Mortality After Multivessel Revascularization in Patients with Diabetes and Acute Coronary Syndromes (JACC: Advances September 2024)-Article: Mortality After Multivessel Revascularization in Patients with Diabetes and Acute Coronary Syndromes

Article: Mortality After Multivessel Revascularization in Patients with Diabetes and Acute Coronary Syndromes

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The KETO trial explores the relationship between carbohydrate-restricted ketogenic diets (KETO) and the occurrence of elevated low-density lipoprotein cholesterol (LDL-C) in "lean mass hyper-responders" (LMHRs). LMHRs, typically lean and metabolically healthy individuals, often experience significant increases in LDL-C levels upon adopting such diets. This study assesses whether these individuals also suffer from increased coronary plaque burden—a marker of atherosclerotic cardiovascular disease (ASCVD)—compared to individuals with lower LDL-C from the Miami Heart (MiHeart) cohort.<br /><br />The study included 80 KETO individuals with LDL-C ≥190 mg/dL, matched one-to-one with MiHeart subjects for various demographic and health factors. Coronary plaque was measured using coronary artery calcium (CAC) scoring and coronary computed tomography angiography (CCTA).<br /><br />Results showed no significant difference in coronary plaque burden between the KETO group and MiHeart controls, despite the KETO group's higher average LDL-C (mean 272 mg/dL compared to 123 mg/dL in controls). Additionally, there was no correlation between LDL-C levels and plaque burden within either group.<br /><br />These findings contrast with the general expectation that high LDL-C levels correlate with increased atherosclerosis, suggesting that elevated LDL-C in the context of KETO diets for metabolically healthy individuals might not impose the same ASCVD risk. This raises important questions regarding whether current LDL-C-focused ASCVD prevention guidelines should be adjusted for such unique phenotypes.<br /><br />The study emphasizes the need for further research into the LMHR phenotype to fully understand its ASCVD risk profile, its driving mechanisms, and effective management strategies. Future studies should include longer-term measurements and explore potential dietary and pharmacological interventions for LDL-C management in LMHR individuals.

Keywords

KETO trial

carbohydrate-restricted ketogenic diets

low-density lipoprotein cholesterol

lean mass hyper-responders

coronary plaque burden

atherosclerotic cardiovascular disease

coronary artery calcium scoring

coronary computed tomography angiography

ASCVD prevention guidelines

LMHR phenotype