3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors increase fibrinolytic activity in rat aortic endothelial cells. Role of geranylgeranylation and Rho proteins

Potential Benefits and Risks Associated with the Use of Statins

HMG-CoA reductase inhibitors, commonly known as statins, are the primary treatment choice for cardiovascular diseases, which stand as the leading global cause of mortality. Statins also offer various pleiotropic effects, including improved endothelial function, anti-inflammatory properties, reduced oxidative stress, anti-thrombotic effects, and the stabilization of atherosclerotic plaques. However, the usage of statins can be accompanied by a range of adverse effects, such as the development of type 2 diabetes mellitus, muscular symptoms, liver toxicity, kidney diseases, cataracts, hemorrhagic strokes, and psychiatric complications. These issues are referred to as statin-associated symptoms (SAS) and are relatively infrequent in clinical trials, making it challenging to attribute them to statin use definitively. Therefore, these symptoms can lead to significant problems, necessitating dose adjustments or discontinuation of statin therapy. This review aims to provide a comprehensive overview of the mechanism of action, potential advantages, and associated risks of statin utilization in clinical settings.

Understanding the molecular mechanisms of statin pleiotropic effects

Statins represent the cornerstone of pharmacotherapy for the prevention of atherosclerotic cardiovascular disease. These medications not only reduce low-density lipoprotein cholesterol (LDL-C) via inhibition of 3-hydroxy-3-methylglutarate attached to CoA reductase, the key rate-limiting step in the cholesterol biosynthetic pathway, but also upregulate expression of the low-density lipoprotein receptor, improving serum clearance. Given LDL-C is a causal risk factor for the development of atherosclerosis, these complementary mechanisms largely explain why statin therapy leads to reductions in major adverse cardiovascular events. However, decades of basic and clinical research have suggested that statins may exert other effects independent of LDL-C lowering, termed pleiotropic effects, which have become a topic of debate among the scientific community. While some literature suggests statins may improve plaque stability, reduce inflammation and thrombosis, decrease oxidative stress, and improve endothelial function and vascular tone, other studies have suggested potential harmful pleiotropic effects related to increased risk of muscle-related side effects, diabetes, hemorrhagic stroke, and cognitive decline. Furthermore, the introduction of newer, non-statin LDL-C lowering therapies, including ezetimibe, proprotein convertase subtilisin/Kexin Type 9, and bempedoic acid, have challenged the statin pleiotropy theory. This review aims to provide a historical background on the development of statins, explore the mechanistic underpinnings of statin pleiotropy, review the available literature, and provide up to date examples that suggest statins may exert effects outside of LDL-C lowering and the cardiovascular system.

The Atrium in Atrial Fibrillation - A Clinical Review on How to Manage Atrial Fibrotic Substrates

Atrial fibrillation (AF) is the most common sustained arrhythmia in the population and is associated with a significant clinical and economic burden. Rigorous assessment of the presence and degree of an atrial arrhythmic substrate is essential for determining treatment options, predicting long-term success after catheter ablation, and as a substrate critical in the pathophysiology of atrial thrombogenesis. Catheter ablation of AF has developed into an essential rhythm-control strategy. Nowadays is one of the most common cardiac ablation procedures performed worldwide, with its success inversely related to the extent of atrial structural disease. Although atrial substrate evaluation remains complex, several diagnostic resources allow for a more comprehensive assessment and quantification of the extent of left atrial structural remodeling and the presence of atrial fibrosis. In this review, we summarize the current knowledge on the pathophysiology, etiology, and electrophysiological aspects of atrial substrates promoting the development of AF. We also describe the risk factors for its development and how to diagnose its presence using imaging, electrocardiograms, and electroanatomic voltage mapping. Finally, we discuss recent data regarding fibrosis biomarkers that could help diagnose atrial fibrotic substrates.

Synergistic actions between angiotensin-converting enzyme inhibitors and statins in atherosclerosis

AIMS

Hypertension and hypercholesterolemia are independent risk factors for atherosclerotic cardiovascular disease (ASCVD) by acting directly on the endothelium and activating the renin-angiotensin aldosterone system (RAAS) and mevalonate pathways. This review examines how the severity and duration of these risk factors may influence the cardiovascular risk through a reciprocal interplay leading to oxidative stress and pro-inflammatory response.

DATA SYNTHESIS

The review highlights the clinical evidence supporting the benefits of statins and angiotensin-converting enzyme (ACE) inhibitors for hypertension, lipid disorders and ASCVD management, both individually and combined, at all stages of the cardiovascular continuum.

CONCLUSION

Drug strategies incorporating an ACE-inhibitor and a statin, and in particular perindopril and atorvastatin, have consistently demonstrated reductions in the rate of ASCVD events in patients with hypertension and lipid disorders, cementing their position as first-line therapies for the management of atherosclerosis complications.

Putting function back in dysfunction: Endothelial diseases and current therapies in hematopoietic stem cell transplantation and cellular therapies

Endothelial dysfunction is characterized by altered vascular permeability and prothrombotic, pro-inflammatory phenotypes. Endothelial dysfunction results in end-organ damage and has been associated with diverse disease pathologies. Complications observed after hematopoietic stem cell transplantation (HCT) and chimeric antigen receptor-T cell (CAR-T) therapy for hematologic and neoplastic disorders share overlapping clinical manifestations and there is increasing evidence linking these complications to endothelial dysfunction. Despite advances in supportive care and treatments, end-organ toxicity remains the leading cause of mortality. A new strategy to mitigate endothelial dysfunction could lead to improvement of clinical outcomes for patients. Statins have demonstrated pleiotropic effects of immunomodulatory and endothelial protection by various molecular mechanisms. Recent applications in immune-mediated diseases such as autoimmune disorders, chronic inflammatory conditions, and graft-versus-host disease (GVHD) have shown promising results. In this review, we cover the mechanisms underlying endothelial dysfunction in GVHD and CAR-T cell-related toxicities. We summarize the current knowledge about statins and other agents used as endothelial protectants. We propose further studies using statins for prophylaxis and prevention of end-organ damage related to extensive endothelial dysfunction in HCT and CAR-T.

Association Between Statin Use at the Time of Intra-abdominal Surgery and Postoperative Adhesion-Related Complications and Small-Bowel Obstruction

IMPORTANCE

Adhesion-related complications (ARCs), including small-bowel obstruction, are common complications of intra-abdominal surgery. Statins, which have antifibrotic pleiotropic effects, inhibit adhesion formation in murine models but have not been assessed in humans.

OBJECTIVE

To assess whether statin use at the time of intra-abdominal surgery is associated with a reduction in ARCs.

DESIGN, SETTING, AND PARTICIPANTS

These 2 separate retrospective cohort studies (The Health Improvement Network [THIN] and Optum's Clinformatics Data Mart [Optum]) compared adults receiving statins with those not receiving statins at the time of intra-abdominal surgery. Individuals undergoing intra-abdominal surgery from January 1, 1996, to December 31, 2013, in the United Kingdom and from January 1, 2000, to December 31, 2016, in the US were included in the study. Those with obstructive events before surgery or a history of inflammatory bowel disease were excluded. Data analysis was performed from September 1, 2012, to November 24, 2020.

EXPOSURE

The primary exposure was statin use at the time of surgery.

MAIN OUTCOMES AND MEASURES

The primary outcome was ARCs, defined as small-bowel obstruction or need for adhesiolysis, occurring after surgery. Sensitivity analyses included statin use preceding but not concurrent with surgery, fibrate use, and angiotensin-converting enzyme inhibitor use. All analyses were adjusted for age, sex, and conditions associated with microvascular disease, such as hypertension, hyperlipidemia, obesity, and tobacco use; surgical approach and site; and diagnosis of a malignant tumor.

RESULTS

A total of 148 601 individuals met the inclusion criteria for THIN (mean [SD] age, 49.6 [17.7] years; 70.1% female) and 1 188 217 for Optum (mean [SD] age, 48.2 [16.4] years; 72.6% female). A total of 2060 participants (1.4%) experienced an ARC in THIN and 54 136 (4.6%) in Optum. Statin use at the time of surgery was associated with decreased risk of ARCs (THIN: adjusted hazard ratio [HR], 0.81; 95% CI, 0.71-0.92; Optum: adjusted HR, 0.92; 95% CI, 0.90-0.95). Similar associations were appreciated between statins and small-bowel obstruction (THIN: adjusted HR, 0.80; 95% CI, 0.70-0.92; Optum: adjusted HR, 0.88; 95% CI, 0.85-0.91).

CONCLUSIONS AND RELEVANCE

This study's findings suggest that, among individuals in 2 separate cohorts undergoing intra-abdominal surgery, statin use may be associated with a reduced risk of postoperative ARCs. Statins may represent an inexpensive, well-tolerated pharmacologic option for preventing ARCs.

Simvastatin and ROCK Inhibitor Y-27632 Inhibit Myofibroblast Differentiation of Graves' Ophthalmopathy-Derived Orbital Fibroblasts via RhoA-Mediated ERK and p38 Signaling Pathways

Transforming growth factor-β (TGF-β)-induced differentiation of orbital fibroblasts into myofibroblasts is an important pathogenesis of Graves' ophthalmopathy (GO) and leads to orbital tissue fibrosis. In the present study, we explored the antifibrotic effects of simvastatin and ROCK inhibitor Y-27632 in primary cultured GO orbital fibroblasts and tried to explain the molecular mechanisms behind these effects. Both simvastatin and Y-27632 inhibited TGF-β-induced α-smooth muscle actin (α-SMA) expression, which serves as a marker of fibrosis. The inhibitory effect of simvastatin on TGF-β-induced RhoA, ROCK1, and α-SMA expression could be reversed by geranylgeranyl pyrophosphate, an intermediate in the biosynthesis of cholesterol. This suggested that the mechanism of simvastatin-mediated antifibrotic effects may involve RhoA/ROCK signaling. Furthermore, simvastatin and Y-27632 suppressed TGF-β-induced phosphorylation of ERK and p38. The TGF-β-mediated α-SMA expression was suppressed by pharmacological inhibitors of p38 and ERK. These results suggested that simvastatin inhibits TGF-β-induced myofibroblast differentiation via suppression of the RhoA/ROCK/ERK and p38 MAPK signaling pathways. Thus, our study provides evidence that simvastatin and ROCK inhibitors may be potential therapeutic drugs for the prevention and treatment of orbital fibrosis in GO.

The effects of statins with a high hepatoselectivity rank on the extra-hepatic tissues; New functions for statins

Statins, as the most common treatment for hyperlipidemia, exert effects beyond their lipid-lowering role which are known as pleiotropic effects. These effects are mainly due to the inhibition of isoprenoids synthesis and consequently blocking prenylation of proteins involved in the cellular signaling pathways regulating cell development, growth, and apoptosis. Statins target cholesterol synthesis in the liver as the major source of cholesterol in the body and so reduce whole-body cholesterol. The reduced level of cholesterol forces other organs to an adaptive homeostatic reaction to increase their cholesterol synthesis capacity, however, this only occurs when statins have unremarkable access to the extra-hepatic tissues. In order to reduce the adverse effects of statin on the skeletal muscle, most recent efforts have been towards formulating new statins with the highest level of hepatoselectivity rank and the least level of access to the extra-hepatic tissues; however, the inaccessibility of statins for the extra-hepatic tissues may induce several biological reactions. In this review, we aim to evaluate the effects of statins on the extra-hepatic tissues when statins have unremarkable access to these tissues.

Regulatory T cells: Possible mediators for the anti-inflammatory action of statins

Statins beside their main effect on reducing the progression of cardiovascular disease through pharmacological inhibition of the endogenous cholesterol synthesis, have additional pleiotropic effects including antiinflammatory effects mediated through the induction of suppressor regulatory T cells (Tregs). Statin-induced expansion of Tregs reduces chronic inflammation and may have beneficial effects in autoimmune diseases. However, statins could represent a double-edged sword in immunomodulation. Drugs that act by increasing the concentration of Tregs could enhance the risk of cancers, particularly in the elderly and may have adverse effects in neurodegenerative disorders and infectious diseases. In the present paper, we review the experimental studies that evaluate the effects of statins on Treg cells in autoimmune and inflammatory diseases and we discuss potential therapeutic applications of statins in this setting.

Increasing the effectiveness of tyrosine kinase inhibitor (TKI) in combination with a statin in reducing liver fibrosis

It has been shown that both nilotinib as a tyrosine kinase inhibitor, and atorvastatin as a rho-kinase inhibitor, have antifibrotic effects. Therefore, considering the relationship between these two pathways, this study aimed to investigate the effects of their co-treatment against hepatic stellate cells (HSCs) activation and liver fibrosis. For this purpose, the activation of HSCs coincided with these therapies. Also, liver fibrosis by carbon tetrachloride (CCl₄ ) was induced in male Wistar rats and treated simultaneously with these compounds. The expression of alpha-smooth muscle actin (α-SMA), connective tissue growth factor (CTGF), Ras homolog gene family, and member A (RhoA)/Rho-associated protein kinase (ROCK) in HSCs were measured. The expression of transforming growth factor beta-1 (TGF-β1), its receptor (TβRII), CTGF, and platelets derived growth factor (PDGF), in the livers, were also investigated, all by real-time PCR and western blot analysis. Also, histopathologic and immunohistochemical evaluations were performed to evaluate changes in liver fibrosis during treatment. The results indicated the down-regulation of RhoA/ROCK, CTGF, and α-SMA, and inhibition of the HSCs activation toward myofibroblasts. The results also showed that the combined use of atorvastatin and nilotinib has significantly higher inhibitory effects. The antifibrotic effects of atorvastatin and nilotinib co-administration were also observed by histopathologic and immunohistochemical observations, and inhibiting the expression of TGF-β1, TβRII, CTGF, and PDGF. Taken together, this study revealed that co-administration of nilotinib-atorvastatin has novel antifibrotic effects, by inhibiting RhoA/ROCK, and CTGF pathway. Therefore, the importance of the common pathway of RhoA/ROCK and CTGF, in reducing fibrosis may almost be concluded.

Propensity-matched analysis of the influence of perioperative statin therapy on outcomes after liver resection

Background

Perioperative use of statins is reported to improve postoperative outcomes after cardiac and non‐cardiovascular surgery. The aim of this study was to investigate the influence of statins on postoperative outcomes including complications of grade IIIa and above, posthepatectomy liver failure (PHLF), and 90‐day mortality rates after liver resection.

Methods

Patients who underwent hepatectomy between 2013 and 2017 were reviewed to identify statin users and non‐users (controls). Propensity matching was conducted for age, BMI, type of surgery and preoperative co‐morbidities to compare subgroups. Univariable and multivariable analyses were performed for the following outcomes: 90‐day mortality, significant postoperative complications and PHLF.

Results

Of 890 patients who had liver resection during the study period, 162 (18·2 per cent) were taking perioperative statins. Propensity analysis selected two matched groups, each comprising 154 patients. Overall, 81 patients (9·1 per cent) developed complications of grade IIIa or above, and the 90‐day mortality rate was 3·4 per cent (30 patients), with no statistically significant difference when the groups were compared before and after matching. The rate of PHLF was significantly lower in patients on perioperative statins than in those not taking statins (10·5 versus 17·3 per cent respectively; P = 0·033); similar results were found after propensity matching (10·4 versus 20·8 per cent respectively; P = 0·026).

Conclusion

The rate of PHLF was significantly lower in patients taking perioperative statins, but there was no statistically significant difference in severe complications and mortality rates.

A revised systematic review and meta-analysis on the effect of statins on D-dimer levels

BACKGROUND

D-dimers are generated during endogenous fibrinolysis of a blood clot and have a central role in diagnostic algorithms to rule out venous thromboembolism. HMG-CoA reductase inhibitors, more commonly called statins, are known to have effects independent of LDL-cholesterol lowering, including antithrombotic properties. An effect of statins on D-dimer levels has been reported in a prior systematic review and meta-analysis, but methodological shortcomings might have led to an overestimated effect. To re-evaluate the association between statins and D-dimer levels, we systematically reviewed all published articles on the influence of statins on D-dimer levels and conducted a novel meta-analysis (PROSPERO registration number CRD42017058932).

MATERIALS AND METHODS

We electronically searched EMBASE, Medline Epub, Cochrane, Web of Science and Google Scholar (100 top relevance) (date of last search: 5 October 2017). We included randomized controlled trials, cohort studies and cross-sectional studies. Two reviewers independently screened all articles retrieved and extracted data on study and patient characteristics, study quality and D-dimer levels.

RESULTS

Study-level meta-analysis involving 18,052 study participants showed lower D-dimer levels in those receiving statin treatment than controls (SMD: -0.165, 95% CI -0.234; -0.096, P = <0.001). Sensitivity analyses and additional analyses on treatment duration (<12 weeks vs ≥12 weeks) and type of statin (lipophilic or hydrophilic) did not modify this overall result.

CONCLUSION

This meta-analysis suggests an association between use of statins and reduction of D-dimer levels, independent of treatment duration and type of statin used. This effect is small but robust, and should be interpreted with caution.

Evaluation of the Effects of Atorvastatin and Ischemic Postconditioning Preventing on the Ischemia and Reperfusion Injury: Experimental Study in Rats

INTRODUCTION

Reperfusion injury leads to systemic morphological and functional pathological alterations. Some techniques are already estabilished to attenuate the damage induced by reperfusion. Ischemic preconditioning is one of the standard procedures. In the last 20 years, several experimental trials demonstrated that the ischemic postconditioning presents similar effectiveness. Recently experimental trials demonstrated that statins could be used as pharmacological preconditioning.

METHODS

41 Wistar rats (Rattus norvegicus albinus) were distributed in 5 groups: Ischemia and Reperfusion (A), Ischemic Postconditioning (B), Statin (C), Ischemic Postconditioning + Statins (D) and SHAM (E). After euthanasia, lungs, liver, kidneys and ileum were resected and submitted to histopathological analysis.

RESULTS

The average of lung parenchymal injury was A=3.6, B=1.6, C=1.2, D=1.2, E=1 (P=0.0029). The average of liver parenchymal injury was A=3, B=1.5, C=1.2, D=1.2, E = 0 (P<0.0001). The average of renal parenchymal injury was A=4, B=2.44, C=1.22, D=1.11, E=1 (P<0.0001). The average of intestinal parenchymal injury was A=2, B=0.66, C=0, D=0, E=0 (P=0.0006). The results were submitted to statistics applying Kruskal-Wallis test, estabilishing level of significance P<0.05.

CONCLUSION

Groups submitted to ischemic postconditioning, to pre-treatment with statins and both methods associated demonstrated less remote reperfusion injuries, compared to the group submitted to ischemia and reperfusion without protection.

Beneficial effect of statins in patients receiving chronic hemodialysis following percutaneous coronary intervention: A nationwide retrospective cohort study

The cardiovascular diseases are the leading cause of mortality in end-stage renal disease (ESRD) patients. However, roles of statins are still controversial in dialysis-dependent ESRD patients regardless of having proven coronary artery occlusive disease. The aim of this study was to examine the benefit of statin following percutaneous coronary intervention (PCI) in ESRD patients who have proven coronary artery occlusive disease. This study was based on the National Health Insurance Service-National Sample Cohort in South Korea. We included 150 ESRD patients on chronic hemodialysis who underwent PCI with stenting between 2002 and 2013. The primary outcome was a composite of myocardial infarction, stroke, and all-cause mortality. Multivariate time-dependent Cox regression analysis were performed, and statin therapy after PCI was treated as a time-dependent variable. During 3.15 ± 2.71 (mean ± standard deviation) years of follow-up, there were 82 patients with primary outcome. The adjusted hazard ratio for statin use was 0.54 [0.33-0.90] compared to no statin use. This study showed that statin has significant benefit on reducing adverse events risk in dialysis-dependent ESRD patients after PCI.

Impact of Statin Therapy on the Blood Pressure-Lowering Efficacy of a Single-Pill Perindopril/Amlodipine Combination in Hypertensive Patients with Hypercholesterolemia

INTRODUCTION

Several lines of research indicate that statins can lower blood pressure (BP) independently of their lipid-lowering effects when used as monotherapy and in combination with antihypertensive agents.

AIM

This short-term, open-label study examined whether statin therapy had a synergistic effect on the BP-lowering efficacy of perindopril/amlodipine in a subgroup of patients in the PERSPECTIVA study with concomitant hypertension and hypercholesterolemia, with or without statin at baseline.

METHODS

The PERSPECTIVA study recruited 732 adults with untreated or uncontrolled hypertension. This subgroup analysis of PERSPECTIVA included 587 patients with concomitant hypertension and hypercholesterolemia (mean age 56.7 years) of whom 226 were receiving a statin at baseline (statin [+] group) and 361 were not (statin [-] group). All patients received treatment with single-pill combination perindopril/amlodipine at a dose of 5/5, 10/5 or 10/10 mg/day. The study duration was 60 days with follow-up visits for BP monitoring at 7, 15, 30 and 60 days.

RESULTS

At day 60, BP control (<140/90 mmHg) was significantly greater in the statin [+] vs statin [-] group: 73 vs 64% respectively (+14%, P < 0.05). In the statin [+] group, the single-pill perindopril/amlodipine combination significantly reduced BP in patients previously untreated (n = 18), or treated with monotherapy (n = 97), dual therapy (n = 93), or triple therapy (n = 18): -38.8/-20.0, -39.1/-20.1, -38.0/-19.4, -39.9/-18.3 mmHg respectively (P < 0.001 vs baseline BP). The greatest BP reductions were observed in the first 7 days. Treatment was well tolerated with a similar rate of adverse events in the statin [+] group (0.9%) vs the statin [-] group (2.5%).

CONCLUSION

BP control rates in patients with uncontrolled hypertension and concomitant hypercholesterolemia are significantly improved with a treatment regimen that combines perindopril/amlodipine with statin therapy, regardless of previous antihypertensive therapy. This subanalysis of the PERSPECTIVA study supports the synergistic BP-lowering effect of statins and perindopril/amlodipine.

Efficacy of Atorvastatin in Prevention of Contrast-induced Nephropathy in High-risk Patients Undergoing Angiography: A Double-blind Randomized Controlled Trial

Objective:

To evaluate the efficacy and safety of atorvastatin (ATN) 80 mg in the prevention of contrast medium- induced nephropathy (CIN) in high risk patients undergoing angiograph.

Materials and Methods:

This was a prospective, double-blind, two-arm, parallel group RCT. A total of 216 patients undergoing coronary angiography were screened, and 188 eligible patients were randomized to two treatment arms. Patients in Group A received tablet N-acetylcysteine (NAC) 1200 mg once daily, and patients in Group B received tablet atorvastatin 80 mg + NAC 1200 mg once daily, for 3 days before, and 2 days after angiography.

Results:

A total of 160 patients completed the trial. Postprocedure, nine and two CIN cases were found in Group A and B, respectively. The mean change in serum creatinine was 0.086 ± 0.168 in Group A and 0.021 ± 0.083 in Group B, which was statistically significant (P = 0.0289). Postprocedure, the estimated glomerular filteration rate was reduced by 19.52 in Group A and 13.55 in Group B (P = 0.003).

Conclusion:

This trial indicates the positive role of statins in preventive strategy against CIN along with NAC.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Lipid Control and Beyond: Current and Future Indications for Statin Therapy in Stroke

OPINION STATEMENT

Statins are a group of lipid-lowering agents that are competitive inhibitors of the enzyme 3-hydroxy-3-methyl-glutaryl-CoA (HMG-CoA) reductase that have been used to reduce cholesterol levels and prevent cardiovascular events. Statins have been also shown to reduce the risk of stroke. In this review, we cover the role of statins in cerebrovascular disease through lipid-lowering mechanisms and other "pleiotropic" effects that provide protection against cerebrovascular events and potentially contribute to improve functional outcome after stroke.

Survival Benefit of Statins in Hemodialysis Patients Awaiting Renal Transplantation

End-stage renal disease (ESRD) patients have extraordinarily high cardiovascular risk and mortality, yet the benefit of statins in this population remains unclear based on the randomized trials. We investigated the prognostic value of statins in a large, pure cohort of prospectively recruited patients with ESRD awaiting renal transplantation, and being followed up in a dedicated cardiac clinic. We prospectively collected demographic, clinical, laboratory, and pharmacological data on 423 consecutive ESRD patients on hemodialysis awaiting renal transplantation. Survival analysis was performed as a function of statin therapy. The baseline characteristics were as follows: age 57 ± 11 years, males 64%, diabetes mellitus in 68%, known coronary artery disease in 30%, left ventricular (LV) ejection fraction 61 ± 11%. Over a mean follow-up of 2 years, there were 43 deaths. Adjusted for age, gender, hypertension, body mass index, diabetes mellitus, coronary artery disease, smoking, and treatment with angiotensin converting enzyme inhibitor, β blocker, and antiplatelet medications, statin use was a predictor of lower mortality (hazard ratio 0.30, 95% confidence interval 0.11-0.79, p = 0.01). This beneficial effect of statin was supported by propensity score analysis (p = 0.02) and was consistent across all clinical subgroups. The benefit of statins seemed to be greater in those with LV hypertrophy and smoking. Statin therapy in hemodialysis patients awaiting renal transplant is independently associated with better survival supporting its use in this high-risk population.

The many roles of statins in ischemic stroke

Stroke is the third leading cause of human death. Endothelial dysfunction, thrombogenesis, inflammatory and oxidative stress damage, and angiogenesis play an important role in cerebral ischemic pathogenesis and represent a target for prevention and treatment. Statins have been found to improve endothelial function, modulate thrombogenesis, attenuate inflammatory and oxidative stress damage, and facilitate angiogenesis far beyond lowering cholesterol levels. Statins have also been proved to significantly decrease cardiovascular risk and to improve clinical outcome. Could statins be the new candidate agent for the prevention and therapy in ischemic stroke? In recent years, a vast expansion in the understanding of the pathophysiology of ischemic stroke and the pleiotropic effects of statins has occurred and clinical trials involving statins for the prevention and treatment of ischemic stroke have begun. These facts force us to revisit ischemic stroke and consider new strategies for prevention and treatment. Here, we survey the important developments in the non-lipid dependent pleiotropic effects and clinical effects of statins in ischemic stroke.

The antithrombotic effects of statins

Hypercholesterolemia is considered the primary risk factor for cardiovascular disease. An estimated 200 million prescriptions are issued per year for statins to treat hypercholesterolemia. Importantly, statins have additional beneficial effects independent of their effects on lipids. Recent studies have shown that statins reduce thrombosis via multiple pathways, including inhibiting platelet activation and reducing the pathologic expression of the procoagulant protein tissue factor. Many of the antithrombotic effects of statins are attributed to inhibiting prenylation of RhoA and effects on other intracellular signaling molecules such as NF-κB and KLF2. These antithrombotic activities of statins likely contribute to the ability of statins to reduce the incidence of cardiovascular death.

Brain proteomics identifies potential simvastatin targets in acute phase of stroke in a rat embolic model

Finding an efficient neuroprotectant is of urgent need in the field of stroke research. The goal of this study was to test the effect of acute simvastatin administration after stroke in a rat embolic model and to explore its mechanism of action through brain proteomics. To that end, male Wistar rats were subjected to a Middle Cerebral Arteria Occlusion and simvastatin (20 mg/kg s.c) (n = 11) or vehicle (n = 9) were administered 15 min after. To evaluate the neuroprotective mechanisms of simvastatin, brain homogenates after 48 h were analyzed by two-dimensional fluorescence Difference in Gel Electrophoresis (DIGE) technology. We confirmed that simvastatin reduced the infarct volume and improved neurological impairment at 48 h after the stroke in this model. Considering our proteomics analysis, 66 spots, which revealed significant differences between groups, were analyzed by matrix-assisted laser desorption/ionization-time of flight mass spectrometry allowing the identification of 27 proteins. From these results, we suggest that simvastatin protective effect can be partly explained by the attenuation of the oxidative and stress response at blood-brain barrier level after cerebral ischemia. Interestingly, analyzing one of the proteins (HSP75) in plasma from stroke patients who had received simvastatin during the acute phase, we confirmed the results found in the pre-clinical model. Our aim was to study statins benefits when administered during the acute phase of stroke and to explore its mechanisms of action through brain proteomics assay. Using an embolic model, simvastatin-treated rats showed significant infarct volume reduction and neurological improvement compared to vehicle-treated group. Analyzing their homogenated brains by two-dimensional fluorescence Difference in Gel Electrophoresis (DIGE) technology, we concluded that the protective effect of simvastatin can be attributable to oxidative stress response attenuation and blood-brain barrier protection after cerebral ischemia.

Human tissue-type plasminogen activator

Tissue-type plasminogen activator (t-PA ) plays an important role in the removal of intravascular fibrin deposits and has several physiological roles and pathological activities in the brain. Its production by many other cell types suggests that t-PA has additional functions outside the vascular and central nervous system. Activity of t-PA is regulated at the level of its gene transcription, its mRNA stability and translation, its storage and regulated release, its interaction with cofactors that enhance its activity, its inhibition by inhibitors such as plasminogen activator inhibitor type 1 or neuroserpin, and its removal by clearance receptors. Gene transcription of t-PA is modulated by a large number of hormones, growth factors, cytokines or drugs and t-PA gene responses may be tissue-specific. The aim of this review is to summarise current knowledge on t-PA function and regulation of its pericellular activity, with an emphasis on regulation of its gene expression.

Rho/Rho-associated coiled-coil forming kinase pathway as therapeutic targets for statins in atherosclerosis

SIGNIFICANCE

The 3-hydroxy-methylglutaryl coenzyme A reductase inhibitors or statins are important therapeutic agents for lowering serum cholesterol levels. However, recent studies suggest that statins may exert atheroprotective effects beyond cholesterol lowering. These so-called "pleiotropic effects" include effects of statins on vascular and inflammatory cells. Thus, it is important to understand whether other signaling pathways that are involved in atherosclerosis could be targets of statins, and if so, whether individuals with "overactivity" of these pathways could benefit from statin therapy, regardless of serum cholesterol level.

RECENT ADVANCES

Statins inhibit the synthesis of isoprenoids, which are important for the function of the Rho/Rho-associated coiled-coil containing kinase (ROCK) pathway. Indeed, recent studies suggest that inhibition of the Rho/ROCK pathway by statins could lead to improved endothelial function and decreased vascular inflammation and atherosclerosis. Thus, the Rho/ROCK pathway has emerged as an important target of statin therapy for reducing atherosclerosis and possibly cardiovascular disease.

CRITICAL ISSUES

Because atherosclerosis is both a lipid and an inflammatory disease, it is important to understand how inhibition of Rho/ROCK pathway could contribute to statins' antiatherosclerotic effects.

FUTURE DIRECTIONS

The role of ROCKs (ROCK1 and ROCK2) in endothelial, smooth muscle, and inflammatory cells needs to be determined in the context of atherogenesis. This could lead to the development of specific ROCK1 or ROCK2 inhibitors, which could have greater therapeutic benefits with less toxicity. Also, clinical trials will need to be performed to determine whether inhibition of ROCKs, with and without statins, could lead to further reduction in atherosclerosis and cardiovascular disease.

Rac1-mediated effects of HMG-CoA reductase inhibitors (statins) in cardiovascular disease

SIGNIFICANCE

HMG-CoA reductase inhibitors (statins) lower serum cholesterol concentrations and are beneficial in the primary and secondary prevention of coronary heart disease. The positive clinical effects have only partially been reproduced with other lipid-lowering interventions suggesting potential statin effects in addition to cholesterol lowering. In experimental models, direct beneficial cardiovascular effects that are mediated by the inhibition of isoprenoids have been documented, which serve as lipid attachments for intracellular signaling molecules such as small Rho guanosine triphosphate-binding proteins, whose membrane localization and function are dependent on isoprenylation.

RECENT ADVANCES

Rac1 GTPase is an established master regulator of cell motility through the cortical actin reorganization and of reactive oxygen species generation through the regulation of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase activity.

CRITICAL ISSUES

Observations in cells, animals, and humans have implicated the activation of Rac1 GTPase as a key component of cardiovascular pathologies, including the endothelial dysfunction, cardiac hypertrophy and fibrosis, atrial fibrillation, stroke, hypertension, and chronic kidney disease. However, the underlying signal transduction remains incompletely understood.

FUTURE DIRECTIONS

Based on the recent advance made in Rac1 research in the cardiovascular system by using mouse models with transgenic overexpression of activated Rac1 or conditional knockout, as well as Rac1-specific small molecule inhibitor NSC 23766, the improved understanding of the Rac1-mediated effects statins may help to identify novel therapeutic targets and strategies.

Long-term management of Kawasaki disease: implications for the adult patient

Coronary artery complications from Kawasaki disease (KD) range from no involvement to giant coronary artery aneurysms (CAA). Current long-term management protocols are calibrated to the degree of maximal and current coronary artery involvement reflecting the known likelihood of severe long-term cardiac complications. It has recently been suggested that all KD patients may be at potential risk of severe long-term cardiac complications. If this assertion was to be confirmed, current follow-up protocols would need to be extensively modified, with important implications both for the growing adult population with a previous history of KD and for the healthcare system. Based on the available evidence, patients with multiple large and/or giant CAA are at substantial risk of severe long-term cardiac complications and should have regular specialized follow-up. Patients with transient or no CAA have not been reported to be at risk of severe long-term cardiac complications. The influence of KD on the atherosclerotic process remains suboptimally defined, and should be the focus of future studies. Heightened cardiovascular risk factor surveillance and management is recommended regardless of coronary artery involvement. Based on the currently available evidence, existing long-term management protocols seem to be appropriately calibrated to the level of risk. Revised long-term management protocols should incorporate newer, noninvasive imaging methods and intensive management of atherosclerotic risk. There is insufficient evidence at this time to mandate long-term specialized follow-up and invasive testing for patients who have not had CAA.

Short-term high-dose effect of lovastatin on thrombolysis by rt-PA in a human whole-blood in vitro clot model

High-dose hydroxymethylglutaryl coenzyme. A reductase inhibitor (statin) administration reduces neuronal injury and improves outcomes in experimental models of acute ischemic stroke, and has been shown to be safe in a phase 1 dose-escalation study using lovastatin at doses higher than currently approved for daily use. Statins also affect the hemostatic system by upregulating t-PA expression and decreasing plasminogen activator inhibitor (PAI-1) expression, platelet adhesion and thrombus formation in animal models. Since a thrombolytic agent, recombinant tissue plasminogen activator (rt-PA), is currently the only FDA-approved therapy for use in ischemic stroke patients, it is important to ascertain whether high statin doses impact the efficacy of rt-PA. The main goal of this study was to evaluate the effect of a high dose of lovastatin and its active form, lovastatin hydroxy acid, on rt-PA thrombolysis in an in vitro model. Percentage clot lysis was measured in the presence and absence of rt-PA in three different treatment groups: lovastatin, lovastatin hydroxy acid, and ethanol. The effect of ethanol on clot lysis was studied since ethanol was used to disperse the highly hydrophobic lovastatin. The decrease in clot width over time was measured using microscopic imaging of an in vitro human whole blood clot model; an approximately 400 μm diameter clot was formed on suture silk, suspended in human fresh frozen plasma (hFFP) and exposed to treatment. In the absence of rt-PA, clot lysis did not show statistically significant differences in the percentage clot lysis between different treatment groups (p=0.103). In the presence of rt-PA, clot lysis was greater than in the absence of rt-PA for all groups, but there were no statistically significant differences between treatment groups (p=0.385). In this in vitro study, high doses of lovastatin neither impaired nor enhanced the lytic efficacy of rt-PA.

Low-density lipoprotein receptor-related protein 1: a physiological Aβ homeostatic mechanism with multiple therapeutic opportunities

Low-density lipoprotein receptor-related protein-1 (LRP1) is the main cell surface receptor involved in brain and systemic clearance of the Alzheimer's disease (AD) toxin amyloid-beta (Aβ). In plasma, a soluble form of LRP1 (sLRP1) is the major transport protein for peripheral Aβ. LRP1 in brain endothelium and mural cells mediates Aβ efflux from brain by providing a transport mechanism for Aβ across the blood-brain barrier (BBB). sLRP1 maintains a plasma 'sink' activity for Aβ through binding of peripheral Aβ which in turn inhibits re-entry of free plasma Aβ into the brain. LRP1 in the liver mediates systemic clearance of Aβ. In AD, LRP1 expression at the BBB is reduced and Aβ binding to circulating sLRP1 is compromised by oxidation. Cell surface LRP1 and circulating sLRP1 represent druggable targets which can be therapeutically modified to restore the physiological mechanisms of brain Aβ homeostasis. In this review, we discuss how increasing LRP1 expression at the BBB and liver with lifestyle changes, statins, plant-based active principles and/or gene therapy on one hand, and how replacing dysfunctional plasma sLRP1 on the other regulate Aβ clearance from brain ultimately controlling the onset and/or progression of AD.

Role of endothelial nitric oxide in cerebrovascular regulation

Endothelial nitric oxide (NO) plays important roles in the vascular system. Animal models that show vascular dysfunction demonstrate the protective role of endothelial NO dependent pathways. This review focuses on the role of endothelial NO in the regulation of cerebral blood flow and vascular tone. We will discuss the importance of NO in cerebrovascular function using animal models with altered endothelial NO production under normal, ischemic and reperfusion conditions, as well as in hyperoxia. Pharmacological and genetic manipulations of the endothelial NO system demonstrate the essential roles of endothelial NO synthase in maintenance of vascular tone and cerebral perfusion under normal and pathological conditions.

Concomitant administration of different doses of simvastatin with ivabradine influence on PAI-1 and heart rate in normo- and hypercholesterolaemic rats

Ivabradine is a novel heart rate lowering agent that inhibits I_f ionic current in the sinus node and demonstrates antiischaemic and antianginal activity. The aim of the paper was to investigate the effect its dose-dependent drug-drug interaction with simvastatin inhibitor HMGCo-A has on PAI-1 blood level, heart rate and blood pressure. The experiments were performed in hyper- and normocholesterolemic Wistar rats receiving simvastatin (1 and 20 mg × kg⁻¹ bw) with ivabradine (10 mg × kg⁻¹ bw) during a 4-week period. Ivabradine exacerbated the decrease of PAI-1 in normocholesterolemic animals receiving simvastatin at a dose of 1 mg/kg bw and was not observed to have any significant influence on the PAI-1 values in rats receiving 20 mg × kg⁻¹ bw simvastatin. Ivabradine, coadministered with simvastatin given at a dose of 20 mg × kg⁻¹ bw, significantly slowed the heart rate in normocholesterolaemic and hypercholesterolaemic groups as compared to the group receiving ivabradine alone. Conclusion. The administration of ivabradine to normocholesterolaemic and hypercholesterolaemic rats receiving simvastatin significantly exacerbated the slowing of heart rate with no effect on blood pressure. The administration of ivabradine has been shown to demonstrate different effects on PAI-1 values depending on lipid disorders.

Isoprenoids and related pharmacological interventions: potential application in Alzheimer's disease

Two major isoprenoids, farnesyl pyrophosphate and geranylgeranyl pyrophosphate, serve as lipid donors for the posttranslational modification (known as prenylation) of proteins that possess a characteristic C-terminal motif. The prenylation reaction is catalyzed by prenyltransferases. The lipid prenyl group facilitates to anchor the proteins in cell membranes and mediates protein-protein interactions. A variety of important intracellular proteins undergo prenylation, including almost all members of small GTPase superfamilies as well as heterotrimeric G protein subunits and nuclear lamins. These prenylated proteins are involved in regulating a wide range of cellular processes and functions, such as cell growth, differentiation, cytoskeletal organization, and vesicle trafficking. Prenylated proteins are also implicated in the pathogenesis of different types of diseases. Consequently, isoprenoids and/or prenyltransferases have emerged as attractive therapeutic targets for combating various disorders. This review attempts to summarize the pharmacological agents currently available or under development that control isoprenoid availability and/or the process of prenylation, mainly focusing on statins, bisphosphonates, and prenyltransferase inhibitors. Whereas statins and bisphosphonates deplete the production of isoprenoids by inhibiting the activity of upstream enzymes, prenyltransferase inhibitors directly block the prenylation of proteins. As the importance of isoprenoids and prenylated proteins in health and disease continues to emerge, the therapeutic potential of these pharmacological agents has expanded across multiple disciplines. This review mainly discusses their potential application in Alzheimer's disease.

Effect of atorvastatin with or without prednisolone on Freund's adjuvant induced-arthritis in rats

Rheumatoid arthritis is a chronic systemic inflammatory disease where cardiovascular diseases have been recognized as major determinants of early morbidity and mortality. Recently, there has been renewed interest in medication with glucocorticoids to decrease joint damage, but in long-term they incur substantial increase in the risk of cardiovascular diseases and their overall risk/benefit ratio is deemed unfavorable. So, the proposed role of statins in treatment of rheumatoid arthritis when corticosteroids indicated as traditional therapy needs to be investigated. Fifty albino rats were divided into 5 equal groups; normal control group, Freund's adjuvant induced arthritis group, group of induced arthritis treated with atorvastatin, group of induced arthritis treated with prednisolone, and group of induced arthritis treated with atorvastatin and prednisolone. The change in paw volume, serum levels of malondialdehyde (MDA), paraoxonase1 (PON1) activity, nitrites, C-reactive protein (CRP) and lipid profile was determined. The results revealed that treatment by atorvastatin in combination with prednisolone produced better satisfactory results than in either remedy alone evidenced by significant decrease in volume of hind paw, levels of MDA, nitrites, CRP, significant increase in PON1 activity and HDL and amelioration of other lipid profile parameters that were impaired by prednisolone. The present work demonstrated that statins exert beneficial anti-inflammatory and antioxidant effects beyond their basic cholesterol-lowering activity. Thus, we suggest that if corticosteroid therapy is indicated in rheumatoid arthritis, atorvastatin could be added to get benefit from its pleiotropic effects. However, further studies are needed to verify to what extent statin therapy contribute to clinical benefits in human.

Do statins have a role in reduction/prevention of post-PCI restenosis?

The pathophysiology of post-PCI restenosis involves neointimal formation that consists of three phases: thrombosis (within 24 h), recruitment (3-8 days), and proliferation, which starts on day 8 of PCI. Various factors suggested to be predictors/risks for restenosis include C-reactive protein (CRP), inflammatory mediators (cytokines and adhesion molecules), oxygen radicals, advanced glycation end products (AGEs) and their receptors (RAGE), and soluble RAGE (sRAGE). The earlier noted factors produce thrombogenesis, vascular smooth muscle cell proliferation, and extracellular matrix formation. Statins have pleiotropic effects. Besides lowering serum cholesterol, they have various other biological effects including antiinflammatory, antithrombotic, CRP-lowering, antioxidant, antimitotic, and inhibition of smooth muscle cell proliferation. They inhibit matrix metalloproteinase and cyclooxygenase-2, lower AGEs, decrease expression of RAGE and increase levels of serum sRAGE. They also increase the synthesis of nitric oxide (NO) by increasing endothelial NO synthase expression and activity. Preprocedural statin therapy is known to reduce peri- and post-PCI myonecrosis and reduce the need for repeat revascularization. There is evidence that statin-eluting stents inhibit in-stent restenosis in animal models. It is concluded that because of the above attributes of statins, they are suitable candidates for reduction of post-PCI restenosis and post-PCI myonecrosis. The future directions for the use of statins in reduction of post-PCI restenosis and myonecrosis have been discussed.

Radiation as a risk factor for cardiovascular disease

Abstract population are ubiquitous background radiation and medical exposure of patients. From the early 1980s to 2006, the average dose per individual in the United States for all sources of radiation increased by a factor of 1.7-6.2 mSv, with this increase due to the growth of medical imaging procedures. Radiation can place individuals at an increased risk of developing cardiovascular disease. Excess risk of cardiovascular disease occurs a long time after exposure to lower doses of radiation as demonstrated in Japanese atomic bomb survivors. This review examines sources of radiation (atomic bombs, radiation accidents, radiological terrorism, cancer treatment, space exploration, radiosurgery for cardiac arrhythmia, and computed tomography) and the risk for developing cardiovascular disease. The evidence presented suggests an association between cardiovascular disease and exposure to low-to-moderate levels of radiation, as well as the well-known association at high doses. Studies are needed to define the extent that diagnostic and therapeutic radiation results in increased risk factors for cardiovascular disease, to understand the mechanisms involved, and to develop strategies to mitigate or treat radiation-induced cardiovascular disease.

Atorvastatin Reduces High Glucose Toxicity in Rat Peritoneal Mesothelial Cells

Objective

Continuous exposure of the peritoneal membrane to high glucose dialysis solutions can produce functional alterations in this membrane. We studied the toxic effects of high glucose (50 mmol/L and 83 mmol/L) and its reversal by atorvastatin (0.5 – 5 μmol/L) on cultures of rat peritoneal mesothelial cells (PMCs).

Methods

Rat PMCs were harvested from the peritonea of male Sprague–Dawley rats and grown in M199 medium supplemented with 10% fetal bovine serum. The effects of high glucose (50 mmol/L and 83 mmol/L) on levels of reactive oxygen species (ROS), on caspase 3 activity, and on phospho-p38 mitogen-activated protein kinase (MAPK) in the cultures were evaluated.

Results

Exposure to high glucose (for 4, 8, and 24 hours) increased intracellular levels of ROS and phospho-p38 MAPK (indices of cellular toxicity). Atorvastatin blocked these toxic effects of high glucose, being more effective against 50 mmol/L glucose (protective effects were observed above 0.5 μmol/L) than against 83 mmol/L (protective effects were observed above 2.5 μmol/L). Atorvastatin was also able to prevent glucose-induced increase in caspase 3 activity.

Conclusions

The present study shows that high glucose may promote oxidative stress and may activate apoptotic pathways in rat PMCs. These toxic effects could be reversed by atorvastatin.

Simvastatin suppresses dexamethasone-induced secretion of plasminogen activator inhibitor-1 in human bone marrow adipocytes

Background

Osteonecrosis of the femoral head is a common complication of high-dose glucocorticoid treatment. Intravascular thrombosis is thought to be associated with the ischemic state of the femoral head. Plasminogen activator inhibitor-1 (PAI-1) is an adipokine, which are physiologically active substances secreted from visceral and subcutaneous adipocytes. PAI-1 suppresses fibrinolysis by binding tissue-type plasminogen activator. Several reports have described the relationship between PAI-1 and steroid-induced osteonecrosis of the femoral head, and the preventive effects of lipid-lowering agents (statins) against steroid-induced osteonecrosis of the femoral head. We previously reported that adipokines and dexamethasone induced PAI-1 secretion from bone marrow adipocytes. The purpose of the present study is to examine the effects of simvastatin on PAI-1 secretion from human bone marrow adipocytes in vitro.

Methods

Primary bone marrow adipocytes were extracted from collagenase-treated bone marrow fluid obtained from the femoral necks of 40 patients (6 men, 34 women; age range, 52-81 years) undergoing hip joint replacement surgery. After suspended culture with or without dexamethasone or simvastatin, PAI-1 mRNA expression was assessed by real-time RT-PCR. Total PAI-1 protein secretion in culture medium was assessed by enzyme-linked immunosorbent assay.

Results

PAI-1 mRNA expression was up-regulated by 388% (P = 0.002) with dexamethasone, and down-regulated by 45% (P = 0.002) with simvastatin, as compared to control levels. Dexamethasone increased total PAI-1 secretion by 166% (P = 0.001) and simvastatin decreased total PAI-1 secretion by 64% (P = 0.002). No significant changes were observed in adiponectin mRNA expression and secretion by dexamethasone and simvastatin, while pre-treatment with simvastatin reversed dexamethasone induced PAI-1 secretion by 89%, as compared to control levels.

Conclusion

The present study confirmed the suppressive effects of simvastatin on PAI-1 expression and secretion from bone marrow adipocytes. Furthermore, pre-treatment with simvastatin reversed dexamethasone induced PAI-1 secretion. Simvastatin may thus exhibit preventive effects against steroid-induced osteonecrosis of the femoral head by suppressing PAI-1 secretion.

Statin use following intracerebral hemorrhage: a decision analysis

CONTEXT

Statins are widely prescribed for primary and secondary prevention of ischemic cardiac and cerebrovascular disease. Although serious adverse effects are uncommon, results from a recent clinical trial suggested increased risk of intracerebral hemorrhage (ICH) associated with statin use. For patients with baseline elevated risk of ICH, it is not known whether this potential adverse effect offsets the cardiovascular and cerebrovascular benefits.

OBJECTIVE

To address the following clinical question: Given a history of prior ICH, should statin therapy be avoided?

DESIGN

A Markov decision model was used to evaluate the risks and benefits of statin therapy in patients with prior ICH.

MAIN OUTCOME MEASURE

Life expectancy, measured as quality-adjusted life-years. We investigated how statin use affects this outcome measure while varying a range of clinical parameters, including hemorrhage location (deep vs lobar), ischemic cardiac and cerebrovascular risks, and magnitude of ICH risk associated with statins.

RESULTS

Avoiding statins was favored over a wide range of values for many clinical parameters, particularly in survivors of lobar ICH who are at highest risk of ICH recurrence. In survivors of lobar ICH without prior cardiovascular events, avoiding statins yielded a life expectancy gain of 2.2 quality-adjusted life-years compared with statin use. This net benefit persisted even at the lower 95% confidence interval of the relative risk of statin-associated ICH. In patients with lobar ICH who had prior cardiovascular events, the annual recurrence risk of myocardial infarction would have to exceed 90% to favor statin therapy. Avoiding statin therapy was also favored, although by a smaller margin, in both primary and secondary prevention settings for survivors of deep ICH.

CONCLUSIONS

Avoiding statins should be considered for patients with a history of ICH, particularly those cases with a lobar location.

Rosuvastatin Treatment is Associated with a Decrease of Serum Oxidised Low-Density Lipoprotein/Beta2-Glycoprotein I Complex Concentration in Type 2 Diabetes

Aims

To evaluate the effect of rosuvastatin on oxidised low-density lipoprotein/beta2-glycoprotein I (oxLDL/β2GPI) complex concentration in type 2 diabetes mellitus.

Methods

Open label 2:1 assignment of consecutive diabetic patients into oral rosuvastatin (10 mg daily for six weeks) arm or observational arm with measurements of serum oxLDL/|β2GPI complexes, nitric oxide metabolites, asymmetric dimethyl arginine, nitrotyrosine alongside routine biochemistry at baseline and end of study in all patients.

Results

After rosuvastatin treatment the mean serum concentration of oxLDL/β2GPI decreased from 0.79±0.49 units/mL to 0.53±0.36 units/mL (p<0.001). The decrease was statistically independent from the decrements of mean cholesterol, LDL and triglyceride concentrations (p<0.001) but probably dependent on the decrement of nitrate (p<0.001).

Conclusion

In type 2 diabetes, treatment with rosuvastatin was associated with a significant reduction of serum concentrations of oxLDL/β2GPI complexes, which is in further support of the already proposed effects of the drug on the oxidative metabolism of lipids and/or LDL. The oxLDL/β2GPI complex may represent a surrogate marker of oxidative stress in type 2 diabetes.

Persistence with statins and onset of rheumatoid arthritis: a population-based cohort study

BACKGROUND

The beneficial effects of statins in rheumatoid arthritis (RA) have been suggested previously, but it is unclear whether statins may prevent its development. The aim of this retrospective cohort study was to explore whether persistent use of statins is associated with onset of RA.

METHODS AND FINDINGS

The computerized medical databases of a large health organization in Israel were used to identify diagnosed RA cases among adults who began statin therapy between 1998 and 2007. Persistence with statins was assessed by calculating the mean proportion of follow-up days covered (PDC) with statins for every study participant. To assess the possible effects of healthy user bias, we also examined the risk of osteoarthritis (OA), a common degenerative joint disease that is unlikely to be affected by use of statins. A total of 211,627 and 193,770 individuals were eligible for the RA and OA cohort analyses, respectively. During the study follow-up period, there were 2,578 incident RA cases (3.07 per 1,000 person-years) and 17,878 incident OA cases (24.34 per 1,000 person-years). The crude incidence density rate of RA among nonpersistent patients (PDC level of <20%) was 51% higher (3.89 per 1,000 person-years) compared to highly persistent patients who were covered with statins for at least 80% of the follow-up period. After adjustment for potential confounders, highly persistent patients had a hazard ratio of 0.58 (95% confidence interval 0.52-0.65) for RA compared with nonpersistent patients. Larger differences were observed in younger patients and in patients initiating treatment with high efficacy statins. In the OA cohort analysis, high persistence with statins was associated only with a modest decrement in risk ratio (hazard ratio = 0.85; 0.81-0.88) compared to nonadherent patients.

CONCLUSIONS

The present study demonstrates an association between persistence with statin therapy and reduced risk of developing RA. The relationship between continuation of statin use and OA onset was weak and limited to patients with short-term follow-up.

Postoperative Statin Therapy Attenuates the Intensity of Systemic Inflammation and Increases Fibrinolysis After Coronary Artery Bypass Grafting

A total of 25 patients undergoing coronary artery bypass grafting (CABG) were included in the study. Patients received statin (20 mg daily) postoperatively for 2 weeks. All analyses were performed at 2 different time points: preoperatively (group 1) and 2 weeks after operation (group 2). Interleukin (IL)-6, IL-8, plasminogen activator inhibitor 1 (PAI-1), tumor necrosis factor α (TNF-α), tissue plasminogen activator (t-PA) levels, and tissue factor pathway inhibitor (TFPI) were evaluated. Statin treatment caused a significant reduction in the plasma level of PAI-1 (preop: 15.04 ± 0.13 ng/mL vs postop: 13.89 ± 2.14 ng/mL; P < .05) and increased t-PA levels (preop: 109.74 ± 0.13 vs postop: 231.40 ± 1.22 ng/mL; P < .001). Plasma TNF-α and IL-6 levels did not change with treatment. Statin treatment caused a significant reduction in plasma IL-8 level (279.70 ± 3.42 ng/mL vs postop: 207.18 ± 3.63 ng/mL, P < .05), and TFPI (4.87 ± 2.05 ng/mL vs postop: 6.27 ± 1.25 ng/mL; P < .05). The results demonstrate that atorvastatin attenuates systemic inflammatory reaction after cardiac surgery.

Comparison of the post-embolization effects of tissue-plasminogen activator and simvastatin on neurological outcome in a clinically relevant rat model of acute ischemic stroke

Data has emerged, largely from non-thromboembolic animal models of stroke, that suggests that statins, which have efficacy in preventing strokes when given pre-ischemically, may have a positive effect on stroke even when given post-ischemically, possibly through pleitropic cerebrovascular effects. The goal of this study was to characterize the effects of IV tPA in a clinically relevant model of stroke utilizing a vascular occlusion with a freshly formed clot, and evaluate the effects of post-ischemic administration of simvastatin on stroke outcome in this model. Neurological deficit, clot burden, and lesion volume were assessed after treatment with tPA in one experiment, and after treatment with simvastatin in another. In the tPA experiment, treatment with 10mg/kg of tPA IV (with 20% given as an initial bolus, and 80% given as an infusion over the remaining 30 min), starting within an hour after stroke, resulted in significant reductions, compared with control animals, in neurological deficit (mean+/-SD neuroscores of 21.5+/-21.1 and 30+/-29.3, respectively, p=0.005), clot burden (p=0.010) and lesion volume (p=0.049) at 24h. In the simvastatin experiment on the other hand, treatment with a 20mg/kg of simvastatin as a single intraperitoneal dose within an hour after stroke resulted in no salutary effects on neurological deficit, clot burden or lesion volume compared with controls at 24h. These results suggest that more research needs to be done to fully ascertain the therapeutic potential and optimal dosing paradigm of a post-ischemic treatment with a statin.

Rho-kinase inhibition: a novel therapeutic target for the treatment of cardiovascular diseases

The Rho/rho-kinase (ROCK) pathway has an important role in the pathogenesis of several cardiovascular diseases. The activation of ROCK is involved in the regulation of vascular tone, endothelial dysfunction, inflammation and remodeling. The inhibition of ROCK has a beneficial effect in a variety of cardiovascular disorders. Evidence from animal models and from clinical use of ROCK inhibitors, such as Y-27632, fasudil and statins (i.e. pleiotropic effects), supports the hypothesis that ROCK is a potential therapeutic target. This review provides a current understanding of the role of ROCK pathway in the regulation of vascular function and the use of ROCK inhibitors in the treatment of cardiovascular disorders.

[Effects of statin use on intracranial hemorrhage and clinical outcome after intravenous rt-PA for acute ischemic stroke: SAMURAI rt-PA registry]

PURPOSE

We evaluated whether pre- and post-stroke statin use was associated with intracranial hemorrhage (ICH) and clinical outcome at 3 months after intravenous recombinant tissue plasminogen activator (IV rt-PA) for acute ischemic stroke.

METHODS

This study enrolled 600 consecutive patients (72 +/- 12 years, woman 37.2%) who received IV rt-PA at ten stroke centers that participated in the SAMURAI rt-PA Registry from October 2005 to July 2008.

RESULTS

Statins were used prior to stroke in 112% and within 72 h after IV rt-PA in 10.0% of patients. One hundred nineteen patients (19.8%) developed ICH. Pre-stroke statin use was not an independent factor associated with ICH (OR 1.46; 95% CI 0.76-2.81, p = 0.225). Of 535 patients with a premorbid mRS < or = 1, 199 (37.2%) had a favorable clinical outcome at 3 months (mRS < or = 1). Pre-stroke statin use (OR 1.05; 95% CI 0.55-2.01, p = 0.879), as well as post-stroke statin use (OR 1.31; 95% CI 0.66-2.59, p = 0.440), was not an independent predictor of outcome.

CONCLUSIONS

In patients who received IV rt-PA for acute ischemic stroke, statin use did not increase ICH after thrombolysis, nor was it associated with clinical outcome.