Shoot for the moon. Even if you miss, you'll land among the stars. 

                                                                                 Les Brown

TUESDAY, Nov. 22 (HealthDay News) -- For patients with a condition called infective endocarditis, coupled with heart failure, heart valve surgery can reduce the risk of dying by nearly two-thirds, a new study suggests.

Infective endocarditis, an infection of the lining of the heart that often includes the heart valves, has been associated with a high risk of death. Previous studies have found that in-hospital mortality can be as high as 20 percent and death after a year can reach 40 percent.

"Cardiac surgery during hospitalization for infective endocarditis is associated with significantly lower in-hospital and one-year mortality, compared to medical therapy [drug therapy] alone, even for heart failure which is mild or moderate in severity," said lead researcher Dr. Andrew Wang, a cardiologist and associate professor of medicine at Duke University.

About one-third of patients with endocarditis experience heart failure as a complication, which is typically advanced or severe in degree and due to an acute heart valve problem, he said.

"Nearly two-thirds of patients with this complication undergo surgery during the initial hospitalization, and surgery is associated with lower mortality at one year," Wang added.

Patients with endocarditis and mild heart failure should be evaluated by a team of specialists for possible cardiac surgery, he noted. "Increased use of cardiac surgery for patients with this complication may lower the mortality rate in endocarditis," Wang said.

The study was published in the Nov. 23/30 issue of the Journal of the American Medical Association.

For the study, Wang's team looked at data from more than 4,000 patients with endocarditis of a heart valve from June 2000 to December 2006, in 61 hospitals in 28 countries.

Among patients with chest X-rays available, 33 percent had heart failure and 67 percent of these patients had heart failure so severe it limited their activities.

More than 800 of these heart failure patients underwent heart valve surgery.

Wang's group found that nearly 30 percent of the heart failure patients died in the hospital, and those who had surgery were at lower risk (20.6 percent) compared with patients treated with drug therapy alone (44.8 percent).

After one year, 29 percent of the patients who had surgery died, compared with 58 percent of the patients who were on drug therapy alone, the researchers found.

Factors connected with dying in the year after treatment included older age, diabetes, an infection contracted in the hospital, other infections, stroke and complications from the surgery, the study authors noted.

In the United States, there are about 15,000 new cases of infective endocarditis each year, according to background information in the study.

Wang noted that the average Medicare payment to hospitals for heart valve replacement surgery ranges from $25,000 to $45,000.

"In our study, surgery for patients with heart failure as a complication of endocarditis was associated with a 50 percent lower mortality, compared to medical treatment alone, so was more effective than medical therapy," he said.

Commenting on the study, Dr. Gregg Fonarow, a professor of cardiology at the University of California, Los Angeles, and a spokesman for the American Heart Association, said that "infective endocarditis results in very substantial morbidity and mortality."

The risks these patients face are even higher if the infective endocarditis results in heart failure. In these patients, the benefits of valvular heart surgery generally outweigh the risk, he said.

"Current guidelines from the American Heart Association and American College of Cardiology recommend surgery in patients with endocarditis complicated by heart failure, even in older patients with multiple comorbid [pre-existing] conditions," Fonarow said.

"These findings suggest that there are further opportunities to improve the care of patients with infective endocarditis, both in identifying appropriate patients for surgery and improving outcomes for those treated surgically," he added.

More information

For more on endocarditis, visit the U.S. National Library of Medicine.

TUESDAY, Nov. 22 (HealthDay News) -- For people with heart disease or diabetes, too little salt may harbor almost as much danger as too much salt, researchers report.

Reducing salt is still very important in people consuming more than 6,000 or 7,000 milligrams of sodium per day, said Dr. Martin O'Donnell, lead author of a study in the Nov. 23/30 issue of the Journal of the American Medical Association.

But people who already consume moderate or average amounts of salt may not need to reduce their intake further, added O'Donnell, an associate clinical professor at McMaster University in Hamilton, Ontario, in Canada.

"We're seeing more and more that there may be an optimal moderate amount of salt that people should be eating," said Dr. John Bisognano, professor of medicine and director of outpatient cardiology at the University of Rochester Medical Center, in New York. "This is reassuring for people who eat a diet that is moderate in salt."

Bisognano was not involved with the study, which was funded by pharmaceutical company Boehringer Ingelheim.

After years of seemingly happy agreement that people should lower their salt intake, experts recently have begun debating whether or not lower salt intake is actually good for everyone.

One recent study found that although cutting back on salt does lower blood pressure, it may also increase levels of cholesterol, triglycerides and other risk factors for heart disease.

Another study found that lower sodium excretion (sodium excretion is a way to measure how much salt is consumed) was associated with an increased risk of heart-related deaths, while higher sodium excretion was not linked with increased risks for blood pressure or complications from heart disease in healthy people.

However, in the latest study, results were somewhat different.

These authors looked at how much sodium and potassium were excreted in urine in a group of about 30,000 men and women with heart disease or at high risk for heart disease. Participants were followed for an average of more than four years.

In this study, sodium excretion levels that were either higher or lower than the moderate range were each associated with increased risk.

For example, people who excreted higher levels of sodium than those with mid-range values had a greater risk of dying from heart disease, heart attack, stroke and hospitalization for heart failure, the report found.

On the other hand, people who excreted lower levels than mid-range were at a raised risk of dying from heart disease or being hospitalized for heart failure.

When the researchers assessed potassium levels, they found that a higher level of excretion of the nutrient was associated with a lower risk of stroke.

"The importance of potassium intake needs to be emphasized, a finding that may be lost in the discussion on sodium," said O'Donnell, who is also an associate professor of translational medicine, at the National University of Ireland in Galway. "Diets rich in fruit and vegetables are also rich in potassium intake."

It's not clear if these findings -- which came from a population already at high risk for heart trouble -- may also apply to lower-risk populations.

"They're really looking at the sickest of the sick. How does that apply to all of us?" said Dr. Daniel Anderson, an assistant professor of medicine at the University of Nebraska Medical Center. "I think the difficulty is it probably doesn't. I worry that we're going to misinterpret this as meaning that too little sodium is a bad thing."

Bisognano agreed. "We don't want to give people the message that they should salt their pizza from this point forward," said Bisognano.

But consuming the right amount of sodium is only one aspect of heart health, said Karen Congro, director of the Wellness for Life Program at the Brooklyn Hospital Center in New York City.

"It's not the be all and end all. You have to do other lifestyle interventions," she said.

New U.S. dietary guidelines now recommend that people aged 2 years and older limit daily sodium intake to less than 2,300 milligrams (mg).

People aged 51 and older, blacks and anyone with high blood pressure, diabetes or chronic kidney disease should consider going down to 1,500 mg per day, many experts say.

It's estimated that the average American consumes 3,400 milligrams of sodium a day.

More information

Find out more about the new dietary guidelines for Americans from the U.S. Department of Agriculture.

TUESDAY, Nov. 15 (HealthDay News) -- People with more risk factors for heart disease are more likely than healthier individuals to suffer a first heart attack, according to a large new study. No surprise there. But patients with fewer or no risk factors are more likely to die from that heart attack.

"Our data show that patients with multiple risk factors present much earlier in age than patients with fewer or no risk factors. However, patients with fewer or no coronary heart disease [CHD] risk factors overall had higher mortality after the first heart attack," said Dr. John Canto, lead study author and director of cardiovascular prevention, research and education at the Watson Clinic in Lakeland, Fla.

The researchers looked at data on about 540,000 patients with a first heart attack but without previous heart disease, from the U.S. National Registry of Myocardial Infarction (NRMI) for 1994 to 2006. They focused on five major risk factors: high blood pressure, smoking, high blood cholesterol, diabetes and family history of heart disease.

Of these patients, about 14.5 percent had no risk factors for heart disease when admitted to the hospital, 81 percent had one to three risk factors, and 4.5 percent had four or five risk factors.

But of those who died while still in the hospital, nearly 15 percent had no risk factors, while slightly more than 4 percent had four risk factors and about 3.5 percent had all five. With every drop in number of risk factors, the odds of dying rose.

The researchers noted that because the NRMI is an observational study, they cannot prove cause and effect between mortality rate and number of heart disease risk factors.

The study, published in the Nov. 16 issue of the Journal of the American Medical Association, is slated for presentation Tuesday at an American Heart Association meeting in Orlando, Fla.

The inverse relationship between death rates and other risk factors -- notably obesity -- previously has been observed, said Dr. Gregg Fonarow, a professor of cardiology at the University of California, Los Angeles, who is familiar with the study findings.

"While it may be expected that the presence of coronary heart disease risk factors would further increase the risk of mortality among patients with acute myocardial infarction [heart attack], multiple studies have shown the opposite is true," Fonarow said. "This has been referred to as the 'risk factor paradox' or 'reverse epidemiology.'"

The new study did look at obesity and found "a direct association between obesity and increasing numbers of risk factors." Obesity rarely occurred in isolation.

Although the reasons for the paradox are not fully clear, Fonarow said, age might contribute. He noted that study patients "without risk factors, presenting with acute myocardial infarction, were over 15 years older than those with multiple risk factors -- and age is a major determinate of in-hospital mortality."

Of those with zero risk factors, the average age for first heart attack was about 72 years, while patients with five risk factors had their first attack at about 57.

"It's not just age. We did adjust for age and stratified results [according to] age," Canto said. For the zero-risk-factor patients, "it might take longer to form significant disease," Canto said, or their biology might be different. Higher-risk patients might have gradually adapted to their disease, perhaps by forming collateral circulation (using other channels) to compensate for clogged arteries.

Another possible explanation: "People with risk factors may also be more likely to be on treatments to modify their risk of dying, such as higher use of aspirin, statins and other cholesterol-lowering meds, blood pressure meds, all treatments known to improve CHD outcome," Canto said. "It might be that these patients are encouraged to go on exercise programs and eat better, and are more likely to be closely monitored and treated by physicians."

Study results notwithstanding, the best bet is to avoid having a heart attack, Fonarow said.

"Acute myocardial infarction is preventable," he said. "Aggressive control of coronary heart disease risk factors including hypertension [high blood pressure], hyperlipidemia [high cholesterol] and smoking can prevent acute myocardial infarction in the vast majority of men and women in the first place."

For people who are at risk, "the clinical implication of our study is that treating CHD factors makes a tremendous difference in reducing CHD mortality, and conversely, absence of CHD risk factors does not necessarily portend a good prognosis after heart attack," Canto said. "We hope the study will motivate people to get evaluated and treated."

More information

The American Heart Association describes how to assess and reduce your own risk  .

MONDAY, Nov. 14 (HealthDay News) -- A once-promising drug for a common and dangerous form of irregular heart rhythm actually seems to raise the odds for patient death, a new study finds.

The drug, dronedarone, had seemed effective against the non-chronic, "intermittent" form of atrial fibrillation in prior trials. But in the newer trial -- involving patients with ongoing, "permanent" atrial fibrillation -- use of dronedarone was tied to a doubling of the patients' death risk. The trial was cancelled early due to concerns over the drug's safety.

Atrial fibrillation is a heart rhythm disorder affecting about 2.7 million Americans that often occurs with age and can raise risks for stroke. In people with intermittent atrial fibrillation, the heart may return to normal rhythm on its own. But it does not do so in people with the more permanent form, who usually receive medications to control their heart rate.

One expert said the new study provides valuable guidance to doctors and patients.

"Rather than being a failure (which it is for the drug), this study is a 'win' for the cardiology community, in that it has tested and shown that this agent should not be used in such a fashion," said Dr. Stephen Green, associate chairman of the department of cardiology at North Shore University Hospital in Manhasset, N.Y.

The study was slated for presentation Monday at the annual meeting of the American Heart Association in Orlando, Fla. It is also being published simultaneously in the New England Journal of Medicine.

Dronedarone is currently used to treat intermittent atrial fibrillation but is not approved for treatment of the permanent form of the condition. This study was designed to investigate if dronedarone would benefit patients 65 and older with permanent atrial fibrillation, but it was halted after enrolling only 30 percent of the intended 10,800 patients.

Compared to those taking a placebo, patients who took dronedarone were 2.2 times more likely to suffer a major vascular event such as stroke, heart attack, systemic blood clot or cardiovascular death, the researchers found.

There were 21 cardiovascular deaths in the dronedarone group and 10 in the placebo (control) group; 13 deaths linked to arrhythmias (heart rhythm disorders) in the dronedarone group and four in the control group; and 23 strokes in the drug group versus 10 in the control group.

The researchers also found that dronedarone increased the risk of hospitalization for heart failure and that the nearly one-third of patients in the dronedarone group who had been taking the heart rhythm drug digitalis had a 36 percent rise in their digitalis blood levels.

That suggests that an "increase in digitalis played a causative role in the increased risk of cardiovascular death," lead author Dr. Stuart J. Connolly, a professor of cardiology at McMaster University in Hamilton, Canada, said in an American Heart Association news release. "But this does not explain the increase in stroke or heart failure," he added.

Still, "the message is that the drug dronedarone should not be used for permanent atrial fibrillation," Connolly said.

Green agreed. "The pertinent points are: Antiarrhythmic agents have traditionally had a difficult risk/benefit ratio, and large-scale studies are useful to choose the correct patient for the correct drug," and, "it is important to trial agents for non-FDA-approved indications, rather than use them indiscriminately," he explained.

More information

The U.S. National Heart, Lung, and Blood Institute has more about atrial fibrillation.