CLINICAL
NEWS JACC in a FLASH
incorporation of direct-acting oral
anticoagulants (DOACs) into clinical
practice has contributed to questions
about when parenteral anticoagulation is appropriate.
The survey, completed by 945
physicians involved in the periprocedural management of anticoagulation, found that few respondents had
standardized periprocedural protocols
at their institutions. The medical
professionals charged with making
the decision to bridge anticoagulation
varied greatly (physicians performing
the procedures, primary care physicians, nurses and pharmacists) and
the decisions made were found to be
inconsistent. The authors explain that
the different philosophies and specialties of the physicians involved can
result in wide variations in dosage as
well as durations of parenteral anticoagulation. The survey also highlights
confusion surrounding periprocedural
management of anticoagulation in
patients treated with a DOAC.
“It has been shown that when
anticoagulation protocols are devised
and implemented, low TE and low
rates of major bleeding are observed,”
note the authors. Flaker, et al., conclude that the survey results represent
“an important opportunity for professional societies and guidelines committees to work together to provide
meaningful suggestions on the basis
of current data.”
“Overall, promotion of anticoagulation education programs and
coordination among specialties,
pharmacists, nursing and other health
care providers are needed to improve
anticoagulation patient care,” said
Flaker. “The College is in the process
of developing a clinical policy document in direct response to this need.”
Flaker GC, Theriot P, Binder LG, et al. J Am
Coll Cardiol. 2016;68(2):217-26.
HF After First
MI May Increase
Cancer Risk
First-time myocardial infarction (MI)
survivors who develop heart failure
(HF) have a greater risk of developing cancer when compared to those
without HF, according to a study
published July 11 in JACC.
20 CardioSource WorldNews
“Promotion of anticoagulation
education programs and coordination
among specialties, pharmacists,
nursing and other health care
providers are needed to improve
anticoagulation patient care.”
—Greg C. Flaker, MD
Researchers examined records
from the Rochester Epidemiological
Project for 1,081 patients in Olmsted
County, MN, who had their first MI
between November 2002 and December 2010. Follow up occurred after
an average of 4.9 years. Overall, 228
patients (21%) were diagnosed with
HF and 28 of those patients (12.3%)
developed cancer, compared to 8.2%
of patients without HF who were
diagnosed with cancer. The average
time from first MI to cancer diagnosis
was 2.8 years, with the most common cancers being respiratory, digestive and hematologic.
Researchers note the incidence of
cancer was similar initially between
those with and without HF, but after
1.5 years of follow up there were
higher rates of cancer among patients
with HF. An association between HF
and cancer remained after adjusting
for age, sex, comorbidities, smoking,
BMI and diabetes. The researchers
also studied the influence of medication on cancer diagnosis and found
that patients who developed HF after
MI were prescribed the same medications at discharge as those who were
not. This suggests that treatment for
MI was not likely responsible for the
higher rate of cancer in HF patients.
These findings support earlier
studies that found a 70% increased
risk of cancer among HF patients.
However, researchers did note the
limited sample size and number of
events.
“Cancer constitutes an enormous
burden to society, and both cancer
and HF are well-known causes of
increased mortality,” said Veronique
Roger, MD, senior author of the
study and director of the Mayo Clinic
Robert D. and Patricia E. Kern Center
for the Science of Health Care Delivery in Rochester, MN. “Our research
suggests an association between both
diseases, and it’s possible that as we
learn more about how this connection works, we can prevent deaths.
In the meantime, physicians should
recognize this increased cancer risk
for HF patients and follow guideline
recommended surveillance and early
detection practices.”
In a related editorial comment,
Paolo Boffetta, MD, MPH, associate
director for population sciences at
The Tisch Cancer Institute and chief
of the Division of Cancer Prevention
and Control of the at Mount Sinai, NY,
addressed whether the increased risk
of cancer in this group of heart failure
patients warranted additional screening beyond what was recommended
for the general public. The two most
prominent cancers were digestive and
respiratory, for which routing screening tests are not available.
Boffetta also said the predominance of these two cancers suggests
“a role of shared risk factors, as both
heart failure and cancer are associated with smoking and alcohol.”
Do Statins Affect
Exercise Reponse in
HF Patients?
In patients with heart failure (HF),
statin use does not appear to cause
short-term changes in aerobic capacity and quality of life with exercise
training, according to results of the
HF-ACTION Trial published July 6 in
JACC: Heart Failure.
The trial included 2,331 patients
with chronic HF with ejection fraction ≤ 35% who were randomized to
usual care with or without exercise
training. A total of 1,353 (58%) of
the patients were prescribed statins.
Statin use was more prevalent in
older men with hypertension, ischemic heart disease, and implanted
cardioverter-defibrillators, but these
patients had similar use of baseline
guideline-directed medical therapy
for HF compared with nonstatin
patients. Researchers found no difference between types of statins and
no interaction between statin use
and exercise adherence.
According to the study authors,
their findings suggest that exercise
therapy offers “significant benefits
on top of guideline medical therapy
for HF.” They write: “With the
recent Centers for Medicare and
Medicaid Services [CMS] expansion
of coverage for cardiac rehabilitation to beneficiaries with HF, many
patients are being referred for such
care, including a sizeable proportion receiving statins. Our results
suggest that there is no apparent
blunting of the response to aerobic
exercise therapy with concomitant
statin use. Instead, the expanded
CMS coverage for exercise therapy
should be welcomed as a new therapeutic option to improve exercise
capacity and quality of life and to
potentially reduce hospitalizations.”
They suggest that future studies
examine the effect of statin therapy
on the responses to exercise therapy
in the HF population. ■
Kelly JP, Dunning A, Schulte PJ, et al. JCHF.
2016;doi:10.1016/j.jchf.2016.05.006
Hasin T, Gerber Y, Weston SA, et al. J Am
Coll Cardiol. 2016;68(2):265-71.
August 2016