Cardiovascular protection by anti-inflammatory statin therapy

The Anti-Atherosclerotic Effects of Endothelin Receptor Antagonist, Bosentan, in Combination with Atorvastatin-An Experimental Study

Bosentan, an endothelin receptor antagonist (ERA), has potential anti-atherosclerotic properties. We investigated the complementary effects of bosentan and atorvastatin on the progression and composition of the atherosclerotic lesions in diabetic mice. Forty-eight male ApoE-/- mice were fed high-fat diet (HFD) for 14 weeks. At week 8, diabetes was induced with streptozotocin, and mice were randomized into four groups: (1) control/COG: no intervention; (2) ΒOG: bosentan 100 mg/kg/day per os; (3) ATG: atorvastatin 20 mg/kg/day per os; and (4) BO + ATG: combined administration of bosentan and atorvastatin. The intra-plaque contents of collagen, elastin, monocyte chemoattractant protein-1 (MCP-1), tumor necrosis factor-a (TNF-a), matrix metalloproteinases (MMP-2, -3, -9), and TIMP-1 were determined. The percentage of lumen stenosis was significantly lower across all treated groups: BOG: 19.5 ± 2.2%, ATG: 12.8 ± 4.8%, and BO + ATG: 9.1 ± 2.7% compared to controls (24.6 ± 4.8%, p < 0.001). The administration of both atorvastatin and bosentan resulted in significantly higher collagen content and thicker fibrous cap versus COG (p < 0.01). All intervention groups showed lower relative intra-plaque concentrations of MCP-1, MMP-3, and MMP-9 and a higher TIMP-1concentration compared to COG (p < 0.001). Importantly, latter parameters presented lower levels when bosentan was combined with atorvastatin compared to COG (p < 0.05). Bosentan treatment in diabetic, atherosclerotic ApoE-/- mice delayed the atherosclerosis progression and enhanced plaques' stability, showing modest but additive effects with atorvastatin, which are promising in atherosclerotic cardiovascular diseases.

Limosilactobacillus fermentum TY-S11 ameliorates hypercholesterolemia via promoting cholesterol excretion and regulating gut microbiota in high-cholesterol diet-fed apolipoprotein E-deficient mice

Hypercholesterolemia is a metabolic disease characterized by elevated cholesterol level in the blood, which is a risk factor for many diseases. Probiotic intervention may be one of the ways to improve hypercholesterolemia. In this study, three strains with better cholesterol removal ability were selected from 60 strains of lactic acid bacteria, and were orally administered to apolipoprotein E-deficient mice on a high-cholesterol diet. Among the three strains, only Limosilactobacillus fermentum TY-S11, which was isolated from the intestine of a longevity person, significantly improved serum and liver lipid levels in hypercholesterolemic mice. Further study found that L. fermentum TY-S11 promoted the excretion of cholesterol in the feces and inhibited the absorption of cholesterol in the small intestine. As for gut microbiota, the results showed that L. fermentum TY-S11 not only prevented the reduction of diversity caused by high-cholesterol diet, but also increased the contents of short-chain fatty acids in feces. These results confirmed the ameliorative effect of L. fermentum TY-S11 on hypercholesterolemia.

How to Use Statins in Secondary Prevention of Atherosclerotic Diseases: from the Beneficial Early Initiation to the Potentially Unfavorable Discontinuation

Statins, a class of lipid-lowering drugs, reduce morbidity and mortality in patients with established atherosclerosis-related cardiovascular disease. Early initiation of statin therapy after admission for acute coronary syndromes (ACS), stroke, or transient ischemic attack (TIA) is associated with improved cardiovascular outcomes. Moreover, high-dose statin treatment prior to coronary or carotid revascularization has been shown to reduce cardiovascular events in these patients. However, many patients may be undertreated, and a residual cardiovascular risk remains in current clinical practice. Despite the beneficial role of statins, their discontinuation rate among patients is still elevated leading to severe adverse cardiovascular events due to atherosclerotic plaque destabilization. In this review, we summarized the impact of statin treatment among patients, focusing on the initiation time-points as well as the potential harm derived by their discontinuation.

Impact of smoking on the outcomes of minimally invasive direct coronary artery bypass

BACKGROUND

Tobacco smoking has been associated with an increased risk of complications after conventional coronary surgery. However, the impact of smoking on the risk of postoperative complications in minimally invasive coronary surgery is yet to be studied. We aimed to analyze the impact of the preoperative smoking status on the short- and long-term outcomes of minimally invasive direct coronary artery bypass grafting (MIDCAB) in the context of isolated surgical revascularization or in association with percutaneous coronary intervention.

METHODS

This was a retrospective observational study of all patients undergoing MIDCAB at our institution between 2006 and 2020. Patients were divided into three groups: active smokers, ex-smokers who have quit smoking for at least 1 month before surgery, and non-smokers. The groups were compared using conventional statistical methods. Multivariate analysis was then performed where significant differences were found to eliminate bias.

RESULTS

Throughout the study period, 541 patients underwent MIDCAB, of which 135 (25%) were active smokers, 183 (34%) were ex-smokers, and 223 (41%) were non-smokers. Smokers presented for surgery at a younger age (p < 0.0001), more frequently with a history of myocardial infarction (p < 0.001), peripheral artery disease (p < 0.001) and chronic obstructive pulmonary disease (p < 0.0001). Using multivariate analysis, active smoking was determined to be a significant risk factor for the need of urgent revascularization (odds ratio 2.36 [1.00-5.56], p = 0.049) and the composite of pulmonary complications (including pneumothorax, respiratory infection, respiratory dysfunction, subcutaneous emphysema and exacerbation of chronic obstructive pulmonary disease; odds ratio 2.84 [1.64-4.94], p < 0.001). Preoperative smoking status did not influence the long-term survival (p = 0.83).

CONCLUSIONS

In our study, active smokers presented for MIDCAB at a younger age and more often with signs of atherosclerotic disease (history of myocardial infarction and peripheral artery disease). Active smoking was found to be the most significant risk factor for postoperative pulmonary complications, and is also associated with a more frequent need for urgent surgery at diagnosis. Long-term postoperative survival is not affected by the preoperative smoking status.

High Serum Aspartate Aminotransferase, Underweight, and Weight Loss in Older People: Results of the KITCHEN-4

Background: Reduced muscle mass is frequently observed in older people and can lead to being underweight and/or weight loss (WL), but prediction and screening systems utilizing hematological biochemical parameters are limited. High serum aspartatSe aminotransferase in conjunction with normal serum alanine aminotransferase (HASNAL) can reflect systemic muscle damage. HASNAL and the incidence of being underweight concomitant with WL (UWWL) were investigated in the present 6-year community-based cohort study. Methods: Clinical parameters, lifestyle, the incidence of being underweight, ≥ 5% WL, and UWWL were investigated in 238,536 Japanese people aged 40-68 years who had normal serum alanine aminotransferase. HASNAL was defined as serum aspartate aminotransferase ≥ 30 U/L and serum alanine aminotransferase < 30 U/L. The subjects were divided into a younger group (< 55 years) and an older group (≥ 55 years). Results: After 6 years, overall body weight had increased by 0.4% in the younger group and decreased by 0.4% in the older group. In logistic regression analysis, in the younger group ≥ 5% WL was significantly associated with baseline HASNAL compared to baseline low serum aspartate aminotransferase (< 20 U/L). In the older group, baseline HASNAL was significantly associated with being underweight, ≥ 5% WL, and UWWL, even after adjustment for potential confounders, and UWWL was inversely associated with regular exercise and daily alcohol consumption-both of which modified the aforementioned associations. Conclusions: Older subjects with HASNAL were at an increased risk of UWWL, possibly via skeletal muscle damage, which may be affected by common lifestyles.

Management of antiplatelet therapy in patients with coronary stents undergoing noncardiac surgery: association with adverse events

BACKGROUND

Perioperative discontinuation of antiplatelet therapy (APT) in patients with coronary stents has been associated with major adverse cardiac events. Our aim was to analyse the perioperative management of APT in such patients and its relationship to the incidence of major adverse cardiac and cerebrovascular events (MACCE) and major bleeding events (MBE) in noncardiac surgery.

METHODS

We completed a prospective multicentre observational study of patients with coronary stents undergoing noncardiac surgery in 11 hospitals in Spain. The main objectives were to record perioperative events and prospectively analyse the management of APT, and to assess whether the different preoperative APT regimens were associated with MACCE and MBE.

RESULTS

Of 432 surgical procedures studied, 15% experienced a perioperative MACCE and 37% a MBE. Overall mortality was 3.0%. Presurgical APT was prescribed in 95% of procedures, and was preoperatively discontinued in 15%. Surgery was urgent or emergent in 22% of patients, 31% were ASA IV, and 38% had a Revised Cardiac Risk Index of IV. MACCE were related to recent myocardial infarction (P=0.038), chronic kidney disease (P<0.001), insulin-dependent diabetes (P=0.006) and no preoperative APT (P=0.018). MBE also increased MACCE risk (P<0.001). We found statin therapy (P=0.049) and obesity (P=0.016) to be protective factors for MACCE.

CONCLUSIONS

Patients with coronary stents undergoing noncardiac surgery suffer a high incidence of perioperative adverse events, even with perioperative APT. Major adverse cardiac and cerebrovascular events are mainly related to previous medical conditions and perioperative major bleeingn events. Our findings should be treated with caution when applied to an elective surgery population.

CLINICAL TRIAL REGISTRATION

NCT01171612.

PPARγ in coronary atherosclerosis: in vivo expression pattern and correlations with hyperlipidemic status and statin treatment

OBJECTIVE

Peroxisome proliferator-activated receptor-γ (PPARγ) is involved in regulation of macrophage inflammation and in atherosclerosis. Herein we investigate the influence of statin treatment on PPARγ expression in coronary artery disease.

METHOD

PPARγ expression was investigated in coronary atherosclerotic atherectomies (N=48) and arteries (N=12) from patients with stable or unstable coronary syndromes or undergoing cardiac transplantation for end-stage ischemic cardiomyopathy, respectively, by immunohistochemistry. Plaque components and tissue factor immunoreactivity were also investigated. Atherectomies were obtained from de novo culprit lesions of hypercholesterolemic (16 statin-treated and 16 untreated) and normolipidemic (N=16) patients. Furthermore, PPARγ expression was evaluated in patients peripheral blood monocytes and in monocytic U937 cells after atorvastatin incubation, by Western blot analysis.

RESULT

PPARγ expression was higher in coronary plaques and peripheral blood monocytes of statin-treated patients, and it significantly increased in monocytes after 24h atorvastatin incubation (p<0.05). Intra-plaque macrophage content, atheroma, neoangiogenesis and hemorrhage, and circulating CRP levels were lower in statin-treated than untreated hypercholesterolemic patients and comparable with normolipidemic subjects. PPARγ immunoreactivity was localized to neointima and media, its distribution pattern being different from that of tissue factor.

CONCLUSION

PPARγ expression was enhanced in statin-treated patients with different distribution and behavior as compared to atheroma, macrophage content, tissue factor immunoreactivity and serum CRP. In vitro studies showed increased PPARγ expression in monocytes after atorvastatin incubation. These findings provide further evidence as to the protective role of statins in coronary artery disease and their influence on PPARγ expression in coronary plaques and on the inflammatory status of patients.

Lipid Control before CABG and Its Association with In-Hospital Mortality

BACKGROUND

Controlling risk factors such as dyslipidemia in patients with coronary artery disease, including candidates for coronary artery bypass grafting (CABG), is of great importance and has serious effects on CABG morbidity and mortality. The aim of this study was to evaluate lipid serum levels, comprising TG, LDL, and HDL, before CABG and their relation with in-hospital outcome.

METHODS

The clinical profiles of 3,593 patients in the hospital cardiac surgery databank who underwent isolated CABG between April 2006 and April 2008 were reviewed. Three components of lipid profile, including TG, LDL, and HDL serum levels, were checked at the time of hospitalization in all the patients. Lipid control was evaluated according to the published guidelines.

RESULTS

The mean LDL, HDL, and TG serum levels were 103.4±48.5, 40.9±16, and 168±87 mg/dl, respectively. Additionally, 487 (13.6%) patients had entire TG, LDL, and HDL serum levels within the acceptable range and in 668 (18.6%) patients, all of these components were within the uncontrolled range. After adjustment for confounders, in-hospital mortality in patients with uncontrolled TG, LDL, and HDL was higher than patients with controlled TG, LDL, and HDL (p value=0.042, OR=1.399, 95% CI =1.012-1.934).

CONCLUSION

The high prevalence of uncontrolled lipids in our patient population is alarming. Regular and frequent pre- and post-operative visits to monitor and modify patient risk factors, including dyslipidemia, seem necessary. An increase in statin dosage or adjunctive therapy with other lipid lowering agents may be helpful. Attempts to maintain all lipids within the controlled range may have beneficial effects on hospital outcome.

Simvastatin attenuates cardiopulmonary bypass-induced myocardial inflammatory injury in rats by activating peroxisome proliferator-activated receptor γ

Statins have been shown to downregulate the systemic inflammatory response after cardiopulmonary bypass. However, the role of statins as anti-inflammatory agents in heart tissue remains unknown. The aim of this study was to test whether statin pretreatment attenuates local inflammatory cytokines production in heart and to explore whether the underlying mechanism involves peroxisome proliferator-activated receptor (PPAR) γ. A rat model of cardiopulmonary bypass was established. The animals were pretreated with simvastatin 5 mg/kg/day or 10 mg/kg/day for 7 days before operation. The serum concentration and myocardial level of tumor necrosis factor (TNF)-α, interleukin (IL)-6, monocyte chemoattractant protein (MCP)-1 was evaluated by enzyme linked immunosorbent assay. The polymorphonuclear neutrophils accumulation in heart tissue was determined by myeloperoxidase activity assay. The activity of nuclear factor (NF)-κB and PPARγ in the heart was determined by electrophoretic mobility shift assay. The myocardial PPARγ expression was also examined by immunohistochemistry. The systemic and local TNF-α, IL-6 and MCP-1 were all significantly elevated after cardiopulmonary bypass. In contrast, simvastatin pretreatment significantly decreases the serum and myocardial expression level of above cytokines, myocardial myeloperoxidase activity and myocardial NF-κB activity. However, there was an evident increase in the activity and expression of PPARγ. In conclusion, simvastatin pretreatment not only attenuates acute systemic and local inflammatory response induced by cardiopulmonary bypass. The anti-inflammatory effect of simvastatin in myocardium may be partly related to the activation of PPARγ and inhibition of NF-κB.

A gene score of nine LDL and HDL regulating genes is associated with fluvastatin-induced cholesterol changes in women

While conventional pharmacogenetic studies have considered single gene effects, we tested if a genetic score of nine LDL- and HDL-associated single nucleotide polymorphisms, previously shown to predict cardiovascular disease, is related to fluvastatin-induced lipid change. In patients with asymptomatic plaque in the right carotid artery, thus candidates for statin therapy, we related score LDL [APOB(rs693), APOE(rs4420638), HMGCR(rs12654264), LDLR(rs1529729), and PCSK9(rs11591147)] and score HDL [ABCA1(rs3890182), CETP(rs1800775), LIPC(rs1800588), and LPL(rs328)] as well as the combined score LDL+HDL to fluvastatin-induced LDL reduction (+/- metoprolol) (n = 395) and HDL increase (n = 187) following 1 year of fluvastatin treatment. In women, an increasing number of unfavorable alleles (i.e., alleles conferring higher LDL and lower HDL) of score LDL+HDL (P = 0.037) and of score LDL (P = 0.023) was associated with less pronounced fluvastatin-induced LDL reduction. Furthermore, in women, both score LDL+HDL (P = 0.001) and score HDL (P = 0.022) were directly correlated with more pronounced fluvastatin-induced HDL increase, explaining 5.9-11.6% of the variance in treatment response in women. There were no such associations in men. This suggests that a gene score based on variation in nine different LDL- and HDL-associated genes is of importance for the magnitude of fluvastatin HDL increase in women with asymptomatic plaque in the carotid artery.

Medical treatment predicts mortality after hip fracture

Background

The mortality after hip fracture has remained high and stable the past 50 years despite improved surgical treatment. The aim of this study was to identify medications and medical factors associated with mortality after hip fracture.

Methods

This is a prospective observational study with median observation time of 21 months. Three hundred and sixty-four patients, mean age 83.4 years and 75.8% women, were enrolled. Information on comorbidity, medications, surgery, and clinical findings were collected at the time of fracture. Information on cause and time of death was obtained from the Norwegian Cause of Death Register.

Results

Six risk factors and one protective factor were identified by Cox proportional hazards model adjusted for propensity score: the use of diuretics (adjusted hazard ratio [HR] = 4.03, 95% confidence interval [CI] = 2.13–7.64), history of coronary heart disease (CHD) (HR = 2.61, CI = 1.37–4.98), male sex (HR = 2.32, CI = 1.27–4.24), Barthel Index ≤ 18/20 (HR = 2.48, CI = 1.23–5.01), heart rate > 100 on admission (HR = 2.47, CI = 1.18–5.14), body mass index ≤ 20 (HR = 1.94, CI = 1.13–3.34), and the use of statins (HR = 0.23, CI = 0.08–0.68). Patients using diuretics had increased risk of death from all causes, including death from CHD, chronic obstructive pulmonary disease, and falls or other accidents.

Conclusions

The use of diuretics is the strongest predictor of mortality, followed by CHD at the time of fracture, whereas the use of statins is associated with improved survival. Future research is needed to evaluate whether improved diagnosis and management of CHD and congestive heart failure among hip fracture patients would improve survival.

Risk factors for preoperative and postoperative delirium in elderly patients with hip fracture

OBJECTIVES

To evaluate risk factors for preoperative and postoperative delirium.

DESIGN

Prospective cohort study.

SETTING

Departments of orthopedic surgery in two Norwegian hospitals.

PARTICIPANTS

Three hundred sixty-four patients with and without cognitive impairment, aged 65 and older.

MEASUREMENTS

Patients were screened daily for delirium using the Confusion Assessment Method. Established risk factors and risk factors regarded as clinically important according to expert opinion were explored in univariate analyses. Variables associated with the outcomes (P<.05) were entered into multivariate logistic regression models.

RESULTS

Delirium was present in 50 of 237 (21.1%) assessable patients preoperatively, whereas 68 of 187 (36.4%) patients developed delirium postoperatively (incident delirium). Multivariate logistic regression identified four risk factors for preoperative delirium: cognitive impairment (adjusted odds ratio (AOR)=4.7, 95% confidence interval (CI)=1.9-11.3), indoor injury (AOR=3.6, 95% CI=1.1-12.2), fever (AOR=3.4, 95% CI=1.5-7.7), and preoperative waiting time (AOR=1.05, 95% CI=1.0-1.1 per hour). Cognitive impairment (AOR=2.9, 95% CI=1.4-6.2), indoor injury (AOR=2.9, 95% CI=1.1-6.3), and body mass index (BMI) less than 20.0 (AOR=2.9, 95% CI=1.3-6.7) were independent and statistically significant risk factors for postoperative delirium.

CONCLUSION

Time from admission to operation is a risk factor for preoperative delirium, whereas low BMI is an important risk factor for postoperative delirium in hip fracture patients. Cognitive impairment and indoor injury are independent risk factors for preoperative and postoperative delirium.

Novel uses for statins in surgical patients

BACKGROUND

Aside from their cholesterol-lowering effects statins are known to have a range of other 'pleiotropic' effects. We present an overview of the basic science behind these effects and then review clinical trials and the current role of statins relevant to modern surgical practice.

METHODS

A systematic review of the literature was performed using the keywords surgery and the MeSH term for statins. All clinical studies relating to statin use in surgical patients were evaluated. An overview of the literature on statin use and cardiac outcomes was performed.

CONCLUSIONS

Statins are safe and have a wide range of pleiotropic effects relevant to surgical practice. Strongest evidence for their clinical use comes in primary cardiac risk reduction in many types of vascular surgery. There is a large body of evidence showing their benefit perioperatively in high-risk vascular and cardiac surgery but the picture is less clear for low-risk patients. Further studies are needed to evaluate exact dosage regimes and timing of administration. Novel uses of their anti-inflammatory properties in sepsis and vasomotor properties in subarachnoid haemorrhage are being further investigated by randomised trials.