Impact of cigarette smoking on recurrence of hyperlipidemic acute pancreatitis

AIM

To investigate the impact of cigarette smoking on the recurrence rate and recurrence-free survival in patients with hyperlipidemic acute pancreatitis (HLAP).

METHODS

A total of 863 patients were admitted to our hospital for acute pancreatitis (AP) from January 2013 to March 2016, of whom 88 diagnosed with HLAP were enrolled in this retrospective study. Demographic data, medical history, previous episodes of pancreatitis, consumption of alcohol and cigarettes, as well as biochemical and hematological data were carefully recorded for univariate and multivariate analyses. During follow-up, the information on current smoking status and recurrent AP was gathered. Recurrence-free survival (RFS) was calculated using the Kaplan-Meier method, and the differences between groups were compared using the log-rank test.

RESULTS

No significant differences were observed between the three groups in age or medical history of hyperlipidemia, fatty liver, diabetes mellitus, hypertension, or AP. The current smokers had a remarkably higher recurrence rate and a greater incidence of repeated episodes of AP (50.0% and 77.8%, respectively) than non-smokers (9.8% and 39.0%), and these two percentages were reduced to 9.1% and 36.4% for patients who gave up smoking. The median follow-up time was 13.5 mo and HLAP recurred after hospital discharge in 23 (26.1%) patients. Multivariate analysis identified current smoking (HR = 6.3, P = 0.020) as an independent risk factor contributing to HLAP recurrence. Current smokers had significantly worse RFS than non-smokers (23 mo vs 42 mo), but no significant difference was documented between ex-smokers (34 mo) and non-smokers. The RFS was not significantly different between light and heavy smokers.

CONCLUSION

Smoking is associated with worse RFS and an increased rate of HLAP recurrence. Continued smoking correlates with a compromised survival and smoking cessation should be recommended.

Myocardial Structural and Biological Anomalies Induced by High Fat Diet in Psammomys obesus Gerbils

Background

Psammomys obesus gerbils are particularly prone to develop diabetes and obesity after brief period of abundant food intake. A hypercaloric high fat diet has been shown to affect cardiac function. Here, we sought to determine whether a short period of high fat feeding might alter myocardial structure and expression of calcium handling proteins in this particular strain of gerbils.

Methods

Twenty Psammomys obesus gerbils were randomly assigned to receive a normal plant diet (controls) or a high fat diet. At baseline and 16-week later, body weight, plasma biochemical parameters (including lipid and carbohydrate levels) were evaluated. Myocardial samples were collected for pathobiological evaluation.

Results

Sixteen-week high fat dieting resulted in body weight gain and hyperlipidemia, while levels of carbohydrates remained unchanged. At myocardial level, high fat diet induced structural disorganization, including cardiomyocyte hypertrophy, lipid accumulation, interstitial and perivascular fibrosis and increased number of infiltrating neutrophils. Myocardial expressions of pro-apoptotic Bax-to-Bcl-2 ratio, pro-inflammatory cytokines [interleukin (IL)-1β and tumor necrosis factor (TNF)-α], intercellular (ICAM1) and vascular adhesion molecules (VCAM1) increased, while gene encoding cardiac muscle protein, the alpha myosin heavy polypeptide (MYH6), was downregulated. Myocardial expressions of sarco(endo)plasmic calcium-ATPase (SERCA2) and voltage-dependent calcium channel (Cacna1c) decreased, while protein kinase A (PKA) and calcium-calmodulin-dependent protein kinase (CaMK2D) expressions increased. Myocardial expressions of ryanodine receptor, phospholamban and sodium/calcium exchanger (Slc8a1) did not change.

Conclusions

We conclude that a relative short period of high fat diet in Psammomys obesus results in severe alterations of cardiac structure, activation of inflammatory and apoptotic processes, and altered expression of calcium-cycling determinants.

Focal aorto-iliac atherosclerosis amenable to endovascular interventions though considered benign carry a significant risk of cardiovascular mortality: clinical investigation

AIM

Peripheral arterial disease (PAD) manifested as claudication is surprisingly stable regarding limb deterioration but may indicate increased risk for cardiovascular events and death. We examined whether focal atherosclerotic iliac lesions (TransAtlantic InterSociety Consensus for The Management of Peripheral Arterial Disease-TASC II Type A,B) undergoing endovascular procedures indicate a high risk for limb and life and what is the effect of atherosclerotic risk factors in the rate of adverse outcomes.

METHODS

We examined patients undergoing iliac endovascular interventions due to TASC II Type A,B lesions causing disabling claudication during a 10-year period. Outcome in terms of limb condition and total mortality during short and long-term follow-up was evaluated.

RESULTS

One-hundred thirty-nine patients and one-hundred seventy limbs were examined. Median follow-up was 4.3 years. There were 100 (58.8%) limbs with Type A and 70 (41.2%) with Type B lesions. Primary patency was 81.2% and secondary patency 92.4%. One-hundred fifteen (67.6%) limbs were improved whereas 42 (24.7%) remained stable and 13 (7.7%) deteriorated during long-term follow-up. Major amputation was performed in 2 and minor amputation in 2 limbs resulting in 2.4% total amputation rate. Overall mortality was 22.6% and 64.5% of all deaths represented cardiovascular events. Statistical analysis revealed significant relations of total mortality with hyperlipidemia and diabetes.

CONCLUSION

Endovascular treatment of localized iliac lesions offers good long-term results regarding patency, clinical improvement and limb salvage. Nevertheless, even focal atherosclerosis indicates a significant risk of cardiovascular mortality. Modification of atherosclerotic risk factors early in the course of PAD may be beneficial for these patients.

Progression of alterations in lipid metabolism in kidney transplant recipients over 5 years of follow-up

BACKGROUND

Alterations in lipid metabolism frequently affect kidney transplant recipients and contribute to the onset of metabolic and cardiovascular diseases that threaten graft integrity. The purpose of this research study was to investigate the pattern of hyperlipidaemia and its progression, as well as to study potential risk factors in kidney transplant recipients.

METHODS

In this study, 119 kidney transplant recipients of both sexes were monitored over a period of 5 years in our posttransplant clinic. During this period, all patients had pretransplant and posttransplant blood tests to measure levels of the following: total cholesterol, low-density lipoproteins (LDL), high-density lipoproteins (HDL) and triglycerides. Furthermore, the subjects were also weighed and their height measured. Their body mass index was then calculated using the weight (kg)/height (m(2) ) formula.

RESULTS

In the 5 years following the transplant, the patients experienced a significant increase in the levels of their biochemical markers as well as in their BMI. Consequently, a greater number suffered from dyslipidaemia, diabetes and hypertension.

CONCLUSIONS

Kidney transplants can often trigger hyperlipidaemia, as reflected in higher levels of total cholesterol, low-density lipoproteins and high-density lipoproteins. The results of our study also showed that despite statin therapy, the patients had higher triglyceride levels, which made them more vulnerable to diabetes, hypertension, cardiovascular disease and graft rejection.

Patterns of statin initiation, intensification, and maximization among patients hospitalized with an acute myocardial infarction

BACKGROUND

Intensive statins are superior to moderate statins in reducing morbidity and mortality after an acute myocardial infarction. Although studies have documented rates of statin prescription as a quality performance measure, variations in hospitals' rates of initiating, intensifying, and maximizing statin therapy after acute myocardial infarction are unknown.

METHODS AND RESULTS

We assessed statin use at admission and discharge among 4340 acute myocardial infarction patients from 24 US hospitals (2005-2008). Hierarchical models estimated site variation in statin initiation in naïve patients, intensification in those undergoing submaximal therapy, and discharge on maximal therapy (defined as a statin with expected low-density lipoprotein cholesterol lowering ≥ 50%) after adjustment for patient factors, including low-density lipoprotein cholesterol level. Site variation was explored with a median rate ratio, which estimates the relative difference in risk ratios of 2 hypothetically identical patients at 2 different hospitals. Among statin-naïve patients, 87% without a contraindication were prescribed a statin, with no variability across sites (median rate ratio, 1.02). Among patients who arrived on submaximal statins, 26% had their statin therapy intensified, with modest site variability (median rate ratio, 1.47). Among all patients without a contraindication, 23% were discharged on maximal statin therapy, with substantial hospital variability (median rate ratio, 2.79).

CONCLUSIONS

In a large, multicenter acute myocardial infarction cohort, statin therapy was begun in nearly 90% of patients during hospitalization, with no variability across sites; however, rates of statin intensification and maximization were low and varied substantially across hospitals. Given that more intense statin therapy is associated with better outcomes, changing the existing performance measures to include the intensity of statin therapy may improve care.

Marital status shows a strong protective effect on long-term mortality among first acute myocardial infarction-survivors with diagnosed hyperlipidemia--findings from the MONICA/KORA myocardial infarction registry

BACKGROUND

Reduction of long term mortality by marital status is well established in general populations. However, effects have been shown to change over time and differ considerably by cause of death. This study examined the effects of marital status on long term mortality after the first acute myocardial infarction.

METHODS

Data were retrieved from the population-based MONICA (Monitoring trends and determinants on cardiovascular diseases)/KORA (Cooperative Health Research in the Region of Augsburg)-myocardial infarction registry which assesses cases from the city of Augsburg and 2 adjacent districts located in southern Bavaria, Germany. A total of 3,766 men and women aged 28 to 74 years who were alive 28 days after their first myocardial infarction were included. Hazard ratios (HR) for the effects of marital status on mortality after one to 10 years of follow-up are presented.

RESULTS

The study population included 2,854 (75.8%) married individuals. During a median follow-up of 5.3 years, with an inter-quartile range of 3.3 to 7.6 years, 533 (14.15%) deaths occurred. Among married and unmarried individuals 388 (13.6%) and 145 (15.9%) deaths occurred, respectively. Overall marital status showed an insignificant protective HR of 0.76 (95% confidence interval (CI) 0.47-1.22). Stratified analyses revealed strong protective effects only among men and women younger than 60 who were diagnosed with hyperlipidemia. HRs ranged from 0.27 (95% CI 0.13-0.59) for a two-year survival to 0.43 (95% CI 0.27-0.68) for a 10-year survival. Substitution of marital status with co-habitation status confirmed the strata-specific effect [HR: 0.52 (95% CI 0.31-0.86)].

CONCLUSIONS

Marital status has a strong protective effect among first myocardial infarction survivors with diagnosed hyperlipidemia, which diminishes with increasing age. Treatments, recommended lifestyle changes or other attributes specific to hyperlipidema may be underlying factors, mediated by the social support of spouses. Underlying causes should be examined in further studies.

Rosuvastatin: a highly potent statin for the prevention and management of coronary artery disease

Since the identification of a fungal metabolite that inhibits HMG-CoA reductase in 1976, statins have emerged rapidly as the global leader in pharmacotherapeutics designed to lower low-density lipoprotein cholesterol (LDL-C). In conjunction, practice guidelines have recommended increasingly aggressive measures to improve coronary heart disease (CHD) outcomes by lowering LDL-C. By virtue of unique chemical characteristics, enhanced binding thermodynamics and limited cytochrome P450 3A4 metabolism, rosuvastatin calcium has a safety profile in line with currently marketed statins, but a different efficacy profile. Mirroring this chemical profile, the GALAXY program represents a comprehensive evaluation of the efficacy, safety and cost-effectiveness of rosuvastatin in individuals representing various clinical diagnoses, pathophysiological states and ethnicities. Also results from the Justification for the Use of statins in Primary prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) study could provide further evidence for the use of rosuvastatin in individuals with traditional and emerging CHD risk factors, such as an elevated high sensitivity C-reactive protein level. This review will provide a comprehensive evaluation of the chemistry, clinical efficacy, safety and tolerability of rosuvastatin, and discuss the future role in the management of CHD and atherosclerosis.

Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden.

METHODS

Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.

RESULTS

The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions.

CONCLUSIONS

The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality.

Treatment strategies in patients with statin intolerance: the Cleveland Clinic experience

BACKGROUND

Statin therapy is a proven effective treatment of hyperlipidemia. However, a significant number of patients cannot tolerate statins. This study was conducted to review treatment strategies for patients intolerant to statin therapy with a focus on intermittent statin dosing.

METHODS AND RESULTS

We performed a retrospective analysis of medical records of 1,605 patients referred to the Cleveland Clinic Preventive Cardiology Section for statin intolerance between January 1995 and March 2010 with at least a 6-month follow-up. The changes in lipid profile, achievement of low-density lipoprotein cholesterol (LDL-C) goals, and statin tolerance rate were analyzed. Most (72.5%) of patients with prior statin intolerance were able to tolerate a statin for the median follow-up time of 31 months. Patients on intermittent statin dosing (n = 149) had significantly lower LDL-C reduction compared with daily dosing group (n = 1,014; 21.3% ± 4.0% vs 27.7% ± 1.4%, P < .04). However, compared with the statin discontinued group (n = 442), they had a significantly higher LDL-C reduction (21.3% ± 4.0% vs 8.3 ± 2.2%, P < .001), and a significantly higher portion achieved their Adult Treatment Panel III goal of LDL-C (61% vs 44%, P < .05). There was a trend toward a decrease in all-cause mortality at 8 years for patients on daily and intermittent statin dosing compared with those who discontinued statin (P = .08).

CONCLUSIONS

Most patients with previous statin intolerance can tolerate subsequent trial of statin. A strategy of intermittent statin dosing can be an effective therapeutic option in some patients and may result in reduction in LDL-C and achievement of LDL-C goals.

Cost-effectiveness of statins revisited: lessons learned about the value of innovation

BACKGROUND

The economic evaluation of statins has undergone a development from risk-factor-based models to modeling of hard end points in clinical trials with a shift back to risk-factor models after increased confidence in their predictive power has now been established. At this point, we can look back on the historical economic data on simvastatin to see what lesson regarding reimbursement we can learn.

METHODS

Historical data on the usage and sales of simvastatin in Sweden were combined with published epidemiological and clinical data to calculate the social value of simvastatin to the present day and to make projection until projected until 2018. The distribution of the social surplus was calculated by taking the costs born by society and the producer of the drug into consideration.

RESULTS

The cost of simvastatin fell drastically following patent expiration, although the number of treated patients has continued to grow. Presently, the use of simvastatin is close to cost neutrality taking direct and indirect cost savings from reduced morbidity into account. However, the major part of the social surplus generated comes from the value of improved quality-adjusted survival. Of the social surplus generated, the producer appropriated 20-43% of the value during the on-patent period, a figure dropping to 1% following loss of exclusivity. The total producer surplus between 1987 and 2018 is 2-5% of the total social surplus.

CONCLUSION

Only a small part of the surplus value generated was appropriated by the producer. A regulatory and reimbursement approach that favors early market access and coverage with evidence development as opposed to long-term trials as a pre-requisite for launch is more attractive from both a company and social perspective.

Meta-analysis of the cardiovascular benefits of intensive lipid lowering with statins

OBJECTIVE

To evaluate the efficacy of intensive lipid lowering with higher-dose statins.

METHODS

Meta-analysis of seven randomized controlled trials comprising 50,972 participants.

RESULTS

Mean follow-up was 3.1 years with mean age 63 years. Final LDL-C levels in intensive lipid-lowering group were 1.42-2.07 mmol/l compared to 2.1-3.5 mmol/l in the less intensive or control group. The intensive arm had significantly lower risks for stroke OR 0.80 (95% CI 0.71-0.89); major coronary events OR 0.74 (95% CI 0.65-0.83); cardiovascular disease (CVD) or coronary heart disease (CHD) deaths OR 0.84 (95% CI 0.74-0.95). Significantly higher liver enzyme abnormalities occurred in intensive group* (OR 3.96; 95% CI 2.08-7.53), but it was not associated with drug discontinuations (OR 1.20; 95% CI 0.88-1.64).

CONCLUSION

In those at high risk of cardiovascular events, intensive lipid lowering with statins to LDL-C level <2.1 mmol/l significantly reduces risk of stroke, major coronary events and CVD or CHD deaths compared to LDL-C level ≥ 2.1 mmol/l. [*Correction added on 11 January 2011 after first online publication on 27 October 2010. The phrase, "Significantly higher liver enzyme abnormalities occurred in less intensive group", was amended to "Significantly higher liver enzyme abnormalities occurred in intensive group".].

The association between symptomatic, severe hypoglycaemia and mortality in type 2 diabetes: retrospective epidemiological analysis of the ACCORD study

OBJECTIVE

To determine whether there is a link between hypoglycaemia and mortality among participants in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial.

DESIGN

Retrospective epidemiological analysis of data from the ACCORD trial. Setting Diabetes clinics, research clinics, and primary care clinics.

PARTICIPANTS

Patients were eligible for the ACCORD study if they had type 2 diabetes, a glycated haemoglobin (haemoglobin A(1C)) concentration of 7.5% or more during screening, and were aged 40-79 years with established cardiovascular disease or 55-79 years with evidence of subclinical disease or two additional cardiovascular risk factors. Intervention Intensive (haemoglobin A(1C) <6.0%) or standard (haemoglobin A(1C) 7.0-7.9%) glucose control.

OUTCOME MEASURES

Symptomatic, severe hypoglycaemia, manifest as either blood glucose concentration of less than 2.8 mmol/l (<50 mg/dl) or symptoms that resolved with treatment and that required either the assistance of another person or medical assistance, and all cause and cause specific mortality, including a specific assessment for involvement of hypoglycaemia.

RESULTS

10 194 of the 10 251 participants enrolled in the ACCORD study who had at least one assessment for hypoglycaemia during regular follow-up for vital status were included in this analysis. Unadjusted annual mortality among patients in the intensive glucose control arm was 2.8% in those who had one or more episodes of hypoglycaemia requiring any assistance compared with 1.2% for those with no episodes (53 deaths per 1924 person years and 201 deaths per 16 315 person years, respectively; adjusted hazard ratio (HR) 1.41, 95% CI 1.03 to 1.93). A similar pattern was seen among participants in the standard glucose control arm (3.7% (21 deaths per 564 person years) v 1.0% (176 deaths per 17 297 person years); adjusted HR 2.30, 95% CI 1.46 to 3.65). On the other hand, among participants with at least one hypoglycaemic episode requiring any assistance, a non-significantly lower risk of death was seen in those in the intensive arm compared with those in the standard arm (adjusted HR 0.74, 95% 0.46 to 1.23). A significantly lower risk was observed in the intensive arm compared with the standard arm in participants who had experienced at least one hypoglycaemic episode requiring medical assistance (adjusted HR 0.55, 95% CI 0.31 to 0.99). Of the 451 deaths that occurred in ACCORD up to the time when the intensive treatment arm was closed, one death was adjudicated as definitely related to hypoglycaemia.

CONCLUSION

Symptomatic, severe hypoglycaemia was associated with an increased risk of death within each study arm. However, among participants who experienced at least one episode of hypoglycaemia, the risk of death was lower in such participants in the intensive arm than in the standard arm. Symptomatic, severe hypoglycaemia does not appear to account for the difference in mortality between the two study arms up to the time when the ACCORD intensive glycaemia arm was discontinued.

TRIAL REGISTRATION

NCT00000620.

[Management of diabetes in cardiac diseases]

Type 2 diabetes mellitus (DM) is a common disease affecting people in the world and its incidence is increasing rapidly. Cardiovascular disease (CVD) is the most important cause of mortality and morbidity among patients with type 2 DM. Patients with diabetes have a poorer prognosis than patients without diabetes. It is well known that other cardiovascular risk factors such as hyperlipidemia, hypertension and obesity that usually accompany to diabetes mellitus or impaired glucose tolerance as a metabolic syndrome component or not, can contribute to accelerated atherosclerosis and increased risk of cardiovascular event in diabetes mellitus. The management of patient with type 2 DM is not only glucocentric but focuses on multiple risk factor intervention.

The clinical and economic burden of nonadherence with antihypertensive and lipid-lowering therapy in hypertensive patients

OBJECTIVE

We sought to determine lifetime costs, morbidity, and mortality associated with varying adherence to antihypertensive and 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statin) therapy in a hypertensive population.

METHODS

A model was constructed to compare costs and outcomes under three adherence scenarios: no treatment, ideal adherence, and real-world adherence. Simulated patients' characteristics matched those of participants in the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid-Lowering Arm and event probabilities were calculated with Framingham Heart Study risk equations. The real-world adherence scenario employed adherence data from an observational study of a US population; risk reductions at each level of adherence were based on linear extrapolations from clinical trials. Outputs included life expectancy, frequencies of primary and secondary coronary heart disease and stroke, and direct medical costs in 2006 US$. The incremental cost per life-year gained and incremental cost per event avoided were calculated comparing the three adherence scenarios.

RESULTS

Mean life expectancy was 14.73 years (no-treatment scenario), 15.07 (real-world adherence), and 15.49 (ideal adherence). The average number of cardiovascular events per patients was 0.738 (no treatment), 0.610 (real-world adherence), and 0.441 (ideal adherence). The incremental cost of real-world adherence versus no treatment is $30,585 per life-year gained, and ideal adherence versus real-world adherence is $22,121 per life-year gained.

CONCLUSIONS

Hypertensive patients taking antihypertensive and statin therapy at real-world adherence levels can be expected to receive approximately 50% of the potential benefit seen in clinical trials. Depending on its cost, the incremental benefits of an effective adherence intervention program could make it an attractive value.

Frequency of abnormal findings detected by comprehensive clinical evaluation at 1 year after allogeneic hematopoietic cell transplantation

Consensus guidelines recommend various screening examinations for survivors after allogeneic hematopoietic cell transplantation (HCT), but how often these examinations detect abnormal findings is unknown. We reviewed the medical records of 118 patients who received comprehensive, standardized evaluations at 1 year after allogeneic HCT at Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance. Abnormal findings were common, including moderate to severe pulmonary dysfunction (16%), fasting hyperlipidemia (56%), osteopenia (52%), osteoporosis (6%), and active chronic graft-versus-host disease (cGVHD) (64%). Recurrent malignancy (4%) and cGVHD (29%) were detected in previously unsuspected cases. Only 3% of patients had no abnormal findings. We conclude that comprehensive evaluation at 1 year after allogeneic HCT detects a high prevalence of medical problems. Longer follow-up is needed to determine whether early detection and intervention affect later morbidity and mortality.

[Update of lipid lowering therapy]

Dyslipidemia is one of the most important cardiovascular risk factors. Accordingly preventive measures to normalize lipids are of great importance. The indication for a lipid lowering therapy according to current guidelines focuses on the identification of a patient's global risk, i.e. the contribution of all major cardiovascular risk factors. The selection of the lipid lowering therapy should be appropriate for the kind of lipid disorder. This may be a special challenge with respect to target values and safety aspects. Statins in monotherapy are generally considered safe drugs. Higher dosages may be associated with liver toxicity and muscle problems. Lifestyle management should underpin all lipid management strategies.

Relation of plasma lipids to all-cause mortality in Caucasian, African-American and Hispanic elders

OBJECTIVES

to investigate the relation of plasma lipids to all-cause mortality in a multi-ethnic cohort of non-demented elderly.

SETTING

community-based sample of Medicare recipients, 65 years and older, residing in Northern Manhattan.

PARTICIPANTS

about two thousand five hundred and fifty-six non-demented elderly, 65-103 years. Among participants, 66.1% were women, 27.6% were White/non-Hispanic, 31.2% were African-American and 41.2% were Hispanic.

METHODS

a standardised assessment, including functional ability, medical history, physical and neurological examination and a neuropsychological battery was conducted. Vital status was ascertained through the National Death Index (NDI). We used survival analyses stratified by race and ethnicity to examine the relation of plasma lipids to subsequent all-cause mortality.

RESULTS

hispanics had the best overall survival, followed by African-Americans and Whites. Whites and African-Americans in the lowest quartiles of total cholesterol, non-HDL cholesterol and low-density lipoprotein cholesterol (LDL cholesterol) were approximately twice as likely to die as those in the highest quartile (White HR: 2.2, for lowest total cholesterol quartile; HR: 2.3, for lowest non-HDL cholesterol quartile; and HR: 1.8, for lowest LDL cholesterol quartile. African-American HR: 1.9, for lowest total cholesterol, HR: 2.0, for lowest non-HDL cholesterol and HR: 1.9, for lowest LDL cholesterol). In contrast, plasma lipid levels were not related to mortality risk among Hispanics.

CONCLUSIONS

hispanic ethnicity modifies the associations between lipid levels and all-cause mortality in the elderly.

Hyperlipidemia After Renal Transplantation and Its Relation to Graft and Patient Survival

INTRODUCTION

Hyperlipidemia is a multifactorial event that frequently develops following renal transplantation and may worsen the patient's prognosis. The aim of this study was to evaluate the incidence and concomitant factors for hyperlipidemia.

METHODS

We studied 687 renal transplant recipients from 1988 to 2004 using a cross-sectional design to determine the frequency of hypercholestrolemia and hypertriglyceridemia before and 1 month to 1 year after renal transplantation, to evaluate its relation to patient and graft prognosis in two medical centers in Iran. Cyclosporine was the constant part of immunosuppressive treatment in all study subjects.

RESULTS

One and 5-year graft survival times were 94.23% and 81.34%, respectively. The prevalence of hypercholestrolemia after transplantation was 59.9%. Mean (+/- 2 SE) serum cholesterol levels before and after transplantation were 161.15 +/- 3.81 and 213.83 +/- 4.53 mg/dL respectively (P=.000). Triglycerides levels, were 159.99 +/- 13.08 and 196.28 +/- 19.6 mg/dL respectively. There was no significant correlation between cyclosporine dose, graft and patient survivals, and severity of hyperlipidemia (determined by cholesterol and triglyceride levels).

CONCLUSIONS

Lipid metabolism abnormalities observed in this study were similar to other reports. There was no correlation with patient or graft survival. In addition, there may routes for development of hyperlipidemia other than adverse complications of immunosuppressive drugs.

[Clinical trials of statins and fibrates --a meta-analysis]

INTRODUCTION

Several clinical trials of hypolipidemics showed a decrease in mortality by 30-40%, while others showed detrimental or no effects. The question remains: which trial should be the basis of clinical decision making in the choice of hypolipidemic therapy?

MATERIAL AND METHODS

Meta-analysis is a method for combining research results of several studies. Effects of statins and fibrates with respect to placebo, were assessed by systematic literature review and meta-analysis. Medline and CENTRAL databases were searched using the following keywords: hyperlipoproteinemia, hypolipidemic agents and individual drug names. The main inclusion criteria were as follows: statin or fibrate, placebo controlled randomized trial, at least one year treatment on average, at least 100 patients per study arm and reported mortality.

RESULTS

Fibrates showed almost complete absence of treatment effects on mortality with odds ratio of 0.99 and 95% confidence interval 0.80 - 1.11. The odds for statins were 0.87, 0.80 - 0.95.

DISCUSSION

Despite the absence of treatment effects of fibrates, it is noteworthy that inclusion criteria of early fibrate trials focused mainly on cholesterol with recent identification of elevated triglycerides as an independent risk factor. As fibrates exert the most pronounced effect on triglycerides, they still may show effect in target populations. Effects of statins are confirmed, but they are noticeably lower than in individual trials which are given most publicity.

CONCLUSION

Even after several decades of fibrate use, conclusive evidence of their beneficial effects still needs to be elucidated in appropriately designed trials. However, a beneficial effect of statins on mortality decrease has been proven. Meta-analysis has an important role in estimating true treatment effects and in the practice of evidence-based medicine.

Benefits of achieving the NCEP optional LDL-C goal among elderly patients with ACS

AIMS

To assess the efficacy and safety of the achievement of the NCEP goal of LDL-C <1.8 mmol/L in elderly patients with ACS.

METHODS AND RESULTS

The relationship between LDL-C at 30 days after ACS and subsequent clinical outcomes were compared among elderly patients (aged > or =70 years) vs. younger counterparts in the PROVE IT-TIMI 22 trial, using the composite endpoint of death, myocardial infarction, or unstable angina. Among 634 elderly patients, the achievement of the NCEP goal was associated with an 8% absolute and a 40% relative lower risk of events [Hazard ratio (HR) 0.60, 95% confidence interval (CI) 0.41-0.87, P = 0.008] vs. corresponding benefits of 2.3 and 26% in 3150 younger patients (HR 0.74, 95% CI 0.59-0.94, P = 0.013). The estimated number of events preventable among the elderly by the achievement of these goals was 80 events at 2 years for every 1000 patients at goal vs. those not at goal, compared with 23 events potentially prevented in younger patients. The incidence of major side effects among the elderly was similar to that in younger patients and did not differ with the intensity of the statin regimen.

CONCLUSION

Among elderly ACS patients, achieving the new NCEP LDL-C optional goal as part of a secondary prevention strategy can be both as safe and effective as in younger patients.

The Effects of Lipid-Lowering Therapy on Graft Patency in Coronary Bypass Surgery Patients

BACKGROUND

Our aim was to investigate the effects of lipid-lowering treatment (LLT) on graft patency in coronary artery bypass grafting (CABG) patients.

METHODS

A total of 209 CABG patients (95 men, 45%) with a total cholesterol level above 200 mg/dL and a low-density lipoprotein level above 100 mg/dL were included. Patients were divided into 2 groups on the basis of administration of LLT after CABG: group 1 received LLT after the operation (those patients undergoing operations after 1998, n = 102, 49% male) and group 2 did not receive LLT after the operation (those patients undergoing operations between 1992 and 1998, n = 107, 42% male). Median duration of follow-up was 5.2 years. Follow-up angiography could be obtained in 108 (52%) patients (56 in group 1, 52 in group 2).

RESULTS

There was a 42% reduction in ischemic events and deaths in group 1, and 60% of these patients had a symptom-free or event-free period for 6 years. The 5-year graft patency for left internal mammary artery-to-left anterior descending artery grafts in group 1 was 95%, and the corresponding figure was 90% in group 2. Right coronary artery-to-saphenous vein graft patency was 66% for group 1 and 30% for group 2. Circumflex artery-to-saphenous vein patency rate was 59% for group 1 and 53% for group 2. A higher graft patency was found in group 1 as a whole.

CONCLUSION

Results of this retrospective study support the fact that LLT provides a higher graft patency for CABG patients.

Selective prescribing led to overestimation of the benefits of lipid-lowering drugs

OBJECTIVE

Observational studies have found beneficial effects of lipid-lowering drugs on diverse outcomes, including venous thromboembolism, hip fracture, dementia, and all-cause mortality. Selective use of these drugs in frail people may confound these relationships.

STUDY DESIGN AND SETTING

We measured 1-year mortality in two cohorts of New Jersey residents, aged 65-99 years, enrolled in state-sponsored drug benefits programs: 112,463 persons hospitalized during the years 1991-1994 and 106,838 nonhospitalized enrollees. Use of lipid-lowering drugs and other medications, as well as diagnoses, were evaluated before follow-up.

RESULTS

In age- and sex-adjusted analyses, users of lipid-lowering drugs had a 43% reduced death rate relative to nonusers among hospitalized enrollees and a 56% reduction in the nonhospitalized sample. Available markers of frailty and comorbidity predicted decreased use of these drugs. Control for the propensity to use lipid-lowering drugs attenuated but did not eliminate these effects. After such adjustment, users had a 30% reduction in death rate (95% confidence interval [CI]: 25%-35%) among hospitalized enrollees and a 41% reduction (95% CI: 35%-47%) in the nonhospitalized sample. Unmeasured frailty associated with a 26%-33% reduced odds of receiving lipid-lowering therapy could explain this effect.

CONCLUSION

Frailty and comorbidity that influence use of preventive therapies can substantially confound apparent benefits of lipid-lowering drugs on outcomes.

[The role of lipid metabolism in the prevention of coronary heart disease]

Prevention of cardiovascular disease should be considered as a continuum from low to high risk: those at the highest risk are patients with clinically manifest cardiovascular disease, followed by subjects without known cardiovascular disease at different levels of risk from high to low. Today there is clear evidence that an independent relationship exists between plasma LDL cholesterol levels and the risk for coronary heart disease. The relationship between other plasma lipoproteins and atherosclerosis is more complex. The threshold for individuals requiring LDL cholesterol reduction is determined by epidemiological data, randomized controlled trials, and economic considerations. Patients with familial dyslipidemia suffer early coronary morbidity and mortality. For these patients, consequent lowering of LDL cholesterol should be the primary objective. For patients with established coronary heart disease or other atherosclerotic disease and for those with diabetes, there is significant evidence that reducing LDL cholesterol, irrespective of the initial values, reduces the risk of further coronary events, stroke, and total mortality. For asymptomatic individuals, the treatment of plasma lipids should be based on their absolute coronary risk, including other cardiovascular risk factors. The goals for plasma LDL cholesterol have been set in national and international recommendations. The goals for LDL cholesterol in patients with low, moderate and high coronary risk are <160, <130 and 100 mg/dl, respectively. In some very high risk patients LDL level markedly below 100 mg/dl should be aimed at. HDL cholesterol and triglyceride measurements should be used to identify individuals at high multifactorial risk of cardiovascular disease and used as additional considerations in the selection of lifestyle and drug interventions.

Independent Effect of Cardiac Rehabilitation on Lipids in Coronary Artery Disease

PURPOSE

We evaluate the effects cardiac rehabilitation (CR) participation independent of using lipid-altering agents (LAAs) on low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, total cholesterol, and triglyceride. Measurements included absolute and relative change in lipids and increases in percent of patients achieving goals.

METHODS

Analysis of 766 patients who participated in CR between 2000 and 2003 was performed. On enrollment to CR, all were being treated with an LAA defined as HIviG-CoA reductase inhibitors, bile acid sequestrant, fibrate, and niacin, hormone replacement therapy. Preenrollment and postenrollment lipids were obtained. Analysis was performed on 2 cohorts, participants enrolled on an LAA with no change in medication (n = 13) and participants enrolled on an LAA with a change in medications (n = 153).

RESULTS

At completion of CR, 74.9% of patients on LAA at enrollment with no medication adjustments during the program were at Adult Treatment Panel III goal for low-density lipoprotein cholesterol compared with 68.5% at entry (P = .01), all other lipid parameters also significantly improved. Sixty-three percent who started CR on an LAA and had dose adjustment or an additional LAA added achieved low-density lipoprotein cholesterol goal compared with 43.1% at entry (P < .0001).

CONCLUSION

Participation in CR significantly potentiates the lipid-improving effects of pharmacological therapy and independently contributed to the percent of patients achieving all lipid levels at Adult Treatment Panel III goal.

Treatment of high-risk patients with diabetes: motivation and teaching intervention: a randomized, prospective 8-year follow-up study

The aim of this study was to examine whether motivating patients to gain expertise and closely follow their risk parameters will attenuate the course of microvascular and cardiovascular sequelae of diabetes. A randomized, prospective study was conducted of 165 patients who had type 2 diabetes, hypertension, and hyperlipidemia and were referred for consultation to a diabetes clinic in an academic hospital. Patients were randomly allocated to standard consultation (SC) or to a patient participation (PP) program. Both groups were followed by their primary care physicians. The mean follow-up was 7.7 yr. The SC group attended eight annual consultations. The PP patients initiated on average one additional consultation per year. There were 80 cardiovascular events (eight deaths) in the SC group versus 47 events (five deaths) in the PP group (P = 0.001). The relative risk (RR) over 8 yr for a cardiovascular event in the intervention (PP) versus the control (SC) group was 0.65 (95% confidence interval, 0.89 to 0.41). There were 17 and eight cases of stroke in the SC and PP groups, respectively (P = 0.05). RR for stroke was 0.47 (95% confidence interval, 0.85 to 0.32). In the SC group, 14 patients developed overt nephropathy (four ESRD) versus seven (one ESRD) in the PP group (P = 0.05). Throughout the study period, BP, LDL cholesterol, and hemoglobin A1c were significantly lower in the PP than in the SC patients. Well informed and motivated patients were more successful in obtaining and maintaining good control of their risk factors, resulting in reduced cardiovascular risk and slower progression of microvascular disease.

Medical morbidity and mortality in schizophrenia: guidelines for psychiatrists

BACKGROUND

Medical morbidity and mortality rates remain elevated in schizophrenia patients compared with the general population, in part due to potentially reversible medical risk factors. Psychiatrists should address this problem by adopting established strategies for prevention and intervention.

METHOD

The literature on modifiable medical risk factors relevant to individuals with schizophrenia and corresponding guidelines for prevention and treatment established by expert consensus panels were reviewed.

RESULTS

Schizophrenia patients are at elevated risk for cardiovascular disease due to high rates of cigarette smoking and, increasingly, due to obesity, diabetes, and hypertriglyceridemia. Rates of human immunodeficiency virus infection and infectious hepatitis are also higher in schizophrenia patients. Interventions that have reduced medical morbidity in the general population can be adopted to reduce premature mortality in individuals with schizophrenia.

CONCLUSIONS

Patients with schizophrenia have high rates of potentially reversible medical morbidity. Implementation of practice guidelines for identifying and modifying risk factors could substantially improve the health of patients with schizophrenia.

Causes et caractéristiques des décès des patients infectés par le VIH-1, en succès immuno-virologique sous traitement antirétroviral

INTRODUCTION

To analyse the causes of death among HIV-infected adults in France in the year 2000.

METHODS

Based on data from a national survey, our study describes and analyses the causes and characteristics of patients with immunological and virological response (CD4>200/mm3, ARN-HIV<500 copies/mL), who died during antiretroviral treatment.

RESULTS

Among a total of 964 deaths registered, data on 864 cases were available for analysis. One hundred forty-nine patients (17%)were immunovirological responders. The underlying causes of death were non AIDS-defining malignancies for 36 (24%), mainly due to lung cancer (16 cases), hepatocarcinoma (7) and ano-rectal carcinoma (3), AIDS for 22 (15%), mainly due to Non Hodgkin Lymphoma (10 cases) and uterine cancer (3), cardiovascular diseases for 22 (15%), post hepatitis C hepatic failure for 16 (11%), suicide for 16 (11%), and bacterial infections for 14(9%). When comparing characteristics of death in the 149 responders versus the 715 other patients, the responders were significantly more frequently: co-infected by HCV+ (45 vs. 33%), injected drug addicts (40 vs. 27%),alcoholics (38 vs. 28 %), and dyslipidemics (19 vs. 11%). In 2000,around 20% of registered deaths of HIV patients in France had occurred among good immunovirological responders.

CONCLUSION

To further reduce mortality among such efficiently treated patients, attention must be focused on treatable conditions such as hepatitis C, dyslipidemia and on the prevention of malignancies such as lung cancer and cervical or ano-rectal carcinoma.

Managing dyslipidemia in chronic kidney disease

OBJECTIVE

Patients with chronic kidney disease (CKD) are at higher risk for cardiovascular disease (CVD) than patients in the general population. One potentially modifiable risk factor for CVD in patients with CKD is dyslipidemia. In the current manuscript we review observational and trial data assessing dyslipidemia and its treatment in this patient population.

RESULTS

Observational studies have noted a "reverse epidemiology" in patients with CKD such that low total cholesterol levels are associated with a higher mortality rate. The complex lipid profile of patients with CKD also raises questions as to whether lipid-lowering therapy will be beneficial in this patient population. Although there are only a few trials assessing the relationship between lipid-lowering therapy and CVD outcomes in CKD patients, many lipid-lowering medications are both safe and effective. In addition, there is suggestive evidence that statin therapy, in particular, also may reduce inflammation and slow the decline in glomerular filtration rate (GFR) in patients during the earlier stages of CKD.

CONCLUSION

Because of the high rate of CVD in patients with CKD and the overall safety of most medical therapies for dyslipidemia in CKD, current guidelines from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative recommend aggressive therapy of dyslipidemia. These guidelines do, however, acknowledge the paucity of trial data in this patient population. There are 3 ongoing randomized controlled trials that are assessing the effect of statin therapy on CVD outcomes. These studies will hopefully provide definitive answers as to the appropriate treatment of dyslipidemia in CKD.

Evidence-based treatment of lipids in the elderly

The elderly (men aged 65 years and older and women aged 75 years and older) constitute a population at high absolute risk for the morbidity and mortality of atherosclerotic cardiovascular disease. Statins have been shown in multiple large trials to reduce the burden of atherosclerotic disease in both middle-aged and elderly patients at elevated risk for coronary events, stroke, and death. We reviewed the major statin trials with particular emphasis on the significant number of elderly subjects. The impact of statins on the elderly, both positive and negative, is tabulated. In addition, we briefly discuss risk assessment in the elderly because selection of elderly patients for intensive low-density lipoprotein cholesterol reduction with statins requires clinical judgment that must weigh the need for subclinical measures of atherosclerosis. We also consider negative aspects, risks, and costs of such therapy.

Fasting triglycerides as a predictor of long-term mortality in middle-aged men with combined hyperlipidaemia

OBJECTIVE

To study cholesterol, triglycerides, smoking and blood pressure as potential predictors of long-term mortality in middle-aged males with combined hyperlipidaemia.

METHODS

The study included 104 healthy men aged 40-49 years with total serum cholesterol >6.45 mmol/L and fasting triglycerides >2.55 mmol/L within the randomized diet and smoking cessation trial of the Oslo study (n=1232).

RESULTS

Thirty-three subjects died during the 24-year observation period. Univariate analysis showed that only age, fasting triglycerides and smoking were significantly related to mortality. An analysis for trend through quartiles of triglycerides showed a statistically significant association with mortality (p=0.049). Subjects in the lowest triglyceride quartile (2.55-2.75 mmol/L) had a 70%, reduction in mortality compared with the remaining subjects (>2.75 mmol/L) (RR=0.30, 95% CI 0.10-0.90, p=0.014). Non-smokers had a 60% reduced mortality compared with smokers (RR=0.40, 95% CI 0.17-0.94, p=0.019). When studied in a Cox regression analysis, with age, triglycerides and smoking as independent variables, triglycerides were significantly related to mortality, 1st quartile vs. 2nd, 3rd and 4th quartiles: risk rate=0.24, (95% CI 0.07-0.77, p=0.02). For non-smokers vs. smokers, the Cox analysis showed a risk rate=0.39, (95% CI 0.15-1.02, p=0.054).

CONCLUSION

This study indicates that high levels of fasting triglycerides (>2.75 mmol) are independently associated with increased late mortality in healthy middle-aged men with combined hyperlipidaemia.

A long-term follow-up study of serum lipid levels and coronary heart disease in the elderly

BACKGROUND

It is still controversial whether or not the correlation between lipid abnormality and coronary heart disease (CHD) becomes weaker in the elderly, and whether patients above 80 years old still benefit from lipid management for the secondary prevention of CHD. The purpose of this study is to assess the correlation between hyperlipidemia and the risk of CHD events in the elderly, and to determine if it is appropriate to use lipid-lowering drugs in those aged above 80, as prescribed by the recommended guidelines for lipid management.

METHODS

One thousand two hundred and eleven retirees, mainly males (92%), aged 70 +/- 9 years, were enrolled in this study. Lifestyle habits and medical history were recorded via questionnaires. During the period 1986 - 2000, all subjects participated in an annual physical examination with a blood chemistry survey. The mean follow-up period was 11.2 years. Subjects with incidental illnesses, especially cardiovascular diseases, were diagnosed or treated promptly. Serum lipid parameters, including total cholesterol (TC), low and high-density lipoprotein cholesterol (LDL-C and HDL-C) and triglyceride (TG) levels were analyzed according to standardization of lipid and lipoprotein measurements. The association between lipid levels and the prevalence of acute myocardial infarction (AMI) or coronary death was analyzed statistically.

RESULTS

Lipid abnormalities occurred in 2/3 of the 1211 subjects. The most common lipid disorder was high TC and high LDL-C, which was much more prevalent than high TG. Among the subjects, 51.6% had TC levels above 5.2 mmol/L. Mean TC and LDL-C reached peak levels in the 65 - 74 age group without significant decrease until ages over 90. The cumulative total number of deaths due to various causes was 397 in the 15-year follow-up period, with the mortality rate in the high lipid group slightly lower than that in the normal lipid group (30.6% vs 35.3%), although the difference was not significant (P = 0.1931). However, there were more cases of coronary death in the high lipid group than in the normal lipid group (7.9% vs 4.6%, P = 0.0045). When examining AMI survivors, more AMI cases were found in the high lipid group than in the low lipid group (20.9% vs 11.4%, P < 0.0001). The cumulative number of coronary deaths was 89 (with 88 cases above age 70), and the total number of CHD cases was 214 (17.7% of the whole group). Logistic regression analysis reveals that age, hypertension, LDL-C, and HDL-C are important risk factors for CHD. Lifestyle changes were common, but only 45% of the hyperlipidemic cases received drug treatment. Statins were commonly used only in recent years.

CONCLUSION

The above results show that high TC and LDL-C levels are correlated with a high CHD risk even in people over 80. For elderly patients with clinical CHD and an aggregation of CHD risk factors, cholesterol-lowering therapy might be considered if the general health of the patient makes this permissible.

Effect of diet intervention on long-term mortality in healthy middle-aged men with combined hyperlipidaemia

OBJECTIVES

The aim was to study the effect of a 5-year diet intervention on 24-year mortality in middle aged men with combined hyperlipidaemia.

SETTING

We studied 104 initially healthy men (in 1972) aged 40-49 years with baseline values of total serum cholesterol >6.45 mmol L-1 and fasting triglycerides >2.55 mmol L-1, within the randomized diet and smoking cessation trial of the Oslo study (n = 1232).

METHODS

The participants were randomized to a 5-year diet intervention or a control group. The diet consisted of a traditional lipid-lowering diet with emphasis on reduction of saturated fat, total caloric intake and body weight. The groups were initially well balanced with regard to traditional risk factors for mortality.

RESULTS

Thirty-three subjects died during the 24-year observation period [17 of cardiovascular disease (CVD) and 12 of cancer]. In the diet intervention group, mortality was 51% lower (RR = 0.49, 95% CI 0.22-0.91, P = 0.022) as compared with the control group. This difference remained significant in a Cox regression analysis after adjusting for age and smoking status (RR = 0.47, 95% CI 0.23-0.96, P = 0.038).

CONCLUSION

This study indicates that the investigated 5-year diet intervention significantly reduces late mortality in healthy middle-aged men with combined hyperlipidaemia.

Secondary prevention of cardiovascular events with long-term pravastatin in patients with diabetes or impaired fasting glucose: results from the LIPID trial

OBJECTIVE

Diabetes, a major health problem worldwide, increases the risk of cardiovascular disease and its associated mortality: The Long-Term Intervention with Pravastatin in Ischemic Disease (LIPID) trial showed that cholesterol-lowering treatment with pravastatin reduced mortality and coronary heart disease (CHD) events in 9014 patients aged 31-75 years with CHD and total cholesterol 4.0-7.0 mmol/l. We measured the effects of pravastatin therapy, 40 mg/day over 6.0 years, on the risk of CHD death or nonfatal myocardial infarction and other cardiovascular outcomes in 1,077 LIPID patients with diabetes and 940 patients with impaired fasting glucose (IFG).

RESULTS

In patients allocated to placebo, the risk of a major CHD event was 61% higher in patients with diabetes and 23% higher in the IFG group than in patients with normal fasting glucose, and the risk of any cardiovascular event was 37% higher in the diabetic group and 19% higher in the IFG group. Pravastatin therapy reduced the risk of a major CHD event overall from 15.9 to 12.3% (relative risk reduction [RRR] 24%, P < 0.001) and from 23.4 to 19.6% in the diabetic group (19%, P = 0.11); in the diabetic group, the reduction was not significantly different from the reductions in the other groups. Pravastatin reduced the risk of any cardiovascular event from 52.7 to 45.2% (21%, P < 0.008) in patients with diabetes and from 45.7 to 37.1% (26%, P = 0.003) in the IFG group. Pravastatin reduced the risk of stroke from 9.9 to 6.3% in the diabetic group (RRR 39%, CI 7-61%, P = 0.02) and from 5.4 to 3.4% in the IFG group (RRR 42%, CI -9 to 69%, P = 0.09). Pravastatin did not reduce the incidence of diabetes. Over 6 years, pravastatin therapy prevented one major CHD event (CHD death or nonfatal myocardial infarction) in 23 patients with IFG and 18 patients with diabetes. A meta-analysis of other major trials confirmed the high absolute risks of diabetes and IFG and the absolute benefits of statin therapy in these patients.

CONCLUSIONS

Cholesterol-lowering treatment with pravastatin therapy prevents cardiovascular events, including stroke, in patients with diabetes or IFG and established CHD.

Specialist nurse-led intervention to treat and control hypertension and hyperlipidemia in diabetes (SPLINT): a randomized controlled trial

OBJECTIVE

To determine the effectiveness of specialist nurse-led clinics for hypertension and hyperlipidemia provided for diabetic patients receiving hospital-based care.

RESEARCH DESIGN AND METHODS

This study was a randomized controlled implementation trial at Hope Hospital, Salford, U.K. The subjects consisted of 1,407 subjects presenting for annual review with raised blood pressure(>or=140/80 mmHg), raised total cholesterol (>or=5.0 mmol/l), or both. Individuals with diabetes were randomized to usual care or usual care with subsequent invitation to attend specialist nurse-led clinics. Nurses provided clinics for participants, with attendance every 4-6 weeks, until targets were achieved. Lifestyle advice and titration of drug therapies were provided according to the locally agreed upon guidelines. Patients with both conditions were eligible for enrollment in either or both clinics. At subsequent annual review, blood pressure and total cholesterol values were obtained from the Salford electronic diabetes register. Data relating to deaths were obtained from the national strategic tracing service. The primary outcome was the odds ratio of achieving targets in hypertension and hyperlipidemia, attributable to the specialist nurse-led intervention.

RESULTS

Overall, specialist nurse-led clinics were associated with a significant improvement in patients achieving the target after 1 year (odds ratio [OR] 1.37 [95% CI 1.11-1.69], P = 0.003). This primary analysis revealed a borderline difference in effect between the two types of clinics (test for interaction between groups: P = 0.06). Secondary analysis, consistent with the prior beliefs of the health care professionals involved, suggested that targets were achieved more frequently in patients enrolled in the specialist nurse-led clinic for hyperlipidemia (OR 1.69 [1.25-2.29], P = 0.0007) than for hypertension (OR 1.14 [0.86-1.51], P = 0.37). Intervention (enrolled to either or both clinics) was associated with a reduction in all-cause mortality (OR 0.55 [0.32-0.92], P = 0.02).

CONCLUSIONS

This study provides good evidence to support the use of specialist nurse-led clinics as an effective adjunct to hospital-based care of patients with diabetes. If the standards of care recommended in the National Service Framework for Diabetes are to be achieved, then such proven methods for delivering care must be adopted.

Antibody to oxidized low-density lipoprotein and cardiovascular mortality in end-stage renal disease

BACKGROUND

Immune response to oxidized low-density lipoprotein (oxLDL) may modulate the process of atherogenesis and cardiovascular disease.

METHODS

We performed a prospective, observational cohort study in 249 patients with end-stage renal disease (ESRD) to examine whether the serum titer of anti-oxLDL antibody can predict cardiovascular mortality.

RESULTS

The median anti-oxLDL antibody titer was 320 mU/mL at baseline. During the follow-up (63 +/- 23 months), 72 deaths including 34 cardiovascular deaths occurred. When the subjects were divided into two groups by the median titer, the high titer group showed a lower risk for cardiovascular mortality (P = 0.040 by Kaplan-Meier analysis and log-rank test). Multivariate Cox proportional hazards model indicated that the lower risk of cardiovascular death in the high titer group remained significant (hazard ratio of 0.46, 95%CI 0.23-0.95, P = 0.037) and independent of age, presence of vascular complications, presence of diabetes mellitus, and elevated C-reactive protein. In contrast, anti-oxLDL antibody titer was not associated with non-cardiovascular mortality.

CONCLUSIONS

These results demonstrate, to our knowledge for the first time, that serum anti-oxLDL antibody titer is an independent predictor of cardiovascular mortality in a cohort of patients with ESRD.

Distribution of risk factors, plasma lipids, lipoproteins and dyslipidemias in a small Mediterranean island: the Ustica Project

BACKGROUND AND AIM

The populations of the Mediterranean area have a low incidence of cardiovascular disease (CHD). The aims of this paper are: 1) to present demographic data of the population of Ustica, a small island in the southern part of the Tyrrhenian sea that has reduced communications with the mainland and a diet presumably rich in fish; and 2) to evaluate the distribution of risk factors, plasma lipids, lipoproteins and dyslipidemias in this population.

METHODS AND RESULTS

We invited all of the free-living resident population aged more than 14 years (about 800 individuals) to participate in the study; 576 responded, for a participation rate of about 73%. The distribution of cardiovascular risk factors, plasma lipids, lipoproteins and dyslipidemias were evaluated in all of the subjects. More than 60% of the population was out of the normal weight range. Total and low-density lipoprotein cholesterol levels were respectively 207.4 +/- 46.7 and 141.7 +/- 42.4 mg/dL, and similar in males and females. Lipoprotein (a) (Lp[a]) levels presented the classical "skewed" distribution and, among the apolipoprotein(a) isoforms, there was a clear predominance of intermediate-sized kringle IV repeats. Overall, 43% of the subjects had a lipid disorder: the prevalence of hypercholesterolemia was 22.8% (3.2% with severe hypercholesterolemia terolemia > or = 300 mg/dL); low high-density lipoprotein cholesterol levels were found in 22.5%; the so-called lipid triad in 2.1%; and high Lp(a) levels in 6.2%. Large familial clusters were found for some lipid disorders.

CONCLUSIONS

A large prevalence of body weight disturbances and high frequency of dyslipidemias are the main characteristics of this population. Ongoing data and future longitudinal studies will better clarify the relative influence of each parameter on CHD risk and total mortality.

Patient survival after renal transplantation: IV. Impact of post-transplant diabetes

BACKGROUND

The development of de novo diabetes mellitus is a serious complication of kidney transplantation. This study examined the cardiovascular risk profile of patients with post-transplant diabetes (PTDM) and assessed the impact of PTDM on patient survival.

METHODS

This analysis included 1811 adult, renal allograft recipients, transplanted in a single institution between 1983 and 1998. Patient survival was analyzed by univariable and multivariable Cox regression considering PTDM as a time dependent variable.

RESULTS

After a follow-up period of 8.3 +/- 4.5 years, 293 patients (20%) developed PTDM, 14% lost their graft, and 20% died. Compared to patients without DM (NoDM, N = 1186) patients with PTDM were significantly older (40 +/- 14 vs. 48 +/- 12 years, P < 0.001), heavier (76 +/- 23 vs. 86 +/- 25 kg, P < 0.001), and included more African Americans (18 vs. 28%, P = 0.001). In addition, the incidence of PTDM was significantly higher in patients who were transplanted after 1995 than prior to that year. In contrast, there were no significant differences between PTDM and patients who had DM before the transplant (DM; N = 332). Compared to NoDM, patients with PTDM had significantly higher total serum cholesterol and triglycerides (TG), higher systolic blood pressure and higher pulse pressure throughout the post-transplant period. Of interest, all of these abnormalities preceded the development of PTDM. Hypertriglyceridemia was particularly pronounced in PTDM and elevated TG levels correlated with the subsequent development of PTDM, independent of other risk factors (P = 0.001 by multivariate Cox). Compared to NoDM (16% mortality) a significantly higher percent of DM (31%, P < 0.001) and PTDM (22%, P = 0.005) patients died. By Cox regression, PTDM correlated with reduced patient survival (hazard ratio = 1.80, CI 1.35 to 2.41, P = 0.001), and that relationship was independent of other correlates of reduced survival that included: increasing age; transplant year; reduced serum albumin; and male sex.

CONCLUSION

s: PTDM is associated with an unfavorable cardiovascular risk profile that precedes the development of hyperglycemia. PTDM is an independent predictor of reduced survival in renal allograft recipients.

New targets for medical treatment of lipid disorders

Coronary heart disease (CHD) is the leading cause of death and disability in the industrialized world. Included among the risk factors for CHD are an elevated level of low-density lipoprotein (LDL) cholesterol and a low level of high-density lipoprotein (HDL) cholesterol. The discovery of drugs that inhibit 3-hydroxy-3-methylglutaryl coenzyme A reductase (statins), the rate-limiting enzyme in cholesterol biosynthesis, constituted a major advance in the treatment of patients with elevated plasma concentrations of LDL cholesterol. However, although the statins are potent LDL-lowering agents, they may not be the therapy of choice for all dyslipidemic patients. This is particularly true for subjects whose primary lipid abnormality is a low level of HDL cholesterol with or without hypertriglyceridemia, a group that includes about one half of patients with CHD. In this report, we review emerging options for the treatment of patients with lipid disorders, including inhibitors of cholesterol absorption, acyl coenzyme A-cholesterol acyltransferase, microsomal triglyceride transfer protein, and cholesteryl ester transfer protein, as well as liver X receptor agonists that up-regulate the expression of ATP-binding cassette transporter A1.

Clinical implications of statin event trials

Event trials using statin therapy have shown a beneficial effect on rates of cardiovascular events. The three statins that have been used in long-term trials have shown generally similar effects on rates of myocardial infarction, stroke, revascularizations, and mortality. Safety data appear to be comparable for lovastatin, pravastatin, and simvastatin. Long-term trials of other statins are in progress or pending. The question of how much low-density lipoprotein cholesterol should be lowered may be answered by studies currently in progress.

Overall mortality in the program on the surgical control of the hyperlipidemias

BACKGROUND

The Program on the Surgical Control of the Hyperlipidemias (POSCH), a secondary intervention trial, was the only lipid/atherosclerosis randomized clinical trial that used a surgical modality--partial ileal bypass. POSCH provided solid evidence for the clinical and arteriographic benefits of lipid profile normalization. Few longterm followup reports have been published in this field. This report concerns overall mortality, the primary endpoint of POSCH, with a mean followup of 18 years (range 15.5 to 23.0 years).

STUDY DESIGN

Overall mortality data were compiled from reports to the POSCH clinics, followup telephone calls, death certificates, and the US National Death Index.

RESULTS

There were 144 deaths in the control group (n = 417) and 120 deaths in the intervention group (n = 421), using intent-to-treat analysis. The risk reduction in the intervention group was 0.201 (20%); the risk ratio was 0.799, or 0.8 (95% confidence intervals, 0.628 to 1.018, p = 0.07). The proportion of patients alive was 65.7% in the control group and 72.0% in the intervention group, for a difference of 6.3% in the intervention group (p = 0.05). Kaplan-Meier survival analysis (p = 0.046) and disease-free intervals analysis at 70% survival (p < 0.001) were confirmatory. The gain in life expectancy in the intervention group was 2.7 years.

CONCLUSIONS

Longterm followup POSCH data demonstrate that lipid profile normalization will decrease overall mortality and will maintain a persistent and constant increase in life expectancy.