Community-based approaches to lowering blood pressure, using the genome to predict cardiovascular risk and employing advanced brain imaging are among the year’s top heart disease and stroke research advances, according to the American Heart Association.
The AHA, one of the top funders of heart- and stroke-related research worldwide, has been compiling an annual list of major advances in heart disease and stroke science since 1996. Here, grouped by topic, are the organization’s picks for leading research accomplishments published in 2018. It’s notable that several of the publications focus on high blood pressure. This underscores the critical role of hypertension as an antecedent to both heart disease and stroke.
Lowering blood pressure through churches, barbershops
Two clinical trials demonstrated the role of community-based lifestyle interventions in helping reduce high blood pressure.
Reported in the American Heart Association journal Circulation: Cardiovascular Quality and Outcomes, the FAITH trial followed 373 adults with high blood pressure in 32 black churches in New York City. One group attended a weekly 90-minute group session for 11 weeks that combined faith-based elements with hypertension management, plus three one-on-one motivational sessions. The other group received one group session, plus 10 sessions on health topics led by experts. After six months, the group that received the comprehensive lifestyle intervention including motivational sessions had an average 5.8 millimeters of mercury reduction in systolic blood pressure – the top number in a blood pressure reading – compared to the control group.
Another study reported in the New England Journal of Medicine followed 319 black men with uncontrolled hypertension who were regular patrons of 52 barbershops. Patrons whose barbers were trained to encourage healthy lifestyle changes and doctor appointments were in the control group. In other barbershops, patrons also met onsite with pharmacists who prescribed and monitored high blood pressure treatment in coordination with the men’s doctors. After six months, systolic blood pressure fell by an average 27 mmHg in the pharmacist-led group compared with 9.3 mmHg in the control group.
Uncovering how racial disparities contribute to high blood pressure
The higher prevalence of high blood pressure among black adults is a major contributor to disparities in life expectancy. Nearly half of black adults have hypertension compared to about one-third of white adults. Yet the reasons for the disparity are unclear.
A study reported in JAMA examined 12 clinical and social factors among 6,897 black and white adults. Nearly a decade later, researchers found that a Southern diet – one that’s high in fried foods, processed meats and sugary drinks – was the largest mediating factor for differences in hypertension. Education level and having too much sodium and too little potassium in the diet also played a role in increasing risk for black men and women. Among women, waist circumference and body mass index also were key factors.
Cholesterol control to combat future cardiovascular risk
Finding ways to lower the risk of having a heart attack, stroke or other potentially fatal cardiovascular problem is a priority for researchers.
In the ODYSSEY OUTCOMES study, published in the New England Journal of Medicine, researchers added the PCSK9 inhibitor alirocumab (Praluent) – a drug that lowers “bad” LDL cholesterol – to statin therapy. The combination significantly reduced the risk of having a heart attack, stroke, dying from heart disease or being hospitalized for unstable angina by 15 percent, from 11.1 percent in the statin-only group to 9.5 percent among those also taking Praluent.
In the REDUCE-IT study, also published in the New England Journal of Medicine, the risk of having or dying from a heart attack, stroke or other heart-related problem fell by 25 percent among those receiving the triglyceride-lowering drug icosapent ethyl (Vascepa). The study included people with cardiovascular disease or diabetes who had been receiving statin therapy but still had high triglyceride levels.
Gene editing in dogs may aid treatment of Duchenne muscular dystrophy
Research published in Science offered hope that a progressive form of muscular dystrophy may one day be treated through gene editing.
In what researchers called a proof-of-concept study representing an important step toward a clinical trial in people, scientists used CRISPR gene editing to treat Duchenne muscular dystrophy in dogs. Researchers edited cells in dogs that served as models of the disease to boost levels of dystrophin, a protein that helps keep muscle cells intact. The protein is missing is people with Duchenne muscular dystrophy.
Potential drug therapy for rare, fatal condition
Transthyretin amyloid cardiomyopathy is an uncommon condition that can lead to heart failure. There are currently no approved drug therapies to treat the condition.
The phase 3 ATTR-ACT study found that the drug tafamidis lowered the risk of death by 30 percent among patients with transthyretin amyloid cardiomyopathy, from 43 percent among people taking a placebo to 30 percent among those taking tafamidis. Patients who received tafamidis also experienced better functional capacity and quality of life than those given the placebo. The study was published in the New England Journal of Medicine.
A heart valve clip to treat severe heart failure
A device called the MitraClip used to repair a leaky mitral valve lowered death rates and reduced hospitalizations in people with severe heart failure, according to a study published in the New England Journal of Medicine.
Researchers enrolled 614 patients in the U.S. and Canada who remained symptomatic despite medical therapy. About half of patients received a MitraClip plus standard medical treatment; the other half received standard care alone. During the next two years, 151 people in the standard care group were hospitalized for heart failure, and 61 died from heart failure. By comparison, 92 people who got the device were hospitalized, and 28 died.
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Using forearm arteries for coronary bypass grafts
For people having coronary artery bypass surgery, the gold standard has been to harvest veins from the legs. But research published in the New England Journal of Medicine showed using an artery from the forearm may be more effective.
The study included 1,036 patients and found the use of radial artery grafts resulted in a lower rate of major adverse cardiac events such as repeat revascularization and heart attack. Using radial artery grafts was also associated with a better rate of staying open after five years, a result that may also explain the better clinical outcomes.
Calculating heart disease risk by looking at your genes
Two studies helped deepen researchers’ understanding about how the entire genome rather than single genes may reveal important information about heart disease risk.
In a study published in the AHA journal Circulation: Genomic and Precision Medicine, researchers found that developing a risk score that measures 182 variants associated with coronary artery disease may more reliably identify people at risk for early-onset disease who need aggressive preventive treatment.
Another study published in Nature Genetics used a polygenic risk score – one that analyzed multiple genetic variants – to more reliably calculate risk for coronary artery disease, atrial fibrillation, Type 2 diabetes, inflammatory bowel disease and breast cancer. Among those tested, 19.8 percent had a three-fold increased risk for at least one of the five diseases. For coronary artery disease, researchers found 8 percent of the population has a genetic predisposition that increases risk threefold. The study relied on data from people of mostly European ancestry, and researchers noted the tool may not be as effective at predicting risk for other ethnic groups.
Blood pressure as young adult predicts future cardiovascular risk
In a study published in JAMA, researchers found that young adults with elevated or high blood pressure before they turned 40 had significantly higher risk for subsequent cardiovascular problems compared to those with normal blood pressure before age 40.
Researchers used data from the CARDIA study of more than 5,100 black and white Americans ages 18 to 30 beginning in 1985. Higher cardiovascular disease risk associated with elevated blood pressure was evident after the initial 10 years of follow-up.
Expanding the time window for treating certain strokes
For people who develop an ischemic stroke – a blood clot in a large artery inside the head supplying part of the brain – a clot retrieval procedure called mechanical thrombectomy allows a physician to thread a catheter through an artery and use a clot-grabbing device to reach and remove the clot.
Some patients may now have mechanical clot removal up to 24 hours after symptoms begin. The limit used to be six hours, but research published in the New England Journal of Medicine showed that some carefully selected patients may benefit even after an extended amount of time.
Researchers in the DAWN study tracked 206 people who had experienced certain types of ischemic strokes six to 24 hours earlier and for whom imaging suggested there was brain tissue that could be salvaged by restoring blood flow. Those treated with thrombectomy in addition to standard care regained significantly more functional independence after 90 days than those who received standard treatment only. The rate of recovery was similar to results in patients who underwent thrombectomy within the six-hour window.
Similarly, the DEFUSE-3 study found that stroke patients treated with thrombectomy in addition to standard care had less disability and a higher rate of functional independence at three months than standard medical therapy alone.
— Update: 17-02-2023 — cohaitungchi.com found an additional article Compared with Men, Women with Heart Disease More Likely to Report More Treatment and Care Disparities from the website www.hopkinsmedicine.org for the keyword men and women risk of heart disease and stroke 2018.
Cardiovascular diseases, including heart attacks and strokes, have for decades persisted as the top cause of death of women in the U.S., according to the American Heart Association (AHA). And the AHA reports an estimated 44 million women in the U.S. have cardiovascular disease, and 1 in 3 women’s deaths each year are due to cardiovascular disease. Cardiovascular disease is also the No. 1 cause of death in men, but women have worse outcomes after certain types of heart attacks.
Decades of research shows that early identification, treatment and attention to such risk factors as high blood pressure, high cholesterol levels, obesity, family history of cardiovascular disease and diabetes can substantially reduce disease burden and deaths. Lifestyle changes, smoking cessation and drugs such as statins are proven mainstays of risk reduction.
But the results of a new study, published online Dec. 10 in the Journal of the American Heart Association, add to evidence that physicians who care for women may be less conscious of and attentive to these risk factors in their female patients, and that women sense that their concerns are not taken as seriously as they should be.
“We showed that women were not getting the same level of care as men, and they feel that way too. Women are more likely to report communication problems with health care providers and dissatisfaction with their health care experience, and we think this contributes to the disparities that we see when it comes to getting preventive and other treatment for cardiovascular disease,” says Erin Michos, M.D., M.H.S., associate professor of medicine at the Johns Hopkins University School of Medicine. “Documenting and addressing these gender gaps in communication with health care providers hopefully will translate into improved outcomes for female patients.
While some metrics evaluated in the study, such as medications and hospital visits, were obtained objectively, the researchers caution that the participants’ reports of their communication and experiences with their health care providers were based upon the participants’ own ratings rather than objective standards, so those findings may be subject to this bias. The study wasn’t designed to objectively determine whether women actually had poorer encounters than men. “It’s possible that social expectations may influence how women perceive their health care experiences,” says Michos. “For example, women may want more participation in deciding their care or may want a more interactive experience with their health care provider than men, which may impact their overall patient satisfaction.”
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Michos says past studies have shown that people with positive experiences with their health care providers report better health and better quality of life, and her team designed the new study to better understand how women (and men) with cardiovascular disease rated their experiences with health care providers and perceived their care.
For their analysis, they used survey data from the Medical Expenditure Panel Survey, which is a U.S. Department of Health and Human Services study that collected information from 21,353 adult men and women with cardiovascular disease, with several rounds of telephone interviews over two years for each participant from 2006 to 2015. The cardiovascular disease diagnosis was determined by self-reporting or medical record insurance billing codes.
Women accounted for 47 percent of the participants. About 75 percent of the participants were white, 14 percent were African-American, 2 percent were Asian and 10 percent were Hispanic. Among the women, 5 percent were less than 40 years of age, 36 percent were ages 40–64, 23 percent were ages 65–74, and 36 percent were 75 years or older. The participants included people who were uninsured, on private insurance, on Medicaid and on Medicare. As for educational levels, the participants ranged from less than high school to college or graduate level.
Participants were asked to rate possible responses on patient-provider communication on a scale of 1–4, with 1 being never and 4 being always on questions such as how well their physician explained things in an easy-to-understand way, if their health care provider respected them, if their provider spent enough time with them, or if their health care provider listened to them.
The participants rated satisfaction with their health care on a scale of zero to 10, with zero being the worst health care possible and 10 being the best health care ever. Participants also rated their own perceived health status, as well as whether they were prescribed aspirin. Additional health data on medications and health care use were acquired from pharmacies, physicians and hospitals to determine whether they were prescribed cholesterol-lowering statins and how often they used the emergency room or were hospitalized.
Using data from a nationwide survey that represents 11 million women with heart and blood vessel diseases, Johns Hopkins Medicine researchers say women continue to report significant disparities in the care they receive compared with men. And the root problem, many women say, is that health care providers don’t listen to or respect them.
Cardiovascular diseases, including heart attacks and strokes, have for decades persisted as the top cause of death of women in the U.S., according to the American Heart Association (AHA). And the AHA reports an estimated 44 million women in the U.S. have cardiovascular disease, and 1 in 3 women’s deaths each year are due to cardiovascular disease. Cardiovascular disease is also the No. 1 cause of death in men, but women have worse outcomes after certain types of heart attacks.
Decades of research shows that early identification, treatment and attention to such risk factors as high blood pressure, high cholesterol levels, obesity, family history of cardiovascular disease and diabetes can substantially reduce disease burden and deaths. Lifestyle changes, smoking cessation and drugs such as statins are proven mainstays of risk reduction.
But the results of a new study, published online Dec. 10 in the Journal of the American Heart Association, add to evidence that physicians who care for women may be less conscious of and attentive to these risk factors in their female patients, and that women sense that their concerns are not taken as seriously as they should be.
“We showed that women were not getting the same level of care as men, and they feel that way too. Women are more likely to report communication problems with health care providers and dissatisfaction with their health care experience, and we think this contributes to the disparities that we see when it comes to getting preventive and other treatment for cardiovascular disease,” says Erin Michos, M.D., M.H.S., associate professor of medicine at the Johns Hopkins University School of Medicine. “Documenting and addressing these gender gaps in communication with health care providers hopefully will translate into improved outcomes for female patients.
While some metrics evaluated in the study, such as medications and hospital visits, were obtained objectively, the researchers caution that the participants’ reports of their communication and experiences with their health care providers were based upon the participants’ own ratings rather than objective standards, so those findings may be subject to this bias. The study wasn’t designed to objectively determine whether women actually had poorer encounters than men. “It’s possible that social expectations may influence how women perceive their health care experiences,” says Michos. “For example, women may want more participation in deciding their care or may want a more interactive experience with their health care provider than men, which may impact their overall patient satisfaction.”
Michos says past studies have shown that people with positive experiences with their health care providers report better health and better quality of life, and her team designed the new study to better understand how women (and men) with cardiovascular disease rated their experiences with health care providers and perceived their care.
For their analysis, they used survey data from the Medical Expenditure Panel Survey, which is a U.S. Department of Health and Human Services study that collected information from 21,353 adult men and women with cardiovascular disease, with several rounds of telephone interviews over two years for each participant from 2006 to 2015. The cardiovascular disease diagnosis was determined by self-reporting or medical record insurance billing codes.
Women accounted for 47 percent of the participants. About 75 percent of the participants were white, 14 percent were African-American, 2 percent were Asian and 10 percent were Hispanic. Among the women, 5 percent were less than 40 years of age, 36 percent were ages 40–64, 23 percent were ages 65–74, and 36 percent were 75 years or older. The participants included people who were uninsured, on private insurance, on Medicaid and on Medicare. As for educational levels, the participants ranged from less than high school to college or graduate level.
Participants were asked to rate possible responses on patient-provider communication on a scale of 1–4, with 1 being never and 4 being always on questions such as how well their physician explained things in an easy-to-understand way, if their health care provider respected them, if their provider spent enough time with them, or if their health care provider listened to them.
The participants rated satisfaction with their health care on a scale of zero to 10, with zero being the worst health care possible and 10 being the best health care ever. Participants also rated their own perceived health status, as well as whether they were prescribed aspirin. Additional health data on medications and health care use were acquired from pharmacies, physicians and hospitals to determine whether they were prescribed cholesterol-lowering statins and how often they used the emergency room or were hospitalized.
One in 4 women reported dissatisfaction with their health care providers, with women reporting a 12 percent higher rate of poor satisfaction with their health care overall compared with men. Women were 23 percent more likely than men to report that their doctors never or only sometimes listened to them, and 20 percent more likely to report that their doctor never or only sometimes showed them respect. In survey data rating their quality of life, women also scored lower than men in both the physical and mental health components.
Compared with male participants, women with cardiovascular disease were overall 35 percent less likely to be prescribed preventive aspirin therapy and 45 percent less likely to be prescribed a statin, standard strategies for reducing cardiovascular disease risks. Even after accounting for ethnicity, age, income level and insurance status, the gender disparities remained, Michos reports. Women were also 28 percent more likely to use the emergency room more than two times per year compared with men.
“Our study suggests that women with cardiovascular disease aren’t getting the same attention and treatment as men with cardiovascular disease, and this can have real-world effects on patient outcomes,” says Victor Okunrintemi, M.D., M.P.H., a former graduate student at Johns Hopkins and now an internal medicine resident at East Carolina University. “We should be more proactive and provide more equitable care for all our patients, irrespective of gender.”
Additional authors included Javier Valero-Elizondo, Shiwani Mahajan and Khurram Nasir of Yale New Haven Hospital; Benjamin Patrick of State House Annex Clinic; Joseph Salami of Baptist Health South Florida; Martin Tibuakuu of St. Luke’s Hospital; Oluseye Ogunmoroti of Johns Hopkins; Saba Ahmad of Lankenau Medical Center; Safi U. Khan of West Virginia University and Martha Gulati of University of Arizona.
The study was supported by the Blumenthal Scholars Fund for Preventive Cardiology Research.
The authors have no disclosures to report.
On the Web:
- Exercise and Vitamin D Better Together for Heart Health
— Update: 17-02-2023 — cohaitungchi.com found an additional article Cardiovascular Risks Associated with Gender and Aging from the website www.ncbi.nlm.nih.gov for the keyword men and women risk of heart disease and stroke 2018.
2. Pathophysiology of CVD in Aged Adults
Functional changes in aging adults hearts have been characterized, which include reports of diastolic and systolic dysfunction, and also electrical dysfunction, including the development of arrhythmias [9]. Collectively, both functional and electrical defects result in a high prevalence of heart failure, atrial fibrillation, and other CVDs, in aging patients [9]. The high prevalence of CVD in this population (Figure 1) has been linked to a number of factors, including increased oxidative stress, inflammation, apoptosis and overall myocardial deterioration, and degeneration [1]. An increase in the production of reactive oxygen species (ROS) is known to occur with the onset of advanced age [1,2], and is linked to persistent inflammation and progression to chronic disease status, as in CVD [1]. Increased production of proinflammatory markers is a hallmark of aged hearts, including high levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNFα), and CRP (C-reactive protein) [1]. Production of inflammatory factors and other mediators contribute to cardiac remodeling, including significant extracellular matrix (ECM) remodeling, which is caused by impaired ECM turnover [1,10]. Dysregulation in matrix metalloproteinase (MMP) and tissue inhibitor of metalloproteinase (TIMP) expression levels are frequently linked to increased collagen deposition and the development of cardiac hypertrophy and fibrosis in aged hearts [10]. Fibrosis and hypertrophy are both significant structural changes that lead to eventual cardiac dysfunction in aging patients [11]. Fibrosis, due to impaired ECM turnover, has been shown to develop in the atria of aging patients, which also results in atrial fibrillation in many of these patients [12].
Oxidative stress, including the production of excess ROS that occurs with cardiac aging, will also lead to mitochondrial dysfunction [9]. Cardiac aerobic metabolism is greatly dependent on mitochondrial production of ATP; thus, the loss of mitochondrial function plays a major role in the development of cardiac dysfunction in aging adults [13]. It has been reported that mitochondrial DNA is particularly susceptible to oxidative damage, since it lacks protective histones, and is in close proximity to ROS production during electron transport [14]. ROS production has also been shown to impair the efficiency of mitochondrial respiration, which also contributes to the cardiac aging process via augmented ROS production [14]. Mitochondrial oxidative stress has also been shown to result in impaired calcium signaling via dysregulation in the type 2 ryanodine receptor (RyR2) [15]. RyR2, a calcium ion channel, is primarily responsible for the release of calcium from the sarcoplasmic reticulum, allowing for muscle contraction [15]. Decreased activity of sarcoplasmic reticulum Ca2+ ATPase pump (SERCA) has also been observed with age [16]. Generation of biologically active lipid mediators may also result in response to age-related inflammation. Mitochondrial dysfunction due to increased ROS has been reported to result in production of lipid oxidation, which has been linked to the development of atherosclerosis [17]. Although impaired lipid metabolism via mitochondrial dysfunction is known to occur with age, however, this process is still not completely understood. One experimental study in mice reported that diets enriched with omega-6 in older aged mice leads to chronic low-grade inflammation and impaired oxidative-redox balance, resulting in electrocardiographic disturbances [18]. Collectively, age-related oxidative stress results in significant cellular and structural changes, and these eventually lead to impaired cardiac functionality and development of CVD.
