Karol Suppan

Improvement in health-related quality of life after therapy with omeprazole in patients with coronary artery disease and recurrent angina-like chest pain. A double-blind, placebo-controlled trial of the SF-36 survey

BackgroundMany patients with coronary artery disease (CAD) have overlapping gastroenterological causes of recurrent chest pain, mainly due to gastroesophageal reflux (GER) and aspirin-induced gastrointestinal tract damage. These symptoms can be alleviated by proton pump inhibitors (PPIs). The study addressed whether omeprazole treatment also affects general health-related quality of life (HRQL) in patients with CAD.Study48 patients with more than 50% narrowing of the coronary arteries on angiography without clinically overt gastrointestinal symptoms were studied. In a double-blind, placebo-controlled, cross-over study design, patients were randomized to take omeprazole 20 mg bid or a placebo for two weeks, and then crossed over to the other study arm. The SF-36 questionnaire was completed before treatment and again after two weeks of therapy.ResultsPatients treated with omeprazole in comparison to the subjects taking the placebo had significantly greater values for the SF-36 survey (which relates to both physical and mental health), as well as for bodily pain, general health perception, and physical health. In comparison to the baseline values, therapy with omeprazole led to a significant increase in the three summarized health components: total SF-36; physical and mental health; and in the following detailed health concept scores: physical functioning, limitations due to physical health problems, bodily pain and emotional well-being.ConclusionsA double dose of omeprazole improved the general HRQL in patients with CAD without severe gastrointestinal symptoms more effectively than the placebo.

Impact of type 2 diabetes on the plasma levels of vascular endothelial growth factor and its soluble receptors type 1 and type 2 in patients with peripheral arterial disease

ObjectiveType 2 diabetes coexistent with lower extremity artery disease (peripheral arterial disease (PAD)) can be observed in numerous patients. The mechanism compensating for ischemia and contributing to healing is angiogenesis—the process of forming new blood vessels. The purpose of this study was to assess the likely impact of type 2 diabetes on the plasma levels of proangiogenic factor (vascular endothelial growth factor A (VEGF-A)) and angiogenesis inhibitors (soluble VEGF receptors type 1 and type 2 (sVEGFR-1 and sVEGFR-2)) in patients with PAD.MethodAmong 46 patients with PAD under pharmacological therapy (non-invasive), we identified, based on medical history, a subgroup with coexistent type 2 diabetes (PAD-DM2+, n=15) and without diabetes (PAD-DM2−, n=31). The control group consisted of 30 healthy subjects. Plasma levels of VEGF-A, sVEGFR-1, and sVEGFR-2 were measured using the enzyme-linked immunosorbent assay (ELISA) method.ResultsThe subgroups of PAD-DM2+ and PAD-DM2−revealed significantly higher concentrations of VEGF-A (P=0.000 007 and P=0.000 000 1, respectively) and significantly lower sVEGFR-2 levels (P=0.02 and P=0.000 01, respectively), when compared with the control group. Patients with PAD and coexistent diabetes tended to have a lower level of VEGF-A and higher levels of sVEGFR-1 and sVEGFR-2 comparable with non-diabetic patients.ConclusionsThe coexistence of type 2 diabetes and PAD is demonstrated by a tendency to a lower plasma level of proangiogenic factor (VEGF-A) and higher levels of angiogenesis inhibitors (sVEGFR-1 and sVEGFR-2) at the same time. Regardless of the coexistence of type 2 diabetes, hypoxia appears to be a crucial factor stimulating the processes of angiogenesis in PAD patients comparable with healthy individuals, whereas hyperglycemia may have a negative impact on angiogenesis in lower limbs.中文概要目 的研究2 型糖尿病对外周动脉疾病患者血浆内的血管内皮生长因子(VEGF-A)及其水溶性受体(sVEGFR-1 和sVEGFR-2)浓度的影响。创新点首次研究了2 型糖尿病对外周动脉疾病患者血浆内sVEGFR-1 和sVEGFR-2 浓度的影响。方 法选取46 个外周动脉疾病患者, 根据有无2 型糖尿病分为糖尿病组(15 例)和无糖尿病组(31 例), 另选30 个健康志愿者为正常对照组。采用酶联免疫吸附法(ELISA)检测他们血浆中VEGF-A及sVEGFR-1 和sVEGFR-2 的浓度, 然后通过对比各组浓度研究2 型糖尿病的影响。结 论与正常对照组相比, 外周动脉疾病患者具有较高的VEGF-A 浓度(2 型糖尿病组 P=0.000 007, 非糖尿病组 P=0.000 000 1)以及较低的sVEGFR-2浓度(2 型糖尿病组 P=0.02, 非糖尿病组 P=0.000 01)。同时, 2 型糖尿病组比非糖尿病组具有较低的VEGF-A 浓度及较高的sVEGFR-1 和sVEGFR-2 浓度。研究结果表明: 无论2 型糖尿病是否共存, 缺氧是导致血管生成的一个关键的刺激因素; 同时, 高血糖状态对下肢的血管生成有抑制作用。

Treatment with double dose of omeprazole increases β-endorphin plasma level in patients with coronary artery disease

Introduction The proton pump inhibitor empirical trial, besides the analysis of symptoms, is the main method in the diagnosis of gastro-oesophageal reflux disease-related chest pain. β-Endorphin acts as an endogenous analgesia system. The aim of the study was verify whether β-endorphin plasma level is affected by omeprazole administration and influences the severity of anginal symptoms and outcome of the “omeprazole test” in patients with coronary artery disease (CAD) and chest pain of suspected non-cardiac origin. Material and methods Omeprazole was administered to 48 patients with CAD in a randomized, placebo-controlled, crossover study design. At the beginning of the study, and again after the 14-day omeprazole and placebo treatment, the β-endorphin plasma concentration was determined. Results The level of plasma β-endorphin after the administration of omeprazole was significantly greater than at the start of the study and following the placebo. Responders to omeprazole had an average lower β-endorphin plasma concentration than subjects who failed to respond to this therapy. Subjects with symptoms in class III (according to the Canadian Cardiovascular Society classification) after omeprazole administration had a greater β-endorphin plasma level than subjects in class II for anginal symptom severity. Conclusions Fourteen-day therapy with a double omeprazole dose significantly increases the β-endorphin plasma concentration in patients with CAD. Circulating β-endorphin does not seem to be involved in the mechanism for the “omeprazole test” outcome, although an individually different effect on pain threshold cannot be excluded.

Overweight and obesity versus concentrations of VEGF-A, sVEGFR-1, and sVEGFR-2 in plasma of patients with lower limb chronic ischemia

ObjectiveBeing overweight or obese comprises a significant risk factor for atherosclerosis. Fat tissue also generates factors stimulating angiogenesis, the process by which new blood vessels form. The purpose of this paper is to assess concentrations of the vascular endothelial growth factor A (VEGF-A) and its soluble type-1 and type-2 receptors (sVEGFR-1 and sVEGFR-2) in plasma of patients with peripheral arterial disease (PAD) depending on the level of nutrition according to body mass index (BMI).MethodsThe study group included patients suffering from symptomatic PAD (n=46) in Fontaine classes IIa–IV without any history of neoplastic disease and who have a normal BMI (n=15), are overweight (n=21) or are obese (n=10). The control group (n=30) consisted of healthy non-smoking volunteers who were neither overweight nor obese. Venous blood plasma samples were collected from both groups at rest in the morning to determine plasma concentrations of VEGF-A, sVEGFR-1, and sVEGFR-2 using the enzymelinked immunosorbent assay (ELISA) method.ResultsThe group of patients with PAD co-existent with being overweight or obese tended to have higher mean concentration levels of VEGF-A and sVEGFR-2 when compared with patients suffering from PAD with normal BMI. A statistically significant positive correlation was obtained between BMI and average plasma concentrations of sVEGFR-2 (R=0.37, P=0.0103). However, no significant correlation was noticed between BMI and VEGF-A or sVEGFR-1 concentrations.ConclusionsA positive correlation determined between the level of antiangiogenic factor and BMI value may be indicative of the linearly growing prevalence of some antiangiogenic factors in patients with metabolic disorders, which may be one of numerous factors contributing to incomplete efficiency of collateral circulation development in patients with PAD.中文概要目 的研究外周动脉疾病(PAD) 患者血浆中血管内皮 生长因子A(VEGF-A) 和它的可溶性1 型和2 型受体(sVEGFR-1 和sVEGFR-2) 的浓度与营 养水平的关系, 同时根据身体质量指数(BMI) 来评估营养水平。创新点将血管生成与超重和肥胖及下肢局部缺血联系起 来, 并根据BMI 评估了它们之间的关系。方 法研究组包括46 名Fontaine 等级IIa 至IV 且没有 任何肿瘤疾病史的PAD 症状患者, 其中15 名 BMI 正常, 21 名超重, 10 名肥胖。对照组由30 名不超重且不肥胖的健康非吸烟志愿者组成。试 验在上午休息时间采集两组静脉血的血浆标本, 用酶联免疫吸附(ELISA) 方法确定血浆中的 VEGF-A、sVEGFR-1 和sVEGFR-2 浓度。结 论如果PAD 患者同时伴随着超重或者肥胖, 会影 响血管再生的过程。sVEGFR-2 水平和BMI 值之 间有正相关关系, 这说明代谢紊乱患者中的一些 抗血管生成因子患病率的线性增长的原因, 同时 这可能是导致PAD 患者侧支循环发展效率不完 全的众多因素之一。

Clinical risk factors for loss of stent primary patency in patients with chronic legs ischemia

BACKGROUND The outcome of endovascular therapy can be influenced by a number of factors, either demographic, biochemical, angiographic or procedural. Knowledge about these factors may help in the individualization of therapeutic methods, surveillance intensity, and should, ultimately, improve intervention efficacy. OBJECTIVES The aim of this study was to estimate the effect of clinical and biochemical factors on the late outcome of lower limb artery stenting. MATERIAL AND METHODS The medical documentation of 91 patients with at least a 1 year follow-up after the stenting of a lower limb artery was retrospectively evaluated. Uniand multivariate analyses were performed. RESULTS Primary patency within an approximately 1.5-year follow-up amounted to 68.2%. The probability of freedom from target lesion revascularization was significantly greater in patients with dyslipidemia. According to the Cox proportional-hazards analysis, the risk of target extremity revascularization was significantly affected by the following (hazard ratio [HR], 95% confidence interval): Age (0.93, 0.88-0.99); dyslipidemia at inclusion (0.046, 0.01-0.23); LDL blood concentration (1.02; 1.01-1.04); hematocrit (1.2, 1.02-1.42); mean platelet volume (0.66, 0.44-0.99); INR (1.58, 1.13-2.21); and aPTT (1.18, 1.07-1.3). CONCLUSIONS Endovascular treatment with stenting in patients with atherosclerotic peripheral arterial disease is effective, but the risk of primary patency loss was affected by the presence of dyslipidemia, age, and blood coagulation parameters. The effect of dyslipidemia on stent failure occurrence should be evaluated in further studies.

Giant gastroduodenal artery pseudoaneurysm as a pancreatic tumor and cause of acute bleeding into the digestive tract

A 42-year-old woman was admitted to our department in October of 2014 due to abdominal pain that had begun 2 weeks earlier. On admission she did not present crucial abnormalities upon physical examination , other than a longitudinal scar in the anterior abdominal wall. Abdominal ultrasonography showed a peripancreatic tumor with signs of blood flow inside (Figure 1 A). According to the patients medical history , three hospitalizations had occurred on other wards due to: severe acute pancreatitis (August of 2012); a pancreatic pseudocyst that required drainage under endoscopic ultrasonography (EUS) control (October of 2013); and a tumor of the pancreatic head (50 × 53 × 51 mm on abdominal computed tomography (CT)) and diabetes mellitus (September of 2014). During the last hospitalization the patient was referred to the Surgical Department because of the obscure character of the tumor of the pancreatic head and a family history of pancreatic cancer in order to perform the pancrea-to-duodenectomy. However, during the laparotomy the surgeons changed the primary plan and biopsies were taken only from the tumor. The results of the biopsies showed inflammatory and fibroid tissue in the pancre-atic lesion (September 2014). In our department, the initial suspicion of a vascu-lar pancreatic lesion was confirmed using computed tomography angiography (angio-CT), which described: pseudoaneurysm of the gastroduodenal artery, 50 × 40 mm in size (Figures 1 B–D), gastric fundus varices, liver steatosis with perfusion disturbances, and a dilated Wirsung duct. The female patient thus qualified for endovascular embolization. However, the procedure failed due to a problem with the catheterization of the vessel supplying the pseudoaneurysm. The patient was discharged without further complications. A second intervention was postponed due to radiation and the unchanged diameter of the pseudoaneurysm compared to September 2014. In November 2014, the patient was admitted due to signs of hemorrhage into the digestive tract with an obscure bleeding source, but without he-modynamic instability or significant decline in hemo-globin blood concentration. A second embolization of the gastroduodenal artery with coils placed distally and proximally to the canal supplying the lesion (to avoid ret-rograde filling) was performed with success. Control an-giography (Figure 1 E) and ultrasonography (Figure 1 F) performed 2 months after discharge did not detect any residual pseudoaneurysm. Visceral artery aneurysms are divided into true or pseudoaneurysms [1]. Moreover, pseudoaneurysms are classified according to: the type of artery from which they originated, communication with the gastrointes-tinal tract, and potential exposure …

Is rosuvastatin better than atorvastatin and simvastatin in the prevention of in-stent restenosis and atherosclerosis progression in patients after superficial femoral artery stenting due to chronic lower limb ischaemia? The preliminary case-control study

Introduction. Statins effect on the outcome of endovascular intervention due to chronic lower limb ischaemia (CLLI) is still uncertain. The aim of this study was to determine the effect of statin type on the late outcome of superficial femoral artery (SFA) stenting in patients with CLLI. Material and methods. Retrospective analysis of the medical documentation of 275 consecutive patients treated with SFA stenting due to CLLI, including 125 (45%) patients with critical limb ischaemia (CLI). Measured outcomes were: target lesion revascularization (TLR), target extremity revascularization (TER), and target limb amputation (TLA). Results. Statins were used by 267 (97%) of the patients, respectively: atorvastatin (n = 191, 70%), simvastatin (n = 31, 11%) and rosuvastatin (n = 45, 16%). During the 675.0 ± 569.7 days of follow-up, TLR was required by 79 (29%) patients, TER by 109 (39%), and TLA by 27 (10%). Patients treated with rosuvastatin in comparison with those treated with atorvastatin, in spite of greater initial LDL and triglyceride levels, required TER (p = 0.01) and TLR (p = 0.03) less frequently. The risk of TER in patients treated with rosuvastatin was significantly (p = 0.016) lower than in individuals treated with atorvastatin and simvastatin, as shown in the Kaplan-Meier analysis. Cox’s proportional hazards regression showed that therapy with rosuvastatin was the strongest factor (HR 0.40 ± 95% CI; 0.2-0.81) decreasing the likelihood of TER. Conclusions. Rosuvastatin after SFA stenting seems to have the strongest effect on reduction in reintervention risk but without influence on limb salvage.

Risk factors for major leg amputation in patients treated endovascularly due to critical limb ischaemia

Introduction. Critical limb ischaemia (CLI) is an advanced phase of chronic lower extremity ischaemia linked to increased mortality, decreased quality of life, and the risk of leg amputation. The aim of this study was to determine factors affecting the risk of leg amputation among patients with CLI treated endovascularly as a first approach. Material and methods. Of 118 patients treated endovascularly, 32 (27%) had a leg amputated. Their clinical data were analysed retrospectively. Results. Patients who had a leg amputated initially had a higher Rutherford class, were older, and had a greater prevalence of comorbidities. In multivariate analysis, amputation-free survival was shortened by a history of dyslipidaemia, female gender, blood creatinine concentration, the need for target lesion revascularization, smoking habit, Rutherford class, and leukocyte blood count. Whereas, the factors which decreased the risk of leg amputation were: use of statins, the number of previous interventions, and blood LDL cholesterol concentration. Angiographic classification of lesion severity did not affect endovascular procedure outcome. Conclusions. The risk of major amputation following endovascular treatment in patients with CLI was associated with a number of characteristics, mainly: atherosclerosis risk factors and necrosis advancement, and the number of reinterventions. To avoid endangering patients and the unnecessary utilization of resources, it would seem to be worth performing large studies to determine a risk stratification scoring system for patients with CLI, which could enable the qualification of risk-adjusted patients for endovascular or surgical revascularization or for primary leg amputation.

The association between periprocedural factors and the late outcome of percutaneous stenting of lower extremity arteries. A retrospective cohort study.

Introduction About 20–30% of the population have peripheral artery disease. Many of them require intervention, with a percutaneous procedure currently being the first choice. However, the outcomes of these interventions need regular evaluation due to continuous progress in endovascular techniques and the devices used. Aim The aim of this study was to analyze procedural factors influencing the outcome of endovascular intervention in patients stented for the first time due to lower extremity atherosclerosis. Material and methods The medical documentation of 91 patients with at least 1 year of follow-up after stenting of a lower limb artery was retrospectively evaluated. Uni- and multivariate analyses were performed. Results The mean observation time was 544.4 ±502.9 days. The primary patency of a stent after such a follow-up was 68.1%. Cox proportional hazard analysis revealed that the risk of target lesion revascularization was affected by the following (hazard risk, 95% confidence interval): the number of vascular segments with significant lesions (13.14, 2.28–75.8); critical limb ischemia (5.68, 1.23–26.2); localization of the target lesion in an aorto-iliac in comparison with a femoro-popliteal vascular segment (0.37, 0.14–0.7); aorto-iliac lesion class according to the TASC-II consensus (1.96, 1.1–3.8); and claudication distance (1.02, 1.01–1.03). Conclusions The common primary patency of a stent implanted into either an aorto-iliac or a femoro-popliteal vascular segment was similar to that found in other reports. The main factors affecting the outcome of the endovascular procedures performed were mainly related to atherosclerosis severity, not to the type of technique or device used.