Is there an additional benefit from coronary revascularization in diabetic patients with acute coronary syndromes or stable angina who are already on optimal medical treatment?

Cardiovascular disease (CVD) is common in patients with diabetes mellitus (DM) and related clinical outcomes are worse compared with non-diabetics. The optimal treatment in diabetic patients with coronary heart disease (CHD) is currently not established. We searched MEDLINE (1975-2010) using the key terms diabetes mellitus, coronary heart disease, revascularization, coronary artery bypass, angioplasty, coronary intervention and medical treatment. Most studies comparing different revascularization procedures in patients with CHD favoured coronary artery bypass graft (CABG) surgery in patients with DM. However, most of this evidence comes from subgroup analyses. Recent evidence suggests that advanced percutaneous coronary intervention (PCI) techniques along with best medical treatment may be non-inferior and more cost-effective compared with CABG. Treatment of vascular risk factors is a key option in terms of improving CVD outcomes in diabetic patients with CHD. The choice between medical therapy and revascularization warrants further assessment

Assessment of non-alcoholic fatty liver disease (NAFLD) severity with novel serum-based markers: A pilot study

BACKGROUND/AIMS: Non-alcoholic fatty liver disease (NAFLD) represents a significant public health issue. Identifying patients with simple steatosis from those with non-alcoholic steatohepatitis (NASH) is crucial since NASH is correlated with increased morbidity and mortality. Serum-based markers, including adipokines and cytokines, are important in the pathogenesis and progression of NAFLD. Here we assessed the usefulness of such markers in patients with NAFLD. METHODS: This prospective, cross-sectional study included 105 adult patients with varying severity of NAFLD. Twelve serum-based markers were measured by 3 biochip platforms and 2 enzyme-linked immunosorbent assay (ELISA) methods. We also developed a NAFLD individual fibrosis index (NIFI) using the serum-based markers mostly correlated with fibrosis severity. RESULTS: Sixty-one out of 105 patients were male (58.1%) with mean age was 53.5 years. Higher Interleukin-6 (IL-6) increased (p = 0.0321) and lower Matrix Metalloproteinase-9 (MMP-9) serum levels (p = 0.0031) were associated with higher fibrosis as measured by Fibroscan® in multivariable regression analysis. Using receiver-operating characteristic (ROC) curve analysis for the NIFI, area under the curve for predicting Fibroscan values ≥ 7.2 kPa was 0.77 (95%CI: 0.67, 0.88, p<0.001), with sensitivity of 89.3%, specificity of 57.9% and a positive likelihood ratio of 2.8. CONCLUSIONS: Increasing fibrosis severity in NAFLD is associated with differential expression of IL-6 and MMP-9. NIFI could be valuable for the prediction of advanced NAFLD fibrosis and potentially help avoid unnecessary interventions such as liver biopsy in low-risk patients

Effects of Morning Versus Evening Statin Administration on Lipid Profile: A Systematic Review and Meta-Analysis

Background: Evidence about the optimal time of day at which to administer statins is lacking. Objective: To synthesize evidence about effects of morning versus evening statin administration on lipid profile. Methods: We searched PubMed, SCOPUS, Web of Science and Embase databases (from inception up to July 24th, 2016) to identify the relevant studies. Mean differences (MDs) between the change scores in lipid parameters were pooled using a fixed-effect model. Results: Eleven articles with 1034 participants were eligible for the analysis. The pooled analysis comparing effects of morning versus evening administration of statins on plasma total cholesterol (TC) (p=0.10), high density lipoprotein cholesterol (HDL-C) (p=0.90) and triglycerides (TG) (p=0.45) was not statistically significant. Low density lipoprotein cholesterol (LDL-C) lowering was statistically greater in the evening-dose group (MD: 3.24 mg/dl, 95%CI: 1.23, 5.25, p=0.002). Subgroup analysis according to statin half-lives showed that evening-dose of statins was significantly superior to morning-dose for lowering LDL-C in case of both short and long half-life statins (MD: 9.68 mg/dl, 95%CI: 3.32, 16.03, p=0.003, and 2.53 mg/dl, 95%CI: 0.41, 4.64, p=0.02, respectively), and also for TC reduction in case of short half-life statins only (p=0.0005). Conclusions: LDL-C and TC lowering were significantly greater in the evening-dose than in the morning-dose in case of short-acting statins. Besides slight but significant effect on LDL-C, the efficacy of long-acting statins was equivalent for both regimens. Therefore, long-acting statins should be given at a time that will best aid compliance. Short-acting statins should be given in the evening

Sex-associated effect of CETP and LPL polymorphisms on postprandial lipids in familial hypercholesterolaemia

Background: This study assessed the gender-specific influence of the cholesteryl ester transfer protein (TaqIB, I405V) and lipoprotein lipase (S447X) polymorphisms on the response to an oral fat tolerance test in heterozygotes for familial hypercholesterolaemia.Methods: We selected and genotyped 80 men and postmenopausal women heterozygous for familial hypercholesterolaemia (main group) as well as 11 healthy control subjects. Patients were subgrouped based on their response to oral fat tolerance test. The oral fat tolerance test was defined as pathological when postprandial triglyceride concentration was higher than the highest triglyceride concentration observed in healthy subjects (220 mg/dl) at any time (2, 4, 6 or 8 h).Results: In the pathological subgroup, men had significantly higher incremental area under the curve after oral fat tolerance test than postmenopausal women. Furthermore, multivariate analysis revealed a gender association of TaqIB and I405V influence on postprandial lipaemia in this subgroup.Conclusion: In conclusion, it seems that gender and TaqIB polymorphism of the cholesteryl ester transfer protein gene were both associated with the distribution of triglyceride values after oral fat tolerance test, only in subjects with a pathological response to oral fat tolerance test. Specifically, men carrying the B2 allele of the TaqIB polymorphism showed a higher postprandial triglyceride peak and a delayed return to basal values compared with women carrying B2. However, further investigations in larger populations are required to replicate and confirm these findings

Regulation of Inducible Nitric Oxide Synthase (iNOS) and its Potential Role in Insulin Resistance, Diabetes and Heart Failure

Nitric oxide synthases (NOS) are the enzymes responsible for nitric oxide (NO) generation. NO is a reactive oxygen species as well as a reactive nitrogen species. It is a free radical which mediates several biological effects. It is clear that the generation and actions of NO under physiological and pathophysiological conditions are regulated and extend to almost every cell type and function within the circulation. In mammals 3 distinct isoforms of NOS have been identified: neuronal NOS (nNOS), inducible NOS (iNOS) and endothelial NOS (eNOS). The important isoform in the regulation of insulin resistance (IR) is iNOS. Understanding the molecular mechanisms regulating the iNOS pathway in normal and hyperglycemic conditions would help to explain some of vascular abnormalities observed in type 2 diabetes mellitus (T2DM). Previous studies have reported increased myocardial iNOS activity and expression in heart failure (HF). This review considers the recent animal studies which focus on the understanding of regulation of iNOS activity/expression and the role of iNOS agonists as potential therapeutic agents in treatment of IR, T2DM and HF

Nutraceutical approaches to non-alcoholic fatty liver disease (NAFLD): A position paper from the International Lipid Expert Panel (ILEP)

Non-Alcoholic Fatty Liver Disease (NAFLD) is a common condition affecting around 10-25% of the general adult population, 15% of children, and even &gt; 50% of individuals who have type 2 diabetes mellitus. It is a major cause of liver-related morbidity, and cardiovascular (CV) mortality is a common cause of death. In addition to being the initial step of irreversible alterations of the liver parenchyma causing cirrhosis, about 1/6 of those who develop NASH are at risk also developing CV disease (CVD). More recently the acronym MAFLD (Metabolic Associated Fatty Liver Disease) has been preferred by many European and US specialists, providing a clearer message on the metabolic etiology of the disease. The suggestions for the management of NAFLD are like those recommended by guidelines for CVD prevention. In this context, the general approach is to prescribe physical activity and dietary changes the effect weight loss. Lifestyle change in the NAFLD patient has been supplemented in some by the use of nutraceuticals, but the evidence based for these remains uncertain. The aim of this Position Paper was to summarize the clinical evidence relating to the effect of nutraceuticals on NAFLD-related parameters. Our reading of the data is that whilst many nutraceuticals have been studied in relation to NAFLD, none have sufficient evidence to recommend their routine use; robust trials are required to appropriately address efficacy and safety

European Society of Vascular Surgery (ESVS) guidelines. Invasive treatment for carotid stenosis: indications, techniques

Europejskie Towarzystwo Chirurgii Naczyniowej (ESVS) zgromadziło grupę ekspertów zajmujących się patologią tętnic szyjnych (CAD) w celu stworzenia uaktualnionych wytycznych dotyczących inwazyjnego leczenia zwężenia tętnicy szyjnej. Zalecenia oceniano, przypisując im odpowiedni poziom dowodów. Wykonanie endarterektomii tętnicy szyjnej (CEA) zaleca się u pacjentów z objawami, u których zwężenie jest większe niż 50%, jeśli częstość występowania udaru mózgu/zgonu w okresie okołooperacyjnym wynosi mniej niż 6% [A]; najlepiej, aby CEA wykonano w ciągu 2 tygodni od wystąpienia ostatnich objawów [A]. Zabieg ten zaleca się także u mężczyzn, u których nie stwierdza się objawów, w wieku poniżej 75 rż., ze zwężeniem wynoszącym 70&#8211;99%, jeśli częstość występowania udaru mózgu/zgonu w okresie okołooperacyjnym wynosi mniej niż 3% [A]. Korzyści z przeprowadzenia CEA u kobiet, u których nie występują objawy, są istotnie mniejsze niż u mężczyzn [A], dlatego wykonanie tego zabiegu powinno rozważać się tylko u młodszych kobiet bez dodatkowych obciążeń. Preferuje się przeprowadzanie angioplastyki z użyciem łaty nad pierwotnym zamknięciem tętnicy [A]. Przed zabiegiem CEA, w jego trakcie i po nim chorym należy zalecić stosowanie kwasu acetylosalicylowego w dawce dobowej 75&#8211;325 mg i terapię statynami [A]. Zabieg stentowania tętnicy szyjnej (CAS) powinno się wykonywać jedynie u pacjentów, u których przeprowadzenie zabiegu CEA wiąże się z dużym ryzykiem, w dużych ośrodkach o udokumentowanym małym ryzyku wystąpienia zgonu i udaru mózgu w okresie okołooperacyjnym lub w ramach randomizowanych kontrolowanych badań klinicznych [C]. Zabieg CAS należy wykonywać, stosując jednocześnie podwójne leczenie przeciwpłytkowe z użyciem kwasu acetylosalicylowego i klopidogrelu [A]. Wykorzystanie systemów protekcji mózgu prawdopodobnie jest korzystne [C]. Acta Angiol 2010; 16, 4: 190&#8211;21

Step-by-step diagnosis and management of the nocebo/drucebo effect in statin-associated muscle symptoms patients: a position paper from the International Lipid Expert Panel (ILEP)

Statin intolerance is a clinical syndrome whereby adverse effects (AEs) associated with statin therapy [most commonly statin-associated muscle symptoms (SAMS)] result in the discontinuation of therapy and consequently increase the risk of adverse cardiovascular outcomes. However, complete statin intolerance occurs in only a small minority of treated patients (estimated prevalence of only 3-5%). Many perceived AEs are misattributed (e.g. physical musculoskeletal injury and inflammatory myopathies), and subjective symptoms occur as a result of the fact that patients expect them to do so when taking medicines (the nocebo/drucebo effect)-what might be truth even for over 50% of all patients with muscle weakness/pain. Clear guidance is necessary to enable the optimal management of plasma in real-world clinical practice in patients who experience subjective AEs. In this Position Paper of the International Lipid Expert Panel (ILEP), we present a step-by-step patient-centred approach to the identification and management of SAMS with a particular focus on strategies to prevent and manage the nocebo/drucebo effect and to improve long-term compliance with lipid-lowering therapy