Septal Reduction Volumes; Primary Prevention Meds; 'Smoker's Paradox'

Septal reduction procedures are too often being done at low-volume centers, a study showed.

U.S. hospitals actually came in at a median of one septal myectomy case per year and 0.7 per year for alcohol septal ablation. Low septal myectomy volumes were associated with poorer outcomes, including in-hospital mortality and bleeding complications, researchers reported in JAMA Cardiology from analysis of the Nationwide Inpatient Sample from 2003 through 2011.

"Why would we subject our patients to this?" an accompanying editorial questioned. "The low-volume safety data are unacceptable. The middle volume data are not good enough. Even the highest volume tertile safety data are dramatically inferior to that achieved at hypertrophic cardiomyopathy Centers of Excellence."

Primary Prevention Meds

A meta-analysis of 35 systematic reviews to support the Million Hearts initiative showed "high-quality evidence" for efficacy in primary prevention of atherosclerotic cardiovascular disease (ASCVD) for aspirin and statins, while blood-pressure lowering therapy reduced coronary heart disease and stroke risk in primary prevention.

Smoking cessation drugs helped 6-month quit rates, but "the direct effects on ASCVD were poorly reported," researchers reported in JAMA Cardiology.

The study didn't look at lifestyle intervention, such as diet, exercise, and the like, because "essentially all included trials of ASCVD prevention included background recommendations of therapeutic lifestyle change in combination with study drugs."

The researchers suggested their "systematic process, with study quality assessment using standardized tools, could be used as a potential model for more rapid development of trustworthy guidelines."

'Smoker's Paradox'

Smokers are more likely to survive their hospitalization for revascularization in ST-segment elevation myocardial infarction (STEMI), an analysis of the National Inpatient Sample databases found.

While some of the association dissipated with risk adjustment, the in-hospital mortality odds remained 40% lower compared with nonsmokers, according to the study in the Journal of the American Heart Association. Length of stay, post-procedure bleeding, and in-hospital cardiac arrest were also less likely for smokers.

Why might smokers do better? First author of the study Tanush Gupta, MD, of New York Medical College in Valhalla, suggested some mechanisms in an email interview with MedPage Today:

"The first likely mechanism is unmeasured confounding. Smokers with STEMI in our study were on average 8 years younger than nonsmokers and had lower prevalence of most cardiovascular comorbid conditions. Although we adjusted for both age and comorbid conditions in our statistical regression models, there is a possibility that there is continued unmeasured confounding at play.

"The likely biological mechanism for the smoker's paradox in STEMI patients is the enhanced activity of antiplatelet drugs such as clopidogrel and prasugrel in smokers. There is ample evidence that these drugs, especially clopidogrel, are much more potent in smokers than in nonsmokers. Even bivalirudin has been shown to be more efficacious in smokers. Since both anti-platelets and anti-thrombotics are used universally in STEMI patients, greater potency of these drugs in STEMI patients could explain these findings."

Childhood Obesity in China

As the world's most populous country increasingly adopts the Western lifestyle, childhood obesity rates have shot up from less than 1% in 1985 to more than 17% in boys and 9% in girls in 2014.

These findings from national surveys of schoolchildren in China over the 29-year period appeared in the European Journal of Preventive Cardiology.

"It is the worst explosion of childhood and adolescent obesity that I have ever seen," journal editor Joep Perk, MD, of Sweden's Linnaeus University, said in a press release. "The study is large and well run, and cannot be ignored. China is set for an escalation of cardiovascular disease and diabetes, and the popularity of the western lifestyle will cost lives."

In Other News

And finally, it's more trouble for the company founded on the original balloon-expandable stent. Palmaz Scientific has not only declared bankruptcy but is now being investigated for misconduct. See the full story in MedPage Today here.

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Septal Reduction Volumes; Primary Prevention Meds; 'Smoker's Paradox'