Wednesday, January 31, 2007

TIA-to-Stroke Risk Prediction Easy As A-B-C-D2

TIA-to-Stroke Risk Prediction Easy As A-B-C-D2 - CME Teaching Brief® - MedPage Today: "The ABCD2 score is based on age, blood pressure, clinical features, diabetes, and TIA duration. It predicts stroke risk during the two-day window during which half of subsequent strokes occur, the researchers said.

Although the study validated the utility of both the existing California and ABCD scales, the new tool is likely to be more useful for emergency management and creates a single standard for use in clinical care and public education, Dr. Johnston and colleagues said.

'Identifying those at highest and lowest risk of stroke in the first days and weeks after a TIA would allow more appropriate utilization of costly secondary prevention strategies, including hospitalization,' they wrote.

'The California Score was developed to predict stroke within 90 days and the ABCD score predicts seven-day stroke risk, whereas the two-day stroke risk is often most relevant for decisions about necessity of emergent evaluation and observation,' they added."

Indications for Heart Transplantation in Pediatric Heart Disease.

Indications for Heart Transplantation in Pediatric Heart Disease. A Scientific Statement From the American Heart Association Council on Cardiovascular Disease in the Young; the Councils on Clinical Cardiology, Cardiovascular Nursing, and Cardiovascular Surgery and Anesthesia; and the Quality of Care and Outcomes Research Interdisciplinary Working Group -- Canter et al., 10.1161/CIRCULATIONAHA.106.180449 -- Circulation: Background--Since the initial utilization of heart transplantation as therapy for end-stage pediatric heart disease, improvements have occurred in outcomes with heart transplantation and surgical therapies for congenital heart disease along with the application of medical therapies to pediatric heart failure that have improved outcomes in adults. These events justify a reevaluation of the indications for heart transplantation in congenital heart disease and other causes of pediatric heart failure.

Methods and Results--A working group was commissioned to review accumulated experience with pediatric heart transplantation and its use in patients with unrepaired and/or previously repaired or palliated congenital heart disease (children and adults), in patients with pediatric cardiomyopathies, and in pediatric patients with prior heart transplantation. Evidence-based guidelines for the indications for heart transplantation or retransplantation for these conditions were developed.

Conclusions--This evaluation has led to the development and refinement of indications for heart transplantation for patients with congenital heart disease and pediatric cardiomyopathies in addition to indications for pediatric heart retransplantation."

Tuesday, January 30, 2007

New Guidelines Issued for Venous Thromboembolism

New Guidelines Issued for Venous Thromboembolism - CME Teaching Brief® - MedPage Today: "Other conclusions were as follows:

* Fifteen studies support that when a D-dimer assay is negative and a clinical prediction rule suggests a low probability of DVT or pulmonary embolism, the negative predictive value is high enough to justify forgoing imaging studies in many patients.
* The evidence in five systematic reviews regarding the use of D-dimer, in isolation, is strong and demonstrates sensitivities of the enzyme-linked immunosorbent assay (ELISA) and quantitative rapid ELISA, pooled across studies, of approximately 95%.
* Eight systematic reviews found that the sensitivity and specificity of ultrasonography for diagnosis of DVT vary by vein. Ultrasonography performs best for diagnosis of symptomatic, proximal vein thrombosis, with pooled sensitivities of 89% to 96%.
* The sensitivity of single-detector helical computed tomography for diagnosis of pulmonary embolism varied widely across studies and was below 90% in four of nine studies. More studies are needed to determine the sensitivity of multidetector scanners."

Human metabolism recreated in lab

BBC NEWS | Health | Human metabolism recreated in lab: "'It's increasingly recognised there are these networks of metabolism and we need to know if we target something how that will spread out and this is potentially a way of dealing with that.'

Dr Anthony Wierzbicki, consultant in specialist laboratory medicine at St Thomas's hospital, has done a lot of work on the role of cholesterol in heart disease.

'This is a potentially interesting tool for investigating metabolism of which cholesterol biochemistry forms a part,' he said.

But he added that the model would have to be 'sophisticated' enough to predict what happens in the production and breakdown of cholesterol as well how it is absorbed from the gut as the two were closely linked."

Pioneering heart surgery trialled

BBC NEWS | UK | England | Leicestershire | Pioneering heart surgery trialled: "Dr Jan Kovac, consultant cardiologist at Glenfield Hospital, said: 'In the past, patients had to endure open heart surgery and would have been in hospital for at least a week after their operation.

'This new catheter treatment is much quicker and in most cases patients will be back home within a few days of having the operation.

'This technique is the biggest invention in cardiology over the last 30 years since the introduction of the coronary angioplasty.'"

Wednesday, January 24, 2007

Preventing stroke: saving lives around the world

The Lancet Neurology

De: [] Em nome de Coleman, Catherine
Enviada em: terça-feira, 23 de janeiro de 2007 17:28
Assunto: [ProCOR] Lancet Neurology: Stroke in developing countries: can theepidemic be stopped and outcomes improved?

["Two-thirds of the global burden of stroke occurs in low-income and middle-income countries, but accurate data on stroke incidence in these countries are scarce. Stroke surveillance systems--which are absent in virtually all resource-poor countries--are essential to obtain an accurate picture of the burden of stroke and to enable policymakers to plan cost-effective strategies....There have been attempts to collect reliable data, and there is a will to do so, but the lack of sound methodology and effective surveillance render studies uninformative or incomparable. As an entry point for countries to begin registration of patients with stroke, WHO recommends a stepwise approach to stroke surveillance (STEPS Stroke). This approach enables researchers to gather information on stroke through identification of the three major subsets of patients that comprise a population's stroke burden: those admitted to hospital (step 1); those who have stroke events that are fatal before admission to hospital (step 2); and those with non-fatal strokes who are cared for entirely in the community (step 3). ("STEPS in the right direction," The Lancet Neurology 2007;
6(2): 93).]


The article below, "Stroke in developing countries: can the epidemic be stopped and outcomes improved?" appears (free full text) in the current issue of The Lancet Neurology. Link to the issue at For those who cannot access the articles online, excerpts are provided below. We welcome your comments.

To help people who want to establish either hospital-based or population- based stroke registers, WHO provides resources at, including a manual which explains in detail how to develop such a register and an application form/criteria for free access to a Data Entry Tool.

"Stroke in developing countries: can the epidemic be stopped and outcomes improved?"
Valery L Feigin
Free full text:

According to WHO estimates, death from stroke in developing (low and
middle-income) countries in 2001 accounted for 85*5% of stroke deaths worldwide, and the number of disability-adjusted life years (DALYs), which comprises years of life lost and years lived with disability, in these countries was almost seven times that in developed (high-income) countries. [1] Stroke burden is likely to increase as a result of ageing and population growth if action is not taken now to remove or reduce the well-established determinants of stroke.

Although good-quality data on the epidemiology, prevention, and management of stroke are rapidly accumulating for economically developed countries, particularly over the past two decades, there is a lack of reliable data for developing countries. These issues and the future of applied stroke research and implementation strategies in these countries are the focus of a series of Review articles, the first of which is published in this issue of The Lancet Neurology.

On the basis of the recent WHO re-assessments of the original Global Burden of Disease (GBD) study and the WHO 2002 mortality estimates, with substantial improvements in data availability and some new methods for dealing with incomplete and biased data, Strong and colleagues [2] review current and projected stroke mortality and burden (as measured in DALYs) for the world, World Bank income groups, and selected countries for the period from 2005 to 2030. The authors estimate that the current global burden of stroke is 16 million first-ever strokes, 62 million stroke survivors, 51 million DALYs, and
5*7 million deaths in 2005. Without additional population-wide interventions, figures are predicted to increase to a staggering 23 million first-ever strokes,
77 million stroke survivors, 61 million DALYs, and 7*8 million deaths by 2030.
Strong and colleagues' data also show that stroke is already a leading cause of death and disability in low and middle-income countries and in the global population under age 70 years, and that 87% of global stroke mortality in 2005 (a 1*5% increase compared with 2001) occurred in these countries, with Russia at the top of the list.

However, if there were a 2% reduction per annum in stroke mortality (due to better management), this would result in 6*4 million fewer deaths from stroke between 2005 and 2015, with most deaths averted and years of life gained in low and middle-income countries. The experience of high-income countries has shown the feasibility of such reductions. The authors advocate a wider use of early administration of aspirin for ischaemic stroke in low and middle-income countries. However, they also correctly argue that the most important contribution to the reduction of stroke mortality in these countries is likely to come from primary prevention, with the emphasis on the major risk factors common to stroke, heart disease, diabetes, and other chronic diseases.


What can we learn from these studies? First, we are witnessing an epidemic of stroke in developing countries. The burden of stroke will be even greater if appropriate measures are not taken. Second, there is a lack of reliable and comparable data on stroke incidence, prevalence, causes, trends, management, and outcomes to inform efficient and sustainable health care and prevention strategies in developing countries. The gap in knowledge on stroke epidemiology between developed and developing countries is also widening. Third, despite apparent differences in the patterns of stroke types and risk factor profiles between developed and developing countries, most occurrences of stroke and cardiovascular disease can be attributed to conventional risk factors, [7,8] and some prevention and management strategies are likely to be equally applicable to all countries and populations. The question is whether we should wait until further evidence on stroke epidemiology, prevention, and management is available from developing countries or act now to stop the stroke epidemic and improve outcomes. On the basis of the available evidence, we should act now. Stroke must be a priority on the health agenda in all countries. This leads us to the next logical questions. How best should we proceed to stop the epidemic and improve stroke outcomes in developing countries, given their very limited resources and many competing demands? How best can we monitor the effects of these interventions at the population level in developing countries? What are the directions of future applied stroke research in these countries?

Given the limited resources available for health care in developing countries, it would be logical to place emphasis on effective population-wide interventions to control or reduce exposure to leading risk factors, such as raised blood pressure, smoking, high cholesterol, low fruit and vegetable intake, physical inactivity, and alcohol excess. [9] Population-wide efforts to reduce salt intake and tobacco use through multiple economic and educational policies and programmes have been suggested as cost-effective primary prevention interventions in developing countries. [7]

Primary prevention measures should be complemented with proven secondary prevention measures, such as early aspirin use in patients with acute ischaemic cerebrovascular events, prescription of blood-pressure-lowering drugs to all patients with stroke, and basic multidisciplinary acute stroke units in hospitals that provide emergency care for patients. Development of consensus statements and national stroke guidelines by recognised experts from the region to address local issues on the basis of the best available evidence should also be encouraged and their use supported. Effective strategies to improve stroke awareness (including campaigns to remove stigma associated with stroke) and training of healthcare workers in the regions need to be developed and implemented on a larger scale. [7,10]

Further research is needed to trial other affordable and potentially widely applicable primary and secondary prevention strategies, such as a polypill containing aspirin, blood-pressure-lowering drugs, statin, and perhaps folic acid. [11] More research also needs to be done to assess indigenous medicines and compare various capacity-building strategies. [7] Emphasis should be placed on effectiveness and efficiency of the interventions in the specific context of developing countries. [7,10] Monitoring of effects of interventions at the population level and obtaining comparable and reliable data on stroke incidence, prevalence, and risk factors in developing countries deserves further attention.
[7,12] The ascertainment of numbers of hospitalised stroke patients in the WHO STEPwise approach to stroke surveillance [13] seems feasible, but the other two suggested steps (ascertainment of fatal stroke events in the same community, and especially the ascertainment of non-fatal, non-hospitalised stroke events in the same community) may be challenging in many low and middle-income countries. An alternative approach for studying stroke incidence and prevalence in countries with very limited resources could include a combination of a stroke prevalence survey (eg, door-to-door study) with a study of death certificates (verbal autopsy procedures) in the same community (figure). The key idea of this approach is that nonfatal first-ever stroke events within the preceding 3 years in the defined population are identified among prevalent cases of stroke (prevalence survey) and then combined in the analysis with fatal first-ever stroke events in the same population for the same study period to calculate cumulative stroke incidence rates. The standard WHO definition of stroke should be used to allow comparisons. [14] This design for studying stroke incidence has been used in Italy [15] and China [16] and shown to be valid. [15]


Only through a comprehensive approach, combining applied stroke research with sustainable, affordable and context-specific evidence-based prevention and management strategies will it be possible to stem the global stroke epidemic, improve outcomes, monitor burden, and save millions of lives around the world.

Valery L Feigin
Clinical Trials Research Unit, School of Population Health, The University of Auckland, New Zealand

Wednesday, January 17, 2007

Expanding Priorities -- Confronting Chronic Disease in Countries with Low Income

NEJM -- Expanding Priorities -- Confronting Chronic Disease in Countries with Low Income: "In a ceremony held at the New York Public Library on June 26, 2006, Microsoft founder and global health philanthropist Bill Gates expressed his belief that 'there is no reason we can't cure the top 20 diseases.'1 To achieve this ambitious objective, however, international health organizations will need to greatly expand their efforts, especially in low-income countries, to prevent and treat noncommunicable chronic diseases.

Although there are many ways to classify diseases and to evaluate the burden of disease, it is clear that by any measure, several noncommunicable chronic diseases have a place in the global top 20. For example, cardiovascular disease alone accounts for nearly 30% of all deaths worldwide and 10% of all years of healthy life lost to disease (called 'disability-adjusted life-years'; see graphs).2 In low-income and lower-middle-income countries (countries with a per capita gross national product of less than $3,255 in 2004), the corresponding figures are similar to the global ones — 27% and 9%, respectively."/.../

Thursday, January 11, 2007

Medicamentos para o SUS (2) - Provocação do Eduardo Costa

De: Eduardo A Costa []
Enviada em: sábado, 6 de janeiro de 2007 11:12
Para: Aloyzio Achutti
Assunto: Re: [2333 - AMICOR-06/01/2007]

Caro amigo Achutti e todos AMICOR,

Tenho um gosto particular pela polêmica, isto é, uma visão de um outro ângulo do mesmo fenômeno.
A visão hegemônica, esconde as outras e deixa encoberto o lado oculto da lua, que nesse caso pode ser fácil de deduzir pela superfície que vemos.
Não é o caso na maioria das vezes. O outro lado é oposto. Vive junto e não aparece. É a cara da moeda. Na coroa está o valor.
Pois bem, o MS em 2003 comprava diretamente 5% de seu orçamento em medicamentos, cerca de 1,5 bilhões de reais e em 2006, gastou 4,2 bilhões, quase 3 vezes mais, agora 11% do seu orçamento. Não está incluido o que repassa para tal fim aos estados e muncipios que também gastam de seus orçamentos, nem o subsidio da Farmácia Popular.
Na face mais visível e utilizada para comprovar o cuidado do Governo com a saúde houve um avanço da política social.
O outro lado é o verdadeiro cifrão (pq não volta para a economia do país, não gera empregos, nem é consumido nos botequins e supermercados brasileiros) : crescem a importação de fármacos e medicamentos e o deficit anual de nosso balanço de pagamentos externo do setor saúde é de mais de 4 bilhões de dólares, sendo quase 3 bilhões em medicamentos e vacinas (10%).
Não temos estimativa de quanto aumentou o acesso dos que precisam a medicamentos, mas aumentou marginalmente.
O destino do aumento de orçamento foram medicamentos patenteados, ou seja monopolizados por alguma grande companhia. Essas continuam a bloquear como podem a indústria nacional.
Para exemplificar: no programa de AIDS (170 mil em tratamento) o orçamento desse ano de 2006 para medicamentos foi de 1,2 bilhões de reais. Os laboratórios oficiais que fornecem 80% das unidades farmacêuticas recebem cerca de 25% dos recursos. Os quase 800 milhões vão para a compra para tratar 30 mil pacientes.
Nada contra. O problema é que não dá mais para acreditar que é cientificamente correto (com a conhecida prática dos conflitos de interesses) e a vulnerabilidade do processo decisório de incorporação aos procedimentos dos "consensos" e da tecnoburocracia estatal.
Não podemos deixar de lembrar que, via de regra, os médicos na maioria dos paises são "treinados" sob a forte pripaganda médica direta ou sutil, em congressos e mesmo na faculdade.
Considero urgente uma revisão dos critérios para a prescrição e incorporação dos "medicamentos de uso excepcional", pois aí está o grande rombo.
Nesse email não vou detalhar mais, mas queria justificar o debate que propus.
E mais, defendo também e com bons dados que o controle de preços não é só sobre preços altos, estamos vivendo frequentemente dumping (preços mais baixos) para tirar o estado ou o nacional do mercado. Depois de sós, voam os preços de novo.
Deixo para outra oportunidade contar alguns dados nossos (de Farmanguinhos) e em particular o último episódio com a insulina humana.
Mas, o centro do questionamento técnico de epidemiologistas clínicos deve partir, na minha opinião:
1 - Clara avaliação dos riscos, não só das vantagens (se devidamente e criticamente estabelecidas);
2 - Contrapor riscos relativos a riscos atribuíveis na população.
3 - Vantagem relativa, sobre o tratamento com medicamentos ou alternativas já bem conhecidas;
4 - Procedimentos para a exclusão de terapêuticas das listas ou recomendações.

Sei que para isso deveríamos ter uma farmacovigilância bem alimentada - raramente as suspeitas de reações adversas são comunicadas e a elas se dá o devido destaque na apuração e organização da informação para a ação.
Mas debater o assunto já é bom.

Abraços a todos, bom ano novo

Eduardo Costa

Saturday, January 06, 2007

AMICOR 10 anos...

Agradeço as menifestações de carinho e sugestões de vários AMICOR.
Enquanto estamos recolhendo novas sugestões e planejando o futuro, gostaria desde já transcrever parte de mansagem recebida do PADRINHO AMICOR (como todos sabem, foi o Eduardo de Azeredo Costa que sugeriu o nome da lista, ao ver que as mensagens começavam sempre com "Caros amigos do coração").
O desafio é válido e provocador. Desde já podemos começar e/ou ir pensando nele.
Um abraço
...No dia 12 passado comemorei de maneira singular meus 40 anos de formatura, sem que eu mencionasse isso, inaugurei uma nova área de produção de medicamentos para hipertensão e diabete e homenagiei o Fadul, último Ministro do Jango, que nos deixou um legado fantástico e ignorado na luta contra os negócios excusos das multinacionais dos medicamentos (em geral os susistas o mencionam porque organizou a 3a. conferência nacional de saúde com o tema central na municipalização da atenção básica).

O discurso do Jango na assinatura do decreto que criou o Geifar (grupo executivo da indústria farmacêutica) é de grande atualidade. Impressionante o que não se sabe que ele fez em pouco mais de dois anos, 40 e poucos anos depois: a primeira lista RENAME, o CADE, a normatização da SECEX para coibir o supoerfaturamento e os dumpings das multis, entre outras coisas.

Nas comemorações dos 10 anos do AMICOR tenho uma sugestão a fazer: porque não pensar em estabelecer um debate sobre a incorporação tecnológica ao SUS na área de medicamentos e equipamentos?

A palavra para definir o descalabro hoje é desvairo orientado para proteger as multis e aumentar nossos gastos....... O que v acha de começar na área cardiovascular definindo uma lista boa e deixar os Amicor discutir os pros e contra? Poruqe e quando substituir uma sinvastatina por outra patenteada? Qual a evidência real, etc.


Friday, January 05, 2007

Cardiosource: ACC Clinical Collection on Coronary Syndromes

Cardiosource: "Dec 20, 2006 unlocked content Course of Depressive Symptoms and Medication Adherence After Acute Coronary Syndromes: An Electronic Medication Monitoring System (J Am Coll Cardiol)
Dec 20, 2006 unlocked content Only Incident Depressive Episodes After Myocardial Infarction Are Associated With New Cardiovascular Events (J Am Coll Cardiol)
Dec 20, 2006 unlocked content Ischemic Mitral Regurgitation and Risk of Heart Failure After Myocardial Infarction (Arch Intern Med)
Dec 20, 2006 locked content Bupropion is not helpful for long term smoking cessation in patients hospitalized with acute coronary syndrome. (Am J Med)/.../"

The Year in Cardiology -

The Year in Cardiology - CME Teaching Brief® - MedPage Today: "Additional Acute Coronary Syndrome Coverage

ATLANTA, Jan. 4 -- Among cardiologists, 2006 will be remembered as the year in which the value of tight cholesterol control was confirmed, the value of various vitamin regimens for preventing heart disease was questioned, a once promising lipid therapy was derailed, and enthusiasm for drug-eluting stents was dampened.

The following summary reviews some of the highlights of the year in cardiology. For fuller accounts, links to the individual articles published in MedPage Today have been provided.

How Low Can You Go?

FTC Fines Diet Pill Makers Millions for Bogus Claims

FTC Fines Diet Pill Makers Millions for Bogus Claims - CME Teaching Brief® - MedPage Today: "WASHINGTON, Jan. 4 -- The Federal Trade Commission said today that it fined four makers of over-the-counter weight-loss products more than $25 million for false advertising, including a $3.2 million civil penalty against Bayer for claims made for One-A-Day Weight Smart.

FTC chairman Deborah Platt Majoras said the Bayer fine was the largest civil penalty ever levied by the agency.

She added that none of the four products involved -- One-A-Day Weight Smart, Xenadrine EFX, Cortislim, and TrimSpa -- posed a health risk to users. None was removed from store shelves.

The Bayer settlement, which was filed yesterday in U.S. Court in the District of New Jersey, came after Bayer had violated an earlier FTC order directing it to cease what Majoras said were bogus weight loss claims for its Weight Smart product, which added green tea extract to a standard multivitamin compound./.../"

Wednesday, January 03, 2007

Promotion of Faster Weight Gain in Infants Born Small for Gestational Age. Is There an Adverse Effect on Later Blood Pressure?

Promotion of Faster Weight Gain in Infants Born Small for Gestational Age. Is There an Adverse Effect on Later Blood Pressure?
Atul Singhal, MD, MRCP; Tim J. Cole, PhD, ScD; Mary Fewtrell, MD, MRCP; Kathy Kennedy, MSc; Terence Stephenson, DM, FRCP, FRPCH; Alun Elias-Jones, FRCP, FRCPCH; Alan Lucas, MD, FRCP, FMed Sci
Background—Being born small for gestational age is associated with later risk factors for cardiovascular disease, such as high blood pressure. Promotion of postnatal growth has been proposed to ameliorate these effects. There is evidence in animals and infants born prematurely, however, that promotion of growth by increased postnatal nutrition increases rather than decreases later cardiovascular risk. We report the long-term impact of growth promotion in term infants born small for gestational age (birth weight 10th percentile).
Methods and Results—Blood pressure was measured at 6 to 8 years in 153 of 299 (51%) of a cohort of children born small for gestational age and randomly assigned at birth to receive either a standard or a nutrient-enriched formula. The enriched formula contained 28% more protein than standard formula and promoted weight gain. Diastolic and mean (but not systolic) blood pressure was significantly lower in children assigned to standard compared with nutrient-enriched formula (unadjusted mean difference for diastolic blood pressure, 3.2 mm Hg; 95% CI, 5.8 to 0.5; P0.02) independent of potential confounding factors (adjusted difference, 3.5 mm Hg; P0.01). In observational analyses, faster weight gain in infancy was associated with higher later blood pressure.
Conclusions—In the present randomized study targeted to investigate the effect of early nutrition on long-term cardiovascular health, we found that a nutrient-enriched diet increased later blood pressure. These findings support an adverse effect of relative “overnutrition” in infancy on long-term cardiovascular disease risk, have implications for the early origins of cardiovascular disease hypothesis, and do not support the promotion of faster weight gain in infants born small for gestational age. (Circulation. 2007;115:)

Essential Features of a Surveillance System to Support the Prevention and Management of Heart Disease and Stroke

Essential Features of a Surveillance System to Support the Prevention and Management of Heart Disease and Stroke
A Scientific Statement From the American Heart Association Councils on Epidemiology and Prevention, Stroke, and Cardiovascular Nursing and the Interdisciplinary Working Groups on Quality of Care and Outcomes Research and Atherosclerotic Peripheral Vascular Disease
David C. Goff, Jr, MD, PhD; Lawrence Brass, MD†; Lynne T. Braun, PhD, RN, CNP; Janet B. Croft, PhD; Judd D. Flesch; Francis G.R. Fowkes, MD, PhD; Yuling Hong, MD, PhD; Virginia Howard, MSPH; Sara Huston, PhD; Stephen F. Jencks, MD, MPH; Russell Luepker, MD, MS; Teri Manolio, MD, PhD; Christopher O’Donnell, MD, MPH; Rose Marie Robertson, MD; Wayne Rosamond, PhD; John Rumsfeld, MD, PhD; Stephen Sidney, MD, MPH; Zhi Jie Zheng, MD, PhD

Executive Summary
A strategic goal of the American Heart Association (AHA) is to reduce heart disease, stroke, and risk for both by 25%,1 and Healthy People 2010 (HP2010) established 4 national goals for
heart disease and stroke prevention and management.2 However, the current health tracking systems (surveillance) in the United States cannot track progress toward these goals in a comprehensive and systematic manner. This article provides a brief overview of these goals, prevention and management strategies, and the role of surveillance in monitoring the impact of prevention and treatment efforts. It also provides a review of the existing surveillance system for monitoring progress toward preventing heart disease and stroke in the United States and recommendations for filling important gaps in that system. This information will serve as an important basis for advocacy to guide the development of a comprehensive surveillance system to support the current HP2010 and AHA goals and the likely future goal of eliminating the epidemic burden of heart disease and stroke.
Recommendations are categorized as overarching (fundamental recommendations that cut across goal areas) or as goal-specific.
They are further classified according to priority (P) (I for high priority and II for intermediate priority. No low-priority recommendations were made), staging (S) (I for early staging [1–2
years], II for intermediate staging [2–4 years], and III for later staging), and cost (C) ($ for items estimated to cost less than $10 million per year, $$ for estimates of $10 to $100 million, and $$$ for estimates exceeding $100 million). In addition, potential barriers to action are addressed.

Primary Prevention of Cardiovascular Diseases in People With Diabetes Mellitus

Primary Prevention of Cardiovascular Diseases in People With Diabetes Mellitus
A Scientific Statement From the American Heart Association and the
American Diabetes Association . John B. Buse, MD, PhD, Co-chair; Henry N. Ginsberg, MD, FAHA, Co-chair; George L. Bakris, MD, FAHA; Nathaniel G. Clark, MD, MS, RD; Fernando Costa, MD, FAHA; Robert Eckel, MD, FAHA; Vivian Fonseca, MD; Hertzel C. Gerstein, MD, MSc, FRCPC; Scott Grundy, MD, FAHA; Richard W. Nesto, MD, FAHA; Michael P. Pignone, MD, MPH; Jorge Plutzky, MD; Daniel Porte, MD; Rita Redberg, MD, FAHA; Kimberly F. Stitzel, MS, RD; Neil J. Stone, MD, FAHA

Abstract—The American Heart Association (AHA) and the American Diabetes Association (ADA) have each published guidelines for cardiovascular disease prevention: The ADA has issued separate recommendations for each of the cardiovascular risk factors in patients with diabetes, and the AHA has shaped primary and secondary guidelines that extend to patients with diabetes. This statement will attempt to harmonize the recommendations of both organizations where possible but will recognize areas in which AHA and ADA recommendations differ. (Circulation. 2007;115:114-126.)

Triglycerides and the Risk of Coronary Heart Disease

Triglycerides and the Risk of Coronary Heart Disease
10 158 Incident Cases Among 262 525 Participants in 29 Western Prospective Studies
Nadeem Sarwar, MPhil; John Danesh, DPhil; Gudny Eiriksdottir, MSc; Gunnar Sigurdsson, PhD; Nick Wareham, PhD; Sheila Bingham, PhD; S. Matthijs Boekholdt, PhD;
Kay-Tee Khaw, MBBChir; Vilmundur Gudnason, PhD

Background—Many epidemiological studies have reported on associations between serum triglyceride concentrations and the risk of coronary heart disease, but this association has not been reliably quantified. In the present study, we report 2 separate nested case-control comparisons in 2 different prospective, population-based cohorts, plus an updated
meta-analysis of 27 additional prospective studies in general Western populations.
Methods and Results—Measurements were made in a total of 3582 incident cases of fatal and nonfatal coronary heart disease and 6175 controls selected from among the 44 237 men and women screened in the Reykjavik and the European Prospective Investigation of Cancer (EPIC)-Norfolk studies. Repeat measurements were obtained an average of 4 years
apart in 1933 participants in the EPIC-Norfolk Study and an average of 12 years apart in 379 participants in the Reykjavik study. The long-term stability of log-triglyceride values (within-person correlation coefficients of 0.64 [95% CI, 0.60 to 0.68] over 4 years and 0.63 [95% CI, 0.57 to 0.70] over 12 years) was similar to those of blood pressure and total serum cholesterol. After adjustment for baseline values of several established risk factors, the strength of the association was substantially attenuated, and the adjusted odds ratio for coronary heart disease was 1.76 (95% CI, 1.39 to 2.21) in the Reykjavik study and 1.57 (95% CI, 1.10 to 2.24) in the EPIC-Norfolk study in a comparison of individuals in the top third with those in the bottom third of usual log-triglyceride values. Similar overall findings (adjusted odds ratio, 1.72; 95% CI, 1.56 to 1.90) were observed in an updated meta-analysis involving a total of 10 158 incident
coronary heart disease cases from 262 525 participants in 29 studies.
Conclusions—Available prospective studies in Western populations consistently indicate moderate and highly significant associations between triglyceride values and coronary heart disease risk. Because these associations depend considerably on levels of established risk factors, however, further studies are needed to help assess the nature of any independent associations. (Circulation. 2006;114:&NA;-.)

Postraumatic Stress Found Cardiotoxic in Older Veterans - CME Teaching Brief® - MedPage Today

Postraumatic Stress Found Cardiotoxic in Older Veterans - CME Teaching Brief® - MedPage Today: "Postraumatic Stress Found Cardiotoxic in Older Veterans

By Judith Groch, Senior Writer, MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine.
January 02, 2007
Additional Acute Coronary Syndrome Coverage

BOSTON, Jan. 2 -- More severe posttraumatic stress disorder (PTSD) increased the risk of coronary heart disease and myocardial infarction in older male veterans, researchers reported."