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Stenting vs. Endarterectomyfor Carotid Artery Stenosis:What Are the Trade-Offs?
 Mid-term CREST findings indicate that sur- gery is more effective for stroke prevention,but stenting has some advantages.
The use of stenting as an alternative to sur-gical endarterectomy for treatment of ca-rotid artery stenosis is controversial (
 JW Cardiol 
May 2010, p. 38, and
2010;375:985). In this North American multi-center trial, 2502 adults with carotid steno-sis (baseline age, 69) were randomizedto undergo endarterectomy or stenting.Forty-seven percent of patients wereasymptomatic, and embolic protection wasemployed in 96% of stenting procedures.The 4-year estimate of the primary combined endpoint of stroke, myocardialinfarction (MI), and death did not differsignificantly between the stenting and end-arterectomy groups (7.2% and 6.8%, re-spectively). During a median follow-up of 2.5 years, the stroke rate was higher in thestenting group than in the endarterectomy group (4.1% vs. 2.3%;
=0.01), and the MIrate was higher in the endarterectomy group than in the stenting group (2.3% vs.1.1%;
=0.03). The treatment effect wasunaffected by sex or symptomatic status.Efficacy was greater for stenting in youngerpatients and for endarterectomy in olderpatients, with a crossover at about age 70.Quality-of-life analyses at 1 year demon-strated a greater detrimental effect forstroke than for MI.
The outcomes for both therapies in thistrial were excellent, probably reflecting therigorous physician training and credential-ing required for participation. These find-ings, like those of previous large trials, failto demonstrate the superiority of stentingover endarterectomy, highlighting the factthat — as the editorialists note — strokeand MI should not be considered equiva-lent events. Nonetheless, I believe thatstenting may be preferable in some pa-tients, such as younger persons, those withideal or nontortuous anatomy, and thosewith severe coronary artery disease. Indi- vidual circumstances and careful patienteducation should guide treatment choices.
 — Howard C. Herrmann, MD
Brott TG et al. for theCREST Investigators. Stenting versusendarterectomy for treatment of carotid-arterystenosis.
N Engl J Med
2010 May 26; [e-pubahead of print]. (http://dx.doi.org/10.1056/ NEJMoa0912321)Davis SM and Donnan GA. Carotid-artery stenting in stroke prevention.
N Engl J Med
2010 May 26;[e-pub ahead of print]. (http://dx.doi.org/10.1056/ NEJMe1005220)
Treating Disease,Not Risk Factors
One center’s experience using total carotid arterial plaque burden to guide therapy for atherosclerotic disease
Quantitative measures of atherosclerosis,such as carotid intima–media thickness, areconsidered to be strong surrogate markers of disease progression. However, patients withhyperlipidemia are typically treated to tar-get LDL and HDL levels, without regard toquantitative measures of plaque. In 2001, in- vestigators at a vascular prevention clinic inwestern Ontario, Canada, began using theresults of ultrasound measurement of totalcarotid plaque area, rather than lipid levels,to guide treatment in adults with knownatherosclerotic disease. They compared theirplaque-progression results through 2007with those of the 5-year period before 2001,during which target lipid levels were used toguide treatment.The investigators included serialplaque measurements from 4378 patients(47% women). Mean age at referral was60 overall; during 1997–2001, mean ageincreased from 50 to 61 as the proportionof patients referred after a stroke grew. In2001–2002, plaque was progressing in 55%of patients and regressing in 26%. By 2006,these proportions had essentially reversed:Plaque was regressing in 50% and pro-gressing in 27%. In earlier years, patientswith plaque progression had higher levels of LDL than those with regression. However,
Stenting vs. Endarterectomyfor Carotid Artery Stenosis:What Are the Trade-Offs? .......................................53Treating Disease, Not Risk Factors ..........................53Stroke Risk Grows with Waistlinesin U.S. Women ...........................................................54Hamburgers, Hot Dogs, and Heart Health ..............54Fibrates and Cardiovascular Prevention ................55Gains in Hypertension Management .......................55“Spin” in Presentation of RandomizedTrial Results ...............................................................55Interruptions and MedicationAdministration Errors ...............................................56Staying Ahead of the Curve .......................................56Trends in AMI: More Good News.............................56Reducing Racial and Ethnic Variationsin Care of Patients with MI .....................................57Discharge Follow-Up and Readmissionfor Heart Failure ........................................................58The Role of CTCA in the Diagnosis of CAD .............58Endovascular AAA Repair:How Durable Is the Benefit? ..................................59Valve Surgery for Asymptomatic Patientswith Very Severe AS....................................59Avoiding Bleeding During PCI ...................................60
Diagnosis and Managementof Thoracic Aortic Disease .....................................57
July 2010 Vol. 16 No. 7
From the publishers of 
The New England Journal of Medicine
by 2007, LDL levels in patients with pro-gression were approximately half as highas in earlier years and were actually lowerthan LDL levels in patients with regression.
The rationale for this treatment paradigmis that, as the authors put it, “treating ar-teries without measuring plaque would belike treating hypertension without meas-uring blood pressure.” In this single-centerstudy, treatment based on carotid totalplaque area led to a substantial increase inplaque regression as compared with treat-ment based on lipid levels. However, theseresults must be tested in a large randomizedtrial with hard clinical outcomes before amajor shift in clinical practice can berecommended.
 — Joel M. Gore, MD
Spence JD and Hackam DG. Treating arteries in-stead of risk factors: A paradigm change in manage-ment of atherosclerosis.
2010 Jun; 41:1193.
Stroke Risk Grows withWaistlines in U.S. Women
Rising obesity is associated with rising midlife stroke rates in women, but not in men.
Recent research has demonstrated thatthe prevalence of stroke in women aged45 to 54 is twice that in men of similar age(
2007; 69:1898). Investigatorssought to determine whether this observedsex difference is a recent phenomenon, andif so, whether it could relate to worseningof vascular risk factors or increases in bio-marker levels among women. They evalu-ated medical histories and biomarkerdata from participants in the NationalHealth and Nutrition Examination Survey (NHANES) 1988–1994 compared withanalogous data from NHANES 1999–2004. In all, 9706 women and men aged35 to 54 answered the question about priordiagnosis of stroke.In women, stroke prevalence increasedfrom 0.6% in 1988–1994 to 1.8% 1999–2004; no such increase was seen in men(0.9% and 1.0% in 1988–1994 and 1999–2004, respectively). The percentage of women with abdominal obesity (defined aswaist circumference >88 cm [34.6 inches])increased from 47% to 59% between thetwo survey periods; average waist circum-ference in women was nearly 4 cm (1.6inches) greater in 1999–2004 than in1988–1994. In contrast, most key biomarkerlevels and traditional vascular risk factorsremained stable or even improved inwomen, with the exception of glycemicmarkers and luteinizing hormone levels,which increased substantially between thetwo survey periods.
NHANES data reveal that midlife strokerates have tripled among U.S. women dur-ing the past two decades. These results in-dicate that risk for stroke between the agesof 35 and 54 is higher in women than inmen and compellingly suggest that obesity and metabolic syndrome (reflected by gly-cemic markers and luteinizing hormonelevels) are driving much of the increase.Further longitudinal studies are requiredto illuminate trends in stroke incidenceand to explore associated factors moreclosely.
 — JoAnne M. Foody, MD
Towfighi A et al. Weight of the obesity epidemic:Rising stroke rates among middle-aged women inthe United States.
2010 May 27; [e-pubahead of print]. (http://dx.doi.org/10.1161/ STROKEAHA.109.577510)
Hamburgers, Hot Dogs,and Heart Health
In a meta-analysis, processed meat con- ferred higher risks for CAD and diabetesthan unprocessed red meat.
We make dietary choices and recommen-dations with less-than-complete evidenceto guide us. A current controversy con-cerns the effects of meat, particularly redand processed meats, on cardiovascularrisk. These investigators conducted a sys-tematic review and meta-analysis of stud-ies evaluating the associations between redand processed meat consumption and risksfor coronary heart disease (CHD), stroke,and diabetes.The researchers did not identify any trials; their analysis included 17 prospectivecohort studies and 3 case-control studies.Consumption of unprocessed red meat wasnot associated with CHD (4 studies; rela-tive risk, 1.00 per 100-g serving/day; 95%confidence interval, 0.81–1.23) or diabetes(5 studies; RR, 1.16; 95% CI, 0.92–1.46).Consumption of processed meat was asso-ciated with a 42% increase in risk for CHD(5 studies; RR, 1.42 per 50-g serving/day;95% CI, 1.07–1.89) and a 19% increase inrisk for diabetes (7 studies; RR, 1.19; 95%
Harlan M. Krumholz, MD, SM,
Harold H. Hines, Jr.,Professor of Medicine, Section of CardiovascularMedicine, Yale University School of Medicine,New Haven
Kristin L. Odmark
Massachusetts Medical Society
Howard C. Herrmann, MD,
Professor of Medicine,Director, Interventional Cardiology and CardiacCatheterization Laboratories, University ofPennsylvania Medical Center, Philadelphia
JoAnne M. Foody, MD,
Director, CardiovascularWellness Center, Brigham and Women’s Hospital,Boston
Joel M. Gore, MD,
Edward Budnitz Professorof Cardiovascular Medicine, University ofMassachusetts, Worcester
Mark S. Link, MD,
Associate Professor of Medicine,New England Medical Center and Tufts UniversitySchool of Medicine, Boston
Frederick A. Masoudi, MD, MSPH,
Division ofCardiology, Denver Health Medical Center andAssociate Professor of Medicine, University ofColorado at Denver
Beat J. Meyer, MD,
Associate Professor ofCardiology, University of Bern; Chief, Division ofCardiology, Lindenhofspital, Bern, Switzerland
 William T. Abraham, MD,
Professor of Medicine,Chief, Division of Cardiovascular Medicine,The Ohio State University Heart Center, Columbus
Hugh Calkins, MD,
Professor of Medicine andDirector of Electrophysiology, The Johns HopkinsHospital, Baltimore
Kim A. Eagle, MD,
Albion Walter Hewlett Professorof Internal Medicine and Chief of ClinicalCardiology, Division of Cardiology, University ofMichigan Medical Center, Ann Arbor
Christopher R. Lynch,
Vice President forPublishing;
Alberta L. Fitzpatrick,
Betty Barrer, Christine Sadlowski, Sharon S.Salinger,
Staff Editors;
Kara O’Halloran,
Misty Horten,
Matthew O’Rourke,
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Robert Dall,
Editorial Director;
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Publishing Services;
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 Customer ServicePublished 12 times a year. Subscription rates peryear: $119 (U.S.), C$166.67 (Canada), US$165 (Intl);Residents/Students/Nurses/PAs: $69 (U.S.), C$96.19(Canada), US$80 (Intl); Institutions: $219 (U.S.),C$256.19 (Canada), US$230 (Intl); individual printonly: $89 (U.S.). Prices do not include GST, HST,or VAT. In Canada remit to: Massachusetts MedicalSociety C/O #B9162, P.O. Box 9100, Postal Station F,Toronto, Ontario, M4Y 3A5. All others remit to:
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Vol. 16 No. 7
CI, 1.11–1.27). Neither type of meat wasassociated with an elevated risk for stroke.
This meta-analysis encompasses relativelfew studies, and confounding by impreciseor unmeasured factors is likely. Moreover,the CIs do not exclude substantial risksassociated with unprocessed meat. Never-theless, the main finding of an increase inrisk with processed meats, with their highsalt and preservative content, bolsters avail-able evidence and should lead us to adviseour patients to be cautious about consum-ing these products.
 — Harlan M. Krumholz, MD, SM
 Micha R et al. Red and processed meat consumptionand risk of incident coronary heart disease, stroke,and diabetes mellitus: A systematic review and meta-analysis.
2010 Jun 1; 121:2271.
Fibrates and CardiovascularPrevention
 A meta-analysis shows a benefit, but theclinical value of fibrates is still in doubt.
Since the publication of the ACCORDLipid Study, in which adding a fibrate (e.g.,gemfibrozil, fenofibrate) to a statin did notimprove cardiovascular outcomes in pa-tients with diabetes (
 JW Cardio
Apr 2010,p. 29, and
N Engl J Med 
2010; 362:1563),fibrates have come under closer scrutiny.Now, investigators in Australia have con-ducted a meta-analysis of randomizedtrials evaluating the effects of fibrates ver-sus placebo on cardiovascular outcomes.The investigators identified 18 trials in-cluding 45,058 patients. Fibrates were asso-ciated with the following:A barely significant 10% reduction inrisk for cardiovascular events (5 trials;
=0.048; 95% confidence interval,0.82–1.00)A 13% reduction in risk for coronary events (16 trials;
<0.0001; 95% CI,0.81–0.93)A nonsignificant 7% reduction in riskfor cardiac death (13 trials;
=0.116;95% CI, 0.85–1.02)No reduction in all-cause death (16trials;
=0.918; 95% CI, 0.93–1.08)Of 14 subgroup analyses for coronary events, none was significant at a level of 
<0.01, although a benefit at
=0.03 wasfound in the subgroup of patients withbaseline triglyceride levels
177 mg/dL.The ACCORD Lipid Study was the only trial in which participants received con-comitant statin treatment.
This analysis has been touted as a vindica-tion of fibrates; however, it is much lessconclusive than it appears at first glance.The effect size is relatively small, most pa-tients in these trials were not on statins,and adding fibrates was unhelpful in theone trial that mandated background statintherapy. The authors highlight the benefitfound in the high-triglyceride subgroup,but that analysis was unadjusted for num-ber of comparisons. Overall, this analysiswill not quiet the controversy over the value of fibrates in general or of fenofibratein particular.
 — Harlan M. Krumholz, MD, SM
 Jun M et al. Effects of fibrates on cardiovascular outcomes: A systematic review and meta-analysis.
2010 May 29; 375:1875.
Gains in HypertensionManagement 
Public health efforts to improve blood pres-sure control reach an important milestone.
As many as 65 million U.S. adults havehypertension. These investigators useddata from the National Health and Nutri-tion Examination Survey 1988–1994and 1999–2008 cohorts to assess progresstoward the U.S. government’s Healthy People 2010 goal of achieving blood pres-sure (BP) control in 50% of individualswith hypertension. The analysis included42,856 adults.The prevalence of hypertension in-creased significantly between 1988–1994and 1999–2000 but remained stable be-tween 1999–2000 and 2007–2008. Con-trolled hypertension (BP <140/90 mm Hg)rates increased from 27.3% in 1988–1994to 50.1% in 2007–2008; during this time,mean BP in hypertensive patients fell from143.0/80.4 mm Hg to 135.2/74.1 mm Hg.Rates of hypertension control improvedsignificantly between 1988–1994 and2007–2008 in all age, race, and sex catego-ries, but the rate was lower in individualsaged 18 to 39 than in those aged 40 to 59and in those aged 60 and older (
<0.001 forboth comparisons), and was also lower inHispanics than in whites (
These data suggest that as of 2008, BP iscontrolled in an estimated 50.1% of alladults with hypertension and that most of the improvement since 1988 has occurredafter 2000. As an editorialist notes, thisachievement merits celebration; however,hypertension control rates remain signifi-cantly lower in younger than in olderadults and in Hispanic than in white pa-tients. Much work remains to be done.
 — JoAnne M. Foody, MD
Egan BM et al. US trends in prevalence, awareness,treatment, and control of hypertension, 1988-2008.
2010 May 26; 303:2043.Chobanian AV. Improved hypertension control:Cause for some celebration.
2010 May 26;303:2082.
“Spin” in Presentationof Randomized Trial Results
 A study of data manipulation
Authors of journal articles often frame dis-cussions to advance particular perspectivesor agendas. To examine this issue, re-searchers searched PubMed and identifiedall randomized controlled trials (RCTs)published in December 2006 and selectedthe 72 RCTs with clearly identified primary outcomes that were not statistically signifi-cant (
0.05). The researchers analyzedeach article for presence of “spin,” usingtheir own classification scheme.Spin was identified in 18% of articletitles; in 38% and 58% of abstract resultsand conclusion sections, respectively; andin 29%, 43%, and 50% of main-text results,discussion, and conclusion sections, respec-tively. The level of spin in conclusion sec-tions was considered “high” in about 30%of articles. Common types of spin were ex-cessive focus on subgroups or secondary outcomes, focus on improvements
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