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Episodic Sexual & Physical Activity and Cardiac Events
Tufts paper assesses effect of episodic sexual/physical activity on cardiac events
Boston (March 23, 2011) – A paper, "Association of Episodic Physical and Sexual Activity With Triggering of Acute Cardiac Events," published in the March 23/30 issue of the Journal of the American Medical Association (JAMA), highlights research done by Tufts Clinical and Translational Science Institute (CTSI) researchers Jessica K. Paulus, ScD, and Issa J. Dahabreh, MD. This paper was also developed into a JAMA Report video, available on the Tufts CTSI website.
The significance of this paper is that it summarizes a body of research that has spanned more than two decades and allows the synthesis of evidence from all available studies and the identification of patterns not discernible by looking at each study individually. This research is of broad interest to the general public since physical and sexual activity are common behaviors that affect a wide segment of the population. It's particularly important to clinicians since the study supports current clinical guidelines regarding the initiation of physical activity programs.
The JAMA paper assesses the effect of episodic physical and sexual activity on acute cardiac events using data from fourteen previously published studies. Acute cardiac events are defined in this study as myocardial infarction or sudden cardiac death. Acute cardiac events are a major cause of morbidity and mortality, with as many as one million myocardial infarctions and 300,000 cardiac arrests occurring in the United States each year. Despite the well-established benefits of regular physical activity, anecdotal evidence has suggested that physical activity and psychological stress can act as triggers of acute cardiac events.
The authors conducted a meta-analysis of fourteen case-crossover studies published in thirteen articles; ten studies investigated physical activity, three studies investigated sexual activity, and one study investigated both exposures. Since many prior reports included a relatively small number of individuals who had had heart attacks, they used a statistical approach that combined the data from these previous studies. "This method can be a powerful way to arrive at a more confident answer about a particular clinical question when prior studies have been limited by small numbers," writes Dr. Paulus.
Each author independently extracted descriptive and quantitative information from the studies identified through MEDLINE, EMBASE and Web of Science. Data collection was limited to case-crossover studies as this design was developed specifically to address the problem of identifying triggers of acute events. Case-control and cohort studies were not included as they are not particularly suitable for identifying triggers of acute events. The individual studies tended to include more males than females, and patients in their 50's and 60's.
This research concluded that episodic physical activity and sexual activity are associated with an increase in the risk of heart attacks for a short window of time during and shortly after the activity. This association was less pronounced among persons with high levels of habitual physical activity. The authors make particular note that this study should not de-emphasize the importance of regular physical activity. Dr. Dahabreh writes, "Our findings should not be misinterpreted as indicating a net harm of physical or sexual activity; instead they demonstrate that these exposures are associated with a temporary short-term increase in the risk of acute cardiac events."
Dr. Paulus comments, "This project would not have been possible without the Tufts CTSI funded Clinical and Translational Science Graduate Program, as well as Tufts CTSI support for interaction between epidemiologists and meta-analysis experts. While our disciplines are not necessarily that far apart, our scientific approaches tend to keep us operating in different spheres. This work is an illustration of what is possible with Tufts CTSI encouragement and support for these types of interactions."
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About the Authors
Dr. Dahabreh, the corresponding author, is a research associate with the Center for Clinical Evidence Synthesis and Evidence-based Practice Center at Tufts Medical Center's Institute for Clinical Research and Health Policy Studies. Dr. Paulus is an assistant professor at Tufts University School of Medicine and Tufts CTSI, associate director of the Research Design Center at Tufts CTSI, and adjunct assistant professor of epidemiology at the Harvard School of Public Health.
Association of Episodic Physical and Sexual Activity With Triggering of Acute Cardiac Events
Systematic Review and Meta-analysis
Issa J. Dahabreh, MD; Jessica K. Paulus, ScD
March 23/30, 2011, Vol 305, No. 12, pp 1165-1256
Context Evidence has suggested that physical and sexual activity might be triggers of acute cardiac events.
Objective To assess the effect of episodic physical and sexual activity on acute cardiac events using data from case-crossover studies.
Data Sources MEDLINE and EMBASE (through February 2, 2011) and Web of Science (through October 6, 2010).
Study Selection Case-crossover studies investigating the association between episodic physical or sexual activity and myocardial infarction (MI) or sudden cardiac death (SCD).
Data Extraction Two reviewers extracted descriptive and quantitative information from each study. We calculated summary relative risks (RRs) using random-effects meta-analysis and absolute event rates based on US data for the incidence of MI and SCD. We used the Fisher P value synthesis method to test whether habitual physical activity levels modify the triggering effect and meta-regression to quantify the interaction between habitual levels of physical activity and the triggering effect.
Results We identified 10 studies investigating episodic physical activity, 3 studies investigating sexual activity, and 1 study investigating both exposures. The outcomes of interest were MI (10 studies), acute coronary syndrome (1 study), and SCD (3 studies). Episodic physical and sexual activity were associated with an increase in the risk of MI (RR = 3.45; 95% confidence interval [CI], 2.33-5.13, and RR = 2.70; 95% CI, 1.48-4.91, respectively).
Episodic physical activity was associated with SCD (RR = 4.98; 95% CI, 1.47-16.91). The effect of triggers on the absolute rate of events was limited because exposure to physical and sexual activity is infrequent and their effect is transient; the absolute risk increase associated with 1 hour of additional physical or sexual activity per week was estimated as 2 to 3 per 10 000 person-years for MI and 1 per 10 000 person-years for SCD.
Habitual activity levels significantly affected the association of episodic physical activity and MI (P < .001), episodic physical activity and SCD (P < .001), and sexual activity and MI (P = .04); in all cases, individuals with lower habitual activity levels had an increased RR for the triggering effect. For every additional time per week an individual was habitually exposed to physical activity, the RR for MI decreased by approximately 45%, and the RR for SCD decreased by 30%.
Conclusion Acute cardiac events were significantly associated with episodic physical and sexual activity; this association was attenuated among persons with high levels of habitual physical activity.
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Highlights of Article by Dr. Erik Hess et of Mayo Clinic ;CIRCOUTCOMES 2012
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Chest pain is the 2nd most common reason patients come to EDs across the United States
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Initial testing – including information obtained from the history, physical exam, electrocardiogram, and cardiac troponin – identifies > 98% of heart attacks
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To avoid missing a diagnosis of heart attack or pre-heart attack symptoms, emergency physicians often admit patients to observation units or to the hospital for extensive diagnostic testing, including stress testing
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This results in false positive test results, unnecessary exposure to radiation, and unnecessary downstream procedures such as stent placement in arteries of the heart
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Decision aids are evidence-based tools designed to educate and engage patients in decisions regarding their care
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We hypothesized that patients who were educated regarding their future risk for a heart attack and engaged in the decision of whether to be admitted to the observation unit for stress testing or to follow-up with a Mayo Clinic heart doctor in the next 72 hours would have greater knowledge about their short-term risk for heart attack, be more aware of the management options, and choose less intensive approaches to evaluation
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We randomly assigned 204 patients who came to the ED with chest pain and were being considered for observation unit admission to the decision aid or to usual care
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Decision aid patients:
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Had greater knowledge regarding their short-term risk for a heart attack
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Less frequently decided to be admitted to the observation unit for stress testing
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Had 4 times greater engagement in the decision making process
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Had no adverse events within 30 days of the ED visit
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Take home points
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Patients want to be educated and engaged in decisions regarding their care
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Once properly informed and engaged in treatment decisions, patients often choose less intensive treatment options
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Integrated health systems like the Mayo Clinic in which physicians collaboratively work together to provide ER patients ready access to outpatient follow-up have potential to improve the value of Emergency care
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Glucose, Insulin and Potassium (“GIK”) TO MINIMIZE IMPACT OF HEART ATTACKS BEFORE PATIENTS GET TO THE HOSPITAL
Study puts life-saving drugs in the hands of paramedics, decreasing rate of cardiac arrest and death from heart attacks
CHICAGO (March 27, 2012) — Paramedics can potentially reduce someone’s chances of having a cardiac arrest or dying by 50 percent by immediately administering a mixture of glucose, insulin and potassium (“GIK”) to people having a heart attack, according to research presented today at the American College of Cardiology’s 61st Annual Scientific Session. The Scientific Session, the premier cardiovascular medical meeting, brings cardiovascular professionals together to further advances in the field.
The study showed that patients who received GIK immediately after being diagnosed with acute coronary syndrome — which indicates a possible heart attack is either in progress or on the way — were 50 percent less likely to have cardiac arrest (a condition in which the heart suddenly stops beating) or die than those who received a placebo, although the treatment did not prevent the heart attack from occurring. The reduction in in-hospital cardiac arrest or death was a “secondary endpoint”, so statistically was not definitive, but was consistent with how GIK seems to work in experimental models of heart attack.
The effect was also present for patients with ST-elevation heart attacks, which require immediate treatment. For those patients, immediate GIK was associated with a 60 percent reduction in in-hospital cardiac arrest or death.
“When started immediately in the home or on the way to the hospital — even before the diagnosis is completely established — GIK appears not completely prevent any heart attack from occurring, but appeared in this trial to reduce the size of heart attacks and to reduce by half the risk of having a cardiac arrest or dying,” said Harry P. Selker, MD, MSPH, executive director of the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center, who led the study with Joni Beshansky, RN, MPH, co-principal investigator and project director. “Acute coronary syndromes represent the largest cause of death in this country. GIK is a very inexpensive treatment that appears to have promise in reducing those deaths and morbidity.”
The cost of the treatment is about $50.
“Because the trial is the first to show GIK could be effective when used by paramedics in real-world community settings, it could have important implications for the treatment of heart attacks,” Dr. Selker said. Previous clinical trials have shown no consistent effect, likely because the GIK was given too late to help. This study, the “IMMEDIATE Trial,” was the first to test the effectiveness of administering GIK at the very first signs of a threatening heart attack, in the community, rather than waiting hours until the diagnosis was well-established at a hospital, as done in previous clinical trials.
“We wanted to do something that is effective and can be used anywhere,” said Dr. Selker. “We’ve done a lot of studies of acute cardiac care in emergency departments and hospitals, but more people die of heart attacks outside the hospital than inside the hospital. Hundreds of thousands of people per year are dying out in the community; we wanted to direct our attention to those patients.”
The researchers trained paramedics in 36 Emergency Medical Services systems in 13 cities across the country to administer GIK after determining that a patient was likely having a threatened or already established heart attack using electrocardiograph-based ACI-TIPI (acute cardiac ischemia time-insensitive predictive instrument) and thrombolytic predictive instrument decision support that prints patient-specific predictions on the top of an electrocardiogram. The paramedics used these predictions to decide if a patient would likely benefit from treatment. There were 911 patients randomized to receive either the GIK treatment or a placebo.
Administering GIK immediately also reduced the severity of the damage to the heart tissue from the heart attack. On average, 2 percent of the heart tissue was destroyed by the heart attack in people receiving GIK, compared with 10 percent in those who received the placebo. Although a significant proportion of suspected heart attacks are later determined to be false alarms (23 percent in this study), administering GIK does not appear to cause any harmful effects in such patients.
The research team will follow up with study participants at six and 12 months to evaluate the longer-term benefit of the GIK treatment.
This study was funded by the NIH’s National Heart, Lung and Blood Institute.
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Be prepared for the unexpected.
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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