Journal Wrap

Are Women Less Likely to Have CVD Risk Factors Measured?

Women attending primary health care services in Australia were less likely than men to have cardiovascular disease risk factors recorded, according to a study published March 1 in Heart.

Karice K. Hyun, PhD, et al., analyzed baseline data from the TORPEDO study between Sept. 2011 and May 2012. Of 53,085 patients, 58 percent were women. Thirty percent were at high cardiovascular disease risk, which was defined as having any of the following: diabetes and age >60 years, diabetes and albuminuria, chronic kidney disease or extreme individual risk factor elevations.

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Overall, 43 percent of patients had all cardiovascular disease risk factors recorded for absolute risk assessment, with women less likely than men to have the risks recorded (41.4 vs. 45.9 percent, respectively). Women were significantly less likely to have smoking status, systolic blood pressure, total cholesterol, HDL cholesterol and body mass index recorded compared with men. When rates of risk factor assessment were compared within age groups, where there were significant differences between women and men, women were consistently less likely to have their risk measured than men.

In the high cardiovascular disease risk group, women and men were prescribed recommended medications in similar proportions (46.9 vs. 48 percent). Younger women (35-54 years) were 37 percent less likely to be prescribed recommended medications than their male peers. Older women were 34 percent more likely to be prescribed medications than men the same age. The authors note that this suggests the “possible presence of age stereotypes in medical management of cardiovascular disease.”

“Despite guidelines … regarding screening for cardiovascular disease risk factors, inequality in cardiovascular disease prevention through assessing risk factors remains between women and men,” the authors conclude. “This indicates that strategies and incentives are needed at the system level, together with education of physicians and the public about this inequality at the individual and social level, to minimize the treatment gap between women and men.”

In an accompanying editorial, Lauren E. Thompson, MD, and Stacie L. Daugherty, MD, FACC, state that the study “adds to the growing evidence that many of the gender differences seen in cardiovascular disease care are age dependent.” They add that moving forward,“comparing whether gender differences in risk estimation and management seen at enrollment into TORPEDO persisted at the end of the trial will improve our understanding of ways to potentially address gender disparities in care.”

Hyun KK, Redfern J, Patel A, et al. Heart 2017;103:492-8.

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Are Effects of RDN Skewed by Poor BP Medication Adherence?

Catheter-based renal denervation (RDN) may not be superior to usual care in reducing blood pressure (BP) in patients with resistant hypertension, according to a study published March 6 in Hypertension. Further, poor medication adherence may partially explain the condition of apparent resistant hypertension.

Rosa L. de Jager, MD, et al., analyzed data from SYMPATHY, a prospective open-label multicenter trial in Dutch patients with resistant hypertension (defined as an average daytime ambulatory systolic BP measurement ≥135 mm Hg, despite use of ≥3 BP-lowering agents or with documented intolerance for ≥2 BP-lowering agents). To assess the efficacy of RDN in resistant hypertension, patients were randomized in a 2:1 ratio to usual care plus RDN or usual care alone. The primary endpoint was a change in daytime ambulatory systolic BP at six months after RDN. In addition, the effect of adherence to BP-lowering drugs was explored.

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Primary analyses of 139 patients showed a mean difference between RDN and control in changes in daytime ambulatory systolic BP after six months of 2.0 mm Hg in favor of control. In 80 percent of patients, fewer medications were detected than prescribed and adherence changed during follow-up in 31 percent of patients. In those with stable adherence mean difference between RDN and control for daytime systolic ambulatory BP was −3.3 mm Hg in favor of RDN. The authors also found that RDN as therapy for resistant hypertension “was not superior to usual care.”

"Our data suggest that the direction and the magnitude of the treatment effect considerably changes when medication adherence is taken into account." Rosa L. de Jager, MD, et al

“Importantly, our data suggest that the direction and the magnitude of the treatment effect considerably changes when medication adherence is taken into account,” the authors explain.

The study’s results “may have considerable societal impact,” the authors conclude. Because patients are filling prescriptions but not using them, they are “staying at increased cardiovascular risk.” The researchers explain the reasons for resistance to prolonged pharmacological therapy are complex, and moving forward, “there is great need to more extensively focus on interventions that potentially improve medication adherence.”

In an editorial, Hillel Sternlicht, MD, and George L. Bakris, MD, note that “Going forward, just because trials of resistant hypertension use ambulatory systolic blood pressure to exclude white coat hypertension, spectrometric evaluation of urine or blood for antihypertensive metabolites should be used to assess adherence before and during a study and should become routine.”

de Jager RL, de Beus E, Beeftink MM, et al. Hypertension 2017;69:678-84.

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Liraglutide Associated With Lower Risk of Type 2 Diabetes

In overweight or obese patients with prediabetes, three years of continuous treatment with once-daily liraglutide, combined with diet and exercise, was associated with a lower risk of type 2 diabetes and sustained weight loss compared with placebo, according to a study published April 8 in The Lancet.

Carel W. leRoux, MBChB, PhD, et al., randomized 2,254 patients in a 2:1 ratio to receive either once-daily subcutaneous liraglutide (3.0 mg) or a matched placebo, as an adjunct to a reduced calorie diet and increased physical activity, over 160 weeks. Participants were 18 years or older and had prediabetes and a body mass index of at least 30 kg/m2 or at least 27 kg/m2 with comorbidities. All participants received standardized lifestyle intervention counseling approximately once a month throughout the trial.

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Results showed that after 160 weeks, 2 percent of individuals in the liraglutide group were diagnosed with diabetes while on treatment compared with 6 percent in the placebo group. The mean time from randomization to diagnosis in the liraglutide group was approximately 99 weeks vs. 87 weeks in the placebo group. The liraglutide group also showed greater weight loss and improvements in glycemic control and cardiometabolic risk factors than the placebo group.

“Liraglutide 3.0 mg, as a GLP-1 receptor agonist, provides a different treatment option for individuals with obesity or overweight, with or without type 2 diabetes, having direct glucose-dependent effects on insulin secretion and weight-loss mediated effects on improved insulin resistance,” the authors conclude.

In an accompanying comment, Olivia M. Farr, PhD, and Christos S. Mantzoros, MD, PhD, say that although liraglutide showed positive results, it may not be the most cost-effective method of reducing type 2 diabetes. They suggest lifestyle modification, which reduces the risk of developing diabetes as well as hypertension and hyperlipidemia, appears to be equally as effective as liraglutide. “A direct comparison of intensive lifestyle modification and liraglutide would be required to determine this, and possibly, specifically designed comparative studies would be advisable to assess the effects of one, the other, or a combination of the two to advance the field,” they explain.

le Roux CW, Astrup A, Fujioka K, et al. Lancet 2017;389:1399-1409.

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WHO Tobacco Demand-Reduction Measures Effective in Reducing Smoking Worldwide

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Deployment of targeted smoking demand-reduction measures may be significantly associated with decreases in smoking prevalence worldwide, according to a study published March 21 in The Lancet Public Health.

Since 2003, the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) has led a coordinated effort to decrease global tobacco use by recommending several demand-reduction measures.

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Shannon Gravely, PhD, et al., analyzed WHO data from 126 countries to examine the association between the demand-reduction measures implemented between 2007 and 2014 and smoking prevalence estimates between 2005 and 2015. The demand-reduction measures were taxation, smoke-free policies, warning labels, bans on tobacco advertising, promotion and sponsorship and smoking cessation programs.

Results showed that overall, there was a significant increase in the proportion of countries that implemented each key measure between 2007 and 2014. The mean smoking prevalence for all 126 countries was 24.73 percent in 2005 and 22.18 percent in 2015, an average decrease in prevalence of 2.55 percent. Unadjusted linear regression showed that increases in implementations of key measures between 2007 and 2014 were “significantly associated with a decrease in smoking prevalence between 2005 and 2015.” Further, each additional measure implemented was associated with an average decrease in smoking prevalence of 1.57 percent and an average relative decrease of 7.09 percent.

“[Our study] highlights the importance of tobacco control in two global initiatives that have set goals of markedly reducing non-communicable diseases through reducing tobacco use: WHO’s Global Action Plan, and the UN’s Sustainable Development Goals, which calls on countries to ‘strengthen the implementation of the [WHO FCTC] in all countries, as appropriate,’” the authors conclude.

In an accompanying editorial, Kenneth E. Warner, PhD, notes that the study affirms the validity of the demand-reduction measures, and commends the authors for reinforcing that “tobacco control policy matters.” “Let us hope that this study increases adoption of all of the core evidence-based demand-reduction policy interventions, especially including raising taxes, the highly effective intervention that has lagged in terms of adoption,” he adds.

Gravely S, Giovino GA, Craig L, et al. Lancet Public Health 2017;2:e166-e174.

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Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Lipid Metabolism, Nonstatins, Hypertension, Smoking

Keywords: ACC Publications, Cardiology Magazine, Antihypertensive Agents, Blood Pressure, Body Mass Index, Cardiovascular Diseases, Cholesterol, HDL, Comorbidity, Denervation, Diabetes Mellitus, Type 2, Diabetes Mellitus, Type 2, Follow-Up Studies, Glucose, Hyperlipidemias, Hypertension, Insulin Resistance, Insulins, Life Style, Medication Adherence, Obesity, Prediabetic State, Prevalence, Primary Health Care, Renal Insufficiency, Chronic, Risk Assessment, Risk Factors, Smoking, Smoking Cessation, Socioeconomic Factors

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