Lipid Management in Patients Presenting With Acute Coronary Syndromes: A Review.

Despite many improvements in its prevention and management, acute coronary syndrome (ACS) remains a major cause of morbidity and mortality in the developed world. Lipid management is an important part of secondary prevention after ACS, but many patients currently remain undertreated and do not attain guideline-recommended levels of low-density lipoprotein cholesterol reduction. This review details the current state of evidence on lipid management in patients presenting with ACS, provides directions for identification of patients who may benefit from early escalation of lipid-lowering therapy, and discusses novel lipid-lowering medication that is currently under investigation in clinical trials. Moreover, a treatment algorithm aimed at attaining guideline-recommended low-density lipoprotein cholesterol levels is proposed. Despite important advances in the initial treatment and secondary prevention of ACS, ≈20% of ACS survivors experience a subsequent ischemic cardiovascular event within 24 months, and 5-year mortality ranges from 19% to 22%. Knowledge of the current state of evidence-based lipid management after ACS is of paramount importance to improve outcomes after ACS.

Contrast-enhanced sonothrombolysis in a porcine model of acute peripheral arterial thrombosis and prevention of anaphylactic shock.

Acute peripheral arterial thrombosis can be threatening to life and limb. Dissolution of the thrombus local catheter-directed intra-arterial infusion of fibrinolytic agents such as urokinase is the standard therapy for thrombosis; however, this method is time-intensive, and amputation of the affected limb is still needed in 10-30% of cases. Furthermore, thrombolytic therapy carries the risk of bleeding complications. The use of small gas-filled bubbles, or ultrasound contrast agents (UCAs), in combination with ultrasound has been investigated as an improved thrombolytic therapy in acute coronary and cerebral arterial thrombosis. The authors describe a porcine model of acute peripheral arterial occlusion to test contrast-enhanced sonothrombolysis approaches that combine ultrasound, UCAs and fibrinolytic agents and recommend a strategy for preventing severe allergic reactions to UCAs in the pigs.

A 6-month assessment of bimatoprost 0.03% vs timolol maleate 0.5%: hypotensive efficacy, macular thickness and flare in ocular-hypertensive and glaucoma patients.

AIM: To compare 6 months of treatment with bimatoprost and timolol in terms of their hypotensive efficacy and secondary effects, including changes in macular thickness and the inflammatory reaction induced in the anterior chamber. METHODS: A prospective, randomized, parallel-group trial performed on 30 eyes of 30 patients per group. The main outcome measure was the difference between the IOP value taken between the baseline visit and the 6-month-visit. Macular thickness determined through optical coherence tomography and anterior chamber inflammation estimated using the laser flare meter was also evaluated. Adverse events were recorded during the study period. RESULTS: Bimatoprost treatment gave rise to a significantly lower mean IOP than timolol in all follow-up visits as from the first month (P<0.05). Bimatoprost achieved high percentage IOP reductions from baseline in a significantly higher proportion of patients (P<0.05). Macular thickness and anterior chamber flare failed to vary significantly both between the two groups and within each group during the 6-month evaluation (P>0.05). CONCLUSIONS: Bimatoprost 0.03% once daily showed a greater efficacy then timolol 0.05% twice daily in patients with elevated IOP. No significant differences were detected in macular thickness or anterior uveitis using optical coherence tomography and laser flare photometry.

Feasibility and efficacy of a mass switch from latanoprost to bimatoprost in glaucoma patients in a prepaid Health Maintenance Organization.

OBJECTIVE: To assess the feasibility of an automatic switch of a large number of patients with glaucoma or suspicion of glaucoma from latanoprost to bimatoprost, and to compare the efficacy of the 2 prostaglandin analogs before and after the switch. DESIGN: Retrospective nonrandomized comparison. PARTICIPANTS: Forty-three thousand four hundred forty-one California patients and 538 patients at one Southern California clinical facility of a nationwide prepaid health maintenance organization (HMO) who were on either prostaglandin between March 2002 and December 2003 (21 months). METHODS: Beginning in April 2002, patients on latanoprost were systemically switched to bimatoprost by the HMO pharmacy service after obtaining approval from the entire ophthalmology staff. PART 1: computerized dispensing records of California patients were retrieved. PART 2: medical records of patients at one clinical facility were reviewed. MAIN OUTCOME MEASURES: Rates of switching or switching back from one prostaglandin to another, intraocular pressure (IOP) control, and intolerability. RESULTS: PART 1: 17847 patients initially received latanoprost. Of them, 84.8% were switched from latanoprost to bimatoprost, and 13.0% were switched back to latanoprost. Twenty-five thousand five hundred ninety-four patients were started on bimatoprost without previous experience with latanoprost. Of them, 8.6% were later switched to latanoprost use instead. Patients who had previous experience with latanoprost had a statistically significantly higher rate of switching back to latanoprost after a period of bimatoprost use when compared with those who had no prior experience with latanoprost (13.0% vs. 8.6%, respectively; P<0.0001). PART 2: 309 patients were switched from latanoprost to bimatoprost. The mean IOP reduction of 0.51+/-2.77 mmHg (95% confidence interval, 0.20-0.82) after the switch was statistically significant (P = 0.001). Forty-one patients (13.3%) had a decrease of >3 mmHg of IOP. The statistical significance of the IOP reduction after the switch remains in the monotherapy group (P = 0.005) but not in the multitherapy group (P = 0.058). Thirty-three patients (10.7%) who were switched from latanoprost to bimatoprost discontinued bimatoprost and resumed latanoprost. CONCLUSION: A systematic pharmacy-level switch from latanoprost to bimatoprost in a nationwide HMO achieved a high switch rate, with little switching back. There was a small but statistically significant reduction in mean IOP after the switch. An appreciable proportion of patients switched had a clinically significant reduction of IOP.

The cost-effectiveness of bimatoprost 0.03% in the treatment of glaucoma in adult patients--a European perspective.

Glaucoma is a condition affecting one or both eyes with raised intraocular pressure (IOP). IOP should be reduced to prevent progression of visual field loss. This study investigates the cost-effectiveness of bimatoprost compared with latanoprost as first-line monotherapies in the treatment of glaucoma in Austria, Finland and France. On the basis of a single multicentre, randomised, investigator-masked controlled trial, a 6- and 12-month cost-effectiveness model was designed following the treatment recommendations from the European Glaucoma Society. Treatment changes due to insufficient IOP reduction and adverse events were included. The cost-effectiveness analysis showed that the need for adjunctive therapy was the major cost driver. On the basis of evidence from the randomised, investigator-masked clinical trial (RCT), the cost-effectiveness analysis found that bimatoprost was a cheaper and a more effective treatment strategy compared with latanoprost. This was true for all three countries and all IOP targets between 13 and 20 mmHg. The cost-effectiveness result may be generalised to a European setting and perspective.

Metabolic and respiratory effects of continuous and discontinuous lipid infusions. Occurrence in excess of resting energy expenditure.

Intravenous hyperalimentation with dextrose can be associated with adverse respiratory and hepatic effects. The purpose of this study was to determine the respiratory and metabolic consequences of fat calories in excess of resting energy expenditure provided both continuously and discontinuously. No significant changes in respiratory mechanics, oxygen consumption, carbon dioxide production, resting energy expenditure, serum substrates, liver function, or nitrogen balance were noted by the addition of 500 kcal of lipid emulsion to dextrose calories sufficient to meet energy requirements. The respiratory quotient declined significantly with the 12- and 24-hour lipid infusions, but persisted for the entire 24 hours only in the latter instance. The sustained and increased (46% v 36%) oxidation of lipid with a 24-hour infusion suggests that a continuous infusion of lipid is preferable to a discontinuous infusion.