Katie Robinson

In post-myocardial infarction patients, chronically impaired renal failure and diabetes are both associated with an increased mortality risk, say researchers recently writing in

Diabetes is associated with both an increased risk of all-cause death, mainly driven by cardiovascular mortality, and poorer outcomes after acute myocardial infarction (AMI). While impaired glomerular filtration rate (GFR) is also associated with an increased risk of cardiovascular mortality, whether diabetes still confers a higher mortality risk in patients with impaired GFR remains unknown.

“The aim of this study was to assess the long-term prognostic significance of both diabetes and renal impairment in two prospective nationwide cohorts of AMI patients: FAST-MI 2005 and FAST-MI 2010,” wrote the authors, led by Louis Potier, M.D., of UniversitÃ© de Paris in France.

Both registries consecutively included AMI patients admitted to cardiac intensive care units within 48 hours of symptom onset during a specified one-month period. The analysis included 7,839 participants (mean age 66 years, 29 percent female, 27 percent with diabetes), of which 7,656 patients had creatinine values assessed before percutaneous coronary intervention. Researchers assessed all-cause mortality at five years according to estimated GFR (eGFR) and diabetes status at inclusion.

Five-year mortality was 38 percent in patients with diabetes versus 19 percent in patients without diabetes (adjusted hazard ratio [HR] 1.47, 95% CI 1.33–1.62, P < 0.001). According to eGFR, among all participants, five-year mortality rates were 8.1 percent for eGFR >90 mL/min, 17.7 percent for 60– 90 mL/min, 36.4 percent for 45–60 mL/ min, 57.6 percent for 30–45 mL/min, and 70.6 percent for <30 mL/min.

Further analysis suggested a gradual increase in mortality with decreasing renal function: adjusted HR versus eGFR >90 mL/min as reference 0.91 (95% CI 0.75– 1.11, P = 0.36) for eGFR 60–90 mL/min; 1.19 (0.96–1.46, P = 0.11) for 45–60 mL/ min; 1.48 (1.19–1.85, P = 0.001) for 30– 45mL/min, and 1.86 (1.48–2.35, P < 0.001) for <30 mL/min.

Moreover, increasing renal impairment was associated with an increased risk of death for participants with diabetes under a threshold of 60 mL/min but only below a threshold of 45 mL/min for participants without diabetes.

Compared with no diabetes, diabetes was associated with an increased risk of five-year death throughout eGFR categories, except for eGFR <30 mL/min: HR 1.45 (95% CI 1.01–2.09) for eGFR >90 mL/min, HR 1.54 (1.28–1.84, P < 0.001) for eGFR 60–90 mL/min, HR 1.64 (1.33–2.02, P < 0.001) for eGFR 45–60 mL/min, HR 1.28 (1.04–1.59, P = 0.02) for eGFR 30–45 mL/min.

“These results suggest that in post-myocardial infarction patients, 1) chronically impaired renal failure and diabetes are both associated with an increased risk of mortality, 2) renal function requires specific attention in patients with diabetes as soon as it is mildly impaired (45–60 mL/min), and 3) tight glycemic control, which is controversial in post-myocardial infarction patients (4), may not be essential in patients with diabetes with eGFR <30 mL/min,” the authors wrote.

The authors noted that the study was observational, with some missing data such as proteinuria in all patients and HbA1c in some patients, and that since 2010 newer glucose-lowering medications have documented an impact on cardiovascular and renal outcomes.

Louis Potier, Ronan Roussel, Marianne Zeller, et al. 

“Chronic Kidney Disease, Diabetes, and Risk of Mortality After Acute Myocardial Infarction: Insight From the FAST-MI Program.”

 January 23, 2020. doi: 10.2337/dc19-2209

Articles

In post-myocardial infarction patients, chronically impaired renal failure and diabetes are both associated with an increased mortality risk, say researchers recently writing in Diabetes Care.

Renal Failure, Diabetes Linked to Increased Mortality in Post-Myocardial Infarction

Screening, testing and counseling for marijuana use is needed, especially in young patients presenting with cardiovascular disease, according to a review recently published in the 

Journal of the American College of Cardiology.

As more states are legalizing cannabis for both medicinal and recreational purposes, marijuana use is increasing, and is more prevalent in younger adults. The U.S. Food and Drug Administration has approved three cannabinoids for medical use: cannabidiol, an oral solution for the treatment of seizures in rare forms of epilepsy;  dronabinol (synthetic delta-9-tetrahydrocannabinol [THC]) to treat refractory chemotherapy-associated nausea/ vomiting and HIV-related anorexia/weight loss; and nabilone (synthetic chemical structure similar to THC) for refractory chemotherapy-associated nausea/vomiting.

Data from the National Health and Nutrition Examination Survey estimate that more than two million people with cardiovascular diseases currently use or have used marijuana in its variety of forms, including inhalation and vaping. Smoking marijuana carries many of the same cardiovascular health hazards as smoking tobacco. Observational studies have suggested an association between THC and a range of cardiovascular risks, but few randomized trials have been conducted to assess the effects of marijuana on cardiovascular risk. Recommendations are lacking to guide the cardiovascular community.

“This review summarizes cardiovascular considerations related to marijuana use, pharmacological interactions, and future steps to provide clearer guidance regarding its cardiovascular safety,” wrote the authors, led by Muthiah Vaduganathan, M.D., M.P.H., of Harvard Medical School in Boston.

Marijuana use may pose potential cardiovascular risk in patients with atherosclerotic cardiovascular disease, especially early after acute coronary syndromes. Smoking cannabis can lead to increases in heart rate and blood pressure, secondary to sympathetic nervous system activation, augmenting myocardial oxygen demands. While long-term use promotes tolerance and may be associated with less pronounced physiological effects, epidemiological studies have found a potential temporal link between marijuana use and myocardial infarction.

Meanwhile, a broad range of cardiac electrical effects, including atrial fibrillation and ventricular tachycardia, have been described with marijuana use, which may be explained by the increased catecholamines and b-adrenergic stimulation with THC that could raise arrhythmogenicity. Cerebrovascular events have also been reported in association with marijuana use, due to the direct vasculotoxic effects, alterations in hemodynamics, or incident atrial fibrillation/flutter.

Further, thrombosis and ischemia have been reported in the peripheral arteries with marijuana use, and delta-8 and delta-9-tetrahydrocannabinols have been shown to stimulate peripheral vasoconstriction. Cannabis use has also been associated with myocardial dysfunction, independent of coronary artery disease. Case reports have suggested associations of cannabis with stress cardiomyopathy and myocarditis/ myopericarditis, an entity ref

http://www.onlinejacc.org/content/75/3/320

erred to as toxic myocarditis. Additionally, heart transplant candidacy may be affected by marijuana use. Potential concerns include medication adherence due to the psychotropic effects of THC, infectious complications in the setting of immunosuppression, and interactions with tacrolimus.

In regard to pharmacological interactions, cannabinoids affect key classes of cardiovascular medications including antiarrhythmics, calcium-channel blockers, statins, beta-blockers, and warfarin, by inhibiting the cytochrome P (CYP) 450 family. However, limited clinical data are available to guide dose or therapeutic changes.

“In light of accumulating data suggesting prevalent use of marijuana, including among patients with established cardiovascular disease, it is important to integrate screening, counseling, and testing when appropriate into clinical care,” the authors wrote.

Questions to patients should include frequency, quantity, and methods of administration, and patients should be made aware potential cardiovascular hazards of marijuana use, especially when used via smoking/inhalation routes. Since marijuana is also being delivered in vaporized forms, especially among young adults, clinicians should counsel patients about the variable concentrations of psychoactive THC delivered via different methods of use, as vaporized cannabis may yield high concentrations with greater pharmacodynamic effects than smoked cannabis.

Additionally, it may be reasonable to perform urine toxicology in the setting of myocardial infarction and new-onset heart failure. Marijuana testing is also required before an evaluation for heart transplantation. Patients should be screened for and counseled regarding the hazards of concurrent use of other illicit drugs, especially those with known adverse cardiovascular effects, such as cocaine and methamphetamines. Meanwhile, multidisciplinary assessment with a pharmacist will help determine whether dose changes are required for therapies with known interactions.

“Shared decision making is encouraged if marijuana is used for symptom management or palliative purposes, incorporating estimates of life expectancy and cardiovascular risks,” the authors wrote.

“Cardiovascular specialists should be aware of local regulations and state-specific legalization status of marijuana products,” the authors wrote.

Ersilia M. DeFilippis, Navkaranbir S. Bajaj, Amitoj Singh, et al. 

“Marijuana Use in Patients With Cardiovascular Disease.”

. January 3, 2020. DOI: 10.1016/j.jacc.2019.11.025

Screening, testing and counseling for marijuana use is needed, especially in young patients presenting with cardiovascular disease, according to a review recently published in the Journal of the American College of Cardiology.

Marijuana Screening Recommended for Cardiovascular Disease

Hot yoga improved ambulatory blood pressure and reduced mental stress, a correlate of hypertension, in adults with elevated blood pressure and stage I hypertension, according to a study presented at AHA’s Hypertension 2019 Scientific Sessions held in New Orleans last month.

Previous research has shown reductions in ambulatory blood pressure with regular, room-temperature yoga, but no studies have investigated the blood pressure impact of hot yoga, which is typically offered in a humid atmosphere, with room temperatures around 105 degrees Fahrenheit.

“Hot yoga is gaining popularity, and we’re even seeing other styles of yoga, like Vinyasa and power yoga, being offered in heated studios,” said study lead Stacy Hunter, Ph.D., of Texas State University in San Marcos.

Researchers randomly assigned 10 sedentary, unmedicated men and women, aged 20 to 65 years, with either elevated blood pressure (120-129 mmHg for systolic with a diastolic below 80 mmHg) or stage I hypertension (130-139 mmHg for systolic or 80-89 mmHg for diastolic) to take 12 weeks of three-times-weekly hour-long hot yoga classes or no yoga classes. The researchers looked at average 24-hour blood pressure readings, along with perceived stress and vascular function.

In the yoga group, 24-hour systolic blood pressure dropped from an average 126 mmHg at the study’s start to 121 mmHg at 12 weeks, and 24-hour diastolic decreased from 82 mmHg to 79 mmHg, while perceived stress levels also fell. Average blood pressure and perceived stress levels did not change in the control group.

“These blood pressure reductions were observed in the absence of blood pressure medications or weight loss, and do not appear to be associated with improvements in pulse wave analysis,” the authors wrote.

“The results of our study start the conversation that hot yoga could be feasible and effective in terms of reducing blood pressure without medication,” Dr. Hunter said, but she recommended larger studies to determine if the practice has true blood pressure lowering effect.

“Hot Yoga and Hypertension: Exploration of a Novel Lifestyle Intervention.” 

Stacy Hunter , A. Tobi Fadeyi , James Shadiow. Sept 5, 2019.  Hypertension 2019. Abstract number P196.

Hot Yoga May Lower Blood Pressure

Local heat therapy applied overnight effectively lowers blood pressure in patients with both primary autonomic failure and nocturnal supine hypertension, according to a study presented at AHA’s Hypertension 2019 Scientific Sessions in New Orleans.

Supine hypertension, which is present in about half of patients with autonomic failure, complicates orthostatic hypotension treatment and induces nocturnal polyuria, which worsens morning orthostatic hypotension. 

Previous research has shown that short exposure to local passive heat acutely decreased systolic blood pressure by around 25 mmHg in these patients due to decreases in stroke volume and cardiac output. This study looked at whether local passive heat therapy applied overnight would lower nocturnal blood pressure and polyuria, and improve early morning orthostatic hypotension.

Researchers studied 10 patients with autonomic failure and supine hypertension, with an average age of 76 years and a mean supine systolic blood pressure of 168 mm Hg. In a two-night crossover study, participants received heat at 100 degrees Fahrenheit from a medical grade heating pad placed under their torso on one night, and an unheated pad was placed in the same position on the second night. Supine blood pressure was monitored every two hours from 8 p.m. to 8 a.m., and heat therapy was applied from 10 p.m. to 6 a.m.

Heat therapy applied during sleep decreased systolic blood pressure, with a maximum reduction of 30 mm Hg after four hours of heat, but did not decrease nocturnal diuresis or improve morning orthostatic hypotension.

“In many patients with autonomic failure, heat exposure decreases blood pressure by shifting blood to skin vessels,” said study lead Luis E. Okamoto, M.D., of Vanderbilt University Medical Center in Nashville, Tenn.

“Local heat therapy offers a novel non-pharmacologic approach to treat this condition, but future studies are needed to assess the long-term safety of this approach,” the authors wrote.

“Local Passive Heat in the Treatment of Nocturnal Supine Hypertension in Autonomic Failure.” 

Luis E Okamoto, Jorge E Celedonio, Emily C Smith, et al. Sept 6, 2019.  Hypertension 2019. Abstract number 043.

Local Heat Lowers Blood Pressure in Supine Hypertension

The number of pregnant women who develop hypertension during the first 20 weeks of pregnancy has spiked in the U.S. since 1979, especially among black women, with advanced maternal age contributing to this upward trend, say researchers writing in Hypertension this month.

Led by Cande V. Ananth, Ph.D., Rutgers Robert Wood Johnson Medical School in New Brunswick, New Jersey, this was a population-based cross-sectional analysis that included 151 million women who were admitted to the hospital with delivery-related complications between 1970 to 2010 in the United States. Researchers reported a “substantial increase in chronic hypertension rates by age and period and an over 2-fold race disparity in chronic hypertension rates.”

The analysis included women aged 15 to 49 years. Hypertension was defined as blood pressure of 140/90 mm Hg before becoming pregnant or during the first 20 weeks of pregnancy. Overall, 0.63 percent of the women experienced chronic hypertension during their pregnancy, with over a two-fold higher rate among black (1.24 percent) than white (0.53 percent) women. The rate of chronic hypertension increased steadily with advancing maternal age and year of delivery, from 0.11 percent in 1970 to 1.52 percent in 2010, representing a 13-fold increase. Chronic hypertension during pregnancy increased on average by 6 percent every year since 1979, with white women showing a 7 percent increase versus a 4 percent increase in black women each year. After adjusting for obesity and smoking rates, the researchers determined that these factors did not influence the upward trend of chronic hypertension during pregnancy.

“Since more women are electing to postpone their first pregnancies, and advanced maternal age is strongly associated with chronic high blood pressure, women should be aware of the risks associated with having high blood pressure during pregnancy,” the authors wrote.

Chronic hypertension complicates around 5 percent of pregnancies. It is associated with increased risks of perinatal and neonatal mortality and morbidity and maternal outcomes including preeclampsia, stroke, heart failure, cardiomyopathy or kidney failure and death among other risks.

The prevalence of chronic hypertension may be increasing in the U.S. due to advanced maternal age and increases in such risk factors as pregestational diabetes, smoking, being overweight, metabolic syndrome and multifetal pregnancy. Black women are at an increased risk of developing chronic hypertension compared with white women.

Cande V. Ananth, Christina M. Duzyj, Stacy Yadava, et al. 

“Changes in the Prevalence of Chronic Hypertension in Pregnancy, United States, 1970 to 2010.”