Alcohol and cardiovascular health: the dose makes the poison…or the remedy

Habitual light to moderate alcohol intake (up to 1 drink per day for women and 1 or 2 drinks per day for men) is associated with decreased risks for total mortality, coronary artery disease, diabetes mellitus, congestive heart failure, and stroke. However, higher levels of alcohol consumption are associated with increased cardiovascular risk. Indeed, behind only smoking and obesity, excessive alcohol consumption is the third leading cause of premature death in the United States. Heavy alcohol use (1) is one of the most common causes of reversible hypertension, (2) accounts for about one-third of all cases of nonischemic dilated cardiomyopathy, (3) is a frequent cause of atrial fibrillation, and (4) markedly increases risks of stroke-both ischemic and hemorrhagic. The risk-to-benefit ratio of drinking appears higher in younger individuals, who also have higher rates of excessive or binge drinking and more frequently have adverse consequences of acute intoxication (for example, accidents, violence, and social strife). In fact, among males aged 15 to 59 years, alcohol abuse is the leading risk factor for premature death. Of the various drinking patterns, daily low- to moderate-dose alcohol intake, ideally red wine before or during the evening meal, is associated with the strongest reduction in adverse cardiovascular outcomes. Health care professionals should not recommend alcohol to nondrinkers because of the paucity of randomized outcome data and the potential for problem drinking even among individuals at apparently low risk. The findings in this review were based on a literature search of PubMed for the 15-year period 1997 through 2012 using the search terms alcohol, ethanol, cardiovascular disease, coronary artery disease, heart failure, hypertension, stroke, and mortality. Studies were considered if they were deemed to be of high quality, objective, and methodologically sound.

Coffee and tea: perks for health and longevity?

PURPOSE OF REVIEW

Tea and coffee, after water, are the most commonly consumed beverages in the world and are the top sources of caffeine and antioxidant polyphenols in the American diet. The purpose of this review is to assess the health effects of chronic tea and/or coffee consumption.

RECENT FINDINGS

Tea consumption, especially green tea, is associated with significantly reduced risks for stroke, diabetes and depression, and improved levels of glucose, cholesterol, abdominal obesity and blood pressure. Habitual coffee consumption in large epidemiological studies is associated with reduced mortality, both for all-cause and cardiovascular deaths. In addition, coffee intake is associated with risks of heart failure, stroke, diabetes mellitus and some cancers in an inverse dose-dependent fashion. Surprisingly, coffee is associated with neutral to reduced risks for both atrial and ventricular arrhythmias. However, caffeine at high doses can increase anxiety, insomnia, calcium loss and possibly the risk of fractures.

SUMMARY

Coffee and tea can generally be recommended as health-promoting additions to an adult diet. Adequate dietary calcium intake may be particularly important for tea and coffee drinkers.

Neutralizing the adverse prognosis of coronary artery calcium

OBJECTIVES

To report and compare the outcomes and survival of patients with abnormal computed tomography-derived coronary artery calcium (CT-CAC) scores undergoing aggressive medical treatment at a cardiac prevention clinic.

PATIENTS AND METHODS

We conducted a retrospective analysis of 849 patients with intermediate risk based on the Framingham risk score and an abnormal CT-CAC score who were aggressively treated in a preventive cardiology risk factor modification program from June 23, 2000, to September 1, 2012. The primary outcome was a composite end point of myocardial infarction, resuscitated cardiac arrest, revascularization, and cardiovascular death. The effect of the CT-CAC subgroup on major adverse coronary heart disease events (MACEs) was evaluated by calculating hazard ratios with Cox proportional hazards regression modeling. The Centers for Disease Control and Prevention Wonder database was used to identify age- and sex-matched controls from the general population of Kansas and Missouri.

RESULTS

The mean age of the study patients was 65.4 years (58.4% men [496]). The median follow-up was 58 months, and the mean CT-CAC score was 336 Agatston units. Thirty-four patients (4.0%) reached the primary end point, including 4 deaths. The adjusted 10-year mortality rates were similar in the study group and control group (9.3 vs 10.6; P=.80). After adjustment, a CT-CAC score greater than 400 Agatston units correlated with a higher risk of MACEs (hazard ratio, 3.55; P=.01).

CONCLUSION

These results suggest that intermediate-risk patients with abnormal CT-CAC scores when treated with intensive risk factor reduction have lower rates of MACEs than predicted by the Framingham risk score and the presence of coronary artery calcium.

Effects of habitual coffee consumption on cardiometabolic disease, cardiovascular health, and all-cause mortality

Coffee, after water, is the most widely consumed beverage in the United States, and is the principal source of caffeine intake among adults. The biological effects of coffee may be substantial and are not limited to the actions of caffeine. Coffee is a complex beverage containing hundreds of biologically active compounds, and the health effects of chronic coffee intake are wide ranging. From a cardiovascular (CV) standpoint, coffee consumption may reduce the risk of type 2 diabetes mellitus and hypertension, as well as other conditions associated with CV risk such as obesity and depression; but it may adversely affect lipid profiles depending on how the beverage is prepared. Regardless, a growing body of data suggests that habitual coffee consumption is neutral to beneficial regarding the risks of a variety of adverse CV outcomes including coronary heart disease, congestive heart failure, arrhythmias, and stroke. Moreover, large epidemiological studies suggest that regular coffee drinkers have reduced risks of mortality, both CV and all-cause. The potential benefits also include protection against neurodegenerative diseases, improved asthma control, and lower risk of select gastrointestinal diseases. A daily intake of ∼2 to 3 cups of coffee appears to be safe and is associated with neutral to beneficial effects for most of the studied health outcomes. However, most of the data on coffee's health effects are based on observational data, with very few randomized, controlled studies, and association does not prove causation. Additionally, the possible advantages of regular coffee consumption have to be weighed against potential risks (which are mostly related to its high caffeine content) including anxiety, insomnia, tremulousness, and palpitations, as well as bone loss and possibly increased risk of fractures.

Clinical factors associated with left ventricular ejection fraction disparity in patients with left ventricular dysfunction undergoing multimodality imaging

Drug and device therapy for heart failure is increasingly determined based on left ventricular ejection fraction. Significant disparity frequently exists between echocardiographic and nuclear scintigraphic techniques, even when testing is performed nearly simultaneously in clinically stable patients. In 119 patients with left ventricular dysfunction who underwent both echocardiography and stress testing with nuclear imaging within seven days (but with significant disparity in reported left ventricular ejection fraction), we identified four clinical variables which were associated with left ventricular ejection fraction difference. These clinical variables included atrial fibrillation, left ventricular hypertrophy, severe mitral regurgitation and paced rhythm.

Meta-analysis of effect of dipeptidyl peptidase-4 inhibitors on cardiovascular risk in type 2 diabetes mellitus

Patients with type 2 diabetes mellitus (DM) have a very high risk for major adverse cardiovascular (CV) events. Previous studies have shown that traditional oral diabetic medications, despite lowering blood glucose levels, generally do not improve CV outcomes. The safety of some oral hypoglycemic medications has been questioned. We aimed to evaluate the CV safety of dipeptidyl peptidase-4 (DPP4) inhibitors, a novel class of oral diabetic medications, by performing a meta-analysis of DPP4 inhibitors for type 2 DM. A search of electronic databases of published and unpublished literature (until September 30, 2011) was performed to identify randomized controlled trials of ≥24 weeks that compared DPP4 inhibitors to other oral diabetic medications. A meta-analysis was performed using fixed and random effects to determine risk ratio (RR) for adverse CV events with DPP4 inhibitor monotherapy compared to other oral diabetic medications or to placebo. Eighteen randomized met our inclusion criteria, comprising 4,998 patients who were randomized to DPP4 inhibitors and 3,546 to a comparator, with a median duration of therapy of 46.4 weeks. In pooled analysis, the RR of any adverse CV event with a DPP4 inhibitor was 0.48 (0.31 to 0.75, p = 0.001), and the RR for nonfatal myocardial infarction or acute coronary syndrome was 0.40 (0.18 to 0.88, p = 0.02). In conclusion, this meta-analysis provides evidence that DPP4 inhibitors are safe from a CV standpoint and may possibly decrease risk of adverse CV events.

Abstract P199: Prevalence of Appropriate Patients for Cardiac Radionuclide Imaging (RNI) Who Are Not Referred for the Procedure

Background: Concern regarding the growth of RNI led to the creation of Appropriate Use Criteria (AUC) as a foundation for evaluating potential overuse. No data exist surrounding the proportion of patients who would be considered appropriate for RNI, but who are not referred for the procedure.

Methods: We reviewed charts of 997 randomly selected patients, regardless of their medical history, seen in the outpatient setting of a single-specialty cardiology group from January to July 2008. Records were reviewed by physicians who were trained to abstract all relevant information to assign an AUC Class; including prior revascularization, recent MI, risk factors, functional capacity, chest pain, anginal control, symptoms and Framingham Risk score. The 2009 Update to the SPECT AUC were used to systematically assign each patient an indication for SPECT of Inappropriate (I), Uncertain (U) or Appropriate (A). Descriptive statistics were calculated to describe the prevalence of AUC ratings.

Results: Of the 997 subjects included, 268 were referred for cardiac RNI and 729 (73%) patients were not. Baseline characteristics of those who were not referred for RNI are reviewed in the table . Among those not referred, 28% (206/729) would have been A, 13% (93/729) U, 42% (308/729) I and 17% (124/729) had insufficient information to classify.

Conclusions: While there are important concerns of RNI overuse, more than 1 in 4 patients not referred for RNI would have meet the AUC criteria for being an appropriate indication. Whether avoiding testing in this group represents judicious use of expensive resources, or these patients outcomes are worse than comparable patients referred for RNI requires follow up and additional research.

Baseline demographics of subjects not undergoing RNI (n= 729) Age; years (mean±SD) 64 ±16 Male 419(57%) Prior Revascularization 253 (35%) CABG>5 yrs 59 (8%) CABG<5 yrs 28 (4%) PCI>2 yrs 112 (15%) PCI<2 yrs 54 (7%) DM 104 (14%) Framingham Risk Score (FRS) Moderate risk 97 (13%) Low risk 229 (31%) Data not available 386 (39%) CHD High Risk (DM or high FRS) 119 (16%) Chest Pain 23 (3%) Anginal equivalent Present 160 (22%) Absent 409 (56%) Data not available 160 (22%) Symptoms Absent 371 (51%) Present 196 (27%) Data not available 162 (22%) Functional capacity Good 457 (63%) Poor 113 (15%) Data not available 161 (22%)

Abstract P105: Clinical Factors Associated With Left Ventricular Ejection Fraction Disparity in Patients With Left Ventricular Dysfunction Undergoing Multimodality Imaging

Background: Drug and device therapy of heart failure is increasingly determined based on left ventricular ejection fraction (LVEF) partition values. Many patients undergo both single photon emission computed tomography (SPECT) and echocardiographic assessment of LVEF. Significant disparity frequently exists between these 2 techniques, even when testing is performed near simultaneously in clinically stable patients.

Objective: We aimed to determine clinical predictors of LVEF disparity in patients undergoing multimodality testing.

Methods: Between January 2006 and July 2007, 2937 patients underwent both echo and SPECT testing within a 7 day period. Of these, 119 patients had an LVEF <50% by 1 or both techniques, and an absolute LVEF difference between the 2 techniques of at least 10%. A control group comprising of 118 patients had an LVEF <50% by 1 or both techniques, and an absolute LVEF difference between the 2 techniques of less than 10%. In a logistic model with a stepwise selection method 30 candidate clinical variables were available to be selected in the model.

Results: The predictive model resulted in five variables: Atrial Fibrillation, Severe mitral regurgitation, Left ventricular hypertrophy, high basal heart rate during echocardiogram and Paced rhythm. The model obtained good predictability(c=0.82) and fit (Hosmer-Lemeshow p=0.51). The point estimates and odds ratios are shown in the figure below.

Conclusions: In patients with LVEF < 50%, atrial fibrillation, severe mitral regurgitation, left ventricular hypertrophy, high basal heart rate during echocardiogram and paced rhythm are associated with a >10% LVEF disparity between the two imaging techniques.

Tuberculosis simulating brain tumour

The purpose of the study is to highlight the varied presentation of tuberculosis (TB) simulating a brain tumour. Headache and seizures are becoming frequent presenting complaints without any history of tuberculosis. The study comprises 1200 patients of both sexes with ages ranging from ten to sixty years. CT scan and MRI brain control with and without contrast medium were the investigations performed in these cases. In some patients Electroencephalography (EEG), cerebral angiography (DSA) and spectroscopy were also performed. The final diagnosis of tuberculosis was made on the basis of craniotomy, stereotactic and burr hole biopsies with histopathology in most of the cases. Forty per cent of the patients were followed up for eight months. They were put on anti-tuberculosis treatment with symptomatic and anti-epileptic drugs. The incidence was 544 and 757 per 100,000 in Africa and Indo Pakistan respectively. The male to female ratio was 1:1. Tuberculosis, especially with CNS involvement, is not only common in immunosuppressed patients in our setting, but TB has been and remains an important public health problem. TB may involve the CNS either as meningitis or as parenchymal granulomas or abscesses. Patients with brain TB usually present with fever, multiple cranial nerve involvement and occasional behavioural changes. CSF findings remain non specific in most cases. The most common sites are the cerebral hemisphere and basal ganglion in adults and the cerebellum in children. Tuberculosis has unique findings on brain CT and MRI. Cortical and subcortical locations are typical whereas the brain stem is a less common site. Tuberculosis lesions are usually solitary but multiple in 10% to 35% of cases. In spite of all these facts some cases of brain TB still need aggressive neurointervention to reach the final diagnosis of brain TB. Tuberculosis in the CNS may manifest in many different ways. So one should always include tuberculosis in the differential diagnosis in the etiology of delayed onset epilepsy and acute on chronic headache. In case of a discrepancy between clinical manifestations and CT/MRI findings, one can always anticipate tuberculous lesion in the brain.