Atenolol: differences in mode of action compared with other antihypertensives. An opportunity to identify features that influence outcome?

The beneficial effect of antihypertensive treatment on the risk of major vascular events is well established. Several trials comparing older and newer drugs in the treatment of primary hypertension suggested that it is the blood pressure achieved, rather than choice of the drug that determines most of the primary outcomes. Beta-blockers have been widely used to treat hypertension and are still recommended as first-line drugs in guidelines. However, recent meta-analyses of trials (either placebo-controlled or using drug comparisons) involving atenolol (a popular beta-blocker), have cast doubt on the suitability of atenolol as a first-line antihypertensive drug. We consider the mechanisms which might be responsible for the inferiority of atenolol in preventing vascular morbidity and mortality in patients with primary hypertension. This knowledge may help design drugs that are not only more effective in achieving blood pressure targets but that also markedly decrease vascular events.

Adequacy of preadmission oral anticoagulation with vitamin K antagonists and ischemic stroke severity and outcome in patients with atrial fibrillation

It is unclear whether vitamin K antagonists affect stroke severity and outcome in patients with atrial fibrillation (AF). We aimed to evaluate this association. We prospectively studied 539 consecutive patients admitted with acute ischemic stroke (41.2 % males, age 78.9 ± 6.6 years). The severity of stroke was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). The outcome was assessed with dependency rates at discharge (modified Rankin scale 2-5) and with in-hospital mortality. 177 patients had a history of AF. The median NIHSS at admission did not differ between patients on acenocoumarol with INR 2.0-3.0, on acenocoumarol with INR < 2.0, on single antiplatelet treatment, on dual antiplatelet treatment, or on no treatment [4 (range 0-26), 13 (0-39), 8 (0-33), 3 (2-23) and 7 (0-33), respectively; p = 0.433]. Dependency rates were lower in patients on acenocoumarol with INR 2.0-3.0 or on dual antiplatelet treatment than in those on acenocoumarol with INR < 2.0, single antiplatelet treatment, or no treatment (20.0, 22.2, 61.5, 58.7 and 68.0 %, respectively; p = 0.024). Independent predictors of dependency were age, NIHSS at admission and history of ischemic stroke. In-hospital mortality did not differ between patients on acenocoumarol with INR 2.0-3.0, on acenocoumarol with INR < 2.0, on single antiplatelet treatment, on dual antiplatelet treatment, or on no treatment (7.7, 18.2, 16.1, 16.7 and 22.2 %, respectively; p = 0.822). In conclusion, optimally anticoagulated patients with AF have more favorable functional outcome after stroke and a trend for less severe stroke whereas patients with subtherapeutic anticoagulation have similar stroke severity and outcome with those on no treatment.

Lack of an association between angiotensin converting enzyme gene polymorphism and peripheral arterial occlusive disease

Numerous factors have been reported to influence the pathogenesis of atherosclerosis. The angiotensin I converting enzyme (ACE) gene is a candidate gene for atherosclerotic-related disease. In the present study, the association between the polymorphism of the ACE gene and peripheral arterial occlusive disease (PAOD) was investigated. Using polymerase chain reaction techniques, 100 patients (age 66.7 +/- 7.7 years) with PAOD and 100 age-matched controls were divided into the three ACE genotypes: II, ID and DD (Insertion I and Deletion D). There was no evidence of any association between ACE gene polymorphism and the presence of PAOD (odds ratio 0.759; 95% confidence interval 0.418-1.377). These results indicate an absence of association between DD genotype and PAOD. Further evaluation in a larger population study is required to examine the possibility of an increased risk of PAOD in DD homozygotes.

Accelerated healing of a diabetic foot ulcer using autologous stromal vascular fraction suspended in platelet-rich plasma

We describe the case of a Type I diabetic patient with a refractory foot ulcer that remained unhealed for 2 years despite conventional therapy. Autologous adipose-derived stromal vascular fraction suspended in autologous platelet-rich plasma was applied to the wound, which completely healed within 1 month. The wound remained closed with no complications for a 2-year follow-up. Reporting of this and similar cases may lead to larger clinical trials that will prove the efficacy of this therapy that may offer accelerated healing and lessen the financial burden of more expensive therapeutic modalities.

Non-alcoholic fatty liver disease: an emerging predictor of stroke risk, severity and outcome

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Effects of different classes of antihypertensive agents on the outcome of acute ischemic stroke

It is unclear whether antihypertensive treatment before stroke affects acute ischemic stroke severity and outcome. To evaluate this association, the authors studied 482 consecutive patients (age 78.8±6.7 years) admitted with acute ischemic stroke. Stroke severity was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). The outcome was assessed with rates of adverse outcome (modified Rankin scale at discharge ≥2). Independent predictors of severe stroke (NIHSS ≥16) were female sex and atrial fibrillation. Treatment with diuretics before stroke was associated with nonsevere stroke. At discharge, patients with adverse outcome were less likely to be treated before stroke with β-blockers or with diuretics. Independent predictors of adverse outcome were older age, higher NIHSS at admission, and history of ischemic stroke. Treatment with diuretics before stroke appears to be associated with less severe neurologic deficit in patients with acute ischemic stroke.

Effect of antiviral treatment on the risk of hepatocellular carcinoma in patients with chronic hepatitis B

Chronic hepatitis B (CHB) is a major risk factor for hepatocellular carcinoma (HCC). The prevention of HCC is of paramount importance in patients with CHB, particularly in those with cirrhosis. Antiviral treatment can potentially reduce the risk for HCC since it suppresses viral replication, induces HBeAg seroconversion and improves liver histology. However, most evidence supporting a protective effect of antiviral treatment originates from non-randomized or retrospective studies and is limited to conventional interferon and lamivudine. There is a paucity of data on the effects of pegylated interferon and "newer" oral agents (telbivudine, tenofovir, entecavir) on HCC risk. However, it should be emphasized that the existing randomized control studies in patients with CHB were relatively short-term and not designed to assess the effects of antiviral treatment on HCC risk. Since viral load directly correlates with HCC risk, it is reasonable to hypothesize that the reduction in viral load with antiviral treatment will also lower the risk of HCC. This benefit might become more readily apparent with the newer agents used in the management of CHB which are more effective and have a more favorable resistance profile.

Treatment options for dyslipidemia in chronic kidney disease and for protection from contrast-induced nephropathy

Chronic kidney disease (CKD) is highly prevalent worldwide and represents a major cardiovascular risk factor. Dyslipidemia is present in most patients with CKD and further worsens CKD, creating a vicious cycle. The treatment of CKD-related dyslipidemia has been a controversial topic. The use of statins is recommended in all stages of CKD, but it appears to reduce cardiovascular and renal events only in the early CKD stages, up to stage 3. The use of atorvastatin has proven very beneficial; thus, the earliest we start statin treatment, the better for the patient. Atorvastatin and pitavastatin do not need dose adjustments at any level of renal function. Fibrates can be administered in mixed hyperlipidemia, combined with statins in early CKD stages. Omega-3 fatty acids are useful for treating hypertriglyceridemia in CKD. Antibodies against proprotein convertase subtilisin/kexin type 9 hold promise for a better control of dyslipidemia and a greater reduction of cardiovascular risk.

Non-Alcoholic Fatty Liver Disease in Patients with HIV Infection

Non-alcoholic fatty liver disease (NAFLD) is highly prevalent in patients with HIV infection and appears to be more severe than in HIV-uninfected patients. Both metabolic (e.g., obesity and insulin resistance) and HIV-related factors (e.g., antiretroviral treatment and inflammation) play a role in the pathogenesis of NAFLD in this population. Accordingly, all patients with HIV infection should be evaluated for the presence of NAFLD. Ultrasound is the first-line diagnostic procedure, but non-alcoholic steatohepatitis has to be diagnosed with liver biopsy. However, non-invasive methods, including serological markers and transient elastography, might also be useful in this population. Lifestyle changes represent the cornerstone of treatment. Bariatric surgery, pioglitazone, and vitamin E can be considered in patients with significant fibrosis or at high risk for progression of NAFLD, including those with type 2 diabetes mellitus, metabolic syndrome, elevated transaminases, or pronounced necroinflammation. However, there are no studies that evaluated the safety of efficacy of diet, exercise, or pharmacotherapy in this population. Therefore, research is needed to identify safe and effective pharmacological treatments for NAFLD in patients with HIV infection.

Skin involvement in Hodgkin's disease

Hodgkin's disease involving the skin is an unusual occurrence and is found in 0.5-3.4 percent of these patients. The most common clinical presentation is of single or multiple dermal or subcutaneous nodules. The mechanisms usually implicated include direct extension from an underlying nodal focus, hematogenous dissemination, and, most often, retrograde lymphatic spread, distal to involved lymph nodes. We report the case of a patient with refractory Hodgkin's disease who presented with skin involvement.

Elevated levels of serum vascular endothelial growth factor in patients with polycythaemia vera

Angiogenesis seems to be a prominent event of myeloproliferative diseases. There are few reported data on angiogenesis and the significance of its stimulator, the vascular endothelial growth factor (VEGF), in polycythaemia vera (PV). We report our observation of elevated serum VEGF levels in patients suffering from PV. Twenty patients with PV and 20 age-matched healthy subjects were enrolled. VEGF levels were measured by a quantitative sandwich enzyme immunoassay. Serum VEGF levels in PV were found to be very significantly higher than in healthy individuals (569.7 +/- 101.2 vs. 164.7 +/- 32.8 pg/ml, p = 0.001). We found no correlation between VEGF and haemoglobin, platelet or leucocyte counts in the patient group. Different therapeutic regimens had no influence on VEGF levels. However, in the control group, we observed a positive correlation between VEGF levels and platelet counts (r = 0.52, p = 0.02). Platelet counts did not differ between patients and healthy subjects. We also evaluated platelet-poor plasma VEGF levels in 10 patients and in all healthy individuals. We found very low levels of VEGF, approximately zero in most cases, in both groups and there was obviously no difference between the two groups. Our results indicate that VEGF is overproduced in PV. However, follow-up studies are needed to verify the role of this factor.

Evaluation of Subclinical Vascular Disease in Diabetic Kidney Disease: A Tool for Personalization of Management of a High-Risk Population

Background: Patients with diabetic kidney disease (DKD) are at increased risk for cardiovascular events but traditional risk factors do not fully explain this association. Evaluation of subclinical vascular disease might improve risk stratification and management of these patients. The aim of the study was to compare the prevalence of markers of arterial stiffness, carotid atherosclerosis and peripheral arterial disease between patients with DKD and patients with type 2 diabetes mellitus (T2DM) and preserved kidney function. Methods: We prospectively enrolled patients with DKD and age- and gender-matched patients with T2DM but without DKD (estimated glomerular filtration rate < and ≥60 mL/min/1.73 m2, respectively). The presence of arterial stiffness was evaluated by measuring pulse wave velocity (PWV), augmentation index (AIx), AIx adjusted to a heart rate of 75 beats/min (AIx@75) and central systolic, diastolic, pulse and mean blood pressure. The presence of carotid atherosclerosis was evaluated by measuring carotid stenosis, carotid intima-media thickness and maximal plaque thickness. The presence of PAD was evaluated with the measurement of ankle-brachial index (ABI). Results: Forty patients with T2DM were included in the study (mean age 71.6 ± 8.9 years). The prevalence of cardiovascular risk factors was similar in patients with and without DKD. PWV was higher in the former (9.8 ± 5.5 and 6.6 ± 4.4 m/s, respectively; p < 0.05) and carotid stenosis of the left carotid artery was also greater in patients with DKD (36.5 ± 12.6 and 22.1 ± 17.2%, respectively; p < 0.05). Other markers of arterial stiffness and carotid atherosclerosis and ABI did not differ between patients with DKD and those without DKD. Conclusions: Patients with DKD appear to have more pronounced arterial stiffness and carotid atherosclerosis than patients with T2DM and preserved kidney function despite the similar prevalence of traditional cardiovascular risk factors in the two groups. Therefore, evaluating the presence of subclinical vascular disease in these patients could be a useful tool for the personalization of their management.

Kidney function and estimated vascular risk in patients with primary dyslipidemia

BACKGROUND

Chronic kidney disease (CKD) is associated with increased vascular risk. Some studies suggested that considering markers of CKD might improve the predictive accuracy of the Framingham risk equation.

AIM

To evaluate the links between kidney function and risk stratification in patients with primary dyslipidemia.

METHODS

Dyslipidemic patients (n = 156; 83 men) who were non-smokers, did not have diabetes mellitus or evident vascular disease and were not on lipid-lowering or antihypertensive agents were recruited. Creatinine clearance (CrCl) was estimated using the Cockcroft-Gault equation. Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease (MDRD) equation. We estimated vascular risk using the Framingham equation.

RESULTS

In both men and women, there was a significant negative correlation between estimated Framingham risk and both eGFR and CrCl (p < 0.001 for all correlations). When men were divided according to creatinine tertiles, there were no significant differences in any parameter between groups. When men were divided according to either eGFR or CrCl tertiles, all estimated Framingham risks significantly increased as renal function declined (p<0.001 for all trends). When women were divided according to creatinine tertiles, all estimated Framingham risks except for stroke significantly increased as creatinine levels increased. When women were divided according to either eGFR or CrCl tertiles, all estimated Framingham risks significantly increased as renal function declined.

CONCLUSIONS

Estimated vascular risk increases as renal function declines. The possibility that incorporating kidney function in the Framingham equation will improve risk stratification requires further evaluation.

Incretin-Based Antidiabetic Agents for the Management of Non-Alcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) is the commonest chronic liver disease and is more prevalent in patients with type 2 diabetes mellitus (T2DM). Incretin-based antidiabetic agents (glucagonlike peptide-1 (GLP-1) receptor agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors) are used in the treatment of T2DM but it is unclear whether they may also play a role in the management of NAFLD. We systematically reviewed the PubMed and Scopus database up to October 2014 and also hand-searched the references of the retrieved articles for studies evaluating the effects of these agents on NAFLD. In animal studies, both GLP-1 receptor agonists and DPP-4 inhibitors reduced transaminase activity and steatosis but their effects on liver inflammation were inconsistent and fibrosis was not assessed. In clinical studies, both agents consistently reduced transaminase activity and steatosis as assessed non-invasively. There are very limited data on the effects of incretin-based treatments on liver histology. In conclusion, GLP-1 receptor agonists and DPP-4 inhibitors appear to hold promise in patients with NAFLD but larger controlled studies with histological and clinical endpoints are needed to evaluate their effects in this population.

Prevalence of resistant hypertension in 1810 patients followed up in a specialized outpatient clinic and its association with the metabolic syndrome

We aimed to assess the prevalence of resistant hypertension (RH) in patients attending hypertension outpatient clinics and to identify risk factors for RH. We studied the medical records of the last visit of all patients (n = 1810; 40.4% males, age 56.5 ± 13.5 years) who attended at least once our hypertension outpatient clinic during the last decade. RH was defined as blood pressure (BP) > 140/90 mmHg in patients without diabetes or chronic kidney disease (or BP > 130/80 mmHg in patients with the latter diseases) despite treatment with full doses of three antihypertensive agents from different classes or controlled BP on four or more different antihypertensive agents. The prevalence of RH was 12.3%, whereas 22.2% of the patients had well-controlled hypertension and 65.5% had uncontrolled hypertension but were on less than three antihypertensive agents. Independent predictors of RH were age (risk ratio, RR = 1.08, 95% confidence interval, CI 1.05-1.12, p < 0.001), body mass index (RR = 1.06, 95% CI 1.00-1.13, p < 0.05) and the presence of the metabolic syndrome (MetS) (RR = 2.01, 95% CI 1.03-3.91, p < 0.05).

CONCLUSIONS

RH is frequent in patients followed up in hypertension outpatient clinics. In addition to age and obesity, MetS appears to be associated with increased risk for RH. Clarification of the mechanisms underpinning the association between MetS and hypertension might reduce the prevalence of RH.

Cardiorenal anemia syndrome: do erythropoietin and iron therapy have a place in the treatment of heart failure?

The cardiorenal anemia syndrome in congestive heart failure (CHF) is an independent risk factor for vascular morbidity and mortality. Several factors play a role in the pathogenesis of anemia in CHF, including inflammation, impaired renal function, use of certain antihypertensive or cardioprotective agents, and gastrointestinal or urinary losses of essential hemopoietic factors. Several trials evaluated the effects of administering erythropoietin (EPO) and/or iron to patients with CHF. Even though most of them were uncontrolled studies, their results suggest that EPO treatment might be beneficial in CHF. Nevertheless, more studies are needed and certain issues should be resolved, particularly the optimal hemoglobin level, before EPO can become part of the treatment of patients with CHF.

Hydrochlorothiazide vs. chlorthalidone as the optimal diuretic for the management of hypertension

Even though hydrochlorothiazide (HCTZ) and chlorthalidone are frequently considered interchangeable antihypertensive agents, they appear to differ both in their blood pressure lowering efficacy and in their effects on the lipid profile and on serum potassium, uric acid and glucose levels. More importantly, in randomized controlled trials, chlorthalidone was equally or more effective than other antihypertensive agents in cardiovascular risk reduction whereas treatment with HCTZ yielded conflicting results. Although there are no randomized trials comparing the effects of these two agents on cardiovascular events, retrospective data from the Multiple Risk Factor Intervention Trial suggest that chlorthalidone might reduce cardiovascular morbidity more than HCTZ. However, current guidelines do not consistently recommend one or the other and it remains to be established which one is the diuretic of choice.

Hypolipidaemic drug treatment: yesterday is not gone yet, today is challenging and tomorrow is coming soon; let us combine them all

Statins remain the cornerstone of hypolipidaemic drug treatment. The recent American College of Cardiology (ACC)/American Heart Association (AHA) lipid guidelines suggest using percent reductions of low density lipoprotein cholesterol (LDL-C), according to cardiovascular disease (CVD) risk, rather than specific LDL-C targets. These guidelines raised concerns and other Societies (US, International, European) have not endorsed them. The implementation of previous guidelines in clinical practice is suboptimal due to attitudes of physicians and restrictions in health care systems. Monoclonal antibodies that inhibit proprotein convertase subtilisin/ kexin type 9 (PCSK9), which degrades the LDL receptor, like alirocumab and evolocumab, are in phase 3 trials. These drugs are suitable for statin intolerant or resistant patients, heterozygous familial hypercholesterolaemia (HeFH) and some forms of homozygous FH (HoFH). Mipomersen (antisense oligonucleotide against apolipoprotein B) and lomitapide (microsomal triglyceride transfer protein blocker) have already been approved for HoFH. Eventually, silencing micro-RNA oligonucleotides may also become available. The repair or silencing of genes implicated in hyperlipidaemia and/or atherosclerosis is also on the horizon. If the new therapeutic options mentioned above prove to be effective and safe then by combining them with statins and/or ezetimibe we should be able to effectively control acquired or hereditary dyslipidaemias and substantially further reduce CVD morbidity and mortality.

Bariatric surgery as a treatment option in patients with type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) is a leading cause of blindness, non-traumatic amputation and end-stage renal disease as well as a major cardiovascular risk factor. Tight glycemic control reduces the incidence of microvascular complications of T2DM whereas its effects on macrovascular complication are more controversial. However, glycemic targets are achieved by a minority of diabetic patients despite the availability of several antidiabetic agents. In the present commentary, we discuss the findings of two recent randomized studies that compared bariatric surgery with medical treatment in patients with uncontrolled T2DM. Both studies showed that bariatric surgery results in remission of T2DM in the majority of patients. However, both studies were limited to relatively young patients without comorbidities, had relatively short follow-up and did not assess the effects of surgery on T2DM complications. Moreover, the perioperative complications of bariatric surgery and its limited availability in some areas are additional barriers to the wider implementation of this therapeutic approach. On the other hand, the elucidation of the mechanisms underpinning the resolution of T2DM following bariatric surgery might result in the development of novel, more effective pharmacotherapies for this common disease.

Sodium-glucose Cotransporter 2 Inhibitors and Ischemic Stroke

BACKGROUND

Type 2 diabetes mellitus (T2DM) is associated with substantially increased risk for cardiovascular events, including ischemic stroke. In turn, ischemic stroke represents a leading cause of mortality and long-term disability worldwide. The recent class of glucose-lowering agents is sodium-glucose cotransporter 2 (SGLT-2) inhibitors, which act through inhibition of glucose reabsorption in the kidney, resulting in glucose excretion without stimulating insulin release. Accumulating data suggests that these agents improve multiple risk factors for ischemic stroke except their glucose-lowering effect.

OBJECTIVE

In the present review, the pleiotropic actions of SGLT-2 inhibitors are summarized and their potential implications on ischemic stroke prevention are discussed.

METHODS

We performed a comprehensive search of the literature in terms of SGLT-2 inhibitors efficacy on ischemic stroke and traditional risk factors of cerebrovascular disease.

RESULTS

Several studies consistently showed that SGLT-2 inhibitors reduce blood pressure, induce weight loss, increase high-density lipoprotein cholesterol levels and reduce triglyceride levels. In addition, they improve several emerging cardiovascular risk factors, most notably arterial stiffness, albuminuria and oxidative stress. However, in the only trial that evaluated the effects of these agents on the incidence of ischemic stroke, empagliflozin did not reduce the risk of first or recurrent stroke despite a significant reduction in cardiovascular and all-cause mortality.

CONCLUSION

Despite the multiple pleiotropic effects of SGLT-2 inhibitors, these agents do not appear to affect stroke risk. Ongoing large trials with longer follow-up will evaluate whether the pleiotropic effects of this class will translate into benefits in ischemic stroke prevention.

Interferon/long-term lamivudine combination therapy in anti-HBe positive chronic hepatitis B patients

BACKGROUND

Monotherapy with a single antiviral agent is insufficient in controlling hepatitis B virus infection in the majority of patients with anti-HBe positive chronic hepatitis B. Interferon/long-term lamivudine combination therapy was evaluated to determine if this strategy would improve treatment efficacy and reduce the emergence of lamivudine resistance.

METHODS

In total, 36 consecutive anti-HBe positive patients were treated with interferon (3 MU subcutaneously three times weekly) and lamivudine (100 mg orally once a day) for 12 months. After completion of the combined treatment, all patients continued to receive lamivudine monotherapy indefinitely.

RESULTS

Overall, 35 patients (97%) showed virological response at 12 months. Four patients (11%) cleared HBsAg and developed anti-HBs. During the follow-up time, after the discontinuation of interferon, of 30 +/- 12 months (range: 7-57 months), 13 patients (36%) exhibited breakthrough infection. The cumulative rates of breakthrough infection at the end of 1, 2, 3 and 4 years of treatment were 0%, 14%, 32%, and 59%, respectively.

CONCLUSIONS

Combination therapy appears to be effective and may also delay the selection of lamivudine-resistant variants. However, controlled trials are definitely warranted to clarify the potential benefits of combination antiviral treatment over monotherapy.