2009-2010 Clinical reviews: Cardiovascular disease


Can statins offset the CVD risk associated with unhealthy eating?

20 Dec 2010Registered users

The relative risk of eating a high-fat, fast food meal may be able to be neutralised by taking a statin, according to researchers from Imperial College, London. The investigators compared the increase in relative risk of cardiovascular disease (CVD) associated with the total and trans fat content of a fast food meal with the reduction in relative risk observed from a recent meta-analysis of seven primary prevention statin trials covering 42, 848 patients. The authors suggest that fast food restaurants could offer customers a statin to go with their meal. They hypothesise that the statin could be sprinkled onto quarter pounders, into milkshakes, or onto supersized French fries to offset the fat found in these fast food delights.

Transcatheter valve implantation improves survival in aortic stenosis

24 Nov 2010Registered users

Transcatheter aortic valve implantation (TAVI) improves one-year mortality and hospitalisation rates in patients with aortic stenosis who are unfit for surgery. The PARTNER study is the first trial to assess the impact of this new procedure. The non-surgical study cohort comprised 358 patients from 21 centres, mainly in North America, randomised to either TAVI or standard (non-surgical) care. There were two primary endpoints: one-year all cause mortality and a composite endpoint of one-year all cause mortality or repeat hospitalisation. 'Severe aortic stenosis is becoming increasingly prevalent with an aging population. The only effective treatment has been valve replacement and no drug intervention has been shown to reduce progression. Significant comorbidities greatly increase the risk of surgery in this population. The recent development of a transcatheter aortic valve prosthesis has provided a real alternative to surgery in patients with severe aortic stenosis felt to be too great a risk for open surgery. Overall these are very impressive results with only five patients needing to be treated to prevent one death.'

Heart rate reduction with ivabradine improves outcomes in heart failure

24 Nov 2010Registered users

Adding ivabradine to standard treatment significantly reduced hospitalisation and deaths from heart failure, in a randomised, placebo-controlled trial. Ivabradine is a new rate-limiting drug which acts as a selective inhibitor of a sodium-potassium channel highly expressed in the sinoatrial node. A total of 6,558 patients with NYHA class ll-lV heart failure, an LVEF ≤ 35%, a resting heart rate ≥ 70 bpm, and a hospital admission for heart failure within the previous year were enrolled in the SHIFT study. 'Critics of the trial have cited an atypical patient population and suboptimal beta-blocker dosing (only 56% of patients were on ≥ 50% of beta-blocker target dosage and only 26% were on the target dosage). However, I think the study population represents a fairly typical real-world situation and would take the result of this trial as encouraging.'

Calcium supplements may raise the risk of MI

21 Sep 2010Paid-up subscribers

A recent meta-analysis has shown that calcium supplementation without co-administration of vitamin D may increase the risk of MI by nearly a third. Studies included in the meta-analysis were randomised, placebo controlled trials of calcium supplements (500 mg/day), with 100 or more participants. The mean age of trial participants had to be >40 years (actual mean age was 75 years) and the trial duration > 1 year. 'While remaining alert to the limitations of meta-analysis this data suggest that we should perhaps reassess our current approach to calcium supplements especially in patients at high risk or with established cardiovascular disease. Calcium supplements are routinely prescribed for, and taken by, patients either at risk of, or with, established osteoporosis and many of these are elderly women who may also be at high risk of cardiovascular disease.'

Folic acid plus B12 does not improve CVD outcomes in high-risk patients

20 Jul 2010Paid-up subscribers

Lowering homocysteine levels with folic acid and vitamin B12 supplements does not reduce the risk of cardiovascular events or stroke in patients who have suffered an MI, a major study has concluded. it would appear that SEARCH has finally laid the homocysteine theory to rest. Raised levels may be associated with increased cardiovascular risk but this would not appear to be a causal association. The authors also noted that a recently submitted meta-analysis of individual patient data from eight homocysteine lowering trials, including SEARCH, with data on 37,485 individuals, confirms that folic acid supplementation has no significant effect on major vascular events, RR 1.01 (95% CI: 0.97-1.05).

Optimal medical therapy boosts one-year survival rates following acute MI

24 Jun 2010Paid-up subscribers

One-year mortality following MI can be significantly improved by giving patients a combination of five drug classes: aspirin, beta-blockers, statins, renin angiotensin system (RAS) blockers and thienopyridines. However, less than half of patients receive this optimal therapy, a study from Germany has shown. 'These findings should further reinforce our efforts to maximise the uptake of these drugs in our post-infarct populations. This should form a key part of cardiac rehabilitation and primary care chronic disease programmes.'

Does chocolate lower CVD risk?

19 May 2010Paid-up subscribers

'I think we still need a randomised controlled trial of flavanol-rich chocolate but in the meantime it would seem that a little bit of chocolate is good for you. Don't get carried away though as those in the highest quartile only consumed 7.5g a day which is equivalent to a small square. A 100g bar has around 500 calories and a fair bit of that is sugar. So everything in moderation.'

Aspirin does not improve outcomes in patients with asymptomatic atherosclerosis

14 Apr 2010Paid-up subscribers

Another study has cast doubt on the role of aspirin in primary prevention. The Aspirin for Asymptomatic Atherosclerosis trial showed no reduction in vascular events with aspirin in asymptomatic subjects with a low ankle brachial index (ABI). Men and women aged 50-75 years living in central Scotland were invited for ABI screening for asymptomatic atherosclerosis over a ten-year period from 1998 to 2008. A total of 28,980 patients were screened of which 3,350 had a low ABI and were randomised to aspirin 100mg or placebo. Patients were followed up for a mean of 8.2 years.'There is little doubt that aspirin is beneficial in patients with symptomatic cardiovascular disease or with a history of stroke but this trial adds further weight to the reluctance to use aspirin for primary prevention in asymptomatic patients even in those considered at high risk with little evidence of benefit and some evidence of harm.'

Raising statin uptake in patients at risk of CVD

15 Feb 2010Paid-up subscribers

Cardiovascular disease

Older AF patients have the most to gain from anticoagulation

01 Oct 2009Paid-up subscribers

This study further reinforces the message that age should not be a barrier to warfarin use and that older patients have the most to gain from anticoagulation. It also shows that the CHADS2 scoring system is not only simple to apply but an accurate predictor of stroke risk. However, not all elderly patients will be candidates for warfarin and it is still important to make a clinical judgment as to the risks and benefits in each individual patient. 

Screening for abdominal aortic aneurysm reduces long term mortality

27 Aug 2009Paid-up subscribers

Screening for abdominal aortic aneurysm has been shown to reduce the short-term mortality associated with this condition. A large study has now demonstrated that the benefits are maintained for up to ten years. The Multicentre Aneurysm Screening Study (MASS) randomised 67, 770 men aged 65-74 to either ultrasound screening or no screening. Four centres were involved in the project and screening and surveillance was mostly delivered in a primary care setting.

Statins lower risk of AF in women with CHD

01 Jun 2009Paid-up subscribers

Giving statins to women with established coronary disease reduces their odds of developing atrial fibrillation (AF), a large observational study has shown. The study cohort was taken from the Heart and Estrogen/Progestin Replacement Study (HERS). In total, 2,673 postmenopausal women with stable coronary disease were enrolled. The main outcome measure was AF prevalence at baseline and incident AF over a mean follow-up of four years.

No 'best diet' for weight loss

01 Jun 2009Paid-up subscribers

Cardiovascular disease

CABG vs PCI for severe coronary artery disease

21 May 2009Paid-up subscribers

Cardiovascular disease

Unhealthy lifestyle can double risk of stroke

25 Apr 2009Paid-up subscribers

Cardiovascular disease

Fish oils reduce cardiac deaths

29 Mar 2009Paid-up subscribers

Cardiovascular disease

Morphine use questioned in acute cardiac failure

29 Mar 2009Paid-up subscribers

Cardiovascular disease

Which combination therapy for hypertension?

01 Jan 2009Paid-up subscribers

Cardiovascular disease