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Studies
make case for pounds of prevention
News conference: 7:30–8:15 a.m., EST, Tuesday, March
19
(ATLANTA)—Several
studies being presented at the American College of Cardiology
51st Annual Scientific Session in Atlanta, March 17–20,
2002, highlight the challenges of identifying people at risk
for heart disease and preventing its development. Together
they suggest that although prevention efforts miss many at-risk
young and middle-age adults, attention to certain worrisome
characteristics, particularly obesity, is key to early detection.
The
most recent guidelines from the National Cholesterol Education
Project (NCEP) identify more people at risk for heart disease
than previous versions did. Nonetheless, they overlook many
young and middle-aged adults who might benefit from preventive
therapy, a study from Gunderson Lutheran in LaCrosse, Wisc.,
suggests (Paul Schoenfeld, #1179-76). Investigators reviewed
the medical records of more than 200 patients with no history
of heart disease who were hospitalized with a heart attack
at an average age of 50. They found that, before having the
heart attack, nearly three out of four did not meet NCEP Adult
Treatment Panel III (ATP III) criteria for cholesterol-lowering
drug therapy on the basis on their clinical risk factors and
blood levels of low-density lipoprotein (“bad”)
cholesterol. (Original presentation on March 19 at a noon–1
p.m. poster session.)
A
simple risk score calculated from information typically obtained
during a general physical examination may improve the ability
to identify young and middle-age people at high risk for heart
disease, according to a new study from Walter Reed Army Medical
Center in Washington, DC (Marc E. Hunt, #1179-77). Using an
approach described in the NCEP ATP III guidelines, researchers
evaluated nearly 1,000 adults ages 40–45 with no symptoms
of heart disease. They calculated a metabolic score on the
basis of abdominal obesity, low levels of high-density lipoprotein
(HDL; “good”) cholesterol, and elevated blood pressure,
fasting blood glucose levels, and total cholesterol levels.
They found that a metabolic score of at least 3 identified
people significantly more likely to have evidence of heart
disease on coronary calcium screening by ultrafast computed
tomography. (Original presentation on March 19 at a noon–1
p.m. poster session.)
Average
levels of HDL cholesterol have declined 10 percent in the
last 25 years, and obesity may be to blame. Researchers from
Children’s Hospital Medical Center in Cincinnati and
Maryland Medical Research Institute in Baltimore studied a
group of people ages 27 to 47 in the mid-1970s, comparing
them to their grown children a generation later (John A. Morrison,
#1179-78). They found not only that HDL levels were lower
on average but that a larger proportion of the younger generation
had HDL levels so low they were considered to be an independent
risk factor for heart disease. Smoking rates and saturated
fat intake both declined over the intervening years, but rates
of obesity increased. (Original presentation on March 19 at
a noon–1 p.m. poster session.)
Being
seriously overweight puts a strain on the heart that can be
detected as early as adolescence and young adulthood, according
to a study from Children’s Hospital Medical Center in
Cincinnati (Thomas Kimball, #1062MP-129). Using echocardiography
to examine nearly 600 young women with an average age just
under 20, researchers found that obesity was the only characteristic
that independently predicted enlargement of the heart and
thickening of the muscular wall of the left ventricle, a pattern
that has been associated with an increased risk of heart disease
and cardiovascular death. (Original presentation on March
17 at a 4:36–4:48 p.m. moderated poster session.)
Obesity
may be a risk factor for heart disease, but once a patient
has heart failure, it appears to offer some protection (Carl
J. Lavie, #869-4). Researchers at the Ochsner Medical Institutions
in New Orleans studied more than 200 patients over 18 months
and found that patients with the most body fat and highest
body mass index—and indicator of the degree of obesity—had
the best outcomes. They speculated that the metabolic demands
of heart failure may force very lean patients to break down
muscle, whereas obese patients may be able to draw on their
fat stores for energy. (Original presentation on March 19,
2:45–3 p.m.)
Moderator:
Dr. Richard Pasternak, Massachusetts General Hospital,
Boston
BNP notches gains as bedside aid in heart
failure diagnosis, prognosis
News conference: 10:30–11:15 a.m., EST, Tuesday,
March 19
(ATLANTA)—A
protein that is released from heart cells stretched by an
overload of fluid is gaining ground in the diagnosis and management
of heart failure, according to studies being presented at
the American College of Cardiology 51st Annual Scientific
Session in Atlanta, March 17–20, 2002. B-type natriuretic
peptide—BNP for short—is proving useful not only
for determining whether heart failure is to blame when patients
suddenly develop difficulty breathing, but also for monitoring
the progression of chronic heart failure and predicting the
long-term risk of cardiac death or hospitalization.
Shortness
of breath is the primary symptom for more than two-thirds
of patients who present to emergency departments, but identifying
the cause can be difficult and time-consuming. Now a simple,
bedside blood test has proven fast and highly accurate at
singling out acute heart failure as the source.
“Given
the worldwide epidemic of heart failure, the test should have
a broad impact on the care of patients in emergency departments,”
according to Dr. Peter A. McCullough, of the University of
Missouri-Kansas City School of Medicine. The bedside test
measures levels of B-type natriuretic peptide, or BNP, a protein-like
molecule
that is released from heart muscle cells in patients with
heart failure.
In
the Breathing Not Properly (BNP) Multinational Study of more
than 1,500 patients with shortness of breath, the bedside
test significantly improved on traditional diagnostic methods
for heart failure.
“It
is the only test for BNP approved by the U.S. Food and Drug
Administration, and the only cardiac blood test for heart
failure that can be performed within 15 minutes,” said
Dr. McCullough. He is slated to present the study’s results
here at 9:23 a.m. on Tuesday, March 19, during the Late-Breaking
Clinical Trials II (#412) session.
A
bedside BNP test may have an edge over echocardiography in
determining why a patient suddenly has difficulty breathing.
Researchers from Beaujon Hospital AP-HP, Clichy, France, (Damien
Logeart, #895-2) performed both tests in patients who came
to the emergency room with severe breathing problems. They
found that Doppler echocardiography was more accurate than
BNP in diagnosing heart failure but couldn’t be used
in one out of four patients because the heart rate was too
rapid or irregular. (Original presentation on March 20, 10:45–11
a.m.)
Even
when heart failure patients are free of fluid overload, BNP
can identify those at highest risk, according to a study from
Universitaetsklinik Luebeck, Germany (Franz S. Hartmann, #895-1).
Researchers measured blood levels of a BNP building block
called N-Terminal proBNP, or NT-proBNP, in more than 1,000
patients with heart failure. They found that patients who
had an elevated NT-proBNP level were three times as likely
to be hospitalized for heart failure or die during the following
year, a highly significant increase in risk when compared
to patients with a normal NT-proBNP level. (Original presentation
on March 20, 10:30–10:45 a.m.)
Moderator:
Margaret Redfield, MD, FACC, Mayo Clinic, Rochester, Minn.
Patients
reap benefits of cardiology’s focus on quality
News conference: 11:30 a.m.–12:15 p.m., EST, Tuesday,
March 19
(ATLANTA)—As
a profession, cardiology has devoted a wealth of resources
to determining the best way to care for patients with heart
disease—and then applying those findings in everyday
practice. Several studies being presented at the American
College of Cardiology 51st Annual Scientific Session in Atlanta,
March 17–20, 2002, show that such efforts are paying
off, even in patients who may have been overlooked in the
past.
When
it comes to treating heart attack, quality-improvement programs
are especially effective in bridging gaps in the care of women
and the elderly, two groups in whom therapy often falls short
of the mark (Rajendra H. Mehta, #849-4). In an analysis of
the Guidelines Applied in Practice—or GAP—project,
researchers from the Michigan Health System in Ann Arbor found
that at the beginning of the GAP project, women and the elderly
were less likely to receive key medications, such as aspirin,
beta blockers, and angiotensin-converting-enzyme inhibitors,
or to be treated for high blood cholesterol and other risk
factors. After the quality-improvement project was in place,
most of these indicators improved to an even greater degree
in women and the elderly than in other patients. (Original
presentation on March 19, 9:15–9:30 a.m.)
Today,
patients return home from the hospital after a heart attack
an average of four days sooner than they did in 1985. Despite
worries that such efficiency might place patients at risk,
survival has improved steadily, an analysis from the University
of Minnesota in Minneapolis has shown (Alan K. Berger, #861-1).
After reviewing the records of more than 4,500 patients hospitalized
with a heart attack between 1985 and 1995, researchers observed
a drop in death rates during the hospital stay, as well as
within the first week and month afer discharge from the hospital.
(Original presentation on March 19, 2–2:15 p.m.)
Patients
who are admitted to the hospital with heart failure receive
better care and return home sooner if they are treated at
an academic medical center and by a cardiologist, according
to a study from the University of Michigan in Ann Arbor and
the Michigan Peer Review Organization in Plymouth (Jay K.
Amin, #849-2). The study involved data from nearly 6,000 Medicare
beneficiaries. Researchers found that those who were treated
at a teaching hospital were significantly more likely to undergo
key measurements of heart failure severity—including
heart function and daily changes in body weight—and receive
recommended medications at discharge. A similar advantage
was observed when patient care was directed by a cardiologist.
(Original presentation on March 19, 8:45–9 a.m.)
A
study from the Miami Heart Research Institute and Mount Sinai
Medical Center in Miami Beach found that coronary bypass surgery
is worthwhile in people who are age 80 and older, even though
it’s riskier than in younger patients (Paul Kurlansky,
#847-3). Researchers analyzed data from 1,000 octogenarians,
most of whom had advanced coronary artery disease that substantially
limited their ability to participate in everyday activities.
They found that even though 9 percent of patients died in
the hospital, most were healthy and symptom-free an average
of three years later and reported an excellent quality of
life. (Original presentation on March 19, 9–9:15 a.m.)
Moderator:
Dr. Raymond Gibbons, Mayo Clinic, Rochester, Minn.
Portable
or wearable, automated defibrillators spark interest
News conference: 12:30–1:15 p.m., EST, Tuesday,
March 19
(ATLANTA)—Nearly
95 percent of people who collapse from cardiac arrest die
before reaching the hospital. New devices that shock the heart
back into a normal rhythm, paired with innovative programs
to make them available to those who need them, can change
that grim statistic, according to research being presented
at the American College of Cardiology 51st Annual Scientific
Session in Atlanta, March 17–20, 2002.
About
a tenth of heart attack patients left with poor heart function
will die of heart-rhythm abnormalities within two years, despite
the best available drug therapy. Whether survival can be improved
by the addition of an implantable defibrillator, a small device
that uses shocks or other tactics to correct abnormal rhythms,
has long been an unanswered question—until now.
In
the second Multicenter Automatic Defibrillator Trial (MADIT-II),
implantation of a defibrillator in addition to medications
was associated with a 31 percent better improvement in two-year
survival than was drug therapy alone in patients with prior
heart attack and poor heart function.
“The
findings from this trial indicate a new prophylactic approach
to reducing mortality in this large group of high-risk patients
with a prior heart attack,” said Dr.
Arthur J. Moss, of the University of Rochester in New York.
Dr. Moss is scheduled to present the results of MADIT-II here
on Tuesday, March 19, at 8:30 a.m. during the Late-Breaking
Clinical Trials (#412) session.
The
debilitating symptoms of heart failure are characterized by
inefficient heart pumping that can result partly from poorly
synchronized contractions of the organ’s two largest
chambers, the ventricles. Recent research has strongly suggested
that an implanted electronic device that corrects the timing
of heart-chamber contractions can reverse some of those symptoms.
Now a multicenter, randomized study has demonstrated with
more authority that such cardiac resynchronization therapy
is not only safe, it can reverse some of the symptoms that
limit the daily lives of patients with heart failure.
In
the InSynch ICD Trial, 362 patients with moderate-to-severe
heart failure and poorly timed ventricular contractions were
implanted with a pacemaker-like device that can resynchronize
the contractions and, if needed, deliver a shock if the ventricles
should stop pumping blood at all. The patients were randomly
assigned to have the resynchronization feature of their implants
turned either on or off.
Those
who had their ventricular contractions resynchronized fared
significantly better over six months with respect to quality-of-life
measures and their ability to perform a standard walking endurance
test, according to Dr. James B. Young, of the Cleveland Clinic
Foundation, Cleveland, Ohio. Dr. Young is scheduled to present
the results of the InSynch ICD Trial here on Wednesday, March
20, at 8:30 a.m., during the Late-Breaking Clinical Trials
III (#421) session.
Patients
who are awaiting heart transplantation, or who are in fragile
health following a heart attack or bypass surgery, may be
temporarily vulnerable to developing a dangerously fast or
irregular heart beat. Wearing an external device that can
shock the heart back into normal rhythm may be the solution,
according to a study from the University of Pittsburgh Medical
Center and Otto Von Guericke University in Magdeburg, Germany
(Arthur Feldman, #826-1). Over three years, nearly 300 patients
enrolled in the study, wearing a temporarly defibrillator
throughout most of the day. The device restored a normal heartbeat
in about three-quarters of the patients who received a shock,
and seldom delivered a shock when it wasn’t needed. (Original
presentation on March 18, 2–2:15 p.m.)
Four
to five hours of training is just about right for learning
to use a portable automated defibrillator, a survey of more
than 4,400 American Airlines flight attendants suggests (Theodore
W. Takata, #1003-33). When the airline equipped its aircraft
with automated defibrillators, it began a massive training
campaign to prepare flight crews to respond to in-flight medical
emergencies. At the end of the training, more than nine of
ten participants gauged the length of class to be “just
right,” and most reported being significantly more comfortable
in using the device to resuscitate a passenger during an in-flight
emergency. (Original presentation on March 17 at a 10–11
a.m. poster session.)
Two
studies from Piacenza, Italy, show that distributing automated
defibrillators at various locations throughout a mid-sized
city and training volunteers to use them can dramatically
increase survival following cardiac arrest. The first study
found that after a four-hour introductory class, followed
by a one-hour refresher six months later, nearly all participants
could pass a test on using the device. (Alessandro Capucci,
#1003-37; original presentation on March 17 at a 10–11
a.m. poster session.)
A
second study from Piacenza compared the outcomes of cardiac
arrest victims treated by volunteers using an automated defibrillator
and those resuscitated by emergency workers (Massimo F. Piepoli,
#870-2). More than half the time, volunteers reached the patient
first. Survival was nearly three times as high among patients
treated by volunteers using the automated defibrillator. (Original
presentation on March 19, 4:15–4:30 p.m.)
Moderator:
ACC President Douglas P. Zipes, MD, FACC, Indiana University
School of Medicine, Indianapolis
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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