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Comorbidities Are Common in Lupus
GOTHENBURG, SWEDEN – Swedes with systemic lupus erythematosus tend to die early and at a substantially higher rate than does the general population.
During 13 years of prospective follow-up, 20% of 208 Swedish SLE patients died at a mean age of 60 years. That translates into an age-adjusted 3.3-fold increased rate of all-cause mortality, Dr. Elisabet Svenungsson reported at the annual congress of the European Academy of Dermatology and Venereology.
Cardiovascular disease accounted for 52% of the deaths, a proportion similar to what's seen in the general population. The difference is that cardiovascular death in the SLE cohort occurred predominantly in women at a substantially younger age than is common in women without SLE, observed Dr. Svenungsson, a rheumatologist at Karolinska University Hospital in Stockholm.
In addition to cardiovascular disease, patients with SLE have a number of other comorbidities, including osteoporosis, Sjögren's syndrome, and autoimmune thyroid disease, she reported.
Vascular disease is one of the most common of the many comorbidities associated with SLE, she noted. In a cross-sectional study of 597 patients in the Swedish SLE Network, 11% had ischemic heart disease, 10% had ischemic cerebrovascular disease, and 16% had a history of venous thromboembolism.
The conventional Framingham risk factors don't explain the accelerated atherosclerosis present in patients with SLE. In a prospective cohort study involving 182 SLE patients with a mean age of 44 years, all of whom were free of known cardiovascular disease at baseline, Dr. Svenungsson and coworkers found that the incidence of a first cardiovascular event was 13% during a mean 8.3 years of follow-up. In an age-adjusted, Cox multivariate regression analysis, the only conventional risk factors independently associated with a first cardiovascular event were smoking and age. Smokers with SLE were 2.6-fold more likely to experience an event than were nonsmokers. The risk rose 2.4-fold per 10 years of age.
The other independent predictors of a first cardiovascular event were the presence of any positive antiphospholipid antibody test, which conferred a 4.2-fold increased risk; an elevated von Willebrand factor level, associated with a 2.0-fold risk; and the presence of thrombocytopenia, which was a protective factor associated with a 65% reduction in the risk of a cardiovascular event, Dr. Svenungsson said in her keynote lecture at the meeting of the European Society of Cutaneous Lupus Erythematosus, which was held in conjunction with the EADV congress.
Multiple studies have established that one or more antiphospholipid antibodies are present in 30%-50% of SLE patients. Among a cohort of 320 SLE patients who were being followed by Dr. Svenungsson and her associates, 18% fulfilled strict 2006 criteria for antiphospholipid syndrome. SLE patients with antiphospholipid syndrome have a high rate of thrombotic events that don't track with SLE disease activity.
"They just hit here and there; you never really know when," she said.
Turning to osteoporosis and SLE, Dr. Svenungsson cited a new cross-sectional study by physicians at the University of Gothenburg, who obtained x-rays of the thoracic and lumbar spine in 150 women with SLE who had a median age of 47 years and disease duration of 11 years. Although 29% of the SLE patients had at least one radiologic vertebral compression fracture, only 4% had been diagnosed with a compression fracture.
"You have here a lot of women with a subclinical history of vertebral fractures. That we don't detect most of these fractures may be one reason why patients with SLE often complain about pain," according to Dr. Svenungsson.
In the Gothenburg study, advanced age was an independent risk factor for one or more vertebral fractures at any site, whereas low bone mineral density in the total hip was associated with vertebral fracture in the lumbar spine. Interestingly, cumulative glucocorticoid dose wasn't predictive of vertebral fracture risk (Arthritis Res. Ther. 2010 Aug. 2 [doi:10.1186/ar3104]).
A number of autoimmune diseases commonly overlap with SLE. Among them is autoimmune thyroid disease, which was present in 17% of 331 SLE patients being followed by Dr. Svenungsson and her associates at Karolinska, compared with 8% of matched controls. Hypothyroidism was far more common than hyperthyroid disease in the Karolinska cohort, as has been reported in other SLE studies.
Another autoimmune disease commonly overlapping with SLE is Sj?gren’s syndrome. In the Karolinska cohort, 25% of SLE patients met strict diagnostic criteria for Sjögren's syndrome. Dry mouth was reported by 40% of patients, compared with 7% of matched controls. Dry eyes were reported by 32% of SLE patients vs. 7% of controls.
In addition to cardiovascular disease, osteoporosis, Sjögren's syndrome, antiphospholipid syndrome, and autoimmune thyroid disease, other conditions that occur at an increased rate in patients with SLE include malignancies, rheumatoid arthritis, systemic sclerosis, myositis, vasculitis, autoimmune hepatitis, and infections.
"Lupus is an imitator. It's difficult to say what is comorbidity and what is really a manifestation of lupus," Dr. Svenungsson concluded.
She reported having no relevant financial interests.
GOTHENBURG, SWEDEN – Swedes with systemic lupus erythematosus tend to die early and at a substantially higher rate than does the general population.
During 13 years of prospective follow-up, 20% of 208 Swedish SLE patients died at a mean age of 60 years. That translates into an age-adjusted 3.3-fold increased rate of all-cause mortality, Dr. Elisabet Svenungsson reported at the annual congress of the European Academy of Dermatology and Venereology.
Cardiovascular disease accounted for 52% of the deaths, a proportion similar to what's seen in the general population. The difference is that cardiovascular death in the SLE cohort occurred predominantly in women at a substantially younger age than is common in women without SLE, observed Dr. Svenungsson, a rheumatologist at Karolinska University Hospital in Stockholm.
In addition to cardiovascular disease, patients with SLE have a number of other comorbidities, including osteoporosis, Sjögren's syndrome, and autoimmune thyroid disease, she reported.
Vascular disease is one of the most common of the many comorbidities associated with SLE, she noted. In a cross-sectional study of 597 patients in the Swedish SLE Network, 11% had ischemic heart disease, 10% had ischemic cerebrovascular disease, and 16% had a history of venous thromboembolism.
The conventional Framingham risk factors don't explain the accelerated atherosclerosis present in patients with SLE. In a prospective cohort study involving 182 SLE patients with a mean age of 44 years, all of whom were free of known cardiovascular disease at baseline, Dr. Svenungsson and coworkers found that the incidence of a first cardiovascular event was 13% during a mean 8.3 years of follow-up. In an age-adjusted, Cox multivariate regression analysis, the only conventional risk factors independently associated with a first cardiovascular event were smoking and age. Smokers with SLE were 2.6-fold more likely to experience an event than were nonsmokers. The risk rose 2.4-fold per 10 years of age.
The other independent predictors of a first cardiovascular event were the presence of any positive antiphospholipid antibody test, which conferred a 4.2-fold increased risk; an elevated von Willebrand factor level, associated with a 2.0-fold risk; and the presence of thrombocytopenia, which was a protective factor associated with a 65% reduction in the risk of a cardiovascular event, Dr. Svenungsson said in her keynote lecture at the meeting of the European Society of Cutaneous Lupus Erythematosus, which was held in conjunction with the EADV congress.
Multiple studies have established that one or more antiphospholipid antibodies are present in 30%-50% of SLE patients. Among a cohort of 320 SLE patients who were being followed by Dr. Svenungsson and her associates, 18% fulfilled strict 2006 criteria for antiphospholipid syndrome. SLE patients with antiphospholipid syndrome have a high rate of thrombotic events that don't track with SLE disease activity.
"They just hit here and there; you never really know when," she said.
Turning to osteoporosis and SLE, Dr. Svenungsson cited a new cross-sectional study by physicians at the University of Gothenburg, who obtained x-rays of the thoracic and lumbar spine in 150 women with SLE who had a median age of 47 years and disease duration of 11 years. Although 29% of the SLE patients had at least one radiologic vertebral compression fracture, only 4% had been diagnosed with a compression fracture.
"You have here a lot of women with a subclinical history of vertebral fractures. That we don't detect most of these fractures may be one reason why patients with SLE often complain about pain," according to Dr. Svenungsson.
In the Gothenburg study, advanced age was an independent risk factor for one or more vertebral fractures at any site, whereas low bone mineral density in the total hip was associated with vertebral fracture in the lumbar spine. Interestingly, cumulative glucocorticoid dose wasn't predictive of vertebral fracture risk (Arthritis Res. Ther. 2010 Aug. 2 [doi:10.1186/ar3104]).
A number of autoimmune diseases commonly overlap with SLE. Among them is autoimmune thyroid disease, which was present in 17% of 331 SLE patients being followed by Dr. Svenungsson and her associates at Karolinska, compared with 8% of matched controls. Hypothyroidism was far more common than hyperthyroid disease in the Karolinska cohort, as has been reported in other SLE studies.
Another autoimmune disease commonly overlapping with SLE is Sj?gren’s syndrome. In the Karolinska cohort, 25% of SLE patients met strict diagnostic criteria for Sjögren's syndrome. Dry mouth was reported by 40% of patients, compared with 7% of matched controls. Dry eyes were reported by 32% of SLE patients vs. 7% of controls.
In addition to cardiovascular disease, osteoporosis, Sjögren's syndrome, antiphospholipid syndrome, and autoimmune thyroid disease, other conditions that occur at an increased rate in patients with SLE include malignancies, rheumatoid arthritis, systemic sclerosis, myositis, vasculitis, autoimmune hepatitis, and infections.
"Lupus is an imitator. It's difficult to say what is comorbidity and what is really a manifestation of lupus," Dr. Svenungsson concluded.
She reported having no relevant financial interests.
GOTHENBURG, SWEDEN – Swedes with systemic lupus erythematosus tend to die early and at a substantially higher rate than does the general population.
During 13 years of prospective follow-up, 20% of 208 Swedish SLE patients died at a mean age of 60 years. That translates into an age-adjusted 3.3-fold increased rate of all-cause mortality, Dr. Elisabet Svenungsson reported at the annual congress of the European Academy of Dermatology and Venereology.
Cardiovascular disease accounted for 52% of the deaths, a proportion similar to what's seen in the general population. The difference is that cardiovascular death in the SLE cohort occurred predominantly in women at a substantially younger age than is common in women without SLE, observed Dr. Svenungsson, a rheumatologist at Karolinska University Hospital in Stockholm.
In addition to cardiovascular disease, patients with SLE have a number of other comorbidities, including osteoporosis, Sjögren's syndrome, and autoimmune thyroid disease, she reported.
Vascular disease is one of the most common of the many comorbidities associated with SLE, she noted. In a cross-sectional study of 597 patients in the Swedish SLE Network, 11% had ischemic heart disease, 10% had ischemic cerebrovascular disease, and 16% had a history of venous thromboembolism.
The conventional Framingham risk factors don't explain the accelerated atherosclerosis present in patients with SLE. In a prospective cohort study involving 182 SLE patients with a mean age of 44 years, all of whom were free of known cardiovascular disease at baseline, Dr. Svenungsson and coworkers found that the incidence of a first cardiovascular event was 13% during a mean 8.3 years of follow-up. In an age-adjusted, Cox multivariate regression analysis, the only conventional risk factors independently associated with a first cardiovascular event were smoking and age. Smokers with SLE were 2.6-fold more likely to experience an event than were nonsmokers. The risk rose 2.4-fold per 10 years of age.
The other independent predictors of a first cardiovascular event were the presence of any positive antiphospholipid antibody test, which conferred a 4.2-fold increased risk; an elevated von Willebrand factor level, associated with a 2.0-fold risk; and the presence of thrombocytopenia, which was a protective factor associated with a 65% reduction in the risk of a cardiovascular event, Dr. Svenungsson said in her keynote lecture at the meeting of the European Society of Cutaneous Lupus Erythematosus, which was held in conjunction with the EADV congress.
Multiple studies have established that one or more antiphospholipid antibodies are present in 30%-50% of SLE patients. Among a cohort of 320 SLE patients who were being followed by Dr. Svenungsson and her associates, 18% fulfilled strict 2006 criteria for antiphospholipid syndrome. SLE patients with antiphospholipid syndrome have a high rate of thrombotic events that don't track with SLE disease activity.
"They just hit here and there; you never really know when," she said.
Turning to osteoporosis and SLE, Dr. Svenungsson cited a new cross-sectional study by physicians at the University of Gothenburg, who obtained x-rays of the thoracic and lumbar spine in 150 women with SLE who had a median age of 47 years and disease duration of 11 years. Although 29% of the SLE patients had at least one radiologic vertebral compression fracture, only 4% had been diagnosed with a compression fracture.
"You have here a lot of women with a subclinical history of vertebral fractures. That we don't detect most of these fractures may be one reason why patients with SLE often complain about pain," according to Dr. Svenungsson.
In the Gothenburg study, advanced age was an independent risk factor for one or more vertebral fractures at any site, whereas low bone mineral density in the total hip was associated with vertebral fracture in the lumbar spine. Interestingly, cumulative glucocorticoid dose wasn't predictive of vertebral fracture risk (Arthritis Res. Ther. 2010 Aug. 2 [doi:10.1186/ar3104]).
A number of autoimmune diseases commonly overlap with SLE. Among them is autoimmune thyroid disease, which was present in 17% of 331 SLE patients being followed by Dr. Svenungsson and her associates at Karolinska, compared with 8% of matched controls. Hypothyroidism was far more common than hyperthyroid disease in the Karolinska cohort, as has been reported in other SLE studies.
Another autoimmune disease commonly overlapping with SLE is Sj?gren’s syndrome. In the Karolinska cohort, 25% of SLE patients met strict diagnostic criteria for Sjögren's syndrome. Dry mouth was reported by 40% of patients, compared with 7% of matched controls. Dry eyes were reported by 32% of SLE patients vs. 7% of controls.
In addition to cardiovascular disease, osteoporosis, Sjögren's syndrome, antiphospholipid syndrome, and autoimmune thyroid disease, other conditions that occur at an increased rate in patients with SLE include malignancies, rheumatoid arthritis, systemic sclerosis, myositis, vasculitis, autoimmune hepatitis, and infections.
"Lupus is an imitator. It's difficult to say what is comorbidity and what is really a manifestation of lupus," Dr. Svenungsson concluded.
She reported having no relevant financial interests.
EXPERT ANALYSIS FROM THE ANNUAL CONGRESS OF THE EUROPEAN ACADEMY OF DERMATOLOGY AND VENEREOLOGY
Comorbidities Are Common in Systemic Lupus Erythematosus
GOTHENBURG, SWEDEN – Swedes with systemic lupus erythematosus tend to die early and at a substantially higher rate than does the general population.
During 13 years of prospective follow-up, 20% of 208 Swedish SLE patients died at a quite young mean age of 60 years. That translates into an age-adjusted 3.3-fold increased rate of all-cause mortality, Dr. Elisabet Svenungsson reported at the annual congress of the European Academy of Dermatology and Venereology.
Cardiovascular disease accounted for 52% of the deaths, a proportion similar to what’s seen in the general population. The difference is that cardiovascular death in the SLE cohort occurred predominantly in women at a substantially younger age than is common in women without SLE, observed Dr. Svenungsson, a rheumatologist at Karolinska University Hospital in Stockholm.
In addition to cardiovascular disease, patients with SLE have a number of other comorbidities, including osteoporosis, Sj?gren’s syndrome, and autoimmune thyroid disease, she reported.
Vascular disease is one of the most common of the many comorbidities associated with SLE, the rheumatologist noted. In a cross-sectional study of 597 patients in the Swedish SLE Network, 11% had ischemic heart disease, 10% had ischemic cerebrovascular disease, and 16% had a history of venous thromboembolism.
The conventional Framingham risk factors don’t explain the accelerated atherosclerosis present in patients with SLE. In a prospective cohort study involving 182 SLE patients with a mean age of 44 years, all of whom were free of known cardiovascular disease at baseline, Dr. Svenungsson and coworkers found that the incidence of a first cardiovascular event was 13% during a mean 8.3 years of follow-up. In an age-adjusted, Cox multivariate regression analysis, the only conventional risk factors independently associated with a first cardiovascular event were smoking and age. Smokers with SLE were 2.6-fold more likely to experience an event than were nonsmokers. The risk rose 2.4-fold per 10 years of age.
The other independent predictors of a first cardiovascular event were the presence of any positive antiphospholipid antibody test, which conferred a 4.23-fold increased risk; an elevated von Willebrand factor level, associated with a 1.97-fold risk; and the presence of thrombocytopenia, which was a protective factor associated with a 65% reduction in the risk of a cardiovascular event, Dr. Svenungsson said in her keynote lecture at the meeting of the European Society of Cutaneous Lupus Erythematosus, which was held in conjunction with EADV congress.
Multiple studies have established that one or more antiphospholipid antibodies are present in 30%-50% of SLE patients. Among a cohort of 320 SLE patients who were being followed by Dr. Svenungsson and her associates, 18% fulfilled strict 2006 criteria for antiphospholipid syndrome. SLE patients with antiphospholipid syndrome have a high rate of thrombotic events that don’t track with SLE disease activity.
"They just hit here and there; you never really know when," the rheumatologist observed.
Turning to osteoporosis and SLE, Dr. Svenungsson cited a new cross-sectional study by rheumatologists at the University of Gothenburg, who obtained x-rays of the thoracic and lumbar spine in 150 women with SLE who had a median age of 47 years and disease duration of 11 years. Although 29% of the SLE patients had at least one radiologic vertebral compression fracture, only 4% had been diagnosed with a compression fracture.
"You have here a lot of women with a subclinical history of vertebral fractures. That we don’t detect most of these fractures may be one reason why patients with SLE often complain about pain," according to Dr. Svenungsson.
In the Gothenburg study, advanced age was an independent risk factor for one or more vertebral fractures at any site, whereas low bone mineral density in the total hip was associated with vertebral fracture in the lumbar spine. Interestingly, cumulative glucocorticoid dose wasn’t predictive of vertebral fracture risk (Arthritis Res. Ther. 2010 Aug. 2 [doi:10.1186/ar3104]).
A number of autoimmune diseases commonly overlap with SLE. Among them is autoimmune thyroid disease, which was present in 17% of 331 SLE patients being followed by Dr. Svenungsson and her associates at Karolinska, compared with 8% of matched controls. Hypothyroidism was far more common than hyperthyroid disease in the Karolinska cohort, as has been reported in other SLE studies.
Another autoimmune disease commonly overlapping with SLE is Sj?gren’s syndrome. In the Karolinska cohort, 25% of SLE patients met strict diagnostic criteria for Sj?gren’s syndrome. Dry mouth was reported by 40% of patients, compared with 7% of matched controls. Dry eyes were reported by 32% of SLE patients vs. 7% of controls.
In addition to cardiovascular disease, osteoporosis, Sj?gren’s syndrome, antiphospholipid syndrome, and autoimmune thyroid disease, other conditions that occur at an increased rate in patients with SLE include malignancies, rheumatoid arthritis, systemic sclerosis, myositis, vasculitis, autoimmune hepatitis, and infections.
"Lupus is an imitator. It’s difficult to say what is comorbidity and what is really a manifestation of lupus," Dr. Svenungsson concluded.
She declared that she has no relevant financial interests.
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GOTHENBURG, SWEDEN – Swedes with systemic lupus erythematosus tend to die early and at a substantially higher rate than does the general population.
During 13 years of prospective follow-up, 20% of 208 Swedish SLE patients died at a quite young mean age of 60 years. That translates into an age-adjusted 3.3-fold increased rate of all-cause mortality, Dr. Elisabet Svenungsson reported at the annual congress of the European Academy of Dermatology and Venereology.
Cardiovascular disease accounted for 52% of the deaths, a proportion similar to what’s seen in the general population. The difference is that cardiovascular death in the SLE cohort occurred predominantly in women at a substantially younger age than is common in women without SLE, observed Dr. Svenungsson, a rheumatologist at Karolinska University Hospital in Stockholm.
In addition to cardiovascular disease, patients with SLE have a number of other comorbidities, including osteoporosis, Sj?gren’s syndrome, and autoimmune thyroid disease, she reported.
Vascular disease is one of the most common of the many comorbidities associated with SLE, the rheumatologist noted. In a cross-sectional study of 597 patients in the Swedish SLE Network, 11% had ischemic heart disease, 10% had ischemic cerebrovascular disease, and 16% had a history of venous thromboembolism.
The conventional Framingham risk factors don’t explain the accelerated atherosclerosis present in patients with SLE. In a prospective cohort study involving 182 SLE patients with a mean age of 44 years, all of whom were free of known cardiovascular disease at baseline, Dr. Svenungsson and coworkers found that the incidence of a first cardiovascular event was 13% during a mean 8.3 years of follow-up. In an age-adjusted, Cox multivariate regression analysis, the only conventional risk factors independently associated with a first cardiovascular event were smoking and age. Smokers with SLE were 2.6-fold more likely to experience an event than were nonsmokers. The risk rose 2.4-fold per 10 years of age.
The other independent predictors of a first cardiovascular event were the presence of any positive antiphospholipid antibody test, which conferred a 4.23-fold increased risk; an elevated von Willebrand factor level, associated with a 1.97-fold risk; and the presence of thrombocytopenia, which was a protective factor associated with a 65% reduction in the risk of a cardiovascular event, Dr. Svenungsson said in her keynote lecture at the meeting of the European Society of Cutaneous Lupus Erythematosus, which was held in conjunction with EADV congress.
Multiple studies have established that one or more antiphospholipid antibodies are present in 30%-50% of SLE patients. Among a cohort of 320 SLE patients who were being followed by Dr. Svenungsson and her associates, 18% fulfilled strict 2006 criteria for antiphospholipid syndrome. SLE patients with antiphospholipid syndrome have a high rate of thrombotic events that don’t track with SLE disease activity.
"They just hit here and there; you never really know when," the rheumatologist observed.
Turning to osteoporosis and SLE, Dr. Svenungsson cited a new cross-sectional study by rheumatologists at the University of Gothenburg, who obtained x-rays of the thoracic and lumbar spine in 150 women with SLE who had a median age of 47 years and disease duration of 11 years. Although 29% of the SLE patients had at least one radiologic vertebral compression fracture, only 4% had been diagnosed with a compression fracture.
"You have here a lot of women with a subclinical history of vertebral fractures. That we don’t detect most of these fractures may be one reason why patients with SLE often complain about pain," according to Dr. Svenungsson.
In the Gothenburg study, advanced age was an independent risk factor for one or more vertebral fractures at any site, whereas low bone mineral density in the total hip was associated with vertebral fracture in the lumbar spine. Interestingly, cumulative glucocorticoid dose wasn’t predictive of vertebral fracture risk (Arthritis Res. Ther. 2010 Aug. 2 [doi:10.1186/ar3104]).
A number of autoimmune diseases commonly overlap with SLE. Among them is autoimmune thyroid disease, which was present in 17% of 331 SLE patients being followed by Dr. Svenungsson and her associates at Karolinska, compared with 8% of matched controls. Hypothyroidism was far more common than hyperthyroid disease in the Karolinska cohort, as has been reported in other SLE studies.
Another autoimmune disease commonly overlapping with SLE is Sj?gren’s syndrome. In the Karolinska cohort, 25% of SLE patients met strict diagnostic criteria for Sj?gren’s syndrome. Dry mouth was reported by 40% of patients, compared with 7% of matched controls. Dry eyes were reported by 32% of SLE patients vs. 7% of controls.
In addition to cardiovascular disease, osteoporosis, Sj?gren’s syndrome, antiphospholipid syndrome, and autoimmune thyroid disease, other conditions that occur at an increased rate in patients with SLE include malignancies, rheumatoid arthritis, systemic sclerosis, myositis, vasculitis, autoimmune hepatitis, and infections.
"Lupus is an imitator. It’s difficult to say what is comorbidity and what is really a manifestation of lupus," Dr. Svenungsson concluded.
She declared that she has no relevant financial interests.
GOTHENBURG, SWEDEN – Swedes with systemic lupus erythematosus tend to die early and at a substantially higher rate than does the general population.
During 13 years of prospective follow-up, 20% of 208 Swedish SLE patients died at a quite young mean age of 60 years. That translates into an age-adjusted 3.3-fold increased rate of all-cause mortality, Dr. Elisabet Svenungsson reported at the annual congress of the European Academy of Dermatology and Venereology.
Cardiovascular disease accounted for 52% of the deaths, a proportion similar to what’s seen in the general population. The difference is that cardiovascular death in the SLE cohort occurred predominantly in women at a substantially younger age than is common in women without SLE, observed Dr. Svenungsson, a rheumatologist at Karolinska University Hospital in Stockholm.
In addition to cardiovascular disease, patients with SLE have a number of other comorbidities, including osteoporosis, Sj?gren’s syndrome, and autoimmune thyroid disease, she reported.
Vascular disease is one of the most common of the many comorbidities associated with SLE, the rheumatologist noted. In a cross-sectional study of 597 patients in the Swedish SLE Network, 11% had ischemic heart disease, 10% had ischemic cerebrovascular disease, and 16% had a history of venous thromboembolism.
The conventional Framingham risk factors don’t explain the accelerated atherosclerosis present in patients with SLE. In a prospective cohort study involving 182 SLE patients with a mean age of 44 years, all of whom were free of known cardiovascular disease at baseline, Dr. Svenungsson and coworkers found that the incidence of a first cardiovascular event was 13% during a mean 8.3 years of follow-up. In an age-adjusted, Cox multivariate regression analysis, the only conventional risk factors independently associated with a first cardiovascular event were smoking and age. Smokers with SLE were 2.6-fold more likely to experience an event than were nonsmokers. The risk rose 2.4-fold per 10 years of age.
The other independent predictors of a first cardiovascular event were the presence of any positive antiphospholipid antibody test, which conferred a 4.23-fold increased risk; an elevated von Willebrand factor level, associated with a 1.97-fold risk; and the presence of thrombocytopenia, which was a protective factor associated with a 65% reduction in the risk of a cardiovascular event, Dr. Svenungsson said in her keynote lecture at the meeting of the European Society of Cutaneous Lupus Erythematosus, which was held in conjunction with EADV congress.
Multiple studies have established that one or more antiphospholipid antibodies are present in 30%-50% of SLE patients. Among a cohort of 320 SLE patients who were being followed by Dr. Svenungsson and her associates, 18% fulfilled strict 2006 criteria for antiphospholipid syndrome. SLE patients with antiphospholipid syndrome have a high rate of thrombotic events that don’t track with SLE disease activity.
"They just hit here and there; you never really know when," the rheumatologist observed.
Turning to osteoporosis and SLE, Dr. Svenungsson cited a new cross-sectional study by rheumatologists at the University of Gothenburg, who obtained x-rays of the thoracic and lumbar spine in 150 women with SLE who had a median age of 47 years and disease duration of 11 years. Although 29% of the SLE patients had at least one radiologic vertebral compression fracture, only 4% had been diagnosed with a compression fracture.
"You have here a lot of women with a subclinical history of vertebral fractures. That we don’t detect most of these fractures may be one reason why patients with SLE often complain about pain," according to Dr. Svenungsson.
In the Gothenburg study, advanced age was an independent risk factor for one or more vertebral fractures at any site, whereas low bone mineral density in the total hip was associated with vertebral fracture in the lumbar spine. Interestingly, cumulative glucocorticoid dose wasn’t predictive of vertebral fracture risk (Arthritis Res. Ther. 2010 Aug. 2 [doi:10.1186/ar3104]).
A number of autoimmune diseases commonly overlap with SLE. Among them is autoimmune thyroid disease, which was present in 17% of 331 SLE patients being followed by Dr. Svenungsson and her associates at Karolinska, compared with 8% of matched controls. Hypothyroidism was far more common than hyperthyroid disease in the Karolinska cohort, as has been reported in other SLE studies.
Another autoimmune disease commonly overlapping with SLE is Sj?gren’s syndrome. In the Karolinska cohort, 25% of SLE patients met strict diagnostic criteria for Sj?gren’s syndrome. Dry mouth was reported by 40% of patients, compared with 7% of matched controls. Dry eyes were reported by 32% of SLE patients vs. 7% of controls.
In addition to cardiovascular disease, osteoporosis, Sj?gren’s syndrome, antiphospholipid syndrome, and autoimmune thyroid disease, other conditions that occur at an increased rate in patients with SLE include malignancies, rheumatoid arthritis, systemic sclerosis, myositis, vasculitis, autoimmune hepatitis, and infections.
"Lupus is an imitator. It’s difficult to say what is comorbidity and what is really a manifestation of lupus," Dr. Svenungsson concluded.
She declared that she has no relevant financial interests.
Comorbidities Are Common in Systemic Lupus Erythematosus
GOTHENBURG, SWEDEN – Swedes with systemic lupus erythematosus tend to die early and at a substantially higher rate than does the general population.
During 13 years of prospective follow-up, 20% of 208 Swedish SLE patients died at a quite young mean age of 60 years. That translates into an age-adjusted 3.3-fold increased rate of all-cause mortality, Dr. Elisabet Svenungsson reported at the annual congress of the European Academy of Dermatology and Venereology.
Cardiovascular disease accounted for 52% of the deaths, a proportion similar to what’s seen in the general population. The difference is that cardiovascular death in the SLE cohort occurred predominantly in women at a substantially younger age than is common in women without SLE, observed Dr. Svenungsson, a rheumatologist at Karolinska University Hospital in Stockholm.
In addition to cardiovascular disease, patients with SLE have a number of other comorbidities, including osteoporosis, Sj?gren’s syndrome, and autoimmune thyroid disease, she reported.
Vascular disease is one of the most common of the many comorbidities associated with SLE, the rheumatologist noted. In a cross-sectional study of 597 patients in the Swedish SLE Network, 11% had ischemic heart disease, 10% had ischemic cerebrovascular disease, and 16% had a history of venous thromboembolism.
The conventional Framingham risk factors don’t explain the accelerated atherosclerosis present in patients with SLE. In a prospective cohort study involving 182 SLE patients with a mean age of 44 years, all of whom were free of known cardiovascular disease at baseline, Dr. Svenungsson and coworkers found that the incidence of a first cardiovascular event was 13% during a mean 8.3 years of follow-up. In an age-adjusted, Cox multivariate regression analysis, the only conventional risk factors independently associated with a first cardiovascular event were smoking and age. Smokers with SLE were 2.6-fold more likely to experience an event than were nonsmokers. The risk rose 2.4-fold per 10 years of age.
The other independent predictors of a first cardiovascular event were the presence of any positive antiphospholipid antibody test, which conferred a 4.23-fold increased risk; an elevated von Willebrand factor level, associated with a 1.97-fold risk; and the presence of thrombocytopenia, which was a protective factor associated with a 65% reduction in the risk of a cardiovascular event, Dr. Svenungsson said in her keynote lecture at the meeting of the European Society of Cutaneous Lupus Erythematosus, which was held in conjunction with EADV congress.
Multiple studies have established that one or more antiphospholipid antibodies are present in 30%-50% of SLE patients. Among a cohort of 320 SLE patients who were being followed by Dr. Svenungsson and her associates, 18% fulfilled strict 2006 criteria for antiphospholipid syndrome. SLE patients with antiphospholipid syndrome have a high rate of thrombotic events that don’t track with SLE disease activity.
"They just hit here and there; you never really know when," the rheumatologist observed.
Turning to osteoporosis and SLE, Dr. Svenungsson cited a new cross-sectional study by rheumatologists at the University of Gothenburg, who obtained x-rays of the thoracic and lumbar spine in 150 women with SLE who had a median age of 47 years and disease duration of 11 years. Although 29% of the SLE patients had at least one radiologic vertebral compression fracture, only 4% had been diagnosed with a compression fracture.
"You have here a lot of women with a subclinical history of vertebral fractures. That we don’t detect most of these fractures may be one reason why patients with SLE often complain about pain," according to Dr. Svenungsson.
In the Gothenburg study, advanced age was an independent risk factor for one or more vertebral fractures at any site, whereas low bone mineral density in the total hip was associated with vertebral fracture in the lumbar spine. Interestingly, cumulative glucocorticoid dose wasn’t predictive of vertebral fracture risk (Arthritis Res. Ther. 2010 Aug. 2 [doi:10.1186/ar3104]).
A number of autoimmune diseases commonly overlap with SLE. Among them is autoimmune thyroid disease, which was present in 17% of 331 SLE patients being followed by Dr. Svenungsson and her associates at Karolinska, compared with 8% of matched controls. Hypothyroidism was far more common than hyperthyroid disease in the Karolinska cohort, as has been reported in other SLE studies.
Another autoimmune disease commonly overlapping with SLE is Sj?gren’s syndrome. In the Karolinska cohort, 25% of SLE patients met strict diagnostic criteria for Sj?gren’s syndrome. Dry mouth was reported by 40% of patients, compared with 7% of matched controls. Dry eyes were reported by 32% of SLE patients vs. 7% of controls.
In addition to cardiovascular disease, osteoporosis, Sj?gren’s syndrome, antiphospholipid syndrome, and autoimmune thyroid disease, other conditions that occur at an increased rate in patients with SLE include malignancies, rheumatoid arthritis, systemic sclerosis, myositis, vasculitis, autoimmune hepatitis, and infections.
"Lupus is an imitator. It’s difficult to say what is comorbidity and what is really a manifestation of lupus," Dr. Svenungsson concluded.
She declared that she has no relevant financial interests.
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Doctor’s Bio
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Doctor’s Bio
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Doctor’s Bio
GOTHENBURG, SWEDEN – Swedes with systemic lupus erythematosus tend to die early and at a substantially higher rate than does the general population.
During 13 years of prospective follow-up, 20% of 208 Swedish SLE patients died at a quite young mean age of 60 years. That translates into an age-adjusted 3.3-fold increased rate of all-cause mortality, Dr. Elisabet Svenungsson reported at the annual congress of the European Academy of Dermatology and Venereology.
Cardiovascular disease accounted for 52% of the deaths, a proportion similar to what’s seen in the general population. The difference is that cardiovascular death in the SLE cohort occurred predominantly in women at a substantially younger age than is common in women without SLE, observed Dr. Svenungsson, a rheumatologist at Karolinska University Hospital in Stockholm.
In addition to cardiovascular disease, patients with SLE have a number of other comorbidities, including osteoporosis, Sj?gren’s syndrome, and autoimmune thyroid disease, she reported.
Vascular disease is one of the most common of the many comorbidities associated with SLE, the rheumatologist noted. In a cross-sectional study of 597 patients in the Swedish SLE Network, 11% had ischemic heart disease, 10% had ischemic cerebrovascular disease, and 16% had a history of venous thromboembolism.
The conventional Framingham risk factors don’t explain the accelerated atherosclerosis present in patients with SLE. In a prospective cohort study involving 182 SLE patients with a mean age of 44 years, all of whom were free of known cardiovascular disease at baseline, Dr. Svenungsson and coworkers found that the incidence of a first cardiovascular event was 13% during a mean 8.3 years of follow-up. In an age-adjusted, Cox multivariate regression analysis, the only conventional risk factors independently associated with a first cardiovascular event were smoking and age. Smokers with SLE were 2.6-fold more likely to experience an event than were nonsmokers. The risk rose 2.4-fold per 10 years of age.
The other independent predictors of a first cardiovascular event were the presence of any positive antiphospholipid antibody test, which conferred a 4.23-fold increased risk; an elevated von Willebrand factor level, associated with a 1.97-fold risk; and the presence of thrombocytopenia, which was a protective factor associated with a 65% reduction in the risk of a cardiovascular event, Dr. Svenungsson said in her keynote lecture at the meeting of the European Society of Cutaneous Lupus Erythematosus, which was held in conjunction with EADV congress.
Multiple studies have established that one or more antiphospholipid antibodies are present in 30%-50% of SLE patients. Among a cohort of 320 SLE patients who were being followed by Dr. Svenungsson and her associates, 18% fulfilled strict 2006 criteria for antiphospholipid syndrome. SLE patients with antiphospholipid syndrome have a high rate of thrombotic events that don’t track with SLE disease activity.
"They just hit here and there; you never really know when," the rheumatologist observed.
Turning to osteoporosis and SLE, Dr. Svenungsson cited a new cross-sectional study by rheumatologists at the University of Gothenburg, who obtained x-rays of the thoracic and lumbar spine in 150 women with SLE who had a median age of 47 years and disease duration of 11 years. Although 29% of the SLE patients had at least one radiologic vertebral compression fracture, only 4% had been diagnosed with a compression fracture.
"You have here a lot of women with a subclinical history of vertebral fractures. That we don’t detect most of these fractures may be one reason why patients with SLE often complain about pain," according to Dr. Svenungsson.
In the Gothenburg study, advanced age was an independent risk factor for one or more vertebral fractures at any site, whereas low bone mineral density in the total hip was associated with vertebral fracture in the lumbar spine. Interestingly, cumulative glucocorticoid dose wasn’t predictive of vertebral fracture risk (Arthritis Res. Ther. 2010 Aug. 2 [doi:10.1186/ar3104]).
A number of autoimmune diseases commonly overlap with SLE. Among them is autoimmune thyroid disease, which was present in 17% of 331 SLE patients being followed by Dr. Svenungsson and her associates at Karolinska, compared with 8% of matched controls. Hypothyroidism was far more common than hyperthyroid disease in the Karolinska cohort, as has been reported in other SLE studies.
Another autoimmune disease commonly overlapping with SLE is Sj?gren’s syndrome. In the Karolinska cohort, 25% of SLE patients met strict diagnostic criteria for Sj?gren’s syndrome. Dry mouth was reported by 40% of patients, compared with 7% of matched controls. Dry eyes were reported by 32% of SLE patients vs. 7% of controls.
In addition to cardiovascular disease, osteoporosis, Sj?gren’s syndrome, antiphospholipid syndrome, and autoimmune thyroid disease, other conditions that occur at an increased rate in patients with SLE include malignancies, rheumatoid arthritis, systemic sclerosis, myositis, vasculitis, autoimmune hepatitis, and infections.
"Lupus is an imitator. It’s difficult to say what is comorbidity and what is really a manifestation of lupus," Dr. Svenungsson concluded.
She declared that she has no relevant financial interests.
GOTHENBURG, SWEDEN – Swedes with systemic lupus erythematosus tend to die early and at a substantially higher rate than does the general population.
During 13 years of prospective follow-up, 20% of 208 Swedish SLE patients died at a quite young mean age of 60 years. That translates into an age-adjusted 3.3-fold increased rate of all-cause mortality, Dr. Elisabet Svenungsson reported at the annual congress of the European Academy of Dermatology and Venereology.
Cardiovascular disease accounted for 52% of the deaths, a proportion similar to what’s seen in the general population. The difference is that cardiovascular death in the SLE cohort occurred predominantly in women at a substantially younger age than is common in women without SLE, observed Dr. Svenungsson, a rheumatologist at Karolinska University Hospital in Stockholm.
In addition to cardiovascular disease, patients with SLE have a number of other comorbidities, including osteoporosis, Sj?gren’s syndrome, and autoimmune thyroid disease, she reported.
Vascular disease is one of the most common of the many comorbidities associated with SLE, the rheumatologist noted. In a cross-sectional study of 597 patients in the Swedish SLE Network, 11% had ischemic heart disease, 10% had ischemic cerebrovascular disease, and 16% had a history of venous thromboembolism.
The conventional Framingham risk factors don’t explain the accelerated atherosclerosis present in patients with SLE. In a prospective cohort study involving 182 SLE patients with a mean age of 44 years, all of whom were free of known cardiovascular disease at baseline, Dr. Svenungsson and coworkers found that the incidence of a first cardiovascular event was 13% during a mean 8.3 years of follow-up. In an age-adjusted, Cox multivariate regression analysis, the only conventional risk factors independently associated with a first cardiovascular event were smoking and age. Smokers with SLE were 2.6-fold more likely to experience an event than were nonsmokers. The risk rose 2.4-fold per 10 years of age.
The other independent predictors of a first cardiovascular event were the presence of any positive antiphospholipid antibody test, which conferred a 4.23-fold increased risk; an elevated von Willebrand factor level, associated with a 1.97-fold risk; and the presence of thrombocytopenia, which was a protective factor associated with a 65% reduction in the risk of a cardiovascular event, Dr. Svenungsson said in her keynote lecture at the meeting of the European Society of Cutaneous Lupus Erythematosus, which was held in conjunction with EADV congress.
Multiple studies have established that one or more antiphospholipid antibodies are present in 30%-50% of SLE patients. Among a cohort of 320 SLE patients who were being followed by Dr. Svenungsson and her associates, 18% fulfilled strict 2006 criteria for antiphospholipid syndrome. SLE patients with antiphospholipid syndrome have a high rate of thrombotic events that don’t track with SLE disease activity.
"They just hit here and there; you never really know when," the rheumatologist observed.
Turning to osteoporosis and SLE, Dr. Svenungsson cited a new cross-sectional study by rheumatologists at the University of Gothenburg, who obtained x-rays of the thoracic and lumbar spine in 150 women with SLE who had a median age of 47 years and disease duration of 11 years. Although 29% of the SLE patients had at least one radiologic vertebral compression fracture, only 4% had been diagnosed with a compression fracture.
"You have here a lot of women with a subclinical history of vertebral fractures. That we don’t detect most of these fractures may be one reason why patients with SLE often complain about pain," according to Dr. Svenungsson.
In the Gothenburg study, advanced age was an independent risk factor for one or more vertebral fractures at any site, whereas low bone mineral density in the total hip was associated with vertebral fracture in the lumbar spine. Interestingly, cumulative glucocorticoid dose wasn’t predictive of vertebral fracture risk (Arthritis Res. Ther. 2010 Aug. 2 [doi:10.1186/ar3104]).
A number of autoimmune diseases commonly overlap with SLE. Among them is autoimmune thyroid disease, which was present in 17% of 331 SLE patients being followed by Dr. Svenungsson and her associates at Karolinska, compared with 8% of matched controls. Hypothyroidism was far more common than hyperthyroid disease in the Karolinska cohort, as has been reported in other SLE studies.
Another autoimmune disease commonly overlapping with SLE is Sj?gren’s syndrome. In the Karolinska cohort, 25% of SLE patients met strict diagnostic criteria for Sj?gren’s syndrome. Dry mouth was reported by 40% of patients, compared with 7% of matched controls. Dry eyes were reported by 32% of SLE patients vs. 7% of controls.
In addition to cardiovascular disease, osteoporosis, Sj?gren’s syndrome, antiphospholipid syndrome, and autoimmune thyroid disease, other conditions that occur at an increased rate in patients with SLE include malignancies, rheumatoid arthritis, systemic sclerosis, myositis, vasculitis, autoimmune hepatitis, and infections.
"Lupus is an imitator. It’s difficult to say what is comorbidity and what is really a manifestation of lupus," Dr. Svenungsson concluded.
She declared that she has no relevant financial interests.
Major Finding: Text.
Data Source: Text.
Disclosures: Text.
Nurse-Led RESPONSE Reduces Post-ACS Risk
Stockholm – A nurse-led secondary prevention program for patients after an acute coronary syndrome led to sustained, impressive improvement in cardiovascular risk factors, a multicenter, randomized, a Dutch clinical trial has shown.
The modest intervention employed in the RESPONSE (Randomized Evaluation of Secondary Prevention by Outpatient Nurse Specialists) trial consisted of four 30-minute individual outpatient sessions with a nurse during the first 6 months after a participant’s acute coronary syndrome (ACS), in addition to standard therapy.
Six months after the final session, and 1 full year post-ACS, patients in the intervention arm were 40% more likely to have good control of their cardiovascular risk factors than controls assigned to standard therapy, Dr. Ron J.G. Peters reported at the congress.
Moreover, the intervention group’s estimated 4.5% 10-year risk of mortality using the SCORE metric was 17% less than in controls. A similar significant advantage in projected 10-year survival favoring the intervention group was seen using the Framingham Risk Score more familiar to American physicians, said Dr. Peters of the Academic Medical Center in Amsterdam.
The RESPONSE trial included 754 patients discharged from 11 participating Dutch medical centers after an ACS. They were randomized in single-blind fashion to the four nurse visits or usual care within 8 weeks of their coronary event.
During the half-hour-long office visits, nurses assessed patients’ cardiovascular risk factor status and counseled them on the importance of adhering to the evidence-based, guideline-recommended preventive measures that are supposed to be part of standard care. Patients on-target for at least 7 of 9 cardiovascular risk factors 1-year post-ACS were categorized as having good control. These risk factors were dyslipidemia, systolic blood pressure, blood glucose, smoking, physical activity, waist circumference, body mass index, alcohol intake, and diet.
The intervention resulted in significantly higher on-target rates than in the control group for systolic blood pressure, LDL cholesterol, physical activity, and a healthy diet. The intervention had no impact on waist circumference, body mass index, smoking status, or identification and treatment of insulin resistance.
Dr. Peters noted, however, that the prevalence of smoking at 1 year of follow-up was cut in half, to about 24% in both study arms. This was probably the result of admonitions to quit smoking coupled with the life-altering nature of hospitalization for ACS, he added.
All nurses in the intervention arm received several hours of special training in cardiovascular risk factor reduction and motivational interviewing techniques. But they did not get any special training in smoking cessation, nor were they authorized to give medications to help patients stop smoking.
The intervention was popular with patients and was well attended. Indeed, 93% of patients went to all four sessions.
The RESPONSE trial was enthusiastically received.
"Although this is not a trial about a new drug or device, I consider this trial extremely important," declared session co-chair Dr. Ralph Brindis, president of the American College of Cardiology.
"We have to figure out a way of better integrating delivery of care in patients at discharge from the hospital. We don’t do this very well in the United States. We have evidence-based therapies that are not being done. And here we have a trial that shows an effective way of delivering care with things that we know work," said Brindis, an interventional cardiologist who is senior advisor for cardiovascular disease at Northern California Kaiser Permanente in Oakland, Calif.
Discussant M. Christie Deaton, Ph.D., agreed this is an intervention that ought to be widely implemented.
"I think if we had a drug therapy that had a 17% relative risk reduction in predicted 10-year mortality we would be very excited about that," observed Dr. Deaton, professor of nursing at the University of Manchester, UK.
"Nurses are well suited to coordinate or lead secondary prevention programs such as this," she added. "I’m not going to say that they’re the only ones who can do it, but by virtue of education, clinical background, and a focus on supporting, coaching, and educating patients, it does make them well suited to this."
The major remaining research questions involve how to optimize the intervention by fine tuning its duration, components, and intensity. For example, waist circumference and body mass index are cardiovascular risk factors that are notoriously difficult to improve. Since eating occurs in a family or social context, perhaps group classes or family-centered interventions are needed in order to see improvement in these domains, she said.
Dr. Peters and Dr. Deaton declared having no conflicts of interest.
The RESPONSE trial provides further evidence that nurse-coordinated prevention programs are an effective means of improving secondary prevention. Nurses are well-suited to this type of role, given that their educational preparation commonly includes behavioral change, counselling, communication and support to patients and families as well as medical and nursing content. The use of SCORE is controversial as the charts are intended for assessment of cardiovascular risk in primary prevention, and absolute scores will be inaccurate for patients with coronary heart disease. However, it does provide a means of quantifying the relative change in risk for cardiovascular events as a result of changes in risk factors in the two groups. Other studies have shown that interventions that include nurse-coordinated programs or nurse case management, are more effective than usual care in managing patient risk factors. Previous randomized trials such as EUROACTION, the Stanford Coronary Risk Intervention Programme (SCRIP) and a study in the Kaiser Permanente healthcare system demonstrated that nurse-led interventions led to significant improvement in individual risk factors compared to usual care. In the SCRIP trial, nurse case management also decreased progression of CHD by angiography and achieved a 45% reduction in cardiovascular events over a 4-year period. Nurse-led secondary prevention clinics in primary care in the UK showed a 20% relative risk reduction in mortality and cardiovascular events compared to usual care over a mean 4.7 year follow-up. Excerpted from remarks by M Christi Deaton, PhD, RN, FESC, FAHA, who was the paper’s discussant at ESC and is professor of nursing at the University of Manchester, UK.
The RESPONSE trial provides further evidence that nurse-coordinated prevention programs are an effective means of improving secondary prevention. Nurses are well-suited to this type of role, given that their educational preparation commonly includes behavioral change, counselling, communication and support to patients and families as well as medical and nursing content. The use of SCORE is controversial as the charts are intended for assessment of cardiovascular risk in primary prevention, and absolute scores will be inaccurate for patients with coronary heart disease. However, it does provide a means of quantifying the relative change in risk for cardiovascular events as a result of changes in risk factors in the two groups. Other studies have shown that interventions that include nurse-coordinated programs or nurse case management, are more effective than usual care in managing patient risk factors. Previous randomized trials such as EUROACTION, the Stanford Coronary Risk Intervention Programme (SCRIP) and a study in the Kaiser Permanente healthcare system demonstrated that nurse-led interventions led to significant improvement in individual risk factors compared to usual care. In the SCRIP trial, nurse case management also decreased progression of CHD by angiography and achieved a 45% reduction in cardiovascular events over a 4-year period. Nurse-led secondary prevention clinics in primary care in the UK showed a 20% relative risk reduction in mortality and cardiovascular events compared to usual care over a mean 4.7 year follow-up. Excerpted from remarks by M Christi Deaton, PhD, RN, FESC, FAHA, who was the paper’s discussant at ESC and is professor of nursing at the University of Manchester, UK.
The RESPONSE trial provides further evidence that nurse-coordinated prevention programs are an effective means of improving secondary prevention. Nurses are well-suited to this type of role, given that their educational preparation commonly includes behavioral change, counselling, communication and support to patients and families as well as medical and nursing content. The use of SCORE is controversial as the charts are intended for assessment of cardiovascular risk in primary prevention, and absolute scores will be inaccurate for patients with coronary heart disease. However, it does provide a means of quantifying the relative change in risk for cardiovascular events as a result of changes in risk factors in the two groups. Other studies have shown that interventions that include nurse-coordinated programs or nurse case management, are more effective than usual care in managing patient risk factors. Previous randomized trials such as EUROACTION, the Stanford Coronary Risk Intervention Programme (SCRIP) and a study in the Kaiser Permanente healthcare system demonstrated that nurse-led interventions led to significant improvement in individual risk factors compared to usual care. In the SCRIP trial, nurse case management also decreased progression of CHD by angiography and achieved a 45% reduction in cardiovascular events over a 4-year period. Nurse-led secondary prevention clinics in primary care in the UK showed a 20% relative risk reduction in mortality and cardiovascular events compared to usual care over a mean 4.7 year follow-up. Excerpted from remarks by M Christi Deaton, PhD, RN, FESC, FAHA, who was the paper’s discussant at ESC and is professor of nursing at the University of Manchester, UK.
Stockholm – A nurse-led secondary prevention program for patients after an acute coronary syndrome led to sustained, impressive improvement in cardiovascular risk factors, a multicenter, randomized, a Dutch clinical trial has shown.
The modest intervention employed in the RESPONSE (Randomized Evaluation of Secondary Prevention by Outpatient Nurse Specialists) trial consisted of four 30-minute individual outpatient sessions with a nurse during the first 6 months after a participant’s acute coronary syndrome (ACS), in addition to standard therapy.
Six months after the final session, and 1 full year post-ACS, patients in the intervention arm were 40% more likely to have good control of their cardiovascular risk factors than controls assigned to standard therapy, Dr. Ron J.G. Peters reported at the congress.
Moreover, the intervention group’s estimated 4.5% 10-year risk of mortality using the SCORE metric was 17% less than in controls. A similar significant advantage in projected 10-year survival favoring the intervention group was seen using the Framingham Risk Score more familiar to American physicians, said Dr. Peters of the Academic Medical Center in Amsterdam.
The RESPONSE trial included 754 patients discharged from 11 participating Dutch medical centers after an ACS. They were randomized in single-blind fashion to the four nurse visits or usual care within 8 weeks of their coronary event.
During the half-hour-long office visits, nurses assessed patients’ cardiovascular risk factor status and counseled them on the importance of adhering to the evidence-based, guideline-recommended preventive measures that are supposed to be part of standard care. Patients on-target for at least 7 of 9 cardiovascular risk factors 1-year post-ACS were categorized as having good control. These risk factors were dyslipidemia, systolic blood pressure, blood glucose, smoking, physical activity, waist circumference, body mass index, alcohol intake, and diet.
The intervention resulted in significantly higher on-target rates than in the control group for systolic blood pressure, LDL cholesterol, physical activity, and a healthy diet. The intervention had no impact on waist circumference, body mass index, smoking status, or identification and treatment of insulin resistance.
Dr. Peters noted, however, that the prevalence of smoking at 1 year of follow-up was cut in half, to about 24% in both study arms. This was probably the result of admonitions to quit smoking coupled with the life-altering nature of hospitalization for ACS, he added.
All nurses in the intervention arm received several hours of special training in cardiovascular risk factor reduction and motivational interviewing techniques. But they did not get any special training in smoking cessation, nor were they authorized to give medications to help patients stop smoking.
The intervention was popular with patients and was well attended. Indeed, 93% of patients went to all four sessions.
The RESPONSE trial was enthusiastically received.
"Although this is not a trial about a new drug or device, I consider this trial extremely important," declared session co-chair Dr. Ralph Brindis, president of the American College of Cardiology.
"We have to figure out a way of better integrating delivery of care in patients at discharge from the hospital. We don’t do this very well in the United States. We have evidence-based therapies that are not being done. And here we have a trial that shows an effective way of delivering care with things that we know work," said Brindis, an interventional cardiologist who is senior advisor for cardiovascular disease at Northern California Kaiser Permanente in Oakland, Calif.
Discussant M. Christie Deaton, Ph.D., agreed this is an intervention that ought to be widely implemented.
"I think if we had a drug therapy that had a 17% relative risk reduction in predicted 10-year mortality we would be very excited about that," observed Dr. Deaton, professor of nursing at the University of Manchester, UK.
"Nurses are well suited to coordinate or lead secondary prevention programs such as this," she added. "I’m not going to say that they’re the only ones who can do it, but by virtue of education, clinical background, and a focus on supporting, coaching, and educating patients, it does make them well suited to this."
The major remaining research questions involve how to optimize the intervention by fine tuning its duration, components, and intensity. For example, waist circumference and body mass index are cardiovascular risk factors that are notoriously difficult to improve. Since eating occurs in a family or social context, perhaps group classes or family-centered interventions are needed in order to see improvement in these domains, she said.
Dr. Peters and Dr. Deaton declared having no conflicts of interest.
Stockholm – A nurse-led secondary prevention program for patients after an acute coronary syndrome led to sustained, impressive improvement in cardiovascular risk factors, a multicenter, randomized, a Dutch clinical trial has shown.
The modest intervention employed in the RESPONSE (Randomized Evaluation of Secondary Prevention by Outpatient Nurse Specialists) trial consisted of four 30-minute individual outpatient sessions with a nurse during the first 6 months after a participant’s acute coronary syndrome (ACS), in addition to standard therapy.
Six months after the final session, and 1 full year post-ACS, patients in the intervention arm were 40% more likely to have good control of their cardiovascular risk factors than controls assigned to standard therapy, Dr. Ron J.G. Peters reported at the congress.
Moreover, the intervention group’s estimated 4.5% 10-year risk of mortality using the SCORE metric was 17% less than in controls. A similar significant advantage in projected 10-year survival favoring the intervention group was seen using the Framingham Risk Score more familiar to American physicians, said Dr. Peters of the Academic Medical Center in Amsterdam.
The RESPONSE trial included 754 patients discharged from 11 participating Dutch medical centers after an ACS. They were randomized in single-blind fashion to the four nurse visits or usual care within 8 weeks of their coronary event.
During the half-hour-long office visits, nurses assessed patients’ cardiovascular risk factor status and counseled them on the importance of adhering to the evidence-based, guideline-recommended preventive measures that are supposed to be part of standard care. Patients on-target for at least 7 of 9 cardiovascular risk factors 1-year post-ACS were categorized as having good control. These risk factors were dyslipidemia, systolic blood pressure, blood glucose, smoking, physical activity, waist circumference, body mass index, alcohol intake, and diet.
The intervention resulted in significantly higher on-target rates than in the control group for systolic blood pressure, LDL cholesterol, physical activity, and a healthy diet. The intervention had no impact on waist circumference, body mass index, smoking status, or identification and treatment of insulin resistance.
Dr. Peters noted, however, that the prevalence of smoking at 1 year of follow-up was cut in half, to about 24% in both study arms. This was probably the result of admonitions to quit smoking coupled with the life-altering nature of hospitalization for ACS, he added.
All nurses in the intervention arm received several hours of special training in cardiovascular risk factor reduction and motivational interviewing techniques. But they did not get any special training in smoking cessation, nor were they authorized to give medications to help patients stop smoking.
The intervention was popular with patients and was well attended. Indeed, 93% of patients went to all four sessions.
The RESPONSE trial was enthusiastically received.
"Although this is not a trial about a new drug or device, I consider this trial extremely important," declared session co-chair Dr. Ralph Brindis, president of the American College of Cardiology.
"We have to figure out a way of better integrating delivery of care in patients at discharge from the hospital. We don’t do this very well in the United States. We have evidence-based therapies that are not being done. And here we have a trial that shows an effective way of delivering care with things that we know work," said Brindis, an interventional cardiologist who is senior advisor for cardiovascular disease at Northern California Kaiser Permanente in Oakland, Calif.
Discussant M. Christie Deaton, Ph.D., agreed this is an intervention that ought to be widely implemented.
"I think if we had a drug therapy that had a 17% relative risk reduction in predicted 10-year mortality we would be very excited about that," observed Dr. Deaton, professor of nursing at the University of Manchester, UK.
"Nurses are well suited to coordinate or lead secondary prevention programs such as this," she added. "I’m not going to say that they’re the only ones who can do it, but by virtue of education, clinical background, and a focus on supporting, coaching, and educating patients, it does make them well suited to this."
The major remaining research questions involve how to optimize the intervention by fine tuning its duration, components, and intensity. For example, waist circumference and body mass index are cardiovascular risk factors that are notoriously difficult to improve. Since eating occurs in a family or social context, perhaps group classes or family-centered interventions are needed in order to see improvement in these domains, she said.
Dr. Peters and Dr. Deaton declared having no conflicts of interest.
Major Finding: The intervention group had an estimated 10-year risk of mortality of 4.5% using the SCORE metric, which was 17% lower than that of controls. A similar significant advantage in projected 10-year survival favoring the intervention group was seen using the Framingham Risk Score.
Data Source: The RESPONSE trial included 754 patients discharged from 11 participating Dutch medical centers after an ACS. They were randomized in single-blind fashion to the four nurse visits or usual care within 8 weeks of their coronary event.
Disclosures: Dr. Peters and Dr. Deaton declared having no conflicts of interest.
Mycoplasma Genitalium Urethritis: Treatment Controversies
GOTHENBURG, SWEDEN – The treatment regimens currently recommended for nongonococcal urethritis and cervicitis by the Centers for Disease Control and Prevention have significant drawbacks for infections caused by Mycoplasma genitalium, according to Dr. Carin Anagrius.
Multiple studies – reported since the CDC guidelines were released in 2006 – indicate that M. genitalium is the second most common cause of nongonococcal urethritis (NGU), with a prevalence about half that of Chlamydia trachomatis, Dr. Anagrius said at the annual congress of the European Academy of Dermatology and Venereology.
The first-line treatment options recommended by the CDC for NGU and presumptive treatment of cervicitis (doxycycline and azithromycin) both have problems, said Dr. Anagrius of Falu Hospital in Falun, Sweden. Doxycycline at 100 mg twice daily for 7 days has an unacceptable eradication rate for M. genitalium, and azithromycin in a single 1-g dose promotes emergence of macrolide-resistant organisms.
For this reason, she said, a revision of the guidelines is in order. The best solution would be to elevate azithromycin given over 5 days to preferred first-line therapy status. This regimen consists of 500 mg of azithromycin on day 1 followed by 250 mg on days 2-5. Studies found it has a 95% M. genitalium eradication rate and a substantially lower risk of inducing azithromycin resistance than with a single 1-g dose, she said.
An observational study by Dr. Anagrius and coworkers showed that eradication rates in symptomatic M. genitalium NGU in Scandinavia were about 85% for azithromycin 1 g and less than 30% for doxycycline (Sex. Transm. Infect. 2008;84:72-6). Similar rates have been confirmed by other investigators, she noted.
For example, University of Mississippi investigators randomized men with known M. genitalium urethritis at a New Orleans STD clinic to doxycycline (100 mg twice a day for 7 days) or azithromycin (1 g as a single dose). The cure rates at the first follow-up visit were 87% with azithromycin, compared with 45% with doxycycline; 47% of those who were initially cured experienced clinical relapse in the next 2-6 weeks (Clin. Infect. Dis. 2009;48:1649-54).
The latest data from large population studies suggest M. genitalium causes about 15% of all NGU, noted Dr. Anagrius. Since there is as no commercially available diagnostic assay for M. genitalium infections, for every 1,000 patients with NGU who are treated with doxycycline, roughly 84 will return with persistent symptomatic M. genitalium urethritis. However, if the 1,000 patients were treated with single-dose azithromycin at 1 g, only 18 would return with persistent symptomatic M. genitalium urethritis.
Dr. Anagrius’ studies indicate roughly 70% of these unsuccessfully treated patients would as a consequence of this unsuccessful treatment develop resistance to azithromycin in the form of a single base mutation in domain V of the 23S rRNA gene. Extended azithromycin as second-line therapy is unlikely to be successful in these patients. For them the only effective second-line antimicrobials are moxifloxacin and gatifloxacin. And there is as yet no third-line therapy.
If, on the other hand, 1,000 NGU patients were treated with 1.5 g of azithromycin over 5 days, only 6 would return because of persistent M. genitalium urethritis, she said. Thus, the number of individuals with azithromycin-resistant M. genitalium infections would be reduced by two-thirds, compared with the count if azithromycin 1 g was used.
The impact of using azithromycin 1 g as first-line therapy for NGU is illustrated by the markedly contrasting prevalence of macrolide-resistant M. genitalium in Sweden and neighboring Denmark. In Sweden, where using 1 g of azithromycin to treat NGU is uncommon, Dr. Anagrius and coworkers found the prevalence of azithromycin resistance to be only 1.6% among 181 patients presenting with new confirmed M. genitalium.
In Denmark, where azithromycin 1 g is widely prescribed as first-line therapy, Dr. Anagrius’ Danish collaborators found a 40% prevalence of macrolide resistance in 415 patients presenting with new confirmed M. genitalium urethritis.
Dr. Anagrius noted that discussion about screening for M. genitalium infection in asymptomatic individuals in high-prevalence settings is starting to occur among venereologists and public health officials. The problem is the lack of a commercial polymerase chain reaction assay, which must be a high developmental priority. In the meantime, Dr. Anagrius urged physicians to "think M. genitalium" in patients with repeated urinary tract infections, abnormal bleeding, lower abdominal pain, persistent discharge, epididymitis, prostatitis, and what is often labeled treatment-resistant candidiasis.
And since M. genitalium NGU and cervicitis are sexually transmitted infections, optimal care includes treatment of the patient’s partner or partners, she stressed.
Dr. Anagrius disclosed having no financial conflicts.
GOTHENBURG, SWEDEN – The treatment regimens currently recommended for nongonococcal urethritis and cervicitis by the Centers for Disease Control and Prevention have significant drawbacks for infections caused by Mycoplasma genitalium, according to Dr. Carin Anagrius.
Multiple studies – reported since the CDC guidelines were released in 2006 – indicate that M. genitalium is the second most common cause of nongonococcal urethritis (NGU), with a prevalence about half that of Chlamydia trachomatis, Dr. Anagrius said at the annual congress of the European Academy of Dermatology and Venereology.
The first-line treatment options recommended by the CDC for NGU and presumptive treatment of cervicitis (doxycycline and azithromycin) both have problems, said Dr. Anagrius of Falu Hospital in Falun, Sweden. Doxycycline at 100 mg twice daily for 7 days has an unacceptable eradication rate for M. genitalium, and azithromycin in a single 1-g dose promotes emergence of macrolide-resistant organisms.
For this reason, she said, a revision of the guidelines is in order. The best solution would be to elevate azithromycin given over 5 days to preferred first-line therapy status. This regimen consists of 500 mg of azithromycin on day 1 followed by 250 mg on days 2-5. Studies found it has a 95% M. genitalium eradication rate and a substantially lower risk of inducing azithromycin resistance than with a single 1-g dose, she said.
An observational study by Dr. Anagrius and coworkers showed that eradication rates in symptomatic M. genitalium NGU in Scandinavia were about 85% for azithromycin 1 g and less than 30% for doxycycline (Sex. Transm. Infect. 2008;84:72-6). Similar rates have been confirmed by other investigators, she noted.
For example, University of Mississippi investigators randomized men with known M. genitalium urethritis at a New Orleans STD clinic to doxycycline (100 mg twice a day for 7 days) or azithromycin (1 g as a single dose). The cure rates at the first follow-up visit were 87% with azithromycin, compared with 45% with doxycycline; 47% of those who were initially cured experienced clinical relapse in the next 2-6 weeks (Clin. Infect. Dis. 2009;48:1649-54).
The latest data from large population studies suggest M. genitalium causes about 15% of all NGU, noted Dr. Anagrius. Since there is as no commercially available diagnostic assay for M. genitalium infections, for every 1,000 patients with NGU who are treated with doxycycline, roughly 84 will return with persistent symptomatic M. genitalium urethritis. However, if the 1,000 patients were treated with single-dose azithromycin at 1 g, only 18 would return with persistent symptomatic M. genitalium urethritis.
Dr. Anagrius’ studies indicate roughly 70% of these unsuccessfully treated patients would as a consequence of this unsuccessful treatment develop resistance to azithromycin in the form of a single base mutation in domain V of the 23S rRNA gene. Extended azithromycin as second-line therapy is unlikely to be successful in these patients. For them the only effective second-line antimicrobials are moxifloxacin and gatifloxacin. And there is as yet no third-line therapy.
If, on the other hand, 1,000 NGU patients were treated with 1.5 g of azithromycin over 5 days, only 6 would return because of persistent M. genitalium urethritis, she said. Thus, the number of individuals with azithromycin-resistant M. genitalium infections would be reduced by two-thirds, compared with the count if azithromycin 1 g was used.
The impact of using azithromycin 1 g as first-line therapy for NGU is illustrated by the markedly contrasting prevalence of macrolide-resistant M. genitalium in Sweden and neighboring Denmark. In Sweden, where using 1 g of azithromycin to treat NGU is uncommon, Dr. Anagrius and coworkers found the prevalence of azithromycin resistance to be only 1.6% among 181 patients presenting with new confirmed M. genitalium.
In Denmark, where azithromycin 1 g is widely prescribed as first-line therapy, Dr. Anagrius’ Danish collaborators found a 40% prevalence of macrolide resistance in 415 patients presenting with new confirmed M. genitalium urethritis.
Dr. Anagrius noted that discussion about screening for M. genitalium infection in asymptomatic individuals in high-prevalence settings is starting to occur among venereologists and public health officials. The problem is the lack of a commercial polymerase chain reaction assay, which must be a high developmental priority. In the meantime, Dr. Anagrius urged physicians to "think M. genitalium" in patients with repeated urinary tract infections, abnormal bleeding, lower abdominal pain, persistent discharge, epididymitis, prostatitis, and what is often labeled treatment-resistant candidiasis.
And since M. genitalium NGU and cervicitis are sexually transmitted infections, optimal care includes treatment of the patient’s partner or partners, she stressed.
Dr. Anagrius disclosed having no financial conflicts.
GOTHENBURG, SWEDEN – The treatment regimens currently recommended for nongonococcal urethritis and cervicitis by the Centers for Disease Control and Prevention have significant drawbacks for infections caused by Mycoplasma genitalium, according to Dr. Carin Anagrius.
Multiple studies – reported since the CDC guidelines were released in 2006 – indicate that M. genitalium is the second most common cause of nongonococcal urethritis (NGU), with a prevalence about half that of Chlamydia trachomatis, Dr. Anagrius said at the annual congress of the European Academy of Dermatology and Venereology.
The first-line treatment options recommended by the CDC for NGU and presumptive treatment of cervicitis (doxycycline and azithromycin) both have problems, said Dr. Anagrius of Falu Hospital in Falun, Sweden. Doxycycline at 100 mg twice daily for 7 days has an unacceptable eradication rate for M. genitalium, and azithromycin in a single 1-g dose promotes emergence of macrolide-resistant organisms.
For this reason, she said, a revision of the guidelines is in order. The best solution would be to elevate azithromycin given over 5 days to preferred first-line therapy status. This regimen consists of 500 mg of azithromycin on day 1 followed by 250 mg on days 2-5. Studies found it has a 95% M. genitalium eradication rate and a substantially lower risk of inducing azithromycin resistance than with a single 1-g dose, she said.
An observational study by Dr. Anagrius and coworkers showed that eradication rates in symptomatic M. genitalium NGU in Scandinavia were about 85% for azithromycin 1 g and less than 30% for doxycycline (Sex. Transm. Infect. 2008;84:72-6). Similar rates have been confirmed by other investigators, she noted.
For example, University of Mississippi investigators randomized men with known M. genitalium urethritis at a New Orleans STD clinic to doxycycline (100 mg twice a day for 7 days) or azithromycin (1 g as a single dose). The cure rates at the first follow-up visit were 87% with azithromycin, compared with 45% with doxycycline; 47% of those who were initially cured experienced clinical relapse in the next 2-6 weeks (Clin. Infect. Dis. 2009;48:1649-54).
The latest data from large population studies suggest M. genitalium causes about 15% of all NGU, noted Dr. Anagrius. Since there is as no commercially available diagnostic assay for M. genitalium infections, for every 1,000 patients with NGU who are treated with doxycycline, roughly 84 will return with persistent symptomatic M. genitalium urethritis. However, if the 1,000 patients were treated with single-dose azithromycin at 1 g, only 18 would return with persistent symptomatic M. genitalium urethritis.
Dr. Anagrius’ studies indicate roughly 70% of these unsuccessfully treated patients would as a consequence of this unsuccessful treatment develop resistance to azithromycin in the form of a single base mutation in domain V of the 23S rRNA gene. Extended azithromycin as second-line therapy is unlikely to be successful in these patients. For them the only effective second-line antimicrobials are moxifloxacin and gatifloxacin. And there is as yet no third-line therapy.
If, on the other hand, 1,000 NGU patients were treated with 1.5 g of azithromycin over 5 days, only 6 would return because of persistent M. genitalium urethritis, she said. Thus, the number of individuals with azithromycin-resistant M. genitalium infections would be reduced by two-thirds, compared with the count if azithromycin 1 g was used.
The impact of using azithromycin 1 g as first-line therapy for NGU is illustrated by the markedly contrasting prevalence of macrolide-resistant M. genitalium in Sweden and neighboring Denmark. In Sweden, where using 1 g of azithromycin to treat NGU is uncommon, Dr. Anagrius and coworkers found the prevalence of azithromycin resistance to be only 1.6% among 181 patients presenting with new confirmed M. genitalium.
In Denmark, where azithromycin 1 g is widely prescribed as first-line therapy, Dr. Anagrius’ Danish collaborators found a 40% prevalence of macrolide resistance in 415 patients presenting with new confirmed M. genitalium urethritis.
Dr. Anagrius noted that discussion about screening for M. genitalium infection in asymptomatic individuals in high-prevalence settings is starting to occur among venereologists and public health officials. The problem is the lack of a commercial polymerase chain reaction assay, which must be a high developmental priority. In the meantime, Dr. Anagrius urged physicians to "think M. genitalium" in patients with repeated urinary tract infections, abnormal bleeding, lower abdominal pain, persistent discharge, epididymitis, prostatitis, and what is often labeled treatment-resistant candidiasis.
And since M. genitalium NGU and cervicitis are sexually transmitted infections, optimal care includes treatment of the patient’s partner or partners, she stressed.
Dr. Anagrius disclosed having no financial conflicts.
EXPERT ANALYSIS FROM THE ANNUAL CONGRESS OF THE EUROPEAN ACADEMY OF DERMATOLOGY AND VENEREOLOGY
Glycemic Control Influences Heart Failure Risk
STOCKHOLM – Suboptimal glycemic control is an independent risk factor for a linear increase in the rate of new-onset heart failure in patients with type 2 diabetes, a large Scottish prospective case-control study indicates.
Moreover, in type 2 diabetes patients who already have established heart failure, poor glycemic control is independently associated with increased mortality, Dr. Chim Choy Lang reported at the congress.
These were the key findings in a new analysis from the Tayside Study, which is directed by Dr. Lang. The ongoing project provides an unusual opportunity to prospectively follow an entire Scottish community, population 400,000.
“We can track patients with diabetes mellitus, looking at mean [hemoglobin A1c] over time, and see who develops heart failure,” Dr. Lang said in an interview.
“Our bioinformatics platform allows us to track all sorts of biologic variables, prescribing information, and outcomes data,” he explained.
The analysis of Tayside Study data was performed because controversy has arisen surrounding the relationship between glycemic control in type 2 diabetes and heart failure.
Some recent evidence has suggested that tight metabolic control in type 2 diabetes is actually associated with worse survival of patients in the setting of heart failure.
“It should be noted that most of these studies were based on a single measure of HbA1c,” observed Dr. Lang, a cardiologist at the University of Dundee. “I think there's always cause for concern about that kind of analysis,” he added.
Dr. Lang reported on more than 9,000 Tayside residents with type 2 diabetes, 841 of whom developed heart failure during the period from 1991 to 2008. Each diabetic heart failure patient was matched by age, gender, and date of diagnosis of diabetes to five controls.
When Dr. Lang and his coinvestigators conducted a multivariate logistic regression analysis, they found that the mean HbA1c level during the study period was associated in linear fashion with the risk of later developing heart failure.
Each 1% increase in HbA1c was independently linked to a 19% increase in incident heart failure after the researchers controlled for patients' mean arterial pressure and use of thiazoli-dinediones.
Further, in type 2 diabetic patients who were diagnosed with heart failure, each 1% increase in mean HbA1c was independently associated with an adjusted 16% increase in all-cause mortality, according to Dr. Lang.
“I think our findings are an argument for tight glycemic control in diabetic patients with heart failure. The question is how to achieve that. I'm a big believer in metformin for that purpose,” the cardiologist said.
When Dr. Lang was asked whether the increased risk of mortality documented in diabetic patients with poor glycemic control and heart failure is a marker for poor adherence to standard heart failure medications or is due to the adverse effects of high blood glucose, he said that's a key unsettled question.
“We have the ability to look at treatment adherence in this cohort and are doing so at the moment,” Dr. Lang noted.
He declared that he had no financial conflicts in connection with the study, which was conducted free of industry involvement.
Each 1% increase in HbA1c was independently linked to a 19% increase in incident heart failure.
Source DR. LANG
STOCKHOLM – Suboptimal glycemic control is an independent risk factor for a linear increase in the rate of new-onset heart failure in patients with type 2 diabetes, a large Scottish prospective case-control study indicates.
Moreover, in type 2 diabetes patients who already have established heart failure, poor glycemic control is independently associated with increased mortality, Dr. Chim Choy Lang reported at the congress.
These were the key findings in a new analysis from the Tayside Study, which is directed by Dr. Lang. The ongoing project provides an unusual opportunity to prospectively follow an entire Scottish community, population 400,000.
“We can track patients with diabetes mellitus, looking at mean [hemoglobin A1c] over time, and see who develops heart failure,” Dr. Lang said in an interview.
“Our bioinformatics platform allows us to track all sorts of biologic variables, prescribing information, and outcomes data,” he explained.
The analysis of Tayside Study data was performed because controversy has arisen surrounding the relationship between glycemic control in type 2 diabetes and heart failure.
Some recent evidence has suggested that tight metabolic control in type 2 diabetes is actually associated with worse survival of patients in the setting of heart failure.
“It should be noted that most of these studies were based on a single measure of HbA1c,” observed Dr. Lang, a cardiologist at the University of Dundee. “I think there's always cause for concern about that kind of analysis,” he added.
Dr. Lang reported on more than 9,000 Tayside residents with type 2 diabetes, 841 of whom developed heart failure during the period from 1991 to 2008. Each diabetic heart failure patient was matched by age, gender, and date of diagnosis of diabetes to five controls.
When Dr. Lang and his coinvestigators conducted a multivariate logistic regression analysis, they found that the mean HbA1c level during the study period was associated in linear fashion with the risk of later developing heart failure.
Each 1% increase in HbA1c was independently linked to a 19% increase in incident heart failure after the researchers controlled for patients' mean arterial pressure and use of thiazoli-dinediones.
Further, in type 2 diabetic patients who were diagnosed with heart failure, each 1% increase in mean HbA1c was independently associated with an adjusted 16% increase in all-cause mortality, according to Dr. Lang.
“I think our findings are an argument for tight glycemic control in diabetic patients with heart failure. The question is how to achieve that. I'm a big believer in metformin for that purpose,” the cardiologist said.
When Dr. Lang was asked whether the increased risk of mortality documented in diabetic patients with poor glycemic control and heart failure is a marker for poor adherence to standard heart failure medications or is due to the adverse effects of high blood glucose, he said that's a key unsettled question.
“We have the ability to look at treatment adherence in this cohort and are doing so at the moment,” Dr. Lang noted.
He declared that he had no financial conflicts in connection with the study, which was conducted free of industry involvement.
Each 1% increase in HbA1c was independently linked to a 19% increase in incident heart failure.
Source DR. LANG
STOCKHOLM – Suboptimal glycemic control is an independent risk factor for a linear increase in the rate of new-onset heart failure in patients with type 2 diabetes, a large Scottish prospective case-control study indicates.
Moreover, in type 2 diabetes patients who already have established heart failure, poor glycemic control is independently associated with increased mortality, Dr. Chim Choy Lang reported at the congress.
These were the key findings in a new analysis from the Tayside Study, which is directed by Dr. Lang. The ongoing project provides an unusual opportunity to prospectively follow an entire Scottish community, population 400,000.
“We can track patients with diabetes mellitus, looking at mean [hemoglobin A1c] over time, and see who develops heart failure,” Dr. Lang said in an interview.
“Our bioinformatics platform allows us to track all sorts of biologic variables, prescribing information, and outcomes data,” he explained.
The analysis of Tayside Study data was performed because controversy has arisen surrounding the relationship between glycemic control in type 2 diabetes and heart failure.
Some recent evidence has suggested that tight metabolic control in type 2 diabetes is actually associated with worse survival of patients in the setting of heart failure.
“It should be noted that most of these studies were based on a single measure of HbA1c,” observed Dr. Lang, a cardiologist at the University of Dundee. “I think there's always cause for concern about that kind of analysis,” he added.
Dr. Lang reported on more than 9,000 Tayside residents with type 2 diabetes, 841 of whom developed heart failure during the period from 1991 to 2008. Each diabetic heart failure patient was matched by age, gender, and date of diagnosis of diabetes to five controls.
When Dr. Lang and his coinvestigators conducted a multivariate logistic regression analysis, they found that the mean HbA1c level during the study period was associated in linear fashion with the risk of later developing heart failure.
Each 1% increase in HbA1c was independently linked to a 19% increase in incident heart failure after the researchers controlled for patients' mean arterial pressure and use of thiazoli-dinediones.
Further, in type 2 diabetic patients who were diagnosed with heart failure, each 1% increase in mean HbA1c was independently associated with an adjusted 16% increase in all-cause mortality, according to Dr. Lang.
“I think our findings are an argument for tight glycemic control in diabetic patients with heart failure. The question is how to achieve that. I'm a big believer in metformin for that purpose,” the cardiologist said.
When Dr. Lang was asked whether the increased risk of mortality documented in diabetic patients with poor glycemic control and heart failure is a marker for poor adherence to standard heart failure medications or is due to the adverse effects of high blood glucose, he said that's a key unsettled question.
“We have the ability to look at treatment adherence in this cohort and are doing so at the moment,” Dr. Lang noted.
He declared that he had no financial conflicts in connection with the study, which was conducted free of industry involvement.
Each 1% increase in HbA1c was independently linked to a 19% increase in incident heart failure.
Source DR. LANG
Lack of Congestion Not Predictive in Acute HF
STOCKHOLM – The absence of signs and symptoms of congestion at discharge in patients hospitalized for acute decompensated heart failure does not predict a favorable prognosis, contrary to the conventional wisdom.
A new secondary analysis of the international EVEREST trial provides an important lesson in the everyday management of acute heart failure: “The fact that a patient improves in-hospital with diuretics and other medications is not sufficient. It's not 'mission accomplished,'” Dr. Mihai Gheorghiade said at the congress.
“There is a dissociation between signs and symptoms of congestion at discharge and outcomes. In spite of having a very low congestion score, the event rate in EVEREST during 10 months of follow-up was astronomical,” said Dr. Gheorghiade, professor of medicine and surgery and associate chief of cardiology at Northwestern University, Chicago.
EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan) was a double-blind study that randomized 4,133 patients with worsening heart failure and a left ventricular ejection fraction of 40% or less to the oral vasopressin V2 receptor blocker tolvaptan or placebo within 48 hours of hospitalization.
Standard background therapy in both study arms included diuretics, ACE inhibitor or angiotensin II receptor blocker therapy, a beta-blocker, and an aldosterone antagonist. In the previously reported primary results, tolvaptan proved to have no benefit over placebo during a mean follow-up of 9.9 months (JAMA 2007;297:1319–31).
Dr. Gheorghiade presented a secondary analysis focusing on the 2,061 patients in the placebo arm. At randomization, following initial treatment with diuretics, these patients had a mean congestion score of 4 points based on their degree of jugular vein distention, rales, and peripheral edema.
At discharge, patients had lost a mean 2.8 kg of body weight, and 72% had a congestion score of 0 or 1. Although that appears to be a high rate of short-term treatment success, this large subgroup of patients with minimal or no signs or symptoms of congestion at discharge had a 15% all-cause mortality and a 29% rate of rehospitalization for heart failure during the next 9.9 months.
The adverse event rate was even greater in those with a higher congestion score at discharge. In the overall placebo group, all-cause mortality was 26%, with a 40% rate of rehospitalization for heart failure during follow-up.
“We're dealing with a disorder that has an event rate as high as 50%. There is no other medical condition for which patients are hospitalized and are improving with therapy that has a comparable event rate,” the cardiologist observed.
The new EVEREST analysis contains an important message for clinical trialists: Using signs and symptoms of congestion as a key target for treatment during hospitalization as well as the standard end point in acute heart failure studies, as has been common until now, is a recipe for a negative trial result.
“It's very difficult to beat placebo, because placebo plus standard therapy has a tremendous effect on congestion,” Dr. Gheorghiade said. “Looking for new therapies that improve signs and symptoms of congestion in the whole population is a waste of time unless you're dealing with special populations who don't respond to standard therapies, such as patients with low blood pressure.”
Better surrogate markers than congestion are needed to guide therapy. One possibility is B-type natriuretic peptide (BNP). The mean BNP at admission in the placebo arm of EVEREST was 1,375 pg/mL. At discharge it was still markedly elevated at 948 pg/mL.
“The lesson here is that by treating the signs and symptoms of congestion, you can make patients feel much better, but even though they are now able to walk up a flight of stairs, inside, in terms of renal function and BNP, they are still very sick,” he said.
Until better treatments for acute heart failure are found, the best thing physicians can do for patients is try to identify specific targets amenable to current therapies, such as renal dysfunction or myocardial ischemia, Dr. Gheorghiade said.
The EVEREST trial was sponsored by Otsuka. Dr. Gheorghiade has received research grants and/or served as a consultant to Otsuka and numerous other pharmaceutical companies.
Dr. Mihai Gheorghiade: The event rate in EVEREST was “astronomical.”
Source Bruce Jancin/Elsevier Global Medical News
STOCKHOLM – The absence of signs and symptoms of congestion at discharge in patients hospitalized for acute decompensated heart failure does not predict a favorable prognosis, contrary to the conventional wisdom.
A new secondary analysis of the international EVEREST trial provides an important lesson in the everyday management of acute heart failure: “The fact that a patient improves in-hospital with diuretics and other medications is not sufficient. It's not 'mission accomplished,'” Dr. Mihai Gheorghiade said at the congress.
“There is a dissociation between signs and symptoms of congestion at discharge and outcomes. In spite of having a very low congestion score, the event rate in EVEREST during 10 months of follow-up was astronomical,” said Dr. Gheorghiade, professor of medicine and surgery and associate chief of cardiology at Northwestern University, Chicago.
EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan) was a double-blind study that randomized 4,133 patients with worsening heart failure and a left ventricular ejection fraction of 40% or less to the oral vasopressin V2 receptor blocker tolvaptan or placebo within 48 hours of hospitalization.
Standard background therapy in both study arms included diuretics, ACE inhibitor or angiotensin II receptor blocker therapy, a beta-blocker, and an aldosterone antagonist. In the previously reported primary results, tolvaptan proved to have no benefit over placebo during a mean follow-up of 9.9 months (JAMA 2007;297:1319–31).
Dr. Gheorghiade presented a secondary analysis focusing on the 2,061 patients in the placebo arm. At randomization, following initial treatment with diuretics, these patients had a mean congestion score of 4 points based on their degree of jugular vein distention, rales, and peripheral edema.
At discharge, patients had lost a mean 2.8 kg of body weight, and 72% had a congestion score of 0 or 1. Although that appears to be a high rate of short-term treatment success, this large subgroup of patients with minimal or no signs or symptoms of congestion at discharge had a 15% all-cause mortality and a 29% rate of rehospitalization for heart failure during the next 9.9 months.
The adverse event rate was even greater in those with a higher congestion score at discharge. In the overall placebo group, all-cause mortality was 26%, with a 40% rate of rehospitalization for heart failure during follow-up.
“We're dealing with a disorder that has an event rate as high as 50%. There is no other medical condition for which patients are hospitalized and are improving with therapy that has a comparable event rate,” the cardiologist observed.
The new EVEREST analysis contains an important message for clinical trialists: Using signs and symptoms of congestion as a key target for treatment during hospitalization as well as the standard end point in acute heart failure studies, as has been common until now, is a recipe for a negative trial result.
“It's very difficult to beat placebo, because placebo plus standard therapy has a tremendous effect on congestion,” Dr. Gheorghiade said. “Looking for new therapies that improve signs and symptoms of congestion in the whole population is a waste of time unless you're dealing with special populations who don't respond to standard therapies, such as patients with low blood pressure.”
Better surrogate markers than congestion are needed to guide therapy. One possibility is B-type natriuretic peptide (BNP). The mean BNP at admission in the placebo arm of EVEREST was 1,375 pg/mL. At discharge it was still markedly elevated at 948 pg/mL.
“The lesson here is that by treating the signs and symptoms of congestion, you can make patients feel much better, but even though they are now able to walk up a flight of stairs, inside, in terms of renal function and BNP, they are still very sick,” he said.
Until better treatments for acute heart failure are found, the best thing physicians can do for patients is try to identify specific targets amenable to current therapies, such as renal dysfunction or myocardial ischemia, Dr. Gheorghiade said.
The EVEREST trial was sponsored by Otsuka. Dr. Gheorghiade has received research grants and/or served as a consultant to Otsuka and numerous other pharmaceutical companies.
Dr. Mihai Gheorghiade: The event rate in EVEREST was “astronomical.”
Source Bruce Jancin/Elsevier Global Medical News
STOCKHOLM – The absence of signs and symptoms of congestion at discharge in patients hospitalized for acute decompensated heart failure does not predict a favorable prognosis, contrary to the conventional wisdom.
A new secondary analysis of the international EVEREST trial provides an important lesson in the everyday management of acute heart failure: “The fact that a patient improves in-hospital with diuretics and other medications is not sufficient. It's not 'mission accomplished,'” Dr. Mihai Gheorghiade said at the congress.
“There is a dissociation between signs and symptoms of congestion at discharge and outcomes. In spite of having a very low congestion score, the event rate in EVEREST during 10 months of follow-up was astronomical,” said Dr. Gheorghiade, professor of medicine and surgery and associate chief of cardiology at Northwestern University, Chicago.
EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan) was a double-blind study that randomized 4,133 patients with worsening heart failure and a left ventricular ejection fraction of 40% or less to the oral vasopressin V2 receptor blocker tolvaptan or placebo within 48 hours of hospitalization.
Standard background therapy in both study arms included diuretics, ACE inhibitor or angiotensin II receptor blocker therapy, a beta-blocker, and an aldosterone antagonist. In the previously reported primary results, tolvaptan proved to have no benefit over placebo during a mean follow-up of 9.9 months (JAMA 2007;297:1319–31).
Dr. Gheorghiade presented a secondary analysis focusing on the 2,061 patients in the placebo arm. At randomization, following initial treatment with diuretics, these patients had a mean congestion score of 4 points based on their degree of jugular vein distention, rales, and peripheral edema.
At discharge, patients had lost a mean 2.8 kg of body weight, and 72% had a congestion score of 0 or 1. Although that appears to be a high rate of short-term treatment success, this large subgroup of patients with minimal or no signs or symptoms of congestion at discharge had a 15% all-cause mortality and a 29% rate of rehospitalization for heart failure during the next 9.9 months.
The adverse event rate was even greater in those with a higher congestion score at discharge. In the overall placebo group, all-cause mortality was 26%, with a 40% rate of rehospitalization for heart failure during follow-up.
“We're dealing with a disorder that has an event rate as high as 50%. There is no other medical condition for which patients are hospitalized and are improving with therapy that has a comparable event rate,” the cardiologist observed.
The new EVEREST analysis contains an important message for clinical trialists: Using signs and symptoms of congestion as a key target for treatment during hospitalization as well as the standard end point in acute heart failure studies, as has been common until now, is a recipe for a negative trial result.
“It's very difficult to beat placebo, because placebo plus standard therapy has a tremendous effect on congestion,” Dr. Gheorghiade said. “Looking for new therapies that improve signs and symptoms of congestion in the whole population is a waste of time unless you're dealing with special populations who don't respond to standard therapies, such as patients with low blood pressure.”
Better surrogate markers than congestion are needed to guide therapy. One possibility is B-type natriuretic peptide (BNP). The mean BNP at admission in the placebo arm of EVEREST was 1,375 pg/mL. At discharge it was still markedly elevated at 948 pg/mL.
“The lesson here is that by treating the signs and symptoms of congestion, you can make patients feel much better, but even though they are now able to walk up a flight of stairs, inside, in terms of renal function and BNP, they are still very sick,” he said.
Until better treatments for acute heart failure are found, the best thing physicians can do for patients is try to identify specific targets amenable to current therapies, such as renal dysfunction or myocardial ischemia, Dr. Gheorghiade said.
The EVEREST trial was sponsored by Otsuka. Dr. Gheorghiade has received research grants and/or served as a consultant to Otsuka and numerous other pharmaceutical companies.
Dr. Mihai Gheorghiade: The event rate in EVEREST was “astronomical.”
Source Bruce Jancin/Elsevier Global Medical News
Greek-Style Coffee May Aid Arterial Elasticity
STOCKHOLM – The fountain of youth just might be a basin filled with rich, strong coffee, a study of one of the world's longest-lived people has shown.
“Our results suggest that drinking coffee in moderation should be encouraged even in elderly hypertensive subjects, as it seems it may improve arterial aging. Maybe regular coffee consumption is one of the key elements of the longevity we have noticed in the Ikaria Islanders, Dr. Christina Chrysohoou said at the congress.
The Aegean Sea island of Ikaria has one of the world's highest proportions of individuals who survive into their 90s and 100s. Residents of the isolated Greek island were featured in “The Blue Zones: Lessons for Living Longer From the People Who've Lived the Longest,” by Dan Buettner (National Geographic Books, 2008).
Seeking an explanation for the Ikarians' exceptional longevity, last year Dr. Chrysohoou led a 5-month University of Athens–sponsored in-depth study of 343 male and 330 female longtime residents aged 65–100 years. As a cardiologist, Dr. Chrysohoou said, one of the factors she was particularly eager to examine was coffee consumption, since it is a deeply embedded part of the Ikarian way of life, and also because coffee – especially Greek-coffee – is a rich source of antioxidants and anti-inflammatory compounds, which could have a salutary effect on cardiovascular risk.
This indeed appeared to be the case. Among the 465 study participants being treated for hypertension, those who were moderate coffee drinkers – averaging 1–2 of the traditional small 50-mL cups daily – had a significantly lower prevalence of diabetes, dyslipidemia, and cardiovascular disease as well as a lower mean body mass index and higher creatinine clearance than did hypertensive non–coffee drinkers (see box, p. 16).
Of particular interest was the finding that hypertensive moderate coffee drinkers had significantly greater aortic distensibility, as measured echocardiographically, than did hypertensive subjects who consumed coffee rarely or never.
Consumption of 1–2 cups/day remained an independent predictor of enhanced arterial elasticity after adjustment for potential confounders including age, physical activity, body mass index, blood pressure, education, diabetes, smoking, and diet.
Islanders who drank less than 1 cup or at least 3 cups of coffee per day did not derive any benefit in terms of aortic distensibility compared with coffee teetotalers. This is probably because modest quaffers do not obtain adequate quantities of the beneficial polyphenolic compounds and other micronutrients, while people who consume 3 or more cups daily ingest so much caffeine that the pressor response outweighs the positive effects of the micronutrients, according to Dr. Chrysohoou.
Traditional Greek coffee is very strong and dark. It is made by boiling the beans for 2–3 minutes. The resultant beverage contains up to 50 times greater concentrations of cafestol, kahweol, and other diterpenes than those of filtered coffee. Greek coffee also is rich in flavonoids, niacin, magnesium, potassium, and vitamin E, she explained.
One caveat regarding the study findings is that coffee drinking on Ikaria is very much a social experience. The elderly study participants generally take their coffee while socializing in the morning or early afternoon with longtime friends in tavernas and cafes, or with family at home. Coffee consumption on the island is a relaxing, unhurried experience enjoyed while discussing daily events.
“The psychological and social circumstances play an important role,” she said.
“I'm a clinical cardiologist, and most clinicians forbid coffee for their hypertensive patients,” noted Dr. Xavier Bosch of the University of Barcelona, who added he will reconsider his stance as a result of the Greek study.
The other key factor Dr. Chrysohoou and her coworkers identified as likely to contribute to the extended life expectancy of Ikaria Islanders is that these oldest residents are of a generation that tends to adhere most strictly to the traditional Mediterranean diet as popularized by the late University of Minnesota cardiovascular epidemiologist Ancel Keys.
Dr. Chrysohoou declared having no financial conflicts.
Vitals
Source Elsevier Global Medical News
'Drinking coffee in moderation should be encouraged, even in elderly hypertensive subjects.'
Source DR. CHRYSOHOOU
Consumption of 1–2 cups/day was a predictor of enhanced arterial elasticity.
Source ©Robert Brown/Fotolia.com
STOCKHOLM – The fountain of youth just might be a basin filled with rich, strong coffee, a study of one of the world's longest-lived people has shown.
“Our results suggest that drinking coffee in moderation should be encouraged even in elderly hypertensive subjects, as it seems it may improve arterial aging. Maybe regular coffee consumption is one of the key elements of the longevity we have noticed in the Ikaria Islanders, Dr. Christina Chrysohoou said at the congress.
The Aegean Sea island of Ikaria has one of the world's highest proportions of individuals who survive into their 90s and 100s. Residents of the isolated Greek island were featured in “The Blue Zones: Lessons for Living Longer From the People Who've Lived the Longest,” by Dan Buettner (National Geographic Books, 2008).
Seeking an explanation for the Ikarians' exceptional longevity, last year Dr. Chrysohoou led a 5-month University of Athens–sponsored in-depth study of 343 male and 330 female longtime residents aged 65–100 years. As a cardiologist, Dr. Chrysohoou said, one of the factors she was particularly eager to examine was coffee consumption, since it is a deeply embedded part of the Ikarian way of life, and also because coffee – especially Greek-coffee – is a rich source of antioxidants and anti-inflammatory compounds, which could have a salutary effect on cardiovascular risk.
This indeed appeared to be the case. Among the 465 study participants being treated for hypertension, those who were moderate coffee drinkers – averaging 1–2 of the traditional small 50-mL cups daily – had a significantly lower prevalence of diabetes, dyslipidemia, and cardiovascular disease as well as a lower mean body mass index and higher creatinine clearance than did hypertensive non–coffee drinkers (see box, p. 16).
Of particular interest was the finding that hypertensive moderate coffee drinkers had significantly greater aortic distensibility, as measured echocardiographically, than did hypertensive subjects who consumed coffee rarely or never.
Consumption of 1–2 cups/day remained an independent predictor of enhanced arterial elasticity after adjustment for potential confounders including age, physical activity, body mass index, blood pressure, education, diabetes, smoking, and diet.
Islanders who drank less than 1 cup or at least 3 cups of coffee per day did not derive any benefit in terms of aortic distensibility compared with coffee teetotalers. This is probably because modest quaffers do not obtain adequate quantities of the beneficial polyphenolic compounds and other micronutrients, while people who consume 3 or more cups daily ingest so much caffeine that the pressor response outweighs the positive effects of the micronutrients, according to Dr. Chrysohoou.
Traditional Greek coffee is very strong and dark. It is made by boiling the beans for 2–3 minutes. The resultant beverage contains up to 50 times greater concentrations of cafestol, kahweol, and other diterpenes than those of filtered coffee. Greek coffee also is rich in flavonoids, niacin, magnesium, potassium, and vitamin E, she explained.
One caveat regarding the study findings is that coffee drinking on Ikaria is very much a social experience. The elderly study participants generally take their coffee while socializing in the morning or early afternoon with longtime friends in tavernas and cafes, or with family at home. Coffee consumption on the island is a relaxing, unhurried experience enjoyed while discussing daily events.
“The psychological and social circumstances play an important role,” she said.
“I'm a clinical cardiologist, and most clinicians forbid coffee for their hypertensive patients,” noted Dr. Xavier Bosch of the University of Barcelona, who added he will reconsider his stance as a result of the Greek study.
The other key factor Dr. Chrysohoou and her coworkers identified as likely to contribute to the extended life expectancy of Ikaria Islanders is that these oldest residents are of a generation that tends to adhere most strictly to the traditional Mediterranean diet as popularized by the late University of Minnesota cardiovascular epidemiologist Ancel Keys.
Dr. Chrysohoou declared having no financial conflicts.
Vitals
Source Elsevier Global Medical News
'Drinking coffee in moderation should be encouraged, even in elderly hypertensive subjects.'
Source DR. CHRYSOHOOU
Consumption of 1–2 cups/day was a predictor of enhanced arterial elasticity.
Source ©Robert Brown/Fotolia.com
STOCKHOLM – The fountain of youth just might be a basin filled with rich, strong coffee, a study of one of the world's longest-lived people has shown.
“Our results suggest that drinking coffee in moderation should be encouraged even in elderly hypertensive subjects, as it seems it may improve arterial aging. Maybe regular coffee consumption is one of the key elements of the longevity we have noticed in the Ikaria Islanders, Dr. Christina Chrysohoou said at the congress.
The Aegean Sea island of Ikaria has one of the world's highest proportions of individuals who survive into their 90s and 100s. Residents of the isolated Greek island were featured in “The Blue Zones: Lessons for Living Longer From the People Who've Lived the Longest,” by Dan Buettner (National Geographic Books, 2008).
Seeking an explanation for the Ikarians' exceptional longevity, last year Dr. Chrysohoou led a 5-month University of Athens–sponsored in-depth study of 343 male and 330 female longtime residents aged 65–100 years. As a cardiologist, Dr. Chrysohoou said, one of the factors she was particularly eager to examine was coffee consumption, since it is a deeply embedded part of the Ikarian way of life, and also because coffee – especially Greek-coffee – is a rich source of antioxidants and anti-inflammatory compounds, which could have a salutary effect on cardiovascular risk.
This indeed appeared to be the case. Among the 465 study participants being treated for hypertension, those who were moderate coffee drinkers – averaging 1–2 of the traditional small 50-mL cups daily – had a significantly lower prevalence of diabetes, dyslipidemia, and cardiovascular disease as well as a lower mean body mass index and higher creatinine clearance than did hypertensive non–coffee drinkers (see box, p. 16).
Of particular interest was the finding that hypertensive moderate coffee drinkers had significantly greater aortic distensibility, as measured echocardiographically, than did hypertensive subjects who consumed coffee rarely or never.
Consumption of 1–2 cups/day remained an independent predictor of enhanced arterial elasticity after adjustment for potential confounders including age, physical activity, body mass index, blood pressure, education, diabetes, smoking, and diet.
Islanders who drank less than 1 cup or at least 3 cups of coffee per day did not derive any benefit in terms of aortic distensibility compared with coffee teetotalers. This is probably because modest quaffers do not obtain adequate quantities of the beneficial polyphenolic compounds and other micronutrients, while people who consume 3 or more cups daily ingest so much caffeine that the pressor response outweighs the positive effects of the micronutrients, according to Dr. Chrysohoou.
Traditional Greek coffee is very strong and dark. It is made by boiling the beans for 2–3 minutes. The resultant beverage contains up to 50 times greater concentrations of cafestol, kahweol, and other diterpenes than those of filtered coffee. Greek coffee also is rich in flavonoids, niacin, magnesium, potassium, and vitamin E, she explained.
One caveat regarding the study findings is that coffee drinking on Ikaria is very much a social experience. The elderly study participants generally take their coffee while socializing in the morning or early afternoon with longtime friends in tavernas and cafes, or with family at home. Coffee consumption on the island is a relaxing, unhurried experience enjoyed while discussing daily events.
“The psychological and social circumstances play an important role,” she said.
“I'm a clinical cardiologist, and most clinicians forbid coffee for their hypertensive patients,” noted Dr. Xavier Bosch of the University of Barcelona, who added he will reconsider his stance as a result of the Greek study.
The other key factor Dr. Chrysohoou and her coworkers identified as likely to contribute to the extended life expectancy of Ikaria Islanders is that these oldest residents are of a generation that tends to adhere most strictly to the traditional Mediterranean diet as popularized by the late University of Minnesota cardiovascular epidemiologist Ancel Keys.
Dr. Chrysohoou declared having no financial conflicts.
Vitals
Source Elsevier Global Medical News
'Drinking coffee in moderation should be encouraged, even in elderly hypertensive subjects.'
Source DR. CHRYSOHOOU
Consumption of 1–2 cups/day was a predictor of enhanced arterial elasticity.
Source ©Robert Brown/Fotolia.com
Glycemic Control Influenced Heart Failure Risk
STOCKHOLM – Suboptimal glycemic control is an independent risk factor for a linear increase in the rate of new-onset heart failure in patients with type 2 diabetes, a large Scottish prospective case-control study indicates.
Moreover, in type 2 diabetes patients who already have established heart failure, poor glycemic control is independently associated with increased mortality, Dr. Chim Choy Lang reported at the congress.
These were the key findings in a new analysis from the Tayside Study, which Dr. Lang directs. The ongoing project provides an unusual opportunity to prospectively follow a Scottish community, population 400,000.
“We can track patients with diabetes mellitus, looking at mean [hemoglobin A1c] over time, and see who develops heart failure,” he eaid in an interview.
The analysis was performed because controversy has arisen surrounding the relationship between glycemic control in type 2 diabetes and heart failure. Some recent evidence suggests tight metabolic control is actually associated with worse survival in the setting of heart failure.
“It should be noted that most of these studies were based on a single measure of HbA1c. I think there's always cause for concern about that kind of analysis,” observed Dr. Lang, a cardiologist at the University of Dundee.
He reported on more than 9,000 Tayside residents with type 2 diabetes, 841 of whom developed heart failure during 1991-2008. Each diabetic heart failure patient was matched by age, gender, and date of diagnosis of diabetes to five controls.
Analysis, revealed that mean HbA1c during the study period was associated in linear fashion with the risk of later developing heart failure. Each 1% increase in HbA1c was independently linked to a 19% increase in incident heart failure after the researchers controlled for patients' mean arterial pressure and use of thiazolidinediones.
Further, in type 2 diabetic patients with diagnosed heart failure, each 1% increase in mean HbA1c was independently associated with an adjusted 16% increase in all-cause mortality.
“I think our findings are an argument for tight glycemic control in diabetic patients with heart failure. The question is how to achieve that. I'm a big believer in metformin for that purpose,” the cardiologist said.
Asked whether the increased risk of mortality documented in diabetic patients with poor glycemic control and heart failure is a marker for poor adherence to standard heart failure medications or is due to the adverse effects of high blood glucose, Dr. Lang said that's a key unsettled question.
“We have the ability to look at treatment adherence in this cohort and are doing so at the moment,” he added.
He declared having no financial conflicts in connection with the study, which was conducted free of industry involvement.
Each 1% increase in HbA1c was independently linked to a 19% increase in incident heart failure.
Source DR. LANG
STOCKHOLM – Suboptimal glycemic control is an independent risk factor for a linear increase in the rate of new-onset heart failure in patients with type 2 diabetes, a large Scottish prospective case-control study indicates.
Moreover, in type 2 diabetes patients who already have established heart failure, poor glycemic control is independently associated with increased mortality, Dr. Chim Choy Lang reported at the congress.
These were the key findings in a new analysis from the Tayside Study, which Dr. Lang directs. The ongoing project provides an unusual opportunity to prospectively follow a Scottish community, population 400,000.
“We can track patients with diabetes mellitus, looking at mean [hemoglobin A1c] over time, and see who develops heart failure,” he eaid in an interview.
The analysis was performed because controversy has arisen surrounding the relationship between glycemic control in type 2 diabetes and heart failure. Some recent evidence suggests tight metabolic control is actually associated with worse survival in the setting of heart failure.
“It should be noted that most of these studies were based on a single measure of HbA1c. I think there's always cause for concern about that kind of analysis,” observed Dr. Lang, a cardiologist at the University of Dundee.
He reported on more than 9,000 Tayside residents with type 2 diabetes, 841 of whom developed heart failure during 1991-2008. Each diabetic heart failure patient was matched by age, gender, and date of diagnosis of diabetes to five controls.
Analysis, revealed that mean HbA1c during the study period was associated in linear fashion with the risk of later developing heart failure. Each 1% increase in HbA1c was independently linked to a 19% increase in incident heart failure after the researchers controlled for patients' mean arterial pressure and use of thiazolidinediones.
Further, in type 2 diabetic patients with diagnosed heart failure, each 1% increase in mean HbA1c was independently associated with an adjusted 16% increase in all-cause mortality.
“I think our findings are an argument for tight glycemic control in diabetic patients with heart failure. The question is how to achieve that. I'm a big believer in metformin for that purpose,” the cardiologist said.
Asked whether the increased risk of mortality documented in diabetic patients with poor glycemic control and heart failure is a marker for poor adherence to standard heart failure medications or is due to the adverse effects of high blood glucose, Dr. Lang said that's a key unsettled question.
“We have the ability to look at treatment adherence in this cohort and are doing so at the moment,” he added.
He declared having no financial conflicts in connection with the study, which was conducted free of industry involvement.
Each 1% increase in HbA1c was independently linked to a 19% increase in incident heart failure.
Source DR. LANG
STOCKHOLM – Suboptimal glycemic control is an independent risk factor for a linear increase in the rate of new-onset heart failure in patients with type 2 diabetes, a large Scottish prospective case-control study indicates.
Moreover, in type 2 diabetes patients who already have established heart failure, poor glycemic control is independently associated with increased mortality, Dr. Chim Choy Lang reported at the congress.
These were the key findings in a new analysis from the Tayside Study, which Dr. Lang directs. The ongoing project provides an unusual opportunity to prospectively follow a Scottish community, population 400,000.
“We can track patients with diabetes mellitus, looking at mean [hemoglobin A1c] over time, and see who develops heart failure,” he eaid in an interview.
The analysis was performed because controversy has arisen surrounding the relationship between glycemic control in type 2 diabetes and heart failure. Some recent evidence suggests tight metabolic control is actually associated with worse survival in the setting of heart failure.
“It should be noted that most of these studies were based on a single measure of HbA1c. I think there's always cause for concern about that kind of analysis,” observed Dr. Lang, a cardiologist at the University of Dundee.
He reported on more than 9,000 Tayside residents with type 2 diabetes, 841 of whom developed heart failure during 1991-2008. Each diabetic heart failure patient was matched by age, gender, and date of diagnosis of diabetes to five controls.
Analysis, revealed that mean HbA1c during the study period was associated in linear fashion with the risk of later developing heart failure. Each 1% increase in HbA1c was independently linked to a 19% increase in incident heart failure after the researchers controlled for patients' mean arterial pressure and use of thiazolidinediones.
Further, in type 2 diabetic patients with diagnosed heart failure, each 1% increase in mean HbA1c was independently associated with an adjusted 16% increase in all-cause mortality.
“I think our findings are an argument for tight glycemic control in diabetic patients with heart failure. The question is how to achieve that. I'm a big believer in metformin for that purpose,” the cardiologist said.
Asked whether the increased risk of mortality documented in diabetic patients with poor glycemic control and heart failure is a marker for poor adherence to standard heart failure medications or is due to the adverse effects of high blood glucose, Dr. Lang said that's a key unsettled question.
“We have the ability to look at treatment adherence in this cohort and are doing so at the moment,” he added.
He declared having no financial conflicts in connection with the study, which was conducted free of industry involvement.
Each 1% increase in HbA1c was independently linked to a 19% increase in incident heart failure.
Source DR. LANG
Congestion Did Not Predict HF Outcomes
STOCKHOLM – The absence of signs and symptoms of congestion at discharge in patients hospitalized for acute decompensated heart failure does not predict a favorable prognosis, contrary to the conventional wisdom.
A new secondary analysis of the international EVEREST trial provides an important lesson in the everyday management of acute heart failure: “The fact that a patient improves in-hospital with diuretics and other medications is not sufficient. It's not 'mission accomplished,' ” Dr. Mihai Gheorghiade said at the congress.
“In spite of having a very low congestion score, the event rate in EVEREST during 10 months of follow-up was astronomical,” said Dr. Gheorghiade, professor of medicine and surgery and associate chief of cardiology at Northwestern University, Chicago.
EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan) was a double-blind study that randomized 4,133 patients with worsening heart failure and a left ventricular ejection fraction of 40% or less to the oral vasopressin V2 receptor blocker tolvaptan or placebo within 48 hours of hospitalization.
Standard background therapy in both study arms included diuretics, ACE inhibitor or angiotensin II receptor blocker therapy, a beta-blocker, and an aldosterone antagonist. In the previously reported primary results, tolvaptan proved to have no benefit over placebo during a mean follow-up of 9.9 months (JAMA 2007;297:1319-31).
Dr. Gheorghiade presented a secondary analysis focusing on the 2,061 patients in the placebo arm. At randomization, following initial treatment with diuretics, these patients had a mean congestion score of 4 points based upon their degree of jugular vein distention, rales, and peripheral edema.
At discharge, patients had lost a mean 2.8 kg of body weight, and 72% had a congestion score of 0 or 1. Although that appears to be a high rate of short-term treatment success, this large subgroup of patients with minimal or no signs or symptoms of congestion at discharge had a 15% all-cause mortality and a 29% rate of rehospitalization for heart failure during the next 9.9 months.
The adverse event rate was even greater in those with a higher congestion score at discharge. In the overall placebo group, all-cause mortality was 26%, with a 40% rate of rehospitalization for heart failure during follow-up.
“We're dealing with a disorder that has an event rate as high as 50%. There is no other medical condition for which patients are hospitalized and are improving with therapy that has a comparable event rate,” the cardiologist observed.
The new EVEREST analysis contains an important message for clinical trialists: Using the signs and symptoms of congestion as a key target for treatment during hospitalization as well as the standard end point in acute heart failure studies, as has been common until now, is a recipe for a negative trial result.
“It's very difficult to beat placebo, because placebo plus standard therapy has a tremendous effect on congestion,” Dr. Gheorghiade said.
“Looking for new therapies that improve signs and symptoms of congestion in the whole population is a waste of time unless you're dealing with special populations who don't respond to standard therapies, such as patients with low blood pressure,” he added.
Better surrogate markers than congestion are needed to guide therapy. One possibility is B-type natriuretic peptide (BNP). The mean BNP at admission in the placebo arm of EVEREST was 1,375 pg/mL. At discharge it was still markedly elevated at 948 pg/mL.
Until better treatments for acute heart failure are found, the best thing physicians can do for affected patients is try to identify specific targets amenable to current therapies, such as renal dysfunction or myocardial ischemia, Dr. Gheorghiade concluded.
The EVEREST trial was sponsored by Otsuka. Dr. Gheorghiade has received research grants and/or served as a consultant to Otsuka and numerous other pharmaceutical companies.
Dr. Gheorghiade: In-hospital improvement is not 'mission accomplished.'
Source Bruce Jancin/Elsevier Global Medical News
STOCKHOLM – The absence of signs and symptoms of congestion at discharge in patients hospitalized for acute decompensated heart failure does not predict a favorable prognosis, contrary to the conventional wisdom.
A new secondary analysis of the international EVEREST trial provides an important lesson in the everyday management of acute heart failure: “The fact that a patient improves in-hospital with diuretics and other medications is not sufficient. It's not 'mission accomplished,' ” Dr. Mihai Gheorghiade said at the congress.
“In spite of having a very low congestion score, the event rate in EVEREST during 10 months of follow-up was astronomical,” said Dr. Gheorghiade, professor of medicine and surgery and associate chief of cardiology at Northwestern University, Chicago.
EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan) was a double-blind study that randomized 4,133 patients with worsening heart failure and a left ventricular ejection fraction of 40% or less to the oral vasopressin V2 receptor blocker tolvaptan or placebo within 48 hours of hospitalization.
Standard background therapy in both study arms included diuretics, ACE inhibitor or angiotensin II receptor blocker therapy, a beta-blocker, and an aldosterone antagonist. In the previously reported primary results, tolvaptan proved to have no benefit over placebo during a mean follow-up of 9.9 months (JAMA 2007;297:1319-31).
Dr. Gheorghiade presented a secondary analysis focusing on the 2,061 patients in the placebo arm. At randomization, following initial treatment with diuretics, these patients had a mean congestion score of 4 points based upon their degree of jugular vein distention, rales, and peripheral edema.
At discharge, patients had lost a mean 2.8 kg of body weight, and 72% had a congestion score of 0 or 1. Although that appears to be a high rate of short-term treatment success, this large subgroup of patients with minimal or no signs or symptoms of congestion at discharge had a 15% all-cause mortality and a 29% rate of rehospitalization for heart failure during the next 9.9 months.
The adverse event rate was even greater in those with a higher congestion score at discharge. In the overall placebo group, all-cause mortality was 26%, with a 40% rate of rehospitalization for heart failure during follow-up.
“We're dealing with a disorder that has an event rate as high as 50%. There is no other medical condition for which patients are hospitalized and are improving with therapy that has a comparable event rate,” the cardiologist observed.
The new EVEREST analysis contains an important message for clinical trialists: Using the signs and symptoms of congestion as a key target for treatment during hospitalization as well as the standard end point in acute heart failure studies, as has been common until now, is a recipe for a negative trial result.
“It's very difficult to beat placebo, because placebo plus standard therapy has a tremendous effect on congestion,” Dr. Gheorghiade said.
“Looking for new therapies that improve signs and symptoms of congestion in the whole population is a waste of time unless you're dealing with special populations who don't respond to standard therapies, such as patients with low blood pressure,” he added.
Better surrogate markers than congestion are needed to guide therapy. One possibility is B-type natriuretic peptide (BNP). The mean BNP at admission in the placebo arm of EVEREST was 1,375 pg/mL. At discharge it was still markedly elevated at 948 pg/mL.
Until better treatments for acute heart failure are found, the best thing physicians can do for affected patients is try to identify specific targets amenable to current therapies, such as renal dysfunction or myocardial ischemia, Dr. Gheorghiade concluded.
The EVEREST trial was sponsored by Otsuka. Dr. Gheorghiade has received research grants and/or served as a consultant to Otsuka and numerous other pharmaceutical companies.
Dr. Gheorghiade: In-hospital improvement is not 'mission accomplished.'
Source Bruce Jancin/Elsevier Global Medical News
STOCKHOLM – The absence of signs and symptoms of congestion at discharge in patients hospitalized for acute decompensated heart failure does not predict a favorable prognosis, contrary to the conventional wisdom.
A new secondary analysis of the international EVEREST trial provides an important lesson in the everyday management of acute heart failure: “The fact that a patient improves in-hospital with diuretics and other medications is not sufficient. It's not 'mission accomplished,' ” Dr. Mihai Gheorghiade said at the congress.
“In spite of having a very low congestion score, the event rate in EVEREST during 10 months of follow-up was astronomical,” said Dr. Gheorghiade, professor of medicine and surgery and associate chief of cardiology at Northwestern University, Chicago.
EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan) was a double-blind study that randomized 4,133 patients with worsening heart failure and a left ventricular ejection fraction of 40% or less to the oral vasopressin V2 receptor blocker tolvaptan or placebo within 48 hours of hospitalization.
Standard background therapy in both study arms included diuretics, ACE inhibitor or angiotensin II receptor blocker therapy, a beta-blocker, and an aldosterone antagonist. In the previously reported primary results, tolvaptan proved to have no benefit over placebo during a mean follow-up of 9.9 months (JAMA 2007;297:1319-31).
Dr. Gheorghiade presented a secondary analysis focusing on the 2,061 patients in the placebo arm. At randomization, following initial treatment with diuretics, these patients had a mean congestion score of 4 points based upon their degree of jugular vein distention, rales, and peripheral edema.
At discharge, patients had lost a mean 2.8 kg of body weight, and 72% had a congestion score of 0 or 1. Although that appears to be a high rate of short-term treatment success, this large subgroup of patients with minimal or no signs or symptoms of congestion at discharge had a 15% all-cause mortality and a 29% rate of rehospitalization for heart failure during the next 9.9 months.
The adverse event rate was even greater in those with a higher congestion score at discharge. In the overall placebo group, all-cause mortality was 26%, with a 40% rate of rehospitalization for heart failure during follow-up.
“We're dealing with a disorder that has an event rate as high as 50%. There is no other medical condition for which patients are hospitalized and are improving with therapy that has a comparable event rate,” the cardiologist observed.
The new EVEREST analysis contains an important message for clinical trialists: Using the signs and symptoms of congestion as a key target for treatment during hospitalization as well as the standard end point in acute heart failure studies, as has been common until now, is a recipe for a negative trial result.
“It's very difficult to beat placebo, because placebo plus standard therapy has a tremendous effect on congestion,” Dr. Gheorghiade said.
“Looking for new therapies that improve signs and symptoms of congestion in the whole population is a waste of time unless you're dealing with special populations who don't respond to standard therapies, such as patients with low blood pressure,” he added.
Better surrogate markers than congestion are needed to guide therapy. One possibility is B-type natriuretic peptide (BNP). The mean BNP at admission in the placebo arm of EVEREST was 1,375 pg/mL. At discharge it was still markedly elevated at 948 pg/mL.
Until better treatments for acute heart failure are found, the best thing physicians can do for affected patients is try to identify specific targets amenable to current therapies, such as renal dysfunction or myocardial ischemia, Dr. Gheorghiade concluded.
The EVEREST trial was sponsored by Otsuka. Dr. Gheorghiade has received research grants and/or served as a consultant to Otsuka and numerous other pharmaceutical companies.
Dr. Gheorghiade: In-hospital improvement is not 'mission accomplished.'
Source Bruce Jancin/Elsevier Global Medical News