<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_189"
                     title="Tailoring Trumps Targeting for Cholesterol Control (CME/CE)"
                     score="-0.004"
                     href="http://www.medpagetoday.com/Cardiology/Dyslipidemia/tb/18023?impressionId=1265812933523"
                     
      &lt;p&gt;Lipid control is more than a simple matter of &quot;knowing your numbers,&quot; according to a computer model that found tailoring statin therapy to fit an individual&apos;s five-year risk of heart attack or stroke is a better prevention strategy than treating to preset goals.&lt;/p&gt;
&lt;p&gt;In the model, patients who whose five-year coronary artery disease risk was 5% to 15% received 40 mg of simvastatin (Zocor), while those whose risk was greater were given 40 mg of atorvastatin (Lipitor).&lt;/p&gt;
&lt;p&gt;In every scenario, the tailored approach was preferable, Rodney A. Hayward, MD, of the University of Michigan and the Veterans Affairs Ann Arbor Healthcare System, and colleagues wrote in the Jan. 19 &lt;em&gt;Annals of Internal Medicine.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;While treating-to-target is appealingly simple, that simplicity may be its main limitation, the researchers argued.&lt;/p&gt;
&lt;p&gt;Treating to a single target means that one risk factor receives &quot;dramatically more weight than all other predictors of treatment benefit, resulting in other highly relevant information being either ignored or underweighted,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;That approach, tailoring treatment to reflect multiple risk factors rather than treating-to-target, is an &quot;interesting&quot; one, according to Christopher Cannon, MD, of Brigham and Women&apos;s Hospital in Boston, who was not involved in the study.&lt;/p&gt;
&lt;p&gt;But Cannon, principal investigator of a number of statin trials, said the idea may be a little too late to impact clinical practice.&lt;/p&gt;
&lt;p&gt;&quot;The guidelines won&apos;t shift to this approach any time soon, and in two years, atorvastatin will be generic, so all patients can inexpensively be treated with more intensive therapy (which is better for everyone at all risk levels),&quot; Cannon wrote in an e-mail.&lt;/p&gt;
&lt;p&gt;Although intensive therapy may be better as a rule, he conceded, it&apos;s less cost-effective when an expensive drug is used. When atorvastatin becomes available as a generic, he wrote, for &quot;$4 a month at Walmart it is simply cheaper  --  and of course better  --  to treat everyone with atorvastatin 80 mg.&quot;&lt;/p&gt;
&lt;p&gt;Assuming a population of Americans ages 30 to 75 with no history of myocardial infarction, the authors developed three treatment models: &lt;ul&gt; &lt;li&gt;Standard National Cholesterol Education Program III (NCEP) treat-to-target recommendation, which requires treatment to an LDL target of less than 190 mg/dL for low-risk individuals, less than 160 mg/dL for moderate-risk, and less than 130 mg/dL for high-risk individuals&lt;/li&gt; &lt;li&gt;Intensive NCEP III treat-to-target approach, with targets of less than 100 mg/dL for high-risk individuals&lt;/li&gt; &lt;li&gt;The tailored model, with 40 mg of simvastatin for patients who whose five-year coronary artery disease risk was 5% to 15% and 40 mg of atorvastatin (Lipitor) for higher-risk patients&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;(In both NCEP III strategies statins would be used in a stepwise fashion  --  20 mg simvastatin, 40 mg simvastatin, 40 mg atorvastatin, and, finally, 80 mg atorvastatin  --  to achieve targets).&lt;/p&gt;
&lt;p&gt;Using standard NCEP III treat-to-target recommendations, &quot;37.9 million U.S. persons should receive statins, of which 7.9 million should receive high dose-potency therapy (atorvastatin 40 to 80 mg),&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;Compared with no treatment, the standard strategy would save an estimated 48 quality adjusted life years (QALYs) per 1,000 Americans treated for five years, or a total of 1.83 million total QALYs.&lt;/p&gt;
&lt;p&gt;The intensive NCEP III treat-to-target recommendations would &quot;recommend that 53.4 million U.S. persons receive statins&quot; and would save about 570,000 more QALYs than the standard treatment.&lt;/p&gt;
&lt;p&gt;Using the computer model, this strategy prevented &quot;about 720,000 more nonfatal CAD events and 30,000 more deaths&quot; than the standard treatment.&lt;/p&gt;
&lt;p&gt;Tailored treatment, by contrast, would require that about the same number of people receive a statin  --  53 million. But only 13.3 million would require high-dose statin therapy, versus roughly 18 million who would be given high-dose statin therapy using the intensive NCEP III strategy.&lt;/p&gt;
&lt;p&gt;Even so, the tailored approach would save 520,000 more QALYs than the intensive treatment approach, the authors found.&lt;/p&gt;
&lt;p&gt;&quot;The tailored treatment approach was superior to both NCEP III approaches, resulting in both more CAD morbidity and mortality prevented in the overall population and higher treatment efficiency (greater benefit per person treated),&quot; they wrote.&lt;/p&gt;
&lt;p&gt;The authors noted a number of limitations, including the paucity of clinical trial data on statin therapy in persons ages 75 or older.&lt;/p&gt;
&lt;p&gt;Moreover, although the model suggested a robust benefit for tailored treatment, &quot;the absolute population-level benefit of the tailored treatment over the treat-to-target approaches are much less certain and can vary substantially on the basis of several factors, such as statin&apos;s effect on total mortality (estimates of which are less precise in the literature than estimates for nonfatal CAD events) and the level of treatment adherence that is achievable in real-world clinical practice.&lt;/p&gt;
&lt;p&gt;&quot;Whether a tailored treatment approach is superior for other conditions in which treat-to-target strategies are currently recommended, such as blood pressure and glycemic control, warrants examination,&quot; they concluded.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded in part by the Department of Veteran Affairs Health Services Research &amp;amp; Development Service&apos;s Quality Enhancement Research Initiative.&lt;/p&gt;&lt;p&gt;Hayward did not report any financial disclosures.&lt;/p&gt;&lt;p&gt;Cannon reported receiving research/grants/suport from Accumetrics, AstraZeneca, Bristol-Myers Squibb/Sanofi Partnership, GlaxoSmithKline, Intekrin Therapeutics, Merck, Merck/Schering-Plough Partnership, Novartis, and Takeda. He is a clinical adviser with equity in Automedics Medical Systems.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_3346"
                     title="Heart Disease Raises Hip Fracture Risk (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Cardiology/CoronaryArteryDisease/tb/16546?impressionId=1265812933523"
                     
      &lt;p&gt;A diagnosis of cardiovascular disease (CVD) significantly increased the risk of subsequent hip fracture in both women and men, a Swedish twin study found.&lt;/p&gt;
&lt;p&gt;The crude absolute rate of hip fracture was 12.6 per 1,000 person-years among patients diagnosed with heart failure or stroke, compared with 1.2 per 1,000 person-years among those without CVD, according to Ulf Sennerby, MD, of Uppsala University in Sweden, and colleagues.&lt;/p&gt;
&lt;p&gt;The rates were 6.6 per 1,000 person-years after a diagnosis of peripheral atherosclerosis and 5.2 after a diagnosis of ischemic heart disease, respectively, the researchers reported in the Oct. 21 issue of the &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Stroke has been widely recognized as a risk factor for hip fracture, in part because of resulting hemiplegia and immobility, but an underlying genetic predisposition may exist for CVD and osteoporosis.&lt;/p&gt;
&lt;p&gt;The researchers turned to the Swedish Twin Registry  --  the largest such registry in the world  --  to determine whether the risk for hip fracture is also increased in other types of CVD and to look for evidence of a genetic connection.&lt;/p&gt;
&lt;p&gt;Their analysis included 15,968 twin pairs who were 50 years old at study entry and were followed until the date of a hip fracture, death, or study conclusion in December 2005.&lt;/p&gt;
&lt;p&gt;Hip fracture was diagnosed in 1,442 patients during the course of the study, 70% of whom were women.&lt;/p&gt;
&lt;p&gt;Multivariable analysis found the following adjusted hazard ratios for hip fracture: &lt;ul&gt; &lt;li&gt;Heart failure, HR 4.40 (95% CI 3.43 to 5.63)&lt;/li&gt; &lt;li&gt;Overall stroke, HR 5.09 (95% CI 4.18 to 6.20)&lt;/li&gt; &lt;li&gt;Ischemic stroke, HR 4.95 (95% CI 4.07 to 6.02)&lt;/li&gt; &lt;li&gt;Hemorrhagic stroke, HR 5.48 (95% CI 3.68 to 8.15)&lt;/li&gt; &lt;li&gt;Peripheral atherosclerosis, HR 3.20 (95% CI 2.28 to 4.50)&lt;/li&gt; &lt;li&gt;Ischemic heart disease, HR 2.32 (95% CI 1.91 to 2.84)&lt;/li&gt; &lt;li&gt;Acute myocardial infarction, HR 2.42 (95% CI 1.85 to 3.17)&lt;/li&gt; &lt;li&gt;Hypertension, HR 1.59 (95% CI 1.36 to 1.85)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Rates were comparable between the sexes except following overall stroke, when men tended to have a higher risk (HR 6.65, 95% CI 4.82 to 9.19) compared with women (HR 4.42, 95% CI 3.49 to 5.61).&lt;/p&gt;
&lt;p&gt;The investigators also calculated 10-year absolute risks for hip fracture according to age and sex, and found that a 75-year-old woman had an 18% risk (95% CI 13 to 22) for fracture within 10 years after a diagnosis of heart failure, while the risk for a man of that age was 10% (95% CI 7 to 14).&lt;/p&gt;
&lt;p&gt;And a 75-year-old woman with a stroke had a 19% 10-year risk (95% CI 15 to 23) for fracture, while a man had a 15% risk (95% CI 12 to 19).&lt;/p&gt;
&lt;p&gt;The highest rates of hip fracture were seen during the first year after heart failure or stroke, which may relate to immobility as well as muscle and bone loss, the researchers said.&lt;/p&gt;
&lt;p&gt;They also looked at fracture risk as related to zygosity, and found that in identical twin pairs where only one sibling had heart failure, the other also had a fourfold increased risk of hip fracture. When only one had a stroke, the other had a doubled risk of hip fracture.&lt;/p&gt;
&lt;p&gt;These increases were &quot;less pronounced&quot; among dizygotic twins when only one had a cardiovascular event, supporting the likelihood of genetic influences, the investigators observed.&lt;/p&gt;
&lt;p&gt;Although the study was not designed to fully explore the shared pathophysiologic mechanisms between CVD and fractures, possible contributing factors might include telomere lengths and genes associated with matrix proteins supporting bone, blood vessel walls, and the myocardium, the researchers said.&lt;/p&gt;
&lt;p&gt;Hormones, proteins involved in lipid metabolism, and chronic inflammation also may contribute, they noted.&lt;/p&gt;
&lt;p&gt;Strengths of the study include its population-based design, inclusion of both sexes, and large number of events.&lt;/p&gt;
&lt;p&gt;Limitations include reliance on telephone interviews for information on body weight, smoking, physical activity, and medications.&lt;/p&gt;
&lt;p&gt;The investigators concluded that clinicians should be aware of the risks for fracture in patients with cardiovascular disease, particularly after hospitalization.&lt;/p&gt;
&lt;p&gt;&quot;We advocate that individuals with a recent diagnosis of CVD should have their future fracture risk evaluated with clinical risk factors and bone scans,&quot; they wrote.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the National Institutes of Health and the Swedish Research Council.&lt;/p&gt;&lt;p&gt;No financial disclosures were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_5_219"
                     title="Loop Diuretics Linked to Hip Bone Loss in Older Men"
                     score="-0.005"
                     href="