Editorial 2006 : le RMLg entre dans la 7e décénnie

in Revue Médicale de Liège (2006)

Editorial

in Revue Médicale de Liège (2005), 60(1), 1-4

L'etude clinique du mois. REVERSAL et PROVE-iT: confirmation du concept the lower, the better" dans le traitement de l'hypercholesterolemie chez le patient coronarien."

in Revue Médicale de Liège (2004), 59(3), 167-73

Statins, as compared to placebo, have proven their efficacy in reducing cardiovascular events in patients with or without cardiovascular disease and in a large range of cholesterol levels. Two new head-to ... [more ▼]

Statins, as compared to placebo, have proven their efficacy in reducing cardiovascular events in patients with or without cardiovascular disease and in a large range of cholesterol levels. Two new head-to-head randomised trials comparing intensive treatment with atorvastatin 80 mg/day with moderate treatment with pravastatin 40 mg/day were recently completed. The mechanistic "Reversing Atherosclerosis with Aggressive Lipid Lowering" (REVERSAL) trial randomised 502 patients with stable coronary disease. Atorvastatin 80 mg (leading to a mean LDL cholesterol of 79 mg/dl) was superior to pravastatin 40 mg (mean LDL of 110 mg/dl) in terms of limiting the progression of atheroma assessed with the use of intravascular ultrasonography after 18 months of follow up (p = 0.02). These differences may be related to the greater reduction in atherogenic lipoprotein (-46% versus -26%, p < 0.001) and C-reactive protein (-36% versus -5%, p < 0.001) in patients treated with atorvastatin as compared to pravastatin. In the clinical "Pravastatin or Atorvastatin Evaluation and Infection Therapy" (PROVE-IT) trial, 4162 patients with acute coronary syndromes were randomised to either atorvastatin 80 mg or pravastatin 40 mg and followed for a mean of 24 months. Again, atorvastatin (mean LDL of 62 mg/dl) was superior to pravastatin (mean LDL of 95 mg/dl), resulting in a 16% percent lower risk of the primary end point, a composite of major cardiovascular events (p = 0.005). Thus, both REVERSAL and PROVE-IT support the concept "the lower, the better". However, they do not allow to disentangle the independent and interdependent effects of statins on LDL cholesterol and the process of arterial inflammation. What so ever, the results suggest that the target LDL cholesterol level may be lower than recommended in the current guidelines in high-risk patient so that a sea change in the prevention and management of atherosclerotic vascular disease may occur very soon. [less ▲]

L'etude clinique du mois. L'etude ALLHAT-LLT.

in Revue Médicale de Liège (2003), 58(1), 53-8

ALLHAT-LLT was part of the ALLHAT study. The purpose was to determine whether pravastatin compared with usual care reduces all-cause mortality in older, moderately hypercholesterolaemic, hypertensive ... [more ▼]

ALLHAT-LLT was part of the ALLHAT study. The purpose was to determine whether pravastatin compared with usual care reduces all-cause mortality in older, moderately hypercholesterolaemic, hypertensive patients with at least one additional coronary heart disease (CHD) risk factor. 10,355 ambulatory patients, aged 55 years or more, with LDL cholesterol of 120-189 mg/dl (or, 100-129 mg/dl if known CHD) and triglycerides < 350 mg/dl, were randomised to pravastatin (40 mg/d; n = 5,170), or usual care (n = 5,185). Mean age was 66 years; 49% were women; 38% were black and 23% hispanic; 14% had a history of CHD and 35%, type 2 diabetes. Baseline mean total cholesterol was 224 mg/dl; LDL-C, 146 mg/dl; HDL-C, 48 mg/dl, and triglycerides, 152 mg/dl. Mean follow-up was 4.8 years. Among usual care patients, 32% of those with known CHD and 29% of those without CHD started taking lipid-lowering drugs. At year 4, total cholesterol was reduced by 17.2% with pravastatin and by 7.6% with usual care. A random sample had their LDL-C levels assessed: there was a reduction of 28% with pravastatin and of 11% with usual care. All-cause mortality was similar in the two groups (RR, 0.99; 95% CI, 0.89-1.11; p = 0.88), with 6-year mortality rates of 14.9% (pravastatin) and 15.3% (usual care). CHD event-rates were not different between the two groups (RR, 0.91; 95% CI, 0.79-1.04; p = 0.16); 6-year CHD event rates were 9.3% (pravastatin) and 10.4% (usual care), respectively. These results are likely due to the small differential in total cholesterol (9.6%) and LDL-C (16.7%) between pravastatin and usual care, compared with prior statin trials. Such an unusual differential essentially results from the open table of the study and from the possibility of prescribing a statin in the usual care group. [less ▲]

Prevention cardio-vasculaire par les statines: faut-il encore doser le cholesterol?

in Revue Médicale de Liège (2003), 58(4), 191-7

Statins, the most popular lipid-lowering agents, have proven their efficacy in preventing cardiovascular events in subjects with lower and lower initial plasma cholesterol levels. Besides, the protective ... [more ▼]

Statins, the most popular lipid-lowering agents, have proven their efficacy in preventing cardiovascular events in subjects with lower and lower initial plasma cholesterol levels. Besides, the protective effect does not seem to be directly related neither to the degree of the cholesterol reduction nor to the final level of plasma cholesterol level reached under treatment. Such observations suggest that statins may exert vascular protective effects, at least in part, independently of their specific cholesterol-lowering effect (so-called pleiotropic effects). The present paper will discuss the arguments pro and contra the dosage of cholesterolaemia before initiating a therapy with statin and during treatment follow up, both in subjects with previous cardiovascular events (secondary prevention) and in subjects with a high cardiovascular absolute risk but without previous clinical expression of atherosclerosis (primary prevention). [less ▲]

Comment je previens ... les maladies cardio-vasculaires par une approche pharmacologique combinee: y a-t-il place pour une polypill"?"

in Revue Médicale de Liège (2003), 58(9), 527-33

In the June 28, 2003 issue of the British Medical Journal, an extensive literature survey based on various large meta-analyses of the efficacy and safety of the reduction of four cardiovascular risk ... [more ▼]

In the June 28, 2003 issue of the British Medical Journal, an extensive literature survey based on various large meta-analyses of the efficacy and safety of the reduction of four cardiovascular risk factors (cholesterol, arterial blood pressure, platelet aggregation, homocysteine) leads to the conclusion that a combined pharmacological intervention should reduce ischaemic heart disease events by 88% and strokes by 80% in at risk individuals. Therefore, a new paradigm is proposed for the prevention of cardiovascular diseases. This new strategy would consist in the systematic prescription to people with a history of heart attack or stroke, those with any form of obliterative atherosclerotic vascular disease or diabetes, and everyone aged 55 and older of a fixed combination of 6 pharmacological agents independently of initial risk factor profile.... Such pharmacological formulation, called "polypill", should contain a statin, three blood pressure lowering drugs (each at half standard dose), aspirin (75 mg/day) and folic acid (0.8 mg/day). We discuss the pros and cons of this new paradigm. However, the efficacy of such "polypill" remains to be demonstrated in a large controlled clinical trial as well as its superiority as compared to a classical approach of cardiovascular prevention based upon the individual optimal correction of each risk factor thanks a dose titration of each pharmacological compound. [less ▲]

Ecueils et chausse-trapes.

in Revue Médicale de Liège (2002), 57(5), 249

L'etude clinique du mois. L'etude PROSPER (PROspective study of pravastatin in the elderly at risk).

in Revue Médicale de Liège (2002), 57(12), 809-13

Statins reduce coronary and cerebrovascular mortality and morbidity in middle-aged individuals. Until recently, their efficacy and safety in elderly people had not yet been firmly established. PROSPER was ... [more ▼]

Statins reduce coronary and cerebrovascular mortality and morbidity in middle-aged individuals. Until recently, their efficacy and safety in elderly people had not yet been firmly established. PROSPER was a controlled, randomised study involving 2,804 men and 3,000 women aged 70-82, with a history of, or risk factors for cardiovascular disease. Their baseline cholesterol level was 135-350 mg/dl; they were randomised to either 40 mg pravastatin per day, or matching placebo. Average follow-up was 3.2 years. The primary endpoint was a composite of coronary death, non-fatal myocardial infarction, and fatal or non-fatal stroke. Pravastatin lowered LDL-cholesterol (-34%), and reduced the incidence of the primary endpoint (-15%; CI 95%: 3-26%; p = 0.014). Coronary death and non-fatal myocardial infarction risk was also reduced (-19%; p = 0.006), and mortality from coronary disease fell by 24% (p = 0.043). The risk for stroke, however, was unaffected (p = 0.8), whereas the incidence of transient ischemic attacks was reduced by 25%, which was (marginally) insignificant (p = 0.051). Pravastatin had no effect on cognitive functions or incapacity. New cancers were more frequent amongst pravastatin-treated individuals (+25%; p = 0.020). However incorporation of this new data in a meta-analysis of all pravastatin and all statin trials revealed no overall increase of cancer risk. [less ▲]

Quelques considerations generales et rappels historiques a propos de la therapeutique.

in Revue Médicale de Liège (2000), 55(4), 201-5

La stenose sous-valvulaire aortique d'origine membraneuse

in Revue Médicale de Liège (1999), 54(10), 801-4

We report the case of a 55 year old patient presenting a discrete obstructive sub-aortic membrane. After clinical examination, complete echocardiographic evaluation and cardiac catheterisation, an ... [more ▼]

We report the case of a 55 year old patient presenting a discrete obstructive sub-aortic membrane. After clinical examination, complete echocardiographic evaluation and cardiac catheterisation, an operative procedure was decided and the sub-aortic membrane was resected. The results were satisfactory but the literature reports risks of re-obstruction of the left ventricular outflow tract. The article points out the importance of an early diagnosis and further stresses the major role played by transoesophageal echocardiography in the evaluation of the patient. [less ▲]