Joint European Society of Cardiology and World Congress of Cardiology Conference

Statin and ezetimibe combination therapy better than statin alone
C-reactive protein (CRP) levels were reduced by 46 % in people at high risk of a cardiovascular event in a study presented at this joint congress.

The EXPLORER (Examination of Potential Lipid modifying effects Of Rosuvastatin in combination with Ezetimibe versus Rosuvastatin alone) study, using a combination of 40 mg rosuvastatin (Crestor; AstraZeneca, Luton) and 10 mg ezetimibe (Ezetrol; MSD and Schering-Plough, Hoddesdon and Welwyn Garden City, respectively), also helped 58 % of participants meet the dual CRP/low density lipoprotein-cholesterol (LDL-c) goals (CRP<2 mg/l; LDL-c >100 mg/dl [2.6 mmol/l] or <70 mg/dl [1.8 mmol/l], depending upon individual’s risk category). Rosuvastatin monotherapy helped the achievement of this same goal in 24 % of study participants. Rosuvastatin monotherapy reduced CRP levels by 29 % (compared with 46 % on combination).

Chris Packard, Professor of Pathological Biochemistry at the University of Glasgow, UK, commented: ‘Appropriately aggressive plasma lipid regulation is a critical component of personalised strategies for coronary heart disease prevention. Doctors now have available a range of therapies to match the needs of their patients. The results of EXPLORER add to the treatment options for patients at particularly high risk of CV disease. The study showed that the combination [of rosuvastatin and ezetimibe] not only lowered LDL-c in a highly effective manner, but also addressed the need to increase HDL-c and to reduce CRP.’

James Shepherd, Professor of Vascular Biochemistry at Glasgow Royal Infirmary, added: ‘These results from EXPLORER are consistent with other earlier data showing that combination therapy with statins and ezetimibe significantly lowers the level of the inflammatory marker CRP in the plasma. The effect seems to derive primarily from the statin and, in this context, rosuvastatin monotherapy has already been shown to lower CRP. These findings bode well for the ongoing JUPITER [Justification for the Use of statins in Primary prevention: an Intervention Trial Evaluating Rosuvastatin] trial.’

Both agents were found to be well tolerated.

CRT is a cost-effective way to improve survival in heart failure
According to data presented at this joint meeting, long-term treatment with cardiac resynchronisation therapy (CRT) is a cost-effective way to improve survival in people with heart failure. The cost-effectiveness is based on clinical evidence of improvements in quality of life, morbidity, mortality and reduction in costs associated with hospitalisation after heart failure. The data is from the CARE-HF (CArdiac REsynchronization in Heart Failure) study. Further data show that CRT reduces mortality in people with heart failure.

Risk of recurrent stroke in high-risk people reduced by pioglitazone
Data presented at this joint meeting showed that pioglitazone (Actos; Takeda, High Wycombe) reduced the risk of recurrent stroke in nearly 50 % of high-risk participants with type 2 diabetes.

These new analyses, from the PROactive (PROspective pioglitAzone Clinical Trial In macroVascular Events) study, examined the effects of pioglitazone on the risk of stroke and other cardiovascular outcomes in high-risk people with type 2 diabetes with and without prior stroke. According to the results, there were statistically significant benefits of pioglitazone in people with a history of stroke. The incidence of recurrent stroke was reduced by 47 % (P=0.008) and the combined risk of death, myocardial infarction or stroke was reduced by 28 % (P<0.05). No effect of the drug was seen on subsequent strokes in people who had never experienced one.

Robert Wilcox (Professor in the Department of Cardiovascular Medicine at Queen’s Medical Centre, University Hospital, Nottingham, UK, said: ‘These results are very encouraging for people with type 2 diabetes because they demonstrated that [pioglitazone] reduced the indidence of strokes in patients who had already experienced a stroke from 10.2 % down to 5.6 %, translating to a risk reduction of almost 50 %.’

Valsartan has wide cardioprotective benefits
A Japanese-based study using the angiotensin receptor blocker (ARB) valsartan (Diovan; Novartis, Camberley) found that its cardiovascular protective effects are greater than other pharmaceutical therapies that give similar blood pressure control.

The trial, conducted by the Jikei University School of Medicine in Tokyo, Japan, examined over 3000 people with high blood pressure, coronary heart disease and/or heart failure who were currently treated with recommended therapies. Participants were assigned either treatment with valsartan or a non-ARB therapy, taken in addition to their current therapy.

The aim of the JIKEI HEART Study was to achieve the same blood pressure control (remaining under the goal of 140/90 mmHg) in both treatment groups and compare benefits in cardiovascular outcomes, including angina, stroke and heart failure.

The trial was halted early for ethical reasons, due to unequivocal benefit from valsartan.

ASCOT reveals combination therapy reduces incidences of new-onset diabetes
New results from a sub-study of ASCOT (Anglo-Scandinavian Cardiac Outcomes Trial), presented at the joint meeting in Barcelona, revealed that new-onset diabetes was reduced by 34 % in hypertensive people receiving the calcium channel blocker (CCB) amlodipine, with or without the angiotensin converting enzyme (ACE) inhibitor perindopril (Coversyl; Servier, Wexham), compared with those receiving the b-blocker atenolol, with or without the diuretic bendroflumethiazide.

Furthermore, all of the participants in the sub-study receiving the newer treatments (CCB ± ACE inhibitor) had their risk of developing diabetes reduced, irrespective of their initial risk factors. Previously, older antihypertensives, such as b-blockers and diuretics, were used with caution in individuals thought to be at high-risk of developing diabetes. However, these results support the use of the newer treatments in all patients, not just those at high risk.

‘Patients with high blood pressure have a much greater risk of developing diabetes. The results of this ASCOT sub-study emphatically add to the evidence that b-blockers and diuretics can exacerbate that risk,’ explained Neil Poulter, Lead ASCOT investigator, Professor of Preventive Cardiovascular Medicine and Co-director of the International Centre for Circulatory Health, Imperial College London.

‘The chance of a patient with raised blood pressure developing diabetes can be cut by the newer treatments irrespective of the patient’s initial level of risk. Many new cases of diabetes could be prevented as a result if GPs avoid prescribing the older treatments to hypertensive patients unless they specifically require them.’

‘The position of ASCOT as a practice-changing trial is extended by the results of this sub-study,’ commented Professor George Alberti, Emeritus Professor of Medicine, University of Newcastle and immediate Past-president of the International Diabetes Federation.

‘Doctors now have further incentive to modify their hypertension prescribing, with these results following on so shortly after the recent update of its treatment guidelines by NICE [National Institute for Health and Clinical Excellence] in conjunction with the BHS [British Hypertension Society].’

Enoxaparin reduces the risk of repeat heart attacks
Results of a trial presented at this joint meeting showed that enoxaparin reduced the risk of death, recurrence of heart attacks and stroke compared with the current standard of using unfractionated heparin in patients with acute ST-segment elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI).

The results also showed that enoxaparin reduces the risk of repeat heart attacks before the PCI procedure and that fewer people in the enoxaparin group had to undergo PCI.

Addition of aspirin to clopidogrel therapy has no clinical benefit
The European Society of Cardiology released a statement saying that people using clopidogrel (Plavix; Bristol-Myers Squibb and Sanofi-Synthelabo, Uxbridge and Guildford, respectively) should continue to do so under their physician’s guidance.

The statement was precipitated by new data from the CHARISMA (Clopidogrel for High Atherothrmbotic Risk and Ischemic Stabilization, Management and Avoidance) trial that demonstrated that the addition of aspirin to clopidogrel therapy has no clinically significant benefits.