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Very High High-Density Lipoprotein Cholesterol Levels and Cardiovascular Mortality

Previous studies have shown reduced cardiovascular risk with increasing high-density lipoprotein cholesterol (HDL-C) levels. However, recent data in the general population have shown increased risk of adverse outcomes at very high concentrations of HDL-C. Thus, we aimed to study the gender-specific relation between very high HDL-C levels (>80, >100 mg/100 ml) and adverse cardiovascular outcomes and the genetic basis in the general population enrolled in the United Kingdom Biobank.

A total of 415,416 participants enrolled in the United Kingdom Biobank without coronary artery disease were included in this prospective cohort study, with a median follow-up of 9 years.

A high HDL-C level >80 mg/100 ml was associated with increased risk of all-cause death (Hazard ratio [HR] 1.11, confidence interval [CI] 1.03 to 1.20, p = 0.005) and cardiovascular death (HR 1.24, CI 1.05 to 1.46, p = 0.01) after adjustment for age, gender, race, body mass index, hypertension, smoking, triglycerides, LDL-C, stroke history, heart attack history, diabetes, eGFR, and frequent alcohol use (defined as ≥3 times/week) using Cox proportional hazard and Fine and Gray's subdistribution hazard models, respectively.

In gender-stratified analyses, such associations were only observed in men (all-cause death HR 1.79, CI 1.59 to 2.02, p <0.0001; cardiovascular death HR 1.92, CI 1.52 to 2.42, p <0.0001), but not in women (all-cause death HR 0.97, CI 0.88 to 1.06, p = 0.50; cardiovascular death HR 1.04, CI 0.83 to 1.31, p = 0.70). The findings persisted after adjusting for the genetic risk score comprised of known HDL-C–associated single nucleotide polymorphisms.

Very high HDL-C levels are associated with an increased risk of all-cause death and cardiovascular death among men but not in women in the general population free of coronary artery disease.


At Cross County Cardiology, we care about you and helping you prevent cardiovascular issues and deaths.  This is why we recommend annual checkups with one of our skilled and knowledgable doctors.  Make an appointment today by calling 201-776-8690 or go online, it could just save your life!

Original article posted March 15, 2022 in ScienceDirect

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Association of Lp(a) and Coronary Artery Calcification With ASCVD

Is the joint association of lipoprotein(a) [Lp(a)] and coronary artery calcification (CAC) with increased risk of atherosclerotic cardiovascular disease (ASCVD) independent?  This study recently published by the American College of Cardiology takes a look.  

Quick Takes

  • Lp(a) and CAC are independently associated with ASCVD risk of death, fatal and nonfatal MI, and stroke after adjusting for other risk factors including family history of MI and each other.
  • Lp(a) has little clinically relevant prognostic implication for guiding primary prevention therapy decisions when CAC is known.
  • A higher 10-year ASCVD incidence occurs in the Lp(a) 5th quintile when compared with Lp(a) quintiles 1-4, but only among participants with CAC ≥100.
  • In persons with CAC from 0 to <100, there was no difference in incident ASCVD when the Lp (a) was ≥50 mg/dL, the level at which Lp(a) is considered a risk-enhancing factor.


Plasma Lp(a) and CAC were measured at enrollment among asymptomatic participants of the MESA (Multi-Ethnic Study of Atherosclerosis; n = 4,512) and DHA (Dallas Heart Study; n = 2,078) cohorts. Elevated Lp(a) was defined as the highest race-specific quintile, and three CAC score categories were studied (0, 1-99, and ≥100). Associations of Lp(a) and CAC with ASCVD risk were evaluated using risk factor–adjusted Cox regression models. ASCVD events included ASCVD-related death, nonfatal myocardial infarction (MI), or fatal or nonfatal stroke.


Among MESA participants (61.9 years of age), 476 incident major ASCVD events were observed during 13.2 years of follow-up. Elevated Lp(a) and CAC score (1-99 and ≥100) were independently associated with ASCVD risk (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.04-1.61; HR, 1.68; 95% CI, 1.30-2.16; and HR, 2.66; 95% CI, 2.07-3.43, respectively), and Lp(a)-by-CAC interaction was not noted. The distribution of CAC scores was similar across quintiles of Lp(a) at about 50% CAC = 0, and 25% for 1-99 and ≥100. Compared with participants with nonelevated Lp(a) and CAC = 0, those with elevated Lp(a) and CAC ≥100 were at the highest risk (HR, 4.71; 95% CI, 3.01-7.40), and those with elevated Lp(a) and CAC = 0 were at a similar risk (HR, 1.31; 95% CI, 0.73-2.35). Similar findings were observed when guideline-recommended Lp(a) and CAC thresholds were considered, and findings were replicated in the DHS.


Lp(a) and CAC are independently associated with ASCVD risk of death, fatal and nonfatal MI, and stroke and may be useful concurrently for guiding primary prevention therapy decisions.


Current national cholesterol management guidelines consider elevated Lp(a) level ≥50 mg/dL as a risk-enhancing factor, and recommend using the CAC score (≥100 or ≥75th percentile for age, sex, and race) measure to guide decisions regarding primary ASCVD prevention. While the relationship of Lp(a) and CAC score and ASCVD are independent and additive, there is minimal clinical value when the CAC score is known. But persons with concomitant Lp(a) and CAC elevation (≥50 mg/dL and ≥100 CAC, respectively) have a >20% cumulative ASCVD incidence (secondary prevention coronary heart disease risk equivalent) over 10 years. These levels justify high-intensity statin therapy, intensifying lifestyle modification, and the addition of aspirin.


At CCC-Mt Sinai, our patients are monitored for their levels and we adjust therapy/treatment based on results.  Give us a call at 201-499-7361 or go online so we can help to check your levels too!


Original article published 2/22/22 by the American College of Cardiology / author: Mehta A, Vasquez N, Ayers CR, et al. 

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Neck Circumference and Risk of Incident Atrial Fibrillation in the Framingham Heart Study

Ever wonder if individuals with high neck circumference have increased risk of incident Atrial Fibrillation (AF) compared with those with low neck circumference? This abstract in the Journal of the American Heart Association discusses the association.  Intriguing!

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Consumption of Olive Oil and Risk of Total and Cause-Specific Mortality Among U.S. Adults

Olive oil has been traditionally used as the main culinary and dressing fat in Mediterranean countries and is a key component of the Mediterranean diet. Well-known for its health benefits, it has become more popular worldwide in recent decades. Olive oil is high in monounsaturated fatty acids, especially oleic acid, and other minor components including vitamin E and polyphenols, contributing to its anti-inflammatory and antioxidant properties (1).

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Olive Oil Consumption and Cardiovascular Risk in U.S. Adults

Cardiovascular disease (CVD), a leading cause of global death, can be largely prevented with a healthy lifestyle (1). Current recommendations highlight the importance of dietary patterns including healthy sources of dietary fats, such as those high in unsaturated fat and low in saturated fat (SFA), for primary prevention of CVD (2). Olive oil is high in monounsaturated fat (MUFA), especially oleic acid, and other minor components including vitamin E, polyphenols, and lipid molecules that may contribute to its anti-inflammatory and antioxidant properties (3). Olive oil has been traditionally used as the main culinary and dressing fat in Mediterranean regions, and recently, it has become more popular worldwide. Early ecological studies observed inverse associations between average country-level consumption of olive oil and the risk of CVD (4). Clinical trials have shown that the consumption of olive oil improves cardiovascular risk factors, including inflammatory and lipid biomarkers (5). In addition, observational studies found that olive oil intake is inversely associated with CVD (6–8) and all-cause death (7).

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‘I Had Never Felt Worse’: Long Covid Sufferers Are Struggling With Exercise

When Natalie Hollabaugh tested positive for Covid-19 in March 2020, her recovery felt extremely slow. Eighteen months later, she was still suffering from a litany of symptoms, including fatigue, shortness of breath, headaches and joint pain. She saw a cardiologist and a pulmonologist, who both ruled out other health problems, she said. And they advised her to start exercising, suggesting that some of her symptoms may have been a result of being out of shape. So Ms. Hollabaugh dutifully began using an exercise bike, speed walking on a treadmill and walking her dogs several miles a day.

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7 Habits for a Healthy Heart

Worldwide, heart disease and strokes are the leading causes of death. They’re also the leading killers of Americans, accounting for one out of every three deaths in the United States. But there’s good news, too. About 80 percent of all cases of cardiovascular disease are preventable. You can lower your risk markedly by making some changes to your lifestyle including doing some things that are easy, simple and even enjoyable. (Two of our favorites? Drink red wine and get a dog.) Here's what you need to know about heart health, along with some of the best ways to improve and protect yours.

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Exercise and Muscle Function in Symptomatic/Asymptomatic Statin Users



The combination of statin therapy and physical activity reduces cardiovascular disease risk in patients with hyperlipidemia more than either treatment alone. However, mitochondrial dysfunction associated with statin treatment could attenuate training adaptations.


This study determined whether moderate intensity exercise training improved muscle and exercise performance, muscle mitochondrial function, and fiber capillarization in symptomatic and asymptomatic statin users.


Symptomatic (n = 16; age 64 ± 4 years) and asymptomatic statin users (n = 16; age 64 ± 4 years) and nonstatin using control subjects (n = 20; age 63 ± 5 years) completed a 12-week endurance and resistance exercise training program. Maximal exercise performance (peak oxygen consumption), muscle performance and muscle symptoms were determined before and after training. Muscle biopsies were collected to assess citrate synthase activity, adenosine triphosphate (ATP) production capacity, muscle fiber type distribution, fiber size, and capillarization.


Type I muscle fibers were less prevalent in symptomatic statin users than control subjects at baseline (P = 0.06). Exercise training improved muscle strength (P < 0.001), resistance to fatigue (P = 0.01), and muscle fiber capillarization (P < 0.01), with no differences between groups. Exercise training improved citrate synthase activity in the total group (P < 0.01), with asymptomatic statin users showing less improvement than control subjects (P = 0.02). Peak oxygen consumption, ATP production capacity, fiber size, and muscle symptoms remained unchanged in all groups following training. Quality-of-life scores improved only in symptomatic statin users following exercise training (P < 0.01).


A moderate intensity endurance and resistance exercise training program improves muscle performance, capillarization, and mitochondrial content in both asymptomatic and symptomatic statin users without exacerbating muscle complaints. Exercise training may even increase quality of life in symptomatic statin users. (The Effects of Cholesterol-Lowering Medication on Exercise Performance [STATEX]; NL5972/NTR6346)

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Aortic Valve Replacement vs Conservative Treatment in Asymptomatic Severe Aortic Stenosis: The AVATAR Trial

We share with you today the AVATAR trial.

Background: Surgical aortic valve replacement (SAVR) represents a class I indication in symptomatic patients with severe aortic stenosis (AS). However, indications for early SAVR in asymptomatic patients with severe AS and normal left ventricular function remain debated.

Methods: The Aortic Valve replAcemenT versus conservative treatment in Asymptomatic seveRe aortic stenosis (AVATAR) trial is an investigator-initiated international prospective randomized controlled trial that evaluated the safety and efficacy of early SAVR in the treatment of asymptomatic patients with severe AS, according to common criteria (valve area ≤1 cm2 with aortic jet velocity >4 m/s or a mean trans-aortic gradient ≥40 mm Hg), and with normal LV function. Negative exercise testing was mandatory for inclusion. The primary hypothesis was that early SAVR would reduce the primary composite endpoint of all-cause death, acute myocardial infarction, stroke or unplanned hospitalization for heart failure, as compared to a conservative strategy according to guidelines. The trial was designed as event-driven to reach a minimum of 35 prespecified events. The study was performed in 9 centers in 7 European countries.

Results: Between June 2015 and September 2020, 157 patients (mean age 67 years, 57 % men) were randomly allocated to early surgery (n=78) or conservative treatment (n=79). Follow-up was completed in May 2021. Overall median follow-up was 32 months: 28 months in the early surgery group and 35 months in the conservative treatment group. There was a total of 39 events, 13 in early surgery and 26 in conservative treatment group. In the early surgery group, 72 patients (92.3 %) underwent SAVR with operative mortality of 1.4 %. In an intention-to-treat analysis, patients randomized to early surgery had a significantly lower incidence of primary composite endpoint than those in the conservative arm (HR 0.46, 95 % CI 0.23-0.90, p=0.02). There was no statistical difference in secondary endpoints, including all-cause mortality, first heart failure hospitalizations, major bleeding or thromboembolic complications, but trends were consistent with the primary outcome.

Conclusions: In asymptomatic patients with severe AS, early surgery reduced a primary composite of all-cause death, acute myocardial infarction, stroke or unplanned hospitalization for heart failure compared with conservative treatment. This randomized trial provides preliminary support for early SAVR once AS becomes severe, regardless of symptoms. 


At CCC Mount Sinai, our team of skilled and seasoned cardiac professionals can evaluate, diagnose and recommend treatments as they pertain to this and other heart conditions.  Make an appointment today and know you have the best care. Call 201-499-7361 or go online to learn more.

Original article published 11/13/21 in American Heart Association Journal by authors: Marko Banovic, Svetozar Putnik, Martin Penicka, Gheorghe Doros, Marek A. Deja, Radka Kockova, Martin Kotrc, Sigita Glaveckaite, Hrvoje Gasparovic, Nikola Pavlovic, Lazar Velicki, Stefano Salizzoni, Wojtek Wokakowski, Guy Van Camp, Serge D. Nikolic, Bernard Iung and Jozef Bartunek on behalf of the AVATAR-trial investigators

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Obstructive sleep apnea associated with presence, burden of coronary plaque

A new study highlights an independent association between obstructive sleep apnea and coronary plaque presence and burden, suggesting it may be a risk factor for coronary events.

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