Technology can spot patients earlier for symptoms beyond traditional heart risk factors

Washington -- Physicians can effectively use a range of technologies, including electrocardiograms and ankle-brachial blood pressure readings, to help determine which of their patients might be headed for a heart attack or stroke, even if they have only moderately elevated risk factors.

"Now we can identify older men and women who don't have any clinical disease or other risk factors and yet who are at very high risk," said the study's author Lewis Kuller, MD, DrPH, professor of public health at the University of Pittsburgh Graduate School of Public Health.

Dr. Kuller presented findings from the Cardiovascular Heart Study, a population-based longitudinal study of coronary heart disease and stroke in adults 65 and older, at the American Heart Assn.'s scientific sessions held in New Orleans in early November.

Dr. Kuller and colleagues found that early cardiovascular changes such as narrowing of the carotid arteries, electrocardiographic abnormalities and measures of carotid intima-media thickness were strong, independent risk factors for future heart attacks and strokes.

The researchers analyzed data for 2,454 patients with subclinical disease and 1,608 people who did not have early evidence of cardiovascular disease. They found that, 10 years later, those with early evidence of subclinical disease faced a substantially higher risk of cardiac events.

"Early interventions, perhaps with drugs to treat cholesterol and hypertension, as well as controlling diabetes and making modifications in exercise and diet, could perhaps help to reverse the process," Dr. Kuller said.

In an effort to fine-tune treatment, a separate study presented at the heart association meeting showed that patients who already receive state-of-the art therapy for heart disease do not always benefit from additional treatment with ACE inhibitors.

"Although ACE inhibitors have been proven to help patients with heart failure, until now it wasn't clear whether all patients with coronary heart disease benefit from this class of drugs," said National Heart, Lung, and Blood Institute Acting Director Barbara Alving, MD. "These results could significantly change clinical care of perhaps millions of Americans with heart disease."

The study showed that many patients whose heart muscle is in good shape and who are receiving intense treatment that includes revascularization and lipid-lowering drugs, get no extra protection from ACE inhibitors, said Eugene Braunwald, MD, who co-chaired the study.

The findings were from the Prevention of Events with Angiotensin Converting Enzyme Inhibition, or PEACE trial, and published in the Nov. 11 New England Journal of Medicine. The researchers studied nearly 8,300 participants who had normal or near normal left ventricular function.

Since the scientific basis for using ACE inhibitors to prevent the progression of vascular disease is strong, the findings of the study are surprising, wrote Bertram Pitt, MD, professor in the Dept. of Internal Medicine at the University of Michigan Health System, in an editorial that accompanied the study.

Dr. Pitt cautioned that it was premature to discard the use of ACE inhibitors for all patients who have vascular disease without left ventricular systolic dysfunction.

Among the additional findings from the conference:

• The addition of extended-release niacin to statin therapy slowed the progression of plaque buildup in the carotid arteries of individuals with known coronary heart disease and moderately low HDL cholesterol. Niacin is recognized as an effective treatment for raising HDL cholesterol but it was notoriously hard to prescribe accurately and carried the unpleasant side effect of flushing, causing it to lose favor as a treatment option when statins came on the scene, said study author Allen J. Taylor, MD, director of cardiovascular research at Walter Reed Army Medical Center in Washington, D.C. An extended-release niacin formula, called Niaspan and manufactured by Kos Pharmaceuticals, which also funded the study, helps reduce those problems, and could attract renewed interest in using the vitamin B-based prescription medication in combination with statins to refine lipid treatment that helps lower LDL cholesterol and raise HDL cholesterol, Dr. Taylor said. The study results were published online in the heart association's journal, Circulation.
• Atorvastatin, or Lipitor, slowed the mental decline in Alzheimer's disease and improved depressive symptoms in patients enrolled in a small pilot study. The Alzheimer's Disease Cholesterol-Lowering Treatment Trial was a double-blind, placebo-controlled study that evaluated 46 patients -- 25 on atorvastatin 80 mg, and 21 on placebo -- for one year. Two larger trials are under way and should provide more definitive results, said William Thies, PhD, vice president for clinical and scientific affairs at the Alzheimer's Assn.
• Daily doses of 400 IUs or more of vitamin E slightly increase an individual's risk of death, according to a study by researchers from Johns Hopkins University in Baltimore. There has been a clash of research findings in recent years, with some studies showing a benefit of high doses of vitamin E, including findings suggesting a decreased risk of Alzheimer's disease and others demonstrating no benefit. Researchers in this study examined death rates in published trials comparing vitamin E supplements to placebo and found that high-dose supplements caused more harm than good. They also concluded there was no increased risk from doses of 200 IUs per day or less and there may even be some benefit. The study was published on the Web site of the Annals of Internal Medicine.