CARDIOVASCULAR JOURNAL OF AFRICA: VOLUME 19, ISSUE 2, MARCH 2008
- Title: Questioning the importance of
LDL cholesterol : don't throw the baby out with
the bathwater! : editorial
Authors: Raal, F.J.
From: Cardiovascular Journal of Africa, Vol 19, Issue 2, Mar / Apr
Published: 2008
Pages: 63-64
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Abstract: Following the recent announcement of the disappointing results of the ENHANCE study, two press articles in the Business Week and the New York Times questioned the importance of lowering LDL cholesterol and asked 'What's cholesterol got to do with it' and 'Do cholesterol drugs do any good'. This resulted in a flurry of correspondence in the lay press questioning whether cholesterol has any role to play in the pathogenesis of atherosclerosis and coronary artery disease (CAD).
- Title: Abnormal cation exchange in
insulin-resistant patients with essential
hypertension : cardiovascular topics
Authors: Taylor, D.R.; Wing, J.R.; Sonnekus, M.I.; Toman, M.; Milne, F.J.
From: Cardiovascular Journal of Africa, Vol 19, Issue 2, Mar / Apr
Published: 2008
Pages: 67-71
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Abstract: Objectives: To identify important factors that may contribute to abnormal glucose tolerance in elderly patients with treated hypertension with primary reference to changes in the following parameters: calculated insulin resistance, endogenous insulin processing and secretion; platelet cation concentration and membrane ATPase activity.
Design: Thirty-nine patients receiving antihypertensive therapy (including low-dose thiazide treatment) were compared to 13 normotensive, normoglycaemic control subjects. Total platelet cation concentration and membrane ATPase activity were measured and, following a 75-g oral glucose test, serum insulin, proinsulin and 31-32 des-proinsulin responses were measured in prospectively defined hypertensive patients with normal glucose tolerance (NG), impaired glucose tolerance (iGT) and diabetes mellitus (DM).
Results: of the total patient cohort, seven patients manifested newly diagnosed DM, 18 had iGT and 14 NG. Among the three groups, no difference in duration of drug use (thiazides and beta-blockers) was noted; BMi and waist-to-hip ratio increased progressively from NG to iGT to overt DM. Compared to NG patients, serum insulin responses were significantly greater in the iGT (all time points) and DM (two-hour measurements) subjects. Proinsulin and 31-32 des-proinsulin serum responses were likewise significantly higher in the iGT and DM groups. The derived measure of insulin resistance in the hypertensive patients showed a significant increase in the progression from NG to iGT and DM. Mean total platelet potassium concentration was reduced in the DM compared to the iGT and the control groups, while platelet sodium, calcium and magnesium concentrations showed no significant differences. Platelet membrane magnesium ATPase activity was significantly higher in the normotensive control versus the hypertensive group. Sodium, potassium and calcium ATPase activity showed no significant differences among the subgroups.
Conclusion: our findings support the strong link between essential hypertension, insulin resistance / hyperinsulinaemia and regional adiposity. Beta-cell dysfunction (hypersecretion and abnormal insulin processing) is manifest in the progression from normality to overt diabetes. The use of antihypertensive therapy (low-dose thiazides and cardioselective beta-blockers) possibly added diabetogenic effect(s). The reduction in platelet total potassium concentration paralleled the diabetic state while a reduced membrane magnesium ATPase activity correlated with the hypertensive state.
- Title: Rates and predictors of
stroke-associated case fatality in black Central
African patients : cardiovascular topics
Authors: Longo-Mbenza, B.; Tshinkwela, M. Lelo; Pukuta, J. Mbuilu
From: Cardiovascular Journal of Africa, Vol 19, Issue 2, Mar / Apr
Published: 2008
Pages: 72-76
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Abstract: Objective: To identify case fatality rates and predictors of stroke in a private clinic in Kinshasa, Democratic Republic of Congo.
Methods: Two hundred and twelve black Africans were consecutively admitted to a clinic and prospectively assessed during the first 30 days by CT scan-proven stroke types and outcome. univariate and multivariate analyses were used to estimate the in-hospital mortality risk for the following baseline characteristics: age, gender, education, arterial hypertension, diabetes, stroke types, leukocyte count, and haematocrit, blood glucose, uric acid, fibrinogen and total cholesterol levels.
Results: Haemorrhagic and ischaemic strokes were present in 52 and 48% of the study population, respectively; and 44% of all stroke type patients, 29% of haemorrhagic stroke and 31% of ischaemic stroke patients died. Compared to the survivors, deceased patients were significantly (p < 0.001) older with higher leukocyte counts and haematocrit, haemoglobin and fibrinogen levels, but lower glycaemic levels. The variable significantly associated with all stroke type mortalities in the multivariate model was ischaemic stroke (HR = 4.28, p < 0.001). The univariate risk factors of mortality in patients with ischaemic stroke were higher fibrinogenaemia (RR = 6.4; 95% Ci = 4.8-8.2 for tertile 3 and RR = 12.9; 95% Ci = 7.8-18.4 for tertile 4; p < 0.001) and higher glycaemia (RR = 3.3; 95% Ci = 1.4-5.7 for tertile 3 and RR = 6.7; 95% Ci = 5.2-9.2 for tertile 4; p < 0.001).
Conclusion: We have shown that all acute stroke types remain a deadly nosological entity, and ischaemic stroke, baseline haematocrit and fibrinogen levels, and dependency on others' care were significantly associated with all stroke mortalities. Moreover, hyperfibrinogaemia and hyperglycaemia were the significant predictors of case fatality in ischaemic stroke patients. in Africa, the top priority for resource allocation for stroke services should go to the primary prevention of stroke.
- Title: William Nelson ECG Quiz
From: Cardiovascular Journal of Africa, Vol 19, Issue 2, Mar / Apr
Published: 2008
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Abstract: 16:29 - This is the ECG of a 16-year-old male. What should your concerns be?
- Title: Signalling pathways activated
by glucagon-like peptide-1 (7-36) amide in the
rat heart and their role in protection against
ischaemia : cardiovascular topics
Authors: Huisamen, Barbara; Genade, Sonia; Lochner, Amanda
From: Cardiovascular Journal of Africa, Vol 19, Issue 2, Mar / Apr
Published: 2008
Pages: 77-83
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Abstract: Glucagon-like peptide-1 is an incretin hormone proposed to have insulinomimetic effects on peripheral insulin-sensitive tissue. We examined these effects on the heart by using isolated, perfused rat hearts and adult ventricular myocytes. During normoxic perfusion, no effects of escalating concentrations of GLP-1 on either heart rate or left ventricular developed pressure were found. With functional performance as readout, we found that GLP-1 directly protected the heart against damage incurred by global low-flow ischaemia. This protection was sensitive to the presence of iodo-acetate, implicating activation of glycolysis, and was abolished by wortmannin, indicative of Pi-3-kinase as mediator of protection. in addition, GLP-1 had an infarct-sparing effect when supported by the presence of the dipeptidyl peptidase-iv inhibitor valine pyrrolidide.
GLP-1 could not directly activate protein kinase B (also called Akt) or the extracellular regulated kinases Erk1/2 in hearts or cardiocytes under normoxic conditions, but phosphorylation of the AMP-activated kinase (AMPK) on Thr172 was enhanced. in addition, the glycolytic enzyme phosphofructokinase-2 was activated dose dependently. During reperfusion after ischaemia, modulation of the phosphorylation of PKB/Akt as well as AMPK was evident. GLP-1 therefore directly protected the heart against low-flow ischaemia by enhancing glycolysis, probably via activation of AMP kinase and by modulating the profile of activation of the survival kinase PKB/Akt.
- Title: Effect of calcium lactate
supplementation on cholesterol concentration in
patients with hyperlipidaemia and previous viral
hepatitis : a preliminary report :
cardiovascular topics
Authors: Andryskowski, G.; Chojnowska-Jezierska, J.; Broncel, M.; Barylski, M.; Banach, M.
From: Cardiovascular Journal of Africa, Vol 19, Issue 2, Mar / Apr
Published: 2008
Pages: 84-87
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Abstract: The aim of the study was to estimate the effect of calcium supplementation on cholesterol concentrations in patients with hyperlipidaemia and previous viral hepatitis.
The study comprised 43 patients, aged 28 to 82 years (21 with type 2 hyperlipidaemia). The control group included 22 healthy subjects. After four weeks of a hypolipaemic diet (wash-out period), the patients with type 2 hyperlipidaemia were recruited to a group administered a complex preparation containing 170 mg of calcium lactate and 60 mg of vitamin C (Calcium C, Polfa-Lodz SA, Poland) at a dose of one tablet three times a day.
After four weeks of active therapy, the concentration of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) and triglycerides (TG) decreased by 4, 6 and 8%, respectively. Statistical significance was obtained for only TC (p = 0.03) when comparing the group of patients with hypercholesterolaemia before and after the therapy with the calcium preparation. A statistically insignificant increase of high-density lipoprotein cholesterol (HDL-C) of 1% was observed. Within the four-week period of calcium supplementation at a dose of 510 mg/24 h, the total concentration of calcium decreased by 3%, whereas the concentration of ionised calcium increased by 7%. None of the obtained values was of statistical significance.
In patients with type 2 hyperlipidaemia and previous viral hepatitis, a four-week supplementation of calcium in a calcium lactate preparation beneficially modified the lipid profile. it statistically significantly decreased the total cholesterol concentration by 4% (p = 0.03), did not cause any significant changes in serum calcium concentration, was well tolerated and did not induce any side effects.
- Title: The evaluation of low-density
lipoprotein cholesterol goals achieved in
patients with established cardiovascular disease
and / or hyperlipidaemia receiving
lipid-lowering therapy : the South African Not
At Goal study (SA-NAG) : cardiovascular topics
Authors: Ramjeeth, Akash; Butkow, Neil; Raal, Frederick; Maholwana-Mokgatlhe, Mandisa
From: Cardiovascular Journal of Africa, Vol 19, Issue 2, Mar / Apr
Published: 2008
Pages: 88-94
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Abstract: Aim: Cardiovascular disease (CvD) is the leading cause of morbidity and mortality worldwide. Dyslipidaemia is a major risk factor that leads to the clinical sequelae of CvD. As a result, it has become essential for South Africa to update its guidelines for the management of dyslipidaemia, and the South African scientific community has recently adopted the European guidelines on CvD prevention in clinical practice. The South African Not at Goal study (SA-NAG) was a survey done to determine the percentage of patients on lipidlowering therapy who were not achieving guideline-specified low-density lipoprotein cholesterol (LDL-C) goals.
Methods: in this cross-sectional study, dyslipidaemic and / or CvD patients on lipid-lowering therapy for more than four months were enrolled. volunteers had their demographic data and previous medical history documented. Blood samples from these patients were analysed (using standardised methods) to obtain fasting blood lipid and glucose levels.
Results: in total, 1 201 patients (age 58 ± 11.4 years) were recruited by physicians and general practitioners from across South Africa. under the new guidelines, 41% of patients were defined as low risk (LR) and 59% were high risk (HR). Sixty-three per cent of LR patients and 77% of HR patients (71% overall) did not achieve their LDL-C target goals of 2.5 and 3.0 mmol/l, respectively. The LR and HR patients who did not achieve their LDL-C goals were on average 19% (0.7 mmol/l ± 0.5) and 31% (1.1 mmol/l ± 1.1) above their LDL-C target levels, respectively.
Conclusions: These results suggest that a considerable number of patients fall into the category 'not at goal' LDL-C. Patients who failed to achieve goal were also far above their LDL-C target levels. The adoption of the new guidelines will necessitate enhanced disease management to reduce the disease burden.
- Title: Decision-making using
absolute cardiovascular risk reduction and
incremental cost-effectiveness ratios : a case
study : cardiovascular topics
Authors: Ker, J.A.; Oosthuizen, H.; Rheeder, P.
From: Cardiovascular Journal of Africa, Vol 19, Issue 2, Mar / Apr
Published: 2008
Pages: 97-101
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Abstract: Background: Many clinical guidelines have adopted a multifactorial cardiovascular risk assessment to identify high-risk individuals for treatment. The framingham risk chart is a widely used risk engine to calculate the absolute cardiovascular risk of an individual. Cost-effective analyses are typically used to evaluate therapeutic strategies, but it is more problematic for a clinician when faced with alternative therapeutic strategies to calculate cost effectiveness.
Aim: We used a single simulated-patient model to explore the effect of different drug treatments on the calculated absolute cardiovascular risk.
Methods: The framingham risk score was calculated on a hypothetical patient, and drug treatment was initiated. After every drug introduced, the score was recalculated. Singleexit pricing of the various drugs in South Africa was used to calculate the cost of reducing predicted cardiovascular risk.
Results: The cost-effective ratio of an antihypertensive treatment strategy was calculated to be R21.35 per percentage of risk reduction. That of a statin treatment strategy was R22.93 per percentage of risk reduction. using a high-dose statin, the cost-effective ratio was R12.81 per percentage ofrisk reduction. Combining the antihypertensive and statin strategy demonstrated a cost-effective ratio of R23.84 per percentage of risk reduction. A combination of several drugs enabled the hypothetical patient to reduce the risk to 14% at a cost-effective ratio of R17.18 per percentage of risk reduction.
Conclusion: This model demonstrates a method to compare different therapeutic strategies to reduce cardiovascular risk with their cost-effective ratios.
- Title: Review of the cardiovascular
safety of COXIBs compared to NSAIDS : review
article
Authors: Moodley, I.
From: Cardiovascular Journal of Africa, Vol 19, Issue 2, Mar / Apr
Published: 2008
Pages: 102-107
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Abstract: There is no doubt that NSAiDs and CoXiBS are the mainstay for managing pain and inflammation in arthritis. overall, at therapeutically equivalent doses, both NSAiDs and CoXiBs provide equivalent analgesic and anti-inflammatory efficacy. However, the gastrointestinal risk associated with NSAiDs is considerable. More recently, the cardiovascular risk associated with NSAiDs and CoXiBs has become a concern.
Most patients, particularly the young, can benefit from NSAiDs without the risk of serious adverse gastrointestinal or cardiovascular events. However, patients with a previous history of serious gastrointestinal complications and the elderly, who could be at risk, do require alternatives.
CoXiBs have significant benefits over NSAiDs in reducing the incidence of serious gastrointestinal complications (perforations, ulcers and gastric bleeding). Currently two oral CoXiBs are available, celecoxib and lumiracoxib, and one parenteral CoXiB, parecoxib. Celecoxib has been on the market for longer and has the largest body of evidence.
The older NSAiDs, such as meloxicam, with preferential CoX-2 inhibition do not have good long-term evidence of reducing the incidence of serious gastrointestinal complications. However, these agents do have evidence of tolerability, ie, reducing the less-serious gastrointestinal effects, mainly dyspepsia. The South African Rheumatoid Arthritis Association's guidelines, amended in November 2005 recommend CoXiBs for elderly patients (> 60 years) with previous gastropathy and those on warfarin and / or corticosteroids, providing they do not have contra-indications.
However, caution is advised when prescribing CoXiBs for patients with risk factors for heart disease. These recommendations are very similar to those made by the National institute for Clinical Excellence (NiCE). in addition, it should be noted that for those patients without any cardiovascular complications but with gastrointestinal risk factors or on aspirin, it may be necessary to add a proton pump inhibitor (PPi). PPis, however, provide little benefit for bleeding and ulceration of the lower intestine. one consequence of this low-grade bleeding is anaemia and a general feeling of malaise in patients with rheumatic disease. Current evidence suggests that CoXiBs such as rofecoxib and celecoxib do not increase small intestinal permeability and that celecoxib does not cause lower intestinal bleeding and may be of benefit to those patients with lower gastrointestinal complications.
In patients at risk for cardiovascular complications, both NSAiDs and CoXiBs have been shown to increase the risk of myocardial infarctions (Mi), hypertension and heart failure. Studies comparing CoXiBs and non-specific NSAiDs should, however, be interpreted with caution. one needs to take into account the underlying baseline cardiovascular risk of the populations being compared. CoXiBs appear to be prescribed preferentially to patients who were at an increased risk of cardiovascular events compared with patients prescribed non-specific NSAiDs.
When the overall risk of cardiovascular complications is relatively low and an anti-inflammatory agent is required, choice because of its lower cardiovascular toxicity potential compared to NSAiDs and other CoXiBs.
- Title: ONTARGET proves telmisartan
efficacy compared to ramipril in cardiovascular
protection of patients at high risk and without
heart failure : drug trends in cardiology
From: Cardiovascular Journal of Africa, Vol 19, Issue 2, Mar / Apr
Published: 2008
Pages: 108-109
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Abstract: Telmisartan now has the status of proven drug therapy in the prevention of cardiovascular events in patients at high risk for cardiovascular disease, and should be regarded as the drug of choice for these patients, considering both its efficacy and tolerability, according to the ONTARGET trial leader Prof Salim Yusuf. He released the results of this pivotal angiotensin receptor blocker (ARB) trial at the American College of Cardiology (ACC) meeting in Chicago recently.
- Title: South African cardiologists
comment on the study : drug trends in cardiology
From: Cardiovascular Journal of Africa, Vol 19, Issue 2, Mar / Apr
Published: 2008
Pages: 109-110
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Abstract: I find it very reassuring to know that this ARB is effective and provides comparable protection to the ACE inhibitor of choice for these patients. What really impressed me was the fact that telmisartan was better tolerated than ramipril, even in the patient population of this study, which excluded ACE-intolerant patients, and in fact was based on ACE tolerance as an inclusive criterion following the run-in period of the study.
- Title: Treating hypertension in
patients with ischaemic disease : the case for
better beta-blocker usage : drug trends in
cardiology
From: Cardiovascular Journal of Africa, Vol 19, Issue 2, Mar / Apr
Published: 2008
Pages: 113
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Abstract: 'Hypertensive patients of all ages with ischaemia will benefit from early use of beta-blockers, providing the selection of the beta-blocker takes cognisance of the specificity of individual drugs in the class and they are used appropriately with firstline diuretics in elderly patients.'
- Title: Rethinking heart rate : and
new horizons in treating it : drug trends in
cardiology
From: Cardiovascular Journal of Africa, Vol 19, Issue 2, Mar / Apr
Published: 2008
Pages: 114-155
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Abstract: When it comes to heart rate and cardiovascular disease, does heart rate matter? This was a question posed by Dr Colin Schamroth at a scientific meeting hosted by Servier Laboratories in February.
- Title: Rosuvastatin therapy shown to
regress atherosclerosis and increase lumen
diameter in extended ASTEROID study : drug
trends in cardiology
From: Cardiovascular Journal of Africa, Vol 19, Issue 2, Mar / Apr
Published: 2008
Pages: 117
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Abstract: Quantitative coronary angiography (QCA) of the coronary arteries of patients in the ASTEROID study has shown regression of diameter stenosis and improvement in the minimum lumen diameter following 24 months of rosuvastatin therapy.
- Title: Rosuvastatin outcomes study
JUPITER closes early due to evidence of benefit
: drug trends in cardiology
From: Cardiovascular Journal of Africa, Vol 19, Issue 2, Mar / Apr
Published: 2008
Pages: 117
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Abstract: During the late-breaking clinical trials session at the ACC 2008, it was announced that the JUPITER clinical study of rosuvastatin (Crestor) will be stopped early, based on a recommendation from an independent data-monitoring board and the JUPITER Steering Committee, which met on 29 March 2008. This is because there was unequivocal evidence of a reduction in cardiovascular morbidity and mortality among patients who received rosuvastatin when compared to placebo.
- Title: Trandolapril / verapamil SR
combination reverses drug-induced new-onset
diabetes : drug trends in cardiology
From: Cardiovascular Journal of Africa, Vol 19, Issue 2, Mar / Apr
Published: 2008
Pages: 118
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Abstract: An exploratory study conducted as an extension of the STAR study, which investigated the benefits of trandolapril / verapamil sustained release in patients with the metabolic syndrome, has shown that new-onset diabetes resulting from thiazide diuretic usage can be reversed by switching patient therapy to the trandolapril / verapamil SR combination.
- Title: PACE : Prevent
ArrhythmicCardiac Events : cardio news
From: Cardiovascular Journal of Africa, Vol 19, Issue 2, Mar / Apr
Published: 2008
Pages: 120
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Abstract: Three years ago, a group of parents and doctors who were involved in caring and managing individuals with arrhythmic heart conditions realised that, in South Africa, there was no support system for affected families or individuals, little awareness along with limited information on these conditions, and a lot of research still required.
