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    <recommendedItem id="20100101_19_222"
                     title="Benefits of Cutting Down on Salt Quantified (CME/CE)"
                     score="-0"
                     href="http://www.medpagetoday.com/Cardiology/Prevention/tb/18075?impressionId=1265742570985"
                     
      &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_187"
                     title="Lower Afib Risk Seen with Some Antihypertensives More than Others (CME/CE)"
                     score="-0.002"
                     href="http://www.medpagetoday.com/Cardiology/Arrhythmias/tb/18022?impressionId=1265742570985"
                     
      &lt;p&gt;Hypertensive patients treated with angiotensin-converting enzyme (ACE) inhibitors, angiotensin II-receptor blockers (ARBs), or beta-blockers have a lower risk for atrial fibrillation than those treated with calcium channel blockers, a nested case-control analysis found.&lt;/p&gt;
&lt;p&gt;Compared with a reference group taking calcium channel blockers, patients receiving one of the other classes of drugs for 12 months or more had lower adjusted odds ratios for atrial fibrillation, according to a report in the Jan. 19 &lt;em&gt;Annals of Internal Medicine&lt;/em&gt;. The findings were as follows: &lt;ul&gt; &lt;li&gt;ACE inhibitors, OR 0.75 (95% CI 0.65 to 0.87, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001)&lt;/li&gt; &lt;li&gt;ARBs, OR 0.71 (95% CI 0.57 to 0.89, &lt;em&gt;P&lt;/em&gt;=0.003)&lt;/li&gt; &lt;li&gt;Beta-blockers, OR 0.78 (95% CI 0.67 to 0.92, &lt;em&gt;P&lt;/em&gt;=0.002)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Antihypertensive drugs lower the risk of atrial fibrillation by reducing blood pressure and thereby decreasing wall stress, as well as by other mechanisms such as through effects on atrial remodeling, Beat A. Schaer, MD, of University Hospital Basel, Switzerland, and colleagues explained.&lt;/p&gt;
&lt;p&gt;Because current opinions about the relative effects of the various classes of drugs on risk of atrial fibrillation are conflicting, Schaer and colleagues turned to the U.K. General Practice Research Database, identifying 4,661 patients who had atrial fibrillation and 18,642 matched controls from a population of 682,993 patients treated for high blood pressure between January 1998 and the spring of 2008.&lt;/p&gt;
&lt;p&gt;Some 62% were ages 70 and older, and 47% were men.&lt;/p&gt;
&lt;p&gt;Patients whose body mass index was 30 kg/m&lt;sup&gt;2&lt;/sup&gt; or greater were at greater risk for atrial fibrillation than those with normal weight (OR 1.71, 95% CI 1.56 to 1.88), while current smoking was associated with a lower risk (OR 0.81, 95% CI 0.72 to 0.90).&lt;/p&gt;
&lt;p&gt;In the study, 2,913 patients were treated exclusively with ACE inhibitors, 899 with ARBs, 2,467 with beta-blockers, and 2,375 with calcium channel blockers.&lt;/p&gt;
&lt;p&gt;Inclusion in the study required that patients be receiving only one of these drugs and therefore were likely to have mild-to-moderate hypertension. Concurrent treatment with diuretics was permitted.&lt;/p&gt;
&lt;p&gt;Only patients with true atrial fibrillation were included, as determined by a diagnosis followed with the introduction of new treatment with antiarrhythmic agents or referral to a cardiologist within 90 days.&lt;/p&gt;
&lt;p&gt;Patients with risk factors such as a history of arrhythmias, ischemic heart disease, or congestive heart failure were excluded. This left a relatively homogeneous sample of patients who were hypertensive but were unlikely to have structural heart disease.&lt;/p&gt;
&lt;p&gt;&quot;This allowed us to focus on the possible effects of the drugs of interest, which would not be possible with a sample that had a high prevalence of atrial fibrillation risk factors,&quot; the investigators noted.&lt;/p&gt;
&lt;p&gt;While the effects of ACE inhibitors and ARBs are thought to relate to their interference with the renin-angiotensin system and atrial remodeling, the positive effects of beta-blockers may be through prevention of premature atrial contractions.&lt;/p&gt;
&lt;p&gt;The study had limitations, the authors acknowledged, such as the fact that they could not assess the effect of blood pressure reduction because this was not routinely recorded.&lt;/p&gt;
&lt;p&gt;In addition, the results may have been affected by the concomitant use of diuretics, although investigators believed inclusion of patients taking diuretics was reasonable because many antihypertensive agents are combined with a small dose of diuretic.&lt;/p&gt;
&lt;p&gt;The investigators also pointed out that they could not determine why patients were treated with the different classes of drugs, and that overall health status and severity of hypertension may have varied among patient groups.&lt;/p&gt;
&lt;p&gt;They concluded that their analysis provides evidence that ACE inhibitors, ARBs, and beta-blockers reduce the risk of atrial fibrillation but called for future research to confirm their findings.&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 received no funding for the study and disclosed no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_130"
                     title="Dementia, Hypertension Linked Again (CME/CE)"
                     score="-0.004"
                     href="http://www.medpagetoday.com/Cardiology/Hypertension/tb/17944?impressionId=1265742570985"
                     
      Another study has found that hypertension may contribute to increased risk of dementia, this time with evidence of actual brain abnormalities.&lt;br&gt;
&lt;br&gt;Data from an offshoot of the Women&apos;s Health Initiative found that participants&apos; baseline blood pressure was strongly correlated with volume of lesions in their brains&apos; white matter, according to Lewis Kuller, MD, DrPH, of the University of Pittsburgh, and colleagues.&lt;br&gt;
&lt;br&gt;Along with earlier studies linking blood pressure to clinical dementia, the evidence &quot;supports tight control of blood pressure levels, especially beginning at younger and middle age as a possible and perhaps only way to prevent dementia,&quot; Kuller and colleagues concluded online in the &lt;em&gt;Journal of Clinical Hypertension&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;One study reported in 2006 found that successful hypertension control reduced the risk of dementia, while another reported the following year indicated that uncontrolled high blood pressure increased the risk. (See &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/Hypertension/3037&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/Hypertension/3037&quot; target=&quot;_blank&quot;&gt;Blood Pressure Medication May Benefit Older Brains&lt;/a&gt; and &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/VASCOG/6147&quot; mce_href=&quot;http://www.medpagetoday.com/MeetingCoverage/VASCOG/6147&quot; target=&quot;_blank&quot;&gt;VAS-COG: Hypertension Linked to Cognitive Decline in Older Patients&lt;/a&gt;)&lt;/p&gt;
&lt;p&gt;Kuller and colleagues analyzed data collected from 1,424 participants in the Women&apos;s Health Initiative who agreed to undergo MRI scans performed an average of eight years after starting the trial. Blood pressure was measured at baseline and annually throughout the trial.&lt;/p&gt;
&lt;p&gt;About half the women had been assigned to placebo in the trial, which primarily was designed to test two hormone replacement regimens. Some 436 received a combination of conjugated equine estrogen and medroxyprogesterone acetate, while the remainder received the equine estrogen alone.&lt;/p&gt;
&lt;p&gt;Kuller and colleagues found significant relationships between baseline systolic blood pressure and abnormal white matter lesion volumes as measured with MRI.&lt;/p&gt;
&lt;p&gt;Among participants not taking blood pressure medications, the lesion volume averaged 4.07 cm&lt;sup&gt;3&lt;/sup&gt; for those with baseline pressure of less than 100 mm Hg, compared with 5.20 cm&lt;sup&gt;3&lt;/sup&gt;among those with systolic pressure of 140 mm Hg or higher (&lt;em&gt;P&lt;/em&gt;=0.0044 for trend).&lt;/p&gt;
&lt;p&gt;A similar but weaker relationship was seen for lesion volumes according to systolic pressure at the last available measurement (&lt;em&gt;P&lt;/em&gt;=0.03) among subjects who were not on antihypertensive therapy.&lt;/p&gt;
&lt;p&gt;Baseline systolic pressure was also significantly correlated with lesion volumes in women taking blood pressure drugs, Kuller and colleagues reported.&lt;/p&gt;
&lt;p&gt;Women with baseline pressure below 100 mm Hg had lesion volumes averaging 5.56 cm&lt;sup&gt;3&lt;/sup&gt; whereas those with pressures of 140 mm Hg or higher at baseline had average lesion volume of 6.09 mm Hg (&lt;em&gt;P&lt;/em&gt;=0.002 for trend).&lt;/p&gt;
&lt;p&gt;There was a nonsignificant trend toward higher lesion volumes with increasing systolic pressure at the last measurement.&lt;/p&gt;
&lt;p&gt;After adjusting for age, race, treatment assignment, total cranial volume, clinical site, and time from study termination to MRI scan, the researchers found that women with normal blood pressure (&amp;lt;140/90 mm Hg) had lower lesion volumes, not only in their white matter but also in the basal ganglia, than participants with high blood pressure.&lt;/p&gt;
&lt;p&gt;The finding held both for baseline blood pressure measurements and for pressure at the last available evaluation (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001 for all comparisons).&lt;/p&gt;
&lt;p&gt;High baseline blood pressure, though not later measurements, was also significantly correlated with the number of brain regions containing abnormal white matter lesions (&lt;em&gt;P&lt;/em&gt;=0.035).&lt;/p&gt;
&lt;p&gt;Regions in which high blood pressure seemed to promote abnormal lesions most strongly included frontal, parietal, and temporal lobes in both hemispheres. The frontal lobes in particular have been associated with vascular dementia and abnormal performance on cognition tests.&lt;/p&gt;
&lt;p&gt;Occipital lobes and the corpus callosum did not appear significantly affected, the MRI data indicated.&lt;/p&gt;
&lt;p&gt;&quot;The association of blood pressure levels with white matter abnormalities years before the MRI is consistent with a long incubation period for the development of the white matter abnormalities,&quot; Kuller and colleagues wrote.&lt;/p&gt;
&lt;p&gt;They said their findings are also consistent with earlier observations that midlife blood pressure is more strongly related to dementia later on than is blood pressure measured at older ages.&lt;/p&gt;
&lt;p&gt;Kuller and colleagues cautioned that it remained uncertain whether blood pressure treatment can prevent development of white matter abnormalities. Nor is it clear what the most appropriate blood pressure targets should be, or what type of treatment may be best.&lt;/p&gt;
&lt;p&gt;&quot;We have only suggestive evidence that the progression of white matter lesions can be slowed by blood pressure-lowering therapy,&quot; they wrote, calling for more clinical trials to clear up these issues.&lt;/p&gt;
&lt;p&gt;Nevertheless, they concluded, &quot;a prudent clinical approach at present would encourage maintaining as low a blood pressure as possible, especially beginning in young and middle ages, in order to possibly prevent dementia as well as stroke. There are no other potentially effective preventive therapies.&quot;&lt;/p&gt;
&lt;p&gt;Study limitations included a lack of MRI data on brain infarcts, no corroborating clinical data on cognitive performance, and, of course, the trial&apos;s restriction to women.&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;Wyeth funded the data analysis in this study. The Women&apos;s Health Initiative was sponsored by the National Heart, Lung, and Blood Institute.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_2_405"
                     title="Hypertension Linked to Risk of Cognitive Impairment"
                     score="-0.005"
                     href="