The impact of smoking on cardiovascular outcomes and comorbidities in statin-treated patients with coronary artery disease: a post hoc analysis of the GREACE study

BACKGROUND

Smoking adversely affects cardiovascular disease (CVD) morbidity and mortality; however the effect of long-term statin treatment in high risk smokers is not entirely clear. The primary endpoint of this post hoc analysis of the GREek Atorvastatin and Coronary Heart Disease Evaluation (GREACE) study (n=1,600 patients with established coronary heart disease, mean follow-up 3-years) was the incidence of major CVD events, a composite of death, myocardial infarction, revascularization, unstable angina, heart failure, and stroke in statin-treated patients (n=880) who continued to smoke (n=129) compared with ex-smokers (n=309) and never smokers (n=442) as well as on patients not treated with a statin (n=720) of all smoking categories. Secondary endpoints were the effect of smoking on chronic kidney disease (CKD) and on non-alcoholic fatty liver disease (NAFLD), two major and common independent CVD risk factors.

RESULTS

Among statin treated patients the hazard ratio (HR) for current smokers compared with never smokers was 1.86 [95% confidence interval-(CI) 1.19-2.10); similar was the HR for current smokers compared with ex-smokers. Absolute (16.3%) and relative (45.6%) CVD risk reduction was great in current smokers on statins compared with those not on a statin; however they still had the highest absolute CVD event incidence (19.4%). Low high density lipoprotein cholesterol and higher triglycerides may account, at least in part, for this. The highest risk of CVD events in any of the 6 groups was in the smokers not on a statin (35.7%). CKD and NAFLD were not negatively affected by smoking and they do not appear to be implicated in the adverse effect of smoking on CVD event rate in patients on a statin.

CONCLUSIONS

Statins reduce CVD morbidity and mortality in current smokers with CVD, but these remain high in terms of absolute incidence compared with ex- and never smokers. CKD and NAFLD are not affected by smoking and do not seem to contribute to this high CVD event incidence. These make smoking cessation imperative in high risk patients even if they are on statins.

Predictive factors that influence the course of medullary thyroid carcinoma

BACKGROUND

Medullary thyroid cancer (MTC) is an infrequent form of thyroid cancer. We aimed to examine how gender and histological characteristics influence the rate of recurrence/persistent disease, distant metastases and survival and also to define specific characteristics of MTC microcarcinomas.

METHODS

The medical records of 85 patients with MTC were reviewed. The following characteristics were recorded: year of diagnosis, age at diagnosis, sex, tumor size, number of tumor foci, lymph node metastases, thyroid capsule and vascular invasion, infiltration of thyroid parenchyma and extrathyroid extension, and distant metastases.

RESULTS

During follow-up (mean 78.8 months), persistent disease occurred in 40 patients, local recurrences in 5 and distant metastases in 32 patients. Local and distant disease appeared more frequently in patients with larger tumors (p < 0.005) and lymph node metastases (p < 0.01). In addition, patients with invasive tumors had local and distant disease more frequently. The percentage of males who had persistent disease and/or local recurrence was significantly higher than the percentage of males who did not (p < 0.05). Similar results were observed for distant disease (p < 0.01). Independent predictors of recurrence and persistent disease was the presence of lymph node metastases at diagnosis (risk ratio 11.66) and of distant metastases were the presence of lymph node metastases at diagnosis (risk ratio 17.42) and the presence of vascular invasion (risk ratio 2.41). Fifteen patients died due to MTC during follow-up (17.6 %). Patients who died were more frequently males, and had thyroid capsule invasion, extrathyroidal extension, vascular invasion and metastatic disease.

CONCLUSIONS

Male sex, tumor size and invasive characteristics of the tumor are negative predictive factors for evolution of MTC.

Weight loss significantly reduces serum lipocalin-2 levels in overweight and obese women with polycystic ovary syndrome

Serum lipocalin-2 levels are elevated in obese patients. We assessed serum lipocalin-2 levels in polycystic ovary syndrome (PCOS) and the effects of weight loss or metformin on these levels. Forty-seven overweight/obese patients with PCOS [body mass index (BMI) >27 kg/m(2)] were instructed to follow a low-calorie diet, to exercise and were given orlistat or sibutramine for 6 months. Twenty-five normal weight patients with PCOS (BMI <25 kg/m(2)) were treated with metformin for 6 months. Twenty-five normal weight and 25 overweight/obese healthy female volunteers comprised the control groups. Serum lipocalin-2 levels did not differ between overweight/obese patients with PCOS and overweight/obese controls (p = 0.258), or between normal weight patients with PCOS and normal weight controls (p = 0.878). Lipocalin-2 levels were higher in overweight/obese patients with PCOS than in normal weight patients with PCOS (p < 0.001). In overweight/obese patients with PCOS, weight loss resulted in a fall in lipocalin-2 levels (p < 0.001). In normal weight patients with PCOS, treatment with metformin did not affect lipocalin-2 levels (p = 0.484). In conclusion, PCOS per se is not associated with elevated lipocalin-2 levels. Weight loss induces a significant reduction in lipocalin-2 levels in overweight/obese patients with PCOS.

Peripheral blood haematopoietic progenitor cells in patients with beta thalassaemia major receiving desferrioxamine or deferiprone as chelation therapy

OBJECTIVES

The main adverse effect of deferiprone is the development of neutropenia, which occurs via an unknown mechanism. We aimed to gain insight into the pathogenesis of deferiprone-induced neutropenia by assessing the peripheral blood haematopoietic progenitor cells.

METHODS

Sixteen patients with beta thalassaemia were studied; nine (Group A) were receiving desferrioxamine and seven (Group B) deferiprone. Ten healthy individuals comprised the control group (Group C).

RESULTS

Granulocyte-erythrocyte-monocyte-megakaryocyte colony forming units were significantly more in Groups A and B compared with Group C. Granulocyte-macrophage colony forming units (CFU-GM) were significantly more in Group B compared with Group C. Macrophage colony forming units were significantly less in Group B compared with Group C. Granulocyte colony forming units (CFU-G) were significantly more in Group A compared with Group C. We found a trend in the difference in the number of CFU-G between patients' groups (P = 0.123). Adding serum from patients receiving deferiprone to cultures of controls resulted in a maturation arrest of the granulocytic lineage.

CONCLUSION

Our findings point to a maturation arrest at the level of CFU-GM as a potential mechanism of deferiprone-induced neutropenia.

Impact of managing atherogenic dyslipidemia on cardiovascular outcome across different stages of diabetic nephropathy

IMPORTANCE OF THE FIELD

The prevalence of chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM) is increasing. In turn, both CKD and T2DM are associated with increased risk of vascular events and progression to end-stage kidney disease (ESKD). In patients with DM, statin treatment can significantly improve estimated glomerular filtration rate (eGFR) or delay eGFR decline as well as significantly reduce CVD morbidity and mortality. In contrast, statins do not seem to decrease events in patients with advanced decline in kidney function.

AREAS COVERED IN THIS REVIEW

This review considers the effects of statins and other lipid lowering drugs on kidney function and vascular events in patients with CKD and T2DM.

WHAT THE READER WILL GAIN

Greater awareness of the links between CKD, T2DM, kidney function and vascular risk as well as the role of lipid-lowering drugs (mainly statins) in this field.

TAKE HOME MESSAGE

Current evidence points towards the need to prescribe statins in patients with T2DM before a major decline in kidney function occurs.

Lack of an association between angiotensin-converting enzyme gene insertion/deletion polymorphism and ischaemic stroke

BACKGROUND AND PURPOSE

Numerous factors have been reported to influence the pathogenesis of stroke. The angiotensin I-converting enzyme (ACE) gene is a candidate gene for atherosclerotic-related diseases. In the present study, the association between the polymorphism of the ACE gene and ischaemic stroke was investigated.

METHODS

Using polymerase chain reaction techniques, 100 patients (48 males, age 69.3 +/- 9.7 years) with cerebral infarction and 100 age- and sex-matched controls were divided into the following three ACE genotypes [deletion (D) and insertion (I)]: II, ID and DD.

RESULTS

There was no evidence of any association between the ACE gene polymorphism and the presence of ischaemic stroke (odds ratio 0.874, 95% confidence interval 0.386-1.973).

CONCLUSIONS

The DD genotype in the human ACE gene does not appear to be a risk factor for ischaemic stroke. Further evaluation in a larger population study is required to examine the possibility of an increased risk of ischaemic stroke in DD homozygotes.

Lipid-lowering agents and new onset diabetes mellitus

Statin treatment (and possibly niacin when given alone or in combination with statins) appears to be associated with a slightly increased risk of new onset diabetes mellitus (NODM). However, statin induced cardiovascular disease (CVD) risk reduction is greater in patients with DM than in non-diabetic patients in several survival studies. Thus, statin treatment outweighs any potential increase in CVD risk related to NODM and in high-risk Caucasian patients present clinical practice should not change. However, the risk/benefit ratio of treatment might not be as favourable in subjects with propensity to develop DM such as the elderly and in subjects of Asian ethnicity. Colesevelam was shown to improve both glycaemic control and lipid profile in inadequately controlled T2DM and might reduce the risk for NODM. There are no data on the incidence of NODM in fibrate-treated non-diabetic patients. Prospective studies are needed to clarify these issues.

Factors associated with delayed presentation at the emergency department in patients with acute ischemic stroke

Background and aims: Pre-hospital delay is a crucial factor that determines the eligibility for intravenous thrombolysis in patients with acute ischemic stroke. We aimed to evaluate the time to presentation at the emergency department (ED) and the factors that affect this time. Patients and methods: We prospectively studied 682 patients who were admitted with acute ischemic stroke (43.3% men, age 79.9 ± 6.6 years). Results: The median time to presentation at the ED was 2.1 h (range 0.15 to 168 h); 68.8% of the patients arrived within 4.5 h and 56.5% arrived within 3 h from the onset of symptoms. Independent predictors of presentation within 4.5 h were the use of emergency medical services (EMS) for transportation to the hospital (OR 2.61, 95% CI 1.38-4.94, p = .003), family history of cardiovascular disease (CVD)(OR 4.0 0,95%CI 1.61-12.23, p = .006) and the absence of history of smoking (OR 2.49, 95% CI 1.13-5.42, p = .021). Independent predictors of presentation within 3 h were the use of EMS for transportation to the hospital (OR 6.24, 95% CI 2.52-16.63, p = .0001), family history of CVD (OR 3.07, 95% CI 1.14-9.43, p = .03), and a moderately severe stroke at admission (OR vs. minor stroke 0.38, 95% CI 0.16-0.87, p = .02). Conclusions: A considerable proportion of patients with acute ischemic stroke arrives at the ED after the 4.5-h threshold for performing intravenous thrombolysis. Non-smokers, patients with a family history of CVD, with moderately severe stroke and those who use the EMS are more likely to arrive on time.

Sodium-Glucose Co-Transporter 2 Inhibitors and Fracture Risk

Patients with type 2 diabetes mellitus (T2DM) appear to have increased risk for fractures. In this context, the finding that canagliflozin, a sodium-glucose co-transporter-2 (SGLT) inhibitor, increased the risk for fracture compared with placebo in the Canagliflozin Cardiovascular Assessment Study (CANVAS), a large randomized controlled trial (RCT) in patients with established cardiovascular disease or multiple cardiovascular risk factors, created concern. In the present review, we summarize the data regarding the association between SGLT2 inhibitors and fracture risk in patients with T2DM. In contrast to the findings reported in CANVAS, canagliflozin did not affect the risk of fracture in a more recent, large RCT in patients with diabetic nephropathy. In addition, empagliflozin and dapagliflozin, other members of this class, also do not appear to affect the incidence of fracture. Moreover, there is no clear pathogenetic mechanism through which SGLT2 inhibitors increase the risk for fractures. Therefore, available data are inconclusive to attribute to these drugs a direct responsibility for bone fractures.

Lipid-lowering agents in the management of nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in developed countries and is associated not only with increased risk for liver disease-related complications but also with higher cardiovascular morbidity. Accordingly, lipid-lowering agents are frequently considered in these patients to reduce cardiovascular risk. However, there have been concerns regarding the safety of these agents in patients with chronic liver diseases. In the present review, we discuss the safety of lipid-lowering agents in patients with NAFLD as well as their effects on both cardiovascular and liver disease in this population. Accumulating data suggest that statins are safe in patients with NAFLD and that they reduce the increased cardiovascular morbidity of this population. However, it is still unclear whether statins are also useful as a treatment for NAFLD per se, since there are very limited and conflicting data on their effects on liver histology. There is also very scarce evidence regarding the safety and efficacy of other lipid-lowering agents in patients with NAFLD. Randomized controlled studies are needed to evaluate the role of lipid-lowering agents and particularly statins for the prevention of both cardiovascular and liver disease-related complications in this high-risk population.

Statins for the prevention of first or recurrent stroke

This review considers the evidence showing that statins can prevent first or recurrent stroke or improve its outcome in subjects at moderate or high risk for cardiovascular disease (CVD). Data are reviewed according to trial design (observational or prospective) and baseline CVD risk. Two (ASCOT, CARDS) out of five primary CVD prevention statin trials showed a considerable reduction in stroke rates. In two (MIRACL and PROVE IT) out of five acute coronary syndrome trials, the prevention of first stroke was significant. Most secondary prevention trials (4S, CARE, LIPID, HPS, GREACE and TNT) showed a beneficial effect of statins in stroke prevention. Finally, SPARCL, the only secondary stroke prevention trial in subjects without overt coronary heart disease (CHD), showed a significant reduction in total and ischaemic (fatal and nonfatal) stroke rate, although a small but significant increase in nonfatal haemorrhagic stroke was noted. There was also a significant reduction in CHD-related events. The possible mechanisms responsible for statin-associated stroke prevention are discussed. The evidence suggests the need to consider early and long-term statin treatment (with substantial low-density lipoprotein cholesterol reduction) in all patients at high risk of any type of major vascular event, without discriminating CHD from stroke. Thus, statins may be beneficial to both the heart and the brain.

Implementation of guidelines for the management of arterial hypertension. The impulsion study

This study assessed the effects of a pilot best practice implementation enhancement program on the control of hypertension. We enrolled 697 consecutive known hypertensive patients with other vascular risk factors but free from overt vascular disease. There was no "control" group because it was considered unethical to deprive high-risk patients from "best medical treatment". Following a baseline visit, previously trained physicians aimed to improve adherence to lifestyle measures and drug treatment for hypertension and other vascular risk factors. Both at baseline and at study completion (after 6 months), a 1-page form was completed showing if patients achieved treatment targets. If not, the reasons why were recorded. This program enhanced compliance with lifestyle measures and increased the use of evidence-based medication. There was a substantial increase in the number of patients who achieved treatment targets for blood pressure (p<0.0001) and other vascular risk factors. In non-diabetic patients (n=585), estimated vascular risk (PROCAM risk engine) was significantly reduced by 41% (p<0.0001). There was also a 12% reduction in vascular risk according to the Framingham risk engine but this did not achieve significance (p=0.07). In conclusion, this is the first study to increase adherence to multiple interventions in hypertensive patients on an outpatient basis, both in primary care and teaching hospitals. Simple, relatively low cost measures (e.g. educating physicians and patients, distributing printed guidelines/brochures and completing a 1-page form) motivated both physicians and patients to achieve multiple treatment goals. Further work is needed to establish if the improvement observed is sustained. [ClinicalTrials.gov NCT00416611].

Impaired antioxidative activity of high-density lipoprotein is associated with more severe acute ischemic stroke

BACKGROUND/AIMS

High-density lipoprotein (HDL) has important anti-atherogenic functions, including antioxidant effects. However, it is unclear whether the antioxidative activity of HDL is associated with the severity and outcome of acute ischemic stroke. We aimed to evaluate this association.

METHODS

We prospectively studied 199 consecutive patients admitted with acute ischemic stroke and followed them up until discharge. We measured HDL antioxidant capacity, HDL-associated paraoxonase-1 (PON1) activity and HDL-associated myeloperoxidase (MPO) levels. Severe stroke was defined as National Institutes of Health Stroke Scale (NIHSS) at admission ≥5. Dependency was defined as modified Rankin scale at discharge between 2 and 5.

RESULTS

Patients with severe stroke had lower HDL antioxidant capacity, higher MPO levels and higher MPO/PON1 ratio. Independent risk factors for severe stroke were female gender (RR 2.80, 95% CI 1.37-5.70, p = 0.005), glucose levels (RR 1.01, 95% CI 1.0-1.02, p < 0.01) and HDL antioxidant capacity (RR 1.03, 95% CI 1.01-1.06, p < 0.05). Patients who were dependent at discharge had lower HDL antioxidant capacity, higher MPO levels and higher MPO/PON1 ratio. Independent predictors of dependency at discharge were lack of lipid-lowering treatment (RR 6.86, 95% CI 1.83-25.67, p < 0.005) and NIHSS (RR 1.56, 95% CI 1.29-1.88, p < 0.0001). The HDL antioxidant capacity did not differ between patients who died during hospitalization and those who were discharged. The only independent predictor of in-hospital mortality was NIHSS (RR 1.16, 95% CI 1.06-1.27, p < 0.005).

CONCLUSIONS

Impaired antioxidative activity of HDL is associated with more severe acute ischemic stroke and might also predict a worse functional outcome in these patients.

Efficacy of Administration of an Angiotensin Converting Enzyme Inhibitor for Two Years on Autonomic and Peripheral Neuropathy in Patients with Diabetes Mellitus

Aim. To evaluate the effect of quinapril on diabetic cardiovascular autonomic neuropathy (CAN) and peripheral neuropathy (DPN). Patients and Methods. Sixty-three consecutive patients with diabetes mellitus [43% males, 27 with type 1 DM, mean age 52 years (range 22-65)], definite DCAN [abnormal results in 2 cardiovascular autonomic reflex tests (CARTs)], and DPN were randomized to quinapril 20 mg/day (group A, n = 31) or placebo (group B, n = 32) for 2 years. Patients with hypertension or coronary heart disease were excluded. To detect DPN and DCAN, the Michigan Neuropathy Screening Instrument Questionnaire and Examination (MNSIQ and MNSIE), measurement of vibration perception threshold with biothesiometer (BIO), and CARTs [R-R variation during deep breathing [assessed by expiration/inspiration ratio (E/I), mean circular resultant (MCR), and standard deviation (SD)], Valsalva maneuver (Vals), 30 : 15 ratio, and orthostatic hypotension (OH)] were used. Results. In group A, E/I, MCR, and SD increased (p for all comparisons < 0.05). Other indices (Vals, 30 : 15, OH, MNSIQ, MNSIE, and BIO) did not change. In group B, all CART indices deteriorated, except Vals, which did not change. MNSIQ, MNSIE, and BIO did not change. Conclusions. Treatment with quinapril improves DCAN (mainly parasympathetic dysfunction). Improved autonomic balance may improve the long-term outcome of diabetic patients.

Sex-specific differences in cardiovascular risk factors and blood pressure control in hypertensive patients

Cardiovascular disease (CVD) and cardiovascular risk factors are frequently undertreated in women. However, it is unclear whether the prevalence of additional cardiovascular risk factors and the total cardiovascular risk differ between hypertensive men and women. There are also limited data regarding rates of blood pressure control in the two sexes outside the United States. The authors aimed to compare the cardiovascular risk profile between sexes. A total of 1810 hypertensive patients (40.4% men, age 56.5±13.5 years) attending the hypertension outpatient clinic of our department were studied. Men were more frequently smokers than women and were more heavy smokers than the latter. Serum high-density lipoprotein cholesterol levels were lower and serum triglyceride levels were higher in men. On the other hand, abdominal obesity and chronic kidney disease were more prevalent in women. The estimated cardiovascular risk was higher in men than in women but the prevalence of established CVD did not differ between the sexes. The percentage of patients with controlled hypertension and the number of antihypertensive medications were similar in men and women. In conclusion, hypertensive men have more adverse cardiovascular risk factor profile and greater estimated cardiovascular risk than women. However, the prevalence of established CVD does not differ between sexes. These findings further reinforce current guidelines that recommend that management of hypertension and of other cardiovascular risk factors should be as aggressive in women as in men in order to prevent cardiovascular events.

The role of statins for the primary and secondary prevention of coronary heart disease in women

Coronary heart disease (CHD) is the leading cause of death in the developed world in both men and women. Elevated low-density lipoprotein cholesterol (LDL-C) levels are strong and independent vascular risk factors in both genders. Statins effectively decrease LDL-C levels, reduce vascular morbidity and mortality and are an essential component of CHD preventive strategies. However, women are less likely to be prescribed statins than men in both primary and secondary prevention settings. It was argued that there is no conclusive evidence showing that statins are beneficial for the prevention of vascular disease in women, particularly in those without established CHD. This review summarizes the evidence regarding the effects of statins in the prevention of CHD in women. Accumulating data suggest that statins are equally effective in both men and women. The lack of significant effects in some studies appears to be primarily due to the under-representation of women and the ensuing lack of statistical power. Current guidelines for the prevention of vascular disease also recommend a similar management of dyslipidemia in both men and women. Therefore, statin treatment should be implemented with the same criteria and with the same goals in both genders.

Brain natriuretic peptide and the athlete's heart: a pilot study

BACKGROUND

The role of brain natriuretic peptide (BNP) in differentiating the athlete's heart from maladaptive cardiac hypertrophy is unclear.

METHODS

To address this issue, an integrated M mode, two-dimensional B mode and Doppler echocardiographical study were performed and plasma BNP levels were measured in 25 strength athletes, 25 patients with established hypertrophic cardiomyopathy (HCM) and 25 healthy volunteers.

RESULTS

Among athletes, BNP levels correlated negatively with the total training time (r = -0.79, p = 0.002) and positively with ejection fraction (r = 0.58, p = 0.049) and fractional shortening (r = 0.57, p = 0.049). A BNP cut-off value of 11.8 pg/ml had 88% specificity and 74% negative predictive value for the exclusion of HCM.

CONCLUSIONS

Brain natriuretic peptide might be useful as a preparticipation screening test in athletes.

The increase in thyroid cancer incidence is not only due to papillary microcarcinomas: a 40-year study in 1 778 patients

AIM

Thyroid cancer incidence has been increased over the last decades. The aims of the present study were: (a) to identify a changing trend in thyroid cancer in Northern Greece, (b) to examine patients' and tumoral characteristics and (c) to investigate the increase of papillary microcarcinomas and that of invasive or larger cancers.

PATIENTS AND METHODS

We retrospectively analyzed the records of 1 778 patients who were diagnosed with thyroid cancer between January 1971 and December 2010. The study period was divided into 4 decades: 1971-1980, 1981-1990, 1991-2000, 2001-2010. Patients were separated into 2 groups: in Group A we have included papillary thyroid microcarcinomas (PTM) and in Group B all cancers with diameter >10 mm as well as invasive cancers ≤10 mm.

RESULTS

Patients diagnosed with thyroid cancer increased substantially per decade. The relative frequency of papillary thyroid cancer cases increased (from 60% up to 84.6% in the last decade) and follicular cancers decreased (from 40% down to 11.6%). During the study period, cancer size declined. Frequency of PTM (Group A) increased from 0% up to 19.3% in the last decade, but cancers of this group represent only a minority of total cancers.

CONCLUSIONS

The increase of thyroid cancer in this cohort was mainly due to tumors larger than 1 cm and also to smaller in size but invasive thyroid tumors. This increase outnumbers the increase in papillary thyroid microcarcinomas.

Plasma plasminogen activator inhibitor-1 levels in the different phenotypes of the polycystic ovary syndrome

We aimed to evaluate plasma plasminogen activator inhibitor-1 (PAI-1) antigen levels in women with polycystic ovary syndrome (PCOS) and different levels of adiposity and PCOS phenotypes. We studied 199 women with PCOS and 50 age-matched healthy women divided in normal weight (n=100 and n=25, respectively) and overweight/obese (n=99 and n=25, respectively). Normal weight and overweight/obese patients with PCOS were further divided in patients diagnosed according to the 1990 criteria (i.e. with anovulation and hyperandrogenemia; 1990 criteria group) and in patients with the additional phenotypes introduced in 2003 (i.e. with polycystic ovaries and either anovulation or hyperandrogenemia; additional 2003 criteria group). In normal weight subjects, plasma PAI-1 levels did not differ between women with PCOS (regardless of group) and controls, or between the 1990 criteria and the additional 2003 criteria groups of PCOS. In overweight/obese subjects, plasma PAI-1 levels were higher in both the 1990 criteria and the additional 2003 criteria groups of PCOS compared with controls (p<0.001 and p=0.004, respectively), but did not differ between the 1990 criteria and the additional 2003 criteria groups of PCOS. In conclusion, plasma PAI-1 levels are elevated in overweight/obese women with PCOS but not in normal weight women with this syndrome. Plasma PAI-1 levels do not differ between the phenotypes of PCOS.

Statin loading in patients undergoing percutaneous coronary intervention for acute coronary syndromes: a new pleiotropic effect?

Intensive statin treatment has proved beneficial in patients with acute coronary syndromes. However, this benefit may apply only to those undergoing percutaneous coronary intervention (PCI). Loading, preloading or reloading with high dose(s) of a statin may decrease major adverse cardiac events, revascularization of both target and non-target vessels as well as myocardial necrosis after PCI. It seems that different actions of statins are responsible for their protective role in target vessel and non-target vessel revascularization procedures. This editorial discusses the results of statin loading trials and comments on the possible mechanisms involved.

Lamivudine/pegylated interferon alfa-2b sequential combination therapy compared with lamivudine monotherapy in HBeAg-negative chronic hepatitis B

BACKGROUND AND AIM

Monotherapy has been proven insufficient in achieving sustained control of chronic hepatitis B. We aimed to assess the efficacy of combined sequential administration of lamivudine and pegylated interferon alfa-2b in patients with hepatitis Be antigen (HBeAg)-negative chronic hepatitis B.

METHODS

Eighteen patients were given sequential combination treatment starting with 3 months of lamivudine monotherapy followed by 9 months of pegylated interferon alfa-2b (after a 3-month period of concomitant administration of the two drugs) and 24 patients received lamivudine monotherapy.

RESULTS

At the end of treatment, 88.9% of the patients who received sequential combination treatment and 70.8% of those who received lamivudine monotherapy had hepatitis B virus (HBV) DNA levels below 400 copies/mL (P = not significant). At the end of treatment, 72.2% of the patients who received sequential combination treatment and 70.8% of those who received lamivudine monotherapy achieved alanine aminotransferase normalization (P = not significant). After 12 months of follow up, 33.3% of the patients who received sequential combination treatment and 16.7% of those who received lamivudine monotherapy had HBV-DNA levels below 400 copies/mL (P = 0.4). After 12 months of follow up, 72.2% of the patients who received sequential combination treatment and 25.0% of those who received lamivudine monotherapy had normal alanine aminotransferase levels (P < 0.01). Twenty-five percent of the patients in the lamivudine monotherapy group had virological breakthrough compared to none in the sequential combination treatment group (P = 0.06).

CONCLUSIONS

Sequential combination treatment is able to improve sustained biochemical response rates and prevent the emergence of lamivudine-resistant mutants in patients with HBeAg-negative chronic hepatitis B.

The Nutrition Health Alliance (NutriHeAl) Study: A Randomized, Controlled, Nutritional Intervention Based on Mediterranean Diet in Greek Municipalities

Objective: The aim of this study was to evaluate the effects of Mediterranean diet on weight loss in a large population in a municipality setting.Methods: A 6-month nutritional intervention was implemented in 50 randomly selected municipalities in Greece. In each municipality, approximately 180 overweight or obese patients were recruited and randomly assigned to an intervention group (n = 4500) or to a control group (n = 4500); 1816 and 2210 patients, respectively, completed the study. At baseline, the intervention group attended a 20-minute session where they received recommendations to follow a personalized, slightly hypocaloric, Mediterranean-type diet. The diet was adjusted every 2 weeks. The control group was provided with a leaflet on healthy nutrition and Mediterranean diet. Adherence to Mediterranean diet was evaluated with the Mediterranean diet score (MedDietScore).Results: Subjects in the intervention group were less frequently males and current smokers, had higher body mass index, and followed a healthier diet at baseline than subjects in the control group. In the intervention group, weight, waist circumference, and body fat percentage decreased. In the control group, weight and waist circumference increased. In the intervention group, 48.8% of subjects lost > 5% of body weight compared with 4.2% in the control group (p < 0.001). The MedDietScore increased in the intervention group and did not change in the control group. Independent predictors of loss > 5% of body weight were the decrease in intake of full-fat dairy products and alcohol and the increase in intake of vegetables, in MedDietScore, in walking and in consuming breakfast.Conclusions: Lifestyle change programs focusing on the adoption of Mediterranean diet with frequent monitoring can be implemented successfully in everyday clinical practice. However, retention rates in such programs need to be improved.