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“For decades, dietary guidelines have
focused on reducing total fat and saturated
fatty acid intake based on the presump-
tion that replacing saturated fatty acids
with carbohydrate and unsaturated fats will
lower LDL cholesterol and should therefore
reduce cardiovascular events,” she added.
She noted that much of the evidence
supporting this approach has been from
studies of Western populations character-
ized by nutritional excess.
Dr. Dehghan concluded, “PURE provided a
unique opportunity to study the impact of
diet on total mortality and cardiovascular
disease in diverse settings, some in which
overnutrition is common and others where
undernutrition is of greater concern.”
Results of PURE also showed that even rel-
atively moderate intake of fruit, vegetables,
and legumes, such as beans and lentils,
may lower risk of cardiovascular disease
and death.
“To our knowledge, this was the first
study to report on the associations of fruit,
vegetable, and legume intake with cardio-
vascular disease risk in countries at varying
economic levels and from different regions.
Previous research, and many dietary
guidelines in North America and Europe,
recommended daily intake of these foods
ranging from 400 to 800 g per day, but this
is unaffordable for many people in low- to
middle-income countries,” Dr. Mente said.
Dr. Mente and colleagues assessed asso-
ciations between fruit, vegetable, and
legume consumption at baseline and risk
of cardiovascular disease and mortality
after a median of 7.4 years of follow-up.
Looking at dietary components sepa-
rately, benefits were attributable to fruit and
legumes, with vegetable intake not signifi-
cantly associated with improved outcomes.
Specifically, compared with fewer than
three servings of fruit per week, more than
three daily was associated with an
18% reduced risk in noncardiovas-
cular mortality (hazard ratio 0.82:
95% confidence interval 0.70–0.97;
P = .0008), and 19% reduction in
total mortality (hazard ratio 0.81;
95% confidence interval 0.72–0.93;
P < .0001).
Regarding legumes, higher con-
sumption was associated with
significant reduction in both non-
cardiovascular mortality and total
mortality risk.
Finally, comparing vegetable
preparation, the study showed a
trend toward lower risk of cardio-
vascular disease and death with
raw vs cooked vegetable intake
“but raw vegetables are rarely
eaten in South Asia, Africa, and
Southeast Asia,” said Dr. Mente.
“Since dietary guidelines do not
differentiate between the benefits
of raw vs cooked vegetables, our
results indicated that recommenda-
tions should emphasize raw over
cooked vegetables.”
Dr. Mente concluded that the
findings “were robust, globally
applicable, and provided evidence
to inform nutrition policies. Many peo-
ple worldwide don’t consume an optimal
amount of fruit, vegetables, and legumes.
The PURE data added to substantial evi-
dence from many studies and extended
them globally.”
PracticeUpdate Editorial Team
apixaban vs warfarin with heparin in anti-
coagulation-naïve (<48 h of anticoagulation
therapy) patients scheduled for elective
cardioversion of predominantly new-on-
set non-valvular atrial fibrillation.
The study included 1500 patients with atrial
fibrillation who were randomized to apix-
aban or parenteral heparin with warfarin.
Apixaban was administered orally at a dose
of 5 mg twice a day (or 2.5 mg twice a
day when two of the following conditions
were met: age ≥80 years, weight ≤60 kg,
or serum creatinine ≥1.5 mg/dL).
At the discretion of the local investigator,
patients could also receive an initial 10 mg
or 5 mg loading dose of apixaban (for study
doses of 5 mg and 2.5 mg, respectively) if
cardioversion was immediate.
Rates of stroke, systemic embolism, death,
major bleeding, and clinically relevant non-
major bleeding were compared between
the two groups.
Patients treated with apixaban suffered
fewer strokes and similar bleeding to those
receiving usual care. No strokes occurred
in the 753 patients treated with apixaban vs
six strokes in the 747 patients who received
usual care (P = .01). No systemic embolic
events occurred in either group.
Major bleeds occurred in three and six
patients in the apixaban and usual care
groups, respectively. Clinically significant
nonmajor bleeding occurred in 11 and 13
patients, respectively. Two deaths occurred
in the apixaban group and one in the hep-
arin/warfarin group.
Of 753 patients in the apixaban group,
342 received a loading dose. No strokes
or systemic embolic events, one death,
one major bleed, and four clinically rel-
evant nonmajor bleeds occurred in this
subgroup.
The researchers noted that like the
other prospective cardioversion studies,
EMANATE was underpowered. However,
they concluded that their findings “support
the use of apixaban in patients with AFib
undergoing cardioversion.”
Jens Cosedis Nielsen, MD, PhD, of Aarhus
University, Aarhus, Denmark commented,
“EMANATE should be considered an
exploratory, not a conclusive trial. Conduct-
ing a 50,000-patient randomized clinical
trial to conclude noninferiority or superior-
ity of one oral anticoagulant is unrealistic.”
He added, “Randomized trials compar-
ing novel oral anticoagulants vs vitamin K
antagonists provide us with important data
on outcomes around direct current cardio-
version for both treatment regimens. I think
EMANATE was well conducted, and rand-
omized trials are the best instrument we
have to compare treatments.”
PracticeUpdate Editorial Team
© ESC Congress 2017 – European Society of Cardiology
ESC 2017
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VOL. 2 • NO. 2 • 2017