Effects of pitavastatin on cardiac structure and function and on prevention of atrial fibrillation in elderly hypertensive patients: a prospective study of 2-years' follow-up

Impact of Dapagliflozin on the Left Ventricular Diastolic Function in Diabetic Patients with Heart Failure Complicating Cardiovascular Risk Factors

Objective Our aim was to investigate the impact of the sodium glucose cotransporter type 2 (SGLT2) inhibitor on the left ventricular (LV) diastolic function in type 2 diabetes mellitus (T2DM) patients with chronic heart failure (HF) complicating cardiovascular risk factors. Methods We analyzed data from our previous prospective multicenter study, in which we investigated the effect of dapagliflozin on the LV diastolic function of T2DM patients with stable HF at five institutions in Japan. Patients who had been taking at least 1 antidiabetic drug other than SGLT2 inhibitors started treatment with dapagliflozin. Echocardiography was performed at baseline and six months after the administration of dapagliflozin. Cardiovascular risk factors other than T2DM were age, gender, hypertension, dyslipidemia, history of cardiovascular events and overweight. Results The LV diastolic function, defined as the ratio of the mitral inflow E to the mitral e' annular velocities (E/e'), significantly decreased from 9.3 to 8.5 by six months after the administration of dapagliflozin (p=0.020) as previously reported. A multivariate logistic regression analysis showed that dyslipidemia was the only independent determinant of improvement in the E/e' after the administration of dapagliflozin among cardiovascular risk factors. Furthermore, the relative change in the E/e' from baseline to six months after the administration of dapagliflozin for HF patients with preserved ejection fraction (HFpEF) and dyslipidemia was significantly larger than that for HFpEF patients without dyslipidemia (-15.2% vs. 29.6%, p=0.014), but no such finding was observed in non-HFpEF patients. Conclusion SGLT2 inhibitors may exert a more beneficial effect on the LV diastolic function for T2DM patients with stable HF, especially those with complicating dyslipidemia, than existing treatments.

Preclinical cardiac organ damage during statin treatment in patients with inflammatory joint diseases: the RORA-AS statin intervention study

OBJECTIVE

Statin treatment has been associated with reduction in blood pressure and arterial stiffness in patients with inflammatory joint diseases (IJD). We tested whether statin treatment also was associated with regression of preclinical cardiac organ damage in IJD patients.

METHODS

Echocardiography was performed in 84 IJD patients (52 RA, 20 ankylosing spondylitis, 12 psoriatric arthritis, mean age 61 (9) years, 63% women) without known cardiovascular disease before and after 18 months of rosuvastatin treatment. Preclinical cardiac organ damage was identified by echocardiography as presence of left ventricular (LV) hypertrophy, LV concentric geometry, increased LV chamber size and/or dilated left atrium.

RESULTS

At baseline, hypertension was present in 63%, and 36% used biologic DMARDs (bDMARDs). Preclinical cardiac organ damage was not influenced by rosuvastatin treatment (44% at baseline vs 50% at follow-up, P = 0.42). In uni- and multivariable logistic regression analyses, risk of preclinical cardiac organ damage at follow-up was increased by higher baseline body mass index [odds ratio (OR) 1.3, 95% CI: 1.1, 1.5, P = 0.01] and presence of preclinical cardiac organ damage at baseline (OR 6.4, 95% CI: 2.2, 18.5, P = 0.001) and reduced by use of bDMARDs at follow-up (OR 0.3, 95% CI: 0.1, 0.9, P = 0.03).

CONCLUSION

Rosuvastatin treatment was not associated with a reduction in preclinical cardiac organ damage in IJD patients after 18 months of treatment. However, use of bDMARDS at follow-up was associated with lower risk of preclinical cardiac organ damage at study end, pointing to a possible protective cardiac effect of bDMARDs in IJD patients.

CLINICALTRIALS.GOV

https://clinicaltrials.gov/NCT01389388.

Inflammatory and Infectious Processes Serve as Links between Atrial Fibrillation and Alzheimer's Disease

Atrial fibrillation (AF) is one of the most prevalent forms of arrhythmia that carries an increased risk of stroke which, in turn, is strongly associated with cognitive decline. The majority of dementia cases are caused by Alzheimer's disease (AD) with obscure pathogenesis. While the exact mechanisms are unknown, the role of inflammatory processes and infectious agents have recently been implicated in both AD and AF, suggesting a common link between these maladies. Here, we present the main shared pathways underlying arrhythmia and memory loss. The overlapping predictive biomarkers and emerging joint pharmacological approaches are also discussed.

Do most patients with obesity or type 2 diabetes, and atrial fibrillation, also have undiagnosed heart failure? A critical conceptual framework for understanding mechanisms and improving diagnosis and treatment

Obesity and diabetes can lead to heart failure with preserved ejection fraction (HFpEF), potentially because they both cause expansion and inflammation of epicardial adipose tissue and thus lead to microvascular dysfunction and fibrosis of the underlying left ventricle. The same process also causes an atrial myopathy, which is clinically evident as atrial fibrillation (AF); thus, AF may be the first manifestation of HFpEF. Many patients with apparently isolated AF have latent HFpEF or subsequently develop HFpEF. Most patients with obesity or diabetes who have AF and exercise intolerance have increased left atrial pressures at rest or during exercise, even in the absence of diagnosed HFpEF. Among patients with AF, those who also have latent HFpEF have increased risk for systemic thromboembolism and death. The identification of HFpEF in patients with obesity or diabetes alters the risk-to-benefit relationship of commonly prescribed treatments. Bariatric surgery and statins can ameliorate AF and reduce the risk for HFpEF. Conversely, antihyperglycaemic drugs that promote adipogenesis or cause sodium retention (insulin and thiazolidinediones) may increase the risk for heart failure in patients with an underlying ventricular myopathy. Patients with obesity and diabetes who undergo catheter ablation for AF are at increased risk for AF recurrence and for post-ablation increases in pulmonary venous pressures and worsening heart failure, especially if HFpEF coexists. Therefore, AF may be the earliest indicator of HFpEF in patients with obesity or type 2 diabetes, and recognition of HFpEF alters the management of these patients.

A Multi-Center, Open-Label, Two-Arm Parallel Group Non-inferiority Randomized Controlled Trial Evaluating the Effect of Pitavastatin, Compared to Atorvastatin, on Glucose Metabolism in Prediabetics with Hypertension and Dyslipidemia: Rationale and Design for the China Hemoglobin A1c Metabolism Protection Union Study (CAMPUS)

BACKGROUND

Hypertension and dyslipidemia are major risk factors for cardiovascular disease (CVD). In 2012, over 270 million patients (25.2%) in China were hypertensive and 40.4% was dyslipidemic. The majority of these patients rely on statins for the prevention of cardiovascular disease. However, certain types of statins (e.g., atorvastatin), compared to others (e.g., pitavastatin), may be associated with unfavorable effects on glucose metabolism. This leads to concerns when prescribing statins to patients who also have a predisposition to glucose metabolic disorders (i.e., prediabetes). Thus, this study aims to investigate the effect of pitavastatin, compared to atorvastatin, on glucose metabolism, as measured by hemoglobin A1c (HbA1c), in Chinese prediabetics with hypertension and dyslipidemias.

METHODS

The China hemoglobin A1c Metabolism Protection Union Study (CAMPUS) is a multi-center, prospective, open-label, 12-month, two-arm parallel group, and non-inferiority randomized controlled trial (RCT). A total of 396 prediabetics with hypertension and dyslipidemias will be randomly assigned 1:1 to either pitavastatin 2 mg/day or atorvastatin 20 mg/day, and followed for 12 months (follow-up visits at 1, 3, 6, and 12 months) for HbA1c levels, as well as other measures of glucose metabolism, serum lipid levels, blood pressure control, measures of inflammation, vascular endothelial function, carotid atherosclerosis, and hypertension-related left ventricular hypertrophy. If the results of low-density lipoprotein cholesterol (LDL-C) levels in month 3 after treatment initiation do not meet individual target, drug dose for the participant would be doubled.

DISCUSSION

CAMPUS will be the first RCT to investigate the effect of pitavastatin, compared to atorvastatin, on glucose metabolism in Chinese prediabetics with hypertension and dyslipidemias. Further, this study might eventually provide information to design a clinical strategy, and facilitate the improvement of primary prevention in patients at risk for diabetes and CVD.

TRIAL REGISTRATION

ClinicalTrials.gov number: NCT03532620. Registered 22 May 2018.

New statin use and left ventricular structure: Estimating long-term associations in the Multi-Ethnic Study of Atherosclerosis (MESA)

PURPOSE

Only small and short-term studies have evaluated statins in relation to changes in heart structure. We estimated the association between new statin use and 10-year remodeling of the left ventricle.

METHODS

The Multi-Ethnic Study of Atherosclerosis collected data on statin use over approximately 10 years, conducting cardiac magnetic resonance (CMR) imaging at baseline and the 10-year exam. Participants were free of baseline cardiovascular disease, and we excluded users of statins at baseline. Statin initiation was defined as a report of current use at any of the 4 subsequent exams. Primary outcomes were the change in left ventricular mass index (LVMI; % predicted by height, weight, and sex) and mass-to-volume ratio. Associations were estimated in a propensity score-matched analysis.

RESULTS

A total of 3113 participants (53% female; 40% European-American, 25% African-American, 22% Hispanic-American, and 13% Chinese-American) were eligible; 2431 returned for follow-up CMR imaging after a median of 9.4 years. Statin therapy (moderate dose, 76%) was started by 36% of participants (N = 872). We excluded 42 participants with incident myocardial infarction. Compared with nonuse, statin use was associated with less 10-year progression in LVMI (-2.35 percentage points; 95% CI, -4.24 to -0.47; P = .01) and mass-to-volume ratio (-0.03 absolute difference; 95% CI, -0.07 to -0.00; P = .02); effects were small in magnitude. A dose response was observed: Higher statin dose was associated with less LVMI progression.

CONCLUSIONS

In contrast to previous small studies, we found very modest associations between statin use and indices of left ventricular remodeling over 10 years in this prospective study of a diverse cohort.

Fluvastatin therapy could not decrease progression of paroxysmal atrial fibrillation in non-valvular disease patients

OBJECTIVE

This study aimed to evaluate whether fluvastatin therapy could decrease the probability of atrial fibrillation (AF) progression from paroxysmal AF to permanent AF and decrease the recurrence frequency of AF.

METHODS

Analyses were performed using two-tailed Student's t test or Mann-Whitney U tests. Categorical variables were compared with the χ2 statistics or Fisher's exact test. Patients with paroxysmal AF were randomized case-control, prospective into either the fluvastatin group (n=61) or control group (n=57). Patients were followed up for 24 months. The primary endpoint event was paroxysmal AF that progressed to permanent AF. Secondary endpoints were AF recurrence, cardiac dysfunction, stroke, or death.

RESULTS

There were no differences in AF progression (fluvastatin group, 8.19% vs. control group, 12.51%; p>0.05) and stroke (fluvastatin group. 6.55% vs.

CONTROL GROUP

8.77%; p>0.05). Patients in the fluvastatin group had a lower rate of AF recurrence (fluvastatin group, 24.59% vs. control group, 49.12%; p<0.05) and a lower rate of cardiac dysfunction (fluvastatin group, 6.55% vs. control group, 19.29%; p<0.05). Death did not occur in both the groups. After 1 week of fluvastatin therapy, C-reactive protein (CRP) and homocysteine (HCY) levels were lower in the fluvastatin group than in the control group. At 24 months of follow-up, CRP and HCY levels remained lower in the fluvastatin group than in the control group. The number of endothelial progenitor cells (EPCs) increased in the fluvastatin group compared with that in the control group (fluvastatin group, 72.27±12.49 counts/105 vs. control group, 57.45±8.24 counts/105, p=0.001).

CONCLUSION

Fluvastatin therapy could not decrease AF progression. However, it could decrease the recurrence frequency of paroxysmal AF and cardiac dysfunction. This may occur because of depressing inflammation and improving circulating EPCs.

Impact of the left ventricular mass index on the outcomes of severe aortic stenosis

Objective

To elucidate the factors associated with high left ventricular mass index (LVMI) and to test the hypothesis that high LVMI is associated with worse outcome in severe aortic stenosis (AS).

Methods

We analysed 3282 patients with LVMI data in a retrospective multicentre registry enrolling consecutive patients with severe AS in Japan. The management strategy, conservative or initial aortic valve replacement (AVR), was decided by the attending physician. High LVMI was defined as LVMI >115 g/m² for males and >95 g/m² for females. We compared the risk between normal and high LVMI in the primary outcome measures compromising aortic valve-related death and heart failure hospitalisation.

Results

Age was mean 77 (SD 9.6) years and peak aortic jet velocity (Vmax) was 4.1 (0.9) m/s. The factors associated with high LVMI (n=2374) included female, body mass index ≥22, absence of dyslipidemia, left ventricular ejection fraction <50%, Vmax ≥4 m/s, regurgitant valvular disease, hypertension, anaemia and end-stage renal disease. In the conservative management cohort (normal LVMI: n=691, high LVMI: n=1480), the excess adjusted 5-year risk of high LVMI was significant (HR: 1.53, 95% CI 1.26 to 1.85, p<0.001). In the initial AVR cohort (normal LVMI: n=217, high LVMI: n=894), the risk did not differ significantly between the two groups (HR: 0.96, 95% CI 0.60 to 1.55, p=0.88). There was a significant interaction between the initial treatment strategy and the risk of high LVMI (p=0.016).

Conclusions

The deleterious impact of high LVMI on outcome was observed in patients managed conservatively, but not observed in patients managed with initial AVR.

Trial registration number

UMIN000012140; Post-results.

The Use of Statins in the Treatment and Prevention of Atrial Fibrillation

The hydroxy-methyl-glutaryl-CoA reductase inhibitors (statins) are used extensively in the treatment of hyperlipidemia and in the primary and secondary prevention of cardiovascular and cerebrovascular diseases. Statins have also been demonstrated to confer secondary pleiotropic benefits in a variety of other disease processes, including a potential advantage in treating and preventing atrial fibrillation. These effects are primarily due to the up-regulation of endothelial nitric oxide synthase activity and a decrease in nicotinamide adenine dinucleotide phosphate oxidase production, which leads to downstream effects that improve the electromechanical function of atrial and myocardial tissue. The following serves as a focused and updated review of the published clinical data regarding the pleiotropic effects of statins in atrial fibrillation.

Waon therapy attenuates cardiac hypertrophy and promotes myocardial capillary growth in hypertensive rats: a comparative study with fluvastatin

Cardiac hypertrophy and fibrosis in heart failure with preserved ejection fraction are associated with a pro-inflammatory state and reduced NO bioavailability. Effects on myocardial structural and molecular alterations were compared between Waon therapy (WT; repeated dry sauna therapy) and statin in hypertensive rats. Seven-week-old Dahl salt-sensitive rats were assigned to 4 groups: low-salt (LS) diet, high-salt (HS) diet, HS diet with oral fluvastatin (FL; 10 mg/kg/day for 4 weeks) starting from the age of 9 weeks, and HS diet with WT treatment in a far-infrared dry sauna (39 °C for 15 min followed by 34 °C for 20 min once daily for 4 weeks). HS rats developed left ventricular (LV) hypertrophy with preserved LV systolic function. WT reduced LV wall thickness and myocyte cross-sectional area along with decreased levels of myocardial ANP and BNP mRNA expression compared with HS rats. Reduction in LV fibrosis and increase in capillary density in WT animals were accompanied by reductions in myocardial levels of TGF-β1, MMP2, p22(phox) and gp91(phox) mRNA expression, and increases in myocardial levels of VEGF and HSP90 mRNA and phosphorylated eNOS protein. These effects were comparable between WT and FL animals. WT improves structural and molecular alterations in salt-induced hypertensive rats similarly to fluvastatin.

Benefit-risk assessment of pitavastatin for the treatment of hypercholesterolemia in older patients

With the practice-shifting changes made with the most recent guidelines for treating blood cholesterol, more older patients may be prescribed statin therapy. Therefore, it is imperative that practitioners have not only a working knowledge of information related to statins, but more specifically to their efficacy and safety in elderly populations. Pitavastatin is the most recent statin to receive regulatory approval. It is indicated for the treatment of primary hyperlipidemia or mixed dyslipidemia as an adjunctive therapy to diet. The overall body of evidence for the efficacy and safety of pitavastatin in elderly patients is small. The available data suggest that the ability of pitavastatin to lower low-density lipoprotein cholesterol in elderly patients is at least similar, and may be greater than that seen in comparatively younger cohorts. Taken together, the limited available data suggest that pitavastatin is effective at improving lipid parameters in elderly patients with a similar safety profile to other agents in the class. Until data become available distinguishing pitavastatin from the other available options, its ultimate role in the hyperlipidemia treatment armamentarium remains unclear.

Incident atrial fibrillation hazard in hypertensive population: a risk function from and for clinical practice

Determining the risk of atrial fibrillation within the hypertensive population without ischemic vascular disease would aid in decision making on preventive approaches. Accordingly, we aimed to estimate the risk of incident atrial fibrillation in this population. We conducted an historical cohort study between July 1, 2006, and December 31, 2011, using anonymized longitudinal patient information from primary care and hospital discharge records contained in the System for the Development of Research in Primary Care database. We included 255 440 hypertensive patients, aged ≥55 years at the time of study entry. Individuals with previous atrial fibrillation, ischemic heart disease, stroke, and peripheral artery disease were excluded. To build the incident atrial fibrillation risk function, a derivation and a validation cohort were defined, representing 60% and 40% of the entire database, respectively, and a Cox proportional hazards model was fitted. Atrial fibrillation incidence was 7.24 per 1000 person-years (95% confidence interval, 7.08-7.40). The final model included age, weight, total cholesterol, heart failure, valvular heart disease, and antihypertensive treatment. Its concordance index (standard error) was 0.769 (0.004) and 0.768 (0.005) in the derivation and validation datasets, respectively. This research provides a tool, built with variables from daily clinical practice, that can be readily used in the primary care setting to predict atrial fibrillation incidence in the hypertensive population without ischemic vascular disease. The tool may help tailor individualized diagnostic and preventive care decisions.