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Heart failure, statins take center stage at AHA conference

From the February ACP Internist, copyright 2009 by the American College of Physicians

By Jessica Berthold

NEW ORLEANS—Heart failure, headphones, statins and self-care were just some of the research topics presented at the annual American Heart Association Scientific Sessions conference last November.

Paul Ridker, MD: Providers could prevent 250,000 d...

Paul Ridker, MD: Providers could prevent 250,000 deaths in five years by expanding statin use.



Not surprisingly, the just-released JUPITER trial took top billing, as physicians debated the consequences of its finding that rosuvastatin lowers heart attack, stroke and death risk in patients with normal LDL cholesterol but high C-reactive protein (CRP) levels. Generally, about half of stroke events and heart attacks are in patients whose cholesterol seems fine.

The results indicate that, not only are statins safe, but providers could prevent 250,000 deaths over a five-year period by expanding their use, said lead study author Paul Ridker, MD, director of the Center for Cardiovascular Disease Prevention at Brigham and Women's Hospital in Boston. Yet others at the conference urged caution, noting that cost needs to be taken into account and more research needs done to determine who, precisely, should be screened for CRP levels.

“I do think we need to review the guidelines of where CRP sits in risk evaluation,” said Andrew Tonkin, MD, head of cardiovascular research at Monash University in Melbourne, Australia. “But we need to see what the absolute risk reduction is in various subgroups before we can figure out who to screen.”

It's not clear whether the statins in the study successfully reduced events because they lowered CRP, or because they lowered LDL, or both, noted Timothy Gardner, MD, president of the American Heart Association.

“This was not a trial that compared a CRP strategy to a non-CRP strategy; it was a statin trial,” agreed Ramachandran Vasan, MD, associate professor at Boston University School of Medicine. “Still, JUPITER does provide food for thought.”

Heart failure

Meanwhile, there was disappointing research on heart failure, including the HF-ACTION study, which found structured exercise training didn't reduce death or hospitalization rates for heart failure patients compared to usual care. The regimen in the study involved 36 supervised sessions of 30 minutes of exercise, three times a week. At the 18th session, patients transitioned into exercising at home for 40 minutes, five times a week, on a treadmill or exercise bike. All patients received optimal medical therapy.

Despite the lackluster results, the finding may ease the minds of physicians and patients who are wary of exercise for heart failure patients. The study found no more adverse events (heart attack, angina or arrhythmia) in patients who exercised compared with those who didn't, noted study author Christopher O’Connor, MD, of Duke University Medical Center.

That wasn't enough of a finding for Philip Poole-Wilson, MD, head of cardiovascular sciences at the National Heart & Lung Institute at Imperial College London, however.

“Safety without benefit is a bit dull, really,” Dr. Poole-Wilson said.

A sub-study of HF-ACTION also found that the patients in the exercise group reported significantly better health status (quality of life, symptoms and physical/social limitations) at three months, and the difference lasted for three years. HF-ACTION involved 2,331 heart failure patients (average age, 59 years) who were followed for about 2.5 years.

A separate study looked at the subset of heart failure patients with an ejection fraction of greater than or equal to 45%, for whom there has historically been no good treatment. Researchers tested whether irbesartan (Avapro) might lower death and hospitalizations for heart failure, myocardial infarction, stroke and arrhythmia. They studied 4,128 subjects and followed them for 4.5 years, with the average patient age at the start being 72 years—appropriate given that that this condition mostly affects older people.

Though there was a difference in those who took irbesartan vs. placebo, it wasn't significant. Again the researchers were left with pointing out that, at least, the study showed the drug was safe, which means it could be a good substitute for patients who can't tolerate other hypertension drugs.

Patient self-care

Patients who don't like to drag themselves into the clinic every month for prothrombin time (INR) testing can take heart: It may no longer be necessary. One study found that atrial fibrillation and heart valve patients on warfarin who did weekly home INR testing had about the same number of strokes, major bleeds or deaths as patients who were monitored monthly at a clinic. Patients also were happier with the home testing approach, which is covered by Medicare for atrial fibrillation, heart valve and venous thromboembolism patients.

The study involved 2,922 Veterans Administration subjects, nearly all of whom were men. Over a three-year period, about 6.2% of home testing patients had a stroke, major bleed or death, compared with 6.9% of patients tested in a clinic.

This is good news for patients who live in remote areas, or who might have other barriers to getting to a clinic, noted study co-author Alan K. Jacobson, MD, staff cardiologist at the Jerry L. Pettis Memorial VA Medical Center in Loma Linda, Calif.

“For patients where access is a problem either because of disability or distance, this potentially has a huge impact,” Dr. Jacobson said.

Speaking of self-care, patients with implanted cardiac devices can make themselves a lot safer by keeping their MP3 player headphones at least 1.2 inches away from their chests, another study found. Researchers tested eight different models of headphones and found that magnets in the headphones interfered with 15% of patients' pacemakers and 30% of their defibrillators.

“For patients with pacemakers, exposure to the headphones can force the device to deliver signals to the heart, causing it to beat without regard to the patients' underlying heart rhythm,” said William H. Maisel, MD, senior study author and director of the Medical Device Safety Institute at Beth Israel Medical Center in Boston. “Headphones can temporarily deactivate a defibrillator.”

Disparities

Several studies looked at disparities in care. Hispanic patients are 57% less likely than white patients to have coronary artery bypass surgery a year after successful angioplasty, one study found. They were also significantly more likely to have hypertension, diabetes and insulin-treated diabetes, which one might expect would lead to higher rates of restenosis, not lower, said study author Shailja V. Parikh, MD, a cardiology fellow at the University of Texas Southwestern Medical Center in Dallas.

“It's possible that a referral bias exists,” Dr. Parikh said. “Or there may be mediating factors intrinsic to the Hispanic patient that could be protective toward restenosis.”

Another study offered a speck of hope in the usual dismal news about racial disparities. After reviewing data on 291,009 Pennsylvania patients admitted for coronary artery bypass surgery (CABG) after heart attack, researchers found that disparities between African Americans and whites had declined in the 10 years between 1997 and 2006.

While African Americans were less likely to have invasive cardiac procedures done during any time period, the gap narrowed from 59% in 1995-1997 to 38% in 2004-2006. Gaps between lower and higher income patients narrowed as well, the study found.

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