CardioExchange Archive

Coronary patients with high levels of omega-3 fatty acid levels in their blood have a lower rate of telomere shortening, according to a new study in JAMA. The study bring together two very different strands of research. In one strand, the shortening of telomeres, the protective caps of DNA at the end of chromosomes, has been closely tied to cellular aging. In the second strand, many epidemiologic studies have found cardiovascular benefits in people with high intake of omega-3 fatty acids.

Nobel Laureate and longtime NHLBI researcher Marshall Nirenberg died at age 82. Following up on the work of Watson and Crick, Nirenberg received the 1968 Nobel Prize in Physiology or Medicine for his seminal work showing how DNA gets translated into proteins. “We found that all species, all forms of life on this planet use the same language, molecular language,” said Nirenberg in an interview. “We compared the code in bacteria to the language used in an amphibian, to a mammal and found that it’s the same language. . . . You can look at trees, flowers, squirrels, birds and you know that we’re all related.” A few resources: a statement from the NHLBI, a Washington Post obituary, and a story in The Scientist.

Hospitals devote a lot of resources to preventing in-hospital cardiac arrests. That makes sense because when one actually occurs, the patient has only a 1 in 6 chance of surviving to discharge. Two popular strategies for helping clinicians recognize and treat clinical deterioration before an in-hospital cardiac arrest are remote ICU monitoring and rapid response teams. After all, it’s intuitively appealing to pay close attention to patients who are doing poorly and, when they deteriorate, to intervene quickly and change their course. Yet, evidence regarding the effectiveness of these two strategies has been mixed.
 
Recently, my colleagues and I did a meta-analysis of studies about rapid response teams. After analyzing data from 1.3 million admissions, we found that the use of such teams was not associated with lower in-hospital mortality in adults. Similarly, two recent multicenter studies, one published in JAMA and the other in Critical Care Medicine, showed that remote ICU monitoring did not reduce ICU or in-hospital mortality rates, or length of stay.
 
These findings are especially disappointing because of the vast financial and human resources required to develop and maintain rapid-response-team and remote-ICU-monitoring programs. But I wonder, given the evidence, how much hospitals are accomplishing with these strategies. More important, what if institutions get complacent after they’ve implemented them?
 
I think we need more data to resolve such questions. But I’d like to ask you: What’s your hospital’s experience with rapid response teams and remote ICU monitoring? Do you think hospitals should continue them in the face of disappointing survival data? Can other “outcomes” touted by these programs, such as nursing satisfaction, be achieved at lower costs? And if your hospital has managed to reduce cardiac arrest rates or improve survival after cardiac arrest using other types of quality-improvement initiatives, please share them with us here on CardioExchange.

New Approach to Statin Therapy: Tailoring statin therapy based on individual risk is more effective and efficient than the treat-to-target approach  adopted by NCEP III, according to a new report in Annals of Internal Medicine by Rodney Hayward and colleagues (including CardioExchange’s Editor Harlan Krumholz). Using data from statin trials and national data on CAD risk factors, the authors concluded that “a tailored treatment strategy prevents more CAD events while treating fewer persons with high-dose statins than low-density lipoprotein cholesterol–based target approaches. Results were robust, even with assumptions favoring a treat-to-target approach.”

ED and CVD: Erectile dysfunction is closely tied to cardiovascular disease but does not improve prognostic power beyond traditional risk factors, according to a study from the prospective Massachusetts Male Aging Study by Andre Araujo and colleagues in the Journal of the American College of Cardiology.

Unnecessary Stents: The hospital with the biggest cardiac catheterization laboratory in Maryland, St. Joseph Medical Center in the community of Towson, has told 369 of its heart patients that they may have received a stent unnecessarily,  according to a story in the Baltimore Sun.

This Journal Watch summary of a recent article from the New England Journal of Medicine made me consider further an issue that seems to be all-consuming: evaluations. In training programs across the country, we are required to give and receive evaluations on a regular basis. The goal, at least in part, seems straightforward enough — trainees require feedback to effectively change (or maintain) certain behaviors.

In many programs, these evaluations are done in the “360” style; that is, fellows evaluate fellows, nurses evaluate fellows, patients evaluate fellows…well, you get the idea. The benefits of these circular evaluations is apparent –- feedback early in the course of training may be one of the most effect means for reinforcing good behaviors and remodeling bad ones. The potential drawback is also apparent, although much less discussed and, in reality, quite rare; we all have nightmares about a colleague or patient with an axe to grind making something up or blowing something out of proportion in order to get us in trouble.

What do you think of these evaluations?  Is constructive criticism from your colleagues helpful or possibly hurtful?  Do you find evaluations of your attendings a beneficial practice?  Are you at all afraid to be honest in evaluations of peers because you want to avoid confrontations and avoid attending evaluations so as to avoid possible repercussions?

Between 1950 and 2003 survivors of Hiroshima and Nagasaki had an increased risk of stroke and heart disease, according to a new analysis published in BMJ.   Japanese researchers estimated a 9% increased risk of stroke per gray and a 14% increased risk of heart disease per gray. An accompanying editorial notes that the study “adds to a growing body of evidence suggesting an association between cardiovascular disease and exposure to low-moderate levels of radiation, as well as the well known (and mechanistically well understood) association at high doses.”

PLATO-Invasive: A large substudy from PLATO of ACS patients undergoing an invasive strategy has been published in the Lancet.  The substudy found that ticagrelor was superior to clopidogrel in 13,408 ACS patients for whom an invasive procedure was planned. Christopher Cannon et al. reported that the combined rate of CV death, MI, and stroke was significantly cut from 10.7% in the clopidogrel arm to 9.0% in the ticagrelor arm. There were no additional major bleeding complications in the ticagrelor group. In an accompanying editorial, Gregg Stone said “the introduction of ticagrelor, a more potent and effective agent which is as safe as its predecessor, is a landmark event that should redefine the care of patients with acute coronary syndromes.”
ACC loses court battle: A US Judge has rejected the American College of Cardiology’s lawsuit to overturn recently established cuts in Medicare reimbursement for cardiology services. The ACC said it plans to continue fighting the reduction in payments. The ACC has a statement on its website.

We welcome Philip A. Kalra, MD, one of the investigators and the lead nephrologist for the UK-based ASTRAL trial, to talk about the group’s article in the November 12 issue of the New England Journal of Medicine: Revascularization versus Medical Therapy for Renal-Artery Stenosis (N Engl J Med 2009; 361:1953). We asked him our questions and encourage you to ask yours.

CardioExchange Editors: In ASTRAL, the rate of decline in renal function for patients with renal-artery stenosis (RAS) did not differ significantly between those randomized to percutaneous revascularization plus medical therapy and those randomized to medical therapy alone. How do you answer the criticism that the study explicitly excluded patients whose doctors felt that stenting would definitely help them?

Kalra: First, although clinicians were permitted to exclude patients they thought would definitely require revascularization, there was no explicit guidance to do that, nor any central adjudication. Second, not all clinicians have the same approach. For example, I was happy to enroll patients with critical bilateral RAS, provided that they had no evidence of deteriorating renal function. Therefore, the ASTRAL population is likely to represent a heterogeneous group of patients with significant anatomical RAS for whom it’s genuinely unclear whether revascularization will improve clinical outcomes. That’s a real-life question. Nonetheless, given the patient exclusions that did occur, ASTRAL probably had a high proportion of largely asymptomatic subjects, such as those being investigated for chronic kidney disease with hypertension, as opposed to more acute presentations such as heart failure or acute kidney injury. For example, only 12% of the ASTRAL population had clear evidence of decline in renal function prior to randomization.

CardioExchange Editors: Clinicians in the U.S. are starting to screen asymptomatic patients for RAS, with a plan for stenting in those who have “significant” disease. Are your results relevant to these patients?

Kalra: The ASTRAL results are probably more relevant to these patients than to any others. That includes people for whom RAS is an incidental finding (for example, during coronary angiography) and outpatients who are being investigated for stable chronic kidney disease, hypertension, or both. For such groups, I think that the ASTRAL data conclusively show no benefit of revascularization — in terms of renal function, blood-pressure control, adverse renal and cardiovascular events, or mortality.

CardioExchange Editors: Your group reported that the mean percent-stenosis of the treated arteries was 76% and that roughly 60% of patients had RAS >70%. But might many of those stenoses have  been hemodynamically unimportant?

Kalra: I have to acknowledge that there was no core-lab assessment of the angiograms, and so no robust validation of the percent-stenosis data. Given the prevalence of CT and MR angiography late in the trial, the degree of RAS was probably overestimated in some patients (a well-known problem with MRA assessment). Indeed, about 13% of patients randomized to revascularization did not undergo the procedure because the degree of RAS was found to be insignificant at definitive on-table angiography. Although we did not assess the hemodynamic significance of RAS lesions, the value of resistive-index assessment remains unclear, and transstenotic pressure gradients are not routinely measured in the UK. Nonetheless, some ASTRAL subjects are likely to have had hemodynamically insignificant lesions. But bear in mind that many such lesions are still being revascularized in clinical practice (witness so-called “drive-by stenting” during coronary angiography).

CardioExchange Editors: Given the ASTRAL findings, will the British National Health Service continue to support stenting?

Kalra: To date there has been no call for our major treatment-review bodies, such as the National Institute for Clinical Excellence (NICE), to review UK revascularization practice. That may be because renal revascularization is relatively uncommon in the UK — currently, about 250 to 600 total cases per year.

CardioExchange Editors: What would be your recommendation to the National Health Service, should NICE decide to revisit this matter?

Kalra: I would recommend that the option to perform renal revascularization in particular clinical subgroups be retained. Although evidence of benefit is limited, clinical consensus would support revascularization in some patients who have anatomically significant RAS and who present with one of the following characteristics:

• acute kidney injury
• sudden-onset heart failure
• critical bilateral RAS (or unilateral, if supplying a sole functioning kidney)
• clear evidence of deteriorating renal function, with no other cause identified, prior to consideration of stenting
• very severe hypertension that is unresponsive to multiple medications
• possibly, chronic heart failure

However, we need more evidence in some of these clinical scenarios. The forthcoming CORAL trial will provide further insights, and eventually a meta-analysis of data from both ASTRAL and CORAL may be a powerful resource. For now, I would suggest that U.S. regulatory bodies consider making recommendations similar to those I’ve offered here.
CardioExchange Editors: We’re very curious to hear from the CardioExchange community: What questions or perspectives do you have on the ASTRAL trial and its implications for clinical practice?

Diabetics in SYNTAX: The one-year results of the subset of diabetic patients enrolled in the SYNTAX trial, the ongoing trial comparing PCI to CABG in patients with left main or multivessel disease for five years, were published in the Journal of the American College of Cardiology. Although the investigators found an increase in revascularizations in the PCI arm, there were no significant differences in the safety endpoint of death, stroke, or MI. In an accompanying editorial, Harold Dauerman asks whether drug-eluting stents have “removed the ‘death penalty’ associated with diabetes and multivessel PCI?”

Obesity in the USA: The good news is that the rate of increase for obesity in the US appears to be stabilizing. The bad news, of course, is that the overall prevalence of obesity remains high: in 2007-2008 it was 33.8%. The new findings from the National Health and Nutrition Examination Survey (NHANES) were published online today in JAMA. J Michael Gaziano, in an accompanying editorial, calls for ” a massive public health campaign to raise awareness about the effects of overweight and obesity.” Another NHANES study reports on trends in children and adolescents.

You can save twice as many lives by increasing adherence to already-prescribed statins than by expanding the pool of people eligible for statins, according to estimates by A Shroufi and JW Powles in the Journal of Epidemiology and Community Health.
The FDA Cardiovascular and Renal Drugs Advisory Committee unanimously recommended that the FDA turn down a heart failure indication for nebivolol (Bystolic, Forest Laboratories). Stories in Cardiology Today, Heartwire, MedPage Today.
A preliminary report in JAMA found that people who had one CETP variant were less likely to experience memory decline and had a lower risk for developing dementia or Alzheimer’s disease.

A study in the Archives of Neurology by James Noble and colleagues found that high CRP may be a marker of memory and visuospatial impairment. Subjects with elevated CRP and at least one APOE ε4 allele had the highest risk of memory loss.
Another study in the Archives of Neurology found that prior to the development of Alzheimer’s disease, carriers of APOE ε4 have reduced cerebral blood flow compared to noncarriers.