Culture

The cholera-causing bacterium, Vibrio cholerae, is commonly found in aquatic environments, such as oceans, ponds, and rivers. There, the bacterium has evolved formidable skills to ensure its survival, growth, and occasional transmission to humans, especially in endemic areas of the globe.

One of the ways the pathogen defends itself against predatory aquatic amoebas involves "hitchhiking" them and hiding inside the amoeba. Once there, the bacterium resists digestion and establishes a replication niche within the host's osmoregulatory organelle. This organelle is essential for the amoeba to balance its internal water pressure with the pressure exerted by the environment.

In a new study, the group of Melanie Blokesch at EPFL in collaboration with the BioEM facility headed by Graham Knott has deciphered the molecular mechanisms that V. cholerae uses to colonize aquatic amoebas. The researchers demonstrated that the pathogen uses specific features that allow it to maintain its intra-amoebal replication niche and to ultimately escape from the succumbed host. Several of these features, including extracellular enzymes and motility, are considered minor virulence factors as they also play a role in human disease.

The study suggests that the aquatic milieu provides a training ground for V. cholerae and that adaptation towards amoebal predators might have contributed to V. cholerae's emergence as a major human pathogen.

"We are quite excited about these new data, as they support the hypothesis that predation pressure can select for specific features that might have dual roles - in the environment and within infected humans," says Blokesch. She also highlights that continuous funding by the ERC (StG & CoG) has been crucial for this project, "as studying the environmental lifestyle of the pathogen is a bit outside the mainstream research on pathogenesis".

Munich, Germany - 26 Aug 2018: Blood pressure and cholesterol lowering drugs continue to improve survival in patients with hypertension after more than a decade, according to late breaking results from the ASCOT Legacy study presented today at ESC Congress 20181 and published in The Lancet.

Dr Ajay K. Gupta, of the William Harvey Research Institute, Queen Mary University London, UK, said: "Patients in their mid-60s with high blood pressure were less likely to die from heart disease or stroke by age 75-80 if they had taken both calcium channel blocker-based blood pressure lowering treatment and a statin."

The ASCOT Legacy study is the long-term follow-up of 8,580 patients from the UK who took part in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT), which between 1998 and 2000 recruited patients with high blood pressure and three or more additional risk factors for cardiovascular disease.

Patients who took a newer blood pressure lowering treatment (based on a calcium channel blocker) for 5.5 years were 29% less likely to have died from a stroke ten years later than those taking an older regimen (based on a beta-blocker). There was a non-significant trend towards 10% fewer cardiovascular deaths with the newer therapy.

Patients with average (6.5 mmol/l) or below average blood cholesterol levels at the start of the trial who took a statin for 3.3-5.5 years were 15% less likely to have died from cardiovascular causes such as heart disease and stroke 16 years later than those randomised to placebo.

A subgroup of patients with above average cholesterol who received standard lipid-lowering therapy for 5.5 years had 21% fewer cardiovascular deaths over ten years of follow-up with the newer blood pressure therapy compared to the older one. There was a non-significant trend towards lower all-cause and stroke deaths with the newer treatment.

"These results are remarkable," said Professor Peter Sever, of the National Heart and Lung Institute at Imperial College London, UK, who jointly led the study with Dr Gupta. "We have previously shown that statins confer long-term survival benefits after trials have stopped, but this is the first time it has been found with a blood pressure treatment."

Dr Gupta said: "The findings provide further support for the use of an effective blood pressure lowering therapy plus a statin in most patients with high blood pressure."

A main objective of the initial ASCOT trial was to find out whether a new treatment strategy for high blood pressure was more effective in preventing heart attacks than an old strategy. Patients with high blood pressure were randomly allocated to the new treatment of amlodipine (a calcium channel blocker) plus perindopril (an angiotensin-converting enzyme inhibitor) if needed to achieve the target blood pressure, or the old therapy of atenolol (a beta-blocker) plus bendroflumethiazide (a diuretic) and potassium if needed. The medicines were taken for a median of 5.5 years, when the trial was stopped because the newer treatment prevented more strokes and deaths.2 After the trial, patients went on to receive usual (or routine) care.

A second aim of the trial was to discover if a statin would provide added protection against coronary heart disease in patients with high blood pressure and cholesterol levels below 6.5 mmol/L. Patients with a blood cholesterol level of 6.5 mmol/l or less were randomly allocated to atorvastatin or placebo for 3.3 years, when the trial was prematurely stopped because atorvastatin prevented more heart attacks and strokes.3 Following this, patients were offered atorvastatin for the remainder of the blood pressuring lowering arm of the trial. During this 2.2 year period approximately two-thirds of patients previously assigned to either atorvastatin or placebo took atorvastatin.

A third aim of the trial was to evaluate the effectiveness of the newer versus older blood pressure lowering treatment in patients with high blood pressure and high cholesterol (above 6.5 mmol/l). These patients did not participate in the randomised lipid-lowering arm of the trial and all received standard lipid-lowering therapy for 5.5 years.

Professor Mark Caulfield, Director of the William Harvey Research Institute, said: "This study confirms the importance of lowering blood pressure and cholesterol to prevent disabling and life-shortening cardiovascular disease."

We use them for everything from banking to workouts, and now research from the University of Sydney shows mobile apps could potentially save lives by helping people with coronary heart disease keep on top of their medication.

Published today in Heart, and presented at the European Society of Cardiology Congress in Germany, the study shows the use of high-quality medication reminder apps increases people's adherence to cardiovascular medication.

While medication apps have long been available online, this is some of the first research to explore the evidence around their effectiveness in people with heart disease and whether they work in terms of health and behaviour.

Senior author Associate Professor Julie Redfern said coronary heart disease is the leading cause of death globally and around 40 percent of patients do not adhere to their medications, therefore increasing their risk of subsequent heart attacks.

"Patients with coronary heart disease can become overwhelmed with the amount of pills they are taking as they are often prescribed up to four different types of medication, which need to be taken sometimes up to three times a day," said Associate Professor Redfern from the University of Sydney's Westmead Applied Research Centre.

The randomised clinical trial followed 160 predominately male patients over a three month period and compared the medication usage of patients in usual care to those supported to download and use medication apps.

Researchers also compared the use of basic apps (with one-time reminder alarms) to those with more advanced features. They found no additional benefits were gained from the advanced apps with elements such as the ability to snooze reminders and track taken and missed doses, adherence statistics and social support structures including alerting a friend or family member to missed doses.

Lead author Dr Karla Santo from the University of Sydney said the results from the trial are very encouraging.

"It's exciting that a basic app - some of which can be accessed for free - could help improve people's medication use and prevent further cardiovascular complications."

In 2016, Dr Santo and colleagues from the University of Sydney and George Institute for Global Health conducted a review of medication reminder apps available via iTunes and Google app stores.

The review rated Medisafe as the top ranking interactive app, and My Heart my Life (currently being updated) and Pill reminder among the top basic apps available at the time. However, the vast majority of the apps on the market were judged to be low quality.

Dr Santo said the next step is to carry out further research to see if apps can be used to sustain medication adherence over a longer period and the impact this has on health outcomes. Also, to trial the apps for other health conditions such as cancer, lung disease and stroke.

"Participants in our trial were followed up after 3 months but longer term and larger studies are more likely to be able to show benefits or challenges of app usage, as well as the impact on additional measures such as blood pressure and cholesterol."

Munich, Germany - 26 Aug 2018: A weight loss drug does not increase cardiovascular events, according to late breaking results from the CAMELLIA-TIMI 61 trial1 presented today in a Hot Line Session at ESC Congress2 and published in the New England Journal of Medicine.

Lorcaserin is an appetite suppressant, increasing the sense of fullness after a meal and reducing hunger before meals. It is not approved as a weight loss drug in Europe. The European Medicines Agency has expressed concerns about the potential risk of tumours based on animal data, psychiatric disorders including depression, and problems with heart valves.

The US Food and Drug Administration (FDA) in June 2012 approved the medication for weight loss in overweight adults with a body mass index (BMI) of 30 kg/m2 or greater, or with a BMI of 27 kg/m2 or greater and at least one weight-related health condition such as high blood pressure, type 2 diabetes, or high cholesterol. As with all weight loss agents, the FDA's approval was contingent on postmarketing studies assessing the risk for major adverse cardiovascular events.

The CAMELLIA-TIMI 61 trial was conducted as part of the FDA's postmarketing requirement. The trial examined the safety and efficacy of the drug with regard to major adverse cardiovascular events (MACE) and progression to diabetes in overweight or obese individuals with, or at risk for, cardiovascular disease.

The trial enrolled 12,000 adults from 473 centres in eight countries between January 2014 and November 2015. Participants had a BMI of at least 27 kg/m2 and either 1) established cardiovascular disease3 (with or without diabetes) or 2) diabetes and at least one other cardiovascular risk factor.4 Participants were randomly allocated in a 1:1 ratio to lorcaserin (10 mg twice a day) or matching placebo. All participants were advised to exercise and eat healthily.

The primary safety endpoint was noninferiority of the drug compared to placebo for MACE (cardiovascular death, myocardial infarction, or stroke) after 460 events had occurred. If the safety endpoint was met, the trial would proceed to completion and assess the primary efficacy endpoint of superiority of the drug for MACE plus hospitalisation for unstable angina, heart failure, or any coronary revascularisation. Secondary endpoints included delay or prevention of conversion to type 2 diabetes in those with pre-diabetes at baseline, and the effect on weight, heart rate, blood pressure, lipids, and blood sugar.

The average age of participants was 64 years, 64% were male, and the median BMI was 35 kg/m2. Three-quarters (8,958; 75%) had a history of at least one established cardiovascular disease: 8,153 (68%) had coronary artery disease, 1,129 (9.4%) had cerebrovascular disease, and 657 (5.5%) had peripheral artery disease. More than half (57%) had diabetes, 90% had hypertension, 94% had hyperlipidaemia, and 20% had renal insufficiency.

The interim analysis after 460 events showed that the trial met its primary safety objective. At study completion with a median follow-up of 3.3 years, MACE occurred in 6.1% of those taking lorcaserin and 6.2% of those on placebo, demonstrating noninferiority (p

The trial did not meet its superiority endpoint. The composite of MACE plus hospitalisation for unstable angina, heart failure, or any coronary revascularisation occurred in 11.8% of participants taking the drug and 12.1% of those on placebo (p=0.55).

On top of lifestyle counselling, those taking lorcaserin lost an average of 4.2 kg in the first year compared to 1.4 kg for those taking placebo (p

Regarding secondary endpoints, compared to placebo, the medication reduced the conversion rate to diabetes in participants with pre-diabetes at baseline. The drug also led to small improvements in levels of triglycerides, blood glucose, heart rate and blood pressure.

In the CAMELLIA-TIMI 61 study, the most common side effects possibly related to the drug and leading to drug discontinuation were dizziness, fatigue, headache and nausea - all of which are listed on the FDA-approved label. There was no difference in the occurrence of malignancy between the drug and placebo groups. In a dedicated echocardiographic substudy, there was a non-significant imbalance in the incidence of valvular disease at one year between the drug and placebo groups (1.8% versus 1.3%; p=0.24). Serious hypoglycaemia was more common in patients on lorcaserin, a side effect observed in prior studies.

Lorcaserin is not approved for use in women who are pregnant, breastfeeding, or planning to become pregnant. It should be used with caution in patients with congestive heart failure. If signs or symptoms of valvular heart disease develop, such as dyspnoea or a new cardiac murmur, patients should be evaluated and discontinuation of the drug considered. People taking the drug should be monitored for depression, changes in mood, and suicidal thoughts or behaviours - the drug should be discontinued if the latter are experienced.

"We have been able to show for the first time that this weight loss drug does what it is intended to do. It helps people lose weight without causing an increase in major adverse cardiovascular events in a population at higher risk for heart attacks and strokes," said Dr Erin Bohula, an investigator with the CAMELLIA-TIMI 61 trial and TIMI Study Group investigator at Brigham and Women's Hospital, Boston, US.

"One of our hypotheses was that losing weight with this medication might also lead to a cardiovascular benefit but we did not see that," she continued. "While there were improvements in multiple cardiovascular risk factors, including weight, lipids and blood glucose, the magnitude of impact on these risk factors was relatively small."

Dr Bohula said: "Nevertheless, the CAMELLIA-TIMI 61 study is notable as it provides the first demonstration of cardiovascular safety of any weight loss agent in a dedicated cardiovascular outcomes trial."

Munich, Germany - 26 Aug 2018: Impaired mental status is associated with a doubled risk of death one year after a heart attack in elderly patients, according to research presented today at ESC Congress 2018.1

"Cardiologists should consider conducting simple tests to assess mental status in elderly people after a heart attack," said study author Professor Farzin Beygui of Caen University Hospital, France. "Patients with reduced mental status can then receive more intensive management such as regular follow-up appointments with their general practitioners or nurses, more specific assessment for an early diagnosis of dementia and tailored therapy."

The risks of dementia, Alzheimer's disease, confusion and delirium increase with age. Elderly people are also at higher risk of having a heart attack and dying afterwards. People aged 75 and over account for approximately a third of heart attack admissions and more than half of those dying in hospital after admission for a heart attack. Until now it was not known whether impaired mental status affects the prognosis of elderly heart attack patients.

This study assessed the impact of mental status on the risk of death in 600 patients aged 75 and above consecutively admitted for heart attack and followed-up for at least one year. Mental status was assessed using the Mini-Mental State Examination (MMSE) and the Confusion Assessment Method (CAM) - both simple bedside tests routinely used in clinical practice.

Cognitive impairment was detected in 174 (29%) patients. Patients with impaired mental function were more than twice as likely to be dead one year after their heart attack than those with healthy mental function (see figure). The association was independent of other potential predictors of death such as age, sex, invasive treatment, type of myocardial infarction, heart failure, and severity of the heart attack.

Impaired mental status was also associated with a nearly four-fold higher rate of bleeding complications while in hospital and a more than two-fold higher risk of being readmitted to hospital for cardiovascular causes within three months after discharge.

Professor Beygui said: "Almost one-third of elderly heart attack patients in our study had reduced mental capacity. These patients had higher risks of bleeding, rehospitalisation, and death. This may be because they forget to take their medicines or take them more than prescribed, rather than because of poor cognitive function itself."

He concluded: "Assessing mental status is a simple way to identify elderly patients at particularly high risk of poor outcomes following a heart attack. Identifying these patients may help us target treatment to those who need it most."

Munich, Germany - 26 Aug 2018: Bleeding in patients treated with anticoagulants should stimulate a search for cancer, according to late breaking results from the COMPASS trial1 presented today at ESC Congress 2018.2

Professor John Eikelboom, principal investigator, of the Population Health Research Institute, McMaster University, Hamilton, Canada, said: "In patients with stable coronary artery disease or peripheral artery disease, the occurrence of major gastrointestinal bleeding predicts a substantial increase in new gastrointestinal cancer diagnoses, while major genitourinary bleeding predicts a substantial increase in new genitourinary tract cancer diagnoses."

Up to one in ten patients with cardiovascular disease have recurrent events each year. As previously reported, the COMPASS trial found that in patients with coronary artery disease or peripheral artery disease, the combination of rivaroxaban (2.5 mg twice daily) and aspirin reduced cardiovascular events compared to aspirin alone, but there were more major bleeding events in the combined drug group.3

For the first time today, the investigators report details on the effect of bleeding on subsequent cancer diagnoses.

Briefly, the trial enrolled 27,395 patients with chronic stable coronary or peripheral artery disease from 602 centres in 33 countries. Patients were randomly allocated to one of three groups: 1) rivaroxaban 2.5 mg twice daily plus aspirin 100 mg once daily 2) rivaroxaban 5 mg twice daily, or 3) aspirin 100 mg once daily. Results in each of the rivaroxaban groups were compared with the aspirin alone group. The mean duration of follow up was 23 months.

The combination increased major bleeding, as defined by the International Society on Thrombosis and Haemostasis (ISTH), compared with aspirin (3.1% versus 1.9%, hazard ratio [HR] 1.70, 95% confidence interval [CI] 1.40-2.05, p

Major gastrointestinal bleeding was associated with a 20-fold increase in new diagnoses of gastrointestinal cancer (9.3% versus 0.7%, HR 22.6, 95% CI 14.9-34.3, p

Major non-gastrointestinal bleeding was associated with a five-fold increase in new non-gastrointestinal cancers (9.4% versus 3.0%, HR 5.49, 95% CI 3.95-7.62, p

Professor Eikelboom said: "More than one in ten patients with major bleeding were subsequently diagnosed with cancer, and more than 20% of new cancer diagnoses were in patients who experienced bleeding. By reducing major cardiovascular events and mortality, the combination of rivaroxaban and aspirin already produces a clear net benefit, and if bleeding unmasks cancer it could potentially lead to the added benefit of improved cancer outcomes."

Munich, Germany - Aug. 26, 2018: Long-term use of coal, wood, or charcoal for cooking is associated with an increased risk of death from cardiovascular disease, according to a study presented today at ESC Congress 2018.1

Dr Derrick Bennett, study author, University of Oxford, UK, said: "Our study suggests that people who use solid fuels for cooking should switch to electricity or gas as soon as possible."

It has been suggested that air pollution from cooking with solid fuels, such as coal, wood, or charcoal, may lead to premature death from cardiovascular disease, but there is limited evidence. This study assessed the association between solid fuel use for cooking and cardiovascular death, as well as the potential impact of switching from solid to clean fuel (electricity or gas).

The study included 341,730 adults aged 30-79 years recruited from ten areas of China in 2004 to 2008. Participants were interviewed about how often they cooked and the main fuel used at their three most recent homes. The researchers then estimated the duration of exposure to solid fuels. The analysis was restricted to those who cooked at least weekly at their three most recent residences and did not have cardiovascular disease. Information on mortality up to 1 January 2017 was collected from death registries and hospital records.

The average age of participants was 51.7 years and three-quarters were female. Nine out of ten had spent at least 20 years in their three most recent residences. Overall, 22.5% of participants had primarily used solid fuels for cooking for 30 years or more, 24.6% for 10-29 years, and 53.0% for less than ten years. Among the latter, 45.9% had never used solid fuels in their most recent three homes and 49.1% had switched from solid to clean fuels during this period.

During 3.4 million person-years of follow-up, 8,304 participants died from cardiovascular disease. After adjusting for education, smoking and other cardiovascular risk factors, each decade of exposure to solid fuel was associated with a 3% higher risk of cardiovascular death (95% confidence interval [CI] 1-4%, p=0.0002). Participants who had used solid fuels for 30 years or longer had a 12% greater risk of cardiovascular death than those who had used them for less than ten years (95% CI 3-21%, p=0.0045) (see figure 1).

Compared to persistent long-term use of solid fuels, adopting clean fuels was associated with a lower risk of death from cardiovascular disease. Each decade earlier switch from solid to clean fuels was associated with a 5% lower risk of cardiovascular death (95% CI 1-8%, p=0.0067). Participants who had changed for ten years or longer had risks comparable to persistent clean fuel users (see figure 2).

Professor Zhengming Chen, principal investigator, University of Oxford, UK, said: "We found that long-term use of solid fuels for cooking was associated with an excess risk of cardiovascular death, after accounting for established risk factors. Switching to electricity or gas weakened the impact of previous solid fuel use, suggesting that the negative association may be reversible."

Munich, Germany – 25 Aug 2018: Confusion over how to diagnose a heart attack is set to be cleared up with new guidance launched today. The 2018 Fourth Universal Definition of Myocardial Infarction is published online in European Heart Journal1, and on the ESC website.2

“Unless there is clarity in the emergency room on what defines a heart attack, patients with chest pain may be wrongly labelled with heart attack and not receive the correct treatment,” said Professor Kristian Thygesen, Aarhus University Hospital, Denmark.

“Many doctors have not understood that elevated troponin levels in the blood are not sufficient to diagnosis a heart attack and this has created real problems,” continued Professor Thygesen, who is joint chair of the Task Force that wrote the document, together with Professor Joseph S. Alpert, University of Arizona, USA and Professor Harvey D. White, Auckland City Hospital, New Zealand.

The international consensus document spells out that a heart attack (myocardial infarction) has occurred when the heart muscle (myocardium) is injured and has insufficient oxygen. Troponin is a protein normally used by the heart muscle for contraction, but is released into the blood when the muscle is injured. Oxygen shortage (ischaemia) is detected by electrocardiogram (ECG) and symptoms such as pain in the chest, arms, or jaw, shortness of breath, and tiredness.

Myocardial injury on its own is now considered a separate condition. There are numerous situations which can cause myocardial injury, and therefore a rise in troponin. These include infection, sepsis, kidney disease, heart surgery, and strenuous exercise. The first step of treatment is to address the underlying disorder.

As for myocardial infarction, there are different types which require specific treatment. Type 1 is the situation which most people associate with a heart attack. Here a fatty deposit in an artery, called a plaque, ruptures and blocks blood flow to the heart which deprives it of oxygen. Treatment can include antiplatelet medication to stop platelets clumping together and forming a clot, inserting a stent via a catheter to open up the artery, or surgery to bypass the artery.

In type 2, oxygen deprivation is not caused by plaque rupture in an artery but is due to other reasons such as respiratory failure or severe hypertension. Professor Alpert said: “Some doctors have incorrectly called this type 1 and given the wrong treatment, which can be harmful. Treatment should be directed at the underlying condition, for example blood pressure lowering medications for patients with hypertension.”

Efforts by doctors to correctly diagnosis myocardial infarction and its subtypes have not been helped by the lack of diagnosis codes in the International Classification of Diseases (ICD). The subtypes of myocardial infarction were first introduced by the joint Task Force in 2007, but were not incorporated into the ICD until October 2017.3,4

Professor White said: “In the consensus document we have expanded the section on type 2 myocardial infarction and included three figures to help doctors make the correct diagnosis. The incorporation of type 2 into the ICD codes is another step towards accurate recognition followed by appropriate treatment. A code for myocardial injury will be added to the ICD next year.”

The international consensus document was produced by the European Society of Cardiology (ESC), American College of Cardiology (ACC), American Heart Association (AHA), and World Heart Federation (WHF).

Munich, Germany - 25 Aug 2018: The initial findings of a study on spontaneous coronary artery dissection, a major cause of heart attacks in women, are reported today in a late breaking science session at ESC Congress 2018.1

Professor Jacqueline Saw, principal investigator, of the University of British Columbia, Vancouver, Canada, said: "Spontaneous coronary artery dissection (SCAD) causes around one-third of heart attacks in women under 60 years of age. SCAD was previously under-diagnosed and considered rare. Advances in intracoronary imaging techniques have improved diagnosis, yet we still know very little about the cause and natural history of SCAD."

SCAD occurs when the lining of an artery supplying blood to the heart tears away from the artery's outer layer. Blood leaks into the space between layers and forms a clot, which narrows the artery and restricts blood flow. Symptoms are similar to a heart attack and include chest pain, rapid heartbeat, pain in the arms, shoulders or jaw, and feeling sick, short of breath, sweaty, and light headed. If you have chest pains or other symptoms, call emergency immediately.

Treatment aims to restore blood flow to the heart. Some patients receive medication only, while others undergo a procedure to open the artery, either with a stent or by surgically bypassing the artery.

The Canadian SCAD Study examined the clinical presentation, natural history, treatment, and outcomes of SCAD. The researchers prospectively enrolled 750 patients presenting acutely with SCAD at 20 centres in Canada and two centres in the US between 2014 and 2018. Diagnosis of SCAD was adjudicated by an angiographic core laboratory. At the start of the study, information was collected on demographics, stressors and conditions that could have caused SCAD, and treatments. Patients are being followed for three years for major adverse cardiovascular events (MACE).

Today researchers report the baseline characteristics and outcomes in-hospital and at one month. The average age of patients in the study was 52 years and 89% were women.

Regarding possible causes for SCAD, about half of patients (49%) reported emotional stress prior to the event, and 30% reported physical stress (in 10% this was lifting more than 23 kg). The most common predisposing condition was fibromuscular dysplasia (40% of those assessed), which causes abnormal cell development in the arteries and can lead to narrowing (stenosis), aneurysms, or tears (dissections). Other predisposing conditions were five or more pregnancies (10%), being peripartum (5.3%), fertility treatment (5.1%), systemic inflammatory conditions (4.7%), and connective tissue disorders (3.5%).

Professor Saw said: "Emotional stress appears to be a major trigger for SCAD. Fibromusclar dysplasia, which is more common in women than men, also played a major role - it often has no symptoms but in some patients it causes headaches or a swooshing sound in the ears called pulsatile tinnitus."

All patients presented with an acute coronary syndrome with their acute SCAD event, with 99.3% having a heart attack and 0.7% having unstable angina. The main symptom was chest pain, which occurred in nine out of ten patients. On angiography, the left anterior descending artery was most commonly affected (52%), and long diffuse narrowing was the most common feature (called type 2 SCAD; 58%).

The majority of patients were treated with medication only (85%), while 14% underwent percutaneous coronary intervention, and less than 1% had coronary bypass surgery.

Almost all patients (99.9%) survived to 30 days. The rate of MACE to 30 days was 7.5% (including recurrent heart attack in 5.1%, cardiac arrest in 3.3%, unplanned revascularisation in 2.1%, severe heart failure in 1.5%, mechanical haemodynamic support in 1.5%, stroke in 1.2%, heart transplant in 0.1%, and death in 0.1% of patients). Within 30 days after discharge, 5.1% had a repeat visit to the emergency room, and 2.5% were admitted for chest pain.

Professor Saw said: "Our study shows that SCAD primarily affects middle-aged women and most acute presentations occur at the same time as a heart attack. The vast majority of patients survived to 30 days with medication alone. However, recurrent heart attacks and emergency room visits were high within 30 days. More research is needed to determine the most appropriate treatment for patients with SCAD."

Munich, Germany - Aug. 25,2018: A single pill with two drugs could transform blood pressure treatment, according to the 2018 European Society of Cardiology (ESC) and European Society of Hypertension (ESH) Guidelines on arterial hypertension published online today in European Heart Journal1, and on the ESC website.2

The guidelines recommend starting most patients on two blood pressure lowering drugs, not one. The previous recommendation was for step-wise treatment, which meant starting with one drug then adding a second and third if needed. This suffered from "physician inertia", in which doctors were reluctant to change the initial strategy despite its lack of success. At least 80% of patients should have been upgraded to two drugs, yet most remained on one drug.

It is now recognised that a major reason for poor rates of blood pressure control is that patients do not take their pills. Non-adherence increases with the number of pills, so administering the two drugs (or three if needed) in a single tablet "could transform blood pressure control rates", state the guidelines.

Professor Bryan Williams, ESC Chairperson of the Guidelines Task Force, University College London, UK, said: "The vast majority of patients with high blood pressure should start treatment with two drugs as a single pill. These pills are already available and should massively improve the success of treatment, with corresponding reductions in strokes, heart disease, and early deaths."

More than one billion people have hypertension (high blood pressure) worldwide. Around 30-45% of adults are affected, rising to more than 60% of people over 60 years of age. High blood pressure is the leading global cause of premature death, accounting for almost ten million deaths in 2015, of which 4.9 million were due to ischaemic heart disease and 3.5 million were due to stroke. High blood pressure is also a major risk factor for heart failure, atrial fibrillation, chronic kidney disease, peripheral artery disease, and cognitive decline.

High blood pressure does not usually cause symptoms. However, people with very high blood pressure may have headaches, blurred or double vision, regular nosebleeds, difficulty breathing, chest pain, irregular heartbeat, blood in the urine, confusion, or pounding in the chest, neck, or ears. See your doctor if you have any of these symptoms.

Treatment thresholds in the 2018 Guidelines are less conservative, with drugs recommended for patients who would previously have received lifestyle advice only. These are patients with low to moderate risk grade I hypertension (140-159/90-99 mmHg), including 65-80 year-olds, and those with high normal blood pressure (130-139/85-89 mmHg).

Professor Williams said: "Many more millions of people, particularly in the older age groups, should be receiving treatment for high blood pressure. See your doctor if you are 65 to 80 years old and your blood pressure is above 140/90 mmHg. The evidence suggests that treatment would reduce your risk of stroke and heart disease."

The guidelines state that "treatment should never be denied or withdrawn on the basis of age". It is increasingly recognised that frailty, independence and biological, rather than chronological, age determine the tolerability and likely benefit of blood pressure lowering medications. For people over 80 years who have not yet received blood pressure treatment, therapy should be started if systolic blood pressure is 160 mmHg or above. People already taking medication should not have it withdrawn at 80 years of age if it is well tolerated.

Blood pressure targets for patients of all ages are lower than in previous guidelines. Systolic blood pressure targets are now 120-129 mmHg for patients under 65 years of age, and 130-139 mmHg for patients over 65 years of age, taking into account treatment tolerability, independence, frailty, and comorbidities. Blood pressure below 120 mmHg should not be the target for any patient since the risk of harm outweighs the potential benefits.

When blood pressure is not controlled by three drugs given in a single pill, a condition known as resistant hypertension, a second pill containing a diuretic such as spironolactone should be added. Device-based therapy is not recommended for routine treatment of these patients and should only be administered within clinical trials.

A healthy lifestyle is recommended for all patients, regardless of blood pressure level, as it can delay the need for drugs or complement their effects. Advice includes salt restriction, alcohol moderation, healthy eating, regular exercise, weight control, smoking cessation, and a new recommendation to avoid binge drinking.

A new section on hypertension and cancer therapy states that temporary discontinuation of anticancer therapy may be considered when blood pressure values are exceedingly high despite multidrug treatment. A section on blood pressure during exercise and high altitude has been added, with the advice that patients with severe, uncontrolled hypertension should avoid exposure to very high altitude (above 4000 metres).

Professor Giuseppe Mancia, ESH Chairperson of the Guidelines Task Force, University of Milano-Bicocca, Milan, Italy, said: "We have effective treatments and, theoretically, 90-95% of patients should have their blood pressure under control, but in reality only 15-20% achieve target levels. The 2018 Guidelines aim to improve these poor rates of blood pressure control by introducing a treatment strategy that is simple and easier to follow."

The effects of a heavy drinking session on our thoughts and performance may last longer we think, according to a new study.

The research, published in the journal Addiction from psychologists at the University of Bath, highlight that impairments in cognition seen when individuals are drunk are still present the day after, when there little to no alcohol left in the bloodstream.

Across the board, they highlight how hungover individuals have poorer attention, memory and psychomotor skills such as coordination and speed when compared to when sober.

The researchers suggest their findings have important implications when it comes to activities performed when hungover, including driving.

For example, while hungover, individuals might typically wait until they believe there is no alcohol in the system before driving. These new results suggest that we could still be impaired in terms of the cognitive processes required, even after alcohol has left the bloodstream. In addition, the researchers warn that although many workplaces have clear policies in place regarding alcohol intoxication at work, few cover the next day effects of alcohol.

For certain jobs, they suggest, employees should be aware of the real effects that hangovers can have, and employers might do well to consider revising guidelines on safety grounds.

Hangover is the most commonly-reported negative consequence of alcohol use, and is already estimated to cost the UK economy £1.9 billion a year due to absenteeism. Despite this, up until this point little has been done to examine the effects of being hungover 'on the job'.

Leader author Craig Gunn of the Department of Psychology at the University of Bath explained: "In our review of 19 studies we found that hangover impaired psychomotor speed, short and long term memory and sustained attention. Impaired performance in these abilities reflects poorer concentration and focus, decreased memory and reduced reaction times the day after an evening of heavy drinking. Our review also indicated limited and inconsistent research on alcohol hangover and the need for future studies in the field."

Senior author Dr Sally Adams added: "Our findings demonstrate that hangover can have serious consequences for the performance of everyday activities such as driving and workplace skills such as concentration and memory.

"These findings also highlight that there is a need for further research in this field where alcohol hangover has implications at the individual level in terms of health and wellbeing, but also more widely at the national level for safety and the economy."

The researchers are now developing this work to further examine the true health and economic costs of hangover and associated risks with the next day effects of heavy drinking. The meta-analysis involved in this study involved a review of 770 articles relating to the topic.

Munich, Germany - 25 Aug 2018: Unnecessary heart procedures can be avoided with a non-invasive test, according to late breaking research presented today at ESC Congress 20181 and published in Journal of the American College of Cardiology.

Dr Bjarne Linde Norgaard, principal investigator, of Aarhus University Hospital, Denmark, said: "This study showed that a non-invasive method can be used to identify which patients with chest pain and clogged coronary arteries (coronary artery disease) can be safely treated with drugs and do not require invasive diagnostic tests."

Chest pain is a warning sign of coronary artery disease which can cause a heart attack or death if the blockage stops blood flow to the heart. The severity of the blockage and its impact on blood flow determines whether treatment should be drugs, inserting a stent to open the artery, or surgery to replace the artery.

Patients with chest pain are initially assessed with coronary computed tomography angiography (CTA), a non-invasive scan that determines the degree of artery narrowing (stenosis), which is expressed as a percentage. An invasive technique called fractional flow reserve (FFR) then assesses whether the stenosis is obstructing blood flow (called ischaemia). FFR involves inserting a pressure wire into the artery then calculating the ratio between the maximum blood flow in the narrowed artery and the maximum blood flow in a normal artery.

A new non-invasive technique for assessing ischaemia uses anatomic information from standard coronary CTA scans and applies a mathematical algorithm simulating blood flow to calculate FFR. Several clinical trials have shown that this method, called FFRCT, accurately reflects invasively measured FFR. However, there is little information on clinical outcomes using coronary CTA followed by FFRCT to decide treatment.

This is the first study to show the clinical benefit of FFRCT in patients with moderate stenosis. The study included 3,674 patients with stable angina who had new onset chest pain between 2014 and 2016. All patients had coronary CTA to determine the degree of stenosis. A total of 2,540 patients had mild stenosis (less than 30%) and had no additional testing.

A total of 677 patients with moderate stenosis (30-70%) had FFRCT to guide further management. Of those, 410 (61%) patients had normal FFRCT (more than 0.80) and were treated with drugs alone, with no referral to invasive testing (coronary angiography).

Over the next three years, the incidence of a combined endpoint of all-cause death, myocardial infarction, hospitalisation for unstable angina, and unplanned revascularisation was similar in patients with mild stenosis on coronary CTA (2.8%) and patients with moderate stenosis on coronary CTA but normal FFRCT (3.9%).

"Patients with moderate stenosis on coronary CTA who had normal FFRCT were deemed at low risk of heart attack and received drugs alone," said Dr Norgaard. "Our study shows that this is a safe strategy, since their prognosis was equally favourable to patients with no or mild stenosis who we know have good outcomes. The findings suggest that coronary CTA followed by FFRCT could be used as a gatekeeper to invasive diagnostic testing, and that patients with moderate stenosis and a normal FFRCT result do not need the invasive test."

Patients with abnormal FFRCT (0.80 or less) either received medical therapy alone or were referred for invasive coronary angiography, depending on the number of affected arteries and their location. Dr Norgaard said: "These patients had more severe disease and a less favourable outcome, particularly those who received only medication. More research is needed to determine the best management strategy for these patients."

Data for the study were obtained from the Western Denmark Cardiac Computed Tomography (WDCT) Registry, the Danish National Patient Registry, and the Civil Registration System.

The market share of a company does not have a strong influence on its financial performance, a new study in marketing at the Faculty of Management, Economics and Social Sciences of the University of Cologne shows. Companies should instead invest in building customer relationships and a strong brand. If the market share increases by 1%, the financial performance of companies only increases by 0.13% on average. To arrive at these results, the researchers examined the relationship between market share and financial profitability using 89 published studies from six different continents published between 1972 and 2017.

Other studies show a much stronger financial effect of other metrics, such as customer satisfaction and brand equity. In fact, customer relationships deliver six times the effect and the brand almost three times the effect of market share gains alone. Dr. Alexander Edeling from the University of Cologne and Professor Dr. Alexander Himme from Kühne Logistics University in Hamburg published their findings in their article, "When Does Market Share Matter? New Empirical Generalizations from a Meta-Analysis of the Market Share-Performance Relationship," in the Journal of Marketing.

"Many CEOs still consider market share to be the most important indicator of business success," says Edeling. "But in today's digital market, small companies can often produce cost-effectively and sell to a global audience. That allows them to compete with the industry's leading companies."

Together with his co-author, Edeling suggests distributing budgets accordingly. Slow and steady investments in the expansion of products, the improvement of customer service and the development of a brand with a potential target customer base are the key to the growth and future security of a company for the authors.

After an almost two-year journey, NASA's asteroid sampling spacecraft, the Origins, Spectral Interpretation, Resource Identification, Security-Regolith Explorer (OSIRIS-REx), caught its first glimpse of asteroid Bennu last week and began the final approach toward its target. Kicking off the mission's asteroid operations campaign on Aug. 17, the spacecraft's PolyCam camera obtained the image from a distance of 1.3 million miles (2.1 million km).

OSIRIS-REx is NASA's first mission to visit a near-Earth asteroid, survey the surface, collect a sample and deliver it safely back to Earth. The spacecraft has traveled approximately 1.1 billion miles (1.8 billion km) since its Sept. 8, 2016, launch and is scheduled to arrive at Bennu on Dec. 3.

"Now that OSIRIS-REx is close enough to observe Bennu, the mission team will spend the next few months learning as much as possible about Bennu's size, shape, surface features, and surroundings before the spacecraft arrives at the asteroid," said Dante Lauretta, OSIRIS-REx principal investigator at the University of Arizona, Tucson. "After spending so long planning for this moment, I can't wait to see what Bennu reveals to us."

As OSIRIS-REx approaches the asteroid, the spacecraft will use its science instruments to gather information about Bennu and prepare for arrival. The spacecraft's science payload comprises the OCAMS camera suite (PolyCam, MapCam, and SamCam), the OTES thermal spectrometer, the OVIRS visible and infrared spectrometer, the OLA laser altimeter, and the REXIS x-ray spectrometer.

During the mission's approach phase, OSIRIS-REx will:

regularly observe the area around the asteroid to search for dust plumes and natural satellites, and study Bennu's light and spectral properties,;

execute a series of four asteroid approach maneuvers, beginning on Oct. 1, slowing the spacecraft to match Bennu's orbit around the Sun;

jettison the protective cover of the spacecraft's sampling arm in mid-October and subsequently extend and image the arm for the first time in flight; and

use OCAMS to reveal the asteroid's overall shape in late-October and begin detecting Bennu's surface features in mid-November.

After arrival at Bennu, the spacecraft will spend the first month performing flybys of Bennu's north pole, equator and south pole, at distances ranging between 11.8 and 4.4 miles (19 and 7 km) from the asteroid. These maneuvers will allow for the first direct measurement of Bennu's mass as well as close-up observations of the surface. These trajectories will also provide the mission's navigation team with experience navigating near the asteroid.

"Bennu's low gravity provides a unique challenge for the mission," said Rich Burns, OSIRIS-REx project manager at NASA's Goddard Space Flight Center in Greenbelt, Maryland. "At roughly 0.3 miles [500 meters] in diameter, Bennu will be the smallest object that any spacecraft has ever orbited."

The spacecraft will extensively survey the asteroid before the mission team identifies two possible sample sites. Close examination of these sites will allow the team to pick one for sample collection, scheduled for early July 2020. After sample collection, the spacecraft will head back toward Earth before ejecting the Sample Return Capsule for landing in the Utah desert in Sept. 2023.

NASA's Goddard Space Flight Center provides overall mission management, systems engineering and the safety and mission assurance for OSIRIS-REx. Dante Lauretta of the University of Arizona, Tucson, is the principal investigator, and the University of Arizona also leads the science team and the mission's science observation planning and data processing. Lockheed Martin Space in Denver built the spacecraft and is providing flight operations. Goddard and KinetX Aerospace are responsible for navigating the OSIRIS-REx spacecraft. OSIRIS-REx is the third mission in NASA's New Frontiers Program. NASA's Marshall Space Flight Center in Huntsville, Alabama, manages the agency's New Frontiers Program for its Science Mission Directorate in Washington.

For more information on the mission, visit:

https://www.nasa.gov/osiris-rex

There is good evidence that polluted air increases the risk of respiratory problems such as asthma -- as well as organ inflammation, worsening of diabetes and other life-threatening conditions.
But new research suggests air pollution can also fuel something else: chronic kidney disease, or CKD, which occurs when a person's kidneys become damaged or cannot filter blood properly.

Recently published in PLOS ONE, a University of Michigan study highlights the lesser-known connection.

"Similar to smoking, air pollution contains harmful toxins that can directly affect the kidneys," says Jennifer Bragg-Gresham, M.S., Ph.D., a Michigan Medicine epidemiologist and the study's lead author.

"Kidneys have a large volume of blood flowing through them, and if anything harms the circulatory system, the kidneys will be the first to sense those effects."

People with diabetes, obesity, high blood pressure or heart disease are at increased risk of developing CKD. Which is why high-risk patients who live in heavily populated or polluted areas should recognize the danger and take precautions, Bragg-Gresham says.

Why air pollution is dangerous

Air pollution contains fine particulate matter, or PM2.5, which is a cocktail of microscopic particles.

Because these particles are virtually weightless, they can stay in the air longer, causing humans to unavoidably inhale them on a regular basis without knowing it. PM2.5 can lead to serious health effects when inhaled often.

By reviewing Medicare claims data and air-quality data from the Centers for Disease Control and Prevention, the study's authors found a positive association between CKD rates and PM2.5 concentration.

Says study co-author Rajiv Saran, M.D., a Michigan Medicine nephrologist and director of the United States Renal Data System Coordinating Center at U-M: "If you look at areas that are heavily polluted versus areas that are less polluted, you will find more chronic kidney disease."

According to figures cited in the new research, chronic kidney disease afflicts more than 27 million Americans. People with CKD have an eightfold increased risk of cardiovascular mortality.

Unfortunately, PM2.5 is almost impossible to avoid.

We encounter air pollution from many simple everyday activities, such as cooking and driving. Other contributors are smoking, burning wood, packaged spray products, household appliances and, perhaps the most obvious, industry and vehicle emissions.

Air pollution also contains heavy metals such as lead, mercury and cadmium -- all of which are known to negatively affect the kidneys.

Problems and preventive measures

The U-M research examined several prior studies on the issue, including an effort conducted in select coal-mining areas of Appalachia that found a 19 percent higher risk of CKD among men and a 13 percent higher risk in women compared with those who lived in counties with no mining.

The good news: PM2.5 levels are much lower in the U.S. than in other industrialized countries such as China and India.

"What this means for the countries with higher PM2.5 is significantly higher odds of CKD," says Bragg-Gresham, also an assistant research scientist at U-M. "Our research was only able to examine a small range of PM2.5 values present in America but was able to find a significant association."

However, it's still important to take precautions when exposed to air pollution, especially for people who have existing health conditions or who live in densely populated or polluted cities.

"In heavily polluted areas, consider wearing masks that cover your nose and mouth, limit hours outside and limit long hours commuting to work in high traffic as well," Saran says, adding that the risk should be taken seriously.

"Many people don't see the seriousness of air pollution because it isn't something visible, but that doesn't mean it's any less important for your health."