Atrial fibrillation set to affect more than 14 million over-65s in the EU by 2060

 

: Urgent action is needed to prevent, detect and treat atrial fibrillation to stop a substantial rise in disabling strokes. That’s the main message of a paper published today in EP Europace, a journal of the European Society of Cardiology (ESC),1 during World Heart Rhythm Week. Atrial fibrillation is the most common heart rhythm disorder2 and accounts for 0.28% to 2.6% of healthcare spending in European countries. Patients with atrial fibrillation have a five times higher risk of stroke. And 20% to 30% of strokes are caused by atrial fibrillation. Strokes due to atrial fibrillation are more disabling and more often fatal than strokes with other causes. The study estimates that 7.6 million people over 65 in the EU had atrial fibrillation in 2016 and this will increase by 89% to 14.4 million by 2060. Prevalence is set to rise by 22%, from 7.8% to 9.5%. The proportion of these patients who are over 80 will rise from 51% to 65%. “Atrial fibrillation patients over 80 have even greater risks of stroke so this shift in demography has enormous implications for the EU,” said study author Dr Antonio Di Carlo, of the Italian National Research Council, Florence, Italy. “Older patients also have more comorbidities linked to atrial fibrillation such as heart failure and cognitive impairment.” Prevention of atrial fibrillation is the same as for other cardiovascular conditions. This includes not smoking, exercise, a healthy diet, keeping alcohol under moderation, and controlling blood pressure and diabetes. Screening for atrial fibrillation is important because oral anticoagulation effectively prevents strokes in these patients. Dr Di Carlo said GPs should opportunistically screen for atrial fibrillation by performing pulse palpation during every consultation. Patients with an irregular pulse would have an electrocardiogram (ECG) for confirmation. “The majority of older people see their GP at least once a year, so this is an efficient and effective method to diagnose atrial fibrillation and prevent complications,” he said. GPs can inform patients about symptoms of atrial fibrillation such as palpitations, racing or irregular pulse, shortness of breath, tiredness, chest pain and dizziness.3 And they can teach patients how to check for an irregular pulse using the fingertips, which can be reported and followed-up with an ECG. “I recommend this approach for now,” said Dr Di Carlo. “In future there may be reliable devices for first line screening by the public such as smartwatch apps, but these technologies are not ready for widespread use.” To calculate the numbers of atrial fibrillation patients over 65 anticipated in the EU in the next four decades, the researchers first measured the prevalence in a representative sample of people over 65 in Italy. They then used population projections from the statistical office of the EU (Eurostat) for all 28 Member States. The study was funded by the Italian Ministry of Health, National Centre for Disease Prevention and Control.

Biomarkers help tailor diuretic use in acute heart failure patients

Adrenomedullin activity predicts which acute heart failure patients are at the greatest risk of death without diuretic treatment post-discharge, according to late breaking research presented today at Heart Failure 2019, a scientific congress of the European Society of Cardiology (ESC).1

“Therapy at discharge often remains unchanged for several weeks and even months in acute heart failure patients,” said first author Dr Nikola Kozhuharov, of the University Hospital Basel, Switzerland. “Our study shows that not re-evaluating the need for diuretics in this critical time period has detrimental consequences for patients.”

Acute heart failure is the most common cause of hospitalisation in people over 50 and up to 30% die in the year after discharge. “This is in part due to the challenge of predicting which patients are at the greatest risk of death and the subsequent uncertainty in defining the appropriate intensity of in-hospital and immediate post-discharge management,” said Dr Kozhuharov.

The study aimed to find biomarkers that predict risk levels in acute heart failure patients discharged from hospital and who would benefit from heart failure drugs. The drugs were diuretics, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta blockers, and aldosterone antagonists.

For the biomarkers, the study used two components of adrenomedullin, a peptide hormone that is a vasodilator, meaning it dilates (opens) blood vessels. Adrenomedullin was selected after pilot studies suggested it can quantify dysfunction of small blood vessels and the associated mortality risk. In addition, activity of adrenomedullin reflects residual congestion in acute heart failure patients and the researchers hypothesised that this could be used to guide diuretic therapy at discharge.

The two components used to quantify the activity of adrenomedullin were midregional proadrenomedullin (MR-proADM), a stable precursor, and the biologically active form of adrenomedullin (bio-ADM).

The study enrolled 1,886 acute heart failure patients presenting with acute breathlessness to emergency departments of university hospitals in the UK, France, and Switzerland. Plasma concentrations of MR-proADM and bio-ADM were assessed within 12 hours of presentation and at discharge from an acute ward.

A total of 514 patients (27%) died during the 365-day follow-up. Patients with bio-ADM levels above the median had significantly lower survival if they were not receiving diuretics at discharge. A similar result was found for MR-proADM. Both associations remained significant after adjusting for age and plasma creatinine concentration at discharge. Associations with the other drugs were not significant after correction for multiple testing.

Patients with bio-ADM plasma concentrations above the median had an 87% increased risk of death during follow-up compared to those with levels below the median. MR-proADM was even more accurate than bio-ADM for predicting death and the combined risk of death and/or acute heart failure rehospitalisation.

Dr Kozhuharov said: “The observation that patients with high bio-ADM have much higher mortality rates if not treated with diuretics at discharge has immediate clinical consequences. Reasons for stopping diuretics during hospitalisation included worsening renal function and low blood pressure. Our study shows that patients should be reassessed for contraindications before discharge so that diuretics can be restarted if appropriate, particularly if they have elevated bio-ADM.”

Stressed at work and trouble sleeping? It’s more serious than you think.

Sophia Antipolis, 28 April 2019:   Work stress and impaired sleep are linked to a threefold higher risk of cardiovascular death in employees with hypertension. That’s the finding of research published today in the European Journal of Preventive Cardiology, a journal of the European Society of Cardiology (ESC).1 Study author Professor Karl-Heinz Ladwig, of the German Research Centre for Environmental Health and the Medical Faculty, Technical University of Munich, said: “Sleep should be a time for recreation, unwinding, and restoring energy levels. If you have stress at work, sleep helps you recover. Unfortunately poor sleep and job stress often go hand in hand, and when combined with hypertension the effect is even more toxic.” One-third of the working population has hypertension (high blood pressure). Previous research has shown that psychosocial factors have a stronger detrimental effect on individuals with pre-existing cardiovascular risks than on healthy people. This was the first study to examine the combined effects of work stress and impaired sleep on death from cardiovascular disease in hypertensive workers. The study included 1,959 hypertensive workers aged 25–65, without cardiovascular disease or diabetes. Compared to those with no work stress and good sleep, people with both risk factors had a three times greater likelihood of death from cardiovascular disease. People with work stress alone had a 1.6-fold higher risk while those with only poor sleep had a 1.8-times higher risk. During an average follow-up of nearly 18 years, the absolute risk of cardiovascular death in hypertensive staff increased in a stepwise fashion with each additional condition. Employees with both work stress and impaired sleep had an absolute risk of 7.13 per 1,000 person-years compared to 3.05 per 1,000-person years in those with no stress and healthy sleep. Absolute risks for only work stress or only poor sleep were 4.99 and 5.95 per 1,000 person-years, respectively. In the study, work stress was defined as jobs with high demand and low control – for example when an employer wants results but denies authority to make decisions. “If you have high demands but also high control, in other words you can make decisions, this may even be positive for health,” said Professor Ladwig. “But being entrapped in a pressured situation that you have no power to change is harmful.”   Impaired sleep was defined as difficulties falling asleep and/or maintaining sleep. “Maintaining sleep is the most common problem in people with stressful jobs,” said Professor Ladwig. “They wake up at 4 o’clock in the morning to go to the toilet and come back to bed ruminating about how to deal with work issues.” “These are insidious problems,” noted Professor Ladwig. “The risk is not having one tough day and no sleep. It is suffering from a stressful job and poor sleep over many years, which fade energy resources and may lead to an early grave.” "The findings are a red flag for doctors to ask patients with high blood pressure about sleep and job strain", said Professor Ladwig. “Each condition is a risk factor on its own and there is cross-talk among them, meaning each one increases risk of the other. Physical activity, eating healthily and relaxation strategies are important, as well as blood pressure lowering medication if appropriate.” Employers should provide stress management and sleep treatment in the workplace, he added, especially for staff with chronic conditions like hypertension. Components of group stress management sessions: Start with 5 to 10 minutes of relaxation. Education about healthy lifestyle. Help with smoking cessation, physical exercise, weight loss. Techniques to cope with stress and anxiety at home and work. How to monitor progress with stress management. Improving social relationships and social support. Sleep treatment can include: Stimulus control therapy: training to associate the bed/bedroom with sleep and set a consistent sleep-wake schedule. Relaxation training: progressive muscle relaxation, and reducing intrusive thoughts at bedtime that interfere with sleep. Sleep restriction therapy: curtailing the period in bed to the time spent asleep, thereby inducing mild sleep deprivation, then lengthening sleep time. Paradoxical intention therapy: remaining passively awake and avoiding any effort (i.e. intention) to fall asleep, thereby eliminating anxiety.

Fathers-to-be: smoking could harm your baby

Fathers-to-be who smoke may increase the risk of congenital heart defects in their offspring, according to a study published today in the European Journal of Preventive Cardiology, a journal of the European Society of Cardiology (ESC). For mothers-to-be, both smoking and exposure to secondhand smoke were detrimental.

“Fathers-to-be should quit smoking” said study author Dr Jiabi Qin, of Xiangya School of Public Health, Central South University, Changsha, China. “Fathers are a large source of secondhand smoke for pregnant women, which appears to be even more harmful to unborn children than women smoking themselves.”

Congenital heart defects are the leading cause of stillbirth and affect 8 in 1,000 babies born worldwide. Prognosis and quality of life continues to improve with innovative surgeries, but the effects are still lifelong.

“Smoking is teratogenic, meaning it can cause developmental malformations. The association between prospective parents smoking and the risk of congenital heart defects has attracted more and more attention with the increasing number of smokers of childbearing age.” said Dr Qin.

This was the first meta-analysis to examine the relationships between paternal smoking and maternal passive smoking and risk of congenital heart defects in offspring. Previous analyses have focused on women smokers. Yet, as Dr Qin points out: “In fact, smoking in fathers-to-be and exposure to passive smoking in pregnant women are more common than smoking in pregnant women.”

The researchers compiled the best available evidence up to June 2018. This amounted to 125 studies involving 137,574 babies with congenital heart defects and 8.8 million prospective parents.

All types of parental smoking were associated with the risk of congenital heart defects, with an increase of 74% for men smoking, 124% for passive smoking in women, and 25% for women smoking, compared to no smoking exposure.

This was also the first review to examine smoking at different stages of pregnancy and risk of congenital heart defects. Women’s exposure to secondhand smoke was risky for their offspring during all stages of pregnancy and even prior to becoming pregnant. Women who smoked during pregnancy had a raised likelihood of bearing a child with a congenital heart defect, but smoking before pregnancy did not affect risk.

“Women should stop smoking before trying to become pregnant to ensure they are smokefree when they conceive.” said Dr Qin. “Staying away from people who are smoking is also important. Employers can help by ensuring that workplaces are smokefree.”

“Doctors and primary healthcare professionals need to do more to publicise and educate prospective parents about the potential hazards of smoking for their unborn child.” added Dr Qin.

Regarding specific types of congenital heart defects, the analysis showed that maternal smoking was significantly associated with a 27% greater risk of atrial septal defect and a 43% greater risk of right ventricular outflow tract obstruction compared to no smoking. The overall risk of congenital heart defects with all types of parental smoking was greater when the analysis was restricted to Asian populations.

“Back to basics” atrial fibrillation procedure could slash waiting lists

A day case catheter ablation procedure which includes only the bare essentials and delivers the same outcomes could slash waiting lists for atrial fibrillation patients, according to late-breaking results from the AVATAR-AF trial presented today at EHRA 2019, a European Society of Cardiology (ESC) congress.¹ With the simplified protocol, 30% more patients could receive catheter ablation for the same cost.

Atrial fibrillation is the most common heart rhythm disorder (arrhythmia). It causes 20–30% of all strokes and increases the risk of dying prematurely.² Symptoms include palpitations, shortness of breath, tiredness, and difficulty exercising. Catheter ablation, aimed at burning or freezing heart tissue causing atrial fibrillation, is recommended to restore normal rhythm after failure of, or intolerance to, drug treatment.

Principal investigator Professor Prapa Kanagaratnam, of Imperial College London, UK, said: “Catheter ablation started in 1998. There has been little improvement in clinical outcomes in the last ten years despite costlier technologies and a more complicated procedure requiring highly skilled staff. In this trial, we stripped the procedure back to the bare essentials to see if it achieved the same outcomes.”

The AVATAR protocol eliminates electrical mapping of the pulmonary veins, thereby removing the need for pulmonary vein catheters, electrical recording equipment, and staff trained to use the equipment.

The trial enrolled 321 patients with atrial fibrillation needing symptom control. Patients were randomly allocated to one of three treatments: 1) AVATAR protocol with cryoballoon ablation and discharge home the same day; 2) antiarrhythmic drugs; 3) conventional cryoballoon ablation with pulmonary vein mapping, and overnight hospitalisation.

For all patients, there was a 12 week treatment period during which procedures were done and drugs were optimised. The primary endpoint was whether patients needed to attend hospital again after that period.

At one year, 21% of patients in the AVATAR group needed hospital treatment to relieve symptoms. This was significantly lower than in the drug therapy group, of whom 76% needed therapy (p<0 .0001="" 18="" ablation="" and="" conventional="" different="" group="" not="" of="" p="0.6).<br" required="" significantly="" the="" to="" treatment="" whom="">
“Some of the more technical parts of the procedure can be omitted, making it easier, cheaper and quicker, without sacrificing results.” said Professor Kanagaratnam. “In the UK, patients with atrial fibrillation have to wait months for catheter ablation. The simpler protocol could shorten waiting lists within the same budget.”

“Eight in ten patients didn’t need to see their specialist again,” he continued. “Currently we medicalise patients with regular monitoring, but the study shows that long-term follow-up is unnecessary. Patients can contact the hospital if they have symptoms.”

The study gives the first direct proof that ablation is better than drugs for controlling symptoms and avoiding hospital treatment. “It is possible that more patients will now choose catheter ablation outright, rather than trying drugs first.” said Professor Kanagaratnam. “The findings also question the value of drug therapy, and whether catheter ablation should be the first line treatment for atrial fibrillation patients with symptoms.”

What’s age got to do with it?

:   It’s often said:  It’s not how old you are, it’s how old you feel.  New research shows that physiological age is a better predictor of survival than chronological age. The study is published today in the European Journal of Preventive Cardiology, a journal of the European Society of Cardiology (ESC).

“Age is one of the most reliable risk factors for death: the older you are, the greater your risk of dying,” said study author Dr Serge Harb, cardiologist at the Cleveland Clinic in the United States. “But we found that physiological health is an even better predictor. If you want to live longer then exercise more. It should improve your health and your length of life.”

Based on exercise stress testing performance, the researchers developed a formula to calculate how well people exercise – their “physiological age” – which they call A-BEST (Age Based on Exercise Stress Testing). The equation uses exercise capacity, how the heart responds to exercise (chronotropic competence), and how the heart rate recovers after exercise.

“Knowing your physiological age is good motivation to increase your exercise performance, which could translate into improved survival,” said Dr Harb. “Telling a 45-year-old that their physiological age is 55 should be a wake-up call that they are losing years of life by being unfit. On the other hand, a 65-year-old with an A-BEST of 50 is likely to live longer than their peers.”

The study included 126,356 patients referred to the Cleveland Clinic between 1991 and 2015 for their first exercise stress test, a common examination for diagnosing heart problems. It involves walking on a treadmill, which gets progressively more difficult. During the test, exercise capacity, heart rate response to exercise, and heart rate recovery are all routinely measured. The data were used to calculate A-BEST, taking into account gender and use of medications that affect heart rate.

The average age of study participants was 53.5 years and 59% were men. More than half of patients aged 50–60 years – 55% of men and 57% of women – were physiologically younger according to A-BEST. After an average follow-up of 8.7 years, 9,929 (8%) participants had died. As expected, the individual components of A-BEST were each associated with mortality.

Patients who died were ten years older than those who survived. But A-BEST was a significantly better predictor of survival than chronological age, even after adjusting for sex, smoking, body mass index, statin use, diabetes, hypertension, coronary artery disease, and end-stage kidney disease. This was true for the overall cohort and for both men and women when they were analysed separately.

Dr Harb said doctors could use A-BEST to report results of exercise testing to patients “Telling patients their estimated age based on exercise performance is a powerful estimate of longevity and easier to understand than providing results for the individual components of the examination.”

Dr Harb noted that this type of approach has shown merit in specific disease areas. For example, ESC guidelines advocate using “cardiovascular risk age” – based on risk factors including smoking, blood cholesterol and blood pressure – to communicate with patients.

Investigadores del Hospital Clínico de Valencia relacionan la proteína PD1 con el infarto de miocardio

Un equipo de científicos del Grupo de Investigación Traslacional en Cardiopatía Isquémica de INCLIVA y del Servicio de Cardiología del Hospital Clínico de Valencia han relacionado “por primera vez” la proteína PD1 con el infarto de miocardio, algo que ha sido publicado recientemente en la revista especializada International Journal of Cardiology.

En concreto, estos investigadores exponen de manera pionera que, en pacientes con infarto agudo de miocardio, “existe una desregulación de la proteína PD-1″, que es inmunomoduladora, ya que si está presente, el sistema inmune “no elimina las células tumorales malignas”. En este sentido, explican que los PD-1 “son receptores que se sitúan sobre la superficie de las células del sistema inmunitario impidiendo que combata las invasiones externas correctamente”.

Por ello, desde este equipo de estudio se informa de que, en la actualidad, ésta es “una prometedora diana terapéutica en distintas patologías como en el cáncer de colon y cáncer de piel”. Sin embargo, hasta el momento “no existían trabajos previos que mostraran participación alguna de PD-1 en enfermedades cardíacas”, declara la miembro de esta investigación, la doctora M. José Forteza, que sí reconoce que “está demostrado que en los infartos miocárdicos existe un proceso inflamatorio”.

A tenor de ello, afirma que se decidió “investigar si la PD-1, proteína relacionada con los procesos inflamatorios, también estaba presente en el infarto agudo de miocardio”. Así, tras examinar a 85 pacientes con infartos de miocardio del Hospital Clínico de la capital del Turia y a 30 pacientes de control cuyas pruebas médicas demostraron que no habían sufrido un infarto, se puso de relieve que durante las primeras horas del infarto “se produce un incremento muy brusco de la expresión de PD-1 en las células T”, sostiene.

Frontiers in CardioVascular Biology: 16 to 19 July, 2010, Berlin, Germany‏

Frontiers in Cardiovascular Biology (FCVB), the first scientific meeting ever organised by the Council on Basic Cardiovascular Science (CBCS) of the European Society of Cardiology (ESC), is being held in Berlin this month to provide a new European platform for the exchange of information about cardiovascular science. Professor Axel Pries, Chairman of FCVB 2010, said, “FCVB will be a comprehensive meeting looking at the cutting edge science to expose delegates to the full array of current thinking. It’s needed to maintain and develop the standards of cardiovascular science in Europe.

”FCVB, which will be held at the Anatomy Institute of Charité Universitätsmedizin, Berlin, will place particular emphasis on the needs of young cardiovascular scientists. “We want to help them explore the scientific landscape and find out where their particular interests lie. This is a make and break stage of their careers. If we can help set them on the right path they’ll be more likely to stay in cardiovascular science,” said Pries. FCVB, which is predicted to attract over 600 attendees, will feature 80 invited talks and over 400 abstracts. Three parallel scientific sessions will run, providing delegates with opportunities to hear the latest developments in their own fields, with time scheduled for the best abstracts to be presented both within the pre-arranged symposia and in two oral award sessions. Highlights include the opportunity to hear world class leaders in their fields deliver key note lectures, with E Marban (Los Angeles, US) talking about stem cells, GA FitzGerald (Philadelphia, US) about drugs, industry and academia, K Alitalo (Helsinki, FI) about the molecular regulation of angiogenesis and lymphangiogenesis, N Rajewsky (Berlin, DE) about post-transcriptional gene regulation by small RNAs and RNA binding proteins, and P Libby (Boston, US) about inflammation in atherosclerosis.

The translational component of the programme is designed to make the meeting of great interest also to clinicians. “Advances in cardiology are driven by good interactions between clinicians and basic scientists, with clinicians setting the questions that basic scientists then try to answer. Without their involvement we would be operating in an ivory tower,” said Pries.Commenting on the opportunities the meeting presents for networking, Professor Raffaele De Caterina, chairman of CBCS, said, “Bringing people together should create an explosive cocktail that will help find solutions for many of the challenges we are facing.”