APPLYING NEW CHOLESTEROL GUIDELINES TO A PATIENT POPULATION REDUCES HEART ATTACKS, STROKES, STUDY FINDS
From the FMS Global News Desk of Jeanne Hambleton UT Southwestern Medical Centre – By Cathy Frisinger Released 18 August 2014
DALLAS – August 18, 2014 – A study from UT Southwestern Medical Center researchers found that recently introduced cholesterol guidelines would significantly reduce new cardiovascular events, when compared to treatment based on previous cholesterol guidelines.
The research identified Dallas Heart Study participants in the 30 to 65 age range who would have newly qualified for statin use under the new cholesterol guidelines introduced in 2013 by the American College of Cardiology (ACC) and the American Heart Association (AHA).
In this subset of patients, the study predicted that 3.6 to 4.9 cardiovascular events would have been prevented for every 1,000 people screened and treated according to the new guidelines rather than the old guidelines (using a risk-reduction factor of 30 percent to 45 percent, depending on the statin dosage). The Dallas Heart Study is a multiethnic, population-based study of thousands of Dallas County adults whose cardiovascular health has been followed for 10 years.
Projecting these findings onto the larger Dallas County population, about 4,500 serious heart problems would have been prevented in individuals 30 to 65 years of age over a 10-year period by following the new cholesterol guidelines.
When the new guidelines were introduced – replacing previous guidelines from the National Cholesterol Education Program/Third Adult Treatment Panel – they provoked heated debate over the sizeable increase in statin eligibility. However, the UT Southwestern study supports the merit of the new cholesterol guidelines, as well as increased statin use.
“This is one of the first studies to carefully predict the implications of the new guidelines in the general population beyond just the amount of increase in statin use,” said Dr. Amit Khera, Associate Professor of Internal Medicine and Director of the Preventive Cardiology Program at UT Southwestern.
“Does it look like these new guidelines will prevent heart attacks and strokes? The answer is, ‘yes,’” he said.
Dr. Khera is senior author of the recently published study, which appeared in Circulation: Cardiovascular Quality and Outcomes.
The 2013 ACC/AHA Cholesterol Guidelines recommend statins for patients with existing atherosclerotic cardiovascular disease, type 2 diabetes, and very high levels of LDL cholesterol, as well as for patients with a high 10-year risk for heart disease.
The previous guidelines from the National Cholesterol Education Program/Third Adult Treatment Panel were based on a different formula that involved targeting specific cholesterol levels. Some patients fall out of statin eligibility under the new guidelines, but some 12.8 million more are newly eligible.
Among Dallas Heart Study participants who actually experienced a cardiovascular event, 37.1 percent more of those patients would have been placed on statins if the new guidelines had been in place. Among participants who did not experience a cardiovascular event, only 3.9 percent more patients would have been prescribed statins.
“There has been a lot of emphasis on the increased use of statins and a lot of emphasis on the risk calculator,” said Dr. Khera, who holds the Dallas Heart Ball Chair in Hypertension and Heart Disease. “Yes, there is some additional statin use, but according to our results, this use seems appropriate, at least in this age group.”
The Dallas Heart Study was funded by the Donald W. Reynolds Foundation and is partially supported by the National Center for Advancing Translational Sciences of the National Institutes of Health.
Other UT Southwestern researchers involved in this study are first author Dr. Andre Paixao, a former UT Southwestern Cardiology Fellow and current Interventional Cardiology Fellow at Emory University; Colby Ayers, Faculty Associate in the Department of Clinical Science; Dr. Jarett Berry, Assistant Professor of Internal Medicine and Clinical Science; and Dr. James de Lemos, Professor of Internal Medicine, Associate Program Director of the Cardiology Fellowship Program, and holder of the Sweetheart Ball‐Kern Wildenthal, M.D., Ph.D. Distinguished Chair in Cardiology.
About UT Southwestern Medical Center – UT Southwestern, one of the premier academic medical centers in the nation, integrates pioneering biomedical research with exceptional clinical care and education. The institution’s faculty includes many distinguished members, including six who have been awarded Nobel Prizes since 1985. Numbering more than 2,700, the faculty is responsible for groundbreaking medical advances and is committed to translating science-driven research quickly to new clinical treatments. UT Southwestern physicians provide medical care in 40 specialties to nearly 91,000 hospitalized patients and oversee more than 2 million outpatient visits a year.
COUNSELLING HAS LIMITED BENEFIT ON YOUNG PEOPLE DRINKING ALCOHOL
From the FMS Global News Desk of Jeanne Hambleton COCHRANE NEWS: August 20 2014 Science newsroom, Wiley.com
Counselling techniques used to help young people with drinking problems may be of limited benefit, a new study suggests. In a systematic review published in The Cochrane Library, researchers found that an approach known as motivational interviewing did not substantially reduce drinking or alter alcohol-related behaviour.
Globally every year, around 320,000 young people between the ages of 15 and 29 die as a result of alcohol misuse. Most of these deaths are due to car accidents, murders, suicides or drowning. Motivational interviewing is a counselling technique developed in the 1980s that is sometimes offered to people with alcohol problems. It aims to help them overcome ambivalence and change behaviour. Counsellors listen, adopt a non-judgemental, non-confrontational stance and provide support to change by highlighting the negative consequences of drinking.
The researchers reviewed evidence from 66 trials involving a total of 17,901 young people aged 25 and under. Many of the studies recruited young people who were at high risk of alcohol related problems. In 49 trials, those involved attended one individual session. In the others, they attended group sessions or a mixture of group and individual sessions.
Four months later, participants who underwent counselling had only slightly reduced the amount they drank and how often they drank compared with people who were untreated. On average participants who had counselling had about 1 and a half fewer drinks per week compared to those who had no counselling (12.2 drinks compared with 13.7).
The effect of counselling on the number of drinking days was also very small: 2.57 days per week compared to 2.74 in untreated people). Participants also slightly reduced their maximum blood alcohol levels from 0.144% to 0.129%, but their average blood alcohol levels did not change. Motivational interviewing had no effect on alcohol-related problems, binge drinking, drink-driving and other risky behaviours related to alcohol.
“The results suggest that for young people who misuse alcohol there is no substantial, meaningful benefit of motivational interviewing,” said lead researcher David Foxcroft, who is based at the Faculty of Health and Life Sciences at Oxford Brookes University in Oxford, UK.
“The effects we saw were probably too small to be of relevance to policy or practice.”
The young people involved in trials included university and college students, army recruits, prisoners and young people attending healthcare centres, youth centres and job centres.
“There may be certain groups of young adults for whom motivational interviewing is more successful in preventing alcohol-related problems,” said Foxcroft.
“But we need to see larger trials in these groups to be able to make any firm conclusions.”
Cochrane is an independent, trusted producer of research into the effects of healthcare treatments and interventions. Policy makers, healthcare practitioners and patients can make better decisions using accessible, high quality, trusted evidence.
TOO LITTLE SALT ALSO HARMFUL
From the FMS Global News Desk of Jeanne Hambleton Posted on August 13, 2014 By Stone Hearth News – New England Journal of Medicine
Newswise — HAMILTON, ON, Aug. 14, 2014 — Two reports from a global collaborative study involving hundreds of investigators from 18 countries published today in the New England Journal of Medicine are shaking up conventional wisdom around salt consumption.
The Prospective Urban & Rural Epidemiological (PURE) study, led by investigators from the Population Health Research Institute, McMaster University and Hamilton Health Sciences, followed more than 100,000 people for nearly four years. The study assessed sodium and potassium intake and related them to blood pressure as well as to deaths, heart disease and strokes.
Current intake of sodium in Canada is typically between 3.5 and 4 grams per day and some guidelines have recommended that the entire population lower its sodium intake to below 2.3 grams per day, a level that fewer than 5 per cent of Canadians (and people around the world) now consume.
Researchers have shown that the effects of increasing sodium intake on raising blood pressure – a risk factor for heart attack, heart failure, stroke and other problems – become dramatically worse as intake rises above 5 grams per day, especially among people who already have high blood pressure, or who are older than 55, or both.
But the blood-pressure effects are more modest at average levels of sodium consumption (3 to 5 grams per day) and not evident at low levels of intake below 3 grams of sodium per day (a level that is higher than the maximum currently recommended by many guidelines), says Andrew Mente, the lead author of one report, and an assistant professor of clinical epidemiology and biostatistics.
“While there has been much focus on reducing salt in the diet, an important and ignored approach to lowering blood pressure is increasing the amount of potassium consumed. A balanced approach is what is likely to have the greatest benefit in lowering blood pressure,” says Mente.
“This can be achieved by moderation in salt intake, combined with eating lots of fruits and vegetables.”
While too much salt has long been recognized as a serious health risk, the researchers have also found that may be a risk from eating too little.
In fact, the lead author of the second report, Martin O’Donnell, suggests that what is now generally recommended as a healthy daily ceiling for salt consumption appears to be set too low.
“Low sodium intake does reduce blood pressure modestly, compared to moderate (or average) intake, but low sodium intake also has other effects, including adverse elevations of certain hormones that are associated with an increase in risk of death and cardiovascular diseases. The key question is whether these competing physiologic effects result in net clinical benefit or not,” says O’Donnell, an associate clinical professor at McMaster University and National University of Ireland Galway.
“In the PURE study, we found the lowest risk of death and cardiovascular events in those who consumed moderate amounts of sodium intake (3 to 6 grams per day), with an increased risk above and below that range. While this finding has been reported in previous smaller studies, PURE is the largest international study to study sodium intake and health outcomes, and adds considerable strength to the contention that moderate sodium intake is optimal.”
The studies were funded from more than 50 sources, including the PHRI, the Heart and Stroke Foundation of Ontario and Canada and the Canadian Institutes of Health Research.
“The findings of both studies are robust, globally applicable and collectively question established dogma and recommended policies. This also means that salt reduction should be primarily targeted at those who have high BP and those who consume a lot of salt.” says Salim Yusuf, the Principal Investigator of the global PURE study, senior author of both reports, and Director of the Population Health Research Institute, which designed and coordinated the study.
Taken together, the papers show there is a “sweet spot” for sodium consumption, where too much or too little can be damaging, while a moderate amount between 3 and 6 grams is optimal. The good news is that most people in the world already consume an amount in that range, the researchers found.
In an accompanying editorial in the NEJM, Prof Suzanne Oparil from the University of Birmingham, Alabama, urged reconsideration of current guidelines and recommended randomized trials comparing outcomes in people who consume usual salt intake to very low intake to assess if further reductions in sodium reduces clinical events.
“These provocative findings beg for a randomized, controlled outcome trial to compare reduced sodium intake with usual diet,” writes Prof Oparil. “In the absence of such a trial, the results argue against reduction of dietary sodium as an isolated public health recommendation.”
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