New research was presented at AHA 2020, the virtual American Heart Association Scientific Sessions 2020. The features below highlight some of the studies that emerged from the conference.
Silent Cardiovascular Disease Common in “Healthy” People
A study that screened more than 25,000 middle-aged people found that about one in 20 have serious coronary artery disease with at least one coronary vessel having at least a 50% stenosis. Overall, however, 42% of that same population have some form of measurable coronary arty disease. The researchers developed two prediction models. One can be performed at home and involves assessing risk factors and being able to do simple tasks such as waist circumference measurements. The other, more precise measurement, was dubbed the “clinical model” and would be performed at doctors’ clinics. Both models appeared to readily identify people who would benefit from further scanning. “We found that 30% of the people who scored the highest on the home model accounted for 67% of all the patients with disseminated coronary artery disease detected through CCTA,” said the presenting author. Of the 10,603 individuals determined to have some form of coronary artery disease, 1,502 had silent coronary disease with coronary arteries that were at least 50% stenosed. A 50% or greater stenosis was observed in one coronary artery in 1,072 patients, while 196 had 50% or greater stenosis in two coronary arteries and 49 had 50% or greater stenosis in three coronary arteries. Also, 35 individuals had blockages of 50% or greater in the critical left main artery.
No Benefit for Omega-3 in STRENGTH Trial
A daily dose of a novel omega-3 carboxylic acid (EPA+DHA) compound did not reduce the risk of heart attacks, stroke, revascularization (stenting or bypass surgery), hospitalization for unstable angina, or cardiovascular (CV) death compared to a daily dose of corn oil, according to findings from the STRENGTH trial. The results stand in stark contrast to the positive results from the REDUCE-IT trial, which reported a reduction in cardiovascular events—including death—for icosapent ethyl, an EPA ethyl ester. One likely explanation can be found in the design of the two trials. The STRENGTH trial “deliberately chose corn oil as its comparator because it has a neutral effect on the clinical parameters, whereas mineral oil has a negative effect,” said the presenting author. REDUCE-IT, as well as other earlier trials that demonstrated benefits of omega-3 compounds, used mineral oil. Additionally, “REDUCE-IT enrolled more patients with established CAD.” The STRENGTH trial recruited 13,078 statin-treated patients who were at high risk for CV events with triglycerides 180-500 mg/dL, and HDL <42 mg/dL (men) or <47 mg/dL (women). Participants were randomized to 4 g of omega-3 CA or an identical corn oil placebo. The outcome for the combined efficacy endpoint was virtually the same between the groups, with a hazard ratio of 0.89. Looking at the primary prevention endpoint, the findings were also disappointing (HR, 1.16). Among patients with established CV disease, the HR was 0.94.
Clever Trial Design Gets Patients Back on Statins
For a study, patients who had previously quit taking a statin due to side effects were randomized to alternating 1-month periods of either 20 mg atorvastatin, placebo, or an empty pill bottle in a blinded fashion for 1 year. They performed daily symptom checks on a smartphone app. When provided with the data showing that their side effects while on placebo were as bad as those reported on statins, one-half patients resumed their lipid-lowering statin treatment. Participants scored their symptom intensity on a 100-point scale using a smartphone app daily throughout the year. As expected, participants scored their mean symptom intensity higher when taking either placebo or the statin, as opposed to months without a pill (8.0 during no-pill months vs 15.4 on placebo and 16.3 on the statin). However, there was no significant difference between placebo and the statin. Pooling the results across patients, 90% of symptoms could be attributed to the nocebo effect (0.90 ratio of placebo-taking months vs no-pill months/statin-taking months vs no-pill months).
Extra Imaging Helps Determine Cause in Women With MINOCA
An international, multicenter study to identify the cause of myocardial infarction with non-obstructive coronary arteries (MINOCA) found that, in a series of more than 300 women with MINOCA, additional diagnostic imaging was able to determine the underlying cause of their heart attack in 84% of the cases. In the study, women diagnosed with MINOCA received two additional imaging tests: optical coherence tomography and cardiac MRI. About 75% of the women with abnormal OCT or cardiac MRI had evidence of heart damage from reduced blood flow. Recently ruptured plaques were also identified, which had not been previously identified. In 21% of the women, cardiac MRI showed myocarditis or another reason for heart dysfunction unrelated to artery blockage or blood clotting. For the remaining 16%, both OCT and MRI scans were normal, and the cause of the heart attack remained elusive. “Our findings demonstrate that even if the angiogram does not show substantial artery blockage, when women have symptoms and blood test findings consistent with a heart attack, it is likely a true heart attack and not heart inflammation,” said the presenting study author. “Additional imaging tests can get to the root of the problem and help healthcare professionals make an accurate heart attack diagnosis for women and to ensure they receive timely treatment.”
Cardiovascular Disease Increased Mortality Risk in Patients With COVID-19
A study of nearly 30,000 patients with COVID-19 revealed that cardiovascular disease or risk factors for cardiovascular disease dramatically increased the risk of in-hospital mortality. The risk of death was particularly high for older, non-White men. The analysis utilized electronic health records from 54 health systems that use a COVID-19 database provided by health information technology firms Cerner and Amazon Web Services, which have made the database free of charge to researchers. The study team sought to understand who is most at risk, which is especially important for deploying immunization strategies. All hospitalized patients (n=28,299) had a positive COVID-19 lab test within 2 weeks of hospitalization. The median age was 52 years, 29.4% were Hispanic, and 47% were female. The results, measured from January to July 2020, showed that in-hospital mortality was 20.7% overall. However, among those for whom mechanical ventilation was required (32.6% of the hospitalized patients), the mortality rate was 74.6%. Mortality rates were 20.4% for patients with hypertension, 21.5% for those with diabetes, 28.8% for those with coronary artery disease, and 34.2% for those with heart failure. Hispanics had a lower risk rate for mortality (0.71) than all other races overall.