<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_449"
                     title="FDA Okays Statin for Primary Prevention"
                     score="0.011"
                     href="http://www.medpagetoday.com/InfectiousDisease/PublicHealth/tb/18380?impressionId=1265795427335"
                     
      &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_443"
                     title="Evidence-Based Treatment Improves Older Stroke Victims&apos; Chances (CME/CE)"
                     score="0.011"
                     href="http://www.medpagetoday.com/Cardiology/Strokes/tb/18360?impressionId=1265795427335"
                     
      &lt;p&gt;Older stroke patients remain at higher risk for adverse outcomes than younger ones, but the gap has narrowed with wider implementation of evidence-based guidelines, researchers say.&lt;/p&gt;
&lt;p&gt;More than 10% of stroke patients over 80 died in the hospital, compared with 3% of those under age 50, Gregg C. Fonarow, MD, of the University of California Los Angeles, and colleagues reported online in &lt;em&gt;Circulation&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;But overall use of guideline-recommended therapies improved substantially in older patients from 2003 to 2009, particularly for patients over 90, they said.&lt;/p&gt;
&lt;p&gt;During that time, several hospitals and stroke centers have adopted &quot;Get with the Guidelines,&quot; an intervention to apply evidence-based guidelines to care. Adopters have seen &quot;substantial improvements ... in performance measures for ischemic stroke patients, including pharmacological and nonpharmacological management in each age group,&quot; the researchers wrote.&lt;/p&gt;
&lt;p&gt;Before launching the initiative in 2003, studies generally showed lower use of guideline-recommended therapy and worse outcomes in older stroke patients.&lt;/p&gt;
&lt;p&gt;To assess changes since initiative started, the researchers analyzed more than 502,036 ischemic stroke admissions to 1,256 hospitals participating in the guidelines program between 2003 and 2009. Mean patient age was 71, and 52.5% were women.&lt;/p&gt;
&lt;p&gt;They found that performance on most evidence-based measures was lower in older patients  --  those ages 80 and up  --  compared with younger patients.&lt;/p&gt;
&lt;p&gt;The largest differences were seen in the proportion of eligible patients who received intravenous tissue plasminogen activator (tPA) treatments (51.1% for older patients versus 61.6% for those under 50, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;Providers were also less likely to treat older stroke patients with lipid-lowering therapies than younger patients (54.2% versus 71.7%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;The smallest differences involved antithrombotic therapy within 48 hours of admission and at discharge.&lt;/p&gt;
&lt;p&gt;In terms of outcomes, older patients had a significantly higher inhospital mortality rate (10.3% versus 3%), and they were less likely to be discharged home. Rather, they were more likely to be discharged to a skilled nursing facility (42.1% versus 5.3%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) or hospice (12% versus 0.5%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;With each 10-year age increase, patients with ischemic stroke were 31% less likely to be discharged home and 27% more likely to die in the hospital.&lt;/p&gt;
&lt;p&gt;But the researchers said that, generally, the use of guideline-recommended therapies improved substantially in older patients from 2003 to 2009.&lt;/p&gt;
&lt;p&gt;In those ages 90 and older, use of intravenous tPA increased threefold, from 20.4% in 2003 to 62.4% in 2009. And use of lipid lowering therapy increased from 15.6% in 2003 to 71.7%.&lt;/p&gt;
&lt;p&gt;The researchers wrote that by 2009, &quot;many of the age-related differences in care had narrowed or were eliminated.&quot;&lt;/p&gt;
&lt;p&gt;They cautioned, however, that there could be residual confounding by unmeasured factors. For example, physicians may be uncertain about risks versus benefits in treating older patients who are under-represented in RCTs.&lt;/p&gt;
&lt;p&gt;The authors noted that their study was limited by its reliance on the accuracy and completeness of medical records.&lt;/p&gt;
&lt;p&gt;Also, they noted, the &quot;Get with the Guidelines&quot; program tends to attract larger teaching hospitals, which already have a &quot;strong interest in stroke care and quality improvement,&quot; and thus the findings may not be generalizable.&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 &quot;Get with the Guidelines&quot; program is supported by the American Heart Association and the American Stroke Association, as well as grants from Pfizer and the Merck-Schering Plough Partnership.&lt;/p&gt;&lt;p&gt;Fonarow reported relationships with Pfizer, Merck/Schering Plough, BMS/Sanofi.&lt;/p&gt;&lt;p&gt;Co-authors reported relationships with Boehringer Ingelheim, Ferrer, CoAxia, Talecris, Concentric Medical, and Cygnis.&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=1265795427335"
                     
      &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_358"
                     title="Poststroke Antidepressant Boosts Mental Agility (CME/CE)"
                     score="0.008"
                     href="http://www.medpagetoday.com/Cardiology/Strokes/tb/18240?impressionId=1265795427335"
                     
      &lt;p&gt;Antidepressants in the first months after a stroke may aid cognitive recovery for patients without depression, according to a randomized trial analysis.&lt;/p&gt;
&lt;p&gt;Global cognitive function scores improved significantly more with escitalopram (Lexapro) than with problem-solving therapy or placebo (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01), according to Ricardo E. Jorge, MD, of the University of Iowa in Iowa City, and colleagues.&lt;/p&gt;
&lt;p&gt;Memory scores rose significantly higher with the antidepressant as well (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01), with both effects independent of those on depression, they reported in the February &lt;em&gt;Archives of General Psychiatry&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;Adjunctive restorative therapies administered during the first few months after stroke, the period with the greatest degree of spontaneous recovery, reduce the number of stroke patients with significant disability,&quot; the researchers concluded.&lt;/p&gt;
&lt;p&gt;The &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/Strokes/9621&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/Strokes/9621&quot; target=&quot;_blank&quot;&gt;primary analysis&lt;/a&gt; of the trial, reported in the &lt;em&gt;Journal of the American Medical Association on&lt;/em&gt; May 28, 2008, showed that prophylactic escitalopram treatment would prevent poststroke depression in one patient for every 7.2 treated &lt;em&gt;(P&lt;/em&gt;&amp;lt;0.001 compared with placebo). That article ultimately raised a controversy over an undisclosed conflict of interest.&lt;/p&gt;
&lt;p&gt;Escitalopram is a selective serotonin reuptake inhibitor (SSRI). Since serotonin plays a role in neuroplastic changes in the developing brain as well as in depression, Jorge&apos;s group analyzed whether there might be such an effect after a stroke.&lt;/p&gt;
&lt;p&gt;The study randomized patients to double-blind treatment with escitalopram (10 mg/d under age 65 or 5 mg/day age 65 and older) or placebo or unblinded problem-solving therapy (12 sessions of going through steps to arrive at a course of action for a patient-selected problem).&lt;/p&gt;
&lt;p&gt;The intent-to-treat analysis included 129 patients treated starting within the first three months after their mild to moderate severity stroke and who did not meet criteria for major or minor depression.&lt;/p&gt;
&lt;p&gt;Overall, global cognitive functioning was significantly changed between groups as measured on the Repeatable Battery for the Assessment of Neuropsychological Status (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01).&lt;/p&gt;
&lt;p&gt;After controlling for change in depression score and type of stroke, escitalopram was associated with the best cognitive recovery, an adjusted mean change of 9.9 points compared with 1.9 for problem-solving therapy (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01) and 4.0 for placebo (&lt;em&gt;P&lt;/em&gt;=0.02).&lt;/p&gt;
&lt;p&gt;Similarly, for delayed memory scores on the same test battery, escitalopram came out on top (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01).&lt;/p&gt;
&lt;p&gt;After adjustment for depression score change and stroke mechanism, the antidepressant was associated with an 11.2 point improvement in delayed memory, compared with a change of -0.7 with problem-solving therapy (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) and 3.9 with placebo (&lt;em&gt;P&lt;/em&gt;=0.02).&lt;/p&gt;
&lt;p&gt;On test of immediate memory, escitalopram again yielded the best recovery.&lt;/p&gt;
&lt;p&gt;The researchers found mean improvement of 13.4 points with the antidepressant compared with 2.0 with problem-solving therapy (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) and 7.2 with placebo (&lt;em&gt;P&lt;/em&gt;=0.04), after adjustment for time between stroke and treatment, depression score change, and stroke type.&lt;/p&gt;
&lt;p&gt;These mental benefits appeared to have an impact on functional status as well.&lt;/p&gt;
&lt;p&gt;Cognitive domain scores on the Functional Independence Measure were better for escitalopram-treated patients than those who didn&apos;t get the drug (&lt;em&gt;P&lt;/em&gt;=0.05), as were memory domain scores on the same measure (&lt;em&gt;P&lt;/em&gt;=0.03).&lt;/p&gt;
&lt;p&gt;At baseline, the global cognitive functioning and delayed and immediate memory scores were nonsignificantly lower in the antidepressant group than in the other two groups, which could have biased the results.&lt;/p&gt;
&lt;p&gt;However, the treatment effects appeared to be real, Jorge explained in an interview.&lt;/p&gt;
&lt;p&gt;In an unpublished regression analysis, the baseline scores were not a significant covariate. &quot;If [the results were] related only to the difference in baseline, this would be significant but it wasn&apos;t,&quot; he told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Moreover, with an initially lower score it might have been expected that the escitalopram-treated group would have had a lower score at the end of the study than the other groups, added co-author Robert G. Robinson, MD, also of the University of Iowa.&lt;/p&gt;
&lt;p&gt;But that wasn&apos;t the case, he said in an interview. With regard to delayed memory, for example, &quot;the escitalopram-treated group went from the most impaired to the best performing.&quot;&lt;/p&gt;
&lt;p&gt;The researchers didn&apos;t compare end scores for the escitalopram, problem solving therapy, and placebo groups, but they were: &lt;ul&gt; &lt;li&gt;For global cognitive functioning 89.8, 89.1, and 91.0 points, respectively&lt;/li&gt; &lt;li&gt;For delayed memory, 96.6, 89.1, and 94.2, respectively&lt;/li&gt; &lt;li&gt;For immediate memory, 95.1, 94.9, and 98.5, respectively&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The treatment showed no effect on other individual cognitive measurements, including those for attention, language, and IQ. Nor were there significant differences in changes in occupational or living conditions.&lt;/p&gt;
&lt;p&gt;Although SSRIs such as escitalopram have been associated with hospitalization for GI bleeding and falls in prior studies, these complications did not occur in Jorge&apos;s study.&lt;/p&gt;
&lt;p&gt;&quot;Long-term administration of SSRIs appears to be an effective and safe treatment option to improve cognitive outcomes among patients with cerebrovascular disease,&quot; they concluded in the &lt;em&gt;Archives&lt;/em&gt; paper.&lt;/p&gt;
&lt;p&gt;The researchers cautioned that the study was limited by lack of CT or MRI scans and the younger age of escitalopram-treated patients, compared with other groups. That may have been a source of bias, although age did not appear to be a significant factor in the trial results.&lt;/p&gt;
&lt;p&gt;In this analysis, the researchers emphasized that the trial was not financially supported in any way by any drug company  --  a declaration hinting at the controversy that brewed last year over failure of one of the authors of the original &lt;em&gt;JAMA&lt;/em&gt; article to &lt;a href=&quot;http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/13391&quot; mce_href=&quot;http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/13391&quot; target=&quot;_blank&quot;&gt;properly disclose ties&lt;/a&gt; to Forest Pharmaceuticals, which makes escitalopram.&lt;/p&gt;
&lt;p&gt;Another scientist who discovered that omission published the information in a competing journal, inducing &lt;em&gt;JAMA&lt;/em&gt; to issue a gag rule on reporting of undisclosed conflicts of interest. That policy encourages those who discover such conflicts to report them to &lt;em&gt;JAMA&apos;s&lt;/em&gt; editors but prohibits them from disclosing the conflicts publicly pending an investigation by the journal.&lt;/p&gt;
&lt;p&gt;In the current analysis, the disclosure statement indicated that co-author Robertson, had received honoraria and speakers&apos; bureau fees from Forest, with the caveat that &quot;none of the design, analysis, or expenses (including the cost of medications) of this study were supported by monies, materials, or any intellectual input from Forest Laboratories.&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 solely by a grant from the National Institute of Mental Health.&lt;/p&gt;&lt;p&gt;Jorge reported having received travel awards to participate in national meetings from the former Hamilton Pharmaceutical Company and Avanir Pharmaceutical Company.&lt;/p&gt;&lt;p&gt;Co-authors reported financial conflicts of interest with Merck, NMT Medical, Eli Lilly, Centocor, Sanofi-Bristol-Meyers-Squibb, Boerhringer-Ingelheim, Schering-Plough, AstraZeneca, and GlaxoSmithKline, the former Hamilton Pharmaceutical Company, Avanir Pharmaceutical Company, Lubeck, Forest Laboratories, and Pfizer.&lt;/p&gt;&lt;p&gt;No pharmaceutical company donated medications for or had any financial interest in the study.&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="0.006"
                     href="http://www.medpagetoday.com/Cardiology/CHF/tb/18193?impressionId=1265795427335"
                     
      &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;
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