theheart.org Comments

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 surgicalKnowledge 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 AnesthesiologyHahnemann University HospitalDrexel 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.htmlalso: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 significanthemodynamic, neuroendocrine, metabolic, homeostatic responses and immunosupression. (3). Anesthesia should prevent responses (segmental from the spinalcord and suprasegmental from the hypothalamus) to surgery. Traditionally, in our anesthesia practice, we judge the level of anesthesia by hemodynamic responses (BP andHR) 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 tosurgery.By using aggressive perioperative B-blockade, we only attenuate the hemodynamic responses to surgery, and perhaps also create a hypodynamic state. As a result, thesepatients may receive a lighter level of anesthesia that fails to attenuate the neuroendocrine, metabolic, homeostatic responses and immunosupression in theperioperative 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, FRCPCClinical Assistant ProfessorDivision of Cardiac AnesthesiaLIBIN Cardiovascular Institute of AlbertaUniversity of CalgaryFoothills Medical CentreCalgary, Alberta, CanadaE-mail: ogopogo@shaw.caPhone: (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? TIAmcobble@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 LDLFifth: 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.pepineplz send me a paper about role of contrast echo in post-stemi patientthis is my research for MD degreethanksmy 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

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

Mon, 26 Oct 2009 00:26:04 EDT

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

Mon, 26 Oct 2009 00:24:40 EDT

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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.

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

Wed, 21 Oct 2009 22:47:16 EDT

Best. . .comment. . .ever.

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

Wed, 21 Oct 2009 20:42:56 EDT

As I tell all of my students:If a drug rep knows more about their drug than you do, then you need to study more.

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

Wed, 21 Oct 2009 19:46:47 EDT

Daniel, ARMPI, from a numbers point of view, seems to be remarkable at ruling our disease (99-100% NPV). My understanding though is that the tracer needs to be injected at the time of pain, or within 2 hours of the last episode of pain. How does your ER handle the stockpiling of nuclear tracer for off hour cases? We've also had shortages of cardiolite as of late, which adds to the problem.The beauty of CAC, and CTA for that matter, is that it can be done anytime, and be transmitted anywhere for immediate interpretation.

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

Wed, 21 Oct 2009 19:31:05 EDT

I have to admit...this one ranks right up there with, "I Get Headaches When I Hit My Head With A Hammer"....

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

Wed, 21 Oct 2009 19:15:03 EDT

Dan, yes send it. I think if we enrolled predm pts over 60 and followed them for 5 years we would see something (especially if they had renovasc dz - think steno 2 and hope - , uncertain what, but that would be very interesting science.

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

Wed, 21 Oct 2009 19:04:27 EDT

I think most clinicians are overwhelmed in many ways. The great thing is that spiro and epleron are both indicated for CHF and if people cant tolerate the former they can use the latter. reps can be a great resource when used appropriately.

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

Wed, 21 Oct 2009 18:08:19 EDT

It should be noted that there is significant peer-reviewed epidemiologic evidence to support the hypothesis that increased fish consumption decreases depression. That said, Omega-3s are in triglyceride form in fish and take time to cross the blood-brain barrier. Perhaps the ethyl ester form of Omega-3 was used in this study (less bioavailability) as well as insufficient time and doses to achieve an amelioration of depression.

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

Wed, 21 Oct 2009 16:40:19 EDT

Hi DanielThat is different than my situation. If plaque is progressing on q6-12monthly scan despite control of risk factors, including LDL aggressively reduced to below 70 mg/dl, I will target Lp(a) and/or HDL-C with niacin, if there are derangements in these two. Combination of statin and niacin beat statin monotherapy for both events, plaque, and Lp(a), HDL, in ARBITER and HATS. It takes a bit of counselling but the event data for niacin is compelling.

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

Wed, 21 Oct 2009 16:37:08 EDT

Dr. Cobble is right. It is truly sad that we have to rely on drug reps to educate us on what medications to use. I thought that's why we went to school -- for an education. And the last time I checked, most drug detailers a) don't have a medical school education, and b) SELL their drugs rather than educate you. I received scads of mass mailings on Eplerenone. Strangely, none came on spironolactone. Why doesn't this surprise me?

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

Wed, 21 Oct 2009 15:21:24 EDT

In our ER, if a patient has chest pain, negative enzymes, and a normal ekg (no Q waves, etc) with low risk for CAD, get a rest mibi. If normal, they go home with outpatient followup. If abnormal, then pending their enzymes, symptoms, etc they get inpatient stress in AM versus cardiac cath.To me, the Framingham Score, while very nice to predict risk, grossly underestimates risk in women and the young. Also, remember the FRamingham population was a predominately caucasian, smoking, male group. I would challenge everyone to calculate a FRS on the next 10 patients that have an MI in your local ER. You will very likely be shocked at how many were low or moderate risk. Great retrospective analysis of patients with first MI who were Daniel

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

Wed, 21 Oct 2009 15:14:46 EDT

Dan, I do check an Lp(a), but only if the LDL-P or ApoB is normal without any other explanation for family history. While Niacin seems to lower Lp(a), remember there is still questionable data regarding this. Also, remember african americans have higher "normal" Lp(a) than caucasians, yet no increased risk versus age matched controls. In addition, there is some data that suggest an LDL-C of I am not saying to ignore it, but I would use it as a secondary target after I have treated the LDL-P/ApoB to goal.Daniel

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

Wed, 21 Oct 2009 15:10:26 EDT

Daniel, does this mean you do not do Lp(a)'s either? I find them an extra incentive to prescribe niacin, and often the only risk factor present in patients with advanced atherosclerosis with often family history strongly positive too.

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

Wed, 21 Oct 2009 15:09:37 EDT

The data for using 4 grams of PUFA is in conjunction with diet for treating TGs greater than 500, where risk of pancreatitis is the goal rather than CV risk reduction. If you are treating TGs with Lovaza or fish oil, using less than 4 grams is like using red yeast rice instead of a statin for an LDL-C of 180 mg/dL.Daniel

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

Wed, 21 Oct 2009 15:06:11 EDT

The cost for the ApoB particle number (by itself) is about $30 in NJ. Not sure of cost in other states. The NMR Lipoprofile, VAP, and Berkeley have greater cost. Most insurances will cover NMR. I don't use VAP and Berkeley provides a lot of "fluff" data that has no bearing on clinical treatment. I will save the bleeding of our healthcare system with a fibrinogen level, insulin level, and LPLAC2 for a simple ApoB that can guide my dose of statin +/- ezetimibe. Daniel

Many cardiologists still not following HF-treatment guidelines

Wed, 21 Oct 2009 15:00:22 EDT

As a consumer, I'd be leery taking a glycoside after MI. When I looked it up, the main points in the NIH website were it's poisonous nature and risk of death. No wonder physicians might not want to prescribe. My cardiologist prescribed beta-blockers after my MI and my impression of that a glycoside should be a last resort. So it this study really that revealing?

Thiazolidinediones have a role for appropriate diabetic patients

Wed, 21 Oct 2009 13:43:37 EDT

They are exorbitantly expensive, melts bones, cause CHF, and never been shown to improve outcome ... Nope, these drugs are not for me

Thiazolidinediones have a role for appropriate diabetic patients

Wed, 21 Oct 2009 12:53:30 EDT

Most common side effects of TZDs are water retention, heart failure, increase of weight and fracture. If we avoid using TZDs in patients with HF, all 4 classes of HF as per NYHA, and take preventive measurement (going for bone densitometry and using bisphosphonates when necessary), we can effectively use this group of drugs in patients with type 2 diabetes. Unfortunately only pioglitazone is now in the hands of clinicians as there are so many disputes about rosiglitazone and I personally avoid rosiglitazone.Increase in weight due to use of pioglitazone is due to increase in subcutaneous, not visceral fat. Metabolic friendly subcutaneous fat by its increased adiponectin secretion may lead to reduction of insulin resistance and chronic inflammatory nature of the disease, type 2 diabetes.In addition to this, the novel drug, pioglitazone offers series of anti-atherosclerotic effects both in diabetic and non-diabetic subjects; reduction in hs-CRP level, improvement of endothelial vasodilatoty action and many more.Due to novel mechanisms of PPAR-gamma agonists, I support using pioglitazone as monotherapy or if needed may be combined with metformin as starting medications for type 2 diabetes to avoid hypoglycemia. Contraindication should be only all 4 classes of HF and severe osteoporosis. As a clinician, I expect more and safer PPAR-gamma agonists in near future.

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

Wed, 21 Oct 2009 12:50:32 EDT

I don't think I need a new violin. UKPDS is one good string on our evidence violin but we would like other evidence too. STENO-2 mixed together antiplatelets, smoking cessation, glucose reduction, LDL reduction, HDL increasing, BP reduction, exercise, diet, stress management - who knows if glucose reduction drove the main benefit (doubtful)? Still an impressive study though. And EDIC and DCCT were insulin studies in type 1 diabetes (nice try, bit of subterfuge, but already had my coffee today).Heh. Mayo clinic int med is conducting a course for internists and family physicians in Hawaii with Mayo faculty in January...are you interested in going? I can send you the details.Bottom line - I would like to see one trial in prediabetes other than UKPDS (which was established diabetes) suggesting event prevention for metformin or pioglitazone (or any other therapy - I know you like rosiglitazone). But you won't see it; why? Because the event rates in diabetes, let alone prediabetes, are now too small for powering trials with hard events, because of widespread use of statins, ACE inhibitors, ARBs, CCBs, diuretics, and beta blockers, not to mention antiplatelets. Defeated by our own success?

Expanded indication for telmisartan

Wed, 21 Oct 2009 11:48:28 EDT

Two PLACEBO controlled trial- TRANSCEND and PROFESS showed NO benefit from Telmisrtan for high CV risk and stroke patients for any measurementof outcomes. Yet, FDA creates its own version of reality ignoring direct trials and using indirect trial ONTARGET. Through use of statistics and proves impossible: telmisrtan is no better than palcebo for these patients, yet approved by FDA for CV risk reduction in the same patients. And then we are expected to practice "on label" medicine that works only in FDA twisted and pharma sponsored "reality"? Reminds me of another precedent: ALLHAT. Zero difference in primary outcome between the drugs, yet "thaizides", not even chlorthalidone specifically, proclaimed superior by trialists and JNC.

Expanded indication for telmisartan

Wed, 21 Oct 2009 11:11:50 EDT

Isn't it TYCOON?

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

Wed, 21 Oct 2009 08:40:05 EDT

Problbly only patients with atrial fibrilation should take warfarin for ever. I think that these patients bear high risk arterial thromboembolism that outweights the risk from dyng after severe trauma while taking warfarin.

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

Wed, 21 Oct 2009 07:54:08 EDT

Great to see you guys engage in such an academic and hypothesis generating discussion!thanks, I've enjoyed it as well!Melissa

Smoking bans reduce the risk of acute coronary events: IOM report

Wed, 21 Oct 2009 07:52:13 EDT

Good luck Becky. On my way now to the local telelvision station to do a "live chat" for an hour about public smoking and legislation. The "crazy business owner's right to choose folks" will be up in arms! :) good idea William.Melissa

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

Wed, 21 Oct 2009 03:37:17 EDT

William,When evaluating the patient in the ER for chest pain, Framingham risk score is not at the top of the ER doc's priority list. Besides, its calculation requires knowledge of the patient's lipid panel, which is not always accessible or available.Whether the patient is low risk or high risk will depend more on the "typicalness" (see Ransi's post) of the chest pain, their risk factor profile, and the ED doc's ultimate "gut instinct".You could make the argument not to perform CAC testing in diabetics, for example. The diabetic patient is at high risk and requires lipid therapy regardless of CAC score. Therefore, for chest pain evaluation, might as well go straight to a perfusion study.However, in the absence of diabetes, PAD or known CAD, and with a negative initial ECG and one or more troponin, I see no value in calculating Framingham risk in the ED. I say go straight to the EBCT scanner.

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

Wed, 21 Oct 2009 01:30:27 EDT

it's getting me excited for AHA!!!

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

Wed, 21 Oct 2009 01:25:42 EDT

Dan, you need to change your violin strings. Be happy. :o) I think STENO 2 was a nice multifactorial approach. I think UKPDS long term data was impressive for DM2 therapy and of course EDIC and DCCT were great for DM1 glucose therapy. Plenty of prevention of DM data with many agents other than lifestyle. It will be interesting to see evidence and outcome data over the next 12 months. I do think that addressing all of these things - lifestyle changes, tobacco cessation, safe glucose mgmt, safe bp mgmt, appropriate lipid mgmt would reward costs and outcomes. That's just my sense of current data over 20 years. Medicine is complicated (that's why we work 80+ hours/week) and art/science. Paint that canvas. I hope we meet sometime next year. mc

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

Wed, 21 Oct 2009 01:19:41 EDT

This is unfortunate to see. I try to encourage appropriate monitored use of this product at any educational opportunity. reading the PI and monitoring labs is important

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

Tue, 20 Oct 2009 22:09:43 EDT

Opening the link, I thought there was a definitive paper addressing this problem, but the Typhoon data, while interesting, doesn't answer the question.More importantly, given the transient nature of the relationship that I have with a patient in the setting of STEMI, it is often very difficult to know whether a patient can be adherent to even 1 year therapy of plavix for DES. Unfortunately, no one comes with a sign saying, "I am compliant", vs, "I am not compliant". Although when someone has a previous HgbA1C of 14, that usually is helpful...Anuj

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

Tue, 20 Oct 2009 21:27:32 EDT

I thought it was lies, damn lies, and statistics.

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

Tue, 20 Oct 2009 20:08:47 EDT

The evidence to date from trials like RECORD, ADVANCE, ACCORD, VADT, do not indicate that glucose lowering prevents events or mortality by 20-40% akin to statins or antihypertensives (e.g. MICRO-HOPE). In aggregate there may be a small reduction in nonfatal MI but that is it, and has to be balanced against more drugs, displacing room for other more effective drugs, costs, risks (hypoglycemia, fractures, heart failure), drug interactions and sheer inconvenience. Data from NHANES in latest Arch Intern Med suggests that glucose-lowering is taking center stage and displacing BP and LDL/HDL-modifying. I can send you the paper. I don't agree with using drugs to prevent diabetes either - no hard outcome data for this approach. Lifestyle modification must be center stage here, then statins and antihypertensives. Prediabetes/early diabetes identifies a stellar opportunity to intervene to prevent macrovascular events, rather than to lower serum glucose or HgA1c (unless sugars are out of control and microvascular complications are imminent or present - i.e. metabolic decompensation). Just my view - I may be wrong - please dissuade me from it.

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

Tue, 20 Oct 2009 18:20:06 EDT

Dan. Thanks. I was just at AAFP in Boston and one of the audience members asked with our diabetics should have their blood pressure, lipids or glucose as primary goal. My first thought was in the larger picture - convince your patients to stop smoking. My next thought is - lowering bp, lipids and glucose all appear to lower events on average 20-40%. Future studies may answer this but. Like my grandma said - diabetes is a 'case of the sugars' that's what she had. Identifying high risk predm pts with igt or ifg or a1c out of range should convince pt, employer, clinician, government to encourage lifestyle changes and possibly based on published evidence to consider an agent shown to prevent DM in clinical trials. Hope you are well and yes this topic is provocative and a hot potatoe as more and more people become cardiometabolic.

Smoking bans reduce the risk of acute coronary events: IOM report

Tue, 20 Oct 2009 13:18:32 EDT

if that was done, then people would get healthy, and wouldn't need socialized medicine, and don't forget all those tax dollars lost if people don't buy tobacco products. (however, the use of tax-payer money to buy something out that would then cut the income from other taxes is probably something that would appeal to the govt in some perverse way......what other taxes would have to be imposed to pay for all this transferring around of non-money????)Melissa, one of my docs is approaching the council here about banning smoking in public places, we'll see.

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

Tue, 20 Oct 2009 12:45:19 EDT

To me, an A1c between 5.3% and 6.5% (even 7.0%) is a warning bell to be very aggressive with lifestyle modification then statin, niacin, and BP lowering; not a warning bell to treat dysglycemia with agents that have not been proven to reduce cardiovascular events (like rosiglitazone, pioglitazone, sulfonylureas like gliclazide, etc, etc). We would medicalize a huge population if we put the 1 in 4 persons with metabolic syndrome on metformin and pioglitazone. Recently the editor of the ACP Journal Club, who happens to be an endocrinologist, suggested that the new goal for type II diabetes should be an A1c of 0.075. Whether you agree or not is not relevant to the debate about treating patients who are already between an optimal A1c of 0.05 +/- 3% and that upper limit of 0.075. They would already be controlled according to that recommendation. My concern is the failure to recognize that the A1c is a marker of future macrovascular events much more than anything else, and the need to intervene off the glucocentric pathway. Nice discussion.

Racial background woefully underreported in CV trials

Tue, 20 Oct 2009 11:15:10 EDT

Certainly there are great reasons to collect such information to improve treatment associated with genetic factors but one can not help but wonder what polititians and activists will do with the data particularly in the realm of government run health care.

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

Tue, 20 Oct 2009 11:04:53 EDT

Melissa, you make a good point and one that ESC recommends: All pts presented to ED with ACS/CV event have 2 hour ogtt prior to discharge as US and European data both show nearly 70% of these pts will have glucose dysregulation. ie. current dm, undiagnosed dm, ifg, igt or both.Normal A1c as discussed would be near 5% +/- 0.3. Any A1c that is chronically above 5.7% is quite abnl and should be considered a candidate for nutrition/lifestyle counseling changes. Winter A1c tends to be higher as patients hibernate. Chronic A1c over 6% is very concering.When treating DM, one should strongly consider limiting/reducing SU's and Insulin therapies or switch to safer analogs.Evidence is very strong that wt loss, metformin, troglitazone, rosiglitazone and acarbose and pioglitazone all 'prevent' DM2 by 33-73%. We use A LOT of metformin in our A1c pops above 5.6% and then add either TZD as we feel appropriate later. I think DPP4 will be an interesting consideration with incretin effects today and in future.The argument regarding bp, ldl, glucose etc..... is an interesting intell/philo debate. I wonder how many pts suffer from hypotension or too low of bp? we used to think asa was cheap and worthwhile in this group now the debate is on again with that drug. Epidemiologically one expects CV event reductions of 20-40% with BP reductions of 10 mm/hg. We expect 20-40% reductions of CV events with standard LDL reductions. We saw Macro/Micro reductions in UKPDS 15-38% with A1c reduction 1%. Our best best is smoking cessation within 3 months, lifestyle changes with exercise/wt loss/salt reduction/dietary changes and target all met abnormalities (glucose, lipids, bp). (those can be tough drugs to prescribe - those lifestyle things)Glucose and Lipid toxicity in both the postprandial and fasting states are quite dangerous on organ systems, endothelium and vessel stability as you all know. As hscrp, a1c and insulin go up (singularly or on conjunction) you will see patients lipids move to lipoprotein TG dense patterns and reductions in larger buoyant HDL2. (this is a recipe for disaster just like pouring sugar and fat in one's arteries). This seperates dramatically with A1c over 5.5% or insulin over 10.That's my two bits. sorry if it was too long. I think the UKPDS short term and long term data speak quite highly for good conservative mgmt of glucose and NNT of 16-32 people.ACCORD isn't the way any of us would practice medicine 'flog your pt with every agent to lower a1c to 6% in less than 2-3 mos?'. 20 years ago we would have 1-2 hypo/week or mos, tody we shouldn't see more than 1-2/year with safer therapies and better monitoring. We try to 'always' reduce su by at least 1/2-3/4 or more once a1c drops under 7%. 40% of pts will have hypo with su and depending on insulin type it can be high as well.

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

Tue, 20 Oct 2009 09:07:08 EDT

Would suggest changing the title of this from "isn't enough" to "may not be enough", to be in line with this hypothesis generating data. Media should be more careful, as many do not go past the title, and this data should not be taken to mandate 24 months of plavix, which we all know will increase bleeds and difficulties with elective/urgent surgical procedures, without definitive evidence as to any improved benefit. The difference in VLST after all is 4 vs. 0 and clearly not powered for significance.

Smoking bans reduce the risk of acute coronary events: IOM report

Tue, 20 Oct 2009 01:15:13 EDT

The FED should ban the formation of new tabacco companies. It should then use TARP money to purchase all existing tobacco companies and shut them down. The ROI would be massive and perpetual.

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

Tue, 20 Oct 2009 01:07:04 EDT

In the presence of very high triglycerides (>500) Lovaza at 4 grams daily, in the absence of a statin, increases LDL yet it decreases non-HDL cholesterol and increases HDL cholesterol. It does increase LDL particle size but the increase in LDL may not be entirely explained by this fact, some may be explained by the technology of measuring LDL its interference from very high triglycerides.When Lovaza is used in subjects already on a statin with moderately elevated triglycerides (200-499) there is no increase in LDL with a significant increase in HDL and reduction in non-HDL and Apo-B.I am not familiar with DATA comparing the results of Lovaza vs fish oil. If there are such studies, I would appreciate the reference.

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

Tue, 20 Oct 2009 00:44:56 EDT

This study looked at the presence of ischemia in symptomatic patients with CAC scores of 0. Prior studies have shown that the vast majority of such subjects with measurable plaque in the presence of a 0 EBT CAC score are high risk by Framingham assessment. When evaluating the patient in the ER, if they are high risk by Framingham, their chest pain needs to be taken seriously and their risk factors treated regardless of ER evaluation. If they are low or intermediate risk by Framingham, the 0 EBT is as close to perfect as we get in medicine. If the subject has symptomatic ischemia and is not revascularized, what is that individuals risk for a coronary event over the next year? Existing DATA suggests that the risk is less than 10% however for the sake of argument, let�s be aggressive and assume an annual risk of 25% untreated. Statistically speaking, 3 of the 4 patients missed by CAC were high risk and would be treated medically anyway therefore we are looking at having only 1 subject out of 100 untreated. This would translate into a NNT of 400 to experience one excess event and a NNT of 1000 to have one excess death by using CAC as an emergency room screening test. This compares favorably to any triage test available to the ER including angiography. Conversely, the presence of measurable calcified plaque diagnoses the presence of CAD and therefore mandates medical intervention regardless of Framingham risk or results of stress imaging. The diagnostic value of CAC imaging in the many patients who would be missed via stress imaging and Framingham risk factors is a much greater gain than the hazard ratio of relying on the negative predictive value of a 0 score is a loss. Keep in mind, a large number of calcium scores in MESA were obtained using the more accurate EBT technology. The accuracy of a 0 calcium score by helical imaging is questionable unless retrospective gating is used looking at all reconstruction intervals with 0.1 sec increments. Therefore one must be careful using this study's DATA in an ER with a helical scanner and either prospective gaiting or limited reconstruction interval retrospective gating.

Scripps starts routine genetic testing for clopidogrel responsiveness

Mon, 19 Oct 2009 17:51:21 EDT

This testing could be helpful but for how long. There are other drugs in progress. We will not prescribe clopidogrel forever!

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

Mon, 19 Oct 2009 17:50:14 EDT

What does particle size testing cost and is the test widely available?

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

Mon, 19 Oct 2009 15:27:40 EDT

Ransi, I like what you have to say. The problem though, as I have noticed, is the lack of time spent talking with patients. The art of history taking seems lost in the ED. A patient with sharp pinpoint chest pain that lasts 5 seconds should be sent home with reassurance, but all too often is kept for a rule out and a stress test because of co-existing risk factors or liability fears.If you limit CAC testing in the ED to low risk patients, e.g atypical chest pain and TIMI risk score 0-2, I think you have already selected a subgroup with low pre-test probability. Whether we should add the benefit of time and serial troponins to the mix is worthy of debate. I think it's a good thing, especially if it's the hospitals first experience with CAC in the ED. That being said, I know of a local area hospital that is discharging zero CAC score patients after the initial negative troponin and ECG. I'm sure they have saved bundles.Again, I have to state that 96% NPV for CAC scoring is near perfect, and if the test is used appropriately for the low risk category of patients, it does have a role to play in the ED.

Rosuvastatin cleared for pediatric FH

Mon, 19 Oct 2009 13:43:38 EDT

Pediatric dyslipidemia is now an emerging problem worldwide. Recent guideline from American Academy of Pediatrics in July 2008 states that along with lifestyle modification, lipid lowering drug is indicated in children with familial hypercholesterolemia (either heterozygous or homozygous). HeFH is not rare as it can be found in 1:500.Atherosclerosis is problem not for adult but in children. Bogalusa Heart Study showed that plaque formation starts even at early childhood irrespective of genetic predisposition. Children with familial hypercholesterolemia having very low level of LDL receptor suffer from very high level of LDL cholesterol and naturally they are severely prone to development of atherosclerotic lesions and subsequent cardiovascular attack.Earlier 4 statins were recommended for use in children, but approval of rosuvastatin, I think will reduce the risk of children with HeFH significantly. In addition to this, rosuvastatin does not use CYP for its metabolism, hence has reduced drug drug interaction and the most potent statin available in the world.

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

Mon, 19 Oct 2009 11:26:47 EDT

I agree that MPI poses a higher radiation exposure to the patient. But, in making such a decision and in interpreting these results, we must remember the importance of both pre-test likelihood and quality of chest pain. If pre-test likelihood is low, one can take comfort in a study whose NPV is As to whether a CAC from the ED can supplant an MPI performed after 3 sets of negative troponins, I offer that the latter approach gives the clinician several additional data points for consideration that are not available when using only a CAC from the ED: time and negative troponins. Though cost rises, the lack of recurrent symptoms and/or ECG changes add incremental information to the dataset. Furthermore, if one were to superimpose even a mildly abnormal MPI on top of normal enzymes, the ultimate decision to discharge or cath is clearer.

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

Mon, 19 Oct 2009 09:24:12 EDT

This is the best series ever!!! But two guests over a couple of months is far too less.....

Can statins prevent and treat infection?

Mon, 19 Oct 2009 08:49:50 EDT

A recent study .... Cardiovasc Drugs Ther. 2009 Aug;23(4):261-2. Curr Allergy Asthma Rep. 2009 Jan;9(1):81-7. Increased levels of 25 hydroxyvitamin d and 1,25-dihydroxyvitamin D after rosuvastatin treatment: a novel pleiotropic effect of statins?Yavuz B, Ertugrul DT, Cil H, Ata N, Akin KO, Yalcin AA, Kucukazman M, Dal K, Hokkaomeroglu MS, Yavuz BB, Tutal E. ..."Increased levels of 25 hydroxyvitamin d and 1,25-dihydroxyvitamin D after rosuvastatin treatment: a novel pleiotropic effect of statins?".......There was a significant increase in 25-hydroxyvitamin D, from mean 14.0 (range 3.7- 67) to mean 36.3 (range 3.8 -117) ng/ml (p PMID: 19543962 Another recent study.... J Immunol. 2009 Vitamin d-directed rheostatic regulation of monocyte antibacterial responses. Adams JS, Ren S, Liu PT, Chun RF, Lagishetty V, Gombart AF, Borregaard N, Modlin RL, Hewison M. ".......These data suggest that a key role of vitamin D in innate immunity is to maintain localized production of antibacterial hCAP following TLR activation of monocytes.PMID: 19299728 And another Vitamin D, respiratory infections, and asthma.Ginde AA, Mansbach JM, Camargo CA Jr.EMNet Coordinating Center, Massachusetts General Hospital, Boston, MA 02114, USA.Over the past decade, interest has grown in the role of vitamin D in many nonskeletal medical conditions, including respiratory infection. Emerging evidence indicates that vitamin D-mediated innate immunity, particularly through enhanced expression of the human cathelicidin antimicrobial peptide (hCAP-18), is important in host defenses against respiratory tract pathogens. Observational studies suggest that vitamin D deficiency increases risk of respiratory infections. This increased risk may contribute to incident wheezing illness in children and adults and cause asthma exacerbations. Although unproven, the increased risk of specific respiratory infections in susceptible hosts may contribute to some cases of incident asthma. Vitamin D also modulates regulatory T-cell function and interleukin-10 production, which may increase the therapeutic response to glucocorticoids in steroid-resistant asthma. Future laboratory, epidemiologic, and randomized interventional studies are needed to better understand vitamin D's effects on respiratory infection and asthma.PMID: 19063829

CAC scoring helps reclassify intermediate-risk patients

Mon, 19 Oct 2009 08:31:52 EDT

Our hospital charges $99.00/patient but lowered it for $50.00/pt. when we first did it during February "heart month". We rarely have a turn down either (whereas there were NO TAKERS at $300.00 over 3 years).Melissa

Coronary events drop in Italy after smoking ban

Mon, 19 Oct 2009 08:25:40 EDT

Ken,As a health care provider (not certain that you are), surely you are not suggesting that the entire world should not ban public smoking. From the perspective of itchy/watery eyes and coughing alone , do you not think it's purely courtesy and common sense to stay out of someone's airspace? Let's say the entire 2nd hand smoke /heart attack issue is a hoax, what about all those asthmatics that have to use rescue inhalers when they encounter it? What about all the studies that demonstrate a correlation between passive smoking and lung cancer death rates? (Not withstanding study after study demonstrating heart attack risk). Tell your theory to the pt.(and many others) I've cath'd whose spouse smokes 2ppd in their home and now the non smoking pt. has coronary artery disease too, (couldn't even PCI her Cx). By the time a child becomes 5 years of age, if they are living in a household with one parent smoking, they've already smoked the equivalent of over 2000 cigarettes, which again, common sense tells you isn't good for healthy young pink lacy lungs that are meant to breath air that you CAN SEE through. Of secondary importance is that fact that we are spending BILLIONS OF DOLLARS every year on tobacco related illnesses and is a MAJOR reason why KENTUCKY and other states in the tobacco belt are "broke". Lack of education = poverty. In Ky. a 1ppd habit = $8,500/5 years...plenty enough to give a child a college education in-state ($7,000/year tuition which is peanuts compared to some). Surely you are not defending the ability to promote poverty and dying. I would think that would be far more sinister than having an undisclaimed "tie" to RWJF.

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

Mon, 19 Oct 2009 08:11:08 EDT

diagnosed with diabetes. Last post prandial BS was 324 at the 1st hour and 200 at the 2nd hour. Pt. was about to be discharged post PCI with no assessment of carb metabolism. Where do you think he would have landed again in 3 years???? (and still will if he doesn't reduce his weight and adhere to his diet). I wonder how many other patients are going home today post PCI this weekend with unknown Post prandials of 300?Melissa

Coronary events drop in Italy after smoking ban

Mon, 19 Oct 2009 08:04:18 EDT

Considering the ties of Friedman to RWJF, it would be much more convincing if the data was presented for evaluation rather than the conclusions. Research integrity has become very questionable on ths subject and there are more and more people questioning the integrity of the "Researchers" and their motivations.

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

Mon, 19 Oct 2009 07:41:23 EDT

One should bear in mind the possibility of Prinzmetal (nocturnal)angina, where there is no underlying morphological alteration of any coronary vessel,but a high sensitivity to vasospasm, therefore CAC score well may be zero in these individuals- mostly women. Myocardial infarction with normal coronary system is not a rare situation: about 4-5 % of all MI...

CAC scoring helps reclassify intermediate-risk patients

Mon, 19 Oct 2009 07:32:38 EDT

We currently charge $125. I have about an 80% acceptance rate at this price. I have used it extensively for risk stratification and convincing patients to do something about their lipids (diet,exercise, +- meds).

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

Mon, 19 Oct 2009 03:30:56 EDT

Most chest pain centers in the US do not perform acute rest MPI (ARMPI), where the negative predictive value (NPV) of the test for the diagnosis of MI approaches 100% (99-100% in most studies). Rather, a stress MPI is done after a "rule out", consisting of serial negative troponin assays. From what I have read, the NPV of stress MPI for the diagnosis of ischemia / CAD is only 87% (a far cry from the NPV of ARMPI).Given what's currently being practiced, therefore, I'd say that a 96% NPV is pretty darn good, and compares quite favorably to the NPV of a regular stress MPI.From a financial perspective, it also makes a lot of sense. EBCT is cheaper than a stress nuclear scan. Furthermore, it's associated with a lot less radiation exposure (8-10 mSV vs Finally, I would argue that a strategy of CAC first, followed be stress MPI for those with an abnormal CAC score is actually beneficial for those who are ultimately discharged without evidence of ischemia. There is great prognostic information inherent in an abnormal CAC score, and such a strategy would may least lead to risk factor modification and possible therapy in those with an abnormal CAC score, but normal stress MPI.All in all, I think CAC is a great tool to be used in the emergency department. I respectfully disagree with Dr. Hecht's editorial.

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

Sun, 18 Oct 2009 22:54:18 EDT

Nice discussion... Is there information on the pacing provided to the non-CRT arm? Just wondering if there is a higher fequency of non-synchronized(back-up) pacing that was seen in the patients who developed HF?

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

Sun, 18 Oct 2009 22:39:51 EDT

Cathy, when clinical trial report averages they miss all "outlanders"; and usually there are very few of those, so it is not a big deal. In case of ApoE 11% are 2, 25% 4 and the rest 3. Two and 4 have opposite responses to fat and alcohol, and carbs in the diet. So they end up canceling each other and "average" ApoE 3 response prevails. Fish oil 4 g a day supplementation will increase LDL in ApoE 4 patient by up to 45 %, although the particle size will increase as well, and I am not sure what happens with ApoB100. HDL will also drop significantly. LDL response to ApoE is a classic Diagnosis Exjuvantibus - diagnosis by treatment. If your patients LDL goes up and HDL goes down after OM3FA - you can bet they are ApoE4 (or stopped taking their statin)ApoE genotyping is widely available from commercial labs.See more in: Arterioscler Thromb Vasc Biol 2000 Aug; 20 (8): 1990 -7And what Daniel is pointing to is correct as well, on an everage, in patients with high TG.

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

Sun, 18 Oct 2009 19:55:14 EDT

AG- 1,5-anhydro-D-glucitol has been proposed as a better marker for glucose instability than HbA1c. AG is a polyol present in human plasma. It is derived largely from ingestion and its main route of elimination is urinary excretion.Therefore, under the condition of hyperglycemia a competition between glucose and AG for tubular absorption occurs.. Therefore, high glucose increases AG excretion and leads to a net Ag depletion. On kinetic models it has been proposed that Ag monitoring should be able to indicate the presence of past glucosuric hyperglycemic excursions during a period of days to weeks

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

Sun, 18 Oct 2009 19:35:06 EDT

I would propose that post-meal glucose could be considered a marker and or a target for therapy? It would meet three criteria for a cvd risk factor ie; evidence for an independent relationship, a plausible causal mechanism, and risk reversibility by intervention

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

Sun, 18 Oct 2009 19:31:08 EDT

the diabetic population of the NHANES III, showed that 39% of patients with HbA1c <7% had a 2-h OGTT plasma glucose level higher than 198 mg/dl(11.1mmol/l). a percentage increasing to 99% in subjects with HbA1c between 7-7.9%

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

Sun, 18 Oct 2009 19:19:24 EDT

the postprandial contribution to the HbA1c only reflects indirectly post meal excursions of glucose not sustained post meal hyperglcemia in fact it has been demonstrated that these excursions illicit a host of reactions inflammatory pro thrmobotic etc these are of course complex metabolic events HbA1c does not necessarily account for glucose fluctuations, ans meal-time glycemic excursions

Doctor-led "hospital-at-home" care subs for hospitalization in acute heart failure

Sun, 18 Oct 2009 18:58:12 EDT

I know that in the areas where there are HF clinics, their admit rates are way down---I can not imagine what it would be if we could dx and treat at home. I would think that being able to keep people home would have NO negatives, only positives---nosocomial infections -NOT!- sunddowners -NOT!- knowing who is caring for you when you are sick (family there and not miles away) -PLUS!- the ability to have home health inspections daily to access workability of the home for your patient- PLUS!, and on and on! I liken this to hospice in design, but of course not as the "deathbed", but comfort for all. Remember when you had to scrub and gown to go into a maternity ward--even if you were the father????? And NO family visits--siblings ONCE and they were scrupulously scrubbed, grandparetns once with the same treatment? NOW-just about anyone can come in, and all you have to do is WASH your hands before you hold the baby. (I have absolutely NO idea where I was going with that!)Keeping people home in their own "germs" would most likely speed up recovery times.NOW--how to get this passed for insurance and get the rest of the medical community on board???

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

Sun, 18 Oct 2009 16:09:25 EDT

I am not accepting the LDL story on Lovaza; dietary fish does not raise LDL but actually lowers LDL and increases HDL.

Diuretics effective as second-line therapy for hypertension

Sun, 18 Oct 2009 13:23:10 EDT

most notably VA trial where it was used at 50 mg b.i.d. dose as a fixed combo with reserpine and hydralazine. On a surface it was a great trial with great outcomes, however, if you look into components of primary end point a lot of them were components of maliganat HTN, not as relevant for today�s HTN practice. Another thing is that patients in the 70s were different physically and probably pathophysiologically. Few of them had MetSyn HTN typically seen today. But, it was a successful trial. Impressive too. With all the caveats that make it almost irrelevant today. Most of all- 50 mg b.i.d. dose. Veterans with malignant HTN could tolerate it. Little old ladies � is another story altogether. From HTN management perspective I would put them in a class of their own. Bill Elliott is probably right when he says that it is the abbreviation �HCTZ�, or even now �HCT� that is the major reason doctors write HCTZ (oops:) for their patients instead of Chlortalidone or Indpapmide. Very sad. But probably true. It takes pharma about 50 mil to put a new combo of already approved drugs on the market (rumors from 2 years ago). Speaking of lifting up their image�this would be a good thing to do for everyone to change to, or at least add, CLT and/or IND combos. New patent too. But, they would rather spend 100s of mil on Direct to Consumer , or inundating us with reps and mailings and journal ads�

Diuretics effective as second-line therapy for hypertension

Sun, 18 Oct 2009 13:03:26 EDT

There is some ration in prevalence of HCTZ in clinical practice in the US. It was thae first thiazide to go off patent and thus went into fist combos (branded!). Other thiazides came later. Not to contradict to what is written in the above discusssion, HCTZ got a"free ride" from succcessful clinical trials of COMBOS

Diuretics effective as second-line therapy for hypertension

Sun, 18 Oct 2009 11:01:32 EDT

If I am going to use a diuretic, I prefer indapamide or chlorthalidone. Unfortunately, when it comes to combination drugs, the former only comes with perindopril and the latter only comes with atenolol. HCTZ comes with so many more drugs which is unfortunate, very unfortunate.My point was that diuretics are probably overused - and I see a lot of the adverse consequences - the elderly 85 year old woman admitted for a fall and a Na of 115 previously normal and then plunging after starting on low dose HCTZ 2 weeks ago, now fractured hip and 1 year mortality of 25%. Or hypokalemia and atrial fibrillation. etc. Renin profiling should help to select the best responders - that was my only point.I cannot tell you why HCTZ is greatly preferred in the community over chlorthalidone/indapamide - certainly it's not evidence-based medicine. Likely it's marketing and what all the ARBs and ACE inhibitors are combined with.

Next up: Drug-eluting stents for erectile dysfunction

Sun, 18 Oct 2009 03:36:34 EDT

Perhaps because Medtronic is sponsoring the trial and has a DES that needs market share?

Diuretics effective as second-line therapy for hypertension

Sun, 18 Oct 2009 01:17:01 EDT

It is good to hear from a doctor who knows where the medicine as science ends and medicine as an art starts. Thank you.

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

Sat, 17 Oct 2009 23:39:16 EDT

Hi Jason! I highly appreciate your opinion about using DPP4 inhibitor as monotherapy or in combination with metformin which do not cause hypoglycemia. Yes, we should avoid hypoglycemia during treatment of hyperglycemia.DPP4 inhibitors together with GLP1 agonists now considered as novel therapeutic agents for the treatment of type 2 diabetes because of their novel actions on beta cells; preventing beta cell apoptosis and even regeneration of beta cells.In my practice I am not so willing to use DPP4 inhibitors at this moment, why?Although DPP4 inhibitor is considered as novel drug but clinical trials on sitagliptin or vildagliptine are relatively sparse in comparison to metformine and pioglitazone which have years of experience. For example, although romonabant, a new anti-obesity drug has already been approved by FDA, still I do not use in my practice for its psychiatric side effects. Among other two drugs, I prefer orlistat (without systemic effect) over sibutramine, because sibutramine has adverse effects on CVD. In addition to this, many patients who are under treatment with sibutramine, may go for some SSRIs for anxiety depressive illness (common in obese patients with metabolic components) which may cause fatal serotonin syndrome.I like to give another example. Torcetrapib, a CETP inhibitor once revolutionized for its HDL raising action. In 2005 this drug was even manufactured commercially but in 2006 use of this drug was halted during its stage III trial for its adverse cardiovascular events.As a new drug, sitagliptin the first DPP4 inhibitor, already approved by FDA also under some question. �It is likely that DPP IV inhibitors will become widely used in type 2 diabetics, many of whom will have hypertension as a comorbidity��...enhance renovascular responses to Ang II��...this could impair renal function, increase arterial blood pressure, and inadvertently lead to an increased risk of stroke and myocardial infarction.� (Ref: Hypertension. 2008;51:1637.).So, more trials are required to prove a new drug like sitagliptin to be �innocent�.

Doctor-led "hospital-at-home" care subs for hospitalization in acute heart failure

Sat, 17 Oct 2009 22:55:27 EDT

Alexandre, I think that's the way we are going. Can't you just imagine having a practice full of patients whose 02 sats, rhythm stips and BP's are measured at home daily or more and banked somewhere by an independant monitoring company who will report trends and sudden shifts acutely? not to mention daily contacts to reinforce compliance. melissa

Scripps starts routine genetic testing for clopidogrel responsiveness

Sat, 17 Oct 2009 22:42:48 EDT

Finally someone gave a step forward.

Diuretics effective as second-line therapy for hypertension

Sat, 17 Oct 2009 21:05:41 EDT

This type of patient may have obstructive sleep apnea from morbid obesity and will never improve on antihypertensives alone. They may have heavily calcified arteries - good luck to them. The case you describe is very common in my practice. They are not yet on dialysis. Yet their 5-year mortality is probably >50% regardless of what you do. They have late stage disease (if not end stage disease).I would never stop their medications to do a renin/aldo profile. That would be tantamount to malpractice. They will usually end up on every class of blood pressure medication and then some. Good luck.

Diuretics effective as second-line therapy for hypertension

Sat, 17 Oct 2009 13:06:36 EDT

Thank you, Dr. Hackam. I am following this literature with great interst myself and absolutely agree with a value of renin testing and attempts of withdrawal of diuretics in high renin patients, and I see the effect, sometimes profound, in a minority of these patients. They deserve this chance of simplified therapy and I give it to them. On the other hand, in recent Laragh article in AJH (2009;22:112 � free access at nature.com) on Aliskiren over 10% of patients had up to 20+points SBP increase with ARB, ACEI and/or DRI, including medium to high renin Pts. Substantial % of med-high renin patients(~40 by my estimate) had no change in BP with R drugs. Thus, even in high renin patients anti-renin drugs may cause no BP decrease or even �paradoxical� BP increases. I cannot run independent referral HTN practice with this type of success rate. Institutional clinics with �locked� referral patterns may be able to. Good for them � My typical patient is 70+ with GFR 35, DM with end organ damage, 3+ stents, no Hx of CHF. Normal EF, non-stenosed renal arteries by angio, PRA of 12+, aldo of 10+ and BNP of 300+. Neck veins and edema present on 40 BID of furosemide, ACEI, BB and spiro 12.5. SBP of 180. Any takers on taking this patient off furosemide because of high renin? Any takers on stopping all antihypertensives for couple of weeks to determine baseline levels of PRA/Aldo/BNP? PRA guided therapy is much more valuable early on in the course of the HTN. In the real world of real patients who are likely to see HTN specialist it as true and as useful as �buy low-sell high� from your financial adviser.

Diuretics effective as second-line therapy for hypertension

Sat, 17 Oct 2009 10:58:14 EDT

...they actually withdrew diuretics in the arm of patients with high renin hypertension, since the thinking is that they just aggravate hyper-reninemia.

Diuretics effective as second-line therapy for hypertension

Sat, 17 Oct 2009 10:54:01 EDT

cardiobrief.org/2009/07/05/hypertension-pioneer-and-rebel-proposes-a-different-treatment-approach/

Diuretics effective as second-line therapy for hypertension

Sat, 17 Oct 2009 10:53:19 EDT

Please check out:>AndAm J Hypertens. 2009 Jul;22(7):792-801. Epub 2009 Apr 16. LinksPlasma Renin test-guided drug treatment algorithm for correcting patients with treated but uncontrolled hypertension: a randomized controlled trial.Egan BM, Basile JN, Rehman SU, Davis PB, Grob CH 3rd, Riehle JF, Walters CA, Lackland DT, Merali C, Sealey JE, Laragh JH.Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA. eganbm@musc.eduBACKGROUND: Undefined pathophysiologic mechanisms likely contribute to unsuccessful antihypertensive drug therapy. The renin test-guided therapeutic (RTGT) algorithm is based on the concept that, irrespective of current drug treatments, subnormal plasma renin activity (PRA) (or=0.65 indicate renin-angiotensin vasoconstriction excess "R" hypertension. METHODS: The RTGT algorithm was applied to treated, uncontrolled hypertensives and compared to clinical hypertension specialists' care (CHSC) without access to PRA. RTGT protocol: "V" patients received natriuretic anti-"V" drugs (diuretics, spironolactone, calcium antagonists, or alpha(1)-blockers) while withdrawing antirenin "R" drugs (converting enzyme inhibitors, angiotensin receptor antagonists, or beta-blockers). Converse strategies were applied to "R" patients. Eighty-four ambulatory hypertensives were randomized and 77 qualified for the intention-to-treat analysis including 38 in RTGT (63.9 +/- 1.8 years; baseline blood pressure (BP) 157.0 +/- 2.6/87.1 +/- 2.0 mm Hg; PRA 5.8 +/- 1.6; 3.1 +/- 0.3 antihypertensive drugs) and 39 in CHSC (58.0 +/- 2.0 years; BP 153.6 +/- 2.3/91.9 +/- 2.0; PRA 4.6 +/- 1.1; 2.7 +/- 0.2 drugs). RESULTS: BP was controlled in 28/38 (74% (RTGT)) vs. 23/39 (59% (CHSC)), P = 0.17, falling to 127.9 +/- 2.3/73.1 +/- 1.8 vs. 134.0 +/- 2.8/79.8 +/- 1.9 mm Hg, respectively. Systolic BP (SBP) fell more with RTGT (-29.1 +/- 3.2 vs. -19.2 +/- 3.2 mm Hg, P = 0.03), whereas diastolic BP (DBP) declined similarly (P = 0.32). Although final antihypertensive drug numbers were similar (3.1 +/- 0.2 (RTGT) vs. 3.0 +/- 0.3 (CHSC), P = 0.73) in "V" patients, 60% (RTGT) vs. 11% (CHSC) of "R" drugs were withdrawn and BP medications were reduced (-0.5 +/- 0.3 vs. +0.7 +/- 0.3, P = 0.01). CONCLUSIONS: In treated but uncontrolled hypertension, RTGT improves control and lowers BP equally well or better than CHSC, indicating that RTGT provides a reasonable strategy for correcting treated but uncontrolled hypertension.

Doubling dose of clopidogrel benefits STEMI patients without risk of bleeding

Sat, 17 Oct 2009 10:36:29 EDT

In the standard clopidogrel arm patients received a 300-mg loading dose on day 1.Why not 600 Mg?

Expert council focuses on left main PCI: Guideline changes suggested

Sat, 17 Oct 2009 03:30:04 EDT

well, actually it seems that interventional cardiologist always rubbing there hands depending on the rule of occulostenotic reflex!!! we will see the nearest future what it is hidding,,,

Scripps starts routine genetic testing for clopidogrel responsiveness

Sat, 17 Oct 2009 02:04:10 EDT

One could hear in Barcelona this year, there should be a need fot dual,triple antiplatelet therapy due to the threat of stent thrombosis. Now clopidogrel hyporesponsiveness is to be tested in EVERY THIRD pts for elective PCI to be sure, that the incidence of this life threatening complication is to be eliminated... However, statistics show, that in any country acute interventions take up about 35, 40 % of all PCI. What with them? One should just pray, the patient shold not be a subject with hyporesponsiveness? PCI' methodology is changing day by day regarding stents, drug to elute, strut to absorb, post interventional medication, which process far exceeded safety limits.(Leading experts of PCI answer the question if they had to have a stent for a high grade LAD stenosis, which were to choose? BARE METAL STENT is occasionally the answer...) Time is coming to go back to balloon angioplasty, or the well established coronary bypass surgery?

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

Fri, 16 Oct 2009 23:57:12 EDT

Effect of OM3FA on LDL, as well as HDL concentration and subclass distribution depends, quite significantly, on ApoE genotype of a patient. In our clinic we do NOT prescribe over 1 g of OM3FA to patients with ApoE 3/4 or 4/4 genotype due to consistently adverse effect on their lipid parameters and no solid evidence for clinical outcome reduction for OM3FA doses above 1 gram.

Smoking bans reduce the risk of acute coronary events: IOM report

Fri, 16 Oct 2009 23:03:43 EDT

Cultural change is coming for our country and given wings by the chatter on health care reform. Now.....LET'S GET the BALL ROLLING!!! If everyone of you would pick up the phone on Monday and contact your local city council/commission to discuss a COMPREHENSIVE BAN on public smoking (NO EXEMPTIONS ALLOWED ), we could move America swiftly toward this initiative. We can't just show up for work at the office everyday. Now that we have data, we should all feel compelled to be politically active. I'm living in tobacco country and if I can get up every single day and do it, anyone can!!!Wake up America and pump up the volume on the great American smoke out! Then, put some teeth into it by LEADING the way on your local legislation. Melissa

Diuretics effective as second-line therapy for hypertension

Fri, 16 Oct 2009 22:59:36 EDT

Thiazides are not effective as a first line anti-hypertensive therapy in the area where I practice. Blood pressures are seldom controlled if they are used alone. However, chlorthalidone has comparatively a higher degree of efficacy. I wonder why it is not being promoted like HCTZ????

Diuretics effective as second-line therapy for hypertension

Fri, 16 Oct 2009 21:57:56 EDT

And renin testing does not obviate the debate over diuretics. We also use renin/aldo and BNP to guide choices of antihypertensives in all our patients in our referral HTN practice. Life is a little bit more complicated than Laragh's textbook Low/high renin or low/high aldo. Thiazides, and loop diuretics, are frequently needed, along with spiro, in patients who are high renin with/without unsuppressed aldo AND high BNP to achieve "BP goal". And, choosing the diuretics with proven outcomes and same low cost sounds like a rational approach to me...after all,- what's the downside? Upseting pharma making branded HCTZ combos?

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

Fri, 16 Oct 2009 18:52:42 EDT

Shouldn't we just measure waist circumference, or even better, calculate waist-to-hip ratio, rather than run A1c's? I have lots of patients with A1c between 0.05 and 0.055 - I am not sure I would start these on medication. Instead I counsel them to change their lifestyle; does it work? Not always. I do run alot of A1c's, mostly to confirm what you are saying - ie metabolic syndrome.

Diuretics effective as second-line therapy for hypertension

Fri, 16 Oct 2009 18:49:29 EDT

We use renin/aldosterone-profiling to 'pathotype' our patients' hypertension. This obviates the debate over which diuretic to use, since it is only in low renin patients that CCBs and diuretics really lower BP. In higher renin states, RAS activation needs to be targeted. In high aldo states, it is aldosterone that should be targeted. Doing this gets the patient much faster to goal BP than the shotgun driven approach advocated by JNC VII.

New biomarker, galectin-3, shows risk-stratification potential in chronic heart failure

Fri, 16 Oct 2009 18:41:08 EDT

turning augment to monitore CVD-HF patients.

Diabetes: An independent risk factor for AF

Fri, 16 Oct 2009 18:33:07 EDT

Diabetes increasy the risk CVD, because degeneration disease anyway.

Doctor-led "hospital-at-home" care subs for hospitalization in acute heart failure

Fri, 16 Oct 2009 18:15:26 EDT

I consider put high tech medicine at home , at lower cost, giving bigger disponibility of beds in hospitals to another patients with acute diseases and bigger confort for family in owner home.

Early statin therapy in ACS: What's the level of evidence?

Fri, 16 Oct 2009 18:01:39 EDT

Really, I use always as routin early statin, with excellent results same in patients with LDL level < 100.

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

Fri, 16 Oct 2009 17:53:40 EDT

One still has to treat all known (and unknown risk factors) to prevent MACE.Having had the good fortune to treat my patients a number of decades, the low hanging BP and lipid targets have been managed, but to my decade long dismay, subclinical atherosclerosis continues to progress, allbeit at slower pace (even with ldl Gauranga's post #11 outlined nicely the pathophysiology of progressive disease in the setting of well controlled BP and lipids. The MACE benefits of aggressive management of new onset DM did not appear in UKPDS in the first years but did at the 10 year mark. A1c seems to be a rather limited surrogate to gauge the dysmetabolic process linked with visceral fat, but for now, it will do. I am not linked to met/pio, but without SU or insulin, I have not seen hypoglycemia. Don't you think hypoglycemia has been an underestimated and underdiagnosed risk factor. Sleep apnea might be another underestimated factor. Perhaps, Dan, someone will find some genotypes associated with lower levels of glucose and demonstrate a benefit similar to the clinical benefit with lifelong lower cholesterol level linked genotypes.ps Dan, you are correct, this is a very time intensive approach. It works if you can stay on in medicine just to cover overhead and modest living cost.

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

Fri, 16 Oct 2009 17:09:03 EDT

Met/ Pio combo?- why dont you consider another angle- a DPP4 INHIBITOR as add-on to Met? Being weight neutral and similar to placebo with regards to hypoglyceamia, a DPP4 inhibitor is a valuable individualised patient option isnt it?

Osteoporosis drugs hint at slowing aortic-stenosis progression

Fri, 16 Oct 2009 16:02:17 EDT

http://www.ncbi.nlm.nih.gov/pubmed/19179058K2 is used as a osteoporosis treatment in Japan and also appears to reduce vascular calcification.

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

Fri, 16 Oct 2009 14:56:46 EDT

each test has been developed within a group of subjects presenting with their symptoms or not in a specific country. CAC is good for asymptomatic people. Emergency patients develop potentially lethal conditions, e.g. sudden cardiac death. For these, CAC was not developed. CAC is a primary care tool and not an emergency tool. We know that since a long time.

Diuretics effective as second-line therapy for hypertension

Fri, 16 Oct 2009 14:07:28 EDT

Since the only evidence is with chlorthalidone and indapamide and JNC is all about evidence, why not limit the next set of recommendations to the evidence supported diuretics - chlorthalidone and indapamide? Two diruetics should be enough anyway.

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

Fri, 16 Oct 2009 14:06:39 EDT

The question is whether reducing the A1c at lower levels, to delay or prevent the onset of diabetes, with pharmacological therapy, is preventing hard events down the road (5, 10, 20 years).Probably it does, but I know of no hard outcome data showing that it is definite (and Chinese Diabetes Prevention Trial was negative at 10 years for hard events). We may need much longer follow-up and drug compliance to show an effect.Personally I go after BP and LDL first, and aggressively initiate lifestyle modification to stave off diabetes. I only use metformin or pioglitazone in patients who have frank diabetes, not prediabetes. If prediabetic, I tell them that a 10-15 lb weight loss may delay if not outright prevent the onset of diabetes and vascular disease (if it can be sustained - always a question).I think you are being ahead of the curve with your pharmacotherapy and I salute you. I wish I had the time to do everything you are doing in one or even a couple clinic visits. The typical patient I see has either very early abnormalities in plaque and sugars or extremely advanced plaque, BP's over 200 systolic, and needs aggressive investigation and management. I wish we had longer times for patient consultation.

New Canadian lipid guidelines will recommend CRP testing for certain patients

Fri, 16 Oct 2009 13:52:24 EDT

I disagree. You can have a terrible lipid profile, smoke, be overweight, and die at 100 without any vascular events. The only way to know if you're going to get the disease is to check to see if you have it already. This means not doing coronary luminograms but rather subclinical atherosclerosis imaging (in our case not IMT but total plaque area measurements). You could have a terrible lipoprotein profile but some other protective genetic factors that prevent disease - the closer you get to the final common pathway (atherosclerosis), the more accurate your prediction will be, and the better to intervene there.

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

Fri, 16 Oct 2009 12:13:59 EDT

In extremely elevated TGs the LDL-C does increase. This is not due to an increased number of atherogenic LDL particles, this is the physiology of shifting more cholesterol ester into the LDL particle in place of the displaced TGs that Lovaza reduces. If you look at the ApoB particle or LDL-P data, there is NOT a statistically significant change in LDL-P.This nicely demonstrates why LDL-C is guesswork rather than using LDL-P or ApoB particle number. Particle testing is the way of the present, not the future. IF you are not doing particle number testing to assess treatment goals, then I believe you are not adequately assessing or treating your patients lipid risk.For those clinging to ATP-III or waiting for ATP-IV, I suggest you read the apoB consensus document or ADA/ACC Consensus statement on metabolic risk. Particle number (ApoB or LDL-P) trumps LDL-C, Triglycerides, HDL-C and non-HDL-C in predicting risk both on or off medications.Daniel

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

Fri, 16 Oct 2009 10:24:55 EDT

You consider Lovaza has no side effects when it increases LDL 44%? It is in the studies on Lovaza. Purity and Potency are in a FDA Drug Registered manufactured fish oil called Eskimo 3. And efficacy and safety as well. We need to be informed with all the facts!

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

Fri, 16 Oct 2009 00:42:00 EDT

In regard of drug therapy in type 2 diabetes, if not contraindicated or accepted by patient, I prefer to start metformin. Secondly I go for pioglitazone (not rosiglitazone as TZDs) if patient is not in any stage of heart failure as per NYHA classification or any signs of osteoporosis (by bone densitometry in elderly patients). I also try metformin and pioglitazone in combination before going for any insulin secretagogues or insulin as these two drugs either in monotherapy or in combination do not cause hypoglycemia.For overweight or obese, I prescribe pioglitazone selectively. Although pioglitazone increases adipose tissue, but it increases subcutaneous (not visceral) fat leading to increased secretion of adiponectin beneficial to reduce insulin resistance, chronic inflammation and other metabolic abnormalities.

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

Thu, 15 Oct 2009 21:10:52 EDT

I do appreciate your being "edema" sensitive: )

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

Thu, 15 Oct 2009 20:24:44 EDT

In a world of buyer beware supplements, at least you know what your getting with an FDA approved PUFA and there is no negative effects to the patient due to the purity and potency of the EPA/DHA content.

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

Thu, 15 Oct 2009 20:01:20 EDT

Dan, somewhat in jest, I was going back to Melissa' query (10/13 9:50) re the conservative 6.5% American vs 5.7% European standard. I was suggesting most of us personally would like an optimal rather than evidence based or cost effective target, perhaps an a1c of 5%.For diabetes prevention, I always use weight loss and exercise first. In the presence of subclinical atherosclerosis, I will start met +/-Pio earlier than most, even with a1c 5.7-6.5%.In diabetes prevention trog beat life style and met (before being pulled for liver effects, 1 year into the study). Pio has and is showing a similar order of benefit in prevention.........and yes Melissa, I do watch for edema so a cardiologist or ER does not need to bail out the tzd patient :)

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

Thu, 15 Oct 2009 18:28:19 EDT

Steve,It sounds like you use drug therapy (metformin/pioglitazone) in patients with suboptimal HbA1c, i.e. >0.05 (i.e. 5%), to prevent onset of type II diabetes. This is not as effective as weight loss and exercise. I have not yet taken this approach as I do not see the evidence on long-term benefits but perhaps am wrong.

New Canadian lipid guidelines will recommend CRP testing for certain patients

Thu, 15 Oct 2009 13:58:39 EDT

I agree CAC has great predictive value, but let us not forget that for $30 (checked with local labs in NJ) you can get ApoB particle number which can be non-fasting and provides greater prognostic information then LDL-C, non-HDL-C, HDL-C or triglycerides or any ratios. I urge anyone who practices preventive cardiology to read: Current Opinion in Lipidology 2009, 20:282�287. Provides great analysis of JUPITER trial and how hs-CRP is not reason people benefited from statins. Simple message: Check ApoB particle or LDL-P. Consider CAC or CIMT for dictating treatment goals and risk. No homocysteine, Lp(a), LPLAC-2, IL-6, yada yada. Start with the basics, if you aren't treating those adequately, then in my humble opinion, you are wasting time and money checking all the other "advanced tests".Daniel

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

Thu, 15 Oct 2009 13:54:02 EDT

I welcome the house of scientists who target lowering blood pressure and hyperlipidemia first than A1C.What are the main causes of death, properly speaking �sudden death� in diabetes? Answer will be cardiovascular causes. These causes may be due to both hypoglycemia and hyperglycemia. About hypoglycemia related death has been described above.Hyperglycemia induced hypertension and atherosclerosis are the main causes of sudden cardiovascular deaths; acute myocardial infarction and stroke in diabetes. Microvascular related death e.g. end stage renal disease (ESRD) needs years to take place.If we ignore autoimmune etiology of type 1 diabetes, insulin resistance is the main pathophysiological factor for the development of not only type 2 diabetes but all cardiometabolic risk factors.Type 2 diabetes is not an isolated disease but it is one of the outcomes of insulin resistance syndrome. Obesity and myriads of other factors by acting on insulin receptors prevent series biochemical reactions inside of the cell responsible for translocation of GLUT4 receptors on the cell membrane leading to prevention of transport of glucose molecules into the cells, hence insulin resistance develops.Two main consequences of insulin resistance are hyperinsulinemia and dysglycemia.Hyperinsulinemia stimulates sympathetic activation, increased secretion aldosterone and angiotensinogen. All these factors are responsible for development of hypertension.Dysglycemia e.g. hyperglycemia firstly can damage endothelium directly. Secondly, hyperglycemia induced advanced glycosylated end products (AGEs) reduce endothelial nitric oxide synthase (eNOS) leading to reduction of NO and ultimately vasoconstriction and hypertension. On the other hand AGEs induce oxidative stress producing excessive amount of reactive oxygen species (ROS). More ROS lead to more oxidized LDL particles (ox-LDL-P) and increased penetration of these particles in to the sub-endothelial macrophages to for foam cells, hence speeding up the atherosclerotic process.As we know that at the time of a newly diagnosed type 2 diabetes patient, about 50% of beta cells are already dead. Death of beta cells takes place long after the development of insulin resistance and hyperinsulinemia and insulin resistance develops even a decade before the first diagnosis of type 2 diabetes.As per the mechanisms described above, endothelial dysfunction and related atherosclerosis and process of development of hypertension occur many years before the patient first knows that he or she has type 2 diabetes.Type 2 diabetes is a chronic inflammatory, vascular metabolic disease. To treat type 2 diabetes patient, main target should not be to treat hyperglycemia, should not aggressively make A1C �as low as possible� but to target other metabolic abnormalities like lowering blood pressure, treating dyslipidemia. Other targets should be to reduce chronic inflammatory process and maintain or restore endothelial integrity. For these reasons lifestyle modification along with ASA, ACEIs or ARBs and statins can be encouraged to use. For exceptionally beneficial effects including regeneration of endothelial progenitor cells, statins should be used in all patients with type 2 diabetes even before prescribing anti-diabetic agents. If we can minimize inflammatory process, restore vascular integrity, reduce insulin resistance by proper diet and physical exercise and other metabolic abnormalities, we can significantly reduce risk of diabetic patients without using aggressive anti-diabetic agents.

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

Thu, 15 Oct 2009 12:59:34 EDT

Thanks for pointing out the error, it's been corrected.

Diuretics effective as second-line therapy for hypertension

Thu, 15 Oct 2009 12:03:02 EDT

If you apply cold rational thinkihg and ask yourself a question "who benefits",- the answer inevitably comes to only two parties:pharma...and...social security trust fund.I would to hear any other explanations, rational or not.

Scripps starts routine genetic testing for clopidogrel responsiveness

Thu, 15 Oct 2009 10:56:08 EDT

Lot of controversy exist over mixing these two therapies. What is the answer?

Scripps starts routine genetic testing for clopidogrel responsiveness

Thu, 15 Oct 2009 09:53:41 EDT

who pays for the test?

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

Thu, 15 Oct 2009 08:49:59 EDT

Melissa, we would probably want to have an A1c of BP and lipids are low hanging fruit, first attended.

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

Thu, 15 Oct 2009 07:25:25 EDT

that I try to impress a patient that they are glucose intolerant because they have a GTT with a post prandial 1 hour of 180. Then, they have a HbAic and someone tells them it's "normal", so they feel they have no pathology.Melissa

Coronary thrombosis�the culprit is not just plaque rupture

Thu, 15 Oct 2009 07:22:57 EDT

MarceloI sometimes am suspicious that this same phenominon occurs after a meal with extremely high fat content. It might not be that the symptoms of angina are just "indigestion" and therefore equated with a meal, but could it be that the foods that often cause indigestion are also changing acutely the density of microparticles in the coronary circulation leading to thrombosis as well?Melissa

Expert council focuses on left main PCI: Guideline changes suggested

Thu, 15 Oct 2009 07:16:56 EDT

was present for changing the guidelines for life saving primary PCI without surgery onsite. THERE IS DATA FOR THAT just a shameful lack of enthusiasm. So while we are changing guidelines, let's not forget the dying patients who languish without an option for lytics in hospitals WITH cath labs and the capability to save a life and dollars. Yep, off topic, but a timely one at that. I'm all for progress but first things first. Think about it.Melissa

Diuretics effective as second-line therapy for hypertension

Thu, 15 Oct 2009 02:15:28 EDT

All evidence in cardiovascular events reduction in "thiazides" group are chortalidone, no hctz.Why all farmacology laboratories use fixed combinations hctz with BBblokers, ACEI, ARB o CCB??

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

Thu, 15 Oct 2009 00:28:37 EDT

I have found that omega-3 fatty acid in the 2 to 4 gm doseage range can be profoundly beneficial for heart failrue. In addition, replacing testosterone adds a remarkable quality of life benefit.

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

Thu, 15 Oct 2009 00:26:21 EDT

Did they mean spironolactone for heart failure, I don't think that treating with aldosterone would be a good idea.

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

Wed, 14 Oct 2009 21:55:21 EDT

Dan, I fully agree, we have great safety and efficacy in rx of bp/lipids.UKPDS 10 year f/u reminds us to attend to the smoldering legacy of diabetes, and cautioned by Accord, avoid hypoglycemia. Amazingly political discussions on health care planning in the USA continue to avoid confronting the obvious pandemic of obesity feeding our A1c's. We will probably have less time in the future for diabetes management given fiscal constraints.

Coronary thrombosis�the culprit is not just plaque rupture

Wed, 14 Oct 2009 18:00:15 EDT

I would wander if part of the so called erosion derived clots are not caused by thrombogenic microparticles, containing tissue factor, as those described by Y.Nemerson as causing the no reflow phenomenon. In my PhD thesis, I have studied microparticles from blood of PCI submitted patients, and there is an increase in platelet, endothelial and leukocyte microparticles after PCI. Those microparticles had the capacity of generating reactive oxygen species, and increased apoptosis rate of endothelial and vascular smooth muscle cells in culture.

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

Wed, 14 Oct 2009 17:22:43 EDT

There are new data from NHANES to suggest that physicians are preoccupied with glucose/HbA1c at the expense of lipids and blood pressure, for which there is ample evidence for prevention of macrovascular events. In a busy clinical practice with a patient who has 3 or 4 problems it becomes critical to prioritize, and this mistaken preoccupation with HbA1c and HbA1c thresholds is simply going to compromise care, as was evident in the outcome of ACCORD.

Diuretics effective as second-line therapy for hypertension

Wed, 14 Oct 2009 16:57:57 EDT

ALLHAT was done entirely in US by NIH and used a "thiazide" -Chlorthalidone - with no market share alone or in combination to speak of, instead of HCTZ which had almost entire market. Why?Anybody who had seen results of MRFIT (Circulation 1990;82:1616-28) knows why - increase in mortality and CV events in HCTZ based clinics vs usual care (i.e. no medication); while chlorthalidone based clinic showed the opposite resuls prompting changing protocol to chlortalidone only...And then "bait and switch" occurred with ALLHAT and JNC 7 calling chlrtalidone a thazide and HCTZ a thiazide and selling us iron for gold. If gold is a metal and iron is a metal and gold is precious that does not make iron precious. At least in my world. If we were to speak of diuretics consistently improving outcomes of patients (and not just office measured BP) � let�s call them by their appropriate names � not �thiazides� � but Chlorthalidone and Indapamide.

PLATO shows benefits of ticagrelor over clopidogrel

Wed, 14 Oct 2009 15:40:41 EDT

Kiran,I have a feeling that one issue will reign king over the future decision tree for antiplatelet choices: cost. If the Tigacrelor folks are smart, they will price their product just a little above generic clopedigrel. That way, they can capture the market away from both clopedigrel (being much more efficient but just a little more costly), and Effient (just by being a little more efficient and a lot LESS costly).If it's very costly, MOST patients will be forced into using generic clopedigrel. For once, I'd like to see a brand new compound come onto the American market without raping those patients who need really need it. We shall see. $5.00/pill US would be an embarrassing shame and enough to recommend clopedigrel period. Melissa

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

Wed, 14 Oct 2009 15:27:11 EDT

This was one of the most indepth looks at where we stand with PUFA's and CHF that I've seen to date. I really enjoyed it as well!Melissa

Diuretics effective as second-line therapy for hypertension

Wed, 14 Oct 2009 15:03:43 EDT

I read your aricle on BP and will talk to "my" doctor. It is very hard to fing right combination for me. Can not take beta blockers.Thanks very much

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

Wed, 14 Oct 2009 13:15:13 EDT

I enjoyed the puns & discussion. Note that Hertzel Gerstein has a trial in the works looking at this therapy in a diabetes population:Am Heart J. 2008 Jan;155(1):26-32, 32.e1-6. Epub 2007 Nov 26. Rationale, design, and baseline characteristics for a large international trial of cardiovascular disease prevention in people with dysglycemia: the ORIGIN Trial (Outcome Reduction with an Initial Glargine Intervention).Origin Trial Investigators, Gerstein H, Yusuf S, Riddle MC, Ryden L, Bosch J.AIMS: Impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and diabetes arise due to insufficient insulin secretion and are risk factors for cardiovascular (CV) events. Thus, targeting normal fasting glucose levels with insulin may reduce CV events. Previous studies suggest that omega-3 fatty acid supplements may reduce CV death; however, their effect in high-risk dysglycemic individuals is not known. METHODS: People aged > or = 50 years with evidence of CV disease and with IFG, IGT, newly detected or established diabetes (on 0 or 1 oral agent), and a local glycated hemoglobin

Diuretics effective as second-line therapy for hypertension

Wed, 14 Oct 2009 12:55:39 EDT

It would appear that Dr. Messerli has a double edged sword bias against HCTZ and BBlockers for treatment of hypertension. This vendetta is not supported by evidence or my personal clinical experience. Not all patients react in the same manner to any given antihypertensive medication. All available options need to be kept on the table, and the very large ALLHAT trial should not be swept under the carpet as irrelevant. Amlodipine is not the big winner that Dr. Messerli would like current day practice to reflect.

Diuretics effective as second-line therapy for hypertension

Wed, 14 Oct 2009 11:34:22 EDT

To my knowledge MRC used a fixed combination of hydrochlorothiazide 25 mg and amiloride 2.5 mg and EWPHE it was hydrochlorothiazide /triamterene. It has been well documented that the potassium sparing drugs mitigate some of the adverse effects of the thiazides. In SHEP, patients who developed hypokalemia on diuretic therapy did not experience any morbidity or mortality reduction compared to placebo despite a significant fall in blood pressure. Thus, fixed potassium sparing combinations have different effects than hydrochlorothiazide alone.

RE-LY: Oral antithrombin dabigatran outshines warfarin in atrial fib

Wed, 14 Oct 2009 10:07:52 EDT

How reliably can we see these results in our practice before we can rely on these data?

PLATO shows benefits of ticagrelor over clopidogrel

Wed, 14 Oct 2009 10:04:40 EDT

The quick action and the rapid offset with reversibility will make Ticagrelor the best agent by far Watchout Effient and Plavix

For the At-Risk Acute Coronary Syndrome Patient: The Era of Triple Antiplatelet Therapy

Wed, 14 Oct 2009 09:38:17 EDT

Thanks for this excellent presentations by all speakers. and also special thanks for theheart.org for always providing the most up-to-date conferences

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

Wed, 14 Oct 2009 08:52:00 EDT

Yes. Higher levels of Lp(a)?Higher levels of A1C?Lower levels of Vit D (because of darker skin)?My thought: higher levelsof grains less vegetables than in the past.No meat and fish does mean something.What is the source of Iodine forIndians for example?Something to think about.Thanks.

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

Wed, 14 Oct 2009 07:16:18 EDT

Steven,that vitamin C and E information is a pearl I shall tuck into my peripheral brain for further reference. Thanks so much!Melissa

Diuretics effective as second-line therapy for hypertension

Wed, 14 Oct 2009 04:11:01 EDT

Dr. Messerli is incorrect when he says first-line HCTZ has not been shown to reduce morbidity and mortality outcomes. If he reads our review Wright JM, Musini VM. First-line drugs for hypertension. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD001841. DOI: 10.1002/14651858.CD001841.pub2, he will see thatboth EWPHBPE and MRC-elderly trials used first-line low dose HCTZ and were associated with significant reductions in total cardiovascular events (RR about 0.70 of the same magnitude as other thiazides and thiazide-like drugs).

Combination Therapy and Cardiovascular Events: A Neurologist's Perspective

Wed, 14 Oct 2009 00:42:20 EDT

is bayer aspirin is good to take for the heart?alone with my others meds.?

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

Wed, 14 Oct 2009 00:35:50 EDT

Melissa, from NGSP (National Glycohemoglobin Standardization Program) >>Other factors: Vitamins C and E are reported to falsely lower test results, possibly by inhibiting glycation of hemoglobin <<

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

Wed, 14 Oct 2009 00:13:19 EDT

Melissa, I look at 5.7 - 6.5 as a risk factor much like managing prehypertension. All these gray areas lend themselves to clinical judgment and individualized therapy. Yeah!The A1c measurement is directly influenced by red cell survival. False normalization of a1c could be the result of shortened red cell life due to hemolysis, subacute blood loss and erythropoitin use.A 2 point a1c rise could come from sickle cell trait or other hemoglobinopathy (depending on methodology). www.ngsp.org can help match hemoglobinopathy/ a1c methodology reliability.Extended red cell life in some of the deficiency anemias could also raise a1c out of proportion to glucose levels due to a disproportionate number of older red cells.I find the a1c less helpful in advanced renal disease. For the vast majority of patients a1c is still more reliable correlate of glycosilation burden and does not require control of food intake prior to measurement.

New joint statement streamlines definition of metabolic syndrome

Tue, 13 Oct 2009 21:54:13 EDT

Couldn't agree more. I've spent gallons/liters of glucola on my patient population in the past three years. (thanks to Gabrielle Stegg for saving lives in Glasgow Kentucky!) and I've diagnosed on average 3-5 new "diabetics" per week. Just today, a patient with moderate CAD, pci'd 9 years ago had post prandials of 204 and 203 at 1 and 2 hours. Yet, she had argued that she was NOT diabetic and "had been checked" multiple times in the past (but not with a GTT). Her chief complaint was fatigue. If we haven't glucose challenged out patients with CAD or obesity, we have not completely worked them up in my book. Melissa

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

Tue, 13 Oct 2009 21:50:13 EDT

I have a couple of questions for all you A1c gurus:1. upon what literature do we base the difference in acceptable A1c between European and American standards? We seem perfectly happy with an A1c of 6.5 whilst the Euopeans seem more militant with an A1c goal of 5.7?2. Why is it that A1c's can be "normal" with post prandial sugars of 250 range? Melissa

Music therapy lowers blood pressure and reduces reinfarction rates in ACS

Tue, 13 Oct 2009 18:04:48 EDT

music therapy also reduces afib

Next up: Drug-eluting stents for erectile dysfunction

Tue, 13 Oct 2009 10:39:46 EDT

TO THE AUTHORS:AND AFTER STENTING? CLOPIDOGREL AND AAS WILL BE NECESSARY? HOW LONG?

Mercury/blood-pressure link should guide fish choices

Tue, 13 Oct 2009 10:14:45 EDT

Issues of mercury and the sustainability of the fish supply are important, but should not preclude efforts to restore the balance of omega-3 to omega-6 fatty acids in the diet. There are now omega-3 preparations isolated from algae that can be farmed without depleting the supply of salmon, and with no risk of mercury exposure...

Early statin therapy in ACS: What's the level of evidence?

Tue, 13 Oct 2009 04:00:01 EDT

Dr. Waters has not kept up with the ACC/AHA Recommendations regarding risk of another MI after ACS. The last 2 statements state the initial ONE month has a high risk, not six months. The six month idea was dropped in 2002, I believe. The most recent 2007 guidelines continue with the one month as highest risk and call for assessing functional capacity to identify risk, not a time period after the first 30 days.(1) His statement may mislead readers and probably should be corrected. 1. Fleisher LA et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines . Circulation 2007;116(17):1971-96.

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

Tue, 13 Oct 2009 03:22:50 EDT

... because sometimes the cure is worse than the ill.

New Canadian lipid guidelines will recommend CRP testing for certain patients

Tue, 13 Oct 2009 01:08:31 EDT

Order multiple novel biomarkers and half will indicate an increased risk and half will indicate a decreased risk. The patient will be $1,500 dollars poorer and the clinician will be minimally smarter. Order one coronary calcium score and the clinician will know with great precision the individual patient�s risk and will have a baseline marker to measure residual risk after treatment. For a small fraction of the cost of measuring multiple biomarkers, you get much better information.

US cardiologists in short supply, and the problem could get worse

Tue, 13 Oct 2009 00:51:42 EDT

It remains a puzzle to me why these editorialists are so inclined to allow the current tragedy of undiagnosed and untreated heart disease to continue when we have a technology, coronary calcium imaging, that can meaningfully change this medical debacle. I assume these �experts� are not involved with patient care on the front lines and therefore do not need to explain why a loved one is dead despite following their advice and yet they still died from undiagnosed and untreated heart disease.We screen for colon cancer which will occur in 6% of the population and cause 50,000 deaths every year with an expensive and invasive colonoscopy. Yet we refuse to screen for coronary disease which affects 50% of the population and will cause 800,000 deaths a year and have an economic consequence of 480 billion dollars a year with a safe and inexpensive calcium score. 150,000 Americans every year die from their first symptom of undiagnosed atherosclerotic coronary artery disease. Current risk factor assessment mischaracterizes the majority of subjects at risk for heart attacks. To wait another decade before we use coronary calcium imaging that has proven to be accurate, safe, inexpensive and dramatically better than anything else we have available strikes me as unconscionable. 1.5 million Americans dying from their first symptom of undiagnosed heart disease while we wait another decade to get more information doesn�t bother them?

New joint statement streamlines definition of metabolic syndrome

Mon, 12 Oct 2009 22:15:17 EDT

Bravo to all above, but what is really driving CV risk in the new millenium is Metabolic Syndrome and Diabetes = Metabetes! As a cardiologist, I don't really treat your hyperglycemia, but I had better be very knowledgable about the risk factors and clustering of risk factors that end up progressing (we hope not!) to CVD.

US cardiologists in short supply, and the problem could get worse

Mon, 12 Oct 2009 18:22:14 EDT

"The group [the editorialists] calls for a study to test the current traditional risk-factors approach with one supplemented for subclinical atherosclerotic screening to determine whether it reduces events and saves lives." I take this to mean that while calcium scoring is thought provoking, it isn't ready for prime time mass screening of populations despite how much sense it may make. Again, HRT, PSA screening, come to mind along with controveries in mammography and lung cancer screening.

Coronary thrombosis�the culprit is not just plaque rupture

Mon, 12 Oct 2009 14:30:58 EDT

THIS IS A VERY INTERESTING TOPIC. WE DEVELOPED IN OUR CLINIC A STRATEGY FOR THE TREATMENT OF AMI ( IT IS A GRANT), HAVING IN MIND THESE ASPECTS; LOCAL INTRACORONARY EPTIFIBATIDE DELIVERED DIRECTLY IN THE THROMBUS( FOR THE YOUNG TRHOMBUS) FOLLOWED BY THROMBASPPIRATION (FOR THE OLDER) FOLLOWED BY STENTING. WITH THESE 2 PROCEDURES, WE TRY TO PROTECT THE MICROCIRCULATION, EVALUATED BEFORE AND AFTER THE PROCEDURE PROF DR ADRIAN IANCU CLINIC OF CARDIOLOGY CLUJ UNIVERITY OF MEDICINE motu_iancu@yahoo.com

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

Mon, 12 Oct 2009 14:08:30 EDT

I think it is really very tough to set a universal goal for HbA1C. Key cornerstone strategy to treat hyperglycemia should be to avoid hypoglycemia. Hyperglycemia creates problems slowly but hypoglycemia can kill a patient within seconds.In my clinical practice I have number of older patients who have not developed any signs of retinopathy during 15-20 years follow ups having A1C >9%. Although there are lots of evidences that stringent glycemic control bring benefit in terms of microvascular complications which are long term process, but recent ACCORD, ADVANCE and VADT trials could not prove any benefit of tight glycemic control in terms of macrovascular events.What happens when hypoglycemia occur?1. Symaptho-adrenal activation.2. Counter-regulatory hormone responses e.g. decrease in insulin and increased secretion of glucagon, epinephrine and nor-epinephrine, cortisol, growth hormone and vasoprassin.Both these two counter-regulatory mechanisms lead to glycogenolysis and gluconeogenesis to restore blood glucose level to normal.In non-diabetic subjects with intact vasculature, hypoglycemia (either real or relative) and counter-regulatory processes go unnoticed, but diabetic patients specifically who are suffering from diabetes for years, having gross endothelial dysfunction can not tolerate this process who develop myriads of outcomes, some of those may be life threatening.Firstly, hypoglycemia in diabetic patients induces ischemia causing either myocardial infarction or stroke.Secondly, direct action of hypoglycemia induced catecholamine on myocardium and hypokalemia through action on Na+/K+ ATPase leads to prolonged myocardial repolarization causing long QTc and QTd which ultimately cause Torsade de Pointes (TdP) ventricular tachycardia (VT) and death.Thirdly, patients with long standing diabetes develop autonomic failure and tight glycemic control causes hypoglycemia desensitization which leads to hypoglycemia unawareness causing neuroglycopenia and death without any previous symptoms.The above pathophysiological mechanisms can happen not only in patients with real hypoglycemia but in patients having relative hypoglycemia who has long standing history of hyperglycemia.In my practice, I follow:1. Not to create hypoglycemia during treatment of hyperglycemia.2. Apply stringent glycemic control to patients with newly diagnosed patients with age 3. Individualize HbA1C according to age and response to anti-hyperglycemic agents.4. Gradual glycemic control instead of aggressive, to reduce risk of fatality by the cost of little microvascular change.

New joint statement streamlines definition of metabolic syndrome

Mon, 12 Oct 2009 12:29:38 EDT

Scientific, Epidemiological and Clinical communities welcome this step, but still is not enough. I agree with Pio Navarese, there are other indices (Homa, for instance). My colleagues from PHC confirm what Tatar assures, it is more useful the comprehensive approach and not just the individual risk factors. Unfurtunately, many clinicians do not use this approach, they do not accept this "cluster" as a syndrome. As a matter of fact, one has to accept that this problem is becoming relevant in developing countries and we need to come to a standardised definition of the Met Synd for the benefit of our populations.

There's Triple Vessel Disease and Triple Vessel Disease: Risk Assessment

Mon, 12 Oct 2009 12:11:55 EDT

BECAUSE OF HIGH RISC OF RESTENOSIS.LVF-?

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

Mon, 12 Oct 2009 10:05:22 EDT

This study demonstrated that compliant patients do better, probably because they are also compliant with lifestyle, diet and exercise in addition to medications. Interesting results but I believe it to be too good to be true as a consequence of statin plus ACE alone.

US cardiologists in short supply, and the problem could get worse

Sun, 11 Oct 2009 22:13:49 EDT

Michael,I whish I understood what you are saying. Can you expand?

New joint statement streamlines definition of metabolic syndrome

Sun, 11 Oct 2009 10:27:34 EDT

However given the "cluster" definition which entails several clinicalfactors, it might be useful to use more reliable indices as Insulin Resitance and HOMA.

Tips for building the ideal lab for transcatheter-valve procedures

Sun, 11 Oct 2009 10:18:44 EDT

polyurethane and others components

Next up: Drug-eluting stents for erectile dysfunction

Sat, 10 Oct 2009 10:46:00 EDT

it is interseting that there was high incidence of pudendal artery stenosis in patients with cad. But how much it be useful to do angioplasty in these patients will be interesting to watch. where is the exact origin of pudendal artery. Can we see an angio picture of stenosis of pudendal artery stenosis?

Doubling dose of clopidogrel benefits STEMI patients without risk of bleeding

Fri, 09 Oct 2009 10:26:08 EDT

The impact on patients undergoing EECP is not included. Please mention any studies relating to this or if such studies have been made.

Beyond Control of Hypertension to Prevention of Renal Damage

Fri, 09 Oct 2009 02:11:19 EDT

This is a good benifit to control HTN by Blocking RASS system to prevent Microalbuminuria.

New joint statement streamlines definition of metabolic syndrome

Fri, 09 Oct 2009 00:08:08 EDT

This is the best glopal definition about METABOLIC SYNDROME.

Experts debate bariatric surgery as a cure for diabetes

Thu, 08 Oct 2009 19:32:30 EDT

A safer, non-surgical, alternative for weight loss, which patients can individually control, using approved DM agents is combining the available well researched and effective analogue agents for the human endocrine agents (a) glucagon-like-peptide-1 and (b) amylin.Additionally, for faster short and better longer term glycemic response, they can along take the insulin sensitizer pioglitazone which does not reduce weight but does reduce associated insulin resistance and is associated with reductions in coronary plaque volume as documented in the Periscope trial.1. Both glucagon-like-peptide-1 and amylin are reduced in individuals with type II DM, are directly involved in the system of apatite suppression humans are born with.2. Strong basic science evidence already exists that much of the improvement in obesity and reduction in apatite associated with bariatric surgery is associated with the marked increase in glucagon-like-peptide-1 output from the lower small bowel K-cells after gastric bypass.3. The analogue agents (already clinically available) have an excellent track record for safety in both clinical trials and subsequent post approval usage, and4. Both agents have a track record of weight loss, though mild and variable from person to person if only used by themselves and only at currently promoted doses.However, if the two analogue agents are used in combination by patients, even just once daily, more so if twice or three times daily, patients typically achieve both dramatic success in reduction of apatite, body weight and glycated hemoglobin values, including to well below 6.0%. I have seen weight loss rates as much 15-20 pounds/month by patients using the combination.Though (a) combining the two available analogue agents is not currently promoted or FDA validated for commercial marketing, (b) it takes some time to teach patients the issues and be successful with the approach and (c) some patients have difficulty with achieving adequate effective apatite suppression without going beyond to the point of feeling queezy and/or having increased burping for a while, the combination is physiologically appropriate and appears quite safe from extensive trial and clinical evidence. Additionally, a once weekly form of the glucagon-like-peptide-1 analogue is typically 30-40% more effective than the currently promoted twice daily form and will likely be FDA approved within the next 8-12 months.Until the dramatically more effective combination of (a) amylin analogue (b) PYY3-36 and (c) leptin option (or something even more effective and easier), is available, a combination which routinely achieves gastric bypass weight loss outcomes combining the current agents is quite effective, does not entail surgical risks or costs and is often covered by insurance.The major advantage and downside of the above approach is that patient�s retain more control and can decide what they do and don�t do day-to-day and surgeons are not paid for doing a surgical procedure. And of course, if patients don�t follow-through on what works, then their problems continue.

New joint statement streamlines definition of metabolic syndrome

Thu, 08 Oct 2009 18:13:16 EDT

Yes, but in a primary care setting, it is more useful to identify the cluster of risk factors and their multiplicative (not just additive) effect on adverse vascular outcome. This allows for a more integrated concepts of therapy, rather than treating traditionally separate disease of obesity, hypertension, dyslipidemia and diabetes. This traditional separation serves to protect the turf of the specialist, but does not yield optimal integrated therapy for the patient. I thought vascular biology had brought an end to this approach.

Experts debate bariatric surgery as a cure for diabetes

Thu, 08 Oct 2009 17:54:48 EDT

An alternative procedure is gastric sleeve (lateral stomach is removed to create a tube shaped stomach). It can be performed laparoscopically, apparently relieves sense of hunger (personal communication from patient), and can be remarkably inexpensive. Total cost for my informant's procedure was $15,000 and included hospital, surgeon's fees, anesthesia fee as well as 18 mo. of post op followup. The group also arranged with the hospital to cap hospital fees for complications to $75,000.\The cap on costs for complications suggests that the hospital concluded that the risk of high cost complications is quite low.

IRIS confirms: No survival gains from early post-MI primary-prevention ICDs

Thu, 08 Oct 2009 17:12:18 EDT

This question should be answered in Dr Jeffrey Olgin's NIH sponsored Vest/Predicts trial. Pts are randomized in a 2:1 fashion to the wearable lifevest or no vest for 60 days post mi , EF <35%.

For the At-Risk Acute Coronary Syndrome Patient: The Era of Triple Antiplatelet Therapy

Thu, 08 Oct 2009 15:11:58 EDT

Wish to thank all speakers for the valuable presentations!

Experts debate bariatric surgery as a cure for diabetes

Thu, 08 Oct 2009 14:31:51 EDT

Appreciate the courageous (and VERY TRUE) statement of Dr John Buse in this article - in the two studies, based on which, some bariatric surgeons are selling gastric bypass to non weight qualified diabetics, NONE of the researchers used the word "Cure". They only used the word "REMISSION". And in the Swedish Obesity study which did a check up on the 10th year post op, they found that only 36 percent of the diabetics were still "disease free" (SOURCE: New England Journal of Medicine: Volume 351:2683-2693 December 23, 2004 Number 26 Lifestyle, Diabetes, and Cardiovascular Risk Factors 10 Years after Bariatric Surgery Lars Sjostrom, M.D., Ph.D et al) To keep in mind is that even with a diabetic diagnosed in 1994, 5 weeks on the weight watchers program reduced his BSLs to normal before he'd lost much weight - he's 65 and had only lost 15 lbs. I loved Dr Buse's analogy to lobotomy (pushed in the 1940's for "behavioral disorders") - again excellent analogy. Dr Rudy Leibel, obesity researcher called the gastric bypass, a "draconian" solution. I really enjoy this newsletter ("Theheart.org") so thanks for excellent health and medical reporting!

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

Thu, 08 Oct 2009 14:11:56 EDT

CHEP recommendations are available on the following website: www.hypertension.ca ACE-I - ARB combination is not recommended if there is no compelling indication like CHF or severe kidney disease when one thinks that more ACE inhibition may be required.

HORIZONS AMI: Bivalirudin reduces bleeding, adverse clinical events in STEMI

Thu, 08 Oct 2009 14:11:43 EDT

NO COMMENTS ON ACT GUIDANCE WITH BIVALURIDIN UNLIKE HEPARIN AND REOPRO

Experts debate bariatric surgery as a cure for diabetes

Thu, 08 Oct 2009 14:04:34 EDT

Too much questions to do, too much answers pending. We need a long term follow up trial

REVERSE, MADIT-CRT make case for extending CRT to mild heart failure: Should guidelines change?

Thu, 08 Oct 2009 03:58:22 EDT

What is the diference between guidelines and practice?What should be done to provide the best treatment to each patient?MADIT-CRT seems to provide clear evidence that CHF patients benefit from early CRT intervention.It will influence changes in guidelines. However, efforts need to be made worldwide to improve their implementation.