Blog observations about this study:
Calcium supplementation may adversely affect cardiovascular health in older women.
New Zealand researchers randomized nearly 1500 postmenopausal women to either 1 g of calcium or placebo daily; they then measured cardiovascular events over the ensuing 5 years
Vascular events in healthy older women receiving calcium supplementation: randomised controlled trial
Mark J Bolland, research fellow1, P Alan Barber, senior lecturer1, Robert N Doughty, associate professor1, Barbara Mason, research officer1, Anne Horne, research fellow1, Ruth Ames, research officer1, Gregory D Gamble, research fellow1, Andrew Grey, associate professor1, Ian R Reid, professor1
Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand
Correspondence to: I R Reid i.reid@auckland.ac.nz
Abstract
Objective
To determine the effect of calcium supplementation on myocardial infarction, stroke, and sudden death in healthy postmenopausal women.
Design
Randomised, placebo controlled trial.
Setting
Academic medical centre in an urban setting in New Zealand.
Participants
1471 postmenopausal women (mean age 74): 732 were randomised to calcium supplementation and 739 to placebo.
Main outcome measures
Adverse cardiovascular events over five years: death, sudden death, myocardial infarction, angina, other chest pain, stroke, transient ischaemic attack, and a composite end point of myocardial infarction, stroke, or sudden death.
Results
Myocardial infarction was more commonly reported in the calcium group than in the placebo group (45 events in 31 women v 19 events in 14 women, P=0.01). The composite end point of myocardial infarction, stroke, or sudden death was also more common in the calcium group (101 events in 69 women v 54 events in 42 women, P=0.008). After adjudication myocardial infarction remained more common in the calcium group (24 events in 21 women v 10 events in 10 women, relative risk 2.12, 95% confidence interval 1.01 to 4.47). For the composite end point 61 events were verified in 51 women in the calcium group and 36 events in 35 women in the placebo group (relative risk 1.47, 0.97 to 2.23). When unreported events were added from the national database of hospital admissions in New Zealand the relative risk of myocardial infarction was 1.49 (0.86 to 2.57) and that of the composite end point was 1.21 (0.84 to 1.74). The respective rate ratios were 1.67 (95% confidence intervals 0.98 to 2.87) and 1.43 (1.01 to 2.04); event rates: placebo 16.3/1000 person years, calcium 23.3/1000 person years. For stroke (including unreported events) the relative risk was 1.37 (0.83 to 2.28) and the rate ratio was 1.45 (0.88 to 2.49).
Conclusion
Calcium supplementation in healthy postmenopausal women is associated with upward trends in cardiovascular event rates. This potentially detrimental effect should be balanced against the likely benefits of calcium on bone.
Showing posts with label Stroke. Show all posts
Showing posts with label Stroke. Show all posts
Wednesday, January 16, 2008
Friday, January 4, 2008
Recent respiratory infection and risk of cardiovascular disease: case-control study through a general practice database.
Recent respiratory infection and risk of cardiovascular disease: case-control study through a general practice database.
European Heart Journal
Volume 29, Number 1 : January 2008
Aims: Respiratory infection may be associated with an increased risk of major cardiovascular events. This case-control study describes associations with these events of respiratory infection.
Methods and results: The IMS Disease Analyzer Mediplus primary care database was used to identify all cases of first-time diagnosis of myocardial infarction (MI) or stroke and single matched controls. Details were extracted on visits for respiratory infection over the preceding year. A total of 11 155 MI cases and 9208 stroke cases were identified. For MI and stroke respectively, there were 326 and 260 respiratory infections during the month preceding the index date. There was strong evidence of an increased risk of both events in the 7 days following infection, for MI adjusted odds ratio (OR) 2.10 (95% confidence interval 1.38–3.21), for stroke OR 1.92 (95% confidence interval 1.24–2.97). The strength of these associations fell over time. The associations for MI occurred at all levels of initial underlying cardiovascular risk.
Conclusions: There are strong associations between recent respiratory infection and major cardiovascular events, for MI at all levels of underlying risk. The benefits of reducing respiratory infection either through immunization or treating or preventing infection may be substantial.
European Heart Journal
Volume 29, Number 1 : January 2008
Aims: Respiratory infection may be associated with an increased risk of major cardiovascular events. This case-control study describes associations with these events of respiratory infection.
Methods and results: The IMS Disease Analyzer Mediplus primary care database was used to identify all cases of first-time diagnosis of myocardial infarction (MI) or stroke and single matched controls. Details were extracted on visits for respiratory infection over the preceding year. A total of 11 155 MI cases and 9208 stroke cases were identified. For MI and stroke respectively, there were 326 and 260 respiratory infections during the month preceding the index date. There was strong evidence of an increased risk of both events in the 7 days following infection, for MI adjusted odds ratio (OR) 2.10 (95% confidence interval 1.38–3.21), for stroke OR 1.92 (95% confidence interval 1.24–2.97). The strength of these associations fell over time. The associations for MI occurred at all levels of initial underlying cardiovascular risk.
Conclusions: There are strong associations between recent respiratory infection and major cardiovascular events, for MI at all levels of underlying risk. The benefits of reducing respiratory infection either through immunization or treating or preventing infection may be substantial.
Tuesday, January 1, 2008
Restless Legs Syndrome Doubles Risk Of Stroke And Heart Disease
Restless Legs Syndrome Doubles Risk Of Stroke And Heart Disease, Study Shows
ScienceDaily (Jan. 1, 2008) — People with restless legs syndrome (RLS) are twice as likely to have a stroke or heart disease compared to people without RLS, and the risk is greatest in those with the most frequent and severe symptoms, according to new research.
The study, the largest of its kind enrolling both men and women, involved 3,433 people with an average age of 68 who were enrolled in the Sleep Heart Health Study. Participants were diagnosed with RLS by detailed questionnaire and asked if they had been diagnosed with a variety of systemic diseases including cardiovascular disease and cerebrovascular disease. Of the participants, nearly seven percent of women and three percent of men had RLS.
The study found people with RLS were more than twice as likely to have cardiovascular disease or cerebrovascular disease. The results remained the same after adjusting for age, sex, race, body mass index, diabetes, high blood pressure, high blood pressure medication, HDL/LDL cholesterol levels, and smoking.
"The association of RLS with heart disease and stroke was strongest in those people who had RLS symptoms at least 16 times per month," said study author John W. Winkelman, MD, PhD, with Harvard Medical School in Boston. "There was also an increased risk among people who said their RLS symptoms were severe compared to those with less bothersome symptoms."
Winkelman says although this study does not show that RLS causes cardiovascular and cerebrovascular disease, a number of potential mechanics for such a process exist. "In particular, most people with RLS have as many as 200 to 300 periodic leg movements per night of sleep and these leg movements are associated with substantial acute increases in both blood pressure and heart rate, which may, over the long term, produce cardiovascular or cerebrovascular disease.
Winkelman says there are limitations to the study, including that the diagnosis of RLS was self-reported by questionnaire rather than by clinical interview.
This research was published in the January 1, 2008, issue of Neurology®, the medical journal of the American Academy of Neurology.
ScienceDaily (Jan. 1, 2008) — People with restless legs syndrome (RLS) are twice as likely to have a stroke or heart disease compared to people without RLS, and the risk is greatest in those with the most frequent and severe symptoms, according to new research.
The study, the largest of its kind enrolling both men and women, involved 3,433 people with an average age of 68 who were enrolled in the Sleep Heart Health Study. Participants were diagnosed with RLS by detailed questionnaire and asked if they had been diagnosed with a variety of systemic diseases including cardiovascular disease and cerebrovascular disease. Of the participants, nearly seven percent of women and three percent of men had RLS.
The study found people with RLS were more than twice as likely to have cardiovascular disease or cerebrovascular disease. The results remained the same after adjusting for age, sex, race, body mass index, diabetes, high blood pressure, high blood pressure medication, HDL/LDL cholesterol levels, and smoking.
"The association of RLS with heart disease and stroke was strongest in those people who had RLS symptoms at least 16 times per month," said study author John W. Winkelman, MD, PhD, with Harvard Medical School in Boston. "There was also an increased risk among people who said their RLS symptoms were severe compared to those with less bothersome symptoms."
Winkelman says although this study does not show that RLS causes cardiovascular and cerebrovascular disease, a number of potential mechanics for such a process exist. "In particular, most people with RLS have as many as 200 to 300 periodic leg movements per night of sleep and these leg movements are associated with substantial acute increases in both blood pressure and heart rate, which may, over the long term, produce cardiovascular or cerebrovascular disease.
Winkelman says there are limitations to the study, including that the diagnosis of RLS was self-reported by questionnaire rather than by clinical interview.
This research was published in the January 1, 2008, issue of Neurology®, the medical journal of the American Academy of Neurology.
Thursday, December 27, 2007
Incidence and Prognosis of Transient Neurological Attacks
Incidence and Prognosis of Transient Neurological Attacks
Michiel J. Bos, MD, MSc; Marie Josee E. van Rijn, MD, PhD; Jacqueline C. M. Witteman, PhD; Albert Hofman, MD, PhD; Peter J. Koudstaal, MD, PhD; Monique M. B. Breteler, MD, PhD
JAMA. 2007;298(24):2877-2885.
Context Transient neurological attacks (TNAs) are attacks with temporary (<24 hours) neurological symptoms. These symptoms can be focal, nonfocal, or a mixture of both. The prognostic significance of TNAs with focal symptoms (better known as transient ischemic attacks [TIAs]) is well understood. Conversely, hardly anything is known about the prognostic significance of TNAs with nonfocal or mixed symptoms.
Objective To study the incidence and prognosis of focal TNAs (or TIAs), nonfocal TNAs, and mixed TNAs.
Design, Setting, and Participants The study population comprised 6062 community-dwelling Rotterdam Study participants who were aged 55 years or older and free from stroke, myocardial infarction, and dementia at baseline (1990-1993). They were followed up for events until January 1, 2005. We analyzed the associations between incident TNAs and subsequent adverse events with age- and sex-adjusted Cox regression models.
Main Outcome Measures Stroke, ischemic heart disease, or dementia.
Results During 60 535 person-years, 548 participants developed TNA (282 focal, 228 nonfocal, and 38 mixed). The incidence rate per 1000 person-years was 4.7 (95% confidence interval [CI], 4.1-5.2) for focal TNA, 3.8 (95% CI, 3.3-4.3) for nonfocal TNA, and 0.6 (95% CI, 0.4-0.9) for mixed TNA. Participants with focal TNA were at higher risk of subsequent stroke than participants without TNA (n = 46 vs 540; hazard ratio [HR], 2.14; 95% confidence interval [CI]; 1.57-2.91) but had an equal risk of ischemic heart disease and dementia. Nonfocal TNA patients were at higher risk of stroke (27 vs 540; HR, 1.56; 95% CI, 1.08-2.28) and dementia (30 vs 552; HR, 1.59; 95% CI, 1.11-2.26) than participants without TNA. Mixed TNA patients were at higher risk of stroke (6 vs 540; HR, 2.48; 95% CI, 1.11-5.56), ischemic heart disease (8 vs 779; HR, 2.26; 95% CI, 1.07-4.78), vascular death (8 vs 594; HR, 2.54; 95% CI, 1.31-4.91), and dementia (7 vs 552; HR, 3.46; 95% CI, 1.72-6.98) than participants without TNA.
Michiel J. Bos, MD, MSc; Marie Josee E. van Rijn, MD, PhD; Jacqueline C. M. Witteman, PhD; Albert Hofman, MD, PhD; Peter J. Koudstaal, MD, PhD; Monique M. B. Breteler, MD, PhD
JAMA. 2007;298(24):2877-2885.
Context Transient neurological attacks (TNAs) are attacks with temporary (<24 hours) neurological symptoms. These symptoms can be focal, nonfocal, or a mixture of both. The prognostic significance of TNAs with focal symptoms (better known as transient ischemic attacks [TIAs]) is well understood. Conversely, hardly anything is known about the prognostic significance of TNAs with nonfocal or mixed symptoms.
Objective To study the incidence and prognosis of focal TNAs (or TIAs), nonfocal TNAs, and mixed TNAs.
Design, Setting, and Participants The study population comprised 6062 community-dwelling Rotterdam Study participants who were aged 55 years or older and free from stroke, myocardial infarction, and dementia at baseline (1990-1993). They were followed up for events until January 1, 2005. We analyzed the associations between incident TNAs and subsequent adverse events with age- and sex-adjusted Cox regression models.
Main Outcome Measures Stroke, ischemic heart disease, or dementia.
Results During 60 535 person-years, 548 participants developed TNA (282 focal, 228 nonfocal, and 38 mixed). The incidence rate per 1000 person-years was 4.7 (95% confidence interval [CI], 4.1-5.2) for focal TNA, 3.8 (95% CI, 3.3-4.3) for nonfocal TNA, and 0.6 (95% CI, 0.4-0.9) for mixed TNA. Participants with focal TNA were at higher risk of subsequent stroke than participants without TNA (n = 46 vs 540; hazard ratio [HR], 2.14; 95% confidence interval [CI]; 1.57-2.91) but had an equal risk of ischemic heart disease and dementia. Nonfocal TNA patients were at higher risk of stroke (27 vs 540; HR, 1.56; 95% CI, 1.08-2.28) and dementia (30 vs 552; HR, 1.59; 95% CI, 1.11-2.26) than participants without TNA. Mixed TNA patients were at higher risk of stroke (6 vs 540; HR, 2.48; 95% CI, 1.11-5.56), ischemic heart disease (8 vs 779; HR, 2.26; 95% CI, 1.07-4.78), vascular death (8 vs 594; HR, 2.54; 95% CI, 1.31-4.91), and dementia (7 vs 552; HR, 3.46; 95% CI, 1.72-6.98) than participants without TNA.
Friday, November 30, 2007
Cholesterol seen tied to heart disease, not stroke
Blood cholesterol and vascular mortality by age, sex, and blood pressure: a meta-analysis of individual data from 61 prospective studies with 55 000 vascular deaths
The Lancet 2007; 370:1829-1839
Summary
Background
Age, sex, and blood pressure could modify the associations of total cholesterol (and its main two fractions, HDL and LDL cholesterol) with vascular mortality. This meta-analysis combined prospective studies of vascular mortality that recorded both blood pressure and total cholesterol at baseline, to determine the joint relevance of these two risk factors.
Methods
Information was obtained from 61 prospective observational studies, mostly in western Europe or North America, consisting of almost 900 000 adults without previous disease and with baseline measurements of total cholesterol and blood pressure. During nearly 12 million person years at risk between the ages of 40 and 89 years, there were more than 55 000 vascular deaths (34 000 ischaemic heart disease [IHD], 12 000 stroke, 10 000 other). Information about HDL cholesterol was available for 150 000 participants, among whom there were 5000 vascular deaths (3000 IHD, 1000 stroke, 1000 other). Reported associations are with usual cholesterol levels (ie, corrected for the regression dilution bias).
Findings
1 mmol/L lower total cholesterol was associated with about a half (hazard ratio 0·44 [95% CI 0·42–0·48]), a third (0·66 [0·65–0·68]), and a sixth (0·83 [0·81–0·85]) lower IHD mortality in both sexes at ages 40–49, 50–69, and 70–89 years, respectively, throughout the main range of cholesterol in most developed countries, with no apparent threshold. The proportional risk reduction decreased with increasing blood pressure, since the absolute effects of cholesterol and blood pressure were approximately additive. Of various simple indices involving HDL cholesterol, the ratio total/HDL cholesterol was the strongest predictor of IHD mortality (40% more informative than non-HDL cholesterol and more than twice as informative as total cholesterol). Total cholesterol was weakly positively related to ischaemic and total stroke mortality in early middle age (40–59 years), but this finding could be largely or wholly accounted for by the association of cholesterol with blood pressure. Moreover, a positive relation was seen only in middle age and only in those with below-average blood pressure; at older ages (70–89 years) and, particularly, for those with systolic blood pressure over about 145 mm Hg, total cholesterol was negatively related to haemorrhagic and total stroke mortality. The results for other vascular mortality were intermediate between those for IHD and stroke.
Interpretation
Total cholesterol was positively associated with IHD mortality in both middle and old age and at all blood pressure levels. The absence of an independent positive association of cholesterol with stroke mortality, especially at older ages or higher blood pressures, is unexplained, and invites further research. Nevertheless, there is conclusive evidence from randomised trials that statins substantially reduce not only coronary event rates but also total stroke rates in patients with a wide range of ages and blood pressures.
The Lancet 2007; 370:1829-1839
Summary
Background
Age, sex, and blood pressure could modify the associations of total cholesterol (and its main two fractions, HDL and LDL cholesterol) with vascular mortality. This meta-analysis combined prospective studies of vascular mortality that recorded both blood pressure and total cholesterol at baseline, to determine the joint relevance of these two risk factors.
Methods
Information was obtained from 61 prospective observational studies, mostly in western Europe or North America, consisting of almost 900 000 adults without previous disease and with baseline measurements of total cholesterol and blood pressure. During nearly 12 million person years at risk between the ages of 40 and 89 years, there were more than 55 000 vascular deaths (34 000 ischaemic heart disease [IHD], 12 000 stroke, 10 000 other). Information about HDL cholesterol was available for 150 000 participants, among whom there were 5000 vascular deaths (3000 IHD, 1000 stroke, 1000 other). Reported associations are with usual cholesterol levels (ie, corrected for the regression dilution bias).
Findings
1 mmol/L lower total cholesterol was associated with about a half (hazard ratio 0·44 [95% CI 0·42–0·48]), a third (0·66 [0·65–0·68]), and a sixth (0·83 [0·81–0·85]) lower IHD mortality in both sexes at ages 40–49, 50–69, and 70–89 years, respectively, throughout the main range of cholesterol in most developed countries, with no apparent threshold. The proportional risk reduction decreased with increasing blood pressure, since the absolute effects of cholesterol and blood pressure were approximately additive. Of various simple indices involving HDL cholesterol, the ratio total/HDL cholesterol was the strongest predictor of IHD mortality (40% more informative than non-HDL cholesterol and more than twice as informative as total cholesterol). Total cholesterol was weakly positively related to ischaemic and total stroke mortality in early middle age (40–59 years), but this finding could be largely or wholly accounted for by the association of cholesterol with blood pressure. Moreover, a positive relation was seen only in middle age and only in those with below-average blood pressure; at older ages (70–89 years) and, particularly, for those with systolic blood pressure over about 145 mm Hg, total cholesterol was negatively related to haemorrhagic and total stroke mortality. The results for other vascular mortality were intermediate between those for IHD and stroke.
Interpretation
Total cholesterol was positively associated with IHD mortality in both middle and old age and at all blood pressure levels. The absence of an independent positive association of cholesterol with stroke mortality, especially at older ages or higher blood pressures, is unexplained, and invites further research. Nevertheless, there is conclusive evidence from randomised trials that statins substantially reduce not only coronary event rates but also total stroke rates in patients with a wide range of ages and blood pressures.
Thursday, November 29, 2007
Patent Foramen Ovale and Cryptogenic Stroke in Older Patients
Patent Foramen Ovale and Cryptogenic Stroke in Older Patients
Michael Handke, M.D., Andreas Harloff, M.D., Manfred Olschewski, M.Sc., Andreas Hetzel, M.D., and Annette Geibel, M.D.
NEW ENGLAND JOURNAL OF MEDICINE
Volume 357 — November 29, 2007 — Number 22
ABSTRACT
Background Studies to date have shown an association between the presence of patent foramen ovale and cryptogenic stroke in patients younger than 55 years of age. This association has not been established in patients 55 years of age or older.
Methods We prospectively examined 503 consecutive patients who had had a stroke, and we compared the 227 patients with cryptogenic stroke and the 276 control patients with stroke of known cause. We examined the prevalences of patent foramen ovale and of patent foramen ovale with concomitant atrial septal aneurysm in all patients, using transesophageal echocardiography. We also compared data for the 131 younger patients (<55 years of age) and those for the 372 older patients (55 years of age).
Results The prevalence of patent foramen ovale was significantly greater among patients with cryptogenic stroke than among those with stroke of known cause, for both younger patients (43.9% vs. 14.3%; odds ratio, 4.70; 95% confidence interval [CI], 1.89 to 11.68; P<0.001) and older patients (28.3% vs. 11.9%; odds ratio, 2.92; 95% CI, 1.70 to 5.01; P<0.001). Even stronger was the association between the presence of patent foramen ovale with concomitant atrial septal aneurysm and cryptogenic stroke, as compared with stroke of known cause, among both younger patients (13.4% vs. 2.0%; odds ratio, 7.36; 95% CI, 1.01 to 326.60; P=0.049) and older patients (15.2% vs. 4.4%; odds ratio, 3.88; 95% CI, 1.78 to 8.46; P<0.001). Multivariate analysis adjusted for age, plaque thickness, and presence or absence of coronary artery disease and hypertension showed that the presence of patent foramen ovale was independently associated with cryptogenic stroke in both the younger group (odds ratio, 3.70; 95% CI, 1.42 to 9.65; P=0.008) and the older group (odds ratio, 3.00; 95% CI, 1.73 to 5.23; P<0.001).
Conclusions There is an association between the presence of patent foramen ovale and cryptogenic stroke in both older patients and younger patients. These data suggest that paradoxical embolism is a cause of stroke in both age groups.
Michael Handke, M.D., Andreas Harloff, M.D., Manfred Olschewski, M.Sc., Andreas Hetzel, M.D., and Annette Geibel, M.D.
NEW ENGLAND JOURNAL OF MEDICINE
Volume 357 — November 29, 2007 — Number 22
ABSTRACT
Background Studies to date have shown an association between the presence of patent foramen ovale and cryptogenic stroke in patients younger than 55 years of age. This association has not been established in patients 55 years of age or older.
Methods We prospectively examined 503 consecutive patients who had had a stroke, and we compared the 227 patients with cryptogenic stroke and the 276 control patients with stroke of known cause. We examined the prevalences of patent foramen ovale and of patent foramen ovale with concomitant atrial septal aneurysm in all patients, using transesophageal echocardiography. We also compared data for the 131 younger patients (<55 years of age) and those for the 372 older patients (55 years of age).
Results The prevalence of patent foramen ovale was significantly greater among patients with cryptogenic stroke than among those with stroke of known cause, for both younger patients (43.9% vs. 14.3%; odds ratio, 4.70; 95% confidence interval [CI], 1.89 to 11.68; P<0.001) and older patients (28.3% vs. 11.9%; odds ratio, 2.92; 95% CI, 1.70 to 5.01; P<0.001). Even stronger was the association between the presence of patent foramen ovale with concomitant atrial septal aneurysm and cryptogenic stroke, as compared with stroke of known cause, among both younger patients (13.4% vs. 2.0%; odds ratio, 7.36; 95% CI, 1.01 to 326.60; P=0.049) and older patients (15.2% vs. 4.4%; odds ratio, 3.88; 95% CI, 1.78 to 8.46; P<0.001). Multivariate analysis adjusted for age, plaque thickness, and presence or absence of coronary artery disease and hypertension showed that the presence of patent foramen ovale was independently associated with cryptogenic stroke in both the younger group (odds ratio, 3.70; 95% CI, 1.42 to 9.65; P=0.008) and the older group (odds ratio, 3.00; 95% CI, 1.73 to 5.23; P<0.001).
Conclusions There is an association between the presence of patent foramen ovale and cryptogenic stroke in both older patients and younger patients. These data suggest that paradoxical embolism is a cause of stroke in both age groups.
Friday, November 23, 2007
Venous thromboembolism and subsequent hospitalisation due to acute arterial cardiovascular events: a 20-year cohort study
Venous thromboembolism and subsequent hospitalisation due to acute arterial cardiovascular events: a 20-year cohort study
The Lancet, Current Issue, Volume 370, Number 9601, 24 November 2007
Henrik Toft Sørensen, Erzsebet Horvath-Puho, Lars Pedersen, John A Baron, Paolo Prandoni
Summary
Background
In some studies, venous thromboembolism has been associated with atherosclerosis and with the risk of arterial cardiovascular events such as myocardial infarction and stroke. Other studies, however, do not show this association. To help clarify these discrepant findings, we aimed to investigate the risk of arterial cardiovascular events in patients who were diagnosed with venous thromboembolism.
Methods
We undertook a 20-year population-based cohort study using data from nationwide Danish medical databases. After excluding those with known cardiovascular disease, we assessed the risk of myocardial infarction and stroke in 25 199 patients with deep venous thrombosis, 16 925 patients with pulmonary embolism, and 163 566 population controls.
Findings
For patients with deep venous thrombosis, the relative risks varied from 1·60 for myocardial infarction (95% CI 1·35–1·91) to 2·19 (1·85–2·60) for stroke in the first year after the thrombotic event. For patients with pulmonary embolism, the relative risks in that year were 2·60 (2·14–3·14) for myocardial infarction and 2·93 (2·34–3·66) for stroke. The relative risks were also raised, though less markedly, during the subsequent 20 years of follow-up, with 20–40% increases in risk for arterial cardiovascular events. Relative risks were similar for those with provoked and unprovoked deep venous thrombosis and pulmonary embolism.
Interpretation
Patients with venous thromboembolism have a substantially increased long-term risk of subsequent arterial cardiovascular events.
The Lancet, Current Issue, Volume 370, Number 9601, 24 November 2007
Henrik Toft Sørensen, Erzsebet Horvath-Puho, Lars Pedersen, John A Baron, Paolo Prandoni
Summary
Background
In some studies, venous thromboembolism has been associated with atherosclerosis and with the risk of arterial cardiovascular events such as myocardial infarction and stroke. Other studies, however, do not show this association. To help clarify these discrepant findings, we aimed to investigate the risk of arterial cardiovascular events in patients who were diagnosed with venous thromboembolism.
Methods
We undertook a 20-year population-based cohort study using data from nationwide Danish medical databases. After excluding those with known cardiovascular disease, we assessed the risk of myocardial infarction and stroke in 25 199 patients with deep venous thrombosis, 16 925 patients with pulmonary embolism, and 163 566 population controls.
Findings
For patients with deep venous thrombosis, the relative risks varied from 1·60 for myocardial infarction (95% CI 1·35–1·91) to 2·19 (1·85–2·60) for stroke in the first year after the thrombotic event. For patients with pulmonary embolism, the relative risks in that year were 2·60 (2·14–3·14) for myocardial infarction and 2·93 (2·34–3·66) for stroke. The relative risks were also raised, though less markedly, during the subsequent 20 years of follow-up, with 20–40% increases in risk for arterial cardiovascular events. Relative risks were similar for those with provoked and unprovoked deep venous thrombosis and pulmonary embolism.
Interpretation
Patients with venous thromboembolism have a substantially increased long-term risk of subsequent arterial cardiovascular events.
Monday, October 15, 2007
A Meta-Analysis of 94,492 Patients With Hypertension Treated With Beta Blockers to Determine the Risk of New-Onset Diabetes Mellitus
A Meta-Analysis of 94,492 Patients With Hypertension Treated With Beta Blockers to Determine the Risk of New-Onset Diabetes Mellitus
The American Journal of Medicine
Volume 100, Issue 8, Pages 1254-1262 (15 October 2007)
Sripal Bangalore, MD, MHAa, Sanobar Parkar, MD, MPHa, Ehud Grossman, MDb, Franz H. Messerli, MDa
Beta blockers used for the treatment of hypertension may be associated with increased risk for new-onset diabetes mellitus (DM).
A search of Medline, PubMed, and EMBASE was conducted for randomized controlled trials of patients taking β blockers as first-line therapy for hypertension with data on new-onset DM and follow-up for ≥1 year. Twelve studies evaluating 94,492 patients fulfilled the inclusion criteria. Beta-blocker therapy resulted in a 22% increased risk for new-onset DM (relative risk 1.22, 95% confidence interval [CI] 1.12 to 1.33) compared with nondiuretic antihypertensive agents. A higher baseline fasting glucose level (odds ratio [OR] 1.01, 95% CI 1.00 to 1.02, p = 0.004) and greater systolic (OR 1.05, 95% CI 1.05 to 1.08, p = 0.001) and diastolic (OR 1.06, 95% CI 1.01 to 1.10, p = 0.011) blood pressure differences between the 2 treatment modalities were significant univariate predictors of new-onset DM.
Multivariate meta-regression analysis showed that a higher baseline body mass index (OR 1.17, 95% CI 1.01 to 1.33, p = 0.034) was a significant predictor of new-onset DM. The risk for DM was greater with atenolol, in the elderly, and in studies in which β blockers were less efficacious antihypertensive agents and increased exponentially with increased duration on β blockers. For the secondary end points, β blockers resulted in a 15% increased risk for stroke, with no benefit for the end point of death or myocardial infarction.
In conclusion, β blockers are associated with an increased risk for new-onset DM, with no benefit for the end point of death or myocardial infarction and with a 15% increased risk for stroke compared with other agents. This risk was greater in patients with higher baseline body mass indexes and higher baseline fasting glucose levels and in studies in which β blockers were less efficacious antihypertensive agents compared with other treatments.
The American Journal of Medicine
Volume 100, Issue 8, Pages 1254-1262 (15 October 2007)
Sripal Bangalore, MD, MHAa, Sanobar Parkar, MD, MPHa, Ehud Grossman, MDb, Franz H. Messerli, MDa
Beta blockers used for the treatment of hypertension may be associated with increased risk for new-onset diabetes mellitus (DM).
A search of Medline, PubMed, and EMBASE was conducted for randomized controlled trials of patients taking β blockers as first-line therapy for hypertension with data on new-onset DM and follow-up for ≥1 year. Twelve studies evaluating 94,492 patients fulfilled the inclusion criteria. Beta-blocker therapy resulted in a 22% increased risk for new-onset DM (relative risk 1.22, 95% confidence interval [CI] 1.12 to 1.33) compared with nondiuretic antihypertensive agents. A higher baseline fasting glucose level (odds ratio [OR] 1.01, 95% CI 1.00 to 1.02, p = 0.004) and greater systolic (OR 1.05, 95% CI 1.05 to 1.08, p = 0.001) and diastolic (OR 1.06, 95% CI 1.01 to 1.10, p = 0.011) blood pressure differences between the 2 treatment modalities were significant univariate predictors of new-onset DM.
Multivariate meta-regression analysis showed that a higher baseline body mass index (OR 1.17, 95% CI 1.01 to 1.33, p = 0.034) was a significant predictor of new-onset DM. The risk for DM was greater with atenolol, in the elderly, and in studies in which β blockers were less efficacious antihypertensive agents and increased exponentially with increased duration on β blockers. For the secondary end points, β blockers resulted in a 15% increased risk for stroke, with no benefit for the end point of death or myocardial infarction.
In conclusion, β blockers are associated with an increased risk for new-onset DM, with no benefit for the end point of death or myocardial infarction and with a 15% increased risk for stroke compared with other agents. This risk was greater in patients with higher baseline body mass indexes and higher baseline fasting glucose levels and in studies in which β blockers were less efficacious antihypertensive agents compared with other treatments.
Thursday, August 30, 2007
Statin treatment withdrawal in ischemic stroke: a controlled randomized study
Statin treatment withdrawal in ischemic stroke: a controlled randomized study.
Neurology. 2007 Aug 28;69(9):904-10.
Blanco M, Nombela F, Castellanos M, Rodriguez-Yáñez M, García-Gil M, Leira R, Lizasoain I, Serena J, Vivancos J, Moro MA, Dávalos A, Castillo J.
Department of Neurology, Hospital Clínico Universitario, Universidad de Santiago de Compostela, Santiago de Compostela, Spain.
BACKGROUND: Pretreatment with statins has been shown to reduce brain injury in cerebral ischemia. In this controlled randomized study, we investigated the influence of statin pretreatment and its withdrawal on the outcome of acute ischemic stroke patients.
METHODS: From 215 patients admitted within 24 hours of a hemispheric ischemic stroke, 89 patients on chronic statin treatment were randomly assigned either to statin withdrawal for the first 3 days after admission (n = 46) or to immediately receive atorvastatin 20 mg/day (n = 43). The primary outcome event was death or dependency (modified Rankin Scale [mRS] score > 2) at 3 months. Early neurologic deterioration (END) and infarct volume at days 4 to 7 were secondary outcome variables. In a secondary analysis, outcome variables were compared with the nonrandomized patients without previous statin therapy (n = 126).
RESULTS: Patients with statin withdrawal showed a higher frequency of mRS score > 2 at the end of follow-up (60.0% vs 39.0%; p = 0.043), END (65.2% vs 20.9%; p < 0.0001), and greater infarct volume (74 [45, 126] vs 26 [12, 70] mL; p = 0.002) compared with the non-statin-withdrawal group. Statin withdrawal was associated with a 4.66 (1.46 to 14.91)-fold increase in the risk of death or dependency, a 8.67 (3.05 to 24.63)-fold increase in the risk of END, and an increase in mean infarct volume of 37.63 mL (SE 10.01; p < 0.001) after adjusting for age and baseline stroke severity. Compared with patients without previous treatment with statins, statin withdrawal was associated with a 19.01 (1.96 to 184.09)-fold increase in the risk of END and an increase in mean infarct volume of 43.51 mL (SE 21.91; p = 0.048).
CONCLUSION: Statin withdrawal is associated with increased risk of death or dependency at 90 days. Hence, this treatment should be continued in the acute phase of ischemic stroke.
Neurology. 2007 Aug 28;69(9):904-10.
Blanco M, Nombela F, Castellanos M, Rodriguez-Yáñez M, García-Gil M, Leira R, Lizasoain I, Serena J, Vivancos J, Moro MA, Dávalos A, Castillo J.
Department of Neurology, Hospital Clínico Universitario, Universidad de Santiago de Compostela, Santiago de Compostela, Spain.
BACKGROUND: Pretreatment with statins has been shown to reduce brain injury in cerebral ischemia. In this controlled randomized study, we investigated the influence of statin pretreatment and its withdrawal on the outcome of acute ischemic stroke patients.
METHODS: From 215 patients admitted within 24 hours of a hemispheric ischemic stroke, 89 patients on chronic statin treatment were randomly assigned either to statin withdrawal for the first 3 days after admission (n = 46) or to immediately receive atorvastatin 20 mg/day (n = 43). The primary outcome event was death or dependency (modified Rankin Scale [mRS] score > 2) at 3 months. Early neurologic deterioration (END) and infarct volume at days 4 to 7 were secondary outcome variables. In a secondary analysis, outcome variables were compared with the nonrandomized patients without previous statin therapy (n = 126).
RESULTS: Patients with statin withdrawal showed a higher frequency of mRS score > 2 at the end of follow-up (60.0% vs 39.0%; p = 0.043), END (65.2% vs 20.9%; p < 0.0001), and greater infarct volume (74 [45, 126] vs 26 [12, 70] mL; p = 0.002) compared with the non-statin-withdrawal group. Statin withdrawal was associated with a 4.66 (1.46 to 14.91)-fold increase in the risk of death or dependency, a 8.67 (3.05 to 24.63)-fold increase in the risk of END, and an increase in mean infarct volume of 37.63 mL (SE 10.01; p < 0.001) after adjusting for age and baseline stroke severity. Compared with patients without previous treatment with statins, statin withdrawal was associated with a 19.01 (1.96 to 184.09)-fold increase in the risk of END and an increase in mean infarct volume of 43.51 mL (SE 21.91; p = 0.048).
CONCLUSION: Statin withdrawal is associated with increased risk of death or dependency at 90 days. Hence, this treatment should be continued in the acute phase of ischemic stroke.
Warfarin Versus Aspirin for Stroke Prevention in an Elderly Community Population With Atrial Fibrillation
Title: Warfarin Versus Aspirin for Stroke Prevention in an Elderly Community Population With Atrial Fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): A Randomised Controlled Trial
Topic: Arrhythmias
Date Posted: 8/28/2007
Author(s): Mant J, Hobbs FD, Fletcher K, et al.
Citation: Lancet. 2007;370:493-503.
Clinical Trial: Yes
Study Question: Does warfarin reduce the risk of major stroke, arterial embolism, or other intracranial hemorrhage, compared with aspirin in elderly patients with atrial fibrillation?
Methods: The authors report the results of the Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) study, a randomized, open-label trial of aspirin versus warfarin in subjects over age 75 with atrial fibrillation. Patients were excluded if they had increased risk for gastrointestinal bleeding, rheumatic heart disease, intracranial hemorrhage, blood pressure >180/110 mm Hg, or at prohibitive risk for bleeding with warfarin, in their physician’s judgment. Subjects were randomized to warfarin (target INR 2-3), or aspirin 75 mg daily, for a mean of 2.7 years’ follow-up. The primary outcome was fatal or nonfatal stroke, intracranial hemorrhage, or clinically significant arterial embolism. Secondary outcomes were major hemorrhage, other vascular events, and all-cause mortality.
Results: The authors report 973 subjects were randomized from April 2001 to November 2004, among whom there were 24 primary events in the warfarin group (21 strokes, two other intracranial hemorrhages, and one systemic embolus), and 48 events in the aspirin group (44 strokes, one other intracranial hemorrhage, and three systemic emboli), (relative risk, 0.48; 95% confidence interval, 0.28-0.80; p = 0.003). This resulted in a yearly risk for primary event of 1.8% and 3.8% in the two groups, respectively. The yearly risk of extracranial hemorrhage was 1.4% (warfarin) versus 1.6% (aspirin) (relative risk, 0.87; 0.43-1.73).
Conclusions: The authors concluded that the data support the use of warfarin in patients with atrial fibrillation over age 75, unless there are contraindications, or the patient refuses warfarin therapy.
Perspective: There is a common misconception that benefits of medical therapy are fixed, while risks associated with medical therapy vary. This fallacy has led to the belief that greater risk of bleeding with advancing age makes warfarin therapy in the elderly more risky. Forgotten is the fact that risk of thromboembolic stroke from atrial fibrillation also increases with age. This same phenomenon is seen in a number of other medical conditions. Our training to compare ‘risk versus benefits’ leads, I believe, to this error in thinking. Benefits are reported and thought of as fixed (e.g., ‘warfarin lowers risk of stroke in atrial fibrillation x%’), whereas risks of therapy are seen as relative to the patient’s condition, age, and other risk factors. This error of medical decision making is compounded by the exclusion of the elderly from clinical trials—leaving us without adequate data. Ideally, we should assess both the risk of therapy, as well as the risk of not taking therapy, on an individual basis for each patient, based on available data (a ‘risk vs. risk’ comparison, rather than ‘risk vs. benefit’). Clearly, more clinical trial data that include the elderly are crucial. And we should remember that if a treatment is effective, it is logically more effective in groups at higher risk from complications of disease, and that usually means the elderly
Topic: Arrhythmias
Date Posted: 8/28/2007
Author(s): Mant J, Hobbs FD, Fletcher K, et al.
Citation: Lancet. 2007;370:493-503.
Clinical Trial: Yes
Study Question: Does warfarin reduce the risk of major stroke, arterial embolism, or other intracranial hemorrhage, compared with aspirin in elderly patients with atrial fibrillation?
Methods: The authors report the results of the Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) study, a randomized, open-label trial of aspirin versus warfarin in subjects over age 75 with atrial fibrillation. Patients were excluded if they had increased risk for gastrointestinal bleeding, rheumatic heart disease, intracranial hemorrhage, blood pressure >180/110 mm Hg, or at prohibitive risk for bleeding with warfarin, in their physician’s judgment. Subjects were randomized to warfarin (target INR 2-3), or aspirin 75 mg daily, for a mean of 2.7 years’ follow-up. The primary outcome was fatal or nonfatal stroke, intracranial hemorrhage, or clinically significant arterial embolism. Secondary outcomes were major hemorrhage, other vascular events, and all-cause mortality.
Results: The authors report 973 subjects were randomized from April 2001 to November 2004, among whom there were 24 primary events in the warfarin group (21 strokes, two other intracranial hemorrhages, and one systemic embolus), and 48 events in the aspirin group (44 strokes, one other intracranial hemorrhage, and three systemic emboli), (relative risk, 0.48; 95% confidence interval, 0.28-0.80; p = 0.003). This resulted in a yearly risk for primary event of 1.8% and 3.8% in the two groups, respectively. The yearly risk of extracranial hemorrhage was 1.4% (warfarin) versus 1.6% (aspirin) (relative risk, 0.87; 0.43-1.73).
Conclusions: The authors concluded that the data support the use of warfarin in patients with atrial fibrillation over age 75, unless there are contraindications, or the patient refuses warfarin therapy.
Perspective: There is a common misconception that benefits of medical therapy are fixed, while risks associated with medical therapy vary. This fallacy has led to the belief that greater risk of bleeding with advancing age makes warfarin therapy in the elderly more risky. Forgotten is the fact that risk of thromboembolic stroke from atrial fibrillation also increases with age. This same phenomenon is seen in a number of other medical conditions. Our training to compare ‘risk versus benefits’ leads, I believe, to this error in thinking. Benefits are reported and thought of as fixed (e.g., ‘warfarin lowers risk of stroke in atrial fibrillation x%’), whereas risks of therapy are seen as relative to the patient’s condition, age, and other risk factors. This error of medical decision making is compounded by the exclusion of the elderly from clinical trials—leaving us without adequate data. Ideally, we should assess both the risk of therapy, as well as the risk of not taking therapy, on an individual basis for each patient, based on available data (a ‘risk vs. risk’ comparison, rather than ‘risk vs. benefit’). Clearly, more clinical trial data that include the elderly are crucial. And we should remember that if a treatment is effective, it is logically more effective in groups at higher risk from complications of disease, and that usually means the elderly
CPAP Machine May Help Prevent Heart Attack, Stroke in People With Obstructive Sleep Apnea
Sleep Apnea Device May Help Save Heart
CPAP Machine May Help Prevent Heart Attack, Stroke in People With Obstructive Sleep Apnea
By Miranda Hitti WebMD Medical News
Reviewed by Louise Chang, MD
Aug. 29, 2007 -- A device that treats a common sleep disorder called obstructive sleep apnea may help prevent heart attacks, strokes, and other cardiovascular problems, a new study shows.
Obstructive sleep apnea is a very serious condition in which people have trouble breathing during sleep because their airway is blocked. They may have very shallow breath or even stop breathing briefly several times per night.
A device called CPAP (continuous positive airway pressure) helps people with obstructive sleep apnea breathe more easily during sleep.
The new study comes from German doctors including Nikolaus Buchner, MD, of Germany's Ruhr University Bochum.
They already knew that CPAP may reduce heart risks in people with severe obstructive sleep apnea. Buchner's team wanted to see if that's also true for people with milder obstructive sleep apnea.
CPAP Study
Buchner and colleagues offered CPAP machines to 449 adults with mild, moderate, or severe obstructive sleep apnea. All but 85 patients accepted the devices.
The patients, who got regular checkups, were typically followed for about six years.Those who accepted CPAP were 64% less likely to have certain fatal or nonfatal cardiovascular problems -- including heart attacks and strokes -- during the study period, regardless of their age, BMI (body mass index), type 2 diabetes, cholesterol, and history of heart disease.
Buchner and colleagues note that their findings may not apply to everyone with obstructive sleep apnea.
However, the researchers write that therapy for obstructive sleep apnea "should be considered" even for mild forms of obstructive sleep apnea.
The study appears in an advance online edition of the American Journal of Respiratory and Critical Care Medicine.
SOURCES: Buchner, N. American Journal of Respiratory and Critical Care Medicine, Aug. 2, 2007; advance online edition. National Heart, Lung, and Blood Institute: "Sleep Apnea." WebMD Medical News: "Treatment for Sleep Apnea May Ease Depression."
CPAP Machine May Help Prevent Heart Attack, Stroke in People With Obstructive Sleep Apnea
By Miranda Hitti WebMD Medical News
Reviewed by Louise Chang, MD
Aug. 29, 2007 -- A device that treats a common sleep disorder called obstructive sleep apnea may help prevent heart attacks, strokes, and other cardiovascular problems, a new study shows.
Obstructive sleep apnea is a very serious condition in which people have trouble breathing during sleep because their airway is blocked. They may have very shallow breath or even stop breathing briefly several times per night.
A device called CPAP (continuous positive airway pressure) helps people with obstructive sleep apnea breathe more easily during sleep.
The new study comes from German doctors including Nikolaus Buchner, MD, of Germany's Ruhr University Bochum.
They already knew that CPAP may reduce heart risks in people with severe obstructive sleep apnea. Buchner's team wanted to see if that's also true for people with milder obstructive sleep apnea.
CPAP Study
Buchner and colleagues offered CPAP machines to 449 adults with mild, moderate, or severe obstructive sleep apnea. All but 85 patients accepted the devices.
The patients, who got regular checkups, were typically followed for about six years.Those who accepted CPAP were 64% less likely to have certain fatal or nonfatal cardiovascular problems -- including heart attacks and strokes -- during the study period, regardless of their age, BMI (body mass index), type 2 diabetes, cholesterol, and history of heart disease.
Buchner and colleagues note that their findings may not apply to everyone with obstructive sleep apnea.
However, the researchers write that therapy for obstructive sleep apnea "should be considered" even for mild forms of obstructive sleep apnea.
The study appears in an advance online edition of the American Journal of Respiratory and Critical Care Medicine.
SOURCES: Buchner, N. American Journal of Respiratory and Critical Care Medicine, Aug. 2, 2007; advance online edition. National Heart, Lung, and Blood Institute: "Sleep Apnea." WebMD Medical News: "Treatment for Sleep Apnea May Ease Depression."
Thursday, August 16, 2007
Reversing Cocaine's Effects On The Cardiovascular System
Reversing Cocaine's Effects On The Cardiovascular System
16 Aug 2007
UT Southwestern Medical Center researchers have discovered a treatment that counteracts the effects of cocaine on the human cardiovascular system, including lowering the elevated heart rate and blood pressure often found in cocaine users.
"We have found that cocaine's effects on the cardiovascular system can be reversed by the use of a drug called dexmedetomidine, which is currently approved by the Food and Drug Administration for anesthetic purposes in operating rooms or intensive care units," said Dr. Wanpen Vongpatanasin, associate professor of internal medicine and senior author of a study appearing in the Aug. 14 issue of the Journal of the American College of Cardiology.
Researchers used dexmedetomidine to test whether cocaine's effect on the cardiovascular system could be muted.
They found that the drug was effective in reversing the actions of cocaine on heart rate, blood pressure and vascular resistance in the skin by interfering with the ability of cocaine to increase nerve activity.
"Typically, patients with cocaine overdoses in the emergency room are treated with nitroglycerin, sedatives such as Valium, and some blood-pressure medications such as calcium channel blockers and some beta blockers," Dr. Vongpatanasin said.
"However, the standard treatments don't alleviate all of the adverse effects of cocaine on the heart, blood pressure and central nervous system."
The study examined results from 22 healthy adults who reported to have never used cocaine.
The investigators administered a small, medically approved dose of cocaine nose drops to the study participants, which doubled their sympathetic nerve activity, part of the body's 'automatic' response system that becomes more active during times of stress.
Participants experienced increases in several cardiovascular parameters including heart rate, blood pressure and resistance to blood flow in the skin. Microelectrodes, similar to acupuncture needles, were used to record sympathetic nerve activity following doses of intranasal cocaine.
Research subjects who were treated with dexmedetomidine had a decrease in sympathetic nerve activity as well as in all three cardiovascular parameters, which returned to baseline levels measured before administration of cocaine.
Dexmedetomidine proved to be more effective than intravenous saline, which was used as a placebo in another group of study participants.
Cocaine abuse in the U.S. is widespread, with nearly 35 million Americans reporting having ever tried cocaine and an estimated 7.3 million users, including 15 percent of young adults ages 18 to 25, according to the National Institute on Drug Abuse.
Life-threatening emergencies related to cocaine use include sudden cardiac death, high blood pressure, stroke and acute myocardial infarctions.
"We also found that dexmedetomidine was equally effective in counteracting effects of cocaine in subjects with a rare genetic mutation thought to disrupt the effects of dexmedetomidine," said Dr. Ronald Victor, professor of internal medicine and co-author of the study.
"Because this particular mutation is more common in African-Americans than in Caucasians, our study results are applicable to a more diverse, multiethnic population."
Further research is needed, study authors said, to determine whether the treatment would be effective for acute cocaine overdose in the emergency room and to gauge whether it would be effective in reversing cocaine-induced constriction of the coronary vessels to the same degree it does in skin vessels.
Article adapted by Medical News Today from original press release.
16 Aug 2007
UT Southwestern Medical Center researchers have discovered a treatment that counteracts the effects of cocaine on the human cardiovascular system, including lowering the elevated heart rate and blood pressure often found in cocaine users.
"We have found that cocaine's effects on the cardiovascular system can be reversed by the use of a drug called dexmedetomidine, which is currently approved by the Food and Drug Administration for anesthetic purposes in operating rooms or intensive care units," said Dr. Wanpen Vongpatanasin, associate professor of internal medicine and senior author of a study appearing in the Aug. 14 issue of the Journal of the American College of Cardiology.
Researchers used dexmedetomidine to test whether cocaine's effect on the cardiovascular system could be muted.
They found that the drug was effective in reversing the actions of cocaine on heart rate, blood pressure and vascular resistance in the skin by interfering with the ability of cocaine to increase nerve activity.
"Typically, patients with cocaine overdoses in the emergency room are treated with nitroglycerin, sedatives such as Valium, and some blood-pressure medications such as calcium channel blockers and some beta blockers," Dr. Vongpatanasin said.
"However, the standard treatments don't alleviate all of the adverse effects of cocaine on the heart, blood pressure and central nervous system."
The study examined results from 22 healthy adults who reported to have never used cocaine.
The investigators administered a small, medically approved dose of cocaine nose drops to the study participants, which doubled their sympathetic nerve activity, part of the body's 'automatic' response system that becomes more active during times of stress.
Participants experienced increases in several cardiovascular parameters including heart rate, blood pressure and resistance to blood flow in the skin. Microelectrodes, similar to acupuncture needles, were used to record sympathetic nerve activity following doses of intranasal cocaine.
Research subjects who were treated with dexmedetomidine had a decrease in sympathetic nerve activity as well as in all three cardiovascular parameters, which returned to baseline levels measured before administration of cocaine.
Dexmedetomidine proved to be more effective than intravenous saline, which was used as a placebo in another group of study participants.
Cocaine abuse in the U.S. is widespread, with nearly 35 million Americans reporting having ever tried cocaine and an estimated 7.3 million users, including 15 percent of young adults ages 18 to 25, according to the National Institute on Drug Abuse.
Life-threatening emergencies related to cocaine use include sudden cardiac death, high blood pressure, stroke and acute myocardial infarctions.
"We also found that dexmedetomidine was equally effective in counteracting effects of cocaine in subjects with a rare genetic mutation thought to disrupt the effects of dexmedetomidine," said Dr. Ronald Victor, professor of internal medicine and co-author of the study.
"Because this particular mutation is more common in African-Americans than in Caucasians, our study results are applicable to a more diverse, multiethnic population."
Further research is needed, study authors said, to determine whether the treatment would be effective for acute cocaine overdose in the emergency room and to gauge whether it would be effective in reversing cocaine-induced constriction of the coronary vessels to the same degree it does in skin vessels.
Article adapted by Medical News Today from original press release.
Tuesday, August 7, 2007
Reduced mortality in treatment group halts BP trial in elderly
Reduced mortality in treatment group halts BP trial in elderly
August 7, 2007
London, UK - The largest ever study to look at the effects of lowering BP in those aged 80 and over—the Hypertension in the Very Elderly Trial (HYVET)—has been halted prematurely due to significant reductions in both stroke and overall mortality in the treatment arm [1].
One of the investigators, Dr Ruth Peters (Imperial College, London), told heartwire that the reductions in stroke and mortality observed "were statistically significant and not trivial." She declined, however, to give specific figures. "We are being really cautious about this." She said the plan is to simultaneously publish the results in a peer-reviewed journal and present them at a major medical meeting, "probably sometime next spring."
The decision to halt the study was taken by the steering committee following a recommendation to that effect from the data safety monitoring board last month. All patients in the study are being brought back to have their treatment reviewed and will have the option of switching to the active-therapy arm. The trial had been slated to end in 2009.
Great news for the over-80s
HYVET was being conducted in a number of countries in Eastern and Western Europe as well as in Tunisia and China and included 3845 patients aged 80 or older. HYVET was undertaken because previous smaller studies had produced inconclusive results with regard to whether blood-pressure lowering was beneficial or not in the very elderly. In some studies, although antihypertensive therapy reduced the risk of stroke, it did not reduce—and in some cases increased—mortality.
The entry criteria for HYVET were a sitting systolic blood pressure of 160 to 199 mm Hg and a diastolic BP of 90 to 109 mm Hg. Peters said that later on in the trial, patients with isolated systolic hypertension were also allowed to participate. Patients were randomized to either placebo or a low-dose diuretic (indapamide 1.5 mg sustained release) and an additional ACE inhibitor (perindopril 2 mg or 4 mg a day) if required.
The primary end point is stroke events (fatal and nonfatal), and secondary outcome measures include total mortality, cardiovascular mortality, cardiac mortality, stroke mortality, and skeletal fracture.
"It was not clear prior to our study whether the over-80s would benefit from blood-pressure-lowering medication in the same way as younger people," says lead investigator Dr Chris Bulpitt (Imperial College, London) in a press release.
"Our results are great news for people in this age group because they suggest that where they have high blood pressure, such treatment can cut their chances of dying as well as [suffering a] stroke," he added.
Source
Imperial College, London. Trial stops after stroke and mortality significantly reduced by blood-pressure-lowering treatment for those aged 80 and over [press release]. August 7, 2007. Available here.
August 7, 2007
London, UK - The largest ever study to look at the effects of lowering BP in those aged 80 and over—the Hypertension in the Very Elderly Trial (HYVET)—has been halted prematurely due to significant reductions in both stroke and overall mortality in the treatment arm [1].
One of the investigators, Dr Ruth Peters (Imperial College, London), told heartwire that the reductions in stroke and mortality observed "were statistically significant and not trivial." She declined, however, to give specific figures. "We are being really cautious about this." She said the plan is to simultaneously publish the results in a peer-reviewed journal and present them at a major medical meeting, "probably sometime next spring."
The decision to halt the study was taken by the steering committee following a recommendation to that effect from the data safety monitoring board last month. All patients in the study are being brought back to have their treatment reviewed and will have the option of switching to the active-therapy arm. The trial had been slated to end in 2009.
Great news for the over-80s
HYVET was being conducted in a number of countries in Eastern and Western Europe as well as in Tunisia and China and included 3845 patients aged 80 or older. HYVET was undertaken because previous smaller studies had produced inconclusive results with regard to whether blood-pressure lowering was beneficial or not in the very elderly. In some studies, although antihypertensive therapy reduced the risk of stroke, it did not reduce—and in some cases increased—mortality.
The entry criteria for HYVET were a sitting systolic blood pressure of 160 to 199 mm Hg and a diastolic BP of 90 to 109 mm Hg. Peters said that later on in the trial, patients with isolated systolic hypertension were also allowed to participate. Patients were randomized to either placebo or a low-dose diuretic (indapamide 1.5 mg sustained release) and an additional ACE inhibitor (perindopril 2 mg or 4 mg a day) if required.
The primary end point is stroke events (fatal and nonfatal), and secondary outcome measures include total mortality, cardiovascular mortality, cardiac mortality, stroke mortality, and skeletal fracture.
"It was not clear prior to our study whether the over-80s would benefit from blood-pressure-lowering medication in the same way as younger people," says lead investigator Dr Chris Bulpitt (Imperial College, London) in a press release.
"Our results are great news for people in this age group because they suggest that where they have high blood pressure, such treatment can cut their chances of dying as well as [suffering a] stroke," he added.
Source
Imperial College, London. Trial stops after stroke and mortality significantly reduced by blood-pressure-lowering treatment for those aged 80 and over [press release]. August 7, 2007. Available here.
Routine Pulse Checks Improve Detection of Atrial Fibrillation
Routine Pulse Checks Improve Detection of Atrial Fibrillation
Routine pulse checking in older patients can lead to a substantial increase in the detection of atrial fibrillation, a major risk factor for stroke, according to a study in the British Medical Journal.
The study, conducted in England on nearly 15,000 patients ages 65 and over, compared active screening for atrial fibrillation — in which practice nurses either measured the patients' radial pulses to determine the need for follow-up electrocardiography or simply offered all patients electrocardiography — versus routine care during office visits.
The annual detection rate of new cases was 1.63% during active screening, compared with 1.04% in control practices.
The detection rate for active screening was nearly identical regardless of whether patients were offered electrocardiography routinely or only if they had an irregular pulse.
The authors concluded that routine electrocardiography is unnecessary for finding atrial fibrillation "as long as healthcare professionals are conscientious about feeling the pulse."
Link: BMJ article (Free)
Published in Physician's First Watch August 6, 2007
Thursday, July 19, 2007
Oral anticoagulants versus antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no history of stroke or transient ischemic attacks
Cochrane Database of Systematic Reviews 2007 Issue 3 (Status: New) Copyright © 2007 The Cochrane Collaboration.
This version first published online: 18 July 2007 in Issue 3,
This record should be cited as: Aguilar MI, Hart R, Pearce LA.
Abstract
Background
Non-valvular atrial fibrillation (AF) carries an increased risk of stroke mediated by embolism of stasis-precipitated thrombi originating in the left atrial appendage. Both oral anticoagulants and antiplatelet agents have proven effective for stroke prevention in most patients at high risk for vascular events, but primary stroke prevention in patients with non-valvular AF potentially merits separate consideration because of the suspected cardio-embolic mechanism of most strokes in AF patients.
Objectives
To characterize the relative effect of long-term oral anticoagulant treatment compared with antiplatelet therapy on major vascular events in patients with non-valvular AF and no history of stroke or transient ischemic attack (TIA).
Search strategy
We searched the Cochrane Stroke Group Trials Register (June 2006). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006), MEDLINE (1966 to June 2006) and EMBASE (1980 to June 2006). We contacted the Atrial Fibrillation Collaboration and experts working in the field to identify unpublished and ongoing trials.
Selection criteria
All unconfounded, randomized trials in which long-term (more than four weeks) adjusted-dose oral anticoagulant treatment was compared with antiplatelet therapy in patients with chronic non-valvular AF.
Data collection and analysis
Two review authors independently selected trials for inclusion, assessed quality and extracted data. The Peto method was used for combining odds ratios after assessing for heterogeneity.
Main results
Eight randomized trials, including 9598 patients, tested adjusted-dose warfarin versus aspirin (in dosages ranging from 75 to 325 mg/day) in AF patients without prior stroke or TIA. The mean overall follow up was 1.9 years/participant. Oral anticoagulants were associated with lower risk of all stroke (odds ratio (OR) 0.68, 95% confidence interval (CI) 0.54 to 0.85), ischemic stroke (OR 0.53, 95% CI 0.41 to 0.68) and systemic emboli (OR 0.48, 95% CI 0.25 to 0.90). All disabling or fatal strokes (OR 0.71, 95% CI 0.59 to 1.04) and myocardial infarction (OR 0.69, 95% CI 0.47 to 1.01) were substantially but not significantly reduced by oral anticoagulants. Vascular death (OR 0.93, 95% CI 0.75 to 1.15) and all cause mortality (OR 0.99, 95% CI 0.83 to 1.18), were similar with these treatments. Intracranial hemorrhages (OR 1.98, 95% CI 1.20 to 3.28) were increased by oral anticoagulant therapy.
Authors' conclusions
Adjusted-dose warfarin and related oral anticoagulants reduce stroke, disabling stroke and other major vascular events for those with non-valvular AF by about one third when compared with antiplatelet therapy.
Plain language summary
Oral anticoagulants versus antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no history of stroke or transient ischemic attacksAtrial fibrillation (AF) is an irregularity of the heartbeat that leads to blood clots forming in the upper chambers of the heart (the atria). These clots can break free and travel through the bloodstream to the brain and cause a stroke. Drugs that slow clotting, such as oral anticoagulants (warfarin and other coumarin derivates) and antiplatelet agents (aspirin and others), reduce the risk of stroke in patients with atrial fibrillation. In this review of eight randomized trials, including 9598 patients, oral anticoagulants are shown to reduce the risk of stroke in patients with non-valvular AF and with no prior stroke or transient ischemic attack by one-third when compared with antiplatelet agents alone. Antiplatelet agents reduce stroke by about 20% in AF patients compared with no therapy, offering a less efficacious therapeutic option for those deemed not eligible for anticoagulation therapy. The threshold of absolute benefit that warrants anticoagulation remains controversial and depends on patient's preferences and availability of optimal anticoagulation monitoring.
Cochrane Database of Systematic Reviews 2007 Issue 3 (Status: New) Copyright © 2007 The Cochrane Collaboration.
This version first published online: 18 July 2007 in Issue 3,
This record should be cited as: Aguilar MI, Hart R, Pearce LA.
Abstract
Background
Non-valvular atrial fibrillation (AF) carries an increased risk of stroke mediated by embolism of stasis-precipitated thrombi originating in the left atrial appendage. Both oral anticoagulants and antiplatelet agents have proven effective for stroke prevention in most patients at high risk for vascular events, but primary stroke prevention in patients with non-valvular AF potentially merits separate consideration because of the suspected cardio-embolic mechanism of most strokes in AF patients.
Objectives
To characterize the relative effect of long-term oral anticoagulant treatment compared with antiplatelet therapy on major vascular events in patients with non-valvular AF and no history of stroke or transient ischemic attack (TIA).
Search strategy
We searched the Cochrane Stroke Group Trials Register (June 2006). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006), MEDLINE (1966 to June 2006) and EMBASE (1980 to June 2006). We contacted the Atrial Fibrillation Collaboration and experts working in the field to identify unpublished and ongoing trials.
Selection criteria
All unconfounded, randomized trials in which long-term (more than four weeks) adjusted-dose oral anticoagulant treatment was compared with antiplatelet therapy in patients with chronic non-valvular AF.
Data collection and analysis
Two review authors independently selected trials for inclusion, assessed quality and extracted data. The Peto method was used for combining odds ratios after assessing for heterogeneity.
Main results
Eight randomized trials, including 9598 patients, tested adjusted-dose warfarin versus aspirin (in dosages ranging from 75 to 325 mg/day) in AF patients without prior stroke or TIA. The mean overall follow up was 1.9 years/participant. Oral anticoagulants were associated with lower risk of all stroke (odds ratio (OR) 0.68, 95% confidence interval (CI) 0.54 to 0.85), ischemic stroke (OR 0.53, 95% CI 0.41 to 0.68) and systemic emboli (OR 0.48, 95% CI 0.25 to 0.90). All disabling or fatal strokes (OR 0.71, 95% CI 0.59 to 1.04) and myocardial infarction (OR 0.69, 95% CI 0.47 to 1.01) were substantially but not significantly reduced by oral anticoagulants. Vascular death (OR 0.93, 95% CI 0.75 to 1.15) and all cause mortality (OR 0.99, 95% CI 0.83 to 1.18), were similar with these treatments. Intracranial hemorrhages (OR 1.98, 95% CI 1.20 to 3.28) were increased by oral anticoagulant therapy.
Authors' conclusions
Adjusted-dose warfarin and related oral anticoagulants reduce stroke, disabling stroke and other major vascular events for those with non-valvular AF by about one third when compared with antiplatelet therapy.
Plain language summary
Oral anticoagulants versus antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no history of stroke or transient ischemic attacksAtrial fibrillation (AF) is an irregularity of the heartbeat that leads to blood clots forming in the upper chambers of the heart (the atria). These clots can break free and travel through the bloodstream to the brain and cause a stroke. Drugs that slow clotting, such as oral anticoagulants (warfarin and other coumarin derivates) and antiplatelet agents (aspirin and others), reduce the risk of stroke in patients with atrial fibrillation. In this review of eight randomized trials, including 9598 patients, oral anticoagulants are shown to reduce the risk of stroke in patients with non-valvular AF and with no prior stroke or transient ischemic attack by one-third when compared with antiplatelet agents alone. Antiplatelet agents reduce stroke by about 20% in AF patients compared with no therapy, offering a less efficacious therapeutic option for those deemed not eligible for anticoagulation therapy. The threshold of absolute benefit that warrants anticoagulation remains controversial and depends on patient's preferences and availability of optimal anticoagulation monitoring.
Monday, June 18, 2007
Risk factors identify stroke patients at high risk of cardiac events
Risk factors identify stroke patients at high risk of cardiac events
18 June 2007
Stroke 2007; Advance online publication
MedWire News: Stroke patients at high risk for early cardiac morbidity and mortality can be identified using a model based on five clinical and demographic characteristics, say researchers.
These characteristics are a history of congestive heart failure (CHF), the presence of diabetes, baseline creatinine of more than 115 μmol/l, severe stroke, and a long heart rate-corrected QT(c) interval or ventricular extrasystoles on electrocardiogram (ECG), report Jane Prosser (Royal Melbourne Hospital, Australia) and team.
Patients with none of these characteristics have a 6.3% risk of a serious cardiac adverse event within 3 months of acute ischemic stroke, while patients with four or more characteristics have a 62.2% risk, Prosser et al report in the journal Stroke.
They explain: "Approximately 2–6% of all stroke patients die from cardiac causes in the first 3 months after ischemic stroke… Despite these relatively high risks, many patients will not have cardiac events.
"An approach to identifying patients at high risk of cardiac events is required to assess potential pre-emptive strategies, including monitoring, investigation, and treatment."
The researchers analyzed data from a trial in the Virtual International Stroke Trials archive that involved 864 participants with ischemic stroke.
By 12 weeks, 180 (21.3%) patients had died, 35 of them from cardiac causes. The risk of death from cardiac causes was highest at 14 days after stroke.
On multivariate analysis, a history of CHF was associated with an odds ratio (OR) of 3.33 for cardiac mortality within 3 months of stroke, creatinine levels of more than 115 μmol/l with an OR of 1.77, and diabetes with an OR of 2.11.
Furthermore, respective ORs of 1.98 and 1.93 were associated with severe strokes – those that scored less than the group's median score on the European Stroke Scale (ESS) – and a long QTc or ventricular extrasystoles on ECG.
Prosser et al comment: "The main points that emerge from our study are that serious cardiac adverse events are common and begin to occur very early after stroke onset.
"Furthermore, cardiac risk can be stratified with a five-point risk score derived from simple clinical and demographic variables available at the time of admission."
18 June 2007
Stroke 2007; Advance online publication
MedWire News: Stroke patients at high risk for early cardiac morbidity and mortality can be identified using a model based on five clinical and demographic characteristics, say researchers.
These characteristics are a history of congestive heart failure (CHF), the presence of diabetes, baseline creatinine of more than 115 μmol/l, severe stroke, and a long heart rate-corrected QT(c) interval or ventricular extrasystoles on electrocardiogram (ECG), report Jane Prosser (Royal Melbourne Hospital, Australia) and team.
Patients with none of these characteristics have a 6.3% risk of a serious cardiac adverse event within 3 months of acute ischemic stroke, while patients with four or more characteristics have a 62.2% risk, Prosser et al report in the journal Stroke.
They explain: "Approximately 2–6% of all stroke patients die from cardiac causes in the first 3 months after ischemic stroke… Despite these relatively high risks, many patients will not have cardiac events.
"An approach to identifying patients at high risk of cardiac events is required to assess potential pre-emptive strategies, including monitoring, investigation, and treatment."
The researchers analyzed data from a trial in the Virtual International Stroke Trials archive that involved 864 participants with ischemic stroke.
By 12 weeks, 180 (21.3%) patients had died, 35 of them from cardiac causes. The risk of death from cardiac causes was highest at 14 days after stroke.
On multivariate analysis, a history of CHF was associated with an odds ratio (OR) of 3.33 for cardiac mortality within 3 months of stroke, creatinine levels of more than 115 μmol/l with an OR of 1.77, and diabetes with an OR of 2.11.
Furthermore, respective ORs of 1.98 and 1.93 were associated with severe strokes – those that scored less than the group's median score on the European Stroke Scale (ESS) – and a long QTc or ventricular extrasystoles on ECG.
Prosser et al comment: "The main points that emerge from our study are that serious cardiac adverse events are common and begin to occur very early after stroke onset.
"Furthermore, cardiac risk can be stratified with a five-point risk score derived from simple clinical and demographic variables available at the time of admission."
Friday, June 15, 2007
Stroke Risk Doubles Within 5 Years After Diabetes Diagnosis
Stroke Risk Doubles Within 5 Years After Diabetes Diagnosis
The risk for stroke is twice as high in patients with newly diagnosed diabetes as in the general population, according to a study in Stroke.
Using health databases of a Canadian province, researchers identified some 12,200 adults aged 30 and older with recent diagnoses of type 2 diabetes. During a mean follow-up of about 5 years, 9.1% of the patients had hospital admissions with a stroke-related diagnosis. The rate ratio for stroke was 2.1 for diabetes patients, compared with the general population.
The authors write that their results "will help to dispel the notion that macrovascular consequences of diabetes occur only in the long term" and may motivate "both patients and providers to aggressively control cardiovascular risk factors soon after diagnosis.”
LINK: Stroke article (Free)
The risk for stroke is twice as high in patients with newly diagnosed diabetes as in the general population, according to a study in Stroke.
Using health databases of a Canadian province, researchers identified some 12,200 adults aged 30 and older with recent diagnoses of type 2 diabetes. During a mean follow-up of about 5 years, 9.1% of the patients had hospital admissions with a stroke-related diagnosis. The rate ratio for stroke was 2.1 for diabetes patients, compared with the general population.
The authors write that their results "will help to dispel the notion that macrovascular consequences of diabetes occur only in the long term" and may motivate "both patients and providers to aggressively control cardiovascular risk factors soon after diagnosis.”
LINK: Stroke article (Free)
Friday, June 1, 2007
Caution With All Pain Medications
Use Caution With All Pain Medications, Reports The 'Harvard Heart Letter'
Not long ago, choosing a pain reliever meant finding one that eased your pain without being too hard on the stomach. Now, research suggests that some commonly used pain medications -- not just the now-banned Vioxx -- can raise the risk of having a heart attack or stroke. New step-by-step recommendations from the American Heart Association (AHA) can help you choose a pain reliever that's good for both the heart and stomach, reports the June 2007 issue of the "Harvard Heart Letter."
The AHA suggests starting with aspirin or acetaminophen (Tylenol) to quell muscle or joint pain. Aspirin is good for the heart, and acetaminophen doesn't affect blood clotting. If they don't work, the next step for most people would be a nonsteroidal anti-inflammatory drug (NSAID). Try naproxen (Aleve) first, then ibuprofen (Advil). Next is diclofenac, but more caution is needed with this drug (which is available only by prescription). Celebrex, the only drug in the class known as COX-2 inhibitors that remains on the market, should be the last resort for managing pain. In addition to the side effect of increasing the risk of clots in the bloodstream, COX-2 inhibitors can also reduce blood flow through the kidneys and raise blood pressure. For short-term pain in some people, a narcotic pain reliever such as tramadol (Ultram), codeine, or fentanyl (Actiq, Duragesic) may be an option.
The "Harvard Heart Letter" notes that you shouldn't be afraid to take aspirin, Tylenol, Advil, or Aleve for occasional aches and pains. But if you need a pain reliever several times a week, pay closer attention to your choices and talk with your doctor.
Harvard Heart Letter
http://www.health.harvard.edu/heart
Not long ago, choosing a pain reliever meant finding one that eased your pain without being too hard on the stomach. Now, research suggests that some commonly used pain medications -- not just the now-banned Vioxx -- can raise the risk of having a heart attack or stroke. New step-by-step recommendations from the American Heart Association (AHA) can help you choose a pain reliever that's good for both the heart and stomach, reports the June 2007 issue of the "Harvard Heart Letter."
The AHA suggests starting with aspirin or acetaminophen (Tylenol) to quell muscle or joint pain. Aspirin is good for the heart, and acetaminophen doesn't affect blood clotting. If they don't work, the next step for most people would be a nonsteroidal anti-inflammatory drug (NSAID). Try naproxen (Aleve) first, then ibuprofen (Advil). Next is diclofenac, but more caution is needed with this drug (which is available only by prescription). Celebrex, the only drug in the class known as COX-2 inhibitors that remains on the market, should be the last resort for managing pain. In addition to the side effect of increasing the risk of clots in the bloodstream, COX-2 inhibitors can also reduce blood flow through the kidneys and raise blood pressure. For short-term pain in some people, a narcotic pain reliever such as tramadol (Ultram), codeine, or fentanyl (Actiq, Duragesic) may be an option.
The "Harvard Heart Letter" notes that you shouldn't be afraid to take aspirin, Tylenol, Advil, or Aleve for occasional aches and pains. But if you need a pain reliever several times a week, pay closer attention to your choices and talk with your doctor.
Harvard Heart Letter
http://www.health.harvard.edu/heart
Thursday, May 31, 2007
BAFTA: Warfarin bests aspirin for stroke prevention in elderly AF patients
BAFTA: Warfarin bests aspirin for stroke prevention in elderly AF patients
Glasgow, Scotland - Results of the Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) trial show that even among elderly patients with atrial fibrillation (AF), anticoagulation with warfarin was superior to aspirin for primary stroke prevention [1].
The benefit of treatment was not at the cost of more major hemorrhage, the rates of which were similar between groups. The results were presented here at the 16th European Stroke Conference.
"Use of anticoagulation rather than aspirin in over-75s in our study will prevent one primary event for every 50 patients treated for a year, or 25 treated for two years," Dr Jonathan W Mant (University of Birmingham, UK) told attendees here. "Our conclusion is that warfarin could be safely used much more widely in the elderly than it is at the moment, and age itself should not be regarded as a contraindication to warfarin therapy."
Glasgow, Scotland - Results of the Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) trial show that even among elderly patients with atrial fibrillation (AF), anticoagulation with warfarin was superior to aspirin for primary stroke prevention [1].
The benefit of treatment was not at the cost of more major hemorrhage, the rates of which were similar between groups. The results were presented here at the 16th European Stroke Conference.
"Use of anticoagulation rather than aspirin in over-75s in our study will prevent one primary event for every 50 patients treated for a year, or 25 treated for two years," Dr Jonathan W Mant (University of Birmingham, UK) told attendees here. "Our conclusion is that warfarin could be safely used much more widely in the elderly than it is at the moment, and age itself should not be regarded as a contraindication to warfarin therapy."
Thursday, May 10, 2007
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults. 2007 Update.
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults. 2007 Update. A Guideline From the American Heart Association, American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group
Joseph Broderick MD, FAHA, Chair; Sander Connolly MD, FAHA, Vice-Chair; Edward Feldmann MD, FAHA; Daniel Hanley MD, FAHA; Carlos Kase MD, FAHA; Derk Krieger MD; Marc Mayberg MD, FAHA; Lewis Morgenstern MD, FAHA; Christopher S. Ogilvy MD; Paul Vespa MD; and Mario Zuccarello MD
Purpose--The aim of this statement is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage.
Methods--A formal literature search of Medline was performed through the end date of August 2006. The results of this search were complemented by additional articles on related issues known to the writing committee. Data were synthesized with the use of evidence tables. The American Heart Association Stroke Council’s Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 5 expert peer reviewers and by the members of the Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years’ time.
Results--Evidence-based guidelines are presented for the diagnosis of intracerebral hemorrhage, the management of increased arterial blood pressure and intracranial pressure, the treatment of medical complications of intracerebral hemorrhage, and the prevention of recurrent intracerebral hemorrhage. Recent trials of recombinant factor VII to slow initial bleeding are discussed. Recommendations for various surgical approaches for treatment of spontaneous intracerebral hemorrhage are presented. Finally, withdrawal-of-care and end-of-life issues in patients with intracerebral hemorrhage are examined.
The guidelines, published in the June issue of Stroke, Journal of the American Heart Association
COMMENTARIES:
Intracerebral hemorrhage, which causes 10% to 15% of first-ever strokes, has a 30-day mortality rate of 35% to 52%
The guidelines suggest that the hemorrhage should be removed as soon as possible if:
It's greater than 3 cm.
The patient is deteriorating neurologically.
The patient has brain stem compression, hydrocephalus from ventricular obstruction, or both.
There is some evidence that using recombinant activated factor VII within four hours of the stroke limits bleeding and may reduce the risk of death.
The guidelines also recommend that:
Appropriate antiepileptic therapy should always be used for treatment of seizures.
Sources of fever should be treated and antipyretic medications should be given as needed.
Early mobilization and rehabilitation are recommended in patients who are clinically stable.
A new aspect of the guidelines is discussion of withdrawal of care and end-of-life issues. The guidelines recommend that do-not-resuscitate orders not be initiated during the first 24 hours after the onset of stroke because they are associated with "an overall lack of aggressiveness of care."
Joseph Broderick MD, FAHA, Chair; Sander Connolly MD, FAHA, Vice-Chair; Edward Feldmann MD, FAHA; Daniel Hanley MD, FAHA; Carlos Kase MD, FAHA; Derk Krieger MD; Marc Mayberg MD, FAHA; Lewis Morgenstern MD, FAHA; Christopher S. Ogilvy MD; Paul Vespa MD; and Mario Zuccarello MD
Purpose--The aim of this statement is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage.
Methods--A formal literature search of Medline was performed through the end date of August 2006. The results of this search were complemented by additional articles on related issues known to the writing committee. Data were synthesized with the use of evidence tables. The American Heart Association Stroke Council’s Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 5 expert peer reviewers and by the members of the Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years’ time.
Results--Evidence-based guidelines are presented for the diagnosis of intracerebral hemorrhage, the management of increased arterial blood pressure and intracranial pressure, the treatment of medical complications of intracerebral hemorrhage, and the prevention of recurrent intracerebral hemorrhage. Recent trials of recombinant factor VII to slow initial bleeding are discussed. Recommendations for various surgical approaches for treatment of spontaneous intracerebral hemorrhage are presented. Finally, withdrawal-of-care and end-of-life issues in patients with intracerebral hemorrhage are examined.
The guidelines, published in the June issue of Stroke, Journal of the American Heart Association
COMMENTARIES:
Intracerebral hemorrhage, which causes 10% to 15% of first-ever strokes, has a 30-day mortality rate of 35% to 52%
The guidelines suggest that the hemorrhage should be removed as soon as possible if:
It's greater than 3 cm.
The patient is deteriorating neurologically.
The patient has brain stem compression, hydrocephalus from ventricular obstruction, or both.
There is some evidence that using recombinant activated factor VII within four hours of the stroke limits bleeding and may reduce the risk of death.
The guidelines also recommend that:
Appropriate antiepileptic therapy should always be used for treatment of seizures.
Sources of fever should be treated and antipyretic medications should be given as needed.
Early mobilization and rehabilitation are recommended in patients who are clinically stable.
A new aspect of the guidelines is discussion of withdrawal of care and end-of-life issues. The guidelines recommend that do-not-resuscitate orders not be initiated during the first 24 hours after the onset of stroke because they are associated with "an overall lack of aggressiveness of care."
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