<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_361"
                     title="Hidden Dangers of Herbal Meds Reviewed"
                     score="0.011"
                     href="http://www.medpagetoday.com/PrimaryCare/AlternativeMedicine/tb/18244?impressionId=1265737657787"
                     
      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;
    </recommendedItem>
    <recommendedItem id="20100101_19_297"
                     title="Ablation Therapy Controls Atrial Fibrillation (CME/CE)"
                     score="0.005"
                     href="http://www.medpagetoday.com/Cardiology/Arrhythmias/tb/18152?impressionId=1265737657787"
                     
      If initial drug therapy fails to control paroxysmal atrial fibrillation, the next step should be radiofrequency catheter ablation, researchers said.&lt;br&gt;
&lt;br&gt;In a prospective randomized trial, catheter ablation succeeded in preventing fibrillation and other forms of treatment failure in 66% of patients, according to David J. Wilber, MD, of Loyola University Medical Center in Maywood, Ill., and colleagues.&lt;br&gt;
&lt;br&gt;By comparison, only 16% of patients who got renewed drug therapy were free from treatment failure by the end of nine months of follow-up, Wilber and colleagues reported in the Jan. 27 issue of the &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;The trial was stopped early, in fact, after a Bayesian analysis showed the predictive probability of success for the catheter treatment to be 99.9%.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;The study &quot;confirmed resoundingly&quot; that catheter ablation is the way to go after a patient has failed an initial attempt to control the heart rhythm with drugs, Wilber told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;This is really a procedure that&apos;s come of age,&quot; he said.&lt;/p&gt;
&lt;p&gt;Although anti-arrhythmic drugs are the usual first-line therapy, they are only inconsistently effective, Wilber said  --  about half of all patients will have a recurrence of fibrillation within six months to a year.&lt;/p&gt;
&lt;p&gt;Also, he said, the drugs have a range of adverse events associated with them that range from nuisance effects, such as dizziness, to more serious consequences, such as inflammation of the liver, lung, or thyroid.&lt;/p&gt;
&lt;p&gt;Several smaller studies have suggested that catheter ablation is more effective and has fewer adverse events, but Wilder and colleagues conducted a study that eventually analyzed results in 167 patients from several centers in the U.S. and elsewhere.&lt;/p&gt;
&lt;p&gt;The primary endpoint was freedom from symptomatic atrial fibrillation, although total atrial fibrillation was also measured. The protocol also defined treatment failure in some other cases, including a need for a repeat ablation procedure more than 80 days after the first.&lt;/p&gt;
&lt;p&gt;Patients were eligible for the study if they did not respond to at least one anti-arrhythmic drug and had experienced at least three symptomatic fibrillation episodes within the six months before randomization, the researchers reported in the journal.&lt;/p&gt;
&lt;p&gt;Most of those randomized to the drug therapy arm of the study were treated with either flecainide (Tambocor) or propafenone (Rythmol).&lt;/p&gt;
&lt;p&gt;Analysis showed that, at the end of the nine-month effectiveness evaluation period: &lt;ul&gt; &lt;li&gt;66% of patients in the ablation group remained free from protocol-defined treatment failure compared with 16% of those treated with drugs. The hazard ratio was 0.30 (with a 95% confidence interval from 0.19 to 0.47, which was significant at &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001). &lt;/li&gt; &lt;li&gt;70% of ablation patients had no recurrences of symptomatic atrial arrhythmia compared with 19% of those getting drugs. (The hazard ratio was 0.24, with a 95% confidence interval from 0.15 to 0.39, which was significant at &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001). &lt;/li&gt; &lt;li&gt;63% of patients treated by ablation were free of any recurrent atrial arrhythmia, symptomatic or not, compared with 17% of those treated with drugs. (The hazard ratio was 0.29; with a 95% confidence interval from 0.18 to 0.45, also significant at &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Major treatment-related adverse events within the first 30 days occurred in 8.8% of patients treated with drugs and 4.9% of those treated with catheter ablation, the researchers said.&lt;/p&gt;
&lt;p&gt;The study has some limitations, the researchers said, including the fact that most of the investigators had considerable experience with the ablation procedure. Outcomes in centers with less experience may vary, they said.&lt;/p&gt;
&lt;p&gt;In addition, the study did not address longer-term outcomes such as mortality, risk of stroke, heart failure, or progression of atrial fibrillation into a more persistent arrhythmia.&lt;/p&gt;
&lt;p&gt;The researchers also noted that study volunteers were relatively young and had less cardiovascular comorbidity than most people with paroxysmal atrial fibrillation. The result may not generalize to patients with significant left ventricular dysfunction, more persistent forms of fibrillation, or advanced heart failure, they said.&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 funded by Biosense Webster, which provided the catheters used.&lt;/p&gt;&lt;p&gt;Wilber reported financial links with Biosense Webster, Boston Scientific, Medtronic, St. Jude Medical, sanofi-aventis, and Blackwell/Futura. Most other authors reported financial links with a range of industrial organizations, including Biosense Webster. Two authors are employees of the company.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_6_893"
                     title="HRS: Statins Linked to Lower Atrial Fibrillation Risk in Women"
                     score="-0.005"
                     href="