Lack of rehab programs leaves cardiac patients underserved globally

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Rehabilitation programs must become an integral part of cardiac care to significantly reduce the burden of living with heart disease, one of the most common chronic diseases and causes of death globally, according to York University Professor Sherry Grace.

“Cardiac rehabilitation is a cost-effective program offering heart patients exercise, education and risk reduction,” says Grace, noting that participation results in 25 per cent less death, lower re-hospitalization rates and better quality of life.

Despite these benefits, cardiac rehabilitation is vastly underused, particularly compared with costly revascularization and medical therapy, according to the review Grace conducted with Karam Turk-Adawi in the Cardiovascular Rehabilitation & Prevention Unit, University Health Network (UHN), and Dr. Nizal Sarrafzadegan, director of Isfahan Cardiovascular Research Center at Isfahan University of Medical Sciences in Iran.

“Cardiac rehabilitation services are insufficiently implemented, with only 39 per cent of countries providing any,” says Grace.

Heart disease has become an epidemic in low-income and middle-income countries (LMICs), and cardiac rehab can reduce the socio-economic impact of the disease by promoting return to work and reducing premature mortality, notes to Grace, who is also the director of research at the GoodLife Fitness Cardiovascular Rehabilitation Unit at the UHN.

“If supportive health policies, funding, physician referral strategies and alternative delivery modes are implemented, we could reduce the ratio from one cardiac rehab program per 6.4 million inhabitants in a middle income country like Paraguay, to the one program per 102,000 available in the US, a high income country,” adds Grace.

Low-income countries such as Afghanistan, Bangladesh and Kenya have one rehab program each for their entire population.

The article, Global availability of cardiac rehabilitation, published online at Nature Reviews Cardiology, indicates that while 68 per cent of high-income countries have cardiac rehabilitation, only 23 per cent of LMICs do, despite the fact that 80 per cent of deaths from heart disease occur in these countries.

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Study links high cholesterol to increased risk of breast cancer

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A new study recently presented at the Frontiers in Cardiovascular Biology meeting in Barcelona, Spain, suggests that women who have high cholesterol may be at higher risk of developing breast cancer.

The research team, led by Dr. Rahul Potluri of the Algorithm for Comorbidities, Associations, Length of Stay and Mortality (ACALM) Study Unit at Aston University School of Medicine in the UK, says their findings indicate that statins – drugs used to reduce levels of low-density lipoprotein, or “bad”cholesterol, in the blood – could be used to prevent breast cancer.

Past research has indicated a link between obesity – which can cause high cholesterol – and increased risk of breast cancer. A 2013 study reported by Medical News Today found that the obesity status of a woman may influence the rate of breast cancer cell growth and tumor size.

The researchers note that a more recent study suggested that cholesterol levels are what feeds this association. But the team wanted to investigate the link further.

Women with high cholesterol ‘1.64 times more likely to develop breast cancer’

To reach their findings, the investigators analyzed information from the ACALM clinical database between 2000 and 2013, which included more than 1 million patients.

Of the 664,159 women in the database, 22,938 had hyperlipidemia, or high cholesterol, and 9,312 had breast cancer. The team found that 530 of the women who had high cholesterol developed breast cancer.

Using a statistical model, the researchers estimated that women with high cholesterol were 1.64 times more likely to develop breast cancer than women with normal cholesterol levels.

The researchers say although their findings are purely observational at this point, they could have important long-term implications for women with high cholesterol.

Dr. Potluri says:

“We found a significant association between having high cholesterol and developing breast cancer that needs to be explored in more depth.

Caution is needed when interpreting our results because while we had a large study population, our analysis was retrospective and observational with inherent limitations. That said, the findings are exciting and further research in this field may have a big impact on patients several years down the line.”

According to the American Cancer Society, breast cancer is the second leading cause of death among women in the US. This year alone, approximately 232,670 American women will be diagnosed with invasive breast cancer.

The researchers point out that if their findings are validated through further research, they would like to see whether reducing cholesterol with statins could also lower the risk of breast cancer.

“Statins are cheap, widely available and relatively safe,” says Dr. Potluri. “We are potentially heading towards a clinical trial in 10-15 years to test the effect of statins on the incidence of breast cancer. If such a trial is successful, statins may have a role in the prevention of breast cancer especially in high risk groups, such as women with high cholesterol.”

Medical News Today recently reported on a study by researchers from University College London in the UK, which revealed the development of a simple blood test that could predict how likely a woman is to develop breast cancer.



One in five people with heart conditions stop having sex, UK survey


Sex is impossible for a fifth of people with heart conditions, according to new statistics released by the British Heart Foundation (BHF).

The BHF’s Heart Matters magazine polled over 1,500 people with heart conditions (1) and found 32 per cent had sex less often, and 19 per cent have stopped having sex completely as a result of their heart condition. One in five respondents said they were worried about having a heart attack or cardiac arrest during sex.

Over 7 million people in the UK suffer from heart and circulatory conditions (2). Based on the survey results, the BHF estimates that issues with sex could mar the lives of over one million people.

It isn’t just the physical effects that are blighting peoples’ sex lives – 14 per cent said they had lost interest in sex because of the emotional impact of their heart condition, and 5 per cent said scarring from an operation made them feel sexually unattractive.

36 year old Martin Tailford, who on Christmas day 2011 had a heart attack and has since had difficulty having sex with his wife Louise, said:

“After my heart attack sex wasn’t natural, it required a lot more planning. I couldn’t spontaneously have sex. I needed to think what to wear to cover up the scars and bruises.

“Sex isn’t what you base a relationship on, but it is really important. My heart attack had put a strain on Louise, and not being able to be physically close to her really took its toll on our relationship. I would advise people in my position to get help as soon as they can, and not be disappointed if things don’t go well at first. It takes time.”

But the BHF’s survey revealed people aren’t getting this help. 30 per cent of people have not discussed the issue with anyone, including their doctor. Eight per cent would have liked to access professional help but couldn’t get any.

The BHF is urging heart patients and GPs to talk openly about issues around sex, so treatment and support can be provided.

Doireen Maddock, Senior Cardiac Nurse at the BHF, said:

“Sex is a hugely important part of life, but isn’t getting the attention it deserves in the consultation room. We’re hearing loud and clear from Heart Matters readers that they need better support and information on how to deal with issues affecting their sex lives.

“Problems like erectile dysfunction can often be tackled and rectified, but the first hurdle is identifying people who need that help. We’d like patients to feel comfortable and empowered to raise these issues, and for the NHS to proactively offer support in this area to everyone who needs it.”

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Air pollution linked to irregular heartbeat and lung blood clots

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Air pollution is linked to an increased risk of developing an irregular heartbeat – a risk factor for stroke – and blood clots in the lung, finds a large study published online in the journal Heart.

But its impact on directly boosting the risk of heart attacks and stroke is rather less clear, the research indicates.

The evidence suggests that high levels of certain air pollutants are associated with a higher risk of cardiovascular problems, but exactly how this association works has not been clarified.

The research team therefore set out to explore the short term biological impact of air pollution on cardiovascular disease, using data from three national collections in England and Wales for the period 2003-9.

These were the Myocardial Ischaemia National Audit Project (MINAP), which tracks hospital admissions for heart attack/stroke; hospital episode statistics (HES) on emergency admissions; and figures from the Office of National Statistics (ONS) on recorded deaths.

Some 400,000 heart attacks recorded in MINAP; more than 2 million emergency admissions for cardiovascular problems; and 600,000 deaths from a heart attack/stroke were linked to average levels of air pollutants over a period of 5 days using data from the monitoring station nearest to the place of residence.

Air pollutants included carbon monoxide, nitrogen dioxide, particulate matter (PM10 and PM2.5), sulphur dioxide, and ozone. Information on ambient daily temperatures, recorded by the UK Meteorological Office, was also factored in.

No clear link with any air pollutant was found for cardiovascular deaths, with the exception of PM2.5 which was linked to an increased risk of irregular heart rhythms, irregular heartbeat (atrial fibrillation) and blood clots in the lungs (pulmonary embolism).

Only nitrogen dioxide was linked to an increased risk of a hospital admission for cardiovascular problems, including heart failure, and an increased risk of a particular type of heart attack (non-ST elevation) in the MINAP data.

The findings prompt the researchers to conclude that there is no clear evidence implicating short term exposure to air pollution in boosting the risk of heart attacks and stroke.

But there does seem to be a clear link between particulate matter levels and heightened risk of atrial fibrillation and pulmonary embolism, they say.

In an accompanying linked editorial, cardiologists from the University of Edinburgh, point out that globally particulate matter is thought to be responsible for more than 3 million deaths around the globe, primarily as a result of heart attacks and stroke.

They go on to point out that patients who sustain a non-ST elevation heart attack generally tend to be older, which may implicate air pollution as being particularly harmful for elderly people.

Nevertheless, they agree that the picture is somewhat muddled and may also be affected by improving air quality, overall.

“The current lack of consistent associations with contemporary UK data may suggest that as the fog begins to clear, the adverse health effects of air pollution are starting to have less of an impact and are more difficult to delineate,” they conclude.

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No Link Seen Between Vaccines and Lupus

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Recent vaccination was not associated with an increased risk for the development of systemic lupus erythematosus (SLE), a case-control study found.

A total of 21% of individuals who developed lupus had received any vaccine within the previous 2 years, as did 25.4% of controls, for an adjusted odds ratio (OR) of 0.9 (95% CI 0.5-1.5), according to Lamiae Grimaldi-Bensouda, PharmD, PhD, of LA-SER and Conservatoire National des Arts et Metiers in Paris, and colleagues.

Similarly, 16.2% of cases and 20.8% of controls had been vaccinated within the previous 12 months, for an adjusted odds ratio of 0.9 (95% CI 0.5-1.6), the researchers reported in the June Arthritis & Rheumatology.

“Because vaccinations are designed to stimulate an antigen-specific immune response, they have been proposed as potential triggers for autoimmunity and the onset or exacerbation of SLE,” they wrote.

To examine this possibility, Grimaldi-Bensouda and colleagues analyzed data from the Pharmacoepidemiologic General Research eXtension (PGRx) system in France and Quebec, which conducts surveillance for vaccine-associated adverse events. The system also maintains a registry of SLE cases.

Between April 2008 and June 2012, there were 105 incident cases of SLE reported from the 36 centers participating in PGRx. A group of 712 controls also were recruited, matched for age, sex, smoking, alcohol use, and family history of autoimmunity.

Participants were interviewed by telephone and provided information about 85 health conditions and medications, as well as 27 vaccines.

The minimum detectable odds ratio for vaccination during the 2 years before SLE onset was set at 1.96.

The most common vaccinations among the cases in the 2 years before disease onset were for influenza and for diphtheria/tetanus/pertussis/poliomyelitis (DTPP).

The influenza vaccine had been given to 7.6% of cases and 9.1% of controls, for an odds ratio of 1.1 (95% CI 0.5-2.6), while the DTPP immunization had been given to 9.5% and 11%, respectively (OR 0.9, 95% CI 0.4-1.9).

The researchers also analyzed the risks according to age, and found an odds ratio of 1.1 (95% CI 0.5-2.3) for patients under 30 versus those older at the time of disease onset.

In an additional analysis, they excluded patients who had been exposed to medications that have been linked with SLE, such as chlorpromazine and isoniazid, and once again found no association (OR 0.8, 95% CI 0.5-1.3).

“Our study shows that exposure to vaccines is not associated with an increased risk of developing SLE. Although our study has some limitations, we are reassured by the finding that the ORs for the relationship between vaccination and SLE onset are less than 1,” Grimaldi-Bensouda and colleagues concluded.

These limitations included the small numbers, potential unmeasured confounders, and the lack of information about ethnicity in the database.

In addition, the study only addressed SLE onset, not disease flares, although other studies have found no association of vaccination with disease exacerbations.

The study was supported by LA-SER. Grimaldi-Bensouda is a director of LA-SER and has received research support from INSERM.

One co-author disclosed relevant relationships with LA-SER, which is a research organization that owns the PGRx database. LA-SER receives funding from various sources, including AstraZeneca, Bioron, Genevrier, GlaxoSmithKline, Pfizer, Novartis, and Sanofi.




Daily aspirin to prevent first heart attack does not get FDA backing

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The US Food and Drug Administration concludes that daily aspirin use can help ward off a heart attack or stroke in some people, but it is not for everyone.

The federal agency says while there is evidence that low-dose aspirin can prevent heart attacks, strokes and cardiovascular problems reoccurring (so-called secondary prevention), the case has yet to be made for using it to prevent a first event (primary prevention).

Aspirin works by interfering with the blood’s clotting action, so reducing the chance of clots developing and obstructing flow of oxygen and blood. Clots that obstruct a coronary artery are a cause of heart attacks, while blockages in the blood supply to the brain are a cause of stroke.

The Food and Drug Administration (FDA) draw these conclusions after “carefully examining scientific data from major studies,” according to a new Consumer Update.

Dr. Robert Temple, FDA’s deputy director for clinical science, says:

“Since the 1990s, clinical data have shown that in people who have experienced a heart attack, stroke or who have a disease of the blood vessels in the heart, a daily low dose of aspirin can help prevent a reoccurrence.”

For primary prevention, ‘benefits not established, while risks are still present’

But for people who have not had a heart attack, stroke or cardiovascular problems, “the benefit has not been established but risks – such as dangerous bleeding into the brain or stomach – are still present,” warn the FDA.

And neither does the data support the use of aspirin to prevent heart attack or stroke in people who have never had them but have a family history of them or are showing evidence of arterial disease, it adds.

However, large trials looking at use of aspirin in primary prevention of heart attack and stroke are ongoing, and the FDA will continue to monitor them and update consumers should the evidence change.

“The bottom line is,” say the FDA, “that in people who have had a heart attack, stroke or cardiovascular problems, daily aspirin therapy is worth considering.”

If you are considering using daily aspirin, says Dr. Temple, you should only do so after talking to your doctor, who can help you weigh the benefits and the risks.

How much aspirin you take is important, he adds. Your doctor should ensure the dose you take and how often you take it is right for you, and recommend the dose and frequency that will bring you the greatest benefit with the fewest side effects.

Aspirin doses range from low-strength, as in an 80 mg tablet, to regular strength, as in a 325 mg tablet.

Also, because aspirin reduces risk of blood clotting, care is needed when using it with other blood thinners like warfarin, dabigatran (Pradaxa), rivaroxaban (Xarelto) and apixaban (Eliquis), warn the FDA.

And, if your doctor recommends daily aspirin to lower your risk of heart attack and clot-related stroke, you should read the labels carefully to make sure you use the correct product. Some combine aspirin with other painkillers and ingredients and should not be taken for long-term use.

Medical News Today recently reported on research that found use of low-dose aspirin is linked to improvedcolon cancer survival, while an earlier study showed regular aspirin is linked to age-related macular degeneration risk.

Written byCatharine Paddock PhD




CDC: Vaccines prevent millions of illnesses, but measles makes a return

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Vaccines will prevent an estimated 322 million illnesses, 21 million hospitalizations, and 732,000 premature deaths during the lifetimes of children born during the two decades after the Vaccines for Children Program began in 1994, according to a report released April 24 by the Centers for Disease Control and Prevention.

In addition, vaccines will save an estimated $295 billion in direct costs and $1.38 trillion in societal costs, according to the analysis, published in the April 25 issue of Morbidity and Mortality Weekly Report (MMWR 2014;61:352-5). The Vaccines for Children (VFC) Program, which provides recommended vaccines to about half the children in the United States, was created in 1993 in response to a resurgence of measles during 1989-1991, caused mostly by a failure to vaccinate uninsured children at the recommended age of 12-15 months.

The VFC provides vaccines to children if they are eligible for Medicaid, are uninsured, or are American Indian or Alaskan native. Children who are underinsured and do not have vaccine coverage are also eligible. About half of the children in the United States receive vaccines through this program.

To estimate the program’s effect on health care costs and the health of all children born from 1994 to 2013, the Centers for Disease Control and Prevention (CDC) evaluated national data on immunization coverage, and used a cost-benefit model that estimated illnesses, hospitalizations, and premature deaths (not including influenza and hepatitis A).

Measles makes 2014 return

But a second MMWR report released April 24 described 58 confirmed measles cases in California during the first 4 months of this year, in children and adults from age 5 months to 60 years. That report illustrates some of the current vaccination challenges, particularly with cases related to people traveling to and from outside the United States.

California’s 58 measles cases were reported from January 2014 through April 16, 2014. It’s the highest number of cases reported for that calendar period in the state since 1995. The 129 cases reported in the United States during this period also were the largest number reported since 1996 (MMWR 2014;61:362-3). No deaths have been reported.

During a CDC media briefing on April 24, Dr. Anne Schuchat said that 34 of the 129 cases were imported cases, and occurred in residents traveling abroad or people traveling to the United States. Among those infected who were traveling to the United States, 17 people were from the Philippines, which is in the midst of a large measles outbreak – with about 20,000 confirmed or suspected cases, including 69 deaths, through February.

“Though not direct imports, most of the remaining cases are known to be linked to importation,” said Dr. Schuchat, director of the CDC’s National Center for Immunization and Respiratory Diseases, and one of the authors of the VFC study.

The 129 cases of measles nationwide have been reported in 13 states. Cities and states with the highest number of cases are California, with 58 cases; New York City, with 24 cases; and Washington state, with 13 cases.

“While the story of the 1989 measles resurgence was one of poor children missing out on vaccines because they didn’t have insurance, today’s measles outbreaks are too often the result of people opting out” of vaccination, she said, noting that 84% of the cases have been in people who were not vaccinated or did not know if they had been vaccinated. This included 68% with personal-belief exemptions.

The California report shows the risk of measles spreading in health care settings, Dr. Schuchat noted. Of the California cases, 11 were transmitted in health care settings, including 6 in health care personnel.

Most of the 58 measles cases in California this year were in people who were not vaccinated (43%) or could not document that they had been vaccinated (31%), according to the report. The 25 patients who were not vaccinated included 19 who had philosophical objections to vaccination, and 3 who were too young for the vaccine. But 19% – two children and nine adults – had received two or more doses of MMR vaccine.

Most cases – 54 (93%) – were associated with imported cases, and included 13 cases of U.S. residents who had traveled internationally, 8 to the Philippines.

Travelers should vaccinate

The increase in imported cases from the Philippines “and subsequent transmission in certain settings in the United States highlight the importance of ensuring age-appropriate vaccination for persons traveling to areas where measles is endemic and maintaining high vaccination coverage at the national and local level,” according to the report’s authors.

The researchers also recommend that all residents of the United States born after 1956 make sure they have received the MMR vaccine “or have serologic evidence of measles immunity.”

If individuals do not have serologic evidence of immunity and are traveling outside of North America or South America, the CDC recommends one dose of MMR vaccine for infants aged 6-11 months, and two doses of MMR vaccine at least 28 days apart in children aged 1 year and older, and in adults.

There were no author disclosures for either report.