Expert consensus on the rational clinical use of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors

Two proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, evolocumab and alirocumab, have recently been approved by both the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) for the treatment of hypercholesterolemia. These fully human monoclonal antibodies selectively block PCSK9, thus permitting the low-density lipoprotein (LDL) receptor to effectively recycle to the surface of liver cells. The administration of these antibodies leads to robust LDL cholesterol (LDL-C) lowering by 50-60% on top of maximum hypolipidemic treatment. At least 4 randomized, placebo-controlled studies are under way and will address the question of whether the administration of these PCSK9 inhibitors is associated with a significant reduction of cardiovascular events. Because of the high cost associated with the use of these medications it is very important to consider which patients may gain the most benefit, at least until the results of outcome studies are available. In this Consensus paper, 34 clinicians/scientists define 3 groups of patients that should be currently considered as candidates for the use of these novel drugs. These include: 1a. Adults with established cardiovascular disease and LDL-C≥100 mg/dL while on lifestyle modifications and maximally tolerated hypolipidemic treatment, i.e. high-intensity statin + ezetimibe, 1b. Adults with diabetes and established cardiovascular disease or chronic kidney disease or target organ damage and LDL-C ≥100 mg/dL while on lifestyle modifications and maximally tolerated hypolipidemic treatment, i.e. high-intensity statin + ezetimibe, 2. Adults with familial hypercholesterolemia (FH) without established cardiovascular disease and LDL-C ≥130 mg/dL while on lifestyle modifications and maximally tolerated hypolipidemic treatment, i.e. high-intensity statin + ezetimibe (evolocumab is also indicated in children above 12 years with homozygous FH), and 3. Adults at high or very high cardiovascular risk who are statin intolerant and have an LDL-C ≥100 and ≥130 mg/dL, respectively, while on any tolerated hypolipidemic treatment.

Prevalence of Diabetes and Its Association with Atherosclerotic Cardiovascular Disease Risk in Patients with Familial Hypercholesterolemia: An Analysis from the Hellenic Familial Hypercholesterolemia Registry (HELLAS-FH)

Familial hypercholesterolemia (FH) and type 2 diabetes mellitus (T2DM) are both associated with a high risk of atherosclerotic cardiovascular disease (ASCVD). Little is known about the prevalence of T2DM and its association with ASCVD risk in FH patients. This was a cross-sectional analysis from the Hellenic Familial Hypercholesterolemia Registry (HELLAS-FH) including adults with FH (n = 1719, mean age 51.3 ± 14.6 years). Of FH patients, 7.2% had a diagnosis of T2DM. The prevalence of ASCVD, coronary artery disease (CAD), and stroke was higher among subjects with T2DM compared with those without (55.3% vs. 23.3%, 48.8% vs. 20.7%, 8.3% vs. 2.7%, respectively, p < 0.001). When adjusted for age, systolic blood pressure, smoking, body mass index, hypertension, waist circumference, triglyceride levels, high-density lipoprotein cholesterol levels, and gender, T2DM was significantly associated with prevalent ASCVD [OR 2.0 (95% CI 1.2−3.3), p = 0.004]. FH patients with T2DM were more likely to have undergone coronary revascularization than those without (14.2% vs. 4.5% for coronary artery bypass graft, and 23.9% vs. 11.5% for percutaneous coronary intervention, p < 0.001). T2DM is associated with an increased risk for prevalent ASCVD in subjects with FH. This may have implications for risk stratification and treatment intensity in these patients.

The Role of Antiobesity Agents in the Management of Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is the commonest endocrine disorder in women of reproductive age. Obesity is frequently present in these patients and plays a key role in the pathogenesis of both the endocrine and metabolic abnormalities of the syndrome, particularly infertility, hyperandrogenism and insulin resistance (IR). Diet and exercise is the mainstay of management of obesity in patients with PCOS. In contrast, the eff ects of antiobesity agents on weight and on the obesityrelated characteristics of the syndrome remain unclear. The aim of the present review is to summarize the current data on the eff ects of antiobesity drugs approved in Europe (orlistat, liraglutide 3 mg od and naltrexone/bupropion) on weight loss in patients with PCOS and to discuss their impact on the endocrine, reproductive and metabolic abnormalities of this population. Several studies reported that orlistat induces weight loss, improves IR and reduces androgen levels in PCOS. In contrast, data regarding the eff ects of the dose of liraglutide that is approved for the treatment of obesity (3 mg od) are very limited. Liraglutide 1.2-1.8 mg od results in weight loss in these patients but does not aff ect IR or androgen levels. Finally, there are no studies that evaluated naltrexone/bupropion in patients with PCOS and early studies reported conflicting results regarding the eff ects of naltrexone monotherapy on weight, IR and androgen levels. In conclusion, orlistat appears to have a role in the management of overweight and obese patients with PCOS whereas more studies are needed to clarify the role of liraglutide and naltrexone/bupropion.

Novel Cardiovascular Risk Factors in Patients with Diabetic Kidney Disease

Patients with diabetic kidney disease (DKD) are at very high risk for cardiovascular events. Only part of this increased risk can be attributed to the presence of diabetes mellitus (DM) and to other DM-related comorbidities, including hypertension and obesity. The identification of novel risk factors that underpin the association between DKD and cardiovascular disease (CVD) is essential for risk stratification, for individualization of treatment and for identification of novel treatment targets.In the present review, we summarize the current knowledge regarding the role of emerging cardiovascular risk markers in patients with DKD. Among these biomarkers, fibroblast growth factor-23 and copeptin were studied more extensively and consistently predicted cardiovascular events in this population. Therefore, it might be useful to incorporate them in risk stratification strategies in patients with DKD to identify those who would possibly benefit from more aggressive management of cardiovascular risk factors.

Impaired fasting glucose in hypertensive patients: prevalence and cross-sectional analysis of associations with cardiovascular disease

BACKGROUND

Impaired fasting glucose (IFG) is frequently present in hypertensive patients and might be induced or aggravated by antihypertensive treatment. However, it is unclear whether IFG is associated with increased cardiovascular risk in this population.

PATIENTS AND METHODS

We performed a cross-sectional study in 1,810 hypertensive patients and recorded the presence of IFG, coronary heart disease (CHD), and ischemic stroke.

RESULTS

IFG was present in 567 patients (31.3%). The prevalence of CHD or ischemic stroke did not differ between patients with IFG and in patients with serum glucose levels <100 mg/dL. Among patients with IFG, 267 (47.0%) were on β-blockers, diuretics, or both β-blockers and diuretics. The prevalence of CHD was numerically but not significantly higher in patients with IFG treated with β-blockers or both β-blockers and diuretics than in patients with IFG treated with diuretics or not treated with either β-blockers or diuretics and patients with serum glucose levels <100 mg/dL (11.1%, 13.6%, 1.4%, 3.7%, and 5.9%, respectively; P=not significant). The prevalence of ischemic stroke did not differ among these groups.

CONCLUSIONS

IFG does not appear to be associated with increased prevalence of cardiovascular disease in hypertensive patients, regardless if it is associated with the antihypertensive treatment or not.

Uterine volume and endometrial thickness in the early follicular phase in patients with polycystic ovary syndrome

OBJECTIVE

We aimed to evaluate uterine volume and endometrial thickness during the early follicular phase in patients with polycystic ovary syndrome (PCOS) and healthy controls.

METHODS

We studied 1,016 PCOS patients and 182 healthy controls. The anthropometric, endocrine, and metabolic characteristics of PCOS were determined. Uterine volume and endometrial thickness were also recorded.

RESULTS

Uterine volume progressively increased with age both in PCOS patients and controls. Patients with PCOS and body mass index (BMI) ≥25 kg/m2 had greater uterine volumes than PCOS patients with BMI <25 kg/m2 (P<.001). Patients with the classic PCOS phenotypes (i.e., with oligo-ovulation and/or anovulation [ANOV] and hyperandrogenemia [HA] with or without polycystic ovaries [PCO]) had smaller uterine volume than PCOS patients with the additional phenotypes introduced by the Rotterdam criteria (i.e., with PCO and either ANOV or HA; P = .033) and controls (P = .045).

CONCLUSION

Uterine volume increases progressively with age and obesity in PCOS patients. The smaller uterine volumes and endometrial thicknesses in the classic PCOS phenotypes might be attributed to the more severe HA of these patients.

Hepatic Fibrosis Is a Risk Factor for Greater Severity and Worse Outcome of Acute Ischemic Stroke

Background: Nonalcoholic fatty liver disease, particularly in the presence of hepatic fibrosis, is associated with an increased risk of cardiovascular events, including ischemic stroke. However, it is unclear whether hepatic fibrosis is associated with the severity and outcome of acute ischemic stroke. Aim: To evaluate the relationship between hepatic fibrosis and the severity at admission and in-hospital outcome of acute ischemic stroke. Patients and methods: We prospectively studied all patients who were admitted to our department with acute ischemic stroke between September 2010 and February 2018 (n = 1107; 42.1% males, age 79.8 ± 7.2 years). The severity of stroke was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). Severe stroke was defined as NIHSS ≥ 21. The presence of hepatic fibrosis was evaluated with the Fibrosis-4 index (FIB-4). The outcome was assessed with dependency at discharge (modified Rankin Scale between 2 and 5) and with in-hospital mortality. Results: Patients with severe stroke had a higher FIB-4 index than patients with non-severe stroke (2.7 ± 1.7 and 2.3 ± 1.4, respectively; p < 0.05). Independent risk factors for severe IS were age (relative risk (RR) 1.064, 95% confidence interval (CI) 1.030−1.100, p < 0.001), female sex (RR 1.723, 95% CI 1.100−2.698, p = 0.012), atrial fibrillation (RR 1.869, 95% CI 1.234−2.831, p = 0.002), diastolic blood pressure (DBP) (RR 1.019, 95% CI 1.006−1.033, p = 0.001), and the FIB-4 index (RR 1.130, 95% CI 1.007−1.268, p = 0.022). At discharge, 64.2% of patients were dependent. The FIB-4 index did not differ between patients who were dependent and those who were independent at the time of discharge (2.3 ± 1.5 and 2.1 ± 1.2, respectively; p = 0.061). During hospitalization, 9.8% of patients died. Patients who died during hospitalization had a higher FIB-4 index than those who were discharged (2.9 ± 1.8 and 2.3 ± 1.4, respectively; p < 0.005). Independent risk factors for in-hospital mortality were DBP (RR 1.022, 95% CI 1.010−1.034, p < 0.001), serum glucose levels (RR 1.004, 95% CI 1.001−1.007, p = 0.007), serum triglyceride levels (RR 0.993, 95% CI 0.987−0.999, p = 0.023), NIHSS (RR 1.120, 95% CI 1.092−1.149, p < 0.001), and the FIB-4 index (RR 1.169, 95% CI 1.060−1.289, p = 0.002). Conclusions: Hepatic fibrosis, evaluated with the FIB-4 index, appears to be associated with more severe ischemic stroke and might also represent an independent risk factor for in-hospital mortality in patients admitted with acute ischemic stroke.

Comparison of Premixed Human Insulin 30/70 to Biphasic Aspart 30 in Well-Controlled Patients with Type 2 Diabetes Using Continuous Glucose Monitoring

AIM

To compare in terms of glycemic variability two premixed insulins, Premixed Human Insulin 30/70 (PHI) and Biphasic Aspart 30 (BiAsp30), using Continuous Glucose Monitoring (CGM) and to estimate the correlation of Glycated Albumin (GA) and Fructosamine (FA) with CGM data. Patients-Data: A total of 36 well-controlled patients with type 2 Diabetes Mellitus (T2DM) underwent 7-day CGM with PHI and subsequently with BiAsp30. GA and FA were measured at the first and last day of each week of CGM.

RESULTS

BiAsp30 was associated with lower Average Blood Glucose (ABG) during the 23:00-03:00 period (PHI: 135.08 ± 28.94 mg/dL, BiAsp30: 117.75 ± 21.24 mg/dL, p < 0.001) and the 00:00-06:00 period (PHI: 120.42 ± 23.13 mg/dL, BiAsp30: 111.17 ± 14.74 mg/dL, p = 0.008), as well as with more time below range (<70 mg/dL) (TBR) during the 23:00-03:00 period in the week (PHI: 3.65 ± 5.93%, BiAsp30: 11.12 ± 16.07%, p = 0.005). PHI was associated with lower ABG before breakfast (PHI: 111.75 ± 23.9 mg/dL, BiAsp30: 128.25 ± 35.9 mg/dL, p = 0.013). There were no differences between the two groups in ABG, Time In Range and Time Below Range during the entire 24-h period for 7 days, p = 0.502, p = 0.534, and p = 0.258 respectively, and in TBR for the 00:00-06:00 period p = 0.253. Total daily insulin requirements were higher for BiAsp30 (PHI: 47.92 ± 12.18 IU, BiAsp30: 49.58 ± 14.12 IU, p = 0.001). GA and FA correlated significantly with ABG (GA: r = 0.512, p = 0.011, FA: r = 0.555, p = 0.005).

CONCLUSIONS

In well-controlled patients with T2DM, BiAsp30 is an equally effective alternative to PHI.

The Role of Mineralocorticoid Receptor Antagonists in the Management of Heart Failure with Preserved Ejection Fraction

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is associated with increased risk for hospitalization and all-cause mortality. Currently, there is no established treatment to improve the survival of these patients. Aldosterone appears to play a role in the pathogenesis of HFpEF.

OBJECTIVE

To discuss the findings of studies that evaluated the effects of mineralocorticoid receptor (MR) antagonists on the outcome of patients with HFpEF.

METHODS

PubMed was searched for relevant papers. References of retrieved articles were also evaluated for pertinent material.

RESULTS

Accumulating data suggest that MR antagonists might be useful in the management of patients with HFpEF. However, existing evidence is limited and conflicting.

CONCLUSIONS

More studies are needed to clearly define the therapeutic potential of MR antagonists in HFpEF. Given the heterogeneity of this disease and the low specificity of the criteria used for its diagnosis, it is also important to improve the definition of HFpEF and include appropriately selected patients in these studies.

Metabolic syndrome in patients with the polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is frequently characterized by abdominal obesity and insulin resistance, which also represent the hallmarks of the metabolic syndrome (MetS). It is well established that MetS is associated with increased risk for both Type 2 diabetes mellitus and cardiovascular disease (CVD) and accumulating data suggest that PCOS is also a risk factor for Type 2 diabetes mellitus and CVD. Accordingly, the association of PCOS with MetS has major health care implications given also the high prevalence of both disorders. We aimed to critically analyze the major studies that compared the prevalence of MetS between women with PCOS and controls, to discuss the anthropometric, endocrine and metabolic characteristics of PCOS, which are implicated in the pathogenesis of Mets in women with PCOS and to comment on the implications and management of MetS in this population. We thus summarize the evidence regarding the prevalence of MetS in PCOS and discuss the primary determinants driving this association. Current evidence shows that MetS is frequently observed in women with PCOS, but this appears to be mainly due to the more pronounced abdominal obesity in these women and not due to PCOS per se. Lifestyle changes are the treatment of choice for MetS in women with PCOS, whereas pharmacotherapy should be individualized.

A case of successful management with splenectomy of intractable ascites due to congenital dyserythropoietic anemia type II-induced cirrhosis

The congenital dyserythropoietic anemias comprise a group of rare hereditary disorders of erythropoiesis, characterized by ineffective erythropoiesis as the predominant mechanism of anemia and by characteristic morphological aberrations of the majority of erythroblasts in the bone marrow. Congenital dyserythropoietic anemia type II is the most frequent type. All types of congenital dyserythropoietic anemias distinctly share a high incidence of iron loading. Iron accumulation occurs even in untransfused patients and can result in heart failure and liver cirrhosis. We have reported about a patient who presented with liver cirrhosis and intractable ascites caused by congenital dyserythropoietic anemia type II. Her clinical course was further complicated by the development of autoimmune hemolytic anemia. Splenectomy was eventually performed which achieved complete resolution of ascites, increase of hemoglobin concentration and abrogation of transfusion requirements.

Combination treatment in HBeAg-negative chronic hepatitis B

Chronic hepatitis B (CHB) represents an important public health problem. HBeAg-negative CHB is frequently associated with advanced liver disease and its prevalence is increasing. Monotherapy with either interferon (conventional or pegylated) or nucleoside/nucleotide analogues has its limitations. It has been suggested that a combination of these agents might increase antiviral efficacy. However, existing data do not support this hypothesis, even though combination treatment appears to reduce the risk for emergence of lamivudine resistance. Nevertheless, most existing combination studies are small, and it is possible that they have not been designed to detect significant differences between combination treatment and monotherapies. Another limitation of these studies is that, in most of them, lamivudine treatment was discontinued after 1 year, a strategy that is not followed in clinical practice. It was thought to be interesting to evaluate the combination of a short course of interferon (particularly pegylated) with the long-term administration of nucleotide or nucleoside analogues. The efficacy of combining pegylated interferon with the newer nucleotide or nucleoside analogues or of nucleotide with nucleoside analogues could also be evaluated. However, findings show that until more data are available, combination therapy cannot be recommended as first-line treatment in patients with CHB. On the other hand, add-on therapy with adefovir or tenofovir is the treatment of choice in patients who develop resistance to lamivudine. In patients with cirrhosis, a combination of lamivudine/adefovir may also be used as initial treatment; another option would be to add tenofovir in patients with an insufficient response to entecavir.

Is There a Role for Continuous Positive Airway Pressure Treatment in the Management of Obstructive Sleep Apnea-related Hypertension?

BACKGROUND

Obstructive sleep apnea (OSA) is a major cause of secondary hypertension. Moreover, a considerable proportion of patients with essential hypertension have OSA. OSA also appears to increase the risk for cardiovascular disease and all-cause mortality. Continuous positive airway pressure (CPAP) treatment substantially reduces daytime somnolence and improves quality of life in patients with OSA. However, the effects of CPAP treatment on blood pressure (BP) are questionable. The aim of the present review is to summarize the evidence regarding the association between OSA with hypertension and the effects of CPAP treatment on BP in patients with OSA. The severity of OSA directly correlates with the increase in BP. Moreover, patients with OSA are at increased risk for developing hypertension. However, CPAP treatment does not result in substantial reductions in BP in unselected patients with OSA with moderate adherence to this treatment. Nevertheless, these effects are more pronounced in patients with more severe hypertension, more severe OSA and more importantly, in those who adhere to CPAP treatment.

CONCLUSION

Therefore, it is essential to improve the adherence to CPAP treatment in order to optimally manage this important cause of hypertension.