Dear Colleagues:
MICHIGAN HEART GROUP IS GOING GREEN!!!
MHG has created a blog! We will continue to publish the Curbside on a bi-monthly basis along with other current medical information relating to Cardiology! However, we will be doing so via the Michigan Heart Group Blog. We are hoping that this information can help serve as a link between our practice and yours. If you would like to receive email updates with an attached link when the blog is updated, please email michiganheartgroup@gmail.com or call Stacie Batur at 248-267-5050 (x6509) and she will add you to the distribution list. THIS LIST IS NOT SHARED WITH ANYONE! As always, if you have any questions, please feel free to contact any of us at anytime. Thank you and we look forward to working with you in the future!
Title: Practice Patterns Among United States Cardiologists for Managing Adults With Atrial Fibrillation (From the AFFECTS Registry)
Topic: Arrhythmias
Date Posted: 3/4/2010
Author(s): Reiffel JA, Kowey PR, Myerburg R, et al.
Citation: Am J Cardiol 2010;Feb 22:[Epub ahead of print].
Clinical Trial: No
Journal Scan: Warfarin and Aspirin Use in Atrial Fibrillation Among Practicing Cardiologists (From the AFFECTS Registry)
Study Question: How do community-based cardiologists treat atrial fibrillation (AF)?
Methods: This was an analysis of 1,461 patients (mean age 66 years) who had AF (paroxysmal in 80%, symptomatic in 77%) without structural heart disease and who were enrolled in a multicenter, prospective registry. Participating cardiologists were trained in the practice guidelines of the American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC). Follow-up data were gathered for 1 year after enrollment. The choice of therapy was at the treating physician’s discretion.
Results: At baseline, a rhythm-control strategy was chosen for 64% of patients and a rate-control strategy for 36%. Rhythm control was attempted significantly more often for paroxysmal AF (67%) than for persistent AF (55%). A rhythm-control strategy also was selected more often for symptomatic than asymptomatic persistent AF (60% vs. 40%, respectively), but in a similar proportion of patients with symptomatic and asymptomatic paroxysmal AF (68% and 63%, respectively). The most common first-line rhythm-control drugs were sustained-release propafenone (43%) and sotalol (17%), and the most common second-line drugs were sustained-release propafenone (36%) and amiodarone (22%).
Conclusions: Community-based treatment of AF in patients without structural heart disease is fairly compliant with ACC/AHA/ESC practice guidelines.
Perspective: The ACC/AHA/ESC guidelines recommend that a rate-control strategy be used for patients with minimally symptomatic or asymptomatic AF. It is noteworthy that a large proportion of patients with asymptomatic AF nevertheless are treated with rhythm-control drugs in community practice. It appears that, despite current guidelines, many cardiologists have not abandoned the deep-rooted (and logical) belief that sinus rhythm is better than AF for many patients.
Title: Glycated Hemoglobin, Diabetes, and Cardiovascular Risk in Nondiabetic Adults
Topic: Prevention/Vascular
Date Posted: 3/3/2010 5:00:00 PM
Author(s): Selvin E, Steffes MW, Zhu H, et al.
Citation: N Engl J Med 2010;362:800-811.
Clinical Trial: No
Study Question: Is the glycated hemoglobin in persons without diabetes predictive of cardiovascular outcomes?
Methods: The prognostic value of glycated hemoglobin and fasting glucose were assessed for their ability to identify adults at risk for diabetes or cardiovascular disease. Glycated hemoglobin (glycohemoglobin or HgA1c) was measured in whole-blood samples from 11,092 black or white adults who did not have a history of diabetes or cardiovascular disease and who attended the second visit (occurring in the 1990–1992 period) of the Atherosclerosis Risk in Communities (ARIC) study.
Results: Fifty-eight percent were women, 77% were white, 32% had hypertension, and 22.7% had a family history of diabetes. Mean values for risk factors were as follows: age 57 years, fasting blood sugar (FBS) 105 mg/dl, glycated hemoglobin 5.5%, low-density lipoprotein cholesterol 133 mg/dl, high-density lipoprotein cholesterol 51 mg/dl, and body mass index 27.7 kg/m2. The glycated hemoglobin value at baseline was associated with newly diagnosed diabetes and cardiovascular outcomes. For glycated hemoglobin values of less than 5.0%, 5.0 to less than 5.5%, 5.5 to less than 6.0%, 6.0 to less than 6.5%, and 6.5% or greater, the multivariable-adjusted hazard ratios for diagnosed diabetes were 0.52, 1.00 (reference), 1.86, 4.48, and 16.47, respectively. For coronary heart disease, the hazard ratios were 0.96, 1.00 (reference), 1.23, 1.78, and 1.95, respectively. The hazard ratios for stroke were similar. In contrast, glycated hemoglobin and death from any cause were found to have a J-shaped association curve. All these associations remained significant after adjustment for the baseline fasting glucose level. The association between the fasting glucose levels and the risk of cardiovascular disease or death from any cause was not significant in models with adjustment for all covariates as well as glycated hemoglobin. For coronary heart disease, measures of risk discrimination showed significant improvement when glycated hemoglobin was added to models including fasting glucose.
Conclusions: In this community-based population of nondiabetic adults, glycated hemoglobin was similarly associated with a risk of diabetes and more strongly associated with risks of cardiovascular disease and death from any cause, as compared with fasting glucose. These data add to the evidence supporting the use of glycated hemoglobin as a diagnostic test for diabetes.
Perspective: Persons with a glycated hemoglobin ≥6.5% or FBS >126 mg/dl are characterized as diabetics. The former represent the average blood sugar over 2 to 3 months. A level greater than 5.5% is associated with an increase in risk for diabetes and coronary disease independent of other variables, and the relative risk for 0.5% increments is considerable. The authors concluded that a glycated hemoglobin exceeding 6% may be a useful marker to identify persons at risk for development of diabetes, and cardiovascular disease and death. Consideration should be given to replacing the FBS with glycated hemoglobin for risk stratification of adults with and without vascular disease.
Title: Warfarin and Aspirin Use in Atrial Fibrillation Among Practicing Cardiologists (From the AFFECTS Registry)
Topic: Arrhythmias
Date Posted: 3/4/2010
Author(s): Kowey PR, Reiffel JA, Myerburg R, et al.
Citation: Am J Cardiol 2010;Feb 22:[Epub ahead of print].
Clinical Trial: No
Related Resources
Journal Scan: Practice Patterns Among United States Cardiologists for Managing Adults With Atrial Fibrillation (From the AFFECTS Registry)
Study Question: What is the pattern of anticoagulation use in patients with atrial fibrillation (AF) in contemporary practice?
Methods: This was an analysis of 1,461 patients (mean age 66 years) who had AF (paroxysmal in 80%) without structural heart disease and who were enrolled in a multicenter registry. Participating cardiologists were trained in the practice guidelines of the American College of Cardiology/American Heart Association/European Society of Cardiology. Follow-up data were gathered for 1 year after enrollment. The choice of therapy was at the treating physician’s discretion. The Congestive heart failure, Hypertension, Age, Diabetes, Stroke (CHADS2) score was determined by post-hoc record review. A CHADS2 score ≥2 was considered indicative of a high risk of stroke.
Results: A rhythm-control strategy was used in 64% of patients and a rate-control strategy in 36%. Overall, 83% of patients received either warfarin (64%) or aspirin (32%), with no significant difference between the rhythm-control and rate-control groups. Among the high-risk patients, warfarin was used in 66% of rhythm-control patients and 73% of rate-control patients. Among the low-risk patients (CHADS2 <2),>
Conclusions: Anticoagulation use in patients with AF often is inconsistent with practice guidelines.
Perspective: Several studies have indicated that warfarin is underused in patients with AF. The registry data in this study demonstrate that this continues to be the case, with approximately 25-35% of high-risk patients not receiving warfarin despite the guidelines training provided to the treating physicians. The results emphasize the need for more effective dissemination and implementation of practice guidelines.
Steven C. Almany, M.D., F.A.C.C.
