Meta-Analysis: Cardiovascular Events Associated with NSAI drugs

(refered by Marcelo Gustavo Colominas [mgcolominas@gigared.com])
Meta-Analysis: Cardiovascular Events Associated with
Nonsteroidal Anti-inflammatory Drugs
Shelley R. Salpeter, MD,a,b Peter Gregor, MD,b Thomas M. Ormiston, MD,b Richard Whitlock, MD,c
Parminder Raina, PhD,c,d Lehana Thabane, PhD,d,e Eric J. Topol, MDf
aStanford University School of Medicine, Stanford, Calif; bSanta Clara Valley Medical Center, San Jose, Calif; cMcMaster Evidencebased
Practice Centre, McMaster University, Hamilton, Ont, Canada; dDepartment of Clinical Epidemiology and Biostatistics,
McMaster University, Hamilton, Ont, Canada; eCentre for Evaluation of Medicines, Saint Joseph’s Healthcare, Hamilton, Ont,
Canada; fDepartment of Genetics, Case Western Reserve University, Cleveland, Ohio.
ABSTRACT
PURPOSE: We performed a meta-analysis of randomized controlled trials to assess the effect of
nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) on cardiovascular events in trials of joint disease and Alzheimer’s disease.
METHODS: We performed comprehensive searches of MEDLINE, EMBASE, CINAHL and Cochrane databases from 1966 to July 2005, and references of identified articles and reviews. We included randomized placebo-controlled trials of at least 6 weeks duration that evaluated nonselective NSAIDs in trials of joint disease or Alzheimer’s disease, and reported at least one cardiovascular event or death. The outcome measured was the composite of death, myocardial infarction or cerebrovascular accident, with the pooled results reported as odds ratios (OR). Subgroup analyses evaluated the difference between trials of joint disease and Alzheimer’s disease, and for naproxen and non-naproxen NSAIDs.
RESULTS: Pooled data from 13 trials with 7718 participants showed that nonselective NSAIDs had no significant effect on cardiovascular events (OR 1.3; 95% confidence interval [CI], 0.8 to 2.1). No significant effect was seen for joint disease trials (OR 0.6; 95% CI, 0.2 to 1.7) or Alzheimer disease trials (OR 1.6; 95% CI, 0.9 to 2.7). There was no significant difference in results for naproxen and non-naproxen NSAIDs.
CONCLUSION: Nonselective NSAIDs have no significant effect on cardiovascular events or death in trials of joint disease and Alzheimer disease, but a small adverse effect could not be excluded. An indication for risk was present in trials of Alzheimer’s disease but not in joint disease trials. There was no significant adverse or cardioprotective effect of naproxen. © 2006 Elsevier Inc. All rights reserved.

The price of growth in the Medical-Device Industry

NEJM -- The Price of Growth in the Medical-Device Industry: "In one of the most dramatic corporate acquisitions in recent memory, Boston Scientific, a large manufacturer of medical devices, outbid industry giant Johnson & Johnson to purchase Guidant Corporation earlier this year. Joining Boston Scientific in this effort was Abbott Laboratories, which paid $5 billion for Guidant's endovascular-device business. The outcome could hardly have been anticipated when Johnson & Johnson agreed to purchase Guidant for $25 billion in December 2004. In the wake of disclosures of lawsuits over allegedly defective Guidant devices, Guidant agreed to reduce the purchase price to $21.5 billion. Then Boston Scientific stepped in with a higher . . ."

Multidetector CT

Multidetector CT Not Yet Ready for Prime Coronary Time - CME Teaching Brief® - MedPage Today: "CLEVELAND, July 25 -- After a real-world multicenter evaluation with varying levels of expertise, the multidetector computed tomography (MDCT) got a thumb's down as a noninvasive competitor for coronary angiography.

Nearly 30% of the time, 16-row MDCT images of coronary artery segments were of too low quality to be evaluated, said Mario J. Garcia, M.D., of the Cleveland Clinic here. But 38% of patients with non-evaluable MDCT images turned out to have significant obstructive disease.

In addition, MDCT resulted in a high rate of false positives, Dr. Garcia and colleagues reported in the July 26 issue of the Journal of the American Medical Association.

Although single-center studies have reported promising results for MDCT in detecting obstructive coronary disease, few multiple-center studies have been done, the investigators said."

Cardiologists urge arterial screening of asymptomatic older people

Cardiologists urge screening of asymptomatic older people -- Charatan 333 (7560): 168 Data Supplement - Longer version -- BMJ: "An international group of prominent cardiologists has called for non-invasive screening for heart disease of all US asymptomatic men aged 45-75 and women aged 55-75.
The Screening For Heart Attack Prevention And Education (SHAPE) task force says that screening should be carried out to measure coronary artery calcium, with computed tomography scan, and carotid intima media thickness and plaque, with carotid ultrasonography.
The group's recommendations were published as a supplement to the American Journal of Cardiology in July, with Pfizer as the major sponsor.
The proposal hinges on the basic principle that traditional risk factor screening -the Framingham risk score and the SCORE criteria in Europe - does a good job of identifying people at very low and high risk of myocardial infarction or stroke over a decade but fails to single out 'at risk' men and women who represent everything in between. The Framingham risk factors include hypertension, hypercholesterolaemia, history of smoking, age, diabetes, and a family history of stroke or heart disease.
Prediman Shah, the head of cardiology at Cedars-Sinai Medical Center, professor of medicine at the University of California in Los Angeles, and a member of the task force, predicted that the new proposed guidelines will change health care./.../ "

Archimedes writings recovered

(From Science)
Sometimes it takes a magnifying glass to decipher an ancient text, and sometimes it takes a linear accelerator. During a live Webcast* from the Exploratorium in San Francisco, California, scholars will fire up an atom smasher to expose concealed writings by the Greek mathematician Archimedes (287-212 B.C.E.).
Known as the Archimedes Palimpsest, the manuscript in question contains the only known copy of one of the great thinker's treatises. But it has taken a beating. Medieval monks reused the pages, and a collector further defaced the work by adding paintings. Applying techniques such as multispectral imaging, researchers have uncovered much of the original text, but some remains unreadable. For the Webcast, experts will train a powerful x-ray beam from the Stanford Linear Accelerator Center on a previously hidden section of the manuscript, causing the underlying ink to fluoresce. A Greek scholar and other Archimedeans will decipher the glowing writing and discuss its significance. The event begins at 7 p.m. U.S. Eastern Time on 4 August. To learn more about the palimpsest, hop over to this site from the Walters Art Museum in Baltimore, Maryland.
* www.exploratorium.edu/archimedes
www.archimedespalimpsest.org

The SuRF Report 2: Surveillance of chronic disease Risk Factors:

This report is the second in the Surveillance of Risk Factors Report Series. SuRF2 updates the Country Profiles provided by SuRF1 in 2003. SuRF2 also presents, for the first time, comparable country-level estimates for raised blood pressure, obesity, and overweight.
The focus of the Country Profiles is recent, nationally representative risk factor data. The risk factors included in this report are those that make the greatest contribution to mortality and morbidity from cardiovascular disease, can be changed through primary intervention, and are easily measured in populations. These risk factors are:

• tobacco and alcohol use
• patterns of physical inactivity
• low fruit/vegetable intake
• overweight/obesity
• blood pressure
• cholesterol
• diabetes
  
  The text of SuRF2 (which includes everything but the Country Profiles) can be viewed in its entirety by clicking here, view complete SuRF2.

Vacina para Febre Reumática e Jorge Kalil

CNPq - Conselho Nacional de Desenvolvimento Científico e Tecnológico:
"Uma vacina contra a febre reumática, que afeta milhares de crianças e adolescentes todos os anos, é a prioridade do pesquisador Jorge Kalil. Mais comum entre 7 e 14 anos de idade, quando leva ao envolvimento do músculo cardíaco a doença implica em tratamento para o resto da vida. As pesquisas de seu grupo já resultaram na produção de proteínas recombinantes, humanização de anticorpos, novos testes diagnósticos e ensaios clínicos baseados em vacinas de DNA. “O grande desafio atual está em uma aproximação mais forte com a indústria farmacêutica, o que incrementaria a transferência para a sociedade dos diversos medicamentos gerados no programa”, afirma Kalil.
Os trabalhos são desenvolvidos no âmbito do Instituto de Investigação em Imunologia (iii), fundado em 2001 como parte dos Institutos do Milênio, programa do Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). O iii é formado por um grupo de 31 pesquisadores localizados em seis estados brasileiros, que interagem de modo colaborativo. Juntos, formam uma rede multidisciplinar de grupos de pesquisa com novas abordagens clínicas para doenças de origem imunológica.
Os conhecimentos gerados resultam de estudos em seres humanos, modelos animais e sistemas “in vitro”, utilizando técnicas que incluem a proteômica e a genômica funcional. São objetivos do iii o aperfeiçoamento do tratamento e diagnóstico de alergias, o aumento da tolerância a enxertos, a identificação de moléculas relevantes que possam servir de alvo no tratamento de imunodeficiências e o desenvolvimento de vacinas para febre reumática, esquistossomose, leishmaniose e HIV, além de câncer e doença de Chagas.
O Programa dos Institutos do Milênio permite que cientistas de alta produtividade e de competências complementares atuem sinergicamente na busca de objetivos comuns. Indo do mais fundamental à aplicação clínica, este Instituto do Milênio incorporou o princípio de agilidade técnico-científica que está na essência da proposição do programa.
Gaúcho de Porto Alegre, o professor Jorge Elias Kalil Filho já é um dos mais produtivos cientistas da história do país. Apresentou 913 trabalhos em congressos, tem 31

AMICOR – HONCode

AMICOR – HONCode
Code of Conduct Department HONcode: http://www.hon.ch/Conduct.html
Health On the Net (HON) HON: http://www.hon.ch/
Geneva University Hospital -
DIM My electronic mail isCH-1211 Geneva 14, Switzerland
HONcode@healthonnet.org
Phone/Fax:(41 22)372 6250/8885
HONcode,
Health On the Net Foundation's initiative to improve the quality of the medical Internet. AMICOR has been visited and reviewed by the HONcode team for compliance.

The following lines are inspired on recommendations received from the HONCode team:
I am the author responsible for AMICOR: Aloyzio Cechella Achutti, physician, specialist in Internal Medicine and Cardiology. Graduation in 1958, in the School of Medicine from the Federal University of Rio Grande do Sul (RGS) State, Porto Alegre, Brazil; and Professor, from the same school, until retirement in 1996.Member of the Brazilian Society of Cardiology, the Medical Association of RGS; and member of the Scientific Advisory Board of the International Society and Federation of Cardiology (after World Heart Federation) from 1989 until 2001; also member of the Academy of Medicine from the RGS, and its President 2001 and 2002; Member of the Smoking or Health Expert Panel from the World Health Organization (WHO) from 1982 until 1999.Several times I was temporary advisor for the Brazil Ministry of Health, WHO, Pan American Health Organization and World Bank; also member of the International Advisory Board of ProCOR (initiative of Professor Bernard Lown. Boston, USA)Now, the author is advisor for the Institute of Education and Research of the Hospital Moinhos de Vento and member of its Medical Orientation Panel.AMICOR was created in 1997 May, 17, following the first National Ten Days Seminar on Epidemiology and Prevention. AMICOR started as an e-mail list to discuss the “Gramado Declaration’ with the participants that had access to this communication resource (23). Soon I discovered that was easy to share with my friends and colleagues the material I found as relevant as to keep to myself surfing in INTERNET. Now the open list is composed of more than 300 members, mostly cardiologists from Brazil. Some of the delivered material is referred by other members of the list.AMICOR have had several styles since its starting point, according to the evolution of the media. Now it is a set of Blogs aiming to facilitate pre-selection to the main interest of the specialists’ members of the list. Although destined primarily to medical professionals, the site is open to visit and "The information provided on this web site is designed to support, not replace, the relationship that exists between a patient/site visitor and his/her physician."The information I receive from the members of the list, to send periodically an alert message, are strictly confidential and not shared with any other person or institution.AMICOR is free and do not have any economic or institutional support. It is a personal, autonomic, self-supported activity, and does not accept advertising.The name AMICOR was borrowed to ProCOR, to similar activities from other countries.Collaboration and suggestions to improvements or corrections are welcome.

Age and CVD and DM in men and women

ScienceDirect - The Lancet : Relation between age and cardiovascular disease in men and women with diabetes compared with non-diabetic people: a population-based retrospective cohort study: "

Adults with diabetes are thought to have a high risk of cardiovascular disease (CVD), irrespective of their age. The main aim of this study was to find out the age at which people with diabetes develop a high risk of CVD, as defined by: an event rate equivalent to a 10-year risk of 20% or more; or an event rate equivalent to that associated with previous myocardial infarction.

Methods

We did a population-based retrospective cohort study using provincial health claims to identify all adults with (n=379 003) and (n=9 018 082) without diabetes mellitus living in Ontario, Canada, on April 1, 1994. Individuals were followed up to record CVD events until March 31, 2000.

Findings

The transition to a high-risk category occurred at a younger age for men and women with diabetes than for those without diabetes (mean difference 14·6 years). For the outcome of acute myocardial infarction (AMI), stroke, or death from any cause, diabetic men and women entered the high-risk category at ages 47·9 and 54·3 years respectively. When we used a broader definition of CVD that also included coronary or carotid revascularisation, the ages were 41·3 and 47·7 years for men and women with diabetes respectively.

Interpretation

Diabetes confers an equivalent risk to ageing 15 years. However, in general, younger people with diabetes (age 40 or younger) do not seem to be at high risk of CVD. Age should be taken into account in targeting of risk reduction in people with diabetes. "

Fluimucil Reduces Kidney Failure in Primary Angioplasty

Fluimucil Reduces Kidney Failure in Primary Angioplasty - CME Teaching Brief - MedPage Today: "MILAN, June 28 � The potent antioxidant Fluimucil (N-acetylcysteine) may prevent contrast-medium-induced nephropathy and preserve kidney function in patients who undergo primary angioplasty after a heart attack.
Moreover, the benefit of Fluimucil appears to be dose dependent, with the rate of death, acute renal failure requiring temporary dialysis or mechanical ventilation only 5% in patients randomized to high-dose Fluimucil, versus 7% in those who received a standard dose and 18% in controls (P=0.002), according to a report in the June 29 issue of New England Journal of Medicine. /.../"

Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke.

Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke. A Scientific Statement From the American Heart Association Council on Cardiovascular Nursing and Stroke Council -- Moser et al., 10.1161/CIRCULATIONAHA.106.176040:
"Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research."

Preventing Cardiovascular Disease and Diabetes

Preventing Cardiovascular Disease and Diabetes: A Call to Action From the American Diabetes Association and the American Heart Association -- Eckel et al. 113 (25): 2943 -- Circulation: "Excess body weight has become a major public health problem in the U.S., with nearly two-thirds of adults either overweight or obese. The steady gain in the prevalence of obesity over the last 25 years has affected our entire population—no racial or ethnic group, no region of the country, and no socioeconomic group has been spared. Perhaps most worrisome is the observation that the rise in the rate of obesity has been greatest in children and minorities, which suggests that future generations of Americans, and our fastest growing populations, may bear the ultimate burden of this condition. /.../"

Working Conditions and Angina Pectoris Symptoms

Associations Between Working Conditions and Angina Pectoris Symptoms Among Employed Women -- Lallukka et al. 68 (2): 348 -- Psychosomatic Medicine:
Reccommended byMarcelo Gustavo Colominas [mgcolominas@hotmail.com]
"Objective: This study aimed to examine whether psychosocial working conditions are associated with angina pectoris (AP) symptoms in women.
Methods: Data were derived from postal questionnaires filled in by 40- to 60-year-old women employed by the City of Helsinki, Finland, in 2000 to 2002 (n = 7093, response rate 67%). AP symptoms were measured by the Rose Questionnaire. Logistic regression analyses were carried out to examine AP symptoms as outcome. Independent variables consisted of Karasek’s job demands and job control, work fatigue, working overtime, work-related mental and physical strain, the work–home interface, and social support, adjusted for age. Confounding effects of socioeconomic status, health behaviors (smoking, binge drinking, body mass index), and menopause were also examined. Pregnant women were excluded.
Results: AP symptoms were reported by 6% of participants. Work fatigue was strongly associated with AP. In addition, working overtime, low job control, and high physical strain at work were associated with AP. The associations between psychosocial working conditions and AP symptoms were unaffected by health behaviors, socioeconomic status, or menopause.
Conclusions: Working conditions were associated with the AP symptoms identified by the Rose Questionnaire. Longitudinal studies are needed to disentangle the causal relationships, i.e., whether psychosocial stress is a true risk factor/cause of angina symptoms and cardiovascular disease among women. "

Very elderly may not benefit from low BP

Very elderly may not benefit from low BP:

Very elderly may not benefit from low BP

Low systolic blood pressure (BP) increases the risk of death among the very elderly, an epidemiological study suggests.

Research into the links between BP, death, and cardiovascular disease in old people have provided conflicting information, say the Finnish researchers.

In an attempt to clarify the matter, they conducted a population-based prospective study among 521 people (79% women) aged 85 years and above living in Vantaa, an industrial city in Southern Finland.

Mean systolic BP in the group was 149 mmHg and mean diastolic pressure was 82 mmHg. Just over half of patients (n=263) were taking BP-lowering medications, of whom 40.3% were taking a diuretic, 10.6% a calcium channel blocker, 9.4% a beta blocker, and 2.5% an ACE inhibitor.

Women were more likely to have previously diagnosed hypertension than men (27.7% vs 18.2%) and also more likely to use antihypertensive drugs (52.6% vs 42.7%).

During follow-up of up to 9 years (mean=3.5 years), 479 participants - 86.6% of the group - died. Multivariate analysis showed that death was linked to smoking (hazard ratio [HR]=1.97), functional status (HR=0.56), cancer (HR=1.42), dementia (HR=1.47), stroke (HR=1.80), and systolic BP of less than 140 mmHg (HR=1.35).

Interestingly, there was a tendency towards lower mortality among individuals with a systolic BP of 160 mmHg or greater. Other factors such as diastolic BP, a history of hypertension, and use of BP-lowering medication were not related to mortality, however.

Sari Rastas (Lohja Hospital) and colleagues report that the effect of lower systolic BP on mortality was particularly evident in patients without cancer, dementia, or a history of stroke.

Writing in the Journal of the American Geriatric Society, they conclude: "It is possible that the very old represent a select group of individuals, and the results from clinical trials including younger participants should be applied cautiously and individually in the very old."

Diet and Lifestyle Recommendations Revision 2006. AHA.

Abstract--Improving diet and lifestyle is a critical component of the American Heart Association’s strategy for cardiovascular disease risk reduction in the general population. This document presents recommendations designed to meet this objective. Specific goals are to consume an overall healthy diet; aim for a healthy body weight; aim for recommended levels of low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides; aim for normal blood pressure; aim for a normal blood glucose level; be physically active; and avoid use of and exposure to tobacco products. The recommendations are to balance caloric intake and physical activity to achieve and maintain a healthy body weight; consume a diet rich in vegetables and fruits; choose whole-grain, high-fiber foods; consume fish, especially oily fish, at least twice a week; limit intake of saturated fat to <7%>trans fat to <1%> to <300> fat-free (skim) or low-fat (1% fat) dairy products and minimize intake of partially hydrogenated fats; minimize intake of beverages and foods with added sugars; choose and prepare foods with little or no salt; if you consume alcohol, do so in moderation; and when you eat food prepared outside of the home, follow these Diet and Lifestyle Recommendations. By adhering to these diet and lifestyle recommendations, Americans can substantially reduce their risk of developing cardiovascular disease, which remains the leading cause of morbidity and mortality in the United States.

Primary Prevention of Ischemic Stroke

This guideline provides an overview of the evidence on various established and potential stroke risk factors and provides recommendations for the reduction of stroke risk.

Methods— Writing group members were nominated by the committee chair on the basis of each writer’s previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee. The writers used systematic literature reviews (covering the time period since the last review published in 2001 up to January 2005), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate recommendations based on standard American Heart Association criteria. All members of the writing group had numerous opportunities to comment in writing on the recommendations and approved the final version of this document. The guideline underwent extensive peer review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

Results— Schemes for assessing a person’s risk of a first stroke were evaluated. Risk factors or risk markers for a first stroke were classified according to their potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented or less well documented). Nonmodifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic factors. Well-documented and modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, alcohol abuse, drug abuse, oral contraceptive use, sleep-disordered breathing, migraine headache, hyperhomocysteinemia, elevated lipoprotein(a), elevated lipoprotein-associated phospholipase, hypercoagulability, inflammation, and infection. Data on the use of aspirin for primary stroke prevention are reviewed.

Conclusion— Extensive evidence is available identifying a variety of specific factors that increase the risk of a first stroke and providing strategies for reducing that risk.

AHA/ACC Guidelines Update for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease

Since the 2001 update of the American Heart Association (AHA)/American College of Cardiology (ACC) consensus statement on secondary prevention (1), important evidence from clinical trials has emerged that further supports and broadens the merits of aggressive risk-reduction therapies for patients with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease. This growing body of evidence confirms that aggressive comprehensive risk factor management improves survival, reduces recurrent events and the need for interventional procedures, and improves quality of life for these patients./.../

ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease

During the past 2 decades, major advances have occurred in diagnostic techniques, the understanding of natural history, and interventional cardiology and surgical procedures for patients with valvular heart disease. These advances have resulted in enhanced diagnosis, more scientific selection of patients for surgery or catheter-based intervention versus medical management, and increased survival of patients with these disorders. The information base from which to make clinical management decisions has greatly expanded in recent years, yet in many situations, management issues remain controversial or uncertain. Unlike many other forms of cardiovascular disease, there is a scarcity of large-scale multicenter trials addressing the diagnosis and treatment of patients with valvular disease from which to derive definitive conclusions, and the information available in the literature represents primarily the experiences reported by single institutions in relatively small numbers of patients./.../

Predition of CHD: Diabetes & Albuminuria

Participants of the Strong Heart Study were examined initially in 1989-1991 and were monitored with additional examinations and mortality and morbidity surveillance. CHD outcome data through December 2001 showed that age, gender, total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein cholesterol, smoking, diabetes, hypertension, and albuminuria were significant CHD risk factors. Hazard ratios for ages 65 to 75 years, hypertension, LDL cholesterol ≥160 mg/dL, diabetes, and macroalbuminuria were 2.58, 2.01, 2.44, 1.66, and 2.11 in men and 2.03, 1.69, 2.17, 2.26, and 2.69 in women, compared with ages 45 to 54 years, normal blood pressure, LDL cholesterol <100 mg/dL, no diabetes, and no albuminuria. Prediction equations for CHD and a risk calculator were derived by gender with the use of Cox proportional hazards model and the significant risk factors. The equations provided good discrimination ability, as indicated by a c statistic of 0.70 for men and 0.73 for women. Results from bootstrapping methods indicated good internal validation and calibration.

Conclusions--A "risk calculator" has been developed and placed on the Strong Heart Study Web site, which provides predicted risk of CHD in 10 years with input of these risk factors. This may be valuable for diverse populations with high rates of diabetes and albuminuria.

Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack

The aim of this new statement is to provide comprehensive and timely evidence-based recommendations on the prevention of ischemic stroke among survivors of ischemic stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches for atherosclerotic disease, antithrombotic treatments for cardioembolism, and the use of antiplatelet agents for noncardioembolic stroke. Further recommendations are provided for the prevention of recurrent stroke in a variety of other specific circumstances, including arterial dissections; patent foramen ovale; hyperhomocysteinemia; hypercoagulable states; sickle cell disease; cerebral venous sinus thrombosis; stroke among women, particularly with regard to pregnancy and the use of postmenopausal hormones; the use of anticoagulation after cerebral hemorrhage; and special approaches for the implementation of guidelines and their use in high-risk populations. (Stroke. 2006;37:577-617.)/.../