AHA: Physical Activity Best First-line for High BP, Cholesterol

The optimal first step to address mild to moderately elevated blood pressure and cholesterol in otherwise healthy adults is a “prescription” to sit less and move more, the American Heart Association (AHA) says in a new scientific statement.

“The current American Heart Association guidelines for diagnosing high blood pressure and cholesterol recognize that otherwise healthy individuals with mildly or moderately elevated levels of these cardiovascular risk factors should actively attempt to reduce these risks,” Bethany Barone Gibbs, PhD, chair of the statement writing group, said in an AHA news release.

“The first treatment strategy for many of these patients should be healthy lifestyle changes beginning with increasing physical activity,” said Gibbs, from the University of Pittsburgh.

The 12-page AHA scientific statement — Physical Activity as a Critical Component of First-Line Treatment for Elevated Blood Pressure or Cholesterol: Who, What, and How? — was published online June 2 in Hypertension.

Every Little Bit Helps

According to the AHA, about 21% of American adults have systolic blood pressure between 120 and 139 mm Hg, or diastolic blood pressure between 80 and 89 mm Hg, which meets the criteria for lifestyle-only treatment for elevated BP outlined in the American College of Cardiology (ACC)/AHA high blood pressure guideline.

In addition, about 28% of American adults have LDL cholesterol above 70 mg/dL and otherwise meet the low-risk criteria for heart disease or stroke. These individuals would meet the criteria for lifestyle-only treatment outlined in the 2018 ACC/AHA cholesterol treatment guidelines, which include increased physical activity, weight loss, better diet, smoking cessation, and moderating alcohol intake.

“Of the recommended lifestyle changes, increasing physical activity has extensive benefits, including improving both blood pressure and blood cholesterol, that are comparable, superior, or complementary to other healthy lifestyle changes,” the writing group says.

“Physical activity assessment and prescription are an excellent lifestyle behavior treatment option for all patients, including for the large population of mild-moderate-risk patients with elevated blood pressure and blood cholesterol,” they note.

Research has shown that increasing physical activity can lead to clinically meaningful 3 or 4 mm Hg reductions in systolic and diastolic blood pressure, and 3 to 6 mg/dL decreases in LDL cholesterol, the authors point out.

Previous evidence also shows that physically active people have a 21% lower risk of developing cardiovascular disease and a 36% lower risk for death from cardiovascular diseases than those who are not physically active.

Physical activity also has benefits beyond heart health, including a lower risk for some cancers; improved bone, brain, and mental health; and better sleep, they note.

The US Department of Health and Human Services (HHS) 2018 physical activity guidelines advise Americans to log 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous aerobic activity each week and to participate in two or more weekly strength training sessions.

However, there is no minimum amount of time to receive benefits from physical activity.

“Every little bit of activity is better than none. Even small initial increases of 5 to 10 minutes a day can yield health benefits,” Gibbs said.

Translational Advice for Clinicians

The AHA statement encourages clinicians to ask patients about their physical activity at every interaction; provide ideas and resources to help patients improve and sustain regular life-long physical activity; and encourage and celebrate small increases in activity, such as walking more or taking the stairs, to help with motivation.

“In our world where physical activity is increasingly engineered out of our lives and the overwhelming default is to sit — and even more so now as the nation and the world is practicing quarantine and isolation to reduce the spread of coronavirus — the message that we must be relentless in our pursuit to ‘sit less and move more’ throughout the day is more important than ever,” said Gibbs.

The statement was prepared by a volunteer writing group on behalf of the AHA Council on Lifestyle and Cardiometabolic Health; the Council on Cardiovascular and Stroke Nursing; and the Council on Clinical Cardiology.

This research had no commercial funding. A list of disclosures for the writing group is available with the original article.

Hypertension. Published online June 2, 2021. Full text

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Commission Outlines Plan for Global Fight Against CVD in Women

An expert panel convened by The Lancet calls for urgent action to reduce the global burden of cardiovascular disease (CVD) in women and has outlined an ambitious agenda to accomplish that goal.

The report, from the all-female-led Lancet Women and Cardiovascular Disease Commission, was presented May 16 during a plenary session at the American College of Cardiology (ACC) 2021 Scientific Session and simultaneously published online in The Lancet.

Stalled Progress

CVD is the number 1 cause of death in women around the world. An estimated 275.2 million women are diagnosed with heart disease worldwide, including 20.8 million in the United States, and most of these cases are preventable, the authors write.

Decades of grassroots campaigns have raised awareness about the impact of CVD in women, and positive changes affecting women and their health have gained momentum. Nonetheless, the past decade has seen “stagnation” in the overall reduction of CVD burden in women, the panel notes. CVD in women remains under-studied, -recognized, -diagnosed, and -treated. 

“For the first time ever, we are trying to gain a comprehensive understanding of what it may take to reduce heart disease among women worldwide. This problem has persisted unchanged for decades, and this commission is a critical step toward finding solutions,” Roxana Mehran, MD, who led the effort, said in a news release.

Dr Roxana Mehran

“For example, physicians are aware that hypertension, smoking, hyperlipidemia, and diabetes are the most important evidence-based risk factors for heart disease. We now need to direct our study toward lesser-known risk factors that impact women’s health,” said Mehran, director, Interventional Cardiovascular Research and Clinical Trials, Icahn School of Medicine at Mount Sinai in New York City.

These include the “pronounced but understudied role” of stress, psychosocial, and economic deprivation, as well as sex-specific CVD risk factors, such as preterm delivery, pre-eclampsia, premature menopause, and domestic violence, Mehran said.

“The commission concludes that by studying these types of factors, we can better prevent, identify, and treat heart disease, reducing mortality rates and improving women’s health on a global scale,” Mehran said.

Key Messages and Recommendations

1. Accurate data on global prevalence and outcomes of CVD in women are absent.

Recommendation: Direct funding for real-time and accurate data collection on prevalence and outcomes of CVD in women globally.

2. Women with CVD remain under-studied, -recognized, -diagnosed, and -treated.

Recommendation: Develop educational programs on CVD in women for physicians, scientists, allied health care professionals, and communities.

3. Sex-specific mechanisms in the pathophysiology and natural history of CVD remain poorly understood.

Recommendation: Prioritize sex-specific research focused on identifying the pathophysiology and natural history of CVD.

4. Women are under-represented in the majority of CV clinical trials.

Recommendation: Develop strategies to improve enrollment and retention of women in CV clinical trials.

5. Socioeconomic deprivation contributes substantially to the global burden of CVD in women.

Recommendation: Prioritize funding in global health organizations for CVD health programs in women from socioeconomically deprived regions.

6. Myocardial infarction and CVD mortality are increasing in young women.

Recommendation: Educate healthcare professionals and patients regarding early detection and prevention of CVD in young women.

7. Hypertension, dyslipidemia, and diabetes are the most crucial risk factors contributing to CVD death in women.

Recommendation: Establish policy-based initiatives and medical and community-outreach CVD risk factor programs in settings frequented by women.

8. Sex-specific and other under-recognized CVD risk factors, such as psychosocial and socioeconomic factors, appear to contribute to the global burden of CVD in women.

Recommendation: Research is needed to identify the effect of sex-specific, psychosocial, and socioeconomic risk factors on CVD in women and to evaluate intervention strategies.

9. Age-adjusted prevalence of CVD in women is increasing in some of the most populous countries of the world.

Recommendation: Scale up healthy heart programs in highly populated and progressively industrialized regions.

10. There is no current established global policy to coordinate prevention and treatment of CVD in women.

Recommendation: Embrace public–private partnerships to develop broad-scale programs to save lives in women with cardiovascular disease.

“These recommendations are a roadmap for combating this number 1 killer of women around the world,” Mehran said.

“It is an undertaking of massive scale and scope and will require total commitment from governments, health organizations, technology sectors, and funding agencies to prioritize this urgent need for change. It is our hope that this roadmap will be the north star for the future of women’s heart health,” she added.

“Establishing these recommendations is an important step, but it’s even more important how the 10 key messages are pragmatically implemented into concrete real-life settings,” Valentin Fuster, MD, PhD, director, Mount Sinai Heart, and physician-in-chief, The Mount Sinai Hospital, said in the news release.

It’s also important to develop “motivating heart disease prevention programs starting in early childhood and for women before and during pregnancy,” Fuster said.

In a Lancet Comment, Ana Olga Mocumbi, MD, PhD, Mozambique National Institute of Health, who was not involved in the commission, says their recommendations calling for additional funding for women’s CV health programs, prioritization of integrated care programs, including combined cardiac and obstetric care, and strengthening of the health systems, align with efforts to “bridge the gap for the world’s worst off.”

“Such a shift in women’s cardiovascular care would be a major step towards equity, social justice, and sustainable development,” Mocumbi writes.

The Lancet Women and Cardiovascular Disease Commission was supported financially by grants from Abbott Vascular, Abiomed, Amgen, AstraZeneca, Bristol Myers Squibb, CSL Behring, Janssen, Medtronic, Orbus Neich, Philips, and Sanofi, which had no role in study design, data collection, data analysis, data interpretation, or writing of the commission article. The funds were used towards the planning, development, and public launch of the commission article. None of the authors were paid for their work on the commission.

Lancet. Published May 16, 2021. Abstract, Comment

 American College of Cardiology (ACC) 2021 Scientific Session. Presented May 16, 2021.

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Follow-up Sinks Candesartan as Cardioprotection in Breast Cancer

After a modest early signal of benefit, candesartan cilexetil (Atacand, Cheplapharm) showed no effect on key markers of heart health 2 years after treatment in patients with early-stage breast cancer in the randomized PRADA trial.

The 2015 study was hailed at the time as the largest randomized trial in breast cancer to look at the effects of angiotensin-receptor blockade with candesartan and the β-blocker metoprolol, both against placebo, on cardiac dysfunction. The 120 patients received adjuvant cancer therapy with anthracyclines with or without trastuzumab and radiotherapy — all well-known to have cardiotoxic adverse effects.

As previously reported, the primary outcome of change in left ventricular ejection fraction (LVEF) from baseline was attenuated by about 3% after cancer treatment in women who took a daily 32-mg dose of candesartan compared with those receiving placebo (P = .026).

At 2 years, however, follow-up with serial MRI showed the benefit on LVEF over placebo had vanished (mean Δ, –1.7% vs –1.8%; P = .91). Candesartan also had no significant effect on troponin I levels (P = .56).

Left ventricular end-diastolic volume was significantly reduced with candesartan compared with placebo (mean Δ, –5 mL vs 2 mL; P = .021), and the decline in global longitudinal strain was less (mean Δ, –0.2% vs 1.0%; P = .046).

“This suggests candesartan has favorable remodeling effects, but the effect sizes were quite small and the clinical relevance of these changes more than a year after endotherapy is unclear,” study author Siri Lagethon Heck, MD, PhD, Akershus University Hospital, Lørenskog, Norway, said.

Dr Siri Lagethon Heck

Metoprolol could not reverse its early lackluster performance, exerting no effect at 2 years on LVEF (P = .73), LV end-diastolic volume (P = .78), or global longitudinal strain (P =.34) vs placebo.

The β-blocker had tamped down the increase in troponin I levels from baseline, but the difference was no longer significant after 2 years (P = .76), according to results published in Circulation and simultaneously presented at the American College of Cardiology (ACC) 2021 Scientific Session.

During a discussion of the late-breaking trial, Heck observed that the decline in LVEF was less than anticipated and that the patients were low-risk, with few comorbidities, a baseline LVEF of at least 50%, and receipt of relatively low doses of anthracyclines.

“Broadly administered cardioprotective therapy may not be required during adjuvant breast cancer therapy, as decline in systolic function was minor and not prevented by neurohormonal blockade,” she said.

Panelist Bonnie Ky, MD, MSCE, director of the Cardio-Oncology Translational Center of Excellence, University of Pennsylvania, Philadelphia, said the study has many important strengths, including careful phenotyping and serial follow-up with cardiac MRI.

“What I think is a critical take-home message for our field is that we need to target cardioprotection therapy according to risk and personalize therapy according to who is at increased risk, either by treatment factors or host factors,” she said.

In a press conference highlighting the study, Ana Barac, MD, PhD, director of the cardio-oncology program at the MedStar Heart and Vascular Institute, Washington, DC, said the results were reassuring in that no one developed heart failure but also point to the need to design cardiovascular prevention trials in oncology patients based on their cardiovascular risk.

“The elephant in the room here is that oncology practice sometimes mandates what the inclusion criteria are for anthracyclines and trastuzumab, which were given in some of your patients, but they are approved only for normal function, and we all know that in clinical practice we see patients who do not have normal function and those are the patients at the highest risk,” she said. “I believe that the next studies, that I hope your group will also take on, will include this high-risk group of patients and show how we can improve their outcomes.”

Heck reported no relevant financial relationships. Ky reported consultant fees/honoraria from Cytokinetics; other relationships with Corvia, Impulse Dynamics, Mardil Medical, and UpToDate; and serving as a speaker for Roche. Barac reported serving on a data safety monitoring board for ACI Clinical.

Circulation. Published online May 16, 2021. Abstract

American College of Cardiology (ACC) 2021 Scientific Session. Abstract 406-17. Presented May 16, 2021.

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Renal, CV Damage May Develop in Mild SLE Despite Treatment

Patients with mild to moderate systemic lupus erythematosus (SLE) disease activity without any past history of organ damage may still progress to develop damage, particularly renal and cardiovascular disease, or death, in a relatively short amount of follow-up time, new research suggests.

The study, published in Lupus Science & Medicine, also showed that use of hydroxychloroquine lowered the risk of death and renal damage, whereas use of NSAIDs or any antihypertensives increased risk for cardiovascular damage.

“The impact of irreversible organ system damage in the prognosis of SLE remains a major concern because patients who develop damage are more likely to accrue additional damage and die,” wrote Deanna Hill, PhD, of GlaxoSmithKline, Collegeville, Pa., and coauthors, including Michelle Petri, MD, of Johns Hopkins University, Baltimore.

The researchers followed 1,168 adult patients with SLE from the Johns Hopkins Lupus Cohort, most of whom were women, 55% of whom were White and 39% of whom were Black. They divided the follow-up period into three parts: first year after enrollment into the cohort as background, second year as observation period, and the remainder of follow-up time until damage occurred, death, or end of available data.

At baseline, 55% of patients had mild to moderate disease, defined as an adjusted mean SELENA-SLEDAI (Safety of Estrogens in Lupus Erythematosus National Assessment SLE Disease Activity Index) score of less than 3. Patients had a median adjusted mean SELENA-SLEDAI score of 3 in the first year, which dropped to 2 in the observation period and remained there during the rest of follow-up.

Eight percent of patients died during the follow-up period. Each one-unit mean increase in SELENA-SLEDAI score during the 1-year observation period was associated with a significant 22% increase in the subsequent risk of death during the subsequent follow-up period (95% confidence interval, 1.13-1.32; P < .001).

Three-quarters of patients (n = 888) had no history of damage at the start of the follow-up period, but 39% of these patients had developed damage by the end of follow-up. Among patients without prior damage, a single-unit increase in disease activity score was also associated with a 9% increase in the risk of accruing organ damage (95% CI, 1.04-1.15; P < .001) after adjustment for confounding factors.

While only 3% of patients – most of whom were women – developed renal damage during the follow-up period, a one-unit increase in disease activity score was associated with a 24% increase in the risk of renal damage (95% CI, 1.08-1.42, P = .003).

The researchers found that 7% of patients developed cardiovascular damage during the follow-up period, and each one-unit increase in disease activity score was associated with a 17% increase in the risk of cardiovascular damage (95% CI, 1.07-1.29; P < .001).

“The findings in this analysis corroborate the influence of disease activity for renal and cardiovascular damage accrual and death and also extend the findings to patients with SLE and mild to moderate disease activity,” the authors wrote.

Impact of Treatment

Researchers also examined the effect of treatments, and found that patients treated with hydroxychloroquine during the 1-year observation period had a 54% lower risk of subsequent death (95% CI, 0.29-0.72; P < .05) and a 70% lower risk of renal damage (95% CI, 0.13-0.68, P < .05). However, patients prescribed NSAIDs had a 66% higher risk of cardiovascular damage, while those who used any antihypertensive had an 81% higher risk of cardiovascular damage.

“This may suggest that the known cardiovascular risk of NSAIDs in the general population is also applicable to patients with SLE and highlights the importance of assessing cardiovascular risk in this patient population,” the authors wrote.

Smoking affected the risk of death: Smokers were 74% more likely to die during the follow-up period than were nonsmokers.

There were no significant differences between different ethnicities in the study. While White patients generally had lower disease activity overall, there was no significant differences in the risk of death or organ damage with ethnicity.

The Hopkins Lupus Cohort is supported by the National Institutes of Health, and the study was funded by GlaxoSmithKline. Three authors were paid employees of GlaxoSmithKline and two were paid consultants or contractors.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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ACC Annual Meeting Pivots to All Virtual

Plans for in-person sessions at the American College of Cardiology (ACC) 2021 Scientific Session (ACC.21) have been scrapped.

Organizers had pushed the meeting to later in the spring in the hope that the pandemic would be under control and the May 15 to 17 event could offer both virtual and much-anticipated in-person sessions in Atlanta.

“Unfortunately, with the continued presence of COVID-19 and a sudden, sharp increase in ongoing travel restrictions imposed by healthcare institutions, academic medical centers, and exhibitor companies, the decision has had to be made to transition the meeting from a hybrid model to entirely virtual,”ACC.21 chair Pamela Morris, MD, Medical University of South Carolina, Charleston, and vice chair Douglas Drachman, MD, Massachusetts General Hospital, Boston, announced Monday.

On a page devoted to frequently asked questions, the ACC says that all of its meetings through August are being planned as virtual events. ACC.22 is slated for April 2 to 4, 2022 in Washington, DC.

The slow rollout and acceptance of the vaccine is also undoubtedly raising concerns among other professional societies. The American Heart Association Scientific Sessions 2021 is currently scheduled for November 13 to 15 in Boston.

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