CardioExchange Archive

HF Readmission: See Me Now Or See Me Later: After being hospitalized for heart failure (HF), patients who are treated at hospitals with higher rates of early follow-up have lower rates of readmission at 30 days, according to a new study appearing in the Journal of the American Medical Association. Adrian Hernandez and colleagues analyzed data from 30,136 patients with HF. They write that “early evaluation after discharge is critical. This evaluation should include a review of therapeutic changes and a thorough assessment of the patient’s clinical status outside of the highly structured hospital setting.”


No Reduction in MI Following Pneumococcal Vaccination: In a large cohort of men 45 years or older, the pneumococcal vaccine did not appear to have any effect on the risk of acute MI or stroke. In their paper in the Journal of the American Medical Association, Hung Fu Tseng and colleagues note that although several studies have shown that influenza vaccination reduces the risk of cardiovascular events, the evidence is less certain for the pneumococcal vaccination. In an accompanying editorial, Mohammad Madjid and Daniel Musher point out the limitations of observational studies and write that “until rigorous data from clinical trials are available to determine whether pneumonia vaccine can prevent MI, physicians should strictly adhere to available guidelines for optimizing vaccination rates in recommended target groups, because these rates are still far from optimal.”

European Heart Journal Editors Defend Nissen Editorial: In an editorial published online in the European Heart Journal, the editors of the journal defend the publication of an editorial by Steven Nissen on rosiglitazone. The editorial had been published online on February 12, prompting a GlaxoSmithKline executive to write the editors asking them not to publish the editorial in the printed journal. The editors declined, and in their editorial called the request “unacceptable.” They went on to write: “We cannot suppress concerns, data or divergent opinions — we must consider them and argue with data, numbers and plausibility. Only through such a discourse can progress evolve.” The editors then offered the manufacturer an opportunity to state its position, and Nissen a chance to respond. Both the GSK statement and the Nissen response are available on the EHJ website.

Further reading: This story was first reported on CardioBrief. A detailed account of the background of this story can be read on Pharmalot.

The Straight Dope — HGH Improves Sprint Capacity: In a study reported in the Annals of Internal Medicine, Udo Meinhardt and colleagues examined the effects of human growth hormone in 96 recreational athletes in Australia. They randomized men to HGH, testosterone, both, or placebo — and women to HGH or placebo — for 8 weeks. Overall, sprint capacity in HGH users increased by 3.9%; in men who also received testosterone, the increase was 8.3%. There were no significant differences in other performance measures (endurance, strength, and power). HGH reduced fat mass, increased lean body mass and, in men who also received testosterone, increased body cell mass. Six weeks after discontinuation of drugs, the increase in sprint capacity was not maintained. The editors of Annals write that “this is the first demonstration of change in physical performance with the drug.”

Genomics Rubber Meets the Clinical Road: In a study without precedent, an asymptomatic 40-year-old man with a family history of coronary disease and sudden death received a comprehensive analysis of his full genome. According to the report in the Lancet, the investigators from Stanford and Massachusetts General Hospital found evidence that the man was at increased risk for MI, type-2 diabetes, and some cancers. He also had several rare variants of genes associated with sudden cardiac death, as well as variants associated with a good response to statins and resistance to clopidogrel. The results, write the authors, “provide proof of principle that clinically meaningful information can be derived about disease risk and response to drugs in patients with whole genome sequence data.”
   In an accompanying comment, Nilesh Samani, Maciej Tomaszewski, and Heribert Schunkert write that “even if the direct cost of sequencing whole-individual genomes becomes affordable, there are many practical challenges that will need to be overcome if the personal genome is going to enter clinical practice. Arguably of greater importance are ethical issues: who should have their genome sequenced, what counseling should be provided before and after testing and by whom, and who should have access to an individual’s genetic information. Whereas these issues are familiar in genetic testing, the scale of the data contained within each personal genome, and the potential implication for so many different aspects of an individual’s health (and the health of their relatives), mean that these issues will need to be even more carefully considered (and legislated on where necessary) to prevent misuse.”
  
The Lancet also published a Viewpoint, in which several of the authors of the original paper note that the clinical relevance of most of the data in genomic studies is unclear, and even when there is a clear message there may be no therapeutic options. They also note the potential strain on the healthcare system of simply conveying the results to people: “We predict that an average person might need information about roughly 100 genetic risks discovered in their genome. Even if that information averaged only 3 min per disorder, this process would take more than 5 h of direct patient contact, after many hours of background research into the importance of the various genomic findings.”

We welcome Kim G. Smolderen, PhD, to answer our questions about her research group’s JAMA study “Health Care Insurance, Financial Concerns in Accessing Care, and Delays to Hospital Presentation in Acute Myocardial Infarction”  Among her coauthors were CardioExchange contributor Dr. Paul S. Chan—who participated in our exchange with Smolderen—and CardioExchange Editor Dr. Harlan M. Krumholz. We encourage you to ask your own questions.

Background: The researchers studied 3721 patients to assess the relation between health insurance status and time from symptom onset to presentation with acute MI at one of 24 U.S. hospitals. Delays of longer than 6 hours were documented in 48.6% of uninsured patients, 44.6% of insured patients who reported financial concerns about access to medical care, and 39.3% of insured patients who did not report such concerns. Delays of 2 hours or less were documented in 27.5%, 33.5%, and 36.6%, respectively. The differences among the groups were statistically significant.

What are your findings’ policy implications for health coverage in the U.S., particularly given the significant differences in prehospital delays between people with insurance who had financial concerns and the uninsured?

Indeed, our data point to a gradient of vulnerability by insurance status. Uninsured patients were the most likely to delay care during a myocardial infarction. Insured patients with financial concerns, often called the “underinsured,” do not delay as much as the uninsured but still wait significantly longer than insured patients without financial concerns.

Notably, a substantial number of the insured with financial concerns in our study actually had private insurance. This suggests that a market-based system of patient-selected private insurance may not be sufficient to guarantee optimal access to care if it fails to account for out-of-pocket costs, which are rising. The number of insured patients is expected to increase in the wake of recently passed health care legislation, so the number of insured patients with financial concerns may grow. Ultimately, health care reform will need not only to provide coverage for the uninsured but also to ensure that patients can afford to use their existing insurance.

Many modifiable factors are known to affect prehospital delays, and you also tracked lower education level and depression. Relative to all those factors, how would you weight the relative impact of lack of health insurance and financial concerns? And notwithstanding the interrelatedness of all the factors, which do you think should be priorities in interventions aimed at minimizing prehospital delays?

Among the predictors of prehospital delays that we identified, health insurance status is the one where action can clearly be taken. Public policy that expands coverage or improves affordability has the potential to have a substantial effect. In fact, disparities in prehospital delay by race—a nonmodifiable patient attribute that has been reported as a predictor of prehospital delay—were substantially attenuated after adjustment for insurance status and other patient characteristics in our study.

Previously studied interventions, both at the population level (i.e., the REACT trial) and the patient level, have been unsuccessful in reducing prehospital delays during acute MI. As a result, these delays have hardly changed in the past decade. Although an approach that integrates educational efforts at the patient, community, and national levels is likely to be valuable, it cannot work if public policy efforts fail to address the structural issues of access to—and affordability of—health care.

Of course, there is no magic bullet. A multimodal approach of patient, community, and policy interventions will provide the best chance for getting patients into hospitals promptly to receive potentially life-saving therapies for acute MI and other emergencies.

Vitamin B May Be Harmful in Diabetic Nephropathy: Once again the early hopes for vitamin B have been dashed against the rocks of a clinical trial. In a paper in the Journal of the American Medical Association, Andrew House and colleagues report the results of DIVINe (Diabetic Intervention with Vitamins to Improve Nephropathy), a multicenter, double-blind trial in which 238 patients with diabetic nephropathy were randomized to either B vitamins or placebo. After three years, GFR declined more in the group taking B vitamins than in the group taking placebo. Even more troubling, the composite outcome of MI, stroke, revascularization, and all-cause mortality occurred twice as often in the B vitamin group than in the placebo group (24% vs. 14%, HR=2.0, CI=1.0-4.0, p=0.04). The authors concluded: “Given the recent large-scale clinical trials showing no treatment benefit, and our trial demonstrating harm, it would be prudent to discourage the use of high-dose B vitamins as a homocysteine-lowering strategy outside the framework of properly conducted clinical research.”

Judge Rejects Guidant Plea Agreement:
A U.S. federal judge has turned down a proposed plea agreement that would have allowed Boston Scientific to settle a case against it for $296 million. The investigation began in 2005 when cardiologists Barry Maron and Robert Hauser accused Guidant (now owned by Boston Scientific) of concealing flaws in the company’s ICDs. Last week the two cardiologists asked the judge to reject the agreement, saying a fine “does not hold the guilty parties fully accountable and inevitably undermines patient safety,” according to a news report in the Minneapolis Star Tribune.

Good News & Bad News for Calcium Scores: Using data from 5,878 participants in the Multi-Ethnic Study of Atherosclerosis (MESA), Polonsky and colleagues assessed the value of adding coronary artery calcium (CAC) scores to traditional risk factor assessments. In their report in the Journal of the American Medical Association, the investigators concluded that adding CAC scores to traditional risk factors “significantly improved the classification of risk and placed more individuals in the most extreme risk categories.”
   In an accompanying editorial, John Ioannidis and Ioanna Tzoulaki generally praise the study, but write that “the authors have not yet demonstrated that the added accuracy in risk stratification can actually aid clinicians in better treating patients or improving their clinical outcomes. Therefore, their findings, no matter how promising, do not suffice to recommend this marker for widespread routine use.” They also point out the radiation risk associated with CAC screening and note that “routine implementation at the population level can be very expensive.”

Really Bad News for Steroid Users: Anabolic steroids may damage the heart more than previously thought, according to a new study in Circulation: Heart Failure. Aaron Baggish and colleagues compared echo measurements in 12 weightlifters who used illicit anabolic-androgenic steroids and 7 weightlifters who were otherwise similar but did not use steroids. When compared to non-steroid users, the steroid users had lower LVEFs (50.6% vs. 59.1%), longitudinal strain (16.9% vs. 21.0%), and radial strain (38.3% versus 50.1%). “I think for the first time we’re starting to realize that the heart is one of the organs that is negatively impacted by long-term steroid use,” said Baggish, in an AHA press release.