Prevalence and severity of liver disease in patients with b thalassemia major. A single-institution fifteen-year experience

During the last years, liver disease has emerged as a major cause of mortality in patients with b thalassemia major (TM). In spite of its clinical relevance, TM-associated liver damage has been insufficiently characterized. We therefore retrospectively analyzed all TM patients of our Department who underwent liver biopsy since 1990.

Heterozygous familial hypercholesterolemia: prevalence and control rates

Introduction: Heterozygous familial hypercholesterolemia (heFH) is associated with a very high risk for cardiovascular events. Treatment with potent statins substantially reduces cardiovascular morbidity in these patients. Moreover, combination therapy with statins plus ezetimibe and/or proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors facilitates achievement of low-density lipoprotein cholesterol (LDL-C) targets in patients with heFH. However, heFH remains underdiagnosed and undertreated worldwide.Areas covered: In this review, we summarize current evidence on the prevalence and control rates of heFH. Accumulating data suggest that heFH is one of the most common hereditary metabolic disorders, affecting approximately 1 in every 300 individuals. However, only a small minority of patients with heFH achieve LDL-C targets, even in high-income countries and in subjects followed-up in specialized lipid clinics.Expert opinion: Given the underdiagnosis of heFH using cascade and opportunistic screening, wider, population-based screening strategies should be evaluated for their feasibility and cost-effectiveness if we aspire to timely diagnosis and therefore prevention of cardiovascular morbidity and mortality in this very high risk population. Overcoming inertia in uptitrating statin dose, adding ezetimibe and/or PCSK9 inhibitors along with more generous reimbursement for lipid-lowering agents in patients with heFH are essential for improving goal attainment rates.

Stiff Heart and Stiff Arteries. Could We Soften Both?

Old age, female gender, hypertension (HTN), cardiac ischaemia, and arterial stiffness (AS) are the main determinants of a stiff heart, diastolic dysfunction (DD), and finally heart failure with preserved ejection fraction (HFpEF); however, several cardiac or extra-cardiac pathologies may also be involved. The combined ventricular-arterial stiffening (abnormal left ventricle-arterial coupling) is the main determinant of the increased prevalence of HFpEF in elderly persons, particularly women, and in younger subjects with HTN. Hospitalization and mortality rates in patients with HFpEF are similar to those of patients with heart failure with reduced EF (HFrEF). However, although the prognosis of HFrEF has improved over time, the optimal treatment of HFpEF remains unclear, because of the differences in the pathophysiology of the two syndromes. A number of new drugs have shown promise but they will not be commercially available for several years. For the time being, aggressive treatment of non-cardiac comorbidities is the only option available for the management of HFpEF. Treatment of anaemia, sleep disorders, chronic kidney disease, non-alcoholic fatty liver disease, atrial fibrillation, diabetes mellitus, and judicious use of diuretics are effective to some degree. Statin treatment deserves special attention, regardless of the presence of dyslipidaemia, because it has been shown, mainly in small studies, post hoc analyses, and in a large recent meta-analysis, that it is related to an improved quality of life and a reduction in HF-related mortality. We urgently need to utilize these recourses to relieve a substantial number of patients suffering from HFpEF, a disease with an ominous prognosis.

Obesity and atherosclerotic cardiovascular disease in adults with heterozygous familial hypercholesterolemia: An analysis from HELLAS-FH registry

BACKGROUND

Familial hypercholesterolemia (FH) and obesity are well-established risk factors of atherosclerotic cardiovascular disease (ASCVD). Despite high prevalence, their joint association with ASCVD remains largely unknown.

OBJECTIVE

To investigate the association of obesity with prevalent ASCVD in individuals with heterozygous FH (HeFH) enrolled in the Hellenic Familial Hypercholesterolemia Registry (HELLAS-FH).

METHODS

FH diagnosis was based on Dutch Lipid Clinic Network (DLCN) criteria. Adults with at least possible FH diagnosis (DLCN score ≥3) and available body mass index (BMI) values were included. Homozygous FH individuals were excluded.

RESULTS

1655 HeFH adults (mean age 51.0 ± 14.4 years, 48.6% female) were included; 378 (22.8%) and 430 (26.0%) were diagnosed with probable and definite FH, respectively. Furthermore, 371 participants (22.4%) had obesity and 761 (46.0%) were overweight. Prevalence of ASCVD risk factors increased progressively with BMI. Prevalence of coronary artery disease (CAD) was 23.4% (3.2% for stroke and 2.7% for peripheral artery disease [PAD]), and increased progressively across BMI groups. After adjusting for traditional ASCVD risk factors and lipid-lowering medication, individuals with obesity had higher odds of established CAD (OR: 1.54, 95% CI: 1.04-2.27, p = 0.036) as well as premature CAD (OR: 1.74, 95% CI: 1.17-2.60, p = 0.009) compared with those with normal BMI. No association was found with stroke or PAD.

CONCLUSIONS

Over half of adults with HeFH have overweight or obesity. Obesity was independently associated with increased prevalence of CAD in this population.

The Role of Angiotensin Receptor Blockers in the Personalized Management of Diabetic Neuropathy

Neuropathy is a frequent complication of diabetes mellitus (DM) and is associated with the increased risk ofamputation and vascular events. Tight glycemic control is an important component inthe prevention of diabetic neuropathy. However, accumulating data suggest that angiotensin receptor blockers (ARBs) might also be useful in this setting. We discuss the findings of both experimental and clinical studies that evaluated the effects of ARBs on indices of diabetic neuropathy. We also review the implicated mechanisms of the neuroprotective actions of these agents. Overall, it appears that ARBs might be a helpful tool for preventing and delaying the progression of diabetic neuropathy, but more data are needed to clarify their role in the management of this overlooked complication of DM.

EDITORIAL-Blood Pressure as a Risk Factor of Global Disease Burden and its Association with Lifetime Risks of Different Manifestations of Cardiovascular Disease

The evaluation of lifetime cardiovascular disease (CVD) risk and the life-years lost due to CVD in specific age groups in a population of 1.25 million people showed that not all elements of hypertension are causally associated with all manifestations of CVD. High systolic blood pressure (BP) was strongly related to intracerebral haemorrhage, subarachnoid haemorrhage, stable angina, myocardial infarction, and peripheral arterial disease (PAD). On the other hand, high diastolic BP had a stronger relationship with abdominal aortic aneurysm and pulse pressure had a stronger association with PAD and an inverse association with abdominal aortic aneurysm. Unstable angina was related to loss of life in younger ages, whereas heart failure and stable angina pectoris were related to years of life lost in the elderly. Thus, specific elements of BP were linked to specific manifestations of CVD and causes of death by CVD. Another recent study analysed the independent effects of 67 all-disease risk factors in 21 regions worldwide in 2010 and compared them with those of 1990. Hypertension immerged as the first cause of all-cause disease burden (7%), while in 1990 it was not included in the first 3 causes. A shift from communicable diseases of the children to the non-communicable diseases of the adults was also recorded in this 20-year period. A plethora of data suggests the hypertension is the number one killer both in Western World and Worldwide. The adoption of lifetime CVD risk estimates combined with efforts for increased awareness, education, and BP control will probably improve outcomes and substantially reduce CVD mortality.

CONGRESS COVERAGE: Renal Sympathetic Denervation for Resistant Hypertension: Symplicity HTN-3 and the Power of Placebo

DEAR EDITOR

The results of the Symplicity HTN-3 trial have been presented a few days ago in the 2014 Scientific Meeting of the American College of Cardiology and simultaneously published in the New England Journal of Medicine [1]. The Symplicity HTN-3 trial was the first placebo-controlled (via sham procedure) study evaluating the effects of renal sympathetic denervation (RSD) in patients with resistant hypertension. The study met its primary safety endpoint but failed to achieve its primary and secondary efficacy endpoints generating major disappointment in the scientific community and raised significant concerns about the future of this novel interventional approach for the management of patients with resistant hypertension.

The Symplicity HTN-3 trial was a multicenter, prospective, randomized, single-blind, sham-controlled study conducted in the United States of America. The study was performed in patients with uncontrolled resistant hypertension, i.e. office systolic blood pressure >160 mmHg despite the use of at least three antihypertensive drugs (one of which was a diuretic) in maximally tolerated doses. Moreover, home blood pressure monitoring for two weeks and 24h ambulatory blood pressure monitoring ensured the diagnosis of true resistant hypertension, excluding patients with pseudoresistance due to the white-coat effect. From a total of 1,441 patients screened for eligibility, 535 patients fulfilled the inclusion/criteria and were randomly assigned to either RSD or a sham procedure (placebo) in a 2 to 1 ratio and were then followed-up for 6 months.

The primary safety endpoint was a composite of hard and surrogate events (all-cause mortality, end-stage renal failure, embolic episodes leading to target organ damage, renovascular complications and new-onset renal artery stenosis, and hypertensive crises) less of approximately 10%, based on prior information. The office blood pressure reduction at 6 months with a superiority margin of 5 mmHg for renal nerve ablation was the primary efficacy endpoint and the ambulatory blood pressure reduction at the same time point was the secondary efficacy endpoint.

The study achieved its primary safety endpoint, since no significant differences in adverse events were observed between RSD and sham procedure. In total, there were 5 significant adverse events in the active treatment group compared with one significant adverse event in the placebo group, and the difference was not significant (p=0.67). Moreover, no significant deterioration of renal function was observed with RSD, even in patients with chronic kidney disease (estimated glomerular filtration rate < 60 ml/min/1.73m2). The reassuring renal safety profile confirms the short-term safety of RSD that was observed in previous studies [2-5], but does not totally exclude potential long-term detrimental effects on renal function [6, 7].

The major disappointment however comes from the efficacy endpoints. The study failed to achieve both its primary and secondary efficacy endpoints. In particular, the mean reduction in office blood pressure was 14.1 mmHg with active therapy and 11.7 mmHg with placebo at 6 months, and was highly significant for both groups compared to baseline (p<0.001). However, the between-group difference in systolic blood pressure reduction was small (2.4 mmHg) and was not significant (p=0.26) in terms of the pre-defined superiority of 5 mmHg. Similarly, the mean reduction in ambulatory blood pressure at 6 months was 6.8 mmHg with active therapy and 4.8 mmHg with placebo compared to baseline, and the small between-group difference (2.0 mmHg) was not significant (p=0.98) for a superiority margin of 2 mmHg.

Several points need to be highlighted and evaluated in the context of previous knowledge in order to avoid misleading conclusion.

Firstly, the magnitude of office blood pressure reduction was almost half than in previous studies (14.1 mmHg versus 25-30 mmHg) [2, 3, 5, 8-11]. The inferior efficacy of RSD in the Symplicity-3 might be attributed to differences in study populations and several other factors. It has to be noted however that all previous studies were uncontrolled. It has been estimated that the anticipated blood pressure reduction with RSD is approximately 15 mmHg, when all other factors are taken in consideration [12].

Secondly, the ambulatory blood pressure reduction was significantly lower than the office blood pressure reduction (6.8 mmHg versus 14.1 mmHg), and this also was not an unexpected finding. A marked disparity between office and ambulatory blood pressure reduction with RSD has been observed in all previous RSD studies [13], and this disparity is significantly higher than with antihypertensive drug therapy [14].

Thirdly, the main factor contributing to the negative findings of the study was the impressive blood pressure reduction with the sham procedure (11.7 mmHg). However, this was also not an unexpected finding and it should have been anticipated based on previous data. Indeed, two studies performed in patients with resistant hypertension and similar baseline characteristics, revealed a strong placebo effect: the Rheos pivotal trial and the darusentan study [15, 16]. The powerful placebo effect almost “killed” both carotid baroreceptor activation and endothelin receptor antagonism for the treatment of resistant hypertension [17, 18].

Finally, potential disadvantages in study design cannot be entirely excluded. The study design was very meticulous and of the highest quality, and included sham procedure and ambulatory blood pressure monitoring overcoming previous concerns [19, 20]. However, one factor might have significantly influenced the findings of the study: the absence of familiarity with this novel procedure. The study was conducted in 88 sites all over the United States and more than 100 interventional cardiologists performed the procedure, for a mean of 3 to 4 procedures for each interventionalist. This raises the concern of a learning curve, especially because RSD was performed with the single-tip Symplicity catheter, which needs a lot of manipulations.

Overall, the negative findings of the Symplicity-3 trial “turned-off” the initial enthusiasm about RSD in many physicians, both hypertension specialists and primary care doctors. However, a sober and dispassionate approach seems more rational, avoiding overwhelming enthusiasm and excessive pessimism. Carefully designed clinical trials along with intensive research about response predictors are eagerly awaited in order to identify patient subgroups that will benefit from RSD.