Editorial: novel data on the pathogenesis of atherosclerosis, treatment targets, and new therapeutic interventions in lipid-related cardiovascular risk factors.

摘要

Cardiovascular disease (CVD) claims more lives than any other disease in the Western World [1]. In US, it is estimated that there was a decline in CVD-related deaths from 1980 to 2000 [1,2]. Nearly half (44%) of this drop resulted from population-wide risk factor reduction (smoking), whereas another (47%) resulted from medical treatment targeting patients at risk or with established atherosclerosis [1,2]. In contrast, only 5% of the reduction in deaths was estimated to be due to revascularization in patients with established CVD [1,2]. No changes in the dietary intake of fat (total, saturated and polyunsaturated) and cholesterol were recorded from 1988-1994 to 2007-2008 [3]. However, the age-adjusted use of cholesterol-lowering medications increased from 1.6 to 12.5% (P < 0.001) [3]. Data suggest that changes in dietary fat intake had minimal contribution to the observed trend in mean concentrations of total cholesterol, while the increased use of cholesterollowering medications was estimated to account for most of the change [3]. The INTERHEART study showed that 9 CVD risk factors - smoking, dyslipidemia, diabetes mellitus (DM), hypertension, abdominal obesity, stress, poor diet, physical inactivity, and excess alcohol consumption - are associated with > 90% of the CVD risk [4]. All the above suggest that despite the substantial effort to inform the public on the benefit of modifying reversible CVD risk factors this has no practical effect, because people are not keen to change their lifestyle on a longterm basis. This led the Centers for Disease Control to design the Million Hearts Initiative, an effort aimed to prevent 1 million myocardial infarctions and strokes over the next 5 years [1, 5]. Moreover, this contributed in embracing the concept of ideal CVD health by the American Heart Association (AHA) among its strategic goals for 2020 [6]. This concept was intended to focus on the promotion of a healthy lifestyle and the adoption of a multi-factorial pharmacological intervention, aimed to improve the CV health of all Americans by 20%, in order to reduce deaths from myocardial infarctions and strokes by 20% by 2020 [6]. All the above seem to have played a significant role in the composition of the new ACC/AHA lipid guidelines [7]. As stated by the authors of the guidelines, they focused on statins and only briefly mentioned other hypolipidemic drugs, because only statins have shown a clearly defined clinical benefit [7]. Also, the ACC/AHA guidelines risk assessment was based on an equation that appears to overestimate CVD risks by 75-150%, roughly doubling the actual risk [7-9]. Based on the new ACC/AHA guidelines, it is probable that 40-50% of the 46 million middle-aged Americans targeted for statin treatment by the ACC/AHA guidelines do not actually need these drugs [7,9]. It may have been the aim of the panel to protect the US population from a greater CVD incidence that is a consequence of the ever increasing prevalence of obesity [10]. By 2015, the prevalence of CVD in US will be 38% [10]. Obesity, hypertension, dyslipidemia, type 2 diabetes mellitus (T2DM), and metabolic syndrome (MetS) are driving CVD risks [10]. Despite the fact that 70% of US adults are overweight or obese, diet quality continues to deteriorate, leading to the fact that at present more than half of US adults have significant lipid abnormalities [10]. All the above point to the necessity to further inform physicians about CVD risk factors and update the information on the pathogenesis and the recent (as well as the near future) advances in the treatment of dyslipidemias and atherosclerosis. In this issue of the Journal, several articles consider recent advances in novel and established CVD risk factors, mainly those related to lipids, aiming to prevent or treat fatal or non-fatal CVD. The current and future therapeutic options targeting residual CVD risk have been summarized in a multidisciplinary manner. Familial hypercholesterolemia (FH) is a fai