Textbook of Cardiology

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| colspan="4" width="450px" | Progression of coronary atherosclerosis can be gradual (bottom) or can lead to plaque rupture with acute occlusion of a coronary vessel due to clot formation
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In primary prevention, pharmacologic agents are the second option when lifestyle modifications fail to achieve targeted lipid profile. There are several groups of lipid-altering medicines such as HMG-CoA reductase inhibitors (statins), niacin, fibric acid derivatives, cholesterol intestinal absorption inhibitors, and bile acid-binding agents. In the clinical setting, statins are widely used, being the most cost-effective LDL-lowering drugs. They reduce intracellular cholesterol concentration by inhibiting HMG-CoA reductase, which is an enzyme that synthesizes cholesterol. This results into increased LDL-receptor expression and therefore leads to higher clearance of LDL molecules from blood. They also affect the liver and thereby lower the rate of VLDL synthesis, which results into lower levels of serum triglyceride. Statins also raise HDL, but this mechanism is not fully understood yet.
 
In primary prevention, pharmacologic agents are the second option when lifestyle modifications fail to achieve targeted lipid profile. There are several groups of lipid-altering medicines such as HMG-CoA reductase inhibitors ('''statins'''), niacin, fibric acid derivatives, cholesterol intestinal absorption inhibitors, and bile acid-binding agents. In the clinical setting, statins are widely used, being the most cost-effective LDL-lowering drugs. They reduce intracellular cholesterol concentration by inhibiting HMG-CoA reductase, which is an enzyme that synthesizes cholesterol. This results into increased LDL-receptor expression and therefore leads to higher clearance of LDL molecules from blood. They also affect the liver and thereby lower the rate of VLDL synthesis, which results into lower levels of serum triglyceride. Statins also raise HDL, but this mechanism is not fully understood yet.




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Inhibiting HMG-CoA reductase results in several mechanisms that explain the beneficial effect of using statins. One beneficial mechanism is via lowering LDL and raising HDL. This results into less lipid content in atherosclerotic plaques and improve their biologic activity. Furthermore, the anti-thrombotic and anti-inflammatory profile is enhanced by other mechanisms such as increased NO synthesis and fibrinolytic activity, inhibition of smooth muscle proliferation and monocyte recruitment, and reduced production of matrix-degrading enzymes by macrophages. Several studies suggest that other mechanisms also contribute to the anti-inflammatory profile. For example, statins reduce endothelial expression of leukocyte adhesion molecules and macrophage tissue factor production by inhibiting the macrophage cytokines or by activating PPAR-α.  Another anti-inflammatory action of statins, supported by clinical trials is reducing the serum level of C-reactive protein, which is a marker of inflammation. <br />
Inhibiting HMG-CoA reductase results in several mechanisms that explain the beneficial effect of using statins. One beneficial mechanism is via lowering LDL and raising HDL. This results into less lipid content in atherosclerotic plaques and improve their biologic activity. Furthermore, the anti-thrombotic and anti-inflammatory profile is enhanced by other mechanisms such as increased NO synthesis and fibrinolytic activity, inhibition of smooth muscle proliferation and monocyte recruitment, and reduced production of matrix-degrading enzymes by macrophages. Several studies suggest that other mechanisms also contribute to the anti-inflammatory profile. For example, statins reduce endothelial expression of leukocyte adhesion molecules and macrophage tissue factor production by inhibiting the macrophage cytokines or by activating PPAR-α.  Another anti-inflammatory action of statins, supported by clinical trials is reducing the serum level of C-reactive protein, which is a marker of inflammation. <br />


Although statin therapy can reduce the risk of atherosclerotic cardiovascular disease by about one third, there is still a need for additional risk-reducing therapies. Thus, a new idea was developed to raise HDL cholesterol as a treatment for atherosclerosis. With the finding of the high-HDL phenotype of a human genetic deficiency of cholesteryl ester transfer protein (CETP), a new class of drugs was developed, which inhibits CETP. CETP functions as a mediator for transfer of cholesteryl ester from HDL to VLDL/LDL, which is then cleared by LDL receptors in liver. Thus when CETP is inhibited, this transfer process is inhibited and the direct hepatic HDL clearance pathway takes over. This leads to less fractional clearance of HDL from plasma, which is beneficial for atherosclerosis. Although the absolute clearance rate of HDL remains the same, the key step for atherosclerosis, which is the removal of cholesterol from macrophage foam cells in artery wall by HDL, is reduced. <br />
Despite the effectiveness of statins, niacin, fibric acid derivatives, cholesterol intestinal absorption inhibitors, and bile acid-binding agents in managing serum lipid levels, further advancements in pharmacologic lipid management have introduced additional options for reducing cardiovascular risk associated with atherosclerosis. Two notable additions to the lipid-lowering arsenal are PCSK9 inhibitors and bempedoic acid.
 
Proprotein convertase subtilisin/kexin type 9 '''(PCSK9) inhibitors''' are a novel class of medications that significantly lower low-density lipoprotein cholesterol (LDL-C). PCSK9 is a protein that binds to LDL receptors on the liver surface, leading to their degradation and preventing them from removing LDL cholesterol from the blood. By inhibiting PCSK9, these drugs increase the number of LDL receptors available to clear LDL from the blood, thus lowering LDL-C levels.
 
Clinical trials have demonstrated that PCSK9 inhibitors, such as evolocumab and alirocumab, can reduce LDL-C levels by up to 60% when used alone or in combination with statins. This significant reduction in LDL-C levels has been associated with a decreased risk of cardiovascular events, making PCSK9 inhibitors an important option for patients who are statin-intolerant or for whom statins alone are insufficient to achieve LDL-C targets.
 
'''Bempedoic acid''' represents another innovative approach to lowering LDL-C levels. It acts by inhibiting ATP citrate lyase, an enzyme upstream of HMG-CoA reductase in the cholesterol biosynthesis pathway. This inhibition leads to reduced hepatic cholesterol synthesis and upregulation of LDL receptors, resulting in decreased LDL-C levels. Bempedoic acid has the advantage of being metabolized in the liver, sparing muscle tissue and potentially offering a safer alternative for patients who experience muscle-related side effects with statins.


The most recently investigated CETP inhibitors are torcetrapib, anacetrapib, and dalcetrapib. In the Investigation of Lipid Level Management to Understand Its Impact in Atherosclerotic Events (ILLUMINATE) trial, involving 15,000 patients at high risk for coronary heart disease, torcetrapib was clinically investigated. Unfortunately this trial was prematurely stopped due to the finding of an increase in cardiovascular events associated with an undiscovered off-target effect. Anacetrapib and dalcetrapib are still under active clinical investigation, since they lack the off-target effects of torcetrapib.
In clinical trials, bempedoic acid has been shown to lower LDL-C levels by up to 20% when used as monotherapy and has shown additional LDL-C lowering when used in combination with statins. Furthermore, bempedoic acid has been associated with reductions in biomarkers of inflammation, such as high-sensitivity C-reactive protein (hsCRP), suggesting potential anti-inflammatory benefits beyond its lipid-lowering effects.


==== ''Tobacco smoking'' ====
==== ''Tobacco smoking'' ====


Tobacco use is known to increase the risk of atherosclerosis and ischemic heart disease based on numerous studies. For example, INTERHEART study shows that smoking is responsible for 36% of the population-attributable risk of a first MI. Other studies showed that smoking is an independent major risk factor for coronary heart disease, cerebrovascular disease and total atherosclerotic cardiovascular disease.  The Atherosclerosis Risk in Communities Study measured the direct effect of smoking on the development of atherosclerosis. They measured intima-medial thickness of the carotid artery of 10,914 patients for three years with ultrasound. Their result showed that current smokers had a 50% increased progression of atherosclerosis in comparison to nonsmokers during the study period. Also patients with environmental tobacco smoke exposure (passive smokers) had 20% higher rate of atherosclerotic progress versus patients without environmental smoke exposure.<br />
Tobacco use, including environmental smoking exposure, is known to increase the risk of atherosclerosis and ischemic heart disease based on numerous studies. For example, INTERHEART study shows that smoking is responsible for 36% of the population-attributable risk of a first MI. Other studies showed that smoking is an independent major risk factor for coronary heart disease, cerebrovascular disease and total atherosclerotic cardiovascular disease.  The Atherosclerosis Risk in Communities Study measured the direct effect of smoking on the development of atherosclerosis. They measured intima-medial thickness of the carotid artery of 10,914 patients for three years with ultrasound. Their result showed that current smokers had a 50% increased progression of atherosclerosis in comparison to nonsmokers during the study period. Also patients with environmental tobacco smoke exposure (passive smokers) had 20% higher rate of atherosclerotic progress versus patients without environmental smoke exposure.<br />
   
   
Tobacco smoking can lead to many mechanisms that contribute to atherosclerosis. Smoking also leads to increased LDL levels, decreased HDL levels in blood and elevated insulin resistance. In addition it enhances oxidative modification of LDL by releasing free radicals and reduces generation of nitric oxide. This can promote endothelial dysfunction and thus lead to impairment of vasodilatation of coronary arteries and reduction of coronary flow reserve even in passive smokers. Tobacco smoking inappropriately stimulates sympathetic nervous system, increasing heart rate, blood pressure and perhaps coronary vasoconstriction. Smoking promotes a prothrombotic environment through inhibition of endothelial release of tissue plasminogen activator, elevation of fibrinogen concentration in blood, enhancement of platelet activity (possibility related to sympathetic activation) and  enhanced expression of tissue factor. Smoking can even damage the vessel wall and ultimately cause a decrease in the elasticity of the artery, enhancing the stiffness of vessel wall. Smoking has been associated with increased C-reactive protein and fibrinogen, suggesting a correlation with inflammatory response, which is an important part of atherogenesis. There have also been findings that show higher expression of leukocyte adhesion molecules among smokers than nonsmokers. Smoking may additionally induce tissue hypoxia through displacement of oxygen with carbon monoxide in hemoglobin. <br />
Tobacco smoking can lead to many mechanisms that contribute to atherosclerosis. Smoking also leads to increased LDL levels, decreased HDL levels in blood and elevated insulin resistance. In addition it enhances oxidative modification of LDL by releasing free radicals and reduces generation of nitric oxide. This can promote endothelial dysfunction and thus lead to impairment of vasodilatation of coronary arteries and reduction of coronary flow reserve even in passive smokers. Tobacco smoking inappropriately stimulates sympathetic nervous system, increasing heart rate, blood pressure and perhaps coronary vasoconstriction. Smoking promotes a prothrombotic environment through inhibition of endothelial release of tissue plasminogen activator, elevation of fibrinogen concentration in blood, enhancement of platelet activity (possibility related to sympathetic activation) and  enhanced expression of tissue factor. Smoking can even damage the vessel wall and ultimately cause a decrease in the elasticity of the artery, enhancing the stiffness of vessel wall. Smoking has been associated with increased C-reactive protein and fibrinogen, suggesting a correlation with inflammatory response, which is an important part of atherogenesis. There have also been findings that show higher expression of leukocyte adhesion molecules among smokers than nonsmokers. Smoking may additionally induce tissue hypoxia through displacement of oxygen with carbon monoxide in hemoglobin. <br />
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==== ''Diet'' ====
==== ''Diet'' ====


Several studies suggest that diet, more specifically intake of fruit and vegetable can reduce the risk of coronary heart disease and stroke. In the INTERHEART study, lack of daily consumption of fruits and vegetables was responsible for 14% of the population-attributable risk of a first MI. Another meta-analysis study showed that additional daily portion of fruit reduced the risk of stroke by 11%, but no such effect was found with vegetable consumption.  Another form of diet such as high fiber consumption can also relatively reduce the risk of coronary heart disease and stroke compared to low fiber consumption. In addition, the Hale project has shown that Mediterranean-styled diet as primary prevention for CVD among elderly aged 70-90 without CVD significantly reduces all-cause, coronary heart disease and CVD mortality.<br />
A healthy diet reduces CVD risk. In general, when following the rules for a healthy diet, no dietary supplements are needed.  N-3 polyunsaturated fatty acid (PUFA) consumption mainly from oily fish, is potentially associated with beneficial effects on cardiac risk factors, notably reduction in triglycerides but not all randomized, controlled trials have shown reductions in CV events Thus current recommendations are to increase PUFA intake through fish consumption, rather than from supplements. Recently, the largest study ever conducted with a so-called ‘Mediterranean’ diet, supplemented with extra-virgin olive oil or nuts, reduced the incidence of major cardiovascular events in patients at high risk of CV events but without prior CV disease.<cite>Estruch</cite>


==== ''Alcohol consumption'' ====
==== ''Alcohol consumption'' ====
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#Theorell Theorell, T., Lind, E., Floderus, B. “The relationship of disturbing life-changes and emotions to the development of myocardial infarction and other serious diseases.” Int J Epidemiol 1975; 4:281.
#Theorell Theorell, T., Lind, E., Floderus, B. “The relationship of disturbing life-changes and emotions to the development of myocardial infarction and other serious diseases.” Int J Epidemiol 1975; 4:281.
#Vita Vita J.A., Keaney J.F. Jr. “Endothelial function: a barometer for cardiovascular risk? Circulation” 2002; 106:640.
#Vita Vita J.A., Keaney J.F. Jr. “Endothelial function: a barometer for cardiovascular risk? Circulation” 2002; 106:640.
#Estruch pmid=23944307
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</biblio>
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