Calling All Heart Patients

Telephone or Internet-based interventions may help heart attack survivors and other cardiac patients improve their heart health and reduce their risk of future cardiac events, Australian researchers say. Read more

Beta Blocker Use Questioned in Non-Heart Surgery

(HealthDay News) -- An analysis of 33 studies on drugs known as beta blockers has concluded that they are not useful in any surgical procedure other than heart surgery. In fact, using beta blockers for non-coronary surgery may actually increase the risk of stroke, the scientists say.

The researchers who conducted the study -- known as a meta-analysis -- recommend that the guidelines committees of both the American College of Cardiology and the American Heart Association "soften" their recommendations that beta blockers be used to prevent surgical complications in non-coronary operations.

"Our study says that if you look at the overall picture, do a meta-analysis, studies that are not particularly well-done come to the conclusion that they are useful," said Dr. Franz Messerli, professor of medicine at Columbia University and an author of a report published online by The Lancet to coincide with the annual heart meeting now underway. "But if you look at the high-quality studies, there are distinctly more strokes with beta blockers." Beta blockers are drugs that inhibit adrenaline and slow the nerve impulses to the heart. They can also be used to treat irregular heartbeat, known as arrhythmia.

The meta-analysis did show a 35 percent reduced risk of heart attacks and a 64 percent reduction in less serious heart artery blockages among the more than 12,000 participants in all the studies where beta blockers were prescribed before surgery. But there was no overall reduction in total deaths, heart failure or deaths due to heart disease, and a doubled risk of nonfatal stroke.

Beta blocker usage was also associated with a high risk of bradycardia, low heart rate requiring medical treatment, which occurred in 1 of every 22 people getting beta blockers, and of lower blood pressure dangerous enough to require treatment.

In September 2008, researchers writing in the Journal of the American College of Cardiology concluded that beta blocker drugs don't prevent development of heart failure in people with high blood pressure and should not be used as first-line treatment for hypertension.

The increased risk of stroke, occurring in 1 of every 293 beta blocker recipients, is especially important, Messerli said. "Stroke is one of the most devastating complications of cardiovascular disease," he said. "For that reason, we would be very reluctant to use beta blockers in noncomplicated patients."

There is a presurgical role for beta blockers in many cases, Messerli said. "If a patient has coronary artery disease, he or she should certainly be on beta blockers," he said. "If they are on beta blockers already, they should remain on beta blockers. But if there is no particular cardiovascular risk, beta blockers should not be prescribed for noncardiac procedures."

Existing recommendations that call for routine use of beta blockers before surgery should be revised, Messerli said. "This is regarded as a quality measure for physicians," he said. "If they don't prescribe a beta blocker, it is considered to be falling short of a quality measure. Since the data are relatively soft, it certainly should not be a quality measure."

But an argument for use of beta blockers before surgery was made in an accompanying comment to the study by Dr. Don Poldermans, professor of medicine at Erasmus Medical Center in Rotterdam, the Netherlands. One major problem with studies showing difficulties when beta blockers were prescribed was that the doses were too high, Poldermans said.

"A low dose is safe, so why not use it?" Poldermans said, citing a study that he presented to the American Heart Association's annual scientific sessions, in New Orleans.

The study of 1,066 people who underwent surgery and were classified as being of intermediate risk of cardiovascular complications found that 2.1 percent of those getting a moderate daily dose of bisoprolol, a widely used beta blocker, suffered heart attacks or died of heart disease, compared to 6 percent of those not getting the beta blocker, Poldermans reported.

What might help decide the issue would be "a study to clarify dose and regimen" of beta blockers before surgery, he said. But such a study might be difficult to do, because the dangers of high-dose beta blockers are clear, Poldermans said.

"I would be very careful with high doses of beta blockers," he said. "There could be an increased risk of stroke. But a low dose is safe, so why take a high dose?"

More information
Learn why and how beta blockers are used from the Texas Heart Institute.

Statin Might Help More People Fight Heart Disease Than Thought

(HealthDay News) -- A widely used cholesterol-lowering drug appears to protect against heart attacks, stroke and other adverse outcomes in people who do not have high cholesterol.

The patients receiving the drug, Crestor (rosuvastatin), did have high levels of C-reactive protein (CRP), a marker for the inflammation process which is implicated in hardening of the arteries.

The study, sponsored by drug maker AstraZeneca and conducted by researchers at Brigham and Women's Hospital in Boston and colleagues, was presented Sunday at the American Heart Association's annual scientific sessions, in New Orleans. It will also be published in the Nov. 20 issue of the New England Journal of Medicine.

Dr. Howard Weintraub, clinical director of the Center for the Prevention of Cardiovascular Disease at New York University's Langone Medical Center, believes these results will change practice and will expand the universe of people who can benefit from the drug.

"This article conveys clearly that if all you do is use LDL cholesterol as a discriminator for cardiovascular risk, you are going to underestimate cardiovascular risk substantially," he said. "Individuals even with modest LDL can have considerable cardiovascular risk when other factors are present."

One of the study authors agreed. "This shifts the paradigm for evaluating risk and treatment," said Dr. Antonio M. Gotto Jr., dean of Weill Cornell Medical College in New York City.

In a statement, Dr. Elizabeth G. Nabel, director of the U.S. National Heart, Lung, and Blood Institute (NHLBI), acknowledged this study and two others concerning CRP.

"New results from three studies being presented at the American Heart Association (AHA) Scientific Sessions in New Orleans and published in scientific journals today provide the strongest evidence to date that a simple blood test for high-sensitivity C-reactive protein (hsCRP) is a useful marker for cardiovascular disease," she said.

But other experts urged caution.

"We have to really not lose sight of traditional guidelines," said Dr. Suzanne Steinbaum, director of women and heart disease at Lenox Hill Hospital in New York City. "This is very interesting, but I think we have to wait and see."

According to the NHLBI, about 450,000 Americans will die of coronary heart disease, which is the leading cause of death for both men and women.

People with increased levels of CRP, a marker of inflammation, have a higher risk for cardiovascular events. And about half of all heart attacks and strokes occur in apparently healthy people with lower LDL levels.

Statins are known to lower CRP levels, in addition to cholesterol levels.

The JUPITER trial randomized almost 18,000 men and women with LDL cholesterol levels less than 130 milligrams per deciliter (130 is considered "borderline high") and CRP levels of 2 milligrams per liter or higher (considered average risk) to take 20 milligrams of Crestor daily or a placebo.

Men were 50 years or older, while women were 60 or older, with no history of cardiovascular disease, no diabetes and no uncontrolled hypertension.

"These people would not have been candidates for statins," Weintraub said. "The use of statins right now is entirely related to LDL cholesterol."

The trial was halted after only two of four planned years of follow-up, when researchers noted a significant reduction (44 percent) in the primary endpoint -- a composite of cardiovascular events including heart attack, stroke and death.

Crestor reduced LDL levels by 50 percent and CRP levels by 37 percent.

"We estimate that the application of this simple screening and treatment strategy, when used over a five-year period, would prevent more than 250,000 heart attacks, strokes, revascularizations and cardiovascular deaths in the U.S. alone," said study author Dr. Paul Ridker.

However, one expert was more cautious.

"We cannot say cannot say CRP is a risk factor nor a causal mediator," said Dr. Andrew Tonkin, head of the cardiovascular research unit at Monash University in Melbourne, Australia. "I don't think we would screen everyone, not at all at this time. We need to know the absolute risk reductions."

The findings do indicate that women could be taking statins for primary prevention, Gotto said. But the specific age group these findings relate to needs to be kept in mind.

Weintraub doubted that the benefit would be seen with all drugs in the class of statins. "There are features in each of the drugs that makes it better or not as good an anti-inflammatory agent," he said.

More information
The American Heart Association has more on C-reactive protein.