Better Long-Term Outcomes with Medications versus Angioplasty

There are some advantages to artery-opening angioplasty over medication treatment for people with heart disease, but those advantages disappear within three years, according to a report in the New England Journal of Medicine.

Angioplasty does offer a higher quality of life for months to a couple of years, says study leader Dr. William S. Weintraub, chief of cardiology at the Christiana Health Care System in Newark, Delaware.

In the COURAGE trial, the researchers tested angioplasty, with stent implants, against medication treatment for 2,287 people with stable coronary disease.

Earlier analysis found improved quality of life for those having the artery-opening procedure that is formally called percutaneous coronary intervention (PCI).

The new report found that by 36 months, there was no significant difference in health status between the two treatment groups.

"What one can say is that for people with chronic, stable coronary disease, PCI can be deferred," Dr. Weintraub says. "They can continue on medication aimed at their specific risk factors - hypertension, lipid disorders, diabetes - and should be encouraged to have a good lifestyle, with exercise, smoking cessation, and weight control."

Doctors Assess Needs

A decision to have PCI can depend on how an individual feels, says Dr. Weintraub.

"If people say, 'My pain is so bad I can't function,' that is one thing. If people say, 'I have angina, but I'm doing OK,' that's another," he says.

Angina is the chest pain that is a chief symptom of coronary disease.

Cost could be a factor in some decisions, notes Dr. Weintraub. PCI is more expensive than medication therapy, but the current report does not mention money.

However, a preliminary cost-benefit analysis presented by Dr. Weintraub last November found that "PCI adds about $10,000, without any significant gain in years of survival or quality of life."

The cost of one year of life added by PCI varies from $150,000 to $300,000, the analysis found.

The cost of PCI versus medication treatment must be considered "by society as a whole," he says. "But when a doctor talks to a patient, the doctor is an advocate for that patient."

An individual's health insurance status can matter, Dr. Weintraub acknowledges.

"Paying the cost out of pocket gives one a different point of view," he says.

The attitude of medical insurance providers does matter, says Dr. Eric D. Peterson, at the Duke Clinical Research Institute. Insurance companies now are quite willing to pay for PCI, and "until that category is changed, the effect of this study will be modest," he says.

Medical Therapy for Stable Heart Disease

The COURAGE results show that PCI should not be the treatment of choice for people with stable heart disease, says Dr. Peterson.

"We have justified angioplasty for years by saying it is of great benefit to patients," he says. "This study shows no survival benefit and shows that the benefit in regard to symptom relief is temporary. Medical therapy should be considered for all patients with stable angina, unless they have severe pain when diagnosed."

The fact that 21 percent of those in the COURAGE trial who started on medication treatment eventually had PCI shows that a decision on surgery can safely be delayed, he says.

The hazards as well as the benefits of PCI should be considered when a decision is made, notes Dr. Peterson.

Of 1,000 persons undergoing PCI, two will die, 28 will have heart attacks related to the procedure, 60 to 90 will have improved symptom relief, and 800 will have no noticeable benefit above that given by drug treatment, his editorial explains.

Always consult your physician for more information.

Heart Failure Hospital Admissions Continue to Rise

The number of Americans admitted to hospitals for heart failure has jumped in recent years, and the trend almost certainly will continue, says a report in the Journal of the American College of Cardiology.

“Our study covers more than two decades, from 1979 to 2004, and the number of hospitalizations almost tripled during that time,” says Dr. Jing Fang, an epidemiologist with Centers for Disease Control and Prevention (CDC).

A major reason for the increase is the aging of the American population, says Dr. Fang. Heart failure, in which the heart progressively loses its ability to pump blood, is more common among older people.

“Another reason is the improvement in technology for treatment of patients with other heart diseases, such as acute myocardial infarction [heart attack],” adds Dr. Fang. “So, people with diseases of the heart live longer.”

Therapy Limited for a Declining Heart

The National Heart Discharge Survey shows that the number of admissions to hospitals with any mention of heart failure rose from over one million in 1979 to nearly four million in 2004, the report says.

More than 80 percent of those admitted to hospitals were 65 or older, with Medicare or Medicaid covering the cost.

The report did not cover the cost of the hospitalizations, but the American Heart Association has estimated it to be more than $20 billion annually, says Dr. Fang.

There has been a marked increase in the number of hospitalizations for which heart failure was not the primary cause.

Heart failure was listed as the primary cause in no more than 35 percent of cases, with respiratory diseases and other conditions given as the reason for hospital admission in all other cases.

“Most are due to pneumonia or another disease that makes heart failure worse,” says Dr. Fang.
Better control of those other conditions, which include diabetes and kidney disease, could reduce hospitalizations for heart failure.

But those people tend to keep coming back to the hospital because “you cannot cure people with heart failure,” explains Dr. Fang. “The best medicine [we] can do is to keep the heart functioning enough for the patient to have good quality of life.”

Hospital-Based Care Could Improve

A basic problem is that there is no effective treatment for heart failure severe enough to cause hospitalization, says Dr. Javed Butler, director of the heart failure research program at Emory University in Atlanta, and co-author of an accompanying editorial.

“When you are talking about medications that have been proven, they all are for chronic, stable outpatients,” explains Dr. Butler. “We don’t have any proven medications for treatment in the hospital.”

What is needed is a major effort to develop in-hospital treatments for severe heart failure, he says.

“When you consider the huge cost, it is right up high on the list of conditions we need to study,” says Dr. Butler. “It is a least-studied, most costly problem. We need to get a better grasp on what we should be doing.”

Always consult your physician for more information.

Online Resources

(Our Organization is not responsible for the content of Internet sites.)
American Heart Association
Centers for Disease Control and Prevention (CDC)
Heart Failure Online
Heart Failure Society of America
Journal of the American College of Cardiology - Heart Failure-Related Hospitalization in the U.S., 1979 to 2004
National Heart, Lung, and Blood Institute (NHLBI)
NIH - Heart Failure

"Silent Strokes" Different than TIAs, Experts Say

If you are an older American with no major health problems, chances are about one in 10 that you have had a stroke and did not know it, according to a report in the medical journal Stroke.

It was probably not severe enough to cause recognizable symptoms, such as vision problems, facial weakness, or trouble walking, but it was still a blockage of a brain artery, and it reduced your thinking powers just a bit.

That estimate comes from a new study of 2,040 people, average age 62, in the long-running Framingham Offspring Study.

Magnetic resonance imaging (MRI) scans showed that 10.7 percent of them had experienced what study author Dr. Sudha Seshadri, at Boston University, calls "a silent brain infarct."
It is the cerebral equivalent of what physicians call a myocardial infarct - blockage of a blood vessel that causes damage to heart tissue. In the case of a silent stroke, the blockage and the damage occurs in the brain, without symptoms.

TIA Has Symptoms, Silent Stroke May Not

A silent stroke is different from a transient ischemic attack (TIA), a momentary loss of brain function, says Dr. Seshadri. A TIA causes some symptoms, while a silent stroke, by definition, does not.

But both are warning signs to pay attention to the well-known risk factors for stroke, such as cholesterol levels, blood pressure, obesity, and smoking.

The incidence found in the Framingham Offspring study "was within the ballpark of what prior studies have suggested," notes Dr. Seshadri.

"But this was a group of people who were younger than in most of the prior studies," she says. "The fact that one in 10 persons had silent attacks that had subtle side effects on the brain is something we should be concerned about and should address."

The effects of a silent brain infarct show up on an MRI scan as "small lesions in various parts of the brain," says Dr. Seshadri. "We can't tell from that whether they had a symptomatic attack."
And the MRI scans give no clues as to when the silent stroke occurred.

Testing showed that "on average, compared to age-matched controls, those with lesions do have subtle signs, such as loss of flexibility of talk," she says.

Address Risks Through Lifestyle Changes

The incidence seen in the study did not startle Dr. Claudette Brooks, at West Virginia University Health Sciences Center.

"When I look for the cause of headaches and similar problems, it doesn't surprise me when I see these lesions, and other colleagues tell me they see them," says Dr. Brooks.
An even higher rate of silent strokes might be expected in a study of African Americans, she notes.

"They have a higher incidence of hypertension [high blood pressure], atherosclerosis, and hyperlipidemia [excess blood fat]," says Dr. Brooks.

Nothing special needs to be done to reduce the risk of silent stroke, both physicians say.
"I wouldn't recommend that people rush out to have an MRI," says Dr. Seshadri. "It's up to the medical and public health community to emphasize the importance of controlling risk factors."
"The whole thing boils down to modifying risk factors," explains Dr. Brooks. "If you don't have risk factors such as high cholesterol, obesity, and diabetes, try to keep yourself out of the group that does. If you do, modify them by keeping blood pressure and cholesterol down, things like that."

Always consult your physician for more information.

Online Resources

(Our Organization is not responsible for the content of Internet sites.)
American Heart Association
American Stroke Association
National Heart, Lung, and Blood Institute (NHLBI)
National Institute of Neurological Disorders and Stroke
National Stroke Association
Stroke - Prevalence and Correlates of Silent Cerebral Infarcts in the Framingham Offspring Study

Some Fats Actually May Help the Heart

Fewer than half of Americans realize there are two types of dietary fat that actually help their hearts, a new survey shows.

So, while many have heeded the warnings about the cardiovascular dangers of trans fats and saturated fats, the American Heart Association (AHA) now thinks people need to pay more attention to the cardiovascular benefits conferred by polyunsaturated and monounsaturated fats.

As a result of its recent survey, the AHA’s new Face the Fats campaign has harnessed the power of the Internet to encourage people to view these lesser known fats with new respect.

“We’re trying to take education to the next level and say when you have the opportunity to choose, choose the better fat, not the bad fat,” says Dr. Clyde W. Yancy, medical director of the Baylor Heart and Vascular Institute in Dallas and the incoming president of the AHA.

HDL Continues to “Sweep” the Bad Away
The campaign’s Web page presents information at varying levels of sophistication.

The pages include an interactive quiz on fats, menus, recipes, and a Fats 101 course. A Fats Translator calculates a body-mass index from the input of height, weight, age, and level of activity.

The index is a scale ranging from underweight to obesity.

The AHA decided to go digital in this phase of its campaign because “the Web really is becoming the world’s premier information source, so we have to be there,” adds Dr. Yancy.

“When we have lots of polyunsaturated and monounsaturated fats in our diet, our HDL cholesterol goes up and helps protect our arteries from clogging up and hardening,” explains Lona Sandon at the University of Texas Southwestern Medical Center in Dallas.

“HDL kind of acts like a broom and sweeps up the artery-damaging molecules and takes them away,” she says.

Trans fats and saturated fats are more able to stick to blood vessel walls and harden arteries, adds Dr. Yancy.

This process can lead to the rupture of an artery or obstructed blood vessels that can cause heart attacks, strokes, or blood vessel disease.

Moderation on all Fats Advised
Sandon supports the idea of greater education on the different forms of dietary fat.

“I think it’s still very confusing for people,” she says. “They don’t know if they should be eating low fat, what kind of fat.”

She also advises moderation in consumption of any kind of fat. All fats have nine calories per gram, she explained, so even too much of the better fats can lead to weight gain. “They’re healthy, but you can’t go wild with them,” she says.

The Face the Fats campaign is funded by $7 million received from McDonalds USA as part of the settlement of a California class action lawsuit brought by a consumer advocacy group, bantransfat.com, according to the AHA.

McDonald’s recently announced that it has eliminated trans fats from its fried foods by changing to a canola-based cooking oil.

Always consult your physician for more information.

Heart Disease in Men Linked to Teen Years

Normal developmental changes during the teenage years leave young adult men at higher risk of heart disease than their female counterparts, researchers report in the journal Circulation.

“Women’s protective advantage against heart disease starts young,” says lead author Dr. Antoinette Moran, at the University of Minnesota Children’s Hospital.

In adults, a set of factors increases the risk of heart disease.

These factors include high blood pressure, smoking, obesity, physical inactivity, abnormal cholesterol levels, and insulin resistance (a pre-diabetic condition in which the body cannot use insulin effectively).

Good Cholesterol Decreased in Males

To track the risk factors, researchers followed 507 Minneapolis school children from ages 11 to 19, when they had all reached sexual maturity. Fifty-seven percent of the children were male, 80 percent were Caucasian, and 20 percent were African American.

During the study, the researchers made 996 observations on the group, noting blood pressure, insulin sensitivity (opposite to insulin resistance), body mass index (BMI) and other body composition measures, blood glucose, and cholesterol measurements.

“We wanted to see which risks emerge first and how they relate to one another in normal, healthy school kids without diabetes or other major illnesses,” says Dr. Moran.

At age 11, boys and girls were similar in their body composition, lipid levels, and blood pressure, the researchers say.

Boys and girls became heavier during adolescence, increasing in body mass index and waist size. As expected during puberty, changes in body composition differed sharply between genders, with percentage of body fat decreasing in boys and increasing in girls.

During the study, changes in several cardiovascular risk factors or risk markers differed significantly between boys and girls:

• Triglycerides (a type of fat in the blood) increased in males and decreased in females.


• High-density lipoprotein (HDL or “good”) cholesterol decreased in males and increased in females.


• Systolic blood pressure (the first number in the blood pressure reading, measuring the pressure when the heart contracts) increased in both, but significantly more in the males.


• Insulin resistance, which had been lower in the boys at age 11, steadily increased until the young men at age 19 were more insulin resistant than the women.

Researchers found no gender difference in two other cardiovascular risk factors, total cholesterol, and low-density lipoprotein (LDL or “bad”) cholesterol.

“By age 19, the boys were at greater cardiovascular risk,” notes Dr. Moran. “This is particularly surprising because we usually think of body fat as associated with cardiovascular risk, and the increasing risk in boys happened at the time in normal development when they were gaining muscle mass and losing fat.”

Although girls gained cardiovascular protection when their proportion of body fat was increasing, excess fat is still a cause for concern.

“Obesity trumps all of the other factors and erases any gender-protective effect,” says Dr. Moran. “Obese boys and girls and men and women all have higher cardiovascular risk.”

Women's Hormones May Offer Protection

The researchers say further studies are needed to better understand the development of cardiovascular protection during adolescence.

“That the protection associated with female gender starts young is fascinating and something that we don’t understand very well,” explains Dr. Moran.

“That this protection emerges during puberty and disappears after menopause suggests that sex hormones give women a protective advantage,” he says.

“There’s still a lot that needs to be sorted out in future studies - estrogen may be protective or testosterone may be harmful,” says Dr. Moran.

Dr. Moran says that this is normal physiology and not something that is influenced by lifestyle factors.

Always consult your physician for more information.

Heart Failure a Concern for Non-Cardiac Surgeries

Older persons with heart failure face heightened odds of complications and death after non-cardiac surgeries, according to a study reported in the medical journal Anesthesiology.

"We're trying to draw attention to this major problem," says lead researcher Dr. Adrian F. Hernandez, at Duke University.

Heart failure, the progressive loss of the heart's ability to pump blood, is widespread among older Americans, but it sometimes is overlooked as a risk factor when surgery is needed, he says.

"Most physicians focus on whether [older patients] have coronary artery disease or have a risk of heart attack," says Dr. Hernandez. "Heart failure is by far a more important risk factor, but it doesn't usually have greater weight when they want to identify patients at risk of complications or consider how they want to treat them after surgery."

Symptoms of heart failure include shortness of breath, fatigue, and swelling of the legs.

Condition Has Impact on Surgery Success
Dr. Hernandez used Medicare data on more than 159,000 people undergoing major surgery not involving the heart, such as hip replacement operations. The study was the largest one ever conducted on this issue.

Past estimates have put the incidence of heart failure in the older population between 5 percent and 12 percent, but the new study found the condition in almost 20 percent of those having surgery.

The study divided the participants into three groups: those with heart failure, with or without coronary artery disease; those with only coronary artery disease; and those with neither condition.

Nearly 98 percent of all those who had surgery were discharged soon afterward from the hospital.

But 17.1 percent of those with heart failure had to be re-hospitalized within 30 days, compared to 10.8 percent of those with coronary artery disease and just 8.1 percent of those with neither ailment.

In the month after having surgery, 1.6 percent of those with heart failure died, compared to 0.5 percent for those with coronary artery disease and 0.3 percent of those with neither condition.

Steps can be taken to reduce the toll, notes Dr. Hernandez.

"The first thing is to check on what the conditions are that might influence the patients' outcomes," he says. "We have to identify therapies that lower the risk of a poor outcome and assure that all patients, when they have surgery, are carefully monitored."

Close attention should be paid to be sure that symptoms of heart failure are kept to a minimum, adds Dr. Hernandez. Medications such as beta blockers and diuretics can be used to keep heart failure under control.

But he notes that it is not certain how effective such measures might be in reducing risks - only a rigorous, controlled study could answer that question definitively.

Steps Can Be Taken to Reduce Risks
Dr. Robert Hobbs, a cardiologist at the Cleveland Clinic, says the increase in surgery risk due to heart failure has been noted before, but "this is a big study that involves a lot of people. It solidifies that the risk is real, and the risk is substantial."

Measures that can be taken to reduce the risk include simply not performing surgery, if possible, on someone whose life might be endangered, says Dr. Hobbs.

"If surgery is necessary for someone with heart failure, there should be targeted use of heart failure medications before the operation and an effort to avoid overloading the body with intravenous fluid during the procedure," he says.

"And we would certainly watch them more carefully in the postoperative period," adds Dr. Hobbs.

Always consult your physician for more information.

Triglycerides Linked to Risk for Heart Disease

High levels of triglycerides are strong predictors of cardiac trouble and this strengthens the case for including measurement of the blood fats in prevention programs, says a study in the Journal of the American College of Cardiology.

"Triglycerides traditionally have been viewed as second-class citizens," says lead author Dr. Michael Miller, at the University of Maryland Medical Center.

"LDL cholesterol has always taken center stage," says Dr. Miller. "We know that LDL is intimately involved in bringing cholesterol to scavenger cells, which deposit them to form plaques in the arteries.

"This study shows that triglycerides in and of themselves are also lipids to blame," notes Dr. Miller.
Under 150 on Triglycerides is Best

The original study was designed to test the effectiveness of two LDL-lowering statins called Pravachol® and Lipitor® in reducing recurring coronary disease after a heart attack.

The new study went over the data on the 4,162 participants in the trial, looking at the association between triglyceride levels and the incidence of heart problems and death.

"The patients who had heart attacks came back after 30 days," says Dr. Miller. "We measured LDL levels and triglyceride levels and followed them over the next two years, evaluating for the occurrence of new events and death. If a patient had triglyceride levels below 150 [milligrams per deciliter], there was a 27 percent lower risk of having a new event over time," he says.

"After multiple adjustments for such things as age, diabetes, high blood pressure, and obesity, the risk reduction was 20 percent," Dr. Miller explains.

Unlike LDL cholesterol, for which there is a recommended blood level of 70 or below, there is no recommended blood triglyceride level but 150 milligrams per deciliter or below is "considered as desirable," says Dr. Miller.

When the participants were divided into four groups on the basis of both LDL and triglyceride levels, those in the group with under 150 for triglycerides and under 70 for LDL did the best.

They had a 28 percent lower risk than those in the group with the highest readings for both LDL and triglycerides, he says.

"At the present time, we don't have a recommendation for triglyceride lowering, so the next logical step is a study to determine whether lowering triglycerides and LDL reduces risk more than lowering LDL alone," he says. Two such studies are in progress, he notes.
Mediterranean Diet a Good Approach

Previous research has already pointed toward such a connection: A study that appeared in the medical journal Neurology last December found a link between triglycerides and stroke risk.

And research published in the Journal of the American Medical Association (JAMA) last July showed that when high triglyceride levels showed up in nonfasting cholesterol tests, there was an increased risk for a future heart attack.

Dr. Leslie Cho of the Women's Cardiovascular Center at the Cleveland Clinic, notes that the new report "is not a huge surprise."

She says, "The unique thing about this study is that even if you control bad LDL cholesterol to less than 70, you still need to look at triglycerides."

The problem with triglycerides is that "they are the most unstable fats in the body," so that at least two readings are needed to get an accurate measure of blood levels, she explains.

Dr. Miller says, "I am proactive about both LDL cholesterol and triglycerides."

Several measures can be taken to lower triglyceride levels - many of them are already recommended on general principles for reduction of coronary risk.

One is to eat a Mediterranean diet, rich in fish. Omega-3 fatty acids can lower triglyceride levels, as can niacin, and exercise has a beneficial effect, says Dr. Miller. Statins also have some triglyceride-lowering effect, he notes.

"If you can effectively get both LDL cholesterol and triglycerides down, you are going to do better," says Dr. Miller.

Always consult your physician for more information.