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Friday, February 25, 2011

US HEART DISEASE COSTS MAY TRIPLE IN NEXT TWO DECADES

Bloomberg News (1/25, Cortez) reports that "the medical bill for Americans with heart disease is expected to triple in the next two decades, increasing to $818 billion in 2030 as the population ages, according to the American Heart Association." The increasing "expense includes only the price of treatment, not the cost of lost time and productivity as patients and their partners miss work or other tasks, a policy paper published today in the association's medical journal Circulation concluded." Currently, "heart disease...costs $273 billion a year in the US, or about 17 percent of the nation's medical spending."

The CNN (1/24, Henry) "The Chart" blog reported that "researchers looked at the current rates of disease as well as census data and projected population shifts in age and race. The study found with the anticipated rise of the Hispanic population in the United States, prevention programs have to be designed in multiple ways."

CQ HealthBeat (1/25, Ferguson, subscription required) reports that "the projection of illness and cost assumes little change in national health policy and factors, such as diabetes and obesity, that contribute to cardiovascular conditions. It also does not make any assumptions about the effect of prevention sections in the health care law...which the Republican House has voted to repeal." The Hill (1/24, Millman) "Healthwatch" blog, Reuters (1/25), WebMD (1/24, Hendrick), and HealthDay (1/24, Reinberg) also covered the story.

POSTED BY STEVEN ALMANY, MD

Monday, February 21, 2011

ILANA KUTINSKY IMPLANTS THE FIRST SE MICHIGAN MRI-SAFE PACEMAKER....

A Beaumont Hospitals Cardiology team led by Michigan Heart Group electrophysiologist Ilana Kutinsky, D.O., implanted the first MRI-safe pacemaker in Southeast Michigan today into a 87-year-old, Bloomfield Hills, man at Beaumont Hospital, Troy. The Revo MRI SureScan pacemaker used in the procedure is the first pacing system designed, tested and FDA-approved for use with magnetic resonance imaging.

MRI procedures for patients with traditional implanted pacemaker implants are not recommended because these patients could face serious complications, such as interference with pacemaker operation, damage to system components, lead or pacemaker dislodgement or changes in pacing.

Approximately 1.5 million Americans have pacemakers, devices designed to keep the heart beating at a steady rhythm. Most pacemaker patients are 65 and older and at an age when illnesses and injuries requiring MRI develop.

The number of patients with pacemakers is growing at the same time the use of MRI is increasing. About 40 million MRI scans are performed annually in the United States. Beaumont performs approximately 65,000 MRI scans each year. MRI scanning is often preferred by physicians because it provides a level of detail and clarity not offered by other soft tissue (bodily organs, muscles, tendons, nerves, tumors, etc.)
imaging methods.

It has been estimated that there is a 50 to 75 percent probability that cardiac device patients will require an MRI over the lifetime of their devices. Furthermore, more than 200,000 patients annually in the U.S. have to forego an MRI scan because they have a pacemaker, an important patient need that this new pacemaker may help address.


Dr. Ilana Kutinsky during implant

"Medical imaging and electronic implantable devices such as pacemakers are important technological advances," says Dr. Kutinsky. "Beaumont is always looking for ways to provide safer access to MRI for patients with pacemakers who also have conditions that may require MRI testing."

Developed by Medtronic after more than a decade of research, the Revo MRI SureScan pacing system has been designed to address safety concerns around MRI procedures for patients who have implanted pacemakers. The Revo MRI pacing system, when programmed into the device's SureScan mode prior to an MRI scan, is designed to be used safely with MRI scans. The pacing system includes hardware modifications to the device and leads that are designed to reduce or eliminate several hazards produced by the
MRI environment.


Dr. Kutinsky looks at the monitor after placing SE Michigan's first MRI-Safe pacemaker

Friday, February 18, 2011

PARENTAL HISTORY OF MI MAY PREDICT FUTURE MI IN OFFSPRING

HeartWire (1/24, Wood) reported, "A new analysis of more than 12.000 subjects participating in the global INTERHEART study shows that having one or both parents who have had an MI is a strong predictor of future MI in their offspring, independent of behavioral, biological, psychosocial, and genetic factors," according to a study published online Jan. 24 in the Journal of the American College of Cardiology. What's more, "the strength of the association with parental history persists across world regions, as well as across socioeconomic, age, and gender groups," the study noted.

POSTED BY STEVEN ALMANY, MD

Tuesday, February 15, 2011

DABIGATRAN VERSUS WARFARIN IN PATIENTS WITH ATRIAL FIBRILLATION: AN ANALYSIS OF PATIENTS UNDERGOING CARDIOVERSION

Title: Dabigatran Versus Warfarin in Patients With Atrial Fibrillation: An Analysis of Patients Undergoing Cardioversion
Date Posted: January 14, 2011
Authors: Nagarakanti R, Ezekowitz MD, Oldgren J, et al.
Citation: Circulation 2011;123:131-136.

Clinical Trial:
Randomized Evaluation of Long-Term Anticoagulant Therapy Warfarin, Compared With Dabigatran

Study Question:
Is anticoagulation with dabigatran adequate for stroke prevention in the setting of cardioversion of atrial fibrillation (AF)?

Methods:
This was a post-hoc analysis of 1,983 cardioversions in 1,270 patients enrolled in the RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) trial, in which 18,113 patients with AF were randomly assigned to anticoagulation with warfarin, dabigatran 110 mg twice daily (D110), or dabigatran 150 mg twice daily (D150). The number of cardioversions in the three groups ranged from 647 to 672, and 86% of the cardioversions were electrical. A transesophageal echocardiogram (TEE) was performed before cardioversion in 13%, 26%, and 24% of patients in the warfarin, D110, and D150 groups, respectively. The primary outcomes were stroke, systemic embolism, and major bleeding episodes within 30 days of cardioversion.

Results:
The stroke/systemic embolism rate did not differ significantly between the three groups (0.6%, 0.8%, 0.3% in the warfarin, D110, and D150 groups, respectively). The stroke/embolism rate did not differ between patients with and without a TEE in any of the three groups. The rates of major bleeding also did not differ significantly between the three groups (0.6%, 1.7%, and 0.6% in the warfarin, D110, and D150 groups, respectively).

Conclusions:
The risks of post-cardioversion stroke and major bleeding are similar with warfarin and dabigatran, whether or not a TEE is performed pre-cardioversion.

Perspective:
The results indicate that dabigatran is a reasonable alternative to warfarin for stroke prevention post-cardioversion. A possible advantage of warfarin is that therapeutic anticoagulation can be verified by measuring the international normalized ratio. With dabigatran, confirmation of anticoagulation with a laboratory test is not clinically feasible and one must rely on patients stating that they took the dabigatran as prescribed.

POSTED BY STEVEN ALMANY, MD

Monday, February 14, 2011

DIET SODA VS. SUGAR VARIETY COULD STILL HAVE A MUCH HIGHER RISK OF VASCULAR EVENTS COMPARED TO THOSE WHO DON'T DRINK SODA

Los Angeles, CA – Even if you drink diet soda — instead of the sugar variety — you could still have a much higher risk of vascular events compared to those who don’t drink soda, according to research presented at the American Stroke Association’s International Stroke Conference 2011.

In findings involving 2,564 people in the large, multi-ethnic Northern Manhattan Study (NOMAS), scientists said, "people who drank diet soda every day had a 61 percent higher risk of vascular events than those who reported no soda drinking."

“If our results are confirmed with future studies, then it would suggest that diet soda may not be the optimal substitute for sugar-sweetened beverages for protection against vascular outcomes,” said Hannah Gardener, Sc.D., lead author and epidemiologist at the University of Miami Miller School of Medicine in Miami, FL.

In separate research using 2,657 participants also in the Manhattan study, scientists found that high salt intake, independent of the hypertension it causes, was linked to a dramatically increased risk of ischemic strokes (when a blood vessel blockage cuts off blood flow to the brain).

In the study, people who consumed more than 4,000 milligrams (mg) per day of sodium had more than double the risk of stroke compared to those consuming less than 1,500 mg per day.

At the start of both studies, researchers assessed diet by a food frequency questionnaire.

NOMAS is a collaboration of investigators at Columbia University in New York and Miami’s Miller School of Medicine, launched in 1993 to examine stroke incidence and risk factors in a multi-ethnic urban population. A total of 3,298 participants over 40 years old (average age 69) were enrolled through 2001 and continue to be followed. Sixty-three percent were women, 21 percent were white, 24 percent black and 53 percent Hispanic.

In the soda study, researchers asked subjects at the outset to report how much and what kind of soda they drank. Based on the data, they grouped participants into seven consumption categories: no soda (meaning less than one soda of any kind per month); moderate regular soda only (between one per month and six per week), daily regular soda (at least one per day); moderate diet soda only; daily diet soda only; and two groups of people who drink both types: moderate diet and any regular, and daily diet with any regular.

During an average follow-up of 9.3 years, 559 vascular events occurred (including ischemic and hemorrhagic stroke, which is caused by rupture of a weakened blood vessel). Researchers accounted for participants’ age, sex, race or ethnicity, smoking status, exercise, alcohol consumption and daily caloric intake. And even after researchers also accounted for patients’ metabolic syndrome, peripheral vascular disease and heart disease history, the increased risk persisted at a rate 48 percent higher.

In the sodium research, 187 ischemic strokes were reported during 9.7 years of follow-up. Stroke risk, independent of hypertension, increased 16 percent for every 500 mg of sodium consumed a day, the scientists calculated. Those figures included adjustment for age, sex, race/ethnicity, education, alcohol use, exercise, daily caloric intake, smoking status, diabetes, high cholesterol, high blood pressure and previous heart disease.

Only a third of participants met the current U.S. Dietary Guidelines for Americans that recommend daily sodium intake fall below 2,300 mg, or about a teaspoon of salt, Gardener said. Only 12 percent of subjects met the American Heart Association’s recommendations to consume less than 1,500 mg a day. Average intake was 3,031 milligrams.

“The take-home message is that high sodium intake is a risk factor for ischemic stroke among people with hypertension as well as among those without hypertension, underscoring the importance of limiting consumption of high sodium foods for stroke prevention,” Gardener said.

Participants’ reporting their dietary behavior is a key limitation of both studies, Gardener said.

In the soda study, investigators also lacked data on types of diet and regular drinks consumed, preventing analysis of whether variations among brands or changes over time in coloring and sweeteners might have played a role.

Co-authors for the soda study are: Tatjana Rundek, M.D., Ph.D.; Clinton Wright, M.D., M.S.; Julio Vieira, B.A.; Mitchell S. Elkind, M.D., M.S.; and Ralph L. Sacco, M.D., M.S.

Co-authors for the sodium study are: Rundek; Wright; Norbelina Disla, B.A.; Elkind; and Sacco. Author disclosures are on the abstract.

Funding for both studies was provided by a Javits award from The National Institute of Neurological Disorders and Stroke and the Evelyn F. McKnight Brain Institute.

POSTED BY JOEL KAHN, MD

Friday, February 11, 2011

COST-EFFECTIVENESS OF DABIGATRAN COMPARED WITH WARFARIN FOR STROKE PREVENTION IN ATRIAL FIBRILLATION

Title: Cost-Effectiveness of Dabigatran Compared With Warfarin for Stroke Prevention in Atrial Fibrillation
Date Posted: January 14, 2011
Authors: Freeman JV, Zhu RP, Owens DK, et al.
Citation: Ann Intern Med 2011;154:1-11.

Study Question:
What is the quality-adjusted survival, costs, and cost-effectiveness of dabigatran compared with adjusted-dose warfarin for preventing ischemic stroke in patients 65 years or older with nonvalvular atrial fibrillation (AF)?

Methods:
The study used a Markov decision model using the RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) trial and other published studies of anticoagulation. The cost of dabigatran was estimated on the basis of pricing in the United Kingdom. The study population consisted of patients ages 65 years or older with nonvalvular AF and risk factors for stroke (CHADS2 score ≥1 or equivalent) and no contraindications to anticoagulation. A lifetime societal perspective was used for the cost-effectiveness analysis. Warfarin anticoagulation (target international normalized ratio, 2.0-3.0) was compared with dabigatran 110 mg twice daily (low dose) and dabigatran 150 mg twice daily (high dose), and quality-adjusted life-years (QALYs), costs (in 2008 U.S. dollars), and incremental cost-effectiveness ratios were analyzed.

Results:
The quality-adjusted life expectancy was 10.28 QALYs with warfarin, 10.70 QALYs with low-dose dabigatran, and 10.84 QALYs with high-dose dabigatran. Total costs were $143,193 for warfarin, $164,576 for low-dose dabigatran, and $168,398 for high-dose dabigatran. The incremental cost-effectiveness ratios compared with warfarin were $51,229 per QALY for low-dose dabigatran and $45,372 per QALY for high-dose dabigatran. The model was sensitive to the cost of dabigatran, but was relatively insensitive to other model inputs. The incremental cost-effectiveness ratio increased to $50,000 per QALY at a cost of $13.70 per day for high-dose dabigatran, but remained less than $85,000 per QALY over the full range of model inputs evaluated. The cost-effectiveness of high-dose dabigatran improved with increasing risk for stroke and intracranial hemorrhage.

Conclusions:
The authors concluded that in patients ages 65 years or older with nonvalvular AF at increased risk for stroke, dabigatran may be a cost-effective alternative to warfarin.

Perspective:
The study suggests that in patients ages 65 years or older with AF who are at increased risk for stroke (CHADS2 score ≥1 or equivalent), dabigatran could be a cost-effective alternative to warfarin. The base-case analysis estimated a cost of $45,372 per QALY gained with high-dose dabigatran compared with warfarin, which was within a range generally considered to be cost-effective. The cost-effectiveness of dabigatran was sensitive to drug costs and relative differences in cost between the high- and low-dose formulations. In addition, for patients at higher risk for ischemic stroke or intracranial hemorrhage, including those with CHADS2 scores of 2 or greater, the cost-effectiveness for high-dose dabigatran compared with warfarin improved. The results of this analysis were derived from a single clinical trial and could change if future effectiveness studies provide alternative estimates for bleeding risk and stroke reduction.

POSTED BY STEVEN ALMANY, MD

Wednesday, February 9, 2011

FEBRUARY IS HEART MONTH!!!!

Heart Disease is the #1 killer of women. Please use this month to speak to the women in your life. Ask if they know their 4 numbers.


1. Blood Pressure: Should be 120/80 or better

2. Cholesterol: LDL should be less then 130

3. Blood Sugar: Less then 100

4. Body Mass Index (Ratio of Height and Weight): Between 18.5 and 25


Heart Disease symptoms are different in women then men. Women have much small hearts and symptoms can present as follows:


Chest Pain or Pressure

Shortness of Breath

Back Pain

Uneasy Stomach

Heart Burn

Indigestion

Fatigue or Weakness

Sweats


If someone you love doesn't know their numbers please urge them to visit their Primary Care Physician or Cardiologist.

Tuesday, February 8, 2011

A RANDOMIZED TRIAL OF INTERNET AND TELEPHONE TREATMENT FOR SMOKING CESSATION

Title: A Randomized Trial of Internet and Telephone Treatment for Smoking Cessation
Date Posted: January 10, 2011
Authors: Graham AL, Cobb NK, Papandonatos GD, et al.
Citation: Arch Intern Med 2011;171:46-53.

Study Question:
Does Internet and telephone treatment for smoking cessation increase quit rates?

Methods:
The Quit Using Internet and Telephone Treatment (iQUITT) study was a randomized controlled trial, which compared basic Internet, enhanced Internet, and enhanced Internet with proactive telephone counseling. QuitNet provided advice to quit, assistance in setting a quit date, assessment of motivation, smoking history, and nicotine dependence, individually tailored information on quitting, problem solving and skills training, assistance with using pharmacologic therapies for quitting, and online social support. The trial was conducted from March 8, 2005, through November 30, 2008. Current adult smokers in the United States who smoked five or more cigarettes per day were eligible. The primary outcome of interest was 30-day abstinence measured at 3, 6, 12, and 18 months after randomization using intent-to-treat analysis.

Results:
A total of 2,005 smokers were enrolled. Mean age of the cohort was 35.9 years, 51.1% were women, and 86.5% were white. The follow-up assessment rate at 18 months was 68.2%. At 18 months, the 30-day multiple point prevalence abstinence rate across all follow-up intervals was 3.5% for the basic Internet group, 4.5% for the enhanced Internet group, and 7.7% for the enhanced Internet with proactive telephone counseling. At 18 months, 30-day single point prevalence abstinence rates were 19.0% for the basic Internet group, 17.4% for the enhanced Internet group, and 19.6% for the enhanced Internet with proactive telephone counseling group, with no significant difference between the groups.

Conclusions:
The investigators concluded that a combined Internet and telephone treatment outperforms static and dynamic Internet interventions for smoking cessation.

Perspective:
The study is a well-designed trial exemplifying the novel aspects of Internet-based interventions for behavioral change. Although the quit rates were modest, the investigators used the Internet to reach a broad group of smokers; thus, the impact of this intervention has potential to be far greater than the traditional multicenter or single-center trial.

POSTED BY STEVEN ALMANY, MD

Friday, February 4, 2011

COMPARATIVE VALIDATION OF A NOVEL RISK SCORE FOR PREDICTING BLEEDING RISK IN ANTICOAGULATED PATIENTS WITH ATRIAL FIBRILLATION

Title: Comparative Validation of a Novel Risk Score for Predicting Bleeding Risk in Anticoagulated Patients With Atrial Fibrillation: The HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) Score
Date Posted: January 6, 2011
Authors: Lip GY, Frison L, Halperin JL, Lane DA.
Citation: J Am Coll Cardiol 2011;57:173-180.

Study Question:
What are the predictors of bleeding events among patients with atrial fibrillation (AF)?

Methods:
A total of 7,329 patients with AF who were enrolled in SPORTIF (Stroke Prevention Using an ORal Thrombin Inhibitor in Atrial Fibrillation) III and V clinical trials were included in this analysis. Predictive risk stratification schemas were evaluated to examine predictors of bleeding events. Patients were anticoagulated orally with either adjusted-dose warfarin (target international normalized ratio [INR] 2-3) or fixed-dose ximelagatran 36 mg twice daily. Major bleeding was the primary outcome of interest. Concurrent aspirin therapy was allowed in patients with clinical atherosclerosis.

Results:
In this cohort, patients who experienced a major bleeding event (n = 217) were more likely to be elderly, nonsmokers, diabetics, have left ventricular dysfunction, prior stroke (or transient ischemic attack), and impaired renal function. Patients with higher CHADS2 scores had higher risk of bleeding. In multivariate analyses, significant predictors of bleeding were concurrent aspirin use (hazard ratio [HR], 2.10; 95% confidence interval [CI], 1.59-2.77; p < 0.001); renal impairment (HR, 1.98; 95% CI, 1.42-2.76; p < 0.001); age 75 years or older (HR, 1.63; 95% CI, 1.23-2.17; p = 0.0008); diabetes (HR, 1.47; 95% CI, 1.10-1.97; p = 0.009), and heart failure or left ventricular dysfunction (HR, 1.32; 95% CI, 1.01-1.73; p = 0.041). Of the tested schemas, the new HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score performed best, with a stepwise increase in rates of major bleeding with increasing HAS-BLED score (p for trend < 0.0001). The c statistic for bleeding varied between 0.50 and 0.67 in the overall entire cohort, and 0.68 among patients naïve to warfarin at baseline (n = 769).

Conclusions:
The authors concluded that factors including diabetes and heart failure or left ventricular dysfunction are potential risk factors for bleeding in AF. In addition, the HAS-BLED scheme offers a useful predictive capacity for identification of patients at increased risk for bleeding.

Perspective:
The study uses a large cohort to identify risk factors of major bleeding among patients with AF. Given the significant increase in AF projected over the next several decades, identification of a predictive scheme is clinically important.

POSTED BY STEVEN ALMANY, MD

Tuesday, February 1, 2011

ATRIAL FIBRILLATION APPEARS TO BE INCREASINGLY COMMON IN KIDNEY DIALYSIS PATIENTS

HealthDay (1/13, Preidt) reported, "The heart rhythm disorder atrial fibrillation is increasingly common in kidney dialysis patients and puts them at increased risk for death." In fact, the "prevalence of atrial fibrillation increased more than threefold between 1992 and 2006, from 3.5 percent to 10.7 percent of dialysis patients," Stanford researchers pointed out. "Among dialysis patients most likely to experience atrial fibrillation were older patients," individuals who identify as white, "and those with other medical conditions," according to the paper in the Journal of the American Society of Nephrology.

POSTED BY STEVEN ALMANY, MD