Attitudes and actions: A survey to assess statin use among Finnish patients with increased risk for cardiovascular events.

BACKGROUND: Statins are the first-line treatment for lowering serum cholesterol and preventing coronary artery disease (CAD). Patients who fail to comply with the prescribed statin treatment face a markedly increased risk for cardiovascular events. OBJECTIVE: The aim of the article was to study the subjective factors, which modulate persistence with and adherence to statin therapy among Finnish patients at high risk for cardiovascular events. METHODS: A total of 1022 Finnish adults diagnosed with CAD, diabetes, hypertension, or severe hereditary dyslipidemia completed an electronic questionnaire survey during a visit in 1 of the 84 community pharmacies participating in the study. RESULTS: Thirty-four percent of the survey respondents were diagnosed with CAD or severe hereditary dyslipidemia and 82% were current or former statin users. Prevalence of nonpersistence with statin therapy was 15% among CAD patients and 17% among respondents without the diagnosis. Most of the nonpersistent statin users had discontinued the medication without consultation of a physician. None of the studied sociodemographic background factors were associated with persistence with statin therapy. Instead, experienced adverse effects, fear of adverse effects, perceived lack of need, and difficulties in use of a statin emerged as powerful predictors of nonpersistence. Awareness of treatment goals was low, and strikingly, public discussion about adverse effects of statins had induced nearly every third discontinuation of statin treatment. CONCLUSION: Several subjective, potentially modifiable reasons for nonpersistence were identified from the patient perspective. Improved utilization of patient-centered approaches in pharmacologic management of cardiovascular risks is necessary to improve adherence, and ultimately, treatment outcomes.

Prasugrel versus clopidogrel in acute coronary syndromes treated with PCI: Effects on clinical outcome according to culprit artery location.

BACKGROUND: Acute coronary syndrome (ACS) mortality increases when the culprit lesion is in the left anterior descending (LAD) artery. We investigated the effects of prasugrel versus clopidogrel according to site of culprit lesion causing ACS treated with percutaneous coronary intervention (PCI) in the TRITON-TIMI 38 study. METHODS: Patients were divided into three groups based on the native coronary artery culprit lesion location. The LAD artery group included also patients with the culprit lesion in the left main (LM) artery. RESULTS: In the whole ACS population, prasugrel recipients had lower rates of the primary endpoint that included cardiovascular (CV) death, non-fatal myocardial infarction (MI) or non-fatal stroke without significant differences across vessel groups. CV death was significantly decreased with prasugrel in the whole ACS population (p=0.03) and in ST-elevation MI (STEMI) patients undergoing primary PCI (p=0.04), with pronounced differences in favour of prasugrel versus clopidogrel when the LAD-LM was the culprit vessel (relative risk reduction 50% in the whole ACS population, 57% in STEMI treated with primary PCI, p for interaction 0.07 and 0.08 respectively). CONCLUSIONS: Prasugrel effects were particularly favourable when LAD-LM was the culprit vessel, resulting in CV mortality reduction in the whole ACS population and in STEMI patients when treated with primary PCI.

[Update on Current Care Guideline. Diabetes]. / Diabetes.

About 500,000 people suffer from diabetes in Finland, a number which is predicted to increase within the next decades. At the moment, diabetes can neither be prevented nor cured. Diabetes is associated with microvascular (kidney, eye and peripheral nerves) and macrovascular complications (coronary heart disease, stroke). These complications affect the quality of life of patients and account for a substantial proportion of healthcare costs in Finland. The.current guidelines offer recommendations for the diagnosis, screening, prevention and treatment of diabetes and its complications.

[Life after cardiac infarction]. / Elämä(ä) sydäninfarktin jälkeen.

Many of those having had cardiac infarction suffer only a minor myocardial injury and are discharged after balloon angioplasty with open coronary arteries and well-pumping cardiac muscle. Returning to normal life may, however, be tough. On the other hand, after a few days of hospital care the discharged person does not always even note having fallen ill. At and between both extremes the affected person needs guidance, support, encouraging and appropriate medication. Living habits have an essential effect on both short-term and long-term prognosis, and sensible living also results in a better well-being.

[Prevention of arterial diseases in the 2010s: the European treatment guideline]. / Valtimosairauksien ehkäisy 2010-luvulla: eurooppalainen hoitosuositus.

Reduction of risk factors at the population level forms the basis of the European recommendation of 2012 for the prevention of arterial diseases. Actions at the individual level arise from risk assessment. The risk of arterial disease is graded into four categories, the uppermost ones comprising patients who have already developed the disease, diabetics, those suffering from renal insufficiency and those carrying a serious gene defect. In Finland the risk among healthy people is assessed by using the FINRISKI tool. Non-smoking, healthy diet and regular exercise are suitable for all. Statins are an effective and safe means of prevention for those at high risk regardless of lipid values.

Heart rate variability associates with asymptomatic coronary atherosclerosis.

PURPOSE: Heart rate variability (HRV) becomes impaired in symptomatic coronary artery disease (CAD), particularly, after myocardial infarction. The mechanism how CAD results in impairment of cardiac autonomic regulation is not known. Whether it results rather from coronary atherosclerosis itself than myocardial ischemia and myocardial injury has remained elusive. METHODS: Quantitative coronary angiography was performed in 30 subjects without history of myocardial ischemia, but with high familial risk for CAD. HRV was measured from 24-h ambulatory ECG recordings in time and frequency domain and also non-linear HRV variables SD1 and SD2 in Poincare plot were calculated. Myocardial ischemia was excluded by Tc-99m sestamibi scintigraphy at rest and during exercise. RESULTS: Coronary angiography revealed mean diameter stenosis of 32 ± 19 % in left anterior descending coronary artery, 26 ± 16 % in left circumflex coronary artery and 25 ± 20 % in right coronary artery. An inverse correlation was found between pNN50 and global severity of coronary artery diameter stenosis (r = -0.415, p < 0.05). Correspondingly, power of HF spectral component correlated negatively with global extent of coronary atherosclerosis (r = -0.366, p < 0.05). In Poincare plot, SD1/SD2 ratio correlated with global extent (r = -0.394, p < 0.05) and global burden (r = -0.388, p < 0.05) of coronary arteries. CONCLUSIONS: The severity and extent of coronary atherosclerosis were related to a shift of cardiac autonomic regulation towards sympathetic predominance in asymptomatic subjects without evidence of myocardial ischemia.

Outcome up to one year following different reperfusion strategies in acute ST-segment elevation myocardial infarction: the Helsinki-Uusimaa Hospital District registry of ST-Elevation Acute Myocardial Infarction (HUS-STEMI).

AIMS: Current guidelines prefer primary percutaneous coronary intervention (pPCI) over fibrinolysis in the treatment of acute ST-elevation myocardial infarction (STEMI). Pre-hospital fibrinolysis followed by early invasive evaluation is an alternative that we have used in patients presenting within three hours of symptom onset. We made a survey of patients suffering an acute STEMI over one year to assess mortality and adverse events following either pPCI or fibrinolysis. METHODS AND RESULTS: Of the 448 consecutive STEMI patients, 194 were treated with pPCI and 176 underwent fibrinolysis; 78 patients received no reperfusion treatment within 12 hours (NRT group). The median TIMI risk scores were 4.0, 3.0 and 4.0 in the pPCI, fibrinolysis and NRT groups, respectively (p<0.001). Mortality at one year was 14.4% following pPCI, 5.1% following fibrinolysis and 12.8% in the NRT group (p=0.011 across all groups and p=0.003 between pPCI and fibrinolysis, adjusted for differences in risk factors). The one-year composite of cardiovascular death, stroke, reinfarction and new revascularization was 20.1%, 18.2% and 26.9% for the pPCI, fibrinolysis and NRT groups, respectively (p=NS). In patients presenting within three hours of symptom onset, one-year mortality was 3.7% in the fibrinolysis group (n=163) and 15.3% in the pPCI group (n=118) (adjusted p =0.001), while the composite of adverse events was 16.6% in the former group and 19.5% in the latter (p=NS). CONCLUSION: Pre-hospital fibrinolysis followed by routine early invasive evaluation provides an excellent reperfusion strategy for low-risk STEMI patients presenting early after symptom onset.

Baroreflex sensitivity in asymptomatic coronary atherosclerosis.

BACKGROUND: Baroreflex sensitivity (BRS) reflects the effectiveness of cardiac parasympathetic regulation. BRS becomes impaired in stable coronary artery disease (CAD) and after myocardial infarction and carries prognostic information in these patients. Whether impaired BRS is found already in asymptomatic subjects, with subclinical coronary atherosclerosis, has remained elusive. METHODS: The relationship between BRS and coronary atherosclerosis was evaluated in 31 subjects with high familial risk for CAD but without evidence of angina pectoris or myocardial ischaemia. Single photon emission tomography was performed with (99m) Tc-sestamibi to rule out myocardial perfusion defects at rest and during exercise. BRS was assessed by phenylephrine technique. Coronary atherosclerosis was analysed by quantitative coronary angiography (QCA). Percentage of diameter stenosis (PDS) was calculated separately for LAD, LCX, RCA coronary arteries as well as for proximal (PROX), middle (MID) and distal (DIST) coronary artery regions; and for all coronary artery regions (global PDS). RESULTS: Baroreflex sensitivity averaged 7·8 ± 5·4 ms mmHg(-1) . BRS showed inverse correlation to PDS of the proximal coronary artery segments (r = -0·315; P<0·05) and with the most severe single coronary artery stenosis (r = -0·374; P<0·05). Five (16%) subjects had BRS ≤ 3 ms mmHg(-1) . They had more severe PDS of proximal coronary artery segment than subjects with BRS > 3 ms mmHg(-1) (24 ± 7% versus 13 ± 11%, P<0·05, respectively). CONCLUSIONS: Impairment of BRS was found to be associated with the severity of subclinical coronary atherosclerosis in healthy asymptomatic subjects with familial risk of CAD. Asymptomatic subjects with severely blunted BRS may have advanced coronary atherosclerosis.

[Statin therapy--for whom?]. / Kenelle aloitan statiinilääkityksen?

For patients with cardiovascular disease, statins belong to routine medical treatment irrespective of blood lipid levels. In primary prevention also, statins have been found to prevent cardiovascular diseases, associated deaths and decrease overall mortality. In previously healthy persons the use of statins should be based on the assessment of total risk--mere cholesterol level does not usually constitute an indication for treatment. The use of statins may lead to adverse effects, the major one being myopathy, for which an elevated risk is associated with increasing statin dosages.

Randomized comparison of coronary bifurcation stenting with the crush versus the culotte technique using sirolimus eluting stents: the Nordic stent technique study.

BACKGROUND: In a number of coronary bifurcation lesions, both the main vessel and the side branch need stent coverage. Using sirolimus eluting stents, we compared 2 dedicated bifurcation stent techniques, the crush and the culotte techniques in a randomized trial with separate clinical and angiographic end-points. METHODS AND RESULTS: A total of 424 patients with a bifurcation lesion were randomized to crush (n=209) and culotte (n=215) stenting. The primary end point was major adverse cardiac events; cardiac death, myocardial infarction, target vessel revascularization, or stent thrombosis after 6 months. At 6 months there were no significant differences in major adverse cardiac event rates between the groups; crush 4.3%, culotte 3.7% (P=0.87). Procedure and fluoroscopy times and contrast volumes were similar in the 2 groups. The rates of procedure-related increase in biomarkers of myocardial injury were 15.5% in crush versus 8.8% in culotte group (P=0.08). A total of 324 patients had a quantitative coronary assessment at the index procedure and after 8 months. The angiographic end-points of in-segment and in-stent restenosis of main vessel and/or side branch after 8 months were found in 12.1% versus 6.6% (P=0.10) and in 10.5% versus 4.5% (P=0.046) in the crush and culotte groups, respectively. CONCLUSIONS: Both the crush and the culotte bifurcation stenting techniques were associated with similar and excellent clinical and angiographic results. Angiographically, there was a trend toward less in-segment restenosis and significantly reduced in-stent restenosis following culotte stenting.

Predicting the culprit artery in acute ST-elevation myocardial infarction and introducing a new algorithm to predict infarct-related artery in inferior ST-elevation myocardial infarction: correlation with coronary anatomy in the HAAMU Trial.

AIMS: The objective of this study is to predict the culprit artery from the electrocardiogram (ECG) by predefined criteria and to compare a new algorithm with a previous one for predicting the culprit artery in inferior ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: In "all-comers" (n = 187) with acute STEMI, with ECG and angiography from the acute phase, the positive and negative predictive values for the prediction of the left anterior descending coronary artery, left circumflex coronary artery, or right coronary artery as the infarct-related artery were 96% and 96%, 65% and 95%, 92% and 97%, respectively. In inferior STEMI (n = 98), positive and negative predictive values to predict the right coronary artery or the left circumflex coronary artery as the culprit artery were 92% and 75% and 75% and 94%, respectively. CONCLUSIONS: In "all-comers" with STEMI, the culprit artery could be predicted by ECG criteria with high predictive values. In inferior STEMI, a new algorithm for culprit artery prediction was successfully tested.

Apolipoprotein E polymorphism is associated with both carotid and coronary atherosclerosis in patients with coronary artery disease.

BACKGROUND AND AIMS: Apolipoprotein E (apoE) polymorphism plays a significant role in the development of atherosclerosis and cardiovascular disease. Therefore, the aim of the present study was to examine the association between apoE polymorphism and carotid intima-media thickness (IMT), and severity and extent of coronary artery disease (CAD). METHODS AND RESULTS: B-mode ultrasound and quantitative coronary angiography (QCA) were used to assess carotid, and coronary artery atherosclerosis in 91 patients with clinically suspected CAD referred for cardiac catheterization. Two apoE phenotype groups were defined: apoE3 (E3/E3) and apoE4 (including E4/E3, E4/E4 phenotypes). Maximum IMT was higher in the apoE4 group than in the apoE3 group (p=0.022). The global atheroma burden index was similarly higher in the apoE4 group than in the apoE3 group (p=0.033). ApoE4 subjects had higher levels of apolipoprotein B (apoB) (p=0.008), triglycerides (p=0.006), remnant lipoprotein-cholesterol (RLP-C) (p=0.023), and lipoprotein(a) [(Lp(a)] (p=0.041) than apoE3 subjects. The mean LDL particle size was smaller in the apoE4 group than in the apoE3 group (p=0.041). CONCLUSIONS: ApoE polymorphism was associated with both carotid and coronary atherosclerosis. Patients with the apoE4 isoform had an increased carotid IMT and a more severe and extensive CAD than patients with the apoE3 isoform.

Meta-analysis of randomized trials on drug-eluting stents vs. bare-metal stents in patients with acute myocardial infarction.

AIMS: To compare the efficacy and safety of drug-eluting stents vs. bare-metal stents in patients with acute ST-segment elevation myocardial infarction. METHODS AND RESULTS: We performed a meta-analysis of eight randomized trials comparing drug-eluting stents (sirolimus-eluting or paclitaxel-eluting stents) with bare-metal stents in 2786 patients with acute ST-segment elevation myocardial infarction. All patients were followed up for a mean of 12.0-24.2 months. Individual data were available for seven trials with 2476 patients. The primary efficacy endpoint was the need for reintervention (target lesion revascularization). The primary safety endpoint was stent thrombosis. Other outcomes of interest were death and recurrent myocardial infarction. Drug-eluting stents significantly reduced the risk of reintervention, hazard ratio of 0.38 (95% CI, 0.29-0.50), P < 0.001. The overall risk of stent thrombosis: hazard ratio of 0.80 (95% CI, 0.46-1.39), P = 0.43; death: hazard ratio of 0.76 (95% CI, 0.53-1.10), P = 0.14; and recurrent myocardial infarction: hazard ratio of 0.72 (95% CI, 0.48-1.08, P = 0.11) was not significantly different for patients receiving drug-eluting stents vs. bare-metal stents. CONCLUSION: The use of drug-eluting stents in patients with acute ST-segment elevation myocardial infarction is safe and improves clinical outcomes by reducing the risk of reintervention compared with bare-metal stents.

Low HDL-C predicts the onset of transplant vasculopathy in pediatric cardiac recipients on pravastatin therapy.

The levels and protein/lipid compositions of major lipoprotein particles of 19 pediatric cardiac transplant recipients (4-18 yr of age) were studied in this prospective, open clinical follow-up study before and at one yr of pravastatin therapy (10 mg/day). The recipients were grouped into those with (n = 6; group A) and those without (n = 13; group B) angiographically detectable vasculopathy. Twenty-one pediatric non-transplant controls were studied at baseline. At baseline, the group A recipients had 29% lower HDL-C concentrations (p = 0.031) and 29% higher apoB-100/apoA-I ratios (p = 0.034) than the group B recipients. At one yr of pravastatin, the respective figures were 29% (p = 0.013) and 33% (p = 0.005). Compared with the healthy pediatric controls, the transplant recipients had significantly higher serum TG before pravastatin [median (range): 1.3 mmol/L (0.6-3.2) vs. 0.7 mmol/L (0.3-2.4), p = 0.0002] and at one yr [1.3 mmol/L (0.5-3.5) vs. 0.7 mmol/L (0.3-2.4), p = 0.0004]. The baseline apoB-100/apoA1 ratios of the recipients were 33% higher (p = 0.005). In conclusion, low HDL-C and high apoB-100/apoA-I ratio were associated with angiographically detectable vasculopathy. Even though pravastatin effectively lowered the TC and LDL-C and improved compositional properties of LDL and HDL(2) particles, it failed to normalize the elevated TG and, in some patients, to prevent the progression of transplant vasculopathy.