Dr K K Aggarwal

eMedinewS Editorial

Patients with abnormal LFTs can take statins

Long–term use of statins does not increase the risk of liver disease in patients with abnormal liver function, and can actually improve liver function, according to a new study as reported by medlineplus.

The study in fact shows that statins provide a substantially greater cardiovascular benefit in patients with abnormal liver function than in those with normal liver function. The study published in the Nov. 24 issue of The Lancet, included 437 patients with moderately abnormal liver tests with non–alcoholic fatty liver disease. Statins were given to 227 patients, while the other 210 controls received no treatment. After three years of follow–up, the patients taking statins did not have a higher rate of liver problems than those in the control group. Levels of SGPT decreased or normalized in the patients taking statins but worsened in the control group.

Patients with abnormal liver tests who took statins had a 39% to 68% reduced risk of cardiovascular events such as heart attack and stroke. The risk–to–benefit ratio of long–term atorvastatin favors statin administration even for patients with moderately abnormal liver tests.

Dr KK Aggarwal
Editor in Chief

eMedinewS Editorial

Anacetrapib lower LDL cholesterol while raising HDL cholesterol

According to a study published Nov. 17 in the New England Journal of Medicine and presented at the American Heart Association meeting, Merck’s experimental drug anacetrapib increases HDL or ‘good cholesterol even as it lowers LDL, the bad cholesterol. The drug, works by inhibiting an enzyme called CETP, which is involved in transforming particles of good cholesterol into bad cholesterol. The drug was tested in 1,623 patients who were already taking statins to control their cholesterol. Researchers at Boston’s Brigham and Women’s Hospital found that patients taking the drug saw a 39.8% reduction in LDL beyond what was seen in patients who got a placebo.

CETP inhibition

Drugs that inhibit CETP raise HDL–cholesterol levels. Investigation of torcetrapib has stopped; anacetrapib and dalcetrapib are under investigation. In the randomized ILLUMINATE trial of over 15,000 patients treated with atorvastatin, a significant increase in HDL–cholesterol (72 %) and an additional decline in LDL–cholesterol (25 %) below baseline were seen after 12 months of torcetrapib therapy. However, the trial was stopped early because, at a mean follow–up of 550 days, torcetrapib therapy was associated with a significant increase in the risk of cardiovascular events and death from any cause.
Anacetrapib: Significant findings include an increase in HDL cholesterol of 129 %, a decrease in LDL–cholesterol of 38 %, and no effect on blood pressure (in contrast to the increase in blood pressure with torcetrapib in the ILLUMINATE trial).
Dalcetrapib: Dalcetrapib use is accompanied by a dose–dependent decrease in CETP activity and an increase (nearly 40 %) in HDL cholesterol.

Dr KK Aggarwal
Editor in Chief

eMedinewS Editorial

Global risk assessment best for predicting heart failure in asymptomatic patients

A global risk assessment rather than extensive testing is the best way to predict heart disease in asymptomatic patients aged 20 or older, according to new guideline from the American College of Cardiology Foundation/American Heart Association. The expert panel reviewed over 400 studies to arrive at their recommendations to be published in the Dec. 14/21 JACC and the Dec. 21 Circulation.

• High risk: Global risk for CHD events of 20% or higher over 10 years
• Intermediate risk: 10–20% risk of CHD events

The guideline recommended that global risk scoring including factors such as cholesterol, blood pressure, age, sex, diabetes and smoking (e.g., the Framingham Score) should be used to assess cardiovascular risk in all adults, and that family history should always be examined. The following tests may be done in certain subgroups of asymptomatic patients:

Intermediate risk patients

• CRP men age 50 and younger and women age 60 and younger
• Coronary artery calcium scoring in diabetics who are over 40 years old, in low to intermediate risk;
• Ankle–brachial index
• Carotid intima–media thickness
• Exercise ECG stress test in previously sedentary adults who are about to start a vigorous exercise program
• Lipoprotein–associated phospholipase A2
• Urine for microalbuminuria

Regardless of risk

• CRP for determining the appropriateness of statin therapy in certain older people
• Resting ECG for patients with high blood pressure or diabetes
• Urine for microalbuminuria in patients with high blood pressure or diabetes
• Conventional echocardiography in hypertensive patients
• Nuclear stress testing in patients who have diabetes or a strong family history of heart disease or if previous tests suggest a high heart disease risk
• HbA1c, regardless of patients’ diabetes status

The following lack benefit in asymptomatic patients:

• Genetic testing
• Lipid parameters besides a standard profile, including lipoproteins, apolipoproteins, particle size and density
• Natriuretic peptide levels
• CT angio
• MRI for detection of vascular plaque
• Stress echocardiography
• Flow–mediated dilation; and
• Measures of arterial stiffness, such as pulse wave velocity

Dr KK Aggarwal
Editor in Chief