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    <recommendedItem id="20100101_19_458"
                     title="Calcium Scoring Misses 20% of CAD Cases (CME/CE)"
                     score="0.011"
                     href="http://www.medpagetoday.com/Cardiology/AcuteCoronarySyndrome/tb/18387?impressionId=1265786414852"
                     
      &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_222"
                     title="Benefits of Cutting Down on Salt Quantified (CME/CE)"
                     score="-0.004"
                     href="http://www.medpagetoday.com/Cardiology/Prevention/tb/18075?impressionId=1265786414852"
                     
      &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_189"
                     title="Tailoring Trumps Targeting for Cholesterol Control (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Cardiology/Dyslipidemia/tb/18023?impressionId=1265786414852"
                     
      &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="20090101_10_958"
                     title="AHA: Women Need Earlier Diagnosis and More Aggressive Treatment for Heart Disease"
                     score="-0.005"
                     href="