AHA News: 3 Simple Steps Could Save 94 Million Lives Worldwide

MONDAY, June 10, 2019 (American Heart Association News) -- Doing three relatively easy things could help save 94.3 million people around the world from premature deaths caused by cardiovascular disease, new research suggests.
Those lives could be saved over a quarter-century span by scaling up treatment of high blood pressure, reducing sodium intake and eliminating artificial trans fat, according to a study published Monday in the American Heart Association journal Circulation.
"We asked, what should we focus our resources on if we wanted to achieve the largest gains in mortality in the next 25 years, and it seems like the combination of these three interventions had the biggest potential impact and, also, feasibility," said Goodarz Danaei, the study's senior author.
Boosting treatment of high blood pressure to 70% could lengthen the lives of 39.4 million people, according to the study's estimates. Cutting sodium intake by 30% would delay an additional 40 million deaths, while also helping to lower high blood pressure, a leading risk factor for cardiovascular disease. Finally, eliminating artificial trans fat would postpone another 14.8 million deaths.
Researchers calculated their figures by analyzing global data from multiple studies, as well as data from the World Health Organization. Sub-Saharan Africa would have the largest proportion of overall delayed deaths, while South Asia would see the greatest impact from eliminating trans fat.
Danaei said scaling up control of high blood pressure might be the easiest goal to achieve because lifestyle changes are now targeted by many health programs and medications used in treatment are safe and often affordable. Efforts to reduce salt and eliminate trans fat may require national legislation or changes by the regional or national ministry of health.
"We are trying to elicit interest and raise resources for countries worldwide to achieve these goals," said Danaei, an associate professor of global health at the Harvard T.H. Chan School of Public Health in Boston. "These are realistic goals that have been shown to be attainable on smaller scales. We need the commitment to scale up the programs to achieve them globally."
Danaei and another researcher in the study are paid consultants for Resolve To Save Lives, a global health initiative that aims to "save 100 million lives from cardiovascular disease and prevent epidemics."
The study notes some nations already have met or surpassed the intervention targets. Canada, for example, has achieved a 70% blood pressure control rate, while parts of the Kaiser Permanente system in the United States have shown a 90% control rate achievable.
A salt-reduction initiative in the United Kingdom, meanwhile, helped cut sodium intake there by 15% between 2003 and 2011. And Denmark's near elimination of trans fat with a law that took effect in 2004 led the way for other countries in Europe and elsewhere to do the same. Canada and the United States recently banned artificial trans fats.
In the United States, high blood pressure accounts for more deaths related to heart disease and stroke than any other modifiable risk factor, according to the 2019 guidelines for preventing cardiovascular disease issued by the AHA and American College of Cardiology.
Dr. Daniel Muñoz, who helped write the guidelines, said the new study "reinforces the power of lifestyle factors. There's an opportunity here to empower people all over the world with the knowledge, information and education they need to make healthier choices."
For instance, guidelines from the federal government and the AHA recommend people limit sodium to less than 2,300 milligrams per day. Yet Americans consume on average more than 3,400 mg of sodium a day.
Education about salt reduction – or just realizing how much salt they consume daily – along with learning which foods may include trans fat can empower people to make wiser choices, said Muñoz, an assistant professor of cardiovascular medicine at Vanderbilt University Medical Center in Tennessee.
It also can encourage them to push for changes on a broader scale.
"Part of translating an admirably lofty goal into reality involves thoughtful public policy and certain requirements, like transparency of food labeling so that people in their day-to-day lives can look at a nutritional label and understand what they're getting," he said. "That degree of daylight on our decisions can go a long way. Engineering that reality is a challenge, but the study powerfully argues that the payoff is clear."

Legalizing Medical Pot Won't Ease Opioid Crisis: Study

 Medical marijuana has been a beacon of hope in the opioid epidemic, with states legalizing weed in hopes that its use will cut down on fatal overdoses from painkiller use.
Now, a new study is throwing cold water on that notion.
There's no association between medical marijuana laws and opioid overdose death rates, researchers report.
The OD death rate actually increased between 1999 and 2017 in states that legalized medical pot, rising by about 23%, according to new results.
However, that doesn't mean medical marijuana is spurring on opioid ODs, researchers emphasize.
"We don't think that means medical cannabis is killing people now, and we also think it wasn't saving them before," said senior researcher Keith Humphreys.
"There must be other things driving this relationship this way and that way, but it's not fundamentally a causal relationship," said Humphreys, a Stanford University professor of psychiatry and behavioral sciences.
The new report -- in the June 10 Proceedings of the National Academy of Sciences -- replicates and extends a 2014 study. That study found that medical marijuana might be providing patients with a less dangerous alternative to opioids for pain relief.
The earlier study discovered that state medical pot laws had been associated with a 21% reduction in opioid overdose death rates between 1999 and 2010.
"States have been using the findings from the earlier study as justification for legalizing medical cannabis," said lead researcher Chelsea Shover, a postdoctoral researcher at Stanford.
But the marijuana legalization landscape has changed in the United States since then. Medical marijuana is now allowable in 47 states, up from just 13 states in 2010.
Humphreys, Shover and their colleagues decided to revisit the earlier study, broadening it by adding seven years of data gathered as pot legalization swept the nation.
"We repeated the original study. We used the same methods," Shover said. "We even found the same thing if we stopped at 2010. But when we looked over a longer time frame, the trend went away and even reversed."
Emily Feinstein is the Center on Addiction's chief operating officer and executive vice president. She said the new study shows that many states "have been misled by insufficient or misinterpreted studies into thinking that marijuana is an effective tool to fight the opioid crisis.
"There is a lot of wishful thinking about marijuana. People want to see it as a magic bullet, or a harmless, beneficial medicine, but that image is being driven by an industry that places profits before the public's health," Feinstein said. "We need to craft marijuana policies that are based in strong, credible data, not associations, suggestions or personal experience."
Researchers suspect that the first set of positive findings was based on other state-level policies that reduced opioid deaths in states that, by coincidence, also were early adopters of medical pot.
These policies included better access to health care, an emphasis on treating addiction as a disease, and policies that steered drug offenders into treatment rather than prison, Humphreys and Shover said.
The researchers also noted that only about 2.5% of the U.S. population uses medical marijuana, which makes it unlikely that its use could affect death stats.
A representative of the marijuana pro-reform group NORML agreed that the new results have been shaped by the inclusion of more states, but the group continues to stand by the idea that medical pot can reduce drug overdoses.
"Not all medical or legalization programs are equal," said Mitch Earleywine, advisory board member of NORML and a professor of psychology at University at Albany-State University of New York.
He believes states that more recently adopted medical marijuana laws are doing a lousy job getting medicinal pot into the hands of people who would benefit from it.
"Including a state with a brand-new, barely functional distribution system in the group of 'legal' or 'medical' states will dilute any impact of the laws, because the cannabis simply isn't as available as it might be in states with established programs that have run for years," Earleywine said.
Marijuana does have a place in medicine, Shover said.
"The takeaway from our study is that not that cannabis has no medical benefit. Cannabinoids do seem to have medical benefits in some contexts," Shover said.
But people shouldn't hold onto false hope that medical pot laws will reduce opioid OD deaths, Humphreys said. Instead, states need to focus on better policies that get addicts into treatment and make the OD-reversing drug naloxone more readily available.
"I understand the desperation that's out there," Humphreys said. "But we have to go with the evidence. It isn't true."

Gene Test Might Someday Gauge Your Heart Attack Risk

 Can a DNA test predict a person's future heart health? Perhaps, researchers say.
A team of Canadian researchers found that by analyzing a person's entire genome, it might be possible to predict their future heart disease risk.
The so-called "polygenic risk score" analysis looks for key heart disease indicators -- genetic "biomarkers" -- along with an individual's entire genetic blueprint, or genome.
Prior research had already suggested that this type of analysis could determine heart attack risk for people of European descent with no prior heart attack history. But the new analysis suggests the approach can work just as well in other populations.
As lead researcher Guillaume Lettre explained, the polygenic risk score "is like having a snapshot of the whole genetic variation found in one's DNA, and [it] can more powerfully predict one's disease risk. Using the score, we can better understand whether someone is at higher or lower risk to develop a heart problem."
Lettre is an associate professor at the Montreal Heart Institute and the University of Montreal.
One U.S. heart expert agreed that an accurate means of pinpointing heart risk is sorely needed.
Too often "the first symptom of a heart attack is the heart attack [itself]," said Dr. Guy Mintz, who directs cardiovascular health at the Sandra Atlas Bass Heart Hospital in Manhasset, N.Y.
Using tools such as the polygenic risk score, patients at risk could be spotted sooner so that "we can apply more intense improvement in their personal cardiac risk factors at an earlier age," he reasoned.
"I would welcome using this type of precision medicine, individualized medicine, to identify children and adolescents as well as adults" at high risk for heart disease, Mintz said.
In the new analysis, Lettre's group compiled polygenic risk scores for more than 3,600 French Canadian heart disease patients. They then compared those results to those from nearly 7,400 who were heart disease-free.
The result: polygenic risk scores were just as predictively useful for French Canadians as they were for people from other genetic backgrounds, with an ability to accurately pinpoint about 6% to 7% of those tested as having a high risk for heart disease.
One caveat: The analysis was not as useful for those who had already experienced a heart attack. That might be because people with prior attacks tended to be older, and most were already taking drugs, such as statins, to lower their cardiovascular risk, the team theorized.
Dr. Eugenia Gianos directs women's heart health at Lenox Hill Hospital in New York City. Reviewing the findings, she said the new test "held up quite well for its predictive ability for the presence of coronary artery disease."
If the test pans out, it "could innovate how we tailor medical therapies to those at greatest risk earlier in life," she believes.
And Mintz noted that many people live with heart disease for years without knowing it.
"A sobering thought is that heart disease, [arterial] plaque, has been found at autopsy in teenagers and young adults," he said. "So, knowing early on who needs more intense surveillance and therapy could be a game-changer," Mintz explained.
"While the polygenic risk score is less accurate in predicting second heart attacks, I am not worried about that population, because we do a good job in treating this group," he said.
Lettre and his colleagues published their findings June 11 in the journal Circulation: Genomic and Precision Medicine.

Study Refutes Notion That People on Warfarin Shouldn't Eat Leafy Greens

 Spinach-loving seniors, rejoice. A new study suggests that -- despite doctor warnings to the contrary -- you can eat leafy greens rich in vitamin K if you are taking the blood thinner warfarin.
In fact, "I think all warfarin-treated patients would benefit from increasing their daily vitamin K intake," said lead author Guylaine Ferland. She's a professor of nutrition at University of Montreal in Canada.
The results of the study were scheduled to be presented Tuesday at the annual meeting of the American Society for Nutrition, in Baltimore.
Vitamin K aids clotting, so patients on the anti-clotting drug (or "anticoagulant") warfarin are often warned by their physicians to limit the amount of foods rich in the nutrient. These foods include green vegetables such as spinach, kale, broccoli, cabbage, Brussels sprouts and many others.
However, Ferland's team wanted to test the long-held notion that vitamin K really does pose a problem for these patients.
The study involved 46 patients, aged 32 to 85, all of whom had trouble maintaining their anticoagulation levels.
Half attended regular dietary counseling and cooking lessons. The other half went to counseling and cooking classes, but instructors in these classes promoted adding more green vegetables, as well as oils with vitamin K, to the diet.
To their surprise, six months later, 50% of people who'd added more vitamin K to their diets were maintaining stable anticoagulation levels, compared to only 20% of those who did not add more of the vitamin.
These results suggest that taking in more vitamin K, not less, might benefit patients on warfarin (Coumadin).
Based on the new findings, Ferland now recommends a minimum of 90 micrograms of vitamin K per day for women and 120 micrograms per day for men.
"Our hope is that health care professionals will stop advising warfarin-treated patients to avoid green vegetables," she said in a meeting news release.
"That said, given the direct interaction between dietary vitamin K and the action of the drug, it is important that (higher) daily vitamin K intakes be as consistent as possible," Ferland said.
One heart specialist was encouraged by the new findings.
"The accepted teachings to patients taking warfarin is to avoid vitamin K at all costs, to prevent any inhibition of warfarin by vitamin K," said Dr. Marcin Kowalski, who directs cardiac electrophysiology at Staten Island University Hospital in New York City. "But this study showed that a reasonable and balanced diet involving vitamin K actually brings better outcomes."
Still, he agreed with Ferland that consistency is key, to avoid upsetting warfarin efficiency.
"Educating patients as to why is it important to maintain constant vitamin K intake helps them obtain appropriate warfarin levels," Kowalski said.
Dr. Satjit Bhusri, a cardiologist at New York City's Lenox Hill Hospital, wasn't as enthusiastic about the findings, however.
First of all, he said, "we now have many new anticoagulant medications to give patients that do not interact with vitamin K and do not need frequent blood work." So this means that "the use of warfarin therapy is becoming very limited," Bhusri said.
But for those who do take warfarin, the best approach is to gauge the patient's dietary intake and try to adjust warfarin dosages accordingly, he believes.
Because this study was presented at a medical meeting, its findings should be considered preliminary until published in a peer-reviewed journal.

U.S. Expert Panel Supports HIV-Prevention Pill Truvada, for People at High Risk

 A daily pill that can block transmission of HIV should be prescribed to people at high risk of infection with the AIDS-causing virus, according to a highly influential panel of experts.
The treatment -- called pre-exposure prophylaxis (PrEP) -- has proven highly effective at preventing HIV spread in clinical trials, an evidence review by the U.S. Preventive Services Task Force (USPSTF) has concluded.
The task force gave PrEP its highest-level recommendation, a grade A, which means that the potential benefit of the treatment is substantial and backed by strong medical evidence.
Best known as the two-drug combo pill Truvada (emtricitabine-tenofovir), the medication prevents HIV from establishing a permanent infection in people exposed through sex or injection drug use, according to the U.S. Centers for Disease Control and Prevention.
"Even though HIV is not in the media as much as it used to be, it's still a major public health problem in the U.S., with almost 40,000 people getting HIV every year," USPSTF Chairman Dr. Doug Owens said. "These are quite effective interventions that can help reduce new HIV infection."
An estimated 1.1 million people in the United States are living with HIV, and more than 700,000 have died of AIDS since the first cases were reported in 1981, the task force said.
The grade A recommendation should help expand insurance coverage of the pricy medication and get it into the hands of people who need it, experts said.
The USPSTF regularly issues evidence-based guidance on preventive health practices, and the Affordable Care Act (also known as "Obamacare") obliges insurance companies to cover preventive measures that receive strong task force recommendations.
"We have seen firsthand at our clinics how the scale up of PrEP can dramatically decrease the rates of new HIV infection, and improve the quality of life for those individuals who have access to this intervention," said Dr. Antonio Urbina. He is an associate professor of infectious diseases at the Icahn School of Medicine at Mount Sinai, in New York City.
"Besides near-perfect protection against HIV, PrEP is a good gateway for young adults to access preventive and primary care services," Urbina added.
With the task force's "bold" recommendation, "the elusive goal of ending the HIV epidemic in the U.S. now seems possible," Urbina said.
But obstacles remain. The only U.S. Food and Drug Administration-approved drug for PrEP, Truvada, currently costs $20,000 a year, said Dr. Rochelle Walensky, an infectious disease specialist at Massachusetts General Hospital in Boston.
"The real challenge with PrEP isn't how good it works once you take it," Walensky said. "We know it's over 90% effective in people who are taking the drug."
Instead, people who should be taking PrEP face a number of barriers, not the least of which is its cost, she said.
"The challenge with PrEP's value in HIV prevention is the number of people who walk in the door and get it, the number of prescribers who are willing and able and knowledgeable to give it, and the ability of people willing to take it reliably once they're prescribed it," Walensky said.
The task force emphasized that PrEP is not for everyone. Groups at high risk of HIV infection who should be on PrEP include:
Men who have sex with other men and are in a relationship with an HIV-positive person; who use condoms inconsistently; or who have had a sexually transmitted disease within the past six months.
Heterosexual women or men whose sex partner is HIV-positive; who use condoms inconsistently with a partner whose HIV status is unknown; or who have contracted syphilis or gonorrhea within the past six months.
People who inject drugs and regularly share needles.
PrEP prescriptions are most often written in the Northeast and the West, "but we also know the epidemic is in the South," Walensky said.
Southern states are least likely to have expanded Medicaid under Obamacare, preventing insurance access to many, and people at high HIV risk in the South also face social stigma in seeking out PrEP, she added.
"This is a really bold and wonderful step forward that needs to be applauded, but I also don't at all think we can let down any sort of guard to say this is going to be the answer," Walensky said. "It probably doesn't do all of the heavy lifting for the patients who need it most."
The task force recommendation was published online June 11 in the Journal of the American Medical Association.

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Health Tip: Drinking and Boating Don't Mix
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Health Tip: Drinking and Boating Don't Mix

-- In most states, laws for drinking and boating are similar to those governing drinking and driving.
Boating laws apply to most any boat, including canoes, kayaks and rowboats. Alcohol is the top contributor to boating accidents, says the American Addiction Centers.
Drinking and boating increase your chances of drowning, falling off the boat and driving recklessly.
There is no safe amount of alcohol for a boat operator, the addiction group says.