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CVD News and Research Updates

19 June 2015
Below is a summary of the latest research, reviews and reports in the
field of cardiovascular disease, gathered by the Heart and Stroke
Foundation South Africa. If you have any additions or comments, please
get in touch.

STROKE
Is blood pressure control for stroke prevention the correct goal? The lost
opportunity of preventing hypertension
Howard G, et al.
May 2015
Link to article: click here
Maintaining the normotensive status solely through pharmacological
treatment has a profound impact on stroke prevention.
Although pharmacological treatment of hypertension has important health
benefits, it does not capture the benefit of maintenance of ideal health
through the prevention or delay of hypertension. A total of 26 875 black and
white participants aged 45+ years were assessed and followed for incident
stroke events. The association was assessed between incident stroke and: (1)
systolic blood pressure (SBP) categorized as normal (<120 mm Hg),
prehypertension (120139 mm Hg), stage 1 hypertension (140159 mm Hg),
and stage 2 hypertension (160 mm Hg+), and (2) number of classes of
antihypertensive medications, classified as none, 1, 2, or 3 or more. During 6.3
years of follow-up, 823 stroke events occurred. Nearly half (46%) of the
population were successfully treated (SBP<140 mm Hg) hypertensives. Within
blood pressure strata, the risk of stroke increased with each additional class of
required antihypertensive medication, with hazard ratio [HR], 1.33; 95%
confidence interval, 1.16 to 1.52 for normotensive, HR, 1.15; 95% confidence
interval, 1.05 to 1.26 for prehypertension, and HR, 1.22; 95% confidence
interval, 1.06 to 1.39 for stage 1 hypertension. A successfully treated
(SBP<120 mm Hg) hypertensive person on 3+ antihypertensive medication
classes was at marginally higher stroke risk than a person with untreated
stage 1 hypertension (HR, 2.48 versus HR=2.19; relative to those with SBP

<120 on no antihypertensive medications). Thus maintaining the normotensive status solely through
pharmacological treatment has a profound impact, as nearly half of this general population cohort were
treated to guideline (SBP<140 mm Hg) but failed to return to risk levels similar to normotensive
individuals. Even with successful treatment, there is a substantial potential gain by prevention or delay
of hypertension.

HYPERTENSION
Blood pressure targets and absolute cardiovascular risk
Odutayo A, et al.
June 2015
Link to article: click here
A large portion of adults 60 to 74 years without chronic kidney disease or diabetes mellitus were at
20% absolute cardiovascular risk when reclassified as not in need of additional treatment
according to the Eighth Joint National Committee guideline.

In the Eighth Joint National Committee guideline


on hypertension, the threshold for the initiation
of blood pressure-lowering treatment for elderly
adults (60 years) without chronic kidney
disease or diabetes mellitus was raised from
140/90 mm Hg to 150/90 mm Hg. However, the
committee was not unanimous in this decision,
particularly because a large proportion of adults
60 years may be at high cardiovascular risk. On
the basis of the Eighth Joint National Committee
guideline, this study sought to determine the
absolute 10-year risk of cardiovascular disease
among these adults through analyzing the National Health and Nutrition Examination Survey (20052012). The primary outcome measure was the proportion of adults who were at 20% predicted
absolute cardiovascular risk and above goals for the Seventh Joint National Committee guideline but
reclassified as at target under the Eighth Joint National Committee guideline (reclassified). The
Framingham General Cardiovascular Disease Risk Score was used. From 2005 to 2012, the surveys
included 12 963 adults aged 30 to 74 years with blood pressure measurements, of which 914 were
reclassified based on the guideline. Among individuals reclassified as not in need of additional
treatment, the proportion of adults 60 to 74 years without chronic kidney disease or diabetes mellitus at
20% absolute risk was 44.8%. This corresponds to 0.8 million adults. The proportion at high
cardiovascular risk remained sizable among adults who were not receiving blood pressure-lowering

treatment. Taken together, a sizable proportion of reclassified adults 60 to 74 years without chronic
kidney disease or diabetes mellitus was at 20% absolute cardiovascular risk.

MAYO CLINICAL PROCEEDINGS


Digital health interventions for the prevention of cardiovascular disease: a systematic review and
meta-analysis
Widmer RJ, et al.
April 2015
Link to article: click here
This systematic review provides evidence that digital health interventions may be a useful tool to
reduce CVD outcomes and impact CVD risk factors.

This review sought to assess the potential benefit of digital health interventions (DHIs) on cardiovascular
disease (CVD) outcomes (CVD events, all-cause mortality, hospitalizations) and risk factors compared
with non-DHIs. 51 full-text articles that met validity and inclusion criteria were included in the review,
and were published between January 1, 1990, through January 21, 2014. Included studies examined any
element of DHI (telemedicine, Web-based strategies, e-mail, mobile phones, mobile applications, text
messaging, and monitoring sensors) and CVD outcomes or risk factors. Digital health interventions
significantly reduced CVD outcomes (relative risk, 0.61; 95% CI, 0.46-0.80; P<.001). Concomitant
reductions in weight (-2.77 lb [95% CI, -4.49 to -1.05 lb]; P<.002) and body mass index (-0.17 kg/m2 [95%
CI, -0.32 kg/m2 to -0.01 kg/m2]; P=.03) but not blood pressure (-1.18 mm Hg [95% CI, -2.93 mm Hg to
0.57 mm Hg]; P=.19) were found in these DHI trials compared with usual care. In the 6 studies reporting
Framingham risk score, 10-year risk percentages were also significantly improved (-1.24%; 95% CI, 1.73% to -0.76%; P<.001). Results were limited by heterogeneity not fully explained by study population
(primary or secondary prevention) or DHI modality. Overall, these aggregations of data provide evidence
that DHIs can reduce CVD outcomes and have a positive impact on risk factors for CVD.

NICOTINE & TOBACCO RESEARCH


Effect of a digital social media campaign on young adult smoking cessation
Baskerville BN, et al.
June 2015
Link to article: click here

This quazi-experimental study of a multi-component web-based approach suggests that a


digital/social media platform can complement the traditional smokers helpline cessation service
for young adult smokers seeking help to quit.

Social Media (SM) may extend the reach and impact


for smoking cessation among young adult smokers.
To date little research targeting young adults has
been done on the use of social media to promote
quitting smoking. This study assessed the effect of
an innovative multi-component web-based and SM
approach known as Break-it-Off (BIO) on young
adult smoking cessation. A quasi-experimental
study design was followed, with baseline and 3month follow-up data from 19 to 29 year old
smokers exposed to BIO (n=102 at follow-up) and a comparison group of Smokers Helpline (SHL) users
(n=136 at follow-up). Logistic regression analysis assessed differences between groups on self-reported
7-day and 30-day point prevalence cessation rates, adjusting for ethnicity, education level, and cigarette
use (daily or occasional) at baseline. The campaign reached 37 325 unique visitors with a total of 44 172
visits. BIO users had significantly higher 7-day and 30-day quit rates compared with users of SHL. At
three month follow-up, BIO participants (32.4%) were more likely than SHL participants (14%) to have
quit smoking for 30 days (odds ratio = 2.95, 95% CI = 1.56 5.57, p < .001)and BIO participants (91%)
were more likely than SHL participants (79%) to have made a quit attempt (odds ratio = 2.69, 95% CI =
1.03-6.99, p = .04). The reach of the campaign and findings on quitting success indicate that a
digital/social media platform can complement the traditional SHL cessation service for young adult
smokers seeking help to quit.

SOCIAL SCIENCE & MEDICINE


Depressive symptoms and self-reported adherence to medical recommendations to prevent
cardiovascular disease: NHANES 2005-2010
Berntson J et al.
May 2015
Link to article: click here
Greater depressive symptoms were associated with poorer adherence to recommendations to
control/lose weight and increase physical activity.

This study's aim was to examine the relationships between depressive symptom severity and adherence
to medication and lifestyle recommendations intended to prevent cardiovascular disease (CVD).
Participants were adults from the National Health and Nutrition Examination Survey (NHANES) 20052010 with a self-reported history of hypertension and/or hypercholesterolemia, but no CVD. The Patient
Health Questionnaire-9 (PHQ-9) was used to assess depressive symptoms, and the Blood Pressure and
Cholesterol interview was used to assess self-reported adherence to five medical recommendations:
take antihypertensive medication (n = 3 313), eat fewer high fat/cholesterol foods (n = 2 924),
control/lose weight (n = 2 177), increase physical activity (n = 2 540), and take cholesterol medication (n
= 2 266). Logistic regression models (adjusted for demographics, diabetes, body mass index, smoking,
and alcohol intake) revealed that a 1-SD increase in PHQ-9 score was associated with a 14% lower odds
of adherence to the control/lose weight recommendation (OR = 0.86, 95% CI: 0.75-0.98, p = .02) and a
25% lower odds of adherence to the increase physical activity recommendation (OR = 0.75, 95% CI: 0.650.86, p < .001). PHQ-9 score, however, was not related to the odds of adherence to the
recommendations to take antihypertensive medication (p = .21), eat fewer high fat/cholesterol foods (p
= .40), or take cholesterol medication (p = .90). These findings suggest that poor adherence to provider
recommendations to control/lose weight and to increase physical activity may partially explain the
excess risk of CVD among depressed persons.

HEART
Coffee consumption and coronary artery calcium in young and middle-aged asymptomatic adults
Choi Y, et al
May 2015
Link to article: click here
Moderate coffee consumption was associated with a lower prevalence of subclinical coronary
atherosclerosis.
This cross-sectional study sought to investigate the
association between regular coffee consumption and
the prevalence of coronary artery calcium (CAC) in 25
138 men and women (mean age 41.3 years) without
clinically evident cardiovascular disease. Participants
underwent a health screening examination that
included a validated food frequency questionnaire
and a multidetector CT to determine CAC scores.
Robust Tobit regression analyses were used to
estimate the CAC score ratios associated with

different levels of coffee consumption compared with no coffee consumption and adjusted for potential
confounders. The prevalence of detectable CAC (CAC score >0) was 13.4% (n=3364), including 11.3%
prevalence for CAC scores 1-100 (n=2832), and 2.1% prevalence for CAC scores >100 (n=532). The mean
SD consumption of coffee was 1.81.5 cups/day. The multivariate-adjusted CAC score ratios (95% CIs)
comparing coffee drinkers of <1, 1-<3, 3-<5, and 5 cups/day to non-coffee drinkers were 0.77 (0.49 to
1.19), 0.66 (0.43 to 1.02), 0.59 (0.38 to 0.93), and 0.81 (0.46 to 1.43), respectively (p for quadratic
trend=0.02). The association was similar in subgroups defined by age, sex, smoking status, alcohol
consumption, status of obesity, diabetes, hypertension, and hypercholesterolaemia. Thus in this large
sample of men and women apparently free of clinically evident cardiovascular disease, moderate coffee
consumption was associated with a lower prevalence of subclinical coronary atherosclerosis.
Habitual chocolate consumption and risk of cardiovascular disease among healthy men and women
Shing Kwok C, et al.
April 2015
Link to full-text: click here
This study supports the previously reported association between habitual chocolate intake and a
lower risk of cardiovascular events.
This prospective study sought to examine the
association between chocolate intake and the risk of
future cardiovascular events by using data from the
European Prospective Investigation into Cancer (EPIC)Norfolk cohort. Habitual chocolate intake (both milk and
dark chocolate) was quantified using the baseline food
frequency
questionnaire
(19931997)
and
cardiovascular end points were ascertained up to March
2008. A systematic review was performed to evaluate
chocolate consumption and cardiovascular outcomes. A total of 20 951 men and women were included
in EPIC-Norfolk analysis (mean follow-up 11.3 2.8 years, median 11.9 years). The percentage of
participants with coronary heart disease (CHD) in the highest and lowest quintile of chocolate
consumption was 9.7% and 13.8%, and the respective rates for stroke were 3.1% and 5.4%. The
multivariate-adjusted HR for CHD was 0.88 (95% CI 0.77 to 1.01) for those in the top quintile of
chocolate consumption (1699 g/ day) versus non-consumers of chocolate intake. The corresponding HR
for stroke and cardiovascular disease (cardiovascular disease defined by the sum of CHD and stroke)
were 0.77 (95% CI 0.62 to 0.97) and 0.86 (95% CI 0.76 to 0.97). The propensity score matched estimates
showed a similar trend. A total of nine studies with 157 809 participants were included in the metaanalysis. Higher compared to lower chocolate consumption was associated with significantly lower CHD
risk (5 studies; pooled RR 0.71, 95% CI 0.56 to 0.92), stroke (5 studies; pooled RR 0.79, 95% CI 0.70 to
0.87), composite cardiovascular adverse outcome (2 studies; pooled RR 0.75, 95% CI 0.54 to 1.05), and

cardiovascular mortality (3 studies; pooled RR 0.55, 95% CI 0.36 to 0.83). Thus cumulative evidence
suggests that higher chocolate intake is associated with a lower risk of future cardiovascular events,
although residual confounding cannot be excluded.

BRITISH MEDICAL JOURNAL


Association of incident obstructive sleep apnoea with outcomes in a large cohort of US veterans
Molnar M, et al.
June 2015
Link to abstract: click here
Obstructive sleep apnoea is associated with higher mortality, incident CHD, stroke and CKD and
with faster kidney function decline, highlighting the importance of diagnosis and management.
There is a paucity of large cohort studies examining the association of obstructive sleep apnoea (OSA)
with clinical outcomes including all-cause mortality, coronary heart disease (CHD), strokes and chronic
kidney disease (CKD). This study sought to assess whether a diagnosis of incident OSA is associated with
higher risks of these adverse clinical outcomes. The study sample included a nationally representative
cohort of 3 079 514 US veterans (93% male) with baseline estimated glomerular filtration rate (eGFR)60
mL/min/1.73 m2. The association between the diagnosis of incident OSA, treated and untreated with
CPAP, and: (1) all-cause mortality, (2) incident CHD, (3) incident strokes, (4) incident CKD defined as
eGFR<60 mL/min/1.73 m2, and (5) slopes of eGFR, was examined. Compared with OSA-negative patients,
untreated and treated OSA was associated with 86% higher mortality risk, (adjusted HR and 95% CI 1.86
(1.81 to 1.91) and 35% (1.35 (1.21 to 1.51)), respectively. Similarly, untreated and treated OSA was
associated with 3.5 times (3.54 (3.40 to 3.69)) and 3 times (3.06 (2.62 to 3.56)) higher risk of incident
CHD; 3.5 times higher risk of incident strokes (3.48 (3.28 to 3.64) and 3.50 (2.92 to 4.19)) for untreated
and treated OSA, respectively. The risk of incident CKD was also significantly higher in untreated (2.27
(2.19 to 2.36)) and treated (2.79 (2.48 to 3.13)) patients with OSA. The median (IQR) of the eGFR slope
was 0.41 (2.01 to 0.99), 0.61 (2.69 to 0.93) and 0.87 (3.00 to 0.70) mL/min/1.73 m2 in OSAnegative patients, untreated OSA-positive patients and treated OSA-positive patients, respectively.
Thus in this large and contemporary cohort of more than 3 million US veterans, a diagnosis of incident
OSA was associated with higher mortality, incident CHD, stroke and CKD and with faster kidney function
decline.

AMERICAN JOURNAL OF CARDIOLOGY


Effect of dietary sodium and potassium intake on left ventricular diastolic function and mass in
adults40 years (from the Strong Heart Study)
Haring B, et al.
May 2015
Link to abstract: click here
An increase in dietary sodium/potassium ratio was related to an accentuation of atrial phase left
ventricular diastolic filling in normotensive young subjects, whereas in prehypertensive or
hypertensive subjects it was associated with higher left ventricular mass index.

The aim of this study was to investigate whether intake of dietary


sodium or potassium is related to changes in left ventricular (LV)
diastolic functioning and LV mass index in young subjects with
normal or elevated blood pressure. Echocardiographic data in 1 065
young adults (18 to 39 years) enrolled in the Strong Heart Family
Study who were free from cardiovascular disease at baseline was
examined: 501 (47%) participants were normotensive and 564
(53%) were prehypertensive or hypertensive. Dietary sodium and
potassium intakes were ascertained using a block food frequency
questionnaire at baseline. Cardiac geometry and functioning were
assessed at baseline and 4 years later. Participants with
prehypertension or hypertension were older, had higher body mass
index, were more likely to be diabetic and reported higher intakes
of sodium than normotensive subjects (2717 mg/day vs. 2554
mg/day) at baseline. In prospective analyses, potassium intake was
found to be negatively related to mitral E velocity (p=0.029) in
normotensive subjects, whereas sodium/potassium ratio was positively associated with atrial filling
fraction (p=0.017). In prehypertensive or hypertensive participants, sodium consumption was positively
associated with atrial filling fraction (p=0.034) and an increase in sodium/potassium ratio was related to
higher LV mass index (p=0.046). In conclusion, an increase in dietary sodium/potassium ratio was
related to an accentuation of atrial phase LV diastolic filling in normotensive young subjects, whereas in
prehypertensive or hypertensive subjects it was associated with higher LV mass index. This analysis in
young American Indians complement other published studies that link excess sodium intake to early
cardiac diastolic functional changes and eventual structural changes.

LANCET
Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and
chronic diseases and injuries in 188 countries, 19902013: a systematic analysis for the Global Burden
of Disease Study 2013
Global Burden of Disease Study 2013 Collaborators
June 2015
Link to article: click here
There is a substantial increase in the numbers of individuals with sequelae of diseases and injuries,
and rates of years living with disability are declining much more slowly than mortality rates. The
non-fatal dimensions of disease and injury will require more and more attention from health
systems.
Up-to-date evidence about levels and trends in disease and injury incidence, prevalence, and years lived
with disability (YLDs) is an essential input into global, regional, and national health policies. In the Global
Burden of Disease Study 2013 (GBD 2013), these quantities for acute and chronic diseases and injuries
were estimated for 188 countries between 1990 and 2013. Estimates were calculated for disease and
injury incidence, prevalence, and YLDs using GBD 2010 methods with some important refinements. Key
improvements include expansion to the cause and sequelae list, updated systematic reviews, use of
detailed injury codes, improvements to the Bayesian meta-regression method (DisMod-MR), and use of
severity splits for various causes. In total, 35620 distinct sources of data were used and documented to
calculated estimates for 301 diseases and injuries and 2 337 sequelae. The comorbidity simulation
provides estimates for the number of sequelae, concurrently, by individuals by country, year, age, and
sex. Disease and injury were highly prevalent; only a small fraction of individuals had no sequelae.
Comorbidity rose substantially with age and in absolute terms from 1990 to 2013. Incidence of acute
sequelae were predominantly infectious diseases and short-term injuries, with over 2 billion cases of
upper respiratory infections and diarrhoeal disease episodes in 2013, with the notable exception of
tooth pain due to permanent caries with more than 200 million incident cases in 2013. Conversely,
leading chronic sequelae were largely attributable to non-communicable diseases, with prevalence
estimates for asymptomatic permanent caries of 2.4 billion. YLDs for both sexes increased from 537.6
million in 1990 to 764.8 million in 2013 due to population growth and ageing, whereas the agestandardised rate decreased little from 114.87 per 1000 people to 110.31 per 1000 people between
1990 and 2013. Leading causes of YLDs included low back pain and major depressive disorder among the
top ten causes of YLDs in every country. YLD rates per person, by major cause groups, indicated the
main drivers of increases were due to musculoskeletal, mental, and substance use disorders,
neurological disorders, and chronic respiratory diseases; however HIV/AIDS was a notable driver of
increasing YLDs in sub-Saharan Africa. Ageing of the world's population is leading to a substantial
increase in the numbers of individuals with sequelae of diseases and injuries. Rates of YLDs are declining
much more slowly than mortality rates. The non-fatal dimensions of disease and injury will require more

and more attention from health systems. The transition to non-fatal


outcomes as the dominant source of burden of disease is occurring
rapidly outside of sub-Saharan Africa. These results can guide future
health initiatives through examination of epidemiological trends and a
better understanding of variation across countries.

Disclaimer: The views contained in this newsletter are not necessarily


the views of the Heart and Stroke Foundation South Africa, and are for
information sharing purposes only.
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About us
The Heart and Stroke Foundation
South Africa plays a leading role
in the fight against preventable
heart disease and stroke, with the
aim of seeing fewer South
Africans suffer premature deaths
and
disabilities.
The
HSF,
established in 1980 is a nongovernmental,
non-profit
organisation and has NPO and
section 21 status.

CVD news and research updates is brought to you by the Heart and
Stroke Foundation SA and supported by the Southern African
Hypertension Society.

www.heartfoundation.co.za
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