Meta-analysis shows PCI beats medical therapy for late reperfusion
28 February 2008
Patients who undergo percutaneous coronary intervention more than 12 hours after suffering an acute myocardial infarction have improved cardiac function and survival compared with those who receive medical management, a meta-analysis indicates.
Chest pain causes sustained psychological distress
28 February 2008
Chest pain causes significant anxiety and depression even after people have been told that is not due to cardiovascular disease, say UK researchers.
Eye disease more than doubles MI risk
28 February 2008
The progressive eye disease age-related macular degeneration doubles the risk for death due to cardiovascular disease, reveals a study from Australia.
Thursday, February 28, 2008
Tuesday, February 26, 2008
Top 10 Articles on Medscape
Top 10 Most Read Articles by Cardiologists:
1.
A 57-Year-Old Asymptomatic Male Presents for Evaluation of an Abnormal ECG Obtained During a Physical CMEThe patient presents with an abnormal ECG. Is there cause for concern?
2.
ENHANCE Saga Continues: Experts Dispute Ezetimibe's Future and "Weight" of Imaging Studies
3.
Questioning the Importance of LDL Cholesterol: The ENHANCE Fallout
4.
Atrial Fibrillation: Diagnosis and Management
CME
5.
Nebivolol Approved in US CME
6.
Abnormal ECG Patterns in Athletes: An Initial Expression of Underlying Cardiomyopathy?
7.
ENHANCE Results Yield Disappointment for Ezetimibe
8.
Staying Active and Drinking Moderately Is Key to a Long Life CME
9.
Meta-Analysis Shows Statins Reduce All-Cause Mortality 22% in Elderly CHD Patients
10.
Folic Acid -- Finally Some Good News: A Best Evidence Review CME/CE
1.
A 57-Year-Old Asymptomatic Male Presents for Evaluation of an Abnormal ECG Obtained During a Physical CMEThe patient presents with an abnormal ECG. Is there cause for concern?
2.
ENHANCE Saga Continues: Experts Dispute Ezetimibe's Future and "Weight" of Imaging Studies
3.
Questioning the Importance of LDL Cholesterol: The ENHANCE Fallout
4.
Atrial Fibrillation: Diagnosis and Management
CME
5.
Nebivolol Approved in US CME
6.
Abnormal ECG Patterns in Athletes: An Initial Expression of Underlying Cardiomyopathy?
7.
ENHANCE Results Yield Disappointment for Ezetimibe
8.
Staying Active and Drinking Moderately Is Key to a Long Life CME
9.
Meta-Analysis Shows Statins Reduce All-Cause Mortality 22% in Elderly CHD Patients
10.
Folic Acid -- Finally Some Good News: A Best Evidence Review CME/CE
HF burden increasing in USA
By Caroline Price
26 February 2008
Arch Intern Med 2008; 168: 418-424
MedWire News: The prevalence of heart failure (HF) has increased recently in the USA, despite a decline in its incidence, study findings indicate.
They show that the incidence of HF fell overall among both men and women from 1994 to 2003, but, owing to improved survival rates, the number of people living with HF increased during this period.
Lesley Curtis (Duke University School of Medicine, Durham, North Carolina) and colleagues studied a nationally representative 5% sample of Medicare beneficiaries, of whom 622,786 were diagnosed with HF between 1994 and 2003.
"Estimates of the incidence and prevalence of HF in elderly persons translate directly into projections of resource use for the Medicare program, so accurate estimates are essential," they note.
The researchers report in the Archives of Internal Medicine that the incidence of HF declined slightly from 32 per 1000 person-years in 1994 to 29 per 1000 person-years in 2003 (p<0.01).
The incidence actually increased over this time in patients aged 65-69 years, but this was offset by the decline among patients aged 75 years or over.
Meanwhile, the prevalence of HF increased steadily from around 140,000 in 1994 to 200,000 in 2003. These numbers equated to rates of around 90 and 121 per 1000 beneficiaries, respectively. Each yearly increase in the prevalence rate was significant (p<0.01) for the whole group and in both men and women.
The increase in prevalence reflected improved survival rates. Between 1994 and 2003, both unadjusted and risk-adjusted mortality declined slightly. Risk-adjusted 30-day mortality decreased by over 5%, from 13.0% to 12.6% in men and from 11.5% to 10.8% for women. There was a 5% decrease in 1-year mortality, from 28.9% to 27.5% overall. And 5-year mortality fell by 3%, from 67.5% to 64.9% in men and from 61.7% to 60.2% in women.
Closer inspection showed that the rate of increase in prevalence slowed over time, growing from 90 per 1000 beneficiaries in 1994 to 121 per 1000 in 2000, after which it remained at around 120 per 1000 up to 2003. This reflected declines in incidence and relatively steady mortality rates, the authors note.
They conclude: "Identifying optimal strategies for the treatment and management of HF will become increasingly important as the size of the Medicare population grows."
Curtis commented: "From all indications, HF will continue to be a major public health burden, consuming billions of dollars each year."
Free abstract
26 February 2008
Arch Intern Med 2008; 168: 418-424
MedWire News: The prevalence of heart failure (HF) has increased recently in the USA, despite a decline in its incidence, study findings indicate.
They show that the incidence of HF fell overall among both men and women from 1994 to 2003, but, owing to improved survival rates, the number of people living with HF increased during this period.
Lesley Curtis (Duke University School of Medicine, Durham, North Carolina) and colleagues studied a nationally representative 5% sample of Medicare beneficiaries, of whom 622,786 were diagnosed with HF between 1994 and 2003.
"Estimates of the incidence and prevalence of HF in elderly persons translate directly into projections of resource use for the Medicare program, so accurate estimates are essential," they note.
The researchers report in the Archives of Internal Medicine that the incidence of HF declined slightly from 32 per 1000 person-years in 1994 to 29 per 1000 person-years in 2003 (p<0.01).
The incidence actually increased over this time in patients aged 65-69 years, but this was offset by the decline among patients aged 75 years or over.
Meanwhile, the prevalence of HF increased steadily from around 140,000 in 1994 to 200,000 in 2003. These numbers equated to rates of around 90 and 121 per 1000 beneficiaries, respectively. Each yearly increase in the prevalence rate was significant (p<0.01) for the whole group and in both men and women.
The increase in prevalence reflected improved survival rates. Between 1994 and 2003, both unadjusted and risk-adjusted mortality declined slightly. Risk-adjusted 30-day mortality decreased by over 5%, from 13.0% to 12.6% in men and from 11.5% to 10.8% for women. There was a 5% decrease in 1-year mortality, from 28.9% to 27.5% overall. And 5-year mortality fell by 3%, from 67.5% to 64.9% in men and from 61.7% to 60.2% in women.
Closer inspection showed that the rate of increase in prevalence slowed over time, growing from 90 per 1000 beneficiaries in 1994 to 121 per 1000 in 2000, after which it remained at around 120 per 1000 up to 2003. This reflected declines in incidence and relatively steady mortality rates, the authors note.
They conclude: "Identifying optimal strategies for the treatment and management of HF will become increasingly important as the size of the Medicare population grows."
Curtis commented: "From all indications, HF will continue to be a major public health burden, consuming billions of dollars each year."
Free abstract
Friday, February 22, 2008
Only One-Third of Adults Know Heart Attack Signs
Only about one-third of U.S. adults are aware of the five major warning signs of heart attacks, according to a CDC survey in MMWR.
The telephone survey of 72,000 people, conducted in 2005, found that, nationally:
48% recognize pain or discomfort in the jaw, neck, or back as a warning sign;
62%, feeling weak, lightheaded, or faint;
85%, pain or discomfort in the arms or shoulder;
92%, chest pain or discomfort;
93%, shortness of breath.
The numbers were even lower among non-Hispanic blacks and Hispanics, men, and those with less than a high school education.
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Physician's First Watch for February 22, 2008
David G. Fairchild, MD, MPH, Editor-in-Chief
Only One-Third of Adults Know Heart Attack Signs
Google Prototyping Personal Health Records
Early Immunosuppression Better Than Conventional Therapy in Crohn Disease
Antioxidants, Folate of No Developmental Benefit to Infants with Down Syndrome
Only One-Third of Adults Know Heart Attack Signs
Only about one-third of U.S. adults are aware of the five major warning signs of heart attacks, according to a CDC survey in MMWR.
The telephone survey of 72,000 people, conducted in 2005, found that, nationally:
48% recognize pain or discomfort in the jaw, neck, or back as a warning sign;
62%, feeling weak, lightheaded, or faint;
85%, pain or discomfort in the arms or shoulder;
92%, chest pain or discomfort;
93%, shortness of breath.
The numbers were even lower among non-Hispanic blacks and Hispanics, men, and those with less than a high school education.
In addition, 86% said they would dial 911 if they thought someone was having a heart attack or stroke.
The telephone survey of 72,000 people, conducted in 2005, found that, nationally:
48% recognize pain or discomfort in the jaw, neck, or back as a warning sign;
62%, feeling weak, lightheaded, or faint;
85%, pain or discomfort in the arms or shoulder;
92%, chest pain or discomfort;
93%, shortness of breath.
The numbers were even lower among non-Hispanic blacks and Hispanics, men, and those with less than a high school education.
To ensure you receive Physician's First Watch, add FirstWatch@jwatch.org to your address book.
Forward Sign Up
My Alerts About Physician's First Watch Editorial Board
Advertisement*
Physician's First Watch for February 22, 2008
David G. Fairchild, MD, MPH, Editor-in-Chief
Only One-Third of Adults Know Heart Attack Signs
Google Prototyping Personal Health Records
Early Immunosuppression Better Than Conventional Therapy in Crohn Disease
Antioxidants, Folate of No Developmental Benefit to Infants with Down Syndrome
Only One-Third of Adults Know Heart Attack Signs
Only about one-third of U.S. adults are aware of the five major warning signs of heart attacks, according to a CDC survey in MMWR.
The telephone survey of 72,000 people, conducted in 2005, found that, nationally:
48% recognize pain or discomfort in the jaw, neck, or back as a warning sign;
62%, feeling weak, lightheaded, or faint;
85%, pain or discomfort in the arms or shoulder;
92%, chest pain or discomfort;
93%, shortness of breath.
The numbers were even lower among non-Hispanic blacks and Hispanics, men, and those with less than a high school education.
In addition, 86% said they would dial 911 if they thought someone was having a heart attack or stroke.
Thursday, February 21, 2008
Cardiac Surgery Drug Proven To Increases Death Rate
21 Feb 2008
The largest study to date of a controversial cardiac surgery drug shows it increases death rates and damages kidney function, according Duke University Medical Center researchers. Aprotinin, a drug used to limit bleeding, was temporarily suspended from marketing in the U.S. in November 2007 after a small Canadian study was stopped because similar findings were discovered. The drug, Trasylol, is manufactured by Baylor AG. "We're not surprised by the results," says Dr. Andrew Shaw, an associate professor in Duke Medicine's department of anesthesiology and the lead author of the paper which appears in the February 21 edition of the New England Journal of Medicine. "It's what we expected to find." The Duke study is significant because "it is more than twice the size of the next largest study of aprotinin," says Shaw. The prospective data was collected between 1996 and 2005. "Unlike the highly selected nature of randomized trial populations, our data represent the every day cardiac bypass surgery patient population. The data were collected at a time when aprotinin was thought to be safe."
The Duke team started analyzing its database of patients after a 2006 NEJM study reported aprotinin use may increase the risk of heart attack, stroke and serious kidney injury. "We were looking for an association between exposure to the drug and subsequent adverse outcomes," Shaw says. "We found an increased incidence of death in patients who received aprotinin. That higher death rate seemed to persist even when we were able to control for the differences seen between the patient groups." Shaw and his Duke colleagues also linked aprotinin to impaired kidney function. "Kidney function is measured by serum creatinine levels which indicate how well the blood is filtering waste products," he says.
The study found aprotinin use increased serum creatinine levels, but they did not report an increase in patients needing dialysis. Shaw believes "that's because we probably didn't have enough patients who needed dialysis in our study to detect a significant statistical difference, although the incidence was numerically higher." Of the 10,275 patients studied, 1343 patients (13.2%) received aprotinin, 6776 patients (66.8%) received aminocaproic acid (another drug used to limit bleeding) and 2029 patients (20.0%) received no therapy. All patients underwent coronary-artery bypass surgery (CABG), and 1181 of them also underwent valve surgery.
Patients who received either aminocaproic acid or no therapy did not have high rates of death or poor kidney function seen in the aprotinin group. After gaining FDA approval in 1993, aprotinin was used routinely during cardiac surgery, particularly on high-risk patients, to reduce bleeding and the need for blood transfusion. According to previously published research, patients undergoing cardiac surgery receive approximately one fifth of all the red cell transfusions in the U.S., and each unit transfused is known to increase the risk of infection. Shaw says this study does not rule out the possibility that the increased death rate was due to high-risk, sicker patients receiving the drug. "You would expect sicker patients would be more likely to die," he said. "The unanswered question is, 'are there differences between the patient groups that we were unable to detect that led to the increased death rate, or is the death rate due to exposure to the drug?' "Our study doesn't answer that question nor was it designed to," he says. "But it does further raise the question of the safety of aprotinin. And, on a broader scale, it highlights the importance of post-marketing observational studies of drugs that are widely used."
Article adapted by Medical News Today from original press release.
The largest study to date of a controversial cardiac surgery drug shows it increases death rates and damages kidney function, according Duke University Medical Center researchers. Aprotinin, a drug used to limit bleeding, was temporarily suspended from marketing in the U.S. in November 2007 after a small Canadian study was stopped because similar findings were discovered. The drug, Trasylol, is manufactured by Baylor AG. "We're not surprised by the results," says Dr. Andrew Shaw, an associate professor in Duke Medicine's department of anesthesiology and the lead author of the paper which appears in the February 21 edition of the New England Journal of Medicine. "It's what we expected to find." The Duke study is significant because "it is more than twice the size of the next largest study of aprotinin," says Shaw. The prospective data was collected between 1996 and 2005. "Unlike the highly selected nature of randomized trial populations, our data represent the every day cardiac bypass surgery patient population. The data were collected at a time when aprotinin was thought to be safe."
The Duke team started analyzing its database of patients after a 2006 NEJM study reported aprotinin use may increase the risk of heart attack, stroke and serious kidney injury. "We were looking for an association between exposure to the drug and subsequent adverse outcomes," Shaw says. "We found an increased incidence of death in patients who received aprotinin. That higher death rate seemed to persist even when we were able to control for the differences seen between the patient groups." Shaw and his Duke colleagues also linked aprotinin to impaired kidney function. "Kidney function is measured by serum creatinine levels which indicate how well the blood is filtering waste products," he says.
The study found aprotinin use increased serum creatinine levels, but they did not report an increase in patients needing dialysis. Shaw believes "that's because we probably didn't have enough patients who needed dialysis in our study to detect a significant statistical difference, although the incidence was numerically higher." Of the 10,275 patients studied, 1343 patients (13.2%) received aprotinin, 6776 patients (66.8%) received aminocaproic acid (another drug used to limit bleeding) and 2029 patients (20.0%) received no therapy. All patients underwent coronary-artery bypass surgery (CABG), and 1181 of them also underwent valve surgery.
Patients who received either aminocaproic acid or no therapy did not have high rates of death or poor kidney function seen in the aprotinin group. After gaining FDA approval in 1993, aprotinin was used routinely during cardiac surgery, particularly on high-risk patients, to reduce bleeding and the need for blood transfusion. According to previously published research, patients undergoing cardiac surgery receive approximately one fifth of all the red cell transfusions in the U.S., and each unit transfused is known to increase the risk of infection. Shaw says this study does not rule out the possibility that the increased death rate was due to high-risk, sicker patients receiving the drug. "You would expect sicker patients would be more likely to die," he said. "The unanswered question is, 'are there differences between the patient groups that we were unable to detect that led to the increased death rate, or is the death rate due to exposure to the drug?' "Our study doesn't answer that question nor was it designed to," he says. "But it does further raise the question of the safety of aprotinin. And, on a broader scale, it highlights the importance of post-marketing observational studies of drugs that are widely used."
Article adapted by Medical News Today from original press release.
Wednesday, February 20, 2008
Patients Less Likely to Survive In-Hospital Cardiac Arrests on Nights, Weekends
Cardiac arrest during the night or on weekends places hospital patients at higher risk for death and complications, a JAMA article reports.
Using national registry data on nearly 87,000 adult cardiac arrests occurring between 2000 and 2007, researchers characterized the events by time-of-day and day-of-week. When compared with arrests that occurred during the day or evening hours, nighttime events (11 p.m. to 7 a.m.) showed significantly lower rates of survival to discharge, return of spontaneous circulation for more than 20 minutes, survival at 24 hours, and favorable neurologic outcome.
Rates on weekends were similar to those on weekday nights.
The authors write that, in searching for causes, "it is reasonable to focus on the potential for decreased physical and psychological performance on the part of the health care worker, different staffing patterns, and less patient surveillance during nights and weekends."
JAMA article (Free abstract; full text requires subscription)
Associated Press story (Free)
Related Journal Watch link(s):
Journal Watch Cardiology summary (Free)
Using national registry data on nearly 87,000 adult cardiac arrests occurring between 2000 and 2007, researchers characterized the events by time-of-day and day-of-week. When compared with arrests that occurred during the day or evening hours, nighttime events (11 p.m. to 7 a.m.) showed significantly lower rates of survival to discharge, return of spontaneous circulation for more than 20 minutes, survival at 24 hours, and favorable neurologic outcome.
Rates on weekends were similar to those on weekday nights.
The authors write that, in searching for causes, "it is reasonable to focus on the potential for decreased physical and psychological performance on the part of the health care worker, different staffing patterns, and less patient surveillance during nights and weekends."
JAMA article (Free abstract; full text requires subscription)
Associated Press story (Free)
Related Journal Watch link(s):
Journal Watch Cardiology summary (Free)
Tuesday, February 19, 2008
Chances Of Survival Depends On What Time Cardiac Arrest Occurs
Medical News Today - 19 Feb 2008
If you are in the hospital and have cardiac arrest at night or on the weekend, you have a significantly lower chance of survival to discharge than if you had the arrest during day or evening times on weekdays, according to Mary Ann Peberdy of Virginia Commonwealth University in Richmond, VA and colleagues. The results of their study are published in The Journal of the American Medical Association (JAMA).
The researchers suggest that patient, hospital, staffing, and response factors could come together to reduce the effectiveness of detecting and treating cardiac arrests at night. The findings are essential to inform decisions regarding hospital staffing, training, care delivery processes, and equipment - especially if in-hospital cardiac arrests are more frequent or survival is less likely on nights and weekends.
The study data consisted of 86,748 adult, in-hospital cardiac arrest events occurring at 507 medical/surgical hospitals from January 2000 to February 2007.
All of the hospitals participate in the American Heart Association's National Registry of Cardiopulmonary Resuscitation. Peberdy and colleagues evaluated survival rates for adults with in-hospital cardiac arrest by time of day and day of week. They examined survival from cardiac arrest using the following definitions:
Day/evening is 7:00 a.m. to 10:59 p.m.
Night is 11:00 p.m. to 6:59 a.m.
Weekend is 11:00 p.m. on Friday to 6:59 a.m. on Monday
There were 58,593 in-hospital cardiac arrest events that occurred during day/evening hours (15,110 on weekends) and 28,155 cases during night hours (7,790 on weekends).Key findings include that compared to day/evening cardiac arrest events:
Rates of survival to discharge were lower at night, 14.7% vs. 19.8%,
Rates of return of spontaneous circulation for longer than 20 minutes were lower at night, 44.7% vs. 51.1%,
Rates of survival at 24 hours were lower at night, 28.9% vs. 35.4%,
Rates of favorable neurological outcomes were lower at night, 11.0% vs. 15.2%,
There was only a slight difference between survival to discharge at night during the week (14.6%) and during weekends (14.8%). However, the rate of survival during day/evening weekdays was higher than on weekends (20.6% vs. 17.4%).
The researchers write, "The principal finding of this study was that survival to discharge following in-hospital cardiac arrest was lower [when the arrest occurred] during nights and weekends compared with day/evening times on weekdays, even after accounting for many potentially confounding patient, arrest event, and hospital factors.".
"The mechanism for the decreased survival during the night is likely multifactorial, potentially including biological differences in patients as well as health care staff and hospital staffing and operational factors.
These data suggest the need to focus on night and weekend hospitalwide resuscitation system processes of care that can potentially improve patient safety and survival following cardiac arrest," conclude the authors.
Click Here to View JAMA website
If you are in the hospital and have cardiac arrest at night or on the weekend, you have a significantly lower chance of survival to discharge than if you had the arrest during day or evening times on weekdays, according to Mary Ann Peberdy of Virginia Commonwealth University in Richmond, VA and colleagues. The results of their study are published in The Journal of the American Medical Association (JAMA).
The researchers suggest that patient, hospital, staffing, and response factors could come together to reduce the effectiveness of detecting and treating cardiac arrests at night. The findings are essential to inform decisions regarding hospital staffing, training, care delivery processes, and equipment - especially if in-hospital cardiac arrests are more frequent or survival is less likely on nights and weekends.
The study data consisted of 86,748 adult, in-hospital cardiac arrest events occurring at 507 medical/surgical hospitals from January 2000 to February 2007.
All of the hospitals participate in the American Heart Association's National Registry of Cardiopulmonary Resuscitation. Peberdy and colleagues evaluated survival rates for adults with in-hospital cardiac arrest by time of day and day of week. They examined survival from cardiac arrest using the following definitions:
Day/evening is 7:00 a.m. to 10:59 p.m.
Night is 11:00 p.m. to 6:59 a.m.
Weekend is 11:00 p.m. on Friday to 6:59 a.m. on Monday
There were 58,593 in-hospital cardiac arrest events that occurred during day/evening hours (15,110 on weekends) and 28,155 cases during night hours (7,790 on weekends).Key findings include that compared to day/evening cardiac arrest events:
Rates of survival to discharge were lower at night, 14.7% vs. 19.8%,
Rates of return of spontaneous circulation for longer than 20 minutes were lower at night, 44.7% vs. 51.1%,
Rates of survival at 24 hours were lower at night, 28.9% vs. 35.4%,
Rates of favorable neurological outcomes were lower at night, 11.0% vs. 15.2%,
There was only a slight difference between survival to discharge at night during the week (14.6%) and during weekends (14.8%). However, the rate of survival during day/evening weekdays was higher than on weekends (20.6% vs. 17.4%).
The researchers write, "The principal finding of this study was that survival to discharge following in-hospital cardiac arrest was lower [when the arrest occurred] during nights and weekends compared with day/evening times on weekdays, even after accounting for many potentially confounding patient, arrest event, and hospital factors.".
"The mechanism for the decreased survival during the night is likely multifactorial, potentially including biological differences in patients as well as health care staff and hospital staffing and operational factors.
These data suggest the need to focus on night and weekend hospitalwide resuscitation system processes of care that can potentially improve patient safety and survival following cardiac arrest," conclude the authors.
Click Here to View JAMA website
Monday, February 18, 2008
(ACC/AHA) scientific statement on clinical performance measures for adults with atrial fibrillation (AF) or atrial flutter (AFl).
Citation: J Am Coll Cardiol. 2008;51:865-884.
Author(s): Estes NA, Halperin JL, Calkins H, et al.
Perspective: The following are 10 points to remember from this American College of Cardiology/American Heart Association (ACC/AHA) scientific statement on clinical performance measures for adults with atrial fibrillation (AF) or atrial flutter (AFl).
1. Antithrombotic therapy is indicated for all patients with AF except those with lone AF or contraindications.
2. Assessment of thromboembolic risk factors should include prior stroke/transient ischemic attack (TIA), age ≥75 years, hypertension, diabetes, and heart failure or left ventricular (LV) systolic dysfunction.
3. Prior stroke/TIA is the strongest risk factor and is an indication for anticoagulation with warfarin.
4. Rheumatic mitral stenosis also is a strong risk factor for stroke and is an indication for warfarin even if no other risk factors are present.
5. Warfarin also is indicated for patients with >1 moderate risk factor (age ≥75 years, hypertension, diabetes, and heart failure/LV systolic dysfunction.
6. Aspirin may be used for stroke prevention in patients without any risk factors.
7. Antithrombotic therapy (warfarin or aspirin) should be used on an individualized basis in patients with one moderate risk factor.
8. The international normalized ratio (INR) initially should be measured at least once per week and then once per month after a stable degree of anticoagulation when an INR of 2-3 is achieved.
9. When aspirin is used for stroke prevention, the daily dose should be 81-325 mg/day.
10. Patients with AFl should receive antithrombotic therapy in the same fashion as patients with AF. Fred Morady, M.D., F.A.C.C.
Author(s): Estes NA, Halperin JL, Calkins H, et al.
Perspective: The following are 10 points to remember from this American College of Cardiology/American Heart Association (ACC/AHA) scientific statement on clinical performance measures for adults with atrial fibrillation (AF) or atrial flutter (AFl).
1. Antithrombotic therapy is indicated for all patients with AF except those with lone AF or contraindications.
2. Assessment of thromboembolic risk factors should include prior stroke/transient ischemic attack (TIA), age ≥75 years, hypertension, diabetes, and heart failure or left ventricular (LV) systolic dysfunction.
3. Prior stroke/TIA is the strongest risk factor and is an indication for anticoagulation with warfarin.
4. Rheumatic mitral stenosis also is a strong risk factor for stroke and is an indication for warfarin even if no other risk factors are present.
5. Warfarin also is indicated for patients with >1 moderate risk factor (age ≥75 years, hypertension, diabetes, and heart failure/LV systolic dysfunction.
6. Aspirin may be used for stroke prevention in patients without any risk factors.
7. Antithrombotic therapy (warfarin or aspirin) should be used on an individualized basis in patients with one moderate risk factor.
8. The international normalized ratio (INR) initially should be measured at least once per week and then once per month after a stable degree of anticoagulation when an INR of 2-3 is achieved.
9. When aspirin is used for stroke prevention, the daily dose should be 81-325 mg/day.
10. Patients with AFl should receive antithrombotic therapy in the same fashion as patients with AF. Fred Morady, M.D., F.A.C.C.
Statins Found to Reduce Risk of Recurrent Atrial Fibrillation
TOURS, France, Feb. 18 -- Statin therapy significantly reduces the risk of atrial fibrillation in patients with a history of the condition and other high-risk groups, a meta-analysis has suggested.
Overall, statins reduced the odds ratio for atrial fibrillation by more than 60% compared with patients who did not receive the drugs, Laurent Fauchier, M.D., Ph.D., of Trousseau University Hospital Center, and colleagues reported in the Feb. 26 issue of the Journal of the American College of Cardiology.
Statins appeared to exert a greater impact in secondary prevention of atrial fibrillation rather than new-onset or postoperative atrial fibrillation.
"These results provide some evidence of the benefit of statins beyond their lipid-lowering activity," the authors concluded. "However, large-scale, prospective, randomized clinical trials are still needed to establish whether statins bring a similar benefit and are an appropriate therapeutic option in all subgroups of patients for the management of atrial fibrillation."
Observational studies have provided evidence of a protective effect of statins against atrial fibrillation. However, data were insufficient to provide a basis for recommending statin therapy to prevent the arrhythmia.
In an attempt to bring the potential atrial fibrillation benefit into sharper focus, Dr. Fauchier and colleagues searched for all randomized controlled trials of statins published from January 1980 through June 2007. They identified six trials involving 3,557 patients given statins versus placebo or a control therapy for treatment or prevention of atrial fibrillation.
Three studies examined the use of statins in patients with a history of paroxysmal atrial fibrillation or who were undergoing cardioversion for persistent atrial fibrillation. The remaining three trials evaluated statins in patients undergoing cardiac surgery or after acute coronary syndrome.
Overall, statin therapy was associated with a 61% decrease in the risk of atrial fibrillation (OR 0.39, 95% CI 0.18 to 0.85, P=0.02). Separate analyses suggested a more marked effect in the setting of secondary prevention (OR 0.33, 95% CI 0.10 to 1.03, P=0.06) than for new-onset or postoperative atrial fibrillation (OR 0.60, 95% CI 0.27 to 1.37, P=0.23).
The authors acknowledged they were unable to evaluate the possible impact of statin dose or the degree of LDL-lowering on arrhythmic events. They also noted that atrial fibrillation might arise from different factors in different patient subgroups, potentially making certain patients more responsive to an intervention compared with others.
Despite those limitations, Dr. Fauchier and colleagues concluded, "Use of statins was significantly associated with a decreased risk of incidence or recurrence of AF inpatients in sinus rhythm with a history of previous AF or undergoing cardiac surgery or after acute coronary syndrome."
The authors reported no disclosures.
Primary source: Journal of the American College of CardiologySource reference:Fauchier L, et al "Antiarrhythmic effect of statin therapy and atrial fibrillation: a meta-analysis of randomized controlled trials" J Am Coll Cardiol 2008; 51: DOI:10.1016/j.jacc.2007.09.063.
Overall, statins reduced the odds ratio for atrial fibrillation by more than 60% compared with patients who did not receive the drugs, Laurent Fauchier, M.D., Ph.D., of Trousseau University Hospital Center, and colleagues reported in the Feb. 26 issue of the Journal of the American College of Cardiology.
Statins appeared to exert a greater impact in secondary prevention of atrial fibrillation rather than new-onset or postoperative atrial fibrillation.
"These results provide some evidence of the benefit of statins beyond their lipid-lowering activity," the authors concluded. "However, large-scale, prospective, randomized clinical trials are still needed to establish whether statins bring a similar benefit and are an appropriate therapeutic option in all subgroups of patients for the management of atrial fibrillation."
Observational studies have provided evidence of a protective effect of statins against atrial fibrillation. However, data were insufficient to provide a basis for recommending statin therapy to prevent the arrhythmia.
In an attempt to bring the potential atrial fibrillation benefit into sharper focus, Dr. Fauchier and colleagues searched for all randomized controlled trials of statins published from January 1980 through June 2007. They identified six trials involving 3,557 patients given statins versus placebo or a control therapy for treatment or prevention of atrial fibrillation.
Three studies examined the use of statins in patients with a history of paroxysmal atrial fibrillation or who were undergoing cardioversion for persistent atrial fibrillation. The remaining three trials evaluated statins in patients undergoing cardiac surgery or after acute coronary syndrome.
Overall, statin therapy was associated with a 61% decrease in the risk of atrial fibrillation (OR 0.39, 95% CI 0.18 to 0.85, P=0.02). Separate analyses suggested a more marked effect in the setting of secondary prevention (OR 0.33, 95% CI 0.10 to 1.03, P=0.06) than for new-onset or postoperative atrial fibrillation (OR 0.60, 95% CI 0.27 to 1.37, P=0.23).
The authors acknowledged they were unable to evaluate the possible impact of statin dose or the degree of LDL-lowering on arrhythmic events. They also noted that atrial fibrillation might arise from different factors in different patient subgroups, potentially making certain patients more responsive to an intervention compared with others.
Despite those limitations, Dr. Fauchier and colleagues concluded, "Use of statins was significantly associated with a decreased risk of incidence or recurrence of AF inpatients in sinus rhythm with a history of previous AF or undergoing cardiac surgery or after acute coronary syndrome."
The authors reported no disclosures.
Primary source: Journal of the American College of CardiologySource reference:Fauchier L, et al "Antiarrhythmic effect of statin therapy and atrial fibrillation: a meta-analysis of randomized controlled trials" J Am Coll Cardiol 2008; 51: DOI:10.1016/j.jacc.2007.09.063.
Restricted clopidogrel access linked to increased mortality after PCI
18 February 2008
Medical insurance restricting access to clopidogrel can delay or stop patients receiving treatment with the drug after percutaneous coronary intervention with stenting, which in turn may increase their risk for dying, a Canadian study suggests.
Medwire News: Restricted clopidogrel access linked to increased mortality after PCI
Medical insurance restricting access to clopidogrel can delay or stop patients receiving treatment with the drug after percutaneous coronary intervention with stenting, which in turn may increase their risk for dying, a Canadian study suggests.
Medwire News: Restricted clopidogrel access linked to increased mortality after PCI
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