theheart.org Comments

What is happening in this tracing?

Fri, 10 Feb 2012 05:29:55 EST

DEAR SIR, AFTER YOUR PROMPT REPLY I RECHECKED THE QRS DURATION AND WAS SHOCKED TO SEE THAT I HAD INDEED OVERLOOKED THE DURATION.I AGREE WITH YOUR SOLUTION FULLY EXCEPTING 2 THINGS ON WHICH I NEED FURTHER ELABORATION- 1-USUALLY THE CAPTURE BEAT IS A PREMATUARE BEAT{WHICH IS LOGICAL AND THE ECG EXAMPLES GIVEN BY DR SCHAMROTH IN HIS ECG BOOK ALSO SHOW CAPTURE BEATS TO BE PREMATUARE.BUT HERE THE CAPTURE BEAT IS COMING AT THE SAME TIME WHEN THE VENTRICULAR COMPLEX DUE TO THE VT IS ANTICIPATED. 2-THE ATRIAL RATE AS MEASURED IN V3 WHERE THE P WAVES ARE THE MOST PROMINENT IS APPROXIMATELY 150 BPM VT WILL EXPLAIN THE HIGH VENTRICULAR RATE BUT WHAT WILL EXPLAIN THE HIGH ATRIAL RATE?IS IT ANXIETY OR IS THERE AN EXPLANATION FOR THAT.

European perspectives on CRT therapy: An update for 2012

Fri, 10 Feb 2012 00:45:49 EST

CRT/D is the best machine to the used in the patient surfured by the heart faiulre

What is happening in this tracing?

Thu, 09 Feb 2012 21:17:05 EST

The rhythm strip of lead III is most revealing. It's an obvious case of VT with AV dissociation, V rate 150/m and atrial rate 100/m with AV dissociation most of times with two capture beats(c) and one fusion beat(f). So, the first wrong assumption was to think the QRS is narrow. They sure are gentle and benign, not ugly and malignant looking which make people think narrow QRS. Print the rhythm strip of lead III, or magnifiy it and measure the QRS width carefully. It is 160ms!!! QRS can be narrower than what it actually is if the initial or the last part is isoelectric in a given lead but it can never be wider than what it actually is. So one has to go with the widest QRS. I will submit a ladder diagram tomorrow.

State-of-the-Art Care for Sudden Cardiac Arrest: Standardizing Care in the United States

Thu, 09 Feb 2012 21:05:58 EST

Please correct NYHA Class II to NYHA class III in paragraph 9. As far as classification is concerned, please read the following reference. The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9th ed. Boston, Mass: Little, Brown & Co; 1994:253-256.

Heart to Heart: Potential Impact of Optimal Implementation of Evidence-Based Heart Failure Therapi

Thu, 09 Feb 2012 20:55:24 EST

Please read my comments in "State-of-the-Art Care for Sudden Cardiac Arrest: Standardizing Care in the United States" under the same forum, 'Arrhythmia/EP'.

State-of-the-Art Care for Sudden Cardiac Arrest: Standardizing Care in the United States

Thu, 09 Feb 2012 20:52:30 EST

The following article suggested antiarrhythmic therapy guided by Holter monitoring (HM), and electrophysiologic (EP) testing for the prevention of SCD. Steinbeck G, Greene HL. (1996). �Management of patients with life-threatening sustained ventricular tachyarrhythmias--the role of guided antiarrhythmic drug therapy.� Prog Cardiovasc Dis;38(6):419-28. RADIOFREQUENCY CATHETER ABLATION is a useful procedure in aborting IVF in patients with FAILED ICD. Takatsuki S, Mitamura H, Ogawa S. ((2001). �Catheter ablation of a monofocal premature ventricular complex triggering idiopathic ventricular fibrillation.� Heart;86(1):E3. As far as out of hospital cardiac arrest is concerned, the following factors contribute to its occurrence/recurrence: �persistence of inducible ventricular arrhythmias (P = 0.0006), a left ventricular ejection fraction of 30 percent or less (P = 0.0138), and the absence of cardiac surgery (P = 0.0512).� Wilber DJ, Garan H, Finkelstein D, et al. (1988). �Out-of-hospital cardiac arrest. Use of electrophysiologic testing in the prediction of long-term outcome.� N Engl J Med;318(1):19-24. Furukawa T, Rozanski JJ, Nogami A, et al. (1989). �Time-dependent risk of and predictors for cardiac arrest recurrence in survivors of out-of-hospital cardiac arrest with chronic coronary artery disease.� Circulation;80(3):599-608. The usefulness of Signal-averaged ECGs in predicting arrhythmic events in patients with ischemic heart disease was reported by the following studies: Anderson KP, Bigger JT Jr, Freedman RA. (1996). �Electrocardiographic predictors in the ESVEM trial: unsustained ventricular tachycardia, heart period variability, and the signal-averaged electrocardiogram.� Prog Cardiovasc Dis;38(6):463-88. el-Sherif N, Turitto G, Fontaine JM. (1988). Risk stratification of patients with complex ventricular arrhythmias. Value of ambulatory electrocardiographic recording, programmed electrical stimulation and the signal-averaged electrocardiogram. Herz;13(3):204-14. To be able to effectively manage patients with structural heart diseases having Ventricular Arrhythmias, EP testing is recommended in patients with EF less than 40%. Turitto G, Fontaine JM, Ursell S, et al. (1990). �Risk stratification and management of patients with organic heart disease and nonsustained ventricular tachycardia: role of programmed stimulation, left ventricular ejection fraction, and the signal-averaged electrocardiogram.� Am J Med;88(1N):35N-41N.

State-of-the-Art Care for Sudden Cardiac Arrest: Standardizing Care in the United States

Thu, 09 Feb 2012 20:51:20 EST

Lampert S, Lown B, Graboys TB, et al. �Determinants of survival in patients with malignant ventricular arrhythmia associated with coronary artery disease.� Am J Cardiol;61(10):791-7. The above article has predicted independent determinants of sudden cardiac deaths among patients with CHD and a history of malignant ventricular arrhythmias, (noninfarction VF or hemodynamically compromising VT), and they are: �rales (p = 0.009), a history of congestive heart failure (p = 0.0009), the number of runs of VT during exercise testing while receiving antiarrhythmic drug therapy (p = 0.0003), and the number of premature beats on Holter monitoring (p = 0.01).� In the following article, it is concluded that abolition of certain advanced grades of ventricular premature beats will protect against recurrences of life threatening arrythmia among those who had manifested and treated for malignant ventricular arrhythmia. Graboys TB, Lown B, Podrid PJ, et al. (1982). �Long-term survival of patients with malignant ventricular arrhythmia treated with antiarrhythmic drugs. Am J Cardiol;50(3):437-43. The predicted variable �rales� is compatible with Congestive Heart Failure. 50% of deaths with NYHA class III and IV heart failure is sudden in patients with chronic CV Diseases that predisposed to occurrence of malignant ventricular arrhythmias. Blood electrolyte abnormalities (particularly K) does promote occurrence of ventricular arrhythmias in patients with failing heart that has structural defects. In the following article, the pathophysiologic mechanism underlying SCD was identified. �When the left ventricular ejection fraction has declined to less than 30 percent and symptoms of heart failure become refractory to treatment with digitalis and diuretics, 35 to 50 percent of patients will die of a lethal cardiac arrhythmia within three years.� Packer M, Gottlieb SS, Blum MA.(1987). �Immediate and long-term pathophysiologic mechanisms underlying the genesis of sudden cardiac death in patients with congestive heart failure.� Am J Med;82(3A):4-10. The best approach to prevent SCD is to control HF before it reaches class II or IV, and correction of electrolyte abnormalities that will predispose to lethal VT rather than to introduce antiarrhythmic therapy in patients with HF. EMIAT, CAMIAT, & DIAMOND trials have proven that antiarrythmic agents cannot prolong life. However, they did prevent death significantly among patients with out-of-hospital ventricular fibrillation (VF) not associated with a Q-wave myocardial infarction. The CASCADE Investigators. (1993). �Randomized antiarrhythmic drug therapy in survivors of cardiac arrest (the CASCADE Study).� Am J Cardiol;72(3):280-7. CAST study counterclaimed CASCADE, by proving the hazards caused by antiarrhythmic agents among non-Qwave MI. Anderson JL, Platia EV, Hallstrom A, et al. (1994). �Interaction of baseline characteristics with the hazard of encainide, flecainide, and moricizine therapy in patients with myocardial infarction. A possible explanation for increased mortality in the Cardiac Arrhythmia Suppression Trial (CAST).� Circulation;90(6):2843-52. Pratt CM, Moye LA. (19900. The Cardiac Arrhythmia Suppression Trial: background, interim results and implications. Am J Cardiol;65(4):20B-29B.

PCI appropriateness criteria draw criticism

Thu, 09 Feb 2012 20:06:43 EST

Only a randomized trial will satisfy present day cardiologists that a high volume physician with many years of interventional experience is better than a cardiology fellow with an attending in the room or watching from outside but from my own experience having been both at different times, results improve with hands on personal experience. So, in our interventional cardiology trials, individual operator experience needs to be accounted for when dealing with technically difficult procedures in complex patients as in the VA or the very elderly in private practice. There is a reason that simulators are becoming more common these days. Placing a stent in a tortuous artery can be a different experience for patients depending upon the skill of the interventionalist and is not like taking a pill in a statin trial. So, please don't impose results of procedural trial like COURAGE on everyone ignoring the varied forms of interventional practice.

PCI appropriateness criteria draw criticism

Thu, 09 Feb 2012 18:52:44 EST

The document included with the AUC makes grand pronouncements of how the patient's preference should be accounted for. It also has several paragraphs regarding vlaue of an experienced physician making a clinical decision incorporating all the patient factors. It then completely ignores all this with a table that does not take any of these into account. Courage showed that patients had improvement in angina immediately, not having to wait years or cross over later with a 2nd procedure, at no increased risk of death, mi, or stroke. How can you then label the procedure inappropriate? (At 25 years the mortality will be close to 100% so everything we do including medical therapy is thereby inappropriate!). "modestly improved angina relief" - means it wasn't your angina that got better. Chan also pointed out that the purpose of the AUCs is to explain the existing evidence base, not pass judgment on each procedure, so nobody should interpret "inappropriate" in the AUCs to mean "fraudulent." By using the perjorative term 'inappropriate' you definitely imply 'fraudulent'. Everyone knows that when a procedure is labeled 'inappropriate' reimbursement will be denied and charges of fraud leveled if paid. Letters to patients denying coverage will use this term creating antagonistic relationships between patients and their doctor. This is the worst form of cookbook medicine.

PCI appropriateness criteria draw criticism

Thu, 09 Feb 2012 16:27:42 EST

Dr. Kang, I take exception to your characterization of VA physicians. You are regurgitating an old and false stereotype of cardiologists who practice in the VA system. We practice high quality medicine without a financial incentive. Yes - there is uneven quality throughout the VA just as there is in the private sector and there have been situations where VA patients have received poor quality care. This also happens outside the VA system. Please don't make sweeping generalizations. Sunil V. Rao (Duke Univ Medical Center and Durham VA Medical Center)

Aspirin as effective as warfarin in heart failure: WARCEF

Thu, 09 Feb 2012 15:37:09 EST

Since my CABG AND STROKE 1994, i have been on enteric bayer 325 mg daily. No recurrent MI, cva or tia so far. minor bleeding from taking ibuprofen for arthritis. My opinion

What is happening in this tracing?

Thu, 09 Feb 2012 15:19:02 EST

FOLLOWING IS A BRIEF DESCRIPTION OF THE ECG - THE ATTACHED ECG WAS TAKEN IN A 20 YR OLD MALE WHO HAD PRESENTED WITH COMPLAINTS OF PALPITATIONS FOR 2 DAYS. HE GAVE HISTORY OF A SIMILAR EPISODE LASTING FOR A FEW HOURS 1 YEAR BACK WHICH HAD BEEN SELFLIMITING.IN THE INTERVENING PERIOD PATIENT WAS ASYMPTOMATIC.NO PREVIOUS ECG WAS AVAILABLE FOR COMPARISON.ON EXAMINATION PATIENT WAS HAEMODYNAMICALLY STABLE. FINDINGS AND INTERPRETATION- NARROW COMPLEX REGULAR TACHYCARDIA WITH A RATE OF 150 BPM.EXTREME LEFT AXIS DEVIATION. INTERESTING FINDINGS- INTERMITTENTLY P WAVES MAKE THEIR APPEARANCES .P WAVE MORPHOLOGY IS ABNORMAL I.E. BIPHASIC P WAVES IN LEAD 3{ENCIRCLED IN RED INK}. CAREFUL OBSERVATION REVEALS HIDDEN P WAVES INSIDE T WAVES WITH P WAVE RATE IDENTICAL TO THE QRS COMPLEX RATE. P WAVES BEAR NO FIXED RELATIONSHIP TO THE QRS. THE S WAVES ARE DEEP IN LEADS 1,2 AND 3. V1 SHOWS A RBBB LIKE PATTERN. IN THE RHYTHM STRIP {LEAD 2}- INTERMITTENTLY PROMINENT P WAVES {UPRIGHT} FOLLOWED BY NARROW QRS COMPLEX AND INVERTED T WAVES MAKE THEIR APPEARANCES{ONE SUCH COMPLEX IS ENCIRCLED IN RED INK}THE 3RD AND THE 6TH BEATS FOLLOWING THIS COMPLEX ARE ALSO SIMILAR IN MORPHOLOGY. WHAT IS THE UNDERLYING RHYTHM? CAN IT BE ATRIAL FLUTTER? FRANKLY I AM CLUELESS.

For stroke risk, look for novel lipid/lipoprotein biomarkers

Thu, 09 Feb 2012 14:45:26 EST

Strokes in women (as well as men) are related to hypertension and cigarette smoking. The ratio between LDL and HDL predicts strokes due to carotid stenosis, but most ischemic strokes are related to hypertension/cigarette smoking. Diabetes can lead to lacunar strokes. Few if any strokes are not predictable by these risk factors, and those occur very late in life (in the ninth decade or later). One does not need any other "risk factor" to define the risk of most strokes, though the pro-thrombotic syndromes (ie, antiphospholipid syndrome) may play limited roles in younger women, and PremPro may play a role in older women.

MI-shock proposal is cold comfort: Hypothermia might boost survival

Thu, 09 Feb 2012 13:53:27 EST

No discussion in this opinion paper about the potential decrease in oxygen extraction in the setting of hypothermia

"Irrational" choices stall adoption of new antiplatelets

Thu, 09 Feb 2012 13:39:50 EST

I think there is psychology involved with prescribing medicines, a comfort of what has worked for your patients. Clopidogrel had extensive data with multiple trials that bred confidence in physicians and familiarity with the drug. So it will be difficult to consider alternatives. I would like to have better anti-platelet assays developed and put into wider use rather than focus on new drugs to better triage patients' response to drugs and look at outcomes with that data information. Being a consultant to various companies that manufacture these drugs does give a pause to all of us to consider the bias in his recommendations, which may also be subject to the same psychology that Dr. Cohen has seen in his discussion with cardiologists not privy to the bowels of the data world.

Wide variation in PCI for "unclear indications"

Thu, 09 Feb 2012 13:12:02 EST

Based on a literature research - - even adjusted mortality rates are misleading. The question is: did a patient die because of an institutional problem or because of his disease. In order to provide correct answers, each death has to be submitted to an audit, that clarifies matters (=golden standard). Then, RSMR may be used. If RSMR classifies institutions correctly, it is superimposable to the golden standard and is therefore sensitive and specific in the way adjustment is being done. If not, mislabelling of institutions will likeli occur. We should not rely too much on statistics, that may not be worth the money.

PCI appropriateness criteria draw criticism

Thu, 09 Feb 2012 12:37:03 EST

Dr. Kang, I don't think your analogy supports a very strong argument. VA patients are usually more difficult to treat than the average patient due to lower socio-economic factors and typically higher acuity on presentation. Lower success rates are expected from any group of doctors whether they are analogous to NBA pros or very good college players. You might be correct but the COURAGE trial data presently provides the best evidence for standards.

Dabigatran: New data on MI and ischemic events

Thu, 09 Feb 2012 11:43:42 EST

Most drugs get initial honey moon period and everyone jumps on the band wagon of zealots. Then the results in the real world come, then let down. I see apathy among the bloggers. Why Rx an expensive drug when 370+ deaths in 3 years are reported due to excessive bleeding, and increased MI risk? I wonder if the lure of "no testing necessary" made everybody blind. "but in studies comparing dabigatran and enoxaparin or placebo, there was no difference in MI." This phrase makes no sense. People who take placebo, implicitly suggest, they do not need to be on anticoagulation therapy. Then why give pradaxa? am I missing something?

Statins reduce cardiovascular events and all-cause mortality in women: Meta-analysis

Thu, 09 Feb 2012 11:38:56 EST

Fair comment, Don Kelsey. We've gone back and reviewed our heartwire story, and added some additional data. Thanks, Shelley Wood Managing editor, heartwire

Risky Business: Organizing Stroke Care for Optimal Outcomes

Thu, 09 Feb 2012 10:11:04 EST

Very interesting

Generalists need education on HF treatment

Thu, 09 Feb 2012 02:53:10 EST

It was remarkable that "only" 10% (155/1523) of cardiologist patients were DNR, compared to a staggering 24% (1162/4901) of generalist patients. These frequencies of DNR are a clear marker of how much sicker the generalist patients were, and one must suspect that the generalists had many more patients very ill with multiple problems, though not quite ill enough to warrant a DNR order. In this regard, I note that the generalist patients had double the prevalence of COPD, and close to triple the prevalence of dementia. Clearly not a fair means of comparing the competence of the physicians. The large differences in co-morbidities would certainly explain the otherwise curious observation that cardiology consultation produced such a modest increase in the prescribing of beta blockers. Most important, the greatest benefit in terms of survival was in the first 30 days post admission. The authors attribute this to the clever cardiologists prescribing more beta blockers. A very odd hypothesis, considering that the three major beta blocker trials (which, unlike this one were randomized) showed absolutely no mortality reduction during the first three months!

CTO, even in non-infarct-related artery, bodes ill in NSTEMI patients

Thu, 09 Feb 2012 00:07:33 EST

In addition to the mechanisms discussed above one should consider the possibility of the CTO artery being collaterised from other artery/arteries thus WASTING the collateral blood supply by diverting it to a dead tissue.I understand that the collateral blood supply will automatically decrease after the myocardium in the area is dead and demand for the blood supply naturally decreases. However it may not totally stop and in this situation this blood supply is wastefully misdirected. Hence it may be possible to shut this collateral supply and improve the perfusion to ischemic viable myocardium. I am anxious to read your comments.

"Tetherless" power-transmission technology could radically change LVAD therapy

Wed, 08 Feb 2012 23:41:39 EST

As a health care provider (PA-C) working in cardiology and the parent of a patient on a bi-VAD for 8 months, I well remember my son's response when asked how he was doing..'I'm doing ok, if I could just get these tubes out of me'. He is surely smiling from somewhere at the mere mention of the word 'wireless'! Keep up the good work in research; someday there will be an app to record data from the patient's own LVAD!

PCI appropriateness criteria draw criticism

Wed, 08 Feb 2012 23:35:36 EST

Just like all trained athletes, all trained cardiologists cannot be expected to have the same skill level. Imagine a trial for shooting three pointers done using NCAA players and then the results imposed on all the NBA players. THat is what we are doing with COURAGE trial. The COURAGE trial with fellows/trainees doing a lot of procedures in VA hospitals and achieving an angiographic success of only 93% (about 99.5% in NCDR data base for many experienced interventionalists) and clinical success of only 89% is hardly the kind of standard that should be uniformly imposed on all interventional cardiologists.

What is happening in this tracing?

Wed, 08 Feb 2012 23:01:37 EST

Let's do it one case at a time. Indicate what the issue is if there is one, or you can just say "what's your interpretation?"

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Wed, 08 Feb 2012 22:45:13 EST

In the short-axis of the AV on TTE, one could see the flap near the non-coronary cusp (if I can, I will post this image, otherwise, I can send it to you). The flap in the descending aorta is anterior: as a rule, the larger of the two lumens is usually the false lumen.

What is happening in this tracing?

Wed, 08 Feb 2012 22:27:21 EST

I want to see them. Who knows, you may have gems!!!

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Wed, 08 Feb 2012 21:36:36 EST

the flap appears to be anterior in the ascending and descending portions. Is that right?

What is happening in this tracing?

Wed, 08 Feb 2012 21:32:57 EST

dear dr wang , ecg interpretation is a rare skill which demands both analytical ability as well as patience.as a student of internal medicine , i sometimes feel frustrated when in response to my query regarding an ecg i hear an answer like-" not everything in the world can be explained" .i have a small collection of ecgs which i could never explain. can i send them to you for clarification.

Fitness and fatness independently linked with CVD risk factors

Wed, 08 Feb 2012 17:07:27 EST

1. The obese toddler is just evidence of the consequences of the cheap �modern� foods. 2. Blaming genetic or lack of exercise misses true etiology of the recent obesity crisis. 3. The modern world is seeing the "economic miracle" of HFCS-High Fructose Corn Syrup and hydrogenated oils/fat which are the true problem. 4. Avoid the cheap concentrated sugars and omega-6 fats of most foods helps. Most foods that can be stored for days, do more harm than good. 5. Moderate saturated fats do not clog arteries, but even small amount of artificial hydrogenated oil leads to atherosclerosis. 6. Placing profit over people has led to these new artificial foods.

Lower mortality in NFL players�if weight is kept in check

Wed, 08 Feb 2012 16:12:16 EST

WHAT!? World class athletes with access to the finest fitness, nutrition, and medical experts have lower mortality than the general public? Is it April fools day already? We better start to list "non-NFL player" as a risk factor...

State-of-the-Art Care for Sudden Cardiac Arrest: Standardizing Care in the United States

Wed, 08 Feb 2012 13:11:26 EST

In Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT), beta receptor stimulation will lead to VT. Blockade of Na+/Ca2+ exchanger will suppress the triggered arrhythmia. Dual blockade of L-type Ca2+ channel and Ca2+-ATPase will have synergistic effect in controlling this VT. "Verapamil given intravenously reduced the number of isolated and successive premature ventricular complexes by 76%, and these complexes appeared later and at higher heart rate than in the absence of verapamil." Chan YH, Wu LS, Yeh YH, et al. (2011)."Possible targets of therapy for catecholaminergic polymorphic ventricular tachycardia. - Insight from a theoretical model -." Circ J;75(8):1833-42.

"Irrational" choices stall adoption of new antiplatelets

Wed, 08 Feb 2012 12:25:08 EST

Every physician should have a look of the significant absolute risk reduction obtained with prasugrel compared with clopidogrel in patients with STEMI, in diabetic patients, and the post-hoc analysis in pts whith age 60 kg to optimize the use of new antiplatelet agents in ACS. Direct comparisons between prasugrel and ticagrelor are needed, but who will promote this trial?

Statins reduce cardiovascular events and all-cause mortality in women: Meta-analysis

Wed, 08 Feb 2012 11:45:16 EST

I'm surprised by the mediocre quality of this article. Why is there essentially no specifics about the data (e.g. p values, 95% confidence intervals, etc). This is uncharacteristic of most heart wire reports.

Fitness and fatness independently linked with CVD risk factors

Wed, 08 Feb 2012 10:17:30 EST

As I see it, the so-called "fit-fat" paradox exists thanks the widespread belief that saturated fats clog arteries. Biochemically speaking, lean tissue is a function of hormone regulation and, to lesser extent, exercise. Fat accumulation is also a function of hormone regulation. Both are modulated by genetic make up and food quality regardless of exercise level. For example, remember those 2004 headlines about that Buff German Tot with the myostatin deficiency? In contrast, there's Varvara Akulova, known as the world's strongest girl, who has normal-looking muscles. The point is, scientists need to focus more on individual responses to caloric consumption, nutrient sufficiency, and macro nutrient configuration appropriateness. In this regard, certain shorter chain lengths of saturated fatty acid promote leanness, especially in individuals sensitive to carbohydrates. Since every one without exception is admonished to restrict saturated fat intake to prevent clogged arteries, this option is off the table for a huge segment of the obese population. To add insult to injury, everyone is also admonished to replace saturated fats with omega-6 industrial seed oils because of the observed cholesterol lowering effects. This sort of move tends to compromise thyroid function and promote inflammation. Google - "omega-6 hazard" and "Omega-6 Me" and "Ray Peat Omega-6" for further discussion on this matter. Also Google - "Reversing the anti-saturated fat campaign" to learn why saturated fats should not be regarded as unhealthy.

"Cardiovascular health," new focus of the AHA, linked with reduced mortality

Wed, 08 Feb 2012 07:37:31 EST

In recent Symposium of more than 4100 Cardiologis coming from the world, last November in Orlando, USA, no one knew qhat does it mean CAD Inherited Reale Risk, bedside recognised and cured (1-6). On the contrary, every type of CAD THERAPY bas been discussed! CAD continues to be a growing epidemics. 1) Stagnaro Sergio. New bedside way in Reducing mortality in diabetic men and women. Ann. Int. Med.2007. 200708070-00167v1 2) Stagnaro-Neri M., Stagnaro S., Deterministic Chaos, Preconditioning and Myocardial Oxygenation evaluated clinically with the aid of Biophysical Semeiotics in the Diagnosis of ischaemic Heart Disease even silent. Acta Med. Medit. 13, 109, 1997. 3) Stagnaro Sergio. Biophysical-Semeiotic Bed-Side Detecting CAD, even silent, and Coronary Calcification. 4to Congreso International de Cardiologia por Internet, 2005, 4) Stagnaro Sergio. Role of Coronary Endoarterial Blocking Devices in Myocardial Preconditioning - c007i. Lecture, V Virtual International Congress of Cardiology. 5) Stagnaro Sergio. Il Reale Rischio Congenito di Cardiopatia Ischemica Arteriosclerotica. Ruolo terapeutico della LLLT e della Melatonina. www.fce.it, Ottobre, 2009. 6)Stagnaro Sergio. CAD Inherited Real Risk, Based on Newborn- Pathological, Type I, Subtype B, Aspecific, Coronary Endoarteriolar Blocking Devices. Diagnostic Role of Myocardial Oxygenation and Biophysical-Semeiotic Preconditioning. www.athero.org, 29 April, 2009

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Wed, 08 Feb 2012 06:18:30 EST

You're absolutely right. Glad you liked it.

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Wed, 08 Feb 2012 05:09:09 EST

There are other clues in the image. The forward jet across the valve is eccentric and there is a suggestion of flap at aortic root with rather abrupt dilatation of aorta .

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Tue, 07 Feb 2012 21:59:40 EST

There were no previous studies.

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Tue, 07 Feb 2012 21:36:55 EST

Has this patient had an echo before and if so what were the findings?

Heart to Heart: Potential Impact of Optimal Implementation of Evidence-Based Heart Failure Therapi

Tue, 07 Feb 2012 19:49:41 EST

Sarcoplasmic reticulum/SR of cardiac muscle contains a series of enzymes linked to glycogenolysis: adenylate cyclase, cyclic AMP-dependent protein kinase, phosphorylase b kinase, and phosphorylase, which were responsible for a significant endogenous phosphorylation responsible for cellular mRNA synthesis, the building block of cardiac muscle proteins/enzymes necessary for cellular respiration as well as cell repair process. These phosphorylating enzymes also stimulated calcium uptake in the SR thus play a major role in regulating intracytoplasmic calcium concentration through beta-adrenergic receptor stimulation. Phosphorylation of phospholamban is also associated with Ca2+ fluxes induced by inotropic agents that activate adenylate cyclase in the myocardium. All muscle cells require a variable degree of energy demands than noncontractile cells. The energy demand of cardiac muscle is 15�20 times greater in maximal workload conditions, i.e. in SYSTOLE, than in DIASTOLE. Cardiac muscle gets its energy through oxidative phosphorylation, glycolysis, and glycogenolysis. Glycogenolysis and subsequent Glycolysis produces ATP, the synthesis of which require more glucose than normal cells in hypoxic state. ATP-dependent Ca uptake by cardiac microsomes rich in SR is mediated by cardiac cyclic AMP-dependent protein kinase. Phospholamban regulates Ca2+-dependent ATPase of SR, through calmodulin-dependent or cAMP-dependent phosphorylation catalyzed by protein kinases. As we have already discussed, protein kinases will not form, and phosphorylation will not occur without glycogenolysis. The same glycogenolysis process form NADH that is necessary for oxidation-reduction reaction of cellular respiration. Being responsible for electron transfer, the NAD+/NADH coenzyme controls many intracellular enzymatic reactions, and links the Krebs Cycle with oxidative phosphorylation. Eggleston LV, Krebs HA. (1974). �Regulation of the pentose phosphate cycle.� Biochem J;138:425-435 Williamson JR, Ford C, Illingworth J, et al. (1976). "Coordination of citric acid cycle activity with electron transport flux." Circ. Res. 38: I39�I51. Entam ML, Kanike K, Goldstein MA, et al. (1976). "Association of gylcogenolysis with cardiac sarcoplasmic reticulum." J Biol Chem;251(10):3140-6. Christian DR, Kilsheimer GS, Pettett G, et al. (1969). �Regulation of lipolysis in cardiac muscle: A system similar to the hormone-sensitive lipase of adipose tissue.� Adv Enzyme Regul: 7 (C)71-82. Birkenfeld AL, Boschmann M, Moro C, et al. (2006). �Beta-adrenergic and atrial natriuretic peptide interactions on human cardiovascular and metabolic regulation.� J Clin Endocrinol Metab;91(12):5069-75. Juhlin-Dannfelt AC, Terblanche SE, Fell RD, et al. (1982). �Effects of beta-adrenergic receptor blockade on glycogenolysis during exercise.� J Appl Physiol;53(3):549-54. Zimmer HG, Ibel H, Suchner U. (1990). �Beta-adrenergic agonists stimulate the oxidative pentose phosphate pathway in the rat heart.� Circ Res;67(6):1525-34. Zimmer HG. (1996). �Regulation of and intervention into the oxidative pentose phosphate pathway and adenine nucleotide metabolism in the heart.� Mol Cell Biochem;160-161:101-9. Zimmer HG. (1992). �The oxidative pentose phosphate pathway in the heart: regulation, physiological significance, and clinical implications.� Basic Res Cardiol;87(4):303-16. Zimmer HG, Trendelenburg C, Kammermeier H, et al. (1973). �De novo synthesis of myocardial adenine nucleotides in the rat: Acceleration during recovery from oxygen deficiency.� Circ Res;32:635-642 Zimmer H-G, Gerlach E. (1974). �Effect of beta-adrenergic stimulation on myocardial adenine nucleotide metabolism.� Circ Res;35:536-543 Goldstein RA, Passamani ER, Roberts R. (1980). �A comparison of digoxin and dobutamine in patients with acute infarction and cardiac failure.� N Engl J Med;303:846-850.

Aspirin in primary prevention: New meta-analysis finds bleeding outweighs benefits for most

Tue, 07 Feb 2012 16:37:27 EST

i prefer asa 325 mg enteric coated my maintenance anti coagulant anti platelets since my cabd and stroke 1996. never had anymore but had occasional gi bleed reversable and treatable. i would rather have gi bleed than irreversable MI and strokes. My opinion

"Irrational" choices stall adoption of new antiplatelets

Tue, 07 Feb 2012 15:07:58 EST

For those who have left comments above but were not at the actual presentation, I think an explanation is in order. Unfortunately, the term "irrational" in the article's headline was taken out of context. In the actual presentation, the term "irrational" was used to refer to an observation that clinicians (including myself) often view bleeding complications and ischemic complications after PCI very differently. On an emotional level, we often see bleeding complications as our "fault" (caused by the medications that we give) whereas ischemic complications (that might have been prevented) are considered to be a reflection of the patient's underlying condition and therefore have a different connotation. Some have termed these "errors of commission" (i.e., bleeding) vs. "errors of omission" (i.e, ischemic events). I certainly never intended to imply that there are not valid reasons for choosing one antiplatelet drug over another (including difference in efficacy, side effects, cost convenience, etc.). Although I cannot speak for everyone, I have spoken with many other cardiologists who acknowledge this emotional aspect to our treatment decisions. I don't think I'm the first, nor will I be the last to point out this aspect of our behavior-- for better or for worse, we are all human.

Lower mortality in NFL players�if weight is kept in check

Tue, 07 Feb 2012 14:36:19 EST

There are very few NFL players who weigh over 300 pounds but are proportional based on their immense size. Look at most linemen, and they have large guts and could stand to lose 20-30 pounds. The NFL is a socialist organization and control freaks about many things. Why not impose a 300 pound weight limit for starting players if it is in the best interest to the players health. Heaven knows there is really not much they can or will ever do to mitigate the risks of concussion related brain injuries. So they might as well aid players when it comes to reducing cardiovascular risk.

"Irrational" choices stall adoption of new antiplatelets

Tue, 07 Feb 2012 14:24:19 EST

"Physicians aren't always rational beings and don't always make the right decisions" proclamates Dr. Cohen from his academic soap box. I am not sure which is worse, being "irrational" or being biased

Not Your Mother's Cath Lab

Tue, 07 Feb 2012 12:19:37 EST

Incredibly sexist. We can--and this professional organization should--do better.

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Tue, 07 Feb 2012 11:24:43 EST

You're quite welcome.

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Tue, 07 Feb 2012 10:55:08 EST

Always consider aortic dissection

"Irrational" choices stall adoption of new antiplatelets

Tue, 07 Feb 2012 10:44:53 EST

Here is my rationale: Cohen has received grants for clinical research from Abbott Laboratories, AstraZeneca, Boston Scientific, Edwards Lifesciences, Eisai, Eli Lilly, and Medtronic and has served as an advisor or consultant for Abbott Laboratories, Boehringer Ingelheim, Cordis, Eli Lilly, Medtronic, and Volcano. He has served as a speaker or a member of a speaker's bureau for Eli Lilly. So if being skeptical about Dr. Coehn's "recommendations" makes me irrational, so be it.

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Tue, 07 Feb 2012 10:43:15 EST

The mitral regurgitation was only mild, a not uncommon finding. Given that the LV was a little dilated, the coaptation of the leaflets could be apically displaced, causing mild functional MR. Clinically, it was insignificant.

Not Your Mother's Cath Lab

Tue, 07 Feb 2012 10:36:53 EST

I might need additional fellowship training to work in that cath lab.

Not Your Mother's Cath Lab

Tue, 07 Feb 2012 10:35:40 EST

I am quite pleased to see that we can now perform both gynecological examinations & cardiac catheterizations in one sitting!

Life and times of leading cardiologists with Rob Califf. Guest: Martin Leon

Tue, 07 Feb 2012 10:29:50 EST

Another home run! The pragmatic tone underlying the genius is striking. Thank you Dr. Califf for another wonderfully conducted interview of a rockstar in cardiology!

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Tue, 07 Feb 2012 10:21:43 EST

that's true. The point is that the flap in the descending aorta is not a coincidence unrealted to the aortic insfficiency, they are "true, true, and related" as it were. Sorry my Spanish isn't better.

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Tue, 07 Feb 2012 10:19:43 EST

and the cause of the mitral regurgitation? just dilatation of the ventricle from long standing hypertension? what are the LV dimensions and wall thickness?

TAVI in the USA

Tue, 07 Feb 2012 10:15:47 EST

no comment

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Tue, 07 Feb 2012 10:09:20 EST

Lindo caso, cometi el error de ver solo la valvula y no la porcion descendente de la aorta donde se ve un claro flap.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 07 Feb 2012 08:02:47 EST

During my 38 years as a cardiologist( invasive and Noninvasive) I have seen the medical profesion deteriorate to a level of savage capitalism. It makes me sick to see patients as second opinions with scanty histories poor Physicals undergo a battery of tests which in retrospect were not neccesary and turned out to be normal Money is very seductive!!!!!

What is happening in this tracing?

Tue, 07 Feb 2012 05:39:20 EST

Slow AF and AV blocs are seeing in former highly trained people.

Aspirin in primary prevention: New meta-analysis finds bleeding outweighs benefits for most

Tue, 07 Feb 2012 02:54:39 EST

Dear Jae-Hun Kim Reading your posts here, shows that you are inclined to judge much too quickly. Don't be so hard on yourself . Sit back , relax and take a look at your statement. " No decent health care pro. should have such a biased opinion" ALL opinions are biased ( including yours ). I suggest that you are confusing opinions with " facts" . Which brings me to yesterdays article in Medscape titled " ASPIRIN as effective as WARFARIN in heart failure : WARCEF (ISC)2012 INTERNATIONAL STROKE CONFERENCE ( please read this study's outcome, before you promulgate another of your opinions ) Table 3. WARCEF: Secondary Endpoint Endpoint Aspirin n (% per year) Warfarin n (% per year) Hazard Ratio (95% Confidence Interval) P Death, ischemic stroke, or intracerebral hemorrhage, myocardial infarction, heart failure hospitalization 435 (12.15) 447 (12.70) 1.07 (0.93 - 1.23) .33 Major hemorrhage was significantly higher with warfarin, although there were no significant differences in intracerebral or intracranial hemorrhage. "Much of the difference in the major hemorrhage came from the difference in gastrointestinal hemorrhage" with warfarin, Dr. Homma noted. After 4 years , Aspirin caused LESS gastrointestinal hemorrhages than did Warfarin! Like me , Dr.Homma in this study, was able to distinguish between GI irritation and real bleeds without any hardship. One more quote from this recent FACTUAL study: "given there is no difference ( between Aspirin and Warfarin )we(decent healthcare professionals )would offer ASPIRIN, because it's SAFER to use,and our patients tolerate it pretty well,there are no food interactions and it's inexpensive" ..... My humble biased opinion still stands; and is now supported by facts from this months ISC . We really need to get the effervescent Aspirin PlusC (400mg)made available in the US and Canada as it has even fewer GI problems than the old enteric coated Aspirins. PS: we should try to stick with the heading ( Aspirin in primary prevention )in this blog. And remember ; all opinions ARE the results of our own personal biased thoughts ; that is why we call them opinions, not proven facts .

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Mon, 06 Feb 2012 23:31:17 EST

There is nothing anyone could ever say or do to cause me to abandon echocardiography in advising anesthesiology with regard to correction of falling BP's and other issues that arise peri=induction or intra op. Knowing an EF is 20 is invaluable prior to guessing at whether to reaach for neo or a fluid challenge for HOTN episodes. Degree of valvular regurgitation guides IVF rates and duration of IV fluid utilization, etc. Moderate territories of reversible ischemia would garner increases in beta blocker therpy pre op. No matter what the talking heads think about this issue, I insist that common sense should be, well.......more common. Melissa

Implementing Quality Enhancement in the Treatment of PAH: Facilitating a Guideline-Based Approach

Mon, 06 Feb 2012 21:36:38 EST

In neonate, PAH is treated with inhaled NO. In Pregnancy PAH is associated with changes in pulmonary vascular tone due to intravascular volume shifts, and hypoxemia. It is is likely to worsen during labor and delivery, and may be lethal. Phosphodiesterase Inhibitors, Prostacyclin, scheduled cesarean delivery with spinal-epidural anesthesia will save lives. Chotigeat U, Khorana M, Kanjanapatakul W. (2002). "Outcome of neonates with persistent pulmonary hypertension of the newborn treated with inhaled nitric oxide." J Med Assoc Thai;85(7):800-7. Kinsella JP, Truog WE, Walsh WF, et al. (1997). "Randomized, multicenter trial of inhaled nitric oxide and high-frequency oscillatory ventilation in severe, persistent pulmonary hypertension of the newborn. J Pediatr;131(1 Pt 1):55-62. Mercier JC, Lacaze T, Storme L, et al. (1998). "Disease-related response to inhaled nitric oxide in newborns with severe hypoxaemic respiratory failure. French Paediatric Study Group of Inhaled NO. Eur J Pediatr;157(9):747-52. Madden BP. (2009)."Pulmonary hypertension and pregnancy." Int J Obstet Anesth;18(2):156-64. Roberts NV, Keast PJ. (1990). "Pulmonary hypertension and pregnancy--a lethal combination." Anaesth Intensive Care;18(3):366-74. Paternoster DM, Pascoli I, Parotto M, et al. (2010) "Pulmonary hypertension during pregnancy: management of two cases." Arch Gynecol Obstet;281(3):431-4. Bonnin M, Mercier FJ, Sitbon O, et al. (2005). "Severe pulmonary hypertension during pregnancy: mode of delivery and anesthetic management of 15 consecutive cases." Anesthesiology;102(6):1133-7; discussion 5A-6A. Bendayan D, Hod M, Oron G, et al. 2005)."Pregnancy outcome in patients with pulmonary arterial hypertension receiving prostacyclin therapy." Obstet Gynecol;106(5 Pt 2):1206-10. Geohas C, McLaughlin VV. (2003). "Successful management of pregnancy in a patient with eisenmenger syndrome with epoprostenol." Chest;124(3):1170-3. Goland S, Tsai F, Habib M, et al (2010)."Favorable outcome of pregnancy with an elective use of epoprostenol and sildenafil in women with severe pulmonary hypertension." Cardiology;115(3):205-8. Huang S, DeSantis ER. (2007). "Treatment of pulmonary arterial hypertension in pregnancy." Am J Health Syst Pharm;64(18):1922-6. Simonneau G, Rubin LJ, Gali� N, et al; PACES Study Group. (2008). "Addition of sildenafil to long-term intravenous epoprostenol therapy in patients with pulmonary arterial hypertension: a randomized trial." Ann Intern Med;149(8):521-30. Erratum in: Ann Intern Med. 2009 Jan6;150(1):63. Ann Intern Med. 2009 Sep 15;151(6):435. COPD is associated with PAH, and Acetylcholine that releases an endothelium-derived contracting factor (EDCF), produced by endothelial cyclooxygenase-1, which stimulates thromboxane A2 receptors on vascular smooth muscle, is the main contributor. Vasoactive intestinal peptide(VIP) is widely expressed in such cases. Paulin R, Meloche J, Jacob MH, et al. (2011). "Dehydroepiandrosterone inhibits the Src/STAT3 constitutive activation in pulmonary arterial hypertension. Am J Physiol Heart Circ Physiol;301(5):H1798-809. Dumas de la Roque E, Savineau JP, Bonnet S. (2010). "Dehydroepiandrosterone: A new treatment for vascular remodeling diseases including pulmonary arterial hypertension." Pharmacol Ther;126(2):186-99. Wu D, Lee D, Sung YK. (2011). "Prospect of vasoactive intestinal peptide therapy for COPD/PAH and asthma: a review." Respir Res;12:45. Groneberg DA, Rabe KF, Fischer A. (2006). "Novel concepts of neuropeptide-based drug therapy: vasoactive intestinal polypeptide and its receptors. Eur J Pharmacol;533(1-3):182-94.

What is happening in this tracing?

Mon, 06 Feb 2012 21:29:29 EST

Regarding the fixed coupling, the conducted impulse which has to go thru the AV node, will resset the junctional pacemaker, making the long RR interval(junctional escape interval) similar, and the conducted P wave occurs almost always near the juctional escape beat and, since the PR interval is more or less fixed, the conducted QRS will occur similar distance away from the junctional escape beat. Thus, it is an obligatory response. Print out the tracing and magnify it. You will note that the third conducted QRS occurs with a little bit longer RR interval compared to the preceding(second) short RR interval which can be explained by the fact that the P wave occured after the QRS then while the second P wave occured in front of the QRS. In fact that is another support that the the QRSs ending the short RR interval is conducted fron the P wave with a long PR interval. Your question about how the atrial impulse can go thru the AV junction when the retrograde impulse from the juction is "blocked" from conducting to the atria, one has to incriminate dual AV nodal pathway-slow and fast. Good qustions. I have another example who initially had a straight-foward 2:1 AV block. later, when sinus rale slowed resulting in the two PP interval becoming longer than the junctional escale interval, junctional beats escape just as in this case (it will always happen inevitably). It was a little easier to "swallow" because the PR interval was not this long and the undisputable 2:1 AV block was happening a moment earlier. I may post it someday.

What is happening in this tracing?

Mon, 06 Feb 2012 17:39:26 EST

The Short R-R interval is nearly constant, while the P-R relationship varies. To me this speaks to fixed coupling as the diagnosis. My main concern with the explanation provided revolves around the p wave preceeding the 3rd QRS. In the ladder diagram, a Jxn escape fires, blocks prior to entering the RA, yet the Sinus P wave manages to find the AV node receptive to antegrade conduction. This is what I find the hardest to believe. Furthermore, If infranodal conduction is normal(as it should be with a narrow QRS) an escape focus below the level of block could have theoretically fired contemporaneous to, rather than prior, to the Sinus beat. The Estimated J-V time implied by the ladder diagram approaches 200ms, which I think is unrealistic. If the relationship between the sinus beat and the jpc is tighter, the likelyhood of conduction would be even less. An alternative explanation remains Junctional rhythm with fixed JPCs. Only one R-R relationship is minimally different than the others. If that is the reason to rule out the possibility of fixed coupling, I would say that the likelihood of 2:1 block with a PR of 840ms is equally as troubled. Regardless, an excellent teaching EKG. Kudos.

"Irrational" choices stall adoption of new antiplatelets

Mon, 06 Feb 2012 16:20:15 EST

It's not seems to me so irrational choice not to prefer a much more expensive drug (ticagrelor) which showed worse outcomes vs clopidogrel in North America (PLATO-study)

What is happening in this tracing?

Mon, 06 Feb 2012 14:27:24 EST

A very interesting ECG and very nice answer.

Aspirin as effective as warfarin in heart failure: WARCEF

Mon, 06 Feb 2012 14:21:18 EST

I would recomend to these patients warfarin and aspirin and to managing INR between 2-3 , because it will reduce death ,stroke and intracerbral hemorrhage,MI and HF hospitalization.

What is happening in this tracing?

Mon, 06 Feb 2012 14:15:16 EST

Good challenging ECG.. Not often seen. Would have liked to see clinical picture along with tracing.

No recurrent stroke prevention seen with clopidogrel plus aspirin

Mon, 06 Feb 2012 11:46:28 EST

Perhaps a better option would have been a low-dose 81mg rapidly disintegrating aspirin tablet combined with clopidrogrel.

Salt, hypertension, and prevention

Mon, 06 Feb 2012 10:52:42 EST

I think people deserve batter attitude from us. We should not confuse general population by discussing the well established notions. The above have confused me, even though I know better. Let people eat less salt, less fat, more fruits and more veggies and let them enjoy life.

What is happening in this tracing?

Mon, 06 Feb 2012 08:26:17 EST

Dr. Wang: nice ecg and even nicer comment #16!

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Mon, 06 Feb 2012 08:13:58 EST

J'esp�re que vous avez appr�ci� cette image

"Tetherless" power-transmission technology could radically change LVAD therapy

Mon, 06 Feb 2012 08:06:13 EST

There was no increase in cancer with nuclear pacemakers. The problems were not safety but regulatory. The NRC was the major hurdles and restrictions, treating a pacemaker as a mini thermonuclear bomb about to go off any minute. Against this background, improvement in Lithium batteries, and the fact that the energy source outlived its components and particularly but not only the electrodes, it was eventually abandoned.

Treat risk and not LDL-cholesterol targets, new perspective argues

Mon, 06 Feb 2012 05:08:39 EST

Taking a statin is like having an insurance. You believe that you will be protected from a risk, and you pay a premium for this. The gain is often portrayed in population terms: the national cost for heart diseases will be less if everyone took a statin. Ponder on this statement - it is not relevant for the individual patient. He pays some money for the medicament, but also - which is never discussed - submits himself to another risk: side-effects. Considering what the statistics say, that an ever increasing cause for hospitalisation is due to side-effects of drugs, be it overdose, misuse or interaction problems, I draw the conclusion that great restriction in the use of sttins should be exercised. I do not think anyone over 75 years of age (except those with familial hypercholesterolemia, if the have come that far) should have a statin, because in relation to other risk factors, the cholesterol one is negligible. And I also venture to say that very few people over 80 should have a blood pressure lowering drug.

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Mon, 06 Feb 2012 04:09:03 EST

the dissection is visible in the descending aorta++

The flap over flavonoids

Mon, 06 Feb 2012 03:34:54 EST

Ever since the fraudulent manipulation of data about fats and cholesterol was suppressed, we have been way off target. Advanced glycosylation of proteins is killing us. Fructose is more than 10 times as reactive as glucose. The liver can process only 15g per diem Fructose, and some drink portions contain 60g. The dogma versus science of the major food groups is where the real fraud is found.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Sun, 05 Feb 2012 19:57:57 EST

i have read the article re the UPMC Hamot physicians and unnecessary cardiac procedures as well as the blog that follows. i appreciate the comments of my colleagues and their insight into some of the problems that might exist in cardiology. there is no question that in the eyes of others, all of us in cardiology have ordered inappropriate tests or procedures at one time or another. and yes, perhaps some physicians do this for financial reasons, but more often it is because of clinical judgement... something that might not necessarily be reflected in a medicare guideline or in a third party reviewer. oftentimes, patient symptoms are vague, and given the legal environment we all practice in, patients do get cathed, have a SPECT study when a plane treadmill will do, or perhaps a repeat echocardiogram that may not absolutely be necessary. i try in my own practice to rise above the pressures of money and administrators and do what is right for the patient but it is not always easy. most in colleagues in cardiology do as well, and im proud to say our subspeciality is especially well versed in the practice of evidence based medicine. i agree completely that standards of care are in place for a reason, and stenting a 20% distal RCA is not appropriate under any situation. monitoring this activity is best handled in our own house with intense and sincere QA and institutional review, especially when third party whistle blowers may have alternate motives that are not disclosed in these sensational headlines. i have the pleasure of knowing the hamot physicians personally and worked as one of their outreach cardiologists in rural PA for a number of years. i have trusted the care of my patients to these physicians and would also entrust my own life with them. i have nothing but the highest respect for the mentioned physicians in terms of their clinical skills, judgement, and most importantly their integrity. and although there may be a difference of opinion in the need for a certain procedure or referral, i am positive that rick petrella, charles furr, bob farraro, tim tragesser, and doug zone do not do so to make a car payment.... they do so because in their expert opinion, it is in the patients best interest. as physicians, we definitely need to continue to work with are colleagues, insurance carriers, and our patients in order to improve in health care delivery and cost conscious care. sensationalization of this problem in the media makes it even more difficult for us to work with our patients and third parties in gaining their trust, does nothing but set the entire profession back. let us all work together to continue to develop guideline driven delivery of evidence based medicine to our patients. work with your colleagues and review honestly your own practices. these efforts will go further than these whistleblower type law suits which oftentimes are not what they appear to be in the headline.

Informed consent questioned in Florida patient's death after stem-cell treatment

Sun, 05 Feb 2012 17:35:25 EST

I am not a judge and the patient is not a medicine doctor, and as physician I believe that in clinical practice we must require the signature of the patients on the informed-consent form only for approved diagnostic, therapeutic, etc. procedures, but in this case as reported above: The FDOH alleges "the treatment provided by Dr Grekos to [the patient] was neither authorized nor recognized by the Federal Drug Administration, [and] Dr Grekos's medical records did not contain medical justification for the injection of autologous bone-marrow aspirate into [the patient's] cerebral circulation as a treatment for [her] neuropathy. Dr Grekos's treatment of [the patient's] neuropathy by the injection of autologous bone-marrow aspirate into the cerebellar circulation had no substantiated medical and/or scientific value."

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Sun, 05 Feb 2012 16:47:47 EST

This is not a fraud case, it is a false claims act case. Those who submit claims to the government are held to the standard of knew,OR SHOULD HAVE KNOWN, that the procedure was unnecessary. A fraud case is tougher to prove since intent has to be shown. P.S. I'm not a lawyer, though I worked for the OIG a long time ago.

Intention To Treat Resistant Hypertension: Looking for a Simple Solution

Sun, 05 Feb 2012 14:51:24 EST

What is the common cause of head injury in the elderly population? Fall. Elderly population live alone after one partner has left the other one. So, Fall occurs insidiously in these patients. I am sure the trial will end up succeeding in proving its intended outcome among population taking Diuretics. I have already explained the MOA. In Psychiatry, almost all anti-psychotic agents cause postural hypotension in addition to QT prolongation.

Heart to Heart: Potential Impact of Optimal Implementation of Evidence-Based Heart Failure Therapi

Sun, 05 Feb 2012 14:43:36 EST

Duration of action for Digoxin tablet is 2 to 6 days, and not 14 to 21 days. I apologize for my error. 14 to 21 days duration is seen with Digitoxin tablets or digitalis leaf preparation.

Heart attack deaths plummet in three EU nations

Sun, 05 Feb 2012 13:10:03 EST

At least 7 people, above, have suggested that the precipitously dropping rates of CHD deaths would be from less smoking. Let me remind one of a bit of Framingham data as reported by Harvard's C.C. Seltzer in Medline 1844127: " ... with Framingham women cigarette smokers experiencing 30-40% lower [sic] rates of uncomplicated angina pectoris than non-smokers, the rates also declining with increasing amounts of cigarettes smoked. Our analysis confirms the absence of a predictive risk factor association in the case of men previously indicated by Framingham investigators. ... ... The Framingham data on the relationship of smoking to angina incidence is clearly at variance with the Surgeon General's sketchy finding of an inconsistent positive association for men and an uncertain relationship for women. It is suggested that special attention should be directed to these results of the Framingham data because of the preeminence of Framingham material world wide, because angina pectoris is the most common manifestation of coronary heart disease, because it will improve the "conventional wisdom" on this subject, and because the negative relationship found for Framingham women does not lend support to the belief held by some that smoking enhances the degree of coronary atherosclerosis. The same Dr. Seltzer reported, in Medline 1743450, the 30 year mortality rates in Framingham as 18/1000 for TC 220 +/-15 as well as for 250 +/-15 mg/dL. That leaves the discontinuation of trans fats, the reintroduction of plant and fish n-3 fatty acids, the population increases in Hcy lowering B vitamins, all factors evident to those familiar with the extensive research on the rise and fall of the CHD epidemic. Obviously smoking is toxic and terrible, but there's no evidence that I have seen proving it's part of the rise and fall of the CHD epidemic.

Cardiac telemetry identifies AF in cryptogenic stroke

Sun, 05 Feb 2012 12:22:50 EST

Afib causes stroke; no question there. The big problem with af is detection and this technology is a big help in that regard. We are using this approach frequently in pts with so-called cryptogenic stroke. Certainly makes more sense than looking for a PFO. If you see afib on a 21 or 30 day event monitor in a patient with cryptogenic stroke would you not consider that the likely cause and treat accordingly?

Aspirin as effective as warfarin in heart failure: WARCEF

Sun, 05 Feb 2012 07:45:34 EST

I was advised to stop Acitrom after six months. Manging INR and dosage is very very difficult. This study will help to reduce/optimize the dosage besides reducing ER hospitalisation due to warfarin. Self management of dosage is ruled out.

Why has the heart rate suddenly slowed down?

Sun, 05 Feb 2012 05:48:43 EST

Yes check if the P wave came in early. So an early P is PAC. See this several times at work (watching waves in real time).

What is happening in this tracing?

Sat, 04 Feb 2012 20:09:26 EST

I hear you. There are three steps in the approach to the ECG:1)What is happening electrocardiographically?(ECG Dx), 2)why is it happening?(etiology) and 3)what to do about it?(Tx). If Dx of this tracing is complete AV block as 37% of our respondents so far indicated, some may put a pacemaker in this patient. Even if it was complete AV block. the QRSs are narrow indicating the escape beats are comming from the AV junction, in which case most likely the block is due to a reversible condition and the block would be transient, not requiring a pacemaker. Thus, a wrong Dx can lead to a wrong Tx. That is why it is so important to interpret ECG findings correctly to start with. This ECG of the Month program is primarily dealing with the first of the three steps mentioned above, i,e, to promote the ECG reading skills.(see comment #7.) By the way, it is not choice a)or d) above right away because the escape rhythm should be regular. Here, the QRSs are not occuring regularly.

Intention To Treat Resistant Hypertension: Looking for a Simple Solution

Sat, 04 Feb 2012 18:33:27 EST

So far, in small studies, postural hypotension was not an issue.

What is happening in this tracing?

Sat, 04 Feb 2012 17:32:12 EST

Wang, please comment whether this block could progress to higher degree. Are you not even told the presenting complaints or primary diagnosis of the patient for whom you are called for ecg reading. Of course we treat patients as a whole not their ecgs or labs.

What is happening in this tracing?

Sat, 04 Feb 2012 16:15:02 EST

I am not quite sure that the QRS complex are conducted by the P wave

Statin Intolerance in the Elderly: Solutions for Complex Cases

Sat, 04 Feb 2012 15:30:05 EST

Cardiac muscle gets its energy through lipolysis and glycogenolysis, both mechanism are regulated by beta receptors. By blocking cardiac muscle's energy resources, DAILY USE OF beta blocker will make infarcted heart muscle worst.

Heart to Heart: Potential Impact of Optimal Implementation of Evidence-Based Heart Failure Therapi

Sat, 04 Feb 2012 15:25:15 EST

First of all, read my comments on the problem caused by daily use of Diuretics under the Resistant HTN forum: "Intention To Treat Resistant Hypertension: Looking for a Simple Solution." In HF management, diuretics are used a lot. Lets go back to Digitalis Glycosides. Is it pharmacological acceptable to prescribe DG as a daily regimen. My response is NO. As I have mentioned in my previous comments, they are DOSE AND TIME DEPENDENT. Daily regimen is sure to create safety problem. That is why doctors are avoiding it. The following facts are some pharmacokinetics/pharmacodynamics of DG preparations. Ouabain (parenteral): Time to peak effect (O) - 1/2 to 1 1/2 hrs; duration of action (D) - 2 to 4 days (even though half-life is 11 hr) Digoxin (Oral): O - 4 to 6 hrs; D - 14 to 21 days (even though half life is 1.5 to 2 days) If you were not familiar with how to safely use DG, please read the following articles, which will recommend daily use strategy. However, you need to tailor your own treatment regimen using their experience especially when you are going to introduce COMBINATION THERAPY to your patients, present practice attitude of most physicians: Smith TW, Antman EM, Friedman PL,et al. (1984). "Digitalis glycosides: mechanisms and manifestations of toxicity. Part I." Prog Cardiovasc Dis;26(5):413-58. Smith TW, Antman EM, Friedman PL, et al. (1984). "Digitalis glycosides: mechanisms and manifestations of toxicity. Part II." Prog Cardiovasc Dis;26(6):495-540. Smith TW, Antman EM, Friedman PL, et al. (1984). "Digitalis glycosides: mechanisms and manifestations of toxicity. Part III." Prog Cardiovasc Dis;27(1):21-56. Caird FI. et al. (1974). "Metabolism of digoxin in relation to therapy in the elderly." Gerontol Clin (Basel);16(1):68-74. Peters U. (1982). "Pharmacokinetic review of digitalis glycosides." Eur Heart J;3 Suppl D:65-78. Doherty JE. (1973). "Digitalis glycosides. Pharmacokinetics and their clinical implications." Ann Intern Med;79(2):229-38. Kochsiek K. (1982). "Clinical consequences of pharmacokinetic properties of cardiac glycosides." Eur Heart J;3 Suppl D:79-86. Doherty JE. (1985). "Clinical use of digitalis glycosides." An update. Cardiology;72(5-6):225-54. Bigger JT Jr, Strauss HC. (1972). "Digitalis toxicity: drug interactions promoting toxicity and the management of toxicity." Semin Drug Treat;2(2):147-77. Chung EK. (1972). "Digitalis intoxication." Postgrad Med J;48(557):163-79. Rios JC, Dziok CA, Ali NA. (1970). "Digitalis-induced arrhythmias: recognition and management." Cardiovasc Clin;2(2):261-79. Chung EK. (1971). "Guide to managing digitalis intoxication." Postgrad Med;49(2):99-101. If you choose not to use DG, then do not read these articles. Tribouilloy C, Rusinaru D, Leborgne L, et al. (2008). "In-hospital mortality and prognostic factors in patients admitted for new-onset heart failure with preserved or reduced ejection fraction: a prospective observational study. Arch Cardiovasc Dis;101(4):226-34. The above article has already predicted caused of in-hospital mortality among HF where EF is assessed; they are CHD; SBP on admission = CHD is the only area where DG will not work. It can improve patients with other 3 causes by increasing Stroke Output without jeopardizing rhythm problem, provided you know how to use it safely.

Intention To Treat Resistant Hypertension: Looking for a Simple Solution

Sat, 04 Feb 2012 14:18:12 EST

Any condition that reduces renal artery/RA perfusion pressure will activate RAAS and AngII. Continuous, daily use of diuretics will activate AngII to act on AT1R, and constrict renal arterioles (both afferent and efferent). Adrenergic sympathetic system will exert its action on alpha1 of RA to counter low blood volume, and thus your Rx will create RHT over time, as diuretics continuously reduce blood volume and AngII is perpetually activated. �STOPPING DIURETICS� is the only answer here. Addition of Vasodilators or Calcium Channel blockers won't have any effect in this clinical situation. That was why most physicians chose to use diuretics every alternate day, or twice weekly, instead of giving it daily, and they were only used as adjunct to others. Diuretics that have action on PCT have greater potential to reduce blood volume drastically over time than others that act on LOH and DCT, and thus have more potential to activate RAAS. If use diuretics daily, there will be a time period, when its effect of diuresis will not be seen, particularly after most of blood�s Na has been depleted; patient got resistant to diuretics. Since diuretics concomitantly depleted blood volume, blood Na concentration will be measured near normal in such cases or may be reduced little. Treatment here is to stop diuretics and to get the patient rehydrated (have him drink juices) before next dose is given. In your propose study, you have set the following inclusion criteria. "Failure to achieve BP goal of Appropriately dosed Diuretics, Ca antagonists, and RAS blockers (ACEI or ARB) in maximally tolerated doses. Failure with drugs having complementary MOA (beta-blocker, Clonidine). Office SBP >= 160 (Stage II HT) Full tolerated doses of 3 meds (inclusive of diuretics) No HTN meds differences in past 3 mo No plan differences in HTN meds in next 6 mo" You deliberately choose to include patients having DIURETICS to PROVOKE RHT. AngII exerts its action not only on Renal Arterioles, but also on PCT to increase reabsorption of Na that was depleted by diuretics. Since daily use of diuretic along with dietary Na restriction have already depleted most of EC Na, AngII�s Na reabsorption and ADH�s water conservation will not reverse the RAAS stimulation. This will cause over-constriction of renal arterioles by AngII favoring HTN to get more resistant to Rx. Calcium Channel blocker cannot reverse the effects caused by AngII on AT1R, and so also Clonidine acting on alpha2. ACEI or ARB use, in the situation where perfusion is very low, will kick in SYMPATHETIC OVERACTIVITY that will JEOPARDIZE RA FLOW. ONLY RENAL ARTERY PERFUSION CAN REVERSE THIS PROCESS. Even in cases of Hypertensive Crisis or Hypertensive Emergency or Malignant HTN, there are drugs that are available and that can effectively reduce BP. For example, IV infusions of short acting Sodium Nitroprusside, Labetalol, and Nicardipine that are preferred over IV boluses of Hydralazine or Diazoxide. Renal Artery Ablation is never needed. Similar procedure, specific para-vertebral sympathetic denervation in Thrombo-Angiitis Obliterans is usually reserved for patients having impending gangrene (with symptoms of intermittent claudication) preceding amputation. In your study, you only need to switch over to other meds for diuretics in addition to augmentation with Oral Rehydration before diagnosis is made as RHT. The problem-maker in patients with RHT, who are on diuretics, is the DAILY REGIMEN of diuretics, which is to be removed in order to improve hard-to-treat situation. I do not agree with Renal Artery Ablation in supposedly �Resistant HTN�, when treatment includes DAILY REGIMEN OF DIURETICS. I FORESEE POSTURAL HYPOTENSION, HYPERSENSITIVITY TO HTN RX (SYNCOPE WITH 1ST DOSE; SIMILAR TO ALPHA BLOCKERS), & ANGINA WITH BLOOD/FLUID LOSS AMONG STUDY POPULATION AFTER RAA.

Betty Crocker, Coke, and CardioSmart at ACC 2011: If CV prevention gets a boost, does it matter wh

Sat, 04 Feb 2012 11:44:16 EST

If Newt Gingrich becomes the lobbyist for this enterprise and Mitt Romney takes over the venture capital. You really do have to smoke a cigarette after reading this story (which is fantastic by the way - the story). I will look for the smoking section at ACC this year. One of my diabetic patients started drinking a 'natural' fruit juice drink marketed by these heart healthy companies. He lost sugar control and couldn�t explain the reason. When we looked up the �natural� sugar content and calories ~ 300/bottle. We had the answer (better to eat fresh fruit/veggies) and he said he would save $4-5/day. His sugar control responded within 10 days by stopping the natl/intntl �natural� juice drink.

What is happening in this tracing?

Sat, 04 Feb 2012 10:40:14 EST

In fact, it was Dr. Marriott who found a case of conducted PR interval of one second. Untill then, the "world record" for the longest conducted PR interval published was supposed to had been 860 msc. We all know Dr. Marriott was a great interpreter of electrocardiography. He subsequently passed away.

Sodium/potassium ratio important for health

Sat, 04 Feb 2012 08:24:46 EST

Exactly, bananas and fruit juice are good sources of potassium and acceptable better than the unpalatable potassium syrup

What is happening in this tracing?

Sat, 04 Feb 2012 07:51:53 EST

How informative was this quiz! we need more and more. Much obliged

What is happening in this tracing?

Sat, 04 Feb 2012 07:05:07 EST

The long conducted P-R looks quite constant.Relationship of the nonconducted to the Atria junctional beat,to Pwave,varies.So one should expect an amount of concealed conduction retrogradely that could further prolong or even block some of the conducted beats,but definately make P-R variable.

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Sat, 04 Feb 2012 05:54:05 EST

Yes, there is a flap there (in the AsAO), but it's subtle. So glad you enjoyed it!

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Sat, 04 Feb 2012 03:46:31 EST

It was good, i had a feeling of flap in the AsAO with dilatation of the same... the DTA was just giving the diagnosis.

What is happening in this tracing?

Sat, 04 Feb 2012 02:18:31 EST

Just last night I was reading about this phenomenon in Marriott's "Pearls & Pitfalls in Electrocardiography," otherwise I certainly would have missed it (Sections 32 and 33). Thanks for the great case.

Fear of Bleeding: An Obstacle to Stroke Prevention

Sat, 04 Feb 2012 01:26:32 EST

I apreciate the great clinical experience of dr Camm and I will employ the risk of bleeding to my patients

Resistant Hypertension: When Medical Therapy Fails

Fri, 03 Feb 2012 22:20:05 EST

have you any ideas why dibetes 2 remits with renal denervation

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Fri, 03 Feb 2012 22:09:56 EST

The jet is actually eccentric, directed towards the interventricular septum. It goes without saying that further imaging was done before the patient went to the OR. The only point being made here is that there's a clear dissection flap in the aorta, just not where the eye is drawn - to the color jet, and that's important, because if one sees the flap, it hastens the urgency of the case.

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Fri, 03 Feb 2012 22:02:54 EST

the regurgitant jet is central and seem that aortic distance is around 5 cm but I cannot see in this long axis the flap.I would like to see a short axis of aorta for bicuspid valve

What is happening in this tracing?

Fri, 03 Feb 2012 20:06:58 EST

I never could have got it right !! kudos to the author!!

The flap over flavonoids

Fri, 03 Feb 2012 19:49:58 EST

Dietary Supplement Health and Education Act of 1994 (DSHEA), created the bureaucracy regulatory framework for dietary supplements. DSHEA also stipulates that for new ingredients are reviewed. Should you need a prescription for Krill oil? The pharmaceutical companies see this as their new cash cow. The FDA has insufficient funding to review the 1000�s of new supplements a year, some may be great, many are useless or harmful.

New antiplatelet ticagrelor could challenge clopidogrel, prasugrel

Fri, 03 Feb 2012 17:48:21 EST

As soon we can have it in the market in order to use it, we will be able to judge it better. The problem for us in Argentina might be the price. A cost/benefit study would be interesting to complete the product monography.

What is happening in this tracing?

Fri, 03 Feb 2012 16:18:42 EST

The longest conducted PR interval has been claimed to be one second!!!

What is happening in this tracing?

Fri, 03 Feb 2012 16:05:37 EST

I approach these ECGs as an official ECG reader for the hospital or the clinic, in which case no clinical information is provided other than the patient's age and gender. You interpret the ECG the best you can. If ECG diagnoses can be made, e.g. complete AV block, you do so. If clinical condition can be suggested, e.g. hypokalemia, you do so, too. So, most of these cases, I am approaching them as an official ECG reader, not as a clinician taking care of the patient. Occasionally exceptions occur, i.e. approach it as a clinician. Re comment#4, yes, those junctional beats are dissociated from the sinus P waves.

Carotid images don't boost quit rates or cut CV risk factors in smokers

Fri, 03 Feb 2012 16:00:40 EST

most of the people are aware that smoking is one of the most potent risk factor for cardio-vascular deseases but if the doctors or any health care professionals try to explain such risk factors to the smokers, they take it in a very light temperment because they know that medical science has come with newer techniques to counter these cv problems but tell them that how much smoking can harm their sexual life, most of the smokers will react seriously to it & try their best to quit smoking because nobody wants to compromise with that. So what i suggest is that showing atherosclerosis imaging may work in some cases but what i said above can be more usefull among the common mass.

What is happening in this tracing?

Fri, 03 Feb 2012 15:53:19 EST

I have never encountered 2:1 block with a conducted PR of close to 900 ms. Are you saying that he has dual pathways with an increbibly long fast pathway ERP? Why not make this mildly accelerated JR where the P wave associated with the second QRS in the grouping of two has concealed conduction into the AV node and just resets the junctional pacemaker?

What is happening in this tracing?

Fri, 03 Feb 2012 15:49:06 EST

All the P waves non conducted to the Ventricles occur during refractory period of the AV node I would have chosen a bigeminal nodal rhythm with sinus captures.That is AV dissociation and not AV block

To prescribe or not to prescribe: That is the statin question, experts debate

Fri, 03 Feb 2012 14:25:11 EST

It is very clear, if the patient has a quite number of risk factor for atheroclerosis in primary prevention we have to prescribe it. If not, start with diet, exercise. In secondary prevention there is no doubt about give statins to the patient.

US bleeding ADRs higher with dabigatran than warfarin

Fri, 03 Feb 2012 14:11:05 EST

Melissa, glad you had a good result, however are u seriously suggesting this lady was taking her warfarin with an INR of 1.1?..Home testing is great for some patients, i would presume an 80 year has help with the equipment. This happy story though just proves that some people dont take the warfarin as rx'd. Once she was closely monitored and with some help from your good self she clearly got the message. Almost all of my self testers have 12 week intervals, however so do a good percentage of clinic attenders. I wont be moved on the fact that unstable patients simply dont comply

What is happening in this tracing?

Fri, 03 Feb 2012 12:19:15 EST

can we also call this AV dissociation?

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Fri, 03 Feb 2012 10:35:00 EST

Very nice thought, and bicuspid AVs are associated with dissection. This AV was actually trileaflet, and the point was as you surmized - to scrutinize the enitre image.

What is happening in this tracing?

Fri, 03 Feb 2012 10:33:55 EST

Exceptionnal PR I fully agree with the discussion. Why do not you put the clinical context? It would be very useful.

Statins reduce cardiovascular events and all-cause mortality in women: Meta-analysis

Fri, 03 Feb 2012 10:31:08 EST

The excellent Editorialist Lori Mosca is absolutely right: no NNTs or absolute risks can be calculated for anybody from this blenderized statistical exercise using studies with different endpoints and non placebo controlled and non gender mortality reporting studies [ASCOT being the most infamous of the latter, a study endign with 2 more non-fatal 'events' in women; JACC Table 3]. One sentence stands out (JACC p.577) "The effect on all-cause mortality in women was not statistically significant for secondary prevention .. OR 1.03 .. p=0.8 That means no benefit in the highest risk group and, incidentally, they took the lower and later corrected female mortality in 4S. There are not enough high risk women in any state, province or practice to alter this conclusion. EBM: in secondary prevention, women should be informed that a statin will not alter her day of death. Ditto in primary prevention men [JACC p.577).

What is happening in this tracing?

Fri, 03 Feb 2012 10:24:15 EST

But I want to know more about the clinical pattern of the patient in to whom this ECG was registered.

What is the mechanism of aortic insufficiency for this 60-year-old man with a murmur?

Fri, 03 Feb 2012 10:06:43 EST

Nice clips which illustrates the need to scrutinize the entire image. The eccentric AV closure line would also support a bicuspid valve although no PSAX image to confirm and with no evidence of the dissection extending to the root in this view possibly a more likely cause of the AR seen?

The flap over flavonoids

Fri, 03 Feb 2012 10:00:57 EST

While it makes for good marketing, this emphasis on single supplements, foods or nutrients demonstrates a lack of understanding of nutrition. Everyone would like a nutrition magic bullet that would prevent or treat heart disease but foods and nutrients work in synergy much like a well tuned symphony orchestra. We should be thinking more about the perfect combining of foods to produce this synergy. So the magic just might be a meal that combines olive oil, aged balsamic vinegar, fatty fish, and leafy greens all chased down with a glass of red wine. The new horizon in nutrition is learning to activate Nrf2 which in turn activates survival genes to produce multiple copies of powerful indirect antioxidant enzymes like glutathione, super oxide dismutase and catalase. It maybe that this Nrf2 activation is the reason the Mediterranean diet is so effective...the thought that the perfect meal described above contains compounds that activate the production of these powerful intracellular antoxidant enzymes that in many cases are 1 million times more powerful than the direct antioxidants. I'm not researcher but just a lowly dietitian that thinks the whole diet is the new magic bullet in nutrition.

The flap over flavonoids

Fri, 03 Feb 2012 09:28:26 EST

"On the mechanism of action of these compounds, a lot again seems uncertain. McCullough said the flavonoids are thought to have multiple mechanisms, including antioxidant and anti-inflammatory properties, reduction of LDL oxidation, and weak estrogenic activity. In their current paper, McCullough et al report that cocoa induces nitric-oxide synthase, which is important in the vasodilator response, and other flavonoid-rich foods (green tea, soy products, and cocoa or chocolate) have been associated with increased flow-mediated dilatation, reduced LDL cholesterol, and reduced blood pressure." For nearly 60 years saturated fats were demonized because they were thought to produce an artery clogging effect. However, since the 2002 publication of a "New York Times" article by Gary Taubes entitled "What if it's all been a Big Fat Lie" researchers have begun to question basic assumptions regarding the cholesterol-altering effects of saturated fats. The latest addition to this literature is a study published in the Netherlands Journal of Medicine. The title of the study is �Saturated fat, carbohydrates and cardiovascular disease.� But if saturated fats don't clog arteries, what dies? I'd say excessive omega-6 consumption is likely a major contributing factor. Unfortunately, there isn't any money to finance trials in which omega-6 consumption is restricted. However, at least one trial has been done in which omega-6 intake was inadvertently reduced. Here's what happened: "The only long-term trial that reduced n-6 LA intake to resemble a traditional Mediterranean diet (but still higher than preindustrial LA intake) reduced CHD events and mortality by 70%. Although this does not prove that LA intake has adverse consequences, it clearly indicates that high LA intake is not necessary for profound CHD risk reduction."

The flap over flavonoids

Fri, 03 Feb 2012 08:21:24 EST

The impression from official statements on the Das case is that there are multiple instances of alledged incorrect data. Generally, a need for polishing outcome data, when actual studies have been done, would argue that there may have been difficulties actually confirming anticipated advantages of these compounds. In that sense does the case affect the view of this research field.

The flap over flavonoids

Fri, 03 Feb 2012 07:40:30 EST

I agree that polyhenols possess some benefical health effect. However, i doubtmechanisms of polyphenols. i thought two things should be born in mind when we understand how polyphenols work: (1)as polyphenols is poorly absorpted, the concentrations of polyphenols are very low, usually below 100 nM. Therefore, most of cell cutures studies (10- 200 uM)utilized to unravel the potential mechanisms of polyphenols on these health-promoting properties. (2)increasing evidence imply that gut microbiota might degrade unabosorbale polyphenols into metabolites, the later would therotically play a role in mediateing the health-promoting effects of these parent polyphenols.

US bleeding ADRs higher with dabigatran than warfarin

Fri, 03 Feb 2012 06:13:15 EST

A patient well into her 80's with a CHADSVASC score of about a million had an INR anywhere from 1.1 to 5 on warfarin. Her family became frustrated with her family doctor so I decided to give it a try. We did a little better ranging from around 1.6 to around 3.8. I discovered that her family thought they could "adjust" her coumadin when they felt like it. They didn't necessarily tell their FP or me when they did it. I convinced them to do home monitoring. Now, they get to play doctor (well, sort of) with my blessing and the last four weeks, their checks have been 2.1-2.6. Home monitoring....it's a beautiful thing. Melissa

Cardiac telemetry identifies AF in cryptogenic stroke

Fri, 03 Feb 2012 01:51:30 EST

Interesting data, but no appropriate control group appears. The rules to assess the validity of a new test are defined: determine sensitivity, specificity, eventualle net reclassification improvement. We need more data, otherwise we end up with the PFO discussion: high prevalence, rare importance.

The flap over flavonoids

Thu, 02 Feb 2012 17:36:13 EST

Dr. Das is currently accused, not convicted of fraud. The news reports on this have been atrocious. Dr. Das will likely be declared guilty but not for any credible evidence. Western blot tests were in question, but the accompanying hard data that was published was accurate.

Statins reduce cardiovascular events and all-cause mortality in women: Meta-analysis

Thu, 02 Feb 2012 16:28:44 EST

My friend promised to give me two lottery tickets, but gave me only one. I'am loosing 50% odds of winning. Relative reduction risk (of winning) is -50%. Is it a pity ? Actually, it doesn't matter if absolute risk is 0,00001 instead of 0,00002. When tenuous, absolute risk reductions are concealed. Ratios of two absolute risk are more attractive, denomanitors falling by the wayside.

Dr Robert Harrington leaves DCRI for Stanford University

Thu, 02 Feb 2012 15:14:28 EST

Congratulations and good luck. You will be missed at one placed, but gained at another. I am sure you will shine at Stanford as you have at DCRI.

Statins reduce cardiovascular events and all-cause mortality in women: Meta-analysis

Thu, 02 Feb 2012 15:09:05 EST

Yes, monacolins 0.4%, but effect on LDL - 1 mmol/l = expected 22% risk reduction (CTT Trial, see http://www.ajcn.org/content/69/2/231.full.pdf+html, right?

US bleeding ADRs higher with dabigatran than warfarin

Thu, 02 Feb 2012 14:36:30 EST

Melissa, In the UK we burned all our witches about 400 years ago, Before the USA was invented. 76% time in range isnt witchcraft, unstable INR's are simply down to compliance, ive dosed 1000's of patients over many years and once ive convinced the nutcases that if they take there pill everyday i wont see them again for 3 months they suddenly remember to do so. Warfarin is a doddle when taken properly, simple.

What is happening in this tracing?

Thu, 02 Feb 2012 12:44:32 EST

Thank you so much for sharing this.

"Cardiovascular health," new focus of the AHA, linked with reduced mortality

Thu, 02 Feb 2012 12:38:07 EST

One thing to note is that hypercholesterolemia did not show any predictive value for all-cause mortality. I enjoyed reading the comments by the authors: they have several explanations but as usual do not dare conceive the inconceivable: that it might be true.... And the article above does not mention it at all. The whole situation is indeed inconceivable. And while I'm at it: BMI had the same very weak predictive value. I know that all dogmatics out there are going to find a lot of reasons to explain these two findings. Faith is indestructible.

Heart attack deaths plummet in three EU nations

Thu, 02 Feb 2012 12:01:20 EST

I don't think there are any data that cholesterol sulfate does that .. the science is truly not there to suggest one way or another. The stuff may be marginally more soluble than plain cholesterol but there's no well established special role. Hcy eventually also does generate sulfate but there's no evidence that omnivorous Western diets are under supplied in sulfur/sulfate.

US "roadmap" for TAVI rollout published

Thu, 02 Feb 2012 08:48:26 EST

"one of the fastest guidances ever issued, says one of the authors". Congratulations to those physicians/researchers who have worked together so quickly to allow the availability of this procedure to grow within our midst! Most admirable!!!!

Heart attack deaths plummet in three EU nations

Thu, 02 Feb 2012 08:42:30 EST

It was tongue in cheek. Lighten up!!! Melissa

Data mixed on role of parents and caregivers in combating childhood obesity

Thu, 02 Feb 2012 01:14:17 EST

This article is indeed a sad commentary on the state of parenting in our country. The sheer fact that the AHA has any kind of a scientific committee or that RCT's need to be conducted on "parental involvement" as it relates to childhood obesity is pathetic. These issues, like many others that our country faces, cannot be solved with clinical trials or the scientific method. I think we may find that exercise, healthy foods, portion control, and the ability of parents to (God forbid) say NO to their kids is a pretty good place to start in preventing this epidemic from getting worse. There is one other component to all of this, though, and that is personal responsibility on behalf of the parents. Hard for a morbidly obese parent with no self control that is inactive to be any kind of a role model for their children...

Heart attack deaths plummet in three EU nations

Wed, 01 Feb 2012 23:41:53 EST

Homocysteine with oxygen is turned into sulfate with the help of vitamin C, Cholesterol-Sulfate makes Cholesterol in the plaque soluble. You have a better explaination? I did not see it on your web pages.

Once-weekly exenatide okayed by FDA for type 2 diabetes

Wed, 01 Feb 2012 21:18:31 EST

We started three new people on GLP1s today. Two Victoza and one Byetta, we have lots of experience with and with out insulin. We are looking foreward to offering our patients a once a week alternative and expect it to be readly accepted.

Dr Robert Harrington leaves DCRI for Stanford University

Wed, 01 Feb 2012 20:54:18 EST

Big win for the Cardinal...big loss for the Blue Devils. Congrats Bob. All the best to you and Rhonda.

"Valve-on-a-stick" transaortic TAVI offers alternative to transfemoral route

Wed, 01 Feb 2012 19:10:06 EST

This is a great development for the betterment of the patient. I envisage this procedure being done via a ministernotomy in an awake high risk case with thoracic epidural anesthesia . This direct route will make safe and secure placement placement possible as shown by Dr Bapat and Dr Moat. The surgeon remains in control with the option of a quick and safe conversion in case of problems .

Cardiologists flagging woeful patient care say they paid with their jobs

Wed, 01 Feb 2012 18:39:44 EST

Actions of JC strongly tends to support these courageous docs' view of probs at this facility. This case illustrates how hospital admin can become too powerful & often is not held accountable for their mistakes. How sad that docs have to pay with their careers to improve patient care. Turning this case into PR campaign is reprehensible. County Council taking cheap shot at the docs' legal fee structure is just beneath contempt since they should know this is attny-client privilege. And refusal of temp restraining order is not unusual & says NOTHING about the ultimate merits of a pending case. Hope The Heart stays on top of this story with regular follow-ups.

Heart attack deaths plummet in three EU nations

Wed, 01 Feb 2012 17:08:59 EST

�Maybe the reason why the CHD deaths have dropped in European women is because they are all secretly taking statins!� Melissa Walton-Shirley

Statins reduce cardiovascular events and all-cause mortality in women: Meta-analysis

Wed, 01 Feb 2012 16:49:52 EST

Dried red yeast rice powder that is approximately 0.4% monacolins, of which roughly half will be monacolin K (identical to lovastatin). Fluvastatin are fully synthetic

Heart attack deaths plummet in three EU nations

Wed, 01 Feb 2012 16:37:03 EST

It won't do any good. Your cache of idle time must be absolutely bottomless. You debate back and forth back and forth to no avail. I could copy and paste your arguments over the past several years and no one would ever know the difference. You cannot agree to disagree. Maybe the reason why the CHD deaths have dropped in European women is because they are all secretly taking statins! Have you thought about changing over to another forum where every single thread is all about lipids? that way you would have like a hundred threads to debate it every day, all day long. Is there not a lipid.org or something? I strongly encourage you to surf the net for a venue like that so that your need to debate it can be served to the fullest.

To prescribe or not to prescribe: That is the statin question, experts debate

Wed, 01 Feb 2012 11:24:22 EST

Poor old Cholesterol sitting behind bars while the real bad guys like cigarettes, spiking insulin / blood sugar levels, homo immobilis / fatness are poking sticks through the Bedlam bars and having fun.And the statinators and makers are banking the $.Yes, statins do a bit of good probably....not a lot but a bit. Probably. But pale beside correction of the above factors. And almost certainly because of their pleiotropic effect. And Dr Cobble, without insulting your intellect, have you done your Insulin / GTT ? Speaking as a T2DM with a strong FH and IGTT abnormalities in virtually ALL of my many siblings, albeit with different levels of penetration and very varying vascular issues ( almost certainly due to lifestyle / smoking and degree of genetic penetration ) I am fixated on this issue and , sadly the statins have detracted us from the main game and what small benefit they have in selected groups is virtually swamped by the noise they and Cardiologists as a group make.

Heart attack deaths plummet in three EU nations

Wed, 01 Feb 2012 11:22:05 EST

William, you make great analogies! Your cigarette experiment is about cause. The topic is mortality and where quitting or Chantex vs placebo is not likely to reduce deaths from existing cancer. Something 'major' is reducing CHD mortality, the debate is as to what that is. B vitamins don't reconstitute the arterial elastic laminae and neither do statins or niacin so they are limited cures at best. To James King re Hcy being causal, copy and paste this www.health-heart.org/why.htm ; it may help explain the mortality phenomenon. An analogy. Before there were cardiologists we had 'pellagrologists' that went out of business after there was finally agreement that a confusing 4-D set of symptoms (dermatitis, diarrhea, dementia and death) were in fact a single deficiency condition. This curve resembles the CHD death curve: www.ajcn.org/content/80/2/264/F2.expansion.html There never was an RTC but the disease became an oddity, probably not by the help of the interventional pellagrologists busy with curing symptoms. No proof re CHD in our lifetime and we've been at it for over 60 years, just supporting science that there ARE long-latency micro-nutrient deficiency diseases with cunning beginnings and endings. There are dozens of supporting pathways that CHD is exactly that, none to refute it. To Melissa, many on this Forum are neither but I have many more original contributions on Medline regarding cardiovascular disease than most. This of course does not prove I'm right, just that I'm really well referenced. Rather than ad hominem, why not refute with evidence as in trial data or material from scientific publications. For example, how do you explain the 2/3rd drop in U.S. female CHD deaths over a mere 27 year period? That is the topic at hand, the massive drop in CHD mortality in Western countries and about which you have not contributed.

Dr Robert Harrington leaves DCRI for Stanford University

Wed, 01 Feb 2012 10:33:34 EST

They could not have chosen a better person for this position!!!

Statins reduce cardiovascular events and all-cause mortality in women: Meta-analysis

Wed, 01 Feb 2012 09:18:57 EST

"the researchers report that treatment with statin therapy significantly reduced the risk of death in women by 10% in the primary- and secondary-prevention studies and by 13% when the primary-prevention studies were analyzed separately." If one excludes the mortality data from JUPITER stopped early and widely questioned where the benefit was driven not by a reduction in CVD mortality but by less cancer deaths : a result even the study authors said is likely a chance result does the mortality benefit still still hold?

Statins reduce cardiovascular events and all-cause mortality in women: Meta-analysis

Wed, 01 Feb 2012 09:03:13 EST

Yet again all we have are relative risk reductions. These are meaningless in isolation. What is the absolute risk reduction? What are the NNT data? Without those numbers the relative risk could be anything from trivial in the extreme, (0.07 to 0.04 for example, or one lottery ticket or two) to mildly interesting, to possibly worthwhile. Can't tell from the information here.

Heart attack deaths plummet in three EU nations

Wed, 01 Feb 2012 08:57:47 EST

I suggest his posts be ignored. Melissa

SYNTAX, FAME trials influence update to PCI/CABG appropriate-use criteria

Wed, 01 Feb 2012 08:54:12 EST

No all scenarios are included is true. But I think that is a good way to stopped the unnecessary procedures make all over the word.

Pay for SGR repeal with war savings, say medical groups

Wed, 01 Feb 2012 08:52:11 EST

I've made this point before, so please forgive me. Like farmers who were subsidized in the 1980's for growing certain crops, cardiologists were enticed to purchase nuclear scanners, echo machines, build larger offices and hire more staff. Like mini skirts, reimbursement patterns come in and out of fashion, but we were directed that out-patient testing was far less expensive than in-patient testing, thus we were directed/instructed/encouraged to follow that trend. After we expanded, purchased necessary equipment,hired more staff, we are now told that we will have our salaries cut by 30%. The "B00-HOO" is appropriate for all of our employees (now in our office 10 employees total) who depend upon this reimbursement pattern to make their house payments, pay their car insurance, fund their profit sharing plans and send their children to college while we are continuing to pay off equipment purchases, building additions/remodels, etc. from years ago because this was the trend we were directed to follow. I do not apologize for driving a good car. I drove a 1978 LaSabre buick until 1986 while all of my friends who were in the work force while I continued my education for another 11 years drove new cars, got married, had kids earlier, etc. etc. I did not begrudge them then, and I do not begrudge them now. I was proud of their successes and they (because they are my true friends) do not begrudge me my successes. They saw all the years of sacrifice and struggling and admired it. If you were willing to attend 13 more years of schooling beyond high school, then you could have enjoyed a higher income level as well at the expense of a grueling schedule of weekend rounds, night call and missing much of your children's "baby-hood" and health issues due to occupational hazards such as radiation exposure, orthopedic issues (still in a cast from thumb joint surgery from three months ago). It is a typical ungrateful American stance to be envious of the success of others ground out by hard work and sacrifice. Bet you wouldn't post that on a website for an NBA star who plays a game he loves, often with no post graduate education.

Dr Gary Roubin to resign as CV chair at Lenox Hill

Wed, 01 Feb 2012 08:39:25 EST

From my perspective, I utilize THO as a networking opportunity to keep up with fellow cardiologists with certain expertise or access to information regarding issues. It is far easier to know where a person is or is not in order to pursue information or just maintain old friendships/ties. Sometimes, there is some other angle to this announcement which is also covered by HEARTWIRE. It is considered news by many. That's the purpose of these announcements. Melissa

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Wed, 01 Feb 2012 07:52:26 EST

Are people REALLY surprised that unnecessary cardiac procedures are being performed? This is more common that you think.

"Valve-on-a-stick" transaortic TAVI offers alternative to transfemoral route

Wed, 01 Feb 2012 07:47:02 EST

Direct aortic access through right minithoracotomy for implantation of self-expanding aortic bioprosthetic valves. Bruschi G, De Marco F, Fratto P, Oreglia J, Colombo P, Paino R, Klugmann S, Martinelli L. J Thorac Cardiovasc Surg 2010;140:715-7

"Valve-on-a-stick" transaortic TAVI offers alternative to transfemoral route

Wed, 01 Feb 2012 07:37:45 EST

I congratulate dr. Bruschi for his dedication to the developement of the transaortic route for transcatheter valve implantation. We developed toghether this technique via minithoracotomy and we strongly believe that this route has significant advantages compared to the subclavian and transapical approaches, above all in very fragile patients,in very obese cases, in hypertrofic hearts, in redo cases, and even in the so called porcelain aorta where a smal spot to introduce the valve is alwais available.

Carotid images don't boost quit rates or cut CV risk factors in smokers

Wed, 01 Feb 2012 01:13:02 EST

You quote your study in young, active duty military personel with relatively low calcium scores as though it were fact. You fail to mention your co-author Dr. Taylor's 6 year follow up which demonstrated a 5X increase in use of ASA plus statin among those with coronary calcium as compared to those with just risk factors. (Taylor AJ. American Heart Association 2006 Scientific Sessions; November 12-15, 2006; Chicago, IL.) Furthermore, we are willing to do mammography every year for women with less than a 1% annual risk of having breast cancer. We do colonoscopy on asymptotic subjects with a 0.2% chance of having colon cancer. Why would we limit atherosclerosis imaging to subjects with greater than 1% chance of having a heart attack. I think that limiting atherosclerosis imaging to "intermediate risk subjects" is reckless as the majority of heart attacks occur in subjects who would be considered "low risk" by conventional standards. People like O'Malley are out of touch with the level of risk that individuals are willing to accept, especially when there is an alternative that can so easily do better.

Statins reduce cardiovascular events and all-cause mortality in women: Meta-analysis

Wed, 01 Feb 2012 00:53:29 EST

I once imagined that the benefit from statin use would increase the longer one took the drug. The opposite seems to be the case in ASCOT-LLA nine year follow up; there was no difference in vascular death between the statin and placebo group at the 9 year follow up. I think this myth is busted.

Heart attack deaths plummet in three EU nations

Wed, 01 Feb 2012 00:48:25 EST

The placebo in AIM-HIGH was indeed 200 mg of niacin. As you did not understand my pregnancy study, let me give you a cigarette study that parallels AIM-HIGH. Let's get 2,000 subjects who have never smoked. We randomize 1,000 subjects to start smoking 2 cigarettes a day (placebo) and a second set of 1,000 subjects and have them smoke 20 cigarettes a day. We follow these groups for 2 years. If someone in the 20 cigarette group stops smoking, we continue to pretend they are still smoking as this is an intent to smoke trial. (about 25% of the treatment group stopped niacin in AIM-HIGH but they were still considered to be in the niacin taking arm) The results will undoubtedly show that there is no statistically significant difference in lung cancer or heart disease between these two groups after 2 years. Would we then conclude that cigarette smoking does not contribute to lung cancer or heart disease? Would we disregard all prior evidence as we finally have a randomized controlled study showing definitive results? That is exactly what you are suggesting we should do with niacin and AIM-HIGH!

Heart attack deaths plummet in three EU nations

Tue, 31 Jan 2012 22:17:34 EST

Treating the elevated homocysteine around atherosclerotic plaque seems like treating fever in sepsis, its not addressing the etiology. Eddie Vos since you went to the �Hcy conference in Germany� what reference and theories do you have that treatment of Hcy helps? Do you think Hcy causes plaque? By- the-way, Eddie greetings from the 47th latitude.

Dr Robert Harrington leaves DCRI for Stanford University

Tue, 31 Jan 2012 21:18:45 EST

Stanford couldn't have chosen a better man! Congrats my friend, and Godspeed in your new adventure!!

Antiarrhythmics for Atrial Fibrillation: Practical Implications of Latest Clinical Developments

Tue, 31 Jan 2012 19:32:30 EST

Thank you for your discussion on this new antiarrhythmic.

Resistant Hypertension: When Medical Therapy Fails

Tue, 31 Jan 2012 15:37:26 EST

i think it is time to define the goal more confidentially on looking to control bp....as a lot of new terms comes to pracice like difference between central and brachial bp....what do you think???

3B or not 3B? Should patients get an LVAD before reaching end-stage HF?

Tue, 31 Jan 2012 14:20:30 EST

definitely should. as a surgeon i must not wait till organs besides the heart start failing specially the brain kidneys etc due to poor perfusion and complex multi medicine therapy causing side effects and interactions. i am in this situation now but cannot argue to much with my surgeon being conservative, thats his choice, but saved lots of class IV in the brink of death who eventually completely recovered from restored perfusion. My opinion

Dr Gary Roubin to resign as CV chair at Lenox Hill

Tue, 31 Jan 2012 13:30:37 EST

Can someone tell me again, why is the resignation of a chair news?

Pay for SGR repeal with war savings, say medical groups

Tue, 31 Jan 2012 12:32:53 EST

I'll take a wager you are not in the medical field. The physician doesn't get the full amount of the charge you see. They have lots of overhead---building, maintenance, payroll, benefits for employees, supplies, all the things people in business have to pay for. They get to negotiate payment amounts from insurances--all kinds---and rarely if ever get the full amount they ask for. Take the blessed Medicare reimbursement---right now that stands at approimately 30-40 cents ON THE DOLLAR. This SGR if it does not remain frozen will be a 27% cut in THAT 30-40 cents on the dollar they get. Most insurances follow suit and reimburse the same or similar amounts that Medicare pays. OK, translate that to YOUR salary: instead of getting 40 cents, you will now get 30 cents or less, get to write off the rest, AND pay for all the above BEFORE you pay for yourself. THEN you pay YOUR liability insurance ($100K+ a year) and all your outstanding student loans. I don't know about you, but I couldn't take a 27% cut in my salary and make it. (and no, I am NOT a doctor---just a nurse.) (Most of the docs you see with the fancy cars, etc---take a look at the year of the car, or how old the doctor is. Most of the really young ones just starting out do NOT get to take Wednesday afternoons off to play golf and drive 10 year old cars just like the rest of us---they are raising families, paying bills, and buying houses. Many of "those" doctors you see are older, have FINALLY finished paying off their student loans, have the kids done with college, and NOW get to play!)

Statins reduce cardiovascular events and all-cause mortality in women: Meta-analysis

Tue, 31 Jan 2012 10:19:08 EST

The reductions in coronary risk in these studies, lets say 22 percent were achieved by the end of the study which is probably a lot shorter than a persons Life so the total benefit of taking a statin over the duration of a patients life may be alot more because people live a lot longer than these studies, even with atherosclerosis

Dr Robert Harrington leaves DCRI for Stanford University

Tue, 31 Jan 2012 10:09:17 EST

Perhaps Shelley can also transform you into a UK Wildcat fan while she's at it!!! (still almost the same color blue?). All kidding aside, you will be fabulous in the PST just as you were in the EST. So proud for your new venue and I know you will be missed by your friends at Duke. Best of LUCK!!!!

ASCERT: Better survival for CABG vs PCI in some high-risk patients

Tue, 31 Jan 2012 09:51:51 EST

Observational studies ALWAYS show that CABG is better because the healthier patients get selected for CABG. This is a ridiculous analysis when randomized data are available. To call this "robust comparative effectiveness research" is just flat wrong. What a waste of taxpayer money. TT

Pay for SGR repeal with war savings, say medical groups

Tue, 31 Jan 2012 07:32:44 EST

This is wrong on so many levels. Was not paying for this war borrowed from China. What war savings are you talking about. I think these people that are fighting this reimbusrment thing should be ashamed of themselves. This country is in debt to the tune of 15 trillion$ and doctors whom own multiple houses, drive the best cars, take awsome vacations, send all their children to whatever collge they can get into and all the meanwhile have stock and savings portfolios that are full lof money, if these people can not afford to take a hit in pay who does? Id be very embarrassed to side up on the side of the Dr's and not saying that a good dr cannot get ahead but come on how much is too much and don't we need money saving reform

ASCERT: Better survival for CABG vs PCI in some high-risk patients

Tue, 31 Jan 2012 07:14:03 EST

NCDR does not capture most of the key elements that determine inoperability (which drive mortality in its own right) thus making this entire analysis susupect

SYNTAX, FAME trials influence update to PCI/CABG appropriate-use criteria

Tue, 31 Jan 2012 06:30:45 EST

It is important to emphasize that not all clinical situations are included in these criteria. If I (man in early 40s playing regular ball sports) develop a severe circumflex lesion and a false negative stress test(common in circumflex disease), I may be denied a stent and my favored athletic lifestyle just because of criteria like "revascularization in patients with one- or two-vessel CAD without involvement of the proximal LAD and no noninvasive testing performed is considered inappropriate." Improvement is lifestyle with stenting severe lesions in large vessels in younger patients underemphasized by these criteria.

Heart attack deaths plummet in three EU nations

Tue, 31 Jan 2012 05:27:00 EST

No need to continue being insulting. Why not look at my easy to find Medline record and I'll look at yours if you give us numbers. Moreover, why not study the mortality data especially re women and statin [links in my Medline record]. This way you may not again misrepresent the trial results.

Heart attack deaths plummet in three EU nations

Tue, 31 Jan 2012 03:04:23 EST

You are an unstoppable force of misinformation.

Heart attack deaths plummet in three EU nations

Tue, 31 Jan 2012 03:03:25 EST

FYI the placebo arm in AIM HGIH was a placebo. From the NJEM paper: "Patients in whom a dose of at least 1500 mg of niacin per day was associated with an acceptable side-effect profile were randomly assigned, in a 1:1 ratio, to niacin or matching placebo" If you have nothing sensible to say then don't bother.

Contaminated cardiac drugs kill more than 100 in Pakistan

Tue, 31 Jan 2012 02:43:38 EST

Thanks for your response Becky. I did not intend to blame the US specifically. Consumerism by all in affluent nations is to blame. The chinese manufacturing industry exists because we demand there products. No demand no industry. Shareholders of companies need to accept a smaller dividend and we all need to accept we can't have everything we want all the time. People need to realise we can't have everything we want with a little piece of plastic and expect it to be consequence free. I visited a store to buy an expensive american branded jacket. It was priced at a few thousand dollars. I looked at where it was made (in a third world nation) and declined to buy it. I wanted a hand made item made in the US. The company decided to maximise its profit margin at the expense of american manufacturing so i refused to buy it. If we all chose quality over quantity and purchased what we could afford - we would all be better off. Thanks

Statins reduce cardiovascular events and all-cause mortality in women: Meta-analysis

Tue, 31 Jan 2012 01:59:46 EST

What we know is that a 22% reduction in coronary risk for every LDL reduction of 37 mg/dl achieved with a statin or what ever (CTT study, 2011). Second, there is apparently ongoing benefit over the years. Therefore, cholesterol levels really do not matter. What matters is coronary risk. Based on published sensitivities and specificities of total carotid plaque area for men and women separately, we calculate coronary risk using the Framgingham algorithm and then we use the Bayes formula to calculate post test risk in 1500 Swiss healthy persons (published in kardio.ch). We find an increase from 7% risk in pretest to 15% in posttest risk. Therefore, many patients with low risk are at intermediate risk. Only imaging of atherosclerosis can solve this problem. We then simulate coronary risk lowering possibilites with LDL lowering intervention. The rest is a decision of open minded discussion between the patient and his doctor. Remember that Fluvastatin was used in Chinese Medicine since thousands of years to reduce atherosclerosis (read rice yeast contains amounts of fluvastatin). So let us not get too much upset about the industry but more about our ingnorant way to intelligently choose those subjects, that need risk lowering to protect their arteries. sites.google.com/site/tpacourse

Heart attack deaths plummet in three EU nations

Tue, 31 Jan 2012 00:20:54 EST

"the recent decline [in AMI deaths] is associated with the effects of evidence-based treatments in primary prevention, coronary care, and secondary prevention." Let's look at evidence-based primary prevention: We look at Framingham risk factors to determine who needs statin therapy. Studies have shown that in women younger than age 65 and men younger than age 55, NCEP-III will not suggest statin therapy in over 2/3rds of the subjects at risk until after their initial heart attack. In subjects over that age, NCEP-III might optimistically predict 50% of those at risk. Of those determined to be at risk, fewer than 50%will be prescribed and take statin medications. Of the fewer than 25% of subjects at risk on statin therapy, statin medication will reduce MI by less than 25% and vascular death by essentially nothing. That factors down to less than a 7% reduction in combined cardiovascular endpoints and no measurable reduction in vascular death. To conclude that the reduction in MI death is due to what we currently call evidence based prevention is patently absurd. We need to look for better explanations. My opinion is that the reduction in smoking plays a larger role than it gets credit for. Increased consumption of vitamin D and fish oil are also important factors. Eddie Vos may be correct with respect to the supplementation of foods with B vitamins. The only certainty is that the decrease in vascular death is not from improved application of evidence based prevention.

Heart attack deaths plummet in three EU nations

Tue, 31 Jan 2012 00:07:07 EST

FYI, the placebo arm in AIM-HIGH was also niacin.

Statins reduce cardiovascular events and all-cause mortality in women: Meta-analysis

Mon, 30 Jan 2012 23:56:55 EST

Really, is this the best that statins can do? Less than 25% reduction in combined outcomes with little or no difference in mortality! How is it possible that the statin industry is a multi-billion dollar industry if this is the best that it can do! How is it conscionable that statins are considered the only drug of value and the only drug we should be using in coronary prevention?

Statins reduce cardiovascular events and all-cause mortality in women: Meta-analysis

Mon, 30 Jan 2012 22:53:22 EST

Statins are portrayed as harmless drugs that almost everyone would benefit from, but little is proven in those without atherosclerosis. This met analysis really doesn't help. Blocking Cholesterol production is from the anti-cholesterol mythology extends far beyond the data. Cholesterol has been demonized, but Cholesterol is the difference between plants and animal. Statin side effects such as muscle problems, decreased mentation and increased risk of diabetes have been trivialized. Cholesterol has been demonized by the statin industry, and as a consequence Americans have become conditioned to avoid many foods and place almost magical benefit to statins.

Proximal balloon superior to distal protection in carotid artery stenting

Mon, 30 Jan 2012 22:50:46 EST

The occurrence of new cerebral ischemic lesions in 87.1% of the distal protection/filter group patients was significantly greater than in the proximal balloon occlusion patients. However almost half of the latter (>45%) still experienced a significant embolic trash load to their brain associated with carotid stenting, It seems unlikely that anyone who does not directly benefit from doing these procedures would consider this favorable safety and outcome evidence. The bottom line from CREST was that long term disability was most persistent and severe after stroke and that the 30-day stroke rate was significantly higher at 4.1% after stenting vs 2.3% after carotid endarterectomy.

3B or not 3B? Should patients get an LVAD before reaching end-stage HF?

Mon, 30 Jan 2012 22:26:49 EST

Was Dick Cheney in FC IIIb or FC IV before he had the LVAD?

Heart to Heart: Potential Impact of Optimal Implementation of Evidence-Based Heart Failure Therapi

Mon, 30 Jan 2012 19:07:39 EST

Physiologically, the followings are true: Beta-adrenoceptors expression is decreased in failing myocardium. All failing hearts have over-stimulation of sympathetic nervous system. Increase in FREQUENCY of stimulation is accompanied by reduced force of contraction. cAMP dependent force of contraction induced by Catecholamines (beta-adrenoceptors increases intracellular cAMP levels), is increased in both failing and non-failing myocardium. High concentration of beta-adrenergic agents increase frequency of stimulation followed by a decrease in force of contraction in nonfailing myocardium. In NYHA class IV, low concentrations of beta-adrenergic agents make force-frequency relationship positive, but high concentrations make that relationship negative. This is related to increase in intracellular cAMP, which increases IC Ca2+ to such a concentration that the process will impair force-frequency relationship. The phospholamban-mediated Ca2+ uptake in sarcoplasmic reticulum can be stimulated in failing heart by cAMP-dependent protein kinase, and this is true in both nonfailing and failing heart. Only moderate stimulation of cAMP is effective in improving myocardial function by facilitating diastolic Ca2+ sequestration with cAMP-dependent phosphorylation of phospholamban. Higher concentrations will decrease the force-frequency relationship by producing cytosolic Ca2+ overload. Peak and resting IC Ca2+ concentration increased in parallel with increasing stimulation frequencies of the heart, which will explain the ineffective CO in AF. Negative force of contraction associated with a frequency increase is not due to a reduced availability of the cytosolic Ca2+ but a diminished Ca2+ reuptake from the cytosol. Hence, pronounced elevation of IC Ca2+ will aggravate the negative force-frequency relationship. Those, who wrote the guidelines, approve beta-blocker use, which control adrenergic stimulation, as the answer to the problem of negative force of contraction in heart failure (HF), and Ca channel blocker use to control intracellular concentration of Ca2+. Physiologically, adrenergic stimulation got excessive in HF to compensate its negative inotropic effect. All failing hearts underexpressed beta-adrenergic receptors, and thus even a low-concentration blockade will completely annul the heart of its potential to increase its force of contraction by the physiologically produced catecholamines. It will be very hard for the practicing physician to appropriately titrate the optimal requirement in each situation, as the combination therapy that includes anti-arrythmic agents has already lower the heart rate at the expense of force of contraction. How are we going to achieve moderate increase in cytosolic Ca? The only answer is to carefully titrate a drug that can increase its force of contraction without effecting cAMP; the binding of Digitalis Glycoside (DG) to Na/K-ATPase induces MAPK signaling resulting in activation of Src (steroid receptor complex), and transactivation of EGFR. DG STIMULATED SRC BINDING TO NA/K-ATPASE IN A TIME-DEPENDENT MANNER (BELL-SHAPED CURVE). Experiments showed that ouabain-induced activation of MAPKs reached its peak after 5 min of treatment. DOSE-DEPENDENT EFFECT OF OUABAIN TO NA/K-ATPASE IS ALSO NOTED WITH CELLS NON-RESPONSIVE TO HIGHER THAN OPTIMAL CONCENTRATION OF OUABAIN. BEAR IN MIND THAT Both Src and EGFR Are Required for Ouabain-induced Activation of MAPK. Inhibition of protein tyrosine kinases by a nonspecific tyrosine kinase inhibitor or a relatively selective Src inhibitor will abolish ouabain-induced stimulation of MAPK. It is therefore, very important that Ouabain should not be combined with drugs that have effect on Tyrosine kinase (e.g., INHIBITORS: newer thrombin inhibitor, Genistein; newer nitrostyrene compound GPIIb/IIIa Inhibitors) or Src (e.g., STIMULATORS: oestrogen, progesterone, and aldosterone).

Heart to Heart: Potential Impact of Optimal Implementation of Evidence-Based Heart Failure Therapi

Mon, 30 Jan 2012 16:37:47 EST

In my comments above, the article that I mentioned did not take into consideration all possible combinations of factors, i.e., �nCr� = n!/r!(n - r)!, which are pathologically (REPEAT, NOT EPIDEMIOLOGICALLY) contributing HF. �Fractional Factorial Design�, an experiment based upon carefully chosen subset of combinations of factors, is in need of proving which combination of variables have caused in-hospital deaths.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Mon, 30 Jan 2012 12:46:08 EST

I find it worrying that the full names of the accused are mentioned here. In my opinion you are innocent until proved otherwise in a proper court of law. One can have his reputation ruined by an article like this. Everybody who now puts these colleagues names in a search engine will see theses accusations, and only the court will tell us if they are true or wrong. As much as I value heart.org for its surprisingly unbiased and balanced reports, I am disappointed about the publication of "suspects" names.

To prescribe or not to prescribe: That is the statin question, experts debate

Mon, 30 Jan 2012 11:57:57 EST

In Europe CHD incidences decrease from North to South. Cholesterol level do not. Same level of Cholesterol at Glascow and at Barcelone,but four fold less CV events in Spain compared to Scotland. We do not know if blood Cholesterol level is on the causal path of CHD. (we know it is linked to) Is there a decreasing North-East-South gradient of Cardio vascular events in USA too ? And Choesterol level too ?

Heart attack deaths plummet in three EU nations

Mon, 30 Jan 2012 11:47:34 EST

AtherO-sclerosis in arteries causes Hcy to go up? Kidney dysfunction predictably does but atherosclerosis? That's a new one. Evidence please. Also, where are the data that show that such-like curves are smoking or "lifestyle" caused: www.health-heart.org/Mortality_CHD_UK_QJM2012.pdf ? That curve concerns the U.K., one of the countries under discussion. Hcy "mobilizes" plaque? That too is a new one to me. If that is the case, a multi-vitamin should be helpful in your reading of the science.

Pathophysiology of Severe Familial Hypercholesterolemia: The Role of Apo B

Mon, 30 Jan 2012 11:38:51 EST

FH is Relative

Data mixed on role of parents and caregivers in combating childhood obesity

Mon, 30 Jan 2012 11:32:51 EST

The one simple strategy that parents and caregivers can implement immediately, at no cost, and with no special training is this: do not buy for, or serve to children large quantities of unhealthy food. If the kid is getting fat, feed them less.

Heart attack deaths plummet in three EU nations

Mon, 30 Jan 2012 11:07:02 EST

Hcy homocysteine is just evidence for atherosclerosis. The body uses this sulfur containing amino acid to mobile the plaque. Hcy is associated with atherosclerosis, not a cause. I agree with William Feeman, Jr there is just less smoking in Europe.

Cardiologists flagging woeful patient care say they paid with their jobs

Mon, 30 Jan 2012 10:41:01 EST

I was staff cardiologist at SCVMC from 1993-1997.There were patient care issues in that time frame that predated dr. Singh's arrival involving some of the same individuals.I know Dr. singh to be a highly competent,compassionate cardiologist and I believe she is pursuing the right path.I am saddened by the events.SCVMC provides a great service to the county of Santa Clara and was very devoted to patient care and teaching.

Heart attack deaths plummet in three EU nations

Mon, 30 Jan 2012 09:42:22 EST

Jamie, 1st a correction: elastin production is almost limited to media Smooth Muscle Cells and very few other cell types, i.e. not 'myocytes' as a whole and cardiac myocytes in particular. Re your 1st paragraph, we agree but I did not say NO repair is possible, but whatever repair, so show the trials, is very slow. Hcy also promotes clotting, LDL/apoB 'dysfunction' [clumping] and it affects virtually all proteins we have if they contain accessible lysine, cysteine or arginine and which proteins do not? I take HOPE-2 as supportive [and stand by my 25% depending upon how early you start]. HOPE-2 despite the short comings you mention and there are others, such as not enough money to monitor Hcy changes in a 70% already folate supplemented near 70 year old 40% diabetic population, with 12% already taking a multivitamin. 27.2% [!] were heavily medicated CAGB survivors. Is it reasonable to expect ANY repair in 5 years from a nice dose of Hcy lowering vitamins? One has to take the Hcy and stroke/CVD picture in context with the thousands of other studies [ex. see my links to the CDC data]. I took the luxury to attend the 5 day 6th Int'l HHcy conference in Germany some years ago. The myriad of pathways that are supportive of anything over minimal Hcy [~6 or 7�M] being deleterious are overwhelming and unidirectional. How do YOU explain first the rise and now the fall of the CHD epidemic? We're now precisely 100 years since the first description of MI [I counted 6 cases] in the English medical literature [Herrick in JAMA], and now we appear on the way down to low levels of folk dying of premature CHD. You mentioned large studies and JUPITER: selected down by ~35% through debatable selection and run-in/compliance criteria, it showed that rosuva for 1.9 years in 8900 consumers [all with some form of metabolic syndrome said Ridker] does NOTHING for cardiovascular mortality. THAT is a drug failure in a class with >100 side effects -vs- none from a no-iron OTC multivitamin that easily, cheaply and with certainty lowers an agreed risk factor. Cost for rosuva: well over $m17 [wasted doctor and patient time, incalculable]. The cost for the same period of high-dose no risk OTC multivitamin, about $700,000. In your 4th line to Dr. Blanchet you seem to regard multivitamins as 'drugs'. In fact it is [re] supplementation with essential micro-nutrients. You suggest I'm selective or one sided. True: the meta-tag of my website includes "cause and prevention" and I try and deal with cause, rationally rejecting things that are not. The lack of circulating prescription drug is never the cause of a disease, sub-optimal micro-nutrient conditions are hundreds. This week's issue of NEJM [p 327] suggests that in a 44% drop in CHD deaths, only 5% is attributable to statin, a called 'modest' drop in the bucket, if true, which it certainly is not for women. Interestingly, NEJM's 2012 cover pages celebrate its 200 year existence, the 1st 100 without the mention of heart attacks. Just a telling factoid.

Contaminated cardiac drugs kill more than 100 in Pakistan

Mon, 30 Jan 2012 09:29:42 EST

George, I agree to your posts to some degree. Yes, there is corruption at all levels of government and greed. And yes, the COL in other countries is much lower than ours. That being said, using inferior material to make inferior products and the lack of "proper" safety standards is what is at issue here. China is by far the largest exporter of many things, made often with material produed right there. Because there is very little if any international oversight, these inferior products get into the world's economy and people die or get very ill from it. Dog food has been contaminated (we lost a dog because of it), building materials are made inferiorly and cause illness, the melamine issue, the heparin issu, this issue, I could go on ad nauseum, all have their roots in one country--China. EVERYTHING is made there! Wal-Mart several years ago was proud to say that all we sell is made in America. No more. You can't buy ANYTHING hardly there that isn't made somewhere else. There's lots of reasons I could post for this problem---since they are all political, I won't list them here in order to stay on topic. There is NO reason for inferior products to be made. Our generic products have been proven just as safe and effective as the name brands and are cheaper. After the Big Pharma gets back what they spend on R&D, the profits should be reasonable---too much is spent on advertising and perks. Spending money for good quality materials to make our pharmaceuticals overseas for the "poorer" nations should be paramount, yet this is more of a moral issue,. I fall short of calling a boycot on China products. I really don't think it would work. But the blame of the deaths of so many people rests squarely on the Chinese government's shoulders here, and I won't take anyone blaming America in any way shape or form here on this issue.

Don't routinely replace spent ICDs: Proposal

Mon, 30 Jan 2012 09:03:51 EST

MADIT CRT sub-group analysis should be used to distinguish between the benefits of CRT-D and CRT-P (bi-ventricular defibrillator vs. pacemaker). This can be correlated with data from those patients who are in the ACC-NCDR for ICD registry who have had a generator change out. We really need to get back to evidence based standards - the data is there but it has been ignored by Medicare. I'm doing something about it. Jim Collins, CPC, CCC, President, CardiologyCoder.Com, Inc.

The Changing Landscape of Atrial Fibrillation. We Want To Know What You Think

Mon, 30 Jan 2012 09:02:04 EST

i have no disclosure

Cardiologists flagging woeful patient care say they paid with their jobs

Mon, 30 Jan 2012 08:30:01 EST

Why don't we change the name of this site to: theheartslander.org?

Cardiologists flagging woeful patient care say they paid with their jobs

Mon, 30 Jan 2012 08:19:22 EST

I totally understand what you are saying TT. Fear is a cloak that can be taken off and lain aside. Once removed, it is most liberating but more than that, makes one most productive. We should be inspired to purse our lips and blow the whistle whenever patient safety is compromised. Be fearless. Melissa

Salt, hypertension, and prevention

Mon, 30 Jan 2012 07:31:56 EST

Just wondering.

Heart attack deaths plummet in three EU nations

Mon, 30 Jan 2012 05:25:40 EST

Sorry I just didn't get the pregnancy analogy. But by your rationale any study where the primary end point occurs as frequently in those on the study drug as in those on the placebo tells us nothing? You say "failure to prove an outcome does not prove the opposite of that outcome." AIM HIGH does not tell us that Niacin is unsafe. It tells us 1500 taking the drug for 3 years had the same number of end-points as those taking the sugar pill. I expect you would get the same result if you gave the 1500 people a glass of water instead. You can always argue that the trial is underpowered. But, really if you need to give tens of thousands of patients a drug for decades to show a small benefit I'm not sure it's worth it. I appreciate that AIM-HIGH is controversial, just like JUPITER, COURAGE, STITCH and many others. They will be debated for years, or until a bigger study comes along.

Carotid images don't boost quit rates or cut CV risk factors in smokers

Mon, 30 Jan 2012 05:21:39 EST

As Dr. Blanchet pointed out, the study design does not support the headline of "heartwire" at all. This study only shows that carotid imaging adds little with patients who are already convinced to try stop smoking, whereas it may still be true, that it boosts quit rates and cut CV risk factors in those persons not "ready" to quit yet. Hopefully none of our fellow readers will stop showing carotid imaging to his smoking patients just because heartwire summarized it's not worth it !

Contaminated cardiac drugs kill more than 100 in Pakistan

Mon, 30 Jan 2012 04:26:18 EST

Thanks for your post Melissa. I am a pharmacist and an interventional fellow in cardiology. I have no affiliation with China at all. The issues here are complex. Firstly I feel a deep sympathy for the exploited workers who work in horrid conditions to support there families - and why? To support the insatiable demand for all types of goods at the cheapest price from us in the affluent west. Would we be willing to pay $10000 for a laptop computer if it meant that it was produced in the united states or australia? No chance. It is out societies that believe that all people can have anything they want at the cheapest price. Its simply not feasible. If China were to improve the working conditions and quality of its products, the cost increase would be enormous and many people would have to go without as they simply wouldn't be able to afford it. Are we willing to do that? The majority are not. The pharmaceutical industry is a huge part of the problem. These nations should have cheap medications supplied to them. This would solve the problem. Until society realises that we can't have everything we want at the cheapest price, the demand for these goods will drive the exploitation of our fellow human beings. James all governments are marred by corruption. Overt and covert. And I must not forgot the model example of an equitable healthcare system that the US represents. Has congress reached a consensus regarding "healthcare priorities" for its citizens? A country where consultants boast of performing "more than 1500 coronary interventions yearly" to the wealthiest of the community leaving those without insurance grossly undertreated. Where transfers from hospital A to be B result in multimillion dollar payments as the family physician struggles to pay his/her bills. It makes little sense to criticise and try to fix anothers backyard where our own is in a state of disrepair. Thanks

Carotid images don't boost quit rates or cut CV risk factors in smokers

Mon, 30 Jan 2012 01:40:02 EST

The value of atherosclerosis imaging is not in improving the resolve of those already seeking to quit smoking. There are a hundred reasons to quit smoking, add the presence or absence of carotid plaque, there is still the same net impetus to quit. Atherosclerosis imaging is however very useful in demonstrating risk to those who assume they have not risk. In someone not already seeking help to quit, it might indeed motivate such behavior. That has certainly been my empiric observation in my practice.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Mon, 30 Jan 2012 01:21:50 EST

For 20 years I did do pre-operative stress tests, some nuclear and I used stress testing to stratify risk among patients with risk factors. I have walked in those shoes and based on current information feel that for 20 years I did the wrong thing. Over the last 5 years, I have needed so few stress tests that I have abandoned performing them myself and refer out the 3 or 4 patients a year whom I feel would benefit from them. Since I have nearly abandoned exercise stress testing and stress imaging (nuclear as well as echo), the incidence of MI and coronary death has only further decreased in my practice.

Contaminated cardiac drugs kill more than 100 in Pakistan

Mon, 30 Jan 2012 01:18:22 EST

First I lived in Europe, never China. But my daughter lived in Chengdu, Sichuan while in college. Her friend (also blond and blue eyed) lived twice, each for a year while her father taught English in elementary and high school. She speaks Chinese like her dad, and she worked for year in Beijing, after graduating college. My opinion is based on their views (my daughter is now in Pharm school, her friend is studying international law). China was for a large part of the last two millennia was the world's largest economy. Only in the 16 century did this change. The political system is partly decentralized and is marred by corruption. Heads will need to roll. Like the tainted vaccines, the melamine scandal is a story about local officials sacrificing the health of Chinese citizens to make a profit. Factories that produced the tainted milk were able to slide through the regulation pipeline by partnering with local government officials. The Chinese government announced a new set of health-care priorities. These goals include strengthening the rural health insurance system and raising production standards for pharmaceuticals. But the government's health-care wish list ignores the corruption, greed and mismanagement that are key barriers to providing essential medical care. These issues are clearly illustrated in what will likely be this big scandal.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Mon, 30 Jan 2012 01:09:30 EST

If a patient has atherosclerotic disease, they should be on a statin peri-operatively and if they can tolerate it, a beta blocker. There is reasonable DATA to support that position. The presence of atherosclerotic disease can easily be determined by simple coronary calcium imaging. Stratifying risk by stress imaging is useful in predicting poor outcomes in those with significant ischemia. I am unaware of any studies demonstrating improvement in that fact by pre-operative revascularization. I agree,that those with massive plaque burdens can benefit from a pre-op stress test to help them make the decision as to whether or not they want to take the risk of surgery. We do not have the evidence to say that it would improve outcomes. Current evidence would suggest that it does not.

Heart attack deaths plummet in three EU nations

Mon, 30 Jan 2012 00:58:44 EST

If you really think that AIM-HIGH being stopped early proved the lack of benefit from niacin, you are misunderstanding a major principle of logic and statistics. Failure to prove an outcome does not prove the opposite of that outcome. The fact that AIM-HIGH was determined to not show promise to prove a benefit from niacin does not begin to prove that niacin is of no benefit. It simply proves that the study, for any of a myriad of reasons, failed to show a pre-specified outcome. Although lack of benefit from niacin is a possibility, it is a very unlikely possibility considering the prior studies showing significant benefit. Math logic 101, if a study fails to prove its endpoint, it does not prove the opposite of the endpoint. Example, we do a study to prove that pregnancy requires sexual intercourse to occur. As it turns out, there is no statistical difference between the frequency of sexual intercourse among those who get pregnant and those who do not. This study fails to prove the association between sex and pregnancy but it certainly does not prove that pregnancy does not require sexual intercourse. (although, as most cardiovascular experts seem to understand studies, it would)_ This fact is also true for the homocysteine studies that have failed to show benefit. It takes a much more rigorous and larger study to prove lack of benefit than any study ever performed looking at homocysteine treatment. That said, I am not a big proponent of treatment of homocysteine as in my experience, it does not seem necessary when other risk factors are adequately controlled and the subject is on aspirin. That said, I am appalled by the simple mathematic and statistical ignorance of so many "experts" mis-interpreting studies.

Cardiologists flagging woeful patient care say they paid with their jobs

Sun, 29 Jan 2012 22:09:14 EST

Here is a story of 2 physicians doing the right thing and only 2 comments. The other story ALLEGING wrongdoing by physicians and there are over 15 comments that have tried and convicted them, with some posters saying that they deserve jail time. This, my friends, underscores what's wrong with American medicine. Physicians are always guilty until proven innocent, especially by our own colleagues. We all should be ashamed of ourselves. TT

What life-threatening condition is shown in this ECG (II)?

Sun, 29 Jan 2012 18:32:45 EST

Yes, it is a continuous strip. The wider QRS intervals in the upper and lower strips are the end of the Wenckebach cycle such as 6:5, 4:3 or 3:2 of the driving rhythm, and is shorter than the two cycle lengths of the driving rhythm, while those in the latter part of the middle strip are indeed 2:1 exit block of the driving rhythm, i.e. two cycle lengths of the driving rhythm. That is why the latters are a little longer than the formers. Again, uncomplicated atrial fib will never manifest as paired QRSs as noted in the first half of the middle strip or perfectly regularly occuring QRSs noted in the later part of the middle strip.

Contaminated cardiac drugs kill more than 100 in Pakistan

Sun, 29 Jan 2012 18:26:33 EST

I'm certain this issue is exceptionally complex. However, before one can dig a hole, he must first remove the top layer of dirt. "China" is the common thread. All roads lead to home but from there all roads begin as well. Everyone who is guilty deserves to be punished no matter with what country they are affiliated. If graft leads to human harm..no stone should go unturned. Curious as to your affiliation with the medical field or ?China. Appreciate your post. Melissa

Heart attack deaths plummet in three EU nations

Sun, 29 Jan 2012 18:14:24 EST

In your above post you tell us you believe that lowering homocysteine cannot repair the pre-existing damage to the arterial wall. I agree with this as multiple RCTs have proven the neutral result of vitamin therapy for secondary prevention. You explain that B-vitamins need to be taken from young adulthood to have their beneficial effect. I guess this is reasonable (although difficult to prove). BUT, on the other hand you use the findings of decreased stroke in HOPE-2 as proof of benefit of B-vitmains! You cannot have it both ways, Eddie. You can't say that the reason HOPE-2 is neutral overall is that B-vitamins cannot repair damaged arteries and need to be given pre-emptively to show benefit, but that they also reduce the risk of stroke in 5 years. You wonder why the authors of HOPE-2 did not include the graph of stroke. Isn't this blindingly obvious? Because they did not feel they were seeing a true effect. The discussion I posted previously makes this crystal clear. To summarise: 1 - there were small numbers of strokes, giving wide confidence intervals 2 - the positive p-value was not adjusted for multiple outcomes 3 - there was no effect on TIAs which makes it hard to propose a mechanism 4 - other trials have shown no benefit "We believe that the apparent beneficial effect of B vitamin supplements on stroke in our trial may represent either an overestimate of the real effect or a spurious result due to the play of chance." Don't forget that the authors invested years of their lives into this study. I'm sure they were as disappointed as you in the final results. No one's trying to hide data or cover something up. However on your website, which is directed towards the layperson, who may be trying to make sense of why their loved one has had a stroke and they read this: "You can't change your genes or gender and may never know your homocysteine level so taking a high 'potency' multi-vitamin + mineral supplement is brilliant prevention, even helping 'bad genes' and leveling the gender gap for men. Such 'anti-rust' vitamins slowly repair existing damage resulting in 25% fewer strokes." (An absolute risk reduction of only 1.6%, mind you!) You show a reprint of your precious graph but you include NOT ONE single qualifying sentence outlining the authors' own concerns regarding this outcome. Not only do you contradict yourself regarding whether or not B-vitamins can repair the "rust" or not but I am sure that the vast majority of readers will agree that you vastly overstate the known benefits of multiviatmins. At best you are being ignorant but I would go so far as to say you are being deliberately misleading to the public. There are numerous other errors, omissions, and lack of balance on your website.

Heart to Heart: Potential Impact of Optimal Implementation of Evidence-Based Heart Failure Therapi

Sun, 29 Jan 2012 17:35:06 EST

Physicians usually avoid Digitalis glycosides use in HF because of safety concerns. I have' nt seen your conference mentioning its use, even though 2005 ACC/AHA guidelines mentioned its use in patients with HF who remained symptomatic after taking Diuretics and ACEI, as well as those who are in AF and who require RATE CONTROL. As per the following article, DIGOXIN use is not associated with in-hospital deaths among patients with HF: Tribouilloy C, Rusinaru D, Leborgne L, et al. (2008). "In-hospital mortality and prognostic factors in patients admitted for new-onset heart failure with preserved or reduced ejection fraction: a prospective observational study. Arch Cardiovasc Dis;101(4):226-34. As per that article, those who were died in hospital the followings were observed in overall patients at the time of deaths: Total admission = 799; Alive = 735; In-hospital deaths = 64 ACEI use: 11.5% Beta Blocker: 15.6% Loop Diuretic: 19.7% Aldosterone Antagonist: 9.8% Ca Channel Blocker: 11.5% Nitrate: 14.8% Angiotensin Receptor Blocker (ARB): 4.9% Amiodarone: 3.3% Oral Anticoagulants: 6.6% Anti-Platelets: 26.2% Digoxin: 8.2% As far as causes of deaths are concerned, the followings were observed: Age: 80.3+/-11.2 NYHA Class III-IV on admission: 98.4% SBP on admission = HR on admission >100bpm: 55.6% CHD: 65.6% Hypertension: 54.7% AF at baseline: 25.0% LBBB; 14.1% Diabetes: 23.4% GFR (ml/min/1.73sqm): 49.1+/- 25.3 Upon multivariate logistic regression analysis, the following factors were observed as predictors of in-hospital mortality among overall study population: CHD (p SBP on admission = older age (p=0.001) HR on admission .100bpm (p=0.002) Among patients wherer EF are assessed, the followings were associated with higher in-hospital mortality: CHD; SBP on admission =<100 mmHg; estimated GFR =<60 ml/min/1.73 sqm; reduced EF (<50%).

MR beats out SPECT in CE-MARC crossover trial

Sun, 29 Jan 2012 17:27:28 EST

FHRWW has been demonstrated to represent physiologic changes by analyzing changes in isotope over time. There are several peer review publications now available demonstrating the parabolic relationship. Our prior work has defined the relationship between %DS and SFR, which when been coupled by software.

Vytorin US label updated with SHARP results

Sun, 29 Jan 2012 17:07:54 EST

Isnt this the drug that the company tried to change the primary outcome data on??...say no more.

Heart attack deaths plummet in three EU nations

Sun, 29 Jan 2012 11:06:09 EST

Dear Jamie, I knew the man originating HOPE-2 and saw its graphs before publication. To my surprise they forgot to give she stroke graph that later was published in correspondence. There are 'coulds' and 'may' in the discussion for which there is no evidence. You misunderstood what I was trying to convey by stating: "You seem to claim that showing the benefit of homocysteine lowering on secondary prevention would be difficult as "a dry garage does not fix a rust hole in a car". I meant to indicate the apparent irreversibility of the [bio/chemical] processes involved. ~50% of the protein in artery is elastin with a reported half life of 40 or 70 years; regardless the exact number in an individual, it is extremely long and the main if not only cell type generating it being the arterial myocyte. I have come to consider that arterial damage is first and foremost a disease of elastin decline that, later, allows myocytes to migrate and try and reestablish some kind of structural integrity but without being able to generate the architecture we had at origin. While collagen and near basement (and basal) membrane structural proteins may regenerate faster, they too require the basic micro-nutrients in those processes. You looked at my site but did that include www.health-heart.org/why.htm ? Back to stroke, the last paragraph in that link has 2 links to what's happened in stroke and CHD deaths in the U.S., phenomena in line with the current Forum item. Here are those links; see Fig. 2 here: http[COLON]/circ.ahajournals.org/cgi/reprint/113/10/1335.pdf and, also from the CDC, re stroke deaths: www.medicalnewstoday.com/medicalnews.php?newsid=6369 To conclude, I'm arguing for the life-long benefit of a dry garage, i.e. by going through life with B-vitamin intakes non food processing mammals consume.

Contaminated cardiac drugs kill more than 100 in Pakistan

Sun, 29 Jan 2012 05:59:49 EST

I find your response interesting. The fundamental issue here is the pharmaceutical industries lack of social conscience when it comes to supplying these medications to those in poorer nations at just above cost. Whether it be HIV drugs or cardiovascular medications. These donations would probably even be tax deductible. The industry generates huge profits from the sale of these medications to richer nations and this should be used to subsidise medications to poorer nations. This would effectively eliminate this underground industry. Should these people go without medications? Im sure if I were a citizen of a poorer country I would I take what was given to me?. It would be a calculated risk. The heparin fiasco of 2008 comes to mind. The drug company outsourced a key aspect of manufacturing to a chinese facility to cut costs! Yet who was criticised ? - the manufacturing industry in China. The real victims are the sweat shop workers of mainland china and those in the third world who are forced into this position by pharmaceutical company greed. And the greed of all of us in affluent nations that demand there products. One final comment - the manufacturing industry in China is responsible for the computers we type on, the clothes we wear, the cars we drive. Much of our quality of life from the goods we use comes from the despair and exploitation of these masses. A sobering and at times distressing thought. We would all be willing to pay 3 times as much for our laptop computers to bring the condition of our fellow human beings to an acceptable level? Point - The issues are not as simple as you may think. Regards George

Heart attack deaths plummet in three EU nations

Sun, 29 Jan 2012 05:20:19 EST

I asked for primary prevention as that seems to be one of your bugbears with the statin evidence. I'd be happy with secondary prevention trials. You seem to claim that showing the benefit of homocysteine lowering on secondary prevention would be difficult as "a dry garage does not fix a rust hole in a car". This goes against the prevailing wisdom that drugs which treat CVD will show more benefit in those with the highest risk, and who could have higher risk than those who have had an event? In your analogy rust may cause one door to fall off but the dry garage may prevent rust making the other door fall off. Let me close with the discussion from the HOPE2 trial. "With regard to the risk of stroke, we observed an absolute reduction of 1.3 percentage points and a relative reduction of 24 percent among patients assigned to the active-treatment group. However, these results must be interpreted with caution. The number of strokes in our study was much lower than the number of coronary events, the confidence intervals around the estimated risk reduction are wide, and the results are not adjusted for the multiplicity of outcomes compared. Also, we found no effect of treatment on transient ischemic attacks. From a biologic perspective, a treatment benefit restricted to stroke would be difficult to explain. Furthermore, the two other large trials of homocysteine-lowering vitamins that have been completed did not show a beneficial effect of treatment on stroke.13,14 Therefore, we believe that the apparent beneficial effect of B vitamin supplements on stroke in our trial may represent either an overestimate of the real effect or a spurious result due to the play of chance. Ongoing trials and a meta-analysis of all homocysteine-lowering trials16 should be able to clarify this issue. The discordance between the epidemiology of homocysteine and the results of the clinical trials completed to date is similar to that noted for antioxidant vitamins17 and estrogen18 and may be related to inherent limitations of observational studies. Indeed, homocysteine levels are related to renal dysfunction, smoking, elevated blood pressure, and other cardiovascular risk factors and are higher in people with atherosclerosis than in those without.4 Therefore, homocysteine could be a marker, but not a cause, of vascular disease, and the epidemiologic data could be the result of residual confounding that cannot be fully adjusted for, of reverse causality, or of both. Our findings may also relate to exposure to folate-fortified food in over 70 percent of the study patients. This exposure probably reduced the number of patients with substantially increased homocysteine levels, the subgroup that might be most likely to benefit from B vitamin supplementation. Several large trials are further exploring these questions.16 In conclusion, combined daily administration of 2.5 mg of folic acid, 50 mg of vitamin B6, and 1 mg of vitamin B12 for five years had no beneficial effects on major vascular events in a high-risk population with vascular disease. Our results do not support the use of folic acid and B vitamin supplements as a preventive treatment." Seems sensible to me.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Sat, 28 Jan 2012 18:14:30 EST

We cannot predict events with any certainty. Deal with it. There is no study showing intervention on patients with nuclear stress test abnormalities improves peri-operative prognosis in individuals undergoing non-cardiac surgery. So with all respect to Dr Eagle (who championed this) this notion of predicting and protecting has been an epic failure however well intentioned. But we are expected to do the impossible and I entirely agree with Dr Walton Stanley for all the wrong reasons.

Vytorin US label updated with SHARP results

Sat, 28 Jan 2012 18:02:21 EST

Without offending you in any way please tell me how niacin after AIM HIGH is any different than Ezetimibe. Can we agree that there is an uncertainty about prognosis beyond maximal stain based LDL reduction?

Data mixed on role of parents and caregivers in combating childhood obesity

Sat, 28 Jan 2012 14:32:04 EST

1. The FDA must heavy tax and stop support by subsidies hydrogenated fats and HFCS-High Fructose Corn Syrups production in the US food industry. 2. Fresh fruits and vegetable need organic fertilizer and not just the common, cheap Haber based fertilizers. The high nitrate and low sulfate foods leads to obesity and atherosclerosis. The cheap, Haber�Bosch process is the nitrogen fixation reaction of nitrogen gas and hydrogen gas, over an enriched iron or ruthenium catalyst, which is used to industrially produce ammonia. 3. The GMO-Genetically Modified Organisms affects fat metabolism. Just eating a corn chip produced from Bt corn that transform our intestinal bacteria into living pesticide factories, possibly for months. 4. Prudent summer sun exposure without SPF lotions will improve immunity and decrease adiposity, especially for children.

Carotid images don't boost quit rates or cut CV risk factors in smokers

Sat, 28 Jan 2012 13:52:38 EST

You are right,one thing is how our healthcare system should be and another one is how it works in the real world.In my country(Argentine) the things work just like in yours.

Heart attack deaths plummet in three EU nations

Sat, 28 Jan 2012 10:25:19 EST

I you asked me for PRIMARY prevention studies and I tried to supply some of the supporting data. I would argue that secondary HOPE-2 despite its impediments finding benefit trumps the balance of the nil benefit studies but indeed what all these studies show is that lowering Hcy does not repair the elastic laminae or remove the atheroma. Neither no drugs. Sure, these results are disappointing as well as revealing as to cause and processes. A dry garage does not fix a rust hole in a car either but it does remove the cause of that decline. Quitting cigarettes does not cure the cancer. You bring in statins and state they lower mortality yet all published studies demonstrate that this is not the case for women. Ditto for all atorva, lova, fluva, ceriva studies and CV deaths from rosuva**). The lack of mortality benefit from statins was not for lack of money or trying. That, too, is telling re cause and processes. With all due respect, mega-niacin has not been disproven; the CDP was relatively small and showed some benefit -- but we now know that B-3 should not be taken without the complement of the other B-vitamins [it was not in CDP] something ditto for the fibrates that also raise Hcy. I do not appreciate being called a "conspiracy theorist" while a request for type 1A recommendations re the minor nutrients is not appreciating a century of data and biochemistry supporting their role. Remove B6 and no x-linking in collagen and elastin in lab animals, and arteriosclerosis in primates: simple. Have a look at the B-M Biochemical Pathways chart Part #1, any biochemistry handbook, or subscribe to AJCN. **) JUPITER: p=0.0001 for non-fatal effects but 0.37, 0.54 or 1.0 [depending upon where/how they report] for CV deaths. My interpretation: all that benefit is via the NO/eNOS pathway, otherwise CV deaths would have been lowered and it was not. You say that arguing differently is 'ludicrous' well maybe not so much. How do YOU explain these findings?

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Sat, 28 Jan 2012 07:59:24 EST

Hold on there.........There are numerous studies suggesting that if no reversible defects are present upon nuclear stress testing, then peri-op events are low. If defects are small-events are low. It is not fraud. It's common sense. As for a negative calcium score, I'm hip to that! but most patients in a cardiology practice (1) don't have a negative calcium score (2) aren't good candidates for scoring because they are on their second bypass surgery or 100th PCI (no snide comments here, just explaining WHO comes into our officeto ask if they can have their knee replaced safetly, and (3) have had a calcium score of a billion counts for years and need to have elective surgery. It is up to US as cardiologists to sort the risks. You can argue all you want, but in 20 years of using nuclear testing and stress echo, I have had ONE patient to have an intraoperative complication (who had multivessel disease, prior PCI/CABG, cancer, Aortic valve disease with renal cell carcinoma. His stress test was mildly abnormal and he was on excellent meds.Unfortunately it happened (suspect hypercoagulable issues) but fortunately, he survived and did well. As an aside, the competing hospital where he had his surgery was positively GLEEFUL that he had a complication. He is now in another cardiology practice though we remain friends. He is under the impression that I "missed something" even though I told him he was NOT cleared for surgery (never utlized the word 'cleared' in my life), but rather going to surgery at low to moderate risk on good meds. I love your passion for calcium scoring and utilize it often in those we are trying to sort. But in patients who have already been sorted into the higher risk categories, those of us who have to do further sorting (namely CARDIOLOGISTS (the master risk stratifiers upon whom everyone depends but still throw rocks at us for doing "too many tests" ) still can't resort to iridology or sooth saying, as much as I'd like too. (though recently, I told a patient that I was better than the local iridologist. I didn't even have to look in his eyes, merely at his ECG to know he had a tight proximal LAD lesion). :) To manage a patient peri-op to the best of our capabilities: We need an echo (to help manage fluid rates and advise with regard to the best method to correct intraop HOTN -induction issues) and we need a stress exam-- YES, I still give beta blockers in my office to prepare folks for surgery if ischemia or tachycardia are present. I rarely get called to bail anyone out who has been adequately stress'd, echo'd and medicated for surgery. Until you've walked in our shoes, you CAN NOT fathom how helpful risk stratification can be with stress echo or stress nuclear. COURAGE trial does not apply here. These folks are going for surgery. I am NOT ONE BIT DETERRED by the stone throwing. If it were my dad (and it has been), he'll get an echo/stress of some sort and a review of his meds STARTING with a good history and physical. Like Newt's recent campaign song (and no, I haven't made up my mind who I'm going to vote for).- HOW DO YOU LIKE ME NOW? Melissa

Contaminated cardiac drugs kill more than 100 in Pakistan

Sat, 28 Jan 2012 07:35:51 EST

....time to pay attention. We've heard it before haven't we? Melissa

Vytorin US label updated with SHARP results

Sat, 28 Jan 2012 07:09:05 EST

Baigent added: "We believe the action does not send out a clear enough message about the benefit of Vytorin in this particular group of patients." That's because the benefit of ezetimibe in CKD is clearly doubtful!

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Sat, 28 Jan 2012 04:08:15 EST

I am a physician and not a judge, and In my opinion the above reported fraudolent use of medical practices by performing unnecessary cardiac and vascular surgeries and interventional procedures, must stimulate the rising in each clinical institution over the world of the Heart TEAMs (toghether everyone achive more) including cardiac surgeons, interventional cardiologists, clinical cardiologists, and so on in order to decide properly what to do in each single patient beyond all discutible manner.

Heart attack deaths plummet in three EU nations

Sat, 28 Jan 2012 03:51:27 EST

You say the RCT looking at folate treatment to lower homocysteine and reduce cardiovascular disease would be unethical and would never be done. Are you blind to the fact that this exact question has been addressed in several large RCTs and the result is neutral? You can argue around the edges that the populations they chose were wrong or that the dose of folate was wrong etc but the results of the trials cannot be disputed. Unfortunately, despite several observational studies suggesting that lowering homocysteine would be beneficial the final verdict is that it doesn't do anything worthwhile at all. This is hardly the first time a RCT has disproved a firmly held belief. The literature is littered with examples - vtiamin E, hormone replacement and now niacin to name a few. On the other side we have statin therapy which has been shown time and again to reduce total mortality, cardiovascular mortality and cardiovascular events, especially in secondary prevention. To argue otherwise is ludicrous. Getting back to your cereal fortification as the sole explanation of a 50% reduction in CV mortality in the last few decades. Can you actually say this with a straight face? Actually a number of other important advancements have been made over the same time: the development of evidence based medicine, widespread population education of the risk factors and warning symptoms, rise of litigation leading to defensive medicine, widespread use of primary prevention risk factor modification, public health initiatives, endless research, rise of the CCU - I could go on for some time here. Why choose vitamin supplementation in cereals as the main cause (or even an important cause? I've read your website and I'm dismayed by your biased discussion regarding vitamin supplementation and statin use. Like a conspiracy theorist you leap on every favourable shred of evidence for vitamins and ignore multiple positive data regarding statins. Why don't you subject your analysis of vitamins to the same rigour as you do the stain debate? Better yet - go through the data on vitamins and assign each point a class of recommendation and the level of evidence. Come back when you find some Class 1A recommendations.

Cardiologists flagging woeful patient care say they paid with their jobs

Sat, 28 Jan 2012 00:07:14 EST

Lisa Nainggolan is to be commended for her outstanding report, not only for its thorough and fair treatment of the issues but making the unspoken case for greater whistleblower protection. This investigative reporter has reviewed several similar cases that revolve around the same scenario--David v. Goliath. Even if complainants receive a monetary settlement it only comes after long delays that benefit the defendants,loss of income,and the stigma of being a troublemaker. The process is often so convoluted and contentious that legitimate complaints never get filed. The ultimate losers are patients. Powerful forces have conspired to defeat corrective legislative action.

Cardiologists flagging woeful patient care say they paid with their jobs

Fri, 27 Jan 2012 23:09:46 EST

You will be rewarded in the end. If that is the case, I applaud you. There are so many subtle ways in which patient safety can be compromised and it is very difficult indeed if one is not in the thick of it to be able to see it. It is difficult yet to prove it days, weeks or months after the fact. Always keep your notes handy. Dates, times, circumstances. Always be on your guard in a constant state of readiness so if you are asked to defend your stance, you can reproduce it immediately and without hesitation.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Fri, 27 Jan 2012 21:06:24 EST

Considering that a coronary calcium score is dramatically better than a stress test in predicting risk and has even been shown to be more predictive than a coronary angiogram, I am amazed that it is not routinely used for the purpose of pre op assessment. If the calcium score is greater than 100 or places the patient in the top quartile of risk, they should be placed on a statin for peri-operative protection. One could argue that most pre-op nuclear stress tests are "unnecessary" and the Feds should go after anyone who does pre-op eval using nuclear imaging for fraud.

To prescribe or not to prescribe: That is the statin question, experts debate

Fri, 27 Jan 2012 13:01:58 EST

"women are at a much lower risk than men from coronary disease anyway". (Redberg) Heart disease is the #1 killer of women, buy a large margin over other diseases. Being a woman does not protect you from heart disease. The gender bias has huge impact on women getting appropriate treatment for a heart attack, and women have a higher risk of dying from an MI than a man. What is the statistical difference between men and women and heart disease?

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Fri, 27 Jan 2012 12:24:35 EST

My wife was going to get a knee procedure so he primary told her to get a stress test. It was done by a cardiologist and the report came back that all was VERY good. Then during the follow up consultation he tells her those things are not very accurate so he propose to look at her heart through the insertion of a camera in her thigh. She told him she just had a mastectomy and and other surgical procedure without this stuff. He said then he wouldn't OK for thee knee procedure. It sounded like black mail so she will not go back to him!!

Heart disease risk begins with middle-age risk factors

Fri, 27 Jan 2012 12:17:19 EST

In conclusion, in addition to such traditional cardiovascular risk factors as past history, diabetes mellitus, aging, systolic blood pressure, oxidative stress (lipid peroxides), and AGE (pentosidine) are associated with extensive coronary artery calcification. Lipid peroxidation and glycoxidation may be involved in the pathogenesis of coronary artery calcification.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Fri, 27 Jan 2012 11:56:58 EST

Is it not necessary to rule out dig toxicity prior to decision making for a perm pacemaker?

Heart attack deaths plummet in three EU nations

Fri, 27 Jan 2012 11:53:10 EST

Dear Melissa, I trust that you are not saying that while Hcy is an undisputed 'major' independent risk factor, it cannot be a 'major' cause of vascular disease. If you meant that Hcy lowering does not reconstitute the elastic laminae, make stronger fibrous caps or remove a protruding atheroma, then we have consensus. The topic here is mortality. We know for a fact that the factual reintroduction of B-vitamins [that lowered Hcy] MAY have played a role in reducing CHD/CVD deaths. [Ditto for n-3's.] We also know for a fact that statins did NOT play a role in reducing deaths in women. How then does anyone explain the statement in the latest U.S. Womens Guidelines that age-adjusted deaths from CHD dropped 2/3rds from 1980 to 2007? That is massive. An interesting quandary.

Contaminated cardiac drugs kill more than 100 in Pakistan

Fri, 27 Jan 2012 11:15:22 EST

Keywords: bulk raw materials from China and India. Heavy metal contaminated food and drugs from China, again and again. The rich get brand medications. The poor get the generics which are made from the above contaminated raw materials. A corrupt system forces hospitals to buy the cheapest source. In a system that no monitoring or checks system. Game over

Heart attack deaths plummet in three EU nations

Fri, 27 Jan 2012 11:02:03 EST

Jamie, you know well that there are no such comprehensive trials, they would be impossible and unethical. Who would volunteer to have their kids on a placebo vitamin and then be followed for as long as it takes to develop atheromas that can be extracted or at least measured. You'd have to prevent the placebo group from consuming any ready made cereals since they contain a multi-vitamin [causing the massive drop in CHD deaths, I propose, since ~1962 when such addition became mandatory]. THERE is your population study! You call it rubbish but a conference in the 1970s about this stunning drop had no other explanation -- no known risk factors had changed. After folate addition almost 20 years ago, the CDC reported a massive increase in the decline in CHD and stroke deahts [accompanying the >10% nation wide drop in Hcy]. THERE's your other population study. In secondary prevention, they even gave a low dose actual vitamin in already folate supplementing Canada in HOPE-2 yet they did find a p= About magnesium .. who would volunteer to a regimen consumed by MOST mid-aged N. Americans of NOT meeting the RDI/DV of magnesium? It has been reported decades ago that 11% of MIs are related to low magnesium status. No placebo trials have been conducted, but MgSO4 intravenous has not been discredited but abandoned for more profitable drugs. I believe the ONLY positive aspirin non-fatal MI preventing study (in men) was with a magnesium buffered form. Coincidence or cause? www.health-heart.org/why.htm has a comprehensive Hcy/B-vitamin story and 2 RCTs are here www.health-heart.org/HIPandHOPE.gif. You mention women: they go through life with just over 10-15% less Hcy than men and get CHD just 10-15 years later, and it ain't estrogen, or cholesterol for that matter. Females simply have to be more efficient with the B-vitamin / Hcy / methylation pathways to generate healthy offspring, a pressure not on the males of a species. I agree it's hard to prove the negative by you're unsupported with your affirmation "To suggest that vitamin B supplementation in cereals is responsible for a 50% reduction in cardiovascular mortality is total rubbish.

Heart disease risk begins with middle-age risk factors

Fri, 27 Jan 2012 10:37:54 EST

I can not believe hat this study uses total cholesterol (CT) as its lipid predictor. CT is a lousy lipid predictor, and no one who wants to accurately predict the population at risk of atherothrombotic disease (ATD) should ever use CT. One's ability to predict depends on one's data, and in this case the data is flawed--so accurate predictions are not possible. A CT of 184 mg/dl or less will pick up most ATD patients, but will also require treatment of many people not at risk of ATD. It's the old law of diminishing returns. The NCEP initially proposed using CT in 1988, but quickly got away from that standard in 1991, so why are Berry et al using CT?

Aspirin in primary prevention: New meta-analysis finds bleeding outweighs benefits for most

Fri, 27 Jan 2012 08:08:15 EST

Could not agree more with your post. I calcium score of 600 just had a "normal cath" after a stress echo that was with such horrendous images that I could not interpret. He wishes to run, condition, etc. had a little chest discomfort with extreme emotional discussions. A nuclear suggested "distal lateral wall reversibility of moderate degree in a small segment". Excellent exercise duration. Courage trial argue for med therapy. His wife insisted we make certain he is "OK" to do these extremely strenuous workouts. A "normal" cath now reassured me wasn't having high grade fixed obstructive based angina, so we cannot mechanically intervene, but he will still receive instruction for nitro prn, and a referral to an excellent primary and secondary (secondary from his perspective due to established wall disease) prevention clinic.

To prescribe or not to prescribe: That is the statin question, experts debate

Fri, 27 Jan 2012 08:06:26 EST

http://www.theheart.org/article/1344241.do

Heart attack deaths plummet in three EU nations

Fri, 27 Jan 2012 07:56:17 EST

hypothesis is dead......though Freddie Kruger, Jason and others have been known to resurrect, only to be slaughtered unmercilessly once again. Melissa

Heart attack deaths plummet in three EU nations

Fri, 27 Jan 2012 05:53:19 EST

Surely you jest? This "study" was non-randomised. Also it studies secondary prevention, not primary and included almost no women or elderly. In fact only 140 people received treatment at "physician discretion". See CHAOS-2, VISP, WAFACS, HOST, HOPE-2, WENBIT, NORVIT, and SEARCH for the results of the RCTs. And the corresponding meta-analyses. To suggest that vitamin B supplementation in cereals is responsible for a 50% reduction in cardiovascular mortality is total rubbish.

Carotid images don't boost quit rates or cut CV risk factors in smokers

Fri, 27 Jan 2012 02:35:32 EST

I completely agree, Alberto, however in today's reimbursement in the US, if a physician does not want to go bankrupt, the time with each patient needs to be less than 15 minutes. "Meaningful use" of the EHR will occupy at least 5 minutes of that time, therefore the patient communication time is less than 10 minutes. This does not allow adequate time for education much less the development of a trust relationship. The result is that we fail at patient adherence and outcomes are much poorer than they could be. How sad that cognitive services have been so devalued to such a degree that they are effectively discarded. The primary care physicians and preventive cardiologists are largely ineffective at prevention and the cost to the healthcare system far exceeds the costs would be for adequate reimbursement for cognitive services. The solution from the geniuses in Washington DC is to force all primary care physicians and preventive cardiologists to an employment situation with a hospital to create an "accountable care organization". As it turns out, hospital owned practices are the most costly version of health care delivery and on average loose 150K on each physician they employ. Hang on to your seats, we are in for a bumpy ride.

Heart attack deaths plummet in three EU nations

Fri, 27 Jan 2012 02:21:50 EST

As reported in Heartwire: Homocysteine lowering cuts mortality in early-onset CAD patients SEPTEMBER 11, 2009 | Lisa Nainggolan Petah Tikva, Israel - Patients with early-onset coronary artery disease (CAD) and elevated homocysteine levels who took folic acid/B vitamins long term had significantly lower mortality than those who did not take this homocysteine-lowering therapy, according to the results of a new Israeli study [1]. Dr Aviv Mager (Rabin Medical Center, Petah Tivka, Israel) and colleagues report their findings in the September 15, 2009 issue of the American Journal of Cardiology. Mager told heartwire: "Our results suggest that patients with CAD and elevated homocysteine at baseline may benefit from taking folic acid in doses similar to the ones we used." He added, however, that they found no effect of the homocysteine-lowering therapy on mortality in those with normal plasma homocysteine levels. He believes that the findings support the hypothesis that elevated homocysteine "is a coronary risk factor, rather than simply a risk marker."

Heart attack deaths plummet in three EU nations

Fri, 27 Jan 2012 01:19:54 EST

Hi, "The European Society of Cardiology's mission is to reduce the burden of cardiovascular disease through education, congresses, clinical practice guidelines" it is partly on achievement as we can see and EACPR and other associations or groups should now answer the comments we see here. (In my opinion the polypill help would be poor, anyway.)

Heart disease risk begins with middle-age risk factors

Fri, 27 Jan 2012 00:31:03 EST

we should make interventions on risk factors as soon as were possible through proper health policy

Thrombotic Complications of ACS: Worldwide Perspectives Condition: ACS

Thu, 26 Jan 2012 17:49:40 EST

have copidrogel alone for manage acute coronary sindrome

Residual CVD Risk After Statin Treatment: Exploring the Promise and Opportunities of HDL Modulation

Thu, 26 Jan 2012 16:58:47 EST

Exercise can provoke Myocardial infarction among patients who already have MI. It is good for primary prevention but not for tertiary prevention. Read the following article from NEJM: Willich SN, Lewis M, L�wel H, et al. (1993). Physical exertion as a trigger of acute myocardial infarction. Triggers and Mechanisms of Myocardial Infarction Study Group. N Engl J Med;329(23):1684-90.

Evaluating the Data: What Recent Clinical Trials Can Teach Us about Treating AF-Related Stroke

Thu, 26 Jan 2012 16:18:13 EST

For General Surgery, you do not need any anticoagulation. However, for hip replacement surgery, heparin/LMWH will do fine. If you choose to use Rivaroxaban, you should be well versed on its pharmacokinetics as well as pharmacodynamics. Read the following articles: Eriksson BI, Borris LC, Dahl OE, et al, ODIXa-HIP Study Investigators. (2006). A once-daily, oral, direct Factor Xa inhibitor, rivaroxaban (BAY 59-7939), for thromboprophylaxis after total hip replacement. Circulation;114(22):2374-81. Kakkar AK, Brenner B, Dahl OE, et al. (2008). RECORD2 Investigators. Extended duration rivaroxaban versus short-term enoxaparin for the prevention of venous thromboembolism after total hip arthroplasty: a double-blind, randomised controlled trial. Lancet;372(9632):31-9. Eriksson BI, Borris LC, Dahl OE, et al. (2007). Dose-escalation study of rivaroxaban (BAY 59-7939)�an oral, direct Factor Xa inhibitor--for the prevention of venous thromboembolism in patients undergoing total hip replacement. Thromb Res;120(5):685-93.

To prescribe or not to prescribe: That is the statin question, experts debate

Thu, 26 Jan 2012 16:08:16 EST

LIFESTYLE INTERVENTION IS THE 1�STEP INCLUDING, STRESS DISORDERS CONTROL( OCCIDENTAL WAY OF LIFE RELATED DISEASES).2� STEP:DRUG THERAPY (STATINS...)

Heart attack deaths plummet in three EU nations

Thu, 26 Jan 2012 16:03:12 EST

Please point me in the direction of the large, well designed RCTs which show that lowering homocysteine through B group vitamins and magnesium supplementation has any benefit whatsoever on primary prevention of heart disease. They need to show benefit in all sub groups (especially elderly women) - a particular issue you time and time again tell us statins fail to do.

Management Decisions When Considering Cardioversion

Thu, 26 Jan 2012 15:59:21 EST

I have seen so many athletics with HR 50-55 bpm. It is usual in such persons who jog regularly. What make you go see your doctor? Ask from him the paper EKG strip that was done on the day that you were reported as having AFib. If you cannot have it, do another EKG. Ask second expert opinion.

Heart attack deaths plummet in three EU nations

Thu, 26 Jan 2012 15:17:06 EST

And then there are B-vitamins in junk cereals [lowering homocysteine] and n-3 from 'junk soybean oil' and from fish and canola. Maybe people have been listening. About aspirin, clearly it helps in an acute event but in women as prevention there is consensus that it does not work while the only non-fatal beneficial trial in men used a magnesium buffered form, the Mg possibly explaining the benefit. I don't think aspirin in the general population accounts for something truly spectacular in mortality as reported here.

Heart attack deaths plummet in three EU nations

Thu, 26 Jan 2012 14:17:47 EST

Most likely due to a drop in cigarette smoking!!!

Heart attack deaths plummet in three EU nations

Thu, 26 Jan 2012 13:59:57 EST

In his book "The Fragile Species" Lewis Thomas, M.D., past dean of both NYU and Yale schools of medicine claims that aspirin is responsible for the decline of deaths due to heart disease and strokes. Deaths due to heart attacks peaked in 1968 and after aspirin became universally used in many products, deaths due to heart attacks declined 66% and strokes by 72% since 1950. If you are worried about GI complications use Fasprin or a chewable aspirin.

Heart attack deaths plummet in three EU nations

Thu, 26 Jan 2012 13:17:09 EST

Poor socioeconomic status is a great risk factor to suffer from CAD,so improving this and implementing proper health policy will result in a fall of both deaths and the incidence of CAD Besides, better treatment of this disease accounts for the better outcomes.

Vytorin US label updated with SHARP results

Thu, 26 Jan 2012 13:14:07 EST

Not only does it have better treatment response across ALL lipid parameters,.. it more specifically tahrets their unique dyslipidemia. Inclusing Lp(a). And,.. it is highly effective in reducing phosphorus levels,.. I'd like to see the 5 year outcomes with niacin,.. In the CDP,.. anyone with FBG > 126 saw a 54% decrease in events,.. vs. 24-27% overall. CKD is largely an end result of dysglycemia,...

Dronedarone gets another chance to prove itself in ranolazine combo trial

Thu, 26 Jan 2012 12:29:12 EST

Is the goal here selling medicine or helping patients? Where is this guy coming from?

Lower mortality rates at two years with transradial PCI, Italian registry shows

Thu, 26 Jan 2012 08:45:05 EST

But - why published by JACCIntervent?

To prescribe or not to prescribe: That is the statin question, experts debate

Wed, 25 Jan 2012 23:32:03 EST

I had acute MI 6 months back followed by kideny failure . I had to stop Statins due to intolerable muscle pain.My HDL/ LDL are ok .I am 58 and doing Pranayam , Meditation and Diet control consistently. In my opinion (as well informed patient ) , Cardiologist should take very balanced view and tell the patients the Facts as on date and individualise the Risk Factor.After All , Cholesterol is not the only villain. It is one of 10 Cardiac markers. To put it in one line--Statins should be prescribed only after Diet and Life style changes do not yield any positive results . Thanks

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Wed, 25 Jan 2012 22:20:35 EST

Dear Sir, Your comment suggesting the need for institutionalized ways to audit PCI led me to this response. There have actually been efforts at different levels of the American College of Cardiology to establish a system that would engender the faith of our patients. Although the Accreditation for Cardiology Excellence (ACE) establishing a certification system for cath labs is the most prominent national ACC initiative it is not the only one. In the state of Maryland, efforts by the Maryland ACC, led by Dr. Sam Goldberg, Dr. Roger Leonard, and Dr. Marc Mugmon, have doggedly advocated to the state of Maryland legislative and regulatory bodies to require random, external peer review of PCI's performed in the state of Maryland. This would be supplement the internal peer review sessions that many hospitals have implemented in the wake of the controversy surrounding PCI performed in the state of Maryland. The legislative and regulatory bodies appear to have heard these arguments, and we hope will incorporate these suggestions in the future. In addition, two of Maryland's University hospitals have been working together to create a voluntary external peer review system that would also randomly review individual operator procedures, using histories, physicals, lab and diagnostic tests, procedural review (including QCA) using both appropriateness criteria and interventional physician judgement to generate a report to each cath lab. This would allow each cath lab to benchmark itself, and potentially identify outliers in need of guidance, education, or further review. It would also help audit the data entered into the ACC NCDR. I anticipate that this review will demonstrate that the vast majority of procedures reviewed in the state of Maryland fall within the appropriateness criteria. There are a myriad other offshoot benefits, too numerous to describe here. This proposal has garnered enthusiasm, and hopefully will be able to be funded by a CMS grant. I hope this addresses some of the concerns you have raised.

EMA investigating CV problems with fingolimod

Wed, 25 Jan 2012 21:15:22 EST

Natalizumab dominates fingolimod in terms of incremental cost per relapse avoided, as it is less costly and more effective.

To prescribe or not to prescribe: That is the statin question, experts debate

Wed, 25 Jan 2012 20:47:45 EST

Would not niacin 'regulate' the lipid factors you cite much more effectively? Also, what was the Hcy level in any of the folk you mention, that is, before or without a B-supplement. Then there is the variation in consumption of the n-3's. About 'lipids', the famed Kastelein with at least 3 lipid trials to his name we've all heard about also found that families with a much increased TC level lived longer in the 1850's. Conclusion: major 'environmental' factors .. and none of which can be altered by a drug. May I propose there are more productive ways of reducing risk than the amount and shape of a lipoprotein.

To prescribe or not to prescribe: That is the statin question, experts debate

Wed, 25 Jan 2012 20:33:54 EST

All forms of CHD were much lower before commercial junk 'food' and processed 'food' and fizzy drinks marketing manufactured the US obesity epidemic. Cars, ass entertainment and new media destroyed any exercise. Now you have the problem statins, even if they did what is claimed, are not even denting the effects. Look at NNT. Life style is the key, statins are just another profit centre.

PLATO: PPI analysis "raises flag" but should not change practice

Wed, 25 Jan 2012 20:09:00 EST

PPIs may inhibit effect of aspirin which requires acidic gastric media for maximal absorption.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Wed, 25 Jan 2012 18:46:36 EST

I kept thinking about how do you named "dysfunctional doctors". istn�t it an euphemism? why don�t we named those doctor as offenders. I feel like George Orwell or Noam Chomsky were watching me.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Wed, 25 Jan 2012 18:12:37 EST

Dr Romanens:in my opinion medical dysfunctionality is a very complex process that is insufficient to be approached solely on the basis of medicine.This question should be addressed on the basis of other disciplines too such as legal,antropology,economics, philosophy ,ethics and socio-political ideologies.

A Balanced Approach to PCI: Treating Ischemia and Eliminating Bleeding

Wed, 25 Jan 2012 18:02:16 EST

I believe the usual practice of sealing the puncture site at Radial Artery is by using hemostats, a closure device, or a compression system. �D-Stat radial, Angioseal, and RadiStop radial artery compression System� are some of the examples. If the site bleeding is not controlled by the above technique, you may suture the site inclusive of superficial layer of access vessel using chromic catgut sutures, which is resorbed in 90 days, or Polydioxanone (Resomer), a synthetic polymer, which is degraded through hydrolysis and completely resorbed within 6-12 months. The simplest procedure of all is to use a hemostat that is widely used in laboratories. When a laboratory is performing aPTT, which measures both the intrinsic and common pathways, the citrated plasma is activated with a contact surface material, viz. �KAOLIN, CALCIUM, AND PHOSPHOLIPID� to induce coagulation. You may try those combination agents to seal your access site bleeding along with the compression device. Since the size of most access site is 21 gauge needle size, one of the above method should work.

To prescribe or not to prescribe: That is the statin question, experts debate

Wed, 25 Jan 2012 16:59:30 EST

Well said. I thought the very same thing - each individual must be treated as such. We can lump people into large groups but therapy must be personalized. I also unfortunatly have a terrible family history for CVD and CAD. Never smoked, not overweight, no diabetes, cholesterol good on paper - when we break it down I have triglyceride rich remnant VLDL3, dense phenotype B/AB pattern LDL and low HDL2. This is highly genetic in our family. This dense lipoprotein pattern is quite dangerous. My CACS was LAD positive at age 36 and CIMT showed atheroma growth at age 41 and continued until I started statin and then combination lipid therapy (regressing). The only risk factor I had was a bad family history and the above lipid subtypes. I�m pretty certain I have significant �Lipo-Protein� disease. I guess we will see over the next 30 years if I prevent the ACS/CABG my Dad had at 52 and the ACS/MI/CHF death my PGF had at 65 and the sudden MI death my MGF had at age 69 and the CV, CAD and CABG my PGM had during her 70�s. Time well tell. I know with mixed lifestyle and pharmacologic management my Dad will celebrate his 70th birthday in 3 weeks.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Wed, 25 Jan 2012 15:58:55 EST

Having gone through 28 comments I found no realistic and mature way to solve the problem - maybe I overlooked some good comments. Clearly, we need institutionalized ways to detect dysfunctional doctors in order to prevent purely money driven interventions. Principally, surveying active doctors has to be done by patients and institutions. Audits performed on a professional medical level by medical doctors should detect the suspicion of dysfunctionality - and these audits should also hit from the unexpected - helping in prevention of dysfunctionality. If a doctors dysfunctionality is not confirmed through this professional audit process, his revalidation is the next step. If confirmed, expulse this doctor from further medical activity payed by insurance companies. Detection of dysfunctionality has to be institutionalized at the national level in order to protect those, who accuse. The medical profession is called for action. Not judges, but medical doctors should reliably detect medical dysfuntionality.

To prescribe or not to prescribe: That is the statin question, experts debate

Wed, 25 Jan 2012 15:50:43 EST

I would have no problem betting that the decrease in early ATD deaths is virtually totally due to the decline in cigarette smoking, and I said so in print in 1999 in my article about cigarette smoking and ATD.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Wed, 25 Jan 2012 15:44:43 EST

Thank you Dr Vanhecke. Calls placed to the doctors were directed to the UPMC vice president of corporate communications, who declined to comment on the lawsuit. Michael O'Riordan, reporter, theheart.org

PLATO: PPI analysis "raises flag" but should not change practice

Wed, 25 Jan 2012 15:37:30 EST

So, what is this mysterious confounder that all the pundits posit but never explain? Maybe rampant PPI use is just a marker of lousy care and that is what leads to worse outcomes? Perhaps people are throwing PPI at what is really angina not otherwise being addressed?

PLATO: PPI analysis "raises flag" but should not change practice

Wed, 25 Jan 2012 15:36:37 EST

Epsom salts (Magnesium sulfate) is easily absorbed in a warm bath (like a 1% solution). This takes about 12 minutes in one study Most modern diets are deficient in sulfates and the sun. Epsom salts seems to have a marked benefit for heart patients. A glass of lemon Epsom salt is a common treatment as a laxative; it has been used for thousands of years. For 5000 years man has instinctive known warm mineral baths are beneficial.

To prescribe or not to prescribe: That is the statin question, experts debate

Wed, 25 Jan 2012 14:59:09 EST

Dr Blanchet I agree with you regarding the use of coronary calcium imaging as an useful tool to reclassify the classic CAD risk factors score and then according with the Ca score decide who is eligible to be treated or not with statins.Ca score is chep ah very low radiation hazard

To prescribe or not to prescribe: That is the statin question, experts debate

Wed, 25 Jan 2012 14:52:19 EST

80% less heart disease in Iceland.

Vytorin US label updated with SHARP results

Wed, 25 Jan 2012 14:35:42 EST

Good for the FDA, �the SHARP data will not be included in the ezetimibe prescribing information�. In 2008 I took most of my about 220 patients on Vytorin to something else. How you are lowering Lipids is more important than just the number. Again this is old news. However, the shenanigans by Merck to delay release of a clinical trial has brought into question the health industry and shaken my core believes. Merck shares worth have never recovered from 2007 high. Ezetimibe decreases cholesterol levels but results of two major, high quality clinical trials (in 2008 and 2009) showed that it did not improve clinically significant outcomes, such as major coronary events. Recent papers have questioned the reliability of �Lipid Hypothesis� data. Like the hormone replacement therapy fiasco of the 1990's will probably pale by comparison to the eventual dramatic rise in the 1987 and probable fall of the statin industry in this decade. Treating Lipids in ASHD is like treating fever in infection, good but it misses the big picture.

Carotid images don't boost quit rates or cut CV risk factors in smokers

Wed, 25 Jan 2012 14:22:25 EST

EDUCATION, EDUCATION, EDUCATION,AND A GOOD PATIENT-DOCTOR RELATIONSHIP ARE IMPORTANT ISSUES THAT WE SHOULD TAKE INTO ACCOUNT IF WEWANTTO IMPROVE THE PATIENT�S ADHERENCE AND THEIR OUTCOMES

PLATO: PPI analysis "raises flag" but should not change practice

Wed, 25 Jan 2012 14:08:56 EST

Doctors King and Dua:Thanks for warning me about those adverse effects. I didn�t know that

PLATO: PPI analysis "raises flag" but should not change practice

Wed, 25 Jan 2012 13:59:07 EST

Dr King, do you have to swallow the bath water?

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Wed, 25 Jan 2012 13:44:28 EST

Dr Vanhecke thanks for replying me.Otherwise I�dont think your earlier words were nor hash neither directed to me .Regarding what palliative means I got your interpretation about the meaning of palliative.It was a matter of semantic consideration.Sometimes I think that medicine is a scientific discipline too delicate for being in the hands of doctors.We should study more ethics and philosophy and the medical comuinity will be less prone to be taken to court.Once again I apologize for my passable english

To prescribe or not to prescribe: That is the statin question, experts debate

Wed, 25 Jan 2012 13:03:06 EST

There has been steady and significant decline in cardiovascular mortality. Even recent signals that cancer will become the leading cause of death. Maybe it is magic or maybe the effect of aggressively treating risk factors including widespread use of statins.

To prescribe or not to prescribe: That is the statin question, experts debate

Wed, 25 Jan 2012 12:45:00 EST

"Regarding the potential for a large-scale, long-term, randomized, clinical trial to definitively answer the questions about statins' benefit in primary prevention, Blumenthal said it would be impossible given how large, time-consuming, and expensive such a trial would be......" Last year I believe statin sales netted about 27 billion is it really about the cost of a well run study?Or about the results of such a study?. The evidence is good that statins save lives in middle aged men with heart disease. .The evidence is particularly weak on women and the elderly. Studies have shown that statin side effects are greatly unreported and in many given these agents as noted "What this means for women is that they are much more likely to be getting adverse events and not likely to get any benefit at all from treatment. "

To prescribe or not to prescribe: That is the statin question, experts debate

Wed, 25 Jan 2012 12:10:09 EST

Please remember that virtually all the adverse ATD effects of HRT are due to continuous combined HRT (PremPro, Fem HRT, etc) or occasionally to unopposed estrogen. None of these adverse ATD effects are attributable to cyclic-sequential HRT. Kindly do not throw the baby out with the bathwater.

To prescribe or not to prescribe: That is the statin question, experts debate

Wed, 25 Jan 2012 12:06:04 EST

If the argument is to put everyone on statins, then I agree that statins are overused. A targeted approach, rather than a herd approach, would seem to be the ideal approach. Treat those at risk of atherothrombotic disease (ATD). ATD has multiple risk factors, as I am certain everyone here knows. The lipid portion of ATD risk is best described by the ratio between LDL and HDL, along with the actual LDL level. (See my website for details at www.bowlinggreenstudy.org. The site is free and open to all. It has almost all the appropriate publications and presentations.) The risk of ATD is dependent on the severity of the LDL/HDL imbalance and how long that imbalance has been present. Hence, treatment that may not be appropriate for a 20 year old might certainly be appropriate for a 50 year old; and a severe LDL/HDL imbalance needs ato be treated at an earlier age than does a less severe imbalance. Cigarette smokers develop ATD about 10 years earlier than do never smokers, even at the same lipid levels. Moreover, cigarette smoking can produce ATD events (likely via thrombosis) even in the face of lipid values that do not usually cause ATD at younger ages. Indeed, a global risk approach is the optimal way to do things, as I show on the website. My patients who have accepted treatment on this basis have reaped the rewards, with only two patients haveing suffered fatal myocardial infarctions so far this century. (One of those was a cigarette smoker who would not kick the habit, while the other was an insulin-dependent diabetic x40 years, whose first heart attack occurred at age 49 years and whose second and fatal heart attack occurred at age 72 years.)

To prescribe or not to prescribe: That is the statin question, experts debate

Wed, 25 Jan 2012 10:34:58 EST

"We should stop treating numbers and start treating patients." The MOST common sensical statement EVER MADE!!!! Doctors/researchers: numbers are just that--numbers. What may be tolerable in one body may not be tolerable in another. "All-cause mortality" numbers drive me nuts!!!!! It's like blaming a drug or therapy modality for causing the death when the patient got killed in the middle of a gunshot battle. TREAT YOUR PATIENT---WHATEVER IS GOOD FOR THEM! (sorry--but I am really getting tired of the flip-flops....what is a good therapy today is banned tomorrow and vice versa.)

To prescribe or not to prescribe: That is the statin question, experts debate

Wed, 25 Jan 2012 10:33:20 EST

I am a 63 yo, with a story similar to Dr. Pattanayak, with less exercise. And have been taking pravastatin for 20 years without issues. It now costs <$50 a year. I am comforted by the 10-year f/u of WOSCOPS (NEJM 2007;357:1477-86), that demonstrated sustained benefits including a mortality benefit (p <0.02).

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Wed, 25 Jan 2012 09:41:11 EST

forgot to conclude. the law of the land should prevail.we should have full faith in it. at every time we should not try to prevail upon the judiciry, as long as it is based on justice and safeguards the human values and rights. and so in the above case let us not behave like the judge,the jury and the hang man. let the justice prevail. let us help to uphold it.respect it and welcome it. let also the judges inside our breasts,(the conscience)take the full control of our deeds and actions and leave nothing for the outsiders to prevail upon us.

To prescribe or not to prescribe: That is the statin question, experts debate

Wed, 25 Jan 2012 09:17:45 EST

You survived 15 years on statin and myself ~40 years of a daily multivitamin [all promoters / facilitators / required co-factors of biochemistry and minimizers of Hcy]. I personally would not dream about inhibiting one of mammalians' most vital pathways with statin. Do you actually know your and your family's homocysteine levels? Did you actually look at the U.K. mortality link I provided? If not, please do and give an opinion about such mortality curve and that anybody would agree cannot be remotely related to to that C27 we've been made to fear, or obviously statin use. Low TC in any population study is early death. Any doubts? Then see the n=~150,000 study www.ncbi.nlm.nih.gov/pubmed/15006277 About Rx Foltix[TM], I'd take a Twinlab Daily-One-Caps [no iron] instead but Foltix WILL lower Hcy. What is wrong with that? Similarly to ANY method ever tried in women to lower TC, such has shown NOT to reduce mortality as an Rx in short term secondary prevention, so far, but at least 5 components in such multivitamin are INTIMATELY involved in maintaining the extra cellular matrix of the artery, and, bonus, elsewhere. The mevalonate derivatives are not**). ww.health-heart.org/HIPandHOPE.gif shows benefit in 2 RCTs. To answer 2 of your points: yes, I believe statins do harm on the long run. How could inhibiting a vital pathway not do harm, and we have >100 side effects when I last counted ~10 years ago] and I submit that the benefit of n-3 in LYON and GISSI [respectively plant and fish n-3] dwarfed anything seen in statin. N-3 promotes biochemistry, statins inhibit it. Moreover, the statin trials are stopped early for non fatal benefit [in men, mainly]. It takes a believer unaware of the biochemistry to think there is no harm at 30 years: we'll never know from RCTs. **) But Q10, is reduced by the same %% as LDL, may be THE most effective 'drug' in heart failure [Morisco's RCT; Medline 8241697]. This mevalonate daughter allows ATP to be released to muscle and nerve cells DOES play roles. 10 mevalonate molecules make Q10, 6 make cholesterol. Predictably, the HF studies have shown zero benefit in any metric from statin in HF. So there is consensus: mortality is NOT affected in women, in HF patients, the elder and, apart from a late and temporary effect in younger men in only 3 studies and massive NNTs, not in men and never from lova, atorva, fluva, and not in CV deaths for rosuva.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Wed, 25 Jan 2012 09:04:53 EST

what is coming to light from some of the honuored medicos opinions, seems a sort of frustration, being rewarded to us after going through all the hard work, and having melted most precious years of life to become a doctor. true indeed. i worked in iran as physician soecialist. i would proceed on leave to travel to my native country, after every two to three years, and stay back for two to three months.one day while i was on leave, a patient had come to the hospital where i worked and asked the medical superintendent as to when i would i return? after coming to know that i was coming in a day or two, the man( patints), fell on his feet(the medical superdent's) and and kissed them.there is a custom in iran that out of respect people kiss each other on their faces and out of sheer respect on their hands. this man became so excited that he lost control of himself on learning about my return. one day a pakistani doctor and his family visited my home as guests. they had come in a taxi from the bus terminal. my house was located in a lane connected to the main road. on learning that these passengers were my guests the cab fellow instead of droping them on the main road(in the normal way),carried them into the lane and droped them near my home. he did not take any money from these people, telling that this doctor( that is my self), was taking lot of trouble for his people. i lived in iran for several years after that, but that modest taxi driver never came to boast to me about his chivalry. i guess he might have visited me atleast some day but i never knew who he was. my wife and children once came from india and we stayed with one my female paient's son in tehran. i had treated this lady (being the mother of the host), for an mi. incidently that lady also had visited her son on that day. on seeing my wife she greeted my wife saying, "qaadam shoma rowe cheshme ma"(walk with your feet on my eyes). not only that, she also gifted two golden necklaces to my two children, accompanying my wife from abroad. many patients tell me that they pray for me while sitting on their prayer mats, in day light and while praying during nights and in the early mornings. let me ask my honoured readers that do these patients owe me anything? they pay their dues to me. they pay money for their tests, drugs surgeries and every thing. they still say that they owe me a lot. now then for God's sake, who am i, and what is my worth if i am not visited by these patients?. what shall i eat, wear and spend on my family and how shall i meet the exorbotant expenditures if the patients stop visiting me? and then i shall try to milk these patient in an unfair!!!!! and that is what we are advocating about. if proved it will be an unpardonable sin and offence. it should be treated like a high grade malignancy to save the rest of the body. these cases of malpractice are not a commonality, but malign the name of our profession which lot of people (despite its having become commercial now), call 'the noble profession'. let the rot go away. let the anerobes be sanitized. let criminals be sent to the prison. let the inefficient be rejected. let the law take is own course. if we are effcient, that is what we are supposed to be. highly educated, experienced, upto date with knowledge of medicine, confident, honest, industious and meticulous, syypathetic and patient,we will succeed.

Revascularization in ischemic heart disease - Case 2: 58-year-old male with intermittent chest pai

Wed, 25 Jan 2012 04:45:59 EST

I would refer you to a recent review: ---PET and PET/CT in cardiovascular disease. Gaemperli O, Kaufmann PA. Ann N Y Acad Sci. 2011 Jun;1228:109-36.In a succinct fashion it summarizes the perfusion/uptake match as well as PET and CAD. There have been relatively few head-to-head studies comparing PET vs. other modalities in viability assessment.

Tai chi movement therapy improves functional capacity and quality of life in patients with stable

Wed, 25 Jan 2012 04:18:24 EST

Tai chi and Yoga both are same form of meditation and is from the same Asian Region.they are great in controlling A F.

Dronedarone gets another chance to prove itself in ranolazine combo trial

Wed, 25 Jan 2012 02:55:01 EST

I AM HAVING CORDORONE FROM 2007 FOR AF.HAVE FITTED WITH DDR PACEMAKER. I THINK DRONEDARONE IS SAME. IT GAVE ME RELIEF. BUT NOW HAME CONTINIOUS AF.OFFER MY SELF FOR CLINICAL TRIALS.

Aspirin in primary prevention: New meta-analysis finds bleeding outweighs benefits for most

Wed, 25 Jan 2012 01:15:17 EST

I agree completely. Many times a week, I have a middle aged patient come to my office to "get checked out." Usually, they are referred from their PCP due to CRF, especially the all dreaded family history. So, I do the drill, have them do a stress test because that's what they want. I know I'm not going to find anything in most of these patients. After they complete their normal stress evaluation, I offer a CaCS to them. IMHO, it helps a great deal when there is a measurable score as it identifies the patients in whom aggressive risk factor modification makes more sense. It's amazing to me that commercial carriers STILL won't cover this test, although that seems to be changing.

PLATO: PPI analysis "raises flag" but should not change practice

Tue, 24 Jan 2012 23:09:34 EST

"a good reminder that observational association can never replace randomized cause-and-effect studies," he continues. Time and time again this has proven true. The conclusions of RCT's have proven opposite that of observational studies more time that I can remember. Jim, while PPI's long term can certainly cause hypomagnesemia and even hypomagnesemic hypoparathyroidism, I have yet to see a case of in my practice. Perhaps I need to monitor magnesium level more frequently in patients on PPI. Anyhow, H-2 blockers should be used in preference to PPI's whenever possible as PPI can have other possible adverse long term effects of increasing risk of fractures, C- Diff colitis, pneumonia, SBP in patients with ascites. Also PPI's are more expensive

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 24 Jan 2012 22:20:45 EST

As a returnee(having returned from the UK after 15 years and having been a consultant there) I can totally refute this allegation. While, yes, I have seen instances of 'dodgy' decisions(no more than in the UK) certainly this is not in the scale alleged in this comment. At least in the institution I work in currently, I have seen no such instances of inappropriate intervention for the sake of financial returns. Therefore do not tar the entire medical community in India with the same brush just because you may have encountered a few bad apples. I totally condemn and deplore this comment.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 24 Jan 2012 21:36:58 EST

No wonder that none of my collegues want their children to become doctors. One's hard earned and illustrious career can be ruined without anything more than an accusation levied by someone who has their own political and financial motivation to do so. I have no doubt that "inappropriate PCI" is sometimes performed, and frankly how may times are inappropriate echos, stress tests, (and for that matter) CT scans, MRIs, CRP blood tests, etc ordered? We need to police ourselves and reign in malpractice to prevent overtesting/treating. Perhaps all elective caths should be reviewed by a multidisciplinary committee prior PCI. This will increase the expense of health care and be highly inconvenient for patients. But at least you won't see you name in any newspaper headlines for "defrauding" the government.

To prescribe or not to prescribe: That is the statin question, experts debate

Tue, 24 Jan 2012 21:18:02 EST

The use of statin-to be or not to be. This Shakesperian doubt should be answered by considering each patient individual profile. We should stop treating numbers and start treating patients.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 24 Jan 2012 21:14:53 EST

I am not an attorney but I can assure you that those accused disagree forcefully with the assertions and have been advised by their attorneys not to comment given that anything they say can potentially be used against them. I suppose a line saying that the defendants declined an interview on advice of counsel would have been appropriate but I think it can be inferred.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 24 Jan 2012 20:23:19 EST

Thanks Dr. Zozaya, My earlier words were harsh and not directed at you... Palliative is a word that means so much to different people. When I use palliative in the context of CAD, it typically is when we offer revascularization to patients that are suffering inpatient with pain, and typically have However, your understanding of the word is actual more correct. Irregardless, this discussion is about rushing to judgement on these 5 cardiologists. Also, there seems to be the thought here that this litigation is actually a criminal case, that is not so. In the U.S. can you can sue someone for any reason, and unfortunately here, major damage is already done and the lawsuit hasn't begun. The plaintiff is releasing this to the media and already in the eye of the public, it seems that all that occurred was a statement release by one side. I have a question for Michael O'Riordan and theheart.org.. Did the other side decline comment or choose not to respond when you asked them for comments? Surely, there must have been an attempt to give them a fair chance to give their side of the story. I am not a journalist, but it seems that there is always a comment in these stories about an attempt to give the other part in a civil suit a chance to respond or comment.

A Balanced Approach to PCI: Treating Ischemia and Eliminating Bleeding

Tue, 24 Jan 2012 20:21:46 EST

As far as access site bleeding is concerned, gauze soaked with EACA (Epsilon Aminocapoic Acid) or tranexamic acid (TXA) should help. "EACA IS USED IN TREATMENT OF PROCEDURES OR DISORDERS IN WHICH FIBRINOLYSIS IS ENHANCED...CARDIAC BYPASS, POSTCAVAL SHUNT, MAJOR THORACIC SURGERY, PROSTATIC POSTOPERATIVE HEMATURIA...NONSURGICAL HEMATURIA, LEUKEMIA, METASTATIC PROSTATIC CARCINOMA, CIRRHOSIS & OTHER HEPATIC DISEASES, ECLAMPSIA, INTRAUTERINE FETAL DEATH, AMNIOTIC FLUID EMBOLISM & ABRUPTIO PLACENTAE. THE DRUG IS OF NO VALUE IN HEMORRHAGE DUE TO THROMBOCYTOPENIA, HYPERHEPARINEMIA, OR OTHER COAGULATION DEFECTS, OR TO VASCULAR DISRUPTION. IT COUNTERACTS THE THROMBOLYTIC EFFECT OF /STREPTOKINASE & UROKINASE." EACA is also known as: 6-aminohexanoic acid, aminocaproic acid, amicar, Caprocid, Epsikapron, Epsamon, Acepramin, Acepramine. It is an antifibrinolytic agent that acts by inhibiting plasminogen activators which have fibrinolytic properties. Schouten ES, van de Pol AC, Schouten AN, et al. (2009). �The effect of aprotinin, tranexamic acid, and aminocaproic acid on blood loss and use of blood products in major pediatric surgery: a meta-analysis.� Pediatr Crit Care Med;10(2):182-90. Henry D, Carless P, Fergusson D, et al. (2009). �The safety of aprotinin and lysine-derived antifibrinolytic drugs in cardiac surgery: a meta-analysis.� CMAJ;180(2):183-93. Munoz JJ, Birkmeyer NJ, Birkmeyer JD, et al. (1999). �Is epsilon-aminocaproic acid as effective as aprotinin in reducing bleeding with cardiac surgery?: a meta-analysis.� Circulation;99(1):81-9. Dietrich W, Spannagl M, Boehm J, et al. (2008). �Tranexamic acid and aprotinin in primary cardiac operations: an analysis of 220 cardiac surgical patients treated with tranexamic acid or aprotinin.� Anesth Analg;107(5):1469-78. Baric D, Biocina B, Unic D, et al. (2007). �Topical use of antifibrinolytic agents reduces postoperative bleeding: a double-blind, prospective, randomized study.� Eur J Cardiothorac Surg;31(3):366-71. Breda JR, Gurian DB, Breda AS, et al. (2009). Topical use of antifibrinolytic agent to reduce postoperative bleeding after coronary artery bypass surgery. Rev Bras Cir Cardiovasc; 24(3):341-5. Tempe DK, Hasija S. (2012). �Are tranexamic acid and ε-aminocaproic acid adequate substitutes for aprotinin?.� Ann Card Anaesth;15:4-5. Benfatti R�, Carli AF, Silva GV, et al. (2010). Epsilon-aminocaproic acid influence in postoperative [corrected] bleeding and hemotransfusion [corrected] in mitral valve surgery. Rev Bras Cir Cardiovasc;25(4):510-5. Raghunathan K, Connelly NR, Kanter GJ. (2011). ε-Aminocaproic acid and clinical value in cardiac anesthesia. J Cardiothorac Vasc Anesth.;25(1):16-9. Kaye JD, Smith EA, Kirsch AJ, et al. (2010). �Preliminary experience with epsilon aminocaproic acid for treatment of intractable upper tract hematuria in children with hematological disorders.� J Urol;184(3):1152-7. Greilich PE, Jessen ME, Satyanarayana N, et al. (2009). �The effect of epsilon-aminocaproic acid and aprotinin on fibrinolysis and blood loss in patients undergoing primary, isolated coronary artery bypass surgery: a randomized, double-blind, placebo-controlled, noninferiority trial.� Anesth Analg;109(1):15-24.

To prescribe or not to prescribe: That is the statin question, experts debate

Tue, 24 Jan 2012 19:53:36 EST

Interestingly two neutral and prestigious groups the Cochrane coalition and the Therapeutics initiative have recently have questioned the use of statins in primary prevention. The evidence of any mortality benefit from statin therapy in primary prevention is indeed lacking yet ."It's sort of silly to have this conversation in 2012 about not giving a cholesterol-lowering medication to a person who has dyslipidemia and other risk factors," Blumenthal told heartwire" as noted... " Do statins have a role in primary prevention? An update. Therapeutics Letter Issue 77 / Mar - Apr 2010 notes '....The claimed mortality benefit of statins for primary prevention is more likely a measure of bias than a real effect.' More troubling is the lack of effect on serious adverse events as the review notes; .." ...The reduction in major CHD serious adverse events with statins as compared to placebo is not reflected in a reduction in total serious adverse events. " and notes that '" ..The fact that it is not suggests that other SAEs are increased by statins negating the reduction in CHD SAEs in this population" If all statins do is trade one serious event for another than the help one ;hurt one approach needs to be revisited.It seems Dr Redberg has been willing to revisit the data. Perhaps others should too

A Balanced Approach to PCI: Treating Ischemia and Eliminating Bleeding

Tue, 24 Jan 2012 19:24:56 EST

Read the following articles on how to use Abciximab efficaciously, and Reversible Inhibitory effect of Bivalirudin: De Luca G, Suryapranata H, Stone GW, et al. (2005). �Abciximab as adjunctive therapy to reperfusion in acute ST-segment elevation myocardial infarction.� JAMA;293:1759 �1765. Thuraisingham S, Tan KH. (1999). �Dissolution of thrombus formed during direct coronary angioplasty with a single 10 mg intracoronary bolus dose of abciximab.� Int J Clin Pract;53:604�607. Barsness GW, Buller C, Ohman EM, et al. (2000). �Reduced thrombus burden with abciximab delivered locally before percutaneous intervention in saphenous vein grafts.� Am Heart J;139: 824�829. Marciniak SJ, Mascelli MA, Furman MI, et al. (2002). �An additional mechanism of action of abciximab: dispersal of newly formed platelet aggregates.� Thromb Haemost;87:1020 �1025. Maioli M, Bellandi F, Leoncini M, et al. (2007). �Randomized early versus late abciximab in acute myocardial infarction treated with primary coronary intervention (RELAX-AMI Trial).� J Am Coll Cardiol;49:1517�1524. Kakkar AK, Moustapha A, Hanley HG, et al. (2004). �Comparison of intracoronary vs. intravenous administration of abciximab in coronary stenting.� Catheter Cardiovasc Interv;61:31�34. Bellandi F, Maioli M, Gallopin M, et al. (2004). �Increase of myocardial salvage and left ventricular function recovery with intracoronary abciximab downstream of the coronary occlusion in patients with acute myocardial infarction treated with primary coronary intervention.� Catheter Cardiovasc Interv;62:186 �192. Antoniucci D, Rodriguez A, Hempel A, et al. (2003). �A randomized trial comparing primary infarct artery stenting with or without abciximab in acute myocardial infarction.� J Am Coll Cardiol;42:1879 �1885. Stone GW, Grines CL, Cox DA, et al. (2002). �Comparison of angioplasty with stenting, with or without abciximab, in acute myocardial infarction.� N Engl J Med;346:957�966. Romagnoli E, Burzotta F, Trani C, et al. (2005). �Angiographic evaluation of the effect of intracoronary abciximab administration in patients undergoing urgent PCI.� Int J Cardiol; 105:250 �255. Sciulli TM, Mauro VF. (2002). �Pharmacology and clinical use of bivalirudin.� Ann Pharmacother; 36(6):1028-41. Parry MA, Maraganore JM, Stone SR. (1994). �Kinetic mechanism for the interaction of Hirulog with thrombin.� Biochemistry; 33(49):14807-14. Fenton JW 2nd, Villanueva GB, Ofosu FA, et al. (1991). �Thrombin inhibition by hirudin: how hirudin inhibits thrombin.� Haemostasis;21 Suppl 1:27-31. Witting JI, Bourdon P, Brezniak DV, et al. (1992). �Thrombin-specific inhibition by and slow cleavage of hirulog-1.� Biochem J;283 ( Pt 3):737-43. Pollack CV Jr, Braunwald E. (2008). �2007 update to the ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: implications for emergency department practice.� Ann Emerg Med;51(5):591-606.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 24 Jan 2012 18:40:40 EST

to be continued and patient-physician relationship

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 24 Jan 2012 18:36:45 EST

5 years later despite my adherence to the treatment was excellent plus cardiac rehab (I go swimming every days I swim 3000 meters).And guess what I started to complain of chest pain at rest(unstable angina)but let me tell you something that I omitted in my 1� cath I had 40% in my left main veru close to the bifurcation, now the 2nd cath was a little bit greater than 50% and the culprit lesion was a 95 % lesion distal of RCA besides the stent was permeable.Now I have done a CABG,SO CAN YOU TELL ME IF THESE 2 PROCEDURES ARE OR NOT PALLIATIVE?.I have felt this in my own body.What support me a lot is my faith in science and I beg that de patient -physician gets better

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 24 Jan 2012 18:12:54 EST

but this doesn�t mean....I apologize for my passable english

To prescribe or not to prescribe: That is the statin question, experts debate

Tue, 24 Jan 2012 18:10:29 EST

Nobody has yet survived 30 years of inhibiting the myriad of the mevalonate dependent pathways. Stains have not reached their 30 year anniversary and no drug studies I know of have tracked patentees for that duration - so are you implying harm not yet noticed after say 25 years? t's what's NOT in the diet. Fix the micro-nutrients, or at least have them easily meet the RDI/DV, and read LYON and GISSI re n-3 My personal read on the literature is that diet is dwarfed by statin therapy. Before statin availability is was hard to prove the lipid hypothesis not after. Unfortunately, lowering Hcy to one's genetic minimum does not reestablish the destroyed elastic layers of the media, IEL et al, that's a given. Not sure how to reply to this - B complex doesn't seem to work - sorry Foltix. To Jan from just another cardiologist with a high risk family history - I have been taking statins for fifteen years with complete understanding of their effects and safety profile with a blood test every other year once I got to reasonable results with complete belief that this is safe and advisable and harmless. Maybe I am just lucky and stupid but when one looks at the biochemistry and the available data it seems reasonable.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 24 Jan 2012 18:08:47 EST

I suffer from CAD I underwent an angioplasty because after being treated aggressively with medical treatment I was not free of symptoms at all. Now I continue with medical treatmant and I�m OK but this doen�t that I�m cured

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 24 Jan 2012 17:55:14 EST

and nobody has shed light on the mechanisms underlying.....

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 24 Jan 2012 17:50:49 EST

Pallitive:Relieving or soothing the symptoms of a disease or disorder without effecting a cure.That was what I meant. Atherosclerotic process is being investigated yet and nobody so nderlying this GLOBAL process so although I can not deny the usefulness of these 2 valuable interventions in "some" patients Do you know what I mean peers? All of us are adults and we know what we are talking about If we don�t take care ourself from an ethical point of view someone from outside will do!!!!

PLATO: PPI analysis "raises flag" but should not change practice

Tue, 24 Jan 2012 17:49:46 EST

Proton pump inhibitor (PPI) drugs may cause low serum magnesium levels (hypomagnesemia) if taken for prolonged periods of time (in most cases, longer than one year). In approximately one-quarter of the cases reviewed, magnesium supplementation alone did not improve low serum magnesium levels. Epsom salts baths 3 times a week helps. Low magnesium concentration seems to contribute to the pathogenesis of coronary atherosclerosis or acute thrombosis.

Yoga therapy for AF yields insight into brain-heart axis

Tue, 24 Jan 2012 16:59:11 EST

Isn't it nice, for a change, to hear about efficacy that does not come in a pill with a laundry list of side-effects?

Treat risk and not LDL-cholesterol targets, new perspective argues

Tue, 24 Jan 2012 16:47:53 EST

We treat coronary risk, not cholesterol, not LDL, not HDL. Statins are risk lowering drugs. Our aim lies in the identification of people who need their risk to be lowered. Primary prevention people without atherosclerosis are at very low risk - where we can wait with statin interventions - , their biological age is usually below their chronologic age. We replace chronologic age by carotid imaging and derive artery age. If someone is well ahead in time - e.g. aged 50 with plaques usually seen in a 70 year old - , we discuss this objective finding with the patient, what are the options - and he or she usually is easily convinced, that action is required. We calculate a posttest risk using published sensitivities and specificities and the Bayes theorem - we have published all this in www.kardio.ch and we show the patient, which risk factor is the most important, second important and so on (www.varifo.ch/VARIFO2.1e.xls). This, we call atherosclerosis management, or according to David Spence: treat arteries not risk factors. Final comment: what we see with ultrasound is 100% specific for atherosclerosis. It would be unethical to randomize people with amounts of atherosclerosis to statin or placebo. In conclusion: let us talk about how risk assessment may be improved. Statins are mandatory in subjects with coronary or stroke risk - whether or not they are in primary or secondary prevention.

Making Same-Day Discharge after PCI a Reality: What You Need to Know

Tue, 24 Jan 2012 15:34:12 EST

Survey for Interventional Cardiologists on Defining Appropriate Length of Stay After PCI We invite interventional cardiologists to participate in an international survey on the appropriate length of stay after PCI. Despite technical advances in PCI, considerable variability remains as regards the appropriate and safe length of stay post-procedure. In an effort to improve standardization whilst maintaining patient safety, SCAI published an Expert Consensus Document providing guidance on patients who may be considered for early discharge or outpatient intervention (Catheter Cardiovasc Interv 2009). However, it is not clear if this guidance reflects current clinical practice or if the assessments of the technical panel are in agreement with a broader range of interventional cardiologists. The aim of the current survey is to identify views on appropriate and safe length of stay after PCI across a range of interventional cardiologists and treatment strategies. As a practising interventional cardiologist, your views on this subject can help to inform and influence the debate. Identifying where there is a broad consensus (or significant variation) in practice will help highlight areas where further research is required to define the most appropriate length of stay post-PCI. The survey will take approximately 6-8 minutes to complete and all responses are anonymous. Simply cut and paste the entire URL into your browser to access the survey: www.surveymonkey.com/s/lengthofstaysurvey Yours sincerely, Dr Jehangir Din Interventional Fellow Royal Jubilee Hospital Dr Simon Robinson Interventional Cardiologist Royal Jubilee Hospital Dr Anthony Della Siega Interventional Cardiologist Director, Cardiac Catheterization Laboratory Royal Jubilee Hospital Victoria, BC, Canada

Yoga therapy for AF yields insight into brain-heart axis

Tue, 24 Jan 2012 15:17:21 EST

Referring to the side effects reported by patients when taking Xanax vs. a placebo, 1.4% of those taking Xanax vs. 3.1% of those on a placebo reported incidences of Tachycardia/Palpitations. Similar results were also evident for symptoms of Nervousness and Tremor. While yoga certainly has a variety of benefits not afforded by Xanax, the fact that benefits regarding lower incidences Tachycardia/Palpitations can be achieved in venues not compatible with practicing yoga certainly makes Xanax worth considering to reduce incidences of tension and anxiety that are associated with some cases of tachycardia and possibly AF.

No reduction in bleeding with vitamin K in high-INR patients

Tue, 24 Jan 2012 14:38:58 EST

Ok i am also inclined to accept let go patients on high INR without treatment but what if the patient has to undergo an urgent operation? I think in this case vitamin K is necessary and sufficient to help rapidly correct bleeding tendency for the patients before letting them undergo any surgical maneuvers.

New Stent Technologies: Clinical Applications of Evidence-Based Medicine

Tue, 24 Jan 2012 14:14:40 EST

what is the speciality of your new stent?

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 24 Jan 2012 13:38:30 EST

For physicians, difference of opinion = fraud and everybody is guilty even if proven otherwise. I agree that bad apples must be erradicated. The verdict must be made by careful, fair and honest peer review. Sign of the times, gentlemen. And it's only going to get worse.

What is the Parsemus Foundation? Small not-for-profit pushes for appropriate PCI

Tue, 24 Jan 2012 13:26:31 EST

Less IS more in many instances, and the public needs to be aware of it. Hurray for Parsemus (who yes have a point of view they think could benefit others but not a conflict of interest), and hurray for Rita Redberg and the Archives! Agree with Vikas Saini that we are seeing some 'protesting too much' here.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 24 Jan 2012 13:01:55 EST

if proved in the court of law, should besides compensation to the patients and in case of death to their dependants,show these cheats the door to out of medical profession. they could do anything but belong to the medical profession. this will serve as a deterrent to others tempted to make quick but fraudulant bucks. the wording from the honoured court should be historical and safeguard, and uphold the human rights.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 24 Jan 2012 11:40:33 EST

If the cardiologists believed that they were acting in the best interest of the patients, there is no fraud. I fear that we are confusing a difference in opinion as to what is "necessary" with intent to defraud the government. The biggest story here is the need to educate physicians as to what Medicare deems "necessary" or "appropriate". In an age of catch and punish technology, I fear that anyone who can leave medicine will leave medicine if a difference in opinion as to what is appropriate can turn into a prison sentence. The net result will be that Medicare will save a lot of money as there will be no physicians left for patients to visit.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 24 Jan 2012 11:05:29 EST

Both sides need to temper emotions and rhetoric and let the due process of law take its course. Who knows what lurks in the minds and hearts of the accused and accuser!!

To prescribe or not to prescribe: That is the statin question, experts debate

Tue, 24 Jan 2012 09:30:23 EST

Nobody has yet survived 30 years of inhibiting the myriad of the mevalonate dependent pathways. From what you say, whatever risk factors you look at [yours suggest no issue but there was] it appears you've missed 1 or 2 key players. What was/is the homocysteine, Lp(a) and the n-3 and magnesium intake? Clearly, most people like Dr. K below, miss the causal issue: it's NOT diet, it's what's NOT in the diet. Fix the micro-nutrients, or at least have them easily meet the RDI/DV, and read LYON and GISSI re n-3. Those studies and the Hcy issue concern things that are NOT in the normal diet and that are causal. Nobody argues that Hcy is an independent risk factor for arterial decline: easy to minimize and zero risk. Unfortunately, lowering Hcy to one's genetic minimum does not reestablish the destroyed elastic layers of the media, IEL et al, that's a given. Lack of circulating statin cannot explain the uniquely human epidemic of CHD. In fact, how can anyone explain this curve using ANY of the usual suspects: www.health-heart.org/Mortality_CHD_UK_QJM2012.pdf While this curve might be slightly off, curves with similar impressive trends exist for the U.S. and for familial hypercholesterolemics.

Dapagliflozin declined by FDA

Tue, 24 Jan 2012 09:12:56 EST

No one can tolerate five fold increase in cancer. However the mode of action of SGLT-2 is novel and sounds promising. It neither stimulates the beta cells, nor has it any action on the liver/adipose tissue. The renal approach to control sugar is novel.The line of research needs to be pursued further.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 24 Jan 2012 09:12:20 EST

Yes, indeed, the title of the article leads the reader to a supposition of guilt. I wholeheartedly agree with Mr. Demello's analysis. And if PCI and CABG are merely "palliative", then why does cardiac rehab exist???

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 24 Jan 2012 08:47:19 EST

We are talking of unnecessary procedures in this particular case and not that of India. I would like see the data compiled before launching on attacks on a particular entity or country otherwise it will be deemed as hate speech.

Carotid images don't boost quit rates or cut CV risk factors in smokers

Tue, 24 Jan 2012 02:17:12 EST

If we want to improve the motivation of doctors to treat their patients at risk more properly, we need to show images to the doctors, not to the patients. In this study, in fact, both lipids and blood pressure were significantly better treated in those with plaque compared to those without plaque and imaging and those without imaging. This point has not been emphasized by the authors with sufficient clarity. Second: the perception of having to quit smoking by the smoker himself may be influenced by his risk perception. In this study, long standing smokers were aged arount 50 years on average. this kind of "pretest perception" of risk was not assessed in this study. I have had referrals from GP's approaching now around 1000 patients. Based on our imaging protocol, we derive the age of the arteries using the total plaque area as originally described by David Spence. (www.varifo.ch/VARIFO2.1e.xls). Usually, when I show a patient that his age is 55 but his amount of plaque is usually seen in a 70 year old, this dramatically increases the motivation for smoking cessation. Further, our imaging study does not cost 400� but 50 �, counselling and personalized report included. Imaging increases the perception both in patients and doctors, that action is required.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 24 Jan 2012 00:56:09 EST

if this is true it will be a big black spot on the white coat which shpuld be clean all the time fron dirty money.

FFR shows benefit in FAME II; enrollment halted

Tue, 24 Jan 2012 00:45:32 EST

What we are looking at is a more rapid reduction of angina symptoms from PCI than OMT; a phenomena that has been demonstrated in all prior stent studies. Not a big surprise and not a real answer to the question as to the value of revascularization in coronary prevention. What many are looking for is justification for continued PCI use in marginally symptomatic patients. This study did not answer that question however those of us who want to justify stenting will undoubtedly take this study as proof positive that stenting is a good and necessary thing. I am looking forward to the in-depth analysis of the DATA and also looking forward to the misinterpretation of that analysis by parties with an ax to grind in this controversy.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Tue, 24 Jan 2012 00:37:11 EST

I am concerned about both Demello's disclosure: "I care deeply about the sanctity of the physician patient relationship." and his ending: ""We must all hang together, or assuredly we shall all hang together." It appears to me that Demello cares more deeply about the physician-physician relationship than he does about the physician-patient relationship. Also consider his: ""What we have here is not a rush to judgment, it is a stampede to judgment." and his: "whistleblower/plaintiff/coward" Actually, it usually takes tremendous courage to be a whistleblower, standing up to the expected ostracism of the peers of ones chosen profession. So let's not rush to judgment to call physicians who question the status quo of the existing financial incentive structure "cowards". I think that his own example about the physicians' conference where the vast majority of participants admitted witnessing someone else in the room conducting inappropriate interventions is telling. The real issue is: are these isolated occurrences of close cases or common occurrences due to institutional biases? What are the particular facts? If the cardiology profession does not do an adequate enough job policing itself -- including by supporting valid whistleblowing actions -- then it has no right to complain when it ends up with strict policing by non-cardiologists. Let's not let our own cognitive dissonances and financial incentives affect our perspectives here...

To prescribe or not to prescribe: That is the statin question, experts debate

Tue, 24 Jan 2012 00:33:35 EST

Blumenthal believes that statins helped in West of Scotland and Jupiter, Redburg believes that too many people at low risk of MI are exposed to the risk of statins. Dr. Redburg, this problem can easily be remedied, it is called coronary calcium imaging. With coronary calcium imaging we can identify and treat only those at greater risk of MI and therefore greatest benefit from statin use. Subjects with CAC scores of 0 are at such low risk for MI and coronary death that the use of statin cannot be justified. In a MESA subset of Jupiter equivalent subjects, it meant that about 25% of Jupiter like subjects would benefit from statin use. Now the next thing to debate is whether there are better choices than statin or is there treatment better than statin alone in coronary prevention. The answer is obviously yes, however that is a subject of a different thread.

Lower mortality rates at two years with transradial PCI, Italian registry shows

Mon, 23 Jan 2012 23:59:47 EST

I really don't understand the criticism of the transradial approach. Seems to me that if you can offer a technique that results in better patient comfort, reduction in vascular trauma, and now multiple studies demonstrating CLINICAL benefit, that operators would be enthusiastically adopting it.

To prescribe or not to prescribe: That is the statin question, experts debate

Mon, 23 Jan 2012 23:39:25 EST

In 1997,�Long-term estrogen replacement therapy after menopause may reduce heart attack risk not only by lowering blood-fat levels, but also by increasing blood flow to the heart and causing blood vessels to stay open wider and longer, according to a study led by Johns Hopkins researchers.�

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Mon, 23 Jan 2012 22:46:05 EST

"What we have here is not a rush to judgment, it is a stampede to judgment." "There is a principle which is a bar against all information, which is proof against all argument, and which cannot fail to keep a man in everlasting ignorance. This principle is contempt prior to examination." William Paley "A few years ago, at a national interventional cardiology meeting, the speaker regaled the audience with an anecdote that may have been apocryphal but was entirely believable. At some earlier meeting, this speaker had challenged his audience with 3 sequential questions to which he invited a show of hands. The first was, "Have any of you witnessed an inappropriate coronary intervention?" in response to which virtually all of the hands in the room were raised. The second was, "Have any of you witnessed someone else in this room conduct an inappropriate intervention?" The vast majority of hands shot up. And finally, "Which of you yourselves has performed an inappropriate intervention?" None of the hands was raised." Paul Vaitkus, JACC 2011;57:1554-6. Has anyone noticed that the whistleblower/plaintiff/coward had financial as well as anti-competitive incentives for his actions? Has anyone noticed that Emanuele's co-counsel, Ms. Bennett, was the US attorney who started all of this misery by fabricating a problem in Baltimore, lecturing on the circuit with the hospital's counsel, and now cashing in as an expert on "unnecessary procedures" in the private sector? Where does conflict of interest begin and end in the legal profession? Attention Plaintiff Experts: A difference in opinion in patient management does not equate a violation in the standard of care. "We must all hang together, or assuredly we shall all hang together." Benjamin Franklin

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Mon, 23 Jan 2012 21:56:27 EST

The writing of this article seems to equate immediate guilt to some of the readers. This article provides anecdotal examples, and quotes stats provided by the plaintiff who has to have an underlying motive. Unfortunately, these are physicians who are part of a culture. To me, if there are unnecessary procedures occurring it is the lack of peer review and accountability by the institution. Let's not rush to accuse without getting more information. Second, the comment that PCI/CABG is for "palliative only" patients demonstrates lack of insight that is almost as bad as "stenting inappropriately". The way that posters immediately seize on this information just demonstrates the witch hunt mentality that has developed. And FYI, I am noninvasive. Let's wait and see what information comes out regarding the person who is suing... He was likely scorned by the institution in some way.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Mon, 23 Jan 2012 21:55:43 EST

Regarging about which encourages some cardiologics are BMW OR Mercedes BENZ cars or luxury lifestyle I agree too and this is not correct Author's disclosure (Jan 23, 2012)

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Mon, 23 Jan 2012 21:52:33 EST

I don`t agree with give money to Dr Emanuelle. May be a public recognition will be better . But I presume will be difficult to prove his position against other doctors positions- i.e. The pain was not typical? any doctor can offer a dozen of patients with atypical chest pain who died or near died from heart attack .Unnecesary revascularizations may be can be prove. In my Country cases like these ends mostly with a debt of unnecesary procedures and time to time in courts

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Mon, 23 Jan 2012 21:52:16 EST

Dr Amarjit Sinh I agree with you that PCI/CABG are merely palliative therapeutic procedures,but the use of them should be done according to the severity of the patient condition.Each case should be approached in an individual way. Regarging about which encourages some cardiologics are BMW OR Mercedes BENZ cars or luxury lifestyle and this is not correct

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Mon, 23 Jan 2012 21:17:11 EST

In india these unwanted procedures are at the drop of hat.Majority of the cardiologists never ask for mycardium viability procedures,hence revacularisation on ? dead myocardium.Target for the cardiologist is greed for mercedes car and lavish lifestyle.There is no accountibility,checks and balances.Cardiologists are practicing 'commercial cardiology' not comprehensive cardiology.WHO should come forward and tell the world that PCI/CABG are merely palliative procedures and meant for dying patients only.

To prescribe or not to prescribe: That is the statin question, experts debate

Mon, 23 Jan 2012 20:46:35 EST

I'm a 35 yo male interventional cardiologist. I don't smoke (obviously), have a BMI of 25, BP 110/70, exercise 4x a week, and eat a generally healthy diet. However my father became the proud owner of 3 Cypher stents at age 64 with a similar profile. 3 months ago I checked my lipids and HDL 54 and LDL 110 with a LDL particle number of 1520. I now take pravastatin 20mg which costs 3 dollars a month. So far no myalgias or other problems. There will NEVER BE A STUDY THAT LOOKS AT 30 YEAR OUTCOMES. I'd be interested to hear from cardiologists who would do differently for themselves in this situation.

Lower mortality rates at two years with transradial PCI, Italian registry shows

Mon, 23 Jan 2012 20:42:51 EST

This provides yet additional support for the supperiority of transradial left heart cathererization and PCI. The results are not unexpected as it is almost impossible for someone to bleed to death from a clinically controlled radial artery puncture, and development of a serious occult retroperitoneal hemorrhage, ischemic foot etc essentially impossible. However the radial approach would appear to require more technical skill which may explain the defensive tone of the first 3 comments.

CT coronary angiography to assess for CAD: What does this image show?

Mon, 23 Jan 2012 19:20:33 EST

Nice example, thank you.

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Mon, 23 Jan 2012 19:15:35 EST

If these allegations are true, they should be fined AND do time in jail. Money wont undo the risk and damage done which is not even assessable at this point.

Lower mortality rates at two years with transradial PCI, Italian registry shows

Mon, 23 Jan 2012 18:06:17 EST

This is a ridiculous study. Radial patients were likely lower risk and were clearly younger. No conclusions can be drawn from this study.

To prescribe or not to prescribe: That is the statin question, experts debate

Mon, 23 Jan 2012 17:54:27 EST

"If we were to spend a small fraction of the annual cost of statins on making fruits and vegetables and physical activity more accessible, the effect on heart disease, as well as high blood pressure, diabetes, cancer, and overall life span, would be far greater than any benefit statins can produce," she writes. The world according to Rita - unreferenced optimism. Is there a trial of statins that shows aggregate harm? Answer NO Is there a definite way to predict what low risk patient will have a cardiac endpoint? Answer NO Is there more potent evidence with regards to cardiac endpoint reduction with diet or statin? Answer Statin. Are statin based recommendations independent of lifestyle / diet alteration? Answer NO So Dr. Redberg is promoting the philosophy that physicians should preach diet and healthy living and deny drug therapy to those who refuse or cannot for some reason comply - it does not seem in keeping with the oath we have all taken. Preventing mortality however enviable is ultimately futile.

FFR shows benefit in FAME II; enrollment halted

Mon, 23 Jan 2012 16:55:28 EST

Jeff -- You are very correct, although no one knows yet whether there will be a difference in death and MI, because the data are just coming in -- and what will be the outcomes at one or two years? Theoretically, these data might actually show a mortality benefit to PCI in this patient population (which is, by the way, NOT the same as the COURAGE patient population). Nevertheless, the Data Monitoring Safety Board (which was constituted at a very high level) clearly felt that continuing to randomize patients to OMT only, when there was clearly FFR-documented ischemia in the proximal portion of a major artery, was unethical! This is really important news for the interventional community. And, of course, being able to document a rationale for proceeding with PCI would eliminate all the controversy about "over-stenting", etc. Burt Cohen Angioplasty.Org

To prescribe or not to prescribe: That is the statin question, experts debate

Mon, 23 Jan 2012 16:29:27 EST

You are right, statins lower risk ... for NON fatal events, not for fatal anything, not for calcicication and not for LDL composition, and they don't improve CV relevant micronutrient intakes. To suggest, as Dr. Blumenthal did, that there was a mortality benefit from statin in JUPITER is not understanding that this was from a chance finding in cancer deaths -same 'new cancers'. Fig. 3 in NEJM showed 12 fatal MIs + strokes in either group. CV deaths were p 0.37 or worse. Bravo Dr. Rita Redberg!

To prescribe or not to prescribe: That is the statin question, experts debate

Mon, 23 Jan 2012 16:08:39 EST

Millions of low and moderate risk people worldwide take statins for "primary prevention". Isn't this malpractice?

To prescribe or not to prescribe: That is the statin question, experts debate

Mon, 23 Jan 2012 15:17:12 EST

"Recalled" Riata ICD leads: Brainstorming conference aims for guidance

Mon, 23 Jan 2012 14:05:39 EST

I was inolved in the recall of the Accufix Atrial J pacing lead back in the mid 1990s - a similar strategic problem in that it was almost impossible to determine externally if a lead had failed, and the number failed was quite small. Eventually many leads were removed and replaced prophylactically. More people died from removal of leads with no problems than died from actual lead failures. What was missing from the dialog with patients and physician (and, incidentally from the regulators including the FDA) was a sensible approach to risk management. If the risk of dying from a lead replacement exceeds the risk of dying from a failed lead - then it should not be done. Unfortunately, people's approach to risk is skewed by the impact - that is why people are much more worried about flying than driving, even though the risks of driving are much much greater. Our society expects medical products to be risk free and they are not, never can be, and never will be.

"Recalled" Riata ICD leads: Brainstorming conference aims for guidance

Mon, 23 Jan 2012 13:05:13 EST

Now we have a problem that need a solution, but in my opinion, based on previous experiences, is time for devices industry and controllers to ceck very carefully looking forward to the patients before to commercialize any device in order to prevent other problems for the patients and implating physician in the future.

"Recalled" Riata ICD leads: Brainstorming conference aims for guidance

Mon, 23 Jan 2012 11:14:37 EST

The problem is who is gonna pay for said registry? Furthermore, who will be in charge of the submission and collection of the data? are you suggesting adding more paperwork and burden to medical practices? As an implanting physician, many times, I literally spend more time before and after a case filling forms and paperwork than the actual implant. By the way I Like your blog. How are we suppose to deliver effective care if a very high percentage of our time is spent filling redundant paperwork?

CT coronary angiography to assess for CAD: What does this image show?

Mon, 23 Jan 2012 09:21:32 EST

No more comment, just remember what we are face a patient suffering !!!

FFR shows benefit in FAME II; enrollment halted

Mon, 23 Jan 2012 08:40:24 EST

Lets just say there is no difference in death and MI but symptomatic benefit and reduced ACS and rehospitalization.What you are left with is a treatment of clear benefit to the patient in terms of QOL , fewer meds and fewer cumulative costs (remember even in BARI 2 PCI was cheaper than med Rx over a lifetime) with NO INCREASED RISK.Would be a class I.

Lower mortality rates at two years with transradial PCI, Italian registry shows

Mon, 23 Jan 2012 08:09:06 EST

This can't be anything more than luck of the draw. I would be hard pressed to believe that a different point of access for a procedure such as a PCI would actually result in a mortality benefit two years later. As ESPN analysts would say, "C'mon Man."

"Recalled" Riata ICD leads: Brainstorming conference aims for guidance

Mon, 23 Jan 2012 08:08:28 EST

I recently recommend that The Department of of Health and Human Services require a standardized set of data from each device interrogation to be submitted to a registry. Wouldn't this data be helpful? This was one of my ten advocacy efforts - see them all on my blog at CardiologyCoder.Com

73-year-old woman with dyspnea

Mon, 23 Jan 2012 05:34:00 EST

The echo findings resembles stress cardiomyopathy. Should be included in DD

Ventricular paced complex: What's your diagnosis?

Sun, 22 Jan 2012 23:57:04 EST

Initial negative deflection in the paced QRS in lead I and avL with positive QRS in II III avF is typical of RVOT septal pacing. And Deep Q in precordial leads can happen in pacing without MI

What life-threatening condition is shown in this ECG (II)?

Sun, 22 Jan 2012 23:49:17 EST

I have an objection to the proposed diagnosis. Assuming that all the ECG strips have been recorde at the same time, why the spaced RR intervals are different during the so called 2:1 conduction? Broadest in the middle panel as compared to the top and bottom panel. Please clarify.

Aspirin in primary prevention: New meta-analysis finds bleeding outweighs benefits for most

Sun, 22 Jan 2012 22:08:33 EST

If you use Coronary calcium imaging to determine who needs aspirin, perhaps a CAC score >100 should be that threshold, we would prevent the toxicity in the larger portion of the population that will not benefit from aspirin while providing the protection to those who need it. I use EBT calcium imaging to stratify risk and those with little or no plaque need little or no pharmacological intervention. Those with large calcified plaque burdens and progressing calcium burdens are the ones most likely to benefit from further pharmacological interventions.

Treat risk and not LDL-cholesterol targets, new perspective argues

Sun, 22 Jan 2012 22:00:22 EST

Coronary calcium imaging has clearly been shown to be the best measure of risk. A calcium score of 0 is associated with an annual heart attack risk of 0.01% and a coronary death rate of almost nil. Stable coronary calcium as defined by an annual percent increase of 15% or less (alternatively the annualized square root progression of 2.1 or less) is associated with a 3X difference in all cause mortality and a 5 to 17X difference in heart attack risk. If we want to treat risk and individualize treatment to optimal levels on an individual basis, there is nothing that compares to coronary calcium imaging. Carotid IMT dose not compare to CAC imaging with respect to MI risk stratification. It is however better than CAC in stroke prediction. Carotid ultrasound for plaque burden is probably better than IMT however it requires further study and standardization. Serial IMT measurements have not been associated with further stratification of risk. The large metanalysis from Europe showed not correlation between IMT changes over time and MI risk in statin treated subjects. We have the technology to prevent almost all heart attacks yet very few people utilize them. I don't understand why.

Late-Breaking Developments in the Treatment of Dyslipidemia: Are All Omega-3 Fatty Acids the Same?

Sun, 22 Jan 2012 20:13:56 EST

states that GISSI-P was a fish oil stugy and JELIS was a EPA Ethyl Ester Stufy. Yet GISSI-P is an ehtyl ester study. Seems that the authors are unable to provide accurate information.

Treat risk and not LDL-cholesterol targets, new perspective argues

Sun, 22 Jan 2012 18:58:01 EST

The role of physicians has been helping patients to reduce ALL risks factors that are able to be modified. LDL Cholesterol is just one of them. Didn�t everybody know this?

What life-threatening condition is shown in this ECG (II)?

Sun, 22 Jan 2012 16:36:07 EST

"junctional tachycardia with variable conduction to the ventricle -- sometimes 2:1 or sometimes 3:2, 4:3, 6:5, etc" how can you make this observation when the atria are in Fib as you have stated. not rocket science . AF is the correct answer.

Resveratrol scientists react to Das fraud scandal: "Research will continue"

Sun, 22 Jan 2012 16:19:11 EST

Dr Dipak Das is accused of enhancing western blot images. Western blot provides a gross analysis of protein expression. However, Dr Das later submitted to the NIH rodent heart tissue exposed to resveratrol prior to an experimentally-induced heart attack for microRNA analysis, a more sophisticated assay of selected gene expression. This report was published in PLoS ONE ) The microRNA analyses showed resveratrol restored heart tissue to a more normal gene expression pattern following a heart attack in rodents. The microRNA analysis validates his prior findings, that resveratrol preconditions cardiac tissue to release protective molecules (heme oxygenate, adenosine, SOD, glutathione, catalase) prior to the occurrence of a heart attack.

BRIDGE study published: Cangrelor suited for important antiplatelet niche

Sun, 22 Jan 2012 16:16:30 EST

Flibuprofene was a long time ago used by the anesthesiologists before surgery... I remember phone calls from my colleagues some days before surgery "I stop Aspirin or Coumadin and I start Flibuprofene. do you agree?" they never wait for my answer they had hung down before. not anymore phone call like these since a long time. the mind changed, now it's "I give LWMH do you agree?..." will it be Cangrelor turn very soon? JP Usdin cardiologist

Resveratrol scientists react to Das fraud scandal: "Research will continue"

Sun, 22 Jan 2012 13:21:32 EST

As time passes, it appears that the researcher may not be guilty of anything other than enhancing a western blot for publication purposes, a practice that is routine, and having a disgruntled lab employee. What an incredible rush to judgement! The university is even backtracking. Yet we, theheart.org included, have all convicted him and thrown away the key! Please do a more investigatively objective follow-up story!!!

What electrolyte problem does this tracing show?

Sun, 22 Jan 2012 10:42:46 EST

while the diag is typical ,bright ones would keep their minds open for hypocalcemia and hypomagnessemia, even after the primary author declares the k+ level as 1.9 meq/l,still fearing dr wang might have read the report incompletly. further a clinical history is not needed here. it has to be a common teaching exercise for medical students, for that matter, all over the globe.

ECG of the month: Is this myocardial infarction?

Sun, 22 Jan 2012 10:04:36 EST

wpw. a commonality. indeed while reading about wpw syndrome all these things are highlighted. some body has told of delta waves in inf leads only, in this ecg, having missed the same,so well seen in chest leads here, in particular v4.

An example of an artifact?

Sun, 22 Jan 2012 09:31:55 EST

only remotely connected here. only the varying heights of rr complexes need further explation.

What life-threatening condition is shown in this ECG (II)?

Sun, 22 Jan 2012 09:22:26 EST

Nice review of dig toxicity but it looks like flutter with variable block in the tracing. In the middle tracing there are biphasic P waves. Also, the grouped regular beats are ~150bpm (AFluttter with 2:1 AV block)

Why has the heart rate suddenly slowed down?

Sun, 22 Jan 2012 09:16:17 EST

pl read in the last but one line of my opinion: and i did, instead of as did. thanks.

Why has the heart rate suddenly slowed down?

Sun, 22 Jan 2012 09:10:05 EST

an excellent ecg quiz strip. few things need to be highlighted.1: that the diagnosis could be made only with the help of lead v1 alone.2: it further highlights the teaching and the fact that leads ii, iii, avf(i.e. the inf wall leads) and vi are the best leads to read the p waves. 3: also that every 3rd p waves in vi here is burried in the SA node. it is perhaps this fact that nearly half of the readers have missed the diagnosis.it there fore becomes essential to measure the rr and pp intervals. i got a print out of this tracing and as did as i said above, to arrive at the correct diagnosis.

FFR shows benefit in FAME II; enrollment halted

Sun, 22 Jan 2012 04:01:42 EST

OK, we'll wait for the results. But the investigators are already telling us that no effects on hard end points will be demonstrated. That is why I don't think it's "unethical" to continue enrollment. And this particular trial most probably will not definitively answer the quiestion of stenting in stable CAD population.

Dronedarone gets another chance to prove itself in ranolazine combo trial

Sun, 22 Jan 2012 03:28:33 EST

Doesn't look promising, does it?

Cardiac CT certificate of advanced proficiency exam comprehensive review: What does this image sho

Sun, 22 Jan 2012 01:48:11 EST

a second scan 10 minutes after the first scan with no additionanl isovue or visipaque will do it. Preferably with prospective gating to reduce rad dose

Dapagliflozin declined by FDA

Sat, 21 Jan 2012 18:07:46 EST

A fivefold increased in cancer is a great concern.We dont need this drug to be released through the fast track.With the new DPP-4 antagonists, GLP-1 agonists and insulins we have enough in our armamentarium for the moment.We need to wait for the SLGT2. Congratulations to the FDA.

New Stent Technologies: Clinical Applications of Evidence-Based Medicine

Sat, 21 Jan 2012 16:59:59 EST

What is the best and appropriate way to access the information online?

Dapagliflozin declined by FDA

Sat, 21 Jan 2012 16:11:36 EST

Good decision, just hope the lunatics on this side of the pond dont give in....i remember many years a go a large Americam drug company being turned down by the FDA when clinical trials showed a rather alarming increase in Liver cancer. The company line..."we hope to work with the FDA to maybe come to an agreement on how we can move this forward"....priceless.

Uncontrolled Hypertension in the Renal Sympathetic Nervous System

Sat, 21 Jan 2012 13:36:53 EST

ACE inhibitors may reduce GFR, and they can exacerbate renal impairment in patients with renal artery stenosis. This is especially a problem if the patient is concomitantly taking an NSAID and a diuretic. When the three drugs are taken together, there is a very high risk of developing renal failure. Thomas MC. (2000). �Diuretics, ACE inhibitors and NSAIDs--the triple whammy.� Med J Aust;172(4):184-5. Seelig CB, Maloley PA, Campbell JR. (1990).�Nephrotoxicity associated with concomitant ACE inhibitor and NSAID therapy.� South Med J;83(10):1144-8. However, if you were treating HF, then you�d better read the following article: Klein L, O'Connor CM, Gattis WA, et al. (2003). �Pharmacologic therapy for patients with chronic heart failure and reduced systolic function: review of trials and practical considerations.� Am J Cardiol;91(9A):18F-40F. Erratum in: Am J Cardiol. 2003 Dec 1;92(11):1378. As far as Ang II inhibitor is concerned, read the following articles, if you want to use it against HF. AngII RI represents a good alternative in case of ACEI intolerance. Ostergren JB. (2006). �Angiotensin receptor blockade with candesartan in heart failure: findings from the Candesartan in Heart failure--assessment of reduction in mortality and morbidity (CHARM) programme.� J Hypertens Suppl;24(1):S3-7. Grothusen A, Divchev D, Luchtefeld M, et al. (2009). �Angiotensin II type 1 receptor blockade: high hopes sent back to reality?� Minerva Cardioangiol;57(6):773-85. Werner C, Baumh�kel M, Teo KK, et al. (2008). �RAS blockade with ARB and ACE inhibitors: current perspective on rationale and patient selection.� Clin Res Cardiol;97(7):418-31. G�nther S, Baba HA, Hauptmann S, et al. (2010). �Losartan reduces mortality in a genetic model of heart failure.� Naunyn Schmiedebergs Arch Pharmacol;382(3):265-78. AT1RI is not effective in HF because AT1-R in atrial and LV tissues was downregulated during chronic heart failure, and AT1-R-mediated functional biochemical responsiveness was decreased in the failing hearts. Tsutsumi Y, Matsubara H, Ohkubo N, et al. (1998). �Angiotensin II type 2 receptor is upregulated in human heart with interstitial fibrosis, and cardiac fibroblasts are the major cell type for its expression.� Circ Res. 1998 Nov 16;83(10):1035-46. However, as far as Hypertension treatment is concerned, it has gotten its place already, especially in patients with Diabetes. Israili ZH. (2000). �Clinical pharmacokinetics of angiotensin II (AT1) receptor blockers in hypertension.� J Hum Hypertens;14 Suppl 1:S73-86. Hern�ndez-Hern�ndez R, Velasco M, Armas-Hern�ndez MJ, et al. (2000). �Angiotensin II receptor antagonists in arterial hypertension.� J Hum Hypertens;14 Suppl 1:S69-72. Leiter LA, Lewanczuk RZ. (2005). �Of the renin-angiotensin system and reactive oxygen species Type 2 diabetes and angiotensin II inhibition.� Am J Hypertens;18(1):121-8. AT1RI reduces AF and subsequent stroke. Wachtell K, Lehto M, Gerdts E, et al. (2005). �Angiotensin II receptor blockade reduces new-onset atrial fibrillation and subsequent stroke compared to atenolol: the Losartan Intervention For End Point Reduction in Hypertension (LIFE) study.� J Am Coll Cardiol;45(5):712-9. Moen MD, Wagstaff AJ. (2005). �Losartan: a review of its use in stroke risk reduction in patients with hypertension and left ventricular hypertrophy.� Drugs. 2005;65(18):2657-74. AT1RI also reduces CV morbidity and mortality in hypertensive patients with AF. Wachtell K, Hornestam B, Lehto M, et al. (2005). �Cardiovascular morbidity and mortality in hypertensive patients with a history of atrial fibrillation: The Losartan Intervention For End Point Reduction in Hypertension (LIFE) study.� J Am Coll Cardiol;45(5):705-11.

New PCI, CABG guidelines emphasize team approach

Sat, 21 Jan 2012 13:04:14 EST

In our Department two treatment strategies are used for the antithrombotic preparation in the PCI patients with chronic CHD. The first, and mostly administrated, includes clopidogrel preloading for approximately 5 days with 75 mg q.d. The second option that we use is giving loading doses of 300 mg. According to the recent guidelines, there are controversial data on this issue. Depending on the experience and evidence, what should be the preferred strategy? P.S. Due to the fact that we have only clopidogrel registred for this purpose, question is related to this drug in combination with ASA. Thank you in advance.

PCI Guidelines 2011: Focus on Antiplatelet Therapies

Sat, 21 Jan 2012 11:45:56 EST

Secondary Stroke Prevention in AF: Impact and Burden on Practice and Healthcare Systems

Sat, 21 Jan 2012 10:46:30 EST

Need more information regarding this procedure

Treat risk and not LDL-cholesterol targets, new perspective argues

Sat, 21 Jan 2012 04:25:15 EST

So, those of us in the International Network of Cholesterol Skeptics (THINCS), who have been battling for many years against the misguided cholesterol hypothesis may have been right after all? Surely not. Anyone who wishes may now write a full letter of apology to Uffe Ravnskov, with humble apologies for the many personal attacks he has received over the years, including burning his book during a television debate. P.S. I am not holding my breath on this.

Salt, hypertension, and prevention

Fri, 20 Jan 2012 22:17:19 EST

I agree completely with E Teitel. Now its time to look at the US governments recommendations to lower fat intake as well. You want a prospective study of dietary fat reduction and outcomes in US population try 50,000 women for 8 years ie Women's Health Initiative. No reduction in cardiac or cancer outcomes with the AHA low fat diet vs usual. For great discussions on this issue I refer to "A Call For Higher Standards For Dietary Guidelines" Marantz, Bird et al Am J Prev Med 2008;34(3):234-240 and "What if it's All Been A Big Fat Lie" an excellently written article by New York Times science writer Gary Taubes in NYT archives. Came out in July 2002 believe it or not.

FFR shows benefit in FAME II; enrollment halted

Fri, 20 Jan 2012 16:47:54 EST

This study seems to replicate the universally ignored JSAP study showing a marked reduction in lesion specific UAP with PCI. Chronic does not equal stable in all cases. One quibble:This doesnt demonstrate the benefit of FFR.It demonstrates the benefit of PCI (with defined ischemia).Look forward to the analysis (esp cost benefit!)

Salt, hypertension, and prevention

Fri, 20 Jan 2012 16:19:01 EST

I think we all agree it is wise to educate people about health benefit and risk ratios for the proportional useage of certain dietary components. I do not think it wise to mandate governmental control of diet. Great Britain raises tax money through taxation of foods with certain percentages of dietary components, (fats, sugar,salt)? Would the US federal government attempt to mimic Britain and have Americans pay more food tax for a pound of bacon than a pound of apples? Is our future monitoring dietary behaviors via tax mechanisms? If so, let's work to improve population health in a much less coersive manner. Educating people about genetic preponderance of certain dietary elements being "risky foods" in large amounts is one thing; allowing government to establish a tax base on fats, sugar and salt is another. Why not more strongly support population education regarding the methodologies for healthy home cooking? Helping people to return to the home cooked meal would help improve population health. Crockpots versus taxation schemes.

Salt, hypertension, and prevention

Fri, 20 Jan 2012 15:12:13 EST

I�m ashamed. How can knowledgeable professors seem to know so little about the physiology of salt that they recommend us to eat less salt? We know that we have just enough salt in the body. We have to excrete exactly the same amount that we eat. The normal amount healthy people excrete via the urine is 9-18 grams of salt per day. Then add salt losses from sweat and faeces and it all ends up to a minimum intake of 15 grams sodium chloride per day. We can eat up to 100 grams of salt per day if we drink enough water. And there is not a single study that has measured the salt intake between 10 and 100 grams salt per day and at the same time the blood pressure. Why? Because we already know that the blood pressure will stay normal as long as we eat less than 100 grams of salt and have enough of water. That experiment will just destroy a beautiful hypothesis and further research money will evaporate in thin air. We all know that if the sodium concentration in the blood is less than 125 mmol/L we die if we are not resalinated slowly during several days back to normal 137-145 mmol/L sodium. 125 mml/L is equal to 41 grams of salt in the blood of a 70 kg person and about 155 g salt in total interstitial fluid volume (including blood volume). 137 mmol/L is equal to 45 grams of sodium chloride in the same individual and about 170 g in total interstitial fluid volume, just 4 (four) grams more in the blood and 145 mmol/L is equal to 48 grams of salt in the same person�s blood volume and about 180 g in total interstitial fluid volume. If the extracellular sodium level is too low more water is forced into the cells and the cells will eventually disrupt due to increased intracellular water volume. This is a well known way to quickly disrupt cells by adding distilled water to a cell sample. So there is a small difference in salt amounts (15-25 grams) that separates continued survival of the individual and death due to sodium deficiency. Shame on seemingly ignorant profe$$ors!

Dapagliflozin declined by FDA

Fri, 20 Jan 2012 13:58:41 EST

"To kick medicine forward and introduce innovative new things" should not be the approach any more for FDA to approve any drug in the future. After 34 years of experience treating diabetes and knowing the relevance of the glucocentric care of the Type 2DM patients and the cardiovascular complications, this new class of drugs, to add to a laundry list of drugs already in the market, has very little place. Looking at the big picture, this drug adds very little in our practice of evidence and value based medicine. FDA has the responsibility and the authority to sensibly restrict drugs and devices coming to the market to prevent irrational rationing of health care in the future, in this country.

BRIDGE study published: Cangrelor suited for important antiplatelet niche

Fri, 20 Jan 2012 13:19:25 EST

we hope to be in comrecial so we need it for many patients but withmore data

Series of Tall T Waves (I)

Fri, 20 Jan 2012 12:56:19 EST

i am resident of cardiology, thanks from your informative ecgs and comments.

Treat risk and not LDL-cholesterol targets, new perspective argues

Fri, 20 Jan 2012 12:55:57 EST

Treat the vulnerable patient, not just the arteries, lumen or risk factors.

Resveratrol scientists react to Das fraud scandal: "Research will continue"

Fri, 20 Jan 2012 12:29:49 EST

"Trust deficit"in clinical research and scientific misconduct in medicine is getting so rampant in the last decade that the public has become so critical if not skeptical about what conclusions that come out of any research now. I hope this trend will not lead the doctors and the public to take an attitude of throwing the baby with the bath water!

Treat risk and not LDL-cholesterol targets, new perspective argues

Fri, 20 Jan 2012 12:28:51 EST

Prominent Endovascular researchers Stephen Epstein, MD & J. Zou, MD, PhD did a large seminal retrospective analysis of ~5000 heart disease patients where they ranked risk-factors....Results: Positivity to Calcifying Nanoparticle antigen & antibodies (CNP or Nanobacteria) were a higher risk-factor for CV events than LDL, VLDL, Homocysteine. Epstein's Findings were presented at AHA. Stephen E. Epstein, MD is the Director of the MedStar Cardiovascular Research Institute in DC, prior to Medstar, Dr. Epstein served for over 30 years as Chief of the Cardiology Branch of the NHLBI at the National Institutes of Health in Bethesda, MD. Read more about this research and CNP research at NanoBiotech Pharma.us

What life-threatening condition is shown in this ECG (II)?

Fri, 20 Jan 2012 12:21:41 EST

I would have thought that if we were observing Wenckebach conduction that there would be progressive R-R shortening in the groups of more that 2 beats. Also I cannot march out the putative driver. The QRS coming in after the pauses is too early to have been conducted from any concealed focus that I can conjure from the preceding beats. Good discussion though, thanks.

Lower mortality rates at two years with transradial PCI, Italian registry shows

Fri, 20 Jan 2012 12:20:07 EST

This isn`t randomized study, obviusly patients with higher risk y/o acute cardiac failure, the access will be femoral.

Salt, hypertension, and prevention

Fri, 20 Jan 2012 11:29:59 EST

Excellent discussion! We also need to remember that when we make recommendations to lower sodium intake to improve health outcomes we do so in conjunction with recommendations to lower fat and most often calorie consumption. The true health benefits come from a lifestyle in which poeple incorporate physical activity, low intake of convenience foods (thereby lowering Na intake), daily intake of fresh fruits and vegetables, low to moderate intake of meat products, moderate intake of fish and omega 3 containing foods, maintain a healthy weight, no smoking, ..... in other words live healthy be healthy. No 1 recommendation alone will do the trick in and of itself. Of course this is a Dietitians perspective. And when studying anything dietary related we know that EVERYONE under reports. You have to lock people up to get accurate information As far as policy - we have to have some kind of public recommendations. Otherwise we have no way to educate people and make comparisons. Personal reposibilty doesnt seem to be adequate in our society. We all have to pay for the healthcare of individuals who are knowingly killing themselves slowly with their food intake and lack of physical activity.As the doctor stated.... Its very hard to change behaviors.

Salt, hypertension, and prevention

Fri, 20 Jan 2012 11:28:56 EST

From my 34 years of experience treating patients with hypertension, I have observed that there is definite relation of salt intake to hypertension especially in black and south asian population but much less for Caucasians and there may be some genetic variation in this as well. So it is not surprising that we get conflicting results in these studies. We should abandon the "one size fits all" attitude in medicine and use common sense and customize our therapy for hypertension.

BRIDGE study published: Cangrelor suited for important antiplatelet niche

Fri, 20 Jan 2012 08:56:03 EST

Heparin, Ticagrelor, Dipiridamol, anything could be compared....really is difficult to me, understand how Cangrelor could be compared with placebo ONLY (are these patients taking or not aspirin, for example ?), especially in patients with stents implanted....Perhaps, Dr. Topol said: Topol said: "From a regulatory view, this trial is small and only has a surrogate end point (platelet inhibition), so I couldn't say that it will gain approval. But as there is nothing else available for this population and there is a clear need for something, maybe cangrelor could be made available, with further data coming from postmarketing studies."....he speaks about "it will gain approval", "postmarketing studies"....is very rare and hard to believe for me. Excuses for my english, i'm a latin american cardiologist.

Treat risk and not LDL-cholesterol targets, new perspective argues

Fri, 20 Jan 2012 08:06:32 EST

Individual risk is absolutely the right assessement tool, but we should be asking if Framingham alone is adequate and where there might be a place for a more comprehensive risk assessment protocol that could incorporte various scans and more advance blood profiling. But let's not throw out the "baby with the bath water." LDL targets will remain useful --- ATP III addresses not only drug treatment protocols but also the theraeputic lifestyle changes. Many boomers are finding great interest in not only avoiding disease but optimzing health. I am not sure that we should be suggesting that an LDL level of 140 is healthy -- but rather it may not be appropriate for drug treatment. An important difference. The recomendation would remain to utilize TLC to bring cholesterol levels down.

What life-threatening condition is shown in this ECG (II)?

Fri, 20 Jan 2012 07:20:25 EST

unfortuantely this is not the only Dig problem. It would be helpful to remove the drug from the agenda, especially in the antiarrhythmic treatment of AF. Thanks

CHADS2 predicts problems in AF patients taking dabigatran, warfarin

Thu, 19 Jan 2012 23:49:53 EST

The article suggests that those with 0-1 chads score benefits more from dabigatran versus those with higher scores. How is it true if the greatest reduction in stroke risk comes from those with higher chads scores? Does inc. risk in bleeding > benefit in stroke reduction in ppl with higher chads2?

Salt, hypertension, and prevention

Thu, 19 Jan 2012 23:48:41 EST

It appears that if there is any evidence that salt restriction is beneficial, it is at the high extremes, inconsequential for the vast majority of people, and harmful at the low extreme. Who in their right mind could, based upon such data justify limiting liberty and using the coercive force of government to impose a low salt policy on the entire nation, and perhaps the world. Perhaps, in the absence of solid data, the government do-gooders should leave us alone.

Late-Breaking Developments in the Treatment of Dyslipidemia: Are All Omega-3 Fatty Acids the Same?

Thu, 19 Jan 2012 22:48:50 EST

excellent

Treat risk and not LDL-cholesterol targets, new perspective argues

Thu, 19 Jan 2012 21:34:50 EST

Small-dense with less cholesterol, large-buoyant with more cholesterol, good, bad and whatever, it all has failed to deliver a clear health message and treatment goal. Here's just maybe why: about any lipid consumed or made [apart from cholecalciferol with its own transporter and some other hormone-type lipids] is carried inside/by LDL. These lipids include the tocopherols, the tocotrienols, the trans-fats, any of the 3 main n-3's, ox-cholesterol from deep-fried or dried stuff, CoQ10 and any of the hundreds of carotenoids that one can consume. Then there is the homocysteinylated or glycated apoB that affect LDL function. Nobody has cared to properly look at the biochemical / nutritional composition of what's in this LDL emulsion particle or at the functionality of its lipoprotein. Missed confounders and players. So now, in 2012, we have to conclude that the quantity of LDL, so effectively slashed by statin, is no longer a valid target if ever it was. If anything, it's what we put into the LDL that affects cellular function, not the amount of this transport emulsion. The one undisputed remaining benefit of statins: they do promote the NO/eNOS pathways and this with the same result, in some, as have the nitrates.

Endothelial Function and Cardiovascular Health: From Hypothesis to Treatment

Thu, 19 Jan 2012 20:40:39 EST

Decreased NO release after myocardial ischemia/reperfusion worsen PMN-induced myocardial injury, and increased NO promotes reduction in infarct size. Ma XL, Weyrich AS, Lefer DJ, et al. (1993). �Diminished basal nitric oxide release after myocardial ischemia and reperfusion promotes neutrophil adherence to coronary endothelium.� Circ Res;72(2):403-12. Lefer AM, Ma XL, Weyrich A, et al. (1993). �Endothelial dysfunction and neutrophil adherence as critical events in the development of reperfusion injury.� Agents Actions Suppl;41:127-35. Egdell RM, Siminiak T, Sheridan DJ. (1994). �Modulation of neutrophil activity by nitric oxide during acute myocardial ischaemia and reperfusion.� Basic Res Cardiol;89(6):499-509. Wang XL, Liu HR, Tao L, et al. (2007). �Role of iNOS-derived reactive nitrogen species and resultant nitrative stress in leukocytes-induced cardiomyocyte apoptosis after myocardial ischemia/reperfusion.� Apoptosis;12(7):1209-17. Stimulation of eNOS reduces nitrative stress and decreases apoptosis whereas stimulation of iNOS increases nitrative stress and enhances myocardial reperfusion injury. Liang F, Gao E, Tao L, et al. (2004). Critical timing of L-arginine treatment in post-ischemic myocardial apoptosis-role of NOS isoforms. Cardiovasc Res;62(3):568-77. Use of AT1R blockade by Losartan will increase bradykinin and NO, and thus coronary artery reperfusion. The effect of AT1R inhibition is crucial in regulation of NO release than AT2R stimulation. Jugdutt BI. (2002). �Nitric oxide and cardioprotection during ischemia-reperfusion.� Heart Fail Rev;7(4):391-405. Sardo MA, Castaldo M, Cinquegrani M, et al. (2004). "Effects of AT1 receptor antagonist losartan on sICAM-1 and TNF-alpha levels in uncomplicated hypertensive patients." Angiology;55(2):195-203. Savoia C, Schiffrin EL. (2007). �Reduction of C-reactive protein and the use of anti-hypertensives.� Vasc Health Risk Manag;3(6):975-83. Savoia C, Schiffrin EL. (2007). "Vascular inflammation in hypertension and diabetes: molecular mechanisms and therapeutic interventions." Clin Sci (Lond);112(7):375-84. Presta I, Tassone EJ, Andreozzi F, et al. (2011). �Angiotensin II type 1 receptor, but no type 2 receptor, interferes with the insulin-induced nitric oxide production in HUVECs.� Atherosclerosis. 2011;219(2):463-7. Gwathmey TM, Westwood BM, Pirro NT, et al. (2010). "Nuclear angiotensin-(1-7) receptor is functionally coupled to the formation of nitric oxide." Am J Physiol Renal Physiol;299(5):F983-90. Cheng WH, Lu PJ, Ho WY, et al. (2010). "Angiotensin II inhibits neuronal nitric oxide synthase activation through the ERK1/2-RSK signaling pathway to modulate central control of blood pressure." Circ Res;106(4):788-95.

Treat risk and not LDL-cholesterol targets, new perspective argues

Thu, 19 Jan 2012 19:46:39 EST

My last comment meant to say the elderly not orderly!,, Small debase LDL and increased triglycerides are the typical atherogenic. Dyliidemia in the type 2 diabetic and probably the metabolic syndrome patient

Treat risk and not LDL-cholesterol targets, new perspective argues

Thu, 19 Jan 2012 19:43:31 EST

A major problem in cardiology is the inaccurate individualized assessment of cardiovascular risk. Primary prevention studies reduce events but the plot of the linear curve is not as steep as in the secondary prevention trials. Risk engines calculating 10 year risk in not the same as analyzing life long risk and over estimates risk in the orderly and under estimates risk in women and younger patiients whom might have one risk factor --- a very very very high cholesterol

Implementing Quality Enhancement in the Treatment of PAH: Facilitating a Guideline-Based Approach

Thu, 19 Jan 2012 19:40:11 EST

Read Angiotensin II in place of Angiotensinogen II.

Implementing Quality Enhancement in the Treatment of PAH: Facilitating a Guideline-Based Approach

Thu, 19 Jan 2012 19:36:36 EST

Nicholls MG, Richards AM & Agarwal M (1998). �The importance of the renin-angiotensin system in cardiovascular disease.� J Hum Hypertens;12, 295�299. Imai Y, Kuba K, Ohto-Nakanishi T, et al. (2010). Angiotensin-converting enzyme 2 (ACE2) in disease pathogenesis. Circ J;74(3):405-10. Kaparianos A, Argyropoulou E. (2011). Local renin-angiotensin II systems, angiotensin-converting enzyme and its homologue ACE2: their potential role in the pathogenesis of chronic obstructive pulmonary diseases, pulmonary hypertension and acute respiratory distress syndrome. Curr Med Chem;18(23):3506-15. Bradford CN, Ely DR, Raizada MK. (2010). �Targeting the vasoprotective axis of the renin-angiotensin system: a novel strategic approach to pulmonary hypertensive therapy.� Curr Hypertens Rep;12(4):212-9. Brilla CG, Scheer C, Rupp H. (1997). Renin-angiotensin system and myocardial collagen matrix: modulation of cardiac fibroblast function by angiotensin II type 1 receptor antagonism. J Hypertens Suppl;15(6):S13-9. Sun Y, Ramires FJ, Weber KT. (1997). Fibrosis of atria and great vessels in response to angiotensin II or aldosterone infusion. Cardiovasc Res;35(1):138-47. Kaparianos A, Argyropoulou E. (2011). �Local renin-angiotensin II systems, angiotensin-converting enzyme and its homologue ACE2: their potential role in the pathogenesis of chronic obstructive pulmonary diseases, pulmonary hypertension and acute respiratory distress syndrome.� Curr Med Chem;18(23):3506-15. Han SX, He GM, Wang T, et al. (2010). �Losartan attenuates chronic cigarette smoke exposure-induced pulmonary arterial hypertension in rats: possible involvement of angiotensin-converting enzyme-2.� Toxicol Appl Pharmacol;245(1):100-7. Yeager ME, Belchenko DD, Nguyen CM, et al. (2012). �Endothelin-1, the unfolded protein response, and persistent inflammation: role of pulmonary artery smooth muscle cells.� Am J Respir Cell Mol Biol;46(1):14-22. Abraham DJ, Vancheeswaran R, Dashwood MR, et al. (1997). �Increased levels of endothelin-1 and differential endothelin type A and B receptor expression in scleroderma-associated fibrotic lung disease.� Am. J. Pathol;151, 831-841. Dohi Y, Hahn AW, Boulanger CM, et al. (1992). �Endothelin stimulated by angiotensin II augments contractility of spontaneously hypertensive rat resistance arteries.� Hypertension; 19, 131-137 Yeager ME, Belchenko DD, Nguyen CM, et al. (2012). �Endothelin-1, the unfolded protein response, and persistent inflammation: role of pulmonary artery smooth muscle cells.� Am J Respir Cell Mol Biol;46(1):14-22. Giaid A, Yanagisawa M, Langleben D, et al. (1993). �Expression of endothelin-1 in the lungs of patients with pulmonary hypertension.� N. Engl. J. Med;328, 1732-1739. Abraham DJ, Vancheeswaran R, Dashwood MR, et al. (1997). �Increased levels of endothelin-1 and differential endothelin type A and B receptor expression in scleroderma-associated fibrotic lung disease.� Am. J. Pathol;151, 831-841. Shenoy V, Qi Y, Katovich MJ, et al. (2011). �ACE2, a promising therapeutic target for pulmonary hypertension.� Curr Opin Pharmacol;11(2):150-5.

Implementing Quality Enhancement in the Treatment of PAH: Facilitating a Guideline-Based Approach

Thu, 19 Jan 2012 19:35:48 EST

Victorino GP, Newton CR & Curran B (2002). �Effect of angiotensin II on microvascular permeability.� J Surg Res ; 104, 77�81. Suzuki Y, Ruiz-Ortega M, Lorenzo O, et al. (2003). Inflammation and angiotensin II. Int J Biochem Cell Biol; 35, 881�900. Fleming I, Kohlstedt K & Busse R (2006). �The tissue reninangiotensin system and intracellular signalling.� Curr Opin Nephrol Hypertens; 15, 8�13. Imai Y, Kuba K, Rao S, et al. (2005). �Angiotensin-converting enzyme 2 protects from severe acute lung failure.� Nature; 436, 112�116. Schanstra JP, Marin-Castano ME, Praddaude F, et al. (2000). �Bradykinin B1 receptor-mediated changes in renal hemodynamics during endotoxin-induced inflammation.� J Am Soc Nephrol; 11, 1208�1215. Marceau F & RegoliD. (2004). �Bradykinin receptor ligands: therapeutic perspectives.� Nat Rev Drug Discov; 3, 845�852. Warner FJ, Smith AI, Hooper NM & Turner AJ (2004). �Angiotensin-converting enzyme-2: a molecular and cellular perspective.� Cell Mol Life Sci; 61, 2704�2713. Vickers C, Hales P, Kaushik V, Dick L, Gavin J, Tang J et al. (2002). �Hydrolysis of biological peptides by human angiotensin-converting enzyme-related carboxypeptidase.� J Biol Chem; 277, 14838�14843. Dostal DE, Hunt RA, Kule CE, et al. (1997). �Molecular mechanisms of angiotensin II in modulating cardiac function: intracardiac effects and signal transduction pathways.� J Mol Cell Cardiol;29(11):2893-902. Hunyady L, Catt KJ. (2006). �Pleiotropic AT1 receptor signaling pathways mediating physiological and pathogenic actions of angiotensin II.� Mol Endocrinol;20(5):953-70. Eguchi S, Numaguchi K, Iwasaki H, et al. (1998). �Calcium-dependent epidermal growth factor receptor transactivation mediates the angiotensin II-induced mitogen-activated protein kinase activation in vascular smooth muscle cells.� J Biol Chem;273(15):8890-6. Griendling KK, Ushio-Fukai M, Lass�gue B, et al. (1997). �Angiotensin II signaling in vascular smooth muscle. New concepts.� Hypertension;29(1 Pt 2):366-73. Seshiah PN, Weber DS, Rocic P, et al. (2002). �Angiotensin II stimulation of NAD(P)H oxidase activity: upstream mediators.� Circ Res;91(5):406-13. Kato H, Suzuki H, Tajima S, et al. (1991). �Angiotensin II stimulates collagen synthesis in cultured vascular smooth muscle cells.� J Hypertens;9:17�22. Tamura K, Nyui N, Tamura N, et al. (1998). �Mechanism of angiotensin II-mediated regulation of fibronectin gene in rat vascular smooth muscle cells.� J Biol Chem;273:26487�26496. Lemari� CA, Schiffrin EL. (2010). The angiotensin II type 2 receptor in cardiovascular disease. J Renin Angiotensin Aldosterone Syst;11(1):19-31.

Implementing Quality Enhancement in the Treatment of PAH: Facilitating a Guideline-Based Approach

Thu, 19 Jan 2012 19:34:36 EST

Ang II exerts its action by primarily acting on Ang 1 receptor (AT1R), and less commonly through Ang 2 (AT2R). Ang II�s action on AT1 contributes to vascular remodelling, inducing hypertrophy, hyperplasia and migration of Vascular Smooth Muscle Cells (VSMC), whereas its action on AT2 causes opposite effects. AT1R signaling in endothelial cells increases vascular resistance, possibly through an alternative of NO (nitric oxide) function. AT1R regulates intracellular signaling through Gq, which in turn leads to IP3 mediated Ca2+ elevation and PKC activation in VSMC. In addition, MAPK, growth factor tyrosine kinases (PDGF, EGFR, IGFR), and nonreceptor tyrosine kinases (the Jak/STAT) signalings are also activated, thus activating NADH/NADPH oxidase and superoxide generation, the antioxidants that protect cellular components from being oxidized by reactive oxygen species. Ang II induces vascular wall thickening by acting directly on smooth muscle cells and enhancing production of ECM type V collagen, and fibronectin. In contrast, AT2R is coupled to intracytoplasmic Gi protein, the stimulation of which leads to inhibition of AT1R�stimulated MAPK activation. PGE2/Prostacyclin treatment reduced collagen synthesis and thus myocardial fibrosis. Funck RC, Wilke A, Rupp H, et al. (1997). �Regulation and role of myocardial collagen matrix remodeling in hypertensive heart disease.� Adv Exp Med Biol;432:35-44. Brilla CG, Zhou G, Rupp H, et al. (1995). Role of angiotensin II and prostaglandin E2 in regulating cardiac fibroblast collagen turnover. Am J Cardiol;76(13):8D-13D. Wanstall JC, Jeffery TK. (1998). �Recognition and management of pulmonary hypertension. Drugs;56(6):989-1007. Olschewski H, Ghofrani HA, Walmrath D, et al. (1999). Inhaled prostacyclin and iloprost in severe pulmonary hypertension secondary to lung fibrosis. Am J Respir Crit Care Med;160(2):600-7. RAAS has been found overexpressed in PAH. Ang II stimulates Endothelin-1 (ET-1). ET1 is a major mediator of hypoxia-induced pulmonary vasoconstriction and plasma ET-1 levels are increased in patients with primary PAH. ET-1 effects are mediated through ETA and ETB receptors, with activation of either produces vasoconstriction. ETA are predominantly expressed in smooth muscle cells, whereas the ETB are expressed in both endothelial and smooth muscle cells. Activation of endothelial ETB receptors produces vasodilatation, through NO release. For this reason, Prostacyclin and ET1 antagonist will relieve the symptoms of PAH, so also, Calcium channel blocker and AT1R antagonist. Verapamil improves endothelium-dependent and -independent relaxations of pulmonary vasculature, an effect shared by losartan. Selective ETA receptor antagonist, sitaxsentan, has been used effectively in the treatment of PAH. However, ET1R antagonist cannot alleviate symptoms of chronic PAH, when underlying cause is fibrosis of vasculature, in which cases, early intervention with AT1R antagonist that regulates the infiltration of perivascular collagen is recommended. Sitbon O, Humbert M, Simonneau G. (2002). Primary pulmonary hypertension: Current therapy. Prog Cardiovasc Dis;45(2):115-28. Barst RJ. (1999). �Recent advances in the treatment of pediatric pulmonary artery hypertension.� Pediatr Clin North Am;46(2):331-45. Ziegler JW, Ivy DD, Wiggins JW, et al. (1998). Effects of dipyridamole and inhaled nitric oxide in pediatric patients with pulmonary hypertension. Am J Respir Crit Care Med;158(5 Pt 1):1388-95. Nagaya N. (2004). �Drug therapy of primary pulmonary hypertension.� Am J Cardiovasc Drugs;4(2):75-85. Barst RJ, Langleben D, Badesch D, et al. (2006). �STRIDE-2 Study Group. Treatment of pulmonary arterial hypertension with the selective endothelin-A receptor antagonist sitaxsentan. J Am Coll Cardiol;47(10):2049-56.

Implementing Quality Enhancement in the Treatment of PAH: Facilitating a Guideline-Based Approach

Thu, 19 Jan 2012 19:26:41 EST

Studies have proved the association between RAAS (activated Ang II via AT1 receptor, increased expression of ACE receptor, increased Bradykinin receptor binding) and myocardial fibrosis (perivascular and interstitial infiltration of collagens within the myocardium), and perivascular fibrosis of aorta and pulmonary artery. Renin that acts on its substrate Angiotensinogen of liver to generate Angiotensin I/Ang I; ACE, in the lung, kidney, and other tissues, cleaves Ang I into Ang II; ACE2 acts on Ang I to yield Ang(1�9), and cleaves Ang II to generate Ang(1�7). Ang (1-9) can be converted to Ang(1-7) by ACE. ACE2 catalytically inactivates bradykinin, one of the mediators of acute inflammation in lungs induced by endotoxins. ACE�Ang II�AT1R axis promotes vasoconstriction, proliferation, and fibrosis, whereas ACE2�Ang-(1-7)�Mas axis protects lungs. Ferrario CM. (1990). �The renin-angiotensin system: importance in physiology and pathology.� J Cardiovasc Pharmacol; 15(Suppl. 3), S1�S5. Skeggs LT, Dorer FE, Levine M, et al. (1980). �The biochemistry of the renin-angiotensin system.� Adv Exp Med Biol; 130, 1�27. Corvol P, Williams TA, Soubrier F. (1995). �Peptidyl dipeptidase A: angiotensin I-converting enzyme.� Methods Enzymol; 248, 283�305. Donoghue M, Hsieh F, Baronas E, et al. (2000). �A novel angiotensin-converting enzyme-related carboxypeptidase (ACE2) converts angiotensin I to angiotensin 1�9.� Circ Res; 87, E1�E9. Tipnis SR, Hooper NM, Hyde R, et al. (2000). �A human homolog of angiotensin-converting enzyme. Cloning and functional expression as a captoprilin sensitive carboxypeptidase.� J Biol Chem; 275, 33238�243. Douglas GC, O�Bryan MK, Hedger MP, et al. (2004). �The novel angiotensinconvertin enzyme (ACE) homolog, ACE2, is selectively expressed by adult Leydig cells of the testis.� Endocrinology; 145, 4703�4711. Causes of PAH and pulmonary fibrosis in patients with COPD has been uniformly reported as attributed by RAAS. Hypertrophic Subaortic Stenosis, one of the common causes of Hypertrophic Cardiomyopathy, and Pneumoconiosis contribute significantly in the cause of PAH among adult population. In evaluation of PAH, these causes should not be missed. Ang II plays major role in these pathogeneses. Ang II stimulates PAI-1 mRNA, which in addition to tissue inhibitors of metalloproteinase inhibits metalloproteinase activity, thus allowing for the accumulation of ECM. Cardiac fibroblasts express PAI-1 mRNA. Activation of TGF-β1, which increases transcription of collagen I and tissue inhibitors of metalloproteinase in human cardiac fibroblasts, mediates the growth effects of Ang II that induces increase in ECM. Ghosh AK, Bradham WS, Gleaves LA, et al. (2010). �Genetic deficiency of plasminogen activator inhibitor-1 promotes cardiac fibrosis in aged mice: involvement of constitutive transforming growth factor-beta signaling and endothelial-to mesenchymal transition.� Circulation; 122:1200�1209.

Endothelial Function and Cardiovascular Health: From Hypothesis to Treatment

Thu, 19 Jan 2012 19:23:32 EST

NO has cardioprotective effects in acute myocardial ischemia. Lefer AM. (1995). �Attenuation of myocardial ischemia-reperfusion injury with nitric oxide replacement therapy.� Ann Thorac Surg;60(3):847-51. Vinten-Johansen J, Zhao ZQ, Nakamura M, et al. (1999). �Nitric oxide and the vascular endothelium in myocardial ischemia-reperfusion injury.� Ann N Y Acad Sci;874:354-70. Blockade of beta3 receptor to inhibit NO release will aggravate myocardial ischemia-reperfusion injury. Arag�n JP, Condit ME, Bhushan S, et al. (2011). Beta(3)-adrenoreceptor stimulation ameliorates myocardial ischemia-reperfusion injury via endothelial nitric oxide synthase and neuronal nitric oxide synthase activation. J Am Coll Cardiol;58(25):2683-91.

Treat risk and not LDL-cholesterol targets, new perspective argues

Thu, 19 Jan 2012 17:46:03 EST

Interesting article, which supports what I have been saying in my conferences and medical practice over the last 25 years. We have to change the LDL paradigm as targeted treatment. I am successful in treating the risk factors difierent from LDL, whether the pacient presents one or all

Treat risk and not LDL-cholesterol targets, new perspective argues

Thu, 19 Jan 2012 16:37:22 EST

DJ Spence put this well in this publication,.. Treating Arteries Instead of Risk Factors A Paradigm Change in Management of Atherosclerosis Spence JD Hackam DG STROKE May 2010