Prophylactic antibiotic treatment in severe acute ischemic stroke: the Antimicrobial chemopRrophylaxis for Ischemic STrokE In MaceDonIa-Thrace Study (ARISTEIDIS)

Infections represent a leading cause of mortality in patients with acute ischemic stroke, but it is unclear whether prophylactic antibiotic treatment improves the outcome. We aimed to evaluate the effects of this treatment on infection incidence and short-term mortality. This was a pragmatic, prospective multicenter real-world analysis of previously independent consecutive patients with acute ischemic stroke who were >18 years, and who had at admission National Institutes of Health Stroke Scale (NIHSS) >11. Patients with infection at admission or during the preceding month, with axillary temperature at admission >37 °C, with chronic inflammatory diseases or under treatment with corticosteroids were excluded from the study. Among 110 patients (44.5 % males, 80.2 ± 6.8 years), 31 (28.2 %) received prophylactic antibiotic treatment, mostly cefuroxime (n = 21). Prophylactic antibiotic treatment was administered to 51.4 % of patients who developed infection, and to 16.4 % of patients who did not (p < 0.001). Independent predictors of infection were NIHSS at admission [relative risk (RR) 1.16, 95 % confidence interval (CI) 1.08-1.26, p < 0.001] and prophylactic antibiotic treatment (RR 5.84, 95 % CI 2.03-16.79, p < 0.001). The proportion of patients who received prophylactic antibiotic treatment did not differ between patients who died during hospitalization and those discharged, or between patients who died during hospitalization or during follow-up and those who were alive 3 months after discharge. Prophylactic administration of antibiotics in patients with severe acute ischemic stroke is associated with an increased risk of infection during hospitalization, and does not affect short-term mortality risk.

JUPITER: major implications for vascular risk assessment

This Editorial comments on the recently published JUPITER trial (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin), the further evidence it provides for supporting the role of statins in primary prevention and the major implications this may hold for vascular risk assessment and clinical practice guidelines.

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.

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.

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.

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.

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.

Treating Arterial Stiffness in Young and Elderly Patients with the Metabolic Syndrome

Arterial stiffness is independently associated with increased cardiovascular risk in patients with cardiovascular risk factors and in the general population. Metabolic syndrome (MetS) is frequently characterized by increased arterial stiffness since all components of MetS are implicated in the pathogenesis of arterial stiffness. We review the management of arterial stiffness in patients with MetS. Several small, short-term studies showed that lifestyle changes, antidiabetic, antihypertensive and lipid-lowering agents improve arterial elasticity. However, differences appear to exist between different classes of agents, with statins and inhibitors of the renin-angiotensin-aldosterone system having the more favorable effects on arterial stiffness. A multifactorial approach appears to be the optimal management of increased arterial stiffness in patients with MetS.

Left ventricular hypertrophy assessed by electrocardiogram is associated with more severe stroke and with higher in-hospital mortality in patients with acute ischemic stroke

BACKGROUND AND AIMS

Left ventricular hypertrophy (LVH), assessed by electrocardiogram (ECG), is associated with increased risk for stroke. However, few studies that evaluated whether ECG-detected LVH predicts ischemic stroke severity and outcome. We aimed to evaluate these associations.

METHODS

We prospectively studied 922 patients consecutively admitted with acute ischemic stroke (age 79.6 ± 6.9 years). Stroke severity was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). Severe stroke was defined as NIHSS≥5. LVH was evaluated with the Sokolow-Lyon index and the Cornell voltage-duration product criteria in an ECG obtained at admission. The outcome was assessed with dependency at discharge (modified Rankin scale 2-5) and in-hospital mortality.

RESULTS

Independent predictors of severe stroke were age (relative risk (RR) per year 1.07, 95% confidence interval (CI) 1.03-1.11, p<0.001), female gender (RR 0.36, 95% CI 0.17-0.76, p<0.01), atrial fibrillation (RR 2.07, 95% CI 1.30-3.29, p<0.005), chronic kidney disease (RR 2.38, 95% CI 1.04-5.44, p<0.05), heart rate (RR per 1/min 1.02, 95% CI 1.01-1.04, p<0.005), glucose levels (RR 1.012, 95% CI 1.006-1.018, p<0.001), high-density lipoprotein cholesterol levels (RR 0.976, 95% CI 0.960-0.993, p<0.005) and LVH defined according to the Cornell voltage-duration product criteria (RR 2.08, 95% CI 1.12-3.86, p<0.05). Independent predictors of dependency at discharge were age (RR per year 1.08, 95% CI 1.03-1.13, p<0.001), past smoking (RR versus no smoking 0.42, 95% 0.19-0.89, p<0.05), history of ischemic stroke (RR 2.13, 95% CI 1.23-3.71, p<0.01) and NIHSS at admission (RR 1.48, 95% CI 1.35-1.63, p<0.001). Independent predictors of in-hospital mortality were glucose levels (RR 1.014, 95% CI 1.003-1.025, p<0.05), NIHSS at admission (RR 1.29, 95% CI 1.19-1.41, p<0.001) and LVH according to the Cornell voltage-duration product criteria (RR 4.95, 95% CI 1.09-22.37, p<0.05).

CONCLUSIONS

LVH according to the Cornell voltage-duration product criteria appears to be associated with more severe stroke and with higher in-hospital mortality in patients with acute ischemic stroke.

Treatment with Clopidogrel Prior to Acute Non-Cardioembolic Ischemic Stroke Attenuates Stroke Severity

BACKGROUND

Clopidogrel reduces the risk of non-cardioembolic ischemic stroke, but it is unclear whether it affects the severity and outcome of stroke. We aimed at evaluating the effect of prior treatment with clopidogrel on acute non-cardioembolic ischemic stroke severity and in-hospital outcome.

METHODS

We prospectively studied 608 consecutive patients (39.5% males, age 79.1 ± 6.6 years) who were admitted with acute ischemic stroke. 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 outcome was assessed using the dependency rates that prevailed at the time of discharge (i.e. modified Rankin scale between 2 and 5) and with in-hospital mortality.

RESULTS

At admission, 397 patients did not have atrial fibrillation or heart valve disease. Among these 397 patients, 69 were receiving monotherapy with clopidogrel prior to stroke, 69 were receiving monotherapy with aspirin and 236 patients were not on any antiplatelet treatment. The prevalence of severe stroke was lower in patients who were receiving clopidogrel than in patients who were receiving aspirin and patients who were not on antiplatelets (1.4, 13.0 and 11.0%, respectively; p < 0.05). Independent predictors of severe stroke at admission were male gender (relative risk (RR) 0.31, 95% CI 0.12-0.78, p < 0.05) and treatment with clopidogrel prior to stroke compared with no antiplatelet treatment (RR 0.13, 95% CI 0.02-0.97, p < 0.05). Treatment with aspirin prior to stroke did not predict severe stroke compared with no antiplatelet treatment (RR 1.24, 95% CI 0.51-2.98, p = NS). The rate of dependency at discharge did not differ between patients who were receiving clopidogrel, patients who were receiving aspirin and those who were not on antiplatelets (57.9, 47.8 and 59.7%, respectively; p = NS). Independent predictors of dependency at discharge were age (RR 1.12, 95% CI 1.05-1.19, p < 0.001) and NIHSS at admission (RR 1.67, 95% CI 1.46-1.92, p < 0.001). In-hospital mortality rate also did not differ between patients who were receiving clopidogrel, patients who were receiving aspirin and those who were not on antiplatelets (4.3, 4.3 and 5.0%, respectively; p = NS). The only independent predictor of in-hospital mortality was NIHSS at admission (RR 1.22, 95% CI 1.14-1.30, p < 0.001).

CONCLUSIONS

Treatment with clopidogrel prior to acute non-cardioembolic ischemic stroke attenuates the severity of stroke at admission but does not appear to affect the functional outcome at discharge or the in-hospital mortality of these patients.

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.

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.

The Role of Proprotein Convertase Subtilisin-Kexin Type 9 Inhibitors in the Management of Dyslipidemia

BACKGROUND

Treatment with statins substantially reduces cardiovascular morbidity and mortality both in patients with and without established cardiovascular disease. Accordingly, statins represent the cornerstone of lipid-lowering treatment. However, there are still unmet clinical needs in the management of dyslipidemia. Indeed, it is difficult to achieve low-density lipoprotein cholesterol (LDL-C) targets in many patients, particularly in those at very high cardiovascular risk or in those with very high baseline LDL-C levels [e.g. with heterozygous familial hypercholesterolemia (FH)]. Moreover, a sizable proportion of patients are not able to tolerate high doses of statins, mostly due to muscle-related adverse effects. In these patient populations, inhibition of proprotein convertase subtilisin-kexin type 9 (PCSK9) with monoclonal antibodies appears to represent a useful tool for achieving LDL-C targets.

METHODS

In the present review, we summarize the current knowledge on the effects of the PCSK9 inhibitors alirocumab and evolocumab on lipid levels in various populations and discuss the role of these agents in the management of dyslipidemia.

RESULTS

In addition to a substantial reduction in LDL-C levels (by 50-60%), PCSK9 inhibitors also lower triglyceride, non-high-density lipoprotein cholesterol (non-HDL-C) and lipoprotein (a) levels and increase HDL-C levels. Preliminary data suggest that PCSK9 inhibitors are safe. However, ongoing randomized, placebo-controlled trials will provide definitive evidence on the safety of these novel agents and on their effects on cardiovascular morbidity and mortality.

CONCLUSION

Given the high cost of PCSK9 inhibitors, their use should be restricted to carefully selected, veryhigh risk patients until the results of these trials are available.

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.

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.

Acenocoumarol vs. low-dose dabigatran in real-world patients discharged after ischemic stroke

The aim of this study was to compare the efficacy of dabigatran 110 mg twice daily and acenocoumarol in patients with atrial fibrillation discharged after ischemic stroke. We prospectively studied 436 consecutive patients who were discharged after acute ischemic stroke (39.2% males, age 78.6 ± 6.7 years). Approximately 1 year after discharge, the functional status was assessed with the modified Rankin scale (mRS). Adverse outcome was defined as mRS between 2 and 6. The occurrence of ischemic stroke, myocardial infarction (MI) and death during the 1-year follow-up was also recorded. At discharge, 142 patients had atrial fibrillation. Acenocoumarol and dabigatran 110 mg twice daily were prescribed to 52.1 and 6.3% of these patients, respectively. At 1 year after discharge, there was a trend for patients treated with acenocoumarol to have lower mRS than patients prescribed dabigatran (2.3 ± 2.4 and 4.1 ± 2.2, respectively; P = 0.060). Adverse outcome rates and the incidence of stroke during follow-up did not differ between the two groups. The incidence of MI was almost three times higher in patients prescribed dabigatran than in those prescribed acenocoumarol, but this difference did not reach significance (11.1 and 4.0%, respectively; P = 0.254). The incidence of cardiovascular death was also almost three times higher in the former, but again this difference was not significant (33.3 and 12.2%, respectively; P = 0.237). In real-world patients with acute ischemic stroke, dabigatran 110 mg twice daily is as effective as acenocoumarol in preventing stroke but appears to be associated with worse long-term functional outcome and higher incidence of MI.

LETTER TO THE EDITOR: Pomegranate Juice is Useful for the Management of Hypertension and the Improvement of Cardiovascular Health

DEAR EDITOR

We thank Prof. Liberopoulos and Dr Barkas you for their letter [1], which helps to enhance the understanding of the message of the associated Editorial.

Price and availability of pomegranate juice (PJ) are indeed two major issues. The daily cost of PJ consumption is ranging from 0.5 to 1 $ per day, according to the dose used. PJ is available in almost all Western and several Asian countries. PJ is preserved in deep refrigeration and is readily available during the entire year. PJ circulates mainly in two forms: pure juice in 200 to 500 mL bottles (adulteration is practically impossible, because the color and the taste are unique) and in 1 L bottles, blended with purple grape juice without added sugar. The later contains resveratrol, a type of natural phenol and a phytoalexin, found in the skin of red grapes with definite antidiabetic effects and proposed but not proved yet anti-aging and anticancer effects. Resveratrol treatment has shown beneficial effects on glucose and lipid metabolism in some, but not all studies [2,3]. Study population, resveratrol source, and dose vary widely, potentially explaining inconsistency of findings among studies. Enhancement in endothelial function, systolic blood pressure, and markers of oxidative stress and inflammation in several studies have been reported [2,3].

The quantity and calorie intake is not a problem. Most studies (performed by Prof Aviram team) used a 50 mL PJ intake [4], mainly from the “wonderful” variety [5]. The juice has a 10% content of sugar (5 g/d). Thus, calorie intake is not significant. In regard to diabetes mellitus the use of PJ, especially if this is mixed with purple crape juice, substantially reduces blood glucose and the risk of diabetes, and not the other way around [2-5]. As a matter of fact PJ has more antiatherogenic effects on patients with diabetes than in non-diabetic individuals [4-6].

The studies showing a beneficial effect of PJ on cardiovascular risk factors indeed included a small number of participants, were mostly not double blinded and evaluated only surrogate end-points. This is why we suggest that PJ might be only used as an adjunctive therapy for arterial hypertension (HTN) on top of other non-pharmacological interventions or drug therapy [7], and mainly in patients with HTN and high oxidative burden such as this caused by diabetes, obesity, metabolic syndrome or smoking [7]. This is not a first line therapy and is not suggested for monotherapy [7]. It is unfortunate that up to day there have been no sponsors or grants available to clear this issue once and for all, regardless of the findings, with a large scale, prospective, randomized, controlled survival study in humans.

The effect of PJ on blood pressure is reported by some studies to be as high as a 21% reduction in systolic blood pressure, which is rather sizable reduction [8]. The long term (3-years) effects of PJ on a surrogate endpoint (carotid atherosclerosis) were shown in a clinical study [8]. There were no adverse effects as reported with other antioxidants, such as alpha-tocopherol and beta-carotene [8]. Finally, PJ was shown to have the highest antioxidant potential than any other functional food or supplementary treatment [9].

Common sense suggests that all appropriate pharmacological or non-pharmacological interventions should be implemented for the optimal control of HTN, however, the use of PJ (the other parts of the fruit have no antioxidant actions) could be considered as an adjunctive therapy to improve the control of HTN and the related, mainly cardiovascular, adverse events.

Effect of antihypertensive treatment on the long-term outcome of patients discharged after acute ischemic stroke

We aimed to evaluate the effects of the five main classes of antihypertensive agents on the long-term outcome of 313 consecutive patients discharged after acute ischemic stroke (36.4% males, age 78.5 ± 6.3 years). One year after discharge, the functional status [evaluated with the modified Rankin scale (mRS)], the occurrence of cardiovascular events, and vital status were recorded. Patients prescribed angiotensin receptor blockers (ARBs) had lower mRS than patients not prescribed ARBs (1.7 ± 2.0 vs. 2.9 ± 2.5, respectively; p = 0.006). The rates of adverse outcome (mRS 2-6) and cardiovascular events did not differ between patients prescribed each one of the major classes of antihypertensive agents and those not prescribed the respective class. Patients who were prescribed ARBs had lower risk of death during follow-up than patients who did not receive ARBs (9.4 and 26.9%, respectively; p < 0.05). In binary logistic regression analysis, the only independent predictor of all-cause mortality during follow-up was the mRS at discharge (relative risk 1.69, 95% confidence interval 1.25-2.28; p < 0.001). In conclusion, in patients discharged after acute ischemic stroke, administration of ARBs appears to have a more beneficial effect on long-term functional outcome and all-cause mortality than treatment with other classes of antihypertensive agents.

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.