Meta-Analysis of Oral Anticoagulants with Dual versus Single Antiplatelet Therapy in Patients after Percutaneous Coronary Intervention

BACKGROUND

The combined use of dual antiplatelet therapy with oral anticoagulation (OAC) is required after coronary artery stenting or acute coronary syndromes (ACS).

METHODS AND RESULTS

We performed a meta-analysis (Embase and MEDLINE search) of the comparative effects of triple antithrombotic therapy (TT) versus OAC with single antiplatelet therapy (dual therapy [DT]) on all-cause mortality, stroke, cardiovascular death, myocardial infarction (MI), target vessel revascularization, and major bleeding. Three prospective controlled studies and five cohort studies compared TT versus DT. We identified three prospective controlled and five cohort studies with 4564 patients on TT and 1848 on DT with an average follow-up duration of 10.1 months. TT is associated with similar rates of all-cause mortality, stroke, and major bleeding but significantly lower rates of MI compared with DT.

CONCLUSIONS

Triple antithrombotic therapy is associated with similar mortality and bleeding rates but fewer MIs compared with OAC and single antiplatelet therapy.

HDL as a prognostic biomarker for coronary atherosclerosis: the role of inflammation

INTRODUCTION

Emerging evidence suggests that the role of high density lipoprotein (HDL) in the atherosclerotic process is not as clear as previously thought, since atheroprotective HDL becomes atherogenic in states of increased inflammatory processes.

AREAS COVERED

In this review we aim to elucidate the role of HDL as a prognostic biomarker and we discuss therapeutic approaches that aim to increase HDL and their possible clinical benefit.

EXPERT OPINION

Given the structural variability and biological complexity of the HDL particle, its role in the atherosclerotic process is far from clear. According to current evidence, the atheroprotective role of HDL turns atherogenic in states of increased inflammatory processes, while even minor alterations in systemic inflammation are likely to hinder the endothelial protective effects of HDL. In accordance, significant data have revealed that HDL-related drugs may be effective in reducing cardiovascular mortality; however they are not as encouraging or unanimous as expected. Possible future goals could be to quantify either HDL subclasses or functions in an attempt to reach safer conclusions as to the prognostic importance of HDL in coronary atherosclerosis. Having achieved that, a more targeted therapy that would aim to raise either HDL functionality or to remodel HDL structure would be more easily designed.

Surgical Planning for the Treatment of a Patient with Multiple, Secondary, Intracranial Echinococcal Cysts

A 27-year-old man with a 2-year history of recurrent hospitalizations for various neurologic and cardiologic emergencies was admitted to our hospital presenting with left hemiparesis, which gradually progressed to quadriparesis, bilateral hemianopsia, intracranial hypertension syndrome, and seizures. A diagnosis of echinococcosis was made, based on the radiologic findings of multiple cerebral hydatid cysts and a sizable cyst of the heart. The hydatid cyst of the heart was treated first with a thoracotomy, and after a month he underwent three consecutive surgical operations for the removal of six cerebral cysts. The patient was on albendazole treatment throughout the entire hospitalization, and this led to the shrinkage and finally to the disappearance of two other cerebral cysts. The patient's focal neurologic signs eventually disappeared, with the exception of a slight unilateral hemianopsia. Ten years after his discharge, he remains in a good condition, with no signs of clinical or radiologic relapse.

Statins and myocardial infarction: Type, dose, and administration time: Does it matter?

Patients with ST-elevation myocardial infarction (STEMI) constitute a vulnerable group that demands the careful assessment and application of all the up-to-date clinical and experimental knowledge, with final aim, the improvement of their prognosis. Statins are an indispensable part of the primary and secondary prevention of coronary artery disease (CAD), not only due to their strong hypolipidemic effect, but also due to their numerous pleiotropic properties that play an important role in the treatment of CAD, especially when the more vulnerable group of STEMI patients is addressed. Nevertheless, there are still issues that require further discussion and clarification, such as the type of statin, the dose of the regimen, the administration time, and the treatment duration.

Metals in tissues of seabass and seabream reared in sites with oxic and anoxic substrata and risk assessment for consumers

Twenty-eight metals and elements were measured in the muscle, liver, gills, bone and intestine of farmed seabass and gilthead seabream from four Mediterranean fish farms. The influence of fish species and the effect of environmental conditions on the metal accumulation in fish tissues was investigated. Most concentrations were lower in muscle and higher in liver and bone than in other body tissues. Seabass accumulates more elements in its tissues than seabream. Fish reared in coarse, oxic sites accumulate more elements with higher concentrations in muscle, bone and intestine and with lower concentrations in liver and gills than fish reared in silty, anoxic sites. This may be attributed to feed type and sediment properties. According to the metal pollution index, hazard quotient, selenium health benefit values, carcinogenic risk of arsenic, maximum safe consumption and the permitted limits, the consumption of both farmed species should be considered as safe for human health.

Genetic testing and antiplatelet treatment: Still way to go?

Despite medical and technical advancements stent thrombosis continued to poses a significant risk in patients after drug eluting stent (DES) implantation and clopidogrel resistance has been recognized as an important determinant of this risk. Novel antiplatelets such as prasugrel and ticagrelor can be used in cases of clopidogrel resistance however bleeding complications remain the Achilles' heel of antiplatelet therapy. Several genetic polymorphisms affect the clopidogrel absorption and bio-activation in the active form of the drug. CYP2C19 is responsible for most of the clopidogrel bio-transformation and loss of function as well as, gain of function polymorphisms of this enzyme has been recognized. Early studies have linked CYP2C19 genetic polymorphisms with clinical events, although, these findings were not confirmed by later studies. However, when the estimated thrombotic risk is high a combination of genetic information and functional platelet tests should be essential for clinicians to access clopidogrel effectiveness and to recommend alternative antiplatelet management.

Diet adaptability by a generalist herbivore: the case of brown hare in a Mediterranean agroecosystem

BACKGROUND

Brown hares (Lepus europaeus) were collected before and after autumn rains from a mixed farmland and scrubland area. The age and sex of each specimen were determined, and microhistological technique was applied to analyze the stomach contents.

RESULTS

Hares consumed a higher number of plant species in comparison with other studies in continental European farmlands. A different pattern in diet of hare was found, where from a partial herbivory, frugivory, and granivory during the dry period, hares turn to primarily herbivory during the wet period. An expansion of diet breadth and an increase in food consumption was found in the dry season. Farming contributes to the enrichment of diet especially during the dry season. Diet composition was differed between ages, but no significant difference was found between the two sexes.

CONCLUSIONS

Hare is a facultative generalist herbivore that adapts its diet to the seasonal vegetation changes. In Mediterranean ecosystems, the seeds, fruits, and grapes are important additions to the diet. Results suggest that during the dry period juveniles cannot exploit all the available food resources, such as fruits and seeds, as effectively as adults.

High platelet reactivity is associated with vascular function in patients after percutaneous coronary intervention receiving clopidogrel

BACKGROUND

In the present study, we evaluated the association of platelet reactivity with vascular function in patients after percutaneous coronary intervention receiving clopidogrel treatment.

METHODS

We enrolled 150 patients with stable CAD receiving clopidogrel regimen (75 mg/d), 1 month after percutaneous coronary intervention. Carotid-femoral pulse wave velocity (PWV) was measured as an index of aortic stiffness and augmentation index (AIx) as an index of arterial wave reflections. High on treatment platelet reactivity (HPR) was evaluated using VerifyNow Assay. VerifyNow reports its results in P2Y12 reaction units (PRU), and the diagnostic cutoff value is 230 PRU. Patients were evaluated prospectively up to 24 months. The primary end point was a composite of death from cardiovascular causes, nonfatal major cardiovascular events and hospitalization for cardiovascular causes.

RESULTS

There was no difference in the basic clinical and demographic characteristics between subjects with HPR and non-HPR. Subjects with high on treatment platelet reactivity and PRU>230 had significantly increased PWV (8.81 ± 2.25 m/s vs. 7.69 ± 1.95 m/s, p = 0.001) and AIx (25.27 ± 8.67% vs. 20.87 ± 10.57%, p = 0.04) compared to subjects with PRU≤230. PWV was also associated with PRU (r = 0.23, p = 0.02). HPR was associated with significantly increased risk of primary end point [HR = 5.38, 95%CI:(1.15, 26.04), p = 0.03].

CONCLUSIONS

Increased platelet reactivity is associated with impaired arterial stiffness in patients after percutaneous coronary intervention receiving clopidogrel treatment, highlighting another clinical factor implicated in individual platelet response to antiplatelet therapy. Moreover, increased platelet reactivity is associated with adverse outcome in these patients.

Antioxidant treatment and endothelial dysfunction: is it time for flavonoids?

Endothelial dysfunction represents an imbalance between vasodilatory and vasoconstrictory molecules secreted by endothelium. Oxidative stress is a major factor leading to endothelial dysfunction with significant prognostic implications for cardiovascular events. The generation of reactive oxygen species is strongly related to various oxidase enzymes such as xanthine oxidase, uncoupled endothelial nitric oxide synthase, cyclooxygenase, glucose oxidase, lipooxygenase, nicotinamide-adenine dinucleotide phosphate oxidase and to mitochondrial electron transport mechanisms. Several pharmaceutical agents exert effects beyond their principal role, such as anti-inflammatory and antioxidant, while the reports on antioxidant vitamins remain controversial especially those based on large scale studies. Moreover, there are studies on other agents already patented, but these are not well evaluated. Recently, there is growing interest in the role of dietary flavonoids and their potential to improve endothelial function by modifying oxidative stress status. Flavonoids are important components of 'functional foods', with beneficial effects on cardiovascular health, mainly due to their antioxidant activity. However, the vascular-protective role of flavonoids and especially their antioxidant properties are still under investigation.

Prognostic role of miRNAs in coronary artery disease

The increasing prevalence of coronary artery disease (CAD) as well as its' monitoring remain crucial problems and fields of long debate. Thus, several circulating biomarkers have been found during the last decade and examined in terms of their potential to assist in the prognosis of CAD. Of great interest, are small non-coding RNAs (microRNAs or miRNAS or miRs), due to their association with many aspects of CAD. microRNAs circulate in the bloodstream, while they exist in tissues and affect plaque initiation and progression. In addition, they have been found to contribute to the pathophysiology of CAD and to the CAD-related manifestations such as myocardial infarction, heart failure and cardiac arrhythmias. Therefore, evaluating the role of these molecules may be of great importance in the understanding of atherogenesis providing new evidence for diagnosis and prognosis of CAD.

Novel biomarkers assessing endothelial dysfunction: role of microRNAs

Endothelial dysfunction reflected by reduced nitric oxide availability is nowadays considered as a causative factor of atherosclerosis. A variety of biomarkers has been used as indicators of endothelial dysfunction in cardiovascular disease. Discovered just over a decade ago, microRNAs have evoked a great deal of interest, due to their importance for many aspects of homeostasis and disease. miRNAs comprise a novel class of endogenous, single-stranded, short RNA sequences able to regulate gene expression by binding to complementary sequences on mRNAs According to a growing body of evidence, they have been implicated in the regulation of several human physiological processes. They have been shown to participate in cardiovascular disease pathogenesis including atherosclerosis and endothelial dysfunction and this may have important clinical implications.

MicroRNAs in the diagnosis and treatment of unstable angina

During the last decade, a growing body of evidence has shown an interplay of genetics and inflammation which leads to a greater understanding of the complex pathophysiology of atherosclerotic vascular disease. Of great interest are non-coding RNAs, called microRNAs due to their importance for many aspects of homeostasis and disease. According significant data, they have been implicated in the regulation of several human physiological processes, while they seem to participate in cardiovascular disease pathogenesis including atherosclerosis and acute coronary syndromes. Accordingly, other biomarkers beyond troponins such as microRNAs, could be proved very useful in the aim of enhancing diagnostic or therapeutic effectiveness. Notably, there is evidence that patients with unstable angina pectoris could be discriminated from stable patients, given higher expression levels of several microRNAs, suggesting that they could be used to identify patients at risk for acute coronary syndromes. Also, they may have a substantial therapeutic impact in the management of athero-thrombotic vascular disorders, even though there are still obstacles in their use for that purposes, such as the delivery of the drug to target cells. Thus, it will be necessary to further explore their complications, before their use as therapeutic option.

Diabetes mellitus-associated vascular impairment: novel circulating biomarkers and therapeutic approaches

It is widely accepted that diabetes mellitus (DM) impairs endothelial nitric oxide synthase activity as well as enhances the production of reactive oxygen species, thus resulting in diminished nitric oxide bioavailability and the consequent pro-atherogenetic alterations. Important biomarkers of the vasculature are related to endothelial dysfunction, to inflammatory and coagulation processes, and to oxidative stress in DM. Several therapeutic strategies might exert favorable effects on the vasculature of diabetic patients, such as insulin analogues, antihypertensive agents, statins, and hypoglycemic agents, whereas in spite of the prominent role of oxidative stress in diabetes, antioxidant therapy remains controversial. The use of specific biomarkers related to vascular function could be a useful therapeutic approach in such patients.

Metals in benthic macrofauna and biogeochemical factors affecting their trophic transfer to wild fish around fish farm cages

Benthic macroinvertebrates and wild fish aggregating in the vicinity of four Mediterranean fish farms were sampled. Concentrations of metals and other elements were measured in macrofaunal taxa and in fish tissues (muscle, liver, gills, bone, gonad, stomach, intestine, and stomach content). Biological and geochemical characteristics play an important role in metal accumulation in benthic invertebrates, and consequently in metal transfer to higher trophic levels. Macroinvertebrates accumulated lower concentrations of most metals and elements than their respective sediment, except As, P, Na, Zn and Cd. Elemental concentrations of benthic organisms increased with increasing sediment metal content, except Cd, and with % silt, refractory organic matter and chlorophyll-a of sediment due to the influence of sediment geochemistry on metal bioavailability. Tolerant species were found to accumulate higher concentrations of most metals and elements, except for Cd, than equilibrium species. The ecological and morphological characteristics of the benthic invertebrates can affect the bioaccumulation of metals and elements in macrobenthos. Hg and P were found to increase their concentrations from zoobenthos to wild fish aggregating around fish cages feeding on macrofauna.

The association of the 174G>C polymorphism of interleukin 6 gene with diabetic nephropathy in patients with type 2 diabetes mellitus

AIMS

To evaluate the association of 174G>C polymorphism on interleukin-6 (IL-6) gene with diabetic nephropathy in patients with type 2 diabetes.

METHODS

A total of 393 Greek subjects with type 2 diabetes (mean age 66.5±10.0years, men n=203, women n=190) were examined. Diabetic nephropathy was defined as presence of microalbuminuria and/or proteinuria. The IL-6 174G>C polymorphism was detected by polymerase chain reaction and appropriate restriction enzyme digestion. High sensitivity C-reactive protein was assayed by particle-enhanced immunonephelometry.

RESULTS

The genotype distribution (%) was GG: 49.1, GC: 26.8 and CC: 24.1, with no gender difference. The CC homozygotes had lower albumin excretion (mg/24h) in comparison with the GC genotype [CC: 8.9 (4.0-20.9) vs GC: 21.95 (9.1-53.35), P=0.004]. Participants with the GC genotype tended to have more frequently nephropathy than those with the GG or the CC genotype [GC: 44.55% vs GG: 35.1% and CC: 28.3%, P=0.07)]. The CC homozygotes in comparison with GC heterozygotes had lower odds to have nephropathy (odds ratio: 0.51, 95% confidence intervals=0.28-0.91, P=0.02), even after adjustment for sex, age, duration of diabetes, body mass index, smoking, hypertension, lipids and glycated hemoglobin, (P=0.01).

CONCLUSION

In type 2 diabetes states, CC homozygotes have lower albumin excretion and are protected from nephropathy in comparison with GC genotypes.

Effects of direct infusion of bone marrow-derived progenitor cells and indirect mobilization of hematopoietic progenitor cells on atherosclerotic plaque and inflammatory process in atherosclerosis

BACKGROUND

We sought to investigate the effects of lin-/sca+ cells, endothelial progenitor cells (EPCs) and granulocyte colony-stimulating factor (G-CSF) administration on atherosclerotic plaque progression.

METHODS

Apolipoprotein E-deficient (apoE(-/-)) mice were splenectomized and treated with high-cholesterol diet for 6 weeks in order to induce atherosclerotic plaque development. Bone marrow-derived Lin-/sca-1+ cells were isolated and further cultured to early growth endothelial progenitor cells (EPCs). Mice were divided in four groups (n=10/group) and received two intravenous injections of 5×10(5) cells (lin-/sca-1+ or EPCs), or granulocyte colony-stimulating factor (G-CSF 100 μg/kg/day) for 7 days or normal saline. The same interventions were administered to animals, which had undergone unilateral hind-limb ischemia. Effects on inflammatory parameters, lesion severity, and atherosclerotic plaque area size were assessed.

RESULTS

The administration of both G-CSF and progenitor cells significantly decreased the levels of IL-6, 6 weeks after the initiation of treatment. Atherosclerotic lesion area was reduced by G-CSF (atherosclerotic plaque area percentage 22.94%±3.68, p=0.001), by lin-/sca-1+ (23.27%±5.98, p=0.002) and cultured EPCs (23.16±4.86%, p=0.002) compared to control (32.75%±7.05). In the atherosclerotic mice that underwent limb ischemia, the atherosclerotic plaque area, was not significantly different between the treatment groups cultured EPCs-treated mice and the control group (p=NS, for all).

CONCLUSIONS

Direct infusion of progenitor cells and indirect mobilization of hematopoietic progenitor cells decreased plaque progression and levels of inflammatory molecules in a murine model of atherosclerosis. Treatment with G-CSF, lin-/sca-1+, or EPCs may exert beneficial effects on vascular inflammation and atherosclerotic plaque progression. However, the effects are diminished in an ischemic setting.