<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_446"
                     title="Proteins Linked to Stress-Induced ACS (CME/CE)"
                     score="0.011"
                     href="http://www.medpagetoday.com/Cardiology/AcuteCoronarySyndrome/tb/18373?impressionId=1265804035064"
                     
      The heart-pounding excitement of Sunday&apos;s Super Bowl football game might have sent some fans to hospital with acute coronary syndrome.&lt;br&gt;
&lt;br&gt;But researchers in Germany say it may be possible to distinguish these cases from people whose coronary syndrome wasn&apos;t stress-related.&lt;br&gt;
&lt;br&gt;Two proteins known as endothelin-1 (ET-1) and &lt;span&gt;monocyte&lt;/span&gt; chemoattractant protein-1 (MCP-1) appear to be highly sensitive and specific markers of excitement-induced acute coronary syndromes, according to Ute Wilbert-Lampen, MD, and colleagues at Ludwig-Maximilians-Universit&amp;#228;t in Munich.&lt;/p&gt;
&lt;p&gt;In a cohort study, the two compounds were markedly elevated in people whose coronary syndromes were associated with excitement and stress over World Cup soccer games, the researchers reported in the Feb. 16 issue of the &lt;em&gt;Journal of the American College of Cardiology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;And the protein levels were significantly higher than in either healthy controls or a group of matched patients whose coronary syndrome was not associated with the soccer matches, the researchers said.&lt;/p&gt;
&lt;p&gt;Wilbert-Lampen and colleagues reported in 2008 that they had found 2.7-fold spike in the incidence of acute cardiovascular events in association with the 2006 World Cup soccer matches. (See &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/Atherosclerosis/8171&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/Atherosclerosis/8171&quot; target=&quot;_blank&quot;&gt;Cardiovascular Events Spike During Critical World Cup Soccer Matches&lt;/a&gt;)&lt;/p&gt;
&lt;p&gt;Although excitement and stress caused the events, exactly how remained unclear, they reported in the journal.&lt;/p&gt;
&lt;p&gt;To help clarify the issue, they looked at 58 representative patients from the earlier analysis for whom blood samples were available. They were compared with the same number of healthy controls and 58 reference patients with acute coronary syndromes&lt;strong&gt; &lt;/strong&gt;who reported no emotional involvement with the World Cup.&lt;/p&gt;
&lt;p&gt;In addition to ET-1 and MCP-1, blood samples were tested for a range of substances, including soluble CD40L (sCD40L), soluble vascular cell adhesion molecule-1 (sVCAM-1), tumor necrosis factor-&amp;#945; (TNF-&amp;#945;), high-sensitivity C-reactive protein (hsCRP), and regulated on activation, normal T-cell expressed and secreted (RANTES).&lt;/p&gt;
&lt;p&gt;The researchers found: &lt;ul&gt; &lt;li&gt;The study group had average ET-1 levels of 4.0 picograms per milliliter, compared with 2.0 for the reference patients and 1.1 for the health controls. Both between-group differences were significant at &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001.&lt;/li&gt; &lt;li&gt;A similar pattern was seen for MCP1 and TNF-&amp;#945;.&lt;/li&gt; &lt;li&gt;The other markers  --  sVCAM-1, hsCRP, and RANTES -- yielded less clear results.&lt;/li&gt; &lt;li&gt;In both groups of patients, ET-1 was significantly correlated (at &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) with sCD40L and with MCP-1, but other markers were correlated with one or the other or neither.&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;In a receiver operating curve analysis, ET-1 and MCP-1 were found to have diagnostic potential, the researchers said, with the areas under the curve being 0.99 and 0.98, respectively.&lt;/p&gt;
&lt;p&gt;In such an analysis, an area under the curve of 1.0 would mean the proposed diagnostic tool would be completely accurate, without either false positives or false negatives.&lt;/p&gt;
&lt;p&gt;Using a cutoff of 3.1 picograms per milliliter, ET-1 had a sensitivity of 100% and a specificity of 96.6%, the researchers said, while a cutoff of 396 picograms per milliliter for MCP-1 resulted in 93.1% sensitivity and 93.1% specificity.&lt;/p&gt;
&lt;p&gt;One implication of the findings, the researchers said, is that it may be valuable to begin developing prophylactic and therapeutic drugs targeting ET-1.&lt;/p&gt;
&lt;p&gt;They noted that because of the design of the original study, a range of information was not available, including data on troponin or stress-hormone levels, cardiovascular risk factors, infarct size, or clinical outcome.&lt;/p&gt;
&lt;p&gt;Despite those gaps, the study has &quot;some exciting features,&quot; according to Karina Davidson, PhD, of Columbia University College of Physicians and Surgeons in New York City.&lt;/p&gt;
&lt;p&gt;Among other things, she wrote in an accompanying editorial, the study provides &quot;evidence for the importance&quot; of ET-1 in stress-induced ischemic syndromes.&lt;/p&gt;
&lt;p&gt;It may now be possible, she argued, to identify what other factors come into play and eventually to determine who is at risk for such events.&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 Else Kr&amp;#246;ner-Fresenius Stiftung. The researchers did not report potential conflicts.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_387"
                     title="Canadian Politician Comes to U.S. for Heart Surgery"
                     score="0.01"
                     href="http://www.medpagetoday.com/Cardiology/AcuteCoronarySyndrome/tb/18279?impressionId=1265804035064"
                     
      &lt;p&gt;It is rare that a simple matter of patient choice causes an international flap.&lt;/p&gt;
&lt;p&gt;But that&apos;s what happened when 60-year-old Danny Williams of St. John&apos;s, Newfoundland, decided to go to the U.S. for heart surgery.&lt;/p&gt;
&lt;p&gt;That&apos;s because Williams isn&apos;t just any old Newfoundlander  --  he&apos;s the premier of Canada&apos;s easternmost province, the head of its government.&lt;/p&gt;
&lt;p&gt;The disclosure Tuesday that Williams was in an undisclosed location in the U.S., having an undisclosed procedure that he couldn&apos;t get in Newfoundland, brought catcalls from both sides of the border.&lt;/p&gt;
&lt;p&gt;The &lt;em&gt;New York Post&lt;/em&gt;, for instance, in an article headlined &quot;Oh (no), Canada&quot; used the news to take a whack at healthcare reform in the U.S. And the American Thinker blog  --  among many others  --  argued that Williams&apos; choice is evidence of the inferiority of Canada&apos;s &quot;technologically second-rate and rationed system.&quot;&lt;/p&gt;
&lt;p&gt;In Canada, cardiac specialists defended the premier&apos;s decision as a matter of choice and at the same time noted that  --  with few exceptions  --  most cardiac procedures are both available and done well in Canada.&lt;/p&gt;
&lt;p&gt;On the other hand, Newfoundland  --  with a population of about 500,000, less than Wyoming  --  is less well equipped. Doctors in the province do coronary artery bypass grafts (CABG) and other common procedures, but often send patients elsewhere in the country for transplants or rare operations.&lt;/p&gt;
&lt;p&gt;By way of contrast, doctors in Ontario  --  Canada&apos;s most populous province  --  handle more than 11,000 cardiac procedures a year in 11 specialized cardiac centers, according to Kori Kingsbury, CEO of Ontario&apos;s Cardiac Care Network.&lt;/p&gt;
&lt;p&gt;It&apos;s one of the places a Newfoundland patient might go if appropriate care wasn&apos;t available in that province, but Kingsbury said most of those 11,000-odd procedures are, in fact, performed on Ontario residents.&lt;/p&gt;
&lt;p&gt;Still, a &quot;handful&quot; of Ontario patients go to the U.S. every year for surgery, usually because they need emergency treatment and live close to the border, she told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;And every year, a few Americans cross the border the other way seeking care, she said, although she did not immediately have exact numbers.&lt;/p&gt;
&lt;p&gt;But for the most part, any required surgery can be obtained in a timely fashion in the province, Kingsbury said. In December, for instance, the median wait time for an elective isolated CABG was 14 days and urgent or emergency care was performed much more quickly.&lt;/p&gt;
&lt;p&gt;The exceptions to that rule are rare, complex procedures the experts in which reside in the U.S., according to cardiac surgeon Chris Feindel, MD, of Toronto&apos;s University Health Network.&lt;/p&gt;
&lt;p&gt;But the only nonexperimental example he can think of is repair of a rare aneurysm in the descending aorta, where the best care for the procedure is at Baylor University in Texas, Feindel told reporters.&lt;/p&gt;
&lt;p&gt;Because the condition is so rare, &quot;there&apos;s really no center across the country that has a large experience with these,&quot; he told the Canadian Press.&lt;/p&gt;
&lt;p&gt;In general, though, top-level cardiac care is readily available, according to Robert Roberts, MD, president of the University of Ottawa Heart Institute in the nation&apos;s capital.&lt;/p&gt;
&lt;p&gt;Roberts, who was head of cardiology at Baylor for 23 years before moving to Canada five years ago, said 99% of what can be done in the U.S. is done both routinely and well at his center.&lt;/p&gt;
&lt;p&gt;Premier Williams&apos; decision may have been influenced by the knowledge that Newfoundland does not fare as well as the rest of the country in some cardiac outcomes.&lt;/p&gt;
&lt;p&gt;According to the Canadian Institute for Health Information, the province has the highest rate of acute myocardial infarction, at 351 per 100,000 patients in 2007-2008.&lt;/p&gt;
&lt;p&gt;More revealing is the unplanned hospital readmission rate after a heart attack, which is regarded as a measure of quality of care. In 2007-2008, 6.2% of Newfoundland patients were readmitted, significantly higher than the national rate of 5.2%.&lt;/p&gt;
&lt;p&gt;And 30-day inhospital mortality  --  another marker of care quality  --  is also higher than the national average at 10.9% compared with 9.4%, the institute said.&lt;/p&gt;
&lt;p&gt;Kathy Dunderdale, the province&apos;s deputy premier, told reporters that Williams made the decision after weeks of consultation with his doctors and is expected make a full recovery.&lt;/p&gt;
&lt;p&gt;But she would not comment on his location or what procedure he needed, saying only that he could not get the care he needed in the province.&lt;/p&gt;
&lt;p&gt;A spokesman for the local health authority did not return telephone calls asking what procedures are not available in the province.&lt;/p&gt;
&lt;p&gt;Dunderdale also did not comment on who will pay for the surgery. Usually, if it&apos;s deemed medically necessary for a patient to travel outside the province for care, the taxpayer-funded medicare system picks up the tab.&lt;/p&gt;
&lt;p&gt;But Williams  --  sometimes known as &quot;Danny Millions&quot;  --  is personally wealthy, having made a fortune in cable television.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_411"
                     title="Older Women with Gout at Risk of MI (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Cardiology/MyocardialInfarction/tb/18319?impressionId=1265804035064"
                     
      &lt;p&gt;Elderly women with gout are at increased risk of acute myocardial infarction (MI), even more so than men with this painful arthritis, a population-based study found.&lt;/p&gt;
&lt;p&gt;After adjusting for age, comorbidities such as hypertension and diabetes, and prescription drug use, the relative risk of MI among women ages 65 and older was 1.39 (95% CI 1.20 to 1.61), according to Mary A. De Vera of the Arthritis Research Centre of Canada in Vancouver, and colleagues.&lt;/p&gt;
&lt;p&gt;In comparison, the multivariate relative risk among men was 1.11 (95% CI 0.99 to 1.23, &lt;em&gt;P&lt;/em&gt;=0.003 for interaction), the researchers reported online in the &lt;em&gt;Annals of the Rheumatic Diseases&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Men with gout are known to be at higher risk for coronary heart disease and acute MI, but corresponding data for women were sparse.&lt;/p&gt;
&lt;p&gt;So De Vera and colleagues conducted a cohort study using the British Columbia Linked Health Database, comparing the incidence rates of MI between 9,642 patients with gout and 48,210 matched controls with no history of ischemic heart disease.&lt;/p&gt;
&lt;p&gt;A total of 3,890 of the cases were women, as were 19,450 of the controls.&lt;/p&gt;
&lt;p&gt;The gout incidence rate in women ages 65 to 85 years was 2.5 per 1,000 person-years, and 2.9 per 1,000 person-years in those ages 85 and higher.&lt;/p&gt;
&lt;p&gt;The rates in men of the corresponding ages were 5.7 and 6.5 per 1,000 person-years.&lt;/p&gt;
&lt;p&gt;Hospital records indicated that the incidence rates of acute MI among women and men were 6.7 and 10.7 per 1,000 person-years, respectively.&lt;/p&gt;
&lt;p&gt;During a median of seven years&apos; follow-up there were 3,268 incident cases of MI, including 996 in women.&lt;/p&gt;
&lt;p&gt;In unadjusted analysis, the relative risk of acute MI among women with gout was 1.67 (95% CI 1.45 to 1.93), while that for men with gout was 1.19 (95% CI 1.07 to 1.32).&lt;/p&gt;
&lt;p&gt;Multivariate analysis determined that the relative risk for nonfatal MI in women was 1.41 (95% CI 1.19 to 1.67), while that in men was 1.11 (95% CI 0.98 to 1.25, &lt;em&gt;P&lt;/em&gt;=0.005 for interaction).&lt;/p&gt;
&lt;p&gt;The gender difference did not show up in fatal events, however. The relative risk for fatal MI was 1.33 in women (95% CI 0.99 to 1.78) and 1.10 in men (95% CI 0.88 to 1.38, &lt;em&gt;P&lt;/em&gt;=0.30 for interaction).&lt;/p&gt;
&lt;p&gt;Overall, there was a 39% increased risk for MI among women with gout, an association that was independent of age, comorbidities, and use of prescription drugs including nonsteroidal anti-inflammatories, diuretics, statins, anticoagulants, and aspirin.&lt;/p&gt;
&lt;p&gt;The association was significantly stronger than for men, according to the researchers.&lt;/p&gt;
&lt;p&gt;These gender differences may relate to serum uric acid levels and metabolism. Levels in men are about 1 mg/dL higher, although levels do rise in women at menopause.&lt;/p&gt;
&lt;p&gt;&quot;Thus, the relative physiological impact of having gout or a certain level of hyperuricemia may be stronger among women than men,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;Possible mechanisms for the contribution of hyperuricemia to cardiovascular disease include vascular smooth muscle cell proliferation and inflammation, as well as platelet adhesiveness and aggregation.&lt;/p&gt;
&lt;p&gt;&quot;Inflammation associated with gout may also have a role in potential mechanisms, including promotion of atherogenesis and thrombogenesis, similar to other inflammatory arthritides associated with cardiovascular disease,&quot; the investigators noted.&lt;/p&gt;
&lt;p&gt;A strength of the study was its population-based design, which makes its findings generalizable. Limitations include the potential for misclassification of diagnosis because of the use of diagnostic codes, and the inability to adjust for lifestyle factors such as smoking.&lt;/p&gt;
&lt;p&gt;Nonetheless, according to the investigators, &quot;These findings provide support for the aggressive management of cardiovascular risk factors for male and female patients with gout.&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 partly funded by the National Institute of Health.&lt;/p&gt;&lt;p&gt;The authors have received support from the Canadian Arthritis Network/The Arthritis Society, and one disclosed receiving research funding and honoraria from TAP Pharmaceuticals and Savient.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_348"
                     title="No Rebound Seen After Antiplatelet Withdrawal (CME/CE)"
                     score="0.008"
                     href="http://www.medpagetoday.com/Cardiology/PCI/tb/18226?impressionId=1265804035064"
                     
      &lt;p&gt;No evidence of a platelet aggregation rebound occurs with abrupt discontinuation of clopidogrel (Plavix) in patients undergoing percutaneous coronary intervention (PCI), investigators in a randomized clinical trial concluded.&lt;/p&gt;
&lt;p&gt;Values for adenosine diphosphate (ADP)-induced platelet aggregation did not differ significantly between patients whose clopidogrel therapy was withdrawn abruptly and those in whom clopidogrel was tapered before discontinuation, they wrote in an article in the Feb. 9 issue of the &lt;em&gt;Journal of the American College of Cardiology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;The findings also showed that tapering of clopidogrel does not lead to lower platelet aggregation values after clopidogrel withdrawal, according to Dirk Sibbing, MD, of Technical University Munich in Germany, and colleagues&lt;em&gt;&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;The time course of platelet aggregation values  --  regardless of the device, the agonist, or the agonist concentration used  --  after clopidogrel cessation provides no evidence for the existence of a rebound phenomenon of platelets after discontinuing clopidogrel,&quot; they wrote in conclusion.&lt;/p&gt;
&lt;p&gt;For patients undergoing PCI, dual antiplatelet therapy with aspirin and clopidogrel has become the mainstay for prevention of thrombotic events. Lifelong aspirin therapy is recommended for patients after PCI, but clinical guidelines recommend discontinuation of clopidogrel after six or 12 months. The standard practice is to withdraw clopidogrel abruptly, the authors noted.&lt;/p&gt;
&lt;p&gt;Recent studies have shown a clustering of thrombotic events in the first few weeks after discontinuation of long-term clopidogrel therapy. The observations have led to the hypothesis of a rebound phenomenon of platelet aggregation. However, the hypothesis had not been examined specifically within the context of clopidogrel withdrawal.&lt;/p&gt;
&lt;p&gt;&quot;Because different studies have demonstrated that insufficient suppression of platelet reactivity to ADP is associated with an increased risk of thrombotic events after coronary stent placement, the observed clustering of adverse events reported in clinical studies might be related to an intermittent status of platelet hyperreactivity or so-called platelet rebound with very high ADP-induced platelet aggregation levels,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;&quot;A tapering of clopidogrel treatment over a certain period of time before stopping the intake of the drug completely might provide a beneficial treatment strategy to attenuate this supposed rebound phenomenon of platelets.&quot;&lt;/p&gt;
&lt;p&gt;Sibbing and colleagues designed a randomized clinical trial to determine whether a rebound phenomenon exists after discontinuation of clopidogrel and whether the rebound can be attenuated by a clopidogrel-tapering regimen.&lt;/p&gt;
&lt;p&gt;The investigators enrolled 69 patients receiving clopidogrel in association with PCI procedures. In all cases, discontinuation of clopidogrel was planned.&lt;/p&gt;
&lt;p&gt;The patients were randomized to two strategies of discontinuation: tapering of the clopidogrel dose over four weeks, followed by discontinuation; or treatment for four weeks, as planned, followed by abrupt discontinuation.&lt;/p&gt;
&lt;p&gt;Investigators assessed platelet aggregation at enrollment and during weeks two through eight after randomization. Aggregation was assessed simultaneously by light transmission aggregometry (LTA) and multiple electrode aggregometry (MEA).&lt;/p&gt;
&lt;p&gt;The primary endpoint was the highest rate of ADP-induced platelet aggregation by LTA in weeks five through eight after clopidogrel withdrawal.&lt;/p&gt;
&lt;p&gt;Platelet aggregation by LTA peaked at 73% in the group that had clopidogrel abruptly withdrawn and at 69.3% in the tapering group, resulting in a nonsignificant difference (&lt;em&gt;P&lt;/em&gt;=0.21). The between-group values did not differ across the range of ADP concentrations used (1.25 to 20 &amp;#181;mol/L).&lt;/p&gt;
&lt;p&gt;Results by MEA were similar: The peak aggregation value associated with abrupt withdrawal was 925 AU x min compared with 890 AU x min with clopidogrel tapering (&lt;em&gt;P&lt;/em&gt;=0.55).&lt;/p&gt;
&lt;p&gt;Studies with different agonists of platelet aggregation also yielded similar results in the two patient groups.&lt;/p&gt;
&lt;p&gt;Despite finding no difference between the two strategies for clopidogrel withdrawal, the authors did not rule out the possibility of a beneficial effect of tapering clopidogrel.&lt;/p&gt;
&lt;p&gt;&quot;It could be hypothesized that, apart from the maximal values of platelet aggregation observed, a more gradual increase of platelet aggregation values achieved by a clopidogrel-tapering regimen is beneficial for the reduction of thrombotic events,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;&quot;In fact, we observed a relatively rapid increase of platelet aggregation values in the [abrupt withdrawal] group of patients in our study. Whether this rapid increase might be disadvantageous in case of stopping clopidogrel treatment remains uncertain.&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 supported by Cordis, Medtronic, and Dynabyte.&lt;/p&gt;&lt;p&gt;Sibbing disclosed relationships with Dynabyte and Eli Lilly.&lt;/p&gt;&lt;p&gt;Co-author Adnan Kastrati disclosed relationships with Eli Lilly, sanofi-aventis, and Bristol-Myers Squibb.&lt;/p&gt;&lt;p&gt;Co-author Nicolas von Beckerath disclosed relationships with Eli Lilly and sanofi-aventis.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_323"
                     title="Peptide Predicts Heart Failure in Older Patients (CME/CE)"
                     score="0.005"
                     href="http://www.medpagetoday.com/Cardiology/CHF/tb/18193?impressionId=1265804035064"
                     
      &lt;p&gt;Serial measurement of a natriuretic peptide predicted the risk of heart failure and cardiovascular death in older patients who were initially free of heart failure, data from a longitudinal cohort study showed.&lt;/p&gt;
&lt;p&gt;An increase of more than 25% in levels of N-terminal pro-B type natriuretic peptide (NT-proBNP) doubled the risk of heart failure and cardiovascular death. In contrast, a more than 25% decrease in NT-proBNP was associated with a greater than 40% reduction in the risk of both end points.&lt;/p&gt;
&lt;p&gt;&quot;NT-proBNP levels frequently change over time, and these fluctuations reflect dynamic changes in cardiovascular risk,&quot; Christopher R. deFilippi, MD, of the University of Maryland in Baltimore, and co-authors concluded in an article in the Feb. 2 issue of the &lt;em&gt;Journal of the American College of Cardiology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;This change in [NT-proBNP] level reflects a significant change in patient risk independent of cardiovascular risk factors, ejection fraction, or medication use,&quot; they added. &quot;Ultimately, NT-proBNP levels may guide further diagnostic testing or potential preventive measures to reduce the risk of developing heart failure or dying of cardiovascular disease.&quot;&lt;/p&gt;
&lt;p&gt;About 80% of cardiovascular deaths occur in older adults. Assessing cardiovascular risk in older patients is challenging because traditional cardiovascular risk factors are less predictive in older versus middle-age populations, the authors wrote.&lt;/p&gt;
&lt;p&gt;Subclinical cardiovascular disease is common among older adults and increases the risk of cardiovascular events, including heart failure. Repeated measures of traditional markers of cardiovascular disease in patients with subclinical disease are associated with increased risk compared with patients who remain free of identifiable disease, the authors continued.&lt;/p&gt;
&lt;p&gt;Levels of BNP and NT-proBNP are associated with long-term cardiovascular outcomes in the general population. However, the peptides&apos; ability to provide additional prognostic information beyond that of traditional risk factors remained controversial.&lt;/p&gt;
&lt;p&gt;To examine the prognostic value of NT-proBNP in an older population, deFilippi and colleagues analyzed data on 3,000 participants in the Cardiovascular Health Study. The authors hypothesized that NT-proBNP levels in an ambulatory population of older patients would independently predict new-onset heart failure and cardiovascular death.&lt;/p&gt;
&lt;p&gt;&quot;Furthermore, we anticipated that serial measurements of NT-proBNP, as a possible surrogate for change in subclinical disease status, identify a dynamic change in long-term risk of incident heart failure and cardiovascular mortality,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;Stored serum samples obtained at enrollment and two to three years later were used to measure NT-proBNP levels. Median follow-up for the cohort was 11.9 years.&lt;/p&gt;
&lt;p&gt;After separating the study group into quintiles of NT-proBNP levels, investigators found that patients with the highest baseline levels of the peptide (&amp;gt;267.7 pg/mL) had a threefold greater risk of new-onset heart failure (HR 3.05, 95% CI 2.46 to 3.78) and cardiovascular death (HR 3.02, 95% CI 2.36 to 3.86) compared with patients in the lowest NT-proBNP quintile (&amp;lt;47.5 pg/mL).&lt;/p&gt;
&lt;p&gt;The researchers identified 190 pg/mL as the NT-proBNP threshold for increased risk. Among study participants with baseline levels less than 190 pg/mL, an increase greater than 25% to a level above 190 pg/mL had a twofold increased risk of heart failure (HR 2.13, 95% CI 1.68 to 2.71) and cardiovascular death (HR 1.91, 95% CI 1.43 to 2.53) compared with participants whose NT-proBNP levels remained below 190 pg/mL.&lt;/p&gt;
&lt;p&gt;Among study participants with elevated baseline NT-proBNP levels, an increase greater than 25% also doubled the risk of heart failure (HR 2.06, 95% CI 1.56 to 2.72) and cardiovascular disease (HR 1.88, 95% CI 1.37 to 2.57).&lt;/p&gt;
&lt;p&gt;A decrease greater than 25% from baseline significantly reduced the risk of heart failure (HR 0.58, 95% CI 0.36 to 0.93) and cardiovascular death (HR 0.57, 95% CI 0.32 to 1.01) compared with participants whose baseline levels remained elevated.&lt;/p&gt;
&lt;p&gt;The investigators noted limitations of the study including the fact that a quarter of the participants did not have a follow-up blood sample and those who did were younger and had fewer cardiac risk factors.&lt;/p&gt;
&lt;p&gt;In addition, the length of follow-up could not account for differences in treatment over time, and the accuracy of NT-proBNP levels in samples as much as 20 years old cannot be assured.&lt;/p&gt;
&lt;p&gt;The study is noteworthy for highlighting the concept of dynamic risk assessment based on serial measurement of NT-proBNP, Richard W. Troughton, MB ChB, PhD, Matthew G. Daly, MB ChB, and Christopher M. Frampton, PhD, of the University of Otago in Christchurch, New Zealand, wrote in an editorial.&lt;/p&gt;
&lt;p&gt;&quot;The findings confirm a modest improvement in risk stratification by including a single measurement of NT-proBNP levels,&quot; they wrote &quot;The investigators take this a step further by showing that serial NT-proBNP measurement at a later time provides a further modest improvement in risk stratification.&quot;&lt;/p&gt;
&lt;p&gt;&quot;Whether the improvement in risk stratification achieved by performing serial NT-proBNP testing crosses a threshold of definite clinical value needs further evaluation, with particular consideration of the cost-effectiveness of such a strategy,&quot; they added.&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 the National Institutes of Health, University of Pittsburgh, and Roche Diagnostics.&lt;/p&gt;&lt;p&gt;DeFilippi disclosed relationships with Siemens, Roche Diagnostics, BG Medicine, and Critical Diagnostics. Co-author Robert H. Christenson disclosed relationships with Roche Diagnostics, Siemens Healthcare Diagnostics, and Response Biomedical. Co-author Stephen L. Seliger disclosed a relationship with Roche.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
</recommendedContent>