Buflomedil: potential new indications for an old agent

Our understanding of vascular pathophysiology has significantly improved during the past two decades. Patients with type 2 diabetes mellitus have an increased vascular risk and a series of modifiable risk factors play a crucial role in the atherosclerotic process. The microvascular dysfunction in diabetes results in increased vascular permeability and impaired regulation of blood flow and vascular tone. These changes culminate in nephropathy, retinopathy and neuropathy and probably contribute to the increase vascular morbidity and mortality in this population. Moreover, studies in the skin microvasculature suggest that this microvascular dysfunction contributes significantly to the pathogenesis of diabetic foot. Several studies showed a beneficial effect of vasoactive drugs, including buflomedil, in non-diabetic patients. However, it remains to be established whether these drugs could also be beneficial in the diabetic population, especially in the early stages of diabetes.

Persistent effect of zoledronic acid in Paget's disease

Paget's bone disease is a disorder in which bone regions with high turnover are replaced by new, vascular, but disorganized and immature bone with excessive fibrosis, high tendency of deformity and diminished mechanical resistance. Treatment aims at the suppression of osteoclast activity and is achieved with bisphosphonates, which represent the treatment of choice for Paget's disease. Zoledronic acid, a relatively new member of this class, normalizes alkaline phosphatase in the majority of patients and has a favorable safety profile. We report the case of an asymptomatic patient who was diagnosed with Paget's disease based on typical biochemical, radiological and histological findings and was treated with a single intravenous infusion of 4 mg of zoledronic acid. No side effects were observed. Alkaline phosphatase levels normalized within four months. At the last follow up examination, three years after treatment, the patient remains asymptomatic, without significant changes in radiology imaging, and alkaline phosphatase levels are still within the normal range. In conclusion, zoledronic acid, apart from being safe and effective in Paget's disease, also appears to be able to achieve significantly prolonged remissions.

Prevalence of Non-coronary Heart Disease in Patients with Familial Hypercholesterolemia: An Analysis from the HELLAS-FH

AIMS

Despite the established link between familial hypercholesterolemia (FH) and increased risk of coronary heart disease (CHD), its association with other common atherosclerotic and metabolic diseases has not been extensively studied. The aim of this study was to report the prevalence of peripheral arterial disease (PAD) [i.e., common carotid artery disease (CCAD) and lower extremity arterial disease (LEAD)], aortic valve stenosis, chronic kidney disease (CKD) and non-alcoholic fatty liver disease (NAFLD) in patients with FH.

MATERIALS & METHODS

This was a cross-sectional study retrieving data from the Hellenic Familial Hypercholesterolemia Registry (HELLAS-FH).

RESULTS

A total of 1,633 adult patients (850 males) with heterozygous FH (HeFH) were included (mean age 51.3±14.6 years at registration and 44.3±15.9 years at diagnosis). Any common carotid artery stenosis (CCAS) was diagnosed in 124 out of 569 patients with available related data (21.8%), while the prevalence of CCAD (defined as a CCAS ≥50%) was 4.2%. The median (interquartile range - IQR) CCAS was 30% (20-40), whereas the median (IQR) carotid intima-media thickness (CIMT) was 0.7 (0.1-1.4) mm. LEAD was reported in 44 patients (prevalence 2.7%). The prevalence of aortic valve stenosis and CKD was 2.0% and 6.4%, respectively. NAFLD was present in 24% of study participants.

CONCLUSION

HeFH is associated with a relatively high prevalence of any CCAS and CCAD. The prevalence of LEAD, CKD and aortic valve stenosis was relatively low, whereas the prevalence of NAFLD was similar to that of the general population.

Effects of buflomedil on skin blood flow in patients with type 2 diabetes mellitus without overt micro- or macroangiopathy

AIM

The aim of this study was to assess the effects of buflomedil on the peripheral microcirculation in patients with type 2 diabetes mellitus (T2DM) without overt micro- or macroangiopathy.

METHODS

Twenty-three patients with T2DM were randomly assigned to receive buflomedil 600 mg/day for six months (N.=12) or no medication (N.=11). Skin blood flow in the lower limbs was assessed at baseline and after 3 and 6 months using Laser Doppler. We measured the following laser Doppler parameters: volume, flow and velocity.

RESULTS

In patients treated with buflomedil, there was a significant increase in volume (P=0.039) and a trend for an increase in both flow and velocity (P=0.097 for both parameters). In contrast, significant decreases in volume and flow were observed in the control group (P=0.045 and P=0.027, respectively) whereas velocity did not change (P=0.150).

CONCLUSION

In conclusion, buflomedil appears to have a beneficial effect on the peripheral microcirculation in patients with T2DM.

Novel insights in the prevention of perinatal transmission of hepatitis B

Perinatal transmission of hepatitis B virus (HBV) infection is major contributor to the growing burden of chronic hepatitis B worldwide. Administration of HBV immunoglobulin and HBV vaccination as soon after pregnancy as possible are the mainstay of prevention of perinatal transmission of HBV infection. In women with high viral loads, antiviral prophylaxis also appears to be useful. Lamivudine, telbivudine and tenofovir have been shown to be both safe and effective in this setting but tenofovir is the first-line option due to its low potential for resistance and more favorable safety profile.

The role of fibroblast growth factor 19 in the pathogenesis of nonalcoholic fatty liver disease

INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD) has emerged as the predominant cause of chronic liver injury worldwide. Bile acids and their receptors are profoundly implicated in the pathogenesis of NAFLD and its progression to nonalcoholic steatohepatitis and cirrhosis.

AREAS COVERED

We conducted extensive literature search using PubMed database, and we summarized the relevant literature. We provided an overview of the fibroblast growth factor 19 (FGF-19)-farnesoid X receptor (FXR) axis and summarized the latest findings derived from animal and human studies concerning the impact of FGF-19 on NAFLD.

EXPERT OPINION

FGF-19, a nutritionally regulated endocrine post-prandial hormone, governs bile acid metabolism, lipid oxidation, lipogenesis, and energy homeostasis. As no approved medication for NAFLD exists, FGF-19 seems to be a propitious therapeutic opportunity for NAFLD, since its administration was associated with ameliorated results in hepatic steatosis, liver inflammation and fibrosis. Furthermore, promising results have been derived from clinical trials concerning the beneficial efficacy of FGF-19 on histological findings and laboratory parameters of NAFLD. However, we should bear in mind the pleiotropic effects of FGF-19 on various metabolically active tissues along with its potential tumorigenic reservoir. Further clinical research is required to determine the clinical application of FGF-19-based therapies on NAFLD.

A European, Observational, 3-Year Cohort Comparative Study on the Safety of the Fixed Dose Combination Pravastatin 40 mg/Fenofibrate 160 mg vs. Statin Alone in Real Clinical Practice: The POSE Study

BACKGROUND AND PURPOSE

The aim of the study was to provide valuable real-world long-term safety data of the fixed pravastatin 40 mg/fenofibrate 160 mg combination in comparison of monotherapy with statins of moderate intensity.

MATERIALS AND METHODS

POSE study was an observational, comparative study conducted in three European countries. Patients treated or planned to be treated with pravastatin 40 mg/fenofibrate 160 mg or with a moderate-intensity statin in monotherapy were assessed over 3 years. The main safety endpoints included the incidence of renal or urinary disorder, musculoskeletal or connective tissue disorder, hepatobiliary disorder and cardiovascular events.

RESULTS

The study included 3075 patients treated for dyslipidaemia, with diabetes mellitus (47%), hypertension (56%) and/or established cardiovascular disease (61%). Over the 3 years of follow-up, the difference in incidence rate of safety events between the pravastatin 40 mg/fenofibrate 160 mg group and the statin group was not statistically significant (RR = 1.366 [95% CI = 0.967-1.929]). The most frequently occurring events were musculoskeletal and connective tissue disorders (AR = 0.030 in the pravastatin 40 mg/fenofibrate 160 mg group and 0.024 in the statin group), renal and urinary disorders (AR = 0.019 vs. 0.016, respectively) and aggravated diabetes mellitus (0.021 vs. 0.014). Most events occurred during the first year, then incidence decreased over the 3-year period. No statistically significant difference was observed between treatment groups regarding the cardiovascular events (RR = 1.209 [95% CI = 0.596-2.453]) and no new signal emerged from the long-term follow-up.

CONCLUSIONS

This study demonstrates a reassuring long-term safety profile of the fixed pravastatin 40 mg/fenofibrate 160 mg combination in routine clinical practice, with low and similar incidence of events over the 3 years follow-up compared to a monotherapy with statins of moderate intensity.

Suboptimal Adherence to Antihypertensive Treatment: Causes and Management

Suboptimal adherence to antihypertensive treatment is very common and is associated with poor control of blood pressure and increased risk for cardiovascular events. Therefore, frequent evaluation of compliance is essential in all hypertensive patients. Simplifying treatment regimens, using fixed-dose combinations and long-acting agents improves adherence, facilitates achievement of treatment targets and reduces cardiovascular morbidity and healthcare expenditures. Accordingly, physicians should be educated to implement these changes in hypertensive patients, particularly in those who require multiple antihypertensive agents to achieve blood pressure controls and in those who receive additional medications for comorbidities.

To Stent or Not to Stent? This is the Renal Artery Stenosis Question

A few days ago (Nov 18, 2013) the results of the large prospective 􀀃􀀇􀀑􀀉􀀌􀀐􀀕􀀇􀀒􀀈􀀔􀀍􀀇􀀑􀀁 􀀅􀀔􀀓􀀈􀀐􀀎􀀊􀀒􀀁 􀀌􀀏􀀁 􀀆􀀊􀀏􀀇􀀍􀀁 􀀂􀀓􀀋􀀊􀀑􀀐􀀖 􀀒􀀈􀀍􀀊􀀑􀀐􀀓􀀌􀀈􀀁 􀀄􀀊􀀒􀀌􀀐􀀏􀀒􀀁 􀀗􀀃􀀅􀀆􀀂􀀄􀀘􀀁 􀀓􀀑􀀌􀀇􀀍 were presented and published. CORAL enrolled 947 participants who had atherosclerotic renal artery stenosis (ARAS), 􀀂 60% and either uncontrolled systolic hypertension despite treatment with 􀀂 2 anti-hypertensive drugs or stage 3 chronic kidney disease (CKD) [1]. CORAL randomly assigned patients to medical therapy plus renal-artery stenting or medical therapy alone. The median follow-up period was 43 months and the primary endpoint was a composite of death from cardiovascular disease (CVD) or renal causes, myocardial infarction (MI), stroke, congestive heart failure, progression of renal insufficiency, or need for renal replacement therapy. Results showed that the addition of renal-artery stenting to thorough multifactorial medical therapy did not contribute a significant clinical benefit with respect to the prevention of CVD events or renal function deterioration. Adverse CVD or renal events occurred in 35.1% of patients who received stenting and 35.8% of those on medical therapy alone (p=0.58) [1]. Thus, the authors concluded that renal artery stenting was not superior to optimal medical therapy alone for moderately severe ARAS [1].

The results of CORAL have a direct impact on clinical practice questioning the need for renal artery stenting in patients managed with optimal medical therapy. The message seems to be very simple. If patients have ARAS and high blood pressure, they need a very aggressive comprehensive medical therapy before considering any interventional procedure.

A recent meta-analysis investigated CVD outcome in patients with ARAS treated either with renal angioplasty or antihypertensive drug therapy [2]. Pooled data from 5 studies (n=1,159 patients) showed that during the 2-year follow-up there were no significant clinical outcome differences between angioplasty and medical therapy [2], both in patients with or without CKD. In another study [3] it was shown that patients with ARAS and normal or near normal renal function (creatinine 􀀁2.0 mg/dl) can be safely treated with effective drug treatment, with a small decrease in GFR. For patients who have atherosclerotic MI, stroke or renal impairment, renal artery stenting may further reduce blood pressure and delay the deterioration or even improve renal function [3].

The Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) trial (n =867) [4], although criticised by some for methodological issues [5], results showed that there were no meaningful clinical benefit from revascularization in patients with ARAS; however considerable risks were present [4].

On the other hand, in patients with renovascular hypertension due to fibromuscular dysplasia (RAFMD) and/or the combination of RAFMD with ARAS, angioplasty is the method of choice and has favourable short- and long-term CVD and renal clinical outcomes [6].

The take away message from all the above is that prior trials showed similar results in mild ARAS; this study established the futility of stenting for a higher severity (moderate severity) of the disease. Substantially severe forms of ARAS will probably have to undergo renal angioplasty with stenting, especially when flash pulmonary oedema occurs [7-9].

Considerations for management of patients with diabetes mellitus and acute COVID-19

Diabetes mellitus (DM) is an independent risk factor for admission to intensive care unit and death in patients with coronavirus disease 2019 (COVID-19). On the other hand, medications used in the management of COVID-19 are potentially associated with increases in blood glucose levels and a higher incidence of infections. Accordingly, care of patients with DM and acute COVID-19 requires careful consideration of both diseases. Hyperglycemia and hypoglycemia are associated with adverse outcomes and therefore frequent measurement of blood glucose levels and a basal-bolus insulin regimen are required in most patients. Regarding the management of COVID-19, dexamethasone increases blood glucose levels and might also increase the risk for infections. On the other hand, limited data suggest that antiviral and immunomodulatory agents used in COVID-19 are not strongly associated with higher incidence of infections in this population. As knowledge evolves in this field, optimization of the management of both DM and COVID-19 will hopefully improve the outcome of these patients.

Should all Hypertensive Patients be Screened for Primary Aldosteronism?

Primary aldosteronism (PA) is not only a leading cause of secondary and resistant hypertension, but is also quite frequent in unselected hypertensive patients. Moreover, PA is associated with increased cardiovascular risk, which is disproportionate to BP levels. In addition, timely diagnosis of PA and prompt initiation of treatment attenuate this increased risk. On the other hand, there are limited data regarding the usefulness of screening for PA in all asymptomatic or normokalemic hypertensive patients. More importantly, until now, no well-organized, large-scale, prospective, randomized controlled trial has proved the effectiveness of screening for PA for improving clinical outcome. Accordingly, until more relevant data are available, screening for PA should be considered in hypertensive patients with spontaneous or diuretic-induced hypokalemia as well as in those with resistant hypertension. However, screening for PA in all hypertensive patients cannot be currently recommended.

Executive summary of the Hellenic Atherosclerosis Society guidelines for the diagnosis and treatment of dyslipidemias - 2023

Atherosclerotic cardiovascular disease (ASCVD) remains the main cause of death worldwide, and thus its prevention, early diagnosis and treatment is of paramount importance. Dyslipidemia represents a major ASCVD risk factor that should be adequately managed at different clinical settings. 2023 guidelines of the Hellenic Atherosclerosis Society focus on the assessment of ASCVD risk, laboratory evaluation of dyslipidemias, new and emerging lipid-lowering drugs, as well as diagnosis and treatment of lipid disorders in women, the elderly and in patients with familial hypercholesterolemia, acute coronary syndromes, heart failure, stroke, chronic kidney disease, diabetes, autoimmune diseases, and non-alcoholic fatty liver disease. Statin intolerance is also discussed.

Advances in the Pathogenesis of Diabetic Kidney Disease

Diabetic kidney disease (DKD) is both a frequent complication of diabetes mellitus (DM) [...].

Which is the optimal antiobesity agent for patients with nonalcoholic fatty liver disease?

Nonalcoholic fatty liver disease (NAFLD) is the commonest chronic liver disease and affects a considerable proportion of the general population worldwide. Obesity is a major risk factor for development and progression of NAFLD and weight loss is an effective intervention for the management of NAFLD. However, few patients achieve substantial and sustained weight loss with lifestyle measures. Therefore, antiobesity agents are frequently considered in patients with NAFLD but there are limited data on their safety and efficacy. In the present review, we discuss the role of antiobesity agents in the management of NAFLD. All approved antiobesity agents appear to reduce transaminase levels and to improve steatosis in patients with NAFLD. However, their effects on fibrosis are less well studied and whether they affect liver-related outcomes, including progression to cirrhosis and hepatocellular cancer, is unknown. The glucagon-like peptide-1 receptor agonists, liraglutide and semaglutide, appear to represent a first-line option in obese patients with NAFLD and type 2 diabetes mellitus (T2DM) since they induce considerable weight loss and have been extensively studied in patients with T2DM. However, more studies are needed to evaluated their effects on liver-related and cardiovascular outcomes in patients with NAFLD, particularly in those without T2DM.

CONGRESS COVERAGE: Antihypertensive Therapy in Acute Ischemic Stroke: Lost in the Mist

The results of the China Antihypertensive Trial in Acute Ischemic Stroke (CATIS) study were presented last month at the 2013 American Heart Association Scientific Meeting and simultaneously published in the Journal of the American Medical Association [1]. The CATIS study was a multicenter, controlled, randomized study that aimed to assess the effects of blood pressure reduction during the acute phase of ischemic stroke on death and major disability at 14 days and 3 months after the episode. The stroke was confirmed by brain CT or MRI and systolic blood pressure levels between 140-220 mmHg were required to enter the study. About half of screened patients with an acute ischemic stroke and hypertension fulfilled all inclusion/exclusion criteria and entered the study (2,038 out of 4,071).

Study participants were randomly assigned to receive or not antihypertensive therapy within 48 hours of stroke onset. In particular, a graded blood pressure reduction was aimed in the active group targeting a 10-25% reduction during the first study day and blood pressure control during the first week post-randomization. In contrast, no antihypertensive therapy was given in the control group and previous antihypertensive medication was discontinued during the acute phase of stroke. After the first week, all patients received antihypertensive therapy to achieve blood pressure control (<140/90 mmHg).

Blood pressure was significantly reduced in both groups during the first 24h post-randomization; however, the reduction was significantly greater in the active compared to the control group (21.8 versus 12.7 mmHg; between group difference: 9.1 mmHg; 95% CI: 8.1-10.2; p<0.001). Similarly, blood pressure levels were significantly lower in the active group at 7 days post-randomization (between group difference 9.3 mmHg; 95% CI: 8.4-10.1; p<0.001). The primary outcome (death or major disability at 14 days or hospital discharge) was identical in the two groups (odds ratio: 1.00; 95% CI: 0.88-1.14; p=0.98). The secondary outcome (death or major disability at 3 months post-randomization) was also the same (odds ratio: 0.99; 95% CI: 0.86-1.15; p=0.93), despite lower blood pressure values in the active group.

Subgroup analysis did not reveal any significant differences between the two groups on study outcomes. Blood pressure reduction during the acute phase of stroke seemed to confer a significant benefit only in one subgroup of patients: those who received antihypertensive therapy after the first 24h of stroke onset (odds ratio: 0.73; 95% CI: 0.55- 0.97; p=0.03). It has to be noted however that the findings of the subgroup analysis should always interpreted with caution, and be considered rather as hypothesis generating than conclusive.

The results of the CATIS study add more gas on the debate about the management of elevated blood pressure during the acute phase of an ischemic stroke. Current guidelines recommend blood pressure lowering in acute ischemic stroke only when blood pressure levels are above 220/120 mmHg [2]. However, such patients represent a minority, with less of 1% of patients admitted for stroke [3]. Therefore, a therapeutic strategy for the vast majority of stroke patients with elevated blood pressure is of utmost importance for practicing clinicians.

Available data in this field is unfortunately limited and inconclusive. About a decade ago, the Acute Candesartan Cilexitil Therapy in Stroke Survivors (ACCESS) study created a lot of enthusiasm [4]. A significantly lower rate of vascular events and all-cause mortality at 12 months was observed with candesartan compared to placebo (odds ratio: 0.475; 95% CI: 0.252-0.895), and the study was prematurely terminated when almost 350 patients were randomized instead of the projected 500 patients.

The ACCESS study questioned the negative findings of the Intravenous Nimodipine West European Stroke Trial (INWEST) [5], and set the basis for the conduction of a larger study, the Scandinavian Candesartan Acute Stroke Trial (SCAST). In the latter study, candesartan was compared to placebo in more than 2,000 patients with acute stroke, either ischemic or hemorrhagic [6]. Unfortunately, the great expectations generated by the ACCESS study were not fulfilled. There was no significant difference in the outcome between the active and the placebo group of the trial.

In the meantime, two other smaller studies were published. The Controlling Hypertension and Hypotension Immediately Post-Stroke (CHHIPS), a placebo-controlled, randomized study of 179 patients with acute stroke compared the effects of labetalol, lisinopril, and placebo [7]. No significant differences between the active and the comparison groups were observed, apart from a marginal benefit in mortality at 3 months post-stroke (hazard ratio: 0.40; 95% CI: 0.2-1.0; p=0.05). The Continue or Stop Post-Stroke Antihypertensives Collaborative Study (COSSACS) compared the effects of continuation or withdrawal of prior antihypertensive therapy in 763 patients with an acute mild stroke [8]. Continuation of antihypertensive therapy did not confer any benefit in mortality or disability.

Taken together, the findings of the CATIS trial combined with the findings of previous trials point towards a neutral effect of antihypertensive therapy during the acute phase of an ischemic stroke. Whether the time of therapy initiation (>24h from stroke onset) or other yet unidentified factors play a role and might identify patient subgroups who will benefit from antihypertensive therapy remains to be clarified by future research. Until then, the ‘non-detrimental – nonbeneficial’ effect of antihypertensive therapy suggests the individualization of management during the acute stroke by treating physicians.

Atherosclerotic renal artery stenosis: an update on diagnosis and management

Atherosclerotic renal artery stenosis (ARAS) is a progressive disease and it is usually associated with hypertension as well as with chronic kidney and cardiovascular disease. Although the anatomical lesions are relatively easy to depict, there is need to identify diagnostic methods to establish the functional significance of the stenosis and predict the response to revascularization. Over the last years, renal revascularization appears to be increasingly performed in patients with ARAS. However, controversy abounds as so far prospective, randomised trials did not document any benefit of revascularization with or without stenting plus optimal medical treatment over optimal medical treatment alone. In this review, we discuss the current data in the field of diagnosis and management of patients with ARAS.

Association of BMI, lipid-lowering medication, and age with prevalence of type 2 diabetes in adults with heterozygous familial hypercholesterolaemia: a worldwide cross-sectional study

BACKGROUND

Statins are the cornerstone treatment for patients with heterozygous familial hypercholesterolaemia but research suggests it could increase the risk of type 2 diabetes in the general population. A low prevalence of type 2 diabetes was reported in some familial hypercholesterolaemia cohorts, raising the question of whether these patients are protected against type 2 diabetes. Obesity is a well known risk factor for the development of type 2 diabetes. We aimed to investigate the associations of known key determinants of type 2 diabetes with its prevalence in people with heterozygous familial hypercholesterolaemia.

METHODS

This worldwide cross-sectional study used individual-level data from the EAS FHSC registry and included adults older than 18 years with a clinical or genetic diagnosis of heterozygous familial hypercholesterolaemia who had data available on age, BMI, and diabetes status. Those with known or suspected homozygous familial hypercholesterolaemia and type 1 diabetes were excluded. The main outcome was prevalence of type 2 diabetes overall and by WHO region, and in relation to obesity (BMI ≥30·0 kg/m2) and lipid-lowering medication as predictors. The study population was divided into 12 risk categories based on age (tertiles), obesity, and receiving statins, and the risk of type 2 diabetes was investigated using logistic regression.

FINDINGS

Among 46 683 adults with individual-level data in the FHSC registry, 24 784 with heterozygous familial hypercholesterolaemia were included in the analysis from 44 countries. 19 818 (80%) had a genetically confirmed diagnosis of heterozygous familial hypercholesterolaemia. Type 2 diabetes prevalence in the total population was 5·7% (1415 of 24 784), with 4·1% (817 of 19 818) in the genetically diagnosed cohort. Higher prevalence of type 2 diabetes was observed in the Eastern Mediterranean (58 [29·9%] of 194), South-East Asia and Western Pacific (214 [12·0%] of 1785), and the Americas (166 [8·5%] of 1955) than in Europe (excluding the Netherlands; 527 [8·0%] of 6579). Advancing age, a higher BMI category (obesity and overweight), and use of lipid-lowering medication were associated with a higher risk of type 2 diabetes, independent of sex and LDL cholesterol. Among the 12 risk categories, the probability of developing type 2 diabetes was higher in people in the highest risk category (aged 55-98 years, with obesity, and receiving statins; OR 74·42 [95% CI 47·04-117·73]) than in those in the lowest risk category (aged 18-38 years, without obesity, and not receiving statins). Those who did not have obesity, even if they were in the upper age tertile and receiving statins, had lower risk of type 2 diabetes (OR 24·42 [15·57-38·31]). The corresponding results in the genetically diagnosed cohort were OR 65·04 (40·67-104·02) for those with obesity in the highest risk category and OR 20·07 (12·73-31·65) for those without obesity.

INTERPRETATION

Adults with heterozygous familial hypercholesterolaemia in most WHO regions have a higher type 2 diabetes prevalence than in Europe. Obesity markedly increases the risk of diabetes associated with age and use of statins in these patients. Our results suggest that heterozygous familial hypercholesterolaemia does not protect against type 2 diabetes, hence managing obesity is essential to reduce type 2 diabetes in this patient population.

FUNDING

Pfizer, Amgen, MSD, Sanofi-Aventis, Daiichi-Sankyo, and Regeneron.

Increased risk of vascular events in systemic lupus erythematosus: is arterial stiffness a predictor of vascular risk?

Patients with systemic lupus erythematosus (SLE) have an increased vascular morbidity and mortality. Several established vascular risk factors are more prevalent in this population but cannot fully explain the reported excess atherosclerotic burden. Emerging vascular risk factors may also contribute to the increased vascular risk in these patients although the evidence is limited and often conflicting. SLE-specific risk factors also play a role in the pathogenesis of atherosclerosis.Given the multifactorial aetiology of vascular disease in SLE, an integrated index of risk could be useful in the management of these patients. Arterial stiffness possibly represents such an index and accumulating data suggest an increased prevalence of arterial stiffness in SLE. Many factors play a role in the loss of arterial elasticity in this population, including both emerging and established vascular risk factors. Arterial stiffness may emerge as a useful index for risk stratification in SLE and has the potential to guide therapeutic decisions in these patients.

The Role of Statins in the Management of Patients Undergoing Coronary Artery Bypass Grafting

Each year, a large number of patients undergo coronary artery bypass grafting surgery (CABG) worldwide. Accumulating evidence suggests that the preoperative administration of statins might be useful in preventing adverse events after CABG. In the present review, we discuss the role of statins in the perioperative management of patients undergoing CABG. Preoperative administration of statins in these patients substantially reduces the risk of postoperative atrial fibrillation and shortens hospital and intensive care unit (ICU) stay. Atorvastatin appears to be more effective, particularly when administered at high doses. Given these benefits and the safety of statins, their administration should be considered in patients undergoing CABG, even though the statins do not appear to affect the incidence of cardiovascular events and overall mortality perioperatively.