Low-dose aspirin benefit shown in stable CVD patients
By Caroline Price
09 January 2008
Am J Med 2008; 121: 43-49
MedWire News: Low-dose aspirin is associated with a significant reduction in the risk for major cardiovascular events and all-cause mortality, and a significant increase in the risk for major bleeding in patients with stable cardiovascular disease (CVD), meta-analysis findings show.
Despite the increased bleeding risk, "the totality of evidence demonstrated the benefit of aspirin in this high-risk group of subjects," comment the authors.
Recommendations for aspirin in secondary prevention are based on analyses of all anti-platelet therapies at all doses and in both stable and unstable patients, such that the role of low-dose aspirin in stable patients remains poorly defined, explain Jeffrey Berger (Duke University, Durham, North Carolina) and colleagues.
To address this issue, the team searched the MEDLINE database for secondary prevention trials of low-dose aspirin in stable CVD patients published between 1966 and 2006.
They identified six randomized placebo-controlled trials, one (Cardiff-I) that enrolled patients with a prior myocardial infarction (MI), one (Swedish Angina Pectoris Asprin Trial) that included patients with chronic stable angina, and four (Danish Low Dose, UK Transient Ischemic Attack, Swedish Aspirin Low-Dose Trial, and European Stroke Prevention Study-2) that included patients with a prior stroke or transient ischemic attack.
The aspirin dose ranged from 50 to 300 mg daily. Overall, there were 1718 cardiovascular events (nonfatal MIs, nonfatal strokes, and cardiovascular deaths) in these studies during a mean follow-up of 33.3 months.
There were significantly fewer cardiovascular deaths among patients taking aspirin (15.8%) than those taking placebo (19.1%), representing a 21% reduction in the odds for cardiovascular events with aspirin use (p<0.01).
Aspirin therapy was also associated with a 13% reduction in the odds for all-cause mortality (p=0.03), a 26% reduction in the odds for nonfatal MI (p<0.01), and a 25% reduction in the odds for stroke (p<0.01).
Against these findings, patients who received aspirin had a more than two-fold increased risk for major bleeding. However, the authors note that the low absolute risk for major bleeding meant that the number needed to treat to cause a major bleed was 111.
Furthermore, the data indicated that treating 1000 patients with low-dose aspirin would prevent around 33 major cardiovascular events, 12 nonfatal MIs, 25 nonfatal strokes, and 14 deaths, while causing just nine major bleeds, the researchers report in the American Journal of Medicine.
Of note, the decreased risk for major cardiovascular events was driven primarily by a reduction in the risk for MI in the two trials including patients with ischemic heart disease, and primarily by a reduction in the risk for stroke in the four trials that enrolled patients who had suffered cerebrovascular events.
Sub-group analyses showed that the effects of aspirin were similar at doses of 50-100 mg/day and 300 mg/day.
Berger and team conclude: "Future studies should focus on proper patient selection and management options to reduce the bleeding risk and the most optimal aspirin dose in each clinical setting for the long-term reduction in CVD and mortality."
Free abstract
Thursday, January 10, 2008
Athletes and Electrocardiograms
Athletes and Electrocardiograms
Journal Watch Cardiology January 9, 2008
Abnormal ECG findings were associated with an increased risk for heart disease in a cohort of highly trained athletes.
The death of a young athlete is the kind of tragedy that inspires poetry and shakes communities. Although such events are rare, there is great interest in identifying individuals at risk and intervening before a fatal event occurs.
Physicians are often challenged to make judgments about risk in individuals who have abnormal 12-lead electrocardiograms but no evidence of structural heart disease. To determine whether an abnormal ECG is a marker of risk in athletically conditioned individuals, investigators analyzed a database of electrocardiographic and echocardiographic findings from 12,550 Italian athletes. The investigators identified 81 athletes with electrocardiographic — but no echocardiographic — abnormalities at initial examination (mean age, 23) and for whom serial follow-up data were available. Inclusion criteria for these cases were marked repolarization abnormalities, defined as inverted T waves in at least three leads. A total of 229 control patients with normal ECGs were matched with case patients by age, sex, and duration of follow-up.
Case patients had participated in a variety of sports (most commonly, soccer and rowing or canoeing). During a mean follow-up of 9 years, 11 athletes with initial electrocardiographic abnormalities developed a cardiovascular disorder (cardiomyopathy in 5, other disorders in 6).
One athlete died from an undetected arrhythmogenic right ventricular cardiomyopathy. None of the control patients developed a cardiomyopathy (P=0.001); four developed other
cardiovascular disorders (P=0.05).
Comment: This small but important study suggests that we clinicians should not dismiss an abnormal electrocardiogram in a trained athlete just because the echocardiogram findings are normal. However, the question remains: How best to advise these athletes? They may be at increased risk, but it is not clear if that risk can be modified, and most of the athletes in this study did not develop cardiovascular problems.
Harlan M. Krumholz, MD, SM
Published in Journal Watch Cardiology January 9, 2008
Citation(s):
Pelliccia A et al. Outcomes in athletes with marked ECG repolarization abnormalities. N Engl J Med 2008 Jan 10; 358:152.
Original article (Subscription may be required)
Journal Watch Cardiology January 9, 2008
Abnormal ECG findings were associated with an increased risk for heart disease in a cohort of highly trained athletes.
The death of a young athlete is the kind of tragedy that inspires poetry and shakes communities. Although such events are rare, there is great interest in identifying individuals at risk and intervening before a fatal event occurs.
Physicians are often challenged to make judgments about risk in individuals who have abnormal 12-lead electrocardiograms but no evidence of structural heart disease. To determine whether an abnormal ECG is a marker of risk in athletically conditioned individuals, investigators analyzed a database of electrocardiographic and echocardiographic findings from 12,550 Italian athletes. The investigators identified 81 athletes with electrocardiographic — but no echocardiographic — abnormalities at initial examination (mean age, 23) and for whom serial follow-up data were available. Inclusion criteria for these cases were marked repolarization abnormalities, defined as inverted T waves in at least three leads. A total of 229 control patients with normal ECGs were matched with case patients by age, sex, and duration of follow-up.
Case patients had participated in a variety of sports (most commonly, soccer and rowing or canoeing). During a mean follow-up of 9 years, 11 athletes with initial electrocardiographic abnormalities developed a cardiovascular disorder (cardiomyopathy in 5, other disorders in 6).
One athlete died from an undetected arrhythmogenic right ventricular cardiomyopathy. None of the control patients developed a cardiomyopathy (P=0.001); four developed other
cardiovascular disorders (P=0.05).
Comment: This small but important study suggests that we clinicians should not dismiss an abnormal electrocardiogram in a trained athlete just because the echocardiogram findings are normal. However, the question remains: How best to advise these athletes? They may be at increased risk, but it is not clear if that risk can be modified, and most of the athletes in this study did not develop cardiovascular problems.
Harlan M. Krumholz, MD, SM
Published in Journal Watch Cardiology January 9, 2008
Citation(s):
Pelliccia A et al. Outcomes in athletes with marked ECG repolarization abnormalities. N Engl J Med 2008 Jan 10; 358:152.
Original article (Subscription may be required)
Wednesday, January 9, 2008
Physical Activity, Moderate Alcohol Intake Associated with Improved Survival
Physical Activity, Moderate Alcohol Intake Associated with Improved Survival
Physical activity and moderate alcohol consumption may help reduce fatal ischemic heart disease (IHD) and all-cause mortality, reports the European Heart Journal.
Nearly 12,000 Danish adults without previous IHD reported their alcohol intake and physical activity level and then were followed for about 20 years. Overall, about half died, with IHD accounting for 20% of the deaths.
After adjustment for confounders such as age and smoking status, active subjects had lower risks for fatal IHD and all-cause mortality than inactive subjects, and moderate drinkers (1 to 14 drinks a week) had lower mortality risks than nondrinkers. A combination of physical activity and moderate drinking appeared most beneficial — active subjects who consumed at least one drink weekly had up to a 50% lower risk for fatal IHD and up to a 33% lower all-cause mortality risk.
European Heart Journal article (Free PDF)
Abstract:
The combined influence of leisure-time physical activity and weekly alcohol intake on fatal ischaemic heart disease and all-cause mortality
Aims
To determine the combined influence of leisure-time physical activity and weekly alcohol intake on the risk of subsequent fatal ischaemic heart disease (IHD) and all-cause mortality.
Methods and results
Prospective cohort study of 11 914 Danes aged 20 years or older and without pre-existing IHD. During _20 years of follow-up, 1242 cases of fatal IHD occurred and 5901 died from all causes. Within both genders, being physically active was associated with lower hazard ratios (HR) of both fatal IHD and all-cause mortality than being physically inactive. Further, weekly alcohol intake was inversely associated with fatal IHD and had a U-shaped association with all-cause mortality. Within level of physical activity, non-drinkers had the highest HR of fatal IHD, whereas both non-drinkers and heavy drinkers had the highest HR of all-cause mortality. Further, the physically inactive had the highest HR of both fatal IHD and all-cause mortality within each category of weekly alcohol intake. Thus, the HR of both fatal IHD and all-cause mortality were low among the physically active who had a moderate alcohol intake.
Conclusion
Leisure-time physical activity and a moderate weekly alcohol intake are both important to lower the risk of fatal IHD and all-cause mortality.
Physical activity and moderate alcohol consumption may help reduce fatal ischemic heart disease (IHD) and all-cause mortality, reports the European Heart Journal.
Nearly 12,000 Danish adults without previous IHD reported their alcohol intake and physical activity level and then were followed for about 20 years. Overall, about half died, with IHD accounting for 20% of the deaths.
After adjustment for confounders such as age and smoking status, active subjects had lower risks for fatal IHD and all-cause mortality than inactive subjects, and moderate drinkers (1 to 14 drinks a week) had lower mortality risks than nondrinkers. A combination of physical activity and moderate drinking appeared most beneficial — active subjects who consumed at least one drink weekly had up to a 50% lower risk for fatal IHD and up to a 33% lower all-cause mortality risk.
European Heart Journal article (Free PDF)
Abstract:
The combined influence of leisure-time physical activity and weekly alcohol intake on fatal ischaemic heart disease and all-cause mortality
Aims
To determine the combined influence of leisure-time physical activity and weekly alcohol intake on the risk of subsequent fatal ischaemic heart disease (IHD) and all-cause mortality.
Methods and results
Prospective cohort study of 11 914 Danes aged 20 years or older and without pre-existing IHD. During _20 years of follow-up, 1242 cases of fatal IHD occurred and 5901 died from all causes. Within both genders, being physically active was associated with lower hazard ratios (HR) of both fatal IHD and all-cause mortality than being physically inactive. Further, weekly alcohol intake was inversely associated with fatal IHD and had a U-shaped association with all-cause mortality. Within level of physical activity, non-drinkers had the highest HR of fatal IHD, whereas both non-drinkers and heavy drinkers had the highest HR of all-cause mortality. Further, the physically inactive had the highest HR of both fatal IHD and all-cause mortality within each category of weekly alcohol intake. Thus, the HR of both fatal IHD and all-cause mortality were low among the physically active who had a moderate alcohol intake.
Conclusion
Leisure-time physical activity and a moderate weekly alcohol intake are both important to lower the risk of fatal IHD and all-cause mortality.
Tuesday, January 8, 2008
Combined Impact of Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospective Population Study
Combined Impact of Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospective Population Study
Kay-Tee Khaw, Nicholas Wareham, Sheila Bingham, Ailsa Welch, Robert Luben, Nicholas Day
Background
There is overwhelming evidence that behavioural factors influence health, but their combined impact on the general population is less well documented. We aimed to quantify the potential combined impact of four health behaviours on mortality in men and women living in the general community.
Methods and Findings
We examined the prospective relationship between lifestyle and mortality in a prospective population study of 20,244 men and women aged 45–79 y with no known cardiovascular disease or cancer at baseline survey in 1993–1997, living in the general community in the United Kingdom, and followed up to 2006. Participants scored one point for each health behaviour: current non-smoking, not physically inactive, moderate alcohol intake (1–14 units a week) and plasma vitamin C >50 mmol/l indicating fruit and vegetable intake of at least five servings a day, for a total score ranging from zero to four. After an average 11 y follow-up, the age-, sex-, body mass–, and social class–adjusted relative risks (95% confidence intervals) for all-cause mortality(1,987 deaths) for men and women who had three, two, one, and zero compared to four health behaviours were respectively, 1.39 (1.21–1.60), 1.95 (1.70–-2.25), 2.52 (2.13–3.00), and 4.04 (2.95–5.54)
Conclusions
Four health behaviours combined predict a 4-fold difference in total mortality in men and women, with an estimated impact equivalent to 14 y in chronological age
LINK:
"http://medicine.plosjournals.org/perlserv/?request=index-html&issn=1549-1676
Kay-Tee Khaw, Nicholas Wareham, Sheila Bingham, Ailsa Welch, Robert Luben, Nicholas Day
Background
There is overwhelming evidence that behavioural factors influence health, but their combined impact on the general population is less well documented. We aimed to quantify the potential combined impact of four health behaviours on mortality in men and women living in the general community.
Methods and Findings
We examined the prospective relationship between lifestyle and mortality in a prospective population study of 20,244 men and women aged 45–79 y with no known cardiovascular disease or cancer at baseline survey in 1993–1997, living in the general community in the United Kingdom, and followed up to 2006. Participants scored one point for each health behaviour: current non-smoking, not physically inactive, moderate alcohol intake (1–14 units a week) and plasma vitamin C >50 mmol/l indicating fruit and vegetable intake of at least five servings a day, for a total score ranging from zero to four. After an average 11 y follow-up, the age-, sex-, body mass–, and social class–adjusted relative risks (95% confidence intervals) for all-cause mortality(1,987 deaths) for men and women who had three, two, one, and zero compared to four health behaviours were respectively, 1.39 (1.21–1.60), 1.95 (1.70–-2.25), 2.52 (2.13–3.00), and 4.04 (2.95–5.54)
Conclusions
Four health behaviours combined predict a 4-fold difference in total mortality in men and women, with an estimated impact equivalent to 14 y in chronological age
LINK:
"http://medicine.plosjournals.org/perlserv/?request=index-html&issn=1549-1676
Monday, January 7, 2008
Anxiety Predicts Increased MI Risk
Anxiety Predicts Increased MI Risk
MedPage Today
LOS ANGELES, Jan. 7 -- Among older men with no history of coronary disease, anxiety predicts an increased risk of myocardial infarction, irrespective of cardiac risk factors, investigators here found.
The adjusted relative risk of MI associated with each standard deviation increase in anxiety was 1.43 (95% confidence interval: 1.17 to 1.75), Biing-Jiun Shen, Ph.D., of the University of Southern California, and colleagues reported in the Jan. 8 issue of the Journal of the American College of Cardiology.
In addition to overall anxiety, several specific manifestations of anxiety also independently predicted an increased risk of MI, the researchers said.
"The results suggest that moderately elevated anxiety is associated with a modest risk of MI and severe anxiety represents an MI risk that may warrant attention," the authors concluded.
"The findings indicate that anxiety not only represents an independent, prospective, and unique risk factor for MI, but may also explain the associations between MI and other psychosocial risk factors observed in earlier studies."
Several psychological conditions, including anxiety, have been associated with the onset of coronary artery disease, independent of conventional CAD risk factors, the authors noted.
However, previous studies left a variety of conceptual and methodologic issues unaddressed.
In an effort to explore some of them, the researchers evaluated 735 older men (mean age 60) enrolled in the prospective Normative Aging Study. The men had no history of coronary artery disease or diabetes at baseline.
The investigators assessed anxiety by means of four scales from the Minnesota Multiphasic Personality Inventory: psychasthenia, social introversion, phobia, and manifest anxiety. Overall anxiety was calculated from scores on the four scales.
After a mean follow-up of 12.4 years, anxiety traits independently predicted MI risk after controlling for age, education, marital status, fasting glucose, body mass index, HDL cholesterol, and systolic blood pressure.
The following adjusted relative risks emerged from the analysis:
Psychasthenia, 1.37 (95% CI: 1.12 to 1.68)
Social introversion, 1.31 (95% CI: 1.05 to 1.63)
Phobia, 1.36 (95% CI: 1.10 to 1.68)
Manifest anxiety, 1.42 (95% CI: 1.14 to 1.76)
Overall anxiety, 1.43 (95% CI: 1.17 to 1.75)
The relationships remained significant after further adjustment for health behaviors, use of medications for hypertension, hypercholesterolemia, and diabetes during follow-up, and additional psychological variables.
The authors suggested several potential explanations for the findings:
Associations between anxiety and repeated and chronic elevations of stress
Dysregulation of stress-related pathophysiologic pathways (such as hypothalamic-pituitary-adrenal axis and disturbed platelet activation)
Stimulation of systemic inflammation
Reduced vagal tone and heart-rate variability
The study was performed mainly in otherwise healthy Caucasian men, which limits extrapolation of findings to other groups.
Although anxiety was the strongest predictor of MI risk among psychological variables, the authors cautioned against dismissing other psychological factors, such as depression and hostility.
"Psychological factors are interrelated and may contribute to one another in a reciprocal fashion," they stated. "Recognizing multiple psychosocial risk components may better inform risk assessment and management for people at higher risk for MI."
MedPage Today
LOS ANGELES, Jan. 7 -- Among older men with no history of coronary disease, anxiety predicts an increased risk of myocardial infarction, irrespective of cardiac risk factors, investigators here found.
The adjusted relative risk of MI associated with each standard deviation increase in anxiety was 1.43 (95% confidence interval: 1.17 to 1.75), Biing-Jiun Shen, Ph.D., of the University of Southern California, and colleagues reported in the Jan. 8 issue of the Journal of the American College of Cardiology.
In addition to overall anxiety, several specific manifestations of anxiety also independently predicted an increased risk of MI, the researchers said.
"The results suggest that moderately elevated anxiety is associated with a modest risk of MI and severe anxiety represents an MI risk that may warrant attention," the authors concluded.
"The findings indicate that anxiety not only represents an independent, prospective, and unique risk factor for MI, but may also explain the associations between MI and other psychosocial risk factors observed in earlier studies."
Several psychological conditions, including anxiety, have been associated with the onset of coronary artery disease, independent of conventional CAD risk factors, the authors noted.
However, previous studies left a variety of conceptual and methodologic issues unaddressed.
In an effort to explore some of them, the researchers evaluated 735 older men (mean age 60) enrolled in the prospective Normative Aging Study. The men had no history of coronary artery disease or diabetes at baseline.
The investigators assessed anxiety by means of four scales from the Minnesota Multiphasic Personality Inventory: psychasthenia, social introversion, phobia, and manifest anxiety. Overall anxiety was calculated from scores on the four scales.
After a mean follow-up of 12.4 years, anxiety traits independently predicted MI risk after controlling for age, education, marital status, fasting glucose, body mass index, HDL cholesterol, and systolic blood pressure.
The following adjusted relative risks emerged from the analysis:
Psychasthenia, 1.37 (95% CI: 1.12 to 1.68)
Social introversion, 1.31 (95% CI: 1.05 to 1.63)
Phobia, 1.36 (95% CI: 1.10 to 1.68)
Manifest anxiety, 1.42 (95% CI: 1.14 to 1.76)
Overall anxiety, 1.43 (95% CI: 1.17 to 1.75)
The relationships remained significant after further adjustment for health behaviors, use of medications for hypertension, hypercholesterolemia, and diabetes during follow-up, and additional psychological variables.
The authors suggested several potential explanations for the findings:
Associations between anxiety and repeated and chronic elevations of stress
Dysregulation of stress-related pathophysiologic pathways (such as hypothalamic-pituitary-adrenal axis and disturbed platelet activation)
Stimulation of systemic inflammation
Reduced vagal tone and heart-rate variability
The study was performed mainly in otherwise healthy Caucasian men, which limits extrapolation of findings to other groups.
Although anxiety was the strongest predictor of MI risk among psychological variables, the authors cautioned against dismissing other psychological factors, such as depression and hostility.
"Psychological factors are interrelated and may contribute to one another in a reciprocal fashion," they stated. "Recognizing multiple psychosocial risk components may better inform risk assessment and management for people at higher risk for MI."
Low Vitamin D Plus Hypertension May Worsen Cardiovascular Risks
Low Vitamin D Plus Hypertension May Worsen Cardiovascular Risks
BOSTON, Jan. 7 -- Moderate vitamin D deficiency nearly doubles the risk of myocardial infarction, stroke, and heart failure over a mean of 5.4 years in patients with high blood pressure, researchers here said.
The finding emerged from the Framingham Heart Study, which now includes the adult offspring of the study's original participants.
The researchers focused on those offspring who had participated in their sixth or seventh quadrennial exams from 1996 to 2001, Thomas J. Wang, M.D., of Massachusetts General Hospital, and colleagues reported online in Circulation: Journal of the American Heart Association. Participants with known cardiovascular or kidney disease at that time were excluded.
Compared with patients with higher vitamin D levels, the adjusted rate of first cardiovascular events was 1.62 times higher (95% CI: 1.11 to 2.36, P=0.01) in those with levels of 25-dihydroxyvitamin D below 15 ng/mL.
This effect was evident in participants with hypertension (hazard ratio: 2.13, 95% CI: 1.30 to 3.48) but not in those without hypertension (HR: 1.04, 95% CI: 0.55 to 1.96).
Up to half of middle-age and older adults in the U.S. have low levels of circulating vitamin D, Dr. Wang and colleagues said. However, they stopped short of calling for routine vitamin D testing or for supplementation in patients with known deficiencies.
"What hasn't been proven yet is that vitamin D deficiency actually causes increased risk of cardiovascular disease," Dr. Wang said. "This would require a large randomized trial to show whether correcting the vitamin D deficiency would result in a reduction in cardiovascular risk."
Earlier research had suggested links between lower vitamin D levels and other factors related to heart disease, such as coronary artery calcification and blood pressure.
Dr. Wang and colleagues wanted to know whether vitamin D levels in the Framingham offspring from the 1996-2001 exams were correlated with the rate of first cardiovascular events occurring later. In addition to MI, ischemic stroke, and heart failure, these events included angina, coronary insufficiency episodes, transient ischemic attacks, and claudication.
The researchers also adjusted for such factors as age, gender, smoking and diabetes status, weight, and cholesterol levels in their statistical analyses. Mean follow-up after the exams was 5.4 years.
Patients with very low vitamin D levels -- less than 10 ng/mL -- along with hypertension were at substantially greater risk of cardiovascular events.
Dr. Wang and colleagues found a hazard ratio of 3.19 (95% CI: 1.70 to 5.99), adjusted for age and gender, for these individuals relative to hypertensive participants with vitamin D levels of 15 ng/mL or greater. When also adjusted for clinical parameters including C-reactive protein levels, the hazard ratio for these participants was 2.43 (95% CI: 1.23 to 4.80).
The study did not investigate potential mechanisms. However, Dr. Wang and colleagues pointed to other research indicating that vitamin D deficiency and hypertension independently affect vascular remodeling and cardiac hypertrophy.
Vitamin D deficiency may also directly promote development of hypertension, they suggested.
As a result, they wrote, "hypertension could magnify the adverse effects of vitamin D deficiency on the cardiovascular system."
Dr. Wang and colleagues could not rule out the possibility that vitamin D deficiency is not causative. "Unmeasured characteristics associated with vitamin D deficiency … could account for the increased cardiovascular risk," they acknowledged.
They pointed out that "an alternate explanation for the present findings is that vitamin D deficiency is a marker of chronic nonspecific illness rather than a direct contributor to disease pathogenesis."
They also noted that all the participants in their study were Caucasian, indicating that the results may not apply to non-whites who have a higher prevalence of vitamin D deficiency.
Dr. Wang said that until future studies confirm a causal link between vitamin D deficiency and cardiovascular risk, patients -- especially the elderly, who are at particular risk for low vitamin D levels -- should simply ensure their diets satisfy the recommended daily allowance of vitamin D.
BOSTON, Jan. 7 -- Moderate vitamin D deficiency nearly doubles the risk of myocardial infarction, stroke, and heart failure over a mean of 5.4 years in patients with high blood pressure, researchers here said.
The finding emerged from the Framingham Heart Study, which now includes the adult offspring of the study's original participants.
The researchers focused on those offspring who had participated in their sixth or seventh quadrennial exams from 1996 to 2001, Thomas J. Wang, M.D., of Massachusetts General Hospital, and colleagues reported online in Circulation: Journal of the American Heart Association. Participants with known cardiovascular or kidney disease at that time were excluded.
Compared with patients with higher vitamin D levels, the adjusted rate of first cardiovascular events was 1.62 times higher (95% CI: 1.11 to 2.36, P=0.01) in those with levels of 25-dihydroxyvitamin D below 15 ng/mL.
This effect was evident in participants with hypertension (hazard ratio: 2.13, 95% CI: 1.30 to 3.48) but not in those without hypertension (HR: 1.04, 95% CI: 0.55 to 1.96).
Up to half of middle-age and older adults in the U.S. have low levels of circulating vitamin D, Dr. Wang and colleagues said. However, they stopped short of calling for routine vitamin D testing or for supplementation in patients with known deficiencies.
"What hasn't been proven yet is that vitamin D deficiency actually causes increased risk of cardiovascular disease," Dr. Wang said. "This would require a large randomized trial to show whether correcting the vitamin D deficiency would result in a reduction in cardiovascular risk."
Earlier research had suggested links between lower vitamin D levels and other factors related to heart disease, such as coronary artery calcification and blood pressure.
Dr. Wang and colleagues wanted to know whether vitamin D levels in the Framingham offspring from the 1996-2001 exams were correlated with the rate of first cardiovascular events occurring later. In addition to MI, ischemic stroke, and heart failure, these events included angina, coronary insufficiency episodes, transient ischemic attacks, and claudication.
The researchers also adjusted for such factors as age, gender, smoking and diabetes status, weight, and cholesterol levels in their statistical analyses. Mean follow-up after the exams was 5.4 years.
Patients with very low vitamin D levels -- less than 10 ng/mL -- along with hypertension were at substantially greater risk of cardiovascular events.
Dr. Wang and colleagues found a hazard ratio of 3.19 (95% CI: 1.70 to 5.99), adjusted for age and gender, for these individuals relative to hypertensive participants with vitamin D levels of 15 ng/mL or greater. When also adjusted for clinical parameters including C-reactive protein levels, the hazard ratio for these participants was 2.43 (95% CI: 1.23 to 4.80).
The study did not investigate potential mechanisms. However, Dr. Wang and colleagues pointed to other research indicating that vitamin D deficiency and hypertension independently affect vascular remodeling and cardiac hypertrophy.
Vitamin D deficiency may also directly promote development of hypertension, they suggested.
As a result, they wrote, "hypertension could magnify the adverse effects of vitamin D deficiency on the cardiovascular system."
Dr. Wang and colleagues could not rule out the possibility that vitamin D deficiency is not causative. "Unmeasured characteristics associated with vitamin D deficiency … could account for the increased cardiovascular risk," they acknowledged.
They pointed out that "an alternate explanation for the present findings is that vitamin D deficiency is a marker of chronic nonspecific illness rather than a direct contributor to disease pathogenesis."
They also noted that all the participants in their study were Caucasian, indicating that the results may not apply to non-whites who have a higher prevalence of vitamin D deficiency.
Dr. Wang said that until future studies confirm a causal link between vitamin D deficiency and cardiovascular risk, patients -- especially the elderly, who are at particular risk for low vitamin D levels -- should simply ensure their diets satisfy the recommended daily allowance of vitamin D.
Friday, January 4, 2008
Persistent post-ACS depression linked to worse physical outcome
Persistent post-ACS depression linked to worse physical outcome
By Caroline Price
04 January 2008
Am J Cardiol 2008; 101: 15-19
MedWire News: Depressive symptoms during hospitalization for acute coronary syndromes (ACS) predict patients’ physical health status 12 months later, study findings show.
However, only patients whose depressive symptoms persist during recovery have significantly poorer physical health than before ACS at 12 months. Patients with transient symptoms are not at risk for worsened physical health.
“These results underscore the importance of assessing depression at the time of ACS and on an ongoing basis,” the study authors say.
Brett Thombs (McGill University, Montreal, Quebec, Canada) and colleagues assessed 425 patients with ACS using the Beck Depression Inventory (BDI) and the Short Form 12 (SF-12) Health Survey during hospitalization and 12 months later.
In all, 123 (28.9%) patients during hospitalization and 102 (24.0%) patients at the 12-month follow-up had at least mild symptoms of depression (BDI ≥10). Based on the “statistically reliable change index” of ≥6.2 points on the BDI, 281 (66.1%) patients were classified as having symptoms not present, 85 (20.0%) as having persistent symptoms, 38 (8.9%) with transient symptoms, and 21 (4.9%) with new symptoms emerging between the index ACS and 12 months after ACS.
The mean BDI score during hospitalization was highest among patients with transient symptoms (19.3), followed by patients with persistent symptoms (14.8), those with symptoms not present (4.2), and those with new symptoms (3.9).
At 12 months, the mean BDI score was highest in those with new symptoms (17.0), followed by the persistent symptom group (14.0), those with transient symptoms (6.3), and patients without symptoms (3.8).
Patients with a BDI score of ≥10 in hospital had significantly poorer health status at 12 months after ACS than patients with lower scores (SF-12 score, 36.7 vs 44.7, p<0.001). Higher BDI scores remained significantly associated with worse physical health at 12 months after controlling for physical health status before ACS, age, gender, diagnosis, history of acute myocardial infarction, and Killip class (p<0.001).
Further analysis replacing baseline BDI score with the symptom classifications during recovery, using symptoms not present as the reference group, showed that persistent symptoms significantly predicted worse physical health at 12 months compared with physical health before ACS (p<0.001).
Meanwhile, new symptoms showed a nonsignificant tendency to predict worse physical health, whereas transient symptoms did not predict worse physical health.
“The findings of this study emphasize the importance of assessing symptoms of depression, not only at the time of the acute ACS hospitalization, but also subsequently during follow-up visits,” the authors conclude in the American Journal of Cardiology.
Free abstract
By Caroline Price
04 January 2008
Am J Cardiol 2008; 101: 15-19
MedWire News: Depressive symptoms during hospitalization for acute coronary syndromes (ACS) predict patients’ physical health status 12 months later, study findings show.
However, only patients whose depressive symptoms persist during recovery have significantly poorer physical health than before ACS at 12 months. Patients with transient symptoms are not at risk for worsened physical health.
“These results underscore the importance of assessing depression at the time of ACS and on an ongoing basis,” the study authors say.
Brett Thombs (McGill University, Montreal, Quebec, Canada) and colleagues assessed 425 patients with ACS using the Beck Depression Inventory (BDI) and the Short Form 12 (SF-12) Health Survey during hospitalization and 12 months later.
In all, 123 (28.9%) patients during hospitalization and 102 (24.0%) patients at the 12-month follow-up had at least mild symptoms of depression (BDI ≥10). Based on the “statistically reliable change index” of ≥6.2 points on the BDI, 281 (66.1%) patients were classified as having symptoms not present, 85 (20.0%) as having persistent symptoms, 38 (8.9%) with transient symptoms, and 21 (4.9%) with new symptoms emerging between the index ACS and 12 months after ACS.
The mean BDI score during hospitalization was highest among patients with transient symptoms (19.3), followed by patients with persistent symptoms (14.8), those with symptoms not present (4.2), and those with new symptoms (3.9).
At 12 months, the mean BDI score was highest in those with new symptoms (17.0), followed by the persistent symptom group (14.0), those with transient symptoms (6.3), and patients without symptoms (3.8).
Patients with a BDI score of ≥10 in hospital had significantly poorer health status at 12 months after ACS than patients with lower scores (SF-12 score, 36.7 vs 44.7, p<0.001). Higher BDI scores remained significantly associated with worse physical health at 12 months after controlling for physical health status before ACS, age, gender, diagnosis, history of acute myocardial infarction, and Killip class (p<0.001).
Further analysis replacing baseline BDI score with the symptom classifications during recovery, using symptoms not present as the reference group, showed that persistent symptoms significantly predicted worse physical health at 12 months compared with physical health before ACS (p<0.001).
Meanwhile, new symptoms showed a nonsignificant tendency to predict worse physical health, whereas transient symptoms did not predict worse physical health.
“The findings of this study emphasize the importance of assessing symptoms of depression, not only at the time of the acute ACS hospitalization, but also subsequently during follow-up visits,” the authors conclude in the American Journal of Cardiology.
Free abstract
Single-lead ST-segment deviation after primary angioplasty
Single-lead ST-segment deviation after primary angioplasty
By Caroline Price
04 January 2008
Heart 2008; 94: 44-47
MedWire News: Residual ST-segment deviation in a single lead 3 hours after primary angioplasty in ST-elevation myocardial infarction (STEMI) patients is an “easy and accurate” predictor of 1-year mortality, cardiologists report.
Electrocardiography (ECG) is a simple way to measure reperfusion outcomes, with ST-segment deviation providing better prognostic accuracy than ST-segment resolution, explain A van’t Hof (Hospital De Weezenlanden, Zwolle, The Netherlands) and team.
To evaluate the prognostic role of postprocedural single-lead ST-segment deviation (STD) in primary angioplasty, relative to single-lead ST-segment resolution and elevation, and 12-lead ST-segment deviation, the researchers prospectively studied 1660 STEMI patients undergoing the procedure between 1997 and 2002.
Successful reperfusion was defined as postprocedural thrombolysis in myocardial infarction (TIMI) 3 flow, residual stenosis <50%, and myocardial blush grade (MBG) 2-3. ECGs were recorded at 3 hours after the procedure.
As reported in the journal Heart, maximal residual STD correlated well with postprocedural MBG 3, distal embolization, enzymatic infarct size, and predischarge left ventricular ejection fraction.
At 1 year of follow-up, 63 (3.8%) patients had died. In multivariate analysis, after correction for baseline characteristics, maximal residual single-lead STD was the strongest predictor of mortality of all postprocedural ECG measures, at a hazard ratio of 1.87 (p<0.001).
Using receiver operating characteristic curves, the researchers identified ≥2 mm as the optimal threshold for maximal single-lead STD.
“The simple evaluation of maximal residual STD in a single lead 3 hours after the procedure is the best electrocardiographic measure for the evaluation of myocardial perfusion and prognostic stratification of patients with STEMI treated with primary angioplasty,” the authors write.
Link: http://heart.bmj.com/cgi/content/abstract/94/1/44
By Caroline Price
04 January 2008
Heart 2008; 94: 44-47
MedWire News: Residual ST-segment deviation in a single lead 3 hours after primary angioplasty in ST-elevation myocardial infarction (STEMI) patients is an “easy and accurate” predictor of 1-year mortality, cardiologists report.
Electrocardiography (ECG) is a simple way to measure reperfusion outcomes, with ST-segment deviation providing better prognostic accuracy than ST-segment resolution, explain A van’t Hof (Hospital De Weezenlanden, Zwolle, The Netherlands) and team.
To evaluate the prognostic role of postprocedural single-lead ST-segment deviation (STD) in primary angioplasty, relative to single-lead ST-segment resolution and elevation, and 12-lead ST-segment deviation, the researchers prospectively studied 1660 STEMI patients undergoing the procedure between 1997 and 2002.
Successful reperfusion was defined as postprocedural thrombolysis in myocardial infarction (TIMI) 3 flow, residual stenosis <50%, and myocardial blush grade (MBG) 2-3. ECGs were recorded at 3 hours after the procedure.
As reported in the journal Heart, maximal residual STD correlated well with postprocedural MBG 3, distal embolization, enzymatic infarct size, and predischarge left ventricular ejection fraction.
At 1 year of follow-up, 63 (3.8%) patients had died. In multivariate analysis, after correction for baseline characteristics, maximal residual single-lead STD was the strongest predictor of mortality of all postprocedural ECG measures, at a hazard ratio of 1.87 (p<0.001).
Using receiver operating characteristic curves, the researchers identified ≥2 mm as the optimal threshold for maximal single-lead STD.
“The simple evaluation of maximal residual STD in a single lead 3 hours after the procedure is the best electrocardiographic measure for the evaluation of myocardial perfusion and prognostic stratification of patients with STEMI treated with primary angioplasty,” the authors write.
Link: http://heart.bmj.com/cgi/content/abstract/94/1/44
Statins for Secondary Prevention in Elderly Patients
Statins for Secondary Prevention in Elderly Patients
A Hierarchical Bayesian Meta-Analysis
Jonathan Afilalo, Gustavo Duque, Russell Steele, J. Wouter Jukema, Anton J.M. de Craen, and Mark J.
J Am Coll Cardiol Volume 51, Issue 1, January 1/8, 2008
Objectives: This study was designed to determine whether statins reduce all-cause mortality in elderly patients with coronary heart disease.
Background: Statins continue to be underutilized in elderly patients because evidence has not consistently shown that they reduce mortality.
Methods: We searched 5 electronic databases, the Internet, and conference proceedings to identify relevant trials. In addition, we obtained unpublished data for the elderly patient subgroups from 4 trials and for the secondary prevention subgroup from the PROSPER (PROspective Study of Pravastatin in the Elderly at Risk) trial. Inclusion criteria were randomized allocation to statin or placebo, documented coronary heart disease, 50 elderly patients (defined as age 65 years), and 6 months of follow-up. Data were analyzed with hierarchical Bayesian modeling.
Results: We included 9 trials encompassing 19,569 patients with an age range of 65 to 82 years. Pooled rates of all-cause mortality were 15.6% with statins and 18.7% with placebo. We estimated a relative risk reduction of 22% over 5 years (relative risk [RR] 0.78; 95% credible interval [CI] 0.65 to 0.89). Furthermore, statins reduced coronary heart disease mortality by 30% (RR 0.70; 95% CI 0.53 to 0.83), nonfatal myocardial infarction by 26% (RR 0.74; 95% CI 0.60 to 0.89), need for revascularization by 30% (RR 0.70; 95% CI 0.53 to 0.83), and stroke by 25% (RR 0.75; 95% CI 0.56 to 0.94). The posterior median estimate of the number needed to treat to save 1 life was 28 (95% CI 15 to 56).
Conclusions: Statins reduce all-cause mortality in elderly patients and the magnitude of this effect is substantially larger than had been previously estimated.
A Hierarchical Bayesian Meta-Analysis
Jonathan Afilalo, Gustavo Duque, Russell Steele, J. Wouter Jukema, Anton J.M. de Craen, and Mark J.
J Am Coll Cardiol Volume 51, Issue 1, January 1/8, 2008
Objectives: This study was designed to determine whether statins reduce all-cause mortality in elderly patients with coronary heart disease.
Background: Statins continue to be underutilized in elderly patients because evidence has not consistently shown that they reduce mortality.
Methods: We searched 5 electronic databases, the Internet, and conference proceedings to identify relevant trials. In addition, we obtained unpublished data for the elderly patient subgroups from 4 trials and for the secondary prevention subgroup from the PROSPER (PROspective Study of Pravastatin in the Elderly at Risk) trial. Inclusion criteria were randomized allocation to statin or placebo, documented coronary heart disease, 50 elderly patients (defined as age 65 years), and 6 months of follow-up. Data were analyzed with hierarchical Bayesian modeling.
Results: We included 9 trials encompassing 19,569 patients with an age range of 65 to 82 years. Pooled rates of all-cause mortality were 15.6% with statins and 18.7% with placebo. We estimated a relative risk reduction of 22% over 5 years (relative risk [RR] 0.78; 95% credible interval [CI] 0.65 to 0.89). Furthermore, statins reduced coronary heart disease mortality by 30% (RR 0.70; 95% CI 0.53 to 0.83), nonfatal myocardial infarction by 26% (RR 0.74; 95% CI 0.60 to 0.89), need for revascularization by 30% (RR 0.70; 95% CI 0.53 to 0.83), and stroke by 25% (RR 0.75; 95% CI 0.56 to 0.94). The posterior median estimate of the number needed to treat to save 1 life was 28 (95% CI 15 to 56).
Conclusions: Statins reduce all-cause mortality in elderly patients and the magnitude of this effect is substantially larger than had been previously estimated.
Recent respiratory infection and risk of cardiovascular disease: case-control study through a general practice database.
Recent respiratory infection and risk of cardiovascular disease: case-control study through a general practice database.
European Heart Journal
Volume 29, Number 1 : January 2008
Aims: Respiratory infection may be associated with an increased risk of major cardiovascular events. This case-control study describes associations with these events of respiratory infection.
Methods and results: The IMS Disease Analyzer Mediplus primary care database was used to identify all cases of first-time diagnosis of myocardial infarction (MI) or stroke and single matched controls. Details were extracted on visits for respiratory infection over the preceding year. A total of 11 155 MI cases and 9208 stroke cases were identified. For MI and stroke respectively, there were 326 and 260 respiratory infections during the month preceding the index date. There was strong evidence of an increased risk of both events in the 7 days following infection, for MI adjusted odds ratio (OR) 2.10 (95% confidence interval 1.38–3.21), for stroke OR 1.92 (95% confidence interval 1.24–2.97). The strength of these associations fell over time. The associations for MI occurred at all levels of initial underlying cardiovascular risk.
Conclusions: There are strong associations between recent respiratory infection and major cardiovascular events, for MI at all levels of underlying risk. The benefits of reducing respiratory infection either through immunization or treating or preventing infection may be substantial.
European Heart Journal
Volume 29, Number 1 : January 2008
Aims: Respiratory infection may be associated with an increased risk of major cardiovascular events. This case-control study describes associations with these events of respiratory infection.
Methods and results: The IMS Disease Analyzer Mediplus primary care database was used to identify all cases of first-time diagnosis of myocardial infarction (MI) or stroke and single matched controls. Details were extracted on visits for respiratory infection over the preceding year. A total of 11 155 MI cases and 9208 stroke cases were identified. For MI and stroke respectively, there were 326 and 260 respiratory infections during the month preceding the index date. There was strong evidence of an increased risk of both events in the 7 days following infection, for MI adjusted odds ratio (OR) 2.10 (95% confidence interval 1.38–3.21), for stroke OR 1.92 (95% confidence interval 1.24–2.97). The strength of these associations fell over time. The associations for MI occurred at all levels of initial underlying cardiovascular risk.
Conclusions: There are strong associations between recent respiratory infection and major cardiovascular events, for MI at all levels of underlying risk. The benefits of reducing respiratory infection either through immunization or treating or preventing infection may be substantial.
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