Journal Wrap
Kim Eagle, MD, MACC, and the editors of, present relevant articles taken from various journals.

CV Death Rate on the Decline?

There is an overall decreasing trend in the age-standardized mortality rate for all causes of death combined, and for five of the six leading causes of death: cardiovascular disease, cancer, stroke, unintentional injuries, and diabetes mellitus, according to recent study published in the Journal of the American Medical Association.

The study analyzed U.S. national vital statistics data from 1969 to 2013, and found the age-standardized death rate for all causes combined decreased from 1,279 per 100,000 population to 730 (43% reduction)—an average annual decrease of 1.3%. The rate of death (per 100,000) decreased for stroke by 77%; for cardiovascular disease, by 68%; for unintentional injuries, by 40%; for cancer, by 18%; and for diabetes, by 17%. However, the death rate for chronic obstructive pulmonary disease increased by 101%. Further, the rate of decrease has slowed for cardiovascular disease, stroke, and diabetes. Specifically, the annual decline for cardiovascular disease slowed from 3.9% from 2000 to 2010, to 1.4% from 2010 to 2013.

The authors noted that “the progress against [cardiovascular disease] and stroke is attributed to improvements in control of hypertension and hyperlipidemia, smoking cessation, and medical treatment.” However, the recent slowing of the decline in death rates for obesity-related diseases “may reflect the lagged consequences of increased obesity prevalence since the 1980s.”

They concluded that, moving forward, “further disease-specific studies are needed to investigate these trends.”

In an accompanying editorial comment, J. Michael McGinnis, MD, MPP, of the National Academy of Medicine, wrote: “Death rate may have, at one time, served as a sufficient measure of health system performance, but assessment now requires more textured insights, including those that reflect the improving capacity to measure health status, risk prevalence, and service access, effectiveness, and affordability.”

He explained that “what is needed is a set of national vital health indicators that is broader than mortality, but still a limited number, tightly constructed, standardized, and reliably available at all levels from local to national.” He pointed to the report, Vital Signs: Core Metrics for Health and Health Care Progress, released earlier this year, that recommends 15 core measures across four domains: healthy people, quality care, affordable care, and engaged people, “which could be assembled from a manageable set of standardized measures to be collected system-wide,” he added.

Ma J, Ward EM, Siegel RL, Jemal A. JAMA. 2015;314:1731-9

Women Less Likely to Take Medication Post-AMI

A majority of patients discontinue or do not take prescription medication regularly following acute myocardial infarction (AMI), according to research published in Circulation: Cardiovascular Quality Outcomes. Of these patients, women over 55 years old are significantly less likely to be on optimal therapy 1 year after discharge.

The population-based study used linked administrative data sets in British Columbia. A total of 12,261 patients who were admitted to the hospital with a primary diagnosis of AMI were included in the analysis. Women were slightly older than men and men were more likely to have ST-elevation myocardial infarction. Over half of the women in the study were in the lowest income quartile, compared with less than a third among men.

Study results found men were more likely to begin appropriate treatment—such as filling prescriptions—within 2 months after discharge in all age groups. The greatest disparity was seen in the 20 to 54 year age group with 75% of men compared with 65% of women initiating therapy. Initiation for appropriate therapy was lowest in the 85+ age group for both sexes—50% of men and 48% of women. Women had a higher likelihood of undertreatment for all drug classes. Adherence rates were similar for men and women.

The study authors, led by Kate Smolina, PhD, from the Centre for Health Services and Policy Research, School of Population and Public Health at the University of British Columbia, noted that “the drivers behind sex disparity in treatment are not well understood” and could be a result of several factors, “including differences in symptom presentation, perceived risk of secondary events, concerns about the limited information about the safety and effectiveness of these drugs in women, physician biases, and demographic factors, such as differences in age and socioeconomic status.”

Moving forward, the authors stressed the need for better education and awareness of the undertreatment of younger women with AMI. They also suggest that health care providers may benefit from training in adherence management that focuses on assessment and mitigation of the factors that influence adherence. “The reasons for the lower adherence among younger women in our study are unclear,” they wrote. “Similar to treatment initiation, this may be the result of the traditional thinking that cardiovascular disease is a man’s disease, influencing female patients’ perceptions of their risk of a recurrent event or death, especially at a younger age.”

Smolina K, Ball L, Humphries KH, et al. Circ Cardiovasc Qual Outcomes. 2015;doi:10.1161/CIRCOUTCOMES.115.001987.

One More Reason to Eat Fruits and Vegetables!

Eating more fruits and vegetables during young adulthood is associated with lower rates of coronary artery calcium (CAC) later in life, according to a recent study published in Circulation.

For the Coronary Artery Risk Development in Young Adults (CARDIA) Study, 5,115 black and white men and women, aged 18-30 years were recruited from four urban sites across the United States in 1985-1986 and then followed for over 25 years. The current analysis included 2,506 participants after exclusions.

Overall findings showed that women and men who ate more fruits and vegetables were more likely to be older, white, more educated, and less likely to smoke. The median intake for women was 8.9 servings per day in the top quartile and 3.3 servings per day in the bottom quartile. Men had a slightly lower intake with 7.2 servings per day in the upper quartile and 2.6 servings per day in the lower quartile. Individuals with a higher intake of fruits and vegetables also had a healthier diet overall, with a higher intake of fish and a lower intake of refined carbohydrates, salt, and fast food.

The study authors noted that fruit and vegetable consumption was inversely associated with prevalent CAC. Adults who averaged seven to nine servings per day at baseline were approximately 25% less likely to have any CAC at the 20-year follow-up than those who averaged two to four servings per day. This association remained significant after adjustment for BMI, smoking, alcohol, physical activity, income, and education. There was a similar association when examining fruits and vegetable intake separately. Updating fruit and vegetable intake at year 20 did not change these results.

According to the authors, these findings support the importance of a diet emphasizing whole foods as opposed to the use of nutritional supplements such as vitamins.

“Lifestyle decisions do make a difference in the prevention of cardiovascular disease,” said Gerard R. Martin, MD, FACC, Medical Director, Global Services and C.R. Beyda Professor of Cardiology at Children’s National Health System in Washington, D.C., and chair of the ACC’s Population Health Policy and Health Promotion Committee. “This study presents more evidence that meeting the recommended intake of fruits and vegetables can attenuate heart disease. First Lady Michelle Obama has been promoting FNV, a program that attempts to encourage school-aged children to eat more fruits and vegetables. The College looks to promote these activities in its new Population Health and Health Promotion activities and stop cardiovascular disease before it starts.”

Miedema MD, Petrone A, Shikany JM, et al. Circulation. 2015;doi:10.1161/CIRCULATIONAHA.114.012562.

Older Patients See Better Outcomes with Cardiac Rehab

Following acute myocardial infarction (AMI), cardiac rehab was associated with improved medication adherence and lower cardiovascular risk in patients 65 years and older.

The study, published in the American Heart Journal, used data from the NCDR ACTION Registry®-Get With the Guidelines™. A total of 11,862 patients aged ≥ 65 who participated in at least one cardiac rehab session made up the study cohort. The median number of completed sessions was 26.

At 1-year post-AMI approximately two-thirds of patients were still taking evidence-based secondary prevention medications. Patients who completed 26 cardiac rehab or more sessions were significantly more adherent to P2Y12 inhibitors and beta-blockers than those who completed less than 26. This association was linear for up to 36 sessions. The authors wrote that multiple factors would likely lead to this association. Patients who participate in cardiac rehab programs could be more likely to continue other positive behaviors after AMI, but it is also possible that cardiac rehab promoted adherence by providing structure and ongoing education.

Increasing the number of cardiac rehab sessions was also associated with lower mortality and fewer clinical events. Each increase of five sessions was associated with significantly lower risk of 1-year mortality, major adverse cardiac events (MACE), and readmission. Again, this relationship was linear for up to 36 sessions. A similar relationship for MACE and death/all-cause readmissions was observed, but the rate of events did not improve beyond 16 sessions. According to the authors, it is possible that the initial sessions helped patients avoid recurrent ischemic events or admissions after discharge when they were particularly vulnerable. Longer durations of participation may provide additional benefits associated with reduced all-cause mortality risk.

This association between cardiac rehab and lower mortality was seen across different subgroups, including those aged ≥ 75 years, sex, race, MI presentation type, in-hospital revascularization strategy, and predicted mortality risk. However, the association was not experienced by current and recent smokers. Only 33% of patients aged 65 years and older participated in cardiac rehab programs after AMI, even with Medicare coverage and referrals.

Doll JA, Hellkamp A, Thomas L, et al. Am Heart J. 2015;170(5):855-64.

Clinical Topics: Diabetes and Cardiometabolic Disease, Prevention, Diet

Keywords: American Medical Association, Cardiovascular Diseases, Diabetes Mellitus, Lipoatrophic, Diet, Medication Adherence, Myocardial Infarction, Neoplasms, Pulmonary Disease, Chronic Obstructive, Risk Factors, Sodium Chloride, Dietary, Stroke

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