Thinking outside the heart

Cardiologists continue to explore the interplay between the heart, other organs and treatments to identify opportunities to improve patient care.

Wei Jiang, MD, of Duke University Medical Center in Durham, N.C., and colleagues took on the challenge of antidepressants and their possible cardiovascular therapeutic effects in a study published May 22 in the Journal of the American Medical Association. They looked at whether selective serotonin reuptake inhibitors could reduce mental stress–induced myocardial ischemia (MSIMI) in patients with coronary heart disease (CHD) in REMIT, a randomized double-blind placebo-controlled clinical trial.

“Few studies have examined therapeutics that effectively modify MSIMI, perhaps because of the mechanistic complexity underlying this phenomenon, which encompasses a wide range of central and peripheral physiological changes associated with emotions and behaviors,” they wrote. “However, recent evidence suggests that selective serotonin reuptake inhibitors (SSRIs) may reduce mental stress–induced hemodynamic response, metabolic risk factors, and platelet activity.”

They reported that six weeks of the SSRI escitalopram led to lower MSIMI compared with placebo but no statistically significant reduction in exercise-induced ischemia. The SSRI group claimed they felt more in control and calmer during mental stress testing than did the placebo group. “This finding is notable because positive expectations and attitudes have been shown to be associated with lower rates of mortality in patients with CHD,” Jiang et al wrote.

That two long-acting bronchodilators for chronic obstructive pulmonary disease (COPD) potentially pose cardiovascular risks is not likely to come as a surprise. Randomized clinical trials have shown clinical benefits of long-acting beta-antagonists and long-acting anticholinergics for treating moderate to severe COPD, but some observational studies and meta-analyses point to possible cardiovascular risks.

In another recent study in JAMA Internal Medicine, Andrea Gershon, MD, of the Institute of Clinical Evaluative Sciences in Toronto, and colleagues put the controversy aside to ask if one appeared to be safer than the other. Their data suggested the answer is no. They determined that new users were more likely to have a hospital or emergency room visit for a cardiovascular event compared with patients not taking either drug, but that the risk was similar between the two options.

The benefits of a medication can be realized only if the patient takes it. Medication nonadherence continues to derail many treatment plans. An interdisciplinary group of healthcare professionals at the University of Pittsburgh offered a solution that requires an attitude adjustment of sorts. They suggested physicians change their approach to medication nonadherence by viewing it as a medical condition that they can diagnose and treat.

Of course, thinking about change and acting on evidence or recommendations that call for change are different things. What systems in your practice facilitate change? Do these systems filter out “change for change’s sake” to ensure only efforts that lead to improvement be initiated? Please share.

Candace Stuart

Cardiovascular Business, editor