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Every year for more than three decades, cardiovascular disease has killed more women than men in North America. While that gap has been narrowing, it still remains. On January 26, the American Heart Association (AHA) issued its first scientific statement on heart attack in women in the journal Circulation.
The AHA released the statement as a comprehensive summary of what the cardiovascular community knows about heart attack in women: its causes, presentation, treatment and outcomes. No matter their age, more women than men die within a year of their first heart attack (26 per cent of women compared with 19 per cent of men). However, women are on average older at the time of first heart attack: 71.8 years compared with 65 for men. This difference explains, in part, the higher mortality that continues to be seen in women five to 10 years after a heart attack.
Although risk factors for heart disease are shared between men and women, some factors—such as high blood pressure, and diabetes in younger women—seem to confer greater risk to women than men. Symptoms of a heart attack can also differ between women and men, a fact that many Canadian women are unaware of.
Women in general seek treatment later for a heart attack than men, which may contribute to poorer outcomes. Women are less frequently referred for appropriate treatment during a heart attack compared with men and, following a heart attack, are less likely to use guideline-recommended medical therapies. Less than 20 per cent of women eligible for cardiac rehabilitation have participated over the last three decades, and even with a referral to rehabilitation, women participate and complete it less frequently than men.
- This post is abridged from the full article published in The Beat, which includes a look at risk based on sex vs. gender
- Visit the Canadian Women’s Heart Health Centre for more on women and heart disease
The health benefits of regular physical activity are well documented and hard to overstate, but too often they are left out of the doctor–patient conversation. In December 2015, JAMA, the Journal of the American Heart Association, published the Viewpoint “Making Physical Activity Counseling a Priority in Clinical Practice: The Time for Action Is Now.” In it, the authors issue a call to action advocating the use of physical activity prescriptions and treating a patient’s level of activity as a vital sign.
In a related commentary at medscape.com, JoAnn Manson, MD of Harvard Medical School and co-author of the article stated, “A prescription for increased physical activity… could be one of the most important prescriptions that a patient receives.”
This is a topic of great interest to Andrew Pipe, MD, Chief of Prevention and Rehabilitation at the Ottawa Heart Institute, one that he is passionate about and has spoken on publicly. (See “Don’t Fear the Exercise Prescription” for coverage of his talk on this subject at the Canadian Cardiovascular Congress in 2013.)
“I’m very pleased to see this call to action in JAMA,” said Dr. Pipe. “It puts a spotlight on something we have known for a very long time: that regular physical activity is one of the most fundamental elements of good health and a powerful way to forestall the development of preventable disease.” The benefits apply not just to heart disease, but to a broad range of diseases and chronic conditions that include diabetes, cancer, stroke, dementia and many others.
Dr. Pipe is a well known advocate for health promotion and smoking cessation and is active in sports medicine with Canadian national teams.
“We have to be clear, though, that participating in physical activity does not mean people need to become athletes. It doesn’t mean that they need expensive equipment or access to special programs or facilities,” he explained. “It can be as simple as regularly walking most days of the week at a level that lets you still carry on a conversation.”
“I like to talk about the three Fs: fun, feasibility and forever,” said Dr. Pipe. “What kind of activity do you like to do the most, and how can you easily make it a part of your daily routine? If you can satisfy both of those questions, then it’s much more likely you will continue to be active for the rest of your life.”
Article: The Seattle Criteria increase the specificity of pre-participation ECG screening among elite athletes, Brosnan et al., Br J Sports Med 2014 48: 1144-1150
Written by: Jody Murray, Bsc/BPhe, MD, CCFP and current Sport Medicine Fellow
Pre-participation ECG’s have been long debated for athletes. The European Society of Cardiology (ESC) and other groups such as the International Olympic Committee are now recommending that elite athletes have a pre-participation ECG testing. This has come as a result of lower sudden cardiac death in Italy’s Veneto region where there has been mandatory ECG screening for the last 30 yrs.
The athletic heart will undergo normal adaptations in response to exercise, which in and of itself, cause electrical changes on ECG. False positive ECG testing leads to further cardiac investigations for the athlete and unnecessary costs to the health care system which has called into question the significance of ecg testing for athletes.
Recently a set of 3 papers categorizing ECG changes has come out helping to sort out what are normal adaptations versus changes associated with cardiac pathology. These papers are known as the Seattle Criteria and can be accessed through the British Journal of Sport Medicine.
In 2014, Brosnan et al., decided to look at the Seattle Criteria compared with the ESC criteria in identifying elite Australian athletes with significant cardiac disease which would put them at risk of sudden cardiac death. As a result of this study they concluded that the use of the Seattle Criteria during ECG interpretation of the elite athlete reduced further screening in individuals from 1 out of 5 athletes to 1 out of 20. Using the Seattle criteria, they were still able to identify the 3 individuals with significant cardiac abnormalities. This study suggests that using this new criteria might be as sensitive as using the 2010 ESC guidelines for detection of athletes at risk but with significantly lower the false positive rates and therefore marked cost reduction to our health care system.
Patients with heart disease who sit a lot have worse health even if they include exercise in their lives. That is the conclusion of new findings that looked at the activity levels and corresponding health indicators of patients with coronary artery disease.
“Limiting the amount of time we spend sitting may be as important as the amount we exercise,” said lead author Stephanie Prince, PhD, post-doctorate fellow in the Division of Prevention and Rehabilitation at the University of Ottawa Heart Institute. “Sitting, watching TV, working at a computer and driving in a car are all sedentary behaviours and we need to take breaks from them.”
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, published in November in the European Journal of Cardiovascular Prevention, investigated levels of sedentary behaviour and the effect on health in 278 patients with coronary artery disease. The patients had been through a cardiac rehabilitation programme which taught them how to improve their levels of exercise in the long term.
Patients wore an activity monitor during their waking hours for nine days. The monitors allowed the researchers to measure how long patients spent being sedentary, or doing light, moderate or vigorous levels of physical activity.
The researchers also assessed various markers of health including BMI and cardiorespiratory fitness to determine whether the amount of time a person spent being sedentary (mainly sitting) was related to these markers.
The patients spent an average of eight hours each day being sedentary. “This was surprising given that they had taken classes on how to exercise more,” said Dr. Prince. “We assumed they would be less sedentary but they spent the majority of their day sitting.”
Men spent more time sitting than women—an average of one additional hour each day. This difference 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.
Dr. Prince said: “Women with coronary artery disease spend less time sitting for long periods, but we need to do more research to understand why. There is some research which suggests that at around the age of 60 men become more sedentary than women and may watch more TV.”
The patients who sat more had a higher BMI and had lower cardiorespiratory fitness. This was assessed using their aerobic capacity. This is the maximum rate at which the heart, lungs and muscles use oxygen during an exercise test.
“These relationships remained even when we controlled for an individual’s age, gender or physical activity levels,” said Dr. Prince. “In other words, people who sat for longer periods were heavier and less fit regardless of how much they exercised.”
Dr. Prince emphasized that sitting less was not a replacement for exercise. “It’s important to limit prolonged bouts of sitting and in addition to be physically active,” she said. “Sedentary time may be another area of focus for cardiac rehabilitation programmes along with exercise.”
How low should treatment targets for blood pressure be? Major medical groups, including the American Heart Association (AHA), recommend maintaining systolic blood pressure below 140 mm Hg. But results from the large randomized Systolic Blood Pressure Intervention Trial (SPRINT) show that, for some patients at risk of cardiovascular disease, bringing systolic blood pressure below 120 mm Hg saves lives with manageable side effects.
Released simultaneously at the AHA 2015 Scientific Sessions and in the New England Journal of Medicine, SPRINT included over 9,000 volunteers, half of whom were assigned to standard therapy (to bring systolic pressure below 140 mm Hg) and half to intensive therapy (below 120 mm Hg). Medication regimens were individualized and relied on standard, widely available drugs: mostly diuretics, ACE inhibitors, calcium channel blockers, and angiotensin receptor blockers, with other drugs used as needed to meet the blood pressure targets.
All participants were at least 50 years old and had high blood pressure and at least one other risk factor for heart disease. The trial included older patients (75 years or older), people with chronic kidney disease, and people with a history of cardiovascular disease. The participants were also diverse: about 36 per cent were women, 30 per cent African American, and 11 per cent Hispanic. People with diabetes, prior stroke or advanced kidney disease were excluded.
SPRINT was scheduled to run for five years but was stopped after less than three and a half because of the strong benefits seen in the intensive therapy group: those participants had a 43 per cent decrease in risk of death from cardiovascular disease and a 27 per cent decrease in overall mortality compared with the standard treatment group. This was true across all subgroups, including older participants.
The benefits seen in the intensive therapy group did come with an increase in side effects: more patients showed an increased indication of kidney damage and an increased risk of low blood pressure episodes and fainting, though not of falls leading to injury. Overall, 4.7 per cent of patients in the intensive therapy group and 2.5 per cent in the standard therapy group experienced a serious adverse event. “Our impression overall is that the beneficial effects [in the intensive therapy group] seem to be much, much more important,” said Paul Whelton, MD, chairman of the SPRINT steering committee. Additional data on kidney function and cognitive performance will be published in 2016.
A concurrent paper, published in the Journal of the American College of Cardiology, estimated that 16.8 per cent of U.S. adults would meet the SPRINT eligibility criteria.
More news from AHA 2015, including updates on cardiac resuscitation, salt intake and the clinical use of genetic risk scores, is available at now at The Beat.
The University of Ottawa Heart Institute has developed several new patient guides about the care and treatment of arrhythmias. These guides are all now available in pdf format on the Heart Institute website. Topics include:
- Atrial Fibrillation (pdf)
- Electrophysiology Studies and Standard Ablation (pdf)
- Complex Ablation (pdf)
- ICDs: Implantable Cardioverter Defibrillators (pdf)
- Pacemaker Implantation (pdf)
See all of our patient guides to help your patients understand more about common types of heart disease and related treatment options.
Blood Test Identifies Those at Risk for Heart Attack
Knowing an individual’s specific risk of heart attack could significantly impact his or her medical care as well as willingness to adopt a healthier lifestyle. A blood test now available in the United States has been shown to do just that.
The PULS (Protein Unstable Lesion Signature) test measures nine proteins that are markers for arterial plaques that have the potential to break away from the wall of the blood vessel and cause blockages. The test has been validated in several clinical trials.
- Read recent coverage of the PULS test following a presentation given at the 20th World Congress on Heart Disease in Vancouver, British Columbia.
Major New Drug Approvals: Cholesterol
PCSK9 inhibitors are a new class of drug that lowers LDL cholesterol by blocking the action of the PCSK9 protein. This lets the liver remove cholesterol from the bloodstream more efficiently.
In late July, the European Union approved the PCSK9 inhibitor evolocumab (Repatha, by Amgen). A second, alirocumab (Praluent, by Sanofi/Regeneron), is on its way to approval.
In the United States, the Food and Drug Administration (FDA) approved alirocumab in July and is expected to approve evolocumab in late August. Evolocumab is currently under review by the Canadian Agency for Drugs and Technologies in Health.
These drugs function differently than the widely prescribed statins, offering a new option for individuals with high cholesterol levels who are resistant to other treatment. A downside is that they are not currently available in pill form and must be injected.
- Last year, researchers at the University of Ottawa Heart Institute discovered that PCSK9 is linked to the occurrence of a heart attack.
Major New Drug Approval: Heart Failure
LCZ696 (Entresto, by Novartis) is the first significant new drug therapy for heart failure in years. It works in two ways, by widening blood vessels, which lowers blood pressure, improves blood flow and reduces the workload on the heart, and by protecting the hormonal system that supports normal heart function.
In July, LCZ696 was given fast-track approval by the FDA in the United States. The drug is under review in Canada and Europe.
- Read a discussion of the promise of LCZ696 with Heart Institute cardiologist Lisa Mielniczuk, MD, Director of the Heart Failure Program.
Motivational Interviewing can be an effective tool employed by health practitioners to help patients come to their own decisions and plans about quitting smoking
This webinar, provided by the Smoking Cessation Leadership Centre, in collaboration with the American Academy of Family Physicians, will:
- Describe how the “spirit” or underlying perspective of motivational interviewing can be applied to smokers
- Explain how to speak with smokers who may not be ready to quit
- Describe how to elicit “change talk” from tobacco users
Date and Registration
The webinar will take place on Wednesday, July 22, 2015 from 2 pm to 3:30 pm EDT.
To register or learn more, visit the Smoking Cessation Leadership Centre website.
“Focus on Heart Failure” is a series of articles examining the toll of this disease now affecting 600,000 Canadians. The series addresses innovative programs in the Champlain Region and looks at the current state of treatment options to improve patient outcomes.
The series includes:
- Addressing a Silent Epidemic
- Strengthening the Network of Care
- Telehome Monitoring Helps Patients Help Themselves
- Advances in Managing the Condition
Click on the links above to read the articles on the University of Ottawa Heart Institute’s website or click on the infographic to learn more about the impact of heart failure.
Published in the May issue of the Canadian Journal of Cardiology, the Canadian Hypertension Education Program published its 2015 Recommendations for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension.
Changes in the 2015 recommendations include:
- aspects of blood pressure measurement and monitoring,
- addressing smoking cessation with patients and
- treatment of renal artery stenosis.