Vascular and metabolic effects of combined therapy with ramipril and simvastatin in patients with type 2 diabetes.

Shin EK.

Department of Cardiology, Gachon Medical School, Incheon, Korea. kwangk ghil.com

Mechanisms underlying biological effects of statin and angiotensin-converting enzyme inhibitor therapies differ. Therefore, we compared vascular and metabolic responses to these therapies either alone or in combination in patients with type 2 diabetes. This was a randomized, double-blind, placebo-controlled crossover trial with 3 treatment arms (each 2 months) and 2 washout periods (each 2 months). Fifty patients with type 2 diabetes were given simvastatin 20 mg and placebo, simvastatin 20 mg and ramipril 10 mg, or ramipril 10 mg and placebo daily during each 2-month treatment period. Ramipril alone or combined therapy significantly reduced blood pressure when compared with simvastatin alone. When compared with ramipril alone, simvastatin alone or combined therapy significantly improved the lipoprotein profile. All 3 treatment arms significantly improved flow-mediated dilator response to hyperemia and reduced plasma levels of malondialdehyde relative to baseline measurements. However, these parameters were changed to a greater extent with combined therapy when compared with simvastatin or ramipril alone (P<0.001 by ANOVA). When compared with simvastatin or ramipril alone, combined therapy significantly reduced high-sensitivity C-reactive protein levels (P=0.004 by ANOVA). Interestingly, combined therapy or ramipril alone significantly increased plasma adiponectin levels and insulin sensitivity relative to baseline measurements. These changes were significantly greater than in the group treated with simvastatin alone (P<0.015 by ANOVA). Ramipril combined with simvastatin had beneficial vascular and metabolic effects when compared with monotherapy in patients with type 2 diabetes.

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Simvastatin regulates myocardial cytokine expression and improves ventricular remodeling in rats after acute myocardial infarction.

Zhang L.

Laboratory of Cardiovascular Immunology, Institute of Cardiology, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China.

PURPOSE: Studies have showed that inflammatory cytokines were involved in the process of left ventricular (LV) remodeling after acute myocardial infarction (AMI), anti-inflammation treatment ameliorated LV remodeling and improved cardiac performance. Hydroxymethylglutary coenzyme A reductase inhibition (statins) could affect the expression of inflammatory cytokines. We hypothesized that statins have beneficial effects on early LV remodeling and cardiac performance in rats with AMI by modulating the production of inflammatory cytokines. METHODS: Rats with AMI were treated with placebo or simvastatin (gastric gavage) for 4 weeks. The pro-inflammatory cytokines: tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta, IL-6 and the anti-inflammatory cytokine: IL-10 excreted by cardiac myocytes was examined. Echocardiography, hemodynamics and collagen type I production were measured to evaluate LV remodeling and cardiac function. RESULTS: The mRNA expression and protein production of TNF-alpha, IL-1beta, IL-6 and IL-10 in AMI group were significantly elevated compared with sham rats. Simvastatin markedly attenuated the production of TNF-alpha, IL-1beta, IL-6 and increased IL-10 levels in the noninfarcted and infarcted regions, reduced collagen deposition in the noninfarcted myocardium and improved left ventricular function. However simvastatin did not alter plasma lipids. CONCLUSIONS: Simvastatin ameliorates early LV remodeling and improve cardiac function after AMI. Simultaneously, it decreased pro-inflammatory and increased anti-inflammatory cytokines, which suggests, but does not prove, a causal relationship independent of plasma lipid-lowering effects.

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Simvastatin: pharmacological response in experimental hyperfibrinogenaemias.

Palma J.

Faculty of Medical Sciences, National University of Cordoba, Cordoba, Argentina. monicamoya hotmail.com

Through a disorder in the endothelial haemostatic balance, hyperfibrinogenaemia could generate endothelial dysfunction. Statins would have antiinflammatory effects on injured endothelium. OBJECTIVE: Simvastatin pharmacological response in rats with hyperfibrinogenaemias induced by laparotomies was studied. METHODS AND RESULTS: Rats were subjected to multiple injuries (MI) for 30 days (1 laparotomy/week) and for 60 days (1 laparotomy/2 weeks). Simvastatin (0.035 mg/kg) was administered orally to the 30-day multiple injuries group after the third injury for a period of 10 days. A similar dose was administered to the 60-day multiple injuries group after the second injury for a period of 45 days. Blood samples of all the groups were obtained 72 hours after the last injury. In the 30 and 60-day multiple injuries groups, a statistically significant fibrinogen increase was observed (336.6 +/- 7.5 and 358.7 +/- 9.9, respectively) compared with the control group (207.0 +/- 3.0) (p < 0.001). There were no significant differences in the plasmatic fibrinogen (PF) levels between the control and simvastatin treated groups (224.9 +/- 1.4 and 216.3 +/- 4.3, respectively). There were significant differences between the 30 or 60-day MI untreated groups compared with the 30 or 60-day multiple injuries + simvastatin treated group (p < 0.001). Endothelial denudation and intima widening were observed in the untreated injured groups, whereas in the 60 day multiple injuries group + simvastatin, a regression of histopathological lesions was observed. CONCLUSIONS: The decrease of the inflammatory component that would accompany early atherogenesis processes and the regression of the histopathological lesions after treatment could be attributed to the decreased plasmatic fibrinogen.

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LDL-C goal attainment with the addition of ezetimibe to ongoing simvastatin treatment in coronary heart disease patients with hypercholesterolemia.

Allen C.

Saint-Luc Hospital-Catholic University of Louvain, Brussels, Belgium. brohet card.ucl.ac.be

OBJECTIVE: To evaluate the addition of ezetimibe or placebo to on-going simvastatin treatment on attaining the LDL-C treatment target of </= 2.60 mmol/L (100 mg/dL) in coronary heart disease (CHD) patients with hypercholesterolemia. METHODS: Patients with documented CHD were recruited if they were on a stable dose of simvastatin 10 mg or 20 mg for at least 6 weeks, had LDL-C > 2.60 mmol/L and </= 4.20 mmol/L (> 100 mg/dL and </= 160 mg/dL), triglycerides </= 4.00 mmol/L (355 mg/dL) and hepatic transaminases and creatine kinase </= 50% above the upper limit of normal. After a 4-week placebo and diet run-in period, eligible patients were randomized to a double-blind, placebo-controlled comparative study with ezetimibe 10mg co-administered with on-going simvastatin 10mg or 20 mg (n = 208) versus placebo to match ezetimibe co-administered with simvastatin 10mg or 20mg for 6 weeks (n = 210). RESULTS: When ezetimibe was added to on-going simvastatin therapy, a significantly greater percentage of patients attained the LDL-C target of </= 2.60 mmol/L after 6 weeks of treatment compared to placebo added to on-going simvastatin (80.4% vs. 17.4%, respectively;p </= 0.001). When co-administered with on-going simvastatin therapy, mean percentage reduction in LDL-C from baseline was significantly larger in the ezetimibe group compared to placebo (27.1% vs. 4.1%, respectively; p </= 0.001). The co-administration of ezetimibe or placebo to on-going simvastatin treatment was generally well tolerated. CONCLUSIONS: Ezetimibe co-administered with on-going simvastatin 10 mg or 20 mg treatment enabled more CHD patients with hypercholesterolemia to attain the LDL-C treatment target of </= 2.60 mmol/L.

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HMG-CoA reductase inhibitors inhibit endothelial exocytosis and decrease myocardial infarct size.

Lowenstein CJ.

Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.

Three-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors protect the vasculature from inflammation and atherosclerosis by cholesterol dependent and cholesterol independent mechanisms. We hypothesized that HMG-CoA reductase inhibitors decrease exocytosis of Weibel-Palade bodies, endothelial cell granules whose contents promote thrombosis and vascular inflammation. We pretreated human aortic endothelial cells with simvastatin for 24 hours, then stimulated the cells with thrombin, and measured the amount of vWF released into the media. We then measured the effect of simvastatin on myocardial infarction in mice. Simvastatin decreased thrombin-stimulated Weibel-Palade body exocytosis by 89%. Simvastatin inhibited exocytosis in part by increasing synthesis of nitric oxide (NO), which S-nitrosylated N-ethylmaleimide sensitive factor (NSF), a critical regulator of exocytosis. Simvastatin treatment attenuated myocardial infarct size by 58% in wild-type but not eNOS knockout mice. Furthermore, simvastatin decreased endothelial exocytosis and neutrophil infiltration into ischemic-reperfused myocardium, which was mediated in part by P-selectin contained in Weibel-Palade bodies. However, simvastatin did not affect exocytosis and inflammation in myocardial infarcts of eNOS knockout mice. Inhibition of endothelial exocytosis is a novel mechanism by which HMG-CoA reductase inhibitors may reduce vascular inflammation, inhibit thrombosis, and protect the ischemic myocardium. These findings may explain part of the pleiotropic effects of statin therapy for patients with cardiovascular disease.

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Simvastatin effects in normo- and hypercholesterolaemic patients with peripheral arterial occlusive disease: a pilot study.

Korbut R.

Department of Pharmacology, Department of Clinical Pharmacology, Jagiellonian University School of Medicine, 31-531 Cracow, 16 Grzegorzecka, Poland.

Improvement of endothelial function caused by statin treatment is not related to lowering of the cholesterol levels but results primarily from statin pleiotropic effects. Accordingly, we designed a pilot study in 10 normocholesterolaemic and 10 hypercholesterolaemic patients with peripheral arterial occlusive disease to investigate potential biological effects of statins in relation to their effects on endothelial function. The patients were treated with simvastatin 40 mg/daily for 3 months. Simvastatin led to significant reduction in total cholesterol and trigliceride levels in normocholesterolaemic and hypercholesterolaemic patients. Elongation of pain-free and total walking distance was observed in both groups studied. Inconsiderable changes in rest ankle brachial index were seen. Flow-mediated dilation increased in normocholesterolaemic group by 153% and in the hypercholesterolaemic group by 180% after 3 months of treatment. Euglobulin clot lysis time was shortened significantly in both groups each time after drug intake. Platelet aggregates ratio was increased in normocholesterolaemic patients by 8.9% and in hypercholesterolaemic patients by 17.6% each time after intake and remained significantly increased during the observation after 1 and 3 months. Simvastatin inhibited platelet aggregation induced by collagen and ADP in both study groups 3 hr after intake, but the platelets of hypercholesterolaemic patients were less sensitive to these aggregatory agents after 3 months of treatment. Simvastatin therapy caused clinical improvement in normocholesterolaemic and hypercholesterolaemic patients with peripheral occlusive disease. It is suggested that this effect is due to the restoration of endothelial function.

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