theheart.org Comments Feed - Cardiology news & opinions

William O'Neill goes home to lead new structural heart group at Henry Ford

Wed, 16 May 2012 11:20:08 EDT

Welcome back Bill, HFHS could use your talents and leadership.

Resuscitation rates in out-of-hospital arrests are woeful

Wed, 16 May 2012 10:37:26 EDT

It has been huypothesized that conversion of TG in myocardial cells to toxic intracellular FFA may be responsible for some arrhythmias during intense myocardial ischaemia(Kurien and Oliver 1970) By changing caloric overload, which causes accumulation of TG in myocardial cells, it may be possible to reduce the incidence of cardiac arrhythmia during myocardial ischemia. Why not divert part of the money we spent to resuscitate people without significant success to help them understand that they could reduce their risk of cardiac arrests by consuming no more calories on a daily basis than they expend in daily activities? Is it too simple an instruction to follow?

FAME II: FFR pinpoints stable CAD patients who fare worse with OMT

Wed, 16 May 2012 09:42:28 EDT

I agree with Dr. Morton. "Urgent" and "nonurgent" revascularization need to be defined. Morover: I wonder who is the pateint without lesions. Is he a patient with CAD? FFR > 0.80 means no ischemia and no symptoms. FAME II adds nothing new to FAME or DEFER studies. "FFR significant" lesions have to be stented. That is clear. You are damned if you stent all lesions and you are damned if you do not stent all SIGNIFICANT lesions.

FDA panel recommends lorcaserin for obesity

Wed, 16 May 2012 09:21:54 EDT

�Eating a high-fructose diet over the long term alters your brain's ability to learn and remember information�. Eating too much sugar can eat away at your brainpower, according to US scientists who published a study Tuesday showing how a steady diet of high-fructose corn syrup sapped lab rats' memories. Researchers at the University of California Los Angeles (UCLA) fed two groups of rats a solution containing high-fructose corn syrup -- a common ingredient in processed foods -- as drinking water for six weeks. Sugar (Glucose-Fructose) is bad, but HFCS is much worse. The Fructose of sugar is not racemic and not as common in foods. HFCS is a racemic mixture of chemicals (Franken sugar) that mammals only can send to the liver as poison.

FDA panel recommends lorcaserin for obesity

Wed, 16 May 2012 08:09:18 EDT

While I agree with James King's comments, I would add sucrose to his list ... it's only less deadly because it is less ubiquitous.

FDA panel recommends lorcaserin for obesity

Wed, 16 May 2012 00:26:15 EDT

Arena's lorcaserin was designed to block appetite signals in the brain in a similar way to "fen-phen," an infamous diet pill that was pulled from the market in 1997 after reports of sometimes-fatal heart-valve problems. Avoiding two of the deadliest and unnatural foods of Modern times: high fructose corn sugar (HFCS) and hydrogenated oils are in almost all American breads. HFCS is not just soda and fruit drinks! McDonalds make people fat because the buns are mostly HFCS. The taxing of HFCS like in Mexico and Europe is not possible due to Grover Norquist's pledge. Maybe Grover would loose some weight.

FAME II: FFR pinpoints stable CAD patients who fare worse with OMT

Tue, 15 May 2012 19:21:38 EDT

This entire study hinges critically on the definition of "urgent revascularisations". As this was unblinded the patient has been sent home with the message "you have a critical narrowing in one of your arteries and we just don't know if it's going to block off at any time, so please come back to see us should you have some pain, any pain in fact, and we'll fix it for you" Urgent to me implies a troponin rise, but from the last paragraph this does not seem to be the case. We are therefore left with the outcome that stenting reduces the need for stenting, much like aortic valve replacement reduces the need the aortic valve replacement (in asymptomatic severe AS) or metformin reduces the development of diabetes (in pre-diabetes).

Analyze this Doppler signal from a 45-year-old man with dyspnea

Tue, 15 May 2012 19:14:31 EDT

Well done! I had no idea this month's question would stump so many. I knew a lot of people would automatically think aortic stenosis. It's great that you looked a second time before going with your reflexes.

What is the primary ECG disorder shown in this tracing?

Tue, 15 May 2012 17:51:27 EDT

I have to admit: It took me a minute ... Good training

Correct interpretation of coronary artery images: What does this image show?

Tue, 15 May 2012 17:44:51 EDT

Great pics

Which congenital heart lesion is depicted in the figures?

Tue, 15 May 2012 17:40:21 EDT

There usually is transposition with double outlet RV. Great study

CT coronary angiography to assess for CAD: What does this image show?

Tue, 15 May 2012 17:32:03 EDT

The images are quite clear

A 45-year-old woman who had an ICD implanted over 10 years ago

Tue, 15 May 2012 17:20:36 EDT

Thought surely there was multivessel disease, with infarction of the inferior walls

Analyze this Doppler signal from a 45-year-old man with dyspnea

Tue, 15 May 2012 17:11:55 EDT

I had to think twice between aortic or pulmonic but then I saw the faint a wave of the diastolic flow pattern

Off-target toxicity of torcetrapib explained, but questions about future of CETP inhibition linger

Tue, 15 May 2012 09:49:04 EDT

Firstly :I think that further toxicity study in relevant to liver ,kidney organs and complete blood cells profile may be needed Secondly The question arrised , what about CETP inhibitors of plant orgin ... ? . Another comment can we test for pridictors for CVD outecome ?

Roche stops dalcetrapib trial for lack of benefit

Tue, 15 May 2012 03:14:27 EDT

Endotheliology is rapidly replacing lipidiology and the HDL hypothesis in terms of explaining the results of outcomes trials. In the future we should focus on interventions that target endothelial function.Statins, the only consistent performers in the outcomes arena, generate outcomes via enhancing endothelial function.

Moderate coffee intake protects against stroke

Tue, 15 May 2012 02:06:17 EDT

Anything good in life is either illegal,immoral or fattening; coffee may be the exception

Dr David Rosenbaum dies, age 54, of pancreatic cancer

Tue, 15 May 2012 01:53:47 EDT

I never knew the man but I followed his work. I love the world and science of electrophysiology. I also know that he had this world as the center of his existence. This is to be respected.

FDA advisors: Benefits trump risks for HeartWare ventricular assist pump

Mon, 14 May 2012 22:55:00 EDT

if device manufacturers would not want to appear seemingly sleeping together with the FDA,they should take into, seriously adequacy and consistency past experiences. my opinion

Some valve patients are too sick for TAVI or surgery

Mon, 14 May 2012 22:53:57 EDT

I am deeply sorry to venture the following opinion. We are spectators of some informations which are not errors in observation or judgement, passed along in good faith, but deliberately fabricated falsehoods which cause material loss or harm to the victims. Who are the winners? Am I wrong?

More adverse events seen on dabigatran vs warfarin

Mon, 14 May 2012 15:28:10 EDT

I think they've gone more warning of Bayer and its product, and even studies that did not include clear definitions of major bleeding, on the other hand when you start the warfarine were more taboo and precautions, we see the advantages that new therapies offer and above the reduction of risks so high that there

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Mon, 14 May 2012 14:57:47 EDT

I just discovered this site, very good case. I was wondering if there was a prolapse of noncoronary cusp as well causing eccentricity to the regurgitation. Thank you

Roche stops dalcetrapib trial for lack of benefit

Mon, 14 May 2012 14:41:05 EDT

The name of the game is to raise HDL while simultaneously lowering LDL. Plaque regression occurs mainly with LDL lowering, but if HDL goes up then LDL does not have to go down so far. If LDL goes down far enough, then HDL is immaterial; but if LDL only goes down a bit , then raising HDL is critical to plaque regression. Results to be submitted for publication in the near future.

Roche stops dalcetrapib trial for lack of benefit

Mon, 14 May 2012 14:22:04 EDT

Any intervention that lowers LDL has been shown to reduce the risk of CAD porportional to the degree of LDL lowering. Has everyone forgotten the LRC primary prevention trial with cholestyramine for heavens sake? 20% LDL lowering, 20% risk reduction in a primary prevention setting. With an agent that has no possibility of systemic or direct vascular effects. All other studies follow from this landmark trial.

Sudden cardiac death risk stratification in athletes

Mon, 14 May 2012 14:10:10 EDT

I am so sorry for your loss. I agree that often the diagnosis is not obvious. Many years ago, I saw a very nice patient who was already around 58 years of age with recurrent syncope. I was called to her beside due to an episode the night of an uncomplicated hysterectomy. After her syncope, the gynecologist asked she be placed on telemetrey only to find that she was having "torsades type rhythm issues with a long QT underlying. When I completed her work up, amazingly she could NEVER be convinced to see an EP or to take medications. "I know how to avoid it" she said and went on her way. I've never seen her again but she lives in our community and I do not beleive she has met with an untimely death. QT issues are lethal and many times, very treatable. I agree that a "light" should be shown on this terrible disease and have done my best to contribute to awareness as several of my family members are affected.

Moderate coffee intake protects against stroke

Mon, 14 May 2012 12:50:07 EDT

Ischaemic stroke is reduced in this meta-analysis. Was there any indication of coffee's effect on other cardio/vascular ischaemic pathology, possibly associated with similar aetiology/ies found in the 11 studies?

Waist-hip ratio excels at SCD risk prediction in ARIC cohort

Mon, 14 May 2012 12:40:06 EDT

In the table row for waist-hip ratio, what does "96-0.95-0.97" and "96-0.98-1.00)" and "96->1.01" for males mean? I don't understand why the "96" is there.

What is the primary ECG disorder shown in this tracing?

Mon, 14 May 2012 12:09:28 EDT

Thank you, Dr. Wang. These tracings are most helpful to me in my studies for the HRS exam.

Whistleblower suit claiming pioglitazone cover-up implicates Nissen, Cleveland Clinic

Mon, 14 May 2012 11:51:59 EDT

When the FDA made its decision to make rosiglitazone difficult to obtain, I protested that rosi cost about $100/mo less than pio (pioglitazone). To yank rosi, I noted, would cost the healthcare industry millions of dollars a year. However, the 900-lb gorilla (Dr Nissen) won out on the basis that rosi caused more heart attacks. However, pio seems to cause more bladder cancer. Also, had the FDA paid attention to my presentations that the blood sugar level is immaterial to heart atacks and that it is the Big Three ATD risk factors (dyslipidemia, cigarette smoking, and hypertension) that cause the heart attacks, then the FDA could have alerted physicians to treat those risk factors, as well as the blood sugar, and left rosi on the market. However, Dr Nissen got his way and rosi was yanked. Now I can see why. I thank Dr Ge for bringing this to the attention of the medical community. Let the chips fall where they may.

Sudden cardiac death risk stratification in athletes

Mon, 14 May 2012 10:30:40 EDT

*Incidentally, I learned that my child had been first identified with absence seizures on her 3rd birthday. Despite caregiver instruction by medical professionals to seek intervention, none was sought. These episodes were transpiring several times each day and were viewed by school and pediatrician. I believe that at 13-1/2 years of age, a time of increased hormonal change, the seizures may have intensified and caused the fatal cardiac event. Medical examiner explained that "all seizures can be dangerous."

Sudden cardiac death risk stratification in athletes

Mon, 14 May 2012 10:23:40 EDT

As the previous poster noted, the issue is not strictly one that affects athletes. Children, too, are susceptible to sudden cardiac events. Many individuals are placed on anti-psychotic, stimulant and type medications without adequate screening for arrythmeias or congenital defect. *Administration of medication is particularly troublesome amongst children in foster care where lack of history, consistent caregiver, and a tendency to use drugs to alter behaviour (in place of alternate therapy) may exist.

Roche stops dalcetrapib trial for lack of benefit

Mon, 14 May 2012 09:16:58 EDT

Skeptics of lipidology should become lipidologists. CETP inhibitors may not work for a number of reasons, i.e. inhibiton of a pathway for generating LDL-C for uptake by hepatic receptors, or production of dysfunctional HDL-C or may work better in certain population and not in others. It would be interesting to see the data (even from anacetrapid) in 'dyslipidemic' populations where CETP inhibition might be most important, i.e. in preventing ultimate production of small dense LDL particles and preserving HDL paticles. Statins work the best, but obviously not in everyone. Fibrates consistenly (5 major trials) lower risk ~30% in higher risk high TG / low HDL populations. The same may be true of niacin. Even TZDs may do their best job of reducing events in this population (i.e. even the 'primary outcome' in PROactive was statistically significant only on the high TG group. In 4S the lipid triad patients had a huge simva benefit (56% RRR) compared to those with only high LDL (14%)-a C. Ballantyne analysis. ENHANCE was a great trial that enhanced our trial design knowledge; you can't delipidate an IMT that has been completely delipidated, utilizing HeFH patients from Registries where patients have been agressively managed with combinations of lipid modifying agents. But ENHANCE participants were left with CVD event rates 90% lower than those seen in observational studies of HeFH patients. Design of trials has to do with having a drug-responsive population that should be affected by the medication and not all great ideas (medications) in research will work, but noone can know the risk / benefit ratio of a drug in a particular population until the randomized blinded trial is completed.

Moderate coffee intake protects against stroke

Mon, 14 May 2012 08:59:30 EDT

It's really interesting these findings. If maybe it's t�o early to recomend our patients to drink coffee, at least we can take off the feeling that this habit is harmful for those fans of this delicious drink!

Pfizer stops promoting Lipitor in US

Mon, 14 May 2012 07:57:39 EDT

I live with country with plenty of lipitor genrics and be prepared to pay little bit less price for much lower effect in same dose of atorvastatin.

Bypass moderate coronary lesions? Taking sides in the debate

Mon, 14 May 2012 00:24:18 EDT

yes medical treatment works! we can suppose the patients were really compliant 1/ they accept the surgery! 2/ they accept the repeat angiography studies! 3/ How they were informed and accepted the study design? 4/ the take home message should be "do not bother them with their minimal lesions (even left or right)" J P Usdin MD physician Paris France

New JNC 7 hypertension guidelines released

Mon, 14 May 2012 00:17:11 EDT

Do we really want the systolic BP in subjects over the age of 80 to be less than 140 if the result is that the diastolic BP drops to less than 60? The only time the myocardium gets blood flow is during diastole. Low diastolic BP in the very elderly may actually lead to increased CHF and symptomatic angina. As we look to more individualization of health care, we need to do better than to make a blanket statement like needing to keep the systolic below 140 in subjects over the age of 50 and suggest that ignoring the diastolic is a good idea.

Should statins be used in primary prevention? JAMA gets in on the debate

Mon, 14 May 2012 00:08:10 EDT

As coronary prevention is an industry with no potential for profit, the tragic reality is EBT centers have closed and been replaced by 64 slice helical CT scanners. Some centers remain, run by individuals with a commitment to heart attack prevention and no need for income. The helical scanners can perform calcium scores although with less precision and greater radiation that EBT. At this time, it is the best we have unless you are fortunate enough to live close to one of the remaining EBT centers. As helical scanners can do other diagnostic ct exams as well as CTA, which can generate reasonable income, they do tend to be profitable and therefore sustainable. The problem with a 64 slice scanner is that follow up scans cannot be performed until enough time has passed for the scan to scan variation to become irrelevant. For EBT that time is one year, for 64 slice helical scanners that time is more like 3 to 5 years to account for the 35 to 45% scan to scan variability. The 256 slice scanners are comparable to the EBT from the perspective of accuracy and reproduciblity of calcium scores however they are no more common than EBT at this time but may represent the hope for the future with calcium imaging. The irony is that while so much resources and energy has been put in CTA and coronary intervention, I have found that all I need to prevent almost all heart attacks is an EBT calcium score and fairly simple medical management.

Femoral vs radial access: Rivals or complements?

Sun, 13 May 2012 12:02:06 EDT

The radial artery occludes after cath/PCI less than 10% of the time which has been demonstrated in multiple trials. I think that argument against radial access is among the poorest out there. But, once again, if you don't want to go from a radial aproach, that's your prerogative.

More adverse events seen on dabigatran vs warfarin

Sun, 13 May 2012 11:29:17 EDT

1) Age (give age appropriate dose). 2) Watch Serum Creatinine (creatinine Clearance) once every 2-3 months and when pt. sick. 3)Be carefull if previous GI bleed(s) or other GI issues such as constipation/obstruction; might experience higher bleeds as tartaric acid releases during it's metabolism in lower GI tract. 4)Do not prescribe new OACs if pt's been non-compliant on warfarin (because of Psychological, Financial, age related dementia issues or any other obstacle for which pt. may be non-compliant. 5) if pt has Liver or Renal impairment (might dose adjust, but will have to be very vigilant) 6) Inform pt. the risks that NSAIDS, other antiplatelet agents can increase the risk of bleed and that there is no approved antidote for these new OACs. I would not stop taking or switch drug to Aspirin while travelling-increases your risk of stroke (educate pt. and family around him/her). My suggestion is to give some thought/assessment time before prescribing these new Oral AntiCoagulants(OACs)to your pt's and do it everytime they become sick. Just my 2 cents.

Bypass moderate coronary lesions? Taking sides in the debate

Sun, 13 May 2012 03:38:38 EDT

Left main stenosis bypass is class IA indication (ESC reco 2012)

Moderate coffee intake protects against stroke

Sat, 12 May 2012 23:55:27 EDT

The German alternative medicine kept describing Coffee for �health benefits�. It�s too weird for me, What is a coffee enema? Why do people do it? What are some of the possible side effects? Do you use cream?

Telemonitoring by pharmacists boosts BP control

Sat, 12 May 2012 17:45:04 EDT

Blood pressure are just a surrogate endpoint (or marker) is a measure of effect of a certain treatment that may correlate with a real clinical endpoint but doesn't necessarily have a guaranteed relationship. The drug used to normalize blood pressure has different clinical effectiveness. An obvious for hypertension is selective α1-adrenergic blockers include: The ALLHAT Study (2002) found that long-term use of alpha blockers seems to increase the risk of heart failure. While this risk is real, it is small, and the main reason that alpha blockers are not used as "first choice".

Taking STEMI patients to PCI hospitals saves time and lives

Sat, 12 May 2012 12:00:40 EDT

The abstract over-emphasizes the role of PCI since it focuses on time to PCI. If the treatment strategy is to eventually transfer for PCI then in field redirection clearly will be more effective. The choice of strategy more realistically is go local for early lysis if transport times may be long vs redirect for somewhat delayed but higher success PCI. The study by Lambert (JAMA 2010;303(21):2148-2155. doi: 10.1001/jama.2010.712) emphasized the importance of the timeliness of reperfusion over mode of reperfusion. Transfer for PCI with long delays does not make sense. From the abstract, the presentation and the story I believe this study has shown that in field redirection is preferable to go local then transfer for PCI but has ignored the more important question of which the best strategy (go local for lysis vs redirect for PCI) based on the expected transport times to each. Unfortunately, I believe clinicians have accepted the message that PCI is better than lysis but ignored the message that timely lysis is preferable to untimely primary PCI.

Analyze this Doppler signal from a 45-year-old man with dyspnea

Sat, 12 May 2012 10:06:03 EDT

is that I try to be educational and "tricky", but only by presenting the data as it is. It would be unfair of me to ask questions where the answer were obscured or ambiguous due to suboptimal Dopplers or "technical factors", as no one would be expected to know that; any educational value would be lost.

Moderate coffee intake protects against stroke

Sat, 12 May 2012 08:32:21 EDT

Relax, have a cup and think about it

More adverse events seen on dabigatran vs warfarin

Sat, 12 May 2012 02:22:13 EDT

If you are over 80 and going on a foreign trip where you might fall or have an accident, why not cut down from 2 to 1 on Pradaxa and then stop Pradaxa and switch to Baby aspirin during the trip? At least that is what I am doing...

Analyze this Doppler signal from a 45-year-old man with dyspnea

Fri, 11 May 2012 19:04:43 EDT

Yes Dr. Elasmad, you are correct. The RVH from the severe PS "crowds out" the RVOT, leading to secondary dynamic RVOT obstruction, similar to the jet to which we are all more accustomed on the left side. Fixing the PS fixed the secondary RVOT obstruction.

Analyze this Doppler signal from a 45-year-old man with dyspnea

Fri, 11 May 2012 19:02:29 EDT

and I enjoy the debate Dr. Levine, you do not lack "sechel". But diastolic hypotension from AI implies severe AI, and it would take a lot of "technical factors" to turn a dense steep jet into a very non-dense, flat jet. In fact, the same "technical factors" that would lead to underestimation of the "AI jet" might also affect the "AS jet", n'est-ce pas?

Analyze this Doppler signal from a 45-year-old man with dyspnea

Fri, 11 May 2012 18:16:34 EDT

The second & third Doppler signals show "late peaking" of the trans-valvular velocities which is consistent with sub-valvular stenosis. This is similar to the Doppler signal seen in HCM taking a "sabre-shaped" configuration. Some cases of pulmonic stenosis have elements of both valvular and sub-valvular pathology as seen in this case. However, balloon valvotomy usually reduces both elements with symptomatic releif of the patients.

Analyze this Doppler signal from a 45-year-old man with dyspnea

Fri, 11 May 2012 18:06:45 EDT

Come on now Ron -- systolic hypotension from poor LV function or afterload mismatch is not the point. It is diastolic hypotension from CHRONIC AI. Heart failure, specifically an elevated LVEDP in this case doesn't have to have anything to do with systolic dysfunction. The density of the signal depends on lots of factors, including technical ones such as the angle of the Doppler beam in relationship to the eccentricity of the jet. You are obviously right about the ultimate dx -- just too quick to dismiss AS/AI based purely on the tracings you showed...

More adverse events seen on dabigatran vs warfarin

Fri, 11 May 2012 17:55:24 EDT

Until now, Warfarin dosage should be adjusted for INR between 2 and 3. Nowadays, age should be taken into account. At 60, INR should be between 2 and 2.4 At 70, INR between 2 and 2.3 At 80, INR should be between 2 and 2.2 INR should not be above 3 minus Age. So doing, no bleeding.

More adverse events seen on dabigatran vs warfarin

Fri, 11 May 2012 17:49:50 EDT

Until now, Warfarin dosage should be adjusted for 2 At 60, 2 At 70, 2 INR should not be above 3 minus Age. So doing, no bleeding.

Dr David Rosenbaum dies, age 54, of pancreatic cancer

Fri, 11 May 2012 16:12:56 EDT

He guided me when I first became interested in Cardiology. A great teacher, scientist and clinician. Patients, students and colleagues will miss him. My condolences to his family.

Analyze this Doppler signal from a 45-year-old man with dyspnea

Fri, 11 May 2012 16:08:47 EDT

Glad you enjoyed it.

Analyze this Doppler signal from a 45-year-old man with dyspnea

Fri, 11 May 2012 15:58:15 EDT

thanks for ur excellent explaination

Telemonitoring by pharmacists boosts BP control

Fri, 11 May 2012 13:47:09 EDT

One company is The Withings Blood Pressure Monitor in the US $ 129.00 Uses the iPhone, iPad or iPod touch as a blood pressure tracking device. The Withings Blood Pressure Monitor measure, calculate, graph and tracking curves and ease the sharing with the doctor. The PCP or pharmacist can deal with the data..

Bypass moderate coronary lesions? Taking sides in the debate

Fri, 11 May 2012 12:57:30 EDT

Ten years ago when I was faced with this problem I opted for EECP (Enhanced External Counter Pulsion" after several severe angina attacks. These attacks (3 events) occured while sprinting at the finish of a road race. I have run in several hundred races since my EECP treatment and have had no more episodes.

Bypass moderate coronary lesions? Taking sides in the debate

Fri, 11 May 2012 12:35:22 EDT

so difficult making a difference between 'marketing' cardiology and good old clinical medecin. Agree with Westib, Kadi, Zozaya and Feeman

Analyze this Doppler signal from a 45-year-old man with dyspnea

Fri, 11 May 2012 12:20:20 EDT

If the hypotension is from a poor LV, that same LV is not going to generate a 5 m/s jet; only a good LV would do that. Also, the diastolic hypotension cannot be from severe AI, because the jet is not particularly dense, nor is its slope particularly steep. So I'm standing my ground on this one.

WHF defends Dubai WCC, reimburses Israelis denied visas

Fri, 11 May 2012 11:53:25 EDT

First Tennis players, now cardiologists!, anyone who has been to Israel in their current passport or are of Jewish descent, are just not welcome there.

Sudden cardiac death risk stratification in athletes

Fri, 11 May 2012 11:47:17 EDT

Terrific discussion, best comment was that SD issue not just for athletes, although this gets the media attention. but for all with non ASHD causes.

Dr David Rosenbaum dies, age 54, of pancreatic cancer

Fri, 11 May 2012 11:18:31 EDT

My father also succumbed to this horrible disease. My sympathy is extended to the Rosenbaum family and all of Dr. Rosenbaum's friends.

Analyze this Doppler signal from a 45-year-old man with dyspnea

Fri, 11 May 2012 11:14:53 EDT

Obviously you are correct based on the subsequent images. However it would also be possible for a patient with chronic AI to have a low arterial diastolic blood pressure, which could even be compounded by the use of a vasodilator. If he is becoming increasingly dyspneic, perhaps in heart failure, then LVEDP could also be high. Therefore it could easily be possible for him to have say an arterial diastolic blood pressure of 46 mmHg, and a LVEDP of 30 mmHg, allowing for your end diastolic gradient to be only 16 mmHg. Therefore I don't think yuou can exclude severe AS with AI just on the tracings you showed initially.

CHA2DS2-VASc score gives best prediction of stroke risk in AF

Fri, 11 May 2012 10:32:06 EDT

The data shows that the stroke risk rises with CHADS-VASc scores of 2 or higher. I would not say that every female with a score of 1 needs anticoagulation.

Roche stops dalcetrapib trial for lack of benefit

Fri, 11 May 2012 10:18:44 EDT

Ever since the torceptrapib trial I have maintained that any new dyslipidemic medication must show proof of significant plaque stabilization/regression and/or significant decrease in ATD events. Even the statins vary in their ability to stabilize/reverse plaque even at the same level of LDL. This is a turning point in interventional lipidology: the medication must show it significantly affects plaque to warrant use. This is a topic for a future paper with Dr Buchwald.

Femoral vs radial access: Rivals or complements?

Fri, 11 May 2012 06:59:28 EDT

In case a patient will eventually need coronary artery bypass grafting: Would it be wise to put a potential arterial graft at risk? Has this issue ever been addressed?

Femoral vs radial access: Rivals or complements?

Fri, 11 May 2012 00:20:55 EDT

I am an avid radialist and consider the transition to going this route to be the single best thing I have ever done in my practice. The advantages have been detailed in many other forums, so I won't belabor the point. That being said, if an interventionalist feels that it is in their patient's interest to continue to use a femoral approach, then more power to them. The "debate" is silly. Both ways are relatively safe. If you decide to continue to use the femoral approach, it doesn't mean you're a bad cardiologist. Radial access will overtake femoral access in the US eventually. Objectively, there is no doubt in this assertion.

Whistleblower suit claiming pioglitazone cover-up implicates Nissen, Cleveland Clinic

Fri, 11 May 2012 00:03:05 EDT

This QUI TAM suit is just looking for deep pockets. Problems on the committee reflect problems at the FDA, Dr, Steven Nissen, added. "There are some big problems," he acknowledged. "The FDA is under-funded.

Roche stops dalcetrapib trial for lack of benefit

Thu, 10 May 2012 23:07:02 EDT

Has the field of lipidology become extinct? Yes. Deader than a door nail. Many patients stopped trusting almost any new drugs after the MERCK Vioxx debacle. For three years the FDA and the pharmaceutical companies marketed these drug despite known harm. The trust maybe forever gone.

Roche stops dalcetrapib trial for lack of benefit

Thu, 10 May 2012 22:32:37 EDT

HDL rose by 11% in Helsinki and 6% in VA-HIT, the only two studies showing a benefit from raising HDL. Dalcetrapib raises HDL much more - 31% in dal-VESSEL. So, how can it be said dal-OUTCOMES failed because dalcetrapib is fails to adequately raise HDL? Steve Nissen needs to explain this.

Roche stops dalcetrapib trial for lack of benefit

Thu, 10 May 2012 20:47:36 EDT

Has the field of lipidology become extinct? Show me good evidence for anything other than statins in secondary prevention. Whether they are LDL lowering or HDL raising it makes no difference. Ezetimibe, fibrates, pioglitizones, CETP inhibitors, niacin, cholestyramine. I can see no convincing evidence for their use.

Roche stops dalcetrapib trial for lack of benefit

Thu, 10 May 2012 20:05:56 EDT

Please feel free to remove anything you feel is scientifically offensive. It is somewhat remarkable that nonsense posted by a full name is left on this site (i.e. Eddie Vos) and obvious comments of fact by a real physician is censored. That is your decision and it is fine with with me. Your readers can decide for themselves.

Roche stops dalcetrapib trial for lack of benefit

Thu, 10 May 2012 19:45:57 EDT

I give up.

Roche stops dalcetrapib trial for lack of benefit

Thu, 10 May 2012 16:53:47 EDT

I am pleased to see the high level of conversation on this topic, and I am sorry for joining this conversation so late. Plaque stabilization/regression is our ultimate goal in the therapy of dyslipidemia. I am at present working with Henry Buchwald, MD, using angiographic data from his POSCH trial of the 1980's, as well seven other angiograhic regression trials. POSCH demonstrates Esko Nikkila, MD,'s Lipid Regulatory Hypothesis to perfection. Nikkila's hypothesis that lowering LDL and raising HDL simultaneously has been at the heart of my practice of preventive cardiology and interventional lipidology since the early 1980's. It works in my practice, and I plan to request to show that regression of plaque in POSCH is linked closely to a decline in the Cholesterol Retention Fraction (CRF, or [LDL-HDL]/LDL) at the 2013 National Lipid Association and European Atherosclerosis Society symposia. I will be doing three posters on lipids at the 2012 NLA symposium, and will bring the data with me to show informally to anyone who wants to see it. My point is that HDL and LDL do NOT live in vacuums and plaque regression best occurs when Nikkila's hypothesis is fulfilled. Plaque regression, of course, leads to dramatic falls in atherothrombotic disease (ATD) events.

Dabigatran for stroke prevention in AF passes cost-effectiveness test

Thu, 10 May 2012 16:21:17 EDT

YES! Pradax is now covered by the ODB for Seniors. I'm sure many people wrote to Deb Mathews, and THANK YOU.

Roche stops dalcetrapib trial for lack of benefit

Thu, 10 May 2012 13:46:21 EDT

Dear Dr K - while we admit that it's very hard to monitor, in the interest of promoting clarity and accountability, we have implemented a new policy on pseudonyms. As indicated below: This forum is intended as a frank but respectful dialogue between healthcare providers, clinicians, and physicians. People found to be using a pseudonym will have their posts removed. To amend your username, visit your profile page at theheart.org/profile/edit.do Please modify your profile settings. Thank you, Steven Rourke Editorial programming

Cheese, please: Could a little Grana Padano drop your BP?

Thu, 10 May 2012 08:11:13 EDT

thanks for that info on riboflavin; i didn't know that; new area to esplore

Roche stops dalcetrapib trial for lack of benefit

Thu, 10 May 2012 06:03:03 EDT

"Torcetrapib was abandoned when studies showed it appeared to increase the risk of cardiovascular events despite substantially increasing HDL-cholesterol levels." "With no off-target effects on activating RAAS, dalcetrapib was regarded as a "clean" CETP inhibitor" The difference between science and fantasy. So far there is no evidence that CTEP inhibitors are beneficial and real evidence of potential harm. That is what we know at this point. To say that dalcetrapib was not potent enough would be the equivalent of saying that dietary reduction of fat is of no use. The explanation of RAAS activation by torcetrapib is convenient and likely untrue. It is interesting over the years to see how experienced researchers on the payroll of pharmaceutical companies spin "disappointing results."

More adverse events seen on dabigatran vs warfarin

Wed, 09 May 2012 21:09:20 EDT

I actually include in my conversation the "class action frenzy" that comes with any new medication or new class of medications.I have started using my office walls as "bill boards" rather than boring pictures of blood vessels and cardiac anatomy. I still use those but I find the information I post regarding nitro refills, the mediterranean diet, the issues of compliance, sodium reduction, etc. is far more productive for my patients. I think I'll add the "class action lawyer feeding frenzy" on Pradaxa, Xarelto and others to the information. My dad bled on pradaxa and he complained that "see that Pradaxa made me bleed". "No, dad. It didn't", I replied. " You had a huge Dilifouy lesion in your duodenum that bled buckets. Pradaxa saved your life. It unmasked a problem that could have gotten you into horrible trouble later on." The bleeder was cauterized and he accepted Clopidogrel/aspirin for the time being. Eventually he needs to get back on Pradaxa because his CHADS-VASC is at least 6. I hope he will try it again. Melissa

Cheese, please: Could a little Grana Padano drop your BP?

Wed, 09 May 2012 17:09:44 EDT

Other agents in milk, such as riboflavin have been shown to cause similar drops in bp. I don't know how much riboflavin is in this particular cheese but the point I wish to make is the active agent could be any or a variety of substances not just the tripe prides.

Roche stops dalcetrapib trial for lack of benefit

Wed, 09 May 2012 14:58:24 EDT

While there are no "pure" HDL-C raising interventions per se, the failure of interventions which raise HDL-C while also lowering TG or lowering LDL-C, such as Niaspan, is still counter to the 'reverse cholesterol transport' (or HDL, or, for that matter, lipid) hypothesis. Also, if evacetrapib or anacetrapib indeed reduce LDL by 35% to 40%, in addition to raising HDL by more than 100%, then even if they do turn out to significantly reduce hard outcomes, they will not necessarily support the HDL hypothesis. Any benefit could simply be through the LDL (or other) mechanism. HPS-2 THRIVE remains in play, but let's not forget that almost half of its pts are in China, with questionable applicability to American pts. Does anyone know if a separate non-Chinese analysis was pre-specified? Some predicted the futility of raising HDL (particularly when LDL were low). See, for example, the meta-regression at BMJ 2009;338:b92. I, too, would like to see a RCT with one of these HDL-raising/LDL-lowering agents on a statin-intolerant population. One would think that that market would be large enough to motivate a drug company and there would be no ethical concerns vis a vis withholding statins.

Roche stops dalcetrapib trial for lack of benefit

Wed, 09 May 2012 13:42:16 EDT

Always interesting to read the blog comments. It is in fact not difficult to be a Monday morning quarterback and we should probably all try to do it less. Other, more potent inhibitors of CETP (which include LDLc lowering) may indeed still be beneficial and its right that those programs continue but I would love to see a study of these agents in patients who cannnot tolerate statins. Clearly of limited value in setting of good LDL control with statin. And good to be reminded that much 'reverse cholesterol transport' still occurs through efficient LDLc turnover.

BP and lipid tests in pharmacies could boost risk-factor control

Wed, 09 May 2012 13:18:08 EDT

Study after study shows not only that lowering carbs lowers BP, but also the mechanism is well understood. Elevated blood sugar from eating carbs increases insulin. Insulin tells the kidneys to retain sodium and elevated sodium increases blood volume, I.e., increases BP. Eliminating carbs is significantly more effective than cutting salt, especially since cutting salt may not actually be effective at all. There is nothing slightly controversial about this effect. Why isn't the first line for MDs to ask patients to significantly lower carb intake, rather than medicate? My experience when asking practitioners why they do not, is oh, well, most patients would find it difficult to cut carbs. So don't tell smokers to quit because it is also difficult?

Analyze this Doppler signal from a 45-year-old man with dyspnea

Wed, 09 May 2012 12:21:32 EDT

Exactly right. Can't give away too much information up front without compromising the teaching point.

Roche stops dalcetrapib trial for lack of benefit

Wed, 09 May 2012 12:05:03 EDT

The results of Dal- OUTCOMES could be predicted by the failure to see an increase in FMD in dal-VESSEL. So, why not a repeat study wherein statin naive subjects are randomized to 3 months of atorvastatin 80/d or placebo, following baseline FMD. Then to both groups give rHDL infusions and repeat the FMD? I would think NHLBI would be interested in such a study so as to answer the question, one way or another as to whether or not raising HDL will benefit patients already maximally treated with a statin, regardless of how HDL is raised.

Analyze this Doppler signal from a 45-year-old man with dyspnea

Wed, 09 May 2012 11:22:19 EDT

Enjoyed the explanation - it's nice to think through the timing and velocities of the jets. It's not very representative of real-world echo, since you don't have the 2D image of the heart to assess the site of interrogation, but I appreciate that you hid it to make your points.

Bypass moderate coronary lesions? Taking sides in the debate

Wed, 09 May 2012 09:56:07 EDT

Is there any way to write this article even more confusing?

Roche stops dalcetrapib trial for lack of benefit

Wed, 09 May 2012 09:43:44 EDT

May seems toe be a bad month for "HDL-Raising" RCTS--in May 2011, our AIM-HIGH was halted for lacxk of clinical efficacy 18 months earlier than planed and this week, Dal-OUTCOMES appears to end the promise of another CETP inhibitor. With no off-target effects on activating RAAS, dalcetrapib was regarded as a "clean" CETP inhibitor, but the BIG unknown is whether this pathway to HDL-raising, despite creating marked increases in plasma HDL-C concentrations, may result in dysfunctional HDL-C regardless of how high the levels are. Time will tell whether this is a class action effect, or drug-specific. While it's easy to become cynical that the landscape is littered with failed attempts to reduce CV events with drugs that raise HDL-C and to beat the drum harder and louder for more LDL-C reduction, residual risk DOES persist in pts with even LDL-C levels in the low 60's. But, what we don't know is whether this residual risk is lipid-related (? HDL-C, non-HDL-C, LDL particle number, etc.) or related to one or more of the other variables shown in INTERHEART to contribute to incident CV event rates. Both niacin and fibrates HAVE been shown to reduce atherosclerosis progression using surrogate outcome measures in NON-STATIN-treated patients. HPS-2 THRIVE remains in play, so the case is not closed here for niacin. As Wayne notes, eNOS activation by HDL-C via the SR-B1 receptor could explain, wholly or in part, the failed results so far of statin + niacin/fibrate and statin + CETP inhibitor trials to date. But, we also don't know if the noncompetitive statin binding is operant across the complete range of baseline HDL-C levels. We really have not had RCTs that have enrolled patients with HDL-C values 5 years). Like ENHANCE, delipidation of the necrtic lipid core with intensive, prolonged statin therapy may negate the incremental benefit attributed to additional agents like niacin or fibrates. Lastly, we must remember that it is fictitious and overly-simplistic to label various agents (fibrates, niacin, CETP inhibitors, and fish oil) as "HDL-raising therapies". These agents alter many targets, as niacin decreases TG, Lp(a), LDL-C, and particle number. There is no "pure" HDL-C raising intervention per se. Nevertheless, the Dal-OUTCOMES Trial news is disappointing, and raises legitimate doubts about this class of agents--especially if they are given to all-comers with even normal to slightly high HDL-C at baseline.

Roche stops dalcetrapib trial for lack of benefit

Wed, 09 May 2012 08:37:36 EDT

Indeed dalcetrapib may be a weaker CETP-Inhibitor than anacetrapib, finally most of the clinically developed CETP-Inhibitor differ to each other and coming to early conclusions on class-effect seems not be appropriate. Nevertheless I would like to know what this failure means for the discussion of HDL-function and the area of reverse-cholesterol transport

Roche stops dalcetrapib trial for lack of benefit

Wed, 09 May 2012 08:27:06 EDT

The results of this study, along with many others including AIM-HIGH, can be seen in figure 6 in Br J Pharmacol.2010;160:1765-1772. These data show that both statins and HDL activate eNOS via the SR-BI receptor and that statins are more efficient at doing this and they do it in a noncompetitive fashion so that no matter how high the HDL level statin binding can not be overridden. Therefore, if statins are baseline therapy,as in all HDL raising trials except Helsinki and VA-HIT, there will be no effect seen from HDL raising drugs, regardless of how potent they are on increasing HDL, since the real mechanism of event reduction is eNOS activation and NOT reverse cholesterol transport.So, another nail in the coffin known as HDL raising therapies!

Cheese, please: Could a little Grana Padano drop your BP?

Wed, 09 May 2012 08:16:00 EDT

osteoporosis is a cardiovascular disease; vitamin k2 (found in aged cheeses) activates enzymes in bone that builds bone and activates enzymes in blood vessels to keep calcium out of these vessels; (Rotterdam heart study)

AIM-HIGH and the HDL Paradigm in Focus

Wed, 09 May 2012 06:43:09 EDT

Would be/could be the larger HDL population,.. carrying the greater RCT & PON-1 levels,.. that plus an MPO assay to determine a good reading on dysfunctionality,.. viable HDL2/HDL2[b] & lack of MPO elevations,.. if not optimal,.. treat/increase treatment with statin/niacin/Omega combinations,..

Analyze this Doppler signal from a 45-year-old man with dyspnea

Wed, 09 May 2012 06:07:18 EDT

Any time

Analyze this Doppler signal from a 45-year-old man with dyspnea

Wed, 09 May 2012 05:20:24 EDT

Nice case. Thanks for your comments.

Cheese, please: Could a little Grana Padano drop your BP?

Wed, 09 May 2012 05:02:03 EDT

grana padano or parmigiano reggiano, the best dietary calcium supplements (total calcium introduction 1000mg or 1200 mg a day) against osteoporosis . Is osteoporosis a cardiovascular disease ?

New IOM report addresses obesity prevention

Tue, 08 May 2012 21:34:20 EDT

A pioneering suggestion would be to dismantle the corn industry by eliminating the food subsidies that have been provided to the midwestern states since the 1970s. The advent of fast food, coupled with the proliferation of high-fructose corn syrup over the past 30 years, has served to substitute America's former obsession with smoking with our current indulgence of sugar-laden food products. In short, our current obesity epidemic is curable, but it will require a monumental political undertaking, which no current political candidate or incumbent individual can attempt. If we are truly focused on reducing the obesity epidemic, with its attendant cardiovascular sequelae, then we must take responsibility collectively as a nation, and admit that all the food products in our stores and along all major roads and highways provide no serving of health, but only serve to dismantle our well-being. Maybe our political leaders should focus their energies, not on how to provide health care coverage to more individuals, but on how to provide healthier eating choices. All echelons of society are at risk of this contaminated food supply, so removing processed food from our communities would benefit all classes of individuals. Too much is at stake to ignore this issue...

More adverse events seen on dabigatran vs warfarin

Tue, 08 May 2012 19:35:02 EDT

All I needed to see was this............. Wurster is chief medical officer of Standing Stone, a subsidiary of Alere, which manufactures of anticoagulation monitoring and management services. Wallentin has been involved with both the RE-LY and ARISTOTLE trials. So he represents the anticoagulation industry, which is threatend by the ne AC's as they will lose business. I am domfounded by the lack of trial design in this so called "study". I think using patients who tolerated warfarin for at least six months is a joke and seriously biases the "study" is wrongheaded and at first thought this was a hit piece from J&J or BMS/Pfizer. I am really dismayed at the lack of peer review that you exert and will publish anything negative regading dabigatran..regardl;ess of the scientific rigor... what if I say Xarelto causes cancer, would you print that on the basis of one terminally ill patient who died while taking this?

Analyze this Doppler signal from a 45-year-old man with dyspnea

Tue, 08 May 2012 18:45:04 EDT

Glad you enjoyed it!

Dr David Rosenbaum dies, age 54, of pancreatic cancer

Tue, 08 May 2012 17:57:48 EDT

An extraordinary mentor, scientist, and teacher...the Cardiology community has suffered a major loss. I was blessed to have worked for him!

Analyze this Doppler signal from a 45-year-old man with dyspnea

Tue, 08 May 2012 17:44:52 EDT

Thankz Alot, Awsome tracing.

Analyze this Doppler signal from a 45-year-old man with dyspnea

Tue, 08 May 2012 13:12:58 EDT

(1) Mitral inflow would have a distinct 'E' and 'A' wave (as the rhythm is sinus), and (2) Mitral regurgitation would start without any "gap" after mitral inflow. Mitral regurgitation starts during the isovolumic contraction period; LVOT and RVOT flow start in the ejection period.

WHF defends Dubai WCC, reimburses Israelis denied visas

Tue, 08 May 2012 12:57:16 EDT

I think that the answer given by Dr. Ralston is very simplistic. I can understand that the WHF can have a hard time choosing a place for the world congress but I think there is no excuse to visa denials without proper explanation. Hope next congress will be held in a more neutral country.

New IOM report addresses obesity prevention

Tue, 08 May 2012 12:20:20 EDT

Haven't we been discussing this right here on this forum FOR YEARS?????? I do NOT want the government doing anything but allowing those blighted abandoned lots in the downtown areas (or wherever) to be reclaimed by the neighbors and turned into useful gardens!!!!!! TEACH the neighbors how to garden, fix, and preserve the food "like way back when". gEt out there and weed! Work off those calories. Walk your dog---walk your cat, walk your kids. Lie on the florr and lift that grandbaby up in the air over you time and time again---play "horsie". You can't legislate this away......but with the little girl (kindergarten) who got her brown bag lunch taken away from here and was "forced" to eat the cafeteria lunch by a food inspector----WRONG!!!!!! So telling food chains what to fix and not to fix won't work----let the consumers decide---if we don't buy something, it won't be prepared anymore. If we ask for more fruits/veges they'll be ordered. It's a choice in most instances. Let's make it an informed choice---and grow this next generation the proper way---recess, play outside all day, drink lots of water, don't give the spinach to the dog (he waon't eat it either). But keep government out of it.

Analyze this Doppler signal from a 45-year-old man with dyspnea

Tue, 08 May 2012 11:47:35 EDT

Why this is not MS with MR ?

New IOM report addresses obesity prevention

Tue, 08 May 2012 10:54:03 EDT

Since 1977 the US government and the medical establishment has pushed the �low fat diet�. All calories and all foods are NOT the same. The feedlot meats, the �factory� eggs, the GMO corn and wheat, vegetables grown in mineral-depleted soils lead to this problem. Exercise is not going to solve America�s obesity and autoimmune diseases. What if It's All Been a Big Fat Lie? By Gary Taubes Published: July 07, 2002 New York Times

Roche stops dalcetrapib trial for lack of benefit

Tue, 08 May 2012 10:52:44 EDT

There seems to be a pattern developing. So far, any drugs whose sole effect is to change blood lipids, such as niacin, ezetimibe, fibrates, and the CETP inhibitors have no signficant effects on plaque progression and/or CVD mortality or cardiac events. Statins have direct effects on arteries independent of their lipid effects which probably explains the reduction in "need" for "revascularization", the major effect in controlled trials in secondary prevention.

Bypass moderate coronary lesions? Taking sides in the debate

Tue, 08 May 2012 10:08:55 EDT

Focusing only on moderate lesions, he said, their progression rate on the left side is high if bypassed but higher if not bypassed. "So our data would favor grafting that left-sided moderate lesion." this statement shocked me ,puting an indication for bypass surgery on the basis of the lesion severity and forgeting the complexity of the problem, what if the patient have more stenosis but less or no ischemia,what if he has more stenosis but much more collateral circulation, what if we find that those more severe lesions are more stable,...

Mixed findings with vitamin D in hypertension

Tue, 08 May 2012 09:53:28 EDT

It 's ever the same story. We are at the beginning. We have to wait some years and .. at the end.... We''ll know if vitamin D can have some useful cardiovascular effect.

WHF defends Dubai WCC, reimburses Israelis denied visas

Tue, 08 May 2012 08:59:59 EDT

In the interest of professional, scientific discourse--and in the context of a contentious and inflammatory topic--let's all try to refrain from accusations which will send the exchange into an unproductive tailspin. Thank you, Steven Rourke Editorial programming Theheart.org

More adverse events seen on dabigatran vs warfarin

Tue, 08 May 2012 07:03:56 EDT

How can you take this so called study seriously It�s crazy out there in blood thinner land. The novel blood thinning drug for patients with atrial fibrillation, Dabigatran (Pradaxa) cannot get a break. It�s all over the TV: Pradaxa = Bad Drug. Look at this image: Today, on the prestigious heart news site, theHeart.org, an insignificant 113-patient study presented as a poster at a small symposium�by a researcher with ties to anti-coagulation clinics�gets attention because a few patients on dabigatran developed well-known complications. Though the author makes important points, namely, that blood-thinners should be used cautiously and patients should be well-informed about the risks and benefits, the study added nothing to what is already known about dabigatran. Gosh. I can�t believe I feel a twinge of empathy for a big pharma company. Here�s a news flash: Dabigatran and rivaroxaban are blood thinners. They lower the risk of stroke, but increase the risk of bleeding. It�s the same for warfarin. When these two agents were compared to warfarin in huge randomized controlled clinical trials, they both looked favorable. For my entire career, I have heard the downsides of warfarin. Now, we have two drugs that prevent more strokes than warfarin, don�t require blood checks, have no dietary interactions, minimal drug-drug interactions and are not used to poison rats. Do they worsen bleeding when one falls? Yes. So does warfarin. Folks, of course it is better to not have a disease that increases the risk of stroke. That�s what I have been saying since I started this blog. Prevention is better. Go to bed on time, exercise every day that you eat, eat less, drink fewer irritants, don�t sweat getting a B+ and smile at your neighbor. I know; these are hard therapies with which to comply adhere. But blood thinners are not bad medicines. They are medicines. They have risks and they have benefits. And the alternative: a patient can have the disease and its inherent risks.

ASCERT CABG, PCI analysis: Lower mortality with surgery

Tue, 08 May 2012 07:00:15 EDT

It is seldom possible or appropriate for the �evidence base", be it from RCTs or registries, to solely dictate best management in any single case. RCTs and registries both allow us different types of insight into where benefit and harm might accrue. We need to try to select the best treatment on an individual patient basis, taking all factors into consideration. Profit and ego must not be allowed to shape what we do. If our practice is in line with current best RCT evidence AND our denominator population has a similar set of demographics to those of the RCTs (which is often not the case!), we should see gradual emergence of similar proportions of cases referred for each revascularisation strategy as the trials imply to be appropriate. That should get us about as close to the ideal as possible. There is then the need for accurate, risk adjusted, statistically robust and transparent outcomes data for every surgeon and interventionist.

New JNC 7 hypertension guidelines released

Tue, 08 May 2012 06:26:13 EDT

One of the best things to have happened to me,all my questions reg hypertension have been answered, I WILL B THAT MUCH more confident while treating these cases in future.I CANNOT THANK ENOUGH

What is the clinical significance of electrical alternans in this tracing?

Tue, 08 May 2012 02:33:28 EDT

interesting not unkown tracings. Educative comments. Thanks. H. Weber

WHF defends Dubai WCC, reimburses Israelis denied visas

Tue, 08 May 2012 01:55:40 EDT

As the truth about this situation will never surface, it seems to me that the WHF should consider Israel as a venue for a future WCC.

WHF defends Dubai WCC, reimburses Israelis denied visas

Tue, 08 May 2012 01:16:21 EDT

it is possible that some israeli nationals can not enter dubai .reason: the more than 20 israeli secret agents who killed the palestenian almabhoh in a hotel in dubai 2 years ago.the videos were widespread.

Lifestyle-based primary-prevention program results in weight loss, other changes

Tue, 08 May 2012 00:19:56 EDT

These promising results most likely had more to do with reductions in simple carbohydrate consumption, a parameter not measured but that always drops when groups adopt a dieting approach. The increase in HDL further suggests that carbs were reduced since lowering carb intake lowers trigylcerides, and triigylcerides are inversely correlated with HDL. Any medical textbook will explain that adipose tissue grows in the presence of insulin (eating carbs), and adipose tissue shrinks when insulin levels drop. Exercise has never been shown convincingly to cause weigh loss. Calorie restriction almost never produces long term weight loss. Salt reduction may actually increase adverse events. But other than that, this study was on the right track.

More adverse events seen on dabigatran vs warfarin

Tue, 08 May 2012 00:00:46 EDT

well, not really. Yet another drug which appears promising in clinical trials, is heavily marketed by industry, and when prescribed widely is not as safe as initially reported. Have we heard this one before?

WHF defends Dubai WCC, reimburses Israelis denied visas

Mon, 07 May 2012 22:30:33 EDT

The visa denial was not limited to the Israelis. One cardiologist from Myanmar could not get the visa on time so his trip has to be cancelled at last minute. The reason given was that his name was on the black-list. But he has never been to Dubai before and he is the Professor of Cardiac Surgery. A complaint was sent to MCI group who took care of the logistics for WCC Dubai but no reply came through. What a disappointment!

Roche stops dalcetrapib trial for lack of benefit

Mon, 07 May 2012 20:54:28 EDT

May 2012 when Phase III trials failed to show clinically meaningful efficacy the study was halted. The FDA has given up on surrogate markers

Present-day efforts to aid quit-smoking attempts are substandard, says expert

Mon, 07 May 2012 20:47:08 EDT

Important article about an important study! I remember working with a not-to-be-named-but-very-famous interventional cardiologist, when his secretary interrupted us and said, "Mrs. X is calling about her father, who you did a procedure on yesterday. She wants to know if you can recommend a support group for him to join to help with smoking, exercise, diet, etc." The cardiologist curtly replied, "Why does he need a support group? Wasn't laying on the table for an hour and having a balloon stuck into his heart enough of a wake-up for him?" In other words, not only did I cure his stenosis, but the shock and awe I subjected him to should have cured all his bad habits too! Yes, those were the Old Tymes, but unfortunately they are, as Dr. Pipe says, still with us. Smoking is a medical problem and needs to be addressed with therapy, be it cognitive, drug-based, whatever...and with ongoing care. Healthcare. As in "care". As in "I care"! Thanks for bringing this study to the attention of all. Burt Cohen Angioplasty.Org

Analyze this Doppler signal from a 45-year-old man with dyspnea

Mon, 07 May 2012 18:33:23 EDT

...for your comments. Glad you liked it.

Present-day efforts to aid quit-smoking attempts are substandard, says expert

Mon, 07 May 2012 17:27:22 EDT

I about only use Chantix for tobacco cessation. Chantix-like drug has been in East Europe for 40 years! (1963) , I actually had a patient who bought this drug in what was East Berlin in the early 1980's. I was clueless at that time. Cytisine is a nicotinic acetylcholine receptor agonist, and as a pharmaceutical preparation, it is available for the treatment of nicotinism. It is extracted from the seeds of Cytisus laborinum L. (Golden Rain acacia) and has been available in former socialist economy (FSE) countries for more than 40 years as an aid to smoking cessation under the brand name Tabex produced by the Bulgarian pharmaceutical company. It was first marketed in Bulgaria in 1964 and then became widely available in FSE countries. The cytisine derivative Chantix (Champix) varenicline was approved in 2006 by the FDA as a smoking cessation drug. There is some evidence cytisine may be prescribed to aid in smoking cessation. On September 29 2011, the first large scale double blinded trial comparing cytisine to placebo in smoking cessation was published in the New England Journal of Medicine, showing that cytisine improved 12-month abstinence from nicotine. The cytisine derivative varenicline Chantix was approved in 2006 as a smoking cessation aid.

Analyze this Doppler signal from a 45-year-old man with dyspnea

Mon, 07 May 2012 16:59:36 EDT

Just saw a case recently (29yr old woman) with dynamic RVOT obstruction due to supravalvular narrowing/hypoplasia of the distal main PA and branch PAs. Peak gradient ~ 85 mmHg. I agree TEE is not very useful for looking at this area. The gradients are much better by TTE and the site of step-up in gradient can be identified by PW while CW gives the maximum gradient.

Roche stops dalcetrapib trial for lack of benefit

Mon, 07 May 2012 16:41:25 EDT

Two Things: A. Real bad for the whole CETP inhibitors class. So, it is not only safety (torcetrapib), but also lack of CV efficacy (dalcetapib). Most likely it was very few events in dal-OUTCOMES what is currently repeatedly happening when events are properly counted. Roche should be applauded for the fast and honest decision, integrity of the DSMB, and guts and glory not to cheat on their shareholders with costly dragging of the agent in later development. B. Reading Dr. Nissen comments is always fun. His statement that dalcetrapib have a low chance to make it since it is a weak CETP inhibitor will be of great value if made BEFORE the drug has been discontinued. I found no prior record of such visionary statements. So, what I am reading between the lines here is a clear danger that Lilly may hold with the Phase 3 evacetrapib trial, for which Dr. Nissen is a chair. If in my next life I will be running such a trial, and bad news will come in such a bad time, I will be scared too. However, bashing the other late-stage CETP-inhibitor after it has been discontinued in order to save your own study is at least questionable.

WHF defends Dubai WCC, reimburses Israelis denied visas

Mon, 07 May 2012 15:31:10 EDT

WCC should be more intelligent in place selection for Congresses.

Ideal blood-pressure goals? "We have no idea"

Mon, 07 May 2012 15:13:57 EDT

One study I believe found that the optimal benefit of treated pressure was about 140 and that at lower levels mortality rates trended higher. Perhaps some time needs to be spent finding the optimal point even if it turns out not to be as low as now recommended?

Lifestyle-based primary-prevention program results in weight loss, other changes

Mon, 07 May 2012 15:10:18 EDT

Granted, I have not reviewed the literature; I wonder if someone has done a cost analysis of cardiac rehab in PRIMARY prevention. We know it is cost effective in secondary prevention, but I wonder about widespread rollout in high risk prevention patients?

Cheese, please: Could a little Grana Padano drop your BP?

Mon, 07 May 2012 14:32:13 EDT

Are there any cases (I assume in Italy) of hyperkalemia or acute renal failure from this cheese?

WHF defends Dubai WCC, reimburses Israelis denied visas

Mon, 07 May 2012 14:25:56 EDT

I was there attending WCC in Dubai ,It was highly organized and informative ,It added more to the CVD prevention and management in the area and the world,I respect that country and the leaders there.

What is the primary ECG disorder shown in this tracing?

Mon, 07 May 2012 14:06:04 EDT

He was born in 1900 and the second tracing was taken in 1970, when he was 70 years old.

What is the primary ECG disorder shown in this tracing?

Mon, 07 May 2012 13:57:02 EDT

It must be. The calibration was doubled for the reason unknown to me.

More adverse events seen on dabigatran vs warfarin

Mon, 07 May 2012 13:53:48 EDT

There is also no antidote for the bleeding with Pradaxa, which is a serious downside that has to be considered

What is the primary ECG disorder shown in this tracing?

Mon, 07 May 2012 13:22:06 EDT

Since the first tracing was taken in 1949, it may have been recorded when the patient was quite young and the second one after a number of years. Since there is evidence of "dual AV pathways physiology", could this be regarded as a chronic anterograde block of the "fast pathways?". The more recent tracing (assuming a normal calibration) shows quite prominent P waves; could you comment on that?

Comparison of risk-assessment strategies favors "statins for all"

Mon, 07 May 2012 11:39:15 EDT

independently of many unknown underlying processes and risks factors. HYPERCHOLESTEROLEMIA is still a noxious stimuli that trigger atheroscleorsis

Anhedonia, not depression or anxiety, linked with death following ACS

Mon, 07 May 2012 11:23:46 EDT

I agree Victor Serebruany.Maybe these 3 mental conditions are due our occidental style of life,which worsen all our health or perception of being well.

Bypass moderate coronary lesions? Taking sides in the debate

Mon, 07 May 2012 11:16:31 EDT

I agree Dr Feeman. and what about 60% left main no suitable for stenting?

More adverse events seen on dabigatran vs warfarin

Mon, 07 May 2012 11:10:32 EDT

I agree # 1 of 2 and # 2 of 2.We also should be cautious about prescribing Dabigatran in CAD patients.

WHF defends Dubai WCC, reimburses Israelis denied visas

Mon, 07 May 2012 10:59:10 EDT

I have attended the WCC in Dubai and I had the best impression of that country. They are a big nation, very polite people. Although there are cultural differences, I see them as good friends. I recomend everybody that go and visit Dubai

Bypass moderate coronary lesions? Taking sides in the debate

Mon, 07 May 2012 10:29:38 EDT

Why bypass them. Modern medical therapy can stabilize/regress plaques, obviating the need for bypass.

Cheese, please: Could a little Grana Padano drop your BP?

Mon, 07 May 2012 08:35:39 EDT

�Let food be your medi- cine,� so said Hippocrates,

Cheese, please: Could a little Grana Padano drop your BP?

Mon, 07 May 2012 07:37:30 EDT

proteins found in whey from milk have natural ACE like effects; they sell them in supplements already in vitamin shops - i.e. C12peptide

Analyze this Doppler signal from a 45-year-old man with dyspnea

Mon, 07 May 2012 07:29:58 EDT

That's a great tracing, author makes a clever point about how to figure out source of systolic high velocity Doppler signal by paying close attention to accompanying diastolic signal. As in this patient the high velocity signal profile looks like either AS or PS, but AS would not b a possibility because accompanying AI signal would be of much higher velocity, given low velocity and the profile of accompanying diastolic signal nothing else other than PS with accompanying PI would make sense. Of the given options only one which suits best with PS is balloon valvotomy

Analyze this Doppler signal from a 45-year-old man with dyspnea

Mon, 07 May 2012 06:27:16 EDT

No. Aortic Insufficiency cannot have velocities as low as this. The end-diastolic jet of 2 m/s suggests a gradient between the aorta and the LV of 16 mmHg. So if the LV pressure is, for example, 10 mmHg at end diastole, that means that the aortic pressure is 26 mmHg. So this is not aortic stenosis - it's pulmonic stenosis, as you can see in the subsequent tracings. Often, adult cardiologists do not think about the pulmonic valve, which is why I showed this case.

Analyze this Doppler signal from a 45-year-old man with dyspnea

Mon, 07 May 2012 01:50:28 EDT

I disagree that diastolic flow is mitral inflow without E, A wave. It is the Aortic insufficiency jet during diastole.In my opinion this patient has severe AS and AI. What does balloon angioplasty going to do for severe AS .only considering patients age valve replacement is the proper intervention but is the patient is a suitable candidate or not will dictate is it going to be open heart surgery or TAVI .

Statin therapy changes plaque composition fast

Sun, 06 May 2012 15:36:02 EDT

thanks Dr King

Ideal blood-pressure goals? "We have no idea"

Sun, 06 May 2012 15:25:11 EDT

Solely on the basis of my opinion hipertensive older patients should keep their diastolic blood pressure above 80 and their systolic between 130 and 140.Younger patients without other risks factors close to <140 and <90 is Ok.But with other risks specially with diabetes and kidney disease <130 and <80 is ok, CAD patient if they are stable <140/90 if ok, but if they are unstable <130/80 should be better.However in general I guess that the lowest blood pressure you can stand the better for your cardiovascular system.People living today on the basis of paleolithic food have 110/70 and cardiovascular diseases are extremely rare

Analyze this Doppler signal from a 45-year-old man with dyspnea

Sun, 06 May 2012 14:54:04 EDT

but have to disagree: TEE is best for looking at posterior structures, since the probe is behind the heart. Supravalvular pulmonic stenosis is very uncommon; congenital PS is a far more often encountered entity. If more anatomic information were needed, a cardiac MRI would be the best option. The point of the question though - given the choices - is to realize that with all of the information provided, the Dopper signal could not be through the tricuspid, aortic, or mitral valves; that's what this is really about.

Analyze this Doppler signal from a 45-year-old man with dyspnea

Sun, 06 May 2012 14:13:44 EDT

Given that diagnosis of the exact location of the stenosis (especially valvular vs. supra-valvular) may not be that easy (especially with an "old" Sonos), I would still go for TEE before any operative decision.

More adverse events seen on dabigatran vs warfarin

Sun, 06 May 2012 12:49:00 EDT

Currently , we should restrict use of Dabigatran to patient not responding to warfarin .

Anhedonia, not depression or anxiety, linked with death following ACS

Sat, 05 May 2012 01:05:55 EDT

A. Anhedonia - inability to feel pleasure; B. Anxiety - .... worry, nervousness, unease; C.Depression - ... mental disturbance, hopelessness, lack of energy, no interest in life So, A seems like a symptom of B. and C. I can hardly believe that depressed patients usually feel a lot of pleasure. Do we know that depression in general cause more CV events including CV death? Definitely "Yes". Was it a strong consistent trend that SSRI's improve CV prognosis. Hell "Yes" in 3 trials. Were ALL these earlier studies larger, and randomized at least matching the quality of ENRICHED - "Yes". So, are we playing word games pretending we made a scientific discovery, or conduct evidence-based research ?

More adverse events seen on dabigatran vs warfarin

Sat, 05 May 2012 00:52:11 EDT

Avoid Pradaxa in elderly, renally impaired, patients at elevated cardiac risk and at a higher risk of bleed. Do home monitoring when ever possible when patient is on coumadin

STAMPEDE and DIBASY: Bariatric surgery for obese patients with diabetes

Fri, 04 May 2012 16:31:39 EDT

The low carbohydrate diet was exposed by WILLIAM BANTING. 4th Ed in 1869, for normalizing weight. The American �low fat diet� in 1977 has killed more Americans and Europeans than World War II. The medical establishment and the Pharmaceutical Industry are heavily invested in the low fat dogma. How do you say �never mind�.

Ideal blood-pressure goals? "We have no idea"

Fri, 04 May 2012 13:41:17 EDT

Sok-Ja Janket, ZhGS formulas connect ideal SBP, DBP, MAP and PP with age of patients . Our can found ZhGS formulas in our papers.

Small study links Tasers to cardiac arrest

Fri, 04 May 2012 13:16:44 EDT

has CAD or microvascular dysfunction and has to restrain a violent criminal? Is that of any concern?

Lifestyle-based primary-prevention program results in weight loss, other changes

Fri, 04 May 2012 13:13:07 EDT

The overall prevalence of cigarette smoking in Ireland at June 2010 was 23.6%. In Ireland at the present time 39% of adults are overweight and 18% are obese. Of these, slightly more men than women are obese and there is a higher incidence of the disease in lower socio-economic groups. Adult counterparts Irish children are also consuming large amounts of sugar energy dense foods outside the home. A recent survey revealed that slightly over half of these children ate sweets at least once a day and roughly a third of them had fizzy drinks and crisps with the same regularity. Sugar sweetened carbonated drinks are thought to contribute to obesity and for this reason the World Health Organization has expressed serious concerns at the high and increasing consumption of these drinks by children.

STAMPEDE and DIBASY: Bariatric surgery for obese patients with diabetes

Fri, 04 May 2012 12:55:31 EDT

There is a scientificially proven alternative to the scientifically nonproven bariatric surgery (BS). The methods have never been compared. But it�s obvious why. The only way to decrease weight is by reducing the amount of carbohydrates. All weight reducing methods includes reduction of one common macronutrient, carbohydrates. There are two ways to reduce the carbohydrates. Both diets can you eat till you die. 1. Eat 800 calories normal food with 50 E% carbs, 15 E% protein and 35 E% fat. 50 E% carbs is 100 g glucose. But you'll be hungry all the time. 2.Eat 2 500 calories with 16 E% carbs, 15 E% protein and 69 E% fat. That is 100 g carbs. And you�ll be satisfied all day. Both diets will give the same weight loss in less than 6 months. The first diet will starve the patient to death within several months or the patient restarts to eat more food, i.e. carbohydrates again with regain of weight to initial weight or more. The second diet will give permanent weight loss for decades and the patient will be free from diabetes as well. It�s all about old fashioned physiology and old fashioned biochemistry. So why BS?

Small study links Tasers to cardiac arrest

Fri, 04 May 2012 12:34:43 EDT

Observational data are so shaky, its a wonder that anyone finds them useful. The taser is used on violent or resisting ofenders, you could just as easily conclude that violence causes VT or VF. I think it would be safer to conclude that if you don't become violent or resist then you will not need to worry about VT or VF.

Small study links Tasers to cardiac arrest

Fri, 04 May 2012 12:25:21 EDT

I would like to know how a taser would affect a patient with undiagnosed microvascular ischemia and is at risk for SCD, due to the cumulative nature of ischemic injury. I would imagine that nitro would be a critical need, and any vaso-constricting agent such as epinephrine would add further risk. The problem with the tasering is the attitude that it is not really lethal, when a significant part of our population carries cardiac risk. The over-application of tasers for non-violent issues, such as political protesting or mental illness type non-compliant behavior vs actual dangerous violent behavior toward police is of great concern to me.

Beware valve involvement in device-related infective endocarditis

Fri, 04 May 2012 11:31:23 EDT

Failure to explant the entire infective device is fraud. Doctors must be more agressive with these infections. Perhaps even prophylactic antibiotics for predetermined time after leaving medical facility when initially installing these devices.

Small study links Tasers to cardiac arrest

Fri, 04 May 2012 11:27:47 EDT

What is the alternative? punches and kicks? tranquilliser gun? Which one seems less dangerous?

Ideal blood-pressure goals? "We have no idea"

Fri, 04 May 2012 10:57:43 EDT

Interesting concept! The goal for lipids is lower in patients in their late 60's and 70's. I am not aware that there are any BP goals, since younger patients with AMI tend to be dyslipidemic cigarette smokers with normal blood pressures, whereas older patients with AMI tend to be those with dyslipidemia with/without hypertension, but no current cigarette smoking. My never-smoking diabetics die on average at 80 years of age.

Statins, diabetes, and the FDA

Fri, 04 May 2012 05:21:13 EDT

Till now nobody can give clear answer about the connection between diabetes,statins and cognitive impairment!

Ideal blood-pressure goals? "We have no idea"

Fri, 04 May 2012 03:15:24 EDT

How do you factor Age into targets? Does each decade need its own target? Does the Glycation (AGE - Advanced Glycation -Endproducts) of elastomers and collagens (as well as HBA1c) have a bearing on this?

AIM-HIGH fell short, leaving experts looking for reasons in new review

Fri, 04 May 2012 00:34:20 EDT

Thanks for the suggestions. My target was really the cadre of other pharm options for lipid lowering. Fish oil certainly has little downside. Fish oil washed down with a Coke at McDonalds? Not so much.... The reality is that many Americans are not terribly interested in adopting a healthy lifestyle. We still don't have all the answers regarding diet.

Small study links Tasers to cardiac arrest

Fri, 04 May 2012 00:31:40 EDT

as we know even 10 joules can knock out the conduction system .as stated: those who are using these sorts of devices should be equipped to rescue victims who develop ventricular fibrillation by having AEDs and training in CPR." it is becoming legal taser field in that how do you judge the user when both the manufacturer and the user well know that it can kill but thats not the intention of the taser is it or is it ..so why use something that is not fail safe . fail safe? = failed not to kill.

Ideal blood-pressure goals? "We have no idea"

Thu, 03 May 2012 19:22:28 EDT

unfortunately we do not have a biomarker for thid vascular disease called hypertesnion we certainly have lipid targets that are proven Hba1c for glcemic control the future will bring us genomics poymorphisms etc the future will be very exciting

Ideal blood-pressure goals? "We have no idea"

Thu, 03 May 2012 18:52:09 EDT

lets remember that these companies were the first to deem what was normal back in the 1940's if i remember correctly. so how do we deal with these bozo's also i.e will they comply with our recommendations for what is normal when assessing their clients. normal for me is 150/90 and if i go below this by even 10 points i will immediately become dizzy ...so again what is normal? ..i agree we dont know.

AIM-HIGH fell short, leaving experts looking for reasons in new review

Thu, 03 May 2012 17:09:22 EDT

I would consider adding vitamin D3 & fish oil as well (plus, of course, BP medication(s), if indicated, dosed at bedtime). Admittedly, vit D3 & fish oil do not yet have the large scale RCTs to back them up, but they are each cheap, have little downside danger, and have compelling association data. For vit D3 supplementation, in particular, I recommend studying the recent: "Vitamin D Deficiency and Supplementation and Relation to Cardiovascular Health," Vacek, et al., Am J Cardiol. 2012 Feb 1;109(3):359-63. It is available on the internet as a pdf. For diet, while I agree on deleting high-carb drinks, potatoes, unnecessary sugars, & refined grains, I think that you will find that the hard outcomes data actually recommend the Mediterranean diet over low-carb and even low-fat. You might also get better long-term compliance. Important and easy to switch vegetable oils and butter to canola for cooking and olive oil for eating.

Ideal blood-pressure goals? "We have no idea"

Thu, 03 May 2012 17:07:19 EDT

Anatoly Zhirkov, if you have the numbers, please, share with us. You may calculated with a theoretical model, I could find the best BP to predict various clinical outcomes. My guess is that differenct outcomes allow different optimal BP levels. I basically aggree with William Feeman, Jr. Also, I think all 5 comments may be right in some circumstances, but one size does not seem to fit all. We Need some thinking.

Ideal blood-pressure goals? "We have no idea"

Thu, 03 May 2012 16:29:40 EDT

If we except High BP from kidney disease, most of patients with High BP have high waist circumference, i e fatty liver and insulin resistance. Attacking insulin resistance would prevent both diabetes and High BP.

Ideal blood-pressure goals? "We have no idea"

Thu, 03 May 2012 16:29:32 EDT

Remember, BP control reduces CVA and CHF, and ESRD, but it does not reduce the risk of AMI--that is to day that coronary plaques can be stabilized/regressed with excellent lipid control even if BP is way out of control.

Ideal blood-pressure goals? "We have no idea"

Thu, 03 May 2012 15:37:49 EDT

This spring was the 6th anniversary of the first presentation of ZhGS (Zhirkov, Golikov, Subbota) formulas for optimal blood pressure at the 2nd Nonlinear Science Conference in Greece. We celebrated this event with students' conference in St. Petersburg State University. Results presented at the conference revealed good correlation between BP calculated using our formulas and HOT and HYVET data. Our formulas are based on complex systems theory and on minimal energy consumption principle.

Ideal blood-pressure goals? "We have no idea"

Thu, 03 May 2012 15:36:13 EDT

How much blood pressure you can stand, once you get below 140/90, depends on your lipids and possibly on your blood sugar levels. Problems with either require a lower BP; normal lipids and blood sugars do not.

Ideal blood-pressure goals? "We have no idea"

Thu, 03 May 2012 14:03:37 EDT

Why not? The inflatable mercury sphygmomanometer has only been around for over a 100 years.Seems like a rather import concept to figure out by 2012. Apparently science wastes a lot of money on other things.

Energy drinks up BP and heart rate; calls for regulation

Thu, 03 May 2012 12:25:01 EDT

It�s the sugar (Sucrose or HFCS-High Fructose Corn Syrup) that raises the BP, obesity, heart disease...

Moderate alcohol consumption post-MI lowers risk of mortality

Thu, 03 May 2012 08:34:28 EDT

A liter of red wine a day? I have suggested the small (airline-type) 187 ml bottle per night for my patients and myself. As a medical student on an out-of-country rotation in Paris I drank a bottle of wine (750 ml) a night. I would bring an empty bottle to a shop and would fill it up for about 10 cents. How much is too much? I think it is less than a liter. I functioned OK in Paris, but I am not sure it is pushing the limits.

Moderate alcohol consumption post-MI lowers risk of mortality

Thu, 03 May 2012 07:35:43 EDT

After CABG in 1988...the following evening I ordered a carafe of red wine with dinner. Been drinking 1 litre of cask wine for over 25 yr s. No doubt, the liver and neurons have taken some punishment. So! the question seems to be: (1) What is a safe limit?..and how do you allow for body weight, liver function and tolerance. (2) Is it? the Resveratrol or Vino-veritas that plays a role? (3) Both James and Melissa have made good points coming from opposite angles.

Mixed findings with vitamin D in hypertension

Thu, 03 May 2012 07:33:08 EDT

Even the low levels of UVB in the winter may be enough (even in Denmark) if you can keep and recycle the Vitamin D made during the summertime. However with Macrobiotic (a dietary regimen which involves eating grains as a staple food supplemented) that is not possible. Grains deplete vitamin D stores by interfere with vitamin D absorption. Is this why the Dean Ornish diet is worse than the Paleo diet?

Small study links Tasers to cardiac arrest

Wed, 02 May 2012 21:44:23 EDT

So be glad that police have an intermediate-level restraining tool.

More data support pulse oximetry in newborns

Wed, 02 May 2012 20:57:30 EDT

Vitamin K coagulant is given routinely to all newborns (in Australia at least). If Oximetry tests indicate some heart abnormality, should withholding these injections be considered? It seems to be a sound preventative measure to do this.

Small study links Tasers to cardiac arrest

Wed, 02 May 2012 20:27:23 EDT

...according to Hugh Calkins -- a TASER spokesman.

Friend or foe? Uric acid a "probable cause" of CVD

Wed, 02 May 2012 13:00:29 EDT

Finding lower risk of hypertension and diabetes in families with lower uric acid certainly doesn't prove causation. And what about multiple sclerosis or other health issues associated with low uric acid? Did the study even look for them?

Small study links Tasers to cardiac arrest

Wed, 02 May 2012 12:32:19 EDT

The idea that high energy electric current would NOT risk VT or VF is laughable. Only the aggressive application of money by the manufacturer and there lawyers makes this anything other than an obvious conclusion. What other applications of high energy electricity to the body are considered safe? Handing these out to marginally trained law enforcement as being "non-lethal" is criminal and I would love to see a few TASER manufacturers on trial for wrongful death. Its long overdue. TO accuse Dr. Zipes of doing exactly what the manufacturer has been doing prettty well defines the pot calling the kettle black.

Mixed findings with vitamin D in hypertension

Wed, 02 May 2012 10:36:32 EDT

AS noted here central pressure is an important consideration Curr Hypertens Rep. 2009 Aug;11(4):253-9. Related Articles, LinkOut Antihypertensive drugs and central blood pressure. McEniery CM. Clinical Pharmacology Unit, University of Cambridge, Addenbrooke's Hospital Box 110, Cambridge CB20QQ, United Kingdom. cmm41@cam.ac.uk " Recent evidence suggests that central blood pressure is a more important determinant of cardiovascular risk than brachial pressure. Interestingly, antihypertensive drugs exert different effects on brachial and central pressure. Traditional beta-blockers, such as atenolol, appear to have an adverse impact on central pressure, despite lowering brachial pressure. This may help to explain the results of recent large outcome studies using atenolol.... " Yet here we have a short trail of a relatively low dose of vitamin d : a trail that almost by design would have a hard time showing benefit ...that shows... "But those patients taking vitamin-D supplementation showed a significant reduction in central systolic BP of 6.8 mm Hg when compared with the placebo group (p=0.007).' Negative another recent study ? " Eur J Heart Fail. 2012 Apr;14(4):357-66. Epub 2012 Feb 3. Vitamin D deficiency is a predictor of reduced survival in patients with heart failure; vitamin D supplementation improves outcome. Gotsman I, Shauer A, Zwas DR, Hellman Y, Keren A, Lotan C, Admon D." ital, Jerusalem, Israel. igotsman@bezeqint.net Abstract ".....Cox regression analysis demonstrated that vitamin D deficiency was an independent predictor of increased mortality in patients with HF [hazard ratio (HR) 1.52, 95% confidence interval (CI) 1.21-1.92, P

Cutting, taxing salt would trim CVD deaths by 3% in half the world

Wed, 02 May 2012 09:26:21 EDT

A good quality unrefined sea salt to the diet may actually help reduce blood pressure, due to the presence of magnesium and other minerals.

Should statins be used in primary prevention? JAMA gets in on the debate

Wed, 02 May 2012 08:48:52 EDT

Yes, it is important to know the amount of CAC for statin therapy. So, the best method to measure CAC, EBCT (or EBT) is required. How many have the EBT scanner running in the world? Very few. Why MDCTs widely used for the determination of CAC? Many studies with MDCT done on noninvasive angiography. Studies of CAC with MDCT need to increase. For example, many doctors in Turkey as in many countries of the world, usually use MDCT for noninvasive coronary angiography. This a is a contradiction? Cardiology society should give attention to this issue.

Report validates risk of high-dose simvastatin

Wed, 02 May 2012 00:00:58 EDT

Not really. With all the influence of pharma on medical research, it is not surprising to me that we are hearing about the alleged risk of simva 80 now that it is a generic. I suspect we'll hear a lot about the risks of atorva in the near future.

AIM-HIGH fell short, leaving experts looking for reasons in new review

Tue, 01 May 2012 23:53:48 EDT

Based on all the conflicting data regarding adjunctive therapy and ineffectiveness of certain, very expensive drugs, I give statins and dietary change(primarily low carb), or nothing else. Seems to me we're still missing something........

DES or bare-metal stents for primary PCI? New meta-analysis provokes debate

Tue, 01 May 2012 23:37:43 EDT

If TLR is the only measure of success, then DES wins. But if they aren't/can't take DAPT and you put in a DES, IMHO, you're not acting in their best interest, only yours. I do think it's easy to figure out whether or not they'll take their meds. Bottom Line, when in doubt, put in a BMS. If they happen to restenose, is this really a big deal? I don't think so.

Rise of "hard-core" smokers warrants tailored approaches

Tue, 01 May 2012 20:02:06 EDT

James, seek another opportunity again in the near future. Not only are multiple tries to quit required for many smokers, multiple tries to CONVINCE someone they need to quit is also required by those who care about that smoker! Who knows!!! Melissa

Statin therapy changes plaque composition fast

Tue, 01 May 2012 19:28:34 EDT

The most important proximal arteries in the heart can develop plaque due to small abnormal LDL in vessel wall. The reason the plaque build-up occurs preferentially in the proximal arteries leading to the heart is so that the heart muscle can be assured an adequate supply of cholesterol sulfate. The argument that the cholesterol sulfate plays an essential role in the caveolae in the lipid rafts, in mediating oxygen and glucose transport. Plaque build-up occurs preferentially in the arteries leading to requiring oxygen. Oxidized and glycated LDL particles become less efficient in delivering their contents to the cells. Thus, they stick around longer in the bloodstream, and the measured serum LDL level goes up. Macrophages in the artery wall and elsewhere in the body through a unique scavenger operation make the plaques. The macrophages combine the oxidized and glycated LDL particles with homocysteine to mobile the plaque.

AIM-HIGH fell short, leaving experts looking for reasons in new review

Tue, 01 May 2012 16:39:51 EDT

1. In AIM-HIGH, the placebo had 100 to 200 mg of niacin. The treatment arm had 1500 to 2000 mg. How likely is it that all of the benefit is in the first 10%, of niacin, but there is no benefit in the next 90%? If 150 mg niacin gives the same benefits as 1750 mg, then we should be crushing each Niaspan pill into twelve pieces. 2. The AIM-HIGH participants were not, contrary to your assertion, �exceptionally well controlled in almost every risk category.� ATP III considers HDL-C 3. There simply is no �vast volume of data that show the benefits of using Niaspan and raising HDL.� Can you cite this vast data showing the outcome benefits of using Niaspan? AIM-HIGH was supposed to be it. That is why [your employer?] Abbott paid $32 million for the study. (HATS does not �show fantastic results from niaspan.� HATS was tiny, with only 40 participants in each arm, not 1300. It did not have a niacin-only arm and did not have a statin-only arm. Any outcome effect was likely just due to the statin, which is already well proven vs placebo.) While there are lots of association data for high HDL and low CVD outcomes, alas it has turned out to be exactly that, just an association, not causal. The best ways to raise to HDL turn out to be by changing diet, or exercise, or losing weight, which, guess what, is what functionally lowers the CVD morbidity. It is not the high HDL, it�s what the people are doing which also happens to produce higher HDL readings. Attempts at artificially raising HDL have met with failure. Fenofibrate. Torcetrapib. And now niacin. What the data from all of the statin trials appear to be saying is that HDL becomes irrelevant once statins bring LDL down to ~ There simply is no �vast volume of data that show the benefits of raising HDL.� Or �showing the benefits of Niaspan.� 4. Niacin, and Niaspan, however, may certainly have application in patients who cannot take statins, although there is no RCT yet indicating any hard outcome benefit with this population.

Statin therapy changes plaque composition fast

Tue, 01 May 2012 15:24:00 EDT

Other intriguingly issue why upper arms arteries are immune to atherosclerosis?.Anyone of you know about an explanation regarding this phenomenon ?

Five OSU cardiologists earned $1-million bonuses in 2011

Tue, 01 May 2012 13:47:33 EDT

Unrelenting, overzealous, peacockish marketing and profligate misspending, borrowing-and-more borrowing by one University President E. Gordon Gee, Ph.D. & a submissive Board of Trustees ARE, to be sure, the story behind the story. It IS the unreported story. Incidentally, E. Gordon Gee's paid salary, privileges, benefits...total well over $1 million-per-year. He remains the highest paid president of any public higher education institution nationwide.

TRITON-TIMI 38: Prasugrel lowers events but ups bleeding vs clopidogrel

Tue, 01 May 2012 13:06:58 EDT

Results of clinical trials OASIS 7, ACUITY, REPLACE 2 and HORIZONS AMI makes it possible to think that an episode of bleeding during treatment of an ACS may establish a deferred risk of death greater than that observed in the short term when treatment fails to avoid reinfarction. The TRITON TIMI 38 trial was conducted in a population with possibly lower risk of bleeding than expected in the real world (almost 2/3 of patients were What about the long-term mortality in this study? And more important, for a hypothetical population of median age only 5 years older than the study, with 15 % more risk of bleeding, can we think that would change the outcome of mortality ?

Should statins be used in primary prevention? JAMA gets in on the debate

Tue, 01 May 2012 12:43:21 EDT

The book is, The Creative Destruction of Medicine, by Eric Topol M.D. In Chapter 3 the vignette is damning for clinical medicine. The narrative has an ASYMPTOMATIC 58-year-old male having a Cardiac CT calcium score done as part of a Valentine gift. The cardiology machine eventually ends up putting in 5 stents. The patient was put on Aspirin, Clopidogrel, Atorvastatin, and a beta-blocker and he is now a �Cardiac Cripple�. Modern Cardiology now has cognitive dissonance, everything I thought was right seems VERY wrong. Although not the primary purpose of Topol�s book, the low fat, low salt, statins for primary prevention, and stenting asymptomatic lesions have proven extremely harmful.

Mixed findings with vitamin D in hypertension

Tue, 01 May 2012 12:07:13 EDT

I must admit that I did see normalization of BP in young black males with oral Vitamin D 5000u. This was an observation, not a study. These guys at baseline had a 25-OH Vitamin D of about 10 ng/ml. This is very low level. I was less impressed with BP affects with Oral Vitamin D pills in older mostly white guys.

Should statins be used in primary prevention? JAMA gets in on the debate

Tue, 01 May 2012 12:05:16 EDT

The thought that statins should be in the water has finally been debunked by both sides in this argument. There are some very important points still left out. 1. What about those at risk for MI without elevated lipids? We know that 75% of heart attacks in young (men 2. Over half of heart attacks occur in individuals who would not qualify for lipid lowering meds by current guidelines. Is that fact OK to ignore? 3. Treating to goal with statins reduces MI risk by 21%, is that good enough? I feel that the answer to all of the above questions is clearly NO! That is why I recommend that everyone, including low risk subjects, get an initial calcium score when they are old enough for the score to be meaningful (men >age 40, women >age 50). If the score is 0, the scan should be repeated in 3-5 years. This will identify over 97% of subjects at risk. I then treat the population with coronary calcium to a goal of calcified plaque stabilization by serial EBT imaging which results in a dramatic reduction in MI (95%) and a 3 fold difference in all cause mortality. The treatment may or may not consist of a statin medication. Statins are OK but there is little or no DATA correlating statin use with stability of calcified coronary plaque. Since stabilization of coronary plaque = dramatic reduction in coronary risk while statin use as the only intervention does not result in plaque stability, it seems that the argument regarding stain use in primary prevention misses a big point. For the cost-radiation crowd, EBT calcium scores can be obtained for less than what a smoker spends in 6 weeks to support a pack a day habit (or a latte drinker for that matter). An EBT calcium score exposes the patient to 0.7 msv of radiation or roughly the same as a mammogram and 1/20th the dose of a nuclear stress test.

Mixed findings with vitamin D in hypertension

Tue, 01 May 2012 11:26:44 EDT

A small sub-study of 97 subjects demonstrated a reduction in systolic and diastolic BP of "borderline significance". Kind of amazing that a sub-study this small could show anything. Subjects taking vitamin D showed a reduction in central BP of 6.8 mm Hg (p=0.007). Despite these remarkable results, Dr. Larsen is quoted as saying "I think that this was a negative study" I admit, I am surprised to see an effect on BP from vitamin D supplementation. I have seen a significant benefit in coronary outcomes since I added vitamin D assessment and supplementation to my primary prevention algorithm however I would not have speculated that the value was based on blood pressure. This study strongly suggests that there is a value of vitamin D correction with respect to blood pressure. Why does the author think not? So what's up Dr. Larsen? How does ABP trump central blood pressure? Why is this small, short study demonstrating significant benefit seen as a negative result?

Rise of "hard-core" smokers warrants tailored approaches

Tue, 01 May 2012 10:04:21 EDT

My recent experience with incalcitrant smokers is with my in-laws. Addiction may be defined as the continued use of a mood altering substance or behavior despite adverse consequences. Years ago (2007) I mail my smoking in-law�s (5) Chantix, as a gift. Unfortunately, this was unsolicited quitting aid and they lived across the continent. This was after I got one 3-pack smoker in-law to quit. He was someone who lived near and who had an MI, he wanted to quit and did succeed! These other 5 had innumerable excuses not to quit. My unbridled enthusiasm for Chantix was temped by the reality of this powerful addiction. I am saddened by this failure to quit.

Maryland set to establish independent review system for PCI

Tue, 01 May 2012 09:52:08 EDT

As an internist and observer of the treatment of my patients in the community, this is a fine policy. Remember Elyria?

Moderate alcohol consumption post-MI lowers risk of mortality

Tue, 01 May 2012 07:48:18 EDT

We have more organs than one. Melissa

Rise of "hard-core" smokers warrants tailored approaches

Tue, 01 May 2012 07:47:00 EDT

My impression is that as the quitters who find it less difficult to quit, do so,.....as practitioners, we are left over time with the more hard core nicotine addicts who are more resistant to smoking cessation therapy.

Seattle Heart Failure Model shows promise as predictor of who needs an LVAD

Tue, 01 May 2012 07:43:54 EDT

We are unable to advise patients specifically on the forum. Please speak with your implanting physician to clarify the information on this topic. Generally speaking, if my family member reached the point of requiring a VAD, I would never hesitate if they were of an appropriate age and had failed all efforts at medical therapy and desired aggressive measures. I wish you and your family the best. Melissa

What is the clinical significance of electrical alternans in this tracing?

Mon, 30 Apr 2012 22:20:19 EDT

You are seeing one. K. Wang.

CHA2DS2-VASc score gives best prediction of stroke risk in AF

Mon, 30 Apr 2012 21:13:23 EDT

They are born with CHA2DS2-VASc score of 1. Males could possibly avoid a positive score till the age of 65. I wonder however, how many physicians put all women on anticoagulants based on se alone without other risk factors.

What is the clinical significance of electrical alternans in this tracing?

Mon, 30 Apr 2012 14:26:42 EDT

Dear Dr Wang, Can we call it "total electrical alternance", since QRS and T are showing alternance? Ofcourse P waves are not recognized. Is Total Electrical Alternance seen in conditions other than cardiac tamponade? Thanks

Mixed findings with vitamin D in hypertension

Mon, 30 Apr 2012 13:25:24 EDT

Oral Vitamin D pills are useless for immunity or hypertension. -The real Vitamin D that is made in the skin exposed to UV-B. Real D is a sulfated compound. The sulfated compounds affect monocyte and TH 17 function. - Keep �25 OH Vitamin D� level in 50 ng/ml range by tanning and not by pills, this will improve blood pressure..

Friend or foe? Uric acid a "probable cause" of CVD

Mon, 30 Apr 2012 12:40:39 EDT

High Uric acid leads to gout, hypertension and diabetes. Ultimately this leads to ASHD.

AIM-HIGH fell short, leaving experts looking for reasons in new review

Mon, 30 Apr 2012 08:47:32 EDT

Thank you for your comments. It is encouraging to hear you question different niacin sources. Niacin IR or crystalline niacin is effective treatment for raising HDL but it imay not be crystalline niacin and the flushing can be very severe. Niaspan is crystalline niacin that minimizes the flushing and liver toxicity. Slo flush and no flush formulations can be hepatotoxic and are metabolized to inositol hexaniacinate which really has little efficacy for raising hdl. Niaspan has a vast volume of data showing valuable benefits for treating dyslipidemia and does have outcomes data but the treatment of lipids is very complex and it would be nice to have more concrete data to deliver but for now all I can encourage are the guidelines.

Rise of "hard-core" smokers warrants tailored approaches

Mon, 30 Apr 2012 05:25:36 EDT

From the description of the study in heartwire, it is not clear to me that the actual number of hard-core smokers in the Hong Kong study is increasing or decreasing. When the total number of smokers has halved, it could be expected that the number of hard-core smokers would probably not fall by as great a proportion. The effect of that would be to increase the proportion of all smokers who are hard-core. However, only if this proportion doubles over time would the absolute number of such smokers be increasing (in a static-sized population).

Rise of "hard-core" smokers warrants tailored approaches

Mon, 30 Apr 2012 04:25:47 EDT

Dear Drs Rose and Akbar - theheart.org forum is not the appropriate location for an exchange of this nature. Sincerely, Steven Rourke Editorial programming

Topol is most influential physician executive in new US poll

Sun, 29 Apr 2012 23:52:38 EDT

Having a phone consultation with Eric Topol in the 80's regarding my physician husband's dose of prednisone after by-pass surgery was like a medical school course which my husband's surgeon in San Francisco obviously never took! And which his cardiologist skipped as well.

Cutting, taxing salt would trim CVD deaths by 3% in half the world

Sun, 29 Apr 2012 22:08:16 EDT

I agree wholeheartedly with P. McInnis above, this is about controlling what we eat, smoke, drink - where we get our healthcare, what we drive - don't get me started and, yes, Damn the constitution!

Cutting, taxing salt would trim CVD deaths by 3% in half the world

Sun, 29 Apr 2012 21:08:01 EDT

Restriction/taxing of salt will inevitably cause an alternative food flavoring to be added to processed food (which by itself due to heavy processing has no flavor). Guess what this flavoring is going to be? The answer is very simple: sugar. Tax salt. Subsidize HFCS production. Great statesmenship. Initially BP may be slightly better, by 1-2 points. But the next loop of a spiral of obesity and diabites epidemics will override any possible (still very uncertain)health benefits of acute BP reduction... It is hard to overeat on salted herring or el jamon Iberica. It is very easy to do it on low salt cookies and candy bars. Guess who has money to spend on lobbying and marketing and public opinion? It does not matter what science really shows - it matters where the money is... Bon appetite...

Rise of "hard-core" smokers warrants tailored approaches

Sun, 29 Apr 2012 20:02:32 EDT

Taukeer, if we are going to deny visas for people from any country which sponsors terrorism, we would have to start with Iran and Pakistan. If the Dubai authorities can't tell a cardiologist from a terrorist they are so ignorant shouldn't be sponsoring international conferences. On the other hand the state of Israel has never sponsored terrorism but will use whatever means necessary to protect itself from known terrorists.

Cutting, taxing salt would trim CVD deaths by 3% in half the world

Sun, 29 Apr 2012 17:49:30 EDT

The claim used to be that education was the answer to many of our ills. It seems that's not enough, we need the help of government coercion in the form of taxes on alcohol, tobacco and now salt. (Is salt really in the same league as tobacco?) As an American, I'm glad our Constitution provides no way for the government to try to control my food selection. Oh I forgot, my government now no longer refers to the Constitution when it makes its decrees. Hence Obamacare...

AIM-HIGH fell short, leaving experts looking for reasons in new review

Sun, 29 Apr 2012 16:56:20 EDT

I have seen time and time again people arguing 200 mg of Niacin negate the effect of therapeutic dose of Niaspan. Why are we wasting time in educating our patients on slow titration and high doses of Niacin up to 2000 mg. simply ask everybody to take 200 mg a day if that is the case?? people those who are arguing this 200 mg dose are ready to accept no need for high dose. I agree with Sid we have asked a question in AIM-High and it was looking futile to continue atleast in a population where LDL is well controlled and perhaps no need for Niaspan. Just like all statins are not made equal we may have to ask ourselves question regarding Niaspan is it time to think intrinsic differences in niacin SR/niacin-IR/Niaspan etc. Laxmana M Godishala, MD,FACP,FASH,FNLA

Moderate alcohol consumption post-MI lowers risk of mortality

Sun, 29 Apr 2012 15:45:37 EDT

Classic Puritans were not opposed to drinking alcohol in moderation. Early New England laws banning the sale of alcohol to Native Americans but taxed the general population. Moderate Alcohol effect is fairly consistent, corresponding to a 25 percent to 40 percent reduction in risk. This is heart attack, ischemic (clot-caused) stroke, peripheral vascular disease, sudden cardiac death, and death from all cardiovascular causes.

Rise of "hard-core" smokers warrants tailored approaches

Sun, 29 Apr 2012 14:14:51 EDT

Surely Mossad has a history of carrying out criminal / terrorist activities in other countries and it's agents passing for tourists or conference delegates. In today's world you can't blame the Dubai officials for being cautious!

Cutting, taxing salt would trim CVD deaths by 3% in half the world

Sun, 29 Apr 2012 12:56:18 EDT

It appears that World Heart Federation CEO Johanna Ralston believes that a ten percent reduction in salt consumption combined with screening will reduce premature deaths by 6 percent, even though no one has ever been able to demonstrate such a dramatic reduction even on a small scale and using much more restrictive salt limits.

Cutting, taxing salt would trim CVD deaths by 3% in half the world

Sun, 29 Apr 2012 12:36:59 EDT

When will schools (such as Harvard) start taking a little responsibility and demand better science in articles associated with the school? The claim that 10 percent reduction in salt would result in three percent reduction in CVD does not pass even the most casual examination. According to Taubes, a meta analysis of just those salt studies that claimed a BP reduction (and ignoring the equal number that failed to find an effect), the average reduction in BP was 5 points! And that was for massive salt reductions, not 10 percent. It takes great mental gymnastics to believe five points is significant when 20 points (120 to 140) is the range between normal and the lower limit for elevated BP, and then to extrapolate that five hundred thousand deaths could be avoided each year due to such a small change is patently absurd! This claim should have been stopped long before publication.

Hands off my wife! Bahrain AED survey points to CPR barriers

Sun, 29 Apr 2012 12:29:29 EDT

I agree with Dr Al-Hina comments , that this is related to ignorance of the subject and it's consequences rather than religous teachings .

Diabetes/statin link probed in EFFECT cohort

Sun, 29 Apr 2012 11:48:42 EDT

16% cases of diabetes over 5 years on statins. Quick calculation shows the 5 year NNT to cause diabetes is 31. That is a pretty substantial risk compared to the apparent benefits of statins, is it not?

Rise of "hard-core" smokers warrants tailored approaches

Sun, 29 Apr 2012 11:46:16 EDT

All conferences in Dubai should be boycotted until guarantees are given that Israelis will be granted visas to attend. See report. "Over a dozen Israeli cardiologists who had been invited to a Dubai conference of the World Heart Federation � attended by 12,000 heart specialists last week � were denied a visa by authorities at the last minute. Only a couple of Israelis � one from the Rabin Medical Center and the other from Tel Aviv�s Sourasky Medical Center � who had been invited to lecture at the conference were allowed to attend and did so." http://www.jpost.com/Health/Article.aspx?id=267461

Cutting, taxing salt would trim CVD deaths by 3% in half the world

Sun, 29 Apr 2012 10:58:10 EDT

Its funny that all the modern salt trials just have two arms (low salt vs "normal" salt) instead of three arms (low salt vs normal salt vs high salt). The third arm is already proven in a lot of experiments that are regarded as "too old to be considered". We ate a lot of salted herring and salted meat (about 5-10 % salt in the food) for more than a century ago. No hypertension in those days. Bj�rn Folkow wrote in the Swedish L�kartidningen 2003 that man can eat up to 100 g salt per day without problems if you have enough water available. NHANES II and III have shown that a low salt level is associated to increased death in CVD. So eat as much salt you like to, have enough water and enjoy a log life.

Cutting, taxing salt would trim CVD deaths by 3% in half the world

Sun, 29 Apr 2012 10:05:22 EDT

Damn science keeps disproving the benefit of salt reduction. Gary Taubes

Cutting, taxing salt would trim CVD deaths by 3% in half the world

Sun, 29 Apr 2012 09:43:29 EDT

And only criminals will die. Our taxes cause us to consume salt, therefore lowering taxes will lower salt consumption, saving lives (nearly as scientific as this report). "Thy consumption of salt shall verily bring thee death." - Hezekiah 2:12

AIM-HIGH fell short, leaving experts looking for reasons in new review

Sun, 29 Apr 2012 08:43:00 EDT

I offer the following comments on hdl and the aim hi study. First, raising hdl does have outcomes data. Look at CDP (coronary drug project ) and the HATS studies. Although small, the HATS study shows fantastic results from niaspan. Second, if you have high HDL and see no plaque reducing results after at least 2.5 years you may have the wrong type of HDL. HDL has 3 forms, hdl2, hdl3, and nascent. By doing advanced lipid testing you can determine which type hdl you have. HDL2 picks up the excess cholesterol and carries it back to the liver. If the HDL particles are irregular they will not function properly kind of like insulin resistence involves enough insulin but it does not function properly to lower glucose. Third, and perhaps most important, the Aim-High population was indicative of about 20% of the patients being treated in the general dyslipidemia population. They were exceptionally well controlled in almost every risk category including LDL, non-HDL, TG. They were looking for an additional 25% reduction in CV events. The results showed no significant reduction in CV IN THIS POPULATION. There may be some subgroups that did benefit and have yet to be reported but in general for a patient this well controlled there appears to be no need to treat with Niaspan. There are 80% of patients that may very well benefit from Niaspan and raising HDL and past studies do provide good reason for raising HDL. According to Castelli and the Framingham Study, low HDL is a much better indicator of risk than high LDL. Also, the study was discontinued after only 3 years. It often takes a minimum of 5 years to see a separation in the data. Remember that the placebo group was given 200 mg of IR Niacin to simulate the flushing effect and blind the study resulting in an increase in HDL not seen with statins alone. More data from the Aim High is yet to come looking at subgroups but there is a vast volume of data that show the benefits of using Niaspan and raising HDL and we should not draw broad conclusions to discontinue treating low HDL based on this one study with such a limited patient profile.

What is the clinical significance of electrical alternans in this tracing?

Sat, 28 Apr 2012 22:22:30 EDT

electrical alternans does not necessarily mean temponade. it indicates that it is a large pericardial effusion and as such associated with low QRS voltage. This ecg with alternans and normal QRS voltage is very unlikely with large pericardial effusion

ACE inhibitors better ARBs in new meta-analysis in hypertensives

Sat, 28 Apr 2012 17:27:31 EDT

1. The real Vitamin D that is made in the skin and is a sulfated compound. The sulfated compounds affect monocyte and TH 17 function. Vitamin D improves immunity, but only by that which is produced by sun exposed skin, not pills. 2. Oral Vitamin D does positively affects Calcium Metabolism, but does not affect immunity. Actually Oral Vitamin D suppresses immunity by blocking thru VDR (Vitamin D Receptor). 3. Most Americas are Sulfate deficient. This deficiency is best solved with Epsom Salt baths. The Magnesium Sulfate is absorbed by a warm bath.

Raise the bar for starting primary prevention, cardiologists argue

Sat, 28 Apr 2012 11:38:13 EDT

More specifically AIM-HIGH failed to demonstrated a benefit by adding niacin in subjects with LDL less than 70 on high dose statin. It was not carried out long enough to prove a lack of benefit even in this subset. I stand by my position that the AIM High results should not change anyone's position on niacin in coronary prevention. The technology used for measuring coronary calcium is important. EBT caclium imaging has been demonstrated to be the most accurate and the studies on serial calcium showing dramatic predictive value of serial imaging have all used EBT technology. Calcium scores on helical scanners are less reproducible due to the motion artifact with an image acquisition time of 0.25 seconds or roughly 1/4th of the heart's cycle. This does not compete with EBT scan acquisition time of 0.1 second. The newest helical scanners, 256 slice, have 0.125sec scan acquisition time, should be able to effectively complete with EBT however one cannot compare an EBT scan one year with a helical scan another year. Considering the average progression of calcified plaque is about 45% annually, and stable plaque is defined as The scan to scan variability of an EBT can be as high as 15% therefore scanning sooner than 12 months after the index scan makes no sense. Helical scanners with 0.25 second scan acquisition time have scan to scan variability of 45% (AHA scientific statement), therefore repeating the scan sooner than 3 to 5 years makes no sense. However repeating an EBT (or 256 slice dual source) scan after 12 months or a helical scan after 3 years can be a most valuable tool in determining the adequacy of primary prevention. Disclosure: The facility where I practice has an EBT heart scanner which we use to measure initial risk and use follow up EBT scans to determine adequacy of management. This has resulted in a dramatic reduction in MI events as well as vascular death in my older, higher risk practice.

A 45-year-old woman who had an ICD implanted over 10 years ago

Sat, 28 Apr 2012 07:10:53 EDT

Muchos gracias

A 45-year-old woman who had an ICD implanted over 10 years ago

Sat, 28 Apr 2012 06:51:27 EDT

Exxcellent case. Very demostrative

ACE inhibitors better ARBs in new meta-analysis in hypertensives

Sat, 28 Apr 2012 02:25:36 EDT

The french rcomendation (HAS) are beta-blockers and diuretics! Note that we're not since many years in the top ten of RCT's producers, ans we have lost two majors inventions: the coronary stent (Jaques PUEL) and the TAVI (Alain Cribier). So now, our health ministry have to reduce our public health expenses. Obviously, the HAS is independant, as it say itself.

FDA advisors: Benefits trump risks for HeartWare ventricular assist pump

Fri, 27 Apr 2012 19:54:08 EDT

I am concerned that the FDA still hasn't learned from experience to be more careful on what it approves for implantation into patients. We have seen from the problems with defibrillator leads and metal to metal hip joint prosthesis what happens when the FDA allows companies to rush products to market with inadequate safety testing. If the FDA is going to approve a device that requires major open heart surgery to implant in the sickest of the sick heart failure patients, and that device is going to be the sole means of keeping those patients alive, then the FDA MUST be able to unequivocably state that that device is as safe in all aspects as existing equipment. If there are questions about the comparator studies, then make the company obtain adequate safety data first, and don't depend on registries to pick up problems after the fact. As an aside to the above, it never fails to amaze me how the FDA can require years of study to approve acne medications, but is so easily satisfied with such scant data on complex implanted devices.

Raise the bar for starting primary prevention, cardiologists argue

Fri, 27 Apr 2012 18:24:54 EDT

Perhaps niacin+fish oil, without statins, stops CAC progression and prevents events. That is not what AIM-HIGH tested. All AIM-HIGH participants had statins. If patients are statin intolerant, then niacin+fish oil makes sense. AIM-HIGH just said that Niaspan on top of statins doesn�t add anything. A question about using serial CAC scores to guide therapy: how much inter- and intra-facility variation is there naturally in scores? If the same person has scores +/-10% on alternate days, how can you use a +/- 15% annual change criterion? Doesn�t the natural variation in these numbers preclude using them to guide therapy?

ACE inhibitors better ARBs in new meta-analysis in hypertensives

Fri, 27 Apr 2012 17:16:04 EDT

Dr. King it seems that vitamin d both as a D3 or from sunlight inhibits renin. But several recent studies raise the question as to weather UVR provides benefit above that of pills. One interesting one was described ...."Intense light prevents, treats heart attacks" ""The study suggests that strong light, or even just daylight, might ease the risk of having a heart attack or suffering damage from one," says Tobias Eckle, MD, PhD, an associate professor of anesthesiology, cardiology, and cell and developmental biology at the University of Colorado School of Medicine. "For patients, this could mean that daylight exposure inside of the hospital could reduce the damage that is caused by a heart attack." What's the connection between light and a myocardial infarction, known commonly as a heart attack? The answer lies, perhaps surprisingly, in the circadian rhythm, the body's clock that is linked to light and dark. The circadian clock is regulated by proteins in the brain. But the proteins are in other organs as well, including the heart. Eckle and Holger Eltzschig, MD, a CU professor of anesthesiology, found that one of those proteins, called Period 2, plays a crucial role in fending off damage from a heart attack. With an international team of expert scientists, including collaborators from CU's Division of Cardiology and the mucosal inflammation program, they published their findings in the April 15, 2012 edition of the research journal Nature Medicine. During a heart attack, little or no oxygen reaches the heart. Without oxygen, the heart has to switch from its usual fuel � fat � to glucose. Without that change in heart metabolism, cells die and the heart is damaged And here's where the circadian rhythm comes in. The study showed that the Period 2 protein is vital for that change in fuel, from fat to glucose, and therefore could make heart metabolism more efficient. In fact, Strong daylight activated Period 2 in animals and minimized damage from a heart attack. " Wondering if you have any insight?

Moderate alcohol consumption post-MI lowers risk of mortality

Fri, 27 Apr 2012 15:26:59 EDT

A glass of red wine nightly as a cardiac patient. That needs to happen despite the Americans fear of the liquid. Hards to fight the bias. Also no HFCS in hospital liquids or foods.

What is the clinical significance of electrical alternans in this tracing?

Fri, 27 Apr 2012 13:27:35 EDT

I think it is really excellent .I do thank Wang. Please . Continue your invaluable contribution .

What is the clinical significance of electrical alternans in this tracing?

Fri, 27 Apr 2012 12:53:41 EDT

aVR could suggest pericarditis and the rhythm could be sinus tachycardia.

Statins, diabetes, and the FDA

Fri, 27 Apr 2012 12:10:08 EDT

Statins may not be as effective in primary prevention of cardiovascular disease in women as in men. Are there sex differences in the risk for these effects on blood glucose, insulin resistance and cognition? Have any of the meta-analyses addressed this issue? In the era of pharmacogenomics and individualized medicince, these quesions are worth answering.

Hands off my wife! Bahrain AED survey points to CPR barriers

Fri, 27 Apr 2012 12:09:21 EDT

Yeah, hypothetically, I'm sure we all have our biases and preferences - and this study may have had some of its own given the direction of the questions and conclusions. Ask any Evangelical GOP supporter during the GOP primary if they would allow a carpe diem Democrat expose his wife's chest and start compressions, we'd see how happy they would be with that scenario. Reality always bites.

What is the clinical significance of electrical alternans in this tracing?

Fri, 27 Apr 2012 11:45:16 EDT

I enjoy being challenged by ECG of the Month. I will use this 12-lead for my cardiac rhythms class. Thank you.

Five OSU cardiologists earned $1-million bonuses in 2011

Fri, 27 Apr 2012 11:43:37 EDT

I'm not a physician and I have no qualms about physicians being well-compensated. Kudos to them and I'd rather the money went to someone saving a life and serving humanity than someone ripping off the rest of society such as in the financial industry for example. Where I see unfairness in bringing in new people and compensating them much better than those already in the system who have remained loyal and worked hard to support it. Definitely 10 times what other cardiologists earn is not defendable.

Cardiologists still earning big bucks, but work frustration abounds

Fri, 27 Apr 2012 11:42:28 EDT

I guess I can't post links. So here is try scribd.com/doc/60145213/2010-MGMA-Physician-Compensation-Survey-Summary

Cardiologists still earning big bucks, but work frustration abounds

Fri, 27 Apr 2012 11:40:39 EDT

There are many such surveys with widely varying data. Perhaps the best is from the MGMA, but it is probably tilted toward their profit driven orientation. See:

ACE inhibitors better ARBs in new meta-analysis in hypertensives

Fri, 27 Apr 2012 08:32:01 EDT

ARBs modulate the activation of two key nuclear receptors-VDR and PPARgamma. Bad class of drugs. In smokers strong ARB's increase lung cancer.

A 45-year-old woman who had an ICD implanted over 10 years ago

Fri, 27 Apr 2012 06:34:10 EDT

Thanks much.

ACE inhibitors better ARBs in new meta-analysis in hypertensives

Fri, 27 Apr 2012 03:43:07 EDT

Evolution favours Enzyme inhibitor rather than receptor blockers.No single trial says till now ARB is better than ACE,ARB has failed everywhere when you compare it with ARB.ACE is european child and ARB seems to be american child.I never mean anything bad but the Guidlines should be strict now and A newly diagnosed patient should be initiated on ACE we want to reduce the burden of complication of Diabetes & CVD.

ADA/EASD issue new hyperglycemia management guidelines

Fri, 27 Apr 2012 03:25:02 EDT

I america most most important Risk factor for Diabetes and infact all NCD disease is High Intake of refined Carbohydrates not fat.A average american take around 240 liters of cold drinks in a year.American culture means PIZZA,Burger,sandwich,Cookies,choclates,Etc. World has to realise the importance of Vegetable and fruit based eating with healthy lifestyle like eastern Meditation,Yoga can help more than anything.

DES or bare-metal stents for primary PCI? New meta-analysis provokes debate

Fri, 27 Apr 2012 00:28:00 EDT

To take a detailed, accurate history about a patient's bleeding risk, possible impending surgeries, their financial and educational ability to comply with a year of DAPT, as well as other confounding medical problems from a patient who likely has had several doses of morphine and who is scared to death getting off a wild helicopter ride while having an MI all the while trying to get their IRA opened safely within 90 minutes of presentation is daunting, to say the least. As such, in our practice, where 50% of patients presenting with STEMI are uninsured or under-insured, it has been our approach to use BMS's unless the issues are very clear and well defined that would otherwise favor DES. In such a scenario, the priorities are to survive the MI, to limit myocardial damage, and to avoid bleeding. Minimizing the risk of restenosis, which is still rare with BMS, is the "icing on the cake". Up front practical concerns likely trump future potential ones.

ACE inhibitors better ARBs in new meta-analysis in hypertensives

Thu, 26 Apr 2012 23:01:03 EDT

There is not a single study that shows that ARB's excel ACE inhibitors in cardiovascular, renal endpoints. The indications or ARB's are only when Ace are not tolerated. Just goes to show that more expensive and heavily promoted medications are not necessarily better.

CHA2DS2-VASc score gives best prediction of stroke risk in AF

Thu, 26 Apr 2012 21:06:18 EDT

I have been using it since it came out first, but not always.Makes sense to include vascular disease,female sex and division of age along with other factors as criteria to assess for risk of stroke in Afib pts.

ADA/EASD issue new hyperglycemia management guidelines

Thu, 26 Apr 2012 11:35:47 EDT

As everyone here well know, retinopathy is rare when the 2 hr pp BSL is less than 200 mg/dl (11 mmoles/L). I stand by my blog.

CHA2DS2-VASc score gives best prediction of stroke risk in AF

Thu, 26 Apr 2012 10:28:00 EDT

The CHA2DS2-VASc score is a refinement of CHADS2 score and extends the latter by including additional common stroke risk factors, as discussed below. The maximum CHADS2 score is 6, whilst the maximum CHA2DS2-VASc score is 9. It's not hard to remember the new score. Go to CHADS2.wiki.

Raise the bar for starting primary prevention, cardiologists argue

Thu, 26 Apr 2012 01:37:24 EDT

See below

Raise the bar for starting primary prevention, cardiologists argue

Thu, 26 Apr 2012 01:33:26 EDT

I have several patients who were on high dose statin. They had significant progression of plaque by serial EBT imaging on this dose of statin despite excellent LDL cholesterol. I added niacin with further improvement in cholesterol markers but no significant improvement in plaque progression. I stopped the statin (due to patient's perceived intolerance)and replaced it with welchol. To my surprise,although the LDL was much higher with the welchol, the calcified plaque score significantly decreased. This observation leads me to think that perhaps in some individuals, high dose statin is not only ineffective, it may indeed prevent niacin from also having a benefit. With the addition of niacin and omega-3 fatty acids, I rarely use high dose statin and almost always get LDL to secondary prevention goals. More importantly, almost all of my patients have stable plaque by serial EBT imaging, the strongest marker of diminished MI risk available at this time. The result is that I have not seen a heart attack in 2.5 years. I have found that niacin is very powerful in stabilizing calcified plaque scores with serial imaging. I did a small study on patients referred in for repeat heart scans. Those on niacin had a remarkably improved plaque progression compared to those not taking niacin.

Cardiologists still earning big bucks, but work frustration abounds

Thu, 26 Apr 2012 01:10:40 EDT

love what you do and do what you love. be contented always.

ACE inhibitors better ARBs in new meta-analysis in hypertensives

Thu, 26 Apr 2012 01:01:30 EDT

need opinion from physician/cardiologist fracternity: if a patient developed angioedema with ACEI, how likely patient will develop angioedema with ARBs, anybody will substitute ACEI with ARB in this kind of patient?

AIM-HIGH fell short, leaving experts looking for reasons in new review

Wed, 25 Apr 2012 23:59:46 EDT

I agree with Sid that there is no reason to use Niaspan. There is zero outcome data to support its use. However, a case could still be made for use of Niacor/Slo-niacin (used in HATS)(1)OR immediate release niacin (used in Coronary Drug Project)(2)- in secondary prevention in combination with statins when lipid targets are not met or in patient intolerant to statins. 1. N Engl J Med 2001; 345:1583-1592 2. J Am Coll Cardiol. 1986 Dec;8(6):1245-55.

ACE inhibitors better ARBs in new meta-analysis in hypertensives

Wed, 25 Apr 2012 23:24:26 EDT

In general practice, I experienced many cares are tolerated and efficacy with ARBs than ACE I especially in T2 DM and hypertension, less side effect , long efficacy and best benefit in cardio Reno syndrome.

ADA/EASD issue new hyperglycemia management guidelines

Wed, 25 Apr 2012 18:59:15 EDT

I do not believe that statins are the problem here but the metamorphosis of the American popualation over the last 60 years transform input population into inactive obese individuals., this stared with the first McDonald's taco bell the interstate highway system the creation of the cafe fast foods cheap glucose loaded cards etc

ADA/EASD issue new hyperglycemia management guidelines

Wed, 25 Apr 2012 18:54:55 EDT

Sure 65 to80 percent of our diabetic patients will die of a cardiovascular event however I propose that the main factors contributing to morbidity is the fact that these patients will suffer decades of their micro vascular complications ie their retinopathy neuropathy, neuropathy and in the case of our ale patients their erectile dysfunction. That is where aggressive glycemic control in the earlier years of there diagnosis will benefit thir quaility of life

Topol is most influential physician executive in new US poll

Wed, 25 Apr 2012 18:09:27 EDT

Well deserved and long overdue. As brilliant as he is, he is an even better person and mentor, as I witnessed firsthand at the Cleveland Clinic. Too bad the Cleveland Clinic did not see it that way.

Dabigatran cuts ICH mortality vs warfarin: RE-LY analysis

Wed, 25 Apr 2012 15:35:55 EDT

I'm surprised of the higher, % of ICH in the 110 mg group of Dabigatran. I think if the cardiologist has enough expertise in managing Warfarin, I would use it, given de abscence oa a real antidote Vs Dabigatran

Assessing the Right Ventricle in Pulmonary Arterial Hypertension: Getting to the Heart of the Matt

Wed, 25 Apr 2012 15:29:55 EDT

LEARNING NEW THINGS

Raise the bar for starting primary prevention, cardiologists argue

Wed, 25 Apr 2012 13:52:08 EDT

I think that Prasad and Vandross� points are very well taken. We should not be basing expensive, large-scale treatment decisions on surrogate-end-point studies. Dr Blanchet - First, I think that your overall practice strategy for patients with CVD is absolutely correct: treat to stable CAC scores as monitored by ~annual EBT CAC scans. So far, this is what appears to show the highest correlations with high reductions in hard outcomes (although I wish we had a larger quantity of data verifying this...). But your lack of self-doubt on niacin (or at least Niaspan) in light of AIM-HIGH is curious. 1. In AIM-HIGH the treatment was 1500-2000 mg of niacin. The placebo had 50 mg (for blinding purposes). The resulting Kaplan-Meier curves superimposed upon each other. How likely is it that all of the benefit is in the first 3%, of niacin, but there is no benefit in the next 97%? If 50 mg niacin gives the same benefits as 1500 mg, then we should be cutting up each Niaspan pill into thirty pieces. 2. The mean follow-up period was 3 years, not 2, and there was no evidence of diverging results in those followed for 4 years. It is true that if the study had gone a few more years, it is not impossible that the Kaplan-Meier curves could have diverged somewhat. Niacin might be more effective in slowly preventing plaque buildup, a longer-term process, as opposed to reducing ruptures of vulnerable plaques, something that would show up more immediately. But, realistically, how many patients are going to want to take medications for five or ten years before seeing slight benefits? And the NNT and net cost/benefit ratios go up proportionally. And at this point, it is just blind faith. 3. To minimize differential dropout rates, AIM-HIGH did an initial screen for niacin toleration, excluding patients with reactions. The resulting trial dropout rates were 25% for the treatment arm (and 20% for the placebo arm). These numbers are close, but it is the absolute dropout rate of the treatment arm that is most important, not the difference in rates. E.g. if 25% of the Niaspan patients immediately dropped out, essentially counting as placebos, then a 12% real event reduction would show up as a 9% reduction. A zero-percent observed difference, though, still �grosses up� to zero. 4. Yes, the subjects were on relatively-high-dose statin therapy. Most secondary prevention patients are, or should be. This was the relevant sample population for this trial. Niacin may indeed have application for those patients who cannot tolerate statins, an unfortunately high fraction (although efficacy there has not yet been demonstrated in an RCT yet). What the data from all of these trials appear to be saying is that HDL appears to become irrelevant once statins bring LDL down to ~ I don�t like the AIM-HIGH results either. But we have to be honest analysts. I believe that those still prescribing Niaspan to patients with LDL Again, Prasad and Vandross� larger point that we should not be so enamored with surrogate endpoint trials is valid.

Hands off my wife! Bahrain AED survey points to CPR barriers

Wed, 25 Apr 2012 12:21:13 EDT

This is what happens when rational humans live in a world of fiction.

Diabetes/statin link probed in EFFECT cohort

Wed, 25 Apr 2012 11:24:17 EDT

The population at risk of atherothrombotic disease (ATD)can be predicted independently of the blood sugar level (BSL). ATD risk in diabetics depends on cigarette smoking, dyslipidemia, and hypertension. When these risk factors are very well treated, the ATD risk in diabetics is minimal. So...treat the "Big Three" risk factors, and treat the elevated BSL when it occurs. My treated diabetics who have never smoked cigarettes die at an average age of 80 years, and my diabetics with ATD die only 55% of the time from a recurrent ATD event. I can not remember the last time a diabetic patient of mine had a limb amputation--certainly not in the last decade or so...Incidentally, pravastatin did the worst job in stabilizing/regressing angiographic coronary artery plaque in my published paper. I never use it.

Raise the bar for starting primary prevention, cardiologists argue

Wed, 25 Apr 2012 11:12:48 EDT

If this article refers to putting statins into the water, then I agree 10,0000,000%. Primary prevention works best in the at-risk population.

Cardiologists still earning big bucks, but work frustration abounds

Wed, 25 Apr 2012 10:50:38 EDT

If you live in Lugano (Lombard: L�g�n), in the south of Switzerland, in the Italian-speaking canton of Ticino, nickname of the "Monte Carlo of Switzerland" you are doing well.

Cutting, taxing salt would trim CVD deaths by 3% in half the world

Wed, 25 Apr 2012 09:06:47 EDT

This is as noted "3%, a new modeling study suggests" no real evidence supports it. It does however play to established beliefs that reducing salt intake will save lives.That has never been shown in RCT something required for less favored interventions like vitamin d. A recnt study in JAMA "Urinary Sodium and Potassium Excretion and Risk of Cardiovascular Events notes "The association between estimated sodium excretion and CV events was J-shaped. Compared with baseline sodium excretion of 4 to 5.99 g per day, sodium excretion of greater than 7 g per day was associated with an increased risk of all CV events, and a sodium excretion of less than 3 g per day was associated with increased risk of CV mortality and hospitalization for CHF. " If the model in JAMA is correct than what results would this "experiment" have. Stange so much resistance to vitamin d which has shown benefit in many albeit small RCTs so much acceptance of salt restiction

Cardiologists still earning big bucks, but work frustration abounds

Wed, 25 Apr 2012 07:53:07 EDT

ho fatto il cardiologo ospedaliero per tutta la vita ancor oggi lavoro come LP nel pubblico.Non ho mai nemmeno lontamente guadagnato come i miei Colleghi americani,per� sono lo stesso fiero di quello che ho fatto e lo rifarei di nuovo.La gioia di un paziente che ti ringrazia non ha prezzo. Dr Fabrizio Zanardi cardiologo ferrarese e del polesine

Five OSU cardiologists earned $1-million bonuses in 2011

Wed, 25 Apr 2012 03:43:26 EDT

I would caution the word 'fair market value' when in fact the price is arbitrarily determined by the government and the insurance companies collude. I'm not sure where the extra money came from, if it is technical fees then yes it is from government money. If it came from the private institution then no the government and noone else has any type of say in the amount. We as physician's are constrained in a box we don't agree with and then a hammer is brought down if we are outside these constraints. Just ask the cardiologists and hospitals that are part of the reviews for pci and aicd implantation. It is frustrating when we try to practice good evidence based medicine but must negotiate in a limited financial system. We just do our best and again I congratulate the osu guys and wish them the best. More cardiologists should figure out how to get fair compensation like they did, kudos on them!

Cardiologists still earning big bucks, but work frustration abounds

Wed, 25 Apr 2012 03:34:57 EDT

I agree with the survey. Certainly it is frustrating and certainly there are more well paid people and professions. I was watching Tony Robbins on Oprah last night and he said something interesting, most people are not fulfilled and that happiness is fleeting like physical pleasure. I'm not saying everything is hunky dorey or that I think it's great to have to deal with malpractice suits, insurance companies and or whining patients. I guess when all is said and done and regardless of what your believe system is, I have to believe more for my own sanity that all the sacrifice and service we do for our fellow man will be rewarded on some cosmic scoreboard. This type of meaning to my life gives me fulfillment. So no I don't dispute the study and agree with most people in it, I would just add that when it comes to doing something of value with my life there is nothing I else I would choose. Yes, nurses calls still irritate me and yes I don't think professsional sports people should be paid exponentially more than us, but then again the world is not perfect. I'm not trying to change the world, just live in it. And in our imperfect world, we are fortunate to be able to do what we do. Just sayin..

PCI bests meds in stable CAD, but message is "do better meds"

Wed, 25 Apr 2012 03:14:23 EDT

In a culture where virtually everyone with stable angina gets stented, as was the case here, one must question the reasons behind not stenting the few who were treated medically. Was it due to such advanced disease that stenting seemed futile? Did the patient have such co-morbidities that stenting seemed inappropriate? I firmly believe that we must look at DATA other than just RCTs, however I think the quality of this DATA is too sketchy to reach any conclusions at all.

SCD risk increased in blacks with HTN, genetics may be key: LIFE analysis

Wed, 25 Apr 2012 03:03:54 EDT

Look at socioeconomic status and vitamin D levels and you will likely explain the increase in sudden cardiac death. In addition, take a peek at the omega-3 fatty acid consumption and there may be some issue there also.

AHA: No evidence that gum disease causes CHD

Wed, 25 Apr 2012 03:00:20 EDT

I agree with post #1. What is the AHA thinking? Just because the quality of the DATA does not meet their unreasonable standard does not mean the casual association does not exist. We have shown that curing periodontal disease can improve carotid IMT. This is something that high dose statin cannot accomplish. We have shown a strong reverse association between tooth brushing and incidence of heart attacks.

Lung cancer? Yep, but smokers, globally, are less aware of CVD risks

Wed, 25 Apr 2012 02:53:59 EDT

The recently published article demonstrating improvement in lung cancer survival with CT screening also demonstrated an improvement in overall survival above what is explained by the reduction in lung cancer deaths. This reduction in overall survival is undoubtedly due to detection of subclinical atherosclerosis in this population and initiating lifestyle changes and possibly drugs to change that risk. This is a strong argument for CT coronary calcium imaging and lung screening in the smoking population.

Raise the bar for starting primary prevention, cardiologists argue

Wed, 25 Apr 2012 02:44:53 EDT

AIM HIGH was stopped because it was not expected to find a positive endpoint and the results were erroneously interpreted to show a signal for stroke. There are hundreds of reasons why it may have failed to reach an endpoint other than ineffectiveness of niacin. 1. The placebo might have also been niacin, oh wait, the placebo was niacin! 2. The study period may have been too short to get a result. the study was stopped at the 2 year mark; it takes niacin 9 months to reach steady state with respect to HDL. 3. It was an "intent to treat" trial. If too many subjects taking the high dose niacin stopped the treatment, it can dilute the results to garbage. It is probable that more subjects dropped the high dose arm than dropped the low dose arm. It is possible if not probable that even low dose niacin is of clinical value and this could have confused this study dramatically. 4. The subjects were on high dose statin therapy. It may be that high dose statin therapy blocks the benefit from niacin. It is inappropriate for Heart Wire to report niacin as being of no value. The National Lipid Association as well as the European Society of Atherosclerosis have both formally stated that clinicians should not make any clinical decisions based upon AIM-HIGH. I guess Heart Wire disagrees!

Cardiologists still earning big bucks, but work frustration abounds

Tue, 24 Apr 2012 22:27:32 EDT

I always find these surveys interesting. In my opinion, cardiology offers one of the most rewarding careers in medicine. I have colleagues in law and business who make more money, but, Good Lord, at what price? My job has stress and headaches, but at least I enjoy the basic premise of my job: taking care of patients.

Five OSU cardiologists earned $1-million bonuses in 2011

Tue, 24 Apr 2012 22:09:07 EDT

I don't know all the details, but you are correct in that there are limits to reimbursement based on fair market value (ie, my hospital cannot pay me $200 per RVU, even if they wanted to). I suspect these bonuses arise from some sort of private endowment and are based on prespecified criteria that have nothing to do with RVU production, technical fees, etc. These 5 EP docs were previously in a group that has long had a reputation for high physician salaries (due to huge workloads and long hours). Long ablation procedures do not fit well with a productivity model, and OSU saw an opportunity to recruit an entire program in one fell swoop. I have no idea if there has been enough "value added" to OSU to justify their pay, but I can assure you that the administrators do. If such bonuses continue, I think we have our answer.

Topol is most influential physician executive in new US poll

Tue, 24 Apr 2012 21:50:59 EDT

"genius", "brilliance", "visionary" are all terms that have largely lost their luster due to gross overuse in modern society; however each generation is blessed with a handful of individuals truly deserving of such accolades. Eric Topol is one of those individuals. One can only wonder "what might have been" if such an individual had been given the reins of a juggernaut like the Cleveland Clinic.

ACE inhibitors better ARBs in new meta-analysis in hypertensives

Tue, 24 Apr 2012 20:34:57 EDT

Vitamin D goes one step further than ACE inhibitors�without the dangers Vitamin D achieves its blood pressure lowering effect by addressing one of the major causes of high blood pressure�a substance called angiotensin II. Angiotensin II is produced by another substance called angiotensin-converting enzyme, or ACE. When ACE is allowed free rein, it sometimes produces too much angiotensin II. Excess angiotensin II constricts blood vessels, which raises blood pressure. But that's not all that excess angiotensin II does.

Another study questions epinephrine for out-of-hospital cardiac arrest

Tue, 24 Apr 2012 14:09:55 EDT

There are many problems with the large observational Japanese study by Hagihara. Theseinclude: i) The pre-study hypothesis (that Epi use in cardiac arrest will increase survival with intact neurologic function) is set up for failure by design of the study. Epi administration given relatively late to patients already in out-of-hospital PEA/asystole is highly unlikely to result in neurologically intact survival. Most patients who do survive OHCA � have VFib as their initial mechanism and have had their arrest recognized sooner with bystander CPR given - and - with defibrillation implemented while VFib is still present. ii) Statistical development of a �propensity-matched� group (from which the most positive results of this study were derived) � may not be a valid concept in a non-randomized observational study obtained from registry data. iii) Use of Epi after the patient with OHCA arrived at the hospital was not tracked. Therefore � there is no way to know how many patients might have received Epi for persistent cardiac arrest after EMS arrival to the hospital. This clearly could have had a conclusion-altering impact on results of this study. iv) Treatment practices in Japan during 2005-to-2008 are not necessarily the same as in the United States (or in other countries). v) Additional Consideration: Data from the Hagihara study were obtained without use of therapeutic hypothermia. While still too early to know what the potential future impact of this new intervention will be for OHCA from VFib or Asystole/PEA � data are lacking for the potential role of Epi (if any) when hypothermia is implemented ... BOTTOM LINES: There is no evidence to date establishing a cause-and-effect relationship between Epi use for cardiac arrest and impaired neurologic outcome. - Observational data is not proof; it merely suggests hypotheses and a need for additional study.In the meantime (awaiting such studies) � Clinicians remain with the dilemma of simply not having any therapeutic drugs proved to improve survival from cardiac arrest, even though they do have an agent that does increase the chance of ROSC. Debate will continue on whether that agent (Epinephrine) should still be used. MY OPINION: Until such time that we have proof of harm from use of Epi in patients with cardiac arrest � I think: i) Epinephrine should continue to be used as it has up until now for in-hospital cardiac arrest. (Bigger issues regarding in-hospital decision-making relate to determination of which patients should or should not be resuscitated � but once that decision has been made, we are committed to doing all we can to increase likelihood of ROSC). ii) Epinephrine should continue to be used as it has up until now for out-of-hospital cardiac arrest when the initial mechanism of arrest is Pulseless VT or VFib. iii) It is reasonable not to use Epi for out-of-hospital cardiac arrest when the initial mechanism of arrest is PEA/Asystole � especially if information about the onset of arrest is lacking and no bystander CPR has been done. Realistic chances of resuscitating such patients with restoration of intact neurologic function are almost negligible for such patients. Epi increases the chance of restoring a pulse � which could lead to a state even less desirable than death. iv) My reason for iii) is not because Epi "causes" neurologic injury (since there to date is no evidence proving this) � but rather because the finding of PEA/Asystole in OHCA almost certainly portends irreversible insult regardless of whatever interventions are attempted. NOTE: Others may have different opinions ...

Topol is most influential physician executive in new US poll

Tue, 24 Apr 2012 13:50:52 EDT

This concept is no different from that which has been described as the "art" of medicine with a genetic explanation. Physicians in practice have long known that "guidelines", like the Pirate Code, are more like "guidelines, than actual rules." Please don't hamstrung us in the trenches into practicing according to some expert consensus document. We applaud Dr. Topol for recognizing the need for personalized tailoring of care for individual patients.

Topol is most influential physician executive in new US poll

Tue, 24 Apr 2012 12:38:02 EDT

Eric Topol is witnessing the �destruction� of the American population by artifical food poisoning. His own history with the power of the Pharmaceutical Industry is sobering. I read his book, but I also benefited by Dick Hill audible version on my Kindle. As discussed in his book: The VA�s Vista and DOD CHCS are working on �BLUE BUTTON� databases for patients to manage their data. This will change the doctor-patient dynamics.

Raise the bar for starting primary prevention, cardiologists argue

Tue, 24 Apr 2012 12:08:42 EDT

The dramatic rise and fall of the statin industry has begun. The tide slowly turning, and it will eventually crescendo into a tidal wave, but misinformation is remarkably persistent, so it may take years to change opinions.

AIM-HIGH fell short, leaving experts looking for reasons in new review

Tue, 24 Apr 2012 11:55:41 EDT

For an interesting perspective on artificially increasing HDL, see "The Yin and Yang of High-Density Lipoprotein Cholesterol," Jacques Genest, J. Am. Coll. Cardiol. 2008;51;643-644 at content.onlinejacc.org/cgi/reprint/51/6/643.pdf (without a "www."). This is a commentary accompanying van der Steeg et al.'s "High-density lipoprotein cholesterol, high-density lipoprotein particle size, and apolipoprotein A-I: significance for cardiovascular risk: the IDEAL and EPIC-Norfolk studies," J Am Coll Cardiol 2008;51:634�42, where high HDL was associated with increased risk, not decreased risk.

Diabetes/statin link probed in EFFECT cohort

Tue, 24 Apr 2012 10:23:29 EDT

There ARE prospective studies loooking at statins and diabetes : the PATROL TRIAL showed lack of AIC increase for pitava , head to head with atorva and rosuva, which DID increase A1C. Large J-PREDICT trial looking at Pitava and diabetes risk also. Randomized head-to-head comparison of pitavastatin, atorvastatin, and rosuvastatin for safety and efficacy (quantity and quality of LDL): the PATROL trial. Saku K,�Zhang B,�Noda K;�PATROL Trial Investigators. Collaborators (61) Source Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Japan. saku-k@fukuoka-u.ac.jp BACKGROUND: Atorvastatin, rosuvastatin and pitavastatin are available for intensive, aggressive low-density lipoprotein cholesterol (LDL-C)-lowering therapy in clinical practice. The objective of the Randomized Head-to-Head Comparison of Pitavastatin, Atorvastatin, and Rosuvastatin for Safety and Efficacy (Quantity and Quality of LDL) (PATROL) Trial was to compare the safety and efficacy of atorvastatin, rosuvastatin and pitavastatin head to head in patients with hypercholesterolemia. This is the first prospective randomized multi-center trial to compare these strong statins (UMIN Registration No: 000000586). METHODS and RESULTS: Patients with risk factors for coronary artery disease and elevated LDL-C levels were randomized to receive atorvastatin (10 mg/day), rosuvastatin (2.5 mg/day), or pitavastatin (2 mg/day) for 16 weeks. Safety was assessed in terms of adverse event rates, including abnormal clinical laboratory variables related to liver and kidney function and skeletal muscle. Efficacy was assessed by the changes in the levels and patterns of lipoproteins. Three hundred and two patients (from 51 centers) were enrolled, and these 3 strong statins equally reduced LDL-C and LDL particles, as well as fast-migrating LDL (modified LDL) by 40-45%. Newly developed pitavastatin was non-inferior to the other 2 statins in lowering LDL-C. There were no differences in the rate of adverse drug reactions among the 3 groups, but HbA(1c) was increased while uric acid was decreased in the atorvastatin and rosuvastatin groups. CONCLUSIONS: The safety and efficacy of these 3 strong statins are equal. It is suggested that the use of these 3 statins be completely dependent on physician discretion based on patient background. Circ J.�2011;75(6):1493-505

Hands off my wife! Bahrain AED survey points to CPR barriers

Tue, 24 Apr 2012 08:46:10 EDT

Dr Said Mohamed Al-Hina obviously never drank in his life, because alcohol dehydrates!! he'd become more thirsty if he drank booze than nothing at all!! i know that this was not the point of this analogy, but funny nonethess

AIM-HIGH fell short, leaving experts looking for reasons in new review

Tue, 24 Apr 2012 05:59:09 EDT

Actually I don't think that CTEP inhibitors will be approved until trial data you and I require. The FDA has learned a lesson from Zetia and the current CTEP agents are in phase 3 outcome trials which Zetia escaped prior to market approval. My understanding is that REVEAL and DAL-Outcomes are both hard endpoint studies that should be hypothesis testing and provide clinical data for decision making.

A 45-year-old woman who had an ICD implanted over 10 years ago

Tue, 24 Apr 2012 05:07:01 EDT

Excellent thought provoking for a GP with special interest in cardiology. i could see no hypokinesia . A systemic inflammation should show some pericardial effusion. We are grateful to for sharing such beautiful images. DR.B.R.LODHIA

ADA/EASD issue new hyperglycemia management guidelines

Tue, 24 Apr 2012 04:17:43 EDT

Is this due to a change in the case definition?

AIM-HIGH fell short, leaving experts looking for reasons in new review

Mon, 23 Apr 2012 23:22:29 EDT

So what we need are large, long-term CTEP trials looking at hard outcomes in relevant, statin-treated primary & secondary prevention populations, right? But I bet many $$ billions in CTEP prescriptions will be consumed before we ever see the results of such studies...

No aliskiren with ACE inhibitors, ARBs in some patients: FDA

Mon, 23 Apr 2012 22:00:50 EDT

Thanks for the confirmation just that the wording in the opening text was confusing , all the best

AIM-HIGH fell short, leaving experts looking for reasons in new review

Mon, 23 Apr 2012 18:55:18 EDT

Well stated. I think you would agree that an ineffective therapy does not negate a hypothesis. Autopsy studies suggested the importance of cholesterol metabolism in coronary plaques in the sixties and it wasn't until large reductions in LDL by statins was there a mechanism to prove the hypothesis. Perhaps the same can be considered now - niacin is a largely ineffectual agent in any way that can be measured but the HDL hypothesis could be true and CTEP inhibitors are what is required to adequately evaluate the hypothesis.

Statins, diabetes, and the FDA

Mon, 23 Apr 2012 18:14:30 EDT

I was placed on 40 mg. of generic lipitor -- prior to that I was on 10 mg simvastatin -- two days into the Lipitor, my blood sugars became difficult to control -- I've had diabetes for 58 years with no complications except for the fact that a Heart Scan revealed a high amounbt of plague which was the reason the cardio placed me on the higher dose of Lipitor. I stopped taking the Lipitor and two days later, my blood sugars were back to normal control. I test 10 times per day so I know that this elevated blood sugar DID occur.

Cutting, taxing salt would trim CVD deaths by 3% in half the world

Mon, 23 Apr 2012 17:25:09 EDT

i shall continue to pile the salt on my deep fried fish and chips after a nite full of lager, and guess what, i shall continue to live my life to the full.

No aliskiren with ACE inhibitors, ARBs in some patients: FDA

Mon, 23 Apr 2012 16:21:06 EDT

I don't see where the FDA is saying anything about not using aliskiren with diuretics or CCBs. The issue is just with other RAAS agents� ARB and ACEi molecules. They do note that all the drugs containing aliskiren. That's where the mentions of fixed dose combination drugs containing both aliskiren and amlodipine and hydrochlorothiazide is coming from. Seems these drugs are all fine and will continue to be available, but that none of these should be combined with a RAAS agent in patients with diabetes or impaired renal function.

Cutting, taxing salt would trim CVD deaths by 3% in half the world

Mon, 23 Apr 2012 16:18:23 EDT

How does the medical establishment profit? Low-salt (LS) diet activates the renin-angiotensin-aldosterone and sympathetic nervous systems, both of which can increase insulin resistance (IR).

No aliskiren with ACE inhibitors, ARBs in some patients: FDA

Mon, 23 Apr 2012 15:01:45 EDT

Why we decide that any type of hypertension must be targeted on RAAS ?? :O It's well known that only 22% cases are are due to high levels of angiotensin ||

AIM-HIGH fell short, leaving experts looking for reasons in new review

Mon, 23 Apr 2012 14:27:36 EDT

AIM-HIGH did indeed answer the important question that investigators set out to answer: Does niacin (Niaspan) add anything significant to statin treatment? And the answer was a resounding "No." Contrary to Michos' statement, the HDL cholesterol hypothesis is not debunked based just on the results of this one trial alone, although this was the largest RCT yet directly testing the best HDL-raiser currently available. There is a great deal more data and analysis available. See the table summarizing the relationship between on-treatment HDL cholesterol concentrations and subsequent cardiovascular outcome risk in seven previous statin trials in the Lancet, Nov. 20, 2010, page 1738, at: actx.beta.download.thelancet.com/pdfs/journals/lancet/PIIS0140673610621320.pdf Somehow, all of this evidence was ignored. See also the outcome results of the fenofibrate and torcetrapib HDL-raising trials. And J. Am. Coll. Cardiol. 2008;51;634-642. For an HDL meta-regression analysis including over 100 randomised trials involving almost 300,000 participants, see BMJ 2009;338:b92. Given no benefit in AIM-HIGH, how can Michos conclude �At this time, there is no clear indication to withdraw niacin in patients receiving this therapy if further LDL-C reduction is needed�? Yes, there is; AIM-HIGH, at least with respect to ER niacin, is clear. Wait for HPS2-THRIVE or REVEAL? AIM-HIGH used American & Canadian patients. In the ongoing HPS2-THRIVE, nearly half the patients are in China, with very different histories, diets, lifestyles, and genes than Americans have. I hope that Nicholls is honest and forthcoming with his patients about that if the HPS2-THRIVE results end up differing from AIM-HIGH and all the other statin trials. He should let his patients decide for themselves which population is the more applicable. REVEAL results won�t be reported until at least 2017. Niacin may have a place for those patients who cannot tolerate statins (though this has not been demonstrated yet with hard outcomes in a RCT). But for those with reasonably-low LDLs due to statins, increasing HDL simply appears to offer no value. Besides pride, why is there so much commentator resistance to accepting the AIM-HIGH (and other) trial results? Could it have to do with all those HDL drugs that are in the pipeline?

AIM-HIGH fell short, leaving experts looking for reasons in new review

Mon, 23 Apr 2012 13:59:37 EDT

I took large dose niacin for years, and my HDL was comfortably high (50-60), but not until I reduced/ eliminated carbohydrates very drastically (and stopped niacin, by the way) did my HDL rise above 70 ( currently 76). Also, my TG dropped from 250-300 down to below 100. These new values have persisted for six years. I've challenged three cardiologists who have written in favor of medicating to lower TG/ raise HDL and who did not mention lo carbs, and the standard response is "oh yeah, lowering carbs works, too". Low carbs also lowers blood pressure by lowering insulin levels, but that seems to be completely ignored.

ADA/EASD issue new hyperglycemia management guidelines

Mon, 23 Apr 2012 13:12:12 EDT

In the U.S., there has been a 61% increase in incidence of Type 2 Diabetes between 1990 and 2001. There are currently 1.5 million new cases per year, and the prevalence in 2005 was almost 21 million. The epidemic has affected developed and developing countries alike, and the worldwide prevalence of diabetes is projected to increase dramatically by 2025. Statins are worsening the incidence of diabetes. Despite the rapid fall of the incidence of smoking, heart disease (ATD) incidence remains high.

ADA/EASD issue new hyperglycemia management guidelines

Mon, 23 Apr 2012 12:20:36 EDT

The chief cause of death in diabetes is atherothrombotic disease (ATD), which is also the chief cause of morbidity. The prediction of the population at risk of ATD is independent of the blood sugar level. No discussion of the care of diabetes is complete unless the subjects of cigarette smoking, dyslipidemia, and hypertension are included. As far as blood sugar level (BSL)is concerned, I keep the 2 hr pp BSL below 200 mg/dl (11 mmoles/L). My nonsmoking diabetics die, the last time I checked, at an average age of 80 years, and die on an ATD event only 55% of the time. The supporting data have been published at a number of scientific symposia and are published in abstract in the respective journals. All data are available at my website (www.bowlinggreenstudy.org), which is free and open to all.

Lung cancer? Yep, but smokers, globally, are less aware of CVD risks

Mon, 23 Apr 2012 12:06:25 EDT

Cigarette smoking is the NUMBER ONE cause of atherothrombotic diseese (ATD) and indeed is one of the prime reasons why atherosclerotic disease is termed atherothrombotic disease. Cigarette smoking moves up the onset of clinical ATD by 10-12 years, and moves the onset of multi-system ATD and death by about the same amount of time. Indeed cigarette smoking can produce ATD events even when lipid levels and blood pressures are low. The mechanism is via inflammation in the plaque's fibrous cap and acute thrombosis. Interestingly, the cigarette effect disappears within 6 months once the patient stops smoking.

Five OSU cardiologists earned $1-million bonuses in 2011

Mon, 23 Apr 2012 11:22:07 EDT

I agree that physicians deserve to be paid what the market will bear. But this doesn't appear to be the opinion of the Federal government, who pays the bills of the patients, and ultimately the salaries of the physicians. Ours is the one profession in which the client determines the fee, and is the ultimate arbiter in determining the "fairness" of a salary determined by the University. It doesn't matter if the University wants to "share" the technical component with the doctors. If the Feds decide that this represents a private inurement--that is a benefit beyond those that the physicians provide in return--the non-profit status of the employer is threatened. I smell a whistleblower lawsuit.

Public smoking bans and cardiovascular health

Mon, 23 Apr 2012 10:24:32 EDT

You can try to justify your addiction with such an incomplete libertarian argument. Your concept of liberty is morally wrong. People are not free to alienate their own freedom. I guess (in your head) people can choose to use heroin or watch child pornography, as per your point of view, they have the right to choose what they please. Well it doesn't make it right regardless of what you think and smoking, especially exposing others to that smoke, goes the same way. It is unethical when one is dealing with a clearly known harmful substance, to allow those perpetrating the harm to continue to do so, especially, when the detrimental effects are so well substantiated. Currently, it is important to change the erroneous �autonomy� concept that some people have about people's right to cause harm on some one else in order to achieve self-pleasure. Those who argue that banning smoking is discrimination against smokers should realize that by not banning it, those who make the wise decision not to smoke are the ones who are truly being discriminated against. There is consistent evidence that cigarette smoke either by direct or indirect means has damaging effects in the human body. Numerous researches have collected unquestionable and reliable data about this issue and every major scientific body, not just in the United States, but also in Europe, Australia, New Zealand, and around the world, acknowledges and agree with the results from these studies and there is no way anyone will to be able to refute these data. You may be getting paid well to post such comments and continue to argue with experts... or your addiction is just so that you have placed it above anything else, including your health, your family's health and other people's health.

Italian soccer player dies on the pitch

Mon, 23 Apr 2012 08:26:58 EDT

Sok-Ja Janket. In our Clinical Trial on Professional athletes that you can see on www.alternans.org we have analized a group of athletes without important arrhythmias and MTWA was negative in all but in athletes with some important arrythmmias we had 10% of positive MTWA. Of these most had also positive EP test. So MTWA can be used as screening in Professional Athletes with important arrhythmias.

A 45-year-old woman who had an ICD implanted over 10 years ago

Mon, 23 Apr 2012 07:49:22 EDT

a RARE BUT EDUCATIONAL CASE

Five OSU cardiologists earned $1-million bonuses in 2011

Mon, 23 Apr 2012 03:40:05 EDT

I'm not sure why every Tom Dick and Harry feels he can comment on the money these guys made. If they don't take government money which I understand they did not..bonuses were paid privately by the university, it is immaterial how 'important' a primary care is, how long they have been in practice etc. It is a free market economy and they have a business, just like society has no right to comment on a professional athelete's exhorbitant salary. As to 'treating' the infirm and the like, that doesn't dictate what your salary is. As to the post that somehow defines what social class doctors should be and defines why we go into the profession, I say mind your own business. If these guys 'resemble a wall street firm' good on them, I'm happy for them and I hope they spend(or save) their money in a way that makes them happy. I wish these cardiologists the best and hope they continue to get large bonuses. It seems to me ridiculous that coaches and other professions make way more money and suddenly when a noble profession like medicine makes money it is wrong..no it is not even our place to judge....

Hands off my wife! Bahrain AED survey points to CPR barriers

Sun, 22 Apr 2012 22:25:49 EDT

I do not understand why the Arabs don't have a problem when someone of European descent does cpr and not indian ! Anyway CPR has many cultural barriers , even today in Delhi a doctor was beaten up for performing CPR on a 16y girl. God save people in dark worlds like India[my country] and the East .

Tough sell: WCC 2012 course coaxes trainees toward preventive cardiology

Sun, 22 Apr 2012 18:48:58 EDT

Radically transformed (Creative Destruction) of the life science industry already is occurring by the Internet. New medicine management will be with the �BLUE BUTTON� databases that will empower the patients to keep and store data regarding their own illnesses. Chimpanzees in the wild do not get atherosclerosis unless they eat sugar. Avoiding sugars and cardiologists only for acute problems. Oxidized and glycated LDL particles become less efficient in delivering their contents to the cells. Thus, they stick around longer in the bloodstream, and the measured serum LDL level goes up and HDL go down. The tide slowly turning, but I believe well educated individuals will choose the correct lifestyle without a preventive cardiologist. Acute care is the only future for clinicians. CAC leads to ineffective therapies.

AHA: No evidence that gum disease causes CHD

Sun, 22 Apr 2012 17:26:42 EDT

Atherosclerosis microbiome, the latest and most critical segment of the human microbiome may have a large periodontal component. Read, "The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care" by Eric Topol Is this the overlooked cause of CAC-Coronary Artery Calcification?

No aliskiren with ACE inhibitors, ARBs in some patients: FDA

Sun, 22 Apr 2012 14:38:10 EDT

I went to the FDA web site for more info there is not any mention of this applying to the cubs and diuretics. Where did this statement come from in the above text?

No aliskiren with ACE inhibitors, ARBs in some patients: FDA

Sun, 22 Apr 2012 14:33:05 EDT

Altitude dd not study aliskiren in combo with CAlcium channel blockers or diuretics. --- can someone explain to me therefore why the statement that te FDA shoud I cued these combos it doesn't,t apply here am I missing something here?

Tough sell: WCC 2012 course coaxes trainees toward preventive cardiology

Sun, 22 Apr 2012 14:11:47 EDT

As a physician who has done interventional lipidology and preventive cardiology for almost four decades, I would like to offer a few comments. The prime reason to try to prevent atherothrombotic disease (ATD) is the simple fact that 1/3 of people with acute myocardial infarction (AMI) do not survive their initial events, so they do not get a second chance. Many people with paralytic strokes with they had not survived either. This does not even begin to cover the immense costs of the treatment of established ATD. What is needed is a simple tool to predict the population at risk of ATD and simple treatment regimens to prevent/stabilize/regress ATD. My treated patients have have so far this century suffered only two fatal AMI's and the occasional non-fatal AMI and minor stroke. The patient who suffered the last paralytic stroke did so in 2004, and he was a cigarette smoking diabetic with dyslipidemia and hypertension, who presented to me about one month prior to his stroke and suffered his stroke shortly after I had initiated therapy. The predictive/therapeutic tool I use can be found at my website (www.bowlinggreenstudy.org) which is free and open to all. The key is to get people to stop smoking and treat their lipids and blood pressure appropriately. Diabetes must also be treated, but comes second line top the "Big Three" ATD risk factors.

AHA: No evidence that gum disease causes CHD

Sun, 22 Apr 2012 12:48:00 EDT

One of Hill's criteria for causality is experimental evidence of the cause-effect relationship, i.e. the condition (CAD) can be altered by an experiment (treatment or prevention of periodontal disease). Peridiodontal disease has too many confounders (smoking, poverty, etc.) to establish a causal link from observational data alone. Can anyone point to experimental data in humans that supports this? Just curious and probably misinformed but I am not aware of any.

Hands off my wife! Bahrain AED survey points to CPR barriers

Sun, 22 Apr 2012 10:58:05 EDT

we have here the strong and definitive confirmation that gender difference exists in the care of heart disease!

A 45-year-old woman who had an ICD implanted over 10 years ago

Sun, 22 Apr 2012 09:58:51 EDT

Glad you liked it. I hope you like the one coming next month.

Hands off my wife! Bahrain AED survey points to CPR barriers

Sun, 22 Apr 2012 09:58:08 EDT

This brings up important gender care essentials - a razor to shave hair from the man's chest for defib pads to stick, AND scissors to remove bra (often metal underwire) from the woman's chest. PLEASE, save HER life!

A 45-year-old woman who had an ICD implanted over 10 years ago

Sun, 22 Apr 2012 09:54:52 EDT

Thanks for showing this,more of these topics are most welcome.

No aliskiren with ACE inhibitors, ARBs in some patients: FDA

Sat, 21 Apr 2012 19:52:06 EDT

�This is panic time, this is truly panic time for the industry.� �I don�t think there�s a company out there that doesn�t realize they don�t have enough products in the pipeline or the portfolio, don�t have enough revenue to sustain their research and development.�

Maryland set to establish independent review system for PCI

Sat, 21 Apr 2012 15:00:23 EDT

The imposition of outside authority on the practice of medicine is our own fault. We, as a profession, have not done anything to promote intelligent self policing or oversight. I have personally seen credentials committees look the other way when a powerful member of the medical staff (i.e. one who brings in revenue) wants to do a procedure he/she has no qualifications to perform. I have seen many patients receive pacemakers from other physicians after I had suggested that there was no indication for a pacemaker (because there was no indication) so the referring simply sent the patient to a physician willing to do a "simple procedure" to keep the referring happy, make money or whatever. I have seen how hard it is to revoke privileges from physicians who are clearly, manifestly and patently incompetent and/or a menace to humanity. We are now suffering the results of our own failure to self regulate. Of course there are other reasons for the NCDR and I think the ACC, AMA and others have not done a great job of protecting our interests but I'd be interested to know how much time The Ventricle has spent interacting and participating with our professional organizations. Before anybody asks I have spent almost no time with ACC/AMA/HRS so don't take it personally. We have all been too busy trying to figure out how to optimally treat our patients. Nevertheless, our failure, and I include myself, to meaningfully police our own plays a large part in our current regulatory environment. Stop griping and get involved. I am a member of the Cath Lab QA committee where I can at least try to make a difference at my hospital. How to address the bigger picture of the madness that the current regulatory system is producing is beyond me.

AHA: No evidence that gum disease causes CHD

Sat, 21 Apr 2012 11:21:23 EDT

This AHA statement is premature. Lockhart said "Such a study (to prove causal link) isn�t likely to be done in the near future" and that is not true. I have data to show you a potential causal link that will be published soon. Of note, my data were all controlled for age, sex, smoking, Diabetes, hypertension and CRP. My cohort has mean BMI Going through gum surgery at present is over-statement of the current scientific evidence. However, Lockhart's review displaying what has been done without any incisive evaluation of the evidence is useless. Most readers do not read the individual studies. Therefore, a critical reviewer has an obligation to guide the readers with scientific understanding, but not pushing his/her opinion down the readers' throat. I did two meta-A(s) and most people consider it very impartial and scientifically correct review. (one is on perio_cardio link; the second on perio Tx and glucose level in DM patients) This topic (perio_cardio) has been a political football between epidemiologists who want to discredit any link at any cost versus periodontists who want to stratch the truth a little for their gains. I belong to neither. I see why AHA went to ADA (mostly general dentists) for the summary opinion. Unfortunately, the person who is doing the summary are not qualified to do the job. It is not personal attack to Dr. Lockhart. Most general dentists do not have knowledge to tell which is evidence and which is fluff. Right now I am trying to correct the damage done by a poorly conducted review by an unqualified General dentist which ADA upheld as if it was God's word. Next week, I will lecture group of periodontists on how to conduct research CORRECTLY. Sorry for a long comment. But you should hear from me, a neutral guy (gal) being kicked from both sides.

No aliskiren with ACE inhibitors, ARBs in some patients: FDA

Sat, 21 Apr 2012 11:11:29 EDT

i do not understand, yes dual RAAS blockade with aliskiren and ace/arb, but why does this apply to the combo with diuretics or calcium channel blockers??? altitude was concerning dual raas blockade with aliskiren and the ace/arb comb , in Canda aliskiren is a third line add on including those on a diuretic or ccb

Statin therapy prior to CABG reduces the risk of postoperative AF

Sat, 21 Apr 2012 10:00:58 EDT

Statins inhibit the expression of pro-inflammatory cytokines and the infiltration of neutrophils and macrophages toward the site of injury. Thus, among others, they serve to limit and terminate the inflammatory phase. Epithelialization, one of the defining parameters of wound healing, is governed by these extracellular signals. IL-1 plays a direct role in re-epithelialization by inducing the expression of keratin 6/16 (K6/K16) in keratinocytes to support migration and proliferation.[12] When the execution of the highly ordered process of wound healing fails, delayed acute or chronic wounds develop. The epidermis is an important site of cholesterol biosynthesis, which is regulated by barrier function. Wounding disrupts barrier function occur during healing.

Positive dalcetrapib data in the dal-PLAQUE MRI and PET/CT study

Sat, 21 Apr 2012 09:51:03 EDT

Starting and formost, patients idiosynchrasis, life styles, etc, bias and self interests etc. My opinion. honest observations with our own long term clinical experiences are still the most effective tools for me when treating patients in general.

Maryland set to establish independent review system for PCI

Sat, 21 Apr 2012 02:31:45 EDT

I have attended many a cath conference and what I have observed is a "heard" mentality among cardiologists. Their understandtanding of the fluid physics and vascular physiology is probably worse then that of a high school kid. Whenever this is pointed out to them they will want you to admire the post palsy angio without followup data as if post plasty/ stent angio was the end of the story and "everyone lives happily ever after". There is need for re-education of the entire profession. And i don't think that is doable. Regarding ACC I think this is just a very smart move! They want to shout that the Empror has no clothes before the grumbling gets any louder and they are put in Jail like some of their colleague. There other motive is to get into the rule making game so that they could protect their interests and before someone actually comes up with an independent review of outcome.

AF patients admitted to the hospital on weekends have worse outcomes

Sat, 21 Apr 2012 00:22:44 EDT

As AF happens mostly during the WE!after drinking eating to much and slepping less! we have so many gap "to bridge": difference in care of myocardial infarction during WE, in women, latino/african,very old people...the list never ends. beside cardiac chest pain unit have we to built Week End Atrial Fibrillation Unit ? I do not see any practical issue in our medical practice with this kind of study.

Report validates risk of high-dose simvastatin

Fri, 20 Apr 2012 22:02:57 EDT

The data is the data - look at the table as reported - 1/16876 patient years of use. That would qualify as extraordinarily safe even not knowing whether clinical decision making was optimal. This is nothing more than an attempt to favor atorvastatin or Crestor for reasons that don't exist. We have seen this with plavix only to be discounted by large trials. At some point maybe physicians will not be coerced by hyped findings. If you want to argue give me the rhabdomyolosis data on lipitor 80 and crestor 40 first.

AIM-HIGH fell short, leaving experts looking for reasons in new review

Fri, 20 Apr 2012 21:47:15 EDT

You have improved your blood test. The question remains whether that matters. The argument of biomarkers as a surrogate for endpoint reduction remains despite AIM-HIGH refuting it - I guess.

Higher HbA1c levels predict better outcomes in advanced heart failure with diabetes

Fri, 20 Apr 2012 20:28:36 EDT

Do Diabetic drugs just increase mortality? The more drugs, the worse the outcome. This was suggested since the 1970�s.

Hands off my wife! Bahrain AED survey points to CPR barriers

Fri, 20 Apr 2012 18:25:48 EDT

If this were posted on Yahoo! news, I could only imagine the comments...

Statin therapy prior to CABG reduces the risk of postoperative AF

Fri, 20 Apr 2012 18:08:53 EDT

less postop af than those who drive BMWs.

Italian soccer player dies on the pitch

Fri, 20 Apr 2012 16:25:58 EDT

David Bach, I checked that website and they mis-presented negative predictive values. NPV is prevalence (in the population, not the sample) dependent) : therefore, even if it had 99% specificity, the prevalence is so low in young atheletes, the negative predictive value would be infinitissimally small.... Thank you for sharing but it is no more than "better than nothing" test. Also, SCA has heterogeneity in etiology even in that small numbers, .... even more difficult to come up with a good test. Someone will, hopefully soon.

AHA: No evidence that gum disease causes CHD

Fri, 20 Apr 2012 16:02:22 EDT

Hernan & Taubman, Int J Obesity, 2008, S8-S14, "Does obesity shorten life? ..."

AIM-HIGH fell short, leaving experts looking for reasons in new review

Fri, 20 Apr 2012 14:47:55 EDT

Niacin works in so many ways to improve plaque that I would be very surprised if it didn't improve outcomes. I have raised my HDL from 33 to 62 on 2 grams of niacin.

TIPS 2: Full-dose polypill boosts efficacy, with no increased side effects

Fri, 20 Apr 2012 14:40:42 EDT

We have atenolol which has not been shown to be very effective at reducing events perhaps because of its bad metabolic effects perhaps because it does not lower central BP effectively. We have the thiazide component: now if any of the benefits that appear to be related to vitamin d are real and especially if any are related to UVR how exactly will that that play out ;and of course the statin was not there a study suggesting beta blockers offset some of the benefit of statins? One thing appears pretty apparent this combination will spike the rates of diabetes.

Maryland set to establish independent review system for PCI

Fri, 20 Apr 2012 14:37:48 EDT

Dr. Gupta, you exemplify why anonymity is desirable. You and your ACC acolytes choose to use the police power of the state to tell your colleagues how to treat patients you've never met. The possible penalties that the commission could impose may ruin careers. Certainly no one would be too clever to cross you openly who would want to continue to practice medicine freely. You have friends in high places...Congratulations. And besides, anonymity is relative. The heart.org doesn't seem to like those who "throw punches at a blind man" either... Through the pseudo-science of outcomes research and its proprietary NCDR registry, the ACC has bolstered the nebulous concept of "unnecessary stent" into a focal target the regulators, hsopital administrators, and third-party payers are more than happy to shoot at to take down doctors. Bravo, ACC!

Report validates risk of high-dose simvastatin

Fri, 20 Apr 2012 13:34:22 EDT

It seems as though the data presented contains a couple errors. The Validated rhabdomyolysis cases for Simvastatin >= 80 mg/d should be 11 NOT 1 as presented. This is corroborated by the statement below the table which begins "In total, 22 cases of statin-related rhabdomyolysis were validated..."; furthermore the number of total rhabdomyalasis cases from the [All doses] row is shown as 23. However adding up the [Validated rhabdomyolysis cases] column as shown gives only 13 not 23 as the [All doses] row indicates. This error could cause the casual reader an order of magnitude of underestimating the potential harm from high dose Simvastatin. The second error is in the [Other statins] row. The 11654 is likely wrong and missing a 0 between the 6 and 5. The correct number is likely 116054. This correcting makes the incidence rate number shown work out. My attempt to validate the data presented against the original study failed for alas I am not a Dr. but only a lowly unemployed hotel worker and was shot down at the gates of the JAMA site. BTW that would make 1 case if you treated 169 patients for a decade. While not exactly Russian roulette 1 in 169 would cause me pause and is a far cry from the 1 in 16,876 originally assumed by the author of another post.

Italian soccer player dies on the pitch

Fri, 20 Apr 2012 13:12:42 EDT

Mr. Morosini death from sudden cardiac arrest (SCA) was preventable. Microvolt T-Wave Alternans (MTWA) can determine who is susceptible to SCA. It was FDA and CE approved years ago. MTWA is non-invasive and takes a half-hour to perform. NASA uses MTWA on astronauts. Why do more than 300,000 Americans have to die annually from SCA? For more MTWA information, go to www.cambridgeheart.com

AHA: No evidence that gum disease causes CHD

Fri, 20 Apr 2012 13:10:22 EDT

good place to cite a recent tweet from the editor-in chief of Lancet: richard horton ‏ @richardhorton I read the contents list of about one epi journal a day. And you just think: what are all these uncertain associations contributing?

SCD risk increased in blacks with HTN, genetics may be key: LIFE analysis

Fri, 20 Apr 2012 13:07:11 EDT

Microvolt T-Wave Alternans (MTWA) can determine who is susceptible to sudden cardiac arrest, regardless if they are black, white, yellow or blue. NASA uses non-invasive MTWA on astronauts. Why is MTWA, which has had FDA approval for 13 years, not used on Americans? For more MTWA information, go to www.cambridgeheart.com

What is the clinical significance of electrical alternans in this tracing?

Fri, 20 Apr 2012 13:04:29 EDT

I agree Gustavo Samaja. It is not an original ECG, but a unusual one and many doctor did not see Medscape (october 2010)

Statins, diabetes, and the FDA

Fri, 20 Apr 2012 11:55:50 EDT

Granted that this statin induced diabetes may be rare but how do you propose to treat the individual who tends to have elevated LDL? Take for example a 54 yo female who is 5'6" tall and weighs only 120 lbs. BP tends to be around 110/70. she has a healthy diet and is in great physical shape with aerobic and strengthening workouts 6 days a week. she was taking only 20 mg of lipitor and out of nowhere now has an elevated fasting test

New obesity index proposed, but further work needed

Fri, 20 Apr 2012 11:31:22 EDT

The BAI could be a good tool to measure adiposity due, at least in part, to the advantages over other more complex mechanical or electrical systems. Probably, the most important advantage of BAI over BMI is that weight is not needed. However, in general it seems that the BAI does not overcome the limitations of BMI. Citation: L�pez AA, Cespedes ML, Vicente T, Tomas M, Bennasar-Veny M, et al. (2012) Body Adiposity Index Utilization in a Spanish Mediterranean Population: Comparison with the Body Mass Index. PLoS ONE 7(4): e35281. doi:10.1371/journal.pone.0035281

AHA: No evidence that gum disease causes CHD

Fri, 20 Apr 2012 10:40:24 EDT

The link with ATD is via cigarette smoking!!!

TIPS 2: Full-dose polypill boosts efficacy, with no increased side effects

Fri, 20 Apr 2012 06:16:16 EDT

These claimed changes are meaninglessly small. Where are the figures for the actual benefits of making them? Impossible to find because the sample was extremely small to start with. Unless the research can demonstrate worthwhile reductions in unwanted outcomes - and to be demonstrably the effect of the pills the reductions must be at least an absolute 10% in five years - then there is no point in taking this pill. All of this research is not science, just marketing

What is the clinical significance of electrical alternans in this tracing?

Fri, 20 Apr 2012 05:40:54 EDT

it seems to me see a change in width between adjacent QRS. What about alternans engagement of the slow nodal pathway?

TIPS 2: Full-dose polypill boosts efficacy, with no increased side effects

Fri, 20 Apr 2012 05:04:32 EDT

Polypill is good for third world and developing countries.But one thing is very important,whether it is effective or not.Indian Pharma companies brought many of polypill in market and they are showing it has less price than multiple dose regime .I have used polypill antihypertensive drugs.It gave good result in few patients.But in few case it shows no role.So my idea is to start Polypill in secondary prevention of hypertension.

AHA: No evidence that gum disease causes CHD

Fri, 20 Apr 2012 04:23:57 EDT

Peter B. Lockhart, DDS has never published anything related to this topic. What gives him the qualification? I am a general dentist turn public health researcher. I did not know anything about research when I was a clinician. Only after taking 79.2 credits of biostatics and epidemiology, I could tell bad research from good ones. Why AHA would ask clinician to evaluate research results is beyond me.

TIPS 2: Full-dose polypill boosts efficacy, with no increased side effects

Fri, 20 Apr 2012 00:46:38 EDT

Polypill cannot be given for primary prevention till now as data from clinical trials very to much,and morever B blocker like atenolol failed to show efficacy in most of trials,its worst B blockers and creates more side effects than benefit.Ramipril is good drug in polypill but again the benefits are seen with 10 mg and more, and most of polypill contains only 5 mg,again statin dose is also half and in Normal health individual its use is associated in new onset diabetes,Both atenolol and statins is known to cause new diabetes.therefore many concern should be taken before it come in public health policy. Polypill is still answer for Secondry prevention and at high risk only.

What is the clinical significance of electrical alternans in this tracing?

Fri, 20 Apr 2012 00:20:04 EDT

SVT is known to cause both electrical alternans as well as non specific ST-T changes if the arrhythmia is sustained-Post tachy cardia syndrome is non specific ST-T abnormality which persists for nearly 24 hours post reversio of tachyarrhythmia.

Intracoronary bolus infusion of abciximab cuts MACE by 50% compared with standard intravenous bolu

Thu, 19 Apr 2012 22:53:02 EDT

The third line from bottom requires "prospective" to be replaced by "retrospective"

Report validates risk of high-dose simvastatin

Thu, 19 Apr 2012 22:07:42 EDT

Should read 1687 patients for a decade

Report validates risk of high-dose simvastatin

Thu, 19 Apr 2012 21:46:01 EDT

Without knowing anything about concomitant metabolic inhibitors the risk is one case of rhabdomyolysis if you treated 16876 patients for a decade. And the fact that appropriately educated patients should alert the clinician to muscle pain prior to the serious consequences of CK elevation makes me pretty underwhelmed by this data.

Focus on vulnerable plaques is too narrow for predicting events

Thu, 19 Apr 2012 19:27:56 EDT

What studies, if any, have established a correlation between CP (as detected by EBCT, perhaps) and VP? Is there a correlation between CP, VP and age? The literature for EBCT, especially serial EBCT, suggests that low scores provide significant confidence against a coronary event, yet EBCT clearly does not detect VP. If VP is a significant risk, then presumably the reason that low EBCT scores are predictive is that low scores just happen to correlate with low VP risk. Has this been documented?

AHA: No evidence that gum disease causes CHD

Thu, 19 Apr 2012 15:58:22 EDT

Gum disease is bad for teeth (there is not any doubt about it) . Cronic periodontal disease cause a systemic proinflammatory status and so according to the new paradigm that inflamation is strongly involved in the genesis and progresion of atherosclerosis disease it is reasonable to infer that if you keep your gum healthy this will be good for your coronary artery but but there not any causative proof about it.I wonder if it's worth looking into this matter I guess it would be useful

AHA: No evidence that gum disease causes CHD

Thu, 19 Apr 2012 15:23:24 EDT

I told you so!!!!

TIPS 2: Full-dose polypill boosts efficacy, with no increased side effects

Thu, 19 Apr 2012 15:11:50 EDT

Changes in surrogate measures may not reflect actual clinical results and as Mr Kelsey pointed out, the changes in blood pressure could be due to normal variation. Mr Hallen's concerns about side effects may be overstated since doctors routinely ascribe side effects to "just getting old". Statins are a wonderful example of a formerly "safe" drug. Once Lipitor went off patent, research was published indicating that the incidence of statin side effects was much higher than previously reported by pharmacuetically-funded studies.

TIPS 2: Full-dose polypill boosts efficacy, with no increased side effects

Thu, 19 Apr 2012 14:51:56 EDT

I have no real idea why the "polypill" is getting so much attention. I am in print saying that it makes little sense to treat conditions that don't exist, or to under-treat those that do.

AHA: No evidence that gum disease causes CHD

Thu, 19 Apr 2012 14:33:50 EDT

Lockhart is a dentist. They asked a dentist if dentistry practices and dental bacteria could be involved in the development of heart disease. I wonder what he would say if asked if dental amalgams were problematic or contributed to mercury toxicity.... Peter B. Lockhart, DDS Director, Oral Medicine Institute Carolinas Medical Center

TIPS 2: Full-dose polypill boosts efficacy, with no increased side effects

Thu, 19 Apr 2012 14:32:33 EDT

-Here are 9 systolic BP measurements from an automated machine: 138,139,142,146,155,157,168,177,153. Their mean is 152.7777778. Hope that takes care of the bad statistics comments. -Each of the components of the polypill are backed by solid hard outcomes data-unless the combination is pharmacokinetically or pharmacodynamically different, not clear to me the need for an outcomes study-which is what these studies are making sure-that the drug effects are reasonably preserved. - The polypills are not horse pills - The polypills have room for dose titration albeit stepwise. - Its quite amazing that folks are missing the forrest for the trees-the polypill is a solution for poor access to care and resources and increasing medication compliance. Does not necessarily have a role for folks who have the luxury of excellent doctors such as the authors of the previous posts watch them closely and frequently.

AHA: No evidence that gum disease causes CHD

Thu, 19 Apr 2012 14:24:44 EDT

"Although we also haven't proved that the link is not causative, it would seem that if it were causative, it would be a small relationship. And it does not appear to be worth creating too much stress about it." WHAT??? This is really a statement from the AHA from learned endovascular researchers? Or did this come from the secretary? There are many studies linking dental calculus and endovascular disease....I guess they're going to ignore endovascular research by Stephen Epstein, MD ???

TIPS 2: Full-dose polypill boosts efficacy, with no increased side effects

Thu, 19 Apr 2012 13:21:26 EDT

A basic tenant of statistics is that you can't get greater precision from a group of data than the precision of the individual measurements. Witness the claimed 2.82 mm and 1.73 reductions in BP -- you can't measure BP to two decimal places by any known method. Therefore, reporting an average or mean with two decimal places is mathematically wrong and, logically, implausible. The best precision in this case would be 3mm and 2 mm, respectively. However, even then the validity of this difference is questionable because the reproducibility of BP measurements on the same patient is likely no better than 2-3 mm. If the measurement variation is 2-3 mm or more on each patient, then one cannot determine a difference of the same magnitude in two groups of data. The best you say is there is no difference within the precision (error) of the measurement. This is an example of the much too common misapplication of math and statistics to medical and drug studies which often focus on small differences and ignore the precision limits (and error ranges) in the original measurements.

TIPS 2: Full-dose polypill boosts efficacy, with no increased side effects

Thu, 19 Apr 2012 12:58:02 EDT

The whole premise of the polypill if flawed. Combining pills like this is the worst thing you can do to a patient due to a number of reasons. 1. You can never tell which drug is causing the side effect and so you pretty much have to stop all of them. 2. Dose titration cannot be done. 3. In the age where patients are on far more meds than what they should be on, this is only going to make things worse. 4. The whole study is looking at surrogate markers, which have been shown time and again is not what we should be looking at.

TIPS 2: Full-dose polypill boosts efficacy, with no increased side effects

Thu, 19 Apr 2012 12:40:15 EDT

People will not swallow a huge pill.It is hard for me to believe that you can put 5 pills intoone pill.Also if patient gets a reaction from the polypill how would you know which pill it is. Changing the dose of the 3 BP meds is crucial. I predict that it will not sell J BARRY,MD

What is the clinical significance of electrical alternans in this tracing?

Thu, 19 Apr 2012 11:54:07 EDT

LAFB would not affect the QRSs in precordial leads that much. Also, it is well known that some cases of SVT can show ST depression without ischemia.

Report validates risk of high-dose simvastatin

Thu, 19 Apr 2012 00:41:36 EDT

I stopped using Simvastatin 80 mg because of myopathy, like most physicians since 2005. In 2011 in the face of wither criticism I began stopping statins 3 years after an MI. I have recommended a low sucrose and fructose diet. I also suggest a level 25-OH Vitamin D of 50 ng/ml with lights not pills. Also suggest Epsom salts baths.

Maryland set to establish independent review system for PCI

Wed, 18 Apr 2012 23:13:16 EDT

I appreciate your willingness to state your opinion, uncloaked. Anonymity rarely serves any purpose other than to throw a punch at a blind man and leave him thrashing at the air. However, despite your very noble cause, there are issues with independent review that many feel are worthy of debate. Rather than all of us throwing punches, I encourage a healthy discussion on the matter, with specific pros and cons.

Maryland set to establish independent review system for PCI

Wed, 18 Apr 2012 22:09:44 EDT

Slander: The action or crime of making a false statement damaging to a person's reputation. Cowardice: a person who lacks courage in facing danger, difficulty, opposition, pain, etc.; a timid or easily intimidated person. I am not the first to note this, but the internet allows individuals to hide behind the cloak of anonymity while meeting the definitions above. Mr. Ventricle: The impetus behind the Maryland chapter of the ACC efforts were to counteract the toxic effects of the accusations and convictions against individuals in my field, interventional cardiology. These accusations and convictions have stained my chosen profession, and what I love doing in irreparable ways. Under the leadership of Sam Goldberg, MD and Marc Mugmon, MD, the Maryland Chapter worked to educate the state legislature and the regulatory bodies of the importance of peer review as important self-regulating mechanism to improve the quality of PCI in the state of Maryland. Peer-review, both internal and external, allows interventional cardiologists (as opposed to non-physicians or physicians who have nothing to do with performing these procedures) to discuss and learn what other interventional cardiologists think about randomly selected cases. It is an excellent mechanism to encourage discussion and learning, and potentially, suggest changes to practices (or detect more difficult to defend behaviour), early on. And it is far better for a practicing interventional cardiologist to learn that his/ her peers would approach patients in different ways, rather than go through what has happened to our accused/ convicted colleagues in the last couple of years. Jerry I: Your statement is absolutely, unquestionably, deceptive, ignorant, and/ or calumnious. I do not scrub with my colleagues, and unless a purposeful effort is made (such as internal/ external peer review), there would be little chance that I would know that a procedure was done for appropriate or inappropriate reasons. Dr. Mugmon is an upstanding individual who has the respect of the individuals in our field who perform these procedures for a living. He also has been instrumental in encouraging change within and without of the system. Anonymous comments of this nature are not helpful to this forum, and injurious to www.theheart.org's reputation.

What is the clinical significance of electrical alternans in this tracing?

Wed, 18 Apr 2012 16:20:40 EDT

I think that �ECG of the month� is a very useful educational tool. The fact that this trace is rehashed is not relevant considering that Dr Wang is not announcing an �original� ECG, but simply a trace for analyzing and discussing. Considering differential diagnosis, the presence of QRS alternant associated with cardiac tamponade many times is accompanied by QRS microvoltage. I agree with Dr Paun regarding alternant LAFB and ischemia. In that line I would be concerned about cardiac failure, taking into consideration that the trace is an educational tool and we don�t have clinical information. Thank you.

What is the clinical significance of electrical alternans in this tracing?

Wed, 18 Apr 2012 15:45:34 EDT

Indeed, there is a SVT, but there are signs of subendocardial ischemia too. The QRS axis is clearly deviated to the left, like in left anterior fascicular block. I would say the ECG depicts an alternant LAFB. Dr Wang would you be so kind as to comment on that - signs of ischemia and alternant LAFB. thank you

A 45-year-old woman who had an ICD implanted over 10 years ago

Wed, 18 Apr 2012 13:24:55 EDT

It was a really strange but well exposed case.

Maryland set to establish independent review system for PCI

Wed, 18 Apr 2012 10:33:11 EDT

Is it any coincidence that Dr. Mugmon was a partner with the fellow who got it all started in Maryland, and who is now in partnership with two of the physicians currently being sued for unnecessary stenting, both of whom were on the Health Care Commission's panel to craft the legislative directives? Oh what a tangled web we weave!

SCD risk increased in blacks with HTN, genetics may be key: LIFE analysis

Wed, 18 Apr 2012 10:18:16 EDT

Vitamin D insufficiency is more prevalent among African Americans (blacks) than other Americans and, in North America, most young, healthy blacks do not achieve optimal 25-hydroxyvitamin D [25(OH)D] concentrations at any time of year. This is primarily due to the fact that pigmentation reduces vitamin D production in the skin. Vitamin D deficiency is associated with heart dysfunction, sudden cardiac death, and death due to heart failure.

CCTA-first ER strategy safely discharges more patients: ACRIN/PA

Wed, 18 Apr 2012 10:16:35 EDT

A negative CT scan represent the goal in the evaluation of patients with chest pain, because it lead us to avoid further evaluations.The stratification of the risk of patients with chest pain (low in case of normal CT scan) is important not only for early e safely discarge of patients from ED, but also in term of no-need of further examinations in outpatients visit. On the other hand, how you treats patients with non obstructive CAD remains the true unresolved question. Obviously, caution need for the selection of patients and the radiation dose to optimize the appropriate use of the CT scan.

Italian soccer player dies on the pitch

Wed, 18 Apr 2012 09:19:06 EDT

We wrote a couple of papers on Arrhythmic Risk in Professional Athetes publised on ANE see www.alternans.org but the test is used in few institutions. The problem could be that blocking an professional athete is a very high economic risk ...

What is the clinical significance of electrical alternans in this tracing?

Wed, 18 Apr 2012 09:06:37 EDT

QRS alternans is the mostly used description occuring in SVT usually in CMT due to accessory pathway - still the exact mechanism no clear.

No mortality risk for losartan vs candesartan seen in heart failure

Tue, 17 Apr 2012 22:31:05 EDT

It is good to hear that getting losartan to 150mg a day is associated with better outcomes. However, according to materials available to me, the maximum does recommended is 100mg/d. So if I place a patient on 150mg or 200mg a day, am I subjecting myself to loosing a malpractice suit if the person develops hyperkalemia and dies?

Salt content variable in fast food in different countries

Tue, 17 Apr 2012 22:11:30 EDT

@james king. Who cares? The people who love to run your life care; those who sit on the CCDE: Central Committee to Decide Everything...that's who.

Maryland set to establish independent review system for PCI

Tue, 17 Apr 2012 21:47:05 EDT

The self-serving ACC gladly acts as the enforcer of choice for third-party payers. This is on top of their extorting large sums of money from physicians and hospitals who are forced adopt their "quality programs" such as the NCDR and ICAEL. The same ACC made untold millions in the heyday of angioplasty from industry underwriting. Now they display this holier-than-thou attitude to pass legislation that will grant it even more power. The silver lining is how clinically irrelevant the ACC is becoming for the average doctor. Meeting attendance is plummeting. I bet membership will decline the way it has for the AMA (which, alas, doesn't keep these 'professional organizations' from causing irreparable damage to the profession)

AF patients admitted to the hospital on weekends have worse outcomes

Tue, 17 Apr 2012 19:05:52 EDT

Perhaps the patients on the weekend are simply self-reverting, thus saving themselves a TOE/TEE and DCCV?

Should statins be used in primary prevention? JAMA gets in on the debate

Tue, 17 Apr 2012 18:12:17 EDT

See also: �Statin Therapy Decreases MyocardialFunction as Evaluated Via Strain Imaging�, Jack Rubinstein, MD; Feras Aloka, MD; George S. Abela, MD, MSc, Clin. Cardiol. 32, 12, 684�689 (2009). �Exposure to statins and risk of common cancers: a series of nested case-control studies� Yana Vinogradova*, Carol Coupland and Julia Hippisley-Cox, BMC Cancer 2011, 11:409

Should statins be used in primary prevention? JAMA gets in on the debate

Tue, 17 Apr 2012 18:11:10 EDT

.... In the XIX century people were as dyslipidemic as today's people are. However, heart disease was rare. This fact points to the importance of a healthy lifestyle on heart health.

What is the conduction problem depicted in this tracing?

Tue, 17 Apr 2012 16:53:56 EDT

I appreciate Dr. Wang's lessons. They are helpful to a rural practice.

Should statins be used in primary prevention? JAMA gets in on the debate

Tue, 17 Apr 2012 16:32:39 EDT

Vince, I am sorry you missed the anology, but you just confirmed my point. I understand they are still recruiting for the study, published a few years ago, in BMJ :-) Perhaps the abstract will help: Objectives To determine whether parachutes are effective in preventing major trauma related to gravitational challenge. Design Systematic review of randomised controlled trials. Data sources: Medline, Web of Science, Embase, and the Cochrane Library databases; appropriate internet sites and citation lists. Study selection: Studies showing the effects of using a parachute during free fall. Main outcome measure Death or major trauma, defined as an injury severity score > 15. Results We were unable to identify any randomised controlled trials of parachute intervention. Conclusions As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute. Footnotes Contributors GCSS had the original idea. JPP tried to talk him out of it. JPP did the first literature search but GCSS lost it. GCSS drafted the manuscript but JPP deleted all the best jokes. GCSS is the guarantor, and JPP says it serves him right. Funding None. Competing interests None declared. Ethical approval Not required

Should statins be used in primary prevention? JAMA gets in on the debate

Tue, 17 Apr 2012 15:37:32 EDT

A poor analogy at best . A parachute has an almost 100% benefit on mortality in its use. Statins in primary prevention not so much.

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Tue, 17 Apr 2012 13:14:46 EDT

ECCENTRIC AI/ FLAP IN ASC AORTA

A 45-year-old woman who had an ICD implanted over 10 years ago

Tue, 17 Apr 2012 13:09:07 EDT

GOOD

Should statins be used in primary prevention? JAMA gets in on the debate

Tue, 17 Apr 2012 10:37:59 EDT

Thanks for sharing clinical expertise Michel and Daniel. Fortunately with nonivasive imaging, we can practice medicine tailored to the individual, not in a lockstep manner to a primary prevention goup of patients with diverse risk. After decades of losing patients and friends unexpectedly to ACS, in the prestatin era, I do not need a prospective randomized mortality trial, before I hand them a statin parachute.

Five OSU cardiologists earned $1-million bonuses in 2011

Tue, 17 Apr 2012 08:39:37 EDT

4) Our best minds in med school are not going into primary care for the aforementioned #3... and it shows. We have become a society of seondary prevention managed by specialists. We need top notch candidates to choose general medicine rather than avoid it for financial considerations.

Five OSU cardiologists earned $1-million bonuses in 2011

Tue, 17 Apr 2012 08:33:25 EDT

1) Dr's absolutely should be well paid given the training and reponsibility involved! 2) $2 mil is too much unless it is partially generated in the private sector. 3) There is a systemic problem as manifest by internists' struggle to stay in business while others are so well compensated. This is not to say that internests should be paid the same, but the difference should not be a factor of 10.

Should statins be used in primary prevention? JAMA gets in on the debate

Tue, 17 Apr 2012 07:11:15 EDT

The debate has been going on for some time. And I am not talking about the debate between these clinicians, but among many other clinicians in different parts of the world. The truth is: each side can preent some sort of strong argument to support their opinion. The fact is, it can sway towards either side. what we need is a large, long term, multicentered RCT, comparing a statin to placebo. (Yeah right. Like the pharma is going to finance such a study). There is so much data out there. Unfortunately it is almost entirely supported by pharma.

AF patients admitted to the hospital on weekends have worse outcomes

Tue, 17 Apr 2012 01:37:53 EDT

The recommendation in the last paragraph is brilliant! Let's see...a "Code Afib" team wheeling the TEE/cardioverter down the hall...just what we need!...But beware of bumping into the Code MI team, Code stroke team, Code blue team, Code-almost-a-Code team, Code pick your color team... "still people are dying" says Dr. Desmukh... Well, we shall have response teams until no more people are dying! And let's make this a quality outcome measure, please.

Five OSU cardiologists earned $1-million bonuses in 2011

Tue, 17 Apr 2012 00:27:35 EDT

To Mike. You have no idea how they spend their money, and it is irrelevant to the discussion. Perhaps they will find "eternal value" in supporting their favorite charities, helping support less fortunate family members in this ailing economy, and paying $800K-$900K in taxes this year to support social programs. There is no more honor in being poor or middle class than there is in being wealthy. The noble and the wretched occupy space along the entire economic spectrum. To make assumptions based on income alone is righteousness at its worst.

Five OSU cardiologists earned $1-million bonuses in 2011

Mon, 16 Apr 2012 23:05:26 EDT

In the egocentric, self serving society that we are all living in, I'm not surprised at the justification(s) for extracting all the money possible before it's gone. I would love to get a glimpse on what these dollars are purchasing. Perhaps someone in the group will find eternal value in their investing/spending?

Higher HbA1c levels predict better outcomes in advanced heart failure with diabetes

Mon, 16 Apr 2012 23:00:34 EDT

The study is too short and too small. The increase in mortality from the There should be further analysis as to what treatments were used to lower the A-1-C. Perhaps this result is a consequence of the use of a specific class of drug. A re-analysis based upon therapies might result in a much different set of pseudo-conclusions. Don't lose site of the fact that these are end stage subjects referred for transplant. This does not apply to the usual heart failure patient treated in the real world.

Five OSU cardiologists earned $1-million bonuses in 2011

Mon, 16 Apr 2012 22:17:36 EDT

It is interesting to see that this thread is still going. My defense of the EP contract was not to suggest that PCPs or other medical specialists are of lesser value than the EP docs in question. It is simply a matter of strategy. OSU is surrounded by numerous high quality CV centers that claim to be regional centers of excellence: Riverside 1 mile to the north, Cleveland Clinic 2 hours to the north, Allegheny and UPMC a couple hours east, St Vincents/IU a few hours west, and The Christ Hospital 2 hours south. They felt it was worth the money to build a cutting edge CV program around these 5 EP docs. Medicine is only profession where there is no correlation between expertise and reimbursement. If you want representation from the top law firm in town, you expect to pay far more than you would pay for the solo attorney three years out of law school. Likewise, when looking for an architect firm, no one would expect that I.M. Pei would charge the same as John Doe, Architect, LLC. Yet, on my first day out of fellowship, I was paid the same amount to put in a coronary stent as Antonio Columbo and Martin Leon. My office consultation reimbursement on Day 1 of practice was exactly the same as that of Eugene Braunwald and Eric Topol. Ludicrous, if you really think about it.

Should statins be used in primary prevention? JAMA gets in on the debate

Mon, 16 Apr 2012 16:12:52 EDT

Interesting study "Eur Heart J. 2010 Jul;31(13):1633-9. Epub 2010 Jun 6. Ezetimibe alone or in combination with simvastatin increases small dense low-density lipoproteins in healthy men: a randomized trial. Berneis K, Rizzo M, Berthold HK, Spinas GA, Krone W, Gouni-Berthold I. Source Division of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Zurich and Zurich Center for Integrative Human Physiology, Zurich, Switzerland. Abstract AIMS: The predominance of small dense low-density lipoproteins (sdLDLs) has been associated with increased cardiovascular risk. The effect of ezetimibe on LDL subfraction distribution has not been fully elucidated. This study assessed by gradient gel electrophoresis the effects of ezetimibe alone, simvastatin alone, and their combination on sdLDL subfraction distribution. METHODS AND RESULTS: A single-centre, randomized, parallel three-group open-label study was performed in 72 healthy men with a baseline LDL-cholesterol (LDL-C) concentration of 111 +/- 30 mg/dL (2.9 +/- 0.8 mmol/L). They were treated with ezetimibe (10 mg/day, n = 24), simvastatin (40 mg/day, n = 24), or their combination (n = 24) for 14 days. Blood was drawn before and after the treatment period. Generalized estimating equations were used to assess the influence of drug therapy on LDL subfraction distribution, controlling for within-subject patterns (clustering). We adjusted for age, body mass index, and baseline concentrations of LDL-C and triglycerides. Ezetimibe alone changed LDL subfraction distribution towards a more atherogenic profile by significantly increasing sdLDL subfractions (LDL-IVA +14.2%, P = 0.0216 and LDL-IVB +16.7%, P = 0.039; fully adjusted Wald chi(2) test). In contrast, simvastatin alone significantly decreased the LDL-IVB subfraction (-16.7%, P = 0.002). This effect was offset when simvastatin was combined with ezetimibe (LDL-IVB +14.3%, P = 0.44). All three treatments decreased the large, more buoyant LDL-I subfraction, the effects of ezetimibe being the most pronounced (ezetimibe -13.9%, P CONCLUSION: In healthy men, treatment with ezetimibe alone is associated with the development of a pro-atherogenic LDL subfraction profile. Potentially atheroprotective effects of simvastatin are offset by ezetimibe. This study is registered with ClinicalTrials.gov, identifier no. NCT00317993. Is there any real outcome data to show this agent reduces events? What data there if has yet to show a benefit and ENHANCE trends in the wrong direction. Yet widely given . In my opinion vitamin d has better data to support its use . Why the different standard of evaluation ?

Five OSU cardiologists earned $1-million bonuses in 2011

Mon, 16 Apr 2012 15:03:23 EDT

Cigna's CEO received $19.1 million in total compensation for 2011, which doesn't include his stock awards, valued at $5.8 million, or long-term option awards theoretically valued at $2.6 million. Humana's CEO earned $7.3 million in 2011. The former Aetna CEO was compensated $72 million in 2010. UnitedHealth CEO Stephen Hemsley received $10.8 million in 2010. Pfizer tripled their new CEO's total compensation last year, to $18 million, including salary of $1.7 million and stock and option awards totaling about $12.5 million. The former Merck CEO's compensation rose 55% to $25 million in 2010. The Novartis CEO earned about $8.5 million last year, including cash and stock. Separately, he also received a one-time retirement benefit worth $12.8 million. And the list goes on and on and on... No doubt health care costs are too high in the US, but blame should be allocated proportionately.

New bleeding score, HAS-BLED, will help guide anticoagulation in AF

Mon, 16 Apr 2012 14:47:59 EDT

Thanks

Five OSU cardiologists earned $1-million bonuses in 2011

Mon, 16 Apr 2012 14:23:22 EDT

I think primary care physicians are equally as valuable as electrophysiologists. If we want to improve health care and lower costs, we have to disincentivize procedures and incentivize cognitive disucssions. This is good journalism - it is important to illuminate this kind of crap.

Five OSU cardiologists earned $1-million bonuses in 2011

Mon, 16 Apr 2012 14:17:23 EDT

To the average person (and even to many CEOs), these compensations are excessive. Obviously, these cardiologists have found the golden goose that seems to drive medical care today. Five doctors at one facility earning nearly $2 million each ---sounds more like a Wall Street brokage than a place to treat the ill and infirm. Let's be realistic. Bonuses are not given for how many lives are saved (perhaps they should be) but for how much revenue is brought in. Based on previous comments about this article, I suspect some readers will be appalled that anyone would question the sacred oath to make as much $ as you can get away with. But save your indignation - likely 80-90% of your patients will agree with me.

Five OSU cardiologists earned $1-million bonuses in 2011

Mon, 16 Apr 2012 13:30:04 EDT

I am "just a cardiology patient", but have also worked in hospital finance for 30+ years. The hospitals do collect large "facility" fees in the cardiology area. If I ever require the services of an EP, I certainly want the best doctor available, who is well compensated for his/her services. Comparing physicians with sports' coaches is illogical.

Higher HbA1c levels predict better outcomes in advanced heart failure with diabetes

Mon, 16 Apr 2012 12:48:25 EDT

paradox... paradox wherever. statins don�t seem as good as appeared( new cases of diabetes and increased HbA1c levels). Otherwise very low LDL level doesn�t seem to be so healthy

Salt content variable in fast food in different countries

Mon, 16 Apr 2012 12:16:49 EDT

But is there any proof of harm? A recent review of all the best science shows that there is not. There is no evidence that reducing the amount of salt you eat will reduce your risk of either heart disease or premature death. This does not mean that unlimited amounts of salt is necessarily safe. Eating a moderate amount is probably best.

Higher HbA1c levels predict better outcomes in advanced heart failure with diabetes

Mon, 16 Apr 2012 12:03:53 EDT

It is likely that the adverse outcomes with lower HgbA1C levels is due to the more aggressive antiglycemic medication treatment for the diabetics with heart failure. In other words, the diabetic medications (insulin, oral insulin sensitizers and other oral agents) may have direct adverse effects on congestive heart failure (by direct cardiac toxins or by adverse hemodynamic effects)or indirect effects through adverse drug-drug interactions with heart failure medications.

Higher HbA1c levels predict better outcomes in advanced heart failure with diabetes

Mon, 16 Apr 2012 11:35:14 EDT

You must remember the reverse epidemiology ;-) It is a term for a medical hypothesis which holds that obesity and high cholesterol may, counterintuitively, be protective and associated with greater survival in certain groups of people, such as CHF-patients. The paradox was first described in 1999 in overweight and obese people undergoing hemodialysis, and has subsequently been found in those with heart failure. The terminology was first proposed by Kamyar Kalantar-Zadeh in the Kidney International in 2003[1] and in the Journal of American College of Cardiology in 2004.[2] 1] Kalantar-Zadeh K, Block G, Humphreys MH, Kopple JD. "Reverse epidemiology of cardiovascular risk factors in maintenance dialysis patients". Kidney Int. 63 (3): 793�808. (March 2003). 2] Kalantar-Zadeh K, Block G, Horwich T, Fonarow GC "Reverse epidemiology of conventional cardiovascular risk factors in patients with chronic heart failure". J. Am. Coll. Cardiol. 43 (8): 1439�44. (April 2004).

A 45-year-old woman who had an ICD implanted over 10 years ago

Mon, 16 Apr 2012 11:02:36 EDT

Which is why I thought it would be worth sharing. Thanks.

Statin safety: theheart.org reader's survey

Mon, 16 Apr 2012 10:45:19 EDT

i am sorry for the mistake in the previous post suggesting statins problems effect minority

Statin safety: theheart.org reader's survey

Mon, 16 Apr 2012 10:43:41 EDT

i have been on statin for last 10 years with perfect dm control had recent double vsc angioplasty severe msc side effects almost crippled cognitive difficulties suicidal almost certainly due increased statin dose , every other person on statins experience msc symptoms i am 53 years old i struggling to decide to discontinue crestor

A 45-year-old woman who had an ICD implanted over 10 years ago

Mon, 16 Apr 2012 10:36:21 EDT

Really very nice rare case

Higher HbA1c levels predict better outcomes in advanced heart failure with diabetes

Mon, 16 Apr 2012 10:14:12 EDT

As Malcolm Kendrick stated above, glucose and HbA1c are measurements, reflections of the complex underlying global disease process which become apparent decades after the disease process started and became persistent. Many treatment strategies change measurements, seemingly for the better (e.g. sulfonylureas), while further complicating the marked differences and progression of the underlying disease from better health. Thus such studies, implying worse measurements are better, should not be interpreted in simplistic ways or as implying that worse measurements reflect a enhanced state of advanced disease.

Should statins be used in primary prevention? JAMA gets in on the debate

Mon, 16 Apr 2012 09:49:02 EDT

When lowering cholesterol had a WORSE clinical outcome my trust of past clinical trials began to crumbled. I questioned the �low-fat� diet and the �cholesterol hypothesis�. My trust in statins, which I had held like a religion since 1987, began to unravel. Lowering cholesterol, a molecule the body needs and loves, especially the brain had to be questioned. Was it all a lie? The ENHANCE study has engendered considerable controversy because, while the study was concluded in 2006, the release of its results has been greatly (and famously) delayed until 2008. The trial did not come out the way the sponsors wanted it to, and that the delay has been for the purpose of trying to salvage something positive before releasing the results. Lowering cholesterol with Ezetimbe did not improve clinical outcomes. Actually patients on Vytorin had MORE plaque growth than patients taking only simvastatin. The FDA, medical societies, the pharmaceutical industry, medical journals and �the diets called healthy� became suspect.

What is the clinical significance of electrical alternans in this tracing?

Mon, 16 Apr 2012 08:55:34 EDT

agree w melissa

Five OSU cardiologists earned $1-million bonuses in 2011

Mon, 16 Apr 2012 08:19:56 EDT

Seriously Cleveland Clinic, you have to stoop down to this level of "journalism" because others near by have done well. I am quite disappointed that you all have allowed this article to be published in this format. The poking analysis seethes with jealousy and vindictive behavior. The editors should be more balanced in their analysis and allow the readers to make this own opinions. Why not compare their salaries to sanitation workers who save our live by preventing the spread of infectious diseases? Or if they are so overpaid as you not so subtly suggest, compared them to Labron James. That way you can paint them as woefully underpaid lifesavers?? I appreciate the attempt at "real" journalism, but letting your personal and obvious local politics affect a previously well-directed platform is juvenile.

Higher HbA1c levels predict better outcomes in advanced heart failure with diabetes

Mon, 16 Apr 2012 08:14:01 EDT

A raised blood sugar is not a disease. Lowering it does not cure a disease - it lowers a measurement. Why do we expect that this will have beneficial effects? Apart from metformin, the other blood sugar lowering agents have all had the unfortunate side-effect of increasing mortality. Time for a re-think on the underlying paradigm? No chance of that, I suppose.

A 45-year-old woman who had an ICD implanted over 10 years ago

Mon, 16 Apr 2012 06:11:40 EDT

I believe you are referring to the ligament of Marshall, which separates the left superior pulmonary vein from the left atrial appendage.

No mortality risk for losartan vs candesartan seen in heart failure

Mon, 16 Apr 2012 06:10:31 EDT

Hi William, not an error, but certainly unclear. We do state that candesartan is Atacand/AstraZeneca. The sentence that prompted you to write, I believe, is merely unclear, intended to point out that another ARB, Valsartan (Diovan, Novartis), will also be off-patent soon. We're going to rewrite that sentence.

A 45-year-old woman who had an ICD implanted over 10 years ago

Mon, 16 Apr 2012 02:46:28 EDT

What's the line/ridge in the left atrium?

What is the conduction problem depicted in this tracing?

Mon, 16 Apr 2012 01:46:28 EDT

Thanks

A 45-year-old woman who had an ICD implanted over 10 years ago

Mon, 16 Apr 2012 01:21:48 EDT

Excelent case