Hormone Replacement Therapy in Postmenopausal Women: Does It Lessen Coronary Heart Disease Risk?

Coronary heart disease is the leading cause of death in adult women in the U.S. Since clinical manifestations of coronary disease predominate in postmenopausal women, the need to evaluate coronary disease-gonadal hormone relationships is compelling. Further, estrogen exerts biologically plausible benefits: improved lipid profile, lower fibrinogen levels, favorable changes in vascular reactivity, possible antioxidant effects, among others. Although observational studies of estrogen use suggest substantial lessening of coronary risk, selection biases favoring a healthy cohort of women mandate randomized clinical trial data, with such trials currently in progress. Information is lacking regarding benefit: risk ratios of transdermal estrogen and estrogen/progestin combinations as coronary preventive therapies.     

Rotablation in the Very Elderly – Safer than We Think?

Background/purposeCalcified coronary artery stenosis remains a challenge for Percutaneous Coronary Intervention (PCI). Calcium modification is facilitated by rotablation and is used in 1–3% of cases. Data on rotablation in patients ≥80 years is limited and perceived to be high risk.We compared PCI with rotablation and outcomes between patients ≥80 years and those <80 years.Methods/materialsRetrospective analysis was performed of consecutive patients who underwent rotablation and PCI from 3 United Kingdom (UK) PCI Centres (2014–2017). In-hospital outcomes (composite of stroke, myocardial infarction, death, emergency coronary artery bypass graft surgery, vascular damage, coronary perforation, advanced AV-block, bleeding and renal impairment) and 30 day mortality risk score was compared between groups.Results213 patients were included. 33.3% (n = 71) were ≥80 years. Baseline and angiographic characteristics were similar in the two groups. Older patients were more likely to present with acute coronary syndrome (ACS) (≥80 years 53.5% vs. 33.8% in <80 years, p = 0.006) and had increased hospital stay (≥80 years 2.8 days (±6.0) vs. 1.3 days (±1.9) <80 years, p = 0.009). Majority of PCI were performed through radial access (≥80 years 91.5% vs. 88.0% <80 years, p = 0.43). In-hospital composite outcomes were similar between the groups (≥80 years 5.6% vs. 4.9% <80 years, p = 1.0). The 30-day mortality risk score demonstrated a higher average risk of 2.5% in ≥80 years versus under 1% risk in <80 years (p < 0.001).ConclusionThis study demonstrates that outcomes after rotablation in the very elderly are similar to younger patients despite being high risk and presenting with ACS.     

PSA Progression under Hormone Therapy - Of Prognostic Relevance?

In clinical routine, the anti-hormone therapy for prostate cancer with drugs is monitored by regular control measurements of the PSA value. An increase in the PSA value is considered to be a first sign of progression and thus of failure of the therapy. In the case of hormone-sensitive prostate carcinoma this means that the first stage of castration resistance has been reached. The question as to the relationship between PSA progression and overall survival as the most important clinical endpoint has been evaluated retrospectively in 2 studies. Both were able to confirm the relationship. However, in a therapy comparison, e.g., in phase III studies, the PSA progression does not have a surrogate status since the currently available analyses do not allow the recognition of an unambiguous relationship between the therapeutic effect on PSA progression and overall survival.     

Is pancreaticogastrostomy safer than pancreaticojejunostomy?

Background/Purpose

Failure of a pancreatic–enteric anastomosis very frequently leads to morbidity and mortality after pancreaticoduodenectomy. Pancreaticojejunostomy or pancreaticogastrostomy is often used after pancreaticoduodenectomy. The many reports on pancreaticogastrostomy support the low rates of anastomotic leakage and mortality compared with pancreaticojejunostomy.

Methods

Between January 1995 and December 2004, 155 pancreaticojejunostomies and 58 pancreaticogastrostomies were performed after pancreatic resection in the Second Department of Surgery of Nagoya University Hospital. Postoperative morbidity and mortality were analyzed.

Results

The incidence of pancreatic fistula was similar for the pancreaticojejunostomy (12.2%) and pancreaticogastrostomy (20.7%) groups and the mortality rate was 0% in both groups.

Conclusions

This restrospective clinical study suggested no significant difference in the incidence rate of pancreatic fistula and mortality between pancreaticojejunostomy and pancreaticogastrostomy.     

High-Density Lipoprotein Therapy: Is There Hope?

The treatment of lipid abnormalities generally has focused on low-density lipoprotein cholesterol (LDL-C) reduction based on extensive clinical trials and the National Cholesterol Education Program Adult Treatment Panel III guidelines. Unfortunately, it has become increasingly clear that a significant percentage of patients continue to have cardiovascular events despite being on LDL-C–lowering medications and having LDL-C levels below 100 mg/dL. Numerous epidemiologic studies have associated low high-density lipoprotein cholesterol (HDL-C) levels with increased risk of cardiovascular disease (CVD). Furthermore, recent data show that up to 55% of patients hospitalized for CVD have low HDL-C levels (<40 mg/dL) on admission, suggesting a possible target for further reducing CVD. Low HDL-C also is part of the atherogenic phenotype associated with obesity, glucose intolerance, and hypertension, termed the metabolic syndrome, and often is seen in patients with insulin resistance states. In general, the first line of therapy for increasing HDL-C in patients with levels below 40 mg/dL is lifestyle modification with smoking cessation, exercise, weight loss, and diet modifications. The pharmacologic treatment of isolated low HDL-C in patients without coronary disease is controversial but should be considered in those with a strong family history of CVD. In patients with coronary artery disease and isolated low HDL-C, statins remain the first-line therapy and should be instituted after lifestyle modifications, with the goal of increasing HDL-C above 40 mg/dL. If concomitant hypertriglyceridemia is present, a fibrate or niacin should be considered. Although statins do offer some HDL-C–raising properties, they tend to have modest effects. If treatment goals have not been achieved with either lifestyle changes or statin therapy, then the next agent of choice is niacin. Among the various HDL-C–raising therapies, niacin continues to be the most potent therapeutic option available. There are several novel HDL-C therapies in the research pipeline; however, only one class of medications is relatively close to clinical use, the cholesteryl ester transferase protein (CETP) inhibitors. Although one of the CETP inhibitors, torcetrapib, has received much negative attention from a large randomized trial showing increased mortality associated with its use, the overall class of therapeutic agents may still hold some benefit. Currently, two new CETP inhibitors without the off-target effects of torcetrapib are undergoing clinical research. Overall, the use of HDL-C–modifying agents likely will increase over the next decade.     

Is Vascular Stiffness a Target for Therapy?

Background  

Early cardiovascular disease starts in the endothelium leading to functional changes in the vasculature. These changes can be depicted by assessment of arterial stiffness or elasticity. There are several techniques to assess arterial stiffness. Increased arterial stiffness or decreased arterial elasticity has been associated with cardiovascular risk factors. There is now evidence that small artery elasticity is a strong predictor for arterial hypertension. Moreover arterial elasticity provides extra prognostic information beyond arterial blood pressure measurement. Arterial stiffness attenuation may reflect the true reduction of arterial wall damage.