Conference Coverage: News From the American Heart Association’s (AHA) Scientific Sessions 2009
November 14 TO 18
Orlando, Florida.

In Statin Patients, Raising HDL With Niacin, But Not Reducing LDL With Ezetimibe, Decreased Plaque

In combination with statins, adding a medication that raises high-density lipoprotein cholesterol (HDL-C) was more effective in reversing artery wall plaque build-up and in reducing heart disease risk than adding a drug that lowers low-density lipoprotein cholesterol (LDL-C) researchers reported here.

According to an AHA news release, the study ARBITER 6- HALTS (Effect of Extended-release Niacin or Ezetimibe Added to Chronic Statin Therapy On Carotid Intima Media Thickness) found:

• Adding niacin to a statin improved HDL-C levels and significantly reduced arterial plaque build-up within 8 months, with further improvement seen at the end of the study (14 months).
• A second approach, adding ezetimibe (Zetia, Merck/Schering-Plough) to a statin, lowered LDL-C to a greater extent, but did not raise HDL-C. No overall effect on arterial build-up in the carotid arteries was observed.
• With ezetimibe, greater reductions in LDL-C paradoxically were associated with more arterial build-up, a result opposite to that expected.
• The incidence of major cardiovascular events such as fatal and nonfatal myocardial infarction (MI) was higher in the ezetimibe group versus the niacin group (5% vs 1% ).

HALTS (HDL and LDL Treatment Strategies) was a prospective, randomized, parallel group, open-label, blinded endpoint study conducted at Walter Reed Army Medical Center in Washington, DC, and Washington Adventist Hospital in Tacoma Park, Md. It included 363 adults (80% male, average age 68 years) with or at high risk for atherosclerotic cardiovascular disease (CVD). All participants were on statin agents and their LDL-C was at the treatment goal of <100 mg/dL. HDL-C was <50 mg/dL for men and 55 mg/dL for women.

“These findings for ezetimibe are counter to the prevailing understanding of LDL-C—that lowering LDL results in slowing of the atherosclerotic process as has been convincingly shown for other classes of lipid modifying drugs, such as statins and bile acid resins,” said Allen J. Taylor, MD, FAHA, in a news release. He is principal investigator of the study and director of Advanced Cardiovascular Imaging and the Lipid/Prevention Clinic in the Department of Medicine (Cardiology) at Washington Hospital Center in Washington, DC.

Earlier studies demonstrating the protective effects of statins found strong associations between LDL reduction and the prevention of CVD. Consequently, many experts view LDL reduction as a way to measure whether a treatment will be useful. But HALTS researchers’ findings “challenge the use of LDL reduction as a guaranteed surrogate for clinical performance, particularly for new clinical compounds, and in this particular case, ezetimibe,” Dr. Taylor said.

Some Obese Individuals Perceive Body Size as OK, Dismiss Need to Lose Weight
Some obese people misperceive that their body size is normal and think they don’t need to lose weight, according to research presented here. In the Dallas Heart Study of 5,893 people, researchers found that 8% of the 2,056 who were obese said they were satisfied with their body size or felt they could gain weight.

“Almost one in 10 obese individuals are satisfied with their body size and didn’t perceive that they need to lose weight,” said Tiffany Powell, MD, in an AHA news release. She is lead author of the study and a cardiology fellow at the University of Texas Southwestern Medical Center in Dallas. “That is a sizeable percentage who don’t understand they are overweight and believe they are healthy.”

According to the news release, participants included about 50% blacks, 20% Hispanics, and 30% whites, similar to other urban populations, Dr. Powell said. About half were women. African Americans (14%) and Hispanics (11%) were significantly more likely than whites (2%) to be satisfied with their body size and believe that they did not need to lose weight.

Those with a misperception of body size believed they were healthy. But 35% of them had hypertension, 15% had hypercholesterolemia, 14% had diabetes, and 27% were current smokers. These risk factors are similar to obese individuals who acknowledged they had a weight problem and needed to lose weight, Dr. Powell said. Overall, 2% to 3% of the study population perceived an above-normal body size as ideal. Compared with individuals who perceived their ideal body size as normal, those who perceived ideal body size to be above normal were more likely to be women, African American, and had higher body mass index, blood pressure and higher insulin resistance.

“Understanding and countering this misconception may be a novel and perhaps vitally important target for obesity prevention and treatment. Because many of these individuals believe they are healthier than they really are, they do not go to the doctor and thus community interventions will be needed,” she said in the release. Dr. Powell also emphasized that her findings show that physicians need to talk with their obese patients about exercise and weight loss.

“The onus falls on us as physicians to determine who this population is and how to talk with them.”

Secondhand Smoke Worse for Toddlers, Obese Children
Toddlers and obese children suffer more than other youth when exposed to secondhand smoke, according to research presented here.

“Secondhand smoke in children is not just bad for respiratory issues, as has been previously described by other researchers,” said John Anthony Bauer, PhD, the study’s senior co-author and principal investigator at Nationwide Children’s Hospital & Research Institute at Ohio State University in Columbus. “Our data support the view that cardiovascular effects of secondhand smoke in children are important, particularly for the very young and those who are obese. We had not investigated the impact of obesity in previous studies.”

According to an AHA news release, Dr. Bauer and colleagues recruited American boys and girls, including 52 toddlers (aged 2 to 5 years) and 107 adolescents (aged 9 to 18 years). The study included black, white and Hispanic children, including obese toddlers and adolescents. The researchers found:

• There was a link between the amount of secondhand smoke exposure and a marker of vascular injury in toddlers. This link was two times greater in toddlers who were obese.
• Obese adolescents exposed to secondhand smoke had two times the evidence of vascular injury compared to normal- weight adolescents.
• Toddlers had a four times greater risk of secondhand smoke exposure when compared to adolescents, despite having similar reported home exposures.
• Toddlers exposed to secondhand smoke had a 30% reduction in circulating vascular endothelial progenitor cells.

“The changes we detected in these groups of children are similar to changes that are well recognized risks for heart disease in adults,” Dr. Bauer said in the news release. “This suggests that some aspects of adult heart disease may be initiated in early childhood, where prevention strategies may have great long-term impact.”