Pablo Lamelas

Physical Activity and Anger or Emotional Upset as Triggers of Acute Myocardial InfarctionClinical Perspective: The INTERHEART Study

Background: Physical exertion, anger, and emotional upset are reported to trigger acute myocardial infarction (AMI). In the INTERHEART study, we explored the triggering association of acute physical activity and anger or emotional upset with AMI to quantify the importance of these potential triggers in a large, international population. Methods: INTERHEART was a case-control study of first AMI in 52 countries. In this analysis, we included only cases of AMI and used a case-crossover approach to estimate odds ratios for AMI occurring within 1 hour of triggers. Results: Of 12 461 cases of AMI 13.6% (n=1650) engaged in physical activity and 14.4% (n=1752) were angry or emotionally upset in the case period (1 hour before symptom onset). Physical activity in the case period was associated with increased odds of AMI (odds ratio, 2.31; 99% confidence interval [CI], 1.96–2.72) with a population-attributable risk of 7.7% (99% CI, 6.3–8.8). Anger or emotional upset in the case period was associated with an increased odds of AMI (odds ratio, 2.44; 99% CI, 2.06–2.89) with a population-attributable risk of 8.5% (99% CI, 7.0–9.6). There was no effect modification by geographical region, prior cardiovascular disease, cardiovascular risk factor burden, cardiovascular prevention medications, or time of day or day of onset of AMI. Both physical activity and anger or emotional upset in the case period were associated with a further increase in the odds of AMI (odds ratio, 3.05; 99% CI, 2.29–4.07; P for interaction <0.001). Conclusions: Physical exertion and anger or emotional upset are triggers associated with first AMI in all regions of the world, in men and women, and in all age groups, with no significant effect modifiers.

Association of Urinary Sodium Excretion With Blood Pressure and Cardiovascular Clinical Events in 17,033 Latin Americans.

BACKGROUND Information on actual sodium intake and its relationships with blood pressure (BP) and clinical events in South America is limited. The aim of this cohort study was to assess the relationship of sodium intake with BP, cardiovascular (CV) events, and mortality in South America. METHODS We studied 17,033 individuals, aged 35-70 years, from 4 South American countries (Argentina, Brazil, Chile, and Colombia). Measures of sodium excretion, estimated from morning fasting urine, were used as a surrogate for daily sodium intake. We measured BP and monitored the composite outcome of death and major CV events. RESULTS Overall mean sodium excretion was 4.70±1.43g/day. A positive, nonuniform association between sodium and BP was detected, with a significant steeper slope for the relationship at higher sodium excretion levels (P < 0.001 for interaction). With a median follow-up of 4.7 years, the primary composite outcome (all-cause death, myocardial infarction, stroke, or heart failure) occurred in 568 participants (3.4%). Compared with sodium excretion of 5-6g/day (reference group), participants who excreted >7g/day had increased risks of the primary outcome (odds ratio (OR) 1.73; 95% confidence interval (CI) 1.24 to 2.40; P < 0.001), as well as death from any cause (OR 1.87; 95% CI 1.23 to 2.83; P = 0.003) and major CV disease (OR 1.77; 95% CI 1.12 to 2.81; P = 0.014). Sodium excretion of <3g/day was associated with a statistically nonsignificant increased risk of the primary outcome (OR 1.20; 95% CI 0.86 to 1.65; P = 0.26) and death from any cause (OR 1.25; 95% CI 0.81 to 1.93; P = 0.29), and a significant increased risk of major CV disease (OR 1.50; 95% CI 1.01 to 2.24; P = 0.048), as compared to the reference group. CONCLUSIONS Our results support a positive, nonuniform association between estimated urinary sodium excretion and BP, and a possible J-shaped pattern of association between sodium excretion over the entire range and clinical outcomes.

Development, Testing, and Implementation of a Training Curriculum for Nonphysician Health Workers to Reduce Cardiovascular Disease

Background Cardiovascular disease (CVD) is the leading cause of death worldwide. The need to address CVD is greatest in low- and middle-income countries where there is a shortage of trained health workers in CVD detection, prevention, and control. Objectives Based on the growing evidence that many elements of chronic disease management can be shifted to nonphysician health care workers (NPHW), the HOPE-4 (Heart Outcomes Prevention and Evaluation Program) aimed to develop, test, and implement a training curriculum on CVD prevention and control in Colombia, Malaysia, and low-resource settings in Canada. Methods Curriculum development followed an iterative and phased approach where evidence-based guidelines, revised blood pressure treatment algorithms, and culturally relevant risk factor counseling were incorporated. Through a pilot-training process with high school students in Canada, the curriculum was further refined. Implementation of the curriculum in Colombia, Malaysia, and Canada occurred through partner organizations as the HOPE-4 team coordinated the program from Hamilton, Ontario, Canada. In addition to content on the burden of disease, cardiovascular system pathophysiology, and CVD risk factors, the curriculum also included evaluations such as module tests, in-class exercises, and observed structured clinical examinations, which were administered by the local partner organizations. These evaluations served as indicators of adequate uptake of curriculum content as well as readiness to work as an NPHW in the field. Results Overall, 51 NPHW successfully completed the training curriculum with an average score of 93.19% on module tests and 84.76% on the observed structured clinical examinations. Since implementation, the curriculum has also been adapted to the World Health Organizations HEARTS Technical Package, which was launched in 2016 to improve management of CVD in primary health care. Conclusions The robust curriculum development, testing, and implementation process described affirm that NPHW in diverse settings can be trained in implementing measures for CVD prevention and control.

Radial access: how do we interpret subgroup analyses

Vascular access selection has been deeply debated in the last 10 years, especially in the context of acute coronary syndromes (ACS). The results from randomized trials suggest that radial access offers better clinical outcomes when compared with femoral access, including access site complications, major bleeding, and major adverse cardiovascular events. Current European Society of Cardiology (ESC) guidelines recommend radial access, performed by experienced operators, over femoral access in ACS. Also, it is recommended to implement a transition from transfemoral to transradial access in centres treating patients with ACS. It had been thought that radial access may be more beneficial in ST-segment elevation myocardial infarction (STEMI) based on a subgroup of the RIVAL study. This analysis showed a significant interaction and suggested a large benefit for radial access in patients with STEMI for mortality, but no reduction in non-ST-segment elevation acute coronary syndrome (NSTEACS) patients. A potential confounder is that higher volume radial operators tended to randomized STEMI patients, but this interaction persisted after adjusting for radial volume. The Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and Systemic Implementation of angioX (MATRIX access) randomized 8404 ACS patients to radial or femoral access. This new large randomized trial provided the opportunity to explore again the subgroups of STEMI vs. NSTEACS reported by RIVAL investigators. Vranckx and collaborators reported in this issue of the journal a pre-specified subanalysis of the MATRIX access study, comparing the effectiveness of radial vs. femoral access in STEMI and NSTEACS. Amongst STEMI patients, death, MI, or stroke occurred in 121 (6.1%) with radial access vs. 126 (6.3%) patients with femoral access [relative risk (RR) 0.96, 95% confidence interval (CI) 0.75–1.24; P = 0.76] and amongst NSTEACS patients in 248 (11.3%) with radial access vs. 303 (13.9%) with femoral access (RR 0.80, 95% CI 0.67–0.96; P = 0.016; interaction P = 0.25). Death, MI, stroke, or major bleeding occurred in 142 (7.2%) STEMI patients with radial access and in 165 (8.3%) patients with femoral access (RR 0.86, 95% CI 0.68–1.08; P = 0.18) and in 268 (12.2%) NSTEACS patients with radial access compared with 321 (14.7%) with femoral access (RR 0.82, 95% CI 0.69–0.97; P = 0.023; interaction P = 0.76). The authors conclude that the benefit of radial access was consistent across the ACS spectrum. The findings are different from RIVAL for these subgroups. The most likely explanation is that subgroup analyses are subject to multiple testing error or chance. Another potential explanation is differences in the trial’s design or conduct that would account for differences. We performed an updated meta-analysis to better understand the available evidence. Randomized trials reporting mortality, major cardiovascular outcomes, or major bleeding were considered eligible. We found 18 randomized trials that reported at least one of the outcomes: 15 reported STEMI exclusively, one NSTEACS exclusively, and two STEMI and NSTEACS. We pooled the results and we calculated interaction P-values for STEMI–NSTEACS presentations. All-cause mortality was 2.5% in the radial vs. 3.6% in the femoral group in STEMI [odds ratio (OR) 0.66, 95% CI 0.52–0.83; P < 0.001; I = 0%] and 1.0% radial vs. 1.2% femoral in NSTEACS (OR 0.87, 95% CI 0.60–1.28; P = 0.49; I = 79%; interaction P = 0.33) (Figure 1). Death, MI, or stroke was 5.2% in the radial vs. 6.3% in the femoral group in STEMI (OR 0.80, 95% CI 0.67–0.95; P = 0.01; I = 0%) and 6.9% radial vs. 7.7% femoral in NSTEACS (OR 0.88, 95% CI 0.76–1.03; P = 0.12; I = 66%; interaction P = 0.40). Major bleeding was 1.5% in the radial group vs. 3.0% in the femoral group in STEMI (OR 0.51, 95% CI 0.38–0.68; P < 0.001; I = 0%) and 0.9% for the radial group vs. 1.3% for the femoral group in NSTEACS (OR 0.71, 95% CI 0.48–1.04; P = 0.08; I = 0%; interaction P = 0.18). The findings of this updated meta-analysis support the benefit of radial access in ACS with the most robust evidence in STEMI. Amongst NSTEACS, there are only three trials with less than half the number of events, leading to much lower power. Not surprisingly, there was heterogeneity between RIVAL and MATRIX for mortality

Effective approaches to address the global cardiovascular disease burden

Purpose of review Describe the global burden of cardiovascular disease (CVD), highlight barriers to evidence-based care and propose effective interventions based on identified barriers. Recent findings The global burden of CVD is increasing worldwide. This trend is steeper in lower income countries, where CVD incidence and fatality remains high. Risk factor control, around the world, remains poor, especially in lower and middle-income countries. Barriers at the patient, healthcare provider and health system have been identified. The use of multifaceted interventions that target identified contextual barriers to care, including increasing awareness of CVD and related risk, improving health policy (i.e. taxation of tobacco), improving the availability and affordability of fixed-dose combined medications and task-shifting of healthcare responsibilities are potential solutions to improve the global burden of CVD. Summary There is a need to address identified barriers using evidence-based and multifaceted interventions. Global initiatives, led by the World Heart Federation and the WHO, to facilitate the implementation of such interventions are underway.

Effect of Body Mass Index on Clinical Events After Acute Coronary Syndromes

The association between body mass index (BMI) and major clinical events after acute coronary syndrome (ACS) remains controversial. We investigated the impact of BMI on major clinical events after ACS in a large individual patient data meta-analysis. Data on 81,553 patients from 45 different countries with ACS enrolled in 8 large randomized clinical trials were included, followed up for a median of 171 days. The mean age was 63.4 ± 11.7, 70% were male, and the mean BMI was 27.3 ± 4.7 kg/m2. Compared with upper-normal-weight participants (BMI 21.75 to 24.9 kg/m2, reference category), underweight participants (<18.5 kg/m2) had an increased risk of death (hazard ratio [HR] 1.35, 95% confidence interval [CI] 1.10 to 1.66, p = 0.004). Both overweight subcategories, BMI 25 to 27.5 kg/m2 (HR 0.81, 95% CI 0.75 to 0.89, p <0.001) and BMI 27.5 to 29.9 kg/m2 (HR 0.84, 95% CI 0.76 to 0.92, p <0.001), and type I obesity (30 to 34.9, HR 0.81, 95% CI 0.73 to 0.89, p <0.001) had a significantly lower mortality. Type II and III obesities were not significantly associated with mortality. Mortality was lowest at a BMI of 30.9 kg/m2. Compared with normal-weight patients, overweight and obese categories were related with a significantly lower risk of bleeding and refractory ischemia. Overweight patients had a lower risk of myocardial infarction, heart failure hospitalizations, and heart failure-related deaths. There were no associations between BMI and revascularization rates or stroke. In conclusion, underweight and normal-weight patients were associated with an increased mortality risk, bleeding, ischemia, and heart failure compared with those with higher BMI after ACS.

Body mass index and mortality after acute coronary syndromes: a systematic review and meta-analysis

Abstract Objective: The association between body mass index (BMI) and mortality after acute coronary syndromes (ACS) is controversial. The objective of this analysis is to summarize the available evidence of this association and perform meta-analysis using adjusted estimates. Methods and results: Systematic review from MEDLINE and EMBASE through May 2015 was performed. Studies were considered eligible if they described the association between BMI and all-cause mortality after ACS, and those reporting adjusted estimates were included in the meta-analysis. We included 35 articles with 316,455 participants, with overall poor to moderate quality. No study reported that overweight, type-I or type-II obesity was related to an increased risk of mortality compared to normal weight. Pooled adjusted estimates from 18 studies (137,975 participants) showed lower adjusted mortality both overweight (RR: 0.83; 95% CI: 0.75–0.91; p < .001; I2 51%) and obese (RR: 0.79; 95% CI: 0.71–0.88; p < .001; I2 33%) categories when compared to normal weight. Heterogeneity was not explained in pre-specified subgroups analysis. Conclusions: Increased BMI was associated with increased adjusted survival after ACS when compared to normal BMI. Unexplained heterogeneity and suboptimal quality of studies limit the strength of the results. This seemingly paradoxical finding needs to be confirmed with further research.

Are all P2Y12 equally effective in vein graft angioplasty? A report from the UK database

Information of P2Y12 inhibitors in acute coronary syndromes with vein graft angioplasty is limited. This new analysis from the UK database was not able to find significant differences between Clopidogrel, Prasugrel and Ticagrelor. Large trials would be needed to reliably confirm the best antiplatelet regimen in this setting.

Rationale and design of a cluster randomized trial of a multifaceted intervention in people with hypertension: The Heart Outcomes Prevention and Evaluation 4 (HOPE-4) Study

BACKGROUND Cardiovascular disease is the leading cause of death throughout the world, with the majority of deaths occurring in low- and middle-income countries. Despite clear evidence for the benefits of blood pressure reduction and availability of safe and low-cost medications, most individuals are either unaware of their condition or not adequately treated. OBJECTIVE The primary objective of this study is to evaluate whether a community-based, multifaceted intervention package primarily provided by nonphysician health workers can improve long-term cardiovascular risk in people with hypertension by addressing identified barriers at the patient, health care provider, and health system levels. METHODS/DESIGN HOPE-4 is a community-based, parallel-group, cluster randomized controlled trial involving 30 communities (1,376 participants) in Colombia and Malaysia. Participants ≥50 years old and with newly diagnosed or poorly controlled hypertension were included. Communities were randomized to usual care or to a multifaceted intervention package that entails (1) detection, treatment, and control of cardiovascular risk factors by nonphysician health workers in the community, who use tablet-based simplified management algorithms, decision support, and counseling programs; (2) free dispensation of combination antihypertensive and cholesterol-lowering medications, supervised by local physicians; and (3) support from a participant-nominated treatment supporter (either a friend or family member). The primary outcome is the change in Framingham Risk Score after 12 months between the intervention and control communities. Secondary outcomes including change in blood pressure, lipid levels, and Interheart Risk Score will be evaluated. SIGNIFICANCE If successful, the study could serve as a model to develop low-cost, effective, and scalable strategies to reduce cardiovascular risk in people with hypertension.

INCIDENCE AND PREDICTORS OF NO REFLOW PHENOMENON: INSIGHTS FROM THE TOTAL TRIAL

Background: No-reflow during percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) has been previously associated with worse outcomes. The TOTAL trial showed that routine thrombus aspiration did not reduce the incidence of no-reflow. We sought to understand the