE in hypertensive patients may be weight dependent. The group with AH and obesity might have potentially benefitted from STE treatment.