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Please click here to view the archive of previous Cardio NewsWire stories. Each item is removed from the archive after 90 days.Warfarin increases stroke risk
ESC News December
AHA Late-Breaking Clinical Trial: The RADAR-AF Trial at AHA
AHA Late-Breaking Clinical Trial: The CTSN SMR Trial at AHA
ACC AHA cardiovascular risk guidelines
India's BP skyrockets
ESC Congress 2014
New EHJ Board members 2014
WARFARIN INCREASES RISK OF STROKE IN AF
Patients with atrial fibrillation (AF) have nearly double the risk of suffering a stroke in the first 30 days after starting warfarin compared to non-users, according to a study of over 70,000 patients.
The study, published in the European Heart Journal , found that the risk was particularly high in the first week after patients started to take the drug. In contrast, once the first 30 days had elapsed, the risk of a stroke was halved.
Randomised controlled trials of other anti-clotting drugs have suggested that there might be an increased risk of stroke at the point when patients move from the trial drugs to warfarin. In addition, it has already been established that there is a possibility that warfarin leads temporarily to a hypercoagulable state. This is thought to be due to the different effects of warfarin on the production of certain coagulation factors that are dependent on Vitamin K.
Dr Laurent Azoulay, Assistant Professor in the Department of Oncology at McGill University (Montreal, Canada) and Project Leader at the Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital in Montreal, led the research. “There is no question that warfarin is highly effective in preventing strokes in patients with AF. Thus, our finding that the initiation of warfarin may be associated with an increased risk of stroke should not deter physicians and patients from using this drug, since this likely affects a small number of patients. Future studies should confirm our results, and identify the small subset of patients who may be at risk. However, the results of our study suggest that physicians should be vigilant when initiating warfarin, particularly in the first week of use,” he said.
“To our knowledge, this is the first population-based study to investigate whether the initiation of warfarin is associated with an increased risk of ischaemic stroke.”
The researchers hope to repeat the study using databases from other countries and settings.
 “Initiation of warfarin in patients with atrial fibrillation: early effects on ischaemic strokes”, by Laurent Azoulay, Sophie Dell’Anielllo, Teresa A. Simon, Christel Renoux, and Samy Suissa. European Heart Journal. doi:10.1093/eurheartj/eht499
ESC NEWS DECEMBER
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THE RADAR-AF TRIAL AT AHA
Presented by Dr Felipe Atienza
Empiric circumferential pulmonary vein isolation (CPVI) is the therapy of choice for drug-refractory atrial fibrillation (AF). The multi-centre randomized RADAR-AF clinical trial was designed to compare the efficacy and safety of high frequency source ablation (HFSA) in AF as compared to CPVI. In a noninferiority study, 115 patients with paroxysmal AF were randomly assigned to receive CPVI or HFSA. In a superiority study, 117 patients with persistent AF were randomly assigned to receive CPVI or CPVI plus HFSA. In patients with paroxysmal AF, HFSA was noninferior to CPVI for the endpoint of freedom from AF at 12 months (HFSA 82% vs. CPVI 79%; P=0.008), with patients receiving HFSA having a reduced risk for adverse events compared with patients receiving CPVI (P=0.028). In patients with persistent AF, there was no difference between the groups in the freedom from AF at 6 or 12 month outcomes, but adverse events tended to occur more frequently in the CPVI plus HFSA group (24% vs. 10%; P=0.05). These results demonstrate that a more limited ablation strategy directed to selectively eliminate AF maintaining sources is equally effective and safer than the empiric CPVI ablation strategy in patients with paroxysmal AF.
THE CTSN SMR TRIAL AT AHA
Presented by Dr. Michael A. Acker
The CTSN Severe Mitral Regurgitation (SMR) randomized trial was designed to evaluate the safety and effectiveness of mitral valve repair versus replacement in patients with severe ischemic MR. The two-year study examined 251 patients with severe ischemic mitral valve regurgitation in 22 US clinical centres. It compared 125 patients who underwent valve replacement to 126 who had their faulty valve repaired.
At one year, the death rate was 14.3% for the repair group and 17.6% for the replacement group. There were no differences between groups in serious adverse events, functional status, quality of life or readmissions. The recurrence of mitral regurgitation at 12 months was 32.6% in the repair group and 2.3% in the replacement group. Three patients in the repair group underwent reoperation while none of the patients in the replacement group needed a repeat procedure.
In summary, patients with leaky heart valves due to severe ischemic mitral regurgitation had similar heart function and survival rates after 1 year, whether their mitral valve was repaired or replaced. Those with repaired valves had a greater risk of the leak returning during the first year after operation.
ACC/AHA GUIDELINES FOR CV RISK ASSESSMENT IN PRIMARY CARE
The American College of Cardiology and American Heart Association have published guidelines for cardiovascular risk assessment in primary care to identify adults who may benefit from preventive lifestyle changes or drug therapy.
The guideline was last updated in 2004 and has been broadened to include assessment for risk of stroke as well as heart attack. It provides new gender- and ethnicity-specific formulas for predicting risk in African-American and white women and men. The recommendations look beyond traditional short-term (10-year) risk estimates to predict an individual’s lifetime risk of having heart disease or stroke.
A primary goal of the new guideline is to help ensure that preventive treatments including lifestyle changes and drug treatment are used in those most likely to benefit without undue risk or harm. Risk assessment methods are outlined that use risk factors for atherosclerosis that can be easily collected by primary care clinicians (e.g. age, cholesterol levels, blood pressure, smoking, and diabetes).
Stroke is included in the new algorithm to enable improved calculation of overall cardiovascular risk, especially in women and African-Americans. The risk for chronic heart failure was not included in the current algorithm because existing data were not sufficient to allow development of a high-quality risk equation.
The guidelines highlight four markers (family history of premature cardiovascular disease, coronary artery calcium score, high-sensitivity C-reactive protein, ankle brachial index) which may help with treatment decisions when uncertainty remains after quantitative risk assessment. The full report is available here: http://circ.ahajournals.org/lookup/doi/10.1161/01.cir.0000437741.48606.98
INDIA'S BLOOD PRESSURE SKYROCKETS
Hypertension is skyrocketing in India, with rural-to-urban migrants at especially high risk. Hypertension (HTN) was the key theme at the 65th Annual Conference of the Cardiological Society of India (CSI), which ended 8 December in Bangalore, India, featuring a collaborative programme with the ESC.
Hypertension expert, Dr Rajeev Gupta from Jaipur, India, said: “HTN is the largest cardiovascular risk factor among Indian adults. Its incidence is more than hypercholesterolemia, metabolic syndrome or diabetes. HTN accounts for 24% deaths from coronary heart disease and 57% of stroke deaths. As the second-most populous country in the world with over 1.2 billion inhabitants, India’s HTN burden presents a major public health challenge. Indeed, India and China account for more cases of cardiovascular disease than all developed countries combined.”
Urbanisation has dramatically increased levels of HTN and rural-to-urban migrants are at especially high risk. Their lifestyle changes, they become more sedentary, their diet is different, their weight increases measured as body mass index (BMI, kg/m2), and waist size increases. They tend to eat more fat, saturated fat, trans fatty acids and salt, and less fruits and vegetables.
Dr Gupta added: “Stress levels are high in migrants and may have an impact. The use of smokeless tobacco, often a mixture of the betel nut, betel leaf and tobacco leaf, may also be a unique risk factor for HTN in Indians.”
Sedentary lifestyles in urban India are fostered by the lack of spaces for physical activity. Dr Gupta said: “Cities are not built to support physical activity. In addition, people in urban areas don’t find time to exercise. Another contributing factor is that while many gyms have opened in India, they are very, very expensive. Finally, there are very few public transport systems in the country that run well, so people tend to live close to their place of work which means they don’t walk much.”
Professor Roberto Ferrari, a Past President of the ESC, said: “One of the duties of the ESC delegation is to share expertise and experiences with our Indian colleagues. This is one of several ‘ESC in India’ events and we are excited about examining pressing issues in cardiovascular disease that are relevant in India and Europe.”
ESC CONGRESS 2014 REGISTRATION NOW OPEN
The ESC Congress is the world’s largest and most influential cardiovascular event with over 500 expert sessions and 10,000 abstracts contributing to global awareness of the latest clinical trials and breakthrough discoveries.
Barcelona is preparing for the arrival of more than 30,000 participants for next year’s ESC Congress. As the world’s premier meeting on the science, management and prevention of cardiovascular disease, it draws professionals with an interest in cardiology from more than 150 countries.
There will be 600 journalists from 46 countries who will join cardiologists, cardiovascular surgeons, nurses, primary care physicians, scientists, technicians, medical students, healthcare industry leaders and regulators to catch up on the latest news in cardiology. Eleven press conferences on specific topics and breaking clinical trials will take place at the Fira Gran Via.
The 2014 Congress Spotlight is “Innovation and the Heart”. With CVD still being the biggest killer in Europe - over 4 million deaths in Europe annually - and with resources dedicated to innovation in cardiology diminishing, a resurgence in cardiovascular R&D is urgently needed to curb a new epidemic of cardiovascular diseases, according to leading cardiologists and industry representatives.
NEW EHJ INTERNATIONAL BOARD MEMBERS 2014
The EHJ Editorial Board have appointed the following new International Editorial Board Members beginning January 2014. They are a welcome addition to the Board.
Open access options for authors visit Oxford Open