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    <recommendedItem id="20100101_19_449"
                     title="FDA Okays Statin for Primary Prevention"
                     score="0.014"
                     href="http://www.medpagetoday.com/InfectiousDisease/PublicHealth/tb/18380?impressionId=1265782765316"
                     
      &lt;p&gt;WASHINGTON  --  The FDA has approved rosuvastatin (Crestor) for primary prevention of cardiovascular disease, making it the first statin to receive this indication.&lt;/p&gt;
&lt;p&gt;The new labeling, recommended by an FDA advisory panel late last year, also marks the first time that a drug label will include an indication based on the biomarker highly-sensitive C-reactive protein, an inflammatory marker.&lt;/p&gt;
&lt;p&gt;The new indication would be for men 50 or older and women 60 or older who have fasting LDL of less than 130 mg/dL, a highly-sensitive CRP of 2.0 mg/L or greater, triglycerides of less than 500 mg/dL, and no prior history of heart attack or stroke, or coronary heart disease risk.&lt;/p&gt;
&lt;p&gt;The basis for the new labeling was the JUPITER trial, a randomized, placebo-controlled trial of 17,802 men and women with a mean age of 66 and no history of atherosclerosis. All participants had LDL of less than 130 mg/dL and a highly-sensitive C-reactive protein concentration of 2 mg/L or higher.&lt;/p&gt;
&lt;p&gt;Patients were randomized to 20 mg of rosuvastatin for 1.9 years, which reduced median LDL cholesterol to 55 mg/dL, down from a median of 108 mg/dL at baseline. The corresponding relative reduction in the rate of MI, stroke, arterial revascularization, or cardiovascular death was 44% (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.00001).&lt;/p&gt;
&lt;p&gt;The number needed to treat to avoid one cardiovascular event was 25.&lt;/p&gt;
&lt;p&gt;Those results, according to Melvyn Rubenfire, MD, of the University of Michigan, were a &quot;home run for JUPITER,&quot; but it is not clear whether the results would be the same with another statin.&lt;/p&gt;
&lt;p&gt;And there were some risks associated with rosuvastatin, including 13 deaths due to gastrointestinal disorders in the rosuvastatin arm, and 18 patients reported experiencing a &quot;confused state&quot; while taking the drug.&lt;/p&gt;
&lt;p&gt;The most troubling adverse event, however, was an uptick in investigator-reported, new onset diabetes mellitus in the treatment arm, 2.8% versus 2.5%, for a hazard ratio of 1.27 (95% CI 1.05 to 1.53, &lt;em&gt;P&lt;/em&gt;=0.015).&lt;/p&gt;
&lt;p&gt;Rosuvastatin in marketed by AstraZeneca, which also sponsored the JUPITER trial.&lt;/p&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_222"
                     title="Benefits of Cutting Down on Salt Quantified (CME/CE)"
                     score="-0.001"
                     href="http://www.medpagetoday.com/Cardiology/Prevention/tb/18075?impressionId=1265782765316"
                     
      &lt;p&gt;Cutting daily salt intake by 3 grams a day  --  about 30% of the current average  --  could prevent 32,000 strokes and 54,000 myocardial infarctions a year, if a computer model developed by researchers at the University of California, San Francisco accurately depicts the clinical impact of salt reduction.&lt;/p&gt;
&lt;p&gt;The results of the analysis, which used a computer simulation of heart disease in U.S. adults ages 35 to 84, also suggest that even a 1 gram per day reduction in salt over the next decade would be a more cost-effective strategy for treating hypertension than use of even the cheapest antihypertensive, wrote Kirsten Bibbins-Domingo, MD, PhD, and colleagues in a paper published online by the &lt;em&gt;New England Journal of Medicine.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;Lee Goldman, MD, MPH, of Columbia University, who co-authored the paper, told &lt;em&gt;MedPage Today&lt;/em&gt; that their study builds on what has long been known about the adverse health effects of salt on a society that believes it to be the spice of life.&lt;/p&gt;
&lt;p&gt;For example, Goldman said that most people seeking a healthy choice will check food labels and restaurant menus for calorie counts and trans fats, but will not pay attention to salt.&lt;/p&gt;
&lt;p&gt;This is not the first time a call for salt reduction has been issued. As recently as last November, a meta-analysis published in &lt;em&gt;BMJ &lt;/em&gt;suggested that cutting salt intake in half  --  a reduction of about 5 grams a day or roughly a teaspoonful  --  would lower the stroke rate by 23% and reduce overall cardiovascular disease by as much as 17%.&lt;/p&gt;
&lt;p&gt;Americans, like those in many Western countries, take in an average of about 10 g of salt a day; whereas the World Health Organization recommends only 5 g per day, and the U.S. Department of Agriculture recommends daily intake be limited to 5.8 g.&lt;/p&gt;
&lt;p&gt;Bibbins-Domingo and colleagues reported that a 3 gram per day reduction in dietary salt would &quot;save 194,00 to 392,00 quality-adjusted life-years and $10 billion to $24 billion in healthcare costs annually.&quot;&lt;/p&gt;
&lt;p&gt;In an editorial that accompanied the study, Lawrence J. Appel, MD, MPH, and Cheryl A.M. Anderson, PhD, MPH, of Johns Hopkins University, wrote that &quot;the evidence supporting the call to reduce salt intake as a means of preventing cardiovascular disease is compelling.&quot;&lt;/p&gt;
&lt;p&gt;They concluded with this admonition: &quot;As we deliberate healthcare reform, let us not neglect this inexpensive, yet highly effective public health intervention for the prevention of disease.&quot;&lt;/p&gt;
&lt;p&gt;It should be noted that Appel was also first author on a position paper from the American Society of Hypertension that also called for salt reduction as public policy.&lt;/p&gt;
&lt;p&gt;Franz H. Messerli, MD, director of the hypertension program at St. Luke&apos;s-Roosevelt Hospital and a colleague of Goldman&apos;s, said the computer model used in the study was impressive but probably underestimates the benefit of reducing dietary salt &quot;because salt reduction has been shown to have a direct (blood pressure independent) effect on the heart, the brain, the kidneys, and also reduces stomach cancer and osteoporosis  --  factors that were not considered in this analysis.&quot;&lt;/p&gt;
&lt;p&gt;But Messerli found it difficult to lead the victory parade, noting &quot;this is a modeling study and statements such as &apos;A modest reduction of 1 gm per day would be more cost-effective than using medication to lower blood pressure in all persons with hypertension&apos; are to be taken with a good grain of salt.&quot;&lt;/p&gt;
&lt;p&gt;Messerli&apos;s measured response was not echoed by his colleagues in the hypertension world.&lt;/p&gt;
&lt;p&gt;For example, Henry Black, MD, president of the American Society of Hypertension, and director of hypertension research at the New York University School of Medicine said that, although the paper extended the findings of many other studies, it is &quot;more comprehensive and is especially useful by comparing the benefits of [sodium] and [salt] reduction to those of other widely accepted public health approaches that the public and governmental bodies have embraced, including drug treatment.&quot;&lt;/p&gt;
&lt;p&gt;Clyde Yancy, MD, president of the American Heart Association, said that while the study was a computer modeling analysis that may be as good as it gets because &quot;it would be impossible to do a randomized trial in large numbers of high versus low sodium consumption, and the use of modeling with reasonable assumptions represents a solid if not ideal alternative.&quot;&lt;/p&gt;
&lt;p&gt;Moreover, Yancy argued that &quot;the costs and effort involved in setting and/or changing policy&quot; require strong imperatives, and he thought the data reported today &quot;provide that imperative.&quot;&lt;/p&gt;
&lt;p&gt;Three grams of salt comes to about a teaspoonful, but Goldman said it was foolish to think of sodium reduction in terms of such measurements because so much sodium comes from processed foods and from restaurant food. Achieving the needed reduction requires a concerted national effort.&lt;/p&gt;
&lt;p&gt;Bibbins-Domingo noted that their study was limited &quot;by any uncertainty concerning the data entered into the model.&quot;&lt;/p&gt;
&lt;p&gt;Also they noted that they did not &quot;account fully for the possible effects of salt reduction that are unrelated to control of blood pressure  --  for example, potential improvements in outcomes for the increasing numbers of patients with heart failure or prevention of other serious conditions, such as end-stage renal 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 study was supported in part by a grant from the American Heart Association Western States Affiliate and a grant from the University of California, San Francisco Clinical and Translational Sciences Institute.&lt;/p&gt;&lt;p&gt;The authors said they had &quot;no potential conflicts of interest relevant to this article.&quot;&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;&lt;p&gt;&lt;em&gt;This article was developed in collaboration with ABC News. &lt;/em&gt;&lt;img src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; mce_src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; alt=&quot;&quot;&gt;&lt;/p&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_189"
                     title="Tailoring Trumps Targeting for Cholesterol Control (CME/CE)"
                     score="-0.002"
                     href="http://www.medpagetoday.com/Cardiology/Dyslipidemia/tb/18023?impressionId=1265782765316"
                     
      &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="20100101_19_97"
                     title="Too Much TV May Lead to Shorter Life (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Cardiology/Atherosclerosis/tb/17888?impressionId=1265782765316"
                     
      Too much television watching could be shortening lifespans, a study of Australian adults showed.&lt;br&gt;
&lt;br&gt;Aussies who reported watching four or more hours of TV a day were 46% more likely to die during a 6.6-year period than those who watched less than two hours a day, according to David Dunstan, PhD, of Monash University in Melbourne, and colleagues.&lt;br&gt;
&lt;br&gt;The risk of dying from cardiovascular disease during follow-up was 80% greater in the excessive viewers, although statistically, the result attained only borderline significance (&lt;em&gt;P&lt;/em&gt;=0.05), the researchers reported online in &lt;em&gt;Circulation: Journal of the American Heart Association&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;The associations were independent of leisure-time exercise and traditional risk factors such as smoking, poor diet, high blood pressure, and abdominal obesity.&lt;/p&gt;
&lt;p&gt;&quot;Sedentary living provokes coronary artery disease,&quot; commented Gerald Fletcher, MD, a cardiologist at the Mayo Clinic in Jacksonville, Fla., and spokesman for the American Heart Association who was not involved in the study.&lt;/p&gt;
&lt;p&gt;&quot;Even if you exercise, if you have a lot of sedentary living with the things that go along with it  --  the bad diet and everything else  --  you still have a net degree of physical inactivity, which is a coronary artery disease risk factor,&quot; Fletcher told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Previous studies had linked increased sedentary time, in general, to cardiovascular events and mortality risk. But the relationship between mortality risk and television viewing  --  the predominant leisure-time sedentary activity  --  had not been studied, Dunstan and colleagues wrote.&lt;/p&gt;
&lt;p&gt;To explore the issue, they turned to the Australian Diabetes, Obesity, and Lifestyle Study (AusDiab).&lt;/p&gt;
&lt;p&gt;Excluding those with a history of cardiovascular disease, the researchers asked 8,800 adults living throughout Australia about the amount of time they spent watching TV and followed them for an average of 6.6 years.&lt;/p&gt;
&lt;p&gt;During follow-up, there were 284 deaths  --  87 from cardiovascular disease, 125 from cancer, and 72 from other causes.&lt;/p&gt;
&lt;p&gt;After adjustment for age, sex, waist circumference, and exercise, each additional hour of television time per day was associated with increased risks of all-cause death (HR 1.11, 95% CI 1.03 to 1.20) and death from cardiovascular disease (HR 1.18, 95% CI 1.02 to 1.35).&lt;/p&gt;
&lt;p&gt;Further adjustment for other factors related to mortality risk eliminated the association between TV watching and cardiovascular death but not with all-cause mortality (HR 1.08, 95% CI 1.00 to 1.17, &lt;em&gt;P&lt;/em&gt;=0.048).&lt;/p&gt;
&lt;p&gt;In fully adjusted models, watching four or more hours of TV a day was associated with greater risk of all-cause mortality and cardiovascular death compared with watching less than two hours.&lt;/p&gt;
&lt;p&gt;TV watching was not significantly related to death from cancer or other causes.&lt;/p&gt;
&lt;p&gt;According to Dunstan and his colleagues, the mechanism underlying the link between sitting and cardiometabolic risks is unclear.&lt;/p&gt;
&lt;p&gt;&quot;Observational studies with objective measures of sedentary time have reported significant associations of total sedentary time with blood glucose, blood lipids, and adiposity that are independent of moderate to vigorous exercise,&quot; they noted.&lt;/p&gt;
&lt;p&gt;In addition, &quot;animal studies have found enforced sedentary time to be related to lipoprotein lipase activity,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;&quot;Our findings broadly support these hypothesized physiological links.&quot;&lt;/p&gt;
&lt;p&gt;Mayo&apos;s Fletcher said studies like this might serve as a wake-up call for some patients, but he was not optimistic.&lt;/p&gt;
&lt;p&gt;&quot;Sometimes one out of 10 people says, &apos;Gosh, that means something and maybe I should stop that,&apos; but the other nine don&apos;t,&quot; he commented.&lt;/p&gt;
&lt;p&gt;The researchers listed some limitations of the study: &lt;ul&gt; &lt;li&gt;Researchers assessed a single sedentary behavior.&lt;/li&gt; &lt;li&gt;TV time was self-reported and evaluated at baseline only.&lt;/li&gt; &lt;li&gt;Residual confounding may have existed.&lt;/li&gt; &lt;li&gt;Reverse causality, in which diagnosed or undiagnosed illness at the beginning of the study may have resulted in elevated TV watching time, could not be excluded.&lt;/li&gt; &lt;/ul&gt;&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;This study was supported by a National Health and Medical Research Council (NHMRC) project grant and by in-kind support from the Australian Institute of Health and Welfare, which collected the mortality data. The AusDiab study has also received financial support from the Australian Government Department of Health and Aging, Abbott Australasia, Alphapharm, AstraZeneca, Aventis Pharma, Bio-Rad Laboratories, Bristol-Myers Squibb, City Health Center Diabetes Service Canberra, Department of Health and Community Services Northern Territory, Department of Health and Human Services Tasmania, Department of Health New South Wales, Department of Health Western Australia, Department of Human Services South Australia, Department of Human Services Victoria, Diabetes Australia, Diabetes Australia Northern Territory, Eli Lilly Australia, Estate of the Late Edward Wilson, GlaxoSmithKline, Highpoint Shopping Center, Jack Brockhoff Foundation, Janssen-Cilag, Kidney Health Australia, Marian &amp;amp; E.H. Flack Trust, Menzies Research Institute, Merck Sharp &amp;amp; Dohme, Multiplex, Novartis Pharmaceuticals, Novo Nordisk Pharmaceuticals, Pfizer Pty Ltd., Pratt Foundation, Queensland Health, Roche Diagnostics Australia, Royal Prince Alfred Hospital Sydney, and Sanofi-Synthelabo. Dunstan is supported by a Victorian Health Promotion Foundation Public Health Research Fellowship. His co-authors reported receiving support from an NHMRC/National Heart Foundation of Australia joint postgraduate scholarship, a National Heart Foundation of Australia postgraduate scholarship, a National Heart Foundation of Australia Career Development Award, sanofi-aventis, a NHMRC/National Heart Foundation of Australia postdoctoral fellowship, a program grant from the NHMRC, and a Research Infrastructure Grant from Queensland Health.&lt;/p&gt;&lt;p&gt;The authors made no other financial disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_1_431"
                     title="Low Thyroid Function May Equal High Heart Disease Risk"
                     score="-0.005"
                     href="