Mary Ann Moon

HF Rate Has Held Steady for 20 Years

The incidence of heart failure has not improved over the past 20 years, according to Veronique L. Roger, M.D., of the Mayo Clinic, Rochester, Minn., and her associates.

The researchers conducted a community-based study to examine trends in heart failure (HF), hoping to avoid the selection biases shown to be present in previous studies of the issue. They studied a cohort of 4,537 cases that were first diagnosed in one Minnesota county between 1979 and 2000, a population with characteristics similar to those of whites across the United States but not to those of other racial groups.

The incidence of HF did not decrease appreciably over these 2 decades, ranging from 360/100,000 men in 1979-1984 to 383/100,000 men in 1996-2000 and from 284/100,000 women to 315/100,000 women in those same periods (JAMA 2004;292:344-50).

Overall HF mortality improved somewhat, from 57% in 1979-1984 to 48% in 1996-2000. However, improvements were not equal across different age groups and genders. Only the youngest men showed improved survival, while women and elderly people of both sexes had steady mortality over the 20-year study period.

A full 42% of cases were diagnosed as outpatients, and 26% of these patients were never hospitalized for their HF. Thus, hospital-based surveillance programs and studies based on inpatient data fail to identify a significant portion of HF cases, the investigators noted.

Pericardial Valves Superior to Porcine

Second-generation pericardial valves are more durable than traditional porcine valves as aortic valve replacements, said Guangqiang Gao, M.D., and associates at Providence Health System, Portland, Ore.

The first generation of pericardial valves was taken off the market because of the high rate of structural failure. The second generation was marketed in 1991 in the United States but has not been as widely used as porcine valves, largely because of the poor history of its predecessors. Dr. Gao and associates compared the two types of valve by reviewing the experience at their facility with all 518 aortic valve replacements using porcine valves, which were done between 1974 and 1996, and all 1,021 aortic valve replacements using second-generation pericardial valves, which were done between 1991 and 2002 (J. Am. Coll. Cardiol. 2004;44:384-8).

Overall late survival rates were similar between the two groups, as was freedom from valve-related complications such as thromboembolic events and endocarditis. But the estimated 10-year rate of explantation was much higher for porcine (10%) than for pericardial valves (3%). Only four pericardial valves required replacement because of structural deterioration.

When Thrombolysis Is the Sole Option

For acute MI patients who either can't afford invasive intervention or don't have ready access to a hospital with a cath lab, medical thrombolysis is the only viable option. Fortunately, it has proved beneficial to most such patients, either as a definitive treatment or as a bridge to later intervention, according to Rami Khouzam, M.D., of the Tucson Hospitals Medical Education Program, and his associates.

The investigators reviewed the experience of 42 MI patients treated between 1999 and 2002 at a small county hospital in southern Arizona that offered only thrombolysis. MI patients in whom thrombolysis produced resolution of ST-segment changes within 90 minutes had a very high likelihood of a patent infarct artery and a very low mortality. Further PCI would be unlikely to improve their outcome. In contrast, those in whom thrombolysis did not produce ST-segment resolution within 90 minutes had a 40% probability for an occluded artery and required transfer for “rescue” PCI, the researchers said (Chest 2004;126:457-60).

Gemfibrozil Does Not Slow Renal Decline

Even though gemfibrozil cuts triglyceride and total cholesterol levels while raising HDL cholesterol, it does not slow renal decline in patients with mild renal insufficiency and concomitant coronary disease, reported Marcello Tonelli, M.D., of the University of Alberta, Edmonton, and his associates.

The researchers analyzed data from a trial conducted at 20 Veterans Affairs medical centers involving 399 subjects with both coronary heart disease and renal insufficiency (Am. J. Kidney Dis. 2004;44:832-9).

Compared with placebo, gemfibrozil (Lopid) cut triglycerides by 55.0 mg/dL, cut total cholesterol by 6.7 mg/dL, and raised HDL cholesterol by 2.3 mg/dL. But it did not slow the decline of renal function or improve subjects' chances of progressing to moderate or severe renal insufficiency.

Both gemfibrozil and statins improved cardiovascular outcomes in this population, but it appears that only statins exert renal benefits as well.

HF Rate Has Held Steady for 20 Years

The incidence of heart failure has not improved over the past 20 years, according to Veronique L. Roger, M.D., of the Mayo Clinic, Rochester, Minn., and her associates.

The researchers conducted a community-based study to examine trends in heart failure (HF), hoping to avoid the selection biases shown to be present in previous studies of the issue. They studied a cohort of 4,537 cases that were first diagnosed in one Minnesota county between 1979 and 2000, a population with characteristics similar to those of whites across the United States but not to those of other racial groups.

The incidence of HF did not decrease appreciably over these 2 decades, ranging from 360/100,000 men in 1979-1984 to 383/100,000 men in 1996-2000 and from 284/100,000 women to 315/100,000 women in those same periods (JAMA 2004;292:344-50).

Overall HF mortality improved somewhat, from 57% in 1979-1984 to 48% in 1996-2000. However, improvements were not equal across different age groups and genders. Only the youngest men showed improved survival, while women and elderly people of both sexes had steady mortality over the 20-year study period.

A full 42% of cases were diagnosed as outpatients, and 26% of these patients were never hospitalized for their HF. Thus, hospital-based surveillance programs and studies based on inpatient data fail to identify a significant portion of HF cases, the investigators noted.

Pericardial Valves Superior to Porcine

Second-generation pericardial valves are more durable than traditional porcine valves as aortic valve replacements, said Guangqiang Gao, M.D., and associates at Providence Health System, Portland, Ore.

The first generation of pericardial valves was taken off the market because of the high rate of structural failure. The second generation was marketed in 1991 in the United States but has not been as widely used as porcine valves, largely because of the poor history of its predecessors. Dr. Gao and associates compared the two types of valve by reviewing the experience at their facility with all 518 aortic valve replacements using porcine valves, which were done between 1974 and 1996, and all 1,021 aortic valve replacements using second-generation pericardial valves, which were done between 1991 and 2002 (J. Am. Coll. Cardiol. 2004;44:384-8).

Overall late survival rates were similar between the two groups, as was freedom from valve-related complications such as thromboembolic events and endocarditis. But the estimated 10-year rate of explantation was much higher for porcine (10%) than for pericardial valves (3%). Only four pericardial valves required replacement because of structural deterioration.

When Thrombolysis Is the Sole Option

For acute MI patients who either can't afford invasive intervention or don't have ready access to a hospital with a cath lab, medical thrombolysis is the only viable option. Fortunately, it has proved beneficial to most such patients, either as a definitive treatment or as a bridge to later intervention, according to Rami Khouzam, M.D., of the Tucson Hospitals Medical Education Program, and his associates.

The investigators reviewed the experience of 42 MI patients treated between 1999 and 2002 at a small county hospital in southern Arizona that offered only thrombolysis. MI patients in whom thrombolysis produced resolution of ST-segment changes within 90 minutes had a very high likelihood of a patent infarct artery and a very low mortality. Further PCI would be unlikely to improve their outcome. In contrast, those in whom thrombolysis did not produce ST-segment resolution within 90 minutes had a 40% probability for an occluded artery and required transfer for “rescue” PCI, the researchers said (Chest 2004;126:457-60).

Gemfibrozil Does Not Slow Renal Decline

Even though gemfibrozil cuts triglyceride and total cholesterol levels while raising HDL cholesterol, it does not slow renal decline in patients with mild renal insufficiency and concomitant coronary disease, reported Marcello Tonelli, M.D., of the University of Alberta, Edmonton, and his associates.

The researchers analyzed data from a trial conducted at 20 Veterans Affairs medical centers involving 399 subjects with both coronary heart disease and renal insufficiency (Am. J. Kidney Dis. 2004;44:832-9).

Compared with placebo, gemfibrozil (Lopid) cut triglycerides by 55.0 mg/dL, cut total cholesterol by 6.7 mg/dL, and raised HDL cholesterol by 2.3 mg/dL. But it did not slow the decline of renal function or improve subjects' chances of progressing to moderate or severe renal insufficiency.

Both gemfibrozil and statins improved cardiovascular outcomes in this population, but it appears that only statins exert renal benefits as well.

HF Rate Has Held Steady for 20 Years

The incidence of heart failure has not improved over the past 20 years, according to Veronique L. Roger, M.D., of the Mayo Clinic, Rochester, Minn., and her associates.

The researchers conducted a community-based study to examine trends in heart failure (HF), hoping to avoid the selection biases shown to be present in previous studies of the issue. They studied a cohort of 4,537 cases that were first diagnosed in one Minnesota county between 1979 and 2000, a population with characteristics similar to those of whites across the United States but not to those of other racial groups.

The incidence of HF did not decrease appreciably over these 2 decades, ranging from 360/100,000 men in 1979-1984 to 383/100,000 men in 1996-2000 and from 284/100,000 women to 315/100,000 women in those same periods (JAMA 2004;292:344-50).

Overall HF mortality improved somewhat, from 57% in 1979-1984 to 48% in 1996-2000. However, improvements were not equal across different age groups and genders. Only the youngest men showed improved survival, while women and elderly people of both sexes had steady mortality over the 20-year study period.

A full 42% of cases were diagnosed as outpatients, and 26% of these patients were never hospitalized for their HF. Thus, hospital-based surveillance programs and studies based on inpatient data fail to identify a significant portion of HF cases, the investigators noted.

Pericardial Valves Superior to Porcine

Second-generation pericardial valves are more durable than traditional porcine valves as aortic valve replacements, said Guangqiang Gao, M.D., and associates at Providence Health System, Portland, Ore.

The first generation of pericardial valves was taken off the market because of the high rate of structural failure. The second generation was marketed in 1991 in the United States but has not been as widely used as porcine valves, largely because of the poor history of its predecessors. Dr. Gao and associates compared the two types of valve by reviewing the experience at their facility with all 518 aortic valve replacements using porcine valves, which were done between 1974 and 1996, and all 1,021 aortic valve replacements using second-generation pericardial valves, which were done between 1991 and 2002 (J. Am. Coll. Cardiol. 2004;44:384-8).

Overall late survival rates were similar between the two groups, as was freedom from valve-related complications such as thromboembolic events and endocarditis. But the estimated 10-year rate of explantation was much higher for porcine (10%) than for pericardial valves (3%). Only four pericardial valves required replacement because of structural deterioration.

When Thrombolysis Is the Sole Option

For acute MI patients who either can't afford invasive intervention or don't have ready access to a hospital with a cath lab, medical thrombolysis is the only viable option. Fortunately, it has proved beneficial to most such patients, either as a definitive treatment or as a bridge to later intervention, according to Rami Khouzam, M.D., of the Tucson Hospitals Medical Education Program, and his associates.

The investigators reviewed the experience of 42 MI patients treated between 1999 and 2002 at a small county hospital in southern Arizona that offered only thrombolysis. MI patients in whom thrombolysis produced resolution of ST-segment changes within 90 minutes had a very high likelihood of a patent infarct artery and a very low mortality. Further PCI would be unlikely to improve their outcome. In contrast, those in whom thrombolysis did not produce ST-segment resolution within 90 minutes had a 40% probability for an occluded artery and required transfer for “rescue” PCI, the researchers said (Chest 2004;126:457-60).

Gemfibrozil Does Not Slow Renal Decline

Even though gemfibrozil cuts triglyceride and total cholesterol levels while raising HDL cholesterol, it does not slow renal decline in patients with mild renal insufficiency and concomitant coronary disease, reported Marcello Tonelli, M.D., of the University of Alberta, Edmonton, and his associates.

The researchers analyzed data from a trial conducted at 20 Veterans Affairs medical centers involving 399 subjects with both coronary heart disease and renal insufficiency (Am. J. Kidney Dis. 2004;44:832-9).

Compared with placebo, gemfibrozil (Lopid) cut triglycerides by 55.0 mg/dL, cut total cholesterol by 6.7 mg/dL, and raised HDL cholesterol by 2.3 mg/dL. But it did not slow the decline of renal function or improve subjects' chances of progressing to moderate or severe renal insufficiency.

Both gemfibrozil and statins improved cardiovascular outcomes in this population, but it appears that only statins exert renal benefits as well.

WASHINGTON — Nothing is gained by giving prophylactic antibiotics earlier than usual in the course of cesarean deliveries, W. Ashley Hood, D.O., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

The traditional approach to antibiotic prophylaxis in cesarean deliveries is to give the mother the drugs just after the cord is clamped. This prevents the antibiotics from being transmitted to the neonate, where they could mask neonatal infection and raise the risk that resistance will develop.

Some physicians argue that to best prevent maternal infection, however, antibiotics should be started just before skin incision so they will be on board as surgery commences. Proponents of this approach note that C-sections still account for 10% of all maternal mortality and that postcesarean infections—endometritis, wound infection, urinary tract infection, and pneumonia—are still a leading cause of maternal morbidity and death, said Dr. Hood of the University of Mississippi Medical Center, Jackson.

He and his associates assessed the effect of the timing of antibiotic prophylaxis in a study of 302 women undergoing nonelective cesarean delivery. Antibiotic prophylaxis was started at skin incision in 153 women and at cord clamping in 149. There were no significant differences between the two groups of patients in demographic characteristics, indications for cesarean delivery, or operative time.

There were fewer cases of postoperative endometritis in the group that received antibiotics at skin incision (12 patients, or 8%) than in the other group (22 patients, or 15%), but this difference was not statistically significant. The rates of wound infection also were similar, with 6 cases (4%) among women who received antibiotics at skin incision and 8 cases (5%) among those who received antibiotics at cord clamping.

Neonatal outcomes also were comparable between the two groups. Both groups had similar rates of neonatal sepsis, Apgar scores, and rates of admission to the neonatal intensive care unit, Dr. Hood said.

These findings confirm that it is still prudent to delay antibiotic prophylaxis until the cord is clamped, since giving the drugs earlier doesn't prevent more maternal infections or improve neonatal outcomes, he said.

WASHINGTON — Nothing is gained by giving prophylactic antibiotics earlier than usual in the course of cesarean deliveries, W. Ashley Hood, D.O., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

The traditional approach to antibiotic prophylaxis in cesarean deliveries is to give the mother the drugs just after the cord is clamped. This prevents the antibiotics from being transmitted to the neonate, where they could mask neonatal infection and raise the risk that resistance will develop.

Some physicians argue that to best prevent maternal infection, however, antibiotics should be started just before skin incision so they will be on board as surgery commences. Proponents of this approach note that C-sections still account for 10% of all maternal mortality and that postcesarean infections—endometritis, wound infection, urinary tract infection, and pneumonia—are still a leading cause of maternal morbidity and death, said Dr. Hood of the University of Mississippi Medical Center, Jackson.

He and his associates assessed the effect of the timing of antibiotic prophylaxis in a study of 302 women undergoing nonelective cesarean delivery. Antibiotic prophylaxis was started at skin incision in 153 women and at cord clamping in 149. There were no significant differences between the two groups of patients in demographic characteristics, indications for cesarean delivery, or operative time.

There were fewer cases of postoperative endometritis in the group that received antibiotics at skin incision (12 patients, or 8%) than in the other group (22 patients, or 15%), but this difference was not statistically significant. The rates of wound infection also were similar, with 6 cases (4%) among women who received antibiotics at skin incision and 8 cases (5%) among those who received antibiotics at cord clamping.

Neonatal outcomes also were comparable between the two groups. Both groups had similar rates of neonatal sepsis, Apgar scores, and rates of admission to the neonatal intensive care unit, Dr. Hood said.

These findings confirm that it is still prudent to delay antibiotic prophylaxis until the cord is clamped, since giving the drugs earlier doesn't prevent more maternal infections or improve neonatal outcomes, he said.

WASHINGTON — Nothing is gained by giving prophylactic antibiotics earlier than usual in the course of cesarean deliveries, W. Ashley Hood, D.O., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

The traditional approach to antibiotic prophylaxis in cesarean deliveries is to give the mother the drugs just after the cord is clamped. This prevents the antibiotics from being transmitted to the neonate, where they could mask neonatal infection and raise the risk that resistance will develop.

Some physicians argue that to best prevent maternal infection, however, antibiotics should be started just before skin incision so they will be on board as surgery commences. Proponents of this approach note that C-sections still account for 10% of all maternal mortality and that postcesarean infections—endometritis, wound infection, urinary tract infection, and pneumonia—are still a leading cause of maternal morbidity and death, said Dr. Hood of the University of Mississippi Medical Center, Jackson.

He and his associates assessed the effect of the timing of antibiotic prophylaxis in a study of 302 women undergoing nonelective cesarean delivery. Antibiotic prophylaxis was started at skin incision in 153 women and at cord clamping in 149. There were no significant differences between the two groups of patients in demographic characteristics, indications for cesarean delivery, or operative time.

There were fewer cases of postoperative endometritis in the group that received antibiotics at skin incision (12 patients, or 8%) than in the other group (22 patients, or 15%), but this difference was not statistically significant. The rates of wound infection also were similar, with 6 cases (4%) among women who received antibiotics at skin incision and 8 cases (5%) among those who received antibiotics at cord clamping.

Neonatal outcomes also were comparable between the two groups. Both groups had similar rates of neonatal sepsis, Apgar scores, and rates of admission to the neonatal intensive care unit, Dr. Hood said.

These findings confirm that it is still prudent to delay antibiotic prophylaxis until the cord is clamped, since giving the drugs earlier doesn't prevent more maternal infections or improve neonatal outcomes, he said.

WASHINGTON — Women who have vulvar disease should be asked specifically about bladder and bowel pain, and these symptoms also must be addressed, Colleen M. Kennedy, M.D., of the University of Iowa, Iowa City, advised.

Women with vulvar disease are twice as likely as are general gynecology patients to have bladder pain and bowel pain. “We hypothesize that certain vulvar or vaginal diseases are not isolated clinical entities, but rather represent symptoms of a global or generalized pelvic floor disorder—a pelvic floor pain disorder,” she said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Kennedy and her associates assessed the rates of painful bladder syndrome (interstitial cystitis) and irritable bowel syndrome in 324 women who were being treated at a vulvar disease clinic, and compared them with the rates among 321 control subjects attending a general gynecology clinic.

Of the women with vulvar disease, 12% reported bladder pain, compared with only 6% of control subjects. Similarly, 23% of those with vulvar disease were found to have bowel pain, compared with only 11% of control subjects.

Looked at another way, the data showed that women who reported bladder pain were 2.18 times more likely than were those who did not report bladder pain to have been treated for vulvar disease. Women with vulvar disease had a mean score of 20.3 on the Urinary Distress Inventory's pain subscale, compared with a mean score of 5.3 for women without vulvar disease.

Likewise, women with functional bowel disorders were 2.13 times more likely than were those who did not have bowel disorders to have been treated for vulvar disease.

The higher prevalence of painful bladder and painful bowel syndromes in women with vulvar disease may reflect a common etiology for all these disorders. The design of this study, however, didn't allow the researchers to tease out whether there is a common etiology “or whether treatments for one disorder may exacerbate or cause the other disorders.

“From a clinical point of view, it is clear that women with vulvar disease should be queried about bladder and bowel pain, and treated accordingly,” Dr. Kennedy said.

She added that the study also showed that women with vulvar disease had nearly a fourfold higher risk of undergoing hysterectomy than did the general gynecology patients. “To our knowledge, ours is the first large clinic comparison to report this association,” she said.

WASHINGTON — Women who have vulvar disease should be asked specifically about bladder and bowel pain, and these symptoms also must be addressed, Colleen M. Kennedy, M.D., of the University of Iowa, Iowa City, advised.

Women with vulvar disease are twice as likely as are general gynecology patients to have bladder pain and bowel pain. “We hypothesize that certain vulvar or vaginal diseases are not isolated clinical entities, but rather represent symptoms of a global or generalized pelvic floor disorder—a pelvic floor pain disorder,” she said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Kennedy and her associates assessed the rates of painful bladder syndrome (interstitial cystitis) and irritable bowel syndrome in 324 women who were being treated at a vulvar disease clinic, and compared them with the rates among 321 control subjects attending a general gynecology clinic.

Of the women with vulvar disease, 12% reported bladder pain, compared with only 6% of control subjects. Similarly, 23% of those with vulvar disease were found to have bowel pain, compared with only 11% of control subjects.

Looked at another way, the data showed that women who reported bladder pain were 2.18 times more likely than were those who did not report bladder pain to have been treated for vulvar disease. Women with vulvar disease had a mean score of 20.3 on the Urinary Distress Inventory's pain subscale, compared with a mean score of 5.3 for women without vulvar disease.

Likewise, women with functional bowel disorders were 2.13 times more likely than were those who did not have bowel disorders to have been treated for vulvar disease.

The higher prevalence of painful bladder and painful bowel syndromes in women with vulvar disease may reflect a common etiology for all these disorders. The design of this study, however, didn't allow the researchers to tease out whether there is a common etiology “or whether treatments for one disorder may exacerbate or cause the other disorders.

“From a clinical point of view, it is clear that women with vulvar disease should be queried about bladder and bowel pain, and treated accordingly,” Dr. Kennedy said.

She added that the study also showed that women with vulvar disease had nearly a fourfold higher risk of undergoing hysterectomy than did the general gynecology patients. “To our knowledge, ours is the first large clinic comparison to report this association,” she said.

WASHINGTON — Women who have vulvar disease should be asked specifically about bladder and bowel pain, and these symptoms also must be addressed, Colleen M. Kennedy, M.D., of the University of Iowa, Iowa City, advised.

Women with vulvar disease are twice as likely as are general gynecology patients to have bladder pain and bowel pain. “We hypothesize that certain vulvar or vaginal diseases are not isolated clinical entities, but rather represent symptoms of a global or generalized pelvic floor disorder—a pelvic floor pain disorder,” she said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Kennedy and her associates assessed the rates of painful bladder syndrome (interstitial cystitis) and irritable bowel syndrome in 324 women who were being treated at a vulvar disease clinic, and compared them with the rates among 321 control subjects attending a general gynecology clinic.

Of the women with vulvar disease, 12% reported bladder pain, compared with only 6% of control subjects. Similarly, 23% of those with vulvar disease were found to have bowel pain, compared with only 11% of control subjects.

Looked at another way, the data showed that women who reported bladder pain were 2.18 times more likely than were those who did not report bladder pain to have been treated for vulvar disease. Women with vulvar disease had a mean score of 20.3 on the Urinary Distress Inventory's pain subscale, compared with a mean score of 5.3 for women without vulvar disease.

Likewise, women with functional bowel disorders were 2.13 times more likely than were those who did not have bowel disorders to have been treated for vulvar disease.

The higher prevalence of painful bladder and painful bowel syndromes in women with vulvar disease may reflect a common etiology for all these disorders. The design of this study, however, didn't allow the researchers to tease out whether there is a common etiology “or whether treatments for one disorder may exacerbate or cause the other disorders.

“From a clinical point of view, it is clear that women with vulvar disease should be queried about bladder and bowel pain, and treated accordingly,” Dr. Kennedy said.

She added that the study also showed that women with vulvar disease had nearly a fourfold higher risk of undergoing hysterectomy than did the general gynecology patients. “To our knowledge, ours is the first large clinic comparison to report this association,” she said.

Statin-Associated Rhabdomyolysis

The risk of rhabdomyolysis is relatively low for the three most frequently prescribed statins—atorvastatin, pravastatin, and simvastatin—but is 10 times higher for cerivastatin, which was taken off the market in August 2001. The risk is more than 5 times higher for fibrates than for statin monotherapy and 12 times higher if the two therapies are combined. Combining cerivastatin with fibrates raises the risk 1,400-fold.

These are some of the conclusions of “the first comprehensive study of rhabdomyolysis incidence associated with statin and fibrate therapy.” The study involved 252,460 patients who began treatment between 1998 and 2001 at 11 medical centers across the United States, reported David J. Graham, M.D., of the Food and Drug Administration, Rockville, Md., and his associates (JAMA 2004;292:2585-90).

Risk increased sharply among older patients and those with diabetes. The number of patients who needed to be treated per year for 1 case of rhabdomyolisis to develop was nearly 228,000 for montherapy with the three major statins, compared with 1 case per 484 for older patients who also had diabetes who took statins plus fibrates, and with 1 case in 10 for patients who took cerivastatin plus fibrates, the researchers said.

Percutaneous PFO Closure After Stroke

Percutaneous closure of a patent foramen ovale is at least as effective as medical therapy in preventing cerebrovascular recurrences among patients whose initial stroke presumably stemmed from the heart condition, according to Stephan Windecker, M.D., and his associates at the University Hospital Bern (Switzerland).

They studied 308 patients treated for cryptogenic stroke that was thought to be related to patent foramen ovale. A total of 158 patients received treatment with standard vitamin K antagonist or antiplatelet medications, while 150 received percutaneous closure with occlusive devices placed under local anesthesia (J. Am. Coll. Cardiol. 2004;44:750-8).

Overall, percutaneous closure was as effective as medication in preventing recurrent TIA or stroke over 4 years of follow-up. The procedure was significantly better in two subgroups of patients: those in whom the intervention induced complete closure of the foramen ovale (event rate of 6.5%, compared with 22.2% for medical therapy) and those who had a history of multiple strokes or TIAs (event rate of 7.3%, compared with 33.2% for medical therapy). This is the first study to compare the percutaneous procedure with medical treatment, and the results indicate that prospective randomized trials are warranted, the investigators said.

Take-Along Pill for Atrial Fibrillation

Patients with occasional atrial fibrillation may eventually be able to treat it by taking a single dose of an antiarrhythmic drug that they carry around with them for that purpose, much as angina patients take nitroglycerin when chest pain arises, according to Paolo Alboni, M.D., of Ospedale Civile, Cento, Italy, and his associates.

The feasibility of this “pill-in-the-pocket” approach was assessed in a study of 210 patients with mild or no heart disease whose AF episodes were infrequent and well-tolerated but lasted long enough to prompt the patients to go to emergency rooms. Over a mean follow-up of 15 months, both flecainide and propafenone interrupted palpitations in 534 of 569 AF episodes (94%), usually within 2 hours. Both drugs were effective for every AF episode in 139 of the 165 patients (84%) who had recurrences (N. Engl. J. Med. 2004;351:2384-91).

The mean number of ER visits for AF among the patients dropped from 45.6 to 4.9 per month, and the mean number of AF-related hospitalizations decreased from 15.0 to 1.6 per month. This approach proved feasible and safe, with a high rate of compliance and a very low incidence of adverse effects, the researchers said.

Biopsy IDs Drug-Induced Myocarditis

For the first time, endomyocardial biopsy was used to identify clozapine-induced hypersensitivity myocarditis in a patient who developed a throat infection, dyspnea, and cardiac enlargement while hospitalized for a schizophrenic break, according to Maurizio Pieroni, M.D., and his associates at San Raffaelel Hospital, Milan.

The 27-year-old man was admitted because resistance to his usual neuroleptic therapy had allowed psychotic symptoms to develop. The patient responded within 12 days to clozapine but on the 12th day developed symptoms that suggested either acute viral myocarditis or a hypersensitivity reaction to the drug. Clozapine-induced myocarditis is often fatal, so clozapine therapy was withdrawn, but it was also the best drug to curb the patient's psychosis (Chest 2004;126:1703-5).

Thus “endomyocardial biopsy was crucial to establish a correct diagnosis and appropriate treatment,” they said.

Statin-Associated Rhabdomyolysis

The risk of rhabdomyolysis is relatively low for the three most frequently prescribed statins—atorvastatin, pravastatin, and simvastatin—but is 10 times higher for cerivastatin, which was taken off the market in August 2001. The risk is more than 5 times higher for fibrates than for statin monotherapy and 12 times higher if the two therapies are combined. Combining cerivastatin with fibrates raises the risk 1,400-fold.

These are some of the conclusions of “the first comprehensive study of rhabdomyolysis incidence associated with statin and fibrate therapy.” The study involved 252,460 patients who began treatment between 1998 and 2001 at 11 medical centers across the United States, reported David J. Graham, M.D., of the Food and Drug Administration, Rockville, Md., and his associates (JAMA 2004;292:2585-90).

Risk increased sharply among older patients and those with diabetes. The number of patients who needed to be treated per year for 1 case of rhabdomyolisis to develop was nearly 228,000 for montherapy with the three major statins, compared with 1 case per 484 for older patients who also had diabetes who took statins plus fibrates, and with 1 case in 10 for patients who took cerivastatin plus fibrates, the researchers said.

Percutaneous PFO Closure After Stroke

Percutaneous closure of a patent foramen ovale is at least as effective as medical therapy in preventing cerebrovascular recurrences among patients whose initial stroke presumably stemmed from the heart condition, according to Stephan Windecker, M.D., and his associates at the University Hospital Bern (Switzerland).

They studied 308 patients treated for cryptogenic stroke that was thought to be related to patent foramen ovale. A total of 158 patients received treatment with standard vitamin K antagonist or antiplatelet medications, while 150 received percutaneous closure with occlusive devices placed under local anesthesia (J. Am. Coll. Cardiol. 2004;44:750-8).

Overall, percutaneous closure was as effective as medication in preventing recurrent TIA or stroke over 4 years of follow-up. The procedure was significantly better in two subgroups of patients: those in whom the intervention induced complete closure of the foramen ovale (event rate of 6.5%, compared with 22.2% for medical therapy) and those who had a history of multiple strokes or TIAs (event rate of 7.3%, compared with 33.2% for medical therapy). This is the first study to compare the percutaneous procedure with medical treatment, and the results indicate that prospective randomized trials are warranted, the investigators said.

Take-Along Pill for Atrial Fibrillation

Patients with occasional atrial fibrillation may eventually be able to treat it by taking a single dose of an antiarrhythmic drug that they carry around with them for that purpose, much as angina patients take nitroglycerin when chest pain arises, according to Paolo Alboni, M.D., of Ospedale Civile, Cento, Italy, and his associates.

The feasibility of this “pill-in-the-pocket” approach was assessed in a study of 210 patients with mild or no heart disease whose AF episodes were infrequent and well-tolerated but lasted long enough to prompt the patients to go to emergency rooms. Over a mean follow-up of 15 months, both flecainide and propafenone interrupted palpitations in 534 of 569 AF episodes (94%), usually within 2 hours. Both drugs were effective for every AF episode in 139 of the 165 patients (84%) who had recurrences (N. Engl. J. Med. 2004;351:2384-91).

The mean number of ER visits for AF among the patients dropped from 45.6 to 4.9 per month, and the mean number of AF-related hospitalizations decreased from 15.0 to 1.6 per month. This approach proved feasible and safe, with a high rate of compliance and a very low incidence of adverse effects, the researchers said.

Biopsy IDs Drug-Induced Myocarditis

For the first time, endomyocardial biopsy was used to identify clozapine-induced hypersensitivity myocarditis in a patient who developed a throat infection, dyspnea, and cardiac enlargement while hospitalized for a schizophrenic break, according to Maurizio Pieroni, M.D., and his associates at San Raffaelel Hospital, Milan.

The 27-year-old man was admitted because resistance to his usual neuroleptic therapy had allowed psychotic symptoms to develop. The patient responded within 12 days to clozapine but on the 12th day developed symptoms that suggested either acute viral myocarditis or a hypersensitivity reaction to the drug. Clozapine-induced myocarditis is often fatal, so clozapine therapy was withdrawn, but it was also the best drug to curb the patient's psychosis (Chest 2004;126:1703-5).

Thus “endomyocardial biopsy was crucial to establish a correct diagnosis and appropriate treatment,” they said.

Statin-Associated Rhabdomyolysis

The risk of rhabdomyolysis is relatively low for the three most frequently prescribed statins—atorvastatin, pravastatin, and simvastatin—but is 10 times higher for cerivastatin, which was taken off the market in August 2001. The risk is more than 5 times higher for fibrates than for statin monotherapy and 12 times higher if the two therapies are combined. Combining cerivastatin with fibrates raises the risk 1,400-fold.

These are some of the conclusions of “the first comprehensive study of rhabdomyolysis incidence associated with statin and fibrate therapy.” The study involved 252,460 patients who began treatment between 1998 and 2001 at 11 medical centers across the United States, reported David J. Graham, M.D., of the Food and Drug Administration, Rockville, Md., and his associates (JAMA 2004;292:2585-90).

Risk increased sharply among older patients and those with diabetes. The number of patients who needed to be treated per year for 1 case of rhabdomyolisis to develop was nearly 228,000 for montherapy with the three major statins, compared with 1 case per 484 for older patients who also had diabetes who took statins plus fibrates, and with 1 case in 10 for patients who took cerivastatin plus fibrates, the researchers said.

Percutaneous PFO Closure After Stroke

Percutaneous closure of a patent foramen ovale is at least as effective as medical therapy in preventing cerebrovascular recurrences among patients whose initial stroke presumably stemmed from the heart condition, according to Stephan Windecker, M.D., and his associates at the University Hospital Bern (Switzerland).

They studied 308 patients treated for cryptogenic stroke that was thought to be related to patent foramen ovale. A total of 158 patients received treatment with standard vitamin K antagonist or antiplatelet medications, while 150 received percutaneous closure with occlusive devices placed under local anesthesia (J. Am. Coll. Cardiol. 2004;44:750-8).

Overall, percutaneous closure was as effective as medication in preventing recurrent TIA or stroke over 4 years of follow-up. The procedure was significantly better in two subgroups of patients: those in whom the intervention induced complete closure of the foramen ovale (event rate of 6.5%, compared with 22.2% for medical therapy) and those who had a history of multiple strokes or TIAs (event rate of 7.3%, compared with 33.2% for medical therapy). This is the first study to compare the percutaneous procedure with medical treatment, and the results indicate that prospective randomized trials are warranted, the investigators said.

Take-Along Pill for Atrial Fibrillation

Patients with occasional atrial fibrillation may eventually be able to treat it by taking a single dose of an antiarrhythmic drug that they carry around with them for that purpose, much as angina patients take nitroglycerin when chest pain arises, according to Paolo Alboni, M.D., of Ospedale Civile, Cento, Italy, and his associates.

The feasibility of this “pill-in-the-pocket” approach was assessed in a study of 210 patients with mild or no heart disease whose AF episodes were infrequent and well-tolerated but lasted long enough to prompt the patients to go to emergency rooms. Over a mean follow-up of 15 months, both flecainide and propafenone interrupted palpitations in 534 of 569 AF episodes (94%), usually within 2 hours. Both drugs were effective for every AF episode in 139 of the 165 patients (84%) who had recurrences (N. Engl. J. Med. 2004;351:2384-91).

The mean number of ER visits for AF among the patients dropped from 45.6 to 4.9 per month, and the mean number of AF-related hospitalizations decreased from 15.0 to 1.6 per month. This approach proved feasible and safe, with a high rate of compliance and a very low incidence of adverse effects, the researchers said.

Biopsy IDs Drug-Induced Myocarditis

For the first time, endomyocardial biopsy was used to identify clozapine-induced hypersensitivity myocarditis in a patient who developed a throat infection, dyspnea, and cardiac enlargement while hospitalized for a schizophrenic break, according to Maurizio Pieroni, M.D., and his associates at San Raffaelel Hospital, Milan.

The 27-year-old man was admitted because resistance to his usual neuroleptic therapy had allowed psychotic symptoms to develop. The patient responded within 12 days to clozapine but on the 12th day developed symptoms that suggested either acute viral myocarditis or a hypersensitivity reaction to the drug. Clozapine-induced myocarditis is often fatal, so clozapine therapy was withdrawn, but it was also the best drug to curb the patient's psychosis (Chest 2004;126:1703-5).

Thus “endomyocardial biopsy was crucial to establish a correct diagnosis and appropriate treatment,” they said.