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Thu, 2014-07-31 14:00 -- OUP Admin

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Blood sugar levels in Heart Failure
Beta blockers in HF plus AF
Good news for Renal Denervation
HTN improved with Renal Denervation
Heparin in HEAT-PPCI
Drug encapsulation reduces cardiac changes
Rheumatic Heart Disease neglected
Free ESC Webinar series
Valve Atlas for iPad
New: EHJ Podcast

Dual antiplatelet treatment no benefit after 1 year from stenting
BCS 'A Year in Cardiology – 2014'
Blood pressure control
Roads and sudden cardiac death
ESC launches new journal
Study results of new stent
 

 

Blood sugar levels predict risk of early death, hospitalisations and diabetes in Heart Failure patients

New research suggests that people who arrive at hospital emergency departments with acute heart failure should have their blood sugar levels checked on arrival. This simple measure could identify patients at high risk of early death, further hospitalisations, or the development of diabetes.

Results of a large study published online 7 January in the European Heart Journal [1], show that even if someone arrives at hospital in heart failure with no prior diagnosis of diabetes if blood sugar levels are above 6.1 mmol/L they are at higher risk of developing diabetes and early death.

Researchers from the Institute for Clinical Evaluative Sciences (ICES), the Peter Munk Cardiac Centre at the University Health Network, and the University of Toronto, Canada, analysed the outcomes for 16,524 people who arrived at hospital emergency departments in Ontario, Canada, with acute heart failure between 2004 and 2007. The patients were aged between 70-85 years old and 56% (9,275) of them did not have pre-existing diabetes.

The researchers compared the outcomes of the patients against a reference group of patients whose blood glucose levels ranged between 3.9-6.1 mmol/L.

Associate Professor of Medicine, Dr Douglas Lee, a senior scientist at the ICES, who led the research, said: “Among patients without pre-existing diabetes, the majority (51%) had blood glucose levels on arrival at hospital that were within ‘normal’ limits but greater than 6.1 mmol/L. Our results suggest that all such patients should undergo further testing for diabetes before discharge. If their fasting blood glucose is not elevated, then they should be monitored subsequently for the development of diabetes as outpatients.

Among all patients, with and without pre-existing diabetes, blood sugar levels above 9.4 mmol/L increased the risks of hospitalisation by 9-15% for heart failure or cardiovascular causes.

Dr Lee said: “Our findings suggest that the measurement of blood sugar levels in all patients arriving at emergency departments with acute heart failure could provide doctors with useful prognostic information and could help to improve outcomes in these patients.

Notes:
[1] “Presentation blood glucose and death, hospitalization, and future diabetes risk in patients with acute heart failure syndromes”, by Maneesh Sud et al. European Heart Journal. doi:10.1093/eurheartj/ehu462

 

Beta-blockers reduce all-cause mortality in heart failure with sinus rhythm but not AF

Beta-blockers lead to a significant reduction in all-cause mortality in heart failure patients with sinus rhythm but not those with atrial fibrillation, according to a study from the Beta-Blockers in Heart Failure Collaborative Group. The individual-patient data meta-analysis included 18,254 patients with heart failure from 10 randomised controlled trials comparing β-blockers with placebo.

Beta-blockers provided significant benefit over placebo in patients with sinus rhythm but not atrial fibrillation in the following outcomes: all-cause mortality, cardiovascular deaths, first cardiovascular hospital admission, death or cardiovascular hospital admission, first heart failure related hospital admission, and cardiovascular death or heart failure related hospital admission. β-blockers had no effect on incident non-fatal stroke in sinus rhythm or atrial fibrillation.

The researchers also found a reduction in incident atrial fibrillation in patients with sinus rhythm who were allocated to β-blockers. While there was no evidence that β-blockers prevent adverse clinical events in patients with heart failure and atrial fibrillation, the therapy appeared to be safe with no increase in mortality or hospital admissions.

The authors concluded that β-blockers should not be used preferentially over other rate control medications and should not be standard therapy to improve prognosis in patients with heart failure and atrial fibrillation.

Read the full paper

 

New analysis of the SYMPLICITY HTN-3 Trial

Key factors of renal denervation may have contributed to the unexpected outcome.

Results of the SYMPLICITY HTN-3 [1] trial sent shock waves through the cardiology community when they appeared to show that there was no significant difference in patient outcome between renal denervation and a sham procedure in patients with drug resistant HTN. As a result, renal denervation procedures came to a halt. Now, an analysis has shown that the results were probably affected by a number of confounding factors that partially explain the unexpected blood pressure responses.
The analysis, published in the European Heart Journal [2], identified factors in the SYMPLICITY HTN-3 trial, such as variations in the performed procedure and changes in patients’ medications and drug compliance, which may have had a significant impact on the results.
 
Professor Thomas Lüscher, editor-in-chief of the European Heart Journal, said: “SYMPLICITY HTN-3 resulted in referrals for the procedure drying up completely, making further trials almost impossible. However, in the analysis published in the European Heart Journal, David Kandzari and colleagues shed light for the first time on the interpretation of the results and suggest that in many patients the number of renal denervations was probably insufficient to achieve the proper degree of reduction in blood pressure that previous research had suggested was possible.”

Prof Lüscher, who has co-authored an editorial [3] to accompany Prof Kandzari’s paper, said: “Professor Kandzari’s analysis shows there were significant variations in the way that patients in SYMPLICITY HTN-3 were ablated. His sub-analysis now shows, for the first time, that if patients received 12 or more ablations in the trial, they experienced the same blood pressure reduction as in the earlier, SYMPLICITY HTN-2 trial and as reported by a large number of registries.”
With this new information, new trials can be performed that may provide the evidence needed to back up anecdotal and registry evidence.

A podcast of the editorial by Felix Mahfoud and Thomas Lüscher is available at eurheartj.oxfordjournals.org/podcast and on iTunes.

Refs:

[1] “A controlled trial of renal denervation for resistant hypertension”, by Deepak L. Bhatt et al. New England Journal of Medicine 2014; 370:1393-1401; April 10, 2014 http://www.nejm.org/toc/nejm/370/15/ ; doi: 10.1056/NEJMoa1402670

[2] “Predictors of blood pressure response in the SYMPLICITY HTN-3 trial”, by David E. Kandzari et al. European Heart Journal. doi:10.1093/eurheartj/ehu441. Published online: http://eurheartj.oxfordjournals.org/content/early/2014/11/13/eurheartj.ehu441

 

[3] “Renal denervation: simply trapped by complexity?”, by Felix Mahfoud and Thomas Felix Lüscher. European Heart Journal. doi:10.1093/eurheartj/ehu450. Published online: http://eurheartj.oxfordjournals.org/content/early/2014/11/13/eurheartj.ehu450

 

REDUCE-HTN shows blood pressure reductions with Renal Denervation

The 6 months results of the REDUCE-HTN trial have shown blood pressure reductions with renal denervation in patients with resistant hypertension. The prospective, multicentre, single-arm study tested the safety and efficacy of the balloon-based bipolar Vessix renal denervation system in 146 patients with office systolic blood pressure ≥160 mmHg despite three or more antihypertensive medications at maximally tolerated doses.

Patients receiving the intervention achieved reductions in both office and ambulatory blood pressure. Renal artery safety and renal function results were favourable. There were no acute events that indicated seriously compromised renal artery integrity or cardiovascular complications and less than 6% of patients had serious procedure related adverse events.

Mean eGFR was stable during the 6 months of follow up. The authors concluded that in addition to lifestyle modifications and antihypertensive medications, renal denervation may be a treatment option for some patients with hypertension.

The full paper is here.

 

HEAT-PPCI shows reduced incidence of major adverse ischaemic events with heparin

HEAT-PPCI was an open-label randomised controlled trial that compared antithrombotic therapy with bivalirudin or unfractionated heparin during primary percutaneous coronary intervention (PPCI). Before angiography, more than 1,800 patients were randomised 1:1 to heparin or bivalirudin then followed up for 28 days.
The use of GP IIb/IIIa inhibitors was reserved for selective bailout use as per European Society of Cardiology guidelines and the rate of use was much the same between groups.

The primary efficacy outcome was a composite of all-cause mortality, cerebrovascular accident, reinfarction, or unplanned target lesion revascularization. The primary safety outcome was incidence of major bleeding.

The primary efficacy outcome occurred in 8.7% of patients in the bivalirudin group and 5.7% of patients in the heparin group (p=0.01). The primary safety outcome occurred in 3.5% of patients in the bivalirudin group and 3.1% of patients in the heparin group (p=0.59).
The study showed that compared with bivalirudin, heparin reduced the incidence of major adverse ischaemic events - in particular acute stent thrombosis and associated reinfarction events – with no difference in bleeding.

The researchers concluded that systematic use of heparin rather than bivalirudin would substantially reduce drug costs.

The full paper is here.

 

Encapsulation of cancer drugs reduces cardiac damage

Austrian researchers have shown that a new technique which wraps chemotherapy drugs in a fatty cover (liposome) reduces heart damage, in a study presented at EuroEcho-Imaging 2014 in Vienna.

Cardiotoxicity can occur acutely or up to 30 years after chemotherapy and is the second most common cause of death in cancer patients, after secondary malignancy in childhood cancer survivors.

Liposomal encapsulation is a new technique which enables more of the drug to reach the cancer cells because there is less degradation. There are fewer side effects on healthy cells because the fat cover acts as a barrier. The drug stays in the bloodstream longer, allowing higher cumulative doses to be given.
Researchers tested whether non-pegylated liposome encapsulation of the anthracycline doxorubicin (called Myocet) could decrease its cardiotoxicity compared to conventional doxorubicin or epirubicin, another anthracycline.

The study included 24 pigs that were randomised to receive the human dose-equivalent of either Myocet, conventional doxorubicin, or epirubicin in 3 cycles. Cardiac function was assessed by echocardiography and magnetic resonance imaging (MRI) at baseline and follow up (after about 3 months). Laboratory follow up included haematology, renal function, and measurement of troponin and BNP. The epirubicin group was excluded from the final analyses because of low survival levels.
The group receiving Myocet had better diastolic and systolic function in the left and right ventricles, compared to conventional doxorubicin. The Myocet group also had less fibrosis development in the myocardium as shown by MRI and histology staining.

 

‘Utter neglect’ of rheumatic heart disease revealed by results from global study

Rheumatic heart disease (RHD) – the most common acquired heart disease in children in many countries of the world – is being neglected and poorly treated, according to new findings from the Global Rheumatic Heart Disease Registry (the REMEDY study), just published online in the European Heart Journal [1].

RHD accounts for up to 1.4 million deaths every year, with the highest numbers of people affected by it and dying occurring in low and middle-income countries.
Results from the pilot phase of the REMEDY study, which looked at 3,343 RHD patients attending one of 25 hospitals in 12 African countries, India and Yemen between January 2010 and November 2012, found that:

  • Only 55% of RHD patients were receiving penicillin (or another antibiotic);
  • Oral anti-coagulants were prescribed in 70% of patients with heart problems that would benefit from it, but less than a third of them were receiving the correct therapeutic levels and 20% of pregnant women were on warfarin;
  • Among the 1,825 women of child-bearing age, only 4 % were taking contraceptive measures,

Professor Bongani Mayosi, Professor of Medicine and head of the Department of Medicine at Groote Schuur Hospital and University of Cape Town, South Africa, who led the research, said: “Our findings reflect the utter neglect of RHD in affected countries. Most of the interventions that are not applied, are available and cheap in the countries concerned, and their application will provide the greatest benefit.”

“At present, the primary healthcare systems are not prioritising these simple, but effective measures. RHD is a disease of poverty, neglected by the health ministries in affected countries and by the international community in general.”

The REMEDY study found that the majority of patients with RHD were young, predominantly female and unemployed. The majority had moderate to severe valvular heart disease, further complicated by congestive heart failure, pulmonary hypertension, atrial fibrillation, stroke and infective endocarditis.

Co-author, Professor Salim Yusuf, said: “The World Health Organization has called upon countries of the world to reduce mortality associated with RHD and other non-communicable diseases by 25% by the year 2025 – known as the 25x25 target. The findings of this study not only set the baseline by which to judge progress, but also point to the need to close the gap in the use of evidence-based interventions if the 25x25 target will be achieved for RHD.”

Prof Mayosi concluded: “We plan to launch the full study of 30,000 patients with RHD from 166 endemic countries from 2015 onwards. The full REMEDY study, which will involve contributors from all inhabited continents of the world, will serve as a platform not only for monitoring progress to the achievement of the 25x25 target, but also for trialling new and novel strategies, such as new oral anti-coagulants, for reducing morbidity and mortality in RHD. REMEDY seeks to put an end to rheumatic heart disease in our own lifetime through the application of preventive measures.”

Notes:

[1] “Characteristics, complications, and gaps in evidence-based interventions in rheumatic heart disease: the Global Rheumatic Heart Disease Registry (the Remedy study)”, by Liesl Zühlke et al. European Heart Journal. doi:10.1093/eurheartj/ehu449

 

Free ESC Webinars for 2014

Check out the latest webinar recordings for free
ACCA Webinar on Prehospital management of cardiac Arrhythmia.

 

 

 

 

Clinical Atlas of Transcatheter Aortic Valve Therapies launched by PCR

The PCR Valve Atlas on aortic valve replacement has been launched as an iPad app. It contains 9 chapters primarily aimed at junior and intermediate practitioners, with a section on complications that will interest experienced interventionists.

Chapter one is focused on the anatomy of the aortic valve apparatus and shows Professor Robert Anderson (UK) describing human aortas on video.
Chapter two covers relevant imaging modalities with all variations of echocardiography, multi slice computed tomography (MSCT) and angiogram imagery.
The third chapter is a parade of all known valve devices that have a CE mark or are in the development pipeline.

Chapter four is dedicated to procedural concepts using moving images of implantations augmented with a 3D phantom model clearly illustrating the various mannerisms of implantations. This is one of the major novelties of the atlas.

The following chapter, five, is entitled complications and bailout procedures and covers the most common complications (cerebrovascular, MI, vascular, device related, etc), presented at the various PCR meetings across the globe. Each case is richly described and illustrated.

With the increased uptake of TAVI comes a need to interpret and treat failing valves with a
valve-in-valve procedure, and this can be found in chapter six. The last three chapters cover items of interest for parties who wish to start up their own TAVI programmes, including accessory equipment , the functioning of the heart valve team, and material set up lists for the TAVI operating table.

The atlas can be downloaded from the iTunes App Store

 

The new European Heart Journal Podcast series is launched

The EHJ with Oxford University Press are delighted to announce that Monday 17th November sees the launch of the first episode in the new, free, European Heart Journal podcast series.  The flagship podcast has been published alongside Dr Felix Mahfoud, and Professor Thomas Lüscher’s editorial "Renal denervation: Symply trapped by complexity?", which accompanies the Fast Track article "Predictors of blood pressure response in the SYMPLICITY HTN-3 trial" from David E. Kandzari et al.

The EHJ Podcast series joins the established suite of digital offerings from the EHJ, building pathways for cardiologists to discover and access the high-quality articles published in the Journal. Each podcast will publish in conjunction with a key Hotline Paper providing an audio summary of the article which can be downloaded and listened to for free.

Not only will cardiologists be able to access the EHJ Podcast series via links from the online table of contents and the Hotline Papers themselves, but individual episodes can be downloaded and listened to via podcast managers such as iTunes. You can also subscribe to the series and receive the latest episodes straight to your device.

With the addition of the EHJ Podcast series you can now listen, watch, and read cutting edge research from the EHJ anytime, anywhere.

The podcasts are available at: eurheartj.oxfordjournals.org/podcast

 

ARCTIC-Interruption trial finds no benefit of DAPT beyond 1 year after stenting

Dual antiplatelet treatment (DAPT) beyond 1 year after drug-eluting stent (DES) implantation provides no benefit and may be harmful in patients with no events in the first year, according to the results of the ARCTIC-Interruption trial.

The trial was a planned extension of the ARCTIC-Monitoring trial, which randomised 2440 patients to a strategy of platelet function testing with antiplatelet treatment adjustment or a conventional strategy after DES implantation. After 1 year, patients with no contraindication to interruption of DAPT were re-randomised to either interruption (624 patients) or continuation (635 patients) of DAPT for a further 6-18 months (ARCTIC-Interruption trial). The primary endpoint was a composite of death, myocardial infarction, stent thrombosis, stroke, or urgent revascularisation, analysed by intention to treat.

After 17 months, there were no differences between the two groups in the primary endpoint, which occurred in 4% of patients in both groups. STEEPLE major bleeding events were more frequent in the continuation (1%) compared to the interruption group (<0.5%) but the difference was not significant. There were significantly more major or minor bleedings in the continuation (2%) versus the interruption group (1%) (p=0.04).

The trial demonstrates that 1 year after stenting just half of the patients could be randomised leading to selection of a low risk population. No conclusions can be made for high-risk patients as they were not randomised.

The authors recommend that guidelines be revisited in favour of shorter duration of DAPT after stenting.

The article can be found here.

 

British Cardiovascular Society ‘A Year in Cardiology – 2014’

‘A Year in Cardiology’ is a very popular one-day symposium, which returns to the Royal College of Physicians in London for its fourth year. Held annually at the end of the international conference calendar by the British Cardiovascular Society, it has rapidly become an essential opportunity for cardiologists to update themselves with the year’s most important developments in Cardiology.

The internationally renowned expert faculty will present a comprehensive review of the headline news for the year. The much anticipated keynote lecture this year will be given by Professor Philippe Gabriel Steg, Professor of Cardiology at the Université Paris and Imperial College London, a leading figure in coronary artery disease.

The morning session provides a succinct update on the important ESC and NICE Guideline updates, whilst the afternoon session reviewing key developments in all major cardiology subspecialties. At the end of each session delegates have the opportunity to pose questions to the speakers in the ‘Ask the Expert’ debate.

This year’s conference will be held on Friday 12 December 2014. The symposium is accredited by EBAC with delegates earning 6 CME or CPD for attendance.

For details on ‘A Year in Cardiology - 2014’ and other symposia run by the British Cardiovascular Society please see www.bcs.com/education/.

 

Doctor visits are greatest predictor of BP control

Visiting a doctor at least twice a year increases likelihood of blood pressure control by more than three-fold compared to one or fewer annual visits.

Visits to the doctor are the greatest predictor of blood pressure control, according to research published in Circulation.

The researchers studied 37,000 adults from the National Health and Nutrition Examination Survey who had their blood pressure checked in 1999-2012. They found that people who visited their doctor at least twice a year were 3.2 times more likely to keep their blood pressure under control than those who saw their doctor once a year or less.

Brent M Egan
Photo courtesy American Heart Association & copyright Greenville Health System

After controlling for diabetes, health insurance, body mass index, smoking and other factors, the investigators found that doctor visits were the strongest predictor of blood pressure control. Having healthcare insurance and getting treated for high cholesterol also increased the likelihood of controlling blood pressure.

Obese people in the study were also more likely to keep their blood pressure under control. This is ‘probably because doctors recognise the need to control risk factors and may be quicker to give them blood pressure medications’, said study author Brent M. Egan (Greenville, South Carolina, US).

 

Living near major roads may increase risk of sudden cardiac death in women

Living near a major road may increase women’s risk of dying from sudden cardiac death (SCD), according to new research.

On a population level, living near a major roadway was as important a risk factor as smoking, poor diet or obesity.

The researchers studied data from 107,130 women (predominately white, average age 60) who took part in the prospective Nurses’ Health Study from 1986-2012. A total of 523 cases of SCD were identified over 26 years of follow-up. The distance from roadways to homes was calculated.

After adjusting for a large number of factors including age, race, calendar time, cigarette smoking, physical activity and diet, the researchers found that living within 50 metres of a major road increased the risk of SCD by 38% compared to living at least 500 metres away. Each 100 metres closer to roadways was associated with a 6% increased risk for SCD. In the 1,159 cases of fatal coronary heart disease, risk increased by 24%.

The investigators said that the public’s exposure to major roadways was comparable to major SCD risk factors. They added that more research was needed among men and among women of different ages, races and income levels because nearly all participants in the study were middle-age to elderly, white and of middle- to upper-socioeconomic class.

The next step in their research will be to determine what specific exposures, such as air pollution, are driving the association between heart disease and major roadway proximity.

The Circulation paper can be found here.

 

ESC Launches Journal on Cardiovascular Pharmacotherapy

A new ESC journal on cardiovascular pharmacotherapy was launched at ESC Congress by the ESC and Oxford University Press. European Heart Journal – Cardiovascular Pharmacotherapy officially starts publishing in 2015. The journal’s website went live in September 2014.

Editor in chief Professor Stefan Agewall said: “We aim to become the number one journal in the field of clinical cardiovascular pharmacology within a couple of years.” The journal aims to improve the pharmacological treatment of patients with cardiovascular disease. Four issues will be published in 2015. Prof Agewall said: “The number of issues will increase annually with the goal of producing a monthly publication within 5 to 6 years.”

An expert and respected editorial board has been recruited from across the globe. Prof Agewall brings significant clinical, research and editorial experience to his role as editor in chief. Currently professor and senior consultant in cardiology at Oslo University Hospital and Oslo University in Norway, he has worked in cardiology for 20 years splitting his time between clinics, research and education.

 

Combo Dual Therapy Stent Findings Presented at TCT Meeting

Prof. Stephen W.L. Lee MD presented two-year optical coherence tomography (OCT) findings and three-year clinical follow up from the EGO COMBO study, showing the healing benefits of the COMBO™ Dual Therapy Stent, a drug eluting stent (DES) with active endothelial projenitor cell (EPC) capture technology. The findings were presented during the 26th Annual Transcatheter Cardiovascular Therapeutics (TCT) meeting, in Washington, D.C., 13-17 September, 2014.

“This is the first study to assess the healing profile of a dual therapy stent by optical coherence tomography,” said Dr Lee of the Queen Mary Hospital, Hong Kong. “The COMBO Stent approach shows early healing benefits and stability over the long-term. The results demonstrate no neoatherosclerosis observed by OCT at 24 months, and no late restenosis or stent thrombosis by 36 months.”

Latest evidence surrounding the COMBO Stent’s active EPC capture was also presented by Prof. Michael Haude, M.D., Lukaskrankenhaus, Neuss, Germany, who demonstrated how the COMBO Stent uses a bound antibody to capture EPCs and promotes accelerated endothelial coverage. The Stent has an abluminal sirolimus drug elution delivered from a biodegradable polymer that is dissipated within 90 days.

Prof. Haude said, “With the dual therapy approach of the COMBO Stent, the abluminal sirolimus release from a bioresorbable polymer matrix controls the restenosis and neointimal proliferation, whilst the luminal surface is coated with an antibody that enables an earlier and more mature healing of the stented lesion. Delayed healing is of continued concern in conventional DES today as it leads to stent thrombosis and in the long-term, to neoatherosclerosis. The COMBO Stent helps to address these concerns and may offer a long-term solution.”

More information at www.OrbusNeich.com.

 

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