Featured topics and Editors’ Picks from all of ACC’s JACC Journals. Special Issue of JACC Focuses on CV Health Promotion A recent special issue of the Journal of the American College of Cardiology (JACC) focuses on cardiovascular health promotion and the latest research on topics like dietary recommendations and heart health, herbal medication use, antioxidant pills, dietary fads, and physical activity, along with BMI and heart failure risk. Issue Highlights Dietary Recommendations and Heart Health: Following current dietary recommendations may lead to small improvements in overall cardiovascular health in overweight individuals, according to a study by David J. A. Jenkins, MD, PhD, Dsc, et al. Patients were divided into three treatment groups: dietary advice only; weekly food basket only; both dietary advice and weekly food basket. After six months, only small increases were observed in the intake of fruits, vegetables, whole grains and cholesterollowering foods across all groups, and the only consistent increases were seen in the group that received both food provisions and advice. At 18 months, small increases remained for the intake of healthy foods, but these increases were significantly reduced from the already modest six-month increases. In an accompanying editorial comment, Ramon Estruch, MD, PhD, notes these results can be viewed as “glass half-full.” “The key question is how to entice the general population to adhere to healthy dietary patterns,” he said. Physical Activity, BMI and HF Risk: Lifestyle patterns, including physical activity and body mass index (BMI), are associated with a risk of overall heart failure (HF), but are more strongly associated with the subtype HF with preserved ejection fraction (HFpEF). “We consistently found an association between physical activity, BMI and overall HF risk,” said lead author Jarett D. Berry, MD. “This was not unexpected, however, the impact of these lifestyle factors on HF subtypes was quite different.” When compared with no physical activity, low levels of physical activity were associated with 6 percent lower risk of HF. Researchers found that higher levels of physical activity had even lower risk of HF – 11 percent lower risk for those who met the guidelinerecommended amount of activity and 22 percent lower risk for greater than guideline-recommended physical activity. In an accompanying editorial, Sanjiv J. Shah, MD, FACC, said the researchers “have provided strong evidence that lack of physical activity is associated with incident HfpEF.” Antioxidant Pills, Juicing, Other Dietary Fads: Researchers analyzed nutrition studies to cut through the confusion about the best dietary patterns to reduce cardiovascular disease. The review concludes current evidence strongly supports eating plenty of fruits, vegetables, whole grains, legumes and nuts in moderation. Although more controversial, some heart-healthy diets may also include very limited quantities of lean meat, fish, low-fat and nonfat dairy products and liquid vegetable oils. “There is a great amount of misinformation about nutrition fads, including antioxidant pills, juicing and gluten-free diets,” said Andrew Freeman, MD, FACC. “However, there are a number of dietary patterns that have clearly been demonstrated to reduce the risk of many chronic diseases, including coronary heart disease.” The review also covers eggs and cholesterol, vegetable oils, berries and antioxidant supplementation, nuts, juicing, and gluten. Herbal Medication Use in CVD Patients: Physicians should be wellversed in the herbal medications cardiovascular disease patients may take to be able to effectively discuss their clinical implications, potential benefits and side effects – despite a lack of scientific evidence to support their use. Researchers selected 10 of the most commonly used herbal medications that have a possible indication for treating one or more cardiovascular condition – including hypertension, heart failure, coronary artery disease, dyslipidemia, thromboembolic disorders or peripheral artery disease – and discussed possible indications, biological and clinical data, and safety concerns. The researchers said that despite all the clinical evidence on these herbal medications, there is an overall lack of evidence available, and it is not always possible to clearly establish a cause-effect link between exposure to herbal medications and potential side effects. They concluded that because of the popularity of these medications and the potential for drug interactions or other safety concerns, physicians should start a conversation around herbal medication use to effectively counsel their patients. Heart Disease in Chinese Population: Researchers in China have found that adherence to a healthy lifestyle may substantially lower the burden of cardiovascular disease in the country. The study examined the associations of six lifestyle factors with ischemic heart disease and ischemic stroke in the China Kadoorie Biobank of 461,211 participants 30 to 79 years of age who did not have cardiovascular diseases, cancer or diabetes at baseline. Low-risk lifestyle factors were defined as nonsmoking status or having stopped smoking for reasons other than illness, alcohol consumption of <30 g/day, a median or higher level of physical activity, a diet rich in vegetables and fruits and limited in red meat, a body mass index of 18.5 to 23.9 kg/m2, and a waist-to-hip ratio <0.90 for men and <0.85 for women. Researchers found that current nonsmoking status, light to moderate alcohol consumption, high physical activity, a diet rich in vegetables and fruits and limited in red meat, and low adiposity were independently associated with reduced risks of major coronary events and ischemic stroke. In an accompanying editorial, Thomas A. Gaziano, MD, FACC, adds that “more research is needed to understand both the long-term effects of … interventions and the reproducibility of these interventions in low-income settings. In the end, we must find a simple but clear message regarding diet and exercise that is a little like what our grandmother might say, ‘Everything in moderation but make sure you eat your vegetables.’” Predicting Presence of CAD: Nasrien E. Ibrahim, MD, FACC, et al., developed a clinical and biomarker scoring strategy to reliably diagnose severe epicardial coronary artery disease (CAD). The scoring system consisted of clinical variables (male sex and previous PCI) and four biomarkers (midkine, adiponectin, apolipoprotein C-I and kidney injury molecule-1). At optimal cutoff, the score had 77 percent sensitivity, 84 percent specificity, and a positive predictive value of 90 percent for =70 percent stenosis. Partitioning the score into five levels allowed for identifying or excluding CAD with 90 percent predictive value in 42 percent of patients. According to the authors, “advantages of such a reliable clinical and biomarker score include the fact such a technology can be widely disseminated in a costeffective manner, is easily interpreted, and might be associated with a well-defined sequence of therapeutic steps to reduce risk for CAD-related complications, such as antiplatelet or lipid-lowering therapy.” In an accompanying editorial, Robert A. Vogel, MD, adds that “the findings of this study … must be considered preliminary because the investigators chose to divide a single population of patients referred for coronary angiography into training and validation groups.” Neutrophil Counts and Initial Presentation of CVD: Neutrophil counts were strongly associated with the incidence of some cardiovascular diseases, but not others, even within the normal range, consistent with underlying disease mechanisms differing across cardiovascular diseases. Among 775,231 individuals in the cohort, 154,179 had complete blood counts performed under acute conditions and 621,052 when they were stable. Over a median 3.8 years of follow-up, 55,004 individuals developed cardiovascular disease. The study revealed a strong association between neutrophil counts and heart failure, peripheral arterial disease, unheralded coronary death, abdominal aortic aneurysm, and nonfatal myocardial infarction. According to an editorial comment from Benjamin D. Horne, PhD, MPH, FACC, “the usefulness of the neutrophil count for prognostic purposes is evident in large sample, broad scope, clinically based investigations … an inexpensive, commonly ordered measure of inflammation and infection, the neutrophil count seems to contain independent, clinically significant information regarding prognosis.” STOP-CHAGAS Trial Finds Benznidazole Monotherapy Superior For Eliminating T. cruzi Benznidazole monotherapy is superior to treatment with posaconazole alone or posaconazole combined with benznidazole for the elimination of Trypanosoma cruzi (T. Cruzi) in asymptomatic Chagas carriers, according to the results of the STOP-CHAGAS trial published Feb. 20 in JACC. Chagas disease is the result of infection with T. cruzi and carries a significant tropical disease burden in the Western hemisphere. It is estimated that between 5.7 and 9.4 million people are infected, 20 to 30 percent of whom will develop cardiomyopathy. Low tolerability of current therapy methods often compromise treatment. Carlos A. Morillo, MD, FACC, et al., conducted a prospective, multicenter randomized placebo-controlled study, in which 120 patients from Latin America and Spain were randomized into four groups receiving either posaconazole; benznidazole and placebo; benznidazole and posaconazole; or placebo alone. T. cruzi parasites were measured by real-time polymerase chain reaction (RT-PCR) at 30, 60, 90, 120, 150, 180 and 360 days. Only 13.3 percent of those receiving just posaconazole achieved the primary outcome – persistent negative RT-PCR by day 180 – compared with 80 percent for benznidazole and posaconazole combination therapy and 86.7 percent for benznidazole monotherapy. Serious adverse events were observed in six of the benznidazole-treated patients. According to the authors, benznidazole monotherapy is superior to posaconazole monotherapy and achieved RT-PCR conversion of T. cruzi in all patients on treatment by 30 days, which was sustained for at least one year. Permanent discontinuation of benznidazole monotherapy was frequent, and combination therapy did not provide any further advantages compared with benznidazole monotherapy. “Exploring novel therapeutic approaches for the treatment of Chagas disease is a priority, given the high rates of adverse effects and therapy discontinuation rates with currently available therapies,” the authors said. “Similarly reducing the burden of disease and progression to cardiomyopathy is critical.” In an editorial comment, Caryn Bern, MD, MPH, adds that, “Development of new regimens for chronic T. cruzi infection remains challenging … Let us hope that the next 5 years bring more optimism and less frustration to Chagas.” Morillo, CA, Waskin, H, Sosa-Estani, S, et al. J Am Coll Cardiol 2017;69:939-47. Flu, Pneumonia Vaccines May Benefit HF Patients Flu and pneumonia vaccines may improve the quality of life and outcomes of heart failure (HF) patients by providing cost-effective protection against life-threatening respiratory infections, according to a review paper published Feb. 1 in JACC: Heart Failure. Robert J. Mentz, MD, FACC, and colleagues examined published studies from January 1990 to July 2016 on interventions involving the use of pneumonia or flu vaccines in HF patients or related to HF outcomes. They found that preliminary evidence across prior studies suggests flu and pneumonia vaccines have a protective effect in HF patients, but data are still limited. Recent evidence also shows a benefit in giving HF patients over the age of 65 a high-dose vaccination, because many patients with HF may have a decreased immune response to a standard dose. However, the authors point out that questions remain. The Centers for Disease Control and Prevention recommend yearly flu vaccinations for adults with chronic cardiovascular disease, including HF. Recommendations for a yearly flu vaccination are supported by cardiology societies, including the ACC, which states in its guidelines that patients with cardiovascular disease should have an annual flu vaccine. The ACC also recommends pneumonia vaccines for secondary prevention of HF. However, the impact of vaccination in HF patients is incompletely studied since most vaccination trials either have not enrolled HF patients or not assessed the impact of vaccines in a HF cohort sub-study. “A deeper understanding of current vaccination practices within the HF population is necessary to guide population-level interventions aimed at improving vaccination rates,” said Mentz. Bhatt AS, DeVore AD, Hernandez AF, Mentz RJ. JACC: Heart Fail 2017;Jan.28:[Epub ahead of print]. NCDR Study Finds Radial Access, Same-Day PCI Could Save $300 Million Annually If hospitals can perform more transradial or same-day PCIs, not only will patients benefit because it is associated with fewer complications, but collectively, hospitals across the U.S. could save $300 million each year, according to research published Feb. 20 in JACC: Cardiovascular Interventions. PCIs cost the U.S. approximately $10 billion each year. Since there have been few data on strategies that can be implemented to help reduce costs of PCI, Amit P. Amin, MD, Msc, et al., evaluated different PCI approaches and care pathways to see which would be least costly. The researchers examined nearly 280,000 Medicare patients in ACC’s CathPCI Registry undergoing PCI who were eligible for same-day discharge. In this group, the arm artery access was used in 9 percent of patients, and same-day discharge occurred in 5.3 percent of patients. The adjusted cost associated with arm access with same-day discharge was $13,389, while the cost associated with leg access and overnight stay was $17,076, a difference of $3,689 per PCI procedure. The authors also found that by shifting practice by 30 percent for more same-day arm access procedures, a hospital performing 1,000 elective PCI procedures per year could reduce costs by approximately $1 million. If collectively all hospitals across the country followed this care pathway, PCI costs would be lowered by almost $300 million annually. Amin AP, Patterson M, House JA, et al. JACC: Cardiovasc Interv 2017;10:342-51.
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