Cardiology

Volume 01 Issue 01, Feb 2021

Times Pollution and menopause are dark underbellies of CVD

Pollutension

1 Exposure to high
particulate matter and
incident hypertension

A threatening transition

2 CVD risk during

menopause transition

Nocebo effect

3 Takeaways on
statin use from the
SAMSON trial
Tech – Talks

4 QT determination by
wearable devices

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Exposure to high particulate matter and incident
hypertension – a 12 year cohort study
P
M10 describes inhalable particles,
with diameters that are generally 10
micrometers and smaller – referred to
commonly as high particulate matter. PM10
emissions from combustion of gasoline, oil,
diesel fuel or wood produce much of the
pollution. PM10 also includes dust from
construction sites, landfills and agriculture,
wildfires, etc. Studies in US and Europe have
associated long-term exposure to PM10 with
incidence of hypertension.
However, these studies have been inconsistent
and do not report data from other parts
of the world. A recently published study
followed more than 39000 participants (over
37000 of whom were not hypertensive)
from 1998 to 2009. Towards the end of the
Ref: J Hum Hypertens (2021). https://doi.org/10.1038/s41371-020-00443-x
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study, the incidence of hypertension was 7%
(2619 cases)- where researchers adjusted for
confounding factors like sociodemographic
information, lifestyle, and diet.
Using hazard ratios for statistical analysis,
the researchers demonstrated that for each 10
microgram/m3 increase in PM10 exposure –
the incidence of hypertension could increase
by more than 50% as compared to those not
exposed to PM10.
A significant positive
association exists between
long term exposure to
PM10 particles and
incidence of hypertension
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CVD risk during menopause transition

A Scientific Statement from the American Heart Association (AHA)

M enopause transition (MT)  is a females. While vasomotor symptoms are

time when the levels of hormones quite common during MT – even sex-specific
produced by the aging ovaries guidelines for CVD prevention in women
fluctuate, leading to irregular menstrual did not include information due to lack of
patterns along with other hormone mediated evidence.
consequences. Cardiovascular disease
(CVD) is the leading cause of death
in women but they typically develop
coronary heart disease several years
later than men – usually during midlife
(a period which coincides with MT).
This observation led to the hypothesis
that MT contributes to the increase in
CVD risk. Over the last two decades,
several longitudinal studies evaluating
peri-menopausal women have
contributed towards understanding
and substantiating this hypothesis.

By following women over such a long

period, researchers have been able to
independently understand temporal
and ovarian aging with respect to
CVD risk. These studies have documented Therefore, to critically summarize the evidence
unique patterns of steroidal hormones and and highlight the implications surrounding it
unfavorable alterations in body composition, – the AHA released a scientific statement in
lipoproteins, and vascular health markers late 2020.
over the MT, which can increase the peri-
menopausal risk of developing CVD.

These findings highlight MT as a point in Significant adverse cardio

life where CVD risk accelerated – which
emphasizes the role of proactively monitoring
and metabolic health–
heart health during midlife. This offers a related changes during
unique window of opportunity to physicians
for screening of CV risk and implementing menopause transition are
appropriate interventions at early stage to
reduce the burden of CVD in young elderly seldom discussed

Ref: Circulation. 2020;142:e506–e532

To read the scientific statement on “CVD prevention during menopause transition”, published by the American Heart Association – click on the link below:
https://www.ahajournals.org/doi/epub/10.1161/CIR.0000000000000912
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The NOCEBO effect

Clever trial design shows that side effects often attributed to
statins were the same for those taking a placebo

S
ome studies have shown that up to 50%
of patients stop taking statins within the
first two years of initiation. Yet, these re-
sults were not replicated in placebo trials –
rather adverse events were similar to placebo
group. To examine this contradiction, a group
of researchers conducted the SAMSON trial
with a unique N-of-1 design.
As expected – the symptom burden was high
during statin treatment period as compared
to the no treatment period (P<0.001). And
unexpectedly, symptom burden was also high
(NOT intermediate) during the placebo pe-
riod compared to the no treatment period
(P<0.001).

SAMSON included 60 patients who had Comparative adverse event

stopped therapy due to intolerable statin side
effects. These patients were given 4 months
burden was experienced
of medication bottles each for statin, place- by trial subjects during
bo and empty bottles. They were provided a
previously randomized order for taking these placebo- or statin-
medications during each month. And report treatment periods
the symptoms they experience on a scale of
1 through 100 on a smartphone app. The re-
searchers expected symptom burden to be No difference in level of symptoms was ob-
low during use of empty bottle, intermediate served between statins and placebo (just like
during placebo intake and high during statin previous placebo-controlled statin trials,
use. If side effects were caused by the noce- P=0.368). The calculated nocebo proportion
bo effect, all treatments would show adverse was found to be 0.90.
symptoms as high as statins.

Only patients exhibiting

symptoms which led to dis-
continuation in first two
weeks of treatment were en-
rolled (so as to ensure that
symptoms will recur during
study).

What are
N-of-1 trials?

Ref: N Engl J Med 2020; 383:2182-2184. https://www.nejm.org/doi/full/10.1056/NEJMc2031173

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How wearable devices can help monitor life

threatening arrhythmias?

last dose. No arrhythmias were detected by

her Apple watch and she completed her treat-
ment uneventfully. Once out of isolation – she
quickly contacted her cardiologist friend to

D
perform a 12-lead ECG on her and validate
r. Ana* – who was isolated at home
the findings. This 12-lead ECG confirmed the
for known exposure to COVID pa-
findings seen on her Apple watch.
tients was suffering from persistent
fevers. She was prescribed hydroxychloro-
Smart monitoring devices (Apple Watch Se-
quine 400 mg on day 1 followed by 200 mg/
ries 4 or AliveCor Kardia System) now have
day from days 2 – 5. While she had no pri-
the capability to record a Lead I equivalent
or history of CVD in the past 40 years of her
ECG and transmit the same to the desired re-
life she was adjudged to be at moderate risk of
cipient. So far, they are validated to monitor
drug-related QT prolongation given her Tis-
heart rates and differentiate abnormal sinus
dale risk score.
rhythms from atrial fibrillation but not for
other purposes. The ability to remotely mon-
itor patients has becoming increasingly im-
Wearable devices are portant – especially with several unplanned
being approved by health medicines added to their existing regimen
owing to COVID. This demonstrates a novel
authorities for remote approach to patient management and is being
monitoring of heart increasingly being adopted by patients and
physicians alike.
rhythm parameters

Dr. Ana was not going to take this risk lightly.

While she could not go to the clinic - she used
her Apple watch to record rhythm strips for
2-3 hours after each dose of HCQ and shared
the data with her friend who was an esteemed
cardiologist himself.

On the first day her QT interval was 439 ms,

shooting up to 478 ms on the third day and fi-
nally coming back to 441 ms one day after the
*Fictitious name used.
Ref. J Innov Card Rhythm Manag. 2020 Sep; 11(9): 4219–4222 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7510469/
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Prepared: Feb 2021

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