Aim Remnant cholesterol has been proposed to promote atherosclerotic cardiovascular disease independent of low-density lipoprotein cholesterol, yet the underlying mechanisms are not well understood. We aimed to study the association of remnant cholesterol with coronary atheroma progression and clinical events. Methods We analyzed data from 5754 patients with coronary artery disease undergoing serial intravascular ultrasonography who were enrolled in 10 trials examining various medical therapies. Remnant cholesterol was calculated as (non-high-density lipoprotein cholesterol – low-density lipoprotein cholesterol (estimated using the Hopkins–Martin equation)). Changes in percentage atheroma volume and 2-year major adverse cardiovascular events were compared across various levels of remnant cholesterol, and multivariable models were used to assess the independent relationship of remnant cholesterol with changes in percentage atheroma volume. Results The mean age was 58.1 ± 9.2 years, 28% were women and 96% received a statin. Percentage atheroma volume progression (changes in percentage atheroma volume > 0) occurred in a linear fashion at on-treatment remnant cholesterol levels of 25 mg/dL or greater. The highest on-treatment remnant cholesterol quartile demonstrated greater percentage atheroma volume progression (+0.53 ± 0.26 vs. –0.15 ± 0.25%, P < 0.001) and 2-year major adverse cardiovascular events (23% vs. 14%, log–rank P < 0.001) compared with the lowest. In multivariable analyses, changes in percentage atheroma volume significantly correlated with on-treatment remnant cholesterol ( P < 0.001] independent of low-density lipoprotein cholesterol, apolipoprotein B, C-reactive protein, high-density lipoprotein cholesterol levels and clinical risk factors. Changes in percentage atheroma volume also significantly correlated with changes in remnant cholesterol following multivariable adjustment. Conclusions In statin-treated patients with atherosclerotic cardiovascular disease, remnant cholesterol was associated with coronary atheroma progression regardless of conventional lipid parameters, C-reactive protein or clinical risk factors. Higher remnant cholesterol levels also correlated with higher major adverse cardiovascular events. These data support further investigations into remnant cholesterol-lowering interventions in statin-treated patients harboring residual atherosclerotic cardiovascular disease risk.

Background Although surgery is indicated in patients with mitral regurgitation (MR) when left ventricular (LV) end-systolic (ES) dimension (D) is >40mm, LV ejection fraction (EF) may decrease post-mitral valve surgery. We hypothesize that significant LV remodeling pre-surgery is not reflected by standard echocardiographic parameters measured at the base of the heart. Methods and Results 94 patients (54±11 years, 38% female) with degenerative isolated MR underwent cine-magnetic resonance imaging (MRI) with tissue tagging and three-dimensional analysis. In 51 control subjects (44±14 years, 53% female), the relation between LVES volume (V) and LVESD was quadratic, while in 94 MR patients this relation was cubic, indicating greater increase in LVESV per LVESD amongst MR patients. Moreover, MRI LVESV from summated serial short axis slices was significantly greater than LVESV using the Bullet formula in MR patients, attributed to a more spherical remodeling distal to the tips of the papillary muscles (P<0.001). 35 patients underwent mitral valve repair per current guideline recommendations. LVEF decreased from 61±7 to 54±8 % (P<0.0001) and maximum shortening decreased significantly below normal at 1-year post-operatively (P<0.0001). Despite normalization of LV stroke volume and LV end-diastolic volume/mass ratio, there was persistent significant increase in distal LVES three-dimensional radius/wall thickness ratio and LVESV index post-surgery. Conclusions Despite apparently preserved LVESD, MR patients demonstrate significant spherical mid to apical LVES remodeling that contributes to higher LVESV than predicted by standard geometry-based calculations. Decreased LV strain post-surgery suggests that a volumetric analysis of LV remodeling and function may be preferred to evaluate disease progression in isolated MR.

High blood pressure (BP) is the leading cause of worldwide cardiovascular disease morbidity and mortality. Patients and clinicians dealing with hypertension have benefited from the evidence of event-based randomized controlled clinical trials. One result from those trials has been the development of evidence-based guidelines. The commitment to using evidence from these event-based randomized trials has been a cornerstone in the development of guideline treatment recommendations. However, in some situations, evidence from event-based trials is not available to guideline writers or clinicians for assistance in treatment decision making. Such is the case for the management of many patients with stage 1 hypertension. The purpose of this scientific statement is to provide information complementary to the 2017 Hypertension Clinical Practice Guidelines for the patient with untreated stage 1 hypertension (systolic BP/diastolic BP, 130–139/80–89 mm Hg) with a 10-year risk for atherosclerotic cardiovascular disease <10% who fails to meet the systolic BP/diastolic goal (<130/80 mm Hg) after 6 months of guideline-recommended lifestyle therapy. This statement provides evidence from sources other than event-based randomized controlled clinical trials and offers therapy options for consideration by clinicians.

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