Cholesterol lowering for secondary prevention: What statin dose should we use?

Over the past decade, 17 large placebo-controlled trials have established that statin therapy lowers LDL cholesterol and prevents cardiovascular events and death in patients with coronary disease or at high risk for atherosclerotic events. Nine trials of higher dose vs. lower dose statins (reporting data from 29,853 patients with coronary artery disease and 486 patients with other indications for statin therapy) have established that higher dose statin therapy is more efficacious than lower dose therapy in reducing myocardial infarctions/coronary death (by 16%) and stroke (by 18%) in patients with coronary disease but only reduces all-cause mortality in patients at high risk for coronary death (such as patients immediately after acute coronary syndrome). Higher dose statins are associated with statistically significantly increased risks of myopathy and elevated transaminases compared to lower dose statins; while relative risks for these outcomes are 1.2 and 4.0, the absolute increases are small (0.5% and 1%). Secondary analyses of these trials using individual patient data and multivariate adjustment will be needed to appropriately examine the incremental benefits of different LDL targets, and trials are needed to determine whether combinations of low dose statins plus other lipid lowering agents may achieve better clinical outcomes than higher dose statin therapy alone

Diabetes and coronary artery bypass surgery. An examination of perioperative glycemic control and outcomes

WSTĘP. Celem pracy była ocena dokładności kontroli glikemii w okresie okołooperacyjnym u chorych na cukrzycę poddanych zabiegowi pomostowania aortalno-wieńcowego (CABG, coronary artery bypass grafting) oraz analiza związku między kontrolą glikemii a wewnątrzszpitalną chorobowością i śmiertelnością. MATERIAŁ I METODY. Było to badanie retrospektywne obejmujące kolejnych chorych na cukrzycę, u których wykonano CABG między kwietniem 2000 roku a marcem 2001 roku. Objęto nim pacjentów, którzy przeżyli co najmniej 24 godziny po zabiegu. WYNIKI. Spośród 291 analizowanych chorych w chwili przyjęcia do szpitala u 95% występowała cukrzyca typu 2, zaś u 40% retinopatia, nefropatia lub neuropatia. Podczas pobytu w szpitalu (średnio 7 dni) 78 pacjentów (27%) doznało udaru mózgu niepowodującego zgonu, zawału serca, zakażenia lub zmarło (wszystkie te sytuacje zaliczano do "zdarzeń niepożądanych"). Kontrola glikemii była niedostateczna (średnia glikemia w 1. dniu po zabiegu wynosiła 11,4 mmol/l [11,2–11,6 mmol/l]) i istotnie wiązała się z wystąpieniem zdarzeń niepożądanych po CABG (p = 0,03). U osób, u których stężenie glukozy we krwi w 1. dniu po zabiegu było najwyższe, stwierdzono największe ryzyko wystąpienia zdarzeń niepożądanych (iloraz szans = 2,5 [1,1–5,3]). Nawet po skorygowaniu wyników pod względem innych objawów klinicznych i czynników wynikających z zabiegu glikemia w 1. dniu po operacji nadal istotnie wiązała się z ryzykiem wystąpienia zdarzeń niepożądanych. Wzrost glikemii o każdy 1 mmol/l powyżej 6,1 mmol/l zwiększał ryzyko o 17%. WNIOSKI. Okołooperacyjna kontrola glikemii w badanej grupie chorych na cukrzycę, u których wykonano CABG w szpitalu o 3. stopniu referencji, była niedostateczna. Zdaniem autorów wyeliminowanie tego czynnika jest konieczne, ponieważ hiperglikemia w 1. dniu po zabiegu w niniejszym badaniu wiązała się z występowaniem zdarzeń niepożądanych.INTRODUCTION. To determine the adequacy of perioperative glycemic control in diabetic patients undergoing coronary artery bypass grafting (CABG) and to explore the association between glycemic control and in-hospital morbidity/mortality. MATERIAL AND METHODS. Retrospective cohort study of consecutive patients with diabetes undergoing CABG between April 2000 and March 2001 who survived at least 24 h postoperatively. RESULTS. Of the 291 patients in this study, 95% had type 2 diabetes and 40% had retinopathy, nephropathy, or neuropathy at baseline. During hospitalization (median 7 days), 78 (27%) of these patients suffered a nonfatal stroke or myocardial infarction, septic complication, or died ("adverse outcomes"). Glycemic control was suboptimal (average glucose on first postoperative day was 11.4 [11.2–11.6] mmol/l) and was significantly associated with adverse outcomes post-CABG (P = 0.03). Patients whose average glucose level was in the highest quartile on postoperative day 1 had higher risk of adverse outcomes after the first postoperative day than those with glucose in the lowest quartile (odds ratio 2.5 [1.1-5.3]). Even after adjustment for other clinical and operative factors, average blood glucose level on the first postoperative day remained significantly associated with subsequent adverse outcomes: for each 1-mmol/l increase above 6.1 mmol/l, risk increased by 17%. CONCLUSIONS. Perioperative glycemic control in our cohort of diabetic patients undergoing CABG in a tertiary care facility was suboptimal. We believe closure of this care gap is imperative, because hyperglycemia in the first postoperative day was associated with subsequent adverse outcomes in our study patients

Chloride in Heart Failure:The Neglected Electrolyte

The increasing burden of heart failure (HF) and emerging knowledge regarding chloride as a prognostic marker in HF have increased the interest in the pathophysiology and interactions of chloride abnormalities with HF-related factors and treatments. Chloride is among the major electrolytes that play a unique role in fluid homeostasis and is associated with cardiorenal and neurohormonal systems. This review elucidates the role of chloride in the pathophysiology of HF, evaluates the effects of treatment on chloride (eg, diuretic agents cause higher urinary chloride excretion and consequently serum hypochloremia), and discusses recent evidence for the association between chloride levels and mortality

Is There Any Interaction Between Sex and Renal Function Change During Hospital Stay in Patients Hospitalized With Acute Heart Failure?

Background: Renal dysfunction is a strong predictor of outcomes in patients with acute heart failure (AHF). However. less is known about how sex may influence the prognostic import of renal function in AHF. Methods and Results: In a post hoc analysis of the ASCEND-HF trial including 5377 patients with AHF (33% female), patients were categorized into 3 groups based on the changes in renal function during their hospital stay. Worsening. stable, and improving renal functions were defined as a >= 20% decrease, a = 20% increase in the estimated glomentlar filtration rate, respectively. The primary outcome was the composite of 30-day all-cause mortality or HF rehospitalization. The median baseline and discharge estimated glomerular filtration rate were 58.4 and 56.9 mL/min/l.73 m(2), respectively. Worsening, stable, and improving renal function was observed in 31.9%, 63.2, and 4.9% of patients. respectively. Worsening renal function was associated with adverse outcomes at 30 days (adjusted hazard ratio [aHR] 1.47, 95% confidence interval [CI] 1.22-1.76). This association existed in both males and females (aHR 1.42 and aHR 1.56, respectively, both P < .01). There was an interaction between renal function changes and sex (P = .025), because improving renal function was associated with better outcomes in men(aHR 0.29, 95% CI 0.13 0.66) as compared with women (aHR 1.18, 95% CI 0.59 2.35). There was no interaction between the ejection fraction and renal function in association with subsequent outcomes. Conclusions: Irrespective of sex, worsening renal function was associated with poorer outcomes at 30 days in patients with AHF. More studies are warranted to further delineate the possible sex differences in this setting