Showing papers in "Vascular Health and Risk Management in 2018"
TL;DR: This review presented a complete overview about physiopathology, diagnosis and holistic management of critical limb ischemia, and the state-of-the-art on gene and cell therapy for the treatment of no-option patients is reported.
Abstract: Critical limb ischemia (CLI) is considered the most severe pattern of peripheral artery disease. It is defined by the presence of chronic ischemic rest pain, ulceration or gangrene attributable to the occlusion of peripheral arterial vessels. It is associated with a high risk of major amputation, cardiovascular events and death. In this review, we presented a complete overview about physiopathology, diagnosis and holistic management of CLI. Revascularization is the first-line treatment, but several challenging cases are not treatable by conventional techniques. Unconventional techniques for the treatment of complex below-the-knee arterial disease are described. Furthermore, the state-of-the-art on gene and cell therapy for the treatment of no-option patients is reported.
109 citations
TL;DR: A review of the literature showed that there is currently insufficient data to suggest that PON1 has clinical relevance, and it is the opinion that robust studies are required to clarify the clinical relevance of Pon1.
Abstract: Paraoxonase-1 (PON1) is a high-density lipoprotein-associated esterase and is speculated to play a role in several human diseases including diabetes mellitus and atherosclerosis. Low PON1 activity has been associated with increased risk of major cardiovascular events, therefore a variety of studies have been conducted to establish the cardioprotective properties and clinical relevance of PON1. The major aim of this review was to highlight the important studies and to subsequently assess if PON1 has clinical relevance. A review of the literature showed that there is currently insufficient data to suggest that PON1 has clinical relevance. It is our opinion that robust studies are required to clarify the clinical relevance of PON1.
87 citations
TL;DR: The analysis of psychological intervention shows that at present there is no evidence of specific psychological interventions in patients with pulmonary arterial hypertension and the introduction of routine psychological intervention, as suggested by the European Society of Cardiology and already applied in other chronic disease.
Abstract: Background Anxiety and depression are frequent disorders in patients with pulmonary arterial hypertension (PAH), but despite this only less than one-fourth of them is treated. Our aim was to review the studies regarding the prevalence and the impact of anxiety and depression and to propose management challenges. Methods A literature review regarding 1) anxiety and depression studies in PAH patients and caregivers, 2) psychological interventions, 3) slow breathing approach, and 4) pharmacological approach was performed, based on evidence of effectiveness through a search of the most well-known databases (Cochrane Library, Medline, PsychINFO [2004-2018]). Results The prevalence of mental disorders in PAH patients lies between 7.5% and 53% for depression and 19% and 51% for anxiety and panic disorders. The latest guidelines of the European Society of Cardiology recommend a psychological support with a class of recommendation I and a level of evidence c. The analysis of psychological intervention shows that at present there is no evidence of specific psychological interventions in these patients. However, treatment approaches based on other chronic illnesses are suggested, especially based on relaxation training, slow breathing, and cognitive behavioral therapy. Finally, data concerning the use of antidepressant drugs are conflicting. Conclusion Firstly, our data demonstrate a common underestimation of mental disorders by health professionals and secondly, the need of implementing appropriate methods of screening for mental disorders in PAH patients. However, the paucity of large observational studies in this area requires the attention of researchers. The evidence about optimal approaches for managing anxiety and depression in PAH also remains unclear and largely speculative. The challenge is the introduction of routine psychological intervention, as suggested by the European Society of Cardiology and already applied in other chronic disease.
45 citations
TL;DR: Estimated prevalence of anemia on admission in the setting of an acute coronary syndrome (ACS) is between 10% and 43% of the patients depending upon the specific population under investigation, and up to 57% of ACS patients may develop hospital-acquired anemia (HAA), even if different mechanisms contribute to their prognostic impact.
Abstract: Reference hemoglobin (Hb) values for the definition of anemia are still largely based on the 1968 WHO Scientific Group report, which established a cutoff value of <13 g/dL for adult men and <12 g/dL for adult nonpregnant women. Subsequent studies identified different normal values according to race and age. Estimated prevalence of anemia on admission in the setting of an acute coronary syndrome (ACS) is between 10% and 43% of the patients depending upon the specific population under investigation. Furthermore, up to 57% of ACS patients may develop hospital-acquired anemia (HAA). Both anemia on admission and HAA are associated with worse short- and long-term mortality, even if different mechanisms contribute to their prognostic impact. Baseline anemia can usually be traced back to preexisting disease that should be specifically investigated and corrected whenever possible. HAA is associated with clinical characteristics, medical therapy and interventional procedures, all eliciting cardiovascular adaptive response that can potentially worsen myocardial ischemia. The intrinsic fragility of anemic patients may limit aggressive medical and interventional therapy due to an increased risk of bleeding, and could independently contribute to worse outcome. However, primary angioplasty for ST elevation ACS should not be delayed because of preexisting (and often not diagnosed) anemia; delaying revascularization to allow fast-track anemia diagnosis is usually feasible and justified in non-ST-elevation ACS. Besides identification and treatment of the underlying causes of anemia, the only readily available means to reverse anemia is red blood cell transfusion. The adequate transfusion threshold is still being debated, although solid evidence suggests reserving red blood cell transfusions for patients with Hb level <8 g/dL and considering it in selected cases with Hb levels of between 8 and 10 g/dL. No evidence supports the use of iron supplements and erythropoiesis-stimulating agents in the setting of ACS.
42 citations
TL;DR: A high CVD prevalence along with an upward trend was observed in Bangladeshi adults, and proper strategies are required for primary prevention of CVD so that a further increase can be alleviated and the morbidity and mortality associated with it can be reduced.
Abstract: Background Cardiovascular disease (CVD) is a group of conditions affecting the functioning of the heart or blood vessels and is one of the leading causes of death globally. Like other countries, CVD prevalence is also rising among the adults in Bangladesh. Epidemiological studies have shown not only a high CVD prevalence but also a significant increase in its prevalence in Bangladesh in the last few decades. To have a better understanding of the current CVD prevalence scenario, we conducted this systematic review and meta-analysis. Our objective was to assess the prevalence of CVD among the Bangladeshi adult population using evidence from the published scientific literature. Methods Electronic databases such as MEDLINE, Embase and PubMed were searched. We also manually checked the references of all relevant publications that describe the prevalence of CVD in Bangladeshi adults. To pool the CVD prevalence, we used random-effects meta-analysis. We assessed heterogeneity using both the formal tests and the subgroup analyses. We also assessed study quality and examined publication bias. Results We retrieved 755 potentially relevant papers through searches of electronic and gray literature, of which only 13 met inclusion criteria after the screening and were included in this review. Of the studies that met inclusion criteria, three were carried out in rural populations, five in both urban and rural populations and two in strictly urban populations. Male and female participation in the studies was almost equal. The weighted pooled prevalence of CVD was 5.0%, regardless of the types of CVD, gender and geographical location of the study participants. There was also a high heterogeneity in the observed CVD prevalence. Weighted pooled prevalence of overall CVD in the Bangladeshi population was higher in urban areas (8%) compared to rural areas (2%). However, no such difference was observed in terms of gender (3% for both males and females). The highest reported prevalence (21%) was for heart disease, while the lowest reported prevalence (1%) was for stroke. Sources of heterogeneity were often unexplained. The criteria used to assess study quality were fulfilled by only a few studies, and adequate sample size criteria was missed by almost all of them. In addition, there was evidence of small-study effects. Conclusion A high CVD prevalence along with an upward trend was observed in Bangladeshi adults. Proper strategies are required for primary prevention of CVD so that a further increase can be alleviated and the morbidity and mortality associated with it can be reduced.
39 citations
TL;DR: This review focuses on recent substudies from these trials and progress in drugs targeting the endothelin pathway, and future perspectives with regard to endothelins-receptor antagonists are discussed.
Abstract: Pulmonary arterial hypertension, a disease largely neglected until a few decades ago, is presently the object of intense studies by several research teams. Despite considerable progress, pulmonary arterial hypertension remains a major clinical problem, because it is not always easy to diagnose, treat, and prevent. The disease was considered incurable until the late 1990s, when Epoprostenol was introduced as the first tool against this illness. More recently, therapy for pulmonary arterial hypertension gained momentum after publication of the SERAPHIN and AMBITION trials, which also highlighted the importance of upfront therapy. This review also focuses on recent substudies from these trials and progress in drugs targeting the endothelin pathway. Future perspectives with regard to endothelin-receptor antagonists are also discussed.
33 citations
TL;DR: In this paper, effects of androgen hormones on EC and EPC function in physiological and pathological conditions are considered.
Abstract: Cardiovascular effects of android hormones in normal and pathological conditions can lead to either positive or negative effects. The reason for this variation is unknown, but may be influenced by gender-specific effects of androids, heterogeneity of the vascular endothelium, differential expression of the androgen receptor in endothelial cells (ECs) and route of androgen administration. Generally, androgenic hormones are beneficial for ECs because these hormones induce nitric oxide production, proliferation, motility, and growth of ECs and inhibit inflammatory activation and induction of procoagulant, and adhesive properties in ECs. This indeed prevents endothelial dysfunction, an essential initial step in the development of vascular pathologies, including atherosclerosis. However, androgens can also activate endothelial production of some vasoconstrictors, which can have detrimental effects on the vascular endothelium. Androgens also activate proliferation, migration, and recruitment of endothelial progenitor cells (EPCs), thereby contributing to vascular repair and restoration of the endothelial layer. In this paper, we consider effects of androgen hormones on EC and EPC function in physiological and pathological conditions.
33 citations
TL;DR: The ABI and baPWV are the useful and significant biomarkers, Nevertheless, caution is sometimes necessary when interpreting them and rigorous patient exclusion criteria should be considered when using those indices in the severely conditioned patient population.
Abstract: Background The ankle-brachial index (ABI) and pulse wave velocity (PWV) are indices of atherosclerosis and arterial stiffness. The Japan-made measuring devices of those indices have spread widely because of their convenience and the significance of the parameters. However, studies that comprehensively discuss the various pitfalls in using these indices are not available. Methods This study presents several representative pitfalls in using the ABI and brachial-ankle PWV (baPWV) by showing the result sheets of the device, "the Vascular Profiler". Furthermore, some considerations when utilizing these indices in the future are also discussed. Results Several diseases such as arteriosclerosis obliterans (ASO), arterial calcification in the lower limb, arterial stenosis in the right upper-limb, aortic valve diseases, arterial stenosis in the upper-limb of the contralateral side of the hemodialysis access, are the representative pitfalls when evaluating ABI and baPWV. Moreover, a measurement error is found to actually exist. Furthermore, same phenomena are considered most likely to occur when using other similar indices and devices. Conclusion The ABI and baPWV are the useful and significant biomarkers. Nevertheless, caution is sometimes necessary when interpreting them. Moreover, rigorous patient exclusion criteria should be considered when using those indices in the severely conditioned patient population. And the results of this study can be applied to enhance the literacy using other indices, such as the cardio-ankle vascular index and other similar devices.
32 citations
TL;DR: An integrated approach to minimizing barriers and enhancing facilitation at the levels of the patient, provider, and health system can help address adherence issues and achieve sustained results.
Abstract: Poor adherence to statin therapy is linked to significantly increased risk of cardiovascular events and death. Unfortunately, adherence to statins is far from optimal. This is an alarming concern for patients prescribed potentially life-saving cholesterol-lowering medication, especially for those at high risk of cardiovascular events. Research on statin adherence has only recently garnered broader attention; hence, major reasons unique to adherence to statin therapy need to be identified as well as suggestions for countermeasures. An integrated approach to minimizing barriers and enhancing facilitation at the levels of the patient, provider, and health system can help address adherence issues. Health care professionals including physicians, pharmacists, and nurses have an obligation to improve patient adherence, as routine care. In order to achieve sustained results, a multifaceted approach is indispensable.
31 citations
TL;DR: The level of stroke treatment knowledge in stroke patients seems to be poor, and public campaigns should probably also focus on information on treatment options, which may contribute to reduce prehospital delay and onset-to-treatment-time.
Abstract: Background Public campaigns focus primarily on stroke symptom and risk factor knowledge, but patients who correctly recognize stroke symptoms do not necessarily know the reason for urgent hospitalization. The aim of this study was to explore knowledge on stroke risk factors, symptoms and treatment options among acute stroke and transient ischemic attack patients. Methods This prospective study included patients admitted to the stroke unit at the Department of Neurology, Akershus University Hospital, Norway. Patients with previous cerebrovascular disease, patients receiving thrombolytic treatment and patients who were not able to answer the questions in the questionnaire were excluded. Patients were asked two closed-ended questions: "Do you believe that stroke is a serious disorder?" and "Do you believe that time is of importance for stroke treatment?". In addition, patients were asked three open-ended questions where they were asked to list as many stroke risk factors, stroke symptoms and stroke treatment options as they could. Results A total of 173 patients were included, of whom 158 (91.3%) confirmed that they regarded stroke as a serious disorder and 148 patients (85.5%) considered time being of importance. In all, 102 patients (59.0%) could not name any treatment option. Forty-one patients (23.7%) named one or more adequate treatment options, and they were younger (p<0.001) and had higher educational level (p<0.001), but had a nonsignificant shorter prehospital delay time (p=0.292). Conclusion The level of stroke treatment knowledge in stroke patients seems to be poor. Public campaigns should probably also focus on information on treatment options, which may contribute to reduce prehospital delay and onset-to-treatment-time.
29 citations
TL;DR: It is demonstrated that a large proportion of patients discontinue PCSK9i therapy at 30 and 90 days, which are the time frames for which many health plans require recertification to continue access to PCSK 9i.
Abstract: Purpose To describe patient characteristics and treatment patterns among early initiators of proprotein convertase subtilisin/kexin type nine inhibitors (PCSK9is) who initiated treatment within the first 6 months of market availability. Patients and methods This retrospective cohort study used IQVIA's longitudinal open-source point-of-sale pharmacy claims database (LRx) and PharMetrics Plus (P+) health plan claims database to identify patients initiating a PCSK9i between January 1, 2016 and June 30, 2016. The index date was defined as the date of the first PCSK9i prescription (index claim) during the enrollment window; patients were followed for ≥6 months postindex. Patient characteristics including use of baseline lipid-lowering therapy (LLT) and measures such as persistence and adherence to PCSK9i therapy were evaluated with respect to health plan type (commercial vs Medicare). Results Overall, patients initiating PCSK9i (n=13,151) had a mean age of 66 years, and 51% were male. Approximately 67.4% of patients used some form of LLT (statin and/or ezetimibe) in the 24 months prior to initiating PCSK9i therapy. The proportion of patients covered by a commercial health plan (51.2%) was similar to that covered by Medicare (48.8%). Persistence on PCSK9i was marginally longer for patients with commercial insurance than Medicare (mean days on therapy 202.2 vs 198.5). Overall, 42.6% of patients discontinued their PCSK9i during the 180 days of follow-up. Conclusion This study demonstrates that a large proportion of patients discontinue PCSK9i therapy at 30 and 90 days, which are the time frames for which many health plans require recertification to continue access to PCSK9i. Future studies looking at treatment patterns among patients who initiate PCSK9i therapy after the first 180 days once health plan formularies and utilization management criteria were finalized are needed to understand more comprehensively real-world PCSK9i usage patterns.
TL;DR: In this study, death and other serious event rates were low during the in-hospital rehabilitation and in the 12-month follow-up period, which underlined the safety and importance of a standardized rehabilitation program after survived PE.
Abstract: Introduction Pulmonary embolism (PE) is a life-threatening disease; in Germany, therefore, rehabilitation after PE is recommended in patients with intermediate- and high-risk PE However, no prospective data on PE after inpatient rehabilitation have been published so far Patients and methods For this monocentric study, 70 patients with PE were prospectively recruited between November 2013 and November 2014 after giving written informed consent This study was approved by the ethics committee of the Medical Association of Saxony-Anhalt Inclusion criteria were as follows: age ≥18 years and a stay at the Paracelsus-Harz Clinic in Bad Suderode, Germany, with the main indication of PE During the hospital stay, history-relevant medical data and diagnostic findings were collected and documented Furthermore, we recorded whether patients were rehospitalized or died during the treatment period in the rehabilitation clinic or during the 12-month follow-up Results The mean age was 645 ± 130 years, the mean body mass index (BMI) was 304 ± 60 kg/m2, and 543% were women During rehabilitation, two patients (39%) were transferred to a primary care hospital; no patient died However, four patients died (57%) in the 12-month follow-up period A total of 20 patients were hospitalized in the 12-month follow-up period (hospitalization rate during the 12-month follow-up period: 286%) Of these 20 patients, one patient was rehospitalized with a newly diagnosed PE (14%) and two patients were rehospitalized for bleeding events (28%) Conclusion PE is a life-threatening disease, and therefore it seems reasonable to recommend rehabilitation at least in patients with an intermediate- or high-risk PE In this study, death and other serious event rates were low during the in-hospital rehabilitation and in the 12-month follow-up period, which underlined the safety and importance of a standardized rehabilitation program after survived PE
TL;DR: Masurable ET-1, NO and 5-HT are related to BP in adolescents and may serve as diagnostic biomarkers of EAH, which could help to better define prehypertensive and hypertensive children.
Abstract: Background Essential arterial hypertension (EAH) in adolescents represents a social burden. The endothelium is involved in the pathogenesis of EAH. Imbalance of key vasoactive factors - namely nitric oxide (NO) and endothelin-1 (ET-1) - is observed, and serotonin (5-HT) release is also impaired. The relationship between the factors and high blood pressure (BP) has been established mainly in preclinical studies and in the adult age. The aim of the present manuscript is to establish the association between plasma ET-1, serum NO and 5-HT, platelet 5-HT levels and BP in male adolescents, analyzing their concentrations in controls, prehypertensive and hypertensive children. Consequently, we want to evaluate ET-1, NO and 5-HT levels as preclinical biomarkers of EAH. Methods Outpatient adolescents, examined at Children's Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan, were recruited between 26th of May and 25th of September 2016. Predictor variables identified were plasma ET-1, serum NO and 5-HT levels and were evaluated in serum and platelets of case and control groups. Results Plasma ET-1 and serum 5-HT concentrations in prehypertensive and hypertensive children were higher than in controls, with hypertensive adolescents showing higher levels of both factors compared with prehypertensive adolescents. Platelet 5-HT levels were lower in prehypertensive and hypertensive children compared with controls, while serum NO levels were higher in prehypertensive children than in hypertensive children. Conclusion Measurable ET-1, NO and 5-HT are related to BP in adolescents and may serve as diagnostic biomarkers of EAH. Furthermore, they could help to better define prehypertensive and hypertensive children.
TL;DR: Real-world evidence supports the use of rivaroxaban as safe and effective in preventing ischemic stroke in non-valvular AF patients with comorbidities – including renal impairment, acute coronary syndrome, diabetes mellitus, malignancy, or old age – though with some important considerations required to reduce bleeding risk.
Abstract: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and it leads to significant morbidity and mortality, predominantly from ischemic stroke. Vitamin K antagonists, mainly warfarin, have been used for decades to prevent ischemic stroke in AF, but their use is limited due to interactions with food and other drugs, as well as the requirement for regular monitoring of the international normalized ratio. Rivaroxaban, a direct factor Xa inhibitor and the most commonly used non-vitamin K oral anticoagulant, avoids many of these challenges and is being prescribed with increasing frequency for stroke prevention in non-valvular AF. Randomized controlled trial (RCT) data from the ROCKET-AF(Rivaroxaban once daily oral direct Factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation) trial have shown rivaroxaban to be non-inferior to warfarin in preventing ischemic stroke and systemic embolism and to have comparable overall bleeding rates. Applicability of the RCT data to real-world practice can sometimes be limited by complex clinical scenarios or multiple comorbidities not adequately represented in the trials. Available real-world evidence in non-valvular AF patients with comorbidities - including renal impairment, acute coronary syndrome, diabetes mellitus, malignancy, or old age - supports the use of rivaroxaban as safe and effective in preventing ischemic stroke in these subgroups, though with some important considerations required to reduce bleeding risk. Patient perspectives on rivaroxaban use are also considered. Real-world evidence indicates superior rates of drug adherence with rivaroxaban when compared with vitamin K antagonists and with alternative non-vitamin K oral anticoagulants - perhaps, in part, due to its once-daily dosing regimen. Furthermore, self-reported quality of life scores are highest among patients compliant with rivaroxaban therapy. The generally high levels of patient satisfaction with rivaroxaban therapy contribute to overall favorable clinical outcomes.
TL;DR: Both devices, the Evolv and the M3 Comfort, achieved a grade A/A for both SBP and DBP and fulfill the validation protocol criteria in pregnancy and pre-eclampsia and can be recommended for home BP measurements in this specific population.
Abstract: Background Electronic devices for blood pressure (BP) measurements need to go through independent clinical validation as recommended by different authorities, both in general and in special populations such as pregnancy. Objective To evaluate the accuracy of the Omron Evolv® (HEM-7600T-E) and the Omron M3 Comfort® (HEM-7134-E) devices in pregnancy and pre-eclampsia according to the Universal Standard Validation Protocol. Methods Both devices, the Evolv and the M3 Comfort, measure BP at the brachial level using the oscillometric method. The study was performed according to the recently published protocol, the so-called "modified Advancement of Medical Instrumentation (AAMI)/British Hypertension Society (BHS)/European Society of Hypertension (ESH) protocol" or the "Universal Standard Protocol." Validation of each device included 45 pregnant women in the second and third gestational trimester of whom 15 had pre-eclampsia, 15 had gestational hypertension and 15 were normotensives. BP differences between the observer and the device BP values were classified into three categories (≤5, ≤10, and ≤15 mmHg) and the mean BP differences (test vs reference) and its SD were calculated. Results Both devices, the Evolv and the M3 Comfort, achieved a grade A/A in both pregnancy and pre-eclampsia. The mean difference (SD) between the mercury standard and the device BP values in pregnancy were: 1) for the Evolv of -0.7±2.3 mmHg for systolic blood pressure (SBP) and -0.1±1.8 mmHg for diastolic blood pressure (DBP); 2) for the M3 Comfort of -1.6±2.8 mmHg for SBP and -0.1±2.3 mmHg for DBP. Conclusion Both devices, the Evolv and the M3 Comfort, achieved a grade A/A for both SBP and DBP and fulfill the validation protocol criteria in pregnancy and pre-eclampsia. Consequently, these two devices can be recommended for home BP measurements in this specific population.
TL;DR: The first report on plasma NOx levels in SCD complication in Ghanaian SCD patients is presented and it is confirmed that reduced plasma NOX levels inSCD patients in general are confirmed.
Abstract: Background Nitric oxide (NO) plays a fundamental role in maintaining normal vasomotor tone. Recent clinical and experimental data suggest that NO may play a role in the pathogenesis and therapy of sickle cell disease (SCD). The aim of this study was to determine NO metabolites (NOx) in SCD patients at steady state and in vaso-occlusive crisis (VOC), as well as those with hemolytic clinical sub-phenotype that includes leg ulcers and priapism. Methodology This was a case-control cross-sectional study conducted on a total of 694 subjects including 148 comparison group HbAA, 208 HbSS SCD patients in steady state, 82 HbSC SCD patients in steady state, 156 HbSS SCD patients in VOC, 34 HbSC SCD patients in VOC, 34 HbSS SCD patients in post VOC, 21 HbSS SCD patients with leg ulcer and 11 HbSS SCD patients with priapism, with age ranging from 15 to 65 years. Laboratory diagnosis of SCD was done at the Sickle Cell Clinic of the Korle-Bu Teaching Hospital. Plasma nitric oxide metabolites were measured using Griess reagent system by ELISA method. Results Mean NOx of 59.66±0.75 µMol/L in the comparison group was significantly different from those in steady state (P=0.02). During VOC, there was a significant reduction in mean NOx levels to 6.08±0.81 µMol/L (P<0.001). Mean NOx levels were however, significantly higher (50.97±1.68 µMol/L) (P<0.001) in the immediate postcrisis period. The mean NOx levels in the leg ulcer (21.70±1.18 µMol/L) (P<0.001) and priapism (28.97±1.27 µMol/L) (P<0.001) patients were significantly low as compared to the SCD patients in the steady state and comparison group. Conclusion This study presents the first report on plasma NOx levels in SCD complication in Ghanaian SCD patients and confirms reduced plasma NOx levels in SCD patients in general.
TL;DR: This study demonstrated that the number of study participants and dialysis population were the independent determinants of the success of prognostic prediction, and showed the importance of exclusion criteria of ASO when using these indices.
Abstract: Background Brachial-ankle pulse wave velocity (baPWV) and cardio-ankle vascular index (CAVI) are indices of arterial stiffness, and several studies have used these indices. However, there is no comprehensive review of these parameters in the prognostic significance. Methods The aim of this study was to review the articles exploring the prognostic significance of these parameters. Articles demonstrating independent significance after multivariate analysis on the Cox proportional hazards model were defined as "successful." The success rate was compared using Fisher's exact test. In addition, multivariate logistic regression analysis was performed to explore the independent determinants of the success of prognostic prediction. Results The success rate of the baPWV articles (65.7% [46/70]) tended to be higher than that of the CAVI articles (40.0% [6/15]; P=0.083). Multivariate analysis demonstrated that log (number of patients) (OR 11.20, 95% CI 2.45-51.70, P=0.002) and dialysis population (OR 0.28, 95% CI 0.08-0.94, P=0.039) were positive and negative independent determinants of the success of prognostic prediction, respectively. In addition, after redefining two studies as the absence of arteriosclerosis obliterans (ASO) exclusion, baPWV (OR 3.36, 95% CI 0.86-13.20, P=0.083) and the existence of exclusion criteria of ASO (OR 3.08, 95% CI 0.96-9.93, P=0.060) exhibited statistical tendency in the multivariate analysis. Conclusion This study demonstrated that the number of study participants and dialysis population were the independent determinants of the success of prognostic prediction. This study also showed the importance of exclusion criteria of ASO when using these indices. In addition, a prospective large-scale study to confirm the superiority in the prognostic prediction of these indices is warranted.
TL;DR: The expression of PLA2R and IgG4 antibody had great significance in the pathological diagnosis of MN and the detection of the serum anti-PLA2R antibodies had great diagnostic value in diagnosing MN.
Abstract: Objectives The aims of this study were to detect the expression of M phospholipase A2 receptor (PLA2R) in the kidney tissue of patients with idiopathic membranous nephropathy (IMN), secondary membranous nephropathy (SMN), and the nonmembranous nephropathy (non-MN), to evaluate the value of PLA2R in the kidney tissue and serum anti-PLA2R antibody in the diagnosis of membranous nephropathy (MN), and to explore the relationship between PLA2R of the kidney tissue or serum anti-PLA2R antibody and clinical features of MN. Methods The kidney tissue was collected by kidney biopsy. Immunofluorescence assay was used to detect the level of PLA2R and IgG4 antigen in kidney tissue. Furthermore, the level of the PLA2R was detected using the enzyme-linked immunosorbent assay (ELISA). The positive and negative rates of PLA2R and IgG4 in different diseases and the sensitivity and specificity, were calculated using the statistical method. The specificity and coincidence rate of PLA2R or anti-PLA2R used in the differential diagnosis of IMN and SMN were evaluated. Results The expression intensities of anti-PLA2R antibody and IgG4 were significantly higher in patients with IMN than in patients with SMN but are not non-MN. There was no significant difference in anti-PLA2R antibody and IgG4 in patients with SMN and non-MN. The coincidence rate of serum anti-PLA2R antibody and PLA2R in kidney tissue was 100%. Conclusion The expression of PLA2R and IgG4 antibody had great significance in the pathological diagnosis of MN. The detection of the serum anti-PLA2R antibody had great diagnostic value in diagnosing MN.
TL;DR: A pharmaceutical prophylaxis protocol using LMWH and dabigatran during the post-discharge period resulted in low incidences of VTE and equivalence between treatments, however, the increased number of major and minor bleeding events in patients taking dabig atran is of concern regarding the safety and needs to be evaluated using analyses adjusted for risk factors.
Abstract: Background Low-molecular-weight heparin (LMWH) is a recommended anticoagulant for thromboprophylaxis after major orthopedic surgery. Dabigatran etexilate is an oral anticoagulant recognized as noninferior to LMWH. We aimed to assess the incidence of symptomatic venous thromboembolic events (VTEs) after discharge in patients who underwent joint replacement, using a hospital registry. Patients and methods Patients who underwent total knee and hip arthroplasty between September 2011 and March 2015 were selected. Subcutaneous enoxaparin (30 mg twice daily) was given during hospitalization. At discharge, patients received either enoxaparin 30 mg twice daily/40 mg once daily or dabigatran 220 mg/150 mg once daily. Patients were seen or called at 2, 6, and 12 weeks after surgery. Outcomes were the number of VTEs, including deep venous thrombosis, pulmonary embolism, and the number of major/minor bleeding events after discharge. Results After discharge, 1468 patients were prescribed enoxaparin and 904 dabigatran (1396 total knee arthroplasty and 976 total hip arthroplasty patients). Mean age was 66±10 years, and 60% were female. The cumulative incidence of VTEs during the 12-week follow-up was 0.7%. One patient sustained a VTE during the switch window. Seven patients sustained a pulmonary embolism (0.3%). There was no statistical difference between the total knee arthroplasty and total hip arthroplasty groups. The incidence of major and minor bleeding events during follow-up was 0.3% and 30.3%, respectively. These events had a higher incidence in the dabigatran group compared to the enoxaparin group after discharge (p<0.05), but not between knee and hip replacement groups for major bleeding events. Conclusion A pharmaceutical prophylaxis protocol using LMWH and dabigatran during the post-discharge period resulted in low incidences of VTE and equivalence between treatments. However, the increased number of major and minor bleeding events in patients taking dabigatran is of concern regarding the safety and needs to be evaluated using analyses adjusted for risk factors.
TL;DR: Redefining DFS into ulcerative, septic and gangrenous by integration of the predominant clinical presentation and the clinical criteria for DFI diagnosis and classification of IDSA/IWGDF showed significant differences in amputation rate.
Abstract: Purpose The aim of this study was to present the redefined clinical spectra of diabetic foot syndrome (RCS-DFS) and determine whether the RCS-DFS can be used to predict amputations. Patients and methods This is a retrospective study of type 2 diabetic patients referred with DFS for management at King Abdullah University Hospital (KAUH) between January 2014 and December 2015. Data collection form and diabetic foot (DF) characteristic chart were used to document the following: demographic data, diabetes-related parameters, DF characteristics, surgical interventions and amputations. The predominant clinical presentations of DF problems (ulcer, sepsis or gangrene) were integrated with the clinical criteria for diabetic foot infection (DFI) diagnosis and classification of Infectious Diseases Association of America (IDSA)/International Working Group on Diabetic Foot (IWGDF) to redefine the clinical spectra of DFS. Related risk characteristics and amputation rate at all levels were compared between the three RCS. Results In this study, there were 95 (47.0%) septic DFS (SDFS) patients, 65 (32.2%) ulcerative DFS (UDFS) patients and 42 (20.8%) gangrenous DFS (GDFS) patients. Poor glycemic control (HbA1c >7.5%), hypertension, history of the same foot problems, duration of symptoms, revascularizations and ischemic severity were significantly different between the three RCS. UDFS had the highest rate of limb salvage without amputations (70.8%). GDFS had the highest rate for final toe amputations (52.4%) and major amputations (23.8%). Final minor amputation rate was around 20% for both SDFS and GDFS. Conclusion Redefining DFS into ulcerative, septic and gangrenous by integration of the predominant clinical presentation and the clinical criteria for DFI diagnosis and classification of IDSA/IWGDF showed significant differences in amputation rate. Therefore, it can be used clinically to categorize patients with DFS to predict amputations and to help in planning their management. Further prospective studies are suggested to validate these results.
TL;DR: A 61-year-old-man with no significant medical history presented to vascular clinic with complaint of a nontraumatic mass on the volar aspect and radial side of his right wrist for 6 years and was managed by open surgical resection with primary end-to-end anastomosis.
Abstract: Introduction The incidence rate of true non-traumatic radial artery aneurysms (RAAs) is low, and very few cases have been described. The majority are traumatic in origin and are iatrogenic pseudo-aneurysms following arterial cannulation. However, other rare causes such as vascular tumors, connective tissue diseases, and occupational injury have also been reported. Only eight cases were reported as idiopathic true RAA. Herein, I describe a case of true idiopathic distal RAA, which was managed by surgical repair. Case presentation A 61-year-old-man with no significant medical history presented to vascular clinic with complaint of a nontraumatic mass on the volar aspect and radial side of his right wrist for 6 years. Duplex ultrasound and computed tomography angiogram revealed distal RAA. It was managed by open surgical resection with primary end-to-end anastomosis. Histopathological studies revealed true aneurysm of the distal radial artery. Conclusion True distal RAAs are an extremely rare entity. Unawareness of this condition might lead to inappropriate management with significant morbidity. Surgical management is generally indicated, but the best treatment remains controversial.
TL;DR: The prevalence of PAD was not as high as expected in this group of patients with high cardiovascular risk infected with HIV, while ARV was protective.
Abstract: Background The prevalence of peripheral artery disease (PAD) is not well known among HIV-infected patients in Africa. The aim of this study was to determine the prevalence and associated risk factors of PAD among HIV-infected patients at the Douala General Hospital (DGH). Methods This was a cross-sectional descriptive and analytic study between November 2015 and April 2016. We recruited patients aged ≥21 years, diagnosed with HIV infection, and who were receiving care at the DGH. We collected sociodemographic data and past medical history of patients. We measured their ankle-brachial index (ABI). We defined PAD as an ABI Results We recruited 144 patients for this study. The mean age was 46±9 years, and 72.2% were females. Of which, 89% were on antiretroviral treatment (ARV). Their mean CD4+ T lymphocytes count was 451±306 cells/mm3. Their mean ABI was 1.12±0.17 and 1.07±0.11, respectively, on the left and right legs (P>0.05). The prevalence of PAD was 6.9% (95% CI: 3.4-12.4), and 60% of patients with PAD were symptomatic. After adjusting for age, sex and ARV, ARV treatment was protective (aOR: 0.18, [95% CI: 0.04-0.82], P=0.034), while WHO stages III or IV was associated with PAD (aOR: 11.1, [95% CI: 2.19-55.92], P=0.004). Conclusion The prevalence of PAD was not as high as expected in this group of patients with high cardiovascular risk infected with HIV. Advanced HIV disease was associated with PAD, while ARV was protective.
TL;DR: Findings of a high prevalence of overweight/obesity, physical inactivity, and junk food intake and low fruits intake among doctors is worrisome and there is a need to educate doctors on adopting healthier lifestyles to reduce risk of CVDs.
Abstract: Introduction Almost one third of deaths globally are caused by cardiovascular diseases (CVDs). Certain occupations may promote the development and worsening of risk factor for CVDs. We assessed some traditional cardiovascular risk factors and lifestyle choices that may predispose to CVDs in medical doctors in a tertiary health facility in Southern Nigeria. Study design Cross-sectional study. Participants and methods One hundred sixty-nine apparently healthy medical doctors were recruited. A structured self-administered questionnaire was used to gather data on CVD risk factors. Anthropometric and blood pressure (BP) measurements were taken. Results Majority were males (68.0%), aged 20-39 years (43.8%), single (62.7%), and house officers (58.0%) with<1 year (48.5%) work experience. Over half were either overweight or obese. While 77.2% of those not centrally obese were males, only about 22.8% of females did not meet the criteria for central obesity (P-value < 0.05). While respondents had BP in prehypertensive (48.2%), stage 1 (18.5%), or stage 2 hypertension (3.6%) ranges, only 7.7% had a previous diagnosis of hypertension. Only 25.4% took fruits on a daily basis and engaged in aerobic exercises up to 30 minutes daily or at least 3-5 times a week. Other poor lifestyle choices included non-lean meat intake (76.8%), low water intake (88.2%), and junk food and soda drinks intake (daily 28%, weekly 51.2%). Conclusion Findings of a high prevalence of overweight/obesity, physical inactivity, and junk food intake and low fruits intake among doctors is worrisome. There is a need to educate doctors on adopting healthier lifestyles to reduce risk of CVDs.
TL;DR: A moderate-to-high level of awareness is revealed among patients for most cardiovascular risk factors, but a low- to-moderate level of adherence for some interventions such as physical exercise, weight loss, and smoking cessation.
Abstract: Background Noncommunicable diseases are the leading cause of death in Lebanon, with cardiovascular diseases accounting for almost half of the annual deaths. Purpose We aimed to determine awareness of noncardiac Lebanese hospitalized patients for their coronary artery disease risk factors, their level of adherence to medications or lifestyle modifications, and assess factors associated with awareness. Materials and methods A cross-sectional study was conducted in 14 hospitals with a total of 382 patients. Levels of awareness were evaluated by the comparison of self-report with measurements and laboratory test results. Healthy behaviors and adherence to treatment were evaluated. Factors associated with better awareness were studied using multivariate regressions, while adherence to treatments and healthy lifestyle were described for the different risk factors and in the Framingham Risk Score categories. Results Our work revealed a moderate-to-high level of awareness (58.7% for overweight/obesity, 75% for hypertension, 85.7% for diabetes, and 86.4% for dyslipidemia) among patients for most cardiovascular risk factors, but a low-to-moderate level of adherence for some interventions such as physical exercise, weight loss, and smoking cessation. Conclusion The results emphasize on the importance of educational campaigns on healthy habits and screening to improve early diagnosis, increase patients' awareness of their risk factors, and, therefore, optimize primary prevention.
TL;DR: The findings indicate that the trigger of TAO might be Gram-negative bacteria, which can be hidden or immunologically suppressed in the quiescent phase ofTAO, leading to a lower level of TLR4 accompanying the normal level of neopterin.
Abstract: Background The possible role of infectious pathogens in the development of thromboangiitis obliterans (TAO) was considered soon after the disease was first described. However, it is not yet known whether infectious pathogens induce thrombotic vasculitis or if they cause a type of autoimmune disease. To investigate whether TAO relapses are more likely due to reinfection or autoimmune flare, the serum levels of toll-like receptor (sTLR) 4, sTLR2, C-reactive protein (CRP), and neopterin were evaluated in TAO patients during both the acute and quiescent phases of the disease as well as in a gender-, age-, and smoking habit-matched control group. Methods Following a cross-sectional study design, 28 patients in the acute phase of TAO and 23 patients in the quiescent phase participated in this study. In addition, 31 matched controls were enrolled. Results Toll-like receptor (TLR) 4 was significantly higher in patients in the acute phase of the disease than in patients in the quiescent phase (P=0.012). Also, TLR4 was significantly higher in the patients with CRP >7 µm/mL than in the patients with lower CRP (P=0.031). Notably, TLR4 in the patients in the quiescent phase of TAO was significantly lower than in the controls (P=0.006). No significant difference in the level of TLR2 was found among the groups (P>0.05). Neopterin was significantly higher in the acute phase of TAO in comparison to the quiescent phase (P=0.003) and the controls (P=0.005). Conclusion These findings indicate that the trigger of TAO might be Gram-negative bacteria, which can be hidden or immunologically suppressed in the quiescent phase of TAO, leading to a lower level of TLR4 accompanying the normal level of neopterin. However, relapses might develop according to toxic or hypoxic cell injuries. Hence, TLR4 shedding will increase, and therefore, sTLR4 could become closer to the level demonstrated in the controls.
TL;DR: Serum levels of vitamin D were measured in 186 Jordanian patients who underwent investigative coronary catheterization and there was a significant association between vitamin D abnormalities and both body mass index and dyslipidemia, however, current results did not show any significant association with other risk factors for IHD.
Abstract: Background Decreased levels of vitamin D were associated with increased risk of multiple diseases, including cardiovascular diseases. However, there seem to be some discrepancies among the results obtained from different studies. The aim of the present study was to explore the importance of having sufficient serum levels of vitamin D in reducing the incidence and the progression of coronary artery stenosis and ischemic heart disease (IHD). Methods Serum levels of vitamin D were measured using radioimmunoassay in 186 Jordanian patients who underwent investigative coronary catheterization. Of these patients, 133 were suffering from coronary artery stenosis. The association between vitamin D levels, coronary stenosis and many risk factors was determined using SPSS software. Results and conclusions Interestingly, the current results did not show an association between vitamin D abnormalities and the incidence or the reoccurrence of coronary artery stenosis. Moreover, significant differences were detected in the prevalence of vitamin D abnormalities based on the patient's gender, and there was a significant association between vitamin D abnormalities and both body mass index and dyslipidemia. However, current results did not show any significant association with other risk factors for IHD. For instance, no association was found with smoking, hypertension, diabetes mellitus, stable and unstable angina or with acute recent myocardial infarction.
TL;DR: Elevated serum levels of endocan and MPO and low 1,25(OH)2D3 levels may underlie the development of psoriasis-related cardiac manifestations and could be used as early predictors of increased CIMT, which is a pathognomonic feature of AAS.
Abstract: Background The aim of the study was to measure serum levels of endocan, myeloperoxidase (MPO), pentraxin 3 (PTX3) and 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) in psoriatic patients and to study their correlations with carotid intima-media thickness (CIMT) in trial to evaluate predictability of these parameters in diagnosing asymptomatic atherosclerosis (AAS). Patients and methods Seventy-five psoriasis patients and 75 control subjects underwent complete clinical examination and Doppler estimation of CIMT using thickness of 0.9 mm as cutoff point for diagnosis of AAS. Blood samples were collected for determination of fasting blood glucose, lipid profile and serum C-reactive protein (CRP), endocan, MPO, PTX3 and 1,25(OH)2D3. Results Estimated blood low-density lipoprotein cholesterol (LDL-c) and serum CRP, PTX3, MPO and endocan levels were significantly higher, while blood high-density lipoprotein cholesterol (HDL-c) and serum 1,25(OH)2D3 levels were significantly lower in patients than in controls. CIMT showed significant positive correlation with disease severity and duration; patients' age; and endocan, MPO, LDL-c, PTX3 and CRP levels, and significant negative correlation with HDL-c and 1,25(OH)2D3 levels. Regression analysis defined high serum endocan and MPO, low serum 1,25(OH)2D3 and increased disease severity as significant predictors of high CIMT. Conclusion Elevated serum levels of endocan and MPO and low 1,25(OH)2D3 levels may underlie the development of psoriasis-related cardiac manifestations. Elevated serum endocan and low 1,25(OH)2D3 levels could be used as early predictors of increased CIMT, which is a pathognomonic feature of AAS.
TL;DR: Overall these studies demonstrate that among patients with type 2 diabetes mellitus, canagliflozin results in decreased systolic and diastolic blood pressure, lower body weight, and also exhibits renoprotective effects, similar to placebo or other antihyperglycemic agents.
Abstract: Cardiovascular disease is the leading cause of morbidity and mortality among patients with diabetes mellitus, as well as the leading diabetes-associated health care cost. The prevalence and associated impact of cardiovascular disease among those with diabetes engenders the need to identify cardiovascular effects of antihyperglycemic agents. This review seeks to evaluate the impact of canagliflozin, a SGLT2 inhibitor, on cardiovascular risk factors and outcomes. The 14 published trials to-date exploring various cardiovascular risk factors and outcomes among patients receiving canagliflozin were identified and included within the review. Overall these studies demonstrate that among patients with type 2 diabetes mellitus, canagliflozin results in decreased systolic and diastolic blood pressure, lower body weight, and also exhibits renoprotective effects. These findings were similar when canagliflozin was compared to placebo or other antihyperglycemic agents and explored among subsets such as those with chronic kidney disease. In addition, findings from the three trials exploring cardiovascular outcomes of canagliflozin included reduction in cardiovascular mortality and lower incidence of heart failure-associated hospitalizations. Results from studies including other SGLT2 inhibitors suggest that cardiovascular benefits are likely a class-effect found among current SGLT2 inhibitors. Continued research specific to canagliflozin is needed to clarify risks of adverse effects and determine optimal dosing requirements for canagliflozin in regard to cardiovascular risk reduction.
TL;DR: Treatment based on FDC was effective in decreasing BP and TOD regression in both patients with and without ischemic heart disease, however, the dynamics of changes in TOD were different between the two groups, which should be taken into consideration during management of patientswith and without IHD.
Abstract: Background The EPHES trial (Evaluation of influence of fixed dose combination Perindo-pril/amlodipine on target organ damage in patients with arterial HypErtension with or without iSchemic heart disease) compared the dynamics of target organ damage (TOD) in hypertensive patients with and without ischemic heart disease (IHD) treated with the fixed-dose combination (FDC) perindopril + amlodipine. Methods The analysis included 60 hypertensive patients (aged >30 years): 30 without IHD and 30 with IHD. At randomization, FDC was administered at a daily baseline dose of 5/5 mg with uptitration to 10/10 mg every two weeks. If target blood pressure (BP<140/90 mmHg) was not achieved after six weeks, indapamide 1.5 mg was added to the regimen. All patients underwent body mass index measurements, office and ambulatory BP measurements, pulse wave velocity (PWVe) and central systolic BP evaluation, augmentation index adjusted to heart rate 75 (Aix@75) evaluation, biochemical analysis, ECG, echocardiography with Doppler, ankle-brachial index measurement, and intima-media thickness measurement. The follow-up period was 12 months. Results Therapy based on FDC perindopril/amlodipine was effective in lowering BP (office, ambulatory, central) in both groups. We noted significant decrease in Aix@75 with the therapy in both groups, but ΔAix@75 was lesser in the group with IHD than the group without IHD. FDC provided significant improvement in PWVe and left ventricular diastolic function, and decrease in albuminuria, left ventricular hypertrophy (LVH), and left atrium size. ΔPWVe was significantly (P<0.005) less in patients without IHD than those with IHD (2.5±0.2 vs 4.4±0.5 m/s, respectively). In spite of almost equal LVH regression, the positive dynamics of ΔE/A and ΔE/E´ were more in patients with IHD than those without IHD (64.4% and 54.1% vs 39.8 and 23.2%, respectively; P<0.05 for both comparisons). Adverse reactions were in 2 (6.5%) patients without IHD and 3 (10%) with IHD (P=NS). In the group with IHD, we noted significant decrease in angina episode rate - from 2.5±0.4 to 1.2±0.2 (P<0.01) per week. Conclusion Thus, treatment based on FDC was effective in decreasing BP and TOD regression in both patients with and without IHD. However, the dynamics of changes in TOD were different between the two groups, which should be taken into consideration during management of patients with and without IHD.
TL;DR: Acute spontaneous IJV thrombosis as a primary presentation of antiphospholipid syndrome is extremely uncommon and patients should be aware of the possibility of this condition in the differential diagnosis and management, as long-term anticoagulation is needed.
Abstract: Introduction Spontaneous and isolated internal jugular vein (IJV) thrombosis is a rare entity, and atypical localization for venous thromboembolism usually occurs after an oropharyngeal infection, cancer, central venous catheter, and ovarian hyperstimulation syndrome This report describes a case of spontaneous IJV thrombosis leading to neck pain and swelling as a primary manifestation of antiphospholipid (Hughes) syndrome Case presentation A 44-year-old male with no significant past medical history presented with a 1-week duration of right-sided painful neck swelling Duplex ultrasound and computed tomography angiogram revealed right IJV thrombosis Hematology studies were normal apart from positive lupus anticoagulant The patient was managed conservatively with low molecular weight heparin, antibiotics, and close follow-up Conclusion Acute spontaneous IJV thrombosis as a primary presentation of antiphospholipid syndrome is extremely uncommon We should be aware of the possibility of this condition in the differential diagnosis and management, as long-term anticoagulation is needed