Statin intolerance - an attempt at a unified definition. Position paper from an International Lipid Expert Panel

Statins are one of the most commonly prescribed drugs in clinical practice. They are usually well tolerated and effectively prevent cardiovascular events. Most adverse effects associated with statin therapy are muscle-related. The recent statement of the European Atherosclerosis Society (EAS) has focused on statin-associated muscle symptoms (SAMS), and avoided the use of the term 'statin intolerance'. Although muscle syndromes are the most common adverse effects observed after statin therapy, excluding other side effects might underestimate the number of patients with statin intolerance, which might be observed in 10 - 15% of patients. In clinical practice, statin intolerance limits effective treatment of patients at risk of, or with, cardiovascular disease. Knowledge of the most common adverse effects of statin therapy that might cause statin intolerance and the clear definition of this phenomenon is crucial to effectively treat patients with lipid disorders. Therefore, the aim of this position paper was to suggest a unified definition of statin intolerance, and to complement the recent EAS statement on SAMS, where the pathophysiology, diagnosis and the management were comprehensively presented.

Systolic Blood Pressure and Outcomes in Patients With Heart Failure With Preserved Ejection Fraction

IMPORTANCE

Lower systolic blood pressure (SBP) levels are associated with poor outcomes in patients with heart failure. Less is known about this association in heart failure with preserved ejection fraction (HFpEF).

OBJECTIVE

To determine the associations of SBP levels with mortality and other outcomes in HFpEF.

DESIGN, SETTING, AND PARTICIPANTS

A propensity score-matched observational study of the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry included 25 354 patients who were discharged alive; 8873 (35.0%) had an ejection fraction of at least 50%, and of these, 3915 (44.1%) had stable SBP levels (≤20 mm Hg admission to discharge variation). Data were collected from 259 hospitals in 48 states between March 1, 2003, and December 31, 2004. Data were analyzed from March 1, 2003, to December 31, 2008.

EXPOSURE

Discharge SBP levels less than 120 mm Hg. A total of 1076 of 3915 (27.5%) had SBP levels less than 120 mm Hg, of whom 901 (83.7%) were matched by propensity scores with 901 patients with SBP levels of 120 mm Hg or greater who were balanced on 58 baseline characteristics.

MAIN OUTCOMES AND MEASURES

Thirty-day, 1-year, and overall all-cause mortality and heart failure readmission through December 31, 2008.

RESULTS

The 1802 matched patients had a mean (SD) age of 79 (10) years; 1147 (63.7%) were women, and 134 (7.4%) were African American. Thirty-day all-cause mortality occurred in 91 (10%) and 45 (5%) of matched patients with discharge SBP of less than 120 mm Hg vs 120 mm Hg or greater, respectively (hazard ratio [HR], 2.07; 95% CI, 1.45-2.95; P < .001). Systolic blood pressure level less than 120 mm Hg was also associated with a higher risk of mortality at 1 year (39% vs 31%; HR, 1.36; 95% CI, 1.16-1.59; P < .001) and during a median follow-up of 2.1 (overall 6) years (HR, 1.17; 95% CI, 1.05-1.30; P = .005). Systolic blood pressure level less than 120 mm Hg was associated with a higher risk of heart failure readmission at 30 days (HR, 1.47; 95% CI, 1.08-2.01; P = .02) but not at 1 or 6 years. Hazard ratios for the combined end point of heart failure readmission or all-cause mortality associated with SBP level less than 120 mm at 30 days, 1 year, and overall were 1.71 (95% CI, 1.34-2.18; P < .001), 1.21 (95% CI, 1.07-1.38; P = .004), and 1.12 (95% CI, 1.01-1.24; P = .03), respectively.

CONCLUSIONS AND RELEVANCE

Among hospitalized patients with HFpEF, an SBP level less than 120 mm Hg is significantly associated with poor outcomes. Future studies need to prospectively evaluate optimal SBP treatment goals in patients with HFpEF.

Comparison of incidences of congestive heart failure in older African-Americans, Hispanics, and whites

In a prospective study of 2,893 African-Americans, Hispanics, and whites, mean age 81 years, at 43-month follow-up, congestive heart failure (CHF) developed in 194 of 686 African-Americans (28%), in 67 of 257 Hispanics (26%), and in 533 of 1,950 whites (27%) (p = NS). The Cox regression model showed that significant independent risk factors for CHF were male gender (risk ratio = 1.4, p = 0.0001); hypertension (risk ratio = 2.5, p = 0.0001); coronary artery disease (risk ratio = 4.0, p = 0.0001); diabetes mellitus (risk ratio = 1.6, p = 0.0001); and age (risk ratio = 1.05, p = 0.0001).

Epidemiology, pathophysiology, prognosis, and treatment of systolic and diastolic heart failure

Underlying causes, risk factors, and precipitating causes of heart failure (HF) should be treated. Drugs known to precipitate or aggravate HF such as nonsteroidal antiinflammatory drugs should be stopped. Patients with HF and a low left ventricular ejection fraction (systolic heart failure) or normal ejection fraction (diastolic HF) should be treated with diuretics if fluid retention is present, with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor because of cough, angioneurotic edema, rash, or altered taste sensation, and with a beta blocker unless contraindicated. If severe systolic HF persists, an aldosterone antagonist should be added. If HF persists, isosorbide dinitrate plus hydralazine should be added. Calcium channel blockers should be avoided if systolic HF is present. Digoxin should be avoided in men and women with diastolic HF if sinus rhythm is present and in women with systolic HF. Digoxin should be given to men with systolic HF if symptoms persist, but the serum digoxin level should be maintained between 0.5 and 0.8 ng/mL.

Effect of ethanol on angina pectoris

We evaluated the effect of ethanol on exercise performance until angina in 12 patients in a double-blind, randomized study. The mean resting heart rate times systolic blood pressure was not changed after Fresca but was increased after 2 ounces of ethanol (P less than 0.001) and after 5 ounces of ethanol (P less than 0.01). Compared to the control periods, the mean exercise time until angina was not different after Fresca but was decreased after 2 ounces of ethanol (P less than 0.001) and after 5 ounces of ethanol (P less than 0.001). Compared to the control periods, the mean maximal ischemic ST-segment depression after angina was not changed after Fresca but was increased after 2 ounces of ethanol (P less than 0.01) and after 5 ounces of ethanol (P less than 0.001). Drinking 5 ounces or 2 ounces of ethanol decreases exercise duration until angina and increases ischemic ST-segment depression after angina.

Cardiac involvement in hemochromatosis

Cardiac hemochromatosis or primary iron-overload cardiomyopathy is an important and potentially preventable cause of heart failure. This is initially characterized by diastolic dysfunction and arrhythmias and in later stages by dilated cardiomyopathy. Diagnosis of iron overload is established by elevated transferrin saturation (>55%) and elevated serum ferritin (>300 ng/mL). Genetic testing for mutations in the HFE (high iron) gene and other proteins, such as hemojuvelin, transferrin receptor, and ferroportin, should be performed if secondary causes of iron overload are ruled out. Patients should undergo comprehensive 2D and Doppler echocardiography to evaluate their systolic and diastolic function. Newer modalities like strain imaging and speckle-tracking echocardiography hold promise for earlier detection of cardiac involvement. Cardiac magnetic resonance imaging with measurement of T2* relaxation times can help quantify myocardial iron overload. In addition to its value in diagnosis of cardiac iron overload, response to iron reduction therapy can be assessed by serial imaging. Therapeutic phlebotomy and iron chelation are the cornerstones of therapy. The average survival is less than a year in untreated patients with severe cardiac impairment. However, if treated early and aggressively, the survival rate approaches that of the regular heart failure population.

Non-ST-elevation myocardial infarction in the United States: contemporary trends in incidence, utilization of the early invasive strategy, and in-hospital outcomes

BACKGROUND

There has been a paradigm shift in the definition of timing of early invasive strategy (EIS) for patients admitted with non-ST-elevation myocardial infarction (NSTEMI) in the last decade. Data on trends of EIS for NSTEMI and associated in-hospital outcomes are limited. Our aim is to analyze temporal trends in the incidence, utilization of early invasive strategy, and in-hospital outcomes of NSTEMI in the United States.

METHODS AND RESULTS

We analyzed the 2002-2011 Nationwide Inpatient Sample databases to identify all patients ≥40 years of age with the principal diagnosis of acute myocardial infarction (AMI) and NSTEMI. Logistic regression was used for overall, age-, sex-, and race/ethnicity-stratified trend analysis. From 2002 to 2011, we identified 6 512 372 patients with AMI. Of these, 3 981 119 (61.1%) had NSTEMI. The proportion of patients with NSTEMI increased from 52.8% in 2002 to 68.6% in 2011 (adjusted odds ratio [OR; per year], 1.055; 95% confidence interval [CI], 1.054 to 1.056) in the overall cohort. Similar trends were observed in age-, sex-, and race/ethnicity-stratified groups. From 2002 to 2011, utilization of EIS at day 0 increased from 14.9% to 21.8% (Ptrend<0.001) and utilization of EIS at day 0 or 1 increased from 27.8% to 41.4% (Ptrend<0.001). Risk-adjusted in-hospital mortality in the overall cohort decreased during the study period (adjusted OR [per year], 0.976; 95% CI, 0.974 to 0.978).

CONCLUSIONS

There have been temporal increases in the proportion of NSTEMI and, consistent with guidelines, greater utilization of EIS. This has been accompanied by temporal decreases in in-hospital mortality and length of stay.

Postprandial hypotension in 499 elderly persons in a long-term health care facility

OBJECTIVE

To present baseline data from a prospective study of postprandial hypotension in 499 elderly persons in a long-term health care facility.

DESIGN

Analyses of baseline data for a prospective study.

SETTING

A large long-term health care facility where 499 ambulatory or wheelchair-bound residents were studied.

PATIENTS

The 499 residents were > or = 62 years of age, mean age 80 +/- 9 years (range 62-100), 71% female, 29% male, 66% white, 27% black, 7% Hispanic, 68% ambulatory, and 32% wheelchair-bound.

MEASUREMENTS AND MAIN RESULTS

The mean maximal decrease in postprandial systolic and diastolic blood pressures was 15 +/- 6 mm Hg/6 +/- 2 mm Hg. The mean maximal decrease in postprandial systolic blood pressure occurred 15 minutes after eating in 13% of residents, 30 minutes after eating in 20% of residents, 45 minutes after eating in 26% of residents, 60 minutes after eating in 30% of residents, and 75 minutes after eating in 11% of residents. Of 499 residents, 118 (24%) had a maximal decrease in postprandial systolic blood pressure of > or = 20 mm Hg. The mean maximal decrease in postprandial systolic blood pressure was 24 +/- 5 mm Hg in residents with syncope in the prior 6 months and 14 +/- 5 mm Hg in residents without syncope (P < 0.0001). The mean maximal decrease in postprandial systolic blood pressure was 21 +/- 5 mm Hg in residents with falls in the preceding 6 months and 13 +/- 4 mm Hg in residents without falls (P < 0.0001). The mean maximal decrease in postprandial systolic blood pressure was significantly greater in residents treated with angiotensin-converting enzyme inhibitors, calcium channel blockers, diuretics, nitrates, digoxin, and psychotropic drugs than in residents not treated with these drugs. The mean maximal decrease in postprandial systolic and diastolic blood pressures was not significantly different in elderly blacks, Hispanics, and whites.

CONCLUSIONS

A more severe reduction in postprandial systolic blood pressure correlates with a history of syncope or falls in the previous 6 months. Long-term follow-up is being planned to determine whether a marked reduction in postprandial systolic blood pressure in elderly persons correlates with a higher incidence of falls, syncope, new coronary events, new stroke, and total mortality.

Comparison of frequency of new coronary events in older subjects with and without valvular aortic sclerosis

In a prospective study of 1,980 subjects (mean age 81 +/- 8 years) without valvular aortic stenosis, 981 (50%) had valvular aortic sclerosis diagnosed by 2-dimensional and continuous-wave Doppler echocardiography. Independent risk factors for new coronary events were prior coronary artery disease (p = 0.0001, risk ratio 2.8), male gender (p = 0.002, risk ratio 1.3), and valvular aortic sclerosis (p = 0.0001, risk ratio 1.8).

Relation of baseline systolic blood pressure and long-term outcomes in ambulatory patients with chronic mild to moderate heart failure

We studied the impact of baseline systolic blood pressure (SBP) on outcomes in patients with mild to moderate chronic systolic and diastolic heart failure (HF) in the Digitalis Investigation Group trial using a propensity-matched design. Of 7,788 patients, 7,785 had baseline SBP data and 3,538 had SBP ≤ 120 mm Hg. Propensity scores for SBP ≤ 120 mm Hg, calculated for each of the 7,785 patients, were used to assemble a matched cohort of 3,738 patients with SBP ≤ 120 and >120 mm Hg who were well-balanced in 32 baseline characteristics. All-cause mortality occurred in 35% and 32% of matched patients with SBPs ≤ 120 and >120 mm Hg respectively, during 5 years of follow-up (hazard ratio [HR] when SBP ≤ 120 was compared to >120 mm Hg 1.10, 95% confidence interval [CI] 0.99 to 1.23, p = 0.088). HRs for cardiovascular and HF mortalities associated with SBP ≤ 120 mm Hg were 1.15 (95% CI 1.01 to 1.30, p = 0.031) and 1.30 (95% CI 1.08 to 1.57, p = 0.006). Cardiovascular hospitalization occurred in 53% and 49% of matched patients with SBPs ≤ 120 and > 120 mm Hg, respectively (HR 1.13, 95% CI 1.03 to 1.24, p = 0.008). HRs for all-cause and HF hospitalizations associated with SBP ≤ 120 mm Hg were 1.10 (95% CI 1.02 to 1.194, p = 0.017) and 1.21 (95% CI 1.07 to 1.36, p = 0.002). In conclusion, in patients with mild to moderate long-term systolic and diastolic HF, baseline SBP ≤ 120 mm Hg was associated with increased cardiovascular and HF mortalities and all-cause, cardiovascular, and HF hospitalizations that was independent of other baseline characteristics.

Use of Inotropic Agents in Treatment of Systolic Heart Failure

The most common use of inotropes is among hospitalized patients with acute decompensated heart failure, with reduced left ventricular ejection fraction and with signs of end-organ dysfunction in the setting of a low cardiac output. Inotropes can be used in patients with severe systolic heart failure awaiting heart transplant to maintain hemodynamic stability or as a bridge to decision. In cases where patients are unable to be weaned off inotropes, these agents can be used until a definite or escalated supportive therapy is planned, which can include coronary revascularization or mechanical circulatory support (intra-aortic balloon pump, extracorporeal membrane oxygenation, impella, left ventricular assist device, etc.). Use of inotropic drugs is associated with risks and adverse events. This review will discuss the use of the inotropes digoxin, dopamine, dobutamine, norepinephrine, milrinone, levosimendan, and omecamtiv mecarbil. Long-term inotropic therapy should be offered in selected patients. A detailed conversation with the patient and family shall be held, including a discussion on the risks and benefits of use of inotropes. Chronic heart failure patients awaiting heart transplants are candidates for intravenous inotropic support until the donor heart becomes available. This helps to maintain hemodynamic stability and keep the fluid status and pulmonary pressures optimized prior to the surgery. On the other hand, in patients with severe heart failure who are not candidates for advanced heart failure therapies, such as transplant and mechanical circulatory support, inotropic agents can be used for palliative therapy. Inotropes can help reduce frequency of hospitalizations and improve symptoms in these patients.

Relation of cardiac troponin I levels with in-hospital mortality in patients with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage

Troponin I levels were drawn within 24 hours of stroke in 161 of 175 patients (92%) with ischemic stroke, 94 of 107 patients (88%) with intracerebral hemorrhage, and 96 of 96 patients (100%) with subarachnoid hemorrhage. A troponin level >0.4 ng/ml was considered increased. In patients with ischemic stroke, in-hospital mortality occurred in 15 of 23 patients (65%) with increased troponin I compared with 6 of 138 patients (4%) with normal troponin I (p <0.001). In patients with intracerebral hemorrhage, in-hospital mortality occurred in 9 of 14 patients (64%) with increased troponin I compared with 22 of 80 patients (28%) with normal troponin I (p <0.005). In patients with subarachnoid hemorrhage, in-hospital mortality occurred in 8 of 20 patients (40%) with increased troponin I compared with 8 of 76 patients (11%) with normal troponin I (p <0.005). In conclusion, patients with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage with elevated troponin I levels have increased in-hospital mortality.

Inability of the submaximal treadmill stress test to predict the location of coronary disease

Two hundred patients had submaximal treadmill stress tests (STSTs) and selective coronary arteriography performed within 2 months of each other. An attempt was made to assess the predictability of disease isolated to any given coronary vessel by performance on the treadmill. This was not possible for disease isolated to the right coronary, the left anterior descending, the circumflex branch of the left coronary, or a combination of right coronary and circumflex arteries. Eleven patients had disease in the left main coronary artery; all had associated disease of some other branch as well. One of these patients had a negative submaximal treadmill stress test but was unable to reach 90% of his maximum predicted heart rate. The remaining 10 patients had positive STSTs. Patients with 26-50% narrowing of any branch had treadmill results similar to those with 51-75% narrowing. There was a large number of patients with single-vessel disease in the study and most of the negative STSTs occurred in this group. Nevertheless, within this group no one vessel gave a higher incidence of positive STSTs than any other. It is concluded that (1) a positive STST is more likely to be associated with increased severity and extent of coronary artery disease; (2) a negative STST is more likely to be found in disease limited to a single vessel; and (3) within the latter group, the STST is of no value in predicting the specific coronary artery involved.

Changes in ventricular septal thickness during diuretic therapy

We report on changes in echocardiographic parameters of left ventricular muscle mass in 20 hypertensive patients during short-term therapy with hydrochlorothiazide. In the group as a whole, blood pressure fell, but septal thickness and posterior wall thickness did not change. Septal thickness decreased in nine patients, and in all of these patients calculated left ventricular cross-sectional area also decreased. Septal thickness did not change or increased in 11 patients and in only one of these patients did cross-sectional area increase. These increases in septal thickness usually were associated with decreases in left ventricular transverse dimension. We therefore conclude that the increases in left ventricular wall and septal thickness during diuretic therapy probably reflect an adaptive change of cardiac muscle tissue around a smaller left ventricle.

Risk factors for new coronary events in a large cohort of very elderly patients with and without coronary artery disease

Independent risk factors for new coronary events in older men include age, prior coronary artery disease, cigarette smoking, systemic hypertension, diabetes mellitus, serum total cholesterol, and serum high-density lipoprotein cholesterol (inverse association). Independent risk factors for new coronary events in older women include age, prior coronary artery disease, cigarette smoking, systemic hypertension, diabetes mellitus, serum total cholesterol, serum high-density lipoprotein cholesterol (inverse association), and serum triglycerides (weak association).

Lipids, blood pressure and kidney update 2014

This paper is an effort to review all the most important studies and guidelines in the topics of lipid, blood pressure and kidney published in 2014. Irrespective of advances, the options for improving simultaneous hypercholesterolemia and hypertension management (as well as its complication - chronic kidney disease) remain a problem. Recommending hypolidemic, hypotensive and kidney disease drugs to obtain therapy targets in cardiovascular, diabetic, elderly and kidney disease (=high risk) patients might strengthen risk factor control, improve compliance and the therapy efficacy, and in the consequence reduce the risk of cardiovascular events and mortality rate. That is why the authors have decided to summary and discuss the recent scientific achievements in the field of lipid, blood pressure and kidney.

Long-term cardiovascular mortality after radiotherapy for breast cancer: A systematic review and meta-analysis

BACKGROUND

Radiotherapy (RT) is frequently associated with late cardiovascular (CV) complications. The mean cardiac dose from irradiation of a left-sided breast cancer is much higher than that for a right-sided breast cancer. However, data is limited on the long-term risks of RT on CV mortality.

HYPOTHESIS

RT for breast cancer is associated with long term CV mortality and left sided RT carries a greater mortality than right sided RT.

METHODS

We searched PubMed, Cochrane Central, Embase, EBSCO, Web of Science, and CINAHL databases from inception through December 2015. Studies reporting CV mortality with RT for left- vs right-sided breast cancers were included. The principal outcome of interest was CV mortality. We calculated summary risk ratio (RR) and 95% confidence intervals (CI) with the random-effects model.

RESULTS

The analysis included 289 109 patients from 13 observational studies. Women who had received RT for left-sided breast cancer had a higher risk of CV death than those who received RT for a right-sided breast cancer (RR: 1.12, 95% CI: 1.07-1.18, P < 0.001; number needed to harm: 353). Difference in CV mortality between left- vs right-sided breast RT was more apparent after 15 years of follow-up (RR: 1.23, 95% CI: 1.08-1.41, P < 0.001; number needed to harm: 95).

CONCLUSIONS

CV mortality from left-sided RT was significantly higher compared with right-sided RT for breast cancer and was more apparent after ≥15 years of follow-up.