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Lege Artis Medicinae

JULY 01, 2020

[Treatment of hypercholesterolemia in the elderly]

BARNA István

[The percentage of population aged ≥65 years is mounting worldwide, among them those over 75 years is also growing. Athe­ro­scle­rosis is one of the most important and common disorder in the elderly responsible primarily for premature death and cognitive declining and impaired quality of life. Adequate lipid lowering therapy can decrease the risk of cardiovascular events – the main cause behind mortality – can extend life expectancy and improve the quality of life of patients. Effect of dietary treatment on cardiovascular risk reduction is as beneficial as in the younger populations. Regular physical activity reduces the risk of cardiovascular and overall mortality by 26% in males and 20% in females aged ≥65 years. If the medical history is negative for vascu­lar disorders, statin administration as a primary prevention is indicated for patients 65>years. In the population aged 75≥years individual benefit/risk assessment is needed before statin administration. Larger risk reduction can be achieved between 65-75 years than in subjects over 75 years. Concerning secondary prevention, statin treatment is of pre-eminent significance, and its administration is evidence-based in the elderly. For achieving the lipid goals, combined therapy with statin and ezetimibe is recommended in the primary as well as secondary cardiovascular prevention. ]

Lege Artis Medicinae

JULY 20, 2019

[How many cardiovascular events can be avoided by a lipid lowering therapy based on preventive guidelines?]

MÁRK László

[The lipid lowering therapy became one of the most important elements in the cardiovascular prevention, yet it is not appropriately evaluated neither by the doctors, nor by the patients. The lipid goal attainment should to be improved according to Hungarian and international data. Using a recommendation guided lipid lowering therapy the most benefit can be expected in the patients at very high risk who alrea­dy had a cardiovascular event, where the LDL-cholesterol goal is 1.8 mmol/L. Calculating upon the data of 170000 patients of Cholesterol Treatment Trialists’ Collaboration a decrease of LDL-cholesterol level from 2.5 mmol/L to 1.8 in 100 patients in 10 years would avoid 3 myocardial infarctions, strokes or death, lowering that from 3.5 mmol/L to the goal would prevent these 3 events within 5 years. Using the traditional LDL-cholesterol lowering medication, high dose statin and ezetimibe, if the attitude of doctors and the compliance of patients would be ideal, the 1.8 mmol/L goal attainment rate would be over 80%. Unfortunately, up to now the reimbursed administration of ezetimibe in Hungary is still bound to a specialist’s recommendation, adding it to any dose of any statin an additional 20% LDL-cholesterol can be expected. The reimbursed administration of PCSK9-inhibitors is possible only based on a special request to National Health Insurance Fund. To achieve a better national cardiovascular morbidity and mortality the attitude of the doctors and the adherence of the patients to the lipid lowering therapy should be improved (it’s the goal of the present paper as well).]

Lege Artis Medicinae

MARCH 20, 2019

[The atherosclerosis can not only be prevented, but also can be cured ]

MÁRK László

[The process of atherosclerosis nowadays plays an important role in the health care not just as a major cause of the most common cardiovascular diseases which lead to death, but also as a major factor in the loss of age-related elasticity in the blood vessels. Over the past two decades, large studies have shown that the treatment of high cholesterol levels can reduce the frequency of cardiovascular events and death and have confirmed the ability to reduce the already existing atherosclerotic plaque, which is almost unique in pharmacotherapy. Using lipid lowering therapy, if we do it properly, we can not only prevent vascular events, but can also cure atherosclerosis. Currently there are three drug groups (statins, ezetimibe and PCSK9- inhibitors), which have complete evidence that their use can reduce the number of cardiovascular events and plaque regression can be achieved. Despite many convincing clinical trials, lipid-lowering therapy is on the cardiovascular prevention palette in the just tolerated or forced applied category. In order to take advantage of its potentials at an appropriate level, as doctors, we have to approach to it by considering its importance. We should communicate to our patients that it’s about a life-long treatment, which not only can reduce the possibility of cardiovascular events, but also can slow down the aging process of the arteries. ]

Lege Artis Medicinae

JULY 20, 2015

[Efficacy of maximal dose rosuvastatin therapy in significant carotis stenosis]

KONCSOS Péter

[The main role of atherogenic dyslipidemia is known for decades. Several studies have proven the beneficial effect of statin therapy on cardiovascular morbidity and mortality. The following case report demonstrates the efficacy of high dose statin therapy regarding lipid goals and clinical signs. The presented 65 year-old female patient had a history of dyslipidemia and hypertension for over 15 years and positive cardiovascular family history. Carotid ultrasound examination showed 15-20% bilateral stenosis in 2008 whereas four years later, control ultrasound showed significant progression with 65% left-sided asymptomatic stenosis. At this time, LDL-cholesterol level was above the target; we managed to reach the recommended level with high-dose statin treatment in combination therapy with ezetimibe. Besides the lipid levels, regression of the carotid stenosis could be observed without statin-associated side effects.]

Lege Artis Medicinae

SEPTEMBER 20, 2012

[Rosuvastatin for the treatment of diabetic dyslipidaemia]

SIMONYI Gábor

[Cardiovascular disease is a leading cause of death. The incidence of type 2 diabetes is increasing worldwide as well as in Hungary. Diabetes mellitus is a high-risk state, and if associated with coronary disease, it is considered a very high-risk condition. According to the 5th Cardiovascular Consensus Conference and ESC/EAS, the target level of LDL-cholesterol should be <2.5 mmol/l in high-risk condition and <1.8 mmol/l in very high-risk condition. In diabetes, one of the main goals is to achieve target LDL-cholesterol levels, which require lifestyle changes as a first step, followed by statin treatment, in combination with with ezetimibe if necessary. Statins are also known to have diabetogenic effects, which are dose-dependent. The advantage of the preventive cardiovascular effects observed in nondiabetic patients substantially outweighs the risk of potentially developing diabetes mellitus, therefore, this risk should not hinder the use of statins. Statin treatment can substantially reduce cardiovascular events in patients with diabetes mellitus. The greatest reduction in LDL-cholesterol level can be achieved by the most efficient statin, rosuvastatin.]

Lege Artis Medicinae

FEBRUARY 20, 2012

[The role of antilipidaemic therapy in chronic kidney disease]

CSÁSZÁR Albert

[In chronic kidney disease (CKD), the risk of cardiovascular mortality is remarkably high, which is partly due to lipid alterations. The results with statin treatment in cardiovascular prevention studies and in CKD, and their metaanalysis show that antilipidaemic therapy decreases overall and cardiovascular mortality in the predialysed state. On the basis of the new study SHARP, coadministration of simvastatin plus ezetimib also significantly reduces the number of atherosclerotic events in predialysed CKD (this was the first positive hard-endpoint result regarding the combination), thus it can be considered as an alternative. A large-scale metaanalysis of two earlier studies assessing the dialysed patients and patients of the SHARP study who received only dialysis indicated that antilipidaemic therapy was successful, as the number of nonfatal myocardial infarctions and coronary revascularisation interventions have been significantly reduced. These new results also show that in patients who need dialysis, the efficiency of statin or statin plus ezetimib therapy is decreased compared to predialysed state - owing to the partly different pathomechanism -, but this antilipidaemic therapy - especially in those with a high cardiovascular risk - can reduce the incidence of cardiovascular events.]

Lege Artis Medicinae

MARCH 19, 2007

[THE ROLE OF SIMVASTATIN IN THE TREATMENT OF DIABETIC DYSLIPIDAEMIA]

BALOGH Zoltán, PARAGH György

[Patients with type 2 diabetes have markedly increased cardiovascular morbidity and mortality. Type 2 diabetes is typically associated with atherogenic dyslipidaemia, which is characterized by elevated triglycerides, low plasma levels of high-density lipoprotein cholesterol, and an increased ratio of small, dense lowdensity lipoprotein particles. Current treatment guidelines stress the importance of lipidlowering therapy in reducing cardiovascular risk in diabetic patients. Statins currently represent the cornerstone of dyslipidaemia management, based on their ability to efficiently reduce cardiovascular risk through lowering low-density lipoprotein cholesterol. They have, however, a relatively modest effect on the components of atherogenic dyslipidaemia, since they reduce triglycerides by only 15 to 35% and elevate high-density lipoprotein cholesterol by less than 10%. This raises the need for combining statins with other lipid-lowering drugs (ezetimibe, nicotinic acid, fibrate) at an early stage of type 2 diabetes. Authors review the role of simvastatin monotherapy in the treatment of diabetic dyslipidaemia and summarize the results of studies on simvastatin as part of a combined lipid-lowering treatment.]

Lege Artis Medicinae

JUNE 20, 2005

[THE CLINICAL PHARMACOLOGIC BASIS OF THE SAFE USE OF STATIN ANALOGS]

KERPEL-FRONIUS Sándor

[Statins, specific inhibitors of the 3-hydroxy-3-methylglutaryl- coenzyme A (HMG-CoA), decrease significantly pathologically elevated cholesterol levels. The effectiveness and the side effects of the different analogs depend on their inhibitory potency, lipid solubility, active uptake into the liver cells and on the difference in their metabolism. The statins can be divided into three groups on the basis of their clinical effectiveness: the highly effective agents are rosuvastatin and atorvastatin; simvastatin exhibits an intermediate activity, while lovastatin, pravastatin and fluvastatin are the least active drugs. The main metabolic pathways of the statins are oxidation and glucoronidation and finally the spontaneous inactivation by lactone ring formation of the glucoronidated products. Gemfibrozil increases the plasma level of all statin analogs by inhibiting the activity of UGT1A1 and UGT1A3 isoenzymes of the UDPglucoronosyltransferase. Therefore, when a statinfibrate combination is needed, fenofibrate and bezafibrate are recommended, the metabolism of which are linked to other UGT isoenzymes. Similarly elevated plasma levels are produced by inhibiting the specific cytochrome isoforms participating in the oxidation of a particular statin. Severe side effects are rarely observed. The most frequent adverse reaction is the development of myopathy of various severity. Using various statins rhabdomyolysis occurred in 0.0-0.3 cases /100 000 statin prescriptions if the already withdrawn cerivastatin is not considered. The statin+gemfibrozil combination increases the number of rhabdomyolysis approximately tenfold. The long-term benefit of statin therapy far exceeds the risk of the treatment. For achieving very low lipid target values even the most effective statins must be used in high doses. Nevertheless, this goal cannot be reached in about 20% of the cases. High dose statin treatment should be administered with the gradual increase of the dose, tight control of the patients and by meticulously selecting the drugs given simultaneously. Further development can be expected from the application of agents with new mechanisms of action, such as the cholesterol uptake inhibitor ezetimibe.]