The American Heart Association’s Scientific Sessions 2017, which took place this year from November 11-15th in Anaheim, California, is a premier global exchange of the latest advances in cardiovascular science for researchers and clinicians. Included here is a compilation of some of the highlights from the meeting.
High Blood Pressure Redefined for First Time in 14 Years: 130 is the New High
High blood pressure should be treated earlier with lifestyle changes and, in some patients, with medication — at 130/80 mmHg rather than 140/90 — according to the first comprehensive new high blood pressure guidelines in more than a decade. The guidelines were published by the American Heart Association (AHA) and the American College of Cardiology (ACC) for detection, prevention, management, and treatment of high blood pressure. The guidelines were presented at the AHA’s 2017 Scientific Sessions conference.
Rather than 1 in 3 U.S. adults having high blood pressure (32 percent) with the previous definition, the new guidelines will result in nearly half of the U.S. adult population (46 percent) having high blood pressure, or hypertension. However, there will only be a small increase in the number of U.S. adults who will require antihypertensive medication, authors said. These guidelines, the first update to offer comprehensive guidance to doctors on managing adults with high blood pressure since 2003, are designed to help people address the potentially deadly condition much earlier.
The new guidelines stress the importance of using proper technique to measure blood pressure. Blood pressure levels should be based on an average of two to three readings on at least two different occasions, the authors said.
High blood pressure accounts for the second largest number of preventable heart disease and stroke deaths, second only to smoking. It’s known as the “silent killer” because often there are no symptoms, despite its role in significantly increasing the risk for heart disease and stroke.
Paul K. Whelton, MB, MD, MSc, lead author of the guidelines published in the American Heart Association journal Hypertension and the Journal of the American College of Cardiology, noted the dangers of blood pressure levels between 130-139/80-89 mmHg.
“You’ve already doubled your risk of cardiovascular complications compared to those with a normal level of blood pressure,” he said. “We want to be straight with people — if you already have a doubling of risk, you need to know about it. It doesn’t mean you need medication, but it’s a yellow light that you need to be lowering your blood pressure, mainly with non-drug approaches.”
Blood pressure categories in the new guideline are:
- Normal: Less than 120/80 mmHg;
- Elevated: Top number (systolic) between 120-129 and bottom number (diastolic) less than 80;
- Stage 1: Systolic between 130-139 or diastolic between 80-89;
- Stage 2: Systolic at least 140 or diastolic at least 90 mmHg;
- Hypertensive crisis: Top number over 180 and/or bottom number over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.
The new guidelines eliminate the category of prehypertension, which was used for blood pressures with a top number (systolic) between 120-139 mmHg or a bottom number (diastolic) between 80-89 mmHg. People with those readings now will be categorized as having either Elevated (120-129 and less than 80) or Stage I hypertension (130-139 or 80-89).
Previous guidelines classified 140/90 mmHg as Stage 1 hypertension. This level is classified as Stage 2 hypertension under the new guidelines.
The impact of the new guidelines is expected to be greatest among younger people. The prevalence of high blood pressure is expected to triple among men under age 45, and double among women under 45 according to the report.
Damage to blood vessels begins soon after blood pressure is elevated, said Whelton, who is the Show Chwan professor of global public health at Tulane University School of Public Health and Tropical Medicine and School of Medicine in New Orleans. “If you’re only going to focus on events, that ignores the process when it’s beginning. Risk is already going up as you get into your 40s.”
The guidelines stress the importance of home blood pressure monitoring using validated devices and appropriate training of healthcare providers to reveal “white-coat hypertension,” which occurs when pressure is elevated in a medical setting but not in everyday life. Home readings can also identify “masked hypertension,” when pressure is normal in a medical setting but elevated at home, thus necessitating treatment with lifestyle and possibly medications.
“People with white-coat hypertension do not seem to have the same elevation in risk as someone with true sustained high blood pressure,” Whelton said. “Masked hypertension is more sinister and very important to recognize because these people seem to have a similar risk as those with sustained high blood pressure.”
Other changes in the new guideline include:
- Only prescribing medication for Stage I hypertension if a patient has already had a cardiovascular event such as a heart attack or stroke, or is at high risk of heart attack or stroke based on age, the presence of diabetes mellitus, chronic kidney disease, or calculation of atherosclerotic risk (using the same risk calculator used in evaluating high cholesterol).
- Recognizing that many people will need two or more types of medications to control their blood pressure, and that people may take their pills more consistently if multiple medications are combined into a single pill.
- Identifying socioeconomic status and psychosocial stress as risk factors for high blood pressure that should be considered in a patient’s plan of care.
The new guidelines were developed by the American Heart Association, American College of Cardiology, and nine other health professional organizations. They were written by a panel of 21 scientists and health experts who reviewed more than 900 published studies. The guidelines underwent a careful systematic review and approval process. Each recommendation is classified by the strength (class) of the recommendation followed by the level of evidence supporting the recommendation. Recommendations are classified I or II, with class III indicating no benefit or harm. The level of evidence signifies the quality of evidence. Levels A, B, and C-LD denote evidence gathered from scientific studies, while level C-EO contains evidence from expert opinion.
The new guidelines are the successor to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC7), issued in 2003 and overseen by the National Heart, Lung, and Blood Institute (NHLBI). In 2013, the NHLBI asked the AHA and ACC to continue the management of guideline preparation for hypertension and other cardiovascular risk factors.
Co-authors are Robert M. Carey, MD, vice chair of the writing committee; Wilbert S. Aranow, MD; Donald E. Casey, Jr., MD, MPH, MBA; Karen J. Collins, MBA; Cheryl Dennison Himmelfarb, RN, ANP, PhD; Sondra M. DePalma, MHS, PA-C, CLS; Samuel Gidding, MD; Kenneth A. Jamerson, MD; Daniel W. Jones, MD; Eric J. MacLaughlin, PharmD; Paul Muntner, PhD; Bruce Ovbiagele, MD, MSc, MAS; Sidney C. Smith, Jr., MD; Crystal C. Spencer, JD; Randall S. Stafford, MD, PhD; Sandra J. Taler, MD; Randal J. Thomas, MD, MS; Kim A. Williams, Sr., MD; Jeff D. Williamson, MD, MHS; and Jackson T. Wright, Jr., MD, PhD, on behalf of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Author disclosures and collaborating organization partners are listed online and in the appendix to the manuscript.
The American Heart Association/American Stroke Association receives funding mostly from individuals. Foundations and corporations donate as well, and fund specific programs and events. Strict policies are enforced to prevent these relationships from influencing the association’s science content. Financial information for the American Heart Association, including a list of contributions from pharmaceutical and device manufacturers and health insurance providers are available at www.heart.org/corporatefunding.
About the American Heart Association
The American Heart Association, the world’s leading voluntary health organization devoted to fighting cardiovascular disease, is devoted to saving people from heart disease and stroke — the two leading causes of death in the world. We team with millions of volunteers to fund innovative research, fight for stronger public health policies, and provide lifesaving tools and information to prevent and treat these diseases. The Dallas-based association is the nation’s oldest and largest voluntary organization dedicated to fighting heart disease and stroke. To learn more or to get involved, visit heart.org.
About the American College of Cardiology
The American College of Cardiology is the professional home for the entire cardiovascular care team. The mission of the College and its more than 52,000 members is to transform cardiovascular care and to improve heart health. The ACC leads in the formation of health policy, standards, and guidelines. The College operates national registries to measure and improve care, offers cardiovascular accreditation to hospitals and institutions, provides professional medical education, disseminates cardiovascular research, and bestows credentials upon cardiovascular specialists who meet stringent qualifications. For more information, visit acc.org.
Catastrophic Costs for Hospitalization Expenses Common Among Uninsured Heart and Stroke Patients
The majority of patients without health insurance who were hospitalized for heart attack, stroke, or coronary artery bypass graft (CABG) surgery experienced catastrophic healthcare expenses before passage of the Affordable Care Act, according to preliminary research presented at the American Heart Association’s Scientific Sessions 2017.
Using data from the National Inpatient Sample, the largest publicly available all-payer inpatient healthcare database in the United States, research reported in presentation 293 found that 15 percent of all heart attack and stroke patients were uninsured during the study period 2008-2012. Using the same data set, research reported in poster presentation T5082 found that 9 percent of patients who underwent CABG were uninsured during the study period 2008-2012. The researchers, who collaborated on the studies, found that among this group of uninsured people, hospital bills exceeded the threshold for a catastrophic health expenses for:
- 85 percent of heart attack patients;
- 75 percent of stroke patients; and
- 83 percent of CABG patients.
During the years of the study, the median hospitalization charges for heart attacks were $53,384; strokes were $31,218. The cost for coronary artery bypass surgeries ranged from $85,891-$177,546.
Catastrophic health expenditures were defined as hospitalization expenses that exceeded 40 percent of annual income after eliminating the cost of food. For many, these medical costs make it difficult to pay for housing, transportation, and other essential expenses. Annual patient income was determined using data from the U.S. Census, and food costs were estimated from the U.S. Bureau of Labor Statistics.
“Medical bankruptcy is the leading cause of bankruptcy in the United States,” said Rohan Khera, MD, first author of the study that examined hospitalization expenses of heart attack and stroke patients and a cardiology fellow at the University of Texas Southwestern Medical Center in Dallas, Texas. “Until there is universal insurance coverage, a catastrophic health experience is very likely to turn into a catastrophic financial experience as well.”
Heart attacks, strokes, and CABG are major, unanticipated healthcare events that require immediate and often costly treatment. The financial burden of heart disease treatment is well documented for patients with health insurance, but little is known about the financial implications for uninsured patients who need care.
“Catastrophic health expenses are an important factor for physicians to consider, and should be thought of as an adverse effect when hospitalization is required for uninsured patients in the United States,” said Jonathan C. Hong, MD, first author of the study that analyzed hospitalization expenses for CABG and a cardiac surgery resident at the University of British Columbia in Vancouver, Canada.
“The majority of uninsured patients undergoing CABG will experience significant financial hardships that are often unexpected and difficult to plan for,” Hong said. “Health policy that expands insurance coverage can help mitigate the economic burden for this lifesaving procedure among this patient population.”
“Although there is still a substantial number of people who are uninsured, the Affordable Care Act increased the number of people who do have insurance. Therefore, the number of people at risk for catastrophic healthcare expenses may have declined. The law also improves the ability to get insurance for people with medical illnesses given its protections for patients with pre-existing conditions,” said Khera.
Co-authors of the heart attack and stroke study are Dr. Hong, Anshul Saxena, PhD, MPH, Alejandro Arrieta, PhD, Salim S. Virani, PhD, Ron Blankstein, MD, James A. de Lemos, MD, Harlan M. Krumholz, MD, and Khurram Nasir, MD.
Co-authors of the CABG study are Dr. Khera, Anshul Saxena, PhD, MPH, Alejandro Arrieta, PhD, Salim S. Virani, PhD, Ron Blankstein, MD, Glenn J.R. Whitman, MD, Harlan M. Krumholz, MD, and Khurram Nasir, MD. Author disclosures are on the abstracts.
The National Heart, Lung, and Blood Institute and the National Center for Advancing Translational Sciences funded the heart attack and stroke study.
Men More Likely to Receive Bystander CPR in Public than Women
Men are more likely to receive bystander CPR in public locations compared to women, and they are more likely to survive after the lifesaving measure, according to preliminary research presented at the American Heart Association’s Scientific Sessions 2017.
Using data from the Resuscitation Outcomes Consortium, a network of regional clinical centers in the United States and Canada studying out-of-hospital treatments of cardiac arrest and trauma, researchers analyzed 19,331 cardiac events in the home and in public. They found:
- Overall, bystanders administered CPR in 37 percent of cardiac events in varied locations.
- 35 percent of women and 36 percent of men received CPR in the home, showing no significant difference in the likelihood of one gender getting assistance over the other in this setting.
- In public settings, 45 percent of men got assistance compared to 39 percent of women.
- Men were 1.23 times more likely to receive bystander CPR in public settings, and they had 23 percent increased odds of survival compared to women.
“CPR involves pushing on the chest so that could make people less certain whether they can or should do CPR in public on women,” said Audrey Blewer, MPH, the study’s first author and assistant director for educational programs at the Center for Resuscitation Science at the University of Pennsylvania in Philadelphia.
These findings identify a gap in bystander CPR delivery that can help improve future messaging and training to lay responders, health care providers, and dispatchers.
“We’re only beginning to understand how to deliver CPR in public, although it’s been around for 50 years,” said Benjamin Abella, MD, MPhil, the study’s senior author and director of Penn’s Center for Resuscitation Science. “Our work highlights the fact that there’s still so much to learn about who learns CPR, who delivers CPR, and how best to train people to respond to emergencies.”
The American Heart Association and the National Institutes of Health funded the study.
According to the American Heart Association, over 350,000 cardiac arrests occur outside of the hospital each year. CPR, especially if administered immediately after cardiac arrest, can double or triple a person’s chance of survival. About 90 percent of people who experience an out-of-hospital cardiac arrest die.
Sudden Cardiac Death Rates May Be Seven Times Higher Among Young People with Diabetes
Children and young adults with diabetes may be seven times more likely to die from sudden cardiac death compared to children and young adults without diabetes, according to preliminary research from Denmark presented at the American Heart Association’s Scientific Sessions 2017.
The study, which was conducted in Denmark, also found that overall, compared to those without diabetes, children and young adults, ages 1-49, with diabetes were eight times more likely to die from any kind of heart disease, such as heart failure or the chronic narrowing of arteries known as atherosclerosis, compared to children and young adults without diabetes.
Young people with diabetes may be at increased risk for sudden cardiac death because of abnormalities in their blood vessels caused by the disease.
“Although we have become better at helping people manage both Type 1 and Type 2 diabetes, it is still associated with increased risk of death, especially among young people,” said Jesper Svane, BM, a research student at Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
Cardiovascular diseases are a common complication of diabetes and the leading cause of death among people with diabetes. Previous studies have demonstrated that intensive management of risk factors had significant beneficial effects on cardiovascular-related death in persons with diabetes. Therefore, it is of importance to monitor people with diabetes in order to identify those at high risk of cardiovascular death.
The study is one of the first to examine causes of death and cause-specific death rates among children and young adults with diabetes in a nationwide setting.
Svane said that because the Danish study population was 89 percent Caucasian, the findings may not be applicable to other western countries, due to differences in demographics and in the organization of the healthcare systems of Denmark and the United States. Other studies have shown that death patterns, especially regarding sudden cardiac death, are heavily influenced by ethnicity, so the findings cannot directly be extended to other countries with more ethnically diverse populations.
The study population consisted of all persons in Denmark age 1 to 35 in 2000-2009 and age 36 to 49 in 2007-2009. During the 10-year study period, 14,294 deaths occurred, and cause of death was established based on information from death certificates and autopsy reports. The Danish Register of Medicinal Product Statistics, which holds information on all prescriptions dispensed from Danish pharmacies, was used to identify persons with either Type 1 or Type 2 diabetes. Among those who died, 669 (5 percent) had diabetes, of which 471 (70 percent) had Type 1 and 198 (30 percent) had Type 2.
“In light of the results from this study, tight control and effective treatment of blood lipids, blood pressure, and blood glucose is also important among children and young persons with diabetes,” said Svane.
“Our study shows the importance of early and continuous cardiovascular risk monitoring in children and young adults with diabetes,” Svane said. “Healthcare providers need to be aware that even young patients with diabetes have elevated risk of mortality and that this is mainly explained by increased risk of sudden cardiac death.”
Co-authors are Thomas H. Lynge, MD, Ulrik Pedersen-Bjergaard, MD, Thomas Jespersen, PhD, DMedSci, Gunnar H. Gislason, MD, PhD, Bjarke Risgaard, MD, PhD, Bo G. Winkel, MD, PhD, and Jacob Tfelt-Hansen, MD, DMedSci. Author disclosures are on the abstract.
Plant-Based Diet Associated with Less Heart Failure Risk
Eating a mostly plant-based diet was associated with less risk of developing heart failure among people without previously diagnosed heart disease or heart failure, according to preliminary research presented at the American Heart Association’s Scientific Sessions 2017.
The study looked at five different dietary patterns and, according to the author, found that people who ate a plant-based diet most of the time had a 42 percent decreased risk of developing heart failure over the four years of the study, compared to people who ate fewer plant-based foods. Other dietary patterns, described as convenience, sweets, Southern or alcohol/salads style were not associated with a decreased risk for heart failure. Heart failure affects about 6.5 million adults over age 20 in the United States.
Previous studies have shown that what people eat can play an important role in increasing or decreasing the risk of atherosclerosis. This study focuses specifically on whether diet can influence the development of heart failure among people with no diagnosed heart disease.
“Eating a diet mostly of dark green leafy plants, fruits, beans, whole grains and fish, while limiting processed meats, saturated fats, trans fats, refined carbohydrates, and foods high in added sugars is a heart-healthy lifestyle and may specifically help prevent heart failure if you don’t already have it,” said Kyla Lara, MD, first author of the study and an internal medicine resident at Icahn School of Medicine at Mount Sinai Hospital in New York, New York.
The researchers used data collected for the Reasons for Geographic and Racial Differences in Stroke (REGARDS), a nationwide observational study of risk factors for stroke in adults 45 years or older sponsored by the National Institutes of Health. The participants, who were recruited from 2003 to 2007 and followed through 2013, included 15,569 patients without known coronary artery disease or heart failure. Incidents of heart failure within this group were confirmed by health care providers. Over the nearly 3000 days of follow-up, 300 instances of hospitalizations for incident heart failure were reported.
Participants in the REGARDS study reported their diets using a food frequency questionnaire, a standard method for classifying diets that uses statistical modeling to assign a person’s diet to one of five dietary patterns:
- Convenience (red meats, pastas, fried potatoes, fast foods);
- Plant-based (dark, leafy vegetables, fruits, beans, fish);
- Sweets (desserts, breads, sweet breakfast foods, chocolate, candy);
- Southern (eggs, fried food, organ meats, processed meats, sugar-sweetened beverages)
- Alcohol/Salads (salad dressings, green, leafy vegetables, tomatoes, wine, butter, liquor).
The researchers found that of the five dietary patterns, greater adherence to the plant-based diet had the strongest association with a decreased risk of incident heart failure when adjusted for age, sex, and race of the participants and for other risk factors. No associations for the other four dietary patterns were found.
The study was observational, which means it can identify a trend or association, but cannot prove cause and effect.
The American Heart Association recommends a dietary pattern that includes a variety of fruits and vegetables, whole grains, low-fat dairy products, poultry, fish, beans, non-tropical vegetable oils, and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats.
Co-authors are Emily B. Levitan, ScD, Orlando M. Gutierrez, MD, James M. Shikany, Dr PH, Monika M. Safford, MD, Suzanne E. Judd, PhD, and Robert S. Rosenson, MD. Author disclosures are on the abstract.
Driving a Tesla May Not Trip Your Defibrillator
Sitting in, or standing close to the charging port of a Tesla electric vehicle didn’t trigger a shock or interfere with implantable defibrillator performance, according to preliminary research presented at the American Heart Association’s Scientific Sessions 2017.
Researchers examined the potential effect of electromagnetic interference while charging an electric vehicle battery at 220 Volts. The study included 26 men and 8 women from Good Samaritan Hospital in Dayton, Ohio, average age 69, with implanted cardiac defibrillators of various types.
Adjusting the defibrillators to both their least and most sensitive settings, the devices did not sense the electromagnetic signal from the electric vehicle battery when patients sat in the driver’s seat, passenger seat, backseat or at the charging post (where the electromagnetic interference is at its highest).
These findings suggest that electric vehicles may be safe to use for individuals with cardiac defibrillators, according to the principal investigator, Abdul Wase, MD and his team.
Statements and conclusions of study authors that are presented at American Heart Association scientific meetings are solely those of the study authors and do not necessarily reflect association policy or position. The association makes no representation or warranty as to their accuracy or reliability. The association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific association programs and events. The association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and device corporations are available at www.heart.org/corporatefunding.
About the American Heart Association
The American Heart Association is devoted to saving people from heart disease and stroke – the two leading causes of death in the world. We team with millions of volunteers to fund innovative research, fight for stronger public health policies and provide lifesaving tools and information to prevent and treat these diseases. The Dallas-based association is the nation’s oldest and largest voluntary organization dedicated to fighting heart disease and stroke. To learn more or to get involved, visit heart.org.
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