Circulation May 8, 2017 Issue

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Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center, and Duke National University of Singapore. In just a moment, we will be discussing the sources of sodium in the US diet, results that may surprise you, and that carry profound public health importance. But first, here's your summary of this week's issue.

The first original paper advances the field of cardiac tissue engineering by establishing a defined serum-free protocol to generate functional human myocardium from pluripotent stem cells. In this paper by first author, Dr. Tiburcy, corresponding author Dr. Zimmermann and colleagues from the University Medical Center Goettingen in Germany, the authors systematically investigated cell composition, matrix and media conditions to generate engineered human myocardium from embryonic and induced pluripotent stem cells and fiberglass, under serum-free conditions. The engineered human myocardium demonstrated important structural and functional properties of post-natal myocardium, including rod-shaped cardiomyocytes with M-bands, systolic twitch forces, a positive force-frequency response, inotropic responses to beta adrenergic stimulation, evidence of advanced molecular maturation by transcriptome profiling and the engineered human myocardium even responded to chronic cholinomimetic toxicity with contractile dysfunction, cardiomyocyte hypertrophy, cardiomyocyte death, and anti-pro BNP release, which are all classical hallmarks of heart failure.

Finally, the authors demonstrated scalability of engineered human myocardium according to anticipated clinical demands for cardiac repair. In summary, this paper provides proof of concept for a universally applicable technology for maturation and scalable production of engineered human myocardium, something that is termed a stride forward in an accompanying editorial by Doctors Yang and Murray, from University of Washington in Seattle.

The next paper describes a new frontier for interventional cardiology, the percutaneous therapy for tricuspid regurgitation. Here, Dr. Nickenig and colleagues, from University Hospital Bonn in Germany, recruited 64 consecutive patients deemed unsuitable for surgery who underwent mitroclip treatment for chronic, severe tricuspid regurgitation for compassionate use. Twenty-two patients were also concurrently treated with a mitroclip system for mitral regurgitation as a combined procedure. The degree of tricuspid regurgitation was severe or massive in 88% of patients before the procedure. The mitroclip device was successfully implanted in the tricuspid valve in 97% of cases.

After the procedure, tricuspid regurgitation was reduced by at least one grade in 91% of patients. 13% of patients with tricuspid regurgitation remained severe after the procedure. There were significant reductions in effective regurgitant orifice area, vena contracta width, and regurgitant volume. There were no intra-procedural deaths, cardiac tamponade, emergency surgeries, stroke, myocardial infarction or major vascular complications.

There were three in-hospital deaths. New York Heart Association class was significantly improved and six minute walk distance increased significantly. In summary, this study demonstrates that trans-catheter treatment of tricuspid regurgitation with the mitroclip system seems to be safe and feasible in this cohort of pre-selected patients.

The next paper describes the pooled safety analysis of evolocumab, a fully human monoclonal antibody to PSK-9. Dr. Toth of Johns Hopkins University School of Medicine and the PROFICIO investigators perform this pooled analysis from the PROFICIO program, which included over 6,000 patients from 12 Phase 2 and 3 trials, and the corresponding open-label extension trials, and they showed that treatment with evolocumab, up to one year, was not associated with discernible differences in adverse events, serious adverse events, or key laboratory assessments, compared to control or standard of care.

In addition, adverse events rates did not increase among patients attaining very low levels of LDL cholesterol, of less than 25 milligrams per deciliter, compared to patients attaining LDL cholesterol levels above 40 milligrams per deciliter. In summary, the present analysis confirms a favorable benefit risk profile for evolocumab treatment for up to one year.

Does aggressive blood pressure lowering prevent recurrent atrial fibrillation after catheter ablation? Well, this question is addressed in a randomized, open-label clinical trial known as the Substrate Modification With Aggressive Blood Pressure Control or SMAC-AF Trial. In this trial, Dr. Parkash of Halifax, Canada and colleagues, randomly assigned 184 patients with atrial fibrillation and a blood pressure of greater than 130 over 80 to aggressive blood pressure lowering, with a target of less than 120 over 80, or to standard blood pressure treatment, to a target of less 140 over 90, prior to their scheduled atrial fibrillation catheter ablation.

The primary outcome was symptomatic recurrence of atrial fibrillation, atrial tachycardia, or atrial flutter lasting greater than 30 seconds, determined 3 months beyond catheter ablation. The authors found no additional benefit to the addition of aggressive blood pressure lowering over a median of 3.5 months, over standard blood pressure therapy, in patients undergoing catheter ablation for atrial fibrillation to prevent recurring atrial arrhythmia.

In subgroup analysis, a signal of benefit was observed in groups whose blood pressure were lower at the point of entry into the study, and in those patients who were older. The duration of blood pressure lowering in the study did not result in reduction of recurrent atrial fibrillation after catheter ablation, however there was a higher rate of hypotension requiring medication adjustment in the aggressive blood pressure group.

Thus, this trial showed that neither aggressive blood pressure lowering compared to standard blood pressure lowering, nor the duration of aggressive blood pressure treatment reduced atrial arrhythmia occurrence after catheter ablation for atrial fibrillation, but resulted in more hypotension.

Well, that wraps it up for our summaries! Now, for our feature discussion ...

Our topic today is so universal and so important. It's about sodium intake and the sources of sodium, at least in the US, and I have with me two lovely ladies, the corresponding author of our paper, Dr. Lisa Harnack, from School of Public Health, University of Minnesota, and a regular on the show, shall I say, Dr. Wendy Post, Associate Editor from Johns Hopkins. Welcome, ladies!

Dr. Wendy Post: Thanks you, Carolyn! It's a pleasure to be here.

Dr. Lisa Harnack: Thanks, thanks.

Dr. Carolyn Lam: Lisa, let's dig right into your paper. Let's start by discussing that there was a prior paper that looked at sources of sodium in the US population. So please tell us, what inspired you to do your paper, and were you surprised by your findings?

Dr. Lisa Harnack: Right, well the previous study was over 25 years old, and it involved just 69 people from one geographic area, and, you know, it was informative, but it didn't tell us about America today, and how much sodium we're getting from different sources, and it didn't tell us much about a variety of ethnic groups ... we're a diverse country. So the CDC actually funded this study, and really they saw the need for it and laid out that this study needed to be done, as it was done, in three geographic areas, representing different ethnic groups.

Dr. Carolyn Lam: Tell us what you did.

Dr. Lisa Harnack: So, we recruited 450 people from 3 different areas, from Minneapolis/St. Paul metropolitan area ... Stanford was a partner in this study and they recruited people from that area of California, and then, finally, Birmingham, Alabama was a partner was a partner, and we got participants from there.

So the racial groups we had represented were white Americans, African Americans, Asian Americans and Hispanics.

Dr. Carolyn Lam: Yeah, I was really struck ... you had almost equal representation of women as well, didn't you?

Dr. Lisa Harnack: Right, so we made sure we had half of the participants were women, so we could really see how things stood with a variety of groups.

Dr. Carolyn Lam: That's excellent. What I was really impressed, as I'm sure, Wendy, you were, too, was the detail of the methodology. Could you tell us a little bit about that?

Dr. Wendy Post: Right, so we wanted to know all the sources of sodium. Part studies have tended to not ask about salt added to food at the table, and in home food preparation, because it's really hard to actually know ... you know, if you ask somebody, "Oh, did you add salt at the table? How much did you add?" They don't know. They just say, "Oh, well, I shook some salt on." So, we had people collect duplicate samples of the salt they added to food at the table and home food preparation. We gave them little baggies ... collection bags ... you know, after they added salt at the table, shake some into the baggy. So, we knew exactly how much because people do add salt in the home, so they have some control over how much sodium is in their diet. But the question is in how much under people's control in their home versus what's coming from the food supply.

Dr. Carolyn Lam: Right. And what I loved about the results is ... I think that it would challenge a lot of what people expect. Because when we talk about sodium restriction, everyone thinks, "Oh, it's the additional salt we add." And your study actually had surprising results. So, could you tell us?

Dr. Wendy Post: Yes, so it really was clear that the salt that people add at the table is just 5% of their total sodium intake, on average, across people in our study, and the salt added in home food preparation, like maybe the salt you add to your pasta when you're boiling it or to your eggs ... that was just 6%. So, 11% of the sodium in our study participants' diets was sort of that under-your-control in-the-home, and the rest was from other sources. So, the other things we looked at was, "Will water contribute some sodium?" So, we wanted to see how much comes from your home tap water. There's sodium that's just naturally occurring in food, like milk just naturally contains some sodium. So we wanted to look and see how much came from just naturally occurring in the food, and then the other question was how much is added by food manufacturers as part of making the food product, and that included the salt that might be added in making potato chips, as well as in restaurants ... the salt that might be added in making French fries or a pasta dish at a restaurant.

Dr. Carolyn Lam: And the biggest culprit?

Dr. Lisa Harnack: Yes, the biggest culprit was that latter source ... food added in processing.

Dr. Carolyn Lam: I thought that was amazing. Wendy, what do you think the public health message is? I mean, 70% almost of the salt's coming from processed foods from outside. What do we do? Stop eating it? What do we do?

Dr. Wendy Post: Right, so, on the editorial board for Circulation, we really liked this paper because of its very high impact for a public health message. So, as was stated, the sodium that we're getting in our diet is largely coming from processed foods and from foods we eat in a restaurant. So there are a number of ways that that can be modified and one is for our patients to read food labels and to make smart choices when they are shopping for processed foods in the supermarket.

But the other is for food manufacturers to decrease the amount of sodium in the products that they are making and there are voluntary suggestions by the FDA that food manufacturers reduce the sodium content of the food, and especially bread is incredibly high in sodium, and I suspect that most of our patients don't know that. So, if we were able to reduce the amount of sodium in the food supply by just a small fraction, it could have a large public health impact because we all eat.

So, it would affect everybody, and then I think the other really important public health message is about eating in restaurants and, of course, some people eat out more than others, and some people eat out in fast food restaurants, which, of course, are very high in sodium, but even in some of the nice restaurants that we go to, even expensive restaurants, the food is very heavily salted and I, for one, when I go out to eat, and sometimes don't like the taste of the food because it has so much salt in it, when I'm used to eating a low sodium diet.

So, there are a number of changes that occur on that level. One is for our patients to understand what foods tend to have a lot of sodium at a restaurant, but also for restaurants to notify their clientele of what foods are potentially lower in sodium and calories and generally provide the nutrient value so that we can make smart choices when we eat out.

Dr. Carolyn Lam: Yeah, indeed, congratulations, Lisa - what an important paper. Quick question, so that was the overall main message, but did you find any differences by different racial groups, by sex, by different socioeconomic status?

Dr. Lisa Harnack: We did find some differences. We found one difference was it looked like African Americans tend to add more salt at the table than some of the other groups, and, actually, Asians add less in our study. But still for all groups, that sodium added to food in processing was still the main source by a long shot, so, although there were some small differences by groups, it was clear that for all groups, the issue was the sodium added in processing.

Dr. Carolyn Lam: And for both Lisa and for Wendy, do you think these results are generalizable even beyond the US?

Dr. Wendy Post: I'd imagine that there would be quite a lot of variability, based on the habits of the various populations. So, here we're talking about eating outside the home, or food that's processed outside of the home, so there may be countries where most people are producing their own food and not necessarily buying processed foods or eating in restaurants, and then this would definitely be less applicable. And, of course, there are differences in foods that we eat based on our different ethnic groups.

Dr. Lisa Harnack: No, I would agree with what's just said. It really could be variable, but it does seem that a lot of countries are concerned about processed foods. Some countries implemented mandatory limits on the sodium in the foods in their food supply, so that would indicate to me that they know there's ... for some countries, there's serious concern about this source of sodium.

Dr. Carolyn Lam: Yeah, and I think this is really a wake-up message for us to examine where these sources of sodium ... I mean, even that simple message that it could be coming from bread, from drinking water, I think that would be surprising to a lot of us, even those of us practicing in medicine. Wendy, finally, you thought this was important enough to invite an editorial. I'd really like your thoughts there.

Dr. Wendy Post: You'll be able to read the editorial when it comes out in print, but the editorial also congratulates the authors on a really important paper, and the important public health messages, and, especially, compliments the authors on having a diverse group of participants, including ethnic minorities and men and women, and different geographic locations, so overall, it's a very important paper that I'm sure will have an important impact on the public health of our country and others.

Dr. Carolyn Lam: Listeners, you heard it right here. Remember, you're listening to Circulation on the Run. Please share this episode, and tune again next week!

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