Fibrates, Hypertriglyceridemia, and CVD Risk: Where Do We Stand After the PROMINENT Trial for Triglyceride Lowering?

PURPOSE OF REVIEW: To evaluate recent clinical trials focusing on patients with hypertriglyceridemia. RECENT FINDINGS: Randomized clinical trials have recently been undertaken in hypertriglyceridemic patients to determine whether effective reductions in triglycerides would improve cardiovascular disease (CVD) outcomes. However, the fibric acid derivative, pemafibrate, failed to reduce cardiovascular events despite significant reductions (~ 25-35%) in triglyceride levels and despite background statin therapy. In contrast, icosapent ethyl, a highly purified omega-3 fatty acid was previously shown to reduce CVD events in hypertriglyceridemic patients, despite more modest reductions (~ 20%) in triglyceride levels in statin treated patients. The divergent results obtained in patients with hypertriglyceridemia (HTG), a group at particularly high risk of CVD, especially when coupled with other risk factors, indicates that triglyceride lowering in of itself is insufficient to offset CVD risk. Rather, the effectiveness of therapy in this high-risk cohort may be the result of the suppression of the inherent atherogenic properties associated with HTG.

The association of exhaled carbon monoxide with atrial fibrillation and left atrial size in the Framingham Heart Study.

Background: Exhaled carbon monoxide (eCO) is associated with subclinical and overt cardiovascular disease and stroke. The association between eCO with left atrial size, prevalent, or incident atrial fibrillation (AF) are uncertain. Methods: eCO was measured using an Ecolyzer instrument among Framingham Heart Study Offspring and Omni participants who attended an examination from 1994 to 1998. We analyzed multivariable-adjusted (current smoking, and other covariates including age, race, sex, height, weight, systolic blood pressure, diastolic blood pressure, diabetes, hypertension treatment, prevalent myocardial infarction [MI], and prevalent heart failure [HF]). Cox and logistic regression models assessed the relations between eCO and incident AF (primary model), and prevalent AF and left atrial (LA) size (pre-specified secondary analyses). We also conducted secondary analyses adjusting for biomarkers, and interim MI and interim HF. Results: Our study sample included 3814 participants (mean age 58 ± 10 years; 54.4 % women, 88.4 % White). During an average of 18.8 ± 6.5 years follow-up, 683 participants were diagnosed with AF. eCO was associated with incident AF after adjusting for established AF risk factors (HR, 1.31 [95 % CI, 1.09-1.58]). In secondary analyses the association remained significant after additionally adjusting for C-reactive protein and B-type natriuretic peptide, and interim MI and CHF, and in analyses excluding individuals who currently smoked. eCO was not significantly associated with LA size and prevalent AF. Conclusion: In our community-based sample of individuals without AF, higher mean eCO concentrations were associated with incident AF. Further investigation is needed to explore the biological mechanisms linking eCO with AF.

Prognosis for patients with heart failure and reduced ejection fraction with and without diabetes: A 7 year nationwide veteran administration analysis.

OBJECTIVE: Evidence suggests diabetes mellitus is an independent risk factor for adverse cardiovascular events in patients with heart failure. As a result, we sought to compare mortality in patients with heart failure with reduced ejection fraction (HFrEF) with and without diabetes. RESEARCH DESIGN AND METHODS: The Veteran Affairs Hospitals' databases were queried to identify all veterans diagnosed with HFrEF from 2007 to 2015. From the overall sample of 165,159 veterans, 41,120 patients with diabetes were matched by their propensity scores (without replacement) 1:1 to non-diabetic patients. To estimate the association between diabetes (Type 1 and 2) and overall mortality of HFrEF patients, a Cox proportional hazard model was used on the matched sample and controlled for patient characteristics for a mean follow up of 3.6 years (standard deviation ±2.3). RESULTS: In a matched sample of 41,120 veterans with HFrEF with and without diabetes, those with diabetes and HFrEF were more often on guideline-directed medical therapy than those without diabetes. In the matched cohort, the mortality risk for patients with concurrent HFrEF and diabetes was 17.7% at 1 year and 74.3% at 5 years, whereas the mortality risk for those without diabetes was 15.3% at 1 year and 69.2% at 5 years. After controlling for patient characteristics such as age, sex, body mass index, heart rate, medical therapies, comorbidities, medications, low-density lipoproteins, high-density lipoproteins, we found that patients with diabetes compared to those without had a significantly increased risk of mortality (HR: 1.85, 95% CI: 1.77-1.92, p < 0.001). CONCLUSIONS: Diabetic HFrEF patients have a higher risk of mortality than non-diabetic HFrEF patients despite controlling for medical therapies and comorbidities.

Are Clinicians Contributing to Excess African American COVID-19 Deaths? Unbeknownst to Them, They May Be.

African Americans are overrepresented among reported coronavirus disease 2019 (COVID-19) cases and deaths. There are a multitude of factors that may explain the African American disparity in COVID-19 outcomes, including higher rates of comorbidities. While individual-level factors predictably contribute to disparate COVID-19 outcomes, systematic and structural factors have not yet been reported. It stands to reason that implicit biases may fuel the racial disparity in COVID-19 outcomes. To address this racial disparity, we must apply a health equity lens and disaggregate data explicitly for African Americans, as well as other populations at risk for biased treatment in the health-care system.