MedicalResearch.com Interview with:
Dr. Sumeet Chugh MDPauline and Harold Price Professor of Cardiac Electrophysiology
Associate director of the Cedars-Sinai Heart InstituteMedical Research: What is the background for this study? What are the main findings?
Response: Research studies performed in the past 2 decades suggest that there is a higher burden of sudden cardiac arrest in black americans compared to whites. However there are no studies that explore the reasons for this phenomenon. Our study confirmed that these observations hold true in the current era. There are two additional novel findings. Firstly, we uncovered the disturbing fact that blacks are significantly younger than whites at the time of their cardiac arrest. The majority of blacks are under the age of 65 and the majority of whites were over 65. Furthermore, blacks who suffered sudden cardiac arrest were more likely to have diabetes, high blood pressure and chronic kidney disease. (more…)
MedicalResearch.com Interview with:
Dr. Jagat NarulaMD, PhD
Associate Dean For Global Affairs
Professor Medicine, Cardiology and Radiology
Mt. Sinai Hospital, NY
Medical Research: What is the background for this study? What are the main findings?
Dr. Narula: The cardiovascular diseases remain number one cause of mortality in men and women and in high as well as middle and low income countries. It is important that we identify those who are likely to die of preventable causes. Identification of the vulnerable plaques that are likely to result in acute events has been an interesting focus of investigators, and numerous intravascular imaging and noninvasive imaging strategies have been employed. CT angiography has offered fairly attractive accuracy. We were the first to establish the features of high-risk plaques (Motoyama, Narula JACC 2007) and their short-term prognostic implications (Motoyama, Narula JACC 2009). In this new paper in a large population we present intermediate- to long-term follow-up that critically analyzes the role of plaque characterization and puts it in perspective. Should we keep chasing plaques or should we treat the patient? Does the answer lie in high risk plaque busting or prevention be the mainstay?
From the previous studies from us and others we have known that computed tomography angiography (CTA)-based plaque characteristics identify high-risk plaque (HRP) that predict short-term risk of acute coronary syndrome (ACS). We in this study wanted to evaluate whether plaque characteristics by CTA would predict intermediate- to long-term likelihood of acute events. The presence of high-risk plaque characteristics were evaluated in more than 3000 patients undergoing CTA and plaque progression (PP) in additional 450 patients who had two CTA one year apart. We recorded fatal and nonfatal acute events and outcomes during follow-up: mean about 4 years and maximum up to 10 years. Acute Coronary Syndrome occurred in about 40 of ~300 (16%) with high risk plaque and 40 (less than 1.5%) of the remaining patients with non high risk plaques. In patients with serial CTA, plaque progression also was an independent predictor of ACS, with HRP (27%) and without HRP (10%) compared with patients without plaque progression (0.3%).
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MedicalResearch.com Interview with:
Carolina Malta Hansen, M.D
Duke Clinical Research Institute
Medical Research: What is the background for this study? What are the main findings?Dr. Hansen: Approximately 300,000 persons in the United States suffer an out-of-hospital cardiac arrest every year and under 10% survive. Cardiopulmonary resuscitation (CPR) and defibrillation within the first few minutes of cardiac arrest can increase the chance of survival from under 10% to over 50%. In 2010, the HeartRescue program in North Carolina initiated statewide multifaceted interventions to improve care and outcomes for cardiac arrest patients in North Carolina. The project included public training programs in defibrillators and compression-only CPR at schools, hospitals and major events such as the N.C. State Fair, plus additional instruction for EMS and other emergency workers on optimal care for patients in cardiac arrest.
We found that following these four years of initiatives to improve care and outcomes for cardiac arrest patients, the proportion of patients who received bystander CPR and first responder defibrillation increased by more than 25% to approximately 50%, the combination of bystander CPR and first responder defibrillation increased from 14% to 23%. Survival with favorable neurologic outcome increased from 7% to 10% and this increase was only observed among patients who received bystander CPR. Finally, we found that compared to patients who received CPR and defibrillation by emergency medical services (EMS), patients who received bystander and/or first responder CPR, defibrillation, or both, were more likely to survive. The combination of bystander CPR and bystander defibrillation was associated with the best survival rates but remained low during the study period with no increase over time.
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MedicalResearch.com Interview with:
Dr Scot GargFRCP PhD (Hons) FESC
Cardiology Department, Royal Blackburn Hospital
United Kingdom
Medical Research: What is the background for this study?
Dr. Garg: In contrast to other countries, in particular the United States, the UK has seen a vast expansion in the number of PCI centres operating without on-site surgical support. Part of the reason for this is that outcome data from these centres are from modest populations at short-term follow-up; consequently the ACC/AHA have failed to give delivery of PCI in centres without surgical back-up a strong endorsement. The study was ultimately driven therefore to show whether any differences existed in mortality between patients having PCI in centres with- and without surgical support at long-term follow-up in large unselected population cohort.
Medical Research: What are the main findings?
Dr. Garg: The study included the largest population of patients treated in centres without off-site surgical support (n=119,036) and main findings were that following multi-variate adjustment there were no differences in mortality for patients treated at centres with- or without surgical support at 30-days, 1-year or 5-year follow-up irrespective of whether patients were treated for stable angina, NSTEMI or STEMI. Furthermore, similar results were seen in a sensitivity analysis of a propensity matched cohort of 74,001 patients. (more…)
MedicalResearch.com Interview with:
Christopher Labos MD CM, MSc FRCPC
Division of Epidemiology, Biostatistics and Occupational Health
McGill University
Montreal, Quebec
Canada
Medical Research: What is the background for this study? What are the main findings?
Response: There have been great advances in the field of genetics in recent years. Especially in cardiology, a number of genetic variants have been identified that are associated with cardiovascular disease. But it is not clear how useful these variants are in terms of predicting future evens in patients that have already suffered a myocardial infarction. What we found in our study is that a genetic risk score composed of the 30 most common genetic variants associated with cardiovascular diseases was not useful in predicting recurrent events in the first year after a patient suffered a myocardial infarction.
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MedicalResearch.com Interview with:
Venkatesh L. Murthy, MD, PhD, FACC, FASNC
University of Michigan
and Dr. Ravi Shah MD
Beth Israel Deaconess Medical Center
MedicalResearch: What is the background for this study? Response: Recent changes recommend statin therapy for cardiovascular risk reduction in an increasingly large number of Americans. Conversely, a number of studies have identified an increased risk of diabetes with statin treatment. Thus, there is increasing need for tools to target statin therapy to those with a favorable risk-benefit profile.
MedicalResearch: What are the main findings?Response: In our study, we analyzed data from 3,153 individuals from the Multi-Ethnic Study of Atherosclerosis who underwent CT scanning at baseline for assessment of calcium score. The CT scans were analyzed to assess liver attenuation as a measure of the amount of liver fat. We demonstrated that high liver fat doubled the risk of diabetes over a median of 9 years of follow-up. Importantly, statin therapy also doubled the risk of diabetes. The two together had an additive effect, even after adjusting for BMI, age, gender, family history of diabetes, waist circumference, lipids, hsCRP and exercise habits. As in prior studies, the risk of cardiovascular disease (CVD) events increased with increasing calcium score, as has previously been shown in MESA and in other studies.
We then divided the cohort into six groups based on calcium score (0, 1-100 and >100) and liver fat (low/high). Using published data from meta-analyses of statin trials, we computed the number needed to treat to prevent one hard CVD event for statin therapy. Using data from our study, we computed the number needed to harm to cause one additional case of diabetes from statin therapy. The numbers needed to treat with ranged from 29-40 for calcium score of >100 to 218-252 for calcium score of 0. Conversely, the numbers needed to harm were approximately 63-68 for those with low liver fat versus 22-24 for those with high liver fat. Thus the combination of calcium score and liver fat assessment, from a single standard calcium score scan, allows for physicians to provide better assessment of risk and benefit of statins in discussion with their patients. (more…)
Medical Research Interview with:
Prof. Johan Bosmans
Interventional cardiologist
University Hospital Antwerp, Wilrijkstraat 10, 2650,
Edegem, Belgium
MedicalResearch: What is the background for this study? What are the main findings?Prof. Bosmans : Transcatheter aortic valve replacement (TAVR) has become standard of care for patients who cannot undergo surgery. With this, it is important to ensure that the risks associated with TAVR be fully understood, and if possible prevented. Even at this stage of the adoption of TAVR, large trials continue to provide information to the clinician about how to select the right patients to ensure the best possible outcomes. The ADVANCE Study is a prospective, multicenter study that evaluated the use of TAVR in 1015 patients at 44 experienced TAVR centers, which was designed to reflect routine clinical practice.
We know that the risk of serious adverse events, such as stroke or transient ischemic attack (TIA), in post-TAVR patients can vary based on the timing before and after the procedure. A patient’s baseline demographics and medical history can affect their risk of procedure-related events as well as long-term outcomes. The manipulations required crossing the aortic valve and appropriately positioning any type of TAV has been thought to be related to procedural stroke events. Therefore, we performed a multivariable analysis looking for predictors of stroke – or stroke and TIA at 3 unique time periods (periprocedural, early and late) following TAVR.
The most striking result from our analyses was that we were not able to identify any predictors of periprocedural (either during the procedure or on the day after) stroke, illustrating this very multifactorial etiology. We were able to show that being female, experiencing acute kidney injury or a major vascular complication positively predicted stroke during the early (2-30 days post procedure) time period. When we combined the outcome of stroke or TIA, we found that a history of prior atrial fibrillation (AF) was also a predictor. The only late predictor (day 31-730 post-procedure) of stroke was a history of coronary artery bypass grafting, which could reflect the patients’ risk of vascular disease.
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MedicalResearch.com Interview with:
Dr. Ankur Pandya Ph.D.
Assistant Professor of Health Decision Science
Department of Health Policy and Management
Harvard T.H. Chan School of Public Health
Boston, MAMedical Research: What is the background for this study? What are the main findings?
Dr. Pandya: The American College of Cardiology and the American Heart Association (ACC-AHA) cholesterol treatment guidelines were controversial when first released in November 2013, with some concerns that healthy adults would be over-treated with statins.
We found that the current 10-year ASCVD risk threshold (≥7.5%) used in the ACC-AHA cholesterol treatment guidelines has an acceptable cost-effectiveness profile (incremental cost-effectiveness ratio of $37,000/QALY), but more lenient ASCVD thresholds would be optimal using cost-effectiveness thresholds of $100,000/QALY (≥4.0%) or $150,000/QALY (≥3.0%). (more…)
MedicalResearch.com Interview with:
Amelia Stanton, Graduate Student
Department of Psychology
The University of Texas at Austin
Austin, TX
Medical Research: What is the background for this study? What are the main findings?
Response: Heart rate variability (HRV) has emerged as a valuable non-invasive test to assess autonomic nervous system (ANS) activity. Several studies have linked low resting Heart rate variability to mental health conditions including depression, anxiety, and alcohol dependence, indicating these disorders may be related to an imbalance in autonomic activity. As Heart rate variability is an index of the balance of sympathetic nervous system (SNS) and parasympathetic nervous system activity (PNS), it has proven a useful tool for examining the relative role of SNS activity in female sexual arousal. Moderate SNS dominance (relative to PNS activity) has been shown to predict women’s genital arousal in the laboratory, while high levels of SNS activation have been shown to inhibit genital arousal. Based on this background evidence and on a growing clinical literature indicating that low HRV (generally indicative of high SNS) is associated with negative health outcomes, we predicted a positive linear relationship between Heart rate variability and sexual arousal function. That is, we predicted that women with autonomic balance indicating moderate or low resting SNS activity (relative to PNS activity) would be less likely than women with autonomic balance indicating high resting SNS to report clinically relevant sexual arousal dysfunction. We also predicted that this relationship would hold for overall sexual function.
To test this hypothesis, sexual arousal function, overall sexual function, and resting HRV were assessed in 72 women, aged 18-39. The main finding of the study is that women with below average Heart rate variability were significantly more likely to report sexual arousal dysfunction (p < .001) and overall sexual dysfunction (p < .001) than both women with average HRV and women with above average HRV. Based on these results, we concluded that low HRV may be a risk factor for female sexual arousal dysfunction and overall sexual dysfunction.
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MedicalResearch.com Interview with:
Dr Emanuele Di Angelantonio FESC FAHA
University Lecturer | University of Cambridge
Director | MPhil in Public Health, University of Cambridge
Deputy Director | NIHR Biomedical Research Unit in Donor Health and Genomics
Honorary Consultant | NHS Blood and Transplant
Department of Public Health and Primary Care
Strangeways Research Laboratory
Cambridge, UK
Medical Research: What is the background for this study? What are the main findings?
Response: Previous research as mainly focused on individual with one cardiometabolic condition alone and, despite it could be expected that having more than one condition poses a greater risk, this is the first study that is able to precisely quantify how much is worst. Furthermore, given that the conditions we study (diabetes, heart attack, and stroke) share several risk factors, it could be expected that the combination of these will not be multiplicative. We were somewhat surprised to find that participants who had 1 condition had about twice the rate of death; 2 conditions, about 4 times the rate of death; and all 3 conditions, about 8 times the rate of death. We estimated that at the age of 60 years, men with any two of the cardiometabolic conditions studied would on average have 12 years of reduced life expectancy, and men with all three conditions would have 14 years of reduced life expectancy. For women at the age of 60 years, the corresponding estimates were 13 years and 16 years. The figures were even more dramatic for patients at a younger age. At the age of 40 years, men with all three cardiometabolic conditions would on average have 23 years of reduced life expectancy; for women at the same age, the corresponding estimate was 20 years.
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MedicalResearch.com Interview with:
Mohamed Boutjdir, PhD, FAHA
Director of the Cardiovascular Research Program
VA New York Harbor Healthcare System
Professor, Depts of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center and
NYU School of Medicine, New York, NY
Medical Research: What is the background for this study? What are the main findings?
Dr. Boutjdir: Patients with autoimmune diseases including Sjogren’s syndrome, systemic lupus erythematosus and other connective tissue diseases who are seropositive for anti-SSA/Ro antibodies may present with corrected QTc prolongation on the surface ECG. This QTc prolongation can be arrhythmogenic and lead to Torsades de Pointes fatal arrhythmia.
In our study, we established for the first time an animal model for this autoimmune associated QTc prolongation that is reminiscent of the clinical long QT2 syndrome. We also demonstrated the functional and molecular mechanisms by which the presence of the anti-SSA/Ro antibodies causes QTc prolongation by a direct cross-reactivity and then block of the hERG channel (Human ether-a-go-go-related gene). This hERG channel is responsible for cardiac repolarization and its inhibition causes QTc prolongation. We were able to pinpoint to the target epitope at the extracellular pore forming loop between segment 5 and segment 6 of the hERG channel.
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MedicalResearch.com Interview with:
Liana C. Del Gobbo, PhD
Postdoctoral Research Fellow
Friedman School of Nutrition Science & Policy
Tufts University Boston MA
Medical Research: What is the background for this study? What are the main findings?
Dr. Del Gobbo: Heart failure most commonly develops in adults over 65 years old- the most rapidly growing portion of the US population. The condition greatly reduces the quality of life of older adults. Heart failure is the leading cause of hospitalizations in the US among those on Medicare, and is associated with large health care costs. Prevention is key for reducing the burden of this disease.
A detailed analysis of factors that might help prevent heart failure, such as a person's pattern of eating (as well as individual foods), in addition to other lifestyle factors (eg. smoking, physical activity, etc), had not been previously examined all together, in the same study.
To get a fuller picture of how to prevent this condition, this study examined the relative importance of dietary habits and other lifestyle factors for development of heart failure.
Our paper shows that older adults can cut their risk in half by adhering to a few healthy lifestyle factors, including moderate physical activity, modest alcohol consumption (eg. more than one drink/week, but not more than 1-2 drinks/day), not smoking, and maintaining a healthy weight.
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MedicalResearch.com Interview with:Jennifer A. Sumner, Ph.D.
Columbia University Mailman School of Public Health
New York, NY 10032
Medical Research: What is the background for this study? What are the main findings?
Dr. Sumner: Cardiovascular disease, which includes conditions like heart attack and stroke, is the leading cause of death worldwide. Stress has long been thought to increase risk of cardiovascular disease, and posttraumatic stress disorder (PTSD) is the quintessential stress-related mental disorder. Some individuals who are exposed to traumatic events, such as unwanted sexual contact, the sudden unexpected death of a loved one, and physical assault, develop PTSD, which is characterized by symptoms of re-experiencing the trauma (e.g., nightmares), avoidance of trauma reminders (e.g., avoiding thinking about the trauma), changes in how one thinks and feels (e.g., feeling emotionally numb), and increased physiological arousal and reactivity (e.g., being easily startled). PTSD is twice as common in women as in men; approximately 1 in 10 women will develop PTSD in their lifetime. Research has begun to suggest that rates of cardiovascular disease are higher in people with PTSD. However, almost all research has been done in men.
My colleagues and I wanted to see whether PTSD was associated with the development of cardiovascular disease in a large sample of women from the general public. We looked at associations between PTSD symptoms and new onsets of heart attack and stroke among nearly 50,000 women in the Nurses’ Health Study II over 20 years, beginning in 1989. Women with the highest number of PTSD symptoms (those reporting 4+ symptoms on a 7-item screening questionnaire) had 60% higher rates of developing cardiovascular disease (both heart attack and stroke) compared to women who were not exposed to traumatic events. Unhealthy behaviors, including lack of exercise and obesity, and medical risk factors, including hypertension and hormone replacement use, accounted for almost 50% of the association between elevated PTSD symptoms and cardiovascular disease. We also found that trauma exposure alone (reporting no PTSD symptoms on the screening questionnaire) was associated with elevated cardiovascular disease risk compared to no trauma exposure.
Our study is the first to look at trauma exposure and PTSD symptoms and new cases of cardiovascular disease in a general population sample of women. These results add to a growing body of evidence suggesting that trauma and PTSD have profound effects on physical health as well as mental health.
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MedicalResearch.com Interview with:
Jessica Parsh MD
Hitinder Gurm MBBS
Department of Internal Medicineb
University of Michigan Health System
Medical Research: What is the background for this study? What are the main findings?
Response: Chronic kidney disease (CKD) is associated with adverse events after percutaneous coronary interventions (PCI). Estimated glomerular filtration rate (eGFR) is used for CKD stage classification and there are several widely used eGFR equations, including the Cockcroft-Gault, CKD-EPI, and MDRD. Others have shown that the CKD-EPI equation is more accurate, more precise and less bias. The current Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommend the use of CKD-EPI. Even so, there remains wide variability among equation choice between different institutions as well as between different health care providers (physicians, pharmacists, etc). In addition, in a recent survey, up to 12% of providers were "unsure" of which equation they used. Furthermore, the FDA has no clear guidelines regarding equation selection for pharmacokinetic studies of novel medications and the equation used for development of a particular drug is not always clearly labeled on package inserts.
Using data from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium for almost 130,000 patients who underwent PCI, we investigated whether use of different eGFR equations would lead to discrepant eGFR output, how this would lead to CKD stage reclassification and whether CKD stage reclassification by a certain equation led to improved risk prognostication for adverse events. We also studied how calculation of eGFR by various equations would affect drug dosing recommendations for common renally-dosed antiplatelet and antithrombotic medications. We found that there was wide discrepancy among the eGFR output of the various equations and this led to significant CKD stage reclassification (with agreement on stage classification as low as 56% for CKD-EPI and Cockcroft-Gault). Further, our data from receiver operating characteristic analysis and net reclassification index analysis support CKD-EPI as superior for risk prognostication for renal adverse outcomes of acute kidney injury and new requirement for dialysis. In regards to drug dosing, agreement between all three equations on dosing adjustment was as low as 34% (bivalirudin with eGFR cutoff < 30 ml/min/1.732).
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MedicalResearch.com Interview with:
Sean D. Pokorney, MD, MBA
Division of Cardiology, Duke University Medical Center
Duke Clinical Research Institute, Durham, North Carolina
Medical Research: What is the background for this study?
Dr. Pokorney: About 350,000 people die of sudden cardiac death in the US each year. Patients who have weakened heart function, particularly those with heart muscle damage as a result of a heart attack, are more likely to experience sudden cardiac death. Defibrillators have been around since the 1980s, and have prolonged countless lives. A previous study showed that 87% of patients who had a cardiac arrest were eligible for an implantable-cardioverter defibrillator (ICD) beforehand but did not get an ICD implanted prior to their arrest. The timing of ICD implantation is critical, as studies have not found a benefit to ICD implantation early after myocardial infarction (MI). Guidelines recommend primary prevention ICD implantation in patients with an EF ≤ 35% despite being treated with optimal medical therapy for at least 40 days after an MI. Given the need to wait for at least 40 days after an MI, ICD consideration is susceptible to errors of omission during the transition of post-MI care between inpatient and outpatient care teams. Also, the benefit of ICDs remains controversial among older patients, as these patients were underrepresented in clinical trials.
Medical Research: What are the main findings?Dr. Pokorney: We looked at Medicare patients discharged from US hospitals after a heart attack between 2007 and 2010. We focused on those patients who had weak heart function, and this left us with a little over 10,300 patients from 441 hospitals for our study. This was an older patient population with a median age of 78 years. We looked to see how many of these patients got an ICD within the first year after MI, and how many patients survived to 2 years after their heart attack. Only 8% of patients received an ICD within 1 year of their heart attack. ICD implantation was associated with a third lower risk of death within 2 years after a heart attack, and this was consistent with the benefit that were seen in the randomized clinical trials. Importantly, 44% of the patients in our study were over 80 years old, and we found that the relationship between ICD use and mortality was the same for patients over and under age 80 years. Increased patient contact with the health care system through early cardiology follow-up or re-hospitalization for heart failure or MI was associated with higher likelihood of ICD implantation. Rates of ICD implantation remained around 1 in 10 patients within 1 year of MI even among patients with the largest heart attacks and the weakest hearts (lowest ejection fractions), who were least likely to have improvement in their heart function over time. Similarly, even after excluding patients at highest risk for non-arrhythmic death (prior cancer, prior stroke, and end stage renal disease), ICD implantation rates remained around 1 in 10 patients.
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MedicalResearch.com Interview with:
Prof. Wilhelm Krek
Institute of Molecular Health Sciences
Zürich, Switzerland
MedicalResearch: What is the background for this study? What are the main findings?
Prof. Krek: Fructose and glucose are major components of dietary sugars consumed in the western world. A current prevailing view holds that glucose is used directly by various tissues as an energy source while fructose is first and foremost metabolized to fat by the liver arguing that these dietary sugars are metabolized differently despite having identical caloric values. Accordingly, overconsumption of fructose causes fatty liver disease and through dissemination of fat to peripheral organs such that adipose tissue contributes to obesity.
The key enzyme in fructose metabolism is ketohexokinase (KHK). KHK-A and KHK-C are two isoforms of KHK that are produced through mutually exclusive alternative splicing of the KHK pre-mRNA. KHK-C displays a much higher affinity for fructose than KHK-A. Unlike other tissues that normally express KHK-A, the liver produces predominantly KHK-C providing a possible explanation of the above-noted pathologies upon overconsumption of fructose. Whether fructose metabolism is subject to signal-induced changes in alternative splicing of KHK isoform expression as a mechanism to mediate context-dependent changes in cell metabolism is not known. In this work, we identify the splicing factor SF3B1 as a key mediator of ketohexokinase alternative splicing and thus activator of fructose metabolism and further show that the SF3B1-KHK system is a direct target of regulation by hypoxia and promoter of heart disease. From the analysis of a series of genetic mouse models of pathologic cardiac hypertrophy and human samples of heart disease, we conclude that activation of the newly identified HIF1α-SF3B1-KHK-C axis and the ensuing promotion of fructose metabolism is essential for pathologic stress-induced anabolic growth and the development of heart disease.
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MedicalResearch.com Interview with:Jaana Halonen Ph.D
Finnish Institute of Occupational Health
Kuopio, FinlandMedicalResearch: What is the background for this study? What are the main findings?Dr. Halonen: Research on predictors of cardiovascular disease has increasingly focused on exposures to risk factors other than the conventional behavioral and biological ones, such as smoking, hypertension, dyslipidaemia, or diabetes. One of the potential predictors beyond the conventional risks is exposure to childhood psychosocial adversities. Previous studies have found that people who had experienced financial difficulties, serious conflicts and long-term disease in the family in childhood have a higher level of cardiovascular risk factors and increased cardiovascular morbidity in adulthood, but the underlying mechanisms linking childhood exposure to adult disease remain unclear. It is possible that childhood adversity sets an individual on a risk pathway leading to adverse future exposures. An important source of adversity experienced in adulthood is residence in a socioeconomically disadvantaged neighborhood. However, no previous study had examined the combined effect of childhood psychosocial adversity and adult neighborhood disadvantage on cardiovascular disease risk.
We found that exposure to childhood psychosocial adversity and adult neighborhood disadvantage in combination was associated with a doubling of the risk of incident cardiovascular disease in adulthood when compared to the absence of such exposures. This association was not explained by conventional cardiovascular risk factors. Neither childhood psychosocial adversity nor adult neighborhood disadvantage alone were significantly associated with incident CVD, although they were associated with CVD risk factors.
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MedicalResearch.com Interview with:
Professor Phyo Kyaw Myint MBBS MD FRCP(Edin) FRCP(Lond)
Clinical Chair in Medicine of Old Age
Epidemiology Group, Division of Applied Health Sciences
University of Aberdeen
Scotland
Medical Research: What is the background for this study? What are the main findings?
Response: The research was carried out by academics from the Universities of Aberdeen, Manchester, Cambridge and East Anglia, as well as the Lancashire Teaching Hospital, the Medical Research Council Epidemiology Unit, Cambridge and the Academic Medical Centre, Amsterdam. It has been published online in the journal Heart. The team base their findings on almost 21,000 adults taking part in the EPIC-Norfolk study, which is tracking the impact of diet on the long term health of 25,000 men and women in Norfolk, England, using food frequency and lifestyle questionnaires. The researchers also carried out a systematic review of the available international published evidence on the links between chocolate and cardiovascular disease, involving almost 158,000 people—including the EPIC study participants.
The EPIC-Norfolk participants (9214 men and 11 737 women) were monitored for an average of almost 12 years, during which time 3013 (14%) people experienced either an episode of fatal or non-fatal coronary heart disease or stroke. Around one in five (20%) participants said they did not eat any chocolate, but among the others, daily consumption averaged 7 g, with some eating up to 100 g.
Higher levels of consumption were associated with younger age and lower weight (BMI), waist: hip ratio, systolic blood pressure, inflammatory proteins, diabetes and more regular physical activity —all of which add up to a favourable cardiovascular disease risk profile. Eating more chocolate was also associated with higher energy intake and a diet containing more fat and carbs and less protein and alcohol.
The calculations showed that compared with those who ate no chocolate higher intake was linked to an 11% lower risk of cardiovascular disease and a 25% lower risk of associated death. It was also associated with a 9% lower risk of hospital admission or death as a result of coronary heart disease, after taking account of dietary factors. And among the 16,000 people whose inflammatory protein (CRP) level had been measured, those eating the most chocolate seemed to have an 18% lower risk than those who ate the least. The highest chocolate intake was similarly associated with a 23% lower risk of stroke, even after taking account of other potential risk factors.
Of nine relevant studies included in the systematic review, five studies each assessed coronary heart disease and stroke outcome, and they found a significantly lower risk of both conditions associated with regular chocolate consumption. And it was linked to a 25% lower risk of any episode of cardiovascular disease and a 45% lower risk of associated death.
The study concluded that cumulative evidence suggests higher chocolate intake is associated with a lower risk of future cardiovascular events.
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MedicalResearch.com Interview with:
Ms. Rikke Elmose Mols
Department of Cardiology, Lillebaelt Hospital-Vejle, Vejle, Denmark.
MedicalResearch.com: What is the background for this study? What are the main findings?Response: Current ESC guidelines for patients with chest pain and low to intermediate pre-test probability of coronary artery disease (CAD) recommend control and modification of risk factors. However, patients with an elevated cardiovascular risk profile are frequently inadequately motivated for lifestyle changes and medicine adherence from knowledge about risk factors and information about risk reduction alone. Coronary artery calcification (CAC) is a marker of coronary atherosclerosis. The degree of coronary artery calcification may be assessed by the Agatston score (AS) derived by non-enhanced cardiac computed tomography, whereas non-invasive CT imaging of the coronary arteries require contrast-enhancement (coronary computed tomography angiography [CTA]). The presence of CAC is associated with an elevated probability of obstructive coronary artery disease (CAD) and an unfavorable clinical outcome. In symptomatic patients, demonstration of non-obstructive CAD identified by coronary CTA is associated with risk modifying behavior and intensified prophylactic medical treatment in observational studies. Among asymptomatic individuals, those with the highest Agatston score levels seem to be motivated for the adoption of risk modifying behaviour and visualization of CAC may stimulate adherence to lipid-lowering therapy and aspirin and a healthier lifestyle. The aim of the present prospective, randomized controlled study was to test the effect of adding visualization of coronary artery calcification to the standard information about risk and lifestyle modification on cholesterol levels and other risk markers in patients with a new diagnosis of non-obstructive CAD.
Visualization of coronary artery calcification and brief recommendations about risk modification (ESC guidelines) after coronary CTA in symptomatic patients with hyperlipidemia and non-obstructive CAD may have a favorable influence on plasma total-cholesterol concentration, adherence to statin therapy and risk behavior. Further investigations are needed.
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MedicalResearch.com Interview with:
Louise Sun, MD SM FRCPC
Assistant Professor Department of Anesthesiology,
University of Ottawa Staff | Division of Cardiac Anesthesiology
University of Ottawa Heart Institute
Medical Research: What is the background for this study? What are the main findings?Dr. Sun: Preoperative testing provides important information for perioperative
planning and decision-making. However, given the rapid increase in health
care costs, there has been growing emphasis on the more rational use of
resources and thus the need to better understand the utilization patterns
of specific tests. Preoperative pulmonary function tests (PFTs) are
important in helping perioperative physicians identify patients at risk
for postoperative pulmonary complications, but few appropriate use
guidelines exist for this test. We conducted a population-based study
using linked administrative databases in Ontario, Canada to describe
temporal trends in preoperative pulmonary function tests
and assess whether the recent 2006 American College of Physicians (ACP) guidelines on risk assessment and prevention of postoperative pulmonary complications for non-cardiothoracic surgery influenced these trends.
We examined 511,625 individuals undergoing non-cardiothoracic surgery, amongst whom
3.6% underwent preoperative pulmonary function tests while 3.3% had non-operative PFTs.
Preoperative pulmonary function tests rates decreased over the study period and following the 2006 ACP guidelines while non-operative rates remained stable. By 2013,
preoperative pulmonary function tests were performed in fewer than 8% of Ontario patients with risk factors for pulmonary complications, while preoperative testing
rates among individuals without known respiratory disease had approached
rates seen in the non-operative setting. The decreasing preoperative pulmonary function tests rates contrast starkly against concurrent increases in rates of other
perioperative interventions such as preoperative anesthesia consultations
and stress testing.
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MedicalResearch.com Interview with:
Nicholas Tatonetti, PhD
Department of Biomedical Informatics
Department of Systems Biology, Department of Medicine
Columbia University
New York, NY
Medical Research: What is the background for this study? What are the main findings?
Dr. Tatonetti: For decades, researchers have studied the link between disease incidence and the seasons. We’ve known, for example, that those born when the dust mite population is highest (summer) will have an increased chance of developing asthma. Traditionally, diseases have been studied one at a time to identify these seasonal trends. Because of the rapid adoption of electronic health records, it is now possible to study thousands of diseases, simultaneously. That is what we did in this study. We evaluated over 1,600 diseases and discovered 55 that showed this seasonal trend. Many of these had been studied previously, but several are new discoveries — most prominently, we found that the lifetime risk of developing cardiovascular disease is highest for those born in the spring.
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MedicalResearch.com Interview with:
Jacob Hollenberg M.D., Ph.D.
Assistant Professor, Cardiologist
Head of Research, Centre for Resuscitation Science
Karolinska Institutet, Stockholm, Sweden
Editor’s note: Dr. Hollenberg and colleagues published two articles in the NEJM this week discussing CPR performed by bystanders in out-of-hospital cardiac arrests.MedicalResearch: What is the background for the first study?Dr. Hollenberg: There are 10,000 cases of cardiac arrest annually in Sweden. Cardiopulmonary Resuscitation (CPR) has been taught to almost a third of Sweden’s population of 9.7 million. In recent years the value of bystander CPR has been debated, largely due to a lack of a randomized trial demonstrating that bystander CPR is lifesaving.
In this study, which included all cases of emergency medical services (EMS) treated and bystander-witnessed out-of-hospital cardiac arrests recorded in the Swedish Cardiac Arrest Registry from January 1, 1990, through December 31, 2011, our primary aim was to assess whether CPR initiated before the arrival of EMS was associated with an increase in the 30-day survival rate.
MedicalResearch: What were the main findings?Dr. Hollenberg: Early CPR prior to arrival of an ambulance more than doubled the chance of survival. (30-day survival rate was 10.5% among patients who underwent CPR before EMS arrival, as compared with 4.0% among those who did not (P<0.001).)
This association held up in all subgroups regardless of sex, age, cause of cardiac arrest, place of arrest, EKG findings or time period (year analyzed).
MedicalResearch: How did the patients who survived cardiac arrest do from a disability standpoint?Dr. Hollenberg: We had cerebral performance scores from 474 patients who survived for 30 days after cardiac arrest. (higher scores indicate greater disability).
At the time of discharge from the hospital, 81% of these patients had a score of category of 1. Less than 2% had category scores of 4 or 5.
MedicalResearch: What should patients and providers take away from this report?Dr. Hollenberg:
For patients with an out-of-hospital cardiac arrest, CPR performed by bystanders before the arrival of emergency medical personnel, saves lives. This has been validated by both the size of this study and the consistency of the results over three decades.
CPR education needs to continue and to increase. In Sweden about one-third of the population has been taught CPR. Legislation has recently been passed that mandates CPR be taught to all teenagers in school which should allow an entire generation to become familiar with this lifesaving technique.
The willingness of the public to become involved also needs to increase. We need new ways of educating lay people to recognize cardiac arrest and to motivate them to perform it. The knowledge that bystander CPR saves lives may enhance that motivation.
MedicalResearch.com Interview with:
Prachi Bhatnagar, MPH, DPhil
Researcher University of Oxford
British Heart Foundation Centre on Population Approaches for Non-Communicable Disease Prevention
Nuffield Department of Population Health
Oxford
Medical Research: What is the background for this study? What are the main findings?
Response: We know that cardiovascular disease presents a large burden to the UK. We aimed to bring together all the main data on cardiovascular disease mortality, morbidity, treatment and economic costs. We found that there are regional inequalities in cardiovascular disease mortality and prevalence in the UK.
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MedicalResearch.com Interview with:
Mark L. Friedell, MD, FACS
Chairman Department of Surgery
University of Missouri Kansas City
School of Medicine
Kansas City, MO 64108
Medical Research: What is the background for this study? What are the main findings?
Response: The controversial practice of administering pre-surgery beta-blockers to patients having noncardiac surgery was associated with an increased risk of death in patients with no cardiac risk factors but it was beneficial for patients with three to four risk factors, according to a report published online by JAMA Surgery.
Pre-surgery β-blockade is a widely accepted practice in patients having cardiac surgery. But its use in patients at low risk of heart-related events having noncardiac surgery is controversial because of the increased risk of stroke and hypotension (low blood pressure).
Because of the persistent controversy, researcher Mark L. Friedell, M.D., of the University of Missouri-Kansas City School of Medicine, and coauthors analyzed data from the Veterans Health Administration to examine the effect of perioperative β-blockade on patients having noncardiac surgery by measuring 30-day surgical mortality.
The analysis included 326,489 patients: 314,114 (96.2 percent) had noncardiac surgery and 12,375 (3.8 percent) had cardiac surgery. Overall, 141,185 patients (43.2 percent) received a β-blocker. Of the patients having cardiac surgery, 8,571 (69.3 percent) received a β-blocker and 132,614 (42.2 percent) of the patients having noncardiac surgery got one.
The unadjusted 30-day mortality rates among patients having noncardiac surgery for those not receiving β-blockers were 0.5 percent for patients with no cardiac risk factors, 1.4 percent for patients with one to two risk factors and 6.7 percent for patients with three to four risk factors. For those patients having noncardiac surgery who did receive β-blockers, the unadjusted 30-day mortality rates for patients with no cardiac risk factors, one to two risk factors and three to four risk factors were 1 percent, 1.7 percent and 3.5 percent, respectively, according to the results.
The results suggest that among patients with no cardiac risk factors having noncardiac surgery, those patients receiving β-blockers were 1.2 times more likely to die than those not receiving β-blockers. The risk of death decreased for those patients with one to two risk factors but the reduction was not significant. However, for patients having noncardiac surgery with three to four cardiac risk factors, those receiving β-blockers were significantly less likely to die than those not receiving β-blockers, the authors found. The authors did not observe similar results in patients having cardiac surgery.
“β-blockade is beneficial perioperatively for patients with three to four cardiac risk factors undergoing NCS [noncardiac surgery] but not in patients with one to two cardiac risk factors. Most important, the use of β-blockers in patients with no cardiac risk factors appears to be associated with a higher risk of death, which has, to our knowledge, not been previously reported,” the study concludes.
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MedicalResearch.com Interview with:
Christopher X WongMBBS MSc PhD
Clinical Research Fellow | Clinical Trial Service Unit, Oxford
Clinical Senior Lecturer | Centre for Heart Rhythm Disorders, Adelaide
Clinical Trial Service Unit, University of Oxford
Roosevelt Drive, Oxford
Medical Research: What is the background for this study? What are the main findings?Dr. Wong: Atrial fibrillation is an increasingly common heart rhythm disorder. This study demonstrates that even small increments in obesity are associated with a significantly increased risk of atrial fibrillation. Our data suggest that for every 1 unit reduction in body mass index there may be a 3-5% reduction in atrial fibrillation; for every 5 unit reduction, there may be 10-29% reductions. It should also be noted that this is likely to be a significant underestimate of the effect of weight reduction on atrial fibrillation rates as weight control has favourable effects on other risk factors for atrial fibrillation, such as hypertension and diabetes. Given the more than 45 million people with atrial fibrillation worldwide, even small but widespread reductions in obesity would thus help contain this ‘epidemic’ of atrial fibrillation.
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MedicalResearch.com Interview with:
Dr. Renjie Chen PhD and Dr. Haidong Kan, PhDSchool of Public Health, Key Lab of Public Health Safety of the Ministry of Education, Fudan University, Shanghai, ChinaMedicalResearch: What is the background for this study? What are the main findings?
Response: Although several previous studies in developed countries with cleaner air have reported health benefits due to air filtration, no such interventional studies were conducted in a developing country with much severer air pollution problems. Our main findings suggested that even a short-term intervention (2 days) could significantly reduce indoor air pollution and improve cardiopulmonary health among healthy young adults. (more…)
MedicalResearch.com Interview with:
Alexandra Gonçalves, MD, PhD
Postdoctoral Research Fellow
Cardiovascular Department
Brigham and Women's Hospital
Boston, MA 02115
MedicalResearch.com: What is the background for this study?Dr. Gonçalves: Excessive alcohol consumption is associated with alcoholic cardiomyopathy, while light to moderate drinking might have benefits in the risk of heart failure (HF). However, the cardiovascular mechanisms and the alcohol dosage associated with risks or potential benefits are uncertain. Furthermore, the variation in the toxic and protective effects of alcohol by sex remains controversial, as women may be more sensitive than men to the toxic effects of alcohol on cardiac function, developing alcoholic cardiomyopathy at a lower total lifetime dose of alcohol compared to men. In this study we assessed the associations between alcohol intake and cardiac structure and function by echocardiography, in elderly men and women in the large, community-based Atherosclerosis Risk in Communities (ARIC) Study.
MedicalResearch.com: What are the main findings?Dr. Gonçalves: We studied 4466 participants (76±5 years and 60% women) with alcohol consumption ascertained, who underwent transthoracic echocardiography. Participants were classified into 4 categories based on self-reported alcohol intake: non-drinkers, drinkers of up to 7 drinks per week, ?7 to 14 and ? 14 drinks per week. In both genders, increasing alcohol intake was associated with larger left ventricular (LV) diastolic and systolic diameters and larger left atrial diameter. In men, increasing alcohol intake was associated with greater LV mass and higher E/E’ ratio. In women, increasing alcohol intake was associated with lower LV ejection fraction. (more…)
MedicalResearch.com Interview with:
Michael B. Weinstock, MD
Professor of Emergency Medicine, Adjunct
Department of Emergency Medicine, The Ohio State University College of Medicine
Emergency Department Chairman and Director of Medical Education, Mt. Carmel St. Ann's Dept. of Emergency Medicine
Columbus, Ohio
Medical Research: What is the background for this study?
Response: Patients with potential cardiac ischemia are often admitted to the hospital even after a negative evaluation in the emergency department due to concern about missed MI, unstable angina, or potential for cardiac arrhythmia.
Medical Research: What are the main findings?
Response: Our study was different than previous studies and clinical decision rules; instead of looking at a 30 day marker, which is important to the cardiologist, ours looked at the risk of a Clinically Relevant Adverse Cardiac Event (CRACE) occurring during hospitalization. These events included inpatient STEMI, life-threatening arrhythmia, cardiac or respiratory arrest, or death. The study found only 4 of these events out of 7266 patients studied and of the 4, two were possibly iatrogenic, suggesting that after a negative ED evaluation (including 2 negative serial cardiac enzyme tests, non-ischemic and interpretable ECG, and nonconcerning vital signs) a patient can be safely sent home for an expedited cardiac outpatient evaluation.
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MedicalResearch.com Interview with:
J L Mehta, MD, PhD
Professor of Medicine and Physiology and Biophysics
Stebbins Chair in Cardiology
University of Arkansas for Medical Sciences
Little Rock, AR 72205
Medical Research: What is the background for this study? What are the main findings?
Dr. Mehta: In 2007, ACC/AHA published new guidelines regarding infective endocarditis (IE) prevention. This guideline drastically differed from the way we practiced and prescribed antibiotics to our patients when they undergo surgery or any other procedure like dental procedure, endoscopy, etc. to prevent infective endocarditis. As a result of these guideline, antibiotic use is now being restricted to only a small number of patients who have cardiac conditions that puts them at very high risk for adverse outcomes from IE. However, there is paucity of data on IE trends in the community following such a major change in practice. Therefore evaluated the trend in incidence of infective endocarditis and their outcomes before and after the advent of new guideline.
Our study has several important findings.
First, there has been a steady increase in the incidence of infective endocarditis hospitalizations over the last decade in the US. However, the incidence of IE pre- and post-inception of new antibiotic prophylaxis guidelines is not significantly different. In parallel to these findings, the rate of valve replacement for infective endocarditis did not change after the release of new guidelines in 2007.
Secondly, the increase in IE incidence was seen across all types of pathogens- Staphylococcus, Streptococcus, gram negative bacteria and fungi. The major offender involved in IE in the United States is Staphylococcus.
Finally, the rate of Streptococcus infective endocarditis related hospitalization increased significantly following the release of new guideline in the US, while Staphylococcus IE hospitalizations although on rise, did not increase significantly following the 2007 ACC/AHA guideline update.
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MedicalResearch.com Interview with:
Kirolos A. Jacob, MD, MSc PhD Candidate
Division Vital Functions, Cardiothoracic Surgery and Intensive Care Medicine
University Medical Center Utrecht
Medical Research: What is the background for this study? What are the main findings?
Dr. Jacob: Heart surgery carries many risks for a patient undergoing such a procedure. One of the most devastating complications following open heart surgery is kidney failure requiring dialysis. Most of these patients who develop kidney failure requiring dialysis after surgery have some form of chronic kidney disease before the operation, which placed them at especially high risk. Approximately one out of every 100 patients undergoing open heart surgery develops severe kidney failure. When such kidney failure occurs, the patient has more than 40% chance of dying. 1% sounds like a small percentage, however given the fact that each year, over half a million people undergo heart surgery in the USA alone, this means that an estimated 5,000 patients develop renal failure and of those about 2,500 die as a result of this complication. This figure is rising yearly as more and more patients are being operated due to the aging population. Also, this elderly population has often significant pre-existing kidney disease, further increasing the incidence of kidney failure after a heart operation.
Thus, treatment strategies are needed for this relatively small yet very important and expanding group of patients. Heart surgery initiates an inflammatory reaction across the human body due to the surgical trauma and the heart-lung machine. This systemic immune system reaction is thought to play a vital role in the development of kidney injury after heart surgery.
Our study investigated the effects of dexamethasone, a strong anti-inflammatory drug, on severe kidney injury after heart surgery. Severe kidney injury was defined as the use of dialysis during the hospital stay after surgery. We discovered that patients who receive the drug used 56% less frequently kidney dialysis, when compared to those receiving a placebo. Thus patients who did not receive the drug had about 2.5x higher risk for developing kidney failure when compared to those receiving dexamethasone. The beneficial effects of dexamethasone were particularly present in those who already had pre-existing kidney disease before heart surgery. This reinforces the fact that this drug could be of major importance for the increasing elderly population with pre-existing kidney disease undergoing a heart operation. (more…)
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MedicalResearch.com Interview with:
Dr. Sumeet Chugh MD
Pauline and Harold Price Professor of Cardiac Electrophysiology
Associate director of the Cedars-Sinai Heart Institute
Medical Research: What is the background for this study? What are the main findings?
Response: Research studies performed in the past 2 decades suggest that there is a higher burden of sudden cardiac arrest in black americans compared to whites. However there are no studies that explore the reasons for this phenomenon. Our study confirmed that these observations hold true in the current era. There are two additional novel findings. Firstly, we uncovered the disturbing fact that blacks are significantly younger than whites at the time of their cardiac arrest. The majority of blacks are under the age of 65 and the majority of whites were over 65. Furthermore, blacks who suffered sudden cardiac arrest were more likely to have diabetes, high blood pressure and chronic kidney disease. (more…)
