Practice Update: Cardiology

CONFERENCE COVERAGE 20

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.

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.

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

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

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 and stroke. Cardioversion—restoring and maintaining the heart’s normal rhythm—is an integral part of management, as are anti- coagulants, to prevent strokes.

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

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

PRACTICEUPDATE CARDIOLOGY