Meat, Fish, and Vegetables: New Data on Heart Disease and Stroke

This transcript has been edited for clarity.

Dear colleagues, I am Christoph Diener, a neurologist from the University of Duisburg-Essen in Germany. Today I would like to discuss six noteworthy publications that came out in September of this year.

Meat, Fish, Vegetables: Impact on Ischemic Heart Disease and Stroke Risk

The EPIC-Oxford study recruited 48,000 people without stroke or ischemic heart disease and followed them for 20 years. Participants were divided into three groups: meat eaters, fish- but not meat eaters, and vegetarians.

Researchers published the results of 18 years of follow-up of these participants in the BMJ,^[1] reporting 2820 cases of ischemic heart disease and 1072 cases of stroke during that time. Compared with meat eaters, fish eaters and vegetarians had a 13% and 22% relative risk reduction of developing ischemic heart disease, respectively. In absolute numbers, this accounts for 10 fewer cases of heart disease per 1000 for vegetarians compared with meat eaters over 10 years. Interestingly, and surprisingly, vegetarians had a 20% higher risk for stroke than meat eaters, mostly due to cerebral hemorrhage. In absolute numbers, this accounts for three more cases out of 1000 over 10 years.

I think the most likely explanation for why meat eaters have a higher risk for ischemic heart disease is LDL cholesterol. This could also explain the increased risk for cerebral hemorrhage, as it's known that very low LDL can [be associated with] a slightly higher risk for stroke.

New Guidelines on Preventing Secondary Stroke

The European Stroke Organisation offered guidelines on antithrombotic therapy for secondary stroke prevention in patients with atrial fibrillation in the European Stroke Journal.^[2]

The most important recommendation is that antiplatelet therapy should no longer be used. The second recommendation is that vitamin K antagonists should be used compared with no treatment or with aspirin, and non–vitamin K antagonist oral anticoagulants are preferred over vitamin K antagonists. There is no recommendation about the timing of when to initiate treatment after ischemic stroke. Another important recommendation is that no bridging with low-molecular-weight heparin is needed until anticoagulation is started. At the moment, there is no recommendation on occlusion of the left atrial appendage in patients with contraindications for long-term anticoagulation, given that the ongoing trials are not yet finished.

Lowering Intracranial Hemorrhage Risk From Cerebral Cavernous Malformations

A third, very interesting paper was published in Lancet Neurology,^[3] looking at people with cerebral cavernous malformations. Investigators identified 300 patients in a registry and followed them for 7 years to determine whether antithrombotic therapy or anticoagulation had an impact on the risk for intracerebral bleeding. Approximately 20% of patients were on antiplatelet therapy or anticoagulation, and they clearly had a lower risk for intracranial hemorrhage. They also performed a meta-analysis of six cohort studies with 1342 patients, which basically showed the same result: a reduced risk for intracerebral hemorrhage with antithrombotic therapy.

The most likely explanation for these results is that antithrombotic therapy allows you to avoid venous thrombosis that can lead to hemorrhage.

Dabigatran Proves Safe in Cerebral Venous Thrombosis

We recently published the results of the RE-SPECT CVT Study in JAMA Neurology.^[4] This was a safety study in 100 patients with cerebral venous thrombosis, who were randomized to either high-dose dabigatran (150 mg twice daily) or warfarin for 25 weeks after an initial treatment period of low-molecular-weight heparin. There was one intestinal bleed on the dabigatran, two intracranial bleeds on warfarin, and no recurrent venous events.

The good news here is that dabigatran is as safe as warfarin for the prevention of recurrent venous events in cerebral venous thrombosis. However, the drug is not approved for this indication.

Treating Depression in Patients With Epilepsy

In a study published in Annals of Neurology,^[5] 140 patients with epilepsy and current major depressive disorder were randomized to receive sertraline or cognitive-behavioral therapy for 16 weeks. Both treatments were effective, with over 50% of patients achieving remission. Importantly, sertraline does not increase the risk for seizures.

Ideally, I think these two treatment methods should be combined in such patients.

Duchenne Muscular Dystrophy: Seeking Benefit Without Side Effects

The last study dealt with Duchenne muscular dystrophy and was published in Neurology.^[6] Young boys with this disorder are usually treated with prednisone, with all of the adverse events that this entails when given long-term.

There is now a new drug called vamorolone which has similar activity to prednisone, but it doesn't have the side effects. In this dose-finding study, vamorolone at 2 mg/day improved motor function and clearly had fewer adverse events than the historical controls of prednisone or cortisone. We now need phase 3 trials to show whether this effect is also replicated in everyday clinical practice.

Ladies and gentlemen, we have six new studies of interest: four on stroke, one on depression and epilepsy, and one on Duchenne muscular dystrophy. Thank you very much for watching and listening.

Hans-Christoph Diener, MD, PhD, is a professor in the Department of Neurology at University Duisburg-Essen in Essen, Germany. He is widely published and best known for his contributions to stroke and headache medicine.

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