Cardiology Digest podcast: Episode #21

Study #1

First, we explore the impact of the new PREVENT calculator on the predicted 10-year risk for atherosclerotic cardiovascular disease and statin eligibility. Will the current guidelines from the American Heart Association and American College of Cardiology remain the gold standard, or will this lead to changes? 

"They did a comparative analysis between the old 2013 calculator and the newer PREVENT calculator using data from over 7700 U.S. adults who didn’t have a history of stroke or myocardial infarction, and were between 30 and 79 years of age. Here’s what they found…"

Diao, JA, Shi, I, Murthy, VL, et al. 2024. Projected changes in statin and antihypertensive therapy eligibility with the AHA PREVENT cardiovascular risk equations. JAMA. Published online. (https://jamanetwork.com/journals/jama/article-abstract/2821624)

Grant, JK, Ndumele, CE, and Martin, SS. 2024. The evolving landscape of cardiovascular risk assessment. JAMA. Published online. (https://jamanetwork.com/journals/jama/article-abstract/2821628)

Khan, SS, and Lloyd-Jones, DM. 2024. Statins for primary prevention of cardiovascular disease—With PREVENT, what's a clinician to do? JAMA. Published online. (https://jamanetwork.com/journals/jama/article-abstract/2821542)

Khan, SS, Matsushita, K, Sang, Y, et al. 2023. Development and validation of the American Heart Association’s PREVENT equations. Circulation. 6: 430–449. (https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.123.067626)

Study #2

Next, we dive into a great study examining the connection between antihypertensive medications and eczematous dermatitis in older adults. This extensive population-based research offers great insights that could change your approach to managing hypertension in patients with dermatologic concerns. Could your favorite antihypertensive medication be the culprit behind your patient's new skin condition?

"A new study of over 1.5 million adults published last month in JAMA Dermatology brings us some answers…An expert in the field said that this new study adds weight to previous findings, and even though it’s only observational data, it’s quite compelling. They included a very large number of patients, controlled for important confounders, and their findings are consistent with the earlier research published on the topic."

Ye, M, Chan, LN, Douglas, I, et al. 2024. Antihypertensive medications and eczematous dermatitis in older adults. JAMA Dermatol. 7: 710–716. (https://jamanetwork.com/journals/jamadermatology/article-abstract/2819258)

Joly, P, Benoit-Corven, C, Baricault, S, et al. 2007. Chronic eczematous eruptions of the elderly are associated with chronic exposure to calcium channel blockers: Results from a case–control study. J Invest Dermatol. 12: 2766–2771. (https://www.sciencedirect.com/science/article/pii/S0022202X15332267)

Summers, EM, Bingham, CS, Dahle, KW, et al. 2013. Chronic eczematous eruptions in the aging: Further support for an association with exposure to calcium channel blocker. JAMA Dermatol. 7: 814–818. (https://jamanetwork.com/journals/jamadermatology/fullarticle/1684846)

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Study #3

Finally, we dissect a hotly discussed study linking semaglutide with non-arteritic anterior ischemic optic neuropathy. Garnering attention both in academia and the lay media, this study's robust methodology lends significant weight to its findings. But does this potential risk necessitate altering prescribing habits for semaglutide?

"It’s an observational study from a Harvard teaching hospital: the Massachusetts Eye and Ear, Boston…They retrospectively looked at records for patients who’d received care there during a 6-year period. They matched patients who weren’t taking semaglutide with similar patients who were. So, what did they find?"

Hathaway, JT, Shah, MP, Hathaway, DB, et al. 2024. Risk of nonarteritic anterior ischemic optic neuropathy in patients prescribed semaglutide. JAMA Ophthalmol. Published online. (https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2820255)

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Please note that these timestamps are auto-generated and may be approximate.

Nora [00:00:06]:
Welcome to Medmastery’s Cardiology Digest! I'm your host, Nora, and in less than 15 minutes, we'll get you up to date on important studies and advancements in cardiology that can impact your clinical practice. In today's episode, we have three fascinating studies you won't want to miss. In our first segment, we explore a JAMA paper that dove into the debate surrounding the new PREVENT calculator, and it’s implications for the 10-year predicted atherosclerotic cardiovascular disease risks and statin eligibility. Next, we dive into a great JAMA Dermatology paper that examined data from over 1.5 million patients to gain clarity on the connection between certain antihypertensive medications and eczematous dermatitis in older adults. See which of your patient’s antihypertensive medications could be the culprit behind their new skin condition. Finally, we'll dissect a hotly discussed study linking semaglutide with non-arteritic anterior ischemic optic neuropathy.

Nora [00:01:01]:
It got lots of attention both in academia and the lay media, so patients are asking about it! I’ll give you the low-down on what these study results mean for your clinical decisions. Before we begin, be sure to subscribe so you never miss an episode. Ok first up for today: Have you heard about the newer calculator for estimating cardiovascular disease risk that’s called PREVENT and wondered if it’s any better than the widely used 2013 calculator that was jointly released by the American Heart Association and the American College of Cardiology? If so, you're right to wonder! Our choice of calculator to predict our patients’ cardiovascular disease risk is important because it impacts their eligibility for statin and anti-hypertensive therapy! This new calculator was borne through a collaboration between the American Heart Association, AHA and a kidney disease research group.

Nora [00:01:51]:
They named it the Predicting Risk of CVD EVENTs (PREVENT). In questioning which calculator to use, you’re in good company! Last month JAMA published a paper by Diao and colleagues to help us sort this out. The paper was titled “Projected changes in statin and antihypertensive therapy eligibility with the AHA PREVENT cardiovascular risk equations” and it fits into a Level of Evidence category 3, which is in the middle of our rating scale. They did a comparative analysis between the old 2013 calculator and the newer PREVENT calculator using data from over 7700 U.S. adults who didn’t have a history of stroke or myocardial infarction, and were between 30 and 79 years of age. Here’s what they found. First and foremost, the estimated 10-year risk for atherosclerotic cardiovascular disease is substantially lower with the new PREVENT calculator versus the 2013 calculator. How much lower? Well, the average predicted 10-year risk for atherosclerotic cardiovascular disease was only 4.6% with the newer PREVENT calculator, versus 9.0% with the 2013 calculator. If we extrapolate that new lower risk estimate across the whole U.S. population, approximately 14 million less people would qualify for statin therapy as primary prevention under the 2019 ACC/AHA guidelines, which recommend treatment for people with a 10-year risk of 7.5% or higher.

Nora [00:03:15]:
Additionally, using those same 2019 ACC/AHA guidelines, the new PREVENT calculator would result in three million fewer people being eligible for antihypertensive therapy. The substantially lower risk predictions by PREVENT raised concerns among experts, including the study’s authors and various editorialists, about potential under-use of statins for primary prevention. One editorial by Grant et al. stated that until we get updated guidelines from the  ACC/AHA, we should keep the 2013 calculator as the standard. Another perspective by Khan and Lloyd-Jones suggests that when they update the guidelines, they should adopt PREVENT but reduce the treatment threshold to a 10-year risk between 3% and 5%, because that way we’d probably end up with the same amount of people being eligible for statin therapy as we get by using the old 2013 calculator. Given these ongoing discussions, the expert said it seems prudent to consider both calculators. Also, they said for patients at intermediate or lower risk, decisions on treatment should be customized for the patient, taking into account patient preferences and any "risk-enhancing" factors highlighted in the 2019 ACC/AHA guidelines.

Nora [00:04:30]:
Now let’s turn our attention to an itchy issue with certain antihypertensive medications and how strongly associated some of them are with the development of eczematous dermatitis. Pop quiz! How much do you think these medications raise a patient’s risk of developing eczema? Which classes of antihypertensive medications do you think proved to be the biggest offenders? A new study of over 1.5 million adults published last month in JAMA Dermatology brings us some answers. Titled "Antihypertensive Medications and Eczematous Dermatitis in Older Adults," and conducted by Ye and colleagues, it’s a Level 3 category of evidence (which is in the middle of our rating scale). This new study builds upon previous research. Over 15 years ago the Journal of Investigative Dermatology published a small case-control study that found a potential risk for eczema tied to calcium-channel blockers. Then in 2013, JAMA Dermatology revisited the issue with another case control study that found the same link, plus, a link between thiazide diuretics and eczema.

Nora [00:05:34]:
But as case control studies, they fall into a weaker category of evidence, Level 4, and we couldn’t be fully confident in their findings. So, this new study aimed to verify those associations. They got their data from electronic health records. All patients studied were 60  years of age or older, and from U.K. primary care practices. The findings were compelling. After accounting for confounding variables, new eczema diagnoses were 29% more likely in patients newly started on antihypertensive medications. The strongest associations occurred with calcium-channel blockers and diuretics, with adjusted hazard ratios of about 1.2. The next highest risk was with angiotensin-receptor blockers and α-blockers.

Nora [00:06:16]:
The lowest risk medications, with only a very weak association with eczema, were β-blockers and angiotensin-converting-enzyme inhibitors (adjusted HRs were 1.04 or less). An expert in the field said this new study adds weight to previous findings, and even though it’s only observational data, it’s quite compelling! This study included a very large number of patients, controlled for important confounders, and their findings are consistent with the earlier research published on the topic. The bottom line? The expert said if they have an older patient who develops eczema after starting on an antihypertensive medication—especially calcium-channel blockers or diuretics—it’s worth considering the discontinuation of that drug if possible.

Nora [00:08:10]:
Next we’re going to explore a hot topic from the pages of JAMA Ophthalmology that patients may be asking you about now that it’s been all over the lay-media. The study in question was done by Hathaway and colleagues and published early last month. They looked at whether semaglutide is raising the risk of nonarteritic anterior ischemic optic neuropathy, an uncommon condition that can result in blindness. The cause of nonarteritic anterior ischemic optic neuropathy is a mystery, but the condition has been associated with age, cardiovascular disease, diabetes, and obstructive sleep apnea. Now, let's unpack the study, which is titled "Risk of nonarteritic anterior ischemic optic neuropathy in patients prescribed semaglutide." It fits into a level 3 category of evidence, so, like the other studies we covered today, it’s in the middle of our rating scale. It’s an observational study from a Harvard teaching hospital: the Massachusetts Eye and Ear, Boston.

Nora [00:09:07]:
Researchers noticed anecdotally that some patients who’d started taking semaglutide ended up presenting with nonarteritic anterior ischemic optic neuropathy. So, they did some digging to find out what’s going on. They retrospectively looked at records for patients who’d received care there during a 6-year period. They matched patients who weren’t taking semaglutide with similar patients who were. So, what did they find? There was indeed a potential link between semaglutide and nonarteritic anterior ischemic optic neuropathy. Among patients taking medication for diabetes, those taking semaglutide had a 36-month incidence of nonarteritic anterior ischemic optic neuropathy that was 9%. But it occurred in only 2% of diabetic patients who weren’t using that drug. Among patients taking medication for weight loss, those taking semaglutide had a 36-month incidence of nonarteritic anterior ischemic optic neuropathy that was 7%. But it occurred in only 1% of diabetic patients who weren’t using that drug. An expert remarked that there still might be confounding factors biasing the results. But they also said the credibility of the study is strengthened by the fact that experts verified each case and researchers used propensity-score matching.

Nora [00:10:27]:
However, I’m going to end with a key point. Although this study’s findings are compelling, the risk for nonarteritic anterior ischemic optic neuropathy is likely very small—it’s thought to occur in around 2–10 cases per 100 000 persons. So, the expert noted that we can still prescribe the drug for valid reasons. So, what did you think about today’s episode? If you have any feedback, please let us know by writing to us at [email protected]. Want to hear more? Be sure to subscribe! Next, quick question… do you have a few seconds to spare? If so, I have a really quick favor to ask of you. 

Nora [00:11:05]:
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Nora [00:12:01]:
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