<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_361"
                     title="Hidden Dangers of Herbal Meds Reviewed"
                     score="0.01"
                     href="http://www.medpagetoday.com/PrimaryCare/AlternativeMedicine/tb/18244?impressionId=1265720990680"
                     
      Herbal medicines are not always the harmless nostrums that many patients and even some physicians think, but may actually contribute to cardiovascular morbidity and mortality, researchers warned in a review covering 44 years of research into the subject.&lt;br&gt;
&lt;br&gt;Many such products, including aloe vera, ginkgo biloba, ginseng, and green tea, can interact with conventional cardiovascular drugs and lead to serious adverse reactions, according to Arshad Jahangir, MD, of the Mayo Clinic in Scottsdale, Ariz., and two other Mayo physicians.&lt;br&gt;
&lt;br&gt;&quot;There is a clear need for better public and physician understanding of herbal products through health education, early detection and management of herbal toxicities, scientific scrutiny of their use, and research on their safety and effectiveness,&quot; they wrote in the Feb. 9 &lt;em&gt;Journal of the American College of Cardiology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Jahangir and colleagues also called for increased regulation of such products, at least requiring manufacturers of herbal medicines to register with the FDA and provide evidence of good manufacturing practices.&lt;/p&gt;
&lt;p&gt;&quot;Some of these adverse drug reactions are preventable,&quot; Jahangir told &lt;em&gt;MedPage Today&lt;/em&gt; in a telephone interview. &quot;Simple things like taking a good history or giving that history and discussing these issues, probably we can avoid [such reactions].&quot;&lt;/p&gt;
&lt;p&gt;Other physicians contacted by &lt;em&gt;MedPage Today&lt;/em&gt; and ABC News agreed that the growth in popularity of herbal medicines poses problems for physicians and patients.&lt;/p&gt;
&lt;p&gt;&quot;Because these remedies are &apos;natural,&apos; their potential dangers are not considered the same way they would be if they were medication,&quot; commented Suzanne Steinbaum, MD, a cardiologist at Lenox Hill Hospital in New York City, in an e-mail.&lt;/p&gt;
&lt;p&gt;&quot;For many reasons, patients tend not to disclose to their doctors if they are taking herbal remedies, including fear that their doctors won&apos;t approve or they will be told to stop them,&quot; Steinbaum added. &quot;This lack of knowledge and full-disclosure, for some, might be a fatal omission.&quot;&lt;/p&gt;
&lt;p&gt;Jahangir and colleagues reviewed nearly 90 publications that have addressed herbal or complementary therapies and cardiovascular effects since 1966.&lt;/p&gt;
&lt;p&gt;Their &lt;em&gt;JACC&lt;/em&gt; article listed 15 common herbal medicines known to interact adversely with conventional cardiovascular drugs.&lt;/p&gt;
&lt;p&gt;In many cases, the herbal products compete with the regular medicines for the same drug-metabolizing cytochrome P450 enzymes, potentiating the latter&apos;s effects. In other cases, the herbal products have their own cardiovascular effects.&lt;/p&gt;
&lt;p&gt;Many physicians already know that grapefruit juice occupies the CYP3A4 enzyme, leading to slower-than-expected metabolism and, therefore, higher blood levels of a host of pharmaceuticals.&lt;/p&gt;
&lt;p&gt;These include the statins, calcium channel antagonists, several common anti-arrhythmic drugs, and the angiotensin receptor blocker irbesartan (Avapro), Jahangir and colleagues noted.&lt;/p&gt;
&lt;p&gt;Garlic is one of several common herbal remedies with specific cardiovascular effects in its own right (others include ginkgo biloba, ginseng, and saw palmetto). Garlic inhibits platelet aggregation and thus can lead to increased bleeding risks when combined with aspirin, clopidogrel (Plavix), or warfarin (Coumadin), the researchers noted.&lt;/p&gt;
&lt;p&gt;The Mayo group identified 10 herbal products that increase bleeding risks with anticoagulant and antiplatelet drugs, as well as 14 that can induce arrhythmias.&lt;/p&gt;
&lt;p&gt;In all, Jahangir and colleagues listed 27 herbal products that patients with cardiovascular diseases would do well to avoid. These include such common and harmless-seeming products as green tea, capsicum pepper, licorice, and kelp, as well as grapefruit juice and garlic.&lt;/p&gt;
&lt;p&gt;&quot;We need to check with our patients what type of products they are using, to identify these potential interactions,&quot; Jahangir told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;He cited the previously reported figure of 100,000 deaths annually from drug interactions, adding, &quot;We don&apos;t even know how many of these are due to use of compounds that we are not aware that our patients are taking.&quot;&lt;/p&gt;
&lt;p&gt;Jahangir said he was surprised, in preparing the review, at the scale of hebal medicine use in the U.S.&lt;/p&gt;
&lt;p&gt;He and his colleagues found data from the 1990s suggesting that more patients consult complementary and alternative medicine providers than regular physicians.&lt;/p&gt;
&lt;p&gt;The total annual out-of-pocket expenditure on complementary and alternative medicine services and products also was greater than for conventional physician services.&lt;/p&gt;
&lt;p&gt;&quot;The surprise for me was . . . how much people are willing to spend on a type of therapy which has not shown, in any scientific way, to be effective or safe,&quot; Jahangir said.&lt;/p&gt;
&lt;p&gt;He added that the trend may reflect shortcomings of the conventional medical system.&lt;/p&gt;
&lt;p&gt;&quot;What is the reason people are going there? Is it because there is some unmet type of need that we are not recognizing as practitioners of conventional medicine?&quot;&lt;/p&gt;
&lt;p&gt;Jahangir said it may be that physicians aren&apos;t spending enough time with patients to understand their true needs. He said it appears that, &quot;despite the advancement in our technology and new medicines, there is a demand for alternative therapies that is increasing.&quot;&lt;/p&gt;
&lt;p&gt;He recommended that, in addition to asking patients in detail about herbal and other alternative therapies they may be using, physicians should educate themselves on what these therapies purport to do and what is known about their real biological effects.&lt;/p&gt;
&lt;p&gt;The &lt;a href=&quot;http://nccam.nih.gov&quot; mce_href=&quot;http://nccam.nih.gov&quot; target=&quot;_blank&quot;&gt;National Center for Complementary and Alternative Medicine&lt;/a&gt; at the National Institutes of Health is a good starting point for such information, both for physicians and for patients, Jahangir said.&lt;/p&gt;
&lt;p&gt;Lenox Hill&apos;s Steinbaum said it was important that conventional physicians &quot;become more open-minded and accepting&quot; of alternative medicine, if only because so many of their patients are already practicing it.&lt;/p&gt;
&lt;p&gt;David Meyerson, MD, JD, a Johns Hopkins University cardiologist, told &lt;em&gt;MedPage Today&lt;/em&gt; and ABC News in an e-mail that he advises patients to limit their use of &quot;unstudied and unproven and FDA-unregulated herbal medications.&quot;&lt;/p&gt;
&lt;p&gt;&quot;It&apos;s unfortunately very big business, and potential drug interactions and potential harmful effects abound,&quot; he wrote.&lt;/p&gt;
&lt;p&gt;But another physician criticized the Mayo physicians&apos; emphasis on adverse effects in their review.&lt;/p&gt;
&lt;p&gt;&quot;For many of products listed, evidence for side effects seems to be minimal,&quot; Scott Grundy, MD, of the University of Texas Southwestern Medical Center in Dallas, argued in an e-mail.&lt;/p&gt;
&lt;p&gt;He agreed that the efficacy and safety of such drugs remains largely unproven, but added, &quot;It is mainly for these reasons that they cannot be recommended for use.&quot;&lt;/p&gt;
&lt;p&gt;Creating alarm about side effects &quot;may not be the appropriate way to discourage their use,&quot; Grundy said.&lt;/p&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_315"
                     title="A Few Extra Pounds May Benefit Older People (CME/CE)"
                     score="0.006"
                     href="http://www.medpagetoday.com/Geriatrics/GeneralGeriatrics/tb/18183?impressionId=1265720990680"
                     
      &lt;p&gt;A little excess weight after age 70 could do the body some good, according to results of a study involving 9,000 older patients.&lt;/p&gt;
&lt;p&gt;Overweight participants in the cohort study had the lowest 10-year mortality. Normal-weight and obese participants ages 70 to 75 had a similar and slightly higher risk of death, Leon Flicker, PhD, of the Western Australian Center for Health and Aging in Perth, and colleagues found.&lt;/p&gt;
&lt;p&gt;The findings add to evidence suggesting that being overweight in older age is not such a bad thing and might even be beneficial.&lt;/p&gt;
&lt;p&gt;&quot;These results lend further credence to claims that the body mass index [BMI] thresholds for overweight and obese are overly restrictive for older people,&quot; the researchers concluded in an article in the &lt;em&gt;Journal of the American Geriatrics Society&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;The authors also found that a sedentary lifestyle doubled the mortality risk for older women but did not affect survival of older men.&lt;/p&gt;
&lt;p&gt;The World Health Organization has established four BMI thresholds to characterize body weight: &lt;ul&gt; &lt;li&gt;&amp;lt;18.5 kg/m&lt;sup&gt;2&lt;/sup&gt;, underweight&lt;/li&gt; &lt;li&gt;18.5 to 24.9 kg/m&lt;sup&gt;2&lt;/sup&gt;, normal weight&lt;/li&gt; &lt;li&gt;25 to 29.9 kg/m&lt;sup&gt;2&lt;/sup&gt;, overweight&lt;/li&gt; &lt;li&gt;&amp;#8805;30 kg/m&lt;sup&gt;2&lt;/sup&gt;, obese&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The authors noted that the thresholds were derived primarily from studies of younger and middle-age adults. Whether the cut points for overweight and obese are appropriate for older individuals has remained unclear.&lt;/p&gt;
&lt;p&gt;Two systematic reviews and a meta-analysis showed no increased mortality risk associated with a BMI in the overweight range for older people (&lt;em&gt;Arch Intern Med&lt;/em&gt; 2001; 161: 1194-1203, &lt;em&gt;Obesity Rev&lt;/em&gt; 2007; 8: 41-59). However, methodologic differences complicated the comparison of different studies, Flicker and colleagues wrote.&lt;/p&gt;
&lt;p&gt;So they sought to address some of the uncertainty by analyzing data from two large Australian cohort studies involving more than 9,000 individuals ages 70 to 75 (4,677 men, 4,563 women).&lt;/p&gt;
&lt;p&gt;The principal objectives were to determine the BMI threshold associated with the lowest mortality in older people and to determine whether the relationship between BMI and mortality differed between men and women.&lt;/p&gt;
&lt;p&gt;Data for the analysis came from self-reported measures of height and weight, which the authors used to calculate BMI for the study participants. Participants also provided demographic, lifestyle, and health information.&lt;/p&gt;
&lt;p&gt;Using the WHO criteria for BMI, the authors found that 1.3% of men and 3.1% of women were underweight; 43.5% of men and 50.3% of women were normal weight; 44.3% of men and 33.5% of women were overweight; and 11% of men and 13.1% of women were obese.&lt;/p&gt;
&lt;p&gt;During 10 years of follow-up, overweight study participants had a 13% lower risk of death compared with normal-weight participants (HR 0.87, 95% CI 0.78 to 0.94). Obese participants had a mortality risk similar to that of normal-weight participants (HR 0.98, 95% CI 0.85 to 1.11).&lt;/p&gt;
&lt;p&gt;Self-reported sedentary lifestyle doubled the mortality risk for women across all BMI categories (HR 2.08, 95% CI 1.79 to 2.41). In contrast, sedentary lifestyle increased the mortality risk for men by 28% (HR 1.28, 95% CI 1.14 to 1.44).&lt;/p&gt;
&lt;p&gt;Separate analyses involving common causes of death, such as cardiovascular disease and cancer, showed similar relationships between BMI and mortality risk.&lt;/p&gt;
&lt;p&gt;&quot;Even after removing the effects of early mortality, those who were overweight were still at lowest risk, a finding consistent with the observation that weight loss in older age groups is associated with greater mortality,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;&quot;Overweight older people are not at greater mortality risk, and there is little evidence that dieting in this age group confers any benefit,&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 authors had no relevant disclosures&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_245"
                     title="Accidents, Illness Cause Most War-Zone Casualties (CME/CE)"
                     score="-0"
                     href="http://www.medpagetoday.com/PublicHealthPolicy/MilitaryMedicine/tb/18100?impressionId=1265720990680"
                     
      &lt;p&gt;More than 85% of American military medical evacuations from the Middle East were not the direct result of enemy action, but the result of non-battle injuries and disease, researchers said.&lt;/p&gt;
&lt;p&gt;Of some 34,000 military personnel in Iraq and Afghanistan who shipped out for medical reasons from 2004 to 2007, only 14% had been wounded or injured in combat, according to Steven P. Cohen, MD, of Johns Hopkins, and colleagues.&lt;/p&gt;
&lt;p&gt;The most common reasons for medical evacuation were non-battle related musculoskeletal and connective tissue disorders, accounting for 24% of evacuations, the researchers wrote in the Jan. 23 issue of &lt;em&gt;The Lancet&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Combat injuries were the second most common, followed by neurological disorders (10%) and psychiatric illnesses (9%).&lt;/p&gt;
&lt;p&gt;&quot;Non-battle related injuries continue to be the leading cause of medical evacuation in modern warfare, and medical officers should be prepared for this burden in subsequent conflicts,&quot; Cohen and colleagues wrote.&lt;/p&gt;
&lt;p&gt;&quot;To reduce the number of evacuees, preventive medicine programmes and educational initiatives need to target health-care providers, non-commissioned officers, and combat soldiers.&quot;&lt;/p&gt;
&lt;p&gt;They also warned that &quot;the burden of psychiatric illness&quot; will increase with the duration of conflict and reliance on reserve units.&lt;/p&gt;
&lt;p&gt;Cohen and colleagues obtained data kept by the U.S. military on all medical evacuations from Iraq and Afghanistan spanning 2004 to 2007.&lt;/p&gt;
&lt;p&gt;In addition to describing the medical reasons for evacuation, the data included the individuals&apos; ranks, service affiliations, active-duty or reserve status, and whether personnel returned to duty.&lt;/p&gt;
&lt;p&gt;Any injury sustained during combat missions, including those not caused directly by enemy fire such as back strains, was counted as battle-related.&lt;/p&gt;
&lt;p&gt;The number of evacuations each year fell from 2004 to 2006  --  from 10,290 to 6,778  --  but abruptly rose in 2007 to 8,444 with the Iraq surge and the reinvigorated Afghan Taliban resistance.&lt;/p&gt;
&lt;p&gt;Not surprisingly, as these conflicts evolved over time, the balance of combat and non-combat injuries and illnesses changed and the characteristics of evacuated soldiers changed as well.&lt;/p&gt;
&lt;p&gt;The proportion of evacuations related to combat injuries climbed steadily in Afghanistan, from 10% in 2004 to 19% in 2007. Injuries from combat also increased over time in Iraq but not as much: from 24% of evacuations to 28% during the study period.&lt;/p&gt;
&lt;p&gt;But by 2007, combat wounds had become only the fourth most common reason for evacuation in both regions.&lt;/p&gt;
&lt;p&gt;Musculoskeletal and connective tissue disorders held steadily as the number one reason throughout the study period, ranging from 21% to 28%.&lt;/p&gt;
&lt;p&gt;But non-combat neurological and psychiatric disorders both increased substantially, especially the latter.&lt;/p&gt;
&lt;p&gt;Evacuations for psychiatric conditions soared from 5% to 6% of the total in 2004 to about 13% in 2007. Neurological disorders accounted for about 10% of evacuations early in the conflicts, rising to more than 12% in 2007. These figures did not differ substantially between Iraq and Afghanistan.&lt;/p&gt;
&lt;p&gt;Most of the evacuees did not return to duty: about 80% of those shipped from Iraq and 75% from Afghanistan.&lt;/p&gt;
&lt;p&gt;Although overall return-to-duty rates changed little with time, evacuations for some types of illness did increase or decrease.&lt;/p&gt;
&lt;p&gt;Personnel evacuated because of infectious disease became more likely to see service again  --  37% returned to active duty in 2007, compared with 8% in 2004. Cohen and colleagues identified better control of leishmaniasis as at least partly responsible for the increase.&lt;/p&gt;
&lt;p&gt;More significantly, the researchers indicated, return-to-duty rates declined progressively after 2004 for psychiatric evacuees, Cohen and colleagues reported.&lt;/p&gt;
&lt;p&gt;By 2007, only 7% of psychiatric evacuees from Iraq and 4% of those from Afghanistan were returning to duty.&lt;/p&gt;
&lt;p&gt;The researchers also found that, among particular types of psychiatric illness, personnel with stress reactions, depression, and bipolar disorder were least likely to return to duty.&lt;/p&gt;
&lt;p&gt;They also found that individuals with back pain were also more unlikely than most evacuees to return to duty.&lt;/p&gt;
&lt;p&gt;In their report, Cohen and colleagues said these latter trends were potentially related.&lt;/p&gt;
&lt;p&gt;&quot;The parallels between emotional distress and spinal pain are intriguing. Findings from several studies in patients presenting with back or neck pain have established that the major risk factors for disability and persistence are psychosocial (e.g., anxiety, depression, poor coping skills, and low job satisfaction),&quot; they wrote.&lt;/p&gt;
&lt;p&gt;&quot;As survival rates of combat injuries increase, and the burden of non-battle-related injuries and psychiatric disorders continues to soar, society must be prepared to deal with the aftermath of these injuries,&quot; Cohen and colleagues concluded.&lt;/p&gt;
&lt;p&gt;In an accompanying commentary, J. Don Richardson, MD, of St. Joseph&apos;s Health Care in London, Ontario, and colleagues also found the results on psychiatric evacuees most striking in the study.&lt;/p&gt;
&lt;p&gt;&quot;The low rate of return to duty in service personnel evacuated for psychiatric conditions warrants further study, and [the] article points out the importance of cumulative stress in repeated deployments and the physical and mental demands on the military member and their family,&quot; Richardson and colleagues wrote.&lt;/p&gt;
&lt;p&gt;&quot;The low rate of return to duty might be related to the nature of the combat operation for which military commanders might be reluctant to deploy an individual with a psychiatric diagnosis to a combat zone,&quot; they speculated.&lt;/p&gt;
&lt;p&gt;&quot;Early intervention becomes crucial to help promote recovery because military members often experience substantial stigma disclosing symptoms of PTSD and other psychiatric problems,&quot; Richardson and colleagues added.&lt;/p&gt;
&lt;p&gt;They also suggested that military doctors &quot;should have a high index of suspicion&quot; for PTSD when soldiers present with spinal pain or other somatic complaints, &quot;especially if there is a physical injury.&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 the federally funded John P. Murtha Neuroscience and Pain Institute and the U.S. Army.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported by study authors or the editorialists.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_222"
                     title="Benefits of Cutting Down on Salt Quantified (CME/CE)"
                     score="-0.002"
                     href="http://www.medpagetoday.com/Cardiology/Prevention/tb/18075?impressionId=1265720990680"
                     
      &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_209"
                     title="Effect of Beta-Blocker Add-On Therapy Quantified (CME/CE)"
                     score="-0.002"
                     href="http://www.medpagetoday.com/Cardiology/Hypertension/tb/18055?impressionId=1265720990680"
                     
      Beta-blockers achieve statistically significant, dose-dependent decreases in blood pressure when added to a diuretic or calcium-channel blocker, a systematic review of published studies showed.&lt;br&gt;
&lt;br&gt;The blood pressure benefits occurred with beta-blocker doses as low as 25% of the recommended dose and reached reductions of 8/6 mm Hg with add-on doses that were twice the recommended starting dose.&lt;br&gt;
&lt;br&gt;A comparison with a previous review of add-on diuretic therapy showed that beta-blockers and diuretics achieved similar reductions in systolic blood pressure, but beta-blockers had a greater effect on diastolic pressure, according to a report in the &lt;em&gt;Cochrane Database of Systematic Reviews&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;The difference in pattern of blood pressure lowering shown for beta-blockers in this review as compared to thiazide diuretics in our previous review is a new finding with important clinical implications,&quot; Jenny Chen, of the University of British Columbia in Vancouver, and colleagues wrote.&lt;/p&gt;
&lt;p&gt;&quot;The important difference in the pattern is that second-line beta-blockers have little or no effect on pulse pressure, whereas second-line thiazides significantly decrease pulse pressure in a dose-dependent manner. This difference in the pattern of blood pressure lowering with beta-blockers as compared to thiazides might explain why beta-blockers appear to be less effective at reducing adverse cardiovascular outcomes than thiazide diuretics, particularly in older individuals.&quot;&lt;/p&gt;
&lt;p&gt;For many clinicians, low-dose monotherapy remains the initial approach to treatment of hypertension. However, studies have shown that most patients require combination therapy to reach blood pressure goals. Knowing the additive blood pressure effects of different drugs is essential for clinical decision-making related to second-line antihypertensive therapy, the authors noted.&lt;/p&gt;
&lt;p&gt;Noting an absence of large randomized clinical trials comparing combination therapy with beta-blockers versus other drugs, the authors performed a systematic review of published data with two principal objectives: &lt;ul&gt; &lt;li&gt;Quantify the additional blood pressure reduction achieved with a second-line beta-blocker versus placebo&lt;/li&gt; &lt;li&gt;Quantify the variability of blood pressure and the effect on pulse pressure, heart rate, and withdrawals due to adverse effects with add-on beta-blocker therapy&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Investigators limited their review to randomized clinical trials that had a double-blind design, parallel design with random allocation to treatment groups, at least two-week washout period prior to randomization, and minimum treatment duration of three to 12 weeks.&lt;/p&gt;
&lt;p&gt;Additionally, the analysis included only studies that compared a beta-blocker plus another class of antihypertensive drug versus the other drug alone.&lt;/p&gt;
&lt;p&gt;The review yielded 20 clinical trials that met inclusion criteria. The trials involved a total of 3,744 patients who had a baseline blood pressure of 158/102 mmHg. The estimated blood pressure reduction with beta-blocker add-on therapy was determined by comparing the blood pressure reduction with and without the beta-blocker.&lt;/p&gt;
&lt;p&gt;The trials evaluated beta-blocker add-on doses that ranged from 0.25 to eight times the recommended starting dose. The magnitude of blood pressure reduction ranged from 2.9/1.4 mm Hg at 0.25 the usual starting dose to 10.2/8.8 mmHg with an add-on dose that was eight times greater than the usual starting dose.&lt;/p&gt;
&lt;p&gt;The blood pressure reduction with the usual beta-blocker starting dose was 5.9/4.3 mm Hg, increasing to 8.0/6.3 mmHg with an add-on dose that was double the usual starting dose.&lt;/p&gt;
&lt;p&gt;The reduction in systolic pressure was almost identical to that observed by Chen and colleagues in a previous review of add-on therapy with thiazide diuretics (&lt;em&gt;Cochrane Database Syst Rev&lt;/em&gt; 2009; 7(4): CD007187). However, add-on therapy with a diuretic had a smaller effect on diastolic blood pressure.&lt;/p&gt;
&lt;p&gt;Only five of the 20 trials evaluated the addition of a beta-blocker to a dihydropyridine calcium-channel blocker. However, the blood pressure-reducing effects of adding a beta-blocker were comparable to those observed when a beta-blocker was added to a diuretic, the authors reported.&lt;/p&gt;
&lt;p&gt;None of the trials examined the effects of beta-blocker add-on therapy on pulse pressure. The authors calculated effects on pulse pressure by subtracting the change in diastolic pressure from the change in systolic pressure in both treatment arms.&lt;/p&gt;
&lt;p&gt;Across the range of doses studied, beta-blocker add-on therapy achieved a nonsignificant reduction in pulse pressure that averaged about 2 mmHg. Blood pressure variability also did not differ significantly between combination and monotherapy treatment arms.&lt;/p&gt;
&lt;p&gt;Adding a beta-blocker to existing antihypertensive therapy resulted in a reduction in heart rate that averaged about 10 bpm with add-on doses of one to two times the usual starting dose.&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 authors had no disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
</recommendedContent>