Cardiovascular Diseases

Pulmonary arterial hypertension (PAH) is a progressive, debilitating disorder associated with poor quality of life and shortened life span. For many years, medical therapy consisted of calcium channel blockers, warfarin, supplemental oxygen, and digitalis glycosides. A better understanding of the pathophysiology of PAH has led to the recent development of effective treatments for this disorder. Therapeutic agents target the pathophysiologic mechanisms of PAH: pulmonary vasoconstriction, pulmonary vascular remodeling, and in situ thrombosis. With better understanding of the pathogenesis of PAH, recent advances in pharmacotherapy have been introduced for the treatment of PAH. Data are presented on efficacy and safety of newer approved and investigational agents: prostacyclin analogues, oral endothelin antagonists, and phosphodiesterase 5 inhibitors.

Ezetimibe (Zetia), approved in late October, represents the first new class of cholesterol-lowering drugs in 15 years. Ezetimibe, an intestinal cholesterol absorption inhibitor, has a unique mechanism of action, distinct from those of statins and bile acid sequestrants. When used as monotherapy, ezetimibe lowers low-density lipoprotein cholesterol (LDL-C) levels up to 18.5%. Coadministration of ezetimibe with statin therapy reduces LDL-C levels up to an additional 22%. The article reviews ezetimibe?s chemistry, pharmacology, pharmacokinetics, and clinical trial results.

Applied Health Outcomes, Tampa, FL-Fixed-dose combination antihypertensive agents may save money for your institution or plan as well as for your patients.

Eplerenone is a selective aldosterone receptor antagonist under FDA review for treatment of hypertension. With a high trough-to-peak ratio, it is suitable for once-daily dosing. It significantly reduces blood pressure in patients with mild to severe hypertension and can be used alone or in combination with other antihypertensives. Although chemically related to spironolactone, eplerenone has a lower binding affinity for androgenic and progestogenic receptors than spironolactone, which may translate into a lower incidence of endocrine-related adverse effects. In addition, eplerenone lowers blood pressure particularly well in patients with low-renin, salt-sensitive hypertension, such as African Americans.

With enoxaparin?s recent labeling change regarding its use in patients with prosthetic valves, clinicians may have several questions about appropriate anticoagulant selection. Specifically, what evidence prompted the labeling change, which patients are affected, what are the options and limitations for bridging patients, what?s the evidence supporting the role of low molecular weight heparins (LMWHs) in bridge therapy, and how can liability be limited should clinicians choose to use LMWH therapy? The authors of this commentary offer their insight on these issues.

The evidence supporting a role for the angiotensin II receptor blockers (ARBs) in patients with nephropathy and/or heart failure continues to evolve. Currently, the FDA is in late-stage review of the first ARB for a heart failure indication and is reviewing another ARB for a diabetic nephropathy indication. The authors of this article present and interpret the clinical evidence for ARB use in these two disease states. Included in their discussion are the most recent recommendations on ARBs’ place in therapy according to the American Diabetes Association, the American College of Cardiology, and the American Heart Association.

New Indication: GlaxoSmithKline Indication broadened to include HIT prevention during PCI

Albert Einstein Healthcare Network, Philadelphia-What are the real-world consequences of inadequate beta blocker therapy in patients with congestive heart failure (CHF)? That is what this group of clinicians at Prestige Health-a 50,000 member managed care organization in Philadelphia-set out to determine.

New Indication: Antiplatelet approved for acute coronary syndrome

Ratherthan shortening the hospital stay and improving clinical outcomes, a 48-hour infusion of milrinone was associated with increased early treatment failure-particularly due to the development of arrhythmias and hypotension-in patients hospitalized with acute exacerbations of chronic heart failure (CHF).

Enoxaparin (Lovenox) is typically used during hospitalization after orthopedic or abdominal surgery. Recent studies of its use after orthopedic surgery have shown that extending administration of the low-molecular-weight heparin after hospital discharge significantly reduces the frequency of deep-vein thrombosis (DVT). A new study confirms this is also the case for abdominal surgery for cancer, which carries a high risk of this complication.

The investigational vasopeptidase inhibitor omapatrilat is as effective as enalapril in preventing major adverse cardiac outcomes in patients with moderate to severe heart failure, but failed to show superiority, said Milton Packer, MD.

LIPS: Statin reduces cardiac event risk by 22% in first PCI procedureAzithromax ineffective for reducing recurrent CV events

Drug therapy to control heart rate is at least as effective as antiarrhythmicdrug therapy in preventing adverse clinical events in patients with atrialfibrillation (AF), according to separate studies.

Therapy starting with the angiotensin receptor blocker (ARB) losartansignificantly reduced the risk of cardiovascular outcomes and new-onsetdiabetes compared with a beta blocker in older high-risk hypertensive patients,said Björn Dahlöf, MD. The improved outcomes with losartan occurredeven after adjusting for small differences in blood pressure reduction betweenthe two study drugs.

Atlanta-The low-molecular-weight heparin enoxaparin improves outcomes compared with currently recommended therapy in patients with non-ST-segment elevation acute coronary syndromes (ACS) who are being treated with a glycoprotein (GP) IIb/IIIa inhibitor, said Shaun Goodman, MD.

Lercanidipine is currently under FDA review for the management of hypertension. In comparative clinical trials, lercanidipine has shown antihypertensive efficacy comparable to that of slow-release nifedipine, amlodipine, nitrendipine, verapamil, captopril, and atenolol. Its side effect profile is similar or superior to these agents. This Focus article reviews those trials as well as lercanidipine?s pharmacologic properties and addresses the agent?s potential role in patients with comorbid conditions.

Adding the investigational cholesterol absorption inhibitor ezetimibe to statin therapy results in additional reductions in low-density lipoprotein (LDL) cholesterol of up to 14%.

Creighton University, Omaha, NE-Despite the evidence that lipid-lowering drug therapy-especially with HMG-CoA reductase inhibitors (statins)-is known to save lives and help prevent subsequent events in coronary heart disease (CHD) patients, utilization of this class of drugs is erratic.

Prompted by a flurry of new evidence, two leading cardiology groups have revised their guidelines for the management of acute coronary syndromes just 18 months after the last revision.

Rosuvastatin is an investigational HMG-CoA reductase inhibitor expected to gain FDA approval later this year for treatment of hypercholesterolemia. It has significantly exceeded atorvastatin, pravastatin, and simvastatin in reducing LDL cholesterol in clinical trials. This Focus article reviews those trials as well as rosuvastatin's pharmacologic and safety profiles in an effort to delineate its likely role in cholesterol-reducing therapy.

VA Medical Center, Miami-ACE inhibitor therapy is recognized as the gold standard treatment for congestive heart failure (CHF) as well as diabetic nephropathy due to its effect on the morbidity and mortality associated with these conditions.

This 287-study meta-analysis aimed to address unanswered questions about antiplatelet therapy in patients at high risk for occlusive vascular events. It yielded several new findings or clarifications, including these: (1) Antiplatelets protect against vascular events in patients with unstable angina, intermittent claudication, and atrial fibrillation. (2) Antiplatelet therapy can be started promptly during acute ischemic stroke and continued long-term. (3) Daily aspirin doses of 75 to 150 mg seem to be as effective as higher doses for long-term treatment.

Clinicians must use caution in adopting newly revised national guidelines for treating elevated cholesterol, concludes a new study from the University of Maryland Pharmaceutical Health Services Research Department.

VA Medical Center, Miami-ACE inhibitor therapy is recognized as the gold standard treatment for congestive heart failure (CHF) as well as diabetic nephropathy due to its effect on the morbidity and mortality associated with these conditions.