theheart.org Comments

ACC/AHA focused update of guidelines for STEMI, PCI

Fri, 20 Nov 2009 23:20:02 EST

I love a passionate forum participant!!! I could not have said it better my self! Love it! love it! There is NO SINGLE OPPORTUNITY IN AMERICA TODAY to begin IMMEDIATELY SAVING THOUSANDS OF LIVES EVERY MONTH. If we combined Primary PCI without sugery onesite with a Nationalwide Smoke Free Stance, think of the MONEY we could amass for things like education and the lives we could save. We could actually become the academic nation that we've claimed to be for so long. Melissa

Niacin not beneficial in patients at goal with statins: NIA Plaque

Fri, 20 Nov 2009 21:49:23 EST

Tolerability, compliance, ease of dosing,... QD vs. TID However, after 1-2 years of success with ER, IR becomes far more "do-able",...

Niacin not beneficial in patients at goal with statins: NIA Plaque

Fri, 20 Nov 2009 17:41:29 EST

Why not use plain old niacin?

Canadian confusion: Primary-care docs lack knowledge of CVD risk factors, prevention

Fri, 20 Nov 2009 16:56:15 EST

I think this research has sound merit, and I support it, but it does not necessarily full cover the need for better stratifiers for cardiovascular risk. If every Canadian physician had access to anatomical plaque imaging, we would not even be having this debate. We would be treating disease and preventing disease complications. The FRS has an AUC-ROC of 0.78 which means lack of discrimination in terms of who will and will not get the disease (FP + FN) of 22%. And this is only looking at 10 year risk of hard events (not lifetime risk, nor other important events like AAA rupture, angina, and revascularization which are economically expensive and detract from QoL). It is hard to understand how the USPTF still supports mammography for breast ca. detection with slender detection while withholding support from plaque imaging tests, which have strong evidentiary support (even from RCTs; I would be happy to send along the references).

Canadian confusion: Primary-care docs lack knowledge of CVD risk factors, prevention

Fri, 20 Nov 2009 16:19:43 EST

What the NCEP has failed to realize in its various guidelines is that a state of dyslipidemia exists whenever there is an imbalance in the pro-atherogenic lipids (primarily LDL) and the anti-atherogenic lipids (primarily HDL). Thus examining LDL or HDL in the absence of knowledge of the opposing lipid moiety will never give an accurate assessment of atherothrombotic disease (ATD) risk. The report by Dr Gupta highlights one of the biggest problems in screening for dyslipidemia. His findings concern Canadian physicians, but are very likely to be generalizeable to physicians all over the world, including the USA. The main problem is that the NCEP guidelines have failed in primary prevention, as evidenced by the need to revise those guidelines over and over again (the most recent update is due out this year), and by the recently released Jupiter trial and the Get with the Guidelines survey. What is needed is a simple, accurate tool that can be used to screen for the population at risk of ATD and can also be used to guide therapy--a tool that embodies the three main ATD risk factors: cigarette smoking, dyslipidemia, and hypertension. These risk factors should be treated as dependent variables, not independent variables. LDL by itself as a primary target of screening is inadequate. As Bill Castelli, MD, pointed out in the 1980's and 1990's, lipid ratios will accurately predict the population at risk of ATD. The NCEP has chosen to ignore lipid ratios and hence their strategies for primary prevention have failed. I wish to offer a solution. I have directed an interventional lipidology clinic for over 35 years and as part of that clinic I have developed a multi-factorial risk factor graph that accurately predicts the population at risk of ATD. This graph utilizes the Cholesterol Retention Fraction (CRF, or [LDL-HDL]/LDL) on the ordinant and systolic blood pressure (SBP) on the abcissa. A threshold line has been delineated that separates the mainstream of ATD patients' CRF-SBP plots from a few outliers. The line coordinates are (0.74,100) and (0.49,140). 85% of the patients in my practice have CRF-SBP plots above the threshold line, and the same is true in the Prosper trial when their CRF-SBP plots are plotted on my graph. Of the 15% of ATD patients with CRF-SBP plots below the threshold line, most are cigarette smokers. That leaves only 6% of all ATD patients who could not have been predicted by CRF-SBP plot position above the threshold line and/or cigarette smoking status--and those people are elderly ( on average, in their late 70's ) at time of ATD onset, and do not die, on average, for an additional 10-15 years. This graph can be viewed at www.healtheurope.org, under the article on ATD.

The AHA 2009 Roundup: ARBITER 6-HALTS, PLATO, the two CHAMPIONs, and CASCADE

Fri, 20 Nov 2009 15:49:32 EST

I liked a lot of thi discussion, completting our knowledge about this trial , and we agree about this.But always we are using only 75 mg of clopidogrel after intervention.

Experienced operators can switch easily and rapidly to radial-access PCI: RAPTOR

Fri, 20 Nov 2009 14:54:28 EST

As a patient with 18 stents from 8 separate PCI procedures over a 6 year period, I can say with 100% confidence that the radial approach is FAR superior from a patient�s perspective. My last 3 PCI were radial entries, and the recovery time was significantly reduced compared to femoral entry. This includes significantly reduced bleeding problems and far superior mobility during recovery.

Blood type of pig may be factor in longevity of porcine replacement heart valves

Fri, 20 Nov 2009 14:33:11 EST

I'm somewhat surprised that patients with type AB blood were at risk of early valve degeneration. It would seem that they should tolerate type A antigens just as type A patients do. Or am I missing something here? Also, does it make sense to attribute the risk to residual protein on the implanted pig valve? In processing, if the valve is fully deglycosylated, why would it matter that there may be some remaining or protein. Or is there some protein component associated with the blood group antigens?

ACC/AHA focused update of guidelines for STEMI, PCI

Fri, 20 Nov 2009 12:15:39 EST

Never mind, Melissa - see from the text that you're in agreement with me here . . .

ACC/AHA focused update of guidelines for STEMI, PCI

Fri, 20 Nov 2009 12:13:50 EST

And the problem with primary PCI without SOS is? You have one large randomized trial which confirms its superiority over lytics (C-PORT) as well as a large Medicare registry of tens of thousands of patients that says it's just as safe as at hospitals with SOS (albeit both studies have their own problems). Why is it shameful to offer patients in the throes of a STEMI primary PCI at a hospital without SOS, given the risk of needing emergency surgery in this setting is unbelievably low?

CMS set to cut Medicare physician fees for cardiovascular imaging

Fri, 20 Nov 2009 09:51:41 EST

Does yesterday's vote put us in the clear as the sgr is stopped?...I'm confused...

Does Early Intervention With CRT-D Improve Outcomes for Patients With Heart Failure?

Fri, 20 Nov 2009 08:46:56 EST

MADIT-CRT trial developed a protocol where both the CRT-D and ICD only arm had a backup bradycardia pacing DDD 40bpm and VVI/DDI 40 bpm with hysteresis off respectively. Investigators claim that due to this bradycardia back-up heart failure induced by pacemaker was less and similarly less non-synchronized pacing in ICD- only group

CASCADE: No significant benefit of clopidogrel in reducing graft disease after CABG

Thu, 19 Nov 2009 23:43:29 EST

To be a headliner at AHA. 113 patients? Seems to me this could have easily been a nationwide study with thousands of enrollees. It is a very important question, IMHO.

CT-STAT: CT angiography rules out CAD faster and cheaper than standard care

Thu, 19 Nov 2009 22:45:11 EST

Were the coronary risks factors assesed versus imaging and with the the 72.5% of patients discharged? What was the readmission rate for chest pain of the patients discharged?

ACC/AHA focused update of guidelines for STEMI, PCI

Thu, 19 Nov 2009 21:42:54 EST

.......same for increasing the emphasis on Primary PCI without surgery on-site. For shame. Melissa

CT-STAT: CT angiography rules out CAD faster and cheaper than standard care

Thu, 19 Nov 2009 21:41:32 EST

Mehrdad, these were described as "low risk" individuals. I had hoped for a trial on intermediate risk patients, the real conundrum in the ER. Melissa

ACC/AHA focused update of guidelines for STEMI, PCI

Thu, 19 Nov 2009 19:20:52 EST

It's really impressive how we have made interventional cardiology better and better. But, what are going to happen when money finish? Medicine is getting more and more expensive as medication and procedures became more complex. And it's impressive how we, doctors, are inapt to convince our patients about the importance of doing prevention. I think people in general believes that inteventional medicine and God are in strict connection, that it is just put a stent inside the artery and all will be ok. Poor of them and poor of us.

CT-STAT: CT angiography rules out CAD faster and cheaper than standard care

Thu, 19 Nov 2009 18:41:28 EST

It's also important to consider the population-based radiation dose. In the SOC, its very rare for a patient to leave without some form of nuclear scan, cath, or both. Opponents of CCTA have often cited its radiation dose as a drawback without comparing this to the overall denominator of the SOC dose for 85%+ of patients. With a NPV this high, you�d think the private payer sponsored physicians who have been lambasting CCTA in the lay press would be realize this is not a technology to funnel more people into the system, but a great filter to keep them out!

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Thu, 19 Nov 2009 18:31:19 EST

There are case reports for hepatotoxicity for IR niacin as well as SR niacin, and for either formulation, higher doses seem to be an important factor. I suspect that niacin in general has potential for hepatotoxicity, irrespective of the formulation, especially at higher doses. Here is what I would really love to see, to help compare the formulations: Incidence of hepatotoxicity on IR niacin: ___ (95% CI ___ to ____), as determined by ____ methodology, and reported in _____. Incidence of hepatotoxicity on SR niacin: ___ (95% CI ___ to ____), as determined by ____ methodology, and reported in _____. Can anyone fill in the blanks? It seems to me that that would be the way to start comparing the risks of the formulations, assuming the methods and doses are actually comparable. I have had a patient develop concerning LFT abnormalities with an ominous drop in LDL on ER niacin that resolved after a de-challenge. Am I the only person who has seen this? I'm not convinced that we have a firm reason to be complacent about the potential for toxicity from IR or ER niacin. I'm wondering if my initial comments were interpreted that I don't believe in hepatotoxicity from niacin. I certainly do, and worry that the dogma that it is primarily related to formulation could come back to bite us. This doesn't stop me from using niacin, but I'm attentive to hepatotoxicity as a result of the problems reported with IR as well as SR niacin.

Kenneth Baughman killed while jogging at AHA

Thu, 19 Nov 2009 15:58:25 EST

...running on the open roads used to be the best thing anyone could do for themselves. That was before Drivers' Ed was dropped from most High School curriculums (as it was here in TX, two years ago). In addition, drunk driving is at its highest level here in this great state, and MADD is still fighting (so far, in vain) for electronic interlocks which could have totally prevented this terrible tragedy--along with many such others each year. (The driver who struck Dr. Baughman would, almost certainly, had to have been drunk.) I now run on a treadmill in the hospital gym. I would no more run on these roads today, than I'd go out on the surface of the Moon without a spacesuit. What a pity that such a great man as Dr. Baughman had to meet his end in that way. Perhaps someday we will have actual laws protecting people who try to use our roads for their health, instead of always getting in their cars to roll along. Perhaps--and I think that the beginning of such laws should perhaps come with those electronic interlocks ("breathalysers" that automatically lock a car down so that a drunk can't start it, thereby necessitating that he call a cab instead of endangering the rest of the population). I propose that such a law requiring electronic interlocks on ALL CARS (just as all cars must be equipped with seat belts) be enacted in Massachusetts--and I further propose that such a law be called the "Dr. Kenneth Baughman" Electronic Interlock Act. Baughman Act for short.

CT-STAT: CT angiography rules out CAD faster and cheaper than standard care

Thu, 19 Nov 2009 15:29:13 EST

Nice study, though 30-day and 1-year outcome of patients discharged post CT is more likely going to convince ED doctors of the value of this technique than any associated cost savings.

Kenneth Baughman killed while jogging at AHA

Thu, 19 Nov 2009 15:00:10 EST

Ken Baughman was more influential in my career than anyone else. Though we never co-authored a paper, he was the one who hired me and helped guide me since 1991. So many of us on the Osler housestaff were inspired to go into Cardiology because we admired Ken so much. He taught me how to become much more productive academically when my career was sputtering, and he helped shape our vision to make the Ciccarone Center a comprehensive clinical and research center. We watched many a lacrosse game together including the 2008 NCAA championships in Boston along with Cheryl, Wendy, and Ross. Cheryl and Ken were at my wedding and they welcomed my mom and wife into their homes in both Baltimore and in Boston. He has been so supportive of my career and he has advised me on so many things. Ken always tried to arrange his schedule to attend Matt's and Chris's athletic events. He encouraged me to do the same and that is what I have done. Ken also strongly suggested that I try to coach my son's (Ross's) teams to spend more time with him and that is what I have done done. I now help coach Ross's soccer, basketball, and lacrosse team and I have Ken to thank for that also! In the future, we will look back and realize that Ken Baughman was the real face of Hopkins Cardiology. He has inspired two generations of great academic physicians. He never got enough of the credit that he deserved here at Hopkins. I am so glad that Cheryl and he thrived in Boston. Harvard and the New England Journal truly appreciated his many talents. Wendy and I extend our deepest sympathies to Cheryl, Matt, and Chris. KLB, you were truly an amazing man. We will always try to make you proud of us.

ACC/AHA focused update of guidelines for STEMI, PCI

Thu, 19 Nov 2009 14:23:56 EST

It's incomprehensible and shameful that the guidelines did not include a section about choice of vascular access and radial intervention. I'm mad as hell.

Statins do not eliminate risk of low HDL-cholesterol levels

Thu, 19 Nov 2009 10:39:58 EST

The Get With The Guidelines survey, oublished earlier this year, showed that in about 137,000 patients with some form of acute coronary syndrome, the overwhelming majority (95%?) were at NCEP goals. I have written the GWTG committee and suggested that they analyze their survey in terms of lipid ratios. I am awaiting their response. My point in writing is that lipid ratios, in the Framingham experience as well as in my own, are far superior to simple LDL levels in predicting the population at risk of atherothrombotic disease (ATD). I have presented this data on numerous occassions at various national and international scientific symposia on dyslipidemia and ATD, most recently at the 2009 International Atherosclerosis Society symposium in Boston. The ratio that I use and its incorporation into a multifactorial risk factor graph is viewable at www.healtheurope.org, under the article on ATD. It is my guess that pataients still at risk of ATD despite low LDL levels have very low HDL levels, and hence an abnormal ratio. Evenso, if LDL levels are less than 80 mg/dl (2 mmoles/L), then HDL does not matter much anymore, and the patient at risk of ATD is probably at risk due to hypertension or cigarette smoking, and possibly elevated blood sugar levels.

Niacin not beneficial in patients at goal with statins: NIA Plaque

Thu, 19 Nov 2009 10:13:01 EST

This study has unequivocally proven that measurement of carotid plaque by MR is an invalid surrogate marker of coronary risk. Until there is clear evidence of correlation between MR findings and clinical outcomes, all MR studies should be halted to avoid the proliferation of inaccurate and harmful DATA as we see here. When physicians are satisfied with the 30% risk reduction provided by statin to goal alone, may god help the patients, because their doctors are not. When will the NIH fund a real study looking at the values of niacin and omega-3 fatty acids in the primary and secondary prevention of heart attacks? We give a lot of lip service to prevention but throw all of the research dollars at expensive and marginally beneficial treatments of end stage disease. I stand by my position that with the appropriate use of atherosclerotic imaging and intervention to the goal of plaque stability by EBT calcium imaging, we can prevent most of the heart attacks and save hundreds of billions of dollars annually. The goal of plaque stability by serial EBT usually requires the inclusion of niacin in subjects already at goal by our current and totally inadequate NCEP-III guidelines.

Latest European and US STEMI guidelines compared and contrasted

Thu, 19 Nov 2009 09:31:02 EST

Ayhan I appreciate your perspective. Simply put, the ability of getting a timely PCI if the patient has to be transferred with ST's up is currently at 4-6%. Nearly 4 years into our program, 88% of our STEMI's have had their artery opened in the last 12 months within the 90 minute window. Tell me it's not deplorable that we don't open more pre-existing cath labs for Primary PCI. We need to take the mystique out of it and forget EVERYTHING we ever thought about "preserving our referral bases" or "monetary impact" because everyone wins when you open these labs. The tertiary centers who were previously quaking in their boots at the thought of losing some of these patients are relieved that they aren't footing the bill for the recurrent CHF admissions and "self-pays" who are absorbed by our programs. "We" win as well because the uninsured go back to work instead of to the diability pay roll. Melissa

CHAMPION: Negative trials but some positive angles for cangrelor?

Thu, 19 Nov 2009 09:20:44 EST

De nada! Gracias! Melissa

Niacin not beneficial in patients at goal with statins: NIA Plaque

Thu, 19 Nov 2009 09:11:12 EST

Michael, I think it's NOT so much the numbers but the pleitrophic effects of niacin that make a difference. I remember some crazy number like an 80% reduction in events in some small subgroup in the ......HATS?? trial a long time ago. It was my first positive impression of just what Niacin can do for us. Melissa

JCHF: Are low doses of carvedilol effective in heart failure?

Thu, 19 Nov 2009 09:07:00 EST

I agree. The best way to treat a CHF patient with carvedilol is to "sneak up" on them by "starting low and going slow". We usually see the very sick patients every 1-2 weeks via nurse practitioner appointments in order to titrate. Melissa

CDC data show LDL screening rate remains stagnant; many who could benefit go without lipid-lowerin

Thu, 19 Nov 2009 09:04:54 EST

Thanks so much for your diligent efforts in this field. We appreciate your sharing this information with us which will certainly be a help to so many. Melissa

ACC/AHA focused update of guidelines for STEMI, PCI

Thu, 19 Nov 2009 09:03:16 EST

Did they get lysed or not? What was the troponin I rise and what did the echo look like? viability is a question in this case and I'd like to know more about the patient. Melissa

Kenneth Baughman killed while jogging at AHA

Thu, 19 Nov 2009 07:33:23 EST

The thing that I will always remember Ken by was his gentlemanly approach to a disagreement; about a manuscript submitted, data analysis, approaches to patients, protocol design, or academic organization. It is sad to see this man gone and in such a tragic way. He will be missed but not forgotten.

ACC/AHA focused update of guidelines for STEMI, PCI

Thu, 19 Nov 2009 04:51:49 EST

WHAT IS YOUR OPINION IN TAKE TO CAT LAB STABLE PATIENT WITH ANTERIOR MI AND ST UP ARRIVING IN HOSPITAL AFTER 12 HOURS THANK YOU RONALDO

PLATO shows benefits of ticagrelor over clopidogrel

Thu, 19 Nov 2009 03:53:09 EST

Aspirin also been taken by all pts taking together tigaclelor, means the result could be confounded by aspirin�s effect. although by theory the net effect of tigaclelor and plavix can be observed and compared by giving all the patients with aspirin, but actually we cannot exactly rule out whether the difference in mortality or bleeding tendency is due to any possible synergistic or additive effect of aspirin, and maybe not the net effect of tigaclelor. I think maybe any interaction should be investigated also either between tigaclelor or plavix.

Kenneth Baughman killed while jogging at AHA

Wed, 18 Nov 2009 23:36:45 EST

I, like everyone else, was shocked to get the news. Ken was an incredible clinician and mentor. He taught by example, setting high standards for himself and for everyone around him, always in the service of better care for the patient. His influence on me as a medical student and house officer made me a better doctor and led to my decision to become a cardiologist. The world of cardiology has suffered the loss of one of its great clinicians and teachers.

JCHF: Are low doses of carvedilol effective in heart failure?

Wed, 18 Nov 2009 21:22:13 EST

Our practice is to start with the lowest possible dose in heart failure that is available to us as 3.125mg and then gradually up-titrate the dose and we have seen the best results with the higher doses. Most of our heart failure patients tolerate doses between 25 and 50 mg per day.

Kenneth Baughman killed while jogging at AHA

Wed, 18 Nov 2009 20:06:28 EST

Undoubtedly one of the greatest cardiologists of our generation: a true master clinician and a kind and humble human being. I knew him from the Brigham where he was THE role model for all trainees with an aspiration for Cardiology. He will be greatly missed.

FAIR-HF: Symptom improvement, functional gains follow correction of iron deficiency in heart failu

Wed, 18 Nov 2009 19:22:08 EST

It is great to have a trial to support our clinical impressions. Iron deficiency is very common in advanced heart failure (especially those with a chronic edematous state) and IV replacement has proven to be a valuable clinical tool to improve outcomes in my patients. I also note a very high incidence in patients with right heart failure and severe TR. This trial is helpful in providing the evidenced base that we need to support the clinical management that I have found helpful.

Kenneth Baughman killed while jogging at AHA

Wed, 18 Nov 2009 19:05:20 EST

Ken was an ACS in medicine at Hopkins when I was on rotation as a medical student. Even then, he was a gifted, dedicated teacher of great integrity. Of all the memories of those days I think my cohort would agree that among the most lasting are the afternoons we spent in awe and appreciation of Ken.

Niacin not beneficial in patients at goal with statins: NIA Plaque

Wed, 18 Nov 2009 18:22:07 EST

Micheal, I am just amused by the ability of academic cardiologist to decide what primary care physicians are ready or not ready to do. Of note, many PCP are way more aggressive and knowledgeable in lipid management than most cariologist, especially interventionists. Braunwald (well, cardiologist) believes that data for KIF6 - multiple randomised DB clinical trials showing very consistent results- amount to grade A1 evidence. Well, it also makes whole LDL and CRP hypotheses immidiatley obsolete. LDL and CRP went down in kif6 TT and Arg patient the same, but it was only Arg group that benefited from statins. Big oops for LDL and hsCRP. This is what academia is not ready for yet: to change their view of thier gods (and cash cows)- LDL and hsCRP...I expect academia will fight this test to the end of thier careers. When it comes to patient care it is clear that statins in KIF6 TT patients only provide sense of false assuranse: LDL is down to target, but outcomes do not chnage. Patients die improved. Even though data is not in (the open yet)these patients deserve a chance to (possibly) benefit from addition of non-statin therapies, notably Niacin, may be bile sequestrants, which they would be denied if KIF6 testing is not provided.

Kenneth Baughman killed while jogging at AHA

Wed, 18 Nov 2009 17:29:24 EST

At the request of Dean and CEO Edward Miller, I and Dr Baumgartner remembered the contributions of Dr Baughman to Cardiology, Medicine, Hopkins and patients at Johns Hopkins from the time of his Osler housestaff training and, his two years as Assistant Chief of Service at the beginning of the firm system. He lead nationally recognized heart failure research including his hats that were worn for his 4000 or so heart biopsies without complication (all hats were different),and his great leadership of Cardiology for 9 years of growth. Dr Baumgartner remembered his personal and family relationship to Ken and his doctors doctor role for anyone with a heart problem but his telling any patient who could not stop smoking to look elsewhere. Ray DePaulo remembered his days of internship with Baughman before going into Psychiatry. Gabe Kellen and David Hellmann also commented on the depth of Baughman's contribution. Miller also had a rememberance of controversy over an echo machine that anesthesia perchased but leading to long term respect. Brem and Dover offered comments personally. All were silent for a prolonged moment of great saddness.

CDC data show LDL screening rate remains stagnant; many who could benefit go without lipid-lowerin

Wed, 18 Nov 2009 17:25:38 EST

The article by Kuklina and accompanying editorials by Gaziano and Gaziano and by Hingorani and Psaty illustrate the chaos, confusion, and even apathy that characterize the field of interventional lipidology in the area of the primary prevention of atherothrombotic disease (ATD) under the NCEP guidelines, which are now in their fourth revision. Guidelines to remedy this situation are far too complex. Guidelines that are unclear or simply too complex are not likely to be utilized by physicians and are of little use in the war against ATD. Guidelines that have failed and/or been subject to repeated revision are likewise of little use. I have directed a study of the primary and secondary prevention of ATD since 1974 and as part of this study have examined the ATD risk facor combinations that have characterized those of my patients who developed some form of clinical ATD during the 1974-2003 timeframe. Pursuant to this, I have developed a multi-factorial risk factor graph for the prediction of the population at risk of ATD. This graph has been published in article form and as letters to the editor in a number of medical journals, as well as presented as posters at numeous regional, national, and international scientific symposia on ATD and dyslipidemia. The graph may be exmined at www.healtheurope.org, under the article on ATD. The graph has a lipid arm, represented by the Cholesterol Retention Fraction (CRF, or [LDL-HDL]/LDL) on the ordinant and systolic blood presure (SBP) on the abcissa. A threshold line has been delineated that separates the mainstream ATD patients' CRF-SBP plots from those of a few ATD outliers. The line coordinates are (0.74,100) and (0.49,140). In my practice 85% of ATD patients have CRF-SBP plots above the threshold, and the same is true in the Prosper trial. Those ATD patients with CRF-SBP plots lying below the threshold line are mostly cigarette smokers, leaving only 6% of all my ATD patients who could not have been predicted by CRF-SBP plot position above the threshold line and/or cigarette smoking status. These latter patients on average do not develop their ATD events until late in life (on average in their mid to late 70's) and do not die for an additional 10-15 years on average. Patients with CRF-SBP plots above the threshold line are considered at risk of ATD, the degree of which depends on age and CRF, and to a lesser extent on SBP. Patients with CRF-SBP plots below the threshold line are not offered dyslipidemic therapy unless their LDL is 170 mg/dl (4.4 mmoles/L)or greater--and that is because HDL cannot compensate for excess LDL. Virtually any therapy that brings the patient's CRF-SBP plot below the threshold line is associated with angiographic stabilization/regression of coronary plaque in a minimum average of 75% of cases. A table defining the ATD risk in terms of CRF sextile and age group is referenced in the www.healtheurope.org website. The graph is simple in concept and relatively easy to use. It is the reason, I believe, that my patients only rarely suffer ATD events.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Wed, 18 Nov 2009 17:20:52 EST

Let me see if I can summ up the above points about "heptotoxicity" of Slo-Niacin. Please comment if I get it wrong... Elevation of LFTs is a well known side effect of any and all Niacin preparations, seems to be dose dependent and may be more pronounced with slower releasing preparations. Niaspan and Slo-Niacin are ER preparations, not SR preparations. No death, fulminant liver failure or even jaundice requiring hospitalization reported with Slo-Niacin or Niaspan. Elevation of LFTs (just above the threshold of discontinuation for statins) reported in one case wit Slo-Niacin (above) with no rechallenge. May have been due to alcohol or just a food binge in a patient with steatohepatitis. I see these things with statins quite frequently LFts go up and go down... Fulminant liver failure is described with SR, not ER preparations of Niacin. I could not access all the articles mentioned, but I assume "sustained release" is SR. So, as long as we limit use of OTC ER Niacin to one brand - So-Niacin from Upsher-Smith for people who cannot afford Niaspan and can not tolerate IR Niacin - what is the problem? If Slo-Niacin has no record of safety, then Niaspan has no record of clinical outcome reduction and should be used - as per PI -for cholesterol lowering and CIMT regression only.

BARI 2D cost-effectiveness analysis favors medication over PCI for less severe CVD in diabetic pat

Wed, 18 Nov 2009 17:07:13 EST

What is missing here is that the surgical group[ in BARI2 did not have "extensive disease".Less than 20% even had proximal LAD and there was a fair representation of 2VD. These are groups that did well in SYNTAX with PCI and DM (especially when not on insulin )as well as other RCTs with just BMS. What BARI 2 actually demonstrates is that a group of diabetics WITHOUT traditional high risk anatomy benefit from prompt revascularization. Whether PCI or CABG is yet to be finally determined but current data say PCI will do just fine in most of these.

Kenneth Baughman killed while jogging at AHA

Wed, 18 Nov 2009 16:50:07 EST

I had the priviledge of training under Ken Baughman during my cardiology fellowship. I share the comments about losing such a gifted clinician and scholar. The only consolation I can take from this is that he will live on through those of us he has trained or touched in his professional and personal life. He will be dearly missed.

Niacin not beneficial in patients at goal with statins: NIA Plaque

Wed, 18 Nov 2009 15:13:13 EST

Dmitri, yet niacin has no evidence for reduction with kif6 populations and heaven forbid if in that genetic population if there blunting. (we just have no evidence) granted that in large meta of outcomes studies NNT with KIF neg were 100 where total pop was 45 and kif pos was 18. But we just don't know and ordering kif in most offices as Dr. Sacks and Foody and Sabatini said at AHA isn't ready for prime time. mc

Kenneth Baughman killed while jogging at AHA

Wed, 18 Nov 2009 15:06:40 EST

I am stunned by his untimely death. Ken was a friend, mentor, and teacher, and approached all these endeavors with the highest work ethic and standards of integrity. We will all miss him dearly and extend our deepest sympathies to his family.

Kenneth Baughman killed while jogging at AHA

Wed, 18 Nov 2009 14:50:41 EST

more then a decade ago, my own chief of cardiology was struck by a car while jogging. We were attending the ACC in Atlanta. He received superb care at Grady and made a full recovery. But lets take these tragedies as a warning, and be careful when we are doing something healthy in an unfamilar environment.

Statins do not eliminate risk of low HDL-cholesterol levels

Wed, 18 Nov 2009 14:42:16 EST

I don't believe in isolated fact of this.I think in the plurimetabolic syndrome and multifocal avaliation.

Kenneth Baughman killed while jogging at AHA

Wed, 18 Nov 2009 14:36:43 EST

Ken and I arrived simultaneously at JHH as house officers in 1972. Always a great clinician and teacher, he was the very definition of Aequinimitas as a Division director, colleague and boss. He was a life force. How we will miss him!

Niacin not beneficial in patients at goal with statins: NIA Plaque

Wed, 18 Nov 2009 14:16:45 EST

We use eventually niacin augmented a statin, always to increasy HDL, with good results.

Niacin not beneficial in patients at goal with statins: NIA Plaque

Wed, 18 Nov 2009 14:16:28 EST

But would you like to double statin benefit? Use KIF6 testing, eleminate non-responders (Trp/Trp), treat them with aggressive non-statin therapy + generic statin to "comply" with the guidelines, but treat KIF6 Arg Pts with maximal dose strongest statin they can afford...you going to get double benefit of the unselected population. For KIF6 Arg, one can argue, you do not need a second agent because their absolute residual risk would be so small...

Kenneth Baughman killed while jogging at AHA

Wed, 18 Nov 2009 14:13:51 EST

This loss will continue to be felt deeply by many of us who owe so much to KLB. He was an understated Master Clinician and role model. His clinical prowess, love of teaching and support of the academic mission was truly exceptional, but it was his personal character that was so amazing. I could tell so many stories, but I'll tell just one. One morning I was feeling a bit frustrated that there were no clean stretchers (not to mention transporters) on the entire floor at "the world's best Hospital" and I needed to get my pt to the cath lab. I ran into KLB who was had just found some clean sheets and was calmly preparing his own stretcher to transport his own pt in for a right heart cath and biopsy. He could fight the battle for appropriate resources as our leader, but was never above pragmatism: rolling up his own sleeves to get the job done for his patients. During the four years I trained under his leadership in the late 90's in Baltimore, he earned over and over again my profound respect. Even today, when confronted with challenging clinical scenarios, I frequently find myself considering: "What Would KLB Do?" He will be sorely missed.

JCHF: Are low doses of carvedilol effective in heart failure?

Wed, 18 Nov 2009 13:55:22 EST

We usually use 25 mg/day; but eventually in some patients 12,5 mg/day because the arterial pressure is < 100x60 mm Hg, or rate<45.

Niacin not beneficial in patients at goal with statins: NIA Plaque

Wed, 18 Nov 2009 13:26:26 EST

Example: diabetes mellitus. CARDS: rate reduction 37% [95% CI -52 to -17], p=0.001, for major cardiovascular events (primary endpoint). This is for atorva 10 mg/d vs placebo. For some endpoints, eg stroke, benefit was even bigger (48% RRR). TNT (DM subgroup): Hazard ratio 0.75 [95% CI 0.58-0.97], P = 0.026. Again, primary endpoint analysis. This time for atorva 80 vs 10 mg/d. Cumulative relative risk reduction atorva 80 mg/d vs placebo based on these two trials = 1-(0.75*0.63) = 53% risk reduction with high dose statin against placebo.

Niacin not beneficial in patients at goal with statins: NIA Plaque

Wed, 18 Nov 2009 13:25:59 EST

All those labs values & compare to NIA Plaque,.. I agree the compliance was not mentioned in NIA Plaque.

Niacin not beneficial in patients at goal with statins: NIA Plaque

Wed, 18 Nov 2009 13:24:57 EST

I would also like to see the baseline & 24 months changes in Arb-6 to HDL2/2b, pattern/density changes, LpPLA2, adiponectin, & Lp(a). There may be more "devil`s" in those details. Dr. Topol`s video clip on Arb-6 was well worth viewing/listening to.

Kenneth Baughman killed while jogging at AHA

Wed, 18 Nov 2009 13:05:39 EST

I'm shocked to hear this news. For those of us who had the privilege to train at Hopkins in the magic days of late '80s - early '90s, Ken was "the" clinician, by definition. There were many superb clinicians, but he was in many ways special. I learned a lot from him. I'm also deeply indebted to Ken as he was the Chief of Cardiology when, having gone back from Italy, I was offered a Faculty position. That brief second stint at Hopkins is among the most intense experiences of my life. Goodbye, Boss. I'll miss you. Nello Ambrosio

Kenneth Baughman killed while jogging at AHA

Wed, 18 Nov 2009 13:00:48 EST

Ken was widely admired as a truly outstanding clinician and mentor, but he was also a good friend and colleague of so many of us. His untimely loss is tragic, and he will be sorely missed by the cardiology community.

Niacin not beneficial in patients at goal with statins: NIA Plaque

Wed, 18 Nov 2009 12:49:51 EST

HDL increase with 1500 mg Niaspan from 55 to 58 is pathetic. Only one thing comes to mind to expalin it: patients compliance. I bet you over a half of the patients did not take Niaspan as directed, this is very typical drop out rate if no mechanisms enforcing compliance are used. Second, HATS was done with Slo-Niacin and Niacin IR. May be we should really practice evidence based medicine from now on:) Third, even maximal dose statin prevents less then a half of recurrent CV events. I do not see how anybody would be satisfied with this record. I would at least consider Niacin for secondary prevention of KIF6 Trp/Trp patients who are known to derive no benefit from statins (CARE, PROVIT-TIMI22 and PROSPER analysis)

Statins do not eliminate risk of low HDL-cholesterol levels

Wed, 18 Nov 2009 12:19:38 EST

Low LDL such as ApoE is associated with dementias and Low LDL-C generally has its problems. www.termedia.pl/ams for the archives of medical science review article about cholesterol depletions.

Kenneth Baughman killed while jogging at AHA

Wed, 18 Nov 2009 11:55:21 EST

Ken was an unparalleled clinician and a great mentor. He was inspiration to me and so many others throughout my training and beyond, and I was very privileged to learn heart failure and transplant cardiology from the master. No matter how busy he was, he always made time to offer his expertise and guidance when asked. His encouragement has been invaluable for me over the years. Since he left Hopkins in 2002, I would stop by his office in Boston whenever I was there for a visit, and we would talk about everything from cardiology and academic medicine to running and triathlon. His death is a tremendous loss for all of us.

Statins do not eliminate risk of low HDL-cholesterol levels

Wed, 18 Nov 2009 11:28:38 EST

After adjustment for LDL-cholesterol levels and age, a 10-mg/dL increase in HDL-cholesterol levels prevented 7.6 MIs per 1000 patient-years in statin-treated patients; this benefit was nearly identical in healthy controls. Similarly, every 10-mg/dL increase in HDL cholesterol prevented 9.7 cardiovascular-disease events per 1000 patient-years in statin-treated patients and 9.9 cardiovascular events in the control arms. "The study did produce the finding that the lower the HDL-cholesterol level, the higher the cardiovascular-disease risk, particularly the risk of myocardial infarction," said Karas. "In other words, what this study shows us is that statins don't alter the risks associated with low HDL-cholesterol levels." To highlight the magnitude of benefit of raising HDL-cholesterol levels, Karas noted there was an approximate 26% reduction in the risk of MI and a 25% reduction in the risk of cardiovascular-disease events in the statin-treated patients for every 40-mg/dL decrease in LDL cholesterol. This translates into four MIs prevented per 1000 patient-years.

Niacin not beneficial in patients at goal with statins: NIA Plaque

Wed, 18 Nov 2009 11:13:46 EST

...a nd more patients,.. the results may have been quite different.

Niacin not beneficial in patients at goal with statins: NIA Plaque

Wed, 18 Nov 2009 11:09:22 EST

Another 12 months might have displayed different results in this specific population. From another source, their results showed: "Seniors on dual drug therapy had an average 5.4 cubic millimeter per month scale back in plaque buildup in the main neck artery, while those taking just a cholesterol-lowering statin medication came down by 4 cubic millimeters per month, a difference that researchers say is not statistically significant" With another 6-12 months what would have ben seen ?

Niacin not beneficial in patients at goal with statins: NIA Plaque

Wed, 18 Nov 2009 10:50:42 EST

So, I guess my questions/comments would be: 1. Why would one use niaspan in this group when they are near or very near LDLc and NHDLc goals and have fantastic TG and HDL values. 2. Both groups were very close to LDLC and NHDLc recs at baseline and at end and minimal difference at end with LDLc 77 vs. 67 and NHDLc 103 vs. 92 at end. I think one would need 19K pts followed for at lest 2-5 yars to see difference this group.

Kenneth Baughman killed while jogging at AHA

Wed, 18 Nov 2009 10:34:54 EST

I also had the great fortune and honor of training under Dr. Baughman from 1995 to 1998 on the Osler Medical Housetaff. He was the true embodiment of Oslerian virtue "Aequanimitas" emblazoned on our neckties and scarves... a patient, courageous, sympathetic leader who served as imperturbable reference standard for all so many clinicians he trained. I still remember walking into his office, admiring his extensive hat and cap collection... I asked Dr. Baughman if he had a favorite cap was and after a short pause, he replied "the train conductors'." In retrospect, the cap, epitomized how he ran our cardiology section at JHH... always working behind the scenes and harder than anyone else to lead by example to make the division run with swiss watch efficiency. we will miss you.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Wed, 18 Nov 2009 10:25:12 EST

http://jama.ama-assn.org/cgi/reprint/264/2/241

Kenneth Baughman killed while jogging at AHA

Wed, 18 Nov 2009 10:14:39 EST

I first met Ken in 1993 as an intern at Johns Hopkins, and I worked closely with him during my residency and fellowship. No one had a greater role in mentoring me as a house officer or cardiology fellow. Although I felt a great loss when he left Hopkins in 2002, he remained a friend and mentor, always readily available for advice - both in the clinical management of tough cases and in professional/career decisions. If not for Ken's guidance and mentorship, I would certainly not be where I am today. Ken�s premature death is truly a profound loss for the Cardiology community, both among patients and professionals. He will be sorely missed.

Niacin not beneficial in patients at goal with statins: NIA Plaque

Wed, 18 Nov 2009 10:12:01 EST

why there needs to be DBRCT's examining these therapies with endpoints that "matter" -- hard endpoints. The parade of surrogate marker trials with differing results, sometimes complimentary other times contradictory, only serve to confuse the public and the medical community. How about a trial with lipid lowering therapies along the lines of the ALLHAT to settle the issue once and for all -- or at least provide some additional clarity. INMHO

Kenneth Baughman killed while jogging at AHA

Wed, 18 Nov 2009 10:08:41 EST

What a shocking and terrible loss. Like so many others in my generation of Hopkins trainees, Ken had a profound influence on my career. I have often joked that I became an academic heart failure specialist because Dr Baughman told me I should and I was afraid to tell him no! Ken was the consummate clinician and clinical teacher. I recall him examining the neck veins and then pulling out his pen and drawing the JVP contour for the assembled housestaff on the patient�s bedsheets. I�m sure these hieroglyphics were perplexing to housekeeping, but we loved it. Dr Baughman set a standard for clinical excellence and work ethic to which we all aspired, but none of us could reach. As I moved on in my academic career, he was a constant source of inspiration, encouragement, and support. My sincere condolences to his family and his patients, as well as those future cardiology trainees who will not have the benefits of his immense clinical wisdom. Michael Felker

Niacin not beneficial in patients at goal with statins: NIA Plaque

Wed, 18 Nov 2009 09:26:49 EST

The most evidence based approach is to maximize the statin dose (rosuva 40, atorva 80, prava 80) before adding another agent. In the aforementioned trials statins were not maxed out. 7 trials and 3 meta-analyses all show that. Whether there is any benefit to adding the second agent on top of the max statin dose was addressed by the NIA Plaque study - there wasn't. However, there was benefit in HATS.

Advocates build support for Canadian Heart Health Strategy in a difficult environment

Wed, 18 Nov 2009 03:48:37 EST

For this kind of money,they could do a calcium score and a screening carotid ultrasound on every Canadian over the age of 40 every 3 years. If you want to take a bite out of heart disease, this is where you should spend your money!

Kenneth Baughman killed while jogging at AHA

Wed, 18 Nov 2009 02:57:31 EST

Ken was a mentor and instructor to me and so many others at Johns Hopkins, and then later at the Brigham. He was truly a master clinician (and especially the art of physical exam), and his depth of knowledge in medicine extended well beyond cardiology. There is a legendary story of Ken in his fellowship training that during a terrible snowstorm in Boston, he was the only physician to show up on the cardiology service. When the surprised in-house physician saw him and said "Baughman, what in the world are you doing here?", Ken only matter of factly replied "Rounding." His motivation inspired us all. We knew that he did not expect any more of others than he demanded of himself.

Kenneth Baughman killed while jogging at AHA

Wed, 18 Nov 2009 01:44:15 EST

Ken was an exemplary mentor for me and hundreds of trainees at Johns Hopkins and the Brigham for over 3 decades. A model physician, the consummate educator, and extraordinary individual so deeply committed to clinical excellence. This is shocking and represents an enormous loss for the cardiology community.

Kenneth Baughman killed while jogging at AHA

Wed, 18 Nov 2009 00:04:40 EST

I first met Dr. Baughman as an intern at the Brigham. Since then, he was not only my greatest mentor but like a father. I am in shock. This is an incredible loss to the cardiology community and the world. He was the perfect physician and the perfect man. He touched so many lives and he will continue to live on in our thoughts for as long as we live. God bless you, Dr Baughman. We miss you so much.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Tue, 17 Nov 2009 23:51:31 EST

CASE 3.--One year after a myocardial infarction and subsequent coronary angioplasty, a 47-year-old man was referred to the Atherosclerosis Detection and Prevention Clinic for evaluation. His medications included dipyridamole, diltiazem hydrochloride, and low-dose aspirin. Results of thyroid and liver function tests were normal. Lipoprotein analysis revealed mild elevations in levels of low-density lipoprotein cholesterol, intermediate-density lipoprotein cholesterol, and very-low-density lipoprotein cholesterol, with moderately reduced levels of high-density lipoprotein cholesterol. In light of the patient's premature coronary heart disease and syslipidemia, crystalline niacin was prescribed. He was instructed to begin with 250 mg/d and to increase the daily dose by 250 mg every week, up to a dose of 2000 mg/d. During the first 2 weeks he experienced pronounced flushing, and on his pharmacist's advice the patient switched to SR niacin (Slo-Niacin caplets, Upsher-Smith Laboratory Inc. Minneapolis, Minn), which he took according to the previously prescribed schedule. On reevaluation 2 months later, just after increasing the daily niacin dose to 500 mg four times daily, the patient's liver function tests revealed the following levels: alanine aminotransferase, 160 U/L; aspartate aminotransferase, 155 U/L; alkaline phosphatase, 85 U/L; and total bilirubin, 9 micromol/L. Treatment with SR niacin was promptly discontinued, and treatment with crystalline niacin was reinstated at a daily dose of 1000 mg, which was gradually increased to 4000 mg/d with careful monitoring of liver function. After 6 months, the patient was tolerating crystalline niacin well and had normal results of liver function tests.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Tue, 17 Nov 2009 23:49:22 EST

http://www.shipbrook.com/jeff/CoS/narconon/niacin.html

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Tue, 17 Nov 2009 23:37:40 EST

Once switched to IR,.. no more issues.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Tue, 17 Nov 2009 23:36:04 EST

Nicotinic Acid-Induced Fulminant Hepatic Failure Clementz, Gregory L. M.D.; Holmes, A. William M.D. October Journal of Clinical Gastroenterology 1987 Niacin and Hepatic Failure R. H. Knopp ANN INTERN MED November 1, 1989 111:769 Rechallenge With Crystalline Niacin After Drug-Induced Hepatitis From Sustained-Release Niacin Y. Henkin, K. C. Johnson, J. P. Segrest JAMA July 11, 1990 264:241-243 Acute Hepatic Failure Associated With the Use of Low-Dose Sustained-Release Niacin H. N. Hodis JAMA July 11, 1990 264:181 The American Journal of Medicine Volume 92, Issue 1, Pages 77-81 (January 1992)

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Tue, 17 Nov 2009 23:29:22 EST

Abstract Niacin (nicotinic acid) is used frequently in the treatment of hypercholesteremia. It is available in both unmodified and time-release preparations. The latter were developed in attempts to minimize the skin-flushing reaction that affects virtually all users and may limit acceptance. Adverse effects on the liver from both unmodified and time-release preparations have been recognized for many years. We reviewed the literature on the hepatic toxicity of both types of niacin preparations. Adverse reactions in six patients resulted from the exclusive use of unmodified niacin and in two patients from the exclusive use of time-release preparations. In 10 additional patients, adverse reactions developed after an abrupt change from unmodified to time-release preparations. Many of these patients were ingesting time-release niacin at doses well above the usual therapeutic doses currently recommended. Signs of liver toxicity developed in less than 7 days in four of these 10 patients. In doses that achieve equivalent reductions in serum lipids, hepatic toxicity occurred more frequently with time-release preparations than with unmodified preparations. An awareness of toxicity associated with ingestion of high doses of time-release niacin preparations is important because of their widespread availability and the potential for self-prescribed, unmonitored use.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Tue, 17 Nov 2009 23:28:56 EST

The American Journal of Medicine Volume 92, Issue 1, Pages 77-81 (January 1992) Jeanne I. Rader, Ph.D., Richard J. Calvert, M.D., John N. Hathcock, Ph.D.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Tue, 17 Nov 2009 23:20:18 EST

wax poly-matrix which was known to release irradically & often had significant serum levels beyond 12 hrs a day. Dosed BID, this could really get someone into a dangerous area. Still, the Olin et al analysis showed 5 X more issues for rhabdo with fibrates vs. SR niacin. All in all, niacin ranks as one of the safest lipid Rx, but only with IR & ER formulations. It does take a lot of tricks to get over the 4-6 week "hump" before the flushing effects tachy-down. It is a real joy to see the labs keep improving for months & even years, the notorious "HDL creep". Lp(a) also takes a long time.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Tue, 17 Nov 2009 23:14:06 EST

IR was the only form and for a time the only cholesterol drug. For robust TC, LDL & apoB reductions 4, 6 & even 8 gms a day were provided. Still, real toxicity was/is rare. And today as an adjunct/add-on therapy, we usually never dose above 3000 mg & have yet to see any evidence of toxicity with IR or ER. The non-standardized SR`s, that is another matter.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Tue, 17 Nov 2009 23:09:59 EST

The 'key' study where fulminant hepatic failure was observed, was a VA study. "Efficacy & Safety of Controlled-release Niacin in Dyslipoproteinemic Veterans" [VA] David R. Gray et al Ann Intern Med 1994 There are a few others in my e-library for sure,.. I`ll have to put an hour or so into retrieving those.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Tue, 17 Nov 2009 22:57:16 EST

We have very good luck using as a titrator. They also have IR in 500 mg after 4-8 weeks titration w the 50`s, it makes a great maintenance dose. 12-15 dollars/month for 1-2 gms maintenance. The time-release is NOT as good on DL,.. but captures more patients who have tolerability-issues & are not-insured.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Tue, 17 Nov 2009 22:49:45 EST

Interesting discussions...I too am a believer in niacin and the (functional) HDL-raising strategy. for patients who like a little wine with their dinner, what have people been advising? avoidance or just don't drink within a couple of hours? any issues with increased hepatotoxicity? i do disagree with a comment made earlier about choice of surrogate endpoint and ebt cac. A surrogate is a surrogate and substituting one for the other in this type of study may not change anything other than resulting in a negative trial. and serial EBT CAC?...really?? so we can ensure that our patients calcium scores are great but they will eventually get cancer...no thanks i'll take the ultrasound.

FAIR-HF: Symptom improvement, functional gains follow correction of iron deficiency in heart failu

Tue, 17 Nov 2009 21:29:00 EST

It's very interesting and can open a big door for our patients, who have for a long time complained of weakness, tiredness and generaly unwell feelings.

Cangrelor in CHAMPION: What went wrong?

Tue, 17 Nov 2009 20:05:17 EST

1) Since CHAMPION-PCI indirectly shown that 600mg clopidogrel will be a better option than 300mg, is it required further investigation? 2) Since CHAMPION-PCI indirectly shown that upstream use of clopidogrel associated with a better end point, is it required further investigation? 3) Can both hypothesis (600mg clopidogrel and upstream use of clopidogrel) be applied into current practice now? thanks for answer my questions.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Tue, 17 Nov 2009 19:25:02 EST

I don't use a lot of IR niacin, but when I do, I prefer to use an FDA-approved brand. Niacor (Upsher-Smith) is approved by the FDA and is by prescription only. As such, it has to meet the FDA's standards of Good Manufacturing Practices, and meets their safety/efficacy requirements.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Tue, 17 Nov 2009 18:48:06 EST

Very hard to find in the Twin Cities at mg less than 500mg. Does anyone suggest a maker to be trusted online or in a "specialty store." I understand starting at 50 or 100 mg twice daily and uptitrating is reasonable with meals.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Tue, 17 Nov 2009 18:19:15 EST

2 more CETP inhibitors to watch that could easily be "ezetimibes" or worse, "torcetrapibs",.......anacetrapib and dalcetrapib[Thrombosis Research (2009) 123, 460�465]. Again, HDL is important but only if it's functional HDL.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Tue, 17 Nov 2009 18:18:51 EST

I have read many reviews that discuss the concept that prolonged-release formulations of niacin are more prone to hepatotoxicity. Perhaps like many readers (and perhaps even the reviewers), I accepted these statements at face value, and fairly uncritically. I have been reviewing this literature recently, and came across a very interesting commentary about this idea by R. Stern. What is fascinating is that it comes from one of the investigators who originated this idea a while ago. His group offered this idea as speculation in the discussion section of a paper. Recently, he critically re-appraised this idea after seeing it repeated endlessly in the literature, and ended up rebuking the speculative relationship in light of the subsequent evidence. He pointedly notes that "The suggestion that nicotinamide metabolites produce hepatotoxicity is not supported by any data. The mechanism of hepatotoxicity is unknown and a toxic metabolite of nicotinic acid has not been identified. Different nicotinic acid formulations produce different metabolite patterns due to nonlinear pharmacokinetics, but there is no evidence that these differences have any clinical importance." Ralph H. Stern, PhD, MD "The role of nicotinic acid metabolites in flushing and hepatotoxicity," Journal of Clinical Lipidology (2007) 1, 191�193. I encourage by fellow niacin enthusiasts to have a look at this paper as food for thought. Perhaps its time to re-evaluate the concept that the differing pharmacokinetics of the formulations predict hepatotoxicity.

CASCADE: No significant benefit of clopidogrel in reducing graft disease after CABG

Tue, 17 Nov 2009 16:05:35 EST

Posthoc analyses of some of the seminal clopidogrel trials suggest that CABG is a marker of severe disease, and patients assigned to ASA+Plavix do much better than ASA alone. I do not discontinue plavix at one year and believe that ASA+plavix should be the standard of care in most patients with advanced CAD (at least until we have ticagrelor available).

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Tue, 17 Nov 2009 15:43:34 EST

A lot of homework needs to be done here. The Poon data do not identify "best" products. They simply measure in-vitro dissolution of 7 non-prescription extended-release niacin products and Niaspan, then compare these rates to a published dissolution rate for niaspan of 100mg/hr. Carlson and Endur-acin were the closest to the reference rate, at 98 and 94 mg/hr, then the actual Niaspan (missing its mark) came in at 90 mg/hr, The slowest of all tested!! So guess what, there are no long-acting niacin products on the market!!! They all dissolve in less than 8 hrs. The hepatic safety of Niaspan has little to do with dissolution, and much do do with dosing REGIMEN. Choose one (with published data)and dose it once a day if you want to improve your safety margin. This is also likely why the HDL benefits are retained - Taking a single daily dose mimics IR with high peaks and CAUSES FLUSHING! This sends more drug down through a secondary metabolic pathway, with different (active?) metabolites. Most everything published about Niaspan's "intermediate" dissolution is bunk.

Kenneth Baughman killed while jogging at AHA

Tue, 17 Nov 2009 15:39:00 EST

I had the privilege to be trained by Dr Baughman at Hopkins from my arrival as an intern in '95 through finishing cardiology fellowship in 2002. He was tough, smart, a gifted "hands on clincian" despite the other burdens of leadership he had. He defined in his persona what integrity is. His passing is a great loss but his influence directly and indirectly will endure. He will remain one of the most important influences in my personal and professional life and I know so many former Hopkins residents and fellows will concur. I am deeply saddened and extend my sympathies to his family.

HEAAL: High-dose trumps low-dose ARB for heart failure in the ACE-inhibitor intolerant

Tue, 17 Nov 2009 12:00:55 EST

very helpful---as a cardiac patient(88yrs)nretired oediatrician and immunologist---discuss with my cardiologist intelligently!

Plasma renin activity associated with cardiovascular events and mortality in HOPE

Tue, 17 Nov 2009 11:55:20 EST

Some of the recent literature, ONTARGET for one, suggests possibility of loss of benefit or even harm in oversuppressing RAS. Is it possible that we should have target level for PRA, especially with availaility of Aliskiren, analogous to what we have for PTH or TSH?

CASCADE: No significant benefit of clopidogrel in reducing graft disease after CABG

Tue, 17 Nov 2009 11:33:19 EST

Since high patency rates were seen in both arms, its hard (wrong) to conclude that the combo is useful. Mechanistic arguments have lead to many unfortunate conclusions over the years that trials have disproven. I think we have to follow the data here. Would been interesting, though, to see an asa vs. plavix trial for vein patency.

hsCRP - How Will Recent Statin Trials Impact CV Risk Assessment?

Tue, 17 Nov 2009 11:15:01 EST

Glad to see different arguments on lipid maintenance and the different approaches being investigated. It is refreshing to see other doctors being involved, leading to more consideration of natural product uses.

CASCADE: No significant benefit of clopidogrel in reducing graft disease after CABG

Tue, 17 Nov 2009 10:44:04 EST

I've been using ASA/Plavix for one year post-CABG for some time now based on indirect data. Historical data suggests a 1-year failure rate for SVG's of around 25%, usually due to graft thrombosis. ASA/Plavix seems like a good idea from a mechanistic standpoint, and I don't think I am dissuaded by this study with a very high patency rate and low numbers. Any other thoughts?

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Tue, 17 Nov 2009 10:32:06 EST

I recently came across an interesting paper on the dissolution rates of various niacin formulations. Niaspan was best in terms of slow dissolution, followed by Enduracin and Slo-niacin. For those interested: Poon, Ivy O., Chow, Diana S.-L., Liang, Dong Dissolution profiles of nonprescription extended-release niacin and inositol niacinate products Am J Health Syst Pharm 2006 63: 2128-2134

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Tue, 17 Nov 2009 09:38:07 EST

HDL levels can mis-direct,... This is a good point. It is important not just to raise HDL but have HDL that can generate EDNO vis the SR-B1 receptor(functional HDL). And there are many ways to raise HDL but not all of them generate functional HDL. For examample one can inhibit cholesterol transport protein(tocetrapib) and very effectively raise HDL but that HDL does not generate EDNO. So, CETP inhibition is another "ezetimibe".

Good news continues for ticagrelor in PLATO STEMI subanalysis

Tue, 17 Nov 2009 04:03:06 EST

The idea of giving initial Ticagrelor followed by a 'switch-over' to clopidogrel for cost cutting is an intriguing one and needs further evaluation. Surgeons are still reluctant to take patients on clopidogrel for CABG - the reversibility of ticagrelor may be a distinct advantage over Clopidogrel in this regard.

Cangrelor in CHAMPION: What went wrong?

Tue, 17 Nov 2009 03:42:05 EST

though most people are focusing on the 'failure' to show superiority of cangrelor than clopidogrel, i think actually cangrelor is quite a good drug, either as an alternative or when IV antiplalet is warranted. We should be grateful that cangrelor is at least not inferior to clopidogrel. Now is time to focus on finding the best way to deliver cangrelor. After that, it will be better time to compare with the other antiplalet available.

2009 Antiplatelet Debate: What's New in ACS

Tue, 17 Nov 2009 00:01:53 EST

The audience should know about the presence of resistance to certain antiplatelet drugs and if combined therapy can overcome such problem.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 20:32:03 EST

HDL levels can mis-direct,... if the MPO is elevated, it is dysfunctional. However,.. @ a tot-HDL of 60 mg/dL, or greater ~99% of the patients will have good, functional HDL2/2b. Lots of PON-1 available & NO production. Via niacin effects there will be reductions in ADMA, increases in adiponectin, etc. HDL functionality also is implicated in modulating glucose regulation, recruitment of endothelial progenitor cells for repair of endothelial damage,... interesting stuff.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 20:25:45 EST

If you are looking to save money on niacin therapy - use an immediate release form. It is safe and it works. We like CarlsonLabs.com, start with the 50 mg, TID, then increase SLOWLY. $12-$15 / month for a maintenance dose 1-2 gms/day [total]. Once at maintenence dose, you can adjust to a BID regimen.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 20:25:10 EST

NCEP ATP III Full Report continued,... "Niaspan is an extended-release preparation; however, its more rapid-release than sustained-release preparation appears to reduce the risk of hepatotoxicity. Niaspan also is associated with less flushing than with crystalline nicotinic acid."

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 20:23:45 EST

On the surface this was a study about lowering LDL vs raising HDL. But in the end it is ultimately about enhancing endothelium derived relaxing factor(EDNO)production by the vessel wall. Two studies have shown when ezetimibe and statins lower LDL to the same extent only the statin improves endothelial function. Also,increased HDL from niacin, acting via the SR-B1 receptor on the surface of the endothelium, enhances EDNO production. And this explains the benefit of Niaspan. Statins, unrelated to lowering LDL, activate endothelial nitric oxide synthase and likewise enhance EDNO output. Again, increasing EDNO explains the findings of this study.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 20:23:40 EST

Here are a couple quotes from the NCEP ATP III Full Report available on the NIH website: "The sustained-release preparations usually increase HDL cholesterol levels by only 10-15% with the exception of Niaspan which retains the HDL -raising potential of the crystalline form." "The risk of hepatotoxicity appears to be greater with the sustained-release preparations, although not with Niaspan"

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 20:22:44 EST

...while the Alka-Setzer dissolves. Fiber slows the absorption curve,.. just a bit, and with ER, that is ideal. If you have a mild flush 15 minutes later,.. with the fiber-snack,.. you are likely asleep,.. you do not wake up,.. and that counts as a "zero". If a tee falls in the forest,... It really is a pretty neat little tip,.. The flush tachy`s down to near zero after 8 weeks. It`s the 1st few days that are critical.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 20:19:37 EST

Dr. castelli mentioned this during his lectures, a few times. He was using IR niacin, TID, at doses well above 2000 mg/daily. He liked the reduction in dyspepsia,.. basic upset stomach from the niacin. However, it is a neat way to increase the compliance with THE ASPIRIN !!! they use it to wash down the pill,.. and the taste reminds them the 2nd, 3rd evenings.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 20:07:36 EST

I am taking one gram of Slo-Niacin a day and will continue it long term, with a statin. Paying $100 extra per month for seal of FDA and NLA appoval just is not worth it to me. I will take the risk. Many patients in my practice with Medicare-D have to make this exact choice as well. I give them the options to make informed choice.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 17:53:54 EST

CJ McConnell, What are the apple sauce and alka-seltzer tricks?

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 17:34:14 EST

I would NOT use this product long term with a statin on board. "Serious hepatic toxicity can occur with niacin therapy, but it is almost entirely associated with the use of slow-release formulations. IR (regular or crystalline) niacin or ER niacin generally should be used rather than SR niacin. Nevertheless, slow-release niacin in doses up to 1,000 mg twice daily can be used safely with liver function test monitoring (1) in exceptional cases in which only slow-release niacin is tolerated or (2) in clinics that have developed experience with a high-quality brand of slow-release niacin. If patients are taking concomitant statin therapy, then even mild liver toxicity from SR niacin might lead to decreased hepatic clearance of statins and potentially to serious myopathy. Therefore, in statin-treated patients, SR niacin doses should be limited to 1,500 mg total daily dose." Guyton and Bays Am J Cardio2007;99[suppl]:22C�31C)

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 17:21:57 EST

IR can be used nearly as successfully as ER. It does take a couple more weeks to titrate, on average. Again, apple-sauce & Alka-Seltzer really help the 1st 2-4 weeks. Quercetin has some utility as well. DR. Castelli`s Alka-Seltzer tip & Dr. Varveris were both a great help.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 17:12:25 EST

Long serum residence times of nicotinic acid actually produce poorer HDL response. The 1st 'inkling' of this effect was 40 years ago,.. see Dr. Wm. Castelli "Interview with the Editor" Am J Cardiol 2005 re: the "Niacin 1st pass effect". The longer the TROUGH between peaks in serum level, the greater the HDL response to niacin. Admittedly Slo-Niacin is the closest to 'standardized',.. still, not as potent on HDL & especially HDL2/2b. However, LDL/ApoB respond BETTER on longer-acting formulations & mysteriously, also with Lp(a). Many studies have reproduced this comparison in response. The formulations are the key to how the patient responds clinically. I have a friend, an endocrinologist, who skips every other day on my recommendation. 1 gram of ER niacin Mon, Wed. & Fri. Once he began skipping days, his HDL increased an additional 35%. This mirrored what I read in Dr. Castelli`s interview. HDL creeps anyway: it takes a LONG time, but it is somewhat inexorable. it "gets there". Evaluating niacin effect on HDL can take 3-4 years. At 2 years on 2 gms of ER niacin, I myself had an HDL increase from 41 to 55. However, my HDL total is now 95, after 5 years on that dose. The HDL2 has increased > 300% !! See Dr. Castelli`s anecodtes. He really pioneered some of these observations.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 16:37:55 EST

Baseline characteristics of this "high-risk" group: one-third diabetic, most overweight or obese with excess visceral fat (large waist circumferences). A proper "comparative-effectiveness" trial would have compared the drugs with a third control group of lifestyle change to reduce waist circumference of all subjects to less then half their heights with a low-fat Mediterranean diet, proven to reduce LDL, raise HDL, prevent and reverse Type 2 diabetes and reverse atherosclerosis, as required, if we really are to practice "evidence-based" mediciine.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 15:03:33 EST

No clinically relavnt hepatotoxicity is reported with Slo-Niacin brand, to my knowledge. VA review found 2% LFT increase with Niaspan and 4% in Slo-Ni, not the same study, of course. Two drugs have very close pharmacodynamics. I would love to see full financial discolosure of NLA and report writers with regard to the money from Abbott. If Abbott wants to dissociate itself from Sl0-Ni on the basis of hepatotoxicity they should as well drop promotion of Niaspan on the basis of HATS trial, the only meaningful outcome trial with ER Niacin, which was done with Slo-Niacin and IR Niacin, not Niaspan. Somebody is trying to sit on two chairs, perhaps?

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 14:34:09 EST

vs. immediate and extended release niacin products.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 14:32:48 EST

the problem with this drug is the increased potential for hepatotoxicity in a statin setting- see the NLA safety paper on Niacin. Since MOST of the time niacin will be used WITH a statin for long periods of time, safety is paramount. We only use branded extended release Niaspan for this reason.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 13:37:11 EST

Slo-Niacin from Upsher-Smith was used by Greg Brown in HATS. You all know the outcomes, I hope...No clinically significant adverse events there, some ALT elevation, as expected. Price $13 for 150 of 500 mg pills (Costco). Somewhat higher in Walmart. Great alternatives for pts with unbarable copays. It is also splittable and can be started at 250 mg, which is great for patients who had flusing with 500 Niaspan. Just be sure it is Slo-Niacin brand.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 13:08:19 EST

It's amazing that in 2009 we are debating the benefits of nictonic acid. The data has been out since the late 1960's!

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 13:07:15 EST

Dr. Nissen says: "Now, here it is," he said. "Niacin is a 50-year-old drug, and you can buy it over the counter at your local pharmacy. When you have an inexpensive therapy like this�there are issues about being able to tolerate high-dose niacin, but if you get patients to tolerate it�niacin looks to be a better strategy."However this test was not done with "over the counter" Niacin but a prescription extended release drug - - which is, for example, listed as a "Tier 2" drug on United Health Care's Medicare Formulary and has, therefore, a $25.00 or $42.00 co-payment. Neither as inexpensive or "over the counter as Dr. Nissen implies.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 12:38:39 EST

I tink so this study is short and small for make dessision. No doubt about effects in HDL C, but what about end points. It�s nessesary a bigger and larger study whit end points...

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 11:58:43 EST

When would anybody notice the elephant? Ultimate surrogate marker here is LDL. It is clear that it works only in the setting of stain therapy where it is better be viewed as a gage of statin potency. LDL reduction with ezetimibe did not live to expectations (of outcomes in ENHANCE, SEAS, SEARCH and now ARBITER-6. Oh, don't forget FIELD, which was for practical purposes designed as an LDL trial too.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 11:52:38 EST

This trial is a saurgoate endpoint trial using CIMT. CIMT measurementa involve both the intima and media, and risk factors that affect the intima differ quantitatively from those that affect the intima. Hence I would not get too upset about the trial results. Remember that rosuvastatin had little effect on CIMT in Meteor, slowing CIMT progression but not inducing regression, whereas in Asteroid, rousvastatin gave the greatest regresson of coronary plaque ever seen on IVUS. Hence, I am not a big fan of CIMT trials and I agree with Dr Pokrywka. I am a BIG FAN of lowering LDL and simultaneously raising HDL, the benefits of which were shown over 25 yers ago. Such therapy does wonderful things to lipid ratios, of which I am also a BIG FAN!!!! So good for Arbiter-6!!!

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 11:22:14 EST

atherosclerosis should be treated for lifelong. Can patients tolerate the lifelong Niacin ? or Ezitamibe? or we need sequential regimen, first by Niacin for 12 months then others?

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 11:21:17 EST

1% vs 5% ? If you are drawing conclusions about clinical events from a small imaging trial with a barely statistically significant difference (on about 10 events !) , you are welcome to it. Not me !

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 10:36:50 EST

AIM-HIGH will be a bit of a shock as well,...

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 09:08:38 EST

It's a SMALL, short duration, surrogate endpoint study, stopped prematurely under questionable circumstances (see Blumenthal editorial). No one knows what a "difference of 0.017 mm over 14 months" in CIMT MEANS in terms of clinical events reduction. The study supports the continued use of niacin, an excellent med., especially in secondary prevention settings. Doesn't tell us much about ezetimibe though, due to the absence of a placebo group for comparison. Ezetimibe is critical to assist in the reduction of LDL-particles, still the best proven method to reduce clinical events, and its' benefits extend to reduction of toxic atherogenic noncholesterol sterols, as well as combating the reflex hyper-absorption of sterols in the statin-treated patient. There is no doubt that manipulation of HDL functionality seems promising, but LDL particle reduction remains the cornerstone of CHD event reduction. We need CLINICAL EVENT TRIALS people ! BOTH these meds will remain a critical part of my lipoprotein reduction regimen. addendum to above : statins also increase Lp(a) and "drop in HDL2" with ezetimibe means nothing to me, in the face of ezetimibe's increased formation of RCT-ready unlipidated HDL in the gut !

Experienced operators can switch easily and rapidly to radial-access PCI: RAPTOR

Mon, 16 Nov 2009 09:01:07 EST

I ask every radial patient who has had prior femoral access which they prefer, and it is no-contest in favor of radial access. Experienced invasive non-interventionalists can learn the technique as well.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 08:52:54 EST

Great evidence that niacin which raises apoA (HDL-C) and lowers TG and lowers ApoB (has other effects) is better than just lowering ApoB. I think lipidologists have been telling us that for years. I am not sure that the -0.014 mm change, at 14 months, in CIMT is super impressive, but these patients may have already been delipidated, by the previous statin use, to a considerable degree. However, there is no reason to believe additional lowering of ApoB with ezetimibe has any negative effects, at all. This trial showed no negative ezetimibe effects at all. In fact, ezetimibe stopped progression (didn't a potent statin stop progression in the METEOR trial; and the event rate, for this high risk group was relatively low. Two additional arms would have been appropriate and revealing: 1. A control arm-- of placebo ezetimibe and placebo niacin, on top of statin; the only way to assess ezetimibe effects alone. 2. A fourth arm-- of ezetimibe plus niacin on top of statin. This triple therapy, i.e. what is done in practice with high risk patients, would have likely been even more impressive than statin and niacin, with more impressive regression and fewer events.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Mon, 16 Nov 2009 07:56:48 EST

I expected this,.. not surprised,.. As Dr. Ziajka and others had indicated, Zetia may have undesirable effects: drop in HDL2, increase in Lp(a),.... No surprises with niacin however,.. AIM-HIGH will no doubt put all of this to rest. Once the results already seen from many other small studies [RE: FATS, HATS, etc] are seen in a large trial like AIM-HIGH,... the drop in hard events will leave everyone debating why. Niacin has far too many beneficial effects to pin-point one. Renoprotection [albuminuria], adiponectin, ADMA, BP effects, etc.

Canadian confusion: Primary-care docs lack knowledge of CVD risk factors, prevention

Mon, 16 Nov 2009 01:20:42 EST

hsCRP is a supporting bio marker for IHD not aabsolutly major risk factor of CAD/IHD.IF HS- CRP LEVEL IS HIGH IT DOES NOT MEAN FOR IHD , IT MAY BE ASSOCIATED WITH OTHER INFLAMATORY CONDITIONS. OUR AIM SHOULD SHOULD BE DO BRING THE LOWER LEVEL OF LDL <70 mg/dl. THAT IS VERY SAFE.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Sun, 15 Nov 2009 23:51:58 EST

It's very interesting to see any critical commentary on this but healthy. So, the study was stopped I presume because MACE was 1% in the Niaspan add on group vs. 5% in the Zetia add on group. p 0.04 Adherance was 95% in zetia and 88% in Niaspan with 75% on 2000 mg dose. CIMT Mean baseline thickness (mm) 0.8957�0.1484 ZET 0.9001�0.1558 NIA Change from baseline to 8 mo Mean thickness (mm) 0.0014�0.0020 ZET vs. −0.0102�0.0030 0.001 NIA Change from baseline to 14 mo Mean thickness (mm) −0.0007�0.0035 ZET −0.0142�0.0041 NIA HDL went up nearly 20% where it dropped nearly 5% with ZET. LDL dropped ~ 10% with NIA and ~ 18% with ZET. LDL achieved 66 mg/dl with ZET. Zetia may be a great LDL product if needed to reach goal. I'm just really glad we started my Dad on Niaspan and this study confirms the benefits (at least to me). mc

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Sun, 15 Nov 2009 23:44:59 EST

Too bad they chose CIMT as the surrogate endpoint rather than serial EBT CAC, a more robust endpoint and powerful predictor of events vs non-events. That said, this is good DATA and we need to include niacin as a routine partner with cholesterol lowering therapy. I fail to understand Dr. Kaul�s reluctance to add this therapy considering the failure that is current coronary prevention.

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Sun, 15 Nov 2009 23:30:12 EST

The torch has been passed,...

Canadian confusion: Primary-care docs lack knowledge of CVD risk factors, prevention

Sun, 15 Nov 2009 23:22:29 EST

NCEP-III suggests treatment of LDL when it exceeds 160 in low risk subjects. Intermediate risk subjects should be treated when LDL exceeds 130. (Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497) I think most PCPs understand that this is what the guidelines suggest. Here is the problem: 1. Subjects with 0-1 risk factor are almost always Framingham �low risk� 2. Approximately 60% of heart attacks occur in subjects with 0-1 risk factors therefore �low risk�. (Khot, et al. JAMA. 2003) 3. 77% of heart attacks occur in subjects with LDL The inescapable conclusion is that using conventional risk factors will mischaracterize the risk in the majority of subjects who will have heart attacks. Add BMI to the equation and we have almost no incremental risk prediction. ( Lancet. 2006;368:624-625, 666-678.) Add HS-CRP in a primary prevention setting and we have almost no incremental risk prediction. (�MESA� Heart Study N Engl J Med 2008;358:1336-45) Bottom line: current guidelines are almost useless and have no credibility as screening tests for coronary risk. Add BMI and HS-CRP and most subjects at risk for heart attacks will still not be identified until after they have their MI. PCPs don�t use the current guidelines because they know better. It is time to throw out the bums who continue to espouse the current guidelines. It is long overdue that we use the current DATA on atherosclerosis imaging to create new guidelines which will lead to real improvement in coronary prevention.

Canadian confusion: Primary-care docs lack knowledge of CVD risk factors, prevention

Sun, 15 Nov 2009 22:27:33 EST

Smoking hot commentary. I like it.

Canadian confusion: Primary-care docs lack knowledge of CVD risk factors, prevention

Sun, 15 Nov 2009 22:26:45 EST

i doubt that there is any hint of a condescending theme here-- this article states the obvious as in so many other situations there is a strong prevailing atmosphere of clinican/physician inertia be it because of a disbelief in the guidelines or simply a lack of knowledge- i-believe it is a mixture of each some are led to feel that this is condescending-but i strongly disagree there is no intention to be critical of the medical professional when a clear signal arrives out of this question based survey- this has been observed many times over in clinical management situations-- with the advent of the new Reynolds risk equation for example and hopefully further education of PCPs through cmes, round table discussions, clinical rounds evening sessions with the pcps involving case-based presentations ete etc the message hopefully will come through and we will in the future be able to eliminate any inertia unfortunately not enough of what we have learned from our clinical experience with lipid lowering intervention is currently applied to the practice of medicine- this applies not only to lower and lower lipid targets but many fields of medicine too many exampples to list ie hypertension inertia glycemic inertia lifestyle inertia and on and on. in the case of lipids very often the initiation of treatment is decided too late and is conducted in a non-intensive manner,so that no significant impact on the natural history of atherosclerosis is accomplished

ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe

Sun, 15 Nov 2009 22:13:13 EST

Robust benefit with 2gm Niaspan x just 14 months of Rx. Perhaps we will see AIM-HIGH outcomes early if the enrollment was successful. I look forward to seeing what the baseline IMT's were in Arbiter 6.

Canadian confusion: Primary-care docs lack knowledge of CVD risk factors, prevention

Sun, 15 Nov 2009 21:04:25 EST

the process of reducing CVD risk entails three components- first is risk factor measurement- the second is risk interpretation and finally the third is intervention to promote risk reduction--- much of the work in this field involves the first of these steps- less is known of the second and third steps

CHAMPION: Negative trials but some positive angles for cangrelor?

Sun, 15 Nov 2009 21:00:43 EST

Gracias por mantenernos informados. Interesante el enfoque del tema.

Experienced operators can switch easily and rapidly to radial-access PCI: RAPTOR

Sun, 15 Nov 2009 19:55:17 EST

Being a recent convert to the radial approach, there were two photo-ops that I suppose we missed capturing which would have painted the merits of the transradial method. One was an CT Surg OR tech who came with typical chest pain (at least that's what he described) and underwent transradial angiography. No critical lesions. The staff shifted him out and after writing my note, I stepped out to find him sitting at the nursing desk sipping coffee (with his left hand) with one of our techs, a buddy of his, like nothing had happened! A second incident a few days thereafter - put in 4 stents in an SVG to RCA using the right radial approach. Relatively longer procedure due to number of stents and then sequential post dilatations so towards the end he really really had to pee. The lab staff stood the bloke up after the case and walked him to the bathroom to take a leak! That said, there definitely IS a learning curve and radiation times are a bit longer (particularly during the diagnostic bit) for newer operators like myself, but I'd say only marginally longer. As Mehrdad said, in expert hands, there's virtually no difference. Fahim H. Jafary Aga Khan University Hospital Karachi, Pakistan

Experienced operators can switch easily and rapidly to radial-access PCI: RAPTOR

Sun, 15 Nov 2009 19:53:49 EST

I have adopted a radial approach for about 80% of my diagnostic procedures and about half of my interventions. The Terumo radial catheters allow for single catheter technique and I dare say that my procedural time for a diagnostic cath is shorted transradially.

Experienced operators can switch easily and rapidly to radial-access PCI: RAPTOR

Sun, 15 Nov 2009 17:44:16 EST

Is my understanding correct that the operators were radial-naive? It would make sense then that procedure time would be longer, as would radiation exposure. It would be nice to see the trend over time. As anything, practice makes perfect.

Latest European and US STEMI guidelines compared and contrasted

Sun, 15 Nov 2009 17:44:11 EST

Enoxaparin use is indicated only subcutaneosly (see data sheet) in Italy. This yelds some trouble when you have to treat a STEMI patient thus encouraging routine use of the sole UFH in this setting. Furthermore, guidelines tell that first subcutaneous enoxaparin dose should be given 15 minutes after the iv bolus and next doses should be given every 12 hours since then. Instead, many physicians don't seem to strictly follow that schedule since they give enoxaparin at fixed times (i.e. 8 am and 8 pm) to make nurses' work easier regardless of first administration. What is your opinion regarding the above issues? Thanks for your reply

Canadian confusion: Primary-care docs lack knowledge of CVD risk factors, prevention

Sun, 15 Nov 2009 13:42:32 EST

I really resent condescending tone of this article with regard to PCPs. NCEP III fails to identify 75% of patients under 55 yo who had their first MI (Akosah A. 8th World Congress on Heart Failure. JACC 2003, Vol. 41, No. 9) LDL is clearly inadequate marker of both risk and treatment effect. While getting LDL to goal statins prevent less than a half of recurrent events. And if anybody thinks LDL is solid, - please examine SEAS, SEARCH with ezetimibe and see if LDL lowering resulted in anything close to predicted event reduction on the basis of LDL lowering. Tim Russert dies from ruptured LAD plaque with LDL 67, while receiving �within the guidelines� care and being in �good health�. Hs-CRP is just a marker, and not even a good enough one to be singled out for promotion to PCP. Commercial interests are clearly behind it now. Classic example of �collaboration� of academia and industry. Brilliantly conceived and executed business plan worthy studying in any MBA program. So why is anybody surprised that PCPs are �confused�? And looking for anything that gives them extra tools to take care of their patients while academia, industry and government tries to push their own agenda, which has, let us be frank, little to do with individual patients interests, or individual PCP interests for that matter. At least two laboratory companies in the US now offer reasonably prized state of the art comprehensive serologic and genetic CV risk factor/ treatment effect monitoring panels, with over 40 �traditional� and �advanced� risk factors between them. This gives power back to PCPs, to test and to do what they feel is right for a particular patient, to practice the art of medicine. Guidelines, tests, pharmaceuticals are just the tools PCP may chose to use or not to use in the individual cases. Doctors and people in general, in free societies usually do not follow the orders that make no sense to them. This study points not to the �confused� state of the doctors, but to the shortcomings of the institutions and the �products� they produce.

Dual Antiplatelet Therapy: Dueling Options in Real-World Practice

Sun, 15 Nov 2009 10:51:31 EST

How will add ticagrelor (PLATO) to the conventional strategy for antiplatelet therapy in ACS ?. Is there a chace for trifusal to be added to the antiplatelet strategy ?

DES fractures occur more often than thought

Sun, 15 Nov 2009 04:43:43 EST

in Nakazawa study, does the nature of the stent's metal influence the frequency of struts fracture ?

Lifestyle-based diabetes prevention seen to endure for at least a decade

Sat, 14 Nov 2009 22:29:21 EST

Any data on the long-term F/U of the DPP- troglitazone group, since that group did better than lifestyle. Any long-term F/U planned for the rosiglitazone (DREAM) and pioglitazone (ACT-NOW) studies, since they were also extremely impressive as diabetes prevention strategies, but have not yet been placed in consensus statments for diabetes prevention. Seems a combination of lifestyle-metformin-TZD would be block buster for diabetes prevention!?

US Senator questions FDA for letting Edwards "off the hook" over Myxo device

Sat, 14 Nov 2009 14:48:08 EST

Still waiting to hear from Senator Grassley and the FDA

Interventional cardiologist sues hospital under Whistleblower's Act

Sat, 14 Nov 2009 14:46:32 EST

What is concerning is that every where you turn there is always a different angle to each story. What is important is the fundamental issue- large institution politics- Sound familiar?

Not all metabolic syndrome is created equal: Framingham Offspring analysis

Sat, 14 Nov 2009 12:01:33 EST

Amen, but you could do equally well using ratios. I invite you to visit www.healtheurope.org and look under the article on atherothrombotic disease (ATD) to see how ratios work Bill

No benefit in lowering BP below "standard" 140/90 mm Hg

Fri, 13 Nov 2009 21:08:17 EST

Much better blood pressure control clearly has resulted in decreased cardiovascular morbidity and mortality, therefore increased life expectancy. Is this cardiovascular protection with "normal" range blood pressure in the elderly decreasing brain perfusion around the clock and particularly during the night and leading to increase incidence of cognitive disease?. I am not aware of studies looking at long term cognitive function on patients with "ideal blood pressure", e.g. < 110/70 or even lower. There is likely a limit on the concept of "lower is better".

Interventional cardiologist Donald Baim dies

Fri, 13 Nov 2009 19:04:59 EST

I didn't know Don like many of those who've commented above, though I'd met and spoken to him at many meetings over the years. Don was a force in interventional cardiology and his contributions and teachings affected me and all of us who have watched this field evolve over the last 3 decades. We all know, in our profession, how thin our hold on life can be. I mourn Don's passing and my sympathies go out to his family and friends. His contributions will be remembered.

New Canadian lipid guidelines will recommend CRP testing for certain patients

Fri, 13 Nov 2009 18:55:29 EST

CardioRisk provides a nice service,.. not practical in our "rust-belt" geography. TPA as well as evaluating changes in echolucency vs. echogenicity seems to be a good predictor of how well treatment is working, re: plaque stabilization, whether prone to rupture, etc. I did a brief search & a large number of studies incl. Tromso seem to reinforce the clinical utility of that. HDL seems to greatly influence echolucency changes to echogenicity.

Interventional cardiologist Donald Baim dies

Fri, 13 Nov 2009 17:56:22 EST

My heartfelt condolences to Baim family in this time of extreme difficulty.

Reducing CV Risk: What Add-On Therapies Do You Use?

Fri, 13 Nov 2009 16:36:29 EST

Daniel, We do TPA same day and see patients that day or that week quite often. I think it takes about 30 minutes for our techs to do the test. One of them actually invented it (in 1990). Reproducibility is not a problem. We have demonstrated kappas in the 0.80-0.90 range. This is not the same as doing IMT. There are about 5 major differences. As you know, I practice in Canada where most imaging is free. Patients do not pay out of pocket for this test, or for any test that I order. The only time I have had a patient pay is when they wanted a TEE done rapidly, in which case I sent them to the US and they had it done in a couple weeks rather than a couple months. Unfortunately, this is a chronic problem with the Canadian medical system (while everyone is insured, our waiting lists are longer, and the general quality of care is lower than the best care available in the U.S.). I am in a blended academic/fee-for-service environment, but I make no money from ordering this test. The picture that develops from a total plaque area measurement (2 x 2 picture of the carotid arteries, with plaque drawn in) is frankly a great motivator to my patients. I would estimate that smoking cessation rates are around 50%, and adherence to statins around 80% (though as you know most physicians overestimate their patients actual compliance which is often lower in reality). The test is an immediate graphic stratifier of cardiovascular risk and allows me to both personalize starting therapy and titrate it over time to achieve plaque regression. Previously, this has only been done in the setting of clinical trials like CAMELOT and REVERSAL. Nowadays, in the real-time, we can do this in clinical practice. It is also nice to see when carotid stenosis is dropping by grades over short periods of time.

Reducing CV Risk: What Add-On Therapies Do You Use?

Fri, 13 Nov 2009 15:54:54 EST

Dan, I am not making a declaration of war on CIMT or CAC or TPA. What I was saying was that while the SANDS trial is interesting, it is not clear how it effects the general population we treat. Obviously you would think/assume that an increase in CIMT versus a reversal of CIMT would confer greater risk, but as far as I know it is a good predictor of stroke risk, less so of CAD risk and frought with reproducibility issues from site to site (near vs far wall, etc). In reference to lipoproteins, they are not the be all end all of tests. But, it is cheap, easily obtained and reliable. Unfortunately, getting most people to take the time to do a CIMT or TPA (at least in New Jersey) is next to impossible. Difficult enough to get a carotid ultrasound approved by insurance imaging precert boards. In reference to obtaining CIMT or TPA, out of curiosity, how long is it taking your techs to do the carotid studies and obtain this information as well? What is the price out of pocket that patients are paying in your area? Thanks. Daniel

ASTRAL finds no benefit of revascularization over medical therapy alone for renal-artery stenosis

Fri, 13 Nov 2009 14:44:00 EST

I enjoyed your pointed remarks. In general, the medical community is highly divided between those who support ezetimibe and those who oppose it. It has been our friend on many occasions, getting LDL's down by another 15-20% over statin monotherapy. My patients often do not tolerate statins or niacin (even niaspan). Ezetimibe prevented atherosclerotic events in SEAS - a decrease in revascularization (CABG) for occluded coronary arteries. This was an underpowered trial which combined simva and ezetimibe against placebo and showed a 60%+ LDL reduction. Still it was underpowered. Many of our patients do not tolerate highest doses of statins and we find that ezetimibe is complementary in blocking the ramped up absorption of lipid caused by blocking synthesis with statins. I am not waiting for IMPROVE-IT or SHARP but I will gladly drop this drug if those trials are well powered and show no benefit, and are otherwise unconfounded. Patients with RAS are super high risk with often multiorgan atherosclerosis and we try to achieve as low an LDL as humanly and tolerably possible, something hard to do without our "add-ons". I would appreciate others perspectives as well as yours. I've sent you those articles you requested. I also have a lengthy list on RAAS interruption in RAS.

ASTRAL finds no benefit of revascularization over medical therapy alone for renal-artery stenosis

Fri, 13 Nov 2009 14:11:58 EST

Thank you, Dr. Hackam. I would love to have the pdfs to drvasin@renalremission.com No need to be sorry. We are not going to make it into a battle of sharp- vs. dull-end egg-beaters from Swift's novel. As long as you can get to the egg/regression its all noble. Although you never know if the regression you see is due to, independent or despite of ezetimibe:) This is one case where I would wait for positive clinical trial results before using it.

FDA investigating external-defib energy levels

Fri, 13 Nov 2009 13:57:52 EST

This doesn't suprise me. I remember well when our hospital suddenly exchanged all of our defribrillators to 200J biphasic models without discussion with all the physicians. With patients sometimes as large as 400 kg, I was sure trouble difibrillating some of them would follow. There just seemed to be inadequate data to justify the change.

Reducing CV Risk: What Add-On Therapies Do You Use?

Fri, 13 Nov 2009 13:16:29 EST

Do you honesty believe that the risk of a patient whose plaque area goes from 1.5 cm2 to 3.0 cm2 (a 100 % increase) is the same as a patient whose plaque area goes from 1.5 cm2 to 0.75 cm2 (a 50% decrease)? Actually we've published that plaque progression predicts a double of vascular risk, so I'm not sure why we are waiting for any trials. I am hard pressed to understand why you are still relying on surrogates like lipoproteins rather than hard disease based biological (imaging of the complications of vascular disease on the arterial wall itself). One can have a terrible apolipoprotein profile and still be protected from atherosclerosis because of other, unknown genetic factors (eg chromosome 9p21). You are looking too far upstream from the disease!

ASTRAL finds no benefit of revascularization over medical therapy alone for renal-artery stenosis

Fri, 13 Nov 2009 13:10:23 EST

1) Regression of atherosclerotic renal artery stenosis with aggressive lipid lowering therapy. Khong TK, Missouris CG, Belli AM, MacGregor GA. J Hum Hypertens. 2001 Jun;15(6):431-3. 2) Regression of atherosclerotic stenosing lesions of the renal arteries and spontaneous cure of systemic hypertension through control of hyperlipidemia.Basta LL, Williams C, Kioschos JM, Spector AA. Am J Med. 1976 Sep;61(3):420-3. I can send you the full PDFs if you'd like, Michael. I have them on file.

ASTRAL finds no benefit of revascularization over medical therapy alone for renal-artery stenosis

Fri, 13 Nov 2009 13:03:15 EST

There are actually 2 case reports published of profound regression of RAS and relief of hypertension with lipid lowering therapy. And there are 4 cohort studies and 3 animal studies all in RAS suggesting that statins improve survival and outcomes in this setting. I see regression of stenosis all the time with high dose statins bundled with ezetimibe (sorry Dmitri).

Walking speed predicts CV mortality in older people

Fri, 13 Nov 2009 12:40:00 EST

No doubt in our minds, walking either regular or brisk is considered an excellent tool to maintain fitness, good health and muscle tone. So, instead of swallowing pills, it is recommended that patients as well as all healthy men and women pratice this simple walking exercise on daily basis mostly to secure safe longevity and continuous good health during old age.

Walking speed predicts CV mortality in older people

Fri, 13 Nov 2009 11:43:23 EST

So, I don't have to walk faster than Death, I just have to walk faster than you in the lowest tertile.

Interventional cardiologist Donald Baim dies

Fri, 13 Nov 2009 11:33:34 EST

While this generation has it share of great leaders in Interventional Cardiology, Don Baim stood alone as a visionary, interventionalist, and physician in the lab. To those of us who had the privilege of training with Don, we were exposed to an approach that was scientific and yet artful. Don believed that nothing done in the lab was too trivial and everything had a rational approach. Thus resulted in a predictability that left little to chance and forced the operator to justify everything done including functions so mundane as exchanging a catheter. Don had little tolerance for those who cut corners or who didn't understnd the "why" of what they were doing. You had to have thick skin to work with Don, but even when he was criticizing you, you always felt you learned. Don's love of science made him the first truly academic Interventional Cardiologist. He will be missed but his legacy lives on in those who embraced his unique approach to our profession.

ASTRAL finds no benefit of revascularization over medical therapy alone for renal-artery stenosis

Fri, 13 Nov 2009 10:38:21 EST

Side effects of lipid lowering and antihypertensive therapy are mild, predictable and reversible without lasting disability. Interventional complications are unpredictable catastrophic and lasting, sometimes quiet permanent (death). Inch long stent is not a cure for 2,000 miles of arteries affected by atherosclerosis. We had lost at least a handful of patients locally following complications of interventions, done for unclear clinical indications, mostly octo and nanogenarians. I am sure trials would not include these type of patients. But at least our local interventionists are only too eager to stent anything stentable, as long as consent is signed. Agree with Dr. Hackam, DRI is extremely useful and better tolerated than ACEI, although have no outcome data (or any data). I would not use ezitimibe, though. So far it failed every surrogate and clinical end point trial. When does the absence of evidence bacomes evidence of absence?

Natural ventricular rate a powerful risk predictor in ICD trial

Fri, 13 Nov 2009 09:47:17 EST

and i guess that would assume that more beta blockade wouldn't cause more RV pacing in that given pt. ie, hopefully their AV node would allow their device to simply atrial pace them after you have slowed them down with bblocker...otherwise, they would need an LV lead, in this presumably low EF / CHF population.

Natural ventricular rate a powerful risk predictor in ICD trial

Fri, 13 Nov 2009 09:42:27 EST

is it as simple as saying these pts may have benefited from more beta blockade, more neurohormonal blockade? i often wonder when i'm checking my device pts and notice a higher than normal vent rate trend (whether sinus or afib), but not current tachy symtpoms, do i need to incr their bblocker (i.e., am i just treating a "number" - their HR - or maybe their elevated rates are a marker for worsened outcomes as this analysis suggests)?

ASTRAL finds no benefit of revascularization over medical therapy alone for renal-artery stenosis

Fri, 13 Nov 2009 08:45:04 EST

The medical therapy-only advocates are happy to prescribe a "panopoly" of medicines and downstate the benfits of mechanical restoration of flow to an organ. But, there are side effects issues associated with multiple max dose antihypertensives and lipid lowering agents too (particularly in octo and nonagenarians). Dmitri, if you have a case of a 95% calcific RAS regressing to 60% on medical therapy, please publish your case report. I frankly don't believe it.

Not all metabolic syndrome is created equal: Framingham Offspring analysis

Fri, 13 Nov 2009 08:33:06 EST

William, I agree. The key is to educate that an LDL-C that appears mildly elevated or "normal" 100-160 mg/dL may in fact be much more atherogenic and the tip of the iceberg if you check apoB or LDL-P routinely. If you check particle number in these patients, many more will require and benefit from lipid lowering therapy than meets the eye. If there apoB or LDL-P is near normal, then it will save inappropriate institution of statins in this population. Daniel

Reducing CV Risk: What Add-On Therapies Do You Use?

Fri, 13 Nov 2009 08:21:14 EST

Michael, Intriguing and certainly contrary to prior studies. Some issues with study: 1. Small sample size/cohort 2. Very specific population studied 3. Short term followup. While I think that CAC or CIMT or TPA predict risk, it is truly hypothesis and not fact, that reducing progression of CIMT predicts lower risk of hard outcomes. One needs to only look at the ENHANCE trial to see how subjective this type of outcome is. Let us remember that ILLUSTRATE showed less progression of CIMT than placebo, yet worse outcomes. I think this is hypothesis generating, but not practice changing data. That is my long winded answer to say that I want to see more before I question what I believe is firm data from MESA and other trials (AMORIS, Copenhagen)looking at the predictive value of LDL-P and apoB in the diabetic or metabolic syndrome patient. Remember that if you incorporate baseline ApoB into risk of patients from the JUPITER trial (40% of which had met syndrome), they were in fact NOT low risk, but moderate by FRS. Daniel

Latest European and US STEMI guidelines compared and contrasted

Fri, 13 Nov 2009 06:45:46 EST

Melissa I share your enthusiasm about primary PCI with or without surgery back-up. When we started we were two interventional cardiologists without formal interventional cardiology training but with ACC/AHA guideline suggested minimum experience in PCI and primary PCI in a community hospital. We looked at our 2 year primary PCI results and presented as a poster in coronary artery disease congres in 2009 in Prague. Primary PCI is the best thing we do for our patients and for healthcare system. Cheap, effective and not very hard to do with or without cardiac surgery back-up!! Here is the abstract. 2 Year Results of A Moderate Volume Primary PTCA Center Aim: Minimum operator volume requirements for elective and primary percutaneous intervention (PCI) for ST elevation myocardial infarction (STEMI) are determined in ACC/AHA guidelines (>75 elective PCIs/year, 11 primary PCIs/year experience). We retrospectively reviewed 2 year results of primary PCIs performed by 2 operators with minimum experience suggested by ACC/AHA guidelines but without formal interventional cardiology training. Methods: 140 STEMI patients admitted for primary PCI within 12 hours of chest pain between years 2007-2008 were retrospectively analysed. Primary PCIs were performed by two operators without formal interventional cardiology education but with minimum experience suggested in guidelines. In-hospital mortality, 1 year mortality, no-reflow development, stent length, stent diameter, TIMI flow at the end of the procedure and length of hospital stay were determined. Results: Avarage patient follow-up was 12.86�6,43 months. Avarage hospital stay was 4.14�2.62 days. In-hospital mortality was 4.3% and 1 year mortality was 7.1% (Tablo 1). Patients� other clinical parameters are given in Table 1. Table 1. Patients� clinical characteristics Parameters Age, year 58,35�11,60 Sex, Male, % 110 (%79.2) Diabetes mellitus, n, % 35 (%25) History of myocardial infarction, n, % 9 (%6.4) Culprit artery LAD, n, % 64 (%45.7) CX, n, % 19 (%13.6) RCA, n, % 52 (%37.1) Saphenous graft, n, % 2 (%1.4) Side branch, n, % 3 (%2.1) No-Reflow, n, % 41 (%29.3) Length of hospital stay, days, % 4.14�2.62 Creatinin, mg/dl 1�0,29 Killip classification 1,18�0,63 IABP use, n, % 7 (%5) Duration of chest pain at presentation, hour 3,74�2,53 TIMI flow before procedure 0,45�0,83 TIMI flow at the end of precudure 2,64�0,67 In-hospital mortality, n, % 6 (%4.3) 1 year mortality, n, % 10 (%7.1) In hospital stent thrombosis, n, % 3 (%2.1) In-hospital reinfarction, n, % 4 (%2.9) In-hospital cerebrovascular accident, n, % 1 (%0.7) Conclusion: Primary PCI is a life saving procedure for STEMI. When there is no formal interventional cardiology training program, primary PCI performed by operators with minimum guideline suggested experience has acceptable mortality, morbidity and length of hospital stay.

DES fractures occur more often than thought

Fri, 13 Nov 2009 05:09:59 EST

In DES I use at least 14 atm deployment pressure and than routine postdilatation with NC balon at 16-20 atm. Does any one think routine postdilatation for obtaining bigger lumens causes unnecessary stent frectures and vessel wall trauma. Shoukd we be more moderate at postdilatation pressures ?

PCI in Left Main Disease: Are We There Yet?

Fri, 13 Nov 2009 00:51:08 EST

PCI in left main stenting is a burning issue in interventional cardiology.I would like to know about the case selection, guide wire selection or any other technological support for better outcome.

DES fractures occur more often than thought

Thu, 12 Nov 2009 21:34:15 EST

What is the approximate fracture rate of BMS's? Any data? Melissa

Latest European and US STEMI guidelines compared and contrasted

Thu, 12 Nov 2009 21:18:51 EST

So glad you lysed this patient. However, I would hope that more PCI centers would open. What if he had just had his gallbladder out two days before? The outcomes for these patients is often tragic. As for routine angiography post STEMI/lytic, I think you have to approach this issue with common sense. If you have a thinned akinetic infarct zone, I usually advocate a thallium viability study, then medicate, then perform an out patient stress if it appears nonviable. If the ventricle is fairly pristine or stunned with normal thickness or only mild reduction in infarct zone thickness, I think you can make a case for intervention. I don't think any one of these cases can be made black or white just by a simple "post lytic" categorization. I'd say you can get in a fair amount of trouble that way. Melissa

The Future of Ambulatory Monitoring: Moving Beyond Rate and Rhythm to Monitor ST-Segment Shifts

Thu, 12 Nov 2009 20:05:54 EST

What a great thing for cardiac patients.This and devices like it can detect those specific events that by getting to the door quicker, can save lives and gather important data for future implementation.

DES fractures occur more often than thought

Thu, 12 Nov 2009 17:50:42 EST

I believe with less severe fracture beyond 1 year there should be no need to extend dual antiplatelet therapy however, patients should be followed for symptom development, because most minor fracture do not result in complications and does not impair healing. In case of severe fracture all patients must get dual antiplatelet therapy for life and if symptomatic surgical revascularization should be recommended.

CMS set to cut Medicare physician fees for cardiovascular imaging

Thu, 12 Nov 2009 17:06:02 EST

Your muffler dude doesn't get sued if you gave you a dud..however,...if your 200$ cath patient gets a cva or even a bad vascular complication...dial 1800malpractice and you are on the hook for millions...interesting system...who are the smartest people, help the most people, who does society value?...from those salaries...you can infer what you will...

CMS set to cut Medicare physician fees for cardiovascular imaging

Thu, 12 Nov 2009 16:59:51 EST

Citigroup paid $390.2 million to 21 people, and Bank of American paid 227.8 million to 13 executives. Thats an average of $18.6 mil for Citigroup and $17.5 mil for Bank of America golf... top golfer made $110 million during the past 12 months and is the best paid sportsman for the eighth straight year. health care administr...Receiving almost $3 million in annual salary and benefits in each of the last two years, Lifespan CEO George Vecchione is the highest-paid health-care executive in New England. and being a cardiologist...not exactly priceless!.. Physician - Cardiology - Non-Invasive 25th%ile Median 75th%ile the United States $217,993 $282,299 $371,059

Life and times of leading cardiologists with Rob Califf. Guest: Bob Harrington

Thu, 12 Nov 2009 16:44:41 EST

I had the pleasure of rounding with Dr. Harrington in the CCU at Duke while completing my pharmacy practice residency many years ago. For a kid who also group in Somerville, MA and attended many of the same local schools as Dr. Harrington, I found this to be a really compelling interview. It is also full of great advice that all individuals can use at some point in their careers.

What's going to be hot at AHA 2009?

Thu, 12 Nov 2009 16:24:51 EST

Thank you guys for keeping us posted. Very Very interesting topics this year. Thanks again.

ASTRAL finds no benefit of revascularization over medical therapy alone for renal-artery stenosis

Thu, 12 Nov 2009 16:07:31 EST

Beta blockers are very useful add-ons to ACE inhibitors, ARBs, or direct renin inhibitors in this setting. In fact you find yourself using the entire panopoly of antihypertensive drugs including CCBs and diuretics too. Maximal statin therapy often with an add-on of ezetimibe or niacin, antiplatelets, glucose-lowering drugs, and vigilant attention to volume, lipids, kidney function and blood pressure.

CMS set to cut Medicare physician fees for cardiovascular imaging

Thu, 12 Nov 2009 15:48:27 EST

I say anything less than 400K is insulting. I just paid 250$ for a muffler replacement on a junker. Yet, that last diagnostic cath reimbursed only about $200. Now in MA and Vermont, docs can't even attend a pharmacuetic dinner or accept a pen, even out of state. Apparently, docs are too stupid and corruptible to be allowed near industry influence. Yet, politicians...... The only way to truly know what a cardiologist or anyone is worth, is to go to pure fee for service just like a plumber. Unfortunately, medicine is being commoditized.

FDA investigating external-defib energy levels

Thu, 12 Nov 2009 15:28:17 EST

Our trial include external defibrillation, in Emergency, ICU in Hospital, aeroambulance, and ambulances, usually using 360 J with excellents results.

Off-pump CABG shows no benefit over on-pump approach: ROOBY study

Thu, 12 Nov 2009 11:58:19 EST

We think that the differences observed in publications regarding this subject is due to the strategy to perform beating surgery in not appropriate patients.Off-pump coronary surgery is not for all patients and even more for all surgeons.It is really an advantage for high risk patients in the hands of trained surgeons.in my experience of more than 4.000 cases my applicability is around 49 %.

ASTRAL finds no benefit of revascularization over medical therapy alone for renal-artery stenosis

Thu, 12 Nov 2009 10:56:36 EST

So far we have one patient who showed unquestionable regression of 95+% RA stenosis to In our experience 80%+ of patients with bilateral/single functional renal artery stenosis have stable or improving renal function and �reasonably� well controlled BP (many are octo and nonagenarians). These patients are placed on aggressive multimodal atherosclerosis regression protocol of 2+ lipid lowering meds, RAAS blockers (with great caution and easing up on diuretics) and other anti-HTN known to affect atherosclerosis (amlodipine, Carvedilol, etc), monitored by serial CIMT with treatment adjustment until regression is achieved. I agree that patients with recurrent/ difficult to control flush pulmonary edema/ malignant HTN should be considered for rescue interventions. And then they should be treated medically, and very aggressively. Which interventionists often times fail to do. Relatively low plasma renin activity (PRA

What's going to be hot at AHA 2009?

Thu, 12 Nov 2009 10:25:35 EST

This preview is a good distillation of what to expect at the meeting. Terrific service. Oye Olukotun, MD

One in four discharged after heart-failure hospitalization are back within a month

Thu, 12 Nov 2009 03:52:20 EST

Many flaws with this analysis not the least of which is that not all readmissions were for heart failure. Sick people get sick. That notwithstanding length of stay for CHF is down 40% since the DRG era began so it's not surprising that readmissions rates are up. It boggles my mind that hospitals and doctors are being blamed for these high readmission rates when patients are being driven from the hospital by insurers (CMS included) at the earliest opportunity. This problem should be addressed by insurers (CMS included) paying for the relatively inexpensive, non-physician, non-hospital related interventions which have been shown to reduce readmission rates. And you don't need to overhaul the health care system to do this.

Life and times of leading cardiologists with Rob Califf. Guest: Bob Harrington

Wed, 11 Nov 2009 23:39:25 EST

another illuminating interview...im hooked.

No benefits of aspirin for primary prevention in diabetics, meta-analysis suggests

Wed, 11 Nov 2009 22:30:35 EST

We performed this exercise while doing the Canadian guidelines and this is why aspirin is grade D in primary prevention. See also this paper (The benefit of aspirin therapy in type 2 diabetes: what is the evidence? Sirois C, Poirier P, Moisan J, Gr�goire JP. Int J Cardiol. 2008 Sep 26;129(2):172-9. Epub 2008 May 20. Review.)

ASTRAL finds no benefit of revascularization over medical therapy alone for renal-artery stenosis

Wed, 11 Nov 2009 21:41:00 EST

In our experience, patients with severe bilateral RAS and renal dysfunction or medically refractory HTH have consistently improved with RA stenting. We have many examples of success with this procedure in our practice for this indication. One patient was brought back from the brink of dialysis dependency and now has a GFR of 40. No amputations so far... Unilateral RAS can usually be managed medically, and "drive by" stenting is clearly not appropriate.

No benefits of aspirin for primary prevention in diabetics, meta-analysis suggests

Wed, 11 Nov 2009 14:22:57 EST

Once again, An inexpensive medicine which has been our friend for so long, is under attack! common sense is better that meta-analysis! keep your DM patients on aspirin unless they are at increased bleeding risk in Jordan,It is unusual to find DM patients who are not suffering from vascular disease. smoking and DM are frequently associated so look at your individual patient

CMS set to cut Medicare physician fees for cardiovascular imaging

Wed, 11 Nov 2009 13:55:17 EST

but for some reason it wouldn't take. Between the OPPS rule going into effect 1/1/10 and this healthcare nonreform that was passed Saturday night, I don't see how ANY practice is going to be able to continue. All you cardiologists and intervention drs work so hard, and have to pay for your equipment, your insurance, your staff salaries and benes, etc.etc. Just where are you to GET all that money????? Yet the queen bee and her hive up there who are all career politicians who make hundreds of thousands of dollars, get their choice of medical insurance, most likely get their care for free at Georgetown or Walter Reed, have use of private jets and go all over the world at our expense, have the unmitigated gall to say that doctors have fraudunlent practices and need to pay for their overusage!!!! Incredible!!!! Take some of that nonstimulous package money they printed up and use it to give those people their healthcare and leave the decisions as to who needs or doesn't need a test or treatment to the ones who are trained to do that! (this wasn't what I said on the blog--it was milder.) Becky

No benefits of aspirin for primary prevention in diabetics, meta-analysis suggests

Wed, 11 Nov 2009 13:50:56 EST

p of 0.05 should not be such a magical number. clearly if the sample sizes were increased the 95% CI's would narrow. i would suggest not being such a frequentist, rather take more of a bayesian perspective. our pretest probability of asa at some dose working in DM is quite high. our posttest with these data remains high.

Reducing CV Risk: What Add-On Therapies Do You Use?

Wed, 11 Nov 2009 12:53:23 EST

It was interesting to see in the recent SANDS trial in JCL that LDLc and NHDLc predicted vascular changes were ApoB and LDLp did not seperate. Any thoughts on this. mc

One in four discharged after heart-failure hospitalization are back within a month

Wed, 11 Nov 2009 12:35:26 EST

Once you have pump failure life is pretty complicated for all parties. I would suspect readmission rates are complex - (1) complicated disease state (2) medication drug drug interactions and tolerability (3) lack of using correct medications (4) patient lack of adherence (5) other. I would bet that if a comprehensive cardiac rehab program and pharmacy program were implemented and supported these numbers would change dramatically. I liked this comment "Rather than rewarding better outcomes, current CMS hospital and physician payment policy rewards greater volume" Isn't this the way 'mis'managed care has operated for years? I'm not rewarded or 'bonused' or acknowledged for preventing events. And I'm poorly paid (but love my work) as are many of us for taking care of such events. The current system needs to focus on early intervention/prevention, better risk assessments and better support to clinician, hospital and patient for continuity care.

No benefits of aspirin for primary prevention in diabetics, meta-analysis suggests

Wed, 11 Nov 2009 12:26:07 EST

Wayne and Dmitri, agreed. The trends were all in the right directions except of course bleeding. JPAD and POPADAD both recent prospective studies in DM2 pops also challenged conventional use of ASA in all.

Interventional cardiologist Donald Baim dies

Wed, 11 Nov 2009 11:05:00 EST

Don's death was shocking and unexpected, and the loss to Cardiology and to me personally is beyond words. It is ironic that Don might have been the only one who could adequately describe the impact of his death, since he was a master of immediately understanding and explaining the solution to difficult problems. I hope readers will bear with me for a few brief comments...Don had many unique talents, and the one that was immediately striking was his remarkable intellect. He had the capacity to distill the most difficult problems into remarkably simple solutions, in ways that 'simple folk' like me could easily understand. Training as a fellow with Don was an almost artistic experience, watching and learning from the master as he created new and beautiful blood vessels. I learned quickly that Don did not like idle chat during procedures, but once the interventions were over I reviewed the angiograms with him like he was a Renaissance artist, explaining the nuances of angiographic projections, equipment selection, avoiding unanticipated problems, and getting out of trouble (which was unusual, since he rarely got into trouble). My own fellows are experts in the 'Baim-isms', like he was the oracle of interventional cardiology. Everyone has heard the saying, "Those who can, do, and those who can't, teach." As applied to don, there was never a more false statement. Don was an incredible teacher, and he was the most skilled interventional cardiologist I have ever worked with. He had a quick wit, an incredibly dry sense of humor, and a fierce commitment to intellectual and scientific integrity. When don moved to Boston Scientific, I told him 2 things: First, I couldn't imagine that BSC fully appreciated how lucky they were to have him as Chief Scientific Office, and second, that I felt a tremendous loss for future interventional cardiology fellows who would not be able to share the "Baim experience", as I had. On the bright side, Don's path has intersected with thousands of doctors, many of whom are leaders in our field. Directly and indirectly, Don's hands have touched the lives of hundreds of thousands of people, and in death, he leaves a tremendous legacy of accomplishment. I miss you, don.

One in four discharged after heart-failure hospitalization are back within a month

Wed, 11 Nov 2009 10:43:18 EST

Another contributor to the high rate of return could be the consistent approach of the system's standardized approach of giving the same drug cocktail to all heart patients, versus treating them individually. The percentages of patient reactions to Beta blockers and other drugs is also consistently high. Perhaps we should be looking at using standardized treatments with drug cocktails.

No benefits of aspirin for primary prevention in diabetics, meta-analysis suggests

Wed, 11 Nov 2009 10:31:28 EST

If you look at the data ASA has similar magnitude of effectiveness in prevention of CV events as other interventions we routinely use (10-20% event reduction). Yet, because p value did not reach 0.05, just 0.06, the conclusion was made that ASA is of �no benefit�. It is a spin showing pre-conceived bias of the authors. From the same data one may as well conclude that �authors were unable to find/ include enough trials to show statistically significant benefits of ASA in DM patients with no CV disease�. If authors would include just one more additional trial with similar trends and p would reaches Equally rational conclusion from this meta-analysis would be that �there is no increase in �any bleeding� in diabetics treated with Aspirin�. It did not make its way to headlines, however� Manipulation of existing data to achieve publicity became one of the major activities of academic institutions, with subsequent calls for more (and larger and more expensive)studies of the problem. Yet, recent megatrials added more confusion than clarity to the questions they were suppose to answer (ONTARGET, TRANSCEND, PROFESS, I-PRESERVE, etc.) Individualization of treatment recommendations on the basis of patients individual risk profile, may be more fruitful, for individual patient that is, than performing yet another trial to clarify previous six trials. LPA genotype 4399 determination may help to identify higher risk patients who are more likely to benefit, and less likely to be harmed, by treatment with Aspirin.

Walking speed predicts CV mortality in older people

Wed, 11 Nov 2009 09:52:35 EST

In my university we have in this moment a group with one investigation, it�s about pedometer, for this reason I think that this information is so good for us.

No benefits of aspirin for primary prevention in diabetics, meta-analysis suggests

Wed, 11 Nov 2009 08:39:01 EST

So, if diabetes is a CHD equivalent why no benefit from aspirin? Until I see this as a conclusion from a prospective randomized controlled clinical trial I will continue with low dose aspirin in diabetics. So much for metaanalyses!

Walking speed predicts CV mortality in older people

Wed, 11 Nov 2009 07:49:45 EST

This is a no brainer. Faster walking speeds would indicate higher fitness levels which we all know has an inverse relationship with CVD. This message is more important for middle-aged---increase your fitness level!!

Overcoming Disparities in ICD Therapy

Wed, 11 Nov 2009 02:46:18 EST

It's useful for me

Latest European and US STEMI guidelines compared and contrasted

Tue, 10 Nov 2009 21:54:33 EST

I work at a public hospital in Arequipa, Peru. We don't have PCI in site. So a year ago , on my afternoon turn, a stemi patient came to the ED. he was treated with TPa, and four hours later i was flying with the patient in stable condition, to a PCI center for a routine angiography, and a subsequent stenting. At that time the other cardiologist refuse this indication...but the time gave me this feeling...now i know i was right and feel good.

New Data and the Clinical Implications on the Use of High Loading and Maintenance Doses of Clopido

Tue, 10 Nov 2009 21:32:08 EST

Based on the information in this article I see uncertain benefit associated with the increased dosing of clopidogrel. Without statistical differences in the primary endopoint I question the wisdom of increasing the dose. Many patients are already resistant to the cost of clopidogrel and the insurance industry is hovering about to be sure our healthcare costs are kept to a minimum. OASIS demonstrates a strong argument for prasugrel, where the benefit is clear without the cost or confusion of doubled doses.

The Era of Triple Antiplatelet Therapy

Tue, 10 Nov 2009 12:48:13 EST

One of the recommendation to start 2B3A is elevated trop as it will be high risk case????,which mean that all NSTEMI pts should receive 2B3A ????

Imaging study shows plaque regression with niacin vs placebo

Tue, 10 Nov 2009 10:30:42 EST

I use as routin statin+ezeptimibe in the CVD patients, and niacin when necessary to decrease homocistein level.

CORONA analysis reopens door for statins in heart failure

Tue, 10 Nov 2009 10:23:06 EST

I agree with CORONA with clinical benefit decreaser NT-ProBNP, better HF CVD.

US updates advice on perioperative beta-blocker use in noncardiac surgery

Tue, 10 Nov 2009 10:12:15 EST

We usually have used Beta-blocker in patients perioperative in both type of surgery, with excellent results.

Better survival in hospitalized flu patients on statins

Tue, 10 Nov 2009 10:03:18 EST

The results of patients using statins pre hospital is really better.

Off-pump CABG shows no benefit over on-pump approach: ROOBY study

Tue, 10 Nov 2009 09:59:34 EST

In trials here Brazil has demonstrated The better results off pump CABG.

Latest European and US STEMI guidelines compared and contrasted

Tue, 10 Nov 2009 02:18:23 EST

recently i gave a lecture strongly advocating routine coronary angiography after lytic therapy in STEMI. after the lecture there was lot of discussion about American guidelines says no about routine angiography after STEMI . When i said European guidelines say so they say which guidelines to believe and the discussion went on quite well. Indian physicians believe only American guidelines. But I strongly feel and recommend routine angiography after thrombolysis within 3 days as reinfarcts are common in first three days

CAC scoring plus SPECT provide long and short view of cardiac risk

Tue, 10 Nov 2009 01:01:19 EST

What percentage of subjects undergoing nuclear stress tests have >15% of their myocardium ischemic? Based upon prior studies, approximately 2%. Is this a good return on investment to stratify risk for 2% of subjects tested? Coronary artery calcium accurately stratifies risk across the continuum of results. Being in the top quartile of coronary calcium is a coronary artery disease equivalent. At the risk of sounding like a broken record, it is way past time to recognize the value of coronary calcium imaging as the primary diagnostic tool for coronary disease and stress imaging should be limited to symptomatic individuals.

CMS set to cut Medicare physician fees for cardiovascular imaging

Mon, 09 Nov 2009 21:12:38 EST

As a cardiologist, I hope to get paid enough to: -be able to see all comers (those who cannot pay, NOT those who WILL not pay) without having to ask for money up front. -be able to perform all the necessary tests in our office without being concerned that it will break the bank for those with no insurance -be able to pay for health insurance for all of our full time employees and fund their profit sharing plans -be able to pay off our building debt, echo machines, nuclear machine, treadmills, computer upkeep, replace our ECG machines when needed and do building maintainance -be able to pay our accountant, lawyer and malpractice insurance -and in return for being away from home for so many weekends, nights and late evenings, missed suppers with my husband and kids and time away from my aging parents .....I want to educate my kids with a college degree, take a vacation yearly and donate to an occasional charity and my church. As it's been said ad nauseum, no one begrudges a pro football player or basket ball player a 30 million dollar contract for less than a decade of play but when a physician makes a few hundred thousand per year, it's criminal. When was the last time Roethlisberger put in a balloon pump????? Melissa

Ambrisentan effective long-term for pulmonary arterial hypertension

Mon, 09 Nov 2009 18:02:18 EST

PAH has a high mortality, but there are no randomized trials with mortality as the endpoint. Why has this been allowed? PAH (particularly secondary causes) should be subjected to the same rigor as CHF, MI and all the rest of cardiology...particularly in view of the high cost of these agents.

CMS set to cut Medicare physician fees for cardiovascular imaging

Mon, 09 Nov 2009 16:46:50 EST

thats hastle and fourty.

CMS set to cut Medicare physician fees for cardiovascular imaging

Mon, 09 Nov 2009 16:45:53 EST

I am truly interested in what other cardiologists think they ought to get paid. I hope people write in and dont feel guilty about what they think they deserve. My nuclear camera repair men charge 200/hour plus 300 minimum travel fee. My lawyer charges 250 and hour. I think 300$ and hour is a reasonable rate. What do the internists here think. Other cardiologists? If that wage is too high then would you increase it for weekends and nights? I love what I do. My grandfather and father were/are both physicians but the headaches and stress that I now feel owning my office space, echo equipment and nuclear camera and using them appropriately to make a reasonable living has become much too difficult. I have another twenty years to practice and Im just not sure that yearly threats of reduction in reimbursement is worth the hassle. Signed, Discouraged and Forty.

A fish tale with merit: Omega-3 PUFAs underrated for heart failure

Mon, 09 Nov 2009 16:37:33 EST

Interview with the Editor. A wealth of data from early lipid sub-fractioning. Castelli, Wm Am J Cardiol 2005

A fish tale with merit: Omega-3 PUFAs underrated for heart failure

Mon, 09 Nov 2009 16:35:47 EST

Lp(a) has 3 response sub-types: 1] NO response,.. so,.. lower LDL as low as possible & increase HDL2 as high as possible. 2] Moset response 3] robust response Almost every case where there IS a response,.. the 1st six months have almost NO effect. My Lp(a) level remained unchanged for almost 24 months. Then suddenly on 2 advanced tests only 30-days appart,.. it dropped 50%. better to "lay siege" with the naicin, and harvets the benefits, even without a drop in Lp(a). Watch out for rosuva & atorva,.. they both are know to increase Lp(a). Simva & prava are largely neutral. I credit Dr. Ziajka for pointing this out to me early on.

A fish tale with merit: Omega-3 PUFAs underrated for heart failure

Mon, 09 Nov 2009 16:30:13 EST

The presence of oxidized Lp(a)increases macrophage/"foam cell" uptake of LDL by a factor of 60 X`s. nastly little lipoprotein. Haberland ME et al [numerous papers on this].

CMS set to cut Medicare physician fees for cardiovascular imaging

Mon, 09 Nov 2009 16:23:55 EST

November 8, 2009 Economic View Maybe a New Day for Doctors� Pay By ROBERT H. FRANK nytimes

A fish tale with merit: Omega-3 PUFAs underrated for heart failure

Mon, 09 Nov 2009 16:20:37 EST

Depends on lipid "phenotype". Either way,.. nicin ANd Omega 3FA`s are wonderful in combo for Trigs. O-3FA`s pull down the Chylo/Chlyo-Remnant series & niacin hits the VLDL/IDL series. Combined you see fibrtae-like reductions.Suposedly, the O3FA`s reduce LDL density & increase the diameter, and the non-HDL series drops, which is a 'net' plus for risk. Especially lowering the IDL & VLDL3. The pattern shift alone reduces risk. 1-2 g niacin & 4-6 capsules [grams] fish oil are quite impressive on a VAP, BHL or NMR. Also, statins & fibrates do not reduce Lp(a). Most of the statins have a history of INCREASING Lp(a).

Blood products should be used conservatively in heart-surgery patients, trial shows

Mon, 09 Nov 2009 15:25:26 EST

Riddell RE, Buth KJ, Cheng C, Sullivan JA. Risks associated with blood product use in a cardiac surgery setting. Can J Cardiol 2009; 25 (suppl B):122b. When I searched in Medline for this, it wasn't there.

Interventional cardiologist Donald Baim dies

Mon, 09 Nov 2009 15:09:46 EST

Known among his Beth Israel Hospital fellows as �DB�, Dr. Baim was indeed one of the most influential figures in Interventional Cardiology for almost three decades. Besides his contributions to the field, Dr. Baim took the time and effort to cultivate a fine breed of interventional cardiologists, many of whom in turn became leaders, innovators, and teachers in the field. In the cath lab, Don�s display of insightfulness and technical mastery was inspiring. Don will be missed, but his teaching legacy shall endure as many of us former trainees, in appreciation and remembrance, continue to pass on his knowledge to new generations of fellows. Thank you Don.

CMS set to cut Medicare physician fees for cardiovascular imaging

Mon, 09 Nov 2009 15:05:17 EST

I am Nuclear Boarded and Echo Boarded, I know the indications for when tests are appopriate. Obviouslly there is some abuse, and many incorrectly ordered tests by Primary care docs. But I ask this of my fellow cardiologists, what should our hourly wage be? Think hard and please compare it to all workers, lawyers etc.?

CMS set to cut Medicare physician fees for cardiovascular imaging

Mon, 09 Nov 2009 12:55:11 EST

I read tons of ECHO's and nucs every day on inpatients which have no business being ordered, at all. Many ECHO's are repeats of ones done less than 3 months ago. Why? either the ordering provider is too busy to look in past records, or they are afraid of missing something, anything, which could end up in a lawsuit. Every pre-op consult ends up with a nuclear study. Every weak and dizzy gets an ECHO, Carotid Doppler, Cardio consult, Neuro consult. Cognitive decisions are poor evidence in court. Objective data is much stronger to refute or support. As Melissa has mentioned, we don't make much on inpatient studies, so again I ask, why are so many performed? In the spirit of full disclosure, why doesn't any version of any Democratic bill contain TORT reform? It couldn't possible have anything to do with the significant support of the trial lawyers could it?

Interventional cardiologist Donald Baim dies

Mon, 09 Nov 2009 12:12:26 EST

Recall live transmissions with Dr. Simpson in "the early days" and soaring to the peaks of our field; an untimely and tragic loss

Not all metabolic syndrome is created equal: Framingham Offspring analysis

Mon, 09 Nov 2009 11:16:48 EST

I appreciate this article because it supports what I have shown for years--namely, that in the absence of dyslipidemia and cigarette smoking, elevated triglycerides do not impact the risk of atherothrombotic disease.

Interventional cardiologist Donald Baim dies

Mon, 09 Nov 2009 10:01:31 EST

When I ask myself what to do in my role as a cath lab director, the answer has pretty much always been the same--what would DB do? A true leader, an always respected mentor, and a long lasting influence.

Interventional cardiologist Donald Baim dies

Mon, 09 Nov 2009 09:56:22 EST

Don was truly one of the great thinkers in Interventional Cardiology. As a fellow in training in Boston in the early 90's, Don transformed our field and made it scientific. On a personal note he always took the time no matter how busy to teach. Our warmest condolences to his family.

Interventional cardiologist Donald Baim dies

Mon, 09 Nov 2009 09:43:25 EST

Another incredibly skilled pioneer and advisor has departed from the team. He did pass his torch to many and will be sorely missed from the ranks. We all need to take heed of the lessons we teach our patients and strive to be compliant examples to our children.

Interventional cardiologist Donald Baim dies

Mon, 09 Nov 2009 08:41:51 EST

As another interventional trainee of Dr. Baim, I too am saddened by the passing of this friend, skillful technician, gifted teacher, and intellectual giant.

Interventional cardiologist Donald Baim dies

Mon, 09 Nov 2009 07:41:08 EST

He was a remarkable man and a leader in the field, which to quote Euegene Braunwald has always managed to attract 'the brightest and the best'.

Interventional cardiologist sues hospital under Whistleblower's Act

Mon, 09 Nov 2009 05:22:43 EST

In the near future, docs and hospitals will be facing 10-40% reduction in reimbursement for most cardiology services rendered. Cath labs will not be able to carry the products of every device manufacturer as many of us have currently enjoyed. It will be necessary to have manufacturers bid against each other for volume discounts, and thus narrow down available product lines.

Imaging study shows plaque regression with niacin vs placebo

Sun, 08 Nov 2009 21:42:13 EST

If ASA is not an option, and it is only 50% effective on reducing the "flush',.. try these steps. - 3TBS apple-sauce followed by 1-2 dissolved Alka-Seltzer in a small glass of water, to was down IR niacin/Niapsan. Other forms NOT reccomended. Most flushing diminishes greatly with time. - Algonot [Quercetin], see flavanoid literature re; Source: Kalogeromitros D, Makris M, Chliva C, Aggelidis X Kempuraj D, Theoharides TC. A supplement containing quercetin reduces niacin-induced flush in humans. Int J Immunopathol Pharmacol. 2008 Jul-Sep; 21 (3) :509-14. Theoharides, TC has a lot of insight into the "flush" mechanisms. It is not just prostaglandin. Serotonin & histamine systems also involved. - A "dead-slow" titration. Go to CarlsonLabs.com & get the 50 mg IR niacin. ~$3/bottle of 100. Start @ [1] 50 mg TID. Move up slow.

Imaging study shows plaque regression with niacin vs placebo

Sun, 08 Nov 2009 21:39:37 EST

L-Carnitine - 1g BID Flaxseed - 2 TBS / day, ground up Raw Almonds [un-blanched] - 4 gms / day > 4 gms [caps] fish oil Low dose estrogen patch, no progest s/p menopause the drop in estrogen will result in the Lp(a) increasing

CMS set to cut Medicare physician fees for cardiovascular imaging

Sun, 08 Nov 2009 20:07:50 EST

I completely agree with Dr Metzger on the source of so called over-utilized tests, I must say over 80% of the echo studies I interpret are ordered by PCP's, in fairness of course every type of practise has its challenges in the present economic reality and this is the expected result, the present health care options will not solve the problems, now for the crystal ball, I look forward to cash pay and trade by barter coming soon

CMS set to cut Medicare physician fees for cardiovascular imaging

Sun, 08 Nov 2009 19:50:03 EST

While I agree that some cardiology practices, in part, over utilize ECHO/nucs when they own the equipment, the vast majority of non-invasive tests I perform/interpret are ordered by PCP's, which in many cases are of dubious value especially when compared with studies ordered by cardiologists. Yet, all cardiologists, even those who practice in accordance with ACC appropriatness criteria, will be penalized equally. Those that overtilize now, will only overutilize even more. I would point out that there is at least a 600K opportunity cost just to pursue a 3 year cardiology fellowship. In time, I suspect there will be short track fellowships, a dumbing down of sort, to meet the shortage of cardiologists. Who in their right mind, after all, would pursue cardiology, as interesting as it is, without the income to offset the rough lifestyle?

Music therapy lowers blood pressure and reduces reinfarction rates in ACS

Sun, 08 Nov 2009 14:33:26 EST

Excellent for arteriotomy (kidding, blood letting seems to be appropriate for that one.....played in every horror movie in the 1950's.) :) Melissa

Blood products should be used conservatively in heart-surgery patients, trial shows

Sun, 08 Nov 2009 14:19:43 EST

Jo, Not certain what you mean by "this study". Do you mean the utilization of LR products (leukocyte reduced) and younger blood? I'm not aware of any study, just conjecture but I think it would be a great option for study design. Melissa

Interventional cardiologist sues hospital under Whistleblower's Act

Sun, 08 Nov 2009 14:08:12 EST

I don't know if you are a health care professional, but if you are, you are mistaken about your perceptions about the stent most commonly being placed into the LAD for reasons that might suggest some kind of sinister motivation. If you aren't a health care professional I'll cut you some slack because you aren't well informed. I know there are crooks in every profession, but I don't know of many in any profession. There has been at least one interventionalist who has been prosecuted for fraud for stenting borderline lesions, but the greatest majority of interventionalists I know just want to relieve angina or abort an infarction. I'm an invasive non-interventional cardiologist I spent three hours in the cath lab yesterday trying to save a critical patient. Though I was happy to devote that time to that patient and their family, there are certainly better ways to spend a sunny warm autumn afternoon. I don't think many folks are stenting for dollars with no underlying pathology. I DO think cardiologists have morph'd post COURAGE trial into less "elective" procedure utilization and more ACS/STEMI utilization. Before we malign our interventionalists further, I think we'd better get down on our knees and thank God they exist because the next vessel that needs wiring just might be our own. Melissa

Latest European and US STEMI guidelines compared and contrasted

Sun, 08 Nov 2009 13:53:35 EST

.....Not even mentioned because it's not relevant in the European community because it is common place. It's not adequately addressed in the US guidelines because we are so far behind on the topic. It's a lethal ommission for so many Americans who can't receive lytic and are left without a timely option because systems' readiness is not a priority for the majority of AMERICAN cardiac STEMI pts. Melissa

CMS set to cut Medicare physician fees for cardiovascular imaging

Sun, 08 Nov 2009 13:37:13 EST

Fact: We have all remained quietly complicit while we and our peers have been doing excessive and marginally useful testing and have watched quietly while the utilization of nuclear stress imaging, cardiac echo, and angiography have increased at an unsustainable pace. 20 years ago, in my community, we had one nuclear stress camera, owned by the hospital which was available on short notice. Today, there are at least 6 nuclear cameras, all reasonably busy and highly profitable. None of us think that we overuse nuclear imaging but we all know of people who do over use it and we remain quietly complicit with this problem. The same analysis applies to cardiac echo and angiography. Medicare must respond to the increase in costs. Their only option is to reduce units of product sold or reduce the price per unit. As Medicare is incompetent at reducing units of product sold, the only option they have is to reduce the price they pay per unit. At the same time, we have priced coronary calcium imaging at a level below its cost (as a loss leader to justify more nuclear stress tests and angiograms). Applying the logic to justify a $150 price for EBT coronary calcium to calculate a price for other imaging technology would result in a nuclear stress test to be priced at $180, or an echo priced under $100. In the current system, perhaps the only way we can get the utilization of stress imaging and cardiac echo under control is to make it unprofitable for cardiologists to perform in their offices thereby ending the cycle of self referral. Unfortunately this punishes the people who are appropriately using this technology as much as it punishes those who abuse the technology. Even if this is the only option for Medicare, it is inappropriate and unfair. For years, cardiologists have lost money talking with patients and making it up with profitable imaging tests. To take away the profits and make cardiologists lose the value of their investments without compensation is incredibly unfair. In addition, to not significantly increase reimbursement for cognitive services makes the practice of quality medicine impossible. As we are discussing a federal option as the best hope for improvement in healthcare delivery, our current federal option is in the process of destroying the healthcare that we currently can provide. In the spirit of full disclosure, I strongly support Obama and feel that health care reform is long overdue, however I have no misconceptions that what is in congress will actually work.

Imaging study shows plaque regression with niacin vs placebo

Sun, 08 Nov 2009 12:33:06 EST

A neat patient who I have been following for about 3 years. Primary prevention status (until very recently). 40ish woman whose only risk factor besides family history was an extremely high lipoprotein(a) level. Plaque had not much changed in the first two years. However, last Christmas, developed unstable angina requiring 3 stents in her RCA - thus she is now secondary prevention status. Her Lp(a) is over 70, one the highest I have seen. She has a remarkable cardiac family history with every first-degree relative affected. Therefore, when you are testing LpPLA2 don't forget to order the Lp(a)!!

Interventional cardiologist Donald Baim dies

Sun, 08 Nov 2009 11:35:57 EST

Like Aaron, I also had the privilege of training with Don during the 'golden era' at Beth Israel Hospital. The stories and memories are legendary, as were the man's accomplishments. History will remember Don as a visionary who was at the center of a transformational moment in Cardiovascular Medicine. Many of his trainees, a cohort of several dozen who went on to academic success or leadership in this field owe him much. We will remember him differently because of the unique program he developed where none previously existed, where we were expected to leave that program and make a mark on the field. He will have an enduring legacy.

Music therapy lowers blood pressure and reduces reinfarction rates in ACS

Sun, 08 Nov 2009 10:17:12 EST

I think Bach's 48 preludes and fugas fit all patients, surgeons and staff alike, whether they like classical music or heavy metal.

Off-pump CABG shows no benefit over on-pump approach: ROOBY study

Sun, 08 Nov 2009 09:10:01 EST

I am practising for last few years both techniques. I feel that the OPCAB proceudre has to be selected based on the patients needs for revascularisation rather than doing it for all. The final aim sholud be to get total revascularistaion and keep the patient asymptomatic as long as we can. 30-40 % of my practice is OPCAB and the rest are On pump. Regarding the recovery, not much differences in both.Our patients walk out of hospital on days 5 / 6 and back to their work in 4-6wks and this depends on the patients pre op status and their out look also.

Interventional cardiologist Donald Baim dies

Sun, 08 Nov 2009 01:00:56 EST

Don was a giant in his field. He is remembered by many groups of trainees that the mentored. I trained with Don in the earlier years of PTCA and one could not escape the intellect that he was. At the same time, he took a personal interest in seeing us succeed and took pride in his trainees. His passing is a tremendous loss to the field of intervention and also a personal loss to his fellows. We owe him much. Thanks, Don.

Off-pump CABG shows no benefit over on-pump approach: ROOBY study

Sun, 08 Nov 2009 00:38:39 EST

As he rightly pointed out , I would like also to conclude that it is too early to draw a final justifiable "conclusion" - being applicable for all people around the world - out of present data , we need to wait for oncoming results.....but again, in my perspective, OPCABG is a highly individualized procedure not only for the cardiac surgeons but also for patients themselves!

Interventional cardiologist Donald Baim dies

Sat, 07 Nov 2009 20:47:39 EST

Don was a terrific friend to many and a visionary for cardiovascular medicine. As if Don had not contributed enough to interventional cardiology in his academic role, his leadership in industry was visionary. We often found ourselves in a collegial debate, and I know through our friendship that he always welcomed a challenge. Missing one of those discussions with him now.

Beyond Control of Hypertension to Prevention of Renal Damage

Sat, 07 Nov 2009 20:03:52 EST

A novel alternative is Aliskiren to treat Hypertension,this drugs blocked the renin angiotensin system in the firt step, Aliskiren showed tolerability, efficacy and organ protection in patientes with hypertension and diabetes, patients with heart failure,its a good alternative for Hypertesion treatment and the organ protection

Interventional cardiologist Donald Baim dies

Sat, 07 Nov 2009 19:57:22 EST

Dr. Baim was a special friend, colleague and my first cardiology fellow at Stanford. I have a million wonderful stories about the man, the doctor, the fellow but he did one thing when we were scrubbed together that no other fellow has ever done . When his glasses would slip down his nose, as happened every few minutes, he would use my shoulder to push them back up. It was cute but looked a little strange to one of our patients who ask if it was a routine practice. I told her then and would remind her as we reflect on Don's departure, nothing he ever did was routine...miss him already.

Reducing CV Risk: What Add-On Therapies Do You Use?

Sat, 07 Nov 2009 14:56:53 EST

54% RRR Glycemic changes are not persistant nor significant. benefit/Risk ration is completely in favor of niacin use in IR/DM

Imaging study shows plaque regression with niacin vs placebo

Sat, 07 Nov 2009 14:52:59 EST

80% VAP,... about 20% BHL now. Really getting to a point where we rely on the LpPLA2 as well,.. for 'occult' lesions. The FFTT is a neat little pre-screening tool as well for insulin resistance. No real cost.

Omega-3s no help to SSRI-treated CHD patients

Sat, 07 Nov 2009 14:49:39 EST

taken straight from freezer,.. "frozen', on an empty stomach with glass of cold water. That hits the 'magic' > 1000 of DHA threshold. Great triglyceride 'drug'.

Imaging study shows plaque regression with niacin vs placebo

Sat, 07 Nov 2009 14:45:47 EST

This is surprisingly effective in a large % of patients with "statin-intolerance". Also,.. I question any documented benefit with inositol hexanicotinate. last item: There is a great quote from Wm. Castelli [Am J cardiol Sept 2005 - "Intervew with the Editor"]on skipping days/every-other-day with niacin. Especially,.. if HDL remains stubbornly low. "The 1st pass effect". This does tie in with long-acting formualtions having poor benefit on HDL or even lowering it. Possibly an up/down regulation of the nicotinic-acid receptors, makimized during the "trough" between doses ? Who knows. I have a friend, an endocrinologist, who "pulsed" his 1000 mg of Niaspan M, W, Fri & the '20-something' baseline HDL rose much further after skipping every-other day. Worth researchin,... maybe.

Just one-third of heart-failure patients receive aldosterone antagonists

Sat, 07 Nov 2009 14:08:41 EST

the truth is that doctors are scared of hyperkalemia.But this is rare and the drug benefits are overwhelming.

Imaging study shows plaque regression with niacin vs placebo

Sat, 07 Nov 2009 12:20:40 EST

If there were as much financing into niacin/CAD research over the last 50 years, as with statins, this discussion would not be occurring.

Imaging study shows plaque regression with niacin vs placebo

Sat, 07 Nov 2009 12:18:16 EST

Or hope merely lowering LDL is enough. I like the Faucet/drain/bathtup analogy, and Dr. Bale`s approach to empwering patients to "get through" the 30-90 day niacin flush.

New data show that Lp(a) is a causal factor for MI, researchers say

Sat, 07 Nov 2009 12:12:24 EST

Interventional cardiologist Donald Baim dies

Sat, 07 Nov 2009 09:27:05 EST

Dr. Baim, an amzing teacher and remarkable interventional cardiologist, who once coined the term "bigger is better" will be forever missed by the interventional cardiology community.

Interventional cardiologist sues hospital under Whistleblower's Act

Sat, 07 Nov 2009 09:01:16 EST

These kinds of situations are interesting studies in social and organizational psychology. Of course it's easy for the hospital to label the physician "disruptive" - because raising an ethical complaint is disruptive. Social pressure to conform can be quite intense and those who don't "go along to get along" do so at their peril. It's a psychological certainty that the payments to the staff and hospital do distort their judgment, and the individuals involved are of course absolutely certain that they don't. Those individuals aren't lying, they really believe they're not affected. That's one of the most dependable features of human psychology, and one that pharma counts on. Now put the pieces together: a doc who contravenes the local social consensus, who levels a serious accusation that's almost surely true against people who believe (quite sincerely) that they are innocent and who are of course very angry about being accused. Recipe for warfare. The fundamental lesion is in our heads. We are affected by the psychology of gifting, of relationships, of reciprocity. Those are enormously powerful effects, they have been repeatedly demonstrated to distort our judgment, and yet we absolutely don't believe they do. As long as that's the case, i.e., as long as we have human brains, these situations will happen. The drug and device industries employ PhD social psychologists in their marketing operations. They know how the effects work, and they work them to their benefit. I study decision making, I know all about these effects, and yet they'd work on me too! The only way to avoid that is not to have the relationships.

Interventional cardiologist Donald Baim dies

Sat, 07 Nov 2009 07:34:49 EST

I'm a trainee descendant of Dr. Baim-- he trained Jim Burke, one of my mentors. The stories I heard about Dr. Baim at the cath lab table were amusing and amazing. I wish his family the best.

CMS set to cut Medicare physician fees for cardiovascular imaging

Sat, 07 Nov 2009 06:18:14 EST

I was told by my cardiologist about these changes coming up. I have most of my outpatient studies done at his practice, not at the hospital though I work for a large teaching hospital in the area. I much prefer the convenience of going to the office, getting in and getting out, as well as getting the results much quicker. I do not believe the hospitals can absorb the amount of outpatient work that will be generated if not done in the cardiologists' offices; the wait time for patients will likely prevent many patients from ever getting necessary studies. I find my copay for having a procedure or outpatient study done in the cardiologist's office much less than what I would pay for the same service to a hospital. Thus, Medicare obviously has not taken into consideration the fact that this decision will impact seniors who simply cannot afford to pay the additional fees. Wonder why AARP and the like are not lobbying against this change?

Interventional cardiologist Donald Baim dies

Fri, 06 Nov 2009 23:44:12 EST

What a sad day for his family and all of cardiology.

Interventional cardiologist sues hospital under Whistleblower's Act

Fri, 06 Nov 2009 21:20:58 EST

A related issue concerns the large number of stents implanted into patients these days, most of which are always in the LAD (why is that?): Could it be that in addition to ethical concerns regarding the brand of stent used, that many cardiac cath professionals are unnecesarily placing stents into arterties? After all it IS a subjective process which determines whether or not a particular artery is sufficiently blocked that it medically requires stent based revascularization.

Interventional cardiologist Donald Baim dies

Fri, 06 Nov 2009 21:10:32 EST

What happened?

Imaging study shows plaque regression with niacin vs placebo

Fri, 06 Nov 2009 13:25:13 EST

Have others found that statin plus ezetimibe is better tolerated than statin plus niacin/niaspan? Even after lengthy counselling of the patient, which ezetimibe does not require? After getting the LDL very low on combination therapy, we often find frank plaque regression (speaking here of statin+ezetimibe).

Imaging study shows plaque regression with niacin vs placebo

Fri, 06 Nov 2009 12:37:34 EST

I know I have many ( 1000's )and more of patients on a combination of statin and Niaspan. My sample of my own clinical outcome is considerd a small size given the need for larger Volium to be menangfull. But my clinical out come on the southside of Idianapolis, is extremly go along with these findings and indeed translate to clinical out come and regression demnstrated by angiogram. I am wholeheardly know that adding Niacin to statin is the only way will lead to angiographic regression, treating residual risk and a meningfull clinical outcome. For some reason my patients volum is the highest in our group practice and they are the least patients need revascularization and had an events. These statistics I recieved it from the Medicar sample when they hire a 3rd party to look whay Dr. Komari's patients in the state of Indiana has the least amount of CV motality morbidity, leass need for invasive procedures ad more important to the Medicar is least $ cost. I have been using these cobminationb for more than 12 years with great results. My sample has the least CV mortality and morbidity. I have no doubts that all cardiologist by 2014 will use these cobimation as part of guidlines. Obviously I am Lipidologist Cardiologist and become recently very aggressive to lower the atherogenic Apo-B particles down to below 700 not even what the NMR cosider 1000 is optimal. I am very much interesteted in my colliques around the world experiance. Thanks. Ps. sorry for the typo. Habib Komari

Blood products should be used conservatively in heart-surgery patients, trial shows

Fri, 06 Nov 2009 10:05:54 EST

Has this study been published anywhere?

ACE inhibitors of benefit in ischemic heart disease patients with preserved LV function

Fri, 06 Nov 2009 07:44:46 EST

Thanks Dan, I'll give it a look. Melissa

US updates advice on perioperative beta-blocker use in noncardiac surgery

Fri, 06 Nov 2009 07:42:41 EST

Thanks Bryan! appreciate the opportunity to learn as always! Melissa

Off-pump CABG shows no benefit over on-pump approach: ROOBY study

Fri, 06 Nov 2009 05:22:07 EST

Commenting as a physician with no surgical Knowledge but able to look critically at the results of this trial. It looks like that there are many confounders in the design of this trial to make any sensible scientific conclusion possible. Abdelwahab Naas

Tips and Approaches to Reducing Bleeding in PCI

Fri, 06 Nov 2009 02:04:05 EST

This forum is more than a advanced expensive scientific library and I wish every one concerned will make use of it and contyribute for its successes.

Off-pump CABG shows no benefit over on-pump approach: ROOBY study

Thu, 05 Nov 2009 22:07:42 EST

I am convinced that in experienced hands, OPCAB is a better procedure than on pump CABG. The sicker the patient, the more appropriate to use OPCABG. I have done a lot of patients with low EF, some as low as 15%, and they did as well as patients with good LV function (no ionotropes etc). I agree that it is not for every surgeon but beleive that it should be for every pstient

Underutilization of ICDs in CABG patients is worst in women and elderly, Halifax study shows

Thu, 05 Nov 2009 21:51:35 EST

It would appear that the rate of ICD implants in Canada is based on several factors including the available resources ( i.e. number of implanting physicans and available funds). It is not lost to this physician that such trends can be expected in the U.S> if we adopt a similar one payor system as exists to our neighbors up North. I do not believe that the Canadian physicians are less trained nor knowleagble with regards to ICD implant recommendations. Additionally, why did it take a medical student to review such critical datawith regards to such an important issue. I also question the editorial process for posting information such as this article, other than perhaps rendering a stealth message to us all. Thank you Dr. Betzu Tampa Florida

Off-pump CABG shows no benefit over on-pump approach: ROOBY study

Thu, 05 Nov 2009 17:47:27 EST

If the higher graft patency rate (87.8% vs 82.6%; p<0.001) in favour of on-pump surgery, and a 41% more chance of dying due to OPCAB at 1 year; if these are not enough to stop the OPCAB-for-all spree, I do not know what will? OPCAB may be offered to a selected group of patients, who may not exceed 20% to 30% of all patients coming for CABG.

Off-pump CABG shows no benefit over on-pump approach: ROOBY study

Thu, 05 Nov 2009 15:50:01 EST

I'm doing only off-pump. No limitation of number of grafts. 99% of CABG I performing only off pump. When I compare on pump cases, off pump patients recover faster, and less chance to receive complication. If surgeon does off pump more often, results of operations is much better.

Adding fuel to the J-curve fire; debate is reignited

Thu, 05 Nov 2009 13:29:50 EST

IF a Disatolic BP is low, in a Pt. with at least Moderate CAD,what marker is there to indicate the BP is too low....if the patient is basically asymptomatic at that point. Some can tolerate a BP of 60 mmHg, and perhaps others can not. How do we tell? Is this a "scare' storey. Do not use BB, the article says. We need to increase elasticity of the great vessels, to keep Diastolic pressure high. How do we attempt this?

Adding fuel to the J-curve fire; debate is reignited

Thu, 05 Nov 2009 13:16:42 EST

"or whether it's simply a marker of damage that causes the BP to be low. I think that's the crucial question."........and the crucial answer is low diastolic pressure is part of a widened pulse pressure, a marker of endothelial dysfunction and the underlying disease causing it, NOT a maker of disease or a risk for events, as shown by the HOT trial.

US updates advice on perioperative beta-blocker use in noncardiac surgery

Thu, 05 Nov 2009 11:18:12 EST

Thank you for the very interesting discussion Dr. Kowalewski, but the controversy exists with high risk cardiac patients undergoing NON-cardiac surgery. I do agree with much of what you say, but by the same token the highest risk patients are those who have high risk co-morbidities who are undergoing major vascular procedures. These patients have been undergoing revascularization in the operating room under neuraxial anesthesia alone or combined with general for decades and yet there remains a discernable risk. We simply must find a better and more cost effective way to identify or attenuate the risk of patients who are already at risk for cardiac adverse events in the perioperative period. Stone, Slogoff and Keats, Poldermans, and of course Mangano to site a couple of authors off the top of my head have demonstrated the value of a controlled heart rate and perioperative cardiac morbidity and mortality. The difference between the trials that show benefit and those that do not ( POISE, POBBLE) is the beta blockade needs to be individualized and preferably started much earlier than the day before or day of surgery. It appears from the data available that there needs to be some time for homeostasis to be achieved before an elective operation, but that duration is yet an unanswered question. My explanation for the phenomena of increased risk of CVA shown in the POISE trial is as follows. Adding an antihypertensive acutely to someone who may be poorly controlled and then subjecting that patient to the vasodilatory effect of a general anesthetic will put that patient at risk for CVA based altered cerebral autoregulation of blood flow. It is well documented that poorly controlled hypertensives need higher MAPs (above 50 mmHg) for perfusion to meet metablolic demands of the brain. With a general anesthetic or deep sedation there is simply no way to tell clinically if the patient�s brain is receiving adequate perfusion. And Dr. Walton-Shirley, I think my collegue is referring to a phenomenon called pre-emptive analgesia wherein by interrupting pain signals to the brain will reduce the overall amount of opiates patients require postoperatively by preventing intracellular changes that occur in the parietal cortical cells (simply put). Also most will use intathecal morphine as a single bolus, or continuous infusion via an epidural catheter. So the answer to your question is both! Bryan P. Chambers, M.D. Assistant Professor, Department of Anesthesiology Hahnemann University Hospital Drexel University School of Medicine

ACE inhibitors of benefit in ischemic heart disease patients with preserved LV function

Thu, 05 Nov 2009 09:29:58 EST

You should be doing renin levels to see who needs ACE inhibitors or ARBs in patients with CAD and hypertension. see cardiobrief.org 2009 07 05 hypertension-pioneer-and-rebel-proposes-a-different-treatment-approach (site won't let me post links, but google this) and: www.nature.com ajh journal v22 n7 full ajh200963a.html also: clinicaltrials.gov ct2 show NCT00834600

Interventional cardiologist sues hospital under Whistleblower's Act

Thu, 05 Nov 2009 08:49:35 EST

Hospitals often lable some physicians "disruptive" and collect dirt on them. These are usually ( not always) the ones who do not follow blindly and have the guts to stand up against these big organizations when it comes to ethical issues. Unfortunately, with the vast resources that hospitals have, they tend to prevail most of the time! If a physician jeopordizes the financial health of a hospital by bringing up legitimate issues, he or she should be ready to face the consequences. Soprano-Style backlash!

Interventional cardiologist sues hospital under Whistleblower's Act

Thu, 05 Nov 2009 06:46:39 EST

Just wanted to address something Daniel said. I have also had multiple companies to ask "can I help you with an outreach program"? In our rural area with limited resources, in our community's best interest, I will always accept help for our patients. For instance, smoking cessation programs with Pfizer. It's not a "Pay off". Chantix works, so I use it. I've had health forums off and on for years so the public can come and get their BP's checked after hours, ask in an open forum anything they want to ask in the CV healthcare arena, get diet info, etc. These afterhours activities are always sponsored by any company that wants to come. The next day, I couldn't ever reeiterate the names of all the companies that sponsored it nor the brand names of any products they promote. So, I think there are many honest networking possibilities. True to human nature, however, we can corrupt every decent thing in this world. If medtronic or St. Jude OR Medtronic AND St. Jude wanted to sponsor something in our community, I would not hesitate to accept that resource in the best interest of the public health. I don't implant pacers but both of my partners do and I could care less which device they pick as long a the characteristics are appropriate for the patient. Melissa

Off-pump CABG shows no benefit over on-pump approach: ROOBY study

Thu, 05 Nov 2009 06:36:34 EST

Stephen, I'm not at a CABG facility, but I've been referring for CABG for 20 years and it seems that my off-pumps are home on day 4 and at the grocery in 3 weeks and my on-pumps are limping around at 7 days, feeling tough for six. Anectdotal yes, but many more patients than a handful to make a comparison. Melissa

Combined home/GP hypertension control program successful in Pakistan

Thu, 05 Nov 2009 02:14:42 EST

This study offers an excellent pointer to the fact that in resource poor countries the training of people, be it doctors or lay people, is the way to go. Mind you this is also a tall order because GP's in particular may not find insentives or inclination to take time out of their busy workload. However, it is certaily worth a try if this approach is adapted jointly at the level of health planners and professional associations and societies.

CAC scoring plus SPECT provide long and short view of cardiac risk

Thu, 05 Nov 2009 02:03:27 EST

The scientific groups around J. David Spence, Canada, and S. Johnson, Norway, have published large studies on outomce (AMI, STROKE) in relation to the extent of total plaque area in carotid arteries. The integration of findings is a statistical problem. Together with M. Pencina, Bosten (Framingham Heart Study) my article on that problem will be soon published in the Eur J Vasc Prev and Rehabilitation. The test is done fast (see tpainfo.ch) and posttest risk can be calculated using different populations on scopri.ch. I use the test since 2003 in several thousand patients and we are currently looking on the effect of smoking and LDL levels on TPA tracking studies over time. In direct comparative studies from Norway, TPA emerged as the best marker for vascular risk prediction, above and beyond IMT and plaque echolucency. TPA predicts AMI and ischemic STROKE with a good sensitivity and specificity, the latter data on stroke are however only available as an abstract so far.

Off-pump CABG shows no benefit over on-pump approach: ROOBY study

Thu, 05 Nov 2009 01:03:48 EST

I am a believer in the advantages of off-pump surgery, having practiced for years in a facility where over 90% of bypass cases are done using this technique. Patients do better and recover faster. Most of the trials done comparing off vs on pump CABG have been done in centers where a relatively small percentage of cases are done off-pump. Surgical technique and experience are crucial to outcomes. In the current study the median number of off-pump cases done by participating surgeons was 50 meaning these surgeons were very much still on the steep part of the learning curve. Of course the outcomes where not as good as in the on-pump group. My concern is that a great technique will get a bad rap and fall out of favor because of studies like this.

Interventional cardiologist sues hospital under Whistleblower's Act

Wed, 04 Nov 2009 21:33:16 EST

This situation goes on all the time in hospitals, clinics and academic centers. If you point out an issue, the hospital can turn it around in a minute against the whistleblower. Why not? They are not afraid of a law suit. They just put their legal team on the issue and spend millions of dollars defending this unethical approach to medicine. Talk about conflicts of interest. Why would the Peimonte family have such heavy conflicts of interest with medtronic, and then expect everyone to do what they ask in terms of device use. What a joke! Stop one man's career to help another man's pocketbook. If Dr. Grossman has needed to take this case to a whistleblower lawsuit then he has doen his homework to get the job done. It is shameful, that doctors have to keep their mouth shut to survive, compromise your ethics, and/or leave your job. Lahey clinic needs to rethink the concept or what it means to be a medical clinic.

Combined home/GP hypertension control program successful in Pakistan

Wed, 04 Nov 2009 20:49:49 EST

who waltzed into my clinic and said "I'm here because my wife made me come here. I will not take any medications you prescribe and I won't do anything you tell me to do." Well, it was a tall order, but he did eventualy agree to quit drinking and using a salt shaker. His BP decreased from 170's systolic to 140's systolic. He did more for himself than I could have done. Melissa

CAC scoring plus SPECT provide long and short view of cardiac risk

Wed, 04 Nov 2009 20:47:42 EST

Would you care to explain for Scott. (Or Dan Hackam, ....Dan don't you guys do TPA?) Melissa

US updates advice on perioperative beta-blocker use in noncardiac surgery

Wed, 04 Nov 2009 20:44:09 EST

Thanks for sharing. I'm a bit confused though. High spinal anesthesia for pain control post op or for the actual surgical procedure? Melissa

CMS set to cut Medicare physician fees for cardiovascular imaging

Wed, 04 Nov 2009 20:41:09 EST

I'm paid $117.00 to interpret a nuclear study at the hospital. Pales in comparison to the reimbursement for interpreting a study if you own the scanner. Still, not quite worth the malpractice risk because I often interpret the study when other cardiolgists have supervised the stress portion. Cardiology is the only subspeciality that juggles so many hats: We are radiologists-nuclear and ultrasound interpretation/angiograms, Primary care physicians in some ways where we admit and request consultation.,... Consultants with an entirely separate service for just consulting work. Procedure-ists: we perform procedure and generate reports. ER physicians-working acute situations often. ....and DON't forget-- Discharge planners. How many times per day are you told : Dr. X says Mr Jones can go home if it's OK with you.ooops, I forgot, that's a malpractice body shield! A little appreciation of all those hats goes a long way and should work in reverse as well. Melissa

Another in-hospital CV risk marker: 24-hour shifts with overnight on-call duty

Wed, 04 Nov 2009 20:29:50 EST

Control group: cardiologists who do a regular 36 hour call/work shift . Study group: cardiologists who do a regular 36 hour call/work shift but with lower reimbursement. I'll bet the study group would have an even higher risk profile. Unfortunately, we are all getting ready to participate but without a signed consent.

CMS set to cut Medicare physician fees for cardiovascular imaging

Wed, 04 Nov 2009 19:56:40 EST

Great points but I think depending of course on your world view that a scale looking at a job satisfaction b contribution to society c stress and lifestyle d financial reimbursement e prestige from society and colleagues is a useful way for me to look at things...cardiology scores highly on all with the exception of lifestyle and reimbursement is coming down. I think in reality your 'children' won't really know the difference..they will practice in a system where they don't know any different. Like the drug companies in the 'old days' with perks like hotels, cruises and the like... younger doctors who can't even get pens never knew how good it was so they can't really 'miss it' the way we do. The people that are the most bitter are the middle aged practioners...they saw the end of the 'good day's ' and they know the difference...senior people made their money and don't care at all; junior people are just happy they are making more than 30k a year as a fellow. That's my piece anyway.

Interventional cardiologist sues hospital under Whistleblower's Act

Wed, 04 Nov 2009 16:00:21 EST

This goes on in most hospitals in the USA at various levels. Old stuff.

Interventional cardiologist sues hospital under Whistleblower's Act

Wed, 04 Nov 2009 15:13:39 EST

Does it take 22 years to determine Dr.Gossman is "unsuited to the kind of behavior that characterizes Lahey Clinic"? On the other hand, maybe he is unsuited, as he has a sense of ethical responsibility that offends Lahey administrators.

Interventional cardiologist sues hospital under Whistleblower's Act

Wed, 04 Nov 2009 13:34:30 EST

A man of Dr.Grossman's stature and experience knew that the allegations that he was about to release would undoubtedly have a very negative effect on his career at Lahey and likely in a broader context as well. It would be ludicrous for him to make these allegations unless they had some truth, and he had some very strong sense of purpose and morality for which he was willing to sacrifice an ongoing promising career.

Interventional cardiologist sues hospital under Whistleblower's Act

Wed, 04 Nov 2009 13:01:41 EST

David Gossman used to work 22 years in that clinic , isn�t it a proof that he did an excellent job. Usually people do not make those claims in court of law as it is very expensive. I do believe that Dr Gossman was fired because of the Medtronic issues. His religious preference doesn�t seem to play a role.

CAC scoring plus SPECT provide long and short view of cardiac risk

Wed, 04 Nov 2009 13:01:01 EST

TPA? Please expand for me (based in UK)

Interventional cardiologist sues hospital under Whistleblower's Act

Wed, 04 Nov 2009 12:31:17 EST

Brilliant. Make a million dollars out of your inevitable firing, by inflating an issue and making ethicality claims as the last straw. A secretary working for a department chief where I worked was just flailing at his job. He claimed Race-inspired "Hostile working conditions." Nope, the chief was just hard to get along with, and he wasn't up to the job. People use these excuses to avoid taking responsibility for not meeting the job requirements; damage control for the CV.

Interventional cardiologist sues hospital under Whistleblower's Act

Wed, 04 Nov 2009 11:18:24 EST

I have personally had medical device reps come up to me and suggest "deals" in which the company would support community outreach programs depending on the number of times our docs would use the company's products in their procedures.

CMS set to cut Medicare physician fees for cardiovascular imaging

Wed, 04 Nov 2009 09:58:08 EST

Thank you Melissa. Dont forget the abolishment of the consultant fees!

CAC scoring plus SPECT provide long and short view of cardiac risk

Wed, 04 Nov 2009 08:20:14 EST

Dear Melissa, I agree. But we are looking at global risk (AMI + STROKE) and at posttest risk. Usually, there is a small chance to UNDERtreat atherosclerosis with TPA when compared to CAC, because TPA visualizes also soft plaques. We are working on that.

US updates advice on perioperative beta-blocker use in noncardiac surgery

Wed, 04 Nov 2009 07:40:21 EST

I would like to present a possible explanation why perioperative B-blockade significantly reduces cardiac death, nonfatal MI and cardiac arrest while increasing overall mortality, stroke and infectious complications in patients undergoing major non cardiac surgery. (2) It is well established that surgical stimulation under general anesthesia evokes significant hemodynamic, neuroendocrine, metabolic, homeostatic responses and immunosupression. (3). Anesthesia should prevent responses (segmental from the spinal cord and suprasegmental from the hypothalamus) to surgery. Traditionally, in our anesthesia practice, we judge the level of anesthesia by hemodynamic responses (BP and HR) to surgical stimulation and adjust the level of anesthesia accordingly. As a result, patients receive deeper levels of anesthesia if their BP and/or HR increase in response to surgery. By using aggressive perioperative B-blockade, we only attenuate the hemodynamic responses to surgery, and perhaps also create a hypodynamic state. As a result, these patients may receive a lighter level of anesthesia that fails to attenuate the neuroendocrine, metabolic, homeostatic responses and immunosupression in the perioperative period. This combination of a hypodynamic state and unsuppressed other non-cardiovascular responses may contribute to hypoperfusion (ischemia/stroke), hypercoagulability (stroke), and immunosupression (sepsis). Therefore, it is not surprising that in the POISE study there was a significantly higher incidence in mortality, stroke and infectious complications in B-blocked patients. (2) These patients expressed much more humoral, metabolic, and homeostatic stress response to surgery and were much more immunosuppressed. This takes place not during the surgery but several days later when the stress response is exhibited the most ! It is very difficult to attenuate all responses to surgical stimulation including ostoperative pain control. The most reliable way is to denervate surgical site.(3,4) For the last 15 years, we have been using high spinal anesthesia combined with GA for cardiac surgery in order to obtain a cardiac sympathectomy and denervation of the surgical site. Our hope is that this attenuates the stress response of the entire body to surgical stimulation (including postoperative pain) and is not limited to being solely cardio protective as is the case with B-blockade. (3,4) High spinal anesthesia combined with GA is our standard anesthetic technique and is used for all cardiac procedures (over 10,000 cases) including those with poor left ventricular function and significant aortic stenosis. (5,6,7) Preliminary retrospective data from our institution (unpublished work) has shown a significant trend to lower incidences of overall mortality, myocardial infarction and wound infection in patients that received high spinal anesthesia for cardiac surgery. I believe that our specialty has much more to offer to our patients than slow heart rate and low BP during the perioperative period. We have tremendous influence in what happens to the patient during surgery and after. I believe that future research should focus on not only what happens to the patient�s cardiovascular system, but also what happens to the whole body in the perioperative period. Richard Kowalewski MD, PhD, FRCPC Clinical Assistant Professor Division of Cardiac Anesthesia LIBIN Cardiovascular Institute of Alberta University of Calgary Foothills Medical Centre Calgary, Alberta, Canada E-mail: ogopogo@shaw.ca Phone: (403) 686-1248 Fax: (403) 68604450

Interventional cardiologist sues hospital under Whistleblower's Act

Wed, 04 Nov 2009 07:04:38 EST

Unfortunately, the introduction of financial incentive inevitably impacts objectivity... it is called reality.

CMS set to cut Medicare physician fees for cardiovascular imaging

Wed, 04 Nov 2009 06:48:23 EST

Caution: If you aren't up for a rant, don't read this: Loss in revenue will translate into losing employees which will limit access to care that is already stretched, plain and simple. With the economy, almost all physicians' salaries will suffer with "end of year" bonuses cut across the board. It will be so difficult to purchase a 250,000$ piece of equipment in the future to replace aging nuclear scanners, to make building payments, pay rent, supply health insurance, etc. In the hospital setting, I was just told yesterday that I make around $20.00/nuclear interpretation. I'm stupid because I just do my work and don't usually worry too much about what I'm paid. With that revelation, I realized that the malpractice risk I take to read nuclears in the hospital setting is enormous compared to the office where I'm acquainted with the patient, have their chart with their meds in hand, understand their symptoms and risk factor profile. It's convenient for the pt. and convenient for us where continuity of care is 100% better when I'm reading in my office with their chart in hand, my nurse practitioner 10 feet from me to enact changes immediately, etc. Perhaps the hospital, who will continue to have a lucrative pay off from my efforts and malpractice risk should consider paying our practice for my services as the "nuclear cardiology officer". Hmm...... Bet some of you already have this in place. Also, try recruiting someone to go into a cardiology fellowship in 10 years with no guarantee that your children will have a comfortable lifestyle and good choices for post graduate education in exchange for your absence as a parent. Firstly, I chose my profession as a cardiologist because I love my profession, but I've been comforted somewhat that after I'm gone, perhaps my children can look forward to a comfortable life. I know that it is a Poor exchange but it is the sacrifice I made 22 years ago when I chose cardiology as my profession. I don't think I quite understood the extent of the sacrifice as much then as I do now. My children are 16 and 21 and are going out the door. But I will have all those nuclears and echo's to comfort me in my old age. Only a wonderful spouse has balanced my family against all the time sacrificed. I mourn the loss of the respect and reimbursement for becoming a subspecialist for younger women (and men) in the future who will struggle much more than I ever did as a young mother. Resources make the difference in finding house keepers, nannies, taking respites from work that keep you safe from burn out and fatigue. Cuts in subspecialty salaries will result in fewer women in the subspecialty work force because for many it won't be worth it. Also, now more than ever, it seems to be impacting males as well who seem to want a "life" as much as a "career" and I don't blame them one bit. No one will want to put in the hours that a cardiovascular specialist puts in weekly for much less pay. Dermatologists have always been the most intelligent of us all. They have a life and a salary and no call and don't wear 20 pounds of lead every day. I'm so angry and disappointed that I just want to say, like the old song: "Mama's...don't let your children grow up to be"... cardiologists.(well, the old song substituted the word "cowboys") .....Dermatologists and opthalmologists rock! . Kids, Be sure when you are choosing a profession, choose a life as well. Melissa

US updates advice on perioperative beta-blocker use in noncardiac surgery

Wed, 04 Nov 2009 06:11:26 EST

Admirable common sense prevailed in this guidelines update. I am shocked and appreciative. Now if only we could update our PCI guidelines!!! This BB edict came down so quickly compared to other issues!!! Interesting--POISE was published in the last couple of years and already, we have a guideline change! That's quick!!! The NCDR data published at the same meeting.......and we are still waiting on advancing PCI without surgery on site in America. Hm...... wonder what the hold up is? What on earth could it be? (Shhh...$ ??).

Interventional cardiologist sues hospital under Whistleblower's Act

Wed, 04 Nov 2009 06:03:28 EST

One can neither defend or prosecute this case without extensive documentation. I have no personal knowledge of this issue but I can't understand why any institution cannot utilize multiple devices from multiple companies and enjoy the benefits of having access to technologies in development from all of them. We love the Medtronic reps and we love the St. Jude guy and they all get along beautifully, sometimes even hanging around with each other on the same day in our lab. It's a win win for all of us. Additionally, We've had to defend something simple like a filing for unemployment by an employee that quit her job because of difficulty in getting along with another employee. I loved her and have worked with her for 20 years but in the end, she tried to claim that she was "fired" so she could draw unemployment. Nothing could have been further from the truth. So, when it gets down to it, objective documentation is the ONLY way anyone can win either side of this argument. Let it be a lesson to us all.... and I suspect there will be many lessons learned from this particular incident. I'm always sorry to hear about in-fighting among professionals. The patients, who should be our main focus, always lose big in the end. Melissa

CAC scoring plus SPECT provide long and short view of cardiac risk

Wed, 04 Nov 2009 05:50:46 EST

Michel, I think there was a study that demonstrated the CAC was a better predictor of Cardiovascular events but TPA was a better predictor of stroke risk. I'll try to find that study. For now, I'll combine Spect and TPA in those that pass the stress exam "for short term risk" assessment but with risk factors for monitoring. Melissa

Diuretics effective as second-line therapy for hypertension

Wed, 04 Nov 2009 04:01:42 EST

I agree with Dr.Messerli`s comment.Diuretics is an effective blood presure lowering drugs as second-line therapy,especially for the elderly patients with systolic hypertension,for young man with high diastolic pressure or obese patients ；and it is dose-depedent. For chinese patients,no more than 12.5mg HCT for long-term second-line therapy.

CAC scoring plus SPECT provide long and short view of cardiac risk

Wed, 04 Nov 2009 02:01:20 EST

all lies in the pretest and the posttest risk. Those with a high CAC score have a higher pretest probability, reducing the warranty time of a normal SPECT study. In my experience TPA of carotid arteries becomes positive (=increased risk) even before CAC becomes high (N=420 simultaneous imaging cases). Therefore, SPECT + TPA would be the first step, not SPECT + CAC.

Combined home/GP hypertension control program successful in Pakistan

Wed, 04 Nov 2009 00:51:47 EST

There is is great need to continously involve first line doctors (GP,S) to ensure hypertention monitoring at the tertiory level and help GPs to convinse/update screened hypertensive patients to go through the required investigation process and most importantly break the myth that hypertention is CURED with a short term treatment, hypertensive patients need proper management through life style modifications & required treatment for effective BP control. Its a life long disease & with effective managment patient can have a very good quality of life.

NRMI data raise more questions about PCI in nonsurgery centers

Tue, 03 Nov 2009 20:10:32 EST

Alexandre, It depends on where you live. Do you care to tell us where you have your practice? Melissa

Target HbA1c levels still the subject of much debate, but tailored therapy should be th

Tue, 03 Nov 2009 16:30:12 EST

Since I started using an DPP4 inhibitors,, specially vildagliptin, plus metformin (Never less than 1500/day), I have seen an improvement in the Hba1c that can not reach with met/pio, an I am trating the 3 main pathophysiologyc problems in T2 DM: Insulin Resistance, Insuficient Insulin Production and Hiperglucagonemia

Imaging study shows plaque regression with niacin vs placebo

Tue, 03 Nov 2009 14:32:32 EST

I've been doing CIMT on a large percentage of my patients in my family practice that have cholesterol problems and or abnormal IMT. I start with a statin and add niacin until their cholesterol/HDL level is I use IR Niacin, Rugby brand purchased from AndaMed - they charge $10 for 1000 500 mg tabs.I start patients at 500 mg tid (titrate the dose over 6 weeks) and tell them to suck it up re the flushing. If you explain the tremendous benefits of niacin 90% of patients will tolerate the flushing and in most instances it becomes very minimal particularly if they take some ASA before a meal and then take the niacin after the meal. IR niacin can be titrated to 4 gm /day and does not have hepatic side effects because of its short half life. Some patients just cannot tolerate the IR niacin and I will put them on Niaspan if they can afford it. It is my understanding that IR niacin is also more effective than Niaspan. FWIW, I take IR niacin 1 gm tid with a statin - my last cholesterol HDL ratio was 2.1 and my CIMT has improved every year over the last 4 years.

Bariatric surgery fails to reduce risk of MI long term

Tue, 03 Nov 2009 14:16:04 EST

I believe that Bariatric Surgery came to contribute decrease CVD risks, once the plurimetabolic syndrome reorganize, and consequently increase natural antioxidants, and decrease overtoxins, improveing Health quality, autoesteen.

Stent pioneer Julio Palmaz urges DES makers to "learn from mistakes of the past"

Tue, 03 Nov 2009 14:08:34 EST

The process on/off label turn on the disciplin to use the STENT, considering inclusively Hypersensivity likely the culprit in late stent trombosis, ongoing late luming loss with Cypher, Tazus supports"cath-up restenosis" teory.

Experts weigh in on calorie lists on menus, despite "mixed" science

Tue, 03 Nov 2009 14:00:11 EST

This fantastic the process to reeducation the patients to eat, menu list increase omega 3, multicolor salads, cereals, red fruits moderate, wine, mediterrane food.

Less exposure to cardiovascular risk factors with intensive diabetes intervention: Look AHEAD

Tue, 03 Nov 2009 13:55:30 EST

Always we need decrease the exposure the patients a CVD risks, lowering glucose level, moderate exercise tree time a week, adequate foods, regular sleep, lower stress, regular meditation.

NRMI data raise more questions about PCI in nonsurgery centers

Tue, 03 Nov 2009 13:49:15 EST

Hom can I submit the a procedures invasives without support about cardiac surgery in Hospitals?

Glucose lowering in type 2 diabetes to prevent CVD remains controversial but still important

Tue, 03 Nov 2009 13:41:59 EST

once we treat the correct form of diabetes, we will prevent irregularity of plurimetabolic syndrome and consequently, decrease CVD

Omega-3s no help to SSRI-treated CHD patients

Tue, 03 Nov 2009 09:18:48 EST

Dietary fish does not negatively affect cholesterol, glucose, or inflammation, because it is in a natural stable EPA/DHA ratio. We must look at the research available to us. If you expect results, it first must not be over a 40% ratio of EPA/DHA to total fish oil grams and it has to have a low TOTOX. The Council for Responsible Nutrition set the guidelines at less than 26 TOTOX. But i have found one that has 120 clinical studies and has a less than 10 totox throughout usage and shelf life.

Thiazolidinediones have a role for appropriate diabetic patients

Tue, 03 Nov 2009 08:07:24 EST

Re-read the first 5 paragraphs substituting the words "low carbohydrate diet" for "thiazolidinedione," and ask yourself what the reaction of the medical community would be. The sixth paragraph is the reaction to the TZD case: "Nevertheless, ongoing research in this class of drugs is "very exciting," he said, adding that when researchers are developing novel PPAR agonists, risks for each compound should be viewed on a case-by-case basis, since compounds in this drug class have distinct differences.

Legacy and Innovation: New Options in the Treatment of Hypertension in Canada

Tue, 03 Nov 2009 04:56:31 EST

Pour une HTA IL NE FAUT SE PRESSER ET Prescrire un IEC OU ARA OU AUTRES .

Legacy and Innovation: New Options in the Treatment of Hypertension in Canada

Tue, 03 Nov 2009 04:51:32 EST

pour une HTA IL NE FAUT SE PRESSER et prescrire un IEC OU un ARA OU AUTRES.

Imaging study shows plaque regression with niacin vs placebo

Mon, 02 Nov 2009 20:55:19 EST

Your retrospective data sounds pretty cool. What lipid testing are you using to monitor lipo changes? TIA mcobble@canyonsmedical.com

Imaging study shows plaque regression with niacin vs placebo

Mon, 02 Nov 2009 19:17:12 EST

Inositol Hexanicotinate has been used is EU for over 30 years, it does have research. When inositol hexanicotinate is administered orally to humans, this results in a sustained increase in the level of free nicotinic acid in blood and plasma according to teh European Food Safety. Perhaps using a product that is FDA Drug Registered manufactured versus a health food store product is the better choice. Solgar is not FDA Drug Registered manufacturer, there is one company in US that is a sole manufacture of dietary supplements.

Imaging study shows plaque regression with niacin vs placebo

Mon, 02 Nov 2009 17:36:15 EST

First: nicotinic acid has always shown marvellous results. Too bad it's naturally occurring, therefore no profits to the drug cartel. Second: almost all "niacin" on the health food market is niacinamide and not nicotinic acid, and useless for any impact on cholesterol. The same goes for Solgar's "No-Flush Niacin" which is inositol hexanicotinate - useless. Third: working in a Pain clinic, I see no end of people suffering from statin-induced muscle pains. Fourth: the myth about LDL Fifth: the 30% dropout rate for niacin included those with MRI claustrophobia. Unfair reporting, IMHO. John Kent, BSc, MD, CFCP, FCFP, FGIMS

Imaging study shows plaque regression with niacin vs placebo

Mon, 02 Nov 2009 12:51:47 EST

LDL 91 on simvastatin 40 mg/d cannot be considered optimal care. Routinely getting patients far below this level (at least below 70 mg/dl and preferably to 50 or less) with rosuva/atorva and other therapies. Given poor tolerability of niacin (30% dropouts in the rct literature), it would be nice to see a comparison of niacin on top of contemporary therapy with highly potent statins at doses to attain NCEP/ATPIIIR guidelines of <70 mg/dl of LDL.

Imaging study shows plaque regression with niacin vs placebo

Mon, 02 Nov 2009 12:33:46 EST

When powerful treatment with statin lowers both a raised LDL (ApoB) and an already too low HDL (ApoA1)the desired improvment of the ApoB/ApoA1 ratio might have resched its limit. Are the data going to be displayed showing how this ratio fits with which subjects experienced the observed vacsular regression?

Combination drugs for weight loss

Mon, 02 Nov 2009 11:30:25 EST

If I am not incorrect in recalling information on pramlitide this drug was shown to increase weight loss by itself. Many attributed this to its effects on nausea. Could it be that the effects seen with pramlintide and metreleptin are also the expression of the effects of nausea on weight? Can the authors correlate the weight loss with nausea and whether patients with higher numbers of Aes are those with the best efficacy results?

Imaging study shows plaque regression with niacin vs placebo

Mon, 02 Nov 2009 10:17:37 EST

I did a small (400 patients total, 60 taking niacin) retrospective study on EBT calcium stability vs progression with respect to the use of niacin. Those subjects on niacin had a dramatic improvement with plaque stability by EBT-CAC compared to subjects not taking niacin. The average annualized progression on those taking niacin was 18%, and with those not taking niacin was 28%. A rather dramatic finding considering that calcified plaque progression of

Imaging study shows plaque regression with niacin vs placebo

Mon, 02 Nov 2009 10:11:00 EST

Years ago, niacin, combined with a bile acid resin, was granted by the FDA, an indication for the slowing of progression, or promoting the regression of athero, based on quantitative coronary angiography data. This study is interesting because of the small number of subjects used, and efficacy demonstrated on top of statin therapy. A downside is that the placebo group had a 10 mmHg higher baseline systolic BP than the niacin arm, and one might have expected that to have possibly mitigated benefit in the statin only arm.

Next up: Drug-eluting stents for erectile dysfunction

Sat, 31 Oct 2009 08:41:56 EDT

let us now christen you as the first I.P!!! Melissa

Next up: Drug-eluting stents for erectile dysfunction

Fri, 30 Oct 2009 23:14:46 EDT

I have coined an interesting name for the new sub- sub - speciality of interventional cardiology who have taken up an interest in using a new DES to stent the pudendal artery for ED: INTERVENIONAL PUDENDOLOGISTS !

ACE inhibitors of benefit in ischemic heart disease patients with preserved LV function

Fri, 30 Oct 2009 22:50:04 EDT

Couldn't have said it better myself. Sorry Dan for the late reply. Melissa

Contrary to common belief, women feel same heart-attack symptoms as men

Fri, 30 Oct 2009 20:25:43 EDT

Ooops, website URL was disallowed. These interviews with female heart attack survivors can be found at My Heart Sisters dot org.

Contrary to common belief, women feel same heart-attack symptoms as men

Fri, 30 Oct 2009 20:21:17 EDT

As a heart attack survivor and a 2008 graduate of the annual "Mayo Clinic Science & Leadership Symposium for Women with Heart Disease" in Rochester, Minnesota, I have a number of concerns about this study reporting and its subsequent sensationalized media coverage, from the BBC to Canadian Press to, yes, theheart.org. For example, a far more accurate and useful headline here might be: "Women More Likely to Report Heart Attack Pain in Neck, Jaw, and Throat". Or how about: "Study Compares Patients' Cardiac Symptoms During Angioplasty"? The study did not collect data about real-time cardiac events, but from a cath lab during scheduled, non-emergency procedures - a far cry from the actual symptoms experienced by real women during real cardiac events. These results might be significant for those interested in learning what sensations 300+ patients are feeling during a medical procedure, but cannot and should not be extrapolated to conclusions about the kinds of cardiac symptoms experienced during an actual MI in real life. It's an uphill battle to educate all women to be aware of the typically vague heart attack symptoms that we know women experience and largely ignore compared to men. Since returning from the Mayo Women's Heart Clinic, I have done presentations on women and heart disease to hundreds of women who are universally well aware of chest pain as a heart attack symptom. What surprises them are symptoms like back pain, crushing fatigue, clammy sweats and what Mayo Clinic cardiologists call "a sense of impending doom" common to many women having a heart attack. Many also report that these heart attack symptoms "come and go" - again, a scenario impossible to replicate during a simple angioplasty procedure. For compelling and surprising descriptions of actual heart attack symptoms experienced by real live women, read: "How Does It ReallY Feel to Have A Heart Attack? Women Surviors Tell Their Stories" at

New Canadian lipid guidelines will recommend CRP testing for certain patients

Fri, 30 Oct 2009 19:04:38 EDT

where are we? have we gotten there yet!in te last several years there has been a shifting paradigm in risk estimation for CVD. Inital efforts to estimate risk focused on single risk factors and the short-term relative riskd associated with them Such an approach provides an incomplete and potentially misleading picture of short-term risk. The emphasis should be on absolute riskd for CVD we need a better risk equation or risk engine.In the Jupiter trial it is interseting to to consider the baseline risks in this study. The estimated Framingham Risk Score for a non-smoking male with average cholesterol, bllood pressure, and HDL-cholesterol was 12%.In comparison to two previous primary prevention placebo-controlled trials(The West of Scotland Coronary Prevention Study and AFCAPS/TEXCAPS), the Framingham Risk Score wa surprisingly similar. This occurs because the mean age for JUPITER was 10 years greater than the previous studies. Thus, with JUPITER we have exchanged total cholesterol for age and conducted a very similar clinical trial with findings that should not be terribly surprising. Risk equations are just not efficient but of course necessary. The approach to CVD risk prevention among younger adults is at odds with the biology of the disease process -young adults with high risk burden are given misleading messages regarding the true natur of their CVD risk. Short term risk estimates bias treatment away from younger adults with risk factors and in favor of treating naerly all older adults regardless of risk factor burden We should consider risk for CVD beyond the 10-year window to consider the remaing lifespan.There are a variety of aproaches here 1. testing with biomarkers and /or imaging2. lowering the absolute risk treatment threhold, and 3. modifying/supplementing the absolute risk estimate with additional methods that need to be developed Finally, I think it is lifetime risk estimation that has to be developed in other words what is the absolute risk of developing a given disease across the lifespan thia approach removes the effect of age from the risk estimate

Imaging study shows plaque regression with niacin vs placebo

Fri, 30 Oct 2009 18:17:50 EDT

showed cimt regression (0.04 mm at 24 months) with addition of 1 gm Niaspan on "optimal" statin therapy (simva 40/ldl 91, meeting ldl guidlines). >>this study is that it is the first one to show regression in patients who were taking established best contemporary treatment," senior author on the JACC paper, Dr Robin P Choudhury Did the simva 40mg/ldl91 fall short of contemporary treatment?

Understanding Heart Failure and Atrial Fibrillation

Fri, 30 Oct 2009 17:22:44 EDT

I use the protocol of HF severe, AAS 200 mg/day, Furosemida 40 mg/day, ACE,or ARBs, espirolactona 25 mg/day, Cardvedilol 25 mg/day, and the excellent results, if necessary, with arritmogenic focus, amiodarona 200 mg/day.

Dual Antiplatelet Therapy: Dueling Options in Real-World Practice

Fri, 30 Oct 2009 16:56:29 EDT

All the patients submited PTCA in first 3 months, use dual drugs of antiplatelet-therapy, if necessary keeping same one year untill.

China death toll due to hypertension worse than predicted

Fri, 30 Oct 2009 16:51:11 EDT

I think there ising bigger occidentlizing costumers in china population, and consequently increase the stroke, coronary disease, in general cardiovascular diseases.

New MESA data: Pericardial fat a better predictor of CHD than BMI

Fri, 30 Oct 2009 16:45:55 EDT

once there ising pericadial-fat in excess, it's to wait bigger coronary-disease consequently.

NHLBI director Nabel named new president of Brigham and Women's Hospital

Fri, 30 Oct 2009 16:42:38 EDT

Dr.Nabel shows the fantastic Curriculum Vittae.

NT-proBNP "remarkable predictor" of incident atrial fibrillation

Fri, 30 Oct 2009 16:36:40 EDT

It's logic, once Heart Failure this natriuretic-peptide risk stratification is bigger, the chance of develop atrial fibrillation is bigger too.

ACE inhibitors of benefit in ischemic heart disease patients with preserved LV function

Fri, 30 Oct 2009 16:06:11 EDT

Look at the NNT in EUROPA and the miniscule AR. Not convincing. HOPE run in period makes me wonder if the results were simply due to BP lowering. I share your concerns Melissa, we need to provide proven eficacious therapies before adding to the pill burden.

Lorcaserin passes weight-loss and valvular hurdles in BLOSSOM study

Fri, 30 Oct 2009 16:00:06 EDT

It is a very promising drug, we are needing something like that after the unsuccessfull results of accomplia.I hope it will help us to fight the burden of obesity

New MESA data: Pericardial fat a better predictor of CHD than BMI

Fri, 30 Oct 2009 12:21:47 EDT

Further investigations are definitely warranted, because if it can predict the chances of getting an MI would warn us that urgent measures are needed. But a cheaper method is needed. Then we can use it way before disaster occurs.

Combination drugs for weight loss

Thu, 29 Oct 2009 21:15:31 EDT

Very recently, these studies where also published in the Journal of Clin Endocrinol Metab. Naltrexon is an opioid receptor antagonist and bupropion activates opiomelanocortin. The combination of these two causes greater weight loss than the each one seperately. That's great news because for some people common diet plans, such as those offered by Nutrisystem and Medifast (the last one known for its enticing Medifast discount coupons) do not work.

Managing the Next Decade of CV Risk: Role of Genetics

Thu, 29 Oct 2009 13:41:46 EDT

Not one iota of thought is given to the facts that most of us value expedience over issues related to heart health that may or may not crop up later in life. Take for instance the college student who gobbles down a Hostess Twinkie for lunch instead of a balanced meal between classes. These may have consequences down the road, but who takes the time to consider the action taken at the moment. Only lately have members of our culture concerned themselves about what, where, when and how we consume food that is so overprocessed, by and large, it requires dressing up with harmful but tasty condiments, spices, salts, etc. just to make this over-processed food palatable. Sorry. We pay the price later.

New AHA/ASA guidelines on TIA management and telemedicine in acute stroke released

Thu, 29 Oct 2009 13:22:16 EDT

PLZ TELL ME RECENT MOST MANAGEMENT GUIDELINES IF TIA.THANX

Primary Prevention of Sudden Death

Thu, 29 Oct 2009 12:18:28 EDT

In India, sudden death is becoming common in the 30s and even in the late 20s. Many are smokers but not all. Perhaps Acute Stress contributes a lot. Many times even Cardiologists dont diagnose the cardiac problem at the first visit. Recently one of our colleagues, Dr Sreenivas, expired suddenly of cardiac arrest though he was seen by a Cardiologist only 2 days ago.

Experts weigh in on calorie lists on menus, despite "mixed" science

Thu, 29 Oct 2009 10:38:35 EDT

If calorie labeling at fast food outlets doesn't have an effect on choice perhaps the next step is to force each person to sign that they read the calorie chart. If that doesn't work a government enforcer could refuse service if the calorie content ordered is too high for their body mass index. If that doesn't work they could tax the calories above a base level. Just think what it will be like after the government takes over health care. Feel like people are trying to control your life?

Novel Approaches to Enhancing Myocardial Contractility for the Treatment of Acute and Chronic HF

Thu, 29 Oct 2009 10:18:55 EDT

But I believe in stem cell, at same I treat my patients with protocol conventional, AAS 200 mg/day; ACE prevallence; or ARBs; Carvedilol 25 mg/day, but I'm waiting arive here, Brazil, Nebivulol; espirolactona, and Furosemida,some times adaptations doses, or suspense diuretics,alwawys treating the cause of Cardiomyopaty.

Contrary to common belief, women feel same heart-attack symptoms as men

Wed, 28 Oct 2009 17:56:41 EDT

While taking a first aid course an experienced paramedic commented that women presented DIFFERENTLY that men. Abdominal pain presented more than chest pain. Good to know if you are a woman and in doubt about getting assistance.

The Importance of Registries in the Study of AF-Related Stroke

Wed, 28 Oct 2009 16:54:34 EDT

I use Warfarin, and AAS 200 mg/day, Keeping INR 2,5-3,0; and drugs to compesate Cardiovascular-disease without complications.

Combination Therapy for the Management of Mixed Dyslipidemia

Wed, 28 Oct 2009 16:50:18 EDT

All the Coronary Disease patients always start the treatment with Statin, if Hipertrigliceridemy level adttion Fibrate 200 mg/day in the first month, and if normal I keep only 20 mg/day of statin.

Guidelines for Atrial Fibrillation in Transition- New Trial Data and Patient Care

Wed, 28 Oct 2009 15:28:49 EDT

Always I treat the eventual cause of Cardiovascular-disease, concomitant the arritmogenic foco, the prevallence amiodarona, and AAS+Warfarin.

Redefining the Therapeutic Goals of Atrial Fibrillation

Wed, 28 Oct 2009 15:25:12 EDT

I ususally treat the eventual cause of AF, Coronary Insuficience, Heart Failure, Cardiomiopathy Hypertrofic, and all of the Cardiovascular-disease, concomitantly I treat the foco arritmogenic ever amiodaron here in Brazil, but I'am waiting to arrive dronaderone.

Reducing CV Risk: What Add-On Therapies Do You Use?

Wed, 28 Oct 2009 13:00:33 EDT

Beware of using only Non-HDL rather than particle number in patients with metabolic syndrome or DM. Best predictor of risk in patients with elevated triglycerides on or off statins is still ApoB-100 particle number or LDL-P, even if the non-HDL is near normal. Daniel

Contrary to common belief, women feel same heart-attack symptoms as men

Wed, 28 Oct 2009 11:09:58 EDT

Women with ACS are more likely to be misdiagnosed or delayed in making a correct diagnosis is not simply because of their atypical presentations. Rather, the busy primary care providers may feel the chance of ACS of a woman is low despite this female patient may have similar risk profiles to a male patient.

ACCORD update: "One size fits all" may not be best glucose-lowering strategy

Wed, 28 Oct 2009 09:51:18 EDT

Was there a difference in the two ACCORD arms regarding the use of insulin?

Diagnosing and Treating Chest Discomfort of Cardiovascular Origin: The Role of Risk Stratification

Wed, 28 Oct 2009 08:47:49 EDT

hi dr\carl j.pepine plz send me a paper about role of contrast echo in post-stemi patient this is my research for MD degree thanks my email adress (elhawy_card@yahoo.com)

ACE inhibitors of benefit in ischemic heart disease patients with preserved LV function

Wed, 28 Oct 2009 08:43:12 EDT

Review 1)HOPE; 2)EUROPA. Both enrolled patients with normal EF and CAD.

Blood products should be used conservatively in heart-surgery patients, trial shows

Wed, 28 Oct 2009 08:05:12 EDT

Our institution is NOT a CABG hospital, yet we utilize blood products for those who have CHF/procedures/unstable angina if their hemoglobin is less than 10.0. I don't remember the end of the world coming for anyone in 10 years that happened to just have a blood tranfusion. I checked with our blood bank to see if there are differences between our blood products and others. We utilize leukocyte reduced blood and we off-load all blood products that are older than 2 weeks. Perhaps the statement that the "later they get the blood" (the worse the outcome) may be more telling than we think? Melissa

ACE inhibitors of benefit in ischemic heart disease patients with preserved LV function

Wed, 28 Oct 2009 07:52:22 EDT

That adding an ace inhibitor to a patient with coronary artery disease and a normal BP who is already juggling aspirin, a statin, a beta blocker and prostate medication who also wants to take an H2 blocker for his GERD but can't afford it.......with a compliance rate of 50% at best and a monthly pharmacy bill of $200.00 is really going to benefit much from the addition of an ace inhibitor.....unless his EF is impaired. Prescribing more medications with no clear cut indication is like impulse shopping at the check out lane. ("Will that be all for you"..."uh....., I'll take those tic tacs and some enalapril please). That is my story and I'm sticking to it. I'm still waiting to be convinced. Melissa

The lowdown on high blood pressure

Tue, 27 Oct 2009 20:48:43 EDT

Dr. Black looked to his right, and his mustach hid his lips, making his words difficult to hear.

ACE inhibitors of benefit in ischemic heart disease patients with preserved LV function

Tue, 27 Oct 2009 17:24:20 EDT

Our prevallence is to use ACE, but eventually ARBS to convenience in once a day.The best results is ACE/Carvedilol/ESPIROLACTONA/FUROSEMIDA/AAS.

Crossroads of Risk - Hypertension and Diabetes

Tue, 27 Oct 2009 14:41:51 EDT

Is it alright to do some light weight lifting with the implanted cadioverter defibrillation to keep the body tuned up at the age of 62 ??

NRMI data raise more questions about PCI in nonsurgery centers

Tue, 27 Oct 2009 14:19:26 EDT

As many of you know, I am from one of those small rural hospitals. Historically, the only MI's that are admitted are the elderly who refuse to be transferred to the city, or whose families say enough, no more surgery. The closest cardiac hospital is at best 45 minutes away by ground, at that's really racing. Copters are available, but generally that takes 30+ minutes round trip on a good day. 1. The guidelines state that if you can't get the pt to the lab in 90 minutes or less, use fibrinolysis. Yet, when talking to the interventionalist, we are continually told NOT to do that, even though it is "implicitly" agreed that the 90 minute timeframe will NOT be met. What can be done to make this timeframe workable for both parties? We might have 10 STEMI's a year, so I am including the transfers for NSTEMI in this question. 2. For NSTEMI, is fibrinolysis even in the standard of care? 3. Would you, as an interventionalist, accept a transfer that had already had one dose of a fibrinolytic to assess for a PCI? We do have a cath lab about 30 miles away, but they do not do emergent PCI. It is very disheartening to see our numbers look so bad when really the medication issue is out of our hands. We DO get the aspirin and beta blockers in consistently. It's just this timeframe of getting to a balloon that we miss. (and no cardiologist here--just an outpt clinic that is held once a week.) Becky

NRMI data raise more questions about PCI in nonsurgery centers

Tue, 27 Oct 2009 14:06:24 EDT

The NRMI concept of using patients that are transferred into a hospital as part of the data analysis, but not patients that are transferred out, is corrupt and nonsensical. There are multiple biases in the selection process of these patients...thereby corrupting any conclusion that can be made.

Reducing CV Risk: What Add-On Therapies Do You Use?

Tue, 27 Oct 2009 12:02:50 EDT

Interesting comments, but no one has considered the second step target by NCEP (non-HDL cholesterol which is often elevated in patients with TG>200).

New Canadian lipid guidelines will recommend CRP testing for certain patients

Tue, 27 Oct 2009 09:49:24 EDT

Daniel, we don't actually use IMT. We do total plaque area measurements. It is quantitatively and qualitatively different. I agree that CAC is preferably over IMT, but not necessarily superior to TPA (in fact, the only comparison, by Brook et al, suggested TPA was better than coronary angiography). So I disagree with your statement. Certainly I would want some measurement of (subclinical) disease to predict events, rather than just measuring upstream markers - unless those upstream markers had proven to be superior or incremental to measuring the disease itself (doubtful). Or if they were reversible and their reversibility tied to disease prevention (such as LDL or even HDL, although the evidence is weaker for the latter). I am actually doing some review work on imaging in cardiovascular prevention and there are data suggesting increased smoking cessation, etc.

Mainly medical unknowns regarding Michael Jackson's apparent cardiac arrest

Tue, 27 Oct 2009 06:19:58 EDT

You are welcome to view HEARTFELT, the topic "Michael Jackson's Coronaries Acquitted". Melissa

New Canadian lipid guidelines will recommend CRP testing for certain patients

Mon, 26 Oct 2009 18:16:32 EDT

Dan, Feasability of study is difficult, I agree. But, perhaps an attempt to demonstrate benefit in risk stratification would quell some of the nay sayers out there. Also, would bring to the light the same attention and discussion as JUPITER about hsCRP. I think that given the predictive value of CCS as demonstrated in MESA and ST Francis Heart study, I am more sold on this modality for assessing risk than CIMT. Unfortunately, I am finding difficulty in getting patients to pay $300 out of pocket cost. Spoke with local radiologists, without any success in improving pricing. For now, relegated to the younger patients who have financial capability to get study done. Daniel

Simple, fixed-dose drug bundle may lower MI and stroke risk

Mon, 26 Oct 2009 18:02:46 EDT

You're right, 75% of the patients were on aspirin too...

HCTZ a "paltry" antihypertensive, with no effect on outcomes, new analysis suggests

Mon, 26 Oct 2009 13:05:24 EDT

Trial showed that HCTZ is a paltry antihypertensive and second-line add-on option compared with amlodipine in patients already treated with ACEi. We are moving more and more away from HCTZ - it demonstrated inferior results (more MI, more revasc, more unstable angina, etc).

New Canadian lipid guidelines will recommend CRP testing for certain patients

Mon, 26 Oct 2009 13:03:46 EDT

All that such a trial will show is that treatment will be more intensive in the imaging group than the standard care, because the imaging group will pick up many more cases of subclinical atherosclerosis than Framingham, resulting in more and higher dose statins, niacin, fibrates, ACE inhibitors, etc. Then any successful positive trial will be deemed only positive because of the imbalance in on-treatment medical therapy. Basically it will break down to a STENO-2. Remember that the AUC-ROC for Framingham is 0.78, meaning that risk factor assessment alone will miss more than 1 in 5 events.

New Canadian lipid guidelines will recommend CRP testing for certain patients

Mon, 26 Oct 2009 11:53:31 EDT

I think the whole focus in cardiology and money to that end, has been driven and shifted over the years to treatment of the disease AFTER or DURING an event. Not to minimize the significant strides we have made in technology and the clear benefits of primary PCI, etc. But it begs the question, what and how can we do better to prevent the FIRST event that knocks off 1/3 of the first MI patients? Framingham has been shown to be insufficient. Risk factors are good, but could and need to be better. I would argue that a trial by the NIH or another "independent" body similar to JUPITER but using CCS or CIMT to determine treatment versus placebo using these "preclinical atherosclerosis" technologies. If we can demonstrate a benefit, then perhaps some of the undue residual skepticism that remains about CCS (probably due to the original direct to patient marketing by those who owned the equipment) can be minimized. This would force the hand of those who simply belittle the technology without any real substance to their argument. NO negative trials exist that I am aware of, yet there has been little to no outcome trials performed, which continues to be the knock on CCS and CIMT. Not talking about predictive value. I am referring to the information/predictive value determining treatment goal and benefits translating to hard outcomes. Thoughts? Daniel

HCTZ a "paltry" antihypertensive, with no effect on outcomes, new analysis suggests

Mon, 26 Oct 2009 11:42:31 EDT

Just a simple clarification to post #11. Dr Turnbow, the reason HCTZ will shift LDL to small dense size is when it elevates Triglycerides. The LDL particle number remains constant. Remember that in all analysis looking at LDL particle number versus size (MESA, etc), the particle size does not matter after accounting for particle number. The converse is NOT true. Size does not trump particle number. That being said, I use HCTZ in most patients due to familiarity and ease of use in combo. Daniel

New MESA data: Pericardial fat a better predictor of CHD than BMI

Mon, 26 Oct 2009 11:35:22 EDT

Looking at thousands of hearts from newborns to adults, we have seen this correlation, and just as a "feeling" have told my residents to be aware of this. Now. somebody is paying attention and we have to support that. We are completely sure there is no redundant fat around the hearts of newborns and children.

New MESA data: Pericardial fat a better predictor of CHD than BMI

Mon, 26 Oct 2009 11:32:50 EDT

EXISTE UNA ESTRECHA RELACI�N ENTRE LOS INDICES DE MASA CORPORAL (IBM) CINTURA, CINTURA CADERA Y LA DISTRIBUCION DE GRASA PERICARDICA.

New MESA data: Pericardial fat a better predictor of CHD than BMI

Mon, 26 Oct 2009 11:13:38 EDT

Seems like this may warrent consideration of expanded measurement inflammatory markers?

New MESA data: Pericardial fat a better predictor of CHD than BMI

Mon, 26 Oct 2009 10:00:40 EDT

Since pericardial fat is concidered to be visceral fat, the findings do not surprise me, but unfortunately, CT scans cannot be used routinely.

Older age, female sex, African American race all associated with higher rates of readmission follo

Mon, 26 Oct 2009 10:00:08 EDT

i would like to have a copy of cardiac surgery reporting system

New MESA data: Pericardial fat a better predictor of CHD than BMI

Mon, 26 Oct 2009 09:37:25 EDT

It has long been held that central obesity was an indicator of visceral fat. Epicardial fat can be considered to be a type of visceral fat. I wonder if measuring mesenteric fat would show similar correlations.

Cutting salt intake in US could save $50 billion a year

Mon, 26 Oct 2009 00:27:15 EDT

Just eat healthy food, like fish, for iodine

Cutting salt intake in US could save $50 billion a year

Mon, 26 Oct 2009 00:26:04 EDT

So please visit saltsucks dot com

Cutting salt intake in US could save $50 billion a year

Mon, 26 Oct 2009 00:24:40 EDT

Please view for all the facts on table salt.

Mainly medical unknowns regarding Michael Jackson's apparent cardiac arrest

Sun, 25 Oct 2009 13:53:12 EDT

If a public person as Michael Jackson happens to die and the diagnosis involves in any aspect our interest in cardiologic issues with use to treat here then the news has a place in our site

New Canadian lipid guidelines will recommend CRP testing for certain patients

Sun, 25 Oct 2009 13:51:50 EDT

risk factors --> subclinical dz. --> clinical dz. There are two options here: 1) you can look at the risk factors for disease events when trying to predict who will/will not get the disease; or 2) you can look at subclinical dz. Philosophically and pragmatically, subclinical disease is closer along the pathway to disease/events. That is the best place to look to predict and intervene (I use plaque area).

Timing and Dosing of Antiplatelet Agents: What Do the Data Say

Sun, 25 Oct 2009 09:06:20 EDT

did not mention prasugrel nor triple RX in high risk patients such as the addition of IIaIIIb agents. Also what about patients in hospitals where no PCI units are available and several hours may elapse prior to arrival in a PCI unit. Also did not mention prior thrombolytic RX in STEMI patients.

New Canadian lipid guidelines will recommend CRP testing for certain patients

Sun, 25 Oct 2009 01:27:41 EDT

Daniel, I understand and agree with your analysis. Unfortunately too many physicians do not recognize that reality. The result is that HS-CRP will be inappropriately used as the new screening test, people will be treated who will not benefit from the treatment and people will remain untreated who should be treated. Harvard and Ridker will get rich and famous, money will be wasted, and coronary prevention will suffer a setback. How does this happen? Are physicians such dupes?

New Canadian lipid guidelines will recommend CRP testing for certain patients

Sat, 24 Oct 2009 23:24:32 EDT

I meant to type that they were NOT "low risk" at baseline. The citation is listed again below: Current Opinion in Lipidology 2009, 20:282�287. Anyone who is interested and unable to access the article I would be happy to email you the pdf. Daniel

New Canadian lipid guidelines will recommend CRP testing for certain patients

Sat, 24 Oct 2009 23:22:33 EDT

Please forget about the hsCRP stuff. Everyone enrolled in JUPITER had elevated hsCRP >2.0 mg/dL on 2 samples. They were not separated by hsCRP. What matters is were they truly "low risk" but at "increased risk" because of hsCRP. I think looking at the baseline risk based on nonHDL and more importantly apoB and metabolic syndrome this was NOT a low risk population as advertised and proported. Therefore it is no surprise that a moderate risk population benefited from statin versus placebo. I urge you all again to look at the brief, easy to read, analysis I cited before regarding the Framingham population percentiles at BASELINE in the JUPITER trial. It will open your eyes to the truth that it was not hsCRP that magically divined who benefits and who does not benefit from statin therapy. Check the particles and move on. Simple, cheap, and validated. Daniel

New Canadian lipid guidelines will recommend CRP testing for certain patients

Sat, 24 Oct 2009 18:20:05 EDT

Did Jupiter look at the hazzard ratio of HS-CRP among subjects with similar triglycerides, HDL, and LDL? I am not aware that this evaluation was made.

Target HbA1c levels still the subject of much debate, but tailored therapy should be th

Sat, 24 Oct 2009 15:30:51 EDT

in a meta-analysis of 20 studies that included more than 100,000 patients, the risk of a cardiovascular event was significantly higher(RR-1.33) in patients with a fasting glucose of 6.10mmo/l(18times 6.10=109.80mg/dl) than in those with fasting glucoe of 4.20mmol/l(18times 4.20=75.6mg/dl) no study needs to be done toshow that treating so-called prediabetes reduces risk

Target HbA1c levels still the subject of much debate, but tailored therapy should be th

Sat, 24 Oct 2009 15:19:52 EDT

it always amazes me about the impact of steno given that it was such a small small small number of patients only 160 patients in total divided up into two groups and only 63 and 67 patients selected for evaluation not too impressive a study to deserve such accolates

New MESA data: Pericardial fat a better predictor of CHD than BMI

Sat, 24 Oct 2009 13:08:09 EDT

As MESA found no value in BMI, being better than nothing does not excite me.

New Canadian lipid guidelines will recommend CRP testing for certain patients

Sat, 24 Oct 2009 11:52:38 EDT

Wiliam, sounds pretty negative on hscrp. I wasn't aware hscrp was a screening tool, but rather a stratification tool much like you use ebct. I think the evidence currently (or at lease the 'designed' evidence shows hscrp does stratify risk. It certainly did in JUPITER. whether another marker such as cystatin c or urine ma or cimt or ebct or insulin etc.. would have been a better tool was not the design. When we looked at hscrp in JUPITER we found it did predict baseline risk that was 30% higher than a formal risk strat tool. Happy Halloween. mc

Thiazolidinediones have a role for appropriate diabetic patients

Sat, 24 Oct 2009 10:44:54 EDT

but none of the oral hypoglycemic agents have beenshown to have cardiovascular protection and the FDA requires this to be noted on the labeling of every OAD --TZDs are excelent drugs in the right patient they can be safely used in patients without left ventricular failure and safely in stable post mi patients look at the data too bad some of tpoou will not provide an agent to those patients who will clarly benefit

Timing and Dosing of Antiplatelet Agents: What Do the Data Say

Sat, 24 Oct 2009 06:58:10 EDT

It was a very professional academic presentation.

New MESA data: Pericardial fat a better predictor of CHD than BMI

Sat, 24 Oct 2009 06:51:15 EDT

An occasional statement in my final assessment on echo is : small pericardial effusion vs. pericardial fat pad, or pericardial thickening vs. fat pad. Needless to say, it's usually in a "technically difficult" study when I can't sort the two. I recall a recent echo where the pericardial fat pad was rather prominent but the BMI wasn't that high. ......hm.... Melissa

Timing and Dosing of Antiplatelet Agents: What Do the Data Say

Sat, 24 Oct 2009 02:10:09 EDT

First speaker killed me....boring slides and a borimg speaker

Thiazolidinediones have a role for appropriate diabetic patients

Fri, 23 Oct 2009 10:29:15 EDT

I have experienced a case of a patient male with 45 year-old with normal cardiovascular function that after the use o rosiglitazone (AVANDIA)8mg/day developed sudden episodes of tachyarrytimias carcterized for frequent ventricular her beats (about 4.000 per 24 hours on the HOLTER) and short periods of ventricular tachycardia que desapeared totaly after the withdrawal of the drug.

New Canadian lipid guidelines will recommend CRP testing for certain patients

Fri, 23 Oct 2009 10:02:35 EDT

I am still confused why anyone believes that HS-CRP should be a screening tool. In the St. Francis Heart study, it provided very little incremental risk prediction compared to Framingham risk factors and provided no incremental risk prediction after EBT-CAC. The MESA heart study found that the baseline HS-CRP in those subjects who subsequently had an MI was slightly lower than in those subjects who did not have an MI. The Jupiter study did not investigate if the presence of elevated HS-CRP was associated with an increased risk of MI compared to a normal HS-CRP, or at least they did not report on that result. If they know that result and did not report on it, someone should be fired. Perhaps the senate should investigate as they did with the Enhance trial. HS-CRP may have some value in conjunction with LP-PLA-2 in monitoring therapy but I fail to see how a test with so many false positive results and minimal predictive value can be considered to be a legitimate screening tool, even if it does make Harvard rich.

Zero CAC score not 100% reassuring in those presenting to ER with chest pain

Fri, 23 Oct 2009 09:50:29 EDT

With an annual MI incidence of 0.1%, I know of no other test as good at predicting lack of MI risk than a 0 EBT CAC score. As calcification of plaque reflects the presence of some inflammation in the plaque, it is logical that a 0 calcium score is more predictive of low MI risk than it is of complete absence of plaque. Prior studies show that the most inflamed plaque has micro-calcifications. When we see a 0 CAC score with some non-calcified plaque in the vessel on CTA, I question how much risk that non-inflamed plaque represents. What I am concerned about are events, and an EBT CAC is a great risk stratifier of unsurpassed accuracy!

Omega-3s no help to SSRI-treated CHD patients

Fri, 23 Oct 2009 09:37:22 EDT

over the years, the psycyiatrist that Iknow who use omega-3 fatty acids to treat depression use in the range of 4 to 6 gms a day of omega-3. Perhaps the doseage in this study was too low.

Zero CAC score not 100% reassuring in those presenting to ER with chest pain

Thu, 22 Oct 2009 22:19:00 EDT

Patient this week came to me for a 2nd opinion. He had a prior nuclear performed at another office with anterior wall MI and peri-infarction ischemia. He underwent a stress cine at our office and the stress ECG was abnormal. Inadvertantly, the tech hit the wrong button on a new machine and all of the images just disappeared. He had a Calcium score of "0" , age early 50's. In face of good exercise tolerance, I was willing to just medicate but he had ongoing shoulder discomfort and his wife really pressed him to have a cath. We both relented and it was angiographically normal. So, I'm HAPPY to report that the calcium score of "0" in this instance was "accurate". Melissa

New Canadian lipid guidelines will recommend CRP testing for certain patients

Thu, 22 Oct 2009 21:10:06 EDT

Michael, Great points, as usual. Was glad to see VAP add the ApoB to their testing about a year ago. I think as long as you are treating particle number rather than guessing with LDL-C or non-HDL-C you are doing a good job. Would be nice to get CAC or CIMT/atheroma at a reasonable cost or reimbursed. For now, have to "sell" the idea to got to a radiologist (for which I get nothing so no real conflict). My only conflict of interest is that I am interested in preventing events in my patients, as are the others who take the time to discuss these and other issues in these blogs. Keep up the great dialogue and discussions. Daniel

Life and times of leading cardiologists with Rob Califf. Guest: Peter Sleight

Thu, 22 Oct 2009 20:42:46 EDT

This is interesting interview! I do wish that Dr. Sleight had not said that his mother "did nothing". Stay at home moms do a great deal.

Zero CAC score not 100% reassuring in those presenting to ER with chest pain

Thu, 22 Oct 2009 16:48:25 EDT

( )IS NOT 100% REASSURING IN THOSE PRESENTING TO ER.. YOU CAN PUT ANY WARD IN THE ABOVE SPACE AND AND IT WILL BE TRUE. MEDICINE IS AN ART OF PROPABILITIES.. AND THOSE WHO WANT TO BE SURE 100% BY ANY SINGLE TEST SHOULD SEARCH FOR ANOTHER JOB.

Combination Therapy for the Management of Mixed Dyslipidemia

Thu, 22 Oct 2009 16:35:54 EDT

Very interesting report. For how long should we keep statin plus fenofibrate treatment?

Just one-third of heart-failure patients receive aldosterone antagonists

Thu, 22 Oct 2009 16:00:17 EDT

I usually use aldosterone antagonists as routine in HF patients, untill stability clinic,after this I try get out this drug, but if necessary go back.

ACE inhibitors of benefit in ischemic heart disease patients with preserved LV function

Thu, 22 Oct 2009 15:50:13 EDT

All of the patients in our trial use as prevallence ACE inhibitors as ARBs, but both decrease the CVD risk.

Expanded indication for telmisartan

Thu, 22 Oct 2009 15:42:02 EDT

We have as prevallence use ACE inhibitors as ARBS, but all of this decrease CVD risk in our trial

TYCOON: One year of dual-antiplatelet therapy with DES isn't enough

Thu, 22 Oct 2009 15:30:53 EDT

We use as routine clopidogrel 75 mg/day, for 3 months, depending of coagulation and seric platellets, if necessary four 6 months, or untill 12 months.If the patient have intollerancy a AAS,we use clopidorel or plagrel.

Data from 1.23 million patients confirms warfarin increases mortality in trauma patients

Thu, 22 Oct 2009 12:51:01 EDT

Our trauma surgeons complain that dual antiplatelet therapy is worse than a warfarin patient.

Just one-third of heart-failure patients receive aldosterone antagonists

Thu, 22 Oct 2009 12:46:18 EDT

all together hleps the heart failure patients with drug titration as the patient can tolerate. I tell my students that the comlex therapy use full Ace i + diuretics and the spirolacton and otheres ...

New Canadian lipid guidelines will recommend CRP testing for certain patients

Thu, 22 Oct 2009 12:41:30 EDT

I do have conflicts with noninvasive imaging - meaning i order both (cacs and cus) and perform CUS/CIMT (atheroma volume should be measured and reported) in our office as well. We perform ~ 40/month, but pay a company to do this. I'm not sure how many cardio referrals and er referrals we make every month. Dan - you make a great point we have many people with athero or risk factors for such whom may never have an event (they are the minority though). If we find athero we treat them based on guideline goals. Daniel - you can get a VAP Lipid (vertical auto profile) for $39 direct if you draw blood in office or send off to labs - this would be max charge for uninsured and most insurances cover it (max charge would be $39 if not covered) Of course that lipid panel doesn't require fasting, isn't exposed to Friedewald errors, provides ApoB, NHDL and LDL. provides density patterns, vldl3, hdl subfractions and ApoA1 as well as ratios. Finally gives Lpa for those who value this test. I have used all expanded panels and all have merit. We have used this test for over 7 years, but this summer I was hired as an advisor (that is my other conflict). But just because I drive a Mercedes at Volkswagen prices doesn't mean that their isn't integrity or transparency in a message. ApoB should and hopefully will be elevated by NCEP and I think hscrp will have further wording and be elevated just as Canada did recently. mc

Next up: Drug-eluting stents for erectile dysfunction

Thu, 22 Oct 2009 08:41:53 EDT

Early, acute / subacute or even late stent thrombosis would be a disaster?? Bioabsorable stent would be a better choice, I guess.