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Saturday, November 8
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AHA President Gardner calls for involvement as ‘citizen leaders’
Brown named next American Heart Association CEO
High-quality CPR, in-hospital cooling improve outcomes
Protein mutations may play a role in cardiomyopathy and CVD
Four Late-Breaking Clinical Trial results presented
AHA President Gardner calls for involvement as ‘citizen leaders’
AHA President Timothy Gardner, M.D., FAHA, welcomed attendees and challenged them to become citizen leaders with a “passion for prevention” to reduce heart disease and stroke.
“Let us remind ourselves that all of us here today are de facto leaders in our communities and also citizen leaders in our societies,” said Gardner, medical director of the Christiana Care Center for Heart and Vascular Health, Wilmington, Del.
Gardner called upon physicians, scientists and healthcare professionals to continue their work “Building a Healthier World, Free of Cardiovascular Disease and Stroke.”
Worldwide heart disease mortality rates peaked more than 30 years ago and have been declining; AHA has achieved two years early its 2010 goal of reducing deaths from coronary heart disease and stroke by 25 percent.
“Despite this progress, serious challenges remain,” Gardner said. “The major threat to continued reductions in preventable and premature deaths from cardiovascular disease and stroke is the increase in the risk factors of obesity and diabetes, untreated high blood pressure, smoking and lack of physical activity.”
A new threat in developing countries is the adoption of unhealthy habits from developed nations, Gardner said. “Global cardiovascular illness is increasing dramatically.”
“Adoption of the lifestyle and culture of the Western world has resulted in increasing problems with cardiovascular disease and stroke. Tobacco use in these countries, often aggressively promoted by U.S.-based multinational corporations, is rampant. “But what more can we do, in our role as citizen leaders, to address these diseases?” Gardner asked.
Physicians and scientists can work to broaden public awareness and education by being part of health campaigns such as one of AHA’s four cause campaigns — Go Red For Women, Power To End Stroke, the Alliance for a Healthier Generation and START!
Healthcare professionals, as citizen leaders, can also work to raise money and provide resources for organizations driving prevention and health promotion efforts.
The country’s anti-smoking movement of the past several decades provides an encouraging lesson for organizing successful health awareness movements and engaging in advocacy, said Gardner. He noted that smoking had once been widespread even among doctors, but by the 1970s virtually all physicians had quit and since then many have helped change public acceptance of smoking.
Gardner concluded by calling for promoting wellness and the active practice of preventive medicine to ensure a healthier world, free of cardiovascular disease and stroke.
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Brown named next American Heart Association CEO
Nancy Brown has been named the next chief executive officer of the American Heart Association, effective January 1, 2009. She was named to the position by the organization’s national Board of Directors at its meeting on Oct. 29. Brown is the first female CEO in the history of the association. She succeeds Cass Wheeler, who has served as CEO of the association for 11 years.
Brown has served as the association’s chief operating officer for the last seven years. Since 1986, she has worked with the American Heart Association in a variety of roles including metro Detroit director in the Michigan Affiliate; executive vice president for the Massachusetts Affiliate; executive vice president for the New England Affiliate; national executive vice president for Science Operations, and her current position of chief operating officer at the National Center.“Most organizations who lose a CEO like Cass Wheeler would be concerned about their transition, but the promotion of Nancy Brown to CEO is a celebration of her leadership and Cass’ commitment to preparing the AHA for succession,” said David A. Josserand, chairman of the American Heart Association Board of Directors. “We will always be indebted to Cass for his years of guidance and look forward to the next era led by Nancy Brown.”
In her role as COO, Brown has been responsible for leading a number of significant advances for the AHA, including the launch of its cause initiatives (Go Red For Women, START!, Power To End Stroke, and the Alliance for a Healthier Generation); the Winning With Talent Task Force, which was initiated to ensure the AHA built upon its reputation as a great place to work; and the nationwide launch of the Get With The Guidelines hospital quality improvement program after successfully creating and piloting the program in the New England Affiliate. She was also responsible for managing the AHA’s 2010 Strategic Planning process, which resulted in a new mission statement, a new Strategic Driving Force statement and a framework for the first-ever Global Strategic Plan. She is currently leading the process for developing the 2020 strategic plan.
Throughout her years at the National Center, Brown has worked closely with the science arm of the organization to further key initiatives in research with scientific journals, science meetings including Scientific Sessions, and also the Scientific Councils.
“I am honored to have been appointed as the next CEO of the American Heart Association,” Brown said. “Although we’ve made great progress in the fight against heart disease and stroke, our work is far from over. Too many people are impacted by the devastating effects of these diseases. The AHA will continue to work aggressively to help people live healthier lives, free of cardiovascular diseases and stroke. I look forward to the opportunity to lead the AHA to its next level of success.”
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High-quality CPR, in-hospital cooling improve outcomes
High-quality CPR and in-hospital therapeutic hypothermia have been shown to improve clinical outcomes for cardiac arrest patients.
Two studies presented Sunday at the Resuscitation Science Symposium tested whether intravenous (IV) access and drug administration compromised CPR quality or whether pre-hospital therapeutic hypothermia improves outcomes.Presenting on behalf of the Cardiopulmonary Resuscitation Group in Oslo, Therese M. Olasveengen, M.D., of the Institute for Experimental Medical Research and the Department of Anesthesiology, Ulieval University Hospital, Oslo, Norway tested the hypothesis that IV access and drug administration leads to poor-quality chest compressions by distracting from the focus on high-quality CPR, thereby leading to poor outcomes.
The study showed that whether or not patients received IV drugs, they received good-quality cardiopulmonary resuscitation (CPR). This was a surprising finding as a number of studies over the past three years, in both Europe and the United States, have shown that CPR quality is often not performed up to the standards in the CPR Guidelines. CPR quality was determined from hands-off ratio, compression rate, the number of compressions and ventilations per minute, and the length of the pre-shock pause, according to Olasveengen.
Patients admitted to the intensive care unit (30 percent vs. 21 percent for patients not receiving an IV) and patient survival to discharge (10 percent vs. 9 percent for patients not receiving an IV) were similar in the two arms of the study. “There is no difference in survival to discharge between the IV and no-IV groups after out-of-hospital cardiac arrest,” Olasveengen concluded.
In the second study, Stephen Bernard, M.D., of the Victoria Trauma Foundation Centre Research and Practice, The Alfred Hospital, Melborne, Australia, tested the hypothesis that immediate pre-hospital cooling of post-cardiac arrest patients improves outcomes compared to initiating hypothermia in the hospital.
The emergency medical services (EMS) cooling protocol included infusion of 2 liters rapid ice cold saline via a peripheral IV line, along with midazolam and pancuronium immediately after the return of spontaneous circulation. Cooling was continued in the emergency department (ED) and hospital. Patient temperature prior to starting the EMS cooling protocol was 35.8oC and was 34.4oC upon arrival at the ED. By comparison, patients not treated by the EMS cooling protocol were 35.9oC upon arrival at the ED.EMS cooling after resuscitation does not improve survival from out-of-hospital cardiac arrest compared to initiating cooling in the hospital. The percentage of ventricular fibrillation survivors who were discharged to their home or a rehabilitation center was similar whether they were cooled by EMS (48 percent) or if cooling was initiated in the hospital (51 percent).
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Protein mutations may play a role in cardiomyopathy and CVD
Mutations in intracellular heat-shock and chaperone proteins may play important roles in the pathogenesis of cardiomyopathy and cardiovascular disease, said two speakers at a Sunday Morning Program on “Protein Misfolding, Unfolding and Cardiovascular Disease.”“Life inside cells is really quite hazardous,” said Ivor J. Benjamin, M.D., chief of cardiology at the University of Utah School of Medicine, Salt Lake City.
Within cells, environmental, chemical and pathophysiologic stresses as well as genetic perturbations affect the maturation of unfolded proteins. Cells have evolved specialized proteins known as molecular chaperones whose principal role is to facilitate the maturation of polypeptides into their native folded state, Benjamin said. Abnormalities in this process can lead to protein misfolding and aggregation.
Environmental stresses, such as elevated temperatures, may increase the expression of heat shock proteins (HSPs), which play a role in cell survival under stress. A mutation in one of these proteins (HSPB5) can lead to desmin-related myopathy, an inherited protein aggregation disease with signs of hypertrophic cardiomyopathy and sudden death, he explained. It also has been shown to cause heart failure in mice.
In a talk on pre-amyloids and heart disease, Jeffrey Robbins, Ph.D., professor of pediatrics and chair of molecular cardiovascular biology at the University of Cincinnati College of Medicine, explained the role of intracellular pre-amyloids in cardiovascular disease.His research has elucidated the role of mutations in the intermediate filament protein desmin and the chaperone alpha-B crystalline protein as potential underlying causes of hypertrophic cardiomyopathy. The alpha-B crystalline is a heat shock-like protein that binds to desmin filaments and has chaperone functions. A mutation in this protein is linked to desmin-related myopathy, Robbins said.
In research in mice, he has shown that expression of an exogenous pre-amyloid oligomer in cardiomyocytes is toxic and sufficient to cause heart failure. The relationship of pre-amyloid oligomer expression to human heart failure is still under study, he said. However, it may represent a potential therapeutic target for heart failure patients.
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Four Late-Breaking Clinical Trial results presented
A lipid-lowering drug reduced heart attacks by 54 percent in people who had normal cholesterol but high levels of high-sensitivity C-reactive protein (hsCRP), researchers said Sunday. Their results were from the late-breaking clinical trial Rosuvastatin in the Prevention of Cardiovascular Events Among 17,802 Men and Women with Elevated Levels of C-Reactive Protein: the JUPITER Trial. The study was simultaneously published in the New England Journal of Medicine.
Compared to apparently healthy men and women who received placeboes, patients receiving the drug rosuvastatin also had a 48 percent reduction in stroke, a 47 percent reduction in the need for interventions to reopen blocked blood vessels and a 20 percent drop in all-cause mortality, said Paul M. Ridker, M.D., lead author of the study and director of the Center for Cardiovascular Disease Prevention at Brigham and Women’s Hospital, Boston, Mass.
Overall, compared to placebo-treated participants in the trial, those given rosuvastatin had a 44 percent reduction in the primary endpoint of first major cardiovascular event — a composite of heart attack, stroke, revascularization, hospitalization for unstable angina and cardiovascular death.
One particularly striking finding was a 37 percent reduction in first events in men and women in the statin group who had no other risk factors except for elevated hs-CRP, a sign of inflammation that can be associated with increased coronary disease risk, said Ridker, Eugene Braunwald Professor of Medicine at Harvard Medical School.
Since statins lower both LDL cholesterol and hs-CRP, it cannot be determined whether cholesterol lowering, a reduction in inflammation or a combination of both is responsible for the reductions seen.
The 17,802 men and women selected from more than 89,000 individuals at 1,300 clinical sites in 26 countries were randomly assigned 20 milligrams (mg) of rosuvastatin a day or a daily placebo. The study’s independent data and safety monitoring board ended the trial in March 2008, more than two years ahead of schedule, when it determined that the study data indicated “unequivocal benefit of rosuvastatin” on coronary-related death and disability.
JUPITER included 6,801 women and 5,119 members of minority groups in the randomized cohort. Benefits extended across gender, race and ethnicity.
Heart attack, stroke deaths in diabetics over 65 reduced in low-dose aspirin trial
In a randomized trial of 2,539 type 2 diabetics at 163 Japanese medical centers, researchers did not find a statistically significant reduction in the primary endpoint of the study (all atherosclerotic events) in the aspirin group. However, in a subgroup analysis, the researchers did find a significantly reduced risk with daily low-dose aspirin use in all atherosclerotic events, both fatal and non-fatal for diabetics over age 65. Individuals over age 65 with diabetes who took aspirin had a hazard ratio of 0.68 compared to those who did not take aspirin.
“Our results indicate that aspirin is effective and safe for primary prevention of cardiac and cerebrovascular death in diabetics,” said Hisao Ogawa, M.D, Ph.D., lead investigator of the Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes (JPAD) Study and a professor of cardiovascular medicine at Kumamoto University in Japan. “In addition, it offers a low-cost approach.”
Also, researchers found a large, statistically significant risk reduction for fatal coronary and cerebrovascular events in the aspirin group vs. the non-aspirin group (hazard ratio of 0.10). But the confidence interval on that finding was wide (CI=0.01 to 0.79), indicating a need for further study, Ogawa said.
During an average of 4.4 years of follow-up, 154 atherosclerotic events occurred, both fatal and non-fatal (68 in the aspirin group, 86 in the non-aspirin group). Those events included one fatal cardiovascular event (a hemorrhagic stroke) in the aspirin group and 10 fatal strokes or heart attacks in the non-aspirin group, Ogawa said.
Study finds folic acid safe but not cardioprotective
In the 12,064-person, randomized Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine (SEARCH), 2 milligrams (mg) of folic acid (vitamin B-9) and 1 mg of vitamin B-12 per day failed to show any reduction in the primary outcome of major vascular events (MVE) compared to placebo.
However, the vitamins did not increase non-vascular death rates or cancer rates during an average follow-up of 6.7 years among patients who had previously had a heart attack, said Jane M. Armitage, BSc, MBBS, MRCP, FFPH, co-principal investigator of the study and professor of clinical trials and epidemiology at the University of Oxford, England. This is important because the United States, Canada and several other countries require folic acid fortification of flour, bread and many cereals to protect newborns from neural tube defects, Armitage said.
At the same late-breaking clinical trial session, Armitage’s co-principal investigator, Rory Collins, MBBS, MSc, professor of medicine and epidemiology at the University of Oxford, presented a second randomized comparison from the SEARCH trial of 80mg versus 20mg per day of simvastatin — the largest direct comparison of more versus less intensive lowering of low-density lipoprotein cholesterol (LDL-C).
Compared with the patients assigned 20mg per day of simvastatin in SEARCH, LDL-C was reduced by an average of 14mg/dL more among the patients assigned 80mg per day of simvastatin.
Collins presented the results of SEARCH in the context of an update of a meta-analysis of individual patient data from previous studies of statin therapy published in The Lancet in 2005 (Lancet 2005 Oct 8: 366:1267-78). Based on that meta-analysis, a 14mg/dL greater reduction in LDL-C would be expected to produce a 6 percent to 7 percent relative reduction in MVE, which is what researchers observed in the SEARCH trial. The investigators noted that a slightly greater reduction of 20mg/dL would be expected to provide a highly significant reduction of 15 percent in the risk of MVE.
Daily doses of 80mg simvastatin were associated with more myopathy cases than 20mg simvastatin, although the SEARCH trial has identified a genetic variant that accounted for much of the excess myopathy risk with the higher-dose simvastatin regimen.
Vitamins E and C don’t protect against heart disease
Vitamins E and C — antioxidant supplements taken by many American adults — don’t protect against cardiovascular disease, according to a long-term study of more than 14,000 male physicians.
J. Michael Gaziano, M.D., M.P.H., principal investigator of the study and a cardiologist at Brigham & Women’s Hospital and VA Boston Healthcare System in Boston, Mass., said results of the Physician’s Health Study II (PHS II) add to the growing consensus about these vitamins’ lack of cardiovascular protection based on several earlier trials that failed to find any effect. The randomized, double-blind, placebo-controlled trial included 14,641 U.S. physicians age 50 and older.
Unlike several earlier studies in which vitamins E and C were often given as part of an antioxidant cocktail, this study investigated the two vitamins individually.
Each year, the investigators mailed participants calendar packs containing each vitamin or its placebo, depending upon the group to which each physician had been randomly assigned. The doses used in the study (400 international units of vitamin E every other day and 500 milligrams of vitamin C daily) correspond to typical amounts available commercially.
During an average eight years of follow-up, participants provided annual updates on compliance, various risk factors and health outcomes, allowing the investigators access to their medical records when necessary to confirm cardiovascular events or cause of death.
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