Mahboob Rahman

A Randomized Trial of Intensive versus Standard Blood-Pressure Control.

BACKGROUND The most appropriate targets for systolic blood pressure to reduce cardiovascular morbidity and mortality among persons without diabetes remain uncertain. METHODS We randomly assigned 9361 persons with a systolic blood pressure of 130 mm Hg or higher and an increased cardiovascular risk, but without diabetes, to a systolic blood-pressure target of less than 120 mm Hg (intensive treatment) or a target of less than 140 mm Hg (standard treatment). The primary composite outcome was myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. RESULTS At 1 year, the mean systolic blood pressure was 121.4 mm Hg in the intensive-treatment group and 136.2 mm Hg in the standard-treatment group. The intervention was stopped early after a median follow-up of 3.26 years owing to a significantly lower rate of the primary composite outcome in the intensive-treatment group than in the standard-treatment group (1.65% per year vs. 2.19% per year; hazard ratio with intensive treatment, 0.75; 95% confidence interval [CI], 0.64 to 0.89; P<0.001). All-cause mortality was also significantly lower in the intensive-treatment group (hazard ratio, 0.73; 95% CI, 0.60 to 0.90; P=0.003). Rates of serious adverse events of hypotension, syncope, electrolyte abnormalities, and acute kidney injury or failure, but not of injurious falls, were higher in the intensive-treatment group than in the standard-treatment group. CONCLUSIONS Among patients at high risk for cardiovascular events but without diabetes, targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, resulted in lower rates of fatal and nonfatal major cardiovascular events and death from any cause, although significantly higher rates of some adverse events were observed in the intensive-treatment group. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01206062.).

Evaluation of the Modification of Diet in Renal Disease Study Equation in a Large Diverse Population

Glomerular filtration rate (GFR) estimates facilitate detection of chronic kidney disease. Performance of the Modification of Diet in Renal Disease (MDRD) Study equation varies substantially among populations. To describe the performance of the equation in a large, diverse population, estimated GFR (eGFR) was compared to measured GFR (mGFR) in a cross-sectional analysis of 5504 participants in 10 studies that included measurements of standardized serum creatinine and urinary clearance of iothalamate. At eGFR <60 ml/min per 1.73 m(2), the MDRD Study equation had lower bias and higher precision than at eGFR > or =60 ml/min per 1.73 m(2). The accuracy of the equation, measured by the percent of estimates that fell within 30% of mGFR, was similar for eGFR values above or below 60 ml/min per 1.73 m(2) (82% and 84%, respectively). Differences in performance among subgroups defined by age, sex, race, diabetes, transplant status, and body mass index were small when eGFR was <60 ml/min per 1.73 m(2). The MDRD Study equation therefore provides unbiased and reasonably accurate estimates across a wide range of subgroups when eGFR is <60 ml/min per 1.73 m(2). In individual patients, interpretation of GFR estimates near 60 ml/min per 1.73 m(2) should be interpreted with caution to avoid misclassification of chronic kidney disease in the context of the clinical setting.

Golimumab, a human antibody to tumour necrosis factor α given by monthly subcutaneous injections, in active rheumatoid arthritis despite methotrexate therapy: the GO-FORWARD Study

Objective: The phase III GO-FORWARD study examined the efficacy and safety of golimumab in patients with active rheumatoid arthritis (RA) despite methotrexate therapy. Methods: Patients were randomly assigned in a 3 : 3 : 2 : 2 ratio to receive placebo injections plus methotrexate capsules (group 1, n  =  133), golimumab 100 mg injections plus placebo capsules (group 2, n  =  133), golimumab 50 mg injections plus methotrexate capsules (group 3, n  =  89), or golimumab 100 mg injections plus methotrexate capsules (group 4, n  =  89). Injections were administered subcutaneously every 4 weeks. The co-primary endpoints were the proportion of patients with 20% or greater improvement in the American College of Rheumatology criteria (ACR20) at week 14 and the change from baseline in the health assessment questionnaire-disability index (HAQ-DI) score at week 24. Results: The proportion of patients who achieved an ACR20 response at week 14 was 33.1% in the placebo plus methotrexate group, 44.4% (p = 0.059) in the golimumab 100 mg plus placebo group, 55.1% (p = 0.001) in the golimumab 50 mg plus methotrexate group and 56.2% (p<0.001) in the golimumab 100 mg plus methotrexate group. At week 24, median improvements from baseline in HAQ-DI scores were 0.13, 0.13 (p = 0.240), 0.38 (p<0.001) and 0.50 (p<0.001), respectively. During the placebo-controlled portion of the study (to week 16), serious adverse events occurred in 2.3%, 3.8%, 5.6% and 9.0% of patients and serious infections occurred in 0.8%, 0.8%, 2.2% and 5.6%, respectively. Conclusion: The addition of golimumab to methotrexate in patients with active RA despite methotrexate therapy significantly reduced the signs and symptoms of RA and improved physical function.

Golimumab in patients with active rheumatoid arthritis after treatment with tumour necrosis factor α inhibitors (GO-AFTER study): a multicentre, randomised, double-blind, placebo-controlled, phase III trial

BACKGROUND Tumour necrosis factor alpha (TNFalpha) inhibitors are frequently used to treat rheumatoid arthritis, but whether use of a different TNFalpha inhibitor can improve patient response is unknown. We assess the efficacy and safety of the TNFalpha inhibitor golimumab in patients with active rheumatoid arthritis who had previously received one or more TNFalpha inhibitors. METHODS 461 patients with active rheumatoid arthritis from 82 sites in 10 countries were randomly allocated by interactive voice response system, stratified by study site and methotrexate use, to receive subcutaneous injections of placebo (n=155), 50 mg golimumab (n=153), or 100 mg golimumab (n=153) every 4 weeks between Feb 21, 2006, and Sept 26, 2007. Allocation was double-blind. Eligible patients had been treated with at least one dose of a TNFalpha inhibitor previously. Patients continued stable doses of methotrexate, sulfasalazine, hydroxychloroquine, oral corticosteroids, and non-steroidal anti-inflammatory drugs. The primary endpoint was achievement at week 14 of 20% or higher improvement in American College of Rheumatology criteria for assessment of rheumatoid arthritis (ACR20). At week 16, patients who had less than 20% improvement in tender and swollen joint counts were given rescue therapy and changed treatment from placebo to 50 mg golimumab, or from 50 mg to 100 mg golimumab. Drug efficacy was assessed by intention to treat and safety was assessed according to the study drug given. This study is registered with ClinicalTrials.gov, number NCT00299546. FINDINGS Patients had discontinued previous TNFalpha inhibitors because of lack of effectiveness (269 [58%] patients) or reasons unrelated to effectiveness (246 [53%] patients), such as intolerance and accessibility issues. Patients had active disease, which was indicated by a median of 14.0 (IQR 9.0-22.0) swollen and 26.0 (16.0-41.0) tender joints for the whole group. 28 (18%) patients on placebo, 54 (35%) patients on 50 mg golimumab (odds ratio 2.5 [95% CI 1.5-4.2], p=0.0006), and 58 (38%) patients on 100 mg golimumab (2.8 [1.6-4.7], p=0.0001) achieved ACR20 at week 14. Two patients were never treated, and 57 patients did not complete the study because of adverse events, unsatisfactory treatment effect, loss to follow-up, death, or other reasons. 155 patients on placebo, 153 on 50 mg golimumab, and 153 on 100 mg golimumab were assessed for drug efficacy. For weeks 1-16, serious adverse events were recorded in 11 (7%) patients on placebo, 8 (5%) on 50 mg golimumab, and 4 (3%) on 100 mg golimumab. For weeks 1-24, after some patients were given rescue therapy, serious adverse events were recorded in 15 (10%) patients on placebo, 14 (5%) on 50 mg golimumab, and 8 (4%) on 100 mg golimumab. INTERPRETATION Golimumab reduced the signs and symptoms of rheumatoid arthritis in patients with active disease who had previously received one or more TNFalpha inhibitors. FUNDING Centocor Research and Development and Schering-Plough Research Institute.

Infliximab for Maintenance of Glucocorticosteroid-Induced Remission of Giant Cell Arteritis: A Randomized Trial

Context Up to 80% of patients with giant cell arteritis (GCA) experience complications related to glucocorticoid therapy. Case reports suggest that patients with GCA who received infliximab achieved sustained disease remission and independence from glucocorticoids. Contribution Patients with glucocorticoid-induced GCA remission were randomly assigned to infusions of infliximab, 5 mg/kg, or placebo at 0, 2, and 6 weeks and every 8 weeks thereafter. The investigators found that infliximab did not reduce rates of relapse or any secondary end point. Caution The study was small and stopped early (after week 22 of the planned 54 weeks), so it could not definitively identify harms or small benefits. Implication Infliximab is unlikely to cause large reductions in rates of relapse of GCA. The Editors In northern Europe and North America, the estimated annual incidence of giant cell arteritis is 19 to 32 cases per 100000 persons older than 50 years of age. In Mediterranean countries, the annual incidence appears to be lower: 6 to 10 cases per 100000 persons (15). Treatment with glucocorticosteroids dramatically alters the symptoms and course of giant cell arteritis, reducing the likelihood that the patient will develop blindness (6, 7). However, relapses usually occur when glucocorticosteroid dosages are tapered, resulting in frequent re-treatment and glucocorticosteroid dependence and toxicity (810). Approximately 80% of patients with giant cell arteritis will eventually experience at least 1 adverse event attributable to glucocorticosteroids, and about 60% will have 2 or more adverse events. Compared with age- and sex-matched controls, patients with giant cell arteritis have an increased risk for fractures and corticosteroid-related cataracts (9). Adjunctive treatments are needed that would effectively reduce the dose and duration of glucocorticosteroid therapy and provide more durable remissions of giant cell arteritis. Other investigators have evaluated the utility of cytotoxic and anti-inflammatory agents in giant cell arteritis. However, the reports have been anecdotal, of uncontrolled studies, or of controlled studies with conflicting results in terms of efficacy (11, 12). Increased knowledge of cell types and mediators within vessels damaged by giant cell arteritis has led to speculation about the potential therapeutic role of several cytokine antagonists. Interleukin-1, interleukin-6, tumor necrosis factor (TNF), and interferon- have been implicated in contributing to vascular injury in patients with giant cell arteritis (1316). Published case studies reported that some patients with giant cell arteritis or polymyalgia rheumatica who received the antiTNF- agent infliximab had sustained remission and became glucocorticosteroid-independent (17, 18). However, the investigators cautioned that randomized, controlled studies were needed to validate these results. We report the results of the first randomized, placebo-controlled, double-blind, multicenter trial of standardized treatment with glucocorticosteroids and adjunctive treatment with placebo or infliximab in patients with newly diagnosed giant cell arteritis. Methods Design We designed a multicenter, randomized, double-blind, placebo-controlled study to determine whether infliximab added to a standardized program of glucocorticosteroid therapy (equivalent daily doses of prednisone or prednisolone) in patients with newly diagnosed giant cell arteritis would decrease the frequency of relapse, cumulative glucocorticosteroid requirement, and glucocorticosteroid-associated toxicity. The study protocol was approved by the institutional review boards or ethics committees of the individual study sites. The study was conducted according to the current regulations of the U.S. Food and Drug Administration, the International Conference on Harmonization guidelines, and the principles of the Declaration of Helsinki. All patients provided written informed consent before participating in any protocol-specific procedures. An independent safety monitoring committee reviewed safety information during the trial. The first patient was enrolled on 22 October 2003, and the last patient completed the study on 29 July 2005. The primary objective was to obtain preliminary evidence on the safety and efficacy of infliximab therapy in patients with glucocorticoid-induced remission of newly diagnosed giant cell arteritis, as measured by the proportion of patients who were relapse-free through week 22 and the incidence of adverse events. The secondary objective was to further evaluate the preliminary evidence of the efficacy of infliximab therapy, as measured by the proportion of patients who remained relapse-free through week 54, time to first relapse, levels of biochemical markers of inflammation and disease activity, and cumulative dose of glucocorticosteroids. Setting The study was conducted at 22 sites in the United States, United Kingdom, Belgium, Italy, and Spain. Participants To be eligible for the study, patients must have had a diagnosis of giant cell arteritis within 4 weeks of enrollment, satisfied the American College of Rheumatology criteria for giant cell arteritis (19), had an erythrocyte sedimentation rate 40 mm or greater in the first hour at the time of diagnosis, and achieved clinical remission before randomization. For at least 1 week before randomization, patients were required to be receiving prednisone or prednisolone at a stable dosage of 40 to 60 mg/d, have a normal erythrocyte sedimentation rate (<40 mm in the first hour, as determined by using the Westergren method), and have no symptoms or signs of active giant cell arteritis. Patients were excluded if they had received a diagnosis of giant cell arteritis or polymyalgia rheumatica more than 4 weeks before screening, did not respond to glucocorticosteroid therapy within 5 days of initiation of therapy, received intravenous glucocorticosteroid therapy with an equivalent dose of methylprednisolone (>1000 mg/d for >3 days), or received other forms of immunosuppressive therapy (such as methotrexate, azathioprine, or other cytotoxic agents) or any investigational or biological agents within the 3 months before screening. Patients with screening blood test results within the following ranges were also excluded: leukocyte count less than 3.5109 cells/L, neutrophil count less than 1.5109 cells/L, hemoglobin level less than 85 g/L, platelet count less than 100109 cells/L, or hepatic aminotransferase or alkaline phosphatase levels greater than 3 times the upper limit of normal. We excluded patients with serious or chronic infections in the previous 3 months; opportunistic infections within the 6 months before screening; cancer within the 5 years before screening (with the exception of treated and cured squamous or basal cell carcinoma of the skin); a history of severe congestive heart failure or demyelinating disease; current signs or symptoms of severe, progressive, or uncontrolled renal, hepatic, hematologic, gastrointestinal, endocrine, pulmonary, cardiac, neurologic, or cerebral disease; a transplanted organ (with the exception of corneal transplantation done more than 3 months before screening); or evidence of active or previous tuberculosis. Randomization and Intervention Patients were randomly assigned in a 2:1 ratio to receive infliximab, 5 mg/kg, or placebo by using adaptive treatment allocation (20, 21) stratified by baseline glucocorticosteroid dosage (40 to 50 mg/d or 51 to 60 mg/d prednisone equivalent). Patients received infusions at weeks 0, 2, and 6 and every 8 weeks thereafter. Allocation to treatment group was performed by using a central randomization procedure through an interactive voice response system. Patients, investigators, and study personnel were blinded to treatment assignments during the study; the site pharmacists, who prepared study medication, were not blinded to this information. Infliximab and placebo were supplied as sterile, white, lyophilized powders that were reconstituted with sterile water for injection. The reconstituted placebo solution contained the same excipients as the infliximab solution but did not contain infliximab. Glucocorticosteroid dosages were tapered according to a predefined schedule (Table 1). Each week, the daily dose of prednisone or prednisolone was decreased by 10 mg until the dosage reached 20 mg/d. It was then tapered by 2.5 mg until it reached 10 mg/d and then by 1 mg until the dosage was 0 mg/d. In the absence of a relapse, this schedule results in a glucocorticosteroid dosage of 10 mg/d after 4 months and no glucocorticosteroid use after 6 months. If a relapse occurred, the patient was to resume treatment with the previous higher dose of prednisone or prednisolone that provided disease remission, plus 10 mg/d. If the relapse resolved within 72 hours, the patient was to continue receiving that dosage for 2 weeks and then resume tapering according to the protocol. If relapse did not resolve within 72 hours, the patient was to receive another increase of 10 mg and resume treatment according to the protocol. Table 1. Schedule of Dosage Tapering for Glucocorticosteroid Therapy* If relapse included visual symptoms, the patient was to receive at least 40 mg/d or the previous higher dosage of prednisone or prednisolone, plus 10 mg (whichever was higher). If the visual symptoms improved within 48 hours, the patient was to resume tapering according to the protocol above. If the visual symptoms did not resolve within 48 hours, the patients vision was threatened, or there was concern about any other catastrophic event, the investigator was to take any measures necessary according to clinical judgment to treat the patient, including but not limited to increasing the glucocorticosteroid dosage to more than 60 mg/d. If a patient received more than 60 mg of oral prednisone or prednisolone daily or more than 1000 mg of intravenous glucocorticosteroid daily for more than

The Chronic Renal Insufficiency Cohort (CRIC) Study: Design and Methods

Insights into end-stage renal disease have emerged from many investigations but less is known about the epidemiology of chronic renal insufficiency (CRI) and its relationship to cardiovascular disease (CVD). The Chronic Renal Insufficiency Cohort (CRIC) Study was established to examine risk factors for progression of CRI and CVD among CRI patients and develop models to identify high-risk subgroups, informing future treatment trials, and increasing application of preventive therapies. CRIC will enroll approximately 3000 individuals at seven sites and follow participants for up to 5 yr. CRIC will include a racially and ethnically diverse group of adults aged 21 to 74 yr with a broad spectrum of renal disease severity, half of whom have diagnosed diabetes mellitus. CRIC will exclude subjects with polycystic kidney disease and those on active immunosuppression for glomerulonephritis. Subjects will undergo extensive clinical evaluation at baseline and at annual clinic visits and via telephone at 6 mo intervals. Data on quality of life, dietary assessment, physical activity, health behaviors, depression, cognitive function, health care resource utilization, as well as blood and urine specimens will be collected annually. (125)I-iothalamate clearances and CVD evaluations including a 12-lead surface electrocardiogram, an echocardiogram, and coronary electron beam or spiral CT will be performed serially. Analyses planned in CRIC will provide important information on potential risk factors for progressive CRI and CVD. Insights from CRIC should lead to the formulation of hypotheses regarding therapy that will serve as the basis for targeted interventional trials focused on reducing the burden of CRI and CVD.

Golimumab, a human anti–tumor necrosis factor α monoclonal antibody, injected subcutaneously every four weeks in methotrexate‐naive patients with active rheumatoid arthritis: Twenty‐four–week results of a phase III, multicenter, randomized, double‐blind, placebo‐controlled study of golimumab before methotrexate as first‐line therapy for early‐onset rheumatoid arthritis

OBJECTIVE To assess the safety and efficacy of golimumab in methotrexate (MTX)-naive patients with active rheumatoid arthritis (RA). METHODS MTX-naive patients with RA (n = 637) were randomized to receive placebo plus MTX (group 1), golimumab 100 mg plus placebo (group 2), golimumab 50 mg plus MTX (group 3), or golimumab 100 mg plus MTX (group 4). Subcutaneous injections of golimumab or placebo were administered every 4 weeks. The dosage of MTX/placebo capsules started at 10 mg/week and escalated to 20 mg/week. The primary end point, the proportion of patients meeting the American College of Rheumatology 50% improvement criteria (achieving an ACR50 response) at week 24, required significant differences between groups 3 and 4 combined (combined group) versus group 1 and significant differences in a pairwise comparison (group 3 or group 4 versus group 1). RESULTS An intent-to-treat (ITT) analysis of the ACR50 response at week 24 did not show a significant difference between the combined group and group 1 (38.4% and 29.4%, respectively; P=0.053), while a post hoc modified ITT analysis (excluding 3 untreated patients) of the ACR50 response showed statistically significant differences between the combined group and group 1 (38.5% versus 29.4%; P=0.049) and between group 3 (40.5%; P=0.038) but not group 4 (36.5%; P=0.177) and group 1. Group 2 was noninferior to group 1 for the ACR50 response at week 24 (33.1%; 95% confidence interval lower bound -5.2%; predefined delta value for noninferiority -10%). The combination of golimumab plus MTX demonstrated a significantly better response compared with placebo plus MTX in most other efficacy parameters, including response/remission according to the Disease Activity Score in 28 joints. Serious adverse events occurred in 7%, 3%, 6%, and 6% of patients in groups 1, 2, 3, and 4, respectively. CONCLUSION Although the primary end point was not met, the modified ITT analysis of the primary end point and other prespecified efficacy measures demonstrated that the efficacy of golimumab plus MTX is better than, and the efficacy of golimumab alone is similar to, the efficacy of MTX alone in reducing RA signs and symptoms in MTX-naive patients, with no unexpected safety concerns.

Chronic Renal Insufficiency Cohort (CRIC) Study: Baseline Characteristics and Associations with Kidney Function

BACKGROUND AND OBJECTIVES The Chronic Renal Insufficiency Cohort (CRIC) Study was established to examine risk factors for the progression of chronic kidney disease (CKD) and cardiovascular disease (CVD) in patients with CKD. We examined baseline demographic and clinical characteristics. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Seven clinical centers recruited adults who were aged 21 to 74 yr and had CKD using age-based estimated GFR (eGFR) inclusion criteria. At baseline, blood and urine specimens were collected and information regarding health behaviors, diet, quality of life, and functional status was obtained. GFR was measured using radiolabeled iothalamate in one third of participants. RESULTS A total of 3612 participants were enrolled with mean age +/- SD of 58.2 +/- 11.0 yr; 46% were women, and 47% had diabetes. Overall, 45% were non-Hispanic white, 46% were non-Hispanic black, and 5% were Hispanic. Eighty-six percent reported hypertension, 22% coronary disease, and 10% heart failure. Mean body mass index was 32.1 +/- 7.9 kg/m(2), and 47% had a BP >130/80 mmHg. Mean eGFR was 43.4 +/- 13.5 ml/min per 1.73 m(2), and median (interquartile range) protein excretion was 0.17 g/24 h (0.07 to 0.81 g/24 h). Lower eGFR was associated with older age, lower socioeconomic and educational level, cigarette smoking, self-reported CVD, peripheral arterial disease, and elevated BP. CONCLUSIONS Lower level of eGFR was associated with a greater burden of CVD as well as lower socioeconomic and educational status. Long-term follow-up of participants will provide critical insights into the epidemiology of CKD and its relationship to adverse outcomes.

Golimumab in patients with active rheumatoid arthritis despite treatment with methotrexate: a randomized, double-blind, placebo-controlled, dose-ranging study

OBJECTIVE To assess the efficacy, safety, and pharmacology of subcutaneous administration of golimumab in patients with active rheumatoid arthritis (RA) despite treatment with methotrexate (MTX). METHODS Patients were randomly assigned in a double-blinded manner to receive injections of placebo plus MTX or 50 mg or 100 mg golimumab every 2 or 4 weeks plus MTX through week 48. Patients originally assigned to receive injections every 2 weeks had the interval increased to every 4 weeks starting at week 20. The primary end point was the proportion of patients meeting the American College of Rheumatology 20% improvement criteria (achieving an ACR20 response) at week 16. The study was powered to detect a difference in the primary end point when the combined golimumab groups and at least 1 of the individual dose groups were compared with placebo. RESULTS The primary end point was attained. Sixty-one percent of patients in the combined golimumab plus MTX dose groups achieved an ACR20 response at week 16 compared with 37% of patients in the placebo plus MTX group (P=0.010). In addition, 79% of patients in the group receiving 100 mg golimumab every 2 weeks achieved an ACR20 response (P<0.001 versus placebo). Through week 20 (after which patients receiving placebo were switched to active infliximab therapy), serious adverse events were reported in 9% of patients in the combined golimumab groups and in 6% of patients in the placebo group. CONCLUSION Golimumab plus MTX effectively reduces the signs and symptoms of RA and is generally well tolerated in patients with an inadequate response to MTX.

Fibroblast growth factor 23 is not associated with and does not induce arterial calcification

Elevated fibroblast growth factor 23 (FGF23) is associated with cardiovascular disease in patients with chronic kidney disease. As a potential mediating mechanism, FGF23 induces left ventricular hypertrophy; however, its role in arterial calcification is less clear. In order to study this we quantified coronary artery and thoracic aorta calcium by computed tomography in 1501 patients from the Chronic Renal Insufficiency Cohort (CRIC) study within a median of 376 days (interquartile range 331 to 420 days) of baseline. Baseline plasma FGF23 was not associated with prevalence or severity of coronary artery calcium after multivariable adjustment. In contrast, higher serum phosphate levels were associated with prevalence and severity of coronary artery calcium, even after adjustment for FGF23. Neither FGF23 nor serum phosphate were consistently associated with thoracic aorta calcium. We could not detect mRNA expression of FGF23 or its co-receptor, klotho, in human or mouse vascular smooth muscle cells, or normal or calcified mouse aorta. Whereas elevated phosphate concentrations induced calcification in vitro, FGF23 had no effect on phosphate uptake or phosphate-induced calcification regardless of phosphate concentration or even in the presence of soluble klotho. Thus, in contrast to serum phosphate, FGF23 is not associated with arterial calcification and does not promote calcification experimentally. Hence, phosphate and FGF23 promote cardiovascular disease through distinct mechanisms.