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American College of Cardiology Meeting

Depression a predictor of death following heart disease diagnosis

The strongest predictor of death in the decade after a diagnosis of coronary heart disease is depression, according to a study presented at the recent American College of Cardiology (ACC) Annual Scientific Session, held in Washington DC.

The study found that among people diagnosed with coronary heart disease, those also diagnosed with depression are about twice as likely to die.

“I think the take-home message is that patients with coronary disease need to be continuously screened for depression, and if found to be depressed, they need to receive adequate treatment and continued follow up,” said Dr Heidi May, a cardiovascular epidemiologist at the Intermountain Medical Centre Heart Institute in Salt Lake City, US, and the study’s lead author.

Depression is linked with behaviours that can be detrimental to cardiovascular health, such as reduced physical activity, poor diet, increased smoking or alcohol use and reduced compliance with medical treatment.

The researchers looked at the health records of 25,000 patients in the Intermountain health system and tracked them for an average of nearly 10 years following a diagnosis of coronary heart disease.

About 15 per cent of patients received a diagnosis of depression following their diagnosis of cardiovascular disease, which is substantially higher than the 7.5 to 10 per cent of people in the general population.

The researchers said that clinicians should seek ways to better identify depression in patients with coronary heart disease, given the significant impact of depression on long-term survival, as demonstrated in this research.

HRT for menopause reduces risk of death from heart disease

Women using hormone replacement therapy (HRT) to relieve symptoms of menopause have a lower risk of death from heart disease and lower levels of plaque build up in the arteries, according to a study presented at the American College of Cardiology (ACC) Annual Scientific Session.

The use of HRT in women experiencing the menopause has been controversial in recent decades as some studies have shown it provides significant health benefits, while other research indicates it elevates some health risks.

HRT has been associated with a lower risk of osteoporosis and some measures of heart health, but also with an increased risk of cancer and stroke.

The fear of promoting cancer, in particular, has led to a dramatic decrease in the number of women using HRT over the past 15 years.

This latest research supports other evidence that HRT, along with supplemental oestrogen, sometimes also along with progesterone or other similar hormones, can improve heart health and overall survival for some women.

The researchers retrospectively analysed the health records of more than 4,200 women who received a coronary calcium scan at Cedars-Sinai Medical Centre, US, between 1998 and 2012. A coronary calcium scan is a CT scan that measures the amount of calcium in the heart’s arteries. Having higher levels of calcium is a marker for the build up of plaque, which increases the risk of having a heart attack or stroke.

After accounting for age, coronary calcium score and cardiovascular risk factors, including diabetes, high blood pressure and high cholesterol, women using hormone replacement therapy were overall 30 per cent less likely to die than those not on hormone therapy.

“Hormone replacement therapy resulted in lower atherosclerosis and improved survival for all age groups and for all levels of coronary calcium,” said Dr Yoav Arnson, a postdoctoral scientist at Cedars-Sinai Medical Centre and the study’s lead author.

Marijuana linked with increased risk of stroke and heart failure

Marijuana use raises the risk of stroke and heart failure, even when all other factors are taken into account, according to research presented at the ACC meeting.

The study sheds new light on how the drug affects cardiovascular health.

The use of marijuana was linked to a variety of factors that increase cardiovascular risk, such as obesity, high blood pressure, smoking and alcohol use. However, after the researchers adjusted their analysis to account for all of these factors, marijuana use was still – independently – associated with a 26 per cent increase in the risk of stroke, and a 10 per cent increase in the risk of developing heart failure.

The study took data from the US Nationwide Study Sample, which includes the health records of patients admitted at more than 1,000 hospitals comprising about 20 per cent of the US medical centres. Marijuana use was diagnosed in about 1.5 per cent (316,000) of more than 20 million health records that were included in the analysis for this study.

“Even when we corrected for known risk factors, we still found a higher rate of both stroke and heart failure in these patients, so that leads us to believe that there is something else going on besides just obesity or diet-related cardiovascular side-effects,” said Dr Aditi Kalla, Cardiology Fellow at the Einstein Medical Center in Philadelphia, US, and the study’s lead author.

“More research will be needed to understand the pathophysiology behind this effect,” said Dr Kalla.

Heightened risk of death for ‘AFib’ patients taking digoxin

Patients with atrial fibrillation (AFib) – with or without heart failure – given digoxin to control their symptoms have an increased risk of death, compared with patients not taking the drug and the risk increases with higher levels of digoxin in the bloodstream, according to research presented at the ACC meeting.

“Based on our study, digoxin should be avoided in patients with AFib, particularly if symptoms can be alleviated with other treatments,” said Dr Renato Lopes, Professor of Medicine in the Division of Cardiology at Duke University and lead author of the study.

The researchers analysed data from the ARISTOTLE trial, which compared apixaban with warfarin for the prevention of blood clots, strokes and death in patients with AFib. Of the 18,201 patients enrolled in ARISTOTLE, 17,897 had data available on heart failure status and digoxin use during the trial. Of these patients, 5,824 were on digoxin at the start of the trial, and 4,434 of these participants had their blood levels of digoxin measured at baseline. A total of 6,693 patients had heart failure at the time of trial enrollment.

The researchers found that in patients already receiving digoxin and, therefore, more likely to tolerate it, the overall relationship between digoxin use and death was non-significant. However, even in this cohort, the risk of death was linked to digoxin concentration in the blood. For every 0.5ng/ml increase in the blood level of digoxin, the risk of death rose by 19 per cent. Among patients whose digoxin levels were greater than 12ng/ml, the death rate was increased by a highly significant 56 per cent.

“We showed that starting digoxin was associated with increased risk of death and sudden death, regardless of the presence of heart failure,” said Dr Lopes. “Thus, based on our findings, avoiding digoxin in patients with AFib – irrespective of the presence of heart failure – seems to be right approach.”

Heart procedure linked with bleeding in the brain

Nearly one-quarter of older patients undergoing transcathether aortic valve replacement (TAVR) developed new microbleeds – small leakages from blood vessels in the brain, which increase with age and are associated with cognitive decline – after the procedure, according to a study presented at the recent ACC meeting.

Microbleeds can be observed using MRI scans of the brain and are detrimental to thinking and memory. This study revealed increased risks of microbleeding among patients who had undergone a previous cardiovascular intervention and among those with more prolonged exposure to anticoagulant medications, which are used to prevent blood clots that cause strokes and mini strokes among patients undergoing cardiac procedures.

“We are all aware of the potential for silent ischaemic [mini strokes] after these endovascular procedures, but our study points to the opposite risk – microbleeding – that we have not previously been aware of,” said Dr Eric Van Belle, Cardiologist at the Centre Hospitalier Regional in Lille, France, and the study’s lead author.

“With more and more endovascular procedures, which require anticoagulants, it could be that these procedures are one of the main triggers of microbleeding seen in the older population,” said Dr Van Belle. “It raises the concern that we may be increasing the risk of this microbleeding with each intervention we perform.”

Drugs as beneficial as procedure for treating fully blocked arteries

Treatment with drugs alone was found to be equal to percutaneous coronary intervention (PCI) in patients with a complete blockage in the heart’s arteries that persists over time, according to a study presented at the ACC meeting.

In this study about 20 per cent of patients with fully blocked arteries died within three years of enrolling in the study or experienced a non-fatal heart attack, stroke or had a procedure such as a PCI or bypass surgery.

That proportion of outcomes was not significantly different for patients randomly assigned to receive PCI compared with those assigned to receive only drugs including aspirin, a beta-blocker, a calcium channel blocker and a statin.

“PCI is not the only solution to treat chronic total occlusion, and in terms of patient outcomes, cost versus benefit and other considerations, it is not beneficial to use PCI for all chronic total occlusion lesions,” said Dr Seung-Jung Park, Cardiologist at Asan Medical Center, Seoul, South Korea, and the study’s lead author. “The size of the ischaemia, patient symptoms and cardiac function must be taken into account prior to the decision to perform PCI,” said Dr Park.

According to the researchers, the study findings suggest that it is not always necessary to open blocked arteries using PCI, which substantially increases costs and also can increase the risk of a heart attack around the time of the procedure. “If patients suffer from a large ischaemic burden, PCI is crucial to open the lesion, but for small occlusions, optimal medical treatment [with drugs alone] is sufficient,” concluded Dr Park.

No evidence of cognitive issues when evolocumab added to statin therapy

There is no evidence that adding a new cholesterol-lowering drug to treatment with a statin causes memory loss or other problems with cognition, according to findings from the EBBINGHAUS study, reported at the ACC meeting.

Some studies had suggested a link between high doses of statins and memory difficulties. In 2012, the US FDA added a safety alert to the labelling for statins, noting that some patients had experienced memory loss and confusion.

In 2014, however, a medical expert panel concluded that the evidence that statins caused cognitive side-effects was weak to nonexistent.

The EBBINGHAUS study enrolled 1,974 patients who were taking part in FOURIER, a large double-blind, randomised trial conducted in 30 countries to test the effectiveness of adding evolocumab or a placebo to statin therapy to reduce LDL cholesterol in high-risk patients with heart or blood vessel disease.

The patients in EBBINGHAUS were 63 years old on average; 75 per cent had had a heart attack, 20 per cent had an ischemic stroke, and 19 per cent had peripheral arterial disease. All were receiving high intensity statin therapy.

“We found no important differences between patients taking evolocumab and those on placebo on any of the four measures of cognitive functioning in the patient questionnaires, or in the physician-report of adverse cognitive events,” said Dr Robert Giugliano, Associate Professor at Harvard Medical School, US, and lead author of the study.

“Our findings are reassuring in that we found no apparent effect on any of these cognitive domains despite achieving very low blood levels of LDL cholesterol,” said Dr Guigliano.

“These findings should enable physicians to feel more secure about adding evolocumab to a statin to achieve very low levels of LDL cholesterol without worrying that patients’ memory or cognitive functioning will be affected,” said Dr Guigliano.

Rivaroxaban three times better than aspirin for preventing recurring clots

In patients at high-risk for a recurrence of potentially life-threatening blood clots, a low dose of the oral blood-thinning medication, rivaroxaban, reduced recurrences more than three-fold compared with aspirin, with no significant increase in bleeding effects, according to research presented at the ACC meeting.

“We have shown that practitioners can safely prescribe rivaroxaban for patients at risk for a recurrent venous thromboembolism (VTE) without being concerned that doing so will increase risk for bleeding side-effects,” said Dr Philip Wells, Chief of the Department of Medicine at the University of Ottawa, Canada, and a co-investigator on the study.

A VTE may occur as a blood clot in a deep vein, usually in a leg, or a clot that travels from elsewhere in the body to the lungs. Patients who have had a VTE are generally treated with a blood thinning medication for six to 12 months after the event.

However, some patients remain at elevated risk for another blood clot, as well as for a heart attack or stroke, if the blood thinning therapy is stopped, said Dr Wells.

This international multicentre study enrolled 3,396 patients who had completed six to 12 months of anticoagulant therapy for a VTE. The patients’ average age was 59, and 55 per cent were men. The patients were randomly assigned to receive 10mg of rivaroxaban, 20mg of rivaroxaban or 100mg of aspirin daily for up to 12 months.

After a median follow up of 351 days, 1.2 per cent of patients receiving 10mg of rivaroxaban and 1.5 per cent of those receiving 20mg of rivaroxaban had had a recurrence of VTE, compared with 4.4 per cent of patients receiving aspirin.

“Rivaroxaban had significantly greater efficacy in preventing VTE recurrence without significantly increasing risk for major bleeding,” said Dr Wells. “Our findings show that it’s [a safe option] and appears to be highly protective against potentially life-threatening recurrent VTE.”

The study has recently been published in the New England Journal of Medicine.

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