Clinical outcomes in statin treatment trials: a meta-analysis

Potential impact of blood cholesterol guidelines on statin treatment in the U.S. population using interrupted time series analysis

BACKGROUND

The 2013 ACC/AHA Guideline was a paradigm shift in lipid management and identified the four statin-benefit groups. Many have studied the guideline's potential impact, but few have investigated its potential long-term impact on MACE. Furthermore, most studies also ignored the confounding effect from the earlier release of generic atorvastatin in Dec 2011.

METHODS

To evaluate the potential (long-term) impact of the 2013 ACC/AHA Guideline release in Nov 2013 in the U.S., we investigated the association of the 2013 ACC/AHA Guideline with the trend changes in 5-Year MACE survival and three other statin-related outcomes (statin use, optimal statin use, and statin adherence) while controlling for generic atorvastatin availability using interrupted time series analysis, called the Chow's test. Specifically, we conducted a retrospective study using U.S. nationwide de-identified claims and electronic health records from Optum Labs Database Warehouse (OLDW) to follow the trends of 5-Year MACE survival and statin-related outcomes among four statin-benefit groups that were identified in the 2013 ACC/AHA Guideline. Then, Chow's test was used to discern trend changes between generic atorvastatin availability and guideline potential impact.

RESULTS

197,021 patients were included (ASCVD: 19,060; High-LDL: 33,907; Diabetes: 138,159; High-ASCVD-Risk: 5,895). After the guideline release, the long-term trend (slope) of 5-Year MACE Survival for the Diabetes group improved significantly (P = 0.002). Optimal statin use for the ASCVD group also showed immediate improvement (intercept) and long-term positive changes (slope) after the release (P < 0.001). Statin uses did not have significant trend changes and statin adherence remained unchanged in all statin-benefit groups. Although no other statistically significant trend changes were found, overall positive trend change or no changes were observed after the 2013 ACC/AHA Guideline release.

CONCLUSIONS

The 2013 ACA/AHA Guideline release is associated with trend improvements in the long-term MACE Survival for Diabetes group and optimal statin use for ASCVD group. These significant associations might indicate a potential positive long-term impact of the 2013 ACA/AHA Guideline on better health outcomes for primary prevention groups and an immediate potential impact on statin prescribing behaviors in higher-at-risk groups. However, further investigation is required to confirm the causal effect of the 2013 ACA/AHA Guideline.

Drug screen identifies verteporfin as a regulator of lipid metabolism in macrophage foam cells

Arterial macrophage foam cells are filled with cholesterol ester (CE) stored in cytosolic lipid droplets (LDs). Foam cells are central players in progression of atherosclerosis as regulators of lipid metabolism and inflammation, two major driving forces of atherosclerosis development. Thus, foam cells are considered plausible targets for intervention in atherosclerosis. However, a compound that directly regulates the lipid metabolism of LDs in the arterial foam cells has not yet been identified. In this study, we screened compounds that inhibit macrophage foam cell formation using a library of 2697 FDA-approved drugs. From the foam cells generated via loading of human oxidized low-density lipoprotein (oxLDL), we found 21 and 6 compounds that reduced and enhanced accumulations of lipids respectively. Among them, verteporfin most significantly reduced oxLDL-induced foam cell formation whereas it did not display a significant impact on foam cell formation induced by fatty acid. Mechanistically our data demonstrate that verteporfin acts via inhibition of oxLDL association with macrophages, reducing accumulation of CE. Interestingly, while other drugs that reduced foam cell formation did not have impact on pre-existing foam cells, verteporfin treatment significantly reduced their total lipids, CE, and pro-inflammatory gene expression. Together, our study identifies verteporfin as a novel regulator of foam cell lipid metabolism and inflammation and a potential compound for intervention in atherosclerosis.

New Targets in Atherosclerosis: Vascular Smooth Muscle Cell Plasticity and Macrophage Polarity

PURPOSE

Despite an increase in treatment options, and substantial reductions in cardiovascular mortality over the past half-century, atherosclerosis remains the most prevalent cause of premature mortality worldwide. The development of innovative new therapies is crucial to further minimize atherosclerosis-related deaths. The diverse array of cell phenotypes derived from vascular smooth muscle cells (SMCs) and macrophages within atherosclerotic plaques are increasingly becoming recognized for their beneficial and detrimental roles in plaque stability and disease burden. This review explores how contemporary transcriptomics and fate-mapping studies have revealed vascular cell plasticity as a relatively unexplored target for therapeutic intervention.

METHODS

Recent literature for this narrative review was obtained by searching electronic databases (ie, Google Scholar, PubMed). Additional studies were sourced from reference lists and the authors' personal databases.

FINDINGS

The lipid-rich and inflammatory plaque milieu induces SMC phenotypic switching to both beneficial and detrimental phenotypes. Likewise, macrophage heterogeneity increases with disease burden to a variety of pro-inflammatory and anti-inflammatory activation states. These vascular cell phenotypes are determinants of plaque structure stability, and it is therefore highly likely that they influence clinical outcomes. Development of clinical treatments targeting deleterious phenotypes or promoting pro-healing phenotypes remains in its infancy. However, existing treatments (statins) have shown beneficial effects toward macrophage polarization, providing a rationale for more targeted approaches. In contrast, beneficial SMC phenotypic modulation with these pharmacologic agents has yet to be achieved. The range of modulated vascular cell phenotypes provides a multitude of novel targets and the potential to reduce future adverse events.

IMPLICATIONS

Vascular cell phenotypic heterogeneity must continue to be explored to lower cardiovascular events in the future. The rapidly increasing weight of evidence surrounding the role of SMC plasticity and macrophage polarity in plaque vulnerability provides a strong foundation upon which development of new therapeutics must follow. This approach may prove to be crucial in reducing cardiovascular events and improving patient benefit in the future.

Phase 1, Single- and Multiple-Ascending-Dose, Food-Effect, and East Asian Subject Studies to Assess the Pharmacokinetics, Safety, and Tolerability of Bempedoic Acid, a Selective Inhibitor of Adenosine Triphosphate Citrate Lyase

Bempedoic acid is an adenosine triphosphate citrate lyase inhibitor that lowers low-density lipoprotein cholesterol by inhibiting cholesterol synthesis and upregulating hepatic low-density lipoprotein receptor expression. After oral dosing, bempedoic acid was readily absorbed, attaining maximum concentrations with a median time of 3.5 hours, and may be taken without regard to food. Steady-state oral pharmacokinetics in healthy adults receiving bempedoic acid at the approved 180 mg/day dose were characterized by mean maximum concentration of 20.6 µg/mL, area under the concentration-time curve over 24 hours of 289 µg·h/mL, and elimination half-life of 21.1 hours. Multiple-dose pharmacokinetics were linear at bempedoic acid doses of 120-220 mg/day. Circulating concentrations of the active metabolite ESP15228 were 18.0% of bempedoic acid concentrations on average. Comparisons of bempedoic acid 180 mg/day pharmacokinetics after single and multiple dosing revealed no clinically meaningful differences between Japanese, Chinese, and Western subjects. Mean estimates of bempedoic acid elimination half-life in Japanese (25.2 hours) and Chinese (20.0 hours) subjects were comparable to Western subjects (23.9 hours) following 14 days of once-daily dosing. Bempedoic acid was generally safe and well tolerated up to a dose of 220 mg/day across the study populations described herein.

Cholesterol-Related lncRNAs as Response Predictors of Atorvastatin Treatment in Chilean Hypercholesterolemic Patients: A Pilot Study

Statins are currently the treatment of choice for hypercholesterolemia. However, wide interindividual variability has been observed in the response to treatment. Recent studies have reported the role of lncRNAs in the metabolism of lipids; nevertheless, there are few studies to date that show their role in the response to treatment with statins. Thus, the aim of this study was to assess the levels of expression of three lncRNAs (RP1-13D10.2; MANTIS; lncHR1) associated with genes involved in cholesterol homeostasis in leukocyte cells of hypercholesterolemic patients after treatment with atorvastatin and compare them with levels in subjects with normal cholesterol levels. A secondary aim was to assess the levels of expression in monocytic THP-1 cells differentiated to macrophages. The study included 20 subjects with normal cholesterol (NC) levels and 20 individuals with hypercholesterolemia (HC). The HC patients were treated with atorvastatin (20 mg/day/4 weeks). THP-1 cells were differentiated to macrophages with PMA and treated with different doses of atorvastatin for 24 h. Expression of lncRNAs was determined by RT-qPCR. The lncRNAs RP1-13D10.2 (p < 0.0001), MANTIS (p = 0.0013) and lncHR1 (p < 0.0001) presented increased expression in HC subjects compared with NC subjects. Furthermore, atorvastatin had a negative regulatory effect on the expression of lncHR1 (p < 0.0001) in HC subjects after treatment. In vitro, all the lncRNAs showed significant differences in expression after atorvastatin treatment. Our findings show that the lncRNAs tested present differential expression in HC patients and play a role in the variability reported in the response to atorvastatin treatment. Further research is needed to clarify the biological impact of these lncRNAs on cholesterol homeostasis and treatment with statins.

Efficacy of Dietary Polyphenols from Whole Foods and Purified Food Polyphenol Extracts in Optimizing Cardiometabolic Health: A Meta-Analysis of Randomized Controlled Trials

The evidence from clinical trials concerning the efficacy of dietary polyphenols on cardiometabolic health is divergent. Therefore, this review aimed to determine the pooled effect of dietary polyphenols on cardiometabolic risk markers and compare the difference in efficacy between whole polyphenol-rich foods and purified food polyphenol extracts. We conducted a random-effect model meta-analysis of randomized controlled trials (RCTs) on the effect of polyphenols on blood pressure, lipid profile, flow-mediated dilation (FMD), fasting blood glucose (FBG), waist circumference, and markers of inflammation. Effect size was expressed as weighted mean difference and 95% CI. RCTs published in English between 2000 and 2021 involving adult participants with cardiometabolic risks were searched in electronic databases. Forty-six RCTs involving 2494 participants with a mean age of 53.3 ±10 y were included in this review. Whole polyphenol-rich food but not purified food polyphenol extracts significantly reduced systolic blood pressure (SBP, -3.69 mmHg; 95% CI: -4.24, -3.15 mmHg; P = 0.00001) and diastolic blood pressure (DBP, -1.44 mmHg; 95% CI: -2.56, -0.31 mmHg; P = 0.0002). Concerning waist circumference, purified food polyphenol extracts led to a larger effect (-3.04 cm; 95% CI: -7.06, -0.98 cm; P = 0.14). Significant effects on total cholesterol (-9.03 mg/dL; 95% CI: -16.46, -1.06 mg/dL; P = 0.02) and TGs (-13.43 mg/dL; 95% CI: -23.63, -3.23; P = 0.01) were observed when purified food polyphenol extracts were considered separately. None of the intervention materials significantly affected LDL-cholesterol, HDL-cholesterol, FBG, IL-6, and CRP. When both whole food and extracts were pooled together, there was a significant reduction in SBP, DBP, FMD, TGs, and total cholesterol. These findings suggest that polyphenols both as whole food and purified extracts can be efficacious in reducing cardiometabolic risks. However, these results must be interpreted with caution because of high heterogeneity and risk of bias among RCTs. This study was registered on PROSPERO as CRD42021241807.

Association between statin exposure and diabetes incidence among privately-insured patients before and after applying a novel technique to control for selection bias

INTRODUCTION

The association between statins and incident diabetes mellitus (DM) in observational studies is much larger than that reported from randomized controlled trials. We sought to assess this association using a novel design controlling for selection bias.

METHODS

Using data from MarketScan, we identified a cohort of non-diabetic patients who initiated a statin and matched them to patients not taking statins. From the statin-user cohort, we identified two subgroups: patients who received statin refills for >6 months (continuers) and patients who received statin refills <6 months (discontinuers). Patients were followed for a minimum of two years to determine incident DM.

RESULTS

We included 442,526 patients, divided equally between statin users and non-users. Statin use was associated with increased DM (9.9% vs. 4.4%, HR 2.2, p < 0.001). Among the 221,263 statin users, there were 194,357 continuers and 26,906 discontinuers. There was no significant difference in the incidence rate of DM between both groups (10.0% vs. 9.3%, HR 1.03, p = 0.22).

CONCLUSIONS

Statin use was strongly associated with incident diabetes when users were compared to non-users but not when continuers were compared to discontinuers. Selection bias confounds the association between statin use and incident diabetes in observational studies.

New Therapeutic Approaches to the Treatment of Dyslipidemia 1: ApoC-III and ANGPTL3

Low-density lipoprotein cholesterol (LDL-C)-lowering therapy that increases LDL receptor expression in several ways robustly reduces the risk of atherosclerotic cardiovascular disease (CVD). However, a substantial risk of CVD still remains after intensive LDL-C reduction, which requires new treatment modalities for dyslipidemia and cardiovascular risk management. Triglycerides (TGs) and triglyceride-rich lipoproteins (TRLs) have received attention as indicators of residual cardiovascular risk and as direct causal factors for atherosclerosis and CVDs. Advances in understanding TG and TRL metabolism and their association with clinically evident CVDs have led to the development of novel therapeutic targets, including apolipoprotein C-III (apoC-III) and angiopoietin-like protein 3 (ANGPTL3). Genetic association studies have indicated that both apoC-III and ANGPTL3 play a causal role in the development of atherosclerotic CVD. Both molecules contribute to lipid dysregulation and atherosclerosis primarily by inhibiting lipoprotein lipase; however, recent evidence has shown that novel pathways exist in relation to their lipid-modifying activities. Notably, recent progress in therapeutic approaches, such as monoclonal antibodies or antisense oligonucleotides, has led to several novel therapeutics targeting apoC-III and ANGPTL3. This review summarized the recent updates and discussions related to apoC-III and ANGPTL3 expression.

Investigating the effect of Fenofibrate on biomarkers of vascular inflammation in L-NAME induced hypertensive rats

This study aims to evaluate the impact of fenofibrate on the levels of (IL-6, hsCRP, Lp-PLA2, sCD40L, and cystatin C) in hypertensive rats. Twenty-four rats were divided into two groups each of twelve. The first group served as the normotensive group, while the second group was regarded as the hypertensive group. Each group was further divided into two subgroups (control and treated). The control subgroups only received a placebo and the treated subgroups were given fenofibrate 30 mg/kg daily orally by gastric gavage for 4 weeks. The level of hsCRP, IL6, and Lp-PLA2 significantly increased, but sCD40L and cystatin C levels were not changed in hypertensive rats. Fenofibrate has significantly reduced the levels of hsCRP and Lp-LPA2 in hypertensive rats while IL6 and sCD40s have not been changed in both groups. In conclusion, Fenofibrate has revealed a pleiotropic anti-inflammatory effect by reducing the level of hsCRP and Lp-LPA2 in hypertensive rats.

Targeting Lipid—Ion Channel Interactions in Cardiovascular Disease

General lipid-lowering strategies exhibit clinical benefit, however, adverse effects and low adherence of relevant pharmacotherapies warrants the investigation into distinct avenues for preventing dyslipidemia-induced cardiovascular disease. Ion channels play an important role in the maintenance of vascular tone, the impairment of which is a critical precursor to disease progression. Recent evidence suggests that the dysregulation of ion channel function in dyslipidemia is one of many contributors to the advancement of cardiovascular disease thus bringing to light a novel yet putative therapeutic avenue for preventing the progression of disease mechanisms. Increasing evidence suggests that lipid regulation of ion channels often occurs through direct binding of the lipid with the ion channel thereby creating a potential therapeutic target wherein preventing specific lipid-ion channel interactions, perhaps in combination with established lipid lowering therapies, may restore ion channel function and the proper control of vascular tone. Here we first detail specific examples of lipid-ion channel interactions that promote vascular dysfunction and highlight the benefits of preventing such interactions. We next discuss the putative therapeutic avenues, such as peptides, monoclonal antibodies, and aspects of nanomedicine that may be utilized to prevent pathological lipid-ion channel interactions. Finally, we discuss the experimental challenges with identifying lipid-ion channel interactions as well as the likely pitfalls with developing the aforementioned putative strategies.

Effects of simvastatin on tissue factor pathway of blood coagulation in STATCOPE (Simvastatin in the prevention of COPD exacerbations) trial

BACKGROUND

Statins are widely used to lower lipids and reduce cardiovascular events. In vitro studies and small studies in patients with hyperlipidemias show statins inhibit tissue factor (TF) and blood coagulation mechanisms. We assessed the effects of simvastatin on TF and coagulation biomarkers in patients entered in STATCOPE, a multicenter, randomized, placebo-controlled trial of simvastatin (40 mg daily) versus placebo on exacerbation rates in patients with chronic obstructive pulmonary disease (COPD).

METHODS

In 227 patients (114 simvastatin, 113 placebo; mean [± standard error of the mean] age 62 ± 0.53 years, 44.5% women) we measured (baseline, and 6 and 12 months): whole blood membrane TF-procoagulant activity (TF-PCA) and plasma factors VIIa, VII, VIII, fibrinogen, TF antigen, tissue factor pathway inhibitor (TFPI), thrombin-antithrombin complexes (TAT), and D-dimer. We excluded patients with diabetes, cardiovascular disease, and those taking or requiring a statin.

RESULTS

In the statin group, there was a small increase in TF-PCA (from 25.18 ± 1.08 to 30.36 ± 1.10 U/ml; p = .03) over 12 months; factors VIIa and VIII, fibrinogen, TAT, and D-dimer did not change. Plasma TFPI (from 52.4 ± 1.75 to 44.7 ± 1.78 ng/ml; p < .0001) and FVIIC (1.23 ± 0.04 to 1.15 ± 0.03 U/ml; p = .03) decreased and correlated with total cholesterol levels. No changes in biomarkers were observed with placebo.

CONCLUSIONS

In contrast to previous studies on statins, in COPD patients without diabetes, cardiovascular disease, or requiring a statin treatment, simvastatin (40 mg per day) did not decrease TF or factors VIIa and VIII, fibrinogen, TAT, or D-dimer. The decreases in TFPI and factor VII reflect the decrease in serum lipids.

Effect of weight loss on cardiometabolic risk: observational analysis of two randomised controlled trials of community weight-loss programmes

BACKGROUND

Guidelines recommend that clinicians identify individuals at high cardiometabolic risk and support weight loss in those with overweight or obesity. However, we lack individual level data quantifying the benefits of weight change for individuals to guide consultations in primary care.

AIM

To examine how weight change affects cardiometabolic risk factors, and to facilitate shared decision making between patients and clinicians regarding weight loss.

DESIGN AND SETTING

Observational analysis using data from two trials of referral of individuals with overweight or obesity in primary care to community weight-loss groups.

METHOD

Linear mixed effects regression modelling examining the association between weight change and change in systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting glucose, glycated haemoglobin (HbA1c), and lipid profile across multiple timepoints (baseline to 24 months). Subgroup analyses examined changes in individuals with hypertension, diabetes, and hyperlipidaemia.

RESULTS

In total, 2041 participants had a mean (standard deviation) age of 50 (SD 13.5) years, mean baseline weight of 90.6 (14.8) kg and mean body mass index (BMI) of 32.7 (SD 4.1) kg/m2. Mean (SD) weight change was -4.3 (SD 6.0) kg. All outcome measures showed statistically significant improvements. Each 1 kg weight loss was associated with 0.4 mmHg reduction in SBP and 0.3 mmHg reduction in DBP, or 0.5 mmHg and 0.4 mmHg/kg respectively in people with hypertension. Each 1 kg weight loss was associated with 0.2 mmol/mol reduction in HbA1c, or 0.6 mmol/mol in people with diabetes. Effects on plasma lipids were negligible.

CONCLUSION

Weight loss achieved through referral to community weight-loss programmes, which are commonly accessible in primary care, can lead to clinically relevant reductions in BP and glucose regulation, especially in those at highest risk.

Hyperlipidemia patients with long-term statin treatment are associated with a reduced risk of progression of benign prostatic enlargement

OBJECTIVE

To evaluate the impacts of statin treatment on the risk of benign prostatic enlargement (BPE) progression in hyperlipidemia patients.

METHODS

Newly diagnosed hyperlipidemia patients (n = 7961), identified from Taiwan's National Health Insurance Research Database, were divided into four statin cohorts (statin use >365 days, n = 1604; statin use 181-365 days, n = 813; statin use 91-180 days, n = 739; and statin use 31-90 days, n = 713) and one control cohort (cohort that used no statins, n = 4092). Study endpoint was occurrence of BPE progression (BPE diagnosis plus receiving BPE-related medications or surgery). Relative risks of BPE progression in the statin cohorts compared to the control cohort were analyzed.

RESULTS

Multivariable Cox proportional hazards regression analyses demonstrated that BPE progression risk in the cohort used statins for >365 days was significantly lower than the control cohort (adjusted hazard ratio: 0.70, 95% confidence interval: 0.58 ∼ 0.85, p < .001). However, BPE progression risks of the other three statin cohorts did not significantly differ from the control cohort. Trend analysis revealed that the effects of statin treatment on decreasing BPE progression risk were significantly related to statin treatment duration (p = .001).

CONCLUSIONS

Hyperlipidemia patients with long-term statin treatment (more than 365 days) are associated with a reduced risk of BPE progression.

Statin treatment reduces the risk of death among elderly frail patients: evidence from a large population-based cohort

AIMS

To assess the protective effect of statins in a large and unselected cohort of frail elderly subjects.

METHODS AND RESULTS

The 460 460 Lombardy residents (Italy), aged ≥65 years, who received ≥3 consecutive prescriptions of a statin during 2011-2012 were identified. A case-control study was performed, the cases being the cohort members who died during 2011-2018. Logistic regression was used to model the outcome risk associated with statin adherence. Adherence to drug therapy was measured by the proportion of the follow-up covered by prescriptions. The analysis was stratified according to four clinical categories (good, medium, poor, and very poor clinical status), based on different life expectancies, as assessed by a prognostic score which had been found to sensitively predict the risk of death. The 7-year death probability increased from 11% (good) to 52% (very poor clinical status). In each clinical status, there was a significant reduction of all-cause mortality as adherence to statin treatment increased. The reduction in the adjusted risk of mortality from the lowest to the highest adherence level was greatest among patients with a good clinical status (-56%) and progressively less among other cohort members, i.e. -48%, -44% and -47% in medium, poor, and very poor groups, respectively. Similar findings were obtained for the risk of cardiovascular mortality.

CONCLUSION

In a real-life setting, adherence to statin treatment reduced the death risk also in frail elderly patients. However, in these patients, the benefit of statin treatment may be lower than in those in good clinical conditions.

Atorvastatin Increases the Expression of Long Non-Coding RNAs ARSR and CHROME in Hypercholesterolemic Patients: A Pilot Study

Atorvastatin is extensively used to treat hypercholesterolemia. However, the wide interindividual variability observed in response to this drug still needs further elucidation. Nowadays, the biology of long non-coding RNAs (lncRNAs) is better understood, and some of these molecules have been related to cholesterol metabolism. Therefore, they could provide additional information on variability in response to statins. The objective of this research was to evaluate the effect of atorvastatin on three lncRNAs (lncRNA ARSR: Activated in renal cell carcinoma (RCC) with sunitinib resistance, ENST00000424980; lncRNA LASER: lipid associated single nucleotide polymorphism locus, ENSG00000237937; and lncRNA CHROME: cholesterol homeostasis regulator of miRNA expression, ENSG00000223960) associated with genes involved in cholesterol metabolism as predictors of lipid-lowering therapy performance. Twenty hypercholesterolemic patients were treated for four weeks with atorvastatin (20 mg/day). The lipid profile was determined before and after drug administration using conventional assays. The expression of lncRNAs was assessed in peripheral blood samples by RT-qPCR. As expected, atorvastatin improved the lipid profile, decreasing total cholesterol, LDL-C, and the TC/HDL-C ratio (p < 0.0001) while increasing the expression of lncRNAs ARSR and CHROME (p < 0.0001) upon completion of treatment. LASER did not show significant differences among the groups (p = 0.50). Our results indicate that atorvastatin modulates the expression of cholesterol-related lncRNAs differentially, suggesting that these molecules play a role in the variability of response to this drug; however, additional studies are needed to disclose the implication of this differential regulation on statin response.

Low-dose statin pretreatment improves function and prognosis of recurrent ischemic stroke patients

Background:

Statins are effective in improving the prognosis of stroke patients. In clinical practice, low-dose statins are often administered to stroke patients in Asian countries but their effects on the prognosis of recurrent ischemic stroke patients are still unclear.

Methods:

Data of consecutive recurrent ischemic stroke patients were prospectively collected. The National Institutes of Health Stroke Scale (NIHSS) of admission and discharge and the modified Rankin scale (mRs) of 90 days after stroke onset were adopted to evaluate primary outcomes. Secondary outcomes included the subgroup analysis.

Results:

Among 219 patients (mean age 65.41 ± 11.58 years), 150 (68.5%) were male. The low-dose statin group had a higher percentage of milder stroke at admission (p < 0.001) and discharge (p < 0.001), and favorable functional outcome at 90 days (p < 0.001). Univariable regression analysis showed that the use of low-dose statins was inversely associated with higher discharge NIHSS [odds ratio (OR) = 0.36, p = 0.009] and higher mRs at 90 days (OR = 0.230, p < 0.001). Multivariable logistic regression analysis revealed that low-dose statins also had a significantly inverse association with higher mRs at 90 days (OR = 0.098, p = 0.049). According to subgroup analysis, a significant effect was found in the good-persistency subgroup (NIHSS score at discharge: OR = 0.051, p = 0.004; mRs score at 3 months: OR = 0.053, p = 0.005), but not in the poor-persistency subgroup.

Conclusion:

Low-dose statin pretreatment alleviated stroke severity and improved functional outcomes of recurrent stroke patients.

Medical Management for Secondary Stroke Prevention

PURPOSE OF REVIEW

This article reviews the evidence base and recommendations for medical management for secondary stroke prevention.

RECENT FINDINGS

Recent developments for secondary stroke prevention include evidence to support the use of short-term dual antiplatelet therapy after minor stroke and transient ischemic attack, direct oral anticoagulants for nonvalvular atrial fibrillation, reversal agents for direct oral anticoagulant-associated hemorrhage, and aspirin rather than presumptive anticoagulation with a direct oral anticoagulant for embolic stroke of undetermined source.

SUMMARY

Most strokes are preventable. The mainstays of medical management for secondary stroke prevention include antihypertensive therapy; antithrombotic therapy, with antiplatelet agents for most stroke subtypes or anticoagulants such as warfarin or a direct oral anticoagulant for cardioembolic stroke specifically; cholesterol-lowering therapy, principally with statins, but with potential roles for ezetimibe or proprotein convertase subtilisin/kexin type 9 inhibitors in selected patients; and glycemic control to prevent microvascular complications from diabetes mellitus or pioglitazone in selected patients with insulin resistance but not diabetes mellitus.

Аn affordability of statins therapy - comparative analysis between Ukraine and Bulgaria

Background

The statins are а developing group of cardiovascular medicines, widely used for dyslipidemia. As a whole statins consumption leads to reduction in cardiovascular events and death, and improves the disease control. The main study issue considers the differences in an affordability to lipid lowering medicines in the countries with the highest morbidity and mortally rate within and outside EU. The affordability has been researched by exploring the price differences and average wages.

Methods

On total 7 international nonproprietary names and 19 dosage forms available on both markets are observed during 2013–2016. An average, minimum, and maximum retail prices per DDD, standard deviation (SD) has been calculated for all marketed dosage forms. A price ratio between the minimal and maximal price per DDD is estimated in order to evaluate their difference. Affordability of the treatment is determined as the number of working hours per month needed for patient to purchase medicines for a monthly therapy.

Results

Large variations of price per DDD, SD and the average price exist between different dosage forms in both countries. The highest value of a price ratio is observed for 5 mg rosuvastatin in Bulgaria and 10 mg rosuvastatin in Ukraine.

The number of working hours needed to cover monthly therapy has increased during 2013–2016 in Ukraine. The most affordable is treatment with a generic atorvastatin in Bulgaria and generic rosuvastatin in Ukraine. The most expensive rosuvastatin in Bulgaria and atorvastatin in Ukraine are found as the least affordable for a monthly therapy.

Conclusions

The decrease of prices for statins is not the only reason influencing patients’ affordability to therapy for statin therapy in Ukraine and Bulgaria. The difference in affordability in Ukraine and Bulgaria is affected mainly by the economic development in the country as well as wages variation.

Associations between statins and coronary artery disease and stroke risks in patients with asthma-chronic obstructive pulmonary disease overlap syndrome: A time-dependent regression study

BACKGOUND AND AIMS

We aimed at determining the effects of statin use on coronary artery disease (CAD) and stroke risks in patients with asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS).

METHODS

We retrospectively enrolled patients with ACOS treated with (N = 916) and without (N = 6338) statins. The cumulative incidence of CAD and stroke (ischemic and hemorrhagic) was analyzed through time-dependent Cox proportional regression. After adjustment for sex, age, comorbidities, inhaled corticosteroid steroid (ICS) use, and oral steroid (OS) use, we calculated the adjusted hazard ratios (aHRs) and their 95% confidence intervals (CIs) for CAD or stroke in the statin users (long-term [>600 days] and short-term [≤600 days]) compared with the non-users.

RESULTS

Among the statin users, aHRs (95% CIs) for CAD and stroke were 0.50 (0.41-0.62) and 0.83 (0.63-1.09), respectively; moreover, aHRs were 0.30 (0.09-0.99) and 0.90 (0.68-1.20) for ischemic and hemorrhagic stroke, respectively. aHRs (95% CIs) for CAD and stroke were 0.58 (0.47-0.71) and 0.93 (0.70-1.23), respectively, in the short-term users and 0.23 (0.13-0.41) and 0.42 (0.19-0.89), respectively, in the long-term users.

CONCLUSIONS

CAD risk was lower in all statin users, regardless of the duration of use, whereas ischemic stroke risk was lower only in the long-term statin users. No association was observed between hemorrhagic stroke risk and statin use.

Statins and Multiple Noncardiovascular Outcomes: Umbrella Review of Meta-analyses of Observational Studies and Randomized Controlled Trials

BACKGROUND

Many effects of statins on non-cardiovascular disease (non-CVD) outcomes have been reported.

PURPOSE

To evaluate the quantity, validity, and credibility of evidence regarding associations between statins and non-CVD outcomes and the effects of statins on these outcomes.

DATA SOURCES

MEDLINE and EMBASE (English terms only, inception to 28 May 2018).

STUDY SELECTION

Meta-analyses (published in English) of observational studies and of randomized controlled trials (RCTs) that examined non-CVD outcomes of statin intake.

DATA EXTRACTION

Two investigators extracted data from meta-analyses and individual studies. Credibility assessments based on summary effect sizes from a random-effects model, between-study heterogeneity, 95% prediction interval, small-study effect, excess significance, and credibility ceilings were devised to classify evidence.

DATA SYNTHESIS

This review explored 278 unique non-CVD outcomes from 112 meta-analyses of observational studies and 144 meta-analyses of RCTs. For observational studies, no convincing (class I) evidence, 2 highly suggestive (class II) associations (decreased cancer mortality in patients with cancer and decreased exacerbation in patients with chronic obstructive pulmonary disease), 21 suggestive (class III) associations, and 42 weak (class IV) associations were identified. One outcome from the RCTs (decreased all-cause mortality in patients with chronic kidney disease) attained a sufficient amount of evidence with no hints of bias. For adverse events, observational studies showed suggestive evidence that statins increase the risk for diabetes and myopathy. Among the RCTs, no statistically significant effects were found on myopathy, myalgia, or rhabdomyolysis.

LIMITATIONS

Studies with relevant data and outcomes not included in the meta-analyses may have been missed. Credibility assessments relied on several assumptions and arbitrary thresholds.

CONCLUSION

The absence of convincing evidence of an association between statins and non-CVD outcomes supports leaving the current recommendations unchanged.

PRIMARY FUNDING SOURCE

None.

Controlling Mast Cell Activation and Homeostasis: Work Influenced by Bill Paul That Continues Today

Mast cells are tissue resident, innate immune cells with heterogenous phenotypes tuned by cytokines and other microenvironmental stimuli. Playing a protective role in parasitic, bacterial, and viral infections, mast cells are also known for their role in the pathogenesis of allergy, asthma, and autoimmune diseases. Here, we review factors controlling mast cell activation, with a focus on receptor signaling and potential therapies for allergic disease. Specifically, we will discuss our work with FcεRI and FγR signaling, IL-4, IL-10, and TGF-β1 treatment, and Stat5. We conclude with potential therapeutics for allergic disease. Much of these efforts have been influenced by the work of Bill Paul. With many mechanistic targets for mast cell activation and different classes of therapeutics being studied, there is reason to be hopeful for continued clinical progress in this area.

Use of cardiovascular polypills for the secondary prevention of cerebrovascular disease

INTRODUCTION

There is little control of cardiovascular (CV) risk factors in secondary prevention after an ischaemic stroke, in part due to a lack of adherence to treatment. The CV polypill may contribute to proper treatment adherence, which is necessary for CV disease prevention. This study aimed to establish how and in what cases the CV polypill should be administered.

METHODS

A group of 8 neurologists drafted consensus recommendations using structured brainstorming and based on their experience and a literature review.

RESULTS

These recommendations are based on the opinion of the participating experts. The use of the CV polypill is beneficial for patients, healthcare professionals, and the health system. Its use is most appropriate for atherothrombotic stroke, lacunar stroke, stroke associated with cognitive impairment, cryptogenic stroke with CV risk factors, and silent cerebrovascular disease. It is the preferred treatment in cases of suspected poor adherence, polymedicated patients, elderly people, patients with polyvascular disease or severe atherothrombosis, young patients in active work, and patients who express a preference for the CV polypill. Administration options include switching from individual drugs to the CV polypill, starting treatment with the CV polypill in the acute phase in particular cases, use in patients receiving another statin or an angiotensin ii receptor antagonist, or de novo use if there is suspicion of poor adherence. Nevertheless, use of the CV polypill requires follow-up on the achievement of the therapeutic objectives to make dose adjustments.

CONCLUSIONS

This document is the first to establish recommendations for the use of the CV polypill in cerebrovascular disease, beyond its advantages in terms of treatment adherence.

No benefits of statins for sudden cardiac death prevention in patients with heart failure and reduced ejection fraction: A meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVES

Statins showed mixed results in heart failure (HF) patients. The benefits in major HF outcomes, including all-cause mortality and sudden cardiac death (SCD), have always been discordant across systematic reviews and meta-analyses. We intended to systematically identify and appraise the available evidence that evaluated the effectiveness of statins in clinical outcomes for HF patients.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

We searched, until April 28, 2016: Medline, Embase, ISI Web of Science and EBM reviews (Cochrane DSR, ACP journal club, DARE, CCTR, CMR, HTA, and NHSEED), checked clinicaltrials.gov for ongoing trials and manually searched references of included studies.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We identified 24 randomized clinical trials that evaluated the efficacy of statins for HF patients. All randomized clinical trials were assessed for risk of bias and pooled together in a meta-analysis. Pre-specified outcomes were sudden cardiac death, all-cause mortality, and hospitalization for worsening heart failure.

RESULTS

Statins did not reduce sudden cardiac death (SCD) events in HF patients [relative risk (RR) 0.92, 95% confidence interval (CI) 0.70 to 1.21], all-cause mortality [RR 0.88, 95% CI 0.75 to 1.02] but significantly reduced hospitalization for worsening heart failure (HWHF) although modestly [RR 0.79, 95% CI 0.66 to 0.94]. Nevertheless, estimated predictive intervals were insignificant in SCD, all-cause mortality and HWHF [RR, 0.54 to 1.63, 0.64 to 1.19, and 0.54 to 1.15], respectively. An important finding was the possible presence of publication bias, small-study effects and heterogeneity of the trials conducted in HF patients.

CONCLUSIONS

Statins do not reduce sudden cardiac death, all-cause mortality, but may slightly decrease hospitalization for worsening heart failure in HF patients. The evaluation of the risk of biases suggested moderate quality of the published results. Until new evidence is available, this study supports the 2013 ACCF/AHA guidelines to not systematically prescribe statins in "only" HF patients, which should help avoid unnecessary polypharmacy.

Weibel-Palade body size modulates the adhesive activity of its von Willebrand Factor cargo in cultured endothelial cells

Changes in the size of cellular organelles are often linked to modifications in their function. Endothelial cells store von Willebrand Factor (vWF), a glycoprotein essential to haemostasis in Weibel-Palade bodies (WPBs), cigar-shaped secretory granules that are generated in a wide range of sizes. We recently showed that forcing changes in the size of WPBs modifies the activity of this cargo. We now find that endothelial cells treated with statins produce shorter WPBs and that the vWF they release at exocytosis displays a reduced capability to recruit platelets to the endothelial cell surface. Investigating other functional consequences of size changes of WPBs, we also report that the endothelial surface-associated vWF formed at exocytosis recruits soluble plasma vWF and that this process is reduced by treatments that shorten WPBs, statins included. These results indicate that the post-exocytic adhesive activity of vWF towards platelets and plasma vWF at the endothelial surface reflects the size of their storage organelle. Our findings therefore show that changes in WPB size, by influencing the adhesive activity of its vWF cargo, may represent a novel mode of regulation of platelet aggregation at the vascular wall.

WITHDRAWN: Artichoke leaf extract for treating hypercholesterolaemia

Withdrawal: The editors of Cochrane Heart consider this title as low priority for the current portfolio of the Heart Group and therefore this title is not open to a new author team.

The editorial group responsible for this previously published document have withdrawn it from publication.

Altered microRNome Profiling in Statin-Induced HepG2 Cells: A Pilot Study Identifying Potential new Biomarkers Involved in Lipid-Lowering Treatment

PURPOSE

Statins are widely prescribed drugs to manage hypercholesterolemia. Despite they are considered effective lipid-lowering agents, significant inter-individual variability has been reported in relation to drug response. Among the reasons explaining this variation, genetic factors are known to partially contribute. Nonetheless, poor evidence exists regarding epigenetic factors involved.

METHODS

We investigated if atorvastatin can modulate the cholesterol related miR-33 family. Furthermore, we analyzed the microRNA expression profiles in HepG2 cells treated for 24 hours with atorvastatin or simvastatin using a microarray platform.

RESULTS

Our results indicate that atorvastatin does not influence the expression of the miR-33 family. In addition, microarray examination revealed that atorvastatin modulated thirteen miRs, whilst simvastatin only affected two miRs. All significantly modulated miRs after simvastastin therapy were also modulated by atorvastatin. In addition, four novel miRs with previously unreported functions were identified as statin-modulated.

CONCLUSION

We identified several novel miRs affected by statin treatment. Additional research is needed to determine the biological significance of differentially expressed miRs identified in statins-induced HepG2 cells.

Association Between Use of Statins and Mortality in Patients With Heart Failure and Ejection Fraction of ≥50%

Background—

The pathophysiology of heart failure with preserved ejection fraction is poorly understood, but may involve a systemic proinflammatory state. Therefore, statins might improve outcomes in patients with heart failure with preserved ejection fraction defined as ≥50%.

Methods and Results—

Of 46 959 unique patients in the prospective Swedish Heart Failure Registry, 9140 patients had heart failure and ejection fraction ≥50% (age 77±11 years, 54.0% women), and of these, 3427 (37.5%) were treated with statins. Propensity scores for statin treatment were derived from 40 baseline variables. The association between statin use and primary (all-cause mortality) and secondary (separately, cardiovascular mortality, and combined all-cause mortality or cardiovascular hospitalization) end points was assessed with Cox regressions in a population matched 1:1 based on age and propensity score. In the matched population, 1-year survival was 85.1% for statin-treated versus 80.9% for untreated patients (hazard ratio, 0.80; 95% confidence interval, 0.72–0.89; P <0.001). Statins were also associated with reduced cardiovascular death (hazard ratio, 0.86; 95% confidence interval, 0.75–0.98; P =0.026) and composite all-cause mortality or cardiovascular hospitalization (hazard ratio, 0.89; 95% confidence interval, 0.82–0.96; P =0.003).

Conclusions—

In heart failure with ejection fraction ≥50%, the use of statins was associated with improved outcomes. The mechanisms should be evaluated and the effects tested in a randomized trial.

Incident user cohorts for assessing medication cost-offsets

OBJECTIVE

To develop and test incident drug user designs for assessing cost savings from statin use in diabetics.

DATA SOURCE

Random 5 percent sample of Medicare beneficiaries, 2006-2008.

STUDY DESIGN

Seven-step incident user design to assess impact of statin initiation on subsequent Medicare spending: (1) unadjusted pre/post initiation test; (2) unadjusted difference-in-difference (DID) with comparison series; (3) adjusted DID; (4) propensity score (PS)-matched DID with static and dynamic baseline covariates; (5) PS-matched DID by drug adherence strata; (6) PS-matched DID for high adherers controlling for healthy adherer bias; and (7) replication for ACE-inhibitor/ARB initiators.

DATA COLLECTION/EXTRACTION METHODS

Subjects with prevalent diabetes and no statin use (January-June 2006) and statin initiation (July 2006-January 2008) compared to nonusers with a random "potential-initiation" month. Monthly Medicare spending tracked 24 months pre- and post-initiation.

PRINCIPAL FINDINGS

Statistically significant savings in Medicare spending were observed beginning 7 months post-initiation for statins and 13 months post-initiation for ACEIs/ARBs. However, these savings were only observed for adherent patients in steps 5 and 6.

CONCLUSIONS

Drug initiator designs are more robust to confounding than prevalent user designs in assessing cost-offsets from drug use but still require other adjustments and sensitivity analysis to ensure proper inference.

Unintended effects of statins from observational studies in the general population: systematic review and meta-analysis

BACKGROUND

Efficacy of statins has been extensively studied, with much less information reported on their unintended effects. Evidence from randomized controlled trials (RCTs) on unintended effects is often insufficient to support hypotheses generated from observational studies. We aimed to systematically assess unintended effects of statins from observational studies in general populations with comparison of the findings where possible with those derived from randomized trials.

METHODS

Medline (1998 to January 2012, week 3) and Embase (1998 to 2012, week 6) were searched using the standard BMJ Cohort studies filter. The search was supplemented with reference lists of all identified studies and contact with experts in the field. We included prospective studies with a sample size larger than 1,000 participants, case control (of any size) and routine health service linkage studies of over at least one year duration. Studies in subgroups of patients or follow-up of patient case series were excluded, as well as hospital-based cohort studies.

RESULTS

Ninety studies were identified, reporting on 48 different unintended effects. Statins were associated with lower risks of dementia and cognitive impairment, venous thrombo-embolism, fractures and pneumonia, but these findings were attenuated in analyses restricted to higher quality studies (respectively: OR 0.74 (95% CI 0.62 to 0.87); OR 0.92 (95% CI 0.81 to 1.03); OR 0.97 (95% CI 0.88 to 1.05); OR 0.92 (95% CI 0.83 to 1.02)); and marked heterogeneity of effects across studies remained. Statin use was not related to any increased risk of depression, common eye diseases, renal disorders or arthritis. There was evidence of an increased risk of myopathy, raised liver enzymes and diabetes (respectively: OR 2.63 (95% CI 1.50 to 4.61); OR 1.54 (95% CI 1.47 to 1.62); OR 1.31 (95% CI 0.99 to 1.73)).

CONCLUSIONS

Our systematic review and meta-analyses indicate that high quality observational data can provide relevant evidence on unintended effects of statins to add to the evidence from RCTs. The absolute excess risk of the observed harmful unintended effects of statins is very small compared to the beneficial effects of statins on major cardiovascular events.

Does combination therapy with statins and fibrates prevent cardiovascular disease in diabetic patients with atherogenic mixed dyslipidemia?

Type 2 diabetes mellitus (T2DM) is associated with the development and progression of cardiovascular disease (CVD). Statins have an established efficacy in the management of dyslipidemia primarily by decreasing the levels of low-density lipoprotein cholesterol and thus decreasing CVD risk. They also have a favorable safety profile. Despite the statin-mediated benefit of CVD risk reduction a residual CVD risk remains, especially in T2DM patients with high triglyceride (TG) and low high-density lipoprotein cholesterol (HDL-C) values. Fibrates decrease TG levels, increase HDL-C concentrations, and improve many other atherosclerosis-related variables. Fibrate/statin co-administration improves the overall lipoprotein profile in patients with mixed dyslipidemia and may reduce the residual CVD risk during statin therapy. However, limited data exists regarding the effects of statin/fibrate combination on CVD outcomes in patients with T2DM. In the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study the statin/fibrate combination did not significantly reduce the rate of CVD events compared with simvastatin/placebo in patients with T2DM. However, it did show a possible benefit in a pre-specified analysis in the subgroup of patients with high TG and low HDL-C levels. Furthermore, in the ACCORD study the simvastatin/fenofibrate combination significantly reduced the rate of progression of retinopathy compared with statin/placebo administration in patients with T2DM. The present review presents the available data regarding the effects of statin/fibrate combination in patients with T2DM and atherogenic mixed dyslipidemia.

Coronary flow reserve from mouse to man--from mechanistic understanding to future interventions

Myocardial ischemia is recognized as an important mechanism increasing the risk for cardiovascular events in both symptomatic and asymptomatic patients. In addition to obstructive coronary diseases, systemic inflammation, macro- and microvascular function are additional important mechanisms contributing to the ischemic myocardium. Accumulating evidence indicates that coronary flow reserve (CFR) is a quantitative measurement of ischemia including integrated information on structure and function of the coronary artery at all levels. Not surprisingly, CFR has been shown to confer strong prognostic value for hard cardiovascular (CV) events in a number of relevant patient cohorts. Using high-resolution imaging, it is now possible to study coronary arteries from mouse to man. Therefore, CFR may be an important translational tool to risk-stratify patients and to perform both preclinical and clinical proof-of-concept studies before investing in large-scale outcome trials, thus improving the translational value for novel CV targets.

Managing cardiovascular risk in overweight children and adolescents

The scientific, medical, and lay communities are currently confronted with a serious medical and public health problem related to the marked non-remitting worldwide epidemic of obesity. This ever-increasing prevalence of obesity is accompanied by a host of inherently associated co-morbidities. As a result, obesity is fast becoming the major cause of premature death in the developed world. As pediatric and adult cardiologists, we have seen a dramatic increase in office referrals of overweight and obese children and adolescents, who already have obesity-related degenerative disease processes such as hypertension, dyslipidemia, the metabolic syndrome, and type 2 diabetes mellitus, as well as manifestations of early preclinical atherosclerotic cardiovascular disease, not previously observed in this age group. This article presents a review of the literature and recent scientific statements and recommendations issued by the American Heart Association (AHA) and the American Academy of Pediatrics (AAP) regarding the metabolic abnormalities associated with obesity, including newer identification and treatment strategies for obesity, dyslipidemia, and early subclinical coronary artery disease seen in high-risk children and adolescents.

Comparative effects of statins on major cerebrovascular events: a multiple-treatments meta-analysis of placebo-controlled and active-comparator trials

Statins are important in the prevention of major cerebrovascular events. Whether, and the extent to which, individual statins differ in terms of their effect on these outcomes has not been studied. The aim of this review was to evaluate the comparative effects of individual statins on major cerebrovascular events. We systematically reviewed 61 trials including 187 038 individuals with, or at risk of developing, cardiovascular disease. We performed pair-wise and multiple-treatments meta-analyses for major cerebrovascular events, in addition to fatal and non-fatal strokes separately. Across all populations, statins were significantly more effective than control in reducing major cerebrovascular events [odds ratio (OR): 0.82, 95% CI: 0.77, 0.87], with no differences among individual statins. Statins were also effective in patients with established cardiovascular disease (OR: 0.83, 95% CI: 0.75, 0.91) and in those without (OR: 0.80, 95% CI: 0.71, 0.91). Considering individual statins, significant risk reductions were achieved with atorvastatin (OR: 0.74, 95% CI: 0.63, 0.85), pravastatin (OR: 0.86, 95% CI: 0.76, 0.97) and simvastatin (OR: 0.75, 95% CI: 0.62, 0.88) as compared with control on major cerebrovascular events across all populations. Statins led to significant reductions in the risk of non-fatal strokes (OR: 0.77, 95% CI: 0.71, 0.85) but not of fatal strokes (OR: 0.96, 95% CI: 0.80, 1.15). Findings were not sensitive to dose differentials of individual statins across the trials. No significant heterogeneity or inconsistency was detected. Statins significantly reduce the incidence of major cerebrovascular events as compared with control. Our analysis provided evidence to confirm the class effect of statins in preventing major cerebrovascular events.

Artichoke leaf extract for treating hypercholesterolaemia

BACKGROUND

Hypercholesterolaemia is directly associated with an increased risk for coronary heart disease and other sequelae of atherosclerosis. Artichoke leaf extract (ALE) has been implicated in lowering cholesterol levels. Whether ALE is truly effective for this indication is still a matter of debate. This is an update of a review first published in 2002 and last updated in 2009.

OBJECTIVES

To assess the efficacy and safety of ALE in the treatment of hypercholesterolaemia.,

SEARCH METHODS

We updated searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) (2012, Issue 5); MEDLINE Ovid (1966 to May Week 2, 2012); EMBASE Ovid (1980 to 2012 Week 19); and CINAHL Ebsco (1982 to May 2012) on 17 May 2012. CISCOM was last searched until June 2001, and AMED until June 2008. We checked reference lists of articles, and contacted manufacturers of preparations containing artichoke extract, and experts on the subject. No language restrictions were applied.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of ALE mono-preparations compared with placebo or reference medication for patients with hypercholesterolaemia. We excluded trials assessing ALE as one of several active components in a combination preparation or as a part of a combination treatment.

DATA COLLECTION AND ANALYSIS

Data were extracted systematically and risk of bias was evaluated using the Cochrane 'Risk of bias' tool. Two authors independently performed the screening of studies, selection, data extraction and assessment of risk of bias. Disagreements in the evaluation of individual trials were resolved through discussion.

MAIN RESULTS

We included three RCTs involving 262 participants. The trials were of adequate methodological quality but had some shortcomings. One trial was at low quality of risk, one at medium and one of unclear risk of bias. One trial is available as abstract only and includes a small sample. In the first trial the total cholesterol level in participants receiving ALE decreased by 4.2% from 7.16 (0.62) mmol/L to 6.86 (0.68) mmol/L after 12 weeks, and increased from 6.90 (0.49) mmol/L to 7.04 (0.61) mmol/L in patients receiving placebo, the total difference being statistically significant (P = 0.025). In the second trial ALE reduced total cholesterol levels by 18.5% from 7.74 mmol/L to 6.31 mmol/L after 42 ± 3 days of treatment, whereas placebo reduced cholesterol by 8.6% from 7.69 mmol/L to 7.03 mmol/L (P = 0.00001). The third trial, which is available as abstract only and provides limited data, stated that ALE significantly reduced blood cholesterol compared with placebo in a subgroup of patients with baseline total cholesterol levels of more than 230 mg/dL (P < 0.05). Trial reports indicate mild, transient and infrequent adverse events.

AUTHORS' CONCLUSIONS

Data from three clinical trials assessing ALE for treating hypercholesterolaemia are available. Athough the trials are of adequate methodological quality they have some shortcomings and one is available as abstract only. There is an indication that ALE has potential in lowering cholesterol levels, but the evidence is, as yet, not convincing. The limited data on safety suggest only mild, transient and infrequent adverse events with the short term use of ALE.

Predictors of Failure of Endovascular Revascularization for Critical Limb Ischemia

Background and Aims:

To characterize predictors of failure when treating critical limb ischemia (CLI) patients with an endovascular intervention as the first-line strategy.

Patients and Methods:

This retrospective, registry-based study included 217 consecutive patients with 240 chronic critically ischemic limbs treated with infrainguinal percutaneous transluminal angioplasty (PTA) during 2006–2007 at Helsinki University Central Hospital, Finland. The primary outcome measures were death, major (above-ankle) amputation, and the need for surgical re-intervention within 6 months after the primary procedure. The secondary outcome measures were overall major amputation and survival rates as well as the overall need for surgical or any other (surgical or endovascular) type of re-intervention. Predictors of outcome endpoints were identified with a univariate screen, and a Cox regression model was used in the multivariate analysis.

Results:

Compared to ulcer, gangrene was significantly more strongly associated with amputation within 6 months post-procedurally as well as during the whole follow-up period (p ≤ 0.028). The patient's inability to walk upon hospital arrival was a significant predictor of death, amputation and surgical re-intervention. Mediasclerotic ankle-brachial index (ABI) was an independent predictor of amputation as well as endovascular re-interventions.

Conclusions:

The strong predictors of poor outcome after endovascular revascularization for patients with CLI are cardiac morbidity, the inability to ambulate upon hospital arrival, and gangrene as a manifestation of CLI. The risk of amputation seems to be significantly higher for gangrene than for ulcer and this matter should be taken into account in the clinical classifications for CLI.

Bias in observational studies of prevalent users: lessons for comparative effectiveness research from a meta-analysis of statins

Randomized clinical trials (RCTs) are usually the preferred strategy with which to generate evidence of comparative effectiveness, but conducting an RCT is not always feasible. Though observational studies and RCTs often provide comparable estimates, the questioning of observational analyses has recently intensified because of randomized-observational discrepancies regarding the effect of postmenopausal hormone replacement therapy on coronary heart disease. Reanalyses of observational data that excluded prevalent users of hormone replacement therapy led to attenuated discrepancies, which begs the question of whether exclusion of prevalent users should be generally recommended. In the current study, the authors evaluated the effect of excluding prevalent users of statins in a meta-analysis of observational studies of persons with cardiovascular disease. The pooled, multivariate-adjusted mortality hazard ratio for statin use was 0.77 (95% confidence interval (CI): 0.65, 0.91) in 4 studies that compared incident users with nonusers, 0.70 (95% CI: 0.64, 0.78) in 13 studies that compared a combination of prevalent and incident users with nonusers, and 0.54 (95% CI: 0.45, 0.66) in 13 studies that compared prevalent users with nonusers. The corresponding hazard ratio from 18 RCTs was 0.84 (95% CI: 0.77, 0.91). It appears that the greater the proportion of prevalent statin users in observational studies, the larger the discrepancy between observational and randomized estimates.

Fenofibrate plus simvastatin (fixed-dose combination) for the treatment of dyslipidaemia

INTRODUCTION

Statin use results in a significant reduction of cardiovascular disease (CVD) risk. However, patients still have residual CVD risk, even if they are receiving optimal statin treatment.

AREAS COVERED

This review, based on a Pubmed/Scopus search, discusses the available evidence regarding the use of a fixed-dose fenofibrate plus simvastatin combination. This combination is useful for patients with mixed dyslipidaemia because it improves the overall lipoprotein profile. Although in clinical trials the rate of adverse events was not significantly greater than monotherapy, patients who receive combination treatment should be monitored carefully. Furthermore, in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Study, this combination did not result in a significant reduction of CVD events compared with simvastatin monotherapy. However, a possible benefit in this trial was observed in the subgroup of patients with high triglyceride and low high-density lipoprotein cholesterol levels.

EXPERT OPINION

The fixed-dose fenofibrate plus simvastatin combination treatment produces additive results and is safe when patients are properly monitored. Existing evidence appears to support the addition of fenofibrate to simvastatin treatment for the reduction of residual CVD risk in patients with atherogenic dyslipidaemia. However, this combination did not lead to better clinical outcomes in the absence of dyslipidaemia.