Jose Venero

Lipid-Lowering Efficacy of Red Yeast Rice in a Population Intolerant to Statins

Chinese red yeast rice is a dietary supplement containing monacolins, unsaturated fatty acids, and phytosterols capable of lowering low-density lipoprotein (LDL) cholesterol. Few studies have reported on its use in clinical practice or in statin-intolerant patients. We reviewed approximately 1,400 clinical charts and identified 25 patients treated with red yeast rice for > or =4 weeks. The patients were included if they had pre- and post-treatment lipid levels without simultaneous changes in other lipid-lowering medications. These patients had experienced myalgias (68%), gastrointestinal intolerance (16%), and/or elevated alanine aminotransferase levels (8%) with previous use of other lipid-lowering agents. The total cholesterol decreased 15% (-37 +/- 26 mg/dl, p <0.001) and LDL cholesterol decreased 21% (-35 +/- 25 mg/dl, p <0.001) during 74 +/- 39 days of treatment. Most (92%) patients tolerated the treatment, and many (56%) achieved their LDL cholesterol goal. In patients unable to tolerate daily statin use, the total cholesterol level decreased 13% (-33 +/- 10 mg/dl, p <0.001) and LDL cholesterol decreased 19% (-31 +/- 4 mg/dl, p <0.001). In conclusion, red yeast rice modestly decreased total and LDL cholesterol, was well-tolerated, and was an acceptable alternative in patients intolerant of other lipid-lowering medications.

Effectiveness of Thrice Weekly Ezetimibe

Ezetimibe is usually dosed daily, but its 22-hour elimination half-life permits significant cholesterol reduction with less frequent dosing. The aim of this study was to examine lipid changes in 33 patients treated with thrice-weekly ezetimibe for > or =1 month, who had pre- and postezetimibe lipid levels and no other concurrent changes in their lipid treatment. Ninety-four percent of the patients were treated with ezetimibe because they experienced myalgias, elevated transaminase levels, or gastrointestinal intolerance with higher doses of other lipid-lowering agents. Total cholesterol decreased by 15% (-36 +/- 28 mg/dl, p <0.001) and low-density lipoprotein cholesterol by 20% (-30 +/- 25 mg/dl, p <0.001) during 58 +/- 50 days of treatment. Most patients (85%) tolerated the treatment, and many (48%) achieved their low-density lipoprotein cholesterol goals. In conclusion, thrice-weekly ezetimibe decreases total and low-density lipoprotein cholesterol and is well tolerated. It is a viable treatment for patients intolerant of other lipid-lowering medications.

Mid wall fibrosis on CMR with late gadolinium enhancement may predict prognosis for LVAD and transplantation risk in patients with newly diagnosed dilated cardiomyopathy—preliminary observations from a high-volume transplant centre

Patients with newly diagnosed dilated cardiomyopathy (DCM) and advanced heart failure have a very high morbidity and mortality with an unpredictable clinical course. We investigated the role of cardiovascular magnetic resonance (CMR) imaging using late gadolinium enhancement (LGE) in this cohort of high‐risk patients. We hypothesized that LGE has high prognostic value in primary DCM patients referred for possible transplantation/left ventricular assist device (LVAD) consideration.BACKGROUND Patients with newly diagnosed dilated cardiomyopathy (DCM) and advanced heart failure have a very high morbidity and mortality with an unpredictable clinical course. We investigated the role of cardiovascular magnetic resonance (CMR) imaging using late gadolinium enhancement (LGE) in this cohort of high-risk patients. We hypothesized that LGE has high prognostic value in primary DCM patients referred for possible transplantation/left ventricular assist device (LVAD) consideration. METHODS Over 49 consecutive months, 61 consecutives DCM patients were referred for standard CMR(1.5T, GE) to interrogate the LV pattern, distribution, and extent of LGE (MultiHance, Princeton, NJ). Inclusion criteria for a primary non-ischaemic DCM and EF <45% were met in 31 patients. DCM patients were categorized into: (i) presence of midwall LV stripe (+Stripe) and (ii) absence of midwall stripe (-Stripe) groups. Primary outcome was defined by the composite of death, need for LV assist device (LVAD), and urgent orthotopic cardiac transplantation (Tx) during a 12-month follow-up period. Kaplan-Meier survival analysis was conducted grouping patients by +Stripe and -Stripe. RESULTS There were no differences between groups for demographics, blood pressure, labs, baseline LVEF, NYHA class, or invasive haemodynamics. There were 18 patients (58%) with +Stripe. Nine events occurred: seven patients required urgent Tx and/or LVAD implantation and two patients died. The +Stripe categorization strongly predicted the need for LVAD, urgent Tx surgery, and death (log-rank = 9, P = 0.002). All the events occurred in the +Stripe patients with no MACE experienced in the -Stripe group. The -Stripe group experienced marked signs of improvement in LVEF (P = 0.01) at follow-up. LVEDD was predictive of need for LVAD/Tx and death by univariate analysis. Otherwise, no common clinical metric such as LVEF, LVEDV, RVEF, RVEDV, or any invasive haemodynamic parameter predicted MACE. CONCLUSIONS The presence of +Stripe on CMR is strongly predictive of LVAD, transplant need, and death during a 12-month follow-up period in DCM patients in this proof of concept study. All -Stripe patients survived without experiencing any events. Incorporating CMR imaging into routine clinical practice may have prognostic value in DCM patients; indicating conservative management in low-risk patients while expectantly managing high-risk patients.

Can cardiac MRI be the 'crystal ball' for risk stratification in dilated cardiomyopathy? The impact of an LV mid-myocardial stripe on LVAD and transplantation risk

Patients with newly diagnosed dilated cardiomyopathy and advanced heart failure have a very high morbidity and mortality with an unpredictable clinical course. We investigated the role of CMR via LGE in this cohort of patients.

Dilated cardiomyopathy risk stratification; the vital role of CMR

Methods Over 24 consecutive months, 49 CMX pts were referred for standard 3D CMR (1.5 T GE) to interrogate the LV pattern, distribution and extent of DHE (MultiHance, Princeton, NJ). 18 pts met follow-up inclusion criteria for the study. Pts were categorized into: 1)+DHE/+midwall Stripe 2)+DHE/-Stripe and 3)-DHE/-Stripe. LVAD, Tx use, major adverse clinical events (MACE) and event free survival were evaluated over the next 6 months.

Can cardiac MRI be the index metric for risk stratification in dilated cardiomyopathy; the impact of an LV mid-myocardial stripe on subsequent risk of LVAD, transplantation and death

Summary The mid-wall intramyocardial ‘stripe’ is now shown to be robust in its prediction of subsequent need for LVAD and/or transplantion and death out to 12 months following index CMR exam. Background Patients with newly diagnosed dilated cardiomyopathy (DCM) and advanced heart failure have a very high morbidity and mortality with an unpredictable clinical course. We investigated the role of CMR via LGE (late gadolinium enhancement) in this cohort of high-risk patients. Hypothesis Utilizing cardiovascular MRI (CMR), we assessed the prognostic value of LGE in primary dilated DCM patients referred for possible transplantation/ LVAD consideration. Methods