cholesterol

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Heart attack (myocardial infarction) patients still at high risk of another cardiovascular event four years after initial attack – a new study shows


Prof Harry Hemmingway

Prof Harry Hemmingway

  • APOLLO study, which looked at data from over 10,000 UK heart attack patients, presented at the European Society of Cardiology congress1
  • Study shows the risk of repeat cardiovascular (CV) events remains high for four years after a patient’s initial heart attack, despite use of secondary prevention interventions, including medication and surgery1
  • Expert says UK has some way to go to prevent patients having repeat attacks or dying from CV disease
  • CV is the UK’s biggest killer with around 180,000 deaths a year, while the British Heart Foundation (BHF) estimates that there are approximately 1 million men and 500,000 women who have had a heart attack, and almost 600,000 men and 600,000 women who have had a stroke.2

PatientTalk.Org were delighted to have the opportunity to interview Professor Harry Hemingway of the Farr Institute of Health Informatics Research and National Institute for Cardiovascular Outcomes Research, University College London about the research and its findings. He was one of the investigators on a this study of major event rates of people who have survived heart attack.

Patient Talk: This is a study of over ten thousand UK patients over a period of 5 years. Is that a particularly large sample for a study of this kind?

HH: So yes and no is the simple answer there. It would have been a large study if you had to individually contact each of these patients and invite them to take part in that study. That not’s all we did. What we did here was exploit the advantages of the high quality NHS patient records so this is anonymised data here to look at. This kind of sample size is needed to get good estimates of these risks.


PT: Would you mind just giving us an overview of the methodology that you touched on briefly there?

HH: We used NHS patient records for this study and that’s a real advantage because we have a country with one health system and it’s got electronic health records in primary care and it’s got data in hospitalisation and course specific death data. So we link those up and that gives us a complete picture of the people, the heart attack and their subsequent risk re heart attack, stroke and death.

PT: My understanding is that the first year is considered the most important to think about how people are reacting after the event but what the study implied here is that you need to start thinking that four years is the period that is going to be when events are going to take place.

HH: I think you are absolutely right –that historically our focus has been really on that acute phase. So somebody comes with a life threating condition of heart attack to hospital that’s where the clinical care is focused and that’s where the research is focused. Let’s face it we in the NHS and in other countries have been having been dramatic improvements in early survival and other outcomes but what this new research shows is that one year after a heart attack risks continue to be high and that’s really important and that suggests a new focus on these heart attack survivors.

PT: Do you think it will be fair to say that it starts to redefine what is high risk?

HH: It’s not about redefining. We don’t actually have a definition to start off with. One of the things that surprised us here is we actually don’t have previous good studies to say in exactly in this population people who have survived a year after their heart attacks what kind of risks can we expect. This study shows that those risks are high and it allows us to then re-orientate the guidelines to say what do we need to do to bring those risks down.

PT: You seem to be saying that this laying the groundwork.

HH: That’s right. This is new. It is laying the ground work. We can compare with some other studies. For example we’ve got, one study looked at people with so called stable coronary disease ie.people who are some months after a heart attack or they’ve got angina and we show that our risks that we see are three times higher in that particular study.

PT: How do your account for such a high level of repeat heart attacks?

HH: I think there a number of factors here. One is that the lifestyle factors so patients continue to smoke, may not exercise, diet may be a factor. Secondly we know that patients and their GPs are maybe not be prescribing or taking the secondary prevention medications that are required long term. Statins to lower bad cholesterol, aspirins to thin the blood, beta blockers. Thirdly I think these patients represent a chronic phase of disease and one may want to look after them in a chronic disease management framework. Often people with heart attack who have survived have other conditions; diabetes, heart failure and so on.

PT: These are the UK results. You have mentioned the NHS information has been quite helpful for this study. How do you see the results stacking up? I know you mentioned Sweden and France in the report. How did you see the NHS stacking up against those health systems and the UK results in the same fashion?

HH: In a sense this is a good news story for the NHS because although the risks are high they are high in all these country’s so this is not a problem about one health care system. This is a problem about how as a system we haven’t given enough focus to these patients. So in the US, in Sweden, in France, in the UK in total we studied 140,000 patients again drawn from records as part of usual clinical care and administrative data. And we showed that about 1 in 5 of these heart attack survivors went onto have a subsequent heart attack, stroke or death over the following three years.

PT: How can a person who has had a cardiac event best prevent recurrence?

HH: It’s really important to pay attention to lifestyle. If you smoke stop smoking. If you’re not taking any exercise then that needs to be looked at. It’s really important to take the right secondary prevention medication the statins, the aspirin, beta blockers and so on. And in addition I think it’s wise to check your heart health with your GP

PT: You mentioned briefly exercise there. Any sort of best practice of exercise that people should be taking into account of?

HH: That wasn’t the focus of this particular study and the recommendations for exercise after heart attack and rehabilitation after heart attack predominantly focus on that early phase after a heart attack. So by twelve months out of a heart attack there would be very few if any patients who were in structured exercise programs or cardiac rehabilitation.

PT: Finally what one piece of advice would you give somebody who has just had a cardiac event?

HH: I think for somebody who has survived twelve months after a heart attack, I would say keep on top of your risk. Be in consultation with your general practitioner. Make sure you are doing everything to keep that risk low.

HARRY HEMINGWAY is Professor of Clinical Epidemiology at University College London. He is the Director of the Farr Institute of Health Informatics Research, London, one of four national centres funded by the MRC and nine other funders, representing a £39M investment in health informatics research, a member of the UCL Partners Informatics Board, Co-Investigator on the Administrative Data Research Centre, England, (£8m ESRC investment), and informatics lead for several Biomedical Research Centre initiatives.

Postscript

AstraZeneca today announced the UK results from the observational APOLLO study, which demonstrates that the risk of repeat CV events remains high for four years after a patient’s initial heart attack, despite use of secondary prevention measures.1 The APOLLO study looked at data from over 10,000 (n=10,854) UK heart attack patients, between April 2005 and March 2010 and found that whilst two thirds of these patients (n=7,238) remained event free in the first year following their heart attack, approximately 17% (17.2%, CI 16.0-18.5) of these went on to suffer another event including heart attack, stroke or fatal cardiovascular disease (CVD) in the subsequent 3 years.1

The study also showed that the proportion of patients remaining on medication for up to 3 years after their first event was high. However, there were some variances with only 65% of patients taking a statin after three years.1

“These important data tell doctors, patients and policy makers in the UK that while we’ve made great strides in reducing cardiovascular risk in the general population, we still have some way to go in preventing people who have already had a heart attack, going on to have further events or dying from cardiovascular disease. This is especially true if we compare ourselves with our neighbours in Sweden and France,” said Harry Hemingway, Professor of Clinical Epidemiology and Director of the Farr Institute of Health Informatics Research, London, at University College London. “For doctors, these data tell us that all patients who have had a heart attack should be considered and treated as ‘high risk’ of subsequent events, regardless of their previous history; for patients, this study highlights that your risk doesn’t disappear after the first year and attention on maintaining good heart health should continue indefinitely.”

CVD (the term for all diseases affecting the heart and circulatory system) is the UK’s biggest killer and, despite the decline in death rates in recent years , it caused 180,000 deaths in 2010.2 The cost of CVD to the UK health care system was £8.7 billion in 2009 and there were approximately 292 million prescriptions issued to patients in England with CVD in 2011.2 In the UK, the British Heart Foundation estimates that there are approximately 1 million men and 500,000 women who have had a heart attack, and almost 600,000 men and 600,000 women who have had a stroke.2
APOLLO was an observational cohort study designed to estimate the event rates of MI, stroke and fatal CVD in patients who have experienced a heart attack and are being managed under usual clinical care.1 It also examined the rates of bleeding events and medication use in this population of patients.1 Similar data were collected from France (n=1,757), Sweden (n=77,976) and the US (n=53,909) and the findings show that the unadjusted risk of a subsequent hospitalisation for another heart attack or a stroke or death within 3 years of the first event is different across the 4 countries and was approximately: 1 in 4 in Sweden and the UK; 1 in 5 in France; and 1 in 3 in the US.3 However, when these risks are adjusted for differences between countries in the demographics and baseline health of the study populations, the rates are similar with about one in five going on to have a subsequent event in each of the four countries.3
References
1 Rapsomaniki E. et al. Health outcomes in patients with stable coronary artery disease following myocardial infarction; construction of a PEGASUS-TIMI-54 like population in UK linked electronic health records. Poster presented at ESC 2014; 31 August 2014
2 Townsend N. et al. (2012). Coronary heart disease statistics 2012 edition. British Heart Foundation: London. Available here. [Last accessed August 2014]
3 Rapsomaniki E, et al et al. International comparison of outcomes among 140,880 patients stable after acute MI; real world evidence from electronic health and administrative records; Abstract presented at ESC 2014; 31 August 2014

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Heart attack and stroke patients in UK called on to take part in global study to reduce risk of secondary attack or stroke


Healthcare professionals

Healthcare professionals

3,000 people in the UK who have suffered a heart attack or stroke or have peripheral arterial disease are being recruited for a world-wide study which will investigate medication that could lower the risk of patients having a second cardiovascular event.

The new study called FOURIER (sponsored by Amgen Inc. and supported by the Imperial College Clinical Trials Unit) has been launched in the UK as part of a global programme (also taking place across Europe, US, Canada, Australia, Asia and Latin America) to provide more evidence to inform and guide future strategies in the secondary prevention of cardiovascular disease

The study will investigate whether taking a new type of treatment, which studies so far suggest can reduce LDL cholesterol by about 50%, on top of a statin will reduce the risk of major cardiovascular events compared to just taking statin therapy.


22,500 people who have had an ischaemic stroke, a heart attack or who have peripheral arterial disease are being recruited world-wide for the trial which is expected to last 5 years. People taking part in the study will receive an experimental cholesterol lowering study drug in combination with optimal statin therapy OR optimal statin therapy alone.

Over 1800 people have taken part in earlier phase studies with this agent to date and studies where it was given on top of a statin indicate it can reduce LDL cholesterol by over 50% compared to statin therapy alone. The new medication currently being researched is not yet licensed for use.

More people die from cardiovascular disease (CVD) each year than any other cause.[ii] In the UK the main cause of death was CVD, accounting for almost 180,000 deaths in 2010 – around 1 in 3 of all deaths.[iii] Almost half (48%) of all CVD deaths was due to coronary heart disease (CHD) and over a quarter (28%) are from stroke.3

If you have already had a heart attack or stroke or have peripheral arterial disease this puts you at greater risk of having a second cardiovascular event.2

However, the risk of recurrence or death can be substantially lowered with a combination of drugs – statins to lower cholesterol, drugs to lower blood pressure, and aspirin.2

High cholesterol is a major contributor to cardiovascular disease.  Every 1 mmol/L reduction in LDL cholesterol (the bad cholesterol) reduces the annual risk of a heart attack or stroke by 20%.[iv]

European heart guidelines state that patients with disease causing stroke merit the same degree of attention to treatment of lipids as to patients with heart disease.[v]

The vast majority of patients are discharged from hospital on statin therapy following an ischaemic stroke.  However, the British Regional Heart Study found that only half continue to receive long-term statin therapy and only 31% receive all three recommended treatments (antiplatelet, blood pressure lowering, and statin).[vi]

The FOURIER study is recruiting patients to determine whether lowering LDL cholesterol by about 50% with a new kind of medication on TOP of a statin will further reduce the risk of having another heart attack or stroke.[vii]  It is the first study investigating this new kind of treatment to specifically include patients who have already suffered an ischaemic stroke.

If you are interested in taking part in the study, watch our video with Professor Neil Poulter – Professor of Preventive Cardiovascular Medicine at Imperial College, London to hear more about how you can put yourself forward for the trials.


[ii] WHO Fact Sheet 317.  March 2013. http://www.who.int/mediacentre/factsheets/fs317/en/

[iii] Townsend N et al.  Coronary Heart Disease Statistics 2012 edition.  British Heart Foundation:London.

[iv] Cholesterol Treatment Trialists’ Collaboration. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170 000 participants in 26 randomised trials. Lancet 2010;376:1670–81

[v] ESC guidelines on cardiovascular disease prevention in clinical practice (version 2012).  Eur Heart J 2012; 33:1635–1701 – page 1686 – accessed September 2013.  http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-CVD-prevention.pdf

[vi] Ramsay S et al. Missed opportunities for secondary prevention of cerebrovascular disease in elderly British men from 1999 to 2005: a population-based study. J Public Health 2007;29:251-57.

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“A journey of 1000 li starts with 1 step” – Some thoughts on fitness, walking and pedometers.


Pedometer

Pedometer

It’s an old Chinese proverb.  But I’m sure you know that.  Similar, I think, to the modern phrase – “You gotta start somewhere!”  And you do you know.

The phrase hit me again after a rather unpleasant chat with my doctor.  She told me in no uncertain terms that I had to lose weight, lower cholesterol, drop the predilection for gin with full fat tonic or I was on the road to perdition.  Well lifelong medication anyhow.

I noted the terrifying visions for my future that were laid out in front of me and decided to do something about them.

My diet has never been a major issue except, I suppose, in the quantities I consume.  That being said my real problem is exercise.  I’ve never really enjoyed it and find it very tough to get motivated.

Yes, I’ve tried the gym (up to and including a personal trainer) and power walking.  But time and real-life always seem to get in the way.


So what am I doing?   Well, the first thing was to dig out my old exercise bike (yes I’ve used that before as well) and once I got it working again I am trying to ride for 10 miles each day.

The other thing I’m doing is using a pedometer.  What I hear you cry is that? Well, it is a small red object  (see the picture illustrating this blog post)  which I wear around my neck which records how far I’ve walked each day.  It can calibrate (calculate) this in a number of different ways including distance, number of steps taken , calories burnt and time taken.

So according to the UK’s NHS site we should all be aiming to walk around 10,000 steps each day at least.  In fact if you work behind a desk (as I do) this is not as easy as I had thought  a couple of weeks ago.  It is damned difficult to combine with a job and having children.

So what is the point of this post?

Well actually I’d like your help please.  I’m really interested in the experiences of our readers who have had to take up exercise in middle age.  I’m thinking in terms of some of the following questions:-

1) What fitness programme do you use and how often do you use it?

2) Do you use any gadgets like pedometers to help?  If so how do they work for you?  Oh, and which one would you recommend?

3) How do you keep motivated to exercise over time?

4) Do you have a particular medical condition which means that you need to exercise more?

5) Any general bits of advice for me and our readers.

Obviously these are just some broad questions.  If you have anything you would like to share in the comments box below that would be brilliant.

 

Many thanks

1 Comment Posted on Diet, Patient Talk

Chia Seeds – Find out more about this amazing Superfood


Chia seeds

Chia seeds

As many of you will know I’m rather partial to what are called superfoods.  While, it seems, there is no formal definition of Superfood the terms is, typically, used to describe foodstuffs which have a high nutrient value.  Therefore offering greater health benefits than the run of the mill stuff we often eat.

In fact superfoods are still a bone of contention in our house.  My wife claims I secretly grated broccoli, which she hates, on her food while she was pregnant with our first child.

For more background on superfoods please have a look at https://patienttalk.org/?p=276 .  It includes links to pro and anti superfoods discussions.

But to return to the point of the blog.  Last week my wife returned home brandishing a copy of a magazine which gave a recipe for a dish which included something called chia seeds.  Which, according to the article, were superfoods?  “What on earth are Chia seeds?” I exclaimed.   To which I received the traditional “search me” look.

So I decided it was my duty, as a healthcare blogger, to find out more about the health benefits of chia seeds.  Indeed in America the chia craze has been going for a few years but it seems that Europe is about to catch up.

Chia is a member of the mint family which grows in Latin America.   Apparently   it was  a staple of Aztec and Mayan cooking. However it is the seeds themselves which are of particular interest.  Chia seeds contain:-

a)      More Omega 3 fatty acids than salmon.

b)      A great source of antioxidants.  You can read up on antioxidants here https://patienttalk.org/?p=252

c)       Very high in dietary fibre

d)      A source of calcium and iron and a number of B vitamins

e)      May lower cholesterol and help prevent heart disease

Chai seeds are often used by athletes and a table spoon of the seeds has been described as the equivalent of a smoothie of salmon and spinach.

So how do you take it?  Well it is a common addition to smoothies and health drinks.  Have a look at https://patienttalk.org/?p=638 for more info.

The downside of chai seeds is the cost.  But if they take off we can only hope it will come down.

In fact today is going to be the first time I’ve tried chai seeds.  I’ll be using this recipe for BLACK BEAN SOUP WITH SUPER CHIA GARNISH for Stylist Magazine which can be found here http://www.stylist.co.uk/life/recipes/black-bean-soup-with-super-chia-garnish.  Once we have tried it I’ll give you an update.  Given that I love black beans I’m sure I’ll be a fan.

If you have used chia seeds it would be great if you can tell us how you found them using the comments box.  If you have any recipes then please share them as well

Many thanks in advance.


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Rosanna Pink Onions – are they the onion worlds answer to a superfood? How can they help raise money for cancer research?


Okay the title of the blog is a bit odd but I don’t really know how else to start.

Rosanna Pink Onion

Rosanna Pink Onion

Actually I think I do.

Yesterday I sent an email to my wife to discuss the upcoming online supermarket shop.  One of the things on my list was “onions – lots”.  A couple of hours later she returned my email saying that she has just bought some Rosanna Pink Onions.

Not just that she thought I should write a blog on the subject knowing my readers in food, diet and health.

So when the truck with the Rosanna Pink Onions arrived I decided to start my research after putting them in the vegetable rack.  One thing which hit me is that they are not that pink.  To be honest they look pretty much like normal onions but I’ve not had the opportunity to chop them so inside might be a different story. I have to say the blurb my wife sent me yesterday was pretty compelling.

On their web site (yes they have their own web site http://www.rosannaonions.com/#panel-2) they feel the onions have the following properties:-

a)      They may help fight cholesterol

b)      They have anti-oxidant properties c)

And they have anti-inflammatory properties. However it is a bit difficult to find any data which supports this.  If the growers or distributors read this blog and have any other information we would love to publish a guest blog from you.  Please write to us at patienttalkblog@gmail.com if you are interested.

That being said according to the web site they donate 2p to Race for Life a UK based cancer research charity for each pack sold.  So that alone, I think, makes them a worthwhile purchase.

So over to you.  Are there any products which you think are great for health?  Use the comments section of our blog to let us know. Thanks in advance.