cholesterol

Friday, April 28, 2006

-- Only three percent of American adults follow the "big four" habits to prevent heart disease: Healthy diet, regular physical activity, proper weight, and not smoking, according to a recent national survey.
In order to help people improve their heart health, the U.S. National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health, has issued two new guidebooks about the factors that increase heart disease risk or that may contribute to worsening existing heart disease.
"Your Guide to a Healthy Heart" includes a detailed action plan for heart health and "Your Guide to Living Well With Heart Disease" has information to help people with heart disease protect and improve their heart health.
"In the United States, heart disease is the number one killer of both women and men. But the good news is that there are many things individuals can do to reduce their risks of heart disease," Dr. Elizabeth G. Nabel, NHLBI director, said in a prepared statement.
Here are some tips on how to reduce your heart-disease risk:
Don't smoke. If you do, quit. Smokers are up to six times more likely to suffer a heart attack than non-smokers.
Stay trim. Overweight and obesity cause many preventable deaths.
Get off the couch. Try to get 30 minutes of moderate-intensity activity on most -- preferably all -- days of the week.
Eat right. Stick to a heart-healthy diet that's low in saturated fat, trans fat, and cholesterol. Be sure to include whole grains, vegetables, and fruits in your diet.
Know your numbers. Ask your doctor to check your blood pressure, cholesterol (total, HDL, LDL, triglycerides), and blood glucose. Work with your doctor to improve any abnormal numbers.
-- Robert Preidt
SOURCE: NHLBI, news release, April 2006

Monday, March 27, 2006

Exercise No Threat to a Woman's Heart

-- Just in case the message wasn't clear already, exercise helps -- and rarely hurts -- your heart.
A new study has found that sudden cardiac death during exertion is extremely uncommon in women, and perhaps even more uncommon in women who exercise regularly.
And in the same vein, a second study showed that women who are heavier and who exercise less are more likely to have warning signs implicated in the development of cardiovascular disease.
These two studies appear in the March 22/29 issue of the Journal of the American Medical Association, a themed issue on women's health.
The issue also includes a study that found that women have about the same incidence of stable angina -- chest pain because of insufficient blood flow to the heart -- as men. And a fourth study found that low-dose aspirin therapy is even more protective in women than in men.
Current guidelines recommend that healthy adults engage in at least 30 minutes or more of moderate-intensity physical activity almost daily.
A previous study, however, had showed a certain risk associated with exercise, namely a risk of cardiac death in men.
"That concerned everybody, even though it was very low," said Dr. Alison Schecter, co-director of the Women's CARE (Cardiac Assessment and Risk Evaluation) Center at Mount Sinai Medical Center in New York City. "Should I run a marathon? Should I not run a marathon?" And little research had investigated the issue in women.
The first new study used data from the Nurses' Health Study, which followed 69,693 women without preexisting cardiovascular disease for up to 28 years and reported results related to sudden cardiac death.
As it turned out, the absolute risk of sudden cardiac death associated with moderate to vigorous exertion was one per 36.5 million hours of exertion, which was only slightly more than the risk associated with lesser or no exertion. The risk was even lower among women who exercised regularly. This rate of risk is even lower than that found in men.
"The risks were very, very low, even lower than in men," said study senior author Dr. Christine Albert, director of the Center for Arrhythmia Prevention at Brigham and Women's Hospital in Boston. "Overall, the women who were exercising regularly had a lower risk of sudden cardiac death during all times, not just during exertion."
Schechter said, "While the risk was low in men, it's even lower in women. This gives women the wherewithal to do vigorous exercise and emphasizes how safe it is."
"The benefit of long-term habitual exercise is that you live longer. That can't be underestimated," she added.
Anybody who has been ill or who already has cardiovascular disease should consult their doctor before starting an exercise program, Schechter advised. And being a weekend warrior is not a good way to exercise, she said.
Albert said: "The take-home message is that the risks are low but that there's an intelligent way to begin exercising, which is to build up slowly rather than to go out and do something vigorous when you haven't been exercising at all. It's also important to consult a physician to see if there's any reason you shouldn't exercise. Overall, exercise has multiple health benefits and these benefits certainly outweigh the small risk."
For the second study, an analysis of 27,158 participants in the Women's Health Study, researchers found that less-active women who also had a higher body mass index (BMI, a ratio of weigh to height) showed higher levels of inflammatory and lipid markers that could spell trouble for later heart disease.
"There was an idea that being a little overweight was OK," Schechter said. "Now it seems your BMI should be in a certain range and you should ask your doctor what the ideal BMI is. If it's higher, it impairs your health. The bottom line is that losing weight is good, if you're overweight."
In the third study, medical records of women aged 45 to 89 who had no history of coronary disease revealed that angina strikes women as often as it does men. Previous research had showed that women with angina had a higher risk of coronary death compared with women with no angina.
The final study delivered more good news: Low-dose aspirin therapy, as a way to prevent heart disease, actually worked better in women than in men. The trial participants, 571 men and 711 women, took 81 milligrams of aspirin a day.
SOURCES: Alison Schechter, M.D., assistant professor, medicine, Mount Sinai School of Medicine, and co-director, Women's CARE (Cardiac Assessment and Risk Evaluation) Center, Mount Sinai Medical Center, both in New York City; Christine Albert, M.D., director, Center for Arrhythmia Prevention, Brigham and Women's Hospital, Boston; March 22/29, 2006, Journal of the American Medical Association
Copyright ? 2006 ScoutNews, LLC. All rights reserved.

Symptom Awareness, Alert Friends Speed Stroke Care

-- A recognition of the seriousness and severity of stroke symptoms, plus the urging of family and friends, are key to how quickly a patient calls for help, new research shows.
"The time from symptom onset to seeking medical help is influenced by a patient's perception of the seriousness of symptoms, being advised by others to seek help, and calling 911 immediately," study author Dr. Lori Mandelzweig, researcher at the Sheba Medical Center in Tel Hashomer, Israel, said in a prepared statement.
A quick response to ischemic stroke can be critical. If a patient arrives at a hospital within three hours of having an ischemic stroke, he or she may receive a clot-busting drug to restore blood flow and reduce brain damage.
When the researchers interviewed 209 stroke patients (average age 62) in this study, they found that:
patients who called for an ambulance reduced their risk of delaying treatment by almost 75 percent;
those who perceived their symptoms as "severe" cut their odds of delayed treatment by almost 60 percent, compared with patients who failed to recognize the severity of their stroke symptoms;
patients who experienced sudden onset of stroke symptoms were highly unlikely to delay seeking treatment;
a patient's perception of control of symptoms was associated with a more than fivefold risk of delay in women;
when another person recognized the seriousness of stroke symptoms and urged the patient to get help, there was a more than 80 percent reduced risk of delaying treatment.
The findings, published in Stroke, highlight the need for more public education about recognizing and responding to signs of stroke, the researchers said.
-- Robert Preidt
SOURCE: American Heart Association, news release, March 23, 2006

Fish Not a Proven Heart Protector: Study

-- The belief that the omega 3 fats found in oily fish can help prevent heart disease is far from proven, a new British study contends.
U.S. experts agreed with that statement, but also stressed that people without heart disease will suffer no harm from consuming fish, and quite possibly could do themselves some good. And there's clear proof that omega 3 consumption helps people who already have had heart attacks or other cardiac problems, they added.
The report, published in the March 25 British Medical Journal, summarized findings from 89 studies aimed at assessing the effects of omega 3 consumption from fish or supplements on total mortality, heart problems, strokes and cancer.
The picture is "mixed," concluded Lee Hooper, a lecturer in research synthesis and nutrition at the University of East Anglia in Norwich, England, and lead author of the report. Two major studies did show a benefit, but the most recent large study did not, she said.
One problem in interpreting the findings is that most of the trials included people who already had cardiac problems such as heart attacks or angina. Putting all the studies together produced conclusions that could be described as equivocal, Hooper said.
"If you put the results all together, for every 100 deaths in the control group (those who didn't get omega 3), you see 87 deaths in those who took supplements," she said. "But that could be as low as 74 and as high as 102; our best guess is 87."
What's needed to determine the true preventive benefits of omega 3 consumption are more and larger trials, Hooper said. "At the moment we just aren't sure, so we should be cautious," she said.
That is pretty much the conclusion reached by an expert panel assembled in June 2004 by the U.S. National Heart, Lung, and Blood Institute.
"In terms of primary prevention, we still don't have the answer, and the conclusion of the panel was that additional studies were needed before making recommendations to the general public," said Dr. Eliseo Guallar, associate professor of epidemiology and medicine at the Johns Hopkins Bloomberg School of Public Health, and a member of the panel.
Those studies, which would be expensive, haven't been started yet, Guallar said. "And even if they were done, we wouldn't know the results for five, six, seven years from today," he said.
There's no question about the value of the omega 3 in fish oil for people with existing heart problems, Guallar said. One study of people who suffered heart attacks showed that taking 850 milligrams of fish oil a day substantially reduced their risk of sudden death, he said.
But while fish oils are "most promising for primary prevention" in people without heart disease, "we still don't know for sure," he said. Still, he endorses the American Heart Association's recommendation of eating at least two fish meals a week.
The heart association also recommends consumption of plants such as soybeans, canola and flaxseed, which contain a different version of omega 3 oils.
Alice R. Lichtenstein, professor of public health and family medicine at Tufts University School of Medicine and vice chair of the heart association's nutrition committee, isn't so sure about the plant part of the recommendation. It's not certain that the omega 3 in plants has the same benefits as the fishy kind, she said.
And even when it comes to fish consumption, "the jury is still out," Lichtenstein said. Nevertheless, eating fish is a good idea, in part because it keeps that much fatty meat out of the diet, she said, adding, that "the secondary benefit of what you don't eat supports moderate fish consumption."
But be careful about what kind of fish you eat, Lichtenstein added. Not all fish are rich in omega 3, and some commercial fish products are fried, which takes away a lot of the benefit, she said.
Mackerel, lake trout, herring, sardines, albacore tuna and salmon are good sources of omega 3, according to the heart association.
SOURCES: Lee Hooper, Ph.D., lecturer in research synthesis and nurition, University of East Anglia, Norwich, England; Eliseo Guallar, M.D., associate professor of epidemiology and medicine, Johns Hopkins Bloomberg School of Public Health, Baltimore; Alice H. Lichtenstein, D.Sc, professor of public health and family medicine, Tufts University School of Medicine, Boston; March 25, 2006, British Medical Journal

Thursday, March 23, 2006

New Cholesterol Drug Fails Human Trial

-- A promising theory, focused on a drug that experts hoped would help prevent heart disease, has been proven wrong in a real-world trial.
The idea was to prevent the formation of the fatty plaques that clog arteries by blocking an enzyme that steers cholesterol into those plaques.
However, pactimibe, a drug designed to interfere with the enzyme, did nothing to stop plaque formation, researchers report in the March 23 issue of the New England Journal of Medicine. In fact, it seems to have increased the danger.
"This approach has proven to be too risky, and it should not be pursued further," said Dr. Sergio Fazio, a professor of medicine at Vanderbilt University Medical Center, and the author of an accompanying editorial in the journal.
The report was rushed into print by the journal, according to lead researcher Dr. Steven E. Nissen, who is interim chairman of cardiovascular medicine at the Cleveland Clinic. Preliminary results from the trial had already been presented earlier this year at an American Heart Association meeting.
Nissen applauded the journal's decision to publish the study results, even though things didn't pan out as hoped.
"Things have really changed in the last few years," he said. "Negative trials used to get buried. In my view, it is very important to publish these negative results because other drugs in this class are in development, and the trial seemed to show an increasing rate of atherosclerosis [hardening of the arteries]."
The class of drugs in question block the effect of an enzyme known by its abbreviated name of ACAT. ACAT inhibitors act in a completely different way from statins, the widely used cholesterol-lowering medications that include blockbusters like Lipitor and Pravachol. While statins prevent the body from producing cholesterol, ACAT inhibitors, in theory, were supposed to prevent cholesterol from forming plaques and also keep it out of cells.
That idea was good on paper, Fazio said. However, he added that the trial's poor results were predictable, based on similar results in a prior clinical trial using a different ACAT inhibitor, and from Fazio's own research using an animal model.
In theory, the way to prevent cholesterol from forming plaque and get cholesterol out of the cell is to make sure it is in a form called "free cholesterol," Fazio said. An ACAT inhibitor does increase the amount of free cholesterol, but there's a catch: animal studies have shown that "too much free cholesterol is toxic to the cell," he said.
For that reason, this line of research may be a dead end, Fazio said. "Instead of telling the cell to make more free cholesterol, we have to think of ways to get cholesterol out of the cell, to open the doors and let cholesterol out."
A number of researchers are working on different methods of "opening the doors and windows of the cell" so that cholesterol can exit, Fazio said. One promising method is to increase the number of cholesterol receptors that would grab hold of the molecule outside the cell, he said.
The pactimibe trial did have one positive result, according to Nissen. The researchers used a technique called intravascular ultrasonography to measure the formation of plaque in the 408 people with coronary disease who took part in the trial. The technique provided good information on plaque formation and can be used in other studies, he said.
Another report on cholesterol and heart disease in the same issue of the journal focused on the role of genetics.
Researchers at the University of Texas Southwestern Medical Center in Dallas report that people who carry one of three variants of genes involved maintaining blood cholesterol levels are at substantially reduced risk of heart disease. Two of the gene variants are found predominantly in blacks, one in whites. One of the gene variants reduced blood levels of LDL cholesterol by 28 percent and the risk of coronary heart disease by 88 percent, the researchers reported.
SOURCES: Steven E. Nissen, M.D., interim chairman, cardiovascular medicine, Cleveland Clinic; Sergio Fazio, M.D., Ph.D., professor, medicine, and co-director, Atherosclerosis Research Unit, division of cardiovascular medicine, Vanderbilt University, Nashville, Tenn.; March 23, 2006, New England Journal of Medicine

Wednesday, March 22, 2006

Women, Minorities Less Likely to Get Best Heart Attack Care

-- When it comes to receiving the best care after heart attack , the deck is stacked against women, minority populations and older people, new research suggests.
Thirty-five percent of patients over age 64 who are rushed to local community hospitals with acute heart attacks are then transferred to larger hospitals for more aggressive interventions -- procedures known to improve survival rates, the researchers said.
But the study found that, in many cases, a person's medical condition has little to do with the decision of who gets to go to the larger hospitals.
Besides health concerns, "age, gender and race are predictive of whether or not patients are transferred after a heart attack from a community hospital to a larger hospital," said lead researcher Dr. Jeffrey Berger, a cardiology fellow at Duke University Medical Center.
His team found that younger, white males were significantly more likely to be sent to high-quality care at larger centers, compared to women or minority patients.
Treatment at larger centers, which have the technology and staff to perform angioplasty and bypass surgery, does make a difference in terms of patient outcomes, Berger said. In their analysis of nearly 400,000 cases involving patients over the age of 64, the researchers found post-heart attack mortality rates of 8.7 percent for patients transferred to larger centers vs. 18.5 percent for those treated at smaller community centers.
Heart attack treatment at community hospitals includes giving the patient powerful clot-busting drugs, Berger said. But he noted that research has shown that, even with the added transfer time to another hospital, surgical interventions tend to have a better outcome than using drugs when it comes to treating a heart attack.
Berger presented the findings Sunday during the annual scientific sessions of the American College of Cardiology, in Atlanta.
In the study, the Duke team looked at 2001-2003 data from the U.S. Centers for Medicare and Medicaid Services. During that time period, a total of 399,775 patients over 64 were admitted to hospitals without the resources to perform angioplasty or bypass surgery. Just over one-third of these patients were subsequently transferred to a larger facility where these procedures were performed.
According to the data, younger, white men with less serious heart attacks were more likely to be transferred to the larger hospitals, Berger said.
Women were 16 percent less likely to be transferred compared to men, the study found. Compared to white patients, African-Americans were 31 percent less likely to be transferred, and Hispanics, 47 percent less likely to be transferred. Age was another deciding factor. As age increased, so too did the likelihood that patients would be kept at a community hospital.
"Our findings underline ongoing concerns about disparity in health care in certain subgroups," Berger said. Teasing out the reasons for these inequities is difficult -- "they could be societal, patient or health care-based," he said.
Societal reasons could include the fact that people from poorer socioeconomic backgrounds have fewer options for transfers, Berger said. Some patients might also refuse to be transferred because they feel more comfortable closer to home, he said. Health-care factors, such as the assumption that older patients are less likely to benefit from more aggressive interventions, might also play a role.
"Further research is required to translate these findings into an improvement of health-care quality," Berger said.
The Duke study is just one of many papers on gender and racial disparities in health care being presented at the Atlanta meeting. According to Dr. Nieca Goldberg, the chief of women's cardiac care at New York City's Lenox Hill Hospital, "some of the sickest patients don't have access to really important care, and we need to evaluate the potential reasons and find the ways to improve care."
SOURCES: Jeffrey Berger, M.D., M.S., cardiology fellow, Duke University Medical Center, Durham, N.C.; Nieca Goldberg, M.D., chief, women's cardiac care, Lenox Hill Hospital, New York City; March 12, 2006, presentation, 55th annual scientific sessions, American College of Cardiology, Atlanta

Folic Acid Supplements Won't Lower Heart-Attack Risk

-- Two new studies question the conventional wisdom that folic acid and B vitamin supplementation lowers cardiovascular risk.
The logic behind supplementation has been that it reduces blood levels of a protein called homocysteine, long linked to heart attack and stroke. But the new research suggests that lowering homocysteine this way has no effect on preventing heart attacks -- and may even trigger a slight rise in heart attack risk.
Both reports will appear in the March 16 issue of the New England Journal of Medicine, but were released early to coincide with their presentation Sunday at the meeting of the American College of Cardiology, in Atlanta.
"Combination vitamin therapies, which do lower homocysteine, have no effect on cardiovascular events, even though the homocysteine level is lowered," said Dr. Joseph Loscalzo, head of the department of medicine at Brigham & Women's Hospital in Boston, and author of an accompanying journal editorial.
There was one glimmer of hope for people taking these supplements, however: One of the two studies did note a "marginally significant" decrease in stroke risk after supplementation.
In the first study, called the Norwegian Vitamin (NORVIT) trial, Norwegian researchers randomly assigned 3,749 men and women who had heart attacks to receive folic acid, vitamins B6 and B12, or a placebo.
Over the three years of the trial, the researchers found that while homocysteine levels dropped an average of 27 percent among people taking folic acid and vitamin B12, this decline in the blood protein had no significant effect on whether people had another heart attack or died from another heart attack.
In fact, people taking all three supplements actually experienced a slightly increased risk of having another heart attack, the researchers found.
"Doctors should not advise patients who have cardiovascular disease to take B vitamins in order to prevent heart disease or stroke," said lead author Dr. Kaare Harald B? a professor of medicine and consultant cardiologist at the Institute of Community Medicine at the University of Troms? vitamins do not prevent heart disease," he added.
In the second study, called the Heart Outcomes Prevention Evaluation (HOPE) 2 study, researchers gave more than 5,500 patients who had diabetes or vascular disease folic acid, vitamins B12 and B6, or a placebo.
Over the five years of the study, homocysteine levels dropped significantly among those receiving the supplements, but -- just as happened with the NORVIT trial -- this lowering of homocysteine did not result in significantly reduced risk of death from heart disease or heart attacks.
There did, however, appear to be a slight reduction in stroke among people taking the supplements, the researchers reported.
Overall, however, the researchers concluded that "combined daily administration of 2.5 mg [milligrams] of folic acid, 50 mg of vitamin B6, and 1 mg of vitamin B12 for five years had no beneficial effects on major vascular events in a high-risk population with vascular disease."
They added that "our results do not support the use of folic acid and B vitamin supplements as a preventive treatment."
However, Anne Dickinson, a consultant and past president of the Council for Responsible Nutrition, which represents the supplements industry, said the findings may not apply to relatively healthy Americans who are turning to these vitamins to help ward off heart disease.
She noted that the two study populations involved sicker individuals with a history of heart attack, heart disease, diabetes and other problems.
"These studies did not test whether B vitamins used by healthy people can help keep them healthy," Dickinson said in a prepared statement. "Instead, they looked at whether B vitamins can treat or reverse heart disease in people who already have it. Vitamins should not be expected to perform like drugs -- their greatest purpose is in prevention."
But Alice H. Lichtenstein, director of the Cardiovascular Nutrition Lab at the USDA Human Nutrition Research Center at Tufts University, in Boston, countered that argument. She noted that even outwardly "healthy" Americans develop some level of atherosclerosis -- hardening of the arteries -- as they age, and so the findings would probably apply to the average consumer, as well.
Loscalzo thinks that the message from these studies may not be that lowering homocysteine doesn't prevent heart attacks, but rather that vitamin therapy is not the best way to lower homocysteine.
"These trials of vitamin therapy for high homocysteine have all been consistent in their message, namely, [that] combination vitamin therapies, which do lower homocysteine, have no effect on cardiovascular events, even though the homocysteine level is lowered," he said.
Loscalzo said he believes the supplement treatment somehow counteracts the effect of lowering homocysteine. "Some of those adverse affects may have to do with the complex metabolism of the vitamins," he said. "These vitamins are important for cell growth. It may be that the doses used might have stimulated the growth of cell and atherosclerotic plaque."
According to Loscalzo, there's strong evidence that homocysteine does adversely affect blood vessels. So perhaps the answer lies in smaller doses of vitamins.
"These high doses of folic acid don't provide any benefit and shouldn't be used," Loscalzo said. "Lower doses are safe and may provide benefit, but we don't know that yet.
"It's not that homocysteine is no longer a bad actor," Loscalzo said. "It's that lowering it with this simple treatment isn't the answer."
Lichtenstein agreed that high doses of vitamins may not be as beneficial as some have thought.
"This is one of those cases where you see an association with reduced risk of heart disease with levels of vitamins that would normally be consumed, but when you go to considerably higher levels than people could consume from diet, we get disappointing results," she said.
SOURCES: Joseph Loscalzo, M.D., Ph.D., head of the department of medicine, Brigham & Women's Hospital, Boston; Alice H. Lichtenstein, D.Sc., director of the Cardiovascular Nutrition Lab and Stanley Gershoff Professor of Nutrition, USDA Human Nutrition Research Center, Tufts University, Boston; Kaare Harald B? M.D., Ph.D, professor of medicine and consultant cardiologist, primary investigator, the NORVIT trial, the Institute of Community Medicine, University of Troms?rway; March 12, 2006, prepared statement, Council for Responsible Nutrition, Washington, D.C.; March 16, 2006, New England Journal of Medicine

Test to Predict Heart-Attack Risk Underused

-- A new test that predicts which patients with heart-attack symptoms are at greater risk of dying isn't being used in younger, healthier patients -- the ones who could benefit most from the exam, a new study contends.
Studies have consistently found that elevated levels of brain natriuretic peptide (BNP) are associated with an increased risk of death in heart attack patients.
In most hospitals, the BNP test is typically performed on patients who already have clinical risk factors, such as a history of congestive heart failure, older age and diabetes, that put them at a higher risk of death, the Duke University researchers found.
Yet younger and healthier patients with elevated BNP levels are at a two- to four-times greater risk of dying in a hospital than high-risk patients with elevated BNP levels, the researchers reported.
Dr. Matthew Roe, from the Duke Clinical Research Institute, presented the findings Tuesday at the American College of Cardiology annual meeting, in Atlanta.
"The BNP test has been used primarily in patients with heart failure to assess their risk of death or other complications," Roe said.
In their study, Roe and his colleagues looked at the use of the BNP test in U.S. hospitals that were part of the CRUSADE study, which stands for "Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines."
Over a 20-month period, Roe's group found that 30,324 patients were treated at 312 CRUSADE hospitals, and 19.4 percent of those patients had their BNP levels measured. "About a quarter of the hospitals did not use the test at all," Roe said.
"We found that in younger patients who did not have heart failure or diabetes, the test was a more powerful predictor of death and other complications than it was in older patients with heart failure," Roe said. "The test was more useful in a lower-risk population in whom it was less likely to be used in the first place," he added.
Roe believes that more studies are needed to determine how to use the test most effectively. "We need to understand who this test will benefit most," he said. "If you can identify patients who are at the most risk, you could treat them more aggressively."
One expert agrees that the BNP test is useful.
"This test is coming into more use in different areas than heart failure, the area it was originally designed for," said Dr. David D. Waters, the chief of cardiology at San Francisco General Hospital and a professor of medicine at the University of California, San Francisco.
There are a lot of different tests to assess risk in heart attack patients, Waters said. "The [BNP] test is a useful tool to add to what we do already," he said, adding that he regularly uses the test with his patients.
Another expert concurred with that view.
"BNP will add information that is separate and unique than what you get from other prognostic indicators," said Dr. Alan S. Maisel, a professor of cardiology at the University of California, San Diego.
Maisel believes it's not yet clear how the test should be used in routine clinical practice. However, he thinks it could help in making treatment decisions. "This data suggests that you should get a BNP, because it's going to be higher in people you don't expect," he said.
Maisel believes the exam will eventually become part of standard guidelines for treating heart attack patients.
Elevated BNP would be a reason to have patients receive further examinations, such as an angiogram, Maisel said. "In addition, elevation in BNP would lead me to get some idea of heart function before sending patients home," he said.
SOURCES: Matthew Roe, M.D., Duke Clinical Research Institute, Duke University, Durham, N.C.; David D. Waters, M.D., chief, cardiology, San Francisco General Hospital, and professor, medicine, University of California, San Francisco; Alan S. Maisel, M.D., professor, cardiology, University of California, San Diego; March 14, 2006, presentation, American College of Cardiology annual meeting, Atlanta

Blood Thinner Protects Heart Patients

-- The anti-clotting drug abciximab reduced the risk of heart attack and other adverse events in heart patients receiving angioplasty or artery-opening stents, German researchers report.
The study included more than 2,000 patients with ACS (a spectrum of conditions involving chest discomfort or other symptoms) undergoing these types of procedures. Some patients received abciximab while others received an inactive placebo. All the patients also received a 600 milligram dose of the anti-platelet agent clopidogrel (Plavix) at least two hours prior to the procedure, as well as 500 milligrams of oral or intravenous aspirin.
Within 30 days, 90 patients (8.9 percent) in the abciximab group had died, suffered a heart attack, or required urgent target vessel revascularization, compared to 120 patients (11.9 percent) in the placebo group. This translated into a 25 percent reduced risk among the patients who received abciximab, said the researchers led by Dr. Adnan Kastrati of the Deutsches Herzzentrum, in Munich. Most of the risk reduction was related to fewer deaths and heart attacks.
The findings will be published in the April 5 issue of the Journal of the American Medical Association, but were released early due to their publication Monday at the annual meeting of the American College of Cardiology, in Atlanta.
The German team also found that the benefits of abciximab seemed confined to patients with elevated levels of troponin, a muscle protein that's present in increased amounts in patients with cardiac ischemia.
-- Robert Preidt
SOURCE: Journal of the American Medical Association, news release, March 13, 2006

Carotid Stenting Safe Alternative to Surgery

-- Placing a vessel-opening stent in the carotid artery is safe for people who have blocked carotid arteries but no symptoms and, due to other medical conditions, can't have surgery to clear the blockages, a new study finds.
Carotid artery stenting combines balloon angioplasty and a stent implant to clear buildups of fat and cholesterol and reopen the artery, which is the major supplier of blood to the brain. Blocked carotid arteries can decrease blood flow and increase the risk of stroke.
The findings were presented Tuesday the American College of Cardiology annual meeting, in Atlanta.
Currently, the U.S. Center for Medicare and Medicaid does not cover carotid stenting for people with carotid artery blockage who have no symptoms, such as weakness, paralysis, visual problems or speech difficulties.
The current study involved 2,500 patients treated at 188 medical centers across the United States. The patients were all treated with Guidant's RX ACCULINK Carotid Stent System with RX ACCUNET Embolic Protection System.
Among asymptomatic patients, the rate of major complications (death, stroke or heart attack) within 30 days after the stenting procedure was 5.7 percent. That's lower than the rate found in other studies of similar patients who had surgery to clear blocked carotid arteries.
"The scope of this landmark trial provides us with a clear picture of the patients who benefit the most from carotid artery stenting. We hope these results will expand coverage to asymptomatic patients who are risk candidates for surgery," principal investigator Dr. William Gray, an associate professor of clinical medicine at Columbia University Medical Center in New York City, said in a prepared statement.
Gray is director of endovascular services at the Center for Interventional Vascular Therapy at New York-Presbyterian Hospital/Columbia and the Cardiovascular Research Foundation.
The study also found that younger patients had better outcomes. Stroke, death or heart attack occurred in 8.9 percent of patients over age 80, compared to 4.8 percent for patients under age 80.
-- Robert Preidt
SOURCE: Columbia University Medical Center, news release, March 14, 2006

Anti-Clotting Drugs May Improve Heart Attack Care

-- Two anti-clotting drugs improved survival and reduced the risk of cardiovascular trouble when given in the hours after a heart attack .
Those findings appear in reports presented Tuesday at the American College of Cardiology annual meeting, in Atlanta.
The reports, by two different teams of researchers, set up a potential duel over which of these two drugs -- Arixtra or Lovenox -- does the most good with the least incidence of excess bleeding.
The new data is "good news for patients who have heart attacks and doctors who take care of patients who have heart attacks," said researcher Dr. Elliott M. Antman, professor of medicine at Brigham and Women's Hospital in Boston and Harvard Medical School. He headed up one of the studies, focused on Lovenox.
Up till now, it has been standard practice to give patients aspirin, a clot-dissolving drug and the anti-clotting drug heparin in the hours and days after a heart attack, Antman noted.
In his team's trial, the drug Lovenox (enoxaparin) -- usually prescribed to prevent deep-vein clotting -- was substituted for heparin for half of the more than 20,000 heart-attack patients in the study.
According to Antman, Lovenox "reduced the chance of dying or having a second heart attack, which is highly significant. There was a 33 percent reduction in the chance of a second heart attack in the first 48 hours."
To put it another way, he said, "for every thousand patients who receive this clot-busting treatment, there will be 15 fewer nonfatal heart attacks, seven less bypass surgeries, six fewer deaths and four more nonfatal major bleeds."
Antman said this "small, statistically significant increase in severe bleeding episodes" was a price worth paying, since there was no increase in fatalities caused by those episodes.
The study results will also be published in the April 6 issue of the New England Journal of Medicine.
Antman's assessment was challenged by researchers investigating a rival anti-clotting drug, Arixtra (fondaparinux). They presented the results of two trials -- one comparing Arixtra to standard therapy, and a second head-to-head comparison of Arixtra vs. Lovenox.
The results, from a group led by physicians at McMaster University in Canada, will appear in the April 5 issue of the Journal of the American Medical Association, but are being released Tuesday to coincide with their publication at the Atlanta conference.
The trial involved more than 12,000 heart-attack patients treated at 447 hospitals around the world.
The Canadian-led team found an overall 14 percent reduction of death or second heart attack one month after heart attack for patients given Arixtra compared to those given standard care.
The results "confirm the value and safety" of the drug "in a broad group of patients with acute coronary syndrome," the researchers wrote.
But Antman said the results should be approached cautiously, because some of the patients in that trial were given a placebo, an inactive substance, rather than heparin. Proof of Arixtra's effectiveness requires a direct comparison with heparin treatment, he said.
Dr. James Velianou, associate professor of medicine at McMaster and a member of the research team, said the patients in the study were given "the standard of care at the time the study was done."
The Arixtra group also challenged Lovenox head-on in a paper that will also appear in the April 6 New England Journal of Medicine.
That paper compared the results of treatment with the two drugs in a trial of more than 20,000 patients who did not have the kind of heart attack of those in the two other studies, but had severe coronary problems.
The results, in terms of major problems -- including death, a heart attack or major artery blockage within nine days -- were similar for both drugs: 5.8 percent for Arixtra, 5.7 percent for Lovenox. But otherwise, the head-to-head study favored Arixtra: The number of severe bleeding episodes was substantially lower in the Arixtra group -- 2.2 percent versus 4.1 percent for Lovenox -- and Arixtra treatment "was associated with a significantly reduced number of deaths at 30 days."
The reduction in bleeding episodes is important, because "bleeding leads to extra problems," Velianou said. "People who bleed less tend to die less."
In a commentary in the Journal of the American Medical Association, Dr. Robert C. Califf, of Duke Clinical Research Institute, said the McMaster results "are sure to lead to an outburst of competitive pronouncements by companies and by leaders in the clinical community about the question of which regimen is truly best."
The answer, Califf said, probably will come from a combination of further clinical trials and lessons learned from experience with the treatments.
"We don't have that answer yet because that study hasn't been done," Velainou said.
SOURCES: Elliott M. Antman, professor, medicine, Harvard Medical School and Brigham and Women's Hospital, Boston; James Velianou, associate professor, medicine, McMaster University, Hamilton, Canada; March 13, 2006, American College of Cardiology annual meeting, Atlanta; April 5, 2006, Journal of the American Medical Association; April 6, 2006, New England Journal of Medicine

Costly Heart Test Could Save Medicare Money

-- It's not currently covered by Medicare , but a $400 test used to spot people who might need an implanted cardiac defibrillator might end up saving the agency hundreds of millions of dollars a year, researchers report.
The finding comes about a week before Medicare announces whether or not it will cover the cost of the microvolt T-wave alternans (MTWA) test, which detects small variations in the electrical impulses in the heart.
A team at the University of Michigan Health System used a computer model to calculate the potential impact of using the MTWA test to help determine which patients are at greatest risk from sudden cardiac death. Those patients would benefit most from an implanted cardiac defibrillator (ICD), which automatically restarts a stopped heart.
The researchers, who have no links to the makers of the MTWA test, concluded that using the screen could save Medicare $690 million a year. Last year, Medicare extended its coverage of ICDs to include many more heart patients -- right now, an estimated 500,000 people over age 65 are candidates.
"ICDs have been shown in several studies to be cost-effective, which means the cost is considered acceptable given the benefit to patients," study lead author and cardiology fellow Dr. Paul Chan said in a prepared statement.
"But a very expensive device can be cost-effective and still not affordable to society, if the condition it treats is highly prevalent. Our study demonstrates the potential impact of using additional factors to aid decisions about the use of expensive devices," Chan said.
The findings were presented this week at the annual meeting of the American College of Cardiology, in Atlanta.
-- Robert Preidt
SOURCE: University of Michigan Health System, news release, March 13, 2006

Outlook Improving for Heart, Lung Transplant Recipients

-- The number of heart- and lung-transplant patients surviving three years or more after transplant continues to rise, according to a new global report.
More than 64 percent of patients who had heart and lung transplants between 2000 and 2003 survived for at least three years, compared to 55 percent of patients who had transplants between 1988 and 1994, according to data from the Registry of the International Society for Heart and Lung Transplantation
Key factors increased the risk of death following transplants, the report found. One of these factors is "primary grant dysfunction" -- a severe, acute lung injury that can occur in the first 72 hours after transplantation. One study found the 30-day death rate for transplant patients with primary grant dysfunction to be 42 percent, compared to six percent for patients without the complication.
Another problem linked to increased death rates among lung-transplant patients is a rejection-linked process called bronchiolitis obliterans syndrome (BOS). According to a University of Pittsburgh study, about 30 percent of lung-transplant patients develop BOS late in the first year after their transplant. About two-thirds of these patients suffer a steady decline of pulmonary function over several years.
A recent workshop on lung transplantation sponsored by the U.S. National Heart, Lung, and Blood Institute concluded that a few key priorities could improve post-transplant survival and care. These included an expansion of the donor pool; accurate prediction of and effective treatment for primary graft dysfunction and BOS; and the development of strategies to facilitate induction of immune tolerance.
The findings appear in the March issue of the American Journal of Respiratory and Critical Care Medicine.
-- Robert Preidt
SOURCE: American Thoracic Society, news release, March 2006

Foods Fortified With Folic Acid May Cut Stroke Risk

-- Cereals and breads fortified with folic acid, mandatory in the United States and Canada to help reduce birth defects, may also help cut your risk of dying from a stroke , a new study suggests.
Folic acid has long been known for its effect on reducing certain birth defects when taken in sufficient quantities by pregnant women. That was the rationale behind the U.S. Food and Drug Administration's 1998 order for folic-acid fortification of enriched grain products such as cereals and breads. Canada made fortification mandatory that same year.
Now, experts have compared stroke mortality rates in both countries before and after fortification and found that death rates, while already on the decline before, dropped substantially after fortification took effect.
"This is the first population-based study of changes in stroke mortality before and after folic-acid fortification in the United States and Canada," said Quanhe Yang, an epidemiologist at the U.S. Center for Disease Control and Prevention's National Center on Birth Defects and Developmental Disabilities.
Yang is the lead author of the new study, which appears in the March 14 issue of Circulation.
The researchers also looked at stroke death rates in England and Wales, where fortification of foods with folic acid is not required, and did not find a significant change in mortality rates between the years 1990 and 2002.
What triggered the study? "There was accumulating evidence to suggest elevated levels of homocysteine [an amino acid in the blood] increases stroke death risk," he said. "It remains controversial." Some research has found that elevated homocysteine in the blood, by itself, can raise stroke risk, Yang said.
"If you have a high level of folic acid [in your blood], the level of homocysteine will decrease," he added.
Not all the evidence supports that view, however. Two studies released early on Sunday by the New England Journal of Medicine found that even after heart patients lowered their homocysteine levels via folic acid and B vitamin supplementation, their risk for heart attack did not change.
One study did find a "marginally significant" decrease in stroke risk linked to supplement use, while another found no decline in stroke and even a slight increase in heart attack risk after years of supplementation with folic acid and vitamins B6 and B12.
According to experts, the findings cast doubt on the conventional wisdom that folate might help ward off heart disease.
However, Yang's population-based study appears to support the traditional view on folate use. When he and his colleagues examined people before and after fortification became mandatory, they found that homocysteine levels -- and their risk of stroke death -- declined.
The researchers found an association, not a cause-and-effect, Yang emphasized. "The part we don't know is, if the folic acid directly reduces the risk of stroke. It may be that something happens in-between. We do not know yet the mechanism of homocysteine," he said, adding that folic acid somehow breaks down the amino acid.
For the study, Yang and his team reviewed national death statistics in the United States and Canada for the years 1990 to 2002. In the United States between 1990 and 1997, before fortification, the overall death rate from stroke declined by 0.3 percent each year. But from 1998 to 2002, the death rate declined 2.9 percent each year. Those findings translate to about 13,000 fewer stroke deaths each year among U.S. residents over age 40, the study said.
In Canada, the annual decline in stroke-related deaths was 1.2 percent among men and 0.9 percent for women over age 40 before fortification went into effect. After fortification, the declines were 5.6 percent for men age 40 and older and 5.4 percent for women 40 and above -- translating to 2,800 fewer stroke deaths each year after fortification.
Blood levels of folic acid have nearly doubled in the U.S. population since 1998, the authors noted.
Another expert familiar with the study findings called them potentially good news. In the past, researchers have looked at the effects of increasing folic acid on cardiovascular disease, including heart attacks and strokes, said Alice H. Lichtenstein, the Stanley Gershoff Professor of Nutrition at the USDA Human Nutrition Research Center at Tufts University in Boston. "The data for cardiovascular disease has not been encouraging," she said. "This [new study] is looking better."
But, like Yang, she stressed that the study only found an association, not a cause-and-effect. Don't go overboard on folic acid, she cautioned.
Currently, the recommended daily intake of folic acid -- also known as folate -- is 400 micrograms a day for adults and 600 for pregnant women. Many multivitamins contain 400 micrograms. Folate, a B vitamin, is also found in dark green leafy vegetables, fruits such as oranges and strawberries, and in fortified products.
SOURCES: Quanhe Yang, Ph.D,, epidemiologist, U.S. Centers for Disease Control and Prevention's National Center on Birth Defects and Developmental Disabilities, Atlanta; Alice H. Lichtenstein, D.Sc., director, Cardiovascular Nutrition Lab and Stanley Gershoff Professor of Nutrition, USDA Human Nutrition Research Center, Tufts University, Boston; March 14, 2006, Circulation

Eat Cholesterol-Lowering Foods in Combination: Study

-- Cholesterol -lowering foods may be most effective when eaten in combination, a Canadian study suggests.
The University of Toronto study included 66 women and men, averaging just over 59 years of age. All of the participants ate a diet high in viscous fibers, soy protein, almonds and plant sterol margarine -- all thought to help lower cholesterol.
The participants were told to follow the diet for a year and to keep records of what they ate. They met every two months with the researchers to discuss their progress and to have their cholesterol levels measured.
After a year, more than 30 percent of the study volunteers had successfully kept to the diet and lowered their cholesterol levels by more than 20 percent. That's comparable to what some of the volunteers achieved after taking a cholesterol-lowering statin drug for a month before they started on the diet.
"The study's findings suggest that the average person can do a lot to improve their health through diet," study author David Jenkins, professor in the department of nutritional sciences and a Canada research chair in nutrition and metabolism, said in a prepared statement.
"The participants found it easiest to incorporate single items such as the almonds and margarine into their daily lives," he said. "The fibers and vegetable protein were more challenging since they require more planning and preparation, and because these types of niche products are less available. It's just easier, for example, to buy a beef burger instead of one made from soy, although the range of options is improving. We considered it ideal if the participants were able to follow the diet three quarters of the time."
The findings appear in the current issue of the American Journal of Clinical Nutrition.
-- Robert Preidt
SOURCE: University of Toronto, news release, March 8, 2006