OBJECTIVE:Reconstituted high-density lipoproteins (rHDL) improve wound healing in diabetes. We aimed to determine if rHDL elicit anti-inflammatory effects in diabetic wounds, as a mechanism to explain their wound healing benefits. APPROACH:Diabetes was induced using streptozotocin in C57Bl6/J mice. Two full-thickness wounds were placed on the subflanks of diabetic and nondiabetic (ND) mice. Phosphate-buffered saline (PBS) or rHDL (50 µg/wound/day) were applied topically. Wound closure was assessed daily. Inflammatory gene transcripts were measured by qPCR and proteins by Western blotting and enzyme-linked immunosorbent assay in wounds collected at baseline, 24 h, and 3 days postwounding. Wound macrophages were assessed by flow cytometry 7 days postwounding. The fate of fluorescent 3,3-dioctadecyloxacarbocyanine, perchlorate (DiO)-labeled rHDL was tracked by flow cytometry, fluorescent imaging, and microscopy. RESULTS:In diabetic mice, rHDL increased wound closure rates at days 6 (+288%, p < 0.01) and 7 (+639%, p < 0.0001) postwounding, compared with PBS controls. After 3 days, rHDL-treated diabetic wounds had lower Rela (-65%) and C-C motif chemokine ligand 2 (Ccl2) (-59%) mRNA levels and CCL2 protein (29%) than PBS controls, p < 0.05 for all. Wound macrophage content was higher in diabetic than ND wounds, but rHDL did not change macrophage content or polarity. DiO-rHDL were taken up by key wound cells including fibroblasts, macrophages, keratinocytes and endothelial cells, and retained in wounds for at least 48 h. INNOVATION:rHDL exerts anti-inflammatory effects in diabetic wounds early postwounding, which may contribute to its wound healing properties. CONCLUSION:The anti-inflammatory properties of rHDL in diabetic wounds present topical rHDL as a novel treatment option for improving healing in patients with diabetic foot ulcers. [Figure: see text].

AIMS:The proprotein convertase subtilisin/kexin Type 9 inhibitor, evolocumab, promoted plaque stabilization on serial imaging in patients following an acute coronary syndrome. The impact of evolocumab in patients with varying lipoprotein(a) [Lp(a)] levels is unknown. METHODS AND RESULTS:Serial optical coherence tomography imaging was performed to evaluate changes in plaque composition in response to treatment with evolocumab 420 mg or placebo for 50 weeks. The current post hoc analysis compared demographics, biochemistry, and plaque imaging changes in those with baseline Lp(a) levels <125 (n = 71) and ≥125 nmol/L (n = 46). Among those with high Lp(a) levels, evolocumab treatment produced lower levels of LDL cholesterol (LDL-C) (21.7 ± 10.3 vs. 94.5 ± 22.9 mg/dL; P < 0.001) and Lp(a) [156.0 (136.0, 187.0) vs. 204.0 (170.5, 290.5) nmol/L; P = 0.007], compared with placebo. Changes in minimum fibrous cap thickness (FCT) (+51.6 ± 40.9 vs. +12.4 ± 23.9 μm; P < 0.001) and lipid arc (-60.9 ± 56.5° vs. -9.1 ± 70.8°; P = 0.008) were greater in the high Lp(a) group with evolocumab compared with placebo. Among patients with low Lp(a) levels, evolocumab produced lower levels of LDL-C (23.3 ± 34.9 vs. 82.9 ± 46.5 mg/dL; P < 0.001) and Lp(a) [11.5 (5.8, 23.8) vs. 25.0 (13.5, 41.0) nmol/L; P = 0.01] compared with placebo, but no differences were observed between groups in changes in minimum FCT (+45.9 ± 37.8 vs. +34.7 ± 36.0 μm; P = 0.21) and lipid arc (-59.9 ± 50.1° vs. -44.5 ± 46.1°; P = 0.18). Baseline Lp(a) levels significantly interacted with the impact of evolocumab on changes in minimum FCT (interaction P = 0.04). CONCLUSION:The ability of evolocumab to more effectively promote plaque stabilization, compared with statin monotherapy, appears more pronounced in patients with higher Lp(a) levels, suggesting that Lp(a) may help identify those who benefit most from intensive lipid-lowering therapy. REGISTRATION:ClinicalTrials.gov: NCT03570697.

Background:Syndecan-1 and endocan are biomarkers of endothelial damage, which associate with worse outcomes after myocardial infarction (MI). As it is unclear how this is mediated, we investigated how they associate with the composition of residual, non-culprit coronary atherosclerotic plaques following acute MI. Methods:This post hoc analysis of the COCOMO-ACS trial used serum samples from forty-five patients with non-ST elevation MI who underwent blood collection and optical coherence tomography (OCT) imaging of non-culprit, lipid-rich coronary plaques at baseline and after a median of 17.8 months. Serum syndecan-1 and endocan concentrations at both time-points were measured by ELISA. Relationships between these biomarkers and OCT parameters of rupture-prone plaque were examined. Results:Serum levels of syndecan-1 (median 161.0 ng/mL at baseline vs 93.5 ng/mL at follow-up, P < 0.0001) and endocan (225.7 pg/mL vs 191.2 pg/mL, P = 0.003) both decreased from time of MI to follow-up, with strong correlation between their changes (R2 = 0.64, P < 0.0001). Only syndecan-1 showed a weak negative correlation with minimum fibrous cap thickness at baseline (R2 = 0.10, P = 0.03) and a weak positive correlation with maximum lipid arc at follow-up (R2 = 0.14, P = 0.01). While syndecan-1 and endocan showed no relationship with plasma lipid concentrations, there were weak associations between follow-up syndecan-1 and interleukin-1-beta (R2 = 0.21, P = 0.001), and follow-up endocan and interleukin-6 (R2 = 0.15, P = 0.008). Conclusions:Although serum syndecan-1 and endocan levels decreased in peripheral blood over time post-MI on guideline-directed therapy, this study identified only modest relationships between syndecan-1 (and not endocan) and OCT compositional characteristics of lipid-rich, rupture-prone plaque.

BACKGROUND AND AIMS:The measurement of lipid species in blood holds promise for identifying new biomarkers associated with coronary atherosclerosis. Here, we examined for relationships between circulating lipid species and coronary plaque changes following acute myocardial infarction (MI) in patients on guideline-recommended treatment. METHODS:In this post-hoc analysis of the INFLAME study, patients presenting with MI underwent serum lipidomic analysis and coronary computed tomography angiography (CCTA) during admission and at 6-month follow-up. Quantitative CCTA plaque analysis was performed on the highest-grade, non-culprit stenosis. A hybrid targeted/untargeted liquid chromatography mass spectrometry strategy was used to identify changes in lipids associated with plaque measurements. RESULTS:48 paired samples from 24 participants with complete imaging and biochemical datasets formed the study basis. Two sphingolipid classes, sphingomyelin (SM) (p.adj<0.001) and ceramides (Cer) (p.adj = 0.02) decreased post-MI as measured by percentage composition of the total serum lipid pool, whereas the lysolipids, lysophosphatidylcholine (LPC) (p.adj<0.001) and lysophosphatidylethanolamine (LPE) (p.adj = 0.04) increased. In multivariable linear regression analysis, each standard deviation temporal decrease in LPC 15:0 or phosphatidyl choline (PC) 39:6 associated with >4 % decreases in total plaque burden. Furthermore, reduction of LPC 15:0 associated with enhanced reduction in low-attenuation plaque burden, and reductions of LPC 18:0 and PC 39:6 with greater reduction of non-calcified plaque burden. Similarly, each standard deviation reduction in the sphingolipids, Cer d43:1 and SM d38:2, associated with >4 % decreases in low-attenuation plaque composition. CONCLUSION:In the early post-MI period, guideline-recommended treatment is accompanied by decreases in sphingolipids, increases in lysolipids, and alterations in the fatty acid composition of lipid subclasses, with some lipidomic changes associating with favorable changes in coronary plaque characteristics.

BACKGROUND:Significant progress has been made in coronary artery disease (CAD) prevention by targeting standard modifiable cardiovascular risk factors (SMuRFs), which include hypertension, hyperlipidaemia, diabetes mellitus, and smoking. However, there is growing incidence of CAD occurring in the absence of SMuRFs, a phenomenon now termed "SMuRF-less" CAD. Identifying novel biomarkers and mechanisms for SMuRF-less CAD is crucial for new therapeutic strategies in this under-recognised group. The role of inflammation in CAD has been extensively studied and was recently validated as a therapeutic target. AIMS:This study aimed to assess coronary inflammation in patients without SMuRFs and patients with SMuRFs using pericoronary adipose tissue (PCAT) attenuation, a novel and specific biomarker of coronary inflammation quantified on computed tomography coronary angiography (CTCA). Our secondary aim was to compare the coronary plaque burden and coronary artery stenosis severity between the groups. METHOD:We conducted a retrospective single-centre study of 309 consecutive patients who underwent clinically indicated serial CTCAs for suspected stable CAD (2010-2016) at Monash Health, Melbourne, Australia. Patients with a history of CAD were excluded. PCATRCA attenuation measurement around the proximal right coronary artery (RCA) was performed using semiautomated software. Plaque burden was assessed using the segment involvement score (SIS) and segment stenosis score (SSS). Coronary artery diameter stenosis severity was assessed using the Coronary Artery Disease - Reporting and Data System (CAD-RADS) classification. RESULTS:In the final study population of 309 patients (median age 57.5 years; 51.8% female), 83 (26.9%) patients were SMuRF-less. Baseline characteristics were similar between patients without SMuRFs and those with SMuRFs, and patients with SMuRFs were more frequently on statins, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and aspirin. Patients without SMuRFs had a similar PCATRCA mean attenuation (Hounsfield units, HU) compared with patients with SMuRFs (-77.5±9.5 vs -78.4±8.9 HU; p=0.481), despite having a lower coronary plaque burden and stenosis severity. The mean SIS and SSS were 18.7% and 39.5% lower, respectively, in patients without SMuRFs than in those with SMuRFs (SIS: 1.78±2.19 vs 2.72±2.88, p=0.01; SSS: 2.22±3.36 vs 3.67±4.38; p=0.004). Patients with SMuRFs were more likely to have obstructive CAD than patients without SMuRFs (odds ratio 2.8; 95% confidence interval 1.3-5.7; p=0.006). CONCLUSIONS:In patients undergoing clinically indicated CTCA, patients without SMuRFs exhibited a similar degree of coronary inflammation to those with SMuRFs, despite having a lower plaque burden and stenosis severity. These findings may provide early mechanistic insights into why patients without SMuRFs still develop CAD and subsequent cardiovascular events. Further research is needed to validate these findings. If confirmed, the therapeutic target of inflammation could be explored further in patients without SMuRFs.

Cardiovascular-kidney-metabolic (CKM) syndrome is a term that is increasingly used to describe interconnected conditions that lead to poor health outcomes, including cardiovascular disease, chronic kidney disease, type 2 diabetes, and obesity. Historically, there have been very few targeted pharmacotherapies available that have changed cardiovascular outcomes for people with CKM syndromes; however, over the past decade, new pharmacologic options have rapidly expanded, with strong evidence for cardiovascular and kidney protective benefits in CKM conditions. Of note, sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists have emerged as key therapeutic options and are now widely guideline-endorsed. However, amid a growing pipeline of therapeutic classes on the horizon, real-world use of these agents has become increasingly complex. This review will compare the efficacy of these therapies, exploring their distinct and complementary mechanisms, with consideration to their role in contemporary clinical care. Emerging classes of therapy that may confer additional benefits for people with CKM syndrome will also be highlighted.

Coronary artery disease remains the leading cause of death worldwide. One of the greatest developments in preventive cardiology has been the identification and treatment of standard modifiable risk factors associated with coronary artery disease. However, despite advances in the management of standard modifiable risk factors, there is an escalating number of patients who continue to present with acute coronary syndromes, a trend that is particularly concerning given the decreasing age-adjusted incidence rates of these conditions. This persistent clinical challenge underscores the urgency to explore alternative approaches for early detection and improved risk stratification. In recent years, the emergence of proteomics technologies has brought forth promising avenues for the discovery of novel biomarkers that hold the potential to revolutionize the timely detection and management of coronary artery disease. Proteomics enables the high throughput and often unbiased analysis of protein abundance, modifications, and interactions within pathways relevant to cardiovascular disease pathogenesis. Of particular importance is the capability to detect low-abundance proteins including those with currently unknown functions. While the functional assessment of these proteins aligns more with mechanistic studies, their role in biomarker discovery is equally important. Such detection may provide new insights into cardiac pathophysiology, including potential new markers for early disease detection and risk assessment. Although the latest proteomics technology and bioinformatic approaches do provide the opportunity for novel discoveries, understanding the limitations of each technology platform is important. This review provides an updated overview of major proteomic platforms and discusses their methodological strengths, constraints, and applications, using recent coronary artery disease studies as illustrative examples. By integrating proteomics data with clinical information, including advanced noninvasive imaging techniques and other omics disciplines, such as genomics and metabolomics, we can deepen our understanding of disease mechanisms and improve risk stratification. Although the discovery of novel biomarkers represents a significant step forward in the field, their true clinical value is contingent upon their rigorous validation in clinical trials and implementation studies. With our current capabilities and emerging advancements, we are well-positioned to advance proteomics-guided precision medicine in cardiovascular care over the coming decade.

AIMS:Low-dose colchicine reduces the risk of cardiovascular events after myocardial infarction (MI). The purpose of this study was to assess the effect of colchicine post-MI on coronary plaque morphology in non-culprit segments by optical coherence tomography (OCT). METHODS AND RESULTS:COCOMO-ACS was a double-blind, placebo-controlled trial that randomized 64 patients (median age 61.5 years; 9.4% female) with acute non-ST-segment elevation MI to colchicine 0.5 mg daily or placebo for a median of 17.8 months in addition to guideline-recommended therapy. Participants underwent serial OCT imaging within a matched segment of non-culprit coronary artery that contained at least one lipid-rich plaque causing ≥20% stenosis. The primary outcome was the change in minimum fibrous cap thickness (FCT) in non-culprit segments from baseline to final visit. Of those randomized, 57 (29 placebo, 28 colchicine) had evaluable imaging at baseline and follow-up. Overall, colchicine had no effect on relative (placebo +48.0 ± 35.1% vs. colchicine +62.4 ± 38.1%, P = 0.18) or absolute changes in minimum FCT (+29.2 ± 20.9 µm vs. + 37.2 ± 21.3 µm, P = 0.18), or change in maximum lipid arc (-38.8 ± 32.2° vs. -54.8 ± 46.9°, P = 0.18) throughout the imaged non-culprit segment. However, in patients assigned colchicine, cap rupture was less frequent (placebo 27.6% vs. colchicine 3.6%, P = 0.03). In post hoc analysis of 43 participants who had been followed for at least 16 months, minimum FCT increased to a greater extent in the colchicine group (placebo +38.7 ± 25.4% vs. colchicine +64.7 ± 34.1%, P = 0.005). CONCLUSION:In this study, OCT failed to detect an effect of colchicine on the minimum FCT or maximum lipid arc of plaques in non-culprit segments post-MI. The post hoc observation that minimum FCT increased to a greater extent with colchicine after more prolonged treatment suggests that longer-term studies may be required to detect the effect of anti-inflammatory therapies on plaque morphology by OCT. CLINICAL TRIAL NUMBER:Australian New Zealand Clinical Trials Registry Identifier, ACTRN12618000809235, registered on the 11 May 2018.

A fundamental challenge in endoscopy is how to fabricate a small fiber-optic probe that can achieve comparable function to devices with large, complicated optics. To achieve high resolution over an extended depth of focus (DOF), the application of needle-like beams has been proposed. However, existing methods for miniaturized needle-beam designs fail to adequately correct astigmatism and other monochromatic aberrations, limiting the resolution of at least one axis. Here, we describe an approach to realize freeform beam-shaping endoscopic probes via two-photon polymerization three-dimensional (3D) printing. We present a design achieving <8 mu m lateral resolution with a DOF of similar to 800 mu m. The probe has a diameter of <260 mu m (without the torque coil and catheters) and is fabricated using a single printing step directly on the optical fiber. The probe was successfully utilized for intravascular imaging in living diabetic swine at multiple time points, as well as human atherosclerotic plaques ex vivo. To the best of our knowledge, this is the first report of a 3D-printed micro-optic for in vivo imaging of the coronary arteries. These results are a substantial step to enable the clinical adoption of both 3D-printed micro-optics and beam-tailoring devices.

Low-dose colchicine is the only anti-inflammatory drug approved for secondary prevention of coronary disease. The CLEAR-SYNGERY trial of colchicine in acute myocardial infarction challenges the results of previous colchicine trials; however, clinicians should be aware of how its design and the COVID-19 pandemic affected the trial outcome.

Microvascular and/or vasospastic angina are two common forms of coronary vasomotor disorders that may occur in patients with ischaemia and non-obstructed coronary arteries (INOCA) or myocardial infarction with non-obstructive coronary arteries (MINOCA). Functional coronary angiography involves invasive guidewire-based assessment of the coronary circulation using pharmacological vasoactive agents to assess small and large vasomotor dysfunction. Typically, responses to adenosine (microvascular vasodilator) and acetylcholine (large and small vessel vasospastic agent) are sequentially assessed. Currently, the assessment and treatment of INOCA and MINOCA patients varies widely. We therefore provide a standard protocol for 'functional coronary angiography' for use in Australia and New Zealand. Ischaemic heart disease (IHD) due to disorders of coronary vasomotion causes angina and impairs quality of life and prognosis. INOCA is prevalent in both men and women, however relative to obstructive CAD, INOCA is over-represented in women. This may also be a relevant contributor to sex differences which persist in IHD outcomes (notably in young women). Recent European Society of Cardiology guidelines make a class I recommendation in support of the use of functional coronary angiography in INOCA. Despite this, testing for disorders of coronary vasomotion is performed in very few centres in Australia and New Zealand. Barriers to more widespread clinical adoption include the lack of a standard protocol for testing, additional time and training required, lack of funding, concerns over safety and physician knowledge pertaining to over diagnosis and treatment options. Taken together, it is not surprising that local prevalence and outcome data are lacking. We summarise indications for functional assessment of coronary vasomotor disorders with a simple standardised operating protocol for use in cardiac catheter laboratories throughout Australia and New Zealand. We provide guidance on training recommendations for clinical proficiency in undertaking and interpreting functional coronary angiography. Clinical performance and research will be enhanced with the establishment of a national clinical quality registry for functional coronary angiography. By unifying the clinical approach, we hope to facilitate better care for this frequently overlooked heterogenous group of patients.