Comparison of the pleiotropic effect of atorvastatin and rosuvastatin on postmenopausal changes in bone turnover: A randomized comparative study.

BACKGROUND: Statins are the first-line treatment for dyslipidemia, which is a major modifiable risk factor for atherosclerotic cardiovascular disease. Studies have shown that in addition to the beneficial lipid-lowering effect, statins also exhibit a number of pleiotropic effects that may find application in other diseases, including osteoporosis. This study aimed to assess the effect of statins on bone turnover, as measured by the concentration of bone turnover markers, and to compare the effect of atorvastatin as a lipophilic statin and rosuvastatin as a hydrophilic statin. METHODS: This study included 34 postmenopausal women aged < 65 years with newly diagnosed dyslipidemia requiring statin therapy. Patients were randomly assigned to receive a statin drug. Statins were initiated at standard doses of 5 to 10 mg of rosuvastatin and 20 mg of atorvastatin. The levels of C-terminal telopeptide of type I collagen as a bone resorption marker and N-terminal propeptide of procollagen type I as a marker of bone formation, lipid concentrations and other biochemical parameters were assessed at baseline and after 6 and twelve months of treatment. RESULTS: There were no statistically significant differences between the levels of bone turnover markers before and 6 months after statin implementation (P > .05) - for all patients or subgroups according to statin use. Analysis of the results showed that after 12 months, there was a statistically significant decrease in N-terminal propeptide of procollagen type I concentration in all subjects (P = .004). By statin subgroup, a statistically significant decrease in N-terminal propeptide of procollagen type I was observed only in patients receiving rosuvastatin (P = .012) and not in those receiving atorvastatin (P = .25). Moreover, changes in bone turnover markers did not correlate with changes in lipid concentrations. CONCLUSIONS: These results may indicate the superiority of atorvastatin over rosuvastatin in inhibiting adverse changes in bone turnover in postmenopausal women. Confirmed by studies involving a larger population, the observed differences might find particular applications in clinical practice, and the choice of atorvastatin over rosuvastatin for women could be considered in the early postmenopausal period to reduce the risk of osteoporosis and subsequent osteoporotic fractures.

Epicardial Fat in Heart Failure with Preserved Ejection Fraction: Bad Actor or Just Lying Around?

Heart failure with preserved ejection fraction (HFpEF) is increasingly recognised to be strongly associated with obesity and abnormalities in fat distribution. Epicardial fat has been associated with abnormal haemodynamics in HFpEF, with potential for direct mechanical effects on the heart causing constriction-like physiology and local myocardial remodelling effects from secretion of inflammatory and profibrotic mediators. However, patients with epicardial fat generally have more systemic and visceral adipose tissue making determination of causality between epicardial fat and HFpEF complex. In this review, we will summarise the evidence for epicardial fat being either directly causal in HFpEF pathogenesis or merely being a correlate of worse systemic inflammatory and generalised adiposity. We will also discuss therapies that directly target epicardial fat and may have potential for treating HFpEF and elucidating the independent role of epicardial fat in its pathogenesis.

Electrocardiographic criteria for anterior STEMI - Does the cut-off point affect treatment delay?

BACKGROUND: Diagnostic criteria for anterior STEMI differ between the European Society of Cardiology (ESC) and the European Resuscitation Council (ERC). A greater degree of ST-segment elevation is required to meet ERC criteria compared to ESC criteria. This may potentially lead to discrepancies in management between emergency teams and cardiologists, subsequent delay in reperfusion therapy and worse prognosis. METHODS: We performed an observational study in patients with anterior STEMI routinely treated with primary PCI and assessed whether differing electrocardiographic diagnostic criteria could impact treatment and short-term prognosis. All patients in the study had anterior STEMI confirmed by electrocardiographic ESC criteria and subsequent coronary angiography. Patients were divided into two groups. Those who did not meet ERC criteria in the index ECG were assigned to the "non-ERC" group and were compared with those who met them - the "ERC" group. RESULTS: Out of 60 patients with anterior STEMI based on ESC criteria (mean age 66.9 ± 13.6 years, 70% males), 26 patients (44%) did not meet ERC criteria ("non-ERC" group) for STEMI. There were no significant differences in age, gender distribution or clinical characteristics between "ERC" and "non-ERC" patients. Total-Ischemic-Time, Patient-Delay, and System-Delay times were significantly longer in "non-ERC" group (433.1 ± 389.9 min vs. 264.2 ± 229.6 min, p = 0.03; 290.8 ± 337.6 min vs. 129.5 ± 144.9 min; p < 0.05 and 158.8 ± 158 vs 134.6 ± 191 min, p < 0.02 respectively). There were no differences in In-Hospital-Delay, procedure duration, and success rate of PCI. Proximal LAD occlusion (64.7%) and TIMI = 0 flow (73.5%) tended to be more frequently observed in "ERC" than in the "non-ERC" group (53.8% and 65.4%, respectively). Hospitalization time and LVEF (44.4 ± 8.7 vs 42.8 ± 9.5%, p = 0.53) were similar between groups. CONCLUSIONS: Differences in electrocardiographic criteria for anterior STEMI leave a significant proportion of patients undiagnosed. Patients with STEMI who failed to meet less strict ERC criteria had more distal LAD disease with better TIMI flow but received reperfusion therapy later. Thus, character of the disease may compensate for treatment delay but this needs to be further evaluated. Finally, lowering the cut-off point with stricter criteria compromises specificity and is expected to increase the false positive rate, however there were no false positives in this study as all patients were angiographically confirmed to have acute coronary obstruction.

COVID-19: What Should the General Practitioner Know?

BACKGROUND: SARS-CoV-2 infection is currently the most significant public health challenge. Its presentation ranges from mild to severe respiratory failure and septic shock. Rapid transmission of the virus is dangerous with a high possibility of life-threatening complications. Lack of treatment standards for SARS-CoV-2 is responsible for the current dilemma in clinical medicine. METHODS: An electronic literature search was done using PubMed to gather information on the pathogenesis, transmission of infection, clinical symptoms, diagnosis, and therapeutic options for COVID-19. Search items included "SARS-CoV-2", "COVID-19" and "coronavirus infection". RESULTS: In light of the current global crisis caused by SARS-CoV-2, the exchange of information within the scientific community should be quick and extremely transparent. Thus, this review presents the available information necessary for a general practitioner. Such presentation of data should allow the reader quick access to basic and crucial information related to epidemiology, viral transmission, clinical symptoms, diagnostics, treatment, and complications that may occur in the course of COVID-19. CONCLUSION: Rapidly increasing amounts of information about the diagnosis and treatment of patients with SARS-CoV-2 allow a better understanding of the etiology and course of the infection. In the current epidemiological situation, readily accessible information helps minimize the time to acquire knowledge and focus on prevention methods, diagnostic and treatment options. Thus, this review highlights key issues related to SARS-CoV-2 infection and contains the most useful data for daily medical practice.

Haloperidol in palliative care: Indications and risks.

Individual response to medication depends on several factors (age, gender, body weight, general clinical condition, genetics, diet, hydration status, comorbidities, co-administered drugs and their mode of administration, smoking, alcohol overuse, environmental factors, e.g. sunlight) that may contribute to adverse drug reactions even at therapeutic doses. Patients in palliative care are at increased risk of these reactions. Unwanted drug effects diminish the quality of life and may lead to a suboptimal dying process. Haloperidol is one of the three most commonly used drugs in palliative care and the most commonly employed typical antipsychotic. It has also been recommended for inclusion into the palliative care emergency kit of home care teams. As such, it is important to be fully conversant with the indications, benefits, and risks of haloperidol, especially in the context of palliative care.

Heart Failure with Preserved Ejection Fraction-a Concise Review.

PURPOSE OF REVIEW: Heart failure with preserved ejection fraction (HFpEF) is a relatively new disease entity used in medical terminology; however, both the number of patients and its clinical significance are growing. HFpEF used to be seen as a mild condition; however, the symptoms and quality of life of the patients are comparable to those with reduced ejection fraction. The disease is much more complex than previously thought. In this article, information surrounding the etiology, diagnosis, prognosis, and possible therapeutic options of HFpEF are reviewed and summarized. RECENT FINDINGS: It has recently been proposed that heart failure (HF) is rather a heterogeneous syndrome with a spectrum of overlapping and distinct characteristics. HFpEF itself can be distilled into different phenotypes based on the underlying biology. The etiological factors of HFpEF are unclear; however, systemic low-grade inflammation and microvascular damage as a consequence of comorbidities associated with endothelial dysfunction, oxidative stress, myocardial remodeling, and fibrosis are considered to play a crucial role in the pathogenesis of a disease. The H2FPEF score and the HFpEF nomogram are recently validated highly sensitive tools employed for risk assessment of subclinical heart failure. Despite numerous studies, there is still no evidence-based pharmacotherapy for HFpEF and the mortality and morbidity associated with HFpEF remain high. A better understanding of the etiological factors, the impact of comorbidities, the phenotypes of the disease, and implementation of machine learning algorithms may play a key role in the development of future therapeutic strategies.

Cardiovascular complications of epileptic seizures.

Seizure disorders are associated with multisystem complications. Cardiovascular complications account for a significant proportion of morbidity and mortality in these patients. As such, particular attention must be paid to the incidence of cardiovascular complications especially in populations at increased risk. The background for cardiac dysfunction lies in the interplay of genetic/molecular, autonomic, and iatrogenic factors that contribute to its onset. The purpose of this review was to summarize the state of literature in the last decade with regard to cardiac complications of epileptic seizures in order to increase awareness of short- and long-term debilitating cardiac complications as well as facilitate informed clinical decision-making. Taken together, the evidence provided in this review suggests that cardiac dysfunction following seizures should not be viewed as a separate entity but as an important complication of epileptic seizures. Appropriate cardiac therapy should be instituted in the postictal medical management of epileptic seizures. In acute states, postictal cardiac troponinemia (elevated cTn) should be worked up. Longer-term, monitoring for the development of cardiac structural and functional abnormalities is prudent.

Disorders of the Aorta and Aortic Valve in Connective Tissue Diseases.

PURPOSE OF REVIEW: The incidence of aortic valve disease in inherited connective tissue disorders is well documented; however, recent studies have only begun to unravel the pathology behind this association. In this review, we aim to describe the etiology, clinical manifestations, management, and prognosis of aortic and aortic valvular disorders that co-exist in a variety of connective tissue diseases. An extensive literature review was performed in PubMed. Articles from 2008 to 2018 were included for review. Predetermined search terms used in PubMed include "aortic manifestation of connective tissue diseases" and "aortic valve disorders in rheumatologic disease." RECENT FINDINGS: Manifestations of aortic valve disease in the context of connective tissue disorders include valvular stenosis, regurgitation, and/or thoracic aortic aneurysms. Both inherited and inflammatory connective tissue disorders contribute to aortic valve damage with increased susceptibility associated with specific gene variants. Anti-inflammatory and immunosuppressive therapies have demonstrated beneficial results in Marfan's syndrome, Behcet disease, rheumatoid arthritis, ankylosing spondylitis, and systemic sclerosis, often leading to remission. Yet, such therapy is less effective in other disorders compared to alternative treatments such as surgical intervention. Additionally, regular echocardiographic studies should be recommended to those suffering from these disorders, especially those at higher risk for cardiovascular involvement. Given the rates of relapse with immunosuppressants, even following aortic valve replacement, further studies are needed to determine if certain dosing and/or combinations of immunosuppressants could be given to those diagnosed with connective tissue diseases to prevent progression of aortic valve involvement.

Midazolam: Safety of use in palliative care: A systematic critical review.

PURPOSE: The undesired effects of midazolam can be life-threatening. This paper delineates the findings related to the pharmacokinetics, adverse effects and drug-drug interactions as well as associated therapeutic implications for safe midazolam use. METHODS: A systematic review of literature was conducted. RESULTS: The pharmacokinetics of midazolam depends on hepatic and renal functions, fat tissue mass, route and duration of administration, as well as potential drug-drug interactions. Palliative care patients constitute a high-risk group prone to side effects of drugs, due to polytherapy and multi-organ failure. CONCLUSION: Midazolam is one of three most frequently administered drugs in palliative care. The indications for its use include anxiety, dyspnea, seizures, vomiting refractory to treatment, agitation, myoclonus, status epilepticus, restlessness, delirium, pruritus, hiccups, insomnia, analgosedation, palliative sedation and preventing or counteracting undesired effects of ketamine.