Kosmas I. Paraskevas

Emerging indications for statins: a pluripotent family of agents with several potential applications.

Statins are pluripotent agents exhibiting multiple non-lipid-lowering actions. Besides their established role in the management of hypercholesterolemia, statins may also have beneficial actions in other pathological conditions, namely: a) osteoporosis and osteoporosis-related bone fractures, b) cancer, c) solid organ transplantation, d) cerebrovascular events (transient ischemic attack and stroke episodes), e) various neurological disorders, such as Alzheimers disease, Parkinsons disease and multiple sclerosis, f) cardiac arrhythmias and heart failure, g) renal diseases, h) rheumatoid arthritis, i) autoimmune diseases, j) sepsis, and k) allergic asthma. We reviewed the literature searching for studies that support or oppose the use of statins in each proposed indication. In some of these emerging indications, a role for statin treatment is more firmly set; for others, current evidence is more controversial. Future trials may reveal more convincing evidence that will make statin use necessary in the therapeutic management of several diseases.

Systematic Review of Guidelines for the Management of Asymptomatic and Symptomatic Carotid Stenosis.

Background and Purpose— We systematically compared and appraised contemporary guidelines on management of asymptomatic and symptomatic carotid artery stenosis. Methods— We systematically searched for guideline recommendations on carotid endarterectomy (CEA) or carotid angioplasty/stenting (CAS) published in any language between January 1, 2008, and January 28, 2015. Only the latest guideline per writing group was selected. Each guideline was analyzed independently by 2 to 6 authors to determine clinical scenarios covered, recommendations given, and scientific evidence used. Results— Thirty-four eligible guidelines were identified from 23 different regions/countries in 6 languages. Of 28 guidelines with asymptomatic carotid artery stenosis procedural recommendations, 24 (86%) endorsed CEA (recommended it should or may be provided) for ≈50% to 99% average-surgical-risk asymptomatic carotid artery stenosis, 17 (61%) endorsed CAS, 8 (29%) opposed CAS, and 1 (4%) endorsed medical treatment alone. For asymptomatic carotid artery stenosis patients considered high-CEA-risk because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 13 guidelines (46%). Thirty-one of 33 guidelines (94%) with symptomatic carotid artery stenosis procedural recommendations endorsed CEA for patients with ≈50% to 99% average-CEA-risk symptomatic carotid artery stenosis, 19 (58%) endorsed CAS and 9 (27%) opposed CAS. For high-CEA-risk symptomatic carotid artery stenosis because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 27 guidelines (82%). Guideline procedural recommendations were based only on results of trials in which patients were randomized 12 to 34 years ago, rarely reflected medical treatment improvements and often understated potential CAS hazards. Qualifying terminology summarizing recommendations or evidence lacked standardization, impeding guideline interpretation, and comparison. Conclusions— This systematic review has identified many opportunities to modernize and otherwise improve carotid stenosis management guidelines.

Statin treatment for rheumatoid arthritis : a promising novel indication

The results of several cross-sectional trials suggest that patients with rheumatoid arthritis (RA) have increased vascular risk and cardiovascular mortality. It was demonstrated that inflammation plays a pivotal role in the pathogenesis of both RA and atherosclerosis. This association may explain the high incidence of cardiovascular disease in RA patients. A number of recent studies show that routine statin use in patients with RA offers considerable advantages. Statin treatment has been supported to exert a beneficial effect on disease activity, swollen joint count, endothelial dysfunction, and arterial stiffness in RA patients. These improvements are coupled with a mild to moderate improvement in plasma markers of inflammation, such as C-reactive protein and erythrocyte sedimentation rate. Statins have a satisfactory safety profile with relatively few adverse effects. In the absence of side effects and contraindications, it may be reasonable to consider statin use in selected cases, particularly in patients with a long history of active RA who are at increased cardiovascular risk.

Renal Function Impairment in Peripheral Arterial Disease: An Important Parameter that Should not Be Neglected

A considerable percentage of patients with peripheral arterial disease (PAD) have impaired renal function. We searched the literature (PubMed/Medline) to determine the clinical significance and assess the management of renal dysfunction in these patients. The results of our literature search suggest that impaired renal function is a frequent finding in patients with PAD. The presence of concomitant renal dysfunction in these patients is associated with higher morbidity and mortality rates, as well as the occurrence of cardiovascular events (stroke, myocardial infarction, and vascular death). Additionally, impaired renal function negatively affects survival, limb salvage, and graft patency rates when these patients undergo lower extremity revascularization procedures. The use of statins and angiotensin-converting enzyme (ACE) inhibitors is associated with improved renal function and reduced cardiovascular risk in patients with PAD. Based on current evidence, renal function should be assessed and regularly monitored in all patients with PAD. More importantly, initiation of appropriate treatment (e.g., statins and ACE inhibitors) should be implemented to preserve renal function and improve vascular morbidity and mortality in these patients.

Internal carotid artery occlusion: association with atherosclerotic disease in other arterial beds and vascular risk factors.

The aim of this article is to investigate the association between internal carotid artery occlusion (ICAO) and the presence of atherosclerotic disease and vascular risk factors. The clinical characteristics and risk factors of 120 patients presenting with ICAO were retrospectively reviewed. All patients (n = 120) had at least 1 of the 4 vascular risk factor (diabetes, smoking, hypercholesterolemia, and hypertension); 2, 3, or all 4 risk factors were present in 14 to 82 of the patients (11.7% to 68.3%), 10 to 39 of the patients (8.3% to 32.5%), and 9 of the patients (7.5%), respectively. A total of 84 patients (70%) with ICAO had disease in at least 1 additional vascular bed (aorta, coronary or lower limb arteries). In addition to ICAO, vascular disease was present in 2 and all 3 of these arterial beds in 42 (35%) and 9 (7.5%) patients, respectively. Furthermore, stenosis or occlusion of the ipsilateral or contralateral vertebral arteries was recorded in 19 of 120 patients (15.8%). Regarding the contralateral carotid artery, 1 patient had bilateral ICAO. One patient had contralateral common carotid artery occlusion, and 1 patient was excluded from the analysis because of surgery to the contralateral carotid artery. Of the remaining 117 patients, 34 (29.0%) had less than 50% contralateral carotid artery stenosis. Thirty-two patients (27.4%) had 50% to 69%, and 51 (43.6%) had 70% to 99% stenosis. Ultrasonographic imaging of the carotid plaque of the contralateral carotid artery revealed that 52 of the 120 arteries (43.3%) were uniformly or predominantly echolucent (types I and II, respectively). Fifty-nine (49.2%) were predominantly or uniformly echogenic (types III and IV), and 9 (7.5%) could not be classified. A similar distribution of echomorphology was observed on the occluded side. ICAO is associated with widespread atherosclerotic disease and a high prevalence of vascular risk factors. Detection of ICAO should prompt the investigation of other arterial beds and treatment of risk factors.

Identifying Which Patients With Asymptomatic Carotid Stenosis Could Benefit From Intervention

Carotid guidelines recommend carotid endarterectomy (CEA) for patients with 60% to 99% asymptomatic carotid stenosis (ACS) provided the perioperative stroke/death rates are <3%.1,2 Several reports have noted that the average annual risk of ipsilateral/any territory stroke among patients with asymptomatic moderate to severe internal carotid artery stenosis receiving medical therapy (MT) alone has now fallen to ≈1%.3–5 The decreased incidence of stroke has been attributed to modern MT and has made opinion leaders demand a revision of management strategies4 by either refraining from CEA6 or by identifying high-risk patients.7 Such high-risk patients should be offered prophylactic CEA in addition to MT to reduce the risk of a future stroke. It is therefore essential to develop methods to identify these ACS patients at high enough risk to warrant prophylactic intervention. Several methods have been proposed for the identification of ACS patients at high risk for future stroke (Table),6,8–22 namely: (1) the detection of microemboli by transcranial Doppler (TCD), (2) identification of the unstable carotid plaque using ultrasound, (3) reduced cerebral blood flow reserve, (4) intraplaque hemorrhage using magnetic resonance imaging (MRI) scans, (5) silent embolic infarcts on brain computed tomography (CT) or MRI, and (6) progression in the severity of ACS. A discussion of the involved mechanisms and the predictive value of each of these methods is presented. View this table: Table. Suggested Predictors of the Development of Stroke/Transient Ischemic Attack in Asymptomatic Carotid Patients The predictive value of microemboli detection on TCD for the identification of ACS patients at high risk for stroke has been validated by 2 independent studies and is further supported by a meta-analysis.6,8–10,23 A small prospective, observational, cohort study failed to verify the association between TCD-detected emboli and …

Comparison of the five 2011 guidelines for the treatment of carotid stenosis

In 2011, five independent, international guideline committees reported their recommendations for the management of symptomatic and asymptomatic carotid artery stenosis. These included the American College of Cardiology/American Heart Association, the Society for Vascular Surgery, the European Society of Cardiology, the Australasian, and the UK National Institute of Health and Clinical Excellence. As the recommendations of these five guideline committees were based on the same published literature, it would be expected that they are similar, at least to a large extent. Surprisingly, there were considerable differences between the five guidelines regarding the management of both symptomatic and asymptomatic carotid patients. The differences in the recommendations between the five Guideline Committees are analyzed and discussed.

Statins Exert Multiple Beneficial Effects on Patients Undergoing Percutaneous Revascularization Procedures

BACKGROUND AND AIMS Statins are an essential component of the therapeutic approach of patients with atherosclerotic disease. Statin use is also associated with improved peri-operative and long-term outcomes in these patients. We aimed to define the role of statin treatment in patients undergoing percutaneous revascularization procedures. LITERATURE SEARCH METHOD We searched Medline for studies assessing the effect of statin treatment on percutaneous interventions. LITERATURE SEARCH RESULTS Early statin treatment is associated with improved outcomes in patients undergoing percutaneous coronary intervention procedures. Current evidence implies that statin treatment may also play a beneficial role in the management of patients undergoing percutaneous renal artery revascularization and endovascular abdominal aortic aneurysm repair, carotid angioplasty/stenting and endovascular peripheral arterial interventions. CONCLUSIONS Preliminary data suggest that statins exert multiple beneficial actions in patients undergoing percutaneous interventions. Future randomized trials are expected to further evaluate the beneficial effects of statins in these procedures.

Why Calls for More Routine Carotid Stenting Are Currently Inappropriate: An International, Multispecialty, Expert Review and Position Statement

Why Calls for More Routine Carotid Stenting Are Currently Inappropriate An International, Multispecialty, Expert Review and Position Statement

C-reactive protein (CRP): more than just an innocent bystander?

ABSTRACT This editorial discusses whether measuring C-reactive protein (CRP) levels can be used as a predictor of vascular risk. The agents that reduce CRP levels and the evidence for a possible causative role of CRP in the pathogenesis of coronary events and atherosclerosis are also considered. There is a need to further elucidate the role of CRP, as well as the clinical relevance, if any, of CRP-lowering agents.