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Two decades have brought little change for women in cardiology

Female cardiologists remain underrepresented and report more work-life challenges than men.

Female cardiologists are less likely than their male counterparts to get married and have children and more likely to face challenges related to child care, family leave policies and professional discrimination, according to a study scheduled for presentation at the American College of Cardiology's 65th Annual Scientific Session.

Women are also underrepresented in the field, comprising less than 20 percent of cardiologists who see adult patients. The study, the third in a series of surveys conducted by the American College of Cardiology, revealed only slight improvements over the past 20 years.

"I'm very concerned that we haven't seen much growth in the number of women in adult cardiology," said Sandra Lewis, M.D., FACC, a cardiologist at Northwest Cardiovascular Institute and the study's lead author. "Twenty years ago, we acknowledged a need to increase the number of women in cardiology, and 10 years ago we saw an increase, but we've hit a wall. We need to understand the barriers to women entering cardiology and work toward breaking down those barriers."

Women make up half of all medical school graduates and nearly half of internal medicine specialists, yet they comprise fewer than one-fifth of adult cardiologists. Women are better represented among pediatric cardiologists.

"It's clear that diverse populations add richness to any field," Lewis said. "We feel that improving the diversity in cardiology will benefit our patients as well as our research efforts and will better reflect the communities that we serve."

More than 2,000 cardiologists completed the 2015 survey, which was a follow-up to surveys conducted in 1996 and 2006. The new survey found 15 percent of female cardiologists were single, as compared to just 5 percent among males - proportions that have not changed significantly since the first survey in 1996. Seventy-two percent of women reported having children, a proportion that is significantly up from 63 percent in 1996 but still well below their male counterparts, of whom 86 percent reported having children in the 2015 survey.

Lewis said the findings suggest a need for workplace policies that make it easier for women to take time off for childbearing and to handle child care during nights and on-call rotations, particularly during residency and fellowships, which often fall during a woman's prime childbearing years.

"We can do a better job of making cardiology a friendly place for young women," Lewis said. "It's definitely not that women don't want to work hard or deal with the demanding schedule that's required. If you look at obstetrics and gynecology, for example, where the schedule is very comparable, that specialty is nonetheless dominated by women."

Men were far more likely to report having a spouse that provides child care at home, at 57 percent as compared to just 13 percent among women. Nearly half of women reported needing additional child care for nights and on-call rotations, as compared to just a quarter of men.

One area of improvement for both women and men was the proportion reporting no official family leave policy at their workplace. That proportion is now around 1 in 10, which is significantly down from rates seen in past surveys and suggests that more workplaces have adopted such policies.

The survey also sheds light on career satisfaction and professional challenges. Although about 7 out of 8 cardiologists of both genders reported overall satisfaction with their careers, women were much more likely to say their level of professional advancement was lower than their peers and significantly less likely to say it was higher than their peers.

Sixty-three percent of women reported experiencing past discrimination, such as receiving a lower salary than others in their cohort or being passed up for promotion. That proportion is significantly down from 71 percent and 69 percent in 1996 and 2006, respectively, but still substantially higher than the rates reported by men, which remained flat at around 22 percent in all three surveys.

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Women, men with suspected heart disease have similar symptoms

Large study finds chest pain, shortness of breath are most common signs in both sexes.

Chest pain and shortness of breath are the most common symptoms reported by both women and men with suspected heart disease, a finding that is in contrast to prior data, according to a study scheduled for presentation at the American College of Cardiology's 65th Annual Scientific Session.

The study, which includes one of the largest cohorts of women ever enrolled in a heart disease study, also found that women had a greater number of risk factors for heart disease than men, yet these women were more likely to be characterized as lower risk not only by their health care providers, but also by scores that objectively measure and predict heart disease risk.

"The most important take-home message for women from this study is that their risk factors for heart disease are different from men's, but in most cases symptoms of possible blockages in the heart's arteries are the same as those seen in men," said Kshipra Hemal of the Duke Clinical Research Institute in Durham, North Carolina, and lead author of the study.

The finding that women have more risk factors for heart disease than men means measures to reduce risk need to be a priority for women, as well as men, Hemal said.

Some previous studies have suggested that women having a heart attack are less likely to have classic symptoms such as chest pain and more likely to have atypical symptoms such as back pain, abdominal pain and fatigue that may be less readily recognized as heart attack symptoms. Hemal and her colleagues sought to shed light on a different group of patients - those without a prior heart disease diagnosis who were being evaluated for symptoms suggestive of heart disease. Few studies, mostly several decades old, have examined sex differences in this group of patients.

The Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE), a randomized trial conducted at 193 centers in the United States and Canada, enrolled 10,003 patients, of whom more than 5,200 were women. Half of the patients were randomly selected to receive a heart CT scan, which generates 3-D images of the heart's arteries that doctors can use to noninvasively assess the degree of narrowing. The rest received a functional or stress test - an exercise electrocardiogram, stress echocardiography or nuclear stress test - used to track the heart's response to stress. Hemal and her colleagues examined patient data to assess differences between women and men in age, race or ethnicity, risk factors, symptoms, evaluation and test results.

The study found that, compared with men, women were older (average age 62 vs. 59 for men), more often non-white, less likely to smoke or be overweight, and more likely to have high blood pressure, high cholesterol, a history of stroke, a sedentary lifestyle, a family history of early-onset heart disease and a history of depression. Chest pain was the primary symptom for 73.2 percent of women and 72.3 percent of men. The two sexes, however, described this pain differently - women were more likely to describe it as "crushing," "pressure," "squeezing" or "tightness, " whereas men were more likely to describe it as "aching," "dull," "burning" or "pins and needles." Equal proportions of women and men (15 percent) reported shortness of breath as a symptom.

Although women were more likely than men to have back pain, neck or jaw pain, or palpitations as their primary symptom, the percentage of patients of both sexes reporting these symptoms was very small (1 percent of women vs. 0.6 percent of men for back pain, 1.4 percent of women vs. 0.7 percent of men for neck or jaw pain, 2.7 percent of women vs. 2 percent of men for palpitations).

Women had lower scores than men on heart disease risk-assessment scores, suggesting a lower risk of heart disease, and before any diagnostic tests were conducted, health care providers were more likely to consider that women probably did not have heart disease. Nontraditional risk factors such as depression, sedentary lifestyle and family history of early-onset heart disease - risk factors that in this study were more commonly found in women than in men - are excluded from most risk-assessment questionnaires, however.

"For health care providers, this study shows the importance of taking into account the differences between women and men throughout the entire diagnostic process for suspected heart disease," Hemal said. "Providers also need to know that, in the vast majority of cases, women and men with suspected heart disease have the same symptoms."

Women were more likely than men to be referred for a stress echocardiography or nuclear stress test and less likely than men (9.7 percent vs. 15.1 percent) to have a positive test. Factors predicting a positive test differed for women compared with men. In women, body mass index and score on one of five risk-assessment questionnaires (the Framingham risk score) predicted a positive test, whereas in men scores on two risk-assessment questionnaires (the Framingham and modified Diamond-Forrester risk scores) predicted a positive test.

"The fact that this is one of the largest cohorts of women ever evaluated in a heart disease study lends validity to our findings," Hemal said. A limitation of the study is that it looks only at the diagnostic process and not at whether there are differences between women and men in numbers of heart attacks or in outcomes from heart attacks, she said.

"The next step in this research will be to examine whether and how the differences we have identified between women and men influence outcomes," she said.

The study is being published simultaneously in the Journal of the American College of Cardiology: Cardiovascular Imaging.

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PTSD may affect blood vessel health in veterans

Post-traumatic stress disorder (PTSD) may decrease the ability of blood vessels to dilate, raising the risk of heart attack and stroke in veterans, according to new research in the Journal of the American Heart Association.

In the largest study to date on the impact of post-traumatic stress disorder (PTSD) on blood vessel health, researchers found that blood vessels of veterans with PTSD were unable to expand normally in response to stimulus - they were less reactive - compared to veterans without PTSD. Less reactive blood vessels are linked to heart disease and other serious conditions.

"Traditional risk factors such as high blood pressure, diabetes, high cholesterol and smoking, have not fully explained why people with PTSD seem to be at higher heart disease risk. Our study suggests that chronic stress may directly impact the health of the blood vessels," said Marlene Grenon, M.D., lead author of the study and associate professor of surgery at the University of California San Francisco and vascular surgeon at the Veterans Affairs Medical Center San Francisco /Veterans Affairs Medical Center-Surgical Services.

Among veterans being treated at the Veteran's Affairs Medical Center in San Francisco researchers used a standard test, flow-mediated dilation (FMD), to gage how well an artery in the arm relaxes and expands in response to the squeezing of a blood-pressure cuff. They compared the FMD scores of 67 veterans (average age 68, 99 percent male) with PTSD and 147 veterans (average age 69, 91 percent male) without PTSD. The presence of PTSD was defined as a score of 40 or higher on the PTSD Symptom Checklist. They found:

Veterans with PTSD had significantly lower FMD scores - their blood vessels expanded 5.8 percent compared to 7.5 percent among the veterans without PTSD - indicating a less-healthy response in the lining of their blood vessels.

Aside from PTSD, lower scores on the FMD test were also linked to increasing age, worse renal function, and high blood pressure.

Veterans with PTSD were more likely to be male and to be diagnosed with depression, but less likely to be taking ace-inhibitors or beta-blockers to treat high blood pressure.

After adjusting for differences in age and the presence of other conditions and treatments, PTSD itself was still very strongly associated with blood vessels that were less able to dilate.

The study only included veterans; but PTSD can also occur in non-veterans as a reaction to experiencing or observing a terrifying event, such as warfare, natural disasters, sexual assault, other physical violence or trauma. People with the condition may experience prolonged anxiety, flashbacks, nightmares and many other life-altering symptoms. The disorder is estimated to affect 7.7 million people in the United States according to the U.S. Department of Health and Human Services National Institutes of Health.

"We need to determine better ways we can help people manage PTSD and other types of stress to reduce the negative impact of chronic stress on blood vessels. At the Veterans Administration in San Francisco, we are in the process of starting a multi-disciplinary vascular rehabilitation clinic to try to better manage traditional and non-traditional risk factors including stress, to improve cardiovascular health," Grenon said.

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LDL cholesterol: positive topline results from Phase 3 Praluent (alirocumab) study announced

Sanofi and Regeneron Pharmaceuticals, Inc. has announced positive results from the Phase 3 ODYSSEY ESCAPE trial evaluating Praluent® (alirocumab) Injection in patients with an inherited form of high cholesterol known as heterozygous familial hypercholesterolemia (HeFH), whose cholesterol levels required chronic, weekly or bi-weekly apheresis therapy. The trial met its primary endpoint, demonstrating that patients who added Praluent to their existing treatment regimen significantly reduced the frequency of their apheresis therapy by 75 percent, compared to placebo (p

"This is the first time a PCSK9 inhibitor has shown in a clinical study that it reduced the frequency of apheresis therapy, an invasive, difficult to access, time-consuming and expensive treatment for some of the most difficult-to-treat patients," said Bill Sasiela, Ph.D, VP, Program Direction, Regeneron. "The ODYSSEY clinical trial program was designed to understand the effect of Praluent on many different patient populations with a high degree of unmet need who required further reduction of their LDL cholesterol."

Apheresis therapy is invasive and burdensome to patients, given that it can take more than three hours. Treatment may also be inconvenient and cost up to $100,000 for each patient per year in the U.S. or up to €60,000 in Germany, where there are 200 centers and LDL apheresis is more frequently used. In the U.S. there are only approximately 60 apheresis centers and many patients must travel significant distances for the procedure.

"Despite statins, a subset of patients with heterozygous familial hypercholesterolemia are unable to sufficiently reduce their LDL cholesterol, and require regular apheresis treatment," said Jay Edelberg, MD., Ph.D, Head of Cardiovascular Development, Sanofi. "The results demonstrate that treatment with Praluent may help these patients decrease the frequency or even eliminate the need for apheresis."

The most common adverse events in the trial were fatigue (15 percent Praluent; 10 percent placebo), nasopharyngitis (10 percent Praluent; 10 percent placebo), diarrhea (10 percent Praluent; 0 percent placebo), myalgia (10 percent Praluent; 5 percent placebo), upper respiratory infection (7 percent Praluent; 19 percent placebo), headache (7 percent Praluent; 5 percent placebo), arthralgia (7 percent Praluent; 10 percent placebo), and back pain (5 percent Praluent; 10 percent placebo).

Detailed data will be presented at future medical congresses.

About ODYSSEY ESCAPE

The completed Phase 3 placebo-controlled ODYSSEY ESCAPE trial involved 62 patients from 14 treatment centers in the U.S. and Germany. These patients were receiving regular baseline apheresis therapy at fixed intervals of every week or every 2 weeks prior to randomization. Patients were randomized to receive Praluent 150 mg (n=41) subcutaneously every 2 weeks or placebo (n=21), in addition to their existing treatment regimen. The double-blind treatment period comprised two intervals: for the first 6 weeks, patients remained on their established apheresis schedule at baseline, and for the following 12 weeks, apheresis frequency was adjusted based on the patient's LDL cholesterol response to treatment. ODYSSEY ESCAPE is part of the overarching

About Praluent

In July 2015, the companies announced that Praluent was approved for use in the U.S. Praluent is a PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitor indicated as adjunct to diet and maximally tolerated statin therapy for the treatment of adults with HeFH or clinical atherosclerotic CVD, who require additional lowering of LDL cholesterol. The effect of Praluent on CV morbidity and mortality has not been determined.

In September 2015, the European Commission approved the marketing authorization for Praluent. In the E.U., Praluent is approved for the treatment of adult patients with primary hypercholesterolemia (HeFH and non-familial) or mixed dyslipidemia as an adjunct to diet: a) in combination with a statin, or statin with other lipid-lowering therapies in patients unable to reach their LDL cholesterol goals with the maximally-tolerated statin or b) alone or in combination with other lipid-lowering therapies for patients who are statin intolerant, or for whom a statin is contraindicated. The effect of Praluent on CV morbidity and mortality has not yet been determined.

This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions.

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New ultrasound method creates better picture of cardiovascular health

Researchers at Lund University in Sweden have discovered a new and more accurate way to distinguish between harmful and harmless plaque in the blood vessels by using ultrasound. This can help healthcare providers determine the risk of strokes and heart attacks - which means avoiding unnecessary surgery for many patients.

In many parts of the world, atherosclerosis is one of the diseases responsible for a large number of cases of premature death.

Six years ago, a handful of researchers at Lund University in Sweden started taking an interest in how to make it easier to recognise unstable plaques that in worst case scenarios rupture and cause heart attacks or strokes.

Illustration from explainer video showing how ultrasound technique can locate harmful plaque in the carotid artery
Illustration from explainer video showing how ultrasound technique can locate harmful plaque in the carotid artery
Image Credit: Lund University / Jonas Andersson

When Tobias Erlöv, who at the time was a doctoral student in biomedical engineering at the Lund Faculty of Engineering, discovered that there is a fairly simple mathematical calculation that can be used to interpret ultrasound signals and thereby figure out whether the plaque in the carotid artery is harmful or not, the researchers were somewhat surprised.

Vascular surgery is currently only performed if there is excessive blockage to the blood flow, due too large plaques. However, determining whether or not the plaque is unstable cannot be done by simply studying flow rates and plaque sizes - knowing the type of cell concerned is more important.

Simply put, harmless plaques consist of connective tissue and smooth muscle cells. Harmful plaques consist of fat (lipids) and macrophages. Unstable plaques can also involve bleeding.

"We have shown that there is a strong correlation between changes in the centre frequency and the size of the reflecting particles. The more harmful substances, the greater the so-called centre frequency shift", says Tobias Erlöv, who is currently continuing his research at the Department of Biomedical Engineering.

The method can become useful to identify patients at risk of developing acute cardiovascular diseases, but also to follow up after surgery where plaque has already been removed.

In the future, ultrasound scans of the carotid artery will lead to the ability to perform surgery at an earlier stage in some cases, and the ability to avoid surgery completely in others.

People with cardiovascular diseases, and diabetics who risk developing them, can benefit from this new and accurate method.

"Ultrasound enables you to screen a larger population, and that in turn means that life-threatening cardiovascular diseases can be detected at an earlier stage", says Magnus Cinthio, senior lecturer in biomedical engineering and one of the researchers leading the work.

"Another advantage is that the method is inexpensive and completely harmless to patients", says Tobias Erlöv.

More studies are needed before the innovation can be picked up by ultrasound manufacturers and used in healthcare facilities. These studies are already underway, including within the European research collaboration Summit that is currently studying 1 500 patients.

Six years ago, Professor Jan Nilsson at the Clinical Research Centre (CRC) initiated a study aimed at finding ways to recognise unstable plaque formations. The study is part of a large European research collaboration called Summit (www.imi-summit.eu/).

The project is a collaboration between the Lund University Department of Biomedical Engineering and Department of Clinical Sciences at CRC, as well as other clinics in the UK and Italy.

Plaque in the carotid artery involves a risk of stroke

Atherosclerosis is an inflammatory disease of the arteries causing a continuous increase of vessel wall thickness and rigidity. Eventually, plaque is formed that partially blocks the blood flow. When plaque ruptures, it can cause a heart attack or a stroke.

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SSRI antidepressants 'do not increase risk of cardiovascular events'

Selective serotonin reuptake inhibitors, commonly prescribed as antidepressants, appear to not be linked to a higher risk of cardiovascular events such as heart attacks and stroke, according to research published in The BMJ.
[depression medication]
The study looked at people aged 20-64 years who had depression.

Depression is a common and debilitating condition. From 1988-1994 to 2005-2008, the use of antidepressants in the US almost quadrupled, and by 2005-2008, antidepressants were the third most frequently prescribed drug in the country.

Globally, cardiovascular diseases are a major cause of death and disability.

People with depression tend to be more susceptible to cardiovascular problems. There has been speculation that antidepressants, and selective serotonin reuptake inhibitors (SSRIs) in particular, contribute to this, as they may affect coagulation. However, this has not been confirmed.

In 2011, the US Food and Drug Administration (FDA) and the European Medicines Association warned that doses of Citalopram, one of the most common antidepressants, should not exceed 40 mg per day, after studies indicated the presence of heart rhythm disorders in participants taking a range of doses.

Study involved 238,963 participants

Researchers from the University of Nottingham in the UK investigated the relationship between different antidepressant drugs and rates of three cardiovascular issues in people with depression.

They analyzed data for 238,963 patients aged 20-64 years, with a first diagnosis of depression between 2000-2011.

The team monitored patients for heart attacks, strokes or transient ischemic attacks and arrhythmia, or irregular heartbeat, until 2012.

The scientists looked at tricyclic antidepressants, SSRIs and other types of antidepressant, as well as the dosage and duration of use.

They also adjusted for age, gender, alcohol and tobacco use, other conditions and use of other drugs.

Fluoxetine appears to decrease risk

In a 5-year period, 772 patients had a myocardial infarction, 1,106 had a stroke or transient ischemic attack, and 1,452 experienced arrhythmia.

However, there was no evidence that SSRIs increase the risk of arrhythmia, heart attacks and stroke or transient ischemic attacks. In fact, in the first year of follow-up, SSRIs were associated with a significantly lower risk of myocardial infarction, compared with no use of antidepressants.

However, during the first 4 weeks of use, tricyclic and related antidepressants appeared to double the risk of arrhythmia.

Author Carol Coupland, who is a professor of Medical Statistics in Primary Care at Nottingham University, says:

"We found some indication that selective serotonin reuptake inhibitors were associated with a reduced risk of heart attacks, particularly with the use of fluoxetine. Absolute risks of heart attacks were six per 10,000 for selective serotonin reuptake inhibitors over 1 year, and four per 10,000 for fluoxetine compared with 10 per 10,000 for non-use."

Citalopram was the most commonly prescribed drug in the study. Findings did not suggest an increased risk of arrhythmia, even at higher doses.

However, since only 18% of the Citalopram prescriptions in the study were for high doses, the authors note that higher doses could pose a risk, and they recommend avoiding them, especially for patients who are already more likely to develop cardiovascular problems.

The researchers note that the results do not prove a causative link, but they describe them as "reassuring in the light of recent safety concerns."

Limitations include the fact that data were not available for all confounders, for example, information about diet and exercise.

Earlier this year, Medical News Today reported on research that suggested taking antidepressants during pregnancy does not increase the risk of congenital heart defects.

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Heart disease declines in US, but disparity grows

Statistics published this week in Circulation show that, although the rate of heart disease is declining in America overall, some areas are improving much slower than others. There are also marked regional variations that are gradually morphing over the decades.
[Diagram of a heart]
America's heart disease rate is on the decline, but the whole story is much more complex.

More than 600,000 people in America die at the hands of heart disease each year.

This accounts for around 1 in 4 deaths, making it the leading cause of mortality in the US.

For the first time, data from 1973-2010 has been analyzed on a county level, highlighting which states have the highest rates of heart disease.

Although the risk factors for heart disease are known to include smoking, excess weight, cholesterol, diabetes and high blood pressure, there is a complex web of social and economic factors that impact these parameters.

This new analysis examines which American counties have an increased risk of heart disease, compared with others.

The research team was headed up by Michele Casper, of the Centers for Disease Control and Prevention's (CDC's) Division for Heart Disease and Stroke Prevention in Atlanta, GA.

Largest cardiac mortality study

The current study into the prevalence of heart disease in America is of unprecedented size and scope. The team looked at heart disease data for individuals under the age of 35 in more than 3,000 US counties between 1973-2010. Casper says:

"This is the most comprehensive study to compare county-level patterns of geographic disparities in heart disease death rates over an extended timeframe."

Although overall, heart disease mortality has declined, the geographical distribution of the most affected areas has shifted over time. Additionally, some areas have seen significantly steeper declines in illness than others.

Some counties' cardiac death rates were shown to have dropped by more than 80% since the 1970s, whereas some had declined by less than 10%.

The counties showing the slowest decline were mostly to be found in Mississippi, Alabama, Louisiana, Oklahoma, Arkansas and Texas. The areas with more substantial rates of improvement were largely seen in the northern half of the US.

Over the course of the research, the gap between the areas of least heart disease and those with the highest levels has almost doubled in size. In other words, the disparity between the best and the worst performers in heart health has grown.

American heart disease by county

In the 1970s, the highest rates of heart disease-related deaths were found in the northeastern counties, comprising parts of the Appalachia and into the Midwest, with the coastal areas of North Carolina, South Carolina and Georgia also being affected.

The following map shows the prevalence of heart disease by county in 1973-1974:

[Map of heart disease in America by county]
American heart disease 1973-1974.
Image credit: American Heart Association

Scroll forward almost 4 decades and the highest rates of heart disease related deaths have moved south of the Mason-Dixon Line.

The next map shows the country's heart disease rates in 2009-2010, with the shifting epicenter of heart disease moving in a southerly direction:

[Map of heart disease in America 2009-2010]
American heart disease 2009-2010.
Image credit: American Heart Association

The research did not delve into the precise reasons for these differences and their shifting patterns, but there are likely to be a great number of parameters at play. These factors might include local health policies, socioeconomic factors, ease of access to healthy food, health care, promotion of smoke-free environments and opportunities for physical activity.

Although the news, in general, is positive, there is still a long way to go. Casper says:

"Despite the overall decline in heart disease death rates, heart disease remains the leading cause of death in the United States, as well as one of the most widespread and costly health problems facing the nation."

Medical News Today recently covered research showing that the global rate of injuries has dropped since the 1990s.

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Stress management may enhance cardiac rehab, improve recovery

Heart patients may benefit from cardiac rehabilitation (rehab) programs even more when stress management is added, according to new research in the American Heart Association's journal Circulation.

"Cardiac rehabilitation programs do not routinely offer stress management, but this may change should demand increase. And because patients may be reluctant to ask for the programs themselves, the onus is on the physicians to recognize that stress management is important for the optimal medical management of patients," said James A. Blumenthal, Ph.D., professor of Psychiatry and Behavioral Sciences at Duke University School of Medicine in Durham, North Carolina.

After a median follow up of more than three years, researchers found that patients who underwent cardiac rehab plus stress management achieved greater benefits than rehab alone. Cardiac events such as heart attack, stroke, recurrent chest pains requiring hospitalization, or even death were observed in:

18 percent of patients in the rehab plus stress management group; 33 percent of patients in the cardiac rehab only group; and 47 percent of patients in those who had no rehab.

Researchers also note that stress reduction was linked to a 50 percent lower risk of cardiac events in the rehab plus stress management group, compared to the rehab group without stress management.

In the study called ENHANCing Cardiac rEhabilitation with stress management training in patients with heart Disease, or ENHANCED, 151 patients (ages 36 - 84) from two centers in North Carolina were randomized into two groups. The first group received 12 weeks of comprehensive, exercise-based cardiac rehabilitation. The second group received the same cardiac rehabilitation plus they participated in weekly 1.5-hour group stress management program for 12 weeks. Stress management included small group discussions, relaxation training, and training in coping skills and stress reduction.

An additional group of 75 patients, matched for age and medical conditions who chose not to participate in cardiac rehabilitation, served as a comparison group. All rehab participants completed standard questionnaires measuring levels of depression, anxiety, anger and general feelings of stress or distress.

Overall, patients in both rehab groups experienced improved levels of blood lipids, lower heart rates during exercise and better exercise tolerance, as well as improvements in other cardiac biomarkers of risk following 12 weeks of rehab.

Blumenthal estimated that only 20 percent to 30 percent of patients eligible for cardiac rehabilitation participate, possibly because of accessibility and cost, or low rates of referrals. Some also may try to rehabilitate on their own. "Despite their good intentions, making lifestyle changes is not an easy thing to do without assistance," he said.

Blumenthal explained that the results of ENHANCED contradict those of a recent British study which found that cardiac rehabilitation did not add value to the medical management of heart patients, and that the stress management program was not effective. In the British study, however, cardiac rehabilitation was performed weekly or biweekly for 6-8 weeks. In ENHANCED, rehab participants engaged in aerobic exercise three times a week for 12 weeks, took classes in nutrition, and were counseled on smoking cessation.

Co-authors are Andrew Sherwood, Ph.D.; Patrick J. Smith, Ph.D.; Lana Watkins, Ph.D.; Stephanie Mabe, M.S.; William E. Kraus, M.D.; Krista Ingle, Ph.D.; Paula Miller, M.D. and Alan Hinderliter, M.D. Author disclosures are on the manuscript.

The National Heart, Lung and Blood Institute supported the study.

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Hundreds of lives lost due to variations in common heart procedure

Despite the successful adoption of modern techniques, new research from the Universities of Keele and Manchester suggests more can be done to reduce fatalities following a non-surgical treatment for blocked arteries.

Data collected from a national cardiovascular database has highlighted that changes in the practice of interventional cardiology have led to improved patient outcomes - although these changes have not been applied universally across England and Wales.

Health data scientists from The University of Manchester's Health eResearch Centre and Keele University analysed the results of 448,853 patients who had received a percutaneous coronary intervention (PCI), a treatment in which stents are used to treat narrowed or blocked arteries, between 2005 and 2012. This non-surgical treatment can be delivered by inserting a catheter into either a patient's leg (the transfemoral route) or wrist (the transradial route).

The research team found that procedures undertaken through the wrist rapidly increased from 14% to 58% and that this change in practice has contributed to an estimated 450 lives saved over the seven year study window. Further, adoption of PCI through the wrist varies significantly in different parts of the UK.

By geographically mapping the data the health informaticians were able to further drill down into statistics and identify where utilisation methods varied the most. The team found that an additional 264 lives could have been saved if the transradial route was more frequently adopted and were able to identify the South East of England as the region with the lowest uptake in transradial PCI delivery.

Lead researcher and Professor in Cardiology, Mamas Mamas said: "It is clear from the research that performing PCI through the transradial route is safer and less invasive for patients. Current research uses large, often national databases to compare different ways of doing the same operation, however, these reports don't explain why the complication rates vary so much across sub-national regions.

"One reason that has been suggested is a lack of training opportunities for more experienced operators. Certainly a recent survey of 204 cardiologists identified an association between newly qualified surgeons and practitioners using the safer transradial route."

These findings build on previously published research by the team which showed that performing PCI via the wrist is associated with a 30% reduction in the risk of mortality in high risk groups undergoing these procedures.

For any corrections of factual information, or to contact our editorial team, please see our contact page.

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Insulin-secreting cells report on insulin resistance

Diabetes researchers at Sweden's Karolinska Institutet have developed a novel technique that makes it possible to monitor insulin resistance in a non-invasive manner over time in mice. The new method, presented in the journal Scientific Reports, can be used to assess insulin resistance during progression and intervention of metabolic diseases.

Insulin resistance is a key contributing factor to a variety of metabolic diseases, including cardio-vascular disease, the metabolic syndrome and Diabetes type 2. A major challenge in the field of insulin resistance is to be able to monitor this process dynamically in individual cell types of insulin target tissues, such as fat, liver, brain, kidney or pancreatic islets in the living organism.

The researchers behind the new study have previously shown that the insulin-secreting beta-cell, situated in the pancreatic islet of Langerhans, not only produces the hormone insulin but is also a target for insulin signaling. Consequently, beta-cell insulin resistance can contribute to the development and progression of type 2 Diabetes.

"The problem is that the islets are embedded in the pancreas and therefore not accessible for direct monitoring", says lead author Meike Paschen, doctoral student at the Rolf Luft Research Center for Diabetes and Endocrinology, Department of Molecular Medicine and Surgery at Karolinska Institutet. "However, by equipping beta-cells with a fluorescent biosensor that reports on insulin resistance and transplanting these reporter islets into the anterior chamber of the eyes of mice, we are now able to study beta-cell insulin sensitivity over months in the living mouse."

This novel technique utilizes the cornea as a natural body-window to allow the investigators to non-invasively monitor insulin resistance in islet of Langerhans transplanted to the anterior chamber of the eye. The biosensor expressed by the engrafted islets makes it possible for the researchers to differentiate insulin-resistant cells from those that have a normal response to insulin. The biosensor signal is measured non-invasively by fluorescence microscopy at single-cell resolution in the living animal.

"This technique allows monitoring of cell type specific insulin sensitivity or resistance in real-time in the context of whole body insulin resistance during progression and intervention of disease", says Professor Per-Olof Berggren, who led the current study together with Associate Professor Ingo Leibiger at the Rolf Luft Research Center for Diabetes and Endocrinology.

For any corrections of factual information, or to contact our editorial team, please see our contact page.

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Pre-pregnancy heart abnormalities may predict recurrent preeclampsia risk

Women who had pregnancy-related high blood pressure multiple times had recognizable heart abnormalities between pregnancies that could help predict their risk for heart and blood vessel disease during subsequent pregnancies and even later in life, according to new research in Hypertension, an American Heart Association journal.

Pregnancy-related high blood pressure, or preeclampsia, is a serious disease that affects 3 percent to 8 percent of pregnancies. This study showed how cardiovascular abnormalities detected in non-pregnant women with a history of preeclampsia might identify the recurrent preeclampsia in subsequent pregnancies.

When preeclampsia develops before 32 weeks of pregnancy, it is considered early. When preeclampsia occurs, the baby may need be delivered early to prevent harm to the mother and baby.

"Women who have early preeclampsia in their first pregnancy should be informed of their risk and should be carefully followed," said Herbert Valensise, M.D., Ph.D., study lead author and associate professor of obstetrics and gynecology at Tor Vergata University School of Medicine in Rome, Italy.

Previous research showed that women who have had preeclampsia are 7 times more likely than women with normal pregnancies to develop the disease in later pregnancies and are more likely to have heart and blood vessel disease later in life. What is unclear is how to predict who is at greater risk for these complications.

In this study, participants included 75 women who had preeclampsia and 147 women who did not have the disease during their previous pregnancy. None were pregnant at the start of the study and all participants underwent heart-imaging tests 12 to 18 months after their first delivery. All participants became pregnant again within 24 months and were followed until the end of their pregnancies. Of the 75 women who had preeclampsia in a previous pregnancy, 22 women (29 percent) developed it again. Participants' average age at the beginning of the study was 34 years.

Researchers found that women who had preeclampsia once and then developed it again in a subsequent pregnancy had pre-pregnancy abnormalities in one of the heart's four chambers. Compared to women who never had preeclampsia or who had it once, these women had abnormal changes in the size and function of the left ventricle, which pumps blood throughout the body. Specifically, the left ventricle was unusually thick and had to work harder while pumping significantly less blood.

"Physicians have to look at the complicated pregnancy history as a potential risk factor for cardiovascular complications later in life, and in a subsequent pregnancy," Valensise said. "When we ask about heart risk factors such as smoking, high cholesterol, family history of heart and blood vessel disease, we should also ask about possible high blood pressure during pregnancy, especially early preeclampsia."

This was a small study. Researchers said larger studies are necessary to confirm their findings.

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Doctors say 40,000 deaths a year linked to air pollution

A new landmark report from the Royal College of Physicians (RCP) and the Royal College of Paediatrics and Child Health (RCPCH) starkly sets out the dangerous impact air pollution is currently having on our nation's health - with around 40,000 deaths a year linked to air pollution. 'Every breath we take: the lifelong impact of air pollution' presents that the harm from air pollution is not just linked to short term episodes but is a long term problem with lifelong implications.

The report notes examples from right across an individual's lifespan, from a baby's first weeks in the womb through to the years of older age. Examples include, the adverse effects of air pollution on the development of the fetus, including lung and kidney development, and miscarriage, increases in heart attacks and strokes for those in later life; and the associated links to asthma, diabetes, dementia, obesity and cancer for the wider population.

In relation to asthma, the report stresses the significant point that after years of debate, there is now compelling evidence that air pollution is associated with both reduced lung growth in childhood and new onset asthma in children and in adults - whilst highlighting that air pollution increases the severity of asthma for those with the disease.

In recent years the dangers of outdoor air pollution have been well documented however, the report highlights the often overlooked section of our environment - that of indoor space. Factors such as, kitchen products, faulty boilers, open fires, fly sprays and air fresheners, all of which can cause poor air quality in our homes, workspaces and schools. According to the report indoor air pollution may have caused or contributed to 99,000 deaths annually in Europe.

Although government and the World Health Organization (WHO) set 'acceptable' limits for various pollutants in our air, the report states that there is in fact no level of exposure that can be seen to be safe, with any exposure carrying an associated risk.

As a result, the report offers a number of major reform proposals setting out what must be done if we are to tackle the problem of air pollution.

These include:

Put the onus on polluters. Polluters must be required to take responsibility for harming our health. Political leaders at a local, national and EU level must introduce tougher regulations, including reliable emissions testing for cars. Local authorities need to act to protect public health when air pollution levels are high. When these limits are exceeded, local authorities must have the power to close or divert roads to reduce the volume of traffic, especially near schools. Monitor air pollution effectively. Air pollution monitoring by central and local government must track exposure to harmful pollutants in major urban areas and near schools. These results should then be communicated proactively to the public in a clear way that everyone can understand. Quantify the relationship between indoor air pollution and health. We must strengthen our understanding of the key risk factors and effects of poor our quality in our homes, schools and workplaces. A coordinated effort is required to develop and apply any necessary policy changes. Define the economic impact of air pollution. Air pollution damages not only our physical health, but also our economic wellbeing. We need further research into the economic benefits of well designed policies to tackle it. Lead by example within the NHS. The health service must no longer be a major polluter; it must lead by example and set the benchmark for clean air and safe workplaces.

The working party for the report was chaired by Professor Stephen Holgate. On the report, Professor Holgate said:

'We now know that air pollution has a substantial impact on many chronic long term conditions, increasing strokes and heart attacks in susceptible individuals. We know that air pollution adversely effects the development of the fetus, including lung development. And now there is compelling evidence that air pollution is associated with new onset asthma in children and adults. When our patients are exposed to such a clear and avoidable cause of death, illness and disability, it our duty to speak out'

Dr Andrew Goddard, the Royal College of Physicians lead for the report said:

'Taking action to tackle air pollution in the UK will reduce the pain and suffering for many people with long term chronic health conditions, not to mention lessening the long term demands on our NHS. This is not just a job for government, local authorities or business - as individuals we can all do our part to reduce pollutant exposure.'

Professor Jonathan Grigg, Professor of Paediatric Respiratory and Environmental Medicine at Queen Mary University of London and the Vice Chair of the working party and representing the Royal College of Paediatrics and Child Health, said:

'There is clear evidence to suggest that long term exposure to air pollution has a wide range of adverse effects in childhood, and exposure during early life can lead to the development of serious conditions such as asthma. As NHS costs continue to escalate due to poor public health - asthma alone costs the NHS an estimated £1 billion a year - it essential that policy makers consider the effects of long term exposure on our children and the public purse.

'We therefore call on Government to monitor exposure to air pollution more effectively to help us identify those children and young people who are most at risk. We also ask the public to consider ways of reducing their own contribution to air pollution by taking simple measures such as using public transport, walking and cycling, and not choosing to drive high-polluting vehicles.'

The report also emphasises how the public can do their part to reduce pollutant exposure. Noting the impact collective action can have on the future levels of air pollution in our communities.

Suggestions include:

trying alternatives to car travel or preferably taking the active option: bus, train, walking and cycling aiming for energy efficiency in our homes keeping gas appliances and solid fuel burners in good repair learning more about air quality and staying informed.

Other key points from the report note:

Estimated cost of air pollution in the UK is £20 billion annually (in Europe €240 billion) A need to develop new technologies to improve air pollution monitoring More research to determine how social and economic trends are affecting air quality and its twin threat climate change.
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Pre-pregnancy heart abnormalities may predict recurrent preeclampsia risk

Women who had pregnancy-related high blood pressure multiple times had recognizable heart abnormalities between pregnancies that could help predict their risk for heart and blood vessel disease during subsequent pregnancies and even later in life, according to new research in Hypertension, an American Heart Association journal.

Pregnancy-related high blood pressure, or preeclampsia, is a serious disease that affects 3 percent to 8 percent of pregnancies. This study showed how cardiovascular abnormalities detected in non-pregnant women with a history of preeclampsia might identify the recurrent preeclampsia in subsequent pregnancies.

When preeclampsia develops before 32 weeks of pregnancy, it is considered early. When preeclampsia occurs, the baby may need be delivered early to prevent harm to the mother and baby.

"Women who have early preeclampsia in their first pregnancy should be informed of their risk and should be carefully followed," said Herbert Valensise, M.D., Ph.D., study lead author and associate professor of obstetrics and gynecology at Tor Vergata University School of Medicine in Rome, Italy.

Previous research showed that women who have had preeclampsia are 7 times more likely than women with normal pregnancies to develop the disease in later pregnancies and are more likely to have heart and blood vessel disease later in life. What is unclear is how to predict who is at greater risk for these complications.

In this study, participants included 75 women who had preeclampsia and 147 women who did not have the disease during their previous pregnancy. None were pregnant at the start of the study and all participants underwent heart-imaging tests 12 to 18 months after their first delivery. All participants became pregnant again within 24 months and were followed until the end of their pregnancies. Of the 75 women who had preeclampsia in a previous pregnancy, 22 women (29 percent) developed it again. Participants' average age at the beginning of the study was 34 years.

Researchers found that women who had preeclampsia once and then developed it again in a subsequent pregnancy had pre-pregnancy abnormalities in one of the heart's four chambers. Compared to women who never had preeclampsia or who had it once, these women had abnormal changes in the size and function of the left ventricle, which pumps blood throughout the body. Specifically, the left ventricle was unusually thick and had to work harder while pumping significantly less blood.

"Physicians have to look at the complicated pregnancy history as a potential risk factor for cardiovascular complications later in life, and in a subsequent pregnancy," Valensise said. "When we ask about heart risk factors such as smoking, high cholesterol, family history of heart and blood vessel disease, we should also ask about possible high blood pressure during pregnancy, especially early preeclampsia."

This was a small study. Researchers said larger studies are necessary to confirm their findings.

Co-authors are Damiano Lo Presti, M.D.; Giulia Gagliardi, M.D.; Grazia Maria Tiralongo, M.D.; Ilaria Pisani, M.D.; Gian Paolo Novelli, M.D., Ph.D.; and Barbara Vasapollo, M.D., Ph.D. Author disclosures are on the manuscript.

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Macrolide antibiotics 'do not increase risk of heart arrhythmia, death'

Macrolide antibiotic use appears not to increase the risk of serious heart rhythm disturbances or death, contrary to warnings issued by the US Food and Drug Administration. These are the findings of a large study published in the CMAJ.
[antibiotics]
Macrolide antibiotics are commonly prescribed for respiratory tract infections.

Some previous research has suggested that macrolides, such as azithromycin, clarithromycin and erythromycin, increase the risk of ventricular arrhythmia or serious heart rhythm disturbances and possibly death, but other studies had reached conflicting conclusions.

Macrolides are commonly prescribed in cases of respiratory tract infections. In 2010, over 57 million outpatient prescriptions for the drugs were written in the US.

Due to the concerns raised, in 2013, the Food and Drug Administration (FDA) warned that risks were associated with the antibiotics.

Dr. Amit Garg, director of the Institute for Clinical Evaluative Sciences (ICES) Western facility in London, Ontario, Canada, and colleagues studied over 600,000 adults aged 65 years and above.

The data were taken from the ICES and universal prescription drug coverage data from the Ontario Health Insurance Plan (OHIP).

The researchers compared people who were taking macrolides with people who were taking non-macrolide antibiotics. All participants were of similar age, health status and other characteristics.

The average age of participants was 74 years, and 57% were women.

Findings showed that the 30-day risk of ventricular arrhythmia for both groups was similar, but that the group using macrolides had a slightly lower risk of all-cause mortality.

In patients with congestive heart failure, coronary artery disease and chronic kidney disease, there did not appear to be any higher risk of adverse events when taking macrolides.

However, other studies have suggested that a combination of major risk factors, such as existing arrhythmia, older age, heart disease, bradycardia, hypokalemia or hypomagnesemia, particularly among females, may put patients at a higher risk of adverse events.

Some experts have proposed that for such patients, the risk could be minimized by carrying out electrocardiography before and after initiating therapy.

One limitation of the study was that the researchers did not know exactly why each patient was taking the antibiotics, although the specialty of the prescribing physician was mentioned.

The researchers comment:

"In contrast to prior studies, we found that these variables did not significantly alter the association between macrolide antibiotic use and our outcomes. Nonetheless, these findings should be interpreted with caution, and physicians should always consider a patient's baseline risk for adverse events before prescribing macrolides or other antibiotics."

They conclude that "the findings are reassuring for health care providers who prescribe macrolide antibiotics to a wide range of patients in routine care."

Medical News Today recently reported that antibiotics can cause delirium among patients, particularly the elderly.

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Supply of GPs and detection of hypertension in England associated with premature mortality rates, study suggests

University of Leicester researchers examine associations between mortality under 75 years and general practice characteristics

General practitioner numbers appear to have a small but important influence on premature mortality rates in England, according to research by the University of Leicester.

The study, published in the journal BMJ Open, records lower levels of premature mortality in less deprived practices - which could support the case for strengthening general practice throughout England.

Professor Richard Baker from the Department of Health Sciences who led the study explained: "We have conducted a study using data on 7,858 general practices in England for 2010 to investigate associations between mortality under aged 75 years and population and general practice characteristics.

"The findings show the importance of population characteristics such as deprivation, but also show associations between general practice characteristics and mortality. Better detection of hypertension was associated with lower mortality, and more general practitioners per 1,000 patient population were associated with lower mortality. Although the study only demonstrates associations, it supports the case for strengthening general practice."

The team set out to investigate whether a conceptual model representing some of the proposed mechanisms of primary care could explain variations in premature mortality in general practice populations, taking particular account of deprivation among population characteristics.

The researchers undertook a cross-sectional study in which population and primary care variables reflecting the model were used to explain variations in mortality of those aged under 75 years.

The number of GPs per 1,000 members of the population and detection of hypertension were negatively associated with mortality - and in less deprived practices, continuity of care was also negatively associated with mortality.

The study suggests that population variables, particularly deprivation, were the most powerful predictors of mortality and that practices with greater levels of diabetes, more smokers, more white patients and greater deprivation had higher levels of premature mortality overall.

Professor Baker added: "Greater supply of primary care is associated with lower premature mortality even in a health system that has strong primary care, such as England. Health systems need to sustain the capacity of primary care to deliver effective care, and should assist primary care providers in identifying and meeting the needs of socioeconomically deprived groups."

Dr Tony Bentley, GP Leicester City CCG has said of the study: "These findings support our plans to recruit more GPs into primary care in Leicester City to improve the health of our deprived populations and reduce health inequalities."

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Patients with no schooling benefit least from blood thinning medications

Atrial fibrillation patients with low education miss treatment targets more often.

Patients with no schooling benefit least from blood thinning medications, reveals a European Heart Rhythm Association (EHRA) / European Society of Cardiology (ESC) survey published in Europace. The poll of more than 1100 patients with atrial fibrillation found those with no schooling missed treatment targets more often, were less aware of bleeding risks, and did not know they could continue normal daily activities.

80% of university educated patients knew they could drive, play sports and travel by plane compared to 52% without schooling.

Atrial fibrillation is the most common cardiac rhythm disorder and affects 1.5-2% of the general population in the developed world. Atrial fibrillation substantially increases the risk of stroke. When strokes occur in patients with atrial fibrillation they are associated with more death and disability, longer hospital stays, and less chance of returning home.

EHRA President Professor Gerhard Hindricks said: "Blood thinning medications, also called oral anticoagulants, are the most effective way of preventing strokes in patients with atrial fibrillation and risk factors for stroke. We asked patients what they knew about their drugs and analysed whether this differed by gender, age, education level, and country of residence."

A total of 1147 patients with atrial fibrillation and taking oral anticoagulation completed 40 questions online. Oral anticoagulation included the vitamin K antagonists (such as warfarin) and the non-vitamin K oral anticoagulants (also called NOACs). Responses were collected over three months. Patients were 66 years old on average and 46% were women. Patients were from eight countries: France (33.6%), Denmark (26.6%), Sweden (20.9%), Spain (7.7%), Norway (4.5%), Germany (3.7%), the UK (2.2%) and Italy (0.8%).

The responses reveal disparities between patients with differing levels of education in terms of the benefits of anticoagulation and knowledge about the medication. Patients taking vitamin K antagonists such as warfarin are advised to keep their international normalised ratio (INR) level, which indicates how long it takes blood to form a clot, between 2 and 3. Patients with no schooling were more likely to exceed the upper limit several times a month than those with college or university education (5.1% vs 2.8%, p

Awareness of the bleeding risks associated with anticoagulant drugs was lowest in patients without schooling (38.5%) and highest in those with college and university education (57.0%) (p

Professor Carina Blomström-Lundqvist, who led the survey and is final author of the paper, said: "The survey shows that differences in patient education level may compromise the safety and efficacy of anticoagulants. Patients unaware of the importance of being compliant have a higher risk for both bleeding events and stroke. The findings underline the importance of providing user-friendly education about risk factors for stroke and adequate use of anticoagulants, and the importance of tailoring the educational message to the target population so that it is understood irrespective of the patient's level of schooling."

The impact of anticoagulation on quality of life differed by education level. The majority (80.2%) of patients with university education knew that they could continue their normal daily activities such as travelling by plane, sports, driving a car, or having a job, compared to just 51.8% of patients without schooling (p

Taking the patient group as a whole, when asked about the purpose of their anticoagulation medication, the majority (91-94%) correctly understood that it was to "thin the blood" but 6-9% incorrectly said it was to control the arrhythmia. Professor Blomström-Lundqvist said: "The survey demonstrated that a significant percentage of patients (around 8%) did not even understand the purpose of anticoagulation correctly and surprisingly, the number of patients who were aware of NOACs was still quite small."

She added: "This survey has important implications as it shows not only the need for more education in general about the indication and use of anticoagulants in patients with atrial fibrillation, but importantly also that differences in educational level among patient populations may significantly compromise the safety and efficacy of anticoagulants."

Professor Blomström-Lundqvist concluded: "We believe that associations and societies like EHRA and the ESC have an important task to provide more user-friendly educational tools to improve knowledge about anticoagulation use - when and how to take it and the importance of taking it - for both atrial fibrillation patients and their physicians. We also need to increase the awareness of NOACs, so that all patients, independent of their educational level, can have access to the most optimal therapy."

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First European advice launched for deadly acute heart failure

Death risk higher than heart attack but care lags 30 years behind.

The first European advice on emergency care for patients with acute heart failure is published in European Heart Journal: Acute Cardiovascular Care. Acute heart failure carries a higher risk of death than heart attack but care lags 30 years behind.

"Only half of patients discharged with acute heart failure are alive in three years."

"Mortality from acute heart failure is even higher than from a heart attack so it is an urgent situation," said Professor Christian Mueller, chair of the Acute Heart Failure Study Group of the Acute Cardiovascular Care Association (ACCA) of the European Society of Cardiology (ESC).

"Only half of patients discharged from hospital with acute heart failure are alive in three years, even though they felt fine," he continued. "Despite the severity of the condition there are no standard treatment pathways, whereas these were agreed across Europe for heart attack 30 years ago. The paper published today is the first step towards catching up with heart attack care and establishing similar standards for acute heart failure."

Acute heart failure is a chronic disorder that flares up and leads to emergency visits. The vast majority of patients present to an emergency department with sudden and severe shortness of breath (called acute dyspnoea) at rest. In 50% of patients the underlying condition is chronic heart failure. The other 50% could have had a heart attack ten years ago, or their underlying heart condition is undiagnosed.

"Most patients with acute heart failure cannot be cured," said Professor Mueller. "We can effectively treat the acute flare ups of dyspnoea with vasodilators or diuretics that remove the extra fluid on the lungs. But the underlying progressive disease remains and patients need long term follow up to make sure they are on the correct medication at the right dosages."

The paper published today focuses on the pivotal decision of whether to discharge patients with acute heart failure from the emergency department and see them as outpatients, or to admit them to hospital. Until now there was no guidance on this issue. The result is that emergency physicians have tended to act conservatively and admit patients to hospital.

"The hospital is not always the best place to care for acutely ill patients," said Professor Mueller. "While in hospital, patients with acute heart failure - who are 78 years old on average - are at risk of developing infections and they have problems sleeping. There is also pressure on hospitals to avoid expensive admissions when possible. But patients do benefit from more intense follow up while in hospital."

The paper outlines criteria to help clinicians select patients that can be safely discharged from the emergency department. A novel algorithm shows the order of decisions to be made and what to consider at each step.

Professor Mueller said: "The paper aims to kick start the process of emergency medicine physicians and cardiologists joining forces to apply or adjust the algorithm so that it works locally. The patient pathway and decisions on place of treatment will vary depending on reimbursement policies and logistics."

The importance of long term follow up is emphasised, regardless of whether patients are discharged directly from the emergency department or spend a period in hospital before being sent home. Follow up planning should be done by the emergency team in collaboration with the general practitioner (GP), cardiologist, and others involved in the patient's long term care.

"It's never ever possible to treat acute heart failure sufficiently in 24 hours in the emergency department," said Professor Mueller. "Intense follow up will always be needed. It's the task of the emergency department physician to either make the first follow up appointment or to ensure that this will occur. Patients should be seen by their GP within 48 hours to fine tune the number of drugs and their doses, and assess vital signs, blood pressure, electrolytes and kidney function."

He concluded: "Ultimately we hope this guidance will improve the management of patients with acute heart failure and make some inroads towards giving them a better outlook."

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Moderate drinking could lower heart attack, heart failure risk

Good news for those who like a drink after a hard day's work: consuming three to five drinks a week could lower the risk of heart attack and heart failure. This is according to two new studies by researchers from Sweden and Norway.
[A person pouring a glass of wine]
Drinking three to five alcohol beverages weekly may benefit heart health.

According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), almost 87% of adults in the US have consumed alcohol at some point in their lifetime, and more than 56% have had a drink in the past month.

While there is no doubt that excessive alcohol use is detrimental to health, studies are increasingly suggesting that moderate drinking may have its benefits.

In December 2015, for example, Medical News Today reported on a study suggesting moderate alcohol intake may lower death rates from early-stage Alzheimer's, while another study suggested that consuming up to seven drinks weekly may lower heart failure risk.

The two new studies further support the link between moderate alcohol intake and better heart health, after finding that drinking three to five alcohol beverages a week may reduce the risk of heart attack and heart failure.

33% lower heart failure risk with moderate drinking

Both studies were conducted by the same team, including Imre Janszky, a professor of social medicine at the Norwegian University of Science and Technology (NTNU).

For the first study, published in the International Journal of Cardiology, the team analyzed the data of 60,665 individuals free of heart failure who were enrolled in the longitudinal HUNT 2 Nord-Trøndelag Health Study between 1995-1997.

The researchers assessed the self-reported drinking habits of the participants and assessed the incidence of heart failure up until 2008. During follow-up, 1,588 of the participants developed heart failure.

The team found that compared with participants who never or rarely consumed alcohol, those who consumed around three to five drinks a week had a 33% lower risk of heart failure.

Additionally, the researchers found that heart failure risk was reduced with more frequent drinking; subjects who drank alcohol five times or more a month had a 21% lower risk of heart failure, compared with non-drinkers and those who rarely drank, while participants who drank one to five times monthly had a 2% lower risk of heart failure.

But there is no need to drink daily to have a healthy heart

In the second study, published in the Journal of Internal Medicine, Janszky assessed the data of 58,827 participants who were also part of the HUNT study and enrolled between 1995-1997. None of the subjects had a history of heart attack.

Once again, the team assessed the participants' self-reported drinking habits and monitored their incidence of heart attack up until 2008. During follow-up, 2,966 subjects had a heart attack.

Compared with non-drinkers and rare drinkers, those who consumed three to five drinks a week had the lowest heart attack risk, with the risk reducing by around 28% with every additional drink consumed, up to five drinks.

However, the researchers note that they did observe an increased risk of death from certain forms of cardiovascular disease with the consumption of at least five drinks weekly, and high alcohol consumption was also linked to greater risk of death from liver disease.

As such, the authors recommend against high alcohol intake and stress that their findings do not suggest people should take up frequent drinking in order to improve their heart health.

Janszky says:

"I'm not encouraging people to drink alcohol all the time. We've only been studying the heart, and it's important to emphasize that a little alcohol every day can be healthy for the heart. But that doesn't mean it's necessary to drink alcohol every day to have a healthy heart."

But for those who do like to indulge in a drink, Janszky recommends that it is best to consume "moderate amounts relatively often," noting that drinking larger amounts in one sitting can raise blood pressure.

Study strengths and limitations

While these studies are not the first to associate moderate drinking with better heart health, the team says they may be more accurate, noting that previous studies have looked at such associations among populations in which alcohol consumption is very common.

In Norway, however, drinking is not as popular. In the second study looking at the association between alcohol consumption and heart attack risk, for example, 41% of participants reported that they did not drink at all or only consumed less than half an alcoholic drink weekly.

"The relationship between alcohol and heart health has been studied in many countries, including the USA and southern European nations," says Janszky. "The conclusions have been the same, but the drinking patterns in these countries are very different than in Norway. In countries like France and Italy, very few people don't drink."

"It raises the question as to whether earlier findings can be fully trusted, if other factors related to non-drinkers might have influenced research results," he adds. "It may be that these are people who previously had alcohol problems, and who have stopped drinking completely."

There are some limitations to these latest studies, however. For instance, the authors note that the alcohol consumption of participants was self-reported, meaning alcohol intake could have been underestimated.

Contrary to these new findings, research reported by MNT last May suggested that moderate drinking may increase the risk of heart damage for elderly women.

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Viagra relieves life-threatening condition in swimmers and divers

A small dose of Viagra could save the lives of swimmers and divers who experience an abrupt and potentially life-threatening form of pulmonary edema on entering cold water, says research published in Circulation: Journal of the American Heart Association.
[swimmer]
SIPE can affect divers and triathletes participating in cold water swims.

Viagra, or sildenafil, is best known for treating male impotence, but it can also help in cases of pulmonary arterial hypertension.

When athletes or scuba divers make a sudden entry into cold water, they can develop a condition called swimming-induced pulmonary edema (SIPE).

When this happens, the blood vessels in the arms and legs constrict, leading to a pooling of blood in the heart and lungs. Symptoms include coughing up blood, difficulty breathing and low blood oxygen.

Although the symptoms often dissipate over 24 hours, the condition can kill. Not everyone is prone to it, and those who are tend to be unaware until they are in the water and rapidly developing symptoms. Those who experience SIPE should seek medical attention.

Small dose of sildenafil reduces pressure in lungs

Dr. Richard Moon, an anesthesiologist and medical director of the Duke Center for Hyperbaric Medicine & Environmental Physiology in Durham, NC, and colleagues studied 10 athletes who had experienced SIPE while exercising or competing in triathlons.

The team monitored the participants carefully as they exercised under conditions similar to those likely to trigger the SIPE response. They then compared the 10 athletes with 20 participants who had no history of SIPE.

None of the participants had heart abnormalities, but those who were prone to SIPE experienced higher pulmonary arterial pressure and pulmonary artery wedge pressure during the exercise.

This confirmed that SIPE is a form of pulmonary edema caused by high pressure in the blood vessels within the lungs.

The SIPE participants then repeated the exercise after taking sildenafil. This time, the pressures were reduced.

Lead author Dr. Moon explains: "During immersion in water, particularly cold water, susceptible people have an exaggerated degree of the normal redistribution of blood from the extremities to the chest area, causing increased pressure in the blood vessels of the lungs and leakage of fluid into the lungs. Some cases of SIPE appear to have been the result of cardiac problems."

Dr. Moon believes that as the blood vessels dilate in the arms and legs, there is less tendency for blood to redistribute to the thorax, and the pressure in the blood vessels of the lungs is relieved.

How one athlete controlled pulmonary edema

One of the participants is triathlete Katherine Calder-Becker, aged 51 years. Her susceptibility to SIPE threatened to end her competitive career because of debilitating shortness of breath and distress during colder open-water swims in competitions.

On coughing up blood, she was hospitalized and diagnosed with SIPE.

After participating in studies at Duke in 2011, her cardiologist prescribed her a low dose of sildenafil that she now takes shortly before competitions.

Calder-Becker says:

"I have successfully raced in 20 triathlons since I started taking sildenafil, including five ultra events that require 10-kilometer swims. I have not had an incident since then. I didn't want to give up racing. This is something my husband and I do together, and we travel together to competitions, so it has meant everything to me to continue."

The researchers would like to see larger studies to replicate the results and to learn about any potential adverse side effects of the drug. They hope that ongoing research will reveal more about what triggers SIPE and how to obtain an early diagnosis.

Medical News Today reported last year on research suggesting that Viagra increases the risk of skin cancer.

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Blood test detects all known genes for inherited heart conditions

Researchers believe they have made a breakthrough in the diagnosis of inherited heart conditions, after developing a rapid, simple blood test that accurately can detect all known genes associated with such disorders.
[Blood in a test tube]
The new blood test can detect 174 known genes for inherited heart conditions, say researchers.

In the Journal of Cardiovascular Translational Research, researchers from the UK and Singapore reveal how the test - called the TruSight Cardio Sequencing Kit - can identify 174 genes related to 17 inherited heart conditions.

These conditions include aortic valve disease, structural heart disease, long and short QT syndrome, Noonan syndrome, familial atrial fibrillation and most cardiomyopathies.

Inherited heart conditions are caused by gene mutations that have been passed down from relatives. If a mother possesses one of these faulty genes, there is a 50% chance that they will pass the mutation on to their child.

While it is possible to have one of these gene mutations and never develop the associated heart condition, the gene significantly increases risk for the disorder.

Genetic testing is key to identifying such mutations, enabling early diagnosis of inherited heart conditions and allowing patients to take steps to lower their risk of sudden death from such disorders.

But according to lead researcher Dr. James Ware, of the National Heart and Lung Institute at the MRC Clinical Sciences Centre at Imperial College London, UK, current genetic tests are only capable of identifying small numbers of genes, which means they often overlook gene mutations that could be key for diagnosing an inherited heart condition.

Could the TruSight Cardio Sequencing Kit address this problem?

Blood test identified all gene mutations with up to 100% accuracy

The new test used next-generation sequencing to simultaneously identify 174 genes known to increase the risk of 17 inherited heart conditions. It works by analyzing the DNA in patients' blood samples.

Dr. Ware and colleagues assessed the effectiveness of the test in the new study by using it to analyze the blood samples of 348 participants from the National Heart Centre Singapore.

The team found that the test was able to quickly identify all gene mutations in the blood samples that were associated with the 17 inherited heart conditions with up to 100% accuracy.

The researchers say their study shows the new test is faster and more reliable than current genetic tests and will allow quicker, more reliable and more cost-effective diagnosis of inherited heart disorders.

Commenting on the findings, Prof. Peter Weissberg, medical director of the UK's British Heart Foundation - which helped fund the study - says:

"As research advances and technology develops, we are identifying more and more genetic mutations that cause these conditions. In this rapidly evolving field of research the aim is to achieve ever greater diagnostic accuracy at ever-reducing cost.

This research represents an important step along this path. It means that a single test may be able to identify the causative gene mutation in someone with an inherited heart condition thereby allowing their relatives to be easily tested for the same gene."

Test 'increasing number of families who benefit from genetic testing'

The new test has already been implemented at the Royal Brompton & Harefield National Health Service (NHS) Foundation Trust in the UK, where the researchers say it is successfully assessing 40 patients per month for an inherited heart condition.

In the US alone, around 100,000 people die from sudden cardiac arrest each year as a result of inherited heart conditions.

The researchers hope that their new test will soon be in clinical use across the globe, aiding the early diagnosis and treatment of inherited heart conditions for some patients and providing peace of mind for others.

"Without a genetic test, we often have to keep the whole family under regular surveillance for many years, because some of these conditions may not develop until later in life. This is hugely costly for both the families and the health system," notes Dr. Ware.

"By contrast, when a genetic test reveals the precise genetic abnormality causing the condition in one member of the family, it becomes simple to test other family members," he continues.

"Those who do not carry the faulty gene copy can be reassured and spared countless hospital visits. This new comprehensive test is increasing the number of families who benefit from genetic testing."

Last September, Medical News Today reported on the development of a genetic test that can identify which breast cancer patients can avoid chemotherapy.

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