Practice Update: Cardiology

ESC 2017 21

“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 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.

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.”

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).

PracticeUpdate Editorial Team

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

© ESC Congress 2017 – European Society of Cardiology

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

VOL. 2 • NO. 2 • 2017