CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 4, July/August 2011
228
AFRICA
Letter to the Editor
Ezetimibe in PAD
The small-group study of peripheral arte-
rial disease (PAD) patients
2
was amagnetic
resonance imaging (MRI) study of plaque
regression and did not show additional
benefit with the addition of ezetimibe to
patients already on statins whose LDL
cholesterol was above the target of 80 mg/
dl. However, tolerability was excellent;
only one patient discontinued simvas-
tatin therapy, while no discontinuations
occurred in the ezetimibe treatment arms.
The PAD study was a surrogate-
outcomes trial of 67 patients using MRI
to evaluate atherosclerosis in the super-
ficial femoral artery. Results showed no
significant progression of atherosclerosis
in the statin-naïve patients who were
randomised to simvastatin 40 mg, or
in those randomised to simvastatin plus
ezetimibe (10 mg).
Patients previously on a statin who
had ezetimibe added at study enrolment,
demonstrated plaque progression despite
the significant reduction in LDL-C. It
should be noted that this part of the trial
had no control arm for comparison.
Prof Derick Raal, University of the
Witwatersrand
Prof Raal noted that the PAD study has
major efficacy limitations. ‘Numbers
were small and the reproducibility of
the technique used is still questionable.
In my view, if ezetimibe is so “ineffec-
tive or valueless”, there should also have
been progression in the statin-naïve group
who received the simvastatin/ezetimibe
combination, which did not happen. In
fact this group had the biggest regression
in plaque volume.’
‘Surrogate endpoint trials can be very
misleading, as shown by the ARBITER 6
study, which, following discontinuation
of the AIM-High study, must be seriously
questioned. Finally, we need to await the
results of the large outcome trial with
ezetimibe (Improve-It).’
J Aalbers, Special Assignments Editor
1.
Baigent C,
et al
. (on behalf of the SHARP
investigators). The effects of lowering LDL
cholesterol with simvastatin plus ezetimibe
in patients with chronic kidney disease.
Lancet
9 June 2011. DOI: 10:1016/50140-
6736(11)60739-3.
2.
West AM, Anderson JD, Meyer CH,
et
al
. The effect of ezetimibe on peripheral
arterial atherosclerosis depends upon statin
use baseline.
Atherosclerosis
2011; DOI:
10.1016/j.atherosclerosis.2011.04.005.
Torulopsis glabrata
endocarditis in a retro-positive
individual
I present an unusual case of
Torulopsis
glabrata
endocarditis in a retro-positive
patient.
An HIV-positive patient presented with
symptoms of endocarditis. He showed
all the usual features of endocarditis,
namely roth spots, splenomegaly, chang-
ing murmurs, slinter haemorrhages, etc.
Initially, a dignosis of either acute or
sub-acute bacterial endocarditis was enter-
tained. However, fungal cultures showed
the patient to have a
Torulopsis glabratea
endocarditis. The most common fungal
culture found in vegetations on the heart
valves is
Candida albicans
but
Torulopsis
glabrata
has also been described.
These vegetations may be detected
with transoesophageal echocardiography
and generally the vegetations in fungal
endocarditis are larger than those seen in
acute or sub-acute bacterial endocarditis.
1
The patient responded to antiretroviral
treatment, intravenous amphoteracin B
and intravenous fluconazole.
With the increase in prevalence of
HIV/AIDS, diabetes and patients on
immunosuppressive treatment for organ
transplantation, there has been an increase
in fungal endocarditis. Rheumatic heart
disease is still rife in South Africa and
many patients therefore have damaged
heart valves, particularly mitral valves.
HD Solomons
Highlands North, Johannesburg, South
Africa
Reference
1.
Sharpe DN. Torulopsis glabrata endocarditis
complicating aortic homograft. 26 March
1975. (
Govpubmed/1055952.)
It's the
shell that
makes
safer.
R
Safety-Coated
R
81mg
The ORIGINAL low dose aspirin
for optimum cardio-protection
Hp
Each tablet contains Aspirin 81mg. Reg.No.: 29/2.7/0767
Pharmafrica (Pty) Ltd, 33 Hulbert Road, New Centre, Johannesburg 2001
Under licence from Goldshield Pharmaceuticals Ltd. U.K.
