IMproving the imPlemEntation of cuRrent guidelines for the mAnagement of major coronary hearT disease rIsk factors by multifactorial interVEntion. The IMPERATIVE renal analysis

The Role of Uric Acid in the Acute Myocardial Infarction: A Narrative Review

Increased serum uric acid (SUA) levels have been associated with various pathologic processes such as increased oxidative stress, inflammation, and endothelial dysfunction. Thus, it is not surprising that increased SUA is associated with various adverse outcomes including cardiovascular (CV) diseases. Recent epidemiological evidence suggests that increased SUA may be related to acute myocardial infarction (AMI). Accumulating data also showed that elevated UA has pathophysiological role in the development of AMI. However, there are also studies showing that SUA is not related to the risk of AMI. In this narrative review, we summarized the recent literature data regarding SUA and AMI after providing some background information for the association between UA and coronary artery disease. Future studies will show whether decreasing SUA levels is beneficial for outcomes related to AMI and the optimum SUA levels for best outcomes in CV diseases.

Impact of statin on long-term outcome among patients with end-stage renal disease with acute myocardial infarction (AMI): a nationwide case-control study

BACKGROUND

Use of statin has been associated with reduced risk of cardiovascular diseases events and mortality. However, in patients with end-stage renal disease (ESRD), the protective effects of statin are controversial. To evaluate the impact of chronic statin use on clinical outcomes of patients with acute myocardial infarction (AMI) with ESRD.

METHODS

We enrolled 8056 patients with ESRD who were initially diagnosed and admitted for first AMI from Taiwan's National Health Insurance Research Database. Of which, 2134 patients underwent statin therapy. We randomly selected and use age, sex, hypertension, diabetes mellitus (DM), peripheral vascular diseases (PVD), heart failure (HF), cerebrovascular accidents (CVA), chronic obstructive pulmonary disease, matched with the study group as controls (non-stain user). We compared the effects of statin use in term of all-cause death among patients with AMI with ESRD.

RESULTS

Statin use resulted in a significantly higher survival rate in patients ith AMI with ESRD compared with non-statin users. After adjusted the comorbidities the male patients and patients with DM, PVD, HF and CVA had lower long-term survival rate (all p<0.001). Patients who underwent percutaneous coronary intervention (p<0.001), ACE inhibitors/angiotensin II receptor blockers (p<0.001), β receptor blockers (p<0.001) and statin therapy (p=0.007) had better long-term survival rate. Patients with AMI with ESRD on statin therapy exhibited a significantly lower risk of mortality compared with non-statin users (p<0.0001).

CONCLUSION

Among patients with ESRD with AMI, statin therapy was associated with reduced all-cause mortality.

Treatment options for dyslipidemia in chronic kidney disease and for protection from contrast-induced nephropathy

Chronic kidney disease (CKD) is highly prevalent worldwide and represents a major cardiovascular risk factor. Dyslipidemia is present in most patients with CKD and further worsens CKD, creating a vicious cycle. The treatment of CKD-related dyslipidemia has been a controversial topic. The use of statins is recommended in all stages of CKD, but it appears to reduce cardiovascular and renal events only in the early CKD stages, up to stage 3. The use of atorvastatin has proven very beneficial; thus, the earliest we start statin treatment, the better for the patient. Atorvastatin and pitavastatin do not need dose adjustments at any level of renal function. Fibrates can be administered in mixed hyperlipidemia, combined with statins in early CKD stages. Omega-3 fatty acids are useful for treating hypertriglyceridemia in CKD. Antibodies against proprotein convertase subtilisin/kexin type 9 hold promise for a better control of dyslipidemia and a greater reduction of cardiovascular risk.

Statins can improve proteinuria and glomerular filtration rate loss in chronic kidney disease patients, further reducing cardiovascular risk. Fact or fiction?

INTRODUCTION

The prevalence of chronic kidney disease (CKD), a risk factor for cardiovascular disease (CVD), is increasing worldwide. Statin treatment, the cornerstone of prevention or treatment of CVD, might have beneficial effects on urine protein excretion and renal function as determined by the glomerular filtration rate, whereas it might protect from acute kidney injury (AKI), mainly due to contrast-induced AKI. These beneficial effects on CKD may not be drug class effects; specific statins at specific doses may help prevent CKD deterioration and reduce CVD risk. We analysed all statin studies that had renal and CVD endpoints as main outcome measures. MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched up to February 2015.

AREAS COVERED

We consider the effects of statins on microalbuminuria, proteinuria, glomerular filtration rate, AKI associated with angiography or percutaneous coronary intervention and on CVD event rates in patients with CKD.

EXPERT OPINION

Current evidence points towards the need to prescribe high-potency statins in patients with CKD, before a major decline in kidney function occurs. This may reduce CVD risk and delay the progress of CKD. Administration of either atorvastatin or rosuvastatin can prevent contrast-induced AKI before angiography or percutaneous coronary intervention. The combination of simvastatin + ezetimibe may decrease vascular events in patients with advanced CKD.

Iron metabolism in hemodialyzed patients - a story half told?

INTRODUCTION

All living organisms have evolved sophisticated mechanisms to maintain appropriate iron levels in their cells and within their body. Recently our understanding of iron metabolism has dramatically increased. Overt labile plasma iron (LPI) represents a component of non-transferrin bound iron (NTBI) that is both redox active and chelatable, capable of permeating into organs and inducing tissue iron overload. The LPI measures the iron-specific capacity of a given sample to produce reactive oxygen species. We studied for the first time NTBI correlations with markers of iron status and inflammation in prevalent hemodialyzed patients.

MATERIAL AND METHODS

Complete blood count, urea, serum lipids, fasting glucose, creatinine, ferritin, serum iron, total iron binding capacity (TIBC) were studied by standard laboratory method. The NTBI was assessed commercially available kits from Aferrix Ltd in Tel Aviv, Israel. A test result of 0.6 units of LPI or more indicates a potential for iron-mediated production of reactive oxygen species in the sample.

RESULTS

Patients with LPI units ≥ 0.6 had higher serum iron, erythropoiesis stimulating agents (ESA) dose, ferritin, high-sensitivity C-reactive protein (hsCRP), hepcidin and lower hemojuvelin. In hemodialyzed patients NTBI correlated with hsCRP (r = 0.37, p < 0.01), ferritin (r = 0.41, p < 0.001), IL-6 (r = 0.43, p < 0.001). In multivariate analysis predictors of NTBI were hemoglobin and alkaline phosphatase, explaining 58% of the variability.

CONCLUSIONS

Elevated NTBI in HD may be due to disturbed iron metabolism. Anemia and liver function might also contribute to the presence of NTBI in this population.

Undertreatment of dyslipidemia: from the Arabian Gulf to the USA. Time to solve this problem!

Undertreatment of dyslipideamia is a universal problem and reduces the efficasy of hypolipidaemic drugs to reduce cardiovascular event rates. The means to face this problem are available and should be utilized to optimize dyslipidaemia control and clinical outcomes.

Achieving lipid targets in primary care settings

Achieving low-density lipoprotein cholesterol (LDL-C) goals in clinical practice is still unsatisfactory. Furthermore, a significant residual risk remains, even after reaching LDL-C targets, in terms of both fasting and postprandial triglycerides, high-density lipoprotein cholesterol (quantity and quality) and small dense LDL particles. Statins are the first choice for treating lipid abnormalities. Other lipid-lowering agents can be administered when statins are not tolerated and if LDL-C targets are not reached. Furthermore, multifactorial treatment, including a statin, exerts several beneficial effects on cardiovascular and residual risk reduction. The role of novel developing lipid therapies in clinical practice remains to be established.

Dietary and nutraceutical approach to type 2 diabetes

Nutritional medical treatment is the first step to achieve adequate glycemic control and prevent diabetic complications. Lifestyle changes include moderate weight loss (7%) and regular physical activity (150 min/week). The appropriate diet composition is < 30% total fat, < 10% saturated fats, > 15 g/1000 kcal fiber, half soluble, 45-60% of carbohydrates with amoderate intake of sugar (50 g/day) and protein intake of 15-20% of the total calories a day. Patients need to limit the intake of saturated fats to < 7% of the daily calorie intake. Monounsaturated fatty acids such as olive oil and other vegetable oils are recommended. L-carnitine, α-lipoic acid, berberine and ω-3 fatty acids can be useful supplements.

Lipid, blood pressure and kidney update 2013

The year 2013 proved to be very exciting as far as landmark trials and new guidelines in the field of lipid disorders, blood pressure and kidney diseases. Among these are the International Atherosclerosis Society Global Recommendations for the Management of Dyslipidemia, European Society of Cardiology (ESC)/European Society of Hypertension Guidelines for the Management of Arterial Hypertension, American Diabetes Association Clinical Practice Recommendations, the Kidney Disease: Improving Global Outcomes Clinical Practice Guidelines for Managing Dyslipidemias in Chronic Kidney Disease (CKD) Patients, the American College of Cardiology/American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, the Joint National Committee Expert Panel (JNC 8) Evidence-Based Guideline for the Management of High Blood Pressure in Adults, the American Society of Hypertension/International Society of Hypertension Clinical Practice Guidelines for the Management of Hypertension in the Community, the American College of Physicians Clinical Practice Guideline on Screening, Monitoring, and Treatment of Stage 1-3 CKD and many important trials presented among others during the ESC Annual Congress in Amsterdam and the American Society of Nephrology Annual Meeting--Kidney Week in Atlanta, GA. The paper is an attempt to summarize the most important events and reports in the mentioned areas in the passing year.

Exercise capacity as an independent risk factor for adverse cardiovascular outcomes among nondiabetic and diabetic patients

INTRODUCTION

To investigate if decreased exercise capacity is an independent risk factor for major adverse cardiovascular events (MACE) in diabetics and nondiabetics.

MATERIAL AND METHODS

The association of decreased exercise capacity (EC) during a treadmill exercise sestamibi stress test with MACE was investigated in 490 nondiabetics and 404 diabetics. Mean follow-up was 53 months.

RESULTS

Nondiabetics with a predicted EC < 85% had a higher prevalence of myocardial ischemia (34% vs. 19%, p = 0.0002), 2- or 3-vessel obstructive coronary artery disease (CAD) (31% vs. 13%, p = 0.016), myocardial infarction (MI) (17% vs. 7%, p = 0.0005), stroke (8% vs. 2%, p = 0.002), death (11% vs. 3%, p = 0.0002), and MI or stroke or death at follow-up (32% vs. 11%, p < 0.001) compared to nondiabetics with a predicted EC ≥ 85%. Diabetics with a predicted EC < 85% had a higher prevalence of myocardial ischemia (48% vs. 32%, p = 0.0009), 2- or 3-vessel obstructive CAD (54% vs. 28%, p = 0.001), MI (32% vs. 14%, p < 0.001), stroke (22% vs. 6%, p < 0.001), death (17% vs. 9%, p = 0.031), and MI or stroke or death at follow-up (65% vs. 27%, p < 0.001). Stepwise Cox regression analysis showed decreased EC was an independent and significant risk factor for MACE among nondiabetics (hazard ratio 3.3, p < 0.0001) and diabetics (hazard ratio 2.7, p < 0.0001).

CONCLUSIONS

Diabetics and nondiabetics with decreased EC were at increased risk for MACE with nondiabetics and decreased EC at similar risk as diabetics with normal EC.

Treatment of non-ST-elevation myocardial infarction and ST-elevation myocardial infarction in patients with chronic kidney disease

Renal dysfunction is frequent in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Chronic kidney disease (CKD) is associated with very poor prognosis and is an independent predictor of early and late mortality and major bleeding in patients with NSTE-ACS. Patients with NSTE-ACS and CKD are still rarely treated according to guidelines. Medical registers reveal that patients with CKD are usually treated with too high doses of antithrombotics, especially anticoagulants and inhibitors of platelet glycoprotein (GP) IIb/IIIa receptors, and therefore they are more prone to bleeding. Drugs which are excreted mainly or exclusively by the kidney should be administered in a reduced dose or discontinued in patients with CKD. These drugs include enoxaparin, fondaparinux, bivalirudin, and small molecule inhibitors of GP IIb/IIIa inhibitors. In long-term treatment of patients after myocardial infarction, anti-platelet therapy, lipid-lowering therapy and β-blockers are used. Chronic kidney disease patients before qualification for coronary interventions should be carefully selected in order to avoid their use in the group of patients who could not benefit from such procedures. This paper presents schemes of non-ST and ST-segment elevation myocardial infarction treatment in CKD patients in accordance with the current recommendations of the European Society of Cardiology (ESC).

Cardiovascular mortality in Hispanics compared to non-Hispanic whites: a systematic review and meta-analysis of the Hispanic paradox

BACKGROUND

Hispanics, the largest minority in the U.S., have a higher prevalence of several cardiovascular (CV) risk factors than non-Hispanic whites (NHW). However, some studies have shown a paradoxical lower rate of CV events among Hispanics than NHW.

OBJECTIVE

To perform a systematic review and a meta-analysis of cohort studies comparing CV mortality and all-cause mortality between Hispanic and NHW populations in the U.S.

METHODS

We searched EMBASE, MEDLINE, Web of Science, and Scopus databases from 1950 through May 2013, using terms related to Hispanic ethnicity, CV diseases and cohort studies. We pooled risk estimates using the least and most adjusted models of each publication.

RESULTS

We found 341 publications of which 17 fulfilled the inclusion criteria; data represent 22,340,554 Hispanics and 88,824,618 NHW, collected from 1950 to 2009. Twelve of the studies stratified the analysis by gender, and one study stratified people by place of birth (e.g. U.S.-born, Mexican-born, and Central/South American-born). There was a statistically significant association between Hispanic ethnicity and lower CV mortality (OR 0.67; 95% CI, 0.57-0.78; p<0.001), and lower all-cause mortality (0.72; 95% CI, 0.63-0.82; p<0.001). A subanalysis including only studies that reported prevalence of CV risk factors found similar results. OR for CV mortality among Hispanics was 0.49; 95% CI 0.30-0.80; p-value <0.01; and OR for all-cause mortality was 0.66; 95% CI 0.43-1.02; p-value 0.06.

CONCLUSION

These results confirm the existence of a Hispanic paradox regarding CV mortality. Further studies are needed to identify the mechanisms mediating this protective CV effect in Hispanics.

J-shaped association between plasma glucose concentration and cardiovascular disease mortality over a follow-up of 32years

OBJECTIVE

We aimed at examining the association between plasma glucose (PG) concentration and cardiovascular mortality in a population sample from Switzerland over a follow-up time of 32 years.

METHODS

We analyzed 7984 men and women enrolled in the first National Research Program (NRP1A, 1977-1979) and followed up for survival until 2008. Mortality hazard ratios (HR) were calculated using adjusted Cox regression models. PG was measured in fasting state or randomly with known fasting time. Models were adjusted for age, sex, socio-demographic, lifestyle and cardiovascular risk factors.

RESULTS

PG concentrations ≥ 6.1 mmol/L were associated with increased risk of cardiovascular disease (CVD) and all-cause mortality. Compared to normal PG (3.8-4.9 mmol/L) the adjusted HR (95% CI) for CVD mortality was 1.26 (1.01-1.58) for PG ≥ 6.1-6.9 mmol/L, 1.56 (1.18-2.06) for PG ≥ 7 mmol/L, 1.67 (1.22-2.30) for known diabetes. All-cause mortality essentially showed the same patterns. All-cause mortality was increased [1.35 (1.01-1.80)] also for PG <3.8 mmol/L.

CONCLUSION

Plasma glucose remained significantly and independently associated with CVD mortality even after full follow-up. The relationship was J-shaped. In order to prevent premature death, persons with abnormal PG concentrations on both extremes should be screened and counseled for other CVD risk factors.

Effect of tobacco smoking and smoking cessation on plasma lipoproteins and associated major cardiovascular risk factors: a narrative review

Cigarette smoking, active or passive, kills about 6 million people each year worldwide. Cardiovascular disease (CVD) is responsible for 40% of all smoking-related deaths, lung cancer accounts for 20% of all smoking-related deaths, and chronic obstructive pulmonary disease is related to another 20% of deaths. In this narrative review we consider the relationship between cigarette smoking and CVD. We discuss disease states and/or CVD risk factors related to smoking, such as dyslipidaemia, vascular inflammation, endothelial dysfunction, arterial stiffness, insulin resistance, type 2 diabetes mellitus (T2DM), chronic kidney disease (CKD), and non-alcoholic fatty liver disease (NAFLD) as well as their complex interrelations. Smoking cessation can correct abnormalities related to smoking; however, success rates are relatively low. In cases of inability to quit, measures to minimize the adverse effects of smoking specifically related to CVD should be taken. Smokers should receive best practice treatment, according to guidelines, as for non-smokers.

Association between metabolic syndrome and chronic kidney disease in perimenopausal women

The purpose of the study was to explore the association between metabolic syndrome (MetS) and chronic kidney disease (CKD) in perimenopausal women. A cross-sectional study was conducted in Zhuhai from June to October 2012. Perimenopausal women (n = 685) were included in the study. All participants were divided into three subgroups: Group 1, 40 years old ≤ Age < 50 years old; Group 2, 50 years old ≤ Age < 60 years old; Group 3, 60 years old ≤ Age ≤ 65 years old. MetS was associated with CKD (p < 0.01) in the unadjusted analyses in total subjects. After adjusting the potential confounders, the odd ratios of CKD for MetS was 2.66 (95% CI 1.56 to 4.49, p < 0.001). There was no relationship between MetS and CKD in both Group 1 and Group 3. MetS was associated with CKD (p < 0.001) in the unadjusted analyses in Group 2. After adjusting for potential confounders, MetS was significantly associated with CKD. The odd ratios for MetS was 6.79 (95% CI 2.30 to 20.09, p < 0.001). There was no relationship between elevated blood pressure, elevated fasting glucose, abdominal obesity, Low HDL cholesterol, elevated triglycerides and CKD in both Group 1 and Group 3. Elevated blood pressure was associated with CKD in Group 2 (unadjusted Odds ratio: 4.52 (1.28-16.02), p = 0.02). After adjusting for potential confounders, there was no relationship between elevated blood pressure and CKD (p = 0.78). Elevated fasting glucose was associated with CKD in Group 2 (unadjusted Odds ratio: 3.69 (1.10-12.38), p = 0.03). After adjusting for potential confounders, there was no relationship between elevated fasting glucose and CKD (p = 0.15). There was no relationship between abdominal obesity, Low HDL cholesterol, elevated triglycerides and CKD in Group 2. These findings suggest that in perimenopausal women aged from 50 or older to 60 MetS was associated with CKD. There is no relationship between MetS and CKD in perimenopausal women aged from 40 or older to 50 and aged from 60 or older to 65.

A meta-analysis of the role of statins on renal outcomes in patients with chronic kidney disease. Is the duration of therapy important?

INTRODUCTION

The efficacy of statin treatment in chronic kidney disease (CKD) patients remains controversial. Therefore, we performed a meta-analysis to investigate whether statins modulate renal function in patients with CKD.

METHODS

Data from Scopus, PubMed, Web of Science, and the Cochrane Central Register of randomized controlled trials for years 1966-December 2012 were searched for appropriate studies.

RESULTS

Twenty trials with 6452 CKD subjects randomized to receive either statin or placebo were included. Statin therapy significantly influenced high sensitivity C-reactive protein levels in patients on or off dialysis [-0.28 mg/dl, 95%CI: -0.93 to -0.37; p<0.05 and -0.46 mg/dl, 95%CI: -0.87 to -0.05; p=0.03], respectively], urinary protein (-0.77 g/24 h, 95%CI: -1.24 to -0.29, p<0.02; this effect persisted for treatment ≤12 months), and serum creatinine but only for long-term therapy (3 years) (-0.65 mg/dl, 95%CI: -1.00 to -0.30; p=0.0003). The summary for standardized effect size of mean differences of glomerular filtration rate was 0.29 ml/min/1.73 m(2) (95%CI: 0.01 to 0.58; p=0.04), and depended on treatment duration - a significant increase was observed for between 1 and 3 years of statin therapy (0.50 ml/min/1.73 m(2), 95%CI: 0.40 to 0.60; p<0.0001), with no significant increase for both ≤1 and >3 years of the therapy.

CONCLUSION

Statins might exert significant renoprotective effects in CKD patients; however, benefit may depend on the duration of treatment. This is an issue that warrants more definitive investigation. More studies are necessary in dialysis patients to credibly evaluate the renal effects of statin therapy.

A 50-year follow-up of the Seven Countries Study: Prevalence of cardiovascular risk factors, food and nutrient intakes among Cretans

OBJECTIVE

To identify the cardiovascular disease (CVD) risk-factor status and dietary habits of the surviving elderly participants of the initial Seven Countries Study (SCS) cohort and newly recruited middle-aged men from the same villages.

DESIGN

Our total cohort of remaining survivors of the SCS consisted of 27 men aged 90 years old and over, while a younger cross-sectional study of 85 men between 53 and 73 years of age of the same catchment area were also examined. Biochemical, anthropometric, dietetic and lifestyle CVD risk factors information was obtained.

RESULTS

It was found that being overweight and having systolic blood pressure higher than the recommended were highly prevalent (>75%) among both age groups as well as abdominal obesity (about 50%). Hypercholesterolemia was highly prevalent in the younger population (68.8%), while smoking rates were relatively low among elderly. The daily meat consumption of SCS participants had doubled, from 35g in the 1960s to 76g among the SCS survivors in 2010 (p=0.002), while daily fruit and vegetable consumption had dropped from 656g to 266g (p<0.001). The younger participants also had increased dietary meat (130g/day) (p<0.001) and decreased fruits-vegetables intake (412g/day) (p<0.001) compared to 50 years ago. However, the younger population and elderly subjects showed higher fish intake (91g/day and 38g/day respectively, p<0.001) compared to 1960 and favorable olive oil consumption. In regard to nutrient intake, the majority of the subjects did not meet the recommendations for CVD prevention.

CONCLUSIONS

The study population is at increased risk for the development of CVD, while current dietary habits of the SCS survivors partially differed from those of 50 years ago.

Statins and cardiovascular outcomes in elderly and younger patients with coronary artery disease: a post hoc analysis of the GREACE study

INTRODUCTION

The effect of cardiovascular disease (CVD) prevention measures aimed at elderly patients requires further evidence. We investigated the effect of statin treatment (targeted to achieve guideline goals) on CVD outcomes in different age groups to determine whether statins are more beneficial in the elderly.

MATERIAL AND METHODS

The primary endpoint of this post hoc analysis of the GREek Atorvastatin and Coronary-heart-disease Evaluation (GREACE) study (n = 1,600 patients with established coronary heart disease (CHD), mean follow-up 3 years) was the absolute and relative CVD event (a composite of death, myocardial infarction, revascularization, unstable angina, heart failure and stroke) risk reduction in age quartiles (each n = 200). Patients on "structured care" with atorvastatin (n = 800) followed up by the university clinic and treated to lipid goal were compared with the corresponding quartiles on "usual care" (n = 800) followed up by specialists or general practitioners of the patient's choice outside the hospital.

RESULTS

In the elderly (mean age 69 ±4 and 70 ±3 years in the "structured" and "usual care", respectively) the absolute CVD event reduction between "structured" and "usual care" was 16.5% (p < 0.0001), while in the younger patients (mean age 51 ±3 years and 52 ±3 years in the "structured" and "usual care", respectively) this was 8.5% (p = 0.016); relative risk reduction (RRR) 60% (p < 0.0001) vs. 42% respectively (p = 0.001). The elderly had higher rates of chronic kidney disease and higher uric acid levels, plus an increased prevalence of diabetes, metabolic syndrome and non-alcoholic fatty liver disease. These factors might contribute to the increased CVD risk in older patients.

CONCLUSIONS

All age groups benefited from statin treatment, but the elderly on "structured care" had a greater absolute and relative CVD risk reduction than the younger patients when compared with the corresponding patients assigned to "usual care". These findings suggest that we should not deprive older patients of CVD prevention treatment and lipid target achievement.

The knowledge and awareness of hypertension among patients with hypertension in central Poland: a pilot registry

We assessed the differences in the knowledge and level of awareness of hypertension among patients with hypertension from Central Poland; 248 (57.6% females) patients diagnosed with hypertension completed a questionnaire. Most (79%) of the patients were unaware of the optimal blood pressure (BP) range. The elderly patients did not know the symptoms of hypertension (23.7%), were not willing to make lifestyle changes (57%-65%), and had a poor awareness of hypertension therapy in the absence of symptoms (28.7%). Poor BP control occurred mainly in rural residents (10.7%) and in people with higher education (39.3%). Untreated patients with hypertension did not know the symptoms of hypertension (29.2%), rarely measured BP (37.5%), but were more likely to engage in regular physical activity (70.8%). Efforts should be made to improve knowledge of hypertension, especially among the rural population, the elderly patients, those with a low-education level, and in young males who had the highest BP.

Effects of statins on lipid profile in chronic kidney disease patients: a meta-analysis of randomized controlled trials

OBJECTIVE

The available data on statin effects in chronic kidney disease (CKD) patients are still conflicting. We investigated the impact of short- and long-term statin therapy on lipid profiles in CKD patients requiring or not requiring dialysis.

RESEARCH DESIGN AND METHODS

Data from Scopus, PubMed, Web of Science, and the Cochrane Library from 1966 to May 2012 were searched for studies that investigated this effect. We included all randomized controlled clinical trials that investigated the impact of statin therapy on lipids and lipoproteins.

RESULTS

The final analysis included 16 trials with 3594 subjects. In CKD patients, statin therapy significantly reduced total cholesterol (TC), triglycerides (TG) and low-density lipoprotein cholesterol (LDL-C) (p < 0.003 for all comparisons), and the effect insignificantly intensified with duration of statin therapy (56.3 vs 66.8, 22.5 vs 24.1, and 53 vs 56.1 mg/dl, respectively). Comparing statin therapy for ≤ 3 and >3 months in CKD patients on dialysis, the magnitude of TC and LDL-C decreased (26.3 vs 25.9, and 42.2 vs 29.8 mg/dl, respectively, p > 0.05 for both), while TG increased modestly (4.5 vs 13.4 mg/dl). Short-term statin therapy increased high density lipoprotein cholesterol by a mean 0.7 mg/dl (p = 0.04), and long-term therapy was associated with a mean reduction of 2.4 mg/dL.

CONCLUSIONS

Statin therapy significantly modifies the lipid profile in CKD patients not on dialysis therapy (with the trend to be more effective with longer therapy), and have less beneficial effect in patients on dialysis with the trend to be less effective with longer duration of therapy.

The effect of combining rosuvastatin with sartans of different peroxisome proliferator receptor-γ activating capacity on plasma 8-isoprostane prostaglandin F2a levels

INTRODUCTION

Oxidative stress is associated with the development and progression of cardiovascular disease. Plasma 8-isoprostane prostaglandin F2a (8-iso-PGF2a) levels are a reliable marker of oxidative stress.

MATERIAL AND METHODS

Patients (n = 151) with hypertension, dyslipidemia and impaired fasting glucose were randomly allocated to rosuvastatin (10 mg/day) plus telmisartan 80 mg/day (RT group, n = 52) or irbesartan 300 mg/day (RI group, n = 48) or olmesartan 20 mg/day (RO group, n = 51). After 6 months of treatment, changes in plasma 8-iso-PGF2a levels were blindly evaluated.

RESULTS

A decrease of 8-iso-PGF2a levels vs baseline was observed only in the RT group (-8.6%; p = 0.02). A trend for decrease vs. baseline was observed in the RI (-5.7%; p = 0.40) and RO (-3.7%; p = 0.60) groups. Changes of 8-iso-PGF2a levels between groups were not significantly different (p = 0.70).

CONCLUSIONS

The combination of rosuvastatin with sartans of different peroxisome proliferator receptor-γ activating capacity was associated with a decrease in levels of plasma 8-iso-PGF2a. This decrease reached significance only in the telmisartan group.

The role of psychobiological and neuroendocrine mechanisms in appetite regulation and obesity

Obesity is a multifactorial disease. Among its causes are physical inactivity and overeating. In addition, other factors may play an important role in the development of overweight/obesity. For example, certain hormones including leptin, insulin and ghrelin, may influence appetite and consequently body weight. Obesity frequently co-exists with metabolic disorders including dyslipidemia, hypertension and insulin resistance, thus constituting the metabolic syndrome which is characterized by increased cardiovascular risk. Lack of comprehensive knowledge on obesity-related issues makes both prevention and treatment difficult. This review considers the psychobiological and neuroendocrine mechanisms of appetite and food intake. Whether these factors, in terms of obesity prevention and treatment, will prove to be relevant in clinical practice (including reducing the cardiovas-cular risk associated with obesity) remains to be established.

Prevention of sudden cardiac death in patients with chronic kidney disease

Cardiovascular deaths account for about 40% of all deaths of patients with chronic kidney disease (CKD), particularly those on dialysis, while sudden cardiac death (SCD) might be responsible for as many as 60% of SCD in patients undergoing dialysis. Studies have demonstrated a number of factors occurring in hemodialysis (HD) that could lead to cardiac arrhythmias. Patients with CKD undergoing HD are at high risk of ventricular arrhythmia and SCD since changes associated with renal failure and hemodialysis-related disorders overlap. Antiarrhythmic therapy is much more difficult in patients with CKD, but the general principles are similar to those in patients with normal renal function - at first, the cause of arrhythmias should be found and eliminated. Also the choice of therapy is narrowed due to the altered pharmacokinetics of many drugs resulting from renal failure, neurotoxicity of certain drugs and their complex interactions. Cardiac pacing in elderly patients is a common method of treatment. Assessment of patients’ prognosis is important when deciding whether to implant complex devices. There are reports concerning greater risk of surgical complications, which depends also on the extent of the surgical site. The decision concerning implantation of a pacing system in patients with CKD should be made on the basis of individual assessment of the patient.

Blood pressure j-curve: current concepts

The blood pressure (BP) J-curve debate started in 1979, and we still cannot definitively answer all the questions. However, available studies of antihypertensive treatment provide strong evidence for J-shaped relationships between both diastolic and systolic BP and main outcomes in the general population of hypertensive patients, as well as in high-risk populations, including subjects with coronary artery disease, diabetes mellitus, left ventricular hypertrophy, and elderly patients. However, further studies are still necessary in order to clarify this issue. This is connected to the fact that most available studies were observational, and randomized trials did not have or lost their statistical power and were inconclusive. Perhaps only the Systolic Blood Pressure Intervention Trial (SPRINT) and Optimal Blood Pressure and Cholesterol Targets for Preventing Recurrent Stroke in Hypertensives (ESH-CHL-SHOT) will be able to finally answer all the questions. According to the current state of knowledge, it seems reasonable to suggest lowering BP to values within the 130-139/80-85 mmHg range, possibly close to the lower values in this range, in all hypertensive patients and to be very careful with further BP level reductions, especially in high-risk hypertensive patients.

Patient with hypertriglyceridemia, type 2 diabetes, and chronic kidney disease treated with atorvastatin and omega-3 Fatty Acid ethyl esters

This is a case report that describes a 67-year-old woman with mixed hyperlipidemia and diabetic nephropathy. She was initially prescribed a combination of simvastatin plus gemfibrozil by her general practitioner (GP). When referred to our cardiovascular unit, we further diagnosed the patient to have mixed hyperlipidemia and rhabdomyolysis. Because of concerns with her chronic kidney disease (CKD), we temporarily stopped all her drug treatments and started insulin treatment for her type 2 diabetes (T2D). A month later when her T2D was stabilised, we prescribed atorvastatin and an omega-3 fatty acid ethyl ester supplement to treat her hypertriglyceridemia. Within two months her blood lipids were within the recommended range. In patients with stage 3–5 CKD, it is not advisable to prescribe the fibrate gemfibrozil, particularly in combination with a statin that is metabolised predominantly in the kidneys. To minimise adverse events without compromise on efficacy, we used a combination of omega-3 fatty acid ethyl esters, which are not metabolised in the kidneys, with a statin that is minimally metabolised in the kidneys for the treatment of her hyperlipidemia.

Renalase, hypertension, and kidney - the discussion continues

Hypertension and cardiovascular complications are very common in chronic kidney disease (CKD). Overactivation of sympathetic nervous system is also widely recognized in CKD. Renalase may play an important role in the control of blood pressure (BP) by its regulatory function of catecholamine metabolism. Renalase could be synthesized not only by the kidney but also by cardiomyocytes, liver, and adipose tissue. It probably exerts a hypotensive action, at least in animal models. Whether it metabolizes catecholamines remains to be proved. Another issue that remains to be resolved is the relationship between renalase and renal natriuresis and phosphaturia. In this review, the updated experimental and clinical data on renalase are presented and possible interactions with the endothelium are discussed. Renalase is "a new postulated therapeutic target." Proof of concept studies are needed to define the pathophysiological link between the kidney, sympathetic tone, BP, and cardiovascular complications.

Predictive Factors for Coronary Artery Disease among Peritoneal Dialysis Patients without Diabetic Nephropathy

OBJECTIVES

Scientific literature indicates that the risk of coronary heart disease morbidity and death among peritoneal dialysis patients exceeds risk observed in non-renal patients. The aims of this study were to establish the independent predictors associated with increased risk of coronary heart disease in peritoneal dialysis patients without diabetic nephropathy.

MATERIALS AND METHODS

A number of 116 end-stage renal disease patients without diabetic nephropathy undergoing peritoneal dialysis were evaluated for coronary heart disease and predictive risk factors were investigated and identified. Also intima-media thickness measurements, as an early sign of atherosclerosis, were analyzed in a subset of patients in correlation with a number of traditional and non-traditional cardiovascular risk factors.

RESULTS

The study sample was found to be characterized by a high prevalence of traditional risk factors: hypertension (95.7%), dyslipidemia (93.1%) and metabolic syndrome (58.6%), but also of dialysis-related risk factors: inflammation (82.8%) and anemia (55.2%). Independent variables found to be associated in regression analysis with coronary heart disease were: age, smoking status, nephroangiosclerosis, albumin, C-reactive protein and iPTH levels. Intima-media thickness was significantly higher in patients with coronary heart disease, values greater than 0.89 mm being associated with increased risks for coronary heart disease, acute coronary syndrome and cardiovascular death.

CONCLUSIONS

The prevalence of traditional cardiovascular risk factors in these peritoneal dialysis patients is extremely high, but there are also some other factors involved, especially malnutrition and inflammation. Age higher than 55 years, smoking, albumin less than 3.5 g/dl, iPTH less than 150 pg/ml and nephroangiosclerosis were associated with highest odds ratio for coronary heart disease. An increasing CRP levels was associated with an increasing gradient for coronary heart disease risk.