Banning
Smoking from Public Places Reduces Community Heart Attack Rates (CHICAGO)—Local
laws banning smoking in workplaces and public areas can greatly reduce the number
of heart attacks that occur in the community, a study has demonstrated for the
first time. Investigators
in Helena, Montana, compared heart-attack rates over the four years before and
six months after a local Clean Indoor Air ordinance took effect in June, 2002.
"We
took advantage of the fact that there is single hospital in the region that treats
heart-attack patients,” said Dr. Richard P. Sargent, St. Peter’s Community
Hospital, Helena, Mont.. The city, with a population of about 66,000, is about
60 miles from the closest other hospital. "The
passage of a local indoor smoke-free-air ordinance was associated with a significant
45% reduction in heart attack incidence for people living in the Helena region
as compared to the surrounding areas,” said Dr. Sargent. “The effect
of eliminating second-hand smoke exposure on admissions for myocardial infarction
was immediate and sustained.” The
discovery, said Dr. Sargent, adds to established evidence that 1) long-term second-hand
exposure to cigarette smoke can increase the risk of heart disease and 2) short-term
exposure causes changes in the blood that can make heart attacks more likely.
He is slated to present the study’s results here at 8:30 a.m., Tuesday, April
1, at the American College of Cardiology 52nd Annual Scientific Session.
ACC’s
GAP Program Shows Benefits of Building Heart Attack Treatment Guidelines
into Hospital Protocols (CHICAGO)—The
quality of care for patients with a acute heart attack improves dramatically when
doctors, nurses, and patients are all aware of and use established therapy guidelines
that have been formally built into their hospital’s standard protocols, according
to Dr. Kim A. Eagle, MD, University of Michigan, Ann Arbor. Dr.
Eagle based his assertion on an evaluation of three quality-improvement initiatives
in Michigan for the care of patients with acute heart attack (myocardial infarction,
or MI), sponsored by the American College of Cardiology’s Guidelines Applied
in Practice (GAP) program. “Many patients with an acute MI have been shown
not to be receiving pharmacologic therapies and lifestyle recommendations that
are proven to improve outcomes,” said Dr. Eagle. "The
ACC–GAP Project has provided a glimpse of how we can improve the application
of key priorities of evidence-based care in cardiovascular disease,” said
Dr. Eagle. The GAP project evaluation looked at the effectiveness of acute-MI
care-delivery “tools” (such as standing orders, discharge documents,
patient-information forms, and critical pathways) that incorporate evidence-based
guidelines. Consistent application of the tools increased appropriate use of acute-MI
drug therapies, smoking cessation and dietary counseling, and measurement and
treatment of abnormal blood lipids. "If
we focus on the actual use of care-delivery tools as our improvement goal, instead
of changes in traditional performance indicators, the performance indicators improve
automatically,” said Dr. Eagle. He is scheduled to present the evaluation’s
results here at 8:45 a.m., Tuesday, April 1, at the American College of Cardiology
52nd Annual Scientific Session.
Enoxaparin
and GP IIb/IIIa Receptor Blocker Combination Tested in Acute Coronary Syndrome
(CHICAGO)—A
variety of drugs that dissolve clots and keep them from recurring are given to
patients with unstable chest pain, which can turn into a full-scale heart attack
if left untreated. Researchers continually test whether some of the newer anticlotting
agents, which are often more potent than more established ones, can be combined
safely while leading improving clinical outcomes. A prospective, randomized trial
has done just that for two drugs introduced only in recent years, the blood thinner
enoxaparin and the antiplatelet drug tirofiban. In
the A-phase of the Aggrastat to Zocor trial, nearly 4,000 patients with unstable
chest pain threatening to become a major heart attack (“non-ST-elevation
acute coronary syndrome”) received aspirin and the glycoprotein (GP) IIb/IIIa
receptor blocker tirofiban—both are antiplatelet agents. The patients were
then randomized to treatment with either enoxaparin or standard heparin, the blood
thinner traditionally used in such cases. Enoxaparin is a low-molecular-weight
heparin, a manufactured derivative of standard heparin that can be more convenient
to use and more predictable in its effects. The
trial will compare the two patient groups with respect to rates of death and the
development of heart attacks, further episodes of chest pain, and serious side
effects such as bleeding, according to Dr. Michael A. Blazing, Duke University,
Durham, N.C. Dr.
Blazing will present the results of the A-phase of the Aggrastat to Zocor trial
here at 9:00 a.m., Tuesday, April 1, at the American College of Cardiology 52nd
Annual Scientific Session.
Metabolic
Therapy May Improve Survival after Angioplasty-Treated Heart Attack (CHICAGO)—If
heart muscle cells needed less oxygen during a heart attack, maybe fewer of the
cells would die and the patient would be more likely to survive. That is the rationale
behind the Glucose-Insulin-Potassium Study, or GIPS, which has tested whether
the results of angioplasty as a heart-attack treatment can be improved by modifying
the heart’s metabolic needs. A
combined infusion of high-dose glucose, insulin, and potassium—also called
“GIK”— led to a significant decrease in 30-day mortality in a subset
of heart-attack patients treated with angioplasty, according to Dr. Iwan C. van
der Horst, Groningen University Hospital, the Netherlands. Standard
therapies for acute heart attack, which is caused when a clot chokes off part
of the heart’s blood supply, consist of measures to restore adequate blood
flow and treatments that lower future risks. “Metabolic regulation”
is an additional approach under investigation, observed Dr. van der Horst. Based
on nearly a century of research, it is thought that a GIK infusion during an acute
heart attack might encourage heart cells to burn glucose for fuel instead of free
fatty acids, which metabolize using more oxygen. Temporarily reduced oxygen needs
could make the heart muscle less vulnerable during a heart attack. In
the GIPS trial, 940 patients experiencing a heart attack were randomly assigned
to undergo angioplasty without or without a GIK infusion. The added GIK treatment
appeared to limit the extent of heart muscle damage over all patients, as well
as improve survival by more than two-thirds in patients initially without signs
of heart failure. Dr.
van der Horst is scheduled to present the GIPS trial here at 9:15 a.m., Tuesday,
April 1, at the American College of Cardiology 52nd Annual Scientific Session.
New
Heart Vessels from Gene Therapy for Coronary Disease: Randomized, Controlled Trial
(CHICAGO)—Early
results from a randomized, controlled trial show that a gene therapy technique
may promote new blood vessel growth in the hearts of some patients with severe
cardiovascular disease. "Using
gene therapy, it is possible to induce production of vascular growth factors locally
within heart muscle,” said Dr. Jens Kastrup, University Hospital Rigshospitalet,
Copenhagen, Denmark. “The Euroinject One study is the first large multicenter,
randomized, double-blind, placebo-controlled gene-therapy study using the gene
encoding for vascular endothelial growth factor A165 [VEGF-A165] in patients with
severe coronary disease.” The
trial’s 80 patients with coronary disease were randomly assigned to receive
injections of either a placebo solution or solution containing tiny packets of
genes, called plasmids, that were engineered to induce VEGF-A165 production. The
solutions were injected directly into regions of heart muscle that nuclear imaging
tests had shown to be undersupplied with blood. The injected growth-factor genes,
observed Dr. Kastrup, do not become built into a patient’s own genes, but
rather work inside the heart muscle for two to four weeks before they are naturally
eliminated. Preliminary
findings from the Euroinject One study suggested that many of the patients had
improved blood flow in previously impaired regions of heart muscle. Dr. Kastrup
will present the three-month follow-up results for all the patients on Tuesday,
April 1, at 9:30 a.m., at the American College of Cardiology 52nd Annual Scientific
Session.
Gene
Therapy for Vascular Disease in the Leg: Results from the Largest Placebo-Controlled
Trial (CHICAGO)—Gene
therapy designed to promote new vessel growth in leg muscles with impaired blood-flow
has been tested in a randomized, double-blind, placebo-controlled trial for the
first time. The
Regional Angiogenesis with Vascular Endothelial Growth Factor in Peripheral Arterial
Disease (RAVE) study tested whether injection of genes engineered to induce production
of VEGF121, a blood vessel growth factor, can prevent claudication in patients
with arterial disease of the leg muscles. Measures
of severity of claudication—mobility-limiting pain caused by reduced leg-muscle
blood flow—“are the most reliable endpoints for assessing angiogenesis
[new blood-vessel growth] in patients with peripheral artery disease,” according
to Dr. Sanjay Rajagopalan, University of Michigan, Ann Arbor. "Prior
to our phase II trial, a number of small phase I studies using claudication-based
endpoints had very promising results. What we really lacked was proof-of-concept,”
said Dr. Rajagopalan. Of
the trial’s 105 enrolled patients, those randomly assigned to receive leg
injections with the growth-factor genes failed to show any improvements in walking
time, the classic measure of claudication, when evaluated at 12 weeks. The study
will follow the patients out to a year. "We
are hoping that the later results will show a benefit that the early results did
not,” said Dr. Rajagopalan, who will present trial’s 26-week findings
at 9:45 a.m., Tuesday, April 1, at the American College of Cardiology 52nd Annual
Scientific Session.
The
American College of Cardiology, a 28,000-member nonprofit professional medical
society and teaching institution, is dedicated to fostering optimal cardiovascular
care and disease prevention through professional education, promotion of research,
leadership in development of standards and guidelines, and the formulation of
health care policy.
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