The Journal of the Association of Physicians of India最新文献

Background: Osteoporosis, a common bone disease among postmenopausal women, where bone is weak by diminished bone mineral density (BMD), increasing the fracture risk. Our body's natural rhythm, called the "circadian rhythm," which is controlled by the brain and body, helps in bone formation and also in breakdown, disruption of this rhythm may affect bone health. This study explores how problems with circadian rhythm might be linked with osteoporosis in postmenopausal women.

Objective: To assess the prevalence of osteoporosis among postmenopausal women and to see if it is related to changes in their body's daily sleep-wake cycle, "circadian rhythm," using a composite morningness-eveningness questionnaire (CMEQ) that groups people as morning, evening, or in between types.

Materials and methods: This cross-sectional observational study was conducted at Swaroop Rani Hospital, Prayagraj, India, between March 2024 and March 2025. This study included 109 postmenopausal women after applying strict inclusion/exclusion criteria. Each woman underwent clinical evaluation, anthropometric measurements, and biochemical testing. BMD by dual-energy X-ray absorptiometry (DEXA) scan at the lumbar spine with right and left femoral necks. To understand their sleep-wake pattern, "circadian rhythm" participants filled out a special questionnaire called the CMEQ, which groups them as morning, evening, or in between types. Data was analyzed using computer software (SPSS v25.0) to find patterns and differences.

Results: The prevalence of osteoporosis was 32.1% (35 among 109 women). Osteoporotic women had significantly lower weight (58.1 ± 11.63 vs 64.3 ± 13.65 kg; p = 0.023) and height (149.1 ± 7.12 cm vs 153.0 ± 7.08 cm; p = 0.008) compared to nonosteoporotic participants. Body mass index (BMI) was lower in the osteoporotic group (26.3 vs 28.1), though not statistically significant (p = 0.093). The mean composite M-E score did not have a significant value between osteoporotic and nonosteoporotic groups (44.8 ± 3.55 vs 44.6 ± 4.23; p = 0.852), indicating no significant association between circadian rhythm and osteoporosis.

Conclusion: About one-third of postmenopausal women in the study had osteoporosis. Although anthropometric differences were significant, no statistical significance was found between circadian rhythm and BMD. The findings suggest that circadian rhythm may affect bone health, but the questionnaires CMEQ used in this study may not be the best way to measure it. Future studies should use more accurate measures of taste, such as circadian hormone levels, and follow people over time to better understand this relationship.

Background: Indirect estimation of low-density lipoprotein cholesterol (LDL-C) is a common clinical practice. The Friedewald equation is used most often but has inherent limitations. Clinical implications of such a practice have not been well defined, especially in the current era of targeting low (<50-70 mg/dL) or ultralow (<30-40 mg/dL) LDL-C levels.

Methods: Overall, 3,028 consecutive subjects with coronary artery disease (CAD) undergoing coronary revascularization were included. Four methods of LDL-C estimation were compared: direct estimation, the Friedewald, Martin, and Sampson equations.

Results: The mean age of the subjects was 61.3 ± 10.2 years, and 2,525 (83.4%) were men. Mean direct LDL-C was 78.9 ± 32.9 mg/dL. Compared with the direct estimation, all three indirect methods significantly underestimated LDL-C, but the Martin equation had the least bias (mean differences of -10.5 ± 9.7 mg/dL, -5.2 ± 7.6 mg/dL, and -7.2 ± 8.3 mg/dL with the Friedewald, Martin, and Sampson equations, respectively; p-values <0.001 for all the comparisons). Among patients with LDL-C >70 mg/dL and >50 mg/dL, the Friedewald equation erroneously classified 24.6% and 19.9%, respectively, as having LDL-C below these thresholds. This error increased with increasing triglyceride levels. The Martin equation was the most accurate, whereas the Sampson equation had intermediate accuracy.

Conclusion: Our study shows that the Friedewald equation underestimates LDL-C and can potentially result in significant undertreatment in patients with CAD in whom aggressive LDL-C lowering is crucial. Direct estimation is the preferred method, but the Martin equation could be a reasonable alternative if the direct estimation is not feasible due to logistical constraints.

Guidelines recommend that the foundation four guideline-directed medical therapy (GDMT), which includes mineralocorticoid receptor antagonists (MRAs), should be initiated early in the treatment paradigm of heart failure due to mortality benefits and reduction in hospitalization for heart failure. However, the practical implementation of these guidelines in the real-world clinical scenario is lacking. Delay in initiating MRA is common, and patients often do not receive the optimum dose of MRA. The clinical considerations and guideline recommendations for early initiation and optimum dosing of MRA in HF can form the scientific basis for improving the correct usage of MRA in HF in real-world settings.

Despite strong class I, level A recommendations from major clinical guidelines, the early initiation and optimization of mineralocorticoid receptor antagonists (MRAs) in heart failure (HF) with reduced ejection fraction (HFrEF) remain suboptimal. MRAs, including spironolactone and eplerenone, provide significant morbidity and mortality benefits, particularly when introduced early in high-risk scenarios such as acute myocardial infarction (AMI) and acute decompensated heart failure (ADHF). Evidence from landmark trials and real-world registries underscores that early MRA therapy reduces cardiovascular events, prevents adverse ventricular remodeling, and lowers sudden cardiac death risk. Delaying or omitting MRAs, even by a few weeks, is associated with increased mortality, recurrent hospitalizations, and irreversible cardiac damage. Clinical evidence demonstrated that early aldosterone blockade exerts rapid and sustained benefits, often within days of initiation. Early initiation and aggressive optimization of MRAs must be prioritized in HFrEF management to fully realize their life-saving potential.

Mineralocorticoid receptor antagonists (MRAs) have significantly evolved since the introduction of the first steroidal MRA, spironolactone, in the 1950s. Initially discovered for treating hypertension and heart failure (HF), the clinical applications of MRAs have been expanded to chronic kidney disease (CKD) and diabetic nephropathy. Steroidal MRAs, such as spironolactone and eplerenone, effectively suppress mineralocorticoid receptor activation but are associated with side effects like hyperkalemia and endocrine abnormalities. Current research aims to optimize MRAs further for broader therapeutic applications, including nondiabetic kidney and cardiovascular diseases, and to improve safety profiles. In this review, we reflect on the historical development, classification, evolution, major clinical trials, and future prospects of MRAs.

Among the established mineralocorticoid receptor antagonists (MRAs), spironolactone and eplerenone have demonstrated significant clinical utility in managing conditions such as chronic heart failure, resistant hypertension, and hyperaldosteronism. Spironolactone, the first steroidal MRA, is known for its broad receptor affinity, contributing to both therapeutic benefits and endocrine-related side effects. Eplerenone, a more selective agent, offers improved tolerability with reduced hormonal adverse effects. This review explores the pharmacokinetic and pharmacodynamic profiles of these agents, highlighting their mechanisms of action, receptor-binding characteristics, and clinical implications. The safety considerations associated with long-term use, particularly hyperkalemia and renal function impairment, are also discussed to provide a comprehensive understanding of their therapeutic roles.