theheart.org Comments

Hibiscus tea reduces blood pressure

Tue, 18 Nov 2008 15:35:42 EST

There is a secondary agenda here. This study was funded by the largest producer of herbal teas in North America. They're trying to sell their product, just like the drug companies.

APPROACH: Rosiglitazone doesn't affect atherosclerosis progression in diabetics with CV disease

Tue, 18 Nov 2008 13:18:23 EST

I would like to know your quibbles with the data. If you have time.

I will re-review the paper and compare notes with you. It's been a long time since I read it.

Bifurcation Stenting: Should You Keep it Simple?

Tue, 18 Nov 2008 10:34:49 EST

Now this is what I call a true solid attempt at imparting high tech knowledge. I am what may be termed a bifurcation addict....which means that on spotting a potentially workable bifurcation I tend to opt for the complex procedure..... and I therefore am delighted with this presentation.

The talk is both lucid and precise..... besides being sensible.

I wish there was a method of downloading the presentation, because over here in Delhi, the broadband is suboptimal and that made the talk a inaudible ( mercifully very briefly) at times.

For the hardcore 2 stenters like me ( the ones that love to put in 2 stents and end the procedure wiit with 2 kisses where required of course) a more detailed version would be even nicer.

But anyway thank you so much. I really found the talk educative and enjoyable.

I keep repeating it..... this website is simply fabulous. Smashing. Tops.

My regards and thanks also to Prof David H Smith.

Thank you!

heartwire journalist wins American Heart Association writing award

Tue, 18 Nov 2008 10:00:19 EST

I have "kept up" on emerging issues thanks to Steve's careful and thoughtful coverage of all the important studies over the past 5 years. This is great recognition for a great medical correspondent.

What are your triglyceride targets?

Tue, 18 Nov 2008 02:15:55 EST

Statistical information on Lipid size for LDL-C small dense LDL is valuable since, small LDL size, even with a normal Traditional Lipid panel.
LDL-c the small dense LDL is a major risk factor even if statins reduce LDL-c to below 70 more so in diabetics. Similarly HDL size and number are important information since a larger proportion of HDL3 is an indicator that HDL is working hard to reverse the small dense LDL and take those small dense triglyceride rich particles back to the liver, HDL-c main function known as RCT (reverse cholesterol transport).
In metabolic syndrome and diabetes, that number may be an important therapeutic decision to prevent events, more so if a cardiac procedure may be anticipated such as PCI or CABG is a possibility in ACS. Stroke rate in PCI and CABG was 2.2% regardless of the succes of either procedure. If Small dense LDL is reduced and HDL2 is increased that stroke rate would be reduced considerably.

What are your triglyceride targets?

Tue, 18 Nov 2008 02:03:25 EST

NMR is the least accurate VAP, Berkley GGE and Quest LIM are much more useful particularly the new Quest Lab Lipid Ion Mibilization which gives an accurate partcile size and number which is much more useful, than either number or size only

Applying New Anticoagulant Data to Clinical Practice

Tue, 18 Nov 2008 01:09:33 EST

i want know about new anticoagulant

APPROACH: Rosiglitazone doesn't affect atherosclerosis progression in diabetics with CV disease

Mon, 17 Nov 2008 21:52:21 EST

Would you like 'candied' walnuts with your salad?

Dan
"3) Clinicians should not have to order BMD and echo before prescribing these drugs as Mike suggests (screening for osteoporosis and heart failure); therefore they should not be considered first-line glucose-lowering agents."

Dan, I don't think anyone is advocating them as first line agents but certainly reasonable as second line agents or for people who need more than 1-2% A1c reduction in combination with other therapies. I agree with the current guideline that advocates tlc and bigaunide first line and bi, su or tzd second line. I also agree with the FDA that current evidence does not warrant the removal of rosi, and since that hearing the data has become even stronger in support of that decision. that's all.

I know how passionate you are about studies and your patient population. I think this is one of those cases where people have painted a picture which has been highly misrepresentative based on politics and special interests. Unfortunately the patient has suffered and continues to do so as this misinformation based on poor science/statistics is propogated.

bon apetite and cheers. mc

Live what you advocate: The exercise habits of busy cardiologists

Mon, 17 Nov 2008 21:08:11 EST

Ilan,
I do believe you are a first!!! I've never met a unicycling cardiologist in my life and I do not believe I ever will again, especially with the caveat of being a "mountain unicyclist". How unique!!! It made me smile to think of it and I applaud your innovation that allowed you to work around your orthopedic limitations. I'm just as focused on protecting my body as I am conditioning it. I think both of those things have to go hand in hand.
Congratulations and thanks so much for sharing!
Melissa

Dr Andre Natale heads up new cardiac arrhythmia institute in Austin

Mon, 17 Nov 2008 19:08:38 EST

Dr. Andre Natale changed my life for the better! After 16 years of chronic and deteriorating AF, he returned me to sinus rhythm for two years and counting. Not one episode of AF in that time. An amazing improvement in quality of life as I now work out at a gym 3 days a week and have improved pulse rate and blood pressure. I waited a year to get his personal services and have never regretted it. I'm so pleased he has his exalted position in Austin, TX.

Updates to the STEMI Guidelines

Mon, 17 Nov 2008 16:07:10 EST

congratulations
it is an exceelent tool to be informed in cardiology

PCI vs CABG in Multivessel Disease

Mon, 17 Nov 2008 10:04:12 EST

thank you all

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP l

Mon, 17 Nov 2008 09:41:45 EST

I agree in some regard. I think this is another study that shows lowering LDL in a 'low risk' population with this age and these demographics shows profound benefit.

Still uncertain how much the hscrp added to the risk prediction or risk reduction. I do however believe that elevated hscrp is bad and having met syn is bad. I have the latter but not the former and have multivessel athero in my 40's. Regret, didn't image myself sooner or believe the results or start lipid mgmt earlier in my life (with 'normal' lipoproteines)

I'm glad to see this study making people think about risk and risk identification and risk stratification and ultimately risk reduction. mc

Music, like laughter, benefits heart health

Mon, 17 Nov 2008 08:09:35 EST

was heavy metal included in the choice of candidates??if not what was the predominance.for those who do not know the virtue of music ...it is maybe time to start dicovering it...

APPROACH: Rosiglitazone doesn't affect atherosclerosis progression in diabetics with CV disease

Mon, 17 Nov 2008 00:41:18 EST

Your comments, heard before, are understandable and typical of the mass hysteria (you have described so well) generated by the metanalysis; a publication that the NEJM, or its authors, are unlikely to apologize for, let alone retract.
If you have not been brainwashed completely and assuming you are not a fundamentalist, you can examine just the article itself, to find out the purposeful manipulation of data and why it should never have been published. Look carefully at the numbers. There were several-fold more reasons for the illegitamacy of the article than even stated by the authors. See if you can find a scrap of evidence that it was a true 'cardiovascular' meta-analysis at all. Was there even a single study that remained in the analysis that was a randomized, controlled study of cardiovascular disease? Were the groups controlled for pre-existing CV disease? pre-existing or in-treatment CV drug use. Look at the numbers. Look at tthe raw data calculations that were left out. If one also examines just some of whatelse is out there, one could only conclude that we are just living in very strange times; pharmacuetical wars abound and strong biases exist, especially with the rewards, or lack thereof, of pharmaceutical research grants.

Given the proper length of a well-conceived, and 'disease-bed' randomized (see the 'REACH' trial), controlled trial, powered sufficiently, for the appropriate duration of trial, at least 5 or more years, TZDs (either pio or rosi) will ultimately be shown to be of considerable CV benefit.
Afterall, lipid modifying trials (the strongest player in CVD progression), with 10-20K participants, take 3-5 years to demonstarte CV benefit and glucose-lowering trials have, historically, taken greater than 10 yrs to show CV benefit (the real problem for the recent FDA mandate), then 5-10 years for insulin sensitizers (TZDs), that reduce greater than 30 different CVD risks, would not be unreasonable.

What we need is a truce in this pointless TZD war; that has only damaged patients, physicians and the Pharmaceutical companies and possibly the reputation of the Institution harboring the instigators.

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP l

Mon, 17 Nov 2008 00:40:59 EST

Quoting Ridker is like quoting Stone on stents. Several independent groups have questioned its value and the issue has thrashed around in Circ and other journals.

It seems people want to ignore the low event rate in the placebo arm in Jupiter, but it seems pretty clear to me. I had hopes for CRP, but that confirmed it. There are plenty of non-Ridker, non-CRP supportive papers out there. I'm surprised how JUPITER has somehow appeared to revive CRP as a test, when it seems like it has done nothing of the sort.

Critical appraisal of CRP measurement for the prediction of coronary heart disease events: new data and systematic review of 31 prospective cohorts
Tina Shah et al

Background Non-uniform reporting of relevant relationships and metrics hampers critical appraisal of the clinical utility of C-reactive protein (CRP) measurement for prediction of later coronary events.

Methods We evaluated the predictive performance of CRP in the Northwick Park Heart Study (NPHS-II) and the Edinburgh Artery Study (EAS) comparing discrimination by area under the ROC curve (AUC), calibration and reclassification. We set the findings in the context of a systematic review of published studies comparing different available and imputed measures of prediction. Risk estimates per-quantile of CRP were pooled using a random effects model to infer the shape of the CRP-coronary event relationship.

Results NPHS-II and EAS (3441 individuals, 309 coronary events): CRP alone provided modest discrimination for coronary heart disease (AUC 0.61 and 0.62 in NPHS-II and EAS, respectively) and only modest improvement in the discrimination of a Framingham-based risk score (FRS) (increment in AUC 0.04 and 0.01, respectively). Risk models based on FRS alone and FRS + CRP were both well calibrated and the net reclassification improvement (NRI) was 8.5% in NPHS-II and 8.8% in EAS with four risk categories, falling to 4.9% and 3.0% for 10-year coronary disease risk threshold of 15%. Systematic review (31 prospective studies 84 063 individuals, 11 252 coronary events): pooled inferred values for the AUC for CRP alone were 0.59 (0.57, 0.61), 0.59 (0.57, 0.61) and 0.57 (0.54, 0.61) for studies of <5, 510 and >10 years follow up, respectively. Evidence from 13 studies (7201 cases) indicated that CRP did not consistently improve performance of the Framingham risk score when assessed by discrimination, with AUC increments in the range 00.15. Evidence from six studies (2430 cases) showed that CRP provided statistically significant but quantitatively small improvement in calibration of models based on established risk factors in some but not all studies. The wide overlap of CRP values among people who later suffered events and those who did not appeared to be explained by the consistently log-normal distribution of CRP and a graded continuous increment in coronary risk across the whole range of values without a threshold, such that a large proportion of events occurred among the many individuals with near average levels of CRP.

Conclusions CRP does not perform better than the Framingham risk equation for discrimination. The improvement in risk stratification or reclassification from addition of CRP to models based on established risk factors is small and inconsistent.

And also see:
Assessment of Incremental Coronary Risk Prediction Using C-Reactive Protein and Other Novel Risk Markers

The Atherosclerosis Risk in Communities Study

C-Reactive Protein and Cardiovascular Disease Risk: Still an Unknown Quantity?
right arrow George Davey Smith, MD, DSc; Nic Timpson, MSc; and Debbie A. Lawlor, MB, PhD

4 July 2006 | Volume 145 Issue 1

Interesting how many have already decided CRP should be on everyone's lab slip.

Live what you advocate: The exercise habits of busy cardiologists

Sun, 16 Nov 2008 23:21:21 EST

I am a general/invasive cardiologist. I strongly agree that we all must serve as role models to our patients in maintaining health and fitness as a priority.
I am a recovering runner -- tough on the joints.
I have discovered mountain unicycling. That's right, I ride a unicycle. After about 10-15 hours of practice, 15 minutes at a time, I was able to ride and get a great workout. I try to get 3 big rides in a week (I only need an hour) and only need to run 1 day a week. Unicycling is low impact and fun. I train with a heart rate monitor/GPS to track my intensity. I have found a sustainable and fun way to maintain my fitness that is low impact, portable (I take the uni on planes) and dynamic.
I suggest anyone to give it a try!

THINRS: Home INR monitoring as effective as clinic-based care

Sun, 16 Nov 2008 16:29:27 EST

Susan,
This website is intended for communication among health care providers only, HOWEVER, congratulations upon taking control of your health and your life. I blogged a similar scenario to yours when I covered this topic in my AHA bloggs.
We wish you all the best health that luck, blessings and common sense can bring you!
Melissa

Hibiscus tea reduces blood pressure

Sun, 16 Nov 2008 16:24:57 EST

The only problem is that my blood pressure after a good night's sleep is about 78 systolic and comes up to 120's during the day. Would be willing to bet that folks like me might get a bit orthostatic on this prep. Also, brings to mind that we might want to ask the tea question to those that run very low BPs?
Melissa

Interferon hope for chronic viral cardiomyopathy

Sun, 16 Nov 2008 16:22:25 EST

Deepak, Barbara and Peter,
I still think this is exciting data, but I believe we have now been able to establish a relationship but not yet causation and we certainly haven't established that a decrease in viral load = a decrease in events or improvements in patient outcome. But, I do think science is on to something here. Just not certain what it is yet and how we can best apply it.
Even more exciting would be any inkling as to prevention or prophylaxis for this terribly debilitating and deadly disease process. We should only be so lucky as to vaccinate for such an entity one day.
Melissa

JUPITER casts a large shadow: Moving from efficacy data to the big picture

Sun, 16 Nov 2008 16:17:25 EST

Dan,
I guess the reason why I'm afraid just to use surrogates instead of exact patient cohorts sometimes is because we've been burned by that already. "Zetia" is a good example of how we MIGHT be wrong about the "lowering LDL is all that matters" stance. Also, just as "LDL lowering" isn't always a surrogate for a regression or even a halt in PROgression, Hard placque regression may not even always = MI/event reduction. I think at this point, I'm afraid to assume anything as a surrogate in the lipidology world.
So, for now, we should probably apply Jupiter to.......well, Jupiter patients who are low or normal LDL patients age 50-male or 60-female with high hsCRP.
Melissa

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

Sun, 16 Nov 2008 16:11:27 EST

Espinoza,
I fear that you are correct about the significant bleeding risk unless a one size fits all dosing recommendation is AVOIDED. I wish for once that po anticoagulants would come right out of the factory with instructions for low weight, elderly, renally insufficient patients and not just in the "small print at the bottom of the page". These folks are a goodly portion of our patient population and should be among the first, not the last to be considered.
Melissa

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

Sun, 16 Nov 2008 11:52:56 EST

Safety first always. I think the major contribution of this database ultimately will be the pharmacogenomics. Understanding that the metabolism of prasugrel and clopidogrel are quite different allows one to appreciate the bioavailabilty and potency of this drug. Will cyp polymorhpisms allow us to determine the "highest risk: genetic patients who are ASA and/or clopidogrel non-responders?? Albeit retrospective and anecdotal I do not appreciate the rates of stent thrombosis and recurrent ischemic events in my patients seen in this study.And I would say that once you apply this drug to real world practice I am concerned the bleeding will be excessive especially in light of the fact that use and timing of routine ACS pharmacology administration is variable across the board. And with patients already being given excessive doses of heparin and patients not universally having their therapy tailored for renal dysfunction that was borne out in the CRUSADE registry this could be a very problematic situation. The potency of this drug is indisputible. But potent for good and bad.

APPROACH: Rosiglitazone doesn't affect atherosclerosis progression in diabetics with CV disease

Sun, 16 Nov 2008 10:14:16 EST

1) There is absolutely no evidence that rosiglitazone decreases cardiovascular events, and some data suggests it increases them.

2) A large hard outcome trial in a high risk population flush with events strongly suggets pioglitazone reduces macrovascular events.

3) Clinicians should not have to order BMD and echo before prescribing these drugs as Mike suggests (screening for osteoporosis and heart failure); therefore they should not be considered first-line glucose-lowering agents.

4) Clinicians are voting with their pads:

Diabet Med. 2008 Jul;25(7):871-4.
New use of rosiglitazone decreased following publication of a meta-analysis suggesting harm.Shah BR, Juurlink DN, Austin PC, Mamdani MM.
Institute for Clinical Evaluative Sciences, Toronto, Canada.

AIMS: It is uncertain whether meta-analyses lead to changes in prescribing practices. We studied trends in the prescribing of glucose-lowering therapy before and after the publication of a meta-analysis suggesting harm from rosiglitazone. METHODS: We examined the prescription records of all residents of Ontario, Canada, aged > or = 66 years. For each week between January and December 2007, we identified new users of five categories of glucose-lowering medications: rosiglitazone, pioglitazone, metformin, glibenclamide (glyburide) and insulin. The effect of the meta-analysis was assessed using interventional autoregressive integrated moving-average models. RESULTS: Following the release of the meta-analysis, there was a sudden decline in new users of rosiglitazone (P = 0.01), mirrored by a nearly identical but transient increase in new users of pioglitazone (P < 0.001). There was also a net decline in new users of thiazolidinediones as a class (P < 0.001). The number of new users of other glucose-lowering medications did not change. CONCLUSIONS: A highly-publicized meta-analysis regarding rosiglitazone's potential harms led to an abrupt decline in new users of the drug, as well as a transient surge in new use of pioglitazone.

Patients believe elective PCI prevents MI and saves lives, but who's to blame?

Sun, 16 Nov 2008 09:18:55 EST

yes anuj your clear discussion with the patient is great and is what needs to be done.Both the physician and patient should be clear about the PCI indication.Where I would depart from you is saying that we ONLY relieve symptoms.The patients you described pretty much constituted the crossovers anyway,so you saved an inevitable second visit.The bottom 2/3 of the courage group had less than an episode a week at baseline.Your patients should be treated ad hoc as you did.But remember the net benefit of OMT on ischemia was ZERO at 1 year,and that's with 16% PCI crossovers counted.The PCI strategy for patients with significant ischemia saves lives.We are not treating oteoarthritis.

Tailoring clopidogrel loading on the basis of responsiveness testing reduces stent thrombosis

Sun, 16 Nov 2008 03:46:38 EST

By viewing these considerations ,is it better to start with the loading dose of 600 mg continue with 300 mg daily for seven days and returning to 75 mg/daily for the rest period of treatment

Salsa subs for cycling in a cardiac-rehab program patients actually like

Sat, 15 Nov 2008 23:10:50 EST

This is information for all.
------------------
Franklin Rose
new mexico drug rehab

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP l

Sat, 15 Nov 2008 14:54:59 EST

If this is the best HS-CRP can do in a study designed to prove its value, while the largest, longest prospective study on heart disease looking at novel markers, MESA, demonstrates that the average HS-CRP was actually slightly lower in those having a heart attack compared to those without, cased closed! HS-CRP is not the answer in primary prevention. It may have a role in monitoring treatment however there are probably better markers for this.

APPROACH: Rosiglitazone doesn't affect atherosclerosis progression in diabetics with CV disease

Sat, 15 Nov 2008 14:45:58 EST

The Heartwire headline is WRONG. Avandia halted progression, as did Actos in PERISCOPE. The only difference in the APPROACH and PERISCOPE primary endpoint results is the significant progression of the glimepiride group (which permitted the significant between-group difference in PERISCOPE, relative to the non- significant progression of the glipizide group in APPROACH. Avandia also significantly reduced Total Atheroma Volume (TAV) and also AV in "most diseased segment" (not achieved by Actos).

I agree with Michael Cobble MD regarding safety of Avandia; there is no evidence Actos is safer than Avandia.

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP l

Sat, 15 Nov 2008 11:53:29 EST

Original Article

C-Reactive Protein and Reclassification of Cardiovascular Risk in the Framingham Heart Study
Peter W.F. Wilson, MD; Michael Pencina, PhD; Paul Jacques, DS; Jacob Selhub, PhD; Ralph D'Agostino, PhD and Christopher J. O'Donnell, MD, MPH
From EPICORE (P.W.F.W.), Emory University School of Medicine, and the Atlanta VAMC Epidemiology and Genetics Section, Atlanta, Ga; National Heart, Lung, and Blood Institute (C.J.O.D.); National Heart, Lung and Blood Institute\'s Framingham Heart Study (M.P., R.D.A., C.J.O.D.), Framingham Mass; Department of Mathematics (M.P., R.D.A.), Boston University, Boston, Mass; Tufts USDA Nutrition Center (P.J., J.S.), Boston, Mass.

Correspondence to Peter W. F. Wilson, MD, Suite 1 North, Emory University School of Medicine, 1256 Briarcliff Rd, and the Atlanta VAMC Epidemiology and Genetics Section, Atlanta, GA 30306. E-mail peter.wf.wilson@emory.edu

BackgroundThe relationship of circulating levels of high-sensitivity C-reactive protein (CRP) with cardiovascular disease (CVD) risk, particularly with consideration of effects at intermediate levels of risk, has not been fully assessed.

Methods and ResultsAmong 3006 offspring participants in the Framingham Heart Study free of CVD (mean age, 46 years at baseline), there were 129 hard coronary heart disease (CHD) events and 286 total CVD events during 12 years of follow-up. Cox regression, discrimination with area under the receiver operating characteristic curve, and net reclassification improvement were used to assess the role of CRP on vascular risk. In an age-adjusted model that included both sexes, the hazard ratios for new hard CHD and total CVD were significantly associated with higher CRP levels. Similar analyses according to increasing homocysteine level showed significant protective associations for hard CHD but not for total CVD. In multivariable analyses that included age, sex, systolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, diabetes mellitus, current smoking, hypertension treatment, and homocysteine, the log CRP level remained significantly related to development of hard CHD and total CVD and provided moderate improvement in the discrimination of events. The net reclassification improvement when CRP was added to traditional factors was 5.6% for total CVD (P=0.014) and 11.8% for hard CHD (P=0.009).

ConclusionsCirculating levels of CRP help to estimate risk for initial cardiovascular events and may be used most effectively in persons at intermediate risk for vascular events, offering moderate improvement in reclassification of risk.

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP l

Sat, 15 Nov 2008 11:52:29 EST

C-Reactive Protein and Parental History Improve Global Cardiovascular Risk Prediction. The Reynolds Risk Score for Men
Paul M Ridker MD*, Nina P. Paynter PhD, Nader Rifai PhD, J. Michael Gaziano MD, and Nancy R. Cook ScD
From the Donald W. Reynolds Center for Cardiovascular Research and the Center for Cardiovascular Disease Prevention, Divisions of Preventive Medicine and Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, and MAVERIC, VA Boston Health Care System, all in Boston, Mass.

* To whom correspondence should be addressed. E-mail: pridker@partners.org.

BackgroundHigh-sensitivity C-reactive protein and family history are independently associated with future cardiovascular events and have been incorporated into risk prediction models for women (the Reynolds Risk Score for women); however, no cardiovascular risk prediction algorithm incorporating these variables currently exists for men.

Methods and ResultsAmong 10 724 initially healthy American nondiabetic men who were followed up prospectively over a median period of 10.8 years, we compared the test characteristics of global model fit, discrimination, calibration, and reclassification in 2 prediction models for incident cardiovascular events, one based on age, blood pressure, smoking status, total cholesterol, and high-density lipoprotein cholesterol (traditional model) and the other based on these risk factors plus high-sensitivity C-reactive protein and parental history of myocardial infarction before age 60 years (Reynolds Risk Score for men). A total of 1294 cardiovascular events accrued during study follow-up. Compared with the traditional model, the Reynolds Risk Score had better global fit (likelihood ratio test P<0.001), a superior (lower) Bayes information criterion, and a larger C-index (P<0.001). For the end point of all cardiovascular events, the Reynolds Risk Score for men reclassified 17.8% (1904/10 724) of the study population (and 20.2% [1392/6884] of those at 5% to 20% 10-year risk) into higher- or lower-risk categories, with markedly improved accuracy among those reclassified. For this model comparison, the net reclassification index was 5.3%, and the clinical net reclassification index was 14.2% (both P<0.001). In models based on the Adult Treatment Panel III preferred end point of coronary heart disease and limited to men not taking lipid-lowering therapy, 16.7% of the study population (and 20.1% of those at 5% to 20% 10-year risk) were reclassified to higher- or lower-risk groups, again with significantly improved global fit, larger C-index (P<0.001), and markedly improved accuracy among those reclassified. For this model, the net reclassification index was 8.4% and the clinical net reclassification index was 15.8% (both P<0.001).

ConclusionsAs previously shown in women, a prediction model in men that incorporates high-sensitivity C-reactive protein and parental history significantly improves global cardiovascular risk prediction.

Key words: epidemiology prevention inflammation genetics risk factors

Interferon hope for chronic viral cardiomyopathy

Sat, 15 Nov 2008 11:11:42 EST

The improvement in the treatment group was symptomatic not objective. Since interferon produces a flu-like side effect the active treatment group likely experienced a placebo effect great than the true placebo group.

Hibiscus tea reduces blood pressure

Sat, 15 Nov 2008 10:46:23 EST

It is heart warming to see a study performed for the pure science of improving health without the secondary agendas of selling drugs or blood tests.

Gotta go, my tea water is boiling.

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP l

Sat, 15 Nov 2008 10:39:53 EST

"we can't have a third of the population ended up on drug therapy"... I disagree

Considering that 1/3rd of the population will die from heart disease and about 1/2 of the population is slated to die from some form of vascular disease, I think that having a significant percentage of the population on cholesterol lowering drugs is a good idea. Too bad this study did not use a reliable technology to predict risk.

The question this study begs is whether HS-CRP finds the correct patients or is it simply a random number generator in the primary prevention population.

Considering the poor performance of HS-CRP in both the St. Francis Heart study and the MESA heart study, my position is that HS-CRP in the primary prevention population is indeed a random number generator. The sad truth is that a random number generator for stratifying risk in subjects with normal LDL cholesterol is better than what we are currently doing with Framingham.

Unfortunately since Crestor is the only statin with reasonable time left on patten, and major teaching institutions rely on big pharma for significant funding, it is necessary for otherwise respectable researchers to froth over this study as though it was real science. But clearly, the Emperor has no clothes.

THINRS: Home INR monitoring as effective as clinic-based care

Sat, 15 Nov 2008 10:37:41 EST

There is doubt in my mind that patient self-monitoring of coumadin (warfain) is a much safer way to go.
Two years ago I was hospitalized for a TIA, at that time I was put on heprin and coumadin. I was released one week later on coumadin taking 4.0 per day and felt better than I had in years. I was 48 years old at the time and had been diagnosed APS and Lupus. I was religious at taking my prescribed dosage and having my Pro-time check.
Here's where the problem came in, my Pro-time was check on a Thursday two weeks after being released, the Pro-time was 1.9 unfornately my doctors office never called me to increase my dosage, I had no clue where the level was.. So I trusted everything was must be OK. That was my first error, second error was that being on the drug for only two weeks and not knowning much about it, I naively felt being on coumadin I was protected from another incident.(WRONG)! The next day after having my Pro-time done I wasn't feeling well, couldn't really explain it just didn't feel right. I went to bed at 7:00 p.m. that evening, woke at 2:00 a.m and could not move the left side of my body, by the time they got me to the E.R. my Pro-time was 1.2 might as well not even been on the drug. I had a major stroke that has left me with a lot of residual effects that could have easily been prevented, if only I had gotten a call from my doctor's office on that Thursday or would have had a way to know my numbers.. That was two years ago now. I have been monitoring my own coumdin levels ever since. I don't have a INR-home machine, but sure would like one. My Doctor's orders now state "release results(verbal and fax) to patient". I now know my results within two hours of my blood draws, the way it should be and adjust dosage as needed. It was a devastating lesson for me to learn. I now know as much if not more about coumadin (warfarin) than most medical professionals, and that's also how it should be. Educate yourself!! Take charge of your own health care, no one cares about your Life as much as you do!! To date I have only had one upper G.I bleed and no ishemic incidents since I took over the monitoring. Coumadin (warfarin) can be a dangerous drug, but with proper monitoring, can save your life!! Thanks for the opportunity for me to tell you my experience. "Sue is still Kicking"!!

heartwire journalist wins American Heart Association writing award

Fri, 14 Nov 2008 23:18:39 EST

We are honored to have Steve Stiles as one of our very own! He is Mr. Heart Failure, gadget guru, etc. etc.
Plus, he's a genuinely NICE guy with keen sense of humour and the big heart!
He knows we all love him! I want to write like him when I grow up!

Melissa

I-PRESERVE: Strike three for RAAS inhibition in preserved-LVEF heart failure

Fri, 14 Nov 2008 23:14:27 EST

No doubt it's a high risk group. Folks who are short of breathe for whatever cause exhibit sky high mortality rates.
As for he 40% being on calcium channel blockers, remember, this group is a subgroup of patients on calcium channel blockers who can't breathe and/or have big legs. They've already selected themselves out and presented themselves as having difficulty. I'd bet the incidence of weight gain in this group is higher than in just 10%.
I absolutely agree that this is a high risk group, however it would be like treating me for prostate cancer with no improvement over 4 years. If I don't have it, and you've missed the diagnosis, whatever I had to begin with is probably going to get worse.
Not trying to be combative, just have too many of these patients who have other problems that can be found often times if another approach is taken for diagnosis.
Melissa

APPROACH: Rosiglitazone doesn't affect atherosclerosis progression in diabetics with CV disease

Fri, 14 Nov 2008 13:05:59 EST

Yup voting with their pads and sales up and down. The point is there has not been a head to head study stating one tzd is safer than the other. Until that is done I will not show preference. You read a lot of article and you must admit that kind of meta-analysis is not what you would do. It's like the Meta with resp agents and then spiriva shows the exact opposite. In our area rosi is less expensive and has better patient assitance. We DON'T feel we are giving up safety nor increasing harm with that agent. Both products are great for the right people. Writing both for nearly 10 years now. good luck. ps. 80 events vs. 90 events over 1-5 years in metas yes stats say 30% rise but I'll take 170 cardiac events in 17K DM pts anytime. talk about a low event rate

APPROACH: Rosiglitazone doesn't affect atherosclerosis progression in diabetics with CV disease

Fri, 14 Nov 2008 12:25:13 EST

There's data to suggest that rosiglitazone sales are down and pioglitazone sales are up. People are voting with their prescription pads. I don't want to be on something that may increase my risk of an MI by 1.5-fold and risk of CHF by more than 2-fold (granted pioglitazone has been implicated in the latter, only the latter). The best data we have on glitazones in a high risk crowd is still PROACTIVE (pio), showing reductions in macrovascular events in patients with diabetes and established large vessel disease. Given that we cannot assume a class effect with these drugs, there should be no reason to write rosiglitazone scripts without writing pioglitazone instead,

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP l

Fri, 14 Nov 2008 12:21:13 EST

Yes it's helpful but with 30% of the adult population having metabolic syndrome by NCEP/ATP criteria, I feel that we need to go beyond MetSyn, since we can't have a third of the population ended up on drug therapy. Perhaps a combination of MetSyn and CRP+ is the way to go?

JUPITER casts a large shadow: Moving from efficacy data to the big picture

Fri, 14 Nov 2008 12:19:18 EST

CRP is a fairly potent risk factor for what is going to happen in the arterial wall so why not image the arterial wall itself. We quantify carotid plaque area in square centimetres and stratify based on that. I feel this is a closer marker to the ultimate disease (atherothrombosis). Even on a conventional doppler you can usually get some comment about atheroma burden.

I-PRESERVE: Strike three for RAAS inhibition in preserved-LVEF heart failure

Fri, 14 Nov 2008 12:16:33 EST

If 40% were on CCB then I would expect 4% would have CCB-induced pedal edema. The incidence of edema on the world's most popular medication (amlodipine) is about 10%, higher with felodipine (about 30%). So we are talking a fraction of a fraction. Mike's point about event rates suggest this was a bona fide high cardiac risk population. The 95% CI is a bit wide and perhaps the patient population was just too optimized in terms of other proven CV agents to show any reduction in risk with IRBESARTAN.

JUPITER casts a large shadow: Moving from efficacy data to the big picture

Fri, 14 Nov 2008 10:41:34 EST

This study is very intriguing and provocative. I attended a HTN meeting last night moderated by a cardiologist and he opened talking about JUPITER and Hscrp even though that wasn't the topic.

I think this brings up a very good point, should we be doing hscrp on all men over age 50 and all women over age 60 to motivate ourselves or them to take a statin irregardless of lipoprotein values?

Or should we apply this to people with BMI's of 28-29. Or people with met syn or borderline met syn?

Do you think new NCEP iiii will incorporate this change?

Would these people have risk reductions in 2 years with wt loss and lifestyle changes, would these people have risk reductions in 2 years with ramipril, with metformin, generic statin that may only lower LDL 30% and Hscrp 23%, 81-100 mg of aspirin etc... (that would be interesting to see)

Again impressive results in a population most would not treat with any medication.

I could see clinicians doing hscrp on every patient over 50 and wonder if that means they would then start them on crestor 20 mg irregardless of history or lipoproteins if hscrp is elevated or would they watchful wait like we do with so many other things like bp and glucose, etc..

Change can be hard and this study changed the landscape somewhat in a test which people have certainly kicked around and not supported very much. Like all the other surrogate markers we talk about that people can be afraid of.

heartwire journalist wins American Heart Association writing award

Fri, 14 Nov 2008 10:03:49 EST

A deserved honor for his contributions. I enjoy heartwire and his contributions!

I-PRESERVE: Strike three for RAAS inhibition in preserved-LVEF heart failure

Fri, 14 Nov 2008 08:28:34 EST

Melissa, I agree with much of this but at the same time realize there are MANY patients like these being treated in our primary care offices (that's me) and 80% were considered stage 3-4 heart failure (I doubt that TZD use comprised more than 3% of the study especially being off label). 40% CCB use is in line with most ischemia, angina and I think CHF studies. Spiro was used aggressively in both arms as the study moved forward. I'm just really impressed by the 4 year event rate in a 'low risk' CHF group if you will. A BNP of 320 while not exciting isn't one that I would want my family or pts to have and yes we get excited when a pt comes in with 800, 1300 or higher. mc

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP l

Fri, 14 Nov 2008 07:22:07 EST

Mike,
that answer is yes. HsCRP has kind of been kicked around by most of us thinking it might be helpful in a very select group of patients but not really convinced. Studies have been less than provocative vs just slapping everyone on a meds. With the public becoming more and more anti pharmacy and less compliant, this is kind of a surrogate of the kind of motivation that can be generated for treatment for IMT,CAC etc. It's a motivator and paid for by third party payors without batting an eye, convenient to do , no scheduling, etc. etc. It's a good first step toward motivating a normal LDL patient toward therapy.
Melissa

JUPITER casts a large shadow: Moving from efficacy data to the big picture

Fri, 14 Nov 2008 07:16:46 EST

Ersan,
Just looking at the cohorts: 50 year old men with 60 year old women with normal LDL's who don't want to take a statin and quite frankly, you weren't sure if they deserved one but then, voila, check an hsCRP and if elevated, you can point to a decrease in event rates.
That's really the purest application I can think of .
Melissa

I-PRESERVE: Strike three for RAAS inhibition in preserved-LVEF heart failure

Fri, 14 Nov 2008 07:04:37 EST

Apologize for the rant in advance. I already blogged this on the AHA blogg section, but can't seem to help myself but drive the point home again.
Mike, all you had to do to get in this study was to come in the door with shortness of breathe and LVH, or shortness of breathe and a LBBB. Your proBNP was nearly normal and in some cases normal. almost half of these patients were on a calcium channel blocker and 1/3 diabetics of which I'd guess that many were filling their monthly actos prescriptions and wondering why the scales were tipping 2 pounds heavier every week.
This type of patient is my favorite patient to see because they can be helped SOOOOooo much with some common sense approaches to changes in their prescriptions to something that doesn't waterlog them, or can be helped with their sleep apnea, etc. OR perhaps their nephrotic syndrome addressed, etc. etc. I would FLUNK any resident who hung a diagnosis of CHF on a patient without FIRST going through all of the things that might make shortness of breathe and peripheral edema better if the echo demonstrated a good EF. THEN, if we could not explain it, we'd cath the patient after several attempts to help them.
The study to have been done would have been to check the EDPs of the patients who were thought to have heart failure. That would have been the interesting first caveat in this trial, just to see how many times we actually got this correct. I'll be willing to bet that many if not most would have had a normal LVEDP. THEN, of those truly with diastolic heart failure, THEN study the right drug FOR the CORRECT diagnosis. Then, we would be fairly certain of the responses.
It amazed me that the design of this study is so flawed that one can hardly glean ANYTHING from it but how often the boat is missed on these poor patients.
AMAZING.
Melissa

JUPITER casts a large shadow: Moving from efficacy data to the big picture

Fri, 14 Nov 2008 00:43:40 EST

The study is interesting, however, how it will be practical and significant in the clinical practise ?

I-PRESERVE: Strike three for RAAS inhibition in preserved-LVEF heart failure

Thu, 13 Nov 2008 23:58:52 EST

It's frustrating to see Irb not show any benefit over 4 years. Also to see nearly 40% event rates (9-10%/year) and CV mort rates of nearly 3%/year and all mort rates nearly 5%/year.

Once again shows it is BEST to prevent CHF whether with a normal or abnormal EF especially if you are median age of 72. Because your long term survival is complicated.

Again would support diovan or atacand based on their studies. I would need go back and pull those 2 studies to see if there were blatant demo differences other than low EF in those 2 studies. It was interesting to see that less than 25% of these pts had ischemic CHF (perhaps they would have done best on N-3 as in GISSI HF which also had a low rate of ischemic chf in addition to RAAS blockade). Nearly 1/3 had a history of Afib as well which I found interesting. I doubt that 1/3 of my chf'ers has afib and 2/3's of my chf'ers are ischemic.

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP l

Thu, 13 Nov 2008 23:23:36 EST

AWAY......

Melissa, I'm a firm believer in statin therapy, does hscrp add value in this setting? These people had A1c 5.7% baseline over 40% had met syn, median age 66 where nearly 1/2 are borderline DM anyway and they have hscrp values that suggest 3-4/5 met syn features.

If your pt has met syn don't you expect high hscrp and higher risk anyway, ie doubling of risk which is what this study confirmed. Rather than 7-8% risk they were really 13-14% risk.

I'm not intending to be the devils advocate as JUPITER has many firsts and some amazing numbers with MI, Stroke and Death reductions all independent. (and confirms why I take it with and LDL similar to this study and why my father is on it post bypass for efficacy and risk reduction)

At AHA are cardiologists really talking about doing more Hscrp measures?

AHA and ACC already rec using hscrp in mod risk pts, will guidelines now rec using hscrp for low risk pts over ages 50-60 yrs of age.

Just curious? And if that is the case why not do lppla2 or ebct or cimt which have been discussed at great length on these forums for more than a year.

APPROACH: Rosiglitazone doesn't affect atherosclerosis progression in diabetics with CV disease

Thu, 13 Nov 2008 23:13:32 EST

I grew up in sheep country. Love the taste of cows. I've learned that 'expert' recommendations are, oh, how shall we say it, kind of like fannie and freddie mac. :o)

Hibiscus tea reduces blood pressure

Thu, 13 Nov 2008 21:08:37 EST

Upkar,
Susan Jeffrey has been covering this stuff for years. She is COMMPLETELY objective and would never promote anything for the sake of promotion, especially because it's herbal. I took a look at this data and it's intriguing. Small trial though.
Melissa

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP l

Thu, 13 Nov 2008 21:04:54 EST

you are correct Dan. Wrote a couple of hsCRP orders today!
Melissa

APPROACH: Rosiglitazone doesn't affect atherosclerosis progression in diabetics with CV disease

Thu, 13 Nov 2008 20:18:01 EST

Lancet. 2008 Nov 1;372(9649):1520.Related Articles, Links
Rosiglitazone no longer recommended.

[No authors listed]

Publication Types:
Editorial

MeSH Terms:
Diabetes Mellitus, Type 2/drug therapy*
Humans
Hypoglycemic Agents/adverse effects*
Thiazolidinediones/adverse effects*

Substances:
Hypoglycemic Agents
Thiazolidinediones
rosiglitazone

APPROACH: Rosiglitazone doesn't affect atherosclerosis progression in diabetics with CV disease

Thu, 13 Nov 2008 20:06:43 EST

The reason why we use any fda approved medication for glucose is to control the glucose. My grandma said she had a 'case of the sugars'. It was interesting how people said it was all about the lipids and the bp in people with dm. Then all of a sudden ukpds 10 year extension comes out and the intense controlled glucose groups (met or su or insulin) all show benefit over the 10 years and the BP groups don't differ at all - surprise on that one.

Why do we use any of these agents:
Insulin has been associated with wt gain, heart failure, severe life threatening hypo, etc..
Met has been associated with GI toxicity and rare cases of renal
SU's wt gain, severe hypo, black boxed for death
TZD's - wt gain, heart failure, bone
Incretin - GI, rare cases pancreatic
Alpha's GI toxicity
etc..

Dan, your just trying to get my goat..
Certainly if people don't believe that TZD offers any control benefit (short term or long term) then they shouldn't use them and if they can't screen for CHF or osteop again the same.

APPROACH: Rosiglitazone doesn't affect atherosclerosis progression in diabetics with CV disease

Thu, 13 Nov 2008 20:00:26 EST

This lancet article?: The Lancet, Volume 370, Issue 9593, Pages 1129 - 1136, 29 September 2007 Congestive heart failure and cardiovascular death in patients with prediabetes and type 2 diabetes given thiazolidinediones: a meta-analysis of randomised clinical trials.

My problem with the JAMA metanalysis JAMA. 2007;298(10):1189-1195 is this - they include 3 large outcome studies - ADOPT, DREAM and interim RECORD all of which are negative in 15K pts and one heart failure study which completely skews the other 3 with only 200 pts (5 MIs in the rosi group vs. 0 could be random in this population). Why would you include a 4th study the Dargie analysis that is comprised of all patients having heart failure. Both TZD's are contraindicated in that population and for several years now.

Very confusing to me that they would do this, again shows the poor science of small metas and also you can make a study show anything you wish when looking back retrospectively.

APPROACH: Rosiglitazone doesn't affect atherosclerosis progression in diabetics with CV disease

Thu, 13 Nov 2008 19:34:25 EST

Meta-analyses in the lancet and jama showed similar increases in risk.

APPROACH: Rosiglitazone doesn't affect atherosclerosis progression in diabetics with CV disease

Thu, 13 Nov 2008 19:33:29 EST

DREAM - too low risk to say anything by itself about CV events; VADT/ACCORD/ADVANCE - patients were not randomized to rosiglitazone vs no rosiglitazone, so, as a recent editorial in JAMA pointed out, can't say anything about specific effects of rosiglitazone (lower risk patients could have gotten it - eg lower risk for CAD at baseline, no nitrates, no CHF, not on insulin).

+ increased fractures
+ increased rates of CHF
+ no demonstrable improvement in any clinical outcome other than HbA1c
+ statistically increased risk of MI and CV death

Why are we using this drug again?

APPROACH: Rosiglitazone doesn't affect atherosclerosis progression in diabetics with CV disease

Thu, 13 Nov 2008 19:16:30 EST

Dan, we had all of those larger and longer prospective studies as mentioned in the post.

ADOPT 5 years 5K pts, DREAM 5 years 5K pts. VADT 7 years 2K pts, ACCORD 5 years 10K pts, ADVANCE 5 years 5K pts, RECORD 3.75 years interim anaysis with 4.5K pts. So then perhaps one could say that BO won in florida, pennsylvania, california, oregon, nevada, etc... Or you could do the meta-analysis with several off label studies and studies in stage 3-4 chf and alzheimers and short term data and put them all together and 'speculate' that in the short term 6 month period this drug caused MI and perhaps death. And then you could force 1 million pts to stop their diabetes medications based on poor statistics and poor science. That's what I'm thinking about.

And of course I think that PROactive and CHICAGO and PERISCOPE are great studies also. I don't think the science supports a special interest message that one TZD is better or safer than another until THAT study is performed. And if Dr. N and Takeda really feel it is safer, why not do the study, put their money where their mouth is. I write both medications equally.

Patients believe elective PCI prevents MI and saves lives, but who's to blame?

Thu, 13 Nov 2008 18:54:02 EST

The Courage data is clear: If your elective PCI outcome success rate is only approx. 90%, then allcomers do approx. the same. Subsets of higher success rates, nonVA U.S. patients,crossovers (30% of patients), and patients with heavy ischemic burdens may do better, with more angina relieved with PCI. Do patients know this?

APPROACH: Rosiglitazone doesn't affect atherosclerosis progression in diabetics with CV disease

Thu, 13 Nov 2008 17:47:14 EST

I would not expect this trial to give any information whatsoever on CV risk. Trials are powered for their primary endpoint and proceed thereby. This trial was neither large enough or long enough to say anything about the hard cardiovascular risk or benefit of rosiglitazone.

It is as though you found out that Barack Obama won in Pennsylvania on Nov 4. Wouldn't you want to know what happened in the other 49 states before you could say he was elected President? This is exactly analogous - we need much larger, longer, hard outcome powered trials to show what is going on with this drug.

APPROACH: Rosiglitazone doesn't affect atherosclerosis progression in diabetics with CV disease

Thu, 13 Nov 2008 17:15:29 EST

High risk DM population indicated for QCA or PCI:

From this article above "There were no significant differences in a composite clinical end point that included death from any cause, nonfatal MI, or stroke, revascularization, or hospitalization for ischemia; a composite end point including CV death or nonfatal MI or stroke; death from any cause; or new congestive heart failure, Nesto reported."

But Doctor Nissen told me last year we would see MI and increased trend to moratlity within six months using rosiglitazone. I'm glad the FDA and AACE looked at the evidence in an unbiased fashion as now APPROACH, RECORD, ACCORD, ADVANCE, ADOPT, VADT, DREAM controlled prospective studies in nearly 45K pts haven't confirmed his and his counterparts conclusions. But, he's still sticking with that message.

From AHA Webpage Peggy Peck report - "Steven Nissen, M.D., of the Cleveland Clinic and principal investigator of the PERISCOPE trial, said, "because the studies were similar, the failure of APPROACH suggests that there are important differences in the efficacy of these two drugs." (See: ACC: Pioglitazone (ACTOS) May Slow Atherosclerosis Progression)

Dr. Nissen, who also authored a meta-analysis of rosiglitazone studies that revealed an increased risk of myocardial infarction (See: Meta-Analysis Links Rosiglitazone (Avandia) to Risk of Myocardial Infarction), said the failure of the APPROACH trial provides one more reason to "use rosiglitazone with caution.""

Looking at PERISCOPE and APPROACH very interesting to see each have one statistical endpoint out of the primary and two secondaries:

PERISCOPE:
Percent Atheroma volume SU vs. Pio +0.73 vs. -0.16 p 0.002
Change Atheroma volume SU vs. Pio -1.5 vs. -5.5 NS
Change AV 10 mm most diseased segment -2.1 vs. -2.0 NS
APPROACH:
PAV change SU vs. Rosi +0.43 vs. -0.21 NS
Change Ather Vol +1.2 vs. -3.9 p 0.04
Change AV most diseased -3.6 vs. -5.3 NS

Patients believe elective PCI prevents MI and saves lives, but who's to blame?

Thu, 13 Nov 2008 12:32:33 EST

Clearly the interventionalists.
Dr. Ihab Suliman

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP l

Thu, 13 Nov 2008 12:01:46 EST

Look at the New England Journal analyses of AFCAPS/TexCAPS (lovastatin) and Physician Health Study (aspirin) both by P. Ridker. Both showed that there was only benefit in the strata with high CRP - for statins this was irrespective of lipids. These analyses, coupled with JUPITER, support the notion of stratifying patient risk on the basis of biomarkers for direct treatment benefit.

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP l

Thu, 13 Nov 2008 11:14:00 EST

The study centered on use of CRP as a screening tool, and the results showed that walking around with an elevated CRP for several years, without statin treatment, lead to little or no increased risk over that predicted by FRS. Despite this, crestor still showed benefit in this group of FRS pts of around 10-15%. So this is the wrinkle: Crestor is so potent, it reduced risk in those with CAD, and the signal was present despite the number of patients without CAD. But as an overall risk marker, CRP did miserably.

So my point is not that Crestor will not reduce events, especially in your typical office practice where you have many higher risk patients. The exclusion criteria in Jupiter were there to establish a traditional low to intermediate risk FRS cohort -- and to enhance the specificity of CRP. So actually, for this study, the exclusion criteria to disallow "spurious" CRP elevation enhance NNT. Think of all the unnecessary troponins that are ordered by the ER and if any pt with an elevated troponin were included in NSTEMI PCI trials. This would dilute the efficacy of intervention. Think if they included patients who had any elevated CRP without repeat CRP testing -- the event rate would have been lower because these people would've had transient viral illness or something similar. Unfortunately, I think that many PCPs will order CRP and treat any elevation without confirming it, as guidelines state.

Jupiter needs to be repeated with CIMT, tape measure or CAC as the screening criterion in a low/mid FRS group. We all know that FRS misses many people who will have an event -- the question is which of these tests is best. They all seem to have validity, and we all appear to use one or the other -- the question is cost and predictive power.

Patients believe elective PCI prevents MI and saves lives, but who's to blame?

Thu, 13 Nov 2008 11:12:39 EST

Dear Melissa
I fully agree with you and the common sense that guides Anuj. This tells us one more time that we should use studies results and guidelines to assist us in optimizing the treatment and providing valuable information to the patients, but we should never forget to LISTEN to them and provide them the optimal most suitable treatment after enlightening them about pro and cons.

Hibiscus tea reduces blood pressure

Thu, 13 Nov 2008 10:48:11 EST

1)Has this tea been compared to regular tea or coffee as they have diuretic effect.
2)What mechansim of action do you suggest for lowering SBP with Hibiscus tea.
Or is this a promotion of an another herbal product.
Thanks

Patients believe elective PCI prevents MI and saves lives, but who's to blame?

Thu, 13 Nov 2008 09:13:54 EST

Anuj,
In the patients that you describe, a PCI may well be life saving, and could only be proven with very long term studies. We don't study much of anything but Framingham for more than 3-5 years. If your patients listed above become sedentary , overweight, depressed, have significant glucose intolerance, there is no doubt in the realm of common sense that these developments would compromise their longevity. Therefore, we must go beyond what a 4 year study can tell us in some instances.
Melissa

Interferon hope for chronic viral cardiomyopathy

Thu, 13 Nov 2008 08:14:11 EST

I was at the meeting at Packer was at the dias table what happened?

Patients believe elective PCI prevents MI and saves lives, but who's to blame?

Wed, 12 Nov 2008 23:45:56 EST

First, It's good to see Dr. Moses on theheart.org. I would like to elaborate a bit on Dr. Moses's comments (he can shoot me later)!

In the last couple of days, I performed a diagnostic cath on two patients who had clear cut stable angina with markedly positive stress tests. Despite the data that Dr. Moses cited above, I spent the better part of two hours with each patient (and their families), explaining the risks and benefits of revascularization in the setting of stable angina, prior to the catheterization, with an emphasis on relieving symptoms (not reducing MI or death, which may be the case in higher risk patients). I specifically brought up the conclusion of the courage investigators, and explained that if I were to treat their CAD, it would be to relieve symptoms only, much like an anesthesiologist, and not to reduce their underlying problem, which would need to be treated with lifestyle changes and medications. Despite this, both patients and their families chose PCI and both requested drug eluting stents. They both stated that they were unhappy with being limited to walking 25-50 feet before they had to stop and needed a better way to live.

What patients understand and believe after a detailed explanation, I leave to the paper below. But presented with the facts in the most detailed way imaginable, perhaps it is that patients with stable angina with significant symptoms do not find the question of MI/death as relevant as their desire to feel normal again.

Patients believe elective PCI prevents MI and saves lives, but who's to blame?

Wed, 12 Nov 2008 22:07:02 EST

The question raised by a meta-analysis needs to be validated with a prospective study. The only 2 prospective studies on stenting vs medical management (Courage and Rita II) demonstrated no reduction in infarction or death from stenting.

The perceived value of stenting is far greater that the real value thus the insanity of stenting that occurs in this country.

HF-ACTION misses, but experts say results support intensive exercise in HF patients

Wed, 12 Nov 2008 21:31:09 EST

Today,
In my Cardiology show interview with Drs. Clyde Yancy and Mariel Jessup, they both agreed that the NNT for HF and exercise is "4" patients.
You can't buy that in a bottle. I'm sure the interview will be up in the next few weeks. You folks might find in interesting.........I hope!
Melissa

No benefit of vitamin C or E for prevention of major cardiovascular events: Physicians' Health Stu

Wed, 12 Nov 2008 21:28:53 EST

Gladys,
thanks for outlining your past work experience. It gives me an idea of your depth of involvement and interest in this issue, which is obviously more than a passing fancy. I would suggest however that the vitamin folks are every bit as wealthy as the prescription pharmaceutical companies, at least some of them. They should fund a study in patients with high hsCrp if anyone should. Why don't YOU approach them to do it?
Melissa

Patients believe elective PCI prevents MI and saves lives, but who's to blame?

Wed, 12 Nov 2008 19:39:57 EST

Maybe the patients are better informed than some physicians
with the recent meta-analysis of Kastati,the recent Japanese randomized PCI vs Medical study both benefit in death,or MI and urgent hospitalixzations,compounded by equivalent death and Mi rates in PCI and CABG seen in SYNTAX there are clearly patients who do benefit.COURAGE demonstrated that all patients do not.PCI is superior with moderate or severe ischemia and certainly superior for symptom relief.

HF-ACTION misses, but experts say results support intensive exercise in HF patients

Wed, 12 Nov 2008 16:18:32 EST

Actualy, not. For money should rather change the sub-esp!! Not just mortality counts. Exercise is cheaper than looks like.

HF-ACTION misses, but experts say results support intensive exercise in HF patients

Wed, 12 Nov 2008 16:05:30 EST

actually, according to medicare, heart failure comes under pulmonary, and so (at least in the past)CHF patients were denied access to cardiac rehab, and medicare paid very little if at all anything on pulmonary rehab. It has been just very recently that there has been any change in the reimbursement for either kind of rehab, and most certainly there is no money to be had in either. And when you look at the regulations set up for outpatient cardiac and pulmonary rehab, you wonder why a hospital would even think about offering it.

Becky

Updates to the STEMI Guidelines

Wed, 12 Nov 2008 13:50:15 EST

I am really impressed with this excellent presentation.
thanks everyone worked on it

No benefit of vitamin C or E for prevention of major cardiovascular events: Physicians' Health Stu

Wed, 12 Nov 2008 13:38:59 EST

Dear Melissa,
I have been on the faculty at the University of California at Berkeley for 17 years (just retired from teaching but not from research). I was head of the Public Health Nutrition Program, and my PhD is in Epidemiology from Johns Hopkins. I have done a number of randomized controlled trials of the effect of vitamins C and E on biomarkers. My current one, on effect on CRP, is online in Free Radical Biology and Medicine, as is a previous one on effect of those vitamins on oxidative stress. In both cases we found that if the biomarker is already low, the vitamins have no effect. But if it is elevated, there was a significant effect of vitamin C. Vitamin E was weaker and not significant.

So if someone will ever do a disease-endpoint study of vitamin C, by itself, on a sample with proven elevations in either CRP or oxidative stress, we might finally have a decent answer. So far, that has never been done. And given the prevailing attitudes that the answers are already in, we may never see such a trial. The trouble is, the existing (two) trials of vitamin C have been in samples in which probably 40-60% did not have elevated CRP or oxidative stress biomarkers. The Jupiter statin trial was the kind of trial that needs to be done -- Jupiter enrolled only people with CRP>2 mg/L. But Jupiter was funded by the drug company, and it is exceedingly unlikely that a drug company will fund a big vitamin C study because it is not proprietary and is cheap as dirt.

Higher nonfasting triglycerides associated with increased ischemic stroke risk

Wed, 12 Nov 2008 12:26:57 EST

The info at cholesterolscore.com , a site dedicated almost exclusively to niacin therapy, seems to put niacin in a league of its own. Niacin moves all the lipid, & CRP numbers in the right directions.

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP l

Wed, 12 Nov 2008 12:05:00 EST

Because of the multiple exclusion criteria, the patients we see in clinic are often much higher risk than in the trial - and therefore have much more to gain in terms of absolute risk reduction and NNT. A good rule of thumb is to halve or even multiple by 1/3rd the NNT for the trial. A good example of this was the >70 y.o. subgroup in HPS -- NNT=10 in this group in the trial versus about 20-25 overall. I therefore would look to JUPITER as providing a very decent relative risk reduction, which, when applied to the average primary prevention population in clinical practice, will produce excellent NNTs and absolute risk reductions.

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP l

Wed, 12 Nov 2008 11:07:52 EST

Michael-- thanks for the detailed and thoughtful reply. I think you are on the right track -- a tape measure may be as useful in risk stratification as CRP and I will be incorporating that. Also, it's an easy way to assess progress.

It is very telling that Ridker, the man who has been trying to bring CRP to every primary care physician's lab slip -- is not trumpeting the elevated risk of those in the placebo group -- because there was none. There's not said much about the few events in the placebo arm: the hard event rate -- MI/death -- was a modest .8 per year. This is no different from Framingham.

I was initially interested in CRP as a risk stratifier, but now that I have been referred many patients with transiently elevated CRP because of URI or some minor scrape, and the need to repeat it for initial elevation, and now with this prospective study showing little if no increase in events, I don't think I will be adding it. The tape measure is probably as good or better -- and serial measurements are easy to do.

However, it is a great day for Crestor. The drug is so potent it essentially crushed whatever CAD was scattered in the active arm.

I use CAC selectively as a risk stratifier. I hoped that CRP would be an easier and cheaper way for patients to get similar info, but I don't think that's the case. At least it's a "good news" study in that treating with rosuva cuts risk in the "low risk" Framingham group.

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP l

Wed, 12 Nov 2008 10:11:04 EST

In our practice and based on published evidence we find that hscrp is most predictive of met syn, prediabetes, fatty liver, central adiposity, risk of developing diabetes. Having elevated hscrp increases one's risk for CV events, etc.. That being said we don't do a lot of hscrp simply because we can tell who has met syn with a simple lipid, bp, cmp and tape measure. Perhaps we will increase this, uncertain at this time. We use CIMT for patients over 45 with risk factors and determine risk based on the imaging technique and target lipids etc. based on this.

I agree with aha/acc that in mod risk scores, hscrp increases risk profiles if elevated and think hscrp adds to clinical decision making.

I have met syn but am not overweight and younger without fatty liver/central adiposity and a low starch diet (my hscrp is normal, yet I have a fhx for cad and have multivessel athero with an LDL under 130 and an ApoB between 80 and 110 depending on the day).

I think in this pt population if hscrp elevations would encourage a clinician to be more agressive with lipid, lifestyle and risk mgmt that has been confirmed now to show benefit. In this setting rosuva prevents events and saves lives and does so in a dramatic fashion.

I do think hscrp if elevated and confirmed and other causes of inflammation are ruled out - shows people who have elevated levels of cytokines, adipokines and are higher vascular risk and higher death risk.

good luck

No benefit of vitamin C or E for prevention of major cardiovascular events: Physicians' Health Stu

Wed, 12 Nov 2008 08:25:53 EST

This concludes more than a decade and a half on antioxidant vitamin trials. It was a great program of research and has shown us that these interventions are not effective (note comparison with statins, antiplatelets, and antihypertensive therapy). I am trying to wean my patients off these useless and sometimes even harmful therapies (note increased risk of intracerebral hemorrhage with vitamin E).

Interferon hope for chronic viral cardiomyopathy

Wed, 12 Nov 2008 05:13:23 EST

The study albeit laudable fails to achieve little beyond reduction in viral load.There apparently is no improvement in functional class or quality of life.It would be interesting to learn of any alterations in objective LV functions. Then again reduction or elimination of virus alone may not translate into clinical improvement.

The cost of the drug would be prohibitive, but a phase 3 trial establishing advantages of the medicine may make repeat endomyocardial biopsies redundant,because a clinical/echo marker would be much easier to employ in assessing clinical response.

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP l

Wed, 12 Nov 2008 00:14:23 EST

Thanks Michael, so you agree that the event rate is extrapolated to be 13% or so in the placebo group. "Low risk" according to FRS is <=10%. The study had both <10 and > 10% risk patients according to FRS, so it seems that CRP does not add much to risk prediction.

We've known for a long time that many "low risk" FRS pts have CAD and deserve treatment. In my mind Jupiter shows that rosuvastatin has the efficacy to lower events in this group. I'm not sure the study shows that CRP should tell us who is at risk. Any thoughts?

HF-ACTION misses, but experts say results support intensive exercise in HF patients

Tue, 11 Nov 2008 23:33:27 EST

Must be good money in cardiac rehab

JUPITER casts a large shadow: Moving from efficacy data to the big picture

Tue, 11 Nov 2008 23:10:24 EST

What about the cost of all post MI and post stroke patients. That is if they survive their first event and become broke and out of work and stop paying their taxes!!! Now what is the cost burden...put statins in the water now!!!!!!

Improving the Quality of Care for Heart Failure

Tue, 11 Nov 2008 21:22:53 EST

Excellent organization and message, Dr. Pina! Simplifying a very complex topic is not easy, but you have done it.

HF-ACTION misses, but experts say results support intensive exercise in HF patients

Tue, 11 Nov 2008 19:25:58 EST

Execise did not harm in HF subjects, so move your patients. That's the message! If it did or not met the end point, that's just a statistic discussion.

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP l

Tue, 11 Nov 2008 18:45:07 EST

Primary end point event rates: 0.77 per 100 person year vs. 1.36 per 100 person year would equate to 7.7% on rosuva over 10 years and 13.6% on placebo over 10 years with an NNT of 16.

Any death 1 per 100 person year on rosuv and 1.25 per 100 person year thus 10% and 12.5% with NNT of 40 during that time.

That is assuming the event rates don't increase dramtically with time, which they most likely would. This is however from a primary and secondary prevention a 'low to very low' risk group with low events. 4S had events of over 20% on treatment in 5 years and nearly 30% on placebo and those with diabetes had event rates on treatment over 30% and nearly 40% on placebo over 5 years to put this into perspective.

cheers.

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP l

Tue, 11 Nov 2008 18:38:31 EST

I have been told by doctors in 3 different states that the pfizer reps are promoting a message that crestor causes diabetes!!!

Jupiter pts had baseline A1c's of 5.7% with 41% of the total group having Met Syn. FPG was 94 mg/dl in both groups.

Primary and Secondary endpoints for which the study was designed showed in 1.9 years statistical reductions in MACE Primary of 44%, nonfatal MI 65% reduction, any MI 54% reduction, nonfatal stroke 48% reduction, any stroke 48% reduction, MI/Stroke/CVdeath 47% reduction and any death 20% reduction. Also 50% LDL reduction and 37% hscrp reduction.

As with all studies monitoring for adverse events was undertaken and any serious adverse event was the same in both groups 15.2R and 15.5 on placebo, muscle issues same in both groups, death from cancer 0.4%R (35 people) and 0.7% (58 people on placebo) CI 0.02. A1c end of study 5.9% rosuva and 5.8% on placebo, FPG 98 mg/dl both groups, GFR 66.8 ml/min on rosuva and 66.6 ml/min on placebo with CI 0.02 and finaly newly diagnosed diabetes physician reported 270 cases on rosuva (3%) and 216 on placebo (2.4%) with CI 0.01.

With this being said one can summarize in this 'low risk' population without DM, CAD, CVD and normal lipoporotein values, using crestor 20 mg for 1.9 year the risk for MACE etc. is indicated above 65-20% reductions with NNT 85-110 people over a very short time period. Tolerability was the same. Monitered adverse events which one cannot make conclusions from above - because if one did state that crestor 20 mg over this time period raised the risk of new onset diabetes 0.6% NNH of 166 one would also have to say that it also reduced the risk of cancer deaths 0.03% NNT 333 and also was better for GFR values. THIS IS NOT correct to conclude based on this study design.

LIPITOR/PFE reps have no business commenting on this study nor promoting misinformation to their clinicians. Statins have been observed in studies to be associated with higher rates and lower rates of diabetes developing in their treatment arms. If I recall correctly Lipitor in a large outcome trial had higher statistical rates of developing diabetes, so it is interesting to see their company and their reps promoting their current message.

No benefit of vitamin C or E for prevention of major cardiovascular events: Physicians' Health Stu

Tue, 11 Nov 2008 18:27:58 EST

Gladys,
I'll make a deal with you. When someone proves that taking C or E vitamins does anything more for us than throwing massive amounts of dollars at the companies who sell them, I'll start taking them.
I'm interested in your background and current occupation, if you wouldn't care to reveal? It may help us understand why you are so convinced of their efficacy?
Melissa

JPAD: No effect of aspirin primary-CV-event prevention in diabetics

Tue, 11 Nov 2008 16:13:14 EST

The primary event rate (which was a composite of atherosclerotic events) was less than a third of predicted. The resulting power to show the a-priori-specified risk reduction was only 56%. The only appropriate conclusion is that the investigators should have done an interim power analysis and recruited 3 times as many patients.

No benefit of vitamin C or E for prevention of major cardiovascular events: Physicians' Health Stu

Tue, 11 Nov 2008 15:53:43 EST

I'm afraid I can't agree. It is indeed a terrible waste that we have spent so much money on these trials and doing them poorly. I know, these are major investigators with impeccable design. But not one of the studies has restricted participants to persons with elevations in oxidative stress or CRP. How would you have felt about negative statin trials where more than half of the participants had neither elevated lipids nor elevated CRP? And almost all the studies have permitted the placebo group to use multivitamins, which do raise vitamin C blood levels. And only two studies have been on vitamin C alone, and one of those was secondary prevention. Some people believe vitamin E at large doses to be actively harmful, and we and others have found that the mixture of C&E is less effective than C alone in reducing oxidative stress and CRP.

JPAD: No effect of aspirin primary-CV-event prevention in diabetics

Tue, 11 Nov 2008 15:51:10 EST

Not a powered enough study for Negative conclusions about aspirin. The trend for CV benefits of low-dose aspirin, even with this relatively small sample, seems a more appropriate perspective.