A synthetic form of the protein apoaequorin is the active ingredient in the over-the-counter dietary supplement Prevagen (Quincy Bioscience), which is heavily marketed to improve memory.

The centuries-old anti-inflammatory drug colchicine (Colcrys, and others) is FDA-approved for prophylaxis and treatment of gout flares and for treatment of familial Mediterranean fever. It is also used off-label to treat pericarditis, and in recent years has been investigated for reduction of cardiovascular risk in patients with coronary artery disease (CAD).

The FDA has approved a new 2.5-mg formulation of the direct factor Xa inhibitor rivaroxaban (Xarelto – Janssen) for use in combination with low-dose aspirin to reduce the risk of major cardiovascular events in patients with chronic coronary artery disease (CAD) or peripheral artery disease (PAD). Rivaroxaban is the first direct oral anticoagulant to be approved for this indication. It was approved earlier for prevention and treatment of deep vein thrombosis (DVT) or pulmonary embolism (PE) and for prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation.

The FDA has warned that use of the macrolide antibiotic clarithromycin (Biaxin, and generics) may increase the risk of cardiovascular morbidity and mortality in patients with heart disease.

A recent article in Circulation reported that acetaminophen (Tylenol, and others; paracetamol outside the US) increased blood pressure in patients with coronary artery disease. This conclusion was based on a randomized, placebo-controlled crossover trial in 33 patients; acetaminophen 1 g three times daily for 2 weeks was associated with statistically significant increases in blood pressure of 2.9 mmHg systolic and 2.2 mmHg diastolic.1

NSAIDs can increase blood pressure; the mechanism is thought to be inhibition of cyclooxygenase leading to decreased renal prostaglandin activity. Acetaminophen also inhibits cyclooxygenase (primarily COX-2) and decreases prostaglandin activity.2

The small increases in blood pressure reported with acetaminophen would probably be inconsequential in low-risk patients, but might be a concern for those with cardiovascular disease. Like most drugs, acetaminophen should be used in the lowest effective doses for the shortest possible time. Mild to moderate pain due to osteoarthritis or headache generally responds to a dose of 650 mg.3

1. I Sudano et al. Acetaminophen increases blood pressure in patients with coronary artery disease. Circulation 2010; 122:1789.

2. B Hinz et al. Acetaminophen (paracetamol) is a selective cyclooxygenase-2 inhibitor in man. FASEB J 2008; 22:383.

3. Drugs for pain. Treat Guidel Med Lett 2010; 8:25.

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Modestly elevated C-reactive protein (CRP) concentrations have been associated with an increased risk of coronary heart disease. The recently published and heavily publicized results of the JUPITER trial will lead many patients to ask health care professionals whether they should have a CRP test to see if they should be taking a statin.

When the use of aspirin for primary prevention of cardiovascular diseases was last reviewed in The Medical Letter, only one placebo-controlled prospective trial was available: the (male) Physicians' Health Study. Last year, a second large, randomized, placebo-controlled study was reported as part of the Women's Health Study. Recently a sex-specific meta-analysis of 6 trials, including these two, was published.

Lipoprotein associated phospholipase A₂ (Lp-PLA₂), an enzyme involved in the repair of oxidative damage to lipoproteins, causes release of inflammatory mediators associated with atherosclerosis. A new assay, PLAC (diaDexus, Inc.), is now available to measure Lp-PLA₂ levels. C-reactive protein (CRP), another inflammatory mediator, appears to be a biomarker for coronary disease (MH Shishehbor et al, Cleve Clin J Med 2003; 70:634). The role of Lp-PLA₂ testing in determining cardiovascular risk is less clear.

Most angioplasty procedures for coronary artery disease now include placement of stents, which have improved both short- and long-term success rates. The main limitation is restenosis, which occurs in about 25% of patients. Drug-eluting stents intended to reduce the incidence of restenosis have been approved for use in Europe, but not yet in the US.

New recommendations for drug treatment of hypercholesterolemia, if widely followed, will lead to a marked increase in the number of people taking lipid-regulating drugs.

Myocardial images produced by injections of radioactive thallium chloride (201Tl), usually during exercise, have been used for many years for diagnosis of coronary artery disease (Medical Letter, 21:49, 1979). Recently, some new techniques and radiopharmaceuticals have become available for myocardial imaging.

Percutaneous transluminal coronary angioplasty (PTCA), in which a balloon catheter distends the vessel at the site of obstruction (Medical Letter, 25:97, 1983), is now an established therapeutic option for treatment of patients with coronary artery disease, especially those with single-vessel disease. Major problems related to PTCA include acute occlusion during the procedure (usually caused by dissection), restenosis at the site of angioplasty, and inability to treat complete occlusions and long or ostial lesions. Some cardiologists have tried using lasers during PTCA to deal with these problems.