Personalized absolute benefit of statin treatment for primary or secondary prevention of vascular disease in individual elderly patients

Objective: To estimate the absolute treatment effect of statin therapy on major adverse cardiovascular events (MACE; myocardial infarction, stroke and vascular death) for the individual patient aged C70 years. Methods: Prediction models for MACE were derived in patients aged C70 years with (n = 2550) and without (n = 3253) vascular disease from the ‘‘PROspective Study of Pravastatin in Elderly at Risk’’ (PROSPER) trial and validated in the ‘‘Secondary Manifestations of ARTerial disease’’ (SMART) cohort study (n = 1442) and the ‘‘Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm’’ (ASCOT-LLA) trial (n = 1893), respectively, using competing risk analysis. Prespecified predictors were various clinical characteristics including statin treatment. Individual absolute risk reductions (ARRs) for MACE in 5 and 10 years were estimated by subtracting ontreatment from off-treatment risk. Results: Individual ARRs were higher in elderly patients with vascular disease [5-year ARRs: median 5.1 %, interquartile range (IQR) 4.0–6.2 %, 10-year ARRs: median 7.8 %, IQR 6.8–8.6 %] than in patients without vascular disease (5-year ARRs: median 1.7 %, IQR 1.3–2.1 %, 10-year ARRs: 2.9 %, IQR 2.3–3.6 %). Ninetyeight percent of patients with vascular disease had a 5-year ARR C2.0 %, compared to 31 % of patients without vascular disease. Conclusions: With a multivariable prediction model the absolute treatment effect of a statin on MACE for individual elderly patients with and without vascular disease can be quantified. Because of high ARRs, treating all patients is more beneficial than prediction-based treatment for secondary prevention of MACE. For primary prevention of MACE, the prediction model can be used to identify those patients who benefit meaningfully from statin therapy.

Primary proteolysis of caseins in cheddar cheese

Studies were undertaken to investigate proteolysis of the caseins during the initial stages of maturation of Cheddar cheese. Isolated caseins were hydrolyzed by enzymes thought to be of importance during cheese ripening and the resulting peptides isolated and identified. Large peptides were also isolated from Cheddar cheese and identified, thus enabling the extent to which casein degradation studies could be extrapolated to cheese to be established. The proteolytic specificity of chymosin on bovine αs1- and αs2-caseins and of plasmin on bovine αs1-casein were determined. The action of cathepsin D, the principal indigenous acid milk proteinase, on caseins was studied and its pH optimum and sensitivity to NaCI determined. The action of cathepsin D on αs1-, αs2-, β- and κ-caseins was compared with that of chymosin and was found to be generally similar for the hydrolysis of αs1- and κ-caseins but to differ for αs2-and β- caseins. β-Casein in solution was hydrolyzed by cell wall-associated proteinases from three strains of Lactococcus lactis; comparison of electrophoretograms of the hydrolyzates with those of Cheddar cheese indicated that no peptides produced by cell wall-associated proteinases were detectable in the cheeses. All the major peptides in the water-insoluble fraction of Cheddar cheese were isolated and identified. It was found that β-casein was degraded primarily by plasmin and αs1 -casein by chymosin. Initial chymosin and plasmin cleavage sites in αs1-, and β-casein, respectively, identified in these and other studies corresponded to the peptides isolated from cheese. The importance of non-starter lactic acid bacteria (NSLAB) to the maturation of Cheddar was studied in cheeses manufactured from raw, pasteurized or microfiltered milks. NSLAB were found to strongly influence the quality and patterns of proteolysis. Results presented in this thesis are consistent with the hypothesis that primary proteolysis in Cheddar is catalysed primarily by the action of chymosin and plasmin on intact αs1- and β-caseins, respectively. The resulting large peptides so produced are subsequently degraded by these enzymes and by proteinases and peptidases from the starter and NSLAB.

Prediction and prevention of venous thrombosis in pregnancy

Venous thromboembolism (VTE) remains the leading cause of maternal mortality. Reports identified further research is required in obese and women post caesarean section (CS). Risk factors for VTE during pregnancy are periodically absent indicating the need for a simple and effective screening tool for pregnancy. Perturbation of the uteroplacental haemostasis has been implicated in placenta mediated pregnancy complications. This thesis had 4 main aims: 1) To investigate anticoagulant effects following a fixed thromboprophylaxis dose in healthy women post elective CS. 2) To evaluate the calibrated automated thrombogram (CAT) assay as a potential predictive tool for thrombosis in pregnancy. 3) To compare the anticoagulant effects of fixed versus weight adjusted thromboprophylaxis dose in morbidly obese pregnant women. 4) To investigate the LMWH effects on human haemostatic gene and antigen expression in placentae and plasma from the uteroplacental , maternal and fetal circulation. Tissue factor pathway inhibitor (TFPI), thrombin antithrombin (TAT), CAT and anti-Xa levels were analysed. Real-time PCR and ELISA were used to quantify mRNA and protein expression of TFPI and TF in placental tissue. In women post CS, anti-Xa levels do not reflect the full anticoagulant effects of LMWH. LMWH thromboprophylaxis in this healthy cohort of patients appears to have a sustained effect in reducing excess thrombin production post elective CS. The results of this study suggest that predicting VTE in pregnant women using CAT assay is not possible at present time. The prothrombotic state in pregnant morbidly obese women was substantially attenuated by weight adjusted but not at fixed LMWH doses. LMWH may be effective in reducing in- vivo thrombin production in the uteroplacental circulation of thrombophilic women. All these results collectively suggest that at appropriate dosage, LMWH is effective in attenuating excess thrombin generation, in low risk pregnant women post caesarean section or moderate to high risk pregnant women who are morbidly obese or tested positive for thrombophilia. The results of the studies provided data to inform evidence-based practice to improve the outcome for pregnant women at risk of thrombosis.