<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_458"
                     title="Calcium Scoring Misses 20% of CAD Cases (CME/CE)"
                     score="0.015"
                     href="http://www.medpagetoday.com/Cardiology/AcuteCoronarySyndrome/tb/18387?impressionId=1265800780374"
                     
      &lt;p&gt;Contrary to guidelines, the absence of coronary artery calcium doesn&apos;t rule out coronary artery disease in symptomatic patients, researchers found in a new study.&lt;/p&gt;
&lt;p&gt;In a multicenter clinical trial, 19% of patients with a coronary calcium score of 0 had stenosis of at least 50% in one or more coronary artery segments, according to Carlos E. Rochitte, MD, of the University of S&amp;#227;o Paulo, Brazil, and colleagues.&lt;/p&gt;
&lt;p&gt;Likewise, 20% of vessels seen to be totally occluded on revascularization had no calcium on scans, they reported in the Feb. 16 issue of the &lt;em&gt; Journal of the American College of Cardiology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;The absence of coronary calcification should not be used as a gatekeeper and should not prevent a symptomatic patient from undergoing angiography,&quot; the researchers wrote.&lt;/p&gt;
&lt;p&gt;Currently, American Heart Association/American College of Cardiology guidelines suggest that excluding measurable coronary calcium could serve as an effective filter for sending patients on to invasive testing or admitting them.&lt;/p&gt;
&lt;p&gt;One systematic review of 18 studies had indicated that a zero calcium score had a negative predictive value of 93% for stenosis and a positive predictive value of 68% in symptomatic patients.&lt;/p&gt;
&lt;p&gt;However, in Rochitte&apos;s trial  --  CORE64 (Coronary Evaluation Using Multi-Detector Spiral Computed Tomography Angiography Using 64 Detectors)  --  the negative predictive value of a coronary calcium score of 0 was 68%, while the positive predictive value was 81%.&lt;/p&gt;
&lt;p&gt;Overall sensitivity to predict the absence of significant (at least 50%) stenosis was 45%, while specificity was 91%.&lt;/p&gt;
&lt;p&gt;&quot;This apparent lack of predictive value of a calcium scan should be enough to give a clinician pause,&quot; Rita F. Redberg, MD, of the University of California San Francisco, wrote in an accompanying editorial.&lt;/p&gt;
&lt;p&gt;Whatever the reason for the discrepancy, neither the trial nor the review provided any information on how coronary calcium scans add incrementally to traditional predictors of coronary artery disease, such as clinical assessment and stress testing, she said. Nor would she rule out their use entirely for patients with chest pain.&lt;/p&gt;
&lt;p&gt;&quot;Given the significant &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/AcuteCoronarySyndrome/12732&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/AcuteCoronarySyndrome/12732&quot; target=&quot;_blank&quot;&gt;radiation risks&lt;/a&gt; of coronary artery calcium scans, however, clinicians must use extreme caution when ordering such scans,&quot; Redberg cautioned.&lt;/p&gt;
&lt;p&gt;The prospective &lt;a href=&quot;http://www.medpagetoday.com/Radiology/DiagnosticRadiology/11927&quot; mce_href=&quot;http://www.medpagetoday.com/Radiology/DiagnosticRadiology/11927&quot; target=&quot;_blank&quot;&gt;CORE64 study&lt;/a&gt; was originally designed to compare diagnostic performance of CT and invasive angiography in symptomatic patients with suspected coronary artery disease. But it also included a coronary calcium scan up to 30 days prior to conventional angiography.&lt;/p&gt;
&lt;p&gt;Of the 291 patients included in the calcium score analysis (73% male, mean age 59.3), 56% had at least 50% coronary stenosis by conventional angiography and 45% had at least 70% stenosis.&lt;/p&gt;
&lt;p&gt;Calcium score only weakly correlated with the highest degree of coronary stenosis found in a patient. Its ability to predict presence of significant lesions was &quot;moderate&quot; (area under the receiver-operating characteristic curve 0.77, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;A non-zero score was associated with 8.1-fold likelihood of having at least 50% coronary stenosis (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) after adjusting for age, sex, hypertension, dyslipidemia, family history of premature heart disease, diabetes, race, and hospitalization.&lt;/p&gt;
&lt;p&gt;Among the 100 patients who went on to revascularization within 30 days of angiography, 13% had a coronary calcium score of 0, 25% had a score of 1 to 10, and 44% had a score over 10 (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001 for trend).&lt;/p&gt;
&lt;p&gt;The fact that significant coronary artery disease occurred in the absence of calcification in almost 20% of patients should not be surprising, since coronary calcification is thought to occur late in the atherosclerotic process, while obstruction can occur earlier, Redberg asserted.&lt;/p&gt;
&lt;p&gt;The researchers also cautioned that the results would not apply to asymptomatic patients with intermediate risk for events, a group in which a score of 0 has been consistently shown to indicate low risk.&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 grants from Toshiba Medical Systems, the Doris Duke Charitable Foundation, the National Heart, Lung, and Blood Institute, the National Institute on Aging, and the Donald W. Reynolds Foundation.&lt;/p&gt;&lt;p&gt;Rochitte reported no conflicts of interest. Co-authors reported financial relationships with Toshiba Medical Systems, Bayer, Schering, GE Healthcare, Bracco, Bristol-Myers Squibb, sanofi-aventis, and Vital Images.&lt;/p&gt;&lt;p&gt;Redberg provided no information on 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_189"
                     title="Tailoring Trumps Targeting for Cholesterol Control (CME/CE)"
                     score="-0.002"
                     href="http://www.medpagetoday.com/Cardiology/Dyslipidemia/tb/18023?impressionId=1265800780374"
                     
      &lt;p&gt;Lipid control is more than a simple matter of &quot;knowing your numbers,&quot; according to a computer model that found tailoring statin therapy to fit an individual&apos;s five-year risk of heart attack or stroke is a better prevention strategy than treating to preset goals.&lt;/p&gt;
&lt;p&gt;In the model, patients who whose five-year coronary artery disease risk was 5% to 15% received 40 mg of simvastatin (Zocor), while those whose risk was greater were given 40 mg of atorvastatin (Lipitor).&lt;/p&gt;
&lt;p&gt;In every scenario, the tailored approach was preferable, Rodney A. Hayward, MD, of the University of Michigan and the Veterans Affairs Ann Arbor Healthcare System, and colleagues wrote in the Jan. 19 &lt;em&gt;Annals of Internal Medicine.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;While treating-to-target is appealingly simple, that simplicity may be its main limitation, the researchers argued.&lt;/p&gt;
&lt;p&gt;Treating to a single target means that one risk factor receives &quot;dramatically more weight than all other predictors of treatment benefit, resulting in other highly relevant information being either ignored or underweighted,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;That approach, tailoring treatment to reflect multiple risk factors rather than treating-to-target, is an &quot;interesting&quot; one, according to Christopher Cannon, MD, of Brigham and Women&apos;s Hospital in Boston, who was not involved in the study.&lt;/p&gt;
&lt;p&gt;But Cannon, principal investigator of a number of statin trials, said the idea may be a little too late to impact clinical practice.&lt;/p&gt;
&lt;p&gt;&quot;The guidelines won&apos;t shift to this approach any time soon, and in two years, atorvastatin will be generic, so all patients can inexpensively be treated with more intensive therapy (which is better for everyone at all risk levels),&quot; Cannon wrote in an e-mail.&lt;/p&gt;
&lt;p&gt;Although intensive therapy may be better as a rule, he conceded, it&apos;s less cost-effective when an expensive drug is used. When atorvastatin becomes available as a generic, he wrote, for &quot;$4 a month at Walmart it is simply cheaper  --  and of course better  --  to treat everyone with atorvastatin 80 mg.&quot;&lt;/p&gt;
&lt;p&gt;Assuming a population of Americans ages 30 to 75 with no history of myocardial infarction, the authors developed three treatment models: &lt;ul&gt; &lt;li&gt;Standard National Cholesterol Education Program III (NCEP) treat-to-target recommendation, which requires treatment to an LDL target of less than 190 mg/dL for low-risk individuals, less than 160 mg/dL for moderate-risk, and less than 130 mg/dL for high-risk individuals&lt;/li&gt; &lt;li&gt;Intensive NCEP III treat-to-target approach, with targets of less than 100 mg/dL for high-risk individuals&lt;/li&gt; &lt;li&gt;The tailored model, with 40 mg of simvastatin for patients who whose five-year coronary artery disease risk was 5% to 15% and 40 mg of atorvastatin (Lipitor) for higher-risk patients&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;(In both NCEP III strategies statins would be used in a stepwise fashion  --  20 mg simvastatin, 40 mg simvastatin, 40 mg atorvastatin, and, finally, 80 mg atorvastatin  --  to achieve targets).&lt;/p&gt;
&lt;p&gt;Using standard NCEP III treat-to-target recommendations, &quot;37.9 million U.S. persons should receive statins, of which 7.9 million should receive high dose-potency therapy (atorvastatin 40 to 80 mg),&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;Compared with no treatment, the standard strategy would save an estimated 48 quality adjusted life years (QALYs) per 1,000 Americans treated for five years, or a total of 1.83 million total QALYs.&lt;/p&gt;
&lt;p&gt;The intensive NCEP III treat-to-target recommendations would &quot;recommend that 53.4 million U.S. persons receive statins&quot; and would save about 570,000 more QALYs than the standard treatment.&lt;/p&gt;
&lt;p&gt;Using the computer model, this strategy prevented &quot;about 720,000 more nonfatal CAD events and 30,000 more deaths&quot; than the standard treatment.&lt;/p&gt;
&lt;p&gt;Tailored treatment, by contrast, would require that about the same number of people receive a statin  --  53 million. But only 13.3 million would require high-dose statin therapy, versus roughly 18 million who would be given high-dose statin therapy using the intensive NCEP III strategy.&lt;/p&gt;
&lt;p&gt;Even so, the tailored approach would save 520,000 more QALYs than the intensive treatment approach, the authors found.&lt;/p&gt;
&lt;p&gt;&quot;The tailored treatment approach was superior to both NCEP III approaches, resulting in both more CAD morbidity and mortality prevented in the overall population and higher treatment efficiency (greater benefit per person treated),&quot; they wrote.&lt;/p&gt;
&lt;p&gt;The authors noted a number of limitations, including the paucity of clinical trial data on statin therapy in persons ages 75 or older.&lt;/p&gt;
&lt;p&gt;Moreover, although the model suggested a robust benefit for tailored treatment, &quot;the absolute population-level benefit of the tailored treatment over the treat-to-target approaches are much less certain and can vary substantially on the basis of several factors, such as statin&apos;s effect on total mortality (estimates of which are less precise in the literature than estimates for nonfatal CAD events) and the level of treatment adherence that is achievable in real-world clinical practice.&lt;/p&gt;
&lt;p&gt;&quot;Whether a tailored treatment approach is superior for other conditions in which treat-to-target strategies are currently recommended, such as blood pressure and glycemic control, warrants examination,&quot; they concluded.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded in part by the Department of Veteran Affairs Health Services Research &amp;amp; Development Service&apos;s Quality Enhancement Research Initiative.&lt;/p&gt;&lt;p&gt;Hayward did not report any financial disclosures.&lt;/p&gt;&lt;p&gt;Cannon reported receiving research/grants/suport from Accumetrics, AstraZeneca, Bristol-Myers Squibb/Sanofi Partnership, GlaxoSmithKline, Intekrin Therapeutics, Merck, Merck/Schering-Plough Partnership, Novartis, and Takeda. He is a clinical adviser with equity in Automedics Medical Systems.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_135"
                     title="Hispanic Groups Differ in Cardiac Conditions (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Cardiology/Atherosclerosis/tb/17952?impressionId=1265800780374"
                     
      Different patterns of left ventricular hypertrophy and ventricular remodeling exist among Hispanic subgroups and in comparison with non-Hispanic whites and blacks, a study found.&lt;br&gt;
&lt;br&gt;After adjustment for hypertension and other variables, Hispanic subgroups had these odds ratios for left ventricular hypertrophy compared with whites, according to an online report in the&lt;em&gt; Journal of the American College of Cardiology:&lt;/em&gt; &lt;ul&gt;&lt;li&gt;Caribbean origin, OR 1.8 (95% CI 1.1 to 3)&lt;/li&gt;&lt;li&gt;Mexican origin, OR 2.2 (95% CI 1.4 to 3.3)&lt;/li&gt;&lt;li&gt;Central/South American origin, OR 1.5 (95% CI 0.7 to 3.1) &lt;/li&gt;&lt;/ul&gt;
All Hispanic subgroups also had a higher prevalence of concentric and eccentric hypertrophy (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001), Carlos J. Rodriguez, MD, of Columbia University in New York, and colleagues wrote.&lt;br&gt;
&lt;br&gt;Some evidence suggests that the prevalence of hypertension differs among Hispanic subgroups, but little is known about the prevalence of left ventricular hypertrophy and remodeling  --  factors that are important for cardiovascular prognosis in a population where heart disease and stroke are the leading causes of death.&lt;/p&gt;
&lt;p&gt;Rodriguez and colleagues therefore analyzed data from the Multi-Ethnic Study of Atherosclerosis (MESA) to identify patterns of prevalence, performing cardiac magnetic resonance imaging on 4,309 subjects from six U.S. locations.&lt;/p&gt;
&lt;p&gt;Participants were aged 45 to 84 and all were free of cardiovascular disease at baseline.&lt;/p&gt;
&lt;p&gt;Left ventricular hypertrophy was defined as the upper 95th percentile of indexed left ventricular mass, and left ventricular remodeling was determined by unadjusted left ventricular mass/left ventricular end-diastolic volume ratio.&lt;/p&gt;
&lt;p&gt;Among the 1,064 Hispanics in the cohort, 54% were of Mexican origin, 31% were of Caribbean origin, and 15% were of Central/South American origin.&lt;/p&gt;
&lt;p&gt;Levels of education and income were lower among Hispanics than among either whites or blacks, as was the proportion with private insurance. Among Hispanics, those of Mexican origin had higher mean body mass index and a greater prevalence of diabetes and metabolic syndrome.&lt;/p&gt;
&lt;p&gt;Non-Hispanic blacks had the highest overall prevalence of hypertension, with an unadjusted prevalence ratio of 1.6 compared with non-Hispanic whites.&lt;/p&gt;
&lt;p&gt;Among Hispanics, only those of Caribbean origin had a greater prevalence of hypertension than whites, with an unadjusted prevalence rate of 1.2 (95% CI 1.03 to 1.4).&lt;/p&gt;
&lt;p&gt;After adjustment for multiple factors, including age, sex, body mass index, and diabetes, the prevalence of hypertension remained higher among blacks. But the difference was only of borderline statistical significance for Caribbean-origin Hispanics, at 1.05 (95% CI 1 to 1.10) compared with whites.&lt;/p&gt;
&lt;p&gt;&quot;Despite the modest or absent differences in hypertension prevalence between Hispanics and non-Hispanic whites, all Hispanic subgroups had higher [left ventricular hypertrophy] prevalence than non-Hispanic whites,&quot; the investigators wrote.&lt;/p&gt;
&lt;p&gt;After adjustment for age and sex, Caribbean and Mexican-origin Hispanics had twice the odds of having left ventricular hypertrophy as whites.&lt;/p&gt;
&lt;p&gt;And after adjustment for other variables including body mass index and blood pressure, all Hispanic subgroups had higher percent predicted left ventricular mass than whites.&lt;/p&gt;
&lt;p&gt;Analysis of left ventricular geometry determined that all Hispanic subgroups, and particularly those of Caribbean and Mexican origin, had a greater prevalence (4%) of concentric hypertrophy than whites (1%).&lt;/p&gt;
&lt;p&gt;Concentric hypertrophy tends to be associated with worse target organ damage than either eccentric hypertrophy or concentric remodeling, according to the researchers.&lt;/p&gt;
&lt;p&gt;The finding that Hispanics of Mexican origin had a greater prevalence of left ventricular hypertrophy and left ventricular remodeling despite lower rates of hypertension was &quot;interesting and unexpected,&quot; and may relate to the elevated prevalence rates of obesity, metabolic syndrome, and diabetes in this group, the authors wrote.&lt;/p&gt;
&lt;p&gt;It is also possible that many of the Mexican-origin Hispanics with metabolic syndrome and diabetes had blood pressure higher than 130/80 mm Hg but had not been given a diagnosis of hypertension, and that determinants other than blood pressure, such as psychosocial stress, may contribute to hypertrophy.&lt;/p&gt;
&lt;p&gt;Moreover, this subgroup had significantly lower levels of hypertension treatment (27.5%) than Hispanics of Caribbean origin (38%), which may reflect factors such as access to care or medication adherence.&lt;/p&gt;
&lt;p&gt;Among the limitations of the study was the fact that MESA is not a representative sample of the larger U.S. Hispanic population. It excludes those with prevalent heart disease and therefore represents a lower-risk group.&lt;/p&gt;
&lt;p&gt;The results also may have been limited by residual confounding by body size.&lt;/p&gt;
&lt;p&gt;Nonetheless, the authors concluded that the prevalence of hypertension, left ventricular hypertrophy, and abnormal left ventricular remodeling differ across Hispanic subgroups.&lt;/p&gt;
&lt;p&gt;&quot;Our findings demonstrate that Hispanics are a [cardiovascular] high-risk group and highlight the fact that Hispanics&apos; subgroup differences need to be appreciated when considering [cardiovascular] risk.&quot;&lt;/p&gt;
&lt;p&gt;&quot;Efforts are warranted to better recognize, understand, and address differences among Hispanic ethnic groups to prevent [cardiovascular disease] events in this large subset of the U.S. population,&quot; they wrote.&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 research was supported by the National Heart, Lung, and Blood Institute and by a Robert Wood Johnson faculty development program.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_127"
                     title="Novel Antiplatelet Called New Standard in ACS (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Cardiology/PCI/tb/17940?impressionId=1265800780374"
                     
      &lt;p&gt;Among patients who underwent planned stenting for treatment of acute coronary syndromes, those treated with the investigational antiplatelet agent ticagrelor (Brilinta) had fewer cardiovascular events than patients who received clopidogrel (Plavix).&lt;/p&gt;
&lt;p&gt;That finding emerged from a prespecified subset analysis of the PLATO (Study of Platelet Inhibition and Patient Outcomes) trial, published online by &lt;em&gt;The Lancet&lt;/em&gt;,&lt;em&gt; &lt;/em&gt;which has ticagrelor being heralded as a potential game-changer in treatment of acute coronary syndromes&lt;em&gt;. &lt;/em&gt;&lt;/p&gt;
&lt;p&gt;For every 1,000 patients admitted to the hospital with a planned invasive strategy, using ticagrelor instead of clopidogrel for 12 months resulted in 11 fewer deaths, 13 fewer MIs, and six fewer cases of stent thrombosis, said Christopher Cannon, MD, of Brigham and Women&apos;s Hospital in Boston.&lt;/p&gt;
&lt;p&gt;Cannon first reported the &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/TCT/16136&quot; mce_href=&quot;http://www.medpagetoday.com/MeetingCoverage/TCT/16136&quot; target=&quot;_blank&quot;&gt;findings of the subset analysis&lt;/a&gt; last fall at the Transcatheter Cardiovascular Therapeutics meeting in San Francisco. The &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/ESCCongress/15752&quot; mce_href=&quot;http://www.medpagetoday.com/MeetingCoverage/ESCCongress/15752&quot; target=&quot;_blank&quot;&gt;full PLATO findings&lt;/a&gt; were reported in August at the European Society of Cardiology meeting in Barcelona.&lt;/p&gt;
&lt;p&gt;At 12 months, 10.7% of the clopidogrel patients versus 9.0% of the ticagrelor patients met the primary endpoint of cardiovascular death, MI, or stroke  --  a 16% relative risk reduction (&lt;em&gt;P&lt;/em&gt;=0.0025).&lt;/p&gt;
&lt;p&gt;Ticagrelor is a direct-acting inhibitor of the adenosine diphosphate receptor P2Y12, which means that the drug turns on and off quickly.&lt;/p&gt;
&lt;p&gt;The study analyzed data from a subset of 13,408 patients who were destined for stenting prior to randomization to ticagrelor or clopidogrel, a population, Cannon said, that better reflected real-world clinical practice.&lt;/p&gt;
&lt;p&gt;In an invited comment also published in &lt;em&gt;The Lancet&lt;/em&gt;, Gregg W. Stone, MD, of Columbia University in New York City, wrote that the &quot;compelling results support ticagrelor as a new standard of care in acute coronary syndromes.&quot;&lt;/p&gt;
&lt;p&gt;However, he wrote, &quot;a personalized approach to drug selection should be used wherein each patient&apos;s individualized risk of ischemia versus bleeding is considered.&quot;&lt;/p&gt;
&lt;p&gt;When the two agents were compared in the total PLATO population of 18,624 ACS patients, the results also favored ticagrelor  --  9.8% versus 11.7% for a relative reduction of 16% (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;Among the &quot;therapeutic considerations&quot; Cannon cited at the fall meeting was that &quot;treating 59 patients with ticagrelor instead of clopidogrel for one year would prevent one cardiovascular death, MI, or stroke. Treating just 88 patients would save one life in one year.&quot;&lt;/p&gt;
&lt;p&gt;Kirk Garratt, MD, clinical director of interventional cardiovascular research at Lenox Hill Hospital in New York City, called the latest PLATO findings &quot;a blockbuster paper.&quot;&lt;/p&gt;
&lt;p&gt;&quot;No new antiplatelet drug has lowered mortality before, and you&apos;d expect a more powerful drug to cause more bleeding complications. For ticagrelor to reduce the chance of dying without increasing bleeding risk is huge,&quot; Garratt said in an e-mail.&lt;/p&gt;
&lt;p&gt;Cannon and co-authors wrote that the &quot;mechanisms of the mortality benefit cannot be defined from this analysis but might relate to the reduction in ischemic events without an increase in bleeding.&quot;&lt;/p&gt;
&lt;p&gt;But even as Garratt suggested that ticagrelor was shaping up as the &quot;next big thing,&quot; he said he was concerned that &quot;the vast majority of patients in PLATO came from Europe, the Middle East, or Africa. For some reason, patients from North America (about 11% of the total) didn&apos;t benefit from ticagrelor.&quot;&lt;/p&gt;
&lt;p&gt;Several people have raised questions about the lack of benefit in North America, but Cannon and others have downplayed that finding noting that this was more likely a function of trial design  --  few North American patients recruited  --  rather than a &quot;real&quot; finding.&lt;/p&gt;
&lt;p&gt;Garratt also noted a potential downside to the fast-on/fast-off mechanism: &quot;if a patient misses his evening dose, he&apos;s almost completely unprotected by morning, when people are typically most likely to form blood clots. This could have serious implications after stent placement.&quot;&lt;/p&gt;&lt;p&gt;Although it is true that the drug has a short half life, it is also a more potent agent than clopidogrel. Cannon explained in an email that even if a dose is missed &quot;at the end of 24 hours, you are still at the level of the peak of clopidogrel.&quot;&lt;/p&gt;
&lt;p&gt;In his commentary in &lt;em&gt;The Lancet&lt;/em&gt;, Stone addressed this concern, writing that clopidogrel might still be the drug to use for &quot;selected patients who are at relatively low risk of major bleeding, and/or for whom noncompliance with ticagrelor because of cost or other considerations (e.g., twice daily dosing) is a concern.&quot;&lt;/p&gt;
&lt;p&gt;The multicenter, double-blind PLATO trial randomized patients to ticagrelor (180 mg loading dose, 90 mg twice daily thereafter) or clopidogrel (300 to 600 mg loading dose, 75 mg thereafter). Patients were followed for 12 months.&lt;/p&gt;
&lt;p&gt;There was no increase in major bleeding with ticagrelor and no need for transfusions.&lt;/p&gt;
&lt;p&gt;The one side effect that might be troublesome was dyspnea. Cannon said that for every 1,000 patients treated with ticagrelor rather than clopidogrel, six were likely to switch to clopidogrel because of reversible breathing problems.&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 PLATO trial was funded by AstraZeneca.&lt;/p&gt;&lt;p&gt;Cannon disclosed research grants/support from the following companies: Accumetrics, AstraZeneca, Bristol-Myers Squibb/Sanofi Partnership, GlaxoSmithKline, Intekrin Therapeutics, Merck, Merck/Schering Plough Partnership, Novartis, and Takeda; and equity in Automedics Medical Systems.&lt;/p&gt;&lt;p&gt;Stone disclosed that he had received honoraria from BMS-Sanofi and AstraZeneca, and that he is on the advisory boards for Boston Scientific and Abbott Vascular.&lt;/p&gt;&lt;p&gt;Garratt had no disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_1_487"
                     title="AHA: Fish Oil Plus Statin Reduces Coronary Events"
                     score="-0.005"
                     href="