31-08-2013 t/m 4-09-2013 ESC Congres 2013 Amsterdam (NH)

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Amsterdam, The Netherlands – Sunday 1 September 2013: Cardiovascular risk factors are highest in winter and lowest in summer, according to research presented at the ESC Congress today by Dr Pedro Marques-Vidal from Switzerland. The analysis included more than 100,000 subjects in 7 countries.

Dr Marques-Vidal said: “Deaths from cardiovascular disease are higher in winter and lower in summer. We decided to conduct a large scale study to see whether cardiovascular risk factors have a seasonal pattern which could explain the seasonality in deaths.”

The study used cross-sectional data from 10 population based studies in 7 countries. Information was obtained on cardiovascular risk factors in 107,090 subjects aged 35 to 80 years. The country breakdown was as follows: 21,128 subjects in Belgium, 15,664 in Denmark, 1,626 in France, 18,370 in Italy, 25,532 in Norway, 9,359 in Russia and 15,411 in Switzerland.

Levels of blood pressure, lipids, glucose, body mass index (BMI, kg/m2) and waist circumference were compared according to season. All data were adjusted for age, gender and smoking. Data on blood pressure, lipids and glucose were adjusted for BMI and whether or not the patient was taking medication.

The researchers found that levels of several cardiovascular risk factors (such as blood pressure, waist circumference and total cholesterol) were higher in winter (January to February) and lower in summer (June to August) compared to the annual average.

Systolic blood pressure levels were on average 3.5 mmHg lower in summer than in winter (see figure).

Dr Marques-Vidal said: “Although this difference is almost irrelevant for an individual, it is considerable for a whole population because the whole blood pressure distribution is shifted to higher values, increasing cardiovascular risk. Indeed, the impact of season on blood pressure levels might have as great an impact on cardiovascular risk as genetic markers for blood pressure. This is because the joint effect of genetic markers on blood pressure is modest, between 2 and 3 mmHg.”

He added: “We are currently conducting a study involving 50 million deaths in 18 countries to discover whether seasonality of risk factors affects the risk of dying from myocardial infarction or stroke.”

Waist circumference was on average 1 cm smaller in summer than in winter, while total cholesterol was on average 0.24 mmol/L lower in summer than in winter. Dr Marques-Vidal said: “We observed a seasonal variation in waist circumference but BMI did not change throughout the year. We have no clear explanation for this finding. Total cholesterol may increase during the winter because of changes in eating habits. There was no seasonal variation in glucose, probably because several cohorts did not collect blood samples in the fasting state. We have begun a study on seasonality of food intake which may help explain these findings.”

He added: “Our large scale study shows that some cardiovascular risk factors take holidays over the summer. This may explain why deaths from cardiovascular disease are higher in winter than summer. People need to make an extra effort to exercise and eat healthily in the winter to protect their health.”

He concluded: “Our team is currently conducting another study to find out if the seasonal pattern in cardiovascular risk factors reverses in the southern hemisphere, where seasons are inverted relative to the northern hemisphere. Based on preliminary data, it does seem to be the case. The overall study is expected to collect information on almost 200,000 subjects from over 12 countries.”

Systolic blood pressure levels in :

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http://www.medpagetoday.com/ESC2013VideoOnTheScene/MeetingCoverage/ESC-Videos/239

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http://www.medpagetoday.com/ESC2013VideoOnTheScene/MeetingCoverage/ESC-Videos/239

De Amerikaanse Hartstichting zorgt via Twitter voor ESC congres updates voor een breder publiek. https://twitter.com/HeartNews

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Amsterdam, The Netherlands – Sunday 1 September 2013: Quitting smoking reduces the risk of heart attack and death to the levels of people who have never smoked, reveals research presented at ESC Congress 2013 by Dr James K. Min and Dr Rine Nakanishi from the USA.

Dr Min said: “Smoking is an established risk factor for cardiovascular disease. Studies have identified that quitting smoking can reduce heart attacks and death but have not examined the relationship of this salutary effect on the presence and severity of coronary artery disease (CAD). Our study aimed to find out what impact stopping smoking had on the risk of cardiovascular events, death and the severity of CAD.”

The prospective CONFIRM (Coronary CT Evaluation for Clinical Outcomes: An International Multicenter Study) registry of 13,372 patients from 9 countries in Europe, North America and East Asia examined the risk of major adverse cardiac events in 2,853 active smokers, 3,175 past smokers and 7,344 never smokers.

Both active smokers and past smokers had a higher prevalence of severely blocked coronary arteries compared to non-smokers. This was determined using coronary computed tomographic angiography (CCTA), a non-invasive imaging technique that enables direct visualisation of the coronary arteries. Active and past smokers had a 1.5-fold higher probability of severe stenoses in 1 and 2 major heart arteries, and a 2-fold increased probability of severe stenoses in all 3 major heart arteries.

Dr Min, who is director of the Institute of Cardiovascular Imaging at the New York-Presbyterian Hospital and the Weill Cornell Medical College, said: “Our results show that quitting smoking does not reduce the amount of disease smoking causes in the coronary arteries, but it does reduce the risk of heart attack and death to the levels of non-smokers.”

After 2.0 years of follow-up, 2.1% of the study patients experienced heart attacks or death. Rates of heart attack or death were almost 2-fold higher in active smokers compared to never smokers. Past smokers had the same rates or heart attack or death as never smokers, despite having a higher prevalence, extent and severity of CAD (see figure). The findings in both active and past smokers persisted even when they were matched with non smokers who were similar in age, gender and CAD risk factors.

Dr Min said: “Our study was the first to demonstrate that the presence and severity of coronary blockages do not go away with quitting smoking, but that the risk of heart attack and death does.  Future studies are being pursued to determine how this protective effect may occur.”

He continued: “Numerous questions remain and require further study.  For example, will the severe blockages observed in patients who have quit smoking provoke adverse events after 2 years (the duration of the present study).  Further, does the duration of smoking or the number of cigarettes smoked per day affect the severity of CAD or the prognosis related to quitting smoking.  Our team and several others are pursuing such investigations.”

Dr Min concluded: “It’s never too late to quit smoking. This study clearly shows that stopping smoking lowers the risk of heart attacks and death to the level of never smokers.”

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Amsterdam, The Netherlands – Sunday 1 September 2013: Survival for out-of-hospital cardiac arrest is just 7%, according to research presented at ESC Congress 2013 by Professor Xavier Jouven and Dr Wulfran Bougouin from France.

Professor Jouven said: “Sudden cardiac death (SCD) is an important public health problem, accounting for more than 400,000 deaths every year. The main cause is ventricular tachyarrhythmias which are often triggered by acute ischaemic events that can occur in persons with or without known heart disease. The survival rate from cardiac arrest has remained low over the last 40 years despite major investment and the epidemiology of SCD in Western Europe is unclear.”

The Paris Sudden Death Expertise Centre (SDEC) Registry is a population based registry using multiple sources to collect every case of cardiac arrest in Greater Paris (population 6.6 million) according to the Utstein Style.1 Cases are continuously recorded (within hours of occurrence) and standardised follow-up is initiated on admission to the intensive care unit. Incidence, prognostic factors and outcomes are recorded.

The results reported today reveal the 2 year experience of the SDEC Registry. From May 2011 to December 2012, 3,670 sudden cardiac arrests, with resuscitation attempted, occurred. Most cases occurred at home (72%) with bystanders in 81% of cases, performing cardiopulmonary resuscitation (CPR) in only 42% of cases. Among those cases only 34% of patients were admitted alive at hospital and 7% were discharged alive.

Professor Jouven said: “The majority of sudden cardiac deaths occur outside hospital so specific programmes are needed in the community. Friends and relatives of people at risk of SCD should learn CPR and attend regular training to keep their skills up-to-date.”

Therapeutic hypothermia and early coronary reperfusion were both significantly associated with survival (p<0.001) but these procedures were used in just 58% of patients admitted to hospital. Professor Jouven said: “These interventions markedly improve survival yet are given to just over half of patients. Most patients should receive both.”

Prognostic factors were initial shockable rhythm (odds ratio [OR]=15.7, 95% confidence interval [CI]=9.0-27.3), age ( OR=0.96, 95%CI=0.95-0.98 ), occurrence at home ( OR=0.5, 95%CI=0.3-0.8 ) and epinephrine (adrenaline) dose >3mg (OR=0.07, 95%CI=0.04-0.1).

Professor Jouven said: “Having a cardiac arrest at home decreases the change of survival by half. People whose initial heart rhythm is shockable have a nearly 16 times greater chance of survival than those with an initial non-shockable rhythm because they can receive immediate defibrillation.”

He added: “The incidence of sudden cardiac arrest was lower than levels reported in previous studies, possibly because of the adjudication process considering only typical phenotype of sudden cardiac death (with also a high specificity), although local specificities of population characteristics could also be involved. As expected, prognosis was poor with just 7% of patients surviving out-of-hospital cardiac arrest.”

Professor Jouven concluded: “Sudden cardiac death is a multidisciplinary field which includes cardiology, emergency medicine, intensive care units, psychology, ethics, public health and medico-economics. At the SDEC all of these competencies are working together to understand and prevent sudden cardiac death. Improving outcomes requires addressing the entire picture of sudden death through population education on basic life support, optimising care, prevention and screening of first degree relatives.”

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Amsterdam, The Netherlands – Sunday 1 September 2013:
The risk of aortic stenosis doubles when a first degree relative had the disease, according to research presented at ESC Congress 2013 today by Dr Mattis F. Ranthe from Denmark. The study of 4.2 million people from Danish registers also found that aortic stenosis risk increased by 8-fold in patients with ischaemic heart disease and family history.

Aortic stenosis is the most common heart valve disease in the elderly. It is associated with congenital bicuspid aortic valve and previous rheumatic heart disease, but is also often caused by calcification of a normal valve. Calcification of a normal valve may be associated with atherosclerotic changes in the portion of the aorta closest to the valve.

Dr Ranthe said: “Genetic factors may play a role in the development of aortic stenosis. A single nucleotide polymorphism in the lipoprotein(a) locus has been associated with aortic valve calcification and aortic stenosis.1 Elevated lipoprotein(a) is a risk factor for atherosclerosis, including ischaemic heart disease, which is known to aggregate in families. Our aim was to discover whether aortic stenosis also aggregates in families.”

The study used information from national Danish registers and included the 4.2 million Danes born in or after 1920. The cohort was followed for more than 73 million person-years, starting in 1977 (the year the Danish Hospital Discharge Register began) and ending in 2012. Cases of aortic stenosis were recorded when they occurred at age 35 years or older.

Patients with any registration of a congenital heart defect and those with cardiovascular disease diagnosed at <35 years were excluded. Family history was defined as a first degree relative registered with aortic stenosis before the cohort member.

During the study period 29,983 patients were registered with aortic stenosis at age >35 years. Of those, 193 had a first degree relative with aortic stenosis and the relative risk was 2.04 (95% confidence interval [CI] 1.77-2.35).

Dr Ranthe said: “The risk of aortic stenosis roughly doubled when patients had a first degree relative with the disease. In addition, aortic stenosis occurred earlier in life in patients with a family history of the condition.”

The impact of family history differed between patients with and without ischaemic heart disease. Family history increased the risk of aortic stenosis by 2-fold in patients without ischaemic heart disease. The risk of aortic stenosis was increased by 8-fold in patients with ischaemic heart disease and a family history of aortic stenosis compared to those with no family history and no ischaemic heart disease.

Dr Ranthe said: “Family history confers a 2-fold increased risk in all patients. Ischaemic heart disease alone is also a strong risk factor for aortic stenosis, increasing the risk of aortic stenosis by 4-fold in patients with no family history. This 4-fold risk increase is doubled, i.e. to 8-fold, in those with both ischaemic heart disease and family history.”

The researchers conducted a robustness analysis with aortic valve replacement as an endpoint and found similar results. In a similar cohort they identified 130 patients with a family history of aortic stenosis out of 12,690 patients undergoing the procedure. The relative risk by family history was 2.18 (95% CI 1.79-2.65).

Dr Ranthe concluded: “We found significant and robust associations indicating that aortic stenosis clusters in families. Although epidemiologic studies cannot directly infer causality, our results suggest the existence of a familial component to the disease. Our results suggest that patients with ischaemic heart disease and a family history of aortic stenosis have a high relative risk of aortic stenosis.”

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Dr. Kim Williams comments on a national study in Taiwan, which showed high-dose, high-potency statins reduced the risk of new-onset dementia in elderly patients. Dr. Williams is chief of cardiology at Wayne State University, Detroit, Michigan, and vice president of the American College of Cardiology.

Commentary: Statins reduced risk of dementia

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In patients with acute ST-segment elevation myocardial infarction, stenting of significant coronary stenoses not responsible for the infarction as well as the infarct-producing lesion led to substantially better outcomes than an intervention that targeted only the infarct-related stenosis in a randomized, multicenter trial with 465 patients.

Dr. Spencer B. King III comments on the study during the European Society of Cardiology's Congress in Amsterdam.

Commentary: The PRAMI trial

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Amsterdam, The Netherlands – Sunday 1 September 2013 : Having a big belly increases the risk of death in heart attack survivors, according to research presented at ESC Congress 2013 by Professor Tabassome Simon and Professor Nicolas Danchin from France. The findings from the FAST-MI 2005 registry suggest that lifestyle interventions in heart attack patients should focus on losing abdominal fat.

Professor Simon said: “The impact of obesity on long term mortality and cardiovascular complications in the general population has been the object of recent debate. Much emphasis has also been given to the deleterious role of abdominal obesity.”

She added: “At the time of a heart attack, early mortality tends to be lower in obese patients, a phenomenon well known in critical care situations and described as the ‘obesity paradox’. Little is known, however, about the potential impact of obesity and abdominal obesity on long-term outcomes in patients who have survived the acute stage of a heart attack.”

The current study sought to determine the associations between body mass index (BMI, kg/m2) and waist circumference with 5-year mortality in patients of the FAST-MI 2005 registry who had left the hospital alive.

FAST-MI 2005 is a French nationwide survey which included 3,670 patients from 223 institutions who were admitted for acute myocardial infarction to an intensive care unit at the end of 2005. Long-term follow-up was achieved in 99.6% at one year, 98% at 3 years, and 95% at 5 years. Of the 3,463 patients who were discharged alive, BMI was recorded in 3,102 and waist circumference in 1,647 patients. Statistical techniques were used to take into account the differences in baseline characteristics between the different BMI groups.

At 5 years, absolute mortality was highest in the leanest patients (BMI <22 kg/m²) and lowest in patients with BMI between 25 and 35 kg/m² (i.e. overweight and mild obesity). Patients with severe obesity (BMI ≥ 35 kg/m²) had a markedly increased mortality after 3 years (Figure 1). Severe abdominal obesity (waist circumference >100 cm in women and >115 cm in men) was also associated with increased long-term mortality (Figure 2).

Professor Simon said: “As waist circumference is strongly linked to BMI, we determined the upper quartile of waist circumference (i.e. quarter of the population with the highest waist circumference) within each BMI category and used both variables together to determine their respective role in association with long-term mortality.”

She continued: “We found that both lean patients (BMI <22 kg/m²) and very obese patients (BMI ≥35 kg/m²) had an increased risk of death at 5 years: + 41% and + 65%, respectively. Being in the upper quartile of waist circumference (i.e. having a big belly considering your weight) was also an indicator of increased mortality at 5 years (+ 44%).”

Figure 3 shows the U-curve observed for risk of 5-year mortality according to baseline BMI. The risk of death at 5 years was the lowest for BMI between 22 and 35 kg/m².

Professor Simon concluded: “High waist circumference, severe obesity and underweight are associated with the greatest risk of death in heart attack survivors. It is not good to be too lean or too fat, but it is worse still when you have a big belly. From a public health standpoint, educational messages in patients having sustained a heart attack should focus more on the most severe forms of obesity and abdominal obesity and on other risk factors (such as smoking and being sedentary), rather than on overweight and mild obesity.”

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Prof. Dan Atar, FESC / Prof. Frank Ruschitzka, FESC

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