Vascular health and risk management
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Vasc Health Risk Manag · Jan 2006
ReviewComplementary therapy to target LDL cholesterol: the role of the ezetimibe/simvastatin combination.
Cardiovascular (CV) disease remains the number 1 cause of death in the USA. Nonetheless, there has been a decline in the age-adjusted death rate for coronary heart disease (CHD) which may be due to more aggressive treatment guidelines for treating CV risk factors, such as hypertension, diabetes, and dyslipidemia. ⋯ One of these newer therapies is the combination of ezetimibe and simvastatin. This article reviews the implications of the updated guidelines and discusses the efficacy and safety of ezetimibe/simvastatin for lowering LDL-C.
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Vasc Health Risk Manag · Jan 2006
ReviewWho should receive a statin drug to lower cardiovascular risk? Does the drug and the dose of the drug matter?
As the numbers of completed outcomes based clinical trials evaluating the use of statin drugs for the management of cardiovascular risk continue to increase, it is clear that the numbers of patients that may benefit from these drugs continues to grow. The recently published studies are reviewed in this summary. ⋯ The review identifies the increasing numbers of patients who may benefit from the use of statins as primary preventive management, and the changing concepts of the utilization of statin drugs for secondary preventive management, including the more aggressive titration of the drugs to provide incremental improvement in patient outcomes. Available data on the use of statins in the elderly patient are reviewed, and observations are made regarding the intrinsic properties and adverse effects of the drugs.
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Vasc Health Risk Manag · Jan 2006
ReviewPlatelet inhibitors in non-ST-segment elevation acute coronary syndromes and percutaneous coronary intervention: glycoprotein IIb/IIIa inhibitors, clopidogrel, or both?
The role of glycoprotein (Gp) IIb/IIIa receptor antagonists remains controversial and these agents are infrequently utilized during non-ST-segment elevation acute coronary syndromes (NSTE-ACS) despite American Heart Association/American College of Cardiology guidelines. Despite recommendations, the NRMI-4 (National Registry of Myocardial Infarction 4) and CRUSADE (Can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the ACC/AHA guidelines?) registries observed that only 25%-32% of eligible patients received early Gp IIb/IIIa therapy, despite a 6.3% absolute mortality reduction in NRMI-4 and a 2% absolute mortality reduction in CRUSADE. A pooled analysis of Gp IIb/IIIa data from these registries suggest a major reduction in mortality (Odds Ratio = 0.43, 95% Confidence Index 0.25-0.74, p = 0.002) with early Gp IIb/IIIa therapy, yet clinicians fail to utilize this option in NSTE-ACS. ⋯ The ISAR-COOL (ISAR: Cooling off strategy) trial found no difference in ischemic outcomes when Gp IIb/IIIa inhibitors were excluded and ARMYDA-2 (Antiplatelet therapy for reduction of myocardial damage during angioplasty) suggested higher doses of clopidogrel are more appropriate during PCI when Gp IIb/IIIa inhibitors are not utilized. This constellation of new trials forces reconsideration of current recommendations in regards to patient risk stratification, choice of antithrombotic therapy, doses, and timing. These new data will impact emerging guidelines and updates are currently in progress.
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Vasc Health Risk Manag · Jan 2006
ReviewTreatment of severe sepsis: where next? Current and future treatment approaches after the introduction of drotrecogin alfa.
Severely septic patients continue to experience excessive morbidity and mortality despite recent advances in critical care. Although significant resources have been invested in new treatments, almost all have failed to improve outcomes. An improved understanding of sepsis pathophysiology, including the complex interactions between inflammatory, coagulation, and fibrinolytic systems, has accelerated the development of novel treatments. ⋯ Replacement doses of hydrocortisone and vasopressin may reduce mortality and improve hypotension, respectively, in a subgroup of patients with catecholamine-refractory septic shock. In addition to discussing these new indications, this review will detail the provocative preliminary data from four promising treatments, including two novel modalities: antagonizing high mobility group box protein and inhibiting tissue factor (TF). Observational data from the uncontrolled administration of heparin or statins in septic patients will also be reviewed.
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Vasc Health Risk Manag · Jan 2005
ReviewVascular endothelium as a target of beraprost sodium and fenofibrate for antiatherosclerotic therapy in type 2 diabetes mellitus.
Diabetes mellitus is an important risk factor for cardiovascular morbidity and mortality. The metabolic abnormalities caused by diabetes mellitus induce vascular endothelial dysfunction that predisposes patients with diabetes mellitus to atherosclerosis. Two mega clinical trials showed that intensive glycemic control does not have favorable effects on reducing macrovascular events although it demonstrated significant reductions in microvascular complications. ⋯ Beraprost sodium lowered circulating vascular cell adhesion molecule- 1 (VCAM-1) concentration and prevented the progression of carotid atherosclerosis in type 2 diabetic patients, probably through inhibiting VCAM-1 expression in vascular endothelium. Fenofibrate up-regulated endothelial nitric oxide synthase expression, which may explain its effects to improve endothelium-dependent vasodilatation and to prevent the progression of coronary atherosclerosis. The approaches to target the molecules expressed in vascular endothelium will become important for preventing the atherosclerosis in type 2 diabetes mellitus.