Iatrogenic severe depression of high-density lipoprotein cholesterol.

The authors present 5 cases of paradoxical depression of high-density lipoprotein (HDL) cholesterol induced by fibrate drugs. In a 24-month review of all cases seen in one physician's practice at the Winnipeg Health Sciences Centre Lipid Clinic, 492 patients made a total of 1187 visits. Sixty-eight of them were given a fibrate drug (14%). Ten patients had HDL cholesterol levels that were less than 0.5 mmol/L (2%), and of these, 5 cases were due to exposure to fenofibrate (1%). These 5 cases comprised 7.4% of the 68 patients who were given any fibrate drug during that period. Mean levels were as follows: HDL cholesterol on fenofibrate 0.27, off fenofibrate 1.0 mmol/L and apo A1 on fenofibrate 0.41, off fenofibrate 1.17 g/L. A literature review revealed documented cases in 37 patients involving fibrates alone or in combination with other drugs known to cause decreased HDL cholesterol levels. In 13 patients, exposure was to fibrate therapy alone; in those exposed to combinations, the effect was clearly attributable to fibrates in 9; in 14, the nonfibrates (mostly rosiglitazone) were the attributable drugs; and in 1, it was impossible to tell. Thus, fibrate therapy should always be suspected as a cause of profoundly depressed HDL cholesterol.

Modulation of cytosolic phospholipase A(2) by PPAR activators in human preadipocytes.

Cytosolic phospholipase A(2) (cPLA(2)) is responsible for the release of arachidonic acid, a precursor for eicosanoid biosynthesis, from cellular phospholipids. The objective of this study is to examine the regulation of cPLA(2) by peroxisome proliferator-activated receptor (PPAR) activators in preadipocyte SW872 (SW) cells. PPAR belong to the superfamily of nuclear hormone receptors that heterodimerize with the retinoid X receptor. In this study, the presence of both PPARalpha and PPARgamma was confirmed in SW cells by positive identification of their mRNA in the cellular homogenate. Clofibrate, a PPARalpha activator, caused an enhancement of ionophore A-23187-induced arachidonate release in SW cells. This increase resulted from an enhancement of cPLA(2) activity, which was caused by an increase in enzyme protein. Clofibrate at lower concentrations (10-200 microM) produced increases in the mRNA levels of cPLA(2) in a dose-response manner. At higher concentrations (>400 microM), clofibrate treatment resulted in the attenuation of the cPLA(2) mRNA level and protein expression. We postulate that clofibrate, acting through the PPARalpha, caused an induction in the transcription of cPLA(2) gene, which led to an increase in the cPLA(2) protein. The observed increase in arachidonate release in SW cells appeared to be a direct result of the enhanced cPLA(2) activity.

Fatty infiltration of liver in hyperlipidemic patients.

Hyperlipidemia is a known risk factor for fatty infiltration of the liver, a condition that can progress to cirrhosis and liver failure. The objectives of this study were to document the prevalence of fatty infiltration in the livers of hyperlipidemic patients and to identify the predictor variables associated with this condition. Over an 18-month recruitment period, clinical, biochemical, and radiologic assessments were performed in a cross-sectional manner in 95 adult patients referred to an urban hospital-based lipid clinic for evaluation and management of hyperlipidemia. The mean (+/-SD) age of the patients was 55 +/- 13 years. Forty-eight (51%) were male. Fifty-two patients (55%) had hypercholesterolemia, 25 (26%) severe hypertriglyceridemia, 14 (15%) mixed hyperlipidemia, and 4 (4%) moderate hypertriglyceridemia. Obesity and diabetes were present in 36 (38%) and 12 (12%) of cases, respectively. A total of 61 (64%) patients had elevated liver enzyme tests. The most common enzyme abnormalities were an elevated serum ALT in 45 (47%) and GGT in 43 (45%) of patients. Ultrasound findings revealed diffuse fatty liver in 47 patients (50%), of which 21 cases (22%) were mild, 18 (19%) moderate, and 8 (9%) severe. The majority of patients with hypercholesterolemia [35/52 (67%)] had normal ultrasounds, whereas severe hypertriglyceridemia and mixed hyperlipidemia were frequently associated with radiologic evidence of fatty liver (odds ratios 5.9 and 5.1 respectively, P < 0.01). Independent predictors of fatty liver were; AST (P = 0.001), hyperglycemia (P = 0.02), and age (P = 0.04). In a model incorporating known risk factors for fatty liver, diabetes was the only risk factor other than hypertriglyceridemia that was significantly associated with fatty infiltration. No such effect was seen with age, gender, obesity, or alcohol consumption. In conclusions, the results of this study indicate that ultrasonographic evidence of fatty infiltration of the liver is evident in approximately 50% of patients with hyperlipidemia. Hypertriglyceridemia is the lipid profile most often associated with this condition. Serum AST values, hyperglycemia, and age independently predict the presence of fatty infiltration, while hypertriglyceridemia and diabetes are the only risk factors that significantly increase the risk of fatty infiltration in hyperlipidemic patients.

Effects of atorvastatin treatment on the oxidatively modified low density lipoprotein in hyperlipidemic patients.

Atorvastatin is an established HMG-CoA reductase inhibitor which effectively reduces the plasma low density lipoprotein (LDL)-cholesterol level in hyperlipidemic patients. The present study was designed to investigate whether atorvastatin treatment can modify the biochemical content of oxidized LDL in hyperlipidemic patients and the ability of oxidized LDL to impair the endothelium-dependent relaxation of blood vessels. With atorvastatin (10 mg/day) treatment for 4 weeks in 19 type IIa hyperlipidemic patients, total cholesterol level was lowered by 23%, LDL-cholesterol was lowered by 32% and triacylglycerol was lowered by 19% as compared with dietary therapy alone. High density lipoprotein levels increased by approximately 9%. The ability of oxidized LDL from hyperlipidemic patients after atorvastatin treatment to impair the endothelium-dependent relaxation was significantly reduced as compared with dietary intervention alone. Analysis of the biochemical contents of oxidized LDL from this group revealed that there was an 11% reduction in lysophosphatidylcholine (LPC) as compared with the group that received only dietary counseling. A decrease in the C16:0 moiety with a corresponding increase in the C18:0 moiety of LPC in the oxidized LDL was also observed in the atorvastatin treated group. We propose that the observed reduction and the change in composition of acyl groups in LPC in the oxidized LDL of the atorvastatin-treated group results from a combination of the continued dietary treatment as well as drug therapy. In view of an observation that both C16:0 and C18:0 LPC species are equally potent in the impairment of endothelium-dependent relaxation of the aortic rings, we feel that the reduced level of LPC in the oxidized LDL produced by atorvastatin treatment is partially responsible for the improvement in endothelium control of vascular tone.

The effect of fenofibrate treatment on endothelium-dependent relaxation induced by oxidative modified low density lipoprotein from hyperlipidemic patients.

The objective of the research project was to investigate whether fenofibrate treatment may alter the biochemical content of the oxidized LDL and consequently its ability to impair the endothelium-dependent relaxation in hyperlipidemic patients. We hypothesized that fenofibrate treatment of hyperlipidemic patients may attenuate the ability of their oxidized LDL to impair the endothelium-dependent relaxation of the blood vessels as a consequence of fenofibrate-induced changes to the content and composition of lysoPC in the LDL molecule. Hyperlipidemic patients (Type IIb and Type IV) were recruited from the Lipid Clinic, HSC, Winnipeg, Canada, for this study. A blood sample was taken immediately after the recruitment, a second sample was taken after 6 weeks of dietary treatment, and a third sample was taken after 8 weeks of fenofibrate treatment. LDL was isolated from the plasma and oxidized by copper sulfate. Fenofibrate was shown to be highly effect in the reduction of total cholesterol, LDL cholesterol and triglycerides in these patients. Fenofibrate treatment also caused the attenuation of impairment of endothelium-dependent relaxation by the oxidized LDL from these patients. A slight reduction of lysophosphatidylcholine level was also found in the oxidized LDL of the fenofibrate treated patients, relative to LDL isolated after dietary treatment. In addition there were no changes in the fatty acid levels of the lysophosphatidylcholine isolated from LDL. Taken together, our results suggest that while the reduced lysophosphatidylcholine levels may contribute to the attenuated impairment of the endothelium-dependent relaxation of the aortic ring, other unidentified factors impacted by fenofibrate are likely to contribute to the attenuated effects.

Atherosclerosis risk factors: the possible role of homocysteine.

Atherosclerosis is the leading cause of death in North America. It is characterized by thickening of the coronary artery wall by the formation of plaques, resulting in reduced blood flow. Plaque rupture and the consequent thrombosis may lead to sudden blockage of arteries and causing stroke and heart attack. In the last several decades, more than 250 factors associated with the development of coronary artery disease have been identified. Recently, a relationship between atherosclerosis and elevated homocysteine level in the blood has been established. The mechanism for the production of atherosclerosis by homocysteine has been investigated. When human hepatoma cells (HepG2) were incubated with 4 mM homocysteine, enhancements in the production of cholesterol and secretion of apolipoprotein B-100 were observed. The stimulatory effect on cholesterol synthesis was mediated via the enhancement of HMG-CoA reductase, which catalyzes the rate-limiting step in cholesterol biosynthesis. Cholesterol appears to play an important role in the regulation of apoB-100 secretion by hepatocytes. It is plausible that the increase in apoB secretion was caused by the elevated cholesterol level induced by homocysteine. The ability of homocysteine to produce a higher amount of cholesterol and promote the secretion of apoB would provide a plausible mechanism for the observed relationship between hyperhomocysteinemia and the development of atherogenesis and coronary artery disease.

Evaluation of a new apolipoprotein(a) isoform-independent assay for serum Lipoprotein(a).

The risk factor, Lipoprotein(a), [(Lp(a)], has been measured in numerous clinical studies by a variety of immunochemical assay methods. It is becoming apparent that for many of these assays antibody specificity towards the apolipoprotein(a) [apo(a)] repetitive component [the kringle 4-type 2 repeats] and apo(a) size heterogeneity can significantly affect the accuracy of serum Lp(a) measurements. To address this issue, we investigated whether our current in house Lp(a) [Mercodia] assay showed such bias compared to a recently available assay [Apo-Tek], claiming to possess superior capability for isoform-independent measurement of Lp(a). Levels of Lipoprotein(a) by both Apo-Tek and Mercodia assays correlated inversely with apo(a) isoform sizes. No significant differences were observed between assays in ranges of Lp(a) concentration within each isoform group. The Mercodia assay exhibited similar isoform-independent behaviour to that of Apo-Tek for the quantitation of serum Lipoprotein(a). Essentially identical results were obtained by the two methods, suggesting that Mercodia assay's capture monoclonal antibody also (as is the case for Apo-Tek) does not recognize the kringle 4-type 2 repetitive domain of apo(a). Correlation of Lp(a) concentrations in patient specimens between Apo-Tek and Mercodia assays showed good agreement, although an overall higher degree of imprecision and non-linearity was noted for the Apo-Tek procedure. A change-over to the Apo-Tek assay would therefore not improve on our current assessment of risk contribution from Lp(a) for atherosclerotic vascular disease in individuals with measurable levels of circulating Lipoprotein(a).

Oxidative modification of low density lipoprotein in normal and hyperlipidemic patients: effect of lysophosphatidylcholine composition on vascular relaxation.

The elevated level of plasma low density lipoprotein (LDL) in hyperlipidemic patients is an important risk factor for the production of atherosclerosis. Plasma LDL must be modified before it can produce an impairment of endothelium-dependent relaxation in aortic rings or enhancement of uptake by macrophages. The dramatic increase in lysophosphatidylcholine (lysoPC) content in oxidatively modified LDL has been touted as an important biochemical factor for the impairment of endothelium-dependent relaxation. The present study was designed to examine the lysoPC composition of oxidized LDL samples from normal and hyperlipidemic subjects, and their effects on the impairment of endothelium-dependent relaxation. Oxidatively modified LDL from hyperlipidemic patients contained a slightly higher level (17%) of lysoPC, but produced a disproportionately greater impairment of endothelium-dependent relaxation than that from normal subjects. As lysoPC is composed of many molecular species, its composition in oxidized LDL samples was analyzed. In hyperlipidemic patients, lysoPC samples were found to contain a higher proportion of long-chain acyl groups. Subsequent studies revealed that only long-chain lysoPC (C > 16:0) were effective in impairing endothelium-dependent relaxation. Experimental loading of oxidized LDL from normal subjects with long chain lysoPC to mimic levels observed in oxidized LDL from hyperlipidemic patients resulted in further impairment of endothelium-dependent relaxation. We conclude that the greater proportion of long-chain lysoPC found in the oxidized LDL of hyperlipidemic subjects is responsible for the increased impairment of endothelium-dependent vascular relaxation. We propose that the high level of LDL found in the plasma of hyperlipidemic patients, coupled with its enhanced ability to generate long chain species of lysoPC during oxidative modification, are important factors for the development of atherosclerosis in these patients.

Polymorphism and peripheral levels of apolipoprotein(a) in polygenic hypercholesterolemia and combined hyperlipidemia.

This study demonstrates that peripheral apolipoprotein(a) [apo(a)] levels are higher in patients with polygenic hypercholesterolemia (PH) and combined hyperlipidemia (CH) than in controls. Levels of apo(a) inversely correlate with apo(a) isoform sizes. For a given apo(a) isoform, apo(a) levels are higher in PH and CH patients. Higher frequencies of smaller apo(a) isoforms were found in PH and CH patients than in controls, and in patients with coronary artery disease (CAD) or a family history of premature cardiovascular diseases than in patients without CAD or family history.

Alteration of lysophosphatidylcholine content in low density lipoprotein after oxidative modification: relationship to endothelium dependent relaxation.

OBJECTIVE: The aim was to examine the formation of lipid peroxidation products and the alteration in phospholipid content in low density lipoprotein (LDL) after oxidative modification by CuSO4, and subsequently, to determine the ability of the modified LDL to impair endothelium dependent relaxation in rat aortic rings. METHODS: Blood samples were obtained from normal human volunteers. LDL was prepared by sequential ultracentrifugation and it was oxidatively modified in the presence of 5 microM CuSO4. Lipid peroxidation products (thiobarbituric acid reactive substances, TBARS), and alterations in electrophoretic mobility and phospholipid content were determined in normal (native) and oxidised LDL. Endothelium dependent relaxation was produced by acetylcholine (10(-8)-10(-5) M) in phenylephrine precontracted rat aortic rings. RESULTS: LDL incubated for 24 h with 5 microM CuSO4 at 20 degrees C and 37 degrees C with constant agitation displayed higher amounts of TBARS than the respective native LDL. While the amounts of TBARS in LDL modified at 20 degrees C and 37 degrees C were similar, the former condition resulted in statistically smaller changes of phospholipid contents. LDL with higher lysophosphatidylcholine content showed greater impairment of endothelium dependent relaxation in rat aortic rings than LDL with lower lysophosphatidylcholine content. CONCLUSIONS: The raised lysophosphatidylcholine level in oxidatively modified LDL was related to the ability of the LDL to impair endothelium dependent relaxation. However, lipid peroxidation products assessed by TBARS did not relate to the phospholipid changes in LDL and therefore cannot be used to predict the vascular effects of LDL after oxidative modification.

Serum lipid profile determines platelet reactivity to native and modified LDL-cholesterol in humans.

The effects of thrombin (0.2 U/ml) and native (n-LDL), malondialdehyde-modified (MDA-LDL) and auto-oxidized (ox-LDL) low-density lipoproteins (20 micrograms of protein/ml) on platelet activation were evaluated in seven hyperlipidemic patients and compared to seven controls (fasting serum cholesterol 8.49 +/- 0.5 and 4.61 +/- 0.4 mM, respectively). Basal and thrombin-induced increases in platelet intracellular free calcium ion concentration ([Ca2+]i; fura-2) were similar in hyperlipidemic patients and controls (45 +/- 5 vs 42 +/- 3 and 635 +/- 51 vs 599 +/- 69 mM, respectively). n-LDL, MDA-LDL and ox-LDL increased basal [Ca2+]i (16, 36 and 81 percent, p < 0.01 between LDL-types), increases were consistently smaller in patients. There was an inverse relationship between LDL-induced responses and fasting serum LDL cholesterol as well as LDL/HDL ratio. In conclusion, modified LDL activated platelets to a greater extent than n-LDL, suggesting different types of LDL-receptors. Their agonistic effect was inversely related to the fasting serum lipid profile, suggesting that blunting of platelet responses to LDL could represent a protective mechanism in hyperlipidemic patients.

The association between exercise blood pressure and the prevalence of ECG abnormalities.

The relationship between atrial and ventricular electrocardiographic abnormalities and exercise systolic blood pressure was studied in 246 male and 183 female subjects, of whom 199 males and 158 females were normotensive (resting blood pressure below 140/90 mmHg) and 47 males and 25 females were borderline hypertensive (resting systolic blood pressure 140 to 159 and/or diastolic blood pressure 90 to 99 mmHg). Subjects were classified into three groups according to systolic blood pressure during treadmill exercise (less than or equal to 180 mmHg, 180 to 199 mmHg and greater than or equal to 200 mmHg). With respect to atrial electrocardiographic abnormalities, the prevalence of abnormal values of the P-terminal force in lead V1 increased significantly with increased levels of resting exercise systolic blood pressure in males and females. The prevalence of electrocardiographic left ventricular hypertrophy, as reflected in abnormal values of one or more RS voltage indices, increased significantly with exercise systolic blood pressure in males but not in females. Males did not show a trend of increasing electrocardiographic left ventricular hypertrophy with increased resting systolic blood pressure means. In females, the significant difference between resting systolic blood pressure means and electrocardiographic left ventricular hypertrophy did not reflect a linear progression across resting systolic blood pressure categories. The significant association of the P-terminal force in lead V1 with exercise systolic blood pressure has not previously been reported. Although an association between left ventricular hypertrophy and exercise systolic blood pressure in hypertensives has been reported by others, the association seen in normotensive and borderline hypertensive males has not been reported previously.(ABSTRACT TRUNCATED AT 250 WORDS)

Walking ability and ankle systolic pressures: observations in patients with intermittent claudication in a short-term walking exercise program.

Walking ability and limb hemodynamics were studied in 56 patients with intermittent claudication in an exercise program. Patients walked 1 hour 3 times a week for 3 to 6 months. Ankle and brachial pressures were measured at rest and after a standard walk, and walking ability on the treadmill and during free walking was determined. Average maximal distance on the treadmill increased from 0.59 to 1.00 km after training (p less than 0.0001). Also, after training 84% of patients were able to walk continuously more than 2 km without severe discomfort. The attained walking ability of individual patients could not be predicted from pressure measurements. Small pressure changes after training suggested that factors other than increased development of collateral vessels were important in determining walking ability. Practically useful walking ability was achieved in patients with aortoiliac and femoropopliteal arterial obstruction in the presence or absence of coronary disease and in patients taking beta-blockers. The results indicate that walking exercise is a valuable treatment for many patients with claudication who are not candidates for arterial reconstruction.

The natural history of primary first-degree atrioventricular heart block.

The long-term prognosis of first-degree heart block in the absence of organic heart disease has not been clearly defined. We addressed this question in a 30-year longitudinal study of 3983 healthy men. We identified 52 cases that were present on entry into the study and 124 incident cases during follow-up. The incidence rose steadily after age 40 and was 1.13 per 1000 person-years over the entire period. Two thirds of the cases had only moderate prolongation of the PR interval (0.22 to 0.23 second). We compared four age-matched controls with each case for histories of scarlet fever, rheumatic fever, diphtheria, smoking, blood pressure, and body-mass index. No significant differences (P greater than 0.05) were found. Likewise, mortality from all causes did not differ between cases and controls. Although somewhat higher rates of morbidity and mortality from ischemic heart disease were observed in the cases than in the controls, the differences were not significant. Progression to higher grades of heart block occurred in only two cases. In view of the prognostic findings and the rare occurrence of advanced degrees of heart block, we conclude that primary first-degree heart block with moderate PR prolongation is a benign condition. This conclusion may not apply, however, to persons with more marked prolongation of the PR interval, a very rare condition.

Myocardial infarction in familial hyper-alpha and hypo-beta-lipoproteinaemia.

This is the documentation of an acute myocardial infarction in a 45-year-old woman with familial hyper-alpha- and hypo-beta-lipoproteinaemia. This dyslipoproteinaemia has been rarely associated with clinical evidence of ischaemic heart disease. Documentation of angiographically normal coronary arteries in this patient is consistent with the concept that increased alpha-lipoprotein (HDL) and low beta-lipoprotein (LDL) may prevent atherosclerosis. Thus, myocardial infarction in patients with this dys-lipoproteinaemia should be attributable to factors other than coronary atherosclerosis.

Moderate exercise and high-density lipoprotein-cholesterol. Observations during a cardiac rehabilitation program.

The effects of a 13-week moderate exercise program on fasting plasma insulin, lipids, and lipoprotein cholesterol concentrations were studied in 32 sedentary, middle-aged men with coronary artery disease. The preponderant component of the exercise program was walking or slow jogging. There was no significant change in the systolic blood pressure and pulse rate product response to a standard exercise load. The high-density lipoprotein-cholesterol (HDL-C) level increased, and the fasting plasma insulin concentration decreased. There were no significant changes in plasma triglycerides or low-density lipoprotein cholesterol levels. In sedentary subjects with coronary artery disease, a modest increase in activity can result in an increase in the HDL-C level and a decrease in the plasma insulin concentration. These changes occurred in the absence of variations in diet, smoking habits, adiposity, or plasma triglyceride concentrations and did not require a cardiovascular training effect.

Total and effective coronary blood flow in coronary and noncoronary heart disease.

There are no data available concerning total coronary blood flow to the whole heart (CBF) in man. "Effective" or "nutrient" coronary blood flow to the whole heart (MBF), supposedly a measure of flow through exchanging channels of the coronary circulation, has been measured but its validity has not been established. Accordingly, CBF and MBF were measured in 9 normal subjects, 26 patients with coronary heart disease (CHD), and 19 with noncoronary, mostly valvular heart disease (NCHD), by coincidence counting 84Rb technique. Two methods were used: single bolus (24 cases) and continuous infusion (30 cases). Various other parameters including myocardial oxygen utilization (MVO2) and lactate extraction ratio were determined. In the normal subjects CBF (386 +/- 77 ml/min) was significantly higher (P < 0.05) than in CHD (288 +/- 124 ml/min) and NCHD (292 +/- 111 ml/min). Likewise the normal MBF (380 +/- 81 ml/min) was significantly higher (P < 0.01) than in CHD (251 +/- 105 ml/min) as well as NCHD (258 +/- 104 ml/min). The myocardial Rb extraction ratio epsilon Rb) was significantly lower in normal subjects (39 +/- 9%) than in CHD (50 +/- 7%) and NCHD (52 +/- 11%) and this supports the view that epsilon Rb is flow-dependent. In both CHD and NCHD there was significant diminution of MVO2 as well as CBF. In CHD this was accompanied by a significant anaerobic trend but in NCHD it was not. It might therefore appear that in CHD, MVO2 is determined by perfusion whereas in NCHD, perfusion is determined by MVO2. In comparing CBF with MBF by paired observation testing, there was no significant difference in the normals (P > 0.3), whereas the differences were significant in CHD (P < 0.01) and NCHD (P < 0.02). This was merely a reflection of a reduced ratio of myocardial to total body epsilon Rb in CHD and NCHD, and available evidence indicates that this may be an expression of depressed transport of Rb+ rather than true shunting.