Kristiina Nyyssönen

Autoantibody against oxidised LDL and progression of carotid atherosclerosis

Oxidative modification of LDL renders it immunogenic and autoantibodies to epitopes of oxidised LDL, such as malondialdehyde (MDA)-lysine, are found in serum and recognise material in atheromatous tissue. However, there has been no prospective study to assess the importance of oxidised LDL among patients with vascular disease. We compared the titre of autoantibodies to MDA-modified LDL and native LDL in baseline serum samples of 30 eastern Finnish men with accelerated two-year progression of carotid atherosclerosis and 30 age-matched controls without progression. Neither group had specific antibody binding to native LDL. A titre was defined as a ratio of antibody binding to MDA-LDL/binding to native LDL. Cases had a significantly higher titre to MDA-LDL (2.67 vs 2.06, p = 0.003). Cases also had a greater proportion of smokers (37% vs 3%), higher LDL cholesterol (4.2 mmol/l vs 3.6 mmol/l), and higher serum copper concentration (1.14 mg/l vs 1.04 mg/l). Even after adjusting for these variables and the severity of baseline atherosclerosis, the difference in antibody titre remained significant in a multifactorial logistic model (p = 0.031). Thus, the titre of autoantibodies to MDA-LDL was an independent predictor of the progression of carotid atherosclerosis in these Finnish men. Our data provide further support for a role of oxidatively modified LDL in atherogenesis.

Kuopio Atherosclerosis Prevention Study (KAPS) A Population-Based Primary Preventive Trial of the Effect of LDL Lowering on Atherosclerotic Progression in Carotid and Femoral Arteries

BACKGROUND The atherosclerotic progression-reducing effect of LDL cholesterol (LDL-C) lowering has been established in subjects with severe atherosclerotic disease but not in persons with elevated LDL cholesterols without severe atherosclerosis. KAPS (Kuopio Atherosclerosis Prevention Study) is the first population-based trial in the primary prevention of carotid and femoral atherosclerosis. METHODS AND RESULTS The eligibility requirements were serum LDL-C > or = 4.0 mmol/L and total cholesterol < 7.5 mmol/L. Out of a geographically defined population, 447 men aged 44 to 65 years (mean, 57) were randomized to pravastatin (40 mg/d) or placebo for 3 years. Less than 10% of the subjects had prior myocardial infarction. Thirty-nine men discontinued study medication; however, efficacy data were available for 424 men. The primary outcome was the rate of carotid atherosclerotic progression, measured as the linear slope over annual ultrasound examinations in the average of the maximum carotid intima-media thickness (IMT) of the far wall of up to four arterial segments (the right and left distal common carotid artery and the right and left carotid bulb). For the carotid arteries, at the overall mean baseline IMT of 1.66 mm, the rate of progression of carotid atherosclerosis was 45% (95% CI, 16 to 69%) less in the pravastatin (0.017 mm/y) than the placebo (0.031 mm/y) group (P = .005). In the common carotid artery there was a treatment effect of 66% (95% CI, 30 to 95%; pravastatin 0.010 mm/y; placebo 0.029 mm/y; P < .002) at the overall mean baseline IMT of 1.35 mm. A treatment effect of 30% (95% CI, -1% to 54%) was found for the carotid bulb (pravastatin, 0.028; placebo, 0.040; P = .056) at the overall mean baseline IMT of 2.0 mm. The treatment effect was larger in subjects with higher baseline IMT values, in smokers and in those with low plasma vitamin E levels. There was no significant treatment effect on atherosclerotic progression in the femoral arteries. CONCLUSIONS These data establish the antiatherogenic effect of LDL-C lowering by pravastatin in hypercholesterolemic men in a primary prevention setting and suggest a greater effect in smokers than in nonsmokers.

The Effect of Polyphenols in Olive Oil on Heart Disease Risk Factors: A Randomized Trial

Context Olive oil, the main fat in the Mediterranean diet, contains polyphenols, which have antioxidant properties and may affect serum lipid levels. Contribution The authors studied virgin olive oil (high in polyphenols), refined olive oil (low in polyphenols), and a mixture of the 2 oils in equal parts. Two hundred healthy young men consumed 25 mL of an olive oil daily for 3 weeks followed by the other olive oils in a randomly assigned sequence. Olive oils with greater polyphenol content increased high-density lipoprotein (HDL) cholesterol levels and decreased serum markers of oxidation. Cautions The increase in HDL cholesterol level was small. Implications Virgin olive oil might have greater health benefits than refined olive oil. The Editors Polyphenol intake has been associated with low cancer and coronary heart disease (CHD) mortality rates (1). Antioxidant and anti-inflammatory properties and improvements in endothelial dysfunction and the lipid profile have been reported for dietary polyphenols (2). Studies have recently suggested that Mediterranean health benefits may be due to a synergistic combination of phytochemicals and fatty acids (3). Olive oil, rich in oleic acid (a monounsaturated fatty acid), is the main fat of the Mediterranean diet (4). To date, most of the protective effect of olive oil within the Mediterranean diet has been attributed to its high monounsaturated fatty acid content (5). However, if the effect of olive oil can be attributed solely to its monounsaturated fatty acid content, any type of olive oil, rapeseed or canola oil, or monounsaturated fatty acidenriched fat would provide similar health benefits. Whether the beneficial effects of olive oil on the cardiovascular system are exclusively due to oleic acid remains to be elucidated. The minor components, particularly the phenolic compounds, in olive oil may contribute to the health benefits derived from the Mediterranean diet. Among olive oils usually present on the market, virgin olive oils produced by direct-press or centrifugation methods have higher phenolic content (150 to 350 mg/kg of olive oil) (6). In experimental studies, phenolic compounds in olive oil showed strong antioxidant properties (7, 8). Oxidized low-density lipoprotein (LDL) is currently thought to be more damaging to the arterial wall than native LDL cholesterol (9). Results of randomized, crossover, controlled clinical trials on the antioxidant effect of polyphenols from real-life daily doses of olive oil in humans are, however, conflicting (10). Growing evidence suggests that dietary phenols (1115) and plant-based diets (16) can modulate lipid and lipoprotein metabolism. The Effect of Olive Oil on Oxidative Damage in European Populations (EUROLIVE) Study is a multicenter, randomized, crossover, clinical intervention trial that aims to assess the effect of sustained daily doses of olive oil, as a function of its phenolic content, on the oxidative damage to lipid and LDL cholesterol levels and the lipid profile as cardiovascular risk factors. Methods Participants We recruited healthy men, 20 to 60 years of age, from 6 European cities through newspaper and university advertisements. Of the 344 persons who agreed to be screened, 200 persons were eligible (32 men from Barcelona, Spain; 33 men from Copenhagen, Denmark; 30 men from Kuopio, Finland; 31 men from Bologna, Italy; 40 men from Postdam, Germany; and 34 men from Berlin, Germany) and were enrolled from September 2002 through June 2003 (Figure 1). Participants were eligible for study inclusion if they provided written informed consent, were willing to adhere to the protocol, and were in good health. We preselected volunteers when clinical record, physical examination, and blood pressure were strictly normal and the candidate was a nonsmoker. Next, we performed a complete blood count, biochemical laboratory analyses, and urinary dipstick tests to measure levels of serum glucose, total cholesterol, creatinine, alanine aminotransferase, and triglycerides. We included candidates with values within the reference range. Exclusion criteria were smoking; use of antioxidant supplements, aspirin, or drugs with established antioxidant properties; hyperlipidemia; obesity; diabetes; hypertension; intestinal disease; or any other disease or condition that would impair adherence. We excluded women to avoid the possible interference of estrogens, which are considered to be potential antioxidants (17). All participants provided written informed consent, and the local institutional ethics committees approved the protocol. Figure 1. Study flow diagram. Sequence of olive oil administration: 1) high-, medium-, and low-polyphenol olive oil; 2) medium-, low-, and high-polyphenol olive oil; and 3) low-, high-, and medium-polyphenol olive oil. Design and Study Procedure The trial was a randomized, crossover, controlled study. We randomly assigned participants consecutively to 1 of 3 sequences of olive oil administration. Participants received a daily dose of 25 mL (22 g) of 3 olive oils with high (366 mg/kg), medium (164 mg/kg), and low (2.7 mg/kg) polyphenol content (Figure 1) in replacement of other raw fats. Sequences were high-, medium-, and low-polyphenol olive oil (sequence 1); medium-, low-, and high-polyphenol olive oil (sequence 2); and low-, high-, and medium-polyphenol olive oil (sequence 3). In the coordinating center, we prepared random allocation to each sequence, taken from a Latin square, for each center by blocks of 42 participants (14 persons in each sequence), using specific software that was developed at the Municipal Institute for Medical Research, Barcelona, Spain (Aleator, Municipal Institute for Medical Research). The random allocation was faxed to the participating centers upon request for each individual included in the study. Treatment containers were assigned a code number that was concealed from participants and investigators, and the coordinating center disclosed the code number only after completion of statistical analyses. Olive oils were specially prepared for the trial. We selected a virgin olive oil with high natural phenolic content (366 mg/kg) and measured its fatty acid and vitamin E composition. We tested refined olive oil harvested from the same cultivar and soil to find an olive oil with similar quantities of fatty acid and a similar micronutrient profile. Vitamin E was adjusted to values similar to those of the selected virgin olive oil. Because phenolic compounds are lost in the refinement process, the refined olive oil had a low phenolic content (2.7 mg/kg). By mixing virgin and refined olive oil, we obtained an olive oil with an intermediate phenolic content (164 mg/kg). Olive oils did not differ in fat and micronutrient composition (that is, vitamin E, triterpenes, and sitosterols), with the exception of phenolic content. Three-week interventions were preceded by 2-week washout periods, in which we requested that participants avoid olive and olive oil consumption. We chose the 2-week washout period to reach the equilibrium in the plasma lipid profile because longer intervention periods with fat-rich diets did not modify the lipid concentrations (18). Daily doses of 25 mL of olive oil were blindly prepared in containers delivered to the participants at the beginning of each intervention period. We instructed participants to return the 21 containers at the end of each intervention period so that the daily amount of unconsumed olive oil could be registered. Dietary Adherence We measured tyrosol and hydroxytyrosol, the 2 major phenolic compounds in olive oil as simple forms or conjugates (7), by gas chromatography and mass spectrometry in 24-hour urine before and after each intervention period as biomarkers of adherence to the type of olive oil ingested. We asked participants to keep a 3-day dietary record at baseline and after each intervention period. We requested that participants in all centers avoid a high intake of foods that contain antioxidants (that is, vegetables, legumes, fruits, tea, coffee, chocolate, wine, and beer). A nutritionist also personally advised participants to replace all types of habitually consumed raw fats with the olive oils (for example, spread the assigned olive oil on bread instead of butter, put the assigned olive oil on boiled vegetables instead of margarine, and use the assigned olive oil on salads instead of other vegetable oils or standard salad dressings). Data Collection Main outcome measures were changes in biomarkers of oxidative damage to lipids. Secondary outcomes were changes in lipid levels and in biomarkers of the antioxidant status of the participants. We assessed outcome measures at the beginning of the study (baseline) and before (preintervention) and after (postintervention) each olive oil intervention period. We collected blood samples at fasting state together with 24-hour urine and recorded anthropometric variables. We measured blood pressure with a mercury sphygmomanometer after at least a 10-minute rest in the seated position. We recorded physical activity at baseline and at the end of the study and assessed it by using the Minnesota Leisure Time Physical Activity Questionnaire (19). We measured 1) glucose and lipid profile, including serum glucose, total cholesterol, high-density lipoprotein (HDL) cholesterol, and triglyceride levels determined by enzymatic methods (2023) and LDL cholesterol levels calculated by the Friedewald formula; 2) oxidative damage to lipids, including plasma-circulating oxidized LDL measured by enzyme immunoassay, plasma total F2-isoprostanes determined by using high-performance liquid chromatography and stable isotope-dilution and mass spectrometry, plasma C18 hydroxy fatty acids measured by gas chromatography and mass spectrometry, and serum LDL cholesterol uninduced conjugated dienes measured by spectrophotometry and adjusted for the cholesterol concentration in LDL cholesterol levels; 3) antioxidant sta

Intake of Mercury From Fish, Lipid Peroxidation, and the Risk of Myocardial Infarction and Coronary, Cardiovascular, and Any Death in Eastern Finnish Men

BACKGROUND Even though previous studies have suggested an association between high fish intake and reduced coronary heart disease (CHD) mortality, men in Eastern Finland, who have a high fish intake, have an exceptionally high CHD mortality. We hypothesized that this paradox could be in part explained by high mercury content in fish. METHODS AND RESULTS We studied the relation of the dietary intake of fish and mercury, as well as hair content and urinary excretion of mercury, to the risk of acute myocardial infarction (AMI) and death from CHD, cardiovascular disease (CVD), and any cause in 1833 men aged 42 to 60 years who were free of clinical CHD, stroke, claudication, and cancer. Of these, 73 experienced an AMI in 2 to 7 years. Of the 78 decreased men, 18 died of CHD and 24 died of CVD. Men who had consumed local nonfatty fish species had elevated hair mercury contents. In Cox models with the major cardiovascular risk factors as covariates, dietary intakes of fish and mercury were associated with significantly increased risk of AMI and death from CHD, CVD, and any death. Men in the highest tertile (> or = 2.0 micrograms/g) of hair mercury content had a 2.0-fold (95% confidence interval, 1.2 to 3.1; P = .005) age- and CHD-adjusted risk of AMI and a 2.9-fold (95% CI, 1.2 to 6.6; P = .014) adjusted risk of cardiovascular death compared with those with a lower hair mercury content. In a nested case-control subsample, the 24-hour urinary mercury excretion had a significant (P = .042) independent association with the risk of AMI. Both the hair and urinary mercury associated significantly with titers of immune complexes containing oxidized LDL. CONCLUSIONS These data suggest that a high intake of mercury from nonfatty freshwater fish and the consequent accumulation of mercury in the body are associated with an excess risk of AMI as well as death from CHD, CVD, and any cause in Eastern Finnish men and this increased risk may be due to the promotion of lipid peroxidation by mercury.

Six-Year Effect of Combined Vitamin C and E Supplementation on Atherosclerotic Progression The Antioxidant Supplementation in Atherosclerosis Prevention (ASAP) Study

Background—Self-selected supplementation of vitamin E has been associated with reduced coronary events and atherosclerotic progression, but the evidence from clinical trials is controversial. In the first 3 years of the ASAP trial, the supplementation with 136 IU of vitamin E plus 250 mg of slow-release vitamin C twice daily slowed down the progression of carotid atherosclerosis in men but not women. This article examines the 6-year effect of supplementation on common carotid artery (CCA) intima-media thickness (IMT). Methods and Results—The subjects were 520 smoking and nonsmoking men and postmenopausal women aged 45 to 69 years with serum cholesterol ≥5.0 mmol/L (193 mg/dL), 440 (84.6%) of whom completed the study. Atherosclerotic progression was assessed ultrasonographically. In covariance analysis in both sexes, supplementation reduced the main study outcome, the slope of mean CCA-IMT, by 26% (95% CI, 5 to 46, P =0.014), in men by 33% (95% CI, 4 to 62, P =0.024) and in women by 14% (not significant). In both sexes combined, the average annual increase of the mean CCA-IMT was 0.014 mm in the unsupplemented and 0.010 mm in the supplemented group (25% treatment effect, 95% CI, 2 to 49, P =0.034). In men, this treatment effect was 37% (95 CI, 4 to 69, P =0.028). The effect was larger in subjects with either low baseline plasma vitamin C levels or CCA plaques. Vitamin E had no effect on HDL cholesterol. Conclusions—These data replicate our 3-year findings confirming that the supplementation with combination of vitamin E and slow-release vitamin C slows down atherosclerotic progression in hypercholesterolemic persons.

Fish Oil–Derived Fatty Acids, Docosahexaenoic Acid and Docosapentaenoic Acid, and the Risk of Acute Coronary Events The Kuopio Ischaemic Heart Disease Risk Factor Study

BackgroundPrevious findings concerning the serum levels of fish-derived (n-3) fatty acids and coronary heart disease are inconsistent. The purpose of this study was to investigate the association between the serum n-3 end-product fatty acids docosahexaenoic acid (DHA), docosapentaenoic acid (DPA), and eicosapentaenoic acid and the risk of acute coronary events in middle-aged men. Methods and ResultsWe studied this association in the Kuopio Ischaemic Heart Disease Risk Factor Study, a prospective population study in Eastern Finland. Subjects were randomly selected and included 1871 men aged 42 to 60 years who had no clinical coronary heart disease at baseline examination. A total of 194 men had a fatal or nonfatal acute coronary event during follow-up. In a Cox proportional hazards’ model adjusting for other risk factors, men in the highest fifth of the proportion of serum DHA+DPA in all fatty acids had a 44% reduced risk (P=0.014) of acute coronary events compared with men in the lowest fifth. Men in the highest fifth of DHA+DPA who had a low hair content of mercury (≤2.0 &mgr;g/g) had a 67% reduced risk (P=0.016) of acute coronary events compared with men in the lowest fifth who had a high hair content of mercury (>2.0 &mgr;g/g). There was no association between proportion of eicosapentaenoic acid and the risk of acute coronary events. ConclusionsOur data provide further confirmation for the concept that fish oil–derived fatty acids reduce the risk of acute coronary events. However, a high mercury content in fish could attenuate this protective effect.

Body iron stores are associated with serum insulin and blood glucose concentrations. Population study in 1, 013 eastern Finnish men

OBJECTIVE To study if there is an association between mildly elevated body iron and glucose homeostasis indexes. RESEARCH DESIGN AND METHODS A cross-sectional population study was conducted in 1,013 middle-aged men, and an association of serum ferritin with concentrations of serum insulin, blood glucose, and serum fructosamine was tested. RESULTS The mean concentration of fasting serum insulin was 21.6% higher (95% CI 7.3–37.9%, P < 0.001) in the 5th quintile of serum ferritin compared with the 1st quintile. The elevation in blood glucose was 6.1% (95% CI 2.3–9.9%, P < 0.001) and in serum fructosamine 3.9% (1.5–6.9%, P < 0.01). CONCLUSIONS Mildly elevated body iron stores are associated with statistically significant elevations in glucose homeostasis indexes.

Association Between Body Iron Stores and the Risk of Acute Myocardial Infarction in Men

BACKGROUND Epidemiological evidence concerning the role of iron, a lipid peroxidation catalyst, in coronary heart disease (CHD) is inconsistent. We investigated the association of the concentration ratio of serum transferrin receptor to serum ferritin (TfR/ferritin), a state-of-the-art measurement of body iron stores, with the risk of acute myocardial infarction (AMI) in a prospective nested case-control study in men from eastern Finland. METHODS AND RESULTS Transferrin receptor assays were carried out for 99 men who had an AMI during an average 6.4 years of follow-up and 98 control men. Both the cases and the controls were nested from the Kuopio Ischemic Heart Disease Risk Factor Study (KIHD) cohort of 1931 men who had no clinical CHD at the baseline study. The controls were matched for age, examination year, and residence. AMIs were registered prospectively. Soluble transferrin receptors were measured by immunoenzymometric assay and ferritin concentration by radioimmunoassay from frozen baseline serum samples. The mean TfR/ferritin ratio was 15.1 (SE, 2.0) among cases and 21.3 (SE, 2.2) among controls (P=.035 for difference). In logistic regression models adjusting for other strongest risk factors for AMI and indicators of inflammation and alcohol intake, men in the lowest and second lowest thirds of the TfR/ferritin ratio had a 2.9-fold (95% CI, 1.3 to 6.6, P=.011) and 2.0-fold (0.9 to 4.2, P=.081) risk of AMI compared with men in the highest third (P=.010 for trend). CONCLUSIONS These data show an association between increased body iron stores and excess risk of AMI, confirming previous epidemiological findings.

Vitamin C deficiency and risk of myocardial infarction: prospective population study of men from eastern Finland.

Abstract Objective: To examine the association between plasma vitamin C concentrations and the risk of acute myocardial infarction. Design: Prospective population study. Setting: Eastern Finland. Subjects: 1605 randomly selected men aged 42, 48, 54, or 60 who did not have either symptomatic coronary heart disease or ischaemia on exercise testing at entry to the Kuopio ischaemic heart disease risk factor study in between 1984 and 1989. Main outcome measures: Number of acute myocardial infarctions; fasting plasma vitamin C concentrations at baseline. Results: 70 of the men had a fatal or non-fatal myocardial infarction between March 1984 and December 1992. 91 men had vitamin C deficiency (plasma ascorbate <11.4 µmol/l, or 2.0 mg/l), of whom 12 (13.2%) had a myocardial infarction; 1514 men were not deficient in vitamin C, of whom 58 (3.8%) had a myocardial infarction. In a Cox proportional hazards model adjusted for age, year of examination, and season of the year examined (August to Octoberv rest of the year) men who had vitamin C deficiency had a relative risk of acute myocardial infarction of 3.5 (95% confidence interval 1.8 to 6.7, P = 0.0002) compared with those who were not deficient. In another model adjusted additionally for the strongest risk factors for myocardial infarction and for dietary intakes of tea, fibre, carotene, and saturated fats men with a plasma ascorbate concentration <11.4 µmol/l had a relative risk of 2.5 (1.3 to 5.2, P = 0.0095) compared with men with higher plasma vitamin C concentrations. Conclusion: Vitamin C deficiency, as assessed by low plasma ascorbate concentration, is a risk factor for coronary heart disease. Key messages This study shows that vitamin C deficiency may be associated with an increased risk of myocardial infarction The findings also provide additional support for the role of oxidative stress and lipid peroxidation in coronary heart disease Although deficiency in vitamin C may increase coronary risk, this study does not provide evidence in favour of the benefit of vitamin C supplements

Increased Risk of Acute Myocardial Infarction in Carriers of the Hemochromatosis Gene Cys282Tyr Mutation: A Prospective Cohort Study in Men in Eastern Finland

Background-Homozygosity for a relatively common Cys282Tyr mutation of the human hemochromatosis-associated (HFE) gene was recently found to account for most cases of hereditary hemochromatosis. Because excess iron has been postulated to enhance risk of vascular disease, we studied whether occurrence of this mutation was associated with increased risk of first acute myocardial infarction in healthy middle-aged men in a prospective cohort study. Methods and Results-Study subjects were the 1150 participants in the population-based Kuopio Ischemic Heart Disease Risk Factor Study (KIHD), aged 42, 48, 54, or 60 years at baseline, who had no coronary heart disease at baseline and for whom a DNA sample was available. Information about myocardial infarctions was collected prospectively by use of FINMONICA (FINnish MONItoring of trends and determinants in CArdiovascular disease study) and hospital data. Events were classified by MONICA (MONItoring of trends and determinants in CArdiovascular disease study) diagnostic criteria. The HFE Cys282Tyr mutation was assayed by a solid-phase minisequencing technique. One subject was homozygous and 76 individuals were heterozygous for the HFE Cys282Tyr mutation (6.7%). During a mean follow-up of 9 years, 8 (10.4%) of 77 carriers and 60 (5.6%) of 1073 noncarriers experienced an acute myocardial infarction. In a Cox proportional hazards model allowing for the other strongest risk factors, the carriers had a 2.3-fold (95% CI 1. 1 to 4.8; P=0.03) risk of acute myocardial infarction compared with noncarriers. Conclusions-Male carriers of the common hemochromatosis gene mutation are at 2-fold risk for first acute myocardial infarction compared with noncarriers.