<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_3244"
                     title="ESC: Pre-Procedure Statins May Cut MI Risk (CME/CE)"
                     score="0.014"
                     href="http://www.medpagetoday.com/MeetingCoverage/ESCCongress/tb/22001?impressionId=1283457929229"
                     
      &lt;p&gt;STOCKHOLM  --  Statins delivered before invasive procedures appear to reduce the occurrence of cardiovascular events, a meta-analysis showed.&lt;/p&gt;
&lt;p&gt;In pooled data from 21 trials, giving statins before percutaneous coronary intervention (PCI), CABG, or noncardiac surgery resulted in a reduction in post-procedural MI (RR 0.57, 95% CI 0.46 to 0.70), according to Anthony Bavry, MD, MPH, of the University of Florida, in Gainesville.&lt;/p&gt;
&lt;p&gt;The reduction in MI was significant only after PCI (7.5% versus 13.3%) and noncardiac surgical procedures (3.5% versus 7.6%; &lt;em&gt;P&lt;/em&gt;&amp;lt;0.05 for both).&lt;/p&gt;
&lt;p&gt;Bavry reported the findings, which were also published online in the &lt;em&gt;Journal of the American College of Cardiology&lt;/em&gt;, at the European Society of Cardiology Congress here.&lt;/p&gt;
&lt;p&gt;&quot;The routine use of statins before invasive procedures should be considered,&quot; he and his colleagues wrote in their paper.&lt;/p&gt;
&lt;p&gt;Current guidelines for CABG, elective PCI, and acute coronary syndrome recommend statins only for use after such procedures.&lt;/p&gt;
&lt;p&gt;&quot;None of these guidelines specifically recommend the use of statins before invasive procedures for the express purpose of preventing periprocedural complications such as MI and atrial fibrillation,&quot; the researchers wrote. &quot;Our analysis adds strength to current recommendations and potentially expands the use of these agents before PCI and surgical procedures.&quot;&lt;/p&gt;
&lt;p&gt;Bavry and his colleagues conducted a meta-analysis of 21 randomized controlled trials involving 4,805 patients in which statins were administered one to seven days before PCI, CABG, or noncardiac surgery. The control interventions included placebo, usual care, or lower doses of statins.&lt;/p&gt;
&lt;p&gt;PCI was usually elective, although four studies included patients with acute coronary syndrome.&lt;/p&gt;
&lt;p&gt;Most of the patients had never received statins before, but one study included patients on long-term statin therapy.&lt;/p&gt;
&lt;p&gt;The reduction in post-procedural MI observed with pre-procedural statins was strengthened when only placebo-controlled trials were considered (RR 0.43).&lt;/p&gt;
&lt;p&gt;Pre-procedural statins also reduced post-CABG atrial fibrillation (19% versus 37%; RR 0.54, 95% CI 0.43 to 0.68), although they did not affect all-cause mortality (RR 0.66, 95% CI 0.37 to 1.17).&lt;/p&gt;
&lt;p&gt;The researchers noted in their paper that the optimal dose, statin type, and timing were unclear.&lt;/p&gt;
&lt;p&gt;&quot;Only a dedicated trial specifically exploring the relationship of dose and type of statin therapy before invasive procedures can answer this question,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;The studies included in the meta-analysis did not report adverse effects, so the researchers could not perform a formal analysis of potential drawbacks to pre-procedural statin use. They noted, however, that statins have a well-established safety record.&lt;/p&gt;
&lt;p&gt;In an accompanying editorial, Kim Eagle, MD, and Vineet Chopra, MD, of the University of Michigan, in Ann Arbor, wrote that the benefits of statins in this context likely came from their pleiotropic effects  --  the enhancement of endothelial function, stabilization of vulnerable plaque, and reduction in adhesion molecules and circulating biomarkers.&lt;/p&gt;
&lt;p&gt;&quot;Therefore, before endothelial injury during coronary procedures, statin treatment likely mitigates the inflammatory cascade by decreasing vascular reactivity and stabilizing plaque, both at the site of intervention and at other &apos;vulnerable&apos; lesions,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;Eagle and Chopra said that it appears statins should be routinely given to patients before undergoing coronary procedures, although questions remain regarding optimal dose and type of statin and whether such a strategy&lt;strong&gt; &lt;/strong&gt;would work in all patient subgroups. Also, they said the possibility of adverse effects still needs to be explored.&lt;/p&gt;
&lt;p&gt;Nevertheless, they wrote, &quot;Given the strong biological rationale and the sum of the clinical data, no patient should undergo coronary procedures without statin therapy unless clear contraindications exist. Indeed, it is time to consider a new indication for an old friend.&quot;&lt;/p&gt;
&lt;p&gt;Bavry and his colleagues acknowledged some limitations of the analysis, including the use of a control group mixing placebo, usual care, and lower statin doses, the fact that some of the surgical trials did not include MI as a primary outcome, and the lack of information on some of the methodological characteristics of the trials, like blinding or randomization technique.&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 supported by an unrestricted grant from the Florida Heart Research Institute.&lt;/p&gt;&lt;p&gt;The study authors and the editorialists reported that they did not have any conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_3217"
                     title="Cardiac Rehab Measures Updated"
                     score="0.014"
                     href="http://www.medpagetoday.com/Cardiology/MyocardialInfarction/tb/21966?impressionId=1283457929229"
                     
      &lt;p&gt;A coalition of major cardiology and pulmonary organizations has updated performance measures with the aim of increasing appropriate and timely referral of patients for cardiac rehabilitation.&lt;/p&gt;
&lt;p&gt;The update  --  a collaborative effort from the American Association of Cardiovascular and Pulmonary Rehabilitation, the American College of Cardiology Foundation, and the American Heart Association  --  clarified two measures that describe opportunities to improve referral to cardiac rehabilitation programs.&lt;/p&gt;
&lt;p&gt;It was published online in the &lt;em&gt;Journal of the American College of Cardiology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;The basic thrust of the updated performance measures remains the same as the original version published jointly in 2007 by the American College of Chest Physicians and the AHA.&lt;/p&gt;
&lt;p&gt;Currently, only 20% of patients who could benefit from cardiac rehabilitation are referred to outpatient rehabilitation facilities.&lt;/p&gt;
&lt;p&gt;&quot;The gap in referral of patients to cardiac rehabilitation represents the largest gap in care for patients following a cardiac event,&quot; Randal J. Thomas, MD, of the Mayo Clinic in Rochester, Minn., and chair of the performance measures writing committee, said in a statement.&lt;/p&gt;
&lt;p&gt;&quot;The updated measures will hopefully help to improve the health of patients with heart disease by increasing the number of eligible patients who are referred to and receive the lifesaving benefits of cardiac rehabilitation,&quot; said Thomas.&lt;/p&gt;
&lt;p&gt;In addition to the members of the writing committee, 10 other national and international organizations endorsed the update, which will appear in September print editions of both &lt;em&gt;JACC&lt;/em&gt; and &lt;em&gt;Circulation&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;The update is limited to Measure Set A, which addresses referral for cardiac rehabilitation. No changes were made to Set B, which pertains to structure and process of care.&lt;/p&gt;
&lt;p&gt;Three changes to Measure A-1 (patient referral from an inpatient setting) pertain to &quot;numerator exclusion criteria&quot; and associated examples. The phrase &quot;patient-oriented barriers&quot; was reworded as &quot;patient-oriented factors.&quot;&lt;/p&gt;
&lt;p&gt;The writing committee decided that patient refusal does not constitute a reason not to refer because &quot;whether the patient chooses at act upon referral or not is beyond the provider&apos;s control.&quot; Instead, the committee offered patients discharged to a nursing-care facility as an example of patients who can be excluded from referral.&lt;/p&gt;
&lt;p&gt;The committee made similar revisions to &quot;provider-oriented barriers&quot; (medical factors) and &quot;healthcare system barriers&quot; (healthcare system factors).&lt;/p&gt;
&lt;p&gt;Patients with a &quot;high-risk condition or a contraindication to exercise&quot; were specified in 2007 as an example of appropriate medical exclusion. The 2010 update specifies &quot;medically unstable, life-threatening condition&quot; as an example of appropriate exclusion from cardiac rehabilitation.&lt;/p&gt;
&lt;p&gt;In the section of healthcare system factors, the writing committee deleted &quot;financial barriers,&quot; and the phrase &quot;lack of CR programs near a patient&apos;s home&quot; was clarified to specific lack of a program within 60 minutes&apos; travel time from the patient&apos;s home.&lt;/p&gt;
&lt;p&gt;Patients discharged for a brief period of inpatient rehabilitation should still be referred to an outpatient program during the initial hospitalization.&lt;/p&gt;
&lt;p&gt;The writing committee also updated the section on corresponding guidelines and clinical recommendations to reflect the latest versions of the guidelines cited.&lt;/p&gt;
&lt;p&gt;Measure A-2 (referral from an outpatient setting) was revised to clarify and expand on the discussion of &quot;what constitutes a referral.&quot; The writing committee also revised patient, medical, and health-system factors in the same manner as in Measure A-1.&lt;/p&gt;
&lt;p&gt;The update specifies that referral should include only those patients who have had a qualifying event or diagnosis within the past 12 months and have not participated in an outpatient cardiac rehabilitation program.&lt;/p&gt;
&lt;p&gt;The writing committee made other revisions to clarify responsibilities for reporting measures.&lt;/p&gt;
&lt;p&gt;The updated performance measures are available at www.cardiosource.org, www.americanheart.org, and www.aacvpr.org.&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;Thomas had no relevant disclosures. Co-author Nell Oldridge disclosed a copyright interest. Co-author Ileana L. Pi&amp;#241;a disclosed relationships with sanofi-aventis, AstraZeneca, Merck, and Novartis. Co-author John Spertus disclosed relationships with St. Jude Medical, United Healthcare, PRISM Technology, Amgen, Bristol-Myers Squibb, sanofi-aventis, Johnson &amp;amp; Johnson, and Eli Lilly, as well as copyright and ownership interests.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_3191"
                     title="ESC: It&apos;s Not Butter and It&apos;s Not Better (CME/CE)"
                     score="0.013"
                     href="http://www.medpagetoday.com/MeetingCoverage/ESCCongress/tb/21921?impressionId=1283457929229"
                     
      STOCKHOLM  --  Adding margarine enriched with omega-3 fatty acids as a dietary intervention did not prevent second heart attacks in older men and women at risk for worsening heart disease, researchers said here.&lt;br&gt;
&lt;br&gt;The study results are doubly disappointing since the margarine intervention did initially reduce events, but by 30 months the evidence of that benefit had disappeared, said Daan Kromhout, MPH, PhD, of Wageningen University in the Netherlands.&lt;br&gt;
&lt;br&gt;After more than 40 months, consumption of the omega-3 fatty acid fortified margarines &quot;had no effect on the rate of major cardiovascular events,&quot; he reported at a Hot Line session today at the European Society of Cardiology meeting. The findings were simultaneously published online by the &lt;em&gt;New England Journal of Medicine.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;The ALPHA-OMEGA trial randomized 4,837 MI survivors, 60 to 80 years old, to margarine supplemented with a combination of eicosapentaenoic acid and docosahexaenoic acid (EPA and DHA), or with 2 grams of the plant-derived fatty acid alpha-linolenic acid (ALA), or a third supplemented with all three versus a placebo margarine.&lt;/p&gt;
&lt;p&gt;The primary endpoint was the combined rate of fatal and non-fatal cardiovascular events and cardiac interventions.&lt;/p&gt;
&lt;p&gt;Neither EPA-DHA nor ALA reduced this endpoint, the researchers reported (hazard ratio with EPA-DHA, 1.01; 95% confidence interval 0.87 to 1.17, &lt;em&gt;P &lt;/em&gt;=0.93).&lt;/p&gt;
&lt;p&gt;A prespecified subgroup analysis in women found that use of the ALA-fortified margarine reduced the rate of cardiovascular events compared with placebo or with the EPA-DHA margarine, but the difference failed to reach statistical significance (HR 0.73, 95% CI 0.51 to 1.03, &lt;em&gt;P&lt;/em&gt;=0.07).&lt;/p&gt;
&lt;p&gt;Alfred Bove, MD, of Temple University in Philadelphia, said the findings surprised him &quot;because most of the data on omega-3 fatty acids come from epidemiologic studies and those were positive.&quot;&lt;/p&gt;
&lt;p&gt;He likened the situation to hormone therapy, which had been widely recommended to reduce cardiovascular risk in postmenopausal women based on data from epidemiologic studies.&lt;/p&gt;
&lt;p&gt;That hypothesis was initially questioned when a randomized controlled trial (Estrogen/Progestin Replacement Study [HERS]) linked hormones to increased risk of events. The HERS finding was confirmed in the landmark Women&apos;s Health Initiative trial in which ischemic events were more common among women randomized to estrogen/progestin.&lt;/p&gt;
&lt;p&gt;R. Scott Wright, MD, of the Mayo Clinic in Rochester, Minn., told &lt;em&gt;MedPage Today&lt;/em&gt; that the trial design was faulty, in that margarine was a bad choice of vehicle for omega-3 fatty acids.&lt;/p&gt;
&lt;p&gt;&quot;It needs to be combined with another food  --  bread,&quot; he said. &quot;So this not a good option for Americans because it would mean eating more bread, which is likely to lead to weight gain and bread is high in sodium, so blood pressure would be a factor.&quot;&lt;/p&gt;
&lt;p&gt;Wright noted that the ALPHA-OMEGA study did not include information on weight or blood pressure, so he considered the findings at best incomplete.&lt;/p&gt;
&lt;p&gt;All of the patients received &quot;state-of-the-art antihypertensive, antithrombotic, and lipid-modifying therapy,&quot; according to Kromhout and colleagues, in addition to margarine, and it may have been that optimal therapy that limited the potential for an omega-3 benefit.&lt;/p&gt;
&lt;p&gt;Statin therapy, along with other improvements in cardiovascular care, means &quot;a beneficial effect of low doses of EPA-DHA is difficult to prove,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;Wright said he wasn&apos;t persuaded by that explanation since, even after optimal therapy, there is about a 30% residual risk. &quot;There is plenty of room to show a benefit,&quot; he declared.&lt;/p&gt;
&lt;p&gt;Most of the patients in ALPHA-OMEGA were men (78%) and 24% were obese, but they differed from the typical high-risk American in at least one way: at baseline they consumed about three times more fish than does the typical American, a median of 15 grams a day.&lt;/p&gt;
&lt;p&gt;According to a report from the Environmental Protection Agency, average fish consumption in the U.S. works out to 4.58 &amp;#177; 0.42 grams a day.&lt;/p&gt;
&lt;p&gt;The authors conducted a post hoc exploratory analysis in patients with diabetes, finding significant reductions in events among patients in the EPA-DHA group. But the authors noted that &quot;[the] results with respect to patients with diabetes are only hypothesis-generating and do not permit definitive conclusions to be drawn.&quot;&lt;/p&gt;
&lt;p&gt;Bove, a former president of the American College of Cardiology, added that the results from the subset analysis in diabetics was reassuring, since patients with diabetes and elevated triglycerides are the patients that &quot;we have believed would be most likely to benefit&quot; from omega-3 fatty acids.&lt;/p&gt;
&lt;p&gt;The margarines used in the trial were supplied by Unilever, an international maker of food and consumer goods, and included the well-known &quot;I Can&apos;t Believe It&apos;s Not Butter,&quot; which contains 420 mg of ALA per serving.&lt;/p&gt;

&lt;p&gt;In a statement released after the ALPHA-OMEGA trial findings were presented, Unilever said the &quot;study outcome for EPA and DHA is surprising considering the weight of evidence published to date. This could be the result of methodological issues such as the relatively low daily dosage compared with previous studies or the fact that in this study serious cardiovascular events were much lower than in studies performed in the past. This is probably due to extensive drug treatment that is nowadays applied. The finding needs further study, but given the totality of evidence does not immediately impact the current advice on fish and fish oil consumption for prevention of cardiovascular disease.&quot;&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 trial was supported by the Netherlands Heart Foundation, the National Institutes of Health, and Unilever.&lt;/p&gt;&lt;p&gt;Kromhout reported that his institution received grant support form Unilever to cover distribution of the trial margarines to patients. His institution also received a grant from the Product Board for Margarine Fats and Oils to support research on polyunsaturated fats and cardiovascular diseases done by a PhD student.&lt;/p&gt;&lt;p&gt;Bove said he had no financial conflicts.&lt;/p&gt;&lt;p&gt;Wright said he consults for Roche and Genentech and conducts trial work for 3M/Littman.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_3248"
                     title="Increased Cardiac Events Seen With Sibutramine (CME/CE)"
                     score="0.012"
                     href="http://www.medpagetoday.com/Cardiology/MyocardialInfarction/tb/22008?impressionId=1283457929229"
                     
      &lt;p&gt;Overweight patients with cardiovascular risks who took the weight-loss drug sibutramine (Meridia) had a 16% increased likelihood of experiencing a cardiac event, a large randomized trial found.&lt;/p&gt;
&lt;p&gt;The overall hazard ratio for a fatal or nonfatal cardiovascular event was 1.16 (95% CI 1.03 to 1.31, &lt;em&gt;P&lt;/em&gt;=0.02) among patients receiving sibutramine compared with those receiving placebo, according to W. Philip T. James, MD, of the London School of Hygiene and Tropical Medicine, and colleagues.&lt;/p&gt;
&lt;p&gt;Specifically, the hazard ratio for nonfatal myocardial infarction was 1.28 (95% CI 1.04 to 1.57, &lt;em&gt;P&lt;/em&gt;=0.02), and the hazard ratio for nonfatal stroke was 1.36 (95% CI 1.04 to 1.77, &lt;em&gt;P&lt;/em&gt;=0.03), the researchers reported in the Sept. 1 &lt;em&gt;New England Journal of Medicine&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;A &lt;a href=&quot;http://www.medpagetoday.com/ProductAlert/Prescriptions/17147&quot; mce_href=&quot;http://www.medpagetoday.com/ProductAlert/Prescriptions/17147&quot; target=&quot;_blank&quot;&gt;preliminary analysis&lt;/a&gt;&lt;a target=&quot;_blank&quot;&gt; &lt;/a&gt;of data from the SCOUT (Sibutramine Cardiovascular Outcomes) trial previously suggested this increased risk, and the FDA required stronger &lt;a href=&quot;http://www.medpagetoday.com/ProductAlert/DevicesandVaccines/18088&quot; mce_href=&quot;http://www.medpagetoday.com/ProductAlert/DevicesandVaccines/18088&quot; target=&quot;_blank&quot;&gt;cautionary language&lt;/a&gt; in the drug&apos;s labeling.&lt;/p&gt;
&lt;p&gt;The final publication has now confirmed it, with James and colleagues stating, &quot;On the basis of these results, sibutramine should continue to be excluded from use in patients with preexisting cardiovascular disease.&quot;&lt;/p&gt;
&lt;p&gt;Sibutramine is a norepinephrine and serotonin reuptake inhibitor that has sympathomimetic effects and therefore can increase blood pressure and pulse rate. Because even small increases in blood pressure and pulse rate are associated with an increased likelihood of cardiovascular events, the SCOUT investigators wanted to determine the drug&apos;s long-term cardiovascular risk.&lt;/p&gt;
&lt;p&gt;They enrolled 9,804 obese or overweight patients who were at least 55 years old. All participants had a history of cardiovascular disease and/or type 2 diabetes.&lt;/p&gt;
&lt;p&gt;The study consisted of a six-week lead-in period in which all patients received 10 mg/day of sibutramine, after which they were randomized to the active treatment or placebo.&lt;/p&gt;
&lt;p&gt;Mean duration of treatment was 3.4 years, and slightly more than 40% of patients in both groups discontinued treatment.&lt;/p&gt;
&lt;p&gt;All patients also participated in individualized diet and exercise programs designed for cardioprotection, and blood pressure decreased in both groups during the lead-in phase.&lt;/p&gt;
&lt;p&gt;However, after randomization the sibutramine group had small but consistent increases in blood pressure and resting pulse rate.&lt;/p&gt;
&lt;p&gt;While there were increases in the nonfatal events, there was no between-group difference for cardiovascular death (HR 0.99, 95% CI 0.82 to 1.19, &lt;em&gt;P&lt;/em&gt;=0.90) or death from any cause (HR 1.04, 95% CI 0.91 to 1.20, &lt;em&gt;P&lt;/em&gt;=0.54).&lt;/p&gt;
&lt;p&gt;The investigators noted that fewer than half of the events they had expected at the outset of the trial occurred during its six-year overall duration, and that during that time the incidence of cardiovascular disease decreased in most of Europe and Australia, where most of the study centers were located.&lt;/p&gt;
&lt;p&gt;They also pointed out that the study was limited by the lack of a true placebo group, the inclusion of only high-risk patients, and the longer-than-recommended time of treatment (one to two years).&lt;/p&gt;
&lt;p&gt;In an accompanying editorial, Gregory D. Curfman, MD, executive editor of &lt;em&gt;NEJM, &lt;/em&gt;and colleagues commented that the cardiovascular risk findings of SCOUT need to be considered in light of the potential clinical benefit of the weight loss seen among those on sibutramine.&lt;/p&gt;
&lt;p&gt;Patients on the drug lost 4.3 kg at one year, but regained about 0.5 kg thereafter, for a net loss of less than 4 kg from a baseline average weight of 96 kg.&lt;/p&gt;
&lt;p&gt;In January 2010, after the preliminary analysis of the SCOUT data, the European Medicines Agency suspended marketing authorizations for sibutramine-containing medications throughout the European Union.&lt;/p&gt;
&lt;p&gt;On Sept. 15, an advisory committee of the FDA plans to meet to decide whether additional regulatory action should be taken here as well.&lt;/p&gt;
&lt;p&gt;Curfman and colleagues concluded, &quot;Given that sibutramine has minimal efficacy for weight loss, no apparent benefit for clinical outcomes, a worrisome cardiovascular risk profile, and a plausible mechanism to explain the cardiovascular risk, it is difficult to discern a credible rationale for keeping this medication on the market.&quot;&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 Abbott Laboratories.&lt;/p&gt;&lt;p&gt;Several of the SCOUT investigators reported serving on advisory boards and receiving fees from multiple pharmaceutical companies, including Abbott, sanofi-aventis, Merck, Johnson &amp;amp; Johnson, Novo Nordisk, GlaxoSmithKline, and Boehringer Ingelheim.&lt;/p&gt;&lt;p&gt;In addition, three of the investigtors were full-time employees of Abbott and had equity interest in the company.&lt;/p&gt;&lt;p&gt;Aside from Curfman&apos;s position with &lt;em&gt;NEJM&lt;/em&gt;, the editorialists had no disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_3241"
                     title="&apos;Brain Exercise&apos; May Worsen Existing Alzheimer&apos;s (CME/CE)"
                     score="0.012"
                     href="http://www.medpagetoday.com/Neurology/AlzheimersDisease/tb/21998?impressionId=1283457929229"
                     
      &lt;p&gt;Keeping mentally active may help stave off Alzheimer&apos;s disease, but once patients are diagnosed with the condition, &quot;brain exercise&quot; may actually speed up cognitive decline, researchers said  --  adding that that may not be a bad thing.&lt;/p&gt;
&lt;p&gt;Among more than 1,000 older individuals in a large, longitudinal cohort study, scores on a measure of cognitive activity were significantly correlated with the rate of worsening in global cognitive function, according to Robert S. Wilson, PhD, of Rush University in Chicago, and colleagues.&lt;/p&gt;
&lt;p&gt;For each one-point increase in cognitive activity scores in Alzheimer&apos;s disease patients, the rate of cognitive decline increased 42% (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001), they reported online in &lt;em&gt;Neurology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;But in patients with no cognitive impairment, each point in cognitive activity scores was associated with a 52% reduction in the rate of cognitive decline (&lt;em&gt;P&lt;/em&gt;=0.003), confirming &lt;a href=&quot;http://www.medpagetoday.com/PrimaryCare/Geriatrics/4735&quot; mce_href=&quot;http://www.medpagetoday.com/PrimaryCare/Geriatrics/4735&quot; target=&quot;_blank&quot;&gt;previous studies&lt;/a&gt; indicating that mental activity reduces the risk of dementia.&lt;/p&gt;
&lt;p&gt;&quot;More frequent cognitive activity was related to slower cognitive decline in those without cognitive impairment and more rapid cognitive decline in Alzheimer&apos;s disease, with no effect in mild cognitive impairment,&quot; Wilson and colleagues wrote.&lt;/p&gt;
&lt;p&gt;They argued that such an effect should not be a total surprise.&lt;/p&gt;
&lt;p&gt;Other researchers have suggested that mental activity maintains cognitive abilities even as the underlying pathologic burden continues to grow with age.&lt;/p&gt;
&lt;p&gt;But, Wilson and colleagues noted, &quot;cognitively active people do develop dementia,&quot; presumably when the pathologic burden becomes overwhelming.&lt;/p&gt;
&lt;p&gt;&quot;If cognitive activity does somehow allow the brain to tolerate more pathologic changes, those with high premorbid cognitive activity are likely to have a higher pathologic burden than those with low premorbid activity at the time of dementia onset and therefore to experience a more rapidly progressive dementia course,&quot; they theorized.&lt;/p&gt;
&lt;p&gt;&quot;In effect, these results suggest that the benefit of delaying the initial appearance of cognitive impairment comes at the cost of more rapid dementia progression.&quot;&lt;/p&gt;
&lt;p&gt;Wilson and colleagues analyzed data from the Chicago Health and Aging Project, an ongoing cohort study that began in 1993. At baseline, participants were 65 or older and were free of cognitive impairment.&lt;/p&gt;
&lt;p&gt;The current analysis focused on 1,157 of the participants with 12 years of follow-up. After six years in the study, participants had been tested for cognitive impairment and categorized as cognitively normal, mildly impaired, or having Alzheimer&apos;s disease. They were then followed for another six years, undergoing periodic mental status evaluations.&lt;/p&gt;
&lt;p&gt;At baseline, participants also rated how often they participated in seven cognitive activities: watching television, listening to the radio, reading newspapers, reading magazines, reading books, playing card or board games, and going to museums.&lt;/p&gt;
&lt;p&gt;Cognitive function was evaluated periodically with four brief assessments including the Mini-Mental State Exam, tests of immediate and delayed word recall, and the Symbol Digit Modalities Test.&lt;/p&gt;
&lt;p&gt;Wilson and colleagues calculated that the interaction of baseline cognitive activity score with changes in cognitive function scores and time was -0.075 in the Alzheimer&apos;s disease patients (SE 0.022), whereas in the participants with no cognitive impairment at follow-up the interaction estimate was 0.029 (SE 0.010).&lt;/p&gt;
&lt;p&gt;&quot;These observational data suggest that interventions designed to enhance cognitive plasticity may prove beneficial in compressing the cognitive morbidity of Alzheimer&apos;s disease,&quot; the researchers wrote.&lt;/p&gt;
&lt;p&gt;In other words, &quot;brain exercise&quot; may shorten the period of time in which patients must live with a diagnosis of Alzheimer&apos;s disease, as they remain mentally healthy deeper into old age and then decline quickly.&lt;/p&gt;
&lt;p&gt;They also noted that, to be effective, cognitive enrichment interventions may need to be initiated before the development of cognitive impairment,&quot; since any degree of cognitive deficit probably means an already substantial pathological burden.&lt;/p&gt;
&lt;p&gt;Wilson and colleagues cited several limitations to their analysis: the possibility of unmeasured differences between the diagnostic subgroups, the lack of detail in the cognitive function tests used, and a relatively small number of follow-up evaluations.&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;No commercial funding for the study was reported.&lt;/p&gt;&lt;p&gt;Wilson serves as consulting editor for two other neurology journals and reported several NIH grants. Other authors reported consulting or other relationships with pharmaceutical companies including Pfizer and Eli Lilly.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
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