Tag: cardiovascular disease

New Easy Biomarker for Cardiovascular Risk

Image by Landon Arnold on Unsplash

A large study has shown that apolipoproteins apoB and apoA-1 together provide early and reliable cardiovascular risk information as well as levels of low-density lipoprotein (LDL) cholesterol. The researchers advocate introducing new guidelines for detecting cardiac risk and say the results, published in PLOS Medicine, may pave the way for early treatment, which could help lower morbidity and mortality rates.

Cardiovascular disease is the most common cause of death globally and includes a wide range of conditions, such as stroke and myocardial infarction with atherosclerosis in different organs of the body. In many cases the disease can be prevented and arrested with lifestyle changes and lipid-lowering treatments using statins and other methods.

The cardiac risk assessment usually uses reference values for the LDL cholesterol. Other types of fat particles can also be measured along with apolipoproteins, which transport cholesterol in the blood. International guidelines for cardiovascular disease recommend using apolipoprotein apoB, which transports LDL cholesterol, as an alternative risk marker for people with type 2 diabetes, overweight and very high levels of blood lipids.

Recent research has, however, indicated the importance of also factoring in the apolipoprotein apoA-1, which transports the protective and anti-inflammatory HDL cholesterol. Calculating the apoB/apoA-1 ratio gives a risk quotient reflecting the balance between the fat particles that expedite atherosclerosis and the “good” protective apoA-1 particles that arrest the process.

In this present study, the researchers have analysed the link between cardiovascular disease and apoB/apoA-1 values in more than 137 000 Swedish adults between the ages of 25 and 84. The individuals were followed for 30 years, during which time 22 000 suffered some form of cardiovascular event. The analysis methods are simple, inexpensive and safe, and do not require pre-test fasting, as is the case with LDL and non-HDL tests. Basing their study on a large database, the researchers linked the laboratory analyses to several clinical diagnosis registers.

“The results show that the higher the apoB/apoA-1 value, the greater the risk of myocardial infarction, stroke and need for coronary surgery,” says Göran Walldius, senior author and professor emeritus at the Institute of Environmental Medicine, Unit of Epidemiology, Karolinska Institutet. “The study also showed that the risk was amplified in the presence of low protective levels of apoA-1.”

Individuals with the highest apoB/apoA-1 values had a 70% higher risk of severe cardiovascular disease and almost triple the risk of non-fatal myocardial infarction compared with those with the lowest apoB/apoA-1 values. Individuals with the highest risk quotient were also more affected by severe cardiovascular diseases many years earlier than individuals with the lowest apoB/apoA-1 values.

The relationship was observed in both men and women and the elevated levels could be detected as early as 20 years before the onset of cardiovascular disease.

“Early preventive treatment and information about cardiovascular risk is, of course, important in enabling individuals to manage their risk situation,” Walldius says. “Early treatment can also reduce the cost burden on the public health services.”

Taken together, the results suggest that the apoB/apoA-1 ratio is a better marker for identifying at-risk individuals for cardiovascular disease compared to the apoB method alone.

“It should be possible to introduce cut-values for apoB, apoA-1 and the apoB/apoA-1 ratio into new guidelines as a complement to current guidance on the detection and treatment of dyslipidaemia,” said Walldius.

Source: Karolinska Institutet

A Review of Progress Toward Heart Muscle Regeneration

Photo from Olivier Collett on Unsplash
Photo from Olivier Collett on Unsplash

Twenty years ago, clinicians first attempted to regenerate a failing human heart by injecting muscle myoblasts into the heart during a bypass operation. Despite high initial hopes and multiple studies since then, attempts to remuscularise an injured heart have met with little, if any, success.

Yet, there is hope that a therapy will be developed, according to experts in a Journal of the American College of Cardiology state-of-the-art review. The challenge is this: A heart attack kills heart muscle cells, leading to a scar that weakens the heart, often causing eventual heart failure. The lack of muscle repair is due to the very limited ability of mammalian heart muscle cells to proliferate, except during a brief period around birth.

In the review, the experts focus on three topics. First are several recent clinical trials with intriguing results. Second is the current trend of using cell-derived products like exosomes rather than muscle cells to treat the injured heart. For the third topic, authors discuss likely future experiments to replace a myocardial scar with heart muscle cells by ‘turning back the clock’ of the existing cardiomyocytes, rather than trying to inject exogenous cells. These efforts try to reverse the inability of mature mammalian heart muscle cells to proliferate.

Clinical trials
One of the clinical trials reviewed involved giving cardiosphere-derived cells to patients with Duchenne muscular dystrophy, which affects both heart and skeletal muscles.

Cardiosphere-derived cells are a type of heart stromal/progenitor cell that has potent immunomodulatory, antifibrotic and regenerative activity in both diseased hearts and skeletal muscle. The HOPE-2 trial gave repeated intravenous doses of cardiosphere-derived cells to patients with advanced Duchenne disease, most of whom were unable to walk. Preliminary results showed safety, as well as major improvements in heart parameters such as left ventricle ejection fraction and reduced left ventricle size.

The HOPE-2 trial evaluated a repeated sequential dosing regimen of cell therapy for any cardiac indication, evaluated intravenous cardiosphere-derived administration, and clinically benefitted Duchenne patients.

Two features of the trial may bode well: a move away from invasive cardiac-targeted cell delivery and toward easily administered intravenous cell delivery, and the use of sequential repeated cell doses.

Cell-derived products
Few cells transplanted into the heart survive, though some functional benefits in heart performance have been seen despite physical clearance of grafted cells. It could be possible that the cells were acting not as replacements but rather boosters of endogenous repair pathways through the release of a wide array of tissue-repairing biomolecules.
This led to investigation of using cell-derived products rather than transplanting cells. Most of these biomolecules – proteins and non-coding nucleic acids – are enclosed in tiny vesicles that cells release naturally. When the vesicles, including exosomes, merge into recipient cells, the biomolecules can modulate signaling pathways. Using vesicles or exosomes involves a simpler manufacturing process compared with live cells, the ability to control quality and potency, and being able to refrigerate the vesicles to make administration simpler.

An alternative approach to the vesicle cell-derived products was the finding that injected stem cells can promote cardiac repair through release of biologically active molecules acting as short-range, paracrine hormones. These molecules are distinct from the biomolecules in vesicles or exosomes.

However, before use of any of these cell-derived products for heart repair in early trials, the reviewers say, more experiments are needed in purification of the products, potential modes of delivery and the suitability of repeated doses.

Proliferation of endogenous heart cells
The final review topic looked ahead toward endogenous generation of cardiomyocytes – in other words, forcing existing native cardiomyocytes to divide, or other cells to become cardiomyocytes.

Pigs can regenerate heart muscle for only a few days after birth. But in one remarkable study, researchers injured the heart by removing part of the apex of the left ventricle one day after birth, and then induced heart attack 28 days after birth. Control pigs without the Day 1 resection showed no repair of heart attack damage at Day 56. In contrast, the pigs that had a resection one day after birth, and then had experimental heart attacks at Day 28, showed heart repair by Day 56 – notably an absence of dead heart muscle, known as an infarction. Furthermore, these pigs had more cardiomyocytes throughout their left ventricles.

This study showed that heart muscle cells in large mammals can be induced to proliferate and regenerate by inducing a heart injury at Day 1 to extend the neonatal regneration window. “If this cardiomyocyte cell-cycle activation can be activated in neonates, the same signaling pathways may be activated in adults as well,” the authors wrote, “which is highly impactful and significant.”

Another possible approach to endogenous generation is the direct programming of cardiac fibroblasts into cardiomyocytes. Inducing proliferation of cardiomyocytes will also need ways to promote growth of heart blood vessels to supply the new cardiomyocytes.

In conclusion, the authors believe that short-term approaches to clinical trials of post heart-attack therapies will use cells like cardiospheres or cell products. The longer-term approach, the reviewers said, will target “a more direct remuscularisation of the injured left ventricle by ‘turning back the clock’ of the cardiomyocyte cell-cycle or generating new cardiomyocytes from other cell types such as fibroblasts.”

“However, the efficiency and safety of these strategies, particularly their ability to generate cardiomyocytes seamlessly coupled with their native counterparts and to allow a regulation of these induced proliferative events preventing an uncontrolled and harmful cardiac growth, still need to be appropriately addressed before moving to clinical applications.”

Source: University of Alabama at Birmingham

Heart Failure Risk Further Increased by Aspirin Use

Aspirin may increase heart failure risk in at-risk people
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Aspirin use is associated with a 26% higher risk of heart failure in people with at least one risk factor for it, according to a study published today in ESC Heart FailureRisk factors included smoking, obesity, hypertension, high cholesterol, diabetes, and cardiovascular disease.

“This is the first study to report that among individuals with a least one risk factor for heart failure, those taking aspirin were more likely to subsequently develop the condition than those not using the medication,” said study author Dr. Blerim Mujaj of the University of Freiburg, Germany. “While the findings require confirmation, they do indicate that the potential link between aspirin and heart failure needs to be clarified.”

The influence of aspirin on heart failure is controversial, and so the study sought to investigate its association with heart failure incidence in people with and without heart disease and assess whether it is related to a new heart failure diagnosis in at-risk individuals.

The analysis included 30 827 individuals at risk for developing heart failure who were enrolled from Western Europe and the US into the HOMAGE study. The definition of “at risk” included one or more of the following: smoking, obesity, hypertension, high cholesterol, diabetes and cardiovascular disease. Participants were aged 40 years and older and were free of heart failure at baseline. Aspirin use was recorded at enrolment and participants were classified as users or non-users. Participants were followed-up for the first incidence of fatal or non-fatal heart failure requiring hospitalisation.

Average participant age was 67, 34% were women, and at baseline, a total of 7,698 participants (25%) were taking aspirin. During the 5.3-year follow-up, 1330 participants developed heart failure.

The investigators assessed the association between aspirin use and incident heart failure after adjusting for factors including demographic variables, medical history and medication. Taking aspirin was independently associated with a 26% raised risk of a new heart failure diagnosis.

For consistency, the researchers repeated the analysis after matching aspirin users and non-users for heart failure risk factors. In this matched analysis, aspirin was associated with a 26% raised risk of a new heart failure diagnosis. After excluding patients with a history of cardiovascular disease, in 22 690 participants (74%) without cardiovascular disease, aspirin use was still associated with a 27% increased risk of incident heart failure.

Dr Mujaj noted that “this was the first large study to investigate the relationship between aspirin use and incident heart failure in individuals with and without heart disease and at least one risk factor. Aspirin is commonly used – in our study one in four participants were taking the medication. In this population, aspirin use was associated with incident heart failure, independent of other risk factors.”

He concluded that “large multinational randomised trials in adults at risk for heart failure are needed to verify these results. Until then, our observations suggest that aspirin should be prescribed with caution in those with heart failure or with risk factors for the condition.”

Source: European Society of Cardiology

Extreme Heat Threatens Cardiovascular Health

Photo from Olivier Collett on Unsplash
Photo from Olivier Collett on Unsplash

With South Africa’s summer being expected to be both wetter and hotter this year, there is a greater risk of adverse cardiovascular incidents, especially for adults with pre-existing cardiovascular diseases. Experts writing in the Canadian Journal of Cardiology discuss how extreme heat affects cardiovascular health, why health professionals should care and what recommendations they can make to minimise consequences.

Extreme heat events are predicted to become longer, more common and more severe. Some 70 000 heat-related deaths occurred during the 2003 European heatwave. Risk factors for heat-related hospitalisation include age, chronic illnesses, social isolation, some medications, and lack of access to air conditioning. Among chronic illnesses, cardiovascular diseases are often identified as a risk factor for heat-related hospitalisation and death.

The Intergovernmental Panel on Climate Change (IPCC) recently reported that global temperatures are rising at a greater rate than previously projected, and that the number of extreme heat days will significantly increase across most land regions,” said senior author Daniel Gagnon, PhD, University of Montreal. “Although we don’t yet fully understand the reasons, people with cardiovascular disease are at greater risk of hospitalisations and death during extreme heat events.”

The researchers reviewed studies and noted a consistent association between extreme heat and increased risk of adverse cardiovascular outcomes. An examination of reviews and meta-analyses on the effect of extreme heat on adverse cardiovascular outcomes showed that heatwaves significantly increase mortality risk from ischaemic heart disease, stroke, and heart failure.

“Although the effects of extreme heat on adverse cardiovascular events have been explained in the context of heatstroke, many events occur without heatstroke, and the mechanisms of these events in the absence of heatstroke remain unclear,” observed Dr Gagnon. “It is likely that heat exposure increases myocardial oxygen needs.”

One possibility is that heat exposure puts excessive strain on the heart for individuals with heart disease and that heat exposure increases the risk of blood clots forming within cardiac blood vessels.

The authors propose that preventive strategies should aim to reduce the extent of hyperthermia and dehydration. In Canada, heat-health warnings systems act as a first line of defence by raising awareness of upcoming heat events and recommending strategies to minimise possible heat complications. For example, heat warnings are issued 18-24 hours before a heat event in Ontario and Québec, when ambient temperature will remain above 30°C for a minimum of two days. Public advisories include identifying the signs of heat stress, ensuring people drink adequate amounts of cold fluid or seeking an air-conditioned environment – though for many people, this is not an option.

Recent research supports electric fan use, skin wetting and immersing the feet in tap water as simple methods to stay cool during extreme heat events. “Air conditioning is the most effective strategy that can be recommended since it effectively removes the heat stimulus and minimises the risk of adverse cardiovascular outcomes,” commented Dr Gagnon. “However, less than one third of global households own air conditioning.”

More studies are needed to explain why extreme heat is linked to increased risk of adverse cardiovascular outcomes; the effect of cardiovascular medication on the human body’s physiological responses during heat exposure; the best cooling strategies in heat waves for individuals with CVD; and safe environmental limits for outdoor exercise in individuals with heart disease.

“Cardiovascular health professionals need to be aware of the negative consequences of extreme heat on cardiovascular health. A better awareness and understanding of the cardiovascular consequences of extreme heat, and of the measures to take to prevent and mitigate adverse events, will help us all assess the risk and optimize the care of patients exposed to an increasingly warm climate,” concluded Dr Gagnon.

Source: Elsevier

Firefighters’ Blood Pressure Soars in an Emergency

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When the emergency alarm sounds, blood pressure (BP) among firefighters often soars, according to preliminary research presented at the American Heart Association’s Scientific Sessions 2021.

“All emergency and first responders should be aware of their health. They should know what their typical blood pressure level is and be aware of how it fluctuates. Most important, if they have high blood pressure, they should make sure it is well-controlled,” said senio author Deborah Feairheller, PhD.

The study recruited 37 male and 4 female volunteer and municipal firefighters who wore ambulatory BP monitors during an on-call work shift lasting at least 12 consecutive hours. In addition to the automatic BP readings from the monitor, study participants were instructed to prompt the monitor to take a BP reading whenever a pager or emergency call sounded and whenever they felt they entered a stressful situation. Participants also logged activities and call types for each measurement. The firefighters’ average age was 41.2 years. Average body mass index (BMI) of all participants was 30.3, with BMI ≥ 25 defined as overweight, while BMI ≥ 30 is defined as obesity. The firefighters all had high blood pressure, defined as systolic BP as 130 mm Hg or higher, or a diastolic BP of 80 mm Hg or higher, as defined by the American Heart Association’s most recent guideline.

The findings were that:

  • Average BP and heart rate (HR) were 131/79.3 mmHg and 75.7 beats per minute (bpm) respectively.
  • Compared with the reading immediately preceding the call, systolic BPsurged an average of 19.2 mm Hg with fire calls and 18.7 mm Hg with medical calls.
  • Meanwhile, diastolic BP surged 10.5 mm Hg with fire calls and 16.5 mm Hg with medical calls.
  • Compared with the average BP during the entire 12-hour shift, systolic BP was 9% higher during fire calls, and diastolic BP was 9% higher during medical calls.
  • Average HR also increased during both types of calls: 10bpm with fire calls, and 15bpm for medical calls.
  • There were no significant differences in BP, HR or BP surge levels when comparing responses among fire calls, medical calls, riding an emergency vehicle or false alarms.

Surprising findings
“The public knows the value that emergency responders provide to communities. We hope to increase awareness that many firefighters have hypertension and that their blood pressure can increase to very dangerous levels when responding to emergency calls,” said Dr Feairheller.

“The current data show that almost 75% of firefighters have hypertension, and less than 25% have their blood pressure under control. I hope that our research can help identify occupational factors that affect blood pressure and increase awareness among this population,” Dr Feairheller added.

They were also surprised at the findings on diastolic BP increases. “We anticipated systolic blood pressure surges because that reading is usually more responsive to stimuli; however, the extent of the diastolic blood pressure surge was unexpected,” said Dr Feairheller.

The investigators are currently exploring whether diet and exercise regimens could help to lower the BP surge that firefighters experience during emergency calls.

Source: EurekAlert!

New Guidance Pivot on Daily Aspirin Advice

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In a distinct on previous advice, new draft recommendations posted by the U.S. Preventive Services Task Force (USPSTF) advise against adults 60 and older to begin taking aspirin to lower their risk of a first heart attack or stroke. 

They further advise that people aged 40 to 59 at higher risk for cardiovascular disease, but without a history of it, should talk to a health care provider before starting an aspirin regimen.

The proposed guidance is based on new evidence that suggests the potential harms of taking aspirin can outweigh the benefits. While daily aspirin use reduces the odds of a first heart attack or stroke, it increases the risks of gastrointestinal and intracerebral bleeding, which progressively increase with age.

“The latest evidence is clear: starting a daily aspirin regimen in people who are 60 or older to prevent a first heart attack or stroke is not recommended,” UPTSTF member Chien-Wen Tseng, MD, a professor at the University of Hawaii John A. Burns School of Medicine, said in a statement. “However, this Task Force recommendation is not for people already taking aspirin for a previous heart attack or stroke; they should continue to do so unless told otherwise by their clinician.”

The new guidance will be finalised after public comments close in November. It pivots from previous recommendations issued in 2016, which suggest that people ages 50 to 59 with a risk of cardiovascular disease ≥ 10% in the next decade and a low risk for bleeding take a daily low-dose aspirin (≤ 100mg/day) to reduce the likelihood of suffering a heart attack or stroke. According to the 2016 recommendations, the decision to start taking aspirin for preventive reasons should be “an individual one” for adults ages 60 to 69 who are at risk for cardiovascular disease

At present, neither the American Heart Association nor the American College of Cardiology recommend aspirin use for the prevention of heart attack and stroke in the general population; this only applies for some people between the ages of 40 and 70 who have never had a heart attack or stroke but have an increased risk for cardiovascular disease and a low risk for bleeding. The groups recommend that adults 70 and up should not take aspirin for first stroke or heart attack prevention.

Still, aspirin use for cardiovascular risk prevention is widespread in the US, “and is often self-initiated rather than recommended by a physician,” the latest USPSTF report states. A 2017 National Health Interview Survey (NHIS) found that 23.4 percent of adults age 40 or older and without cardiovascular disease took aspirin for primary prevention; among adults 60-69 years, 34.7 percent reported aspirin use.
Tomas Ayala, MD, a cardiologist at Mercy Personal Physicians, said that this pivot had been anticipated by doctors.

“It is not that aspirin is less effective at reducing heart attacks or strokes than it once was,” he told Health. “Rather, it is that we have other therapies at our disposal that have reduced the overall population risk of these conditions, so the relative benefit of aspirin is less, and in many cases, is outweighed by the risks.” 

Source: AARP

Impact of Pandemic Delay to Cardiac Procedures

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A Canadian study found that after the onset of the COVID pandemic, there was a significant decline in referrals and procedures for common cardiac interventions. 

Patients awaiting coronary bypass surgery or stenting were at higher risk of dying while waiting for their procedure compared to before the pandemic, despite wait times not being longer. The study was published in the Canadian Journal of Cardiology.

“In the first wave of the COVID pandemic, we kept hearing stories from patients and other doctors that there were delays in care for patients with heart disease,” explained lead investigator Harindra C. Wijeysundera, MD, PhD, University of Toronto. “We decided to look into these claims using the Ontario database that keeps track of wait lists and wait times for individuals with heart disease who require a procedure or surgery.”

The researchers were able to link multiple population-based administrative data sources and clinical registries. The study looked at adult patients who were referred for four commonly performed cardiac procedures: percutaneous coronary intervention; isolated coronary bypass grafting; valve surgery; or transcatheter aortic valve implantation from January 1, 2014 to September 30, 2020, and the start of the pandemic was put at March 31 2020. Outcomes were defined as death while awaiting procedure and hospitalisation while waiting for procedure.

Of 584 341 patients identified, 37 718 were referred during the pandemic. As expected, a decline in referrals was observed at the outset of the pandemic, although those numbers steadily increased throughout the pandemic period, along with an initial decline in the number of procedures performed. Individuals waiting for coronary bypass surgery or stenting were at higher risk of dying while waiting for their procedure compared to before the pandemic. Mortality rates increased even though wait times did not during the pandemic, suggesting patients may have delayed in presenting to their doctors with symptoms.

“We found that the increase in wait list mortality was consistent across patients with stable coronary artery disease, acute coronary syndrome, or emergency referral,” said Dr Wijeysundera. “Coupled with reduced referrals, this raises concerns of a care deficit due to delays in diagnosis and wait list referral.”

A number of potential explanations were suggested by the researchers for the decline in referrals during the pandemic, from patient factors such as fear of contracting COVID in the hospital or concerns about missing work, to system factors including testing delays and pressures on hospital beds and staffing.

Source: EurekAlert!

High Fat Dairy Intake not Tied to CVD Risk

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In a study of countries with high dairy consumption, higher intakes of dairy fat, as measured by bloodstream levels of fatty acids, had a lower risk of cardiovascular disease (CVD) compared to those with low intakes. Higher intakes of dairy fat were not linked to an increased mortality risk.

In a study published in PLoS Medicine, researchers combined results from 4000 Swedish adults with those from 17 similar studies in other countries, creating the most comprehensive evidence to date on the relationship between this more objective measure of dairy fat consumption, risk of  and death.

Dr Matti Marklund from The George Institute for Global Health, Johns Hopkins Bloomberg School of Public Health, and Uppsala University said that with rising dairy consumption around the world, a better understanding of the health impact was needed.

“Many studies have relied on people being able to remember and record the amounts and types of dairy foods they’ve eaten, which is especially difficult given that dairy is commonly used in a variety of foods.

“Instead, we measured blood levels of certain fatty acids, or fat ‘building blocks’ that are found in dairy foods, which gives a more objective measure of dairy fat intake that doesn’t rely on memory or the quality of food databases,” he added.

“We found those with the highest levels actually had the lowest risk of CVD. These relationships are highly interesting, but we need further studies to better understand the full health impact of dairy fats and dairy foods.”

Sweden has one of the world’s highest consumption of dairy. An international team of researchers assessed dairy fat consumption in 4150 Swedish 60-year-olds by measuring blood levels of a particular fatty acid that is mainly found in dairy foods and therefore can be used to reflect intake of dairy fat.

The participants were then followed up for an average of 16 years, recording heart attacks, strokes and other serious circulatory events, and all cause mortality.

After adjustment for other known CVD risk factors including things like age, income, lifestyle, dietary habits, and other diseases, the CVD risk was lowest for those with high levels of the fatty acid (which reflects a high intake of dairy fats). Those with the highest levels had no increased all-cause mortality risk.

These findings highlight the uncertainty of evidence in this area, which is reflected in dietary guidelines, noted  Dr Marklund.

“While some dietary guidelines continue to suggest consumers choose low-fat dairy products, others have moved away from that advice, instead suggesting dairy can be part of a healthy diet with an  emphasis on selecting certain dairy foods — for example, yoghurt rather than butter — or avoiding sweetened dairy products that are loaded with added sugar,” he said.

Combining these results with 17 other studies with a total of almost 43 000 participants from the US, Denmark, and the UK confirmed these findings in other populations.

“While the findings may be partly influenced by factors other than dairy fat, our study does not suggest any harm of dairy fat per se,” Dr. Marklund said.

Lead author Dr Kathy Trieu from The George Institute for Global Health pointed out that consumption of some dairy products, especially fermented products, have been shown to be linked to cardiovascular benefits.

“Increasing evidence suggests that the health impact of dairy foods may be more dependent on the type — such as cheese, yoghurt, milk, and butter — rather than the fat content, which has raised doubts if avoidance of dairy fats overall is beneficial for cardiovascular health,” she said.

“Our study suggests that cutting down on dairy fat or avoiding dairy altogether might not be the best choice for heart health.”

“It is important to remember that although dairy foods can be rich in saturated fat, they are also rich in many other nutrients and can be a part of a healthy diet. However, other fats like those found in seafood, nuts, and non-tropical vegetable oils can have greater health benefits than dairy fats,” Dr Trieu added.

Source: The George Institute for Global Health

A Year of Exercise Reverses Heart Failure Signs

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In a small study, a year of exercise training helped to maintain or increase the youthful elasticity of the heart muscle among people in late middle age showing early signs of heart failure.

Published in Circulation, the research reinforces the notion that “exercise is medicine,” an important shift in approach, according to the researchers.

The study focused on heart failure with preserved ejection fraction, which is characterised by stiffening of the heart muscle and high pressures inside the heart during exercise. Once established, the condition is largely untreatable and causes fatigue, excess fluid in the lungs and legs, and shortness of breath.

“It is considered by some to be one of the most important virtually untreatable diseases in cardiovascular medicine,” said senior author Dr Benjamin Levine,  professor of internal medicine at UT Southwestern and director of the Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Dallas. “So, of course, if there are no therapies, then the most important thing to do is to figure out how to prevent it from happening in the first place.”

In previous studies, prolonged exercise training was shown to improve heart elasticity in younger people, but was ineffective for heart stiffness in people 65 and older. The researchers decided to see if committed exercise could improve heart stiffness in healthy, sedentary men and women ages 45 to 64.

The study recruited 31 participants who showed some thickening of the heart muscle and an increase in blood biomarkers associated with heart failure, even though they had no other symptoms such as shortness of breath.

Eleven were randomly assigned to a control group and prescribed a program of yoga, balance and strength training three times a week. The rest were assigned to an individually tailored exercise regimen that gradually ramped up until the participants were doing intensive aerobic interval training for at least 30 minutes at least twice a week, plus two to three moderate-intensity training sessions and one to two strength training sessions each week. 

After one year, the group assigned vigorous exercise training showed a physiologically and statistically significant improvement in measures of cardiac stiffness and cardiorespiratory fitness, compared to no change in the control group.

The results suggest late middle age may be a “sweet spot” for using exercise to prevent heart failure with preserved ejection fraction, before the heart gets too stiff, Prof Levine said. He compared the heart muscle to an elastic band: a new one stretches easily and snaps right back.

“That’s a youthful cardiovascular system,” he said. “Now, stick it in a drawer and come back 30 years later—it doesn’t stretch, and it doesn’t snap back. And that’s one of the things that happens to the circulation, both the heart and the blood vessels as we age, particularly with sedentary aging.”

However, the study cannot determine if the participants will still go on to develop heart failure. This question will have to be addressed by larger studies. Furthermore, it is difficult for people to adhere to an exercise program, and the intensive intervention studied may be difficult and expensive to replicate on a large scale.

Source: American Heart Association

Is Heart Pump Development Dead in the Water?

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At an annual meeting of the Heart Failure Society of America (HFSA), heart failure specialists agreed that recalling the HeartWare heart pump was good but debated whether its departure leaves the field of mechanical circulatory support (MCS) dead in the water.

In June, Medtronic stopped sales of its HeartWare Ventricular Assist Device (HVAD), citing excess neurological events and mortality with the device. As a result, Abbott’s HeartMate 3 became the only FDA-approved, durable left ventricular assist device (LVAD) on the market.

“Competition breeds innovation. When competition is absent or minimal, there is little incentive for corporations to innovate,” said Jennifer Cowger, MD, MS, of Henry Ford Hospital in Detroit, during the annual scientific meeting.

“While I believe the removal of the HVAD from the market was the ethical thing to do, unless we as a field start embracing MCS technology and change our messaging to the general cardiology community, our field is going to be viewed as niche to referring cardiologists and we’re going to face irrelevance and we’re going to have bad times ahead,” she added.

However Nancy Sweitzer MD, PhD, of the University of Arizona in Tucson, disagreed, pointing out that there are plenty of advances on the horizon.

Nine companies worldwide are developing heart pumps for this $3-4 billion market, Dr Sweitzer noted. Several devices under investigation — implantable ones with no external component — will probably proceed to first-in-man trials in the next year, she said. “There’s a lot of money if you do this well,” she added

Internal competition alone may be enough to advance the field, Sweitzer argued, citing Thoratec’s HeartMate II superseding their old HeartMate XVE.

“They put their own device up against their own device. So I would argue that corporate competition isn’t necessary when the stakeholders realize that we need to get better at this. I think the companies in this space realize there’s a huge unmet need here if we develop a really good MCS that was truly portable, gave people excellent quality of life, and had lower complications,” she said.

Yet given the pace of LVAD research, “in the next decade, we have cause for concern in the MCS field,” Dr Cowger countered.

Both debaters suggested that MCS technology shouldn’t stop at HeartMate 3, even with its relatively impressive performance.

“Outcomes on HeartMate 3 are not the outcomes we really want for these patients. There are still innumerable complications. Hospitalization rates are extraordinarily high in these patients post-implant even if they’re successful implants. They bleed, they get infected, they get strokes. That still happens,” noted Dr Sweitzer.

Innovation issues aside, Dr Cowger pointed out that HeartMate 3 is also much larger than the HVAD, and the smaller device’s loss leaves a gap for patients. She said negative media views had not helped the recent “sense of apathy and loss of enthusiasm for MCS”.

“Physicians don’t want to use technology that will harm or be perceived to harm patients,” she said, noting that sentiment has shifted from “VADs are sexy, cool” to “we would not choose LVADs over [heart] transplant.”

Source: MedPage Today