Pharmacological Preventive Potential Among Attenders at Vascular Screening: Findings from the VIVA Trial

Exploring Drug Re-Purposing for Treatment of Abdominal Aortic Aneurysms: a Systematic Review and Meta-analysis

OBJECTIVE

Large abdominal aortic aneurysms (AAAs) present a significant mortality risk. While numerous medical interventions have been proposed, no drugs have convincingly reduced AAA progression, rupture rates, or repair risk. This systematic review and meta-analysis aimed to assess the impact of re-purposed drugs or dietary supplements on slowing expansion rates, reducing the risk of rupture, or minimising the risk of repair for individuals with AAA.

METHODS

A systematic search was conducted in five databases. Both observational studies and randomised controlled trials were included. Unpublished data from two screening trials were incorporated. Risk of bias was assessed using the Newcastle-Ottawa scale and revised Cochrane risk of bias tool. Meta-analyses were performed for each identified drug subclass and were stratified by overall risk of bias. Results were reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Of 7 484 screened studies, 39 met the inclusion criteria. No studies on dietary supplements were included. A total of 84 cohorts were derived from the included studies, and twelve distinct drug groups underwent meta-analyses. Two drug groups, metformin and statins, were statistically significant in slowing AAA growth. No low risk of bias studies were included for these two drug groups, and the results had very high heterogeneity (I2 > 80%). Both groups had a GRADE certainty of very low. Metformin, excluding high risk of bias studies, presented an estimated mean growth difference of AAA diameter between users and non-users of -0.73 mm/year, whilst statins had an overall estimated mean difference of -0.84 mm/year.

CONCLUSION

This systematic review and meta-analysis suggests that metformin and statins may provide some effect in slowing AAA progression. However, no definitive evidence was found for any of the investigated drugs included in this study. Further research is needed to identify effective medical treatments for AAA progression with more robust methodology.

Arabic-speaking male immigrants' perceptions of preventive initiatives: An interview study

BACKGROUND

Arabic-speaking men are a sparsely investigated population in health promotion and disease prevention. This may hamper their ability to achieve the highest obtainable health due to less accessibility and acceptability of preventive measures.

AIM

We explored Arabic-speaking (Palestinian, Iraqi and Somali) male immigrants' perceptions of preventive initiatives in general and such initiatives for cardiovascular diseases (CVD) in particular to understand how to address inequalities in engagement in prevention.

METHODS

This qualitative study employed content analysis of semistructured interviews with 60-66-year-old Arabic-speaking men living in Denmark. Supplementary, structured data, for example, health data, were collected. From June to August 2020, 10 men were interviewed.

FINDINGS

Preventive initiatives were found ethically and culturally acceptable alongside personally and socially relevant; they were perceived as humanitarian and caring for the participants' health, respecting of their self-determination and enabling their empowerment. Thus, the participants entreated that their fellow countrymen be assisted in achieving the prerequisite coping capabilities to address inequality in access, perceived acceptance and relevance. This led us to define one main category 'Preventive initiatives - Caring and humanitarian aid empower us' with the underlying subcategories: 'We are both hampered and strengthened by our basic assumptions' and 'We need help to achieve coping capabilities enabling us to engage in preventive initiatives'.

CONCLUSION

Prevention was perceived as acceptable and relevant. Even so, Arabic-speaking men may be a hard-to-reach group due to their basic assumptions and impaired capabilities for engaging in prevention. Addressing inequality in accessibility, acceptability and relevance in regard to prevention may be promoted through a person-centred approach embracing invitees' preferences, needs and values; and by strengthening invitees' health literacy through efforts at the structural, health professional and individual levels.

PUBLIC CONTRIBUTION

This study was based on interviews. The interviewees were recruited as public representatives to assist us in building an understanding of Arabic-speaking male immigrants' perceptions of preventive initiatives in general and preventive initiatives for CVD in particular.

No Effect of Hypercholesterolemia on Elastase-Induced Experimental Abdominal Aortic Aneurysm Progression

OBJECTIVE

Epidemiological studies link hyperlipidemia with increased risk for abdominal aortic aneurysms (AAAs). However, the influence of lipid-lowering drugs statins on prevalence and progression of clinical and experimental AAAs varies between reports, engendering controversy on the association of hyperlipidemia with AAA disease. This study investigated the impact of hypercholesterolemia on elastase-induced experimental AAAs in mice.

METHODS

Both spontaneous (targeted deletion of apolipoprotein E) and induced mouse hypercholesterolemia models were employed. In male wild type (WT) C57BL/6J mice, hypercholesterolemia was induced via intraperitoneal injection of an adeno-associated virus (AAV) encoding a gain-of-function proprotein convertase subtilisin/kexin type 9 mutation (PCSK9) followed by the administration of a high-fat diet (HFD) (PCSK9+HFD) for two weeks. As normocholesterolemic controls for PCSK9+HFD mice, WT mice were infected with PCSK9 AAV and fed normal chow, or injected with phosphate-buffered saline alone and fed HFD chow. AAAs were induced in all mice by intra-aortic infusion of porcine pancreatic elastase and assessed by ultrasonography and histopathology.

RESULTS

In spontaneous hyper- and normo-cholesterolemic male mice, the aortic diameter enlarged at a constant rate from day 3 through day 14 following elastase infusion. AAAs, defined as a more than 50% diameter increase over baseline measurements, formed in all mice. AAA progression was more pronounced in male mice, with or without spontaneous hyperlipidemia. The extent of elastin degradation and smooth muscle cell depletion were similar in spontaneous hyper- (score 3.5 for elastin and 4.0 for smooth muscle) and normo- (both scores 4.0) cholesterolemic male mice. Aortic mural macrophage accumulation was also equivalent between the two groups. No differences were observed in aortic accumulation of CD4+ or CD8+ T cells, B cells, or mural angiogenesis between male spontaneous hyper- and normocholesterolemic mice. Similarly, no influence of spontaneous hypercholesterolemia on characteristic aneurysmal histopathology was noted in female mice. In confirmatory experiments, induced hypercholesterolemia also exerted no appreciable effect on AAA progression and histopathologies.

CONCLUSION

This study demonstrated no recognizable impact of hypercholesterolemia on elastase-induced experimental AAA progression in both spontaneous and induced hypercholesterolemia mouse models. These results add further uncertainty to the controversy surrounding the efficacy of statin therapy in clinical AAA disease.

Involving people with type 2 diabetes in facilitating participation in a cardiovascular screening programme

BACKGROUND

Knowledge is lacking about how to increase uptake among people with type 2 diabetes (T2D) invited to preventive initiatives like cardiovascular screening.

AIM

To explore how to improve participation of people with T2D in cardiovascular screening using patient and public involvement (PPI).

METHODS

Patient and public involvement was included in a qualitative research design. From April to October 2019, we invited 40- to 60-year-old people with T2D (n = 17) to individual consultative meetings, using an interviewing approach. Before the interviews, participants were asked to read a proposed invitation letter to be used in a cardiovascular screening programme. Inductive content analysis was undertaken.

RESULTS

Participants considered cardiovascular screening important and beneficial from both a personal and social perspective. We found that the relational interaction between the person with T2D and the health-care professional was key to participation and that nudging captured through the design of the screening programme and the wording of the invitation letter was requested.

CONCLUSION

In preventive initiatives perceived as meaningful by the invitee, a focus on recruitment is crucial to facilitate participation. This study contributed with knowledge about how to promote participation by involving health-care professionals in recruitment initiatives and through nudging. This knowledge may assist researchers, policymakers and ethicists' understanding and assessment of the ethical appropriateness and public acceptability of nudging in cardiovascular screening.

PATIENT OR PUBLIC CONTRIBUTION

By consulting 17 people with T2D, we are now in a position to suggest how a screening initiative should be altered because tools to improve uptake have been identified.

PAD screening: why? whom? when? how? - a systematic review

An estimated 237 million people suffer from peripheral arterial disease (PAD), which is associated with high morbidity and mortality, and prevalence is still increasing. Currently, we do not have any randomized trials that compare screening to no screening specifically for PAD in the general population. Presently, PAD screening is not generally established. This systematic review gives an overview of relevant literature and guidelines. Screening usually focuses on ankle-brachial index (ABI)-measurement, which enables detection of asymptomatic and symptomatic PAD, but has limitations in diabetics. There are no sufficient data on PAD screening. Guideline recommendations are heterogeneous. While some advocate no screening until better data are available, most recommend selective screening despite insufficient data on morbidity and mortality reduction in consequence of screening. We support the only evidence-based screening strategy for PAD: combined screening for abdominal aortic aneurysm (AAA), PAD and arterial hypertension in men aged 65-74 according to the VIVA study. We additionally suggest a new simple three-step screening strategy for symptomatic PAD in all individuals aged 40 and older, who see a general practitioner: Asking one question ("Do you have pain or cramps in the legs during normal walking?") followed by physical examination (normal lower extremity pulse status?) in those, whose answer is "yes", and ABI measurement unless all pulses are normal.