News in brief from the world of cardiology
Approval for new heart failure treatment
A breakthrough drug for the treatment of chronic heart failure is now available in the UK. The new drug sacubitril/valsartan (Entresto®, Novartis) has been approved for the treatment of adults with symptomatic heart failure with reduced left ventricular ejection fraction (HFREF).
Sacubitril/valsartan – the first drug in the angiotensin receptor neprilysin inhibitor (ARNI) class of drugs – was found to be superior to an evidence-based dose of the angiotensin-converting enzyme (ACE) inhibitor, enalapril, in the PARADIGM-HF study, the largest heart failure study conducted to date.
PARADIGM-HF (Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure trial), which involved 8,442 patients with HFREF, was stopped early due to a clear benefit of sacubitril/valsartan over enalapril. It significantly reduced the risk of cardiovascular death and first hospitalisation for heart failure by 20% when compared to enalapril (absolute risk reduction: 4.7%). Analysis of safety data showed that sacubitril/valsartan had a similar tolerability profile to enalapril.
The availability of sacubitril/valsartan may change the way heart failure patients are treated. Outlook for many patients with heart failure remains poor with current treatments. Heart failure costs the NHS about £2.3 billion a year, accounts for one million in-patient bed days and 5% of all emergency and medical admissions to UK hospitals; hospital admissions are projected to rise by 50% over the next 25 years, largely as a result of an ageing population.
New guidelines for managing blood pressure before surgery
The Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the British Hypertension Society (BHS) have released the first-ever National Guidelines for managing patients with high blood pressure before surgery. Published in the journal Anaesthesia, the guideline aims to reduce unnecessary cancellations for surgery because of a patient’s blood pressure.
Dr Terry McCormack, General Practitioner and co-Chair of the Guidelines Working Party, states: “This is the first time that there has been a collaboration between hypertension specialists, anaesthetists and general practitioners to produce a clear set of guidelines as to how we manage blood pressure before elective anaesthesia”. Dr Mike Durkin, National Director of Patient Safety, NHS England, added: “We welcome the intention of these new National Guidelines to improve patient safety through the collaborative work of primary and secondary healthcare”.
Cancellations and postponements of planned surgery are a major, long-standing problem for NHS – nearly 1% of planned operations are cancelled at the last minute. The quantifiable loss of resource is pitted against unquantifiable and significant psychological, social and financial implications of postponement for patients and their families. Some cancellations are unavoidable, but this Guideline will go a long way towards reducing cancellations overall, by ensuring that surgery is only cancelled because of the patient’s blood pressure when the evidence supports this.
The guidelines can be accessed at:
BHF calls for national rollout of genetic testing for FH
As many as 250,000 people in the UK may be living with the inherited gene which causes familial hypercholesterolaemia (FH). Now the British Heart Foundation (BHF) is calling on health services across the country to urgently rollout a nationwide cascade testing programme.
Only around 20,000 people are thought to be receiving full treatment in lipid clinics. On average, FH can shorten life expectancy by 20 to 30 years if left untreated.
Despite recommendations by the National Institute for Health and Care Excellence (NICE) that NHS Trusts and health boards roll out cascade testing for FH for families across the UK, setting up of FH services has been slow in England and Scotland.
To start tackling the problem, the BHF have funded 25 FH nursing posts across 13 different locations to make sure millions of people have access to testing. Since these posts have been set up over the past two years, 974 people have been tested and 374 people (38% of those tested) have been shown to have FH, ensuring they get the treatment they need. The charity believes that the slow response by health services is putting thousands of people across the UK at an unnecessary risk of heart attacks early in life.
New BJC editorial board member
Dr Aynsley Cowie, Scientific Officer for the British Association for Cardiac Prevention and Rehabilitation (BACPR), has joined the BJC editorial board.
Aynsley has worked as cardiac rehabilitation physiotherapist within NHS Ayrshire and Arran for 11 years. In 2011, she completed a PhD examining effects of home- versus hospital-based exercise training in chronic heart failure. Aynsley has recently started in a new post as consultant physiotherapist in cardiology. One of her first tasks is to lead on a Scottish Government funded project to develop a patient-reported outcome measure (PROM) for cardiology
Wide differences in UK prescribing rates for NOACs
Stark differences in access to new medicines such as non-vitamin K oral anticoagulant (NOACs) to reduce the risk of strokes in people atrial fibrillation (AF) are revealed today in a new report from the Atrial Fibrillation Association.
The chance of receiving the newer treatments varies 16-fold across England, the report says. In one part of England 69% of patients receive the newer treatments compared to just 4% in another part of the country.
The report, In pursuit of excellence in the prevention of AF-related stroke, which was supported by an unrestricted educational grant from Daiichi Sankyo UK, points out that more than half (56%) of Clinical Commissioning Groups (CCGs) are at or below the national average in England for NOAC use of 16.5% compared to warfarin. Within this 56%, 53 CCGs (25%) have NOAC prescribing rates of 10% or less.
Just seven CCGs have reached or exceeded the recommended level of 35% NOAC use as set out by the National Institute for Health and Care Excellence (NICE) in June 2014.
Trudie Lobban, Founder of the AF Association, said: “This variation is completely unacceptable. It makes a mockery of the concept of a National Health Service that patients with the same condition living just miles apart receive such dramatically different rates of the newer therapies”.
Dabigatran reversal agent available
Idarucizumab (Praxbind®, Boehringer Ingelheim), a reversal agent specifically designed for the non-vitamin K oral anticoagulant (NOAC), dabigatran etexilate (Pradaxa®, Boehringer Ingelheim), has been approved for use in adult patients when rapid reversal of the anticoagulant effect is required for emergency surgery/urgent procedures and in life-threatening or uncontrolled bleeding. Dabigatran is the first NOAC to have a specific reversal agent – idarucizumab specifically binds to dabigatran molecules only, neutralising their effect without interfering with the coagulation cascade.
Eating eggs does not increase risk of heart attack
A new study from the University of Eastern Finland shows that a relatively high intake of dietary cholesterol, or eating one egg every day, is not associated with an elevated risk of coronary heart disease (CHD) in this population.
The findings published in the American Journal of Clinical Nutrition (doi: 10.3945/ajcn.115.122317) also show no association was found among those with the APOE4 phenotype, which affects cholesterol metabolism and is common among the Finnish population, in whom the effect of dietary cholesterol on serum cholesterol levels is greater. Research data on the association between a high intake of dietary cholesterol and the risk of cardiovascular diseases in this population group has not been available until now.
In the study, the dietary habits of 1,032 men aged between 42 and 60 years and with no baseline diagnosis of a cardiovascular disease were assessed at the onset the Kuopio Ischaemic Heart Disease Risk Factor Study (KIHD) in 1984–1989 at the University of Eastern Finland. During a follow-up of 21 years, 230 men had a myocardial infarction, and 32.5% of the study participants were carriers of APOE4. A high intake of dietary cholesterol was found not to be associated with the risk of incident CHD in either the entire study population or in those with the APOE4 phenotype.
The consumption of eggs, a significant source of dietary cholesterol, was also found not to be associated with risk of incident CHD. No link was found between dietary cholesterol (or eating eggs) with thickening of the common carotid artery walls. In the highest control group, the study participants had an average daily dietary cholesterol intake of 520 mg and they consumed an average of one egg per day, which means that the findings cannot be generalised beyond these levels, the authors suggest.
Sedentary CHD patients have worse health even if they exercise
Sedentary coronary heart disease (CHD) patients have worse health even if they exercise, reveals research published in the European Journal of Cardiovascular Prevention (doi: 10.1177/2047487315617101).
“Limiting the amount of time we spend sitting may be as important as the amount we exercise,” says lead author Dr Stephanie Prince, (Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ontario, Canada).
Previous research has shown that being sedentary increases the risk of cardiovascular disease but until now its effect on patients with established heart disease was unknown. The current study investigated levels of sedentary behaviour and the effect on health in 278 CHD patients who had been through a cardiac rehabilitation programme, which taught them how to improve long-term exercise levels.
The researchers, from using activity monitors, found that CHD patients spent an average of eight hours each day being sedentary. Men spent more time sitting than women – an average of one hour more each day. This was primarily because women tended to do more light intensity movement – things like light housework, walking to the end of the drive, or running errands. Recent research suggests that, at around the age of 60, men become more sedentary than women and may watch more TV.
The researchers have provided the following practical tips to help to get moving more:
- get up and move every 30 minutes
- stand up during TV commercials or, even better, do light exercises while watching TV
- set a timer and take regular breaks from your desk
- take lunch breaks outside instead of in front of the computer
- go to bed instead of sitting in front of the TV and get the benefits of sleeping
- monitor your activity patterns to find out when you are most sedentary.