Journal Wrap

The hottest research from various peer-reviewed journals — handpicked weekly by the ACC.org Editorial Board led by Kim Eagle, MD, MACC.

Can Reducing Nicotine Levels in Cigarettes Reduce Tobacco-Related Mortality?

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Enacting a regulation to lower the nicotine levels in cigarettes to minimally addictive levels in the U.S. may “substantially reduce” tobacco-related mortality, according to an analysis published in the New England Journal of Medicine.

In July 2017, the U.S. Food and Drug Administration (FDA) announced a regulatory plan to explore lowering the nicotine level in cigarettes to improve the rate of smoking-related diseases and mortality in the U.S. To assess the potential risks and benefits prior to enacting such a regulation, Benjamin J. Apelberg, PhD, MHS, et al., used a simulation model derived from empirical evidence and expert opinion to estimate the effect the regulation could have on the prevalence of tobacco use, tobacco-related mortality and life-years gained. Read more >>>

The authors established a projection period from 2016 through 2100 to simulate a baseline scenario that predicted the future use of cigarettes and non-combusted tobacco products and compared the baseline scenario with a scenario incorporating the anticipated effects of the policy. The model included data points accounting for population, births, migration, mortality and tobacco-use behavior, among others.

Results showed that approximately five million additional smokers would quit smoking within a year of implementation of the policy. That number would increase to 13 million additional former smokers within five years of implementation. In subsequent years within the policy scenario, the difference in smoking prevalence would continue to grow because of sustained increases in cessation and decreases in initiation of cigarette use.

Since a sustained decrease in the rate of smoking initiation is expected, it is projected that the cumulative number of persons dissuaded from ever starting to smoke would continue to increase over time. The authors further estimated that by 2060, 16 million persons who would have otherwise initiated smoking, would not start because of the policy.

“Despite inherent uncertainty, the data from our model contribute to a growing base of evidence about the role of nicotine reduction that can inform the development of policy with respect to tobacco products, including an assessment of the risks and benefits to the population as a whole,” the authors conclude. “Our findings show that reducing the nicotine level in cigarettes has the potential to substantially reduce the enormous burden of smoking-related death and disease. We estimate that a nicotine product standard for cigarettes in the U.S. could save millions of lives and tens of millions of life-years over the next several decades.”


Apelberg BJ, Feirman SP, Salazar E, et al. N Engl J Med 2018;March 15:[Epub ahead of print].

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Impact of HF Medication Adherence on Hospitalization and Mortality Outcomes

Medication adherence is associated with fewer heart failure (HF) symptoms and lower rates of hospitalization and death, according to a recent study published in the Journal of Cardiovascular Nursing.

Jia-Rong Wu, PhD, RN, et al., conducted a secondary analysis of two tandem, prospective studies with parallel methods on medication adherence using the Medication Event Monitoring System (MEMS), with up to 3.5 years of follow-up in patients with HF. Patients were enrolled in outpatient clinics and inpatient hospital stays for HF. Demographic, clinical, symptom, medication adherence and outcomes data were analyzed for 219 patients enrolled in the parent study. Patient data were analyzed according to those who did and did not have symptoms during the data collection period. Two medications, beta-blockers and angiotensin-converting enzyme (ACE) inhibitors, were used to measure HF medication adherence. The cutoff of 88 percent was used to determine adherence. Read more >>>

Patients from the two prospective studies who reported having symptoms during the previous three months were younger, had greater body mass index, and were less likely to take ACE inhibitors than those who reported not having symptoms. Ninety patients (41 percent) were nonadherent to HF medications: 66 (46 percent) had symptoms during the previous three months and 24 (32 percent) did not. OveralI, there were four cardiac deaths and 46 cardiac-related hospitalizations: 38 events in patients who had symptoms and 12 events for patients without symptoms in the previous three months.

Kaplan-Meier survival estimates of time-to-event plots demonstrated that cardiac event-free survival was worse among patients with symptoms than those without symptoms (p=0.039). After modeling the data using medication adherence, HF symptoms were not significant predictors of event-free survival (p=0.091).

“It is important to develop interventions to improve medication adherence that may reduce HF symptoms and high hospitalization and mortality in patients with HF,” the authors write.


Wu JR, Moser DK. J Cardiovasc Nurs 2018;33:40-6.

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Self-Monitored BP Beneficial, With or Without Telemonitoring

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Self-monitoring of blood pressure (BP), with or without telemonitoring, used by general practitioners to titrate antihypertensive medication in individuals with poorly controlled BP, leads to significantly lower BP than titration guided by clinic readings, according to a study published in The Lancet.

Richard J. McManus, PhD, et al., examined hypertensive patients older than 35 years with a BP above 140/90 mm Hg. Patients were randomly assigned (1:1:1) to self-monitoring BP (self-monitoring group), to self-monitoring BP with telemonitoring (telemonitoring group) or to usual care. The primary outcome was clinic measured systolic BP at 12 months from randomization. Read more >>>

A total of 1,182 patients from 138 practices were enrolled and randomly assigned: 394 to usual care, 395 to self-monitoring alone and 393 to self-monitoring with telemonitoring. After 12 months, mean systolic BP was lower in both intervention groups (137.0 and 136 mm Hg in the self-monitoring and telemonitoring groups), compared with 140.4 mm Hg with usual care. The adjusted mean difference was −3.5 mm Hg with self-monitoring (p=0.0029) and −4.7 mm Hg with telemonitoring (p<0.0001). The difference between the self-monitoring and telemonitoring groups was not significant. Adverse events were similar between all three groups.

Patients whose medication was adjusted using self-monitoring, with or without telemonitoring, had significantly lower systolic BP than those receiving treatment adjusted using clinic blood pressure.

“Self-monitoring can be recommended for the ongoing management of hypertension in primary care in all patients who wish to use it, and will require provision of validated blood pressure monitors for home use, ideally with integrated telemonitoring systems,” the authors conclude. “[General practitioners] should incorporate self-monitored readings into their titration of blood pressure medications.


McManus RJ, Mant J, Franssen M, et al. Lancet 2018;Feb 27:[Epub ahead of print].

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Low-Calorie Vegetarian vs. Mediterranean Diets: Which is Best?

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Low-calorie lacto-ovo vegetarian (Vd) and Mediterranean diets are equally effective at reducing body weight, body mass index (BMI) and fat mass, while Vd diets are more effective at reducing LDL-C levels and Mediterranean diets are more effective in reducing triglyceride levels, according to research published in Circulation.

Francesco Sofi, MD, PhD, et al., observed clinically healthy participant omnivores (18-75 years of age) with a low-to-moderate cardiovascular risk profile (<5 percent at 10 years). Eligibility criteria included being overweight (BMI ≥25 kg/m2) and the simultaneous presence of ≥1 of the following: total cholesterol >190 mg/dL, LDL-C >115 mg/dL, triglycerides >150 mg/dL or glucose between 110-126 mg/dL. Participants were randomly assigned to a low-calorie Vd diet compared with a low-calorie Mediterranean diet, each lasting three months, with a crossover design. The primary outcome was the difference in weight, BMI and fat mass changes between the two groups. Secondary outcomes were differences in circulating risk factor parameter changes between the two groups. Read more >>>

A total of 107 participants completed at least one phase of intervention and were included in the analysis, while 100 participants (50 participants for each intervention) completed the entire study, with a participation rate of 84.7 percent at the end. Researchers found that the total energy, total fat, saturated fat and cholesterol intakes of participants significantly decreased compared with baseline. No significant difference was seen in the proportion of decrease observed between groups, with the exception of cholesterol intake, which decreased more in the Vd group. Protein intake increased in the Mediterranean diet group and decreased in the Vd diet group.

Regarding body weight and body composition, both diets produced equally effective results. Vd diet resulted in a significant decrease (5.44 percent) in LDL-C, while the Mediterranean diet did not. Subgroup analyses showed that changes in the lipid profile during the Vd diet were more evident in men, participants >50 years of age, nonsmokers, sedentary lifestyles, and BMI >30 kg/m2 with the most significant results in participants with class I obesity. The Mediterranean diet resulted in a significant decrease (5.91 percent) in triglyceride levels compared with the Vd diet. Both diets resulted in a significant improvement of the participants’ cardiovascular risk profile.

Limitations of the study include the lack of data on blood pressure levels, limited study duration and limited number of participants who completed the entire study. According to the researchers, studies with a larger population and a longer duration are needed to confirm these results.

“In conclusion, in the context of the behavioral counseling that promoted a reduced caloric intake, the results of this dietary randomized intervention study, the first comparing a [vegeterian diet] and [Mediterranean diet] in the same group of clinically healthy omnivorous participants, showed no difference in weight change between the [vegeterian diet] and [Mediterranean diet] groups, but the [vegeterian diet] reduced LDL cholesterol levels compared with the [Mediterranean diet], which reduced triglyceride levels compared with the [vegeterian diet],” the authors write.


Sofi F, Dinu M, Pagliai G, et al. Circulation 2018;Feb 26:[Epub ahead of print].

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Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Lipid Metabolism, Nonstatins, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Diet, Hypertension, Smoking

Keywords: ACC Publications, Cardiology Magazine, Adrenergic beta-Antagonists, Ambulatory Care Facilities, Angiotensin-Converting Enzyme Inhibitors, Antihypertensive Agents, Blood Pressure, Blood Pressure Monitors, Blood Pressure Determination, Body Composition, Body Mass Index, Body Weight, Cardiovascular Diseases, Cardiovascular Nursing, Cholesterol, LDL, Counseling, Cross-Over Studies, Diet, Mediterranean, Diet, Vegetarian, Disease-Free Survival, Energy Intake, Expert Testimony, Follow-Up Studies, General Practitioners, Glucose, Healthy Volunteers, Heart Failure, Hospitalization, Hypertension, Inpatients, Medication Adherence, Micro-Electrical-Mechanical Systems, Nicotine, Obesity, Overweight, Peptidyl-Dipeptidase A, Prevalence, Primary Health Care, Prospective Studies, Risk Assessment, Risk Factors, Sedentary Lifestyle, Smoking, Tobacco Products, Tobacco Use, Triglycerides, United States Food and Drug Administration


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