Fresh Approach To Diet And Medication Improves Recovery After Heart Attack

American Heart Association or Mediterranean Diet Improves Cardiovascular Outcomes After Myocardial Infarction Trial

A low-fat, low-cholesterol diet, as recommended by the American Heart Association (AHA), is equally beneficial for people who have had a heart attack as a Mediterranean-style diet rich in fish, monounsaturated fats, and other sources of omega-3 fatty acids, according to a community-based study that featured intensive nutrition counseling and tracked patients for an average of nearly four years.

"We did not find even a suggestion of a difference between the two groups," said Dr. Katherine R. Tuttle, medical and scientific director for Providence Medical Research Center, Sacred Heart Medical Center, Spokane, Wa. "There has been a lot of interest in the Mediterranean diet because epidemiological studies have shown that it is associated with lower rates of cardiovascular disease. The good news for patients is that either diet is a good choice."

Dr. Tuttle and her colleagues recruited 101 patients who had had a heart attack within the previous six weeks to participate in The Heart Institute of Spokane Diet Intervention and Evaluation Trial (THIS-Diet), randomly assigning patients to the AHA Step II diet or a Mediterranean-style diet. Each patient met twice with a dietitian for individual counseling within the first month, and again at three, six, 12, 18, and 24 months. In addition, study participants attended six or more group nutrition classes over 24 months.

Patients in both groups were advised to limit cholesterol intake to no more than 200 mg daily and saturated fat intake to no more than seven percent of calories. Those assigned to the AHA diet were also advised to keep total fat intake to less than 30 percent of calories, while those assigned the Mediterranean diet were allowed to consume up to 40 percent of calories as fat, with the difference made up of healthy, monounsaturated fats. In addition, the intake of omega-3 fatty acids was higher with the Mediterranean diet (more than 0.75 percent of calories as compared to 0.3-0.45 percent of calories with the AHA diet).

After an average of nearly four years, there was no difference between the two groups in the combined rates of death, repeat heart attack, unstable chest pain, stroke or hospitalization for heart failure. When the two groups of patients were combined and compared to a matched "usual care" group of 101 patients who did not receive intensive dietary counseling after heart attack, the relative risk of cardiovascular complications was reduced by two-thirds in the dietary intervention groups.

"Our study shows that, in addition to excellent medical care, dietary intervention truly benefits patients," Dr. Tuttle said.

How Early Should Eplerenone Be Initiated in Acute Myocardial Infarction Complicated by Heart Failure? An Analysis of Early Versus Late Initiation in the EPHESUS Trial

In patients who have had a heart attack complicated by heart failure, a medication that has been shown to reduce the risk of death and other cardiovascular complications is most effective when prescribed within the first week of recovery, according to a new analysis of the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS).

"Attending physicians tend to delay prescribing eplerenone until after the patient is discharged from the coronary care unit," said Dr. Faiez Zannad, a professor of therapeutics and cardiology, CHU and University Henri Poincaré, Nancy, France. "Our analysis shows that initiating treatment early provides the best opportunity for patients," said Dr. Zannad.

Eplerenone blocks cell receptors for aldosterone, a hormone that, in a healthy person, helps regulate how much sodium and water the kidney retains or excretes. After a heart attack, however, high aldosterone levels are partially responsible for causing enlargement of the heart, replacement of muscle with scar tissue, and changes in the heart's electrical system. Together this "remodeling" of the heart can lead to heart failure and place the patient at risk for serious abnormalities in the heart's rfhythm, including sudden death.

The original EPHESUS trial, which was published in the New England Journal of Medicine in 2003, found that patients whose hearts were no longer pumping as effectively as they should following a heart attack fared significantly better over the long term if they were treated with eplerenone, in addition to other proven medical therapies. In this trial, eplerenone therapy was initiated anytime within three to 14 days after the heart attack. Since aldosterone begins to do its damage very early on, researchers wondered whether the timing of eplerenone therapy had any influence on its clinical benefits.

To answer that question, Dr. Zannad and his colleagues analyzed data from 6,632 patients in the original EPHESUS trial, dividing patients into two groups based on initiation of eplerenone therapy on days three to seven, or on days 8 to 14. They found that early eplerenone therapy significantly reduced the risks of both death from any cause and a combination of death or hospitalization for cardiac causes. Most impressive was a 37 percent reduction in the risk of sudden cardiac death. Patients who started taking eplerenone after the first week enjoyed none of these benefits.

"The results are clear cut and the level of evidence very strong: Early eplerenone administration should be standard therapy," Dr. Zannad said, noting that additional research is needed to evaluate the safety and effectiveness of starting eplerenone even earlier, within the first three days after a heart attack.