Spotlight on cardiology

The European Society of Cardiology Congress – a key get-together in the cardiovascular world – took place in tragic circumstances in Barcelona this year, just days after the August terrorist attack which killed at least 16 people and left many others injured. While the organisers issued a strong statement of sympathy and solidarity, there was no stopping the Congress which is set to be one of the most important in years, with a number of large trials reporting results.

One of the potential game-changers is the CANTOS trial, involving over 10,000 people with prior myocardial infarction. The trial is testing canakinumab, a monoclonal antibody which targets an inflammatory pathway, for the prevention of major adverse cardiac events. Preliminary results, announced at ESC 2017 and simultaneously published in the New England Journal of Medicine, showed that the drug reduced events by 15% compared with placebo.

Cantos provides long-awaited evidence to bolster the so-called “inflammatory hypothesis” in heart disease. The potential downsides of the treatment are the high cost of the immunotherapy and the fact that it increased the risk of fatal infections.

Another key trial reporting at ESC 2017 is COMPASS, which shows that the novel anticoagulant (NOAC) rivaroxaban plus aspirin improves outcomes in stable cardiovascular disease.

The trial, which randomised over 27,000 patients to various combinations of treatments, found that the addition of rivaroxaban to aspirin reduced the likelihood of myocardial infarction, stroke or cardiovascular death by 24%, improving overall survival by 18%.

Addition of the NOAC did increase the risk of GI bleeding, but not for fatal or cerebral bleeding. Analysis showed that with 23 months of treatment in 1000 patients, the addition of rivaroxaban to aspirin would prevent 13 infarctions or strokes and seven deaths from any cause, at a cost of 12 major bleeds, most of which would be easily treatable.

Here are some other highlights from the congress:

Japanese researchers found that poor sleep is significantly associated with ischaemic heart disease and stroke, in an observational study of 13,000 patients.
Swedish researchers found that in contrast to major guideline recommendations, giving antiplatelet therapy to STEMI patients in the ambulance on the way to the hospital was no better than waiting for in-hospital treatment.
A Swiss team found a reduction in the gender gap in mortality from heart attack. Younger women had been shown to be more likely to die from MI than men of a similar age in previous studies, but that gap has narrowed over the past 20 years.
A substudy of the PRECISION trial looked at the effect of various NSAIDs on blood pressure. Ibuprofen was associated with a significant increase in systolic blood pressure, while celecoxib was not.
Apixaban lowers stroke risk in atrial fibrillation patients undergoing cardioversion, according to late-breaking results from the EMANATE trial.
A 14-year study has found that statins lower the risk of both breast cancer and overall mortality. The huge study involved over a million people.
And finally, married patients with heart disease are more likely to survive than those who are single or widowed, a large study from the ACALM Study Unit has found.

For more information on these and other studies, click here.

Need some fast facts on hypertension? Buy our handbook at the Doctorportal bookshop for advice on:

accurate measurement of blood pressure and problems such as ‘white-coat’ hypertension;

routine assessments for people with high blood pressure;

non-pharmacological measures (reducing salt, losing weight, increasing physical activity etc.);

identification of people with secondary hypertension;

distinguishing between patients with primary (low renin) and secondary aldosteronism;

greater use of home BP measurement in clinical decision-making

the latest thinking on BP treatment thresholds;

new guidance on fourth-line therapy for resistant hypertension.

[Perspectives] Jeroen Bax: inspiring the next generation of cardiologists

A conversation with the eminent cardiologist Eugene Braunwald fuelled Jeroen Bax’s interest in nurturing aspiring cardiologists. “Braunwald told me that what really matters is developing the next generation of researchers and clinicians”, he recalls. By 2018, Bax will have mentored 60 international PhD students in his cardiac imaging research centre at Leiden University Medical Center (LUMC) in the Netherlands. “Jeroen’s students have achieved prominent positions at medical institutions throughout the world”, says Anthony DeMaria, Professor of Medicine at the University of California, San Diego.

[Comment] Intravenous fibrinolytics in STEMI: a 25-year perspective

Heart disease remains the number one cause of mortality and morbidity across most of the world.1 Although rates of acute myocardial infarction have fallen in high-income countries, mostly as a consequence of improved lifestyle modifications and continued evolution of risk factor modification,2 acute myocardial infarction remains the most important driver of cardiac mortality. The cornerstones of therapy for acute myocardial infarction have been based on the open-artery hypothesis.3 Previous experimental animal models have shown the initiation of myocardial cell death early after ligation of an epicardial coronary artery.

[Editorial] 40 years of percutaneous coronary intervention: where next?

When cardiologists gather in Barcelona, Spain, from Aug 26–31 for the annual European Society of Cardiology meeting, they will celebrate Andreas Grüntzig in a special tribute session. Grüntzig performed the first percutaneous coronary angioplasty on Sept 16, 1977, at the University Hospital Zurich, Switzerland, on a 38-year-old patient with a high-grade discrete stenosis of the proximal left anterior descending coronary artery. He reported the first five patients in The Lancet in 1978. To mark this breakthrough and the birth of interventional cardiology, this year’s conference spotlight is on 40 years of percutaneous coronary interventions (PCI).

Heart disease and suicide killing more methamphetamine users

A national seven-year study has found that the number of methamphetamine-related deaths in Australia doubled between 2009 and 2015, with heart disease and violent suicide identified as prominent causes of death.

The study, undertaken by the National Drug and Alcohol Research Centre was published in the journal Addiction.

It analysed 1649 cases of methamphetamine-related death retrieved from the National Coronial Information System (NCIS) and found that in a fifth of cases (22 per cent) death was attributed to natural disease in conjunction with methamphetamine toxicity.

The most frequent natural disease was cardiac and/or cardiovascular disease and stroke.

Lead author Professor Shane Darke said the results were indicative of a major public health issue and highlighted a hidden problem.

“To see such large and significant increases in mortality rates over the study period indicates a major methamphetamine problem,” Professor Darke said.

“With so much public attention focused on violence, many users may be unaware that heart disease is a major factor in methamphetamine-related death.

“Without increased awareness of the connection between methamphetamine use and cardiac and/or cardiovascular disease we could expect to see a significant increase in cases of this kind in the coming years.”

Suicide accounted for 18 per cent of methamphetamine-related deaths, with specific characteristics around methods and gender. Studies of suicide in the general population have consistently shown that males predominately use violent means and females self-poisoning.

Professor Darke urged health professionals to be aware of the prominent role of violent suicide and take appropriate steps to monitor methamphetamine users.

“The impulsivity and disinhibition associated with methamphetamine intoxication may be a factor,” he said.

“In this series, suicide by violent means – most prominently hanging – was the main method used by both genders.”

Other findings of the study include: nearly half of cases occurring in rural and regional locations; the most common manner of death (43 per cent) is accidental drug toxicity; and even modest amounts of methamphetamine may provoke cardiac arrhythmia.

The research also noted that there were 245 deaths from traumatic accidents, including 156 where the person was driving a car or motorbike.

The AMA is very concerned about the health impacts crystal methamphetamine has on users, their families, and the health system. The AMA’s Position Statement on methamphetamine can be found on their website here: position-statement/methamphetamine-2015

MEREDITH HORNE

Are we measuring blood pressure accurately? Probably not.

The most common method of measuring blood pressure is often inaccurate, a new study has found. This could mean people at risk of serious conditions such as heart disease are missing diagnosis and potentially life-saving treatment.

The so-called “cuff method” involves strapping an inflatable cuff over the upper arm to temporarily cut off the blood supply; then calculating the blood pressure once the cuff is relaxed.

In our study, published in the Journal of the American College of Cardiology, we found the method, which is more than a century old, is inaccurate when monitoring people with mid-range blood pressure. This is the range most common among people worldwide.

Accurate measurement of blood pressure is regarded among the most important of all medical tests. A misdiagnosis of low blood pressure can be a missed opportunity for lowering a person’s risk of cardiovascular disease, which often presents as a stroke, heart attack or kidney disease. A misdiagnosis of high blood pressure, on the other hand, could lead to people being prescribed unnecessary medication.

What is blood pressure?

Blood pressure is the force exerted in the large arteries – vessels that carry blood away from the heart – with every heartbeat. Blood pressure measurement provides a high (systolic) and a low (diastolic) value. The high value represents the peak pressure during heart contraction; the low value represents the pressure during heart relaxation.

Healthy levels of blood pressure are typically less than 120/80 mmHg (the 120 mmHg is systolic, and 80 mmHg diastolic). Decades of research clearly tell us if a person’s blood pressure is raised they are at higher risk of cardiovascular disease. The higher the blood pressure, the higher the risk.

Blood pressure readings include a systolic and a diastolic value, with the normal healthy range less than 120/80 mmHg.
Shutterstock

About one in three adults have high blood pressure. Lifestyle factors such as regular exercise, normal body weight and healthy dietary choices, as well as medications, can lower blood pressure and prevent cardiovascular disease.

Although there are many factors to consider when assessing if someone has high blood pressure, the conventional threshold at which doctors might consider giving medication to lower pressure is 140/90 mmHg.

How is blood pressure measured?

The method to measure blood pressure is based on a technique invented in 1896, then refined in 1905, but the basic principal has remained virtually unchanged.

A broad cuff is placed over the upper arm and inflated until the main artery in the arm is completely occluded and blood flow is stopped. The cuff is then slowly deflated until blood flow returns into the lower arm.

A series of signals can then be measured that represent the systolic and diastolic blood pressure. These are measured by either listening with a stethoscope or, more often, using automated devices.

Our study

It’s uncertain whether cuff blood pressure accurately measures the pressure in the arteries of the arm or the major artery just outside the heart, called the aorta. This is important as blood pressure readings can be different in these two spots – a potential difference of 25 mmHg or more.

The central aorta blood pressure is a better indicator of the pressure experienced by organs, such as the heart and brain, so it is more clinically relevant.

The possibility of big blood pressure differences between the arm and the aorta could result in very different clinical decisions on diagnosis and treatment. So it is important to resolve the uncertainty as to what cuff blood pressure actually measures.

We retrieved data from studies from the 1950s until now that compared cuff blood pressure of more than 2,500 people with that of the gold standard method, called invasive blood pressure. Here, a catheter that measures pressure is inserted inside the artery either at the arm (same site as the cuff) or at the aorta.

Readings from this method were used as a reference and compared with those of the cuff method to determine the accuracy of cuff measurements.

Research has found there can be significant differences between the blood pressure measured in the arm and in the aorta.
from www.shutterstock.com

What did we find?

Cuff blood pressure had reasonable accuracy compared with the reference standard, at either the arm or aorta, among people with low cuff blood pressure (lower than 120/80 mmHg) and high cuff blood pressure (the same or higher than 160/100 mmHg). These people are at the extreme ends of the blood pressure risk spectrum.

We found the accuracy when compared to invasive blood pressure was up to 80%.

But for the rest of the population with blood pressure in the middle range – systolic 120 to 159, and diastolic 80 to 99 mmHg – accuracy compared with invasive blood pressure at the arm or the aorta was quite low: only 50% to 57%.

Why is this important?

If people have their blood pressure measured using the cuff method and the values are either low (under 120/80 mmHg) or high (over 160/100 mmHg), we can have reasonable confidence the values are a good representation of the true (invasive) blood pressure.

But for people whose blood pressure is in the most common mid-range of 120 to 160 mmHg systolic or 80 to 100 mmHg diastolic, there is much less certainty as to whether the cuff blood pressure is truly representative of the actual blood pressure.

Our findings do not mean people should stop taking their medication or stop having their blood pressure measured using the cuff device. While this study reveals accuracy issues, the evidence from many large clinical trials clearly shows taking medication to lower blood pressure from high levels reduces the chances of stroke, heart attack and vascular disease.

Cuff blood pressure measurements are still useful, but we could help more people if we could measure blood pressure more accurately. The problem is that some people in the mid blood pressure range may fall through the diagnosis cracks.

Until the accuracy standards of pressure-measuring devices are improved, the best available confirmation of blood pressure levels comes from an average of many repeated measures over time. This is better than one or two measures, as is often the way in busy daily clinical practice, and was closest to the method examined in this study.

People can have repeated measures of blood pressure undertaken in consultation with their general practitioners or at specialist centres. These can include self-measured home blood pressure, 24-hour ambulatory blood pressure and automated unobserved blood pressure.

James Sharman, Professor of Medical Research and Deputy Director, Menzies Institute for Medical Research., University of Tasmania

This article was originally published on The Conversation. Read the original article.

[Comment] Eliminating acute rheumatic fever and rheumatic heart disease

Acute rheumatic fever and its major sequela rheumatic heart disease are conditions of poverty. Acute rheumatic fever is an autoimmune response to pharyngitis caused by infection with Streptococcus pyogenes that is characterised by various combinations of fever, arthritis, cardiac valvular disease, chorea, and skin manifestations. Chronic valvular damage due to repeated episodes of acute rheumatic fever is known as rheumatic heart disease and is the major cause of morbidity and mortality from acute rheumatic fever.

American doctors urge hospitals to stop serving processed meat to patients

The American Medical Association’s House of Delegates recently adopted a resolution calling on hospitals to remove processed meats from their menus and instead provide plant-based meals.

The resolution, which passed in June, was co-sponsored by the Medical Society of the District of Columbia and the American College of Cardiology.

It stated: “RESOLVED, That our American Medical Association hereby call on US hospitals to improve the health of patients, staff, and visitors by (1) providing a variety of healthful food, including plant-based meals and meals that are low in fat, sodium, and added sugars, (2) eliminating processed meats from menus, and (3) providing and promoting healthful beverages.”

There has been a growing, often uphill, push in the United States to remove processed meats from hospitals there.

Earlier this year, the University of Mississippi Medical Center (UMMC) in Jackson, Mississippi, announced it would remove hot dogs from its patient menus – making the centre the fourth hospital on the UMMC campus moving towards compliance with the American Medical Association’s recommendation on processed meat.

Stony Brook University Hospital in Stony Brook, New York, is nearly in compliance with the new resolution. The hospital provides patients with vegetables from its rooftop garden and features healthful plant-based options on its patient menu.

The New York Times reports that Stony Brook University Hospital’s head chef has banished bacon, soda, and hot dogs.

The Physicians Committee – a non-profit organisation of 12,000 doctors – commended the American Medical Association on its leadership in improving hospital food environments.

“Hospitals that provide and promote fruits, vegetables, whole grains, and beans are likely to reduce readmissions, speed recovery times, and measurably improve the long-term health of visitors, patients, and staff,” said the Committee’s Dr James Loomis, Medical Director of the Barnard Medical Center.

In the Physicians Committee’s 2016 Hospital Food Report, Stony Brook University Hospital and Aspen Valley Hospital were tied for the top Patient Food Score.

The Physicians Committee placed a billboard near UMMC’s Batson Children’s Hospital and sent a letter urging the hospital to protect patients from hotdogs with processed meats.

CHRIS JOHNSON

[Obituary] Patrick Gerard Johnston

Cancer researcher and university Vice-Chancellor. Born in Derry, UK, on Sept 14, 1958, he died of a cardiac arrest in Buncrana, Donegal, Ireland, on June 4, 2017, aged 58 years.

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