The latest guidelines, issued in August 2016 by both the European society of cardiology and European atherosclerosis society, have shed light on the therapeutic means to be implemented in order to achieve the cardiovascular risk-based lipid targets. The dietary recommendations focusing on the reduction of saturated fatty acid intakes, along with the increased consumption of grain products, vegetables, fruits, and fish, remain essential for an optimal preventive approach to cardiovascular diseases. Their benefits extend well beyond their measurable effects on the lipid profile. If these measures prove insufficient, they should be complemented by drug therapy in high-risk patients. In very-high-risk patients (e.g., with cardiovascular disease, diabetes, or renal insufficiency), drug therapy is, however, added immediately, irrespective of dietary compliance. Statins are the first-line agents for reducing LDL-cholesterol levels and must be chosen and prescribed to the required dose in order to achieve the predetermined target. Ezetimibe can be administered in combination with a statin to better reach these targets or in the event of intolerance to high statin doses. Second-line treatments, including ezetimibe, fibrates, or omega-3 supplementation in addition to ongoing statin therapy, are aimed at correcting non-HDL cholesterol levels. The introduction and reimbursement of these new drugs will likely complement these therapeutic tools.
Patrick C. ChenuPublished in the journal : November 2016Category : GRAPA
Lipid goals depend on the patients' cardiovascular risk level, patients in secondary prevention being by principle at “very-high risk”. For patients in primary prevention, their cardiovascular risk must first be assessed with the aid of the “SCORE” table, except for those who can be classified without any risk calculation, owing to their many cardiovascular risk factors or associated diseases. The calculated risk SCORE must then be modulated by the patients' HDL-cholesterol levels, significant family history of premature cardiovascular disease, and certain others physical, biological, or life style parameters. Depending on the risk score obtained, we next determine the lipid objectives, along with the treatments required to achieve these goals.
Olivier S. Descamps, Patrick ChenuPublished in the journal : November 2016Category : GRAPA
Lipid management for cardiovascular disease prevention has significantly evolved over the last 20 years, and each novel recommendation brings about new proposals to further improve our patients’ prognosis. The latest 2016 guidelines overlap quite well with those of 2011, stressing once more the relevance of correcting promptly the LDL-cholesterol levels by means of first-line statin therapy. These updated guidelines, however, do define more precisely the LDL-cholesterol levels to target in very-high-risk patients, and the non-HDL cholesterol levels to target in moderate-risk patients. To achieve these targets, they also emphasize the need to combine ezetimibe with statins. Yet over the last years, the implementation of these recommendations has been threatened owing to various controversies casting doubt on statins' safety and usefulness. On account of the introduction of new anti-PCSK9 monoclonal antibodies, familial hypercholesterolemia treatment has now returned to the forefront. These new treatments, along with the more conventional agents, should enable us, at last, to correct the severely-high LDL-cholesterol levels exhibited by these patients from birth onwards. This article briefly addresses these various topics, which are detailed, point-by-point, in the following Louvain Médical issue.
Jean-Philippe Lengelé, Alexandre PersuPublished in the journal : November 2016Category : GRAPA
Hypertension represents a major cardiovascular risk factor worldwide.
In Belgium, chronic kidney disease is mainly related to either diabetes or hypertension. In patients with chronic kidney disease, the aim of antihypertensive therapy is to delay the decline in glomerular filtration rate and reduce cardiovascular event occurrence. Blood pressure targets <140/90-85mmHg are recommended in patients with chronic kidney disease, with likely added benefits when targeting blood pressure values <130/80mmHg for patients with hypertension and overt proteinuria. It is still too early to find out whether the SPRINT study will likely modify blood pressure targets to <120/80 mmHg for these patients.
For patients suffering from erectile dysfunction resistant to medical treatment, surgical implantation of a penile prosthesis is a potential therapeutic solution. At the urology department of the Liege University Hospital (CETISM), a psycho-sexologic interview is proposed to the man and his partner prior to performing the implantation procedure. This check up may likely reveal the false beliefs of both the man and his partner about the implant and can identify the patient's psychopathological disturbances, while further exploring the couple's relational, emotional, cognitive and erotic life, all of which can influence the psychological outcome of the implant. This consultation is meant to provide information regarding the prosthesis and identify the resources of the couple enabling them to rehabilitate an alive intimacy after surgery. This pre-intervention interview has been shown to optimize the satisfaction rates following penile prosthetic implantation.
Edoxaban (Lixiana®) is a novel factor Xa-inhibiting oral anticoagulant that has recently been validated both for the treatment of venous thromboembolism (VTE) and for the prevention of arterial thrombotic events associated with non-valvular atrial fibrillation (NVAF). This article aims at reviewing the results of the two large studies (HOKUSAI-VTE and ENGAGE-AF) that validated this new anticoagulant in these two indications.
These clinical studies clearly demonstrated the efficacy and tolerability of this new oral anticoagulant in both indications as compared to conventional anticoagulants. They especially established the role of a standard dose of 60 mg edoxaban administered once daily and demonstrated the value and effectiveness of a dose reduction to 30 mg daily in some patients at risk of accumulation. This article also summarizes the main properties of edoxaban, which should establish itself as a promising anticoagulant for patients with VTE or NVAF.
In patients suffering from organic erectile dysfunction that proves resistant to medical treatment, penile implant is a reliable, efficient, and long-lasting third-line treatment option. Postoperative complications are well-codified and rather limited, if the intervention is performed by surgeons with implants expertise. In Belgium, the number of implantations is proportionally five times lower than in the USA, which can be accounted for by various factors including a lack of promotion and information of therapists, limited number of experimented "implanters", and lack of knowledge by patients who could benefit from the procedure. The overall management of this common sexual disorder using a penile implant is associated with high satisfaction rates for both the patients and their partners.
Nowadays, erectile dysfunction (ED) can only be managed with symptomatic treatments. Regenerative medicine, which is based on administering stem cells, has the potential to provide the first curative treatment for ED. Two types of stem cells were tested preclinically in animal models, namely mesenchymal (stromal) stem cells isolated from either bone marrow or adipose tissue. The application of both cell types yielded positive effects in various animal ED models. In acute animal models, such as cavernous nerve injury-induced ED, neither engraftment nor differentiation was observed, and stem cells are believed to interact with the host tissue in a paracrine fashion. In chronic disease models, some evidence suggested that engraftment and paracrine factors might boost function improvement. Clinical trials are currently enrolling patients so as to confirm the beneficial effects observed in rodents. If confirmed, this could pave the way for a broad use of stem cell therapy and thus revolutionize the treatment of ED.
SGLT2 inhibitors, when administered to patients with Type 2 diabetes, result in an improved glycemic control, which is attributable to the agents' glucuretic effect, in addition to weight loss and reduced blood pressure. Dapagliflozin (Forxiga®), a new SGLT2 inhibitor, has been available in Belgium since October 2016. This article sought to review recent scientific data from controlled trials assessing dapagliflozin versus placebo or active comparators in Type 2 diabetic patients. Forxiga® was found to be associated with a reduction in HbA1c, along with weight loss and decreased blood pressure levels. The reported adverse events included mild urinary and genital infections. In Belgium, Forxiga® is approved for use in a dual- or triple-therapy regimen, also in combination with basal insulin.
In the space of 20 years, impotence has transformed into erectile insufficiency, a relevant clinical marker for quality of life, and more surprisingly, for poor men's health. Between the age of 30 and 65 years, it has been found to be a marker of both cardiovascular and overall mortality, which represents a major breakthrough and thus renders its proactive opportunistic screening unequally valuable. Any clinician dealing with chronic diseases, particularly cardiometabolic conditions or mood disorders, can no longer ignore the recommendation (Grade A, Level 1) to assess the physical and mental health status in terms of benefits for the primary prevention of acute cardiovascular events, but also for the secondary and tertiary prevention of chronic diseases.