Category: Cardiovascular Disease

Categories : Cardiovascular Disease Surgeries & ProceduresTags :

Troponin Levels Help Inform When to Perform Surgery after Heart Attack

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Photo by Natanael Melchor on Unsplash

New research from a large study published in the International Journal of Cardiology shows that timing of surgery for some heart attack patients can be improved by analysing troponin levels.

Troponin is a protein involved in muscle contraction that is released into the bloodstream after heart attack, with higher levels indicating more heart damage. Troponin levels help clinicians to determine whether a patient is having a heart attack, or myocardial infarction (MI), and to decide on treatment options such as coronary artery bypass graft (CABG) surgery.

The optimal time to perform surgery following an MI remains unclear. Previous reports have suggested that carrying out surgery in the first few days following an MI is associated with a higher risk of surgical complications and death by not leaving time for the heart to recover. As a result, following an MI, many patients who need bypass surgery wait for more than 10 days before surgery is performed.

Researchers in this study found that some patients who have lower levels of troponin would benefit from having earlier surgery. However, the researchers show that patients with very high troponin levels should have surgery postponed, as their risk of dying was higher if surgery was performed within 10 days of their MI.

There was no benefit in delaying surgery for those with low levels of troponin, according to the study.

Early surgery for MI patients

The researchers suggest that early surgery for MI patients with lower troponin levels would reduce overall length of stay and ease pressure on resources such as staff.

This is the first multicentre study to investigate the interaction between the extent of heart damage, as indicated by troponin levels, and the optimal time to wait for surgery in a large series of MI patients. 

Dr Amit Kaura, lead author of the research, said: “The approach on the safest time to operate on patients following a heart attack varies in hospitals across the UK. Our study could help clinicians make more informed decisions on the best treatment plans for heart attack patients requiring surgery, based on their levels of troponin. It could also lead to a more standardised approach in the NHS on how we treat this patient group, leading to resources being used effectively, shorter stays and improved outcomes for patients.”

The study reviewed patients who had a non-ST segment elevation myocardial infarction (NSTEMI) due to a blockage to their coronary arteries who required a CABG.

About 20% of NSTEMI patients have a CABG. The optimal timing for CABG surgery in patients with uncomplicated NSTEMI has been unclear. Prior to the new research, some studies had suggested that early surgery was associated with higher mortality post operation. This has led to a tendency for CABG to be delayed if a patient’s condition remains stable. However, other studies had reported similar mortality rates after early versus late surgery, concluding that delaying surgery in all patients after uncomplicated NSTEMI is not warranted and does not improve outcomes. No previous study had investigated in a large group of patients whether there was an association between the extent of heart damage (as measured by troponin levels) and the wait for surgery on survival.

Heart data insights

The team analysed data from the NIHR HIC of 1746 patients with NSTEMI and unstable angina (UA) where insufficient cardiac blood supply leads to an MI. The cohort consisted of 1684 patients with NSTEMI and 62 with UA. The average age of the group was 69 and 21% were female. They underwent CABG within 90 days at one of five cardiac centres before their surgery between 2010 and 2017. 

The researchers compared patients’ troponin levels, wait between surgery and outcomes after surgery within the first 30 days and over a period of five years. Pre-operative troponin level strongly predicted early mortality, and this was significantly influenced by the interval to surgery. The average wait for patients with high troponin levels to surgery was nine days. Sixty patients died within 30 days after surgery and another 211 patients died over a period of five years following surgery. They found that for those who had troponin levels of less than 100 times the normal upper limit, delaying surgery to after 10 days was not associated with lower survival. For patients with higher troponin levels, early survival increased progressively with a longer time to surgery – survival was highest in those who had surgery after day 10. 

Dr Amit Kaura said: “For patients with troponin levels of under 100 times the normal upper limit, extending the waiting time or surgery did not improve early survival. This finding is particularly significant as two-thirds of patients presenting with troponin levels of under 100 are waiting on average 12 days for surgery after being admitted to hospital. There are potential cost saving implications with our research by performing earlier surgery in this group of patients with lower troponin levels”.

The effect of troponin levels pre-operation on survival was limited to the first 30 days after surgery. Late survival was determined by other risk factors, such as age and other co-morbidities such as hypertension.

Further studies are needed in the form of prospective trials to assess the impact of troponin and timing of surgery on survival following a heart attack, the researchers say.

Source: Imperial College London

Categories : Cardiovascular DiseaseTags :

Nanoparticles Amplify Benefits of Magnetic Stroke Treatment

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Chinese researchers have reported in Materials Today Chemistry that magnetic brain stimulation combined with a nasal spray containing nanoparticles can improve recovery in a mouse model of ischaemic stroke.

The nasal spray non-invasively delivers magnetic nanoparticles into the brain, which serve to amplify the benefits of transcranial magnetic stimulation (TMS). TMS is a method of non-invasive brain stimulation already used clinically or in clinical trials to treat neurological conditions like stroke, Parkinson’s disease, Alzheimer’s disease, depression, and addiction.

Rats that were given combined nanoparticle and TMS treatment every 24 hours for 14 days after an ischaemic stroke had better overall health, put on weight more quickly and had improved cognitive and motor functions compared to those treated with TMS alone. TMS stimulation uses a magnetic field to induces an electrical current in the brain, but is often not able to penetrate deeply enough.

In this new study, the researchers show that magnetic nanoparticles, administered intranasally, can make neurons more responsive and amplify the magnetic signal from TMS to reach deeper brain tissue, aiding recovery. The finding offers new opportunities for treating neurological disorders. 

From impossible to possible

The research answers a key question in nanomedicine – whether it is possible to enhance TMS by using nanoparticles that are non-invasively delivered into the brain. Experts had believed that it was almost impossible because of the blood-brain barrier.

However, the team of researchers overcame this by guiding the magnetic nanoparticles closer to the correct area with a large magnet near the head. 

Dr Gang Ruan, a corresponding author of the study, said: “We were able to overcome the blood-brain barrier and send enough nanoparticles into the brain to use in combination with TMS simulation to improve recovery from stroke. 

“TMS devices are already used for the clinical treatment of neurological disorders but have severe limitations in terms of stimulation strength and depths of the brain they can penetrate. 

“By non-invasively putting magnetic nanoparticles into the brain, we can amplify and enhance the TMS stimulation effects on neurons, making the treatment more effective,” Dr Ruan added.

“Showing it is possible to use nanoparticles in this way paves the way for medical applications of nanoparticles for other neurological disorders.”

Crossing barriers 

The iron oxide nanoparticles, normally used to treat anaemia, were coated various non-toxic substances. 

Dr Ruan explained: “The coating causes the nanoparticles to stick to the blood-brain barrier, increasing their chances of passing through it. Without this coating, the particles just bounce back from the barrier instead of crossing it.

“The modifications of the iron oxide particles also ensure that the nanoparticles can stick to the neurons and increase their responsiveness to TMS stimulation.”

The safety of using the modified nanoparticles needs to be assessed in clinical trials but has the potential to be used in combination with TMS, and other methods such as brain imaging, to gain more insight into how the brain works and improve the treatment of neurological disorders. 

“Many scientists still think it is impossible to non-invasively send enough nanoparticles into the brain to affect brain function. Yet we have shown that it is possible,” said Dr Ruan.

“We combined the expertise on our team in four different disciplines, materials science, biophysics, neuroscience, and medical science, to push the boundaries of our knowledge and challenge what is currently thought in the field.”

Source: EurekAlert!

Categories : Cardiovascular DiseaseTags :

Coffee Extends Life as Well as Consciousness

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Coffee cup and beans
Photo by Mike Kenneally on Unsplash

Coffee lovers have another thing to rejoice about: drinking two to three cups of coffee a day is linked with a longer lifespan and lower risk of cardiovascular disease (CVD) compared with avoiding coffee, according to a study in the European Journal of Preventive Cardiology. The association was strongest with drinking ground coffee, though instant and decaffeinated preparations also showed this benefit.

“In this large, observational study, ground, instant and decaffeinated coffee were associated with equivalent reductions in the incidence of cardiovascular disease and death from cardiovascular disease or any cause,” said study author Professor Peter Kistler of the Baker Heart and Diabetes Research Institute, Melbourne. “The results suggest that mild to moderate intake of ground, instant and decaffeinated coffee should be considered part of a healthy lifestyle.”

There is little information on the impact of different coffee preparations on heart health and survival. This study examined the associations between types of coffee and incident arrhythmias, CVD and death using data from the UK Biobank, with participants aged 40–69. CVD was comprised of coronary heart disease, congestive heart failure and ischaemic stroke.

The study included 449 563 participants free of arrhythmias or other CVD at baseline. The median age was 58 years and 55.3% were women. Participants completed a questionnaire asking how many cups of coffee they drank each day and whether they usually drank instant, ground (such as cappuccino or filtered coffee), or decaffeinated coffee. They were then grouped into six daily intake categories, consisting of none, less than one, one, two to three, four to five, and more than five cups per day. The usual coffee type was instant in 198 062 (44.1%) participants, ground in 82 575 (18.4%), and decaffeinated in 68 416 (15.2%). A comparator group of 100 510 (22.4%) non-coffee drinkers was included.

Coffee drinkers were compared to non-drinkers for the incidence of arrhythmias, cardiovascular disease and death, after adjusting for age, sex, ethnicity, obesity, hypertension, diabetes, obstructive sleep apnoea, smoking status, and tea and alcohol consumption. Outcome information was obtained from medical records and death records. The median follow up was 12.5 years.

A total of 27 809 (6.2%) participants died during follow up. All types of coffee were linked with a reduction in death from any cause. The greatest risk reduction seen with two to three cups per day, which compared to no coffee drinking was associated with a 14%, 27% and 11% lower likelihood of death for decaffeinated, ground, and instant preparations, respectively.

CVD was diagnosed in 43 173 (9.6%) participants during follow up. All coffee subtypes were associated with a reduction in incident cardiovascular disease. Again, the lowest risk was observed with two to three cups a day, which compared to abstinence from coffee was associated with a 6%, 20%, and 9% reduced likelihood of cardiovascular disease for decaffeinated, ground, instant coffee, respectively.

During follow up, an arrhythmia was diagnosed in 30 100 (6.7%) participants. Ground and instant coffee, but not decaffeinated, was associated with a reduction in arrhythmias including atrial fibrillation. Compared with non-drinkers, the lowest risks were observed with four to five cups a day for ground coffee and two to three cups a day for instant coffee, with 17% and 12% reduced risks, respectively.

Professor Kistler said: “Caffeine is the most well-known constituent in coffee, but the beverage contains more than 100 biologically active components. It is likely that the non-caffeinated compounds were responsible for the positive relationships observed between coffee drinking, cardiovascular disease and survival. Our findings indicate that drinking modest amounts of coffee of all types should not be discouraged but can be enjoyed as a heart healthy behaviour.”

Source: European Society of Cardiology

Categories : Cardiovascular Disease Diet and NutritionTags :

Milk Risky for CVD Patients – but Perhaps not Cheese

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Source: Pixabay CC0

For people with established cardiovascular disease (CVD), consuming more dairy products was linked to worse health outcomes, according to a study in the European Journal of Preventive Cardiology. However, the type of dairy product appeared to make a difference, with the outcomes for cheese remaining unclear.

In patients with stable angina, significant associations with stroke, cardiovascular mortality, and all-cause mortality were seen with increasing daily intakes of total dairy and milk over follow-up of 5 to 14 years.

While acute myocardial infarction (MI) had no clear linear relationship with total dairy intake or milk consumption, a risk increase was seen for butter consumption of more than 2g per 1000kcal of daily intake.

Data were also inconclusive when it came to cheese consumption and CVD risk, with no significant associations between greater cheese consumption with acute MI, stroke, CVD mortality, or all-cause mortality.

Thus, the study draws a more complicated picture of dairy’s risks that supports other observational data suggesting that different dairy products may have different effects. “We can speculate that at least part of the differential associations seen for milk, butter, and cheese may be because cheese contains intact MFGM [milk fat globule membrane], while milk and butter does [sic] not,” the researchers wrote.

Dairy is “probably harmful” overall, the verdict on cheese is unclear, and some of the fermented dairy products may be less dangerous if dairy is to be consumed at all, commented Andrew Freeman, MD, a cardiologist at National Jewish Health in Denver, who was not involved with the study.

Even without a randomised trial, Dr Freeman said in an interview, “there’s enough signal in the noise to draw the conclusion that higher-fat dairy products, the number one source of saturated fat in our diet, are probably not going to be helpful to human health, and heart health in particular.”

He nevertheless cautioned that there may be worldwide variation in the effects of dairy products, which may be different between countries that place more restrictions on raising cattle with chemicals such as growth hormones.

Nevertheless, the global PURE study of people around the world consistently found the best outcomes from eating a balanced diet including lots of fruits and vegetables and a modest amount of dairy, unprocessed red meat, and nuts and legumes. The PURE investigators had also reported that at least two servings of dairy per day was linked with less CVD and mortality, compared with no dairy.

“Dairy is a heterogenous food group with divergent health effects and dairy products should therefore be investigated individually,” the researchers maintained.

Their data was drawn from 1929 patients with stable angina (80% men, mean age 62 years) from the Western Norway B Vitamin Intervention Trial.

All had undergone coronary angiography due to suspected coronary artery disease or aortic stenosis in 1999–2004. Use of preventive medications was high and included aspirin (90%), statins (90%), and beta-blockers (77%).

Participants self-reported dietary habits on a food frequency questionnaire. Average dairy intake was 169g/1000 kcal; mostly milk (133g/1000 kcal).

Bias and confounding were possible due to the observational nature of the study: people who ate more dairy already tended to eat less meat, vegetables, fruit and berries, fish, and potatoes. These individuals also got more calories from protein and less from fats (except saturated fats).

Further limitations include the lack of additional dietary evaluations over years of follow-up and the potential for participants to mischaracterize their diets on a survey.

Source: MedPage Today

Categories : Ageing Cardiovascular DiseaseTags :

More Older Adults Should Monitor Blood Pressure at Home

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Blood pressure cuff
BP cuff for home monitoring, Source: Pixabay

Only 48% of people age 50 to 80 taking blood pressure medications or have a health condition affected by hypertension regularly check their blood pressure at home or other places, found a new study published in JAMA Network Open.

A somewhat higher number (62%) say a health care provider encouraged them to perform such checks. Poll respondents whose providers had recommended they check their blood pressure at home were three and a half times more likely to do so than those who didn’t recall getting such a recommendation.

The findings underscore the importance of exploring the reasons why at-risk patients aren’t checking their blood pressure, and why providers aren’t recommending they check — as well as finding ways to prompt more people with these health conditions to check their blood pressure regularly. This could play an important role in helping patients live longer and maintain heart and brain health, the study’s authors say.

Past research has shown that regular home monitoring can help with blood pressure control, and that better control can mean reduced risk of death; of cardiovascular events including strokes and heart attacks; and of cognitive impairment and dementia.

A team from Michigan Medicine, the University of Michigan’s academic medical centre, conducted the research. The data come from the National Poll on Healthy Aging and build on a report issued last year.

The poll, based at the U-M Institute for Healthcare Policy and Innovation and supported by Michigan Medicine and AARP, asked adults aged 50 to 80 about their chronic health conditions, blood pressure monitoring outside of clinic settings, and interactions with health providers about blood pressure. Study authors Mellanie V. Springer, M.D., M.S., of the Michigan Medicine Department of Neurology, and Deborah Levine, M.D., M.P.H., of the Department of Internal Medicine, worked with the NPHA team to develop the poll questions and analyze the findings.

The data in the new paper come from the 1,247 respondents who said they were either taking a medication to control their blood pressure or had a chronic health condition that requires blood pressure control — specifically, a history of stroke, coronary heart disease, congestive heart failure, diabetes, chronic kidney disease or hypertension.

Of them, 55% said they own a blood pressure monitor, though some said they don’t ever use it. Among those who do use it, there was wide variation in how often they checked their pressure — and only about half said they share their readings with a health provider. But those who own a monitor were more than 10 times more likely to check their blood pressure outside of health care settings than those who don’t own one.

The authors note that blood pressure monitoring is associated with lower blood pressure and is cost-effective. They say that the results suggest that protocols should be developed to educate patients about the importance of self blood pressure monitoring and sharing readings with clinicians.

Source: Michigan Medicine – University of Michigan

Categories : Cardiovascular DiseaseTags :

Switch to Tenecteplase for Ischaemic Strokes Improves Outcomes and Lowers Costs

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Credit: American Heart Association

A newer, faster-administration clot-busting drug called tenecteplase outperforms the traditional treatment for ischaemic strokes in several key areas, including better health outcomes and lower costs, according to a new study published in the journal Stroke.

The 15-month study was led by a team of neurologists at Dell Medical School at The University of Texas at Austin.

“The Dell Med Neurology Stroke Program was one of the first in the United States to make this change,” said Steven Warach, MD, lead author of the study . “Based on even the earliest results from this study, other experts across the country were convinced and made the switch from alteplase to tenecteplase at their own stroke centres, including at Ascension hospitals nationwide.” 

The vast majority of strokes of the 800 000 strokes in the US (about 87%) each year are ischaemic.

Both tenecteplase and alteplase are federally approved for use in dissolving clots in blocked heart arteries. But the newer drug tenecteplase is also being used by clinicians, off-label, to treat ischaemic strokes, because clinical trials in stroke suggest that it may be at least as good as alteplase and it is easier to administer. Tenecteplase is administered by a single five- to 10-second intravenous injection. The researchers compared its performance with the standard drug for stroke, alteplase, which is injected over 60 minutes.

“When it comes to treating patients with a stroke, every second matters,” said Warach, who is also a professor of neurology at Dell Med. “The shorter preparation and injection time with tenecteplase not only eliminates a lot of dosing errors related to alteplase, but it’s also more efficient. We were able to deliver the clot-busting medicine more quickly after patients arrived in the emergency department, and for patients who needed to be transferred to another hospital for more advanced care after receiving the clot buster, we were able to initiate the transfer sooner in those treated with tenecteplase.”

For patients who come into the emergency department after a stroke, Warach’s study found that the “door-to-needle” time (from patients’ arrival to treatment) was on average six minutes quicker with tenecteplase. And for patients who also required a thrombectomy, the surgical removal of a blood clot causing the stroke, tenecteplase slashed to the time to transferring the patient to a thrombectomy-capable stroke centre by 25 minutes.

Researchers also saw improvements in clinical outcomes for patients given tenecteplase, including:

  • A 5% increase in patients who were able to walk independently at time of hospital discharge to home.
  • A 4% decrease in occurrences of bad events such as brain haemorrhages, discharge to hospice care or death.

The third major improvement: cost. The research team found that tenecteplase treatment cost the hospitals about US$ 2500 less than alteplase per patient.

Source: EurekAlert!

Categories : Cardiovascular Disease HIVTags :

People with HIV and Hepatitis C Have Increased Heart Attack Risk

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Source: Wikimedia Commons CC0

As people with HIV age, their risk of myocardial infarction increases far more if they also have untreated hepatitis C virus, according to new research published today in the Journal of the American Heart Association.

According to the findings, even with antiretroviral therapy (ART), the risk of myocardial infarction (MI) among people with HIV is at least 50% higher than people without HIV. This new study evaluated if people with HIV who also have hepatitis C have a higher risk of MI.

“HIV and hepatitis C coinfection occurs because they share a transmission route – both viruses may be transmitted through blood-to-blood contact,” said Associate Professor Keri N. Althoff, PhD, MPH, senior author of the study. “Due in part to the inflammation from the chronic immune activation of two viral infections, we hypothesised that people with HIV and hepatitis C would have a higher risk of heart attack as they aged compared to those with HIV alone.”

Researchers analysed health information for 23 361 people with HIV in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) between 2000–2017 started on antiretroviral treatment for HIV, median age 45 at enrolment. One in 5 study participants (4677) were also positive for hepatitis C. During a median follow-up of about 4 years, the researchers compared the occurrence of a heart attack between the HIV-only and the HIV-hepatitis C co-infected groups as a whole, and by each decade of age.

The analysis found:

  • With each decade of increasing age, MI incidence increased 30% in people with HIV alone and 85% in those who were also positive for hepatitis C.
  • The risk of heart attack increased in participants who also had traditional heart disease risk factors such as high blood pressure (more than 3 times), smoking (90%) and Type 2 diabetes (46%).
  • The risk of heart attack was also higher (40%) in participants with certain HIV-related factors such as low levels of CD4 immune cells (200 cells/mm3, signalling greater immune dysfunction) and 45% in those who took protease inhibitors (one type of ART linked to metabolic conditions).

“People who are living with HIV or hepatitis C should ask their doctor about treatment options for the viruses and other ways to reduce their cardiovascular disease risk,” said Assistant Professor Raynell Lang, MD, MSc, lead study author.

“Several mechanisms may be involved in the increased heart attack risk among co-infected patients. One contributing factor may be the inflammation associated with having two chronic viral infections,” A/Prof Lang said. “There also may be differences in risk factors for cardiovascular disease and non-medical factors that influence health among people with HIV and hepatitis C that plays a role in the increased risk.”

“Our findings suggest that HIV and hepatitis C co-infections need more research, which may inform future treatment guidelines and standards of care,” Althoff said.

The study is limited by not having information on additional factors associated with heart attack risk such as diet, exercise or family history of chronic health conditions. Results from this study of people with HIV receiving care in North America may not be generalizable to people with HIV elsewhere. In addition, the study period included time prior to the availability of more advanced hepatitis C treatments.

“Because effective and well-tolerated hepatitis C therapy was not available during several years of our study period, we were unable to evaluate the association of treated hepatitis C infection on cardiovascular risk among people with HIV. This will be an important question to answer in future studies,” Lang said.

Source: American Heart Association

Categories : Cardiovascular DiseaseTags :

Elevated Cardiovascular Disease Risk in Adults with ADHD

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Adults with ADHD have a greater risk of developing a range of cardiovascular diseases than those without the condition, according to a large observational study. The study researchers say that these findings, published in the journal World Psychiatry, underscore the need to monitor cardiovascular health in people with ADHD.

Attention deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders, with a global prevalence of around 2.5% in adults. It often exists in parallel with other psychiatric and physical conditions, some of which have been linked to an increased risk of cardiovascular disease (CVD). But whether ADHD is independently associated with overall and specific cardiovascular diseases has not received as much attention.

In the current study, led by Karolinska Institutet and Örebro University, the researchers investigated associations between ADHD and some 20 different cardiovascular diseases when separated from other known risk factors such as smoking and diabetes.

A doubled risk

“We found that adults with ADHD were more than twice as likely to develop at least one cardiovascular disease, compared with those without ADHD,” says the study’s first author Lin Li, postdoctoral researcher at Karolinska Institutet. “When we accounted for other well-established risk factors for CVDs, the association weakened but still remained significant, which indicates that ADHD is an independent risk factor for a wide range of cardiovascular diseases.”

The study accessed data of more than five million Swedish adults, of which some 37 000 had ADHD. After an average 11.8 years of follow-up, 38% of individuals with ADHD had at least one diagnosis of cardiovascular disease, compared with 24% of those without ADHD.

Risks were elevated for all types of cardiovascular diseases and especially high for cardiac arrest, haemorrhagic stroke and peripheral vascular diseases, with somewhat stronger associations in men than in women. Some psychiatric comorbidities, especially eating and substance use disorders, significantly increased the risk of cardiovascular disease in people with ADHD. Pharmacological treatments for ADHD, such as anti-anxiety drugs, did not significantly affect the association between ADHD and cardiovascular disease. A causal link could not be established due to the observational nature of the study, and limitations included a lack of information about confounding factors such as lifestyle.

Important information for clinicians

“Clinicians needs to carefully consider psychiatric comorbidity and lifestyle factors to help reduce the CVD risk in individuals with ADHD, but we also need more research to explore plausible biological mechanisms, such as shared genetic components for ADHD and cardiovascular disease,” said Henrik Larsson, the study’s last author, a professor at the School of Medical Sciences, Örebro University, and affiliated researcher at Karolinska Institutet.

Source: Karolinska Institutet

Categories : Cardiovascular DiseaseTags :

With Warfarin, Dropping Aspirin Reduces Bleeding Complications for Some

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Red blood cells
Source: Pixabay

Research from Michigan Medicine suggests that, for venous thromboembolism (VTE) or atrial fibrillation (AF) patients without a history of heart disease who are taking warfarin, stopping aspirin use causes their risk of bleeding complications to drop significantly.

For the study, which is published in JAMA Network Open, researchers analysed over 6700 people treated at anticoagulation clinics across Michigan for VTE as well as AF. Patients were treated with warfarin but also took aspirin despite not having history of heart disease.

“We know that aspirin is not a panacea drug as it was once thought to be and can in fact lead to more bleeding events in some of these patients, so we worked with the clinics to reduce aspirin use among patients for whom it might not be necessary,” said senior study author and cardiologist Geoffrey Barnes, MD.

Over the course of the study, aspirin use among patients fell by 46.6%. With aspirin used less commonly, the risk of a bleeding complication dropped by 32.3% – equivalent to preventing one major bleeding event per every 1000 patients who stop taking aspirin.

“When we started this study, there was already an effort by doctors to reduce aspirin use, and our findings show that accelerating that reduction prevents serious bleeding complications which, in turn, can be lifesaving for patients,” said Dr Barnes. “It’s really important for physicians and health systems to be more cognisant about when patients on a blood thinner should and should not be using aspirin.”

Several studies had found concerning links between concurrent use of aspirin and different blood thinners, which prompted this aspirin de-escalation.

One study reported that patients taking warfarin and aspirin for AF and VTE experienced more major bleeding events and had more ER visits for bleeding than those taking warfarin alone. Similar results were seen for patients taking aspirin and direct oral anticoagulants – who were found more likely to have a bleeding event but not less likely to have a blood clot.

“While aspirin is an incredibly important medicine, it has a less widely used role than it did a decade ago,” Dr Barnes said. “But with each study, we are seeing that there are far fewer cases in which patients who are already on an anticoagulant are seeing benefit by adding aspirin on top of that treatment. The blood thinner they are taking is already providing some protection from clots forming.”

For some people, aspirin can be lifesaving. Many patients who have a history of ischaemic stroke, heart attack or a stent placed in the heart to improve blood flow — as well as those with a history of cardiovascular disease — benefit from the medication.

The challenge comes when some people take aspirin without a history of cardiovascular disease and are also prescribed an anticoagulant, said first author Jordan Schaefer, MD.

“Many of these people were likely taking aspirin for primary prevention of heart attack or stroke, which we now know is less effective than once believed, and no one took them off of it when they started warfarin,” Dr Schaefer said. “These findings show how important it is to only take aspirin under the direction of your doctor and not to start taking over-the-counter medicines like aspirin until you review with your care team if the expected benefit outweighs the risk.”

Source: Michigan Medicine – University of Michigan

Categories : Cardiovascular DiseaseTags :

SGLT2 Inhibitors may be Effective for All HF Ejection Fractions

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Researchers presented new evidence that SGLT2 inhibitors may benefit a wide range of patients with heart failure (HF). At the ESC Congress 2022 in Barcelona, and in simultaneous publications in The New England Journal of Medicine and The Lancet, physician-scientists presented late-breaking research from the largest trial to date of heart failure patients with mildly reduced or preserved ejection fraction (EF).

They showed that dapagliflozin, which had previously been shown to benefit patients with heart failure with reduced ejection fraction (HFrEF), is likely to also reduce cardiovascular death and hospitalisation for patients with mildly reduced or preserved EF, for whom therapeutic options are limited. A meta-analysis that included two clinical trials further strengthened the evidence that this class of drugs may provide protection for a wide range of heart failure patients.

Scott Solomon, MD, at the Brigham, presented results from the AstraZeneca-funded DELIVER trial, a randomised, placebo-controlled trial of dapagliflozin among patients with heart failure with mildly reduced or preserved EF.

“In the largest and most inclusive trial of heart failure with mildly reduced or preserved ejection fraction, we found that treatment with the SGLT2 inhibitor dapagliflozin can benefit patients across the full spectrum of heart failure,” explained Dr Solomon. “These findings establish SGLT2 inhibitors as foundational treatment for patients living with heart failure, regardless of ejection fraction, to help prevent hospitalisation and morbidity and to extend meaningful survival and improve health-related quality of life. These are the outcomes that matter most to patients and to clinicians – to keep patients feeling well and living longer.”

Muthiah Vaduganathan, MD MPH, also at the Brigham, presented results from a pre-specified meta-analysis of DELIVER and EMPEROR-Preserved, a large-scale clinical trial of empagliflozin, funded by Boehringer Ingelheim and Eli Lilly.

“Our meta-analysis, encompassing more than 12 000 patients, provides a summary of the totality of the evidence and drives home the message that, when it comes to heart failure, this is a therapy for all,” said Dr Vaduganathan. “These trials included patients across a broad range of ages, race, functional class, sex and medical histories, but regardless of individual characteristics, they benefited consistently from this treatment.”

Dapagliflozin is a sodium-glucose co-transporter-2 (SGLT2) inhibitor, which causes the body to excrete sugar in urine. As well as blood glucose control in diabetes, SGLT-2 inhibitors have been shown to provide significant cardiovascular and kidney disease benefits. The DELIVER trial was designed to determine whether dapagliflozin would decrease cardiovascular morbidity and mortality in patients with heart failure with mildly reduced or preserved EF.

The international trial enrolled patients aged 40 or older and had symptomatic HF with an EF of greater than 40%, including mildly reduced ejection fraction and preserved EF, as well as patients who had previously had reduced EF that had improved to greater than 40%, and in both the outpatient and inpatient setting. More than 6000 participants were randomised to receive dapagliflozin or placebo and followed for a median of 2.3 years. The primary endpoint was a composite of cardiovascular death or worsening heart failure.

Dapagliflozin significantly reduced the primary composite endpoint by 18 percent. In the dapagliflozin group, 11.8% experienced worsening heart failure compared to 14.5% of the placebo group. Cardiovascular death in these groups occurred in 7.4 % and 8.3% of participants, respectively. Key secondary outcomes were also significantly reduced, including total heart failure hospitalisations and total symptom burden.

The meta-analysis used data from DELIVER and EMPEROR-Preserved, with a composite of cardiovascular death or first hospitalisation for heart failure. SGLT2 inhibitors were found to reduce primary outcome risk by 20%. Effects were consistent across subgroups by age, sex, race, body mass index, systolic blood pressure, history of various medical conditions and more.

The team further incorporated data from additional clinical trials with SGLT2 inhibitors, including those performed with dapagliflozin and empagliflozin in patients with HFrEF, and in patients from a clinical trial of the SGLT1/2 inhibitor sotagliflozin. Taken together, the evidence with all these data suggest that patients across the full spectrum of HF benefit from this class of drugs, regardless of EF or care setting.

Limitations were noted by the authors. Black patients made up less than 5% of the patients enrolled in DELIVER; the COVID pandemic limited symptom assessment after March 2020; and subgroups in the trial were underpowered. However, findings were consistent across prespecified subgroups.

“There are more than 64 million people worldwide affected by heart failure, half of whom have mildly reduced or preserved ejection fraction,” said Dr Solomon. “Our goal is to rigorously and scientifically evaluate potential treatments so that we can provide the best evidence-based care to help them lead longer, healthier lives.”

Source: Brigham and Women’s Hospital