AHA President: Disparities in health care must be eliminated
Change coming to PCI treatment
Neurologist honored for role in stroke awareness program for African Americans
Conner Lecturer: Social inequality boosts heart disease
Stent research focuses on cost-effectiveness, risk
must be eliminated
Great strides have been made in treating cardiovascular disease in recent years, but those advances have not reached some Americans because of disparities in health care that must be addressed, according to AHA President Daniel Jones, M.D., FAHA.
“While in the United States the medical care glass is indeed half full, I’d like us to spend a few moments to focus on the half that is empty,” Dr. Jones said in his President’s Address Sunday. “To make this metaphor more apt, the glass is clearly full for some of us — most of us in this room — but it is nearly empty for many of our neighbors.”Dr. Jones outlined four areas where the American Heart Association should lead the effort to build healthier lives for everyone. Those areas are making the reduction of health disparities a priority, expanding research, increasing the AHA’s efforts in advocacy and increasing efforts in the prevention of disease.
To highlight the differences in health care, he traced the histories of two patients — an elderly white male living near a large city and a black female living in the rural south. The man benefited from medical advances for almost 30 years after he was diagnosed with hypertension at age 45. The woman was diagnosed with hypertension and diabetes at 24 and suffered a stroke at 38, which caused her to move to a nursing home and her family to declare bankruptcy because of the medical debt.
“We must find ways to address the serious disparity in cardiovascular disease outcomes across geography, race, gender and economics,” Dr. Jones said. “Should we consider the problem of health disparities a social issue outside our area of interest? No, we should not.”
Dr. Jones called for all government agencies and voluntary health organizations to make reducing disparities a priority.
“The American Heart Association’s recently adopted strategic driving force calls for measuring our progress toward eliminating health disparities in cardiovascular disease,” he said. “This will help us keep eliminating health disparities a priority.”
Expanding research will help increase the understanding of the causes of disparities and ways to eliminate them.
“This will require continued investment in basic science, and translational, clinical, population, and quality and outcomes research,” Dr. Jones said.
In advocacy, the AHA must be a leader in calling for more cardiovascular disease research that focuses on disparities.
“It is clear that in the U.S., we cannot achieve good health for all until the issue of access to health care is addressed,” he said.
Prevention is also important in reducing disparities, particularly primordial prevention in early life.
“We must prevent obesity from an early age, as present science suggests prevention is our only real hope in managing the obesity epidemic,” Dr. Jones said. Some studies have shown that programs can reduce disparities in diseases like hypertension, he added.
Although disparities are a problem, recognizing the problem has created an opportunity, Dr. Jones said.
“I ask you to rise to this medical and moral challenge, seize the opportunity before us and commit to eliminating health disparities in cardiovascular diseases,” he said.
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Change coming to PCI treatment
TRITON-TIMI 38 compared several groups receiving a single dosing regimen of prasugrel, an agent which has not been approved by the Food and Drug Administration, with groups receiving a single dosing regimen of clopidogrel, which is the standard treatment in patients undergoing PCI. Patients treated with prasugrel had a reduction in the primary endpoint, which was a combination of death from cardiovascular causes, non-fatal MI or non-fatal stroke, but there was an increase in serious bleeding, including deaths due to bleeding.
Prasugrel compared to Clopidogrel
“Prasugrel is definitely an approvable drug based on these results,” said Elliott Antman, M.D., head TIMI investigator and director of the Samuel A. Levine Cardiac Unit at Brigham and Women’s Hospital and professor of medicine at Harvard School of Medicine.
The multicenter trial enrolled 13,608 patients with acute coronary syndromes who were slated for PCI. Clopidogrel patients received a standard 300 mg loading dose and 75 mg daily for six to 15 months. Prasugrel patients received a 60 mg loading dose and 10 mg daily for the same period. Secondary endpoints included major bleeding and stent thrombosis.
Only 9.9 percent of patients taking prasugrel reached the primary endpoint, Dr. Antman reported, versus 12.1 percent on clopidogrel. The difference represents a hazard ratio of 0.81 in favor of prasugrel (p<0.001).
There was, however, no difference in mortality between the two groups.
“The most dramatic effect was in stent thrombosis, with twice the rate in the clopidogrel group,” Dr. Antman said.
Two prasugrel groups failed to benefit. Patients with a prior stroke or TIA had worse bleeding and worse outcomes. Patients older than 75 or who weighed less than 60 kg had more bleeding.
An important determination as the drug is evaluated will be whether those at higher risk for adverse outcomes can clearly be identified before the decision is made on which drug to administer.
During the discussion, there was speculation about the effect of different doses of aspirin and increased dosing of clopidogrel, but the study did not address these issues.
Eptifibatide and abciximab
The EVA-AMI study showed similar outcomes between eptifibatide and abciximab. The study randomized 400 patients with STEMI scheduled for primary PCI, explained Uwe Zeymer, M.D., Herzzentrum Ludwigshafen, Germany. Half got eptifibatide before PCI, and half got abciximab. The primary endpoint was complete ST resolution within one hour following PCI. Secondary endpoints included death, reinfarction, target vessel revascularization, stroke and bleeding 30 days post-PCI.
“There was no statistical difference between the two agents for these endpoints,” Dr. Zeymer said. “And eptifibatide is less expensive.”
BRIEF-PCI
BRIEF-PCI compared 624 patients who underwent successful non-emergent uncomplicated PCI with stenting. Patients were randomized to receive standard eptifibatide therapy, a double bolus followed by an 18-hour infusion or a double bolus and a two-hour infusion.
There was no difference in peri-procedural ischemic myocardial injury between the two groups. The two-hour group experienced less bleeding.
“We believe that eptifibatide infusion can safely be reduced to two hours in this select population,” said Anthony Fung, M.D., Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada. “That change in treatment reduces drug costs to 37 percent of the standard regimen and significantly reduces length of stay and associated costs.”
MPS helpful
A fourth study, a subanalysis of the COURAGE trial, concluded that myocardial perfusion SPECT(MPS) can identify a subset of more severely ischemic patients who will most benefit from PCI.
Initial results from COURAGE, released in April 2007, showed no difference in outcome between PCI and aggressive, guideline-driven medical treatment for coronary artery disease patients. However, a nuclear substudy found that serial MPS could identify at-risk patients in whom PCI plus optimal medical therapy (OMT) is better than OMT alone.
“Adding PCI to OMT offered significant benefit,” said Leslee Shaw, Ph.D., professor of medicine at Emory University School of Medicine, Atlanta. “The benefit was greatest in patients with more severe ischemia at baseline.”
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Neurologist honored for role in stroke awareness program for African Americans
Ralph L. Sacco, M.D., M.S., FAHA, Miami, Fla., received the American Heart Association’s Chairman’s Award, which honors exceptional volunteer service to the association in non-science areas, at Sunday’s Opening Session.
Dr. Sacco was recognized for his “invaluable leadership” in creating Power To End Stroke, a nationwide educational campaign to raise awareness of the risk of stroke among African Americans.
American Heart Association Board Chairman Gary Ellis and Chief Executive Officer M. Cass Wheeler presented the award, a citation and $1,000 honorarium.
“Dr. Sacco has brought enthusiasm, energy and expertise to the creation and implementation of Power To End Stroke,” Ellis said. “His tireless championing of this cause has been crucial to its success.”
Power To End Stroke is designed to have a greater impact in states with larger African-American populations. It has reached every state in the continental United States.
The community-based program “has made measurable progress in spreading potentially lifesaving messages to minority citizens,” Ellis said.
Sacco is Miller Professor of Neurology, Epidemiology and Human Genetics and chairman of the department of neurology at the University of Miami’s Miller School of Medicine. He is a member of the AHA’s national Board of Directors and chairman of the American Stroke Association Advisory Committee. Before moving to Miami in 2007, he held numerous leadership roles in the association’s New York City Affiliate.
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Conner Lecturer: Social inequality
boosts heart disease
Poverty is widely recognized as a risk factor for poor health and lower life expectancy, but lack of income is not the main determinant of health. Where you stand in the social pecking order is critically important. Social inequality is the leading risk factor for higher incidences of cardiovascular disease and increased mortality.
“The issue of inequality is key to all of our activities,” said Professor Sir Michael Marmot, M.D., Ph.D., director of the International Institute for Society and Health, London, and head of the World Health Organization Commission on Social Determinants of Health.
Cardiovascular disease has already emerged as the No. 1 cause of mortality in all but the poorest countries, Dr. Marmot said during the Lewis A. Conner Memorial Lecture on Sunday afternoon. That puts reducing cardiovascular risk at the top of the disease prevention list, and the No. 1 risk for CVD is social inequality.
Psychosocial factors, such as empowerment, can affect health. The life expectancy for Oscar winners, for example, is four years longer than Oscar nominees who have not won.
“Winning an Oscar is like reducing your risk of dying from heart attack from population normal to zero,” Dr. Marmot said. “That is a tremendous improvement.”
Population studies around the world show that social inequality affects control over one’s own life and work, he explained. In the United States, United Kingdom, Sweden, South Korea and other countries, the key factors are education and social status in the workplace. Better-educated individuals and those with more authority at work have lower rates of cardiovascular disease and longer life expectancy.
Education and status even trump access to health care, he noted. In the United States, for example, education and workplace status are positively associated with longer life expectancy, even in populations with similar access to health insurance and medical care.
“Health equity, putting inequality right, is a matter of social justice,” he said. “The medical profession should take the lead.”
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Stent research focuses on cost-effectiveness, risk
During a Sunday news conference, two researchers discussed their findings about the cost-effectiveness of PCI as an initial management strategy, the incidence of stent thrombosis and outcomes associated with drug-eluting stents, and the safety of novel stents designed to reduce complications. In discussing the economic outcomes from the COURAGE trial, William Weintraub, M.D., said that these outcomes “fit perfectly with the initial results.
“Compared with optimal medical therapy, PCI plus optimal medical therapy as a first choice of therapy for stable coronary artery disease is not cost-effective,” said Dr. Weintraub, the John H. Ammon Chair of Cardiology and director of the Christiana Center for Outcomes Research, Newark, Del.Incremental cost-effectiveness analysis demonstrated that PCI was associated with a cost of $288,474 per quality-adjusted life year gained. This cost was $10,401 more than optimal medical therapy (OMT), which includes pharmacologic therapy and lifestyle interventions. The additional expense was incurred without any significant gain in quality-adjusted life years (gain of 0.036).
In another study, definite or probable stent thrombosis occurred in 210 patients (83 with definite thrombosis and 127 with probable thrombosis) among 8,402 patients who had unrestricted PCI with one or more drug-eluting stents. The “striking” finding about the incidence was that it did not plateau over a two-year period, said a study author, Ron Waksman, M.D., FACC, professor of medicine at Georgetown University and associate director of the Division of Cardiology at Washington (D.C.) Hospital Center.
For 30 days to two years after stent implantation, the incidence of stent thrombosis was 0.36 percent per year for patients who had definite stent thrombosis and 0.84 percent for patients who had definite or probable thrombosis.
Among the outcomes related to definite or probable stent thrombosis were higher rates of early (30 days), late (one year) and very late (two years) death; Q-wave myocardial infarction; and target vessel revascularization. Stent thrombosis was significantly associated with a history of diabetes mellitus, myocardial infarction during hospital admission and stent implantation in a restenotic lesion.
Another study focused on promising new technology that may help to reduce the complications associated with stents. The PROGRESS-AMS study is a first-in-human study to evaluate the use of an absorbable magnesium stent (AMS) in 63 patients at eight clinical sites outside the United States.
Dr. Waksman, who was also involved with that study, noted that the AMS was clinically safe after 28 months of follow-up. The results were durable over that time period, with no late adverse events as demonstrated on angiography or intravascular ultrasound.
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© American Heart Association.
Scientific Sessions Daily News is published daily during Scientific Sessions, November 4-7, 2007.