The National Institute for Health and Clinical Excellence (NICE) has issued guidelines to help healthcare professionals care for women with, or at risk of, developing hypertension during their pregnancy.

Key recommendations in the guideline for obstetricians, general practitioners, midwives, and other healthcare professionals include:

• Advising pregnant women with a moderate to high risk of developing preeclampsia to take a low dose (75mg) of aspirin each day from the twelfth week of pregnancy until birth to reduce their risk of developing the condition.
• Informing women with hypertension who are planning a pregnancy that angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs), which can be used to control hypertension in non-pregnant women, can increase the risk of congenital abnormalities if taken during pregnancy and discuss more suitable forms of antihypertensive treatment.
• Offering women with hypertension or preeclampsia a package of care including admission to hospital, treatment, measurement of blood pressure, testing for protein in their urine and blood tests.
• Carrying out ultrasounds to assess foetal growth, amniotic fluid volume and Doppler ultrasound to measure blood flow in the umbilical artery at different stages of pregnancy (as stated in the guideline) and according to the seriousness of hypertension in the expectant mother.
• Offering birth to women with preeclampsia after 34 weeks, but only once their blood pressure is under control, after discussions with specialists and, if needed, a course of antenatal steroids to be given to the woman to help mature the baby's lungs before birth.
• Advising women who have had preeclampsia to keep or achieve a healthy body mass index before their next pregnancy.
  
  The guidelines also state that restricting salt intake and taking dietary supplements such as magnesium or antioxidants (vitamins C and E) will not help prevent hypertension during pregnancy.
  
  http://guidance.nice.org.uk/CG107. Last accessed on 30.08.10

Relief from dyspnoea in patients with acute heart failure (AHF) is often incomplete and may lead to poor prognosis, as per results from the Pre-RELAX-AHF study.

Italian researchers found a trend toward improvement in both dyspnoea and HF symptoms in patients given relaxin, a naturally occurring vasodilator.

In the Preliminary study of RELAX in Acute Heart Failure (Pre-RELAX-AHF), the researchers randomly assigned 232 individuals admitted to hospital with AHF to receive relaxin at a dose of 10, 30, 100, or 250 µg/kg/day, or placebo and then followed them up for 180 days. Treatment with other drugs was allowed at the treating physicians' discretion.

Dyspnoea severity and relief was assessed at various time points using a visual analog scale (VAS) where patients were asked to draw a horizontal line across a 100-mm vertical line to indicate their breathing, with 100 mm being the best health state and 0 mm the worst. The seven-point Liker scale was also used to assess changes in dyspnoea from baseline.

Early dyspnoea relief (within first 24 hours) occurred in only 25% of the overall cohort, in 23% of the placebo group and 26% of the relaxin-treated group. At 14 days, 70% of patients overall had moderately or markedly better dyspnoea.

At baseline, VAS was 42.3 mm. By Day 5, it had increased by 14.3 mm in the placebo group versus 23.3 mm in the overall relaxin group. Average relative improvements from baseline in VAS area under the curve (AUC) through Day 5, were 31.7% and 50.0% in placebo- and relaxin-treated patients, respectively.

Worsening HF symptoms were seen in 21% of the placebo group and 14% of the combined relaxin treatment groups at Day 5.

Lack of dyspnoea relief and presence of worsening heart failure were associated with slower improvement in clinical signs of congestion and worse short- and intermediate-term outcomes, wrote researchers.

This suggests that, beyond being the main measure of AHF related to patients' symptoms, these endpoints are also related to prognosis and hence may be regarded as important and meaningful targets of therapy.

The trend toward improvement in dyspnoea and reduction in HF worsening achieved by relaxin administration suggested that a further improvement in symptoms and outcomes with new therapies is possible, said the researchers.

The most effective 30 µg/kg/day dose is currently being investigated further in the ongoing phase III RELAX-AHF study.

Eur J Heart Fail 2010; Advance online publication .
Last accessed on 30.08.10

A recent study testing the use of rheolytic thrombectomy prior to direct stenting of the infarct-related artery in patients with acute MI showed that mechanical thrombectomy was associated with more frequent ST-segment resolution, but there was no improvement in scintigraphic infarct size and other surrogate markers of myocardial reperfusion.

The routine removal of thrombus before infarct artery stenting is still a matter of debate. Researchers conducted the study to determine whether rheolytic thrombectomy (RT) before direct infarct artery stenting as compared with direct stenting (DS) alone in improved myocardial reperfusion and clinical outcome in patients with acute myocardial infarction.

The JETSTENT (AngioJet Rheolytic Thrombectomy Before Direct Infarct Artery Stenting in Patients Undergoing Primary PCI for Acute Myocardial Infarction) study was a multicenter, international, randomized, 2-arm, prospective study. Eligible patients were those with acute myocardial infarction, angiographic evidence of thrombus grade 3 to 5, and a reference vessel diameter ≥2.5 mm. Coprimary end points were early ST-segment resolution and 99m Tc-sestamibi infarct size. An α value = 0.05 achieved by both coprimary surrogate end points or an value = 0.025 for a single primary surrogate end point would be considered evidence of statistical significance. Other surrogate end points were Thrombolysis In Myocardial Infarction (TIMI) flow grade 3, corrected TIMI frame count, and TIMI grade 3 blush. Clinical end points were a composite of major adverse cardiovascular events at 1, 6, and 12 months.

From December 2005 to September 2009, 501 patients were randomly allocated to RT before DS or to DS alone. The ST-segment resolution was more frequent in the RT arm as compared with the DS alone arm: 85.8% and 78.8%, respectively (p = 0.043), while no difference between groups were revealed in the other surrogate end points. The 6-month major adverse cardiovascular events rate was 11.2% in the thrombectomy arm and 19.4% in the DS alone arm (p = 0.011). The 1-year event-free survival rates were 85.2 ± 2.3% for the RT arm, and 75.0 ± 3.1% for the DS alone arm (p = 0.009).

Although the primary efficacy end points were not met, the results of this study supported the use of RT before infarct artery stenting in patients with acute myocardial infarction and evidence of coronary thrombus.

An analysis of patients in the Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) trial stratified by their underlying level of absolute risk suggested that intermediate-risk patients with elevated C-reactive protein (CRP), including those with a 5% to 10% 10-year risk of cardiovascular disease, benefit from statin therapy.

Results of the study showed that rosuvastatin 20 mg reduced major cardiovascular events among men and women with normal LDL-cholesterol levels, elevated CRP levels, and a 5% to 10% or 10% to 20% 10-year risk of cardiovascular events based on the Framingham and Reynolds risk scores.

Researchers said the data showing the benefits of statin therapy in the JUPITER patients with varying levels of absolute risk provide evidence supported the 2009 Canadian guidelines recommending the use of CRP to determine statin eligibility among patients considered "intermediate risk. The data showed that the Canadian model works very well and is a cost-effective, evidence-based approach to primary prevention, an issue of importance as new US guidelines are being considered.

In this new analysis, researchers assessed the treatment benefit in JUPITER patients with different baseline absolute risks, including those considered low risk, intermediate risk, and high risk. JUPITER was not a study of low-risk patients, despite their low baseline LDL-cholesterol levels, said researchers. The event rate in the placebo group was substantially higher than in AFCAPS/TexCAPS , and most patients, more than 13 000, had a 10-year Framingham risk score between 5% and 20%, he added.

In stratifying patients based on underlying risk, treatment with rosuvastatin 20 mg reduced the primary end point — a composite of nonfatal MI, nonfatal stroke, hospitalization for unstable angina, arterial revascularization, or confirmed cardiovascular death — in individuals with a 10-year Framingham risk between 5% and 10% and in those with a 10-year risk between 11% and 20%. Similar reductions were observed when risk was classified using a risk estimate based on the Reynolds risk score.

No benefit was observed in low-risk patients, and none observed in the highest-risk patients when the Framingham risk score was used. Using the Reynolds risk score, however, those at highest risk benefited from statin therapy, a finding that reinforces the utility of CRP, because Reynolds incorporates the biomarker into its risk estimate, said researchers.

Researchers noted that intermediate risk is usually defined as a 10-year Framingham risk of 10% to 20%, and most guidelines adhere to that approach. However, there are a number of men and women who are at increased cardiovascular risk if they have a 5% to 10% Framingham risk and an elevated CRP, he said. Women, he pointed out, have typically been excluded from prior clinical guidelines because they often do not have 10-year Framingham risk scores >10%, much less >20%.

This is important, as JUPITER included nearly 7000 women who had relative benefits of rosuvastatin just as large as that of the men, but almost none of these women would qualify for treatment under current guidelines, said researchers.

Based on current US guidelines, few intermediate-risk patients with low levels of LDL cholesterol receive statins. The Canadian guidelines, recommend statins as an adjunctive therapy to lifestyle interventions in those with elevated CRP and a 10-year Framingham risk between 10% and 20%.

Above all, however, researchers stressed that diet, exercise, and smoking cessation form the cornerstone of primary prevention and that statins are not a substitute for good primary care.

Circ Cardiovasc Qual Outcomes 2010; DOI: 10.1161/circoutcomes.110938118. http://circoutcomes.ahajournals.org . Last accessed on 30.08.10

Data from more than 84,000 women over 26 years suggested that shifting dietary protein sources away from red meat to more poultry, fish, and nuts can reduce an individual's risk of coronary heart disease.

Researchers analyzed data from 26 years of follow-up from 84 135 women, aged 30 to 55 years, in the Nurses' Health Study. The patients enrolled in the study had no known cancer, diabetes mellitus, angina, MI, stroke, or other cardiovascular disease. Their diet was tracked with a standard questionnaire every four years. During 26 years of follow-up, 2210 incident nonfatal infarctions and 952 deaths from coronary heart disease were reported.

A multivariable analysis of diet and traditional risk factors, such as age and smoking, showed that consumption of red meat and high-fat dairy were significantly associated with an elevated risk of coronary heart disease, whereas higher intakes of poultry, fish, and nuts were significantly associated with lower risk.

A statistical model controlling for total intake of calories, cereal fiber, alcohol, trans-unsaturated fatty acids, and other potential non-dietary confounding variables showed that one serving per day of nuts was associated with a 30% lower risk of coronary disease than one serving per day of red meat. The same one-serving exchange comparison found a 13% lower risk with low-fat dairy, a 19% lower risk with poultry, and a 24% lower risk with fish.

This latest analysis from the study affirms the findings from 14 years and 16 years of follow-up, and red meat continues to be significantly related to coronary disease risk, independent of measured confounders and known intermediate outcomes.

The authors also found a link between total meat intake and coronary disease risk, likely driven by the high proportion of red meat in the total meat intake, but the strong association between red meat and coronary disease cannot be entirely explained by the intake of processed meat, because red meat remained associated with coronary disease even when processed meat was excluded. However, a recent study by a researcher at Boston found that eating unprocessed red meat did not increase the risk of coronary heart disease or diabetes, but eating 50 g of processed meat per day was associated with a 42% higher risk of CHD and a 19% increased risk of diabetes, most likely because of the volume of sodium and other preservatives.

The authors recalled that dietary iron, particularly the heme iron found in red meat has been positively associated with MI and fatal coronary disease in most, but not all, previous studies. The effect of heme iron on systolic blood pressure, the high sodium content of processed meats, and the compounds created by cooking red meat, such as heterocyclic amines and advanced glycation end products, might also increase coronary risk.

When major sources of protein, such as nuts and fish, are used to replace red meat; saturated fat, heme iron, and sodium decrease, whereas intake of polyunsaturated fat increases. The benefit on CHD risk of such a substitution is thus likely to be due to multiple simultaneous changes in nutrient intake, concluded researchers.

Circulation 2010; DOI:10.1161/circulationaha.109.915165. http://circ.ahajournals.org/. Last accessed on 30.08.10.