Mary Ann Moon

ESR Can Predict Heart Failure

An elevated erythrocyte sedimentation rate was found to be a good predictor of heart failure, independent of established risk factors for the condition, reported Erik Ingelsson, M.D., of Uppsala (Sweden) University, and his associates.

ESR, a marker for systemic inflammation, is known to predict coronary disease but had not been assessed as a marker for heart failure. In this community-based study of 2,314 middle-aged men, the subjects were free of heart failure, MI, and valvular disease at study entry and were followed for a median of 30 years; 282 developed heart failure during that time.

A high ESR predicted heart failure independently of hypertension, diabetes, left ventricular hypertrophy, smoking, body mass index, and cholesterol level. “The diagnostic capacity of ESR as a test for incident [heart failure], in terms of sensitivity and specificity, was comparable with that of hypertension,” they said (J. Am. Coll. Cardiol. 2005;45:1802–6).

Given the long lag time they found between an initial high ESR result and the development of heart failure, it appears that inflammation is a key factor early in the disease process, the researchers added.

PCI, CABG for Cardiogenic Shock

Both percutaneous coronary interventions and coronary artery bypass grafting are seriously underused in patients with MI complicated by cardiogenic shock, according to a nationwide survey.

The American College of Cardiology and the American Heart Association revised their guidelines in 1999, elevating early mechanical intervention for cardiogenic shock to a class I recommendation for patients younger than 75 with an ST-elevation left bundle-branch block acute MI. However, a national database that has tracked practice patterns and MI outcomes since 1990 showed that physicians have been slow to comply with this change and had only marginally increased the use of PCI and CABG in this patient group by early 2004, said Anvar Babaev, M.D., of New York University, New York, and colleagues (JAMA 2005;294:448–54).

The database included nearly 300,000 MI patients treated at 775 hospitals with revascularization capability. Of these patients, more than 25,000 (8.6%) had cardiogenic shock. Mortality clearly decreased with increasing use of revascularization, illustrating the benefit of early mechanical intervention. But it appears that physicians may still be reluctant to try these interventions in high-risk patients, the investigators said.

Marker Signals CAD in Renal Disease

For patients with kidney disease, a high serum level of N-terminal pro-B-type natriuretic peptide reflects underlying ischemic heart disease, even when the patient has no cardiac symptoms, according to Christopher R. deFilippi, M.D., and his associates at the University of Maryland, Baltimore.

The significance of elevated NT-proBNP levels in this patient population has been uncertain because clearance of the peptide was thought to depend on renal function. But in their study of 207 patients with different degrees of renal insufficiency, NT-proBNP was found to be a powerful indicator of ischemic heart disease and left ventricular hypertrophy, independent of the degree of renal dysfunction and of known cardiac risk factors such as advanced age and diabetes, the researchers said (Am. J. Kidney Dis. 2005;46:35–44).

Further study is needed to determine whether NT-proBNP screening would be worthwhile for detecting heart disease in the large population of kidney patients who have no symptoms but are at very high risk for cardiac events, they noted.

Assessing Aspirin 'Resistance'

Platelet aggregation testing is not sufficient to identify people with so-called aspirin resistance, but platelet function analysis may be, according to Rocio Gonzalez-Conejero, Ph.D., of the University of Murcia (Spain), and associates.

They evaluated several lab tests that have been proposed for measuring aspirin resistance, in a study of 24 healthy white subjects with a mean age of 35 years. Four subjects were known to have genetic variations cited by other researchers as possible predisposers to aspirin resistance.

All subjects showed maximal platelet aggregation before taking aspirin therapy; aggregation was inhibited by more than 90% in all of them with a 100-mg dose of aspirin. “Thus, according to this test, all individuals can be classified as normal responders to aspirin 100 mg,” the investigators said (Stroke 2005;36:276–80).

In contrast, results on the platelet function analyzer-100 showed that eight subjects (33%) could be considered nonresponders, which is similar to the overall rate of aspirin resistance reported in several other studies. Even these “resistant” subjects showed the appropriate platelet response when the aspirin dose was raised to 500 mg, the researchers noted.

ESR Can Predict Heart Failure

An elevated erythrocyte sedimentation rate was found to be a good predictor of heart failure, independent of established risk factors for the condition, reported Erik Ingelsson, M.D., of Uppsala (Sweden) University, and his associates.

ESR, a marker for systemic inflammation, is known to predict coronary disease but had not been assessed as a marker for heart failure. In this community-based study of 2,314 middle-aged men, the subjects were free of heart failure, MI, and valvular disease at study entry and were followed for a median of 30 years; 282 developed heart failure during that time.

A high ESR predicted heart failure independently of hypertension, diabetes, left ventricular hypertrophy, smoking, body mass index, and cholesterol level. “The diagnostic capacity of ESR as a test for incident [heart failure], in terms of sensitivity and specificity, was comparable with that of hypertension,” they said (J. Am. Coll. Cardiol. 2005;45:1802–6).

Given the long lag time they found between an initial high ESR result and the development of heart failure, it appears that inflammation is a key factor early in the disease process, the researchers added.

PCI, CABG for Cardiogenic Shock

Both percutaneous coronary interventions and coronary artery bypass grafting are seriously underused in patients with MI complicated by cardiogenic shock, according to a nationwide survey.

The American College of Cardiology and the American Heart Association revised their guidelines in 1999, elevating early mechanical intervention for cardiogenic shock to a class I recommendation for patients younger than 75 with an ST-elevation left bundle-branch block acute MI. However, a national database that has tracked practice patterns and MI outcomes since 1990 showed that physicians have been slow to comply with this change and had only marginally increased the use of PCI and CABG in this patient group by early 2004, said Anvar Babaev, M.D., of New York University, New York, and colleagues (JAMA 2005;294:448–54).

The database included nearly 300,000 MI patients treated at 775 hospitals with revascularization capability. Of these patients, more than 25,000 (8.6%) had cardiogenic shock. Mortality clearly decreased with increasing use of revascularization, illustrating the benefit of early mechanical intervention. But it appears that physicians may still be reluctant to try these interventions in high-risk patients, the investigators said.

Marker Signals CAD in Renal Disease

For patients with kidney disease, a high serum level of N-terminal pro-B-type natriuretic peptide reflects underlying ischemic heart disease, even when the patient has no cardiac symptoms, according to Christopher R. deFilippi, M.D., and his associates at the University of Maryland, Baltimore.

The significance of elevated NT-proBNP levels in this patient population has been uncertain because clearance of the peptide was thought to depend on renal function. But in their study of 207 patients with different degrees of renal insufficiency, NT-proBNP was found to be a powerful indicator of ischemic heart disease and left ventricular hypertrophy, independent of the degree of renal dysfunction and of known cardiac risk factors such as advanced age and diabetes, the researchers said (Am. J. Kidney Dis. 2005;46:35–44).

Further study is needed to determine whether NT-proBNP screening would be worthwhile for detecting heart disease in the large population of kidney patients who have no symptoms but are at very high risk for cardiac events, they noted.

Assessing Aspirin 'Resistance'

Platelet aggregation testing is not sufficient to identify people with so-called aspirin resistance, but platelet function analysis may be, according to Rocio Gonzalez-Conejero, Ph.D., of the University of Murcia (Spain), and associates.

They evaluated several lab tests that have been proposed for measuring aspirin resistance, in a study of 24 healthy white subjects with a mean age of 35 years. Four subjects were known to have genetic variations cited by other researchers as possible predisposers to aspirin resistance.

All subjects showed maximal platelet aggregation before taking aspirin therapy; aggregation was inhibited by more than 90% in all of them with a 100-mg dose of aspirin. “Thus, according to this test, all individuals can be classified as normal responders to aspirin 100 mg,” the investigators said (Stroke 2005;36:276–80).

In contrast, results on the platelet function analyzer-100 showed that eight subjects (33%) could be considered nonresponders, which is similar to the overall rate of aspirin resistance reported in several other studies. Even these “resistant” subjects showed the appropriate platelet response when the aspirin dose was raised to 500 mg, the researchers noted.

ESR Can Predict Heart Failure

An elevated erythrocyte sedimentation rate was found to be a good predictor of heart failure, independent of established risk factors for the condition, reported Erik Ingelsson, M.D., of Uppsala (Sweden) University, and his associates.

ESR, a marker for systemic inflammation, is known to predict coronary disease but had not been assessed as a marker for heart failure. In this community-based study of 2,314 middle-aged men, the subjects were free of heart failure, MI, and valvular disease at study entry and were followed for a median of 30 years; 282 developed heart failure during that time.

A high ESR predicted heart failure independently of hypertension, diabetes, left ventricular hypertrophy, smoking, body mass index, and cholesterol level. “The diagnostic capacity of ESR as a test for incident [heart failure], in terms of sensitivity and specificity, was comparable with that of hypertension,” they said (J. Am. Coll. Cardiol. 2005;45:1802–6).

Given the long lag time they found between an initial high ESR result and the development of heart failure, it appears that inflammation is a key factor early in the disease process, the researchers added.

PCI, CABG for Cardiogenic Shock

Both percutaneous coronary interventions and coronary artery bypass grafting are seriously underused in patients with MI complicated by cardiogenic shock, according to a nationwide survey.

The American College of Cardiology and the American Heart Association revised their guidelines in 1999, elevating early mechanical intervention for cardiogenic shock to a class I recommendation for patients younger than 75 with an ST-elevation left bundle-branch block acute MI. However, a national database that has tracked practice patterns and MI outcomes since 1990 showed that physicians have been slow to comply with this change and had only marginally increased the use of PCI and CABG in this patient group by early 2004, said Anvar Babaev, M.D., of New York University, New York, and colleagues (JAMA 2005;294:448–54).

The database included nearly 300,000 MI patients treated at 775 hospitals with revascularization capability. Of these patients, more than 25,000 (8.6%) had cardiogenic shock. Mortality clearly decreased with increasing use of revascularization, illustrating the benefit of early mechanical intervention. But it appears that physicians may still be reluctant to try these interventions in high-risk patients, the investigators said.

Marker Signals CAD in Renal Disease

For patients with kidney disease, a high serum level of N-terminal pro-B-type natriuretic peptide reflects underlying ischemic heart disease, even when the patient has no cardiac symptoms, according to Christopher R. deFilippi, M.D., and his associates at the University of Maryland, Baltimore.

The significance of elevated NT-proBNP levels in this patient population has been uncertain because clearance of the peptide was thought to depend on renal function. But in their study of 207 patients with different degrees of renal insufficiency, NT-proBNP was found to be a powerful indicator of ischemic heart disease and left ventricular hypertrophy, independent of the degree of renal dysfunction and of known cardiac risk factors such as advanced age and diabetes, the researchers said (Am. J. Kidney Dis. 2005;46:35–44).

Further study is needed to determine whether NT-proBNP screening would be worthwhile for detecting heart disease in the large population of kidney patients who have no symptoms but are at very high risk for cardiac events, they noted.

Assessing Aspirin 'Resistance'

Platelet aggregation testing is not sufficient to identify people with so-called aspirin resistance, but platelet function analysis may be, according to Rocio Gonzalez-Conejero, Ph.D., of the University of Murcia (Spain), and associates.

They evaluated several lab tests that have been proposed for measuring aspirin resistance, in a study of 24 healthy white subjects with a mean age of 35 years. Four subjects were known to have genetic variations cited by other researchers as possible predisposers to aspirin resistance.

All subjects showed maximal platelet aggregation before taking aspirin therapy; aggregation was inhibited by more than 90% in all of them with a 100-mg dose of aspirin. “Thus, according to this test, all individuals can be classified as normal responders to aspirin 100 mg,” the investigators said (Stroke 2005;36:276–80).

In contrast, results on the platelet function analyzer-100 showed that eight subjects (33%) could be considered nonresponders, which is similar to the overall rate of aspirin resistance reported in several other studies. Even these “resistant” subjects showed the appropriate platelet response when the aspirin dose was raised to 500 mg, the researchers noted.

BP Too High in Kidney Disease

Primary care physicians often fail to properly control blood pressure of patients with kidney disease, prescribing too few antihypertensive drugs and inadequate diuretic therapy, reported Roberto Minutolo, M.D., of the Second University of Naples, and his associates.

The researchers evaluated the adequacy of blood pressure control in 445 hypertensive patients with mild to severe chronic kidney disease. Cardiovascular risk is very high in such patients, and intensive antihypertensive treatment is known to prevent CV events in them, the investigators said (Am. J. Kidney Dis. 2005:46:18–25).

Like most people with kidney disease, 259 of these patients were managed solely by primary care physicians. The remaining 186 were treated by nephrologists at a hospital outpatient clinic. Patients in the former group were nearly three times more likely to fall short of the target blood pressure of 130/80 mm Hg.

Primary care physicians prescribed fewer antihypertensive drugs (1.9 per patient, compared with 2.5 per patient for nephrologists) and almost exclusively prescribed thiazides for diuresis, while the nephrologists prescribed furosemide. Primary care physicians also prescribed inadequate doses of both antihypertensive and diuretic drugs, compared with nephrologists.

Postop Renal Dysfunction in CABG

N-acetylcysteine did not prevent postoperative renal dysfunction in a randomized clinical trial of patients undergoing coronary artery bypass graft with cardiopulmonary bypass, reported Karen E.A. Burns, M.D., of the University of Toronto, and her associates.

N-acetylcysteine is known to attenuate ischemic declines in renal function, including the kidney complications that result from exposure to contrast dyes. Because cardiopulmonary bypass during CABG also is associated with renal complications, the researchers studied whether perioperative intravenous administration of the agent would preserve renal function in patients at risk for kidney complications.

In their study, 148 patients were randomly assigned to receive N-acetylcysteine and 147 to receive placebo infusions during CABG. There were no significant differences between the two groups in the number of patients who developed renal dysfunction (approximately 29% in both groups) or in the number who required renal therapy. Similarly, there were no differences between the two groups in the number of adverse events, the need for ICU care, or the length of hospital stay, the investigators said (JAMA 2005:294:342–50).

BNP Helps Identify CHF

When patients present to the emergency department with dyspnea of unknown origin, B-type natriuretic peptide level is better than echocardiography in identifying or excluding heart failure as the cause, according to Philippe Gabriel Steg, M.D., of Hopital Bichat-Claude Bernard, Paris, and his associates.

Accurate diagnosis or exclusion of HF is often difficult in patients who present with acute dyspnea, “especially in elderly or obese patients, given the frequency of comorbidities such as COPD,” the researchers noted. In their study of 709 such patients who underwent both echocardiographic assessment of left ventricular function and blood sampling to determine BNP level, the sensitivity of echocardiography was 70% and the specificity was 77% in diagnosing HF. For BNP, the sensitivity was 89% and the specificity was 73%.

The proportion of patients who were correctly diagnosed was 55% for EF determined by echocardiography alone, 67% for BNP assessment alone, and 82% when the two variables were considered together. This marked additive diagnostic value “strongly suggest[s] the value of combining both methods,” the investigators said (Chest 2005;128:21–9).

Dietary Fish Lowers Inflammation

Fish consumption shows a strong inverse correlation with levels of several inflammatory markers that have been associated with cardiovascular disease, according to Antonis Zampelas, Ph.D., of Harokopio University, Athens, and his associates.

In a population-based sample of 3,042 “free-eating” adults who completed a food frequency questionnaire, all the inflammatory markers that were tested showed an inverse dose-response relation with fish consumption. Subjects who ate at least 300 g of fish per week had a 33% lower C-reactive protein level, a 33% lower interleukin-6 level, a 21% lower tumor necrosis factor-α level, and a 28% lower serum amyloid A level than those who did not eat fish. They also had a 4% lower white blood cell count, the investigators said (J. Am. Coll. Cardiol. 2005;46:120–4).

The researchers hypothesized that fish intake increases IL-6 synthesis, which in turn decreases the liver's production of CRP and serum amyloid A. The link to production of TNF-α is less clear, they said.

BP Too High in Kidney Disease

Primary care physicians often fail to properly control blood pressure of patients with kidney disease, prescribing too few antihypertensive drugs and inadequate diuretic therapy, reported Roberto Minutolo, M.D., of the Second University of Naples, and his associates.

The researchers evaluated the adequacy of blood pressure control in 445 hypertensive patients with mild to severe chronic kidney disease. Cardiovascular risk is very high in such patients, and intensive antihypertensive treatment is known to prevent CV events in them, the investigators said (Am. J. Kidney Dis. 2005:46:18–25).

Like most people with kidney disease, 259 of these patients were managed solely by primary care physicians. The remaining 186 were treated by nephrologists at a hospital outpatient clinic. Patients in the former group were nearly three times more likely to fall short of the target blood pressure of 130/80 mm Hg.

Primary care physicians prescribed fewer antihypertensive drugs (1.9 per patient, compared with 2.5 per patient for nephrologists) and almost exclusively prescribed thiazides for diuresis, while the nephrologists prescribed furosemide. Primary care physicians also prescribed inadequate doses of both antihypertensive and diuretic drugs, compared with nephrologists.

Postop Renal Dysfunction in CABG

N-acetylcysteine did not prevent postoperative renal dysfunction in a randomized clinical trial of patients undergoing coronary artery bypass graft with cardiopulmonary bypass, reported Karen E.A. Burns, M.D., of the University of Toronto, and her associates.

N-acetylcysteine is known to attenuate ischemic declines in renal function, including the kidney complications that result from exposure to contrast dyes. Because cardiopulmonary bypass during CABG also is associated with renal complications, the researchers studied whether perioperative intravenous administration of the agent would preserve renal function in patients at risk for kidney complications.

In their study, 148 patients were randomly assigned to receive N-acetylcysteine and 147 to receive placebo infusions during CABG. There were no significant differences between the two groups in the number of patients who developed renal dysfunction (approximately 29% in both groups) or in the number who required renal therapy. Similarly, there were no differences between the two groups in the number of adverse events, the need for ICU care, or the length of hospital stay, the investigators said (JAMA 2005:294:342–50).

BNP Helps Identify CHF

When patients present to the emergency department with dyspnea of unknown origin, B-type natriuretic peptide level is better than echocardiography in identifying or excluding heart failure as the cause, according to Philippe Gabriel Steg, M.D., of Hopital Bichat-Claude Bernard, Paris, and his associates.

Accurate diagnosis or exclusion of HF is often difficult in patients who present with acute dyspnea, “especially in elderly or obese patients, given the frequency of comorbidities such as COPD,” the researchers noted. In their study of 709 such patients who underwent both echocardiographic assessment of left ventricular function and blood sampling to determine BNP level, the sensitivity of echocardiography was 70% and the specificity was 77% in diagnosing HF. For BNP, the sensitivity was 89% and the specificity was 73%.

The proportion of patients who were correctly diagnosed was 55% for EF determined by echocardiography alone, 67% for BNP assessment alone, and 82% when the two variables were considered together. This marked additive diagnostic value “strongly suggest[s] the value of combining both methods,” the investigators said (Chest 2005;128:21–9).

Dietary Fish Lowers Inflammation

Fish consumption shows a strong inverse correlation with levels of several inflammatory markers that have been associated with cardiovascular disease, according to Antonis Zampelas, Ph.D., of Harokopio University, Athens, and his associates.

In a population-based sample of 3,042 “free-eating” adults who completed a food frequency questionnaire, all the inflammatory markers that were tested showed an inverse dose-response relation with fish consumption. Subjects who ate at least 300 g of fish per week had a 33% lower C-reactive protein level, a 33% lower interleukin-6 level, a 21% lower tumor necrosis factor-α level, and a 28% lower serum amyloid A level than those who did not eat fish. They also had a 4% lower white blood cell count, the investigators said (J. Am. Coll. Cardiol. 2005;46:120–4).

The researchers hypothesized that fish intake increases IL-6 synthesis, which in turn decreases the liver's production of CRP and serum amyloid A. The link to production of TNF-α is less clear, they said.

BP Too High in Kidney Disease

Primary care physicians often fail to properly control blood pressure of patients with kidney disease, prescribing too few antihypertensive drugs and inadequate diuretic therapy, reported Roberto Minutolo, M.D., of the Second University of Naples, and his associates.

The researchers evaluated the adequacy of blood pressure control in 445 hypertensive patients with mild to severe chronic kidney disease. Cardiovascular risk is very high in such patients, and intensive antihypertensive treatment is known to prevent CV events in them, the investigators said (Am. J. Kidney Dis. 2005:46:18–25).

Like most people with kidney disease, 259 of these patients were managed solely by primary care physicians. The remaining 186 were treated by nephrologists at a hospital outpatient clinic. Patients in the former group were nearly three times more likely to fall short of the target blood pressure of 130/80 mm Hg.

Primary care physicians prescribed fewer antihypertensive drugs (1.9 per patient, compared with 2.5 per patient for nephrologists) and almost exclusively prescribed thiazides for diuresis, while the nephrologists prescribed furosemide. Primary care physicians also prescribed inadequate doses of both antihypertensive and diuretic drugs, compared with nephrologists.

Postop Renal Dysfunction in CABG

N-acetylcysteine did not prevent postoperative renal dysfunction in a randomized clinical trial of patients undergoing coronary artery bypass graft with cardiopulmonary bypass, reported Karen E.A. Burns, M.D., of the University of Toronto, and her associates.

N-acetylcysteine is known to attenuate ischemic declines in renal function, including the kidney complications that result from exposure to contrast dyes. Because cardiopulmonary bypass during CABG also is associated with renal complications, the researchers studied whether perioperative intravenous administration of the agent would preserve renal function in patients at risk for kidney complications.

In their study, 148 patients were randomly assigned to receive N-acetylcysteine and 147 to receive placebo infusions during CABG. There were no significant differences between the two groups in the number of patients who developed renal dysfunction (approximately 29% in both groups) or in the number who required renal therapy. Similarly, there were no differences between the two groups in the number of adverse events, the need for ICU care, or the length of hospital stay, the investigators said (JAMA 2005:294:342–50).

BNP Helps Identify CHF

When patients present to the emergency department with dyspnea of unknown origin, B-type natriuretic peptide level is better than echocardiography in identifying or excluding heart failure as the cause, according to Philippe Gabriel Steg, M.D., of Hopital Bichat-Claude Bernard, Paris, and his associates.

Accurate diagnosis or exclusion of HF is often difficult in patients who present with acute dyspnea, “especially in elderly or obese patients, given the frequency of comorbidities such as COPD,” the researchers noted. In their study of 709 such patients who underwent both echocardiographic assessment of left ventricular function and blood sampling to determine BNP level, the sensitivity of echocardiography was 70% and the specificity was 77% in diagnosing HF. For BNP, the sensitivity was 89% and the specificity was 73%.

The proportion of patients who were correctly diagnosed was 55% for EF determined by echocardiography alone, 67% for BNP assessment alone, and 82% when the two variables were considered together. This marked additive diagnostic value “strongly suggest[s] the value of combining both methods,” the investigators said (Chest 2005;128:21–9).

Dietary Fish Lowers Inflammation

Fish consumption shows a strong inverse correlation with levels of several inflammatory markers that have been associated with cardiovascular disease, according to Antonis Zampelas, Ph.D., of Harokopio University, Athens, and his associates.

In a population-based sample of 3,042 “free-eating” adults who completed a food frequency questionnaire, all the inflammatory markers that were tested showed an inverse dose-response relation with fish consumption. Subjects who ate at least 300 g of fish per week had a 33% lower C-reactive protein level, a 33% lower interleukin-6 level, a 21% lower tumor necrosis factor-α level, and a 28% lower serum amyloid A level than those who did not eat fish. They also had a 4% lower white blood cell count, the investigators said (J. Am. Coll. Cardiol. 2005;46:120–4).

The researchers hypothesized that fish intake increases IL-6 synthesis, which in turn decreases the liver's production of CRP and serum amyloid A. The link to production of TNF-α is less clear, they said.

People who first develop bipolar disorder at age 60 years or older are less ill overall than are those with the more typical pattern of early-onset bipolar disorder, said Martha Sajatovic, M.D., of the University Hospitals of Cleveland, and her associates.

The researchers used a large Veterans Affairs (VA) database to compare differences between early-onset and late-onset bipolar disorder in clinical presentation, use of health care services, and use of psychotropic medications over 2 years.

They identified 16,330 patients aged 60 years or older with bipolar disorder who were treated in 2001. These patients represented nearly one-fourth of all patients with bipolar disorder in the VA system at that time. Those who had their first diagnosis before 2001 were considered early-onset patients. Although late-onset has not been clearly defined, those whose first bipolar disorder diagnosis was made in 2001 and who were not diagnosed with psychosis or depression before that time were considered to have new-onset illness (NOI).

The great majority of these older patients with bipolar disorder (82.5%) had early-onset disease, whereas only 6.1% had NOI. The remaining patients either were new to the VA or had a questionable diagnosis and were excluded from the study.

Given that this was a sample of older veterans, it was a predominantly male and white population. The percentages of female and African American subjects were quite low, at 4.5% and 5.0% respectively, the investigators noted (Am. J. Geriatr. Psych. 2005;13:282–9).

Patients with early-onset bipolar disorder were hospitalized for mania much more often than those with NOI. They had a similar number of hospitalizations for depression, and a similar rate of homelessness and substance abuse. Those with early-onset bipolar disorder were more likely to be divorced or separated.

There was a substantial difference between the two groups in length of hospital stay. Total length of stay averaged 59.7 days for patients with early-onset bipolar disorder, compared with 43.5 days for those with NOI. The median duration of inpatient stay was 22 days for the early-onset bipolar disorder group, compared with 16 days for the NOI group.

Patients with early-onset bipolar disorder also used other health care services to a much greater degree than did those with NOI. In particular, they showed “substantial utilization of inpatient nonpsychiatric care,” the researchers noted.

Those with early-onset bipolar disorder also were much more likely to be treated with lithium or any mood stabilizer than were patients with NOI. (See box.) Those with early-onset bipolar disorder also were much more likely to receive an atypical antipsychotic compound. Thus, older individuals with early-onset bipolar disorder appear to be generally more severely ill than their late-onset counterparts, Dr. Sajatovic and her associates said.

These findings suggest that “these are indeed two separate subgroups of older adults with bipolar disorder,” the investigators said.

“Previous investigators have noted that late-onset bipolar illness is characterized by neurological comorbidity, absence of a family history, and a greater likelihood of psychotic presentation,” Dr. Sajatovic and her associates noted. Various researchers have linked late-onset bipolar disorder with organic cerebral disorders and with cerebrovascular risk factors, such as smoking, hypertension, diabetes, and coronary disease.

In this study, patients with NOI were nearly twice as likely to receive a diagnosis of “type II/not otherwise specified bipolar illness.”

This increased prevalence might be explained by aging-related vascular and CNS pathology in such patients. “It has been suggested that late-onset bipolar disorder is associated with peripheral vascular burden and vascular brain abnormalities,” the investigators said.

They also noted that in this study, fewer than two-thirds of the patients with early-onset bipolar disorder–and just 30% of those with NOI–were receiving mood stabilizers, which “is at odds with current treatment guidelines for bipolar disorder in adults.”

It may be that treatments “known to be efficacious and well tolerated in younger bipolar populations” do not work as well in geriatric bipolar patients. Moreover, in older patients, “first-line treatments have not been definitively established,” Dr. Sajatovic and her associates said.

RICHARD FRANKI, RESEARCH

People who first develop bipolar disorder at age 60 years or older are less ill overall than are those with the more typical pattern of early-onset bipolar disorder, said Martha Sajatovic, M.D., of the University Hospitals of Cleveland, and her associates.

The researchers used a large Veterans Affairs (VA) database to compare differences between early-onset and late-onset bipolar disorder in clinical presentation, use of health care services, and use of psychotropic medications over 2 years.

They identified 16,330 patients aged 60 years or older with bipolar disorder who were treated in 2001. These patients represented nearly one-fourth of all patients with bipolar disorder in the VA system at that time. Those who had their first diagnosis before 2001 were considered early-onset patients. Although late-onset has not been clearly defined, those whose first bipolar disorder diagnosis was made in 2001 and who were not diagnosed with psychosis or depression before that time were considered to have new-onset illness (NOI).

The great majority of these older patients with bipolar disorder (82.5%) had early-onset disease, whereas only 6.1% had NOI. The remaining patients either were new to the VA or had a questionable diagnosis and were excluded from the study.

Given that this was a sample of older veterans, it was a predominantly male and white population. The percentages of female and African American subjects were quite low, at 4.5% and 5.0% respectively, the investigators noted (Am. J. Geriatr. Psych. 2005;13:282–9).

Patients with early-onset bipolar disorder were hospitalized for mania much more often than those with NOI. They had a similar number of hospitalizations for depression, and a similar rate of homelessness and substance abuse. Those with early-onset bipolar disorder were more likely to be divorced or separated.

There was a substantial difference between the two groups in length of hospital stay. Total length of stay averaged 59.7 days for patients with early-onset bipolar disorder, compared with 43.5 days for those with NOI. The median duration of inpatient stay was 22 days for the early-onset bipolar disorder group, compared with 16 days for the NOI group.

Patients with early-onset bipolar disorder also used other health care services to a much greater degree than did those with NOI. In particular, they showed “substantial utilization of inpatient nonpsychiatric care,” the researchers noted.

Those with early-onset bipolar disorder also were much more likely to be treated with lithium or any mood stabilizer than were patients with NOI. (See box.) Those with early-onset bipolar disorder also were much more likely to receive an atypical antipsychotic compound. Thus, older individuals with early-onset bipolar disorder appear to be generally more severely ill than their late-onset counterparts, Dr. Sajatovic and her associates said.

These findings suggest that “these are indeed two separate subgroups of older adults with bipolar disorder,” the investigators said.

“Previous investigators have noted that late-onset bipolar illness is characterized by neurological comorbidity, absence of a family history, and a greater likelihood of psychotic presentation,” Dr. Sajatovic and her associates noted. Various researchers have linked late-onset bipolar disorder with organic cerebral disorders and with cerebrovascular risk factors, such as smoking, hypertension, diabetes, and coronary disease.

In this study, patients with NOI were nearly twice as likely to receive a diagnosis of “type II/not otherwise specified bipolar illness.”

This increased prevalence might be explained by aging-related vascular and CNS pathology in such patients. “It has been suggested that late-onset bipolar disorder is associated with peripheral vascular burden and vascular brain abnormalities,” the investigators said.

They also noted that in this study, fewer than two-thirds of the patients with early-onset bipolar disorder–and just 30% of those with NOI–were receiving mood stabilizers, which “is at odds with current treatment guidelines for bipolar disorder in adults.”

It may be that treatments “known to be efficacious and well tolerated in younger bipolar populations” do not work as well in geriatric bipolar patients. Moreover, in older patients, “first-line treatments have not been definitively established,” Dr. Sajatovic and her associates said.

RICHARD FRANKI, RESEARCH

People who first develop bipolar disorder at age 60 years or older are less ill overall than are those with the more typical pattern of early-onset bipolar disorder, said Martha Sajatovic, M.D., of the University Hospitals of Cleveland, and her associates.

The researchers used a large Veterans Affairs (VA) database to compare differences between early-onset and late-onset bipolar disorder in clinical presentation, use of health care services, and use of psychotropic medications over 2 years.

They identified 16,330 patients aged 60 years or older with bipolar disorder who were treated in 2001. These patients represented nearly one-fourth of all patients with bipolar disorder in the VA system at that time. Those who had their first diagnosis before 2001 were considered early-onset patients. Although late-onset has not been clearly defined, those whose first bipolar disorder diagnosis was made in 2001 and who were not diagnosed with psychosis or depression before that time were considered to have new-onset illness (NOI).

The great majority of these older patients with bipolar disorder (82.5%) had early-onset disease, whereas only 6.1% had NOI. The remaining patients either were new to the VA or had a questionable diagnosis and were excluded from the study.

Given that this was a sample of older veterans, it was a predominantly male and white population. The percentages of female and African American subjects were quite low, at 4.5% and 5.0% respectively, the investigators noted (Am. J. Geriatr. Psych. 2005;13:282–9).

Patients with early-onset bipolar disorder were hospitalized for mania much more often than those with NOI. They had a similar number of hospitalizations for depression, and a similar rate of homelessness and substance abuse. Those with early-onset bipolar disorder were more likely to be divorced or separated.

There was a substantial difference between the two groups in length of hospital stay. Total length of stay averaged 59.7 days for patients with early-onset bipolar disorder, compared with 43.5 days for those with NOI. The median duration of inpatient stay was 22 days for the early-onset bipolar disorder group, compared with 16 days for the NOI group.

Patients with early-onset bipolar disorder also used other health care services to a much greater degree than did those with NOI. In particular, they showed “substantial utilization of inpatient nonpsychiatric care,” the researchers noted.

Those with early-onset bipolar disorder also were much more likely to be treated with lithium or any mood stabilizer than were patients with NOI. (See box.) Those with early-onset bipolar disorder also were much more likely to receive an atypical antipsychotic compound. Thus, older individuals with early-onset bipolar disorder appear to be generally more severely ill than their late-onset counterparts, Dr. Sajatovic and her associates said.

These findings suggest that “these are indeed two separate subgroups of older adults with bipolar disorder,” the investigators said.

“Previous investigators have noted that late-onset bipolar illness is characterized by neurological comorbidity, absence of a family history, and a greater likelihood of psychotic presentation,” Dr. Sajatovic and her associates noted. Various researchers have linked late-onset bipolar disorder with organic cerebral disorders and with cerebrovascular risk factors, such as smoking, hypertension, diabetes, and coronary disease.

In this study, patients with NOI were nearly twice as likely to receive a diagnosis of “type II/not otherwise specified bipolar illness.”

This increased prevalence might be explained by aging-related vascular and CNS pathology in such patients. “It has been suggested that late-onset bipolar disorder is associated with peripheral vascular burden and vascular brain abnormalities,” the investigators said.

They also noted that in this study, fewer than two-thirds of the patients with early-onset bipolar disorder–and just 30% of those with NOI–were receiving mood stabilizers, which “is at odds with current treatment guidelines for bipolar disorder in adults.”

It may be that treatments “known to be efficacious and well tolerated in younger bipolar populations” do not work as well in geriatric bipolar patients. Moreover, in older patients, “first-line treatments have not been definitively established,” Dr. Sajatovic and her associates said.

RICHARD FRANKI, RESEARCH

β-Blocker Results Vary With Risk

β-Blockers clearly cut mortality in patients at high risk for cardiac events who are undergoing major surgery, and may benefit patients at moderate cardiac risk. But these drugs do not benefit, and may even harm, low-risk patients undergoing surgery.

These results are from a large observational study undertaken while the medical community awaits the results of randomized trials that are expected to settle the issue of whether β-blockers should be given routinely to prevent perioperative cardiac events. This observational study involved a diverse population of more than 660,000 patients undergoing a wide variety of surgeries at more than 300 hospitals throughout the country, said Peter K. Lindenauer, M.D., of Tufts University, Boston, and his associates (N. Engl. J. Med. 2005;353:349–61).

Perioperative β-blocker therapy reduced the risk of cardiac mortality by 10%–44% in patients who scored 2 or higher (out of a possible 5) on the Revised Cardiac Risk Index. The number needed to treat to prevent a single death in these moderate- and high-risk patients was only 33. In contrast, the drugs did not cut mortality and were actually associated with a slight increase among low-risk patients who scored 0 or 1 on the index, indicating that patient selection is critical, the researchers said.

Prayer, Healing Touch Fail to Help

For patients undergoing cardiac catheterization or percutaneous coronary intervention, neither congregational prayer nor a therapy involving calming music, positive imagery, and healing touch improved outcomes, according to Mitchell W. Krucoff, M.D., of Duke Clinical Research Institute, Durham, N.C., and his associates.

Such noetic therapies “are used extensively by the general population,” although their safety and effectiveness is difficult to evaluate (Lancet 2005;355:211–7). The researchers assessed these interventions in a study of 748 patients undergoing catheterization or PCI at nine U.S. medical centers. The subjects were randomly assigned to receive standard care (192 subjects); bedside music, imagery, and touch therapy (185); off-site prayer involving large congregations of Christians, Muslims, Jews, and Buddhists (182); or combined noetic therapy plus prayer (189).

None of the interventions showed any effect on the rates of in-hospital major adverse cardiovascular events or in-hospital mortality, nor did they affect event, readmission, or death rates over 6 months of follow-up, the investigators noted.

Beware Warfarin Overdosing in Elderly

Warfarin dose requirements vary so dramatically with patient age and gender that almost all elderly women and most elderly men are overdosed from the very start of treatment, according to David Garcia, M.D., of the University of New Mexico, Albuquerque, and his associates.

Noting that data are scarce to guide clinicians in the dosing of warfarin for the elderly, the researchers assessed established dosing practices in two large cohorts of more than 12,000 ambulatory patients with INR target ranges of 2.0–3.0. This included 2,359 patients aged 80 or older. All patients had achieved stable warfarin dosing (Chest 2005;127:2049–56).

“Based on the actual warfarin maintenance doses observed in our study populations, the often-recommended 5 mg daily warfarin starting dose would be too high for up to 82% of women and 65% of men who were over 70 years of age. Our data suggest that the higher rates of bleeding and erratic INR values that have been reported in the early phase of warfarin therapy may in part be explained by overly aggressive dosing in the elderly,” they said.

Physicians should be cautious in empiric dose selection, particularly in older women.

Counterfeit Lipitor Batch Is Recalled

The U.S. Food and Drug Administration alerted Americans that its British counterpart has recalled a batch of Lipitor (atorvastatin) because it was found to contain counterfeit tablets. Initial test results do not indicate that the fake drug poses any immediate risks.

The product is not sold through “legitimate” pharmacies, but it may have been purchased by some Americans through other online or storefront operations, or through state-run programs that purchase foreign drugs, according to the FDA.

The United Kingdom's Medicines and Healthcare products Regulatory Agency (MHRA) discovered counterfeit 20-mg Lipitor tablets sold in packages of 28 pills in blister packs. The batch number 004405K1 is printed on the end of the outer package, near the expiration date of “11 2007,” as well as on the foil backing of the blister pack. In concert with Lipitor's manufacturer, Pfizer Ltd., the MHRA recalled this entire batch of Lipitor even though there is genuine Pfizer Lipitor with the same batch number.

β-Blocker Results Vary With Risk

β-Blockers clearly cut mortality in patients at high risk for cardiac events who are undergoing major surgery, and may benefit patients at moderate cardiac risk. But these drugs do not benefit, and may even harm, low-risk patients undergoing surgery.

These results are from a large observational study undertaken while the medical community awaits the results of randomized trials that are expected to settle the issue of whether β-blockers should be given routinely to prevent perioperative cardiac events. This observational study involved a diverse population of more than 660,000 patients undergoing a wide variety of surgeries at more than 300 hospitals throughout the country, said Peter K. Lindenauer, M.D., of Tufts University, Boston, and his associates (N. Engl. J. Med. 2005;353:349–61).

Perioperative β-blocker therapy reduced the risk of cardiac mortality by 10%–44% in patients who scored 2 or higher (out of a possible 5) on the Revised Cardiac Risk Index. The number needed to treat to prevent a single death in these moderate- and high-risk patients was only 33. In contrast, the drugs did not cut mortality and were actually associated with a slight increase among low-risk patients who scored 0 or 1 on the index, indicating that patient selection is critical, the researchers said.

Prayer, Healing Touch Fail to Help

For patients undergoing cardiac catheterization or percutaneous coronary intervention, neither congregational prayer nor a therapy involving calming music, positive imagery, and healing touch improved outcomes, according to Mitchell W. Krucoff, M.D., of Duke Clinical Research Institute, Durham, N.C., and his associates.

Such noetic therapies “are used extensively by the general population,” although their safety and effectiveness is difficult to evaluate (Lancet 2005;355:211–7). The researchers assessed these interventions in a study of 748 patients undergoing catheterization or PCI at nine U.S. medical centers. The subjects were randomly assigned to receive standard care (192 subjects); bedside music, imagery, and touch therapy (185); off-site prayer involving large congregations of Christians, Muslims, Jews, and Buddhists (182); or combined noetic therapy plus prayer (189).

None of the interventions showed any effect on the rates of in-hospital major adverse cardiovascular events or in-hospital mortality, nor did they affect event, readmission, or death rates over 6 months of follow-up, the investigators noted.

Beware Warfarin Overdosing in Elderly

Warfarin dose requirements vary so dramatically with patient age and gender that almost all elderly women and most elderly men are overdosed from the very start of treatment, according to David Garcia, M.D., of the University of New Mexico, Albuquerque, and his associates.

Noting that data are scarce to guide clinicians in the dosing of warfarin for the elderly, the researchers assessed established dosing practices in two large cohorts of more than 12,000 ambulatory patients with INR target ranges of 2.0–3.0. This included 2,359 patients aged 80 or older. All patients had achieved stable warfarin dosing (Chest 2005;127:2049–56).

“Based on the actual warfarin maintenance doses observed in our study populations, the often-recommended 5 mg daily warfarin starting dose would be too high for up to 82% of women and 65% of men who were over 70 years of age. Our data suggest that the higher rates of bleeding and erratic INR values that have been reported in the early phase of warfarin therapy may in part be explained by overly aggressive dosing in the elderly,” they said.

Physicians should be cautious in empiric dose selection, particularly in older women.

Counterfeit Lipitor Batch Is Recalled

The U.S. Food and Drug Administration alerted Americans that its British counterpart has recalled a batch of Lipitor (atorvastatin) because it was found to contain counterfeit tablets. Initial test results do not indicate that the fake drug poses any immediate risks.

The product is not sold through “legitimate” pharmacies, but it may have been purchased by some Americans through other online or storefront operations, or through state-run programs that purchase foreign drugs, according to the FDA.

The United Kingdom's Medicines and Healthcare products Regulatory Agency (MHRA) discovered counterfeit 20-mg Lipitor tablets sold in packages of 28 pills in blister packs. The batch number 004405K1 is printed on the end of the outer package, near the expiration date of “11 2007,” as well as on the foil backing of the blister pack. In concert with Lipitor's manufacturer, Pfizer Ltd., the MHRA recalled this entire batch of Lipitor even though there is genuine Pfizer Lipitor with the same batch number.

β-Blocker Results Vary With Risk

β-Blockers clearly cut mortality in patients at high risk for cardiac events who are undergoing major surgery, and may benefit patients at moderate cardiac risk. But these drugs do not benefit, and may even harm, low-risk patients undergoing surgery.

These results are from a large observational study undertaken while the medical community awaits the results of randomized trials that are expected to settle the issue of whether β-blockers should be given routinely to prevent perioperative cardiac events. This observational study involved a diverse population of more than 660,000 patients undergoing a wide variety of surgeries at more than 300 hospitals throughout the country, said Peter K. Lindenauer, M.D., of Tufts University, Boston, and his associates (N. Engl. J. Med. 2005;353:349–61).

Perioperative β-blocker therapy reduced the risk of cardiac mortality by 10%–44% in patients who scored 2 or higher (out of a possible 5) on the Revised Cardiac Risk Index. The number needed to treat to prevent a single death in these moderate- and high-risk patients was only 33. In contrast, the drugs did not cut mortality and were actually associated with a slight increase among low-risk patients who scored 0 or 1 on the index, indicating that patient selection is critical, the researchers said.

Prayer, Healing Touch Fail to Help

For patients undergoing cardiac catheterization or percutaneous coronary intervention, neither congregational prayer nor a therapy involving calming music, positive imagery, and healing touch improved outcomes, according to Mitchell W. Krucoff, M.D., of Duke Clinical Research Institute, Durham, N.C., and his associates.

Such noetic therapies “are used extensively by the general population,” although their safety and effectiveness is difficult to evaluate (Lancet 2005;355:211–7). The researchers assessed these interventions in a study of 748 patients undergoing catheterization or PCI at nine U.S. medical centers. The subjects were randomly assigned to receive standard care (192 subjects); bedside music, imagery, and touch therapy (185); off-site prayer involving large congregations of Christians, Muslims, Jews, and Buddhists (182); or combined noetic therapy plus prayer (189).

None of the interventions showed any effect on the rates of in-hospital major adverse cardiovascular events or in-hospital mortality, nor did they affect event, readmission, or death rates over 6 months of follow-up, the investigators noted.

Beware Warfarin Overdosing in Elderly

Warfarin dose requirements vary so dramatically with patient age and gender that almost all elderly women and most elderly men are overdosed from the very start of treatment, according to David Garcia, M.D., of the University of New Mexico, Albuquerque, and his associates.

Noting that data are scarce to guide clinicians in the dosing of warfarin for the elderly, the researchers assessed established dosing practices in two large cohorts of more than 12,000 ambulatory patients with INR target ranges of 2.0–3.0. This included 2,359 patients aged 80 or older. All patients had achieved stable warfarin dosing (Chest 2005;127:2049–56).

“Based on the actual warfarin maintenance doses observed in our study populations, the often-recommended 5 mg daily warfarin starting dose would be too high for up to 82% of women and 65% of men who were over 70 years of age. Our data suggest that the higher rates of bleeding and erratic INR values that have been reported in the early phase of warfarin therapy may in part be explained by overly aggressive dosing in the elderly,” they said.

Physicians should be cautious in empiric dose selection, particularly in older women.

Counterfeit Lipitor Batch Is Recalled

The U.S. Food and Drug Administration alerted Americans that its British counterpart has recalled a batch of Lipitor (atorvastatin) because it was found to contain counterfeit tablets. Initial test results do not indicate that the fake drug poses any immediate risks.

The product is not sold through “legitimate” pharmacies, but it may have been purchased by some Americans through other online or storefront operations, or through state-run programs that purchase foreign drugs, according to the FDA.

The United Kingdom's Medicines and Healthcare products Regulatory Agency (MHRA) discovered counterfeit 20-mg Lipitor tablets sold in packages of 28 pills in blister packs. The batch number 004405K1 is printed on the end of the outer package, near the expiration date of “11 2007,” as well as on the foil backing of the blister pack. In concert with Lipitor's manufacturer, Pfizer Ltd., the MHRA recalled this entire batch of Lipitor even though there is genuine Pfizer Lipitor with the same batch number.

Impaired cerebral blood flow may contribute to the mild deficits in memory and other cognitive functions in people with hypertension, compared with their normotensive peers, according to J.R. Jennings, Ph.D., of the University of Pittsburgh, and associates.

The researchers assessed regional cerebral blood flow using MRI and PET brain scans in 37 hypertensive and 59 normotensive subjects (median age 60 years) who performed a battery of memory and sensorimotor tasks. The blood flow response to performance demands was significantly blunted in certain areas of the brain in hypertensive subjects, who also showed mild deficits in performance, compared with the normotensive subjects (Neurology 2005;64:1358–65).

“Our results are far from conclusive but suggest that vascular factors may play a role” in mild memory and cognitive deficits seen in hypertensive people, the researchers said. Moreover, the findings show that common systemic diseases such as hypertension can have unanticipated effects on brain function, they added.

Impaired cerebral blood flow may contribute to the mild deficits in memory and other cognitive functions in people with hypertension, compared with their normotensive peers, according to J.R. Jennings, Ph.D., of the University of Pittsburgh, and associates.

The researchers assessed regional cerebral blood flow using MRI and PET brain scans in 37 hypertensive and 59 normotensive subjects (median age 60 years) who performed a battery of memory and sensorimotor tasks. The blood flow response to performance demands was significantly blunted in certain areas of the brain in hypertensive subjects, who also showed mild deficits in performance, compared with the normotensive subjects (Neurology 2005;64:1358–65).

“Our results are far from conclusive but suggest that vascular factors may play a role” in mild memory and cognitive deficits seen in hypertensive people, the researchers said. Moreover, the findings show that common systemic diseases such as hypertension can have unanticipated effects on brain function, they added.

Impaired cerebral blood flow may contribute to the mild deficits in memory and other cognitive functions in people with hypertension, compared with their normotensive peers, according to J.R. Jennings, Ph.D., of the University of Pittsburgh, and associates.

The researchers assessed regional cerebral blood flow using MRI and PET brain scans in 37 hypertensive and 59 normotensive subjects (median age 60 years) who performed a battery of memory and sensorimotor tasks. The blood flow response to performance demands was significantly blunted in certain areas of the brain in hypertensive subjects, who also showed mild deficits in performance, compared with the normotensive subjects (Neurology 2005;64:1358–65).

“Our results are far from conclusive but suggest that vascular factors may play a role” in mild memory and cognitive deficits seen in hypertensive people, the researchers said. Moreover, the findings show that common systemic diseases such as hypertension can have unanticipated effects on brain function, they added.

Sudden Death in First Month After MI

The risk of sudden death is dramatically higher in the first 30 days after MI than thereafter, and is particularly high in the first week and in patients with a low ejection fraction, according to Scott D. Solomon, M.D., of Brigham and Women's Hospital, Boston, and his associates.

Current American College of Cardiology/American Heart Association recommendations, which specify that implantable cardioverter defibrillators should be implanted 30 days or more after MI in patients with low ejection fractions or heart failure, may need to be reconsidered in light of these findings, they noted (N. Engl. J. Med. 2005;352:2581–8).

The investigators analyzed data from a randomized, controlled trial of 14,609 patients. They were followed for 2 years after MI complicated by an impaired ejection fraction, heart failure, or both. The rate of sudden death was 10 times higher within the first month after MI (1.4% per month) than it was 2 years later (0.14% per month). Even among patients with the highest ejection fractions, the rate of sudden death was six times higher in the first month than it was at 1 year. The findings suggest that early intervention would be beneficial, even in relatively low-risk patients, they said.

Staph Is Major Cause of Endocarditis

The epidemiology of Staphylococcus aureus infection has shifted so dramatically in recent years that the organism is now the leading cause of infective endocarditis in most of the developed world—a direct consequence of medical “progress,” said Vance G. Fowler Jr., M.D., of Duke University Medical Center, Durham, N.C., and his associates.

For decades, infective endocarditis due to S. aureus has been considered a relatively minor problem linked with injection drug use, and patients with nosocomial S. aureus bacteremia were considered to be at low risk for endocarditis. But in the 48-month prospective cohort study of 1,779 endocarditis patients treated in 16 countries, S. aureus was found to be the single most common cause of endocarditis, and the infection was often associated with medical devices or procedures such as pacemakers, prosthetic valves, or hemodialysis (JAMA 2005;293:3012–21). Patients with such “health care-associated” staph endocarditis had much higher mortality and a much greater incidence of methicillin resistance than did those with other forms of the disorder. Methicillin-resistant S. aureus accounted for up to 40% of the cases in many areas, the researchers noted.

Impaired Memory in Hypertension

Impaired cerebral blood flow may contribute to the mild deficits in memory and other cognitive functions in people with hypertension, compared with their normotensive peers, according to J.R. Jennings, Ph.D., of the University of Pittsburgh, and associates.

The researchers assessed regional cerebral blood flow using MRI and PET brain scans in 37 hypertensive and 59 normotensive subjects (median age 60 years) who performed a battery of memory and sensorimotor tasks. The blood flow response to performance demands was significantly blunted in certain areas of the brain in hypertensive subjects, who also showed mild deficits in performance, compared with the normotensive subjects (Neurology 2005;64:1358–65).

“Our results are far from conclusive but suggest that vascular factors may play a role” in mild memory and cognitive deficits seen in hypertensive people, the researchers said. Moreover, the findings show that common systemic diseases such as hypertension can have unanticipated effects on brain function, they added.

Choosing Meds for Decompensated HF

When intravenous vasoactive medications are required for acute decompensated heart failure, patients who receive a vasodilator or natriuretic peptide are more likely to survive than are those who receive a positive inotropic agent, reported William T. Abraham, M.D., of Ohio State University, Columbus, and his associates.

There are no published guidelines for managing acute decompensated HF because the evidence base is inadequate. The investigators used data from a recently established national registry for this disorder to compare the effects of four medications on in-hospital mortality. They analyzed data on more than 65,000 patients hospitalized at 263 U.S. medical centers, which they said provides a better real-world picture of treatment safety and efficacy than has been available from “highly controlled, short-term, clinical trials of carefully selected patient populations” (J. Am. Coll. Cardiol. 2005;46:57–64).

Patients treated with the vasodilator nitroglycerin or the natriuretic peptide nesiritide had better survival rates and shorter hospital stays than did those treated with the positive inotropic agents dobutamine and milrinone, the researchers said.

Sudden Death in First Month After MI

The risk of sudden death is dramatically higher in the first 30 days after MI than thereafter, and is particularly high in the first week and in patients with a low ejection fraction, according to Scott D. Solomon, M.D., of Brigham and Women's Hospital, Boston, and his associates.

Current American College of Cardiology/American Heart Association recommendations, which specify that implantable cardioverter defibrillators should be implanted 30 days or more after MI in patients with low ejection fractions or heart failure, may need to be reconsidered in light of these findings, they noted (N. Engl. J. Med. 2005;352:2581–8).

The investigators analyzed data from a randomized, controlled trial of 14,609 patients. They were followed for 2 years after MI complicated by an impaired ejection fraction, heart failure, or both. The rate of sudden death was 10 times higher within the first month after MI (1.4% per month) than it was 2 years later (0.14% per month). Even among patients with the highest ejection fractions, the rate of sudden death was six times higher in the first month than it was at 1 year. The findings suggest that early intervention would be beneficial, even in relatively low-risk patients, they said.

Staph Is Major Cause of Endocarditis

The epidemiology of Staphylococcus aureus infection has shifted so dramatically in recent years that the organism is now the leading cause of infective endocarditis in most of the developed world—a direct consequence of medical “progress,” said Vance G. Fowler Jr., M.D., of Duke University Medical Center, Durham, N.C., and his associates.

For decades, infective endocarditis due to S. aureus has been considered a relatively minor problem linked with injection drug use, and patients with nosocomial S. aureus bacteremia were considered to be at low risk for endocarditis. But in the 48-month prospective cohort study of 1,779 endocarditis patients treated in 16 countries, S. aureus was found to be the single most common cause of endocarditis, and the infection was often associated with medical devices or procedures such as pacemakers, prosthetic valves, or hemodialysis (JAMA 2005;293:3012–21). Patients with such “health care-associated” staph endocarditis had much higher mortality and a much greater incidence of methicillin resistance than did those with other forms of the disorder. Methicillin-resistant S. aureus accounted for up to 40% of the cases in many areas, the researchers noted.

Impaired Memory in Hypertension

Impaired cerebral blood flow may contribute to the mild deficits in memory and other cognitive functions in people with hypertension, compared with their normotensive peers, according to J.R. Jennings, Ph.D., of the University of Pittsburgh, and associates.

The researchers assessed regional cerebral blood flow using MRI and PET brain scans in 37 hypertensive and 59 normotensive subjects (median age 60 years) who performed a battery of memory and sensorimotor tasks. The blood flow response to performance demands was significantly blunted in certain areas of the brain in hypertensive subjects, who also showed mild deficits in performance, compared with the normotensive subjects (Neurology 2005;64:1358–65).

“Our results are far from conclusive but suggest that vascular factors may play a role” in mild memory and cognitive deficits seen in hypertensive people, the researchers said. Moreover, the findings show that common systemic diseases such as hypertension can have unanticipated effects on brain function, they added.

Choosing Meds for Decompensated HF

When intravenous vasoactive medications are required for acute decompensated heart failure, patients who receive a vasodilator or natriuretic peptide are more likely to survive than are those who receive a positive inotropic agent, reported William T. Abraham, M.D., of Ohio State University, Columbus, and his associates.

There are no published guidelines for managing acute decompensated HF because the evidence base is inadequate. The investigators used data from a recently established national registry for this disorder to compare the effects of four medications on in-hospital mortality. They analyzed data on more than 65,000 patients hospitalized at 263 U.S. medical centers, which they said provides a better real-world picture of treatment safety and efficacy than has been available from “highly controlled, short-term, clinical trials of carefully selected patient populations” (J. Am. Coll. Cardiol. 2005;46:57–64).

Patients treated with the vasodilator nitroglycerin or the natriuretic peptide nesiritide had better survival rates and shorter hospital stays than did those treated with the positive inotropic agents dobutamine and milrinone, the researchers said.

Sudden Death in First Month After MI

The risk of sudden death is dramatically higher in the first 30 days after MI than thereafter, and is particularly high in the first week and in patients with a low ejection fraction, according to Scott D. Solomon, M.D., of Brigham and Women's Hospital, Boston, and his associates.

Current American College of Cardiology/American Heart Association recommendations, which specify that implantable cardioverter defibrillators should be implanted 30 days or more after MI in patients with low ejection fractions or heart failure, may need to be reconsidered in light of these findings, they noted (N. Engl. J. Med. 2005;352:2581–8).

The investigators analyzed data from a randomized, controlled trial of 14,609 patients. They were followed for 2 years after MI complicated by an impaired ejection fraction, heart failure, or both. The rate of sudden death was 10 times higher within the first month after MI (1.4% per month) than it was 2 years later (0.14% per month). Even among patients with the highest ejection fractions, the rate of sudden death was six times higher in the first month than it was at 1 year. The findings suggest that early intervention would be beneficial, even in relatively low-risk patients, they said.

Staph Is Major Cause of Endocarditis

The epidemiology of Staphylococcus aureus infection has shifted so dramatically in recent years that the organism is now the leading cause of infective endocarditis in most of the developed world—a direct consequence of medical “progress,” said Vance G. Fowler Jr., M.D., of Duke University Medical Center, Durham, N.C., and his associates.

For decades, infective endocarditis due to S. aureus has been considered a relatively minor problem linked with injection drug use, and patients with nosocomial S. aureus bacteremia were considered to be at low risk for endocarditis. But in the 48-month prospective cohort study of 1,779 endocarditis patients treated in 16 countries, S. aureus was found to be the single most common cause of endocarditis, and the infection was often associated with medical devices or procedures such as pacemakers, prosthetic valves, or hemodialysis (JAMA 2005;293:3012–21). Patients with such “health care-associated” staph endocarditis had much higher mortality and a much greater incidence of methicillin resistance than did those with other forms of the disorder. Methicillin-resistant S. aureus accounted for up to 40% of the cases in many areas, the researchers noted.

Impaired Memory in Hypertension

Impaired cerebral blood flow may contribute to the mild deficits in memory and other cognitive functions in people with hypertension, compared with their normotensive peers, according to J.R. Jennings, Ph.D., of the University of Pittsburgh, and associates.

The researchers assessed regional cerebral blood flow using MRI and PET brain scans in 37 hypertensive and 59 normotensive subjects (median age 60 years) who performed a battery of memory and sensorimotor tasks. The blood flow response to performance demands was significantly blunted in certain areas of the brain in hypertensive subjects, who also showed mild deficits in performance, compared with the normotensive subjects (Neurology 2005;64:1358–65).

“Our results are far from conclusive but suggest that vascular factors may play a role” in mild memory and cognitive deficits seen in hypertensive people, the researchers said. Moreover, the findings show that common systemic diseases such as hypertension can have unanticipated effects on brain function, they added.

Choosing Meds for Decompensated HF

When intravenous vasoactive medications are required for acute decompensated heart failure, patients who receive a vasodilator or natriuretic peptide are more likely to survive than are those who receive a positive inotropic agent, reported William T. Abraham, M.D., of Ohio State University, Columbus, and his associates.

There are no published guidelines for managing acute decompensated HF because the evidence base is inadequate. The investigators used data from a recently established national registry for this disorder to compare the effects of four medications on in-hospital mortality. They analyzed data on more than 65,000 patients hospitalized at 263 U.S. medical centers, which they said provides a better real-world picture of treatment safety and efficacy than has been available from “highly controlled, short-term, clinical trials of carefully selected patient populations” (J. Am. Coll. Cardiol. 2005;46:57–64).

Patients treated with the vasodilator nitroglycerin or the natriuretic peptide nesiritide had better survival rates and shorter hospital stays than did those treated with the positive inotropic agents dobutamine and milrinone, the researchers said.

Fish Oil May Promote Arrhythmia

Fish oil supplements not only failed to suppress arrhythmias, they may have promoted them in a study of patients with implantable defibrillators, reported Merritt H. Raitt, M.D., of Oregon Health and Science University, Portland, and associates.

Many studies have suggested that fish oil supplements or increased intake of certain fatty fish exerts an antiarrhythmic effect, leading both the American Heart Association and the Food and Drug Administration to recommend fish oil for patients with coronary artery disease and for the general population.

To assess the possible antiarrhythmic properties of fish oil, the investigators conducted a multicenter study of 200 patients who received implantable cardioverter defibrillator (ICDs) for sustained ventricular tachycardia (VT) or ventricular fibrillation (VF). Subjects were randomly assigned to receive either fish oil supplements or placebo and were followed for a median of 2 years. There was a significantly increased rate of recurrent episodes of VT/VF in patients assigned to fish oil. “Fish oil may be proarrhythmic in this population,” the investigators concluded (JAMA 2005;293:2884–91).

Statins vs. Calcific Aortic Stenosis

Intensive statin therapy did not induce regression of calcific aortic stenosis or even halt the progression of the condition in a study of 155 patients, even though it reduced cholesterol levels dramatically, reported S. Joanna Cowell, of the Royal Infirmary, Edinburgh, and her associates.

The researchers proposed that statins might halt the progression of calcific aortic stenosis because the drugs can do so with coronary artery disease and because they reduce coronary artery calcification (N. Engl. J. Med. 2005;352:2389–97).

In the 2-year prospective trial, 77 patients with mild to moderate or severe calcific aortic stenosis were randomly assigned to receive high-dose atorvastatin (Lipitor) and 78 received placebo. There were no significant differences in the rate of disease progression as measured with Doppler echocardiography and helical CT. Moreover, progression of stenosis showed no relation to cholesterol levels, nor did high-dose atorvastatin show any effect on clinical end points such as mortality or the need for hospitalization or valve replacement.

Telemonitoring for High-Risk HF

Daily home telemonitoring may prove valuable for managing high-risk heart failure patients who require repeated hospital admissions, according to John G.F. Cleland, M.D., of the University of Hull (U.K.), and his associates.

The researchers evaluated 426 heart failure patients with left ventricle ejection fractions of less than 40% who were treated at 16 hospitals in Germany, the Netherlands, and the United Kingdom. A total of 168 patients were randomly assigned to a home telemonitoring program in which they transmitted data on weight, blood pressure, heart rate, and heart rhythm twice a day to a nursing staff. The remaining patients received either usual care or verbal support via telephone from a nurse.

Those in the telemonitoring program showed lower mortality rates and shorter hospital stays than the other groups, although the differences did not reach statistical significance. They also were more likely to receive appropriate medications. The benefits of telemonitoring will probably become more distinct as medical staff become accustomed to the technology, the investigators said (J. Am. Coll. Cardiol. 2005;45:1654–64).

Cystatin C Predicts CV Events

Serum level of cystatin C, which measures renal function, was a stronger predictor of cardiovascular events and of mortality in a study of elderly subjects than were creatinine level and estimated glomerular filtration rate, according to Michael G. Shlipak, M.D., of the University of California, San Francisco, and his associates.

In 4,637 ambulatory elderly subjects followed for a mean of 7 years, cystatin C was the best predictor of CV events, cardiac mortality, and overall mortality. They were able to define low-risk levels (<1.00 mg/L), intermediate-risk levels (1.00–1.28 mg/L), and high-risk levels (1.29 mg/L or more) of cystatin C, the researchers said (N. Engl. J. Med. 2005;352:2049–60).

In an editorial, Lesley A. Stevens, M.D., and Andrew S. Levey, M.D., both of Tufts-New England Medical Center, Boston, said these results suggest that the higher risk of CVD among elderly patients with kidney disease “may be stronger and occur at higher levels of [glomerular filtration rate] than previously suspected.”

All elderly patients should be evaluated for possible kidney disease, and those found to have it “should be considered to be in the highest risk group for [cardiovascular] disease and should receive intensive risk-reduction therapy,” they said (N. Engl. J. Med. 2005;352:2122–4).

Fish Oil May Promote Arrhythmia

Fish oil supplements not only failed to suppress arrhythmias, they may have promoted them in a study of patients with implantable defibrillators, reported Merritt H. Raitt, M.D., of Oregon Health and Science University, Portland, and associates.

Many studies have suggested that fish oil supplements or increased intake of certain fatty fish exerts an antiarrhythmic effect, leading both the American Heart Association and the Food and Drug Administration to recommend fish oil for patients with coronary artery disease and for the general population.

To assess the possible antiarrhythmic properties of fish oil, the investigators conducted a multicenter study of 200 patients who received implantable cardioverter defibrillator (ICDs) for sustained ventricular tachycardia (VT) or ventricular fibrillation (VF). Subjects were randomly assigned to receive either fish oil supplements or placebo and were followed for a median of 2 years. There was a significantly increased rate of recurrent episodes of VT/VF in patients assigned to fish oil. “Fish oil may be proarrhythmic in this population,” the investigators concluded (JAMA 2005;293:2884–91).

Statins vs. Calcific Aortic Stenosis

Intensive statin therapy did not induce regression of calcific aortic stenosis or even halt the progression of the condition in a study of 155 patients, even though it reduced cholesterol levels dramatically, reported S. Joanna Cowell, of the Royal Infirmary, Edinburgh, and her associates.

The researchers proposed that statins might halt the progression of calcific aortic stenosis because the drugs can do so with coronary artery disease and because they reduce coronary artery calcification (N. Engl. J. Med. 2005;352:2389–97).

In the 2-year prospective trial, 77 patients with mild to moderate or severe calcific aortic stenosis were randomly assigned to receive high-dose atorvastatin (Lipitor) and 78 received placebo. There were no significant differences in the rate of disease progression as measured with Doppler echocardiography and helical CT. Moreover, progression of stenosis showed no relation to cholesterol levels, nor did high-dose atorvastatin show any effect on clinical end points such as mortality or the need for hospitalization or valve replacement.

Telemonitoring for High-Risk HF

Daily home telemonitoring may prove valuable for managing high-risk heart failure patients who require repeated hospital admissions, according to John G.F. Cleland, M.D., of the University of Hull (U.K.), and his associates.

The researchers evaluated 426 heart failure patients with left ventricle ejection fractions of less than 40% who were treated at 16 hospitals in Germany, the Netherlands, and the United Kingdom. A total of 168 patients were randomly assigned to a home telemonitoring program in which they transmitted data on weight, blood pressure, heart rate, and heart rhythm twice a day to a nursing staff. The remaining patients received either usual care or verbal support via telephone from a nurse.

Those in the telemonitoring program showed lower mortality rates and shorter hospital stays than the other groups, although the differences did not reach statistical significance. They also were more likely to receive appropriate medications. The benefits of telemonitoring will probably become more distinct as medical staff become accustomed to the technology, the investigators said (J. Am. Coll. Cardiol. 2005;45:1654–64).

Cystatin C Predicts CV Events

Serum level of cystatin C, which measures renal function, was a stronger predictor of cardiovascular events and of mortality in a study of elderly subjects than were creatinine level and estimated glomerular filtration rate, according to Michael G. Shlipak, M.D., of the University of California, San Francisco, and his associates.

In 4,637 ambulatory elderly subjects followed for a mean of 7 years, cystatin C was the best predictor of CV events, cardiac mortality, and overall mortality. They were able to define low-risk levels (<1.00 mg/L), intermediate-risk levels (1.00–1.28 mg/L), and high-risk levels (1.29 mg/L or more) of cystatin C, the researchers said (N. Engl. J. Med. 2005;352:2049–60).

In an editorial, Lesley A. Stevens, M.D., and Andrew S. Levey, M.D., both of Tufts-New England Medical Center, Boston, said these results suggest that the higher risk of CVD among elderly patients with kidney disease “may be stronger and occur at higher levels of [glomerular filtration rate] than previously suspected.”

All elderly patients should be evaluated for possible kidney disease, and those found to have it “should be considered to be in the highest risk group for [cardiovascular] disease and should receive intensive risk-reduction therapy,” they said (N. Engl. J. Med. 2005;352:2122–4).

Fish Oil May Promote Arrhythmia

Fish oil supplements not only failed to suppress arrhythmias, they may have promoted them in a study of patients with implantable defibrillators, reported Merritt H. Raitt, M.D., of Oregon Health and Science University, Portland, and associates.

Many studies have suggested that fish oil supplements or increased intake of certain fatty fish exerts an antiarrhythmic effect, leading both the American Heart Association and the Food and Drug Administration to recommend fish oil for patients with coronary artery disease and for the general population.

To assess the possible antiarrhythmic properties of fish oil, the investigators conducted a multicenter study of 200 patients who received implantable cardioverter defibrillator (ICDs) for sustained ventricular tachycardia (VT) or ventricular fibrillation (VF). Subjects were randomly assigned to receive either fish oil supplements or placebo and were followed for a median of 2 years. There was a significantly increased rate of recurrent episodes of VT/VF in patients assigned to fish oil. “Fish oil may be proarrhythmic in this population,” the investigators concluded (JAMA 2005;293:2884–91).

Statins vs. Calcific Aortic Stenosis

Intensive statin therapy did not induce regression of calcific aortic stenosis or even halt the progression of the condition in a study of 155 patients, even though it reduced cholesterol levels dramatically, reported S. Joanna Cowell, of the Royal Infirmary, Edinburgh, and her associates.

The researchers proposed that statins might halt the progression of calcific aortic stenosis because the drugs can do so with coronary artery disease and because they reduce coronary artery calcification (N. Engl. J. Med. 2005;352:2389–97).

In the 2-year prospective trial, 77 patients with mild to moderate or severe calcific aortic stenosis were randomly assigned to receive high-dose atorvastatin (Lipitor) and 78 received placebo. There were no significant differences in the rate of disease progression as measured with Doppler echocardiography and helical CT. Moreover, progression of stenosis showed no relation to cholesterol levels, nor did high-dose atorvastatin show any effect on clinical end points such as mortality or the need for hospitalization or valve replacement.

Telemonitoring for High-Risk HF

Daily home telemonitoring may prove valuable for managing high-risk heart failure patients who require repeated hospital admissions, according to John G.F. Cleland, M.D., of the University of Hull (U.K.), and his associates.

The researchers evaluated 426 heart failure patients with left ventricle ejection fractions of less than 40% who were treated at 16 hospitals in Germany, the Netherlands, and the United Kingdom. A total of 168 patients were randomly assigned to a home telemonitoring program in which they transmitted data on weight, blood pressure, heart rate, and heart rhythm twice a day to a nursing staff. The remaining patients received either usual care or verbal support via telephone from a nurse.

Those in the telemonitoring program showed lower mortality rates and shorter hospital stays than the other groups, although the differences did not reach statistical significance. They also were more likely to receive appropriate medications. The benefits of telemonitoring will probably become more distinct as medical staff become accustomed to the technology, the investigators said (J. Am. Coll. Cardiol. 2005;45:1654–64).

Cystatin C Predicts CV Events

Serum level of cystatin C, which measures renal function, was a stronger predictor of cardiovascular events and of mortality in a study of elderly subjects than were creatinine level and estimated glomerular filtration rate, according to Michael G. Shlipak, M.D., of the University of California, San Francisco, and his associates.

In 4,637 ambulatory elderly subjects followed for a mean of 7 years, cystatin C was the best predictor of CV events, cardiac mortality, and overall mortality. They were able to define low-risk levels (<1.00 mg/L), intermediate-risk levels (1.00–1.28 mg/L), and high-risk levels (1.29 mg/L or more) of cystatin C, the researchers said (N. Engl. J. Med. 2005;352:2049–60).

In an editorial, Lesley A. Stevens, M.D., and Andrew S. Levey, M.D., both of Tufts-New England Medical Center, Boston, said these results suggest that the higher risk of CVD among elderly patients with kidney disease “may be stronger and occur at higher levels of [glomerular filtration rate] than previously suspected.”

All elderly patients should be evaluated for possible kidney disease, and those found to have it “should be considered to be in the highest risk group for [cardiovascular] disease and should receive intensive risk-reduction therapy,” they said (N. Engl. J. Med. 2005;352:2122–4).

Occult CAD in Intracranial Ischemia

People who have a transient ischemic attack or nondisabling ischemic stroke but are not thought to have heart disease often harbor occult coronary artery disease, reported Juan F. Arenillas, M.D., and his associates at Vall d'Hebron University Hospital, Barcelona, Spain.

They assessed 65 patients with a recent, nondisabling ischemic stroke and 22 with a recent TIA in what they described as the first study to assess myocardial perfusion in patients with intracranial atherosclerosis. The patients were found to have a total of 175 intracranial stenoses. None of the subjects were thought to have CAD (Stroke 2005;36:1201–6).

Myocardial perfusion single-photo emission CT revealed that 34 patients (52%) had significant myocardial ischemia, including anterior, septal, or apical defects, as well as inferior or lateral perfusion defects. Patients whose stroke or TIA was attributed to middle cerebral artery or vertebrobasilar stenoses and who were found to have asymptomatic internal carotid artery stenoses had a 100% chance of having silent CAD. “We suggest that this pattern of distribution … may serve as an indicator of a generalized atherosclerotic disease,” the researchers said. Coronary testing should be considered for these patients because they are at high risk for occult CAD, they said.

Impaired Cognition Predicts CHD, Stroke

Low cognitive function predicts cardiovascular events independent of established cardiovascular risk factors, said Jacob S. Elkins, M.D., of the University of California, San Francisco, and his associates.

The researchers used data on 12,096 middle-aged subjects enrolled in a population-based prospective study to evaluate whether below-normal cognitive function could be an early manifestation of vascular end-organ injury to the brain, and could therefore identify people at risk for impending CV events. During a mean follow-up of 6.4 years, there were 292 incident MIs, 50 deaths from coronary heart disease, and 174 strokes in the study population (Neurol. 2005;64:1750–5).

Subjects in the lowest quartile of cognitive performance for their demographic backgrounds had a 50% higher risk of such events than did those in the highest quartile of cognitive performance, after the data were adjusted for known CV risk factors. The magnitude of this association was comparable to that for other major risk factors such as left ventricular hypertrophy or low HDL cholesterol. This suggests that simple cognitive testing might prove useful for risk stratification, the investigators said.

ICDs Perform Outside Clinical Trials

In routine medical practice with diverse patient populations, implantable cardioverter-defibrillators reduce mortality as much as in clinical trials with highly selected subjects who received optimal care, according to Paul S. Chan, M.D., of the University of Michigan, Ann Arbor, and his associates.

They assessed mortality in 6,996 patients treated at Veterans Administration hospitals who had preexisting ischemic heart disease and clinical heart failure at the onset of ventricular arrhythmia. About 20% of the patients received ICDs; the others were managed medically. Both all-cause and cardiac-specific mortality were significantly lower in the ICD group, with an overall risk reduction of 28% (J. Am. Coll. Cardiol. 2005;45:1474–81).

Only 4.2 patients needed to be treated with an ICD to avert a single cardiovascular death. “Few therapies in all of medicine have shown such striking benefits for overall survival,” the researchers noted.

Can Hair Loss Signal CVD?

Sometimes a prosaic symptom such as hair loss provides the clue that is crucial to diagnosis, according to Yvo Smulders, M.D., of VU University Medical Center, Amsterdam, and his associates.

They reported on a 39-year-old man who felt fine but mentioned at a routine physical exam that he had more hair loss than usual during the previous year. The only abnormalities found on the exam were alopecia and hypertension. But testing revealed ECG abnormalities, high cholesterol, elevated serum creatine phosphokinase, and renal insufficiency. Silent ischemic heart disease was suspected.

Clinicians at a cardiology clinic where the patient was referred thought that the combination of hair loss and high creatine phosphokinase indicated hypothyroidism instead. Daily thyroxine therapy led to normalization of the patient's blood pressure, ECG readings, renal function, and serum enzymes—and hair regrowth, the investigators said (Lancet 2005;365:544).

Hypothyroidism often involves hypertension due to increased systemic vascular resistance, high cholesterol due to reduced hepatic clearance of LDL cholesterol, and renal insufficiency, presumably due to a hypodynamic circulation, they said.

Occult CAD in Intracranial Ischemia

People who have a transient ischemic attack or nondisabling ischemic stroke but are not thought to have heart disease often harbor occult coronary artery disease, reported Juan F. Arenillas, M.D., and his associates at Vall d'Hebron University Hospital, Barcelona, Spain.

They assessed 65 patients with a recent, nondisabling ischemic stroke and 22 with a recent TIA in what they described as the first study to assess myocardial perfusion in patients with intracranial atherosclerosis. The patients were found to have a total of 175 intracranial stenoses. None of the subjects were thought to have CAD (Stroke 2005;36:1201–6).

Myocardial perfusion single-photo emission CT revealed that 34 patients (52%) had significant myocardial ischemia, including anterior, septal, or apical defects, as well as inferior or lateral perfusion defects. Patients whose stroke or TIA was attributed to middle cerebral artery or vertebrobasilar stenoses and who were found to have asymptomatic internal carotid artery stenoses had a 100% chance of having silent CAD. “We suggest that this pattern of distribution … may serve as an indicator of a generalized atherosclerotic disease,” the researchers said. Coronary testing should be considered for these patients because they are at high risk for occult CAD, they said.

Impaired Cognition Predicts CHD, Stroke

Low cognitive function predicts cardiovascular events independent of established cardiovascular risk factors, said Jacob S. Elkins, M.D., of the University of California, San Francisco, and his associates.

The researchers used data on 12,096 middle-aged subjects enrolled in a population-based prospective study to evaluate whether below-normal cognitive function could be an early manifestation of vascular end-organ injury to the brain, and could therefore identify people at risk for impending CV events. During a mean follow-up of 6.4 years, there were 292 incident MIs, 50 deaths from coronary heart disease, and 174 strokes in the study population (Neurol. 2005;64:1750–5).

Subjects in the lowest quartile of cognitive performance for their demographic backgrounds had a 50% higher risk of such events than did those in the highest quartile of cognitive performance, after the data were adjusted for known CV risk factors. The magnitude of this association was comparable to that for other major risk factors such as left ventricular hypertrophy or low HDL cholesterol. This suggests that simple cognitive testing might prove useful for risk stratification, the investigators said.

ICDs Perform Outside Clinical Trials

In routine medical practice with diverse patient populations, implantable cardioverter-defibrillators reduce mortality as much as in clinical trials with highly selected subjects who received optimal care, according to Paul S. Chan, M.D., of the University of Michigan, Ann Arbor, and his associates.

They assessed mortality in 6,996 patients treated at Veterans Administration hospitals who had preexisting ischemic heart disease and clinical heart failure at the onset of ventricular arrhythmia. About 20% of the patients received ICDs; the others were managed medically. Both all-cause and cardiac-specific mortality were significantly lower in the ICD group, with an overall risk reduction of 28% (J. Am. Coll. Cardiol. 2005;45:1474–81).

Only 4.2 patients needed to be treated with an ICD to avert a single cardiovascular death. “Few therapies in all of medicine have shown such striking benefits for overall survival,” the researchers noted.

Can Hair Loss Signal CVD?

Sometimes a prosaic symptom such as hair loss provides the clue that is crucial to diagnosis, according to Yvo Smulders, M.D., of VU University Medical Center, Amsterdam, and his associates.

They reported on a 39-year-old man who felt fine but mentioned at a routine physical exam that he had more hair loss than usual during the previous year. The only abnormalities found on the exam were alopecia and hypertension. But testing revealed ECG abnormalities, high cholesterol, elevated serum creatine phosphokinase, and renal insufficiency. Silent ischemic heart disease was suspected.

Clinicians at a cardiology clinic where the patient was referred thought that the combination of hair loss and high creatine phosphokinase indicated hypothyroidism instead. Daily thyroxine therapy led to normalization of the patient's blood pressure, ECG readings, renal function, and serum enzymes—and hair regrowth, the investigators said (Lancet 2005;365:544).

Hypothyroidism often involves hypertension due to increased systemic vascular resistance, high cholesterol due to reduced hepatic clearance of LDL cholesterol, and renal insufficiency, presumably due to a hypodynamic circulation, they said.

Occult CAD in Intracranial Ischemia

People who have a transient ischemic attack or nondisabling ischemic stroke but are not thought to have heart disease often harbor occult coronary artery disease, reported Juan F. Arenillas, M.D., and his associates at Vall d'Hebron University Hospital, Barcelona, Spain.

They assessed 65 patients with a recent, nondisabling ischemic stroke and 22 with a recent TIA in what they described as the first study to assess myocardial perfusion in patients with intracranial atherosclerosis. The patients were found to have a total of 175 intracranial stenoses. None of the subjects were thought to have CAD (Stroke 2005;36:1201–6).

Myocardial perfusion single-photo emission CT revealed that 34 patients (52%) had significant myocardial ischemia, including anterior, septal, or apical defects, as well as inferior or lateral perfusion defects. Patients whose stroke or TIA was attributed to middle cerebral artery or vertebrobasilar stenoses and who were found to have asymptomatic internal carotid artery stenoses had a 100% chance of having silent CAD. “We suggest that this pattern of distribution … may serve as an indicator of a generalized atherosclerotic disease,” the researchers said. Coronary testing should be considered for these patients because they are at high risk for occult CAD, they said.

Impaired Cognition Predicts CHD, Stroke

Low cognitive function predicts cardiovascular events independent of established cardiovascular risk factors, said Jacob S. Elkins, M.D., of the University of California, San Francisco, and his associates.

The researchers used data on 12,096 middle-aged subjects enrolled in a population-based prospective study to evaluate whether below-normal cognitive function could be an early manifestation of vascular end-organ injury to the brain, and could therefore identify people at risk for impending CV events. During a mean follow-up of 6.4 years, there were 292 incident MIs, 50 deaths from coronary heart disease, and 174 strokes in the study population (Neurol. 2005;64:1750–5).

Subjects in the lowest quartile of cognitive performance for their demographic backgrounds had a 50% higher risk of such events than did those in the highest quartile of cognitive performance, after the data were adjusted for known CV risk factors. The magnitude of this association was comparable to that for other major risk factors such as left ventricular hypertrophy or low HDL cholesterol. This suggests that simple cognitive testing might prove useful for risk stratification, the investigators said.

ICDs Perform Outside Clinical Trials

In routine medical practice with diverse patient populations, implantable cardioverter-defibrillators reduce mortality as much as in clinical trials with highly selected subjects who received optimal care, according to Paul S. Chan, M.D., of the University of Michigan, Ann Arbor, and his associates.

They assessed mortality in 6,996 patients treated at Veterans Administration hospitals who had preexisting ischemic heart disease and clinical heart failure at the onset of ventricular arrhythmia. About 20% of the patients received ICDs; the others were managed medically. Both all-cause and cardiac-specific mortality were significantly lower in the ICD group, with an overall risk reduction of 28% (J. Am. Coll. Cardiol. 2005;45:1474–81).

Only 4.2 patients needed to be treated with an ICD to avert a single cardiovascular death. “Few therapies in all of medicine have shown such striking benefits for overall survival,” the researchers noted.

Can Hair Loss Signal CVD?

Sometimes a prosaic symptom such as hair loss provides the clue that is crucial to diagnosis, according to Yvo Smulders, M.D., of VU University Medical Center, Amsterdam, and his associates.

They reported on a 39-year-old man who felt fine but mentioned at a routine physical exam that he had more hair loss than usual during the previous year. The only abnormalities found on the exam were alopecia and hypertension. But testing revealed ECG abnormalities, high cholesterol, elevated serum creatine phosphokinase, and renal insufficiency. Silent ischemic heart disease was suspected.

Clinicians at a cardiology clinic where the patient was referred thought that the combination of hair loss and high creatine phosphokinase indicated hypothyroidism instead. Daily thyroxine therapy led to normalization of the patient's blood pressure, ECG readings, renal function, and serum enzymes—and hair regrowth, the investigators said (Lancet 2005;365:544).

Hypothyroidism often involves hypertension due to increased systemic vascular resistance, high cholesterol due to reduced hepatic clearance of LDL cholesterol, and renal insufficiency, presumably due to a hypodynamic circulation, they said.

Cardiac Power Index Predicts Stroke

An index of cardiac power during exercise can be used to identify men at risk for stroke, according to Sudhir Kurl, M.D., of the University of Kuopio (Finland) and associates.

Two measures of cardiorespiratory fitness currently are used in stratifying stroke risk: maximal oxygen uptake (VO_2max) during exercise, which indicates cardiac capacity, and systolic blood pressure at rest, which indicates peripheral resistance. The researchers proposed combining these measures into an “index of exercise cardiac power (ECP)” to enhance the prognostic value of either measure alone. The ECP index is the ratio of VO_2max to peak systolic blood pressure during exercise.

In their population-based study of 1,761 healthy Finnish men (mean age 52 years), 91 had a stroke during an average of 12 years of follow-up. Men with the lowest ECP index values, indicating low cardiac power, had nearly three times the risk of stroke as did those with the highest ECP index values, indicating greater cardiac power (Stroke 2005;36:820–4).

The ECP index was found to be one of the strongest predictors of stroke, as predictive as body mass index, diabetes, hypertension, and smoking. It also was a better predictor than exercise capacity alone.

Amiodarone, Sotalol Equally Effective

Amiodarone and sotalol appear to be equally effective in converting atrial fibrillation to sinus rhythm, reported Bramah N. Singh, M.D., of the Veterans Affairs Medical Center, West Los Angeles, and associates.

“The optimal long-term drug strategy is controversial” in atrial fibrillation (AF), the researchers noted. They conducted a multicenter clinical trial between April 1998 and October 2002 in which 267 patients were randomly assigned to receive amiodarone, 261 to receive sotalol, and 137 to receive placebo (N. Engl. J. Med. 2005;352:1861–72).

The rate of conversion to sinus rhythm was 79.8% for amiodarone and 79.9% for sotalol, compared with 68.2% for placebo. Both agents were markedly more effective than placebo at preventing recurrence of AF. There were no differences between the two drugs in mortality or rates of adverse events except for minor bleeding episodes—more common with amiodarone.

Patients in whom sinus rhythm was restored scored significantly higher than did those with persistent AF on measures of physical functioning, general health, and social functioning, the researchers noted.

H. pylori Tied to Vascular Inflammation

Chronic asymptomatic infection with Helicobacter pylori appears to contribute to atherosclerosis by increasing vascular inflammation and impairing vasodilation, according to Tetsuya Oshima, M.D., and associates at Hiroshima (Japan) University Graduate School of Biomedical Sciences.

In a study of 81 healthy Japanese men who were nonsmokers (average age 40 years), serum levels of C-reactive protein and soluble intercellular adhesion molecule, both of which are markers for endothelial activation and vascular inflammation, were markedly higher in subjects who were seropositive for H. pylori than in men who were seronegative. The infection also attenuated flow-mediated vasodilation, they reported (J. Am. Coll. Cardiol. 2005;45:1219–22).

In contrast, there were no correlations between the vascular parameters and seropositivity for cytomegalovirus or Chlamydia pneumoniae.

“We hypothesize that chronic infection with H. pylori directly or indirectly induces a persisting systemic and vascular inflammation and endothelial dysfunction,” the researchers said.

Folate Improves Coronary Vasodilation

High-dose folic acid acutely improves coronary vasodilation in patients with coronary artery disease, reported Ahmed Tawakol, M.D., and his associates at Massachusetts General Hospital, Boston.

Folate is known to improve vasodilation in the peripheral circulation, but its effect on dilation within the heart in people who have ischemic heart disease hadn't been tested. In a preliminary study, the investigators used PET scans to assess myocardial blood flow in 14 such patients after they ingested either folate syrup or placebo syrup.

The folate did not affect blood flow in normal areas of the patients' hearts, but increased vasodilator-stimulated blood flow by 49% in ischemic areas. It also raised dilator reserve by 83% in ischemic areas without affecting dilator reserve in normal areas.

Folate also lowered arterial blood pressure independently of its ability to decrease homocysteine (J. Am. Coll. Cardiol. 2005;45:1580–4).

These results raise the possibility that long-term folate therapy at higher doses than are usually taken might reduce ischemia as well as lower blood pressure in CAD patients, the researchers said.

Cardiac Power Index Predicts Stroke

An index of cardiac power during exercise can be used to identify men at risk for stroke, according to Sudhir Kurl, M.D., of the University of Kuopio (Finland) and associates.

Two measures of cardiorespiratory fitness currently are used in stratifying stroke risk: maximal oxygen uptake (VO_2max) during exercise, which indicates cardiac capacity, and systolic blood pressure at rest, which indicates peripheral resistance. The researchers proposed combining these measures into an “index of exercise cardiac power (ECP)” to enhance the prognostic value of either measure alone. The ECP index is the ratio of VO_2max to peak systolic blood pressure during exercise.

In their population-based study of 1,761 healthy Finnish men (mean age 52 years), 91 had a stroke during an average of 12 years of follow-up. Men with the lowest ECP index values, indicating low cardiac power, had nearly three times the risk of stroke as did those with the highest ECP index values, indicating greater cardiac power (Stroke 2005;36:820–4).

The ECP index was found to be one of the strongest predictors of stroke, as predictive as body mass index, diabetes, hypertension, and smoking. It also was a better predictor than exercise capacity alone.

Amiodarone, Sotalol Equally Effective

Amiodarone and sotalol appear to be equally effective in converting atrial fibrillation to sinus rhythm, reported Bramah N. Singh, M.D., of the Veterans Affairs Medical Center, West Los Angeles, and associates.

“The optimal long-term drug strategy is controversial” in atrial fibrillation (AF), the researchers noted. They conducted a multicenter clinical trial between April 1998 and October 2002 in which 267 patients were randomly assigned to receive amiodarone, 261 to receive sotalol, and 137 to receive placebo (N. Engl. J. Med. 2005;352:1861–72).

The rate of conversion to sinus rhythm was 79.8% for amiodarone and 79.9% for sotalol, compared with 68.2% for placebo. Both agents were markedly more effective than placebo at preventing recurrence of AF. There were no differences between the two drugs in mortality or rates of adverse events except for minor bleeding episodes—more common with amiodarone.

Patients in whom sinus rhythm was restored scored significantly higher than did those with persistent AF on measures of physical functioning, general health, and social functioning, the researchers noted.

H. pylori Tied to Vascular Inflammation

Chronic asymptomatic infection with Helicobacter pylori appears to contribute to atherosclerosis by increasing vascular inflammation and impairing vasodilation, according to Tetsuya Oshima, M.D., and associates at Hiroshima (Japan) University Graduate School of Biomedical Sciences.

In a study of 81 healthy Japanese men who were nonsmokers (average age 40 years), serum levels of C-reactive protein and soluble intercellular adhesion molecule, both of which are markers for endothelial activation and vascular inflammation, were markedly higher in subjects who were seropositive for H. pylori than in men who were seronegative. The infection also attenuated flow-mediated vasodilation, they reported (J. Am. Coll. Cardiol. 2005;45:1219–22).

In contrast, there were no correlations between the vascular parameters and seropositivity for cytomegalovirus or Chlamydia pneumoniae.

“We hypothesize that chronic infection with H. pylori directly or indirectly induces a persisting systemic and vascular inflammation and endothelial dysfunction,” the researchers said.

Folate Improves Coronary Vasodilation

High-dose folic acid acutely improves coronary vasodilation in patients with coronary artery disease, reported Ahmed Tawakol, M.D., and his associates at Massachusetts General Hospital, Boston.

Folate is known to improve vasodilation in the peripheral circulation, but its effect on dilation within the heart in people who have ischemic heart disease hadn't been tested. In a preliminary study, the investigators used PET scans to assess myocardial blood flow in 14 such patients after they ingested either folate syrup or placebo syrup.

The folate did not affect blood flow in normal areas of the patients' hearts, but increased vasodilator-stimulated blood flow by 49% in ischemic areas. It also raised dilator reserve by 83% in ischemic areas without affecting dilator reserve in normal areas.

Folate also lowered arterial blood pressure independently of its ability to decrease homocysteine (J. Am. Coll. Cardiol. 2005;45:1580–4).

These results raise the possibility that long-term folate therapy at higher doses than are usually taken might reduce ischemia as well as lower blood pressure in CAD patients, the researchers said.

Cardiac Power Index Predicts Stroke

An index of cardiac power during exercise can be used to identify men at risk for stroke, according to Sudhir Kurl, M.D., of the University of Kuopio (Finland) and associates.

Two measures of cardiorespiratory fitness currently are used in stratifying stroke risk: maximal oxygen uptake (VO_2max) during exercise, which indicates cardiac capacity, and systolic blood pressure at rest, which indicates peripheral resistance. The researchers proposed combining these measures into an “index of exercise cardiac power (ECP)” to enhance the prognostic value of either measure alone. The ECP index is the ratio of VO_2max to peak systolic blood pressure during exercise.

In their population-based study of 1,761 healthy Finnish men (mean age 52 years), 91 had a stroke during an average of 12 years of follow-up. Men with the lowest ECP index values, indicating low cardiac power, had nearly three times the risk of stroke as did those with the highest ECP index values, indicating greater cardiac power (Stroke 2005;36:820–4).

The ECP index was found to be one of the strongest predictors of stroke, as predictive as body mass index, diabetes, hypertension, and smoking. It also was a better predictor than exercise capacity alone.

Amiodarone, Sotalol Equally Effective

Amiodarone and sotalol appear to be equally effective in converting atrial fibrillation to sinus rhythm, reported Bramah N. Singh, M.D., of the Veterans Affairs Medical Center, West Los Angeles, and associates.

“The optimal long-term drug strategy is controversial” in atrial fibrillation (AF), the researchers noted. They conducted a multicenter clinical trial between April 1998 and October 2002 in which 267 patients were randomly assigned to receive amiodarone, 261 to receive sotalol, and 137 to receive placebo (N. Engl. J. Med. 2005;352:1861–72).

The rate of conversion to sinus rhythm was 79.8% for amiodarone and 79.9% for sotalol, compared with 68.2% for placebo. Both agents were markedly more effective than placebo at preventing recurrence of AF. There were no differences between the two drugs in mortality or rates of adverse events except for minor bleeding episodes—more common with amiodarone.

Patients in whom sinus rhythm was restored scored significantly higher than did those with persistent AF on measures of physical functioning, general health, and social functioning, the researchers noted.

H. pylori Tied to Vascular Inflammation

Chronic asymptomatic infection with Helicobacter pylori appears to contribute to atherosclerosis by increasing vascular inflammation and impairing vasodilation, according to Tetsuya Oshima, M.D., and associates at Hiroshima (Japan) University Graduate School of Biomedical Sciences.

In a study of 81 healthy Japanese men who were nonsmokers (average age 40 years), serum levels of C-reactive protein and soluble intercellular adhesion molecule, both of which are markers for endothelial activation and vascular inflammation, were markedly higher in subjects who were seropositive for H. pylori than in men who were seronegative. The infection also attenuated flow-mediated vasodilation, they reported (J. Am. Coll. Cardiol. 2005;45:1219–22).

In contrast, there were no correlations between the vascular parameters and seropositivity for cytomegalovirus or Chlamydia pneumoniae.

“We hypothesize that chronic infection with H. pylori directly or indirectly induces a persisting systemic and vascular inflammation and endothelial dysfunction,” the researchers said.

Folate Improves Coronary Vasodilation

High-dose folic acid acutely improves coronary vasodilation in patients with coronary artery disease, reported Ahmed Tawakol, M.D., and his associates at Massachusetts General Hospital, Boston.

Folate is known to improve vasodilation in the peripheral circulation, but its effect on dilation within the heart in people who have ischemic heart disease hadn't been tested. In a preliminary study, the investigators used PET scans to assess myocardial blood flow in 14 such patients after they ingested either folate syrup or placebo syrup.

The folate did not affect blood flow in normal areas of the patients' hearts, but increased vasodilator-stimulated blood flow by 49% in ischemic areas. It also raised dilator reserve by 83% in ischemic areas without affecting dilator reserve in normal areas.

Folate also lowered arterial blood pressure independently of its ability to decrease homocysteine (J. Am. Coll. Cardiol. 2005;45:1580–4).

These results raise the possibility that long-term folate therapy at higher doses than are usually taken might reduce ischemia as well as lower blood pressure in CAD patients, the researchers said.

Psychological stress either at work or at home raises the risk of myocardial infarction across all ethnic groups, all geographic regions, and both genders, reported Annika Rosengren, M.D., of Sahlgrenska University Hospital, Göteborg, Sweden, and her associates.

They assessed preexisting psychosocial stressors in 11,119 patients who had experienced acute MI and 13,648 controls matched for age, sex, and geographic location who were free of heart disease. The subjects, recruited at 262 medical centers in 52 countries over a 4-year period, were questioned about how often and how strongly they had experienced stress in the preceding year at home and at work. Internal stressors included feeling irritable, anxious, or depressed or having difficulty sleeping. External stressors included experiencing major adverse life events or serious financial distress, or having little control over life circumstances (Lancet 2004;364:953–62).

After the data were adjusted to account for cardiovascular risk factors, the MI patients showed consistently higher levels of stress and for a longer period than did controls. The size of this effect makes stress a much more important risk factor than is commonly recognized and a likely contributor to the incidence of MI, they said.

Psychological stress either at work or at home raises the risk of myocardial infarction across all ethnic groups, all geographic regions, and both genders, reported Annika Rosengren, M.D., of Sahlgrenska University Hospital, Göteborg, Sweden, and her associates.

They assessed preexisting psychosocial stressors in 11,119 patients who had experienced acute MI and 13,648 controls matched for age, sex, and geographic location who were free of heart disease. The subjects, recruited at 262 medical centers in 52 countries over a 4-year period, were questioned about how often and how strongly they had experienced stress in the preceding year at home and at work. Internal stressors included feeling irritable, anxious, or depressed or having difficulty sleeping. External stressors included experiencing major adverse life events or serious financial distress, or having little control over life circumstances (Lancet 2004;364:953–62).

After the data were adjusted to account for cardiovascular risk factors, the MI patients showed consistently higher levels of stress and for a longer period than did controls. The size of this effect makes stress a much more important risk factor than is commonly recognized and a likely contributor to the incidence of MI, they said.

Psychological stress either at work or at home raises the risk of myocardial infarction across all ethnic groups, all geographic regions, and both genders, reported Annika Rosengren, M.D., of Sahlgrenska University Hospital, Göteborg, Sweden, and her associates.

They assessed preexisting psychosocial stressors in 11,119 patients who had experienced acute MI and 13,648 controls matched for age, sex, and geographic location who were free of heart disease. The subjects, recruited at 262 medical centers in 52 countries over a 4-year period, were questioned about how often and how strongly they had experienced stress in the preceding year at home and at work. Internal stressors included feeling irritable, anxious, or depressed or having difficulty sleeping. External stressors included experiencing major adverse life events or serious financial distress, or having little control over life circumstances (Lancet 2004;364:953–62).

After the data were adjusted to account for cardiovascular risk factors, the MI patients showed consistently higher levels of stress and for a longer period than did controls. The size of this effect makes stress a much more important risk factor than is commonly recognized and a likely contributor to the incidence of MI, they said.