One in 5 at Risk for Congestive Heart Failure
Relying on the landmark data from the Framingham Heart Study, a group of researchers has determined that one in 5 people is at risk of developing congestive heart failure—a growing epidemic worldwide. Their report appears in this week’s issue of Circulation (Circulation. 2002;106:3068–3072).
Led by Donald M. Lloyd-Jones, MD, of the study’s personnel, the researchers monitored the course of 3757 men and 4472 women from 1971 until 1996. Of those people, 583 developed congestive heart failure and 2002 died without a diagnosis of prior congestive heart failure.
They determined from these data that at age 40, the lifetime risk of developing heart failure was 21% for men and 20.3% for women. The risk for the remaining lifetime did not change significantly. For example, at age 80, the risk was 20.2% for men and 19.3% for women.
In men who had not had a myocardial infarction, lifetime risk was nearly half—11.4% for men. For women, the lifetime risk was 15.4%. The authors recommended using these results in health planning for the coming burden of congestive heart failure and in making policy decisions about prevention of the ailment by controlling hypertension and preventing heart attack.
Identifying the “Haywire Hearts” of Newborns
A condition in newborns that is similar to long-QT syndrome appears to be responsible for 1 in 20 deaths presently attributed to Sudden Infant Death Syndrome (SIDS), according to researchers led by Michael J. Ackerman, MD, PhD, Assistant Professor at the Mayo Clinic in Rochester, Minn. Dr Ackerman presented his results at the 75th Annual Scientific Sessions of the American Heart Association in Chicago, Ill, in November.
In what he called the first comprehensive population-based genetic autopsy, Dr Ackerman and members of his team from a variety of centers in the United States performed genetic autopsies on every unexplained infant death investigated by the Arkansas State Crime Laboratory between September 1997 and August 1999. In their study of 93 deaths, the researchers extracted DNA from frozen heart tissue and studied the 5 genes that are associated with long-QT syndrome. They found 21 different mutations of the genes in 30 children (32%). Four (5%) of the SIDS cases had genetic anomalies that were not found in the genes of 200 healthy, racially matched controlled subjects.
“Long-QT syndrome is sometimes called the perfect killer, because it leaves no clues,” said Dr Ackerman in a released statement. “Neither does SIDS. Our goal is to discover the truth. SIDS will probably turn out to have 20 different underlying causes. If we can figure out what they are, we can screen for them and hopefully one day, prevent future cases of SIDS.”
Peter J. Schwartz, MD, of the Istituto di Clinica Medica Generale e Terapia Medica, Universita degli Studi di Milano, Italy, hailed the study as important to better understanding of both long-QT syndrome and SIDS. “The bottom line is that he has confirmed by molecular analysis that some of the infants who have died of SIDS actually have the long-QT syndrome,” said Dr Schwartz. “We have done this on individual cases and we are collaborating with 2 groups to study a large series of patients.”
“One point he fails to make is that even if you used the best laboratory—the gold standard—you only identify 55% of the patients with long-QT syndrome. Forty to 45% of patients who have the disease have mutations that cannot be identified with current techniques,” he said.
Dr Schwartz disagrees with Dr Ackerman’s belief that there is presently no routine test to screen for such a cardiac cause, and he has lobbied in Italy to have routine electrocardiograms performed on newborns. Presently, he said, he is starting a pilot study of the prevalence of the disease among newborns and the feasibility of performing ECGs on them as a routine screen. “Within one year, we will have data to indicate the feasibility, drawbacks, and limitations of the test,” he said. “We will also know how many of these children we can pick up.” He plans to test ≈50 000 newborns as part of his pilot study.
Seniors in Nursing Homes Not Receiving Same Heart Care as Counterparts in Community
Older patients in nursing homes are less likely to receive state-of-the-art treatment for congestive heart failure than those in the community, said Edward Havranek, MD, Clinical Coordinator of the Colorado Foundation for Medical Research in Denver during a session on treatment of heart disease in the elderly at the 75th Annual Scientific Sessions of the American Heart Association in Chicago, Ill, on November 17, 2002.
“Nursing homes represent a significant reservoir of missed opportunity to provide high-quality heart care,” said Dr Havranek, who also pointed out that the use of drugs such as ACE inhibitors could reduce costly hospitalizations.
Researchers examined the records of >32 000 Medicare patients admitted to hospitals with heart failure and compared the 11% admitted to the hospital from nursing homes with those admitted from private homes. Nursing home patients were more likely to be female, older, and have co-morbidities such as dementia and prior stroke. They were less likely to have undergone tests to determine their ejection fraction and less likely to receive an ACE inhibitor at discharge when they had documented systolic dysfunction. The odds ratio for prescription of an ACE inhibitor in the elderly population was 0.69.
“It should be pointed out that this is a global problem,” said Simon Stewart, Chief of Cardiovascular Nursing at the University of South Australia. “Heart failure consumes 2 to 4% of health care budgets in developed countries of the world. It is much cheaper to manage heart failure in the community and keep people out of the hospital.”
Dr Havranek added that moving back and forth from nursing homes to hospitals does not provide seniors with the level of comfort in the remainder of their lives that most go to those facilities to attain.
Some of the problem can be attributed to the lack of specialized care for nursing home patients, Dr Havranek said. Nursing home patients are 4 times more likely to receive heart care from a primary care physician than a cardiologist. —John Tyler, BA, Circulation Newswriter
Fruits and Vegetables Result in Healthier Hearts
Fruit and vegetable consumption can be directly tied to lower incidences of cardiovascular disease and obesity, said Simin Liu, ScD, MD, Assistant Professor of Medicine at Harvard School of Medicine during a presentation at the 75th Annual Scientific Sessions of the American Heart Association on November 18, 2002.
Examining the self-reported eating habits of the >74 000 women in the 12-year Nurses Health Study, Dr Liu found that those consuming the highest amounts of fruits and vegetables reduced their risk of obesity and cardiovascular disease by 26%.
“This confirms diet is fundamental to controlling the epidemic of obesity,” said Dr Liu. He reported that all subjects gained weight as they aged, but those eating the most fruits and vegetables gained the least. —John Tyler, BA, Circulation Newswriter
Looking for Flow in the Heart Can Avert False Positives, Negatives
The use of myocardial perfusion imaging in the emergency department might identify patients who do not need hospitalization for their chest pain and the small number who are discharged from the emergency department who do have acute ischemia, according to researchers from Tufts-New England Medical Center in Boston, Mass, in a study published in the December 3, 2002, issue of the Journal of the American Heart Association (JAMA. 2002;288:2693–2700).
In a 7-center randomized trial, the researchers led by James E. Udelson, MD, of Tufts-New England Medical Center, evaluated 2475 adult patients who arrived at the emergency departments with chest pains or symptoms suggestive of reduced heart flow to the heart and normal electrocardiogram results or results that were equivocal. Of these, 1260 were assigned to the usual ED strategy and 1215 were to receive the usual diagnostic strategy augmented with acute resting myocardial perfusion using single photon-emission computer tomography. The results were provided to the ED physicians to incorporate into their decision-making.
Although the results were the same in patients with acute myocardial infarction or unstable angina, the researchers found that hospitalization was reduced by 10% (52% in the usual care group versus 42% in the perfusion imaging group) in the patients who did not have acute cardiac ischemia. “Incorporating acute resting. . .myocardial perfusion imaging into an ED evaluation strategy for patients with symptoms suggestive of acute cardiac ischemia reduced unnecessary hospitalizations among patients without acute ischemia, without reducing appropriate admissions of patients with acute ischemia, thereby improving the overall clinical effectiveness of the ED triage,” the authors wrote.
In an editorial commentary on the report (JAMA. 2002:288: 2745–2746), Raymond J. Gibbons, MD, of the Mayo Clinic in Rochester, Minn, wrote that the trial represents an important step forward. “The care of patients with known or suspected cardiovascular disease is increasing evidence-based,” he wrote. “The triage of ED patients with acute pain is an important clinical problem for which previous randomized trial data were limited. Future clinical practice guidelines should consider including resting myocardial perfusion imaging as an option in the evaluation of patients with acute chest pain.”