Prabhjot S. Nijjar

Role of dietary supplements in lowering low-density lipoprotein cholesterol: A review

Coronary heart disease (CHD) remains a major source of morbidity and mortality. As the epidemic of obesity, diabetes, and hypertension continues to grow among young adults, the population at risk for atherosclerotic CHD is ever increasing. More than a century of laboratory and human findings link cholesterol levels with a propensity to develop atherosclerosis. Low-density lipoprotein (LDL) is the major atherogenic lipoprotein, and numerous clinical trials have shown the efficacy of lowering LDL-cholesterol (LDL-C) for reducing CHD risk. New trial data have resulted in LDL-C goals being lowered over time and expansion of the population of patients that are candidates for LDL-lowering therapy to decrease their lifetime risk of CHD. Although statins are relatively safe and well tolerated, there are still significant numbers of patients who cannot tolerate them and many others who only require mild LDL-C reduction and prefer nonprescription alternatives to statin therapy. A number of dietary supplements and functional foods have been suggested to reduce LDL-C levels, but only a few have withstood the rigors of randomized controlled trials. Here we review the evidence in support of dietary supplements and their LDL-C-lowering effects. We also review supplements that, after initial excitement about their purported effect, were not found to lower LDL-C significantly.

Race and gender variation in response to evoked inflammation

BackgroundRace- and gender-variation in innate immunity may contribute to demographic differences in inflammatory and cardiometabolic disease; yet their influence on dynamic responses during inflammatory stress is poorly understood. Our objective was to examine race and gender influence on the response to experimental endotoxemia.MethodsThe Genetics of Evoked Responses to Niacin and Endotoxemia (GENE) study was designed to investigate regulation of inflammatory and metabolic responses during low-grade endotoxemia (LPS 1 ng/kg intravenously) in healthy individuals (median age 24, IQR=7) of European (EA; n=193, 47% female) and African ancestry (AA; n=101, 59% female).ResultsBaseline clinical, metabolic, and inflammatory biomarkers by race and gender were consistent with epidemiological literature; pre-LPS cytokines (e.g. median (IQR) IL-6, 2.7 (2) vs.2.1 (2) pg/ml, P=0.001) were higher in AA than EA. In contrast, acute cytokine responses during endotoxemia were lower in AA than EA (e.g. median (IQR) peak IL-1RA, 30 (38) vs.43 (45) ng/ml P=0.002) as was the induction of hepatic acute-phase proteins (e.g. median (IQR) peak CRP 12.9 (9) vs.17.4 (12) mg/L P=0.005). Further, baseline levels of cytokines were only weakly correlated with peak inflammatory responses (all rs <0.2) both in AA and in EA. There were less pronounced and less consistent differences in the response by gender, with males having a higher AUC for CRP response compared to females (median (IQR) AUC: 185 (112) vs. 155 (118), P=0.02).ConclusionsWe observed lower levels of evoked inflammation in response to endotoxin in AA compared with EA, despite similar or higher baseline levels of inflammatory markers in AA. Our data also suggest that levels of inflammatory biomarkers measured in epidemiological settings might not predict the degree of acute stress-response or risk of diseases characterized by activation of innate immunity.Trial registrationFDA clinicaltrials.gov registration number NCT00953667

Modulation of the autonomic nervous system assessed through heart rate variability by a mindfulness based stress reduction program

Heart rate variability (HRV) is an established method to evaluate cardiac sympatho-vagal balance [1]. Reduced HRV is an adverse prognostic marker for fatal arrhythmias in myocardial infarction and heart failure patients [2,3]. Mindfulness based stress reduction (MBSR) is a well-delineated 8-week meditation program that has a standardized technique [4]. Certain meditation practices have been shown to positively influence HRV [5,6], but the effects of MBSR on HRV have not been established. Twenty two healthy volunteerswere recruited fromparticipants of a MBSR program. After excluding for followup loss and ECG artifact, final study population was 18 subjects (44% men, mean age 52.7 ± 11.8 years, mean BMI 24.0 ± 3.9 kg/m). The study protocol was approved by the University of Minnesota Institutional Review Board, and written informed consent (in accordancewith theHelsinki Declaration) was obtained. Volunteers were reimbursed US

Insulin-sensitizing antihyperglycaemic medications are associated with better outcome in patients with diabetes undergoing cardiac stress testing.

50 per visit to cover travel costs. MBSR consists of an 8-week intervention with weekly classes that last 2–3 h, and daily home practice is encouraged [7].

Role of contrast CT for the diagnosis and the prognosis of suspected LVAD thrombosis

Background:  There are several treatment modalities available for diabetes; however, the effects of the different medications on coronary artery disease are less understood. The purpose of this study was to evaluate the correlation of insulin‐sensitizing therapy with the outcome of stress myocardial perfusion testing and to compare it with conventional therapy.

Benefits and Limitations of Multimodality Imaging in the Diagnosis of a Primary Cardiac Lymphoma

There is an urgent need for further studies evaluating the role of imaging modalities in the management of left ventricular assist device (LVAD) thrombosis. This study reviews the role of computed tomography (CT) in the diagnosis of suspected LVAD thrombosis.

Primary pulmonary artery sarcoma masquerading as pulmonary embolism: role of cardiac MRI.

Primary cardiac tumors are far rarer than tumors metastatic to the heart. Angiosarcoma is the primary cardiac neoplasm most frequently detected; lymphomas constitute only 1% of primary cardiac tumors. We present the case of a 55-year-old woman with a recently diagnosed intracardiac mass who was referred to our institution for consideration of urgent orthotopic heart transplantation. Initial images suggested an angiosarcoma; however, a biopsy specimen of the mass was diagnostic for diffuse large B-cell lymphoma. The patient underwent chemotherapy rather than surgery, and she was asymptomatic 34 months later. We use our patients case to discuss the benefits and limitations of multiple imaging methods in the evaluation of cardiac masses. Certain features revealed by computed tomography, cardiac magnetic resonance, and positron emission tomography can suggest a diagnosis of angiosarcoma rather than lymphoma. Cardiac magnetic resonance and positron emission tomography enable reliable distinction between benign and malignant tumors; however, the characteristics of different malignant tumors can overlap. Despite the great usefulness of multiple imaging methods for timely diagnosis, defining the extent of spread and the hemodynamic impact, and monitoring responses to treatment, we think that biopsy analysis is still warranted in order to obtain a correct histologic diagnosis in cases of suspected malignant cardiac tumors.

Computed tomography (CT) assessment of the membranous septal anatomy prior to transcatheter aortic valve replacement (TAVR) with the balloon-expandable SAPIEN 3 valve

A 49-year-old healthy man presented with 2 months history of progressive shortness of breath and hemoptysis. Physical examination was remarkable for new systolic heart murmur. Chest X-ray revealed a small opacity in the right lower lobe, and non-contrast computed tomography (CT) demonstrated two sub-pleural masses at the right lung base. Computed tomography-guided biopsy showed benign tissue with extensive necrosis and inflammation. To evaluate the heart murmur, echocardiogram was done and showed moderate pulmonary hypertension with flow acceleration in the main pulmonary artery (PA). Contrast CT revealed a large filling defect in the main PA …

Quantification of left atrial volume using cardiac magnetic resonance imaging: comparison of left atrial volume index measurements using the Simpson's and bi-plane area-length methods

OBJECTIVES The lower limit of the membranous septum (MS) is considered an anatomic landmark for the emergence of the Bundle of His into the left ventricle. Computed tomography (CT) assessment of MS anatomy may provide useful information about the risk of conduction abnormalities following transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS The study included 102 consecutive patients undergoing TAVR with the Edwards Sapien 3 (S3) valve. Using pre-TAVR CT and post-procedure angiography we evaluated for the presence of calcium in the left ventricular outflow tract (LVOT), calcium depth (CD), implantation depth (ID) and MS length. The MS length minus the prosthesis ID was calculated (Delta MSID). Outcomes included new left bundle branch block (LBBB) or permanent pacemaker (PPM) within 30days. Seventeen patients (17%) received a PPM and 28 (27%) developed new LBBB following TAVR. Mean (±SD) MS length and delta MSID were 7.5mm (2) and 0.9mm (4.5), respectively. Twenty-one patients (20%) had calcium in the device landing zone and the mean (SD) CD was 6.8mm (±4). Calcium in the device landing zone (37% versus 16%, p=0.02) and implantation depth (6mm (4-8) versus 4mm (4-5), p=0.02) predicted new conduction abnormalities after TAVR. CONCLUSIONS The presence of calcium in the device landing zone is associated with increased risk of conduction abnormalities after TAVR with S3. In such cases, a more aortic deployment of the prosthesis may be warranted.

Reduction in radiation exposure with coronary computed tomography over seven years in a real world setting

Background Increased left atrial volume index (LAVI) has been shown to be an independent predictor of hard cardiovascular events. It can be determined by calculating left atrial (LA) volume through the use of either Simpson’ sm ethod or area-length method and indexing it to body surface area (BSA). Although there is no standardized method of calculating LA volume using Cardiac Magnetic Resonance Imaging (CMR), the aforementioned methods, which were originally validated for 2-dimensional echocardiography, have been used. We sought to assess the agreement between LAVI, obtained with the use of cardiac gated steady state free precession cine pulse sequence of contiguous short axis slices (LAVI1) and area-length method (LAVI2). Methods