Angina.com Heart Disease Interviews October 2012

Angina.com

Angina.com
Research Interviews on Heart Disease
, Coronary Artery Disease and Angina.

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Read more interviews on Hemodialysis.com

Safety and feasibility of hospital discharge 2 days following primary percutaneous intervention
for ST-segment elevation myocardial infarction
Angina.com Author Interview: Dr Andrew Wragg,
Consultant Cardiologist at BMI Healthcare.

• Angina.com: What are the main findings of the study?
• This is the first large observational study exploring the safety and feasibility of
discharge from hospital two days after primary percutaneous coronary
intervention (PPCI) for ST-elevation myocardial infarction (STEMI).
We showed in 2,653 patients that simple clinical criteria (TIMI III flow in the
infarct related artery, LV ejection fraction >40%, rhythmic and hemodynamic
stability, absence of heart failure, absence of severe co-morbidity) can be used to
easily identify low risk patients.
These low-risk patients can then be discharged very early at two days after their
PPCI in a manner that is both feasible and safe with low clinical event rates
(Major adverse cardiac events) during follow-up.
However we would like to emphasize that this study does not attempt to
investigate the direct effect of length of hospital stay on outcome in a causative
manner. Rather this study presents data regarding the feasibility and safety of an
early discharge policy.
• Read the rest of the interview on Angina.com

The mediating effect of the Mediterranean diet on the role of discretionary and hidden salt
intake regarding non-fatal acute coronary syndrome or stroke events: A case/case-control study
Angina.com Author Interview: Prof.DB Panagiotakos

• This study highlighted the detrimental role of salt and salty food consumption on
cardiovascular events, and mainly on ischemic stroke events, as use of salt added
in table was associated with 81% higher likelihood of stroke, while each unit
increase of the score evaluating total salty food consumption (processed
meat, canned food, fast food, feta-cheese, yellow-cheese, white-cheese, salted
nuts, olives, prepared sauces, bread and rusks) was associated with 33% higher
likelihood of stroke presence.

• Furthermore, the negative effect of salt and salty food consumption regarding
stroke presence was more evident for participants with lower adherence to the
Mediterranean diet.

• This is one of the few studies that have examined the role of salt intake and foods
which are sources of hidden salt, under the perspective of adherence to the
Mediterranean dietary pattern, offering additional information on cardiovascular
disease prevention.

Statins use and coronary artery plaque composition
Results from the International Multicenter CONFIRM Registry
Angina.com Author Interview:
Ryo Nakazato, MD, PhD, FACC, FAHA, FASNC, FSCCT
Cedars-Sinai Medical Center

• We evaluate the association of statin use to coronary artery plaque composition in patients
without known coronary artery disease undergoing coronary CT angiography.
Statin use was associated with increased prevalence of calcified plaque, but not coronary
segments with non-calcified plaque.

• Statin use was associated with increasing numbers of coronary segments possessing CP, but not
coronary segments with non-calcified plaque.
Further, in the subgroup of individuals with successful lipid control—as defined by
LDL<130, TC<200 or HDL≥40 mg/dl—statin use was associated with increasing numbers of
coronary segments possessing calcified plaque, but not for non-calcified plaque.
• Angina.com: What should clinicians and patients take away from this study?
• Our findings may reflect a differential effect of statins on plaque progression by composition
type, or alternatively, may represent a conversion of non-calcified plaque to calcified plaque
composition.
Germane to the latter, we noted that the use of statins and, in particular, the effectiveness of
statins (as surrogate determined by achieving goal cholesterol levels), was associated with
increasing presence and numbers of coronary segments with calcified plaque components.

Mortality risk of triglyceride levels in patients with coronary artery disease
Takatoshi Kasai, MD, PhD
Department of Cardiology, Juntendo University, School of Medicine

• Elevated fasting triglyceride level is associated with increased risk of
cardiac mortality in patients following complete coronary
revascularization.
• Angina.com: Were any of the findings unexpected?
• We expected to see our main findings since some other studies including
studies in the primary prevention filed.
• Angina.com: What should clinicians and patients take away from this
study?
• Clinicians and patients should remind the importance of fasting
triglyceride levels to reduce cardiac mortality in patients with coronary
artery disease. In addition, they should note that fasting triglyceride
levels indicate mortality risk in the secondary prevention of CAD
regardless of the presence or absence of other concomitant
cardiovascular risks.

Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal
women: randomized trial
Dr. Louise Lind Schierbeck

• In this randomized trial of newly postmenopausal women, the women on HRT
had after 10 years a 50% statistically significantly reduced risk of a cardiovascular
event or death. This persisted after the intervention stopped, thus 6 years later
the risk was still reduced with 40% in the women who had received HRT.
Furthermore, it has previously been claimed that the risk of breast cancer is
severely increased when using HRT; We DID NOT find this – actually, there was a
trend towards a reduction in breast cancer in the HRT treated in DOPS, but this
result was not statistically significant. Though, the HRT-treated women had a
reduced risk of “death or breast cancer” – which was statistically significant after
10 years of treatment, but waned after further 6 years off-treatment.

• Yes, the results on breast cancer actually surprised us, but may not be all that
different from what has been found in other trials, when those have been
adjusted for baseline confounding.

Cognitive-Perceptual Factors in Noncardiac Chest Pain and Cardiac Chest Pain
Angina.com Author Interview: Stefanie Schroeder

• In our sample of patients with chest pain of unknown origin in an outpatient and
inpatient setting 70 % were classified as having non-cardiac chest pain (NCCP)
based on the results of cardiac angiography (normal or near-normal coronary
arteries with a luminal narrowing of less than 50%).
A range of cognitive-perceptual factors, such as subjective illness
perceptions, were associated with the experience of chest pain in NCCP as well as
in patients with a cardiac origin of chest pain (cardiac chest pain, CCP).
In multivariable analyses, somatic amplification was the only cognitive-
perceptual factor that was higher in NCCP than in CCP and thus being able to
differentiate between NCCP and CCP.
• Previous research reported not only somatic amplification but also anxiety
sensitivity as well as illness perceptions to be more pronounced in patients with
NCCP than in patients with CCP. In our study anxiety sensitivity and subjective
illness perceptions did not turn out to be features specific for NCCP.

β-Blocker Use and Clinical Outcomes in Stable Outpatients With and
Coronary Artery Disease
Sripal Bangalore, MD, MHA, FACC, FSCAI,

• We found, from an analysis of over 44,000 patients that beta blockers
were not associated with lower risk of CV death, MI or stroke in patients
with prior history of MI, those with CAD but without MI and those with
risk factors alone. In patients with recent MI (<1 year) there was
however a benefit for a softer 'secondary' outcome that included
hospitalization but no benefit for primary outcome.
• The lack of association of beta blocker use with lower events in the prior
MI cohort was somewhat unexpected.
However, a review of the clinical trial data suggests that in patients
without heart failure, there is no robust data to support long term use of
beta blockers even in this group of patients.

Impact of ESC/ACCF/AHA/WHF universal definition of myocardial infarction on
mortality at 10 years
Francisco Costa, MD
• 1- Our study was the first to demonstrate the impact of the Universal Definition of myocardial
infarction (based on cardiac troponins) in mortality at 10 years.
In a population admitted with the diagnosis of ACS, the use cardiac troponin I allowed the
detection of small amounts of myocardial necrosis, increasing the diagnosis of acute MI by
25%, when compared with the old definition based on CK-MB.
AMI by the new definition was associated with a 60% increase in long-term mortality (HR 1.58;
95%CI 1.07-2.04, p= 0.003).
2- In our population, revascularization in the setting of an ACS had a protective role, being
associated with 40% lower risk of death.
3- Our study is also the first to validate the impact of the GRACE score in mortality at 10 years.
Having a score >148 presented a risk of death 3 times higher.
• Yes, we expected higher long-term mortality in patients with MI compared with those without MI
using ST-segment elevation criteria, as well as, old definition.

Impact of Chronic Obstructive Pulmonary Diseases on Outcomes and Hospital Days After
Percutaneous Coronary Intervention
Angina.com Author Interview: Jian Wei Zhang, MD

• COPD is associated with significantly increased Composite
MACE and hospital stay in patients after PCI. Increasing
severity of COPD is associated with increased Composite
MACE and hospital stay after PCI.
• Increasing severity of COPD is associated with increased
Composite MACE and hospital stay after PCI.
• Angina.com: What should clinicians and patients take
away from this study?
• Pay attention to COPD and treat COPD aggressively.

Long-term cardiovascular risk of NSAID use according to time passed after first-time myocardial
infarction. A nationwide cohort study
Anne-Marie Schjerning Olsen MD

• The current study addresses the risk of all NSAIDs in a selected population of post-MI patients.
• We present a comprehensive analysis on the effect of time passed following first-time MI NSAID
treatment on risk of death or coronary death CHD/recurrent MI (Re-MI) in a nationwide cohort of
MI survivors.
Our new findings are that the risk of death and CHD/Re-MI remains elevated in NSAID users for
up to five years after first MI.
The results support previous findings suggesting that NSAIDs have no apparent safe treatment
window among heart attack patients, and show that coronary risk related to using the drugs
remains high, regardless of the time that has passed since the heart attack.
• Yes. The risks of cardiovascular mort
ality and morbidity are well-known complications after MI. The risk is highest soon after the MI
but declines as time passes and eventually corresponds to the risk of the background population
after 5–10 years.
It was unexpected that the risk associated with using NSAIDs remained virtually unchanged
throughout all 5 years after discharge from hospital after the first MI.

Chronic aspirin and statin therapy in patients with impaired renal function and acute coronary
syndromes: results from the IN-ACS Outcome Study
Angina.com Author Alessandro Sciahbasi MD

• The IN-ACS Outcome Registry is an Italian multi center observational registry of patients with acute coronary
syndromes.
In the context of this study we performed a sub-analysis evaluating if a previous chronic aspirin or statin therapy
in patients with impaired renal function may affect their outcome after the acute coronary syndrome.
More than 1400 patients with impaired renal function were enrolled in this analysis and these patients were
divided in 4 groups according to their previous therapy: aspirin alone, statin alone, combination therapy with
aspirin and statin and no therapy.
The main finding of our study was that despite a baseline higher risk profile, the group on chronic aspirin aspirin
and statin therapy was associated with better outcome compared to the other groups.
Aspirin alone was ineffective to obtain a significant improvement in outcome, whereas statin alone therapy was
effective but in a lower risk population.
Consequently the association of aspirin and statin therapy should be considered a possible therapy in patients
with impaired renal function to reduce the cardiovascular risk.
The main limitation of our study is the observational design of the study.
Then to confirm our results, future randomized studies evaluating the possible role of the combination therapy
with aspirin and statin in the prevention of cardiovascular risk of patients with impaired renal function are
necessary.

Body Composition and Survival in Stable Coronary Heart Disease Impact of Lean Mass Index
and Body Fat in the "Obesity Paradox"
Carl J. Lavie, M.D.,FACC,FACP,FCCP

• The main finding is that both higher lean body mass and body fat were strong independent
predictors of better survival in patients with coronary heart disease.
The best survival was in those with both high lean mass and body fat, and the highest mortality
was in those with both low lean mass and body fat, who had a 7-fold higher mortality than did
the high lean mass and high body fat group (the group with either high lean mass or high body
fat, but not both, had intermediate mortality.)
• One would expect that having a higher lean mass would be good, but one would also predict that
having a higher body fat would be bad.
The obesity paradox regarding body fat, however, is not a totally new finding , as we
demonstrated this with Heart Failure in American Journal of Cardiology about 8 years ago and
with Coronary Heart Disease in American Journal of Medicine 2 years ago and in two
separate Mayo Clinic Proceedings in the past year.
What is new, however, was that both high lean mass and high body fat were independent of each
other and both predicted better survival.

Association Between Omega-3 Fatty Acid Supplementation and Risk of Major Cardiovascular
Disease EventsA Systematic Review and Meta-analysis
Evangelos C. Rizos, M.D., Ph.D., of the University Hospital of Ioannina, Ioannina, Greece

• Analysis indicated no statistically significant association with all-
cause mortality, cardiac death, sudden death, heart attack, and
stroke when all supplements tudies were considered across
various patient populations.
• Our analysis is consisted with the results of many of the landmark
trials on this field.
• Angina.com: What should clinicians and patients take away from
this study?
• In our pooled analysis of the data, we did not find a statistical
significant reduction in "hard" outcomes including all cause
mortality.

Number of Coronary Heart Disease Risk Factors and Mortality in Patients
With First Myocardial Infarction
John G. Canto, MD, MSPH, FACC, FAHA, FACP, FACE

• Our study challenges conventional wisdom that patients with more coronary heart disease (CHD)
risk factors have worse outcome.
Our data clearly show that patients with multiple coronary heart disease (CHD) risk factors
present much earlier in age than patients with fewer or no risk factors.
However, patients with fewer or no CHD risk factors overall had higher mortality after first heart
attack.
• The reasons for this surprising finding may be attributed to the fact that patients with multiple
CHD risk factors [as compared to those with fewer or no CHD risk factors]:
• 1) may also be more likely to be on treatments to modify their risk, such as higher use of
aspirin, statins & other cholesterol lowering meds, blood pressure meds, all treatments known to
improve CHD outcome;
• 2) more likely to have closer medical follow-up and care to manage their risk factors in the first
place.
• Lastly, the biology of disease may be different in older patients without CHD risk factors.

Mortality outcome of out-of-hours primary percutaneous coronary intervention
in the current era
Dr Mohaned Egred BSc (Hons) MB ChB MD FRCP FESC

• The study was conducted in the Freeman Hospital, Newcastle upon Tyne, UK which is a large
tertiary cardiac centre performing more than 3000 angioplasty (PCI)/year of which >850 are for
acute myocardial infarction called primary PCI.
Previous publications have indicated that patients, surgical or medical, outcome may be worse if
admitted out of working hours or on the weekend in comparison to normal working hours.
Our study looked at patients who underwent primary PCI for acute myocardial infarction and
assessed their outcome and in-hospital and long-term mortality in relation to the time of
admission, normal working hours or nights and weekends.
Our main finding was that there is no difference in the outcome regardless of the time of
admission. The in-hospital and long term mortality were similar in the 2 groups, normal working
hours or out of hours and weekends.
• The findings were to a degree not un-expected given that our centre is well staffed and all
operators are high volume operators and the same team composition covers primary PCI whether
during working hours as well as out of hours and weekend. However, this study was performed to
affirm this.

Perfluorooctanoic Acid and Cardiovascular Disease in US Adults
Angina.com Author Interview: Anoop Shankar, MD, MPH, PhD

• Angina.com: What is the background for your study?
• Perfluorooctanoic acid (PFOA) is a manmade chemical used in the manufacture of common
household consumer products, including surfactants, lubricants, polishes, paper and textile
coatings, food packaging, and fire-retarding foams.
PFOA has been detected in the blood of more than 98% of Americans and has a long half life of
approximately 3.8 years. We know that Cardiovascular disease (CVD) is the leading cause of death
in the United States.
Recent evidence suggests that an association between PFOA exposure and CVD may be
biologically plausible as:
-PFOA exposure has been linked to higher cholesterol levels which represent a
strong, independent risk factor for CVD development.
-Higher PFOA levels were shown to be related to insulin resistance and metabolic syndrome, both
associated with CVD development.
• We have recently shown that higher PFOA levels are associated with serum uric acid levels, a
marker associated with an increased risk of developing CVD. Our hypothesis for the study was to
determine if exposure to PFCs may be associated with a higher risk of developing CVD.

One-Hour Rule-out and Rule-in of Acute Myocardial Infarction Using
High-Sensitivity Cardiac Troponin T
Professor Dr. Christian Müller

• Using new hs-cTn assays it is possible to reliably rule out
AMI within 1h in 60% of consecutive patients
• Yes, both the high percentage of patients eligible for early
rule-out as well as the very high NPV in both the
derivation and validation cohort were surprising
• Angina.com: What should clinicians and patients take
away from this study?
• Hs-cTn levels, if used as quantitative
variables, significantly improve the management of
patients with suspected AMI in the ED

Angina.com Heart Disease Interviews October 2012

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Angina.com Heart Disease Interviews October 2012