NYU Langone cardiovascular experts present new research findings at AHA 2011

Experts from the Cardiac & Vascular Institute at NYU Langone Medical Center presented new research findings at the American Heart Association Scientific Sessions 2011 held November 12-16, 2011 in Orlando, Florida. Significant research findings shared by NYU Langone cardiovascular experts include:

Exercise is Associated with a Significant Reduction in Peripheral Vascular Disease in a Self Referred Population of Over 3.8 Million US Adults
Author: Richard A. Stein, MD, Professor, Medicine, NYU Langone Medical Center
Data regarding the role of exercise in the prevention of peripheral artery disease (PAD) and carotid artery disease is less robust than for coronary artery disease.
This study analyzed a database of 3,896,778 people in the US (63.7+10.6yrs, 62.3% female) who underwent screening ankle brachial index (ABI) and carotid duplex ultrasound studies. Collected information included demographics, exercise history, cardiovascular risk factors and symptom information. In this study, NYU researchers report the relationship between use of exercise, exercise frequency and type of exercise (versus no exercise) with PAD (ABI<0.9), CarAD (>50% stenosis of the internal carotid artery), and any peripheral vascular disease (PVD; PAD and/or CarAD). The study shows, any exercise was associated with a significant and clinically important reduction in the prevalence of PVD, PAD and CarAD as compared with patients who reported no exercise. Increasing frequency of exercise was associated with a lower prevalence of any PVD. The association of exercise frequency with prevalence of PVD was most evident for PAD. Among all the different types of exercise reported (running, swimming, tennis, bicycling, walking, and other), running had the lowest odds ratio of any PVD.
The results of this study demonstrate a significant association between regular physical exercise and a decreased risk of PVD in several vascular diseases. Increasing exercise frequency was associated with the greatest reduction in vascular disease. In the study, physical activity is associated, in the very large population of both men and women with a reduction in the prevalence of PAD and CarAD. Exercising more times per week, and selection of more activities that require more physical work (e.g. running vs. walking) is associated with the greatest reductions in disease.
Abstract 13157: Wednesday, November 16, 2011, 3:45PM
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Door-To-Balloon Time Decreases with Pre-Hospital Wireless Electrocardiogram Transmission in Patients with ST-Segment Elevation Myocardial Infarction
Authors: Andrea Mignatti, MD, resident and Robert O. Roswell, MD, Assistant Professor, Medicine,
NYU Langone Medical Center
Current American Heart Association/American College of Cardiology (AHA/ACC) guidelines recommend a goal of less than 90 minutes from initial hospital contact to percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). In April 2010, the FDNY implemented wireless transmission of electrocardiograms (ECG) from the field to receiving hospitals so that physicians could review the ECG before the patient's arrival. The aim of the study was to determine the effect of pre-hospital ECGs on door to balloon time in a highly populated metropolitan area. Retrospective analysis of door to balloon times was performed on those patients who presented to the emergency department for possible STEMI and underwent primary PCI from 2009 to 2011 with successful notification of patients' arrival while in transit and successful transmission of the ECG and door to balloon times. Analysis showed the median door to balloon time for patients who walked in the ED was 76 minutes and the median door to balloon time for patients transported by FDNY with notification to the ED while in transit was 64.76 minutes. However, the median door to balloon time for patients arriving in the ED via FDNY with successful ECG transmission was 47.52 min. The study shows pre-hospital wireless ECG transmission results in a statistically significant reduction in door to balloon time in this cohort. This study is significant because any delay in door-to-balloon time for patients with STEMI undergoing primary PCI is associated with higher mortality, even among patients treated within 90 minutes of admission. Researchers stress that reducing door to balloon time to the greatest extent possible for all patients, including those currently treated within 90 minutes of admission, might reduce mortality. The data suggests that pre-hospital ECGs should be sent from the field to the receiving hospital for all potential STEMI patients.
Abstract 14281: Monday, November 14, 2011, 9:30AM
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Ventricular Reshaping for Repair of Functional Mitral Regurgitation has Persistent Survival Advantage Over Traditional Annuloplasty: A Single Center Analysis
Author: Eugene A. Grossi, MD, Professor, Cardiothoracic Surgery, NYU Langone Medical Center
The RESTOR-MV trial showed improved early survival in patients with functional mitral regurgitation (FMR) requiring revascularization randomized to left ventricular reshaping device (Coapsys) compared to mitral valve reduction annuloplasty (MVRA). The trial, prematurely terminated due to inadequate funding, showed Coapsys had a 2 year survival advantage compared to MVRA. For this new study, NYU Langone evaluated midterm survival of thirty-one RESTOR-MV patients receiving bypass surgery who were randomized to MVRA (15) or Coapsys treatment (16). Research showed ventricular reshaping for FMR demonstrated survival advantage at four-year follow-up. Researcher's analysis indicates that patients with FMR requiring revascularization had consistently improved survival when treated with CABG and Coapsys compared to standard CABG and MVRA. Researchers suggest this study confirms the potential value of ventricular reshaping in FMR patients and warrants further research into mechanisms of remote myocardial remodeling.
Abstract 12895: Monday, November 14, 2011, 2:45PM
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Demographics, Clinical Risk Factors and Peripheral Vascular Disease Among 3.6 Million Adults
Authors: Jeffrey S. Berger, MD, Assistant Professor of Medicine, NYU Langone Medical Center
Peripheral vascular disease (PVD) is associated with significant morbidity and mortality. The precise relationship between age, sex, race, clinical cardiovascular risk factors and prevalence of disease in different vascular areas is uncertain.
Researchers analyzed a prospective database of more than 3.5 million U.S. adults from 2003-2008 who completed a medical and lifestyle questionnaire and were evaluated by carotid and abdominal ultrasound imaging for the presence of internal carotid artery stenosis (CAS), abdominal aortic aneurysm (AAA) and ankle brachial indexes for the detection of PAD. The research study showed among 3.6 million adults, any PVD was found in 274,891 (7.4%) adults (carotid-3.8%, AAA-0.9%, and PAD-3.6%). The prevalence of PVD increased with increasing age (<40 - 1.6%, 41-60 - 3.1%, 61-80 - 9%, >80 - 21.1%, P<0.0001). Also, women were less likely to have PVD than men and race was significantly associated with PVD (White-7.4%, Black-8.6%, Hispanic-4.4%, Asian-4.3%, Native American-12.0%, other-7.4%, P<0.0001). Patients with PVD were more likely obese, smokers, and have a history of diabetes, hypertension, and hypercholesterolemia. Multivariate analysis identified age as the strongest predictor of any PVD followed by smoking and hypertension. Age and smoking were the strongest risk factors for each vascular phenotype. Hypertension was the strongest risk factor for carotid, male sex for AAA and diabetes for PAD.
Authors conclude this large study shows PVD is common and associated with traditional cardiovascular risk factors; however, risk factors differed across the spectrum of PVD. The authors suggest the study findings have significant implications for risk factor reduction strategies and selection of patients for PVD screening.
Abstract 13135: Monday, November 14, 2011, 9:30 AM
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Blood Pressure Targets in Patients with Coronary Artery Disease: Observations from Traditional and Bayesian Random Effects Meta-Analysis of Randomized Trials
Authors: Alexander Volodarskiy, MD, and Sripal Bangalore, MD, Assistant Professor, Medicine, NYU Langone Medical Center
Most guidelines for treatment of hypertension recommend a blood pressure goal of less than 140/90 mm Hg for hypertensive patients and a more aggressive goal of 130/80 mm Hg for patients with coronary artery disease (CAD), based largely on expert consensus. The optimal BP target in subjects with CAD is therefore not well defined. In this study, researchers wanted to define the optimal systolic pressure target in patients with CAD. They analyzed randomized clinical trials of antihypertensive therapy in patients with CAD, enrolling at least 100 patients, with achieved systolic pressure of ≤135 mm Hg in the intensive BP control group and ≤140 mm Hg in the standard BP control group with follow-up for at least 1 year and evaluating cardiovascular outcomes. Research shows the present body of evidence suggests in patients with CAD, intensive systolic BP control to ≤135 mm Hg and possibly to ≤130 mm Hg is associated with a modest reduction in stroke and heart failure but at the expense of hypotension. Lower was better, although not consistently so for myocardial infarction, stroke, heart failure and perhaps angina.
Abstract 11151: Monday, November 14, 9:15AM
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Genetic Testing in Patients with Acute Coronary Syndromes to Determine Optimal Anti-Platelet Strategy: A Cost Effective Analysis
Authors: Anuradha Lala, MD, and Jeffrey S. Berger, MD, Assistant Professor of Medicine, NYU Langone Medical Center
Prasugrel (Effient) is effective at decreasing cardiovascular events compared to clopidogrel (Plavix), but increases the risk of bleeding. In 2010, the FDA issued a black box warning to consider genetic testing in clopidogrel users. In this study researchers evaluated the balance of potential benefits and harms and the cost-effectiveness that would result from adopting a genotype-guided strategy of dual anti-platelet therapy following PCI for acute coronary syndromes (ACS) vs. no testing strategies of prasugrel plus aspirin or clopidogrel plus aspirin. In the study, researchers found genetic testing guided strategy yielded more benefits than harms, and was less costly compared to both "no testing" strategies. Over 15 months, the study showed total costs were lower with a gain of 0.0007 quality-adjusted life year (QALY) in the genotype-guided strategy compared to prasugrel. Compared to clopidogrel, it was $0.38 lower with a gain of 0.0036 QALY. The strongest predictor of the preferred strategy was the relative risk of a thrombotic event occurring in CYP2C19*2 carriers versus wild-type patients. Researchers concluded among ACS patients undergoing PCI, a genotype-guided strategy is economically favorable in determining which anti-platelet regimen is used, assuming that the risk of thrombotic events in CYP2C19*2 carriers is approximately 30-50% higher than wild type patients.

Abstract 15474: Tuesday, November 15, 2011, 11:00 AM
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miR-33 as a Therapeutic Target for the Metabolic Syndrome
Author: Carlos Fernández-Hernando, PhD, Assistant Professor, Medicine, NYU Langone Medical Center
Many diseases result from perturbations in cholesterol and fatty acid homeostasis including atherosclerosis, type II diabetes, and metabolic syndrome. Recent research advances at NYU Langone and others have shown that miR-33, an intronic microRNA (miRNA) located within the sterol response element-binding protein (SREBP)-2 and -1 genes, regulates lipid homeostasis in concert with its host genes. In addition to suppressing the expression of the cholesterol transporter, ABCA1, miR-33 also targets key enzymes involved in the regulation of fatty acid oxidation including CROT, CPT1a, HADHB, and AMPK. In addition, miR-33 also targets the insulin receptor substrate 2 (IRS-2), an essential component of the insulin signaling pathway. To uncover the role of miR-33 in lipid metabolism in vivo, NYU Langone researchers assessed the impact of miR-33 inhibition in mice fed a chow and high fat diet (HFD). Following a five-week treatment with 2'-Omethoxyethyl (2'MOE) phosphorothioate ASO (miR-33 ASO) or control anti-sense oligonucleotides (control ASO), plasma lipid concentrations, VLDL-secretion, and glucose/insulin levels were determined. Notably, anti-miR-33 treated mice showed a significant increase in HDL cholesterol levels compared to controls. These data demonstrate the efficacy of raising HDL levels by miR-33 inhibitors and support targeting of miR-33 as a therapeutic strategy to regulate pathways controlling three of the risk factors of metabolic syndrome, specifically, levels of HDL, triglycerides, and insulin signaling.
Abstract 16635: Monday, November 14, 2011, 10:45AM
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Invited Expert Talks:

Nonobstructive Coronary Artery Disease: Not Important?
Moderator: Judith S. Hochman, MD, director, Cardiovascular Clinical Research Center, NYU Langone Medical Center
Sunday, November 13, 2011, 5:30 PM
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Acute Coronary Syndromes and Nonobstructive Disease in Women
Presenter: Harmony R. Reynolds, MD, director, Cardiovascular Clinical Research Center at NYU Langone Medical Center
Sunday, November 13, 2011, 5:30PM
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RyR2 Dysfunction and Mechanisms of Cardiac Arrhythmias
Presenter: Glenn Fishman, MD, director, Leon H. Charney Division of Cardiology, NYU Langone Medical Center
Sunday, November 13, 2011, 6:15PM
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The His-Purkinje System as an Arrhythmogenic
Source
Presenter: Glenn Fishman, MD, director, Leon H. Charney Division of Cardiology, NYU Langone Medical Center
Sunday, November 13, 2011, 8:40 AM
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The Intercalated Disc of the Purkinje Myocyte
Presenter: Glenn Fishman, MD, director, Leon H. Charney Division of Cardiology, NYU Langone Medical Center
Monday, November 14, 2011, 6:15PM
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