Advances to Fight Heart Disease and Stroke Selected for 2010
Association/American Stroke Association 2010 select two lists
Jan. 3, 2011 -
Research on reducing risks, improving medical treatment and improving
lifestyle behaviors to fight the battles against heart disease and stroke
are among the key scientific findings that make up last year’s top
cardiovascular and stroke research recognized by the American Heart
Association/American Stroke Association.
association has been compiling an annual list of the top 10 major
advances in heart disease and stroke research since 1996. Last year, for
the first time, two separate lists were compiled that highlight the top
ten research advances in each respective area.
“We have come
far in the past decade, reducing heart disease deaths by more than 27
percent and stroke deaths by more than 44 percent,” said Ralph Sacco,
M.D., president of the AHA and chairman at the department of neurology
for the Miller School of Medicine at University of Miami.
“But we know
there is still much to be done in improving the lives of heart disease
and stroke patients – and more importantly, in preventing these
devastating diseases in the first place. Scientific research will help
us lead the way. ”
2010 noted by the association include (in no ranking order):
Top Ten Advances in Cardiovascular Research in 2010
treatment for people with diabetes to reduce their risk of
More than 17
million Americans are diagnosed with diabetes, and heart disease death
rates are two to four times higher for them compared to people without
diabetes. New research from the ACCORD Study Group offers insight into
specific treatments that can reduce their risk of cardiovascular disease
The first study
found that aggressive blood pressure control does not reduce CVD risk in
people with type 2 diabetes at high risk for CVD.
In a second
study, a combination therapy with a statin plus a fibrate was no better
at reducing risk than a statin alone in patients with type 2 diabetes at
high risk for CVD. However, the combination lipid therapy may be
successful in reducing CVD risk in those type 2 diabetes patients who
had low HDL cholesterol and low triglycerides. These results will be
helpful for targeting specific treatments that best reduce CVD risk in
people with diabetes.
·● The ACCORD
Study Group – New England Journal of Medicine, March 14,2010;
N Engl J Med 2010;362:1575-85. N Engl J Med 2010;
www.nejm.org; Funding: National
Heart, Lung, and Blood Institute and other National Institutes of Health
advances for patients who aren’t candidates for conventional valve
with severe aortic blockage have other medical conditions that make it
risky for them to have conventional surgery to replace the blocked
aortic valve. Transcatheter aortic valve implantation (TAVI) is an
emerging alternative therapy to open-heart surgery in these high-risk
Two new studies
support the evidence that TAVI can improve symptoms and outcomes –
including quality of life – even over the course of several years. While
there are some risks associated with TAVI, including strokes and other
major cardiovascular events, the catheter-based procedure offers
significant progress in this area.
·● PARTNER Trial
Investigators – New England Journal of Medicine, Sept. 22, 2010;
N Engl J Med; 363(17):1597-607.
www.nejm.org; Funding: Edwards
·● Ye, et al –
Journal of Thoracic and Cardiovascular Surgery, May 1, 2010; J.
Thorac. Cardiovasc. Surg.; 139: 1107-1113.
Funding: Edward Lifesciences.
the way we reverse sudden cardiac arrest
300,000 people suffer out-of-hospital sudden cardiac arrest each year.
Many die because the people around them didn’t know how to or were
uncomfortable performing cardiopulmonary respiration (CPR). Significant
studies now report that chest compression only, or ‘Hands Only CPR’ for
adults by bystander lay rescuers improves survival outcome.
campaigns resulted in increased use of hands only CPR, as well as
improved survival rates. While the new procedure appears successful in
adults, it is important to note that using conventional chest
compressions with rescue breathing is still important for children
stricken with sudden cardiac arrest.
In October, the
American Heart Association issued updated Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science, reflecting new
advances in this field.
·● Bobrow, et al –
Journal of the American Medical Association, Oct. 6, 2010; JAMA;304(13):1447-54;
Funding: Support from Medtronics Foundation
·● Rea, et al –
New England Journal of Medicine, July 29, 2010; N Engl J Med;363(5):423-33.
Funding: Laerdal Foundation for Acute Medicine, Medic One Foundation.
Field, et al – Circulation,
Oct. 18, 2010; Circulation;122[suppl 3]:S640 –S656.
options for reducing stroke risk in atrial fibrillation
For the first
time in more than 20 years there are viable alternatives to the primary
prevention of stroke for patients
with atrial fibrillation (AF). AF is a major risk factor for stroke and
affects more than 2 million senior citizens over the age of 65. Warfarin
(Coumadin) has long been the standard anti-clotting drug used to reduce
the risk of stroke for these patients. But it carries its own
complications from bleeding, and managing the dose requires regular
blood tests, making it difficult to manage for both patients and
new drugs have been found to work as well as warfarin – and are simpler
for patients to take – offering an important advance in this field.
2010, following further positive findings from the RE-LY trial, the U.S.
Food and Drug Administration approved dabigatran for stroke prevention
in AF patients. The ROCKET-AF trial presented at the American Heart
Association’s Scientific Sessions 2010. Rivaroxiban, apixiban, edoxaban
and other oral anticoagulants are being or have been studied in AF and
may show future promise.
ROCKET-AF – American Heart
Association Scientific Sessions 2010, Abstract 21839. Funding: Johnson &
Johnson, Bayer HealthCare.
AVERROES – European Society
of Cardiology Congress 2010. Funding: Bristol-Myers Squibb Company,
pacing therapies can improve outcomes for heart failure patients
failure patients experience abnormal heart rhythms, known as arrhythmia.
There are a number of devices available to treat arrhythmia, including
implantable cardioverter difibrillators (ICDs) which can shock the heart
beat back into a normal rhythm. New studies show that adding additional
resynchronization pacing to ICD therapy can lead to improved outcomes in
an expanded group of heart failure patients. In addition, new types of
ICDs (defibrillators without leads, for example) can offer options that
reduce some of the risks associated with traditional devices.
· ● MADIT-CRT
Trial Investigators – New England Journal of Medicine, Sept. 1, 2009; N
Engl J Med;361(14) 1329-1338.
www.nejm.org; Funding: Boston
· ● RAFT
Investigators – American Heart Association Scientific Sessions 2010,
Abstract 21768; New England Journal of Medicine, Nov. 14, 2010.
www.nejm.org; Funding: Canadian
Institutes of Health Research; Medtronic of Canada.
· ● Bardy, et al –
New England Journal of Medicine, May 12, 2010; N Engl J Med;363:36-44;
www.nejm.org; Funding: Cameron
new procedure for infants with congenital heart disease
Heart Network’s randomized trial of Norwood shunt types in infants with
single-ventricle lesions showed that the type of shunt used makes a
difference in outcomes. Better transplantation-free survival at 12
months is a possibility with this new understanding of the better shunt
choice for these patients. This was the first large-scale randomized
trial in congenital heart surgery, offering an approach that should
provide answers to other questions in the future.
· ● Pediatric
Heart Network Investigators – New England Journal of Medicine,
May 27, 2010; N Engl J Med;
Funding: National Heart, Lung, and Blood Institute.
the right anti-clotting (anti-platelet) therapy
right type of anti-clotting drug and the right dosage can be tricky, and
risky. New research from the PLATO investigators has found that
ticagrelor may improve outcomes and reduce adverse events better than
the current standard, clopidogrel. The CURRENT-OASIS 7 Trial is
exploring the optimal dosing of clopidogrel and aspirin in patient
undergoing invasive surgery. These studies will help providers better
understand the situations where new choices and dosages may improve
results for the patient.
CURRENT-OASIS 7 Investigators –
New England Journal of Medicine, Sept 2, 2010; N Engl J Med;
Lancet, Sept. 1, 2010; Lancet 2010; 376:1233-43; www.thelancet.com;
Funding: Sanofi-Aventis; Bristol-Myers Squibb
science findings offer insight into future progress
this year brought the future of medicine closer to the present with new
insight into emerging technologies. Findings from stem cell therapy have
shown improved quality of life and survival in several early studies of
patients with chronic heart failure and support the development of
future cell-based therapeutics.
A large animal
study defined the basic mechanisms for heart muscle regeneration
initiated by specific types of stem cells. The results demonstrated that
these stem cells repair scarred myocardium through promotion of the
generation of new heart muscle and blood vessel).
A second study
supported the notion that the heart has the capacity to regenerate large
numbers of heart muscle cells several times during its lifetime. Being
able to directly reprogram stem cells into working heart muscle is a big
step toward use in therapeutic settings. The STaR-Heart Study showed
that injecting the patient’s own bone marrow stem cells into the heart
improved hemodynamics and long-term survival in the treatment of chronic
· ● Hatzistergos,
et al – Circulation Research, July 29, 2010; Circ Res.;107(7):913-22.
Funding: National Heart, Lung, and Blood Institute.
· ● Kajstura et al
– Circulation Research, June 3, 2010; Circ Res;107(2):305-15.
Funding: National Institutes of Health.
· ● The STAR-heart
study – European Journal of Heart Failure;
doi:10.1093/eurjhf/hfq095; Funding: Cardiogenesis Corporation.
science to support healthy lifestyle behaviors
examining lifestyle behaviors in adults and children, with particular
emphasis on physical activity and consumption pattern, show that such
conditions as obesity and hypertension are positively influenced by a
change in diet with decreasing sodium levels. Results from the school
setting suggest that the earlier one starts to adopt healthy behaviors
the better the effect on health outcomes.
physical activity is an important
lifestyle factor in improving cardio-metabolic factors, especially in
those trying to reduce weight. Although most people don’t associate poor
diet quality and physical inactivity with heart disease, the American
Heart Association has created a national goal to improve seven health
factors and lifestyle behaviors in support of raising awareness and
helping all Americans move closer to optimal heart health over the next
Bibbins-Domingo et al – New England Journal of Medicine, Jan. 20,
2010; N Engl J Med 2010;362:590-9.
www.nejm.org; Funding: American
Heart Association Western States Affiliate; University of California,
San Francisco Clinical and Translational Sciences Institute
The HEALTHY Study Group – New
England Journal of Medicine, July 20, 2010; N Engl J Med10.1056; www.nejm.org;
Funding: National Institutes of Health; American Diabetes Association
· ● Franks et al –
New England Journal of Medicine, Feb. 11, 2010; N Engl J
www.nejm.org; Funding: National
Institute of Diabetes and Digestive and Kidney Diseases.
· ● Goodpaster, et
al – Journal of the American Medical Association, Oct. 9, 2010;
JAMA;304(16):1795-1802; Funding: Commonwealth of Pennsylvania Department
10. Get With
The Guidelines participation eliminates disparity gaps in care
ethnic disparities have been found in the quality of care delivered to
patients with cardiovascular disease and achieving equity and addressing
disparities has implications for quality, cost, risk management, and
community benefit. Eliminating these disparities is a top priority for
the American Heart Association.
are the first to show that participating in a quality improvement
program, such as Get With The Guidelines–Coronary Artery Disease, can
eliminate racial and ethnic disparities of care while increasing the
overall use of evidence-based care for heart attack patients.
Cohen et al – Circulation, June
1, 2010; Circulation;121(21):2294-301;
Funding: GWTG-CAD is supported by the American Heart Association in
part through an unrestricted education grant from
Top Ten Advances in Stroke Research in 2010
is brain”: Clot-dissolving treatment for acute ischemic stroke found
beneficial in the first 4.5 hours after onset, potentially harmful later
patient analysis of eight trials of intravenous tissue plasminogen
activator (tPA) for acute ischemic stroke reinforced prior findings of a
strong time-to-treatment effect, with greatest benefit in the first few
hours after onset, and, for the first time, demonstrated increased
mortality from late treatment beyond 4.5 – 6 hours after onset.
· ● Pooled
analysis of the ECASS, ATLANTIS, NINDS and EPITHET trials – Lancet,
May 15, 2010;
Lancet 2010;375(9727):1695-703; Funding: There was no funding
source for this study.
New mechanism of emboli clearance from the brain vasculature discovered
identified an entirely new way by which brain blood vessels are kept
open by the body in the face of clots – extravasation. Clots that are
not able to be dissolved are sometimes pushed out through blood vessel
walls into the surrounding tissue, restoring nourishing flow in blood
Lam, et al; Nature, May 27,
Nature 2010;465:478-482; Funding: No funding sources were listed.
endarterectomy and carotid artery stenting directly compared
CREST trial compared head-to-head the two
major methods to reopen narrowed carotid arteries carrying blood flow to
the brain: carotid endarterectomy (open surgical repair) and carotid
stenting (endovascular placement of a stent). Overall, both techniques
had similar rates of success and complication, but among younger
patients, under 70 years of age, stenting appeared advantageous while
among older patients endarterectomy appeared advantageous. Those
findings were also supported in a preplanned meta-analysis of individual
patient data from three randomised controlled trials.
· ● CREST – New England Journal,
July 1, 2010;
www.nejm.org; N Engl J Med
2010;363(1):11-23; Funding: National Institute of Neurological
Disorders and Stroke (NINDS).
· ● Carotid Stenting Trialists'
Collaboration – Lancet, Sept. 10, 2010;
2010;376:1062-73; Funding: Medical Research Council, the Stroke
Association, Sanofi-Synthélabo, European Union.
Million person milestone, emerging research shows quality initiatives
In an analysis
of the first one million stroke patients enrolled in the national Get
With the Guidelines® – Stroke quality improvement program at nearly 1400
hospitals across the country, quality of care on 10 performance measures
improved substantially from 2003 to 2009. More than 80 percent of
patients were receiving defect-free care by 2009, up from less than half
in 2003. The Get With The Guidelines database is an invaluable resource
in furthering development of tools and outcomes results that are making
marked improvement in stroke patient care.
Get With The Guidelines®–Stroke (GWTG-Stroke) is provided by the
American Heart Association/American Stroke Association. The program is
currently supported in part by a charitable contribution from
Bristol-Myers Squib/Sanofi Pharmaceutical Partnership and the American
Heart Association Pharmaceutical Roundtable. GWTG-Stroke has been funded
in the past through support from Boeringher-Ingelheim and Merck.
study identifies the ten major risk factors for stroke
In the worldwide
INTERSTROKE study, 10 simple risk factors were found to be associated
with 90 percent of the risk of stroke. Targeted interventions that
reduce blood pressure and smoking, and promote physical activity and a
healthy diet, could substantially reduce the worldwide burden of stroke.
· ● INTERSTROKE
Investigators – Lancet, June 18, 2010;
2010;376,112-123; Funding: Canadian Institutes of Health Research, Heart
and Stroke Foundation of Canada, Canadian Stroke Network, Pfizer
Cardiovascular Award, Merck, AstraZeneca, Boehringer Ingelheim.
Ultrasound detection of silent emboli identifies patients at high risk
international, multicenter, prospective study confirms that detection of
silent, microclots traveling to the brain on transcranial Doppler
ultrasound identifies a subgroup of patients with asymptomatic narrowing
of the carotid artery who are at high risk for stroke and might benefit
from surgery or stenting.
· ● ACES –
Lancet Neurology, July 2010;
Neurol;9(7):663-71; Funding: British Heart Foundation.
therapy beneficial for long-term arm impairment after stroke
trial suggested that robot-assisted therapy can improve the
rehabilitation of arm function after stroke compared with ordinary care,
though no more than intensive therapist care.
· ● Lo, et al –
New England Journal of Medicine, May 16, 2010;
www.nejm.org; N Engl J Med.
2010;362(19):1772-83; Funding: Veterans Affairs Cooperative Studies
Program and Rehabilitation Research and Development Service.
8. Genetic findings
important in understanding, treating aneurysms
Two new studies
looked at the genetics and treatment of aneurysms, balloon-like
dilations of arterial walls that can be fatal if they rupture or tear.
Saccular intracranial aneurysms are located in the intracranial arterial
wall; their hemorrhage commonly
results in severe neurologic impairment and death.
multicenter genome-wide association study in Europe and Japan identified
three new and confirmed two previously-suspected chromosome sites as
harboring genes predisposing to the formation of intracranial aneurysms.
Vascular Ehlers-Danlos syndrome is a rare, genetic, severe disease that
causes arterial dissections and ruptures that can lead to early death.
This randomized trial found that treatment with a beta-blocker
medication to lower mechanical stress on arterial walls prevents
dissection and hemorrrhages in Ehlers-Danlos patients.
· ● Yasuno, et al
– Nature Genetics, May 2010;
www.nature.com; Nat Genet;2010;42(5):420-5;
Funding: Yale Center for Human Genetics and Genomics,Yale Program on
Neurogenetics, US National Institute of Health, Howard Hughes Medical
· ● Ong, et al –
Lancet, Sept. 7, 2010;
2010;376;1476 – 1484. Funding: French Ministry of Health, Programme
Hospitalier de Recherche Clinique 2001.
blood pressure early reduces brain hemorrhage growth
One out of six
strokes is due to bleeding into the brain, intracerebral hemorrhage, a
major cause of death and disability. Two pilot trials found that
aggressively lowering blood pressure, starting within six hours of
stroke onset, is feasible and can reduce hemorrhage expansion. Larger
trials have been launched to determine if this improves patient final
· ● ATACH
Investigators – Critical Care Medicine, Feb. 2010;
www.ccmjournal.org; Crit Care
Med. 2010;38(2):637-48; Funding: ?
· ● INTERACT –
Stroke, Dec. 31, 2009; Stroke. 2010;41(2):307-12; Funding:
National Health and Medical Research Council (NHMRC) of Australia.
· ● INTERACT –
Hypertension, Sept. 7, 2010; Hypertension; 2010;56:852-858;
Funding: National Health and Medical Research Council of Australia.
activity, even moderate in degree, reduces stroke risk
A large study
found leisure-time physical activity, even in modest degree, is
associated with lower stroke risk in women. In particular, walking was
generally associated with lower risks of total, ischemic, and