Understanding the gender divide (AHA Scientific Sessions 2006)

Attention turns to young adults with high lifetime risk of heart disease

With tools to quantify a person's 10-year heart disease risk well established, physicians are seeking strategies to assess and reduce lifetime risk. This is particularly the case for patients younger than those usually considered to be candidates for most preventive measures, according to a presentation at the American Heart Assn.'s scientific sessions in Chicago in November 2006.

"There's a focus on chronologic age that reduces the likelihood of identifying young adults with a high lifetime risk," said Roger Blumenthal, MD, director of the Johns Hopkins University Ciccarone Preventive Cardiology Center in Baltimore. "[But] chronologic age does not necessarily correlate with biologic age."

This expansion of prevention efforts to those who appear to be heading toward a cardiovascular event -- even more than a decade away -- follows data suggesting risk factors start developing early.

"At every life stage, identifying the major risk factors is extremely useful, not only as a prediction of what's to come, but also to treat," said Neil J. Stone, MD, clinical professor of cardiology at Northwestern University's Feinberg School of Medicine in Chicago. "This doesn't necessarily mean giving them a medication, but every doctor should be comfortable looking a patient in the face and saying there are things we can do that make a difference."

Experts recommend such an assessment consider activity levels, obesity and any family history of premature cardiovascular disease, factors left out of most tools that measure short-term risk.

"Family history is a strong independent risk factor," said Christopher J. O'Donnell, MD, MPH, associate director of the Framingham Heart Study.

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Risks, benefits of aspirin and NSAIDs vary with patient problems

Risks, benefits vary with patient problems

Rather than a patient's genetic makeup, it may be co-morbidities that explain why some benefit less than others from aspirin therapy to reduce heart disease risk, according to several studies presented at the American Heart Assn. Scientific Sessions in Chicago.

Two studies, for instance, suggested that patients with diabetes and metabolic syndrome have a higher turnover rate of platelets that, in turn, may lead to an over-expression of cyclooxygenase-2 (COX-2). Whether these conditions or their treatment caused this was unclear, but the authors suggested the finding could explain why aspirin therapy is less likely to reduce cardiovascular events in these patients. Another paper found that genetics -- specifically a rare allele evidenced by variation in the thromboxane A2 synthase gene -- also may cause aspirin resistance.

These papers are the latest efforts to understand why regular aspirin use is not equally protective.

"The optimal effect in most patients is seen at a low dose of aspirin, but this raises the issue of whether selected patients would derive a benefit from higher doses," said Paul Gurbel, MD, director of the Center for Thrombosis Research at Baltimore's Sinai Hospital.

While several papers explored the mechanisms behind aspirin resistance, others attempted to quantify further the dangers of various nonsteroidal anti-inflammatories taken for pain control.

This issue has come up repeatedly since the September 2004 revelation of an increased risk of heart disease associated with the use of COX-2 inhibitor drugs. Physicians have since been looking for ways to ensure that patients get the pain relief they need while minimizing associated dangers.

One systematic review found that chronic use of nonselective NSAIDs increased the risk of hypertension, although this risk was highest with ibuprofen.

Another study concluded that rates of thrombotic cardiovascular events for patients taking the investigational, highly selective COX-2 inhibitor etoricoxib were comparable to those experienced by those who took the less-selective diclofenac. Patients who took etoricoxib had a higher rate of congestive heart failure and were more likely to discontinue the drug because of hypertension. The diclofenac group was more likely to stop taking this medication because of gastrointestinal and liver events.

"Our results do show that in these patients with arthritis that the COX-2 selective agent did not increase the risk relative to a traditional agent," said Christopher P. Cannon, MD, study leader and associate professor of medicine at Harvard Medical School in Boston.

A heart association statement issued in the wake of these results expressed caution and called for more long-term data that fully evaluates the risks and benefits of COX-2 inhibitors as well as the safety of traditional pain relievers.

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Treatment tips

Here are some treatment tips from the meeting:

Framingham leader calls for attention to risk factor clusters. Efforts should be made to reduce a patient's risk factor groupings rather than focusing on a single one, said William Kannel, MD, MPH, former head of the Framingham Heart Study and professor of medicine and public health at Boston University School of Medicine.

"It's difficult to get people to lose weight and keep it off, but, if you look at the data, the risk is variable in obese persons, depending on the cluster of risk factors," said Dr. Kannel, who was given an American Heart Assn. Distinguished Scientist Award at the meeting.

Dr. Kannel also called for attention to the ratio of total cholesterol to HDL cholesterol rather than any lipid level in isolation and for better control of the blood pressure of those with diabetes. "Control the other risk factors. Don't be confining your attention just to the blood sugar," he said.

Not all MI/heart failure patients need long-term aldosterone blockade. Patients who develop heart failure along with myocardial infarction may not need such intensive regimens if congestion resolves quickly.

"If after six months or so, they have a pretty normal ejection fraction, I would be content leaving them on an ACE and a beta-blocker and withdrawing the aldo-blocker, but I certainly would want it there for that initial several months," Bertram Pitt, MD, professor emeritus at the University of Michigan, Ann Arbor, said during a panel discussion.

About 25% to 40% of MI patients will have heart failure concomitantly or develop it soon after. These patients tend to have worse outcomes.

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Research findings: Men, migraines and cardiovascular risk; salt-sensitive hypertension

Men with migraines are at higher risk of cardiovascular disease, according to a study presented at the American Heart Assn.'s Scientific Sessions.

Researchers analyzed data from the Physicians' Health Study and found that migraines increased the risk of a major cardiovascular event by 24%.

"This does not mean that individuals with migraine headaches should panic," said Tobias Kurth, MD, ScD, lead author and assistant professor of medicine at Brigham and Women's Hospital and Harvard Medical School in Boston. "Physicians should emphasize modifying other risk factors for CVD to their migraine patients. Further research is needed to understand why migraine is associated with CVD before potential preventive strategies can be developed."

Other research focused on addressing more traditional risk factors such as hypertension that does not respond to reductions in dietary salt. One study suggested that patients with resistant hypertension could have high levels of the aldosterone.

"High aldosterone and high dietary sodium ingestion combine for poor blood pressure control," said Eduardo Pimenta, MD, lead author and a research associate in the Vascular Biology and Hypertension Dept. at the University of Alabama. "These patients need much lower salt intake than the general hypertensive population."

Another study suggested arm exercises might reduce the pain associated with peripheral arterial disease.

Researchers randomized 35 patients to supervised aerobic leg workouts, arm exercises, a combination of the two or usual care. Those in the exercise groups were able to increase their walking distance.

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