How Hurricane Harvey Became So Destructive
Scientists say warm waters and stagnant winds in the upper atmosphere built a monster of a storm. Whether climate change is to blame is less clear, The New York Times reports. Read more here.
Combination Therapy Works Best for Heart Diseases: Study
Combining two drugs – rivaroxaban and aspirin — reduced strokes, heart attacks and cardiovascular death by nearly 25% compared to either drug alone in both patients with stable coronary or peripheral artery disease and is superior to aspirin alone in preventing further heart complications in people with vascular disease.
That’s the conclusion of a major international study of 27,400 people with stable coronary or peripheral artery disease from 33 countries worldwide. Results show that the combination of 2.5 mg of rivaroxaban twice daily plus 100 mg of aspirin once daily was significantly better than only aspirin or only rivaroxaban in preventing heart attacks, strokes and death. Rivaroxaban, often known by the brand name Xarelto, is an anticoagulant, aspirin is an antiplatelet drug, and both are blood thinners.
The results will be presented today at the Congress of the European Society of Cardiology (ESC) in Barcelona, Spain, and the overall results will be published in the New England Journal of Medicine.
The study, called COMPASS, is led by the Population Health Research Institute (PHRI) of McMaster University and Hamilton Health Sciences (HHS) in Hamilton, Canada. The study is funded by Bayer AG.
The findings are significant because there are about 300 million people around the world living with cardiovascular disease, and every year as many as 5% to 10% have a stroke or heart attack. Although aspirin reduces the risk of major cardiovascular events by 19%, a more effective antithrombotic strategy could have major benefits for the large population of patients with stable cardiovascular disease.
The clear result of this clinical study caused the clinical trial to be stopped early, after 23 months, in February 2017.
The researchers report that the drug combination does increase the chance of a major bleeding. These bleeds were mainly gastroenterological, and not in critical organs such as the brain nor fatal.
A second paper from the same study, which is forthcoming in The Lancet, shows that the same drug combination is superior to aspirin for the risk of losing limbs or severe limb ischemia (limitation of blood flow to a limb), as well as decreasing cardiovascular events, among patients with peripheral artery disease (PAD).
The study looked at 7,470 patients with PAD who took part in the COMPASS study, and found the combination reduced heart attacks, stroke or cardiovascular death by 28% and damage to limbs by 46%. Rivaroxaban alone was not superior to aspirin in preventing heart attacks, stroke, cardiovascular death, or limb events.
Both the combination and rivaroxaban alone had increased major bleeding, but not fatal nor critical organ bleeding.
Dr. Sonia Anand, who led the PAD component of the COMPASS trial, said: “This is an important advance for patients with peripheral artery disease. Until now we have only had aspirin for these patients, which is only modestly effective. To now have a therapy that both reduces major adverse cardiovascular events and major adverse limb events by one-third is going to be a great benefit for these high-risk patients.”
Anand is a professor of medicine at McMaster, a senior scientist at the PHRI, and a vascular medicine physician at HHS.
Dr. Salim Yusuf, executive director of PHRI, McMaster professor of medicine and chief scientist at HHS, said the large size of the study, broad inclusion criteria and consistent results in all regions of the world means the results are widely applicable around the world.
“The benefits seen in COMPASS are on the top of other effective therapies such as statins, aspirin, ACE inhibitors and beta blockers, and so their collective impact is substantial. It is likely the combination therapy will reduce the risk of recurrent cardiovascular events by well over two-thirds,” said Yusuf.
Low Weight Linked to Highest Mortality,
Costs After Cardiac Catheterization
Being underweight, and not overweight, has the highest mortality, cost, length of stay, and readmission rate for those undergoing cardiac catheterization, according to an analysis of more than one million patients presented at ESC Congress today.1
“Elevated body mass index (BMI) is a risk factor for coronary artery disease, yet studies have shown that overweight and obese patients actually have fewer complications and better clinical outcomes after revascularization using percutaneous coronary intervention (PCI) – a phenomenon dubbed the obesity paradox,” said lead author Dr. Afnan Tariq, an interventional cardiology fellow, Lenox Hill Hospital, New York, USA.
This study examined the association of BMI with in-hospital mortality, cost of care, length of stay, and rate of readmission within 30 days in patients undergoing cardiac catheterization (coronary angiography) in 2013 in a nationally representative cohort.
Researchers used the National Readmission Database and Nationwide Inpatient Sample Database to retrospectively analyze discharge and readmission data. These are the largest all payer USA inpatient databases and include more than 35 million hospitalizations annually.
In 2013, 1,035,727 patients underwent cardiac catheterization, of which 42% also received PCI with a stent or balloon. When categorized by BMI, 0.4% of patients were underweight (BMI<19 kg/m2), while 11.4% were obese (BMI 30.1-40 kg/m2) and 8.0% were morbidly obese (BMI over 40 kg/m2). Of those undergoing cardiac catheterization, only 25.8% of the underweight patients went on to receive PCI, while 32.5% of the morbidly obese, 41% of the overweight, 41% of the obese, and 43.2% of the normal weight categories went on to have a balloon or stent (PCI) placed for coronary blockages (adjusted for comorbidities: all values p<0.001).
Despite the low percentage of cardiac catheterizations and lower rate of PCI compared to normal and overweight BMI groups, underweight patients were over three times more likely to die after cardiac catheterization than morbidly obese patients and five times more likely to die than obese patients (6.0% mortality for underweight patients, 2.3% normal weight, 1.7% overweight, 1.2% obese, 1.9% morbidly obese, all values adjusted for comorbidities: p<0.001). Interestingly, despite the extreme BMI, morbidly obese patients had a lower mortality rate than normal weight patients and obese patients had the lowest mortality of all groups undergoing cardiac catheterization.
Length of stay for underweight patients was more than double that of normal weight patients (10.5 days versus 5.1 days) resulting in nearly 50% higher costs for underweight patients ($USD 33 540 versus $USD 22 581). Morbidly obese patients had a slightly longer length of stay and higher costs compared to normal weight patients (6.2 days, p<0.01 and $USD 23 889, p<0.01).
After adjustment for comorbidities, underweight patients were 18% more likely than normal weight patients to be readmitted within 30 days (p<0.007), while morbidly obese patients were 8.2% less likely to be readmitted within 30 days (p<0.001). Overweight and obese patients had the lowest readmission rates, and were over 10% less likely to be readmitted than normal weight patients within 30 days.
Dr. Tariq said: “The obesity paradox has flummoxed researchers for some time, and our research also flips the conventional wisdom that a higher BMI should portend a worse outcome. We found that the lower BMI group had worse outcomes across the board, including readmission, length of stay, cost, and mortality.”
“Furthermore, using the largest all payer publicly available database in the USA, we observe that obese and morbidly obese patients receive stents or balloons at a lower rate than normal weight patients, are less likely to be readmitted within 30 days, and have lower mortality than normal weight patients undergoing cardiac catheterization,” he continued.
Dr. Tariq concluded: “Further research will certainly add to the growing body of evidence, but the scales seem to be tipping in favor of higher BMI patients having better outcomes than normal weight patients. This study also reinforces the notion that the frail, those with the lowest BMI, have the worst outcomes – suggesting that when it comes to cardiac catheterization, the smaller they are, the harder they fall.”