Coronary Heart Disease: CT Scans May Reduce Tests, Procedures and Radiation Exposure

Pamela S. Douglas, M.D. Duke University School of Medicine Duke University Medical Center Durham, NC Interview with:
Pamela S. Douglas, M.D.
Duke University School of Medicine
Duke University Medical Center
Durham, NC 27715

Medical Research: What is the background for this study?

Dr. Douglas: The primary objective of the PROMISE study was to compare the health outcomes of people who went to the doctor with new symptoms such as shortness of breath and/or chest pain that were suggestive of coronary artery disease and that required additional evaluation. This was an important investigation because no large research trial has ever been conducted to help guide the care of such patients. Instead, the selection of tests for such patients—which constitutes at least 4 million patients in the United States each year—has been largely left up to physician and patient preference rather than proven results.

Medical Research: What are the main findings?

Dr. Douglas: 10,003 patients from 193 different medical facilities across the US and Canada agreed to be part of the PROMISE study and  were randomized to a functional stress test or an anatomic test Using CT angiography.  The study found that the clinical outcomes of participants with suspected coronary artery disease were excellent overall, and were similar in terms of death and major cardiac conditions regardless of whether patients had a functional stress test or a computed tomographic scan. However, the CT scan may be better at ruling out the need for subsequent tests and procedures in patients who are free of heart disease, and involved a lower radiation exposure relative to a stress nuclear study. We also found, in a separately reported study, that the costs of the two diagnostic strategies were similar.

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Non-Obstructive Coronary Artery Disease Still Confers Heart Attack Risk

Thomas M. Maddox MD MSc Cardiology, VA Eastern Colorado Health Care System Associate Director, VA CART Interview with:
Thomas M. Maddox MD MSc
Cardiology, VA Eastern Colorado Health Care System
Associate Director, VA CART Program
Associate Professor, Department of Medicine
University of Colorado School of Medicine

Medical Research: What is the background for this study? What are the main findings?

Dr. Maddox: Nonobstructive coronary artery disease (CAD) is atherosclerotic plaque that would not be expected to obstruct blood flow or result in anginal symptoms (such as chest pain). Although such lesions are relatively common, occurring in 10 percent to 25 percent of patients undergoing coronary angiography, their presence has been characterized as “insignificant” or “no significant CAD” in the medical literature.  However, this perception of nonobstructive coronary artery disease may be incorrect, because prior studies have noted that the majority of plaque ruptures and resultant myocardial infarctions (MIs; heart attacks) arise from nonobstructive plaques. Despite the prevalence of nonobstructive CAD identified by coronary angiography, little is known about its risk of adverse outcomes, according to background information in the article.

During the study period, 37,674 patients underwent elective coronary angiography for indications related to CAD; of those, 22.3 percent had nonobstructive CAD and 55.4 percent had obstructive CAD.  Within 1 year, 845 patients died and 385 were rehospitalized for myocardial infarction. The researchers found that the 1-year myocardial infarction risk progressively increased by the extent of coronary artery disease, rather than abruptly increasing between nonobstructive and obstructive CAD.  Patients with nonobstructive CAD had an associated risk of MI that was 2-to 4.5-fold greater than among those with no apparent coronary artery disease. Similar observations were seen with 1-year mortality and the combined outcome of 1-year myocardial infarction and death. Continue reading

Anxiety Disorders Common in Patients With Coronary Heart Disease Interview with:
Phil Tully PhD
Early Career Research Fellow, Discipline of Medicine
University of Adelaide Australia and
Abteilung für Rehabilitationspsychologie und Psychotherapie
Institut für Psychologie, Universität Freiburg Freiburg Germany

Medical Research: What are the main findings of the study?

Response: The systematic review indicated that anxiety disorders ascertained by clinical interview are highly prevalent in patients with verified coronary heart disease. Also, approximately 50% of anxiety disorders were comorbid with depression. There was however some uncertainty in prevalence estimates with high level heterogeneity observed between studies. It was also evident that studies measuring generalized anxiety disorder in outpatient samples reported an increased prognostic risk for major adverse cardiac events in the longer term, when adjusted for confounding factors, however there was limited data. There were no randomized controlled trials targeting anxiety disorders in this population.
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Foods With Polyunsaturated Fat May Decrease Risk of Coronary Heart Disease

Jyrki Virtanen, PhD Adjunct Professor of Nutritional Epidemiology University of Eastern Finland Kuopio, FinlandFor
Jyrki Virtanen, PhD
Adjunct Professor of Nutritional Epidemiology
University of Eastern Finland
Kuopio, Finland

Medical Research: What are the main findings of the study?

Dr. Virtanen: The main finding was that saturated fat intake was not an independent risk factor for Coronary Heart Disease even in a population with relatively high average saturated fat intake, like in this population with middle-aged and older men from Eastern Finland. In other words, intake of carbohydrates in place of saturated fat was not associated with lower risk, not even when the quality of carbohydrates was taken into account. Only when polyunsaturated fat replaced saturated fat in the diet, was the risk of Coronary Heart Disease, especially Coronary Heart Disease mortality, lower. In fact, also replacing trans fat or carbohydrates with polyunsaturated fat was associated with lower risk. The associations were similar with both n-6 and n-3 polyunsaturated fatty acids.

Trans fat intake was not associated with the Coronary Heart Disease risk, but that is most likely explained by the low intake of trans fat in Finland already in mid-1980s.

We also investigated the associations of the fatty acid intake with carotid artery atherosclerosis, and the results were generally similar to the findings with incident Coronary Heart Disease events.

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Military Combat Increases Risk of Subsequent Coronary Heart Disease

Dr. Nancy Crum-Cianflone Deployment Health Research Department, Naval Health Research Center San Diego, Interview with:
Dr. Nancy Crum-Cianflone MD
Deployment Health Research Department, Naval Health Research Center, San Diego, CA What are the main findings of the study?

Dr. Nancy Crum-Cianflone: There have been several studies examining the health outcomes of service members who recently deployed to the conflicts in Iraq and Afghanistan.  However, none of these studies to date had examined the potential role of military deployment experiences and PTSD on coronary heart disease (CHD) among young US service members.  We believed that this would be an important study to undertake since these data would not only be useful to the US military, but may also have implications regarding job-related stressors on the health of young adults in the general population.

After studying over 60,000 current and former US military personnel, we found that those who deployed and experienced combat were at a 60%-90% increased risk of subsequently developing CHD.  This finding was noted when we examined both self-reported CHD and medical record validated coronary heart disease.  These data suggest that experiences of intense stress may increase the risk for coronary heart disease over a relatively short period among young, previously healthy adults.

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Coronary Heart Disease : What Correlates with Repeat Lipid Testing? Interview with Salim S. Virani, MD, PhD

Health Policy and Quality Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center of Excellence, and Section of Health Services Research, Department of Medicine, Baylor College of Medicine,
Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, and Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas What are the main findings of the study?

Dr. Virani: The main findings of the study are that despite having cholesterol levels at goal (LDL cholesterol <100 mg/dL), about one-third of patients (9200 out of 27947) with coronary heart disease had repeat cholesterol testing in 11 months from their last lipid panel. As expected, no intervention was performed as a response to these lipid panels. Collectively, 12686 additional lipid panels were performed in these patients.  Among 13,114 patients who met the optional treatment target of LDL-C<70 mg/dL, repeat lipid testing was performed in 8,177 (62.3% of those with LDL-C<70) during 11 months of follow-up.

Patients with a history of diabetes mellitus (odds ratio [OR], 1.16; 95% CI, 1.10-1.22), a history of hypertension (OR, 1.21; 95%CI, 1.13-1.30), higher illness burden (OR, 1.39; 95%CI, 1.23-1.57), and more frequent primary care visits (OR, 1.32; 95%CI, 1.25-1.39) were more likely to undergo repeat testing, whereas patients receiving care at a teaching facility (OR, 0.74; 95%CI, 0.69-0.80) or from a physician provider (OR, 0.93; 95%CI, 0.88-0.98) and those with a medication possession ratio of 0.8 or higher (OR, 0.75; 95%CI, 0.71-0.80) were less likely to undergo repeat testing.
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