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Tuesday, November 29, 2005

Risk of High Blood Pressure Among Young Men Increases With the Degree of Immaturity at Birth -- Johansson et al. 112 (22): 3430 -- Circulation

Risk of High Blood Pressure Among Young Men Increases With the Degree of Immaturity at Birth -- Johansson et al. 112 (22): 3430 -- Circulation: "Background� Survivors of preterm birth constitute a new generation of young adults, but little is known about their long-term health. We investigated the association between gestational age (GA) and risk of high blood pressure (HBP) in young Swedish men and whether GA modified the risk of HBP; ie, whether HBP was related to being born small for gestational age (SGA).
Methods and Results� This population-based cohort study included 329 495 Swedish men born in 1973 to 1981 who were conscripted for military service in 1993 to 2001. Multivariate linear- and logistic-regression analyses were performed. Main outcome measures were systolic and diastolic BPs at conscription. Linear-regression analyses showed that systolic BP increased with decreasing GA (regression coefficient �0.31 mm Hg/wk, P<0.001). Systolic and diastolic BPs both increased with decreasing birth weight for GA, but the association with systolic BP was most evident (regression coefficient �0.67 mm Hg per SD score in birth weight for GA, P<0.001). Compared with men born at term (GA, 37 to 41 weeks), the adjusted odd ratios (95% confidence intervals [CIs]) for high systolic BP (140 mm Hg) were as follows: moderately preterm (33 to 36 weeks), 1.25 (1.19 to 1.30); very preterm (29 to 32 weeks), 1.48 (1.30 to 1.68); and extremely preterm (24 to 28 weeks), 1.93 (1.34 to 2.76). Being SGA was associated only with an increased risk of high systolic BP among men born at 33 weeks or later. The risk estimates for high diastolic BP (90 mm Hg) increased with decreasing GA, but the risk reached significance only among men born moderately preterm.
Conclusions� Preterm bir"

Beyond Trial Registration: A Global Trial Bank for Clinical Trial Reporting

PLoS Medicine: Beyond Trial Registration: A Global Trial Bank for Clinical Trial Reporting: "A clinical trial is a research study in which human volunteers are treated and observed to an-swer a particular biomedical question. Clinical trials are one of the most valuable sources of evidence to determine which therapies are safe and effective. However, instances of selective re-porting of results to benefit proprietary interests rather than public health have recently come to light. For example, in 2004, GlaxoSmithKline settled a US$2.5 million lawsuit for suppressing trial results showing that its antidepressant paroxetine (Paxil) increased suicidal ideation in children [1]. More re-cently, Merck and Pfizer have been criticized for with-holding results showing increased risk of heart disease from COX-2 drugs such as rofecoxib (Vioxx) [2�4], which was withdrawn from the market because of these risks.
A complete public register of trials and the subsequent release of all results are crucially impor-tant to prevent drug and device makers from skewing the public record on the effectiveness of therapies. However, even when local laws require that trials be registered, compliance has been incomplete. In the United States, the Food and Drug Administration Modernization Act [5] requires that all trials on life-threatening diseases be registered into (a register maintained by the National Institutes of Health), yet only 48% of industry-sponsored trials were registered during the initial period of the law's implementation [6]. Moreover, trials are sometimes registered with uninformative data (e.g., not giving the name of the tested drug) [7], thus subverting the central purpose of registration, which is to increase transparency."/.../

Cardiopulmonar Resuscitation - Part 1: Introduction

Part 1: Introduction -- , 10.1161/CIRCULATIONAHA.105.166550 -- Circulation
This publication presents the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC). The guidelines are based on the evidence evaluation from the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, hosted by the American
Heart Association in Dallas, Texas, January 23–30, 2005.These guidelines supersede the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care./.../

Several other chapters follow on the same issue. The addresses to *.pdf are to open access.

Part 2: Ethical Issues
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166551

Part 3: Overview of CPR
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166552

Part 4: Adult Basic Life Support
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166553

Part 5: Electrical Therapies. Automated External Defibrillators, Defibrillation, Cardioversion, and Pacing
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166554

Part 6: CPR Techniques and Devices
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166555

Part 7.1: Adjuncts for Airway Control and Ventilation
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166556

Part 7.2: Management of Cardiac Arrest
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166557

Part 7.3: Management of Symptomatic Bradycardia and Tachycardia
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166558

Part 7.4: Monitoring and Medications
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166559

Part 7.5: Postresuscitation Support
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166560

Part 8: Stabilization of the Patient With Acute Coronary Syndromes
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166561

Part 9: Adult Stroke
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166562

Part 10.1: Life-Threatening Electrolyte Abnormalities
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166563

Part 10.2: Toxicology in ECC
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166564

Part 10.3: Drowning
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166565

Part 10.4: Hypothermia
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166566

Part 10.5: Near-Fatal Asthma
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166567

Part 10.6: Anaphylaxis
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166568

Part 10.7: Cardiac Arrest Associated With Trauma
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166569

Part 10.8: Cardiac Arrest Associated With Pregnancy
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166570

Part 10.9: Electric Shock and Lightning Strikes
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166571

Part 11: Pediatric Basic Life Support
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166572

Part 12: Pediatric Advanced Life Support
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166573

Part 13: Neonatal Resuscitation Guidelines
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166574

Part 14: First Aid
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.166575

Major Changes in the 2005 AHA Guidelines for CPR and ECC. Reaching the Tipping Point for Change
Mary Fran Hazinski, Vinay M. Nadkarni, Robert W. Hickey, Robert Connor, Lance B. Becker, and Arno Zaritsky
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.170809

Management of Conflict of Interest Issues in the Activities of the American Heart Association Emergency Cardiovascular Care Committee, 2000-2005
John E. Billi, Brian Eigel, William H. Montgomery, Vinay M. Nadkarni, and Mary Fran Hazinski
Circulation published 28 November 2005, 10.1161/CIRCULATIONAHA.105.170810

Friday, November 25, 2005

Men Born Preterm at Increased Risk for High Blood Pressure -

Men Born Preterm at Increased Risk for High Blood Pressure - CME Teaching Brief - MedPage Today: "Men Born Preterm at Increased Risk for High Blood Pressure

By Katrina Woznicki, MedPage Today Staff Writer
Reviewed by Robert Jasmer, MD; Assistant Professor of Medicine, University of California, San Francisco
November 23, 2005
Also covered by: ABC News, Forbes

MedPage Today Action Points

Explain to patients with a history if premature birth that this study showed a direct and proportional association between an increase in systolic blood pressure and decreased gestational age. There was also an association between diastolic blood pressure and premature birth. "

Stress Can Cause Rising Cholesterol Levels -

Stress Can Cause Rising Cholesterol Levels - CME Teaching Brief - MedPage Today: "Stress Can Cause Rising Cholesterol Levels

By Neil Osterweil, Senior Associate Editor, MedPage Today
Reviewed by Robert Jasmer, MD; Assistant Professor of Medicine, University of California, San Francisco
November 23, 2005
Also covered by: BBC News

MedPage Today Action Points

Understand that in this study, participants who initially responded with high levels of stress to a psychological challenge test had the highest levels of cholesterol three years later.

LONDON, Nov. 23 - Stress can cause cholesterol levels to climb, researchers here have found.
A study of 199 men and women here found that 'a person's reaction to stress is one mechanism through which higher lipid levels may develop,' said epidemiologist Andrew Steptoe, D.Sc., of University College London.
He and colleague Lena Brydon, Ph.D., reported in the November issue of Health Psychology that people who showed high levels of stress responses on a test designed to evoke them had more unfavorable lipid profiles three years later than did people who took the same test but managed it without stressful responses.
The participants were 199 men and women who were part of the Whitehall II study. Three years earlier it assessed demographic, psychosocial, and biological risk factors for coronary artery disease in more than 10,000 British civil servants.
The investigators measured cardiovascular, inflammatory, and hemostatic responses as participants performed moderately stressful behavioral tasks involving color and word matching on a computer screen, and tracing an image seen in a mirror.
They were evaluated for stress-induced changes in total cholesterol, LDL cholesterol concentration, HDL /.../"

Noisy Environment Linked to Heart Attack Risk - CME Teaching Brief - MedPage Today

Noisy Environment Linked to Heart Attack Risk - CME Teaching Brief - MedPage Today

Advise patients who ask that long-term exposure to high noise levels can damage hearing and recommend ear protection.

Note that this study finds a link between chronic exposure to noise and the risk of myocardial infarction, even after other risk factors are taken into account.

BERLIN, Nov. 23 - Too much noise may increase the risk of heart attack, European researchers say.
In a large case-control study, chronic exposure to environmental noise was associated with an increased risk of myocardial infarction in both men and women, according to Stefan Willich, M.D., of the Charité University Medical Center here./.../

Monday, November 21, 2005

Edital Residencias: Instituto Cardiologia-FUC-RS

De: Ruschel []
Enviada em: segunda-feira, 21 de novembro de 2005 21:52

1.1) ENFERMAGEM: (2 ANOS) ...................... 06 vagas
(Pré-requisito: Curso de graduação na área correspondente, registro no devido conselho regional)
1.2) FISIOTERAPIA: (2 ANOS) ....................... 04 vagas
(Pré-requisito: Curso de graduação na área correspondente, registro no devido conselho regional)
1.3) NUTRIÇÃO: (2 ANOS) ........................... 02 vagas
(Pré-requisito: Curso de graduação na área correspondente, registro no devido conselho regional)
1.4) PSICOLOGIA: (2ANOS)........................... 02 vagas
(Pré-requisito: Curso de graduação na área correspondente, registro no devido conselho regional)
1.5) MEDICINA: Cardiologia (13 vagas), Área de Atuação Cardiologia Pediátrica (2 vagas), Cirurgia Cardiovascular (2 vagas), Radiologia e Diagnóstico Por Imagem (2 vagas), ver Edital específico a ser publicado em 28 de outubro de 2005 no Jornal Zero Hora e no site

Obesity and Risk of New-Onset Atrial Fibrillation After Cardiac Surgery -- Zacharias et al. 112 (21): 3247 -- Circulation

Obesity and Risk of New-Onset Atrial Fibrillation After Cardiac Surgery -- Zacharias et al. 112 (21): 3247 -- Circulation: "Conclusions Obesity is an important determinant of new-onset AF after cardiac surgery. Future postoperative AF risk models should incorporate BMI or obesity levels. Studies examining the efficacy of AF-minimizing prophylactic interventions in high-BMI patients, particularly in the elderly, may be warranted. "

5o. Simp�sio Internacional de Cardiologia Invasiva para Clínicos

5o. Simpósio Internacional de Cardiologia Invasiva para Clínicos

Sunday, November 20, 2005

Metabolic syndrome -- Khunti and Davies 331 (7526): 1153 -- BMJ

Metabolic syndrome -- Khunti and Davies 331 (7526): 1153 -- BMJ
Independently raises cardiovascular risk and should be picked up in primary care

Metabolic syndrome is characterised by hyper-insulinaemia, low glucose tolerance, dyslipidaemia, hypertension, and obesity. This cluster of factors has been recognised for many years, but the syndrome was not formally labelled until Reaven did so in 1988 and suggested that insulin resistance was its central characteristic.1 Insulin resistance seems to be the main underlying factor leading to the increased risk of mortality from coronary heart disease among people with the syndrome.2 Strategies to combat the forecast epidemic of type 2 diabetes and its vascular complications should focus on preventing and intervening early in metabolic syndrome./.../

It is becoming increasingly clear that a proinflammatory state is a common feature of the syndrome and of atheromatous disease. A recent randomised controlled trial showed that insulin resistance and measurements of C reactive protein were significantly lower at two year follow-up in patients with metabolic syndrome who had been allocated to a Mediterranean diet than in those who continued their normal diets.12 Although large intervention studies have shown that intensive modification of lifestyle delays the onset of diabetes in patients with impaired glucose tolerance,w9 no similar trials have aimed at reducing all the cardiovascular disease risk factors among people with metabolic syndrome.

Saturday, November 19, 2005

Japanese study: small LDL reductions = big CHD

De: Marcelo Gustavo Colominas []
Enviada em: sexta-feira, 18 de novembro de 2005 22:09
Para: undisclosed-recipients:
Assunto: MEGA (AHA News)

MEGA: Japanese study finds small LDL reductions translate into big CHD

Nov 16, 2005. Michael O'Riordan
Dallas, TX - The addition of a low-dose statin to a low-fat diet rich in
fish reduced the risk of coronary heart disease in a Japanese study of
individuals with moderately elevated cholesterol levels. Investigators
report that the combination of diet and pravastatin 10 mg reduced the risk
of CHD by 33%, approximately the same reduction observed in US and European
primary-prevention trials that have used larger statin doses.

The results of the Management of Elevated Cholesterol in the Primary
Prevention Group of Adult Japanese (MEGA) study were presented today at the
American Heart Association Scientific Sessions 2005. Lead investigator Dr
Haruo Nakamura (National Defense Medical College, Saitama, Japan) said the
purpose of the Japanese study was to examine whether the addition of a
low-dose statin to a diet rich in omega-3 fatty acids could reduce the risk
of CHD. In Japan, the incidence of coronary disease is about one third lower
than the US and Europe, where most of the statin trials have been conducted,
but the risk of stroke and cancer is higher.

Dr Daniel Rader (University of Pennsylvania School of Medicine,
Philadelphia), who commented on the study during the late-breaking
clinical-trials session, called the MEGA study a landmark primary-prevention
trial for the Asian population, not unlike the West of Scotland Coronary
Prevention Study (WOSCOPS) and the Air Force/Texas Coronary Atherosclerosis
Prevention Study (AFCAPS/TexCAPS). He said the results support the concept
that a modest shift in population cholesterol distribution can have a major
impact on the incidence of coronary disease and will spur debate about the
role low-dose statin therapy might have in achieving such a shift.

"The MEGA study will undoubtedly have a major impact on the treatment of
hypercholesterolemia in Asia, as it provides reassurance of safety and proof
of benefit of low-dose statin therapy," said Rader. "It should have impact
in the West, as well. These results suggest that the potential for the
broader use of low-dose statin therapy make it important to utilize
available approaches to identify that subset of healthy individuals who are
at high risk and may merit statin therapy despite only modestly elevated LDL

Relatively low risk patients

The MEGA study was a prospective, randomized, open-label trial comparing
diet and pravastatin 10 mg with diet alone for the reduction of
first-occurrence CHD in 7832 patients. Of those randomized to statin
therapy, approximately 25% were uptitrated to the 20-mg dose of pravastatin.
The diet followed by patients was low in total cholesterol, low in saturated
fat, and included at least three servings of fish per week.

Average baseline LDL cholesterol levels were 156 mg/dL in both study arms
before treatment. Mean HDL-cholesterol levels were relatively high,
measuring 57 mg/dL in both treatment groups. During a mean follow-up of 5.3
years, treatment with pravastatin 10 mg significantly decreased total- and
LDL-cholesterol levels, 11.5% and 18%, respectively.

The MEGA investigators report that treatment with pravastatin reduced the
risk of CHD 33% compared with patients randomized to diet alone. Although
the absolute benefit was small, a little over a 1% absolute reduction in
risk, the number needed to treat to prevent one additional CHD event was

MEGA: Primary and secondary end points

End point
Hazard ratio (95% CI)

Coronary heart disease (a composite end point of fatal/nonfatal MI, angina,
cardiovascular death, need for revascularization)
0.67 (0.49-0.91)

Coronary heart disease and cerebral infarction
0.70 (0.54-0.90)

0.83 (0.57-1.21)

Total mortality
0.72 (0.51-1.01)

Speaking with heartwire, Nakamura said that the relatively small reduction
in LDL-cholesterol levels translated into a statistically significant
reduction in CHD risk, a reduction similar to those observed in the major
lipid-lowering studies. Asked why the 10- to 20-mg dose of pravastatin
yielded benefit that was previously achieved with 20- to 40-mg doses of
pravastatin in the US and Europe, he said he suspects that the traditional
Japanese diet and baseline HDL-cholesterol levels were cardioprotective.

"We understand that LDL cholesterol is very important for developing
coronary heart disease, but not only LDL is important. Levels of HDL are
also important, and there are many studies that have showed a protective
benefit of HDL cholesterol against coronary heart disease. In general,
Japanese people usually have high HDL cholesterol, about 10 mg/dL higher
than people in the US, so this might have provided some protective benefit
that allowed us to reduce the dose of statin in this trial."

Cartilha do Coração para Crianças

Acaba de ser concluída a cartilha brasileira de prevenção das doenças cardiovasculares em crianças e adolescentes. É a primeira vez que se estabelece quais os parâmetros ideais para a população infanto-juvenil controlar os fatores de risco para infartos e derrames. Com divulgação prevista para esta semana, durante um congresso da Sociedade Brasileira de Cardiologia, o documento traz recomendações sobre peso, pressão arterial, colesterol, atividades físicas, alimentação e níveis de açúcar no sangue. Até agora, alguns médicos aplicavam aos jovens as mesmas diretrizes destinadas aos adultos. Outros adotavam normas estrangeiras – que podiam ser tanto americanas quanto dinamarquesas ou canadenses. A falta de consenso comprometia o diagnóstico e o tratamento dos males que predispõem a infartos e derrames. "A partir de agora, os médicos brasileiros contam com uma ferramenta bastante precisa para preservar a saúde cardiovascular futura dos meninos e meninas de hoje", diz o cardiologista Bruno Caramelli, diretor do departamento de aterosclerose da Sociedade Brasileira de Cardiologia e um dos autores da cartilha.

Criado pelas sociedades brasileiras de cardiologia, pediatria, endocrinologia pediátrica e hipertensão, o documento tem por objetivo conter o avanço de distúrbios tipicamente adultos entre meninos e meninas. A vida sedentária, as dietas gordurosas, a obesidade e o stress estão fazendo com que males como a hipertensão, o colesterol alto e o diabetes comecem a manifestar-se ainda na infância. "Se não controlarmos esse quadro, em menos de três décadas não haverá hospital disponível para abrigar tantos infartados", diz a pediatra Isabela Giuliano, pesquisadora do Instituto do Coração, em São Paulo. Estudos baseados na necropsia de crianças vítimas de morte inesperada mostram que, apesar da idade, algumas apresentavam artérias repletas de estrias, sinal da agressão sofrida pelos vasos sanguíneos e indício de problemas cardiovasculares no futuro. Um desses estudos, publicado na revista científica The New England Journal of Medicine, em 1998, revelou que quase 30% dos meninos e meninas de 2 a 15 anos já tinham as artérias coronárias e a aorta comprometidas.

Estabelecer os níveis ideais de glicemia, colesterol, pressão arterial ou peso para crianças e adolescentes não é tarefa simples. Um bom exemplo é o colesterol. O perfil lipídico de um homem de 40 anos, por exemplo, pode ser muito semelhante ao de outro vinte anos mais velho. O mesmo não acontece, porém, entre um garoto de 1 ano e outro de 5. Até os 2 anos, o colesterol tende a ser abundante na circulação, já que é matéria-prima para a produção de GH, o hormônio do crescimento, e para a maturação dos neurônios (veja quadro). Embora seja mais fácil mudar hábitos de vida de crianças e adolescentes, pelo fato de que ainda não estão tão arraigados, isso exige estratégias de convencimento e educação que devem envolver pais, educadores e médicos. "Não basta dizer a uma criança que o consumo exagerado de gordura pode fazer mal às suas artérias", diz a pediatra. "Mesmo que ela se convença, é provável que se sinta constrangida ao chegar à escola com um sanduíche natural."

Há cerca de dois anos, quando Djeneffer Cris Antero, hoje com 13 anos, recebeu o diagnóstico de colesterol alto, sua mãe até tentou mostrar-lhe o perigo que isso representava. Em vão. A garota continuou preferindo doces e frituras a frutas e verduras. Também não se incomodou em se engajar numa atividade física. Recentemente, Djeneffer descobriu que também sofre de diabetes tipo 2. "Agora eu me assustei de verdade. É muito chato não poder comer o que quero, quando quero, mas vou fazer de tudo para me cuidar." Vale a pena, em nome de um coração saudável por muitos anos.

Monday, November 14, 2005

Managing Abnormal Blood Lipids: A Collaborative Approach -- Fletcher et al. 112 (20): 3184 -- Circulation

Managing Abnormal Blood Lipids: A Collaborative Approach -- Fletcher et al. 112 (20): 3184 -- Circulation

Abstract—Current data and guidelines recommend treating abnormal blood lipids (ABL) to goal. This is a complex process and requires involvement from various healthcare professionals with a wide range of expertise. The model of a multidisciplinary case management approach for patients with ABL is well documented and described. This collaborative approach encompasses primary and secondary prevention across the lifespan, incorporates nutritional and exercise management as a significant component, defines the importance and indications for pharmacological therapy, and emphasizes the importance of adherence. Use of this collaborative approach for the treatment of ABL ultimately will improve cardiovascular and cerebrovascular morbidity and mortality. (Circulation. 2005;112:3184-3209.)

Friday, November 11, 2005

Cardiovascular Disease Mortality in Men

Cardiosource: "Revised Adult Treatment Panel III Guidelines and Cardiovascular Disease Mortality in Men Attending a Preventive Medical Clinic
Topic: Prevention/Vascular
Date Posted: 11/5/2005
Author(s): Ardern CI, Katzmarzyk PT, Janssen I, Church TS, Blair SN.
Citation: Circulation. 2005;112:1478-1485.

Study Question: What is the relative contribution of cardiovascular fitness (CardFit) and the metabolic syndrome on cardiovascular disease (CVD) mortality within each intervention window, as defined by the revised Adult Treatment Panel (ATP) III guidelines (ATP III-R)?
Methods: Risk factor and CardFit data from 19,125 men (aged 20-79 years) who attended a preventive medical clinic between 1979 and 1995 were used. Mortality follow-up was completed until December 31, 1996. Five classic risk factors were considered: age =45 years, family history, current smoker, hypertension, and low high-density lipoprotein cholesterol (HDL-C). Participants were assigned to one of four ATP III-R groups (high risk as coronary heart disease [CHD] or CHD risk equivalent, moderate risk as 2+ risk factors or 10-year Framingham risk of 10-20%, moderate risk 10-year risk <10%, and low risk 0-1 risk factor). The ATP III-R group was then used to assign one of the groups: LDL-C at goal, therapeutic lifestyle change (TLC) initiation, and drug consideration. Unfit was defined as in the lowest age-adjusted lowest quintile. The risk of CVD mortality was assessed by Cox proportional hazards regression.
Results: Mean age was 45 years; 58% were classified as being at the LDL goal, whereas 18% were eligible for TLC initiation and 24% for drug treatment. There were 179 CVD deaths over an average 10.2 years of follow-up. Compared with those with LDL-"

Wednesday, November 02, 2005

Guidelines, Lighthouses, and a Toe in the Water

Artigos na �ntegra - Merck Sharp & Dohme: "Guidelines, Lighthouses, and a Toe in the Water
Holmes, David R. Jr MD; Hodgson, Patricia BA; Singh, Mandeep MD
From Mayo Clinic (D.R.H., M.S.), Rochester, Minn, and Duke Clinical Research Institute (P.H.), Durham, NC.
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.
Correspondence to Mandeep Singh, MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
A guideline tells you how to get someplace, whereas a lighthouse keeps you off the rocks; both can shepherd you on a safe journey toward your goal. The American College of Cardiology (ACC), in concert with the American Heart Association (AHA), has been at the forefront of developing guidelines for percutaneous coronary interventions (PCI).1 In an era in which there are multiple data sets to draw from, guidelines help to sort out optimal from less optimal evidence-based approaches. Application of these guidelines makes intuitive sense as we counsel our individual patients about the risk/benefit ratio of PCI and as we develop treatment strategies for healthcare delivery systems to employ."/.../

Putting theory into practice: First survey to show that following guidelines improves outcomes
Nov 1, 2005 Lisa Nainggolan

Houston, TX - The first survey of its kind—involving more than 400 000 patients—has shown that following evidence-based guidelines for cardiac care can improve patient outcomes [1]. The results are published online before print October 31, 2005 in Circulation.

This is a reminder that guidelines can work and be useful.

"This research shows that carefully crafted guidelines can be used to improve quality of care and outcomes. This has not been shown before," lead author Dr H Vernon Anderson (University of Texas Health Science Center, Houston) commented to heartwire.

Anderson said that previous studies have revealed that adoption of effective clinical practices can be scattered, inconsistent, and haphazard, and there can be a tendency for doctors to feel "guideline fatigue" when new recommendations are issued. "But this is a reminder that guidelines can work and be useful," he stressed.

Physicians heeding guidelines
Anderson and colleagues say that the US National Cardiovascular Data Registry (NCDR) was established several years ago to provide an objective mechanism to assess guidelines-based practice. This is the first look at outcomes from the NCDR, which will be used by the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines Committee to periodically reassess and revise clinical practice guidelines.

Using the NCDR, the researchers analyzed the impact of the 2001 ACC/AHA recommendations for selecting patients most likely to benefit from percutaneous coronary interventions [2]. (Procedures for ST-elevation MI were excluded.) They examined patient records from 363 hospitals during the 39 months after the 2001 guidelines were released: 412 617 patients underwent PCI and could be classified according to the recommendations.

The data show that physicians in the participating hospitals (94% community hospitals and 6% university hospitals) seemed to be heeding the guidelines when selecting patients for PCI.

Of all the procedures performed on patients, 64% were designated (according to the guidelines) as class I (medical evidence for and/or general agreement that the procedure is useful and effective) and 21% were class IIa (weight of evidence is in favor of the usefulness).

Of the PCIs, 7% of the procedures conducted were class IIb (usefulness/efficacy is less well established) and 8% were class III (medical evidence and/or general agreement that the procedure is not useful or effective and in some cases may be harmful).

Clinical success declined from almost 93% of class I procedures to 85% of class III procedures. Adverse events (MI, CABG, and death) were generally lower in the class I procedures and highest in class III procedures (with the exception of CABG in class III, which was thought by the researchers to be due to the high percentage of previous CABG in these patients).

Adherence to guidelines associated with better outcomes
The review found a relationship among procedure indications, clinical success, and adverse events, and discovered that a small number of procedures are being carried out against recommendations.

"We observed that most PCI procedures were done for class I indications and that only a small fraction were done against recommendations," the researchers say. "This finding suggests that PCI practice conforms to the guidelines to a large extent, [and] adherence to the recommended indications for PCI was associated with better outcomes.

"A more careful consideration of procedures with class IIb and III indications might improve clinical outcomes and, by extension, the quality of patient care," they note. However, they add that understanding the reasons PCIs are done against recommendations "may provide valuable clues . . . into new or developing approaches."

"Over time, the evidence and the guidelines will change, as they should, and there will always be special cases, but overall, the quality of patient care will be improved by a conscious effort to adhere to guideline recommendations," Anderson concludes.


Anderson HV, Shaw RE, Brindis RG, et al. Relationship between procedure indications and outcomes of percutaneous coronary interventions by American College of Cardiology/American Heart Association Task Force Guidelines. Circulation 2005; DOI: 10.1161/CIRCULATIONAHA.105.553727. Available at
Smith SC Jr, Dove JT, Jacobs AK, et al. ACC/AHA guidelines of percutaneous coronary interventions (revision of the 1993 PTCA guidelines)—executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty). J Am Coll Cardiol 2001; 37:2215-2239.

Tuesday, November 01, 2005

WHO Study on Prevention of Recurrences of Myocardial Infarction and Stroke

820.pdf (application/pdf Object)
This work on Secondary Prevention of Cronary and Cerebro Vascular Disease, has the contribution of at least three members of th AMICOR list: Shanti Mendis, Jefferson G. Fernandes and E. Moriguchi.