Tratamento otimizado antiplaquetário, antilipêmico, controle de pressão arterial e frequência cardíaca na doença coronariana crônica assintomática ou angina classe I / Optimized antiplatelet and hypolipidemic treatment, control of blood pressure and heart rate in chronic asymptomatic coronary artery disease or angina class 1

Neste artigo revisaremos o tratamento antiplaquetário e antilipêmico, controle da pressão arterial e controle da frequência cardíaca e sua influência na mortalidade e novos eventos, aplicável a todo paciente portador de doença coronariana crônica.

We review the antiplatelet and hypolipidemic treatment, blood pressure and heart rate control and its influence on mortality and new events, applicable to all patients with chronic coronary disease.

Elevando el colesterol HDL: ¿Cuál es la mejor estrategia?: [revisão] / Raising HDL cholesterol: which is the best strategy?: [review]

Após atingir as metas para os níveis de LDL-colesterol, é imperativo alcançar a meta do HDL-colesterol, por suas conhecidas propriedades antiaterogênicas confirmadas amplamente em muitos estudos epidemiológicos. Esta revisão analisa de maneira objetiva e concisa as diversas alternativas disponíveis na prática clínica diária para aumentar os níveis de HDL-colesterol em nosoos pacientes, com o objetivo de alcançar melhores prognósticos em termos de morbimortalidade cardiovascular.

After having reached the objective for the LDL cholesterol levels, it becomes imperative to reach the objective for HDL cholesterol, known for its anti-atherogenic properties, generally confirmed in many epidemiological studies. This review deals, in a clear and concise manner, with the different alternatives available in daily clinical practice to raise the HDL cholesterol levels of patients, to achieve better outcomes in terms of morbidity and mortality in cardiovascular disease.

Efeitos dos medicamentos hipolipêmicos no perfil lipídico de população idosa de Porto Alegre, RS, Brasil / Effects of hypolipemic drugs on the lipidic profile of Porto Alegre, RS, Brasil in older population

O perfil lipídico pode estar relacionado com doenças crônico-degenerativas e suas complicações. Alguns dos medicamentos usados para controlar os níveis lipêmicos são estatinas e fibratos. O objetivo deste trabalho foi verificar o perfil lipídico da população idosa de Porto Alegre, RS, Brasil, que faz uso desses medicamentos. Foram coletadas amostras de sangue de 456 idosos e as dosagens foram realizadas através da metodologia química seca. Para análise estatística foram utilizados os testes Student e Qui-quadrado. Analisou-se o perfil lipídico de 22 homens e 51 mulheres que faziam uso de medicamentos hipolipêmicos e comparou-se esse perfil com o de 85 homens e 161 mulheres que não faziam uso destes. Os resultados demonstraram diferença significativa na classificação dos riscos e nos valores médios de colesterol total, LDL e triglicerídeos, nas idosas que usavam hipolipêmicos em relação às quenão os utilizavam. No entanto, para os homens, ocorreu uma diminuição significativa nos resultados de LDL, nos que faziam uso dos hipolipêmicos, apresentando valores controlados para todos os índices. É necessário um maior acompanhamento para a utilização correta dos medicamentos citados pelas pacientes idosas, a fim de se obter um melhor controle da lipemia e uma melhoria nas condições de saúde dessas pacientes.

The lipidic profile can be related to chronic degenerative diseases and their complications. Some of the drugs used to control the lipidic levels are statins and fibrates. The aim of the study was to verify the lipidic profile of the elderly population of Porto Alegre, RS, Brazil that makes use of these medicines. Blood samples were collected from 465 elderly and the dosages were determined by drought chemical methodology. For statistical analysis were used the Student t test and Chi-square test. There were examined the lipidic profile of 22 men and 51 women that made use of hypolipemic drugs and compared with 85 men and 161 women that did not use these. The results showed significant differences in the classification of risk and the average values of total cholesterol, LDL and triglycerides in the elderly that used hypolipemic in relation to those that did not use. However, for men there was a significant decrease in LDL results of those that made use of hypolipemic drugs, presenting controlled values for all indexes. It’s necessary a better monitoring for the correct use of the drugs mentioned by elderly women patients in order to get a better control of lipidic profile and an improvement in the health conditions of these patients.

Terapia hipolepemiante intensiva en el manejo del riesgo cardiovascular ateroesclerótico / Intensive cholesterol lowering therapy to reduce cardiovascular risk

Primary and secondary prevention trials have clearly demonstrated that lowering serum cholesterol levels with statins reduces the incidence of cardiovascular events. Recent studies plus post hoc analysis of previous clinical trials show that risk reduction is proportional to the magnitude of LDL cholesterol lowering. Therefore, new recommendations of the National Cholesterol Education Program (USA) have defined a category of patients with very high cardiovascular risk, who should achieve serum LDL cholesterol levels below 70 mg/dl. This proposal will require new and more efficient pharmacologic strategies to attain the increasingly strict therapeutic goals for LDL cholesterol. This article reviews the clinical studies that support the use of intensive lipid lowering therapy to reduce cardiovascular risk. An effective reduction of serum cholesterol can be obtained using statins in high doses or a combination of hypolipidemic drugs with different mechanisms of action.

Tratamento das dislipidemias: como e quando indicar a combinação de medicamentos hipolipemiantes / Treatment of dyslipidemia: how and when to combine lipid lowering drugs

Hiperlipidemia combinada familiar (HCF) é a forma mais comum de hiperlipidemia familial e se caracteriza por resistência à insulina, níveis baixos de HDL-C, níveis altos de triglicérides (TGC) e colesterol total associados a vários fenótipos dentro da mesma família. HCF associa-se, também, a um alto risco cardiovascular (RCV), e os níveis-alvo de tratamento das anormalidades lipídicas têm se modificado recentemente. Reduzir os níveis de LDL-C e não HDL-C devem ser os alvos da terapia. Níveis de LDL-C abaixo de 70 mg/dl têm se mostrado benéficos na RCV em pacientes de alto risco. Várias estatinas com diferentes potências e interações medicamentosas estão disponíveis no mercado. A terapia combinada de estatinas com seqüestradores de ácidos biliares ou ezetimiba pode ser necessária para se alcançar os valores-alvo de LDL-C estabelecidos pelas diretrizes. Níveis altos de TGC e baixos de HDL-C devem ser também considerados no tratamento, e freqüentemente somente o uso das estatinas se mostra insuficiente para normalizá-los. A combinação de estatinas com fibratos pode auxiliar para reduzir os níveis de colesterol e aumentar os de HDL-C, mas está associada à maior freqüência de miopatia e toxicidade hepática. Assim, a avaliação cuidadosa dos riscos e benefícios da terapia é recomendável. A associação de estatina e niacina parece ser útil para pacientes com HCF, particularmente por aumentar os níveis de HDL-C, uma vez que tem sido menos relacionada à alta freqüência de miopatia. A niacina pode ser causa de flushings que podem ser reduzidos com o uso de aspirina. O efeito pode também ser minimizado com o uso de formas de liberação lenta (Niaspan). A niacina pode também elevar os níveis de glicemia e ácido úrico. Assim, os riscos e benefícios da associação devem ser avaliados.

Familial combined hyperlipidemia (FCH) is a frequent familial lipid disorder associated with insulin resistance, low HDL cholesterol, high triglycerides and cholesterol levels with variable phenotypes within the same family. FCH is linked to a high risk for cardiovascular diseases. Treatment goals for lipid abnormalities are changing in recent years. Lowering elevated levels of LDL e Non HDL-cholesterol levels are primary targets of therapy. Lower LDL-C than 70 mg/dL seems to be useful to lower cardiovascular risk in patients with very high risk. Many statins are available, with different potencies and drug interactions. Combination therapy of statins and bile acid sequestrants or ezitimibe may be necessary to further decrease LDL cholesterol levels in order to meet guideline goals. High triglycerides and low HDL cholesterol are also important goals in the treatment of these patients, and frequently statins alone are insufficient to normalize the lipid profile. Combination therapy with fibrates will further lower triglycerides and increase HDL cholesterol levels; this combination is also associated with higher incidence of myopathy and liver toxicity; appropriate evaluation of patients' risk and benefits is necessary. Association of statin/niacin seems be very useful in patients with FCH, especially as niacin is the best drug to increase HDL cholesterol; this association is not linked to a higher frequency of myopathy. Niacin causes flushing, that can in part be managed with use of aspirin and extended release forms (Niaspan); niacin also may increase plasma glucose and uric acid levels. Evaluation of risks and benefits for each patient is needed.

Associação de medicamentos: estatinas e fibratos / Combination of drugs: statins and fibrates

Monoterapia para o tratamento das dislipidemias é frequentemente insuficiente para o alcance das metas recomendadas pelas diretrizes. Entretanto, nos últimos anos, o uso de terapia combinada tem se apresentado como uma nova opção em muitos casos. Uma revisão de 36 estudos envolvendo a combinação de estatinas com fibratos apresentou 29 casos de rabdomiólise e uma prevalência geral de miopatia de 0,12 por cento. A combinação de estatinas com o genfibrozil parece causar mais rabdomiólise que com os fibratos de nova geração (especialmente quando comparado com fenofibrato ou bezafibrato). Idade avançada, diabetes, mulheres, medicações concomitantes, disfunção renal, consumo excessivo de álcool, exercícios, traumatismos e cirurgias estão também associados com maior risco de efeitos adversos.

Statin and fibrate associed myopathy: study of eight patients

As drogas redutoras de colesterol são ocasionalmente associadas a sintomas neuromusculares e alterações morfológicas observadas na biopsia muscular. Relatamos o curso clínico e achado da biopsia muscular em oito pacientes com hiperlipoproteinemia tratados com drogas redutoras de colesterol (estatinas/fibratos). Cinco pacientes tiveram mialgia e em dois havia fraqueza muscular proximal. Todos os pacientes ficaram assintomáticos após retirada da medicação embora a creatinoquinase permanecesse elevada. Analisamos a biopsia muscular em seis casos realizados entre três meses e dois anos após a suspensão da droga. Encontramos variação no calibre das fibras em todos os casos com necrose de fibras em cinco, infiltrado inflamatório em um caso, presença de vacúolos em um e "ragged red fiber" em três deles. Concluímos que, embora os achados da biopsia muscular não fossem específicos, o uso prolongado de estatinas e/ou fibratos pode induzir a uma miopatia crônica até mesmo na ausência de sintomas.

Etofibrate but not controlled-release niacin decreases LDL cholesterol and lipoprotein (a) in type IIb dyslipidemic subjects

Etofibrate is a hybrid drug which combines niacin with clofibrate. After contact with plasma hydrolases, both constituents are gradually released in a controlled-release manner. In this study, we compared the effects of etofibrate and controlled-release niacin on lipid profile and plasma lipoprotein (a) (Lp(a)) levels of patients with triglyceride levels of 200 to 400 mg/dl, total cholesterol above 240 mg/dl and Lp(a) above 40 mg/dl. These patients were randomly assigned to a double-blind 16-week treatment period with etofibrate (500 mg twice daily, N = 14) or niacin (500 mg twice daily, N = 11). In both treatment groups total cholesterol, VLDL cholesterol and triglycerides were equally reduced and high-density lipoprotein cholesterol was increased. Etofibrate, but not niacin, reduced Lp(a) by 26 percent and low-density lipoprotein (LDL) cholesterol by 23 percent. The hybrid compound etofibrate produced a more effective reduction in plasma LDL cholesterol and Lp(a) levels than controlled-release niacin in type IIb dyslipidemic subjects

Protective effect of two anti-hepato toxic agents: silymarin and alpha-tocopherol against the subcellular toxicity induced by the hypolipidemic agent etofibrate

Etofibrate, a nicotinoyl derivative of clofibrate which belongs to the family of fibric acids. Both nicotinic acid and clofibrate are known for their hypolipidemic action and are used for the treatment of hyperlipoproteinemia. In the present study, the effect of three concentration levels of etofibrate on four rat liver lysosomal enzymes [Acid phosphatase, beta-Galactosidase, B, N-Acetyl glucosaminidase and b-Glucuronidase] for three incubation periods [30, 60 and 120 minutes] were studied in vitro, and were then compared with their combined effects together with a single therapeutic dose of each of two anti-hepato toxic agents. Silymarin and alpha-tocopherol [vitamin E] separately on the same enzymes for the same incubation periods. The results obtained showed that the three doses of etofibrate induced a marked releasing effect on the four lysosomal enzymes irrespect of the incubation time. Meanwhile, a considerable stabilization of these enzymes was observed when each of the two single doses for alpha-tocopherol and silymarin were used separately with etofibrate at the lowest concentration level

Avaliação da eficácia e segurança do etofibrato em pacientes dislipidêmicos. Estudo multicêntrico / Evaluation of efficacy and safety of etofibrate in primary hyperlipidemia. A multicenter study

PURPOSE: To evaluate the clinical efficacy of etofibrate in primary hyperlipidemia in patients from clinical centers representative of all main Brazilian cities. METHODS: One thousand, nine hundred and fourty three hyperlipidemic patients were submitted to diet and drug treatment with etofibrate (500 mg/day) for eight weeks. The data b WAS analyzed as to changes in the lipoprotein profile, as well as the side effects. RESULTS: There was an important reduction in total cholesterol (19.88), triglycerides (29.59), LDL-c (14.89) and VLDL-c (14.54) concentration. There was a significant increase in HDL-c (18.14). Adverse effects were observed in 8.5 of the patients, without major clinical relevance, however, in 1.44 the treatment had to be interrupted. CONCLUSION: Administration of etofibrate promoted positive changes in all parameters of the lipid and lipoprotein profile, thus reducing the risk of atherosclerotic disease, without significant side effects in the great majority of sample studied.