Statins for the prevention of first or recurrent stroke

This review considers the evidence showing that statins can prevent first or recurrent stroke or improve its outcome in subjects at moderate or high risk for cardiovascular disease (CVD). Data are reviewed according to trial design (observational or prospective) and baseline CVD risk. Two (ASCOT, CARDS) out of five primary CVD prevention statin trials showed a considerable reduction in stroke rates. In two (MIRACL and PROVE IT) out of five acute coronary syndrome trials, the prevention of first stroke was significant. Most secondary prevention trials (4S, CARE, LIPID, HPS, GREACE and TNT) showed a beneficial effect of statins in stroke prevention. Finally, SPARCL, the only secondary stroke prevention trial in subjects without overt coronary heart disease (CHD), showed a significant reduction in total and ischaemic (fatal and nonfatal) stroke rate, although a small but significant increase in nonfatal haemorrhagic stroke was noted. There was also a significant reduction in CHD-related events. The possible mechanisms responsible for statin-associated stroke prevention are discussed. The evidence suggests the need to consider early and long-term statin treatment (with substantial low-density lipoprotein cholesterol reduction) in all patients at high risk of any type of major vascular event, without discriminating CHD from stroke. Thus, statins may be beneficial to both the heart and the brain.     

Spironolactone versus eplerenone for the treatment of idiopathic hyperaldosteronism

The aim of this prospective, randomised, open-label, blinded-end point study was to compare the efficacy and safety of eplerenone versus spironolactone in patients with bilateral idiopathic hyperaldosteronism (IHA). After a 2-week washout period, 34 patients with IHA were assigned to receive either spironolactone 25 mg b.i.d. (n = 17) or eplerenone 25 mg b.i.d. (n = 17) for 24 weeks. If the patients' blood pressure (BP) was not < 140/90 mmHg, the doses were gradually increased up to 400 mg for spironolactone and 200 mg for eplerenone. If the patients' BP remained uncontrolled, a daily dose of hydrochlorothiazide 12.5 mg was added at week 16. The primary outcome was the percentage of patients with BP < 140/90 mmHg at 16 weeks (i.e., with aldosterone antagonist monotherapy). The patients' BP was normalised in 13 out of 17 (76.5%) and 14 out of 17 (82.4%) patients in the spironolactone and eplerenone groups, respectively (p = 1.00). Systolic BP decreased more rapidly with eplerenone. Serum potassium levels were normalised (> 3.5 mmol/l) in all patients at 4 weeks. Mild hyperkalaemia was observed in two patients receiving 400 mg of spironolactone and in three patients receiving 150 mg of eplerenone. Two patients presented with bilateral painful gynaecomastia at the end of week 16 while receiving 400 mg of spironolactone. Switching spironolactone to 150 mg of eplerenone daily resulted in resolution of gynaecomastia and also maintained BP control. At the end of the study, 19 patients were on eplerenone and 15 were on spironolactone. However, this did not affect the primary end point, because the switch from spironolactone to eplerenone (in two patients) occurred at the end of week 16. It was concluded that eplerenone was as effective as spironolactone in reducing BP in patients with IHA. The risk of mild hyperkalaemia was similar with both drugs.     

Primary aldosteronism in patients with adrenal incidentaloma: Is screening appropriate for everyone?

Primary aldosteronism (PA) is a common form of secondary hypertension. Several guidelines recommend that patients with adrenal incidentaloma have a high probability of suffering from PA. We conducted a prospective study of 269 consecutive adults with adrenal incidentaloma to investigate the prevalence and clinical characteristics of PA. In total, 9 participants were detected with PA, suggesting a prevalence of 3.35% among the study population. PA participants had a higher blood pressure level by 14/20.8 mm Hg and a lower serum potassium level by 0.8 mmol/L (P < .05). Importantly, all patients with PA presented with concurrent indications (hypertension with or without hypokalemia) for screening of the disease, but they have not undergone relative screening by the referring physician, thus casting doubts about the appropriate implementation of current guidelines in real‐life practice. Intense efforts are needed to familiarize physicians with recommendations for PA to minimize undiagnosed cases and the detrimental sequelae of this endocrine form of hypertension.     

Detection of human papillomavirus DNA in esophageal carcinoma in Greece

AIM:To detect human papillomavirus(HPV)in theesophageal mucosa and the possible relationship with esophageal cancer in Greece.METHODS:Forty-nine patients underwent esophagogastroduodenoscopy(EGD)and esophageal biopsy at a university hospital that acts as a referral center for Northern Greece.Nineteen of these patients(14 male and 5 female)had esophageal squamous cell carcinoma(ESCC)and 30(15 male and 15 female)did not have any reported esophageal malignancy.Histopathological assessment was followed by polymerase chain reaction analysis of all the samples.Patient demographic data(age,sex,and place of birth)and information regarding smoking habits,alcohol consumption or sexual habits were collected.A method of statistical interference,verification of hypotheses based on homogeneity and independentχ2 test,was used.RESULTS:From the 49 patients that underwent EGD and biopsy,19 had ESCC and 30 had normal esophageal mucosa,with a mean age of 65.2 years.Regarding the prevalence of oncogenic risk factors for esophageal carcinoma,an interesting conclusion was that 78%of the patients used tobacco and almost one-third had multiple sexual partners,whereas only 20%of the patients consumed alcohol,which was not statistically significant,when compared to the control group.In the ESCC group,the only two positive samples were among the male patients(2/14 male patients with ESCC,14.5%).No HPV was identified in the control group.The predominant HPV types identified were 11 and 31,which have a low malignancy potential.The presence of HPV DNA in the ESCC group was not statistically significant,95%confidence interval(χ2=3.292,P=0.07).CONCLUSION:This is the first relevant study in Greece,and despite the lack of statistical significance,the issue of HPV infection and ESCC does merit further investigation.     

Role of Antihypertensive Drugs in Arterial ‘De-Stiffening’ and Central Pulsatile Hemodynamics

Arterial stiffness is an independent predictor of cardiovascular (CV) morbidity and mortality in patients with hypertension, as well as a potential therapeutic target. There is increasing awareness that the pulsatile hemodynamics (central blood pressure [CBP], pulse pressure [PP], wave reflections [augmentation index or AIx] and pulse wave velocity [PWV]) may provide better insight into the pathophysiology of CV disorders and target organ damage related to hypertension. Different antihypertensive drugs produce diverse effects on arterial stiffness variables, despite similar effects on peripheral (brachial) blood pressure. Identifying the pharmacologic interventions that can improve arterial stiffness ('de-stiffening' treatment) is a promising field of research.     

Treatment of primary aldosteronism: Where are we now?

Primary aldosteronism (PA) is an important cause of secondary hypertension, is being increasingly diagnosed and may account for more than 10% of hypertensive patients, both in primary care and in referral centers. Aldosterone excess is associated with adverse cardiovascular, renal and metabolic effects that are in part hypertension-independent. Laparoscopic adrenalectomy remains the mainstay of treatment for unilateral forms of PA, whereas medical treatment is recommended for bilateral forms of PA. However, a favourable surgical outcome depends on several factors and many patients are not suitable for this treatment. On the other hand, surgery in patients considered to have bilateral PA may contribute to better blood pressure control. In this review, established and novel strategies for the management of different types of PA are discussed.