Journal Wrap

More African Americans Qualify for Statin Therapy With ACC/AHA Guidelines

Under the 2013 ACC/American Heart Association (AHA) guidelines on the treatment of blood cholesterol, 25 percent more African Americans qualify for statins compared with the U.S. Preventive Services Task Force (USPSTF) guidelines, according to a study presented at ACC.17 and simultaneously published in JAMA Cardiology. Read More >>>

Ravi V. Shah, MD, et. al., identified 2,812 African Americans without prevalent atherosclerotic cardiovascular disease (ASCVD) and who were not receiving statin treatment. The researchers evaluated statin eligibility in all participants, and 1,743 of these patients also underwent computed tomography (CT) imaging.

The researchers found that 38.1 percent of the patients were statin-eligible by USPSTF Grade B guideline recommendations compared with 49.9 percent by ACC/AHA guidelines. Overall, statin recommendations were consistent for both guidelines in 86.1 percent of patients. While 12.8 percent were statin-eligible based on ACC/AHA guidelines alone, only 1.0 percent was eligible by USPSTF alone, and 25.7 percent of African Americans recommended for statin therapy under the ACC/AHA guidelines were not recommended for statin therapy under the USPSTF guidelines.

Over the median 10-year follow-up, there were 123 incident ASCVD events. The researchers found a 5.0-fold increased hazard of incident ASCVD among statin-eligible participants by the USPSTF guidelines compared with non-eligible participants and a 5.5-fold increased hazard of incident ASCVD among statin-eligible participants by the ACC/AHA guidelines. Those eligible for statins under both guidelines had a higher event rate than those eligible under only the ACC/AHA guidelines.

Finally, the researchers found that while statin-eligible participants under the USPSTF guidelines did not have a significantly higher 10-year ASCVD event rate in the presence of coronary artery calcium (CAC), African American participants not eligible for statins under USPSTF guidelines had a higher ASCVD event rate in the presence of CAC compared with those without CAC.

These data support the use of the ACC/AHA guidelines to identify African American adults likely to have vascular calcification and may benefit from statin therapy.

“Despite debate over the potential cost, risk calibration and metabolic health implications of increasing statin use, these results support a guideline-based approach to statin recommendation, leveraging targeted imaging (or other atherosclerotic measures) in African American individuals to further personalize statin-based prevention programs,” the authors conclude.

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Shah RV, Spahillari A, Mwasongwe S, et al. JAMA Cardiol 2017:March 18:[Epub ahead of print] <<< Return to top

Mother’s Plasma Folate Levels May Influence Child’s Systolic BP

Higher levels of maternal plasma folate may help counteract the adverse associations of maternal cardiometabolic risk factors on systolic blood pressure (SBP) of the mother’s child, according to research presented at ACC.17 and published March 6 in the American Journal of Hypertension. Read More >>>

Hongjian Wang, MD, and colleagues examined 1,290 mother-child pairs from the Boston Birth Cohort, comprised of predominantly urban, low-income, racial and ethnic minority populations. Of the mothers, 38.2 percent had one or more cardiometabolic risk factors, 14.6 percent had hypertensive disorders, 11.1 percent had diabetes and 25.1 percent had pre-pregnancy obesity. The median for maternal plasma folate levels, taken two to three days after delivery, was 30.32 nmol/L. A total of 28.7 percent of the children had elevated SBP at age three to nine years. These children were more likely to have mothers with pre-pregnancy obesity, hypertensive disorders and diabetes and were also more likely to have lower birthweight, lower gestational age and higher current body mass index.

Overall, maternal folate levels were not associated with child SBP percentile or elevated SBP. However, the association of maternal folate levels and child SBP was modified by cardiometabolic risk factors of the mother. Children born to mothers with cardiometabolic risk factors and folate levels below the median had a 1.65 to 1.90-fold higher odds of elevated SBP compared with children whose mothers had high median folate levels with no maternal cardiometabolic risk factors. The researchers observed similar associations when only analyzing African American patients. These associations were not found to be explained by gestational age, size at birth, prenatal folate intake or breastfeeding.

The authors write that the mechanisms underlying the potentially beneficial influence of maternal folate on the SBP of children who have mothers with risk factors are not clear and that future studies are needed to examine this point.

They conclude that “interventions focused on increasing maternal folate intake among mothers with metabolic risk factors may help mitigate the transgenerational association of cardiometabolic diseases.”

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Wang H, Mueller NT, Li J, et al. Am J Hypertens 2017;Mar 6:[Epub ahead of print]. <<< Return to top

NCDR Study Looks at Safety of Vascular Closure Device

Among patients who undergo a PCI procedure with femoral access, the risk of a vascular complication may be higher with the Mynx vascular closure device compared with other vascular closure devices, according to a study published in the New England Journal of Medicine. Read More >>>

The study, led by Frederic S. Resnic, MD, FACC, was designed to assess the postmarketing safety of the Mynx device, and looked at data from 73,124 patients enrolled in ACC’s CathPCI Registry who received the device between Jan. 1, 2011 and Sept. 30, 2013.

Results showed that the Mynx device was associated with a “significantly greater risk” of the primary outcome of any vascular complication – a composite of access-site bleeding, access-site hematoma, retroperitoneal bleeding, or any vascular complication requiring intervention – compared with other devices (absolute risk, 1.2 percent vs. 0.8 percent; relative risk, 1.59; 95 percent confidence interval, 1.42 to 1.78; p < 0.001). There was also a “significantly greater risk” of the secondary safety endpoints: access-site bleeding requiring treatment and postprocedural blood transfusion. However, the authors note that the absolute risk differences were small.

The authors add that alerts for the Mynx device were “triggered early, persisted throughout the duration of surveillance, and were present in all subgroups of patients.” In addition, “the primary results were confirmed in an independent, more contemporary cohort of patients.”

In an editorial, Jon Resar, MD, FACC, and Myron L. Weisfeldt, MD, FACC, explain that there may be mitigating factors associated with the use of the Mynx device. “There may have been selective use of this device for arteries that pose a subjectively greater challenge for closure without complications...,” they note. Further, there is a learning curve for using these devices.

They conclude that the study “highlights the value of professional society registries for post-marketing evaluation of device performance in clinical practice and emphasizes the need for the establishment of a National Evaluation System for Health Technology.”

Resnic FS, Majithia A, Marinac-Dabic D, et al. N Engl J Med 2017;376:526-34.

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Drones: Future Delivery System for AEDs?

A drone network that was designed with the aid of a novel mathematical model was shown to reduce the time to deliver an automated external defibrillator (AED) to respond to an out-of-hospital cardiac arrest (OHCA), according to recent work by Justin J. Boutilier, BSc, and the Rescu Epistry Investigators. Read More >>>

The authors applied a two-level (optimization and queuing) theoretical model to 53,702 OHCAs that occurred within eight regions (covering about 10,000 square miles) of the Toronto Regional RescuNET emergency medical system between Jan. 1, 2006 and Dec. 31, 2014. The objective of their primary analysis was to determine the size of a drone network needed to deliver an AED at one minute, two minutes or three minutes faster than the historical median 911 response times for each region. A secondary analysis was conducted to determine the size of the reduction in the number of drones required for one large coordinated RescuNET region versus the current eight regions.

Their region-specific primary analysis found that in order to deliver an AED three minutes faster than the median 911 response times, a total of 81 bases and 100 drones would be required. In the most urban region, there was a reduction of six minutes and 43 seconds for the 90th percentile of the AED arrival time relative to historical 911 response times in the region. In the most rural region, this reduction was 10 minutes and 34 seconds.

The investigators determined in their secondary analysis that a single coordinated drone network across all regions would reduce the number of bases required by 39.5 percent and the number of drones by 30.0 percent to achieve similar AED delivery times.

The authors write that prototype drone technology has been developed by several companies and researchers to deliver AEDs to the scene of an OHCA, and that Google has obtained a patent for drone delivery of medical supplies including AEDs. “Although there are technical challenges to overcome, drone-delivered AEDs are a potential transformative innovation in the provision of emergency care to cardiac arrest patients, especially to those who arrest in a private or rural setting,” they state. They also note that the camera on the drone used for navigation also could be employed by the 911 dispatcher to assess the patient visually and provide support for bystander CPR and AED application.

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Boutilier JJ, Brooks SC, Janmohamed A, et al. Circulation 2017;March 2:[Epub ahead of print].

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Clinical Topics: Arrhythmias and Clinical EP, Dyslipidemia, Implantable Devices, SCD/Ventricular Arrhythmias, Nonstatins, Novel Agents, Statins

Keywords: ACC Publications, Cardiology Magazine, Registries, National Cardiovascular Data Registries, African Americans, Defibrillators, Pediatrics, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Vascular Closure Devices

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