Physician's Weekly Article - Conference Highlights: The AHA 2008 Annual Meeting

       The American Heart Association held its 2008 Scientific Sessions from November 8-12 in New Orleans. The features below highlight just some of the news emerging from the meeting. For more information on these items and other research that was presented, go to http://scientificsessions.americanheart.org/.

      JUPITER

      The Particulars: Increased levels of high-sensitivity C-reactive protein (CRP) can help predict cardiovascular events. Statins have been proven to lower CRP levels as well as cholesterol. JUPITER (Justification for Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) was a large, multinational, long-term, double-blind, placebo-controlled, randomized clinical trial intended to evaluate whether healthy individuals with normal LDL cholesterols but elevated CRP levels would benefit from statin therapy (rosuvastatin 20 mg/day).

      Data Breakdown: Researchers randomly assigned 17,802 healthy men and women with LDL cholesterol levels less than 130 mg/dL and high-sensitivity CRP levels of 2.0mg/L or higher to 20 mg/day of rosuvastatin or placebo. Participants were evaluated for the occurrence of the combined primary end point of myocardial infarction, stroke, arterial revascularization, hospitalization for unstable angina, or death from cardiovascular causes. At 12 months follow-up, the rosuvastatin group showed a decrease in median LDL cholesterol levels from 108 mg/dL to 55 mg/dL. CRP levels decreased from 4.2 mg/L to 2.2 mg/L, and triglyceride levels dropped by 17%. At 1.9 years follow-up, rosuvastatin was associated with a 44% reduction in cardiovascular events when compared with placebo.

      Take Home Pearl: Use of statin therapy in individuals with low LDL but elevated high-sensitivity CRP significantly reduced the incidence of major cardiovascular events.

      TIMACS

      The Particulars: Optimal timing of an invasive strategy is still unknown in the management of unstable angina or NSTEMI. TIMACS (Timing of Intervention in Patients with Acute Coronary Syndromes) compared the usefulness, safety, and cost effectiveness of an early invasive strategy (within 24 hours of onset) with a delayed invasive strategy (more than 36 hours of onset).

      Data Breakdown: More than 3,000 patients with unstable angina or NSTEMI were randomized to early or delayed invasive management. Overall, researchers did not find a significant reduction in the risk of death, myocardial infarction (MI), or stroke between the groups. However, secondary endpoints of death, MI, or refractory ischemia were significantly lower in the early invasive management group. Additionally, patients at high risk for adverse events showed a significant reduction in the incidence of death, MI, and stroke in the early invasive group versus the delayed invasive group.

      Take Home Pearls: Patients with unstable angina or NSTEMI who are at high risk for death or cardiovascular events should receive early invasive management. However, the course of action for low- to moderate-risk patients should be determined based on individual circumstances.

      FIT Heart

      The Particulars: Family members of patients who experienced an acute cardiovascular event are not achieving national standards for preventive care. The Family Intervention Trial for Heart Health, or FIT Heart, assessed the association between non-adherence to diet and social support in relatives of cardiovascular disease (CVD) patients.

      Data Breakdown: In FIT Heart, adult relatives of CVD patients were randomized to a control intervention group that received a general handout about reducing risk factors or a special intervention group that received on-the-spot risk factor screening with immediate feedback and a year of diet and exercise counseling. Both groups experienced significant reductions in the consumption of dietary saturated fat, dietary cholesterol, and trans fat as well as improved physical activity. Participants who had low social support at baseline were 2.7 times more likely to be non-adherent to diet counseling at 1 year versus participants with high social support. Intervention participants were more likely to exercise at least 3 days per week.

      Take Home Pearl: Low social support at baseline was independently associated with non-adherence to diet at 1 year in family members of patients with CVD.

      BACH Multinational Trial

      The Particulars: Shortness of breath is a common patient symptom that presents in the ED but may be due to several causes, including asthma, respiratory infections, and congestive heart failure. The BACH Multinational Trial assessed Mid-Regional pro Adrenomedullin MR-proADM, a new blood test recently approved for use in Europe. It indirectly measures adrenomedullin, a hormone that affects blood vessel dilation and is associated with cardiac and infectious disease.

      Data Breakdown: The trial was a prospective, 15-center, international multiple serum biomarker study of 1,641 patients presenting to the ED with shortness of breath. It compared the B-Natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NTproBNP) tests to MR-proADM. Researchers found that 34.6% of patients had a diagnosis of heart failure, of which 11.4% died within 90 days. For all 1,641 enrolled patients, the prognostic accuracy of MRproADM was 73.1% compared with a 60.6% rate for BNP and a 63.0% rate for NTproBNP.

      Take Home Pearl: MRproADM appeared to be superior to BNP and NTproBNP, regardless of troponin levels, for predicting 90-day mortality in patients with shortness of breath and acute heart failure.

      ATHENA

      The Particulars: Dronedarone is an investigational drug currently under FDA review for the treatment of atrial fibrillation/atrial flutter (AF/AFL). The ATHENA trial was a double-blind, anti-arrhythmic, morbidity-mortality study in patients with AF/AFL. A new post-hoc analysis from ATHENA compared safety and efficacy of dronedarone as compared with placebo in patients with AF/AFL.

      Data Breakdown: Patients were randomized to receive 400 mg of dronedarone twice daily or placebo. There were 675 first cardiovascular hospitalizations on dronedarone and 859 on placebo. The main reasons for first hospitalization (dronedarone/placebo) were: AF (296/457), ischemic heart disease (93/102), heart failure (78/92). Dronedarone reduced total hospital burden—cardiovascular and non-cardiovascular hospitalization—by 28% when compared with placebo (9,995 days vs 13,986 days). For cardiovascular hospitalizations alone, the number of nights was reduced by 35%.

      Take Home Pearl: Dronedarone substantially reduced the risk of cardiovascular hospitalization and significantly reduced total hospitalization burden in patients with AF/AFL.

      APPROACH

      The Particulars: Rosiglitazone (RSG) has effects on insulin resistance and other cardiovascular risk factors that may decrease progression of coronary atherosclerosis. APPROACH was a prospective, multicenter, double-blind, randomized, active-controlled clinical trial that compared the effects of RSG with glipizide on the progression of coronary atherosclerosis.

      Data Breakdown: APPROACH investigators followed 672 patients with type 2 diabetes and coronary artery disease undergoing clinically indicated coronary angiography or PCI. Patients were randomized to receive RSG or glipizide for 18 months. Intravascular ultrasound (IVUS) was used to measure the affects of both drugs on progression of atherosclerosis. Patients receiving RSG had nearly an 8% higher HDL level compared with patients receiving glipizide. Following the treatment period, IVUS found that RSG appeared to stall or possibly reverse atherosclerotic progression. A 0.21% reduction of plaque volume was observed in RSG patients compared with a 0.43% increase in plaque in glipizide recipients.

      Take Home Pearl: In patients with type 2 diabetes, RSG increased levels of HDL cholesterol, improved blood pressure, and reduced highly-sensitive C reactive protein levels.