<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_459"
                     title="Murtha Dead at 77"
                     score="0.011"
                     href="http://www.medpagetoday.com/Washington-Watch/Washington-Watch/tb/18388?impressionId=1265764512769"
                     
      &lt;p&gt;Representative John P. Murtha (D-Pa.), 77, long-time chairman of the House Appropriations Subcommittee on Defense, died yesterday afternoon from complications following a planned laparoscopic cholecystectomy, according to a statement from the congressman&apos;s office.&lt;/p&gt;
&lt;p&gt;He had been admitted to the intensive care unit at Virginia Hospital Center in Arlington on Jan. 31, days after surgeons at the National Naval Medical Center in Bethesda, Md., accidentally nicked his intestine during the operation, according to a report in &lt;em&gt;The Washington Post&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;In that same report, Rep. Bob Brady (D-Pa.), a close friend of Murtha&apos;s, said the congressman developed an infection and fever.&lt;/p&gt;
&lt;p&gt;Citing a request for privacy from the Murtha family and patient privacy laws, a spokesperson for the National Naval Medical Center declined to provide information on the operation.&lt;/p&gt;
&lt;p&gt;In a statement, Virginia Hospital Center said Murtha died &quot;despite aggressive critical care interventions.&quot;&lt;/p&gt;


  &lt;p&gt;Mark Malangoni, MD, surgeon-in-chief at MetroHealth Medical Center in Cleveland, told &lt;em&gt;MedPage Today&lt;/em&gt; that serious complications, including bowel damage and death, are not common following cholecystectomy. More complicated patients, such as the obese and diabetics, have a greater risk of complications and of a switch to an open procedure.&lt;/p&gt;
    &lt;p&gt;Death is extremely rare in healthy individuals, occurring in no more than one per 1,000 patients, according to the American College of Surgeons (ACS).
    &lt;p&gt;More common, but still infrequent, are bleeding and leakage of bile, both of which can be treated fairly easily, said Malangoni, a regent of the ACS.&lt;/p&gt;


&lt;p&gt;When the bowel is damaged, as reportedly occurred in Murtha&apos;s case, it typically occurs in two ways -- either from a sharp injury when the trocars used for a laparoscopic procedure are inserted or from a cautery burn.
    &lt;p&gt;Both types of injury can go unnoticed by the surgeon and may not become apparent for days after the operation, Malangoni said.&lt;p&gt;
    &lt;p&gt;Although he did not know the details of Murtha&apos;s case, Malangoni said a patient would usually be admitted right away, at least overnight, if the surgeon realized that an injury had occurred. The procedure likely would have switched from a laparoscopic one to an open one as well.&lt;/p&gt;


&lt;p&gt;A 2009 Cochrane Review comparing laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis found no difference in mortality in 38 trials. No patients died in the laparoscopic group and only 0.09% died in the open group.&lt;/p&gt;
&lt;p&gt;Severe complications were reported in 2.2% of the laparoscopic patients and 6.8% of the open patients.&lt;/p&gt;


 &lt;p&gt;Malangoni said most surgeons become experienced with performing laparoscopic cholecystectomies before completing their residency; most will perform 40 or 50 by the end of training.&lt;p&gt;
    &lt;p&gt;&quot;It is a very common operation, so once out into practice, most general surgeons are doing dozens of these each year,&quot; he said. &quot;So your experience comes about pretty quickly.&quot;
    &lt;p&gt;It is unclear how much experience Murtha&apos;s surgeon had.&lt;/p&gt;

&lt;p&gt;Murtha had recently become the longest serving member of Congress in Pennsylvania state history.&lt;/p&gt;
&lt;p&gt;First elected in 1974, Murtha, a former Marine, was the first Vietnam War combat veteran to serve in Congress, and he served as an advocate for the military throughout his career. He was also a prominent critic of the Iraq War.&lt;/p&gt;
&lt;p&gt;Murtha is survived by his wife, Joyce, and three children.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_448"
                     title="Inflammatory Bowel Disease Linked to Dangerous VT (CME/CE)"
                     score="0.011"
                     href="http://www.medpagetoday.com/Gastroenterology/InflammatoryBowelDisease/tb/18362?impressionId=1265764512769"
                     
      &lt;p&gt;Patients with active inflammatory bowel disease (IBD) could be at far greater risk for potentially deadly blood clots than doctors previously thought, a new British study found.&lt;/p&gt;
&lt;p&gt;Nonhospitalized patients with active IBD are 16 times more likely to suffer venous thromboembolism than the general population, with an occurrence rate of 6.4 per 1,000 person-years (HR 15.8, 95% CI 9.8 to 25.5, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001), according to an online report in the Feb. 9 issue of &lt;em&gt;The Lancet&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;The authors concluded that such patients could benefit from preventative treatment to prevent blood clotting.&lt;/p&gt;
&lt;p&gt;&quot;Despite the low absolute risks during nonhospitalised periods, these results suggest that active inflammatory bowel disease in ambulatory patients might be a far greater risk factor for venous thromboembolism than previously recognised,&quot; Matthew J. Grainge, MD, of the University of Nottingham, and colleagues wrote.&lt;/p&gt;
&lt;p&gt;Patients with venous thromboembolism in the leg have a short term-mortality rate of about 6%, increasing as high as 20% when the clot has circulated to the lung.&lt;/p&gt;
&lt;p&gt;Researchers believe that infection and inflammation, such as occur in IBD, predispose patients to this life-threatening condition, and those with inflammatory bowel disease seem to be at particular risk.&lt;/p&gt;
&lt;p&gt;Grainge and colleagues used records from the U.K. General Practice Research Database from November 1987 through July 2001, to match 13,756 patients with IBD against 71,672 controls without the disease.&lt;/p&gt;
&lt;p&gt;Of the subjects, 139 patients and 165 controls developed a blood clot during the study period.&lt;/p&gt;
&lt;p&gt;Their results agreed with previous studies indicating that patients hospitalized for IBD are at high risk for venous thromboembolism. However, the new study also found the danger extends to nonhospitalized IBD patients, particularly during a flare-up.&lt;/p&gt;
&lt;p&gt;Overall, the researchers reported, patients with IBD had three times as much risk of an embolism as controls (HR 3.4, 95% CI 2.7 to 4.3; &lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001) with an occurrence rate of 2.6 per 1,000 per person-years.&lt;/p&gt;
&lt;p&gt;During a flare-up, IBD patients were at dramatically greater risk.&lt;/p&gt;
&lt;p&gt;The researchers cautioned that the study excluded patients likely to have received corticosteroids for chronic respiratory disease and rheumatoid arthritis, so the results may not reflect blood clotting rates in these populations.&lt;/p&gt;
&lt;p&gt;They also noted that they relied on anonymous patient records and were dependent on family doctors&apos; diagnoses of inflammatory bowel disease, flare-ups and venous thromboembolism.&lt;/p&gt;
&lt;p&gt;Despite the limitations of the study, they argued that research into ways to prevent embolism in IBD outpatients is warranted.&lt;/p&gt;
&lt;p&gt;&quot;We believe that the medical profession needs to recognise the increased risk in people with inflammatory bowel disease when assessing the likelihood of venous thromboembolism and to address the difficulty of reducing this risk in patients with a flare who are not admitted to hospital,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;They suggested that strategies used to prevent blood clots in hospitalized patients  --  courses of low molecular weight heparin or other newly available anticoagulants  --  might be also be used to prevent clots in nonhospitalized IBD patients experiencing a flare-up.&lt;/p&gt;
&lt;p&gt;In an accompanying editorial, Geoffrey C. Nguyen, MD, and Erik L. Yeo, MD, of the University of Toronto, noted that &quot;the use of steroid prescriptions as a surrogate indicator of acute disease flare restricts the applicability of Grainge and colleagues&apos; findings to flares that are moderate to severe. Whether patients with mild flares are also at increased risk is not clear.&quot;&lt;/p&gt;
&lt;p&gt;&quot;Recognition of venous thromboembolism might be increased during periods of frequent contact with doctors, such as during flares compared with during remission of inflammatory bowel disease, thus potentially introducing a bias in ascertainment of venous thromboembolism,&quot; they added.&lt;/p&gt;
&lt;p&gt;Nguyen and Yeo also argued that the clinical efficacy and cost-effectiveness of pharmacological prevention in patients with inflammatory bowel disease should be proven before it is routinely recommended during acute flares.&lt;/p&gt;
&lt;p&gt;However, they acknowledged that such evidence could be difficult to acquire, given the low numbers of nonhospitalized IBD patients who suffer venous thromboembolism.&lt;/p&gt;
&lt;p&gt;&quot;A pragmatic initial approach to reduction of the rates of morbidity and mortality resulting from venous thromboembolism in ambulatory patients with inflammatory bowel disease would be nonpharmacological thromboprophylaxis, including patients&apos; education and awareness of risk and signs and symptoms of venous thromboembolism, and use of support stockings,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;&quot;Physicians should clinically assess for signs and symptoms of this embolism during visits for acute flare of inflammatory bowel 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 funded by the National Association for Colitis and Crohn&apos;s Disease.&lt;/p&gt;&lt;p&gt;The authors reported no financial conflicts of interest.&lt;/p&gt;&lt;p&gt;Nguyen reported serving on advisory boards for Schering-Plough, Canada, and Abbott Pharmaceuticals.&lt;/p&gt;&lt;p&gt;Yeo reported receiving an honorarium from sanofi-aventis.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_441"
                     title="Be Ready for Drug-Induced Vfib, Groups Urge (CME/CE)"
                     score="0.011"
                     href="http://www.medpagetoday.com/Cardiology/Arrhythmias/tb/18358?impressionId=1265764512769"
                     
      Awareness of medication-induced torsade de pointes and a preset protocol for treating it could save lives in the hospital with swift action to prevent cardiac arrest, according to a joint statement from two professional associations.&lt;br&gt;
&lt;br&gt;These cases &quot;should be avoidable&quot; with consistent electrocardiographic monitoring of patients receiving drugs known to prolong the QT interval, the American Heart Association and American College of Cardiology wrote in a statement endorsed by the American Association of Critical-Care Nurses.&lt;br&gt;
&lt;br&gt;The rare arrhythmia often provides telltale signs on ECG an hour or so before ventricular fibrillation, according to writing committee chair Barbara J. Drew, RN, PhD, of the University of California San Francisco, and colleagues.&lt;/p&gt;
&lt;p&gt;However, the statement made no one-size-fits-all recommendation on what cardiac monitoring should entail, given hospital-to-hospital differences in equipment that range from fully automated QT-monitoring systems at the high end to a computer-assisted electronic caliper feature at the other.&lt;/p&gt;
&lt;p&gt;&quot;Of utmost importance, however, is that a hospital protocol be established so that a single consistent method is used by all healthcare professionals charged with the responsibility for cardiac monitoring,&quot; Drew&apos;s group wrote.&lt;/p&gt;
&lt;p&gt;This protocol should stipulate which equipment to use for QT measurement, how to determine the end of the T wave, the formula for heart rate correction, lead-selection criteria, and the importance of measuring the same lead in the same patient over time, they said.&lt;/p&gt;
&lt;p&gt;The new statement, published online in &lt;em&gt;Circulation: Journal of the American Heart Association&lt;/em&gt; and the &lt;em&gt;Journal of the American College of Cardiology&lt;/em&gt;, included the following signs of impending torsade de pointes: &lt;ul&gt; &lt;li&gt;An increase of 60 ms in heart-rate&amp;#8211;corrected QT interval (QTc) from the preadministration baseline&lt;/li&gt; &lt;li&gt;Marked QTc interval prolongation of more than 500 ms&lt;/li&gt; &lt;li&gt;The characteristic &quot;twisting&quot; of the points on ECG as T-U wave distortion becomes more exaggerated in the beat after a pause&lt;/li&gt; &lt;li&gt;Visible (macroscopic) T-wave alternans&lt;/li&gt; &lt;li&gt;New-onset ventricular ectopy&lt;/li&gt; &lt;li&gt;Couplets and &lt;span&gt;nonsustained&lt;/span&gt; polymorphic ventricular tachycardia initiated in the beat after a pause&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Prompt recognition of these ECG harbingers allows for treatment with intravenous magnesium, removal of the drug that induced the condition, and correction of electrolyte abnormalities and other exacerbating factors, including the prevention of bradycardia and long pauses with temporary pacing if necessary, according to the new statement.&lt;/p&gt;
&lt;p&gt;Prior guidelines on ventricular arrhythmias provided little help with prevention of torsade de pointes in the hospital but did recommend discontinuation of whatever drug induced long QT syndrome.&lt;/p&gt;
&lt;p&gt;The most common drugs associated with this potentially fatal arrhythmia are antibiotics, antipsychotics, and antiarrhythmia drugs.&lt;/p&gt;
&lt;p&gt;Administration in the hospital is more likely to be associated with torsade de pointes than is treatment of an outpatient population with the same drug, Drew&apos;s group noted.&lt;/p&gt;
&lt;p&gt;Hospitalized patients are often elderly, with comorbidities such as underlying heart disease and renal or hepatic dysfunction. They are also more likely to get intravenous push of the drugs.&lt;/p&gt;
&lt;p&gt;Clinical risk factors for torsade de pointes include: &lt;ul&gt; &lt;li&gt;A preexisting long QTc interval of more than 500 ms&lt;/li&gt; &lt;li&gt;Concurrent use of more than one QT-prolonging drug&lt;/li&gt; &lt;li&gt;Rapid infusion of a QT-prolonging drug intravenously&lt;/li&gt; &lt;li&gt;Heart disease, such as MI or heart failure&lt;/li&gt; &lt;li&gt;Advanced age&lt;/li&gt; &lt;li&gt;Female sex&lt;/li&gt; &lt;li&gt;Hypokalemia&lt;/li&gt; &lt;li&gt;Hypomagnesemia&lt;/li&gt; &lt;li&gt;Hypocalcemia&lt;/li&gt; &lt;li&gt;Treatment with diuretics&lt;/li&gt; &lt;li&gt;Impaired hepatic drug metabolism, whether from hepatic dysfunction or drug-drug interactions&lt;/li&gt; &lt;li&gt;Bradycardia&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;Drew reported conflicts of interest with GE Healthcare and Philips.&lt;/p&gt;&lt;p&gt;Co-authors reported conflicts of interest with Medtronic, Pfizer, PGxHealth, FAMILION, GE HealthCare, Philips Healthcare, Abbott, Bristol-Myers Squibb, sanofi-aventis, Schering Plough, Inovise, Siloam, ArgiNOx, Astellas, Daiichi Sankyo/Lilly, Heartscape Technologies, Biosite, Inovise, Medicines Co., Millennium Pharmaceuticals, PDL BioPharma, Roche Diagnostics, Scios, Mortara Instrument, Cardiac Science, MDS Pharma, Medicure, St. Jude, Adolor, ARCA, AstraZeneca, Avanir, Cardiome, CardioDx, Novartis, Ortho Diagnostics, Sanofi, Vanderbilt/Clinical Data, iCardiac Technologies, LipoScience, Anthera, Abbott Vascular, Novo Nordisk, Roche, Biotronic, and Boston Scientific.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_388"
                     title="Laser Cardiac Lead Extraction Gets Better Grades (CME/CE)"
                     score="0.009"
                     href="http://www.medpagetoday.com/Cardiology/Arrhythmias/tb/18280?impressionId=1265764512769"
                     
      &lt;p&gt;Laser-assisted extraction of implanted heart device leads appears to have become safer and more successful in recent years, researchers said.&lt;/p&gt;
&lt;p&gt;A retrospective multicenter series suggested a 97.7% clinical success rate and complete lead removal in 96.5% of cases attempted with the newer iteration of transvenous excimer laser extraction tools.&lt;/p&gt;
&lt;p&gt;Major procedural complication rates were low at 1.4% with 0.28% procedure-related deaths, Oussama M. Wazni, of the Cleveland Clinic, and colleagues reported in the Feb. 9 issue of the &lt;em&gt;Journal of the American College of Cardiology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;Since the initially reported experiences, which employed earlier editions of the extraction tools and largely represented the learning curve with laser extraction techniques, this consecutive patient experience represents the mature contemporary practice in multiple centers with varying degrees of experience,&quot; the researchers wrote.&lt;/p&gt;
&lt;p&gt;These results suggested improvements, they said, compared with the original PLEXES trial using the first version of a laser sheath for lead extraction, which showed 94% procedural success and 1.96% procedure-related major complications.&lt;/p&gt;
&lt;p&gt;Another study of the total initial U.S. experience of laser lead extraction indicated 90% procedural success with a 1.9% major complication rate and an inhospital death rate of 0.8%.&lt;/p&gt;
&lt;p&gt;The early, relatively small trials and voluntary registry results upon which the perceptions of lead extraction safety and effectiveness were based had painted a &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/Arrhythmias/3162&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/Arrhythmias/3162&quot; target=&quot;_blank&quot;&gt;picture&lt;/a&gt; that limited it to patients with life-threatening situations, Wazni&apos;s group explained.&lt;/p&gt;
&lt;p&gt;It used to be felt that removing infected leads was dangerous because of the potential for infected debris to spread through the bloodstream and become lodged in the lungs, commented Ann Bolger, MD, of San Francisco General Hospital and a spokesperson for the American Heart Association.&lt;/p&gt;
&lt;p&gt;&quot;Because there are just more and more patients all the time with these devices and because we went through a phase when we might not have always retrieved wires that were no longer functional completely, there are patients who have what they call abandoned leads,&quot; she said in an interview.&lt;/p&gt;
&lt;p&gt;AHA guidelines released last month now recommend removal of all hardware even in the absence of symptoms for patients with more than a superficial or incisional infection at the pocket site, suggesting percutaneous extraction as the preferred method despite significant risks.&lt;/p&gt;
&lt;p&gt;The AHA agreed with guidelines from the Heart Rhythm Society released last spring cautioning that only experienced centers should do extractions. The HRS went so far as to set &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/HRS/14255&quot; mce_href=&quot;http://www.medpagetoday.com/MeetingCoverage/HRS/14255&quot; target=&quot;_blank&quot;&gt;minimum standards&lt;/a&gt; for operators.&lt;/p&gt;
&lt;p&gt;For a look at more contemporary data, Wazni&apos;s group examined outcomes for 1,449 consecutive patients treated with transvenous laser-assisted lead extraction at 13 U.S. and Canadian centers between January 2004 and December 2007.&lt;/p&gt;
&lt;p&gt;Among the 2,405 procedures, 70% were for pacemakers leads and 29.2% for defibrillator leads, with most being active fixation leads (1,226).&lt;/p&gt;
&lt;p&gt;The extracted leads had been in place for an average of 82.1 months (range 0.4 to 356.8). They were taken out predominantly because of infection (29.2% device-related endocarditis and 27.7% pocket infection).&lt;/p&gt;
&lt;p&gt;More than a quarter were nonfunctional (26.6%), while an additional 11.1% were functional but abandoned.&lt;/p&gt;
&lt;p&gt;Removal was complete for 96.5% of the leads and partial for 2.3%. Clinical success  --  achieving the clinical goals associated with the indication for lead removal  --  was achieved in 97.7% of the cases.&lt;/p&gt;
&lt;p&gt;Clinical failure of the procedure was associated with low patient body mass index (less than 25 kg/m&lt;sup&gt;2&lt;/sup&gt;) and with a lower volume of procedures (60 or fewer) at a center over the four years (&lt;em&gt;P&lt;/em&gt;=0.0128).&lt;/p&gt;
&lt;p&gt;Procedural adverse events, too, were more common for low BMI patients (&lt;em&gt;P&lt;/em&gt;=0.0132).&lt;/p&gt;
&lt;p&gt;Procedural failure was linked to a long implant duration (at least 10 years) and lower center volume (&lt;em&gt;P&lt;/em&gt;=0.0005).&lt;/p&gt;
&lt;p&gt;Although extraction of noninfected but nonfunctional leads is controversial, leaving them in place may just serve as a nidus for infection such that they have to be removed eventually anyway, the researchers suggested.&lt;/p&gt;
&lt;p&gt;Considering extraction in such cases requires carefully weighing patient risks individually, including operator experience in the equation, they wrote.&lt;/p&gt;
&lt;p&gt;A significant learning curve for laser-assisted extraction is not surprising, but the results in experienced hands are encouraging, Bolger concluded.&lt;/p&gt;
&lt;p&gt;By the end of the study, physicians averaged 11.4 years of experience with lead extraction (range 2.0 to 19.0 years) and 7.87 years at laser-assisted lead extraction (range 2.0 to 13.0 years).&lt;/p&gt;
&lt;p&gt;The researchers agreed that the high success and low complication rate may have been due to the experienced centers and operators.&lt;/p&gt;
&lt;p&gt;&quot;However, in the community, these more challenging cases are usually referred to centers experienced in laser-assisted lead extraction,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;They noted that any selection bias in the retrospective study was most likely toward the most challenging cases &quot;as laser-assisted extraction is reserved for leads with ingrown tissue and inability to be removed with traction only.&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 sponsored by Spectranetics, manufacturer of the laser lead removal system.&lt;/p&gt;&lt;p&gt;Wilkoff reported being on the advisory board of Spectranetics.&lt;/p&gt;&lt;p&gt;Co-authors reported financial conflicts of interests with Spectranetics, St. Jude, Medtronic, Boston Scientific, and Biotronik. One is an employee of Spectranetics; another is the senior biostatistician with the company.&lt;/p&gt;&lt;p&gt;Bolger reported no conflicts of interests.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_361"
                     title="Hidden Dangers of Herbal Meds Reviewed"
                     score="0.008"
                     href="http://www.medpagetoday.com/PrimaryCare/AlternativeMedicine/tb/18244?impressionId=1265764512769"
                     
      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;
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