Month: September 2011

In a presentation at the European Society of Cardiology (ESC), August  2011 Congress, British investigators are reporting that individuals who ate the most chocolate had a 37% lower risk of cardiovascular disease and a 29% lower risk of stroke compared with individuals who ate the least amount of chocolate.

In the study, published online August 29, 2011 in the British Medical Journal (BMJ) to coincide with the ESC presentation, Dr Adriana Buitrago-Lopez (University of Cambridge, UK) and colleagues state: “Although over consumption can have harmful effects, the existing studies generally agree on a potential beneficial association of chocolate consumption with a lower risk of cardio-metabolic disorders. Our findings confirm this, and we found that higher levels of chocolate consumption might be associated with a one-third reduction in the risk of developing cardiovascular disease.”

In this meta-analysis of six cohort studies and one cross-sectional study, overall chocolate consumption was reported. Chocolate in any form was included, such as chocolate bars, chocolate drinks, and chocolate snacks, such as confectionary, biscuits, desserts, and nutritional supplements. Chocolate consumption was reported differently in the trials but ranged from never to more than once per day. Most patients included in the trials were white, although one study included Hispanic and African Americans and one study included Asian patients.

Overall, the pooled meta-analysis results showed that high levels of chocolate consumption compared with the lowest levels of chocolate consumption reduced the risk of any cardiovascular disease 37% (RR 0.63; 0.44-0.90) and stroke 29% (RR 0.71; 0.52-0.98). There was no association between chocolate consumption and the risk of heart failure, and no association on the incidence of diabetes in women.

Buitrago-Lopez and colleagues concluded that these favorable effects seem mainly mediated by the high content of polyphenols present in cocoa products and are probably accrued through the increasing bioavailability of nitric oxide, which subsequently might lead to improvements in endothelial function, reductions in platelet function, and additional beneficial effects on blood pressure, insulin resistance, and blood lipids.

In the trial (the ARISTOTLE trial), presented on August 28, 2011, at the European Society of Cardiology (ESC) 2011 Congress and simultaneously published online in the New England Journal of Medicine, apixaban was superior to warfarin in preventing stroke or systolic embolism (the primary end point) and was also associated with less bleeding and lower mortality than warfarin.

The results have been positioned as the most positive yet for one of the new oral anticoagulants in atrial fibrillation (AF) and appear to give apixaban the edge over its two major competitors, dabigatran (Pradaxa) and rivaroxaban (Xarelto). Both dabigatran and rivaroxaban have also shown benefits over warfarin in the RE-LY and ROCKET-AF trials respectively, but apixaban is the first of these three agents to have shown definite reductions in each of the major outcomes of stroke, bleeding, and mortality.

The ARISTOTLE trial randomized 18, 201 patients with atrial fibrillation to apixaban (5 mg orally twice daily) or warfarin (target INR of 2.0 to 3.0). After a median follow-up of 1.8 years, results showed that apixaban was associated with a 21% reduction in the risk of stroke or systemic embolism, a 31% reduction in bleeding, and an 11% reduction in all-cause mortality.

Addressing the question of whether these new oral agents will completely replace warfarin, Mega points out that that they overcome the need for monitoring with warfarin and have shown encouraging results in many different subgroups, but “switching to a newer agent may not be necessary for the individual patient in whom the INR has been well controlled with warfarin for years.”

The superior data for these new drugs presents a challenge for anyone to continue on warfarin. However, switching to a newer agent may not be necessary for the individual patient in whom the INR has been well controlled with warfarin for years. Another important issue that might prevent people from switching is cost. These new drugs will be much more expensive. It would be more reasonable to give these new drugs to new patients and switch over those not managing well on warfarin.