Non-HDL cholesterol is an independent risk factor for aspirin resistance in obese patients with type 2 diabetes

Accepted Manuscript Non-HDL cholesterol is an independent risk factor for aspirin resistance in obese patients with type 2 diabetes Jong Dai Kim, Cheol-Young Park, Kue Jeong Ahn, Jae Hyoung Cho, Kyung Mook Choi, Jun Goo Kang, Jae Hyeon Kim, Ki Young Lee, Byung Wan Lee, Ji Oh Mok, Min Kyong Moon, Joong Yeol Park, Sung Woo Park PII:

S0021-9150(14)00039-2

DOI:

10.1016/j.atherosclerosis.2014.01.015

Reference:

ATH 13377

To appear in:

Atherosclerosis

Received Date: 7 October 2013 Revised Date:

6 January 2014

Accepted Date: 6 January 2014

Please cite this article as: Kim JD, Park C-Y, Ahn KJ, Cho JH, Choi KM, Kang JG, Kim JH, Lee KY, Lee BW, Mok JO, Moon MK, Park JY, Park SW, Non-HDL cholesterol is an independent risk factor for aspirin resistance in obese patients with type 2 diabetes, Atherosclerosis (2014), doi: 10.1016/ j.atherosclerosis.2014.01.015. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Non-HDL cholesterol is an independent risk factor for aspirin resistance in obese patients with type 2 diabetes.

Authors: Jong Dai Kim1*, Cheol-Young Park1*, Kue Jeong Ahn2, Jae Hyoung Cho3, Kyung

Mok9, Min Kyong Moon10, Joong Yeol Park11, Sung Woo Park1

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Mook Choi4, Jun Goo Kang5, Jae Hyeon Kim6, Ki Young Lee7, Byung Wan Lee8, Ji Oh

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Affiliations: 1. Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University College of Medicine, #108 Pyung-

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Dong, Jongno-Gu, Seoul, Republic of Korea.

2. Division of Endocrinology and Metabolism, Department of Internal Medicine, Gangdong Kyunghee Hospital, Kyunghee University College of Medicine, #892 Dongnam-Ro, Gangdong-Gu, Seoul, Republic of Korea.

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3. Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul Saint Mary’s Hospital, The Catholic University of Korea College of Medicine, #222 Banpodae-Ro, Seocho-Gu, Seoul, Republic of Korea.

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4. Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, #148 Gurodong-Ro, Guro-

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Gu, Seoul, Republic of Korea. 5. Division of Endocrinology and Metabolism, Department of Internal Medicine, Pyungchon Sacred Heart Hospital,

Hallym University College of Medicine, #896 Pyungchon-Dong,

Dongan-Gu, Anyang, Gyunggi-Do, Republic of Korea. 6. Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Seoul Hospital, University of Sungkyunkwan College of Medicine, #50 Ilwon-Dong, Gangnam-Gu, Seoul, Republic of Korea. 1

ACCEPTED MANUSCRIPT 7. Division of Endocrinology and Metabolism, Department of Internal Medicine, Gil Hospital, Gacheon University College of Medicine, #774-2 Namdongdae-Ro, Namdong-Gu, Incheon, Republic of Korea. 8. Division of Endocrinology and Metabolism, Department of Internal Medicine, Severance

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Hospital, Yonsei University College of Medicine, #50 Yonsei-Ro, Seodaemun-Gu, Seoul, Republic of Korea.

9. Division of Endocrinology and Metabolism, Department of Internal Medicine, Bucheon

Wonmi-Gu, Bucheon, Gyunggi-Do, Republic of Korea.

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Soonchunhyang Hospital, Soonchunhyang University School of Medicine, #170 Jomaru-Ro,

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10. Division of Endocrinology and Metabolism, Department of Internal Medicine, Boramae Hospital, Seoul National University College of Medicine, #20 Boramae-Ro5, Dongjak-Gu, Seoul, Republic of Korea.

11. Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul Asan

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Hospital, Ulsan University, College of Medicine, #88 Olympic-Ro43, Songpa-Gu, Seoul, Republic of Korea.

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Running title : Atherogenic dyslipidemia and aspirin resistance

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Corresponding authors: Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University College of Medicine, #108 Pyung-Dong, Jongno-Gu, Seoul 110-746, Republic of Korea. Tel.: +82 2 2001 2440; fax: +82 2 2001 2579. E-mail address: [email protected]

*Jong Dai Kim and Cheol Young Park contributed equally to this study. 2

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Keywords: aspirin resistance, non-HDL cholesterol, atherogenic dyslipidemia, and diabetes

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Word Count: 2098 words; Tables: 2, Figure; 2

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ACCEPTED MANUSCRIPT Abstract

Objective : We evaluated the prevalence of aspirin resistance and predictive factors for aspirin resistance in Korean type 2 diabetes patients.

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Approach and Results: A total of 1045 type 2 diabetes patients from 11 hospitals who were taking aspirin (100 mg/day for ≥ 2 weeks) and no other antiplatelet agents were studied to evaluate aspirin resistance. Aspirin resistance was measured in aspirin reaction units using

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VerifyNowⓡ. Aspirin resistance was defined as ≥550 aspirin reaction units.

Aspirin resistance was detected in 102 of the 1045 subjects (prevalence 9.8%). Aspirin

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resistance was associated with total cholesterol (P = 0.013), LDL-cholesterol (P = 0.028), and non-HDL cholesterol (P = 0.008) concentrations in univariate analysis. In multivariate logistic regression analysis, only non-HDL cholesterol was associated with aspirin resistance in obese

0.017).

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(BMI >25kg/m2) type 2 diabetes patients (adjusted odds ratio 3.55, 95% CI: 1.25-10.05, P =

Conclusions: The prevalence of aspirin resistance in Korean type 2 diabetes patients is 9.8%. Non-HDL cholesterol is an independent risk factor for aspirin resistance, especially in obese

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type 2 diabetes patients.

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ACCEPTED MANUSCRIPT Introduction

It is estimated that between 75 and 80% of diabetes-related deaths are attributable to cardiovascular complications (1). Diabetes patients have a 2- to 4-fold increased risk of

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developing atherosclerotic cardiovascular disease (2). Diabetes without previous myocardial infarction (MI) carries a risk for subsequent acute coronary events equivalent to non-diabetes patients with previous MI (3).

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Current American Diabetes Association (ADA) guidelines recommend that aspirin be considered as a primary prevention strategy in subjects with type 1 or type 2 diabetes who are

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>50 years of age (men) or >60 years of age (women), and who have at least one additional major risk factor. Aspirin is recommended as a secondary prevention strategy in those with diabetes and a history of cardiovascular disease (CVD) (4).

In diabetes patients, aspirin is less effective than in non-diabetes patients for decreasing

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cardiovascular events (5). Subjects with aspirin resistance have a 4-fold higher cardiovascular event rate than those without aspirin resistance (6). And subjects with diabetes have higher aspirin resistance prevalence (4). Once a subject begins to take aspirin, they should take it

early as possible.

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consistently. It may be helpful to identify aspirin resistance in subjects with type 2 diabetes as

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There is no consensus on when to check for aspirin resistance, and it may be useful to find clinical factors associated with aspirin resistance in type 2 diabetes patients. No large-scale, multicenter studies of aspirin resistance epidemiology in type 2 diabetes patients exist, so we investigated the prevalence of aspirin resistance and predicting factors for aspirin resistance in this multicenter study.

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ACCEPTED MANUSCRIPT Research design and methods Study Participants A total of 1056 type 2 diabetes patients over 20 years of age who were taking aspirin (100 mg/day for at least weeks) were recruited from 11 hospitals between March 2011 and May

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2012 for our aspirin resistance research group. We excluded 11 subjects who had not had their aspirin reaction unit values checked.

Subjects were excluded if they had type 1 diabetes, gestational diabetes, were pregnant or

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lactating, had anemia (hemoglobin < 80 g/L), thyrotoxicosis, hypothyroidism, active liver disease (aspartate aminotransferase (AST), alanine aminotransferase (ALT) ≥ 2 upper normal

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limit), liver cirrhosis or malignancy, were taking other anti-platelet agents (sarpogrelate, beraprost, indobufen, triflusal, clopidrogel, cilostazol or ticlipidine) or non-steroidal antiinflammatory drugs (NSAIDS), were taking warfarin, coumarin or digoxin, were administered heparin within 24 hours of enrollment, or had a history of bleeding disorders, a

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platelet count <150x109/L or >500x109/L, a history of myeloproliferative disorder, or a history of thrombocytopenic disorder.

The study protocol was approved by the institutional review board at each participating

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institution. This study was conducted in accordance with the Declaration of Helsinki. All

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participants provided signed, written informed consent.

Anthropemetric and laboratory measurements Laboratory aspirin resistance was measured using a commercially available Ultegra Rapid Platelet Function Assay-ASA (VerifyNowⓡ System; Accumetrics, SanDiego, CA, USA), which measures agonist (arachidonic acid)-induced platelet aggregation by detecting optical signal changes caused by aggregation and is expressed as aspirin reaction units (ARUs). Aspirin resistance was defined as ≥ 550 aspirin reaction units (ARUs) according to the 6

ACCEPTED MANUSCRIPT manufacturer’s manual. Anthropometric measures (height, weight, abdominal circumference), systolic blood pressure (SBP), diastolic blood pressure (DBP), peak wave velocity (PWV), fasting serum glucose, fasting insulin, hemoglobin A1C (HbA1C), homeostasis model assessment-insulin

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resistance (HOMA-IR), blood pressure, lipid profile, complete blood count (CBC), blood urea nitrogen (BUN)/creatinine (Cr), AST/ALT, ophthalmological medical records, and 24hour urine or spot urine microalbumin values were checked. Several clinical parameters were used

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within six months from the time ARU was checked.

Questionnaires for diabetes duration, past medical history for angina, myocardial infarction,

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stroke, peripheral vascular disease, family history for angina, myocardial infarction, stroke, peripheral vascular disease, alcohol history, and smoking status were completed. BMI (kg/m2) was calculated as body weight in kilograms divided by height in meters squared. HbA1c levels were measured using high performance liquid chromatography

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(HPLC). Serum insulin levels were measured using an immunoradiometric assay. Insulin resistance was estimated using HOMA-IR, defined as [fasting plasma insulin (mU/L) x fasting plasma glucose (mmol/L)] ÷ 22.5. Chemistry values were determined using standard

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assays in each local laboratory. Glomerular filtration rate (GFR) was estimated by the

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Modification of Diet in Renal Disease (MDRD) Study Group formula (7). A high HbA1C level is defined as above 6.5% (8). Obesity is defined as a BMI ≥ 25 kg/m2 by the WHO Asiapacific region definition (9). Remnant cholesterol was calculated as total cholesterol – high density lipoprotein (HDL) cholesterol – low density lipoprotein (LDL) cholesterol (10).

Statistical analysis To compare clinical characteristics between the aspirin resistance group and aspirin sensitive group, the Chi-square test or Fisher’s exact test was used for nominal variables, and a two7

ACCEPTED MANUSCRIPT sample t-test or Mann-Whitney test was used for continuous variables. An analysis of the relationship between variables, with aspirin resistance as an independent risk factor, was performed through a backward stepwise regression method of logistic regression analysis. The odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Statistical

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using PASW Statistics version 18 (SPSS Inc., Chicago, IL, U.S.A).

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significance was considered a two-tailed P-value<0.05. Statistical analysis was performed

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ACCEPTED MANUSCRIPT Results

We found that 102 of 1045 subjects had aspirin resistance; the prevalence of aspirin resistance was thus 9.8%. The clinical characteristics and parameters of the aspirin resistance

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group and aspirin non-resistance groups are described in Table 1. There was no difference in aspirin resistance by sex. A history of hypertension was more common in the aspirin nonresistant group; however, there was no difference in blood pressure values between the two

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groups by virtue of medication. Fasting serum glucose and HbA1C levels were higher in the aspirin resistant group, but were not significantly different between the two groups (P = 0.158

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and 0.373, respectively). Among lipid parameters, non-HDL cholesterol (P = 0.008), total cholesterol (P = 0.013), and LDL cholesterol (P = 0.028) levels were associated with aspirin resistance. HDL, triglyceride (TG) levels and remnant cholesterol were not significantly associated with aspirin resistance (P = 0.096, 0.316 and 0.166 respectively), but TG/HDL

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ratio was significantly higher in the aspirin resistance group (P = 0.036). We investigated the prevalence of aspirin resistance by non-HDL quartile and we defined high non-HDL cholesterol as the highest non-HDL cholesterol quartile (≥3.18mmol/L).

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Prevalence of aspirin resistance was increased according to non HDL quartile (Figure 1). In multivariate logistic regression analysis, only high non-HDL cholesterol was marginally

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correlated with aspirin resistance (P = 0.049, adjusted OR 1.84, 95% CI 1.00-3.37) among parameters such as age, sex, HbA1C level, non-HDL cholesterol, SBP, BMI, smoking status, and statin treatment. A subgroup analysis was performed by BMI, using 25 kg/m2 as a cutoff point (9). After multiple logistic regression analysis, in the BMI < 25 kg/m2 groups, high nonHDL cholesterol levels were not associated with aspirin resistance (P=0.701). In the BMI ≥ 25 kg/m2 groups, high non-HDL cholesterol levels were correlated with aspirin resistance (adjusted OR 3.55, 95% CI: 1.25-10.05, P = 0.017) after adjusting for age, sex, smoking status, 9

ACCEPTED MANUSCRIPT systolic blood pressure, BMI, HbA1C level, and statin treatment (Table 2). When we compared the odds ratios for aspirin resistance in the high remnant cholesterol, high non-HDL cholesterol and high LDL cholesterol (defined as the highest quartile of each cholesterol) groups with a BMI≥25kg/m2, subjects with high non-HDL cholesterol levels

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showed a higher odds ratio than those with high LDL cholesterol levels and high remnant cholesterol (adjusted OR 3.55, 95% CI 1.25-10.05 vs. adjusted OR 1.67, 95% CI: 0.53-5.25

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vs adjusted OR 1.43, 95% CI: 0.61-3.45 respectively ) (Figure 2).

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ACCEPTED MANUSCRIPT Discussion

Diabetic patients have increased platelet reactivity compared with non-diabetes subjects on aspirin treatment (11). Patients with diabetes have not only high cardiovascular risk, but also a

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high prevalence of aspirin resistance (2, 12). In our study, the prevalence of aspirin resistance in Korean type 2 diabetes patients was 9.8%. This result is similar to a previous small-scale study that also used VerifyNowⓡ and reported a prevalence of 9.4% in Korean type 2

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diabetes patients (13). In coronary artery disease patients in China, the same region of East Asia, the prevalence of aspirin resistance was 8.8% using the same method (14).

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Analysis of aspirin resistance has not been routinely performed in clinical practice. However, several studies have clearly shown that different cardiovascular outcomes can occur in patients with or without aspirin resistance (15-16). One factor limiting widespread analysis of aspirin resistance has been the lack of a gold-standard laboratory test to facilitate clinical

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definition of aspirin resistance. We used the FDA-approved VerifyNowⓡ to evaluate aspirin resistance. VerifyNowⓡ provides a relatively straightforward and rapid procedure to evaluate aspirin resistance in the clinical setting. Indeed, several prospective longitudinal outcome

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studies using by VeryfyNowⓡ have now shown that patients who do not respond adequately

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to aspirin may be at greater risk of coronary heart disease, acute ischemic stroke and other vascular events (17-22).

Many previous studies differ in identifying predicting factors. These studies have several limitations to finding these factors; many are small-scale studies involving only a single center. In previous studies, age, sex, low hemoglobin, glucose, HbA1C, fibrinogen, high platelet count, low GFR, waist circumference, BMI, coronary heart disease history, HDL cholesterol, LDL cholesterol, TG, and total cholesterol values have been reported as factors associated with aspirin resistance (12-14, 23-33). In our study, in univariate analysis, we 11

ACCEPTED MANUSCRIPT found total cholesterol, LDL cholesterol, non-HDL cholesterol, and TG/HDL ratio values to be associated with aspirin resistance. In multivariate analysis, only high non-HDL cholesterol was associated with aspirin resistance. Obese conditions hyperactivate platelets through inflammatory triggers and enhanced lipid

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peroxidation in vitro (34). Some clinical trials show that aspirin resistance is significantly associated with obesity (12, 29), so we conducted a subgroup analysis by BMI. In our study, high non-HDL cholesterol was associated with aspirin resistance in the obesity group

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(BMI≥25kg/m2), but not in the non-obesity group. Therefore, we infer that the overall

dependent on the presence of obesity.

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significance of the association between non-HDL cholesterol and aspirin resistance may be

Several studies have reported that LDL cholesterol is associated with aspirin resistance (3032). Both non-oxidized LDL and oxidized LDL cholesterol activate platelets in in vitro studies (35, 36). And statin therapy reduces aspirin resistance after several months of

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treatment (37, 38). In our study, LDL cholesterol and was not associated with aspirin resistance. And TG/HDL ratio also was not associated with aspirin resistance. Both VLDLand IDL cholesterol, as a marker for remnant lipoproteins are triglyceride-rich lipoproteins. In

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this study, we calculated the remnant cholesterol (10) in place of VLDL fraction measurement. But remnant cholesterol was not correlated with aspirin resistance.

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These results may be influenced by several factors. In our study population, a considerable number (96.7%) of dyslipidemic subjects were taking lipid lowering agents. The target goal achievement group (LDL cholesterol <2.6mmol/L) had a low prevalence of aspirin resistance, even in the obese subgroup (P = 0.004 (data were not shown)). Type 2 diabetic patients have a high frequency of atherogenic dyslipidemia, especially with respect to low HDL cholesterol, high triglycerides, and elevated small dense low density lipoprotein levels. Both apolipoprotein B (apoB) and non-HDL cholesterol levels have been 12

ACCEPTED MANUSCRIPT shown to be more powerful predictors of cardiovascular risk than other conventional lipid parameters, including LDL cholesterol (39). Although most dyslipidemic subjects (96.7%) were treated and the mean LDL cholesterol level was lower than the American Diabetes Association target goal (2.35 ± 0.68 mmol/L), aspirin resistance was still found in 10% of our

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study population. This shows that non-HDL cholesterol level may be a better predictor of aspirin resistance than LDL cholesterol level under these conditions. Therefore, an atherogenic dyslipidemia profile associated with high cardiovascular risk and non-HDL

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cholesterol-related aspirin resistance may influence cardiovascular risk.

One advantage of our study is that it is the largest epidemiologic study for aspirin resistance

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to our knowledge. This study is also a multicenter study. Because a considerable proportion of our East Asian type 2 diabetes subjects were non-obese, we could compare the effect of obesity on aspirin resistance. This study has several limitations. First, we did not include a control group. Second, we did not measure apo B, small dense LDL and VLDL fraction for

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further analysis. Third, we used only one method to detect aspirin resistance. Lastly, it was based on a cross-sectional analysis and thus, it was not possible to determine causal relationships.

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We have demonstrated that non-HDL cholesterol is an independent predictor of aspirin resistance in obese subjects with type 2 diabetes. This is the first study to elucidate the

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association between non-HDL cholesterol and aspirin resistance in type 2 diabetes subjects. A prospective study of the relationship between cardiovascular outcome and non-HDL cholesterol-related aspirin resistance is needed.

Acknowledgement J.D.K analysis the data and wrote the manuscript. C.Y.P designed the study, interpreted the data, contributed to the discussion, and wrote the manuscript. K.J.A., J.H.C, K.M.C, J.G.K, 13

ACCEPTED MANUSCRIPT J.H.K, K.Y.L, B.Y.L., J.O.M., M.K.M and J.Y.P. recruited the patients and reviewed the manuscript. S.W.P designed the study and is the guarantor of this study.

Sources of funding : This work was funded by Korea Otsuka pharmaceuticals. The design,

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analysis, interpretation of the data and decision to publish was the sole responsibility of the authors and independent of the funders.

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Disclosure : No other actual or potential conflicts of interest to disclose.

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ACCEPTED MANUSCRIPT Table 1. Baseline characteristics of the study subjects Total (n=1045)

Aspirin

resistance(-)

Aspirin resistance(+) p-value

61.4 ± 9.4

61.5 ± 9.4

60.4 ± 9.9

0.231

Sex (F:M%)

42.4:57.6

42.7:57.3

39.2:60.8

0.494

ARUs

462.1 ± 63.1

446.8 ±43.0

610.3 ± 65.5

<0.001

DM duration

9.8 ± 7.2

9.9 ± 7.3

9.0 ± 6.7

0.216

Smoking (%)

26.0%

25.0%

25.3%

0.956

HTN history (%)

67.3

68.5

58.4

0.031

HTN treatment (%)

98.2

98.1

98.4

1.000

Dyslipidemia history (%)

69.1

69.7

63.0

0.168

Dyslipidemia treatment (%)

96.8

97.0

96.7

0.168

Stroke (%)

4.6

4.6

4.9

0.805

CAD (%)

11.6

11.8

9.8

0.550

PAD (%)

2.9

2.8

4.2

0.347

Family CV event history (%)

19.9

20.0

18.6

0.754

Retinopathy (%)

15.9

15.7

18.0

0.579

Microalbuminuria (%)

11.0

10.9

12.1

0.736

TE D

M AN U

RI PT

Age (yrs)

SC

(n=105)

EP

(n=940)

10.8

10.3

15.2

0.147

Waist (m)

0.876 ± 0.096

0.876 ± 0.097

0.877 ±0.087

0.744

BMI (kg/m2)

25.3 ± 3.4

25.3 ± 3.4

25.5 ± 3.5

0.900

SBP (mmHg)

124.3 ± 13.3

124.3 ± 13.1

125.1 ± 14.7

0.525

DBP (mmHg)

74.5 ± 18.0

74.6 ± 18.7

73.7 ± 10.0

0.770

FSG (mmol/L)

7.48 ± 2.36

7.44 ± 2.31

7.89 ± 2.78

0.158

HbA1C (%)

7.4 ± 1.4

7.4 ±1.4

7.5 ± 1.4

0.373

High HbA1C (%)

76.1%

75.4%

83.7%

0.060

Hgb (g/L)

134 ± 17.8

134 ± 17.8

137 ± 17.4

0.207

AC C

Peripheral neuropathy (%)

20

ACCEPTED MANUSCRIPT Total cholesterol (mmol/L)

3.96 ± 0.9

3.93 ± 0.88

4.17 ± 0.98

0.013

HDL (mmol/L)

1.23 ± 0.33

1.24 ± 0.33

1.18 ± 0.34

0.096

LDL (mmol/L)

2.19 ± 0.75

2.18 ± 0.75

2.35 ± 0.68

0.028

TG (mmol/L)

1.51 ± 1.01

1.51 ± 1.02

1.59 ± 0.87

0.316

0.58 ± 0.36

0.57 ± 0.35

0.72 ± 0.47

0.166

2.73 ± 0.84

2.69 ± 0.86

2.95 ± 0.86

0.008

TG/HDL ratio

3.2 ± 3.0

3.1 ± 2.7

4.0 ± 5.1

0.036

AST (U/L)

25.6 ± 12.8

25.5 ± 12.8

25.7 ± 13.2

0.826

ALT (U/L)

27.3 ± 16.6

27.1 ± 16.2

29.0 ± 19.3

0.883

Creatinine (mmol/L)

1.0 ± 0.3

1.0 ± 0.3

1.0 ± 0.3

0.958

eGFR(ml/min/1.73m2)

65.3 ± 20.3

65.2 ± 20.2

66.2 ± 21.1

0.410

Insulin (pmol/L)

70.1 ± 45.1

71.5 ± 45.1

56.9 ± 44.4

0.070

HOMA-IR

3.3 ± 2.5

3.3 ± 2.5

2.9 ± 2.7

0.205

cholesterol

RI PT

Remnant (mmol/L)* Non-HDL

TE D

M AN U

SC

Cholesterol (mmol/L)

Data are presented as mean ± S.D. or %.

F, female; M, male; ARUs, aspirin reaction units; DM, diabetes mellitus; HTN, hypertension; CAD, coronary

EP

artery disease; PAD, peripheral artery disease; CV, cardiovascular; SBP, systolic blood pressure; DBP, diastolic blood pressure; FSG, fasting serum (serum) glucose; HbA1C, Hemoglobin A1C; Hgb, Hemoglobin; TG, triglycerides; VLDL, very low density lipoprotein cholesterol; IDL, intermediate density cholesterol; AST,

AC C

aspartate aminotransferase; ALT, alanine aminotransferase; HOMA-IR, homeostatic model assessment – insulin resistance. *Remnant cholesterol = total cholesterol - HDL – LDL.

21

ACCEPTED MANUSCRIPT Table 2. Associations of aspirin resistance with high non-HDL cholesterola using BMI categories Model

BMI<25(kg/m2)

Total

BMI≥25(kg/m2)

OR

95% CI

P

OR

95% CI

P

OR

95% CI

Model 1b

0.043

1.72

1.02-2.90

0.701

0.84

0.350-2.04

0.003

3.34

1.50-7.47

Model 2b

0.034

1.76

1.04-2.98

0.718

0.85

0.35-2.07

0.001

3.93

1.72-8.97

Model 3b

0.049

1.84

1.00-3.37

0.928

0.94

0.26-3.45

0.017

3.55

1.25-10.05

High non-HDL cholesterol was defined as highest quartile non-HDL cholesterol quartile (≥3.18mmol/L).

b

Model 1 is unadjusted. Model 2 is adjusted by age and sex. Model 3 is further adjusted by smoking status,

SC

a

RI PT

P

AC C

EP

TE D

Values are expressed as OR and 95% CI.

M AN U

systolic blood pressure, hemoglobin A1C value, BMI, and statin medication use,

22

ACCEPTED MANUSCRIPT Legends Figure 1. Prevalence of aspirin resistance by non-HDL quartile in type 2 diabetes.

AC C

EP

TE D

M AN U

SC

RI PT

Figure 2. Comparison of odds ratio between high non-HDL cholesterol, high LDL cholesterol, and high remnant cholesterol for aspirin resistance in obese type 2 diabetes.

23

ACCEPTED MANUSCRIPT

Highlights

This is the first study to elucidate the association between non-HDL cholesterol and aspirin resistance in type 2 diabetes.

AC C

EP

TE D

M AN U

SC

RI PT

Even statin treatment, there is still residual risk. This study support the hypothesis that the residual risk is related to non-HDL cholesterol especially in patients with atherogenic dyslipidemia.

ACCEPTED MANUSCRIPT

RI PT

Figure 1. Prevalence of aspirin resistance by non-HDL quartile in type 2 diabetes.

SC

%

40

M AN U

34.8% P for trend = 0.007

29.0%

30

TE D

21.7% 20

EP

14.5%

0 1st

AC C

10

1 quartile

2nd

2 quartile

3rd

3 quartile

4th

4 quartile

Non-HDL cholesterol

ACCEPTED MANUSCRIPT

RI PT

Figure 2. Comparison of odds ratio between high non-HDL cholesterol, high LDL cholesterol, and high remnant cholesterol for aspirin resistance in obese type 2 diabetes. OR

unadjusted

SC

High non-HDL cholesterola

M AN U

High LDL cholesterolb High remnant cholesterolc,d

e

High non-HDL cholesterola

adjusted

TE D

High LDL cholesterolb

1

decreased risk for aspirin resistance

AC C

0.1

EP

High remnant cholesterolc,d

95% CI

3.34

1.50-7.47

2.27

1.00-5.13

1.43

0.61-3.45

3.55

1.25-10.05

1.67

0.53-5.25

1.43

0.61-3.45

10 Increased risk for aspirin resistance

non-HDL, LDL and remnant cholesterol is defined as 4th quartile non-HDL, LDL, and remnant cholesterol. remnant cholesterol is calculated by total cholesterol – HDL cholesterol – LDL cholesterol. e adjusted for age, sex, smokings, systolic blood pressure, hemoglobinA1C, body mass index and statin medication.

a,b,c High d

100 Odds ratio

ACCEPTED MANUSCRIPT

Highlights

This is the first study to elucidate the association between non-HDL cholesterol and aspirin resistance in type 2 diabetes.

RI PT

This study support the hypothesis that the residual cardiovascular risk after statin is related to non-HDL cholesterol.

AC C

EP

TE D

M AN U

SC

This study suggest that more aggressive statin treatment is needed to achieve non-HDL target in obese type 2 diabetes.