Effects of fluvastatin and bezafibrate combination on plasma fibrinogen, t-plasminogen activator inhibitor and C reactive protein levels in coronary artery disease patients with mixed hyperlipidaemia (FACT study). Fluvastatin Alone and in Combination Treatment

AIM OF THE STUDY

We studied the effects of fluvastatin and bezafibrate in monotherapy and in combination on plasma fibrinogen, t-plasminogen activator inhibitor (PAI-1) and C reactive protein (CRP) in patients with coronary artery disease (CAD) and mixed hyperlipidaemia.

DESIGN

In this randomised, double blind, multicentre trial 333 patients with stable angina pectoris or previous myocardial infarction or coronary revascularisation and mixed hyperlipidaemia (LDL-cholesterol 135-250 mg/dl and triglycerides (TG) 180-400 mg/dl) were randomised to fluvastatin 40 mg, bezafibrate 400 mg, fluvastatin 20 mg + bezafibrate 400 mg or fluvastatin 40 mg + bezafibrate 400 mg treatments for 24 weeks.

RESULTS

Plasma fibrinogen significantly decreased after treatment with the combinations fluvastatin+bezafibrate (-14 and -16%) and with bezafibrate monotherapy (-9%). No significant reduction was observed after fluvastatin monotherapy (-4%). No significant changes were observed in PAI-1 and CRP plasma levels. Combination therapy significantly decreased both LDL-C and TG, and significantly increased HDL-C.

CONCLUSIONS

The combined effects on fibrinogen and plasma lipids achieved by fluvastatin and bezafibrate combination treatment might be more useful than the simple reduction of cholesterol in preventing ischaemic cardiovascular disease.

Long-term results in non randomized patients with acute myelogenous leukemia: a single institution experience

Sixty-three non randomized adults with acute myelogenous leukemia were treated with an idarubicin-based protocol. The patients achieving complete remission received autologous bone marrow transplantation or (if > 50 years or refusing autologous bone marrow transplantation) high-dose Ara-C, as late intensification. Fifty-two patients (82.5%) achieved complete remission, 45 after one induction course and 16 of them underwent autologous bone marrow transplantation a median of 11 months later. As of December 1997 (median follow-up 112 months, range 50-135 months), 16 patients were still in complete remission (10 after autologous bone marrow transplantation, 6 after high-dose Ara-C) and 29 had relapsed (median time to relapse 14 months, range 2-75 months). Four patients died in complete remission. The median disease-free survival was 25 months; the 50-months and 10-year disease-free survival were 41% and 35% respectively. No significant differences were observed between the autologous bone marrow transplantation and high-dose Ara-C treated patients whose complete remission had lasted more than 11 months. The median disease-free survival in the autografted patients had not been reached after 120 months (the 50-month and 10-year disease-free survival chances were both 67%). Age was the only predictive variable for leukemic relapse. These long-term results confirm the antileukemic efficacy of an idarubicin-containing protocol, which led to high complete remission rates and favorably influenced disease-free survival. Furthermore, the efficacy of late intensification treatment with either autologous bone marrow transplantation or high-dose Ara-C is underscored. The disease-free survival chances after autologous bone marrow transplantation are comparable with those published for allogeneic bone marrow transplantation; however, disease-free survival of the patients receiving a high-dose Ara-C intensification regimen is not significantly worse than that seen after autologous bone marrow transplantation.

[Three-dimensional transesophageal echocardiography: a new cardiologic diagnostic tool. Initial experience with 150 patients]

BACKGROUND

Three-dimensional transesophageal echocardiography is a new diagnostic tool and its potential has been investigated mainly in international centers dealing with research in the field of cardiac pathologies. The clinical usefulness and the potential additional information over multiplane transesophageal echocardiography in daily clinical practice have not been exstensively studied.

OBJECTIVES

This study sought to assess the feasibility and to define the potential role of three-dimensional technique in a clinical cardiology department.

POPULATION AND METHODS

One hundred-fifty patients (73 males, 77 females) aged 17-82 underwent a three-dimensional transesophageal echocardiographic study. Indications for the study were the following: 39 mitral (26%), 13 aortic (8%) and 4 tricuspidal (2%) valvulopathies, 23 valvular prostheses (15%), 6 aortic diseases (4%), 16 sources of embolism (10%), 16 congenital heart diseases (10%), 14 ischemic heart diseases (9.3%), 14 cardiomyopathies (9%), 5 other pathologies (3%). The 3 D examination quality was graded as insufficient, sufficient and good. The information obtained by "volume rendered" and "anyplane" three-dimensional echocardiography were compared with the traditional two-dimensional images to determine whether they provided additional information.

RESULTS

A total of 288 acquisitions were obtained in the 150 patients (1.9 acquisitions per patient). Examinations were graded of good quality in 99 patients (61%), sufficient in 36 (24%) and insufficient in 15 patients (10%). Additional informations were obtained in 33 patients (22%) by "volume rendered" echocardiography and by "anyplane echocardiography", including mitral regurgitation or repair for valvular prolapse (11 patients), aortic valve malformations and endocarditis (4 patients), congenital heart diseases (9 patients), right ventricular dysplasia (6 patients) or hypertrophic cardiomyopathy (1 patient), tricuspid regurgitation (2 patients). The additional information were obtained in patients in the group of good 3 D reconstructions quality in all but two cases.

CONCLUSIONS

The diagnostic use of the transesophageal technique with 3 D facilities permitted to obtain an overall 22% of additional information. These results will stimulate further study to evaluate the advantages of the three-dimensional technique in specific clinical fields of application.

Relation between hemostatic variables and increase of common carotid intima-media thickness in patients with peripheral arterial disease

BACKGROUND AND PURPOSE

Increases in common carotid intima-media thickness (CC-IMT), as measured by B-mode ultrasonography, have been widely used in both population studies and clinical trials in the search for risk factors for early atherosclerosis progression and have been found to correlate with age and with high concentrations of low-density lipoprotein cholesterol, leukocytes, and hemoglobin. We have now investigated the relation between several baseline hemostatic and conventional risk factors and CC-IMT changes over 16 months in 64 patients with peripheral arterial disease randomly selected from the prospective PLAT study series.

METHODS

Samples from 24 patients (37.5%) who showed increases in CC-IMT during the follow-up period were compared with those from 40 (62.5%) in whom CC-IMT remained unchanged.

RESULTS

Baseline conventional risk factors and coagulation variables were similar in the two groups except for higher plasma concentrations of von Willebrand factor (vWF) (178.3 +/- 53.6% versus 141.2 +/- 53.7%, P=.01) and factor VII (FVII) (133.9 +/- 36.4% versus 107.0 +/- 27.3%, P=.001) in the patients with increased CC-IMT. CC-IMT increase correlated positively with plasma levels of FVII (r=.31, P<.01) and vWF (r=.31, P<.01). Multiple stepwise regression analysis identified FVII as the only independent variable associated with an increase in CC-IMT (beta=.83, P=.01).

CONCLUSIONS

High plasma concentration of FVII and vWF may be associated with the progression of early carotid atherosclerosis in patients with peripheral arterial disease.

A nuclear magnetic resonance method for the determination of the purity of commercial dequalinium chloride

4-amino-1-(10-4'-quinaldinylaminodecyl)quinaldinium chloride (3) has been identified through nuclear magnetic resonance (NMR) studies as one of the impurities of a commercial sample of dequalinium chloride (CAS 522-51-0). The NMR technique is proposed as a rapid method for the recognition and quantification of the impurities in dequalinium chloride samples.

Treatment of chronic disseminated Geotrichum capitatum infection with high cumulative dose of colloidal amphotericin B and itraconazole in a leukaemia patient

A case of disseminated granulomatous Geotrichum capitatum infection is reported. A young patient with blastic crisis of chronic myelogenous leukaemia developed septicaemia caused by G. capitatum in the post-chemotherapy aplastic phase. Subsequently, disseminated infection of the liver, spleen, pancreas and kidneys was observed. Treatment with high cumulative doses of a lipid formulation of amphotericin B (Amphocil, 20.2 g in 11 weeks) and maintenance with itraconazole resolved clinical manifestations of G. capitatum granulomatous disseminated disease and controlled reactivation of the infection during the two subsequent courses of cytotoxic chemotherapy.

Association of lipoprotein(a) with atherothrombotic events and fibrinolytic variables. A case-control study

Elevated plasma levels of lipoprotein(a) [Lp(a)] have been associated with an increased risk of cardiovascular disease. The aim of the present study was to investigate whether Lp(a) plasma levels were associated with subsequent ischemic events and with fibrinolytic variables in patients with established atherosclerotic disease enrolled in the prospective PLAT study. Lp(a) levels and fibrinolytic variables in 37 atherosclerotic patients who subsequently developed an atherothrombotic event during the first year of follow-up (cases) were compared with those in paired controls, matched for age, sex, diagnosis at enrollment and lipid pattern, who remained free from vascular events during the same time frame. Median and mean Lp(a) levels were similar in cases (6.05 mg/dl; 13.8 +/- 19.4 mg/dl) and controls (6.05 mg/dl; 17.1 +/- 21.6 mg/dl). In the whole group plasma Lp(a) levels correlated significantly with the increase of t-PA antigen (r = 0.368; p = 0.002) and fibrinolytic activity (r = 0.410; p = 0.001) induced by venous stasis but not with baseline fibrinolytic variables. These findings indicate that in patients with established atherosclerotic disease Lp(a) may interfere in vivo with the fibrinolytic process but is not predictive of subsequent ischemic events.

Association of increased fibrin turnover and defective fibrinolytic capacity with leg atherosclerosis. The PLAT Group

Patients with peripheral arterial disease have a high risk of death from cardiovascular events. As defective fibrinolysis associated with leg atherosclerosis has been suggested as a predisposing factor, we sought a relation among decreased fibrinolysis, the presence of leg atherosclerosis and the incidence of thrombotic events in a case-control study nested in the PLAT. Fifty-eight patients with coronary and/or cerebral atherothrombotic disease, free of leg atherosclerosis at Doppler examination, were compared with 50 atherosclerotic patients with leg involvement. High D-dimer (153.0 vs 81.3 ng/ml, p < 0.001) and tPA antigen before venous stasis (14.4 vs 11.8 ng/ml, p < 0.03), and low tPA antigen (6.7 vs 15.6 ng/ml, p < 0.01) and fibrinolytic activity released after venous stasis (fibrinolytic capacity: 113.2 vs 281.4 mm2, p < 0.001) were found in patients with leg atherosclerosis. D-dimer and fibrinolytic capacity, in addition to age, were selected by stepwise discriminant analysis as characterizing patients with leg atherosclerosis. Moreover, higher D-dimer and tPA inhibitor characterized patients with leg atherosclerosis who subsequently experienced thrombotic events. These findings constitute evidence of high fibrin turnover and impaired fibrinolytic potential in patients with leg atherosclerosis. Thus impaired fibrinolysis may contribute to the prothrombotic state in these patients.

Value of low-dose echodobutamine in the diagnosis of patency of the infarct related coronary artery

The resumption of contractility of asynergic segments in survivors after acute myocardial infarction (AMI) may be detected in viable myocardial areas. We have correlated the detection of viable myocardium, assessed with low dose dobutamine testing, with coronary angiography and clinical outcome in 66 consecutive survivors of AMI using the echocardiographic evidence of left ventricular wall motion abnormalities. The test enabled the identification of two groups: group A, comprising 32 patients (pts) demonstrating wall motion recovery at dobutamine infusion and group B, comprising 34 pts without wall motion recovery. The mean basal asynergy score index was 5.8 +/- 4.2 in group A and 6.0 +/- 4.2 in group B (p = ns). With dobutamine testing the score decreased to 2.8 +/- 3.6 in group A (p < 0.001 with respect to basal value), while it did not change significantly in group B. Left ventricular end diastolic volume (ml) was similar in the two groups (114 +/- 35 vs 107 +/- 79, p = NS). The infarct related artery (IRA) patency rate was 87.5% in group A, vs 26.5% in group B (p < 0.001). After a mean follow-up of 11 +/- 5 months, group A pts had basal asynergy score improvement (2.6 +/- 3.1, p < 0.001) and mild left ventricular end diastolic volume (ml) reduction, (108 +/- 32, p = NS), while group B pts had left ventricle end diastolic volume enlargement (130 +/- 38, p < 0.05), without score asynergy modification. Moreover all pts who experienced heart failure at follow-up were in group B.(ABSTRACT TRUNCATED AT 250 WORDS)

Dermatan sulphate for the treatment of disseminated intravascular coagulation (DIC) in acute leukemia: a randomised, heparin-controlled pilot study

Efficacy and safety of i.v. dermatan sulphate (DS) and heparin (H) in controlling laboratory alterations due to DIC were compared in 10 patients with acute leukaemia, in a prospective, randomised pilot study. The time courses of the coagulation and fibrinolysis markers for DIC were similar in the two treatment groups except for activated partial thromboplastin time and thrombin time, which were prolonged in the H but not in the DS group. Blood product support tended to be greater in the H than in the DS group. DS appears to be as effective as H in controlling thrombin production during leukaemic cytolysis and may represent a safer alternative to H in the management of DIC in acute leukaemia.

Increased fibrin turnover and high PAI-1 activity as predictors of ischemic events in atherosclerotic patients. A case-control study. The PLAT Group

A case-control comparison within the framework of the prospective, multidisciplinary PLAT Study was performed to assess whether altered baseline fibrinolytic variables were associated with an elevated risk of ischemic thrombotic events in patients with documented coronary, cerebral, and/or peripheral atherosclerotic disease. Fibrinogen, D-dimer, tissue plasminogen activator (t-PA) antigen, and fibrinolytic activity before and after venous stasis (delta = difference between the two values), t-PA inhibitor, and lipid levels in 60 atherosclerotic patients with a thrombotic event during the first year of follow-up were compared with those in 94 atherosclerotic patients without such events, who were matched for age, sex, and diagnosis at enrollment. Events were associated with a higher release of delta t-PA antigen (P = .047), higher D-dimer (P = .024), and higher t-PA inhibitor (P = .001) levels. delta Fibrinolytic activity was correlated inversely with t-PA inhibitor (P < .01) and triglycerides (P < .05). D-Dimer was also correlated with systolic blood pressure (P < .01). Atherosclerotic patients at higher risk of thrombotic ischemic events are characterized by increased fibrin turnover and impaired fibrinolytic activity due to high t-PA inhibitor levels. This hemostatic disequilibrium may participate with conventional risk factors such as elevated triglyceride levels and systolic blood pressure in the multifactorial mechanism of ischemic sequelae in patients with preexisting vascular atherothrombotic disease.

The PLAT Study: hemostatic function in relation to atherothrombotic ischemic events in vascular disease patients. Principal results. PLAT Study Group. Progetto Lombardo Atero-Trombosi (PLAT) Study Group

The Progetto Lombardo Atero-Trombosi (PLAT) Study was a prospective, multicenter, multidisciplinary study of the association among hemostatic variables, conventional risk factors, and atherothrombotic events in four groups of patients with preexisting vascular ischemic disease (335 myocardial infarction survivors, 123 patients with stable angina pectoris, 160 with transient ischemic attacks, and 335 with peripheral vascular disease). In the myocardial infarction group, univariate analysis showed that atherothrombotic events were associated with high fibrinogen (p = 0.001), factor VIII:C (p less than 0.001), and von Willebrand factor antigen (vWF:Ag) (p = 0.004) levels and with low high density lipoprotein cholesterol (p = 0.043), factor VII (p = 0.019), and protein C (p = 0.044) levels; multivariate analysis produced associations with high fibrinogen and factor VIII:C levels and low protein C levels. By both univariate and multivariate analysis, events in the angina pectoris group were associated with high vWF:Ag (p = 0.026) and leukocyte (p = 0.033) levels and the presence of carotid arterial stenosis (p = 0.063); associations with high leukocyte (p = 0.037) and factor VIII:C (p = 0.186) levels, family history (p = 0.031), and diabetes (p = 0.061) were also found in the group with transient ischemic attacks. In those with peripheral vascular disease, events were associated with Fontaine stage greater than or equal to IIB (p = 0.024), high factor VIII:C levels (p = 0.073), and low protein C (p = 0.028), fibrinogen (p = 0.030), antithrombin III (p = 0.054), and factor VII (p = 0.057) levels by univariate analysis and with Fontaine stage and low fibrinogen levels by multivariate analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy of liposomal amphotericin B (AmBisome) in the eradication of Fusarium infection in a leukaemic patient

We recently succeeded in eradicating a Fusarium infection by treatment with liposomal amphotericin B (L-AmB). The patient, a 22-year-old man with acute lymphoblastic leukaemia (ALL), developed fever and diffuse cutaneous maculopapular necrotising nodules during post-chemotherapy neutropenia. Fusarium verticilloides was isolated from the skin, and hyphae were observed on direct microscopy. Despite increased WBC and amphotericin B (AmB) treatment (0.7 mg/kg/day for 11 days), he remained febrile and a chest X-ray revealed pulmonary lesions. Fusarium infection was confirmed by bronchial aspirate. AmB was increased to 1 mg/kg/day, and continued for 16 days (total dose 1630 mg). A slight improvement was observed at tomography, but nephrotoxicity developed. Treatment was changed to L-AmB (3 mg/kg/day). The patient received this drug for 20 days (total dose of 3850 mg) with complete regression of the pulmonary lesions. No adverse event occurred, and nephrotoxicity resolved. The patient was discharged from hospital cured of the Fusarium infection and in clinical and haematological remission. No relapse of fusariosis occurred, despite additional courses of intensive chemotherapy. Ambisome could represent an important advance in antifungal treatment since it allows aggressive treatment and eradication of mycoses refractory to conventional therapy while avoiding renal toxicity.

Cyclic hormonal replacement therapy after the menopause: transdermal versus oral treatment

In an open, randomized, comparative, between-patient trial, 45 postmenopausal women were treated for 4 months with cyclical transdermal oestradiol 0.05 mg per day or oral conjugated equine oestrogens 0.625 mg per day, in both cases, plus, medroxyprogesterone acetate 10 mg per day on the last 8 days of each cycle. Similar relief from postmenopausal symptoms was obtained with both treatments. Post-treatment histological evaluation of the endometrium did not reveal neoplastic or hyperplastic change in any patient. Early follicular-phase plasma oestradiol levels were observed only after transdermal oestradiol. There was a significant reduction in serum total cholesterol and LDL cholesterol in both treatment groups, with no difference between treatments, whereas serum triglyceride levels were decreased only by transdermal oestradiol. Plasma calcium and phosphorus fell significantly and serum intact parathyroid hormone rose significantly, with no difference between the therapies. No significant changes were observed in clotting factors. Transdermal oestradiol appears to be an effective and safe hormonal replacement therapy, and this route of administration may be responsible for the more useful action of the drug on serum lipids and plasma oestradiol levels.