An insight into familial hypercholesterolemia in Greece: rationale and design of the Hellenic Familial Hypercholesterolemia Registry (HELLAS-FH)

Familial hypercholesterolemia (FH) is the most common metabolic genetic disorder. It is estimated that around 13 million people worldwide have FH. At the same time, only 25% of FH patients have been diagnosed. Moreover, these patients are often undertreated. The true prevalence of FH in Greece is unknown, but it is estimated that there are at least 40,000 FH patients nationwide pointing to a prevalence of 1:250. Patients with FH are at a high risk for cardiovascular events and death at an early age. Therefore, prompt detection of these patients is of pivotal importance in order to implement appropriate preventive measures at a young age. Patient registries are a powerful tool for recording and monitoring a disease and promoting clinical practices, thus contributing to improved outcomes and reduction of healthcare costs. National registries of FH patients have been a success in the Netherlands, Spain and Wales. As Greece did not have a national FH registry, the Hellenic Atherosclerosis Society has organized, established and funded the Hellenic Familial Hypercholesterolemia (HELLAS-FH) national registry in order to promote a better understanding of FH in our country.

Cardiovascular Risk in the Different Phenotypes of Polycystic Ovary Syndrome

BACKGROUND

The polycystic ovary syndrome (PCOS) is the commonest endocrine disorder in women of reproductive age and shows substantial phenotypic variability. According to the presence of the three diagnostic criteria of PCOS, i.e. oligo- and/or anovulation, hyperandrogenemia and/or clinical signs of high androgen levels, and polycystic ovaries, four different phenotypes of PCOS are identified. It appears that these phenotypes differ in the prevalence of several established and emerging cardiovascular risk factors.

METHODS

We searched the literature for studies that compared the cardiovascular risk profile of patients with the different phenotypes of PCOS.

RESULTS

Patients with both anovulation and hyperandrogenemia have more pronounced insulin resistance and higher levels of proinflammatory and prothrombotic mediators than patients with polycystic ovaries and either anovulation or hyperandrogenemia.

CONCLUSION

Given that these differences appear to be mainly driven by the more pronounced obesity of the former patients, diet and exercise aiming at weight loss should constitute the cornerstone of management of PCOS and should be particularly emphasized in patients with the higher risk phenotypes of the syndrome.

The Role of Lipid-Lowering Treatment in the Secondary Prevention of Ischemic Stroke

Dyslipidemia is a major modifiable risk factor for ischemic stroke. Treatment with statins reduces the incidence of recurrent ischemic stroke and also reduces coronary events in patients with a history of ischemic stroke. Therefore, statins represent an important component of secondary prevention of ischemic stroke. In patients who do not achieve low-density lipoprotein cholesterol (LDL-C) targets despite treatment with the maximal tolerated dose of a potent statin, ezetimibe should be added to their lipid-lowering treatment and also appears to reduce the risk of cardiovascular events. Selected patients who do not achieve LDL-C targets despite statin/ezetimibe combination are candidates for receiving proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. Finally, it appears that adding icosapent ethyl might also reduce cardiovascular morbidity in patients who have achieved LDL-C targets but have persistently elevated triglyceride levels.

Editorial: Vascular Calcification, Cardiovascular Risk and microRNAs

Vascular calcification, both in the coronary and in the peripheral arteries, is associated with increased cardiovascular (CV) risk. However, agents that prevent vascular calcification (e.g. estrogens or calcimimetic agents) might have neutral or detrimental effects on CV events. Moreover, statins and antihypertensive agents do not appear to modify vascular calcification, despite their established benefits on CV disease prevention. On the other hand, recent data suggest that microRNAs play a role in the regulation of vascular calcification. It is therefore possible that modulation of the expression of microRNAs might represent a useful strategy for preventing or delaying the progression of this process.

Cardiometabolic effects of direct-acting antivirals in patients with hepatitis C

Hepatitis C virus (HCV) has long been associated with several extrahepatic manifestations, including increased cardiovascular risk. The emergence of direct-acting antivirals (DAAs) has allowed us to evaluate the potential reversal of these manifestations after successful treatment. Therefore, many studies have provided significant takeaways regarding the positive effect of DAAs therapy on insulin resistance, type 2 diabetes mellitus, cardiovascular disease and atherosclerosis. In contrast, studies have shown detrimental effects on lipid metabolism and indeterminate results regarding renal function and uric acid metabolism. Nevertheless, as more and more patients achieve sustained virological response, the effects of HCV eradication on cardiometabolic processes will be extensively studied, allowing more reliable conclusions on the extent of extrahepatic outcomes.

Epidemiology and Risk Factors for Stroke in Chronic Kidney Disease: A Narrative Review

Patients with chronic kidney disease (CKD) have a higher risk ofboth ischemic and hemorrhagic stroke. This association appears to be partly independent from the higher prevalence of established risk factors for stroke in patients with CKD, including hypertension and atrial fibrillation. In the present review we aim to discuss the impact of CKD on the risk of stroke and stroke-related consequences, and explore the pathophysiology underpinning the increased risk of stroke in patients with CKD. We cover the clinical association between renal dysfunction and cerebrovascular disease including stroke, silent brain infarct, cerebral small vessel disease, microbleeds, and white matter hyperintensity, and discuss the underlying mechanisms.

Greek gynecology healthcare professionals towards quality management systems

PURPOSE

Today, quality management systems (QMS) are a promising candidate for the improvement of healthcare services. The purpose of this paper is to investigate the opinions/attitudes of gynecology healthcare professionals toward quality and quality management in healthcare facilities (HFs) in Greece.

DESIGN/METHODOLOGY/APPROACH

An anonymous self-administered questionnaire was distributed to healthcare professionals, asking for opinions on quality objectives associated with the everyday workflow in HFs (e.g. management of patients, resources, etc.) and on QMS. The study was conducted in Hippokration Hospital of Thessaloniki, including 187 participants. Statistical assessment and analysis of the questionnaires were carried out.

FINDINGS

Although 87.5 percent recognized the importance of potential QMS implementation and accreditation, over 50 percent believed that it would lead rather to increased workload and bureaucracy than to any considerable quality improvement. More than 60 percent were completely unaware of the implementation of quality objectives such as quality handbook, quality policy, audit meetings and accreditation status in their HFs. This unawareness was also reported in terms of patient, data, human and general resources management. Finally, awareness over medical malpractice and positive attitude toward official reporting were detected.

ORIGINALITY/VALUE

Most respondents acknowledged the significance of quality, QMS implementation and accreditation in Greek hospitals. However, there was a critical gap in knowledge about quality management objectives/processes that could be possibly resolved by expert teams and well-organized educational programs aiming to educate personnel regarding the various quality objectives in Greek HFs.

Editorial: Do We Have Effective Means to Treat Arterial Stiffness and High Central Aortic Blood Pressure in Patients with and without Hypertension?

The reduction or loss of arterial elasticity or distensibility leads to arterial stiffness (AS), which has a substantial predictive value for all-cause and cardiovascular disease (CVD) mortality, as well as for non-fatal CVD events [1]. A plethora of evidence consistently showed the prognostic value of aortic stiffness for fatal and nonfatal CVD events in various populations at different levels of CVD risk, including the general population, elderly subjects and patients with hypertension, type 2 diabetes mellitus (T2DM) and end-stage renal disease (ESRD) [2]. It has been reported that 1-SD increase in pulse wave velocity (PWV) is associated with a 47% increase in the risk for total mortality [95% confidence interval (CI), 1.31-1.64] and a similar 47% increase in the risk for CVD mortality (95% CI, 1.29-1.66) [2].

Age is the major CVD risk factor and this is attributable in part to stiffening of large elastic arteries, a natural process [3]. During aging, the elastic lamella grows to be fragmented and the mechanical load is transferred to collagen fibers, which are several hundred times stiffer than elastic fibers. This loss of the elastic properties (AS) mainly happens with large arteries and causes arteriosclerosis different than atherosclerosis, which refers to the arterial intima [4]. Arteriosclerosis usually does not affect the smaller muscular arteries [5]. Besides age, a number of changes in arterial wall, related to CVD risk factors, also increase AS and contribute to early arterial aging [3]. Matrix remodelling of the media and adventitia may result from endothelial dysfunction, reduction of elastin, increase of collagen metalloproteinases, vascular smooth muscle cells and adhesion molecules, and deposition of advanced glycation end-products and calcium due to lowgrade inflammation, dyslipidaemia, T2DM, hypertension (HTN) and chronic kidney disease (CKD) [3]. Arterial stiffness increases PWV; this causes an early return of the reflection wave in the aorta during left ventricular systole [6]. This early return increases central aortic pressure and systolic blood pressure, while it reduces diastolic blood pressure 2/6 and thus coronary perfusion [6]. Central aortic pressure is only an indirect, surrogate measure of AS. However, it provides additional information concerning wave reflections [6,7]. Central pulse-wave analysis should be optimally used in combination with the measurement of aortic PWV value to determine the contribution of AS to wave reflections [6,7]. Given the complex pathogenesis of AS, it is obvious that the treatment of AS should also be multifactorial. Both lifestyle and pharmacological approaches should be implemented in these patients. Central pulse-wave analysis should be optimally used in combination with the measurement of aortic PWV value to determine the contribution of AS to wave reflections [6,7]. Given the complex pathogenesis of AS, it is obvious that the treatment of AS should also be multifactorial. Both lifestyle and pharmacological approaches should be implemented in these patients. Increased leisure time physical activity, weight reduction, avoidance of diatery salt and alcohol abuse as well as increased consumption of diatery heavy chain omega fatty acids as recommended [7]. Drug treatment for arterial hypertension [diuretics, angiotensin-converting enzyme inhibitors (ACE-I), angiotensin- receptor blockers (ARBs), and calcium-channel blockers (CCB)] [8-10]; lipid-lowering agents, mainly statins [11,12], hypoglecaemic drugs (thiazolidinediones) [13]; and potentially other novel agents, including AGE breakers [14]. There are been data suggesting that the reduction in AS during treatment for arterial hypertension is not only attributed to the reduction in BP per se but to additional BP loweringindependent effects of antihypertensive drugs [15]. Indeed, the renin – aldosterone - angiotensin –system (RAAS) blockers, ACE inhibitors and ARBs, have been shown to have a BP- independent beneficial effect on AS [16] and to possess antifibrotic effects [17].

In antithesis, β-blockers do not reduce AS in the same degree, because non-vasodilating 􀀁-blockers are less effective in reducing central pulse pressure than other antihypertensive drugs [7]. In fact, older 􀀁-blockers may increase vasoconstriction and assist the early return of the reflected pulse wave in late systole (and not in diastole), thus increasing central blood pressure and inducing a mismatch between the heart and the arterial system [7].

The substudy of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) [18], Conduit Artery Function Evaluation (CAFE) trial [19], showed that amlodipine combined with perindopril reduce central aortic pressure more than atenolol 3/6 combined with thiazide despite a similar impact on brachial BP. Moreover, central aortic pulse pressure may be a determinant of clinical outcomes, and differences in central aortic pressures may be a potential mechanism to explain the different clinical outcomes between the latter treatment arms in ASCOT [19]. In conclusion, even AS increases with age, this process might be accelerated by the simultaneous presence of other CVD risk factors, resulting in early vascular aging. AS is associated with increased risk for CVD and all-cause mortality, and it is possible that a decrease in AS might improve outcomes. Various approaches, particularly those targeting HTN, T2DM, dyslipidaemia, metabolic syndrome and CKD, preferably combined in a multifactorial approach, contribute to reduction in AS. In addition, the potential role of newer therapies, including AGE breakers and those aiming to break collagen crosslinks, should be tested.

Sodium/glucose cotransporter 2 inhibitors for the treatment of type 1 diabetes: what are the latest developments?

Despite the improvements in insulin therapy, many patients with type 1 diabetes mellitus (T1DM) do not achieve glycemic targets. Hypoglycemia and weight gain are important barriers in reaching these targets. Sodium/glucose cotransporter 2 (SGLT2) inhibitors lack these side effects and have an insulin-independent mechanism of action. Therefore, they might be useful in patients with T1DM. The authors discuss the safety and efficacy of SGLT2 inhibitors in T1DM. Several randomized controlled trials have evaluated dapagliflozin, sotagliflozin and empagliflozin in this population whereas fewer data are available for other members of this class. In these studies, SGLT2 inhibitors reduced HbA1c levels and body weight without a greater risk of hypoglycemia. However, a higher incidence of diabetic ketoacidosis (DKA) was observed in patients treated with these agents. SGLT2 inhibitors improve glycemic control in patients with T1DM but this effect is modest. Even though weight loss and the neutral effect on the incidence of hypoglycemia are advantages of these agents, the increased risk of DKA is a cause of concern. Overall, SGLT2 inhibitors should be used with caution and only in carefully selected patients with T1DM who are motivated, adherent to treatment, well-trained in recognizing DKA and are closely followed-up.

Role of Metalloproteinases in the Pathogenesis of Unexpected Poor Ovarian Response with a Possible Genetic Predisposition

Aim

To study the role of matrix metalloproteinase (MMP- 1,2,3), inhibitor tissue inhibitors of metalloproteinase (TIMP)-2, and specific gene polymorphisms in unexpected poor ovarian responders (un-PORs).

Materials and methods

Group I consisted of 44 un-PORs, group II of 42 subfertile, normal ovarian responders (NORs), and group III of 66 fertile women in a prospective study. Matrix metalloproteinase-1,2,3 and TIMP-2 were assessed in 40 patients from groups I and II. Specific polymorphisms (SP; MMP-1 −519 A/G, MMP-2 −1575 G/A, MMP-3 −1171 5A/6A, and TIMP-2 rs55743137T/G) were investigated in group I, II, and III patients.

Results

Group I required similar amount of gonadotropins compared with group II, with fewer oocytes retrieved, lower fertilization rates, embryos/embryo transfer, clinical pregnancies/cycle, and “take-home babies” (p = 0.900, 0.001, 0.002, 0.001, 0.031, and p = 0.128) respectively, Table 1). Group I had lower MMP-2 with higher TIMP-2 (p = 0.002, 0.037 respectively; Table 2). In the same group, MMP-1 was higher in women with GG genotype of the MMP-1 polymorphism, vs GA genotype (p = 0.047; Table 3). The MMP-2, MMP-3, and TIMP-2 polymorphisms did not affect MMP-2, MMP-3, and TIMP-2 respectively. The same applied for MMP-1,2,3 and TIMP-2 in group II. Comparing frequencies of different genotypes of the MMP-1,2,3 and TIMP-2 polymorphisms, they did not differ between the three different groups: A, B, and C (Table 4).

Conclusion

Impaired MMP-2 activity, associated with significantly higher TIMP-2 detected, could be involved in un-POR pathogenesis. There was no strong association between MMP polymorphisms and un-POR susceptibility. However, women with A/G polymorphism (MMP-1 −519) had lower MMP-1 compared with GG homozygotes.

Clinical significance

Identification of patients with poor ovarian response in a pretreatment environment would help improve their ongoing fertility plan and manage their expectations. Also by having the ability to investigate if one belongs to that group, it could provide important family planning information for the patient.

How to cite this article

Tzafetas M, Lathouras K, Tantanasis T, Fidani S, Tziomalos K, Kalinderi K, Loufopoulos A, Zournatzi V. Role of Metalloproteinases in the Pathogenesis of Unexpected Poor Ovarian Response with a Possible Genetic Predisposition. Int J Infertil Fetal Med 2017;8(1):5-11.

Cancer prevention in patients with human immunodeficiency virus infection

Cancer is a leading cause of death in patients with human immunodeficiency virus (HIV) infection. With the advent of antiretroviral treatment, the risk of AIDS-defining cancers declined but the ageing of this population resulted in the emergence of other common cancers, particularly lung and hepatocellular cancer. Accordingly, screening programs similar to the general population should be implemented in patients with HIV infection. Vaccination against common oncogenic viruses is also essential. However, rates of cancer screening and vaccination against HPV and HBV are considerably low in this population, highlighting a pressing need to educate patients and healthcare professionals about the importance of cancer preventive measures in these vulnerable patients.

Is propofol the optimal sedative in gastrointestinal endoscopy?

Propofol is a sedative agent commonly used for sedation in gastrointestinal endoscopy. Its pharmacologic properties render propofol an almost ideal drug to achieve and maintain the targeted level of sedation in even complex gastrointestinal procedures. When compared with other sedative agents, propofol is associated with better patient and endoscopist satisfaction and shorter recovery times. Furthermore, propofol can be combined with other sedatives to reduce the total dosage required to achieve the targeted sedation. Its safety is demonstrated by multiple studies, in which adverse events occurred very rarely. Nevertheless, the use of propofol by non-anesthesiologists is illegal in many countries and in those permitted, a structured curriculum with clinical training must first be successfully completed. However, various studies have shown that non-anesthesiologist administration of propofol is comparable in efficacy and safety to administration by an anesthesiologist and more cost-effective. The results of numerous studies indicate that propofol is superior in many aspects compared with traditional sedative agents.

Unresolved issues in lipid-lowering treatment

Elevated low-density lipoprotein cholesterol (LDL-C) levels are a major modifiable risk factor for cardiovascular disease (CVD). In addition, treatment with statins reduces cardiovascular morbidity and mortality both in patients without and with established CVD. However, there still exist unresolved issues in the management of dyslipidemia. First, which are the optimal LDL-C levels? Second, do low high-density lipoprotein cholesterol (HDL-C) levels play a role in the pathogenesis of atherosclerosis and should they also represent treatment targets? In the present review, we discuss these two pertinent questions. Accumulating data, both from observational studies and from interventional studies with statins and other lipid-lowering agents, suggest that lowering LDL-C levels considerably below the currently recommended targets is both safe and further reduces cardiovascular morbidity and mortality. These benefits are particularly relevant for patients at very high cardiovascular risk, i.e. those with established CVD. On the other hand, it is questionable whether HDL-C is causally related to atherosclerosis and whether increasing HDL-C levels will translate into reduced cardiovascular risk. This uncertainty is even more pronounced in patients who achieve very low LDL-C levels with statin treatment.

Athyros V. EDITORIAL: Hypertension Guidelines: The 2014 Joint National Committee 8 vs All the Rest. We Can do Better

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HDL cholesterol efflux capacity and phospholipid content are associated with the severity of acute ischemic stroke and predict its outcome

BACKGROUND/AIMS

Impaired high-density lipoprotein (HDL) function and composition are more strongly related to cardiovascular morbidity than HDL concentration. However, it is unclear whether HDL function and composition predict ischemic stroke severity and outcome. We aimed to evaluate these associations.

METHODS

We prospectively studied 199 consecutive patients who were admitted with acute ischemic stroke. The severity of stroke was evaluated at admission with the National Institutes of Health Stroke Scale (NIHSS). Severe stroke was defined as NIHSS ≥ 5. The outcome was assessed with dependency at discharge (modified Rankin scale 2-5) and in-hospital mortality. Cholesterol efflux capacity (CEC), phospholipid levels, lecithin:cholesterol acyl transferase (LCAT)-phospholipase activity, paraoxonase-1 (PON1)-arylesterase activity and serum amyloid A1 (SAA1) content of HDL were measured.

RESULTS

CEC, phospholipid levels and LCAT-phospholipase activity of HDL were lower and SAA1 content of HDL was higher in patients with severe stroke. Patients who were dependent at discharge had lower CEC, PON1-arylesterase activity, phospholipid content and LCAT-phospholipase activity of HDL and higher HDL-SAA1 content. Independent predictors of dependency at discharge were the NIHSS at admission (RR 2.60, 95% CI 1.39-4.87), lipid-lowering treatment (RR 0.17, 95% CI 0.01-0.75), HDL-CEC (RR 0.21, 95% CI 0.05-0.87) and HDL-associated PON1-arylesterase activity (RR 0.95, 95% CI 0.91-0.99). In patients who died during hospitalization, phospholipids, LCAT-phospholipase and PON1-arylesterase activities of HDL were lower.

CONCLUSIONS

Changes in CEC and composition of HDL appear to be associated with the severity and outcome of acute ischemic stroke and could represent biomarkers that may inform risk stratification and management strategies in these patients.