Sterol and stanol ester based margarines have a
significant role in reducing plasma cholesterol levels.
Arvind Reddy, M.D,
M.P.H . Department of Medicine,
Research Question:
In normocholesterolemic and mildly
hypercholesterolemic individuals, do sterol and stanol ester based margarines help in lowering cholesterol
levels when used alone or in adjunct with other cholesterol lowering agents?
Data Source:
Experimental studies from the MEDLINE database from 1998 –
2003 using Pubmed and Ovid.
Study Selection:
Randomized trials included in this review were identified by
a MEDLINE search term "plant sterols." Studies focusing on
normal to mildly hypercholesterolemic subjects who
were not on any cholesterol lowering therapy except the NCEP step 1 diet were
selected. A small group of studies involving subjects already on a single lipid
lowering drug were also selected.
Outcome Measures:
The data points chosen as outcome measures in these studies
were the plasma levels of total cholesterol, LDL cholesteorol
and HDL cholesterol.
Results:
The first randomized controlled study involving 224 subjects
already on NCEP step 1 diet, showed that sterol based
margarines decreased total cholesterol by 7.1 % and LDL cholesterol by as much
as 10% at the end of the 5 week trial period with no significant impact on HDL
levels. In another study involving 100 subjects on three different doses of
sterol based margarines a dose dependent response was observed with a decrease in
total cholesterol by 4.9%, 5.9% and 6.8% and LDL cholesterol by 6.7%, 8.5% and
9.9%. There was no significant change in HDL levels. In another study involving
141 subjects comparing sterol and stanol ester based
margarines, stanols showed an increase in HDL
cholesterol levels by 1.4% apart from lowering LDL levels by about 13% at the
end of the 90 day period. In the last study involving 167 subjects, stanol ester based margarine showed a reduction in LDL
cholesterol by as much as 24% when used in adjunct to intermediate dose of statins at the end of 8 weeks.
Conclusion:
Stanol and sterol
ester based margarines are very effective in reducing total and LDL cholesterol
levels in normocholesterolemic and mildly hypercholesterolemic individuals when used alone or in
adjunct to statin therapy. Stanol
ester based margarines have an additional benefit of raising HDL cholesterol
levels when compared to sterol ester based margarines.
ANTIPLATELET
THERAPY FOR SECONDARY PREVENTION OF CORONARY ARTERY DISEASE.
Question: In patients undergoing thrombolysis
for treatment of myocardial infarction, what is the optimal antiplatelet
therapy regimen for secondary prevention of myocardial infarction (MI)?
Data sources: Studies were identified by searching MEDLINE (1966 to
2003), Cochrane Library, and Web of Science database.
Study Selection: Double-blinded randomized trials comparing an antiplatelet regimen with a control regimen or with another
antiplatelet regimen, in patients with MI treated
with pharmacological thrombolysis..
Data Extraction: Data was extracted from 12 trials comparing the
efficacy of antiplatelet regimens in patients with
history of MI and 15 trials comparing antiplatelet
regimens in patients with acute MI. The occurrence of reinfarction
(fatal and non-fatal) and the composite outcome of vascular death, MI
and stroke were studied.
Results: In patients with ST-elevation MI, therapy with aspirin or clopidogrel was found to have equivalent effects on the
prevention of reinfarction. In patients with a non
ST-elevation MI receiving therapy with aspirin and clopidogrel,
the relative risk of MI was 0.77 and the relative risk for the composite
outcomes of MI, stroke or vascular death was 0.80 (p <0.001) as compared to
those receiving aspirin only.
Conclusion: Optimal anitplatelet therapy
for secondary prevention of coronary artery disease in patients with ST
elevation MI consists of aspirin life long or clopidogrel
life long in case of aspirin allergy, aspirin intolerance or aspirin
resistance. In patients with non-ST elevation MI, therapy with aspirin life
long combined with clopidogrel for the first 9 to 12 months provides maximum
benefit. In non-ST elevation MI patients in whom aspirin cannot be used,
therapy with clopidogrel life long should be used.
RUPTURE OF ABDOMINAL AORTA ANEURYSM IN A 24
YEAR OLD FEMALE WITH CYSTIC MEDIAL NECROSIS.
K
Department of Medicine and Department of
Pathology*,
Abdominal Aortic Aneurysm is a
disease that is rarely manifested before the age of fifty-five. The most common
cause is atherosclerosis.
We present a 24 year old African
American female, who came to the emergency room with sudden onset of abdominal
pain, low back pain and vomiting. Physical examination revealed diffuse
abdominal tenderness. CT Scan of the abdomen reported, a large infrarenal
pseudoaneurysm and rupture of the abdominal aorta
with extensive retroperitoneal hemorrhage. Patient was in shock and underwent
an emergency resection of the abdominal aorta aneurysm with a bypass graft.
Intra-operative findings revealed a nine centimeter infrarenal
aortic “blow out” rupture. Although the post-operative period was complicated,
the patient survived this event. The pathology of the aorta revealed extensive myxoid degeneration and cystic medial necrosis.
Aortic aneurysms in patients
younger than 40 years are most often associated with cystic medial necrosis.
The thoracic aorta is more commonly involved.
Very few cases of the abdominal
aorta aneurysm rupture secondary to cystic medial necrosis have been reported. Cystic medial necrosis may occur as an
isolated abnormality or as part of a systemic connective tissue disease such as
Marfans syndrome or Ehlers Danlos syndrome. This patient had some features
of Marfans but failed to meet all the criteria of Marfans. There was no family history of aneurysms. Our patient
could have idiopathic cystic medial necrosis or a partial expression of the Marfan syndrome with a possibility of a new missense mutation.
Regardless of the diagnosis,
prophylactic treatment and prevention of further complications associated with cystic
medial necrosis is
important. Awareness of the broad spectrum of manifestations in myxoid degeneration disorders needs to be increased among
practitioners, to lower the threshold of suspicion necessary for referral to a
specialist center.