Heart News and Notes

We noted in these pages last June that Brown University, in Providence, RI, had started a registry for “broken heart syndrome,” also called Takotsubo cardomyopathy and now called stress cardiomyopathy. They now report that it’s clearly different from the heart attacks that it mimics, and it isn’t an abortive heart attack. For one thing, it peaks in summer, while heart attacks peak in winter.

Another study reported that stress cardiomyopathy, a rare condition usually caused by emotional stress, can also result from intravenous administration of epinephrine or dobutamine during routine procedures, apparently by triggering stress reactions.

Stress cardiomyopathy is rarely fatal. Unlike heart attack, it is usually followed by rapid and complete recovery.

Heart failure patients who undergo coronary bypass surgery frequently also get SVR, surgical ventricular reconstruction, at the same time. This is a procedure to downsize and reshape a weakened heart that has ballooned out of shape.

A randomized trial called STICH, for Surgical Treatment of Ischemic Heart failure, reported that while SVR appears to be effective, a three year followup showed no improvement in symptoms, exercise tolerance, survival or return visits to the hospital.

But the trial has had problems. For one, many of the doctors who recruited patients for the trial were so convinced of the benefits of SVR that they enrolled only patients they thought might not benefit from the procedure; the rest went straight to surgery.

Depression, we know, is associated with heart disease, and now several studies have looked into the details. A review of data from the Nurses’ Health Study found an association between sudden cardiac death and diagnosis of clinical depression, particularly with the use of antidepressants. No causal relationship could be determined. The authors recommend that antidepressants still be used.

A study in the Netherlands found that depression is associated with low blood pressure, but could not tell which is the cause and which the effect. But some antidepressants - tricyclic antidepressants, but not SSRIs (selective serotonin uptake inhibitors) - raise blood pressure.

A study of twins who served in Vietnam found that heart disease risk is not associated with a genetic predisposition to depression, but only with actual depression.

Black heart attack patients at ten hospitals in the U.S., in a study published last month in the Annals of Internal Medicine, averaged worse outcomes than white patients solely because of worse preexisting conditions: diabetes, heart failure, chronic kidney failure, hypertension and stroke. Treatments did not differ significantly, and when the preexisting conditions were statistically factored out the racial difference disappeared.

A different result came from a study of treatment of black heart attack patients in racially segregated areas: they were more likely to be sent to hospitals with higher mortality rates, even if hospitals with lower mortality were closer.

Another study found that blacks are far more likely than whites to develop heart failure - considered a disease of the elderly - before age 50. Early predictors included hypertension, overweight, low HDL, and kidney disease.

Canada’s guidelines for treatment of high blood pressure currently cover 162 recommendations, including a choice of five first-line drugs, and family doctors did not handle it well, according to a recent Canadian study.

Their patients did better with a simple four-step algorithm called STITCH (Simplified Treatment Intervention To Control Hypertension). First try a fixed low-dose combination of a diuretic with an ARB or ACE inhibitor. If needed, raise that to maximum dose. Then add a calcium channel blocker. Finally, use a non-first-line drug.

STITCH uses fixed-dose combination pills. In Canada, where patients pay a fixed prescription fee, that lowers the cost. In the U.S. where new pills cost more than old ones, the cost might rise.

Prasugrel, an alternative to the antiplatelet drug clopidogrel (Plavix) used to inhibit blood clotting, was unanimously recommended for FDA approval by an advisory panel in February in a process that has aroused some controversy. In particular, Dr. Sanjay Kaul, who criticized the prasugrel trial, was excluded from the advisory panel after Eli Lilly, a co-developer of prasugrel, objected to his participation.

Early results from the TRITON-TIMI 38 trial found that prasugrel was more effective than clopidogrel in preventing heart attacks but had a greater risk of bleeding. Later results identified subgroups of patients in which bleeding was not a problem.

Prasugrel was approved in February by the European Commission to be marketed as Efient. If it’s approved in the U.S., Lilly would market it as Effient.