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As time has come to translate trial results into individualized medical diagnosis and therapy, we analyzed how to minimize residual risk of cardiovascular disease (CVD) by reviewing papers on “residual cardiovascular disease risk”. During this review process we found 989 papers that started off with residual CVD risk after initiating statin therapy, continued with papers on residual CVD risk after initiating therapy to increase high-density lipoprotein-cholesterol (HDL-C), followed by papers on residual CVD risk after initiating therapy to decrease triglyceride (TG) levels. Later on, papers dealing with elevated levels of lipoprotein remnants and lipoprotein(a) [Lp(a)] reported new risk factors of residual CVD risk. And as new risk factors are being discovered and new therapies are being tested, residual CVD risk will be reduced further. As we move from CVD risk reduction to improvement of patient management, a paradigm shift from a reductionistic approach towards a holistic approach is required. To that purpose, a personalized treatment dependent on the individual’s CVD risk factors including lipid profile abnormalities should be configured, along the line of P5 medicine for each individual patient, i.e., with Predictive, Preventive, Personalized, Participatory, and Psycho-cognitive approaches.

Fernanda A Orsi,1,2 Willem M Lijfering,2,3 Arnoud Van der Laarse,4,5 L Renee Ruhaak,4 Frits R Rosendaal,2 Suzanne C Cannegieter,2–3,6 Christa Cobbaert41Department of Clinical Pathology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil; 2Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands; 3Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands; 4Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands; 5Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; 6Department of Internal Medicine, Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The NetherlandsPurpose: Apolipoproteins C-I, C-II, C-III and E have been associated with risk of arterial thrombotic diseases. We investigated whether these apolipoproteins have prothrombotic properties and are associated with risk of venous thromboembolism (VTE).Patients and methods: A total of 127 VTE patients and 299 controls were randomly selected from the Multiple Environmental and Genetic Assessment of Risk Factors for Venous Thrombosis study (1999–2004), in the Netherlands. The apolipoproteins were quantified using mass spectrometry (LC/MS/MS), and their levels were analyzed as continuous variable (per SD increase).Results: In controls, increases in levels of apolipoproteins were associated with increases in levels of vitamin K-dependent factors, factor XI, antithrombin and clot lysis time. Additionally, increasing apolipoproteins C-III and E levels were associated with higher factor VIII and von Willebrand factor levels. Levels of C-reactive protein were not associated with any apolipoprotein. The age- and sex-adjusted odds ratios of apolipoproteins E, C-III, CII and CI to the risk of venous thrombosis were 1.21 (95% CI, 0.98–1.49), 1.19 (95% CI, 0.99–1.44), 1.24 (95% CI, 0.95–1.61) and 1.06 (95% CI, 0.87–1.30) per SD increase, respectively. These odds ratios did not attenuate after adjustments for statin use, estrogen use, BMI, alcohol use, and self-reported diabetes.Conclusions: Levels of apolipoproteins C-I, C-II, C-III and E are associated with those of several coagulation factors. However, whether these apolipoproteins are also associated with an increased risk of VTE remains to be established.Keywords: thrombosis, proteomics, lipids, cholesterol, coagulation, risk factors

While the heart regenerates poorly in mammals, efficient heart regeneration occurs in zebrafish. Studies in zebrafish have resulted in a model in which preexisting cardiomyocytes dedifferentiate and reinitiate proliferation to replace the lost myocardium. To identify which processes occur in proliferating cardiomyocytes we have used a single-cell RNA-sequencing approach. We uncovered that proliferating border zone cardiomyocytes have very distinct transcriptomes compared to the nonproliferating remote cardiomyocytes and that they resemble embryonic cardiomyocytes. Moreover, these cells have reduced expression of mitochondrial genes and reduced mitochondrial activity, while glycolysis gene expression and glucose uptake are increased, indicative for metabolic reprogramming. Furthermore, we find that the metabolic reprogramming of border zone cardiomyocytes is induced by Nrg1/ErbB2 signaling and is important for their proliferation. This mechanism is conserved in murine hearts in which cardiomyocyte proliferation is induced by activating ErbB2 signaling. Together these results demonstrate that glycolysis regulates cardiomyocyte proliferation during heart regeneration.

Currently available data on the energetics of isolated muscle preparations are based on bouts of less than 10 muscle contractions, whereas metabolic energy consumption is mostly relevant during steady state tasks such as locomotion. In this study we quantified the energetics of small fiber bundles of mouse soleus muscle during prolonged (2 min) series of contractions. Bundles (N = 9) were subjected to sinusoidal length changes, while measuring force and oxygen consumption. Stimulation (five pulses at 100 Hz) occurred either during shortening or during lengthening. Movement frequency (2–3 Hz) and amplitude (0.25–0.50 mm; corresponding to ± 4–8% muscle fiber strain) were close to that reported for mouse soleus muscle during locomotion. The experiments were performed at 32°C. The contributions of cross-bridge cycling and muscle activation to total metabolic energy expenditure were separated using blebbistatin. The mechanical work per contraction cycle decreased sharply during the first 10 cycles, emphasizing the importance of prolonged series of contractions. The mean ± SD fraction of metabolic energy required for activation was 0.37 ± 0.07 and 0.56 ± 0.17 for concentric and eccentric contractions, respectively (both 0.25 mm, 2 Hz). The mechanical efficiency during concentric contractions increased with contraction velocity from 0.12 ± 0.03 (0.25 mm 2 Hz) to 0.15 ± 0.03 (0.25 mm, 3 Hz) and 0.16 ± 0.02 (0.50 mm, 2 Hz) and was -0.22 ± 0.08 during eccentric contractions (0.25 mm, 2 Hz). The percentage of type I fibers correlated positively with mechanical efficiency during concentric contractions, but did not correlate with the fraction of metabolic energy required for activation.

Fish may be extremely hypoxia resistant. We investigated how muscle fibre size and oxidative capacity in zebrafish (Danio rerio) adapt during severe chronic hypoxia. Zebrafish were kept for either 3 or 6 weeks under chronic constant hypoxia (CCH) (10% air/90%N2 saturated water). We analyzed cross-sectional area (CSA), succinate dehydrogenase (SDH) activity, capillarization, myonuclear density, myoglobin (Mb) concentration and Mb mRNA expression of high and low oxidative muscle fibres. After 3 weeks of CCH, CSA, SDH activity, Mb concentration, capillary and myonuclear density of both muscle fibre types were similar as under normoxia. In contrast, staining intensity for Mb mRNA of hypoxic high oxidative muscle fibres was 94% higher than that of normoxic controls (P

In contrast to other European countries 19 th century-court architecture in the Netherlands has not left a strong imprint on public memory. Just as most historical cities, most palaces in the Netherlands were restored in 17 th century Dutch Classicist Style, suggesting that after the Golden Age nothing happened. This article shows that such an impression is misleading. Focusing on the new monarchy of the Restoration era (1813-1848) it becomes clear that the first Orange kings William I and II started impressive building campaigns in both the Southern and Northern Netherlands, comparable to those of the 17 th century. Prince Frederick Henry and the Anglo-Dutch King-Stadtholder William III. Remarkably, in the early 19 th century the most magnificent palaces in neoclassicist style - except for Soestdijk - were built by the prince royal in and around Brussels. Nevertheless, the Belgian revolution of 1830 ended the role of the Orange dynasty in Brussels, after which royal and princely palaces, summer houses, and art collections were appropriated by the new Belgian monarchy. Although most of them are still in use, their origin has been completely forgotten. Strangely, this also happened to King William II's new palaces of the 1830s and 1840s in Windsor Tudor Style. This so-called William II Gothic was very popular at the time, but from the 1870s no longer fashionable in Protestant court circles after having been appropriated by Roman-Catholic architects for church building. The King was influenced by the memory of his Oxford college days, as can still be seen in the Gothic Hall of his Kneuterdijk Palace in The Hague, designed by himself as a Painting Gallery modelled after the hall of Christ Church College. A much larger project, however, the so-called Zorgvliet Palace at his huge private domain Williams Park between his The Hague palaces and the beach of Scheveningen, had a different origin. With the help of the English architect Ashton, the King made plans for a residential palace that would surpass his lost Brussels palaces and compete with the royal 'court scapes' of Versailles, Windsor and Potsdam. Connected by kinship and marriage to the Hohenzollern, William II shared the Prussian longing for castellated palaces as developed by Schinkel for his sisters, brothers and nephews in Germany. Nevertheless, palace building was stopped abruptly after the liberal revolution of 1848, when the Orange court lost its political power and almost went bankrupt because of overspending. After William II's death in 1849 the court had to sell its magnificent art collection, and William III - who disliked Roman Catholics and the Gothic Revival - sold most of his father's palaces. For almost three decades palaces in the Netherlands were only built by the king's relatives, such as his uncle Prince Frederick who owned the famous estate Muskau at the German-Polish Border as well as the Dutch estate The Horsten near The Hague. With the help of the Prussian architect Wentzel and the Muskauer landscape designer Petzold, Frederick introduced the Schinkel Style in the Netherlands. Nevertheless, enriched by the inheritance of his brother Prince Henry grand duke of Luxembourg, William III started a last royal building campaign in the 1870s, supporting the Baroque Revival of his favourite Eberson. Just as in the case of his father, his new plan for a residential castle at Zorgvliet failed, however, and after the king's death in 1890 the royal domains in and around The Hague were sold to the city government and some private investors. Ironically, near Lord Portland's former summer house Zorgvliet or Catshuis (used today as the official residence of the Prime Minister), the Carnegy Foundation built the famous Peace Palace in French Neo-Renaissance Style in the early 20 th century, which could be seen as the final outcome of the royal dream of a Williams Park Court.

Background: Fibrosis is associated with various cardiac pathologies and dysfunction. Current quantification methods are time-consuming and laborious. We describe a semi-automated quantification technique for myocardial fibrosis and validated this using traditional methods.

BACKGROUND:Near-infrared spectroscopy (NIRS) measurements of oxygenation reflect O2 delivery and utilization in exercising muscle and may improve detection of a critical exercise threshold. PURPOSE:First, to detect an oxygenation breakpoint (Δ[O2HbMb-HHbMb]-BP) and compare this breakpoint to ventilatory thresholds during a maximal incremental test across sexes and training status. Second, to assess reproducibility of NIRS signals and exercise thresholds and investigate confounding effects of adipose tissue thickness on NIRS measurements. METHODS:Forty subjects (10 trained male cyclists, 10 trained female cyclists, 11 endurance trained males and 9 recreationally trained males) performed maximal incremental cycling exercise to determine Δ[O2HbMb-HHbMb]-BP and ventilatory thresholds (VT1 and VT2). Muscle haemoglobin and myoglobin O2 oxygenation ([HHbMb], [O2HbMb], SmO2) was determined in m. vastus lateralis. Δ[O2HbMb-HHbMb]-BP was determined by double linear regression. Trained cyclists performed the maximal incremental test twice to assess reproducibility. Adipose tissue thickness (ATT) was determined by skinfold measurements. RESULTS:Δ[O2HbMb-HHbMb]-BP was not different from VT1, but only moderately related (r = 0.58-0.63, p

Hypertriglyceridemia (HTG) is associated with insulin resistance, increased cholesteryl ester transfer (CET), and low HDL cholesterol. Phospholipid transfer protein (PLTP) may be involved in these relationships. Associations between CET, lipids, insulin resistance, CETP and PLTP activities, and PLTP mass were investigated in 18 HTG patients and 20 controls. Effects of 6 weeks of bezafibrate treatment were studied in HTG patients. HTG patients had higher serum triglycerides, insulin resistance, free fatty acid (FFA), and CET, lower levels of HDL cholesterol (−44%) and PLTP mass (−54%), and higher CETP (+20%) and PLTP activity (+48%) than controls. Bezafibrate reduced triglycerides, CET (−37%), insulin resistance (−53%), FFA (−48%), CETP activity (−12%), PLTP activity (−8%), and increased HDL cholesterol (+27%), whereas PLTP mass remained unchanged. Regression analysis showed a positive contribution of PLTP mass (P = 0.001) but not of PLTP activity to HDL cholesterol, whereas insulin resistance positively contributed to PLTP activity (P < 0.01). Bezafibrate-induced change in CET and HDL cholesterol correlated with changes in CETP activity and FFAs, but not with change in PLTP activity. Bezafibrate-induced change in PLTP activity correlated with change in FFAs (r = 0.455, P = 0.058). We propose that elevated PLTP activity in HTG is related to insulin resistance and not to increased PLTP mass.Bezafibrate-induced diminished insulin resistance is associated with a reduction of CET and PLTP activity.

Serum troponin assays, widely used to detect acute cardiac ischemia, might be useful biomarkers to detect chronic cardiovascular disease (CVD). Cardiac-specific troponin-I (cTnI) and troponin-T (cTnT) generally detect myocardial necrosis equally well. In dialysis patients however, serum cTnT levels are often elevated, unlike cTnI levels. The present study aims to elucidate the associations of cTnI and cTnT with CVD in clinically stable dialysis patients.Troponin levels were measured using 5th generation hs-cTnT assays (Roche) and STAT hs-cTnI assays (Abbott) in a cohort of dialysis patients. Serum troponin levels were divided into tertiles with the lowest tertile as a reference value. Serum troponins were associated with indicators of CVD such as left ventricular mass index (LVMI), left ventricular ejection fraction (LVEF) and the presence of coronary artery disease (CAD). Associations were explored using regression analysis.We included 154 consecutive patients, 68±7 years old, 77% male, 70% hemodialysis. Median serum cTnT was 51ng/L (exceeding the 99th percentile of the healthy population in 98%) and median serum cTnI was 13ng/L (elevated in 20%). A high cTnI (T3) was significantly associated with a higher LVMI (Beta 31.60; p=0.001) and LVEF (Beta -4.78; p=0.005) after adjusting for confounders whereas a high serum cTnT was not. CAD was significantly associated with a high cTnT (OR 4.70 p=0.02) but not with a high cTnI. Unlike cTnI, cTnT was associated with residual renal function (Beta:-0.09; p=0.006).In the present cohort, serum cTnI levels showed a stronger association with LVMI and LVEF than cTnT. However, cTnT was significantly associated with CAD and residual renal function, unlike cTnI. Therefore, cTnI seems to be superior to cTnT as a marker of left ventricular dysfunction in asymptomatic dialysis patients, while cTnT might be better suited to detect CAD in these patients.

AimGuideline implementation programs are of paramount importance in optimizing acute ST-elevation myocardial infarction (STEMI) care. Assessment of performance indicators from a local STEMI network will provide knowledge of how to improve the system of care.Methods and resultsBetween 2008-2011, 1505 STEMI patients were enrolled. We compared the performance indicators before (n = 869) and after implementation (n = 636) of a local STEMI network. In 2011 (after introduction of STEMI networking) compared to 2008-2010, there were more inter-hospital referrals for STEMI patients (61% vs 56%, p12 hours after symptom onset) were similar (53% vs 51%, NS). Moreover, the numbers of patients with door-to-balloon time ≤ 90 minutes were similar (49.1% vs 51.3%, NS), and in-hospital mortality rates were similar (8.3% vs 6.9%, NS) in 2011 compared to 2008-2010.ConclusionAfter a local network implementation for patients with STEMI, there were significantly more inter-hospital referral cases, primary PCI procedures, and patients with a door-to-needle time ≤ 30 minutes, compared to the period before implementation of this network. However, numbers of patients who presented very late, the targeted door-to-balloon time and in-hospital mortality rate were similar in both periods. To improve STEMI networking based on recent guidelines, existing pre-hospital and in-hospital protocols should be improved and managed more carefully, and should be accommodated whenever possible.