Updated ACC/AHA guidelines on managing valvular heart disease, the insidious nature of

Cardiology Review® Online, September 2006, Volume 23, Issue 9

ACC/AHA release updated guidelines on managing patients with valvular heart disease

Physicians treating patients with valvular heart disease may want to clear some time in their schedule. The updated guidelines for the management of patients with valvular heart disease have now been published, and the full guideline runs 148 pages and contains 1066 references.

The guidelines were released jointly by the American College of Cardiology and the American Heart Association, and they update an earlier set of guidelines released in 1998. The guidelines discuss evaluating patients with heart murmurs, preventing and treating endocarditis, managing valve disease in pregnancy, and treating patients with concomitant coronary artery disease, as well as more specialized issues regarding specific valve lesions.

The new guidelines reflect the improved tools and techniques used in managing valvular heart disease that have developed since the release of the earlier version. “These guidelines highlight major advances in noninvasive testing and surgery for patients with valvular heart disease," said Robert O. Bonow, MD, lead author of the joint statement, and chief of cardiology at Northwestern Memorial Hospital and the Goldberg Distinguished Professor of Cardiology at Northwestern University's Feinberg School of Medicine in Chicago.

A key change in the 2006 document is a focus on the proper timing of valve surgery.

The guidelines include more precise and quantitative definitions of mild, moderate, and severe valvular disease, based on the patient's symptoms and the results of exercise testing, echocardiography, and other tests. This change may prompt earlier referral of some patients for surgery, even before they develop noticeable symptoms.

Patrick T. O'Gara, MD, director of clinical cardiology at Brigham & Women's Hospital and an associate professor of medicine at Harvard Medical School, Boston, further developed this thought. “The guidelines encourage physicians to look behind the scenes,” he said. “For example, an abnormal response to exercise could help identify patients with aortic stenosis who may be candidates for surgery sooner rather than later.”

Additional highlights of the new guidelines are given in the

. The full guidelines are available at:

.

Tablewww.acc.org/qualityandscience/clinical/guidelines/valvular/index.pdf

Getting patients to quit smoking is already difficult. But that process may be even harder for physicians counseling smokers of “light” cigarettes, a surprising number of whom believe these cigarettes do in fact reduce smoking-related health risks.

“Light” cigarettes impose heavy quitting burden

An analysis of 2000 National Health Interview data, by Hilary Tindle, MD, MPH, assistant professor of medicine at the University of Pittsburgh School of Medicine, and colleagues, found that those who used light cigarettes were about 50% less likely to quit smoking than those who smoked ordinary cigarettes.

Light cigarettes are advertised as being lower in tar and nicotine—and therefore healthier—and may provide smokers with the assurance that they can continue to smoke these products rather than quitting altogether.

Among the national sample of 12,285 self-reported smokers, 37% said they used light cigarettes to reduce their health risks (which would translate into more than 30 million US adult smokers). “Even though smokers may hope to reduce their health risks by smoking lights, the results suggest they are doing just the opposite because they are significantly reducing their chances of quitting. Moreover, as they get older their chances of quitting become more and more diminished,” said Dr Tindle.

In addition, the odds of switching to light cigarettes were about 30% greater among those with any higher education as compared with those having any high school or less education. This surprised Dr Tindle, who remarked “I would have thought that this group of people would quote-unquote 'know better’ about lights.”

To counter the message that light cigarettes are an improvement over traditional cigarettes, Dr Tindle and colleagues suggest a 2-part approach employing both public health and individual clinical messages. General education on smoking risk delivered via radio or phone might serve to broadly counter the tobacco industry’s message, while specific messages on light cigarettes could be delivered in an individual patient setting.

Tailoring advice for the individual patient may be an effective means of driving home the facts about light cigarettes during smoking cessation counseling. Simply “asking the patient about the method of cessation that he or she intends to use” would be a good starting point, Dr Tindle pointed out. If that intended method involves switching brands, then the physician could query the patient about his or her beliefs regarding lights. In addition, simply making a statement to the patient about lights, such as “they are not a safe alternative to quitting, and there is at least some evidence to suggest that they may hinder quitting smoking” would also be appropriate.

“Because smoking is such a major cause of death and disability in this country and worldwide, we believe that it is critical to give smokers accurate information on the potentially detrimental effects of the use of lights to reduce health risks and the potential impact on subsequent smoking cessation,” she said.

The full study is available in the American Journal of Public Health. 2006;96(8):1498-1504.

Spanish researchers have uncovered a link between sleep apnea and ischemic stroke in the elderly, finding those with severe sleep apnea have more than twice the risk of stroke than those with no or mild sleep apnea.

Elderly at increased risk of stroke due to severe sleep apnea

Sleep apnea is characterized by episodes of breathing stoppages during sleep. Earlier studies of stroke and sleep apnea focused on middle-aged people, but strokes occur most frequently in older people. In addition, “sleep apnea is 2 to 3 times more common in the elderly compared to middle-aged people,” said lead researcher Roberto Munoz, MD.

The researchers studied 394 people, 70 to 100 years old (average age 77, 57% male), who participated in the Vitoria Sleep Project in Vitoria, Spain, a small town in northern Spain. Researchers first gathered basic information on height, weight, body mass index, neck circumference, and medications for hypertension, diabetes and cholesterol. They then monitored patients' breathing patterns overnight in a sleep study. Researchers tracked medical events in the patients for 6 years, registering 20 ischemic strokes.

People who suffered a stroke were more likely to be male and have more severe sleep apnea, the researchers found. Patients with severe sleep apnea had a two-and-a-half times greater risk of suffering a stroke during the study than patients with no apnea, mild apnea, or moderate apnea.

Researchers suggest apnea treatment be started if doctors find a high rate of episodes of decreased breathing or breathing interruption, particularly in patients with other cardiovascular risk factors.

“Snoring is the most important warning sign for sleep apnea,” said Munoz. However, loud snoring or other typical symptoms of sleep apnea, such as excessive daytime sleepiness, are less prevalent in the elderly compared to middle-aged people. “We should be aware of these symptoms, and specifically look for the presence of repetitive breathing pauses in our patients and relatives,” Munoz said.

This study was published in Stroke. 2006;37(9):2317-2321