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ESC 2017: Two Results of the PURE StudyMay Be Game
Changers in Heart Disease Prevention
Global dietary guidelines on fat intake and recommendations for high intake of fats, vegetables, and legumes to reduce
cardiovascular risk and mortality need to be revisited. This conclusion, based on results of the Prospective Urban-Rural
Epidemiology (PURE) study of 135,335 individuals age 35 to 70 years, from countries in North America, Europe, South
America, the Middle East, South Asia, China, Southeast Asia, and Africa, was presented at the 2017 European Society of
Cardiology (ESC) Congress, from August 26–30.
ESC 2017: Apixaban Lowers Stroke Risk in Patients Undergoing
Cardioversion for Atrial Fibrillation – EMANATE Trial
Apixaban has been shown to lower the risk of stroke vs warfarin in
anticoagulation-naïve patients with atrial fibrillation scheduled for elective
cardioversion. Rates of bleeding were similar between the two groups.
T
his conclusion, based on results of
the multicenter, prospective, rand-
omized, open-label Eliquis evaluated
in acute cardioversion coMpared to usuAl
treatmeNts for AnTicoagulation in subjects
with NVAF (EMANATE) trial, was presented
at the 2017 European Society of Cardiol-
ogy (ESC) Congress, from August 26–30.
Michael D. Ezekowitz, MD, PhD, of the Sid-
ney Kimmel Medical College at Thomas
Jefferson University, Philadelphia, Pennsyl-
vania, explained that atrial fibrillation is the
most common heart rhythm disorder and
is associated with increased risks of death
and stroke. Cardioversion—restoring and
maintaining the heart’s normal rhythm—is
an integral part of management, as are anti-
coagulants, to prevent strokes.
Apixaban blocks the action of the clotting
factor Xa and like other blood thinners, low-
ers the chance of blood clots forming. Other
blood thinners include heparin and warfa-
rin. While blood thinners prevent clotting
and decrease the chance of having a stroke,
they also increase the risk of bleeding.
Patients scheduled for cardioversion for
atrial fibrillation have traditionally received
heparin and/or warfarin to reduce their risk
of stroke. Post hoc analyses of cardiover-
sion in the RE-LY, ARISTOTLE, ROCKET-AF,
and ENGAGE-AF trials found low event
rates. These trials were limited, however,
by prolonged periods of precardioversion
anticoagulation.
To evaluate more immediate cardioversion,
prospective trials comparing rivaroxaban
(x-VeRT) and edoxaban (ENSURE-AF) vs
heparin/vitamin K antagonism in patients
undergoing cardioversion found compara-
ble efficacy and safety with low event rates.
Apixaban has not been tested prospec-
tively in patients undergoing cardioversion.
The purpose of EMANATE was to com-
pare rates of stroke and bleeding with
M
ahshid Dehghan, PhD, and Andrew Mente,
PhD, of the Population Health Research Insti-
tute, McMaster University, Hamilton, Ontario,
Canada, reported on this study of 135,535 individuals,
age 35–70 years, from 18 low-, middle-, and high-in-
come countries.
Dr. Dehghan said that data from the study showed that
high carbohydrate intake is linked to worse total mor-
tality and noncardiovascular mortality outcomes, while
high fat intake is associated with lower risk.
“Limiting total fat consumption is unlikely to improve
health in populations, and a total fat intake of approx-
imately 35% of energy with concomitant lowering of
carbohydrate intake may lower risk of total mortality,”
Dr. Dehghan said. “In fact, individuals with high carbo-
hydrate intake, above 60% of energy, may benefit from
a reduction in carbohydrate intake and an increase in
the consumption of fats.”
Consumption of carbohydrate, total fat, and types of
fat were recorded using country-specific, validated
food frequency questionnaires, and associations with
cardiovascular disease and mortality were assessed.
Among 5796 deaths and 4784 major cardiovascular
events over a median follow-up of 7.4 years, carbo-
hydrate intake in the highest vs lowest quintile was
associated with a significant, 28% increased risk of
total mortality (hazard ratio 1.28; 95% confidence inter-
val 1.12–1.46, highest vs lowest quintile category, P ≤
.0001) but not cardiovascular risk.
Conversely, total fat intake in the highest vs lowest
quartile was associated with a significant, 23% reduc-
tion of total mortality risk, an 18% reduced risk of stroke,
and a 30% reduced risk of noncardiovascular mortality.
Each type of fat was associated with significantly
reduced mortality risk: 14% lower for saturated fat, 19%
for monounsaturated fat, and 20% for polyunsaturated
fat. Higher saturated fat intake was also associated with
a 21% decrease in stroke risk.
Dr. Dehghan and colleagues also examined the impact
of fats and carbohydrates on blood lipids.
Consistent with other reports from Western countries,
they found that while LDL increases with higher intakes
of saturated fat, HDL also increases. So the net effect
is a decrease in the total cholesterol/HDL ratio.
They found that LDL cholesterol (the basis of many die-
tary guidelines) is not reliable in predicting effects of
saturated fat on future cardiovascular events. Instead,
ApoB/ApoA1 provides the best overall indication of
effect of saturated fat on cardiovascular risk.
“Focusing on a single lipid marker such as LDL cho-
lesterol alone does not capture the net clinical impact
of nutrients on cardiovascular risk,” Dr. Dehghan said.
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