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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 6, November/December 2016
394
AFRICA
by calcium carbonate, alkalinisation, beta-stimulants, insulin
and potassium, and Na
+
polystyrene sulphonate (Kayexalate).
Patiromer
4
and Na
+
zirconium cyclosilicate
5
are two agents
currently in development that control hyperkalaemia in the
long term and may enable the uninterrupted continuation of
therapeutic doses of RAAS inhibitors.
The CLARIFY study analysed data from 22 672 patients with
stable coronary artery disease (CAD) and treated hypertension.
It found an increase in cardiovascular events in those with
systolic blood pressure
>
140 mmHg and diastolic blood pressure
>
80 mmHg. However systolic blood pressure
<
120 mmHg and
diastolic blood pressure
<
70 mmHg were also associated with
an increase in cardiovascular events, except for stroke. This
finding supports the presence of a J-shaped curve in relation to
outcomes and the blood pressure achieved on treatment.
6
Prevention
The 2016 guidelines on the prevention of CV disease target
smoking, diet, physical activity, body weight, blood pressure,
serum lipids and diabetes. Management should be individualised
after assessment of personal risk using the SCORE tables. No
additional predictive accuracy derives from the measurement of
biomarkers. In apparently healthy individuals, risk assessment
should be carried out from the age of 40 years in men and
50 years in women or when they are post-menopausal. Risk
assessment may be repeated at five-year intervals in those with
no identifiable risk factors and more often in those with risk
close to threshold. Broadly speaking, management targets are
avoidance of any exposure to smoking, a diet low in saturated
fat, activity for at least 150 minutes each week, a body mass index
(BMI) of 20–25 kg/m
2
, blood pressure
<
140/90 mmHg, LDL-C
according to the guideline on dyslipidaemia (i.e.
<
3.0 mmol/l in
low- to moderate-risk individuals) and, in patients with diabetes,
an HbA
1c
level
<
7%. Aside from the general recommendations,
the guidelines contain specific recommendations for the
management of patients with hypertension, CAD, chronic heart
failure, cerebrovascular disease and peripheral vascular disease.
A ‘naturally randomised’ study evaluated outcomes
dependent on whether the study population’s LDL-C and blood
pressure lay above or below the median, therefore evaluating
lifelong exposure to these recognised risk factors. The differences
between the lower and higher groups were LDL-C 0.31 mmol/l
and blood pressure 5 mmHg. Outcomes were better in those with
a lower LDL-C or blood pressure with a multiplicative effect
observed when both were below the median.
Population data have been collected in Finland since 1972.
At the outset, the regions in the east of the country had the
world’s highest incidence of CAD. A programme to encourage
behavioural change was launched, including, smoking cessation
and a reduction in dairy product intake. Since then there has
been a continuous decline in CV disease of 4.4% per annum,
thus achieving a cumulative reduction of 80% since the start of
the project. Two-thirds of the decline is ascribed to risk factor
management and one-third to medication and intervention.
7
The Europe-wide survey EURO-ASPIRE IV demonstrates
persistent overweight and obesity in the population. Eighty-
eight per cent of respondents were found to be overweight
with two-thirds exhibiting central obesity. Women were more
frequently affected than men.
A study from the Netherlands examined medication
compliance in 59 000 patients after either ST-elevationmyocardial
infarction (STEMI) or non-ST-elevation myocardial infarction
(NSTEMI). It showed that only 34% of patients took all five of
the recommended therapies. STEMI patients were more likely
to adhere (43%) than those with NSTEMI (28%). The latter
group was more likely not to be taking statins and antiplatelet
therapy. A Korean study showed that medication adherence can
be improved by simplifying the timing of daily administration.
The PALM registry found that underdosing of secondary
preventative therapies was prevalent and that untreated and
underdosed patients exhibited a higher LDL-C value.
The OPTICARE study involved an educational and
interventional programme in patients after ACS, comparing
standard care versus a face-to-face physical training programme
combined with counselling, versus a programme of telephone
contact. More than 80% of patients completed the programme.
A high percentage received optimal medical therapy (OMT).
The study found no benefit to patients from more intensive
management.
Depression and anxiety are frequent concomitants in patients
with CAD (25%) or stroke (33%). Its occurrence is more
frequent with advancing age, elevated blood pressure and alcohol
use. In the study reported at the meeting, effective secondary
preventative treatment did not influence the rate of depression
or anxiety. Very few patients had received treatment for their
depression/anxiety.
Bisphosphonates may reduce arterial calcification and
so influence the progression of atherosclerotic disease. A
retrospective analysis showed that the cardiovascular mortality
rate was reduced by 19% and all-cause mortality by 10%.
An international randomised study in 2 717 patients with
prior CAD or stroke, who had obstructive sleep apnoea, showed
that the use of continuous positive airway pressure (CPAP) over
four years failed to improve cardiovascular outcomes. Quality of
life was improved. The apparatus was used on average only for
around 3.5 hours each night. Fewer stroke events were noted in
those who used CPAP for more than four hours per night.
8
Coronary artery disease
Several reports were predicated on concerns about the high
incidence of normal coronary angiograms in patients investigated
for suspected stable CAD. Most quoted an incidence of 60–70%
without obstructive disease. The CONSERVE trial over 12
months used coronary computed tomography angiography
(CCTA) first, to assess whether invasive angiography was
required. This approach reduced the assessed need for invasive
angiography by 78%, revascularisation from 17 to 10% and the
cost by 50%. In the Clinical Evaluation of Magnetic Resonance
Imaging in Coronary Heart Disease 2 trial (CE-MARC 2), the
NICE guidelines were compared to cardiac magnetic resonance
(CMR) and to myocardial perfusion imaging. This reduced the
‘unnecessary’ angiography rates to 28, 7 and 7%, respectively.
In both studies, the MACE rates were not impacted on by
avoidance of angiography.
9
The PACIFIC study carried out a head-to-head comparison
of CCTA, myocardial perfusion single-photon emission
computed tomography (SPECT), positron emission tomography
(PET) and hybrid imaging in the diagnosis of ischaemic heart