Recurrent depression and cardiovascular risk in women
Psychosom Med 2010 doi:10.1097/PSY.0b013e3181eeeb17
Depressive symptoms are risk factors for clinical CHD. This longitudinal cohort study looked at 149 women with depression before the onset of any heart disease.
These women had annual psychiatric interviews and CT-assessed coronary artery calcium (CAC) measured on two occasions approximately two years apart. The women who had recurrent major depression (n = 33) had greater progression of CAC than women with single or no episodes.
The other significant covariates were BMI, systolic BP, initial CAC and time between scans. Stratified analyses showed that the effect was obtained in those women who had any CAC on the first examination.
Recurrent major depression may be a risk factor for progression of atherosclerosis, especially in those who have at least some initial calcification. The authors conclude that women with a history of depression may be candidates for aggressive cardiovascular risk factor prevention therapy, but this was a very small study with no hard endpoints (such as death or MI).
GPs are seeing such women at least annually for a mental health assessment. This paper is a useful reminder to look at their cardiovascular risk too.
Autograft versus homograft aortic root replacement
Lancet 2010 doi:10.1016/S0140-6736(10)60828
The ideal substitute for aortic valve replacement in patients with aortic valve disease is not known. In this UK study, 216 male and female patients (<69 years) requiring aortic valve surgery were randomly assigned to receive an autograft or a homograft aortic root replacement.
There was one perioperative death in the autograft group versus three in the homograft group (p=0.621). At 10 years, four patients had died in the autograft group compared with 15 in the homograft group.
Actuarial survival at 10 years was 97 per cent in the autograft group, which is similar to their age-matched peers, versus 87 per cent in the homograft group. Hazard ratio for death in the homograft group was 4.61 (95% CI 1.71 - 16.03; p=0.0060).
So, patients needing aortic valve replacement should opt for a living valve as it will not affect their overall 10-year mortality.
B vitamins in patients with recent TIA or stroke
Lancet Neurology 2010 doi:10.1016/S1474-4422(10)70187-3
Some studies suggest that raised concentrations of total homocysteine might be a risk factor for major vascular events.
Whether lowering total homocysteine with B vitamins prevents major vascular events in patients with previous stroke or TIA is unknown.
Patients are keen to adopt a healthier lifestyle after a stroke, and often ask about vitamin supplements.
In this randomised, double-blind, parallel, placebo-controlled trial, 8,164 patients who had a stroke or TIA in the past seven months received either B vitamins (2 mg folic acid, 25 mg vitamin B6, and 0.5 mg vitamin B12) or placebo daily.
The primary endpoints were stroke, MI or vascular death. Patients were followed for approximately three years.
The findings were that daily administration of folic acid, vitamin B6, and vitamin B12 to patients with recent stroke or TIA was safe but did not seem to be more effective than placebo in reducing the incidence of major vascular events.
These results do not support the use of B vitamins to prevent recurrent stroke.
Therefore, we can give our patients normal health promotion advice and information about reduction of risk factors without having to worry about vitamin supplements.
Five-year survival of patients after out-of-hospital cardiac arrest
Arch Gerontol Geriatr 2010 doi:10.1016/j.archger.2010.06.021
This week I had a very upset patient whose 75-year-old friend died in front of her in her garden. She was distraught with grief and guilt that she had not managed to save him, despite doing CPR until the ambulance came. I looked up studies to see if anyone survives an out-of-hospital cardiac arrest (OHCA) in this age group, and found this new paper from the Czech Republic.
An analysis of 560 people aged 16-97 years, for whom a professional CPR for OHCA was attempted, gave me the answer.
Researchers found that if a patient was successfully resuscitated and managed to survive 30 days, their prognosis improved.
In patients under 70 years, 29 patients (10%) survived to year five, but in the over seventies, only 2 per cent lived for five years, with more than 70 per cent dying in the 30 days after resuscitation.
Vitamin D deficiency and aromatase inhibitors in women
Maturitas 2010; 66: 291-7
Aromatase inhibitors (letrozole, anastrozole and exemestane) radically reduce circulating estrogens in postmenopausal women, and increase breast cancer survival. However, these drugs also cause osteoporosis.
This Spanish study looked at 232 women with early breast cancer and baseline vitamin D deficiency (<30ng/ml) who are treated with aromatase inhibitors. The aim of the study was to assess serum levels of vitamin D, bone mineral density (BMD), calcium intake, and the increase of serum 25(OH)D after three months of vitamin D supplements.
Approximately 1 in 5 women had severe vitamin D deficiency (defined as <10ng/ml).
The study did not answer the questions around aromatase inhibitors and whether the high vitamin D deficiency was cause or effect, but they do recommend women on these drugs have their vitamin D levels measured.
- Dr Hope is a GP in Woodstock, Oxfordshire and a member of our team who regularly review the journals
|The Quick Study|
Recurrent depression in women was shown to increase cardiovascular risk.
Aortic valve replacement using an autograft aortic root replacement had better long-term outcome than homograft.
Supplements of B vitamins were found to be no more effective than placebo in reducing future major vascular events in patients with TIA or stroke.
Out-of-hospital cardiac arrest in those over 70 years was shown to have a worse outcome at five years than the under seventies.
Vitamin D deficiency may be unrecognised in women with early breast cancer who are treated with aromatase inhibitors.