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Zhang Y, Qi X, Wang S, Zhang W, Yang R, Wang X, Chen W, Ji F, Dong J, Yu X. Serum immunoglobulin M is associated with the severity of coronary artery disease in adults. PeerJ 2024; 12:e17012. [PMID: 38464758 PMCID: PMC10921929 DOI: 10.7717/peerj.17012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/05/2024] [Indexed: 03/12/2024] Open
Abstract
Purpose The purpose of this study was to investigate the relationship between serum immunoglobulin M (IgM) and the severity of coronary artery disease in Chinese patients who underwent coronary angiography. Methods A total of 2,045 patients who underwent coronary angiography (CAG) from March 2017 to March 2020 at Beijing Hospital were included in this study. Serum IgM concentration and biochemical indicators were measured before coronary angiography (CAG). The triquartile IgM levels at baseline in the population were analysed. Spearman rank correlation was used to analyse the association between IgM and traditional risk factors for coronary artery disease (CAD). CAD patients were divided into subgroups by affected area, number of affected vessels, and Gensini score to analyse the relationship between IgM and CAD severity. Multivariable logistic regression analysis was used to evaluate the association between IgM and CAD severity. Results Serum IgM levels were significantly lower in the CAD group (63.5 mg/dL) than in the non-coronary artery disease (NCAD) group (72.3 mg/dL) (P < 0.001). Serum IgM levels were significantly associated with sex. Serum IgM levels were positively correlated with traditional CAD risk factors such as TG, TC and LDL-C (P < 0.05), and negatively associated with the number of obstructed vessels, the number of affected areas, and Gensini scores. After adjusting for age, sex, smoking status, hypertension, dyslipidaemia, diabetes, stroke, and statin use history, a high IgM level was independently negatively associated with the severity of CAD expressed by the Gensini score. Conclusion We determined that serum IgM was independently negatively associated with the severity of CAD diagnosed by angiography in Chinese adults.
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Affiliation(s)
- Yanan Zhang
- The Affiliated Hospital of Qingdao University, Qing Dao, Shan Dong, China
| | - Xi Qi
- Beijing Hospital, Beijing, China
| | | | | | | | | | | | - Fusui Ji
- Beijing Hospital, Beijing, China
| | - Jun Dong
- Beijing Hospital, Beijing, China
| | - Xue Yu
- Beijing Hospital, Beijing, China
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Adams SP, Alaeiilkhchi N, Tasnim S, Wright JM. Pravastatin for lowering lipids. Cochrane Database Syst Rev 2023; 9:CD013673. [PMID: 37721222 PMCID: PMC10506175 DOI: 10.1002/14651858.cd013673.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
BACKGROUND A detailed summary and meta-analysis of the dose-related effect of pravastatin on lipids is not available. OBJECTIVES Primary objective To assess the pharmacology of pravastatin by characterizing the dose-related effect and variability of the effect of pravastatin on the surrogate marker: low-density lipoprotein (LDL cholesterol). The effect of pravastatin on morbidity and mortality is not the objective of this systematic review. Secondary objectives • To assess the dose-related effect and variability of effect of pravastatin on the following surrogate markers: total cholesterol; high-density lipoprotein (HDL cholesterol); and triglycerides. • To assess the effect of pravastatin on withdrawals due to adverse effects. SEARCH METHODS The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials (RCTs) up to September 2021: CENTRAL (2021, Issue 8), Ovid MEDLINE, Ovid Embase, Bireme LILACS, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions. SELECTION CRITERIA Randomized placebo-controlled trials evaluating the dose response of different fixed doses of pravastatin on blood lipids over a duration of three to 12 weeks in participants of any age with and without evidence of cardiovascular disease. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility criteria for studies to be included, and extracted data. We entered lipid data from placebo-controlled trials into Review Manager 5 as continuous data and withdrawal due to adverse effects (WDAEs) data as dichotomous data. We searched for WDAEs information from all trials. We assessed all trials using Cochrane's risk of bias tool under the categories of sequence generation, allocation concealment, blinding, incomplete outcome data, selective reporting, and other potential biases. MAIN RESULTS Sixty-four RCTs evaluated the dose-related efficacy of pravastatin in 9771 participants. The participants were of any age, with and without evidence of cardiovascular disease, and pravastatin effects were studied within a treatment period of three to 12 weeks. Log dose-response data over the doses of 5 mg to 160 mg revealed strong linear dose-related effects on blood total cholesterol and LDL cholesterol, and a weak linear dose-related effect on blood triglycerides. There was no dose-related effect of pravastatin on blood HDL cholesterol. Pravastatin 10 mg/day to 80 mg/day reduced LDL cholesterol by 21.7% to 31.9%, total cholesterol by 16.1% to 23.3%,and triglycerides by 5.8% to 20.0%. The certainty of evidence for these effects was judged to be moderate to high. For every two-fold dose increase there was a 3.4% (95% confidence interval (CI) 2.2 to 4.6) decrease in blood LDL cholesterol. This represented a dose-response slope that was less than the other studied statins: atorvastatin, rosuvastatin, fluvastatin, pitavastatin and cerivastatin. From other systematic reviews we conducted on statins for its effect to reduce LDL cholesterol, pravastatin is similar to fluvastatin, but has a decreased effect compared to atorvastatin, rosuvastatin, pitavastatin and cerivastatin. The effect of pravastatin compared to placebo on WADES has a risk ratio (RR) of 0.81 (95% CI 0.63 to 1.03). The certainty of evidence was judged to be very low. AUTHORS' CONCLUSIONS Pravastatin lowers blood total cholesterol, LDL cholesterol and triglyceride in a dose-dependent linear fashion. This review did not provide a good estimate of the incidence of harms associated with pravastatin because of the lack of reporting of adverse effects in 48.4% of the randomized placebo-controlled trials.
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Affiliation(s)
- Stephen P Adams
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada
| | - Nima Alaeiilkhchi
- Faculty of Science, University of British Columbia, Vancouver, Canada
| | - Sara Tasnim
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada
| | - James M Wright
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada
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Mu H, Yang R, Wang S, Zhang W, Wang X, Li H, Dong J, Chen W, Yu X, Ji F. Association of Serum β-Hydroxybutyrate and Coronary Artery Disease in an Urban Chinese Population. Front Nutr 2022; 9:828824. [PMID: 35252305 PMCID: PMC8893320 DOI: 10.3389/fnut.2022.828824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/17/2022] [Indexed: 11/13/2022] Open
Abstract
Ketone bodies, including β-hydroxybutyrate (BHB), acetoacetate (AA), and acetone, can substitute and alternate with glucose under conditions of fuel/food deficiency. Ketone-body metabolism is increased in a myriad of tissue-metabolism disorders. Perturbations in metabolism are major contributors to coronary artery disease (CAD). We investigated the association of BHB with CAD. A total of 2,970 people of Chinese Han ethnicity were enrolled. The Gensini score was calculated for all patients who had positive findings. The serum level of BHB and other laboratory parameters were measured. The association of serum levels of metabolites with traditionally risk factors and CAD severity was analyzed. The BHB was found to be associated with some traditional risk factors of CAD and CAD severity, as determined by the Gensini score or the number of diseased regions. Moreover, BHB was associated with the T3/T1 tertiles of the Gensini score after the adjustment for traditional risk factors by multivariable logistic regression analysis. The association of BHB with CAD severity was more obvious in women. Taken together, these data suggest that the circulating BHB level is independently associated with CAD severity, and that this association is more pronounced in women.
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Affiliation(s)
- Hongna Mu
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China
| | - Ruiyue Yang
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China
| | - Siming Wang
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China
| | - Wenduo Zhang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinyue Wang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Hongxia Li
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China
| | - Jun Dong
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China
| | - Wenxiang Chen
- National Center for Clinical Laboratories, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology, Beijing, China
| | - Xue Yu
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Xue Yu
| | - Fusui Ji
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Fusui Ji
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Serial myocardial perfusion imaging: defining a significant change and targeting management decisions. JACC Cardiovasc Imaging 2015; 7:79-96. [PMID: 24433711 DOI: 10.1016/j.jcmg.2013.05.022] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Revised: 05/20/2013] [Accepted: 05/30/2013] [Indexed: 12/22/2022]
Abstract
Myocardial perfusion imaging (MPI) with gated single-photon emission tomography provides important information on the extent and severity of myocardial perfusion abnormalities, including myocardial ischemia. The availability of software for automated quantitative assessment of myocardial perfusion in an objective and more reproducible manner than visual assessment has allowed MPI to be particularly effective in serial evaluation. Serial testing using MPI is widely used in guiding patient care despite the lack of well-defined appropriateness use criteria. This should not be surprising because ischemic heart disease is a life-long malady subject to dynamic changes throughout its natural course and particularly following man-made interventions that may improve or worsen the disease process, such as medical therapy and coronary revascularization. Serial MPI has filled an important clinical gap by providing crucial information for managing patients with changes in clinical presentations or in anticipation of such changes in patients with stable symptoms. In the research arena, serial MPI has been widely applied in randomized controlled trials to study the impact of various medical and interventional therapies on myocardial perfusion, as well as the relative merits of new imaging procedures (hardware and/or software), radiotracers, and stressor agents. Serial testing, however, unlike initial or 1-time testing, has more stringent requirements and is subject to variability because of technical, procedural, interpretational, and biological factors. The intrinsic variability of MPI becomes important in interpreting serial tests in order to define a true change in a given patient and to guide clinical decision making. The purpose of this first comprehensive review on this subject is to illustrate where serial MPI may be useful clinically and in research studies, and to highlight strategies for addressing the various issues that are unique to serial testing in order to derive more valid and robust data from the serial scans.
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Temporal trends in the frequency of inducible myocardial ischemia during cardiac stress testing: 1991 to 2009. J Am Coll Cardiol 2013; 61:1054-65. [PMID: 23473411 DOI: 10.1016/j.jacc.2012.11.056] [Citation(s) in RCA: 280] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 11/10/2012] [Accepted: 11/12/2012] [Indexed: 01/05/2023]
Abstract
OBJECTIVES This study sought to assess whether the frequency of inducible myocardial ischemia during stress-rest single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) has changed over time. BACKGROUND The prevalence of cardiac death and other clinical cardiac events have declined in recent decades, but heretofore no study has examined if there has been a temporal change in the frequency of inducible myocardial ischemia during cardiac stress testing. METHODS We assessed 39,515 diagnostic patients undergoing stress-rest MPI between 1991 and 2009. Patients were assessed for change in demographics, clinical symptoms, risk factors, and frequency of abnormal and ischemic SPECT-MPI. RESULTS There was a marked progressive decline in the prevalence of abnormal SPECT studies, from 40.9% in 1991 to 8.7% in 2009 (p < 0.001). Similarly, the prevalence of ischemic SPECT-MPI declined, from 29.6% to 5.0% (p < 0.001), as did the prevalence of severe ischemia. The decline of SPECT-MPI abnormality occurred among all age and symptom subgroups, falling to only 2.9% among recent exercising patients without typical angina. We also noted a progressive trend toward performing more pharmacological rather than exercise stress in all age and weight groups, and pharmacological stress was more likely than exercise to be associated with SPECT-MPI abnormality (odds ratio: 1.43, 95% confidence interval: 1.3 to 1.5; p < 0.001). CONCLUSIONS Over the past 2 decades, the frequency and severity of abnormal stress SPECT-MPI studies has progressively decreased. Notably, the frequency of abnormal SPECT-MPI is now very low among exercising patients without typical angina. These findings suggest the need for developing more cost-effective strategies for the initial work-up of patients who are presently at low risk for manifesting inducible myocardial ischemia during cardiac imaging procedures.
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Lynn Fillipon NM, Kitkungvan D, Dani SS, Downey BC. The relationship between glycosylated hemoglobin and myocardial perfusion imaging. Clin Cardiol 2012; 35:565-9. [PMID: 22753267 DOI: 10.1002/clc.22028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Revised: 05/03/2012] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The relationship between long-term glucose control (measured by glycosylated hemoglobin [HgbA1C]) and myocardial perfusion imaging (MPI) abnormalities in symptomatic diabetic patients has not been studied. HYPOTHESIS We hypothesized that diabetic patients with poorly controlled HgbA1C would have more abnormal MPI compared to both patients without diabetes and diabetic patients with tighter glycemic control. METHODS This was a retrospective evaluation of 1037 consecutive patients referred for MPI. All patients completed a 1-day MPI protocol. The electronic medical records were accessed for demographics and relevant medical history. RESULTS Diabetic patients had a higher risk of abnormal MPI (including ischemia, infarction, and mixed ischemia/infarction) compared to nondiabetic patients (relative risk [RR] = 1.77). The populations with suboptimal (HgbA1C ≥ 7%) and poor (HgbA1C ≥ 8%) glycemic control had significantly higher risk of abnormal MPI (RR = 1.78 and 2.17, respectively) compared to nondiabetic patients. Coronary angiography supported the MPI results; 66% of diabetic patients had coronary artery disease (CAD), which was higher than the 53% of patients without diabetes found to have CAD. CONCLUSIONS The importance of strict glycemic control to reduce cardiovascular complications in diabetic patients is well known. Our study shows a significantly higher risk of abnormal MPI and CAD in diabetic patients with suboptimal and poor long-term glycemic control, further emphasizing the need for aggressive risk factor modification to minimize vascular complications from DM.
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Abstract
Angina pectoris resulting from myocardial ischemia afflicts half of all patients with coronary heart disease (CHD). Chronic angina remains a major public health burden despite state-of-the-art therapies, and improvement in survival from myocardial infarction and CHD has only increased its prevalence. There is growing experimental and clinical evidence pointing to the anti-ischemic and anti-anginal properties of statins. Some data suggest that the degree of anti-ischemic efficacy of statins may be comparable to the current standard pharmacologic and mechanical strategies. The pleiotropic effects of statins are postulated to be primarily responsible for their anti-ischemic and anti-anginal properties. These include improvement of endothelial function, enhancement of the ischemic vasodilatory response, modulation of inflammation, and protection from ischemia-reperfusion injury. The anti-ischemic effects of statins further strengthen their role as a crucial component of the optimal medical therapy for CHD.
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Affiliation(s)
- Joel A Lardizabal
- Division of Cardiology, Fresno Medical Education Program, University of California - San Francisco, 155 N. Fresno St., Fresno, CA 93301, USA
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Schwartz RG. Early insights of cardiac risk and treatment response with quantitative PET monitoring of coronary-specific endothelial dysfunction and myocardial perfusion reserve. J Nucl Cardiol 2010; 17:985-9. [PMID: 20963538 DOI: 10.1007/s12350-010-9295-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Djaberi R, Roodt JO', Schuijf JD, Rabelink TJ, de Koning EJ, Pereira AM, Stokkel MP, Smit JW, Bax JJ, Jukema JW. Endothelial Dysfunction in Diabetic Patients with Abnormal Myocardial Perfusion in the Absence of Epicardial Obstructive Coronary Artery Disease. J Nucl Med 2009; 50:1980-6. [DOI: 10.2967/jnumed.109.065193] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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10
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Del Val Gómez M, Gallardo F, Peraira R, García Á, Terol I. Cuantificación del estudio de perfusión miocárdica en pacientes con baja probabilidad de cardiopatía isquémica. Valores normales de gated-SPECT con 201Tl. ACTA ACUST UNITED AC 2009; 28:193-9. [DOI: 10.1016/s0212-6982(09)00002-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Accepted: 01/16/2009] [Indexed: 11/29/2022]
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Mahmarian JJ. Myocardial perfusion imaging to evaluate the efficacy of medical therapy in patients with coronary artery disease. CURRENT CARDIOVASCULAR IMAGING REPORTS 2009. [DOI: 10.1007/s12410-009-0023-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Yoon AJ, Melduni RM, Duncan SA, Ostfeld RJ, Travin MI. The effect of beta-blockers on the diagnostic accuracy of vasodilator pharmacologic SPECT myocardial perfusion imaging. J Nucl Cardiol 2009; 16:358-67. [PMID: 19266249 DOI: 10.1007/s12350-009-9066-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Revised: 01/30/2009] [Accepted: 02/02/2009] [Indexed: 11/26/2022]
Abstract
BACKGROUND The effect of beta (beta) blockers on the accuracy, particularly the sensitivity, of vasodilator radionuclide myocardial perfusion imaging (MPI) is not entirely clear. This study aimed to further assess the effect of beta-blockers on the ability of MPI to identify significant and high-risk coronary artery disease (CAD). METHODS AND RESULTS For 555 patients who underwent vasodilator MPI and had coronary angiography within 90 days, global and per-vessel sensitivities and specificities were calculated, and were found to be similar between patients taking beta-blockers and those who were not. beta-blockers did not decrease the ability to detect patients with multivessel disease. Summed stress scores and summed rest scores were likewise similar in both groups. To account in part for catheterization referral bias and the potential of false-negative MPI studies in patients receiving beta-blockers, survival analysis was performed on 2646 patients with normal MPI studies who did not undergo cardiac catheterization and failed to demonstrate significant mortality difference related to the taking of beta-blockers. CONCLUSIONS beta-blocker therapy does not diminish the ability of vasodilator stress MPI to detect clinically significant CAD, nor hide the mortality risk of patients with normal studies not referred for catheterization.
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Affiliation(s)
- Andrew J Yoon
- Department of Nuclear Medicine and Department of Medicine/Division of Cardiology, Montefiore Medical Center, 111 East-210th Street, Bronx, NY, 10467-2490, USA
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The Effects of Medications on Myocardial Perfusion. J Am Coll Cardiol 2008; 52:401-16. [PMID: 18672159 DOI: 10.1016/j.jacc.2008.04.035] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Revised: 04/14/2008] [Accepted: 04/21/2008] [Indexed: 11/23/2022]
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Shaw LJ, Berman DS, Maron DJ, Mancini GBJ, Hayes SW, Hartigan PM, Weintraub WS, O'Rourke RA, Dada M, Spertus JA, Chaitman BR, Friedman J, Slomka P, Heller GV, Germano G, Gosselin G, Berger P, Kostuk WJ, Schwartz RG, Knudtson M, Veledar E, Bates ER, McCallister B, Teo KK, Boden WE. Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation 2008; 117:1283-91. [PMID: 18268144 DOI: 10.1161/circulationaha.107.743963] [Citation(s) in RCA: 1131] [Impact Index Per Article: 70.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Extent and severity of myocardial ischemia are determinants of risk for patients with coronary artery disease, and ischemia reduction is an important therapeutic goal. The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) nuclear substudy compared the effectiveness of percutaneous coronary intervention (PCI) for ischemia reduction added to optimal medical therapy (OMT) with the use of myocardial perfusion single photon emission computed tomography (MPS). METHODS AND RESULTS Of the 2287 COURAGE patients, 314 were enrolled in this substudy of serial rest/stress MPS performed before treatment and 6 to 18 months (mean=374+/-50 days) after randomization using paired exercise (n=84) or vasodilator stress (n=230). A blinded core laboratory analyzed quantitative MPS measures of percent ischemic myocardium. Moderate to severe ischemia encumbered > or = 10% myocardium. The primary end point was > or = 5% reduction in ischemic myocardium at follow-up. Treatment groups had similar baseline characteristics. At follow-up, the reduction in ischemic myocardium was greater with PCI+OMT (-2.7%; 95% confidence interval, -1.7%, -3.8%) than with OMT (-0.5%; 95% confidence interval, -1.6%, 0.6%; P<0.0001). More PCI+OMT patients exhibited significant ischemia reduction (33% versus 19%; P=0.0004), especially patients with moderate to severe pretreatment ischemia (78% versus 52%; P=0.007). Patients with ischemia reduction had lower unadjusted risk for death or myocardial infarction (P=0.037 [risk-adjusted P=0.26]), particularly if baseline ischemia was moderate to severe (P=0.001 [risk-adjusted P=0.08]). Death or myocardial infarction rates ranged from 0% to 39% for patients with no residual ischemia to > or = 10% residual ischemia on follow-up MPS (P=0.002 [risk-adjusted P=0.09]). CONCLUSIONS In COURAGE patients who underwent serial MPS, adding PCI to OMT resulted in greater reduction in ischemia compared with OMT alone. Our findings suggest a treatment target of > or = 5% ischemia reduction with OMT with or without coronary revascularization.
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Affiliation(s)
- Leslee J Shaw
- Emory University School of Medicine, Atlanta, GA 30306, USA.
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Beaudry D, Stone KE, Wetherold S, Hemphill J, Do D, McClish J, Chilton R. Statin therapy in cardiovascular diseases other than atherosclerosis. Curr Atheroscler Rep 2007; 9:25-32. [PMID: 17228487 DOI: 10.1007/bf02693937] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Statins are drugs that inhibit 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase, thereby blocking the synthesis of cholesterol. Since being discovered in Japan in the mid 1970s, statins have been widely used to lower low-density lipoprotein cholesterol. However, analysis of cardiovascular research has revealed other important effects beyond changes in lipid parameters, referred to as pleiotropic effects. This paper focuses on the effects of statins as anti-ischemic agents with improvement in endothelial function, along with studies on valvular aortic stenosis, atrial fibrillation, heart failure, peripheral arterial disease, and cancer. As the evolution of statin research continues, there appear to be new potential benefits from statins to be found in many facets of cardiovascular disease.
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Boushra NN, Muntazar M. Review article: The role of statins in reducing perioperative cardiac risk: physiologic and clinical perspectives. Can J Anaesth 2006; 53:1126-47. [PMID: 17079641 DOI: 10.1007/bf03022882] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To review the pathobiology and clinical implications of coronary vulnerable atherosclerotic plaques (VAPs), to discuss the role of statin therapy in VAP stabilization, and the potential benefits of perioperative statin therapy (PST) in reducing perioperative risk of acute coronary syndromes (ACSs). SOURCE MEDLINE search using "perioperative", "cardiac morbidity", "atherosclerosis", "vulnerable plaque", "statins" and combinations of these terms as keywords. The reference lists of relevant articles were further reviewed to identify additional citations. PRINCIPAL FINDINGS The nonstenotic, yet rupture-prone VAP causes most myocardial infarctions (MIs) and other ACSs, both in the nonsurgical and surgical patients. Large clinical trials in both primary and secondary prevention and in patients with ACSs have demonstrated that statin therapy will reduce cardiovascular morbidity and mortality across a broad spectrum of patient subgroups. These trials also suggest, and laboratory investigations establish, that statins possess favourable vascular effects independent of cholesterol reduction. Statins appear to interfere specifically with the pathophysiologic mechanisms implicated in atherothrombotic disease. Statins reduce vascular inflammation, improve endothelial function, stabilize VAPs, and reduce platelet aggregability and thrombus formation. Recent studies have shown that PST is associated with a reduced incidence of perioperative and long-term cardiovascular complications in high-risk patients. Combined therapy with statins and ss-blockers is a conceptually valid strategy targeting critical steps in the pathogenesis of an ACS. CONCLUSION Emerging evidence for the efficacy and safety of PST is promising, especially when combined with ss-blocker therapy in patients at highest risk. Confirmation of this early evidence awaits the results of ongoing and future prospective randomized controlled trials.
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Affiliation(s)
- Nader N Boushra
- Department of Anesthesia, Lower Bucks Hospital, 501 Bath Road, Bristol, PA 19007, USA.
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Gulati M, McBride PE. Functional capacity and cardiovascular assessment: submaximal exercise testing and hidden candidates for pharmacologic stress. Am J Cardiol 2005; 96:11J-19J. [PMID: 16246649 DOI: 10.1016/j.amjcard.2005.06.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Submaximal exercise testing is often used to estimate functional capacity in non-athletes, to assess cardiovascular disease in elderly or frail patients, to demonstrate exercise equipment, or to risk-stratify patients after myocardial infarction. However, submaximal exercise testing is not sufficiently sensitive, specific, or predictive to have widespread clinical utility, except in post-myocardial infarction protocols. Many patients for whom submaximal exercise testing is not useful are unable to exercise sufficiently for maximal testing and are referred for imaging with pharmacologic stress. Although some patients who are unable to exercise adequately are easily recognized, many are not. The identification of such patients before they fail a maximal exercise test attempt is beneficial to both the patient and the imaging laboratory.
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Affiliation(s)
- Martha Gulati
- Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA.
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Abstract
The utility of stress myocardial perfusion imaging (MPI) for the diagnosis and prognosis of coronary artery disease (CAD) has been firmly established in numerous clinical studies and has become an essential component of clinical practice. Stress MPI is now used regularly to guide initial risk stratification and management of patients with CAD. Because stress MPI provides an assessment of the physiologic significance of CAD, it is a particularly attractive procedure for assessing follow-up risk. Today, sequential stress MPI is being used increasingly to track disease progression, assess follow-up risk, detect restenosis following revascularization, and evaluate the efficacy of aggressive medical therapy and risk-factor modification. By providing serial snapshots of the disease and its impact on perfusion, sequential stress MPI may alter treatment decisions and ultimately improve long-term patient management and outcomes. Use of sequential stress MPI to detect changes in perfusion following surgical or medical therapies is being tested currently in the Clinical Outcomes Using Revascularization and Aggressive Drug Evaluation (COURAGE) and Adenosine Sestamibi Single-Photon Emission Computed Tomography Postinfarction Evaluation (INSPIRE) trials.
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Affiliation(s)
- Leslee J Shaw
- Department of Medicine and Imaging, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA.
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20
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Ling MC, Ruddy TD, deKemp RA, Ukkonen H, Duchesne L, Higginson L, Williams KAP, McPherson R, Beanlands R. Early effects of statin therapy on endothelial function and microvascular reactivity in patients with coronary artery disease. Am Heart J 2005; 149:1137. [PMID: 15976803 DOI: 10.1016/j.ahj.2005.02.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Recent data suggest an early outcome benefit with reduction in cholesterol using statin therapy in patients with coronary artery disease (CAD). This may be caused by effects of low-density lipoprotein cholesterol (LDL-C) reduction on endothelial function and vascular reactivity in the coronary bed. The aim of this randomized placebo-controlled study was to examine the early effects of important reductions in LDL-C on myocardial perfusion and peripheral endothelial function. METHODS AND RESULTS Seventy-two patients with CAD and LDL-C between 3.0 and 5.9 mmol/L (116-228 mg/dL) were randomized to receive simvastatin 20 mg daily, pravastatin 40 mg daily, or placebo for 8 weeks. At baseline, 2 weeks, and 8 weeks, patients underwent dynamic positron emission tomography perfusion imaging to quantify the retention of rubidium-82 as a measure of myocardial flow at rest and after dipyridamole stress. Patients also underwent brachial artery ultrasound to measure endothelium-dependent flow-mediated vasodilatation. At 2 and 8 weeks, the simvastatin and pravastatin groups showed a significant reduction (P < .001) in LDL-C compared with placebo. At 8 weeks, simvastatin led to an improvement in flow-mediated vasodilatation compared with placebo (6.86% +/- 4.4% vs 3.44% +/- 4.0%, P < .05), whereas pravastatin was not significantly different than placebo (5.62% +/- 4.1% vs 3.44% +/- 4.0%, P = NS). Despite this improvement in peripheral endothelial function with simvastatin, there were no significant differences observed in global stress flow and coronary flow reserve at 8 weeks with either drug. CONCLUSIONS Short-term LDL reduction with simvastatin therapy improves peripheral endothelial function in patients with stable CAD, although an early effect on coronary vascular reactivity could not be demonstrated.
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Affiliation(s)
- Michael C Ling
- Division of Cardiology, Department of Medicine, Cardiac PET Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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21
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Michelena HI, VanDecker WA. Radionuclide-Based Insights into the Pathophysiology of Ischemic Heart Disease: Beyond Diagnosis. J Investig Med 2005; 53:176-91. [PMID: 15974244 DOI: 10.2310/6650.2005.00401] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This review article discusses the historical origin of cardiac radionuclide-based methods, the physiologic background that justifies their existence, as well as the basic pathophysiologic concepts of coronary artery disease and their connection with the technologic design and application of these methods. Most importantly, this review discusses the important insights that these methods have provided to the understanding of the mechanisms of ischemia, risk stratification, and both treatment choice and treatment efficacy in ischemic heart disease. Nuclear cardiology originated as an attempt to provide complementary physiologic information to the anatomic information provided by coronary angiography. To comprehend the design and applications of nuclear cardiology methods, one must have a basic understanding of coronary artery disease as an inflammatory process that may manifest as acute or chronic states. Basic concepts on myocyte metabolic pathways, coronary blood flow, ischemic cascade, ventricular remodeling, and ejection fraction become critical for this purpose. Insights into risk stratification may permit patient-tailored therapy approaches. Insights into prognosis have made nuclear cardiology a robust tool for outcome predictions, with an exceptionally high negative predictive value. Evaluation of prognosis in special patient populations such as diabetics has originated important pathophysiologic concepts. Most insights into phenomena such as myocardial hibernation, myocardial stunning, and viability have been generated by nuclear cardiology techniques. Finally, new applications of radionuclide-based methods such as molecular identification of "vulnerable" atherosclerotic plaques, "ischemic memory" using fatty acid imaging, and myocardial innervation imaging provide new avenues for insightful research.
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Affiliation(s)
- Hector I Michelena
- Department of Cardiology, Temple University Hospital, Temple University School of Medicine, Philadelphia, PA, USA
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22
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Stone PH, Lloyd-Jones DM, Kinlay S, Frei B, Carlson W, Rubenstein J, Andrews TC, Johnstone M, Sopko G, Cole H, Orav J, Selwyn AP, Creager MA. Effect of Intensive Lipid Lowering, With or Without Antioxidant Vitamins, Compared With Moderate Lipid Lowering on Myocardial Ischemia in Patients With Stable Coronary Artery Disease. Circulation 2005; 111:1747-55. [PMID: 15809368 DOI: 10.1161/01.cir.0000160866.90148.76] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Lipid lowering with statins prevents adverse cardiac events. Both lipid-lowering and antioxidant therapies may favorably affect vasomotor function and thereby improve ischemia.
Methods and Results—
In a randomized, double-blind, placebo-controlled trial, 300 patients with stable coronary disease, a positive exercise treadmill test, 48-hour ambulatory ECG with ≥1 episode of ischemia, and fasting total cholesterol of 180 to 250 mg/dL were assigned to 1-year treatment with intensive atorvastatin to reduce LDL to <80 mg/dL (n=96), intensive atorvastatin to reduce LDL to <80 mg/dL plus antioxidant vitamins C (1000 mg/d) and E (800 mg/d) (n=101), or diet and low-dose lovastatin, if needed, to reduce LDL to <130 mg/dL (n=103; control group). Ischemia end points, including ambulatory ECG monitoring and exercise treadmill testing, and endothelial assessment using brachial artery flow-mediated dilation were obtained at baseline and at 6 and 12 months. Baseline characteristics were similar in all groups. LDL decreased from ≈153 mg/dL at baseline in the 2 atorvastatin groups to ≈83 mg/dL at 12 months (each
P
<0.0001) and from 147 to 120 mg/dL in the control group (
P
<0.0001). During ambulatory ECG monitoring, mean number of ischemic episodes per 48 hours decreased 31% to 61% in each group (each
P
<0.001;
P
=0.15 across groups), without a change in daily heart rate activity. Mean duration of ischemia for 48 hours decreased 26% to 62% in each group (each
P
<0.001;
P
=0.06 across groups). Mean exercise duration to 1-mm ST-segment depression significantly increased in each group, but total exercise duration and mean sum of maximum ST depression were unchanged. Angina frequency decreased in each group. There was no incremental effect of supplemental vitamins C and E on any ischemia outcome. Flow-mediated dilation studies indicated no meaningful changes.
Conclusions—
Intensive lipid lowering with atorvastatin to an LDL level of 80 mg/dL, with or without antioxidant vitamins, does not provide any further benefits in ambulatory ischemia, exercise time to onset of ischemia, and angina frequency than moderate lipid lowering with diet and low-dose lovastatin to an LDL level of <120 mg/dL.
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Affiliation(s)
- Peter H Stone
- Cardiovascular Division, Brigham & Women's Hospital, Boston, Mass 02115, USA.
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23
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Affiliation(s)
- Leslee J Shaw
- Atlanta Cardiovascular Research Institute, Atlanta, GA 30342, USA.
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24
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Schwartz RG, Pearson TA, Kalaria VG, Mackin ML, Williford DJ, Awasthi A, Shah A, Rains A, Guido JJ. Prospective serial evaluation of myocardial perfusion and lipids during the first six months of pravastatin therapy: coronary artery disease regression single photon emission computed tomography monitoring trial. J Am Coll Cardiol 2003; 42:600-10. [PMID: 12932588 DOI: 10.1016/s0735-1097(03)00767-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study was designed to assess prospectively changes in serum lipid profile and myocardial perfusion with serial radionuclide single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) during the first six months of pravastatin therapy. BACKGROUND Morbid coronary events occur despite statin therapy and lipid-lowering in patients with coronary artery disease (CAD). A reliable strategy to identify responders with effective treatment from nonresponders on statin therapy before clinical events is needed. METHODS Rest and stress SPECT MPI and lipids were assessed serially in 25 patients (36% women) with CAD and dyslipidemia during the first six months of pravastatin therapy. RESULTS Total cholesterol, low-density lipoprotein cholesterol, and triglycerides declined (26%, 32%, and 30%, respectively) by six weeks and remained reduced at six months. Mean stress perfusion defect (summed stress score [SSS]) was severe (13.3 +/- 6.0) at baseline, showed no change at six weeks, and improved significantly at six months (10.3 +/- 7.3, p < 0.01). The six-month study SSS improved in 11 (48%) patients, was unchanged in 10 (43%) patients, and worsened in 2 (9%) patients. Changes in lipid levels did not reliably predict changes in myocardial perfusion at six weeks or six months in this small pilot study. CONCLUSIONS Serial SPECT MPI demonstrated improved stress myocardial perfusion in 48% of patients treated for six months with pravastatin. Time course of improved myocardial perfusion during pravastatin therapy is delayed compared to lipids. Direction and magnitude of changes in the myocardial perfusion vary and do not correlate closely with improvements in lipids.
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Affiliation(s)
- Ronald G Schwartz
- Cardiology Unit, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
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25
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Blumenthal RS, Gluckman TJ. New insights into the relationship between myocardial perfusion and lipid-lowering. J Am Coll Cardiol 2003; 42:611-3. [PMID: 12932589 DOI: 10.1016/s0735-1097(03)00768-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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26
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Patel AD, Iskandrian AE. Role of single photon emission computed tomography imaging in the evaluation of therapy for angina pectoris. Am Heart J 2003; 145:952-61. [PMID: 12796749 DOI: 10.1016/s0002-8703(03)00088-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Amar D Patel
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, USA
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27
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Fathi R, Haluska B, Short L, Marwick TH. A randomized trial of aggressive lipid reduction for improvement of myocardial ischemia, symptom status, and vascular function in patients with coronary artery disease not amenable to intervention. Am J Med 2003; 114:445-53. [PMID: 12727577 DOI: 10.1016/s0002-9343(03)00052-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To determine the effects of aggressive lipid lowering on markers of ischemia, resistance vessel function, atherosclerotic burden, and symptom status in patients with symptomatic coronary artery disease. METHODS Sixty consecutive patients with coronary artery disease that was unsuitable for revascularization were assigned randomly to either usual therapy of lipids for patients with a low-density lipoprotein (LDL) cholesterol target level <116 mg/dL, or to a more aggressive lipid-lowering strategy involving up to 80 mg/d of atorvastatin, with a target LDL cholesterol level <77 mg/dL. The extent and severity of inducible ischemia (by dobutamine echocardiography), vascular function (brachial artery reactivity), atheroma burden (carotid intima-media thickness), and symptom status were evaluated blindly at baseline and after 12 weeks of treatment. RESULTS After 12 weeks of treatment, patients in the aggressive therapy group had a significantly greater decrease in mean (+/- SD) LDL cholesterol level than those in the usual care group (29 +/- 38 mg/dL vs. 7 +/- 24 mg/dL, P = 0.03). Patients in the aggressive therapy group had a reduction in the number of ischemic wall segments (mean between-group difference of 1.3; 95% confidence interval: 0.1 to 2.0; P = 0.04), flow-mediated dilatation (mean between-group difference of 5.9%; 95% confidence interval: 2.5% to 9.4%; P = 0.001), and angina score after 12 weeks. There were no significant changes in atherosclerotic burden in either group. CONCLUSION Patients with symptomatic coronary artery disease who are treated with aggressive lipid lowering have improvement of symptom status and ischemia that appears to reflect improved vascular function but not atheroma burden.
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Affiliation(s)
- Robert Fathi
- Department of Medicine, University of Queensland, Brisbane, Australia
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28
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29
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Hellstrom HR. Can the premises of the altered homeostatic theory permit improvement in the prevention of ischemic heart disease? Med Hypotheses 2003; 60:12-25. [PMID: 12450764 DOI: 10.1016/s0306-9877(02)00328-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In this communication, the altered homeostatic theory will be discussed and updated, and evidence will be presented that the premises of the theory might permit improvement of the prevention of ischemic heart disease (IHD). This hypothesis, first described in 1999, argues that IHD is due basically to an inappropriate shift of homeostasis, and the theory includes the position that S-RV directly induces symptoms. In contrast, the standard approach to IHD is based fundamentally on two principles: that atherosclerosis is due fundamentally to lipid abnormalities, and that symptoms in IHD are due to obstructive complications of atherosclerosis in epicardial coronary arteries. Suggestions for prevention stem from the altered homeostatic theory's different basic conceptualization of this disorder, and it seems reasonable that accepted basic pathogenetic mechanisms help shape measures to prevent IHD. Many of the theory's positions for preventing IHD parallel standard views, but the theory's basic premises have resulted in significant differences between the standard and the theory's overall approach to the prevention of IHD. Positions for the prevention of IHD include: the possibility that any preventative factor can improve any risk factor, the use of substitute preventative factors to counter unmodifiable or difficult to correct risk factors, underestimation of the risk of IHD by the standard position in individuals with normal lipid levels but multiple other risk factors, the probable relative overemphasis of the risk factor of cholesterol, the value of a national program to reduce the incidence of multiple disorders with similar risk factors, an alternate approach to the use of statins, and the value of an evolutionary approach to preventing IHD and other disorders.
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Affiliation(s)
- H R Hellstrom
- College of Medicine, SUNY Upstate Medical University, Syracuse, New York 13210, USA.
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30
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Koga N. Meaning of low-density lipoprotein-apheresis for hypercholesterolemic patients at high risk for recurrence of coronary heart disease. THERAPEUTIC APHERESIS : OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY FOR APHERESIS AND THE JAPANESE SOCIETY FOR APHERESIS 2002; 6:372-80. [PMID: 12423532 DOI: 10.1046/j.1526-0968.2002.00422.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The goal of cholesterol-lowering therapy in hypercholesterolemic patients at high risk for recurrence of coronary heart disease (CHD) is the prevention of acute coronary syndrome by stabilization of coronary atheromatous plaque. We often encounter patients in whom it is difficult to maintain the serum cholesterol level at a desirable level with dietary therapy and drug treatment, despite the development and use of statins. For secondary prevention in patients who are at high risk for the recurrence of CHD and whose cholesterol level cannot be controlled by drugs alone, low-density lipoprotein (LDL)-apheresis therapy, which involves removal of LDL through extracorporeal circulation, is now available. Many reports concerning improvement of vascular endothelial function, improvement of myocardial ischemia, regression of coronary atherosclerotic lesions, stabilization of coronary plaque, and reduction in the incidence of cardiac events as a result of LDL-apheresis treatment have been published in various countries. We believe that LDL-apheresis should be performed on hypercholesterolemic patients with existing CHD for whom diet and maximum cholesterol-lowering drug therapies have been ineffective or not tolerated and whose LDL cholesterol level is 160 mg/dL or higher.
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31
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Abstract
To date, there are no well controlled trials in the literature that demonstrate an outcome benefit using stress testing as a screening procedure before noncardiac surgery. Perioperative beta-blockade significantly decreases morbidity and mortality, and thus reduces any potential benefit stress testing may have in identifying patients who may advance to more invasive treatment. Preoperative percutaneous coronary intervention has unproven perioperative benefit, and coronary artery bypass graft carries risks that often offset the risk of noncardiac surgery. Unless an outcome benefit from cardiac testing and procedures can be demonstrated in a properly designed trial, their use should generally be restricted to situations in which symptoms or other cardiac findings warrant cardiac evaluation and treatment, regardless of upcoming surgery.
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Affiliation(s)
- Stewart J Lustik
- Department of Anesthesiology, Strong Medical Hospital, University of Rochester Medical Center, Box 604, 601 Elmwood Avenue, Rochester, NY 14642, USA.
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32
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Chilton R, O'Rourke RA. The expanding role of HMG-CoA reductase inhibitors (statins) in the prevention and treatment of ischemic heart disease. Curr Probl Cardiol 2001; 26:734-64. [PMID: 11743453 DOI: 10.1067/mcd.2001.119386] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- R Chilton
- Cardiac Catheterization Laboratory, Audie L. Murphy Veterans Affairs Hospital, San Antonio, Texas, USA
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33
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Affiliation(s)
- B Hornig
- Abteilung Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hannover, Germany.
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34
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Meco JF, Vila R, Pujol R, Bros R, Domènech P, Fiol C, Pintó X. Improvement in endothelial dysfunction in patients with hypoalphalipoproteinemia and coronary artery disease treated with bezafibrate. J Cardiovasc Pharmacol 2001; 38:250-8. [PMID: 11483875 DOI: 10.1097/00005344-200108000-00011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Isolated low high-density lipoprotein cholesterol (HDLc) is a well-known risk factor for cardiovascular disease and is associated with arterial endothelium dysfunction. Several studies have shown that cholesterol lowering in patients with hypercholesterolemia improves endothelial function, but the effect of treating low HDLc levels remains unknown. We studied the effect of increasing HDLc on endothelial function in patients with coronary artery disease (CAD) and isolated low HDLc (HDLc) <0.91 mM, low-density lipoprotein cholesterol (LDLc) <4.1 mM, and triglycerides <2.8 mM. Flow-mediated endothelium-dependent dilatation (FMD) in response to reactive hyperemia was measured by brachial ultrasound, before and after bezafibrate treatment (400 mg daily for 6 months) in 16 patients with CAD and impaired FMD (<10%). After bezafibrate therapy, HDLc increased from 0.79-1.0 mM (p = 0.0008) at the expense of both HDL2 and HDL3 subfractions, apolipoprotein A-I increased from 1.04-1.19 g/l (p = 0.0012), and fibrinogen decreased from 4.45-3.39 g/l (p = 0.0007). The impaired FMD increased after bezafibrate treatment from a median of 2.5-12.3% (p = 0.0004). Endothelial function was normalized in eight patients (50%), improved in four (25%), and did not change in four (25%). These observations indicate that in patients with isolated low HDLc and CAD, bezafibrate treatment improves endothelial function of brachial arteries, increases HDLc and apolipoprotein A-I, and lowers fibrinogen concentrations.
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Affiliation(s)
- J F Meco
- Internal Medicine Department, Ciutat Santiària I Universitària de Bellvitge, Barcelona, Spain.
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35
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Thompson PL. Clinical relevance of statins: instituting treatment early in acute coronary syndrome patients. ATHEROSCLEROSIS SUPP 2001; 2:15-9. [PMID: 11286151 DOI: 10.1016/s1567-5688(00)00005-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The efficacy of statins in lowering the total and low-density lipoprotein cholesterol and reducing the risk of cardiac events is now well established. The secondary prevention studies started treatment several months after the acute event. However, the greatest risk of recurrence is shortly after the index event. Recent evidence from small-scale clinical trials shows that standard doses of statins can be both safe and effective when given early after an acute coronary event, including early after thrombolytic therapy for myocardial infarction. Angiographic studies have shown beneficial effects of pravastatin on coronary stenosis when initiated after a coronary event. While none of these studies have been powered to demonstrate an effect on outcome, each has shown a reduction in major cardiovascular events. Two large observational studies have shown a reduction in 6- and 12-month risk-adjusted mortality among post-MI patients treated early with statins. Large-scale trials of all statins are now in progress to evaluate further the efficacy of early initiation of statin therapy in acute coronary syndromes. The largest of these is the Australian Pravastatin Acute Coronary Treatment (PACT) study, which will compare early outcomes in patients treated with pravastatin versus placebo prescribed within the first 24 h of an acute coronary event.
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Affiliation(s)
- P L Thompson
- Departments of Medicine and Public Health, University of Western Australia, Department of Cardiovascular Medicine, Sir Charles Gairdner Hospital, 4th Floor, G Block, Nedlands, Perth, WA 6009, Australia.
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36
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Sotiriou CG, Cheng JW. Beneficial effects of statins in coronary artery disease--beyond lowering cholesterol. Ann Pharmacother 2000; 34:1432-9. [PMID: 11144702 DOI: 10.1345/aph.10124] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To review the benefits of statins in coronary artery disease management beyond their cholesterol-lowering effects. DATA SOURCES A MEDLINE search (1966-May 2000) was conducted using the following terms: lovastatin, pravastatin, simvastatin, atorvastatin, fluvastatin, cerivastatin, endothelium, plaque stabilization, antithrombotic effects. STUDY SELECTION English-language human studies and case reports. DATA EXTRACTION Studies published demonstrating other mechanisms of statins' clinical beneficial effects were evaluated and reviewed. DATA SYNTHESIS The understanding of the pharmacologic effects of statins has led to the realization that the benefits of these agents extend beyond simply lowering cholesterol. These properties include beneficial effects on vessel endothelial tissue; decreased low-density lipoprotein oxidation and inflammation; ability to stabilize atherosclerotic plaques and perhaps promote regression; proliferative effects on smooth-muscle growths, possibly strengthening atherosclerotic plaques; antithrombotic effects by inhibiting platelet aggregation and stimulation of fibrinolytic factors; and improvement of blood viscosity and flow. With these actions, statins may benefit the situation of long-term atherosclerotic plaque formation and the setting of acute coronary syndrome. CONCLUSIONS Further large-scale studies are needed to determine the clinical importance and validity of these postulated beneficial effects of statins.
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Affiliation(s)
- C G Sotiriou
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY 11201-5372, USA
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