Aspirin: Primary Prevention

American Journal of Cardiology:
(Recommended by Marcelo Gustavo Colominas [mgcolominas@hotmail.com]
"Until recently, 5 major studies have formed the basis for the use of aspirin (acetylsalicylic acid) in primary prevention of cardiovascular (CV) events. Despite these data, the role of aspirin in primary prevention has not been established firmly. Six randomized trials have evaluated the benefits of aspirin for the primary prevention of CV events: the British Doctors’ Trial, the Physicians’ Health Study, the Thrombosis Prevention Trial, the Hypertension Optimal Treatment study, the Primary Prevention Project, and the Women’s Health Study. The combined sample consists of 47,293 subjects on aspirin and 45,580 not on aspirin or placebo. A meta-analysis of these 6 trials assessed 6 CV end points: total coronary heart disease (CHD), nonfatal myocardial infarction (MI), total CV events, stroke, CV mortality, and all-cause mortality. No covariate adjustment was performed and appropriate tests for treatment effect, heterogeneity, and study size bias were applied. Using odds ratios and confidence intervals, the meta-analysis suggested superiority of aspirin for total CHD, nonfatal MI, and total CV events (p ≤0.001 in each case), with a nonsignificant trend (0.07 <>0.05). Given the study size and cohort, aspirin decreased the risk of CV events in this large patient sample. In conclusion, primary prevention with aspirin decreased the risk of total CHD, nonfatal MI, and total CV events, but there were no significant differences in the incidences of stroke or CV mortality."

Ulcer Risk From Aspirin Use May Outweigh Cardiac Benefits - CME Teaching Brief® - MedPage Today

Ulcer Risk From Aspirin Use May Outweigh Cardiac Benefits - CME Teaching Brief® - MedPage Today: "BOSTON, Sept.20 -- Low-dose aspirin for cardioprotection may cause one extra case per year of gastrointestinal ulcers in every 50 aspirin users, but only in certain high-risk groups, researchers reported.
The study, reported in the Sept. 20 issue of BMC Medicine, is intended as a physician alert, because as the researchers noted, it was not possible to weigh gastrointestinal complications, such as bleeding or perforated ulcers, against actual cardiovascular risks.
For men older than 70 with a history of peptic ulcer, the excess risk was estimated at 20 extra cases per 1,000 aspirin users per year, said Sonia Hernández-Diaz, M.D., of the Harvard School of Public Health here and Luis A.G. Rodriguez of Centro Español de Investigación Farmacoepidemiológica in Madrid. "

Update of the Clinical Competence Statement on Invasive Electrophysiology Studies, Catheter Ablation, and Cardioversion

American College of Cardiology/American Heart Association 2006 Update of the Clinical Competence Statement on Invasive Electrophysiology Studies, Catheter Ablation, and Cardioversion. A Report of the American College of Cardiology/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training. Developed in Collaboration With the Heart Rhythm Society
WRITING COMMITTEE MEMBERS, Cynthia M. Tracy, Masood Akhtar, John P. DiMarco, Douglas L. Packer, Howard H. Weitz, TASK FORCE MEMBERS, Mark A. Creager, David R. Holmes, Jr, Geno Merli, George P. Rodgers, ynthia M. Tracy, and Howard H. Weitz
Circulation published 20 September 2006,
10.1161/CIRCULATIONAHA.106.178893
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.106.178893v1?papetoc

Cardiac Cell Therapy -- Mixed Results from Mixed Cells

NEJM -- Cardiac Cell Therapy -- Mixed Results from Mixed Cells: "Despite substantial advances in treatment, ischemic cardiac injury and the ventricular dysfunction it can provoke remain major causes of morbidity and mortality throughout the world. The endogenous regenerative capacity of the heart appears inadequate to repair injured myocardium, leading to the cumulative loss of cardiomyocytes over the lifetime of a patient. This may contribute to the prevalence of heart failure as a diagnosis at hospital admission — particularly among the elderly.
For these reasons, experiments in animals suggesting that the transfer of cells derived from bone marrow (BMC) could dramatically improve cardiac function after infarction through regeneration of the myocardium1 or neovascularization2 generated tremendous excitement. In addition, they stimulated clinical studies suggesting that this approach is feasible, safe, and potentially effective in humans.3,4 In this issue of the Journal, Schächinger et al.,5 Assmus et al.,6 and Lunde et al.7 — following authors of other recent reports8,9 — provide a realistic perspective on this approach while leaving room for cautious optimism and underscoring the need for further study (Table 1). "

Prostate Cancer Therapy Linked to Diabetes and Heart Disease - CME Teaching Brief® - MedPage Today

Prostate Cancer Therapy Linked to Diabetes and Heart Disease - CME Teaching Brief® - MedPage Today: "BOSTON, Sept. 19 -- Androgen deprivation with a GnRH agonist for local or regional prostate cancer is associated with an increased risk of diabetes, coronary heart disease, heart attack, and sudden cardiac death, according to researchers here.
An observational analysis of more than 73,000 men with local or regional disease showed that treatment with a gonadotropin-releasing hormone (GnRH) agonist increases the risk of diabetes by 44%, with smaller increases in the risks of cardiovascular disease, according to Nancy Keating, M.D., of Harvard Medical School and Brigham and Women's Hospital.
As they make treatment decisions about locoregional disease, 'patients and physicians need to be aware of the elevated risk' of a GnRH agonist, Dr. Keating said. "

Physiological Assessment of Coronary Artery Disease in the Cardiac Catheterization Laboratory:

Physiological Assessment of Coronary Artery Disease in the Cardiac Catheterization Laboratory: A Scientific Statement From the American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology -- Kern et al. 114 (12): 1321 -- Circulation: "With advances in technology, the physiological assessment of coronary artery disease in patients in the catheterization laboratory has become increasingly important in both clinical and research applications, but this assessment has evolved without standard nomenclature or techniques of data acquisition and measurement. Some questions regarding the interpretation, application, and outcome related to the results also remain unanswered. Accordingly, this consensus statement was designed to provide the background and evidence about physiological measurements and to describe standard methods for data acquisition and interpretation. The most common uses and support data from numerous clinical studies for the physiological assessment of coronary artery disease in the cardiac catheterization laboratory are reviewed. The goal of this statement is to provide a logical approach to the use of coronary physiological measurements in the catheterization lab to assist both clinicians and investigators in improving patient care."

CT Angiography Warrants Paradigm Shift in Nuclear Cardiology

ASNC: CT Angiography Warrants Paradigm Shift in Nuclear Cardiology - CME Teaching Brief® - MedPage Today: "'The first test in the future of the evaluation of the patient, be it symptomatic or asymptomatic, will be a CTA rather than a stress test because it's more accurate, provides more information, and avoids patients having unnecessary cardiac catheterizations which follows in a substantial number of patients who undergo stress testing because of the high false positive rate,'"

Green Tea Found to Cut All-Cause and Cardiovascular Mortality - CME Teaching Brief® - MedPage Today

Green Tea Found to Cut All-Cause and Cardiovascular Mortality - CME Teaching Brief® - MedPage Today: "SENDAI, Japan, Sept. 12 -- Cup after cup of green tea earned a high grade for reducing all-cause and cardiovascular mortality in a study here, but cancer mortality drew a blank.
Compared with participants who consumed less than one cup of green tea a day, those who drank five or more cups had a risk of all-cause mortality that was 16% lower during 11 years of follow-up and 26% lower for cardiovascular deaths during seven years of follow-up, according to a report in the Sept. 13 issue of JAMA."

Would You Still Recommend Drug-Eluting Stents? -

Survey: Would You Still Recommend Drug-Eluting Stents? - CME Teaching Brief® - MedPage Today: "Drug-eluting stents essentially eliminated short-term restenosis as a complication of coronary angioplasty, but suddenly the coated devices have come under a cloud for possible late-term risks.
Cardiologists attending the European Society of Cardiology/World Congress of Cardiology in Barcelona last week were shocked by meta-analyses data that raised serious questions about the long-term safety of the devices.
This Medpage Today survey asks for your opinion about whether you still have confidence in the elective use of drug-eluting stents. "
Additional Stent Coverage from ESC:
Meta-Analyses Find Increased Death and MI with Cypher Stent
Real World Trial Confirms Drug-Eluting Stents Better in Small Vessels
Investigational Drug-Eluting Stent Superior to Taxus
Drug-Eluting Stent Debate Develops Fever Pitch http://www.medpagetoday.com/2005MeetingCoverage/2005ESCCongress/dh/4075

Promoting Physical Activity in Children and Youth: A Leadership Role for Schools: A Scientific Statement From the American Heart Association Council o

Promoting Physical Activity in Children and Youth: A Leadership Role for Schools: A Scientific Statement From the American Heart Association Council on Nutrition, Physical Activity, and Metabolism (Physical Activity Committee) in Collaboration With the Councils on Cardiovascular Disease in the Young and Cardiovascular Nursing -- Pate et al. 114 (11): 1214 -- Circulation: "Schools have played a central role in the provision of physical activity to American children and youth for more than a century. Physical education (PE) has been an institution in American schools since the late 1800s,1 and school sports have been a growing component of the educational enterprise since the early 1900s. Traditionally, students have engaged in physical activity during recess breaks in the school day and by walking or riding bicycles to and from school. However, as we move into the 21st century, alarming health trends are emerging, suggesting that schools need to renew and expand their role in providing and promoting physical activity for our nation’s young people.

Over the past 20 years, obesity rates in US children and youth have skyrocketed. Among children ages 6 to 11, 15.8% are overweight (≥95th percentile body mass index [BMI] for age) and 31.2% are overweight or at risk for overweight (≥85th percentile BMI for age).2 Among adolescents ages 12 to 19, 16.1% are overweight (≥95th"

Atrial fibrillation ablation: State of the art

Atrial fibrillation ablation: State of the art: "Atrial fibrillation (AF) is a common and recurrent arrhythmia that can result in significant morbidity and mortality [1]. Pharmacological therapy used to control rate or to achieve and maintain normal sinus rhythm is of limited efficacy, and can result in serious side effects including proarrhythmia and death [2-4]. Although ablation of the AV node and implantation of a permanent pacemaker can provide effective rate control, this loss of atrioventricular synchrony renders the patient dependent on the pacemaker and will require lifelong anticoagulation therapy. "

Framingham Gene Hunt

DATABASE:
(from: http://www.sciencemag.org/content/vol313/issue5792/netwatch.dtl)
The race to find the genes behind common ailments is heating up as many research groups scan patients' entire genomes for markers linked to disease. When it opens later this month, the Genomic Medicine Database (GMED) from Boston University (BU) will showcase such results from 1320 participants in the famed Framingham Heart Study, which has followed the health of a small Massachusetts town for 50 years. You can peruse the chromosomes for possible associations between about 10 traits--such as hypertension and high cholesterol levels--and 100,000 genetic markers, known as SNPs. Click to zoom in on the genes near a SNP. The BU team is posting data before publication so that other researchers can quickly seek to replicate the findings, says GMED co-curator Marc Lenburg. "Our hope is that others will follow our lead" and share unpublished data, he says.
gmed.bu.edu

Treatment of elderly patients with minor ischaemic attacks is inadequate

Treatment of elderly patients with minor ischaemic attacks is inadequate -- 333 (7567): 0 -- BMJ: "Patients aged 80 or older with transient ischaemic attack or minor ischaemic stroke have an increased incidence of symptomatic carotid stenosis but are substantially underinvestigated and undertreated. Fairhead and Rothwell (p 525) compared the management of a total of over 680 000 patients undergoing carotid imaging either in a vascular study (in which all patients were investigated as per published guidelines) or in routine clinical practice in secondary care services. In the group aged 80, rates of carotid imaging, diagnosis of > 50% symptomatic stenosis, and carotid endarterectomy were substantially lower in routine clinical practice. "

Drug-Eluting Stent Debate

ESC/WCC: Drug-Eluting Stent Debate Develops Fever Pitch - CME Teaching Brief® - MedPage Today: "BARCELONA, Spain, Sept 5 -- The long-term safety of drug-eluting stents suddenly eclipsed all other concerns this week at the world's largest gathering of cardiologists.
Many of the more than 25,000 cardiologists meeting here are shaking their heads in disbelief at the meta-analysis data that raised serious questions about the long-term safety of the coated devices.
The two meta-analyses reported Sunday at the Europeans Society of Cardiology/World Congress of Cardiology have highlighted 'the dark side of drug-eluting stents,' as Robert Harrington, M.D., of Duke put it.
Dr. Harrington's 'dark-side' is the finding that first generation drug-eluting stents are associated with an increased risk of late stent thrombosis, an increased cardiac mortality, an increased risk of myocardial infarction, and an increased risk of all cause mortality.
But even as every hallway buzzed with the grim potentialities, should the meta-analyses be borne out by prospective randomized studies, a new positive report emerged about the drug-eluting stents. This was a report of an investigational device showing that that it was superior to one of the two already approved stents.
That device is just one of a handful of second- and third- generation drug-eluting stents wending their way through the approval process.
Weighing the darker and the brighter sides of drug eluting stents has been the focus of heated discussions here, inside and outside the sessions.
An estimated six million of the first generation drug eluting stents-Cypher, a sirolimus-eluting stent, and Taxus, which elutes paclitaxel-have been implanted.
The meta-analyses reported here found that Cypher had significant risks compared with bare metal stents" /.../

BP-lowering effects of aliskiren are additive to amlodipine, persist after withdrawal

BP-lowering effects of aliskiren are additive to amlodipine, persist after withdrawal: ", Spain - A pooled data analysis of antihypertensive treatment with the still-investigational oral renin inhibitor aliskiren (Rasilez, Novartis) in more than 8000 patients suggest that the drug reduces blood pressure (BP) effectively regardless of age or gender, is well tolerated, and appears to be additive to most other antihypertensive agents, with the exception of angiotensin receptor blockers [1].
Dr Matthew R Weir (University of Maryland School of Medicine, Baltimore) presented the pooled analysis of results to date with this new antihypertensive agent.
'Obviously, the hope is that the mechanism of action will provide an incremental opportunity in a sense to tame the renin angiotensin system and better facilitate risk reduction with regard to cardiovascular and kidney disease progression,' he concluded. "

How Sudden Is Sudden Cardiac Death

How Sudden Is Sudden Cardiac Death? -- Müller et al., 10.1161/CIRCULATIONAHA.106.616318 -- Circulation: "Background--Out-of-hospital sudden cardiac death (SCD) is a frequent cause of death. Survival rates remain low despite increasing efforts in medical care. Better understanding of the circumstances of SCD could be helpful in developing preventive measures and facilitating proper reactions to such a pending event.
Methods and Results--Information on cases of out-of-hospital SCD was collected in the Berlin, Germany, emergency medical system via a questionnaire. Bystander interviews were performed by the emergency physician on scene immediately after declaration of death or return of circulation. Of 5831 rescue missions, 406 involved patients with presumed cardiac arrest. Sixty-six percent had a known cardiac disease. In 72%, the arrest occurred at home, and in 67%, it occurred in the presence of an eyewitness. Information on symptoms immediately preceding the arrest was available in 80% (n=323) of all 406 patients and in 274 of those with witnessed arrest. Symptoms were identical in the 2 groups. Typical angina was present for a median of 120 minutes in 25% of the 274 patients with witnessed arrest and in 33% with a symptom duration of less than 1 hour.
Conclusions--SCD occurs most often at home in the presence of relatives and after a longer period of typical warning symptoms. Although the much-hailed use of public access defibrillation is supported by several studies, the present results raise the question of whether educational measures and targeted educational programs tailored for patients at risk and their relatives should have a higher priority.

Key words: death, sudden • resuscitation • myocardial infarction • defibrillation "

EUROACTION: Cardiologists should champion prevention as well as cure

EUROACTION: Cardiologists should champion prevention as well as cure:

"Sep 3, 2006
Lisa Nainggolan
Barcelona, Spain - Results from the largest-ever European-wide preventive cardiology project, EUROACTION, show that a nurse-led multidisciplinary team approach, together with the support and involvement of a patient's family, can generate significant lifestyle improvements and risk-factor reductions in coronary patients and those at risk of developing cardiovascular disease.
The message for cardiologists, says lead investigator Dr David Wood (Imperial College, London, UK), "is that you need to match your PCIs with a preventive program." Wood presented the results of EUROACTION today at the hotline session during the World Congress of Cardiology 2006.
"What we now know is that there has been a collective failure of medical practice to address lifestyle and risk-factor targets. We have clearly demonstrated that this nurse-led program works in a wide range of European countries, in ordinary general hospitals and GP surgeries," he told heartwire. "On the basis of these impressive results, we are going to talk to the national cardiology societies to discuss how we can implement this," he added.
Dr Thomas A Pearson (University of Rochester, NY), who was the discussant for the study, said EUROACTION "will become the benchmark to improve upon. It joins a list of landmark studies of implementation of what we already know from intervention studies."
Eight countries and almost 9000 patients
EUROACTION spanned eight countries—Denmark, France, Italy, the Netherlands, Poland, Spain, Sweden, and the UK—and 24 hospital and general practice centers, in a cluster randomized trial. It addressed the cardiovascular health of more than 8500 patients—half of whom already had coronary heart disease (recruited in hospitals) and half of whom were deemed high risk (from GP practices)—and compared outcomes with "usual-care" patients.
Unusually, partners were also included, something Pearson said was "particularly novel." The EUROACTION nurses performed complete lifestyle and risk-factor assessment of patients and partners and then supported them in making lifestyle changes. Advice was issued according to European preventive cardiology guidelines published in 2003 [1].
In hospitals, this involved regular one-to-one meetings as well as group workshops with members of a multidisciplinary team (including dieticians, physiotherapists, and cardiologists). For the high-risk patients, advice was given by nurses and GPs alone.
Significant improvements were observed after one year, not only in the EUROACTION patients but also in their partners, compared with patients treated by usual care and their partners, across a number of key lifestyle and risk factors.
Significantly more patients in both groups met physical-activity targets, reduced weight, reached blood-pressure goals, and improved use of cardioprotective therapies compared with usual-care patients.
For diet, significant improvements were seen in all three areas—increasing consumption of fruits and vegetables, eating more oily fish, and reducing saturated fat intake—in the coronary patients. For the high-risk patients, only fruit and vegetable intake was significantly improved compared with usual-care patients.
Hospital patients achieved significant reductions in waist circumference, but the GP patients did not, compared with usual care. For LDL-cholesterol levels, the opposite was true—the high-risk GP patients achieved significant reductions but the hospital coronary patients did not, compared with usual-care patients.
Smoking cessation was not significantly improved in either group compared with usual-care patients, but the hospital patients "came quite close with a p-value of 0.06," Wood told heartwire.
Even though significance was not achieved in some key areas, the trends were all in the right direction, he noted, adding that the study was underpowered.
Pearson observed that this "is a difficult kind of research to do. It's a different kettle of fish from efficacy studies."
The partners varied in their abilities to achieve targets but came out significantly better than the partners of the usual-care patients for fruit and vegetable consumption and physical activity.
Cost-effectiveness analysis planned
Wood also revealed that EUROACTION included a cost-effective analysis, with results expected in six months.
"This unique project has shown we can raise standards of preventive cardiology care for coronary and high-risk metabolic patients and their families in everyday care," he commented.
European Society of Cardiology president Dr Michal Tendera said: "It is now up to us to follow the EUROACTION example and work to establish similar prevention programs in every general hospital and GP practice so that patients across Europe can achieve the best possible care."
Source
De Backer G, Ambrosioni E, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2003; 24 (17): 1601-1610.
Related link
EuroAction Demonstration Project in Preventive Cardiology

The Worsening Landscape of Cardiovascular Disease

Cardiosource: "Title:
The Worsening Landscape of Cardiovascular Disease
Author: Suzanne Hughes, MSN, RN
Author Disclosure: Johnson & Johnson
Merck advisory board, AstraZeneca speakers' bureau, Guidant Corporation consultant

Author: Alfred A. Bove, M.D., Ph.D., F.A.C.C.
Author Disclosure: Stock Options, Consulting Fees: Insight Telehealth.
Date: 8/30/2006

While we have witnessed a decline in the number of deaths from cardiovascular disease (CVD) in the last 20-30 years, the trends for the future look much less bright. For some years, the increasing incidence of obesity was considered to be a consequence of prosperity, and obesity was even debated as an acceptable lifestyle. However, as the epidemiology of obesity became more apparent and the incidence began to reach astronomic levels, the consequences of obesity with its accompanying metabolic derangements, sometimes in the form of type 2 diabetes, or in the form of the metabolic syndrome, and now being understood as an obesity-induced rise in insulin resistance, have become more apparent./.../
"

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

Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Council on Stroke: Co-Sponsored by the Council on Cardiovascular Radiology and Intervention: The American Academy of Neurology affirms the value of this guideline. -- Sacco et al. 37 (2): 577 -- Stroke: "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.)

"

The Economic Burden of Angina in Women With Suspected Ischemic Heart Disease

The Economic Burden of Angina in Women With Suspected Ischemic Heart Disease: Results From the National Institutes of Health-National Heart, Lung, and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation -- Shaw et al. 114 (9): 894 -- Circulation:
"Background— Coronary angiography is one of the most frequently performed procedures in women; however, nonobstructive (ie, <50% style="font-weight: bold;">Methods and Results— A total of 883 women referred for coronary angiography were prospectively enrolled in the National Institutes of Health–National Heart, Lung, and Blood Institute–sponsored Women’s Ischemia Syndrome Evaluation (WISE). Cardiovascular prognosis and cost data were collected. Direct (hospitalizations, office visits, procedures, and drug utilization) and indirect (out-of-pocket, lost productivity, and travel) costs were estimated through 5 years of follow-up. Among 883 women, 62%, 17%, 11%, and 10% had nonobstructive and 1-vessel, 2-vessel, and 3-vessel CAD, respectively. Five-year cardiovascular death or myocardial infarction rates ranged from 4% to 38% for women with nonobstructive to 3-vessel CAD (P<0.0001).> 12% for 1-vessel to 3-vessel CAD; P=0.001). For women with nonobstructive CAD, average lifetime cost estimates were $767 288 (95% CI, $708 480 to $826 097) and ranged from $1 001 493 to $1 051 302 for women with 1-vessel to 3-vessel CAD (P=0.0003).
Conclusions— Symptom-driven care is costly even for women with nonobstructive CAD. Our lifetime estimates for costs of cardiovascular care identify a significant subset of women who are unaccounted for within current estimates of the economic burden of coronary heart disease. "

Fixed-dose unfractionated heparin, given subcutaneously, as effective as low-molecular-weight heparin for VTE

Fixed-dose unfractionated heparin, given subcutaneously, as effective as low-molecular-weight heparin for VTE:
"August 22, 2006 Michael O'Riordan
Hamilton, ON - Fixed-dose subcutaneous unfractionated heparin, without monitoring of activated partial thromboplastin time (APTT), is as effective as fixed-dose low-molecular-weight heparin in patients with acute venous thromboembolism, according to the results of a new study [1]. In addition, the administration of unfractionated heparin was safe, with no increased bleeding risks, and could be considered an alternative for outpatient use, say investigators.

'We're pleased with the results, and we feel the findings are consistent with our expectations, that there would not be a difference between outcomes when you use unfractionated heparin and low-molecular-weight heparin in the same way,' lead investigator Dr Clive Kearon (McMaster University, Hamilton, ON) told heartwire. 'I think the data will be of interest to the medical community because it departs from what has been usual practice with a drug that has been in use clinically now for over 50 years.'

The results of the study are published in the August 23, 2006 issue of the Journal of the American Medical Association."

NSAIDs During First Trimester Linked to Congenital Defects

NSAIDs During First Trimester Linked to Congenital Defects - CME Teaching Brief® - MedPage Today: "MONTREAL, Aug. 24 -- Women who take NSAIDs during the first trimester have a greater risk of having babies with congenital anomalies, particularly cardiac septal defects, researchers here reported.

According to a population-based, nested case-control study of 36,387 pregnant women in Quebec province, women who filled NSAID prescriptions early in pregnancy had more than twice the risk for any congenital defect, reported Anick Berard, Ph.D., of Sainte-Justine Hospital, and colleagues, in the September issue of Birth Defects Research Part B.

Women who took first-trimester NSAIDs also and more than three times the risk of anomalies related to cardiac septal closure, mainly ventricular and atrial septal defects, the investigators found.

The effect of NSAID exposure on the fetus toward the end of pregnancy, causing premature closure of the ductus arteriosus and patent ductus arteriosus, are well documented, but the risks related to NSAID use in early pregnancy are less well defined, they said."/.../

New Guideline for Screening Apparently Healthy Individuals to Prevent a Heart Attack

The American Journal of Cardiology : From Vulnerable Plaque to Vulnerable Patient—Part III: Executive Summary of the Screening for Heart Attack Prevention and Education (SHAPE) Task Force Report:

Screening for early-stage asymptomatic cancers (eg, cancers of breast and colon) to prevent late-stage malignancies has been widely accepted. However, although atherosclerotic cardiovascular disease (eg, heart attack and stroke) accounts for more death and disability than all cancers combined, there are no national screening guidelines for asymptomatic (subclinical) atherosclerosis, and there is no government- or healthcare-sponsored reimbursement for atherosclerosis screening. Part I and Part II of this consensus statement elaborated on new discoveries in the field of atherosclerosis that led to the concept of the “vulnerable patient.” These landmark discoveries, along with new diagnostic and therapeutic options, have set the stage for the next step: translation of this knowledge into a new practice of preventive cardiology. The identification and treatment of the vulnerable patient are the focuses of this consensus statement.

In this report, the Screening for Heart Attack Prevention and Education (SHAPE) Task Force presents a new practice guideline for cardiovascular screening in the asymptomatic at-risk population. In summary, the SHAPE Guideline calls for noninvasive screening of all asymptomatic men 45–75 years of age and asymptomatic women 55–75 years of age (except those defined as very low risk) to detect and treat those with subclinical atherosclerosis. A variety of screening tests are available, and the cost-effectiveness of their use in a comprehensive strategy must be validated. Some of these screening tests, such as measurement of coronary artery calcification by computed tomography scanning and carotid artery intima–media thickness and plaque by ultrasonography, have been available longer than others and are capable of providing direct evidence for the presence and extent of atherosclerosis. Both of these imaging methods provide prognostic information of proven value regarding the future risk of heart attack and stroke. Careful and responsible implementation of these tests as part of a comprehensive risk assessment and reduction approach is warranted and outlined by this report. Other tests for the detection of atherosclerosis and abnormal arterial structure and function, such as magnetic resonance imaging of the great arteries, studies of small and large artery stiffness, and assessment of systemic endothelial dysfunction, are emerging and must be further validated. The screening results (severity of subclinical arterial disease) combined with risk factor assessment are used for risk stratification to identify the vulnerable patient and initiate appropriate therapy. The higher the risk, the more vulnerable an individual is to a near-term adverse event. Because SHAPE Task Force reinforces existing guidelines for the screening and treatment of risk factors in younger populations.

Development and Validation of a Risk Score for Predicting Death in Chagas' Heart Disease

NEJM -- Development and Validation of a Risk Score for Predicting Death in Chagas' Heart Disease:
Anis Rassi, Jr., M.D., Ph.D., Anis Rassi, M.D., William C. Little, M.D., Sérgio S. Xavier, M.D., Ph.D., Sérgio G. Rassi, M.D., Alexandre G. Rassi, M.D., Gustavo G. Rassi, M.D., Alejandro Hasslocher-Moreno, M.D., Andrea S. Sousa, M.D., Ph.D., and Maurício I. Scanavacca, M.D., Ph.D.
"ABSTRACT
Background Chagas' disease is an important health problem in Latin America, and cardiac involvement is associated with substantial morbidity and mortality. We developed a model to predict the risk of death in patients with Chagas' heart disease.
Methods We retrospectively evaluated 424 outpatients from a regional Brazilian cohort. The association of potential risk factors with death was tested by Cox proportional-hazards analysis, and a risk score was created. The model was validated in 153 patients from a separate community hospital.
Results During a mean follow-up of 7.9 years, 130 patients in the development cohort died. Six independent prognostic factors were identified, and each was assigned a number of points proportional to its regression coefficient: New York Heart Association class III or IV (5 points), evidence of cardiomegaly on radiography (5 points), left ventricular systolic dysfunction on echocardiography (3 points), nonsustained ventricular tachycardia on 24-hour Holter monitoring (3 points), low QRS voltage on electrocardiography (2 points), and male sex (2 points). We calculated risk scores for each patient and defined three risk groups: low risk (0 to 6 points), intermediate risk (7 to 11 points), and high risk (12 to 20 points). In the development cohort, the 10-year mortality rates for these three groups were 10 percent, 44 percent, and 84 percent, respectively. In the validation cohort, the corresponding mortality rates were 9 percent, 37 percent, and 85 percent. The C statistic for the point system was 0.84 in the development cohort and 0.81 in the validation cohort.
Conclusions A simple risk score was developed to predict death in Chagas' heart disease and was validated in an independent cohort. "

Redefinition of Myocardial Infarction: Prospective Evaluation in the Community

Redefinition of Myocardial Infarction: Prospective Evaluation in the Community -- Roger et al. 114 (8): 790 -- Circulation: "Background— The 2000 European Society of Cardiology/American College of Cardiology definition for myocardial infarction (MI) combines ischemic symptoms, electrocardiographic changes, and troponin rather than creatine kinase levels. The use of troponins will increase the detection of MI by a magnitude to be quantified, and the clinical acceptance of the new definition is unknown.
Method and Results— Subjects presenting to an Olmsted County facility with a troponin T value 0.03 ng/mL between November 2002 and March 2005 were prospectively classified through the use of standardized MI criteria, relying on cardiac pain, Minnesota coding of the ECG, and troponin, creatine kinase, and its MB fraction measured simultaneously. Through the use of dynamic changes in troponin, 538 MIs were identified versus 327 with creatine kinase and 427 with only the MB fraction of creatine kinase. This represents a 74% (95% confidence interval [CI], 69% to 79%) increase above the number of MIs identified with creatine kinase and a 41% (95% CI, 37% to 46%) increase above the number identified with criteria including only its MB fraction. When relying on single values of troponin, increases in the number of MIs were always large but varied widely according to the threshold used for troponin. Cases meeting only troponin-based criteria were less likely to have electrocardiographic ST-segment elevation and had better survival than those identified with previous criteria. Clinician diagnoses mentioned MI in 42% (95% CI, 34% to 49%) of cases meeting only troponin-based criteria versus 74% (95% CI, 69% to 78%) for MIs meeting the previous criteria (P<0.001).
"

Ventricular arrhythmias AHA Guidelines

Several excellent guidelines already exist on treating patients who have ventricular arrhythmias (Table 1). The purpose of this document is to update and combine the previously published recommendations into one source approved by the major cardiology organizations in the United States and Europe. We have consciously attempted to create a streamlined document, not a textbook that would be useful specifically to locate recommendations on the evaluation and treatment of patients who have or may be at risk for ventricular arrhythmias. Thus, sections on epidemiology, mechanisms and substrates, and clinical presentations are brief, because there are no recommendations for those sections. For the other sections, the wording has been kept to a minimum, and clinical presentations have been confined to those aspects relevant to forming recommendations.

World Heart Day 2006: September 24

A healthy heart is vital for living life to the full, regardless of your age or gender. Controlling the major cardiovascular risk factors, by choosing a healthy diet, being physically active and by not smoking can prevent heart attacks and strokes and may help the heart to age more slowly. That's why this year's World Heart Day, under the theme "How Young is Your Heart?", will encourage people around the world to adopt a heart-healthy lifestyle to help maintain a young heart for life

BMI Fails as a Cardiovascular Risk Factor - CME Teaching Brief® - MedPage Today:

"BMI Fails as a Cardiovascular Risk Factor

By Judith Groch, Senior Writer, MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine.
August 18, 2006

MedPage Today Action Points

ROCHESTER, Minn., Aug. 18 -- Because body mass index (BMI) cannot discriminate between fat and lean mass, it cannot reliably predict the outcome for patients with coronary artery disease, according to researchers here.
In fact, in a meta-analysis of 40 studies, including 250,152 patients with established coronary artery disease, outcomes for cardiovascular and total mortality were better for overweight and mildly obese groups compared with normal-BMI patients, found a study reported in the Aug. 19 issue of The Lancet. Adjustment for confounding factors did not change the findings.
"Rather than proving that obesity is harmless, our data suggest that alternative methods might be needed to better characterize individuals who truly have excess fat, compared with those in whom BMI is raised because of preserved muscle mass," said Francisco Lopez-Jimenez, M.D., of the Mayo Clinic here, and colleagues.
The meta-analysis, with a mean follow-up of 3.8 years, included studies with sufficient information to allow the calculation of unadjusted and adjusted relative risks or studies that gave the actual risk estimate for each BMI group, said Dr. Lopez-Jimenez. Most data were collected in the late 1980s and 1990s.
Coronary artery disease was defined as history of percutaneous coronary intervention, coronary artery bypass graft, or myocardial infarction. BMI was used as a measure of obesity.

The findings were:

Patients with a low BMI) (<20) had a one-third increased relative risk (RR)
for total mortality (RR=1.37, 95% CI 1.32-1.43), and cardiovascular mortality
(RR 1.45, CI 1.16-1.81) compared with risks for normal-BMI patients who served
as the reference group.
Overweight patients (BMI 25-29.9) had the lowest
risk for total mortality (RR=0.87, CI 0.81-0·94) and cardiovascular mortality
(RR=0.88, CI 0.75-1.02).
Obese patients (BMI 30-35) had no increased risk
for total mortality (RR=0.93, CI 0.85-1.03) or cardiovascular mortality (RR
0.97, CI 0.82-1.15). However, obesity was associated with higher total mortality
specifically among patients with a history of coronary artery bypass surgery.
Severely obese patients (≥35) did not have an increase in total mortality
(RR 1.10, CI 0·87-1.41), but they had an almost 90% higher risk for
cardiovascular mortality (RR 1.88 CI, 1.05-3.34).

These findings, the researchers wrote, could be explained by the failure of BMI to discriminate between body fat and lean mass. The better outcomes for overweight people may be because they have more muscle than normal-weight people.
In addition, lower BMI values have been related to low lean body mass, and BMI might not adequately reflect adiposity, the authors wrote.
Also, they suggested, because low and normal BMI groups were almost consistently associated with a lower prevalence of established cardiovascular risk factors, these groups were less likely to receive effective secondary prevention therapies, such as exercise, a healthy diet, and treatment for other risk factors.
Finally, they said, extensive data have shown that central obesity poses a greater risk for cardiovascular disease than BMI.
Among the study's limitations, the researchers mentioned the lack of individual data and possible publication bias (papers suggesting no connection between BMI were not submitted or accepted). However, this bias was probably not a factor in their study, they said. Finally, and most important, they wrote, is the substantial heterogeneity of the results, making it difficult to detect small differences across studies.
From a clinical standpoint, the researchers said, a fundamental question is whether weight loss or maintaining a normal weight can decrease cardiovascular event in patients with coronary artery disease.
Because exercise and diet are the main components of a weight-loss program, it can be assumed that interventions for overweight patients with coronary disease will reduce cardiovascular outcomes, including mortality. However, Dr. Lopez-Jimenez said, no randomized controlled trials have yet been undertaken to address this relationship.
Additional studies with different methods are needed, he said, particularly those with different weight-loss strategies and those that use other methods of identifying obesity. These might include body composition techniques to measure body fat and distribution that also account for lean mass.
Pending further information, patients with coronary artery disease who are truly obese should be encouraged to pursue interventions that reduce body fat, the researchers said.
In an accompanying comment in the same Lancet issue, Maria G. Franzosi, M.D., of the Istituto Mario Negri in Milan, Italy, asked the question: "Is the debate on the relation between BMI and mortality over?" Her answer: "The meta-analysis does not provide new information, but some useful implications can be drawn from it. BMI can definitely be left aside as a clinical and epidemiological measure of cardiovascular risk for both primary and secondary prevention."
She explained that the "BMI is not a good measure of visceral fat, the key determinant of metabolic abnormalities that contribute to cardiovascular risk. Estimates of the effect of obesity based on BMI are therefore too low."
She also pointed out that "the better outcomes in overweight and mildly obese people might be because these individuals have a greater lean mass than normal weight and severely obese people. An increased lean mass is related to physical activity and independently contributes to reduced coronary artery disease risk."
The contribution of body fat to cardiovascular risk requires integrated basic research to which retrospective analyses of existing databases cannot add relevant insights, she wrote. However, she emphasized, "Uncertainty about the best index of obesity should not translate into uncertainty about the need for a prevention policy against excess bodyweight, which must be strongly supported."

Coronary heart disease: from a disease of middle-aged men in the late 1970s to a disease of elderly women in the 2000s

Coronary heart disease: from a disease of middle-aged men in the late 1970s to a disease of elderly women in the 2000s -- Kattainen et al. 27 (3): 296 -- European Heart Journal: "Aims To analyse secular changes in the prevalence of coronary heart disease (CHD) and to assess changes in the burden of CHD at population level.

Methods and results Data were used from two large cross-sectional health examination surveys representing the entire Finnish adult population in 1980 and 2000. In the 1978–80 survey, the sample covered 5101 individuals aged ≥45, of whom 88% participated. The 2000–2001 survey comprised 5310 individuals in the same age range. Participation rate in the health examination was 87%. Prevalence of CHD decreased in men and women under the age of 65 and increased among those aged ≥75. Prevalence of large Q-waves indicating previous myocardial infarction decreased in all male age groups and in women aged 65–74. The total estimated number of persons with CHD increased by 18% (95% CI=6–30) during the past 20 years in Finland. In 1980, the most dominant CHD group was men aged 45–64, whereas in 2000, women aged ≥75 comprised the largest CHD group.

Conclusion Although the prevalence of CHD has decreased among middle-aged persons, the number of CHD cases has increased during the past 20 years in Finland."

Cardiovascular disease prevention with a multidrug regimen

(Referred by Marcelo Gustavo Colominas [mgcolominas@gigared.com])
Cardiovascular disease prevention with a multidrug regimen
in the developing world: a cost-eff ectiveness analysis
Thomas A Gaziano, Lionel H Opie, Milton C Weinstein
Summary
Background Cardiovascular disease is the leading cause of death, with 80% of cases occurring in developing countries.
We therefore aimed to establish whether use of evidence-based multidrug regimens for patients at high risk for cardiovascular disease would be cost-eff ective in low-income and middle-income countries.
Methods We used a Markov model to do a cost-eff ectiveness analysis with two combination regimens. For primary prevention, we used aspirin, a calcium-channel blocker, an angiotensin-converting-enzyme inhibitor, and a statin, and assessed them in four groups with diff erent thresholds of absolute risks for cardiovascular disease. For secondary prevention, we assessed the same combination of drugs in one group, but substituted a β blocker for the
calcium-channel blocker. To compare strategies, we report incremental cost-eff ectiveness ratios (ICER), in US$ per quality-adjusted life-year (QALY).
Findings We recorded that preventive strategies could result in a 2-year gain in life expectancy. Across six developing World Bank regions, primary prevention yielded ICERs of US$746–890/QALY gained for patients with a 10-year absolute risk of cardiovascular disease greater than 25%, and $1039–1221/QALY gained for those with an absolute risk greater than 5%. ICERs for secondary prevention ranged from $306/QALY to $388/QALY gained.
Interpretation Regimens of aspirin, two blood-pressure drugs, and a statin could halve the risk of death from cardiovascular disease in high-risk patients. This approach is cost-eff ective according to WHO recommendations, and is robust across several estimates of drug effi cacy and of treatment cost. Developing countries should encourage the use of these inexpensive drugs that are currently available for both primary and secondary prevention.

Approved a new antianginal agent

Cardiosource: "New Agent Approved
In January 2006, the U.S. Food and Drug Administration (FDA) approved a new antianginal agent for the treatment of chronic stable angina, ranolazine (Ranexa™; CV Therapeutics, Inc.). The drug, patented in 1986 as a new molecular entity, is approved for use as combination therapy when angina is not adequately controlled with other antianginal agents.

Ranolazine was originally thought to have its greatest effect as a partial fatty oxidation inhibitor.12 Fatty acids rise precipitously in response to stress, including acute myocardial ischemia. " /.../

Ischemic Stroke Has $2.2 Trillion Total Price Tag Through 2050

Ischemic Stroke Has $2.2 Trillion Total Price Tag Through 2050 - CME Teaching Brief® - MedPage Today: "ANN ARBOR, Mich., Aug. 16 -- When the cumulative bill for ischemic stroke comes due in 2050 it is likely to total $2.2 trillion, and that's a conservative estimate, calculated researchers here.
The total cost of ischemic stroke from 2005 to 2050, in 2005 dollars, is projected to be $1.52 trillion for non-Hispanic whites, $313 billion for Hispanics, and $379 billion for African Americans, added up Devin Brown, M.D., M.S., of the University of Michigan, and colleagues.
The high cost of stroke care is an example of a perfect demographic storm -- an aging population, combined with an increase in ethnic groups at risk for stroke, and an health care system that emphasizes acute rather than preventive care. " /.../

UK Guidelines for treatment of Atrial Fibrillation

(Enviado por Marcelo Gustavo Colominas [mgcolominas@gigared.com]. A disposição arquivo em *.pdf a quem solicitar)
The association of an irregular pulse with morbidity has been recognised since antiquity, and as long ago as 1628 William Harvey observed cardiac irregularity directly in animals. The modern emphasis on electrical demonstration of atrial fibrillation (AF) dates back a mere 100 years to the first publication by William Einthoven of an electrocardiogram showing the abnormality. Even the treatment of this disorder has a long and venerable history: William Withering published An account of the foxglove and some of its medical uses in 1785, and digoxin, the active extract of his remedy, remains in use today.
A patient developing AF in 2006 is faced with a wide array of potential therapies. A number of drugs can be employed to control the rapid heart rate, which is often an intrinsic part of AF; attempts can be made to restore sinus rhythm using drugs or direct current electrical shock; and an increasing number of surgical procedures are described. Despite the wide number of options available, there is an acknowledgement that AF is too frequently treated with the almost
automatic prescription of monotherapy with digoxin: this is still a useful drug over 200 years on but the best option for only a minority of patients. This failure to appreciate or implement proper treatment options in such a common condition makes AF an excellent topic for a national clinical guideline.
The guideline covers aspects of diagnosis and the management of AF in a number of different circumstances. It covers paroxysmal, persistent and permanent AF, considers AF developing after surgical procedures, and offers advice on haemodynamically unstable AF. Many of the recommendations relate to control of AF and the important decision of whether to attempt to restore sinus rhythm or concentrate on control of the heart rate. In a linked set of recommendations, the importance of considering anticoagulation in all these patients is emphasised.
This is sometimes neglected in clinical practice, but anticoagulation is of enormous potential benefit because of its role in stroke prevention, and one of the key recommendations in the guideline is that the risk of thromboembolism should be formally assessed. A simple clinical model that includes advice on appropriate prophylaxis is suggested for this purpose. Other key
recommendations cover the use of the electrocardiogram in diagnosis, and the preference in most patients for beta-blockers or rate-limiting calcium antagonists over digoxin for rate control.
The work of producing the guideline has been in the hands of a Guideline Development Group (GDG) comprising a small team from the National Collaborating Centre for Chronic Conditions working together with patients and health professionals with particular interest and experience in the management of AF. They have used the available evidence and their own clinical and personal judgement to produce guidance that is both clinically relevant and methodologically sound.
The GDG has had to evaluate a large amount of evidence during this process, and debate on some of the recommendations has been lively. The members have been driven throughout by the desire to produce a guideline that will be of value throughout the NHS. I am grateful to them for their hard work and for their expertise, and I am confident that they have produced a guideline that deserves to meet that aim.
Dr Bernard Higgins MD FRCP
Director, National Collaborating Centre for Chronic Conditions

RAS inhibitors 'protect against AF'

RAS inhibitors 'protect against AF': "Friday, August 04, 2006

RAS inhibitors 'protect against AF'
Drugs that inhibit the renin-angiotensin system (RAS) protect against new-onset atrial fibrillation (AF), particularly in patients with heart failure, a meta-analysis has shown. Kishlay Anand and co-workers from Creighton University in Omaha, Nebraska, searched PubMed for randomized controlled clinical trials reporting the incidence of AF in patients receiving ACE inhibitors or angiotensin II type 1 receptor blockers (ARBs). Their meta-analysis included a total of nine studies with 72,469 participants conducted between 1999 and 2005. The median follow-up period was 3.4 years, during which time 3738 new cases of AF were diagnosed. The pooled risk ratio for new-onset AF associated with RAS inhibition was 0.82, Anand and co-authors report in the American Heart Journal. Of the nine trials, just two – STOP-2 (enalapril/lisinopril) and VALUE (valsartan) – failed to show a benefit of treatment on AF incidence. In subgroup analyses, ACE inhibitors had a greater protective effect than ARBs (Risk Ratio [RR]=0.75 vs 0.81) and patients with heart failure benefited the most from RAS blockade (RR=0.57). There was no significant benefit on incident AF in patients with hypertension or myocardial infarction. A test for heterogeneity was significant, however, and the authors were unable to exclude the possibility of publication bias. "Currently, there is not sufficient evidence to recommend the use of ACE inhibitors and ARBs in routine clinical practice for prevention of AF," Anand and team conclude. "Our meta-analysis is hypothesis-generating and will lead to further investigation."
Am Heart J 2006; 152: 217–222

Amiodarone-plus-RAS-inhibitor-best-for-paroxysmal AF

Amiodarone plus RAS inhibitor best for paroxysmal AF: "Amiodarone plus RAS inhibitor best for paroxysmal AF
Adding an inhibitor of the renin-angiotensin system (RAS) to low-dose amiodarone is more effective than amiodarone alone for preventing arrhythmias in patients with paroxysmal atrial fibrillation (AF), study results have shown. Yuehui Yin (Chongqing University of Medical Sciences, China) and colleagues undertook a randomized study involving 177 patients with lone paroxysmal AF. The patients were randomly assigned to receive one of three open-label treatment regimens: (1) amiodarone 600 mg/day decreasing to 200 mg/day; (2) low-dose amiodarone plus losartan 50–100 mg/day; or (3) low-dose amiodarone plus perindopril 2–4 mg/day The primary endpoint, AF incidence between 14 days and 24 months of randomization, was reached by 41% patients in group 1, 19% in group 2, and 24% in group 3, reflecting a statistically significant difference between group 1 and groups 2 and 3. Furthermore, AF recurrence was significantly reduced in groups 2 and 3 versus group 1, although there was no difference in AF recurrence-free survival. Interestingly, left atrial diameter was significantly smaller in groups 2 and 3 than in group 1, the first time such an effect has been demonstrated. Writing in the European Heart Journal, Yin and co-authors say several mechanisms may underlie the beneficial effects of losartan and perindopril observed in their study. The drugs may reverse electrical remodeling caused by AF; they may inhibit AF-induced structural remodeling; or they may cause sympatholytic effects by reducing plasma norepinephrine levels. "The combination of perindopril or losartan with low-dose amiodarone is more effective than low-dose amiodarone alone for the prevention of AF recurrence in patients with lone paroxysmal AF," Yin et al conclude. "Adding losartan or perindopril to amiodarone can inhibit left atrial enlargement in this group of patients."
Eur Heart J 2006; 27: 1841-1846"

Men With Gout Have Increased Risk of Heart Attack

PITTSBURGH, Aug. 3 -- Gout and hyperuricemia are independent predictors of heart attack in men, according to an analysis of nearly 13,000 participants in a major trial.
This was the first study to identify a significant risk of acute MI among men with gout and no history of coronary artery disease, wrote Eswar Krishnan, M.D., M.P.H., and colleagues, of the University of Pittsburgh and the University of Pennsylvania in the August issue of Arthritis & Rheumatism. /.../

For Out-of-Hospital Cardiac Arrest, Knowing When to Quit

TORONTO, Aug. 2 -- Most out-of-hospital cardiac arrests end on the scene, and investigators here have devised a simple clinical prediction rule to help emergency workers know when to stop.
Implementation of a clinical prediction rule based on three simple factors would reduce futile resuscitation efforts by almost 63%, reported the Termination of Resuscitation (TOR) trial investigators in the Aug. 3 issue of the New England Journal of Medicine.
"The prediction rule had a positive predictive value of 99.5% [for death] and a specificity of 90.2% [for death]," wrote Laurie J. Morrison, M.D., of the University of Toronto, and colleagues there and at Owen Sound (Ontario) Hospital.
The investigators analyzed data from 1,240 adult patients treated by 24 emergency medical systems in the province of Ontario from Jan. 1, 2002 to Jan. 30, 2004.

Guidelines for the Management of Patients With AtrialFibrillation

ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation--Executive Summary. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines
(Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) WRITING COMMITTEE MEMBERS, Valentin Fuster et al
Circulation published 2 August 2006, 10.1161/CIRCULATIONAHA.106.177031
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.106.177031v1?papetoc

Frequency of and Risk Factors for Stent Thrombosis After Drug-Eluting Stent Implantation During Long-Term Follow-Up

ScienceDirect - The American Journal of Cardiology : Frequency of and Risk Factors for Stent Thrombosis After Drug-Eluting Stent Implantation During Long-Term Follow-Up: "Despite concerns regarding the long-term safety of drug-eluting stent (DES) implantation because of late-onset stent thrombosis, the actual incidence of stent thrombosis after 1 year is unknown. We investigated the incidence, risk factors, and association of antiplatelet therapy interruption for the development of stent thrombosis after DES implantation during long-term follow-up. A total of 1,911 consecutive patients with DES implantation were enrolled (sirolimus-eluting stents in 1,545 patients, 2,045 lesions; paclitaxel-eluting stents in 366 patients, 563 lesions). During long-term follow-up (median 19.4 months, interquartile range 15.3 to 24.3), 15 patients (0.8%, 95% confidence interval 0.5% to 1.3%) developed stent thrombosis within 6 hours to 20.4 months. Eleven patients (0.6%, 95% confidence interval 0.3% to 1.0%) had late thrombosis (median 6.1 months). The incidence of stent thrombosis was 3.3% (4 of 121 patients) in patients with complete interruption of antiplatelet therapy (vs 0.6% in those without, p = 0.004) and 7.8% (5 of 64 patients) with premature interruption of aspirin or clopidogrel, or both"

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.)/.../

Personality, lifestyle and risk

People's belief that the onset and progress of disease is caused by their behaviour may be linked to a reduced risk of myocardial infarction but not of stroke and cancer. High "time urgency" may be associated with a reduced risk of cancer but not of cardiovascular disease. Stürmer and colleagues (p 1359) analysed the presence of chronic diseases in more than 5000 adults 7-10 years after those people had completed a questionnaire on psychological traits, lifestyle, and comorbidity. Most personality traits that were assessed did not have a major impact on incidence and mortality from cardiovascular disease or cancer.

Related Article

Personality, lifestyle, and risk of cardiovascular disease and cancer: follow-up of population based cohort
Til Stürmer, Petra Hasselbach, and Manfred Amelang
BMJ 2006 332: 1359. [Abstract] [Full Text]

Third Heart Sound

http://www.cardiosource.com/media/HS08_Third_Heart_Sound.mp3

Rimonabant

Rimonabant is a selective cannabinoid type 1 (CB1) receptor blocker that is part of the newly discovered endocannabinoid (EC) system. The EC plays an important role in the central and peripheral regulation of energy balance and body composition, offering a new target to induce weight loss and improve carbohydrate and lipid metabolism./.../

Dr LEE Jong-wook, Director-General of the World Health Organization, has died

Dr LEE Jong-wook, Director-General, WHO
22 May 2006 -- Dr LEE Jong-wook, Director-General of the World Health Organization, has died. He had been in hospital since Saturday afternoon, where he underwent surgery to remove a blood clot on his brain (a subdural hematoma). He remained in intensive care. At 0743 this morning, he was declared dead.

All of the staff of the World Health Organization extend their most sincere condolences to Dr Lee's family. The sudden loss of our leader, colleague and friend, is devastating.

Dr Lee led WHO to continue its mission to help people attain the highest possible level of health.

He was 61 years old. He is survived by his wife and son, two brothers and a sister and their families.
Statement | Official photograph | Statement regarding the Acting Director-General