Should I take statins as a preventive measure?

A new Cochrane systematic review conducted by London School of Hygiene and Tropical Medicine and the University of Bristol questioned the benefits of prescribing statins to people without heart disease.

Researchers reviewed 14 trials involving more than 34,000 patients with low risk of heart attack and strokes. They found that overall statins reduced mortality, but the effect was very small - 1000 people have to be treated for 1 year to prevent 1 death. Previous studies have found that statins have been associated with a range of side effects including kidney failure and muscle weakness, therfore not worth the risk in people without history of cardiovascular disease.

They pointed out that the findings of the trials were biased due to several shortcomings: 1/3 of the trials outcomes were selectively reported, 8 trials did not report on the adverse effects, 2 large trials were stopped prematurely, only 1 trial has been funded publicly while 9 trials were sponsored by drug companies partially or fully. They concluded "widespread use of statins in people at low risk of cardiovascular events ..... is not supported by the existing evidence".

Oxford researchers noted that the Cochrane review did not include the recent meta-analysis conducted by the Oxford group which was more reliable than the Cochrane review.

In an accompanying editorial, the author said that the current evidence supports the NICE guidance that statins should be used for the primary prevention of CVD for people with more than 20% risk of developing the disease. Given the limitations of the study, he suggested an alternative approach to focus on population-wide prevention.

Source:

Taylor F, Ward K, Moore THM et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews 2011, Issue

Editorial :Considerable uncertainty remains in the evidence for primary prevention of cardiovascular disease. Cochrane Library 2011, (January 19, 2011).

http://www2.cochrane.org/reviews/en/ab004816.html

Brush your teeth twice a day could lower cardiovascular risk

According to a new research by University College London, published in the BMJ, people who brushed their twice a day had a lower risk of heart disease compared with those with less frequent toothbrushing.


The researchers analysed data from more than 11,000 adults who took part in the Scottish Health Survey between 1995 and 2003. Each survey was linked to hospital admissions and deaths, followed up until 2007. They found that people who rarely brushed their teeth had a 70% greater risk of cardiovascular disease than those who brushed their teeth twice a day. However they said that the study did not prove a cause and effect association between oral health and cardiovascular disease.


Previous studies have established a link between gum disease and cardiovascular risk, but the researchers said this is the first study to show an association between self-reported toothbrushing and incident cardiovascular disease and suggest "a possible role of poor oral hygiene in the risk of cardiovascular disease via systemic inflammation." They noted that further studies are needed to confirm whether the observed association is causal or merely a risk marker.


Source: Toothbrushing, inflammation, and risk of cardiovascular disease: results from Scottish Health Survey. BMJ 2010;340:c2451

Should healthy people use low-dose aspirin routinely?

Low-dose aspirin is widely used as secondary prevention of cardiovascular disease in people who have had heart attacks or stroke. The latest issue of the Drug and Therapeutics Bulletin (DTB) examined whether healthy people who have not had cardiovascular events should use low-dose aspirin as primary prevention.


The DTB study is not a systematic review but looked at current research evidence and expert opinion. It pointed out that although aspirin is not specifically licensed for use as primary prevention in the UK, various guidelines including NICE and SIGN recommend aspirin for primary prevention in certain groups of people such as those with type 2 diabetes and high blood pressure.


However, DTB found that current evidence does not support routine use of low-dose aspirin in these groups due to the potential risk of serious bleeds and its low effect on death rates. It says "it is hard to recommend starting aspirin for primary prevention" and concludes that "... low -dose aspirin prophylaxis should not be routinely used for primary prevention."


Source: "Aspirin for primary prevention of cardiovascular disease?" Drug and Therapeutics Bulletin 2009;47:122-125 (Relevant BNF section: 2.9)

Doubts over aspirin use in diabetes

UK guidelines recommend a daily dose of aspirin as a "preventive" treatment in the diabetics as they are at a much higher risk of cardiovascular disease. However, a study published in the BMJ found no benefit from either aspirin or antioxodants in preventing heart attacks. It also increases the risk of internal bleeding.

The study invloved 1,276 adult patients with diabetes mellitus from 16 diabetic clinics in Scotland between November 1997 and July 2001. Participants were randomly assigned in four groups to receive the aspirin tablet + antioxidant capsule, or aspirin tablet + placebo capsule, or placebo tablet + antioxidant capsule or both a placebo tablet and a placebo capsule.

The findings show that in adults with diabetes and no symptoms of cardiovascular disease, there was no evidence that aspirin or antioxidants use prevented heart attacks, strokes, amputations or death. However, the drug was beneficial in people who already have a history of heart attack or stroke.

Experts said the study was "extremely important" because it confirms the concerns of aspirin use by the general population and it is worth revisiting the guidelines.

Source: Belch J, MacCuish A, Campbell I, et al. The prevention of progression of arterial disease and diabetes (POPADAD) trial: factorial randomised placebo controlled trial of aspirin and antioxidants in patients with diabetes and asymptomatic peripheral arterial disease. BMJ 2008; Published 16 October ( f/t via Athens)

Vegan diet can help arthritis sufferers

A Swedish study found people with rheumatoid arthritis (RA) could cut their risk of heart attacks and strokes by excluding meat, dairy products and gluten from their diets.

Some 66 RA sufferers were assigned at random to either a vegan diet that was free of gluten or a well-balanced non-vegan diet for a year. The result showed that the vegan group had lower body mass index and levels of bad cholesterol than the non-vegan group. Levels of antibodies associated with protection against cardiovascular disease was also increased in the vegan group.

Some limitations of the trial - the sample size was very small and almost half of the people assigned to the gluten-free vegan diet dropped out of the study before one year elapsed.

Source: "Gluten-free vegan diet induces decreased LDL and oxidized LDL levels and raised atheroprotective natural antibodies against phosphorylcholine in patients with rheumatoid arthritis: a randomized study" Arthritis Research & Therapy 2008 (free open access)

Waist size tells heart risk

Several studies have shown waist size is linked with heart attack, stroke and heart disease rsisk. They suggested that a waist circumference of over 35in for a woman, 40in for a man indicates a high risk of developing diabetes and heart disease.

A new US study looked for the early signs of atherosclerosis - narrowing and hardening of the arteries linked to the development of cardiovascular disease, of more than 2700 people with an average age of 45. Using MRI and EBCT scans that specially look for calcium deposits in the heart, they found the smaller a person's waist, the clearer the arteries, regardless of the body weight.

The researchers said the key message is to prevent accumulation of central fat early on in people's lives. "Even a small pot belly puts us at higher risk when compared to a flat tummy."

The report was published in the August 21 issue of Journal of the American College of Cardiology

Vitamin supplements may not protect your heart

Some previous researches have found viatmin C, E and beta carotene linked to reduced risk of cardiovascular disease, but a new study published in the journal Archives of Internal Medicine casts doubt on these findings.

The latest study involved 8000 women who have a history of cardiovascular disease, randomly assigned to 2 groups : one taking vitamin alone or in combination and one a placebo over 9 years. The results showed that the antioxidants, either alone or in combination had no effect on reducing the risk of heart disease or death in high-risk women.

Some experts suggested that the form of vitamin in over-the-counter dietry supplements may be different from the vitamins found in fruits and vegetables and recommended that lifestyle change with healthy diet and regular exercises is the key to prevent heart disease.

Read the abstract - "A Randomized Factorial Trial of Vitamins C and E and Beta Carotene in the Secondary Prevention of Cardiovascular Events in Women - Results From the Women's Antioxidant Cardiovascular Study " Arch Intern Med. 2007;167 (15):1610-1618. 13-27 August.

Diabetes drugs double heart failure risk

More than 1.5 million prescriptions for rosiglitazone (Avandia) and pioglitazone (Actos) were issued in England alone last year, but experts warn these 2 commonly used diabetes drugs could double the risk of heart failure, even for those who have never suffered the condition, in a new study in the journal Diabetes Care.

The two drugs are prescribed to millions of patients to treat type 2 diabetes and approved by NICE for use on the NHS. Experts call for a re-evaluation of the benefits and risks of both drugs in view of the concerns on cardiovascular safety.

Drug agencies urge patients not to panic over research findings and should contact their doctors if concerned. Read more ...

1.5m misdiagnosed heart disease risk

A BMJ study "Derivation and validation of QRISK, a new cardiovascular disease risk score for the United Kingdom: prospective open cohort study" (BMJ Online First) that tracked 1.28 million healthy adults aged 35-74 over a period of 12 years and used GP records from 318 practices found that the traditional score over- estimated cardiovascular disease risk by 35%.
It suggests the current estimates of the number of UK adults at risk of cardiovascular disease are 1.5 million too high.

The study found that white middle-aged men had a lower risk than previously thought and women from poorer backgrounds had a significantly higher risk. It also found that 1 in 3 women, (not 1 in 4 as previously thought ) in their 60s are at risk of heart disease. This has raised the concern of " potentially missing the right people for treatment" and the possibility of over-prescription of statins to many patients who do not need it.

The authors argued that over-predicted estimates of heart disease were derived from the out-dated American model which involves a score based on smoking, blood pressure and cholesterol, along with age and sex, but the the new score used by the BMJ study also takes into account social deprivation, genetic factors and weight, reducing estimates. Read more...