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    <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=1265778166577"
                     
      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=1265778166577"
                     
      &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_79"
                     title="Women by the Millions Have Undiagnosed Heart Disease"
                     score="-0.005"
                     href="