What's New In Medicine?

Do artificial sweeteners have a negative effect on cardiovascular health?

This study set out to investigate whether artificial sweeteners have a negative effect on cardiovascular health with a sample population size of 103,388 adults excluding individuals with cardiovascular disease (CVD) or preexisting diabetes. 24-hour dietary records were collected at baseline and every six months thereafter with a median follow-up of 9 years. The final results showed 37.1% of participants consumed artificial sweeteners and Higher total artificial sweetener intake was associated with an increased risk of cardiovascular and cerebrovascular disease.

The take-home message?

With mounting evidence of the harmful health effects of added sugars, the food industry and consumers have increasingly turned to artificial sweeteners as an alternative. However, results from this prospective cohort study show that intake of artificial sweeteners is associated with higher cardiovascular disease risk, adding to the growing evidence that sugar-free products are not necessarily risk-free.

Original study: Artificial sweeteners and risk of cardiovascular diseases: results from the prospective NutriNet-Santé cohort 

Authors: Debras C et al.

Journal: BMJ

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Polypill strategy in secondary cardiovascular prevention

This study investigated if combining key medications into a single polypill affects cardiovascular outcomes and medication adherence.

The study population included 2499 older adults (age > 75 years or > 65 years with risk factors) who had had a type 1 myocardial infarction ≤ 6 months prior 

• Methods

  • Phase 3 RCT with a 36-month follow-up

  • Polypill (aspirin 100 mg; ramipril 2.5, 5, or 10 mg; and atorvastatin 20 or 40 mg) vs. usual care

  • Primary composite outcome: cardiovascular death, nonfatal myocardial infarction, nonfatal ischemic stroke, or urgent revascularization

• Main results

  • Primary composite outcome was lower in the polypill group compared to the usual care group 

  • Adherence was higher in the polypill group compared to the usual care group (70% vs. 62.7%).

  • Results were consistent across prespecified subgroups (e.g., country, age, sex, health history).

  • Adverse events similar between groups

• Limitations include 

  • Lack of blinding

The take-home message?

Adherence to secondary ASCVD prevention medications is low and decreases with more complex medication regimens. In this RCT, a polypill strategy was associated with a significantly lower risk of major adverse cardiovascular events and significantly better adherence than usual care, further contributing to the large body of high-level evidence favoring the polypill strategy; but will this become the standard of care anytime soon?

Original study: Polypill strategy in secondary cardiovascular prevention [11]

Authors: Castellano JM et al.

Journal: NEJM

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Early rhythm control therapy for atrial fibrillation in low-risk patients: a nationwide propensity score–weighted study

This study investigated whether early rhythm control may be beneficial for patients with atrial fibrillation (AF) who are at low risk of cardiovascular complications.

The study population was 54,216 patients with AF who received rhythm control (with either antiarrhythmic drugs or ablation) or rate control within 1 year of AF diagnosis and were divided into 2 groups according to their CHA2DS2-VASc score: 

• < 2: low risk (median age: 54 years)

• ≥ 2: high risk (median age: 70 years)

• Methods

  • Population-based retrospective cohort study

  • Primary composite outcome: cardiovascular death, ischemic stroke, hospitalization for heart failure, or myocardial infarction

  • Follow-up: median of 3 years

• Main results

  • Early rhythm control was associated with lower risk for the primary composite outcome in both the low-risk group and the high-risk group.

  • Safety outcomes did not differ between groups.

• Limitations include

  • Residual confounding: Data was extracted from a claims-based database.

  • Generalizability: Patients treated with catheter ablation at baseline were underrepresented.

The take-home message?

Early rhythm control has previously been shown to be beneficial for patients with AF who are at high risk of cardiovascular complications (i.e., CHA2DS2-Vasc score ≥ 2). Results from this study show that early rhythm control in AF is associated with a reduced risk of cardiovascular events, even in patients with CHA2DS2-VASc score < 2. Early rhythm control should, therefore, be considered for all patients with AF.

Original study: Early rhythm control therapy for atrial fibrillation in low-risk patients: a nationwide propensity score–weighted study 

Authors: Kim D et al.

Journal: Ann Intern Med
 

New AHA/ACC/HFSA guidelines for heart failure management (April 2022)​

The American Heart Association (AHA), American College of Cardiology (ACC), and Heart Failure Society of America (HFSA) have released updated guidelines for the management of heart failure (HF). These guidelines present a new algorithm for the classification of HF, as well as updated recommendations for the diagnosis and treatment of cardiac amyloidosis. In addition, the guidelines strongly recommend that patients with HF with reduced ejection fraction receive treatment with four classes of medications including a sodium-glucose cotransporter 2 (SGLT2) inhibitor and weakly recommend use of an SGLT2 inhibitor and sacubitril-valsartanin patients with HF with preserved ejection fraction.

Further Reading

Source: UpToDate.com

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Dietary sodium restriction and clinical events in patients with heart failure (May 2022)

In patients with heart failure (HF), high sodium intake can lead to HF exacerbations, but the impact of dietary sodium restriction on clinical outcomes remains controversial. In a trial that randomly assigned over 800 patients with stable HF to a low sodium diet (<1.5 g/day) or usual care, rates of all-cause death, cardiovascular-related hospitalization, and cardiovascular-related emergency department visits were similar between the treatment groups. Changes in body weight and caloric consumption were also similar between the groups, suggesting that sodium restriction did not cause a deterioration in nutritional status. For ambulatory patients with HF, we suggest a moderate dietary sodium restriction to <3 g/day. 

Further Reading

Source: UpToDate.com

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Investigational factor XIa inhibitor for atrial fibrillation (April 2022)

Asundexian is an inhibitor of activated factor XI (factor XIa) in development for atrial fibrillation (AF). In a dose-finding study in which 753 participants with AF (mean age 74 years) were randomly assigned to receive one of two doses of asundexian or apixaban 5 mg twice daily, rates of bleeding were similar or lower in the asundexian arms. There was no major bleeding, and clinically relevant nonmajor bleeding occurred in ≤1.2 percent of those taking asundexian and 2.4 percent of those taking apixaban. The observation period lasted 12 weeks, and during this limited period, stroke was too rare to make statistical comparisons. Additional data with longer follow-up and assessment of efficacy for thromboembolic prevention will be informative.

Further Reading

Source: UpToDate.com

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Lower risk for orthostatic hypotension with higher-intensity hypertension treatment goals?

Orthostatic hypotension (OH) is a common cause for concern in patients starting or intensifying antihypertensive treatment, as it may lead to falls, especially in the elderly and frail population.

This systematic review and meta-analysis included data from 5 randomized trials that studied the effect of pursuing a higher-intensity BP goal vs. lower-intensity BP goals or placebo on the development of OH (defined as a drop of ≥ 20 mmHg in the SBPor ≥ 10 mmHg in the DBP when shifting from a seated to a standing position). In total, the primary studies included 18,466 patients (mean age 64.5 years, 38.9% women).

The mean postural change in SBP was similar between those with a higher-intensity vs. lower-intensity BP goal. In the pooled analysis of the 5 primary trials, intensive BP treatment goals proved to be a protective factor for OH, which persisted after performing sensitivity analysis. The protection was not modified by the presence or absence of OH at baseline.

Limitations include lack of information regarding falls or syncope. Also, since patients in open-label studies may have received extra attention and a better standard of care, generalizability to real-world circumstances is limited.

The take‑home message?

This meta-analysis showed not only that higher-intensity treatment goals for arterial hypertension did not increase the risk of OH but, in fact, that they reduced it, even in patients with preexisting OH before the start of treatment. The authors hypothesize that these findings may be due to improved diastolic filling and baroreflex function but more research is required.

Title of study: Effects of intensive blood pressure treatment on orthostatic hypotension 

Authors: Juraschek et al.

Journal: Annals of Internal Medicine

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