Journal Wrap

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

Study Finds Universal Masking Reduced Rates of COVID-19 Among Health Care Workers

Universal masking of all health care workers and patients at Mass General Brigham (MGB), the largest health care system in Massachusetts, was associated with significantly lower rates of health care workers testing positive for COVID-19. The study, published in the Journal of the American Medical Association, suggests the association "may be related to a decrease in transmission between patients and health care workers and among health care workers."

Xiaowen Wang, MD, et al., identified 9,850 health care workers at MGB who were tested for COVID-19 between March 1 and April 30, 2020. The primary criterion for testing was having symptoms consistent with the virus. The median age of those tested was 39 years and 73% were female; 7.4% were physicians or trainees and 26.5% were nurses or physician assistants. Of those tested, 1,271 (12%) had positive results.


Wang and colleagues noted that prior to implementing universal masking (the pre-intervention period), the COVID-19 positivity rate among health care workers "increased exponentially" from 0 to 21.32%. However, this rate declined significantly – from 14.65% to 11.46% – once masking was required for both patients and health care workers.

While the decrease in health care worker infections could be confounded by other state-wide measures both inside and outside the health system, the authors highlight that COVID-19 cases were on the rise in Massachusetts throughout the study period, suggesting the decrease in positive testing within MGB took place before the decrease in the general public.

"Based on this research, masks work in public," says Deepak L. Bhatt, MD, MPH, FACC, one of the study's authors. "Hopefully, these data can help convince those who are still in doubt and thereby save many lives globally. The very insightful editorial from the Centers for Disease Control and Prevention (CDC) leadership got it right – the time for universal masking is now!"

In the CDC editorial, John T. Brooks, MD; Jay C. Butler, MD; and Robert R. Redfield, MD, write that "with cloth face coverings, personal protection is derived from their use by all members of the community." They note that "public health officials and leaders need to ensure that the public understands clearly when and how to wear cloth face coverings properly and continue building the evidence base for their effectiveness." They also acknowledge the need for innovation to extend the physical comfort and use of masks. "At this critical juncture when COVID-19 is resurging," they write, "broad adoption of cloth face coverings is a civic duty, a small sacrifice reliant on a highly effective low-tech solution that can help turn the tide favorably in national and global efforts against COVID-19."

Wang X, Ferro E, Zhou G, et al. JAMA 2020;July14:[Epub ahead of print].


REDUCE-IT Trial Results Guide New Era in Dyslipidemia Therapeutics

REDUCE-IT trial results should alter the approach to managing a growing population of patients with hypertriglyceridemia whose lipid phenotype requires more intensive treatment beyond LDL-C lowering alone, according to a clinical review published in the European Heart Journal.

William E. Boden, MD, FACC, et al., describe the findings and clinical implications of the REDUCE-IT trial in which ethyl eicosapentaenoic acid significantly improved atherosclerotic cardiovascular disease (ASCVD) outcomes. They also highlight the importance of elevated baseline triglycerides in the setting of well-controlled LDL-C on statins as a major contributor to residual ASCVD risk.


The authors explain that prior placebo-controlled trials using niacin, fibrates, omega-3 fatty acids and dietary supplement fish oil preparations have failed to demonstrate significant cardiovascular event reduction when added to statin therapy. However, REDUCE-IT convincingly demonstrated that the administration of high-dose prescription icosapent ethyl 4 g daily (2 g twice daily with meals) in 8,179 patients at high risk for ASCVD with increased baseline triglycerides but well-controlled LDL-C levels had a highly significant clinical benefit and reduced incident events across both the trial primary endpoint and multiple prespecified secondary endpoints, including cardiovascular death, as well as both subsequent and total primary endpoint and key secondary endpoint events.

In addition, REDUCE-IT trial results showed that icosapent ethyl clearly contributed to ASCVD event reduction over and above statin therapy.

The authors note that both the updated 2019 Lipid Guidelines of the European Society of Cardiology and the U.S. National Lipid Association have referenced and endorsed icosapent ethyl as a Class IIa and Class IB dyslipidemic therapy, respectively, for patients with hypertriglyceridemia. "We believe these recommendations underscore that icosapent ethyl and the profoundly positive findings of REDUCE-IT herald a new era in dyslipidemia therapeutics, and one in which the previously unfulfilled promise of residual cardiovascular risk reduction in these high-risk patients can now be achieved," the authors conclude.

Boden WE, Bhatt DL, Toth PP, et al. Eur Hear J 2020;41:2304-12.


Secondary Prevention Low in Most MI Patients With High LDL-C

Only about a third of patients with a prior myocardial infarction (MI) and elevated LDL-C levels received evidence-based medical therapy, according to a research letter published in JAMA Network Open.

Suzanne V. Arnold, MD, MHA, et al., examined postdischarge use of evidence-based therapies for secondary prevention in GOULD, a large contemporary cohort of U.S. patients with prior MI and elevated LDL-C.


Researchers examined data from 1,564 patients with atherosclerotic cardiovascular disease and prior MI. The median age was 67 years, about 33% were women and 38% had diabetes; median LDL-C level was 90 mg/dL.

Results showed 87% were on statins and 48.5% on high-intensity statins, and 94.3% were taking an antiplatelet agent or anticoagulant. Of the 259 patients with an MI within the past year, 68.3% were taking dual antiplatelet therapy, 61.8% high-intensity statin, 81.5% a beta-blocker and 3.3% an ACE inhibitor or ARB.

Notably, 571 (36.5%) of study participants were receiving optimal medical therapy for secondary prevention.

"Persistence with each of these classes of medications substantially reduces recurrent ischemic events, heart failure and cardiovascular mortality," the authors write. "As such, ensuring patients with a prior MI and elevated LDL cholesterol levels, who represent some of the highest risk patients, are receiving consistent and aggressive secondary prevention therapy over time (and not just at hospital discharge) must be a priority."

Arnold SV, de Lemos JA, Liu Y, et al. JAMA Netw Open 2020;3(4):e203032.


Women, Older Adults Inadequately Represented in Trials of Lipid-Lowering Therapies

A systematic review of randomized clinical trials (RCTs) of lipid-lowering therapies (LLTs) found women and older adults are consistently underrepresented, despite ongoing efforts to increase inclusion of these populations, according to a study published in JAMA Network Open.

For this analysis, Safi U. Khan, MD, et al., selected primary and secondary prevention studies of LLTs with at least 1,000 participants conducted between 1990 and 2019 with follow-up of at least one year. In total, 60 trials with 485,409 participants were included, to examine the prevalence of women and older (age >65 years) participants, temporal trends in their participation, representations of women in RCTs relative to disease burden (using the participation-to-prevalence ratio [PPR] metric) and trends in reporting outcomes based sex and age.


Looking at women, representation overall was 28.5%, increasing from 19.5% for the period of 1990 to 1994 to 33.6% for the period of 2015 to 2018.

Some common factors limiting the representation of women in RCTS was the inclusion of only postmenopausal women or surgically sterile women and the exclusion of pregnant and lactating women. Compared with their disease burden, women were underrepresented in lipid RCTs of diabetes (PPR, 0.74); heart failure (PPR, 0.27); stable coronary heart disease (PPR, 0.48); and acute coronary syndrome (PPR, 0.51).

Regarding older adults, only 23 RCTs with 263,628 participants reported the proportion of older participants. Their overall representation was 46.7%, a numerical increase from 31.6% to 46.2% for the periods of 1995 to 1998 and 2015 to 2018.

Only 53% of trials reported outcomes according to sex and only 36.6% according to older adults, with no improvement found over time.

Noting there was only modest improvement in enrollment over time, likely reflective of regulations by the U.S. Food and Drug Administration, they add there are no legal or regulatory mandates requiring a specific proportion of participants based on sex or age.

"Therefore, practical steps should be undertaken to develop new strategies to achieve optimal recruitment of these subsets of the population in RCTs, and investigators should be encouraged to report results based on these subgroups to enhance generalizability of their results," the authors write.

Khan SU, Khan MZ, Subramanian CR, et al. JAMA Netw Open 2020;3(5):e205202.


Keywords: ACC Publications, Cardiology Magazine

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