Heart Disease: Talking Points

Start a conversation with your physician customers by sharing news from the most recent American Heart Association’s Scientific Sessions Conferences

E-cigarettes match traditional smoking in some heart risks

E-cigarettes may be perceived as safer than traditional cigarettes, but two studies say they are just as dangerous, or even worse, for your heart. One study found vaping can worsen several heart disease risk factors – cholesterol, triglycerides and glucose levels – at levels equal to traditional cigarettes. A second study found e-cigarettes decrease blood flow in the heart even more than traditional cigarettes. The preliminary findings were presented at the American Heart Association’s most recent Scientific Sessions meeting, held in November 2019 in Philadelphia.

In the first study, which included 476 healthy adults, e-cigarette users had higher “bad” LDL cholesterol and lower overall cholesterol compared to nonsmokers. In people who both vaped and smoked, “good” HDL cholesterol was lower.

The second study analyzed heart blood flow in 19 smokers, ages 24 to 32, immediately before and after using either e-cigarettes or traditional cigarettes. Blood flow was measured while participants were at rest and again as they performed a handgrip exercise.

Study co-author Dr. Susan Cheng, director of public health research at Cedars-Sinai Medical Center, said the finding that heart blood flow was reduced in e-cigarette users while at rest was a surprise. “Providers counseling patients on the use of nicotine products will want to consider the possibility that e-cigs may confer as much and potentially even more harm to users and especially patients at risk for vascular disease,” she said.

High blood pressure, unhealthy diets in women of childbearing age
One in five women of childbearing age has high blood pressure, and a new study shows that few of them are on a diet that could help them – and their babies – reduce their risk for health problems.

Nearly 40% of maternal deaths from any cause are associated with hypertension. Women who go into a pregnancy with high blood pressure are at risk of having a baby who has a low birth weight or is born premature. Dr. Lara Kovell, an assistant professor of cardiology at the University of Massachusetts Medical School in Worcester, presented preliminary findings of the study at the American Heart Association’s Scientific Sessions in Philadelphia.

Kovell and her colleagues analyzed data collected on 8,740 women ages 20 to 50 taking part in a national health and nutrition study from 2001 to 2016. They found that 22.4% had high blood pressure.

Researchers scored how healthy the women ate and how much salt they consumed compared to guidelines set out in the Dietary Approaches to Stop Hypertension – or DASH – diet. It is recommended for all adults with high blood pressure. They found that 7% of the women who had high blood pressure were adhering to a DASH-like diet, while 10% with normal blood pressure were.

People who follow DASH eat foods low in salt and that contain high levels of nutrients to help lower blood pressure, such as potassium, magnesium and calcium. These foods include fresh fruit and vegetables, beans and lentils, and whole grains.

HIV could increase risk of death from heart failure
After a heart failure diagnosis, people who are HIV-positive are more likely to be hospitalized or die of any cause than those not infected with HIV, new research shows. The study is the largest to date to look at how HIV status affects people diagnosed with heart failure, a chronic condition in which the heart is unable to pump enough blood and oxygen that cells need.

“We found that people with heart failure who are HIV-positive are more likely than those who are HIV-negative to be smokers, have heart and liver disease, and have depression or abuse drugs,” said lead study author Dr. Sebhat Erqou, an assistant professor of medicine at Brown University in Providence, Rhode Island. He also is a cardiologist at the Providence VA Medical Center and Lifespan Cardiovascular Institute. “But even after taking this into account, people with HIV still have worse outcomes than people who don’t have HIV.”

Erqou and his colleagues analyzed data on 5,747 HIV-positive and 33,497 HIV-negative veterans with heart failure being cared for from 2000 to 2018 in the Veterans Affairs Health Care System. The study found 30.7% of HIV-positive veterans with heart failure died from any cause, compared with 20.3% of HIV-negative veterans with heart failure. Hospital admission rates for any cause were 50.2% for those with HIV compared with 38.5% for those without.

Obesity, other factors may speed up brain aging
The brains of middle-age adults may be aging prematurely if they have obesity or other factors linked to cardiovascular disease, new research has found.

Almost one-quarter of adults have metabolic syndrome, a set of factors that in combination amplify a person’s risk of heart disease, diabetes, stroke and other illnesses. In the research, participants were considered metabolically unhealthy if they had two or more such factors: high blood pressure; high blood sugar; high blood triglyceride levels; or low levels of HDL, the “good” cholesterol – or if they took medicine for diabetes, high blood pressure or cholesterol.

Researchers used magnetic resonance imaging and tests of thinking skills to evaluate more than 2,100 women and men ages 37 to 55. Compared with the healthiest participants, those who were metabolically unhealthy, obese or both showed evidence of brain decline. The preliminary study was presented in November at the American Heart Association’s Scientific Sessions in Philadelphia.

Participants were part of the Framingham Heart Study, a decades-long investigation of cardiovascular disease risk. None had diabetes or neurological conditions such as stroke or dementia. Among people who were metabolically unhealthy, MRIs revealed lower total cerebral brain volume – in essence, a smaller brain – than was measured in metabolically healthy people.

Lower cerebral brain volume is a sign of injury throughout the brain that leads to the loss of neurons and supporting cells, said lead researcher Dr. Rebecca Angoff, clinical fellow in medicine at Harvard Medical School’s Beth Israel Deaconess Medical Center in Boston. “Aging, decreased blood flow and diseases like Alzheimer’s can lead to a smaller brain.”

Participants who were both metabolically unhealthy and obese showed the most signs of subtle injury to the brain’s white matter – tissue that provides crucial connections throughout the brain. These injuries, which have been linked to early Alzheimer’s disease, result from blood vessel abnormalities and may be due to risk factors such as high blood pressure and diabetes, Angoff said.

On the cognitive tests, obesity was linked to poorer scores. Specifically, those who were obese but metabolically healthy performed worse on a combination of six tests of thinking skills, and on individual tests that measured verbal memory and abstract reasoning. Participants who were obese and metabolically unhealthy scored lower for abstract reasoning and on a test measuring visual details and spatial memory.

Could mammograms screen for heart disease?
By screening for breast cancer, mammography has helped save hundreds of thousands of lives. Using the test to also screen for heart disease might someday help save many more.

Besides revealing masses that may be tumors, digital mammography – a technique in which low-dose X-ray images are captured and enhanced using computer technology – can reveal buildup of calcium in the arteries in the breast. About 13% of women are estimated to have this buildup, called breast arterial calcification, or BAC, including about 10% of women in their 40s and around half of women in their 80s.

Early studies so far have found BAC’s presence appears to signal an elevated risk for heart attack, stroke and other cardiovascular consequences. Research has begun to reveal a link between calcium buildup in the breast and coronary artery calcification, an established measure that helps predict cardiovascular disease risk.

At the American Heart Association’s Scientific Sessions conference in November 2019, Dr. Quan Minh Bui, general cardiology fellow at the University of California, San Diego, and his UCSD colleagues presented preliminary researchexamining the utility of BAC in predicting existing or future heart failure, a condition in which the heart is weakened and doesn’t pump properly.

The study looked at records from 2006-2016 for 278 middle-aged and older women who had both a mammogram and coronary calcium test within a one-year window. Almost one-third of the women had BAC, and 7% had heart failure. Even after accounting for age, diabetes and high blood pressure, all heart failure risk factors, women with calcium buildup in the breast arteries had 2.2 times the odds of having or developing heart failure.

Meth use producing younger, harder-to-treat heart failure patients
Widespread methamphetamine use is creating a unique form of severe heart failure, according to research that shows these patients tend to be younger and have poor outcomes, according to the American Heart Association. “This is a strikingly different type of patient,” said Dr. Isac Thomas, an assistant professor at the University of California, San Diego School of Medicine, and lead author of a study released at the American Heart Association’s Scientific Sessions conference in Chicago in November 2018.

In the study, Thomas and his colleagues reviewed electronic health records for patients treated at UC San Diego Health between 2005 and 2016. They identified 4,470 patients with methamphetamine abuse; 20,576 patients with heart failure; and 896 patients with both meth abuse and heart failure.

Compared to the average 67-year-old heart failure patient in the study, people with heart failure who use meth were 17 years younger and predominantly male. They also were more likely to have other substance abuse or psychiatric problems, such as mood and anxiety disorders. Even though meth-using patients were younger, they had a higher five-year hospital readmission rate for heart failure.

The good news is, other studies suggest that if meth users with heart failure go through a treatment program and stop using the drug, depending on the amount of inflammation and scarring, there is the potential to reverse some of the heart damage. The challenge, says Thomas, is for doctors to identify these patients, who can mistrust healthcare providers and don’t always disclose drug use.

Coronary calcium test could help clarify heart disease risk– and control cholesterol
When doctors are sorting out what to do about a patient’s cholesterol, a key calculation is the patient’s future risk for developing heart disease. But what if that risk is uncertain? Cholesterol guidelines released in November 2018 suggest a coronary artery calcium test (CAC) can help identify patients between 40 and 75 years who will benefit from statins when risk status is uncertain.

The CAC takes cross-sectional images of the vessels that supply blood to the heart muscle, to check for the buildup of calcified plaque. The measurement can help a doctor identify who is at risk for heart disease before a person has signs or symptoms. The test isn’t recommended for everyone, but according to the guidelines, some groups where CAC testing may be useful are:

  • People reluctant to begin statin therapy and who want to understand their risk and potential benefit more precisely.
  • People concerned about restarting statin therapy after stopping treatment because of side effects.
  • Men ages 55 to 80 or women 60 to 80 with few risk factors who question whether they would benefit from statin therapy.
  • People ages 40 to 55 with an estimated 10-year risk for developing heart disease between 5% and 7.5%, and risk factors that increase their chances of heart disease.

Heart attacks are becoming more common in younger people, especially women
Heart attacks are increasingly occurring in younger people, especially women, according to a study presented at the 2018 American Heart Association’s Scientific Sessions meeting.

Past research has shown heart attack rates in the U.S. have declined in recent decades among 35- to 74-year-olds. But in a more recent study, researchers wanted to look specifically at how many younger people were having heart attacks. They included data from a multi-state study of more than 28,000 people hospitalized for heart attacks from 1995 to 2014. The results showed 30% of those patients were young, age 35 to 54.

More important, they found the people having heart attacks were increasingly young, from 27% at the start of the study to 32% at the end. Among women having heart attacks, the increase in young patients went from 21% to 31%, a bigger jump than in young men. Researchers also found that young women had a lower probability than men of getting lipid-lowering therapy, including antiplatelet drugs, beta blockers, coronary angiography and coronary revascularization.

“Traditionally, coronary artery disease is seen as a man’s disease, so women who come to the emergency department with chest pain might not be seen as high-risk,” said Dr. Sameer Arora, the study’s lead author and a cardiology fellow at the University of North Carolina School of Medicine. “Also, the presentation of heart attack is different in men and women. Women are more likely to present with atypical symptoms compared to men, and their heart attack is more likely to be missed.”

People with diabetes need to monitor cholesterol
For people with diabetes, blood sugar isn’t the only important measurement. The most recent cholesterol guidelines, issued in November 2018, suggest the more than 110 million U.S. adults with diabetes or prediabetes also should manage their cholesterol. The guidelines suggest doctors consider prescribing cholesterol-lowering drugs (statins) to people with diabetes who are age 40 to 75. The guidelines also give other recommendations for people with diabetes based on age and other risk factors.

The reality has been scientifically clear for a while, but many people are not aware of the connection: Middle-age adults with diabetes are usually considered at moderate to high risk for cardiovascular disease.

More than 30 million people in the United States have diabetes, although one in four doesn’t know it, according to Centers for Disease Control and Prevention (CDC). Another 80 million have prediabetes, a serious health condition where blood sugar levels are higher than normal, but not high enough yet to be diagnosed as Type 2 diabetes. Over the past 20 years, the number of adults diagnosed with diabetes has more than tripled as the population has aged and become more overweight or obese.

There are well-established risk factors for heart disease, such as smoking, high blood pressure and high blood sugar. There also are what the new cholesterol guidelines call “risk-enhancing factors” such as family history, chronic kidney disease and metabolic syndrome. Metabolic syndrome is a cluster of at least three diagnosed conditions, including high blood pressure, high blood sugar, excess body fat around the waist and abnormal cholesterol levels.


Medicare adds coronary angioplasty to ASC coverage

The Centers for Medicare & Medicaid Services (CMS) added six coronary intervention procedures to its list of ambulatory-surgery-center-covered surgical procedures. Effective Jan. 1, the following three coronary intervention procedures, and three associated add-on procedures, were to be covered by Medicare:

  • CPT code 92920 (Percutaneous transluminal coronary angioplasty; single major coronary artery or branch).
  • CPT code 92921 (Percutaneous transluminal coronary angioplasty; each additional branch of a major coronary artery (list separately in addition to code for primary procedure).
  • CPT code 92928 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch).
  • CPT code 92929 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary procedure).
  • CPT code C9600 (Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch).
  • CPT code C9601 (Percutaneous transcatheter placement of drug-eluting intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary procedure) to the ASC CPL.

“While we acknowledge that a majority of Medicare beneficiaries may not be suitable candidates to receive these procedures in an ASC setting due to factors such as age and comorbidities, we believe it is important to make these procedures payable in the ASC setting, in order to ensure access to these coronary intervention procedures for those beneficiaries who are appropriate candidates to receive them in an ASC setting,” wrote CMS in its Final Rule. (https://www.federalregister.gov/documents/2019/11/12/2019-24138/medicare-program-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center)