The field of family medicine is continuously advancing, making it challenging for members of the interprofessional team to stay aware of key developments. This article focuses on recent updates in cardiovascular health that may impact the management of patients by family medicine practitioners. 

MORE REHOSPITALIZATIONS FOR YOUNGER WOMEN 1-YEAR POST-MI

Acute myocardial infarction (AMI) is a leading cause of death in developed nations,^[1] and is estimated to affect 3 million people annually.^[1,2] Furthermore, it is the cause of more than 1 million deaths in the United States alone each year.^[1] AMI is defined as either non-ST-segment elevation MI (NSTEMI) or ST-segment elevation MI (STEMI). Unstable angina is a disease state that overlaps with non-STEMI; however, cardiac markers are not typeically elevated.^[1,3] A new analysis of the VIRGO study, which enrolled men and women with AMI across 103 US hospitals indicated that younger women (those aged 18 to 55) have more adverse outcomes than men in the year after an AMI and are at greater risk for both cardiac and noncardiac rehospitalizations.^[4]

All-cause hospitalization rates within 1 year of discharge were 34.8% for women compared with 23% for men. Most hospitalizations for women were coronary-related. Women with a myocardial infarction with nonobstructive coronary arteries (MINOCA) had lower rates of rehospitalization than women who experienced myocardial infarction with obstructive coronary artery disease (MI-CAD). There was a more significant sex disparity between women and men for noncardiac hospitalizations compared with all other hospitalizations (incidence rate, 145.8 [women] vs 69.6 [men] per 1000 person-years).

"We were surprised to see the significance of sex difference in 1-year outcomes despite adjusting for over 30 variables, variables that often hold significant impact, such as belonging in the self-reported non-Hispanic Black population and lower socioeconomic status, [and] scores on health status questionnaires," Mitsuaki Sawano, MD, PhD, of the Yale School of Medicine, New Haven, Connecticut, told theheart.org | Medscape Cardiology. "Our findings indicate that women may indeed be at higher risk for 1-year hospitalizations."

Comprehensive data capturing healthcare utilization in young patients with AMI are lacking in the United States, Sawano said. "That is exactly why the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study started more than decade ago. Since there is no indication that much has changed in the care provided to young patients over the last decade, we think the data from VIRGO remain relevant to this day," he added.

The results were published online May 1 in the Journal of the American College of Cardiology.^[4]

Sex Disparities Apparent

Average age of the enrolled patients was 47 years and 70% self-identified as non-Hispanic White. A high proportion of women self-identified as non-Hispanic Black compared with men. Women also had a higher prevalence of comorbidities, including obesity, congestive heart failure, prior stroke, and renal disease, and a greater history of depression at baseline (48.7% vs 24.2%).

Among the 2979 patients (67% women) included in the analysis, at least 1 hospitalization occurred in 905 (30.4%) in the year after discharge. The leading causes of hospitalization were coronary-related (incidence rate [IR], 171.8 among women vs 117.8 among men), followed by noncardiac hospitalization (IR, 145.8 vs 69.6) and dissection and vasospasm (1.4% vs 0.2%).

Women with MINOCA had a lower incidence of 1-year all-cause, coronary-related, and stable or unstable angina hospitalizations compared with women with MI-CAD. The women with MINOCA also reported lower treatment satisfaction compared with men or women presenting with MI-CAD. At the time of discharge, the total length of stay was longer for women vs men, and women received lower rates of guideline-recommended medical therapies, including aspirin (92.6% vs 95%), statins (67.5% vs 71.7%), beta-blockers (89.6% vs 94.1%), and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (61.2% vs 70.6%).

"Greater burden of risk factors, chest discomfort symptoms deemed 'noncardiac,' delays in hospital presentation, delays in care after arriving at the hospital, inequalities in timely reperfusion therapies or any revascularization, lower prescription and continuation rate of optimal medical therapy, etc. all have been proposed as contributing factors to worse clinical outcomes in young women," Sawano said. "More importantly, we have not seen any full-scale attempts to lessen sex disparity."

To minimize the risk of avoidable hospitalizations, a multidisciplinary team of cardiologists, psychiatrists, ob/gyn doctors, diabetes clinicians, and obesity specialists, among others, "is warranted during the index hospitalization," he added. "Clinicians would need to understand the patient better," including factors like financial status, insurance, access to healthcare, and possible constraints related to household roles. "All are relevant to taking care of the young patients," he said.

Beyond Traditional Risk Factors

"I am not surprised by the current findings, as young women are the least aware of their risk for heart attacks," American Heart Association volunteer expert Nieca Goldberg, MD, clinical associate professor of medicine at NYU Grossman School of Medicine and medical director of Atria, New York City, told theheart.org | Medscape Cardiology. "The current health system seems fixed on the image of men and older women being at risk for heart disease. A different analysis will likely have the same results."

Physicians need to look beyond traditional risk factors like high blood pressure, high cholesterol, family history, cigarette smoking, lack of exercise, and obesity, she said. "They should incorporate questions about autoimmune disease and pregnancy-related disorders such as preeclampsia, gestational diabetes, preterm birth as well as mental health issues like depression, anxiety, and stress. These disorders can widen out the net of women who are at risk for heart disease."

Martha Gulati, MD, MS, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, and colleagues conclude in a related editorial that the new analysis "adds to decades worth of literature clearly illustrating that young women with AMI experience more adverse outcomes than men. The disparities are evident," they conclude. "Now it is time to stop adding insult to infarct and to solve these persistent sex gaps in cardiovascular care."^[5]

LONG-TERM BETA-BLOCKERS NOT NEEDED AFTER MI WITH PRESERVED SYSTOLIC FUNCTION?

Beta-blockers are a class of medicines primarily used to manage cardiovascular diseases.^[6] They are an established therapy for patients with heart failure and/or left ventricular systolic dysfunction because they reduce morbidity and mortality. For those without heart failure or left ventricular systolic dysfunction, evidence supports the use of beta-blockers in the early phase after MI, but there is uncertainty as to whether they should be continued beyond the first year in the absence of other clinical indications.^[7]

Beta-blocker treatment beyond 1 year after myocardial infarction (MI) for patients without heart failure or left ventricular systolic dysfunction was not associated with improved cardiovascular outcomes in a new analysis of a nationwide cohort of more than 40,000 patients.^[7]

"The results of our study address an existing gap in the current evidence and provide an insight into long-term optimal secondary prevention strategies for a large proportion of MI survivors, namely patients with no heart failure or left ventricular systolic dysfunction who may have longer survival compared with those who develop such complications after an MI," state the authors, led by Divan Ishak, MD, Uppsala University, Sweden.

The study was published online in Heart on May 2.^[7]  

The researchers explain that clinical outcomes following MI have improved in recent years, partly because of the use of evidence-based therapies including timely reperfusion and secondary prevention medications. As such, more patients are surviving MI with no heart failure or left ventricular systolic dysfunction.

In historical randomized trials, longer-term beta-blocker therapy has been shown to reduce mortality rates, but these trials were conducted before the introduction of invasive reperfusion strategies and antithrombotic agents into routine MI care. More recent studies have been limited by the inclusion of only a subset of MI patients, relatively small sample size, or short follow-up, the authors note.

While more comprehensive randomized trials are in progress, the benefit of beta-blockers in the chronic phase beyond the first year might remain unknown and the long follow-up required to draw firm conclusions may be challenging to achieve.

The current study therefore aimed to investigate the association between beta-blocker therapy and cardiovascular outcomes beyond the first year after MI in patients without heart failure or left ventricular systolic dysfunction using real-world data from the SWEDEHEART registry of patients with coronary heart disease in Sweden. The study included all 43,618 patients aged 18 years or over with MI, including ST-elevation (STEMI) and non-STEMI, who had been hospitalized at one of the 74 cardiac care units in Sweden between 2005 and 2016.

Follow-up started 1 year after hospitalization (index date). Patients with heart failure or left ventricular systolic dysfunction up until the index date were excluded. Patients were allocated into 2 groups according to beta-blocker treatment. The primary outcome was a composite of all-cause mortality, MI, unscheduled revascularization, and hospitalization for heart failure.

Results showed that, overall, 78.5% of patients received a beta-blocker and 21.5% did not take a beta-blocker at the index date 1 year following MI. The median age was 64 years, and 25.5% were female. The median follow-up was 4.5 years. In the intention-to-treat analysis, the unadjusted rate of primary outcome was lower among patients who received a beta-blocker vs those who did not (3.8 vs 4.9 events/100 person-years; HR 0.76; 95% CI: 0.73, 1.04). However, following inverse propensity score weighting and multivariable adjustment, the risk of the primary outcome was not different according to beta-blocker treatment (HR 0.99; 95% CI: 0.93, 1.04). These findings were consistent across individual secondary endpoints and across patient subgroups.

The authors say that this is the largest study to have evaluated beta-blocker therapy in patients without heart failure or left ventricular systolic dysfunction following MI. Although the design is observational, it includes a large sample of patients, has a median follow-up of 4.5 years, and implements causal inference techniques, they state. They also point out that the results align with those of a recent meta-analysis of contemporary trials looking at this question.^[8]

They note that the potential mechanism of beta-blockers in improving cardiovascular outcomes following MI is attributed to the inhibition of the sympathetic overdrive, lowering heart rate, and thus reducing myocardial oxygen consumption. However, routine and timely coronary reperfusion, as well as usage of potent antiplatelet therapy, reduces infarct size, minimizing the upregulation of sympathetic activity, particularly in those individuals who do not sustain substantial myocardial damage.

In addition, beta-blockers have been associated with several side effects, including depression and fatigue, so determining whether they are indicated beyond the first year after MI may have an impact on patient health-related quality of life, the authors suggest.

In an accompanying editorial,^[9] Tom Evans, MD, and Ralph Stewart, MD, Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand, say the current study raises an important question directly relevant to the quality of care: Do patients with a normal left ventricular ejection fraction benefit from long-term beta-blocker therapy after myocardial infarction?

They note that the study had a number of strengths including a large sample size, a representative study population, detailed information on risk markers used for the propensity adjusted analysis, and unbiased evaluation of outcomes from administrative datasets up to 12 years after the index MI. But they caution that the potential for unrecognized confounding is a limitation, and therefore more evidence from large randomized clinical trials is needed to answer this question.

BETTER ACCESS TO TRANSCATHETER AORTIC VALVE REPLACEMENT ASSOCIATED WITH IMPROVED OUTCOMES

Aortic stenosis (AS) is the second most frequent valvular lesion in the United States. AS is thought to affect 5% of individuals aged 65 years and its prevalence rises with age.^[10] Severe AS can be fatal and requires surgical intervention. A transcatheter aortic valve replacement (TAVR) is a minimally invasive procedure used to manage patients with severe AS who are symptomatic.^[11] Greater access to TAVR may be associated with improved outcomes in patients with severe aortic stenosis, data suggest.^[12]

In an observational, retrospective cohort study that included almost 22,000 patients who received TAVR, the 30-day mortality rate was 3.1% in Ontario, where access was lower, and 2.5% in New York State, where access was greater.

"We compared the outcomes in 2 jurisdictions to better understand if outcome differences exist and if they are related to access to technology," senior study author Art Sedrakyan, MD, PhD, professor of population health sciences at Weill Cornell Medical College in New York City and director of the Institute for Health Technologies and Interventions, told Medscape Medical News.

"There are outcome differences that favor patients getting care in New York, but we believe it might be related to early access to the technology in New York and accumulating more experience," said Sedrakyan.

The study was published online February 1 in the Canadian Journal of Cardiology.^[12]

Comparing 2 Jurisdictions

The investigators examined population-based administrative data to identify adults in Ontario and New York who received TAVR between January 2012 and December 2018. They included 5007 patients at 11 hospitals in Ontario and 16,814 patients at 36 hospitals in New York in their analysis. The primary outcome was 30-day in-hospital mortality after TAVR.^[12]

The Ontario hospitals had a higher median TAVR volume (528 vs 268), but New York hospitals had a broader range of volumes: 1-2559 TAVRs compared with 13-839 in Ontario. From 2012 to 2018, access to TAVR increased from 18.2 per million to 87.4 per million in Ontario and from 31.9 per million to 220.4 per million in New York, representing an almost threefold higher use of TAVR in the latter.

The rate of 30-day in-hospital mortality was higher in Ontario. The rate of readmissions, which was a secondary outcome, did not differ significantly between Ontario and New York (14.6% vs 14.1%, respectively). Access site, urgency status, and year of procedure were the most important influences on mortality. Patients who had transfemoral TAVR had a 58% lower mortality rate than did those who did not. Mortality risk was more than twice as high for patients who had urgent TAVR (odds ratio, 2.31). Finally, mortality rates were higher in the early years of the study period.

The investigators also calculated what the mortality rate for New York patients would have been if they had been treated in Ontario. The expected mortality for the New York patients was 3.6% compared with the 2.5% observed in the study, resulting in an observed-expected (O-E) ratio of 0.7. The O-E ratio for readmission was not significantly different between the 2 jurisdictions. A sensitivity analysis restricted to patients undergoing elective, transfemoral-access-only TAVR found no significant differences in mortality or readmission between the 2 cohorts.

The investigators noted that Ontario patients were likely sicker than were those in New York because the province had restricted TAVR access to inoperable and high-risk patients during the study period, whereas New York did not. The reduction of the gap in short-term outcomes between the 2 locations when urgent cases were excluded from the analysis suggests that New York has a lower bar for performing urgent procedures in wait-listed patients. The investigators did not compare wait times, however, because New York State did not collect those data.

Potential data-recording differences between the primary databases were a limitation of the study, according to the investigators. "Comorbidity coding might be different in the countries, and risk stratification can be improved," said Sedrakyan. "But this is an important study that helps policy makers understand that there are public health implications related to decisions to approve, adopt, and conduct TAVR operation."

Further study would help determine whether more recent outcomes have improved, he said. "Unfortunately, we don't have funding to do more of these cross-border analyses," said Sedrakyan. "We think more international outcome studies are warranted with direct comparison."

Ensuring Equal Access

Commenting on the study for Medscape Medical News, David Messika-Zeitoun, MD, PhD, a cardiologist at the University of Ottawa Heart Institute, pointed out 2 notable limitations. First, the predictive model did not have any individual comparisons. Second, valve-on-valve procedures represented 0.2% of the New York cohort but 11% of the Ontario group. Messika-Zeitoun was not involved in the study.

"If you look at the patients who had proximal (transfemoral) transaortic valve intervention (TAVI) and elective interventions, there is no difference," he said. However, the use of province- and state-wide data and the relatively long period of observation are strengths of the study, Messika-Zeitoun added.

The results provide 4 key lessons, he continued. They underscore the importance of monitoring access, waiting time, and results. They also remind clinicians "to assess whether aortic stenosis patients are treated according to their need, meaning, for example, that all patients over 75 years suitable for a TAVI get a TAVI in Canada," said Messika-Zeitoun. The results also reveal the need to ensure equity of access and treatment opportunities across Canada. Finally, they "emphasize the importance of early detection, follow-up by a cardiologist with expertise in valvular heart disease, and timely intervention, which is the mandate of the Canadian Cardiology Society Working Group," he concluded.

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