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Vuorio A, Kovanen PT, Raal FJ. Coronary microcirculatory dysfunction in hypercholesterolemic patients with COVID-19: potential benefit from cholesterol-lowering treatment. Ann Med 2023; 55:2199218. [PMID: 37068045 PMCID: PMC10116911 DOI: 10.1080/07853890.2023.2199218] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
Patients with hypercholesterolemia often have coronary microvascular dysfunction (CMD). Viral infections, such as the SARS-CoV-2 infection, may also result in CMD. Three non-randomized studies have shown significant beneficial effects of statins on CMD in non-infected patients. Similarly, in SARS-CoV-2 - infected patients one beneficial mechanism of action of statins may be the amelioration of endothelial dysfunction, which is a major driver of CMD. Apart from statins, lipoprotein apheresis and PCSK9 inhibitors can also improve or even reverse CMD. The potential reversal of CMD by using effective cholesterol-lowering medications during and after COVID-19 infection, especially in hypercholesterolemic COVID-19 patients, is important.KEY MESSAGESCoronary microvascular dysfunction (CMD) is common in patients hospitalized with SARS-CoV-2 infectionThree nonrandomized studies in non-infected patients are showing the beneficial effects of statin treatment on CMDEffective cholesterol-lowering medication during and after SARS-CoV-2 infection, especially in hypercholesterolemic COVID-19 patients, is of great significance.
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Affiliation(s)
- Alpo Vuorio
- Forensic Medicine, Mehiläinen Airport Health Centre, Vantaa, Finland
- Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
| | - Petri T Kovanen
- Atherosclerosis Research Laboratory, Wihuri Research Institute, Helsinki, Finland
| | - Frederick J Raal
- Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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2
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Vuorio A, Budowle B, Raal F, Kovanen PT. Wildfire smoke exposure and cardiovascular disease-should statins be recommended to prevent cardiovascular events? Front Cardiovasc Med 2023; 10:1259162. [PMID: 37781301 PMCID: PMC10537918 DOI: 10.3389/fcvm.2023.1259162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/28/2023] [Indexed: 10/03/2023] Open
Affiliation(s)
- Alpo Vuorio
- Mehiläinen, Airport Health Center, Vantaa, Finland
- Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
| | - Bruce Budowle
- Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
| | - Frederick Raal
- Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Petri T. Kovanen
- Cardiovascular Research, Wihuri Research Institute, Helsinki, Finland
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Vuorio A, Kovanen PT. Statins for Coronary Patients Exposed to Wildfire-Related Air Pollution: An Opportunity to Reduce the Increased Risk of Coronary Events. Can J Cardiol 2023; 39:1278. [PMID: 37343718 DOI: 10.1016/j.cjca.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 06/23/2023] Open
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4
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Kovanen PT, Vuorio A. SARS-CoV-2 reinfection: Adding insult to dysfunctional endothelium in patients with atherosclerotic cardiovascular disease. Atheroscler Plus 2023; 53:1-5. [PMID: 37293388 PMCID: PMC10238112 DOI: 10.1016/j.athplu.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 05/24/2023] [Accepted: 06/02/2023] [Indexed: 06/10/2023]
Abstract
In this short narrative review, we aim at defining the pathophysiological role endothelial dysfunction in the observed COVID-19-associated rise in risk of cardiovascular disease. Variants of the SARS-CoV-2 virus have caused several epidemic waves of COVID-19, and the emergence and rapid spread of new variants and subvariants are likely. Based on a large cohort study, the incidence rate of SARS-CoV-2 reinfection is about 0.66 per 10 000 person-weeks. Both the first infection and reinfection with SARS-CoV-2 increase cardiac event risk, particularly in vulnerable patients with cardiovascular risk factors and the accompanying systemic endothelial dysfunction. By worsening pre-existing endothelial dysfunction, both the first infection and reinfection with ensuing COVID-19 may turn the endothelium procoagulative and prothrombotic, and ultimately lead to local thrombus formation. When occurring in an epicardial coronary artery, the risk of an acute coronary syndrome increases, and when occurring in intramyocardial microvessels, scattered myocardial injuries will ensue, both predisposing the COVID-19 patients to adverse cardiovascular outcomes. In conclusion, considering weakened protection against the cardiovascular risk-enhancing reinfections with emerging new subvariants of SARS-CoV-2, treatment of COVID-19 patients with statins during the illness and thereafter is recommended, partly because the statins tend to reduce endothelial dysfunction.
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Affiliation(s)
| | - Alpo Vuorio
- Mehiläinen, Airport Health Center, Vantaa, Finland
- University of Helsinki, Department of Forensic Medicine, Helsinki, Finland
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5
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Vuorio A, Raal F, Kovanen PT. Familial hypercholesterolemia: The nexus of endothelial dysfunction and lipoprotein metabolism in COVID-19. Curr Opin Lipidol 2023; 34:119-125. [PMID: 36924390 DOI: 10.1097/mol.0000000000000876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
PURPOSE OF REVIEW Patients with heterozygous familial hypercholesterolemia (HeFH) are at increased risk for COVID-19 cardiovascular complications in the acute phase of the infection. Elevated levels of LDL-C and often lipoprotein(a) are present from birth and lead to endothelial dysfunction, which is aggravated by a direct viral attack of the endothelial cells and their exposure to the toxic levels of circulating proinflammatory and prothrombotic mediators during the hyperinflammatory reaction typical of COVID-19. RECENT FINDINGS Evidence to date shows the benefit of lipid-lowering therapy in patients with COVID-19. In HeFH patients who are at much higher cardiovascular risk, the focus should, therefore, be on the effective lowering of LDL-C levels, the root cause of the greater cardiovascular vulnerability to COVID-19 infection in these patients. The ongoing use of statins and other lipid-lowering therapies should be encouraged during the ongoing COVID pandemic to mitigate the risk of cardiovascular complications from COVID-19, particularly in HeFH patients. SUMMARY Epidemiologic registry data show that the incidence of myocardial infarction is increased in SARS-CoV-2-infected HeFH patients. There is a need to study whether the risk for acute cardiovascular events is increased in the long-term and if there are changes in lipid metabolism after SARS-CoV infection(s) in patients with HeFH.
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Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Centre, Vantaa
- Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
| | - Frederick Raal
- Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Petri T Kovanen
- Wihuri Research Institute, Atherosclerosis Research Laboratory, Helsinki, Finland
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Vuorio A, Raal F, Kovanen PT. Drug-drug interaction with oral antivirals for the early treatment of COVID-19. Int J Infect Dis 2023; 127:171-172. [PMID: 36470504 PMCID: PMC9715460 DOI: 10.1016/j.ijid.2022.11.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022] Open
Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Centre, Vantaa, Finland; University of Helsinki, Department of Forensic Medicine, Helsinki, Finland.
| | - Frederick Raal
- Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Vuorio A, Kovanen PT, Raal F. Statin Needs to be Continued During Paxlovid Therapy in COVID-19. Clin Infect Dis 2022; 75:2281-2282. [PMID: 35975652 PMCID: PMC9494321 DOI: 10.1093/cid/ciac667] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 08/12/2022] [Indexed: 01/19/2023] Open
Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Centre, Vantaa, Finland
- Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
| | | | - Frederick Raal
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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8
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Vuorio A, Raal F, Kovanen PT. Familial Hypercholesterolemia Patients with COVID-19—Effective Cholesterol-Lowering Therapy is Urgent both during and after Infection. Rev Cardiovasc Med 2022. [DOI: 10.31083/j.rcm2312410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Abstract
Based on separate protective mechanisms related to lipid metabolism, viral cell entry and inflammation, fibrate treatment might be advantageous among patients who have been taking fibrates before SARS-CoV-2 infection and continue taking them during the infection. Based on published data on hospitalized COVID-19 patients, we recommend that the clinicians should ask their patients with metabolic syndrome who are already taking fibrates to continue fibrate treatment during the COVID-19 illness. This recommendation applies to both outpatients and hospitalized patients. However, results from the ongoing randomized controlled trials (RCTs) using fenofibrate treatment for the prevention or treatment of COVID-19 have yet to prove that fenofibrate is clinically significant for this indication.KEY MESSAGESThe role of fibrates as a repurpose to treat SARS-CoV-2 is under investigation in at least three ongoing RCTs.Obesity, diabetes, hypertension and dyslipidaemia, individually or clustered as a discrete phenotype, the metabolic syndrome, typically associate with a more severe course of COVID-19.Fibrate treatment seems to be most advantageous among patients who have been taken fibrates before SARS-CoV-2 infection and are continuing to take them during the infection.We recommend that the clinicians encourage their patients who are already taking fibrate to continue using the drug throughout the COVID-19 illness.
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Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Centre, Vantaa, Finland.,Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
| | - Jonas Brinck
- Department of Medicine Huddinge (MEDH7), Karolinska Institutet, Endokrinexpeditionerna C2:94, Karolinska Universitetssjukhuset Huddinge, Stockholm, Sweden.,Unit of Endocrinology, Theme Inflammation and Aging, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Petri T Kovanen
- Atherosclerosis Research Laboratory, Wihuri Research Institute, Helsinki, Finland
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Vuorio A, Ramaswami U, Holven KB. Editorial: Genetics of familial hypercholesterolemia: New insight—Volume II. Front Genet 2022; 13:1041342. [DOI: 10.3389/fgene.2022.1041342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
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Vuorio A, Kovanen PT, Raal F. Cholesterol-lowering drugs for high-risk hypercholesterolemia patients with COVID-19 while on Paxlovid™ therapy. Future Virol 2022. [PMID: 35935448 PMCID: PMC9345303 DOI: 10.2217/fvl-2022-0060] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/25/2022] [Indexed: 01/04/2023]
Abstract
Paxlovid™ is a promising antiviral oral medication for patients at a high risk of a severe form of COVID-19. Regarding COVID-19 patients who have hypercholesterolemia and are at high or very high risk for an acute atherothrombotic cardiovascular event, we are highlighting patients with heterozygous familial hypercholesterolemia as an example of severe hypercholesterolemia. Unfortunately, the concomitant use of Paxlovid and a statin, which is highly dependent on cytochrome P4507A (CYP3A) for clearance, may result in significant drug interactions. Since an abrupt withdrawal of statin use may cause serious negative rebound effects on the cardiovascular system, it is essential to continue statin treatment also during the 5-day Paxlovid treatment period. During Paxlovid treatment, simvastatin and lovastatin need to be substituted with another statin, such as pravastatin or fluvastatin, while a reduction of the dose of atorvastatin and rosuvastatin is recommended.
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Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Centre, Vantaa, Finland
- Department of Forensic Medicine, University of Helsinki, Helsinki, 00271, Finland
| | | | - Frederick Raal
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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12
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Vuorio A, Raal F, Kovanen PT. Monkeypox is a global public health emergency: The role of repurposing cholesterol lowering drugs not to be forgotten. J Clin Lipidol 2022; 16:757-758. [PMID: 36153280 PMCID: PMC9528222 DOI: 10.1016/j.jacl.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/16/2022] [Indexed: 11/06/2022]
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Vuorio A, Raal F, Ijäs P, Kaste M, Kovanen PT. Long-Term Cardiovascular and Cerebrovascular Challenges Posed by COVID-19 in Patients With Familial Hypercholesterolemia. Front Pharmacol 2022; 13:890141. [PMID: 35645833 PMCID: PMC9131188 DOI: 10.3389/fphar.2022.890141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Alpo Vuorio
- Mehiläinen, Airport Health Center, Vantaa, Finland.,Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
| | - Frederick Raal
- Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Petra Ijäs
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markku Kaste
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Vuorio A, Bor R. Safety of Health Care Workers in a War Zone-A European Issue. Front Public Health 2022; 10:886394. [PMID: 35433616 PMCID: PMC9005878 DOI: 10.3389/fpubh.2022.886394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/08/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Alpo Vuorio
- Department of Forensic Medicine, University of Helsinki, Helsinki, Finland.,Mehiläinen Airport Health Centre, Vantaa, Finland
| | - Robert Bor
- Centre for Aviation Psychology, London, United Kingdom.,Royal Free Hospital, London, United Kingdom
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15
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Vuorio A, Bekker A, Suhonen-Malm AS, Bor R. Promoting Flight Crew Mental Health Requires International Guidance for Down-Route Quarantine Circumstances. Front Public Health 2022; 10:854262. [PMID: 35309189 PMCID: PMC8931271 DOI: 10.3389/fpubh.2022.854262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/11/2022] [Indexed: 12/04/2022] Open
Affiliation(s)
- Alpo Vuorio
- Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
- Mehiläinen Airport Health Centre, Vantaa, Finland
- *Correspondence: Alpo Vuorio
| | | | | | - Robert Bor
- Centre for Aviation Psychology, London, United Kingdom
- Royal Free Hospital, London, United Kingdom
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16
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Vuorio A, Kovanen PT, Raal F. Opportunities for preventing further endothelial dysfunction in pregnant COVID-19 patients with familial hypercholesterolemia. J Clin Lipidol 2022; 16:356-357. [PMID: 35232697 PMCID: PMC8837469 DOI: 10.1016/j.jacl.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/27/2022] [Accepted: 02/07/2022] [Indexed: 12/04/2022]
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17
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Vuorio A, Budowle B, Kovanen PT. Airborne particles and cardiovascular morbidity in severe inherited hypercholesterolemia: Vulnerable endothelium under multiple attacks. Bioessays 2021; 44:e2100273. [PMID: 34967031 DOI: 10.1002/bies.202100273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 11/07/2022]
Abstract
Despite recent advances in the research related to air pollution and associated adverse cardiovascular events, the combined effects of air pollution, climate change, and SARS-CoV-2 infection on cardiovascular health need to be researched further. This Commentary addresses their impacts on cardiovascular health in the approximately 25 million people with a severe form of inherited hypercholesterolemia, called familial hypercholesterolemia (FH). The arterial endothelium in these individuals is potentially under multiple attacks caused by particles of both endogenous and exogenous origin. Thus, they have a lifelong highly elevated level of circulating low density lipoprotein (LDL) cholesterol which drives premature atherosclerosis. The high levels of LDL particles, often associated with an elevated level of circulating lipoprotein(a) particles, are both capable of inducing and maintaining endothelial dysfunction. Such pre-existing endothelial dysfunction can be exacerbated by exposure to SARS-CoV-2 viral particles, by exposure to fine particulate matter generated by climate change-associated wildfires, and by dehydration during deadly heatwaves linked to the globally rising temperatures. The external factors can severely worsen the pre-existing endothelial dysfunction, and thereby significantly increase the risk of a cardiovascular event in the exposed FH patients.
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Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Centre, Occupational Health Unit, Vantaa, Finland.,Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
| | - Bruce Budowle
- Center for Human Identification, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Petri T Kovanen
- Wihuri Research Institute, Cardiovascular Research Laboratory, Helsinki, Finland
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18
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Vuorio A, Lassila R, Kovanen PT. Hypercholesterolemia and COVID-19: Statins for Lowering the Risk of Venous Thromboembolism. Front Cardiovasc Med 2021; 8:711923. [PMID: 34722654 PMCID: PMC8548371 DOI: 10.3389/fcvm.2021.711923] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/09/2021] [Indexed: 12/22/2022] Open
Affiliation(s)
- Alpo Vuorio
- Department of Forensic Medicine, University of Helsinki, Helsinki, Finland.,Mehiläinen Airport Health Centre, Vantaa, Finland
| | - Riitta Lassila
- Research Program Unit in Systems Oncology, Coagulation Disorders Unit, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Petri T Kovanen
- Wihuri Research Institute, Biomedicum Helsinki 1, Helsinki, Finland
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19
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Affiliation(s)
- Alpo Vuorio
- Department of Forensic Medicine, University of Helsinki, Helsinki, Finland.,Mehiläinen Airport Health Centre, Vantaa, Finland
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20
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Vuorio A, Strandberg TE, Raal F, Santos RD, Kovanen PT. Familial hypercholesterolemia and COVID-19: A menacing but treatable vasculopathic condition. Atheroscler Plus 2021; 43:3-6. [PMID: 34622243 PMCID: PMC8349422 DOI: 10.1016/j.athplu.2021.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/05/2021] [Accepted: 08/05/2021] [Indexed: 01/14/2023]
Abstract
SARS-CoV-2 infection continues to cause increased morbidity and mortality, and due to the slow pace of vaccination COVID-19 will probably remain a global burden to health systems for a long time. Unfortunately, the necessary prevention and treatment strategies of COVID-19 have led to restriction measures that are hampering the routine care of common chronic metabolic conditions like hypercholesterolemia. It is of particular concern that during the acute phase of COVID-19, the control of pre-existing metabolic diseases tends to get worse which again increases the risk for complications and a poor outcome in these patients. A significant contributor to these complications is endothelial dysfunction which is associated with COVID-19. This Commentary will discuss the impact of COVID-19 on endothelial function particularly in patients with familial hypercholesterolemia (FH), a metabolic inherited disease known to in itself adversely affect endothelial function. There should be no hesitation to continue with statin therapy in severe hypercholesterolemic patients with COVID-19. We argue that in FH patients with COVID-19 the clinicians need even consider intensifying statin therapy as well as the addition of other lipid-lowering agents, such as proprotein convertase subtilisin/kexin type 9(PCSK9) inhibitors. In contrast to statins, the PCSK9 inhibitors lower lipoprotein(a) [Lp(a)] level, and, accordingly, these latter drugs need to be considered particularly in FH patients with an elevated level of Lp(a). This call applies to the in-hospital stay and also beyond. When considering that the vasculopathic effects of COVID-19 may persist, a long-term follow-up of individualized therapies in FH patients is warranted.
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Affiliation(s)
- Alpo Vuorio
- Mehiläinen, Airport Health Center, Vantaa, Finland,University of Helsinki, Department of Forensic Medicine, Helsinki, Finland,Corresponding author. University of Helsinki, Department of Forensic Medicine, Helsinki, Finland.
| | - Timo E. Strandberg
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland,University of Oulu, Center for Life Course Health Research, Oulu, Finland
| | - Frederik Raal
- Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Raul D. Santos
- Lipid Clinic Heart Institute (Incor), University of São Paulo, Medical School Hospital, São Paulo, Brazil,Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
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21
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Affiliation(s)
- Alpo Vuorio
- Department of Forensic Medicine, University of Helsinki, Turku, Finland
- Mehiläinen Airport Health Center, Vantaa, Finland
| | - Robert Bor
- Center for Aviation Psychology, London, United Kingdom
- Royal Free Hospital, London, United Kingdom
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22
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Kovanen PT, Raal F, Vuorio A. Patients with familial hypercholesterolemia and COVID-19: Efficient and ongoing cholesterol lowering is paramount for the prevention of acute myocardial infarction. Am J Prev Cardiol 2021; 7:100224. [PMID: 34312613 PMCID: PMC8289723 DOI: 10.1016/j.ajpc.2021.100224] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 07/17/2021] [Indexed: 01/17/2023] Open
Affiliation(s)
- Petri T Kovanen
- Wihuri Research Institute, Biomedicum Helsinki 1, 00290 Helsinki, Finland
| | - Frederick Raal
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alpo Vuorio
- University of Helsinki and Mehiläinen Airport Health Centre, 01530 Vantaa, Finland.,Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
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23
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Vuorio A, Raal F, Klingel R, Kovanen PT. Why continued lipoprotein apheresis is vital for homozygous familial hypercholesterolemia patients with COVID-19. J Clin Lipidol 2021; 15:379-380. [PMID: 34099192 PMCID: PMC8176771 DOI: 10.1016/j.jacl.2021.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 02/22/2021] [Indexed: 01/15/2023]
Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Centre, Vantaa, Finland; Department of Forensic Medicine, University of Helsinki, Helsinki, Finland.
| | - Frederick Raal
- Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany; 1(st) Department of Internal Medicine, University of Mainz, Mainz, Germany
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24
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Vuorio A, Kaste M, Kovanen PT. Familial hypercholesterolemia and statins in the COVID-19 era: Mitigating the risk of ischemic stroke. eNeurologicalSci 2021; 23:100344. [PMID: 33937536 PMCID: PMC8078044 DOI: 10.1016/j.ensci.2021.100344] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/18/2021] [Accepted: 04/25/2021] [Indexed: 02/06/2023] Open
Abstract
There is a continuing need for research about the underlying mechanisms behind ischemic strokes in COVID-19 patients. Pre-existing endothelial dysfunction, especially if it is accompanied by a viral infection of the endothelial cells may present an important mechanism behind the immunothrombotic/thromboembolic complications of the COVID-19 illness. Here we emphasize that pharmacotherapy with statins could partly counteract such pathophysiological scenarios. Accordingly, using familial hypercholesterolemia (FH) as a pertinent example of a lifelong endothelial dysfunction, we aim to make the clinicians and consulting neurologists aware of statins as a possible adjuvant therapy in the context of an increased risk of ischemic stroke in patients with COVID-19. Based on recent clinical evidence, there is a need to encourage clinicians and consulting neurologists to continue or initiate effective statin treatment to prevent an ischemic stroke, particularly when they encounter a hypercholesterolemic COVID-19 patient with FH.
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Affiliation(s)
- Alpo Vuorio
- University of Helsinki, Department of Forensic Medicine, 00014 Helsinki, Finland
- Mehiläinen Airport Health Centre, 01530 Vantaa, Finland
| | - Markku Kaste
- Department of Neurosciences, University of Helsinki, Helsinki, Finland
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Petri T. Kovanen
- Wihuri Research Institute, Biomedicum Helsinki 1, 00290 Helsinki, Finland
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Vuorio A, Kaste M, Kovanen PT. Elevated Lipoprotein(a) and Cerebral Venous Sinus Thrombosis in COVID-19. J Stroke Cerebrovasc Dis 2021; 30:105865. [PMID: 34039523 PMCID: PMC8108374 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/24/2021] [Indexed: 01/23/2023] Open
Affiliation(s)
- Alpo Vuorio
- University of Helsinki, Department of Forensic Medicine, 00014 Helsinki, Finland; Mehiläinen Airport Health Centre, 01530 Vantaa, Finland.
| | - Markku Kaste
- Department of Neurosciences, University of Helsinki, Helsinki, Finland; Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Petri T Kovanen
- Wihuri Research Institute, Biomedicum Helsinki 1, 00290 Helsinki, Finland
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Vuorio A, Ramaswami U, Holven KB. Editorial: Genetics of Familial Hypercholesterolemia: New Insight. Front Genet 2021; 12:669373. [PMID: 34025723 PMCID: PMC8134746 DOI: 10.3389/fgene.2021.669373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 04/07/2021] [Indexed: 12/13/2022] Open
Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Centre, Vantaa, Finland.,Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
| | - Uma Ramaswami
- Lysosomal Disorders Unit, Royal Free London National Health Service Foundation Trust, London, United Kingdom.,Genetics and Genomics Department, University College London, London, United Kingdom
| | - Kirsten B Holven
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Norwegian National Advisory Unit on Familial Hypercholesterolemia, Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Oslo, Norway
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Vuorio A, Kovanen PT. PCSK9 inhibitors for COVID-19: an opportunity to enhance the antiviral action of interferon in patients with hypercholesterolaemia. J Intern Med 2021; 289:749-751. [PMID: 33222314 PMCID: PMC7753347 DOI: 10.1111/joim.13210] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 10/28/2020] [Accepted: 11/18/2020] [Indexed: 12/15/2022]
Affiliation(s)
- A Vuorio
- From the, Mehiläinen Airport Health Centre, Vantaa, Finland.,Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
| | - P T Kovanen
- Wihuri Research Institute, Helsinki, Finland
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28
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Vuorio A, Raal F, Kovanen PT. Hospitalized Children With Familial Hypercholesterolemia and COVID-19: A Case for Preventive Anticoagulation. Front Cardiovasc Med 2021; 8:657719. [PMID: 33959645 PMCID: PMC8093379 DOI: 10.3389/fcvm.2021.657719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 03/25/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Centre, Vantaa, Finland.,Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
| | - Frederick Raal
- Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Petri T Kovanen
- Atherosclerosis Laboratory, Wihuri Research Institute, Helsinki, Finland
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Vuorio A, Kovanen PT, Strandberg TE. Older Familial Hypercholesterolemia Patients with COVID-19. Gerontology 2021; 67:608-610. [PMID: 33735871 DOI: 10.1159/000514447] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/15/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Alpo Vuorio
- Mehiläinen, Airport Health Center, Vantaa, Finland, .,Department of Forensic Medicine, University of Helsinki, Helsinki, Finland,
| | | | - Timo E Strandberg
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Center for Life Course Health Research, University of Oulu, Oulu, Finland
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Vuorio A, Raal F, Kaste M, Kovanen PT. Familial hypercholesterolaemia and COVID-19: A two-hit scenario for endothelial dysfunction amenable to treatment. Atherosclerosis 2021; 320:53-60. [PMID: 33540179 PMCID: PMC7830285 DOI: 10.1016/j.atherosclerosis.2021.01.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/17/2020] [Accepted: 01/20/2021] [Indexed: 02/06/2023]
Abstract
Patients with familial hypercholesterolemia (FH) are likely at increased risk for COVID-19 complications in the acute phase of the infection, and for a long time thereafter. Because in FH patients the level of low density lipoprotein cholesterol (LDL-C) is elevated from birth and it correlates with the degree of systemic endothelial dysfunction, both heterozygous FH (HeFH) patients and, in particular, homozygous FH (HoFH) patients have a dysfunctional endothelium prone to further damage by the direct viral attack and the hyper-inflammatory reaction typical of severe COVID-19. Evidence to date shows the benefit of statin use in patients with COVID-19. In FH patients, the focus should therefore be on the effective lowering of LDL-C levels, the root cause of the expected excess vulnerability to COVID-19 infection in these patients. Moreover, the ongoing use of statins and other lipid-lowering therapies should be encouraged during the COVID pandemic to mitigate the risk of cardiovascular complications from COVID-19. For the reduction of the excess risk in FH patients with COVID-19, we advocate stringent adherence to the guideline determined LDL-C levels for FH patients, or maybe even to lower levels. Unfortunately, epidemiologic data are lacking on the severity of COVID-19 infections, as well as the number of acute cardiac events that have occurred in FH subjects during the COVID-19 pandemic. Such data need to be urgently gathered to learn how much the risk for, and the severity of COVID-19 in FH are increased.
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Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Centre, 01530, Vantaa, Finland; University of Helsinki, Department of Forensic Medicine, 00014, Helsinki, Finland.
| | - Frederick Raal
- Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Markku Kaste
- Department of Neurosciences, Neurology, University of Helsinki, Department of Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland
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Vuorio A, Kovanen PT. Statins as Adjuvant Therapy for COVID-19 to Calm the Stormy Immunothrombosis and Beyond. Front Pharmacol 2021; 11:579548. [PMID: 33542685 PMCID: PMC7851087 DOI: 10.3389/fphar.2020.579548] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 12/04/2020] [Indexed: 12/15/2022] Open
Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Centre, Vantaa, Finland.,Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
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32
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Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Care Centre, Vantaa and University of Helsinki, Helsinki, Finland
| | - Robert Bor
- Centre for Aviation Psychology, Royal Free Hospital, London, United Kingdom
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33
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Vuorio A, Watts GF, Kovanen PT. Familial hypercholesterolaemia and COVID-19: triggering of increased sustained cardiovascular risk. J Intern Med 2020; 287:746-747. [PMID: 32242993 DOI: 10.1111/joim.13070] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 03/30/2020] [Indexed: 12/26/2022]
Affiliation(s)
- Alpo Vuorio
- From the, Mehiläinen Airport Health Centre, Vantaa, Finland.,Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
| | - Gerald F Watts
- Faculty of Medicine and Health Sciences, School of Medicine, University of Western Australia, Perth, WA, Australia.,Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, WA, Australia
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Vuorio A, Watts GF, Schneider WJ, Tsimikas S, Kovanen PT. Familial hypercholesterolemia and elevated lipoprotein(a): double heritable risk and new therapeutic opportunities. J Intern Med 2020; 287:2-18. [PMID: 31858669 DOI: 10.1111/joim.12981] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 06/20/2019] [Indexed: 12/24/2022]
Abstract
There is compelling evidence that the elevated plasma lipoprotein(a) [Lp(a)] levels increase the risk of atherosclerotic cardiovascular disease (ASCVD) in the general population. Like low-density lipoprotein (LDL) particles, Lp(a) particles contain cholesterol and promote atherosclerosis. In addition, Lp(a) particles contain strongly proinflammatory oxidized phospholipids and a unique apoprotein, apo(a), which promotes the growth of an arterial thrombus. At least one in 250 individuals worldwide suffer from the heterozygous form of familial hypercholesterolemia (HeFH), a condition in which LDL-cholesterol (LDL-C) is significantly elevated since birth. FH-causing mutations in the LDL receptor gene demonstrate a clear gene-dosage effect on Lp(a) plasma concentrations and elevated Lp(a) levels are present in 30-50% of patients with HeFH. The cumulative burden of two genetically determined pro-atherogenic lipoproteins, LDL and Lp(a), is a potent driver of ASCVD in HeFH patients. Statins are the cornerstone of treatment of HeFH, but they do not lower the plasma concentrations of Lp(a). Emerging therapies effectively lower Lp(a) by as much as 90% using RNA-based approaches that target the transcriptional product of the LPA gene. We are now approaching the dawn of an era, in which permanent and significant lowering of the high cholesterol burden of HeFH patients can be achieved. If outcome trials of novel Lp(a)-lowering therapies prove to be safe and cost-effective, they will provide additional risk reduction needed to effectively treat HeFH and potentially lower the CVD risk in these high-risk patients even more than currently achieved with LDL-C lowering alone.
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Affiliation(s)
- A Vuorio
- From the, Mehiläinen Airport Health Centre, Vantaa, Finland.,Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
| | - G F Watts
- School of Medicine, Faculty of Medicine and Health Sciences, University of Western Australia, Perth, Australia.,Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, Australia
| | - W J Schneider
- Department of Medical Biochemistry, Max F. Perutz Laboratories, Medical University of Vienna, Vienna, Austria
| | - S Tsimikas
- Vascular Medicine Program, Sulpizio Cardiovascular Center, Division of Cardiovascular Medicine, University of California, San Diego, CA, USA
| | - P T Kovanen
- Wihuri Research Institute, Helsinki, Finland
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Abstract
BACKGROUND Familial hypercholesterolemia is one of the most common inherited metabolic diseases and is an autosomal dominant disorder meaning heterozygotes, or carriers, are affected. Those who are homozygous have severe disease. The average worldwide prevalence of heterozygous familial hypercholesterolemia is at least 1 in 500, although recent genetic epidemiological data from Denmark and next generation sequencing data suggest the frequency may be closer to 1 in 250. Diagnosis of familial hypercholesterolemia in children is based on elevated total cholesterol and low-density lipoprotein cholesterol levels or DNA-based analysis, or both. Coronary atherosclerosis has been detected in men with heterozygous familial hypercholesterolemia as young as 17 years old and in women with heterozygous familial hypercholesterolemia at 25 years old. Since the clinical complications of atherosclerosis occur prematurely, especially in men, lifelong treatment, started in childhood, is needed to reduce the risk of cardiovascular disease. In children with the disease, diet was the cornerstone of treatment but the addition of lipid-lowering medications has resulted in a significant improvement in treatment. Anion exchange resins, such as cholestyramine and colestipol, were found to be effective, but they are poorly tolerated. Since the 1990s studies carried out on children aged 6 to 17 years with heterozygous familial hypercholesterolemia have demonstrated significant reductions in their serum total and low-density lipoprotein cholesterol levels. While statins seem to be safe and well-tolerated in children, their long-term safety in this age group is not firmly established. This is an update of a previously published version of this Cochane Review. OBJECTIVES To assess the effectiveness and safety of statins in children with heterozygous familial hypercholesterolemia. SEARCH METHODS Relevant studies were identified from the Group's Inborn Errors and Metabolism Trials Register and Medline. Date of most recent search: 04 November 2019. SELECTION CRITERIA Randomized and controlled clinical studies including participants up to 18 years old, comparing a statin to placebo or to diet alone. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for inclusion and extracted data. MAIN RESULTS We found 26 potentially eligible studies, of which we included nine randomized placebo-controlled studies (1177 participants). In general, the intervention and follow-up time was short (median 24 weeks; range from six weeks to two years). Statins reduced the mean low-density lipoprotein cholesterol concentration at all time points (high-quality evidence). There may be little or no difference in liver function (serum aspartate and alanine aminotransferase, as well as creatinine kinase concentrations) between treated and placebo groups at any time point (low-quality evidence). There may be little or no difference in myopathy (as measured in change in creatinine levels) (low-quality evidence) or clinical adverse events (moderate-quality evidence) with statins compared to placebo. One study on simvastatin showed that this may slightly improve flow-mediated dilatation of the brachial artery (low-quality evidence), and on pravastatin for two years may have induced a regression in carotid intima media thickness (low-quality evidence). No studies reported rhabdomyolysis (degeneration of skeletal muscle tissue) or death due to rhabdomyolysis, quality of life or compliance to study medication. AUTHORS' CONCLUSIONS Statin treatment is an effective lipid-lowering therapy in children with familial hypercholesterolemia. Few or no safety issues were identified. Statin treatment seems to be safe in the short term, but long-term safety remains unknown. Children treated with statins should be carefully monitored and followed up by their pediatricians and their care transferred to an adult lipidologist once they reach 18 years of age. Large long-term randomized controlled trials are needed to establish the long-term safety issues of statins.
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Affiliation(s)
- Alpo Vuorio
- University of HelsinkiDepartment of Forensic MedicineHelsinkiFinland
| | | | - Petri T Kovanen
- Wihuri Research InstituteKalliolinnatie 4HelsinkiFinlandFIN‐00140
| | - Steve E Humphries
- BHF Laboratories, Royal Free and University College Medical SchoolCenter for Cardiovascular GeneticsThe Rayne Institute5 University StreetLondonUKWC1E 6JJ
| | - Serena Tonstad
- Ullevål University HospitalDept. of Preventive CardiologyOlsoNorway
| | - Albert Wiegman
- Academic Medical CenterDepartment of PediatricsMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Euridiki Drogari
- National and Kapodistrian University of Athens, Medical SchoolUnit of Metabolic Disorders, First Department of PediatricsAthensGreece
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Vuorio A, Watts GF, Kovanen PT. Lipoprotein(a) as a risk factor for calcific aortic valvulopathy in heterozygous familial hypercholesterolemia. Atherosclerosis 2019; 281:25-30. [DOI: 10.1016/j.atherosclerosis.2018.11.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 11/17/2018] [Accepted: 11/28/2018] [Indexed: 12/24/2022]
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37
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Vuorio A, Kovanen PT. Decreasing the Cholesterol Burden in Heterozygous Familial Hypercholesterolemia Children by Dietary Plant Stanol Esters. Nutrients 2018; 10:nu10121842. [PMID: 30513705 PMCID: PMC6315790 DOI: 10.3390/nu10121842] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 11/20/2018] [Accepted: 11/21/2018] [Indexed: 11/16/2022] Open
Abstract
This review covers the current knowledge about plant stanol esters as a dietary treatment option for heterozygous familial hypercholesterolemia (he-FH) children. The current estimation of the prevalence of he-FH is about one out of 200–250 persons. In this autosomal dominant disease, the concentration of plasma low-density lipoprotein cholesterol (LDL-C) is strongly elevated since birth. Quantitative coronary angiography among he-FH patients has revealed that stenosing atherosclerotic plaques start to develop in he-FH males in their twenties and in he-FH females in their thirties, and that the magnitude of the plaque burden predicts future coronary events. The cumulative exposure of coronary arteries to the lifelong LDL-C elevation can be estimated by calculating the LDL-C burden (LDL-C level × years), and it can also be used to demonstrate the usefulness of dietary stanol ester treatment. Thus, when compared with untreated he-FH patients, the LDL-C burden of using statin from the age of 10 is 15% less, and if he-FH patients starts to use dietary stanol from six years onwards and a combination of statin and dietary stanol from 10 years onwards, the LDL-C burden is 21% less compared to non-treated he-FH patients. We consider dietary stanol treatment of he-FH children as a part of the LDL-C-lowering treatment package as safe and cost-effective, and particularly applicable for the family-centered care of the entire he-FH families.
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Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Centre, 01530 Vantaa, Finland.
- Department of Forensic Medicine, University of Helsinki, 00014 Helsinki, Finland.
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38
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Vuorio A, Laukkala T, Junttila I, Bor R, Budowle B, Pukkala E, Navathe P, Sajantila A. Aircraft-Assisted Pilot Suicides in the General Aviation Increased for One-Year Period after 11 September 2001 Attack in the United States. Int J Environ Res Public Health 2018; 15:ijerph15112525. [PMID: 30424489 PMCID: PMC6266333 DOI: 10.3390/ijerph15112525] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/15/2018] [Accepted: 11/06/2018] [Indexed: 11/16/2022]
Abstract
Pilot aircraft-assisted suicides (AAS) are rare, and there is limited understanding of copycat phenomenon among aviators. The aim of this study was to evaluate the possible effect the 11 September 2001, terrorist attacks had on pilot AASs in the U.S. Fatal aviation accidents in the National Transportation Safety Board (NTSB) database were searched using the following search words: “suicide”, “murder-suicide” and “homicide-suicide”. The timeline between 11 September 1996, and 11 September 2004, was analyzed. Only those accidents in which NTSB judged that the cause of the accident was suicide were included in the final analysis. The relative risk (RR) of the pilot AASs in all fatal accidents in the U.S. was calculated in order to compare the one, two, and three-year periods after the September 11 terrorist attacks with five years preceding the event. The RR of a fatal general aviation aircraft accident being due to pilot suicide was 3.68-fold (95% confidence interval 1.04–12.98) during the first year after 11 September 2001, but there was not a statistically significant increase in the later years. This study showed an association, albeit not determinate causal effect, of a very specific series of simultaneous terrorist murder-suicides with subsequent pilot AASs.
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Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Centre, 01530 Vantaa, Finland.
- Department of Forensic Medicine, University of Helsinki, 00014 Helsinki, Finland.
| | - Tanja Laukkala
- Mehiläinen Kielotie Health Centre, 01300 Vantaa, Finland.
| | - Ilkka Junttila
- Faculty of Medicine and Life Sciences, University of Tampere, Finland and Fimlab Laboratories, 33014 Tampere, Finland.
| | - Robert Bor
- Royal Free Hospital, Pond Street, London NW3 2QG, UK.
- Centre for Aviation Psychology, London NW3 1ND, UK.
| | - Bruce Budowle
- Center for Human Identification, University of North Texas Health Science Center, 3500 Camp, Bowie Blvd, Fort Worth, TX 76107, USA.
| | - Eero Pukkala
- Faculty of Social Sciences, University of Tampere, 33014 Tampere, Finland.
| | | | - Antti Sajantila
- Department of Forensic Medicine, University of Helsinki, 00014 Helsinki, Finland.
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Kontula K, Ylikorkala A, Miettinen H, Vuorio A, Kauppinen-Mäkelin R, Hämäläinen L, Palomäki H, Kaste M. Arg506GIn Factor V Mutation (Factor V Leiden) in Patients with Ischaemic Cerebrovascular Disease and Survivors of Myocardial Infarction. Thromb Haemost 2018. [DOI: 10.1055/s-0038-1653820] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
SummaryThe point mutation Arg506->Gln of factor V was recently shown to be an important and relatively common genetic cause of venous thromboembolism. Using a DNA technique based on polymerase chain reaction, we surveyed the blood samples of 236 patients with ischaemic stroke or a transient ischaemic attack, 122 survivors of myocardial infarction and 137 control subjects for the presence of this mutation. Although the frequency of the factor V mutation in patients with arterial disease (4.5%) was not significantly different from that in healthy blood donors (2.9%), a carrier status for this mutant gene was associated with symptoms of migraine and relatively mild angiographic abnormalities among patients with cerebrovascular disease. A more extensive study addressing the occurrence and significance of the mutant factor V mutation in patients with vasospastic cerebrovascular diseases seems to be warranted.
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Affiliation(s)
- Kimmo Kontula
- The Second Department of Medicine, University of Helsinki, Helsinki, Finland
| | - Antti Ylikorkala
- Institute of Biotechnology, University of Helsinki, Helsinki, Finland
| | - Helena Miettinen
- Institute of Biotechnology, University of Helsinki, Helsinki, Finland
| | - Alpo Vuorio
- Institute of Biotechnology, University of Helsinki, Helsinki, Finland
| | | | | | - Heikki Palomäki
- Department of Neurology, University of Helsinki, Helsinki, Finland
| | - Markku Kaste
- Department of Neurology, University of Helsinki, Helsinki, Finland
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40
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Junttila IS, Vuorio A, Budowle B, Laukkala T, Sajantila A. Challenges in investigation of diabetes-related aviation fatalities-an analysis of 1491 subsequent aviation fatalities in USA during 2011-2016. Int J Legal Med 2018; 132:1713-1718. [PMID: 29974235 DOI: 10.1007/s00414-018-1879-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 06/15/2018] [Indexed: 11/25/2022]
Abstract
Diabetes mellitus (DM) could cause pilot incapacitation and result in aviation fatalities. The mechanisms could be directly as a consequence of acute hypoglycemia/subacute diabetic ketoacidosis (DKA) or indirectly as an acute cardiovascular event by contributing to the development of atherosclerosis in coronary or carotid and cerebral arteries. In this study, DM-related fatal flight accidents in the US National Transport Bureau's database between years 2011-2016 were analyzed with special emphasis on postmortem (PM) glucose levels and correlation of toxicological reports with anamnestic information on DM. Additionally, autopsy results on coronary arteries were reviewed. In 43 out of 1491 (~ 3%) fatal accidents pilots had DM. Postmortem glucose or glycated hemoglobin percentage (Hb1Ac) was measured in 12 of the 43 cases; while antidiabetic medication was found in 14 of the cases (only two of the cases had both glucose measurements and medication). With the increasing prevalence of DM, a possibility of pilot incapacitation due to DM or complications of DM should be actively studied, even if no anamnestic information of DM was available. While PM hypoglycemia is difficult to assess, we propose a systematic investigation based on measurement of glucose, Hb1Ac%, and ketone bodies, and documentation of atherosclerotic lesions in major arteries to identify or rule out DM as a cause of pilot incapacitation.
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Affiliation(s)
- Ilkka S Junttila
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Fimlab Laboratories, Tampere, Finland
| | - Alpo Vuorio
- Mehiläinen Airport Health Centre, Vantaa, Finland.,Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
| | - Bruce Budowle
- Center for Human Identification, University of North Texas Health Science Center, 3500 Camp, Bowie Blvd., Fort Worth, TX, 76107, USA
| | | | - Antti Sajantila
- Department of Forensic Medicine, University of Helsinki, Helsinki, Finland.
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41
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Laukkala T, Vuorio A, Bor R, Budowle B, Navathe P, Pukkala E, Sajantila A. Copycats in Pilot Aircraft-Assisted Suicides after the Germanwings Incident. Int J Environ Res Public Health 2018. [PMID: 29534475 PMCID: PMC5877036 DOI: 10.3390/ijerph15030491] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Aircraft-assisted pilot suicide is a rare but serious phenomenon. The aim of this study was to evaluate changes in pilot aircraft-assisted suicide risks, i.e., a copycat effect, in the U.S. and Germany after the Germanwings 2015 incident in the French Alps. Aircraft-assisted pilot suicides were searched in the U.S. National Transportation Safety Board (NTSB) accident investigation database and in the German Bundestelle für Flugunfalluntersuchung (BFU) Reports of Investigation database five years before and two years after the deliberate crash of the Germanwings flight into the French Alps in 2015. The relative risk (RR) of the aircraft-assisted pilot suicides was calculated. Two years after the incident, three out of 454 (0.66%) fatal incidents were aircraft-assisted suicides compared with six out of 1292 (0.46%) in the prior five years in the NTSB database. There were no aircraft-assisted pilot suicides in the German database during the two years after or five years prior to the Germanwings crash. The relative aircraft-assisted pilot suicide risk for the U.S. was 1.4 (95% CI 0.3–4.2) which was not statistically significant. Six of the pilots who died by suicide had told someone of their suicidal intentions. We consider changes in the rate to be within a normal variation. Responsible media coverage of aircraft incidents is important due to the large amount of publicity that these events attract.
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Affiliation(s)
- Tanja Laukkala
- Mehiläinen Kielotie Health Centre, Vantaa 01300, Finland.
| | - Alpo Vuorio
- Department of Forensic Medicine, University of Helsinki and Mehiläinen Airport Health Centre, Lentäjäntie 1 E, 01530 Vantaa, Finland.
| | - Robert Bor
- Royal Free Hospital, Pond Street, London NW3 2QG, UK.
- Centre for Aviation Psychology, London NW3 1ND, UK.
| | - Bruce Budowle
- Center for Human Identification, University of North Texas Health Science Center, 3500 Camp Bowie Blvd., Fort Worth, TX 76107, USA.
- Center of Excellence in Genomic Medicine Research (CEGMR), King Abdulaziz University, Jeddah 21577, Saudi Arabia.
| | | | - Eero Pukkala
- Faculty of Social Sciences, University of Tampere, 33100 Tampere, Finland.
| | - Antti Sajantila
- Department of Forensic Medicine, University of Helsinki, 00014 Helsinki, Finland.
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Vuorio A, Watts GF, Kovanen PT. Depicting new pharmacological strategies for familial hypercholesterolaemia involving lipoprotein (a). Eur Heart J 2017; 38:3555-3559. [DOI: 10.1093/eurheartj/ehx546] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 09/04/2017] [Indexed: 01/17/2023] Open
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Laukkala T, Bor R, Budowle B, Sajantila A, Navathe P, Sainio M, Vuorio A. Attention-Deficit/Hyperactivity Disorder and Fatal Accidents in Aviation Medicine. Aerosp Med Hum Perform 2017; 88:871-875. [PMID: 28818147 DOI: 10.3357/amhp.4919.2017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder with symptoms of inattention and/or hyperactivity-impulsivity that interfere with functioning and/or development. ADHD occurs in about 2.5% of adults. ADHD can be an excluding medical condition among pilots due to the risk of attentional degradation and therefore impact on flight safety. Diagnosis of ADHD is complex, which complicates aeromedical assessment. This study highlights fatal accident cases among pilots with ADHD and discusses protocols to detect its presence to help to assess its importance to flight safety. METHODS To identify fatal accidents in aviation (including airplanes, helicopters, balloons, and gliders) in the United States between the years 2000 to 2015, the National Transportation Safety Board (NTSB) database was searched with the terms ADHD, attention deficit hyperactivity disorder, and attention deficit disorder (ADD). RESULTS The NTSB database search for fatal aviation accidents possibly associated with ADHD yielded four accident cases of interest in the United States [4/4894 (0.08%)]. Two of the pilots had ADHD diagnosed by a doctor, one was reported by a family member, and one by a flight instructor. An additional five cases were identified searching for ADD [5/4894 (0.1%)]. Altogether, combined ADHD and ADD cases yielded nine accident cases of interest (0.18%). DISCUSSION It is generally accepted by aviation regulatory authorities that ADHD is a disqualifying neurological condition. Yet FAA and CASA provide specific protocols for tailor-made pilot assessment. Accurate evaluation of ADHD is essential because of its potential negative impact on aviation safety.Laukkala T, Bor R, Budowle B, Sajantila A, Navathe P, Sainio M, Vuorio A. Attention-deficit/hyperactivity disorder and fatal accidents in aviation medicine. Aerosp Med Hum Perform. 2017; 88(9):871-875.
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Abstract
BACKGROUND Familial hypercholesterolemia is one of the most common inherited metabolic diseases and is an autosomal dominant disorder meaning heterozygotes, or carriers, are affected. Those who are homozygous have severe disease. The average worldwide prevalence of heterozygous familial hypercholesterolemia is at least 1 in 500, although recent genetic epidemiological data from Denmark and next generation sequencing data suggest the frequency may be closer to 1 in 250. Diagnosis of familial hypercholesterolemia in children is based on elevated total cholesterol and low-density lipoprotein cholesterol levels or DNA-based analysis, or both. Coronary atherosclerosis has been detected in men with heterozygous familial hypercholesterolemia as young as 17 years old and in women with heterozygous familial hypercholesterolemia at 25 years old. Since the clinical complications of atherosclerosis occur prematurely, especially in men, lifelong treatment, started in childhood, is needed to reduce the risk of cardiovascular disease. In children with the disease, diet was the cornerstone of treatment but the addition of lipid-lowering medications has resulted in a significant improvement in treatment. Anion exchange resins, such as cholestyramine and colestipol, were found to be effective, but they are poorly tolerated. Since the 1990s studies carried out on children aged 6 to 17 years with heterozygous familial hypercholesterolemia have demonstrated significant reductions in their serum total and low-density lipoprotein cholesterol levels. While statins seem to be safe and well-tolerated in children, their long-term safety in this age group is not firmly established. This is an update of a previously published version of this Cochane Review. OBJECTIVES To assess the effectiveness and safety of statins in children with heterozygous familial hypercholesterolemia. SEARCH METHODS Relevant studies were identified from the Group's Inborn Errors and Metabolism Trials Register and Medline.Date of most recent search: 20 February 2017. SELECTION CRITERIA Randomized and controlled clinical studies including participants up to 18 years old, comparing a statin to placebo or to diet alone. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for inclusion and extracted data. MAIN RESULTS We found 26 potentially eligible studies, of which we included nine randomized placebo-controlled studies (1177 participants). In general, the intervention and follow-up time was short (median 24 weeks; range from six weeks to two years). Statins reduced the mean low-density lipoprotein cholesterol concentration at all time points (moderate quality evidence). Serum aspartate and alanine aminotransferase, as well as creatinine kinase concentrations, did not differ between treated and placebo groups at any time point (low quality evidence). The risks of myopathy (low quality evidence) and clinical adverse events (moderate quality evidence) were very low and also similar in both groups. In one study simvastatin was shown to improve flow-mediated dilatation of the brachial artery (low quality evidence), and in another study treatment with pravastatin for two years induced a significant regression in carotid intima media thickness (low quality evidence). AUTHORS' CONCLUSIONS Statin treatment is an effective lipid-lowering therapy in children with familial hypercholesterolemia. No significant safety issues were identified. Statin treatment seems to be safe in the short term, but long-term safety remains unknown. Children treated with statins should be carefully monitored and followed up by their pediatricians and their care transferred to an adult lipidologist once they reach 18 years of age. Large long-term randomized controlled trials are needed to establish the long-term safety issues of statins.
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Affiliation(s)
- Alpo Vuorio
- Vantaa and Finnish Institute of Occupational HealthMehiläinen Airport Health CentreLappeenrantaFinland
| | | | - Petri T Kovanen
- Wihuri Research InstituteKalliolinnatie 4HelsinkiFinlandFIN‐00140
| | - Steve E Humphries
- BHF Laboratories, Royal Free and University College Medical SchoolCenter for Cardiovascular GeneticsThe Rayne Institute5 University StreetLondonUKWC1E 6JJ
| | - Serena Tonstad
- Ullevål University HospitalDept. of Preventive CardiologyOlsoNorway
| | - Albert Wiegman
- Academic Medical CenterDepartment of PediatricsMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Euridiki Drogari
- National and Kapodistrian University of Athens, Medical SchoolUnit of Metabolic Disorders, First Department of PediatricsAthensGreece
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Vuorio A, Asmayawati S, Budowle B, Griffiths R, Strandberg T, Kuoppala J, Sajantila A. General Aviation Pilots Over 70 Years Old. Aerosp Med Hum Perform 2017; 88:142-145. [PMID: 28095959 DOI: 10.3357/amhp.4717.2017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Currently it is not unusual for general aviation pilots in the United States to continue to fly beyond the age of 70, even into their 80s and 90s. Pilots have regular examinations according to protocols which do not specify special or additional requirements for pilots over 70 yr of age. Additionally, the third class medical reforms passed by the U.S. Senate on 15 July 2016 could potentially result in even less stringent medical certification requirements for general aviation pilots. METHODS Accident rates, medical parameters, autopsy findings, and toxicological findings from the U.S. National Transportation Safety Board (NTSB) general aviation (GA) accident database were analyzed to assess potential risk factors with accident outcomes. RESULTS During 2003-2012, there were 114 (113 men, 1 woman) general aviation fatal accidents involving pilots ages 70 to 92 yr. A combination of 3 or more drugs were found in 13 (13%) of deceased pilots. The most frequent drugs were first generation antihistamines and antidepressants represented the next highest proportion of possible performance-affecting medications. CONCLUSION This study indicates that there are critical medical factors that may contribute to fatal accidents among elderly pilots. Polypharmacy use should be taken into consideration, especially during periodic health examinations and fatal aviation investigations involving elderly pilots.Vuorio A, Asmayawati S, Budowle B, Griffiths R, Strandberg T, Kuoppala J, Sajantila A. General aviation pilots over 70 years old. Aerosp Med Hum Perform. 2017; 88(2):142-145.
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Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Centre, Vantaa, Finland
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Abstract
BACKGROUND One of the most difficult challenges in aviation medicine is to diagnose, as early as possible, pilots with psychiatric disorders that may impair pilot performance and increase the risk of incidents and accidents. This diagnosis applies particularly to bipolar disorder (BD), where return to flying duty is not an option in the majority of cases. BD is a long-term mental disorder presenting remittent depressive, hypomanic, manic, or mixed episodes between low symptomatic or asymptomatic intermediate periods. Onset in most cases is in late teen or early adult years. Suicidal intentions and suicide risk are significantly elevated in individuals with BD compared to the general population. METHODS A systematic literature search was performed of BD and aviation accidents and the National Transportation Safety Board database of fatal general aviation accidents was searched. One case report and two database reports of interest from 1994 to 2014 were identified. RESULTS The findings set a minimum frequency of BD in general aviation fatalities to be approximately 2 out of 8648 (0.023%) in the United States. DISCUSSION The reported incidence may underestimate the real number of BD cases for several reasons, including the fact that the medical history of pilots is not always available or is sometimes not the primary interest of a safety investigation. This study suggests that the demarcation of psychiatric disorder related to fitness to fly is an important step in safety.Vuorio A, Laukkala T, Navathe P, Budowle B, Bor R, Sajantila A. Bipolar disorder in aviation medicine. Aerosp Med Hum Perform. 2017; 88(1):42-47.
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Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Centre, Vantaa, Finland
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Vuorio A, Strandberg TE, Schneider WJ, Kovanen PT. Response to Dr. Gerald M Reaven: good news for patients with familial hypercholesterolaemia: statins are not diabetogenic in this disease. J Intern Med 2016; 280:419-20. [PMID: 27451964 DOI: 10.1111/joim.12536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- A Vuorio
- Mehiläinen Airport Health Centre, Vantaa, Finland.
| | - T E Strandberg
- Geriatrics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - W J Schneider
- Department of Medical Biochemistry, Medical University of Vienna, Vienna, Austria
| | - P T Kovanen
- Wihuri Research Institute, Helsinki, Finland
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Vuorio A, Watts GF, Kovanen PT. Rescue therapy with PCSK9 inhibitors for patients with delayed diagnosis of heterozygous familial hypercholesterolemia: Redressing the balance of missed opportunities. J Clin Lipidol 2016; 10:1278-9. [DOI: 10.1016/j.jacl.2016.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 07/04/2016] [Accepted: 07/09/2016] [Indexed: 10/21/2022]
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Vuorio A, Strandberg TE, Schneider WJ, Kovanen PT. Statins and new-onset diabetes mellitus - a risk lacking in familial hypercholesterolaemia. J Intern Med 2016; 279:358-61. [PMID: 26260225 DOI: 10.1111/joim.12405] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- A Vuorio
- Mehiläinen Airport Health Centre, Vantaa, Finland
| | - T E Strandberg
- Geriatrics, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland.,Institute of Health Sciences/Geriatrics, University of Oulu, Oulu, Finland
| | - W J Schneider
- Department of Medical Biochemistry, Medical University of Vienna, Vienna, Austria
| | - P T Kovanen
- Wihuri Research Institute, Helsinki, Finland
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Vuorio A, Watts GF, Kovanen PT. Initiation of PCSK9 inhibition in patients with heterozygous familial hypercholesterolaemia entering adulthood: a new design for living with a high-risk condition? Eur Heart J 2016; 37:1353-6. [PMID: 26851704 DOI: 10.1093/eurheartj/ehw010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 01/11/2016] [Indexed: 01/12/2023] Open
Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Center, Lentäjäntie 1 E, Vantaa 00150, Finland
| | - Gerald F Watts
- Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, School of Medicine and Pharmacology, University of Western Australia, Crawley, Australia
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