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MAIN
PRODUCT OR TOPIC HEADING
Effects of Homocysteine-Lowering With Folic Acid Plus Vitamin B12 vs Placebo on Mortality and Major Morbidity in Myocardial Infarction Survivors
JAMA Vol. 303 No. 24, June 23/30, 2010
A Randomized Trial
Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine (SEARCH) Collaborative Group*
JAMA. 2010;303(24):2486-2494
Context Blood homocysteine levels are positively associated with cardiovascular disease, but it is uncertain whether the association is causal.
Objective To assess the effects of reducing homocysteine levels with folic acid and vitamin B12 on vascular and nonvascular outcomes.
Design, Setting, and Patients Double-blind randomized controlled trial of 12 064 survivors of myocardial infarction in secondary care hospitals in the United Kingdom between 1998 and 2008.
Interventions 2 mg folic acid plus 1 mg vitamin B12 daily vs matching placebo.
Main Outcome Measures First major vascular event, defined as major coronary event (coronary death, myocardial infarction, or coronary revascularization), fatal or nonfatal stroke, or noncoronary revascularization.
Results Allocation to the study vitamins reduced homocysteine by a mean of 3.8 µmol/L (28%). During 6.7 years of follow-up, major vascular events occurred in 1537 of 6033 participants (25.5%) allocated folic acid plus vitamin B12 vs 1493 of 6031 participants (24.8%) allocated placebo (risk ratio [RR], 1.04; 95% confidence interval [CI], 0.97-1.12; P = .28).
There were no apparent effects on major coronary events (vitamins, 1229 [20.4%], vs placebo, 1185 [19.6%]; RR, 1.05; 95% CI, 0.97-1.13), stroke (vitamins, 269 [4.5%], vs placebo, 265 [4.4%]; RR, 1.02; 95% CI, 0.86-1.21), or noncoronary revascularizations (vitamins, 178 [3.0%], vs placebo, 152 [2.5%]; RR, 1.18; 95% CI, 0.95-1.46). Nor were there significant differences in the numbers of deaths attributed to vascular causes (vitamins, 578 [9.6%], vs placebo, 559 [9.3%]) or nonvascular causes (vitamins, 405 [6.7%], vs placebo, 392 [6.5%]) or in the incidence of any cancer (vitamins, 678 [11.2%], vs placebo, 639 [10.6%]).
Conclusion Substantial long-term reductions in blood homocysteine levels with folic acid and vitamin B12 supplementation did not have beneficial effects on vascular outcomes but were also not associated with adverse effects on cancer incidence.
Featured Angina| Acute Coronary Syndrome and Heart Disease Interviews
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Author Interview: Claes Held MD
Associate professor at Uppsala Clinical Research Center and the
Cardiology department at Uppsala University Hospital in Sweden
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Publication:
Physical activity levels, ownership of goods promoting sedentary behaviour and risk of myocardial infarction: results of the INTERHEART study
Eur Heart J first published online January 11, 2012 doi:10.1093/eurheartj/ehr432
2012 doi:10.1093/eurheartj/ehr432
Claes Held, Romaina Iqbal, Scott A. Lear, Annika Rosengren, Shofiqul Islam,James Mathew, and Salim Yusuf
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What are the main findings of the study?
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The main findings are he following:
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It is well known that physical inactivity is a risk factor for developing cardiovascular disease.
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Our study shows that being physically active reduces the risk of having a heart attack.
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Older studies have mostly studied people in the developed countries. This study which has a global perspective and includes 52 countries from all continents, shows that physical inactivity reduces the risk also in both low- middle-and high-income countries.
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We also found that ownership of a car and TV was associated with a more than doubled risk of being sedentary and that in low- and middle income the risk for a heart attack was increased with 27 %.
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We can however, not conclude from this study that there is a causal relationship but it is an interesting finding.
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Were any of the findings unexpected?
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We looked at the relationship between physical activity both at work and during leisure time.
A bit surprising was that people with heavy physical labor did not have a reduction in the risk of heart attacks, whereas people with both mild and moderate intensity did.
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What should clinicians and patients take away from this study?
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The main findings above and also that physical activity with duration below the recommended 30 minutes/day does seem to prevent from heart attacks as well although not as much as when you do it according to guidelines.
This may be a comfort to those who are completely sedentary and feel that it would be a too big step to move to the 30 minutes/day right away.
All PA does a good job for the heart as compared to not doing anything at all!
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What recommendations do you have for cardiology health care providers as a result of your study?
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It would be interesting to follow up on the ownership of car and TV and do a prospective study to see if the theory holds true.
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Abstract
Background— Despite data showing the benefits of implantable cardioverter-defibrillator (ICD) insertion for primary prevention in populations at risk for sudden death, professional society guidelines recommending primary prevention, and recognition by payers of the clinical value of ICDs in these populations, ICDs for primary prevention remain underused. We sought to determine whether implementing a screening tool would increase appropriate identification of patients showing clinical evidence of ICD benefit and prompt referral to an electrophysiologist for ICD implantation.
Methods and Results— Screening tools were affixed to medical records for patients seen in 2 outpatient cardiology offices that queried ejection fraction and whether referral to an electrophysiologist was made (N=6632).
The number of appropriate referrals in the screening period were compared with analogous data collected before implementation of the screening tool (control period) through retrospective record review (n=3606). Significantly more eligible patients were offered referral during the screening period than during the control period at both sites, 80% (8/10 eligible) versus 33% (5/15) at site 1 (P<0.02) and 100% (44/44) versus 60% (21/35) at site 2 (P<0.001). Of all patients offered referral, 41% (32/78) accepted.
Conclusions— The use of a screening tool increases referral to electrophysiology for patients in whom placement of an ICD confers the benefit of sudden cardiac death primary prevention. Barriers to referral include both physician and patient factors. Verification of these findings on a larger scale as well as studies defining the foundation of these barriers may further improve use of ICDs in patients for whom their mortality benefit is well described.
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Angina | Heart Disease Resourses
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When sudden cardiac arrest (SCA) strikes, the electrical system of the heart short circuits, causing the heart to quiver rather than pump in a normal rhythm. It typically results in the abnormal heart rhythm know as ventricular fibrillation (VF). It usually happens without warning and the majority of people have no previously recognized symptoms of heart disease. And it most often happens at home. For the best chance of survival from SCA caused by VF, a defibrillator should be used within 5 minutes. Yet, less than 1 in 20 people survive largely because a defibrillator does not arrive in time.
Just as seat belts or airbags do not save every life in a traffic accident, a defibrillator will not save every person who suffers a sudden cardiac arrest. Yet many lives could be saved if more people could be reached more quickly.
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