Depression after coronary artery disease diagnosis raises mortality risk


A diagnosis of depression increases the risk of mortality and hospital readmission due to myocardial infarction (MI) in patients with stable coronary artery disease (CAD), according to a Canadian study presented at the recent American College of Cardiology’s 65th Annual Scientific Session in Chicago, Illinois, US.

CAD patients who were diagnosed with depression had an elevated risk of mortality (hazard ratio [HR], 1.83, 95 percent CI, 1.62-2.07) and readmission for MI (HR, 1.36, 95 percent CI, 1.10-1.67). This risk was highest when depression was diagnosed 90-180 days after diagnosis of stable CAD. Depression did not appear to affect the risk of requiring bypass surgery or coronary stent placements. [ACC 2016, abstract 16-A-10562]

Women (HR, 1.31, 95 percent CI, 1.23-1.39) and individuals with severe angina based on the Canadian Cardiovascular Society (CSS) class (HR, 1.43, 95 percent CI, 1.16-1.76) were at higher risk of depression.

“Based on these findings, there may be an opportunity to improve outcomes in people with coronary heart disease by screening for and treating mood disorders, but this needs to be further studied,” said Dr. Natalie Szpakowski, Internal Medicine Resident at the University of Toronto, Canada, and lead author of the study.

Participants in this retrospective cohort study were 22,917 CAD patients, 18.8 percent of whom had depression after being diagnosed with CAD.

In a separate study involving 7,550 individuals aged ≥40 years, researchers from the Intermountain Medical Center Heart Institute, Salt Lake City, Utah, US found that treating depression appeared to reduce the risk of future major adverse cardiac events (MACE).

Based on results of two questionnaires, incidence of MACE among individuals who were no longer depressed was 4.6 percent (similar to those who were not depressed at all [4.8 percent]) compared to 6.0 and 6.4 percent in those who remained or became depressed (p=0.03). [ACC 2016, abstract 16-A-9223]

“Our study shows that prompt, effective treatment of depression appears to improve the risk of poor heart health,” said Dr. Heidi May, a Cardiovascular Epidemiologist at the Intermountain Institute and one of the investigators of the study. “The key conclusion of our study is, if depression isn’t treated, the risk of cardiovascular complications increases significantly,” she said.

Study authors were unable to confirm if depression led to cardiovascular risk factors or vice versa.

“What we’ve done thus far is simply observe data that has previously been collected. In order to dig deeper, we need to do a full clinical trial to fully evaluate what we’ve observed,” said May.

Bone Loss May Indicate Poor Heart Health in Dialysis Patients


High parathyroid hormone levels and bone loss may predict progression of coronary artery calcification (CAC) in patients receiving dialysis, according to a study published online April 2 in the Journal of the American Society of Nephrology.

“We discovered that high parathyroid hormone and the consequential bone loss are major risk factors for progression of vascular calcifications,” Hartmut H. Malluche, MD, from the Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, commented in a news release.

“These two factors were heretofore not appreciated and were independent from traditional known risk factors,” he added.
Elevated parathyroid hormone levels cause the release of calcium from bone, leading to bone loss and thinning. Most patients receiving dialysis for chronic kidney disease have CAC. CAC increases the risk for cardiovascular events, which in turn cause the majority of deaths in patients with CKD, the authors note.

Therefore, Dr Malluche and colleagues recommend monitoring bone loss with measurements of parathyroid hormone or bone mineral density (BMD) as a way to predict progression of CAC in patients receiving dialysis.

Between August 2009 and April 2013, the researchers enrolled 213 participants from 38 dialysis centers in Kentucky. Participants underwent measurement of routine laboratory tests, serum markers of bone metabolism, and CAC at baseline and 1 year. The researchers also evaluated BMD at both points using dual-energy X-ray absorptiometry scans and quantitative computed tomography. They assessed CAC using multislide computed tomography of the heart and CAC square root of coronary artery calcification volume, an analytic technique that accounts for variability in scanning.

About 80% of participants had CAC at baseline, and almost 50% of these had measurements suggesting high risk for cardiovascular events. One third of participants had osteoporosis.

Independent positive predictors of baseline CAC included coronary artery disease, diabetes, length of time receiving dialysis, age, and concentration of fibroblast growth factor 23, which regulates serum phosphate levels and helps maintain bone strength. In contrast, BMD of the spine inversely predicted baseline CAC.
CAC progression at 1 year occurred among three quarters of the 122 patients who completed the study. Independent risk factors for CAC progression included age, osteoporosis (β = 4.6; 95% confidence interval, 1.8 – 7.5; P = .002), and baseline total or whole parathyroid hormone more than nine times the normal value, after adjusting for age (β = 6.9; 95% confidence interval, 2.4 – 11.4; P = .003).

The researchers note several limitations for the study, including exclusion of about 20% of screened patients because of severe comorbidities or impaired mental status. In addition, the prospective, short-term nature of the study precluded determination of disease mechanisms and long-term relationships.

Dr Malluche noted in the press release that important links may exist between the level of calcification in bones and calcifications in blood vessels.

“Studies need to be done to find out whether prevention of bone loss will reduce progression of vascular calcifications,” he emphasized.

Mild Stenosis Linked to Death in Diabetes


Even modest coronary plaque causing no symptoms has a long-term impact on mortality and heart disease in diabetes, an observational study showed.

The adjusted mortality risk was similarly elevated by twofold whether coronary CT angiography showed mild stenosis of less than 50% or obstructive stenosis of 50% or more (hazard ratios 2.0 and 2.1,P=0.003 and P<0.001, respectively), Philipp Blanke, MD, of the University of British Columbia and St. Paul’s Hospital in Vancouver, and colleagues found in the CONFIRM registry.

The mortality risk with nonobstructive coronary artery disease was similar to that of having single-vessel obstructive disease (P=0.42), the researchers reported at the Radiological Society of North America meeting here.

Overall major adverse cardiovascular events (death, myocardial infarction, unstable angina, or late coronary revascularization) showed about double the risk with obstructive disease as with the milder stenosis, but both were significant, with HRs of 10.4 and 4.9, respectively (both P<0.001).

“Coronary computed tomographic angiography in diabetics can be used for long-term prognostication with respect to mortality and major adverse cardiovascular events,” the group concluded.

However, screening of diabetes patients for asymptomatic coronary artery disease with coronary CT angiography to guide management wasn’t any better than simply aggressively targeting risk factors in the FACTOR 64 trial, reported in November at the American Heart Association meeting.

“A lot of patients end up having their first symptom as a heart attack or even death. We would like to be able to identify those patients and treat them before they die or have a heart attack,” said J. Brent Muhlestein, MD, of the FACTOR 64 trial. Muhlestein is from Intermountain Medical Center and the University of Utah in Salt Lake City.

While CT screening wasn’t the solution, “aggressive medical management of all patients significantly reduced the number of adverse events that happened in diabetic patients in both the patients who were in the control arm and also in the scanning arm,” he pointed out to MedPage Today. “We also found that 70% of the patients who did have asymptomatic diabetes also did have some degree of atherosclerosis in their coronary arteries which justifies secondary prevention risk management.”

The Coronary CT Angiography Evaluation For Clinical Outcomes: An International Multicenter (CONFIRM) Registry was designed to look for prognostic value of cardiac CT angiography in coronary artery disease-related events.

Among the more than 40,000 patients with CT angiography data from more than a dozen centers around the world, Blanke’s analysis included the 1,823 with diabetes and at least 5-years of follow-up but no prior clinically-apparent coronary artery disease.

Action Points

  • Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
  • In patients with diabetes, both nonobstructive and obstructive CAD by coronary computed tomographic angiography are associated with higher rates of all-cause mortality and MACE when followed for 5 years. The relative risk of nonobstructive disease is comparable to single vessel obstructive disease.

Some cardiac MRI findings predict future heart events.


Certain MRI findings can independently predict future cardiovascular events in patients with coronary artery disease or those who recently had a heart attack, but you have to be careful which ones you choose, according to a study published online January 29 in the Journal of the American College of Cardiology.

In a meta-analysis of 56 previous studies, Dutch researchers found that some cardiac MRI findings are predictive for some types of patients, while there aren’t enough data to support the prognostic power of other results.

“An important finding is that different cardiac MR features are associated with events depending on the patient population under consideration,” wrote lead author Dr. Hamza El Aidi, from the department of cardiology at University Medical Center Utrecht, and colleagues (JACC, January 29, 2014).

Benefits of cardiac MRI

As the authors noted in their study, cardiac MRI has advantages over other imaging modalities because of its high spatial and temporal resolution, its ability to visualize ischemic heart disease in one scan, and its lack of ionizing radiation. Cardiac MRI is also considered the current reference standard for evaluating ventricular function and myocardial fibrosis using late gadolinium enhancement.

“However, data on prognosis from individual studies is limited, most often due to small sample sizes and/or a low number of events in these studies,” they wrote. “Furthermore, the relative prognostic value of the available cardiac MR imaging findings is unclear.”

The researchers decided to assess cardiac MRI’s predictive power based on the following imaging features:

  • Left ventricular ejection fraction (LVEF)
  • Wall motion abnormalities
  • Abnormal myocardial perfusion
  • Microvascular obstruction
  • Late gadolinium enhancement
  • Presence of edema
  • Presence of intramyocardial hemorrhage

Patients were divided into two groups: The first group consisted of those who had experienced a recent myocardial infarction, while the second included patients with suspected or known coronary artery disease (CAD).

The imaging findings were then correlated with “hard events” — all-cause mortality, cardiac death, cardiac transplantation, and myocardial infarction — or major adverse cardiovascular events (MACE), which included hard or other events as defined by authors of the evaluated papers. For each finding, a hazard ratio was calculated to show the association between that factor and future cardiac events in each of the two patient groups.

Paper chase

Cardiac MRI papers published before February 2013 were drawn from Medline and Embase. A total of 56 papers were found to meet the study’s criteria, representing a total population of 25,497 patients.

There wasn’t enough evidence to link cardiac MRI findings with hard events in the patients with recent myocardial infarction, according to the authors. However, findings that did demonstrate prognostic value included the following:

  • In patients with a recent myocardial infarction, LVEF was an independent predictor of MACE in more than 50% of the studies, with a change in hazard ratio (HR) of 1.03 to 1.05 per 1% decrease in LVEF.
  • In patients with suspected or known CAD, the following cardiac MRI findings were predictors of hard events:
    • Wall motion abnormalities (HR range of 1.87-2.99)
    • Perfusion defects (HR range of 3.02-7.77)
    • LVEF (HR range of 0.72-0.82 per 10% increase in LVEF)
    • Infarction (HR range of 2.82-9.43)
  • In patients with suspected or known CAD, perfusion defects were associated with MACE (HR range of 1.76-3.21).

Important predictors

According to the authors, their study is one of the first comprehensive systematic reviews investigating the predictive abilities of different cardiac MRI findings for future cardiovascular events.

“Among patients with suspected or known coronary artery disease, inducible wall motion abnormalities and inducible perfusion defects were the most important independent predictors of hard events,” they wrote. “Other independent predictors were LVEF and infarct size.”

To better assess cardiac MRI, the authors advocated the development of reporting guidelines for prognostic studies in cardiovascular imaging.

They cited the Reporting Recommendations for Tumor Marker Prognostic Studies (REMARK), which are used for oncology, and the Prognosis Research Strategy (PROGRESS) recommendations as examples.

“In conclusion, cardiac MRI is capable of providing independent prognostic information that allows for risk stratification after myocardial infarction as well as in patients with suspected or known coronary artery disease,” they wrote.

Aircraft Noise and CVD: Two New Studies Bolster Link.


Aircraft noise from some of the world’s busiest airports is linked to an increased risk of hospital admissions for cardiovascular disease, according to two new papers. The studies broaden concerns about the impact of living close to airports; previously, aircraft noise, as well as other “sound pollutants,” has been linked to hypertension.

In the first of two studies published online October 8, 2013 in BMJ,Dr Anna L Hansell (Imperial College London, UK) and colleagues assessed hospital admissions for 3.6 million people living near Heathrow Airport. Their paper linked daytime and nighttime aircraft noise and hospital visits for stroke, coronary heart disease, and cardiovascular disease by comparing residents in the noisiest areas with those living farther from the airport.

They found that, after adjustment for confounders, high-noise areas (>63 dB) had significantly increased risks for all three diagnostic codes as compared with the quieter areas (<51 dB).

High vs Low Aircraft Noise Exposure

Admission diagnosis Relative risk 95% CI
Stroke 1.24 1.08–1.43
Coronary artery disease 1.21 1.12–1.31
Cardiovascular disease 1.14 1.08–1.20

In the second paper, Dr Andrew W Correia (NMR Group, Somerville, MA) and colleagues looked at hospitalization for cardiovascular disease among subjects 65 years or older according to “contours of aircraft noise levels” around 89 airports in the US[2].

They report that every 10-dB increase in noise exposure (by zip code) was associated with a 3.5% higher rate of hospital admissions for cardiovascular disease. The observation held up after they controlled for other covariates, including air pollution as well as ethnic and socioeconomic factors. Importantly, note the authors, the effects were particularly marked at the highest levels of aircraft noise (above the 90th percentile for noise exposure) suggesting a threshold effect above 55 dB.

In an accompanying editorial[3], Dr Stephen Stansfeld (Barts and the London School of Medicine, UK) asserts: “the link seems real.”

The findings also echo a somewhat larger body of work looking at traffic noise, including the large HYENAstudy. He notes that a link between aircraft noise and stroke, seen in the Hansell et al paper, “is new and fits with associations between aircraft noise and hypertension and between road traffic noise and death from stroke.”

Other factors that could not be controlled for in the current analyses include individual-level confounders, including smoking status and household income, he notes. “There is a need for prospective cohort studies of exposure to aircraft and road traffic noise . . . that might also take account of air pollution, social disadvantage, and migration in and out of study areas,” Stansfeld writes.

Still, he continues, the results have implications for the siting of airports, he concludes. “Planners need to take this into account when expanding airports in heavily populated areas or planning new airports.”

Hansell disclosed receiving consultancy fees from AECOM as part of a UK Department for Environment, Food and Rural Affairs report on health effects of environmental noise. Disclosures for the coauthors are listed in the paper. Stansfeld disclosed being a member of the Acoustic Review Group for High Speed 2. Correia et al had no conflicts of interest.

Egyptian princess now known to be the first person in human history with diagnosed coronary artery disease.


The Egyptian princess Ahmose-Meryet-Amon, who lived in Thebes (Luxor) between 1580 and 1550 BC and who is now known to be first person in human history with diagnosed coronary artery disease, lived on a diet rich in vegetables, fruit and a limited amount of meat from domesticated (but not fattened) animals. Wheat and barley were grown along the banks of the Nile, making bread and beer the dietary staples of this period of ancient Egypt. Tobacco and trans-fats were unknown, and lifestyle was likely to have been active.

Both presentations were based on findings from the Horus study, in which arterial atherosclerosis was investigated in 52 ancient Egyptian mummies. Results have shown that recognisable arteries were present in 44 of the mummies, with an identifiable heart present in 16. Arterial calcification (as a marker of atherosclerosis) was evident at a variety of sites in almost half the mummies scanned, prompting the investigators to note that the condition was common in this group of middle aged or older ancient Egyptians; the 20 mummies with definite atherosclerosis were older (mean 45.years) than those with intact vascular tissue but no atherosclerosis (34.5 years).

Although relatively common at other vascular sites, atherosclerosis in the coronary arteries was evident in only three of the mummies investigated, but was clearly visualised in Princess Ahmose-Meryet-Amon (in whom calcification was present in every vascular bed visualised).

The CT scan image below shows that the princess, who died in her 40s, had atherosclerosis in two of her three main coronary arteries. “Today,” said Dr Gregory S Thomas, director of Nuclear Cardiology Education at the University of California, Irvine, USA, and co-principal investigator of the Horus study, “she would have needed by-pass surgery.”

CT scan shows atherosclerosis in the coronary arteries of Egyptian Mummy

Image: Calcification, seen as white, in the right (RCA) and left coronary arteries (LCA), each indicative of coronary artery disease.

“Overall, it was striking how much atherosclerosis we found,” said Dr Thomas. “We think of atherosclerosis as a disease of modern lifestyle, but it’s clear that it also existed 3500 years ago. Our findings certainly call into question the perception of atherosclerosis as a modern disease.”

If, however, the princess enjoyed a diet deemed to be healthy and pursued a lifestyle probably active, how could this “disease of modern life” affect her so visibly? Dr Thomas and his co-principal investigator Dr Adel Allam of Al Azhar University, Cairo, suggest three possibilities.

First, that there is still some unknown risk factor for cardiovascular disease, or at least a missing link in our understanding of it. Dr Allam noted a likely effect of genetic inheritance, pointing out that much of the human predisposition to atherosclerosis could be secondary to their genes. He similarly raised the possibility that an inflammatory response to the frequent parasitic infections common to ancient Egyptians might predispose to coronary disease – in much the same way that immunocompromised HIV cases seem also predisposed to early coronary disease. Nor can a dietary effect be excluded, despite what we know of life in ancient Egypt. Princess Ahmose-Meryet-Amon was from a noble family, her father, Seqenenre Tao II, the last pharaoh of the 17th Dynasty.

So it’s likely that her diet was not that of the common Egyptian. As a royal, she would have eaten more luxury foods – more meat, butter and cheese. Moreover, foods were preserved in salt, which may also have had an adverse effect.

Despite the suggestion of a genetic, inflammatory or unknown effect, Drs Thomas and Allam were keen not to discount those risk factors for heart disease which we do know about. Indeed, even in the study’s apparent association of atheroma with increasing age, there was a pattern of prevalence consistent with our own epidemiology today. “Recent studies have shown that by not smoking, having a lower blood pressure and a lower cholesterol level, calcification of our arteries is delayed,” said co-investigator Dr Randall C Thompson of the St Luke’s Mid-America Heart Institute in Kansas City, USA. “On the other hand, from what we can tell from this study, humans are predisposed to atherosclerosis, so it behoves us to take the proper measures necessary to delay it as long as we can.”

Most of the Horus study research was performed at the National Museum of Antiquities in Cairo and would not have been possible without the availability of non-invasive CT scanning, the focus of the ICNC congress in Amsterdam. CT scanning and nuclear medicine imaging are the cornerstones of modern quantifiable cardiac disease detection, with safe and reproducible results.

Should We Set a Higher Bar for Coronary Angiography?


Compared with Ontario, obstructive disease is less common in patients who undergo catheterization in New York.

A recent study indicated that more cardiac catheterizations are performed per capita in New York State than in Ontario, Canada). Now, the same investigators have compared the prevalence of obstructive coronary artery disease (CAD) — defined as diameter stenosis ≥50% in the left main or ≥70% in a major epicardial vessel — in patients undergoing the procedure in the two regions.

Obstructive CAD was found in significantly more of approximately 55,000 patients undergoing a first elective cardiac catheterization during 2008–2011 in Ontario than in some 18,000 such patients in New York (45% and 30%, respectively). Compared with the Canadian patients, the New Yorkers were younger and more likely to be women or to have no or atypical symptoms; the prevalence of several other risk factors also differed significantly between the two groups. Fewer patients in New York than in Ontario had noninvasive evaluations (63% vs. 75%, P<0.001), and the predicted preprocedure probability of obstructive CAD was significantly lower in New York.

Among patients with obstructive CAD, those in New York were significantly more likely than those in Ontario to undergo revascularization (percutaneous coronary intervention, 55% vs. 35%; coronary artery bypass grafting, 20% vs. 14%). Higher crude 30-day mortality in New York than in Ontario was mainly attributable to higher mortality in patients without obstructive CAD.

COMMENT

These findings suggest that the relatively high cardiac catheterization rate in New York results primarily from selecting patients at lower predicted probabilities of obstructive coronary artery disease. The investigators could not control for regional differences in patient, societal, and physician characteristics, preferences, and expectations; nor could they assess which catheterization rate is more appropriate. Nonetheless, the higher prevalence of interventionalists and cardiac invasive capabilities — as well as market-oriented financing — in New York seems likely to account for much, if not all, of the disparity; if so, these data illuminate an opportunity to reduce unnecessary healthcare expenditures.

Source: NEJM

Coronary artery calcium score prediction of all cause mortality and cardiovascular events in people with type 2 diabetes: systematic review and meta-analysis


 

Objective To investigate the association of coronary artery calcium score with all cause mortality and cardiovascular events in people with type 2 diabetes.

Design Systematic review and meta-analysis of observational studies.

Data sources Studies were identified from Embase, PubMed, and abstracts from the 2011 and 2012 annual meetings of the American Diabetes Association, European Association for the Study of Diabetes, American College of Cardiology, and American Heart Association (2011).

Eligibility criteria Prospective studies that evaluated baseline coronary artery calcium score in people with type 2 diabetes and subsequent all cause mortality or cardiovascular events (fatal and non-fatal).

Data extraction Two independent reviewers extracted the data. The predictive value of the coronary artery calcium score was assessed by random effects model.

Results Eight studies were included (n=6521; 802 events; mean follow-up 5.18 years). The relative risk for all cause mortality or cardiovascular events, or both comparing a total coronary artery calcium score of ≥10 with a score of <10 was 5.47 (95% confidence interval 2.59 to 11.53; I2=82.4%, P<0.001). The overall sensitivity of a total coronary artery calcium score of ≥10 for this composite outcome was 94% (95% confidence interval 89% to 96%), with a specificity of 34% (24% to 44%). The positive and negative likelihood ratios were 1.41 (95% confidence interval 1.20 to 1.66) and 0.18 (0.10 to 0.30), respectively. For people with a coronary artery calcium score of <10, the post-test probability of the composite outcome was about 1.8%, representing a 6.8-fold reduction from the pretest probability. Four studies evaluated cardiovascular events as the outcome (n=1805; 351 events). The relative risk for cardiovascular events comparing a total coronary artery calcium score of ≥10 with a score of <10 was 9.22 (2.73 to 31.07; I2=76.7%, P=0.005). The positive and negative likelihood ratios were 1.67 (1.30 to 2.17) and 0.11 (0.04 to 0.29), respectively.

Conclusion In people with type 2 diabetes, a coronary artery calcium score of ≥10 predicts all cause mortality or cardiovascular events, or both, and cardiovascular events alone, with high sensitivity but low specificity. Clinically, the finding of a coronary artery calcium score of <10 may facilitate risk stratification by enabling the identification of people at low risk within this high risk population.

Discussion

In people with type 2 diabetes, the presence of a coronary artery calcium score of ≥10 predicts both all cause mortality and cardiovascular events as well as cardiovascular events alone, with high sensitivity but low specificity. The negative likelihood ratio of the coronary artery calcium score for these outcomes was strikingly low (0.18 for all cause mortality and cardiovascular events, and 0.11 for cardiovascular events). Indeed, our evaluation of risk estimates through the Bayes normogram suggests that the coronary artery calcium score may be especially helpful in clinical practice when it is below 10.

Our meta-analyses showed that the coronary artery calcium score might have a role in predicting events in people with type 2 diabetes. The findings of an increased relative risk for all cause mortality and cardiovascular events and cardiovascular events alone were consistent. The exploratory analysis of heterogeneity identified the variables associated with higher variance between studies, especially for cardiovascular events alone (where the sensitivity analysis eliminated the heterogeneity). We used the likelihood ratio as an alternative statistic because of its clinical applicability. Interestingly, we found a low negative likelihood ratio, in the range (that is, 0.1) that Deeks and Altman have previously suggested as providing strong evidence for ruling out the occurrence of an outcome in most circumstances.37

When evaluating a predictor of adverse outcomes, it is recognised that a useful predictor should have a favourable risk-benefit ratio, reasonable cost, acceptability, and convenience. In addition, to make screening worthwhile an effective treatment should be available, and this treatment should not be equally effective in everyone.38 In this context, screening using the coronary artery calcium score is a convenient and non-invasive test, although it involves exposure to ionising radiation of about 1 millisieverts (which is comparable to screening mammography).39 No formal cost effectiveness analyses have been done on the coronary artery calcium score in people with type 2 diabetes integrating risk, benefits, and cost; however, the current findings raise the possibility that screening using the coronary artery calcium score may be cost effective in some subgroups of people with diabetes. Moreover, a previous report showed that patient awareness of an abnormal score was associated with increased adherence to aspirin use and lifestyle changes,40 suggesting that, besides risk stratification, the coronary artery calcium score might help to support behavioural modification.

The American Heart Association has supported the use of the coronary artery calcium score quantification in people at intermediate risk to improve risk assessment (class IIb recommendation).41 Conversely, the American Diabetes Association does not recommend its routine use in people with type 2 diabetes because the overall balance of risk, benefits, and cost of such an approach in people without symptoms remains controversial.1 In light of the lack of previous evidence to support the routine use of the coronary artery calcium score as a screening test in people with type 2 diabetes, we feel that the current meta-analysis is much needed and holds implications for the design of future studies. In particular, the finding of such a low likelihood ratio suggests that a coronary artery calcium score of <10 might help with risk stratification of people with type 2 diabetes and potentially would change prevention strategies in those people. In fact, it has been suggested that the coronary artery calcium score may help to identify people with diabetes who may benefit from aspirin therapy among those without a clear indication based on current guidelines.13 Most importantly, if we consider that the prevalence of a coronary artery calcium score of <10 was 28.5% in our study population, the current findings might have an important impact on clinical care. Indeed, considering the worldwide prevalence of 346 million cases of type 2 diabetes,42 these data suggest that about 86.5 million people with type 2 diabetes would have a coronary artery calcium score of <10 and hence a low risk of cardiovascular events. In addition, a score of <10 has been observed in a significant proportion of people with diabetes at intermediate risk on pretest assessment, a subgroup of people who would most benefit from the coronary artery calcium score test.13 33 In this way, screening using the coronary artery calcium score may facilitate clinical risk stratification by identifying a sizeable subgroup of people at low risk within the high risk population of people with diabetes.

The concept of a low risk subgroup within the population of people with diabetes has been demonstrated in a previous report that showed a similar risk of all cause mortality between people with and without diabetes who had no coronary artery calcium score at baseline (survival 98.8% v 99.4% over five years, P=0.49).30 These data reinforce the results of our meta-analysis, in which a coronary artery calcium score of <10 was indicative of low risk for future events in people with diabetes. In addition, in the same way that the coronary artery calcium score adds to current predictive scores in the general population,6 these data raise the possibility that incorporation of coronary artery calcium score into existing risk scores for people with diabetes might improve risk prediction and hence warrants further investigation.

Limitations of this review

A limitation of our meta-analysis is that an analysis of additional risk stratification beyond current available risk scores for people with type 2 diabetes could not be performed owing to the absence of such studies. Secondly, most studies did not take into consideration the use of drugs (that is, aspirin and lipid lowering drugs) that could interfere with the estimates of event rate prediction based on the coronary artery calcium score. Nevertheless, as all studies were performed after 2004, we believe that the people were possibly treated similarly based on current clinical practice recommendations. Thirdly, only three studies reported baseline glycated haemoglobin A1c and duration of diabetes. However, although these covariates could not be included in metaregression analyses, our models were able to identify the studies that better explained the variance between studies. Of note, although most studies measured the coronary artery calcium score using the same technique, differences in the protocol for obtaining the scores could also have contributed to the variance between studies. Finally, we recognise that publication bias and the quality limitations of individual studies may still be relevant despite our best efforts to conduct a comprehensive search and the lack of statistical evidence of bias. The subjective nature of the Newcastle-Ottawa scale by which the quality of studies was assessed should also be noted.

Our meta-analysis strongly suggests that the coronary artery calcium score warrants further investigation as a prediction tool in people with type 2 diabetes. In particular, randomised controlled trials evaluating the impact of screening using the coronary artery calcium score on mortality are needed. Another point to consider in future studies is that atherosclerosis is a dynamic process, as shown by studies documenting both progression and regression of plaque.43 44 45 Glucose levels are an independent risk factor for progression of coronary artery calcium score,46 and people with type 2 diabetes have been shown to have a higher rate of progression than those without diabetes.47 Thus, the optimal frequency of screening using the coronary artery calcium score also needs to be established.

Conclusion

The coronary artery calcium score predicts all cause mortality and cardiovascular events and cardiovascular events alone in people with type 2 diabetes. People with a coronary artery calcium score of <10 were 6.8 times less likely to have cardiovascular event. Taken together, our meta-analysis strongly suggests the need for further investigation of the utility of using the coronary artery calcium score, particularly because of the implications that a negative screening test may hold for clinical risk stratification and preventive management in this population.

What is already known on this topic

  • The coronary artery calcium (CAC) score has been shown to predict the risk for cardiovascular events and facilitate reclassification of people from intermediate to low or high risk in large prospective studies of the general population
  • However, most of these studies excluded people with diabetes
  • The role of the CAC score in people with type 2 diabetes is unclear and given the broad range of cardiovascular risk observed in people with diabetes, this population warrants focused investigation on the predictive capacity of the CAC score
  • A CAC score of ≥10 predicted all cause mortality or cardiovascular events, or both compared with a score of <10, with high sensitivity but low specificity
  • For people with a CAC score of <10, the post-test probability of all cause mortality or cardiovascular events was reduced by 6.8-fold from their pretest probability
  • In people with diabetes, the finding of a CAC score of <10 may facilitate risk stratification by enabling the identification of low risk people within this otherwise high risk population

What this study adds

Source: BMJ

 

 

Lowering Your Blood Pressure Using Drugs May Increase Your Risk of Death, Study Shows .


 

blood-pressure

Hypertension is dangerous if uncontrolled, increasing your risk for heart attack and stroke. But using drugs to lower your blood pressure may shorten your lifespan instead of extending it, according to the results of a University of Florida study.

The study, published in the Journal of the American Medical Association,1 suggests that when it comes to blood pressure medication, less is more.

This is another example of using drugs to “Band Aid” a health problem without addressing the underlying cause. There is a major difference between achieving a healthy blood pressure number by eating well, exercising and managing stress, versus “forcing” your body to produce that number with a drug.

Drugs promised to be safe have, on many occasions, done more harm than good, yet blood pressure medications join sleeping pills and painkillers as some of the most popular drugs in America.

Be Careful—Blood Pressure Drugs May Backfire On You

The featured study was performed on individuals age 50 and up who had been diagnosed with both type 2 diabetes and CAD (coronary artery disease). The standard hypertension guidelines for diabetics suggest maintaining a systolic blood pressure under 130 mm Hg, but there is little data for the growing number of diabetics who also have CAD. This study aimed at filling that informational gap.

Each person in the study received one or more blood pressure medications (a combination of calcium antagonist, beta-blocker, ACE inhibitor, and diuretic) in whatever combination required to achieve a systolic blood pressure less than 130 mm Hg.

Researchers discovered that tighter control of blood pressure in these patients was NOT associated with better outcomes! The uncontrolled group fared worst, which wasn’t surprising. But the group whose systolic blood pressure was held between 130 and 140 actually showed a slightly lower risk of death than the group whose systolic was maintained at the recommended level—under 130 mm Hg. The authors write:2

“In this observational study, we have shown for the first time, to our knowledge, that decreasing systolic BP to lower than 130 mm Hg in patients with diabetes and CAD was not associated with further reduction in morbidity beyond that associated with systolic BP lower than 140 mm Hg, and, in fact, was associated with an increase in risk of all-cause mortality. Moreover, the increased mortality risk persisted over the long term.”

Tight Control Group

12.7 percent risk for death

Usual Control Group

12.6 percent risk for death

Uncontrolled Group

19.8 percent risk for death

Is It ‘Pharmageddon’?

This isn’t the first time pharmaceutical drugs have backfired. In fact, prescription drugs now kill more people than illegal drugs. Death by prescription drugs is a 21st-century epidemic, now killing even more Americans than motor vehicle accidents.

Drug fatalities more than doubled for teens and young adults between 2000 and 2008, and more than tripled among people age 50 to 69. It’s estimated there are 450,000 preventable adverse events related to medications in the U.S. every year, accounting for a substantial proportion of emergency room visits.

In a June 2010 report in the Journal of General Internal Medicine, almost a quarter of a million deaths resulted from in-hospital medication errors between the 1976 and 2006, based on a review of 62 million death certificates.

This doesn’t include the people who died after taking drugs exactly as prescribed! And when you add in deaths from hospital-acquired infections, unnecessary medical procedures, and adverse surgical outcomes, conventional medicine should top the list of the leading causes of death in the United States.

The Little-Known Connection Between Carbohydrates and Your Blood Pressure.

The good news is, the vast majority of you don’t need prescription drugs to normalize your blood pressure. In most cases, hypertension can be reversed with a few basic adjustments to your diet and lifestyle.

Are you on a high grain, low fat regimen? If so, I have bad news for you. This nutritional regimen is a prescription for many to develop hypertension. For years I’ve been advocating avoiding wheat, and this advice is finally making its way into the mainstream. The LA Times just featured an article discussing how wheat (and low-fat diets) contribute to inflammation, heart disease, diabetes, joint pain and many other chronic health problems. Cardiologist William Davis is quoted as saying:3

Eat more fat. Eat as little grain as possible. Grains don’t really belong in the human experience.”

This is not new information. Scientific research published way back in 1998 in the journal Diabetes reported that nearly two-thirds of the test subjects who were insulin resistant also had high blood pressure. Insulin resistance is directly attributable to a high sugar, high grain diet, especially if accompanied by inadequate exercise.

So, chances are that if you have hypertension, you also have poorly controlled blood sugar levels, because these two problems often go hand in hand. As your insulin level increases, so does your blood pressure.

Along with excessive carbohydrates, most people are consuming inadequate dietary fats, in terms of both quality and quantity. Contrary to what you’ve been told, glucose is not the preferred fuel of human metabolism—fat is. And fat doesn’t make you fat—excess carbohydrates make you fat. I believe that most people would benefit by consuming around 50 to 70 percent of their diet as beneficial fats. Sources of healthy fats include

Olives and Olive oil (for cold dishes)

Coconuts, and coconut oil (for all types of cooking and baking)

Butter made from raw grass-fed organic milk

Raw nuts, such as, almonds or pecans

Organic pastured egg yolks

Avocados

Pasture finished meats

Palm oil (make sure it’s the eco-friendly variety!)4

Unheated organic nut oils

My Prescription for Achieving Healthy Blood Pressure WITHOUT Drugs

  • Replace most of your carbs with non-starchy vegetables and replace the lost calories with healthy fats as mentioned above
  • Normalize your omega 6:3 ratio. Both omega-3 and omega-6 fats are essential for your health. Most Americans, however, are getting too much omega-6 and too little omega-3 in their diets. Consuming omega-3 fats is one of the best ways to re-sensitize your insulin receptors if you suffer from insulin resistance. Omega-3 fats are also important for strong cell membranes and good arterial elasticity. The best sources of omega-3 fats are fish and animal products. Unfortunately, most fresh fish today contains dangerously high levels of mercury. Your best bet is to find a safe source of fish, or if this proves too difficult, supplement with a high quality krill oil.
  • Eliminate caffeine. The connection between caffeine consumption and high blood pressure is not well understood, but there is ample evidence to indicate that if you have hypertension, coffee and other caffeinated drinks and foods can ex­acerbate your condition.
  • Consume fermented foods. Disturbances in gut flora appear to be a significant factor in the development of heart disease, as well as in many other chronic health problems. The best way to optimize your gut flora is by including some naturally fermented foods in your diet, such as sauerkraut and other fermented vegetables, yogurt, kefir, cheese and natto. Fermented foods (especially gouda and edam cheeses) are an important source of vitamin K2, which plays a crucial role in protecting your heart and brain.
  • Optimize your vitamin D level. Vitamin D deficiency has been linked to metabolic syndrome, as well as to high blood pressure. Vitamin D is a negative inhibitor of your body’s renin-angiotensin system (RAS), which regulates blood pressure. If you’re vitamin D deficient, it can cause inappropriate activation of your RAS, which may lead to hypertension. Ideally, you’ll want to get your vitamin D by safely exposing your skin to the sun, or using a safe tanning bed. If those are not possible, then consider taking a vitamin D3 supplement.
  • Make exercise a priority. A comprehensive exercise regimen such as my Peak Fitness program is very important in maintaining a healthy cardiovascular system. Your routine should incorporate high-intensity burst-type exercises and weight training one to three times a week, as these have been shown to be even more effective than aerobic exercises at reducing your risk of dying from a heart attack.
  • Get Grounded. Lack of grounding, due to widespread use of rubber or plastic-souled shoes, is likely contributing to chronic inflammation today. When you walk on the earth barefoot there is a massive transfer of beneficial electrons rom the Earth into your body. Experiments show that walking barefoot outside improves blood viscosity and blood flow, which help regulate blood pressure.So, do yourself a favor and put your bare feet upon the sand or dewy grass to harness the healing power of the Earth.
  • Manage your stress. It’s a well-known fact that stress elevates blood pressure, so controlling stress is an essential element of good heart health. My preferred stress-busting tool is Emotional Freedom Techniques (EFT), which is easy to learn and easy to use. However, you might find other methods like yoga, meditation, or prayer, equally effective.

Final Words

High blood pressure is reaching epidemic proportions in the Western world. Hypertension is best addressed using a natural approach, as opposed to a cocktail of prescription drugs that may actually backfire on you. One study showed that tighter control of blood pressure using pharmaceutical drugs is NOT associated with better outcomes and in fact may shorten your lifespan. Lifestyle changes, with particular emphasis on normalizing your insulin levels, will put you on the safest and most reliable path toward optimal health.

Source: mercola.com

Can We Build a Better SYNTAX Score?


 

Adding clinical factors to the anatomical SYNTAX model improved prediction of 4-year mortality with surgery versus stenting for complex coronary artery disease.

The SYNTAX score provides an anatomically based measure of coronary artery disease to help physicians and patients choose an appropriate revascularization strategy. However, other patient characteristics are often important factors in clinical decisions.

To improve the SYNTAX scoring system, investigators used SYNTAX trial data to identify six clinical factors — age, creatinine clearance, left ventricular ejection fraction [LVEF], peripheral vascular disease, female sex, and chronic obstructive pulmonary disease [COPD]) — that independently predicted 4-year mortality or showed an interaction effect between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for long-term mortality (notably, diabetes did not meet either of these criteria and was excluded from the model). These variables were combined with two anatomic measures: SYNTAX score and presence of left main disease.

Compared with the original SYNTAX model, the SYNTAX score II predicted similar 4-year mortality with CABG and PCI at lower scores with some clinical factors (female sex, lower LVEF) and at higher scores with others (older age, COPD, left main disease). The new model discriminated well between CABG and PCI, both in the SYNTAX population and in a validation cohort of 2900 participants in an international registry.

Comment: The inclusion of clinical variables improves the SYNTAX score by allowing clinicians to identify lower-risk patients in high categories of anatomic risk, and vice versa. Although externally validated, the new score requires further validation in randomized studies. In the meantime, clinicians should consider taking this common-sense approach to making revascularization decisions.

Source: Journal Watch Cardiology