1,721,357 research outputs found
Who Needs Acetylsalicylic Acid? Some Order After Many Studies
Full text linkThe role of acetylsalicylic acid (ASA) in cardiovascular prevention is essentially consequence of its ability to inhibit platelet aggregation, thus reducing the impact of atherosclerotic disease. The preventive power of this drug is clear when used in patients with previous cardiovascular event (myocardial infarction, stroke, etc.), but the data are less dependable when considering patients who did not experienced a cardiovascular event or in the diabetic population, in whom recent studies reported neutral results in term of efficacy, in face of an increase in the risk of bleeding. Furthermore, the interpretation of the efficacy results of ASA should be reconsidered in light of the increasing clinical complexity, not addressed in the clinical studies on which current evidences are based. Accordingly the rationale for ASA use in cardiovascular prevention is ever more of current interest, and requires a particular attention, considering the crucial role of antithrombotic therapy in the foreseeable future. What could be learned on the use of ASA in cardiovascular prevention after a century since its chemical synthesis? In secondary prevention, supporting evidences have now a couple of decades of history, and the use of the drug appears to be firmly established: in this setting, the benefits clearly surpass the risks. On the other hand, in primary prevention, where age and diabetes are among the main risk factors, the risk/benefit ratio for prophylactic therapy with ASA does not support its widespread use. Deciding when this treatment should be implemented should require a case-by-case evaluation, considering, first, the correction of each risk factor, whose control has led to a reduction of global cardiovascular mortality. The other fundamental aspect is the compliance to the treatment, particularly in patients subjected to multiple drugs regimens, in whom the physician should take into account the specific needs of the patient, as not to provide a mere prescription service
Gout, urate-lowering drugs, and risk of cardiovascular disease: can we clinically trust in the adjusted real-life data?
No full textUric acid (UA) is the final product of purine metabolism and its increase in the circulating blood defines the presence of hyperuricaemia usually considered as a concentration of uric acid in serum above the threshold level of 7 mg/dL (416 μmol/L) in men and >6 mg/dL (357 μmol/L) in women.1 The typical consequence of elevated UA levels is the development of gout, a relatively common inflammatory arthritis affecting from 2% to 4% of the population with a significant increase in prevalence in patients with renal dysfunction as well as cardiac and metabolic diseases.
In addition to its effects at the articular level, there is mixed evidence to support gout (and hyperuricaemia) as independent risk factors for cardiovascular disease (CVD)
Surprises in cardiology: efficacy of gliflozines in heart failure even in the absence of diabetes
Full text linkIt is now well-established that the therapy of type II diabetes mellitus has undergone a radical change in the past 15 years: countless innovative drugs, such as SGLT2I, able to guarantee an optimization of glycaemic control without causing hypoglycaemia, today represent real therapeutic cornerstones not only for the intrinsic ability of these molecules to ensure better glycaemic control but also for the effects they exert on the cardiovascular system. Several pioneering clinical trials, such as EMPA-REG, CANVAS, and DECLARE-TIMI-58, have demonstrated clear benefits of empagliflozin, canagliflozin, and dapagliflozin, respectively, in reducing cardiovascular risk and diabetes-associated macrovascular complications in the diabetic population. The promising results that emerged from these trials represent the spark that triggered a series of studies aimed at evaluating the efficacy of gliflozines in the treatment of patients with heart failure even in the absence of diabetes. Preliminary results confirm the efficacy of SGLT2I in the treatment of this population, representing a real therapeutic revolution
Hyperuricemia and Mortality in Heart Failure: Is It Time to Change the Route?
No full textThe prevalence of heart failure (HF) is increasing worldwide and in particular in the industrialized countries [
, 2]
. This is associated with a parallel increase in the rate of hyperuricemia and gout [
, 4]
that occurs with a high rate of hypertension, chronic kidney disease, atrial fibrillation, metabolic syndrome, diabetes, dyslipidemia, and obesity [ 5
], leading to an overall increase in urate mediated cardiovascular risk. The close correlation between uric acid and HF is based on a complex pathophysiological mechanism that, probably, does not reflect a direct effect of elevated uric acid on left ventricular function, but rather involves the extensive activation of the enzyme xanthine-oxidase (XO) that is responsible for urate production and increased levels of oxidative stress [ 6
]. In HF patients, serum uric acid is probably representative of XO levels or activity that can play an important role in the pathophysiologic process leading to heart failure through inflammatory damage and loss of vascular endothelial function. In practical terms, the overexpression of XO and related oxidative stress could be a potential mechanism for the identification of those HF patients where hyperuricemia can be associated with a poor clinical prognosis. The main problem is how to identify these patients across the heterogeneous population of patients with HF where the clinical diagnosis and the severity of the disease can be a major confounder due to the extensive interaction between HF severity, renal function and diuretic use
Nephrotic Range Proteinuria and Acute Heart Failure
No full textCase presentation: A 66-year-old woman with mild obesity, systemic hypertension and no history of previous treatment presented to our emergency department (ED) because of progressive exertional dyspnea and bilateral lower limbs swelling. At admission in the ED, arterial pressure was 188/86 mmHg, heart rate was 84 bpm and oxygen blood saturation was 96%. Physical examination confirmed bilateral symmetrical lower limbs pitting edema and bilateral rales at thoracic auscultation. Both laboratory and imaging findings were suggestive of acute decompensated heart failure (HF): BNP was 421 pg/mL and chest X-rays showed signs of congestion, mild pleural effusion and an enlarged cardiac shadow. Cardiac ultrasound revealed left ventricular concentric hypertrophy, mild left atrial enlargement and mild–moderate diastolic dysfunction (LVEF 60%, E/A 0.81, E/Eʹ 17, PAPS 30–40 mmHg). The patient was, thus, treated with intra-venous Furosemide and admitted to our Internal Medicine department with a diagnosis of “acute heart failure with preserved ejection fraction”
Effects of early treatment with zofenopril in patients with myocardial infarction and metabolic syndrome: the SMILE Study
No full textClaudio Borghi, Arrigo FG Cicero, Ettore AmbrosioniDepartment of Clinical Medicine, University of Bologna, Bologna, Italy. On behalf of the Survival of Myocardial Infarction Long-term Evaluation (SMILE) StudyObjective: To evaluate the clinical efficacy of the early administration of zofenopril in a group of patients with and without metabolic syndrome (MS+ and MS–) and anterior myocardial infarction enrolled in the Survival of Myocardial Infarction Long-Term Evaluation (SMILE) Study.Methods: Patients were randomized double-blind to zofenopril (n = 719) or placebo (n = 699) for 6 weeks. The primary end point was the effect of treatment on the 6-week combined occurrence of death and severe congestive heart failure. The secondary end point was the 1-year mortality rate.Results: Of the 1418 patients included in this post-hoc analysis, 686 (48.3%) had MS. After 6 weeks of treatment zofenopril significantly reduced the incidence of all-cause death and severe congestive failure (risk reduction: 69%, 95% CI: 7–78; 2p = 0.002) in MS+ patients. This was the case for 1-year mortality, too (29%, 95% CI: 4–41; 2p = 0.048). Zofenopril was effective also in MS− patients but the amount of relative risk reduction was less than in MS+ for both the primary (–11%; 2p = 0.61) and secondary endpoint (–19%; 2p = 0.025).Conclusions: Results of this post-hoc analysis of the SMILE Study demonstrate the striking benefit of early administration of zofenopril in MS+ patients with acute anterior myocardial infarction.Keywords: SMILE Study, angiotensin converting enzyme inhibitor, zofenopril, myocardial infarction, metabolic syndrom
Dual RAAS Inhibition and Cardiorenal Disease: Is Enough Really Enough?
No full textSince the frst appearance of captopril on the market in 1981, the management of cardiovascular and renal diseases relies greatly on the drugs inhibiting the renin angiotensin system (RAAS) [1] that have proven to be efective in the treatment of hypertension, heart failure, acute myocardial infarction and renal disease [1]. Ace-inhibitors (ACEI), angiotensin II receptor inhibitors (ARBs), Direct Renin inhibitors (DRI) and Aldosterone receptors blockers are commonly used in patients with or at risk or cardio-renal disease where they prevent cardiovascular complications and the decline of renal function [2]. All classes of drugs have a comparable antihypertensive efect with no clinically meaningful difference in blood pressure control in comparison with nonRAAS mediated classes of blood pressure lowering drugs and regardless of the methods employed to measure blood pressure [3]. ACEI and ARBs are the most investigated drugs and a large number of studies have been conducted to demonstrate their efcacy in a large population of hypertensive and non-hypertensive patients. The information about DRI is limited to two major trials mainly focused in patients with renal disease while the aldosterone receptors inhibitors have achieved some evidence in the management of resistant hypertensio
Possible Advantages Deriving from Patiromer Use in Hypertensive Patients Made Hyperkalemic by Renin-Angiotensin-Aldosterone Blocking Agents
No full textHyperkalemia is an elevated level of serum potassium (K+) and does represent a life-threatening condition. In clinical practice, hyperkalemia mainly derives from an impaired renal K+ excretion which, in turn, is usually caused by either acute or chronic renal failure. In concordance with this, hyperkalemia is very common in several chronic conditions, such as kidney disease, diabetes mellitus, heart failure, hypertension, and coronary heart disease. In all of these conditions the use of Renin-Angiotensin-Aldosterone System inhibitors (RAASIs), such as angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), and mineralocorticoid receptor antagonist is widely recommended and further increases the risk of hyperkalemia. As hypertension is concerned, clinical trials suggest that the risk of hyperkalemia associated with RAASIs ranges from 2 to 10%. This often leads to a reduction or complete cessation of RAASIs, leaving patients without protective medications. Patiromer, a new oral potassium-binding agent, has been approved for clinical use in several countries, including Europe and US. Clinical studies have demonstrated that patiromer is effective in inducing a rapid and sustained K+ reduction in various patient settings, including those where RAASIs are a fundamental component of cardiorenal protection. Patiromer is generally well tolerated and characterised by a good safety profile. Most importantly, patiromer use might allow the continuation of ACEIs and ARBs in hypertensive patients developing hyperkalemia during treatment and thereby favour a more effective and long-lasting cardiorenal protection
Clinical Management of Patients with Hypertension and High Cardiovascular Risk : Main Results of an Italian Survey on Blood Pressure Control.
No full textHypertension management and control still represents a major clinical challenge for physicians, as well as for National Health Care Systems, since high blood pressure (BP) levels in treated uncontrolled outpatients are related to a persistently increased risk of cardiovascular (CV) events. The Italian Society of Hypertension (SIIA) has prompted several educational interventions for improving BP control in Italy. To evaluate clinical attitudes and preferences of large community sample of both specialized physicians and general practitioners, included in an educational program, endorsed by SIIA and aimed at improving interventions for achieving better BP control in Italy. A predefined questionnaire, which included a main body with 17 questions and 15 specific items (3-4 questions for each item), was anonymously administered to a large community sample of physicians who have practice in managing outpatients with hypertension and high CV risk profile. Both specialized physicians and general practitioners, distributed throughout the whole Italian territory, have been included in this educational program. Data were reported into a computerised spreadsheet and centrally analysed. Confidentiality of the data were guaranteed during each phase of the study. From a total of 64 questions, 557 physicians (478 male, mean age 54.2 ± 7.1 years, average age of medical activity 28.0 ± 8.1 years), among which 261 (46.9 %) specialised physicians and 296 (53.1 %) general practitioners, provided 60,713 answers to the survey questionnaire. Physicians devote time and effort for achieving the recommended BP targets (<140/90 and <130/80 mmHg in high risk subgroups), yet they reported a very high rate of BP control (about 70 %). Concomitant presence of diabetes, cardiac and renal organ damage (35-50 %), as well as comorbidities (20-35 %), is reported to be high and able to impact on antihypertensive treatment's efficacy. Appropriate BP assessment is also viewed as a key tool for verifying effectiveness of a given drug therapy. Beyond non-pharmacological options, ACE inhibitors and ARBs were considered to most useful, effective and well tolerated options to start and maintain antihypertensive treatment, thus adding diuretics or calcium-channel blockers if needed. Direct renin inhibitors was considered to be effective in difficult to treat hypertension and to provide sustained antihypertensive efficacy. With the well-known limitations of an observational, cross-sectional survey, in which a predefined questionnaire was administered to physicians rather than collecting data from medical databases, this study provides useful and updated information on attitudes and preferences, as well as on difficulties and troubles for physicians when managing outpatients with hypertension and high CV risk profile in Italy
Cost-effectiveness analysis of different hypertension management strategies
No full textDespite the availability of a large number of effective and relatively safe antihypertensive drugs, the control of hypertension in general population is suboptimal, reaching the 70% in the best practice settings. In particular, despite its economic power, Europe also ranges among the regions with the lowest rates of hypertension awareness and control worldwide [1]. On the one hand, this predominance reflects the increasing life expectancy in European population, whereas on the other hand, it can be attributed to the sedentary lifestyle and the nutritional habits of wealthy societies, but also to medical inertia, insufficient patient education and contradictory recommendations from different institutions and scientific societies [2]. In this context, the comparative evaluation of the effectiveness of different tools to improve hypertension control is of great interest, especially if the cost of the intervention is also estimated
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