Rashmi Thapa

Clinical and laboratory phenotype of patients experiencing statin intolerance attributable to myalgia

BACKGROUND Muscle pain without elevation of serum creatine phosphokinase (CPK) (myalgia) is the most common medication-related adverse effect of statin therapy; it occurs in up to 10% of patients who are prescribed statin therapy. Although much is known regarding risk factors for overt myositis, very few studies have provided information on this common form of statin intolerance. METHODS We defined a detailed clinical and laboratory phenotype of a cohort of patients referred to the lipid clinic of a governmental health maintenance organization for statin intolerance attributable to muscle pain without CPK elevation (myalgia) and characterized their response to alternative lipid-lowering therapy. Baseline and follow-up data were analyzed for 104 patients with statin intolerance attributable to myalgia and 211 statin-tolerant control patients identified from the referral population. RESULTS Among patients with myalgia, more were white and had hypertension. The prevalence of known risk factors for overt myositis, including renal disease, type 2 diabetes mellitus, thyroid disease, and electrolyte abnormalities, did not differ between statin intolerant and statin tolerant patients. Although individual cases were identified in which the addition of interacting medications was temporally associated with development of statin intolerance, overall use of interacting medications was not more frequent among statin-intolerant patients. The majority of patients were intolerant of two or more statins; however, in more than one-half the cases, successful rechallenge with an alternative statin was accomplished. Despite this and extensive use of nonstatin lipid medications after lipid clinic referral, control of plasma lipoproteins remained significantly worse in statin-intolerant patients. CONCLUSIONS Statin intolerance attributable to myalgia is a significant barrier to effective treatment of hyperlipidemia. Conventional clinical risk factors for myositis do not appear to predictive of statin-associated myalgia. These findings underscore the need to better define the pathophysiology of statin-induced myalgia and develop methodologies to guide treatment of statin-intolerant patients.

Comparison of Lipid Management in Patients With Coronary Versus Peripheral Arterial Disease

Peripheral arterial disease (PAD), similar to coronary artery disease (CAD), is a significant predictor of cardiovascular morbidity and mortality. Guidelines recommend a low-density lipoprotein (LDL) goal of <100 mg/dl for both groups. We assessed whether lipid control and statin use were as aggressively applied to PAD as to patients with CAD. This retrospective study of patients with the diagnosis of CAD, PAD, or both CAD and PAD compared lipid levels and statin use. For comparison of statins, we used a statin potency unit (1 potency unit=10 mg of simvastatin). Among 11,134 subjects (CAD 9,563, PAD 596, and both CAD and PAD 975), mean LDL in the PAD group was higher than the CAD (92 vs 83 mg/dl, respectively, p<0.001) and the combined CAD and PAD groups (92 vs 80 mg/dl, respectively, p<0.001). Fewer patients with PAD achieved a target LDL of <100 mg/dl compared with CAD (62% vs 78%, respectively, p<0.001) and the combined group (62% vs 79%, respectively, p<0.001). Similar differences were noted for a target LDL of <70 mg/dl. Compared with the CAD group, a lesser number of patients with PAD received statin therapy (76% vs 100%, respectively, p<0.001) with lower mean potency unit (5.3 vs 8.1, respectively, p<0.001). In conclusion, our study demonstrated lower use and less aggressive application of statins in patients with PAD compared with patients with CAD, ensuing lower mean LDL in the CAD and combined PAD and CAD groups. Our study suggests that physicians are more aggressive with lipid control in patients with CAD compared with patients with PAD alone.

Tricuspid Regurgitation: Pathophysiology and Management

Tricuspid regurgitation (TR) is one of the most commonly encountered valvular problems in clinical practice. Although diagnosed easily with echocardiography, it contributes to significant mortality and morbidity when severe. Once thought to be a benign functional valvular abnormality, TR has received more attention in recent years and different treatment options have emerged. However, there is no consensus regarding the superiority of one treatment approach over another. With the development of percutaneous atrioventricular valves, new horizons are open for exploration in the treatment of TR. Clinical indications of treatment are likely to change with increased use of left ventricular assist devices and increased survival of patients with poor right ventricular function. This review discusses the pathophysiology and management of TR along with newer treatment modalities currently under investigation.

Optimal Medical Management Reduces Risk of Disease Progression and Ischemic Events in Asymptomatic Carotid Stenosis Patients: A Long-Term Follow-Up Study.

Background and Purpose: To assess the effect of optimal medical management including atherosclerotic risk factor control on ischemic stroke (IS), transient ischemic attack (TIA), carotid revascularization (CRV), and progression of severity of carotid stenosis (PSCS) in patients with asymptomatic carotid artery stenosis (ACAS). Methods: We conducted a retrospective analysis of patients with ACAS (who had at least 3 serial carotid duplex ultrasounds) for incidence of IS, TIA, and PSCS. Results: Eight hundred sixty-four patients with a mean follow-up duration of 79 ± 36 months were included. IS/TIA and CRV occurred in 12.2% of the patients and PCSS was observed in 21.5% vessels. On univariate analysis it was found that low-density lipoprotein (LDL) levels >100 mg/dL, no statin or low-potency statins, average systolic blood pressure (SBP) ≥140 mm Hg and/or diastolic blood pressure (DBP) ≥90 mm Hg and history of smoking were predictors of the combined endpoint of IS/TIA/CRV and PSCS. On multivariate analysis, it was found that LDL >100 mg/dL, no statin or low-potency statin, SBP ≥140 mm Hg and/or DBP ≥90 mm Hg, and Hx of smoking were independent predictors of PSCS. Similarly no statin or low-potency statin, SBP ≥140 mm Hg and/or DBP ≥90 mm Hg, Hx of atrial fibrillation/flutter, Hx of chronic kidney disease, and PSCS were independent predictors of IS/TIA. No statin or low-potency statin, SBP ≥140 mm Hg and/or DBP ≥90 mm Hg, diabetes mellitus, baseline carotid artery stenosis ≥70%, and PSCS were found to be independent predictors of combined endpoint IS/TIA and CRV. Conclusion: Intensive medical therapy in the patients with ACAS results in lower incidence of IS/TIA, CRV, and PSCS with a significant incremental beneficial effect.

EFFECT OF AGGRESSIVE LIPID THERAPY ON PROGRESSION OF CAROTID ARTERY STENOSIS: A LONGTERM FOLLOW UP STUDY

The relationship of serum lipid levels, aggressive statin use and progression of carotid stenosis (CS) severity has not been well studied. We assessed the correlation between aggressive risk modification, statin use, and lipid levels with progression of carotid artery stenosis and incidence of

DISPARITIES IN LIPID MANAGEMENT IN PATIENTS WITH PERIPHERAL ARTERY DISEASE VERSUS CORONARY ARTERY DISEASE: COMPARISON BETWEEN ATP III AND 2013 AHA/ACC GUIDELINES

Recent studies using ATP III guidelines show that peripheral artery disease (PAD) patients have less optimal lipid control compared to those with coronary artery disease (CAD). Our study aimed to compare lipid management in patients with PAD, CAD and CAD with PAD by applying the new 2013 guidelines

COMPARISON OF LIPID CONTROL AMONG DIABETICS WITH NONCORONARY ATHEROSCLEROTIC VASCULAR DISEASE VERSUS CORONARY ARTERY DISEASE

methods: We retrospectively identified 3,336 patients with DM and known atherosclerotic vascular disease between January 2009 and March 2012, for whom lipid levels were available. We compared demographic variables, lipid levels and statin use in diabetics with CHD alone versus diabetics with one or more NCVD (peripheral artery disease, carotid stenosis or abdominal aortic aneurysm). To enable comparison of the doses of various statins, we used statin potency unit where 1 potency unit = 10mg of Simvastatin.

Solitary Coronary Artery : A Rare Coronary Anomaly

A 57-year-old man presented with chest pain suggestive of obstructive coronary artery disease. Coronary angiography revealed a rudimentary left main coronary artery arising from the left sinus of Valsalva. A large right coronary artery was visualized arising from the right sinus of Valsalva and