Effects of atorvastatin on arterial stiffness in chronic kidney disease: a randomised controlled trial

HMG CoA reductase inhibitors (statins) for people with chronic kidney disease not requiring dialysis

BACKGROUND

Cardiovascular disease is the most frequent cause of death in people with early stages of chronic kidney disease (CKD), and the absolute risk of cardiovascular events is similar to people with coronary artery disease. This is an update of a review first published in 2009 and updated in 2014, which included 50 studies (45,285 participants).

OBJECTIVES

To evaluate the benefits and harms of statins compared with placebo, no treatment, standard care or another statin in adults with CKD not requiring dialysis.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 4 October 2023. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. An updated search will be undertaken every three months.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of statins with placebo, no treatment, standard care, or other statins, on death, cardiovascular events, kidney function, toxicity, and lipid levels in adults with CKD (estimated glomerular filtration rate (eGFR) 90 to 15 mL/min/1.73 m2) were included.

DATA COLLECTION AND ANALYSIS

Two or more authors independently extracted data and assessed the study risk of bias. Treatment effects were expressed as mean difference (MD) for continuous outcomes and risk ratios (RR) for dichotomous benefits and harms with 95% confidence intervals (CI). The risk of bias was assessed using the Cochrane risk of bias tool, and the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We included 63 studies (50,725 randomised participants); of these, 53 studies (42,752 participants) compared statins with placebo or no treatment. The median duration of follow-up was 12 months (range 2 to 64.8 months), the median dosage of statin was equivalent to 20 mg/day of simvastatin, and participants had a median eGFR of 55 mL/min/1.73 m2. Ten studies (7973 participants) compared two different statin regimens. We were able to meta-analyse 43 studies (41,273 participants). Most studies had limited reporting and hence exhibited unclear risk of bias in most domains. Compared with placebo or standard of care, statins prevent major cardiovascular events (14 studies, 36,156 participants: RR 0.72, 95% CI 0.66 to 0.79; I2 = 39%; high certainty evidence), death (13 studies, 34,978 participants: RR 0.83, 95% CI 0.73 to 0.96; I² = 53%; high certainty evidence), cardiovascular death (8 studies, 19,112 participants: RR 0.77, 95% CI 0.69 to 0.87; I² = 0%; high certainty evidence) and myocardial infarction (10 studies, 9475 participants: RR 0.55, 95% CI 0.42 to 0.73; I² = 0%; moderate certainty evidence). There were too few events to determine if statins made a difference in hospitalisation due to heart failure. Statins probably make little or no difference to stroke (7 studies, 9115 participants: RR 0.64, 95% CI 0.37 to 1.08; I² = 39%; moderate certainty evidence) and kidney failure (3 studies, 6704 participants: RR 0.98, 95% CI 0.91 to 1.05; I² = 0%; moderate certainty evidence) in people with CKD not requiring dialysis. Potential harms from statins were limited by a lack of systematic reporting. Statins compared to placebo may have little or no effect on elevated liver enzymes (7 studies, 7991 participants: RR 0.76, 95% CI 0.39 to 1.50; I² = 0%; low certainty evidence), withdrawal due to adverse events (13 studies, 4219 participants: RR 1.16, 95% CI 0.84 to 1.60; I² = 37%; low certainty evidence), and cancer (2 studies, 5581 participants: RR 1.03, 95% CI 0.82 to 1.30; I² = 0%; low certainty evidence). However, few studies reported rhabdomyolysis or elevated creatinine kinase; hence, we are unable to determine the effect due to very low certainty evidence. Statins reduce the risk of death, major cardiovascular events, and myocardial infarction in people with CKD who did not have cardiovascular disease at baseline (primary prevention). There was insufficient data to determine the benefits and harms of the type of statin therapy.

AUTHORS' CONCLUSIONS

Statins reduce death and major cardiovascular events by about 20% and probably make no difference to stroke or kidney failure in people with CKD not requiring dialysis. However, due to limited reporting, the effect of statins on elevated creatinine kinase or rhabdomyolysis is unclear. Statins have an important role in the primary prevention of cardiovascular events and death in people who have CKD and do not require dialysis. Editorial note: This is a living systematic review. We will search for new evidence every three months and update the review when we identify relevant new evidence. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

The effect of exercise on vascular health in chronic kidney disease: a systematic review and meta-analysis of randomized controlled trials

Patients with chronic kidney disease (CKD) are at increased risk of cardiovascular disease. This increased risk cannot be fully explained by traditional risk factors such as hypertension. Endothelial dysfunction and arterial stiffness have been suggested as factors that explain some of the increased risk and are independently associated with important cardiovascular outcomes in patients with CKD. Studies in other disease populations have shown the positive effects of exercise on vascular dysfunction. The aim of this review was to determine whether exercise training interventions improve measures of vascular function and morphology in patients across the spectrum of CKD and which exercise training interventions are most efficacious. A systematic search of Medline, Embase, and the Cochrane Central Register identified 25 randomized controlled trials. Only randomized control trials using an exercise intervention with a nonexercising control group and at least one measure of vascular function or morphology were included. Participants were patients with nondialysis CKD or transplant patients or those requiring dialysis therapy. A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A meta-analysis was completed for pulse wave velocity, augmentation index, and measures of endothelium-dependent vasodilation. Data from 25 studies with 872 participants showed that exercise training reduced pulse wave velocity and augmentation index but had no effect on endothelium-dependent vasodilation. Subgroup analyses suggested that exercise interventions of at least moderate intensity were more likely to be effective. Limitations included the absence of observational studies or other interventions aimed at increasing habitual physical activity. Further studies are warranted to investigate which are the most effective exercise interventions.NEW & NOTEWORTHY A thorough systematic review and meta-analysis of the effects of exercise training on measures of vascular function in patients with chronic kidney disease, including arterial stiffness and endothelial function, were conducted. Subgroup analyses investigated how differences in exercise training, according to frequency, intensity, type, and timing, have an impact on the efficacy of the intervention.

Vascular Aging: Assessment and Intervention

Vascular aging represents a collection of structural and functional changes in a blood vessel with advancing age, including increased stiffness, vascular wall remodeling, loss of angiogenic ability, and endothelium-dependent vasodilation dysfunction. These age-related alterations may occur earlier in those who are at risk for or have cardiovascular diseases, therefore, are defined as early or premature vascular aging. Vascular aging contributes independently to cardio-cerebral vascular diseases (CCVDs). Thus, early diagnosis and interventions targeting vascular aging are of paramount importance in the delay or prevention of CCVDs. Here, we review the direct assessment of vascular aging by examining parameters that reflect changes in structure, function, or their compliance with age including arterial wall thickness and lumen diameter, endothelium-dependent vasodilation, arterial stiffness as well as indirect assessment through pathological studies of biomarkers including endothelial progenitor cell, lymphocytic telomeres, advanced glycation end-products, and C-reactive protein. Further, we evaluate how different types of interventions including lifestyle mediation, such as caloric restriction and salt intake, and treatments for hypertension, diabetes, and hyperlipidemia affect age-related vascular changes. As a single parameter or intervention targets only a certain vascular physiological change, it is recommended to use multiple parameters to evaluate and design intervention approaches accordingly to prevent systemic vascular aging in clinical practices or population-based studies.

Statin's role on blood pressure levels: Meta-analysis based on randomized controlled trials

Statins have been proven to be effective in minimizing the risk of cardiovascular adverse events, however, their effect on BP variability is debatable with respect to their significance and their use as a potential anti-hypertensive. Using a meta-analysis approach, the aim of this study was to explore whether certain statins have the potential to lower blood pressure (BP). For the period 2002-2022, Scopus, PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials databases were searched for the studies that examined the effect of statins on blood pressure in normotensive or hypertensive individuals. Randomized controlled clinical trials that investigated this effect were included based on our inclusion criteria. Our primary outcomes were changes in systolic and diastolic blood pressure (DBP). The final analysis of the study included 49 RCTs involving 45 173 participants randomized to receive either statins or placebo. Among the two groups, the total weighted mean difference (WMD) for systolic blood pressure (ΔSBP) was -1.42 (95% CI: -2.38, -0.46; p = .004) and diastolic blood pressure (ΔDBP) was 0.82 (95% CI: -1.28, -0.36; p = .0005). Despite various studies suggesting the efficacy of statins in blood pressure lowering to be significant and non-significant both, we observed a decrease in SBP and DBP both, although the change was not as large and could be considered significant. A large multicenter, multi-ethnic, large sample pool size, and a long period follow-up study is still required to assert these claims.

Association of statin therapy with progression of carotid arterial stiffness: the Multi-Ethnic Study of Atherosclerosis (MESA)

Arterial stiffness progresses with age and is a predictor of adverse cardiovascular disease events. Studies examining associations of statin therapy with arterial stiffness have yielded mixed results. Associations between the duration and intensity of statin therapy and arterial stiffness have not been studied in a prospective multiethnic cohort. MESA participants (n = 1242) with statin medication use data at each exam (1-5) and who had undergone B-mode carotid ultrasound at baseline and at Exam 5 after (mean ± [SD]) 9.4 ± 0.5 years were analyzed. Carotid arterial stiffness was measured using the distensibility coefficient (DC) and Young's elastic modulus (YEM). Linear regression models were used to evaluate associations between DC and YEM and statin treatment duration and intensity. At baseline, participants were 66.5 ± 8.1 years old, 41% female, 36% White, 30% African American, 14% Chinese American, and 20% Hispanic. The mean baseline low-density lipoprotein cholesterol (LDL-C) was 149.5 ± 14.5 mg/dL. After adjusting for age, sex, race/ethnicity, and CVD risk factors, the percent changes in DC and YEM were found to not be significantly different in individuals on statin therapy at any combination of visits (1-4) compared to participants never on statin therapy (all p > 0.32). There were also no differences in the percent change in DC and YEM based on statin therapy intensity by quartile (all p > 0.14) over the 10-year follow-up period. Based on the aforementioned results, statin therapy was not associated with changes in carotid artery stiffness over nearly a decade of follow-up regardless of therapy duration or intensity.

Effects of Long-Term Intervention with Losartan, Aspirin and Atorvastatin on Vascular Remodeling in Juvenile Spontaneously Hypertensive Rats

Hypertension in adolescents is associated with adverse cardiac and vascular events. In addition to lowering blood pressure, it is not clear whether pharmacological therapy in early life can improve vascular remodeling. This study aimed to evaluate the effects of long-term administration of losartan, aspirin, and atorvastatin on vascular remodeling in juvenile spontaneously hypertensive rats (SHRs). Losartan, aspirin, and atorvastatin were administered via gavage at doses of 20, 10, and 10 mg/kg/day, respectively, on SHRs aged 6-22 weeks. Paraffin sections of the blood vessels were stained with hematoxylin-eosin (H&E) and Sirius Red to evaluate the changes in the vascular structure and the accumulation of different types of collagen. The plasma levels of renin, angiotensin II (Ang II), aldosterone (ALD), endothelin-1 (ET-1), interleukin-6 (IL-6), and neutrophil elastase (NE) were determined using ELISA kits. After the 16-week treatment with losartan, aspirin, and atorvastatin, the wall thickness of the thoracic aorta and carotid artery decreased. The integrity of the elastic fibers in the tunica media was maintained in an orderly manner, and collagen deposition in the adventitia was retarded. The plasma levels of renin, ALD, ET-1, IL-6, and NE in the SHRs also decreased. These findings suggest that losartan, aspirin, and atorvastatin could improve vascular remodeling beyond their antihypertensive, anti-inflammatory, and lipid-lowering effects. Many aspects of the protection provided by pharmacological therapy are important for the prevention of cardiovascular diseases in adults and older adults.

A systematic review and meta-analyses on the effects of atorvastatin on blood pressure and heart rate

AIMS

Considering the inconsistencies in the literature on the atorvastatin effect on blood pressure (BP), we performed these meta-analyses.

METHODS AND RESULTS

Through a search of the Excerpta Medica Database (EMBASE), PubMed, and Web of Science databases, 1412 articles were identified, from which 33 randomized clinical trials (RCT) and 44 pre-clinical were selected. Populations from RCT were stratified according to baseline BP and lipid levels. We performed meta-analyses of the effect of atorvastatin on systolic (SBP), diastolic and mean BP; heart rate (HR); HR variability, and baroreflex. Atorvastatin reduced SBP in the overall population (P = 0.05 vs. placebo; P = 0.03 vs. baseline), in normotensive and hyperlipidaemic (P = 0.04 vs. placebo; P = 0.0001 vs. baseline) and in hypertensive and hyperlipidaemic (P = 0.02 vs. placebo; P = 0.008 vs. baseline) individuals in parallel RCT, but it did not affect SBP in normotensive and normolipidaemic individuals (P = 0.51 vs. placebo; P = 0.4 vs. baseline). Although an effect of atorvastatin was detected in hyperlipidaemic individuals, the meta-regression coefficient for the association of low density lipoprotein (LDL)-cholesterol reduction with SBP reduction in the overall population demonstrated that SBP reduction is not dependent on the changes in LDL-cholesterol. A meta-analysis of preclinical reports demonstrated that SBP was reduced in atorvastatin-treated hypertensive and normolipidaemic rats (spontaneously hypertensive rats: P < 0.00001), but not in normotensive and normolipidaemic rats (control rats: P = 0.97). Atorvastatin also reduced the HR in spontaneously hypertensive rat.

CONCLUSION

Atorvastatin lowers BP independent of LDL-cholesterol levels. Additional studies are needed to estimate the involvement of the autonomic nervous system in the BP-lowering effect of atorvastatin.

Atorvastatin can delay arterial stiffness progression in hemodialysis patients

Purpose

Arterial stiffness is one of the vascular pathologies in hemodialysis (HD) patients with increased cardiovascular mortality and morbidity. Few approaches have been tested to reduce arterial stiffness in patients with chronic kidney disease (CKD). We aimed to assess effects of atorvastatin on arterial stiffness in hemodialysis patients.

Methods

This research is a double-blinded, placebo-controlled, randomized clinical trial which included 50 patients maintained on regular HD. Patients were allocated to receive 10 mg atorvastatin or placebo for 24 weeks. Aortic pulse wave velocity (PWV) as an index of large artery stiffness and augmentation index (AIx) as an index of wave reflections were assessed at baseline and after 6 months in both groups.

Results

In atorvastatin group at study end, there was no significant difference from baseline findings in aortic PWV (7.86 ± 2.5 vs 7.88 ± 2.6 m/sec; p = 0.136), AIx (26.04 ± 8.5 vs 26.0 ± 8.6%; p = 0.714) and central pulse pressure (PP) (p = 1.0). On the other hand, in placebo group after 24 weeks, aortic PWV (7.80 ± 2.16 vs 7.63 ± 2.1 m/sec; p < 0.001), AIx (25.88 ± 9.4 vs 25.04 ± 9.4%; p < 0.001) increased significantly from baseline measurements but central pulse pressure (PP) (p = 0.870) did not. Also, the change (Δ) in aortic PWV and AIx was significantly higher than the change in the atorvastatin group with p value of < 0.001 and < 0.001, respectively.

Conclusions

Arterial stiffness parameters remained stable in atorvastatin group but increased significantly in placebo-treated patients suggesting a potential role for atorvastatin to delay arterial stiffness progression in HD patients. Larger randomized clinical trials are needed to confirm these findings.

Clinical Trials registration

ClinicalTrials.gov NCT04472637.

Beneficial Effect of Statin Therapy on Arterial Stiffness

Arterial stiffness describes the increased rigidity of the arterial wall that occurs as a consequence of biological aging and several diseases. Numerous studies have demonstrated that parameters to assess arterial stiffness, especially pulse-wave velocity, are predictive of those individuals that will suffer cardiovascular morbidity and mortality. Statin therapy may be a pharmacological strategy to improve arterial elasticity. It has been shown that the positive benefits of statin therapy on cardiovascular disease is attributable not only to their lipid-lowering capacity but also to various pleiotropic effects, such as their anti-inflammatory, antiproliferative, antioxidant, and antithrombotic properties. Additionally, statins reduce endothelial dysfunction, improve vascular and myocardial remodeling, and stabilize atherosclerotic plaque. The aim of the present review was to summarize the evidence from human studies showing the effects of statins on arterial stiffness.

Comparative effect of physical exercise versus statins on improving arterial stiffness in patients with high cardiometabolic risk: A network meta-analysis

BACKGROUND

The comparative analysis of the effect of several doses of statins against different intensities of physical exercise on arterial stiffness (a measure of cardiovascular risk) could shed light for clinicians on which method is most effective in preventing cardiovascular disease (CVD) and be used to inform shared decision-making between doctors and patients. This study was aimed at analyzing the effect, in high cardiometabolic risk patients, of different statins doses and exercise intensities on arterial stiffness (a measure of cardiovascular risk) by integrating all available direct and indirect evidence in network meta-analyses.

METHODS AND FINDINGS

We systematically searched MEDLINE, Embase, SPORTDiscus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Web of Science databases from their inception to February 28, 2020; for unpublished trials, we also searched ClinicalTrials.gov. We searched for studies concerning the effect of statins or physical exercise on arterial stiffness, measured by pulse wave velocity (PWV). For methodological quality assessment, Cochrane Collaboration's tool for assessing risk of bias (RoB2) was used. A network geometry graph was used to assess the strength of the evidence. Comparative evaluation of the interventions effect was performed by conducting a standard pairwise meta-analysis and a network meta-analysis (NMA) for direct and indirect comparisons between interventions and control/nonintervention. A total of 22 studies were included in the analyses (18 randomized controlled trials (RCTs) and 4 nonrandomized experimental studies), including 1,307 patients with high cardiometabolic risk from Asia (3 studies), Oceania (2 studies), Europe (10 studies), North America (5 studies), and South America (2 studies). The overall risk of bias assessed with RoB2 was high in all included studies. For standard pairwise meta-analysis and NMA, high-intensity exercise versus control (mean difference (MD) -0.56; 95% CI: -1.01, -0.11; p = 0.015 and -0.62; 95% CI: -1.20, -0.04; p = 0.038, respectively) and moderate statin dose versus control (MD -0.80, 95% CI: -1.59, -0.01; p = 0.048 and -0.73, 95% CI: -1.30, -0.15; p = 0.014, respectively) showed significant MDs. When nonrandomized experimental studies were excluded, the effect on high-intensity exercise versus control and moderate statin dose versus was slightly modified. The main limitation of this study was that the magnitude of the effect of the exercise interventions could be underestimated due to regression toward the mean bias because the baseline cardiometabolic risk profile of patients in the physical exercise intervention trials was healthier than those in the statins ones; consequently, more modest improvements in physical exercise interventions compared to statins interventions can be expected. Additionally, we might consider as limitations the small study sizes, the heterogeneous patient groups, the focus on a proxy endpoint (PWV), and the high risk of bias.

CONCLUSIONS

In this NMA, we found that although many patients could benefit from statins for reducing CVD risk, our results support that, considering the beneficial effects of high-intensity exercise on arterial stiffness, it would be worthwhile to refocus our attention on this type of exercise as an effective tool for the prevention of CVD.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019123120.

Arterial stiffness: A brief review

Apart from the result of multiple diseases as well as aging, arterial stiffness (AS) predicts cardiovascular disease (CVD), especially in patients with chronic kidney disease (CKD). Patients with CKD have high CVD prevalence, and an extraordinarily high risk for CVD might be related to nontraditional risk factors, including AS. The mechanism of AS development could be attributed to oxidative stress, inflammation, uremic milieu (e.g., uremic toxins), vascular calcification, and cumulative effects of traditional cardiovascular risk factors on arteries such as diabetes mellitus or hypertension. There were a variety of non-invasive techniques to measure AS. One of these techniques is carotid–femoral pulse wave velocity, which is the reference measurement of AS and is related to long-term CVD outcomes. AS progression has corresponding medical treatments with modest beneficial results. This review briefly discusses the risk factors, measurements, and treatments associated with AS.

Cardiovascular Risk Assessment Using Ultrasonographic Surrogate Markers of Atherosclerosis and Arterial Stiffness in Patients With Chronic Renal Impairment: A Narrative Review of the Evidence and a Critical View of Their Utility in Clinical Practice

PURPOSE OF THE REVIEW

Validated tools to improve cardiovascular disease (CVD) risk assessment and mortality in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) are lacking. Noninvasive measures of arteriosclerosis and subclinical atherosclerosis such as pulse wave velocity (PWV) and carotid intima-media thickness (cIMT), respectively, have emerged as promising risk stratification tools and potential modifiable biomarkers. Their wide use as surrogate markers in clinical research studies is based on the strong pathophysiological links with CVD. However, whether their effect as risk stratification or intervention targets is superior to established clinical approaches is uncertain. In this review, we examine the evidence on the utility of PWV, cIMT, and plaque assessment in routine practice and highlight unanswered questions from the clinician's perspective.

SOURCES OF INFORMATION

Electronic databases PubMed and Google Scholar were searched until February 2020.

METHODS

This narrative review is based on peer-reviewed meta-analyses, national and international societies' guidelines, and on focused critical review of recent original studies and landmark studies in the field.

KEY FINDINGS

Although patients with CKD are considered in the high-risk CVD groups, there is still need for tools to improve risk stratification and individualized management strategies within this group of patients. Carotid intima-media thickness is associated with all-cause mortality, CVD mortality, and events in CKD and hemodialysis cohorts. However, the evidence that measurement of cIMT has a clinically meaningful role over and above existing risk scores and management strategies is limited. Plaque assessment is a better predictor than cIMT in non-CKD populations and it has been incorporated in recent nonrenal-specific guidelines. In the CKD population, one large observational study provided evidence for a potential role of plaque assessment in CKD similar to the non-CKD studies; however, whether it improves prediction and outcomes in CKD is largely understudied. Pulse wave velocity as a marker of arterial stiffness has a strong pathophysiological link with CVD in CKD and numerous observational studies demonstrated associations with increased cardiovascular risk. However, PWV did not improve CVD reclassification of dialysis patients when added to common risk factors in a reanalysis of ESRD cohorts with available PWV data. Therapeutic strategies to regress PWV, independently from blood pressure reduction, have not been studied in well-conducted randomized trials.

LIMITATIONS

This study provides a comprehensive review based on extensive literature search and critical appraisal of included studies. Nevertheless, formal systematic literature review and quality assessment were not performed and the possibility of selection bias cannot be excluded.

IMPLICATIONS

Larger, prospective, randomized studies with homogeneous approach, designed to answer specific clinical questions and taking into consideration special characteristics of CKD and dialysis, are needed to study the potentially beneficial role of cIMT/plaque assessment and PWV in routine practice.

Disability of Dialysis Patients and the Condition of Blood Vessels

The number of elderly hemodialysis patients is constantly increasing worldwide. This population has a high burden of comorbid conditions, which impair daily activities. The aim of the study was to analyze problems of disability in hemodialysis patients in the context of cardiovascular (CV) complications and vascular condition. In this cross-sectional study, 129 patients (mean age 64.5) were enrolled. The degree of disability in Barthel index (Bi) and 10-year cardiovascular risk (QRISK®3) were assessed. A Mobil-O-Graph monitor was used for measuring hemodynamic parameters. Only 6.2% of patients were professionally active, 19% used a wheelchair for transport, and 16% used crutches. More than half (51%) were independent in everyday activities reaching 80-100 points on Bi. The rest, with Bi < 80, were considered as dependent. The most common causes of disability were CV complications. The independent group (80-100 points) was characterized by significantly lower pulse wave velocity (PWV) and lower QRISK®3 compared to dependent patients. The degree of disability negatively correlated with age, PWV, and QRISK®3. Multivariate logistic regression revealed that disability (Bi < 80) was independently associated with CV events in the past adjusted odds ratio (adj.OR) 4.83 (95% confidence interval (95% CI): 1.74-13.41) and higher PWV adj.OR 1.45 (95% CI: 1.15-1.82). Our results indicate that CV diseases are the most important cause of functional impairment.

Effects of Simvastatin on Augmentation Index Are Transient: Outcomes From a Randomized Controlled Trial

Background

Statins improve endothelial function, but their effects on arterial stiffness and aortic blood pressure in middle‐aged adults are uncertain.

Methods and Results

This was a prospective, randomized, double‐blind, placebo‐controlled trial of middle‐aged (40‐72 years old) adults who were randomly assigned to receive simvastatin 40 mg (n=44) or placebo (n=44) daily for 18 months to evaluate impact on dementia‐related biomarkers (primary end points) and measures of vascular health (secondary end points). This analysis focuses on the predetermined secondary end points of changes in central aortic blood pressure, aortic augmentation index, and brachial artery flow‐mediated dilation. Measurements were performed at baseline and after 6, 12, and 18 months. Multivariable models were used to identify predictors of these prespecified vascular end points. Study groups were similar at baseline; low‐density lipoprotein cholesterol declined in the statin group but not in the placebo group (P<0.01). There were no significant differences in changes in central blood pressure parameters or flow‐mediated dilation (all P>0.2). After 12 months, augmentation index decreased from baseline in the statin group compared with the placebo group (−2.3% [5.5%] versus 1.2% [5.7%], P=0.007), but by 18 months the response in both groups trend toward baseline (−1.1% [5.8%] versus 0.2% [4.8%], P=0.3). Low‐density lipoprotein cholesterol was not associated with changes in augmentation index at any time point.

Conclusions

Statin therapy led to a short‐term reduction in augmentation index after 12 months, but this effect did not persist after 18 months despite continued reduction in low‐density lipoprotein cholesterol levels. These findings suggest that statins may have a transient effect on aortic stiffness.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00939822.

Arterial Stiffness in the Heart Disease of CKD

CKD frequently leads to chronic cardiac dysfunction. This complex relationship has been termed as cardiorenal syndrome type 4 or cardio-renal link. Despite numerous studies and reviews focused on the pathophysiology and therapy of this syndrome, the role of arterial stiffness has been frequently overlooked. In this regard, several pathogenic factors, including uremic toxins (i.e., uric acid, phosphates, endothelin-1, advanced glycation end-products, and asymmetric dimethylarginine), can be involved. Their effect on the arterial wall, direct or mediated by chronic inflammation and oxidative stress, results in arterial stiffening and decreased vascular compliance. The increase in aortic stiffness results in increased cardiac workload and reduced coronary artery perfusion pressure that, in turn, may lead to microvascular cardiac ischemia. Conversely, reduced arterial stiffness has been associated with increased survival. Several approaches can be considered to reduce vascular stiffness and improve vascular function in patients with CKD. This review primarily discusses current understanding of the mechanisms concerning uremic toxins, arterial stiffening, and impaired cardiac function, and the therapeutic options to reduce arterial stiffness in patients with CKD.

Chronic Kidney Disease and Pulse Wave Velocity: A Narrative Review

Chronic kidney disease (CKD) is associated with excess cardiovascular mortality, resulting from both traditional and nontraditional, CKD-specific, cardiovascular risk factors. Nontraditional risk factors include the entity Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) which is characterised by disorders of bone and mineral metabolism, including biochemical abnormalities of hyperphosphatemia and hyperparathyroidism, renal osteodystrophy, and vascular calcification. Increased arterial stiffness in the CKD population can be attributed amongst other influences to progression of vascular calcification, with significant resultant contribution to the cardiovascular disease burden. Pulse wave velocity (PWV) measured over the carotid-femoral arterial segments is the noninvasive gold-standard technique for measurement of aortic stiffness and has been suggested as a surrogate cardiovascular end-point. A PWV value of 10 m/s or greater has been recommended as a suitable cut-off for an increased risk of cardiovascular mortality. CKD is a risk factor for an excessive rate of increase in aortic stiffness, reflected by increases in PWV, and increased aortic PWV in CKD shows faster progression than for individuals with normal kidney function. Patients with varying stages of CKD, as well as those on dialysis or with a kidney transplant, have different biological milieu which influence aortic stiffness and associated changes in PWV. This review discusses the pathophysiology of arterial stiffness with CKD and outlines the literature on PWV across the spectrum of CKD, highlighting that determination of arterial stiffness using aortic PWV can be a useful diagnostic and prognostic tool for assessing cardiovascular disease in the CKD population.

Effect of 12-month intervention with low-dose atorvastatin on pulse wave velocity in subjects with type 2 diabetes and dyslipidaemia

Cardiovascular disease is the leading cause of morbidity and mortality in subjects with type 2 diabetes mellitus. Increased aortic stiffness, assessed with the carotid-femoral pulse wave velocity, is an independent risk factor for cardiovascular disease. Statins reduce effectively cardiovascular disease and mortality in high-risk patients. The aim of this prospective non-randomized, observational study was to examine the impact of treatment with either 10 mg atorvastatin plus diet or diet alone on carotid-femoral pulse wave velocity in subjects with type 2 diabetes mellitus and dyslipidaemia. A total of 79 subjects with type 2 diabetes mellitus and dyslipidaemia were included; 46 subjects were treated with atorvastatin 10 mg daily plus diet and 33 were managed by diet alone for 12 months. Carotid-femoral pulse wave velocity and carotid-radial pulse wave velocity were measured using applanation tonometry. In the atorvastatin-treated group, carotid-femoral pulse wave velocity reduced significantly during the study and there was a trend for reduction in the carotid-radial pulse wave velocity. Total cholesterol, low-density lipoprotein cholesterol, triglycerides and C-reactive protein were reduced only in the atorvastatin-treated participants. No significant changes were found in body mass index, blood pressure, heart rate, diabetes control and high-density lipoprotein cholesterol in either study group. Treatment with low-dose atorvastatin for 12 months improves carotid-femoral pulse wave velocity in subjects with type 2 diabetes mellitus and dyslipidaemia.

Arterial stiffness in end-stage renal disease-pathogenesis, clinical epidemiology, and therapeutic potentials

Arterial stiffness is an important risk factor for cardiovascular morbidity and mortality in patients with end-stage renal disease (ESRD). Arterial stiffness aggravates cardiovascular risk via multiple pathways, such as augmentation of aortic systolic pressure, subendocardial hypoperfusion, and excess pulsatile energy transmission from macro- to microcirculation. Pathogenesis of the arteriosclerotic process in ESRD is complex and not yet fully understood. Several factors unique to ESRD, such as mineral metabolism disturbances, vascular calcifications, formation of advanced glycation end-products, and acute and chronic volume overload, are proposed to play a particular role in the progression of arteriosclerosis in ESRD. As these and other mechanistic pathways of arterial stiffening in ESRD are elucidated, there is hope that this knowledge will be translated into novel therapeutic interventions targeting arterial stiffness. In the meantime, blood pressure (BP) lowering via strict volume control and appropriate use of antihypertensive drugs is a fundamental step in reversing accelerated arterial stiffening and modifying the cardiovascular risk profile of ESRD patients. In this article, we review the pathogenesis, clinical epidemiology, and therapies targeting arterial stiffness in ESRD, discussing recent advances and high-priority goals of future research in these important areas.

Sex differences in vascular stiffness and relationship to the risk of renal functional decline in patients with type 2 diabetes

BACKGROUND

Recent data suggest that the higher risk of end-stage renal disease in women compared with men is associated with waist circumference. We investigated whether vascular stiffness which is linked to visceral fat accumulation is gender specific and associated with a loss in renal function.

METHODS

We studied 166 patients with type 2 diabetes at high risk of progressive renal disease. A vascular stiffness index was derived from measurement of the peripheral arterial pulse waveform using infrared finger photoplethysmography. Multiple regression analysis was used to examine the relationship between vascular stiffness and traditional clinical and biochemical renal disease risk factors.

RESULTS

Women were of similar mean (standard deviation) age [61.6 (6.8) vs 60.0 (8.3) years; p = 0.444] and duration of diabetes [9.8 (7.2) vs 10.9 (8.1) years; p = 0.885] compared to men. Waist circumference was significantly associated with vascular stiffness [regression coefficient B = 0.15 (95% confidence interval: 0.06-2.24); p = 0.001]. There was a negative slope parameter for the relationship between glomerular filtration rate and vascular stiffness [ B = -0.15 (95% confidence interval: -0.22 to -0.09); p < 0.001] in women only.

CONCLUSION

In this cohort, early renal functional decline in women is linked to increased vascular stiffness which may be associated with visceral fat accumulation as determined by waist circumference.

Effects of statin therapy on augmentation index as a measure of arterial stiffness: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effects of statin therapy on augmentation index (AIx) as a measure of arterial stiffness using a meta-analysis of clinical trials.

METHODS

The search included PubMed-Medline, Embase, SCOPUS, Web of Science and Google Scholar databases to identify randomized controlled trials investigating the effects of statin therapy on arterial stiffness measured as AIx. A random-effects model and generic inverse variance method were used for quantitative data synthesis. Sensitivity analysis was conducted using the leave-one-out method. Random-effects meta-regression was performed using unrestricted maximum likelihood method to evaluate the impact of potential confounders.

RESULTS

18 trials examining the effects of statin therapy on arterial stiffness were included. A significant reduction in aortic AIx following statin therapy was proven (WMD: -2.40%, 95% CI: -4.59, -0.21, p=0.032; I(2): 51.20%). HR-adjusted AIx 75% values also revealed a significant improvement by statin therapy (WMD: -5.04%, 95% CI: -7.81, -2.27, p<0.001; I(2): 0%), but not when analysis was restricted to unadjusted AIx values (WMD: -2.30%, 95% CI: -4.83, 0.23, p=0.075; I(2): 53.83%). There was no significant change in carotid (WMD: -2.75%, 95% CI: -8.06, 2.56, p=0.309; I(2): 26.86%) and peripheral (WMD: 0.25%, 95% CI: -3.31, 3.82, p=0.889; I(2): 72.19%) AIx due to statin treatment. There was also no difference in the effect size calculated for different statins subgroups. The impact of statins on AIx was independent of LDL-cholesterol level (slope: 0.05; 95% CI: -0.02, 0.13; p=0.181).

CONCLUSION

Statin therapy causes a significant reduction in aortic AIx which is independent of LDL-cholesterol changes.

Renin-Angiotensin System Blockade Associated with Statin Improves Endothelial Function in Diabetics

Background

Studies suggest that statins have pleiotropic effects, such as reduction in blood pressure, and improvement in endothelial function and vascular stiffness.

Objective

To analyze if prior statin use influences the effect of renin-angiotensin-aldosterone system inhibitors on blood pressure, endothelial function, and vascular stiffness.

Methods

Patients with diabetes and hypertension with office systolic blood pressure ≥ 130 mmHg and/or diastolic blood pressure ≥ 80 mmHg had their antihypertensive medications replaced by amlodipine during 6 weeks. They were then randomized to either benazepril or losartan for 12 additional weeks while continuing on amlodipine. Blood pressure (assessed with ambulatory blood pressure monitoring), endothelial function (brachial artery flow-mediated dilation), and vascular stiffness (pulse wave velocity) were evaluated before and after the combined treatment. In this study, a post hoc analysis was performed to compare patients who were or were not on statins (SU and NSU groups, respectively).

Results

The SU group presented a greater reduction in the 24-hour systolic blood pressure (from 134 to 122 mmHg, p = 0.007), and in the brachial artery flow-mediated dilation (from 6.5 to 10.9%, p = 0.003) when compared with the NSU group (from 137 to 128 mmHg, p = 0.362, and from 7.5 to 8.3%, p = 0.820). There was no statistically significant difference in pulse wave velocity (SU group: from 9.95 to 9.90 m/s, p = 0.650; NSU group: from 10.65 to 11.05 m/s, p = 0.586).

Conclusion

Combined use of statins, amlodipine, and renin-angiotensin-aldosterone system inhibitors improves the antihypertensive response and endothelial function in patients with hypertension and diabetes.

Effect of Simvastatin on Arterial Stiffness in Patients with Statin Myalgia

Statins reduce arterial stiffness but are also associated with mild muscle complaints. It is unclear whether individuals with muscle symptoms experience the same vascular benefit or whether statins affect striated and smooth muscle cells differently. We examined the effect of simvastatin treatment on arterial stiffness in patients who did versus those who did not exhibit muscle symptoms. Patients with a history of statin-related muscle complaints (n = 115) completed an 8 wk randomized, double-blind, cross-over trial of daily simvastatin 20 mg and placebo. Serum lipids and pulse wave velocity (PWV) were assessed before and after each treatment. Muscle symptoms with daily simvastatin treatment were reported by 38 patients (33%). Compared to baseline, central PWV decreased (P = 0.01) following simvastatin treatment but not placebo (drug ∗ time interaction: P = 0.047). Changes in central PWV with simvastatin treatment were not influenced by myalgia status or time on simvastatin (P ≥ 0.15). Change in central PWV after simvastatin treatment was inversely correlated with age (r = -0.207, P = 0.030), suggesting that advancing age is associated with enhanced statin-mediated arterial destiffening. In patients with a history of statin-related muscle complaints, the development of myalgia with short-term simvastatin treatment did not attenuate the improvement in arterial stiffness.

Cardiovascular risk across the histological spectrum and the clinical manifestations of non-alcoholic fatty liver disease: An update

Non-alcoholic fatty liver disease (NAFLD) is considered to be an independent cardiovascular disease (CVD) risk factor. However, simple steatosis has a benign clinical course without excess mortality. In contrast, the advanced form of NAFLD, non-alcoholic steatohepatitis (NASH) with liver fibrosis increases mortality by approximately 70%, due to an increase in CVD mortality by approximately 300%. Chronic kidney disease (CKD) may be caused by NAFLD/NASH and it substantially increases CVD risk, especially in the presence of type 2 diabetes mellitus. Moreover, CKD may trigger NAFLD/NASH deterioration in a vicious cycle. NAFLD/NASH is also related to increased arterial stiffness (AS), an independent CVD risk factor that further raises CVD risk. Diagnosis of advanced liver fibrosis (mainly by simple non-invasive tests), CKD, and increased AS should be made early in the course of NAFLD and treated appropriately. Lifestyle measures and statin treatment may help resolve NAFLD/NASH and beneficially affect the CVD risk factors mentioned above.

A low-dose combination of fluvastatin and valsartan: a new "drug" and a new approach for decreasing the arterial age

We have developed a new “drug” and approach that appear to be effective in reducing arterial age. This “drug” represents a low, subtherapeutic dose of statin and sartan and particularly their low-dose combination. The improvement of arterial wall characteristics, also reflecting in a decrease of arterial age, was achieved after a short period of treatment (one month) with the above-mentioned drugs. In addition, we have also implemented a new, innovative therapeutic approach, consisting of intermittent (cyclic) treatment—alternating short “treatment” periods and much longer “rest” periods (when the beneficial effects are still present but gradually decline). This new “drug” and approach both merit further investigation in order to confirm their antiaging efficacy.

"Inflammation and arterial stiffness in humans"

Arterial stiffness is an established marker of cardiovascular morbidity and mortality and a potential therapeutic target. While hypertension and aging are established factors contributing to arterial stiffness, the role of inflammation in stiffening of the arteries is less well understood. We summarize existing literature regarding inflammation and arterial stiffness, including a discussion of the potential mechanisms by which inflammation may lead to arterial stiffening and studies assessing: (1) The association between subclinical inflammation and arterial stiffness in the general population; (2) The presence of increased arterial stiffness in primary inflammatory diseases; (3) The effect of anti-inflammatory therapy on arterial stiffness in primary inflammatory disease including the effect of statins; (4) Experimental evidence of immunization-induced arterial stiffening in normal adults. We discuss potential opportunities to assess the impact of anti-inflammatory interventions on arterial stiffness in subjects without primary inflammatory conditions. We also review the effect of inflammation on wave reflections.

Arterial stiffness and cardiovascular therapy

The world population is aging and the number of old people is continuously increasing. Arterial structure and function change with age, progressively leading to arterial stiffening. Arterial stiffness is best characterized by measurement of pulse wave velocity (PWV), which is its surrogate marker. It has been shown that PWV could improve cardiovascular event prediction in models that included standard risk factors. Consequently, it might therefore enable better identification of populations at high-risk of cardiovascular morbidity and mortality. The present review is focused on a survey of different pharmacological therapeutic options for decreasing arterial stiffness. The influence of several groups of drugs is described: antihypertensive drugs (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, beta-blockers, diuretics, and nitrates), statins, peroral antidiabetics, advanced glycation end-products (AGE) cross-link breakers, anti-inflammatory drugs, endothelin-A receptor antagonists, and vasopeptidase inhibitors. All of these have shown some effect in decreasing arterial stiffness. Nevertheless, further studies are needed which should address the influence of arterial stiffness diminishment on major adverse cardiovascular and cerebrovascular events (MACCE).

HMG CoA reductase inhibitors (statins) for people with chronic kidney disease not requiring dialysis

BACKGROUND

Cardiovascular disease (CVD) is the most frequent cause of death in people with early stages of chronic kidney disease (CKD), for whom the absolute risk of cardiovascular events is similar to people who have existing coronary artery disease. This is an update of a review published in 2009, and includes evidence from 27 new studies (25,068 participants) in addition to the 26 studies (20,324 participants) assessed previously; and excludes three previously included studies (107 participants). This updated review includes 50 studies (45,285 participants); of these 38 (37,274 participants) were meta-analysed.

OBJECTIVES

To evaluate the benefits (such as reductions in all-cause and cardiovascular mortality, major cardiovascular events, MI and stroke; and slow progression of CKD to end-stage kidney disease (ESKD)) and harms (muscle and liver dysfunction, withdrawal, and cancer) of statins compared with placebo, no treatment, standard care or another statin in adults with CKD who were not on dialysis.

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register to 5 June 2012 through contact with the Trials' Search Co-ordinator using search terms relevant to this review.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of statins with placebo, no treatment, standard care, or other statins, on mortality, cardiovascular events, kidney function, toxicity, and lipid levels in adults with CKD not on dialysis were the focus of our literature searches.

DATA COLLECTION AND ANALYSIS

Two or more authors independently extracted data and assessed study risk of bias. Treatment effects were expressed as mean difference (MD) for continuous outcomes (lipids, creatinine clearance and proteinuria) and risk ratio (RR) for dichotomous outcomes (major cardiovascular events, all-cause mortality, cardiovascular mortality, fatal or non-fatal myocardial infarction (MI), fatal or non-fatal stroke, ESKD, elevated liver enzymes, rhabdomyolysis, cancer and withdrawal rates) with 95% confidence intervals (CI).

MAIN RESULTS

We included 50 studies (45,285 participants): 47 studies (39,820 participants) compared statins with placebo or no treatment and three studies (5547 participants) compared two different statin regimens in adults with CKD who were not yet on dialysis. We were able to meta-analyse 38 studies (37,274 participants).The risk of bias in the included studies was high. Seven studies comparing statins with placebo or no treatment had lower risk of bias overall; and were conducted according to published protocols, outcomes were adjudicated by a committee, specified outcomes were reported, and analyses were conducted using intention-to-treat methods. In placebo or no treatment controlled studies, adverse events were reported in 32 studies (68%) and systematically evaluated in 16 studies (34%).Compared with placebo, statin therapy consistently prevented major cardiovascular events (13 studies, 36,033 participants; RR 0.72, 95% CI 0.66 to 0.79), all-cause mortality (10 studies, 28,276 participants; RR 0.79, 95% CI 0.69 to 0.91), cardiovascular death (7 studies, 19,059 participants; RR 0.77, 95% CI 0.69 to 0.87) and MI (8 studies, 9018 participants; RR 0.55, 95% CI 0.42 to 0.72). Statins had uncertain effects on stroke (5 studies, 8658 participants; RR 0.62, 95% CI 0.35 to 1.12).Potential harms from statin therapy were limited by lack of systematic reporting and were uncertain in analyses that had few events: elevated creatine kinase (7 studies, 4514 participants; RR 0.84, 95% CI 0.20 to 3.48), liver function abnormalities (7 studies, RR 0.76, 95% CI 0.39 to 1.50), withdrawal due to adverse events (13 studies, 4219 participants; RR 1.16, 95% CI 0.84 to 1.60), and cancer (2 studies, 5581 participants; RR 1.03, 95% CI 0.82 to 130).Statins had uncertain effects on progression of CKD. Data for relative effects of intensive cholesterol lowering in people with early stages of kidney disease were sparse. Statins clearly reduced risks of death, major cardiovascular events, and MI in people with CKD who did not have CVD at baseline (primary prevention).

AUTHORS' CONCLUSIONS

Statins consistently lower death and major cardiovascular events by 20% in people with CKD not requiring dialysis. Statin-related effects on stroke and kidney function were found to be uncertain and adverse effects of treatment are incompletely understood. Statins have an important role in primary prevention of cardiovascular events and mortality in people who have CKD.

Atorvastatin Treatment Does Not Alter Pulse Wave Velocity in Healthy Adults

Introduction. Both statins and regular physical activity (PA) reduce arterial stiffness. The present post hoc analysis examined if arterial stiffness was improved with high-dose atorvastatin treatment in healthy adults and whether PA levels magnified this response. We utilized data from a double-blind, random-assignment clinical trial investigating the effects of atorvastatin 80 mg/d for 6 mo on skeletal muscle symptoms. Methods. Central and peripheral arterial pulse wave velocity (PWV) were measured and PA levels assessed at baseline and 6 mo in subjects randomized to atorvastatin (n = 21, 9 men) or placebo (n = 29, 16 men). Results. Baseline participant characteristics, PWV, and PA levels were not different between treatments. Central (means ± SD; 8.7 ± 2.6 to 9.0 ± 2.5 m/sec) and peripheral PWV (9.9 ± 1.3 to 9.8 ± 1.6 m/sec) were unchanged from baseline following atorvastatin treatment (time × drug interaction: P ≥ 0.13). Similarly, PA levels were unaffected by time or treatment. In sex and age adjusted models, baseline levels of PA were not related to changes in PWV with atorvastatin treatment. Conclusion. These data indicate that high-dose atorvastatin treatment for 6 mo does not influence arterial stiffness in healthy adults. Participation in habitual PA did not magnify the vascular effects of statin therapy. This study was registered with ClinicalTrials.gov NCT00609063.

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.

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.

Venous and arterial disease in inflammatory bowel disease

Awareness is increasing that risk of venous thromboembolism and development of atherosclerosis is elevated in patients with some chronic inflammatory diseases. This review aimed to examine the risk of vascular disease in patients with inflammatory bowel disease (IBD) and to identify potential pathogenic mechanisms and therapeutic approaches. An extensive literature search was conducted using MEDLINE database, Cochrane Library and international conference abstracts for studies pertaining to venous and arterial thromboembolism in adult IBD patients. There is a 1.1-3.6 fold risk of venothromboembolism in IBD, affecting 0.55-6.15% of patients. Risks are increased during a flare or with chronically active inflammation. Evidence is building that there may be a modestly increased risk of arterial disease overall, despite evidence that traditional risk factors may be reduced. Multiple pathogenic factors have been identified including endothelial dysfunction, inflammation-mediated calcium deposition in the media of arteries, hyperhomocysteinemia, platelet activation, and altered coagulation and fibrinolysis. The key to active and preventive therapy is to effectively treat inflammation. Recommendations for prophylaxis of venothromboembolism have followed guidelines where they exist and have been extrapolated from studies of other at-risk conditions, as have those for arterial disease, where screening for risk factors and actively treating abnormalities is encouraged. In conclusion, patients with IBD are at considerably increased risk of venothromboembolism and probably of arterial disease, in particular mesenteric ischemia and ischemic heart disease. Increased penetration of gaps between this knowledge and clinical therapeutic action to prevent thromboembolic events into IBD clinical practice is needed.

Effects of low-dose atorvastatin on arterial stiffness and central aortic pressure augmentation in patients with hypertension and hypercholesterolemia

BACKGROUND

Experimental and clinical data suggest that statins exert anti-inflammatory and antiproliferative actions on vasculature beyond their lipid-lowering properties. Whether these pleiotropic effects of statins translate into a beneficial effect on arterial stiffness is not clear. This study aimed to evaluate the potential effects of low-dose atorvastatin treatment on arterial stiffness and central arterial pressure waveforms in patients with mild hypertension and hypercholesterolemia.

METHODS

In a double-blind, randomized, placebo-controlled fashion, 50 hypertensive and hypercholesterolemic patients were allocated to receive 10 mg of atorvastatin or placebo for 26 weeks. Arterial stiffness was assessed by aortic pulse-wave velocity (PWV) using a Sphygmocor device. Central arterial pressure waveform parameters were estimated by radial artery applanation tonometry. Heart rate-adjusted augmentation index (AIx(75)) was used as measure of wave reflections.

RESULTS

At study end, aortic PWV (9.0 ± 1.5 vs. 10.9 ± 2.6 m/sec; P < 0.001) and AIx(75) (24.9% ± 9.7% vs 28.8% ± 11.8%; P < 0.001) were significantly lower in the atorvastatin group than that placebo group. Furthermore, decreases in central aortic systolic blood pressure and pulse pressure were evident at study-end with atorvastatin but not with placebo (130 ± 8 vs. 138 ± 6 mm Hg, P < 0.001; 48 ± 7 vs. 53 ± 6 mm Hg, P < 0.05, respectively). Atorvastatin-induced reductions in aortic PWV during follow-up showed significant associations with changes in AIx(75) and central aortic systolic blood pressure and pulse pressure.

CONCLUSIONS

This study shows that low-dose atorvastatin treatment improves arterial stiffness and exerts a reduction on central aortic pressures. These effects may represent a potential mechanism of cardiovascular risk reduction observed with statin use.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Database Identifier Number: NCT01126684.

Antihypertensive effects of statins: a meta-analysis of prospective controlled studies

In experimental studies, statins have been shown to lower blood pressure through increased nitric oxide bioavailability and improved arterial compliance. The clinical significance of this effect remains poorly documented. The authors performed a meta-analysis of the effect of statins on systolic blood pressure (SBP) and diastolic blood pressure (DBP) including prospective randomized, controlled trials of statin therapy. EMBASE and MEDLINE searches for studies in which patients were randomized to treatment with a statin plus standard treatment (or placebo) vs standard treatment (or placebo) were conducted. Studies that provided data on SBP and DBP values before the initiation of the treatment and at the end of the follow-up period were included. A total of 40 studies with 51 comparison groups examining 22,511 controls and 22,602 patients taking statins were examined. Mean SBP in the statin group decreased by 2.62 mm Hg (95% confidence interval [CI], -3.41 to -1.84; P<.001) and DBP by 0.94 mm Hg (95% CI, -1.31 to -0.57; P<.001). In studies including hypertensive patients, the decrease in blood pressures with statins was slightly greater (SBP, -3.07 mm Hg; 95% CI, -4.00 to -2.15 and DBP, 1.04; 95% CI, -1.47 to -0.61). Similarly, statins effectively reduced SBP in diabetic patients. In this large meta-analysis of prospective controlled studies, the authors found a small but statistically significant reduction of SBP in patients taking statins. The decrease in blood pressure may contribute to the pleiotropic effect of statins in reducing cardiovascular risk.

A new anti-ageing strategy focused on prevention of arterial ageing in the middle-aged population

Ageing is a progressive process that according to available knowledge cannot be effectively reversed, slowed or stopped. Here we propose a new anti-ageing approach that may lead to the design of effective therapeutic intervention. First, we hypothesize that the "organ system" oriented anti-ageing approach represents a better anti-ageing target than the "whole body" or "cellular ageing" concepts. The arterial system is the most suitable target, as it interconnects all the organs in the body, thus influencing them all. Second, we propose that an anti-ageing approach could be more successful in early than late ageing stages; middle-aged people seem to be the most appropriate candidates. Third, we believe that instead of searching for new medication, we should rely on already established medications with beneficial effects on the arterial wall. Renin-angiotensin system inhibitors and statins fulfill these criteria and are potential cornerstones of the new approach. The fourth hypothesis is based on the concept that in the early stages of arterial ageing only slight injury is present and therefore subtherapeutic, low-dose treatment would be effective. Fifth, we hypothesize that slight initial age-related arterial wall changes are reversible and could be corrected by a short-term (one month) treatment. Sixth, we hypothesize that the effects would be present for a certain period of time even after treatment termination. The listed assumptions combined represent the basis for a new, original anti-ageing approach - a subtherapeutic low-dose combination of a renin-angiotensin system inhibitor and a statin for one month (followed by approximately 6-12 months without treatment) could delay or even reverse the arterial ageing process and consequently decrease the incidence of cardiovascular disorders.

Effects of adding ezetimibe to fluvastatin on kidney function in patients with hypercholesterolemia: a randomized control trial

AIMS

Statins not only reduce low-density lipoprotein (LDL) cholesterol, but also prevent the progression of kidney dysfunction. Ezetimibe, a cholesterol-absorption inhibitor, also lowers LDL cholesterol levels when added to statins; however, the effect of add-on ezetimibe on kidney function has had conflicting results.

METHODS

We conducted an open-labeled, randomized, 12-month trial, comparing the effects of daily therapy with 20 mg fluvastatin either with or without 10 mg ezetimibe in 54 patients with dyslipidemia. The prespecified primary outcome was the percent change from baseline in kidney function, which was defined by the estimated glomerular filtration rate. The secondary outcomes were the changes in surrogate atherosclerotic markers. All analyses were by intention to treat.

RESULTS

The primary outcome, the percent change from baseline (±SE) of the estimated glomerular filtration rate, was -5.5±1.9% in the fluvastatin-only group and 6.6±1.9% in the fluvastatin-plus-ezetimibe (combined-therapy) group (p=0.0002). Secondary outcomes, consisting of the cardioankle vascular index, augmentation index, ankle-brachial index, and maximum intima-media thickness of the carotid arteries, did not differ significantly between the two groups. At the end of the study, the mean (±SD) LDL cholesterol was 122±23 mg per deciliter in the fluvastatin group and 111±29 mg per deciliter in the combined-therapy group (a between-group difference of 9.2%, p= 0.036). Side-effect and safety profiles were similar in the two groups.

CONCLUSION

Combined therapy with fluvastatin 20 mg plus ezetimibe 10 mg daily resulted in a significant improvement in changes in the estimated glomerular filtration rate.

Pharmacological modulation of arterial stiffness

Arterial stiffness has emerged as an important marker of cardiovascular risk in various populations and reflects the cumulative effect of cardiovascular risk factors on large arteries, which in turn is modulated by genetic background. Arterial stiffness is determined by the composition of the arterial wall and the arrangement of these components, and can be studied in humans non-invasively. Age and distending pressure are two major factors influencing large artery stiffness. Change in arterial stiffness with drugs is an important endpoint in clinical trials, although evidence for arterial stiffness as a therapeutic target still needs to be confirmed. Drugs that independently affect arterial stiffness include antihypertensive drugs, mostly blockers of the renin-angiotensin-aldosterone system, hormone replacement therapy and some antidiabetic drugs such as glitazones. While the quest continues for 'de-stiffening drugs', so far only advanced glycation endproduct cross-link breakers have shown promise.

Arterial stiffness in chronic kidney disease: the usefulness of a marker of vascular damage

Increased arterial stiffness is a marker of vasculopathy in chronic kidney disease (CKD) patients, suggesting a significant cardiovascular damage. Detection of arterial stiffness provides physicians with useful prognostic information independent of traditional cardiovascular (CV) risk factors. In addition, this knowledge may help guide appropriate therapeutic choices and monitor the effectiveness of antihypertensive therapies. We review the relationship between arterial stiffness and CKD, as well as the prognostic implications of increased arterial stiffness and the potential therapeutic strategies to ameliorate arterial compliance and outcome in CKD.