Real-world data from the use of ranolazine in patients with stable angina pectoris: the RANGER study

Background

Although ranolazine is available since years as a second-line treatment to reduce angina attacks in patients with stable angina pectoris, real-world data on effectiveness, tolerability and safety of ranolazine are limited.

Methods

A non-interventional, prospective study conducted to assess the effectiveness and safety of ranolazine. Patients eligible for enrolment had a baseline assessment between one and fourteen days after initiating ranolazine for the first time and a follow-up visit three months later. Primary endpoints comprised the weekly frequency of angina attacks, total adverse events and ranolazine discontinuation rate. Secondary endpoints included the use of short-acting nitrates, changes on the Canadian Cardiovascular Society (CCS) angina classification score and quality of life scale score (QoL).

Results

In total, 1,101 patients were enrolled in 214 sites. Mean weekly angina attacks were reduced from 3.6±2.9 to 0.4±0.9 (p<0.0001) and the mean weekly consumption of short-acting nitrates decreased by 1.7±2.2 (p<0.0001). CCS class and QoL were also improved (p<0.0001). Adverse events were reported by 11 (1%) patients totally, while 2 of them (0.2%) were characterized as serious. Treatment was discontinued for any reason in 23 patients (2.1%) after the follow-up period. Ranolazine treatment was equally effective in all subgroups tested, with larger benefits observed in patients with more frequent angina and CCS angina class III and IV. Up-titration of ranolazine during the study improved the outcomes.

Conclusion

Ranolazine was well-tolerated and effectively reduced angina attacks with simultaneous improvement of CCS class and QoL score in patients with stable angina.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The study was sponsored by Menarini Hellas. The study sponsor was involved in the study concept and design and in the interpretation of the data included in this publication, but not in the data collection and analysis. Menarini Hellas also funded the medical writing support for this publication.

Plasma nesfatin-1 and DDP-4 levels in patients with coronary artery disease: Kozani study

Background

Nesfatin-1, a novel adipokine and dipeptidyl peptidase-4 (DPP4), a mam malian serine protease, are potent factors of atherosclerosis. In the present cross-sectional study, we investigated whether the plasma nesfatin-1 and DPP4 is associated with the prevalence and severity of coronary artery disease (CAD) with and without diabetes mellitus (DM).

Methods

We consecutively enrolled a total of 240 patients with significant CAD (previous revascularization or angiographically-proven coronary artery stenosis > 50%) presented with either unstable angina (UA, N = 76) or stable chronic CAD (SCAD, N = 165). 85 patients with at least 2 classical cardiovascular risk factors but without significant CAD served as controls. The severity of CAD was assessed using coronary angiography by the Gensini score. Clinical parameters, glycemic and lipid profile, high-sensitivity CRP (hsCRP), nesfatin-1 and DPP4 levels were assayed.

Results

No differences were found for age, sex, hypertension and diabetes distribution between groups. Low nesfatin-1 levels were found in both CAD groups (UA & SCAD) with respect to controls. The difference between UA and SCAD groups was marginally non-significant. There was a significant increase of DPP4 along UA to SCAD and control groups. Differences between groups remained unchanged in non-diabetic participants. Nesfatin-1 significantly correlated to hsCRP (r = − 0.287, p = 0.036), HOMA-IR (r = − 0.587, p = 0.007) and hyperlipidemia (r = − 0.331, p = 0.034). DPP4 was significantly associated with hs-CRP (r = 0.353 p < 0.001) and FPG (r = 0.202, p = 0.020) in univariate analysis, but those correlations were lost in multiple regression analysis. There was a negative correlation between nesfatin-1 and the severity of CAD, quantified by the Gensini score (r = − 0.511, p < 0.001), but no association was found for DPP4.

Conclusions

Serum DPP4 levels are increased in patients with CAD, while serum nesfatin-1 levels have a negative association with both the incidence and the severity of CAD. These results are independent of the presence of diabetes mellitus. In addition, both peptides have a strong association with hsCRP.

Trial registration ClinicalTrials.gov Identifier: NCT00306176

The impact of nationwide lockdown on acute coronary syndromes hospitalization rate in the Western Macedonia regional hospital of Greece

Funding Acknowledgements

Type of funding sources: None.

Introduction

 World Health Organization declared the Covid-19 outbreak a global pandemic on March 11, 2020. The pandemic is associated with more than 75 million cases and more than 1.5 million deaths worldwide. Greece implemented a nationwide lockdown on March 23, 2020, to control the pandemic wave and prevent reducing morbidity and mortality due to Covid-19. During this period, acute coronary syndromes (ACS) hospitalization in the cardiology department was reduced. In addition, the second pandemic wave also led to a new national lockdown on November 7, 2020, although it was implemented 15 days earlier in the relative regional hospital area due to high viral load.

Purpose

 Our study evaluated the number of hospitalized patients with ACS during the nationwide lockdown period, comparing them with the previous years (period 2018 and 2019).

Material and Methods

 Data recordings regarding ACS (unstable angina, NSTEMI, STEMI) hospitalization rates in the Cardiology department were collected from the hospital"s register. Each year"s data analysis interval included the periods of the nationwide lockdown of 2020; March 23 to May 3 and October 14 to December 10. Statistical analysis was performed between periodic groups using the chi-square test (IBM SPSS Statistics software, version 23.0).

Results

 During 2018, the number of patients hospitalized for ACS was 81 and consisted of 39,1% of the total hospitalizations in the Cardiology Department. In 2019 the number of patients hospitalized for ACS was 62 and consisted the 48,8% of the total hospitalizations, while in 2020, the number of patients hospitalized for ACS was 30 and consisted the 27,5% of the total hospitalizations. Furthermore, there was a statistically significant difference (p < 0,05) regarding ACS event hospitalization rate between the period of lockdown (March to May and October-December 2020) and the COVID-19-free period of the previous year (March to May and October to December 2019). There was no statistically significant difference (p > 0,05) regarding ACS event hospitalization rate between the period of lockdown (March to May and October to December 2020) and the COVID-19-free period of the year 2018 (March to May and October to December). Finally, there was no statistically significant difference (p > 0,05) in ACS event hospitalization rate between March to May and October to December regarding the years 2018 and 2019.

Conclusion

 Our results are in compliance with the ESC"s comparative survey regarding the observed worldwide reduction of hospitalizations for ACS during the COVID-19 lockdown era, suggesting a potential impact of lockdown in both non-environmental and environmental risk factors for cardiovascular disease. Factors of the relative epidemiological reduction are complexed and puzzled, while morbidity and mortality of ACS remained relatively stable even after the lockdown, so future studies are necessary to further investigate them.

Patients with Acute Coronary Syndrome are at High Risk Prior to the Event and Lipid Management is Underachieved Pre- and Post- Hospitalization

BACKGROUND

Current European Guidelines suggest the use of cardiovascular risk categories and also recommend using high-intensity statins for patients with acute coronary syndromes (ACS).

OBJECTIVE

We examined the risk of ACS patients prior to the event, as well as the overall use and intensity of statins.

METHODS

We enrolled 687 ACS patients (mean age 63 years, 78% males). Low-density lipoprotein cholesterol (LDL-C) levels upon admission were used to assess attainment of LDL-C targets. Patients were categorized as very high, high, moderate and low risk based on their prior to admission cardiovascular (CV) risk. We examined statin use and dosage intensity among patients discharged from the hospital. Patients were followed for a median period of 189 days.

RESULTS

The majority of the patients (n=371, 54%) were at very high CV risk prior to admission, while 101 patients were at high risk (15%), 147 (21%) moderate risk and 68 (10%) low risk. Interestingly, LDL-C target attainment decreased as the risk increased (p<0.001). The majority (96%) of patients received statins at discharge; however, most of them (60.4%) received low/moderate intensity statins and just 35.9% received the suggested by the Guidelines high-intensity dose of statins. At follow-up, the rate of patients at high-intensity dose of statins remained similar (34.8%); 6% received no statins at all at follow-up.

CONCLUSION

According to our study, the majority of ACS patients are already at high risk prior to their admission. Further, LDL-C targets are underachieved prior to the event and high-intensity statins are underutilized in ACS patients at, and post-discharge.

Serum levels of fetuin-A, osteoprotegerin and osteopontin in patients with coronary artery disease: effects of statin (HMGCoA-reductase inhibitor) therapy

BACKGROUND AND OBJECTIVES

Statins (HMGCoA-reductase inhibitors) produce numerous non-lipid related, 'pleiotropic' effects. Our aim was to investigate whether simvastatin treatment affects serum levels of vascular calcification inhibitors, such as fetuin-A, osteoprotegerin (OPG) and osteopontin (OPN), in patients with coronary artery disease (CAD).

METHODS

A total of 98 statin-free patients with angiographically proven, newly diagnosed CAD were treated with simvastatin (20-40 mg daily) for 6 months to target a low-density lipoprotein (LDL) level <100 mg/dL (the statin group [SG]). Thirty-five age- and sex-matched healthy individuals without any chronic metabolic or cardiovascular disease at baseline served as a healthy control group (HCG). Clinical, anthropometrical and metabolic parameters and serum fetuin-A, OPG, OPN and high-sensitivity C-reactive protein (hsCRP) levels were assayed at baseline in all participants and after 6 months only in SG patients.

RESULTS

Compared with HCG subjects at baseline, SG patients exhibited higher serum levels of OPG (7.39 ± 2.94 pmol/L vs 2.47 ± 1.15 pmol/L, p < 0.001), OPN (60.99 ± 17.52 ng/mL vs 45.45 ± 10.26 ng/mL, p = 0.005) and hsCRP (4.66 ± 1.74 mg/L vs 1.58 ± 0.56 mg/L, p < 0.001) as well as lower serum levels of fetuin-A (0.222 ± 0.036 μg/L vs 0.839 ± 0.092 μg/L, p < 0001). Apart from significantly reducing plasma total cholesterol and LDL, simvastatin also reduced serum levels of fetuin-A (by ~62.6 %), OPG (by ~47.2 %), OPN (by ~44.6 %) and hsCRP (by ~45.3 %) (p < 0.05) in SG patients. In standard multiple regression analysis, the simvastatin-induced reduction in fetuin-A was independently associated with changes in total cholesterol (β = -0.289, p = 0.048) and LDL (β = -0.302, p = 0.032) (R (2) = 0.305, p = 0.040).

CONCLUSION

Patients with CAD showed derangements in serum levels of all vascular calcification inhibitors compared with those in healthy controls. Simvastatin treatment for 6 months significantly decreased serum fetuin-A, OPG and OPN levels, but the clinical relevance of this requires further investigation.

The effects of resistance training on ApoB/ApoA-I ratio, Lp(a) and inflammatory markers in patients with type 2 diabetes

The purpose of this study was to investigate the effects of resistance training (RT) on novel cardiovascular risk factors in patients with type 2 diabetes mellitus (T2DM). We enrolled 52 overweight/obese, type 2 diabetic patients, with inadequate glycemic control (HbA1c > 6.5 %), but without overt diabetic vascular complications. Participants were randomly assigned into two equivalent groups (n = 26): (1) Resistance exercise group: subjects underwent a supervised RT program (3-times/week, 60 min/session, 2-3 sets of 8 machine-weight exercises, 60-80 % of one-repetition maximum). (2) Control group (CG): at study entrance, they received a structured exercise counseling to increase daily physical activity. Clinical parameters, cardiorespiratory capacity, glycemic and lipid profile, apolipoprotein A-I (ApoA-I), apolipoprotein B (ApoB), Lipoprotein(a) [Lp(a)], insulin resistance (HOMA-IR), high-sensitivity CRP (hsCRP), fibrinogen were measured before and after 3 months. RT significantly reduced glycemic indexes, insulin resistance and systolic blood pressure, compared to CG (p < 0.05). Moreover, exercise-treated patients conferred a remarkable downregulation in ApoB levels (from 135.92 ± 30.97 mg/dL to 85.9 ± 26.46 mg/dL, p < 0.001) as compared to CG (from 126.33 ± 36.59 mg/dL to 116.23 ± 27.52 mg/dL, p = 0.872) (p < 0.001). Similarly, ApoB/ApoA-I ratio was considerably decreased in REG rather than CG (-0.32 ± 0.09 vs 0.02 ± 0.01, p < 0.001). Notably, ApoA-I, Lp(a), hsCRP, fibrinogen, the rest of lipid parameters, body weight and exercise capacity remained unaltered in both groups (p > 0.05). Among variables, HOMA-IR reduction was found to be an independent predictor of changes in ApoB/ApoA-I ratio (R (2) = 0.406, p = 0.041) in REG. Long-term RT ameliorated glycemic control, insulin sensitivity and ApoB/ApoA-I ratio in individuals with T2DM. Although we did not observe significant benefits in the rest of cardiovascular risk factors, our results indicate a merely beneficial impact of RT.

Effects of atorvastatin on apelin, visfatin (nampt), ghrelin and early carotid atherosclerosis in patients with type 2 diabetes

To investigate the influence of atrovastatin treatment on carotid intima-media thickness (CIMT) and serum levels of novel adipokines, like apelin, visfatin (nampt), and ghrelin, in patients with type 2 diabetes mellitus (T2DM). 87 statin-free patients (50 males) with T2DM, aged 55-70, but without carotid atherosclerotic plaques were initially enrolled. CIMT was assayed in all participants by ultrasound. Patients were then treated with atorvastatin (10-80 mg) to target LDL <100 mg/dl. Anthropometric parameters, blood pressure, glycemic and lipid profile, high-sensitivity CRP (hsCRP), insulin resistance (HOMA-IR), apelin, visfatin and ghrelin were measured at baseline and after 12 months. Atorvastatin treatment significantly improved lipid profile across with increased apelin (from 0.307 ± 0.130 pg/ml to 1.537 ± 0.427 pg/ml; P < 0.001) and suppressed visfatin (from 21.54 ± 10.14 ng/ml to 15.13 ± 7.61 ng/ml; P = 0.002) serum levels in our diabetic patients. Standard multiple regression analysis showed that the atorvastatin-induced increment in apelin was independently associated with changes in total cholesterol (β = -0.510, P = 0.030) and LDL-cholesterol (β = -0.590, P < 0.001) (R (2) = 0.449, P = 0.014), while the reduction of visfatin concentration was independently associated with the change in hsCRP (β = 0.589, P < 0.001; R (2) = 0.256, P = 0.006), after adjustment for age, sex and BMI. CIMT and ghrelin did not alter significantly after 12 months of atorvastatin treatment (NS). Among participants, high-dose (80 mg) rather than low-dose (10 mg) of atorvastatin treatment yielded greater (P < 0.05) changes in apelin, visfatin and CIMT levels despite the final equivalent levels of LDL. Atorvastatin administration increased apelin and decreased visfatin serum levels significantly, without change of CIMT, in patients with T2DM. However, high-dose of atorvastatin exerted more favourable impact on adipokines and CIMT than low-dose. Our results implicate another important link between adiposity and atherosclerosis.

Epidemiological characteristics and in-hospital management of acute coronary syndrome patients in Greece: results from the TARGET study

INTRODUCTION

Conduction of national surveys is needed to depict temporal trends in the risk profile, type of implemented treatment strategy and outcome of patients with acute coronary syndromes (ACS). The TARGET study is a multicenter, observational study that aimed to evaluate the epidemiological characteristics, management pattern and outcome of ACS patients in Greece.

METHODS

A total of 418 consecutive patients with ACS (44.7% STEMI, 34.2% NSTEMI, 21.1% unstable angina) from 17 centers (52.9% with catheterization facilities) were enrolled in the study (78.0% males, 63.9 ± 12.9 years).

RESULTS

Overall, 67.9% of the patients had hypertension, 27.5% were diabetics and 57.4% had dyslipidemia. Thrombolytic therapy (60.7% tenecteplase, 38.2% reteplase) was administered in 22.7% of the study population, while invasive management was performed in 40.2% of patients (27.0% PCI and 1.0% CABG) during the index hospitalization. In-hospital all-cause mortality was 1.9%, with 12.2% of patients experiencing adverse clinical events. Evidence-based medications were prescribed to the majority of enrolled patients during hospitalization and upon discharge (97% and 94% received aspirin, 93% and 84% clopidogrel, 87% and 86% beta-blockers, 96% and 93% statins, respectively).

CONCLUSION

The prevalence of modifiable risk factors exhibits an increasing trend among ACS patients in Greece. The prescription pattern of evidence-based medications has improved considerably, while there remains considerable room for improvement in expanding the implementation of invasive management in realworld clinical practice.

The pathophysiology of HIV-/HAART-related metabolic syndrome leading to cardiovascular disorders: the emerging role of adipokines

Individuals infected with human immunodeficiency virus (HIV) frequently demonstrate metabolic syndrome (MS) associated with increased incidence of cardiovascular disorders. Characteristics of HIV infection, such as immunodeficiency, viral load, and duration of the disease, in addition to the highly active antiretroviral therapy (HAART) have been suggested to induce MS in these patients. It is well documented that MS involves a number of traditional cardiovascular risk factors, like glucose, lipids, and arterial blood pressure abnormalities, leading to extensive atherogenic arterial wall changes. Nevertheless, the above traditional cardiovascular risk factors merely explain the exacerbated cardiovascular risk in MS. Nowadays, the adipose-tissue derivatives, known as adipokines, have been suggested to contribute to chronic inflammation and the MS-related cardiovascular disease. In view of a novel understanding on how adipokines affect the pathogenesis of HIV/HAART-related MS and cardiovascular complications, this paper focuses on the interaction of the metabolic pathways and the potential cardiovascular consequences. Based on the current literature, we suggest adipokines to have a role in the pathogenesis of the HIV/HAART-related MS. It is crucial to understand the pathophysiology of the HIV/HAART-related MS and apply therapeutic strategies in order to reduce cardiovascular risk in HIV patients.

The impact of hypertension on systolic and diastolic left ventricular function. A tissue Doppler echocardiographic study

BACKGROUND

The purpose of this study is to assess the impact of hypertension on systolic function and diastolic function using 2-dimensional echocardiography, conventional Doppler imaging of the transmitral inflow, and tissue Doppler imaging (TDI) of the mitral annulus.

METHODS

From an outpatient clinic population, 414 consecutive patients underwent 2-dimensional echocardiography, conventional Doppler imaging of the transmitral inflow, and TDI of the septal, lateral, inferior, and posterior walls near the mitral annulus. Parameters of systolic left ventricular (LV) function and diastolic LV function were assessed. Patients were divided according to the presence or absence of systemic hypertension (blood pressure > or = 140/90 mm Hg on > or = 3 measurements or treatment with antihypertensive medication).

RESULTS

A complete echocardiographic evaluation was obtained in 397 patients. Among these, 269 (68%) had hypertension. There was no difference with respect to age between patients with and without hypertension. Patients with hypertension had higher LV mass index and relative wall thickness and lower TDI peak systolic velocity (V(S)) when compared with patients without hypertension. In addition, indices of diastolic LV function were significantly impaired in hypertensive patients.

CONCLUSIONS

Quantitative echocardiography using TDI reveals that hypertensive patients with preserved global LV systolic function often have combined impairment of systolic function and diastolic function.

Haemodynamics and gas exchange in liver cirrhosis: the effect of orally administered almitrine bismesylate

The present study was conducted to analyse the effect on haemodynamics and to evaluate the role of hypoxic pulmonary vasoconstriction (HPV) in cirrhotic patients with hypoxaemia using almitrine bismesylate, an agent which increases the response of HPV. Six male patients, mean age of 51 years, with hepatic cirrhosis and associated hypoxaemia were studied. All patients had normal lung and cardiac function tests. When the patients were clinically stable, right heart and radial artery catheterization were performed. Data from the pulmonary artery catheter and blood gases were obtained before and after 4 days of oral almitrine bismesylate. The results indicated that these cirrhotics were in a mild hyperdynamic circulatory state. The cardiac output (CO), cardiac index (CI), oxygen delivery (DO2), and oxygen consumption (VO2) were elevated while the pulmonary vascular resistance (PVR) and systemic vascular resistance (SVR) were low. Almitrine significantly increased PVR (P < 0.05) and mean pulmonary artery pressure (mPAP) (P < 0.01). In addition, almitrine improved alveolar arterial oxygen content difference [D(A-a)O2] (P < 0.01) and shunt fraction (Qva/QT) (P < 0.01). The PaCO2 and PaO2 increased slightly but this was not statistically significant. In conclusion, in our group of patients with hepatic cirrhosis, four days of treatment with almitrine improved their gas exchange. The data suggest a weak HPV response in this group of cirrhotics; that response may be enhanced by almitrine.