Dyslipidaemia, diet and drugs

When considering dyslipidaemia, the cardiologist’s predominant concern is the relationship between serum low density lipoprotein cholesterol (LDLc) and the development of atherosclerotic cardiovascular disease (ASCVD). However, ASCVD is a multifactorial condition with its roots in our physical environment, the lifestyle we choose, our exposure to tobacco smoke, the diet to which we have become accustomed from a young age, the presence of specific morbidities: hypertension, diabetes, adiposity and elevated cholesterol levels, male sex and individual genetic propensities. Frequently these risk factors are found clustering in susceptible individuals. They ultimately find their expression as ASCVD and its complications as we age. Accepting the complexity of its origins, it is unsurprising that a multifaceted approach to the prevention of ASCVD, or its containment once it has emerged, is mandatory

Foundations of the South African Heart Association: The South African Society of Cardiac Practitioners 1985 - 1999

The South African Heart Association (SA Heart®) was established in 1999. Prior to 1999, 2 professional societies represented the interests of cardiologists and cardiac surgeons in South Africa – the South African Cardiac Society and the South African Society of Cardiac Practitioners. The latter was formed in 1985 by cardiologists in private practice to serve the interests of private practitioners. At the time, the South African Cardiac Society was based mainly in the academic training institutions and the need arose to have a representative body addressing the needs of private practice.In the late 1990s it became clear that the 2 societies were competing for the same support from industry and were diluting each other’s influence. The realisation that strength lay in unity led to an amalgamation of the 2 societies in 1999 – to form the SA Heart® Association.In this commentary, Dr Tony Dalby provides us with a personal reflection of the history of the South African Society of Cardiac Practitioners. In future issues of the SA Heart® Journal, we will feature similar personal reflections to document the history of the South African Cardiac Society and the South African Heart Association

Statin-induced Myopathy

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death worldwide. HMGCoA reductase inhibitors or “statins” reduce low density lipoprotein cholesterol and reduce the risks of myocardial infarction, stroke and death in the presence of dyslipidaemia. In consequence, statins are prescribed to a large number of patients requiring primary or secondary prevention. A variety of side-effects may arise during the course of statin treatment which interfere with the quality of patients’ lives and reduce their compliance with therapy. Muscle symptoms constitute the most common of these side-effects and are the most frequent reason for discontinuing treatment. This review defi nes the muscle, tendon and joint disorders encountered by patients on statin treatment, their possible relationship to statin use, and the factors that facilitate the emergence of symptoms. The subtypes of statin myopathy are discussed and a general defi nition of statin myopathy is offered. Expert advice on managing statin myopathy is summarised

Warfarin in non-valvular atrial fibrillation

The development of novel oral anticoagulants that are effective alternatives to warfarin in non-valvular atrial fibrillation (AF) is a welcome advance. However, a variety of unresolved problems with their use, and not least with their cost, make it important to re-evaluate the use of warfarin as it will likely remain the anticoagulant of choice in South African patients with non-valvular AF for the foreseeable future. In this article, we review the correct clinical use of warfarin. Guidance is provided on commencing warfarin treatment, maintenance dosing, the recommended steps when temporary withdrawal of treatment is necessary, the management of bleeding, and the use of warfarin in chronic kidney disease. Techniques for changing from warfarin to one of the new oral anticoagulants and vice versa are included

Different types of soluble fermentable dietary fibre decrease food intake, body weight gain and adiposity in young adult male rats

We thank Donna Wallace and the Rowett Animal House staff for the daily care of experimental rats, body weight and food intake measurements and MRI scanning, Vivien Buchan and Donna Henderson of the Rowett Analytical Department for proximate analyses and SCFA GC, and Andrew Chappell for conducting the beta-glucan analysis. This research was funded by the Scottish Government’s Rural and Environment Science and Analytical Services Division.Peer reviewedPublisher PD

Warfarin in non-valvular atrial fibrillation

The development of novel oral anticoagulants that are effective alternatives to warfarin in non-valvular atrial fibrillation (AF) is a welcome advance. However, a variety of unresolved problems with their use, and not least with their cost, make it important to re-evaluate the use of warfarin as it will likely remain the anticoagulant of choice in South African patients with non-valvular AF for the foreseeable future. In this article, we review the correct clinical use of warfarin. Guidance is provided on commencing warfarin treatment, maintenance dosing, the recommended steps when temporary withdrawal of treatment is necessary, the management of bleeding, and the use of warfarin in chronic kidney disease. Techniques for changing from warfarin to one of the new oral anticoagulants and vice versa are included.

Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and Multivessel Disease

BACKGROUND: The optimal management of patients found to have multivessel disease while undergoing primary percutaneous coronary intervention (P-PCI) for ST-segment elevation myocardial infarction is uncertain.   OBJECTIVES: CvLPRIT (Complete versus Lesion-only Primary PCI trial) is a U.K. open-label randomized study comparing complete revascularization at index admission with treatment of the infarct-related artery (IRA) only.   METHODS: After they provided verbal assent and underwent coronary angiography, 296 patients in 7 U.K. centers were randomized through an interactive voice-response program to either in-hospital complete revascularization (n = 150) or IRA-only revascularization (n = 146). Complete revascularization was performed either at the time of P-PCI or before hospital discharge. Randomization was stratified by infarct location (anterior/nonanterior) and symptom onset (≤3 h or >3 h). The primary endpoint was a composite of all-cause death, recurrent myocardial infarction (MI), heart failure, and ischemia-driven revascularization within 12 months.   RESULTS: Patient groups were well matched for baseline clinical characteristics. The primary endpoint occurred in 10.0% of the complete revascularization group versus 21.2% in the IRA-only revascularization group (hazard ratio: 0.45; 95% confidence interval: 0.24 to 0.84; p = 0.009). A trend toward benefit was seen early after complete revascularization (p = 0.055 at 30 days). Although there was no significant reduction in death or MI, a nonsignificant reduction in all primary endpoint components was seen. There was no reduction in ischemic burden on myocardial perfusion scintigraphy or in the safety endpoints of major bleeding, contrast-induced nephropathy, or stroke between the groups.   CONCLUSIONS: In patients presenting for P-PCI with multivessel disease, index admission complete revascularization significantly lowered the rate of the composite primary endpoint at 12 months compared with treating only the IRA. In such patients, inpatient total revascularization may be considered, but larger clinical trials are required to confirm this result and specifically address whether this strategy is associated with improved survival. (Complete Versus Lesion-only Primary PCI Pilot Study [CvLPRIT]; ISRCTN70913605)

Vorapaxar in Patients With Diabetes Mellitus and Previous Myocardial Infarction: Findings From the Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events-TIMI 50 Trial

Background— Vorapaxar reduces cardiovascular death, myocardial infarction (MI), or stroke in patients with previous MI while increasing bleeding. Patients with diabetes mellitus (DM) are at high risk of recurrent thrombotic events despite standard therapy and may derive particular benefit from antithrombotic therapies. The Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events-TIMI 50 trial was a randomized, double-blind, placebo-controlled trial of vorapaxar in patients with stable atherosclerosis. Methods and Results— We examined the efficacy of vorapaxar in patients with and without DM who qualified for the trial with a previous MI. Because vorapaxar is contraindicated in patients with a history of stroke or transient ischemic attack, the analysis (n=16 896) excluded such patients. The primary end point of cardiovascular death, MI, or stroke occurred more frequently in patients with DM than in patients without DM (rates in placebo group: 14.3% versus 7.6%; adjusted hazard ratio, 1.47; P<0.001). In patients with DM (n=3623), vorapaxar significantly reduced the primary end point (11.4% versus 14.3%; hazard ratio, 0.73 [95% confidence interval, 0.60–0.89]; P=0.002) with a number needed to treat to avoid 1 major cardiovascular event of 29. The incidence of moderate/severe bleeding was increased with vorapaxar in patients with DM (4.4% versus 2.6%; hazard ratio, 1.60 [95% confidence interval, 1.07–2.40]). However, net clinical outcome integrating these 2 end points (efficacy and safety) was improved with vorapaxar (hazard ratio, 0.79 [95% confidence interval, 0.67–0.93]). Conclusions— In patients with previous MI and DM, the addition of vorapaxar to standard therapy significantly reduced the risk of major vascular events with greater potential for absolute benefit in this group at high risk of recurrent ischemic events. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00526474

Prasugrel versus Clopidogrel for Acute Coronary Syndromes without Revascularization

peer reviewedBACKGROUND: The effect of intensified platelet inhibition for patients with unstable angina or myocardial infarction without ST-segment elevation who do not undergo revascularization has not been delineated. METHODS: In this double-blind, randomized trial, in a primary analysis involving 7243 patients under the age of 75 years receiving aspirin, we evaluated up to 30 months of treatment with prasugrel (10 mg daily) versus clopidogrel (75 mg daily). In a secondary analysis involving 2083 patients 75 years of age or older, we evaluated 5 mg of prasugrel versus 75 mg of clopidogrel. RESULTS: At a median follow-up of 17 months, the primary end point of death from cardiovascular causes, myocardial infarction, or stroke among patients under the age of 75 years occurred in 13.9% of the prasugrel group and 16.0% of the clopidogrel group (hazard ratio in the prasugre