Effects of HMG-CoA reductase inhibitors on coagulation and fibrinolysis processes

The association between statins and gait speed reserve in older adults: effects of concomitant medication

Statins are frequently prescribed to older adults, yet their effects on ageing phenotypes such as frailty or physiological reserves remain poorly understood. Gait Speed Reserve (GSR), defined as the difference between maximal and usual gait speeds, serves as an indicator of physiological reserve, reflecting the body's ability to perform beyond baseline functional levels. Polypharmacy, prevalent in this population, may contribute to inconsistent findings through interactions between statins and concomitant medications. We aimed to investigate how concomitant medications moderate the association between statin use and GSR in older adults. To this end, we conducted a cross-sectional observational cohort study using data from the Mobility Center at the University Department of Geriatric Medicine FELIX PLATTER, Basel, Switzerland (n = 5519 adults aged ≥ 60 years). Moderation regression analyses with propensity score weighting were used to evaluate the effect of concomitant medications on the association between statin use and GSR. Results showed statin use was associated with a lower GSR compared to non-use (- 1.9 cm/s [95% CI, - 3.1 to - 0.72]). However, ACE inhibitors and aspirin significantly influenced this association. The GSR difference for statin users compared to non-users increased by 3.7 cm/s (from - 2.2 to 1.5 cm/s; 95% CI, 0.0 to 7.4) with concomitant ACE inhibitor use and by 5.8 cm/s (from - 3.4 to 2.3 cm/s; 95% CI, 2.5 to 9.1) with aspirin use. We found no statistically significant association between statin use and usual gait speed, the secondary outcome. In conclusion, ACE inhibitors and aspirin interacted with statins, reversing the negative association with GSR into a positive one when co-used. Future clinical trials are needed to determine causality and further investigate the impact of concomitant medication use on statin effects in aging populations. Meanwhile, our findings underscore the importance of considering concomitant medication use when assessing the effects of statins in older adults.

Vitamin D Status Determines Cardiometabolic Effects of Testosterone Replacement Therapy in Men with Late-Onset Hypogonadism

Background/Objectives: Low testosterone levels and low vitamin D status are associated with increased cardiometabolic risk. The purpose of this study was to investigate whether vitamin D status determines the cardiometabolic effects of testosterone replacement therapy. Methods: The study population consisted of three groups of men with late-onset hypogonadism: vitamin D-naive individuals with 25-hydroxyvitamin D levels between 20 and 30 ng/mL (group I), males with 25-hydroxyvitamin D levels between 30 and 60 ng/mL receiving vitamin D supplementation because of previous low vitamin D status (group II), and vitamin D-naïve subjects with 25-hydroxyvitamin D levels between 30 and 60 ng/mL (group III). Circulating levels of total testosterone, 25-hydroxyvitamin D, glucose, insulin, lipids, uric acid, high-sensitivity C-reactive protein (hsCRP), homocysteine, fibrinogen, and urinary albumin-to-creatinine ratio (UACR) were assessed before and six months after intramuscular testosterone administration (250 mg every three weeks). Results: Group I differed from the remaining groups in baseline values of 25-hydroxyvitamin D, hsCRP, homocysteine, fibrinogen, UACR, and the Framingham Risk Score. In all three groups, testosterone injections increased plasma testosterone levels and had a neutral effect on 25-hydroxyvitamin D concentration. In groups II and III, the drug improved insulin sensitivity and reduced LDL cholesterol, uric acid, hsCRP, homocysteine, fibrinogen, and UACR. In group I, the impact of testosterone was limited to a small decrease in HDL cholesterol and hsCRP. Only in groups II and III did testosterone reduce the Framingham Risk Score. There were no differences in the strength of testosterone action between both groups. In groups II and III, the replacement-induced changes in insulin sensitivity, LDL cholesterol, uric acid, hsCRP, homocysteine, fibrinogen, UACR, and the Framingham Risk Score positively correlated with 25-hydroxyvitamin D concentration. Conclusions: The study results suggest that the cardiometabolic effects of exogenous testosterone in men with testosterone deficiency may be determined by vitamin D status.

Effect of Statin on Clinical Outcomes in Critically Ill Patients with Non-traumatic Subarachnoid Hemorrhage: A Retrospective Analysis Based on MIMIC Database

BACKGROUND

Nontraumatic subarachnoid hemorrhage (NSAH) is a type of hemorrhagic stroke with high mortality and low recovery rates. Although statins are commonly used in cardiovascular diseases, their impact on subarachnoid hemorrhage prognosis remains unclear. This study aimed to explore the relationship between statin use and short-term and long-term all-cause mortality in critically ill patients with NSAH.

METHODS

Data from the Medical Information Mart for Intensive Care IV database were used to categorize critically ill patients with NSAH into statin and nonstatin groups. A Cox proportional hazards model assessed the association between statin use and all-cause mortality. Subgroup analyses were conducted to examine the consistency of statin effects on mortality.

RESULTS

The study included 750 patients, with 43% male. One-month mortality was 21%, and intensive care unit mortality was 17%. Cox regression analysis showed that statin use was independently associated with reduced intensive care unit mortality (hazard ratio [HR = 0.52; P = 0.010), 1-month mortality (HR = 0.49; P < 0.001), 3-month mortality (HR = 0.62; P = 0.012), and 1-year mortality (HR = 0.70; P = 0.040). Subgroup analyses showed no significant interactions. Simvastatin and atorvastatin both significantly reduced 1-month mortality.

CONCLUSIONS

Statin use may improve mortality outcomes in critically ill patients with NSAH, suggesting their potential benefit in this population.

Coagulation in familial hypercholesterolemic patients: effect of current hypolipidemic treatment and anticoagulants

Familial hypercholesterolemia (FH) is a relatively rare genetic disease associated with high serum cholesterol levels but also with abnormalities in blood coagulation. Novel pharmacotherapeutic approaches in FH including proprotein convertase subtilisin/kexin type 9 antibodies (PCSK9Ab) are very efficient in decreasing cholesterol levels but their impact on coagulation in FH is not yet established. Therefore, we hypothesized that these novel antidyslipidemic drugs can positively impact blood coagulation due to their more potent effect on cholesterol. A total of 15 healthy volunteers and all 15 available patients with severe FH treated at the University Hospital Hradec Králové were enrolled, coagulation was assessed by mechanic coagulometer, and the impact of four clinically used direct anticoagulants was analyzed ex vivo. FH patients were treated effectively as their total cholesterol was 4.11 ± 1.57 mM and LDL cholesterol was 2.44 ± 1.46 mM, which were even lower values than detected in our generally healthy controls. Twelve from the 15 FH patients were finally analyzed as 3 were treated with anticoagulants. Coagulation in FH patients was prolonged more extensively by dabigatran and rivaroxaban, when compared to healthy controls. Treatment with PCSK9Ab or lipid apheresis did not seem to have a significant effect on coagulation. The latter procedure however significantly decreased serum levels of one vitamin K form, MK4. Shorter coagulation time was associated with higher levels of LDL, non-HDL, and total cholesterol. Current treatment of FH seems to improve the effects of direct anticoagulants beyond known effects on LDL cholesterol levels.

Statins during Anticoagulation for Emergency Life-Threatening Venous Thromboembolism: A Review

Venous thromboembolism (VTE) is the leading cause of morbidity and death worldwide, after cancer and cardiovascular diseases. VTE is defined to include pulmonary embolism (PE) and/or deep vein thrombosis (DVT). Approximately 25% of PE patients experience sudden death as an initial symptom of VTE, and between 10% and 30% of patients die within the first month after diagnosis. Currently, the only drugs approved for the treatment of both acute and chronic VTE are vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). However, their effectiveness is limited due to their associated risk of bleeding. Ideally, therapy should be able to treat VTE and limit the risk of VTE recurrence without increasing the risk of bleeding. Several studies have shown that the use of statins during anticoagulation for VTE reduces the risk of death and VTE recurrence. However, to date, there are conflicting data on the impact of statins during anticoagulation for VTE. A biological protective function of statins during anticoagulation has also been reported. Statins affect D-dimer levels; tissue factor (TF) gene expression; and VIII, VII, and Von Willebrand clotting factors-the major clotting factors they are able to affect. However, the usefulness of statins for the treatment and prevention of VTE is currently under debate, and they should not be substituted for guideline-recommended VTE prophylaxis or anticoagulation treatment. In this review of the literature, we illustrate the advances on this topic, including data on the role of statins in primary VTE prevention and secondary VTE prevention, related biological mechanisms, the risk of bleeding during their use, and their ability to reduce the risk of death.

Association between statin use and acute pulmonary embolism in intensive care unit patients with sepsis: a retrospective cohort study

Introduction

Acute pulmonary embolism (APE) is a life-threatening medical condition that is frequently encountered and associated with significant incidence and mortality rates, posing a substantial threat to patients' well-being and quality of life. Sepsis is prominent independent risk factor for the development of APE. Despite recent investigations indicating a reduced APE risk through statin therapy, its impact on patients with sepsis and APE remains unresolved.

Methods

The Medical Information Mart for Intensive Care (MIMIC)-IV database was utilized to identify patients diagnosed with sepsis and APE, irrespective of statin treatment status, as part of this study. The primary study aim was to assess the risk of APE, which was analyzed using multivariate logistic regression models.

Results

The study encompassed a total of 16,633 participants, with an average age of 64.8 ± 16.2 years. Multivariate logistic regression revealed that septic patients receiving statin therapy in the intensive care unit (ICU) exhibited a 33% reduction in the risk of developing APE (OR = 0.67, 95% CI: 0.52-0.86, p < 0.001). The findings of further analyses, including stratification based on statin usage, dosage, and propensity score matching, consistently reinforced the hypothesis that administering statins to patients with sepsis effectively mitigates their potential APE risk.

Discussion

The results of the study provide compelling evidence in favor of administering statins to septic patients as a prophylactic measure against APE, given that statins may reduce the risk of developing APE, and their anti-APE effect appears to be dose-dependent. Nonetheless, future randomized controlled trials are needed to validate these results.

Combination of aspirin and rosuvastatin for reduction of venous thromboembolism in severely injured patients: a double-blind, placebo-controlled, pragmatic randomized phase II clinical trial (The STAT Trial)

INTRODUCTION

Venous thromboembolism (VTE) remains a significant source of postinjury morbidity and mortality. Beta-hydroxy beta-methylglutaryl-CoA (HMG-CoA) reductase inhibitors (rosuvastatin) significantly reduced pathologic clotting events in healthy populations in a prior trial. Furthermore, acetylsalicylic acid (ASA) has been shown to be noninferior to prophylactic heparinoids for VTE prevention following orthopedic surgery. We hypothesized that a combination of rosuvastatin/ASA, in addition to standard VTE chemoprophylaxis, would reduce VTE in critically ill trauma patients.

METHODS

This was a double-blind, placebo-controlled, randomized trial, evaluating VTE rates in two groups: ASA + statin (Experimental) and identical placebos (Control). Injured adults, 18-65 years old, admitted to the surgical intensive care unit without contraindications for VTE prophylaxis were eligible. Upon initiation of routine VTE chemoprophylaxis (i.e. heparin/heparin-derivatives), they were randomized to the Experimental or Control group. VTE was the primary outcome.

RESULTS

Of 112 potentially eligible patients, 33% (n = 37, median new injury severity scale = 27) were successfully randomized, of whom 11% had VTEs. The Experimental group had no VTEs, while the Control group had 6 VTEs (4 PEs and 2 DVTs) in 4 (22%) patients (P = 0.046). The Experimental treatment was not associated with any serious adverse events. Due to the COVID-19 pandemic, the study was interrupted at the second interim analysis at <10% of the planned enrollment, with significance declared at P < 0.012 at that stage.

DISCUSSION

The combination of ASA and rosuvastatin with standard VTE prophylaxis showed a favorable trend toward reducing VTEs with no serious adverse events. An appropriately powered phase III multicenter trial is needed to further investigate this therapeutic approach.

LEVEL OF EVIDENCE

Level II, Therapeutic.

Statins Effects on Blood Clotting: A Review

Statins are powerful lipid-lowering drugs that inhibit cholesterol biosynthesis via downregulation of hydroxymethylglutaryl coenzyme-A reductase, which are largely used in patients with or at risk of cardiovascular disease. Available data on thromboembolic disease include primary and secondary prevention as well as bleeding and mortality rates in statin users during anticoagulation for VTE. Experimental studies indicate that statins alter blood clotting at various levels. Statins produce anticoagulant effects via downregulation of tissue factor expression and enhanced endothelial thrombomodulin expression resulting in reduced thrombin generation. Statins impair fibrinogen cleavage and reduce thrombin generation. A reduction of factor V and factor XIII activation has been observed in patients treated with statins. It is postulated that the mechanisms involved are downregulation of factor V and activated factor V, modulation of the protein C pathway and alteration of the tissue factor pathway inhibitor. Clinical and experimental studies have shown that statins exert antiplatelet effects through early and delayed inhibition of platelet activation, adhesion and aggregation. It has been postulated that statin-induced anticoagulant effects can explain, at least partially, a reduction in primary and secondary VTE and death. Evidence supporting the use of statins for prevention of arterial thrombosis-related cardiovascular events is robust, but their role in VTE remains to be further elucidated. In this review, we present biological evidence and experimental data supporting the ability of statins to directly interfere with the clotting system.

Effect of Statin on Radiographic and Clinical Outcomes of Intracranial Aneurysms Treated With Pipeline Embolization: A Propensity Score-Matched Analysis

BACKGROUND AND OBJECTIVES

Studies have shown that use of statin can improve radiographic and clinical outcomes in patients receiving treatment for coronary artery or peripheral vascular stenosis. Statins are thought to be effective by reducing arterial wall inflammation. The same mechanism may have an influence on the efficacy of pipeline embolization device (PED) for intracranial aneurysm treatment. Although this question has been of interest, there is a lack of well-controlled data in the literature. The objective of this study is to analyze the effect of statins on outcomes of aneurysms treated with pipeline embolization through propensity score matching.

METHODS

Patients who underwent PED for unruptured intracranial aneurysms at our institution between 2013 and 2020 were identified. Patients on statin treatment vs those who were not were matched through propensity score by controlling for confounding factors including age, sex, current smoking status, diabetes, aneurysm morphology, volume, neck size, location of aneurysm, history of treatment for the same aneurysm, type of antiplatelet therapy, and elapsed time at last follow-up. Occlusion status at first follow up and last follow-up, and incidence of in-stent stenosis and ischemic complications during the follow-up period were extracted for comparison.

RESULTS

In total, 492 patients with PED were identified, of whom 146 were on statin therapy and 346 were not. After one-to-one nearest neighbor matching, 49 cases in each group were compared. At last follow-up, 79.6%, 10.2%, and 10.2% of cases in the statin therapy group and 67.4%, 16.3%, and 16.3% in the nonstatin group were noted to have Raymond-Roy 1, 2, and 3 occlusions, respectively ( P = .45). No significant difference was observed in immediate procedural thrombosis ( P > .99), long-term in-stent stenosis ( P > .99), ischemic stroke ( P = .62), or retreatment ( P = .49).

CONCLUSION

Statin use does not affect occlusion rate or clinical outcomes in patients treated with PED treatment for unruptured intracranial aneurysms.

Statin therapy is not warranted for a person with high LDL-cholesterol on a low-carbohydrate diet

PURPOSE OF REVIEW

Although there is an extensive literature on the efficacy of the low carbohydrate diet (LCD) for weight loss and in the management of type 2 diabetes, concerns have been raised that the LCD may increase cardiovascular disease (CVD) risk by increasing the level of low-density lipoprotein cholesterol (LDL-C). We have assessed the value of LDL-C as a CVD risk factor, as well as effects of the LCD on other CVD risk factors. We have also reviewed findings that provide guidance as to whether statin therapy would be beneficial for individuals with high LDL-C on an LCD.

RECENT FINDINGS

Multiple longitudinal trials have demonstrated the safety and effectiveness of the LCD, while also providing evidence of improvements in the most reliable CVD risk factors. Recent findings have also confirmed how ineffective LDL-C is in predicting CVD risk.

SUMMARY

Extensive research has demonstrated the efficacy of the LCD to improve the most robust CVD risk factors, such as hyperglycemia, hypertension, and atherogenic dyslipidemia. Our review of the literature indicates that statin therapy for both primary and secondary prevention of CVD is not warranted for individuals on an LCD with elevated LDL-C who have achieved a low triglyceride/HDL ratio.

Implications of COVID-19 to Stroke Medicine: An Epidemiological and Pathophysiological Perspective

The neurological complications of Coronavirus 2019 (COVID-19) including stroke have been documented in the recent literature. COVID-19-related inflammation is suggested to contribute to both a hypercoagulable state and haemorrhagic transformation, including in younger individuals. COVID-19 is associated with a heightened risk of ischaemic stroke. Haemorrhagic stroke in COVID-19 patients is associated with increased morbidity and mortality. Cerebral venous sinus thrombosis (CVST) accounts for <1% of stroke cases in the general population but has come to heightened public attention due to the increased risk associated with adenoviral COVID-19 vaccines. However, recent evidence suggests the prevalence of stroke is less in vaccinated individuals than in unvaccinated COVID-19 patients. This review evaluates the current evidence of COVID-19-related ischaemic and haemorrhagic stroke, with a focus on current epidemiology and inflammatory-linked pathophysiology in the field of vascular neurology and stroke medicine.

Effect of PCSK9 Inhibitors on Hemostasis in Patients with Isolated Hypercholesterolemia

Background: In addition to reducing plasma lipids, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors may produce numerous nonlipid-related pleiotropic effects. The purpose of this trial was to determine the efficacy of PCSK9 inhibitors alone in patients with isolated hypercholesterolemia. Methods: The trial enrolled 21 individuals with isolated hypercholesterolemia and atherosclerosis who received alirocumab for 90 days (150 mg every two weeks). Lipids, glucose homeostasis factors, and hemostatic markers were measured in the plasma at baseline and after treatment. Results: The PCSK9 inhibitor administered to these patients reduced plasma levels/activity of fibrinogen (from 3.6 ± 0.5 to 2.9 ± 0.4 g/L, p < 0.01), factor VII (from 143.8 ± 16.7 to 114.5 ± 14.1%, p < 0.01) and plasminogen activator inhibitor-1 (PAI-1) (from 74.9 ± 13.9 to 52.8 ± 9.1 ng/mL, p < 0.001) without a significant reduction in von Willebrand factor levels, and it tended to prolong the partial thromboplastin and prothrombin times. Conclusion: Our findings indicate that treatment with PCSK9 inhibitors has a multipotential effect on fibrinolysis and coagulation in patients with isolated hypercholesterolemia and that this medication may have some future benefits in patients who are statin-intolerant or contraindicated to statin use.

The impact of hypotestosteronemia on cardiometabolic effects of atorvastatin in men with hypercholesterolemia: a pilot study

BACKGROUND

Hypothyroidism, hyperprolactinemia, macroprolactinemia and low vitamin D status were found to impair pleiotropic effects of hypolipidemic agents. The aim of the current study was to investigate whether cardiometabolic effects of atorvastatin in men are determined by endogenous testosterone.

METHODS

We studied three groups of men matched for age, BMI, plasma lipids and blood pressure: 19 untreated subjects with low testosterone levels (group A), 19 normotestosteronemic men receiving testosterone preparations (group B) and 21 untreated men with testosterone levels within the reference range (group C). Because of coexistent hypercholesterolemia, all subjects were managed with atorvastatin (40 mg daily) for 6 months. Glucose homeostasis markers, plasma lipids, as well as circulating levels of testosterone, uric acid, high-sensitivity C-reactive protein (hsCRP), fibrinogen, homocysteine and 25-hydroxyvitamin D were determined at the beginning and at the end of the study.

RESULTS

At baseline, group A was more insulin-resistant and was characterized by higher levels of hsCRP, fibrinogen and homocysteine, and lower levels of 25-hydroxyvitamin D than the remaining groups of patients. Despite reducing total and low-density lipoprotein cholesterol and hsCRP levels in all treatment groups, this effect was stronger in groups B and C than in group A. In groups B and C, atorvastatin use was also associated with a decrease in uric acid, fibrinogen and homocysteine concentrations and with an increase in 25-hydroxyvitamin D levels. In group A, but not in the remaining groups, the drug decreased insulin sensitivity.

CONCLUSION

The obtained results suggest that untreated hypotestosteronemia may attenuate cardiometabolic effects of atorvastatin in men.

Impact of lisinopril on cardiometabolic risk factors in men with hypertension and early-onset androgenetic alopecia: a pilot study

ABSTRACT

Women with polycystic ovary syndrome are at high cardiometabolic risk. Early-onset male-pattern baldness is considered the phenotypic equivalent of polycystic ovary syndrome in men. The aim of the present study was to assess whether early-onset androgenetic alopecia modifies cardiometabolic effects of lisinopril in men with arterial hypertension. The study population consisted of 62 young men with grade 1 hypertension, 31 of whom were diagnosed with early-onset male-pattern baldness (group A). Thirty-one blood pressure-matched men with normal hair growth (group B) served as a control group. All participants were treated with lisinopril (10-40 mg daily). Blood pressure, glucose homeostasis markers, urinary albumin-to-creatinine ratio (UACR), as well as plasma levels of uric acid, high-sensitivity C-reactive protein (hsCRP), fibrinogen, homocysteine, total and calculated free testosterone, dehydroepiandrosterone-sulfate and estradiol were assessed before lisinopril treatment and six months later. At baseline, levels of all cardiometabolic risk factors were higher in group A than group B. Although lisinopril reduced systolic and diastolic blood pressure, UACR, hsCRP and fibrinogen in both study groups, these effects were stronger in group B than in group A. Only in group B, the drug decreased levels of uric acid and homocysteine, as well as improved insulin sensitivity. The impact of lisinopril on uric acid, hsCRP, fibrinogen, homocysteine and UACR correlated weakly with its hypotensive properties, androgen levels and insulin sensitivity. The obtained results suggest that cardiometabolic effects of lisinopril in men are less pronounced in case of coexisting early-onset androgenetic alopecia.

The Impact of Telmisartan on Cardiometabolic Risk Factors in Hypertensive Male Siblings of Women With Polycystic Ovary Syndrome

Brothers of women with polycystic ovary syndrome (PCOS) were found to be at increased risk for cardiometabolic disorders. This risk may be exacerbated by concurrent poorly controlled hypertension. Angiotensin II receptor blockers are the most frequently used antihypertensive drugs. The aim of the present study was to compare blood pressure-lowering and pleiotropic effects of telmisartan between male siblings of PCOS probands and unrelated men. The study included 2 age-, blood pressure-, and mass index-matched groups of men with grade 1 hypertension: 24 brothers of women with PCOS (group A) and 26 brothers of healthy women (group B). All subjects were treated with telmisartan (80 mg daily). Blood pressure, glucose homeostasis markers, and plasma lipids, as well as plasma levels of total testosterone, bioavailable testosterone, androstenedione, uric acid, high-sensitivity C-reactive protein (hsCRP), homocysteine, fibrinogen, and 25-hydroxyvitamin D were measured before and after 12 weeks of therapy. At entry, there were between-group differences in the degree of insulin resistance, plasma levels of high-density lipoprotein-cholesterol, triglycerides, calculated bioavailable testosterone, androstenedione, hsCRP, and 25-hydroxyvitamin D. Although telmisartan reduced blood pressure in both study groups, this effect was stronger in group B. Irrespective of the study group, the drug improved insulin sensitivity and reduced circulating levels of uric acid and homocysteine, but these effects were more pronounced in group B than group A. Only in group B, telmisartan decreased hsCRP and fibrinogen, as well as increased 25-hydroxyvitamin D. The obtained results suggest that hypertensive male relatives of PCOS probands may gain less benefit from telmisartan treatment than unrelated hypertensive men.

Cardiometabolic Risk Factors in Rosuvastatin-Treated Men with Mixed Dyslipidemia and Early-Onset Androgenic Alopecia

Men with early-onset androgenetic alopecia are characterized by hormonal profiles similar to those observed in women with polycystic ovary syndrome. The purpose of this research was to investigate levels of cardiometabolic risk factors in 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA)-treated men with early-onset androgenic alopecia. We studied two matched rosuvastatin-treated groups of men with mixed dyslipidemia: subjects with early-onset androgenic alopecia (group A) and subjects with normal hair growth (group B). Plasma lipids, glucose homeostasis markers, and levels of sex hormones, uric acid, hsCRP, homocysteine, fibrinogen, and 25-hydroxyvitamin D were measured before entering the study and six months later. Both groups differed in insulin sensitivity and levels of calculated bioavailable testosterone, dehydroepiandrosterone-sulfate, uric acid, hsCRP, fibrinogen, and 25-hydroxyvitamin D. Though observed in both study groups, treatment-induced reductions in total cholesterol, LDL cholesterol, hsCRP, and fibrinogen were more pronounced in group B than group A. Moreover, only in group A did rosuvastatin deteriorate insulin sensitivity, and only in group B did the drug affect uric acid, homocysteine, and 25-hydroxyvitamin D. The impact of rosuvastatin on cardiometabolic risk factors correlated with insulin sensitivity, calculated bioavailable testosterone, and dehydroepiandrosterone-sulfate. The obtained results suggest that men with early-onset androgenic alopecia may benefit to a lesser degree from rosuvastatin treatment than their peers.

Effect of Statin Therapy on the Carboxypeptidase U (CPU, TAFIa, CPB2) System in Patients With Hyperlipidemia: A Proof-of-concept Observational Study

PURPOSE

Statins are commonly used in patients with hypercholesterolemia to lower their cholesterol levels and to reduce their cardiovascular risk. There is also considerable evidence that statins possess a range of cholesterol-independent effects, including profibrinolytic properties. This pilot study aimed to explore the influence of statins on procarboxypeptidase U (proCPU) biology and to search for possible effects and associations that can be followed up in a larger study.

METHODS

Blood was collected from 16 patients with hyperlipidemia, before and after 3 months of statin therapy (simvastatin 20 mg or atorvastatin 20 mg). Fifteen age-matched normolipemic persons served as control subjects. Lipid parameters and markers of inflammation and fibrinolysis (proCPU levels and clot lysis times) were determined in all samples.

FINDINGS

Mean (SD) proCPU levels were significantly higher in patients with hypercholesterolemia compared to control subjects (1186 [189] U/L vs 1061 [60] U/L). Treatment of these patients with a statin led to a significant average decrease of 11.6% in proCPU levels and brought the proCPU concentrations to the same level as in the control subjects. On a functional level, enhancement in plasma fibrinolytic potential was observed in the statin group, with the largest improvement in fibrinolysis seen in patients with the highest baseline proCPU levels and largest proCPU decrease upon statin treatment.

IMPLICATIONS

Increased proCPU levels are present in patients with hyperlipidemia. Statin treatment significantly decreased proCPU levels and improved plasma fibrinolysis in these patients. Moreover, our study indicates that patients with high baseline proCPU levels are most likely to benefit from statin therapy. The latter should be examined further in a large cohort.

The impact of vitamin D status on cardiometabolic effects of fenofibrate in women with atherogenic dyslipidemia

Vitamin D deficiency is a risk factor for cardiometabolic disease. The aim of this study was to determine the role of vitamin D status in the impact of fenofibrate on plasma levels of cardiometabolic risk factors. The study population (n = 61) consisted of three matched groups of women with atherogenic dyslipidaemia: vitamin D-naïve women with vitamin D insufficiency (group A), women receiving vitamin D preparations because of vitamin D deficiency (group B), as well as vitamin D-naïve women with normal vitamin D status (group C), who were treated with micronized fenofibrate (200 mg daily). Glucose homeostasis markers, plasma lipids, as well as plasma levels of 25-hydroxyvitamin D, uric acid, high-sensitivity C-reactive protein (hsCRP), fibrinogen and homocysteine were determined at the beginning of the study and 6 months later. At entry, group A was characterized by lower levels of 25-hydroxyvitamin D, reduced insulin sensitivity and higher concentrations of uric acid, hsCRP, fibrinogen and homocysteine. Apart from a weaker effect on HDL-cholesterol and triglycerides in group A, there were no differences between the treatment arms in the effect of fenofibrate on plasma lipids. However, only in groups B and C the drug improved insulin sensitivity and reduced circulating levels of uric acid and hsCRP, as well as increased levels of 25-hydroxyvitamin D and these effects correlated with the degree of improvement in insulin sensitivity. Treatment-induced increase in homocysteine was observed only in group A. The results of the study indicate that cardiometabolic effects of fibrates may depend on the vitamin D status of patients.

Cardiometabolic risk factors in women with non-classic congenital adrenal hyperplasia

Background: No previous study has investigated cardiometabolic risk factors in untreated patients with congenital adrenal hyperplasia (CAH).Methods: The study population consisted of 14 premenopausal women with previously untreated non-classic congenital adrenal hyperplasia (NC-CAH) and 20 matched healthy women. Apart from 17-hydroxyprogesterone and androgen levels, the outcomes of interest were glucose homeostasis markers, plasma lipids, plasma levels of uric acid, C-reactive protein, fibrinogen, homocysteine and 25-hydroxyvitamin D, as well as urinary albumin-to-creatinine ratio (UACR).Results: As expected, women with NC-CAH were characterised by higher levels of 17-hydroxyprogesterone and were more insulin-resistant than control women. The mean values of C-reactive protein, fibrinogen, homocysteine and UACR were higher while 25-hydroxyvitamin D levels were lower in subjects with NC-CAH. The investigated cardiometabolic risk factors correlated with androgen levels and insulin sensitivity.Conclusions: The obtained results suggest that the occurrence of NC-CAH in premenopausal women may increase cardiometabolic risk.

The impact of atorvastatin on cardiometabolic risk factors in brothers of women with polycystic ovary syndrome

Background

Women with polycystic ovary syndrome (PCOS) are characterized by increased cardiometabolic risk. The aim of the current study was to compare the impact of atorvastatin on plasma levels of cardiometabolic risk factors between men whose sisters had either PCOS or were unaffected.

Methods

The study population consisted of two age-, fat-free mass index-, blood pressure- and plasma lipid-matched groups of men with elevated total and LDL cholesterol levels: 20 brothers of PCOS probands (group 1) and 20 brothers of healthy women (group 2). Both groups were then treated with atorvastatin (40 mg daily) for the following 6 months. At the beginning and at the end of the study, we assessed plasma lipid levels, glucose homeostasis markers and levels of dehydroepiandrosterone sulfate, testosterone, bioavailable testosterone, uric acid, high-sensitivity C-reactive protein (hsCRP), homocysteine, fibrinogen and 25-hydroxyvitamin D.

Results

At the beginning of the study, both treatment arms differed in the degree of insulin resistance, calculated bioavailable testosterone, as well as in plasma levels of dehydroepiandrosterone sulfate, uric acid, hsCRP and 25-hydroxyvitamin D. Although atorvastatin reduced total and LDL cholesterol levels, this effect was stronger in group 2 than group 1. In group 2, atorvastatin exerted also a more potent impact on hsCRP, fibrinogen and homocysteine. An unfavorable impact on insulin sensitivity was observed only in group 1; while, statistically significant changes in uric acid and 25-hydroxyvitamin D levels were found only in group 2.

Conclusion

The obtained results suggest that cardiometabolic effects of atorvastatin are less pronounced in male siblings of PCOS probands than in brothers of unaffected women.

Impaired Spontaneous/Endogenous Fibrinolytic Status as New Cardiovascular Risk Factor?: JACC Review Topic of the Week

Endogenous fibrinolysis is a powerful natural defense mechanism against lasting arterial thrombotic occlusion. Recent prospective studies have shown that impaired endogenous fibrinolysis (or hypofibrinolysis) can be detected in a significant number of patients with acute coronary syndrome (ACS) using global assays and is a strong marker of future cardiovascular risk. This novel risk biomarker is independent of traditional cardiovascular risk factors and unaffected by antiplatelet therapy. Most prospective prognostic data have been obtained using a global assay using native whole blood at high shear or plasma turbidimetric assays, which are described herein. Tests of endogenous fibrinolysis could be used to identify patients with ACS who, despite antiplatelet therapy, remain at high cardiovascular risk. This review discusses the impact of currently available medications and those in development that favorably modulate fibrinolytic status and may offer a potential new avenue to improve outcomes in ACS.

Sexual Functioning in Hyperprolactinemic Patients Treated With Cabergoline or Bromocriptine

BACKGROUND

Elevated prolactin levels were found to be associated with impaired sexuality.

STUDY QUESTION

The aim of the study was to compare the impact of bromocriptine and cabergoline on sexual functioning in both genders.

STUDY DESIGN

The study enrolled 39 young women and 18 young men receiving bromocriptine treatment. In 19 women and 8 men, because of poor tolerance, bromocriptine was replaced with cabergoline, whereas the remaining ones continued bromocriptine treatment.

MEASURES AND OUTCOMES

Apart from measuring serum levels of prolactin and insulin sensitivity, at the beginning of the study and 16 weeks later, all included patients completed questionnaires evaluating female or male sexual functioning (Female Sexual Function Index; International Index of Erectile Function-15).

RESULTS

Irrespective of the gender, posttreatment prolactin levels were lower in cabergoline-treated patients than in bromocriptine-treated patients. Baseline sexual functioning did not differ between patients well and poorly tolerating bromocriptine treatment. Neither in men nor in women receiving bromocriptine, posttreatment sexual functioning differed from baseline one. In both genders, cabergoline improved sexual desire. Moreover, in men, the drug improved erectile and orgasmic function, whereas in women, it improved sexual arousal. All these effects correlated with the impact of this drug on prolactin levels and on insulin sensitivity.

CONCLUSIONS

Cabergoline is superior to bromocriptine in affecting male and female sexual functioning and should be preferred in hyperprolactinemic men and women with sexual dysfunction.

Impact of Macroprolactinemia on Cardiometabolic Effects of Atorvastatin in Women With Hypercholesterolemia

Premenopausal women with macroprolactinemia are characterized by increased cardiometabolic risk. No previous study has investigated the impact of any lipid-lowering agent on circulating levels of cardiometabolic risk factors in patients with elevated macroprolactin content. We studied 2 groups of women matched for age, body mass index, plasma lipids, and blood pressure: 12 women with macroprolactinemia and 14 women with prolactin levels within the reference range. Because of coexistent isolated hypercholesterolemia, all subjects were then treated with atorvastatin (20 mg daily). Glucose homeostasis markers, plasma lipids, as well as circulating levels of uric acid, high-sensitivity C-reactive protein (hsCRP), fibrinogen, homocysteine, and 25-hydroxyvitamin D were measured before entering the study and 6 months later. The treatment arms differed in baseline values of hsCRP and 25-hydroxyvitamin D, as well as in insulin sensitivity. Atorvastatin decreased total and low-density lipoprotein cholesterol levels stronger in women without than in women with macroprolactinemia. In normoprolactinemic women, atorvastatin decreased circulating levels of uric acid, hsCRP, fibrinogen, homocysteine, and increased concentrations of 25-hydroxyvitamin D, whereas in women with macroprolactinemia the drug decreased levels of hsCRP and homocysteine, as well as impaired insulin sensitivity. Both study groups differed in post-treatment insulin sensitivity and post-treatment values of prolactin before polyethylene glycol precipitation, macroprolactin, total cholesterol, low-density lipoprotein cholesterol, glycated hemoglobin, uric acid, hsCRP, fibrinogen, homocysteine, and 25-hydroxyvitamin D. In conclusion, the obtained results suggest that macroprolactinemia may attenuate cardiometabolic effects of atorvastatin.

Cardiometabolic Risk Factors in Men with Elevated Macroprolactin Content: A Pilot Study

BACKGROUND

Macroprolactinemia is a condition associated with the presence of large amounts of high molecular weight complexes of prolactin. Despite high prevalence, clinical significance of macroprolactin remains poorly understood.

OBJECTIVE

The aim of this study was to assess cardiometabolic risk in men with isolated macroprolactinemia.

METHODS

The study population included 11 men with isolated macroprolactinemia, 14 subjects with monomeric hyperprolactinemia and 14 men with prolactin levels within the reference range. Glucose homeostasis markers, plasma lipids, as well as plasma levels of uric acid, high-sensitivity C-reactive protein (hsCRP), fibrinogen, homocysteine and 25-hydroxyvitamin D were determined in all included patients.

RESULTS

Compared to healthy counterparts, men with isolated macroprolactinemia had higher levels of 2-h postchallenge glucose, hsCRP and fibrinogen, lower levels of 25-hydroxyvitamin D and reduced insulin sensitivity. Patients with monomeric hyperprolactinemia were characterized by increased plasma levels of 2-h postchallenge glucose, triglycerides, uric acid, hsCRP, fibrinogen and homocysteine, reduced insulin sensitivity and decreased plasma concentrations of HDL cholesterol and 25-hydroxyvitamin D. Subjects with isolated macroprolactinemia differed from patients with monomeric hyperprolactinemia in postchallenge plasma glucose, insulin sensitivity, uric acid, hsCRP, fibrinogen, homocysteine and 25-hydroxyvitamin D. In men with monomeric hyperprolactinemia, uric acid, hsCRP, fibrinogen, homocysteine and 25-hydroxyvitamin D, while in men with elevated levels of macroprolactin, uric acid, hsCRP, fibrinogen and 25-hydroxyvitamin D correlated with a content of monomeric prolactin or macroprolactin, respectively, as well as with a degree of insulin sensitivity.

CONCLUSIONS

The obtained results suggest that macroprolactinemia may increase cardiometabolic risk but to a lesser extent than monomeric hyperprolactinemia.

The effect of atorvastatin on cardiometabolic risk factors in women with non-classic congenital adrenal hyperplasia: A pilot study

BACKGROUND

Individuals with non-classic congenital adrenal hyperplasia (NC-CAH) often show evidence of hyperandrogenism, including premature pubarche, accelerated linear growth velocity, short final height, hirsutism, acne, alopecia, impaired ovulation, menstrual dysfunction and subfertility. Although statins were found to reduce elevated levels of androgens in subjects with this disorder, no previous study has investigated whether 3-hydroxy-3-methylglutaryl-CoA reductase inhibitors affect cardiometabolic risk factors in patients with NC-CAH.

METHODS

We studied 12 women with NC-CAH, 6 of whom because of coexisting hypercholesterolemia received atorvastatin (20-40 mg daily). Circulating levels of lipids, glucose homeostasis markers, plasma levels of androgens, 17-hydroxyprogesterone, high-sensitivity C-reactive protein (hsCRP), uric acid, fibrinogen, homocysteine and 25-hydroxyvitamin D, as well as urinary albumin-to-creatinine ratio (UACR) were determined at the beginning of the study and 12 weeks later.

RESULTS

Beyond affecting plasma lipids, atorvastatin reduced circulating levels of testosterone, dehydroepiandrosterone sulphate, androstenedione and 17-hydroxyprogesterone, and decreased free androgen index. Moreover, atorvastatin caused a decrease in plasma levels/urinary loss of uric acid, hsCRP, homocysteine and UACR, and insignificantly increased circulating levels of 25-hydroxyvitamin D. The drug produced no effect on plasma fibrinogen. The effect of atorvastatin on hsCRP, uric acid, homocysteine, 25-hydroxyvitamin D and UACR correlated with the magnitude of reduction in 17-hydroxyprogesterone and androgens.

CONCLUSION

Our results suggest that statin therapy reduces cardiometabolic risk in women with NC-CAH.

Identification of DKK-1 as a novel mediator of statin effects in human endothelial cells

This study shows that DKK-1, a member of the Dickkopf family and a regulator of the Wnt pathways, represents a novel target of statins which, through the inhibition of HMG-CoA reductase and of non-steroidal isoprenoid intermediates, exert extra-beneficial effect in preventing atherosclerosis beyond their effect on the lipid profile. We found that atorvastatin downregulates DKK-1 protein (−88.3 ± 4.1%) and mRNA expression (−90 ± 4.2%) through the inhibition of Cdc42, Rho and Rac geranylgeranylated proteins. Further, a combined approach based on the integration of label-free quantitative mass spectrometry based-proteomics and gene silencing allowed us to demonstrate that DKK-1 itself mediates, at least in part, statin effects on human endothelial cells. Indeed, DKK-1 is responsible for the regulation of the 21% of the statin-modulated proteins, which include, among others, clusterin/apoJ, plasminogen activator inhibitor type 1 (PAI-1), myristoylated alanine-rich C-kinase substrate (MARCKS), and pentraxin 3 (PTX3). The Gene Ontology enrichment annotation revealed that DKK-1 is also a potential mediator of the extracellular matrix organization, platelet activation and response to wounding processes induced by statin. Finally, we found that plasma level of DKK-1 from cholesterol-fed rabbits treated with atorvastatin (2.5 mg/kg/day for 8 weeks) was lower (−42 ± 23%) than that of control animals. Thus, DKK-1 is not only a target of statin but it directly regulates the expression of molecules involved in a plethora of biological functions, thus expanding its role, which has been so far restricted mainly to cancer.

Statin Therapy and Diabetes Do Not Affect Aneurysm Occlusion or Clinical Outcomes After Pipeline Embolization Device Treatment: A Preliminary Study

BACKGROUND

The effect of statins and diabetes on angiographic and clinical outcomes in aneurysms treated with pipelines has not been adequately reported. Our aim is to assess the effect of concurrent statin medications and diabetes mellitus (DM) on aneurysm occlusion status and outcomes in patients treated with the pipeline embolization device.

METHODS

A retrospective review of our institution's database of aneurysms treated with the pipeline embolization device between 2013 and 2017 was conducted. We collected data about statin therapy status and intensity, and identified patients with a documented history of DM. Our primary outcome was aneurysm obliteration seen on digital subtracted angiography or magnetic resonance angiography at last follow-up.

RESULTS

We identified 151 patients with 182 aneurysms for this cohort, with a median radiographic follow-up time of 7.2 months (6.1-14.5). Thirty-nine patients were taking statins, and 112 patients did not receive statins. Log-rank tests revealed no statistically significant difference in occlusion rates between patients with and without statin therapy (P = 0.30). A history of DM was documented in 11 patients, with 14 aneurysms in total; 140 patients with 168 aneurysms had no history of DM. Similarly, there were no differences in occlusion rates between the diabetic and nondiabetic groups in multivariate analysis (P = 0.24). Only 2 patients showed significant in-stent stenosis on angiographic follow up, and both were diabetic.

CONCLUSIONS

Our analysis did not identify a statistically significant association between statin therapy or DM and higher occlusion rates or better outcomes after pipeline embolization. Diabetic patients may have a theoretic risk of significant in-stent stenosis.

Different Effects of Atorvastatin on Cardiometabolic Risk Factors in Young Women With and Without Hyperprolactinemia

Long-term prolactin excess is often accompanied by numerous metabolic complications. No previous study has compared the effect of statin therapy on circulating levels of cardiometabolic risk factors in patients with elevated and normal prolactin levels. The study population consisted of 3 age-, weight-, and lipid-matched groups of young women: 19 women with untreated hyperprolactinemia (group A), 20 normoprolactinemic women receiving bromocriptine treatment (because of previous hyperprolactinemia) (group B), and 20 untreated women with prolactin levels within the reference range (group C). Because of elevated total and low-density lipoprotein cholesterol levels, all women were then treated with atorvastatin (40 mg daily). Apart from measuring plasma lipids, glucose homeostasis markers, and hormone levels at the beginning of the study and 12 weeks later, we measured circulating levels of uric acid, high-sensitivity C-reactive protein, homocysteine, and fibrinogen. Despite similar baseline levels of plasma lipids, levels of uric acid, high-sensitivity C-reactive protein, homocysteine, and fibrinogen as well as the degree of insulin resistance were higher in group A than in the remaining 2 groups. Atorvastatin reduced total and low-density lipoprotein cholesterol levels in all study groups. However, only in normoprolactinemic women (groups B and C) did atorvastatin reduce circulating levels of nonlipid cardiometabolic risk factors, whereas only in group A did the drug slightly impair insulin sensitivity. The results of the study suggest that cardiometabolic effects of atorvastatin depend on the prolactin status of patients.

Association between statin use and plasma D-dimer levels

D-dimers, specific breakdown fragments of cross-linked fibrin, are generally used as circulating markers of activated coagulation. Statins influence haemostatic factors, but their effect on plasma D-dimer levels is controversial. Therefore, the aim of this meta-analysis was to evaluate the association between statin therapy and plasma D-dimer levels. We searched PubMed, Web of Science, Cochrane Library, Scopus and EMBASE (up to September 25, 2014) to identify randomised controlled trials (RCTs) investigating the impact of statin therapy on plasma D-dimer levels. Two independent reviewers extracted data on study characteristics, methods and outcomes. Meta-analysis of data from nine RCTs with 1,165 participants showed a significant effect of statin therapy in reducing plasma D-dimer levels (standardised mean difference [SMD]: –0.988 µg/ml, 95 % confidence interval [CI]: –1.590 – –0.385, p=0.001). The effect size was robust in sensitivity analysis and omission of no single study significantly changed the overall estimated effect size. In the subgroup analysis, the effect of statins on plasma D-dimer levels was significant only in the subsets of studies with treatment duration ≥ 12 weeks (SMD: –0.761 µg/ml, 95 %CI: –1.163– –0.360; p< 0.001), and for lipophilic statins (atorvastatin and simvastatin) (SMD: –1.364 µg/ml, 95 % CI: –2.202– –0.526; p=0.001). Hydrophilic statins (pravastatin and rosuvastatin) did not significantly reduce plasma D-dimer levels (SMD: –0.237 µg/ml, 95 %CI: –1.140–0.665, p=0.606). This meta-analysis of RCTs suggests a decrease of plasma D-dimer levels after three months of statin therapy, and especially after treatment with lipophilic statins. Well-designed trials are required to validate these results.

Note: The review process for this paper was fully handled by Christian Weber, Editor in Chief.

Recent Advances in the Development of Mammalian Geranylgeranyl Diphosphate Synthase Inhibitors

The enzyme geranylgeranyl diphosphate synthase (GGDPS) catalyzes the synthesis of the 20-carbon isoprenoid geranylgeranyl diphosphate (GGPP). GGPP is the isoprenoid donor for protein geranylgeranylation reactions catalyzed by the enzymes geranylgeranyl transferase (GGTase) I and II. Inhibitors of GGDPS result in diminution of protein geranylgeranylation through depletion of cellular GGPP levels, and there has been interest in GGDPS inhibitors as potential anti-cancer agents. Here we discuss recent advances in the development of GGDPS inhibitors, including insights gained by structure-function relationships, and review the preclinical data that support the continued development of this novel class of drugs.

[The etiopathogenetic aspects of idiopathic sensorineural impairment of hearing]

The objectives of the present work were the overview of the results of the modern investigations concerning etiology of idiopathic sensorineural impairment of hearing as well as the analysis of the theory of microthrombus formation and its role in pathogenesis of hearing impairment.

Different cardiometabolic effects of atorvastatin in men with normal vitamin D status and vitamin D insufficiency

BACKGROUND

Vitamin D is suggested to reduce cardiovascular risk.

HYPOTHESIS

Circulating levels of plasma lipids and other cardiovascular risk factors may differ between statin-treated patients with different vitamin D status.

METHODS

We studied 3 age- and weight-matched groups of men with elevated low-density lipoprotein cholesterol (LDL-C) levels: vitamin D-naïve men with vitamin D insufficiency (group A, n = 18), men with vitamin D deficiency/insufficiency effectively treated with vitamin D preparations (group B, n = 16), and vitamin D-naïve men with normal vitamin D status (group C, n = 16). All patients were then treated with atorvastatin (20 mg daily) for 4 months. Plasma lipids, glucose homeostasis markers, and plasma levels of uric acid, high-sensitivity C-reactive protein (hsCRP), homocysteine, and fibrinogen were assessed before and at the end of atorvastatin therapy.

RESULTS

Study groups did not differ in baseline levels of plasma lipids. Men with vitamin D deficiency or insufficiency effectively treated with vitamin D preparations were characterized by decreased insulin sensitivity and higher circulating levels of hsCRP, homocysteine, and fibrinogen in comparison with the remaining groups of patients. Although atorvastatin decreased plasma levels of total cholesterol and LDL-C to a similar extent in all study groups, its effect on uric acid, hsCRP, homocysteine, and fibrinogen was more pronounced in patients from groups B and C than in men from group A. Moreover, in patients with vitamin D insufficiency, atorvastatin impaired insulin sensitivity.

CONCLUSIONS

The obtained results indicate that the strength of pleiotropic effects of atorvastatin depends on vitamin D status.

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.

Fibrosis and coronary perfusion - a cardiovascular disease risk in an African male cohort: The SABPA study

Low-grade inflammation has been correlated with risk factors of cardiovascular diseases (CVD). Whether the pro-inflammatory and thrombotic ratio (fibrosis) may contribute to CVD is not known. We therefore aimed to assess whether Cornell Product left ventricular hypertrophy (LVH) is associated with fibrosis and coronary perfusion (silent ischemia) in a bi-ethnic male cohort from South Africa. A cross sectional study was conducted including 165 African and Caucasian men between the ages of 20-65. Fasting blood samples were obtained to measure fibrinogen, C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor (TNF-α). Ambulatory blood pressure, ECG and 12 lead ECG measures were obtained to determine silent ischemic events (ST events) and LVH, respectively. Africans revealed more silent ischemia, higher 24 h blood pressure, inflammatory, coagulation as well as fibrosis levels than Caucasians. In a low-grade inflammatory state (CRP > 3 mg/l), Africans revealed higher fibrosis (p ≤ 0.01) values, but lower IL-6 and TNF-α values than Caucasians. Linear regression analyses in several models demonstrated positive associations between silent ischemia and fibrosis [Adj. R(2) 0.23; ß 0.35 (95% CI 0.13, 0.58), p ≤ 0.01]. In a low-grade inflammatory state (CRP>3mg/l), fibrinogen predicted AV-block in African men [OR 3.38 (95% CI 2.24, 4.53); p = 0.04]. Low-grade inflammation may induce AV-block through mechanisms involving fibrosis and ischemia to increase the burden on the heart in African men.

The association of statin therapy with the risk of recurrent venous thrombosis

Essentials A lowered risk of recurrent venous thrombosis (VT) with statin treatment is controversial. Among observational inception cohort of 2,798 adults with incident VT, 457 had recurrent VT. Time-to-event models with time-varying statin use and adjustment for potential confounders was used for analysis. Compared to nonuse, current statin use was associated with 26% lower risk of recurrent VT. Click to hear Prof. Büller's perspective on Anticoagulant Therapy in the Treatment of Venous Thromboembolism

SUMMARY

Background Meta-analyses of randomized controlled trials suggest that treatment with hydroxymethylglutaryl-coenzyme A reductase inhibitors (statins) lowers the risk of incident venous thrombosis (VT), particularly among those without prevalent clinical cardiovascular disease (CVD). Whether this is true for the prevention of recurrent VT is debated. We used an observational inception cohort to estimate the association of current statin use with the risk of recurrent VT. Methods and Results The study setting was a large healthcare organization with detailed medical record and pharmacy information at cohort entry and throughout follow-up. We followed 2798 subjects 18-89 years of age who experienced a validated incident VT between January 1, 2002, and December 31, 2010, for a first recurrent VT, validated by medical record review. During follow-up, 457 (16%) developed a first recurrent VT. In time-to-event models incorporating time-varying statin use and adjusting for potential confounders, current statin use was associated with a 26% lower risk of recurrent VT: hazard ratio 0.74, 95% confidence interval 0.59-0.94. Among cohort members free of CVD (n = 2134), current statin use was also associated with a lower risk (38%) of recurrent VT: hazard ratio 0.62, 95% confidence interval 0.45-0.85. We found similar results when restricting to new users of statins and in subgroups of different statin types and doses. Conclusions In a population-based cohort of subjects who had experienced an incident VT, statin use, compared with nonuse, was associated with a clinically relevant lower risk of recurrent VT. These findings suggest a potential secondary benefit of statins among patients who have experienced an incident VT.

The Effect of Testosterone and Fenofibrate, Administered Alone or in Combination, on Cardiometabolic Risk Factors in Men with Late-Onset Hypogonadism and Atherogenic Dyslipidemia

INTRODUCTION

Oral testosterone was found to reduce plasma levels of HDL cholesterol. No previous study has examined the effect of fibrates, known to increase HDL cholesterol, in patients with low testosterone levels requiring testosterone replacement.

AIMS

The study included three age-, weight-, and lipid-matched groups of older men with atherogenic dyslipidemia and late-onset hypogonadism, treated with oral testosterone undecanoate (120 mg daily, n = 15), micronized fenofibrate (200 mg daily, n = 15), or testosterone plus fenofibrate (n = 18). Plasma lipids, glucose homeostasis markers, as well as plasma levels of androgens, uric acid, high-sensitivity C-reactive protein (hsCRP), homocysteine, and fibrinogen were assessed before and after 16 weeks of therapy.

RESULTS

Apart from an increase in plasma testosterone and a reduction in HDL cholesterol, testosterone undecanoate tended to decrease hsCRP and to improve insulin sensitivity. Fenofibrate administered alone increased HDL cholesterol, reduced triglycerides, decreased insulin resistance, reduced circulating levels of uric acid, hsCRP, and fibrinogen, as well as increased plasma levels of homocysteine. The strongest effect on testosterone, HOMA1-IR, uric acid, hsCRP, and fibrinogen was observed if fenofibrate was administered together with testosterone. Testosterone-fenofibrate combination therapy was also devoid of unfavorable effect on HDL cholesterol and homocysteine.

CONCLUSIONS

Our study shows that fenofibrate produces a stronger effect on cardiometabolic risk factors in men with late-onset hypogonadism and atherogenic dyslipidemia than oral testosterone undecanoate. The obtained results suggest that this group of patients may benefit the most from the combined treatment with oral testosterone undecanoate and micronized fenofibrate.

The effect of fenofibrate on cardiometabolic risk factors in bromocriptine-treated women with mixed dyslipidemia: A pilot study

BACKGROUND

Elevated prolactin levels are associated with metabolic and hormonal complications. No previous study has investigated the effect of any fibrate on plasma levels of lipids and other cardiometabolic risk factors in patients receiving dopamine agonist therapy.

METHODS

The study included 36 premenopausal women with mixed dyslipidemia and slightly increased prolactin levels, 17 of whom had already been treated with bromocriptine (5.0-7.5mg daily). The included patients received micronized fenofibrate (200mg daily) for 6 months. Plasma lipids, glucose homeostasis markers, as well as plasma levels of prolactin, uric acid, high-sensitivity C-reactive protein (hsCRP), homocysteine and fibrinogen were determined before and after 12 weeks of fenofibrate therapy.

RESULTS

Insulin sensitivity was more expressed while baseline plasma levels of hsCRP and fibrinogen were lower in patients treated with bromocriptine than in women not receiving dopamine agonist therapy. Although fenofibrate improved plasma lipids and insulin sensitivity, as well as reduced plasma levels of the investigated cardiometabolic risk factors in both groups of patients, its action on HDL cholesterol, triglycerides, insulin sensitivity, hsCRP and fibrinogen was stronger in subjects receiving bromocriptine. Moreover, only in bromocriptine-naïve patients, fenofibrate increased plasma homocysteine.

CONCLUSIONS

Our study shows that the effect of fenofibrate on plasma lipids and circulating levels of cardiometabolic risk factors may be potentiated by bromocriptine treatment. They also suggest that hyperprolactinemic women with mixed dyslipidemia and early glucose metabolism abnormalities may receive the greatest benefits from concomitant treatment with a fibrate and bromocriptine.

The effect of statin therapy on thyroid autoimmunity in patients with Hashimoto's thyroiditis: A pilot study

BACKGROUND

Statins have been found to exert antiinflammatory and immunomodulatory properties. The aim of this study was to compare the effects of intensive and less aggressive statin treatment on thyroid autoimmunity and hypothalamic-pituitary-thyroid axis activity in patients with Hashimoto's thyroiditis.

METHODS

The study included 38 adult women with Hashimoto's thyroiditis, who required statin therapy and were allocated into one of two groups. Patients at very high cardiovascular risk (n=16) received intensive statin treatment (rosuvastatin 20-40mg daily), while patients at moderate or moderately high cardiovascular risk (n=22) were treated with simvastatin (20-40mg daily) for the following 6 months. Serum levels of thyrotropin, total and free thyroid hormones, and high-sensitivity C-reactive protein (hsCRP), as well as titers of thyroid peroxidase and thyroglobulin antibodies were measured at the beginning and at the end of the study.

RESULTS

Thirty-six individuals completed the study and were included in the final analyses. Apart from improving plasma lipids and reducing circulating levels of hsCRP, intensive, but not less aggressive, statin therapy reduced thyroid peroxidase and thyroglobulin antibody titers, as well as tended to reduce circulating levels of thyrotropin. The effect of intensive statin therapy on thyroid antibody titers was lipid-independent but correlated with treatment-induced changes in thyrotropin and hsCRP.

CONCLUSIONS

Although 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors are able to reduce thyroid autoimmunity in women with Hashimoto's thyroiditis, intensive statin therapy is required to produce this effect.

The effect of testosterone on cardiometabolic risk factors in atorvastatin-treated men with late-onset hypogonadism

BACKGROUND

By reducing LDL cholesterol levels, statins may decrease androgen production. This study was aimed at investigating whether testosterone treatment has an impact on cardiometabolic risk factors in statin-treated men with late-onset hypogonadism (LOH).

METHODS

The study included 31 men with LOH who had been treated for at least 6 months with atorvastatin (20-40mg daily). On the basis of patient preference, atorvastatin-treated patients were divided into two matched groups of patients: receiving intramuscular testosterone enanthate (100mg weekly, n=16) and not treated with this hormone (n=15). Plasma lipids, glucose homeostasis markers, as well as plasma levels of androgens, uric acid, high-sensitivity C-reactive protein (hsCRP), homocysteine, and fibrinogen were assessed before and after 4 months of therapy.

RESULTS

Compared with the control age-, weight, and lipid-matched statin-naïve subjects with LOH (n=12), atorvastatin-treated patients were characterized by decreased levels of testosterone, hsCRP, and homocysteine. In patients not receiving testosterone therapy, plasma lipids, glucose homeostasis markers, as well as plasma levels of the investigated risk factors remained at the similar levels throughout the whole period of atorvastatin treatment. In atorvastatin-naïve patients, testosterone increased its plasma levels and decreased HDL cholesterol. Apart from an increase in testosterone levels, if administered to atorvastatin-treated subjects with LOH, testosterone reduced plasma levels of LDL cholesterol, uric acid, hsCRP, homocysteine, and fibrinogen, as well as improved insulin sensitivity.

CONCLUSIONS

Our study may suggest the clinical benefits associated with combination therapy with a statin and testosterone in elderly men with LOH.

The Effect of Atorvastatin on Cardiometabolic Risk Factors in Bromocriptine-Treated Premenopausal Women with Isolated Hypercholesterolemia

AIMS

Hyperprolactinemia is often associated with hyperinsulinemia, insulin resistance, atherogenic dyslipidemia, and subclinical atherosclerosis. Dopamine agonists were found to reduce the prevalence of metabolic syndrome and cardiometabolic risk. The aim of this study was to compare the effect of statin therapy on cardiovascular risk factors between patients treated with a dopamine agonist and patients treated with metformin.

METHODS

The study included two age-, weight-, lipid-, and prolactin level-matched groups of premenopausal women with hypecholesterolemia and a history of hyperprolactinemia: patients treated with bromocriptine (5.0-7.5 mg daily, n = 14) and subjects receiving metformin (1.7-2.55 g daily, n = 17). Plasma prolactin, lipids, glucose homeostasis markers, and plasma levels of cardiometabolic risk factors were assessed before and after 12 weeks of atorvastatin treatment.

RESULTS

Baseline levels of the investigated variables were similar in women treated with bromocriptine and metformin. Apart from lowering total and LDL cholesterol, atorvastatin decreased plasma levels of uric acid, hsCRP, homocysteine, and fibrinogen, with no difference between treatment groups.

CONCLUSIONS

The obtained results suggest that the effect of atorvastatin on plasma lipids and circulating levels of cardiometabolic risk factors does not differ between patients receiving bromocriptine and metformin. Bromocriptine-statin combination therapy may be an alternative to metformin-statin combination therapy in hypercholesterolemic patients with glucose metabolism abnormalities in whom metformin administration is either contraindicated or results in adverse effects.

The effect of testosterone on cardiovascular risk factors in men with type 2 diabetes and late-onset hypogonadism treated with metformin or glimepiride

BACKGROUND

Men with type 2 diabetes are often characterized by abnormal plasma testosterone levels. This study was aimed at investigating whether testosterone treatment has an impact on cardiovascular risk factors in patients with type 2 diabetes and late-onset hypogonadism (LOH), chronically treated with hypoglycemic agents.

METHODS

This study included 51 men with type 2 diabetes, 26 of whom had already been treated with metformin and 25 with glimepiride for at least 6 months. On the basis of patient preference, 15 men receiving metformin and 12 receiving glimepiride were treated with intramuscular testosterone enanthate (100mg weekly) for 12 weeks. Plasma lipids, glucose homeostasis markers, as well as plasma levels of androgens, uric acid, high-sensitivity C-reactive protein (hsCRP), homocysteine and fibrinogen were determined before and at the end of the study.

RESULTS

With the exception of insulin sensitivity, plasma hsCRP and homocysteine, there were no differences between patients treated with metformin and glimepiride. Testosterone enanthate administered to both groups of patients increased plasma testosterone, reduced plasma hsCRP and improved insulin sensitivity. Testosterone-metformin combination therapy reduced also circulating levels of uric acid, homocysteine and fibrinogen. These effects, stronger in patients treated with metformin than glimepiride, correlated with the impact of testosterone on insulin sensitivity.

CONCLUSIONS

Our results suggest that testosterone may bring more clinical benefits to metformin- than sulfonylurea-treated men with diabetes and LOH.

Immunotherapy in antiphospholipid syndrome

Antiphospholipid syndrome (APS) is a disorder characterized by the association of arterial or venous thrombosis and/or pregnancy morbidity with the presence of antiphospholipid antibodies (anticardiolipin antibodies, lupus anticoagulant antibodies, and/or anti-β2-glycoprotein I antibodies). Thrombosis is the major manifestation in patients with aPLs, but the spectrum of symptoms and signs associated with aPLs has broadened considerably, and other manifestations, such as thrombocytopenia, non-thrombotic neurological syndromes, psychiatric manifestations, livedo reticularis, skin ulcers, hemolytic anemia, pulmonary hypertension, cardiac valve abnormality, and atherosclerosis, have also been related to the presence of those antibodies. Several studies have contributed to uncovering the basis of antiphospholipid antibody pathogenicity, including the targeted cellular components, affected systems, involved receptors, intracellular pathways used, and the effector molecules that are altered in the process. Therapy for thrombosis traditionally has been based on long-term oral anticoagulation; however, bleeding complications and recurrence despite high-intensity anticoagulation can occur. The currently accepted first-line treatment for obstetric APS (OAPS) is low-dose aspirin plus prophylactic unfractionated or low-molecular-weight heparin (LMWH). However, in approximately 20% of OAPS cases, the final endpoint, i.e. a live birth, cannot be achieved. Based on all the data obtained in different research studies, new potential therapeutic approaches have been proposed, including the use of new oral anticoagulants, statins, hydroxychloroquine, coenzyme Q10, B-cell depletion, platelet and TF inhibitors, peptide therapy or complement inhibition among others. Current best practice in use of these treatments is discussed.

Pharmacological modulation of fibrinolytic response - In vivo and in vitro studies

Fibrinolysis is an action of converting plasminogen by its activators, like tissue- or urokinase-type plasminogen activators (t-PA, u-PA), to plasmin, which in turn cleaves fibrin, thereby causing clot dissolution and restoration of blood flow. Endothelial cells release t-PA, prostacyclin (PGI2) and nitric oxide (NO), the potent factors playing a crucial role in regulation of the fibrinolytic system. Since blood platelets can release not only prothrombotic, but also antifibrinolytic factors, like plasminogen activator inhibitor type-1 (PAI-1), they are involved in fibrynolysis regulation. Therefore agents enhancing fibrinolysis can be preferred pharmacologicals in many cardiovascular diseases. This review describes mechanisms by which major cardiovascular drugs (renin-angiotensin-aldosterone system inhibitors, statins, adrenergic receptors and calcium channel blockers, aspirin and 1-methylnicotinamide) influence fibrinolysis. The presented data indicate, that the influence of these drugs on endothelium-blood platelets interactions via NO/PGI2 pathway is fundamental for its antithrombotic and profibrinolytic action. We also described new approaches for intravital confocal real-time imaging as a tool useful to investigate mechanisms of thrombus formation and the effects of drugs affecting haemostasis and mechanisms of their action in the circulation.

Different effects of fenofibrate on metabolic and cardiovascular risk factors in mixed dyslipidemic women with normal thyroid function and subclinical hypothyroidism

AIMS

Subclinical hypothyroidism is suggested to increase cardiovascular risk. No previous study compared the effect of any fibrate on plasma levels of lipids and other cardiovascular risk factors in patients with different thyroid function status.

METHODS

The study included three age-, weight- and lipid-matched groups of women with mixed dyslipidemia in different thyroid function status: patients with untreated subclinical hypothyroidism (group 1, n = 18), women with treated hypothyroidism (group 2, n = 15), and subjects without thyroid disorders (group 3, n = 19). Plasma lipids, glucose homeostasis markers, as well as plasma levels of uric acid, high-sensitivity C-reactive protein (hsCRP), homocysteine, and fibrinogen were determined before and after 12 weeks of fenofibrate therapy.

RESULTS

Despite similar plasma lipid levels, mixed dyslipidemic patients with untreated hypothyroidism had decreased insulin sensitivity, as well as higher circulating levels of uric acid, hsCRP, homocysteine, and fibrinogen in comparison with the other groups. The effect of fenofibrate on plasma lipids and, with the exception of homocysteine, on circulating levels of all investigated risk factors was stronger in patients from groups 2 and 3 than in patients from group 1.

CONCLUSIONS

The obtained results indicate that the effect of fenofibrate on plasma lipids and circulating levels of cardiovascular risk factors is partially related to thyroid function. They also suggest that to improve the strength of fibrate action in dyslipidemic patients with subclinical hypothyroidism, they should be administered together with L-thyroxine.