Prevalence, etiology and management of non-alcoholic fatty liver disease in patients with polycystic ovary syndrome

Obesity and insulin resistance (IR) are frequently present in patients with polycystic ovary syndrome (PCOS). Both disorders also play an important role in the pathogenesis of non-alcoholic fatty liver disease (NAFLD). Accordingly, NAFLD is frequently present in patients with PCOS. In the present review, we summarize the findings of the major studies that assessed the prevalence of NAFLD in patients with PCOS. The factors driving the increased frequency of NAFLD in patients with PCOS are also analyzed. Finally, we discuss the management options of NAFLD in patients with PCOS. In addition to IR, elevated androgen levels and inflammation also appear to play a role in the development and progression of NAFLD in patients with PCOS. Lifestyle changes should represent the cornerstone of management of NAFLD. On the other hand, pharmacotherapy appears to have limited efficacy and questionable safety. Moreover, there are very limited data with the various agents used for the management of NAFLD specifically in patients with PCOS. Accordingly, well-designed studies are clearly needed to evaluate the role of pharmacotherapy in the management of NAFLD in PCOS.

Management of statin-intolerant high-risk patients

Statins are an essential part of the management of patients at high vascular risk and are generally well-tolerated. However, statin intolerance will be observed more frequently as more stringent low density lipoprotein cholesterol (LDL-C) targets are pursued in an ever increasing number of patients. We review the management options for high-risk patients intolerant to statin treatment. Potential strategies include switching to a different statin, reducing the frequency of statin administration, substituting statins with other LDL-C-lowering agents (e.g. ezetimibe, colesevelam or nicotinic acid) and combining low-dose statin treatment with other lipid-modifying drugs. A limited number of studies specifically assessed statin-intolerant patients and most were small and of short duration. It is therefore difficult to make evidence-based recommendations for the management of this population. In addition, all treatment options have limitations in terms of safety and/or efficacy.

Management of acute bleeding in a patient with congenital afibrinogenaemia

Congenital afibrinogenaemia is a rare bleeding disorder characterized by absence of fibrinogen and varying bleeding tendency. Treatment with fibrinogen concentrates is considered to be the best choice for afibrinogenaemic patients who experience bleeding. We report the case of a 22-year-old Greek patient who presented with large muscular haematomas and was treated with fibrinogen concentrates. The efficacy of this treatment and the problems that arose during his hospitalization are being discussed.

Ductal plate malformation and congenital hepatic fibrosis Clinical and histological findings in four patients

Congenital hepatic fibrosis belongs to the fibrocystic diseases of the liver and represents ductal plate malformation of interlobular bile ducts, along with a destructive cholangiopathy associated with fibrosis. Four patients with congenital hepatic fibrosis are described. Their median age at presentation was 25 years; none of them had a family history of liver or renal disease. Variceal bleeding was the initial manifestation in three patients. All of them required frequent endoscopic variceal ligation sessions and distal splenorenal shunting was also performed in two, almost obviating the need for further variceal ligation. Variceal bleeding did not recur during follow-up. One of these three patients rarely exhibited acute cholangitis; administration of ursodeoxycholic acid resulted in complete remission. In contrast, the fourth patient showed frequent severe episodes of acute cholangitis but normal cholangiographic findings. He underwent liver transplantation but died 2 months later. Laboratory findings disclosed pancytopenia in all patients whereas hepatic synthetic capacity was well preserved. Renal function was unaffected despite the presence of polycystic kidneys in two patients. In summary, congenital hepatic fibrosis can also be diagnosed in older ages, might have strikingly different manifestations and is associated with prominent portal hypertension necessitating aggressive management in order to prevent variceal bleeding.

Experimental therapies targeting apolipoprotein C-III for the treatment of hyperlipidemia - spotlight on volanesorsen

INTRODUCTION

Despite the substantial reduction in cardiovascular morbidity and mortality after the management of dyslipidemia with statins, residual risk remains even after achieving low-density lipoprotein cholesterol targets. This residual risk appears to be partly attributed to low levels of high-density lipoprotein cholesterol (HDL-C) and high levels of triglycerides (TG). Apolipoprotein C3 (APOC3) is a key regulator of TG metabolism and its targeting may reduce TG levels and cardiovascular risk.

AREAS COVERED

We discuss APOC3-targeted experimental treatments for dyslipidemia. There is an emphasis on volanesorsen because it the agent in the most advanced stage of development. M580, a retinoic acid receptor-α specific agonist, an agent in early-stage development is briefly covered. Preclinical data suggest that this agent decreases APOC3 mRNA levels and reduces total cholesterol, TG levels and hepatic lipid accumulation.

EXPERT OPINION

The effects of this novel therapeutic approach on cardiovascular morbidity and mortality should be determined in randomized controlled trials. The cost of volanesorsen, the unfavorable safety profile and the need for subcutaneous administration present barriers to long-term use. AM580 may hold promise in the management of hypertriglyceridemia but further investigations are necessary to evaluate safety and efficacy.

Do we need a statin-nicotinic acid-aspirin mini-polypill to treat combined hyperlipidaemia?

This review considers the treatment for combined hyperlipidaemia (CH) with a combination formulation of three drugs: a statin, nicotinic acid (NA) and aspirin--a mini-polypill. CH is a highly atherogenic dyslipidaemia manifested either as familial combined hyperlipidaemia or dyslipidaemia related to the metabolic syndrome or Type 2 diabetes mellitus. These types of dyslipidaemia are highly prevalent in the general population. Statin plus extended-release NA is a promising treatment option for the normalisation of these atherogenic lipid alterations, regression of atherosclerosis, as well as for primary or secondary prevention of cardiovascular disease (CVD) events. The addition of aspirin might prove a useful adjunct that might reduce the cutaneous side effects of NA while also acting as an antiplatelet agent in high-CVD-risk patients. However, the effective dose of aspirin may need to be at least 160 mg/day. This triple combination might improve patient compliance when compared with the three drugs administered separately.

Inhibition of apoptosis in the management of nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is the leading cause of chronic liver disease in the developed world. The pathogenesis of NAFLD is multifactorial, involving obesity, insulin resistance, inflammation and oxidative stress. Accordingly, several treatments targeting these pathways have been evaluated in patients with NAFLD but have either shown limited efficacy or an unfavorable safety profile. On the other hand, increased hepatocyte apoptosis also appears to be implicated in the development and progression of NAFLD and recent pilot studies suggest that inhibition of apoptosis might represent a useful approach in this disease. However, several issues pertaining both to the efficacy and safety of this new class of agents remain unresolved and larger studies are required to clarify the role of this therapeutic modality in the management of NAFLD.

Endocrine hypertension: diagnosis and management of a complex clinical entity

Hypertension is a major contributor to vascular morbidity and mortality. Endocrine hypertension (EH) refers to secondary hypertension caused by specific endocrine abnormalities. The significance of EH is that the identification of the underlying disorder and its management may lead to partial or complete normalization of blood pressure. When EH is suspected thorough investigation with biochemical and imaging testing are necessary to establish or exclude mineralocorticoid, catecholamine, glucocorticoid, thyroid, parathyroid or growth hormone disorders as well as rare hereditary syndromes. In addition, it is important to differentiate benign from malignant tumors. The present review provides an update on the pathophysiology and clinical presentation of EH. We also discuss the diagnostic work-ups and therapeutic strategies.

Initiative for a new diabetes therapeutic approach in a Mediterranean country: the INDEED study

AIM

To assess the efficacy of a strategy to improve vascular risk management in patients with type 2 diabetes mellitus (T2DM).

METHODS

This was a pilot best practice implementation enhancement programme that enrolled 578 patients with T2DM. A baseline visit was followed by a concerted effort from previously trained physicians to improve adherence to lifestyle advice and optimise drug treatment for all vascular risk factors. The patients were followed-up for 6 months. The UKPDS risk engine was used to estimate vascular risk in patients without established coronary heart disease (CHD) (n = 279).

RESULTS

There was an improvement in compliance to lifestyle measures and increased prescription of evidence-based medication. In patients without established CHD there was a 37% reduction in estimated risk for CHD, 44% for fatal CHD, 10% for stroke and 25% for fatal stroke (p < or = 0.003 for all comparisons vs. baseline). There was also a substantial increase in the proportion of patients with established CHD who achieved their vascular risk factor targets.

CONCLUSIONS

This is the first study to increase the adherence to multiple interventions in patients with T2DM in both primary care and hospital settings. Education of physicians and patients, distribution of guidelines/brochures, and the completion of a one-page form, motivated both physicians and patients to achieve multiple vascular risk factor goals.

Dyslipidemia induced by drugs used for the prevention and treatment of vascular diseases

Dyslipidemia is a major vascular risk factor. Interestingly, several agents used for the prevention and treatment of vascular diseases have an adverse effect on the lipid profile. In addition, agents belonging to the same class (e.g. beta blockers) can have significantly different actions on lipid levels. We summarize the effects of drugs used for the prevention and treatment of vascular diseases on the lipid profile. These effects should be considered when selecting a specific agent, particularly in high-risk patients.

The phenotypes of polycystic ovary syndrome defined by the 1990 diagnostic criteria are associated with higher serum vaspin levels than the phenotypes introduced by the 2003 criteria

OBJECTIVE

Patients with polycystic ovary syndrome (PCOS) diagnosed with the 1990 criteria (i.e. presence of oligo- and/or anovulation (ANOV) and hyperandrogenemia and/or hyperandrogenism (HA) with or without polycystic ovaries (PCO)) appear to have a more adverse metabolic profile than patients diagnosed with the additional criteria introduced in 2003 (i.e. presence of HA and PCO without ANOV and presence of ANOV and PCO without HA). Vaspin is a novel adipokine that appears to preserve insulin sensitivity. We aimed to assess serum vaspin levels in patients with different PCOS phenotypes.

METHODS

We studied 100 patients with PCOS diagnosed with the 1990 criteria (group I), 100 patients with PCOS diagnosed with the additional 2003 criteria (group II) and 50 healthy controls.

RESULTS

Serum vaspin levels were higher in groups I and II than in controls (p < 0.001 and p = 0.001, respectively) and in group I when compared to group II (p = 0.045). In patients with PCOS, serum vaspin levels were independently correlated with BMI (p < 0.001) and the homeostasis model assessment of insulin resistance (HOMA-IR) (p = 0.002).

CONCLUSIONS

PCOS is associated with elevated serum vaspin levels. This increase might represent a compensatory mechanism to preserve insulin sensitivity. Moreover, serum vaspin levels reflect the severity of PCOS and are significantly increased in its 'classical' phenotypes.

Disparate effects of pharmacotherapy on plasma plasminogen activator inhibitor-1 levels in women with the polycystic ovary syndrome

OBJECTIVE

Polycystic ovary syndrome (PCOS) is characterized by obesity and insulin resistance (IR), which result in elevated plasminogen activator inhibitor-1 (PAI-1) levels. We aimed to assess the changes in PAI-1 levels in PCOS during treatment with metformin and during weight loss.

DESIGN

Twenty-three normal weight women with PCOS were given metformin 850 mg bid for 6 months. Fifty overweight/obese women with PCOS were prescribed an energy-restricted diet, were instructed to exercise and were randomized to orlistat 120 mg tid or sibutramine 10 mg qd for 6 months.

RESULTS

In normal weight women, treatment with metformin reduced the body mass index (BMI) and circulating androgens, improved markers of IR and lowered PAI-1 levels. In overweight/obese women, sibutramine and orlistat yielded comparable reductions in BMI and markers of IR. In contrast, the effects on the free androgen index (FAI) differed (p=0.027): sibutramine reduced the FAI (p=0.005), whereas orlistat had no effect. The effects of sibutramine and orlistat on PAI-1 levels also differed (p=0.042): sibutramine reduced PAI-1 levels (p<0.001), whereas orlistat had no effect.

CONCLUSIONS

Metformin and sibutramine, but not orlistat, reduce PAI-1 levels in PCOS. The reduction in circulating androgens during metformin and sibutramine treatment might be implicated in this decline.

Lipid accumulation product is associated with metabolic syndrome in women with polycystic ovary syndrome

OBJECTIVE

There is a need for a simple and accurate method for the assessment of cardiovascular risk in polycystic ovary syndrome (PCOS). Lipid accumulation product (LAP) is based on the assessment of waist circumference and serum triglycerides that yield an estimation of lipid overaccumulation. We aimed to determine whether LAP is associated with metabolic syndrome (MetS) in Caucasian women with PCOS.

DESIGN

We studied 222 women with PCOS who were diagnosed using the Rotterdam criteria. In all the subjects and controls, LAP was determined and the MetS was assessed using three different international criteria, NCEP-ATP III, IDF, and JIS. ROC curve and logistic regression analyses were performed to determine and analyze associations with the MetS.

RESULTS

In the study population the prevalence of MetS was 16.2-19.4%. The cut-off value of 25.9 determined that LAP has the strongest association with MetS whichever international criteria are used, followed by HDL (NCEP-ATP III and JIS) and glucose (IDF).

CONCLUSIONS

LAP is used as an independent clinical indicator for MetS in our PCOS women of Caucasian origin. The high diagnostic accuracy of LAP is superseding the need for the use of multiple clinical indicators for the assessment of lipid accumulation as a prerequisite for diagnosis of metabolic and cardiovascular diseases in PCOS women.

Pegylated IFN-alpha 2b added to ongoing lamivudine therapy in patients with lamivudine-resistant chronic hepatitis B

AIM

To investigate the role of pegylated-interferon (IFN) alpha-2b in the management of patients with lamivudine-resistant chronic hepatitis B.

METHODS

Twenty consecutive anti-HBe positive patients were treated with pegylated IFN alpha-2b (100 mug sc once weekly) for 12 mo. There was no interruption in lamivudine therapy. Hematology, liver biochemistry, serum HBV DNA levels were detected by PCR, and vital signs were also assessed. Liver histology was assessed in some patients at entry and at wk 52 for comparison.

RESULTS

Nine patients (45%) had a partial virological end-treatment response; seven patients (35%) showed complete virological end-treatment response. Eight patients (40%) showed biochemical end-treatment response. There was a trend for higher virological response rates in patients who had previously responded to IFN and relapsed compared to IFN non-responders (four out of seven patients vs none out of six patients, respectively; P=0.1). Patients without virological end-treatment response showed significant worsening of fibrosis [median score 2 (range, 1 to 3) vs median score 3 (range, 1 to 4)], in the first and second biopsy respectively (P=0.014), whereas necroinflammatory activity was not significantly affected. Patients with complete or partial virological end-treatment response did not show any significant changes in histological findings, possibly due to the small number of patients with paired biopsies (n=5). Nevertheless, after 12 mo of follow-up, only one patient (5%) showed sustained virological response and only 2 patients (10%) showed sustained biochemical response. Two patients (10%) discontinued pegylated IFN both after 6 mo of treatment due to flu-like symptoms.

CONCLUSION

Pegylated IFNalpha-2b, when added to ongoing lamivudine therapy in patients with lamivudine-resistant chronic hepatitis B, induces sustained responses only in a small minority of cases.

High density lipoprotein cholesterol and statin trials

Epidemiological studies show that high density lipoprotein cholesterol (HDL-C) levels are inversely related to the risk of vascular events. Statins are the most widely prescribed drugs for the treatment of dyslipidaemias and their use for the prevention of vascular events is evidence based. Statins raise HDL-C but this effect seems to vary considerably between studies. We searched the literature to assess the relationship between statin-induced increases in HDL-C levels and surrogate and/or clinical endpoints. Based on the existing evidence, it is difficult to determine how much reduction, if any, in vascular risk is attributable to a statin-induced increment in HDL-C levels. Whether a statin that beyond its LDL-C lowering effect also raises HDL-C has additional benefits in the prevention of vascular events remains to be established.

Can capsule endoscopy be used as a diagnostic tool in the evaluation of nonbleeding indications in daily clinical practice? A prospective study

OBJECTIVE

To evaluate the diagnostic yield of capsule endoscopy (CE) and its impact on treatment and outcome in patients without bleeding indications.

SUBJECTS AND METHODS

One hundred and sixty-five nonbleeding patients were enrolled in the study. The most common indications for CE were chronic abdominal pain alone (33 patients) or combined with chronic diarrhea (31 patients) and chronic diarrhea alone (30 patients). Among the 165 patients, 129 underwent CE for evaluation of gastrointestinal symptoms and 36 for surveillance or disease staging.

RESULTS

CE findings were positive, suspicious and negative in 73 (44.2%), 13 (7.9%) and 79 (47.9%) of cases, respectively. The diagnostic yield was highest in patients with refractory celiac disease (10/10, 100%) and suspected Crohn's disease (5/6, 83.3%), followed by patients with chronic abdominal pain and chronic diarrhea (13/31, 41.9%), established Crohn's disease (2/6, 33.3%), chronic diarrhea alone (8/30, 26.7%), chronic abdominal pain alone (8/33, 24.2%) and other indications (3/13, 23.1%) (p < 0.005). The CE findings led to a change of medication in 74 (47.7%) patients, surgery in 15 (9.7%), administration of a strict gluten-free or other special diet in 13 (8.4%) and had other consequences in 11 (6.7%). Management was not modified in 42 (27.1%) patients. Among symptomatic patients (n = 129), 29 (22.5%) were lost to follow-up. The remaining 100 patients were followed up for 8.7 ± 4.0 months (range 2-19). Among the latter, resolution or improvement of symptoms was observed in 86 (86%) patients, no change in 11 (11%) and 3 (3%) died. All 86 patients who experienced resolution or improvement of their symptoms had a modification of their management after CE; only 7/11 patients whose symptoms did not change (63.6%) and 2/3 patients who died (66.7%) had a modification of management (p < 0.001).

CONCLUSIONS

CE appears to be a useful tool in the evaluation of patients with nonbleeding indications. The outcome of most patients with negative findings was excellent.

Preventing type 2 diabetes mellitus: room for residual risk reduction after lifestyle changes?

It is well known that type 2 diabetes mellitus (T2DM) is a major risk factor for cardiovascular diseases (CVD). A predicted worldwide increase in the incidence of T2DM, taking the form of an epidemic, is expected to induce a substantial increase in CVD incidence. Impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) are related to an increased risk of developing T2DM, especially in obese people. Prevention of T2DM aiming to reversal of pre-diabetes to normal glucose tolerance seems to be a very attractive target, and favourably affects CVD risk factors. The Diabetes Prevention Program and the Finnish Diabetes Prevention studies showed that changes in lifestyle prevented or delayed the onset of new cases of T2DM in subjects with pre-diabetes by 58%. However, a fraction of participants still developed T2DM, suggesting a residual risk. Moreover, lifestyle changes are not usually followed on a long-term basis as shown in EUROASPIRE with an increase in new onset T2DM by 60% in subjects with CVD in just over a decade. T2DM is characterized by insulin resistance and/or β-cell dysfunction (impaired insulin secretion). Various interventions targeting those two mechanisms (e.g. metformin, thiazolidinediones, acarbose, orlistate, bariatric surgery, renin-angiotensin-aldosterone system axis inhibitors, fibrates, incretin mimetics or enhancers) can prevent or delay T2DM. Widespread application of these measures has, however, been limited by financial considerations, even though cost-effectiveness might be achieved at the population level. This review will investigate feasibility and usefulness of T2DM prevention, further to that achieved with lifestyle changes, in a cost-effective manner.

Masked hypertensives: A disguised arterial stiffness population

The aim of this study was to determine whether masked hypertension (MHT) and white coat hypertension (WCHT) could be related to increased arterial stiffness and to identify the best office cutoff values of office BP for the diagnosis of MHT and WCHT. A total of 542 consecutive patients (50.2% male, age 42.5 ± 26.2 years) were included in the study. Patients were never treated before for hypertension. Patients were classified as true normotensives (44%), true hypertensives (30%), WC hypertensives (19%), and masked hypertensives (7%). Carotid-femoral pulse wave velocity (c-f PWV) was 9.91 ± 0.20 m/s in true normotension, 10.26 ± 0.27 m/s in WCHT, 11.28 ± 0.47 m/s in MHT, and 11.86 ± 0.23 m/s in true hypertension after adjustment for age and sex. Decision limits yielding 65% sensitivity were 130 mm Hg for office systolic BP with 72% specificity for the diagnosis of MHT. The optimal cutoff value of 80 mm Hg for office diastolic BP provides 60% sensitivity and 68% specificity. Decision limits yielding 63% sensitivity were 150 mm Hg for office systolic BP with 72% specificity for the diagnosis of WCHT. The optimal cutoff value of 95 mm Hg for office diastolic BP provides 75% sensitivity and 51% specificity. The presence of MHT should be taken into account when increased c-f PWV is detected in the absence of office hypertension. The optimal office BP of 130/80 mm Hg provides the best sensitivity and specificity for the diagnosis of MHT. As regards the diagnosis of WCHT, the cutoff value of 150/95 mm Hg seems to provide the best option.

Recommendations for lipid modification in patients with ischemic stroke or transient ischemic attack: A clinical guide by the Hellenic Stroke Organization and the Hellenic Atherosclerosis Society

This document presents the consensus recommendations of the Hellenic Stroke Organization and the Hellenic Atherosclerosis Society for lipid modification in patients with ischemic stroke or transient ischemic attack. This clinical guide summarizes the current literature on lipid management and can be of assistance to the physicians treating stroke patients in clinical practice.

Established and emerging vascular risk factors and the development of aortic stenosis: an opportunity for prevention?

BACKGROUND

Aortic stenosis (AS) is the commonest valvular heart disease in the developed world. It is becoming increasingly accepted that the pathogenesis of AS and of its preceding abnormalities, aortic valve sclerosis (AVS) and aortic valve calcification (AVC), shares many characteristics with the atherosclerotic process.

OBJECTIVE

To assess the contribution of established and emerging vascular risk factors in the development of AS and to evaluate the potential of pharmacological intervention to modify the natural history of AS.

METHODS

We reviewed the epidemiological data that link AS and atherosclerosis and studies of vasculoprotective agents in patients with AS.

RESULTS/CONCLUSIONS

AS, AVS and AVC share many common risk factors with atherosclerosis and are possible markers of preclinical vascular disease. Statins appear to delay the progression of AS. However, more studies are needed before introducing such pharmacologic treatment for AS. The future may point towards targeted prevention of AS.

Predictive value of the ankle brachial index in patients with acute ischemic stroke

Background: Peripheral arterial disease (PAD) is frequently present in patients with acute ischemic stroke. However, there are limited data regarding the association between ankle brachial index (ABI) ≤ 0.90 (which is diagnostic of PAD) or > 1.40 (suggesting calcified arteries) and the severity of stroke and in-hospital outcome in this population. We aimed to evaluate these associations in patients with acute ischemic stroke. Patients and methods: We prospectively studied 342 consecutive patients admitted for acute ischemic stroke (37.4 % males, mean age 78.8 ± 6.4 years). The severity of stroke was assessed with the National Institutes of Health Stroke Scale (NIHSS)and the modified Rankin scale (mRS) at admission. The outcome was assessed with the mRS and dependency (mRS 2 - 5) at discharge and in-hospital mortality. Results: An ABI ≤ 0.90 was present in 24.6 % of the patients whereas 68.1 % had ABI 0.91 - 1.40 and 7.3 % had ABI > 1.40. At admission, the NIHSS score did not differ between the 3 groups (10.4 ± 10.6, 8.3 ± 9.3 and 9.3 ± 9.4, respectively). The mRS score was also comparable in the 3 groups (3.6 ± 1.7, 3.1 ± 1.8 and 3.5 ± 2.3, respectively). At discharge, the mRS score did not differ between the 3 groups (2.9 ± 2.2, 2.3 ± 2.1 and 2.7 ± 2.5, respectively) and dependency rates were also comparable (59.5, 47.6 and 53.3 %, respectively). In-hospital mortality was almost two-times higher in patients with ABI ≤ 0.90 than in patients with ABI 0.91 - 1.40 or > 1.40 but this difference was not significant (10.9, 6.6 and 6.3 %, respectively). Conclusions: An ABI ≤ 0.90 or > 1.40 does not appear to be associated with more severe stroke or worse in-hospital outcome in patients with acute ischemic stroke.

Is there an additional benefit from coronary revascularization in diabetic patients with acute coronary syndromes or stable angina who are already on optimal medical treatment?

Cardiovascular disease (CVD) is common in patients with diabetes mellitus (DM) and related clinical outcomes are worse compared with non-diabetics. The optimal treatment in diabetic patients with coronary heart disease (CHD) is currently not established. We searched MEDLINE (1975-2010) using the key terms diabetes mellitus, coronary heart disease, revascularization, coronary artery bypass, angioplasty, coronary intervention and medical treatment. Most studies comparing different revascularization procedures in patients with CHD favoured coronary artery bypass graft (CABG) surgery in patients with DM. However, most of this evidence comes from subgroup analyses. Recent evidence suggests that advanced percutaneous coronary intervention (PCI) techniques along with best medical treatment may be non-inferior and more cost-effective compared with CABG. Treatment of vascular risk factors is a key option in terms of improving CVD outcomes in diabetic patients with CHD. The choice between medical therapy and revascularization warrants further assessment.

Statins and cardiovascular events in patients with end-stage renal disease on hemodialysis. The AURORA results suggest the need for earlier intervention

The recently published Assessment of Survival and Cardiovascular Events (AURORA) trial showed that rosuvastatin (10 mg/d) compared with placebo did not result in a significant reduction in vascular events despite a 43% fall in low density lipoprotein cholesterol (LDL-C) levels in patients with end-stage renal disease (ESRD). The reasons for this and previous negative findings are discussed. In contrast, there is evidence that statins exert a nephroprotective action in less advanced chronic kidney disease (CKD). There is need for further trials to establish if patients at various stages of CKD will benefit from statin treatment in terms of both nephroprotection and reduction in vascular events.