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    <recommendedItem id="20100101_19_222"
                     title="Benefits of Cutting Down on Salt Quantified (CME/CE)"
                     score="-0.003"
                     href="http://www.medpagetoday.com/Cardiology/Prevention/tb/18075?impressionId=1265799811757"
                     
      &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="20090101_19_1322"
                     title="AAN: Stroke Risk Cut 65% in Patients Who Hit Major Risk Factor Targets"
                     score="-0.005"
                     href="http://www.medpagetoday.com/MeetingCoverage/AAN/tb/13979?impressionId=1265799811757"
                     
       SEATTLE, April 29 -- Patients who meet guideline targets for &quot;good&quot; and &quot;bad&quot; cholesterol, triglycerides, and blood pressure can expect a 65% reduction in stroke risk, according to research presented here.
              &lt;br&gt; 
              &lt;br&gt;Analysis of data on more than 4,700 patients in the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) study showed that hitting all four targets reduced the risk of major cardiovascular events collectively by 75%, reported Pierre Amarenco, M.D., of Denis Diderot University in Paris.
              &lt;br&gt; 
              &lt;br&gt;&quot;The take-home message [for clinicians] is to treat patients to target,&quot; Dr. Amarenco said at the American Academy of Neurology annual meeting here.
              &lt;br&gt; 
              &lt;br&gt;Between September 1998 and March 2001, the double-blind SPARCL trial randomized 4,731 patients who had baseline LDL levels of 100 to 190 mg/dL and no known history of coronary heart disease to 80 mg atorvastatin (Lipitor) or placebo.
              &lt;p&gt; 
              &lt;p&gt;All patients were enrolled within six months of a stroke or transient ischemic attack.
              &lt;p&gt; 
              &lt;p&gt;The average age of patients was 63, and 60% were men. In both arms the baseline mean LDL levels were about 133 mg/dL. The median duration of follow-up was 4.9 years.
              &lt;p&gt; 
              &lt;p&gt;The primary analysis of the SPARCL results found that aggressive cholesterol-lowering was effective as secondary stroke prevention. (See &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/Dyslipidemia/3893&quot; target=&quot;blank&quot;&gt;High-Dose Statins Following a Stroke Can Prevent a Second&lt;/a&gt;)
              &lt;p&gt; 
              &lt;p&gt;The data also showed that raising HDL cholesterol and lowering blood pressure and triglycerides also independently reduced stroke risk.
              &lt;p&gt; 
              &lt;p&gt;But it had not been clear whether the risk reductions seen with these factors individually were additive, Dr. Amarenco said, prompting the new analysis.
              &lt;p&gt; 
              &lt;p&gt;He and colleagues went over the SPARCL data to identify patients who met the following targets as recommended in major treatment guidelines:
              &lt;p&gt; 
              &lt;table style=&quot;font-size:12px;&quot;&gt;
                &lt;tr&gt;&lt;td valign=&quot;top&quot;&gt;&lt;li&gt;&lt;/li&gt;&lt;/td&gt; &lt;td&gt;LDL cholesterol: less than 70 mg/dL&lt;/td&gt;&lt;/tr&gt;
                &lt;tr&gt;&lt;td valign=&quot;top&quot;&gt;&lt;li&gt;&lt;/li&gt;&lt;/td&gt; &lt;td&gt;HDL cholesterol: at least 50 mg/dL&lt;/td&gt;&lt;/tr&gt;
                &lt;tr&gt;&lt;td valign=&quot;top&quot;&gt;&lt;li&gt;&lt;/li&gt;&lt;/td&gt; &lt;td&gt;Triglycerides: less than 150 mg/dL&lt;/td&gt;&lt;/tr&gt;
                &lt;tr&gt;&lt;td valign=&quot;top&quot;&gt;&lt;li&gt;&lt;/li&gt;&lt;/td&gt; &lt;td&gt;Blood pressure: less than 120 mm Hg diastolic/80 mm Hg systolic&lt;/td&gt;&lt;/tr&gt;
              &lt;/table&gt;
              &lt;p&gt; 
              &lt;p&gt;Meeting these targets were associated with the following reductions in stroke risk, compared with patients who did not meet any of the targets:
              &lt;p&gt; 
              &lt;ul&gt;
                &lt;li&gt;Any one target: HR 0.98 (95% CI 0.76 to 1.27)
                &lt;li&gt;Any two targets: HR 0.78 (95% CI 0.61 to 0.99)
                &lt;li&gt;Any three targets: HR 0.62 (95% CI 0.46 to 0.84)
                &lt;li&gt;All four targets: HR 0.35 (95% CI 0.13 to 0.96)
              &lt;/ul&gt;
              &lt;p&gt; 
              &lt;p&gt;Dr. Amarenco also reported that patients whose measurements of blood pressure and LDL and HDL cholesterol were on the &quot;good&quot; side of the median were at significantly less risk for stroke than those on the &quot;bad&quot; side.
              &lt;p&gt; 
              &lt;p&gt;For triglycerides, there was a nonsignificant trend toward reduced risk for patients below the median, he said.
              &lt;p&gt; 
              &lt;p&gt;He noted that relatively high HDL cholesterol reduced stroke risk even in patients with very low LDL levels, &quot;opening the door for raising HDL cholesterol [with] agents like niacin or new CETP inhibitors which are in development right now and very promising.&quot;
              &lt;p&gt; 
              &lt;p&gt;At a press briefing announcing the findings, Dr. Amarenco called the findings &quot;a message of hope for patients.&quot;
              &lt;p&gt; 
              &lt;p&gt;&quot;We can now tell them that if they are adherent to the treatment, and follow the target recommendation we have made to them, they may reduce the risk of stroke by 65% and the risk of major cardiovascular events by 75%,&quot; he said.
              &lt;p&gt; 
              &lt;p&gt;He added that, in light of these findings, clinicians should consider making more effort to ensure that patients stay compliant with treatment.
              &lt;p&gt; 
              &lt;p&gt;For example, he said, it may make sense to have nurse practitioners contact patients periodically to monitor and encourage adherence.

               &lt;p&gt;Edgar J. Kenton III, M.D., a neurohospitalist at Emory University Hospital Midtown in Atlanta, who was not involved with the study, said it added important new information to the knowledge about stroke risk factors.
                 &lt;p&gt;
                &lt;p&gt;&quot;We haven&apos;t really had a handle on any of [the four risk factors addressed in the study] separately, and the question has always been, are they related?&quot; Dr. Kenton said.
                 &lt;p&gt;
                &lt;p&gt;&quot;Putting it together, it gives us a look at the big picture rather than just LDL, HDL, and so forth.&quot;
                &lt;p&gt;
               &lt;p&gt;But Dr. Kenton noted that the findings came from an unplanned post-hoc analysis. He said they needed to be confirmed in a prospective trial designed specifically to address the combined roles of these risk factors.
               &lt;p&gt;
               &lt;p&gt;He pointed out that blood sugar is part of the mix affecting stroke risk as well.
              &lt;p&gt; 
              &lt;p&gt;&lt;table cellspacing=&quot;0&quot; hspace=&quot;1&quot; style=&quot;border-style:solid; border-width:1px; border-color:#8dabbc; font-family:arial; font-size:12px; background-color:#DBE9F2; padding:5px 5px 5px 5px;&quot;&gt;
&lt;tr&gt;&lt;td&gt; The study was supported by Pfizer.
              &lt;p&gt; 
              &lt;p&gt;Dr. Amarenco reported relationships with AstraZeneca Pharmaceuticals, Bristol-Myers Squibb Company, Daiichi, Eli Lilly, GlaxoSmithKline, Guerbet, Negma, Novartis, Pfizer, Sankyo, sanofi-aventis, Servier, Boehringer Ingelheim, and Eisai.
              &lt;p&gt; 
              &lt;p&gt;Other co-authors reported relationships with other firms including Merck, CytRx, MedPointe, Organon, NMT Medical, PhotoThera, Johnson &amp; Johnson, and Ambit, among others.&lt;/td&gt;&lt;/tr&gt;&lt;/table&gt;
    </recommendedItem>
    <recommendedItem id="20090101_1_203"
                     title="Cardiovascular Risk Factors Undertreated in Heart Patients Worldwide"
                     score="-0.005"
                     href="