Patients satisfaction with warfarin and willingness to switch to dabigatran: a patient survey.

Warfarin is an anticoagulant medication that is challenging to manage. Dabigatran has been approved by the FDA for stroke and systemic embolism prevention in non-valvular atrial fibrillation as an alternative to warfarin. Dabigatran does not require routine monitoring, has an established dose, and lacks many of the drug, herbal, and food interactions that afflict warfarin. To evaluate patients' satisfaction with their current warfarin treatment and their opinion on switching to a newly marketed medication (dabigatran) through a brief survey. Two separate surveys were administered to (1) evaluate the patients' opinion of their warfarin therapy and (2) evaluate their thoughts on switching to a newer anticoagulant. Responses were recorded on a rating scale of 1-5; 1 being the least and 5 being the highest. Study was conducted at the Georgia Regents Health System (GRHS) pharmacy-based anticoagulation clinic. Two hundred sixty patients on warfarin treatment were enrolled. Patients expressed high satisfaction with warfarin treatment (4.7 ± 0.78). However, a vast majority of the patients were willing to switch to an agent that: requires less frequent follow-up visits (3.9 ± 1.35); lacks interaction with food and/or beverage (4.1 ± 1.25); is as efficacious as warfarin (3.7 ± 1.38). Patients expressed that out-of-pocket cost would be a major barrier to switch to this new medication (1.3 ± 0.58). Patients are satisfied with their warfarin treatment but willing to consider a new anticoagulant. Cost was highlighted as the most significant barrier. Efficacy, dietary freedom and less frequent visits are the major factors affecting the patients' decision.

Genetic Factors Associated with Morphine Consumption in Women Undergoing Laparoscopic Cholecystectomy: A Prospective Cohort Study.

Introduction: Morphine has been a crucial analgesic agent used perioperatively in various surgical procedures. Genetic factors can lead to morphine dose requirement interpatient variability. Our objective was to determine the contribution of genetic polymorphisms in human µ-opioid receptor gene (OPRM1), ATP binding cassette gene (ABCB1) and rs2952768 to the variation of the perioperative morphine consumption in women undergoing laparoscopic cholecystectomy. Methods: This is a prospective cohort study that included 102 adult Arab females undergoing laparoscopic cholecystectomy. The exposures were carrying the genetic variants of OPRM1, ABCB1 and rs2952768. Our primary outcome was total morphine or morphine equivalent dose required perioperatively. The secondary outcomes were pain score during the first 24 hours and adverse drug reactions. A standardized, general anaesthesia was used for all subjects. In addition to the genetic factors, we also investigated non-genetic factors influencing post-operative pain sensitivity and morphine consumption. Results: Both (rs1799971, A>G) in OPRM1 and (rs2952768, T>C) showed statistically significant association with intra-operative total morphine dose requirements. Patients carrying the "G" allele in OPRM1 had a significantly higher total morphine mean rank dose compared to the AA genotype [62.9 vs 47.1, p=0.008]. Furthermore, patients homozygous for the rs2952768 (T>C) minor allele "CC" had a higher mean rank compared to the other genotypes [72.7 vs 50.1, p=0.046]. Conclusion: OPRM1 (rs1799971) and rs2952768 are associated with variation of intra-operative morphine consumption in laparoscopic cholecystectomy. Clinical Trial Identifier: This study was registered at ClinicalTrials.gov, NCT04621864. https://clinicaltrials.gov/ct2/show/NCT04621864.

Candesartan augments ischemia-induced proangiogenic state and results in sustained improvement after stroke.

BACKGROUND AND PURPOSE: We have shown that acute treatment with candesartan in an experimental model of stroke resulted in vascular protection and improved outcomes at 24 hours poststroke, but the mechanisms are unknown. We now examine effects of candesartan on proangiogenic factors and 7-day outcomes using the same treatment paradigm. METHODS: Male Wistar rats underwent 3 hours of middle cerebral artery occlusion followed by reperfusion. A single dose of 1 mg/kg candesartan intravenously was given at reperfusion. Animals received neurobehavioral testing before middle cerebral artery occlusion, at 24 hours after middle cerebral artery occlusion, and at 7 days. Blood pressure was measured by telemetry. Animals euthanized at 24 hours had brain tissue and cerebrospinal fluid collected for matrix metalloproteinase activity, vascular endothelial growth factor expression, and tube formation assay. Neurobehavioral testing included elevated body swing test, Bederson, beam walk, and paw grasp. Cerebrovascular density was quantified using immunohistochemistry at 24 hours and 7 days. RESULTS: Matrix metalloproteinase-2 activity and vascular endothelial growth factor expression were higher (P=0.035, P=0.042, respectively) and cerebrospinal fluid was significantly more proangiogenic (5x tube formation; P=0.002) in the candesartan group at 24 hours. Although no difference was seen in infarct size at 7 days, treatment improved Bederson scores (2.1 versus 2.9, P=0.0083), elevated body swing test (22.9 versus 39.4, P=0.021), and paw grasp (1.29 versus 2.88, P=0.0001) at 7 days. Candesartan treatment resulted in increased vascular density in the striatum at 7 days (P=0.037). CONCLUSIONS: Candesartan after reperfusion augments ischemia-induced angiogenic state and provides long-term benefits. The beneficial effects may involve vascular protection and enhancement of early angiogenic remodeling.

Early atorvastatin reduces hemorrhage after acute cerebral ischemia in diabetic rats.

Ischemic stroke is a leading cause of death in the United States, and diabetes mellitus is a major risk factor for stroke. Our previous work showed that type II diabetic rats [Goto-Kakizaki (GK)] have more bleeding after stroke than their normoglycemic controls (Wistar). Our aim was to evaluate the vascular protective properties of acute atorvastatin therapy after experimental ischemic stroke in diabetes and to explore the effect of stroke in GK rats compared with their normoglycemic controls. Fifty male Wistar and 40 GK rats (270-305 g) underwent 3 h of middle cerebral artery occlusion followed by reperfusion for 21 h. Animals received atorvastatin (5 mg/kg), atorvastatin (15 mg/kg), or vehicle, administered by oral gavage, one dose 5 min after reperfusion and a second dose after 12 h. At 24 h, functional outcome was measured, and brain tissue was analyzed for infarct volume, hemoglobin content, and molecular biomarkers. Plasma was collected for analysis of atorvastatin concentrations. Atorvastatin-treated groups had significantly lower bleeding rates (p = 0.0011) and infarct volume (p = 0.0007) compared with controls. There was a significant reduction in hemoglobin content and infarct volume only in the higher dose group (15 mg/kg) (p < 0.05), and these benefits were more than 4 times greater in the diabetic animals. Atorvastatin (15 mg/kg) improved neurological outcome in both Wistar and GK rats (p = 0.029) at a peak concentration of 27 to 77 ng/ml and was associated with an increase in Akt phosphorylation (p = 0.0007). We concluded that atorvastatin is a vascular protective agent after experimental ischemic stroke, especially in diabetes.

Vascular protection with candesartan after experimental acute stroke in hypertensive rats: a dose-response study.

We have shown that candesartan decreases the acute stroke-induced elevation of mean arterial blood pressure (MAP) in Wistar rats and improves functional outcome. The aim of the present study was to determine whether the same benefit could be achieved in spontaneously hypertensive rats (SHR). Animals were subjected to middle cerebral artery occlusion (MCAO) or sham for 3 h followed by reperfusion. Either candesartan (0.1, 0.3, or 1.0 mg/kg) or saline was administered. MAP of the rats was monitored by means of telemetry, and neurological function was assessed. Infarct size, edema formation, and hemoglobin content in the ischemic hemisphere were evaluated 24 h after the stroke. MAP of SHR increased immediately upon MCAO from 135 (baseline) to 189 mm Hg, and it remained elevated until reperfusion. Candesartan decreased MAP in a dose-dependent manner, with a drop below baseline after a dose of 1.0 mg/kg. SHRs experienced greater blood pressure (BP)-lowering effects of candesartan after stroke compared with a sham condition (p < 0.0001). Neurological deficit after stroke was reduced in candesartan-treated animals, revealing a dose-dependent effect (p < 0.01). Infarct size, edema formation, and hemoglobin content were all reduced by candesartan at doses of 0.1 and 0.3 mg/kg (p < 0.05 for all). Candesartan (1 mg/kg) was not different from saline. Low doses of candesartan provide neurovascular protection after stroke in SHRs. Caution is warranted because acute stroke increases the sensitivity to BP lowering, which, in turn, increases the likelihood of overshooting.

Blood pressure lowering after experimental cerebral ischemia provides neurovascular protection.

BACKGROUND: There is evidence that acutely elevated blood pressure (BP) after stroke is associated with increased cerebral hemorrhage and edema. Previous experiments in our laboratory have shown that candesartan 1 mg/kg administered after reperfusion in a model of hypertension after experimental ischemic stroke reduces neurovascular damage and improves outcome. These results could be either mediated by BP lowering or a BP-independent cerebrovascular protective effect. OBJECTIVES: To determine the contribution of BP lowering to the neurovascular protection previously reported with candesartan after stroke. METHODS: Male Wistar rats (280-305 g) underwent 3 h of middle cerebral artery occlusion (MCAO). At reperfusion, either hydralazine 1 mg/kg (n = 8), enalapril 5 mg/kg (n = 7) or enalapril 10 mg/kg (n = 8) were administered intravenously. BP was measured by telemetry for 2 days before and 24 h after MCAO. After neurological function was assessed, brain tissue was processed for infarct size and hemoglobin content analyses. RESULTS: Mean arterial pressure (MAP) increased from 92 to 124 mmHg immediately upon MCAO and decreased to 112 mmHg after reperfusion, remaining elevated for 24 h (P < 0.0001) in the saline group. Hydralazine reduced MAP (P = 0.048) and infarct size (53 versus 30%, P = 0.0083), and there was a trend towards decreased hemoglobin content. Enalapril 5 mg/kg did not significantly change MAP or other outcomes. Enalapril 10 mg/kg reduced MAP (P < 0.0001) and infarct size (53 versus 29%, P = 0.003). There was an intermediate effect on both hemoglobin content and neurological function, neither one was significant. The time course of BP lowering varied with each treatment. CONCLUSION: Acute BP lowering after reperfusion in acute ischemic stroke is an effective strategy to achieve neurovascular protection. The rate, extent and mechanism of BP lowering may determine the magnitude of protection.

Minocycline for short-term neuroprotection.

Minocycline is a widely used tetracycline antibiotic. For decades, it has been used to treat various gram-positive and gram-negative infections. Minocycline was recently shown to have neuroprotective properties in animal models of acute neurologic injury. As a neuroprotective agent, the drug appears more effective than other treatment options. In addition to its high penetration of the blood-brain barrier, minocycline is a safe compound commonly used to treat chronic infections. Its several mechanisms of action in neuroprotection -- antiinflammatory and antiapoptotic effects, and protease inhibition -- make it a desirable candidate as therapy for acute neurologic injury, such as ischemic stroke. Minocycline is ready for clinical trials of acute neurologic injury.

Diverse effects of statins on angiogenesis: new therapeutic avenues.

Angiogenesis is an important process for a variety of physiologic and pathologic conditions. Different angiogenic modulating targets are under extensive investigation both experimentally and clinically. The 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are the first-line agents used in hypercholesterolemia. They are also characterized by having other benefits apart from their lipid-lowering effects. Among these pleiotropic effects are the pro- and antiangiogenic properties of statins. The pleiotropic effects of statins and how they modulate new blood vessel formation are discussed in this review. The currently available data from both animal and human studies regarding the effects of statins on angiogenesis in ischemic heart disease, stroke, ocular diseases, and cancer are also reviewed. Statins are safe, orally available agents that may acquire novel therapeutic indications through their angiogenic modulating effects.