Stage of chronic kidney disease and severity of coronary heart disease manifestation

A recent study suggested that patients with chronic kidney disease (CKD) with a glomerular filtration rate (GFR) < 45 ml/min/1.73 m(2) are more likely to present with acute myocardial infarction (AMI) than with stable exertion angina. Thus, the degree of renal impairment seems to be related to the presentation of coronary heart disease (CHD). In this context, there is evidence indicating that statins decrease the excess risk for AMI and other CHD-related events in patients with CKD (although the benefit may depend on the stage of CKD). This effect might be attributed to stabilization of atherosclerotic plaques, which seem to be more vulnerable if CKD is present. Thus, statin treatment in early CKD, a condition considered to be a CHD equivalent by several guidelines, is likely to minimize the risk for CHD events.     

Lipid lowering agents and the endothelium: an update after 4 years

Endothelial dysfunction represents an important step in the pathogenesis of atherosclerosis. All vascular risk factors can induce endothelial dysfunction, which in turn results in the loss of the protective effects of the endothelium culminating in the development of atherosclerosis. Dyslipidemia is a major vascular risk factor and is associated with endothelial dysfunction. Several studies showed that lipid-lowering agents exert beneficial effects on endothelial function in different populations at increased vascular risk, including patients without dyslipidemia. Therefore, other actions besides lipid-profile modification appear to be implicated in this benefit. However, it is unclear whether the improvement in endothelial function independently contributes to the vascular risk reduction during lipid-lowering treatment (e.g. with statins). It is also unclear whether the assessment of endothelial function would help identify patients who require more aggressive lipid-lowering treatment.     

Unusual manifestation of diarrhea-associated haemolytic uraemic syndrome in an adult

Hemolytic-Uremic Syndrome (HUS) is an uncommon disease characterized by microangiopathic hemolytica anaemia, thrombocytopenia, and acute renal failure. There are two forms of HUS: diarrhoea (D+)- and non-diarrhoea (D-)-associated HUS. We report the case of a 21-year-old woman presented to our department with jaundice, anaemia, thrombocytopenia, and anuria, preceded by a diarrheal prodrome, secondary to infection with Escherichia coli O157:H7. The whole clinical and laboratory investigation led to the diagnosis of HUS. Her condition was complicated with cholestasis, liver dysfunction, bleeding from the vagina, and myocardial involvement. She was treated only with fresh frozen plasma transfusions and hemodialysis, and despite the long duration of anuria (22 days), the patient showed subsequent improvement over days until full recovery one month later.     

Endothelial function, arterial stiffness and lipid lowering drugs

The endothelium is a dynamic organ that plays a pivotal role in cardiovascular homeostasis. Alteration in endothelial function precedes the development of atherosclerosis and contributes to its initiation, perpetuation and clinical manifestations. It has been suggested that the assessment of endothelial function could represent a barometer of vascular health that could be used to gauge cardiovascular risk. This review summarises the various methods used to assess endothelium-dependent vasodilatation and their potential prognostic implications. In addition, the techniques used to evaluate arterial stiffness are discussed. The latter is to some extent controlled by the endothelium and has been the subject of considerable research in recent years. This paper also discusses the effects of lipid lowering treatment on both endothelial function and arterial stiffness.     

Effect of atorvastatin on high density lipoprotein cholesterol and its relationship with coronary events: a subgroup analysis of the GREek Atorvastatin and Coronary-heart-disease Evaluation (GREACE) Study

OBJECTIVE: To investigate the relationship between changes in high density lipoprotein cholesterol(HDL-C) levels after statin treatment and the risk for coronary heart disease (CHD)-related events in the secondary CHD prevention GREek Atorvastatin and Coronary heart disease Evaluation (GREACE) Study. These findings suggested that dose titration with atorvastatin (10-80 mg/day, mean 24 mg/day)achieves the National Cholesterol Educational Program treatment goals and significantly reduces morbidity and mortality, in comparison to usual care. METHODS: Analysis of variance was used to assess the effect of atorvastatin on HDL-C over time (up to 48 months) in 1600 CHD patients. The time-dependent multivariate Cox predictive model,involving backward stepwise logistic regression,was used to evaluate the relation between coronary events and HDL-C changes. RESULTS: The mean increase in HDL-C levels during the study was 7%. All doses of atorvastatin significantly increased HDL-C levels. Increases were greater in men (7.8 vs 6.1%; p = 0.02), in combined hyperlipidaemia (7.9 vs 6.4% for hypercholesterolaemia; p = 0.04), and in the lower baseline HDL-C quartile (9.2 vs 5.3%, 1st vs 4th quartile; p = 0.001). After adjustment for 24 predictors of coronary events, multivariate analysis revealed a Hazards Ratio of 0.85 (95% confidence interval 0.76-0.94; p = 0.002) for every 4 mg/dL(0.1 mmol/L) increase in HDL-C. CONCLUSIONS: There was a significant beneficial effect on HDL-C levels across the dose range of atorvastatin. Clinical outcomes in the structured care arm of GREACE were determined in part by the extent of atorvastatin-induced HDL-C increase.This effect was independent from benefit induced by low density lipoprotein cholesterol (LDL-C)reduction, suggesting that the CHD risk reduction associated with a rise in a low HDL-C at baseline remains significant under aggressive (-46%) LDL-C lowering conditions. However, the relationship between HDL-C and vascular risk may be weaker when LDL-C levels are aggressively lowered.