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WEDNESDAY, June 18 (HealthDay News) -- When added to heart failure, the irregular heartbeat called atrial fibrillation can form a deadly combination.

Now, an international study shows that a less onerous strategy called "rate control" may be the best first option for keeping patients healthy under these circumstances.

"Our results show that one strategy was not superior to the other in terms of major endpoints such as cardiovascular mortality," explained the study's lead author, Dr. Denis Roy, chair of medicine at the University of Montreal, Canada. That indicates that rate control should be the primary approach, Roy said.

"If patients on rate control do not feel well, then the physician can switch to the other approach," he said.

The findings are published in the June 19 issue of the New England Journal of Medicine.

An estimated 4.8 million Americans have heart failure, which involves a progressive loss of the heart's ability to pump blood. About 20 percent of these patients also have atrial fibrillation, an abnormal function of the upper chambers of the heart, Roy said.

Cardiologists have long been divided in their choice of treatments for the combination, Roy said. Some prefer to control the heart's rhythm, first by delivering a shock, then by prescribing powerful antiarrythmic drugs, notably amiodarone. Others prefer to use less potent drugs such as beta blockers to reduce the heart's rate, which can reach 140 to 150 beats per minute.

The trial, conducted at centers in seven countries, including the United States and Canada, enrolled almost 1,400 people affected by both atrial fibrillation and heart failure. Half had treatment aimed at controlling the heart's rhythm control, the other got therapies focused on managing the heart's rate.

Over an average follow-up period of a little more than three years, the death rate from cardiovascular causes was near equal between the two groups -- 27 percent in the rhythm-control group and 25 percent in the rate-control group. The overall death rate was 32 percent in the rhythm-control group and 33 percent in the rate-control group. The rates of other adverse outcomes, such as stroke and worsening heart failure, were also almost identical in the two groups.

So, all things being equal, rate control should be the primary approach, Roy concluded, since antiarrythmic drugs are tougher on patients. "We know they can be successful, but they have many side effects, particularly in patients with heart failure," Roy said.

Making heart rate control first-line treatment in such cases "would reduce the number of hospitalizations, reduce the number of procedures, and the major outcomes would be the same," he said.

But the concept of rhythm control need not be abandoned, stressed Dr. Michael E. Cain, dean of the University at Buffalo School of Medical and Biomedical Sciences, and co-author of an accompanying editorial.

"One of the points we tried to make [in the editorial] is that we don't know if the concept is wrong, or we just don't have the optimal therapy to attain nature's rhythm," Cain said. "We can't prove it, because the existing therapies are not good enough to ensure that if you put someone on antiarrythmic therapy, it will be a normal rhythm and will not have severe side effects."

So, until that question is cleared up, "let's use a therapy [such as rate control] that works better and has less side effects, and see which works better," Cain said.

Another paper in the same issue of the journal announced discouraging news in the effort to develop a better antiarrythmic drug. An earlier report on the first trials for the drug, called dronedarone, noted that preliminary results did look promising. But the new study -- led by physicians at the University of Copenhagen, Denmark, and including more than 600 patients -- was ended early after researchers reported increased mortality in the group getting dronedarone.

Still, the trial was too small to give definitive results, the researchers added. A conclusive result could come from a large controlled study now in progress, they said.

The Danish-led study also included only people with heart failure, Cain noted. "Other data that haven't been published yet will be showing efficacy when the drug is used in people with atrial fibrillation who don't have heart failure," he said.

More information

There's more on heart failure at the American Heart Association  .

FRIDAY, June 13 (HealthDay News) -- An intensive, across-Europe effort to offer lifestyle advice to people at high risk of heart disease effectively helped them reduce such risk factors as high blood pressure, cholesterol and smoking.

"The results we see are very encouraging compared to what we see in usual care," said Dr. David Wood, a cardiology professor at Imperial College in London and the lead author of a report on the trial in the June 13 issue of The Lancet.

But, he added, "there is certainly room for improvement, particularly in relation to helping patients quit smoking."

The program, mainly run by nurses, was developed by the European Society of Cardiology and tested on more than 5,000 people in six pairs of hospitals and six pairs of general practice in eight countries.

"It was for two groups of patients," Wood said. "One was those who already had developed coronary heart disease, another those who were asymptomatic but at high risk because of a combination of risk factors that gives a high chance of developing heart disease over 10 years."

The trial, called the Euroaction study, compared the results of added counseling on lifestyle issues such as diet, physical activity and smoking to the usual care. It included more than 3,000 people with coronary heart disease and 2,300 at high risk. Half got the counseling from a team headed by nurses, assisted by dietitians and physiotherapists, with doctors in the background. The counseling was given to families as well as individuals.

"It was the nurses who coordinated the day-to-day program, with a comprehensive assessment of lifestyle and risk factors such as blood pressure and glucose," Wood said.

In diet, 55 percent of those getting the counseling reduced their intake of saturated fat, compared to 40 percent for those note getting the advice. Increased consumption of fruits and vegetables was seen in 72 percent of the counseled group, and 17 percent of them also increased their consumption of heart-friendly oily fish, compared to 35 percent and 8 percent in the other group.

Similar results were seen for blood pressure, cholesterol and physical activity, but it proved difficult to have people seen in general practice quit smoking, Wood said.

"But the fact that we ran it in eight countries and both in general hospitals and general practice means that we have demonstrated that this nurse-administered program is practical," he said. "We are looking at cost-effectiveness at this moment, and the early data suggest that it is cost-effective in preventing heart attack and stroke."

"What really was new here was that they actually made an effort to give the advice we know should be given but often isn't," said Dr. Dariush Mozaffarian, an assistant professor of medicine at Harvard Medical School and the Harvard School of Public Health, who wrote an accompanying comment in the journal.

While there have been many trials aimed at improving drug treatment in cardiology, "there are few trials in getting doctors and patients to concentrate on lifestyle," Mozaffarian said. "This shows that a relatively modest intervention can bring dramatic improvements in lifestyle."

However, he added, it's not clear whether such a program could be started in many U.S. hospitals and medical practices. "In principle, every physician should be doing it," he said. "But the system would have to change."

For such a program to work, Mozaffarian said, "policy makers, insurance companies and indicators of quality would have to focus on lifestyle and stimulate hospitals to put preventive measures into place."

More information

Recommendations on a healthy diet and lifestyle are given by the American Heart Association  .

MONDAY, May 19 (HealthDay News) -- Two new studies give greater incentive for people with obstructive sleep apnea to seek treatment for this disorder.

In one study, Swedish researchers found that stroke victims with obstructive sleep apnea (OSA) die sooner than stroke victims who don't have the sleep disorder or another less common type of it.

The other study, done by Spanish researchers, reports that people with obstructive sleep apnea and hypertension may be able to lower their blood pressure if the breathing condition is treated with continuous positive airway pressure.

The studies were to be presented Monday at the American Thoracic Society's 2008 International Conference, in Toronto.

In obstructive sleep apnea, the brain signals throat muscles to relax to the point the airway becomes blocked. A less common form of the disorder is central sleep apnea, in which the brain fails to properly regulate the signals to the muscles that control breathing. In both cases, the person wakes in his or her effort to take in oxygen.

The Swedish study, following 132 stroke patients for a decade, found that those with an obstructive apnea-hypopnea index of 15 or greater were 76 percent more likely to die earlier than those with a less severe condition or none at all. Those with a lower apnea-hypopnea index of 10 were also at greater risk of early death.

"The findings are particularly interesting, because obstructive sleep apnea is a treatable condition," lead researcher Dr. Karl Franklin, of the University Hospital in Umea, Sweden, said in a prepared statement.

He added that those with central sleep apnea also had an increased risk of earlier death, but unlike their counterparts with obstructive sleep apnea, that risk was not independent of variables such as age, gender, smoking, body mass index, hypertension, diabetes, atrial fibrillation, cognitive ability and how dependent patients were on help in their daily lives.

Based on these findings, Franklin said a clinical trial is needed to determine whether treating obstructive sleep apnea in stroke patients helps extend their lives.

In the Spanish study, which looked at 394 patients with high blood pressure and OSA mild enough that it did not affect their daytime alertness, those being treated with a continuous positive airway pressure (CPAP) machine over a one-year period experienced, on average, a 2mmHg drop in both systolic and diastolic blood pressure compared with those not using the machine. Use of the machine for five or more hours a night produced the greatest effect.

"This is the largest study trial in the field, and it shows that CPAP has an effect on cardiovascular outcomes regardless of symptoms," lead researcher Dr. Ferran E. Barbe said in a prepared statement. "This suggests that CPAP cannot only be used to treat the symptoms of sleep apnea (daytime sleepiness), but also to reduce cardiovascular risk in apneic patients."

However, the researchers stopped short of recommending use of the machine for all OSA patients with high blood pressure and no daytime drowsiness. Instead, they called for further study of the cardiovascular benefits.

"In the future, we would like to know the effects of CPAP treatment on other cardiovascular outcomes such as stroke, myocardial infarction or heart failure," Barbe said.

More information

The National Institute of Neurological Disorders and Stroke has more about sleep apnea.

THURSDAY, April 24 (HealthDay News) -- The old saying, rich or poor, it's good to have money, appears to apply to the risk of stroke, a new Dutch study finds.

Wealthy Americans have a lower risk of stroke between the ages of 50 and 64, according to the data on the almost 20,000 participants in the ongoing University of Michigan Health and Retirement Study.

And the most probable reason why the difference vanishes at the age of 65 is that more of the poorer, more vulnerable, people have already died off, said study author Mauricio Avendano, a research fellow at the Erasmus Medical Center in the Netherlands. The report was published in the April 24 issue of Stroke.

Of the 780,000 Americans who are struck by new or recurrent strokes each year, 27 percent are under 65, according to the American Heart Association.

Avendano and his fellow researcher, M. Maria Glymour of the Harvard School of Public Health, examined the possibility that a later beneficial effect comes from the full health coverage provided by Medicare after age 65.

"It is possible that because more people have care, the differences between the wealthy and others doesn't matter as much," Avendano said. "But this is not a good explanation. We tend to think it is more an effect of what we call selective survival. There is a selection of people who reach age 65. People with low incomes are more likely to die, so when you reach age 65, you have a selected group of very healthy people."

This is the first study to assess the age patterns of wealth, income and education in stroke incidence in older Americans, he said, and also the first to report that economic status predicts stroke risk.

Many earlier reports have linked lower socioeconomic status with an increased risk of stroke. This one draws a distinction between wealth, defined as the total of all financial and housing assets minus liabilities, and high income, but it is not much of a distinction, Avendano said.

"If you are born into a rich family, it doesn't matter whether you have a high income," he said. "You have a lower risk of stroke."

The study divided the participants into six groups, based on their wealth. They zeroed in on those in the fifth highest group, leaving out the rich and ultra rich. The people in that group, formally those in the 75th to 89th percentile, had one-third the risk of a stroke between 50 and 64 of the 10 percent with the lowest wealth.

Not surprisingly, the study found that lower income, wealth and education was associated with a higher incidence of smoking, low physical activity, diabetes and high blood pressure, all major risk factors for stroke.

Education didn't matter much in terms of stroke risk, either before or after age 65.

The public health application of the finding is that giving more money to poor people could reduce their risk of early stroke, Avendano said. But, as he noted in a statement, "diminishing wealth inequality requires transforming structural policies beyond the health-care system that aim to redistribute income and wealth to benefit the most disadvantaged members of society."

The report "didn't surprise me much, but just a little bit," said Dr. Claudette Brooks, an assistant professor of neurology at West Virginia University.

"We know that the risk of stroke increases after age 65, but there are other factors at work," she said.

More information

Risk factors for stroke other than lack of money are described by the American Heart Association  .