Lege Artis Medicinae

[Importance of statin therapy in stroke prevention]


JANUARY 27, 2009

Lege Artis Medicinae - 2009;19(01)

[Stroke is the third leading cause of death and a leading cause of major adult disability in developed countries. The annual incidence of hospitalized stroke varies between 400-500 per 100 000 inhabitants every year in Hungary. In the past decade, cholesterol lowering with 3- hydroxy-3-methylglutaryl-coenzyme A (HMGCoA) reductase inhibitors (statins) has proved to reduce risk of stroke in patients with and without coronary disease (CAD). In patients with CAD, statin therapy reduces the risk of first stroke by 25% to 35% versus placebo and, moreover, intensive statin therapy to LDL-C targets below 2.6 mmol/L (100 mg/dL) appears to reduce the risk further. More recently it has also been shown that intensive statin therapy can reduce risk of recurrent stroke in nondiabetic as well as diabetic patients with recent stroke or transient ischaemic attack but no CAD. The overall reduction of stroke and TIA was 23%. Evidence from retrospective studies suggests that in addition to risk reduction statin pretreatment may improve stroke outcome. It may due to their pleiotropic effects that include improvement of endothelium function, anti-inflammatory, antithrombotic, and immunomodulatory effects. As statins have both an excellent safety profile and simple administration, physicians should consider using statins, at dosages shown to have efficacy in clinical trials, in all patients whose cardiovascular risk profile puts them at high risk of stroke.]



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[Rivaroxaban: a new and efficient direct factor Xa inhibitor anticoagulant]


[Rivaroxaban is a directly acting, orally administrable selective inhibitor of the activated blood clotting factor X, which could replace low molecular weight heparins and oral coumarintype anticoagulants. It was registered by European (EMEA) and US authorities (FDA) for the prevention of venous thrombotic events in orthopedic surgery. It is being investigated in phase III studies for the treatment of established, symptomatic venous thrombosis, surgical thromboprophylaxis, prevention and treatment of pulmonary embolism, as well as in ST-elevation and non-ST-elevation myocardial infarction. Until this time it was given to more than 24,000 patients. Its sideeffect profile is favorable, bleeding risk is similar to other drugs in its group, and other side effects are acceptable, although it may result in elevation of hepatic enzymes. The drug is investigated at present in the secondary prevention of stroke in atrial fibrillation and in the prevention of acute ischemic events in acute coronary syndromes. It could be one of the first alternative drugs for the presently used oral vitamin K antagonist anticoagulant products.]

Lege Artis Medicinae

[Relationships in recovery, recovery in relationships]


[INTRODUCTION - Some of the recent researches based on analyses of autobiographies pointed out, that the quality and the quantity of our social relations are in connection with our life longevity, and the frequency of words referring social roles and integration gives a respective measurement possibility of it. Conception of the term “social words” had been introduced. The influence of the degree of social support to the recovery from alcohol addiction is also a well-known phenomenon. Based on the above we supposed that examining their autobiography vocabularies we find special differences which can show the distinction between the social support of the relapsed and recovering addicted persons. We planned to prove the being of these special differences via revealing bias of the frequency and pattern of social word usage. PATIENTS AND METHODS - Two separate groups were created for purpose of the examination. The first consisted of relapsed alcohol dependent persons, who were treated in hospital (department of addiction psychiatry) diagnosed alcohol-dependent (F 10.2) (and nothing else) at least twice within a year (N=30). We chose earlier treated (because of alcohol-dependency, and nothing else mental disease) persons who had been being abstinent for at least 2 years into the second group (N=20). Beside the earlier diagnosis we used the parts of the ASI test to sreen any other mental diseases. We created similar groups with regards to gender, age and qualification. We collected autobiographies from the persons, and made two common documents of them. Afterwards we compared these documents by the Atlas.ti 5.0 (trial free version) content analysing software. We defined the frequency of the found social words in the rate of these words and the sum of the words in the whole text. We found the most prominent difference between the frequency of social words referring to the family and relatives, opposite the words dealing with friendship. RESULTS - In the latter case we could not detect any difference between the two groups. We got results confirming our hypothesis in the frequency of such words as “help”, “love”, “give” and “get”. We experienced in connection with the pattern that the words referring to social organisations, for example “team”, “community”, “company”, “club”, “meeting”, “collective” and the word “guest” practically did not appear (R<0.001) in the texts of relapsed persons, while they could be detected in the case of the recovering group (R=0.023). We did khisquare test to compare the frequency in the mentioned categories and we experienced significant differences between the social word usage of the two groups. CONCLUSION - Our results confirmed that the recovery from alcohol addiction was related to the quality and quantity of person's social relations, what we can get relevant information from the frequency of social words in the autobiographies about, so the high frequency of the social words can be considered as a good predictor of recovery.]

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[In the fight against atherosclerosis, statin therapy is one of the most important elements. On the basis of data from the past few years the clinical introduction of a more effective statin is not expected, however, in order to improve cardiovascular prevention further development of agents that reduce LDL-cholesterol levels more effectively than currently used statins is warranted. The need for the development of new cholesterol-lowering therapeutic options is also supported by the existence of statin intolerance. The currently available combination therapies do not provide additional mortality benefits compared with statin monotherapy. The new solutions include fourth-generation statin molecules that primarily aim to enhance the NO-donor capacity of statins, and to reduce their muscle toxicity. Certain compounds that affect cholesterol synthesis (squalene synthase inhibitors, MTP inhibitors, ACAT inhibitors) need to be further analysed because of the risk of side effects. The use of an antisense oligonucleotid that blocks the mRNA of apoB, the main protein on the LDL-particle and antibodies that inhibit the protein PCSK9 that promotes the intracellular breakdown of the LDL-receptor seems to be much more promising. Besides the lowering of LDLcholesterol level, studies have focused on the benefits of increasing HDL-cholesterol levels. Unfortunately, recently completed analyses show that new forms of the strong HDL-C increasing nicotinic acid have not provided any additional benefit when added to statin therapy. Similarly, the adverse effects associated with the promising CETP inhibitors and the lack of additional benefit when combined with statins question the significance of this drug class. The necessity for an absolute increase of HDL-cholesterol levels needs to be revised on the basis of new data, in other words, the exact role of the HDL particle in atherosclerosis needs to be further investigated.]

Clinical Neuroscience

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KENÉZ József, BARSI Péter

[In the article digital imaging methods are presented with special emphasis on the use on diagnostics of cerebral circulation studies. Recently, fundamental changes have happened in this field, concerning especially the MR investigations. These changes have influenced the therapeutic strategies of ischaemic stroke. Authors give the theoretical background on the diffusion and perfusion MR imaging, emphasising the importance of their “mismatch” and its impact in the estimation of the outcome of ischaemic events. More recently, new, controversial facts arose, regarding the reasons of the introduction of the theory of so called “negative” and “positive” mismatches. As a consequence, a level of uncertainty took place in the judgement of prognostics. The leading institutions are searching the way to solve the problem which seems to be the quantitative evaluation of the diffusion, perfusion and mismatch data. The advent of the multislice spiral CT with very fast imaging and the importance of CT investigations increased. With this new kind of equipment, even perfusion studies can be performed using iodinated contrast medium.]

Clinical Neuroscience

[Immune responses and neuroimmune modulation in the pathogenesis of acute ischemic stroke and poststroke infections]

PAPP Viktória, MOLNÁR Tihamér, BÁNÁTI Miklós, ILLÉS Zsolt

[Acute-onset cerebrovascular diseases are connected to a number of immunological changes. Here, we summarize immune responses participating in the evolution of atherosclerotic plaques and poststroke local immune responses in the injured CNS as well as in the systemic circulation. Ischemic injury of the CNS alters the balanced neuroimmune modulation resulting in CIDS, the central nervous system injury-induced immune deficiency syndrome. Due to the immunodepression and reduced pro-inflammatory immune responses, the susceptibility for infection is increased; indeed, poststroke infection plays a major role in stroke-related mortality. On the other hand, CIDS may protect against damaging autoimmune responses elicited by exposed CNS antigens. Investigation of immune responses related to ischemic stroke may result in novel therapies indicated by an increasing number of experimental and clinical trials altering poststroke immune responses and preventing infections.]

LAM Extra for General Practicioners



[Statins have become crucial components of the therapy of cardiovascular diseases. Beyond their cholesterol-lowering effect, statins turned out to have further beneficial effects on various vascular mechanisms. One of the best known effects is antithrombotic capacity, which is related partly to platelet function and partly to the coagulation cascade. Besides experimental observations, interventional clinical trials have also demonstrated that statins have an antithrombotic effect both in arterial and venous thrombosis. Regarding the effects of statins on dementia, previous studies with relatively small sample sizes had controversial results. Recently, two observational studies of tens of thousands of elderly patients reported that statins reduce the incidence of nonvascular dementia. Evaluation of the data revealed that statins have pleiotropic effects in this case, too. The results discussed here shed light on new benefits of statin therapy used for reducing cardiovascular mortality, namely the prevention of thrombotic events and dementia. These benefits are related to the antithrombotic and anti-inflammatoric capacity of statins.]

Lege Artis Medicinae


TÓTH Károly

[With the new era of the medicaments, erectile dysfunction has become of great interest among sexual problems. Earlier, psychogenic origin was thought to be the main background, but today vasculogenetic reasons are have become equally important factors. Experimental data and clinical investigations demonstrate that erectile dysfunction is part and consequence of the same vascular process which is observed in aging and in atherosclerotic processes of the well-known arterial localisations (coronary arteries, cerebral arteries etc.). It was also common previously to associate erectile dysfunction with obliterative atherosclerotic disease but today endothel dysfunction, vascular remodelling and atherosclerosis are thought to be main pathogenetic factors affecting the whole arterial vascular system causing erectile dysfunction. Classic risk factors can also be observed in these patients, such as hypertension, dyslipidaemia, smoking and diabetes. Neurogenic factors are also involved in the development of erectile dysfunction. Based on this, erectile dysfunction is considered as the predictor of cardiovascular diseases preceding the general manifestation of the disease by 2-3 years.]