Asterios Karagiannis

Diabetes, bilirubin and amputations: is there a link?

A study by Chan et al in this issue of Diabetologia (DOI:10.1007/s00125-012-2818-4) reports that low plasma bilirubin levels are associated with an increased risk of amputation in patients with type 2 diabetes mellitus participating in the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study. These findings raise the interesting and clinically relevant hypothesis that bilirubin protects against risk of amputation in patients with type 2 diabetes. This commentary considers some of the limitations associated with research aiming to define any link between circulating bilirubin levels and vascular disease. Numerous confounding factors (several of which may be present in patients with type 2 diabetes) may explain why the literature regarding this potentially protective role of bilirubin remains controversial.

Diabetes and lipid metabolism.

The authors review the association between diabetes mellitus (DM) and aberrations of lipid metabolism related to DM, diabetic dyslipidemia (DD). DM is considered as a major health burden worldwide and one of the most important modifiable cardiovascular disease (CVD) risk factors. This applies to both the developed and the developing countries, especially the latter. While patients with type 1 DM, 10% of all DM cases, usually do not have dyslipidemia, DD is frequent among patients with type 2 DM (T2DM) (prevalence > 75%) and is mainly a mixed dyslipidemia [increase in triglycerides (TGs), low high-density lipoprotein cholesterol (HDL-C), and small-dense (atherogenic), low-density lipoprotein cholesterol (LDL-C) particles]. The components of DD, which is characterized by quantitative (mentioned above), qualitative, and kinetic abnormalities all contributing to CVD risk, are mostly related to insulin resistance. Statins, ezetimibe, and PCSK9 inhibitors can be used in monotherapy or consecutively in combinations if needed. Statins compose the main drug. For the residual CVD risk after statin treatment, the use of statin-fibrate combinations is indicated only in patients with mixed dyslipidemia. In conclusion, DD is a major health problem worldwide. It is a significant CVD risk factor and should be treated according to current guidelines. The means today exist to normalize all quantitative, qualitative, and kinetic aberrations of DD, thereby reducing CVD risk.

2013 American College of Cardiology/American Heart Association Lipid Guidelines after the 2016 American College of Cardiology Expert Panel Consensus Statement: To err is human; to admit it, divine

Citation Athyros V. G, Sfikas G, Boutari C, et al. 2013 American College of Cardiology/American Heart Association Lipid Guidelines after the 2016 American College of Cardiology Expert Panel Consensus Statement: To err is human; to admit it, divine. Hell J Atheroscler 2016, 7: 63-75 The 2016 American College of Cardiology (ACC) Expert Panel Consensus Statement addresses the current gaps in low-density lipoprotein cholesterol (LDL-C) lowering strategies to reduce cardiovascular risk. The goal was to provide practical guidance for clinicians and patients in cases not covered by the 2013 ACC/American Heart Association lipid guidelines until the next round of guidelines has the opportunity to formally review recent scientific evidence and cardiovascular outcomes trials are completed with new agents for cardiovascular risk reduction. The new aspects in comparison to the 2013 guidelines are mainly two. The Writing Committee suggests specific LDL-C targets (which were absent in the 2013 ACC/AHA guidelines) rather than LDL-C percent reductions so that we have a benchAbstract

Protecting the brain and the heart: antithrombotic treatment in nonvalvular atrial fibrillation.

Novel anticoagulants (NOACs) are the recent therapeutic breakthrough in the prophylaxis of stroke in patients with nonvalvular atrial fibrillation (NVAF). Patients with NVAF seem to have a high atherosclerotic burden, but it has not yet been established whether these agents also protect against cardiovascular disease (CVD). Different NOACs could have cardioprotective properties of different importance, but data come only from indirect comparisons. Patients with NVAF are at risk of stroke when there is concomitant atherosclerosis that also necessitates optimal treatment to reduce CVD risk. Combining antiplatelets with anticoagulants is a common clinical scenario and not always justified by current data and guidelines, putting patients at unnecessary bleeding risk. This review provides current knowledge about the cardioprotective properties of NOACs, the clinical importance of the link between CVD and NVAF, and the pitfalls of combining antiplatelet therapy with warfarin or NOACs.