Improved survival with earlier intervention for common form of heart attack


Changes in the treatment of the most common form of heart attack over the past decade have been associated with higher survival rates for men and women regardless of age, race and ethnicity, according to a UCLA-led analysis.

But the study also suggests that there is room for improvement in how current treatment guidelines are applied among specific patient groups.

The researchers reviewed records for 6.5 million people who were treated for heart attacks between 2002 and 2011. The analysis was among the first and largest national studies to assess the impact of the trend toward more aggressive care for patients who experience the type of heart attack known as non-ST elevation myocardial infarction, or NSTEMI.

Their findings are reported in the current online edition of the peer-reviewed Journal of the American Heart Association.

“The substantial reductions in in-hospital mortality observed for NSTEMI patients nationwide over the last decade reflect greater adherence to evidence-based, guideline-directed therapies,” said Dr. Gregg C. Fonarow, the study’s senior author and UCLA’s Eliot Corday Professor of Cardiovascular Medicine and Science.

“Nevertheless, there may be further opportunities to improve care and outcomes for patients with NSTEMI, who represent the greater proportion of patients presenting with myocardial infarction,” said Fonarow, who also is director of the Ahmanson-UCLA Cardiomyopathy Center at the David Geffen School of Medicine at UCLA.

Heart attacks are broadly classified into two types. The more severe form, ST-elevation myocardial infarction (STEMI), involves complete blockage of an artery supplying blood to the heart muscle. The less severe type, NSTEMI, involves partial or temporary blockage of the artery. Studies in the U.S. and Europe have found that although the incidence of STEMI heart attacks is declining, the number of NSTEMI heart attacks increased in the past decade.

Guidelines issued in 2012 by the American College of Cardiology and American Heart Association recommended initiating cardiac catheterization in high-risk NSTEMI patients within 12 to 24 hours after the patient arrives at the hospital. This strategy had been evolving since 2009 following publication of the Timing of Intervention in Acute Coronary Syndromes trial. Previously, the recommendation was to begin catheterization in high-risk NSTEMI patients within 48 hours.

Fonarow and his colleagues examined trends in the use of cardiac catheterization for people who had been hospitalized after suffering an NSTEMI, within 24 hours and within 48 hours of presentation, seeking to determine whether changes in their care may have resulted in better outcomes.

The researchers analyzed publicly available records from the Nationwide Inpatient Sample, the largest U.S. database of hospitalized individuals. Of the 6.5 million patients whose records they examined, 3.98 million were admitted to hospitals with NSTEMI diagnoses.

The study tracked the proportion of those patients who underwent cardiac catheterization each year, and their outcomes – how many died in the hospital, the average length of their hospital stays, and the cost of hospitalization. They found that as the trend toward earlier intervention in NSTEMI patients took hold – with doctors beginning treatment within 24 hours after patients arrived at the hospital, rather than within 48 hours – the rate of in-hospital death declined from 5.5 percent in 2002 to 3.9 percent in 2011. Improvements were found for men and women, older and younger patients, and across all races and ethnic groups.

In addition, the average length of patients’ hospital stays decreased during the decade-long study, from 5.7 days to 4.8 days. NSTEMI patients who underwent cardiac catheterization within the first 24 hours had the shortest average stays.

Although more NSTEMI patients in all demographic groups received early cardiac catheterization as the study progressed, there were still significant differences across age, gender, and racial and ethnic groups in how frequently early intervention was used. Men, for example, were more likely to receive earlier catheterization than women.

“Despite the improvement, there are significant differences in the age-, gender-, and ethnicity-specific trends in the use of invasive management of NSTEMI, and these findings may help guide further improvements in care and outcomes for male and female patients of all ages, races and ethnicities,” said New York Medical College’s Dr. Sahil Khera, the study’s first author. “Further efforts are needed to enhance the quality of care for patients with NSTEMI and to develop strategies to ensure more equitable care for patients with this type of heart attack.”



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