LANCET: CLASSIFY CHRONIC KIDNEY DISEASE AS A HEART DISEASE RISK EQUIVALENT

Researchers recommended making chronic kidney disease (CKD) a coronary heart disease risk equivalent after their results showed the risk of MI was similar for CKD and diabetic patients in a study published online June 19 in The Lancet. Writers in an accompanying editorial praised the study despite its falling short on its primary outcome.

Marcello Tonelli, MD, of the department of medicine at the University of Alberta in Edmonton, Canada, and colleagues posed the question: Given the high rates cardiovascular (CV) events in patients with CKD, should CKD be considered a risk equivalent for heart disease? The authors argued that the U.S. National Cholesterol Education Program Adult Treatment Panel III guidelines for cholesterol lowering therapies already classify diabetes as a risk equivalent based in part on data linking diabetes and the risk of CV events.

The researchers used the Alberta Kidney Disease Network database in Canada to obtain routine laboratory data from all patients in Alberta. They selected patients who were 18 years or older who had serum creatinine measured at least once as an outpatient between 2002 and 2009. They excluded patients with an estimated glomerular filtration rate (eGFR) indicating end-stage kidney disease. Of those remaining, they identified patients who also had been tested for proteinuria.

They defined CKD as eGFR lower than 60mL/minute per 1.73 m² (stage 3 or 4). They followed patients from their index date until March 31, 2009. The primary outcome was first MI admission to a hospital and the secondary outcome was all-cause mortality. Using the Alberta Bureau of Vital Statistics, they also assessed short-term and long-term mortality after MI.

One percent of the patients were admitted to a hospital for MI during a median 48-month follow-up. Those with a previous MI had the highest unadjusted rate of MI (18.5 per 1,000 person years). In those with no previous MI, patients with diabetes and no CKD had a rate of 5.4 per 1,000 person-years while patients with CKD and no diabetes had a rate of 6.9 per 1,000 person-years. Adjusted relative rates of MI, though, were similar for patients with CKD and severely increased proteinuria and those with diabetes.

But the proportion of patients who died within 30 days of admission for MI was much higher among patients with CKD and no diabetes, at 14 percent, than for those with diabetes and no CKD, at 8 percent. It even topped the proportion of patients with a history of prior MI, at 10 percent.

“Our findings show that the risk of myocardial infarction in people with chronic kidney disease and proteinuria is similar or greater than the risk in those with diabetes,” the authors wrote. “The rate of mortality after myocardial infarction in our study was significantly higher in participants with chronic kidney disease than in those with diabetes.”

The authors concluded that their findings support adding CKD to the list of criteria when defining those at high risk of future coronary events. “Our research suggests that there is a strong case for considering chronic kidney disease to be a coronary heart disease risk equivalent, meaning that people with chronic kidney disease are at a comparable risk of coronary events as those who previously had a heart attack,” Tonelli said in a release.

In an accompanying editorial, Tamar S. Polonsky, MD, and George L. Bakris, MD, both University of Chicago Medicine in Chicago, pointed out that the study had negative findings in the primary outcome: first MI admission to a hospital. They also addressed limitations, including the lack of information about individual patient’s medications and efforts to control CV risk factors.

But they praised the study’s use of a population-based cohort of almost 1.3 million people in a real-world setting and its findings. “Tonelli and colleagues offer new insight by comparing individuals with chronic kidney disease with those who have a history of myocardial infarction, on a very large scale,” they wrote. “Their findings emphasize the importance of primary prevention, particularly because patients with chronic kidney disease comprise a large proportion of the patients who have myocardial infarction.”

POSTED BY:  Steven Almany M.D.

ADDING MARKERS ADDS LITTLE TO CV PREDICTION

Action Points

• Only slight improvements in cardiovascular risk prediction were gained by adding more blood lipid-related markers to conventional factors, a study has found.
• Note that adding factors such as apolipoprotein B and A-I, lipoprotein(a), or lipoprotein-associated phospholipase A2 mass to total and HDL cholesterol only rarely altered participants' classifications into low-, medium-, or high-risk groups.

Only slight improvements in cardiovascular risk prediction were gained by adding more blood lipid-related markers to conventional factors, researchers said.

Fewer than 5% of individuals would have their risk classifications changed by including such markers as apolipoprotein A-I, apolipoprotein B, lipoprotein(a), or lipoprotein-associated phospholipase A₂ (LpA-PLA₂) in gauging the likelihood of major cardiovascular events, reported John Danesh, FRCP, of the University of Cambridge in England, and colleagues belonging to the Emerging Risk Factors Collaboration.

At best, adding more lipid markers to the risk prediction equation brought "slight improvement," the researchers wrote in the June 20 issue of the Journal of the American Medical Association. Replacing the standard markers with the other lipoprotein-associated factors reduced the accuracy of risk prediction.

"These findings applied to clinically relevant subpopulations, including people with diabetes and people with elevated triglyceride levels," Danesh and colleagues noted.

Earlier studies have gone back and forth on whether blood lipid measurements besides total and HDL cholesterol contribute significantly to the accuracy of risk prediction. Some research groups have proposed supplementing or even replacing standard cholesterol markers with various other lipid components that appear to be associated with cardiovascular event risk.

But other research has failed to confirm the value of additional lipid parameters, leading Danesh and colleagues to perform a meta-analysis of data from 37 prospective cohorts in which blood lipids were measured and cardiovascular events systematically recorded.

Overall, these cohorts comprised more than 165,000 individuals experiencing some 15,000 cardiovascular deaths and nonfatal MIs and strokes over a median of 10.4 years of follow-up.

Measurements of apolipoprotein A-I and B and lipoprotein(a) were available in more than 130,000 of the study participants. Information on LpA-PLA₂ was obtained for about 32,000 participants.

The pooled data showed that each of these factors, except for apolipoprotein A-I, was significantly associated with increased event risk after adjusting for age, smoking status, systolic blood pressure, and history of diabetes. Hazard ratios ranged from 1.13 to 1.24 for each standard deviation of higher age and systolic blood pressure (P<0 .05=".05" a="a" and="and" apolipoprotein="apolipoprotein" b="b" for="for" lipoprotein="lipoprotein" span="span">LpA-PLA

₂.

But adding these factors to total and HDL cholesterol only rarely altered participants' classifications into low-, medium-, or high-risk groups.

Adding each marker individually changed risk classifications in fewer than 1% of participants, Danesh and colleagues found.

The researchers also looked more narrowly at the effect on the number of participants estimated to have at least a 20% 10-year risk of major events, which would qualify them for statin treatment.

The most influential additional marker in this respect was lipoprotein(a). Adding it to conventional risk factors boosted the number of participants in this risk group by 4.1%.

Adding a combination of apolipoproteins B and A-I to conventional risk factors would boost the number qualifying for statins by 1.1%, and LpA-PLA₂ would increase it by 2.7%.

Danesh and colleagues estimated that, on the basis of these calculations, it would be necessary to test from 800 to 4,500 individuals for these markers in order to prevent one major cardiovascular event over 10 years.

WBH Comment

In an accompanying editorial, Scott Grundy, MD, PhD, of the University of Texas Southwestern Medical Center in Dallas, suggested that the study's implicit basic assumption -- that accurate risk classification as currently defined is important -- can be questioned.

"These [low-medium-high] risk categories were designated more than a decade ago to guide in the use of cholesterol-lowering drugs (e.g., statins) in primary prevention, and were defined to reduce use of expensive drugs for lower-risk persons," he wrote.

Now that statins are available in cheap generic form and their safety is "well established," the need for risk categories in deciding who should get them is "less compelling," Grundy suggested.

Instead, it makes more sense to identify patients now classified as low-risk who may benefit from statins, he argued. Recent research has suggested that this may be a sizable population.

Grundy wrote that imaging methods for detecting early, sub-clinical atherosclerosis or simple risk prediction algorithms based on age, sex, LDL cholesterol, "and perhaps another major risk factor" may be the best way to select such patients.

POSTED BY: Steven Almany M.D.

WEIGHT LIFTING MAY REDUCE TYPE 2 DIABETES RISK IN MEN

ABC World News (8/6, story 8, 0:20, Stephanopoulos) reported, "And in healthy living, a new way to reduce the risk of diabetes: A study by Harvard School of Public Health" published online August 6 in the Archives of Internal Medicine "found that men who lift weights at least two and a half hours per week decrease their risk of getting type 2 diabetes by a third."

 

CardioSource (8/7) reports that "the risk of T2DM [type 2 diabetes mellitus] was lowered by 13 percent for every 60 minutes of weight training per week. There was a stronger association of weight training and T2DM risk in men under the age of 65 as well as in men with no family history of T2DM." 

 

POSTED BY:  Steven Almany M.D.

RED MEAT CONSUMPTION MAY BE LINKED TO INCREASED RISK OF STROKE

MedPage Today (8/7, Neale) reports, "Eating red meat -- including beef, pork, lamb, ham, hot dogs, sausage, and bacon -- may increase the risk of stroke," according to a meta-analysis published online in Stroke: Journal of the American Heart Association. Investigators found that "each one-serving-per-day increase in fresh, processed, and total red meat intake was associated with an 11% to 13% relative increase in the risk of all strokes, driven by an increase in the risk of ischemic stroke." But, the investigators reported, "there was...no relationship between red meat consumption and hemorrhagic stroke risk."

 

POSTED BY:Steven Almany M.D.

SHAPE OF LEFT ATRIAL APPENDAGE MAY BE LINKED TO STROKE RISK IN AFIB PATIENTS

 "The shape of the left atrial appendage may have something to do with the risk of ischemic stroke in patients with atrial fibrillation," according to a study that was published in the Journal of the American College of Cardiology. Researchers found that "of the four shapes characterized by researchers, the one called Chicken Wing carried a 79% decreased risk of stroke or transient ischemic attack (TIA)." The investigators reported that, "compared with Chicken Wing, the other three shapes were four to eight times more likely to be associated with stroke or TIA." 

POSTED BY:  Steven Almany M.D.

MICHIGAN HEART GROUP INTERGRATES WITH WILLIAM BEAUMONT HOSPITAL

On June 1, 2012 a change occurred at Michigan Heart Group we became integrated with William Beaumont Hospital in the form of a Professional Services Agreement. Our signage will soon read Beaumont Michigan Heart Group, Beaumont Michigan Heart Rhythm Group and Beaumont Western Wayne Heart Group.

This professional agreement will integrate some of the services that we provide with the hospital as well as some of our operations including our outpatient testing and billing, but will allow Michigan Heart Group to maintain operational control of the practice. Management of these operations still occurs locally within Michigan Heart Group. We have not experienced that these changes with Beaumont have disrupted any of the services that you currently receive from your physician.

We believe that with this integration model, we will be best able to provide you with the high quality of care that you have come to expect and deserve from our practice. All of our physicians will continue practicing from their current locations and your records will remain available to your physician without any further actions taken on your part. This is intended to be essentially a transparent change to you, the patient, in terms of how your care is delivered. Such a change has been made necessary after we have experienced years of progressive cuts in insurance reimbursement while our fixed costs have steadily increased. The status quo was no longer a viable option for the future.

You will notice changes specific to billing. Beaumont will bill applicable charges to your insurance. You will receive a billing statement from Beaumont rather than from Michigan Heart Group. You may still call Michigan Heart Group for billing inquiries however questions/determinations will be advised and directed by Beaumont.

We value your loyalty and trust that you have placed in our physicians and staff over the past several years and we continue to look forward to serving you in the future. As we indicated above, we believe that most of these changes will be transparent to your healthcare needs. If you have any questions, please contact our administrator, Darlene Nichols at 248-267-5050, select option 2.

Thank you for choosing Michigan Heart Group, in affiliation with William Beaumont Hospital for your healthcare services. We look forward to serving you now and in the future.

Very truly yours,

Beaumont Michigan Heart Group

The cardiovascular benefits of taking statins outweigh the risk of diabetes, even in high risk individuals, according to a study published on Aug. 9 in The Lancet.

The study, the first placebo-controlled statin trial to formally report an increased risk of developing diabetes, found "in individuals with one or more risk factors, statin allocation was associated with a 39 percent reduction in the primary endpoint, a 36 percent reduction in venous thromboembolism, a 17 percent reduction in total mortality, and a 28 percent increase in diabetes." Whereas in individuals with "no major diabetes risk factors, statin allocation was associated with a 52 percent reduction in the primary endpoint, a 53 percent reduction in venous thromboembolism, a 22 percent reduction in total mortality, and no increase in diabetes."

By comparison with placebo, statins accelerated the average time to diagnosis of diabetes by 5•4 weeks (84•3 [SC 47•8] weeks on rosuvastatin vs. 89•7 [50•4] weeks on placebo, the authors add. 

 

The trial, called JUPITER, was a randomized, double-blind trial that looked at 17,603 men and women without previous cardiovascular disease or diabetes over five years. As previous studies have suggested that statins increase risk of development of diabetes, which have led to recent regulatory changes, the authors aimed to "address the balance of vascular benefits and diabetes hazard of statin use."

 

In an editorial comment, Gerald F. Watts and Esther M. Ooi from the Cardiometabolic Research Centre and Clinical Services at the Royal Perth Hospital in Perth, Australia, note, "these findings reaffirm the net value of statins in the primary prevention of cardiovascular disease, but intuitively caution that the diabetogenic effect of these drugs is highest in individuals with risk factors for diabetes, including raised C-reactive protein."

POSTED BY:  Steven Almany M.D.

ADDING CLOPIDOGREL TO DAILY ASPIRIN MAY NOT REDUCE RISK OF SECOND STROKE

HealthDay (8/30, Reinberg) reports, "Adding the clot-busting drug Plavix [clopidogrel] to a daily dose of aspirin is no better than taking aspirin alone to prevent a second stroke in people who have had a type of stroke that is typically caused by chronic high blood pressure," according to a study published in the New England Journal of Medicine.

MedPage Today (8/30, Petrochko) reports, "In the halted SPS3 trial, dual antiplatelet therapy with clopidogrel and aspirin did not significantly reduce recurrent stroke risk at follow-up compared with aspirin alone (2.5% versus 2.7%) at a hazard ratio of 0.92 (95% CI 0.72 to 1.16)." But, "compared with aspirin alone, dual therapy almost doubled the risk of major bleeding (HR 1.97 95% CI 1.41 to 2.71, P<0 .001=".001" 1.14="1.14" 1.52="1.52" 2.04="2.04" 95="95" all-cause="all-cause" and="and" ci="ci" div="div" mortality="mortality" p="0.004)." to="to">

POSTED BY: Steven Almany M.D.

GREAT CHARITY STARTED BY DR. STEVEN ALMANY- STUDENT HEART CHECK

http://www.myfoxdetroit.com/video?autoStart=true&topVideoCatNo=default&clipId=7608635

CARDIAC ARREST MAY BE MORE COMMON IN YOUNG PEOPLE THAN PREVIOUSLY BELIEVED

According to a study published online in Circulation, while cardiac arrest is fairly uncommon in young people, it may be more common than previously believed. Investigators looked at data from a 30-year period in Washington's King County. The investigators reported that the cardiac arrest rate among kids and young adults was approximately 2.3 per 100,000 annually.

POSTED BY: Steven Almany M.D.

TWO JAMA STUDIES LOOK AT EFFECTIVE WEIGHT LOSS APPROACHES

ABC World News (6/26, story 7, 1:45, Stephanopoulos) reported, "A surprising study" published in the Journal of the American Medical Association "that could change the way we think about dieting. When it comes to counting calories, what kind we take in may matter as how many we take in." Reuters (6/27, Pittman) reports that, according to another study, also published in the Journal of the American Medical Association, a stepped-care program may be nearly as effective as a standard weight-loss intervention for helping people lose weight, and is cheaper as well.

        

CardioSource (6/27) reports that one "study, 'Effects of Dietary Composition on Energy Expenditure During Weight-Loss Maintenance,' looked at the effect on energy expenditure and components of the metabolic syndrome of three types of commonly consumed diets following weight loss and found that decreases in resting energy expenditure and total energy expenditure were greatest with a low-fat diet, intermediate with a low-glycemic index diet and least with a very low-carbohydrate diet." The other "study, 'Effect of a Stepped-Care Intervention Approach on Weight Loss in Adults: A Randomized Clinical Trial,' showed that although a standard behavioral weight loss intervention among overweight and obese adults resulted in greater average weight loss over 18 months, a stepped care intervention resulted in clinically meaningful weight loss that cost less to implement."

       
Also covering the first study were the Wall Street Journal (6/27, A3, Dooren, Subscription Publication), USA Today (6/27, Hellmich), the Los Angeles Times (6/27, Brown), Bloomberg News (6/27, Ostrow), and the New York Times (6/27, Bittman) "Opin

Posted by:  Steven Almany MD

MICHIGAN HEART GROUP'S PHYSICIAN LIAISON IS HERE TO HELP YOU

Michigan Heart Group has a Physician Liaison on staff to assist with questions, concerns or problems you, your staff or your patients may have with our office.

Stacie Batur is available Monday through Thursday at (248) 267-5050 (x6509). She is often between two buildings or visiting referring physician offices. If you get her voice mail, please leave a message and she will call you back shortly. If you need to speak to her immediately you can reach her on her cell phone at (248) 765-4466.