In the News

Cardiology criteria guide therapy over intervention

Joint criteria offer a practical tool to help physicians choose between therapy and intervention for chest pain, criteria that focus on cardiac treatment rather than on diagnostic testing.

“Appropriate Criteria for Coronary revascularization,” a document created jointly by several medical groups, presents information from patients not typically included in the clinical trials used to form guidelines. Appropriate use criteria also present easily understood clinical scenarios that characterize patients according to:

• symptom severity and type,
• how much cholesterol plaque has built up and in which arteries,
• ischemia, and
• whether the patient is already taking the right heart medications and dosages.

Revascularization was considered appropriate if the expected improvements in survival, symptoms, functional status and/or quality of life outweighed the possible risks, according to a news release from the Society for Cardiovascular Angiography and Interventions (SCAI). In most cases, the panel considered revascularization as either bypass surgery or percutaneous coronary intervention. Because evidence supported either procedure for patients with advanced coronary disease, each revascularization method was independently rated.

The panel determined that revascularization would be inappropriate in a patient who had plaque build-up in one or two arteries, experienced symptoms only during heavy exercise, had a small amount of heart muscle at risk and was not taking medication to help control symptoms. However, revascularization is appropriate if a similar patient had severe symptoms despite already taking medication.

The criteria were published online in the Journal of the American College of Cardiology. They were jointly developed by the American College of Cardiology, SCAI, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and American Society of Nuclear Cardiology. They have been endorsed by the American Society of Echocardiography, Heart Failure Society of America and Society of Cardiovascular Computed Tomography.

Elderly can benefit from ICDs as much as the young

Older people with left ventricular systolic dysfunction can benefit from implantable cardiovascular defibrillators (ICDs) just as much as younger people, a new study found.

In a prospective cohort study of 965 patients, researchers compared mortality in patients who received and didn't receive ICDs. The patients were treated from March 2001 though June 2005 and followed through March 2007. Their median age was 67 years, which is 3-7 years older than previous studies that looked at ICD use in patients with heart conditions. All patients had ischemic or nonischemic cardiomyopathies with an ejection fraction ≤ 35% and no prior ventricular arrhythmias. The study was published in the Jan. 6 online version of Circulation: Cardiovascular Quality and Outcomes.

ICD therapy was associated with a 31% reduction in risk of all-cause mortality compared with not having an ICD (adjusted hazard ratio, 0.69; 95% confidence interval, 0.50 to 0.96; P=0.03). The benefit remained after patients were stratified by age, ejection fraction, ischemic etiology and comorbidities. ICDs were also shown to be about as cost effective in patients age 75 and older compared with younger patients, though cost effectiveness depended on the degree and number of comorbidities.

One limitation of the study is that it included relatively few patients over age 80, the authors said. The decision to use an ICD still needs to be made on a case-by-case basis, but patients shouldn't be ruled out strictly because they are in their 70s or have comorbidities, the authors concluded.

Cardiologists balance oral contraceptive risks, benefits

A new review article, published in the Jan. 20 Journal of the American College of Cardiology, assesses current research and guidelines on contraceptive hormone use and cardiovascular disease.

An analysis of the safety, efficacy and side effects of hormone therapy was prompted by data from the Women's Health Initiative that demonstrated links between hormone therapy and cardiovascular risk, researchers said. Recent statistics have also shown that mortality from cardiovascular disease has been increasing among women between age 35 and 44 coincident with an increase in oral contraceptive use. The new paper includes basic science, animal and human clinical studies and outlines the physiology and mechanisms of the cardiovascular action of contraceptive hormones, particularly in oral contraceptives.

The study authors concluded that newer generation oral contraceptives do not increase myocardial infarction risk for current users, but that they do carry the increased risk of venous thromoboembolism. Because there is no cardiovascular data available for the newest hormonal contraceptives (including nonoral methods and pills that also lower blood pressure), physicians should consider them similar to, not safer than, other oral contraceptives, the review said.

In general, the risks and benefits of contraceptive hormones should be weighed based on the characteristics of each individual patient, the authors concluded. As stated in current guidelines, women 35 years or older should be assessed for cardiovascular risk factors including hypertension, smoking, diabetes, nephropathy and other vascular diseases including migraines before hormonal contraceptives are prescribed.

The authors called for more research to uncover whether oral contraceptives provide protection from atherosclerosis and cardiovascular events. Such a determination will require long-term follow-up of the cardiovascular health of menopausal women compared with their history of oral contraceptive use, they said.