American College of Cardiology Spotlights Diabetes and Heart Resynchronization and Honors Its Own
Double Whammy of Glitazone Antidiabetics and Heart Failure Risk
Thomas Delea was quick to point out that he is not a physician when he presented the results of his retrospective-based analysis of antidiabetic drugs, called glitazones, and the risk of heart failure. As a health policy analyst at Policy Analysis Inc, in Brookline, Mass, he is concerned about the decisions physicians and insurance companies make when delivering health care.
Yet his study, which compared one person with type 2 diabetes taking glitazones to 5 controls on a different antidiabetic medication, demonstrated that 4.5% of patients taking glitazone-type medication suffered from heart failure, compared with 2.6% of those taking another medication. It is a study that could have significant effect on prescription and treatment practices. (Rezulin, Avandia, and Actos are the brand names of some typical glitazones.)
The patients using glitazones were younger and more likely to have coronary artery disease and complications of diabetes, Delea said. They also were more likely to be on insulin and taking drugs for heart disease. Their health expenses were higher than those of the controls before they started taking glitazone. The increased risk was consistent among subpopulation groups, Delea said.
“In summary, we observed consistent association between the use of glitazones and the risk of heart failure,” Delea said. “It is approximately a relative risk increase of 50%. However, we advise interpreting these findings cautiously. Because of the strength of what we have observed, we advise continued research into the effects of glitazone antidiabetics on heart failure. Physicians should be vigilant for symptoms for heart failure in patients receiving these drugs.”
Diabetics’ Mortality Risk Increased in Non–ST-Elevation Myocardial Infarction
Diabetes increases the risk of death for patients with unstable angina or non–ST-segment elevation myocardial infarction, said Marco Roffi of the Cleveland Clinic, describing a study carried out by researchers at his institute and Duke Clinical Research Institute in Durham, NC.
Pooling data from 4 large studies on treatment of acute coronary syndromes, the researchers were able to study >5400 people with acute coronary syndromes. Analysis of these data indicated that diabetes increased the risk of dying within 30 days by >50%. The subjects also had a higher risk of ST-elevation myocardial infarction.
“Our study has a 2-fold relevance,” said Dr Roffi. “Diabetic patients have a poor prognosis and higher mortality at 30 days. This is relevant because of the increased prevalence of diabetes worldwide and in western countries. We need more specific research for patients with acute coronary syndromes and diabetes.”
The study is also important, he said, because of a second trial that demonstrated that patients with diabetes have a significant mortality benefit when treated with glycoprotein IIb/IIIa inhibitors.
ST-Elevation Acute Myocardial Infarction in Diabetics
When Hitinder S. Gurm, MD, of the Cleveland Clinic analyzed the outcome of diabetics with ST-elevated acute myocardial infarction, he found that such patients were more likely than others to die while in the hospital or during the month after hospital discharge . He said, however, that the increased use of β-blockers and angiotensin-converting enzymes in the most recent studies improved the likelihood of survival.
What Diabetics Don’t Know Will Hurt Them
Many diabetics are unaware that the most life-threatening complications of diabetes are heart disease and stroke, said John Buse, MD, of the American Diabetes Association and director of the University of North Carolina Diabetes Care Center. Dr Buse outlined the results of a recent survey on the topic during the American College of Cardiology meeting in Atlanta, Ga, March 17 to 20, 2002.
“Heart attack occurs at an earlier age in people with diabetes. It is imperative that people with diabetes realize that managing their disease is more than controlling blood glucose. It is also means managing blood pressure and cholesterol,” he said.
In the survey, 68% of people did not identify cardiovascular disease as one of the most serious health problems related to diabetes. According to Dr Buse, more than two thirds of diabetics will die from heart disease or stroke.
“They are not making the link that heart disease is associated with their disease. While heart disease is declining in the general population, the reverse is happening in those with diabetes,” he said. “Only a few of the patients surveyed could describe any way to reduce heart attack and stroke other than diet and exercise.”
He said the medical community has an obligation to turn these facts around by informing patients of their risks. Many of those surveyed said they visited their physicians 5 times a year to discuss managing their diabetes. “About half said that their healthcare providers never discussed managing blood pressure or cholesterol,” Dr Buse said.
“We need to find ways to educate people with diabetes about the risk for heart disease. We have to ask, ‘Are the patients hearing us, and are the doctors hearing us?’ We need to find out how to break through the barrage of information people hear every day.”
“The challenge is great but manageable,” he said. “The urgency increases as diabetic risks elevate day-by-day and solutions are not uniformly applied.”
When scientists involved in the Multicenter Insync Randomized Clinical Evaluation (MIRACLE) study evaluated the data from the large-scale, randomized, double-blind control trial of cardiac resynchronization therapy for heart failure, they found that the treatment seemed to reduce the risk of being hospitalized for heart failure by ≈50%, according to William Abraham, MD, of the University of Kentucky in Lexington.
Previously, the study had shown that the therapy improved exercise endurance and well-being, he said. This study also demonstrated a 40% reduction in the combined end point of death or worsening health failure requiring hospitalization, he said. The study did not, however, demonstrate a statistically significant difference in death from heart failure and death from all causes.
Notable Cardiologists Honored
Henry D. McIntosh of Lakeland, Fla, was named the first recipient of the American College of Cardiology (ACC) International Service Award, which recognizes a commitment to medically developing or underdeveloped countries. Dr McIntosh was honored for founding Heartbeat International in 1984, which has set up 41 pacemaker banks in 27 nations. More than 500 new pacemakers are distributed through the bank each year. Dr McIntosh was the ACC president from 1974 to 1975.
The Distinguished Scientist Award was presented to J. Thomas Bigger, Jr, MD, of New York, NY, for his 40 years of research that has contributed to the understanding of the mechanisms of cardiac arrhythmias and the treatment of these arrhythmias with drugs and devices.
John Eisenberg, MD, of Rockville, Md, received the Distinguished Service Award for his contributions to medicine and the delivery of health care. Dr Eisenberg worked early to establish clinical practice guidelines and to foster their use among cardiologists.
Alfred A. Bove, MD, of Philadelphia, Pa, received the Distinguished Fellow Award for his diverse service to the College, which includes co-chairing the Annual Scientific Sessions in 1988, serving as governor of the eastern Pennsylvania Chapter for several years, and as president of the ACC Pennsylvania Chapter. Dr Bove is also executive editor of the ACC web site and has spent much time and effort developing ACCardio, the College’s web-based learning management system.
The Gifted Teacher Award was given to C. Richard Conti, MD, of Gainesville, Fla, and Roberta G. Williams, MD, of Los Angeles, Calif. Dr Conti served as chief of the Division of Cardiology at the University of Florida for 25 years. He was also instrumental in the success of ACCEL, the ACC’s audio journal, and now serves as its editor-in-chief. Dr Conti was also editor of ACCSAP 2000, another tool for physician education for those preparing for board examinations. Dr Williams is a long-time member of the faculty at the University of California at Los Angeles Medical School and has taught many of the leaders of pediatric cardiology. She played a large role in the development of modern echocardiography for use in pediatric cardiology.
A Presidential Citation went to Eugene Braunwald, MD, of Boston, Mass, who was recognized for his scientific contributions to the field of medicine.
Bruce H. Brundage, MD, of Bend, Ore, Michael A. Nocero, Jr, MD, of Orlando, Fla, and Douglas P. Zipes, MD, of Indianapolis, Ind, were named Masters of the American College of Cardiology. Dr Brundage was recognized for his long-time devotion to the College. He is a former member of the board of trustees, has served on the annual scientific sessions program committee 4 times, and has been a member of the editorial board of the ACC. He currently serves as chair of the ACC Credentials and Membership Committee.
Dr Nocero also was honored for long-time service to the College, including service on the executive committee and the board of governors and acting as chair in 1993 and 1994. Dr Zipes was honored for his work for the ACC since 1972. He is the College’s immediate past president.
Rajendra Mehta, MD, of Ann Arbor, Mich, and James H. Stein, MD, of Madison, Wis, received the W. Proctor Harvey, MD, Young Teacher Award. Dr Mehta has been praised by fellows at the local Veterans Affairs hospital for his teaching in echocardiography. Dr Stein was honored for his work at the University of Wisconsin, where he created the first online continuing medical education course.
Air Pollution And Heart Disease
In the current issue of Circulation, Robert D. Brook, MD, of the University of Michigan in Ann Arbor, and colleagues form the University of Toronto, Environment Canada, and Health Canada, describe the mechanism behind the increased incidence of heart attacks and other events and fine particulate air pollution (Circulation. 2002;105:1534–1536).
In their study, 25 healthy adults underwent a randomized, double-blind crossover study comparing vascular responses to 2-hour inhalation of very fine ambient particles plus ozone versus responses to filtered air. The scientists used high-resolution vascular ultrasonography to measure alterations in brachial artery diameter, endothelial-dependent flow-mediated dilatation, and endothelial-independent nitroglycerin-mediated dilatation.
Exposure to the fine particulate pollution with ozone caused significant brachial artery vasoconstriction compared with filtered air inhalation. However, there was no difference in flow-mediated dilatation and endothelial-independent nitroglycerin-mediated dilatation.